Download Nutrition Support in Patient with Cancer Altered intake

Nutrition Support in Patient with Cancer
Altered intake
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胃腸道功能與生理影響
Dysphagia, particularly in head and neck cancer
Obstruction of any area of the G-I tract
Decreased intake secondary to depression, sadness,
and fear and anxiety
• Multiple modalities used to treat cancer patient
adversely affect intake
– Operative therapy
– Chemotherapeutic agents
– Radiation therapy
Nutritional support
cures malnutrition, not cancer
Brennan; N. Engl. J. Med. 305;375. 1981
•Weight loss can be prevented and reversed
•postsurgical complications and deaths diminished,
but lean tissue accrual or conservation
CRC Crit Rev in Oncology/Hematology vol 7, Issue 4. 1987 289-327
Multifactorial etiology of cancerassociated malnutrition
• Inadequate intake from primary tumor induced
anorexia and/or obstructing lesion
• Toxicity from chemotherapy or radiotherapy
• Primary catabolic effects of the tumor
• Abnormal metabolism of nutritients
Components of cancer Cachexia
• 50% - 80 % of cancer patients have
symptoms and signs of cachexia
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weight loss
anorexia
weakness
asthenia
anemia
abnormalities in protein, lipid, and
carbohydrate metabolism
Hematology/Oncology Clinics of North America; 5:Feb103-110, 1991
Weight loss
• Over 20 % of death are due simply to
malnutrition and host tissue wasting
• 50% of newly diagnosed cancer patients are
anorexia
Nutrition; 12: 358-371, 1996
Nutritional Oncology:
A Proactive, Integrated Approach to the
Cancer Patient
• Loss of at least 5% of pre-illness weight in
one third of patient with malignancy
• 20% of cancer patients succumb to
progressive nutritional deterioration or
inanition rather than to the malignancy
• Adversely impact the outcomes, quality, and
cost of care
• Malnourished patients have an average
length of stay that is twice that of diagnosisadjusted well-nourished patients
Major goals of supportive
nutrition
• Adjunctive to the specific oncology treatment goal
• maintain adequate nutritional status, body composition,
performance status, immune function, and quality of life
• Stabilize or improve nutritional status as well as increasing
the potential of a favorable response to therapy and
enhancing recovery from any adverse effect of therapy
• early supportive nutritional intervention is to avoid
irreversible nutritional and physiological deficits
• Weight loss in the cancer patient can often be prevented ,
but generally only of addressed proactively
Questions concerning the
effectiveness of nutritional care
• Inherent part of cancer
– Several treatable impediments to adequate
nutritional intake
– Appropriate pharmacological, behavioral or
surgical treatment will alleviate many of these
impediments
– Just as one treats a cancer patient’s diabetes or
congestive heart failure as a separate disease
from the cancer, so should one treat the
malnutrition or symptoms impacting nutrient
intake as separate from the cancer
Questions concerning the
effectiveness of nutritional care
• Inappropriate study design
– have often times used inappropriate eligibility
and ineligibility criteria
• ineligible or nutritional intervention was not
initiated until end-stage cancer and/or malnutrition
• supportive nutrition should not be put in the same
category as phase I chemotherapy - only used when
all other treatment fails
Questions concerning the
effectiveness of nutritional care
• Quality of Intervention
– Assessment of the quality of nutritional
intervention regiments and meeting of the
individual patient’s requirements have not
generally been addressed in individual reports
of nutrition support
– nutritional intervention is not consistent in a
number of reports of the use of parenteral or
enteral nutrition in treating malnutrition of the
cancer patient
Questions concerning the
effectiveness of nutritional care
• Nutrition Support is High-Technology
Nutrition
– usually parenteral nutrition, but it may also
include enteral tube feedings
– In the oncology patient, the concept of nutrition
support is used primarily in the context of the
severely malnourished, terminal, or end-stage
patient rather than proactive, often oral
intervention
Questions concerning the
effectiveness of nutritional care
• Cost
– Generally considered to be a costly intervention
– one that is to be avoided if possible
– Combined with poorly defined indicators for
initiation of supportive nutrition, has led to delayed
and/or inappropriate use of supportive nutritional
intervention
– Consideration of the use of nutritional counseling
and aggressive symptom management is less often
considered in the development of nutritional
intervention protocols
Questions concerning the
effectiveness of nutritional care
• Poor Performance Status
– Placed on nutritional intervention are frequently
malnourished, with decreased performance
status, marked decrease in muscle mass and
function
– Although function may improve with nutrition
per se, mass loss is generally not reversible
without a component of physical activity or
exercise
Proactive Nutritional Assessment
of the Oncology Patient
• Easy of use, cost-effectiveness, and
reproducibility in several clinical settings
• Ability to predict those patients who need
nutritional intervention
• Little interobserver variability
Patient-Generated Subjective Global Assessment (PG-SGA)
of Nutritional Status
Patient-Generated Subjective Global Assessment
(PG-SGA) of Nutritional Status
• Lack of time on the part of oncologists or oncology nurses
to incorporate an additional assessment procedure or
instrument
• Perception on the part of p’ts and family that nutrition and
weight loss are import in the overall oncology course
• PG-SGA add less than a minute to the overall clinic process
and add directly to the quality of nutritional and other
components of supportive care
• In addition to outcome-based, cost-effective results, patient
satisfaction is increasingly becoming as important
component of physician and institution report cards
Nutritional Intervention Options
• Presence or absence of a functional
gastrointestinal tract
• Treatment plans: surgery, radiation,
chemo/hormonal/biological response
modifier therapy
• Degree of baseline nutritional deficit
• Issues of quality of life and prognosis
• Issues of cost effectiveness and utility
Components of Successful Oral Intervention
Aggressive and Proactive Symptom
Management
• GI symptoms: nausea and vomiting, constipation
or diarrhea, mucositis/stomatitis, delayed gastric
emptying/slowed GI transit time, food intolerances
• Anorexia
• Pain
• Depression/anxiety/psychosocial considerations
Components of Successful Oral Intervention
Inclusion of the following principles of oral
nutrition
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Definition of calorie and protein goals
Removal of dietary restrictions
Management of sensory changes
Definition food intolerances with avoidance, treatment
Education of patient to thinks of food as medicine
Addressing patient issues of control and self-image
Timing of nutritional counseling and timing of trials of
nutritional supplements to optimize compliance
• Addressing appropriate vitamin use in terms of timing and
dose