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Supportive Nutritional Management of the Patient With Pancreatic

Supportive Nutritional Management of the Patient With Pancreatic

ABSTRACT: Progressive weight loss and nutritional deterioration are commonly found in the patient with pancreatic cancer. The combined effects of the central anatomic location of the pancreas, endocrine and exocrine hormonal insufficiency, and treatment toxicity place patients with pancreatic cancer at high risk for developing symptoms that affect their ability to consume and absorb adequate calories and protein. The use of standardized nutritional assessment and an algorithmic approach for nutritional intervention fosters determination of the patient's nutritional risk status early in the course of disease, fosters early detection of treatable symptoms that interfere with nutritional intake/absorption, and can assess the effect of nutritional interventions. Supportive nutritional efforts can decrease complications, shorten hospital stays, reduce costs, and improve the patient's sense of well-being. [ONCOLOGY 10(Suppl):26-32, 1996]

Introduction

Definition of standardized assessment tools and interventions
has been the backbone of protocol treatment in the context of
the national cooperative oncology groups. In a similar manner,
an algorithm of standardized nutritional assessment and intervention
in the oncology patient has been developed and is increasingly
being used as a guide to supportive nutrition in patients with
cancer (Figure 1).

The proactive approach to nutritional care as defined by the algorithm
is particularly important in patients with pancreatic cancer.
These patients are at high risk for nutritional problems, based
on the combined effects of the central anatomic location of the
pancreas, endocrine and exocrine hormonal insufficiency, and treatment
toxicity of multimodality therapy. When symptoms that affect nutrition
(eg, anorexia or fat malabsorption) or significant weight loss
are present at the time of diagnosis, the risk of progressive
nutritional deterioration is further increased.

Because the onset of pancreatic cancer is insidious (delaying
the presentation of the patient for diagnosis and treatment) and
since weight loss is often progressive and may be rapid and severe,
all factors that contribute to anorexia and other nutritional
impact symptoms need to be assessed promptly and interventions
initiated expeditiously. Extreme weight loss and malnutrition
are important contributors to morbidity and mortality in patients
with cancer and negatively impact response to antineoplastic therapy
[1].

Rationale for Proactive Nutritional Approach

The goals of nutritional care are to support adequate caloric
and nutrient intake, body composition, functional or performance
status, immune function, and quality of life [2]. A proactive
nutritional approach in the care of oncology patients was outlined
by Shils in 1979 in the principles of nutritional care in the
cancer patient [3]. Early detection of nutritional problems and
prompt intervention are essential for success, whether the aim
of treatment is cure or palliation. Once a patient's nutritional
status has deteriorated to the point of severe depletion, attempts
to reverse the condition rarely succeed, especially in the face
of severe muscle wasting.

The primary cause of clinically evident nutritional deterioration
in the patient with pancreatic cancer is inadequate intake and
absorption of calories and protein. Examples of nutritional impact
symptoms commonly noted in this patient population include early
satiety, anorexia, fat malabsorption with crampy abdominal pain
and bloating, nausea and/or vomiting, diarrhea or constipation,
pain, and fatigue. These symptoms are treatable, but they require
early detection and aggressive management. The pervasiveness of
nutritional challenges in the patient with pancreatic cancer necessitates
the use of standardized nutritional assessment tools and prompt
intervention to optimize outcomes and quality of life for these
patients.

Impact of Malnutrition

Malnutrition has a wide range of adverse effects [1, 4-10]. The
general impact of weight loss on outcomes has been known since
the 1930's [11] and has been confirmed in a number of subsequent
studies [9]. Malnutrition is associated with adverse outcomes
on a number of levels and contributes to higher health-care costs
and prolonged hospitalizations [4, 12-14].Weight loss, nutritional
deterioration, and inanition can hasten death, reduce response
to treatment, exacerbate treatment toxicities and complications,
and adversely affect quality of life in the oncology patient.

