Nutrition in cancer patients

Background: Despite being recognised that nutritional intervention is essential, nutritional support is not widely accessible to all patients. Given the incidence of nutritional risk and nutrition wasting, and because cachexia management remains a challenge in clinical practice, a multidisciplinary approach with targeted nutrition is vital to improve the quality of care in oncology. Methods: A literature search in PubMed and Cochrane Library was performed from inception until 26 March. The search consisted of terms on: cancer, nutrition, nutritional therapy, malnutrition, cachexia, sarcopenia, survival, nutrients and guidelines. Key words were linked using “OR” as a Boolean function and the results of the four components were combined by utilizing the “AND” Boolean function. Guidelines, clinical trials and observational studies written in English, were selected. Seminal papers were referenced in this article as appropriate. Relevant articles are discussed in this article. Results: Recent literature supports integration of nutrition screening/assessment in cancer care. Body composition assessment is suggested to be determinant for interventions, treatments and outcomes. Nutritional intervention is mandatory as adjuvant to any treatment, as it improves nutrition parameters, body composition, symptoms, quality of life and ultimately survival. Nutrition counselling is the first choice, with/without oral nutritional supplements (ONS). Criteria for escalating nutrition measures include: (1) 50% of intake vs. requirements for more than 1–2 weeks; (2) if it is anticipated that undernourished patients will not eat and/or absorb nutrients for a long period; (3) if the tumour itself impairs oral intake. N-3 fatty acids are promising nutrients, yet clinically they lack trials with homogeneous populations to clarify the identified clinical benefits. Insufficient protein intake is a key feature in cancer; recent guidelines suggest a higher range of protein because of the likely beneficial effects for treatment tolerance and efficacy. Amino acids for counteracting muscle wasting need further research. Vitamins/minerals are recommended in doses close to the recommended dietary allowances and avoid higher doses. Vitamin D deficiency might be relevant in cancer and has been suggested to be needed to optimise protein supplements effectiveness. Conclusions: A proactive assessment of the clinical alterations that occur in cancer is essential for selecting the adequate nutritional intervention with the best possible impact on nutritional status, body composition, treatment efficacy and ultimately reducing complications and improving survival and quality of life.info:eu-repo/semantics/publishedVersio

