Nutrition 31 (2015) 585–586
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Evidence-based nutritional support of the elderly cancer patient Federico Bozzetti M.D. * Faculty of Medicine, University of Milan, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 November 2014 Accepted 24 November 2014
The papers included in this section represent the effort of the Task Force on Nutrition of the International Society of Geriatric Oncology to synthetize the evidence-based concepts on nutritional support of the elderly cancer patients. In the attempt of presenting a comprehensive overview of the topic, the panel included experts from different specialties: basic researchers, nutritionists, geriatricians, nurses, dieticians, gastroenterologists, oncologists. Cancer in elderly people is a growing problem. Not only in almost every country, the proportion of people aged over 60 years is growing faster than any other age group, but cancer per se is also a disease of old adultelderly people, hence the oncologists face an increasing number of these patients both now and in the next years. The are several studies on nutrition of elderly subjects and many other on nutrition of cancer patients but relatively few specifically devoted to the nutritional support of the elderly cancer patients. However, the awareness that elderly subjects account for a high proportion of the mixed cancer patients population, in some way legitimates us to extend some conclusions of the literature also to the elderly cancer patients. Although the topics of this Experts’ Consensus have been written by specialists in different areas of nutrition, the final message is addressed to the oncologists. Not only they should be more directly involved in the simplest steps of the nutritional care (recognition of the potential existence of a “nutritional risk” which can compromise the planned oncologic program, use of some oral supplements, etc.) but, as the true experts of the natural history of their cancer patient, they should also coordinate the process of the nutritional support, integrating this approach in the overall multidisciplinary cancer care. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nutritional support of the cancer patient Nutritional support of the elderly cancer patient Nutritional supplementation of the elderly cancer patient Tube feeding of the elderly cancer patient Parenteral nutrition of the elderly cancer patient
This document represents the effort of the International Society of Geriatric Oncology Task Force on Nutrition, which I have the privilege to chair, to synthetize the evidence-based concepts on nutritional support of the elderly cancer patients on the basis of a Consensus of an International Panel of Experts on this topic. The panel includes M. Elia and J. Hopkinson (UK), E. Isenring (Australia), P. Ravasco (Portugal), M. Sheffield More (United States), Y. Orreval (Sweden), S. Schneider and X. Hebuterne (France), C. Sieber (Germany), and A. Vigano (Canada). This Consensus is mainly addressed to the oncologists for two reasons. First, as we will see, malnutrition is so common in cancer patients that it appears difficult to delegate all the nutritional approach to the nutritionist. Secondly, the oncologist knows better than anyone the natural history of the * Corresponding author. Tel: þ39 3297655385; fax: þ39 0226410267. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.11.004 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
disease and adverse effects of the oncologic treatments, hence he/she may easily recognize the proper indication, advise the potential duration of the treatment, and also the more suitable route for feeding. Obviously, the exact formulations of the admixtures to be administered enterally or parenterally belong to the expertise of the nutritionists and dietitians, but the prescription of nutritional supplements is so frequent and their use so simple that probably the intervention of a specialist is not necessary. Cancer in elderly people is a growing problem. In almost every country, the proportion of people aged over 60 y is growing faster than any other age group. They were 841 million in 2013, and it is forecast they will reach 2 billion by 2050 when they will account for the 21.1% of all world population [1]. Cancer is primarily a disease of older people [2] and epidemiologic studies have shown [3] more than half of all newly diagnosed cancer patients and 71% of cancer deaths are in subjects 65 y old and older. In the United States, experts predict by 2030, adults 65 y
586
F. Bozzetti / Nutrition 31 (2015) 585–586
and older will account for 20% of the population and by 2050, 42% of the cancer population are predicted will be 75 y and older [4]. Currently, in the UK, more than three out of five (63%) cancers are diagnosed in people ages 65 and over [2]. In the attempt of presenting a comprehensive overview of the topic, the panel included experts from different specialties: basic researchers, nutritionists, geriatricians, nurses, dietitians, gastroenterologists, and oncologists. Although this approach represents an advantage because all different issues of the nutrition of the elderly cancer patients are covered by such a specialized panel of experts ranging from biological-experimental to the curative and palliative areas, there is always the risk that some statements reflect the specific experience of a single area of research or a single clinical context and cannot generalized to