Dietary intake and nutritional indicators are transiently compromised during radiotherapy for rectal cancer

Diet and nutrition in patients who have received pelvic radiotherapy: A mixed-methods study to explore dietary habits, nutritional awareness, and experiences of nutritional care

OBJECTIVES

Individuals who have survived cancer may benefit from dietary modifications to improve quality of life and future health outcomes. The aim of this study was to explore dietary habits and experiences of nutritional support in patients with a cancer diagnosis who have received radiotherapy to the pelvic area.

METHODS

A mixed-methods approach was used. Individuals diagnosed with a pelvic cancer (anal, bladder, rectal, and cancers of the reproductive organs), either undergoing or having completed pelvic radiotherapy 6 to 24 mo previously, were invited to participate in a postal survey. A purposive subsample was also invited to take part in telephone interviews. Thematic analysis of interview data was undertaken and integrated with data from quantitative analysis.

RESULTS

The survey was completed by 254 (38%) respondents. Two-thirds of respondents (170) reported dietary changes since diagnosis; most notable changes were reduction of sugary foods (48%) and alcohol (41%). Receipt of support from the health care team was significantly associated with dietary change (odds ratio, 3.26; 95% confidence interval, 1.58-6.75); however, only 43% (108) had received dietary support from the health care team. Of the respondents, 68% (171) said they would like to receive additional dietary support. The effect of the condition on diet was highlighted in the theme "Impact of diagnosis and treatments on dietary choices." Self-management of disease was influenced by personal resources, social resources, comorbidities and disabilities, influence of work, regaining normality, and barriers to dietary changes.

CONCLUSION

Lack of routine provision of nutritional care to patients after a cancer diagnosis and patient interest in this area highlighted unmet needs in managing diet-related problems and leading a healthy future lifestyle.

Repurposing Individualized Nutritional Intervention as a Therapeutic Component to Prevent the Adverse Effects of Radiotherapy in Patients With Cervical Cancer

Worldwide, cervical cancer was the fourth leading cause of cancer death among women, while in Mexico was the second cause (5.28%). Cancer patients receiving chemotherapy and radiotherapy have a high risk of malnutrition secondary to the disease and treatment, affects the patient's overall, with adverse effects on gastrointestinal symptoms. These use affects the medical therapy. The aim of the present study was to evaluate the benefits on individualized nutritional therapy on decrease weight loss and gastrointestinal adverse effects and to consider these outcomes in pharmacology research, especially in repurposing drugs. We conducted a longitudinal design with two comparation groups with medical diagnosis of cervical cancer and received radiotherapy weekly, 1) the intervention group (nutritional intervention and counseling -INC-) with 20 participants and 2) control group (retrospective cohort -CG-) with 9 participants. Weekly body composition, dietary intake, adverse effects (gastrointestinal symptoms), glucose, hemoglobin, and blood pressure were analyzed during 4 to 5 weeks. Both groups had weight loss weekly (p = 0.013 and p = 0.043 respectively) but the CG vs INC presented loss fat-free mass ≥500g in 67 and of 37% respectively. By the end of the intervention a 25% of the INC group had <10 g/dL of hemoglobin vs 60% for the CG. To compare the dietary intake of vitamins (A and folic acid), fiber (p = 0.006), iron (p = 0.03) and energy (mainly carbohydrates) (p = 0.04) were according to the recommendations in INC group (p>0.05). The number needed to treat was 4 (95% CI, 2 to 13). The nutritional intervention and counseling weekly during radiotherapy in cervical cancer to maintain/improve muscle mass, hemoglobin, and dietary intake above 70% of the recommendations for INC group compared to the evidence. Adequate nutritional status was maintained and decrease the rate of complications, mainly gastrointestinal symptoms, in INC group. The efficacy of drug repurposing can improve through individualized nutritional therapy for preventing adverse effects of radiotherapy in patients with cervical cancer.

Nutritional Status in Patients with Esophageal Cancer Receiving Chemoradiation and Assessing the Efficacy of Usual Care for Nutritional Managements

BACKGROUND

Malnutrition is prevalent in esophageal cancer patients which affects cancer prognosis. The purpose of this study was a comprehensive assessment of nutritional status during Chemoradiation (CRT).

METHODS

Newly diagnosed adults with esophageal cancer were recruited for this study. Patient-Generated- Subjective Global Assessment (PG-SGA), anthropometric indices, body composition, dietary intake, laboratory tests, and nutritional-related complications were assessed before, after, and 4 to 6 weeks after CRT.

