Nutrition in oncology: the case of micronutrients (Review)

Navigating pain and appetite challenges in palliative care for pancreatic cancer: insights from a national, longitudinal consecutive cohort study

PURPOSE

Pancreatic cancer poses significant challenges in symptom management. Many people have intractable pain and anorexia which is often not amenable to current available options for palliation. This study aims to outline the longitudinal patterns and assess the burden of distress related to pain and appetite experienced by individuals with pancreatic cancer in people referred to Australian palliative care services.

METHODS

Consecutive national cohort study using point-of-care data on symptom distress in people referred to specialist palliative care services.

RESULTS

From 2013 to 2022, information from 20,558 care episodes involving 15,536 people with pancreatic cancer referred to 203 palliative care services nationally were included. Similar numbers of people were admitted to inpatient and community services, with 69% and 60% reporting distress due to pain and appetite, respectively. Distress extended to sleeping (79%, 82%), nausea (83%, 85%), bowels (80%, 83%), breathing (70%, 77%) and fatigue (77%, 77%) for pain and appetite, respectively. Strongest associations were with psychological/spiritual issues (inpatient OR 1.78, 95% CI 1.66-1.90) and pain severity (community OR 1.51, 95% CI 1.42-1.60) for appetite-related distress and pain severity (inpatient OR 1.60, 95% CI 1.49-1.72; community OR 1.35, 95% CI 1.27-1.44) for pain distress. Trends within the cohort revealed increased mild appetite-related distress (+ 10%) and decreased moderate (- 22%) and severe (- 11%) distress, with similar trends for pain.

CONCLUSION

This study underscores prevalent distress in people with pancreatic cancer in Australian palliative care, highlighting the need for optimised referrals and strategies targeting pain severity, appetite-related concerns and psychological and spiritual aspects for improved care outcomes.

Usual Intake of Micronutrients and Prevalence of Inadequate Intake among Chinese Adults: Data from CNHS 2015-2017

Previous studies have used the traditional average-value method to calculate the usual dietary intake of a population, but the results may be biased due to the measurement errors. The aim of this study was to provide an assessment of the usual micronutrient intake and estimate the prevalence of inadequate intake among Chinese adults. Data from the Chinese Nutrition and Health Surveillance 2015−2017 as well as a total of 72,231 subjects aged 18 years and older were included in the analysis. The 24 h recall method combined with the condiment weighing method were used for three consecutive days to collect daily food and condiments intake. The daily intake of 16 micronutrients was calculated based on the Chinese Food Component Tables. The National Cancer Institute (NCI) method was used to estimate the usual intake of micronutrients, and the prevalence of inadequate intake was estimated using the estimated average requirement (EAR) cut-point method. The results showed that, except for sodium, copper, iron (only for males), vitamin E, and phosphorus, the usual intake of micronutrients in Chinese adults was low, and the prevalence of inadequate intake ranged from 38.67 to 97.63%. The prevalence of inadequate calcium and riboflavin intake was more than 90%, and the proportion of individuals with a usual intake of thiamine, vitamin A, potassium, and selenium below EAR also reached 80%. Manganese, magnesium, vitamin C, and zinc were potentially deficient micronutrients, with the prevalence of inadequate intake ranging from 38.67% to 77.09%. However, usual sodium intake was extremely high with an average of 5139.61 mg/day, and only a quarter of Chinese adults were below the World Health Organization (WHO) recommended value. For most micronutrients, the usual dietary intake declined with age and the prevalence of inadequate intake increased with age. Except for zinc, vitamin A, and B-vitamins, the prevalence of micronutrient deficiencies was higher in females than in males in the same age group (p < 0.05). Therefore, Chinese adults do not receive enough micronutrients. Effective nutrition supplementary strategies and measures are needed to address these problems.

Food to Overcome Outcomes Disparities: A Randomized Controlled Trial of Food Insecurity Interventions to Improve Cancer Outcomes

PURPOSE

Food insecurity is prevalent among low-income immigrant and minority patients with cancer. To our knowledge, this randomized controlled trial is the first to prospectively examine the impact on cancer outcomes of food insecurity interventions, with the goal of informing evidence-based interventions to address food insecurity in patients with cancer.

METHODS

A three-arm randomized controlled trial was conducted among food-insecure (18-item US Department of Agriculture Household Food Security Survey Module score ≥ 3) patients with cancer (N = 117) at four New York City safety net cancer clinics. Arms included a hospital cancer clinic-based food pantry (arm 1), food voucher plus pantry (arm 2), and home grocery delivery plus pantry (arm 3). Treatment completion (primary outcome) and full appointment attendance were assessed at 6 months. Food security status, depression symptoms (Patient Health Questionnaire-9), and quality-of-life scores (Functional Assessment of Cancer Therapy-General) were assessed at baseline and at 6 months.

