Nutrition and Cancer
ISSN: 0163-5581 (Print) 1532-7914 (Online) Journal homepage: http://www.tandfonline.com/loi/hnuc20
Nutritional Therapy for Patients with Esophageal Cancer Taja Jordan, Denis Mlakar Mastnak, Nizra Palamar & Nada Rotovnik Kozjek To cite this article: Taja Jordan, Denis Mlakar Mastnak, Nizra Palamar & Nada Rotovnik Kozjek (2017): Nutritional Therapy for Patients with Esophageal Cancer, Nutrition and Cancer, DOI: 10.1080/01635581.2017.1374417 To link to this article: http://dx.doi.org/10.1080/01635581.2017.1374417
Published online: 10 Oct 2017.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hnuc20 Download by: [University of Liverpool]
Date: 11 October 2017, At: 01:47
NUTRITION AND CANCER https://doi.org/10.1080/01635581.2017.1374417
Nutritional Therapy for Patients with Esophageal Cancer Taja Jordana, Denis Mlakar Mastnakb, Nizra Palamarb, and Nada Rotovnik Kozjekb
Downloaded by [University of Liverpool] at 01:47 11 October 2017
a Institute of radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia; bDepartment for Clinical nutrition, Institute of Oncology, Ljubljana, Slovenia
ABSTRACT
ARTICLE HISTORY
Malnutrition develops in 79% patients with esophageal cancer. Thus, these patients represent a group of cancer patients, which is the most nutritionally compromised. Dysphagia and more than 10% loss of body weight are already present at the time of diagnosis. Treatments for esophageal cancer contribute significantly to the development of malnutrition. This paper describes the nutritional treatment of patients and nutritional strategies in patients with dysphagia and other nutritional problems that accompany the treatment of patients with esophageal cancer. Here are shown the types and methods of nutritional support, which are suitable for this group of patients. Nutritional support of patients with esophageal cancer is performed as a parallel therapeutic route.
Received 5 January 2017 Accepted 20 July 2017
Nutritional Status of Patients with Esophageal Cancer
Impact of Treatment on the Nutritional Status of Patients with Esophageal Cancer
In patients with esophageal cancer, nutrition disorders are frequent. Most such patients suffer from malnutrition, which is defined as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” (1) and up to 79% of them are nutritionally compromised (2). According to available data, this is nutritionally the most compromised group of cancer patients—the loss of body weight (BW) >10% is present in more than 70% of patients at diagnosis (3). The loss of BW is, in most cases, quite rapid and starts in the first few months. The underlying cause is a rapidly developing dysphagia which is the primary symptom of esophageal cancer. Initially, patients experience difficulty swallowing solid food, followed by difficulty swallowing soft food, and ultimately also liquids and saliva (3). Following the onset of the cachectic state, dysphagia is often accompanied by anorexia (2). Cachexia is defined as “a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle mass with or without loss of fat.” The prominent feature of cachexia is weight loss in adults (4, 5). Because the loss of BW is an alarming prognostic indicator in cancer treatment, early nutritional intervention is a priority in patients with esophageal cancer (6).
Patients with esophageal cancer are treated according to different protocols, which normally include a surgical procedure, radiotherapy and chemotherapy. Simultaneous occurrences of different esophageal cancer treatments contribute immensely to the development of nutrition disorders like malnutrition and cachexia. Surgical procedures on the esophagus or gastroesophageal junction greatly affect the patient’s ability to consume enough food. Due to a decreased volume of the stomach, early satiety and stomach content reflux occur, while nausea and vomiting are also frequent. When upper gastrointestinal tract resection is combined with vagotomy, gastric retention, and dilatation are frequent. Complications following the surgical procedures, e.g., anastomotic dehiscence or damaged lymph paths like ductus thoracicus, can additionally contribute to a decreased intake of food. Insufficient intake of energy and nutrients brings about not only malnutrition in terms of proteins and energy, but often also a lack of micronutrients (3). Radiotherapy treatment does not only cause mucosal inflammation but frequently also leads to odynophagia and esophageal narrowing. Swallowing becomes increasingly painful and difficult, hence oral intake of food is greatly reduced. When a tracheoesophageal fistula develops, oral intake of food is no longer possible (7).