Cancer : metabolic dysfunction, nutrition and quality of life

Tese de doutoramento em Ciências da Saúde (Nutrição), apresentada à Universidade de Lisboa através da Faculdade de Medicina, 2007Cancer is a major cause of morbidity and mortality worldwide. Cancer is the second most frequent cause of death and is becoming the leading cause of death in an ageing population, as most cancers occur in older adults; of note, cancer-related malnutrition is the immediate cause of death of 20% of the patients with cancer. Notwithstanding that different cancer types or locations may display different nutritional patterns, there is some inconsistency between studies in what concerns nutritional status assessment and cancer/treatment-related variables. A thorough analysis of their interaction is long due, in order to step forward the eagerly awaited evidence to foster the integration of appropriate nutritional therapy. Moreover, although 8 to 84% of cancer patients may present some degree of nutritional deterioration, which has been associated with functional impairment, the interaction between nutritional status and intake, symptoms and other disease/treatment-related factors, is a complex combination which may dictate patients’ Quality of Life (QoL). Nevertheless, the multitude of interactions between cancer location and stage, treatments, nutritional status and intervention, morbidity and QoL has never been thoroughly explored. The evidence for these interactions will be demonstrated in this thesis, which results from the collision of data from several prospective studies conducted in cancer patients. The present Thesis is structured into five sections. 1. Section 1 comprises Chapter 1 and Chapter 2. Chapter 1 describes the aims and the outline of the thesis. Chapter 2 consists of a general introduction reviewing the main concepts relevant to the studies’ design and analyses undertaken in the work ascribed to this thesis; specifically the multifactorial nature of cancer-related malnutrition, its impacts on the patients’ disease progress as well as the interactions between nutrition, morbidity and Quality of Life. 2. In Section 2, a pilot study conducted in a heterogeneous cancer patient population referred for radiotherapy is presented, which includes a critical analysis of different methods to measure QoL and the effect of nutritional intervention on nutritional parameters and QoL: • Chapter 3. Patients submitted to radiotherapy (RT), particularly of the head and neck or the gastrointestinal tract, are at higher risk of malnutrition, aggravated by the therapy induced toxicity that may further compromise nutrition and functional status. Since patients’ QoL reflects functional status, psychosocial well being, health perceptions and disease/treatment-related symptoms, the patients’ nutritional status, nutritional intake and symptoms are thus likely to assume a significant role in their QoL. We investigated: 1) the patients’ nutritional status, nutrient intake and QoL at the onset and at the end of RT, 2) whether individualised nutritional counselling, despite RT-induced symptoms, was able to enhance nutrient intake over time and whether the latter influenced the patient’s QoL and 3) which symptoms may have anticipated poorer QoL and/or reduced nutritional intake. This study showed that in patients prone to develop nutritional problems and to report the worst QoL during RT, an individualised nutritional counselling did improve nutritional intake which was identified as central to a better QoL. Additionally, from the two QoL instruments tested, the non-specific EUROQOL should be used routinely because its completion is less time consuming; the more comprehensive cancer-specific EORTC QLQ C-30 instrument covers more items and scales, identifies more domains and specific complaints, and although time consuming provides the accuracy required for research. Both instruments were able to assess patients’ QoL and both revealed the relevance of nutrition care. 3. Section 3. • Chapter 4. Based on this background, gathering validated objective data on nutritional status and its evolution throughout the disease course is of prime concern. Thus, we conducted a prospective study in head and neck, oesophageal, stomach and colorectal cancer patients, aiming to explore the intricate construct of various disease-related and diet-related factors potentially implicated in the patients’ nutritional deterioration. The disease extent was hypothesized as key to current nutritional status, which was assessed by three different methods, further compared in order to disclose their reliability. Regardless of the nutritional assessment method used, nutritional depletion was a multifactorial outcome determined by cancer and diet-related factors, all of which were simultaneously evaluated in a general linear model. Advanced cancer stage showed by far the most significant association with worse nutritional status; cancer locations, duration of the disease, protein and energy intake, and previous surgery or chemotherapy, were also significantly associated. Besides the identification of valid nutrition assessment tools, this study provided novel clinical evidence of the complex interactions between cancer and/or treatment-related variables and diet modifications, all of which exerted a combined effect on the patients’ nutritional deterioration. Cancer location was the dominant factor influencing the pattern and/or progression of nutritional deterioration; though the tumour burden for the host was of major importance. Our results were consistent with the hypothesized relations between progressive disease and wasting, which purportedly exacerbate every organ/systemic physiological derangement. • Chapter 5. It then became necessary to explore the potential interaction(s) between various disease-related and diet-related factors likely to be implicated in the patients’ QoL. A prospective cross-sectional study was thus conducted in head and neck, oesophageal, stomach and colorectal cancer patients; the specific aims were to evaluate patients’ nutritional status, nutrient intake and QoL, taking into account the disease stage and previous therapeutic interventions, to determine the potential inter-relations, and to quantify the relative impact of cancer/treatments and/or nutrition-related factors on patients’ QoL. This study provided objective evidence that cancer, diet deficits, nutritional deterioration and therapeutic interventions are determinants of the patients’ QoL, but with distinct relative weights. Whilst chemotherapy and surgery were perceived by the patients as of minor relevance, nutritional deficits and/or deterioration were intrinsic to the cancer location and stage, to reduced energy/protein intake and to weight loss, which were independent determinants of QoL. These results concur with seminal landmark data which revealed that semi-starvation impairs functional and psychological abilities, and in addition corroborated our previous study demonstrating the relationship between progressive disease and wasting. 