Malnutrition and Chemotherapy-Induced Nausea and Vomiting: Implications for Practice

The potential impact of exercise upon symptom burden in adolescents and young adults undergoing cancer treatment

PURPOSE

Adolescents and young adults (AYAs) experience vast symptom burden resulting from cancer treatment-related toxicities (TRTs). Evidence supports integrated exercise to mitigate several TRTs in other cohorts; however, evidence in AYAs is lacking. Conventional reporting of TRTs adopts a maximum grade approach failing to recognise the trajectory over time, of persistent, or lower grade toxicities. Alternatively, longitudinal analysis of toxicities over time (ToxT) may provide clinically meaningful summaries of this data. We evaluated the longitudinal impact of an exercise intervention on TRTs in AYAs undergoing cancer treatment.

METHODS

A prospective, randomised trial allocated participants to a 10-week exercise intervention (EG) or control group (CG) undergoing usual care. Detailed information on TRTs was collected throughout the intervention. All TRTs were graded per the Common Terminology Criteria for Adverse Events (CTCAE v5.0).

RESULTS

Forty-three (43) participants (63% male, mean age 21.1 years) were enrolled. When categorised to reflect the maximal worst grade experienced (Grade 0, Grade 1-2 and ≥ Grade 3), the CG reported an increased incidence of severe fatigue (≥ Grade 3) compared with the EG (p = 0.05). No other differences between groups were evident (p > 0.05). ToxT analysis of the four most common toxicities (fatigue, pain, nausea and mood disturbances) demonstrated no difference in the mean grade of each over time (p > 0.05).

CONCLUSION

A 10-week exercise intervention reduces the severity of fatigue in AYAs undergoing treatment. While the ToxT approach provided insight into the toxicity profile, adequately powered studies are needed to better understand these differences within a homogenous sample.

TRIAL REGISTRATION

(ACTRN12620000663954) 10th June 2020.

Chemotherapy-Induced Nausea and Vomiting in Patients With Breast Cancer: Risk Factor and Predictive Model Using Classification and Regression Tree (CART)

Introduction Chemotherapy-induced nausea and vomiting (CINV) is a common and debilitating adverse effect of breast cancer chemotherapy. The incidence of CINV in the first cycle of chemotherapy is essential, as it sets the tone for anticipatory CINV and the overall patients' treatment experience. We aimed to investigate the risk factors of first cycle CINV in breast cancer patients and to develop a classification and regression tree (CART) model to predict its occurrence. Methods This is a cross-sectional study that nested in a prospective cohort. One hundred and thirty-seven female breast cancer patients receiving highly emetogenic chemotherapy were included. We used the Common Toxicity Criteria for Adverse Events (CTCAE) version 4.0 to assess patient-reported nausea and vomiting in the first chemotherapy cycle. The proportional difference of CINV between sociodemographic and clinicopathologic variables was analyzed using chi-square, and the strength and direction of the relationship with CINV were analyzed using bivariable logistic regression analysis. Multivariable logistic regression and CART analysis included variables with a p-value <0.250. Results The incidence of first-cycle CINV was 43.1%. The chi-square test revealed a significant association between insurance status and CINV (p<0.001) and between the stage at diagnosis and CINV (p<0.001). Underweight to normal body mass index (BMI) patients are significantly associated with an increased risk of first-cycle CINV (OR =2.17, 95% CI 1.03-4.56, p =0.041). In hierarchical order, three variables (stage at diagnosis, BMI, and age) were included in the CART model, which significantly influenced the probability of first cycle CINV. With an accuracy of 61.3%, the CART model had a sensitivity of 28.8%, a specificity of 85.9%, a positive predictive value of 60.7%, a negative predictive value of 61.5%, and an area under curve (AUC) of 0.602.  Conclusion Breast cancer patients with an underweight to normal BMI have a higher risk of developing first-cycle CINV. Our CART model was better at identifying patients who would not develop CINV than those who would. The CART model may provide a simple and effective way to individualize patient care for first-cycle CINV.

