Post on 02-Apr-2018
ESPEN Congress Geneva 2014ESPEN GUIDELINES
ESPEN Guidelines: nutrition support in cancerJ. Arends (DE)
ESPEN GL Oncology
Ethical dilemmasBioethical principlesApplication of bioethical
principles to “Nutrition at the end-of-life”
The decision-making process
ESPEN GL Oncology
aim of the guideline
Translate current evidence and expert opinion into recommendations for the multi‐disciplinary team responsible for prevention, identification and treatment of reversible elements of malnutrition in cancer patients and contribute to decreasing the risk of cancer recurrence.
ESPEN GL Oncology
Guideline: Problems
Evidence of high quality is very limited
Recommendations triggered solely by the level of evidenceare not helpful for clinical practice
ESPEN Cancer‐GL 2006&2009AGREE rating of applicability: 0‐7/100
[van den Berg T et al. JPEN 2011]
ESPEN GL Oncology
Evidence Recommendations: GRADE
Level of evidence: initially after adjustmentRCT: high very low .. highObserv. Study: low very low .. highExpert opinion: very low very lowadjusting for: study quality, inconsistencies, indirectness, imprecision, bias
magnitude of effect, dose‐response relationship
Strength of recommendationSTRONG: desirable effects clearly outweigh harmsWEAK: trade‐offs are uncertain
ESPEN disease‐specific guideline framework. Preiser JC & Schneider SM, Clin Nutr 2011Grading quality of evidence and strength of recommendations. Oxman AD et al., Br Med J 2004GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Guyatt GH et al., Br Med J 2008
ESPEN GL Oncology
2011 ‐ 201420 experts, 2 ESPEN leaders, 2 methodologistsevidence search and GRADE technique*recommendations consensus process
online review, ESPEN website
*ESPEN disease‐specific guideline framework; Clin Nutr 2011
time frame and methodology
ESPEN GL Oncology
0 MethodsGoals, target population, professional groups involvedpatient views, target users, conflict of interest and fundingdesign, searches, recommendations, consensusprofessional review, updating of GLfacilitators/barriers, costs, monitoring/auditing
A IntroductionMajor alterations in cancer patientseffects on clinical outcomeaims of nutritional interventions
B General concepts – relevant to all cancer patients
C Interventions relevant to specific patient categories
outline
ESPEN GL Oncology
0 Methods
A Introduction
B General concepts – relevant to all cancer patientsB1 Screening and assessmentB2 Energy and substrate requirementsB3 Nutritional interventionsB4 Physical exerciseB5 Pharmacological agents
C Interventions relevant to specific patient categories
outline
ESPEN GL Oncology
0 Methods
A Introduction
B General concepts – relevant to all cancer patients
C Interventions relevant to specific patient categoriesC1 SurgeryC2 RadiotherapyC3 Curative medical anticancer treatmentC4 High‐dose chemotherapy and HSCTC5 Cancer survivorsC6 Incurable cancer patients
outline
ESPEN GL Oncology
Section B1, Statement 1
B1 ‐ 1 ScreeningStrength of recommendation
STRONG To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change and BMI, beginning with cancer diagnosis and repeated depending on the stability of the clinical situation.
Level of evidence Very low
Questions for research relationship of screening to assessmentinterventions and clinical outcomes
ESPEN GL Oncology
Section B1, Statement 2
B1 ‐ 2 AssessmentStrength of recommendation
STRONG In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, physical performance and the degree of systemic inflammation.
Level of evidence Very low
Questions for research Linking outcomes from current and future intervention trials with appropriate screening and assessment tools
ESPEN GL Oncology
Section B2, Statement 1
B2 ‐ 1 Energy requirementsStrength of recommendation
STRONG We recommend, for practical purposes, that total energy expenditure of cancer patients, if not measured individually, be assumed to be rather similar to healthy subjects and ranging between 25 and 30 kcal/kg/day.
Level of evidence Low
Questions for research improve prediction of energy requirements in the individual patient
ESPEN GL Oncology
Section B2, Statement 2
B2 ‐ 2 Protein intakeStrength of recommendation
WEAK We suggest that protein intake should be above 1 g/kg/day and if possible up to 1.5 g/kg/day
Level of evidence Moderate
Questions for research effect on outcome of increased supply and composition of protein/amino acids
ESPEN GL Oncology
Section B2, Statement 3
B2 ‐ 3 Choice of energy substratesStrength of recommendation
STRONG In most patients general recommendations are applicable. In weight‐losing patients with advanced cancer we recommend a fat intake of 35‐50% of total energy requirement.