4. Section 4. Based on the knowledge that in the above mentioned cancer patients, the location and stage of the disease as well as nutritional aspects are major determinants of patients’ QoL, it remained to be proven whether nutritional intervention might influence outcomes; therefore two prospective randomised controlled trials of nutritional therapy were conducted: 1) in colorectal cancer or 2) head and neck cancer outpatients, in order to address the potential role of adjuvant oral nutritional support on patients’ outcomes. • Chapter 6. The study herewith summarised was designed to test the hypothesis of a causal pathway between nutritional therapy and functional/clinical outcomes. A prospective randomised controlled trial, in colorectal cancer patients referred for radiotherapy, was designed to investigate whether, and to what degree, total oral intake was affected by dietary counselling or ad libitum intake supplemented with commercial supplements, both provided during RT. Furthermore the impact of nutritional intake on predefined outcomes, nutritional status and QoL, during treatment and 3 months later was examined. Despite the expected and experienced detrimental effects of RT, concurrent nutrition care integrated in the overall patient management allowed proper assessment of nutritional status and nutritional requirements, dietary counselling, education and monitoring of diet compliance and timely management of symptoms. Nutrition intervention was central to the improvement of colorectal cancer patients’ nutritional as well as non-nutritional outcomes: nutritional intake and status, QoL and lessened morbidity even in the medium term. Adding oral nutritional supplements to the diet did not appear to be as effective as dietary counselling. The control group showed a progressive deterioration in all items. • Chapter 7. Within a similar framework, with the same goals and an identical study design as in Chapter 6, the results of a prospective randomised controlled trial of nutritional therapy in head and neck cancer patients, referred for radiotherapy, are presented. The results were similar to those registered in colorectal cancer patients: nutritional counselling was indeed central to the improvement of a diversity of patient outcomes in such patients: nutritional intake, nutritional status, QoL and lessened morbidity, even in the medium term, after treatment completion. Adding oral nutritional supplements to the diet did not appear to be as effective as dietary counselling. Indeed, concurrent individualized dietary counselling based on regular foods, was the most effective means of improving patients’ nutritional intake, status and QoL during RT which are sustained 3 months after its completion, thereby lessening RT induced morbidity. The control group showed a progressive deterioration in all items. 5. Finally, Section 5 comprises Chapter 8 in which results of the studies ascribed to this thesis are discussed and some guidelines for potential future research are also suggested.O cancro é causa major de morte e morbilidade a nível mundial. É a segunda causa de morte mais frequente, e a mais importante em populações cada vez mais idosas, uma vez que a maioria dos tumores são diagnosticados em indivíduos mais velhos; de notar que a malnutrição associada ao cancro é causa de morte em 20% dos doentes. Apesar de cancros de diferentes tipos e localizações anatómicas determinarem padrões nutricionais diferentes, existe enorme discrepância entre estudos quanto à avaliação do estado nutricional e variáveis associadas à doença oncológica e/ou decorrente do(s) tratamento(s). É de há muito necessária uma análise aprofundada das potenciais interacções entre estas variáveis, com o objectivo de gerar evidência científica que justifique a integração de adequada terapêutica nutricional nos cuidados prestados ao doente. Adicionalmente, embora a prevalência da malnutrição em doentes oncológicos seja de 8 a 84%, e estando associada a limitações da capacidade funcional, a interacção entre estado e ingestão nutricionais, sintomas e outros factores associados à doença/tratamento(s) é uma combinação complexa que pode determinar a Qualidade de Vida (QV) destes doentes. No entanto, a multiplicidade de interacções entre o tumor, sua localização e estadio, tratamentos, estado e intervenção nutricionais, morbilidade e QV nunca foi explorada de forma sistemática. A evidência que consubstancia estas interacções será demonstrada na presente tese, que resulta da compilação de resultados obtidos em diversos estudos prospectivos realizados com doentes oncológicos. A presente Tese está estruturada em cinco secções. 1. A Secção 1 contém o Capítulo 1 e o Capítulo 2. O Capítulo 1 inclui a descrição dos objectivos e o esquema do conteúdo temático desta tese. O Capítulo 2 consiste numa introdução geral que engloba uma revisão dos principais conceitos relevantes para o desenho e análises realizados nos estudos que dão corpo a esta tese; em concreto, a natureza multifactorial da malnutrição associada ao cancro, o seu impacto da progressão da doença, bem como as interacções entre nutrição, morbilidade e Qualidade de Vida. 2. A Secção 2 contém o Capítulo 1 no qual é apresentado um estudo piloto realizado numa população heterogénea de doentes oncológicos referenciados para radioterapia; nesse estudo é realizada uma análise crítica de diferentes métodos de avaliação da QV e o efeito da intervenção nutricional em parâmetros nutricionais e de QV: • Capítulo 3. Os doentes submetidos a radioterapia (RT), em particular a cancro da cabeça e pescoço ou tracto gastrintestinal, apresentam maior risco de vir a desenvolver malnutrição agravada pela toxicidade decorrente do tratamento, que pode ainda influenciar a sua alimentação e estado funcional. Porque a QV dos doentes reflecte vários aspectos que englobam: estado funcional, bem-estar psicológico, percepções relativas à sua saúde e a sintomas decorrentes da doença/tratamento(s), também o estado e ingestão nutricionais podem ter um papel significativo na QV de cada doente. Neste estudo foram avaliados: 1) o estado e ingestão nutricionais e QV dos doentes no início e no fim da RT, 2) se o aconselhamento nutricional individualizado, apesar da sintomatologia decorrente da RT, seria capaz de melhorar a ingestão, e se esta melhoria viria a ter algum reflexo na QV dos doentes, e 3) quais os sintomas que pudessem antecipar uma pior QV e/ou redução da ingestão nutricional. Este estudo mostrou que, em doentes com maior probabilidade de vir a desenvolver problemas nutricionais e pior QV durante a RT, o aconselhamento nutricional individualizado melhorou a ingestão nutricional, identificada como fulcral para uma melhor QV. Para além disso, verificámos que dos dois instrumentos de QV avaliados, o instrumento inespecífico EUROQOL pode ser utilizado na rotina, uma vez que o seu preenchimento é menos moroso; porém, o instrumento mais abrangente e específico para doentes oncológicos EORTC QLQ C-30, engloba mais itens e escalas, identifica mais domínios e sintomas específicos e embora seja mais moroso, tem a precisão e rigor exigidos para uso em investigação. Ambos os instrumentos avaliaram eficazmente a QV dos doentes e ambos revelaram a relevância da terapêutica nutricional. 