other contexts. Viewed in this perspective, some discrepancies are probably more apparent than real. On the contrary, there is some overlapping. As a matter of fact, I was more concerned to avoid contradictory statements than to avoid repetitions, also because nutrition is a continuum and despite the original fragmentation of the topics, some concepts were necessarily recalled in different articles. The reader will note that terminology is somewhat spurious, sometimes suggesting different terms may mean the same thing or, more rarely, different things are expressed through the same word. This is because we preferred, in general, to maintain the terms used in the original publications rather than to convey them into a conventional definition. The reader might be confused by the indifferent use of some words, namely weight loss, malnutrition, and cachexia to define the state of wasting of the cancer patients. Obviously, these terms have different meaning: “malnutrition” would suggest wasting is mainly caused by a poor intake of nutrients (hence could be in some way reversed by an adequate nutritional support), “cachexia” would underline the role of a deranged metabolism as a key factor for wasting (hence a poor response to nutrition and the need for the use of specific anticachectic agents), and finally, the term “weight loss” does not imply any etiopathogenetic meaning and just reflects the clinical presentation of the patient. Unfortunately there is a paucity of randomized clinical trials in this area and most of the suggestions simply rely on the experience of professionals who have dedicated many years to clinical nutrition or to laboratory research in elderly people and in cancer patients. Although there is an abundant literature on nutritional aspects of cancer patients and elderly people, studies focusing on nutrition of the elderly cancer patients are definitely scanty [5]; however, because the proportion of elderly people in the cancer series is very high, it is quite likely the findings achieved from studies in mixed patients’ populations, may also apply to the elderly cancer patients. We were careful to report in all
documents it some statements regarded healthy/sarcopenic people, cancer patients, or, more rarely, elderly cancer patients. The document will follow in the different articles the chronological sequence of an elderly cancer patient who may potentially need a nutritional support. The first article [6] will deal with the general issues of elderly cancer patients, nutrients’ intake and nutritional support, then the effect of “malnutrition” on patient outcome [7], followed by a review of the main nutritional screenings tools [8]. Then, we move to the nutritional care with distinct but interrelated papers on the role of nurses [9], the effects of the dietary counseling and oral supplementation on the clinical outcome [10] and on the metabolic response [11], and the approach with the tube feeding [12] and parenteral nutrition [13]. Finally, after an article on the optimization of the nutritional support [14], the following contributions will deal with parenteral [15] and enteral [16] nutrition in patients with advanced and incurable cancer. The last article [17] will summarize the difficulty of implementing the nutritional support in elderly patients where coexistence of malignancy, malnutrition, and frailty and polypharmacy pose a tremendous challenge to the oncologist. References [1] World Health Organization. Health topics: Ageing. Available at: http:// www.who.int/topics/ageing/en/. Accessed December 1, 2013. [2] Cancer Research UK. Cancer incidence by age. Available at: http://www. cancerresearchuk.org/cancer-info/cancerstats/incidence/age/. Accessed January 13, 2013. [3] Yancik R. Population aging and cancer: A cross-national concern. Cancer J 2005;11:437–41. [4] Edwards BK, Howe HL, Ries LAG, Thun MJ, Rosenberg HM, Yancik R, et al. Annual report to the nation on the status of cancer 1973 to 1999, featuring implications of age and ageing on U.S. cancer burden. Cancer 2002;94:2766–92. [5] Bozzetti F. Nutritional aspects of the cancer/aging interface. J Geriatr Oncol 2011;2:177–86. A, Morais CN. The elderly patient with cancer: A holistic view. [6] Vigano Nutrition 2015;31:587–9. [7] Bozzetti F. Why the oncologist should consider the nutritional status of the elderly cancer patient. Nutrition 2015;31:590–3. [8] Isenring E, Elia M. Which screening method is appropriate for older cancer patients at risk for malnutrition? Nutrition 2015;31:594–7. [9] Hopkinson J. Nutritional support of the elderly cancer patient: The role of the nurse. Nutrition 2015;31:598–602. [10] Ravasco P. Nutritional approaches in cancer: Relevance of individualized counseling and supplementation. Nutrition 2015;31:603–4. [11] Horstman AM, Sheffield Moore M. Nutritional/metabolic response in older cancer patients. Nutrition 2015;31:605–7. [12] Bozzetti F. Tube feeding in the elderly cancer patient. Nutrition 2015;31: 608–9. [13] Orreval Y. Parenteral nutrition in the elderly cancer patient. Nutrition 2015;31:610–1. [14] Bozzetti F. Tailoring the nutritional regimen in the elderly cancer patient. Nutrition 2015;31:612–4. [15] Orreval Y. Nutritional support at the end of life. Nutrition 2015;31:615–6. [16] Schneider S. Nutritional support of the elderly cancer patient: Long-term nutritional support. Nutrition 2015;31:617–8. [17] Bozzetti F. The oncologist as coordinator of the nutritional approach. Nutrition 2015;31:619–20.
