Nutrition Support Improves Patient Outcomes, Treatment Tolerance and Admission Characteristics in Oesophageal Cancer

Abstract

Aims

Patients with oesophageal cancer undergoing chemoradiation with curative intent are at high risk of malnutrition and its complications, including increased side effects of treatment. We have developed a nutrition pathway (NP), involving the early then periodic nutrition assessment of all patients presenting to the multidisciplinary oesophageal clinic who were planned to receive definitive chemoradiation.

Materials and methods

Patients were assessed as at ‘low’, ‘moderate’ or ‘severe’ nutrition risk, and were provided with appropriate nutrition intervention ranging from preventative advice (low risk), oral nutrition support (moderate risk) to enteral feeding (severe risk). Outcomes for 24 patients treated before implementation of the NP were compared with those of 24 patients treated using the NP.

Results

Patients managed using the NP experienced less weight loss (mean weight change −4.2 kg ±6.4 cf. −8.9 kg ±5.9, P = 0.03), greater radiotherapy completion rates (92% cf. 50%, P = 0.001), fewer patients had an unplanned hospital admission (46% cf. 75%, P = 0.04), and those that did had a shorter length of stay (3.2 days ±5.4 cf. 13.5 days ±14.1, P = 0.002).

Conclusion

Early and regular nutrition assessment/intervention and a multidisciplinary approach to nutrition care results in improved treatment tolerance for patients with oesophageal cancer receiving chemoradiation.

Introduction

Patients with cancer of the oesophagus are often malnourished at presentation 1, 2. Dysphagia has been found to be the primary symptom in more than 90% of patients [3], and this has an adverse effect on nutritional status.

Treatments for oesophageal cancer are commonly multimodal, incorporating polychemotherapy, radiotherapy and surgery 4, 5. These treatments frequently cause or exacerbate poor nutritional status through commonly experienced side effects, such as nausea, vomiting, anorexia, lethargy, diarrhoea, oesophagitis and dysphagia 6, 7. Malnutrition has been found to negatively affect response to therapy and survival in oncology patients 8, 9. It increases the length of hospital stays [8] and is associated with higher health-care costs, slower healing, increased complications and higher mortality rates 10, 11.

Over recent years, a growing body of literature has examined the role of aggressive nutrition support, through percutaneous endoscopic gastrostomies (PEGs), aimed at correcting or preventing malnutrition during treatment for head and neck, and oesophageal malignancies.

Studies have shown that PEGs are a feasible, safe method of delivering nutrition support to this group of patients 12, 13, 14, 15, 16, 17, 18. Some studies have focused on identifying indicators to target those patients who require this type of aggressive nutrition support 14, 19. Other studies demonstrate nutritional status and rate of hospitalisation benefits when patients are supported in this manner 14, 15, 16, 20, 21, 22. Margolis et al. [15] showed PEG placement before treatment to be significantly related to attainment of target doses of chemoradiation and survival at 1 year.

The Newcastle Mater Misericordiae Hospital (NMMH) is the tertiary referral centre for oncology patients in the Hunter New England Area Health Service. Before 1996, the nutrition management of patients receiving definitive chemoradiation for oesophageal cancer was reactive and often occurred late in the treatment period. Debilitating weight loss and frequent unplanned hospital admissions were a significant management problem.

In 1996, a newly formed multidisciplinary oesophageal clinic, comprising medical and radiation oncologists, a thoracic surgeon and a dietitian, devised a nutrition pathway (NP) to improve the nutritional management of patients with oesophageal cancer. The NP was developed by the investigators on the basis of their clinical experience and a literature review 8, 9, 11, 23, 24, 25. Levy et al. [24] made a number of recommendations based on the work of Shils [26] on nutritional support for oncology patients, including (1) a therapeutic diet plan that analyses factors contributing to nutrition depletion; (2) early and periodic assessment of nutritional status; (3) nutrition support, initiated early when indicated; (4) optimal nutrition care requires a multidisciplinary approach.

More recently, these recommendations have been incorporated into Medical Nutrition Therapy Protocols [27]. The NP also incorporated these recommendations into a specific pathway designed to facilitate the challenging nutritional management of patients with oesophageal cancer receiving definitive chemoradiation (Fig. 1).

The NP promoted a proactive approach to nutrition intervention, ensuring that early and aggressive dietetic intervention occurred. The NP also provided management guidelines for the initiation and maintenance of nutrition support throughout the treatment course. We report here a retrospective evaluation of the NP. The outcomes studied were weight status, percentage of planned treatment delivered, number of unplanned hospital admissions (UHA) and length of hospital stay during treatment.