Recommendations Summary
ONC: Pancreatic Cancer: Use of Omega-3 Fatty Acid-Enhanced Medical Food Supplement or Oral Supplement 2007
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
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Recommendation(s)
ONC: Pancreatic cancer: Use of omega-3 supplements for weight loss
Use of omega-3 fatty acids to alter the prolonged acute-phase response is not recommended for pancreatic cancer patients. Consumption of an omega-3 fatty acid-enhanced medical food supplement (mean dose 2.2g daily) or an oral supplement (2g EPA daily) for pancreatic cancer patients experiencing weight loss has not been shown to reduce serum CRP concentrations after 12 weeks of EPA supplementation and there are potential drug-nutrient interactions (e.g., anti-coagulant and anti-hypertensive medications/herbal supplements).
Rating: Fair
ImperativeONC: Pancreatic cancer: Use of omega-3 supplements for anticachetic effects
Use of supplemental omega-3 fatty acids for anticachetic effects leading to changes in body composition (e.g., increase in LBM, weight gain or weight stabilization) is not recommended for patients with pancreatic cancer. EPA as a capsule or in a medical food supplement was not associated with an increase in LBM. Evidence that fish oil supplements stabilize weight or produce weight gain is inconclusive. There are potential drug-nutrient interactions (e.g., anti-coagulant and anti-hypertensive medications/herbal supplements).
Rating: Strong
Imperative-
Risks/Harms of Implementing This Recommendation
There are no potential risks or harms associated with this recommendation.
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Conditions of Application
No conditions are associated with the application of this recommendation.
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Potential Costs Associated with Application
There are no obvious costs associated with this recommendation.
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Recommendation Narrative
Use of Omega-3 supplements and weight loss
Four studies (two neutral quality time series, one neutral quality non-randomized trial, and one negative quality time series), published by the same group of industry-sponsored researchers, evaluated acute phase response as measured by serum CRP, in patients with pancreatic cancer and ongoing weight loss.
- In three studies, patients were instructed to consume an omega-3 fatty acid-enhanced MFS which provided a mean dose of 2.2g EPA daily. All 3 studies indicated no change in acute phase response over the treatment period of 7-12 weeks.
- In a neutral quality timeseries (7 weeks) (Barber, Ross, Voss, et al, 1999) which included twenty weight losing pancreatic cancer patients consented to consume two cans per day of an omega-3 fatty acid-enhanced MFS (Mean Dose Consumed: 1.9 cans, 2.09g EPA, 0.91g DHA) indicated that patients experienced weight gain compared to pre-intervention (p=0.033), an increase in LBM (p=0.0047), an increase in performance status (p=0.046), an increase in EPA (p=0.0003) and DHA (p=0.0086) in plasma phospholipids, and an increase in appetite (p=0.0095).
- In a neutral quality non-randomized trial (4 weeks) (Barber, Ross, Preston et al, 1999), 36 patients pancreatic cancer patients with ongoing weight loss consented to consume two cans per day of an omega-3 fatty acid-enhanced MFS (Mean Dose Consumed: Not reported) or supportive care alone versus 6 healthy controls found an increase in CRP in control patients (p=0.0013) with no change in CRP in fish oil group.
- They also found an increase in total negative APP in fish oil group (P=0.048), a decrease in total negative APP in control group (p=0.016), with a reduction of albumin (P=0.012), prealbumin (P=0.0048) and transferrin (p=0.038) in control patients.
- In a neutral quality timeseries (12 weeks) by Wigmore et al, 2000 of 26 patients unresectable pancreatic cancer patients consented to consume fish oil supplements daily (Mean Dose Consumed: Not reported), researchers found a decrease in rate of weight loss at 4 weeks (P=0.0009) and an increase in plasma EPA (P=0.03) and arachidonic acid (P=0.05) at 4 weeks.
- The negative quality time-series (Wigmore et al, 1996) indicated a reduction in CRP concentration and rate of weight loss after four weeks of supplementation with 2g of EPA daily (P<0.002), but not at 3 months.
Use of Omega-3 supplements for anticachetic effects
- Three positive quality RCTs (Bauer et al, 2005; Moses et al, 2004; Fearon et al, 2003) showed no difference in LBM in pancreatic cancer patients who consumed 1.5-2.1 g EPA and 0.9-1.0 DHA per day vs. the control group.
- One positive quality RCT (Fearon et al, 2003) reported an association between plasma EPA and LBM gain (P=0.04) and weight gain (P<0.01) in the group receiving an oral nutritional supplement with omega-3 fatty acids.
- Two studies, one neutral quality (Wigmore et al, 2000), one negative quality (Wigmore et al, 1996) lacked control groups, but did not observe an increase in LBM over time in patients receiving fish oil supplements.
