ESPEN Guidelines: nutrition support in cancer

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ESPEN Guidelines: nutrition support in cancer

Transcript of 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

  • ESPEN GL Oncology

    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

  • ESPEN GL Oncology

    Section B1,Statement1

    B1 1 ScreeningStrength of recommendation

    STRONG Todetectnutritionaldisturbancesatanearlystage,werecommendtoregularlyevaluatenutritionalintake,weightchangeandBMI,beginningwithcancerdiagnosisandrepeateddependingonthestabilityoftheclinicalsituation.

    Levelof evidence Very low

    Questions for research relationshipofscreeningtoassessmentinterventionsandclinicaloutcomes

  • ESPEN GL Oncology

    Section B1,Statement2

    B1 2 AssessmentStrength of recommendation

    STRONG Inpatientswithabnormalscreening,werecommendobjectiveandquantitativeassessmentofnutritionalintake,nutritionimpactsymptoms,physicalperformanceandthedegreeofsystemicinflammation.

    Levelof evidence Very low

    Questions for research Linkingoutcomesfromcurrentandfutureinterventiontrialswithappropriatescreeningandassessmenttools

  • ESPEN GL Oncology

    Section B2,Statement1

    B2 1 Energy requirementsStrength of recommendation

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

    Levelof evidence Low

    Questions for research improvepredictionofenergyrequirementsintheindividualpatient

  • ESPEN GL Oncology

    Section B2,Statement2

    B2 2 ProteinintakeStrength of recommendation

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

    Questions for research effectonoutcomeofincreasedsupplyandcompositionof protein/aminoacids

  • ESPEN GL Oncology

    Section B2,Statement3

    B2 3 Choice of energy substratesStrength of recommendation

    STRONG Inmostpatientsgeneralrecommendationsareapplicable.Inweightlosingpatientswithadvancedcancerwerecommendafatintakeof3550%oftotalenergyrequirement.

    Levelof evidence Low

    Questions for research effectofhighfatonoutcomeinspecificpatientgroups

  • ESPEN GL Oncology

    Section B2,Statement4

    B2 4 Vitaminsand trace elementsStrength of recommendation

    STRONG WerecommendthatvitaminsandmineralsbesuppliedinamountsapproximatelyequaltotheRDAanddiscouragetheuseofhighdosemicronutrientsintheabsenceofspecificdeficiencies.

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section B3,Statement1

    B3 1 Efficacy of nutritionalinterventionStrength of recommendation

    STRONG Werecommendnutritionalinterventiontoincreaseoralintakeincancerpatientswhoareabletoeatbutaremalnourishedoratriskofmalnutrition.Thisincludesdietaryadvice,thetreatmentofsymptomsandderangementsimpairingfoodintake,andofferingoralnutritionalsupplements.

    Levelof evidence Moderate

    Questions for research effectofadviceandONSonoutcome

  • ESPEN GL Oncology

    Section B3,Statement2

    B3 2 Lowefficacy of special dietsStrength of recommendation

    STRONG Werecommendagainstdietaryprovisionslikeanticancerdietswhichrestrictenergyintakeinpatientswithoratriskof malnutrition.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section B3,Statement3

    B3 3 Modes of nutritionStrength of recommendation

    STRONG Werecommendenteral nutritioniforalnutritionremainsinadequatedespitenutritionalinterventions,andparenteralnutritionifenteral nutritionisnotsufficientorfeasible.

    Levelof evidence Moderate

    Questions for research effectofEN or PNorcombinations onoutcome

  • ESPEN GL Oncology

    Section B3,Statement4

    B3 4 Refeeding syndromeStrength of recommendation

    STRONG Iforalfoodintakehasbeendecreasedseverelyforaprolongedperiodoftime,werecommendtoincreaseenteralorparenteral nutritiononlyslowlyoverseveraldaysandtotakeadditionalprecautionstopreventarefeeding syndrome.

    Levelof 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,Statement5

    B3 5 Home artificial nutritionStrength of recommendation

    STRONG Inpatientswithchronicinsufficientdietaryintakeand/oruncontrollablemalabsorption werecommendhome artificialnutritioninsuitablepatients

    Levelof evidence Low

    Questions for research Effect of longterm ENand PNonclinical outcome

  • ESPEN GL Oncology

    Section B4,Statement1

    B4 1 Exercise incombination with nutritionStrength of recommendation

    STRONG Werecommendmaintenanceorincreasedlevelofphysicalactivityincancerpatientsduringandaftertreatmenttosupportmusclemass,physicalfunctionandmetabolicpattern.