3. Secção 3. • Capítulo 4. Com base nos resultados antes obtidos, a recolha e análise de dados objectivos e válidos sobre o estado nutricional e sua evolução no decorrer da doença oncológica passou a ser um objectivo necessário. Assim, realizámos um estudo prospectivo em doentes com cancro da cabeça e pescoço, esófago, estômago e cólon/recto com o objectivo de explorar a complexidade decorrente de vários factores associados à doença e/ou à nutrição, potencialmente implicados na deterioração nutricional dos doentes. O estadio da doença foi a hipótese levantada como tendo potencialmente maior influência no estado nutricional; este foi avaliado por três métodos diferentes, posteriormente comparados de forma a analisar a sua validade. Independentemente do método de avaliação nutricional utilizado, verificámos que a deterioração nutricional, “outcome” de natureza multifactorial, é determinada por factores associados ao tumor e a aspectos relacionados com a nutrição, quando todos os factores foram avaliados em simultâneo por método linear generalizado. O estadio avançado do tumor revelou claramente ter a associação mais significativa com um pior estado nutricional; a localização anatómica do tumor, a duração da doença, a ingestão calórica e proteica, e a cirurgia ou quimioterapia prévias, também estavam significativamente associadas. Para além da identificação de ferramentas de avaliação nutricional validadas, este estudo contém evidência clínica pioneira e reveladora das complexas interacções entre numerosas variáveis, não apenas associadas ao tumor e/ou tratamentos mas também a modificações na ingestão nutricional; todas, embora com pesos diferentes, exercem um efeito combinado na deterioração nutricional dos doentes. A localização do tumor foi o factor dominante a influenciar o padrão e/ou progressão da deterioração nutricional, mas o estadio avançado do tumor teve uma importância major. Os nossos resultados foram consistentes com as relações anteriormente suspeitadas entre progressão da doença e deterioração nutricional, esta ultima com o potencial de agravar disfunções orgânicas/sistémicas e fisiológicas. • Capítulo 5. Tornou-se então necessário investigar potenciais interacções entre vários factores, relacionados com a doença e com a nutrição potencialmente associados com a QV dos doentes. Foi assim desenvolvido um estudo prospectivo transversal em doentes com cancro da cabeça e pescoço, esófago, estômago e cólon/recto. Os seus objectivos específicos consistiram em avaliar o estado e ingestão nutricionais e QV dos doentes, tendo em consideração o estadio da doença e intervenções terapêuticas prévias, de molde a determinar as potenciais inter-relações e quantificar o impacto relativo para a QV dos doentes, atribuível ao tumor/tratamentos e/ou factores associados à nutrição. Este estudo evidencia que o cancro, défices de ingestão, deterioração do estado nutricional e intervenções terapêuticas, são determinantes da QV dos doentes, apesar de terem pesos relativos distintos. Enquanto os doentes atribuiam uma importância minor à quimioterapia e cirurgia, os défices nutricionais e a deterioração do estado nutricional eram mais valorizados e intrinsecamente relacionados com a localização e estadio do tumor, com a reduzida ingestão calórico-proteica e com a perda ponderal, factores determinantes e independentes da QV. Estes resultados, concordantes com anterior demonstração experimental irrefutável de que o semi-jejum prolongado compromete as capacidades funcional e psicológica, corroboram ainda o nosso estudo anterior ao demonstrarem a relação entre doença avançada e depleção nutricional. 4. Secção 4. Tendo como base o conhecimento de que nos grupos de doentes oncológicos supracitados, a localização e estadio da doença bem como aspectos nutricionais são determinantes major da sua QV, permanecia a hipótese a testar de que forma a intervenção nutricional poderia influenciar diversos “outcomes”. Foram assim realizados dois ensaios clínicos prospectivos randomizados e controlados com terapêutica nutricional, 1) em doentes com cancro colorectal e 2) em doentes com cancro da cabeça e pescoço, de forma a estudar o potencial papel desempenhado pelo suporte nutricional oral adjuvante em diversos “outcomes”. • Capítulo 6. O estudo aqui resumido foi desenhado para testar a hipótese da existência de uma relação causal entre terapêutica nutricional e “outcomes” funcionais/clínicos. Este ensaio clínico prospectivo randomizado controlado de terapêutica nutricional, em doentes com cancro colorectal referenciados para RT, foi desenhado para investigar se, e de que forma, a ingestão oral total era influenciada por aconselhamento dietético individualizado ou por ingestão ad libitum suplementada com suplementos comerciais, ambos administrados apenas durante a RT. Foi também examinado o impacto da ingestão nutricional em “outcomes” pré-definidos, estado nutricional e QV, durante o tratamento e 3 meses após o seu terminus. Apesar dos esperados, e verificados, efeitos deletérios da RT, a intervenção nutricional integrada na abordagem terapêutica global permitiu não só a avaliação do estado nutricional e necessidades dietéticas, mas também o aconselhamento e educação nutricionais, a monitorização do cumprimento das recomendações nutricionais, bem como a adequação atempada da nutrição conforme a sintomatologia. A terapêutica nutricional foi essencial para a melhoria de “outcomes” nutricionais e não-nutricionais em doentes com cancro colorectal, a saber: estado e ingestão nutricionais, QV e redução da morbilidade mesmo a médio prazo. A adição de suplementos orais à dieta não foi tão eficaz como o aconselhamento nutricional. Todos os itens sob avaliação pioraram significativamente no grupo controlo apenas com ingestão ad libitum. • Capítulo 7. Partindo de uma hipótese semelhante, com objectivos e desenho de estudo idênticos ao do Capítulo 6, apresentamos neste capítulo os resultados de um ensaio clínico prospectivo randomizado controlado com terapêutica nutricional em doentes com cancro da cabeça e pescoço referenciados para RT. Os resultados foram semelhantes aos verificados em doentes com cancro colorectal: o aconselhamento nutricional foi de facto essencial para a melhoria de uma diversidade de “outcomes” nestes doentes, a saber: estado e ingestão nutricionais, QV e redução da morbilidade, mantidos a médio prazo mesmo após o terminus do tratamento. O efeito da adição à dieta de suplementos nutricionais não foi tão benéfico como o aconselhamento nutricional. O aconselhamento nutricional individualizado baseado em alimentos correntes foi realmente a forma mais eficaz de melhorar o estado e ingestão nutricionais e a QV dos doentes durante a RT, melhoria que se mantém 3 meses após o fim do tratamento e com consequente redução da morbilidade decorrente da RT. Todos os itens sob avaliação pioraram significativamente no grupo controlo apenas com ingestão ad libitum. 5. Por fim, a Secção 5 inclui o Capítulo 8 no qual se apresenta a discussão dos resultados dos estudos que formam esta tese, e são apontadas algumas linhas orientadoras e sugestões para investigação futura.The studies presented in this Thesis were performed at the Unit of Nutrition and Metabolism of the Institute of Molecular Medicine - Faculty of Medicine of the University of Lisbon, in collaboration with the Radiotherapy Department of the Santa Maria Hospital, Lisbon,

