Malnutrition and cancer, diagnosis and treatment
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short review
memo
https://doi.org/10.1007/s12254-020-00672-3
Malnutrition and cancer, diagnosis and treatment
Angelika Beirer
Received: 23 September 2020 / Accepted: 17 December 2020
© The Author(s) 2021
Summary cachexia, while Evans et al. put forward a defini-
Background The prevalence of malnutrition in cancer tion for cachexia associated with all types of under-
patients ranges from about 20% to more than 70%. lying chronic diseases. However, if there is a cancer
However, 10–20% of cancer patients’ deaths are re- cachexia diagnosis, additional pharmacological and
lated to malnutrition, not the malignancy itself. To psychological treatment should be considered.
reverse the pattern of weight loss, improve the pa-
tients’ quality of life, reduce the treatment toxicity, the Keywords Cachexia · Sarcopenia · Obese cancer
psychological stress and the risk of mortality, the di- patients · Involuntary weight loss · Oncology
agnosis of malnutrition should be made as early as
possible to facilitate the best possible treatment. Introduction
Methods A systematic literature search was conducted
following guidelines of ESPEN (European Society for Malnutrition means a significant loss of weight and
Clinical Nutrition), DGEM (German Society for Nu- body resources, which results in an impairment of
tritional Medicine) and ASPEN (American Society for quality of life and prognosis [1]. Worldwide studies
Parenteral and Enteral Nutrition). show that the prevalence of malnutrition in cancer
Results and conclusion To assess the risk of malnu- patients ranges from about 20% to more than 70%.
trition, all cancer patients should be screened reg- However, 10–20% of cancer patients’ deaths are re-
ularly with a valid screening tool (e.g., MUST [Mal- lated to malnutrition, not the malignancy itself. Al-
nutrition Universal Screening Tool], NRS [Nutritional though certain cancer patient groups are more vul-
Risk Screening] or PG-SGA [Scored Patient-Generated nerable to malnutrition than others, many of these
Subjective Global Assessment]). If risk of malnutri- patients are never treated for malnutrition. The risk
tion is present, adequate nutritional therapy is rec- of malnutrition is particularly evident after gastroin-
ommended to stop involuntary weight loss. Patients testinal tumor surgery such as gastrectomy, pancre-
should engage in exercise to maintain and improve atectomy, small bowel surgery, or high-lying stoma
muscle mass, strength and function. They should be and therapy-induced diarrhea, whereby 80% of pa-
offered regular dietetic counselling, and their mus- tients with these tumor entities, and 30% of all cancer
cle depletion should be monitored by determining patients have already lost weight prior to diagnosis [1].
fat-free mass. As cachectic patients in particular are
at risk, the presence of cachexia should also be rec- Causes of malnutrition
ognized at an early stage. Three consensus-based
definitions are widely accepted: Fearon et al. and In an interactive network, mutually reinforcing factors
the EPCRC (European Palliative Care Research Col- are understood to be the causes of malnutrition in
laborative) propose definitions specifically for cancer cancer patients [1, 2].
