Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

The Role of Registered Dietitians in Cancer Palliative Care: Responsibilities, Challenges, and Interdisciplinary Collaboration-A Cross-Sectional Survey

Registered dietitians (RDs) in palliative care help maintain patients' quality of life by providing personalized nutritional support that alleviates eating-related distress. This study aimed to clarify the role of RDs in palliative care by examining their responsibilities and challenges in caring for cancer patients. A nationwide mailed survey was conducted in 2022, focusing on RDs involved in cancer palliative care. One RD per facility was included from all 501 hospitals accredited by Japan's Ministry of Health, Labour and Welfare. Multivariate analysis identified factors related to collaboration with palliative care teams and challenges in cancer care. Responses from 325 RDs (63.9%) across 325 hospitals (63.9%) were analyzed. Among RDs who consistently collaborated with the palliative care team (PCT), significant associations (p < 0.05) were found with exclusive engagement in cancer/palliative care, providing nutritional counseling to inpatients, the frequency of ward rounds, and individualized meal provision. Challenges included the following: "I struggled with determining appropriate food choices for patients unable to eat", and "Metabolic complications like cachexia hindered my ability to provide adequate support". RDs play a crucial role in providing individualized meals for cancer patients through PCT collaboration and ward rounds. To ensure effective support in challenging situations, RDs must be exclusively engaged in palliative care and receive specialized education.

CLINICALLY ASSISTED NUTRITION AND HYDRATION AT THE END-OF-LIFE

The initiation, continuance, or discontinuance of clinically-assisted hydration and nutrition are some of the most challenging decisions in patients near the end-of-life. This article reviews the limited evidence to support or otherwise these medical treatments, and provides an overview of relevant clinical practice guidance. Essentially, decisions need to be individualised, and importantly regularly reviewed to ensure that the objectives of treatment are being achieved.

Enteral and parenteral nutrition in patients with cancer: complication rates compared-updated systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis is to compare the complication rates of enteral nutrition (EN) (oral or tube feeding (TF)) and parenteral nutrition (PN) in patients with any cancer.

METHODS

A systematic review of the literature until 2024 was conducted, including randomised controlled trials comparing EN and PN with respect to one or more of four endpoints: (1) infection, (2) nutrition support complications, (3) major complications and (4) mortality. A meta-analysis was conducted to generate summary effect estimates. Analysis was stratified by paediatric (≤21 years old) versus adults (>21 years old) patients. Subgroup analyses were conducted, based on including patients with (vs without) protein-energy malnutrition (PEM) and type of EN. Cumulative meta-analysis and leave-one-out analysis was conducted. Type I error was set at 0.05.

RESULTS

49 studies reporting on 6361 patients were included: 41 reported on adults and 8 on children. Among adults, the infection rate was higher for PN compared with EN (risk ratio=1.07, 95% CI: 1.00 to 1.14), with no differences in rates of nutrition support complications, major complications or mortality. Among children, there were no differences in all four endpoints. On cumulative meta-analysis, EN was overall marginally superior to PN for infection, although results fluctuated over time between superiority and no difference. Subgroup analysis found no differences in effects among patients with (vs without) PEM and patients provided with EN options of standard care versus TF.

DISCUSSION

From the perspective of complications, EN and PN are equivalent, with EN demonstrating marginal superiority for infection among adults.

Nutrition in Advanced Disease and End of Life Cancer Care

OBJECTIVES

This paper addresses nutritional challenges in advanced cancer and at the end of life and implications for oncology nursing practice.

METHODS

Recent literature and position statements regarding nutritional support in advanced disease and at the end of life were reviewed and case studies were developed to illustrate the nutritional issues facing patients and family members.

RESULTS

The literature and case examples illustrate the many issues confronting patients, families, and clinicians related to nutritional support including balancing the goals of comfort versus prolonged survival. Patients and families often face difficult decisions regarding the use of medically assisted nutrition and hydration while considering potential burdens and harms. Principles of ethics can be applied in the process of making these decisions.

CONCLUSIONS

Providing nutrition is one of the most important aspects of care provided by families for patients with advanced disease with deep meaning in these relationships, especially at the end of life. Oncology nurses provide valuable guidance in these decisions and offer support to both patients and families to ensure quality of life across the trajectory of cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can apply skills in patient and family caregiver education, communication, and support to help navigate nutritional decisions.

Efficacy of a WeChat-Based, Multidisciplinary, Full-Course Nutritional Management Program on the Nutritional Status of Patients With Ovarian Cancer Undergoing Chemotherapy: Randomized Controlled Trial

Background

As the most malignant type of cancer in the female reproductive system, ovarian cancer (OC) has become the second leading cause of death among Chinese women. Chemotherapy is the main treatment for patients with OC, and its numerous adverse effects can easily lead to malnutrition. It is difficult to centrally manage patients with OC in the intervals between chemotherapy. The use of WeChat, an effective mobile tool, in chronic disease management has been highlighted.