Dairy products: is there an impact on promotion of prostate cancer? A review of the literature

This review of the literature aims to study potential associations between high consumption of milk and/or dairy products and prostate cancer (PC). Literature is scarce, yet there is a direct relationship between mTORC1 activation and PC; several ingredients in milk/dairy products, when in high concentrations, increase signaling of the mTORC1 pathway. However, there are no studies showing an unequivocal relationship between milk products PC initiation and/or progression. Three different reviews were conducted with articles published in the last 5 years: (M1) PC and intake of dairy products, taking into account the possible mTORC1signaling mechanism; (M2) Intake of milk products and incidence/promotion of PC; (M3) mTORC1 activation signaling pathway, levels of IGF-1 and PC; (M4) mTORC pathway and dairy products. Of the 32 reviews identified, only 21 met the inclusion criteria and were analyzed. There is little scientific evidence that directly link the three factors: incidence/promotion of PC, intake of dairy products and PC, and PC and increased mTORC1 signaling. Persistent hyper-activation of mTORC1 is associated with PC promotion. The activity of exosomal mRNA in cellular communication may lead to different impacts of different types of milk and whether or not mammalian milks will have their own characteristics within each species. Based on this review of the literature, it is possible to establish a relationship between the consumption of milk products and the progression of PC; we also found a possible association with PC initiation, hence it is likely that the intake of dairy products should be reduced or minimized in mens' diet.info:eu-repo/semantics/publishedVersio

