Nutrition in Cancer Care (PDQ®)

Malnutrition

In 2010, the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism published their proposed etiology-based definitions of malnutrition. These have been accepted by both groups and the Academy of Nutrition and Dietetics (the Academy).[7,11,13] The definitions and characteristics of malnutrition have also been accepted by the Academy’s Oncology Nutrition Evidence Analysis Library Work Group.[14]

Etiology-based definitions of malnutrition include the following:

• Starvation-related malnutrition: pure chronic starvation (e.g., anorexia nervosa).
• Chronic disease–related malnutrition (e.g., organ failure, pancreatic cancer, rheumatoid arthritis, and sarcopenic obesity, resulting in mild to moderate inflammation).
• Acute disease–related or injury-related malnutrition (e.g., major infection, burns, trauma, and closed head injury, resulting in moderate to severe inflammation).

In 2012, ASPEN and the Academy released a joint statement regarding assessment of malnutrition.[12] The statement serves as a guide for nutrition assessment, including nutrition-focused physical assessment, to determine nutrition status. The assessment takes into consideration that obesity may mask malnutrition and that weight and BMI alone are not good surrogates for nutrition status.[13] The consensus statement provides the criteria for evaluating each of the following six potential indicators of malnutrition, with the recommendation that if two or more characteristics are present, the diagnosis of malnutrition is warranted.

• Insufficient energy intake.
• Weight loss.
• Loss of muscle mass.
• Loss of subcutaneous fat.
• Localized or generalized fluid accumulation that may sometimes mask weight loss.
• Diminished functional status as measured by hand grip strength.

Significant Weight Loss

Weight loss is often used as a surrogate for malnutrition. It has been correlated with adverse outcomes, including increased incidence and severity of treatment side effects and increased risk of infection, thereby reducing chances for survival.[15] Weight loss has been used as an indicator of poor prognosis in cancer patients.[16] One limitation of using weight loss as a surrogate for malnutrition is that it does not take into account the time course of the weight loss or the type of tissue loss.[7] In addition, weight may be affected by fluid shifts and may represent changes in hydration status, edema, or ascites rather than actual changes in fat and lean body mass.

The major nutrition societies in the United States have published criteria for the evaluation of weight loss over time and classifications as moderate or severe [12] (see Table 1). It is important that changes in weight be evaluated in the context of other clinical characteristics of underhydration or overhydration.

Table

Table 1. Interpretation of Adult Weight Loss^a.

Anorexia and Cachexia

Anorexia, the loss of appetite or desire to eat, is typically present in 15% to 25% of all patients with cancer at diagnosis and may also occur as a side effect of treatments or related to the tumor itself. In an observational study of patients in outpatient clinics, anorexia was reported by 26% of patients receiving chemotherapy.[17] Anorexia can be exacerbated by chemotherapy and radiation therapy side effects such as taste and smell changes, nausea, and vomiting. Surgical procedures, including esophagectomy and gastrectomy, may produce early satiety, a premature feeling of fullness.[18] Depression, loss of personal interests or hope, and anxious thoughts may be enough to bring about anorexia and result in malnutrition.[19] Anorexia is an almost-universal symptom in individuals with widely metastatic disease [20,21] because of physiologic alterations in metabolism during carcinogenesis.

Anorexia can hasten the course of cachexia,[19] a progressive wasting syndrome evidenced by weakness and a marked and progressive loss of body weight, fat, and muscle. It can develop in individuals who have adequate protein and calorie intake but have primary cachexia whereby tumor-related factors prevent maintenance of fat and muscle. Patients with diseases of the gastrointestinal tract are particularly at risk of developing anorexia. For more information, see the Tumor metabolism section.

Sarcopenia

Sarcopenia is the condition of severe muscle depletion.[1] The importance of lean body mass is shown in studies of sarcopenia in cancer. A meta-analysis of 38 studies found that a low skeletal muscle index at cancer diagnosis was associated with worse survival in patients with solid tumors.[8] Other studies have also reported poorer overall survival and increased chemotherapy toxicity in patients with sarcopenia.[1,2,9] Sarcopenic obesity may represent a chronic low-level inflammatory state that, as with disease-related malnutrition, often limits the effectiveness of nutrition interventions and requires successful treatment of the underlying disease or condition.[11] Sarcopenia is associated with increased toxicity of treatment and therefore treatment interruptions and dose reductions. It is reported to occur in 50% of patients with advanced cancer.[22-24]

Sarcopenic obesity is the presence of sarcopenia in individuals with a high BMI (≥25 kg/m²), often precipitated by the loss of skeletal muscle and gain of adipose tissue. Sarcopenic obesity is an independent risk factor for poor prognosis.[1,25,26]

It is important to identify and anticipate malnutrition and other nutrition impact symptoms early. (Nutrition impact symptoms are a range of side effects of cancer and cancer treatment that impede oral intake, e.g., alterations in taste and smell, mucositis, dysphagia, stomatitis, nausea, vomiting, diarrhea, constipation, malabsorption, pain, depression, and anxiety.) Nutrition intervention improves outcomes by helping a patient do the following:[4,6,16,22,27-29]

• Maintain weight.
• Maintain the ability to stay on the intended treatment regimen with fewer changes.
• Improve quality of life.
• Produce better surgical outcomes.

It is suggested that the treating clinician assess baseline nutrition status and be aware of the possible implications of the various therapies. Patients receiving aggressive cancer therapies typically need aggressive nutrition management. For more information, see the Nutrition Screening and Assessment section.

