ESPEN Congress Leipzig 2013
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ESPEN Congress Leipzig 2013 Nutrition and cancer: impact on outcome Survival, quality of life, reduced toxicity: what can be achieved in cancer patients? M.A.E. van Bokhorst - de van der Schueren (NL)
Transcript of ESPEN Congress Leipzig 2013
ESPEN Congress Leipzig 2013
Nutrition and cancer: impact on outcome
Survival, quality of life, reduced toxicity: what can be achieved in cancer patients?
M.A.E. van Bokhorst - de van der Schueren (NL)
Survival, reduced toxicity,
quality of life
What can be achieved in cancer patients?
Marian A.E. van Bokhorst – de van der Schueren, RD PhD
Contents
• Overview of studies associating malnutrition to outcome
measures
• Overview of studies investigating the effects of nutritional
intervention on outcome measures
– by treatment modality
• Summary, conclusions and recommendations
3
Nutritional status of patients with cancer;
frequency and severity of weight loss
.
- 80%
- 60%
- 40%
- 20%
0%
0% – 5% 5% – 10% >10%
Weight loss in previous 6 months
Colon Prostate
Lung small cell
Lung non - small
cell Pancreas
Non - measurable
gastric Measurable
gastric
14%
14
%
28%
10%
20%
14%
21%
15%
28%
26%
32%
30%
29%
38%
% P
atients
With W
eig
ht Loss
26%
18%
23% 18% 29%
21% 20%
DeWys Am J Med 1980; 491-497
Prognostic impact of weight loss
• Shorter median survival time
• Trend towards diminished chemotherapy response rates
• Decreasing performance status
5
DeWys Am J Med 1980; 491-497
Weight loss, toxicity, QoL, survival
• 1555 GI cancer patients undergoing chemotherapy
• Retrospective study
• Relation to
– Toxicity: stomatitis, plantar palmar syndrome
– QoL
– Performance status
– Failure free and overall survival
Andreyev et al. 1998. Eur J Cancer 34:503-509
Weight loss and quality of life
Andreyev et al. 1998. Eur J Cancer 34:503-509
QOL score (EORTC QLQ C-30)
Esophageal Gastric Pancreatic Colorectal 0
25
50
* * *
Type of cancer
QO
L s
core
Patients with weight loss
Patients without weight loss
*P< 0.01 for each comparison
P< 0.0001 for all groups combined
75
Effect of weight loss on outcomes :
chemotherapy in GI cancer
• Patients received 1 month less chemo
• Weight loss was associated with decreased response rate
(p< 0.006), quality of life (p<0.0001) and performance
status (p<0.0001)
• Weight loss associated with shorter survival duration
(p<0.0001)
• Those who stopped losing weight had better overall
survival
• => rationale for attempting randomised nutritional
intervention trials
Andreyev HJN et al Eur Journal Cancer 1998,34:503-9
Malnutrition and poor QoL
• QoL score (EORTC QLQ-C30)
• Strong relation between QoL and weight loss, independent of
tumour stage, treatment
9
< 10% WL ≥ 10% WL
Tumour
localisation
NS
Tumour stage
at diagnosis
Local 64 49 P<0.001
Locoregional 64 49 P<0.001
Metastatic 58 49 P=0.002
Chemotherapy
Yes 62 49 P<0.001
No 62 52 P=0.155
Nourissat Eur J Cancer 2008: 1238 - 1242
How nutritional status affects outcome
10 Marin Caro 2007. Curr Opin Clin Nutr Metab Care 10:480–487.
Malnutrition and toxicity
11
Langius. Radiother Oncol. 2010 Oct;97(1):80-5
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8
Time (weeks)
%
Xerostomia
Mucositis
Dysphagia
Malnutrition
Total Anorexia
No WL
(A)
WL > 10%
No anorexia
(WL)
No WL
No anorexia
(N)
Cancer Anorexia
Cachexia
Syndrome
484 (100%) 163 (34%) 46 (10%) 125 (26%) 150 (30%)
Lasheen W & Walsh D. Support Care Cancer 2010; 10:265-272
Impact of anorexia and weight loss on
mortality
Observational studies
•There is (enough) evidence that a
diminished nutritional status is
associated with impaired quality of
life, increased adverse events and
even higher mortality
Evidence for effects of nutritional
interventions?
