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Oncology

ONC: Nutrition and the Adult Oncology Patient (2013)

The Academy's Oncology Expert Work Group reviewed articles on malnutrition screening and nutrition assessment in the oncology population in order to evaluate the available tools and provide evidence-based guidance for the oncology dietitian caring for those patients experiencing nutrition impact symptoms or those at risk for malnutrition. The Work Group chose to limit the definition of malnutrition to undernutrition, recognizing that other areas of practice have a broader interpretation that includes both under- and over-nutrition or nutrient imbalance, rather than inadequate caloric intake.
 

Poor nutritional intake and the effect of cancer or cancer treatment can lead to malnutrition. Malnutrition has been defined as "a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome."1 The consequences of malnutrition include impaired immune response, reduced muscle strength, increased fatigue, impaired wound healing, impaired psycho-social function, reduced quality of life (QoL), reduced response and tolerance to prescribed oncology treatment and may increase costs of health care and increase hospital length of stay (LOS).1 Therefore, early and timely screening and identification of malnutrition, resulting in referral for nutrition assessment and intervention by a registered dietitian nutritionist (RDN) is imperative for improved outcomes.2
 

The work group also recognizes that patients may have a cachexia syndrome in addition to malnutrition. Cachexia does not mean end of life or hospice. There are several stages of cancer cachexia: Pre-cachexia, cachexia and refractory cachexia.3 Nutrition assessment and intervention by an RDN should is most effective if provided in the stages of pre-cachexia and cachexia. The metabolic response to cancer is heterogeneous, so it is important to intervene and manipulate the factors that are behavior-related, to address the direct causes of decreased intake (obstruction, dysphagia) and address the secondary causes (depression, fatigue, pain, gastrointestinal function) because “symptom management alone can improve survival in patients with advanced cancer.”4 
 

In cancer-specific pre-cachexia, early clinical and metabolic signs such as loss of appetite and impaired glucose tolerance can precede substantial involuntary weight loss (i.e., up to 5%). The risk of progression is variable and depends on cancer type, stage, presence of systemic inflammation, low food intake and lack of response to anti-cancer therapy.3

  Cancer cachexia A multi-factorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. The pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism.3 

  Pre-cachexia, in general ⇒ Defined by the presence of all of the following criteria:5

  • Underlying chronic disease
  • Unintentional weight loss of up to 5% usual body weight during the last six months
  • Chronic or recurrent systemic inflammatory response
  • Anorexia or anorexia-related symptoms.

  Pre-cachexia, in cancer ⇒ Characterized by early clinical and metabolic signs such as loss of appetite and impaired glucose tolerance; can precede substantial involuntary weight loss (i.e., up to 5%). The risk of progression is variable and depends on cancer type, stage, presence of systemic inflammation, low food intake and lack of response to anti-cancer therapy.3 

  Refractory cachexia⇒ May be a result of very advanced cancer (pre-terminal) or the presence of rapidly progressive cancer unresponsive to anti-cancer therapy. This stage is associated with active catabolism or the presence of factors that make active management of weight loss no longer possible or appropriate. Refractory cachexia is characterized by a low performance score (e.g., WHO grade 3 or 4) and a life expectancy of less than three months.3


There are additional articles on cancer cachexia and inflammatory response, but this was not part of the scope of this question.

See Screening Adult Oncology Patients for Malnutrition Risk and Nutrition Assessment for Adult Oncology Patients.

 


References

  1. Stratton RJ, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients and inpatients: Prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr. 2004; 92(5): 799-808.
  2. Bozzetti F, Mariani L, Lo Vullo S; SCRINIO Working Group, Amerio ML, Biffi R, Caccialanza G, Capuano G, Correja I, Cozzaglio L, Di Leo A, Di Cosmo L, Finocchiaro C, Gavazzi C, Giannoni A, Magnanini P, Mantovani G, Pellegrini M, Rovera L, Sandri G, Tinivella M, Vigevani E. The nutritional risk in oncology: a study of 1,453 cancer outpatients. Support Care Cancer. 2012 Aug; 20 (8): 1,919-1,928. doi: 10.1007/s00520-012-1387-x. Erratum in: Support Care Cancer. 2012 Aug; 20 (8): 1,929. Capuano, Giovanni [corrected to Capuano, Giorgio]. PMID: 22314972.
  3. Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, Jatoi A, Loprinzi C, MacDonald N, Mantovani G, Davis M, Muscaritoli M, Ottery F, Radbruch L, Ravasco P, Walsh D, Wilcock A, Kaasa S, Baracos VE. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011 May; 12 (5): 489-495. Epub 2011 Feb 4. Review. PMID: 21296615.
  4. Fearon KC. Cancer cachexia and fat-muscle physiology. N Engl J Med. 2011 Aug 11; 365 (6): 565-567. doi: 10.1056/NEJMcibr1106880. No abstract available. PMID: 21830971.
  5. Muscaritoli M, Anker SD, Argil├ęs J, Aversa Z, Bauer JM, Biolo G, Boirie Y, Bosaeus I, Cederholm T, Costelli P, Fearon KC, Laviano A, Maggio M, Rossi Fanelli F, Schneider SM, Schols A, Sieber CC.Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics". Clin Nutr. 2010 Apr; 29 (2): 154-159. Epub 2010 Jan 8. PMID: 20060626.