CONTACT Taja Jordan
[email protected]
© 2017 Taylor & Francis Group, LLC
Institute of Radiology, University Medical Centre Ljubljana, Zaloska cesta 2, 1000 Ljubljana, Slovenia.
2
T. JORDAN ET AL.
Downloaded by [University of Liverpool] at 01:47 11 October 2017
Mucosal inflammation in the upper gastrointestinal tract can be caused by some forms of chemotherapy treatment. Because chemotherapy treatment can be carried out simultaneously with radiotherapy treatment, symptoms of esophageal inflammation can be accompanied by stomatitis and frequently also nausea, vomiting and diarrhea. In the last case, per os intake of food becomes completely impossible (3, 7, 8). In patients with advanced stages of esophageal cancer, stents and esophageal dilation can be used for palliative treatment of dysphagia. These procedures can improve oral tolerance of food to an extent that the intake is sufficient for palliative nutritional therapy (3).
Nutritional Therapy in Patients with Esophageal Cancer Nutritional therapy complements the treatment in cancer patients. The process of nutritional therapy starts when the nutritional diagnosis is made and the patient’s nutrition is monitored for the whole duration of cancer treatment. Nutritional therapy is implemented in accordance with the nutritional status and metabolic state of the patient. The main goal of presurgical nutritional therapy is to decrease the negative protein balance and thus improve the patient’s postsurgical recovery. It is of vital importance that patients retain their muscle mass, a strong immune system, and good cognitive functions before the surgical procedure (9). Nutritional therapy consists of multiple steps (10–17): Screening for nutritional risk; Nutritional examination and assessment of the nutritional status (nutritional diagnosis, metabolic diagnosis), including diagnostic processes; Nutrition plan; Nutritional therapy; Monitoring the effects of nutritional care and therapy, appropriate adaptations; and Documentation. Nutritional Screening The assessment of a patient’s nutritional risk is the initial part of their nutritional treatment. In clinical practice, different tools are used for nutritional screening. The European Society for Clinical Nutrition and Metabolism recommends NRS 2002 (Nutritional Risk Screening) as the most appropriate method of screening in hospitals. Screening needs to be done in all patients who are scheduled for cancer treatment. NRS 2002 is also validated for outpatient nutritional screening in cancer patients who are treated outside hospitals. MUST (Malnutrition Universal Screening Tool) can
also be used by general practitioners for outpatient treatment. In Slovenia, both questionnaires are available. In hospitals screening is done on a weekly basis, while in the case of outpatient treatment, it is done once every 1–3 months. When screening for nutritional risk is positive, a nutritional examination needs to be done on the patient (18). Nutritional Examination Nutritional screening has to be followed by a nutritional examination of the patient—a diagnostic process with which we can determine or assess the patient’s nutritional status. Nutritional examination provides us with information about the patient’s metabolic, nutritional, and functional variables, which enable the assessment of the patient’s nutritional status and nutritional needs. Assessment of Energy and Nutrient Balance Energy and nutritional balance tells us to what extent the patient’s needs for energy and nutrients have been satisfied. To obtain information about all the conditions that can affect the patient’s nutrition and nutritional state, we carry out a nutritional anamnesis in the form of an interview at the beginning of the treatment. With this anamnesis we obtain the information necessary to assess the nutritional intake by means of a nutritional diary or some other method; information on any potential nutritional problems related to oncological disease or treatment; information on past and present nutritional habits; information about any religious, cultural or ethical standpoints that influence the patient’s nutritional habits, etc. Physical Examination of the Patient With a physical examination we can discover physical signs and symptoms of nutrient deficiency or toxicity. We assess the patient’s general appearance, the state of their skin and mucosal membranes, hair and other organs such as the eyes, gastrointestinal tract (presence of diarrhea, peristalsis), etc. It is of vital importance that we assess the dynamics of the patient’s BW loss. Measuring BW and assessing the loss of BW in the last 3 to 6 months or the percentage of unintentional BW loss is a prognostic parameter that will aid in predicting the outcome of both the treatment and the disease (functional deterioration, complications, and other adverse events). A high percentage of BW loss is linked to a higher degree of functional deterioration in the patient and a higher risk for the development of potential complications and other negative occurrences of disease and treatment. Because the loss of BW is present in esophageal cancer patients from the very beginning, assessing the patient’s BW status is essential from the start of their treatment.