RESULTS

Voucher plus pantry had the highest treatment completion rate (94.6%), followed by grocery delivery plus pantry (82.5%) and pantry (77.5%; P = .046). Food security scores improved significantly in all arms, and Patient Health Questionnaire-9 and Functional Assessment of Cancer Therapy-General scores improved significantly in the pantry and delivery plus pantry arms.

CONCLUSION

Our findings in this preliminary study suggest that voucher plus pantry was the most effective intervention at improving treatment completion, and it met our a priori criterion for a promising intervention (≥ 90%). All interventions demonstrated the potential to improve food security among medically underserved, food-insecure patients with cancer at risk of impaired nutrition status, reduced quality of life, and poorer survival. All patients with cancer should be screened for food insecurity, with evidence-based food insecurity interventions made available.

Evaluation of the Concentration of Selected Elements in Patients with Cancer of the Reproductive Organs with Respect to Treatment Stage-Preliminary Study

(1) Background: The aim of this study was to assess the concentrations of selected elements in female patients with cancer of the reproductive organs, taking into account the stage of treatment. (2) Methods: The study sample consisted of 51 patients with advanced endometrial cancer and ovarian cancer, undergoing chemotherapy. The median age of the studied patients with endometrial cancer was 66.0 years (IQR: from 60.75 to 70.25), and with ovarian cancer―60.0 years (IQR: from 49.0 to 64.0). Each of the qualified women, after consent to participate in the study, had her blood drawn several times (before surgery, the first course of chemotherapy, the third course of chemotherapy, and the sixth course of chemotherapy) in order to determine serum levels of macro- and micronutrients (Na, Mg, Ca, Zn, P, Cu, Fe, Cd, Ni, and Sr). (3) Results: In the study group of patients with cancer of the reproductive tract, the concentrations of iron (<0.001), magnesium (0.038), sodium (0.014), and nickel (0.037) varied significantly over the course of the study. The analysis showed that the interaction between the stage of chemotherapy and the type of cancer had an effect on the concentrations of magnesium and cadmium (p < 0.05). (4) Conclusions: In the studied group of patients with ovarian and endometrial cancer, the applied chemotherapy significantly changed the concentrations of Fe, Na, and Ni, regardless of the type of tumor. Changes in Mg and Cd concentrations resulted from the interaction between the stage of chemotherapy and the type of cancer. The results of serum concentrations of selected elements in women with cancer of the reproductive organs may help understand the physiological changes resulting from the applied chemotherapy.

Cost-Effectiveness of Nutrient Supplementation in Cancer Survivors

Cancer patients are at risk for malnutrition; the aim of this study was to provide a cost-effectiveness analysis of dietary supplementation in cancer survivors. We estimated prevalence of supplementation, hospitalization rates, quality of life (QOL), cost of care and mortality among cancer survivors. We built a decision analytic model to simulate life-long costs of health care and supplementation and QOL among cancer survivors with and without supplementation. Cost of supplements was derived from national pharmacy databases including single- and multivitamin formularies. One-way and probabilistic sensitivity analysis were performed to evaluate the robustness of the incremental cost-effectiveness ratio (ICER) to changes in supplementation costs and duration. The study cohort represented the national cancer survivor population (average age 61 years, 85% white, 52% male, and 94% insured). Hospitalization rates for supplement users and non-users were 12% and 21%, respectively. The cost of hospitalization was $4030. Supplementation was associated with an additional 0.48 QALYs (10.26 vs. 9.78) at the incremental cost of $2094 ($236,933 vs. $234,839) over the remaining lifetime of survivors (on average 13 years). Adequate nutrition provides a cost-effective strategy to achieving potentially optimum health. Further studies are needed to determine the effects of specific nutrient doses and supplementation on long-term outcomes per cancer type.

