Oral Nutrition Support in Cancer- Does it help?

By Artika Datta Specialist Dietitian

Head and Neck Oncology and Home Enteral Nutrition

Addenbrookes Hospital, Cambridge

Email: artika.datta@addenbrookes.nhs.uk

Agenda

Why nutrition? Objectives of nutrition support Assessment Oral nutrition supplements – what is the

evidence Novel supplements Summary References

Malnutrition

Affects 40-80% of cancer patients

Prevalance factors

46- 61% of patients with lung cancer and

mesothelioma experience weight loss before

diagnosis and treatment (Brown and Radke, 1998)

Approx 80% of patients in advanced stages

have cancer cachexia (Goo and Hill, 2003)

Why Nutrition ?

Up to 85% of patient with GI tumours are

malnourished (Stratton et al., 2003)

Head and Neck Cancer – the incidence can range from

40 - 58% (Connally, 2004; Grobbelaar et al., 2004)

Risk increases with multi-modality treatments

75-80% of patients with H&N cancer have

significant weight loss (>10% of BW) during treatment

period (Hammerlid et al., 1998; Lopez et.al., 1994)

Consequences

BMI of <18.5 kg/m2 and/or unintentional weight loss of > 10% (over the preceding 3 mths) associated with increased risk of perioperative complications (NICE, 2006)

Reduced QOL

Increased length of hospital stay

Increased risk of death

Up to 20% of cancer patients die of the effects of malnutrition rather than of the malignancy itself (Ottery, 2004)

Objectives of Nutrition Support

To maintain physical strength and optimise status within the confines of the disease during treatment and in many cases for

several months post discharge

prevent or correct nutritional depletion reduce the nutrition-related side effects and

complications Improve tolerance of, and response to cancer

treatment maintain strength and energy maintain quality of life Reduce period of hospital stay

Nutrition Screening

Early identification and intervention can

Promote recovery

Improve prognosis

Cost effective

Reduces complication rates

Reduces length of hospital stay

Assessment

Subjective global assessment (SGA) – simple, reliable and inexpensive

Assesses nutritional status based on the features of:

a history

physical examination

Oral Nutrition Supplements

A simple, non-invasive method of increasing

nutrient intake

Most ONS are nutritionally complete

Majority contain 1-1.5 kcal/ml, but also

available as ‘concentrated’ feed (2kcal/ml)

Protein content varies from 4 to 10g/100ml

Available in liquid form, soups, powders, and

other consistencies such as puddings

Compliance is dependent on appetite and taste

Oral Nutrition Supplements

Appropriate prescription

Studies limited in cancer patients

May improve energy and protein intake

ONS significantly increased dietary

intake (381 kcal/day, 95% CI 193 to 569

in 3 RCTs) in patients undergoing

radiotherapy (Elia M et al, 2006)

Impact on Nutrition Outcome

75 patients with Head and Neck cancer Referred for Radiotherapy (RT) Randomised to:

Group 1 (n=25) patients who received dietary counseling with regular foods

Group 2 (n = 25), patients who maintained usual diet plus supplements

Group 3 (n = 25), patients who maintained intake ad lib

Ravasco et.al, 2005 Head and Neck, 27, 659-68.

Methods and study design

Inclusion criteria : Referral for RT and absence of renal disease and/or diabetes mellitus

Study design:

Total Patients

Men Women Mean Age

Stage I/II

Stage III/IV

75 60 15 60+/- 11

yrs 30

Patients 45

Patients

Methods and study design

ONS used were ready-to-use, high protein,

energy-dense liquid formulations

Each 200ml can provided 20 g of protein and

200 kcal

Amount of ONS – 2 cans/d, which covered the

calculated requirement

Study measures

Evaluated the following at baseline, at the

end of RT, and at 3 months:

Nutritional intake

Nutritional status

QOL

Results: Nutritional Intake

Results: Nutritional Status

Results: QOL

At end of RT

Group 1 – all function scores improved and

proportional to an increase in Energy and

Protein intake

Group 2 – all function scores improved but

proportional to an increase in Protein intake

Group 3 – all function scores worsened

Results: QOL

At 3 months follow up

Group 1 - all maintained or improved overall

QOL

Group 2 – all maintained or experienced

decline in QOL

Group 3 – function scores further

deteriorated

Discussion

Nutrition intervention was central

ONS not as effective as dietary counselling

Impact of ONS on energy intake short lived

Novel Supplements

n-3 fatty acids arginine, glutamine, nucliec

acids, and antioxidants

Immmuno-modulatory effects

Perioperative supplementation with arginine,

ribonucleic acids and n- fatty acid resulted in

fewer wound infections than control group in

patients with laryngeal and oral cancers

( Casas-Rodera P et al 2008)

Novel Supplements

ONS containing n-3 PUFA beneficially affected nutritional status of patients with Stage III Non-Small Cell Lung Cancer during Multimodality treatment (Van der Meij Bs et al, 2010)

Limited evidence to support the use of fish oils for

management of cachexia

Fearon KC et al (2006) in their double blind, placebo

controlled trial of 518 weight-losing patients with

advanced gastrointestinal or lung cancer showed no

statistically significant benefit from single agent

EPA (2g or 4g) in treatment of cancer cachexia

A Cochrane review

5 trials (involving 587 participants) met the inclusion criteria 3 trials compared EPA at different doses with

placebo 2 two trials compared different doses of EPA with

an active matched control (but without EPA) Outcomes measured

Primary outcomes- weight gain, body composition, median survival

Secondary outcome - functional or performance status, improvement in quality of life, energy expenditure, reduction in fatigue, nutritional status, compliance rates, side effects, adverse events

Dewey et.al (2007) Cochrane Database Syst Rev, 24(1)

Conclusion

Insufficient data.

No evidence that EPA improves symptoms

Need to conduct further research

Summary

Little or no beneficial effects of ONS in

terms of weight gain

Some evidence that ONS can increase total

energy intake and improves QOL indices

Inconsistent results on the effects of EPA

ONS prescription

Dietary counseling

References

Brown JK and Radke KJ (1998). Nutritional assessment, intervention and evaluation of weight loss in patients with non small cell lung cancer. Oncology Nursing forum, 25, 547-553.

Casas-Rodera P, Gomez-Candela C, Benitez S, et al (2008) Immonuenhanced enteral nutrition formulas in head and neck cancer surgery: a prospective, randomised clinical trial. Nutr Hosp, 23(2), 105-10.

Connally, C (2004). Head and Neck cancer: preventing malnutriiton. World of Irish Nursing, 12 (8), 27-28.

Del Fabbro E, Baracos V, Denmark-Wahnefried W, Bowling T, Hopkinson J and Bruera E (2010) Nutrition and the Cancer Patient: Oxford University press Inc., New York

Dewey A et.al (2007) Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia. Cochrane, January 2007

Elia, M. A.E. Van Bokhorst-de van der Schueren, J. Garvey, A. Goedhart, K. Lundholm, G. Nitenberg, R. J. Stratton (2006) Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: A systematic review. International Journal of Oncology, 28: 5-23

Fearon KC, Barber MD, Moses AG et al (2006) double-blind, placebo-controlled, randomised study of eicosapentaenoic acid diester in patients with cancer cachexia. Journal of Clinical Oncology, 24(21), 3401-7.

Goo, C and Hill, D (2003). Nutrition Support in Cancer. Clinical Nutrition Update, 8, 3-5. Grobbelaar, EJ, Owen S, Torrance AD and Wilson JA (2004). Nutritional challenges in head

and neck cancer. Clinicla Otolaryngology and Allied Sciences, 29 (4), 307-313. Hammerlid E, Wirblad B, Sandin C, Mercke C, Edstrom S, Kaasa S, Sullivan M and Westin

(1998). Malnutrition and food intake in relation to Quality of life in Head and Neck cancer patients. Head &Neck, 20(6), 540-548.

References

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Supplements containing (n-3) Polyunsaturated fatty acids affect the nutritional status of patients with stage III Non-Small Cell Lung Cancer during Multimodality Treatment. Journal of Nutrition, Aug 25 (Epub ahead of print)