Medication Prescription, Common Side-effects, and Nutritional Status are Associated in Patients With Chronic Kidney Disease

OBJECTIVE

Chronic kidney disease (CKD) is associated with metabolic, nutritional, and extra-renal changes, as well as a high rate of comorbidities, which necessitates the prescription of numerous medications. Patients with CKD often experience poor nutritional status related to disease severity and prescribed medication; however, this association has not been investigated in depth. Therefore, this study aimed at investigating the association between prescribed medication and nutritional status in patients with CKD.

METHODS

Assessment of nutritional status was performed using anthropometric and functional measurements and by biochemical measures. Patient history and the number and type of currently prescribed medications were collected from patients' records. We evaluated the total number and the number of specific medicines with common or very common side-effects of nausea or xerostomia.

RESULTS

Two hundred seventeen patients with CKD were included in this cross-sectional study (n = 112 with pre-dialysis CKD stages 3-5, n = 33 with hemodialysis, and n = 72 with kidney transplant). On average, patients were prescribed nine medications concurrently. The number of prescribed medications was inversely associated with mid-upper arm circumference, skinfold thickness triceps, handgrip strength, serum albumin, and hemoglobin after adjustment for age, sex, and kidney function. Prescription of medications with nausea as a side-effect showed similar associations, whereas prescription of medications with xerostomia as a side-effect was associated with lower handgrip strength.

CONCLUSION

Medication prescription was associated with poor nutritional status in patients with CKD, and monitoring of nutritional status in patients with CKD with long medication lists is warranted to identify and treat patients with poor nutritional status.

Drinking Ice-Cold Water Reduces the Severity of Anticancer Drug-Induced Taste Dysfunction in Mice

Taste disorders are common adverse effects of cancer chemotherapy that can reduce quality of life and impair nutritional status. However, the molecular mechanisms underlying chemotherapy-induced taste disorders remain largely unknown. Furthermore, there are no effective preventive measures for chemotherapy-induced taste disorders. We investigated the effects of a combination of three anticancer drugs (TPF: docetaxel, cisplatin and 5-fluorouracil) on the structure and function of mouse taste tissues and examined whether the drinking of ice-cold water after TPF administration would attenuate these effects. TPF administration significantly increased the number of cells expressing apoptotic and proliferative markers. Furthermore, TPF administration significantly reduced the number of cells expressing taste cell markers and the magnitudes of the responses of taste nerves to tastants. The above results suggest that anticancer drug-induced taste dysfunction may be due to a reduction in the number of taste cells expressing taste-related molecules. The suppressive effects of TPF on taste cell marker expression and taste perception were reduced by the drinking of ice-cold water. We speculate that oral cryotherapy with an ice cube might be useful for prophylaxis against anticancer drug-induced taste disorders in humans.

The GDF15-GFRAL Pathway in Health and Metabolic Disease: Friend or Foe?

GDF15 is a cell activation and stress response cytokine of the glial cell line-derived neurotrophic factor family within the TGF-β superfamily. It acts through a recently identified orphan member of the GFRα family called GFRAL and signals through the Ret coreceptor. Cell stress and disease lead to elevated GDF15 serum levels, causing anorexia, weight loss, and alterations to metabolism, largely by actions on regions of the hindbrain. These changes restore homeostasis and, in the case of obesity, cause a reduction in adiposity. In some diseases, such as advanced cancer, serum GDF15 levels can rise by as much as 10-100-fold, leading to an anorexia-cachexia syndrome, which is often fatal. This review discusses how GDF15 regulates appetite and metabolism, the role it plays in resistance to obesity, and how this impacts diseases such as diabetes, nonalcoholic fatty liver disease, and anorexia-cachexia syndrome. It also discusses potential therapeutic applications of targeting the GDF15-GFRAL pathway and lastly suggests some potential unifying hypotheses for its biological role.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice

PURPOSE

Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities.

METHODS

This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted.

RESULTS

Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89).

