Journal of Cancer 2016, Vol.

7 131

Ivyspring
International Publisher
Journal of Cancer
2016; 7(2): 131-135. doi: 10.7150/jca.13818
Review

Nutritional Support in Cancer Patients: A Position Paper

from the Italian Society of Medical Oncology (AIOM)
and the Italian Society of Artificial Nutrition and
Metabolism (SINPE)
Riccardo Caccialanza1, Paolo Pedrazzoli2, Emanuele Cereda1, Cecilia Gavazzi3, Carmine Pinto4, Agostino
Paccagnella5, Giordano Domenico Beretta6, Mariateresa Nardi7, Alessandro Laviano8 and Vittorina
Zagonel9
1. Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;
2. Division of Medical Oncology, Department of Hemato-Oncology Fondazione IRCCS Policlinico San Matteo, Pavia, Italy;
3. Clinical Nutrition Unit, National Cancer Institute, Milan, Italy;
4. Medical Oncology, IRCCS-Arcispedale S. Maria Nuova, Reggio Emilia, Italy;
5. Endocrinology, Metabolism and Nutrition Unit, Local Health Authority ULSS 9, Treviso, Italy;
6. Medical Oncology Unit, Humanitas Gavazzeni, Bergamo, Italy;
7. Clinical Nutrition Service, Veneto Institute of Oncology-IRCCS, Padova, Italy;
8. Department of Clinical Medicine, University La Sapienza, Rome, Italy;
9. Medical Oncology 1, Veneto Institute of Oncology-IRCCS, Padova, Italy.

 Corresponding author: Dr. Riccardo Caccialanza, Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy.
Tel.: +39 0382 501615; fax: + 39 0382 502801. E-mail: r.caccialanza@smatteo.pv.it

© Ivyspring International Publisher. Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited. See
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Received: 2015.09.11; Accepted: 2015.11.01; Published: 2016.01.01

Abstract
Malnutrition is a frequent problem in cancer patients, which leads to prolonged hospitalization, a
higher degree of treatment-related toxicity, reduced response to cancer treatment, impaired
quality of life and a worse overall prognosis. The attitude towards this issue varies considerably and
many malnourished patients receive inadequate nutritional support.
We reviewed available data present in the literature, together with the guidelines issued by sci-
entific societies and health authorities, on the nutritional management of patients with cancer, in
order to make suitable and concise practical recommendations for appropriate nutritional support
in this patient population. Evidence from the literature suggests that nutritional screening should
be performed using validated tools (the Nutritional Risk Screening 2002 [NRS 2002], the Mal-
nutrition Universal Screening Tool [MUST], the Malnutrition Screening Tool [MST] and the Mini
Nutritional Assessment [MNA]), both at diagnosis and at regular time points during the course of
disease according to tumor type, stage and treatment. Patients at nutritional risk should be
promptly referred for comprehensive nutritional assessment and support to clinical nutrition
services or medical personnel with documented skills in clinical nutrition, specifically for cancer
patients. Nutritional intervention should be actively managed and targeted for each patient; it
should comprise personalized dietary counseling and/or artificial nutrition according to sponta-
neous food intake, tolerance and effectiveness. Nutritional support may be integrated into pallia-
tive care programs. “Alternative hypocaloric anti-cancer diets” (e.g. macrobiotic or vegan diets)
should not be recommended as they may worsen nutritional status.
Well-designed clinical trials are needed to further our knowledge of the nutritional support re-
quired in different care settings for cancer patients.
Key words: malnutrition, cancer, nutritional support

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Journal of Cancer 2016, Vol. 7 132