Micronutrient Food Supplements in Patients with Gastro-Intestinal and Hepatic Cancers

Colorectal carcinogenesis is the second most common cause of mortality across all types of malignancies, followed by hepatic and stomach cancers. Chemotherapy and radiotherapy are key approaches to treating cancer patients, but these carry major concerns, such as a high risk of side effects, poor accessibility, and the non-selective nature of chemotherapeutics. A number of natural products have been identified as countering various forms of cancer with fewer side effects. The potential impact of vitamins and minerals on long-term health, cognition, healthy development, bone formation, and aging has been supported by experimental and epidemiological studies. Successful treatment may thus be highly influenced by the nutritional status of patients. An insufficient diet could lead to detrimental effects on immune status and tolerance to treatment, affecting the ability of chemotherapy to destroy cancerous cells. In recent decades, most cancer patients have been taking vitamins and minerals to improve standard therapy and/or to decrease the undesirable side effects of the treatment together with the underlying disease. On the other hand, taking dietary supplements during cancer therapy may affect the effectiveness of chemotherapy. Thus, micronutrients in complementary oncology must be selected appropriately and should be taken at the right time. Here, the potential impact of micronutrients on gastro-intestinal and hepatic cancers is explored and their molecular targets are laid down.

Effects of the food additive monosodium glutamate on cisplatin-induced gastrointestinal dysmotility and peripheral neuropathy in the rat

BACKGROUND

Cisplatin is an antineoplastic drug known to produce intense vomiting, gastric dysmotility, and peripheral neuropathy. Monosodium glutamate (MSG) is a flavor enhancer with prokinetic properties potentially useful for cancer patients under chemotherapy. Our aim was to test whether MSG may improve gastrointestinal motor dysfunction and other adverse effects induced by repeated cisplatin in rats.

METHODS

Male Wistar rats were exposed or not to MSG (4 g L^-1 ) in drinking water from week 0 to 1 week after treatment. On the first day of weeks 1-5, rats were treated with saline or cisplatin (2 mg kg^-1  week^-1 , ip). Gastrointestinal motility was measured by radiological methods after first and fifth administrations, as well as 1 week after treatment finalization. One week after treatment, the threshold for mechanical somatic sensitivity was recorded. Finally, samples of stomach, terminal ileum and kidneys were evaluated in sections using conventional histology. The myenteric plexus was immunohistochemically evaluated on distal colon whole-mount preparations.

KEY RESULTS

Monosodium glutamate prevented the development of cisplatin-induced neuropathy and partially improved intestinal transit after the fifth cisplatin administration with little impact on gastric dysmotility. MSG did not improve the histological damage of gut wall, but prevented the changes induced by cisplatin in the colonic myenteric plexus.

CONCLUSION AND INFERENCES

Our results suggest that MSG can improve some dysfunctions caused by anticancer chemotherapy in the gut and other systems, associated, at least partially, with neuroprotectant effects. The potentially useful adjuvant role of this food additive to reduce chemotherapy-induced sequelae warrants further evaluation.

Vitamins and minerals intake adequacy in hematopoietic stem cell transplant: results of a randomized controlled trial

Micronutrient intake among hematopoietic stem cell transplant (HSCT) recipients is poorly studied. This randomized control trial (RCT) assessed the effect of nutritional counseling on micronutrient intake post HSCT. Patients with hematological malignancies receiving HSCT were randomized at hospital discharge into an intervention group (IG) and a control group (CG) between 2016 and 2017. IG received individualized nutritional counseling in the first 3 months post HSCT while CG received general qualitative education without reinforcement. At assessment points (hospital admission, discharge, 30, 60, and 100 days post HSCT termed T4), 24-h recalls were analyzed, and micronutrient intake was compared to patients' individual needs. Results were reported as percentages of dietary reference intake. Groups (IG, n = 22 and CG, n = 24) had similar characteristics pre HSCT. Copper and α-tocopherol intake at T4 were significantly better in IG. Many B vitamins, vitamin C, Manganese, Potassium, Zinc, and vitamin K improved in IG only at T4 compared to baseline intake. Median vitamin D intake remained low in both groups with <20% of patients meeting their individual needs post HSCT. In conclusion, counseling was associated with a trend of improved micronutrient intake. Vitamin D levels remained low irrespective of counseling.

A National Evaluation of Food Insecurity in a Head and Neck Cancer Population

OBJECTIVES/HYPOTHESIS

To determine the food security status of patients with a history of head and neck cancer and compare to other types of cancer.

STUDY DEIGN

A retrospective analysis using the National Health Interview Series.

METHODS

The National Health Interview Series (NHIS) for the calendar years 2014 to 18 was used to elicit food security status (secure, marginally secure/not secure) among adult patients with a history of throat/pharynx head and neck cancer (pHNC), thyroid cancer, and colon cancer. The relationship between food security and the primary site was compared and subanalyses were performed according to sex, race, and ethnicity.

