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February 2014 VOL 5, NO 1
Malnutrition in Patients with Cancer: An Often Overlooked and Undertreated Problem
Abby C. Sauer, MPH, RD
Patients with cancer face many challenges, including eating well to maintain a good nutritional status and avoid weight loss and malnutrition. Research shows that the majority of patients with cancer suffer from nutritional deficits, and up to 85% of patients with certain cancer types experience some form of weight loss and/or malnutrition during their cancer treatment.1 For some patients, the nutritional deficits can progress to cancer cachexia, a specific form of malnutrition characterized by loss of lean body mass, muscle wasting, and impaired immune, physical, and mental function.2 Poor nutritional status and weight loss can lead to poor outcomes for patients, including decreased quality of life, decreased functional status, increased complication rates, and treatment disruptions.1,3,4 Fortunately, early nutrition intervention can improve patients’ nutritional status and help patients to maintain body weight, maintain lean body mass, better tolerate treatment, and improve quality of life.3,5-8 Therefore, all healthcare professionals who care for patients with cancer need to recognize the signs of malnutrition and provide early and effective nutrition intervention to improve outcomes.
The continuum of cancer includes diagnosis, treatment, recovery, and survivorship. Each stage in this continuum is associated with specific nutritional challenges to patients. Changes in nutritional status may begin prior to diagnosis, when physical and psychosocial issues commonly have a negative impact on appetite and food intake. At cancer diagnosis, half of patients present with some form of nutritional deficit.9 Nutritional status also often declines further during cancer treatment due to various treatment-related side effects such as anorexia, mucositis, and nausea and vomiting. The incidence of malnutrition and weight loss in people with cancer ranges from 31% to 87%.1 Patients with cancer of the lung, esophagus, stomach, colon, rectum, liver, and pancreas are at greatest risk.10
Weight loss has been found to lead to poor outcomes, with as little as a 5% weight loss predicting decreased response to therapy and decreased survival.1 Malnutrition also leads to numerous negative outcomes, including decreased quality of life, increased complication rates, decreased treatment tolerance, and increased mortality (Figure).3 Of people who die from cancer, up to half have been malnourished.11 Furthermore, up to 20% of patients die from the effects of malnutrition rather than from the cancer itself.12
In addition to malnutrition and weight loss, patients with cancer often experience loss of lean body mass, or muscle mass. Loss of muscle mass can result in outcomes that are similar to those of malnutrition and include decreased immunity, increased infections, increased skin breakdown, decreased healing, and increased mortality.13 A study of patients with head and neck cancer who were starting treatment with concurrent chemotherapy and radiation found that weight loss began 1 week after the start of treatment.14 On average, the subjects lost almost 15 pounds over the course of treatment, and of that weight loss, lean body mass accounted for 71.7%.14
In some patients, malnutrition can progress to cancer cachexia, which is “a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.”2 Its pathophysiology is characterized by a negative protein and energy balance driven by a combination of reduced food intake and abnormal metabolism.2
Due to the high prevalence of nutritional issues in these patients, nutrition screening, assessment, and intervention are crucial to preventing or minimizing the development of malnutrition. Many studies have demonstrated that maintaining a good nutritional status through nutrition intervention can help individuals with cancer improve outcomes, including3,6-8,15-17:
- Increase energy and protein intake
- Maintain and gain body weight
- Improve quality of life
- Improve strength and energy levels
- Manage treatment-related side effects
- Avoid dose reduction and treatment delays
- Reduce unplanned hospital admissions.