Introduction Nutritional screening and assessment

Malnutrition is a frequent problem in cancer pa- Early recognition of nutritional problems is the
first key point for appropriate nutritional manage-
tients, whose prevalence and degree mainly depend
ment of cancer patients. Different tools for nutritional
on tumor stage and site (1). Its negative consequences
screening have been validated in the oncologic setting
are prolonged hospitalization, a higher degree of
treatment-related toxicity, reduced response to cancer and effectively allow the identification of patients at
treatment, lower activity level, impaired quality of life nutritional risk, who are likely to benefit from nutri-
and a worse overall prognosis (2). Even minimal tional support. They are: the Nutritional Risk Screen-
weight loss during chemo/radiotherapy (CRT) is as- ing 2002 (NRS 2002), the Malnutrition Universal
sociated with significantly reduced survival (3). Screening Tool (MUST), the Malnutrition Screening
Tool (MST) and the Mini Nutritional Assessment
Nutritional support is a step by step interven-
(MNA) (9).
tion, which should be actively managed and targeted
Nutritional screening should be performed using
for each patient according to nutritional conditions,
clinical status, planned oncologic treatment and ex- a validated tool upon diagnosis and systematically
pected outcome. Its goal is preventing or treating repeated at regular time points during the course of
malnutrition, in order to allow the successful comple- disease in patients with cancer type, stage or treat-
tion of oncologic treatments, improve prognosis and ment potentially affecting nutritional status.
preserve functional status and quality of life (4, 5). Patients at nutritional risk should be promptly
Although recommendations on the optimal referred for comprehensive nutritional assessment
and support to clinical nutrition services or medical
management of nutritional support for patients with
personnel with documented skills in clinical nutrition,
malignancies have been provided (4, 6, 7), the attitude
specifically for cancer patients.
towards this issue varies considerably among oncol-
ogists, sometimes even within one center, and an Recent studies have highlighted the importance
important proportion of malnourished patients is re- of assessing body composition in cancer patients (10).
ported not to receive adequate nutritional support (1). Bioelectrical impedance vectorial analysis (BIVA) can
This could be related to the continuing insufficient be performed in different clinical settings and allow
awareness of nutritional problems among health care the suitable assessment of patients in whom calcula-
professionals (8), the lack of structured collaboration tion of body composition fails due to altered hydra-
tion (11). In particular, the primary output measure of
between oncologists and clinical nutrition specialists
this technique, phase angle, was found to be associ-
and the still limited number of clinical trials aimed at
ated with functional status (12) and energy intake
improving our understanding of the nutritional sup-
port required in different care settings for cancer pa- (13), and to be predictive of quality of life and prog-
tients. nosis in cancer patients (12, 14). As nutritional therapy
Another worrying issue, which may hamper the is primarily intended to preserve or restore lean body
appropriate nutritional care of cancer patients, is the mass, the assessment of body composition by BIVA
expanding market of “alternative anti-cancer diets”, should be integrated in the nutritional assessment of
which are not supported by scientific evidence and cancer patients.
may lead to insufficient protein-calorie intake. Indications for nutritional support
The purpose of this paper is to highlight the nu-
tritional issues in cancer patients, thus allowing the Indications for nutritional support in cancer pa-
Italian Association of Medical Oncology (AIOM) and tients vary throughout the continuum of care, de-
the Italian Society of Artificial Nutrition and Metabo- pending on whether patients are undergoing active
lism (SINPE) to make suitable and concise practical oncologic treatment, are in remission or in a palliative
recommendations for appropriate nutritional support stage. This means that regular nutritional monitoring
in this patients’ population. is mandatory in all patients with cancer type, stage or
We reviewed the available literature – prioritiz- treatment potentially affecting nutritional status.
ing meta-analyses, systematic reviews and random- Nutritional interventions should compensate for
ized controlled trials where available – and interna- inadequate energy intake with the objective of im-
tional guidelines on the nutritional management of proving clinical outcomes (4, 6, 7, 15).
patients with cancer. In addition, experts from the two The correct identification of candidates for nu-
societies, who are listed among the authors, provided tritional support relies on the evaluation of current
additional clinical information which helped in clari- and expected nutritional status and energy intake.
fying some issues. Accordingly, nutritional support should be provided
to malnourished patients and those at nutritional risk,

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Journal of Cancer 2016, Vol. 7 133