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

References

1. Martin L, Birdsell L, Macdonald N, et al.: Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol 31 (12): 1539-47, 2013. [PubMed: 23530101]
2. Prado CM, Baracos VE, McCargar LJ, et al.: Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res 15 (8): 2920-6, 2009. [PubMed: 19351764]
3. Bozzetti F, Mariani L, Lo Vullo S, et al.: The nutritional risk in oncology: a study of 1,453 cancer outpatients. Support Care Cancer 20 (8): 1919-28, 2012. [PMC free article: PMC3390688] [PubMed: 22314972]
4. Hébuterne X, Lemarié E, Michallet M, et al.: Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parenter Enteral Nutr 38 (2): 196-204, 2014. [PubMed: 24748626]
5. Muscaritoli M, Arends J, Bachmann P, et al.: ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr 40 (5): 2898-2913, 2021. [PubMed: 33946039]
6. 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 104 (5): 371-85, 2012. [PubMed: 22345712]
7. Marian M, August DA: Prevalence of malnutrition and current use of nutrition support in cancer patient study. JPEN J Parenter Enteral Nutr 38 (2): 163-5, 2014. [PubMed: 24748623]
8. Shachar SS, Williams GR, Muss HB, et al.: Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review. Eur J Cancer 57: 58-67, 2016. [PubMed: 26882087]
9. Kazemi-Bajestani SM, Mazurak VC, Baracos V: Computed tomography-defined muscle and fat wasting are associated with cancer clinical outcomes. Semin Cell Dev Biol 54: 2-10, 2016. [PubMed: 26343952]
10. Beaudart C, McCloskey E, Bruyère O, et al.: Sarcopenia in daily practice: assessment and management. BMC Geriatr 16 (1): 170, 2016. [PMC free article: PMC5052976] [PubMed: 27716195]
11. Jensen GL, Mirtallo J, Compher C, et al.: Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr 34 (2): 156-9, 2010 Mar-Apr. [PubMed: 20375423]
12. White JV, Guenter P, Jensen G, et al.: Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 36 (3): 275-83, 2012. [PubMed: 22535923]
13. White JV, Guenter P, Jensen G, et al.: Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet 112 (5): 730-8, 2012. [PubMed: 22709779]
14. Levin R: Nutrition risk screening and assessment of the oncology patient. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 25-32.
15. Vigano A, Watanabe S, Bruera E: Anorexia and cachexia in advanced cancer patients. Cancer Surv 21: 99-115, 1994. [PubMed: 8565002]
16. McMahon K, Decker G, Ottery FD: Integrating proactive nutritional assessment in clinical practices to prevent complications and cost. Semin Oncol 25 (2 Suppl 6): 20-7, 1998. [PubMed: 9625379]
17. Tong H, Isenring E, Yates P: The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in medical oncology patients. Support Care Cancer 17 (1): 83-90, 2009. [PubMed: 18551322]
18. Rivadeneira DE, Evoy D, Fahey TJ, et al.: Nutritional support of the cancer patient. CA Cancer J Clin 48 (2): 69-80, 1998 Mar-Apr. [PubMed: 9522822]
19. Bruera E: ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ 315 (7117): 1219-22, 1997. [PMC free article: PMC2127742] [PubMed: 9393230]
20. Langstein HN, Norton JA: Mechanisms of cancer cachexia. Hematol Oncol Clin North Am 5 (1): 103-23, 1991. [PubMed: 2026566]
21. Tisdale MJ: Cancer cachexia. Anticancer Drugs 4 (2): 115-25, 1993. [PubMed: 8490191]
22. Academy of Nutrition and Dietetics Oncology Expert Work Group: Nutrition and the Adult Oncology Patient. Chicago, Ill: Academy of Nutrition and Dietetics Evidence Analysis Library, 2013.
23. Cushen SJ, Power DG, Ryan AM: Nutrition assessment in oncology. Top Clin Nutr 30 (1): 103-19, 2015.
24. de van der Schueren M, Elia M, Gramlich L, et al.: Clinical and economic outcomes of nutrition interventions across the continuum of care. Ann N Y Acad Sci 1321: 20-40, 2014. [PubMed: 25123208]
25. Prado CM, Lieffers JR, McCargar LJ, et al.: Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol 9 (7): 629-35, 2008. [PubMed: 18539529]
26. Carneiro IP, Mazurak VC, Prado CM: Clinical Implications of Sarcopenic Obesity in Cancer. Curr Oncol Rep 18 (10): 62, 2016. [PubMed: 27541923]
27. Aapro M, Arends J, Bozzetti F, et al.: Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task Force. Ann Oncol 25 (8): 1492-9, 2014. [PubMed: 24569913]
28. Baldwin C, Weekes CE: Dietary counselling with or without oral nutritional supplements in the management of malnourished patients: a systematic review and meta-analysis of randomised controlled trials. J Hum Nutr Diet 25 (5): 411-26, 2012. [PubMed: 22672102]
29. Ravasco P, Monteiro-Grillo I, Vidal PM, et al.: Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol 23 (7): 1431-8, 2005. [PubMed: 15684319]

Tumor-Induced Effects on Nutrition Status

Tumors may have systemic or local effects that affect nutrition status, including hypermetabolism, malabsorption, dysmotility, and obstructions.[5]

Disease site

Nutrition complications are usually most notable and severe with tumors involving the digestive tract or head and neck, owing to mechanical obstruction or dysfunction. See Table 2 for common side effects of tumor locations.

Table

Table 2. Common Side Effects Related to Tumor Location^a.

Treatment-Induced Effects on Nutrition Status

Cancer treatments may cause acute and chronic effects. Nutrition intervention is based on symptom management. Patients who maintain good nutrition are more likely to tolerate the side effects of treatment. Adequate calories and protein can help maintain patient strength and prevent body tissues from further catabolism. Side effects of cancer treatments vary among patients, depending on the type, length, and dose of treatments and the type of cancer being treated (see Table 3). Cancer treatment has toxic effects on the GI tract, including the following:

• Nausea.
• Vomiting.
• Constipation.
• Diarrhea.
• Xerostomia.
• Mucositis.
• Dysphagia.
• Loss of appetite.

Table

Table 3. Treatment-Induced Effects on Nutrition Status^a.

Radiation therapy

Radiation therapy causes localized symptoms. Some of the common nutrition-related side effects caused by irradiation include the following:[16]

• Changes in taste or ability to swallow.
• Nausea/vomiting.
• Changes in bowel movements (usually diarrhea).
• GI symptoms such as gas.

The side effects of radiation therapy depend on the area that is irradiated, total dose, fractionation, duration, and volume irradiated (see Table 4). Most side effects are acute, begin around the second or third week of treatment, and diminish 2 or 3 weeks after radiation therapy has been completed. Some side effects can be chronic and continue or occur after treatment has been completed.[21] For more information, see the Behavioral strategies for symptom management section.

Nutrition support during radiation therapy is vital. The effect of radiation therapy on healthy tissue in the treatment field can produce changes in normal physiologic function that may ultimately diminish a patient’s nutrition status by interfering with ingestion, digestion, or absorption of nutrients.

Many nutrition-related side effects result from radiation therapy. Quality of life and nutrition intake can be improved by managing these side effects through appropriate medical nutrition therapy and dietary modifications. For example, medications such as pilocarpine (Salagen) may be useful in treating the xerostomia that accompanies radiation therapy targeting the head and neck.[22] This medicine may reduce the need for artificial saliva agents or other oral comfort agents such as hard candy or sugarless gum.

Table

Table 4. Radiation-Induced Effects on Nutrition Status by Treatment Site^a.