- One neutral quality, timeseries study (Barber et al, 1999) reported an increase in LBM (P<0.01) over time; however, this study had a small sample size and no control group.
- One small neutral quality timeseries study (Wigmore et al, 2000) and one small negative quality timeseries (Wigmore et al, 1996) using EPA produced conflicting results on the effectiveness of EPA as fish oil supplement to reduce weight loss in pancreatic cancer patients.
- The dosage of EPA as a fish oil supplement and length of supplementation varied among the studies.
- In patients with pancreatic cancer, one large positive quality RCT (Fearon et al, 2003) showed no difference in effect between control and intervention groups with use of an EPA containing supplement over 8 weeks.
- One negative quality, non-placebo controlled, non-blinded longitudinal study (Barber et al, 2001), and one neutral quality time-series (Barber et al, 1999) of 2.2 g EPA in which patients consumed an EPA-containing nutritional supplement (2 cans for 2.2 g EPA per day) from three weeks to seven weeks in length did result in weight stabilization or weight gain in patients with pancreatic cancer.
- More studies with better compliance and consistent length of EPA-nutritional supplementation are needed.
The EPA and DHA in Prosure®, the MFS used in most of the studies referenced, comes from sardine oil rather than isolated EPA or DHA.
- In three studies, patients were instructed to consume an omega-3 fatty acid-enhanced MFS which provided a mean dose of 2.2g EPA daily. All 3 studies indicated no change in acute phase response over the treatment period of 7-12 weeks.
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Recommendation Strength Rationale
Recommendation ONC: Pancreatic cancer: Use of omega-3 supplements for weight loss
- Based on four studies (two neutral quality time series, one neutral quality non-randomized trial, and one negative quality time series), conclusion statement is a Grade III.
Recommendation ONC: Pancreatic cancer: Use of omega-3 supplements for anticachetic effects
- Based on six studies (three positive quality RCTs, two neutral quality time series, one negative quality time series), conclusion statement is a Grade I.
- Based on two small time series studies (one neutral quality and one negative quality), conclusion statement is a Grade III.
- Based on one large positive quality RCT, one negative quality, non-placebo controlled, non-blinded longitudinal study, and one neutral quality time-series study conclusion statement is a Grade III.
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Risks/Harms of Implementing This Recommendation
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Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Can the acute phase response in cancer patients can be altered by fatty acids?
Can lean body mass in pancreatic cancer patients be altered by fatty acids?
Is there a relationship between the use of EPA as a fish oil supplement to the reduction of weight loss associated with pancreatic cancer?
Is there a relationship between a patient's consumption of EPA-containing medical food supplement to the reduction of weight loss associated with pancreatic cancer?-
References
Barber MD, Ross JA, Preston T, Shenkin A, Fearon KC. Fish oil-enriched nutritional supplement attenuates progression of the acute-phase response in weight-losing patients with advanced pancreatic cancer. J Nutr. 1999 Jun;129(6):1120-5.
Barber MD, Ross JA, Voss AC, Tisdale MJ, Fearon KCH. The effect of an oral nutritional supplement enriched with fish oil on weight-loss in patients with pancreatic cancer. Br J Cancer. 1999;81:80-86.
Wigmore SJ, Barber MD, Ross JA, Tisdale MJ, Fearon KCH. Effect of oral eicosapentanoic acid on weight loss in patients with pancreatic cancer. Nutr Cancer. 2000;36:177-84
Wigmore SJ, Ross JA, Falconer JS, Plester CE, Tisdale MJ, Carter DC, Fearon KC. The effect of polyunsaturated fatty acids on the progress of cachexia in patients with pancreatic cancer. Nutrition. 1996;12(1 Suppl):S27-30.
Bauer J, Capra S, Battistuttab D, Davidson W, Ashe S. Compliance with nutrition prescription improves outcomes in patients with unresectable pancreatic cancer. Clinical Nutrition (2005) 24, 998 - 1004.
Fearon KCH, von Meyenfeldt MF, Moses AGW, van Geenen R, Roy A, Gouma DJ, Giacosa A, Van Gossum A, Bauer J, Barber MD, Aaronson NK, Voss AC, Tisdale MJ. 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.
Moses AWG, Slater C, Preston T, Barber MD, Fearon KCH. Reduced total energy expenditure and physical activity in cachectic patients with pancreatic cancer can be modulated by n energy and protein dense oral supplement enriched with n-3 fatty acids. Br J Can 2004;90:996-1002.
Barber MD, Fearon KCH, Tisdale MJ, McMillan DC, Ross JA. Effect of a Fish Oil-Enriched Nturitional Supplement on Metabolic Mediators in Patients with Pancreatic Cancer Cachexia. Nutr Cancer 2001;40(2);118-124. -
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
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References