Downloaded by [University of Liverpool] at 01:47 11 October 2017
NUTRITION AND CANCER
Using various diagnostic tools, the state of the patient’s hydration, edema, ascites, and other factors that affect BW changes also need to be taken into account (11, 19). BW loss can be categorized as mild, moderate, or severe (15): Mild loss of BW—less than 5% in the last 3 months; Moderate loss of BW—from 5% to 10% in the last 3 months; Severe loss of BW—more than 5% in the last months and more than 10% in the last 3 months. BW loss is one of the diagnostic criteria for cachexia in cancer patients (15). We frequently assess the patient’s body mass index (BMI, kg/m2), however, it tells us little in patients with chronic conditions. It is especially important that we use BMI < 20 as one of the diagnostic criteria for cachexia in cancer patients (15). When assessing BMI, we must always take into account the patient’s body composition, namely the value of muscle mass (physically active patients can have a high lean muscle mass value) and body water (ascites, edema) that can increase the body mass. Body Composition Analysis Bioelectrical impedance analysis (BIA) is a noninvasive and quick method of analyzing body composition and body functions. The basic principle of bio-impedance is based on the fact that muscle tissue—due to a higher content of water or electrolytes—is a better electrical conductor than fat tissue. Based on the measurements of resistance of various tissues that contain different amounts of water, we can determine the proportion of lean muscle mass, fat, body water (total, intracellular, and extracellular body water), and other parameters such as the phase angle, index of lean body mass, basal energy needs, etc. The index of lean body mass is one of criteria for diagnosing a patient with cachexia. In men, the clinically significant low index of lean body mass is
ISSN: 0163-5581 (Print) 1532-7914 (Online) Journal homepage: http://www.tandfonline.com/loi/hnuc20
Nutritional Therapy for Patients with Esophageal Cancer Taja Jordan, Denis Mlakar Mastnak, Nizra Palamar & Nada Rotovnik Kozjek To cite this article: Taja Jordan, Denis Mlakar Mastnak, Nizra Palamar & Nada Rotovnik Kozjek (2017): Nutritional Therapy for Patients with Esophageal Cancer, Nutrition and Cancer, DOI: 10.1080/01635581.2017.1374417 To link to this article: http://dx.doi.org/10.1080/01635581.2017.1374417
Published online: 10 Oct 2017.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hnuc20 Download by: [University of Liverpool]
Date: 11 October 2017, At: 01:47
NUTRITION AND CANCER https://doi.org/10.1080/01635581.2017.1374417
Nutritional Therapy for Patients with Esophageal Cancer Taja Jordana, Denis Mlakar Mastnakb, Nizra Palamarb, and Nada Rotovnik Kozjekb
Downloaded by [University of Liverpool] at 01:47 11 October 2017
a Institute of radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia; bDepartment for Clinical nutrition, Institute of Oncology, Ljubljana, Slovenia
ABSTRACT
ARTICLE HISTORY
Malnutrition develops in 79% patients with esophageal cancer. Thus, these patients represent a group of cancer patients, which is the most nutritionally compromised. Dysphagia and more than 10% loss of body weight are already present at the time of diagnosis. Treatments for esophageal cancer contribute significantly to the development of malnutrition. This paper describes the nutritional treatment of patients and nutritional strategies in patients with dysphagia and other nutritional problems that accompany the treatment of patients with esophageal cancer. Here are shown the types and methods of nutritional support, which are suitable for this group of patients. Nutritional support of patients with esophageal cancer is performed as a parallel therapeutic route.
