ESPEN Guidelines: nutrition support in cancer

ESPEN Congress Geneva 2014ESPEN GUIDELINES

ESPEN Guidelines: nutrition support in cancerJ. Arends (DE)

espenandepaacguidelinesnutritionincancer

JannArendsTumorBiologyCenterFreiburg

ESPEN GL Oncology

Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the end-of-life The decision-making process

ESPEN GL Oncology

sponsors

20092014

ESPEN GL Oncology

ESPEN GL Oncology

aim of the guideline

Translatecurrentevidenceandexpertopinionintorecommendationsforthemultidisciplinaryteamresponsibleforprevention,identificationandtreatmentofreversibleelementsofmalnutritionincancerpatientsandcontributetodecreasingtheriskofcancerrecurrence.

ESPEN GL Oncology

Guideline:Problems

Evidence of high quality is very limited

Recommendations triggered solely by the level of evidenceare nothelpful for clinical practice

ESPENCancerGL2006&2009AGREErating of applicability: 07/100

[vandenBergTetal.JPEN2011]

ESPEN GL Oncology

EvidenceJ Recommendations:GRADELevelofevidence: initially afteradjustment

RCT: high verylow..highObserv.Study: low verylow..highExpertopinion: verylow verylowadjustingfor: studyquality,inconsistencies,indirectness,imprecision,bias

magnitudeofeffect,doseresponserelationship

StrengthofrecommendationSTRONG: desirableeffectsclearlyoutweighharmsWEAK: tradeoffsareuncertain

ESPENdiseasespecificguidelineframework.PreiserJC&SchneiderSM,ClinNutr2011Gradingqualityofevidenceandstrengthofrecommendations.OxmanADetal.,BrMedJ2004GRADE:anemergingconsensusonratingqualityofevidenceandstrengthofrecommendations.GuyattGHetal.,BrMedJ2008

ESPEN GL Oncology

2011 201420experts,2ESPENleaders,2methodologistsevidencesearchandGRADEtechnique*recommendationsconsensusprocess onlinereview,ESPENwebsite

*ESPENdiseasespecificguidelineframework;ClinNutr2011

timeframe and methodology

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0 MethodsGoals,targetpopulation,professionalgroupsinvolvedpatientviews,targetusers,conflictofinterestandfundingdesign,searches,recommendations,consensusprofessionalreview,updatingofGLfacilitators/barriers,costs,monitoring/auditing

A IntroductionMajoralterationsincancerpatientseffectsonclinicaloutcomeaimsofnutritionalinterventions

B Generalconcepts relevanttoallcancerpatients

C Interventionsrelevanttospecificpatientcategories

outline

ESPEN GL Oncology

0 Methods

A Introduction

B Generalconcepts relevanttoallcancerpatientsB1 ScreeningandassessmentB2 EnergyandsubstraterequirementsB3 NutritionalinterventionsB4 PhysicalexerciseB5 Pharmacologicalagents

C Interventionsrelevanttospecificpatientcategories

outline

ESPEN GL Oncology

0 Methods

A Introduction

B Generalconcepts relevanttoallcancerpatients

C InterventionsrelevanttospecificpatientcategoriesC1 SurgeryC2 RadiotherapyC3 Curative medical anticancer treatmentC4 Highdosechemotherapy and HSCTC5 Cancer survivorsC6 Incurable cancer patients

outline

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Section B1,Statement1

B1 1 ScreeningStrength of recommendation

STRONG Todetectnutritionaldisturbancesatanearlystage,werecommendtoregularlyevaluatenutritionalintake,weightchangeandBMI,beginningwithcancerdiagnosisandrepeateddependingonthestabilityoftheclinicalsituation.

Levelof evidence Very low

Questions for research relationshipofscreeningtoassessmentinterventionsandclinicaloutcomes

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B1 2 AssessmentStrength of recommendation

STRONG Inpatientswithabnormalscreening,werecommendobjectiveandquantitativeassessmentofnutritionalintake,nutritionimpactsymptoms,physicalperformanceandthedegreeofsystemicinflammation.


Questions for research Linkingoutcomesfromcurrentandfutureinterventiontrialswithappropriatescreeningandassessmenttools

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B2 1 Energy requirementsStrength of recommendation

STRONG Werecommend,forpracticalpurposes,thattotalenergyexpenditureofcancerpatients,ifnotmeasuredindividually,beassumedtoberathersimilartohealthysubjectsandrangingbetween25and30kcal/kg/day.