RESULTS

Seventy-one cases were enrolled. The mean age was 66.8±12 years. Patients' mean weight loss was 2.42±2.4 kilograms during treatment. A significant reduction observed in mean MUAC (26.68±4.9 vs. 25.42±5.1 cm), fat mass percentage (24.11±11.8 vs. 22.8±12.5), fat free mass index (16.87±2.4 vs. 16.47±2.6 kg/m2) and hand grip strength (43.2±19 vs. 36.1±20 kg) during CRT (all p-values <0.0001). We had also a non-significant change in mean energy intake (19.5±11 vs. 18.3±11 kcal/kgw. day) and protein intake (0.56±0.4 vs. 0.66±0.5 g/kgw.day) during CRT.  In our assessment before, immediately after and 4-6 weeks following CRT, we recorded energy intake insufficiency in 55.7%, 58.7% and 27.3% and protein intake inadequacy in 89.8%, 89.1% and 72.7% of cases, respectively. The most common complications were dysphagia (56.7%), anorexia (25%), and constipation (47.9%) at admission. Dysphagia improved in some cases (42%), but anorexia (35%), early satiety (25%), Esophagitis (25%), dysosmia (21%) and dysgeusia (17%) were increased as CRT complication. yet, 25% of patients had dysphagia and 34.4% had constipation 4-6 weeks after CRT. The twelve-months mortality was significantly associated with lower BMI after CRT, primary PG-SGA score, weight loss, BMI<18.5, MUAC, physical performance, living in rural or urban areas, addiction.

CONCLUSION

Our study demonstrated a high prevalence of malnutrition among esophageal cancer patients which worsened during Chemoradiotherapy. Our findings warrant early screening and monitoring of nutritional status and effective nutritional interventions with symptoms management during treatment in these patients.
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Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection

BACKGROUND

Malnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m², weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes.

RESULTS

Of the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models.

CONCLUSIONS

Malnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.

Food Insecurity among Cancer Patients Enrolled in the Supplemental Nutrition Assistance Program (SNAP)

Purpose: Food insecurity, which leads to adverse health outcomes, has even more severe implications for cancer patients. Yet medically underserved cancer patients are more likely to be food insecure than the general population.Methods: This study is a cross-sectional analysis of intake data from patients who participated in the Integrated Cancer Care Access Network (ICCAN). ICCAN is a specialized program that addresses socioeconomic barriers to cancer care among underserved cancer patients in NYC. This study utilized ICCAN data from 2011 to 2017. The USDA food insecurity score, self-reported SNAP receipt, and SNAP eligibility based on household income were compared between SNAP and non-SNAP recipients.Results: 681 patients were assessed for food insecurity. Sixty-nine percent of participants lived in food insecure households. Despite SNAP assistance, most SNAP recipients (68%) were food insecure; 69% of respondents who did not receive SNAP were also food insecure.Conclusions: Underserved cancer patients who receive SNAP are still food insecure, hence at more significant risk for its associated negative outcomes. Supplemental programs for patients with chronic diseases are needed in clinics with large low income populations. SNAP benefits should account for the additional financial burden posed by treatment costs and exceptional circumstances faced by cancer patients.

Deterioration of nutritional status of patients with locally advanced cervical cancer during treatment with concomitant chemoradiotherapy

BACKGROUND

In Mexico, 80% women with cervical cancer are diagnosed at locally advanced stages and are treated with concomitant chemoradiotherapy. The treatment modality and catabolic state confer a nutritional risk. The present study aimed to thoroughly evaluate the nutritional status and change in body composition of locally advanced cervical cancer (LACC) patients throughout treatment.

METHODS

An observational prospective study, carried out at the Mexican National Cancer Institute, included 55 LACC patients. Nutritional status was evaluated before, during and after treatment, using anthropometric, dietary and biochemical measurements. Body composition was analysed using computed tomography images obtained at the time of diagnosis and approximately 4 months after treatment completion. Clinical outcomes were associated with changes in body composition.

