Symposium 6 Part l BAPEN M d e i di l ca /N l/n t u i r ti ition S i oc t e y Nutrition S upport Support i n in C ancer Cancer Therapy

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1 Symposium 6 Part l BAPEN Medical/Nutrition iti Society Nutrition Support in Cancer Therapy

2 HPN and cancer chemotherapy : time for a re-appraisal of the UK approach h? Jon Shaffer Hope Hosptal Salford

3 Nutrition and cancer? Trends in HPN in the UK HPN and cancer world-widewide UK and Cancer HPN? Times they are a changing

4 Nutrition and Cancer? Feed the patient or?f Feed dthe cancer

5 Glucose/lipid based PN do not stimulate glucose uptake by human tumours Glucose is the preferred fuel for cancer cells Uptake of a radiolabel via PET scan in healthy and liver metastastic cells in vivo X 3 higher in cancer fasting No change in lipid or glucose based feeds Bozzetti 2004

6 Cancer, nutrition and surgery N=1410 surgery Ca Colon Post op complications IV Saline 149 TPN 368 Ent 893 NS v IVF p> Bozzetti 2007

7 HPN in the UK

8 Adult HPN in UK, UK Adult HPN, Patients New point prevalence period prevalence

9 IF Aetiology ogy Admitted patients ( ) Hope 30 St Mark's Crohn 's disease Vascular Surgic cal comps Motility disorders Radiation enteritis Scle leroderma Familial l p polyposis Malignancy Other 0 % patients

10 60 50 Trends in Admissions St Mark's Crohn's St Mark's Malignancy Hope Crohn's Hope malignancy 40 % patient ts / /1 2001/2 2002/3 2003/4 2004/5 2005/6

11 Residence of All New Referrals St Mark s & Hope Hospitals /99 99/00 00/01 01/02 02/03 03/04 04/05 05/ North West Northern & Yorkshire Trent West Midlands Eastern London South West South East

12 Diagnostic categories of Adult HPN % New registrations Point prevalence Crohn s Colitis Ischaemia Rad enteritis Pseudoobst Syst Scler Cancer BANS 2006

13 HPN and cancer, BANS 2004 New registrations 17.8% CRCa 3.8 Gastric 1.3 Oesoph 1.3 ENT 1.3 Pancreas 3.8 Small bowel 2.5 Elsewhere 3.8 Point prevalence 6.8% CRCa 2 Gastric 0.2 Oesoph 0.9 ENT 0.6 Pancreas 0.9 Small bowel 1.1 Elsewhere 0.4

14 HPN and Cancer Is the UK the odd one out?

15 Elsewhere?

16 Cancer and HPN UK v Rest of Europe Europe: up to 75% HPN for cancer Mean = 39% UK: 14% HPN but 17.5% Enteral feeding (2001 BANS) Bakker H et al Clin Nutr;1999:18;

17 Worldwide HPN differences (Point prevalence) Europe USA Japan BANS Year(s) Number ** M:F Atil Aetiology % % % % Cancer 39* Crohn s disease Vascular disease Irradiation AIDS 2 5 Oth Other *78% in Germany, 80% in Sweden.** may be as high as 40,000

18 HPN Denmark pts 26% cancer 34 % IBD 22 % surgical complications 19% others Prevalence 19.2/million Annual incidence 5.0/million/year Ugur 2006

19 HPN UK and Italy 2005 UK HPN 12.3/ million HEN 384 / mill Italy HPN 31/million HEN 150 ish/mill BANS 2006 Pironi i 2006

20 HPN & cancer in Italy 75 cancer patients Intestinal obstruction = indication in 66% Metastases in 72% TPN median 4/12(1-15) 69 died on HPN Karnowsky up in 68% if survival >3/12 QOL up in only 9% if survival <3/12 Karnowsky status >50% predictor of benefit Cozzaglio et al; JPEN,1997;21:339-42

21 Italy, HPN and cancer Naples 140 ( 88% ) cancer 19 ( non- cancer ) Median HPN 81 days Violante 2006

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23 HPN & cancer - USA data- Oley Foundation/ASPEN n=1362 v 122 radiation enteritis v 416 Crohns Increase of 13% pa Survival Cancer:25%, RE: 88%, Crohns: 95% 50% cancer die within 6-9/12 Rehospitalisation x4 v radiation or Crohns Cost implications for US health care Nutritional costs 1% US health budget!!! Howard L, JPEN;1992:16:93S-99S

24 Should patients t with advanced d incurable cancers ever be sent home with total parenteral nutrition? A single institution s 20 year experience Hoda Cancer 2005

25 Mayo clinic i 52 pts. Obstruction 20 SBS/Malab 16 Fistula 11 Median survival 5 mo ( ) 16 ( 30 % ) 12/12 or more 27 complications

26 HPN & Gynaecological cancers N=61 USA 92% disease present at onset HPN 56% ovarian CA 64% Chemo/RTduring HPN Median survival: 72 days(ovarian); y( 52.5(non ovarian) 9% hospitalisation due to HPN comps QOL & nutrition better than pre HPN P<0.05 King LA et al, Gynecol Oncol 1993;51:377-82

27 Terminally ill Ovarian cancer Retrospective trial, pnvnopn no 55 pts Inpatient study Survival72dv41d v d Worse if concurrent chemotherapy? Medicalising a non-medical problem Brard 2006

28 European attitudes,? Changing Survey of NST s in Spain 62 individuals ( 62% medical ) 77% agree HPN for cancer ce if stable and family support 92% major complication - contra indicated decrease in function - 91% periodic review Moreno Villares 2007

29 13 patients with advanced cancer on HPN and 11 family members. Patients and family members said prior to HPN, eating was source of worry and often desperation. Patients reported wanting and trying to eat, but being unable to do so. Family members experienced powerlessness and frustration. The desperate and chaotic nutritional situation led to willingness to accept HPN which was viewed as a positive alternative. Orrevall 2004 Karolinska, Stockholm

30 1 yr Survival Cancer and HPN USA 20% Howard 2002, Mullady 2007 Europe 26% Bakker et al, 1997 Mayo 38% Scolapio, 1999 Taiwan 20 % Wang 2007 UK 60% BANS, 2000

31 Mortality on HPN n median ( days ) range Cozzaglio 1997,Pasanisi 2001,Santarpio 2006

32 HPN and Cancer Should the UK still be the odd one out?

33 Cancer: HETF v HPN New UK Registrations (adult); BANS 2001 HETF HPN New registrations 26% New registrations 14% Point Prevalence 19% Point Prevalence 5%

34 Nutrition Support in Cancer accepted indications NG/PEG for head and neck/oesophageal cancers PEJ/RIJ/Surg Jej for gastric Ca/ outflow obstruction PN for? proximal small bowel obstruction or Short bowel syndrome +/- drainage PEG

35 HPN in cancer patients Logistically difficult Dangerous Expensive Takes time to implement Invasive Complicated dfor patient tand carers Not widely available in UK

36 UK HPN and Cancer? Referral bias Enteral feeding Hospice End of life pathways Sc fluid v i.v. food QOL PATIENT choice

37 Options Home + nutrition PN support required Delay in discharge Receive nutrition & fluids Venting PEG Macmillan backup? Not hospice Home - nutrition Could have s/c fluids or no fluids Ensure comfort Venting PEG Macmillan backup Consider hospice

38 HPN and Cancer Conclusions How do we select patients that are likely to How do we select patients that are likely to get the maximum benefit from HPN?

39 Conclusions In a climate of scarce resources and QALY s how can we justify an expensive therapy ( 50,000/ pa ) that can improve a patients quality of remaining life