The clinical and cost-effectiveness of supplemental parenteral nutrition in oncology

Enteral nutrition support in patients with cancer: association of short-term prognosis and medical costs with inflammation

BACKGROUND

Enteral nutrition (EN) is commonly used for nutritional support in patients with cancer. Whether inflammation, one of the driving factors of malnutrition and cancer, affects the association between EN and short-term prognosis and medical costs in patients with cancer remains unclear. We aimed to investigate the association between EN and short-term prognosis of patients with cancer and the effect of inflammation on EN-associated medical costs.

METHODS

This multicentre prospective cohort study evaluated patients with pathologically confirmed solid tumours. After admission, all patients who received EN, including oral or tube feeding, were assigned to the EN group. The log-rank test was used to identify the optimal cutoff values for inflammatory markers. Cox regression analysis was used to analyse the associations among EN, inflammation, and prognosis. Propensity score matching was used to balance biases between the EN and non-EN groups and validate the stability of the results.

RESULTS

A total of 5121 patients were included, with 2965 (57.90%) men and an average age of 59.06 (11.30) years. A total of 462 patients received EN, with 390 (84.4%) receiving oral nutritional supplementation. During the 90-day follow-up, 304 patients died. In the low inflammation group, there was no association between EN and short-term prognosis (hazard ratio [HR] = 0.92, 95% confidence interval [CI] = 0.39-2.18). In the high inflammation group, EN significantly improved the short-term prognosis (HR = 0.48, 95% CI = 0.30-0.76). In patients with low inflammation (p < 0.001), EN increased hospitalisation costs (p < 0.001) without reducing length of stay (LOS) (p = 0.15). In patients with high inflammation, EN did not increase hospitalisation expenses (p = 0.47) but reduced the LOS (p = 0.004).

CONCLUSION

EN can improve the short-term prognosis of patients with high inflammation and reduce LOS without increasing the hospitalisation expenses. Baseline inflammation levels may serve as effective indicators for personalised and precise EN treatment.

CLINICAL TRIAL REGISTRATION

ChiCTR1800020329 (chictr.org.cn).

The effect of preoperative supplementary parenteral nutrition on nutrition and inflammation in gastric cancer patients

OBJECTIVES

Supplemental parenteral nutrition (SPN) is recommended to add when enteral nutrition alone is not sufficient. This research aims to evaluate the effect of preoperative SPN in patients with gastric cancer.

METHODS

A total of 180 patients with gastric cancer were divided into three groups (60 patients per group) according to different nutritional support scheme. The primary endpoint was the changes in nutrition and inflammatory, while the secondary endpoint included the changes in prognosis.

RESULTS

Compared with the control group, there were significant differences in nutrition and inflammation related indicators in the oral nutrition supplement (ONS) group and the SPN + ONS group (P < 0.05). Compared with the ONS group, the SPN + ONS group showed significant differences in the above indicators (P < 0.05). However, no significant changes were observed in the incidence of complications, the postoperative exhaust time, and the hospitalization time.

CONCLUSIONS

Preoperative SPN had a positive effect on nutrition and inflammation of gastric cancer patients undergoing surgery, but had no significant effect on their prognosis.

Cancer-Related Malnutrition and the Role of Parenteral Nutrition in Cancer; A Narrative Review

The growing incidence rate of cancer and its associated morbidity and mortality prompts the need to identify factors that could improve the quality of life (QoL) and survival of a patient with cancer. Cancer-associated malnutrition is a common complication that could start at the early stages of cancer and could further develop into advanced cachexia. Response to treatment, length of hospital stay, progression of infection, and other complications of cancer including chemotherapy adverse events could all be influenced by the progression of malnutrition. Nutritional interventions may vary from oral to enteral and parenteral therapy. Parenteral nutrition (PN) therapy may benefit patients at certain stages of cancer in whom contraindications or inefficacy of other modalities of nutritional support are present. This method may seem invasive, costly, and risky but at the same time may improve certain patients' QoL and chance of survival. In trained settings with proper facilities, this method of nutritional support can benefit patients; However, the indication for starting PN must be carefully supervised considering that other nutritional support methods may be equally efficient and at the same time easier to access and apply.

