Elsevier

Clinical Nutrition

Volume 26, Issue 1, February 2007, Pages 7-15
Clinical Nutrition

REVIEW
Cancer wasting and quality of life react to early individualized nutritional counselling!

https://doi.org/10.1016/j.clnu.2006.10.005Get rights and content

Summary

To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients’ expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients’ quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients’ outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.

Introduction

Cancer-related weight loss is known to worsen patients well-being,1, 2 tolerance to antineoplastic therapies3 and prognosis.4, 5 Specifically, weight loss seems to reduce immunological competence6 and resistance to infection,7, 8 enhances susceptibility to postoperative complications,5, 9, 10 and increases disability and overall cost of care.11

Although a few studies were undertaken in the early 20th century,12, 13, 14 malnutrition remained a bewildering syndrome even in relatively recent publications. Indeed, estimates of the prevalence of malnutrition in cancer patients range from 8% to 84%15 apparently associated with the cancer site, e.g. 80% in patients with gastrointestinal cancer16, 17 and 70% in patients with head and neck cancer.18 Despite the fact that nutritional deterioration has been associated with patients’ functional impairment,19 neither potential interactions between cancer location and stage, treatments, nutrition, morbidity and quality of life (QoL) nor the impact of individualized nutritional counselling on patients’ nutritional, clinical and QoL outcomes have ever been thoroughly explored.20, 21 In fact, there is remarkably little information about the effect of oral nutrition on functional outcome measures and QoL.15 Innovative and consistent evidence to support integrated nutritional counselling as a major topic in oncology will be illustrated in this overview, which results from the collision of data from prospective studies in cancer patients conducted by our group.22, 23, 24, 25, 26

Section snippets

Nutritional deterioration, intake deficits and tumour burden

In order to tackle nutritional deterioration, gathering objective data on nutritional status and its evolution throughout the disease course is an absolute necessity. There are indeed studies reporting cancer-related weight loss as the most frequent presenting symptom27 or potentially associated with advanced disease.28 Nonetheless, previous data have been inconsistent regarding nutritional status assessment and cancer/treatment-related variables even when addressing similar cancer locations.29

Nutrition: a key determinant of cancer patients QoL

Multifactorial cancer-related malnutrition22 is also swayed by experienced symptoms, e.g. anorexia, taste changes, odynophagia, dysphagia, nausea, vomiting, diarrhoea, often subsequent to antineoplastic therapies, may further compromise nutrition and functional ability.48, 49, 50, 51 Thus, the interaction between the reported symptoms and/or disease/treatment-related factors, as well as nutritional status and intake, add up to a complex combination potentially capable of dictating patients’ QoL.

Nutrition intervention improves patients outcomes and QoL

Cancer location and its progression are central to nutritional decline.22 Notwithstanding, nutritional deterioration and intake deficits were shown to be the 2nd most relevant factor (Table 1).22, 24 Our studies were conducted in outpatients referred for radiotherapy and radiation injury is known to aggravate symptoms with nutritional consequences.61, 62 Thus, such patients were suitable to test whether nutritional therapy would influence outcomes. Therefore, a pilot prospective intervention

Conclusions

Nutritional deterioration in cancer is a highly complex end-result of multiple interactions which are most likely individual to each patient and the tumour.22, 62, 74, 75 In what concerns nutrition and its impact on the patients’ QoL, cancer location and stage are the major determinants; nutritional aspects are equally important for QoL functional scores, in which the impact of nutritional deterioration combined with deficiencies in nutritional intake may be from a clinical perspective as

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