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Evidence-based nutritional support of the elderly cancer patient Federico Bozzetti M.D. * Faculty of Medicine, University of Milan, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 November 2014 Accepted 24 November 2014
The papers included in this section represent the effort of the Task Force on Nutrition of the International Society of Geriatric Oncology to synthetize the evidence-based concepts on nutritional support of the elderly cancer patients. In the attempt of presenting a comprehensive overview of the topic, the panel included experts from different specialties: basic researchers, nutritionists, geriatricians, nurses, dieticians, gastroenterologists, oncologists. Cancer in elderly people is a growing problem. Not only in almost every country, the proportion of people aged over 60 years is growing faster than any other age group, but cancer per se is also a disease of old adultelderly people, hence the oncologists face an increasing number of these patients both now and in the next years. The are several studies on nutrition of elderly subjects and many other on nutrition of cancer patients but relatively few specifically devoted to the nutritional support of the elderly cancer patients. However, the awareness that elderly subjects account for a high proportion of the mixed cancer patients population, in some way legitimates us to extend some conclusions of the literature also to the elderly cancer patients. Although the topics of this Experts’ Consensus have been written by specialists in different areas of nutrition, the final message is addressed to the oncologists. Not only they should be more directly involved in the simplest steps of the nutritional care (recognition of the potential existence of a “nutritional risk” which can compromise the planned oncologic program, use of some oral supplements, etc.) but, as the true experts of the natural history of their cancer patient, they should also coordinate the process of the nutritional support, integrating this approach in the overall multidisciplinary cancer care. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nutritional support of the cancer patient Nutritional support of the elderly cancer patient Nutritional supplementation of the elderly cancer patient Tube feeding of the elderly cancer patient Parenteral nutrition of the elderly cancer patient
This document represents the effort of the International Society of Geriatric Oncology Task Force on Nutrition, which I have the privilege to chair, to synthetize the evidence-based concepts on nutritional support of the elderly cancer patients on the basis of a Consensus of an International Panel of Experts on this topic. The panel includes M. Elia and J. Hopkinson (UK), E. Isenring (Australia), P. Ravasco (Portugal), M. Sheffield More (United States), Y. Orreval (Sweden), S. Schneider and X. Hebuterne (France), C. Sieber (Germany), and A. Vigano (Canada). This Consensus is mainly addressed to the oncologists for two reasons. First, as we will see, malnutrition is so common in cancer patients that it appears difficult to delegate all the nutritional approach to the nutritionist. Secondly, the oncologist knows better than anyone the natural history of the * Corresponding author. Tel: þ39 3297655385; fax: þ39 0226410267. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.11.004 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
disease and adverse effects of the oncologic treatments, hence he/she may easily recognize the proper indication, advise the potential duration of the treatment, and also the more suitable route for feeding. Obviously, the exact formulations of the admixtures to be administered enterally or parenterally belong to the expertise of the nutritionists and dietitians, but the prescription of nutritional supplements is so frequent and their use so simple that probably the intervention of a specialist is not necessary. Cancer in elderly people is a growing problem. In almost every country, the proportion of people aged over 60 y is growing faster than any other age group. They were 841 million in 2013, and it is forecast they will reach 2 billion by 2050 when they will account for the 21.1% of all world population [1]. Cancer is primarily a disease of older people [2] and epidemiologic studies have shown [3] more than half of all newly diagnosed cancer patients and 71% of cancer deaths are in subjects 65 y old and older. In the United States, experts predict by 2030, adults 65 y
586
F. Bozzetti / Nutrition 31 (2015) 585–586
and older will account for 20% of the population and by 2050, 42% of the cancer population are predicted will be 75 y and older [4]. Currently, in the UK, more than three out of five (63%) cancers are diagnosed in people ages 65 and over [2]. In the attempt of presenting a comprehensive overview of the topic, the panel included experts from different specialties: basic researchers, nutritionists, geriatricians, nurses, dietitians, gastroenterologists, and oncologists. Although this approach represents an advantage because all different issues of the nutrition of the elderly cancer patients are covered by such a specialized panel of experts ranging from biological-experimental to the curative and palliative areas, there is always the risk that some statements reflect the specific experience of a single area of research or a single clinical context and cannot generalized to other