RESULTS

The study population included 199.0 thousand patients with pHNC, with 17.7% (95% confidence interval, 10.5%-28.1%) of pHNC patients reporting their food security status as marginally secure or not secure. Food insecurity was significantly higher among pHNC patients when compared to thyroid cancer (insecurity 10.7%, [7.7%-14.7%]) and colon cancer patients (10.1%, [7.8%-13.2%]). Among pHNC patients, there was no significant difference in rates of food insecurity when stratified by gender, race, or ethnicity. However, black individuals were more likely to have food insecurity with a history of thyroid or colon cancer (P < .042) and Hispanics were more likely to have food insecurity with a history of thyroid cancer (P = .005).

CONCLUSIONS

Food insecurity disproportionally affects patients with a history of pHNC, though there is less demographic variability when compared to other cancer primary sites. Food security assessments should be part of the tailored approach to survivorship management in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1539-E1542, 2021.

Nutrition and gastroenterological support in end of life care

Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.

Nutrition interventions to treat low muscle mass in cancer

Many patients with cancer experience poor nutritional status, which detrimentally impacts clinical outcomes. Poor nutritional status in cancer is primarily manifested by severe muscle mass (MM) depletion, which may occur at any stage (from curative to palliative) and often co-exists with obesity. The objective of this article was to discuss gaps and opportunities related to the role of nutrition in preventing and reversing low MM in cancer. It also provides a narrative review of relevant nutritional interventions for patients capable of oral intake. The impact of nutrition interventions to prevent/treat low MM in cancer is not well understood, potentially due to the limited number of studies and of clinically viable, accurate body composition assessment tools. Additionally, the type of study designs, inclusion criteria, length of intervention, and choice of nutritional strategies have not been optimal, likely underestimating the anabolic potential of nutrition interventions. Nutrition studies are also often of short duration, and interventions that adapt to the metabolic and behavioural changes during the clinical journey are needed. We discuss energy requirements (25-30 kcal/kg/day) and interventions of protein (1.0-1.5 g/kg/day), branched-chain amino acids (leucine: 2-4 g/day), β-hydroxy β-methylbutyrate (3 g/day), glutamine (0.3 g/kg/day), carnitine (4-6 g/day), creatine (5 g/day), fish oil/eicosapentanoic acid (2.0-2.2 g/day EPA and 1.5 g/day DHA), vitamin/minerals (e.g. vitamin D: 600-800 international units per day), and multimodal approaches (nutrition, exercise, and pharmaceutical) to countermeasure low MM in cancer. Although the evidence is variable by modality type, interventions were generally not specifically studied in the context of cancer. Understanding patients' nutritional requirements could lead to targeted prescriptions to prevent or attenuate low MM in cancer, with the overall aim of minimizing muscle loss during anti-cancer therapy and maximizing muscle anabolism during recovery. It is anticipated that this will, in turn, improve overall health and prognostication including tolerance to treatment and survival. However, oncology-specific interventions with more robust study designs are needed to facilitate these goals.

Effective nutritional status screening in orthopaedic oncology patients and post-operative complications

PURPOSE

This study aims to determine the prevalence of malnutrition among orthopaedic oncology patients with malignant tumour during preoperative period.

METHODS

This is a prospective observational study involving patients from the orthopaedic oncology unit who were undergoing surgery. They were assessed with Patient Generated Subjective Global Assessment (PG-SGA), Malnutrition Screening Tool (MST) and 3-minute Nutritional Screening (3MinNS) questionnaires. Anthropometric data such as body mass index, mid upper arm circumference (MUAC) and blood parameters such as serum albumin, total lymphocyte count and haemoglobin were also investigated. Patients were then followed up for 3 months. Post-operative complications were divided into infectious and non-infectious groups. Length of stay and unplanned readmission were also documented.

RESULTS

Prevalence of malnutrition ranged from 13.3% to 45.8% under different nutritional assessment methods. Patients who were determined as malnourished were significantly associated with both infectious and non-infectious post-operative complications ( p < 0.001). PG-SGA and 3MinNS values were also significant in univariate and multivariate analysis, respectively. Low serum albumin (<35 g/L) was associated with post-operative infectious complications, especially surgical site infection ( p < 0.001), prolonged hospital stay ( p = 0.009) and unplanned readmission ( p = 0.017). 3MinNS and Charlson Comorbidity Index were predictive of non-infectious complications, whereas serum albumin and the presence of metastasis were predictive of infectious complications.

