Nutritional Consequences of Radiotherapy Simon Lal Consultant Gastroenterologist Intestinal Failure Unit Salford Royal Foundation Trust BAPEN, November 2010
Nutritional Consequences…. SHORT-TERM LONG-TERM UNITED KINDGOM Pelvic XRT: ~17000 patients/yr 1 H&N XRT: ~3500 patients/yr 2 1. West CM Curr Opin Supp Paliative Care 2009. 3: 36-40 2. Cancer research UK 2007.
Nutritional Consequences…. SHORT-TERM LONG-TERM
‘Short - term’ Consequences – H&N XRT 57% malnourished before XRT 1 Mucositis Dysgeusia Xerostomia Dysphagia Odynophagia MUCOSITIS Upto 80% lose weight 1. Lees J Eur J Cancer Care 1999; 8(3): 133-5 during XRT 2 2. Nugent B et al. Cochrane Review 2010.
‘Short - term’ Consequences - Pelvic XRT 11-33% malnourished before XRT 1 Acute Radiation Enteritis >70% 2 Diarrhoea Bloating ACUTE Abdo pain RADIATION ENTERITIS Nausea Upto 83% lose weight 1. McGough C et al. Br J Cancer 2004; 90:2278-87 during XRT 1 2. Resbeut M et al. Radiother Oncol 1997; 44: 59-63
‘Short - term’ Consequences XRT Toxicity 1 RADIOTHERAPY Hospitalisation 1,2,3 Interrupted XRT 1,2,4 -ve Incomplete XRT 5,6 MALNUTRITION Surgical complications 1.Beaver M H&N Surgery 1998;124:1141-4 4. Beer K Nutrition & Cancer 2005; 52: 29-34 2. Paccagnella A Support Care Cancer 2010;18:837-45 5. Margolis M Ann Thorac Surg 2003;76:1694-7 3. Lee JH Archives of Otolaryngology. 124:871-5 6. Odelli C. Clin Oncol 2005; 17: 639-45
‘Short - term’ Consequences XRT Toxicity 1 RADIOTHERAPY Hospitalisation 1,2,3 Interrupted XRT 1,2,4 -ve Incomplete XRT 5,6 MALNUTRITION Surgical complications Sarcopenia? 1.Beaver M H&N Surgery 1998;124:1141-4 4. Beer K Nutrition & Cancer 2005; 52: 29-34 2. Paccagnella A Support Care Cancer 2010;18:837-45 5. Margolis M Ann Thorac Surg 2003;76:1694-7 3. Lee JH Archives of Otolaryngology. 124:871-5 6. Odelli C. Clin Oncol 2005; 17: 639-45
Sarcopenia & Cancer Outcome Loss muscle Patient A mass/function. Can be masked in overweight/obese. 1 Increased chemotherapy Patient B toxicity & faster tumour progression. 2 Impact on radiotherapy Identical BMI=24.3 kg/m 2 outcome? 1.Prado C et al. Curr Opin Supp Pall Care 2009. 3: 269-75 2. Prado C et al. Clin Cancer Res 2009. 15(8): 2920-6
Nutritional Status & Cancer Treatment Wt, BMI Sarcopenia? Nutritional Status Diagnosis XRT Surgery
Nutritional Status & Cancer Treatment Wt, BMI Sarcopenia? Nutritional Status Diagnosis XRT Surgery [Nutritional] Interventions
Radiotherapy: Nutritional Management What are the roles of… Oral nutrition support/Dietary Counselling? Enteral tube feeding? Parenteral Nutrition? Nutritional ‘Therapies’?
Radiotherapy: Nutritional Management What are the roles of… Oral nutrition support/Dietary Counselling? Enteral tube feeding? Parenteral Nutrition? Nutritional ‘Therapies’?
Role of Oral Nutrition Support Study Oral No Study No supplement Oral supplement suppl length favourable favourable Douglass 15 15 6-35d 1978 Moloney 42 42 21-35d 1983 Arnold 23 27 70d 1989 ONS increased energy intake by 381kcal/d Standardised mean difference (95% CI) Elia M et al. Int J Oncol (2006) 28: 5-23
. Dietary Counselling: sustained increase in nutritional intake in patients undergoing XRT Protein Intake (grams) Counselling Supplements Control Ravasco P et al. JCO 2005;23:1431-1438
ESPEN Guidelines on EN 2006: Non-surgical Oncology Recommendation Grade Use intensive dietary counselling & During ONS to increase intake & prevent radio- therapy-associated wt loss & A interruption of radiation therapy in therapy patients undergoing radiotherapy of GI or H+N areas. RECOMMENDATION GRADE A=At least 1 randomised controlled trial C=Expert opinions and/or clinical experience
Radiotherapy: Nutritional Management What are the roles of… Oral nutrition support/Dietary Counselling? Enteral tube feeding? Parenteral Nutrition? Nutritional ‘Therapies’?