The effect of flaxseed in breast cancer: a literature review

Breast cancer is one of the most common cancers and the second most responsible for cancer mortality worldwide. In 2014, in Portugal approximately 27,200 people died of cancer, of which 1,791 were women with breast cancer. Flaxseed has been one of the most studied foods, regarding possible relations to breast cancer, though mainly in experimental studies in animals, yet in few clinical trials. It is rich in omega-3 fatty acids, α-linolenic acid, lignan, and fibers. One of the main components of flaxseed is the lignans, of which 95% are made of the predominant secoisolariciresinol diglucoside (SDG). SDG is converted into enterolactone and enterodiol, both with antiestrogen activity and structurally similar to estrogen; they can bind to cell receptors, decreasing cell growth. Some studies have shown that the intake of omega-3 fatty acids is related to the reduction of breast cancer risk. In animal studies, α-linolenic acids have been shown to be able to suppress growth, size, and proliferation of cancer cells and also to promote breast cancer cell death. Other animal studies found that the intake of flaxseed combined with tamoxifen can reduce tumor size to a greater extent than taking tamoxifen alone. Additionally, some clinical trials showed that flaxseed can have an important role in decreasing breast cancer risk, mainly in postmenopausal women. Further studies are needed, specifically clinical trials that may demonstrate the potential benefits of flaxseed in breast cancer.info:eu-repo/semantics/publishedVersio

Dairy Products: Is There an Impact on Promotion of Prostate Cancer? A Review of the Literature

This review of the literature aims to study potential associations between high consumption of milk and/or dairy products and prostate cancer (PC). Literature is scarce, yet there is a direct relationship between mTORC1 activation and PC; several ingredients in milk/dairy products, when in high concentrations, increase signaling of the mTORC1 pathway. However, there are no studies showing an unequivocal relationship between milk products PC initiation and/or progression. Three different reviews were conducted with articles published in the last 5 years: (M1) PC and intake of dairy products, taking into account the possible mTORC1signaling mechanism; (M2) Intake of milk products and incidence/promotion of PC; (M3) mTORC1 activation signaling pathway, levels of IGF-1 and PC; (M4) mTORC pathway and dairy products. Of the 32 reviews identified, only 21 met the inclusion criteria and were analyzed. There is little scientific evidence that directly link the three factors: incidence/promotion of PC, intake of dairy products and PC, and PC and increased mTORC1 signaling. Persistent hyper-activation of mTORC1 is associated with PC promotion. The activity of exosomal mRNA in cellular communication may lead to different impacts of different types of milk and whether or not mammalian milks will have their own characteristics within each species. Based on this review of the literature, it is possible to establish a relationship between the consumption of milk products and the progression of PC; we also found a possible association with PC initiation, hence it is likely that the intake of dairy products should be reduced or minimized in mens' diet