CONCLUSION

This pilot study of patients with soft tissue and bone sarcoma of upper and lower limbs showed that malnutrition is a significant independent factor related to infectious and non-infectious complications which leads to unplanned readmission and prolonged length of stay. Periodic screening using the PG-SGA or 3MinNS questionnaires, MUAC and evaluation of serum albumin levels is recommended during clinic session and pre-surgery assessment rounds to identify those predisposed to malnutrition and help in reducing incidence of post-operative complications.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Use of biologically based complementary medicines in patients with neuroendocrine tumors

Background: Biologically based complementary medicines (BB-CMs) are popular in patients with cancer. However, there are only limited data for BB-CMs in patients with neuroendocrine tumors (NET). We aimed to identify the prevalence and type of BB-CM use and the association to the nutritional risk score (NRS-2002) in NET patients. Methods: We performed a cross-sectional questionnaire study in NET outpatients at the Department of Hepatology and Gastroenterology at Aarhus University Hospital. The nutritional risk was determined by the NRS-2002. Results: We included 186 patients (51% women, median age 66 years). Sixty-six percent were regular BB-CM users. Forty-two percent used at least two supplements. The most popular BB-CMs were vitamin and mineral supplements (47%), calcium and vitamin D (34%). One-third used non-vitamin non-mineral supplements such as fish oil, herbs, Ginger, Q-10, garlic and probiotics. The use of BB-CMs was associated with female gender (48% vs. 37%, p < .05). Intake was significantly more frequent among patients with an NRS score ≥ 3, (60% vs. 76%) and in patients with change in performance status (58% vs. 76%), (p < .05, all). Patients reporting dietary changes used BB-CMs more frequently than patients without dietary changes (61% vs. 77%) (p < .05). Conclusions: In our study, 66% percent of NET patients use BB-CM and 42% used two or more supplements. Vitamins with and without herbal ingredients, minerals, calcium, vitamin D, and fish oil were the most popular supplements. The use of BB-CMs was associated with an NRS score ≥ 3, change in dietary intake, female gender, and change in ECOG performance status.

Nutritional and vitamin status in patients with neuroendocrine neoplasms

Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.

Vitamin Status and the Development of Postoperative Cognitive Decline in Elderly Surgical Oncologic Patients

Background

This study aimed to evaluate the influence that serum levels of vitamin B12, folate, and homocysteine have on the development of short-term postoperative cognitive decline in the elderly surgical oncology patient.

Methods

This study was part of a prospective cohort study focused on postoperative cognitive outcomes for patients 65 years of age or older undergoing surgery for a solid malignancy. Postoperative cognitive decline was defined as the change in the combined results of the Ruff Figural Fluency Test and the Trail-Making Test Parts A and B. Patients with the highest change in scores 2 weeks postoperatively compared with baseline were considered to be patients with cognitive decline. Patients with the lowest change were considered to be patients without cognitive decline. To analyze the effect of vitamin levels on the changes in postoperative cognitive scores, uni- and multivariate logistic regression analysis were performed.

Results

The study enrolled 61 patients with and 59 patients without postoperative cognitive decline. Hyperhomocysteinemia was present in 14.2% of the patients. Patients with postoperative cognitive decline more often had hyperhomocysteinemia (27.9 vs 10.2%). Hyperhomocysteinemia was associated with a higher chance for the development of postoperative cognitive decline (odds ratio_adjusted, 11.9; 95% confidence interval, 2.4–59.4). Preoperative vitamin B12 or folate deficiency were not associated with the development of postoperative cognitive decline.

Conclusion

Preoperative hyperhomocysteinemia is associated with the development of postoperative cognitive decline. The presence of preoperative hyperhomocysteinemia could be an indicator for an increased risk of postoperative cognitive decline developing in the elderly.

Nutritional support and parenteral nutrition in cancer patients: an expert consensus report

BACKGROUND

Malnutrition is a frequent medical problem of cancer patients that negatively impacts their quality of life.

METHODS

A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Nutrition convened to discuss the management of the nutritional support in cancer patients.

RESULTS

Of the 18 questions addressed, 9 focused on nutritional support, 5 were related to parenteral nutrition (PN) and 4 about home PN (HPN). The panel of experts recommends using nutritional screening routinely, at diagnosis and throughout the disease course, for detecting the risk of malnutrition and, if it is positive, to perform a complete nutritional assessment, to diagnose malnutrition. Currently, there are different screening tools and methods that allow us to detect nutritional risk. Based on the evidence and experience, the panel stated that PN is indicated mainly when it is not possible to use the digestive tract and/or oral feeding and/or enteral nutrition is not sufficient or possible. The nutritional needs of the cancer patients, except in those cases where individualized measures are required, should be considered similar to healthy individuals (25-30 kcal/kg/day). The panel considers that the nutritional monitoring of the cancer patient should be multidisciplinary and adapted to the characteristics of each center. Additionally, the objective of the HPN is to improve or maintain the nutritional status of a patient at home.

