NUTRITIONAL SUPPORT IN

CANCER PATIENTS

Kartika W. Taroeno-Hariadi
Div. Hematology and Medical Oncology, Department of Internal Medicine
Faculty of Medicine, Gadjah Mada University - Dr Sardjito Hospital AMC
Yogyakarta
 Outline
• Weight loss and cancer cachexia-anorexia
syndrome among cancer patients
• Consequences of malnutrition in cancer patients
• How can clinically relevant under nutrition is
diagnosed?
• Nutritional support. Does it improve nutritional
status? Does it affect prognosis?
• Evidence based-benefits of nutritional support in
cancer patients
 Weight loss among cancer patients
• Weight loss and eating related concerns are commonly found in
advanced cancer patients

Number of Number of Pooled 95% CI

studies patients Prevalence
Fatigue 17 6,727 74 % (63;83)
Pain 37 21,917 71 % (67;74)
Lack of energy 6 1,827 69 % (57;79)
Weakness 14 14,910 60 % (51;68)
Appetite loss 37 23,112 53 % (48;59)
Nervousness 5 727 48 % (39;57)
Weight loss 17 13,167 46% (34;59)

Journal of Pain and Symptoms Management 2007:34; 94-104

 PREVALENCE OF WEIGHT LOSS

• Weight loss plus anorexia, Cancer type Weight

fatigue, and asthenia is the loss
marker of cachexia. Urogenital 9 %
Gynecologycal 15 %
• Prevalence of weight loss is Colorectal cancer 33 %
8-84% Lung cancer 46 %
Head and Neck Cancer 67 %
• It depends on cancer type Esophageal and gastrointestinal 57-80 %
and stage Pancreatic Cancer 87 %

Critical Reviews in Oncology/Hematology 87 (2013) 172–200

Weight loss is a common toxicity in Nasophryngeal Cancer treated
with CCRT in dr Sardjito Hospital 2009
NCI CTC Grade
0 1 2 3 4-5

No of % No of % No of % No of % No of %
patients patients patients patients patients

Hemoglobine 0 22 95.65 0 0 1 4.35

Neutrophils 8 34.78 8 34.78 5 21.74 1 4.35 1 4.35
Platelets 9 39.1 13 56.52 0 1 4.35 0
Xerostomia 0 0 2 8.69 21 91.30 0
Dysphagia 0 0 2 8.69 21 91.30 0
Mucositis 0 0 11 47.83 12 52.17 0
Sensory 23 100 0 0 0 0
neuropathy
Weight loss 2 8.69 5 21.74 11 47.83 5 21.74 0

Taroeno-Hariadi , Kurnianda et al. South East Asia Medical Oncology Forum 2009
Progression of Weight Loss

Argiles. ESMO Symposium on Nutrition, Zurich 2009

Stages of Cancer Cachexia

Fearon et al. The LancetOncology 2011;12:489-495

 Multivariate Cause of Cancer Related Cachexia

Critical Reviews In Oncology/Hematology 2000:34:137-168 European Journal of Oncology Nursing 2005;9:S51-S63

CORI CYCLE as MAIN ADAPTATION ASSOCIATED WITH TUMOR BURDEN

Tisdale. Nature Review of Cancer 2002;2: 826

Skeletal Muscle Wasting during Cachexia

Argilles et al. Nature Reviews of Cancer 2014;14:754-762

Browning Adipose Tissue in Cancer Cachexia

Argilles et al. Nature Reviews of Cancer 2014;14:754-762

Cachexia as Multi-organ Dysfunction

Argilles et al. Nature Reviews of Cancer 2014;14:754-762

Nutritional Complication Associated with
Chemotherapy

ESMO Handbook of Nutrition and Cancer 2011

Nutritional Complication Associated with
Radiotherapy

ESMO Handbook of Nutrition and Cancer 2011

Impact of Cancer Related Malnutrition
Cancer-related
Malnutrition

Reduced
Increased risk of post
Increased infection rate tolerance/response to
operative complication
chemo/radiotherapy

