This article highlights the nutritional struggles in advanced cancer patients, advocating for personalised care. It covers screening, counselling, nutrient-dense foods, and interventions such as oral supplements and tube feeding, emphasising a comprehensive approach.

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Patients with advanced cancer are at high risk of losing vital body resources resulting in malnutrition, immunodeficiency, impaired quality of life and worse clinical outcomes. The support needs to address and focus on all physical, psychological and social problems interfering with food intake, digestion and anabolism. This individualised multimodal care helps address the problem holistically.

While inadequate food intake inexorably is followed by weight loss, the presence of advanced cancer frequently is associated with a systemic inflammatory response syndrome (SIRS), which in turn promotes catabolism and especially protein breakdown in skeletal muscles.

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Screening for malnutrition

Malnutrition is often overlooked in routine clinical care. International clinical guidelines ask for standard screening of all cancer patients for the presence of malnutrition or the risk of malnutrition. Screening should best be carried out in every inpatient and at each outpatient visit. It should be rapid, valid, preferably low-cost and easy enough to be carried out reliably by non-specialists.

Some questionnaire tools include:

• Nutrition Risk Screening (NRS)
• Subjective Global Assessment (SGA)
• Malnutrition Universal Screening Tool (MUST)
• Mini Nutritional Assessment (MNA)

These tools collect easily available and mostly semi-quantitative or qualitative information on, e.g. food intake, recent weight loss, body mass index and metabolic stress level.

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Counselling

The most basic but critically important step in improving food intake is diligent but compassionate and usually repeated counselling by a professional nutrition expert. The goal is to ensure adequate energy and nutrient intake by considering the individual food habits, tolerances and preferences as well as the presence of nutrition impact symptoms and derangements expected during the course of planned or ongoing anticancer treatments.

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Nutrient-dense foods

To improve energy and protein intake when appetite is decreased or satiety appears early, it is advisable to use techniques to increase the energy density of foods, thus supplying more nutrients in a smaller volume.

One option is to choose more energy-dense (e.g. high-fat vs low-fat) and protein-rich vs protein-poor products (meat, dairy products and legumes vs fruits and vegetables). Enriching foods with proteins or fats may be achieved by, e.g. adding protein powders (10–30 g/day) to liquids and cream or oils to foods and sauces. Taste and tolerance need to be taken into account on an individual basis.

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Oral nutritional supplements

Another option to improve energy intake is by offering commercially available balanced oral nutrition supplements. These products are either liquids or creamy or powders to be reconstituted with liquids to yield milky or sweet drinks or aromatic soups. Some products are highly concentrated to provide more than 3 kcal/ml.

Guidelines recommend using standard formulas; however, in addition, specialised products are available, enriched in protein, selected amino acids, fats, N-3 fatty acids and other components. Evidence to support using specialised instead of standard products in cancer patients is sparse and heterogenous and today at best suggests a potential benefit of protein-rich oral nutritional supplements (ONS) with a high content of N-3 fatty acids when supplied to patients undergoing chemotherapy.

Dietary supplements high in protein, especially branched-chain amino acids, enhance whole-body protein synthesis and might improve mortality in malnourished patients with cardiac or pulmonary disease.

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Enteral tube feeding

While it is agreed that oral route be preferred over enteral or parenteral nutrition, in a number of settings oral nutrition will not suffice to provide adequate amounts of nutrients and energy. This has been studied most frequently in patients with head and neck cancers undergoing combined radio-chemotherapy but may be offered for severe dysphagia or anorexia if gastrointestinal functions distal to the tube are known to be normal.

Tubes may be placed via the nasal or percutaneous route. Both nasogastric tubes and either endoscopically (PEG) or radiologically inserted (RIG) gastrostomies carry a similar risk of regurgitation and aspiration (REF), but long-term (more than 3 weeks) placement is more reliable with PEG or RIG.

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Parenteral nutrition

If inadequate oral food tolerance is combined with severe small bowel defects, like peritoneal carcinosis, parenteral nutrition may ensure an adequate supply of energy and nutrients.

Parenteral nutrition may be offered as a daily or several weekly supplements or may be used daily to supply the complete requirement of all nutrients (total parenteral nutrition). A large selection of pre-compounded multi-component (all-in-one, AIO) bags is commercially available. In cooperation with well-trained home-care teams, parenteral nutrition may be supplied within the home setting over longer periods.

Administration and considerations:

1. Infusion of macronutrients is limited by metabolic tolerance; therefore, the average daily requirement of fat, carbohydrates and amino acids may be infused within 6, 12, and 14 h, respectively. Thus, the online time for total parenteral nutrition is considerable and may favour overnight infusions.
2. Risks and burdens of parenteral nutrition may be serious and need to be taken into account. This includes limiting this form of nutrition to patients undergoing anticancer treatment or having an expected overall survival of more than a few weeks.
3. The potential benefits of avoiding malnutrition have to be discussed with the patient as well as the burden of long infusion times, strict hygiene techniques and complex preparations for starting and ending the infusions. In addition, there are risks for serious complications, e.g. sepsis, catheter occlusion and thrombosis.

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Metabolic modulation

To counter the catabolic effects of systemic inflammation, a diverse spectrum of anti-inflammatory and anabolic agents have been studied, including :

• Anti-cytokines
• Melatonin
• Cannabinoids
• Insulin
• Amino acids
• Proteasome inhibitors
• β-receptor modulators
• Hydrazine
• ATP
• Anabolic steroids

Evaluation of agents:

Non-steroidal anti-inflammatory agents have been reported to improve body weight and muscle mass but trial quality has been low rendering results unreliable.

Corticosteroids may improve appetite and fatigue for short periods of up to 2 or 3 weeks but are associated among other effects with muscle loss, loss of immune competence and insulin resistance; progestins may increase appetite and weight gain while increasing the risk for thromboembolic complications; cannabinoids appear to be insufficient to stimulate appetite in cancer patients.

N-3 fatty acids:

N-3 fatty acids mainly obtained from cold water fish compete with N-6 arachidonic acid for conversion by cyclooxygenases and lipoxygenases, resulting in eicosanoids with only low or no inflammatory activity.

In clinical trials, N-3 fatty acids or fish oil may decrease inflammatory markers. The evidence to support the use of these fatty acids to counter cancer cachexia, however, is heterogeneous and still inconclusive.

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Exercise training

Exercise has been proposed to modulate muscle metabolism, insulin sensitivity, and levels of inflammation and thus attenuate the effects of cancer cachexia. It appears well-tolerated and safe at different stages of cancer.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Bipinesh Sansar, DM Medical Oncology, Associate Professor Medical Oncology at MPMMCC and HBCH, Varanasi.