CONCLUSIONS

This document seeks to lay down a set of recommendations and to identify key issues that may be useful for the nutritional management of cancer patients.

Micronutrient status (calcium, zinc, vitamins D and E) in patients with medullary thyroid carcinoma: A cross-sectional study

OBJECTIVE

The aim of this study was to evaluate the micronutrient status of Iranian patients with medullary thyroid carcinoma (MTC) and to analyze potential relationships with respect to MTC risk.

METHODS

This was a cross-sectional study (Tehran Thyroid Cancer Survey 2015-2016). We measured and compared preoperative serum calcium, zinc, and vitamins D and E in patients with MTC and healthy controls. Forty cases with MTC and 40 (age-, sex-, and body mass index-matched) healthy controls voluntarily participated in the project.

RESULTS

Serum calcium, zinc, and vitamin D and E concentrations were lower in the patients with cancer (P_Ca < 0.001, P_Zn = 0.01, P_D = 0.056, P_E = 0.002) than in the healthy controls. We found that serum calcium remarkably associated with enhanced risk for thyroid cancer (odds ratio [OR], 6.5; P = 0.001). Likewise, serum vitamin E was linked to the risk for cancer (OR, 1.31; P = 0.056). Moreover, serum zinc was correlated with vitamin E and calcium (r = +0.23; P = 0.04 and r = +0.25, P = 0.03; respectively). We also observed a correlation between calcium and vitamin E (r = +0.27; P = 0.02).

CONCLUSIONS

A multiple-micronutrient decrease was confirmed in patients with MTC. A low serum calcium level was a potent risk factor for MTC. Findings from the present study suggest that dietary intake and/or supplementation of micronutrients, especially calcium and vitamin E, may be beneficial in reducing the risk for thyroid cancer.

Detailed Dietary Assessment in Patients with Inoperable Tumors: Potential Deficits for Nutrition Care Plans

Advanced cancer often results in reduced dietary intake; however, data on actual intake at the time of diagnosis are limited. In the present study, a detailed dietary intake assessment was performed in patients with metastatic lung and upper gastrointestinal cancer, before initiation of systemic therapy. Basic demographics and performance status (PS) were recorded. Nutritional status was evaluated through anthropometry, Mini Nutritional Assessment (MNA), and 3 nonconsecutive 24-hour dietary recalls. Of the 84 patients enrolled, 61.4% were protein, energy, or protein-energy undernourished, regardless of body mass index (BMI) or MNA category. No differences in energy, macronutrients, and micronutrients intakes across BMI categories were recorded. Very low consumption of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), irrespective of energy intake, tumor site, BMI category, or PS was found. Suboptimal micronutrients intakes were recorded even in well-nourished and overweight/obese patients. Patients with adequate PS and better MNA score reported significantly higher intake of certain macro- and micronutrients (all P < 0.05). Most patients exhibited reduced dietary intake in terms of energy, macronutrient, and micronutrient. Very low EPA and DHA intake was recorded for the whole sample, whereas micronutrient suboptimal intakes were also prevalent in well-nourished or overweight patients. All the above should be taken into account during patients' nutritional care.

Use of Hospital-Based Food Pantries Among Low-Income Urban Cancer Patients

To examine uptake of a novel emergency food system at five cancer clinics in New York City, hospital-based food pantries, and predictors of use, among low-income urban cancer patients. This is a nested cohort study of 351 patients who first visited the food pantries between October 3, 2011 and January 1, 2013. The main outcome was continued uptake of this food pantry intervention. Generalized estimating equation (GEE) statistical analysis was conducted to model predictors of pantry visit frequency. The median number of return visits in the 4 month period after a patient's initial visit was 2 and the mean was 3.25 (SD 3.07). The GEE model showed that younger patients used the pantry less, immigrant patients used the pantry more (than US-born), and prostate cancer and Stage IV cancer patients used the pantry more. Future long-term larger scale studies are needed to further assess the utilization, as well as the impact of food assistance programs such as the this one, on nutritional outcomes, cancer outcomes, comorbidities, and quality of life. Cancer patients most at risk should be taken into particular consideration.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Do our patients have enough to eat?: Food insecurity among urban low-income cancer patients

