Download Nutrition assessment & support in esophageal cancer

1
Nutrition assessment &
support in esophageal cancer
實習生：林廷駿
指導老師：陳燕慈營養師
報告日期：2012/12/25
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Introduction
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Treatment & Esophageal
cancer
radiotherapy
chemotherapy
Only 30% to
40% of patients
surgery
Stahl et al., 2005
Schneider et al., 2007
Bedenne et al., 2007
Malnutrition & Esophageal
cancer
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Immune
functions
Survival
Malnutrition
(60~85%)
Response to
chemotherapy
Performance
status
Muscle
function
Quality of
life
Van Cutsem et al., 2005
Mariette et al., 2012
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Postoperative complications

Malnutrition enhances the chance of postoperative
complications in patients with esophageal cancer.
Kelsen et al., 1998
Senesse et al., 2008
Garth et al., 2010
Mariette et al., 2012

Postoperative complications delay postoperative
recovery and impair quality of life.
Viklund et al., 2005

Nutritional support can improve postoperative
outcome in patients with gastrointestinal cancer.
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Preoperative nutritional
condition

The preoperative physiological status of the
patient is known to influence postoperative
mobidity and mortality.
Lund et al., 1990
Law et al., 1994

Pretreatment nutritional support to maintain body
weight throughout treatment could possibly
decrease postoperative complications.
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Nutritional Status as a Risk
Factor in Esophageal Surgery
I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran,
H.W. Tilanus
Dig Surg 2006; 23: 159-163
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Purpose
Prognostic
nutritional
index(PNI)
Body mass
index(BMI)
Nutritional
risk
index(NRI)
Weight loss
Preoperative
nutritional
condition
Postoperative
morbidity
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Patients

In total, 400 patients with an esophageal
malignancy undergoing esophageal resection and
gastric tube reconstruction between 1996 and 2003.
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Methods
PNI
NRI
• Borderline mild: > 97.5
• Moderate: 83.5-97.5
• Severe: < 83.5
Weight loss
None, < 5%, 5-10%, > 10%
BMI
< 18.5, 18.5-24.9, 25-29.9, > 30
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Methods

Data were obtained on postoperative infectious
complications, length of hospital stay and
postoperative mortality.

Data analysis:
 Chi-square test
 Mann-Whitney’s test
 Logistic regression
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Results
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Results
P value for trend = 0.01
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Results
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Results
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Results
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Discussion

The ROC curve shows that PNI and NRI do not
make sensitive tests for predicting infectious
complications.

No correlation was found between the degree of
preoperative weight loss and BMI and the
incidence of postoperative infectious complication
rate.
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Discussion

Takagi et al. evaluated the relationship between
preoperative immunosuppression and morbidity
and demonstrated a higher BMI in patients with
postoperative complications.

They concluded that not the nutritional state but
depression of cell-mediated immunity was related
to the complication rate in patients who received
preoperative nutritional support.
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Conculsion

Preoperative nutritional status established by PNI,
NRI, BMI and weight loss has no predictive value
on postoperative infectious complications in
patients with an esophageal malignancy.
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Baseline nutritional status is
prognostic factor after definitive
radiochemotherapy for esophageal
cancer
J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani,
C. Schumacher, P. Dufour, J.-E. Kurtz, G. Noel
Dis Esophagus 2012 Oct 26 doi: 10.1111/j.14422050.2012.01441.x
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Purpose
Local recurrence-free survival (LFS)
Locoregional recurrence-free survival
(LRFS)
Prognostic
factors:
Nutritonal
status
Distant-metastasis recurrence-free survival
(MFS)
Disease-free survival (DFS)
Overall survival (OS)
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Materials and Methods

Study population: between 2003 and 2006
143 esophageal
cancer patients
Excluded
Treated by
definitive
Concurrent
radiochemother
apy
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Materials and Methods

Pretreatment evaluation:
 Medical history
 Clinical examination
 Routine blood tests

Cancer staging system: 2002 Union for
International Cancer Control (UICC) TNM
classification
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Materials and Methods


Nutritional factors:
 Weight loss
 BMI
 Serum albumin level
 Nutritional Risk Index (NRI)
Treatment:
 Three-dimensional conformal radiotherapy
 Concurrent cisplatin and 5-fluorouracil (5-FU)
chemotherapy
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Materials and Methods


Follow-up: Every 3 months for the first year,
every 6 months for the second year, and yearly
thereafter.
Statistical analysis:





Kaplan-Meier method and Log-rank test
Cox regression
Hazards ratios (HR), and within 95% confidence
interval (CI)
Log-minus-log plots and Schoenfeld residuals
IBM SPSS Statistics v20 (IBM Inc., Armonk, NY,
USA)
Results
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Results
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Results
P=0.0098
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Discussion

In the study, NRI is described as an independent
prognostic factor for both DFS and OS, which
emphasizes the major impact of nutrition on the
outcome of esophageal cancer patients.