Impact of body composition on prognosis and dose-limiting toxicities on metastatic colorectal cancer

Sarcopenia is a progressive skeletal muscle disease, often present in oncological patients, that is associated with multiple adverse events such as worse prognosis, physical performance, and quality of life. Body composition evaluation by CT cross-section at the L3 vertebrae region appears to be a precise method to quantify skeletal muscle. The optimal cut-off for the definition of sarcopenia is not yet established, therefore the incidence of sarcopenia varies according to different studies. The main goal was to evaluate the presence of sarcopenia in patients with metastatic colorectal cancer (mCRC) and its impact on overall survival (OS) and dose-limiting toxicities (DLT). A retrospective cohort study of 178 patients with mCRC under first-line chemotherapy (ChT) in association with target therapy, in two hospital units, between January 2015 and December 2018. Skeletal mass area (SMA) was quantified with the NIH ImageJ software in CT cross-sectional images at the L3 vertebrae region. Statistical analysis was performed with IBM SPSS v25 software https://www.ibm.com/analytics/spss-statistics-software. The median age was 62 (SD ± 11) years old, 65% were men and 62.9% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0. The cut-off value was established based on ROC analysis, with sarcopenia defined as SMI 2.80 (p = 0.038; HR 2.20, CI 95% [1,05–4.62]), and sarcopenia (p = 0.01; HR 4.73, CI 95% [1.85–12.09]). Additionally, in a logistic regression model, age (p = 0.014; OR 1.09, IC 95% [1.02–1.16]) and sarcopenia (p= 0.030, OR 4.13, IC 95% [1.15-14.8]) were associated with higher incidence of DLT. The CT evaluation of the body composition at the L3 region allows for the quantification of sarcopenia, providing prognostic information and predictive value of DLT in patients with mCRC, although the establishment of optimal cut-off values are required for implementation in clinical practice. A multimodal strategy to delay muscle waste should be considered in these patients.info:eu-repo/semantics/publishedVersio

Nutritional Counseling for Head and Neck Cancer Patients Undergoing (Chemo) Radiotherapy—A Prospective Randomized Trial

Background: Locally advanced head and neck cancer is managed either by combined surgery and (chemo) radiotherapy or definitive (chemo) radiotherapy, which may deteriorate nutritional status. Previous data have shown that intensive nutritional intervention by a dietician reduces radiation-induced adverse events including weight loss.Objective: To determine if on-demand nutritional counseling (ODC, control group) would be as efficacious as intensive nutritional counseling (INC, experimental group) in patients undergoing (chemo) radiotherapy.Methods: Fifty-eight patients were randomly assigned to receive INC (n = 26) or ODC (n = 32). Outcome measures were nutritional status (PG-SGA), weight loss, handgrip strength (HGS), body composition, and survival.Results: Weight loss and impaired nutritional parameters during oncological treatment were seen equally in both groups (NS). Leaner patients at baseline maintained their weight, while overweight patients lost both weight and handgrip strength during treatment. Disease-free survival (DFS) (median = 43 months) was not affected by weight loss during treatment. Lower baseline HGS and malnutrition were associated with worse DFS (low vs. normal HGS: 15 vs. 42 months; p = 0.05 and malnutrition vs. good nutrition status: 17 vs. 42 months; p = 0.014, respectively). Survival according to low vs. normal HGS in the INC group was 4 vs. 44 months (p = 0.007) and in the ODC group 28 vs. 40 months (p = 0.944). According to malnutrition vs. good nutritional status in the INC group, DFS was 21 vs. 43 months (p = 0.025) and in the ODC group 15 vs. 41 months (p = 0.03).Conclusions: As for our primary endpoint, individualized on-demand nutritional counseling was as efficacious as intensive counseling in preventing deterioration of nutritional status and incidence of malnutrition during (chemo) radiotherapy. This should be verified with larger number of patients. Additional findings were that overweight patients had more severe weight loss, but not poorer survival. Low HGS and malnutrition at baseline were associated with poor survival.Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02159508

