Aims of Nutritional Support in Oncology (Parenteral) Part 2

Transcription

1 Aims of Nutritional Support in Oncology (Parenteral) Part 2 Rachel Barrett MSc, BSc (Hons) RD Principal Haematology-Oncology Dietitian Hong Kong Hospital Authority Commissioned Training November 20 th 2010

2 Main points of reference: Bozzetti et al., (2009) ESPEN Guidelines on Parenteral Nutrition: Non-Surgical Oncology Clinical Nutrition 28: Braga et al., (2009) ESPEN Guidelines on Parenteral Nutrition: Surgery Clinical Nutrition 28:

3 Why do we use PN in Oncology?

4 Practical Indications for PN in Oncology Severe mucositis of the gut post chemotherapy Radiation enteritis Short bowel syndrome post complex gut surgery colorectal / gynae / urological cancers High output ileostomy / fistulas Bowel obstruction / ileus Intractable nausea / vomiting Severe diarrhoea Malabsorption No available enteral access route

5 What are our aims with PN as a nutritional support method? Similarities with the ESPEN Guidelines for EN Therapeutic goals are the improvement of function & outcome by: -preventing & treating undernutrition -enhancing compliance with anti-tumours treatments -controlling adverse effects of these -improving QoL (Grade C)

6 ESPEN Indications for PN in Oncology Generally evidence is lacking fail to achieve nutritional benefit PN does not overcome metabolic alterations seen in cachexia Grade A evidence that PN is ineffective & probably harmful in non-aphagic oncological patients with no GI reason for gut failure

7 ESPEN Indications for PN in Oncology (2) No rationale for giving PN if nutrient intake is adequate via the oral / enteral route (Grade A) PN recommended for severe mucositis or severe radiation enteritis (Grade C) No study has reported benefits of PN in preventing sideeffects of chemo/radiotherapy Value of long-term PN in sub-acute & chronic radiation enteropathy is well recognised (Grade C) (Scolapio et al., 1999; Bozzetti, 2006)

8 PN Nutrient Provision The majority of patients requiring PN for a short time do not require any specialist formulation Routinely use in the UK standard ready to mix regimens Using a higher than usual % of lipid (e.g. 50% of nonprotein energy), may be beneficial for those with frank cachexia needing prolonged PN (Grade C) Fat is efficiently mobilized & utilized as a fuel source in cancer patients

9 PN Nutrient Provision (2) Glucose-based PN may cause positive balance of water & sodium in cancer patients (Fan et al., 1988; Bozzetti et al., 1998) ESPEN guidelines recommend a 1:1, fat : glucose energy ratio Optimal nitrogen supply for cancer patients not determined (Nitenberg et al., 2000) Recommendations range from 1g/kg/d (Nitenberg et al., 2000) to 1.2-2g/kg/d (Barrera, 2002; Baracos, 2006)

10 Role of EPA Cochrane systematic review of published studies on EPA in cancer patients oral EPA no benefit (Dewey et al., 2005) Parenteral EPA limited to peri-operative patients no ground-breaking studies reporting any marked nutritional benefits RCT comparing fish oil-containing lipid emulsion with a standard soya-bean emulsion reported a significantly shorter length of hospital stay with enriched PN (Wichmann et al., 2007)

11 Peri-Operative Care Peri-operative PN is recommended in malnourished patients for nutritional support when EN is not possible (Grade A) In weight losing cancer patients, 2 RCT s have shown that peri-operative PN, starting 7-10 days pre-operatively & continuing post operatively decreased complications &/or mortality (Meguid et al., 1988; Bozzetti et al., 2000) Peri-operative PN should not be used in the well - nourished (Grade A)

12 During Oncological treatment Routine use of PN during chemo/radiotherapy or combined therapy is not recommended (Grade A) In malnourished patients, or in those facing a week or longer period of starvation & EN is not feasible PN is recommended (Grade C) If patients develop severe GI toxicities from treatment, short-term PN should be considered if EN is not tolerated in order to restore gut function & minimise impact on nutritional status RCT s are not feasible in these circumstances

13 PN in BMT/HSCT PN should be reserved for those with severe mucositis (grades 3-4), ileus or intractable vomiting (Grade B) (Keefe et al., 2007) PN has be shown to be safe & feasible in patients undergoing HSCT (Iestra et al., 1999) It is widely used due to the presence of central venous access & the ease of manipulation of fluid & electrolytes (Muscaritoli et al., 2002) Need to carefully consider the increased risk of line infections when compared to standard IV fluids (Murray & Pindoria, 2008)

14 PN in BMT/HSCT (2) No clear recommendations on the timings of introducing PN day +1 for days (Raynard et al., 2002); once oral intake > 60-70% of requirements for 3/7 PN should cease when the patient is tolerating 50% + of the requirements orally / enterally (Grade C) May benefit from glutamine-supplemented PN (Grade B) Optimal dose of glutamine not established suggestion 0.6g/kg/day (Mercadal Orfila et al., 2007; Gomez Candela et al., 2006)

15 Palliative / Terminal Care In aphagic incurable cancer patients, survival maybe limited by undernutrition rather than tumour progression There are no RCT s unethical to randomize PN vs. no PN Intestinal failure long-term PN should be offered: 1) if EN is insufficient 2) expected survival >2-3/12 3) expected that PN will stabilize / improve performance status & QoL 4) patient desires this mode of nutritional support (Grade C) There is probable benefit in supporting incurable cancer patients with weight loss & reduced nutrient intake with supplemental PN (Grade B)

16 Role of Home Parenteral Nutrition (HPN) in Oncology Awareness that survival in healthy starved individuals is less than 2 months Patients with malignant obstruction of the GI tract receiving palliative care, but no nutritional support mean survival 48 days (Mercadante et al., 2007) 20-50% palliative cancer patients selected for HPN are alive at 6 months (Messing et al., 1998; Van Gossum et al., 1999; Howard, 2000; Bozzetti, 2006) Median survival 66.5 days (King et al.,1993) to 4 months (Cozzaglio et al., 1997)

17 Tumour Growth PN will supply nutrients to the tumour No evidence that this has a negative influence on outcome The need for PN should not be influenced by this, if PN is clinically indicated appropriate nutritional support should be provided

18 Any questions?