Objective

This study aimed to implement a continuous follow-up strategy and health monitoring based on the WeChat platform for patients with OC undergoing chemotherapy to ensure that each phase of chemotherapy was delivered on schedule and to improve the survival rate of patients with OC.

Methods

Participants were recruited and randomly assigned to either the WeChat-based nutrition intervention group or the usual care group. A self-administered general information questionnaire was used at enrollment to obtain basic information about the patients. The Patient-Generated Subjective Global Assessment (PG-SGA) Scale was used to investigate the nutritional status of the patients at 3 time points (T0=before the first admission to the hospital for chemotherapy, T1=2 weeks after the first chemotherapy, and T6=2 weeks after the sixth chemotherapy). The blood indices of patients were investigated through the inhospital health care system at 3 times（T0=before the first admission to the hospital for chemotherapy, T1=2 weeks after the first chemotherapy, and T6=2 weeks after the sixth chemotherapy). Patients in the intervention group were introduced to the nutrition applet, invited to join the nutrition management group chat, and allowed to consult on nutritional issues in private chats with nutrition management team members. Linear mixed models were used to analyze changes in each nutritional indicator in the 2 groups, with their baseline measurements as covariates; with group, time, and group-time interactions considered as fixed effects; and with patients considered as random effects.

Results

A total of 96 patients with OC undergoing chemotherapy were recruited into the study. Distribution was based on a 1:1 ratio, with 48 patients each in the nutrition intervention group and the usual care group. The attrition rate after the first chemotherapy session was 18.75%. The mixed linear model revealed that the group-based effect and the group-time interaction effect on PG-SGA scores were significant (F38,38=4.763, P=.03; F37,37=6.368, P=.01), whereas the time-based effect on PG-SGA scores was not (F38,38=0.377; P=.54). The findings indicated that the group-based effect, the time-based effect, and the group-time interaction effect on nutrition-inflammation composite indices were significant (F38,38=7.653, P=.006; F38,38=13.309, P<.001; F37,37=92.304, P<.001; F37,38=110.675, P<.001; F38,38=10.379, P=.002; and F37,37=5.289, P=.02).

Conclusions

This study provided evidence that a WeChat-based, multidisciplinary, full-course nutritional management program can significantly improve the nutritional status of patients with OC during chemotherapy.

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Malnutrition is Associated With Fatigue and Anxiety in Advanced Cancer Patients Admitted to Home Palliative Care

OBJECTIVE

Information regarding the nutrition profile of advanced cancer patients followed at home is lacking. The aim of this study was to assess the nutritional status of patients who were admitted to specialized home palliative care, and examine eventual factors associated with malnutrition.

DESIGN

Cross-sectional. Setting/subject: patients who were admitted to 2 specialized home palliative care programs.

PARTICIPANTS

A consecutive sample of patients admitted to home care was selected. Depression, anxiety, nausea, poor appetite, and poor well-being were measured by numerical scale 0-10. Mini nutritional assessment form (MNA-SF), fatigue assessment scale (FAS), and sarcopenia by SARC-F. were performed. The use of drugs used for anorexia, including corticosteroids, progestins, or others, was recorded.

RESULTS

Data of 135 patients were analyzed. Sixty-eight per cent and 77% of patients resulted to be malnourished and sarcopenic. In the multivariate regression analysis, anxiety (P = 0.036) and total FAS (P = 0.013) were independently associated with malnutrition. Fifty-five per cent of patients were receiving corticosteroids or megestol acetate. No significant associations with parameters examined were found.

CONCLUSION

The majority of advanced cancer patients admitted to home palliative care were malnourished independently of the primary tumor diagnosis. Indeed, fatigue and anxiety were independently associated with malnutrition.

Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer

PURPOSE

Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option.

METHODS

This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks.

RESULTS

A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5).

CONCLUSION

ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted hydration in patients with advanced cancer

PURPOSE

The provision of clinically assisted hydration (CAH) in patients with advanced cancer is controversial, and there is a paucity of specific guidance and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a sub-group to develop evidence-based guidance on the use of CAH in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials, respectively.

RESULTS

Due to the paucity of evidence, the sub-group was not able to develop a prescribed guideline, but was able to generate a number of "expert opinion statements": these statements relate to assessment of patients, indications for CAH, contraindications for CAH, procedures for initiating CAH, and reassessment of patients.

CONCLUSIONS

This guidance provides a framework for the use of CAH in advanced cancer, although every patient requires individualised management.

Vitamin and Mineral Supplementation, Weight Gain, and Poor Appetite in Patients With Cancer: Many Questions and Fewer Answers

Patients with cancer or with a history of cancer often seek nutritional advice. In turn, cancer health care providers are often asked questions related to nutrition and cancer. Should I take high-dose vitamins or other high-dose supplements? Should I take a regular-dose vitamin or other regular-dose nutritional supplements? Will I experience weight loss during postoperative chemotherapy? What should be my weight goals during and after adjuvant therapy? In the setting of advanced cancer, what should I do to keep my appetite and weight up? This review attempts to provide data-driven answers to some of these commonly posed questions.