in particular when oral energy intake is already in- asked for by cancer patients. Their purported anti-
sufficient or expected to be inadequate (<60% of es- tumor effects are not yet demonstrated by appropriate
timated caloric requirements) for more than 7 days (4, efficacy evaluations, so their use cannot be recom-
6, 7, 15). mended. However, healthcare professionals involved
Undernourished cancer patients with planned in the nutritional treatment of cancer patients should
elective surgery should receive at least 7-day be knowledgeable on this issue, in order to discuss
pre-operative nutritional support to improve with the patients the potential risks, benefits and ex-
post-operative outcomes, even if this may delay sur- pectations deriving from specific dietary supplement
gery (16). consumption (22).
Dietary counseling, including the use of oral A healthy dietary pattern is known to be associ-
nutritional supplements (ONS), should be the ated with reduced cancer risk (23), so it is reasonable
first-step towards achieving satisfactory energy in- to argue that it would reduce cancer recurrence, as
take. In presence of normal gut function and inade- well. However, the available clinical supporting evi-
quate food intake, total or integrative enteral tube dence is limited to reduction of fat intake in women
feeding must be considered. If enteral nutrition (EN) with early-stage breast cancer (24). Since cancer and
is not feasible due to gut dysfunction, symptoms related treatments may be responsible for metabolic
which could be worsened by enteral support (i.e. changes affecting nutritional requirements, dietary
nausea, vomiting, diarrhea) or patients’ refusal, par- advice should be tailored to the individual patient
enteral nutrition (PN) is required for delivering nutri- and “hypocaloric alternative anti-cancer diets” (e.g.
tional support (4, 6, 7, 15). macrobiotic or vegan) are not recommended, as they
could worsen protein-calorie intake with no proven
Nutritional counseling, complementary benefits on recurrence rates (25).
nutrients and oral nutritional supple- Finally, although recent animal model studies
ments showed that pretreatment short-term starvation could
improve chemotherapy (CT) efficacy and reduce tox-
Nutritional counseling is the first-line of treat-
icity by diminishing malignant cells’ resistance to
ment in malnourished cancer patients or in those at
drugs while protecting normal tissues (26), this hy-
nutritional risk, due to its proven efficacy in increas-
pothesis still needs to be confirmed in humans.
ing protein-calorie intake, body weight and improv-
Therefore, this practice is not recommended, particu-
ing body composition (17, 18). In head and neck can-
larly in malnourished patients and those at nutritional
cer patients undergoing CRT, nutritional counseling
risk, since weight and lean body mass loss is associ-
was found to be associated with lower CRT toxicity
ated with dose-limiting toxicity and mortality in pa-
and symptom-induced morbidity (19), and to have
tients undergoing CT (3, 10).
beneficial effects on quality of life (20). Individualized
nutrition intervention was also shown to improve Enteral Nutrition
survival in colorectal cancer patients (21).
EN by means of tube feeding offers the possibil-
Therefore, all malnourished or at nutritional risk
ity of increasing or ensuring nutrient intake whenever
cancer patients who are able to eat should be referred
the gastrointestinal tract is functional and oral nutri-
to a dietitian with documented skills in cancer patient
tion is not feasible or remains inadequate despite nu-
care for appropriate dietary intervention and its
tritional counseling and ONS consumption (6, 7, 27).
monitoring. While taking into account individual
EN should not be used routinely during anti-
preferences, ethnicity and culture, the optimization of
cancer treatment in all patients, but only in those who
oral diet should consider predominantly the issue of
are malnourished or judged to be unable to eat ade-
appropriate protein-calorie content and texture, in
quately (the intention being to introduce an amount of
order to cope with nutritional deficiencies and swal-
calories ≥60% of estimated requirements) for more
lowing difficulties. In addition, any practical sugges-
than 7 days (6, 7, 27).
tions for managing the common symptoms related to
Tube feeding can either be delivered via
cancer treatments, leading to impaired food intake or
trans-nasal (nasogastric / nasojejunal tube) or a per-
malabsorption should be included, as well.
cutaneous route (percutaneous endoscopic / radio-
When dietary measures fail to meet patients’
logically inserted / surgical gastrostomy or jejunos-
protein-calorie requirements as detected by nutri-
tomy). To date, there is insufficient evidence to rec-
tional monitoring, the prescription of energy-dense
ommend the best route in terms of efficacy and safety
ONS should be considered, due to their proven effi-
(27, 28); however, gastrostomy should be preferred for
cacy in increasing protein-calorie intake (6, 21).
long term treatment (i.e. home artificial nutrition,
Complementary therapies in the form of “natu-
HAN), as it may be more comfortable for patients and
ral” dietary supplements are frequently used and