CONCLUSIONS

Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

Cyclophosphamide-Induced Disruptions to Appetitive Qualities and Detection Thresholds of NaCl: Comparison of Single-Dose and Dose Fractionation Effects

Chemotherapy is one of the most common treatments for cancer; however, a side effect is often altered taste. This study examined how cyclophosphamide, a chemotherapy drug, affects salt taste in mice. On the basis of previous findings, it was predicted that cyclophosphamide-induced disruptions in salt taste would be observed near days 2-4, 8-12, and 22-24 posttreatment, and that multiple, smaller doses would cause more severe disruptions to taste. To test these predictions, two experiments were performed, one using brief access testing to measure appetitive qualities, and another using operant conditioning to measure detection thresholds. After a single 100 mg/kg cyclophosphamide injection, peak alterations in brief access lick rates were seen near days 5-8 and 15 posttreatment, whereas peak alterations in detection thresholds were seen days 6, 14, and 20 posttreatment. After five 20 mg/kg injections of cyclophosphamide, brief access lick rates revealed disruptions only on postinjection day 8 whereas thresholds appeared to cycle, gradually increased to and decreased from peak elevations on posttreatment days 4, 10, 15, 20, and 23. Although salt taste functions were disrupted by cyclophosphamide, the patterns of these disruptions were less severe and shorter than expected from cell morphology studies, suggesting a functional adjustment to maintain behavioral accuracy. Fractionation of cyclophosphamide dosing had minimum effect on brief access responses but caused longer, cyclic-like disruptions of detection thresholds compared to single-dose administration.

Cyclophosphamide and the taste system: Effects of dose fractionation and amifostine on taste cell renewal

Chemotherapy often causes side effects that include disturbances in taste functions. Cyclophosphamide (CYP) is a chemotherapy drug that, after a single dose, elevates murine taste thresholds at times related to drug-induced losses of taste sensory cells and disruptions of proliferating cells that renew taste sensory cells. Pretreatment with amifostine can protect the taste system from many of these effects. This study compared the effects of a single dose (75 mg/kg) of CYP with effects generated by fractionated dosing of CYP (5 doses of 15 mg/kg), a dosing approach often used during chemotherapy, on the taste system of mice using immunohistochemistry. Dose fractionation prolonged the suppressive effects of CYP on cell proliferation responsible for renewal of taste sensory cells. Fractionation also reduced the total number of cells and the proportion of Type II cells within taste buds. The post-injection time of these losses coincided with the life span of Type I and II taste cells combined with lack of replacement cells. Fractionated dosing also decreased Type III cells more than a single dose, but loss of these cells may be due to factors related to the general health and/or cell renewal of taste buds rather than the life span of Type III cells. In general, pretreatment with amifostine appeared to protect taste cell renewal and the population of cells within taste buds from the cytotoxic effects of CYP with few observable adverse effects due to repeated administration. These findings may have important implications for patients undergoing chemotherapy.

Agreement between the Malnutrition Universal Screening Tool and the Patient-Generated Subjective Global Assessment for Cancer Outpatients Receiving Chemotherapy: A Cross-Sectional Study

Malnutrition is a common occurrence in cancer. Early detection of malnutrition is imperative but often overlooked in busy clinical routine. This study aimed to assess the agreement between malnutrition universal screening tool (MUST) and the patient-generated subjective global assessment (PG-SGA) to detect risk of malnutrition in a medical oncology outpatient setting. A cross-sectional study was conducted with 100 adult patients with cancer receiving chemotherapy. Nutrition screening and assessment were performed using MUST and PG-SGA, respectively. Sensitivity, specificity, predictive values, kappa agreement, and receiver operating characteristics (ROC) curve were used to compare MUST with PG-SGA. Prevalence of malnutrition or risk of malnutrition among subjects was 45% according to the MUST. Body mass index (BMI) against PG-SGA indicated a low capacity to detect malnutrition with 28.9% sensitivity and 96.4% specificity. Unintentional weight loss in the last 3-6 mo against PG-SGA resulted in 55.6% sensitivity and 98.2% specificity. MUST against PG-SGA resulted in 86.7% sensitivity and 94.5% specificity. MUST indicated a perfect agreement with PG-SGA (Kappa = 0.81; P < 0.05) and highest area under the ROC curve (AUC ROC = 0.91). MUST has high level of agreement with PG-SGA to detect chemotherapy outpatients at risk of malnutrition.

