Nutrition Support Needs to Be Patient Specific

SALT LAKE CITY—Early identification of nutrition status and treatmentrelated nutrition risk are important steps in the continuum of care for cancer patients, according to an oral presentation at the annual meeting of the Hematology/Oncology Pharmacy Association.

However, “provision of nutrition support...is extremely patient specific. So there are a lot of gray areas and a lot of unknowns,” said Sharla Tajchman, PharmD, BCPS, BCNSP, critical care/ nutrition support clinical pharmacy specialist at The University of Texas M. D. Anderson Cancer Center in Houston, during her presentation.

She noted that the American Cancer Society has estimated that almost 25% of all deaths “in Western society” result from cancer and up to 20% of these are directly attributed to cachexia/malnutrition.

A past study by Dewys and colleagues found that at least 50% of all cancer patients have significant weight loss, with the highest frequency found among patients with pancreas and metastatic and nonmetastatic gastric cancer (Am J Med. 1980;69:491-497). These patients then often have a poorer response to chemotherapy, worse performance status, and shorter survival duration.

Those who have inadequate oral intake for an extended time or no oral intake for 7 days or more are especially at risk nutritionally, according to Tajchman. She said it is also important to predict what impact anticancer treatment will have on nutrition (Table).

Tajchman noted that after a patient’s nutritional risk is determined, it’s important to create a follow-up plan that defines the next move. “As pharmacists, we know these side effects and we mediate them. That’s our job.”

This could involve counseling for the patient by an oncology-trained nutrition support specialist (especially if they have difficulty swallowing); nutrition-support therapy (NST); prophylactic pharmacotherapy for treatment-related side effects, such as nausea, vomiting, and pain; and assessments for long-term complications. The latter may include electrolyte imbalances caused by nephrotoxins from chemotherapy or adhesions and bowel obstruction from surgery.

She urged caution, however, when it comes to using appetite stimulants, as the weight gain is usually seen in fat mass. “If our patients gain 5 lb of fat or 5 lb of water, how does that impact mortality? How does that impact chemotherapy? It lends a feeling of comfort by letting patients feel they have control so it’s not all bad. It’s just that we don’t truly know their effect on outcomes.”

In their guidelines for the care of adult cancer patients, the American Society of Parenteral and Enteral Nutrition (ASPEN) recommends that every patient should receive a formal nutrition screening on clinical presentation, as well as a formal follow-up plan.

Although the guidelines include that nutrition support “should not be routinely used in patients undergoing active anticancer treatment,” Tajchman said that the studies that were used to make this assessment were limited and included “very heterogeneous” populations.

The ASPEN guidelines note that nutrition support is appropriate for patients who are malnourished or predicted to be unable to ingest adequate nutrients for 7 to 14 days. “This recommendation is also for patients undergoing hematopoietic stem cell transplant,” said Tajchman. Past studies on this, however, have shown conflicting outcomes. “There’s not a good answer for these patients. I come across this every day but unfortunately there are no studies to lead us in the right direction.”

Overall, “the guideline recommendations are limited and should not replace clinical judgment,” said Tajchman. “The guidelines give you a starting point.”

She added that past research has shown that nutritional markers such as pre-albumin can be improved with nutritional support, but no studies have shown improved survival or morbidity. Still, “there are studies that show you can improve quality of life if you maintain performance status.”

Tajchman recommended that patients who are moderately to severely malnourished, have an anticipated prolonged inability to meet nutritional requirements, have continued weight loss despite adequate oral intake, and/or have complications related to malnutrition are the ones most likely to need NST.

However, “there are more questions than answers” when it comes to nutrition in cancer patients overall. “The mantra is: ‘It’s always better to do something than nothing.’ But that’s not always true with nutrition support and must be weighed very carefully for every patient,” concluded Tajchman.