What is the nutrition and lifestyle profile in oncology patient? Cross-sectional study

© Ordem dos MédicosBackground: Cancer aetiology is multifactorial and risk factors include: obesity, central adiposity, sedentarism, excessive or deficient intake of foods and/or nutrients with pro-carcinogenic effects vs protective ones. Objectives: To evaluate the pattern of nutritional status, life styles, physical activity and diet in a cohort of cancer patients. Methods: This pilot cross-sectional study was conducted in 64 patients referred for radiotherapy at the Radiotherapy Department of the University Hospital of Santa Maria (CHLN). Evaluations were: waist circumference associated with potential cardio-metabolic risk, body composition by Tetrapolar Bioimpedance Analysis (XITRON®), Body Mass Index, dietary intake pattern with a short food frequency questionnaire, physical activity with Jackson questionnaire. Results: The most frequent diagnosis were breast and colorectal cancers; 53% of patients were overweight/obese, and there was a significant correlation between this nutritional pattern and weight gain in comparison with usual weight (p<0.005). There were 78% of patients with a waist circumference above the maximum cut-off limit, indicating moderate/ high cardio-metabolic risk, and most were female patients (87%). The great majority of patients (61%) had excessive fat mass highly above the maximum recommended cut-off value, especially male patients (74%). The dietary pattern was poor in vegetables (55%) and excessive in meat and simple carbohydrates (78%); physical activity was low with a high prevalence of sedentarism. Conclusions: This population presented excessive body weight, excessive fat mass, high cardio-metabolic risk, sedentarism and an unbalanced diet poor in protective foods/nutrients. This population's life styles and nutritional pattern, may be considered of risk in oncology disease. The elevated and growing incidence of cancer in Portugal, reinforces the need for further research in order to identify nutritional factors involved in the etiology/evolution and probably prognosis of cancer.info:eu-repo/semantics/publishedVersio

GLIM in diagnosing malnutrition and predicting outcome in ambulatory patients with head and neck cancer

Peer reviewe

Body Composition Evaluation in Head and Neck Cancer Patients: A Review

Introduction: Head and neck cancer (HNC) patients show a high risk of malnutrition due to the lifestyle habits adopted prior to the diagnosis as well as to the compromising impact of both the anatomical location of the tumor and the treatment modalities on food intake. Weight change, measurement of skinfold thickness, biochemical parameters, bioelectrical impedance analysis (BIA), computed tomography (CT), magnetic resonance (MRI), or dual-energy x-ray absorptiometry (DXA) are available techniques to evaluate nutritional status and/or body composition in the clinical practice. Evaluating body composition alterations in HNC patients is essential to be able to offer the best therapeutical interventions. In this paper, we review the existing literature regarding body composition evaluation in HNC patients to determine, which is the most suitable method for this population, regarding availability in the day-to-day practice, patient burden, cost, sensibility, and specificity.Methodology: A literature search for relevant papers indexed in MEDLINE, Cochrane Library and Scielo was conducted, with no publication date restriction and for all published articles until the 31 January, 2019. All the papers written in English, with interventions in humans, exclusively considering HNC patients were selected.Results: A total of 41 studies with different methodologies were included in this review. In 15 studies BIA was the used assessment method and three of them also evaluated skinfold thickness and one was a bioelectric impedance vector analysis (BIVA). Body composition assessment was made with DXA in eight studies, one of which also included muscle biopsies. In two studies the chosen method was both BIA and DXA. CT/ positron emission tomography-CT was applied in 11 studies and one also included MRI. In two studies body composition was assessed with skinfold measurements alone and one study only used BIVA.Conclusions: Despite the different existing body composition assessment tools, it seems that skeletal muscle mass (SMM) measurement at the level of cervical spine C3 vertebra may be a reliable method for SMM assessment as it strongly correlates with cross-sectional area measures at the level of L3 and it allows a cost-effective body composition assessment without the need for additional radiation exposure.Peer reviewe