Bozzetti博士认为，营养对于老年癌症患者非常重要，但仍有许多肿瘤医生忽视了这一点。他承认目前的问题是缺乏能够证实癌症患者(尤其是老年患者)营养支持效果的随机临床试验。但已有证据显示，营养不良与普通患者临床结局不良、住院时间延长、恢复期延长、生活质量下降、发病率提高以及死亡率增加有关(Clin. Nutr. 2008;27:340-9; Eur. J. Clin. Nutr. 2007;62:687-94; Br. J. Nutr. 2004; 92:105-11; Am. J. Clin.Nutr. 1997;66:1232)。他强调，无论健康与否，老年人均需要营养。
Stanga博士指出，高达56%的老年患者营养不良(Clin. Nutr. 2006;25:563-72)，20~80%的癌症患者处于严重营养风险之中。他建议，应该对所有癌症患者进行营养筛查， 以便制定恰当的营养治疗计划，实施个体化干预措施，并时常调整以满足个体需求。
Ravasco博士此前报告了该领域为数不多的一项随机对照试验结果(Am. J. Clin. Nutr. 2012 Nov. 7 [doi: 10.3945/ajcn.111.018838])。该研究表明，个体化营养咨询结合食用常规食物有益于结直肠癌放疗患者。与未接受咨询的患者相比，接受咨询的患者在营养摄入与状态改善、毒性降低、生活质量改善方面均有所受益。
营养问题专题会得到雅培营养公司无限制教育基金部分支持。Bozzetti博士、 Ravasco博士和 Stanga博士没有就潜在利益冲突做任何披露。
By: SARA FREEMAN, Oncology Practice
MANCHESTER, ENGLAND – Elderly cancer patients need to be screened for malnutrition, and individualized, multimodal interventions should be used in those found to require nourishment, according to the chair of a task force on nutrition in geriatric oncology.
"Nutrition is important in [elderly] cancer patients, yet still many oncologists neglect this aspect [of treatment]," the chair, Dr. Federico Bozzetti, told attendees during a special session on nutritional issues at the annual meeting of the International Society of Geriatric Oncology.
Standing in the way is a paucity of randomized clinical trials demonstrating the efficacy of nutritional support in cancer patients, and notably in those who are elderly, acknowledged Dr. Bozzetti, a surgical oncologist from the University of Milan.
Evidence links malnutrition to worse clinical outcomes, increased hospital stays, a longer duration of convalescence, reduced quality of life, increased morbidity, and increased mortality in the general patient population, however (Clin. Nutr. 2008;27:340-9; Eur. J. Clin. Nutr. 2007;62:687-94; Br. J. Nutr. 2004; 92:105-11; Am. J. Clin.Nutr. 1997;66:1232), Dr. Bozzetti noted.
"Old people, regardless of whether they are healthy or ill, need to be nourished," he said.
The International Society of Geriatric Oncology (SIOG) Task Force on Nutrition has as its initial aim development of a consensus-based report to provide practical guidance on nutritional support. The report is due for publication early next year.
Nutritional support currently falls "somewhere between medicine and supportive care," Dr. Bozzetti suggested, adding that beneficial effects are more likely to be seen in patients who are severely malnourished than in those who are mildly malnourished.
How Can You Screen For Malnutrition?
"Malnutrition is a subacute or chronic state of nutrition," said Dr. Zeno Stanga of University Hospital Bern (Switzerland), citing the European Society for Clinical Nutrition and Metabolism definition. It is a state "in which a combination of varying degrees of over- or undernutrition and inflammatory activity have led to a change in body composition and diminished function," he added.
Data suggest that up to 56% of geriatric patients are malnourished (Clin. Nutr. 2006;25:563-72), he noted, with around 20%-80% of cancer patients at severe nutritional risk.
"All cancer patients must receive a nutritional screening at presentation," Dr. Stanga proposed. This should be performed in order to plan adequate nutritional therapy, with interventions tailored to the individual’s needs and revised often.
Nutritional status can be influenced by a variety of factors, with food intake, body mass index, pathologic weight loss, and the severity of disease being the four key ones to assess. Measuring a single parameter is not enough, he said, and there are several screening tools that may help to identify if a patient is at risk of malnutrition and requires nutritional support.
Although there is no consensus on which tool is best for nutritional screening, the options include the Malnutritional Universal Screening Tool (MUST), the Nutritional Risk Screening (NRS) 2002, and the Mini Nutritional Assessment Short Form (MNA-SF).
What is important, Dr. Stanga maintained, is that a screening protocol be implemented at institutions using a validated tool, and that patients be given appropriate action plans as a result.
What Type of Nutritional Support?
Adjuvant nutrition can play an important role in the management of cancer patients, said Dr. Paula Ravasco of the University of Lisbon.
"The evidence today argues for the integration of both early and individualized nutritional counseling as adjuvant therapy," said Dr. Ravasco, a member of the SIOG Task Force on Nutrition.
Dr. Ravasco has previously reported the findings of one of the few randomized controlled trials in this area (Am. J. Clin. Nutr. 2012 Nov. 7 [doi: 10.3945/ajcn.111.018838]), showing that individualized nutritional counseling with regular foods is of benefit in patients with colorectal cancer treated with radiotherapy. Patients who underwent nutritional counseling had improved nutritional intake and status, reduced toxicity, and improved quality of life compared with patients who received no counseling.
The evidence-based dietary intervention used at her institution involves counseling and using prescribed therapeutic diets that are modified to fulfill the specific requirement of patients. "We perhaps have to maintain, as far as possible, the usual dietary pattern that the patient usually has," Dr. Ravasco said.
On the topic of tailoring nutritional support, Dr. Bozzetti noted that patients with a functioning gastrointestinal (GI) tract might respond to counseling and the use of oral dietary supplements or stimulants. "These have the potential to be used in a very large number of patients," he said.
Nasogastric or nasojejunal tube feeding might be the best option for short-term nutritional support if the upper GI tract is not working, he suggested. Percutaneous gastrostomy may be needed for long-term support. Parenteral nutrition may be used on its own in those with a nonfunctioning GI tract, or as a practical way to supplement inadequate oral nutrition, Dr. Bozzetti said.
The session on nutritional issues in elderly cancer patients was partially supported by an unrestricted educational grant from Abbott Nutrition. Dr. Bozzetti, Dr. Ravasco, and Dr. Stanga did not make any disclosures about potential conflicts of interest.