Latent Inhibition Reduces Nocebo Nausea, Even Without Deception

BACKGROUND

Nocebo nausea is a debilitating and prevalent side effect that can develop after conditioning occurs between cues present in the treatment context and the experience of nausea. Interventions that retard conditioning may therefore be able to reduce nocebo nausea.

PURPOSE

To test whether 'latent inhibition', where pre-exposing cues in the absence of an outcome retards subsequent learning about those cues, could reduce nocebo nausea in healthy adults.

METHODS

We examined this possibility using a Galvanic Vestibular Stimulation (GVS) model of nausea in healthy participants, with pre-exposure to the treatment cues achieved using a placebo version of GVS.

RESULTS

In Experiment 1 we found clear evidence of conditioned nocebo nausea that was eradicated by latent inhibition following pre-exposure to placebo stimulation. Experiment 2 tested whether deception, which may be unethical in clinical settings, was necessary to produce latent inhibition by including an open pre-exposure group informed they were pre-exposed to placebo stimulation. Experiment 2 replicated the latent inhibition effect on nocebo nausea following deceptive pre-exposure from Experiment 1 and found that open pre-exposure was just as effective for reducing nocebo nausea. In both experiments, there was an interesting discrepancy found in expectancy ratings whereby expectations appeared to drive the development of conditioned nocebo nausea, but were not responsible for its suppression through latent inhibition.

CONCLUSIONS

These findings have significant clinical implications. Applying open pre-exposure in clinical settings may effectively and ethically reduce the development of nocebo effects for nausea and other conditions via latent inhibition.

[The Relationships among Chemotherapy-Induced Nausea and Vomiting (CINV), Non-Pharmacological Coping Methods, and Nutritional Status in Patients with Gynecologic Cancer]

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) can cause severe malnutrition. However, relationships between CINV levels, non-pharmacological coping methods, and nutritional status of female cancer patients have rarely been investigated. Therefore, this study aimed to analyze their relationships in gynecologic cancer patients.

METHODS

Participants receiving a highly and moderately emetogenic chemotherapy were recruited. The level of CINV was assessed using a numeric rating scale. Coping methods were determined using multiple-choice self-report questionnaires and categorized into seven types for statistical analysis. Nutritional status was evaluated using biochemical and anthropometric parameters.

RESULTS

Among all the 485 patients, 200 eligible inpatients were included. Despite the administration of prophylactic antiemetics, 157 patients (78.5%) still experienced CINV, and several used nonmedically recommended coping methods, such as just enduring the symptom or rejecting food intake. A total of 181 patients (90.5%) had nutritional disorders. Although the level of CINV was indirectly related to the occurrence of nutritional disorders, patients who rejected food (β=1.57, p=.023) and did not use physical measures (β= -1.23, p=.041) as coping methods were under the high risk of nutritional disorders.

CONCLUSION

Korean gynecologic cancer patients had high levels of CINV and were at high risk of nutritional disorders, which may be related to the use of nonscientific coping methods, possibly due to cultural backgrounds and lack of proper nutritional program. Therefore, developing a culturally appropriate educational program for the cancer patients with CINV is urgently needed.

The Effect of a Standardized Ginger Extract on Chemotherapy-Induced Nausea-Related Quality of Life in Patients Undergoing Moderately or Highly Emetogenic Chemotherapy: A Double Blind, Randomized, Placebo Controlled Trial

Ginger supplementation could be an effective adjuvant treatment for chemotherapy-induced nausea (CIN). The aim of this clinical trial was to address significant methodological limitations in previous trials. Patients (N = 51) were randomly allocated to receive either 1.2 g of standardised ginger extract or placebo per day, in addition to standard anti-emetic therapy, during the first three cycles of chemotherapy. The primary outcome was CIN-related quality of life (QoL) measured with the Functional Living Index- Emesis (FLIE) questionnaire. Secondary outcomes included acute and delayed nausea, vomiting, and retching as well as cancer-related fatigue, nutritional status, and CIN and vomiting-specific prognostic factors. Over three consecutive chemotherapy cycles, nausea was more prevalent than vomiting (47% vs. 12%). In chemotherapy Cycle 1, intervention participants reported significantly better QoL related to CIN (p = 0.029), chemotherapy-induced nausea and vomiting (CINV)-related QoL (p = 0.043), global QoL (p = 0.015) and less fatigue (p = 0.006) than placebo participants. There were no significant results in Cycle 2. In Cycle 3, global QoL (p = 0.040) and fatigue (p = 0.013) were significantly better in the intervention group compared to placebo. This trial suggests adjuvant ginger supplementation is associated with better chemotherapy-induced nausea-related quality of life and less cancer-related fatigue, with no difference in adverse effects compared to placebo.