Nutrition intervention in patients with cancer can involve many strategies, including diet education and oral nutritional supplementation. The goals of nutritional support in patients with cancer are numerous and include maintaining an acceptable weight and preventing or treating malnutrition, leading to better tolerance of treatment and its side effects, more rapid healing and recovery, reduced risk of infection during treatment, and enhanced overall survival.3,18,19
Research has demonstrated that nutritional intervention in patients with cancer can result in positive outcomes. A recent systematic review and meta-analysis of oral nutritional interventions in malnourished patients with cancer showed that nutritional intervention, including nutritional counseling and oral nutritional supplementation, was associated with statistically significant improvements in weight and energy intake compared with routine care and had a beneficial effect on some aspects of quality of life.17 Another recent study showed that patients undergoing chemoradiotherapy for esophageal cancer who had participated in a nutrition intervention program experienced better outcomes than those who had received usual care. The patients receiving nutrition intervention had greater treatment completion rates and fewer unplanned hospital admissions; those who were admitted to a hospital had shorter length of stay compared with the patients receiving usual care.7
Additionally, expert nutrition groups including the American Society for Parenteral and Enteral Nutrition (ASPEN) and The European Society for Clinical Nutrition and Metabolism (ESPEN) have both issued clinical guidelines for nutritional treatment of patients with cancer. These guidelines state that patients with cancer should undergo nutrition screening and assessment and receive early nutrition intervention to improve outcomes.18,19 Research and expert recommendations support a preventive, rather than therapeutic, approach that encompasses nutrition screening as early as possible and treatment of nutritional problems through nutrition intervention.2,12,18,19 The entire healthcare team needs to work together to identify cancer patients at risk of malnutrition early in order to plan the best possible intervention and follow-up during cancer treatment and progression.20
Poor nutritional status, weight loss, and malnutrition are common in patients with cancer. These nutritional challenges significantly increase morbidity and mortality in these patients, and severe cases can lead to cancer cachexia. Early nutrition screening and intervention is vital to help these patients prevent this nutritional decline and to better tolerate their treatment regimen. Research has demonstrated that early nutrition intervention in patients with cancer, including oral nutritional supplementation, improves outcomes such as nutritional status, weight, treatment tolerance, and quality of life. A multidisciplinary approach among all healthcare professionals involved in cancer care is necessary to identify at-risk patients early in the process and provide appropriate and effective nutritional interventions, so that malnutrition does not remain an overlooked, underrecognized, and undertreated problem.
- DeWys WD, Begg C, Lavin PT, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980;69:491-497.
- Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12:489-495.
- Marín Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007;26:289-301.
- Andreyev HJN, Norman AR, Oates J, et al. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer. 1998;34:503-509.
- Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer. 2004;91:447-452.
- Bauer J, Capra S, Battistutta D, et al. Compliance with nutrition prescription improves outcomes in patients with unresectable pancreatic cancer. Clin Nutr. 2005;24:998-1004.
- Odelli C, Burgess D, Bateman L, et al. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol. 2005;17:639-645.
- Nayel H, el-Ghoneimy E, el-Haddad S. Impact of nutritional supplementation on treatment delay and morbidity in patients with head and neck tumors treated with irradiation. Nutrition. 1992;8:13-18.
- Halpern-Silveira D, Susin LR, Borges LR, et al. Body weight and fat-free mass changes in a cohort of patients receiving chemotherapy. Support Care Cancer. 2010;18:617-625.
- Capra S, Ferguson M, Ried K. Cancer: impact of nutrition intervention outcome—nutrition issues for patients. Nutrition. 2001;17:769-772.
- Capra S, Bauer J, Davidson W, et al. Nutritional therapy for cancer-induced weight loss. Nutr Clin Pract. 2002;17:210-213.
- Ottery FD. Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract. 1994;2:123-131.
- Demling RH. Nutrition, anabolism, and the woundhealing process: an overview. Eplasty. 2009;9. www.eplasty.com/index.php?option=com_content& view=article&id=272&catid=170:volume-09-eplasty-2009. Accessed September 9, 2013.
- Silver HJ, Dietrich MS, Murphy BA. Changes in body mass, energy balance, physical function, and inflammatory state in patients with locally advanced head and neck cancer treated with concurrent chemoradiation after low-dose induction chemotherapy. Head Neck. 2007;29:893-900.
- Bozzetti F. Nutritional support of the oncology patient. Crit Rev Oncol Hematol. 2013;87:172-200.
- Isenring EA, Bauer JD, Capra S. Nutrition support using the American Dietetic Association Medical Nutrition Therapy protocol for radiation oncology patients improves dietary intake compared with standard practice. J Am Diet Assoc. 2007;107:404-412.
- Baldwin C, Spiro A, Ahern R, et al. Oral nutritional interventions in malnourished patients with cancer: a systematic review and meta-analysis. J Natl Cancer Inst. 2012;104:371-385.
- August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors. ASPEN clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoeitic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33:472-500.
- Arends J, Bodoky G, Bozzetti F, et al. ESPEN Guidelines on Enteral Nutrition: non-surgical oncology. Clin Nutr. 2006;25:245-259.
- Santarpia L, Contaldo F, Pasanisi F. Nutritional screening and early treatment of malnutrition in cancer patients. J Cachexia Sarcopenia Muscle. 2011;2:27-35.