contexts. Viewed in this perspective, some discrepancies are probably more apparent than real. On the contrary, there is some overlapping. As a matter of fact, I was more concerned to avoid contradictory statements than to avoid repetitions, also because nutrition is a continuum and despite the original fragmentation of the topics, some concepts were necessarily recalled in different articles. The reader will note that terminology is somewhat spurious, sometimes suggesting different terms may mean the same thing or, more rarely, different things are expressed through the same word. This is because we preferred, in general, to maintain the terms used in the original publications rather than to convey them into a conventional definition. The reader might be confused by the indifferent use of some words, namely weight loss, malnutrition, and cachexia to define the state of wasting of the cancer patients. Obviously, these terms have different meaning: “malnutrition” would suggest wasting is mainly caused by a poor intake of nutrients (hence could be in some way reversed by an adequate nutritional support), “cachexia” would underline the role of a deranged metabolism as a key factor for wasting (hence a poor response to nutrition and the need for the use of specific anticachectic agents), and finally, the term “weight loss” does not imply any etiopathogenetic meaning and just reflects the clinical presentation of the patient. Unfortunately there is a paucity of randomized clinical trials in this area and most of the suggestions simply rely on the experience of professionals who have dedicated many years to clinical nutrition or to laboratory research in elderly people and in cancer patients. Although there is an abundant literature on nutritional aspects of cancer patients and elderly people, studies focusing on nutrition of the elderly cancer patients are definitely scanty [5]; however, because the proportion of elderly people in the cancer series is very high, it is quite likely the findings achieved from studies in mixed patients’ populations, may also apply to the elderly cancer patients. We were careful to report in all
documents it some statements regarded healthy/sarcopenic people, cancer patients, or, more rarely, elderly cancer patients. The document will follow in the different articles the chronological sequence of an elderly cancer patient who may potentially need a nutritional support. The first article [6] will deal with the general issues of elderly cancer patients, nutrients’ intake and nutritional support, then the effect of “malnutrition” on patient outcome [7], followed by a review of the main nutritional screenings tools [8]. Then, we move to the nutritional care with distinct but interrelated papers on the role of nurses [9], the effects of the dietary counseling and oral supplementation on the clinical outcome [10] and on the metabolic response [11], and the approach with the tube feeding [12] and parenteral nutrition [13]. Finally, after an article on the optimization of the nutritional support [14], the following contributions will deal with parenteral [15] and enteral [16] nutrition in patients with advanced and incurable cancer. The last article [17] will summarize the difficulty of implementing the nutritional support in elderly patients where coexistence of malignancy, malnutrition, and frailty and polypharmacy pose a tremendous challenge to the oncologist. References [1] World Health Organization. Health topics: Ageing. Available at: http:// www.who.int/topics/ageing/en/. Accessed December 1, 2013. [2] Cancer Research UK. Cancer incidence by age. Available at: http://www. cancerresearchuk.org/cancer-info/cancerstats/incidence/age/. Accessed January 13, 2013. [3] Yancik R. Population aging and cancer: A cross-national concern. Cancer J 2005;11:437–41. [4] Edwards BK, Howe HL, Ries LAG, Thun MJ, Rosenberg HM, Yancik R, et al. Annual report to the nation on the status of cancer 1973 to 1999, featuring implications of age and ageing on U.S. cancer burden. Cancer 2002;94:2766–92. [5] Bozzetti F. Nutritional aspects of the cancer/aging interface. J Geriatr Oncol 2011;2:177–86. A, Morais CN. The elderly patient with cancer: A holistic view. [6] Vigano Nutrition 2015;31:587–9. [7] Bozzetti F. Why the oncologist should consider the nutritional status of the elderly cancer patient. Nutrition 2015;31:590–3. [8] Isenring E, Elia M. Which screening method is appropriate for older cancer patients at risk for malnutrition? Nutrition 2015;31:594–7. [9] Hopkinson J. Nutritional support of the elderly cancer patient: The role of the nurse. Nutrition 2015;31:598–602. [10] Ravasco P. Nutritional approaches in cancer: Relevance of individualized counseling and supplementation. Nutrition 2015;31:603–4. [11] Horstman AM, Sheffield Moore M. Nutritional/metabolic response in older cancer patients. Nutrition 2015;31:605–7. [12] Bozzetti F. Tube feeding in the elderly cancer patient. Nutrition 2015;31: 608–9. [13] Orreval Y. Parenteral nutrition in the elderly cancer patient. Nutrition 2015;31:610–1. [14] Bozzetti F. Tailoring the nutritional regimen in the elderly cancer patient. Nutrition 2015;31:612–4. [15] Orreval Y. Nutritional support at the end of life. Nutrition 2015;31:615–6. [16] Schneider S. Nutritional support of the elderly cancer patient: Long-term nutritional support. Nutrition 2015;31:617–8. [17] Bozzetti F. The oncologist as coordinator of the nutritional approach. Nutrition 2015;31:619–20.