Effect of transcutaneous electrical acupoint stimulation combined with palonosetron on chemotherapy-induced nausea and vomiting: a single-blind, randomized, controlled trial

BACKGROUND

Chemotherapy-induced nausea and vomiting adversely affects the quality of life of patients who receive chemotherapy via intravenous infusion or transcatheter arterial chemoembolization (TACE). This study aimed to investigate the clinical effects of transcutaneous electrical acupoint stimulation (TEAS) on nausea and vomiting after TACE.

METHODS

A total of 142 patients who received TACE with cisplatin for primary or metastatic liver cancer were assigned to the active-acupuncture (n = 72) or placebo-acupuncture (n = 70) groups using a covariate-adaptive randomization at a ratio of 1:1. The acupoints Hegu (LI4), Neiguan (P6), and Zusanli (ST36) were stimulated twice daily for 6 days. The effects of TEAS on nausea and vomiting were assessed by using occurrence rate and severity of these symptoms. Anorexia scale and M. D. Anderson Symptom Inventory (MDASI) scores were secondary endpoints and were used to assess the effect of TEAS on patient appetite and quality of life. The safety of the treatments was also monitored.

RESULTS

Between the two groups, the differences in occurrence rates and severities of nausea and vomiting after TACE were not significant (all P > 0.05). From the second day after TACE, anorexia scores were significantly lower in the active-acupuncture group than in the placebo-acupuncture group and continued to decrease over time with treatment (all P values less than 0.01). On days 0, 1, and 2, the mean MDASI scores for the active-acupuncture group were slightly lower than those for the placebo-acupuncture group, but the differences were not statistically significant (all P > 0.05). No significant differences were found between the two groups in the occurrence rate of any adverse event (P > 0.05).

CONCLUSION

TEAS appears to be a safe and effective therapy to relieve patients' gastrointestinal discomfort after chemotherapy. Trial registration NCT01895010. Registered 21 June 2013.

Ginger-Mechanism of action in chemotherapy-induced nausea and vomiting: A review

Despite advances in antiemetic therapy, chemotherapy-induced nausea and vomiting (CINV) still poses a significant burden to patients undergoing chemotherapy. Nausea, in particular, is still highly prevalent in this population. Ginger has been traditionally used as a folk remedy for gastrointestinal complaints and has been suggested as a viable adjuvant treatment for nausea and vomiting in the cancer context. Substantial research has revealed ginger to possess properties that could exert multiple beneficial effects on chemotherapy patients who experience nausea and vomiting. Bioactive compounds within the rhizome of ginger, particularly the gingerol and shogaol class of compounds, interact with several pathways that are directly implicated in CINV in addition to pathways that could play secondary roles by exacerbating symptoms. These properties include 5-HT3, substance P, and acetylcholine receptor antagonism; antiinflammatory properties; and modulation of cellular redox signaling, vasopressin release, gastrointestinal motility, and gastric emptying rate. This review outlines these proposed mechanisms by discussing the results of clinical, in vitro, and animal studies both within the chemotherapy context and in other relevant fields. The evidence presented in this review indicates that ginger possesses multiple properties that could be beneficial in reducing CINV.

