Original articleNutrition Support Improves Patient Outcomes, Treatment Tolerance and Admission Characteristics in Oesophageal Cancer
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.
Section snippets
Methods
Eligible patients were planned to receive definitive, synchronous chemoradiation for oesophageal cancer over the study period (1990–2001). Most patients were entered on the Trans Radiation Oncology Group (TROG) trials 89-04, 96-02 or 98-06. Previously untreated patients were planned to receive the chemotherapy regimen cisplatin 80 mg/m2 by IV infusion on day 1 and day 21 (or day 28) plus 5-fluorouracil 800 mg/m2 by continuous infusion on days 2–5 and days 22–25 (or days 29–32). Patients were
Results
The control group was well matched with the NP group for age, tumour position/length, weight loss and dysphagia at initial presentation to the oesophageal cancer clinic (Table 1). The number of patients in each nutrition risk category was similar for the two groups.
There were, however, significant differences between the groups in timing and indication for dietetic interventions that reflected the operation of the Pathway (Table 2).
Automatic referral as a reason for intervention at presentation
Discussion
This study shows that nutrition intervention delivered according to the NP had a significant positive affect on nutritional status and treatment tolerance during definitive chemoradiation for oesophageal cancer.
Patients in the NP group lost less weight throughout the treatment period, were less likely to have a UHA and had a shorter hospital stay if they did have a UHA. The NP group also received significantly more of the planned radiotherapy dose.
Aggressive nutrition support, often involving
Conclusion
Implementation of this NP has been associated with improved clinical outcomes, including decreased weight loss, number of UHAs and length of stay during the treatment course, and a higher tolerance of planned treatment. We recommend that all patients with oesophageal cancer planned for definitive chemoradiation receive a proactive nutritional assessment by a specialist oncology dietitian on initial presentation, and appropriate nutritional support and follow-up within the multidisciplinary team.
Acknowledgements
L. Francis and B. Aldrich (Department of Radiation Oncology, NMMH) for assistance with the Statistics Package, SPSS 10.0; J. Kilmurray (Department of Radiation Oncology, NMMH) for technical assistance; F. McLean (Department of Dietetics, Gosford Hospital) for assistance with the manuscript; M. Diamantes for assistance with the manuscript. This research was supported by a Margaret Mitchell Research Grant.
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