How should cancer patients cope with malnutrition?

Author: Sun Jingting, deputy chief physician, Harbin Jiarun Hospital

Reviewer: Yu Hongyang, Chief Physician, Harbin Jiarun Hospital

"Doctor, I have no appetite for anything I see", "Doctor, my throat hurts as if it was cut by a knife when I swallow, and I can't eat anything", "Doctor, I vomited violently after the treatment and even vomited bile, I am in so much pain"... These words are very familiar to everyone who has something to do with tumors, but every time they encounter such a situation, both doctors and patients will be at a loss as to what to do.

Aunt Jia, who is over 60 years old, has survived more than half a year on the road of "acute lymphocytic leukemia" treatment. At present, her bone marrow is in complete remission. There is no doubt that she is successful in the treatment of the disease. Aunt Jia is a cheerful person. The children in the ward affectionately call her "Grandma Jia". The children like her very much. Whenever chemotherapy makes the children suffer, they like to eat the meals made by Aunt Jia. Aunt Jia sees that the children are still so young and so cute fighting against the disease. She always responds to the children's requests. Sometimes she has no food to share, and she quietly buys an egg as a meal.

One day, I saw Aunt Jia sitting quietly by the bed in a daze, so I walked over to ask her what she was thinking about. Unexpectedly, Aunt Jia started crying: "Doctor Sun, my food is spinning in my mouth, but I just can't swallow it."

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In my impression, Aunt Jia is a strong person. She didn't cry when she was diagnosed with "leukemia", she didn't cry when her hair fell out, and she didn't cry when the hospital issued a critical illness notice. But she cried out loudly because of the food that was "turning around in her mouth". I didn't know how to comfort her for a while. I remembered that she had just finished chemotherapy yesterday. From a treatment perspective, it is normal for chemotherapy to cause anorexia, nausea and even vomiting. However, if anorexia continues, it will lead to malnutrition, which will not only affect the subsequent treatment, but the tumor will gradually increase, the body will slowly lose weight, and even a series of vicious cycle chain reactions will occur. More importantly, malnutrition itself can lead to death.

1. What impact does malnutrition have on cancer patients?

1. The incidence of malnutrition in cancer patients

Cancer patients have a high incidence of malnutrition. Studies have shown that 15% to 40% of cancer patients are already malnourished when diagnosed, and anti-cancer treatment can further increase the incidence of malnutrition. The incidence of malnutrition in adult cancer patients ranges from 38.7% to 61.2%, depending on the type and stage of the tumor. The incidence of malnutrition in hospitalized patients ranges from 20% to 50%, depending on the patient population and the definitions and criteria used for diagnosis. The incidence of malnutrition in children and adolescents with cancer is as high as 75%, depending on the type of tumor, stage, and the definitions and criteria used for diagnosis.

2. Possible consequences of malnutrition

Malnutrition can lead to increased mortality, decreased quality of life, accelerated organ function decline, and prolonged recovery time in cancer patients. These combined problems will further increase medical costs.

Why does malnutrition make tumors grow? Patients with malignant tumors are at high risk of malnutrition. In recent years, more and more studies have found that malnutrition is extremely harmful to tumor patients, both physiologically and psychologically, and has different degrees of negative impact on tumor patients. Not only that, the nutritional status of patients is also closely related to the effect of anti-tumor treatment. Malnutrition can directly or indirectly delay or even terminate the patient's treatment, which may shorten the patient's survival time and lead to the patient's death. Clinical studies have found that patients with severe malnutrition have a 2 to 5 times higher risk of death than patients with good nutritional status or mild malnutrition. Even 20% of malignant tumor patients die directly from malnutrition rather than the tumor itself. It can be seen that the harm of malnutrition to tumor patients cannot be ignored.

