Interventions

Malnutrition and nutritional interventions will include different symptoms and patient factors (such as age, performance status, and frailty) and disease factors, including primary tumor site, tumor stage, comorbidities, metastatic disease, and treatment plan. For example, patients undergoing chemotherapy for GI cancers will experience different nutrition impact symptoms than those undergoing chemoradiation for head and neck cancer. In addition, patients with advanced metastatic disease and short life expectancy are less likely to benefit from aggressive nutritional interventions than patients with lower-stage cancers and longer life expectencies.1 Dietary counseling and planning are typically the responsibility of licensed dieticians, whereas oncology nurses are involved in symptoms management, patient education, and care, such as antiemetic pharmacotherapy for nausea, or analgesics for swallowing or abdominal pain, and appetite-stimulating progestin (megestrol acetate and medroxyprogesterone acetate) therapy.1

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Supportive feeding via parenteral or enteral feeding might be necessary for patients whose symptoms prevent normal eating and food retention (without vomiting).1 Gastrostomy is recommended for long term (4 weeks or longer) nutritional support; it is associated with better nutritional outcomes and patient convenience than nasogastric tubes.1 Short-term parenteral nutritional support is considered when enteral support is not possible, such as among patients with acute GI complications associated with radiation enteritis.1 Long-term enteral feeding complications such as tube obstruction, displacement, diarrhea, or intestinal motility issues resulting in constipation, can occur among patients of any age.1

At every stage, nutritional intervention decision-making should involve patients as much as possible, to ensure that they are consistent with patient values and goals. When interventions are likely to prove futile, this should be communicated gently but plainly to patients and their caregivers to ensure informed decision making that respects patient autonomy as much as possible.

References

1. Mislang AR, Di Donato S, Hubbard J, et al. Nutritional management of older adults with gastrointestinal cancers: an International Society of Geriatric Oncology (SIOG) review paper. J Geriatr Oncol. 2018;9(4):382-392.

2. Sharour LA. Improving oncology nurses’ knowledge, self-confidence, and self-efficacy in nutritional assessment and counseling for patients with cancer: a quasi-experimental design. Nutrition. 2019;62:131-134.

3. Abd Aziz NAS, Teng NIMF, Zaman MK. Geriatric nutrition risk index is comparable to the mini nutritional assessment for assessing nutritional status in elderly hospitalized patients. Clin Nutr ESPEN. 2019;29:77-85.

4. de Pinho NB, Martucci RB, Rodrigues VD, et al. Malnutrition associated with nutrition impact symptoms and localization of the disease: results of a multicentric research on oncological nutrition. Clin Nutr. 2019;38(3):1274-1279.

5. Bruijnen CP, van Harten-Krouwel DG, Koldenhof JJ, Emmelot-Vonk MH, Witteveen PO. Predictive value of each geriatric assessment domain for older patients with cancer: a systematic review. J Geriatr Oncol. 2019;10(6):859-873.

6. Omlin A, Blum D, Wierecky J, Haile SR, Ottery FD, Strasser F. Nutrition impact symptoms in advanced cancer patients: frequency and specific interventions: a case-control study. J Cachexia Sarcopenia Muscle. 2013;4(1):55-61.

7. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464.

8. Kaiser MJ, Bauer JM, Ramsch C, et al; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782-788.

9. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS-2002): a new method based on analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321-336.