ESPEN guidelines on nutrition in cancer patients

Abstract

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Impact of different palliative systemic treatments on skeletal muscle mass in metastatic colorectal cancer patients

“…In addition, we found that the changes in SMM are not reflected by the observed changes in body weight. This is in agreement with previous studies that state that body weight and BMI are not appropriate tools to understand the effect of systemic treatment on body composition 4, 6…”

“…The presence of malnutrition and weight loss in mCRC patients (which are present in up to 60% of patients) have been identified as risk factors for adverse events during these treatments and may limit the outcome of these treatments 2, 3. The most devastating syndrome in patients with cancer‐related malnutrition is cancer cachexia, which is defined as a progressive multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (SMM), with or without loss of fat, and which cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment 4, 5. Cancer cachexia results from reduced food intake caused by a range of symptoms like anorexia, gastro‐intestinal symptoms, pain, and fatigue, occurring in combination with systemic inflammation and abnormal metabolism 4.…”

“…The most devastating syndrome in patients with cancer‐related malnutrition is cancer cachexia, which is defined as a progressive multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (SMM), with or without loss of fat, and which cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment 4, 5. Cancer cachexia results from reduced food intake caused by a range of symptoms like anorexia, gastro‐intestinal symptoms, pain, and fatigue, occurring in combination with systemic inflammation and abnormal metabolism 4. The most relevant phenotypic feature of cancer cachexia is low SMM (sarcopenia), as this relates to lower quality of life, increased dose limiting toxicities, and reduced overall survival 4, 6, 7.…”

“…In recent years, the importance of early recognition and prevention of cancer cachexia by detecting underlying SMM loss has received more attention 4. By the use of advanced imaging techniques for disease staging or response evaluation in standard oncology practice, such as computed tomography (CT) scanning or magnetic resonance imaging, reliable and precise quantification of SMM is possible, without any additional patient burden or costs 8, 9, 10.…”

Project "Eat well, live healthy": preparation of three menus to ensure good nutritional support for special disease conditions

“…Cancer is among the leading causes of morbidity and mortality throughout the world, and it is expected that the number of new cases will increase significantly in the next decades 1,2,3,4 . In Portugal, the incidence rate of new cases of malignant tumors has increased regularly, recording between 2009 and 2010 a 4% increase of cases 1 .…”