Metabolic and Nutritional Issues in Oncology

Julia Fechtner,¹ Carolyn Lammersfeld,² Carol Ireton-Jones,² Pankaj Vashi¹

¹Midwestern Regional Medical Center, Cancer Treatment Centers of America, Zion, IL, USA

²Cancer Treatment Centers of America, Dallas, TX, USA

Introduction

Nutritional management of the patient with cancer is multifactorial. Individuals may have been well nourished prior to diagnosis or may be debilitated from weight loss or surgical procedures and other therapies. In addition, prognosis and available therapies play a role in the overall plan for nutrition care. Assessment of nutrition status forms the basis for the nutrition plan and allows the determination of type and route of administration of nutrients.

Multiple Choice Question

Nutritional Evaluation Tools in Oncology Patients

1. True or false? Serum albumin is a good indicator of nutritional status in oncology patients.

True
False

Using serum albumin alone to make an assessment of nutritional status or risk in people with cancer is not recommended. In oncology patients who receive large amounts of fluid with chemotherapy or after surgery, a low serum albumin can be secondary to a dilution effect rather than malnutrition. Similarly, a dehydrated patient may present with a normal serum albumin that will drop with hydration.

Several tools exist to assess nutritional status; however, few have been validated in the oncology population. The Subjective Global Assessment (SGA) was originally validated for use in gastrointestinal (GI) surgical patients, but it has been used in the oncology population with good sensitivity and specificity. It has been shown to have more sensitivity and specificity than serum albumin. The SGA takes into account weight loss history, oral intake, GI symptoms, functional capacity, and stress of disease. A potential drawback is that it requires a nutrition-related physical examination. The Scored Patient-Generated Subjective Global Assessment (PG-SGA) is an adaptation of the SGA developed by Ottery to be more specific to the oncology population. This tool is completed by the patient and scored by a clinician. It includes nutrition impact symptoms and a triage component.

Case study 135.1

A 54-year-old male with a 30-year history of chewing tobacco developed an ulcer on the tongue, causing difficulty with speech and swallowing. The ulcer was eventually biopsied, and squamous cell cancer of the tongue was diagnosed (Figure 135.1). The patient had a 20-lb. weight loss prior to diagnosis and is scheduled for chemoradiation therapy (CRT).

Figure 135.1 Large infiltrative tumor of the tongue with severe dysphagia (Source: Pankaj Vashi, Cancer Treatment Centers of America. Reproduced with permission of Pankaj Vashi).

1. What is the best nutritional intervention for this patient?

Naso-gastric (NG) feeding
Nutrition counseling and supplementation
Percutaneous endoscopic gastrostomy (PEG) tube placement before starting CRT
Megesterol acetate as an appetite stimulant
B and C

Although nutritional counseling and PEG tube should be considered for this particular patient due to dysphagia and weight loss, the role of enteral feeding (nasogastric or PEG) in asymptomatic patients is controversial due to a lack of good randomized trials. Nutritionally compromised patients with head and neck squamous cell cancer (HNSCC) have a higher incidence of infection, increased complications, and poor treatment response. Currently, most HNSCC patients receiving radiation therapy (RT) or CRT are offered nutrition counseling and nutritional supplements plus enteral tube feeding if significant weight loss is present prior to treatment. Randomized studies have shown the benefit of continued nutrition counseling and oral supplementation and should be offered to all of the patients. Poor patient tolerance to NG tube feeding has made it a less desirable option in most of the developed countries. Radiotherapy treatment toxicities that compromise nutritional status include painful mucositis, dysgeusia (altered taste), xerostomia (dry mouth), odynophagia, thickened secretions, and anorexia. Many of these symptoms can last for months after the radiation therapy is completed. Thus, addressing these symptoms with topical regimens that include local saliva substitutes for dry mouth, and zinc-containing products to improve taste sensation, is crucial in improving oral intake, nutritional status, and quality of life.

