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Nutritional support is of great
significance for cancer patients, especially those in the treatment stage.
The highest goals of nutritional support therapy are metabolic regulation, tumor control, quality of life and prolonging patient survival, and to achieve this goal, the clinical administration of nutritional support therapy should be adjusted
according to the different treatment methods received by the patient.
At present, the treatment received by tumor patients generally includes surgical treatment, chemotherapy and radiation therapy, in addition to immunotherapy, targeted therapy and interventional therapy and other treatments, this article will be divided into two phases, this issue we will learn the nutritional therapy options
of three types of patients such as surgical treatment, chemotherapy and radiation therapy.
Surgical treatment
Surgical treatments are commonly used to remove tumour cells and nearby tissues and include radical surgery, debulking surgery, restorative surgery, preventive surgery, palliative debulking surgery, diagnostic or staged surgery¹
.
The success of surgery depends not only on the skill of the surgeon, but also on the metabolic load that the patient can withstand and the nutritional therapy received²
.
The impact of surgery on the nutritional status of patients will also vary depending on the surgical site and surgical method, for example, tumors on the head, face and neck will interfere with chewing and swallowing after surgery, patients often cannot eat and digest normally after resection of digestive system tumors, and nasogastric feeding will cause discomfort to
patients.
Therefore, nutritional support should be implemented in clinical practice in accordance with the principles and procedures of Accelerated Rehabilitation Surgery (ERAS) to reduce symptoms and improve postoperative nutritional status
for patients.
Perioperative patient nutrition goals include²:
(1) prevention and treatment of catabolism and malnutrition; (2) maintain perioperative nutritional status (i.
e.
correct preoperative malnutrition and maintain postoperative nutritional status); (3) improve patients' tolerance to surgery; (4) Reduce the incidence of surgical complications and surgical mortality
.
The "White Paper on Dietary Nutrition of Chinese Cancer Patients" pointed out that patients generally need nutritional risk screening or nutritional assessment before surgery, if the patient has severe malnutrition, it is not recommended to perform surgery immediately, and nutritional risk screening and assessment are required again after at least 7~10 days of nutritional therapy to determine that it meets the indications for surgery before surgery
.
Patients who meet the indications for surgery, most patients are not allowed to eat any solid and high-protein foods at least 6 hours before surgery; After surgery, the doctor should decide the starting time to eat according to the location, type and whether there are complications of surgical resection, ranging from 6~48 hours to 1~2 weeks or more
.
After the patient starts eating, he should follow the principle of gradually transitioning from less to more, from thin to thick, from single to multiple foods, from liquid food semi-liquid food to soft food, if the energy requirement of oral intake < 60% and the duration is 3~5 days, enteral nutrition therapy, partial parenteral nutrition combined with enteral nutrition therapy and total parenteral nutrition therapy are selected to give nutritional support¹<b12>.
The General Principles of Tumor Nutrition Therapy also believes that patients with severe malnutrition or planned major surgery and moderate malnutrition should receive nutrition therapy for 1~2 weeks
before surgery.
In all cases, enteral nutrition should be preferred as long as enteral nutrition routes are available, and enteral nutrition
should be started as soon as possible (within 24 hours) after surgery.
The general rule specifically points out that for patients undergoing major open surgery, regardless of their nutritional status, it is recommended to use immune-enhanced nutrition therapy for 5~7 days before surgery, and continue until 7 days after surgery or until the patient's energy requirement is ≥ 60% through oral ingestion, and immune-enhanced nutrition therapy should include omega-3 polyunsaturated fatty acids (PUFA), arginine and nucleotide three types of substrates³
.
Chemotherapy
Chemotherapy, also known as chemotherapy, is one of the main means of treating malignant tumors, which can damage normal tissue cells while killing tumor cells
.
The effect of chemotherapy on the nutritional status of patients is two-way: on the one hand, chemotherapy can inhibit tumor growth and relieve the compression symptoms caused by tumors, thereby improving the nutritional status of patients; On the other hand, adverse reactions caused by chemotherapy can affect the nutritional intake and absorption of patients, aggravate the deterioration of nutritional status², lead to weight loss, skeletal muscle and fat loss, inhibit the function of important organs of the body, and then affect the effect of anti-tumor treatment⁵⁻⁷.
Goals of nutritional therapy during chemotherapy in cancer patients include²:
(1) maintain or improve dietary intake; (2) reduce metabolic disorders; (3) Maintain and increase skeletal muscle mass and maintain physical performance; (4) reduce the risk of dose reduction or treatment interruption during anti-tumor therapy; (5) Improve the quality of
life.
To achieve this goal, the Guidelines for Nutritional Support for Oncology Patients strongly recommend oral nutritional supplementation for patients with normal swallowing and gastrointestinal function, and tube feeding for patients with eating disorders but normal or tolerable gastrointestinal function; Supplemental parenteral or total parenteral nutrition should be chosen when intestinal dysfunction, in-field nutrition is not available, or where the energy and protein target requirements are not available⁴
.