References

1. Levin R: Nutrition risk screening and assessment of the oncology patient. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 25-32.
2. Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues 17 (2): 15-7, 2002.
3. Martin L, Birdsell L, Macdonald N, et al.: Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol 31 (12): 1539-47, 2013. [PubMed: 23530101]
4. Huhmann M: Nutrition management of the surgical oncology patient. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 135-42.
5. August DA, Huhmann M: Nutrition support of the cancer patient. In: Ross AC, Caballero B, Cousins RJ, et al., eds.: Modern Nutrition in Health and Disease. 11th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, pp 1194-1213.
6. McGuire M: Nutritional care of surgical oncology patients. Semin Oncol Nurs 16 (2): 128-34, 2000. [PubMed: 10842782]
7. Leser M: Medical nutrition therapy for esophageal cancer. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 181-6.
8. Gill C: Nutrition management for cancers of the gastrointestinal tract. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 187-200.
9. Nguyen A, Nadler E: Medical nutrition therapy for head and neck cancer. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 201-8.
10. Petzel MQB: Medical nutrition therapy for pancreatic and bile duct cancer. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 219-28.
11. Fearon K, Strasser F, Anker SD, et al.: Definition and classification of cancer cachexia: an international consensus. Lancet Oncol 12 (5): 489-95, 2011. [PubMed: 21296615]
12. Tisdale MJ: Pathogenesis of cancer cachexia. J Support Oncol 1 (3): 159-68, 2003 Sep-Oct. [PubMed: 15334872]
13. Ramos EJ, Suzuki S, Marks D, et al.: Cancer anorexia-cachexia syndrome: cytokines and neuropeptides. Curr Opin Clin Nutr Metab Care 7 (4): 427-34, 2004. [PubMed: 15192446]
14. Strasser F, Bruera ED: Update on anorexia and cachexia. Hematol Oncol Clin North Am 16 (3): 589-617, 2002. [PubMed: 12170570]
15. Gambardella A, Tortoriello R, Tagliamonte MR, et al.: Metabolic changes in elderly cancer patients after glucose ingestion. The role of tumor necrosis factor-alpha. Cancer 79 (1): 177-84, 1997. [PubMed: 8988743]
16. Grant BL: Nutritional effects of cancer treatment: chemotherapy, biotherapy, hormone therapy and radiation therapy. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 97-114.
17. American Cancer Society: Cancer Surgery. Atlanta, Ga: American Cancer Society, 2019. Available online. Last accessed June 22, 2023.
18. LeFebvre KB, Stiver W: Overview of cancer and cancer treatment. In: Polovich M, Olsen M, LeFebvre KB, eds.: Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. Oncology Nursing Society, 2014, pp 1-16.
19. Fishman M, Mrozek-Orlowski M, eds.: Cancer Chemotherapy Guidelines and Recommendations for Practice. Oncology Nursing Press, 1999.
20. Olsen M, Davis PF, Douglas TT, et al.: Side effects of cancer therapy. In: Polovich M, Olsen M, LeFebvre KB, eds.: Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. Oncology Nursing Society, 2014, pp 171-436.
21. Donaldson SS: Nutritional consequences of radiotherapy. Cancer Res 37 (7 Pt 2): 2407-13, 1977. [PubMed: 861954]
22. Scarantino C, LeVeque F, Swann RS, et al.: Effect of pilocarpine during radiation therapy: results of RTOG 97-09, a phase III randomized study in head and neck cancer patients. J Support Oncol 4 (5): 252-8, 2006. [PubMed: 16724649]
23. Romano MC: General symptom management: nutritional issues. In: Iwamoto RR, Haas ML, Gosselin TK, eds.: Manual for Radiation Oncology Nursing Practice and Education. 4th ed. Oncology Nursing Society, 2012, pp 80-94.
24. Harris DJ, Witt ME: Site-specific management: head and neck. In: Iwamoto RR, Haas ML, Gosselin TK, eds.: Manual for Radiation Oncology Nursing Practice and Education. 4th ed. Oncology Nursing Society, 2012, pp 122-44.
25. Huhmann MB, August DA: Perioperative nutrition support in cancer patients. Nutr Clin Pract 27 (5): 586-92, 2012. [PubMed: 22875752]
26. Shim H, Cheong JH, Lee KY, et al.: Perioperative nutritional status changes in gastrointestinal cancer patients. Yonsei Med J 54 (6): 1370-6, 2013. [PMC free article: PMC3809878] [PubMed: 24142640]
27. American Cancer Society Website. Atlanta, Ga: American Cancer Society, 2023. Available online. Last accessed June 22, 2023.
28. August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors: A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr 33 (5): 472-500, 2009 Sep-Oct. [PubMed: 19713551]
29. Macris PC: Medical nutrition therapy for hematopoietic cell transplantation. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 157-64.

Screening

Early recognition of nutrition-related issues is necessary for appropriate nutrition management of cancer patients. Nutrition screening can be performed with a validated tool before treatment begins and at regular intervals over the course of treatment.

Nutrition screening can be a simple process that may be completed by hospital staff or members of the community/ambulatory health care team, with the goal of early identification of individuals with or at risk of malnutrition.[1,5,17,18] Leading nutrition organizations—including the American Society for Parenteral and Enteral Nutrition, the European Society for Clinical Nutrition and Metabolism, and the Academy of Nutrition and Dietetics (the Academy)—recommend screening patients in both acute and ambulatory settings for risk of malnutrition.[8,17,18] The Academy’s Oncology Nutrition Dietetic Practice Group, the Oncology Nursing Society, and the Association of Community Cancer Centers recommend screening all patients with cancer in the outpatient setting.[1,5] Because of a mandate from The Joint Commission that all patients admitted to the hospital undergo nutrition screening,[19] most acute care facilities have a screening system set up,[17] although such a system may not be specific to or validated in the oncology setting.

In the outpatient oncology setting, it is recommended that patients be screened initially before treatment begins and rescreened at planned intervals. Screening can most often coincide with the patient’s treatment schedule, such as weekly during radiation therapy and as frequently as every 2 to 3 weeks during chemotherapy, before surgery, and at follow-up visits after completion of treatment or surgical recovery.[1,2,5]

The following five screening tools are validated for use in oncology:[5,20-24]

• The Malnutrition Screening Tool for Cancer Patients.
• The Malnutrition Universal Screening Tool.
• The Malnutrition Screening Tool (MST).
• The Patient-Generated Subjective Global Assessment (PG-SGA).
• The NUTRISCORE tool.

Only the MST and the PG-SGA have been validated for use in both inpatient and outpatient oncology settings. Several studies have validated use of the abridged PG-SGA (abPG-SGA) or short-form PG-SGA (PG-SGAsf), each of which is simply the section of the PG-SGA completed by the patient.[25,26]

The Nutrition Risk Screening-2002 has not been validated in the oncology setting, but it has been used in several studies of oncology patients. Scores are correlated to general outcomes associated with malnutrition, such as hospital length of stay, complications, and mortality.[2,3,18,27,28]

The NUTRISCORE tool utilizes the MST as a base but has additional items, including tumor location and treatment, that help improve sensitivity (97.3% vs. 84%) and specificity (95.9% vs. 85.6%). The authors used the PG-SGA as the reference for validation in the outpatient oncology setting, also finding that it took less time to complete the NUTRISCORE than it did to complete the PG-SGA.[24] When choosing a screening method, consider who will perform the screen, how much time may be devoted to the process, and what the process will be for referring the patient for a full nutrition assessment.[1] It is also ideal to use a validated tool. The two tools validated for both inpatient and outpatient in oncology settings are presented in further detail below.

Assessment

Nutrition assessment is a comprehensive approach to evaluating and diagnosing nutrition problems and designing interventions.[17] A full nutrition assessment involves evaluation of the following six components:

• Food- and nutrition-related history.
• Anthropometric measurements.
• Biochemical data, medical tests, and procedures.
• Nutrition-focused physical assessment.
• Medical history.
• Treatment plan.

The assessment of anthropometric measurements evaluates weight loss, takes into account the time frame of weight loss, and is considered in the context of physical findings such as dehydration or fluid retention. Evaluation of food- and nutrition-related history ideally involves a dietitian obtaining a diet history and comparing intake with the patient’s calculated energy needs.[2,6] The nutrition-focused physical assessment evaluates loss of muscle mass and subcutaneous fat, fluid accumulation, and potential micronutrient deficiencies. The physical examination of the following areas determines loss of subcutaneous fat or muscle:

Subcutaneous fat loss

• Orbit.
• Upper arm.
• Thoracic and lumbar regions.

Subcutaneous muscle loss

• Temple.
• Clavicle.
• Clavicle and acromion.
• Scapula.
• Dorsal hand.
• Patella.
• Anterior thigh.
• Posterior calf.

Within the nutrition assessment, the following factors are considered in diagnosing malnutrition:[8]

• Insufficient energy intake.
• Weight loss.
• Loss of muscle mass.
• Loss of subcutaneous fat.
• Localized or generalized fluid accumulation.
• Diminished functional status (e.g., grip strength).