Received 5 January 2017 Accepted 20 July 2017
Nutritional Status of Patients with Esophageal Cancer
Impact of Treatment on the Nutritional Status of Patients with Esophageal Cancer
In patients with esophageal cancer, nutrition disorders are frequent. Most such patients suffer from malnutrition, which is defined as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” (1) and up to 79% of them are nutritionally compromised (2). According to available data, this is nutritionally the most compromised group of cancer patients—the loss of body weight (BW) >10% is present in more than 70% of patients at diagnosis (3). The loss of BW is, in most cases, quite rapid and starts in the first few months. The underlying cause is a rapidly developing dysphagia which is the primary symptom of esophageal cancer. Initially, patients experience difficulty swallowing solid food, followed by difficulty swallowing soft food, and ultimately also liquids and saliva (3). Following the onset of the cachectic state, dysphagia is often accompanied by anorexia (2). Cachexia is defined as “a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle mass with or without loss of fat.” The prominent feature of cachexia is weight loss in adults (4, 5). Because the loss of BW is an alarming prognostic indicator in cancer treatment, early nutritional intervention is a priority in patients with esophageal cancer (6).
Patients with esophageal cancer are treated according to different protocols, which normally include a surgical procedure, radiotherapy and chemotherapy. Simultaneous occurrences of different esophageal cancer treatments contribute immensely to the development of nutrition disorders like malnutrition and cachexia. Surgical procedures on the esophagus or gastroesophageal junction greatly affect the patient’s ability to consume enough food. Due to a decreased volume of the stomach, early satiety and stomach content reflux occur, while nausea and vomiting are also frequent. When upper gastrointestinal tract resection is combined with vagotomy, gastric retention, and dilatation are frequent. Complications following the surgical procedures, e.g., anastomotic dehiscence or damaged lymph paths like ductus thoracicus, can additionally contribute to a decreased intake of food. Insufficient intake of energy and nutrients brings about not only malnutrition in terms of proteins and energy, but often also a lack of micronutrients (3). Radiotherapy treatment does not only cause mucosal inflammation but frequently also leads to odynophagia and esophageal narrowing. Swallowing becomes increasingly painful and difficult, hence oral intake of food is greatly reduced. When a tracheoesophageal fistula develops, oral intake of food is no longer possible (7).
CONTACT Taja Jordan
[email protected]
© 2017 Taylor & Francis Group, LLC
Institute of Radiology, University Medical Centre Ljubljana, Zaloska cesta 2, 1000 Ljubljana, Slovenia.
2
T. JORDAN ET AL.
Downloaded by [University of Liverpool] at 01:47 11 October 2017
Mucosal inflammation in the upper gastrointestinal tract can be caused by some forms of chemotherapy treatment. Because chemotherapy treatment can be carried out simultaneously with radiotherapy treatment, symptoms of esophageal inflammation can be accompanied by stomatitis and frequently also nausea, vomiting and diarrhea. In the last case, per os intake of food becomes completely impossible (3, 7, 8). In patients with advanced stages of esophageal cancer, stents and esophageal dilation can be used for palliative treatment of dysphagia. These procedures can improve oral tolerance of food to an extent that the intake is sufficient for palliative nutritional therapy (3).
