Nutrition in cancer patients   

Why do cancer patients loose weight? Is weight loss important to cancer patients? Evidence: does nutrition support help cancer patients?

Jens Kondrup Professor, senior physician, dr med sci Honoraria and grants from Danish government, Arla dairy company, Danish Meat Association, Fresenius-Kabi, Nutricia, Nestle, Skaroe ice-cream

Rigshospitalet University of Copenhagen

Cytokines and weight loss in pancreatic cancer Falconer et al. 1994. Ann Surg 219: 325-31. editorial: Mullen 1994. Ann Surg 219: 323-4

Pos Acute Phase proteins

Neg Acute Phase Proteins

CRP, mg/l

72

5% wt loss, %

Benign (524)

54.9  0.6

18.8  0.2

6.6  0.3

7.7  0.1

7.9  0.1

55.8  0.6

4.4

5.3

Malignant (459)

60.4  0.7

20.3  0.2

9.5  0.4

7.9  0.1

7.3  0.1

60.8  0.7

6.8

3.7

 



Why do cancer patients loose weight? Is weight loss important to cancer patients? Evidence: does nutrition support help cancer patients?

Associations with  5% wt loss within 3 months % with YES

no loss, or 1 km Difficulty in walking 100 m? Difficulty in bathing or dressing? Had fever in last month? BW is too low? Kondrup et al 2001 unpublished

26 46 14 13 59 46 35 10 12 7 8

5% wt loss N=292

P

36 * 74 * 57 * 57 * 79 * 63 * 56 * 25 * 25 * 20 * 45 * * P = 3

< 3 >= 3

< 3 >= 3

< 3 >= 3

< 3 >= 3

< 3 >= 3

Kondrup et al. Clin Nutr 2003; 22: 321-336

Clinical effect, if present: Surgery infection/ON (82) infection/ON (79) infection/EN (20) infection/EN (37) infection/EN (83) infection/EN (84) infection/PN (1) infection/PN (19) infection/PN (38) infection/PN/EN (80) infection/PN (123)

complications/ PN (77) complications/PN (78) complications/PN (87) complications/PN (124) LOS/EN (86) LOS/PN (21) survival/PN (43) survival/PN (125)

( ) = References in Kondrup et al. Clin Nutr 2003; 22: 321-336

Clinical effect, if present: Cancer tolerance/ON (2) tolerance/PN (39) tolerance/PN (40) tolerance/ON (41) QoL/EN (35) survival/PN (44) survival/PN (91)

Femoral fracture LOS/ON (3) LOS/ON (4) survival/EN (5)

Acute Renal Failure survival/PN (89) survival/PN (90)

Cirrhosis Clin Index/PN (36) encephalopathy/EN (42) infection/EN (81) LOS/PN (88) survival/ON (93) Trauma infection/EN (18) LOS/EN (29) survival/PN (30)

Geriatry ADL/ON (34) ADL/ON (85) survival/ON (45)

Misc. infection/burns/EN (28) survival/BMT/PN (31) survival/stroke/ON (92)

( ) = References in Kondrup et al. Clin Nutr 2003; 22: 321-336

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Most RCTs in cancer patients have been performed in patiens in whom there was no indication for nutrition support The intervention was inefficient (oral), or added to adequate intake (oral & PN) The major end-points investigated (survival, reponse to therapy) may not be sensitive to nutrition support Some RCTs show an effect on minor end-points incl QoL

Nutitional counselling in head & neck cancer 3 x N = 75 Ravasco et al. Head Neck 2005;27:659-68 RT

g protein, or Kcal energy, or Global QoL

2400

Counsel Energy Supplement Energy

1400

Control Energy

100 90

Counsel QoL

*

80

Counsel Protein Supplement QoL

70 60 50

Supplement Protein

40

*

Control QoL Control Protein

30 20 10 0

Paula H&N *Sign change form baseline

2

1

Months

3

Nutitional counselling in colorectal cancer 3 x N = 111 Ravasco et al. J Clin Oncol. 2005 Mar 1;23(7):1348-9. RT

2400

g p r o t e in , o r K c a l e n e r g y , o r G lo b a l Q o L

C o u n s e l E n e rg y 1900

S u p p le m e n t E n e rg y C o n tro l E n e rg y

1400 100 90

C ounsel Q oL

*

80

C o u n s e l P ro te in 70 60

S u p p le m e n t Q o L

50

*

S u p p le m e n t P ro te in 40

C o n tro l P ro te in

30

C o n tro l Q o L

20 0

*Sign change form baseline

Paula colorectal

1

2

M o n th s

3

QoL: oral nutritional interventions in malnourished patients with cancer (active treatment or palliative care).

Baldwin et al. J Natl Cancer Inst 2012;104:371-85

QoL: oral nutritional interventions in malnourished patients with cancer (active treatment or palliative care). Without heterogeneity.

Baldwin et al. J Natl Cancer Inst 2012;104:371-85

Long-term follow-up of a randomized controlled trial of nutritional therapy in colo-rectal patients Ravasco et al. Am J Clin Nutr 2012;96:1346-53

Counselling Supplement Control

Long-term follow-up of a randomized controlled trial of nutritional therapy in colo-rectal patients Ravasco et al. Am J Clin Nutr 2012;96:1346-53

Control 26

Supplement 29

Counsel 34

4.9

6.5

7.3

Local recurrence, N (%)

9 (30)

-

7 (19)

Liver metastases, N (%)

6 (20)

3 (9)

-

Positive lymph nodes, N (%)

-

6 (16)

-

Event frequency (P < 0.01)

>

>

Median disease-specific survival, yrs

Perioperative arginine-supplemented nutrition in malnourished patients with head and neck cancer improves long-term survival. Buijs et al. Am J Clin Nutr 2010;92:1151-6.

Perioperative arginine-supplemented nutrition in malnourished patients with head and neck cancer improves long-term survival. Buijs et al. Am J Clin Nutr 2010;92:1151-6.

Perioperative arginine-supplemented nutrition in malnourished patients with head and neck cancer improves long-term survival. Buijs et al. Am J Clin Nutr 2010;92:1151-6

Effect of arginine?  

 

Proliferating remnant malignant cells were killed by argininestimulated T cells ? Arginine-derived NO activates the p53 genes and switch on the immune system to clear pre-malignant cells from the residual normal-appearing cells? etc etc

Buijs et al. Am J Clin Nutr 2010;92:1151-6

12 mths PN in palliative chemotherapy of advanced colon or rectal carcinoma. 67% with liver metastasis. 2N = 82. Malnourished: BMI 20 or  5% wt loss in 3 mths. BW: 67 kg; BMI: 23.0; 3 mths wt loss: 7 kg. Hasenberg et al. 2010. Colorectal Dis 12: e190-e199

PN

Ctr

Total energy, kcal/d

2247

2233

Total protein/AA, g/d

103

103

PN energy, kcal/d

675

-

PN AA, g/d

28

-

Nausea (%)

22

491)

Vomiting (%)

12

381)

Abdominal pain (%)

18

371)

Diarrhoea (%)

9

241)

Mucositis (%)

22

322)

Survival (%)

27

173)

 QoL, EORTC QLQ-C30

22

123)

1)

P