[Fat Bear Science] Are cancer patients prone to malnutrition? These 7 tips can help a lot

The incidence of malnutrition in patients with malignant tumors is extremely high, which not only reduces the tolerance to anti-tumor treatment, but also seriously affects the quality of life of patients and increases the risk of death.

Due to the stress state of the tumor-bearing body and the continuous proliferation of tumor tissue, cancer patients have obvious metabolic abnormalities of energy nutrients, which are manifested as a significant decrease in fat and protein storage, anorexia, progressive weight loss, anemia, hypoproteinemia, etc. In the late stage, they even have difficulty breathing and organ failure. Today, I will introduce to you how to treat patients with tumor malnutrition.

Is it malnutrition? Assess and diagnose first

A complete nutritional assessment and diagnosis includes nutritional risk screening, nutritional status assessment, and comprehensive testing.

The PG-SGA tool is recommended for comprehensive measurement and systematic evaluation of nutrition in cancer patients to detect malnutrition and its severity; thereby understanding the type and cause of malnutrition and determining a comprehensive treatment plan for malnutrition.

Comprehensive measurements include energy consumption level, stress level, inflammatory indicators, metabolic status, and body composition analysis.

The systematic evaluation includes the evaluation of tumor factors and organ function. Based on imaging examinations, the location, number and size of space-occupying lesions in the body are determined. Pathological and molecular biological methods are used to obtain the biological characteristics of the tumor at the tissue cytology, protein and/or nucleic acid levels, and tumor marker data are detected.

Evaluate the functions of important organs and tissues of cancer patients: eating ability (chewing, gastric emptying, intestinal function, etc.), cardiopulmonary function, liver and kidney function, bone marrow hematopoietic function, subcutaneous tissue effusion/serous cavity effusion, etc.

At the same time, psychological status and physical activity assessments are conducted. Psychological assessments are conducted through observation, interviews, and psychological tests, combined with depression and anxiety self-rating scales. After comprehensive assessment and clear diagnosis, the next step is taken.

01Anti-tumor treatment! Choose a “low-toxic and high-efficiency” plan

Inadequate nutritional intake and abnormal energy-nutrient metabolism and obstruction in cancer patients are all caused by the tumor itself. Effective anti-tumor treatment to reduce tumor burden is an effective guarantee for the success of nutritional therapy.

Patients with poor nutritional status and weak constitution have poor tolerance and are usually at a greater risk of anti-tumor treatment. For malnourished cancer patients who cannot tolerate conventional treatment, if organ function permits, a balance should be struck between tolerance and high efficiency, and “low-toxic and high-efficiency” anti-tumor treatments should be chosen as much as possible, including low-dose chemotherapy, targeted therapy, immunotherapy, endocrine therapy, local therapy, etc.

■ Chemotherapy

Single-agent, low-dose, multiple-dose chemotherapy can reduce toxic and side effects, reduce the emergence and growth of tumor-resistant cells, prolong the minimum effective blood drug concentration, lead to the maximum killing of tumor cells, and reduce the adverse reactions of single large-scale administration.

■ Targeted therapy

Targeted therapy is a treatment that utilizes specific targets of tumor tissues or cells and uses drugs that can specifically bind to these targets to specifically kill tumor cells.

For patients with driver genes, it has good efficacy and few adverse reactions. It is one of the options for malnourished cancer patients, especially digestive tract tumors with the highest incidence of malnutrition. Targeted therapy for lung cancer, breast cancer, kidney cancer, etc. has been widely used in clinical practice.

■ Immunotherapy

Immunotherapy has shown remarkable results in anti-tumor treatment, among which the more popular one is immune checkpoint blockade therapy: for example, drug O and drug K, which were launched in China last year, have more lasting clinical responses compared with chemotherapy and targeted therapy, enabling patients to have better survival and quality of life.

It can be used as an anti-tumor program in malnourished tumor patients, but it is not suitable for patients whose general condition is too poor, because immunotherapy needs to activate the body's immune function on a certain immune basis, and there will be some autoimmune-related adverse reactions, some of which may even be life-threatening.

■ Endocrine therapy

The growth and reproduction of tumor cells are also affected by hormones. During treatment, some hormones or anti-hormonal substances can be used to inhibit tumor growth, which is called endocrine therapy.

Endocrine therapy is effective in treating hormone-related tumors such as breast cancer, prostate cancer, endometrial cancer, and ovarian cancer. It is easy to treat and has better tolerance. It is one of the preferred options, especially for patients with tumor malnutrition.