ONS vs. Tube Feeding? MUCOSITIS Both can reduce wt loss & Maintain QOL Reduce hosp admissions Reduce interruptions to treatment OESOPH CA No RCTs Choice depends on tolerability. Arends J et al. Clin Nutr 2006; 25: 245-59
NG vs. Gastrostomy? NG vs. Gastrostomy? mobility, cosmesis, QOL 1 vs. gastrostomy risk inc. persistent dysphagia? 3 irritation, blockage 1,2 COCHRANE: 1 RCT (n=33) insufficient evidence 4,5 1.Lees J. Eur J Cancer Care 1997;6:45-9 4.Corry J J Med Imag Rad Onc 2008;52:503-10 7.Wiggenraad R Clin Otolaryngology 2007;32:384-90 2.Baredes ENT Journal 2004;83:417-9 5.Nugent B Cochrane Review 2010 8.Beer K Nutr&Cancer 2005;52:29-34. 3, Mekhail T Cancer 2001;91:1785-90 6.Lee JH Archives Otolaryngology 1998;124:871-5 9. Margolis M Ann Thorac Surg 2003; 76: 1694-7
NG vs. Gastrostomy? NG vs. Gastrostomy? mobility, cosmesis, QOL 1 vs. gastrostomy risk inc. persistent dysphagia? 3 irritation, blockage 1,2 COCHRANE: 1 RCT (n=33) insufficient evidence 4,5 Prophylactic Gastrostomy vs. ‘as required’? Wt loss, hospitalisation, Rx interruption 6,7,8 Achieve target chemo-radiation dose 9 NO RANDOMISED STUDIES 1.Lees J. Eur J Cancer Care 1997;6:45-9 4.Corry J J Med Imag Rad Onc 2008;52:503-10 7.Wiggenraad R Clin Otolaryngology 2007;32:384-90 2.Baredes ENT Journal 2004;83:417-9 5.Nugent B Cochrane Review 2010 8.Beer K Nutr&Cancer 2005;52:29-34. 3, Mekhail T Cancer 2001;91:1785-90 6.Lee JH Archives Otolaryngology 1998;124:871-5 9. Margolis M Ann Thorac Surg 2003; 76: 1694-7
Pull through vs. Push Gastrostomy? Incidence [estimates]: 0.06% to 3% gastrostomy insertions 1,2 BSG recommend direct introducer or RIG approach. 3 77% UK H&N Units: pull- through technique. 1 1.Barber A, Lowe D, Lal S, Rogers S. J Craniomaxfacial Surg.2010.38:60-3 Tumour Seeding 2. Pickhardt P et al. Am J Radiol. 2002;179:735-9 2.O’Toole P. Complications of GI Endoscopy. BSG Guidelines. 2006.
ESPEN Guidelines on EN 2006: Non-surgical Oncology Recommendation Grade If an obstructing H+N or oesophageal C tumour interferes with swallowing, EN During should be delivered by tube. radio- Tube feeding is suggested if severe C therapy local mucositis is expected. PEG may be preferred because of oral C or oesophageal mucositis. RECOMMENDATION GRADE C=Expert opinions and/or clinical experience
Radiotherapy: Nutritional Management What are the roles of… Oral nutrition support/Dietary Counselling? Enteral tube feeding? Parenteral Nutrition? Nutritional ‘Therapies’?
ESPEN Guidelines on PN 2009: Non-surgical Oncology Recommendation Grade The routine use of PN during radio- or During A radio-chemotherapy is not radio- recommended. PN is recommended if patients are therapy malnourished or facing a period longer C than one week of starvation and EN is not feasible. RECOMMENDATION GRADE A=At least 1 randomised controlled trial C=Expert opinions and/or clinical experience
Radiotherapy: Nutritional Management What are the roles of… Oral nutrition support/Dietary Counselling? Enteral tube feeding? Parenteral Nutrition? Nutritional ‘Therapies’?
Nutritional ‘Therapies’? Probiotics Elemental Diet REDUCED RADIATION INJURY? Glutamine Fish Oil McGough C Br J Cancer 2004; 90: 2278-87 Crowther M Proc Nutr Soc 2009; 68: 269-73 Fuccio L J Clin Gastro 2009; 43: 506-513 Spyropoulos B Dig Dis Sci 2010. Epub
Efficacy of probiotics in the prevention of radiation-induced diarrhoea Fuccio L J Clin Gastro 2009; 43: 506-513
Nutritional ‘Therapies’? Probiotics Elemental Diet REDUCED RADIATION INJURY? Glutamine Fish Oil Mixed results…more studies required McGough C Br J Cancer 2004; 90: 2278-87 Crowther M Proc Nutr Soc 2009; 68: 269-73 Fuccio L J Clin Gastro 2009; 43: 506-513 Spyropoulos B Dig Dis Sci 2010. Epub
Nutrition Support Reduced Treatment Toxicities XRT SHORT TERM
Nutrition Support Reduced Anti Treatment Inflammatory Toxicities Cachexia Anorexia Appetite Counselling Stimulants Anabolic Physical Agents Activity
Nutritional Intervention XRT Toxicity RADIOTHERAPY Hospitalisation Interrupted XRT X X Incomplete XRT MALNUTRITION Surgical complications
Nutritional Consequences…. SHORT-TERM LONG-TERM UNITED KINDGOM Pelvic XRT: ~17000 patients/yr 1 H&N XRT: ~3500 patients/yr 2 1. West CM Curr Opin Supp Paliative Care 2009. 3: 36-40 2. Cancer research UK 2007.
Nutritional Consequences…. SHORT-TERM LONG-TERM Chronic Radiation Enteritis UNITED KINDGOM Pelvic XRT: ~17000 patients/yr 1 1. West CM Curr Opin Supp Paliative Care 2009. 3: 36-40
Radiation Enteritis Acute RE: Resolves within 3 months of XRT. Chronic RE: Onset >3 months – 6 yrs….or later. Chronic RE:- Histopathological changes Obliterative endarteritis Submucosal fibrosis Lymphatic dilatation Ischaemic necrosis malabsorption, bleeding, stricture, fistulae… 20% of patients receiving pelvic XRT or more ? Theis V, Sripadam R, Ramani V, Lal S. Clin Onc 2010: 22(1): 70-83
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