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Journal of Cancer 2016, Vol. 7 134

easier to manage for care-givers, whereas trans-nasal For long-term PN, a tunneled-catheter or im-
tubes need to be replaced approximately every 6 planted chamber is needed. Peripherally inserted
weeks (6, 7). Whenever trans-nasal tubes or gastros- central catheters (PICC) can also be used.
tomy placement is not feasible, as may be the case in Rigorous monitoring, particularly of glycemia
severe obstructing esophageal or gastric cancer, nee- and electrolytes, should be implemented from the
dle catheter jejunostomy represents the most appro- time of starting PN, in order to prevent clinical and
priate EN delivery route (6, 7, 27). metabolic complications and to evaluate the impact of
With regards to timing, prophylactic feeding PN on clinical outcomes.
does not seem to offer advantages in terms of nutri-
tional outcomes, treatment interruptions and survival Home artificial nutrition and palliative
compared to reactive feeding, which is initiated once care
nutritional counseling and ONS have failed to satisfy Home Artificial Nutrition (HAN) is a well estab-
energy requirements (27, 28). lished extra-hospital therapy, which helps to decrease
EN represents the first-line peri-operative nutri- the costs of health care, mostly by reducing the num-
tional treatment also for surgical cancer patients re- ber and length of hospitalizations (29). HAN can im-
quiring artificial nutrition (6, 7). Both European and prove the prognosis of patients in several acute and
American guidelines recommend preoperative EN chronic diseases, including cancer, and allows pa-
with immune-enhancing formulas, containing argi- tients to integrate into their families and into society,
nine, ω-3 fatty acids and nucleotides, in cancer pa- thus improving their quality of life (30). Due to its
tients undergoing major head-neck or abdominal organizational complexity, potentially serious com-
surgery (6, 7, 16), although the grade of this recom- plications and the necessity of periodic outcomes as-
mendation is still being debated. Post-operative EN is sessment, HAN should be prescribed and regularly
recommended in surgical patients malnourished at monitored using defined protocols shared between
the time of intervention, in those who cannot reinitiate oncologists and clinical nutrition specialists.
oral nutrition early or when this is expected to be in- Nutritional support, including HAN, may be
adequate for more than 10 days (16). also integrated into palliative care programs, when it
is expected to be beneficial to quality of life and if it is
Parenteral Nutrition estimated that patients may die from malnutrition
The use of PN in cancer patients has been de- prior to dying from cancer progression (4, 27).
bated because of the risk of infection. Both European While patients who are not in the terminal phase
and American guidelines clearly stated that PN is of cancer may benefit from nutritional support and
indicated in patients receiving active cancer treatment other medical therapies for cancer cachexia (31),
who are malnourished or are facing a period longer low-quality evidence (i.e. in the absence of random-
than 7 days of inadequate energy intake when nutri- ized trials) suggests that the administration of EN or
tional counseling, ONS or EN are not feasible or inef- PN in the last weeks of life does not change the course
fective (4, 7). of the disease, so it may not be indicated (32).
Routine PN during cancer treatment is strongly According to international guidelines, artificial
not recommended (4, 7). nutrition may not be appropriate in incurable cancer
A short period of PN (10-15 days) is indicated in patients with life expectancy shorter than 3 months or
patients with acute and severe mucositis, ileus or in- Karnowfsky score ≤ 50 or ECOG performance status ≥
tractable vomiting, whereas long-term PN (more than 3 (4, 6, 7, 15).
30 days) should be implemented in patients with in- In conclusion, nutritional support, including
testinal failure due to extensive bowel resection, se- HAN, may be integrated into palliative care pro-
vere malabsorption, mechanical bowel obstruction, in grams, according to individual-based evaluations,
sub-acute or chronic radiation enteritis and in patients quality of life implications, life expectancy and pa-
with graft versus host disease of the digestive tract (4, tients’ awareness.
7). PN may also aid insufficient oral intake in hypo-
phagic patients with a working gut (supplemental Discussion
PN) (27). It should be emphasized that malnutrition is an
PN is contraindicated in hemodynamically un- important issue in cancer patients, which should be
stable patients, with ascites, severe organ failure, or in appropriately managed by structured collaboration
the presence of severe glycemic instability and it is between oncologists and clinical nutrition specialists.
rarely appropriate in incurable cancer patients with The AIOM and SINPE recommend validated
life expectancy shorter than 3 months, Karnowfsky nutritional screening upon diagnosis and at regular
score ≤ 50 or ECOG performance status ≥ 3 (4, 7, 15). time points in all patients with cancer type, stage or

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 Journal of Cancer 2016, Vol. 7 135

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