ESPEN Congress Leipzig 2013

Transcription

1 ESPEN Congress Leipzig 2013 Nutrition and cancer: impact on outcome Survival, quality of life, reduced toxicity: what can be achieved in cancer patients? M.A.E. van Bokhorst - de van der Schueren (NL)

2 Survival, reduced toxicity, quality of life What can be achieved in cancer patients? Marian A.E. van Bokhorst de van der Schueren, RD PhD

3 3 Contents Overview of studies associating malnutrition to outcome measures Overview of studies investigating the effects of nutritional intervention on outcome measures by treatment modality Summary, conclusions and recommendations

4 % Patients With Weight Loss Nutritional status of patients with cancer; frequency and severity of weight loss 0% Colon Prostate Lung small cell Lung non - small cell Pancreas Non - measurable gastric Measurable gastric - 20% 26% 28% 23% 18% 29% 21% 20% - 40% - 60% 14% 14 % 18% 10% 20% 14% Weight loss in previous 6 months 21% 15% 28% 26% 32% 30% 29% 38% - 80% 0% 5% 5% 10% >10%. DeWys Am J Med 1980;

5 Prognostic impact of weight loss Shorter median survival time Trend towards diminished chemotherapy response rates Decreasing performance status DeWys Am J Med 1980;

6 Weight loss, toxicity, QoL, survival 1555 GI cancer patients undergoing chemotherapy Retrospective study Relation to Toxicity: stomatitis, plantar palmar syndrome QoL Performance status Failure free and overall survival Andreyev et al Eur J Cancer 34:

7 QOL score Weight loss and quality of life QOL score (EORTC QLQ C-30) * * * 25 0 Esophageal Gastric Pancreatic Colorectal Type of cancer Patients with weight loss Patients without weight loss *P< 0.01 for each comparison P< for all groups combined Andreyev et al Eur J Cancer 34:

8 Effect of weight loss on outcomes : chemotherapy in GI cancer Patients received 1 month less chemo Weight loss was associated with decreased response rate (p< 0.006), quality of life (p<0.0001) and performance status (p<0.0001) Weight loss associated with shorter survival duration (p<0.0001) Those who stopped losing weight had better overall survival => rationale for attempting randomised nutritional intervention trials Andreyev HJN et al Eur Journal Cancer 1998,34:503-9

9 Malnutrition and poor QoL QoL score (EORTC QLQ-C30) Strong relation between QoL and weight loss, independent of tumour stage, treatment Nourissat Eur J Cancer 2008: Tumour localisation Tumour stage at diagnosis < 10% WL 10% WL NS Local P<0.001 Locoregional P<0.001 Metastatic P=0.002 Chemotherapy Yes P<0.001 No P=

10 How nutritional status affects outcome Marin Caro Curr Opin Clin Nutr Metab Care 10:

11 Malnutrition and toxicity 100 % Time (weeks) Xerostomia Mucositis Dysphagia Malnutrition Langius. Radiother Oncol Oct;97(1):

12 Impact of anorexia and weight loss on mortality Total Anorexia No WL (A) WL > 10% No anorexia (WL) No WL No anorexia (N) Cancer Anorexia Cachexia Syndrome 484 (100%) 163 (34%) 46 (10%) 125 (26%) 150 (30%) Lasheen W & Walsh D. Support Care Cancer 2010; 10:

13 Observational studies There is (enough) evidence that a diminished nutritional status is associated with impaired quality of life, increased adverse events and even higher mortality

14 Evidence for effects of nutritional interventions? Treatment modality radiotherapy chemotherapy surgery Form of nutritional intervention 14

15 Relevant outcome measures? Weight stabilisation Maintenance / gain in fat free mass Improved intake in energy and protein Reduced toxicity Less delay in treatment / less dose adaptations Reduction of postoperative complications Improved (overall / recurrence free) survival Quality of life Improved (Karnofksy) performance status (KPS)

16 Radiotherapy (H&N), effects of nutritional intervention Systematic review including 12 trials Counseling vs no-counseling or counseling by a nurse : Positive effects: intake, nutritional status, QoL Inconsisent: complications ONS vs no supplements: Positive effects: intake. To be further studied: QoL?? (1 positive study) Langius. Clin Nutr 2013, in press

17 Protein intake in grams Benefits of Nutritional Counselling on Protein Intake During RTh (colon) NC ONS NIL RTh start end Ravasco P et al, JCO 2005; 23:

18 Long term follow-up NC ONS NIL Survival Late toxicity symptoms Ravasco P. Am J Clin Nutr 2012;96:

19 Nutritional counseling 2 Meta-analyses: Halfdanarson: J Support Oncol 2008;6: : Dietary counseling Outcome: QOL Trend towards increasing QoL Baldwin: J Natl Cancer Inst 2012;104: Dietary counseling, or ONS, or both Outcome: nutritional and clinical outcomes and QoL Improvement in weight and in energy intake Improvement in some aspects of QoL No effects on mortality

20 Chemotherapy Many studies have shown associations between weight loss and adverse events, dose reduction, severity of toxicity symptoms But only few studies have addressed effects of nutritional intervention: results not convincing

21 Chemotherapy Dintinjana, Coll Antropol Sep;32(3):737-40: Historical control group, n=173 Nutrition intervention (+ megestrol acetate), n=215 Temporary stop of weight loss (esp. in those receiving megestrol acetate); no influence on course of disease, KPS Baldwin, J Hum Nutr Diet 2011, Oct;24(5):431-4: 4 different nutritional interventions during 6 weeks, starting at beginning of chemotherapy (n=358) No differences in 1 y survival, weight, or QoL Study stopped early because of lack of effects

22 Upper GI Surgery Meta-analysis including 11 trials, > 1000 patients, immunonutrition (IN):,arg, n3-fa, RNA, glu, vs standard diet postoperative infections non-infection complications length of hospital stay in upper GI surgical oncology patients Either with preoperative, postoperative or combined preoperative and postoperative use Irrespective of nutritional status, iso-nitrogenous regimen. What about clinical practice? Changing operative techniques > laparascopic. Effects? Zhang, Surgical Oncology 21 (2012) e87-e95

23 Head and neck surgery Much less convincing evidence Systematic review including 14 trials, > 800 patients, IN (mostly: arginine) vs polymeric feeds A possible reduction in the length of postoperative hospital? but the reason for this reduction is not clear Some studies showed statistical differences with less complications / decrease of fistula formation in arginine enhanced group One study studied long term survival Casas Rodera, Nutr Hosp. 2012;27(3):

24 Survival Arginine.. Polymeric feed Buijs, Am J Clin Nutr 2010; 92 (5):

25 Multiple sites EN, TPN, separate nutrients

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27 In conclusion (1) Weight loss has been associated with poor outcomes in multiple studies Nutritional intervention has been shown to maintain weight, to improve intake, and, maybe, to influence some aspects of QoL Most evidence available for RTh, however few studies Studies in patients undergoing chemotherapy are scarce Upper GI surgery: immunonutrition

28 In conclusion (2) Need for studies investigating relevant outcomes: Toxicity Treatment delay Complications Survival We know what to do!

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