In terms of specific food choices, chemotherapy patients should pay attention to choosing light, soft and easy to digest foods when eating, avoid greasy, coarse or spicy foods, take eggs, dairy products and other protein-rich foods on the basis of a balanced diet, and recommend a daily intake of 300~500 g of fresh vegetables and fruits to supplement vitamins and dietary fiber, reduce chemotherapy response, and improve gastrointestinal function
.
For patients with anemia, it is recommended to supplement iron-rich foods in moderation, such as red meat, animal liver, animal blood, etc.
¹.
Radiation therapy
Radiotherapy, also known as radiotherapy, is one of the main means of comprehensive treatment of malignant tumors, about three-quarters of patients need radiotherapy during treatment, and adverse reactions caused by radiotherapy can cause or aggravate malnutrition
to a certain extent.
Adverse effects of radiotherapy can manifest as nonspecific systemic reactions and local reactions
within the radiation area.
Systemic reactions include fatigue, bone marrow suppression, and gastrointestinal reactions; Local reactions vary according to different radiotherapy sites, such as head and neck tumors after radiotherapy, easy to lead to oral mucosal reactions, swallowing pain, decreased appetite, taste changes, chest tumor radiotherapy can easily cause radiation esophagitis, dysphagia, abdominal tumors after radiotherapy can cause gastrointestinal reactions, mucosal damage, decreased appetite, etc
.
Nutritional goals for oncology patients receiving radiation therapy include²:
(1) maintain or improve dietary intake; (2) maintain weight and physical performance; (3) Reduce the adverse reactions of radiotherapy, improve radiotherapy tolerance, and reduce the risk of radiotherapy interruption; (4) Ensure and maintain radiotherapy sensitivity and radiotherapy positioning accuracy; (5) Improve the quality of
life.
The 2021 edition of the Chinese Society of Clinical Oncology (CSCO) Guidelines for Nutritional Treatment of Malignant Tumors pointed out that nutrition education and dietary guidance should be provided to patients first, and nutritional intervention should be carried out for radiotherapy patients with nutritional risks or malnutrition and insufficient nutritional intake, as well as patients with oral cavity, esophageal and gastrointestinal mucosal reactions graded ≥ grade 3 after radiotherapy; If nutritional therapy is needed, it should be started
as early as possible.
In the pathway selection of nutrition therapy, enteral nutrition is recommended for those who allow intestinal function, and oral nutrition is preferred for enteral nutrition, followed by tube feeding
.
Patients with obstructive head and neck tumors or oesophageal cancer with affected swallowing function should be given enteral nutrition
as soon as possible by tube feeding.
Parenteral nutrition is recommended for patients who require nutrition therapy but cannot tolerate enteral nutrition, except for routine parenteral nutrition² in patients without gastrointestinal dysfunction.
brief summary
As the most commonly used cancer treatment methods, there are differences in the treatment concepts of surgery, chemotherapy and radiotherapy, and the nutritional goals of patients are also different
.
What is certain, however, is that good nutritional support is of paramount importance to the successful implementation of surgery, chemotherapy and radiotherapy
.
Clinicians should do a good job in nutrition education and dietary guidance, provide patients with the best nutritional support strategies, and let nutritional support and treatment methods work together to help patients survive
.
In the next phase, we will understand and learn about the nutritional goals and intervention strategies
of patients receiving immunotherapy, targeted therapy and interventional therapy in the clinic.
References:
1 Cancer Nutrition Management Branch of Chinese Nutrition Society.
White paper on nutritious diet for Chinese cancer patients.2.
Guidelines for nutritional therapy of malignant tumors of the Chinese Society of Clinical Oncology (2021 edition).3.
Chinese Anti-Cancer Association.
General principles of tumor nutrition therapy[J].
Electronic Journal of Tumor Metabolism and Nutrition, 2016(1):6.4.
Guidelines for nutritional support for cancer patients[J].
Chinese Journal of Surgery, 2017, 55(11):29.5.
BAKITAS MA,TOSTESON TD,Li Zet al.
Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial[J].
J Clin Oncol, 2015, 33(13): 438-1445.6.
KIMURAMNAITO TKENMOTSU Het al.
Prognostic impact of cancer cachexia in patients with advanced non-small cell lung cancer[J].
Support Care Cancer, 2015, 23(6): 1699-178.7.
DE WAELE E,MATTENS SHONORÉPM,et al.
Nutrition therapy in cachectic cancer patients.
The Tight Caloric Control (TiCaCo) pilot trial[J].
Appetite, 2015, 91: 298-301.
Editor: Youshi
Reviewed by Mia
Typesetting: Youshi
Execution: Uni
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