Gastrointestinal disorders such as nausea or diar-
Mag. A. Beirer, Bsc. ()
rhea, changes in smell and taste, drug side effects,
FH St. Pölten, Matthias Corvinus-Straße 15, 3100 St. Pölten, psychological stress and pain can all lead to a reduced
Austria food intake and consequently to weight loss. This in
angelika.beirer@fhstp.ac.at turn leads not only to a weakening of the immune sys-
K Malnutrition and cancer, diagnosis and treatmentshort review tem but also to muscle loss, which is increased both Starvation lasting for more than seven days is defined by the inflammation of the tumor stroma and by the as an independent criterion for risk of malnutrition. reduced mobility. Systemic inflammation processes The above criteria also apply to obese patients [7]: and the loss of cell and muscle mass associated with a 40-year-old person weighing 80 kg, with a height of weight loss cause fatigue, which in turn leads to re- 160 cm, a BMI of 31 and a weight loss of 10% is also duced physical activity [1]. malnourished, although still obese with a BMI of 28. Immunologic, metabolic and clinical phenomena Minor weight loss is often not mentioned in this group are related. The upregulated innate immune response of patients and not seriously considered [7]. causes systemic inflammation which leads to differ- As a meta-analysis of Winter et al. shows that the ent symptoms such as anorexia, weight loss and re- all-cause mortality risk increases in older people with duced physical function, as well as fatigue, pain and a BMI 5.0 mg/L, IL-6 >4.0 pg/mL without inflammation), chronic disease-related mal- – Anemia (Hb
short review
SCREEN EVERY CANCER PATIENT WITH A VALID SCREENING TOOL TO VERIFY DISEASE-RELATED MALNUTRITION
BMI < 18.5 kg/m² or unwanted weight loss >10% in the last 3-6 months
OR
BMI < 20 kg/m² and unwanted weight loss >5% in the last 3-6 months [6]
screening
negative
screening
positive
Repeat malnutrition risk screening, amount of food
intake, physical performance and severity of disease
every 4-8 weeks [4]
CACHEXIA
the following 3 criteria [16] :
Systemic inflammation (C-
OR
Weight loss>5% over past 6 months without starvation and/or weight loss>2% and BMI2% and sarcopenia [14]
NO YES
Stop involuntary weight loss [7]:
Prepare a nutritional protocol covering 2-3 days and
calculate it with the help of IT in order to carry out targeted
nutritional therapy [7] [1]
Increase energy intake [21]
Offer regular small meals [21]
Allow flexible size, frequency and type of meals [21]
Reduce or eliminate dietetic restrictions if possible [4]
Hydration [21]
Emphasize eating and drinking as an important part of
therapy [21]
Integrate energy and protein additives [4] [21] [2] Pharmacological treatment [13] :
Provide oral nutritional supplements and/or
enteral/parenteral nutrition if needed [21][2][7]
Reduce the tumor-associated inflammation
Stimulate the appetite
Engage in exercise to maintain and improve muscle mass,
Counter the wasting and hypercatabolic state
strength and function [13]
Psychological treatment [13]
Schedule regular dietetic counselling [21]
Determine fat-free mass and monitormuscle depletion [19] [13]
REGULAR AFTERCARE AND CHECK-UP [21]
Fig. 1 Diagnosis and treatment. Regular aftercare and check-up [20]. BMI body mass index
K Malnutrition and cancer, diagnosis and treatmentshort review
Step 7: parenteral nutrion
Step 6: parenteral nutrion + minimal enteral nutrion
Step 5: mainly enteral nutrion + parenteral nutrion
Step 4: enteral nutrion
Step 3: step 1 or 2 + addional enteral / parenteral nutrion
Step 2: step 1 + orally balanced diet (OBD); maltodextrin, protein powder, fat
emulsion, ONS (oral nutrional supplements)
Step 1: Regular food, special diet, food forficaon (micro- and macronutrients),
dietary counselling
Fig. 2 Always pay attention to refeeding in regard to enteral/parenteral nutrition
Systemic inflammation (C-reactive protein [CRP] Treatment of malnutrition and cachexia
≥10 mg/L).
If risk of malnutrition is present, nutritional assess-
EPCRC (European Palliative Care Research Collabora- ment is required to improve physical performance,
tive) proposed [14]: metabolism, tolerability of antitumor therapies, qual-
Weight loss >5% over past 6 months without starva- ity of life, and course of disease. Nutritional coun-
tion and/or selling includes a recording of food intake (computer-
Weight loss >2% and BMI < 20 and/or aided evaluation of food log), nutritionally relevant
Weight loss >2% and sarcopenia. symptoms, body and muscle mass, systemic inflam-
mation, and performance status [4].