Levelof evidence Low

Questions for research improvepredictionofenergyrequirementsintheindividualpatient

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B2 2 ProteinintakeStrength of recommendation

WEAK Wesuggestthatproteinintakeshouldbeabove1g/kg/dayandifpossibleupto1.5g/kg/dayLevelof evidence Moderate

Questions for research effectonoutcomeofincreasedsupplyandcompositionof protein/aminoacids

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B2 3 Choice of energy substratesStrength of recommendation

STRONG Inmostpatientsgeneralrecommendationsareapplicable.Inweightlosingpatientswithadvancedcancerwerecommendafatintakeof3550%oftotalenergyrequirement.


Questions for research effectofhighfatonoutcomeinspecificpatientgroups

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B2 4 Vitaminsand trace elementsStrength of recommendation

STRONG WerecommendthatvitaminsandmineralsbesuppliedinamountsapproximatelyequaltotheRDAanddiscouragetheuseofhighdosemicronutrientsintheabsenceofspecificdeficiencies.


Questions for research Assessment of micronutrient status incancer patients and effect ofsupplementation

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B3 1 Efficacy of nutritionalinterventionStrength of recommendation

STRONG Werecommendnutritionalinterventiontoincreaseoralintakeincancerpatientswhoareabletoeatbutaremalnourishedoratriskofmalnutrition.Thisincludesdietaryadvice,thetreatmentofsymptomsandderangementsimpairingfoodintake,andofferingoralnutritionalsupplements.

Levelof evidence Moderate

Questions for research effectofadviceandONSonoutcome

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B3 2 Lowefficacy of special dietsStrength of recommendation

STRONG Werecommendagainstdietaryprovisionslikeanticancerdietswhichrestrictenergyintakeinpatientswithoratriskof malnutrition.


Questions for research

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B3 3 Modes of nutritionStrength of recommendation

STRONG Werecommendenteral nutritioniforalnutritionremainsinadequatedespitenutritionalinterventions,andparenteralnutritionifenteral nutritionisnotsufficientorfeasible.


Questions for research effectofEN or PNorcombinations onoutcome

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B3 4 Refeeding syndromeStrength of recommendation

STRONG Iforalfoodintakehasbeendecreasedseverelyforaprolongedperiodoftime,werecommendtoincreaseenteralorparenteral nutritiononlyslowlyoverseveraldaysandtotakeadditionalprecautionstopreventarefeeding syndrome.


Questions for research Assessment of phosphate,potassium and magnesium levels in malnourishedcancer patients and response to artificial feeding

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B3 5 Home artificial nutritionStrength of recommendation

STRONG Inpatientswithchronicinsufficientdietaryintakeand/oruncontrollablemalabsorption werecommendhome artificialnutritioninsuitablepatients


Questions for research Effect of longterm ENand PNonclinical outcome

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B4 1 Exercise incombination with nutritionStrength of recommendation

STRONG Werecommendmaintenanceorincreasedlevelofphysicalactivityincancerpatientsduringandaftertreatmenttosupportmusclemass,physicalfunctionandmetabolicpattern.

Levelof evidence High

Questions for research effectofphysicalactivityonoutcome

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B4 2 Type of exercise recommendedStrength of recommendation

WEAK Wesuggestindividualizedresistanceexercisetomaintainmusclestrengthandmusclemassduringtreatment.Levelof evidence Low

Questions for research effectofresistanceandenduranceexerciseonoutcome

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B5 1 Corticosteroids to increase appetiteStrength of recommendation

WEAK Wesuggesttoconsiderusing corticosteroidstoincreasetheappetiteofanorecticcancerpatientsforarestrictedperiodoftimebuttobeaware ofpotentialsideeffects(e.g.musclewasting).


Questions for research Methods to counteract corticosteroidrelated muscle wasting

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B5 2 Progestins to increase appetiteStrength of recommendation

WEAK Wesuggesttoconsiderusing progestins toincreasetheappetiteofanorecticcancerpatientsforalimitedperiodoftimebuttobeaware ofpotentialserioussideeffects.


Questions for research Prospective studies to evaluate the combined effects of appropriatenutritionalsupport and progestins

ESPEN GL Oncology


B5 3 Cannabinoids to improve appetiteStrength of recommendation

WEAK Wesuggesttoconsidercannabinoids toattempttoimprovetastedisordersandanorexiaincancerpatientsLevelof evidence Low

Questions for research Effects of cannabinoids onnutritionalstate inanorectic cancer patients withtastealterations

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B5 4 Androgensto increase muscle massStrength of recommendation

NONE Thereareinsufficientdatatorecommendonandrogenicsteroidstoincreasemuscle massLevelof evidence High

Questions for research MechanismandlongtermeffectsofSARMs inpatientswithcachexia.