RESULTS

At the time of diagnosis, no patients were clinically malnourished, although 33.3% presented sarcopenia and most were overweight; by the end of treatment, 69% became clinically malnourished and 58% were sarcopenic. Average weight loss was 7.4 kg (P = 0.001). Adequacy of energy intake was reduced to 54%, obtained predominantly from carbohydrates. By the week 9, 62.8% patients became anemic and 34.5% had low albumin levels. Body composition analysis revealed that patients lost both, muscle and adipose tissues, although 27% patients were muscle depleted by the end of treatment. Patients who lost ≥10% skeletal muscle presented a higher tumour recurrence (hazard ratio = 2.957, P = 0.006) and a tendency towards diminished overall survival (hazard ratio = 2.572, not significant).

CONCLUSIONS

The nutritional status of cervical cancer patients deteriorates during treatment with concomitant chemoradiotherapy and, most importantly, muscle loss impacts the clinical outcome of patients.

A prospective study on the radiation therapy associated changes in body weight and bioelectrical standardized phase angle

BACKGROUND & AIMS

Standardized phase angle (SPA) is a value derived from bioelectrical impedance phase angle analysis and has been recognized as marker of nutritional risk and clinical status of cancer patients. This study aimed to evaluate the changes in SPA during radiation therapy of cancer patients and identify possible nutritional and clinical determinants of these changes.

METHODS

Nutritional assessment was performed before the initiation and at the end of the radiotherapy. It included anthropometrics and bioelectrical impedance analysis. A generalized linear mixed model was used to evaluate the effects of selected independent variables on the changes in standardized phase angle.

RESULTS

A total of 104 patients entered the study and those with complete information were included in the analysis (n = 62). Most patients (61%) were at clinical stage I and II, the most prevalent irradiation site was the pelvis (39%) and 98% were well nourished or overweight. According to the regression analysis, changes in body weight and irradiation at head and neck/upper abdomen and thorax were associated with standardized phase angle modifications during radiotherapy. Clinical stage and radiation dose were not associated with changes in standardized phase angle. Compared to baseline values, for every 1 kg weight reduction during the radiation therapy, the standardized phase angle also decreased by 0.107 (p < 0.0001).

CONCLUSIONS

In well nourished or overweight patients, weight loss during radiation therapy is closely associated with decrease in standard phase angle.

Food insecurity: limitations of emergency food resources for our patients

Rates of food insecurity are high among medically underserved patients. We analyzed food pantry responsiveness to the needs of medically ill cancer patients in New York City with the intent ofidentifying barriers to available food resources. Our data, collected from 60 pantries, suggest that the emergency food system is currently unable to accommodate patient needs. Accessibility issues include restricted service hours and documentation requirements. Food services were limited in quantity of food provided and the number of nutritious, palatable options. Additional emergency food resources and long-term approaches that provide ongoing food support to patients throughout their treatment period are needed.

Early supplementation of parenteral nutrition is capable of improving quality of life, chemotherapy-related toxicity and body composition in patients with advanced colorectal carcinoma undergoing palliative treatment: results from a prospective, randomized clinical trial

AIM

Patients suffering from advanced colorectal cancer can experience unintended weight loss and/or treatment-induced gastrointestinal toxicity. Based on current evidence, the routine use of parenteral nutrition (PN) for patients with colorectal cancer is not recommended. This study evaluates the effect of PN supplementation on body composition, quality of life (QoL), chemotherapy-associated side effects and survival in patients with advanced colorectal cancer.

METHOD

Eighty-two patients with advanced colorectal cancer receiving a palliative chemotherapy were prospectively randomized to either oral enteral nutrition supplement (PN-) or oral enteral nutrition supplement plus supplemental PN (PN+). Every 6 weeks body weight, body mass index (BMI), chemotherapy-associated side effects and caloric intake were assessed, haemoglobin and serum albumin were measured. Body composition was assessed by body impedance analysis, and QoL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQC30 questionnaire.

RESULTS

No differences were evident at baseline between the groups for age, sex, diagnosis, weight, BMI or QoL. A difference in BMI was observed by week 36, whereas differences of the mean body cell mass could be observed from week 6, albumin dropped significantly in the PN- group in week 36 and QoL showed significant differences from week 18. Chemotherapy-associated side effects were higher in PN-. The survival rate was significantly greater in the PN+ group.

CONCLUSION

A supplementation with PN slows weight loss, stabilizes body-composition and improves QoL in patients with advanced colorectal cancer. Furthermore, it can reduce chemotherapy-related side effects.