This study assessed the prevalence and predictors of food insecurity among a cohort of underserved oncology patients at New York City cancer clinics. A demographic survey and the U.S. Household Food Security Survey Module were administered. A multivariate General Linear Model Analysis of Covariance was used to evaluate predictors of food insecurity. Four hundred and four (404) completed the surveys. Nearly one-fifth (18%) had very low, 38% low, 17% marginal, and 27% high food security. The Analysis of Covariance was statistically significant (F[7, 370] = 19.08; p &lt; .0001; R-Square = 0.26). Younger age, Spanish language, poor health care access, and having less money for food since beginning cancer treatment were significantly associated with greater food insecurity. This cohort of underserved cancer patients had rates of food insecurity nearly five times those of the state average. More research is needed to understand better the causes and impact of food insecurity among cancer and chronic disease patients.

STAT3 in the systemic inflammation of cancer cachexia

Weight loss is diagnostic of cachexia, a debilitating syndrome contributing mightily to morbidity and mortality in cancer. Most research has probed mechanisms leading to muscle atrophy and adipose wasting in cachexia; however cachexia is a truly systemic phenomenon. Presence of the tumor elicits an inflammatory response and profound metabolic derangements involving not only muscle and fat, but also the hypothalamus, liver, heart, blood, spleen and likely other organs. This global response is orchestrated in part through circulating cytokines that rise in conditions of cachexia. Exogenous Interleukin-6 (IL6) and related cytokines can induce most cachexia symptomatology, including muscle and fat wasting, the acute phase response and anemia, while IL-6 inhibition reduces muscle loss in cancer. Although mechanistic studies are ongoing, certain of these cachexia phenotypes have been causally linked to the cytokine-activated transcription factor, STAT3, including skeletal muscle wasting, cardiac dysfunction and hypothalamic inflammation. Correlative studies implicate STAT3 in fat wasting and the acute phase response in cancer cachexia. Parallel data in non-cancer models and disease states suggest both pathological and protective functions for STAT3 in other organs during cachexia. STAT3 also contributes to cancer cachexia through enhancing tumorigenesis, metastasis and immune suppression, particularly in tumors associated with high prevalence of cachexia. This review examines the evidence linking STAT3 to multi-organ manifestations of cachexia and the potential and perils for targeting STAT3 to reduce cachexia and prolong survival in cancer patients.

Micronutrients in Oncological Intervention

Nutritional supplements are widely used among patients with cancer who perceive them to be anticancer and antitoxicity agents. Depending on the type of malignancy and the gender 30%-90% of the cancer patients supplement their diets with antioxidant and immuno-stabilizing micronutrients, such as selenium, vitamin C, and vitamin D, often without the knowledge of the treating physician. From the oncological viewpoint, there are justifiable concerns that dietary supplements decrease the effectiveness of chemotherapy and radiotherapy. Recent studies, however, have provided increasing evidence that treatment is tolerated better-with an increase in patient compliance and a lower rate of treatment discontinuations-when micronutrients, such as selenium, are added as appropriate to the patient's medication. Nutritional supplementation tailored to an individual's background diet, genetics, tumor histology, and treatments may yield benefits in subsets of patients. Clinicians should have an open dialogue with patients about nutritional supplements. Supplement advice needs to be individualized and come from a credible source, and it is best communicated by the physician.

Nutrient intake and nutritional status of newly diagnosed patients with cancer from the East Coast of Peninsular Malaysia

BACKGROUND

Cancer therapy in Malaysia primarily focuses on the clinical management of patients with cancer and malnutrition continues to be one of the major causes of death in these patients. There is a dearth of information on the nutrient intake and status of newly diagnosed patients with cancer prior to the initiation of treatment. The present study aims to assess the nutrient intake and status of newly diagnosed patients with cancer from the East Coast of Peninsular Malaysia.

METHODS

A cross-sectional study was conducted using a convenient sample of newly diagnosed adult patients with cancer (n = 70) attending the Oncology clinic, Hospital Universiti Sains Malaysia in the East Coast of Peninsular Malaysia. Information on socio-demographic characteristics, clinical status, anthropometry, dietary intake and biochemical data including blood samples was obtained.

RESULTS

The mean (SD) age, triceps skin fold (TSF), mid upper arm circumference (MUAC) and body mass index (BMI) of participants was 21.1(3.9) years, 17.6(7.9) mm, 24.1(5.5) cm, and 21.1(3.9) Kg/m(2), respectively; 39% participants had BMI <18.5 Kg/m(2). One-third of newly diagnosed patients with cancer were undernourished (i.e. women: MUAC <220 mm; men: <230 mm). The proportion (%) of participants with low haemoglobin (<120 g/L) and serum albumin (<38 g/dL) were 62% and 26%, respectively. The older women had significantly lower macro and micro nutrient intakes compared to men in the same age group (P <0.05).