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B5 5 Amino acidsStrength of recommendation

NONE Thereisnotenough clinicaldatatorecommendthesupplementationwithbranchedchainaminoacidsormetabolitestoimprovefatfreemass.


Questions for research Effects of leucine or HMB(hydroxy methylbutyrate)in weight losing patientsstudied inlargerandomized trials

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B5 6 Non steroidal antiinflammatory drugsStrength of recommendation

NONE Thereisnotenoughdatatorecommendnonsteroidalantiinflammatory drugstoimprovebodyweightinweightlosingcancerpatients.


Questions for research Effect of NSAIDsonbody composition and clinical outcome in cancer patientswith systemic inflammation

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B5 7 N3fatty acids to improve appetite and body weightStrength of recommendation

WEAK Incancerpatientsundergoingchemotherapyatriskofweightloss,wesuggesttousethesupplementationwithlongchainn3fattyacidsorfishoiltostabilize/improveappetite,foodintake,leanbodymassandbodyweight.


Questions for research Effect of longchain N3fatty acids onbody composition and clinical outcomein cancer patients undergoing antineoplastic treatment

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Section C1,Statement1

C1 1 Enhanced recovery aftersurgery (ERAS)careStrength of recommendation

STRONG Forallcancerpatientsundergoingeithercurativeresectionalorpalliativesurgerywerecommendmanagementwithinanenhancedrecoveryaftersurgeryprogram.


Questions for research optimalcomponentsincludingnutritionofERASprotocolforoncologypatients

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C1 2 Surgery:Multimodaloncological pathwayStrength of recommendation

STRONG Forapatientundergoingrepeatedsurgeryaspartofamultimodaloncological pathway,managementofeachsurgicalepisodeshouldbewithinanERASprogramme.


Questions for research roleofmultimodalrehabilitationduringprolongedoncological therapy

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C1 3 Surgery:Careafterhospital dischargeStrength of recommendation

STRONG InsurgicalcancerpatientsatmoderateorseverenutritionalriskwerecommendappropriateONS/enteral nutritionalsupportbothbeforeandfollowingdischargefromhospital.


Questions for research Theroleofimmunonutrition whenupperGIcancerpatientsaremanagedwithinanERASpathway.Theoptimalpostoperativeregimenintermsoftype,preparationandaccesstonormalfood+/ oralnutritionalsupplementsforpatientsmanagedwithinanERASpathway.Theroleofn3enrichedoralsupplements/enteral nutritioninupperGIcancerpatientsforpreservationofleanbodymassandoptimisationoforganfunction.

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C1 4 Traditional perioperativecareStrength of recommendation

STRONG InupperGIcancerpatientsundergoingsurgicalresectioninthecontextoftraditional perioperative carewerecommendoral/enteral immunonutrition.


Questions for research Role ofimmunonutrition forupperGIcancerpatientsmanagedwithinanERASpathway

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C2 1 RT:Ensuring adequate nutritionalintakeStrength of recommendation

STRONG WerecommendthatduringRTtotheheadneck,upperandlowGItractandthorax,anadequatenutritionalintakeshouldbeensuredprimarilybyindividualizednutritionalcounselingand/orwithuseofONS,inordertoavoidnutritionaldeterioration,maintainintakeandavoidRTinterruptions



ESPEN GL Oncology


C2 2 RT:Use of tube feedingStrength of recommendation

STRONG Werecommendthattubefeedingmaybedoneusingtransnasal orPEGinRTinducedseveremucositis orinheadneck/throracic cancerswithobstructivetumormasses.



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C2 3 RT:Maintaining swallowing functionStrength of recommendation

STRONG WerecommendthatpatientsshouldbeencouragedandeducatedonhowtomaintaintheirswallowingfunctionduringEN.



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C2 4 Radiationinduced diarrhea: glutamineStrength of recommendation

STRONG WedonotrecommendusingglutamineduringpelvicRTtopreventRTinducedenteritis/diarrhea.Levelof evidence Low


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C2 5 Radiationinduced diarrhea:probioticsStrength of recommendation

NONE ThereisnotenoughdatatorecommendLactobacilluscontainingprobiotics toreduceradiationinduced diarrhea.Levelof evidence Low


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C2 6 RT:Use of parenteralnutritionStrength of recommendation

STRONG Parenteral nutrition(PN)isnotrecommendedingeneralinRT;itshouldonlybeinitiatedifadequateoral/enteralnutritionisnotpossible,e.g.severeRTenteritis,severemucositis orheadneck/oesophageal obstructivecancermasses.