Level of evidence Low
Questions for research effect of high fat on outcome in specific patient groups
ESPEN GL Oncology
Section B2, Statement 4
B2 ‐ 4 Vitamins and trace elementsStrength of recommendation
STRONG We recommend that vitamins and minerals be supplied in amounts approximately equal to the RDA and discourage the use of high‐dose micronutrients in the absence of specific deficiencies.
Level of evidence Low
Questions for research Assessment of micronutrient status in cancer patients and effect ofsupplementation
ESPEN GL Oncology
Section B3, Statement 1
B3 ‐ 1 Efficacy of nutritional interventionStrength of recommendation
STRONG We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake, and offering oral nutritional supplements.
Level of evidence Moderate
Questions for research effect of advice and ONS on outcome
ESPEN GL Oncology
Section B3, Statement 2
B3 ‐ 2 Low efficacy of special dietsStrength of recommendation
STRONG We recommend against dietary provisions like “anticancer diets” which restrict energy intake in patients with or at riskof malnutrition.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section B3, Statement 3
B3 ‐ 3 Modes of nutritionStrength of recommendation
STRONG We recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions, and parenteralnutrition if enteral nutrition is not sufficient or feasible.
Level of evidence Moderate
Questions for research effect of EN or PN or combinations on outcome
ESPEN GL Oncology
Section B3, Statement 4
B3 ‐ 4 Refeeding syndromeStrength of recommendation
STRONG If oral food intake has been decreased severely for a prolonged period of time, we recommend to increase enteralor parenteral nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome.
Level of evidence Low
Questions for research Assessment of phosphate, potassium and magnesium levels in malnourishedcancer patients and response to artificial feeding
ESPEN GL Oncology
Section B3, Statement 5
B3 ‐ 5 Home artificial nutritionStrength of recommendation
STRONG In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption we recommend home artificial nutrition in suitable patients
Level of evidence Low
Questions for research Effect of long‐term EN and PN on clinical outcome
ESPEN GL Oncology
Section B4, Statement 1
B4 ‐ 1 Exercise in combination with nutritionStrength of recommendation
STRONG We recommend maintenance or increased level of physical activity in cancer patients during and after treatment to support muscle mass, physical function and metabolic pattern.
Level of evidence High
Questions for research effect of physical activity on outcome
ESPEN GL Oncology
Section B4, Statement 2
B4 ‐ 2 Type of exercise recommendedStrength of recommendation
WEAK We suggest individualized resistance exercise to maintain muscle strength and muscle mass during treatment.
Level of evidence Low
Questions for research effect of resistance and endurance exercise on outcome
ESPEN GL Oncology
Section B5, Statement 1
B5 ‐ 1 Corticosteroids to increase appetiteStrength of recommendation
WEAK We suggest to consider using corticosteroids to increase the appetite of anorectic cancer patients for a restricted period of time but to be aware of potential side effects (e.g. musclewasting).
Level of evidence High
Questions for research Methods to counteract corticosteroid‐related muscle wasting
ESPEN GL Oncology
Section B5, Statement 2
B5 ‐ 2 Progestins to increase appetiteStrength of recommendation
WEAK We suggest to consider using progestins to increase the appetite of anorectic cancer patients for a limited period of time but to be aware of potential serious side effects.
Level of evidence High
Questions for research Prospective studies to evaluate the combined effects of appropriatenutritional support and progestins
ESPEN GL Oncology
Section B5, Statement 3
B5 ‐ 3 Cannabinoids to improve appetiteStrength of recommendation
WEAK We suggest to consider cannabinoids to attempt to improve taste disorders and anorexia in cancer patients
Level of evidence Low
Questions for research Effects of cannabinoids on nutritional state in anorectic cancer patients withtaste alterations
ESPEN GL Oncology
Section B5, Statement 4
B5‐ 4 Androgens to increase muscle massStrength of recommendation
NONE There are insufficient data to recommend on androgenic steroids to increase muscle mass
Level of evidence High
Questions for research Mechanism and long term effects of SARMs in patients with cachexia.
ESPEN GL Oncology
Section B5, Statement 5
B5 ‐ 5 Amino acidsStrength of recommendation
NONE There is not enough clinical data to recommend the supplementation with branched‐chain amino acids or metabolites to improve fat free mass.
Level of evidence Low
Questions for research Effects of leucine or HMB (hydroxy methylbutyrate) in weight losing patientsstudied in large randomized trials
ESPEN GL Oncology
Section B5, Statement 6
B5 ‐ 6 Non steroidal antiinflammatory drugsStrength of recommendation
NONE There is not enough data to recommend non‐steroidal antiinflammatory drugs to improve body weight in weight losing cancer patients.