Cruz-Jentoft et al. defined sarcopenia as a “syndrome If the caloric intake is less than 60% of the esti-
characterised by progressive and generalised loss mated requirements over a period of 1–2 weeks, or
of skeletal muscle mass and strength with a risk of if eating is not possible for a week, insufficient nu-
adverse outcomes such as physical disability, poor tritional intake is validated [2]. High-quality medical
quality of life, and death [17]”. The SCWD (task force nutritional intervention is provided by dieticians. The
of the Society for Sarcopenia, Cachexia and Wasting structure of the therapeutic interventions is shown by
Disorders) recommends to screen for sarcopenia us- the following scheme described by Valentini et al. ([6];
ing a simple tool like the SARC-F. It is necessary to Fig. 2):
diagnose sarcopenia using following examinations: Enteral or parenteral nutrition is indicated in
grip strength or chair stand and—if possible—a mea- case of inadequate nutritional intake (less than
surement of fat-free mass [18]. DXA (dual X-ray 500 kcal/day for a couple of days or oral nutritional
absorptiometry), MRI (magnetic resonance imaging), intake of less than 75% of TEE for 1–2 weeks), and if
CT (computed tomography), US (ultrasound) and an improvement of quality of life, increased longevity
BIA (bioelectrical impedance analysis) can be used to and greater patient comfort can be expected ([1, 4];
determine fat-free mass and to monitor muscle de- Table 1).
pletion. DXA seems to be the most valid method but The main goals in the treatment of cachexia are
the BIA method is widely used due to its simplicity improvements in lean body mass, resting energy
and low cost ([13, 19]; Fig. 1). expenditure, fatigue, anorexia, quality of life, and per-
formance status as well as a reduction of the tumor-
associated inflammation [13]. Appetite stimulants,
Malnutrition and cancer, diagnosis and treatment Kshort review
Table 1 Recommended energy and nutrient intake of must be treated, while continued normal food intake
malnourished cancer patients lacking allowances for end-of-life care would put an
Energy Use indirect calorimetry to determine resting energy expenditure unacceptable burden on the dying person [1, 2].
if available, or estimate REE with formulas like Harris–Benedict,
Schofield or WHO.
Assume a physical activity level of 1.0–1.5 [4] Take-Home Message
Protein 1.2–1.5 g/kg body weight Enrich with supplements (e.g. pro-
per day to maintain or re- tein powder, ONS) Every cancer patient should be screened for malnu-
store lean body mass [4] Choose foods with a high biological trition.
Protein amounts of more value Adequate nutritional therapy and regular dietetic
than 2 g/kg body weight per Offer immunomodulatory enteral
day are of no benefit [4] formulas containing arginine and counselling should be offered.
nucleotides to patients undergoing Cachectic patients should receive additional sup-
cancer surgery [2] port.
Fat Intake should amount to at Enrich with high-quality vegetable
least 35% of TEE [4] oils as well as butter, cream or Funding Open access funding provided by FH St. Pölten -
In case of insulin resistance other fatty dairy products University of Applied Sciences.
or if a higher energy density Fish oil (omega-3 fatty acids) is
is required, up to 50% of suggested to improve appetite, oral Conflict of interest A. Beirer declares that she has no com-
TEE may be considered [4] intake, lean body mass and body peting interests.
weight [2]
REE resting energy expenditure, WHO World Health Organization, ONS oral Open Access This article is licensed under a Creative Com-
nutritional supplement, TEE total energy expenditure mons Attribution 4.0 International License, which permits
use, sharing, adaptation, distribution and reproduction in
any medium or format, as long as you give appropriate credit
Table 2 Pharmacological treatment options to the original author(s) and the source, provide a link to
Drug Effects Side effects the Creative Commons licence, and indicate if changes were
Prokinetics Appetite stimulating, No effects on body made. The images or other third party material in this article
Reduced sickness [7] weight [7] are included in the article’s Creative Commons licence, unless
Gestagenes Appetite stimulating Adrenal insufficiency
indicated otherwise in a credit line to the material. If material
Weight gain [4, 7] Thromboembolism is not included in the article’s Creative Commons licence and
Impotence [4, 7] your intended use is not permitted by statutory regulation or
exceeds the permitted use, you will need to obtain permis-
Glucocorti- Appetite stimulating Cushing syndrome
coids Reduced systemic inflammation Short-lived positive sion directly from the copyright holder. To view a copy of this
Increase in ingestion, quality of life, effects [4, 7, 13] licence, visit http://creativecommons.org/licenses/by/4.0/.
physical performance and well-being
[4, 7, 13]
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