    Levelof evidence High

    Questions for research effectofphysicalactivityonoutcome

  • ESPEN GL Oncology

    Section B4,Statement2

    B4 2 Type of exercise recommendedStrength of recommendation

    WEAK Wesuggestindividualizedresistanceexercisetomaintainmusclestrengthandmusclemassduringtreatment.Levelof evidence Low

    Questions for research effectofresistanceandenduranceexerciseonoutcome

  • ESPEN GL Oncology

    Section B5,Statement1

    B5 1 Corticosteroids to increase appetiteStrength of recommendation

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

    Levelof evidence High

    Questions for research Methods to counteract corticosteroidrelated muscle wasting

  • ESPEN GL Oncology

    Section B5,Statement2

    B5 2 Progestins to increase appetiteStrength of recommendation

    WEAK Wesuggesttoconsiderusing progestins toincreasetheappetiteofanorecticcancerpatientsforalimitedperiodoftimebuttobeaware ofpotentialserioussideeffects.

    Levelof evidence High

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

  • ESPEN GL Oncology

    Section B5,Statement3

    B5 3 Cannabinoids to improve appetiteStrength of recommendation

    WEAK Wesuggesttoconsidercannabinoids toattempttoimprovetastedisordersandanorexiaincancerpatientsLevelof evidence Low

    Questions for research Effects of cannabinoids onnutritionalstate inanorectic cancer patients withtastealterations

  • ESPEN GL Oncology

    Section B5,Statement4

    B5 4 Androgensto increase muscle massStrength of recommendation

    NONE Thereareinsufficientdatatorecommendonandrogenicsteroidstoincreasemuscle massLevelof evidence High

    Questions for research MechanismandlongtermeffectsofSARMs inpatientswithcachexia.

  • ESPEN GL Oncology

    Section B5,Statement5

    B5 5 Amino acidsStrength of recommendation

    NONE Thereisnotenough clinicaldatatorecommendthesupplementationwithbranchedchainaminoacidsormetabolitestoimprovefatfreemass.

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section B5,Statement6

    B5 6 Non steroidal antiinflammatory drugsStrength of recommendation

    NONE Thereisnotenoughdatatorecommendnonsteroidalantiinflammatory drugstoimprovebodyweightinweightlosingcancerpatients.

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section B5,Statement7

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

    WEAK Incancerpatientsundergoingchemotherapyatriskofweightloss,wesuggesttousethesupplementationwithlongchainn3fattyacidsorfishoiltostabilize/improveappetite,foodintake,leanbodymassandbodyweight.

    Levelof evidence Moderate

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

  • ESPEN GL Oncology

    Section C1,Statement1

    C1 1 Enhanced recovery aftersurgery (ERAS)careStrength of recommendation

    STRONG Forallcancerpatientsundergoingeithercurativeresectionalorpalliativesurgerywerecommendmanagementwithinanenhancedrecoveryaftersurgeryprogram.

    Levelof evidence High

    Questions for research optimalcomponentsincludingnutritionofERASprotocolforoncologypatients

  • ESPEN GL Oncology

    Section C1,Statement2

    C1 2 Surgery:Multimodaloncological pathwayStrength of recommendation

    STRONG Forapatientundergoingrepeatedsurgeryaspartofamultimodaloncological pathway,managementofeachsurgicalepisodeshouldbewithinanERASprogramme.

    Levelof evidence Low

    Questions for research roleofmultimodalrehabilitationduringprolongedoncological therapy

  • ESPEN GL Oncology

    Section C1,Statement3

    C1 3 Surgery:Careafterhospital dischargeStrength of recommendation

    STRONG InsurgicalcancerpatientsatmoderateorseverenutritionalriskwerecommendappropriateONS/enteral nutritionalsupportbothbeforeandfollowingdischargefromhospital.

    Levelof evidence Moderate

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

  • ESPEN GL Oncology

    Section C1,Statement4

    C1 4 Traditional perioperativecareStrength of recommendation

    STRONG InupperGIcancerpatientsundergoingsurgicalresectioninthecontextoftraditional perioperative carewerecommendoral/enteral immunonutrition.

