Oral Nutrition Support in Cancer- Does it help?

Transcription

1 Oral Nutrition Support in Cancer- Does it help? By Artika Datta Specialist Dietitian Head and Neck Oncology and Home Enteral Nutrition Addenbrookes Hospital, Cambridge

2 Why nutrition? Agenda Objectives of nutrition support Assessment Oral nutrition supplements what is the evidence Novel supplements Summary References

3 Malnutrition Affects 40-80% of cancer patients Prevalance factors 46-61% of patients with lung cancer and mesothelioma experience weight loss before diagnosis and treatment (Brown and Radke, 1998) Approx 80% of patients in advanced stages have cancer cachexia (Goo and Hill, 2003)

4 Why Nutrition? Up to 85% of patient with GI tumours are malnourished (Stratton et al., 2003) Head and Neck Cancer the incidence can range from 40-58% (Connally, 2004; Grobbelaar et al., 2004) Risk increases with multi-modality treatments 75-80% of patients with H&N cancer have significant weight loss (>10% of BW) during treatment period (Hammerlid et al., 1998; Lopez et.al., 1994)

5 Consequences BMI of <18.5 kg/m2 and/or unintentional weight loss of > 10% (over the preceding 3 mths) associated with increased risk of perioperative complications (NICE, 2006) Reduced QOL Increased length of hospital stay Increased risk of death Up to 20% of cancer patients die of the effects of malnutrition rather than of the malignancy itself (Ottery, 2004)

6 Objectives of Nutrition Support To maintain physical strength and optimise status within the confines of the disease during treatment and in many cases for several months post discharge prevent or correct nutritional depletion reduce the nutrition-related side effects and complications Improve tolerance of, and response to cancer treatment maintain strength and energy maintain quality of life Reduce period of hospital stay

7 Nutrition Screening Early identification and intervention can Promote recovery Improve prognosis Cost effective Reduces complication rates Reduces length of hospital stay

8 Assessment Subjective global assessment (SGA) simple, reliable and inexpensive Assesses nutritional status based on the features of: a history physical examination

9 Oral Nutrition Supplements A simple, non-invasive method of increasing nutrient intake Most ONS are nutritionally complete Majority contain kcal/ml, but also available as concentrated feed (2kcal/ml) Protein content varies from 4 to 10g/100ml Available in liquid form, soups, powders, and other consistencies such as puddings Compliance is dependent on appetite and taste

10 Oral Nutrition Supplements Appropriate prescription Studies limited in cancer patients May improve energy and protein intake ONS significantly increased dietary intake (381 kcal/day, 95% CI 193 to 569 in 3 RCTs) in patients undergoing radiotherapy (Elia M et al, 2006)

11 Impact on Nutrition Outcome 75 patients with Head and Neck cancer Referred for Radiotherapy (RT) Randomised to: Group 1 (n=25) patients who received dietary counseling with regular foods Group 2 (n = 25), patients who maintained usual diet plus supplements Group 3 (n = 25), patients who maintained intake ad lib Ravasco et.al, 2005 Head and Neck, 27,

12 Methods and study design Inclusion criteria : Referral for RT and absence of renal disease and/or diabetes mellitus Study design: Total Patients Men Women Mean Age Stage I/II Stage III/IV /- 11 yrs 30 Patients 45 Patients

13 Methods and study design ONS used were ready-to-use, high protein, energy-dense liquid formulations Each 200ml can provided 20 g of protein and 200 kcal Amount of ONS 2 cans/d, which covered the calculated requirement

14 Study measures Evaluated the following at baseline, at the end of RT, and at 3 months: Nutritional intake Nutritional status QOL

15 Results: Nutritional Intake

16 Results: Nutritional Status

17 Results: QOL At end of RT Group 1 all function scores improved and proportional to an increase in Energy and Protein intake Group 2 all function scores improved but proportional to an increase in Protein intake Group 3 all function scores worsened

18 Results: QOL At 3 months follow up Group 1 - all maintained or improved overall QOL Group 2 all maintained or experienced decline in QOL Group 3 function scores further deteriorated

19 Discussion Nutrition intervention was central ONS not as effective as dietary counselling Impact of ONS on energy intake short lived

20 Novel Supplements n-3 fatty acids arginine, glutamine, nucliec acids, and antioxidants Immmuno-modulatory effects Perioperative supplementation with arginine, ribonucleic acids and n- fatty acid resulted in fewer wound infections than control group in patients with laryngeal and oral cancers ( Casas-Rodera P et al 2008)