02Nutritional support therapy! Follow the five-step principle

Nutritional support therapy is the basis for the treatment of malnourished cancer patients and runs through the entire treatment process. Accurate assessment, diagnosis and correct application of nutritional support are one of the essential skills for clinical physicians. The basic requirement for malnutrition treatment is to meet the target requirements for energy, protein, fluid and micronutrients; the ultimate goal is to regulate abnormal metabolism, improve immune function, control disease, improve quality of life and prolong survival.

After admission, nutritional risk screening and assessment are performed, and nutritional therapy is recommended for patients with existing malnutrition or nutritional risk. PG-SGA ≥ 9 points indicates severe malnutrition and nutritional therapy is required; PG-SGA score of 4 to 8 points indicates moderate malnutrition and nutritional therapy is required.

Nutritional support therapy for tumors follows the five-step principle: ① Nutritional consultation, ② Nutritional consultation + oral nutritional supplementation; ③ Enteral nutrition; ④ Enteral nutrition + parenteral nutrition; ⑤ Total parenteral nutrition. Total parenteral nutrition is mostly used for patients with complete upper gastrointestinal obstruction, dysphagia, severe mucositis, esophageal tracheal/mediastinal fistula, severe gastroparesis, etc. Commonly used routes include nasogastric tube, nasointestinal tube, gastrostomy, and jejunostomy. If enteral nutrition can be performed, do not use parenteral nutrition. The advantages of enteral nutrition are maintaining the intestinal barrier, fewer infectious complications and lower costs. In clinical work, most of the treatments are partial enteral combined with parenteral nutrition support.

03Metabolic regulation therapy! The treatment process is essential

Metabolic regulation therapy is essential in the treatment of malnourished cancer patients. Commonly used therapeutic agents in clinical practice include ω-3 polyunsaturated fatty acids, glutamine, branched-chain amino acids, arginine and nucleotides.

Oral mucositis and diarrhea caused by chemoradiotherapy are very common in clinical practice. Glutamine supplementation can reduce adverse reactions such as oral mucositis, radiation enteritis, vomiting, diarrhea, neurotoxicity, etc. caused by chemoradiotherapy. It plays an important role in restoring and maintaining intestinal barrier function and preventing enteric infection in patients with intestinal dysfunction.

Branched-chain amino acids maintain liver function, improve anorexia and early satiety. Arginine and nucleotides are important components of tumor immunonutritional therapy.

04 Gastrointestinal function maintenance treatment! It is very important for patients with intestinal dysfunction

Tumor malnutrition is often accompanied by intestinal dysfunction. The gastrointestinal tract is the organ for digestion and absorption of nutrients, and the intestine is the largest immune barrier organ in the human body. Gastrointestinal dysfunction not only affects the intake and absorption of nutrients, but also the ectopic intestinal flora can easily lead to enteric infection, sepsis, etc.

Therefore, maintaining gastrointestinal function is an important part of the comprehensive treatment of tumor malnutrition.

Common causes of intestinal dysfunction: infiltration of the intestinal wall by abdominal and pelvic metastatic tumors, intestinal obstruction related to cancer and anti-tumor treatment (surgery, radiotherapy and chemotherapy, etc.), radiation enteritis, diffuse damage to the intestinal mucosa caused by chemotherapy drugs, cachexia, and long-term total parenteral nutrition leading to atrophy of the digestive tract mucosa.

Common symptoms include abdominal distension, abdominal pain, nausea, vomiting, poor appetite, abnormal bowel sounds, diarrhea, reduced or absent anal defecation and flatulence, weight loss, fatigue, and water and electrolyte imbalance. Treatment includes promoting appetite and promoting gastrointestinal motility recovery.

Repair and maintenance of the intestinal barrier: Actively treat malignant intestinal obstruction, radiation enteritis, cachexia, etc., try to support oral feeding or enteral nutrition (nasogastric tube, nasointestinal tube, gastrostomy, jejunostomy, etc.), supplement glutamine, probiotics, dietary fiber in appropriate amounts, and use antibiotics prudently and reasonably.

Actively treat the primary disease: Gastrointestinal dysfunction is caused by the tumor itself, and ultimately requires anti-tumor treatment such as chemotherapy to reduce or eliminate the lesions.