14
• Treatment modality
– radiotherapy
– chemotherapy
– surgery
• Form of nutritional intervention
Relevant outcome measures?
• Weight stabilisation
• Maintenance / gain in fat free mass
• Improved intake in energy and protein
• Reduced toxicity
• Less delay in treatment / less dose adaptations
• Reduction of postoperative complications
• Improved (overall / recurrence free) survival
• Quality of life
• Improved (Karnofksy) performance status (KPS)
Radiotherapy (H&N), effects of
nutritional intervention
• Systematic review including 12 trials
• Counseling vs ‘no-counseling or counseling by a nurse’:
– Positive effects: intake, nutritional status, QoL
– Inconsisent: complications
• ONS vs no supplements:
– Positive effects: intake.
– To be further studied: QoL ?? (1 positive study)
Langius. Clin Nutr 2013, in press
Benefits of Nutritional Counselling on
Protein Intake During RTh (colon)
Ravasco P et al, JCO 2005; 23: 1431-8
NC
ONS
NIL
Pro
tein
inta
ke
in g
ram
s
RTh start end
Long term follow-up
18
NC
ONS
NIL
Survival Late toxicity symptoms
Ravasco P. Am J Clin Nutr 2012;96:1346–53
Nutritional counseling 2 Meta-analyses:
• Halfdanarson: J Support Oncol
2008;6:234–237:
–Dietary counseling
–Outcome: QOL
–Trend towards increasing QoL
• Baldwin: J Natl Cancer Inst 2012;104:371–385
–Dietary counseling, or ONS, or both
–Outcome: nutritional and clinical outcomes and QoL
–Improvement in weight and in energy intake
–Improvement in some aspects of QoL
–No effects on mortality
Chemotherapy
• Many studies have shown associations between weight loss
and adverse events, dose reduction, severity of toxicity
symptoms
• But only few studies have addressed effects of nutritional
intervention: results not convincing
Chemotherapy
• Dintinjana, Coll Antropol. 2008 Sep;32(3):737-40:
– Historical control group, n=173
– Nutrition intervention (+ megestrol acetate), n=215
– Temporary stop of weight loss (esp. in those receiving
megestrol acetate); no influence on course of disease, KPS
• Baldwin, J Hum Nutr Diet 2011, Oct;24(5):431-4:
– 4 different nutritional interventions during 6 weeks, starting at
beginning of chemotherapy (n=358)
– No differences in 1 y survival, weight, or QoL
– Study stopped early because of lack of effects
Upper GI Surgery
• Meta-analysis including 11 trials, > 1000 patients,
immunonutrition (IN):,arg, n3-FA, RNA, glu, vs standard diet
– postoperative infections
– non-infection complications
– length of hospital stay in upper GI surgical oncology patients
• Either with preoperative, postoperative or combined
preoperative and postoperative use
• Irrespective of nutritional status, iso-nitrogenous regimen….
• What about clinical practice?
• Changing operative techniques > laparascopic. Effects?
Zhang, Surgical Oncology 21 (2012) e87-e95
Head and neck surgery
• Much less convincing evidence
• Systematic review including 14 trials, > 800 patients, IN (mostly:
arginine) vs polymeric feeds
• A possible reduction in the length of postoperative hospital?
– but the reason for this reduction is not clear
• Some studies showed statistical differences with less
complications / decrease of fistula formation in arginine
enhanced group
• One study studied long term survival
Casas Rodera, Nutr Hosp. 2012;27(3):681-690
Survival
Arginine
….. Polymeric feed
Buijs, Am J Clin Nutr 2010; 92 (5): 1151-6.
Multiple sites
EN, TPN,
separate
nutrients
In conclusion (1)
• Weight loss has been associated with poor outcomes in
multiple studies
• Nutritional intervention has been shown to maintain weight, to
improve intake, and, maybe, to influence some aspects of QoL
• Most evidence available for RTh, however few studies
• Studies in patients undergoing chemotherapy are scarce
• Upper GI surgery: immunonutrition
In conclusion (2)
• Need for studies investigating relevant outcomes:
– Toxicity
– Treatment delay
– Complications
– Survival
• We know what to do!