In addition to the issues described above, the oncology nutrition assessment also takes into account the following:[5]

• Tumor location (current or anticipated mechanical function impairment).
• Current side effects/symptoms.
• Anticipated treatment/side effects.
• Anticipated duration of symptoms.
• Intent of treatment.

The goal of an oncology nutrition assessment is to collect the information necessary to determine current or anticipated nutrition issues and to formulate a plan with the patient, caregivers, and other members of the health care team involved with nutrition interventions. Additionally, this multidisciplinary team approach may also include metabolic, pharmacologic, and functional interventions to address and prevent the identified or anticipated nutrition issues.[1,5,30]

References

1. Levin R: Nutrition risk screening and assessment of the oncology patient. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 25-32.
2. Cushen SJ, Power DG, Ryan AM: Nutrition assessment in oncology. Top Clin Nutr 30 (1): 103-19, 2015.
3. 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 104 (5): 371-85, 2012. [PubMed: 22345712]
4. Marian M, August DA: Prevalence of malnutrition and current use of nutrition support in cancer patient study. JPEN J Parenter Enteral Nutr 38 (2): 163-5, 2014. [PubMed: 24748623]
5. Academy of Nutrition and Dietetics Oncology Expert Work Group: Nutrition and the Adult Oncology Patient. Chicago, Ill: Academy of Nutrition and Dietetics Evidence Analysis Library, 2013.
6. Aapro M, Arends J, Bozzetti F, et al.: Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task Force. Ann Oncol 25 (8): 1492-9, 2014. [PubMed: 24569913]
7. de van der Schueren M, Elia M, Gramlich L, et al.: Clinical and economic outcomes of nutrition interventions across the continuum of care. Ann N Y Acad Sci 1321: 20-40, 2014. [PubMed: 25123208]
8. White JV, Guenter P, Jensen G, et al.: Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet 112 (5): 730-8, 2012. [PubMed: 22709779]
9. Gioulbasanis I, Martin L, Baracos VE, et al.: Nutritional assessment in overweight and obese patients with metastatic cancer: does it make sense? Ann Oncol 26 (1): 217-21, 2015. [PubMed: 25361991]
10. Gonzalez MC, Pastore CA, Orlandi SP, et al.: Obesity paradox in cancer: new insights provided by body composition. Am J Clin Nutr 99 (5): 999-1005, 2014. [PubMed: 24572565]
11. Rock CL, Doyle C, Demark-Wahnefried W, et al.: Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 62 (4): 243-74, 2012 Jul-Aug. [PubMed: 22539238]
12. Daniel CR, Shu X, Ye Y, et al.: Severe obesity prior to diagnosis limits survival in colorectal cancer patients evaluated at a large cancer centre. Br J Cancer 114 (1): 103-9, 2016. [PMC free article: PMC4716542] [PubMed: 26679375]
13. Greenlee H, Shi Z, Sardo Molmenti CL, et al.: Trends in Obesity Prevalence in Adults With a History of Cancer: Results From the US National Health Interview Survey, 1997 to 2014. J Clin Oncol 34 (26): 3133-40, 2016. [PMC free article: PMC5012707] [PubMed: 27458295]
14. Rock CL, Byers TE, Colditz GA, et al.: Reducing breast cancer recurrence with weight loss, a vanguard trial: the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial. Contemp Clin Trials 34 (2): 282-95, 2013. [PMC free article: PMC3593786] [PubMed: 23266440]
15. Rock CL, Flatt SW, Byers TE, et al.: Results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial: A Behavioral Weight Loss Intervention in Overweight or Obese Breast Cancer Survivors. J Clin Oncol 33 (28): 3169-76, 2015. [PMC free article: PMC4582146] [PubMed: 26282657]
16. Rock CL, Pande C, Flatt SW, et al.: Favorable changes in serum estrogens and other biologic factors after weight loss in breast cancer survivors who are overweight or obese. Clin Breast Cancer 13 (3): 188-95, 2013. [PMC free article: PMC4153749] [PubMed: 23375717]
17. Mueller C, Compher C, Ellen DM, et al.: A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr 35 (1): 16-24, 2011. [PubMed: 21224430]
18. Kondrup J, Allison SP, Elia M, et al.: ESPEN guidelines for nutrition screening 2002. Clin Nutr 22 (4): 415-21, 2003. [PubMed: 12880610]
19. The Joint Commission: 2017 Comprehensive Accreditation Manual for Hospitals (CAMH). Joint Commission Resources, 2016.
20. Isenring E, Cross G, Daniels L, et al.: Validity of the malnutrition screening tool as an effective predictor of nutritional risk in oncology outpatients receiving chemotherapy. Support Care Cancer 14 (11): 1152-6, 2006. [PubMed: 16622648]
21. Ottery FD: Rethinking nutritional support of the cancer patient: the new field of nutritional oncology. Semin Oncol 21 (6): 770-8, 1994. [PubMed: 7992092]
22. Bauer J, Capra S, Ferguson M: Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr 56 (8): 779-85, 2002. [PubMed: 12122555]
23. Ferguson M, Capra S, Bauer J, et al.: Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15 (6): 458-64, 1999. [PubMed: 10378201]
24. Arribas L, Hurtós L, Sendrós MJ, et al.: NUTRISCORE: A new nutritional screening tool for oncological outpatients. Nutrition 33: 297-303, 2017. [PubMed: 27751743]
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Goals of Nutrition Therapy

The goals of medical nutrition therapy are to do the following:[1]

• Address current cancer- and treatment-related issues.
• Minimize treatment-related side effects.
• Anticipate and manage acute, delayed, and late-occurring side effects of cancer and/or cancer treatment.

Goals must be individualized for each patient on the basis of the following:

• Nutrition status.
• Type and stage of disease.
• Comorbid conditions.
• Overall medical treatment plan.

Decisions about the best approach for therapy are informed by symptom severity and function of the gastrointestinal (GI) tract. Treatment could include multiple strategies based on these factors.

Nutrition goals during and after cancer therapy are integrated with goals related to nutrition status and the presence of malnutrition.[2] Table 5 summarizes nutrition goals on the basis of nutrition status, malnutrition as defined by current guidelines,[3] and stage of cancer treatment.

A healthy diet with an emphasis on plant-based foods, regular physical activity, and achievement of a healthy weight has been recommended for all patients after cancer treatment on the basis of extensive reviews of the evidence.[4,5] Evidence-based guidelines for a healthy diet for cancer risk reduction are available online from the American Institute for Cancer Research (AICR) and the American Cancer Society (ACS).

Table

Table 5. Nutrition Goals During Treatment^a.

Methods of Nutrition Therapy

Prompt and aggressive nutrition intervention is required for patients with precachexia or cancer cachexia. Intervention is more likely to be effective when started early. Interventions include an individualized approach to oral, enteral, and parenteral nutrition using evidence-based recommendations, guidelines, and program and regulatory standards.