2. Nutritional therapy strategies for cancer patients

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Since the late 1960s, parenteral nutrition and enteral nutrition have been successively applied in clinical practice, achieving significant results and greatly improving the nutritional status of many patients. We recommend a three-step nutritional treatment strategy for cancer patients: nutritional risk screening and assessment, nutritional education and dietary guidance should be carried out throughout the entire process of diagnosis and treatment of malignant tumors. When patients do not eat enough orally, supplementary enteral nutrition is recommended, with oral nutritional supplementation as the first choice. For patients with basically normal digestive tract function but insufficient intake due to eating disorders and other reasons, tube feeding can be considered; when oral feeding and enteral nutrition still cannot meet the nutrient needs, enteral nutrition combined with parenteral nutrition is used. When enteral nutrition is not feasible or intolerant, parenteral nutrition is given.

1. Enteral nutrition

As long as the patient still has some gastrointestinal function, enteral nutrition is the preferred route. Compared with parenteral nutrition, enteral nutrition has many advantages and is more in line with physiological conditions. Oral nutritional supplementation is the preferred route for enteral nutrition treatment. The energy provided by oral nutritional supplementation every day is 400 to 600 kcal to better play the role of oral nutritional supplementation. It is generally chosen to supplement between meals, such as 9 am, 3 pm and 8 pm.

The implementation of oral nutritional supplements should pay attention to details and provide individualized nutritional treatment. The principle of individualization, that is, to choose appropriate nutritional preparations, quantities, methods and routes according to the actual situation of each patient; pay attention to details, pay attention to the speed of oral intake of nutritional supplements, the temperature of the liquid, the concentration of the liquid, the tolerance (control of the single supplement amount and the total amount), and follow the principle of quantity from small to large, speed from slow to fast, and concentration from low to high. Pay attention to the patient's body position during and shortly after intake. Observe whether there is gastric intolerance and intestinal intolerance. The former is mostly related to gastric motility, manifested as nausea, vomiting, etc., and the latter is mostly related to improper use methods, manifested as diarrhea, constipation, stool frequency, changes in nature, etc. Pay attention to whether there is aspiration, reflux, abdominal distension, abdominal pain, and abnormal bowel sounds and intestinal type during nutritional treatment.

Enteral nutrition therapy can be combined with drugs to improve appetite, such as megestrol 160 mg (once a day), digestive enzymes, probiotics, vitamins and micronutrients, etc. Enteral nutrition should always be the first choice for nutritional therapy unless there are the following contraindications, such as intestinal obstruction, intestinal wall ischemia, severe intestinal bleeding, severe gastrointestinal fistula, severe shock, etc.

2. Parenteral Nutrition

Supplementary parenteral nutrition refers to parenteral nutrition when oral or enteral nutrition intake is insufficient. It is an inevitable choice when enteral nutrition is insufficient. When enteral nutrition is not feasible, including enteral nutrition intolerance or digestive tract dysfunction, such as patients with severe intestinal dysfunction due to radiation enteritis, intestinal obstruction, short bowel syndrome, peritoneal cancer, etc., or patients with chylothorax and chylothorax, total parenteral nutrition can be used to maintain the patient's nutritional status. According to the nutritional risk assessment (such as NRS 2002 ≥ 3 points), if enteral nutrition is used for more than 7 days and still cannot meet 60% of the target requirement, supplementary parenteral nutrition should be considered; for patients with higher nutritional risk (such as NRS2002 ≥ 5 points), it is recommended to start supplementary parenteral nutrition. The nutritional status of tumor patients and their tolerance to enteral nutrition are the key to determining the use of supplementary parenteral nutrition. For some patients with severe nutritional impairment, enteral nutrition combined with parenteral nutrition is required to achieve the nutritional treatment goals. When the patient's intestinal function gradually recovers, enteral nutrition should be gradually increased and the use of supplementary parenteral nutrition should be reduced.

References

[1] Pan Hongming. Interpretation of Nutritional Therapy Guidelines for Patients with Malignant Tumors[M]. Beijing: Peking University Medical Press, 2019, 12: 33-37.

[2] Fan Daiming. Guidelines for Integrated Diagnosis and Treatment of Cancer in China (CACA) Nutritional Therapy[M]. Tianjin: Tianjin Science and Technology Press, 2023.2, 3-12.

[3] Cong Minghua. Theory and practice of tumor nutrition education[M]. Beijing: People's Medical Publishing House, 2020, 2-3.