Nutritional Therapy in Patients with Esophageal Cancer Nutritional therapy complements the treatment in cancer patients. The process of nutritional therapy starts when the nutritional diagnosis is made and the patient’s nutrition is monitored for the whole duration of cancer treatment. Nutritional therapy is implemented in accordance with the nutritional status and metabolic state of the patient. The main goal of presurgical nutritional therapy is to decrease the negative protein balance and thus improve the patient’s postsurgical recovery. It is of vital importance that patients retain their muscle mass, a strong immune system, and good cognitive functions before the surgical procedure (9). Nutritional therapy consists of multiple steps (10–17): Screening for nutritional risk; Nutritional examination and assessment of the nutritional status (nutritional diagnosis, metabolic diagnosis), including diagnostic processes; Nutrition plan; Nutritional therapy; Monitoring the effects of nutritional care and therapy, appropriate adaptations; and Documentation. Nutritional Screening The assessment of a patient’s nutritional risk is the initial part of their nutritional treatment. In clinical practice, different tools are used for nutritional screening. The European Society for Clinical Nutrition and Metabolism recommends NRS 2002 (Nutritional Risk Screening) as the most appropriate method of screening in hospitals. Screening needs to be done in all patients who are scheduled for cancer treatment. NRS 2002 is also validated for outpatient nutritional screening in cancer patients who are treated outside hospitals. MUST (Malnutrition Universal Screening Tool) can
also be used by general practitioners for outpatient treatment. In Slovenia, both questionnaires are available. In hospitals screening is done on a weekly basis, while in the case of outpatient treatment, it is done once every 1–3 months. When screening for nutritional risk is positive, a nutritional examination needs to be done on the patient (18). Nutritional Examination Nutritional screening has to be followed by a nutritional examination of the patient—a diagnostic process with which we can determine or assess the patient’s nutritional status. Nutritional examination provides us with information about the patient’s metabolic, nutritional, and functional variables, which enable the assessment of the patient’s nutritional status and nutritional needs. Assessment of Energy and Nutrient Balance Energy and nutritional balance tells us to what extent the patient’s needs for energy and nutrients have been satisfied. To obtain information about all the conditions that can affect the patient’s nutrition and nutritional state, we carry out a nutritional anamnesis in the form of an interview at the beginning of the treatment. With this anamnesis we obtain the information necessary to assess the nutritional intake by means of a nutritional diary or some other method; information on any potential nutritional problems related to oncological disease or treatment; information on past and present nutritional habits; information about any religious, cultural or ethical standpoints that influence the patient’s nutritional habits, etc. Physical Examination of the Patient With a physical examination we can discover physical signs and symptoms of nutrient deficiency or toxicity. We assess the patient’s general appearance, the state of their skin and mucosal membranes, hair and other organs such as the eyes, gastrointestinal tract (presence of diarrhea, peristalsis), etc. It is of vital importance that we assess the dynamics of the patient’s BW loss. Measuring BW and assessing the loss of BW in the last 3 to 6 months or the percentage of unintentional BW loss is a prognostic parameter that will aid in predicting the outcome of both the treatment and the disease (functional deterioration, complications, and other adverse events). A high percentage of BW loss is linked to a higher degree of functional deterioration in the patient and a higher risk for the development of potential complications and other negative occurrences of disease and treatment. Because the loss of BW is present in esophageal cancer patients from the very beginning, assessing the patient’s BW status is essential from the start of their treatment.
Downloaded by [University of Liverpool] at 01:47 11 October 2017
NUTRITION AND CANCER
Using various diagnostic tools, the state of the patient’s hydration, edema, ascites, and other factors that affect BW changes also need to be taken into account (11, 19). BW loss can be categorized as mild, moderate, or severe (15): Mild loss of BW—less than 5% in the last 3 months; Moderate loss of BW—from 5% to 10% in the last 3 months; Severe loss of BW—more than 5% in the last months and more than 10% in the last 3 months. BW loss is one of the diagnostic criteria for cachexia in cancer patients (15). We frequently assess the patient’s body mass index (BMI, kg/m2), however, it tells us little in patients with chronic conditions. It is especially important that we use BMI < 20 as one of the diagnostic criteria for cachexia in cancer patients (15). When assessing BMI, we must always take into account the patient’s body composition, namely the value of muscle mass (physically active patients can have a high lean muscle mass value) and body water (ascites, edema) that can increase the body mass. Body Composition Analysis Bioelectrical impedance analysis (BIA) is a noninvasive and quick method of analyzing body composition and body functions. The basic principle of bio-impedance is based on the fact that muscle tissue—due to a higher content of water or electrolytes—is a better electrical conductor than fat tissue. Based on the measurements of resistance of various tissues that contain different amounts of water, we can determine the proportion of lean muscle mass, fat, body water (total, intracellular, and extracellular body water), and other parameters such as the phase angle, index of lean body mass, basal energy needs, etc. The index of lean body mass is one of criteria for diagnosing a patient with cachexia. In men, the clinically significant low index of lean body mass is