Longitudinal assessment of nutritional risk in patients under chemo or radiotherapy

Summary Objective: To compare nutritional risk in adult patients undergoing chemotherapy and radiotherapy in the beginning, middle, and end of oncologic treatment. Method: This prospective, comparative study included 83 adult patients, 44 undergoing chemotherapy (CT group) and 39 undergoing radiotherapy (RT group) at an oncology treatment center. Nutritional risk was determined by NRS-2002 in the beginning, middle, and end of therapy. Statistical analysis was performed using Statistica 8.0 software. Results: No differences in food intake or body mass index were observed between the CT (24.6±4.8 kg/m²) and RT groups (25.0±5.9 kg/m², p=0.75). Weight loss in the preceding 3 months was detected in 56.8% of CT group and 38.5% of RT group (p=0.09). The weight loss percentage compared with the usual weight within 3 months was greater (p<0.001) in the CT (11.4±6.5%) than in the RT group (3.9±6.8%). In the beginning of treatment, we observed high percentages of patients at moderate (18.2 vs. 15.4%, p=0.73) and high nutritional risk (61.4 vs. 48.7%, p=0.25), with no statistical difference between the CT and RT groups, respectively. During therapy, the nutritional risk remained unaltered in both groups. In the end of therapy, the majority of patients were at moderate (18.2 vs. 12.8%, p=0.50) or severe nutritional risk (50.0 vs. 51.3%, p=0.91), in the CT and RT groups, respectively, regardless of the type of oncologic treatment. Conclusion: The high prevalence of patients at moderate or high nutritional risk in the beginning of treatment indicates the need for an early and continuous follow-up of the nutritional status of patients undergoing oncologic treatment.

Rolapitant improves quality of life of patients receiving highly or moderately emetogenic chemotherapy

PURPOSE

Addition of rolapitant to standard antiemetic therapy improved protection against chemotherapy-induced nausea and vomiting (CINV) in phase 3 trials of patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Here, we assessed the impact of CINV on the daily lives of patients receiving HEC or MEC using the Functional Living Index-Emesis (FLIE).

METHODS

In three double-blind phase 3 studies, patients receiving HEC or MEC were randomized 1:1 to receive oral rolapitant 180 mg or placebo prior to chemotherapy plus 5-hydroxytryptamine type 3 receptor antagonist and dexamethasone therapy. Patients completed the FLIE questionnaire on day 6 of cycle 1. Endpoints included FLIE total score, nausea and vomiting domain scores, and the proportion of patients with no impact on daily life (total score >108 [range 18-126]). We performed a prespecified analysis of the MEC/anthracycline-cyclophosphamide (AC) study and a post hoc analysis of two pooled cisplatin-based HEC studies.

RESULTS

In the pooled HEC studies, rolapitant significantly improved the FLIE total score (114.5 vs 109.3, p < 0.001), nausea score (55.3 vs 53.5, p < 0.05), and vomiting score (59.2 vs 55.8, p < 0.001) versus control; similar results were observed in the MEC/AC study for FLIE total score (112.7 vs 108.6, p < 0.001), nausea score (54.1 vs 52.3, p < 0.05), and vomiting score (58.6 vs 56.3, p < 0.001). A higher proportion of patients reported no impact on daily life with rolapitant than with control in the MEC/AC study (73.2 vs 67.4, p = 0.027).

CONCLUSIONS

Compared with control, rolapitant improved quality of life in patients receiving HEC or MEC.

Chemotherapy-Induced Nausea and Vomiting: A Narrative Review to Inform Dietetics Practice

Chemotherapy-induced nausea and vomiting (CINV) are common symptoms experienced by patients with cancer that influence nutrition. They exert a detrimental effect on dietary intake, risk of malnutrition, and quality of life. Whereas CINV are primarily managed with medication, nutrition and dietetics practitioners play an important role in the management of CINV-related complications such as reduced dietary intake. This review discusses the burden of nausea and vomiting that patients with cancer can experience, including the effect on quality of life, nutritional status, and treatment outcomes. Implications for dietetics practice include the need to explore the nature of reported symptoms, identify predisposing risk factors, and to consider the use of a variety of interventions that are individualized to a patient's symptoms. There are little clinical data regarding effective dietetic interventions for nausea and vomiting. In summary, this review discusses dietetics-related issues surrounding CINV, including the pathophysiology, risk factors, prevalence, and both pharmacologic and dietetic treatment options.

Nutritional counseling and nutritional supplements: a cornerstone of multidisciplinary cancer care for cachectic patients

PURPOSE OF REVIEW

The challenge with cancer cachexia is that it is not fully reversed by nutrition support. The purpose of this review is to provide an opinion on the nutritional management of cancer cachexia based on the most recent available evidence.

