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
Main points of reference: Bozzetti et al., (2009) ESPEN Guidelines on Parenteral Nutrition: Non-Surgical Oncology Clinical Nutrition 28:445-454 454 Braga et al., (2009) ESPEN Guidelines on Parenteral Nutrition: Surgery Clinical Nutrition 28:378-386 386
Why do we use PN in Oncology?
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
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)
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
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)
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
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)
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)
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)
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
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)
PN in BMT/HSCT (2) No clear recommendations on the timings of introducing PN day +1 for 15-20 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)
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)
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)
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
Any questions?