Ready-to-Use Multichamber Bags in Home Parenteral Nutrition for Patients with Advanced Cancer: A Single-Center Prospective Study

Home parenteral nutrition (HPN) is increasingly prescribed for patients with advanced cancer. This therapy improves free-fat mass, quality of life and survival, but it is not free from complications, especially catheter-related bloodstream infections (CRBSIs). The use of commercial multichamber bags in HPN has not been extensively explored in oncologic patients and their association with complications is not well known. In this prospective cohort study, we included 130 patients with advanced cancer and HPN. We compared the effects of individual compounded bags (n = 87) vs. commercial multichamber bags (n = 43) on complications. There were no differences in any complication, including thrombosis (p > 0.05). There were 0.28 episodes of CRBSI per 1000 catheter days in the individual compounded bag group and 0.21 in the multichamber bag group (p > 0.05). A total of 34 patients were weaned off HPN, 22 with individual bags and 12 with multichamber bags (p = 0.749). Regarding survival when on HPN, the group with individual bags showed a median of 98 days (95% CI of 49-147), whereas those with multichamber bags showed a median of 88 days (95% CI of 43-133 (p = 0.913)). In conclusion, commercial multichamber bags for HPN in patients with advanced cancer are non-inferior when compared to individual compounded bags in terms of complications.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Pre-operative hypoalbuminemia is associated with increased mortality in patients undergoing surgery for gynecologic malignancy - A retrospective cohort study

OBJECTIF

L'objectif était d'évaluer l'association entre un faible taux d'albumine préopératoire sur la mortalité à court terme (mortalité à 90 jours et à 1 an) chez des patientes ayant subi une intervention chirurgicale à XXXX pour traiter une tumeur maligne gynécologique. MéTHODES: Cette étude de cohorte rétrospective porte sur des patientes ayant subi une intervention chirurgicale à XXXXX entre le 1^erjanvier 2010 et le 30 juin 2016 pour des tumeurs malignes gynécologiques. Des analyses de régression logistique univariée et multivariée ont été réalisées pour évaluer l'association entre le taux sérique d'albumine préopératoire et le taux de mortalité à 90 jours et à 1 an. L'analyse a d'abord examiné le taux d'albumine en tant que variable continue, puis comme variable catégorielle après la détermination des seuils cliniquement pertinents. RéSULTATS: Au total, 2 183 patientes ont été incluses dans l'analyse. Dans la population à l'étude, 51,8 % des patientes avaient un taux sérique d'albumine préopératoire inférieur à 35 g/L. L'étude a relevé deux points d'inflexion déterminants dans le taux de mortalité par taux sérique d'albumine. Le taux de mortalité était nettement le plus élevé chez les patientes ayant un taux d'albumine inférieur à 20 g/L (mortalité à 90 jours : 17,2 %; mortalité à 1 an : 31,9 %) et plus élevé chez celles ayant un taux d'albumine entre 20 et 25 g/L (mortalité à 90 jours : 2,7 %; mortalité à 1 an : 12,0 %) comparativement à celles ayant un taux d'albumine supérieur à 25 g/L (mortalité à 90 jours : 0,9 %; mortalité à 1 an : 3,9 %). Dans les analyses univariée et multivariée, une importante association indépendante a été établie entre l'hypoalbuminémie préopératoire et l'augmentation du taux de mortalité à 90 jours et à 1 an (p< 0,001).

CONCLUSION

L'hypoalbuminémie préopératoire est indépendamment associée à une augmentation du risque de mortalité à court terme. Les patientes qui sont opérées pour des tumeurs malignes gynécologiques et qui ont un taux sérique d'albumine préopératoire inférieur à 20 g/L présentent un risque très élevé de mortalité à court terme.

Supplemental parenteral nutrition in cancer care: why, who, when

Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.

Long-term changes in nutritional status and body composition in patients with malignant pancreatic disease - A systematic review

BACKGROUND AND AIMS

Patients with pancreatic cancer often experience significant deterioration in nutritional status over time. Malnutrition is complex and multifactorial, with malabsorption, pain, toxic dependencies, co-morbidities and malignant processes all playing a role. The aims of this systematic review were to assess nutritional changes over time and identify tolerance of nutritional intervention, thus identifying potential areas for further research to improve patient outcomes.

MATERIALS AND METHODS

A systematic review of MEDLINE, EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short-term measures, with only one data point, or in the wrong population, thirteen papers were selected for analysis (four trials in neo-adjuvant treatment, five in populations undergoing palliative treatment for pancreatic cancer, and four in mixed populations undergoing pancreatic resection).

RESULTS

Overall, studies were limited by predominantly retrospective designs, and poor control of potentially confounding variables. Meta-analysis could not be performed due to heterogenicity in study design and reporting methods. Surgery in mixed cohorts did not appear to result in weight loss. Only one small intervention study was identified. Patients with pancreatic cancer experienced a decline in nutritional status, with 44-63% of patients undergoing neoadjuvant chemotherapy having low muscle mass prior to starting treatment.

CONCLUSION

There is a paucity of data regarding nutritional intervention in pancreatic cancer. Future work should include the use of validated functional and clinical assessment tools to further explore the impact of nutritional intervention, and the relationship between nutritional status and outcome.