RECENT FINDINGS

There continues to be a paucity of nutrition intervention studies in patients with cancer cachexia. In patients with cancer undergoing radiotherapy, there is strong evidence that nutrition counseling increases dietary intake, body weight, nutritional status and quality of life with some suggestion that dietary counseling may improve nutrition impact symptoms, treatment response and survival. In patients with cancer undergoing chemotherapy, the evidence is less clear. The use of n-3 polyunsaturated fatty acids may have some positive effects in patients with cancer; however, clinical judgment and care need to be taken in its application. Preliminary results of studies in the use of L-carnitine in improving fatigue are promising; however, the largest trial in 'healthy' cancer patients showed no benefit.

SUMMARY

Further research into the most appropriate methods for identifying and treating cancer cachexia is required. Regardless of whether patients are experiencing reduced dietary intake resulting in malnutrition or due to cachexia, nutrition remains a cornerstone of multimodal treatment.

Can ginger ameliorate chemotherapy-induced nausea? Protocol of a randomized double blind, placebo-controlled trial

BACKGROUND

Preliminary research shows ginger may be an effective adjuvant treatment for chemotherapy-induced nausea and vomiting but significant limitations need to be addressed before recommendations for clinical practice can be made.

METHODS/DESIGN

In a double-blinded randomised-controlled trial, chemotherapy-naïve patients will be randomly allocated to receive either 1.2 g of a standardised ginger extract or placebo per day. The study medication will be administrated as an adjuvant treatment to standard anti-emetic therapy and will be divided into four capsules per day, to be consumed approximately every 4 hours (300 mg per capsule administered q.i.d) for five days during the first three cycles of chemotherapy. Acute, delayed, and anticipatory symptoms of nausea and vomiting will be assessed over this time frame using a valid and reliable questionnaire, with nausea symptoms being the primary outcome. Quality of life, nutritional status, adverse effects, patient adherence, cancer-related fatigue, and CINV-specific prognostic factors will also be assessed.

DISCUSSION

Previous trials in this area have noted limitations. These include the inconsistent use of standardized ginger formulations and valid questionnaires, lack of control for anticipatory nausea and prognostic factors that may influence individual CINV response, and the use of suboptimal dosing regimens. This trial is the first to address these issues by incorporating multiple unique additions to the study design including controlling for CINV-specific prognostic factors by recruiting only chemotherapy-naïve patients, implementing a dosing schedule consistent with the pharmacokinetics of oral ginger supplements, and independently analysing ginger supplements before and after recruitment to ensure potency. Our trial will also be the first to assess the effect of ginger supplementation on cancer-related fatigue and nutritional status. Chemotherapy-induced nausea and vomiting are distressing symptoms experienced by oncology patients; this trial will address the significant limitations within the current literature and in doing so, will investigate the effect of ginger supplementation as an adjuvant treatment in modulating nausea and vomiting symptoms.

TRIAL REGISTRATION

ANZCTR.org.au Identifier: ACTRN12613000120774.

A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU)

PURPOSE

Paper-based nutrition screening tools can be challenging to implement in the ambulatory oncology setting. The aim of this study was to determine the validity of the Malnutrition Screening Tool (MST) and a novel, automated nutrition screening system compared to a 'gold standard' full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

An observational, cross-sectional study was conducted in an outpatient oncology day treatment unit (ODTU) within an Australian tertiary health service. Eligibility criteria were as follows: ≥ 18 years, receiving outpatient anticancer treatment and English literate. Patients self-administered the MST. A dietitian assessed nutritional status using the PG-SGA, blinded to the MST score. Automated screening system data were extracted from an electronic oncology prescribing system. This system used weight loss over 3 to 6 weeks prior to the most recent weight record or age-categorised body mass index (BMI) to identify nutritional risk. Sensitivity and specificity against PG-SGA (malnutrition) were calculated using contingency tables and receiver operating curves.

RESULTS

There were a total of 300 oncology outpatients (51.7% male, 58.6 ± 13.3 years). The area under the curve (AUC) for weight loss alone was 0.69 with a cut-off value of ≥ 1% weight loss yielding 63% sensitivity and 76.7% specificity. MST (score ≥ 2) resulted in 70.6% sensitivity and 69.5% specificity, AUC 0.77.