The dietitian works with the patient, caregivers, and members of the health care team to (1) improve compliance and the effectiveness of pharmacotherapy interventions prescribed to manage cancer and cancer treatment–related symptoms; and (2) counsel patients about behavioral strategies to alleviate nutrition impact symptoms.[1]

Pharmaceutical management of cancer-associated cachexia and weight loss

Many treatments have been suggested for cachexia-anorexia syndrome (CAS), but few of these treatments have resulted in consistent improvement, probably because of the multifactorial mechanisms involved.[39-41] Treatment must both reverse the metabolic disturbances in carbohydrate, lipid, and protein metabolism and treat the associated decrease in caloric intake.[42] Although most studies have examined single agents targeting one part of the multifactorial issues associated with CAS, many investigators have suggested that a multidrug approach might be more beneficial.[42-44] A summary of selected agents can be found in Table 6. Agents studied in CAS with inconclusive evidence or no statistically significant benefit to date include:

• Fluoxymesterone.[45]
• Oxandrolone.[46]
• Thalidomide.[47-49]
• Pentoxifylline.[50,51]
• Melatonin.[52,53]
• Omega-3 fatty acids.[54,55]
• Dronabinol.[56,57]
• Mirtazapine.[58]
• Fomoterol.[59,60]

Appetite stimulants

The first widely studied treatment issue has been anorexia associated with CAS. The use of agents that improve appetite and resultant caloric intake have been widely studied; these agents include corticosteroids, progesterone analogs, androgens, cannabinoids, and cyproheptadine.

Corticosteroids

Perhaps the earliest agents studied for the management of cancer cachexia are dexamethasone and prednisolone. Used in cancer treatment for their anti-inflammatory, antimalignancy, and antiemetic properties, steroids have produced side effects such as increased appetite and weight gain, probably because of their effects on the hypothalamus.

Several large placebo-controlled studies have shown increases in appetite and weight gain associated with steroid use in this setting.[61] However, the palliative effects on CAS have typically been short lived, and prolonged use is associated with significant side effects such as furthering catabolic effects on muscle, myopathy, joint disease, hyperglycemia, and hypertension.[62,63]

Progesterone analogs

Like steroids, progesterone antagonists are effective in improving appetite and weight in patients with AIDS-related cachexia and CAS.[59,64] A Cochrane review of 38 trials involving 4,304 patients reported the use of megestrol at doses of 160 to 800 mg per day for the treatment of CAS.[65] The only consistent benefits seen were weight gain and improved appetite. No definitive conclusions about other outcomes related to lean body mass, quality of life, or fatigue could be drawn. No improvement in survival was found.[65] In some clinical trials, the improvement was shown to be temporary increases in fat and water mass without concomitant improvements in lean body mass or quality of life.[66,67] However, another trial showed statistically significant improvements in weight, quality of life (as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30), appetite, and grip strength at 1- and 2-month intervals, compared with baseline.[68] In contrast, a 2022 meta-analysis of eight trials providing sufficient anthropometric data in the evaluation of megestrol in cancer-related anorexia concluded that megestrol acetate did not provide symptomatic improvement of anorexia/cachexia in patients with advanced cancer.[69] The overall pooled mean change in weight was 0.75 kg (95% confidence interval, -1.64 to 3.15 kg).

A placebo-controlled study looked at megestrol acetate at a dose of 7.5 mg/kg per day in 26 children with weight loss exceeding 5%. The megestrol group had a mean weight gain of 19.7% compared with weight loss of 1.2% (P = .003) in the placebo group.[70] Megestrol has also been studied in prophylaxis of weight loss, but again there was no demonstrated improvement in quality of life, lean muscle mass, or survival.[71-73] Concerns have also been raised about a possible increase in thromboembolic phenomena, sex hormone dysregulation, and suppression of the hypothalamic-pituitary axis, resulting in symptomatic adrenal insufficiency.[74]

Cannabinoids

Interest in the use of cannabinoids in CAS is ongoing because of their effects on appetite and potential benefit in HIV-related cachexia.[75] However, in a study of 469 patients comparing dronabinol alone versus megestrol acetate alone versus dronabinol plus megestrol acetate, dronabinol was inferior to megestrol acetate, and there was no additive effect when the drugs were used together.[56] A similar European trial of 243 patients comparing dronabinol with placebo also found no benefit.[57] For more information, see Cannabis and Cannabinoids.

Cyproheptadine

Cyproheptadine is a serotonin and histamine antagonist developed as an antihistamine. Side effects include increased appetite and weight gain.[76] A number of studies, mostly in children with a wide range of disorders associated with anorexia and weight loss, have shown that cyproheptadine results in significant improvements in weight in a number of studies.[77-79]

In a study of cyproheptadine use in children with CAS, one group of investigators evaluated 66 children with weight loss exceeding 5%.[78] The children received cyproheptadine at a daily dosage of 0.25 mg/kg. A total of 76% of the patients were classified as responders, experiencing either weight gain or no further weight loss. Patients also showed a significant increase in serum leptin levels.[78] Leptin is a protein hormone produced by adipocytes and is associated with body mass, particularly body fat. An increase in serum leptin has been correlated with an increase in body mass index.[78]

Anti-inflammatory agents

CAS is a multifactorial disorder that occurs in more than 50% of patients with advanced cancer. Increases in cytokines associated with cancer—including tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1—have been shown to be important in the etiology of this disorder.[80] Pharmaceutical agents that inhibit the cytokine increases seen with cancer have been studied in patients with CAS.[81-83] EPA, an omega-3 fatty acid found in fish oil, has been used in a number of trials.[84] However, a meta-analysis failed to show a consistent improvement in CAS.[21] Similarly, several literature reviews of studies using nonsteroidal anti-inflammatory agents have failed to show conclusive evidence of efficacy.[85,86]

Specific targeted agents have also been studied. These include agents targeting TNF-alpha, such as etanercept, infliximab, and pentoxifylline, which, in small trials, have not had a significant impact.[87]

Several studies using thalidomide, a nonspecific antagonist to TNF, have been performed.[47,48,88-90] Thalidomide is of interest as a treatment for CAS because of its immunomodulatory properties.[47] A single-center, double-blind trial randomly assigned 50 pancreatic cancer patients who had lost at least 10% of their body weight to receive thalidomide 200 mg or placebo for 24 weeks. Patients who took thalidomide had a statistically significant reduction in weight loss compared with those who took a placebo.[48] A similarly sized trial of thalidomide 100 mg demonstrated no significant treatment effect.[47] Additionally, a Cochrane review on this topic reported insufficient evidence to support the use of thalidomide in patients with advanced cancer.[49]

Olanzapine

Olanzapine is an antipsychotic that blocks multiple neurotransmitters, including dopamine, serotonin, catecholamines, acetylcholine, and histamine.[91] Side effects of increased appetite and weight gain have been investigated in CAS with varying degrees of success. A single-center dose escalation trial evaluated the effect of olanzapine 2.5 mg to 20 mg daily on CAS and metabolic cytokines in 31 patients with advanced cancer receiving antineoplastic treatments.[92] A nonsignificant trend in attenuation of weight loss did not correlate with changes in metabolic cytokines. In contrast, a retrospective review evaluated food intake 3 days before and after initiation of olanzapine in 80 cancer patients hospitalized due to anorexia.[93] The average dose of olanzapine was 2.28 mg, which resulted in an increase in average relative food intake of 149%. Interestingly, olanzapine increased food intake by 143% in the cohort of patients who did not have preexisting nausea/vomiting.