Level of evidence Low
Questions for research Effect of NSAIDs on body composition and clinical outcome in cancer patientswith systemic inflammation
ESPEN GL Oncology
Section B5, Statement 7
B5 ‐ 7 N‐3 fatty acids to improve appetite and body weightStrength of recommendation
WEAK In cancer patients undergoing chemotherapy at risk of weight loss, we suggest to use the supplementation with long‐chain n‐3 fatty acids or fish oil to stabilize/improve appetite, food intake, lean body mass and body weight.
Level of evidence Moderate
Questions for research Effect of long‐chain N‐3 fatty acids on body composition and clinical outcomein cancer patients undergoing antineoplastic treatment
ESPEN GL Oncology
Section C1, Statement 1
C1 ‐ 1 Enhanced recovery after surgery (ERAS) careStrength of recommendation
STRONG For all cancer patients undergoing either curative resectionalor palliative surgery we recommend management within an enhanced recovery after surgery program.
Level of evidence High
Questions for research optimal components including nutrition of ERAS protocol for oncology patients
ESPEN GL Oncology
Section C1, Statement 2
C1 ‐ 2 Surgery: Multimodal oncological pathwayStrength of recommendation
STRONG For a patient undergoing repeated surgery as part of a multimodal oncological pathway, management of each surgical episode should be within an ERAS programme.
Level of evidence Low
Questions for research role of multimodal rehabilitation during prolonged oncological therapy
ESPEN GL Oncology
Section C1, Statement 3
C1 ‐ 3 Surgery: Care after hospital dischargeStrength of recommendation
STRONG In surgical cancer patients at moderate or severe nutritional risk we recommend appropriate ONS/enteral nutritional support both before and following discharge from hospital.
Level of evidence Moderate
Questions for research The role of immunonutrition when upper GI cancer patients are managed within an ERAS pathway. The optimal post‐operative regimen in terms of type, preparation and access to normal food +/‐ oral nutritional supplements for patients managed within an ERAS pathway.The role of n‐3 enriched oral supplements/enteral nutrition in upper GI cancer patients for preservation of lean body mass and optimisation of organ function.
ESPEN GL Oncology
Section C1, Statement 4
C1 ‐ 4 Traditional peri‐operative careStrength of recommendation
STRONG In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care we recommend oral/enteral immunonutrition.
Level of evidence High
Questions for research Role of immunonutrition for upper GI cancer patients managed within an ERAS pathway
ESPEN GL Oncology
Section C2, Statement 1
C2 ‐ 1 RT: Ensuring adequate nutritional intakeStrength of recommendation
STRONG We recommend that during RT to the head‐neck, upper and low GI tract and thorax, an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of ONS, in order to avoid nutritional deterioration, maintain intake and avoid RT interruptions
Level of evidence Moderate
Questions for research
ESPEN GL Oncology
Section C2, Statement 2
C2 ‐ 2 RT: Use of tube feedingStrength of recommendation
STRONG We recommend that tube feeding may be done using transnasal or PEG in RT‐induced severe mucositis or in head‐neck/throracic cancers with obstructive tumor masses.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C2, Statement 3
C2 ‐ 3 RT: Maintaining swallowing functionStrength of recommendation
STRONG We recommend that patients should be encouraged and educated on how to maintain their swallowing function during EN.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C2, Statement 4
C2 ‐ 4 Radiation‐induced diarrhea: glutamineStrength of recommendation
STRONG We do not recommend using glutamine during pelvic RT to prevent RT‐induced enteritis/diarrhea.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C2, Statement 5
C2 ‐ 5 Radiation‐induced diarrhea: probioticsStrength of recommendation
NONE There is not enough data to recommend Lactobacillus‐containing probiotics to reduce radiation‐induced diarrhea.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C2, Statement 6
C2 ‐ 6 RT: Use of parenteral nutritionStrength of recommendation
STRONG Parenteral nutrition (PN) is not recommended in general in RT; it should only be initiated if adequate oral/enteralnutrition is not possible, e.g. severe RT enteritis, severe mucositis or head‐neck/oesophageal obstructive cancer masses.
Level of evidence Moderate
Questions for research
ESPEN GL Oncology
Section C3, Statement 1
C3 – 1 Medical anticancer treatment: Ensuring adequate nutritionStrength of recommendation
STRONG During anticancer drug treatment we recommend to ensure an adequate nutritional intake and to maintain physical activity.
