Early Nutrition Intervention Improves Outcomes and Treatment Tolerance in Patients With Esophageal Cancer

Patients with head and neck cancer, including esophageal cancer, are at high risk for nutritional issues, including difficulty eating, weight loss, and malnutrition. Often at diagnosis, patients with esophageal cancer experience dysphagia, or difficulty swallowing, and are subsequently malnourished.¹ Treatment for esophageal cancer often involves surgery, chemotherapy, and/or radiation, all of which can lead to further nutritional adverse effects, including poor appetite and esophagitis, and increased nutritional risk. A 2014 study of malnutrition prevalence in cancer patients found that, overall, 39% were malnourished, and for those with esophageal or stomach cancer, 60.2% were malnourished.² Weight loss and malnutrition in patients with cancer results in negative outcomes, including decreased treatment tolerance and response, decreased quality of life, increased hospital length of stay (LOS) and readmissions, and increased healthcare costs.³

However, research has demonstrated that early and targeted nutrition screening, assessment, education, and intervention can improve outcomes in patients with esophageal cancer.^1,4-6 Poulsen and colleagues found that individual dietary counseling (and an optional oral nutritional supplement) was associated with better weight maintenance and protein and energy intake in patients with cancer, including esophageal cancer.⁴ Enteral nutrition has also been shown to result in positive outcomes in patients with esophageal cancer after esophagectomy, including improved nutritional status, improved immune function, faster recovery, and decreased costs.^5,6 Xiao-Bo and colleagues examined the effect of enteral versus parenteral nutrition in patients with esophageal cancer undergoing esophagectomy. The authors reported that patients receiving enteral nutrition had significantly higher albumin and prealbumin levels than did those receiving parenteral nutrition.⁵ In addition, nitrogen balance was better, there were no severe complications associated with the enteral nutrition, and the cost of nutritional support was significantly less in the enteral nutrition group.⁵ Furthermore, Zhao and colleagues showed that early enteral nutrition (initiated soon after surgery) can promote recovery of gastrointestinal function and improve nutritional and immune function, therefore leading to faster postoperative recovery in patients with esophageal cancer.⁶

Odelli and colleagues developed a targeted nutrition pathway involving early and periodic nutrition assessment of all patients presenting to a multidisciplinary esophageal clinic for chemoradiation treatment.¹ The nutrition pathway promoted a proactive approach to nutrition intervention, ensuring that early and aggressive nutrition assessment and intervention was undertaken for all patients. It also provided guidelines for the initiation and maintenance of nutrition support throughout the treatment course. The outcomes studied included weight status, percentage of planned treatment delivered, number of unplanned hospital admissions, and hospital LOS during treatment. Each patient’s nutrition risk was assessed and defined as low, moderate, or severe.

Appropriate nutrition interventions were provided based on nutrition risk level. Interventions included:

• Preventive advice for low-risk patients
• Oral nutritional supplements for moderate-risk patients
• Enteral feeding for severe-risk patients

The study compared outcomes between 2 groups of patients—the control group (n = 24), who received nutrition support in a reactive manner (referred to the dietitian only as problems arose, which resulted in delayed initiation of nutrition support); and the treatment group (n = 24), who received nutrition support proactively at the initial clinic visit (automatically interviewed by a dietitian) and began the nutrition pathway based on their risk level. The study demonstrated that approximately 80% of the patients were at moderate to severe nutritional risk.¹ Patients receiving the nutrition pathway in the treatment group had significantly better outcomes than those in the control group.¹ Patients who received the nutrition pathway experienced less weight loss, fewer chemotherapy dose reductions, higher rates of radiation completion, fewer unplanned hospital admissions, and shorter hospital LOS with admissions (Table).¹

Table

This study showed that early nutrition assessment and intervention delivered according to a nutrition pathway had a significant positive effect on the nutritional status and treatment tolerance during chemoradiation in patients with esophageal cancer. Implementation of this nutrition pathway was associated with improved clinical outcomes, including decreased weight loss, number of unplanned hospital admissions, and a higher tolerance of planned treatment.¹ In the environment of a multidisciplinary clinic, the nutrition pathway and proactive nutrition support were easy to adopt and were readily accepted by the patients, as all members of the healthcare team repeatedly reinforced the role of nutrition during the treatment course. ^l

References
1. Odelli C, Burgess D, Bateman L, et al. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol (R Coll Radiol). 2005;17(8):639-645.
2. Hébuterne X, Lemarié E, Michallet M, et al. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parenter Enteral Nutr. 2014;38(2):196-204.
3. Marin Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007;26(3):289-301.
4. Poulsen GM, Pedersen LL, Osterlind K, et al. Randomized trial of the effects of individual nutritional counseling in cancer patients [published online ahead of print November 8, 2013]. Clin Nutr. doi: 10.1016/j.clnu.2013.10.019.
5. Xiao-Bo Y, Qiang L, Xiong Q, et al. Efficacy of early postoperative enteral nutrition in supporting patients after esophagectomy. Minerva Chir. 2014;69(1):37-46.
6. Zhao G, Cao S, Zhang K, et al. Effect of early enteral nutrition on immune response and clinical outcomes after esophageal cancer surgery. Zhonghua Wei Chang Wai Ke Za Zhi. 2014;17(4):356-360.