Early Nutritional Intervention Recommended for Cancer Patients

by Manny Gonzales

The relationship between nutrition and cancer is not yet fully understood, but researchers do know that well-nourished patients have a better prognosis. For many patients with cancer, however, the onset of cachexia will ultimately make it difficult to avoid weight loss. Therefore, early intervention may be the key to effective nutritional support.

Traditionally, nutritional support has been recommended after a patient has lost at least 10% of his or her body weight, but experts now recommend intervening much sooner. Egidio Del Fabbro, M.D., assistant professor in the Department of Palliative Care and Rehabilitation Medicine at The University of Texas M. D. Anderson Cancer Center, pointed out that studies have shown that patients with a 5% or more loss in body weight have decreased survival rates and an inability to tolerate chemotherapy. “We think that there’s enough evidence that a patient is not going to be able to tolerate chemotherapy as well; there are more side effects and decreased survival,” he said. “Over the last few years, there’s been a realization that not only is 5% too much weight loss, but even less than that may be problematic,” Dr. Del Fabbro said.

Carefully designed nutritional guidelines should be provided to patients with cancer as early as possible to help avoid the loss of fat and muscle associated with cachexia. Dr. Del Fabbro, who is the director of M. D. Anderson’s Cachexia Clinic, encourages patients to eat foods that they like, but he and his colleagues also pay close attention to protein, fat, and carbohydrate composition. Protein is especially important because someone with insufficient protein intake will not be able to maintain and rebuild the muscle that is lost with cachexia.

Nicki Lowenstein, a manager in the Department of Clinical Nutrition, believes that patients should speak to a doctor and a dietician as soon as possible after the diagnosis, even before any weight loss is evident. “From a dietician’s perspective, it’s great if you can get them really early in the diagnosis, because they’re very open to making changes to their diet that might be beneficial,” said Ms. Lowenstein.

Registered dieticians at M. D. Anderson meet with patients and encourage them to maintain their weight in a healthy manner. “Now, we’re looking at the issue as more of a balance—what they can eat, what they will eat, and what they should eat,” Ms. Lowenstein said. “There are still some clinicians who will say, ‘Eat whatever you want because you’re going to have a difficult time eating,’ but the general consensus among nutrition professionals is to try to steer patients in the direction of things that will support their body’s immune system and their body’s good health to give them the best physical edge possible in fighting the disease.”

Because the nutritional needs of people with cancer differ from those of the general population, dieticians educate their patients on the specifics of their changing nutritional needs and how best to introduce changes to their diets. “Some patients are diagnosed and become very proactive, going into warrior mode. They arm themselves with all that they can, and diet is one of those things. And we encourage patients to take every advantage they can that’s not detrimental,” said Ms. Lowenstein.

Changes in diet should be made gradually to allow the body time to adjust, and patients should avoid radical changes in diet altogether. A dietician can work with patients who want to introduce certain changes and help them evaluate the alternatives. “It’s not unusual for a patient to get diagnosed and decide that this is the time in his or her life to become vegetarian, and that’s not always the best idea, because obviously, when you exclude a big food group, like meat, you’re excluding one of the best sources of protein,” said Ms. Lowenstein.

The use of appetite stimulants or meal replacement drinks, such as Boost or Ensure, should also be considered to help patients achieve adequate nutritional intake. Doctors should raise the issue of nutritional supplements with their patients as well because many patients may already be taking them at the time of diagnosis. “We have people come in with bags of stuff that they’re taking,” Ms. Lowenstein said. “We go through them on a case-by-case basis and decide what’s going to work and what’s not going to work with their treatment.”

“There’s a lot of opinion about what is the best supplement and what is the best food but very little data in randomized trials,” said Dr. Del Fabbro. Recent studies have shown that a combination of the amino acids glutamine-arginine and beta-hydroxy beta-methylbutyrate appears to improve cachexia, he noted. However, appetite stimulants, like megestrol, can cause side effects such as deep venous thrombosis.

Dr. Del Fabbro cited some recent findings showing intriguing benefits of melatonin, including improvement of nausea, appetite, and fatigue. “A systematic review of these trials suggested there may even be improved survival with melatonin,” he said. Based on this evidence, Dr. Del Fabbro and colleagues will conduct a trial of melatonin supplementation in cancer patients. Another study will examine the effect of a combination of exercise, nutrition, nutritional supplements, and medications.

The etiology of cachexia is complex, however, and not all aspects of cachexia are driven by improper food or nutritional intake, Dr. Del Fabbro noted. Cachexia and its associated breakdown of muscle and fat may be hastened by the effects of cancer byproducts, such as cytokines. “We hope that we’ll find some intervention to modulate this process,” he said.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

Other articles in OncoLog, June 2006 issue:

• Breast Cancer in the Prime of Life
• In Brief: Research News from the Laboratories and Clinics of M. D. Anderson
• House Call: How to Deal with Pain

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