21 Novel Supplements ONS containing n-3 PUFA beneficially affected nutritional status of patients with Stage III Non- Small Cell Lung Cancer during Multimodality treatment (Van der Meij Bs et al, 2010) Limited evidence to support the use of fish oils for management of cachexia Fearon KC et al (2006) in their double blind, placebo controlled trial of 518 weight-losing patients with advanced gastrointestinal or lung cancer showed no statistically significant benefit from single agent EPA (2g or 4g) in treatment of cancer cachexia

22 A Cochrane review 5 trials (involving 587 participants) met the inclusion criteria 3 trials compared EPA at different doses with placebo 2 two trials compared different doses of EPA with an active matched control (but without EPA) Outcomes measured Primary outcomes- weight gain, body composition, median survival Secondary outcome - functional or performance status, improvement in quality of life, energy expenditure, reduction in fatigue, nutritional status, compliance rates, side effects, adverse events Dewey et.al (2007) Cochrane Database Syst Rev, 24(1)

23 Conclusion Insufficient data. No evidence that EPA improves symptoms Need to conduct further research

24 Summary Little or no beneficial effects of ONS in terms of weight gain Some evidence that ONS can increase total energy intake and improves QOL indices Inconsistent results on the effects of EPA ONS prescription Dietary counseling

25 References Brown JK and Radke KJ (1998). Nutritional assessment, intervention and evaluation of weight loss in patients with non small cell lung cancer. Oncology Nursing forum, 25, Casas-Rodera P, Gomez-Candela C, Benitez S, et al (2008) Immonuenhanced enteral nutrition formulas in head and neck cancer surgery: a prospective, randomised clinical trial. Nutr Hosp, 23(2), Connally, C (2004). Head and Neck cancer: preventing malnutriiton. World of Irish Nursing, 12 (8), Del Fabbro E, Baracos V, Denmark-Wahnefried W, Bowling T, Hopkinson J and Bruera E (2010) Nutrition and the Cancer Patient: Oxford University press Inc., New York Dewey A et.al (2007) Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia. Cochrane, January 2007 Elia, M. A.E. Van Bokhorst-de van der Schueren, J. Garvey, A. Goedhart, K. Lundholm, G. Nitenberg, R. J. Stratton (2006) Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: A systematic review. International Journal of Oncology, 28: 5-23 Fearon KC, Barber MD, Moses AG et al (2006) double-blind, placebo-controlled, randomised study of eicosapentaenoic acid diester in patients with cancer cachexia. Journal of Clinical Oncology, 24(21), Goo, C and Hill, D (2003). Nutrition Support in Cancer. Clinical Nutrition Update, 8, 3-5. Grobbelaar, EJ, Owen S, Torrance AD and Wilson JA (2004). Nutritional challenges in head and neck cancer. Clinicla Otolaryngology and Allied Sciences, 29 (4), Hammerlid E, Wirblad B, Sandin C, Mercke C, Edstrom S, Kaasa S, Sullivan M and Westin (1998). Malnutrition and food intake in relation to Quality of life in Head and Neck cancer patients. Head &Neck, 20(6),

26 References Kern KA & Norton JA (1988): Cancer cachexia. J. Parenter. Enteral Nutr. 12, Lopez, MJ, Robinbson P, Madden T and Highbarger, T(1994). Nutritional support and prognosis in patients with head and neck cancer. Journal of Surgical Oncology, 55 (1), Massad LS, Vogler G, Herzog TJ, Mutch DG (1993). Correlates of length of stay in gynecologic oncology patients undergoing inpatient surgery. Gynecol Oncol 51, Obermair A, Hagenauer S, Tamandl D, Clayton RD, Nicklin JL, Perrin LC et al. (2001). Safety and efficacy of low anterior en bloc resection as part of cytoreductive surgery for patients with ovarian cancer. Gynecol Oncol 83, Ollenschlager G, Viell B, Thomas W, Konkol K & Burger B (1991): Tumour anorexia: causes, assessment, treatment. Rec. Results Cancer Res. 121, Ottery FD. Cancer cachexia: prevention, early diagnosis, and management.cancer Pract 1994;2: Shike M (1996): Nutrition therapy for the cancer patient. Hematol. Oncol. Clin. N. Am. 10, Stratton RJ, Green CJ, and Elia, M (2003). Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing. Van der Meij BS, Langius JA, Smit EF, Spreeuwenberg MD et al (2010) Oral Nutritional Supplements containing (n-3) Polyunsaturated fatty acids affect the nutritional status of patients with stage III Non-Small Cell Lung Cancer during Multimodality Treatment. Journal of Nutrition, Aug 25 (Epub ahead of print)