Symptomatic treatment: anti-nausea, anti-emetic, antispasmodic, analgesic, anti-anxiety, depression, sedation; exercise, etc.

05Treatment of psychological disorders! Effectively relieve patients’ negative emotions

Cancer patients face changes in family relationships and social status, as well as physical discomfort such as tumors, surgery, adverse reactions to chemotherapy and radiotherapy, cancer pain, etc. Most of them have psychological disorders such as insomnia, anxiety, and depression. Common symptoms: low mood, slow thinking, pessimism, fatigue, loss of appetite, insomnia, chest tightness, palpitations, etc.

Psychological disorders not only seriously affect the patient's mood, but also affect the symptom control of the disease. At present, the treatment of tumors mainly focuses on drug therapy and tumor control, while there is a lack of assessment and treatment of the psychological state of tumor patients. The treatment of psychological disorders includes psychotherapy (psychological support, cognitive behavioral therapy), drug therapy, physical therapy, and exercise therapy. At present, psychotherapy is the main and effective treatment for emotional disorders in patients with malignant tumors.

06Exercise therapy! Comprehensively improve the patient's body

The physical activity and physical condition of most cancer patients are limited, often accompanied by skeletal muscle loss, muscle atrophy, enhanced catabolism and decreased gastrointestinal function.

Physical activity can reduce muscle catabolism, increase protein synthesis and body mass index, reduce inflammation and regulate immune function levels. It can effectively improve the aerobic metabolism, gastrointestinal function, and immunity of cancer patients; improve blood circulation and prevent thrombosis; and improve patients' insomnia, anxiety and other adverse psychological states.

Cancer patients should avoid inactive or sedentary lifestyles. Aerobic and resistance exercise are recommended for patients, but the physical activity level varies greatly among different patients, so individualized guidance is needed.

07Reduce consumption and treat symptoms! Control fever, infection, and cancer pain

Cancer patients often suffer from fever, infection, cancer pain, etc., which increase the patient's nutritional consumption and affect the patient's intake.

Fever. It may be caused by tumor fever or concurrent infection. Tumor fever can be treated with nonsteroidal anti-inflammatory drugs or effective anti-tumor treatment to control body temperature.

Infection. Cancer patients undergo chemotherapy, surgery, and various invasive procedures, as well as the combined use of hormones and immunosuppressants, which can lead to a decrease in the body's resistance and neutrophil count, creating conditions for infection. Patients with long-term intestinal obstruction need to closely prevent and treat lung infections and sepsis caused by intestinal flora translocation; elderly patients and long-term use of broad-spectrum antibiotics and hormones increase the chance of fungal infection; timely and reasonable anti-infection treatment is very necessary, and when necessary, antifungal treatment and immune-enhancing thymosin and immunoglobulin can be used in combination.

Cancer pain. One of the common symptoms of patients with advanced malignant tumors, cancer pain affects patients' sleep and appetite, reduces the body's resistance, causes patients to feel anxious and depressed, accelerates disease progression, and reduces the quality of life of patients. Rapid, reasonable, and effective pain control is essential in tumor treatment, and standardized full-process management of cancer pain patients is required.

Malnutrition in cancer patients is related to tumor type, clinical stage, age and treatment. It is crucial to accurately understand the mechanism of energy nutrient metabolism disorder in cancer patients and make a correct nutritional diagnosis. Effective anti-tumor treatment provides a basic guarantee for the improvement of abnormal metabolic status, and a good nutritional status is the prerequisite for the smooth progress of anti-tumor treatment.

Metabolic regulators can reverse the nutritional status of cancer patients, reduce chemotherapy-induced toxicity, improve chemotherapy tolerance and efficacy, and maintain gastrointestinal function to provide an input pathway for nutritional support and reduce the risk of infection. Psychological adjustment and physical activity can improve patients' mood and promote gastrointestinal function recovery. Reducing consumption and reducing symptoms can improve patients' quality of life.

Therefore, the medical treatment of patients with tumor malnutrition should take into account the implementation of anti-tumor treatment, nutritional support, metabolic regulation, repair and maintenance of gastrointestinal function, psychological support, and symptom reduction treatment.

In short, treatment of the primary disease is the premise, nutritional support is the basis, metabolic regulation is the key, and inflammation suppression is the fundamental. Multiple treatment methods are taken into account to reverse malnutrition and improve the patient's quality of life and survival.

Text/ Fat Bear Picture/ Internet (Please contact to delete) Review/ Yu Huiqing

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