A prospective trial randomly assigned 124 patients starting chemotherapy for untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary, and lung cancers to receive olanzapine 2.5 mg daily or placebo to evaluate appetite stimulation and weight gain.[94] At baseline, one-third of patients were underweight, almost all had anorexia, and over half reported greater than 5% weight loss from their prediagnosis weight. After 12 weeks, a greater proportion of patients in the olanzapine group versus the placebo group achieved more than 5% weight gain (60% vs. 9%, respectively). The olanzapine group also experienced a statistically significant improvement in appetite using a visual analog scale (43% vs. 13%, P < .001). The fraction of patients with grade 3 or greater adverse effects was lower with olanzapine than placebo (12% vs. 37%, P = .002), which resulted in the ability to increase chemotherapy to full dose in 12 of 16 patients.

Table

Table 6. Commonly Prescribed Medications for Cachexia-Anorexia Syndrome^a.

Combination therapy

Given the multifactorial etiology of and multiple mechanisms involved in the development of CAS, it is possible that combining agents with different mechanisms of action might result in greater efficacy.[98,99] In one study, 332 patients diagnosed with CAS were randomly assigned to one of five treatment arms: medroxyprogesterone alone, oral supplementation with EPA, L-carnitine, thalidomide, or a combination of all four agents.[90] Investigators looked at lean body mass, resting energy expenditure, and fatigue. In this study, the combination arm was found to be superior. Another trial used megestrol alone versus megestrol plus L-carnitine, celecoxib, and antioxidants to treat 104 women with gynecologic malignancies.[98] Again, the combination arm was found to be superior. Conversely, a randomized placebo-controlled trial of megestrol acetate and placebo versus megestrol acetate and celecoxib found no significant difference in weight gain, quality of life, appetite score, or grip strength between the two groups. However, both groups showed improvements, suggesting a benefit of the single-agent use of megestrol acetate.[68]

Researchers also looked at the combination of formoterol, an anabolic beta-2 adrenergic agonist, and megestrol acetate in 13 patients. Six of seven evaluable patients achieved a major response, with increases in muscle mass.[59] Conversely, another study looking at megestrol plus meloxicam versus meloxicam plus EPA versus megestrol plus meloxicam and EPA showed no advantage to the three-drug regimen.[100] However, such combinations also may result in increased cumulative toxicity. For these reasons, there is no recommended combination at this time. In addition, combining drug therapy with nutrition support and increased physical activity may have even greater efficacy.

Summary of pharmaceutical treatment strategies

CAS is a complex, multifactorial complication of cancer and its therapy, resulting in weight loss and decreased lean body mass. As understanding of the mechanisms of CAS improves and new agents that selectively target proposed pathways become available, more efficacious treatments are expected to become available. Trials of new agents must be able to compare similar groups of patients. In addition, treating preventively in high-risk patients, as opposed to treating patients already experiencing CAS, may have better outcomes. Further clinical trials are essential to determine the best possible therapies.

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73. Argilés JM, Anguera A, Stemmler B: A new look at an old drug for the treatment of cancer cachexia: megestrol acetate. Clin Nutr 32 (3): 319-24, 2013. [PubMed: 23395103]
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78. Couluris M, Mayer JL, Freyer DR, et al.: The effect of cyproheptadine hydrochloride (periactin) and megestrol acetate (megace) on weight in children with cancer/treatment-related cachexia. J Pediatr Hematol Oncol 30 (11): 791-7, 2008. [PMC free article: PMC2917791] [PubMed: 18989154]
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81. Chasen M, Bhargava R, Hirschman S: Immunomodulatory agents for the treatment of cachexia. Curr Opin Support Palliat Care 8 (4): 328-33, 2014. [PubMed: 25111255]
82. Solheim TS, Fearon KC, Blum D, et al.: Non-steroidal anti-inflammatory treatment in cancer cachexia: a systematic literature review. Acta Oncol 52 (1): 6-17, 2013. [PubMed: 23020528]
83. Palus S, von Haehling S, Flach VC, et al.: Simvastatin reduces wasting and improves cardiac function as well as outcome in experimental cancer cachexia. Int J Cardiol 168 (4): 3412-8, 2013. [PubMed: 23680591]
84. Di Girolamo FG, Situlin R, Mazzucco S, et al.: Omega-3 fatty acids and protein metabolism: enhancement of anabolic interventions for sarcopenia. Curr Opin Clin Nutr Metab Care 17 (2): 145-50, 2014. [PubMed: 24500439]
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Goals of Nutrition Therapy in Advanced Cancer

Nutrition goals for a patient with advanced cancer may depend on the overall plan of care. These patients may be receiving anticancer therapy (with or without concurrent palliative care), may be receiving palliative care alone, or may be enrolled in hospice. Regardless of the care setting, patients are screened to determine the need for nutrition intervention. The Patient-Generated Subjective Global Assessment (PG-SGA) has been validated in cancer patients and addresses body weight history, food intake, symptoms, and functional status.[9,10] When palliative care is initiated early in the disease process, nutrition goals focus on supporting active treatment and aim to improve treatment outcomes, body composition, physical function, and symptom palliation.

As the focus of care shifts from cancer-modifying therapy to hospice or end-of-life care, nutrition goals may become less aggressive, with a shift toward comfort. Continued assessment and adjustment of nutrition goals and interventions is required throughout this continuum to meet the changing needs of the patient receiving palliative or hospice care services.[9]

Nutrition Intervention in Advanced Cancer

Ethical issues may arise when patients, families, or caregivers request artificial nutrition and hydration when there is no prospect of recovering from the underlying illness or benefiting appreciably from the intervention. When there is uncertainty about whether a patient will benefit from artificial nutrition, hydration, or both, a time-limited trial with clear, measurable endpoints may be useful. The caregiving team will explain that, as with other medical therapies, artificial nutrition and hydration can be stopped if the desired nutrition effects do not occur.[11]

Randomized controlled trials of enteral or parenteral nutrition in cancer patients receiving formal palliative care are lacking.[12] On the basis of available evidence and expert consensus, clinical guidelines recommend that the use of nutrition support therapy in advanced cancer be limited to carefully selected patients.[13,14] Patients who have demonstrated a favorable response to parenteral nutrition include those with the following:[15 ,13,16]

• A good performance status, such as a Karnofsky Performance Status score higher than 50%.
• Inoperable bowel obstruction.
• Minimal symptoms from disease involving major organs.
• Indolent disease.

If patients are to benefit from parenteral nutrition, they must be physically and emotionally capable of participating in their own care and have the following:[13]

• A life expectancy longer than 40 to 60 days.
• Strong social and financial support at home, including a dedicated informal caregiver.
• Failed trials of less-invasive medical therapies such as appetite stimulants and enteral feedings.

Patients with a life expectancy shorter than 40 days may be palliated with home intravenous (IV) fluid therapy, although this practice is controversial.[13]

Nutrition Considerations for the End of Life

Patients and caregivers often consider the provision of food and fluids to be basic care. However, the use of artificial nutrition and hydration at the end of life is a complex and controversial intervention that is influenced by clinical, cultural, religious, ethical, and legal factors. Patients and families often believe these interventions will improve quality and length of life, but evidence of clear benefit is lacking.[12,17] There are also potential burdens associated with this care, including the following:

• Sepsis (a risk of parenteral nutrition).
• Aspiration and diarrhea (a risk of tube feeding).
• Pressure sores and skin breakdown.
• Complications caused by fluid overload.

