Counseling cancer patients on effective nutritional practices
Many patients with GI cancer require nutritional guidance.
Screening for early diagnosis and treatment of gastrointestinal (GI) cancers has improved prognosis for many patients, focusing attention on healthy lifestyle modifications to help patients through the rigors of treatment while preparing them for a healthy life after treatment completion.1 The 5-year survival rate with colorectal cancer, by far the most common GI cancer with more than 130,000 new diagnoses annually, is 65% overall and up to 90% for patients diagnosed with localized disease.2 Survival for other common GI cancers (pancreatic, stomach, and liver) is not as high, but can reach 30% with localized liver cancer and 64% with localized stomach cancer.2 Although a new study reported that cancer survivors were more likely than the general population to engage in healthy eating,3 the findings of multiple studies with survivors of various adult and childhood cancers suggest that only 20% to 50% closely adhere to dietary recommendations and physical activity guidelines while many indulge in behaviors—especially in their food choices—that may increase their risk for poor health.1,4
The most recent American Cancer Society (ACS) evidence-based nutrition guidelines for cancer survivors emphasize a so-called prudent diet that focuses on increased intake of vegetables, fruits, and whole grains and restrictions on processed grains, meats, and red meat, in sharp contrast to the typical Western diet, which is high in fatty and processed foods and meats.1,5 Following these dietary recommendations reduces both cancer-related and total mortality among cancer patients, providing a strong incentive to patients and their oncology teams. A recent meta-analysis found the risk for cancer-specific mortality was 22% lower among patients who reported greater adherence with dietary guidelines, which also reduced the risk for developing colorectal cancer (CRC) by 21%.6 In survivors of stage III CRC, consumption of a Western diet, a high carbohydrate intake, and high glycemic indices independently increase risk of recurrence and mortality.7,8 Further, the negative effects of carbohydrate and glycemic loads were most pronounced in patients who were overweight or obese.8 In breast cancer survivors, adherence with prudent diets prior to and after diagnosis is associated with reduced overall mortality risk and in some studies is associated with significant reductions in recurrence and cancer-related mortality.1,9,10
The need for interventions to promote healthy eating is particularly acute among patients with GI cancers, who may have trouble meeting nutritional needs during and after therapy as a byproduct of their disease, surgery, or systemic treatment. Specific interventions include small, more frequent meals with minimal liquids to help patients with anorexia or early satiety and the use of fortified commercially available calorie-dense products, such as Ensure, to help patients who cannot get necessary nutrients from food alone. Additional options depending on the patient's specific requirements and abilities include consideration of pharmacologic appetite stimulants, enteral nutrition through tube feeding, or parenteral nutrition support.5
During the transition after treatment ends, patients may have lingering issues that undermine nutrition and require ongoing nutrition counseling and support from their oncology team. Appetite stimulants and medications to relieve symptoms may be necessary to help patients who are underweight or whose nutritional status is compromised. If the aftereffects of disease or treatment leave CRC survivors unable to absorb nutrients normally, referral to a registered dietician is recommended.5 In this transition period, the oncology team is crucial to reinforcing the importance of starting or maintaining a prudent diet and a regular program of physical activity to improve long-term outcomes. In a recent study from South Korea, a dietary intervention with patient participation that took place at hospital discharge resulted in significant improvements in functional status, performance status, dietary intake, and adherence with dietary guidelines among patients who had undergone gastrectomy for stomach cancer. The simple intervention included two in-person meetings and two follow-up telephone interventions between patient and oncology caregiver to obtain patients' assessment of their functional ability and general dietary knowledge and engage their participation in postdischarge dietary change through food diaries.11