ESPEN GL Oncology


C3 1 Medical anticancer treatment:Ensuring adequate nutritionStrength of recommendation

STRONG Duringanticancerdrugtreatmentwerecommendtoensureanadequatenutritionalintakeandtomaintainphysicalactivity.



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C3 2 Medical anticancer treatment:Use of artificial nutritionStrength of recommendation

STRONG IforalfoodintakeisinadequatedespitecounsellingandONS,werecommendtoinitiateenteral or,ifthisisnotsufficientorpossible,parenteral nutrition.



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C3 3 Medicalanticancer treatment:use of glutamineStrength of recommendation

NONE Thereisinsufficientevidencetorecommendglutaminesupplementationduringconventionalcytotoxic ortargetedtherapy.



ESPEN GL Oncology


C3 4 Medical anticancer treatment:fish oilStrength of recommendation

NONE Foroncological outcomesthereisinsufficientevidencetorecommendfororagainstfishoilsupplementationduringchemotherapy.


Questions for research Effects of longchain N3fatty acids onthe therapeutic index of chemotherapy

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C4 1 HSCT: ensuring adequate nutrition and physical activityStrength of recommendation

STRONG Duringhighdoseanticancerdrugtreatmentandstemcelltransplantationwerecommendtomaintainphysicalactivityandtoensureanadequatenutritionalintake.Thismayoftenrequireartificialnutrition.


Questions for research Effects of physical actvity onclinical outcome

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C4 1 HSCT:Artificial nutritionStrength of recommendation

WEAK Ifartificialnutritionisrequiredwesuggesttopreferenteraltubefeedingoverparenteral nutrition,unlessthereisseveremucositis orsymptomaticgastrointestinalGvHD.



ESPEN GL Oncology


C4 3 HSCT: Germfree foodStrength of recommendation

NONE Thereisnotenoughevidencetorecommendgermfreefoodforpatientsmorethan30daysafterallogeneictransplantation



ESPEN GL Oncology


C4 4 HSCT: glutamineStrength of recommendation

NONE Thereisnotenoughevidencetorecommendfororagainstglutaminetoreduceanticancertherapysideeffectsespeciallyinhighdoseprotocols.



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C5 1 Cancer survivors:Physical activityStrength of recommendation

STRONG Werecommendthatcancercontinuetoengageinregularphysicalactivityandavoidphysicalinactivity.Levelof evidence Low

Questions for research Effectsofphysicalactivityonphysicalfunction,recurrenceandsurvivalincancersurvivors

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C5 2 Cancer survivors:Healthy lifestyleStrength of recommendation

STRONG Incancersurvivorswerecommendahealthyweightandahealthy(primarilyplantbased)diet,highinfruits,vegetablesandwholegrains,andlowinfat,redmeatandalcohol.


Questions for research Effectsofhealthydietonoutcome

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C6 1 Incurable patients:screening and assessmentStrength of recommendation

STRONG Werecommendtoroutinelyscreen alladvanced,incurablecancerpatients whetherreceivingornotreceivinganticancertreatment forinadequatenutritionalintake,weightlossandlowbodymassindex,andiffoundatrisk,toassessthesepatientsfurther.


Questions for research Effects of malnutrition screening programs onquality of life inincurablecancer patients

ESPEN GL Oncology


C6 2 Incurable patients:ensuring nutritionalintakeStrength of recommendation

STRONG Nutritionalinterventionsshouldbeusedinpatientswithadvancedincurtable canceriftheirexpectedbenefitoutweighsthepotentialharmandthepatientwantsit.


Questions for research Effects of nutrtional care onquality of life inincurable cancer patients

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C6 3 Very advanced terminal phaseStrength of recommendation

STRONG Inpatientswhoareimminentlydyingtreatmentshouldbebasedoncomfort.Artificialhydrationandnutritionareunlikelytoprovideanybenefitformostpatients.



ESPEN GL Oncology

espen epaac gl group

CA

oncology Arendsanesthesiology Bachmannphysiology Baracosradiooncology Barthelemyhematology Bertzsurgery Bozzettisurgery Fearondietitian Httererradiooncology Kaasagastroenterology Krznaricnutrition Isenringpalliativemedicine Lairdnursing Larssonpharmacology Mhlebachinternalmedicine Muscaritolhealthscience Oldervollnutrition RavascoNutrition v.d.Schuerenoncology Solheimpalliativemedicine Strasser

ESPEN LavianoPreiser

(someexpertshaveseveralaffiliations)

AU

ESPEN Guidelines: nutrition support in cancer

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