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    Clinical Nutrition xxx (2016) 1e38

    Contents lists avai

    Clinical Nutrition

    journal homepage: ht tp: / /www.elsevier .com/locate/c lnu

    ESPEN Guideline

    ESPEN guidelines on nutrition in cancer patients*

    Jann Arends a, Patrick Bachmann b, Vickie Baracos c, Nicole Barthelemy d, Hartmut Bertz a,Federico Bozzetti e, Ken Fearon f, y, Elisabeth Htterer g, Elizabeth Isenring h, Stein Kaasa i,Zeljko Krznaric j, Barry Laird k, Maria Larsson l, Alessandro Laviano m, Stefan Mhlebach n,Maurizio Muscaritoli m, Line Oldervoll i, o, Paula Ravasco p, Tora Solheim q, r,Florian Strasser s, Marian de van der Schueren t, u, Jean-Charles Preiser v, *

    a Department of Medicine I, Medical Center e University of Freiburg, Faculty of Medicine, University of Freiburg, Germanyb Centre Regional de Lutte Contre le Cancer Leon Berard, Lyon, Francec Department of Oncology, University of Alberta, Edmonton, Canadad Centre hospitalier universitaire, Liege, Belgiume University of Milan, Milan, Italyf Western General Hospital, Edinburgh, United Kingdomg Medical University of Vienna, Austriah Bond University, Gold Coast, Australiai Norwegian University of Science and Technology, Trondheim, Norwayj University Hospital Center and School of Medicine, Zagreb, Croatiak Beatson West of Scotland Cancer Centre, Edinburgh, United Kingdoml Karlstad University, Karlstad, Swedenm University of Rome La Sapienza, Roma, Italyn University of Basel, Basel, Switzerlando The Norwegian Heart and Lung Association (LHL), Oslo, Norwayp Faculty of Medicine, University of Lisbon, Lisbon, Portugalq European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, NorwegianUniversity of Science and Technology, Norwayr Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norways Oncological Palliative Medicine, Clinic Oncology/Hematology, Dept. Internal Medicine and Palliative Center, Cantonal Hospital St. Gallen, Switzerlandt VU University Medical Center (VUmc), Amsterdam, Netherlandsu HAN University of Applied Sciences, Nijmegen, Netherlandsv Erasme University Hospital, Universite Libre de Bruxelles, Brussels, Belgium

    a r t i c l e i n f o

    Article history:Received 21 July 2016Accepted 28 July 2016


    * These guidelines have been officially endorsed bySociety of Clinical Oncology (CSCO).* Corresponding author.

    E-mail address: jean-charles.preiser@erasme.ulb.ay Deceased. 2016 European Society for Clinical Nutr

    Please cite this article in press as: Arends J, e10.1016/j.clnu.2016.07.015

    s u m m a r y

    Cancers are among the leading causes of morbidity and mortality worldwide, and the number of newcases is expected to rise significantly over the next decades. At the same time, all types of cancertreatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophis-tication, precision and in the power to target specific characteristics of individual cancers. Thus, whilemany cancers may still not be cured they may be converted to chronic diseases. All of these treatments,however, are impeded or precluded by the frequent development of malnutrition and metabolic de-rangements in cancer patients, induced by the tumor or by its treatment.

    These evidence-based guidelines were developed to translate current best evidence and expertopinion into recommendations for multi-disciplinary teams responsible for identification, prevention,and treatment of reversible elements of malnutrition in adult cancer patients.

    The guidelines were commissioned and financially supported by ESPEN and by the European Part-nership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group wereselected by ESPEN to include a range of professions and fields of expertise.

    the European Society of Surgical Oncology (ESSO), the European Association for Palliative care (EAPC) and the Chinese (J.-C. Preiser).

    ition and Metabolism. Published by Elsevier Ltd. All rights reserved.

    t al., ESPEN guidelines on nutrition in cancer patients, Clinical Nutrition (2016),

  • J. Arends et al. / Clinical Nutrition xxx (2016) 1e382

    Hematopoietic stem cell transplantationPalliative care

    Nutrition assessmentNutrition therapyExercise training

    Please cite this article in press as: Arends J,10.1016/j.clnu.2016.07.015

    We searched for meta-analyses, systematic reviews and comparative studies based on clinical ques-tions according to the PICO format. The evidence was evaluated and merged to develop clinical rec-ommendations using the GRADE method. Due to the deficits in the available evidence, relevant still openquestions were listed and should be addressed by future studies.

    Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect onclinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolicmetabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standardoperating procedures, responsibilities and a quality control process should be established at eachinstitution involved in treating cancer patients.

    All cancer patients should be screened regularly for the risk or the presence of malnutrition. In allpatients e with the exception of end of life care e energy and substrate requirements should be met byoffering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. How-ever, benefits and risks of nutritional interventions have to be balanced with special consideration inpatients with advanced disease. Nutritional care should always be accompanied by exercise training. Tocounter malnutrition in patients with advanced cancer there are few pharmacological agents andpharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activityand adopt a prudent diet.

    2016 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rightsreserved.

    GL Nutrition in Cancer Patients e Outline

    Abbreviations usedAML acute myeloic leukemia

    O. Methods

    ASCO American Society of Clinical OncologyBCAA branched-chain amino acidsBIA bio impedance analysisBMI body mass indexBMT bone marrow transplantationBMR basal metabolic rateCHT chemotherapyCRP C-reactive proteind dayDEXA dual-energy x-ray absorptiometryDHA 22:6 docosahexaenoic acidECOG Eastern Cooperative Oncology GroupEAPC European Association for Palliative CareEFSA European Food Safety AuthorityEN enteral nutritionEPA 20:5 eicosapentaenoic acidERAS enhanced recovery after surgeryESMO European Society for Medical OncologyFDA U.S. Food and Drug AgencyGI gastrointestinalGL guidelineGPS Glasgow Prognostic ScoreGvHD graft versus host diseaseHCT hematopoietic stem cell transplantationHMB -hydroxy methyl butyrateHTA 16:4 hexadecatetraenoic acidIGF-I insulin-like growth factor IISOO International Society of Oral OncologyLOS length of hospital stay (days)MA megestrol acetateMASCC Multinational Association of Supportive Care in CancermGPS modified Glasgow Prognostic Score

    O1. Basic informationO2. MethodsO3. Post-publication impact

    A. BackgroundA1. Catabolic alterations in cancer patientsA2. Effects on clinical outcomeA3. Aims of nutrition therapy

    B. General concepts of treatment relevant to all cancer patientsB1. Screening and assessmentB2. Energy and substrate requirementsB3. Nutrition interventionsB4. Exercise trainingB5. Pharmaconutrients and pharmacological agents

    C. Interventions relevant to specific patient categoriesC1. SurgeryC2. RadiotherapyC3. Curative or palliative anticancer drug treatmentC4. High-dose chemotherapy and hematopoietic stem celltransplantation (HCT)C5. Cancer survivorsC6. Patients with advanced cancer receiving no anticancertreatment

    Appendix A. Supplementary data: Evidence tablesReferences

    MNA Mini Nutritional AssessmentMNI Medical Nutrition InternationalMST Malnutrition Screening ToolMUST Malnutrition Universal Screening ToolNSAID non-steroidal anti-inflammatory drugsNSCLC non-small cell lung cancerONS oral nutritional supplementsN-3 fatty acids polyunsaturated fatty acids of the N-3 or omega-3 seriesPAL physical activity levelPEG percutaneous endoscopic gastrostomyPG-SGA patient-generated Subjective Global AssessmentPICO populations of interest, interventions, comparisons, outcomesPN parenteral nutritionQoL quality of lifeRCT randomized controlled trialREE resting energy expenditureRT radiotherapySARM selective androgen receptor modulator

    Chapter O: Methods

    O1. Basic information

    1. Terms and abbreviationsA cancer patient is a patient with a cancer diagnosis who is

    either waiting for or on cancer directed treatment, on symptomatictreatment, and/or receiving palliative care.

    Patients cured from their cancer are termed cancer survivors.Pharmaconutrients are nutrients supplied in pharmacolog-

    ical doses to modulate immune and metabolic functions and exerteffects on clinical outcome.

    et al., ESPEN guidelines on nutrition in cancer patients, Clinical Nutrition (2016),

  • (continued )

    SGA Subjective Global AssessmentTEE total energy expenditureTHC tetrahydrocannabinolTNF tumor necrosis factorTPN total parenteral nutritionWHO World Health Organization