    Levelof evidence High

    Questions for research Role ofimmunonutrition forupperGIcancerpatientsmanagedwithinanERASpathway

  • ESPEN GL Oncology

    Section C2,Statement1

    C2 1 RT:Ensuring adequate nutritionalintakeStrength of recommendation

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

    Levelof evidence Moderate

    Questions for research

  • ESPEN GL Oncology

    Section C2,Statement2

    C2 2 RT:Use of tube feedingStrength of recommendation

    STRONG Werecommendthattubefeedingmaybedoneusingtransnasal orPEGinRTinducedseveremucositis orinheadneck/throracic cancerswithobstructivetumormasses.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C2,Statement3

    C2 3 RT:Maintaining swallowing functionStrength of recommendation

    STRONG WerecommendthatpatientsshouldbeencouragedandeducatedonhowtomaintaintheirswallowingfunctionduringEN.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C2,Statement4

    C2 4 Radiationinduced diarrhea: glutamineStrength of recommendation

    STRONG WedonotrecommendusingglutamineduringpelvicRTtopreventRTinducedenteritis/diarrhea.Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C2,Statement5

    C2 5 Radiationinduced diarrhea:probioticsStrength of recommendation

    NONE ThereisnotenoughdatatorecommendLactobacilluscontainingprobiotics toreduceradiationinduced diarrhea.Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C2,Statement6

    C2 6 RT:Use of parenteralnutritionStrength of recommendation

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

    Levelof evidence Moderate

    Questions for research

  • ESPEN GL Oncology

    Section C3,Statement1

    C3 1 Medical anticancer treatment:Ensuring adequate nutritionStrength of recommendation

    STRONG Duringanticancerdrugtreatmentwerecommendtoensureanadequatenutritionalintakeandtomaintainphysicalactivity.

    Levelof evidence Very low

    Questions for research

  • ESPEN GL Oncology

    Section C3,Statement2

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

    STRONG IforalfoodintakeisinadequatedespitecounsellingandONS,werecommendtoinitiateenteral or,ifthisisnotsufficientorpossible,parenteral nutrition.

    Levelof evidence Very low

    Questions for research

  • ESPEN GL Oncology

    Section C3,Statement3

    C3 3 Medicalanticancer treatment:use of glutamineStrength of recommendation

    NONE Thereisinsufficientevidencetorecommendglutaminesupplementationduringconventionalcytotoxic ortargetedtherapy.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C3,Statement4

    C3 4 Medical anticancer treatment:fish oilStrength of recommendation

    NONE Foroncological outcomesthereisinsufficientevidencetorecommendfororagainstfishoilsupplementationduringchemotherapy.

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section C4,Statement1

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

    STRONG Duringhighdoseanticancerdrugtreatmentandstemcelltransplantationwerecommendtomaintainphysicalactivityandtoensureanadequatenutritionalintake.Thismayoftenrequireartificialnutrition.

    Levelof evidence Very low

    Questions for research Effects of physical actvity onclinical outcome

  • ESPEN GL Oncology

    Section C4,Statement2

    C4 1 HSCT:Artificial nutritionStrength of recommendation

    WEAK Ifartificialnutritionisrequiredwesuggesttopreferenteraltubefeedingoverparenteral nutrition,unlessthereisseveremucositis orsymptomaticgastrointestinalGvHD.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C4,Statement3

    C4 3 HSCT: Germfree foodStrength of recommendation

    NONE Thereisnotenoughevidencetorecommendgermfreefoodforpatientsmorethan30daysafterallogeneictransplantation

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C4,Statement4

    C4 4 HSCT: glutamineStrength of recommendation

    NONE Thereisnotenoughevidencetorecommendfororagainstglutaminetoreduceanticancertherapysideeffectsespeciallyinhighdoseprotocols.

    Levelof evidence Low

    Questions for research

  • ESPEN GL Oncology

    Section C5,Statement1

    C5 1 Cancer survivors:Physical activityStrength of recommendation

    STRONG Werecommendthatcancercontinuetoengageinregularphysicalactivityandavoidphysicalinactivity.Levelof evidence Low

    Questions for research Effectsofphysicalactivityonphysicalfunction,recurrenceandsurvivalincancersurvivors

  • ESPEN GL Oncology

    Section C5,Statement2

    C5 2 Cancer survivors:Healthy lifestyleStrength of recommendation

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

    Levelof evidence Low

    Questions for research Effectsofhealthydietonoutcome

  • ESPEN GL Oncology

    Section C6,Statement1

    C6 1 Incurable patients:screening and assessmentStrength of recommendation

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

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section C6,Statement2

    C6 2 Incurable patients:ensuring nutritionalintakeStrength of recommendation

    STRONG Nutritionalinterventionsshouldbeusedinpatientswithadvancedincurtable canceriftheirexpectedbenefitoutweighsthepotentialharmandthepatientwantsit.

    Levelof evidence Low

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

  • ESPEN GL Oncology

    Section C6,Statement3

    C6 3 Very advanced terminal phaseStrength of recommendation

    STRONG Inpatientswhoareimminentlydyingtreatmentshouldbebasedoncomfort.Artificialhydrationandnutritionareunlikelytoprovideanybenefitformostpatients.

    Levelof evidence Low

    Questions for research

  • 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