Factors contributing to weight loss, nutrition-related concerns and advice received by adults undergoing cancer treatment

PURPOSE

The opinions and perceptions of patients are crucial throughout the cancer treatment process, as treatment is more effective when patient concerns are addressed. The present study was designed to identify history of weight loss since initiation of cancer treatment, specific nutrition-related problems and concerns (including food aversions, factors contributing to poor food intake and perceived nutrition-related problems), nutrition advice received by cancer treatment patients, and relations between items studied and reported unintentional weight loss.

MATERIAL AND METHODS

A 23-item survey was completed by a convenience sample of 79 patients from treatment centers at a community hospital and oncologist office, of which 66 were included in the final analysis. Descriptive statistics included means, standard error, 95% confidence intervals, and frequency distributions. ANOVA and Pearson chi2 were used to evaluate differences in responses by treatment type and relations between items studied and reported unintentional weight loss. Twenty-seven (41%) of the 66 (27 males, 39 females) were receiving radiation, 20 (30%) chemotherapy, and 19 (29%) both.

RESULTS

Unintentional weight loss occurred for 41% since initiation of treatment (13% deficit), 27% had food aversions, 52% reported factors contributing to poor food intake, 50% had nutrition-related problems since initiation of treatment, and 89% had received nutrition advice. The prevalence of unintentional weight loss was significantly greater among patients who reported having food aversions, factors that had contributed to poor food intake, or nutrition-related problems.

CONCLUSIONS

This study demonstrates that adults commonly present with factors that contribute to poor food intake and perceive nutrition-related problems resulting from cancer treatment. Further, there is a greater prevalence of unintentional weight loss among those who report food aversions and perceive nutrition-related problems. The findings provide a framework that may aid healthcare providers in recognizing nutrition-related concerns and needs of cancer patients.

Time patterns of changes in biomarkers, symptoms and histopathology during pelvic radiotherapy

Acute radiation proctitis was evaluated before, during and after radiotherapy (RT) for prostate cancer. The main aims of the study were to examine changes related to the increasing radiation dose, and identify surrogate markers of gastrointestinal (GI) reaction to radiation. Twenty consecutive prostate cancer patients scheduled for 7 weeks of conformal RT were prospectively included in a longitudinal study assessing symptoms, inflammation in rectal mucosa biopsies, and blood and stool samples at four time points (before RT and 2, 6 and 11 weeks after start of RT). Blood samples were examined for acute phase response-related markers, fatty acids (FAs), vitamin E and leukotriene B(4) (LTB(4)). Lactoferrin, calprotectin and S100A12 were measured in stool samples and FAs in biopsies from rectal mucosa. The increase in histopathological inflammation reached a maximum 2 weeks after start of RT. Symptoms of GI toxicity increased with higher radiation dose and had not returned to pre-treatment level 4 weeks after RT. Lactoferrin concentrations in stool increased significantly at week 6. Significant decreases of vitamin E, leukocyte count, hemoglobin and some groups of FAs were discovered, while a few FAs increased significantly during the study period. Time courses vary between the selected indicators of acute radiation proctitis. The biopsy grading of inflammatory changes were most intense 2 weeks into the treatment period while symptoms continued to increase until week 6. Lactoferrin in stool samples could be a non-invasive marker of GI inflammation during RT. A transient decrease in vitamin E and some FAs during RT warrants further studies.

Impact of nutrition on quality of life during cancer

PURPOSE OF REVIEW

This review addresses the relationship between nutritional intervention and quality of life in oncology patients.

RECENT FINDINGS

Nutrition related symptoms, such as anorexia and weight loss, reflect impaired nutritional status, which is often associated with reduced quality of life. Malnutrition can be related to reduced response or tolerance to cancer treatment. Early nutritional intervention may positively impact on quality of life and enhance clinical response in oncology patients.

SUMMARY

Nutritional intervention should be considered as a supportive measure within the global oncology strategy. In curative oncology care, it contributes to reduced postoperative infection rate, better control of cancer-related symptoms, shortened length of hospital stay and improved tolerance to treatment. In palliative care, the nutritional intervention focuses on controlling symptoms, thus improving quality of life. The evaluation of nutritional status should include an assessment of quality of life in order to optimize nutritional treatment for patients' individual requirements. Because of the potentially clinically relevant impact of nutritional intervention on quality of life, nutritional care should be included in any antineoplastic strategy.

Nutritional intervention and quality of life in adult oncology patients

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.