Xerostomia in patients with advanced cancer: a scoping review of clinical features and complications

BACKGROUND

The aim of this project was to review the literature on dry mouth / xerostomia in patients with advanced cancer, with the objectives being to determine its prevalence, clinical features, and complications.

METHODS

Standard methodology was used to conduct this scoping review. Detailed searches of the Medline, Embase, CINAHL, and PsycInfo databases were conducted to identify relevant studies: eligible studies had to include patients with advanced cancer, and to contain details of clinical features and/or complications of xerostomia. Commercial bibliographic / systematic review software was used to support the process.

RESULTS

Forty-three studies were discovered from the database and hand searches. The studies included 23 generic symptom studies, eight "symptom cluster" studies, nine oral symptom / problem studies, and three xerostomia-specific studies. In depth data is described on the clinical features and complications of xerostomia, and on the "symptom clusters" including xerostomia, in this cohort of patients.

CONCLUSION

This review discovered a relatively small number of focused studies (involving a similarly small number of patients). Nonetheless, it demonstrates that xerostomia is a very common problem in patients with advanced cancer and is often associated with significant morbidity (and impairment of quality of life).

Taste disturbance in patients with advanced cancer: a scoping review of clinical features and complications

PURPOSE

The purpose of this scoping review is to appraise the published literature on taste disturbance in patients with advanced cancer, with the specific objectives being to determine its prevalence, clinical features and complications.

METHODS

This scoping review was conducted using the recommended methodological framework. A detailed search of databases (Medline, Embase, CINAHL and PsycInfo) was conducted to identify eligible studies: eligible studies needed to include patients with advanced cancer and needed to include details of clinical features and/or complications of taste disturbance. Standard bibliographic/systematic review software was used to store the records and manage the review process, respectively.

RESULTS

Twenty-five studies were identified from the database searches. The studies identified included eight physical and/or psychological symptom studies, six symptom cluster studies, five oral symptom studies and six taste and/or smell specific studies. Detailed data is presented on the clinical features and complications of taste disturbance and on the symptom clusters involving taste disturbance in this cohort of patients.

CONCLUSION

This scoping review identified a relatively small number of relevant studies involving a relatively small number of participants. Nevertheless, it confirms that taste disturbance is a common problem in patients with advanced cancer and is associated with significant morbidity because of the primary condition and the associated complications.

Psychosocial Factors and the Need for Multidisciplinary Support in Nutrition Counselling for Cancer Chemotherapy Patients

This study aims to identify the background factors and experiences of patients with cancer with eating-related problems who require nutrition counselling. Using a mixed-methods approach, this secondary analysis study was conducted on patients with head and neck, oesophageal, gastric, colorectal, or lung cancers who were receiving outpatient chemotherapy. They completed a questionnaire measuring nutrition impact symptoms, eating-related distress, and quality of life (QOL). Patients who required nutrition counselling were interviewed to identify the specific issues they experienced. We reported on nutritional status and nutrition impact symptoms in a previous study. Of the 151 participants, 42 required nutrition counselling. Background factors associated with nutrition counselling were related to the following psychosocial variables: small number of people in the household, undergoing treatment while working, low QOL, and eating-related distress. Four themes were extracted from the specific issues experienced by patients: motivation for self-management, distress from symptoms, seeking understanding and sympathy, and anxiety and confusion. The desire for nutrition counselling was attributable to 'anxiety caused by the symptoms' and 'confusion about the information on eating'. Healthcare professionals should promote multidisciplinary collaboration after considering the factors associated with the required nutrition counselling to provide nutritional support.

GI Symptoms in Pancreatic Cancer

This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.

Best Supportive Care of the Patient with Oesophageal Cancer

BACKGROUND

Oesophageal cancer patients have poor survival, and most are unfit for curative or systemic palliative treatment. This article aims to review the best supportive care for oesophageal cancer, focusing on the management of its most frequent or distinctive symptoms and complications.

METHODS

Evidence-based review on palliative supportive care of oesophageal cancer, based on Pubmed search for relevant clinical practice guidelines, reviews and original articles, with additional records collected from related articles suggestions, references and societies recommendations.

RESULTS

We identified 1075 records, from which we screened 138 records that were related to oesophageal cancer supportive care, complemented with 48 additional records, finally including 60 records. This review summarizes the management of oesophageal cancer-related main problems, including dysphagia, malnutrition, pain, nausea and vomiting, fistula and bleeding. In recent years, several treatments have been developed, while optimal management is not yet standardized.

CONCLUSION

This review contributes toward improving supportive care and decision making for oesophageal cancer patients, presenting updated summary recommendations for each of their main symptoms. A robust body of evidence is still lacking, and the best supportive care decisions should be individualized and shared.