Level of evidence Very low
Questions for research
ESPEN GL Oncology
Section C3, Statement 2
C3 – 2 Medical anticancer treatment: Use of artificial nutritionStrength of recommendation
STRONG If oral food intake is inadequate despite counselling and ONS, we recommend to initiate enteral or, if this is not sufficient or possible, parenteral nutrition.
Level of evidence Very low
Questions for research
ESPEN GL Oncology
Section C3, Statement 3
C3 – 3 Medical anticancer treatment: use of glutamineStrength of recommendation
NONE There is insufficient evidence to recommend glutamine supplementation during conventional cytotoxic or targeted therapy.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C3, Statement 4
C3 – 4 Medical anticancer treatment: fish oilStrength of recommendation
NONE For oncological outcomes there is insufficient evidence to recommend for or against fish oil supplementation during chemotherapy.
Level of evidence Low
Questions for research Effects of long‐chain N‐3 fatty acids on the therapeutic index of chemotherapy
ESPEN GL Oncology
Section C4, Statement 1
C4 – 1 HSCT: ensuring adequate nutrition and physical activityStrength of recommendation
STRONG During high‐dose anticancer drug treatment and stem cell transplantation we recommend to maintain physical activity and to ensure an adequate nutritional intake. This may often require artificial nutrition.
Level of evidence Very low
Questions for research Effects of physical actvity on clinical outcome
ESPEN GL Oncology
Section C4, Statement 2
C4 – 1 HSCT: Artificial nutritionStrength of recommendation
WEAK If artificial nutrition is required we suggest to prefer enteraltube feeding over parenteral nutrition, unless there is severe mucositis or symptomatic gastrointestinal GvHD.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C4, Statement 3
C4 – 3 HSCT: Germ‐free foodStrength of recommendation
NONE There is not enough evidence to recommend germ‐free food for patients more than 30 days after allogeneictransplantation
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C4, Statement 4
C4 – 4 HSCT: glutamineStrength of recommendation
NONE There is not enough evidence to recommend for or against glutamine to reduce anticancer therapy side effects especially in high dose protocols.
Level of evidence Low
Questions for research
ESPEN GL Oncology
Section C5, Statement 1
C5 – 1 Cancer survivors: Physical activityStrength of recommendation
STRONG We recommend that cancer continue to engage in regular physical activity and avoid physical inactivity.
Level of evidence Low
Questions for research Effects of physical activity on physical function, recurrence and survival in cancer survivors
ESPEN GL Oncology
Section C5, Statement 2
C5 – 2 Cancer survivors: Healthy lifestyleStrength of recommendation
STRONG In cancer survivors we recommend a healthy weight and a healthy (primarily plant based) diet, high in fruits, vegetables and whole grains, and low in fat, red meat and alcohol.
Level of evidence Low
Questions for research Effects of healthy diet on outcome
ESPEN GL Oncology
Section C6, Statement 1
C6 – 1 Incurable patients: screening and assessmentStrength of recommendation
STRONG We recommend to routinely screen all advanced, incurable cancer patients ‐ whether receiving or not receiving anti‐cancer treatment ‐ for inadequate nutritional intake, weight loss and low body mass index, and if found at risk, to assessthese patients further.
Level of evidence Low
Questions for research Effects of malnutrition screening programs on quality of life in incurablecancer patients
ESPEN GL Oncology
Section C6, Statement 2
C6 – 2 Incurable patients: ensuring nutritional intakeStrength of recommendation
STRONG Nutritional interventions should be used in patients with advanced incurtable cancer if their expected benefit outweighs the potential harm and the patient wants it.
Level of evidence Low
Questions for research Effects of nutrtional care on quality of life in incurable cancer patients
ESPEN GL Oncology
Section C6, Statement 3
C6 – 3 Very advanced terminal phaseStrength of recommendation
STRONG In patients who are imminently dying treatment should be based on comfort. Artificial hydration and nutrition are unlikely to provide any benefit for most patients.
Level of evidence Low
Questions for research
ESPEN GL Oncology
espen ‐ epaac gl group
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oncology Arendsanesthesiology Bachmannphysiology Baracosradiooncology Barthelemyhematology Bertzsurgery Bozzettisurgery Fearondietitian Hüttererradiooncology Kaasagastroenterology Krznaricnutrition Isenringpalliative medicine Lairdnursing Larssonpharmacology Mühlebachinternal medicine Muscaritolhealth science Oldervollnutrition RavascoNutrition v.d. Schuerenoncology Solheimpalliative medicine Strasser
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