Health-Care Outcomes

The incidence of malnutrition in general medical and surgical
patients reported between 1973 and 1986 ranged from 30% to 50%
[15]. Malnutrition increases health care costs and prolongs hospital
stays due to slower wound healing and increased incidence of complications
[16-19]; it also increases mortality [11,13,14,20-22].

It has been estimated that 20% to 40% of patients with cancer
die from the effects of malnutrition and its complications, as
opposed to the malignancy per se [23]. Significant weight loss
is a major prognostic indicator in patients with cancer in terms
of response to treatment and overall survival [1]. Weight loss,
malnutrition, or failure to thrive are the most commonly listed
causes of death in cancer patients [7,8,24].

Criteria for grading of treatment-related toxicity are standardized
and included in all oncology protocols. Criteria for weight loss
are included in Table 1. The current grading of this nutritional
toxicity, however, is inadequate [2,25,26]. Table 2 includes the
standard definitions of severe and significant weight loss that
are used in the nutrition literature. Significant weight loss
is defined as that for which there is a statistically significant
increase in morbidity and mortality. The weight loss toxicity
criteria used in oncology protocols do not take into consideration
1) the time interval during which weight loss is experienced or
2) total cumulative weight loss, including pretreatment loss.
In addition, the basis for the grading of life-threatening (grade
4) nutritional toxicity is not defined. Aspects of weight loss
such as acuity and the extent of cumulative loss need to be incorporated
into current treatment protocols to be consistent with known outcome
data in the nutrition literature.

Quality of Life

Nutritional status affects quality of life in terms of self-image,
the patient's ability to perform activities of daily living, and
overall life satisfaction. The ability or desire to eat significantly
affects a patient's ability to socialize and interact with family
and friends [27,28]. Progressive weight loss causes distress to
patients, their families, and the health care team.

With malnutrition and cachexia, muscle weakness and fatigue contribute
to depression and may compound difficulties in meal preparation
or participation in eating with family or friends [2]. Reduced
activity and bed rest lead to constipation and progressive muscle
wasting. Progressive fatigue secondary to nutritional deterioration
and inanition (severe muscle wasting) are the primary determinants
affecting patients' ability to continue working at their jobs
or to carry on any aspects of normal life.

Progressive nutritional deterioration in many patients with pancreatic
cancer is caused by symptoms that affect food intake and nutrient
absorption. Those symptoms that affect nutrition (anorexia, diarrhea,
pain) can, in addition to contributing to weight loss, adversely
affect quality of life. Weight loss often can be slowed or prevented
by directing attention to those aspects which can be treated pharmacologically
and/or behaviorally [2,23,29-31].

Economic Impact

Few data are available on the economic impact of malnutrition
in cancer patients. A significant contribution to health care
costs is the average length of stay (ALOS) in a hospital. The
average length of stay is nearly twice as long for malnourished
patients as it is for patients with the same diagnosis who are
well nourished [4]. Little or no data have been available concerning
the impact of nutritional status in the patient with cancer. Review
of discharge data from the Fox Chase Cancer Center from 1993 to
1994 was carried out to evaluate the affect of nutritional status
on ALOS. The average length of stay for all discharged patients
was 5.8 days, whereas patients with a discharge diagnosis of dehydration
and/or malnutrition had an ALOS of 9.4 days. With a discharge
diagnosis of malnutrition alone, the ALOS was 13.4 days [32].
The category of malnutrition/dehydration was important to consider,
since patients in this category were not eating adequately during
the 9.4 days and yet such patients often are not identified as
being at risk of nutritional deficit.

Studies by Robinson et al [5] support the concept of proactive
nutritional intervention. In these studies, the majority of increased
health care dollars spent for care (approximately two- fold) involved
patients with borderline malnutrition as compared with well-nourished
patients. Only a relatively small additional cost was associated
with managing severe malnutrition, as compared with borderline
malnutrition.

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