Treatment of malnutrition in cancer

The goal of nutritional treatment with cancer is o improve function and outcome by:⁵

• Preventing and treating malnutrition
• Enhancing anti-tumour treatment effects
• Reducing adverse effects of anti-tumour therapies
• Improving quality of life

Much research exists to support the role of enteral nutrition in the treatment of malnutrition and weight loss in oncology patients.

• A systematic review showed that ONS significantly increased total energy intake in patients undergoing radiotherapy and improved protein intake.⁶
• The European Society for Parenteral and Enteral Nutrition (ESPEN) have concluded that ONS can be used in combination with dietary advice to prevent therapy-associated weight loss and interruption of therapy in non-surgical oncology patients.⁵
• In patients with pancreatic cancer an eicosapentanoeic acid (EPA) enriched ONS has been shown to increase energy and protein intake and to improve body mass.⁷
• Research suggests that, when taken appropriately, voluntary food intake is not substantially reduced among patients taking ONS.³
• A 50% reduction in complications and improved patient outcomes has been observed among cancer patients who used medical nutrition preoperatively.⁸
• Cancer patients who are initiated on ONS have, on average, a shorter hospital stay post-operatively than those who are not prescribed ONS, resulting in reduced healthcare costs.⁹

When should nutrition support be commenced in cancer patients?

ESPEN guidelines on nutrition in cancer state that enteral nutrition in the form of oral nutritional supplements or tube feeding should be started if malnutrition already exists or if food intake is markedly reduced for more than 7-10 days.⁵

As a guideline, malnutrition exists if a patient has:

• A Body Mass Index (BMI) less than 18.5
• Lost more than 10% of body weight in the past 3 to 6 months without trying
• A BMI less than 20 and has lost more than 5% of body weight over the past 3 to 6 months without trying.

What ONS are most appropriate for use in patients with cancer?

It is difficult to give exact guidance on which ONS is most suitable for cancer patients, as requirements will be determined by a range of factors including:

• Type of cancer (tumour site/stage/prognosis)
• Appetite/ability to tolerate large volumes (patients often experience early fullness and may only tolerate a "little and often" approach)
• Intake of normal food (are they eating quite well and only need an energy boost, or has their intake of normal foods declined significantly?)
• Taste preference (patients may experience taste changes associated with their treatment)
• Age of the patient

References

1. Pressoir M et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010; 102(6): 966-71.
2. DeWys WD et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Am J Med. 1980; 69: 491-497.
3. Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford: CABI Publishing; 2003.
4. Andreyev HJN et al. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998; 34: 503-509.
5. Arends J et al. ESPEN Guidelines on enteral nutrition: non-surgical oncology. Clin Nutr 2006; 25: 245-259.
6. Elia M et al. Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: a systematic review. Int J Oncol 2006; 28: 5–23.
7. Fearon KCH et al. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut 2003; 52: 1479-86.
8. Kabata et al. Preoperative nutritional support in cancer patients with no clinical signs of malnutrition – prospective randomised control trial. Support Cancer Care 2015; 23(2): 365-70.
9. Manasek et al. Perioperative oral nutritional support in colorectal cancer patients may improve clinical and health economics outcomes. Ann Oncol 2015; 26(suppl 4): 1-100.