Reduced performance
Increased cost Social burden
status

Decreased Quality
of Life
Clinical Nutrition 2007:26;289-301
Cancer Cachexia Reduced Survival in Many Cancer Types
Recognition and Assessment of
Cancer-related Malnutrition
Nutritional Assessment
Measurement of Nutrient balance
• Nutrition input
• Nutrition out put

Measurement of Body Composition

• BMI
• Anthopometry

Measurement of Inflammatory activity

• C-reactive protein
• Leucocyte count

Measurement of function
• Respiratory function, muscle function
• Immune function

ESMO Handbook Nutrition and Cancer 2011

Nutritional Screening Tools

ESMO Handbook Nutrition and Cancer 2011

 Nutritional Risk Screening 2002 (NRS 2002)

Initial Screening Yes No

1 Is BMI < 20.5

2 Has the patient lost weight within the last
3 months ?
3 Has the patients had a reduced dietary
intake in the last week ?
4 Is the patient severely ill ? (e.g. in
intensive therapy )
 Diagnostic Criteria for Cachexia
Decreased muscle strength
Fatique
Anorexia
Low fat free mass index
Weight loss at least 5 %
in ≤ 12 month
Increase inflammatory level
( CRP, IL-6)
Anemia Hb < 12 g/dL
Low serum albumin < 3.2 g/dL

Donohue et al 2010 Gastroentrology Research and Practice

Nutritional Support in Cancer Patients
A man with NSCLC. Previous body weight was 70kg.
At the time of diagnosis he was 65 kg.
No asthenia, no loss of appetite syndromes.
He received radiotherapy and chemotherapy.
He suffered from severe mucositis , nausea, and
vomiting. His body weight became 55 kg in 8 weeks
 WEIGHT LOSS
10-20%
NRS score 4
Loss of Appetite
Asthenia
Under intensive treatment
Oncology Cases
NUTRITIONAL SUPPORT IS
INDICATED

How
When What
much
Planning Nutritional Support
Enteral Nutrition Indication and Goal in Cancer
Patients

Preventing and
Treating Reducing Side effects
Under-nutrition Of Anti Tumor agents

Enhancing
Improving QOL
Anti tumor activity

ESPEN guidelines 2006

 When to start EN ?

• Under nutrition is already exist

• It is anticipated that the patients will be
unable to eat > 7 days
• Inadequate ( <60 % estimated energy
expenditure) for more then 10 days

European Society of Parenteral and Enteral Nutrition Guideline 2006

 Standard Oral Nutrition Supplement during
Radiation / Chemotherapy

• SONS are generally used • SONS is depended on

when patients are not
severely compromised and
maintain some ability to
continue oral feeding.
• Dietary counseling and
nutritional supplement
improve weight
loss faster and improved
QOL
Clinical Review in Oncology/Hematology 2013; 87:172-200
patient compliance.
• Liquid SONS are better
than solids
• Clinical benefit occurs
when SONS intake 250-
600 kcal/day
• Less effect seen in cancer
patient receiving
chemotherapy
 Nutritional Requirement for Cancer Patients

Nutritional Components Requirement and benefits Level of Evidence

Calorie per day 30-35 kcal/kgBW/day B
Protein 1.2 – 3 g/kgBW/day B
BCAA Improved appetite C
Lipid 30-50% total non protein calorie C
requirement
Immunomodulator Maintain normal immune A
(arginin, glutamin, nucleic function especially in major
acids, essential fatty acids) surgery, head and neck cancer,
and gastrointestinal cancer
Prebiotic and Probiotics Maintan gastrointesninal health E
ESPEN GUIDELINE FOR EN IN CANCER

ESPEN guideline 2006

Parenteral Nutrition in Cancer Patients during
Chemotherapy

ESPEN Guideline 2012

 Summary
• Undernutrition and cachexia occur frequently
in cancer patients and are indicators of poor
prognosis.
• EN should be started if undernutrition already
exists
• Parenteral Nutrition only recommended when
EN is not possible