In addition, agitated or confused patients receiving artificial nutrition and hydration may need to be physically restrained to prevent them from removing a gastrostomy tube, nasogastric tube, or central IV line.[18]

Patients at the end of life who have increased difficulty with swallowing have less risk of aspiration with thick liquids than with thin liquids.[7] Thirst can often be alleviated with sips of water, ice chips, and good mouth care. In the last few days of life, the incidence of swallowing problems can be as high as 79% and include frequent coughing, anorexia, and problems with oral secretions.[19] Communication within the health care team and support of the family and caregivers is important in alleviating the distress concerning decreased food and fluid intake and in eliminating unrealistic expectations.[7]

For patients at the end of life, the goal of nutrition therapy is to alleviate symptoms rather than reverse nutrition deficits. The pleasure of tasting food and the social benefits of participating in meals with family and friends can be emphasized over increasing caloric intake.[6] A systematic review of practices and effects on cancer patients in the last week of life found no study supporting the use of artificial nutrition, and studies with artificial hydration had mixed results.[20] Studies on hydration with positive effects reported less chronic nausea and physical signs of dehydration, while studies with negative effects found more ascites and intestinal drainage. Other studies found no effect on terminal delirium, thirst, chronic nausea, or fluid overload.[20]

A well-designed randomized trial reported that hydration at 1 L/d for a week did not improve dehydration symptoms (fatigue, myoclonus, sedation, hallucinations) and provided no benefit in quality of life or survival.[21] A prospective evaluation of Japanese national guidelines for parenteral hydration at the end of life suggests little harm or benefit; however, patients expressed a high level of satisfaction and felt it was beneficial.[22] A subsequent study utilizing the Japanese guidelines reported that hydration-related symptoms (nausea, edema, dyspnea, abdominal pain/distention) were significantly improved, as were quality of life, global satisfaction, and feeling of benefit.[23]

The American Academy of Hospice and Palliative Medicine suggests that providers facilitate respectful and informed discussions about the effects of artificial nutrition and hydration near the end of life among physicians, other health care professionals, patients, and families.[11] It is incumbent on physicians and other health care providers to describe the options when the implementation, continuation, or discontinuation of artificial nutrition and hydration is being considered, and to establish goals of care with the patient and/or surrogate decision-maker. Ideally, patients will make their own decisions on the basis of a careful assessment of potential benefits and burdens, consistent with legal and ethical norms that permit patients to accept or forgo specific medical interventions.[11]

Ethical, Cultural, and Religious Issues in Medically Assisted Nutrition and Hydration in Advanced Cancer

Decisions about whether to provide artificial nutrition and hydration to patients in the late stages of life are complex and influenced by ethical, cultural, and religious issues, as well as by legal issues, clinical considerations, and patient and family preferences. The event of death itself, the manner in which it occurs, and the patient’s quality of life are significant matters that have spiritual and psychological consequences for each person involved.[24]

A number of organizations have published guidelines on the ethical considerations about whether to forgo or discontinue hydration and nutrition support, including the following:

• American Medical Association.[25]
• American Academy of Hospice and Palliative Medicine.[11]
• Hospice and Palliative Nurses Association.[18]
• American Society for Parenteral and Enteral Nutrition.[26,27]
• Academy of Nutrition and Dietetics.[28]

These guidelines reflect judicial decisions that have supported the authority and liberty of the competent individual to refuse life-saving hydration and nutrition, the role of medical expertise, and respect for the dignity and values of the patient and family. For more information, see the sections on Artificial Hydration and Artificial Nutrition in Last Days of Life.

Religion and religious traditions provide a set of core beliefs about life events and an ethical foundation for clinical decision-making.[24] Although the fundamental principles of major religions provide perspectives on death and dying, decisions related to artificial nutrition and hydration remain complicated, varying even within the same major religion or faith tradition.

To provide an optimal and inclusive healing environment, all palliative team members need to be aware of their own spirituality and how it may differ from that of fellow team members and the patients and families they serve.[29,30] Clinical practice guidelines established by the National Consensus Project for Quality Palliative Care address spiritual, religious, and existential aspects of care.[31] One group of researchers [24] has provided insight into the principles and perspectives held by Roman Catholic, Jewish, Buddhist, and Islamic faith traditions. Another group [32] has provided an extensive analysis of how world religions formulate ethical decisions related to withdrawing treatment and determining when death has occurred.

Religious beliefs are often closely related to cultural views. Individuals living in the midst of a particular tradition can continue to be influenced by it, even if they have stopped believing in or practicing it.[32] In some cultures, individual autonomy is not the prevailing or predominant principle; some Asian, American Indian/Alaska Native, and Hispanic cultures favor family or community autonomy.[26] Distinguishing between majority and minority cultures is important. Patients may rely on religion and spirituality as important means to interpret and cope with illness.[33]

Religious and cultural preferences about artificial nutrition and hydration are expressions of a patient’s autonomy and, in many cases, may outweigh clinical considerations. When these values conflict with clinical judgment, practitioners may work with the patient and/or surrogate in consulting with faith leaders and the patient's ethnic community, as well as the institutional ethics committee, to facilitate resolution.[26,27]

