Cancer care

Call for action on cancer malnutrition

Dr Stephen Clarke

Cancer-related malnutrition is common but can be averted by early intervention nutrition programs as pioneered by Victorian health services, according to a special session at the COSA 2018 meeting.

Rates of malnutrition are around 57% for cancer inpatients and 25% for cancer patients in the community, which is a concern because malnutrition is related to poor prognosis, higher rates of treatment toxicity, reduced quality of life and ultimately leads to cachexia, said Dr Stephen Clarke an oncologist at the Royal North Shore Hospital, Sydney.

Speaking at a COSA 2018 forum on cancer malnutrition Professor Clarke said oncologists often did not appreciate the extent of malnutrition in their patients or had a heavy clinic workload and lacked resources such as dietician services to manage it adequately.

“We often don’t recognise there’s a nutritional issue until the patient is too unwell,” he said.

“But almost every patient I see asks what they should eat, what they should I be doing – so it’s a big obsession of patients and we should be able to answer that.”

Dr Marian de van de Schueren (PhD), Professor of Nutrition, at VU University Medical Center, Netherlands, said cancer malnutrition was multifactorial and could be due to poor appetite, tumour factors causing catabolism and secondary to widespread systemic inflammation.

Malnutrition could lead to sarcopenia, and this may not be apparent in overweight and obese people who maintain a normal or high BMI and waist measurement, she said.

Dr de van de Schueren said early intervention is the key to preventing cancer malnutrition, and she pointed to new European (ESPEN) guidelines that recommend screening and identification of at-risk patients, who can be targeted for nutrition interventions from dieticians.

In Europe there is particular interest in the use of omega-3 fish oils for the management of cancer malnutrition, which have been shown to be effective in meta-analyses, presumably due to an anti-inflammatory effect, she suggested.

The forum also saw the presentation of positive outcomes from the Victorian Cancer Malnutrition Collaborative which has overseen a reduction in malnutrition prevalence within Victorian health services  through a series of education and quality improvement initiatives.

Jane Stewart a dietitian at the Peter MacCallum Cancer Centre, Melbourne, said the overall prevalence of cancer malnutrition had fallen from 31% in 2012 to 23% in 2016 through a combination of increased awareness, screening and identification of malnutrition and improved referral rates to dietitian services.

However she said it was important to acknowledge that cancer malnutrition is a system-wide issue and not just confined to inpatients, nor just a ‘silo’ issue for dieticians. She said the next steps will be to encourage a shift in screening and management of cancer malnutrition into the community and primary care services.

Dr Clarke said the Holy Grail for cancer malnutrition lies in the search for interventions to manage systemic inflammation, with interest currently focusing on NSAIDs and statins.

Meanwhile, nutrition still needs to be better appreciated by oncologists, he suggested.

“In general nutrition interventions aren’t regarded as sexy as new drugs – and  oncologists are obsessed with new drugs all the time and perhaps we should be more obsessed with dealing with issues such as nutrition and exercise,” he concluded.

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