Several previous studies have shown that weight
loss, serum albumin level, BMI, performance
status (PS) were able to be identified as
independent prognostic factors.
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Conclusion

This study found a major impact of baseline
nutritional status on the outcome of esophageal
cancer patients treated by definitive
radiochemotherapy.

NRI was an independent prognostic factor of both
DFS and OS.
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Dietician-delivered intensive nutritional
support is associated with a
decrease in severe postoperative
complications after surgery in patients
with esophageal cancer
G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S.
Buskermolen, C. P. Earthman, H. M. W. Verheul, E. S.
M. de Lange- de Klerk, S. J. B. van Weyenberg, D. L.
van der Peet
Dis Esophagus 2012 Dec 13 doi: 10.1111/dote.12008
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Purpose

To evaluate the effect of an intensive nutritional
support (INS) program under the guidance of a
dietician on postoperative outcome in patients
with esophageal cancer.
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Patients
65 patients with
esophageal
cancer
37 patients who underwent an
esophagectomy between January
2006 and February 2009 were
included in the control group.
28 patients who underwent an
esophagectomy between March
2009 and April 2010 were included
in the INS intervention group.
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Nutritional treatment

INS group
Frequent meals
Able to meet the
nutritional goals
orally
Not able to meet
the nutritional
goals orally
Additional sip
feeding
Tube feeding
Nutritional treatment
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Results
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Results

Preoperative weight change
P=0.048 unadjusted
Adjusted: non-significant
With NAT
P=0.002 unadjusted
P=0.009 adjusted
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Results
The adjusted odds ratio
after surgery was 0.23
(95% CI: 0.05–0.97;
P=0.045)
The adjusted odds ratio
undergoing NAT was 0.14
(95% CI: 0.23–0.89;
P=0.037)
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Results
Patients undergoing NAT
ICU/MCU stay: P=0.049
Hospital stay: P=0.04
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Discussion

Dietary intervention is especially beneficial in
patients who received NAT.

The longer time between diagnosis and surgery
may have been to the advantage of the INS group.

The prevention of preoperative weight loss may
also be an explanation for the observed effect of
INS on postoperative complications in patients
receiving NAT.
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Discussion

In the present study, patients in the INS group
were intensively guided by a dietitian without the
use of immune system modulating nutrients.

This result suggests that a lot is to gain with plain
improvement of energy and protein intake.
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Conclusion

This study shows that INS by a dietician is
associated with preoperative weight preservation
and less severe short-term postoperative
complications in patients with esophageal cancer.
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Summary

Nutritional status such as NRI, weight loss, serum
albumin, and performance status can be
independent prognostic factors in patients with
esophageal cancer and lead to an early specific
nutritional support.
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Summary

Patients with esophageal cancer should have
dietary counseling once every two week, whether
in preoperative stage or in postoperative stage. As
well as the most important thing is that patients
with NAT is a high risk group that is most likely
to suffer from malnutrition, however, treating
them with INS can evidently improve their
nutritional condition, then it finally affect
prognosis positively and rise survival rate.
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Reference



I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran, H.W. Tilanus. Nutritional
Status as a Risk Factor in Esophageal Surgery. Dig Surg 2006; 23:
159-163
J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani, C.
Schumacher, P. Dufour, J.-E. Kurtz, G. Noel. Baseline nutritional
status is prognostic factor after definitive radiochemotherapy for
esophageal cancer. Dis Esophagus 2012 Oct 26 doi: 10.1111/j.14422050.2012.01441.x
G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S. Buskermolen,
C. P. Earthman, H. M. W. Verheul, E. S. M. de Lange- de Klerk, S. J.
B. van Weyenberg, D. L. van der Peet. Dietician-delivered intensive
nutritional support is associated with a decrease in severe postoperative
complications after surgery in patients with esophageal cancer. Dis
Esophagus 2012 Dec 13 doi: 10.1111/dote.12008