CONCLUSIONS

At the time of diagnosis, greater than one-third of patients with cancer from the East Coast of Peninsular Malaysia were underweight and undernourished. The majority of patients with cancer had poor micronutrient intakes; the older women had a poor macro and micronutrient intakes. Before the initiation of rigorous clinical management of patients with cancer, screening for nutritional status, subsequent nutrition counseling, and interventions are essential to improve their nutritional status; consequently, response to cancer therapy, survival and quality of life.

The role of vitamin D in skeletal and cardiac muscle function

Myopathy is a feature of many inflammatory syndromes. Chronic inflammation has been linked to pathophysiological mechanisms which implicate 1,25 dihydroxyvitamin D₃ (1,25-(OH)₂D₃)-mediated signaling pathways with emerging evidence supporting a role for the vitamin D receptor (VDR) in contractile and metabolic function of both skeletal and cardiac muscle. Altered VDR expression in skeletal and cardiac muscle has been reported to result in significant effects on metabolism, calcium signaling and fibrosis in these tissues. Elevated levels of serum inflammatory cytokines, such as IL-6, TNF-α and IFNγ, have been shown to impact myogenic and nuclear receptor signaling pathways in cancer-induced cachexia. The dysregulation of nuclear receptors, such as VDR and RXRα in muscle cells, has also been postulated to result in myopathy via their effects on muscle structural integrity and metabolism. Future research directions include generating transcriptome-wide information incorporating VDR and its gene targets and using systems biology approaches to identify altered molecular networks in human tissues such as muscle. These approaches will aid in the development of novel therapeutic targeting strategies for inflammation-induced myopathies.

Serum levels of selenium in patients with brain metastases from non-small cell lung cancer before and after radiotherapy

PURPOSE

This study was to evaluate the influence of radiotherapy on the selenium serum levels of non-small cell cancer patients with brain metastases.

PATIENTS AND METHODS

This prospective study included 95 non-small cell cancer patients with brain metastases treated by radiotherapy from December 2007 until November 2010. Plasma selenium levels were determined before and at the end of the radiotherapy. Age, body mass index (BMI), prior chemotherapy, pathological type and personal habits (smoking and alcoholism) were recorded for each patient.

RESULTS

The mean age was 63 years; the mean BMI was 27.6. Seventy-six patients (80%) were non-smokers. Sixty-two patients (65.3%) showed no drinking habits and 8 (8.4%) have no prior chemotherapy. Thirty-nine patients (41.1%) were adenocarcinoma, 51 (53.7%) were squamous cell carcinoma and five (5.3%) were large cell carcinoma. At the beginning of radiotherapy, the mean selenium level for all patients was 90.4 μg/l and after radiation this value dropped to 56.3 μg/l. Multivariate analysis showed statistically significant difference in the plasma selenium concentration before and after radiotherapy for age (P<0.001), BMI (P<0.001), smoking (P<0.001), alcoholism (P<0.001), prior chemotherapy (P<0.001) and pathological type (P<0.001).

CONCLUSION

Significant reduction in plasma levels of selenium was recorded in patients undergoing radiotherapy, suggesting attention to the nutritional status of this micronutrient and other antioxidant agents.

New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition

Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of quality of life (QoL). Cancer-related malnutrition may evolve into cancer cachexia due to complex interactions between pro-inflammatory cytokines and the host metabolism. Depending on the type of cancer treatment (either curative or palliative), the clinical condition of the patient and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counseling, oral supplementation, enteral or total parenteral nutrition). Nutritional support has been widely advocated as adjunctive therapy for a variety of underlying illnesses, including surgery and medical oncotherapy (radiation or chemotherapy for cancer). Glutamine, n-3 fatty acids and probiotics/prebiotics are therapeutic factors that potentially modulate gastrointestinal toxicity related to cancer treatments. Enteral and parenteral nutrition may help improve patient survival, functional status and QoL, yet the benefits appear to be primarily limited to patients with good functional status and with gastrointestinal disease affecting nutritional intake. Parenteral nutrition offers the possibility of increased or maintenance of the nutrient intake in patients for whom normal food intake is inadequate and for whom enteral nutrition is not feasible, is contraindicated or is not accepted by the patient. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with cancer.