References

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2. Bovio G, Montagna G, Bariani C, et al.: Upper gastrointestinal symptoms in patients with advanced cancer: relationship to nutritional and performance status. Support Care Cancer 17 (10): 1317-24, 2009. [PubMed: 19199106]
3. Mercadante S, Aielli F, Adile C, et al.: Prevalence of oral mucositis, dry mouth, and dysphagia in advanced cancer patients. Support Care Cancer 23 (11): 3249-55, 2015. [PubMed: 25832897]
4. Del Fabbro E, Hui D, Dalal S, et al.: Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. J Palliat Med 14 (9): 1004-8, 2011. [PMC free article: PMC3166181] [PubMed: 21793729]
5. Dhingra L, Shuk E, Grossman B, et al.: A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliat Med 27 (5): 447-56, 2013. [PubMed: 22707180]
6. Dev R, Hui D, Chisholm G, et al.: Hypermetabolism and symptom burden in advanced cancer patients evaluated in a cachexia clinic. J Cachexia Sarcopenia Muscle 6 (1): 95-8, 2015. [PMC free article: PMC4435101] [PubMed: 26136416]
7. Orrevall Y: Nutritional support at the end of life. Nutrition 31 (4): 615-6, 2015. [PubMed: 25770331]
8. Hopkinson JB: The emotional aspects of cancer anorexia. Curr Opin Support Palliat Care 4 (4): 254-8, 2010. [PubMed: 20881500]
9. Trentham K: Nutrition management of oncology patients in palliative and hospice settings. In: Leser M, Ledesma N, Bergerson S, et al., eds.: Oncology Nutrition for Clinical Practice. Oncology Nutrition Dietetic Practice Group, 2018, pp 241-8.
10. Nutrition screening and determining malnutrition risk in adults with cancer. In: Grant BL: Academy of Nutrition and Dietetics Pocket Guide to the Nutrition Care Process and Cancer. Academy of Nutrition and Dietetics, 2015, pp 15-27.
11. Statement on Artificial Nutrition and Hydration Near the End of Life. Chicago, Ill: American Academy of Hospice and Palliative Medicine, 2013. Available online. Last accessed Nov. 16, 2023.
12. Good P, Richard R, Syrmis W, et al.: Medically assisted nutrition for adult palliative care patients. Cochrane Database Syst Rev (4): CD006274, 2014. [PMC free article: PMC7388544] [PubMed: 24760679]
13. August DA, Huhmann MB; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors: A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr 33 (5): 472-500, 2009 Sep-Oct. [PubMed: 19713551]
14. Bozzetti F, Arends J, Lundholm K, et al.: ESPEN Guidelines on Parenteral Nutrition: non-surgical oncology. Clin Nutr 28 (4): 445-54, 2009. [PubMed: 19477052]
15. Karnofsky DA, Abelmann WH, Craver LF, et al.: The use of the nitrogen mustards in the palliative treatment of carcinoma: with particular reference to bronchogenic carcinoma. Cancer 1 (4): 634-56, 1948.
16. Soo I, Gramlich L: Use of parenteral nutrition in patients with advanced cancer. Appl Physiol Nutr Metab 33 (1): 102-6, 2008. [PubMed: 18347659]
17. Good P, Richard R, Syrmis W, et al.: Medically assisted hydration for adult palliative care patients. Cochrane Database Syst Rev (4): CD006273, 2014. [PMC free article: PMC8988261] [PubMed: 24760678]
18. HPNA position statement: artificial nutrition and hydration in advanced illness. J Hosp Palliat Nurs 14 (3): 173-6, 2012.
19. Bogaardt H, Veerbeek L, Kelly K, et al.: Swallowing problems at the end of the palliative phase: incidence and severity in 164 unsedated patients. Dysphagia 30 (2): 145-51, 2015. [PubMed: 25533181]
20. Raijmakers NJ, van Zuylen L, Costantini M, et al.: Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 22 (7): 1478-86, 2011. [PubMed: 21199887]
21. Bruera E, Hui D, Dalal S, et al.: Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 31 (1): 111-8, 2013. [PMC free article: PMC3530688] [PubMed: 23169523]
22. Yamaguchi T, Morita T, Shinjo T, et al.: Effect of parenteral hydration therapy based on the Japanese national clinical guideline on quality of life, discomfort, and symptom intensity in patients with advanced cancer. J Pain Symptom Manage 43 (6): 1001-12, 2012. [PubMed: 22651946]
23. Nakajima N, Takahashi Y, Ishitani K: The volume of hydration in terminally ill cancer patients with hydration-related symptoms: a prospective study. J Palliat Med 17 (9): 1037-41, 2014. [PubMed: 25050699]
24. Jahn Kassim PN, Alias F: Religious, Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for Medical Decision Making. J Relig Health 55 (1): 119-34, 2016. [PubMed: 25576401]
25. AMA Code of Medical Ethics’ Opinions on Care at the End of Life. Opinion 2.20 - Withholding or Withdrawing Life-Sustaining Medical Treatment. Virtual Mentor 13 (12): 1038-40, 2013. Also available online. Last accessed June 22, 2023.
26. Geppert CM, Andrews MR, Druyan ME: Ethical issues in artificial nutrition and hydration: a review. JPEN J Parenter Enteral Nutr 34 (1): 79-88, 2010 Jan-Feb. [PubMed: 19897766]
27. Barrocas A, Geppert C, Durfee SM, et al.: A.S.P.E.N. ethics position paper. Nutr Clin Pract 25 (6): 672-9, 2010. [PubMed: 21051546]
28. O'Sullivan Maillet J, Baird Schwartz D, Posthauer ME, et al.: Position of the academy of nutrition and dietetics: ethical and legal issues in feeding and hydration. J Acad Nutr Diet 113 (6): 828-33, 2013. [PubMed: 23684296]
29. Ferrell B, Otis-Green S, Economou D: Spirituality in cancer care at the end of life. Cancer J 19 (5): 431-7, 2013 Sep-Oct. [PubMed: 24051617]
30. Dahlin C, ed.: Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. National Consensus Project for Quality Palliative Care, 2013. Also available online. Last accessed Nov. 16, 2023.
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32. Setta SM, Shemie SD: An explanation and analysis of how world religions formulate their ethical decisions on withdrawing treatment and determining death. Philos Ethics Humanit Med 10: 6, 2015. [PMC free article: PMC4396881] [PubMed: 25890378]
33. El Nawawi NM, Balboni MJ, Balboni TA: Palliative care and spiritual care: the crucial role of spiritual care in the care of patients with advanced illness. Curr Opin Support Palliat Care 6 (2): 269-74, 2012. [PubMed: 22469668]

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2. van Dalen EC, Mank A, Leclercq E, et al.: Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia. Cochrane Database Syst Rev (9): CD006247, 2012. [PubMed: 22972091]
3. van Tiel F, Harbers MM, Terporten PH, et al.: Normal hospital and low-bacterial diet in patients with cytopenia after intensive chemotherapy for hematological malignancy: a study of safety. Ann Oncol 18 (6): 1080-4, 2007. [PubMed: 17369599]
4. Moody K, Finlay J, Mancuso C, et al.: Feasibility and safety of a pilot randomized trial of infection rate: neutropenic diet versus standard food safety guidelines. J Pediatr Hematol Oncol 28 (3): 126-33, 2006. [PubMed: 16679934]
5. Gardner A, Mattiuzzi G, Faderl S, et al.: Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. J Clin Oncol 26 (35): 5684-8, 2008. [PMC free article: PMC4879706] [PubMed: 18955453]
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Special Diets

Maintaining adequate nutrition while undergoing treatment for cancer is imperative because it can reduce treatment-related side effects, prevent delays in treatment, and help maintain quality of life.[1] However, many patients view their diet as a way to enhance treatment effectiveness, minimize treatment-related toxicities, or target the cancer itself, often by following a specific diet with supposed cancer-fighting benefits or by taking dietary supplements. Patients are likely to search the internet and other lay sources of information for dietary approaches to manage cancer risk and to improve prognosis. Unfortunately, much of this information is not supported by a sufficient evidence base.

The sections below summarize the state of the science on some of the most popular diets and dietary supplements.

Dietary Supplements

References

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2. Tantamango-Bartley Y, Jaceldo-Siegl K, Fan J, et al.: Vegetarian diets and the incidence of cancer in a low-risk population. Cancer Epidemiol Biomarkers Prev 22 (2): 286-94, 2013. [PMC free article: PMC3565018] [PubMed: 23169929]
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6. Rieger J, Bähr O, Maurer GD, et al.: ERGO: a pilot study of ketogenic diet in recurrent glioblastoma. Int J Oncol 44 (6): 1843-52, 2014. [PMC free article: PMC4063533] [PubMed: 24728273]
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10. Cohen CW, Fontaine KR, Arend RC, et al.: A Ketogenic Diet Is Acceptable in Women with Ovarian and Endometrial Cancer and Has No Adverse Effects on Blood Lipids: A Randomized, Controlled Trial. Nutr Cancer 72 (4): 584-594, 2020. [PubMed: 31352797]
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Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about nutrition before, during, and after cancer treatment. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

• be discussed at a meeting,
• be cited with text, or
• replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Nutrition in Cancer Care are:

• Marilyn J. Hammer, PhD, DC, RN, FAAN (Dana-Farber Cancer Institute)
• Jared R. Lowe, MD, HMDC (University of North Carolina School of Medicine)
• Kristina B. Newport, MD, FAAHPM, HMDC (Penn State Hershey Cancer Institute at Milton S. Hershey Medical Center)
• Maria Petzel, RD, CSO, LD, CNSC, FAND (University of TX MD Anderson Cancer Center)

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Nutrition in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389293]

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