The decision for timing of PEG tube placement should be made at diagnosis given the risks and benefits of this procedure. It is important to facilitate risk assessment, appropriate placement, effective patient counseling, and monitoring for major and minor complications. Nutritional outcomes need to be measured and evaluated. These include the effects of enteral feeding on nutritional status, gastrostomy complications, and overall survival. Patient-related factors that can dictate the need for enteral feeding prior to radiation therapy in HNSCC include dysphagia, weight loss of more than 10% within the previous 6 months, and poor performance status.

2. PEG and radiologically inserted gastrostomy are safe procedures and should be considered for all the patients receiving radiation therapy for head and neck cancers?

Gastrostomy tube insertion can be achieved with PEG, RIG (radiologically inserted gastrostomy), or surgical gastrostomy. PEG remains a preferred procedure for most of the patients with HNSCC who have dysphagia and weight loss. Surgical gastrostomy is only considered for patients who have failed PEG or RIG. Complications related to PEG or RIG can be divided into postprocedure mortality, either minor or major complications. Wollman et al. (1995) reported a procedure-related fatality rate 0.3% for RIG and 0.53% for PEG, which has been also reported in other meta-analysis. Other major complications include bowel perforation, GI hemorrhage, intra-abdominal abscess, peritonitis, aspiration, and sepsis. Minor complications include dislodged tube, tube malfunction, peristomal leak, peristomal infection, postprocedure ileus, subcutaneous emphysema, and recently reported cases of mucosal herniation-induced occlusion. Meta-analysis of 2379 patients has shown no statistical differences in major and minor complications with PEG or RIG procedures.

In HNSCC, the success of either procedure depends on the experience of the performing physician and the status of the lumen of the upper GI tract to allow either an endoscope or a nasogastric tube to be introduced into the stomach. Malignant seeding at the PEG tube insertion site is a rare but recently recognized complication of the PEG procedure (Figure 135.2). A recent review of 44 cases has shown that this complication is most common with pharyngo-esophageal cancers. In potentially curable HNSCC, this rare complication should be discussed with the patients, especially with pharyngo-esophageal cancer, and other options including RIG or surgical gastrostomy tube placement should be considered.

Figure 135.2 Malignant seeding at the percutaneous endoscopic gastrostomy (PEG) site—a rare complication of endoscopically placed G tubes (Source: Pankaj Vashi, Cancer Treatment Centers of America. Reproduced with permission of Pankaj Vashi).

• What are the nutritional needs, and what tube-feeding formula is appropriate for this patient?

Energy intake should be 1.2 to 1.5 times the predicted resting energy expenditure, or about 30–35 kcal/kg/day. Protein intake can be from 1.5 to 2 grams/kg/day. To counteract cachexia, the lipid intake may need to exceed 30% of total calories. A standard tube feeding (enteral) formula would be appropriate for this patient.

Commercially available tube feedings can be categorized into the following groups:

Standard: 1–1.2 kcal/ml with 50–55% carbohydrates, 30–35% fats, and 15–18% of proteins. These may or may not contain fiber, and most are isotonic.
Calorically dense: 1.5–2 kcal/ml with approximately the same percentage of carbohydrate, fat, and protein.
Specialized: This includes peptide-based and chemically defined or elemental formulas for patients with malabsorption or GI intolerance. These contain easily digested forms of carbohydrate, protein, and fat, and most are fiber-free.
Disease specific formulations: These are also available; however, the current American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines support the use of these products in specific cases and not for general use. Immunomodulating formulations (usually 1 kcal/ml), enriched with arginine, glutamine, omega-3 fatty acids, and nucleotides and antioxidants, are recommended for patients with major elective surgery, trauma, burns, and head and neck cancer, and for critically ill patients on mechanical ventilation.

• When should you use bolus versus continuous feeding?

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135: Metabolic and Nutritional Issues in Oncology

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Introduction

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Nutritional Evaluation Tools in Oncology Patients

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