CONCLUSIONS

Both the MST and the automated method fell short of the accepted professional standard for sensitivity (~≥ 80%) derived from the PG-SGA. Further investigation into other automated nutrition screening options and the most appropriate parameters available electronically is warranted to support targeted service provision.

Outcomes of percutaneous endoscopic gastrostomy in hospitalized patients at a tertiary care center in Turkey

BACKGROUND/OBJECTIVES

The aim of this study was to perform a retrospective analysis characterizing patients receiving tube feeding following percutaneous endoscopic gastrostomy (PEG) tube placement between 2004 and 2012 at Erciyes University Hospital in Turkey.

SUBJECTS/METHODS

Patients above the age of 18 years who required long-term enteral tube feeding were studied. All PEGs were performed using the pull-through technique by one experienced endoscopist. Demographic, clinical outcomes and PEG-related complication data were collected.

RESULTS

Of the 128 subjects studied, 91 were men (71%) and 37 were women (29%). The mean age of this patient population was 54 ± 19 years. The most common reason for PEG tube insertion was the inability to consume oral diet due to complications of cerebrovascular disease (27%), while cerebral hypoxia, occurring after nonneurological medical disorders, was the second most common indication (23%). A total of 70 patients (55%) had chronic comorbidities, with hypertension being the most common (20%). The most common procedure-related complication was insertion-site bleeding, which occurred in 4% of patients. Long-term complications during 1 year were insertion-site cellulitis, gastric contents leakage and peristomal ulceration, which occurred in 14%, 5% and 0.5% of patients, respectively. There were no PEG insertion-related mortalities; 1-year mortality was unrelated to the indication for PEG tube insertion.

CONCLUSIONS

PEG tube insertion was a safe method to provide enteral access for nutrition support in this hospitalized patient population.

Pre-treatment with amifostine protects against cyclophosphamide-induced disruption of taste in mice

Cyclophosphamide (CYP), a commonly prescribed chemotherapy drug, has multiple adverse side effects including alteration of taste. The effects on taste are a cause of concern for patients as changes in taste are often associated with loss of appetite, malnutrition, poor recovery and reduced quality of life. Amifostine is a cytoprotective agent that was previously shown to be effective in preventing chemotherapy-induced mucositis and nephrotoxicity. Here we determined its ability to protect against chemotherapy-induced damage to taste buds using a mouse model of CYP injury. We conducted detection threshold tests to measure changes in sucrose taste sensitivity and found that administration of amifostine 30 mins prior to CYP injection protected against CYP-induced loss in taste sensitivity. Morphological studies showed that pre-treatment with amifostine prevented CYP-induced reduction in the number of fungiform taste papillae and increased the number of taste buds. Immunohistochemical assays for markers of the cell cycle showed that amifostine administration prevented CYP-induced inhibition of cell proliferation and also protected against loss of mature taste cells after CYP exposure. Our results indicate that treatment of cancer patients with amifostine prior to chemotherapy may improve their sensitivity for taste stimuli and protect the taste system from the detrimental effects of chemotherapy.

Ginger (Zingiber officinale) and chemotherapy-induced nausea and vomiting: a systematic literature review

Chemotherapy-induced nausea and vomiting (CINV) is a common side-effect of cytotoxic treatment. It continues to affect a significant proportion of patients despite the widespread use of antiemetic medication. In traditional medicine, ginger (Zingiber officinale) has been used to prevent and treat nausea in many cultures for thousands of years. However, its use has not been confirmed in the chemotherapy context. To determine the potential use of ginger as a prophylactic or treatment for CINV, a systematic literature review was conducted. Reviewed studies comprised randomized controlled trials or crossover trials that investigated the anti-CINV effect of ginger as the sole independent variable in chemotherapy patients. Seven studies met the inclusion criteria. All studies were assessed on methodological quality and their limitations were identified. Studies were mixed in their support of ginger as an anti-CINV treatment in patients receiving chemotherapy, with three demonstrating a positive effect, two in favor but with caveats, and two showing no effect on measures of CINV. Future studies are required to address the limitations identified before clinical use can be recommended.