Adelaide, Australia—The prevalence of malnutrition in patients with lung cancer is particularly high, but early and intensive individualized dietary counseling can improve quality of life for these patients and decrease their chances of experiencing significant weight loss, said Nicole Kiss, PhD, Joint Head of Nutrition and Speech Pathology at Peter MacCallum Cancer Centre, Melbourne, Australia, at the 2016 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology annual meeting.
According to Dr Kiss, the patients most likely to experience clinically significant weight loss are patients with stage III or higher non–small-cell lung cancer (NSCLC), and those undergoing treatment with concurrent chemotherapy.
“Depending on disease stage, treatment modality, and assessment technique, malnutrition prevalence ranges from 45% to 73% in patients with lung cancer. These patients require prioritization for nutrition services along with other high-risk tumor groups,” she said.
Lung Cancer and Malnutrition
Malnutrition in patients with lung cancer can arise as a result of cancer- or treatment-related factors. The most common toxicities associated with horacic radiotherapy are anorexia, fatigue, and acute esophagitis that often affects food intake, and as many as 50% of patients treated with concurrent chemotherapy have the latter, said Dr Kiss.
She and her colleagues completed a series of retrospective and prospective studies to identify patient and clinical factors associated with clinically significant (≥5%) weight loss in the 90 days after starting thoracic radiotherapy for lung cancer.
The retrospective studies were completed in 2 cohorts with different clinical and treatment factors. The first cohort comprised patients with NSCLC or with small-cell lung cancer who received high-dose palliative or curative-intent thoracic radiotherapy with or without chemotherapy (N = 96); of these, 31% (n = 30) of patients presented with clinically significant weight loss.
“The odds of an NSCLC patient with late-stage disease (stage III or IV) having ≥5% weight loss were 15 times greater than those with early-stage disease (I or II; P = .009), and clinically significant weight loss was 40% greater in patients with concurrent chemotherapy compared with radiotherapy alone (P <.001),” Dr Kiss reported.
The second cohort comprised patients with NSCLC who received high-dose palliative or curative-intent chemoradiation (N = 50); the investigators analyzed a range of doses (20-60 Gy) to the whole or partial esophageal circumference.
A total of 22% (n = 11) of patients in this cohort experienced clinically significant weight loss, and the strongest association was with the increase in the length of esophagus in those receiving a dose of 60 Gy.
“This meant that the odds of a patient having clinically significant weight loss increased by 32% for every centimeter increase in the esophageal length receiving a dose of 60 Gy to the partial circumference,” she explained.
“A total of 82% of patients with ≥5% weight loss received 60 Gy to at least 5 cm of esophagus, suggesting that might be an important cutoff point,” Dr Kiss added.
3 Factors Associated with Weight Loss in Lung Cancer
Based on the results of the retrospective studies, the investigators identified 3 factors associated with weight loss: disease stage III or higher, treatment with concurrent chemotherapy, and absolute esophageal length receiving 60 Gy to the partial circumference (with a possible cutoff point of 5 cm).
“So the next step was a prospective study where we could study all 3 factors together in order to develop a model to predict at the start of thoracic radiotherapy which patients were more likely to experience clinically significant weight loss,” said Dr Kiss.
In the prospective study cohort, comprising NSCLC patients who received high-dose palliative or radical thoracic radiotherapy with or without chemotherapy (N = 51), 43% (n = 22) had ≥5% weight loss.
The researchers observed that in patients treated with high-dose palliative or curative-intent thoracic radiotherapy, advanced-stage disease (stage ≥III) was the best predictor of clinically significant weight loss, and in patients receiving curative-intent thoracic radiotherapy alone, disease stage ≥III combined with concurrent chemotherapy was most predictive of weight loss. She, therefore, recommends appropriate screening measures to identify those patients most at risk for nutritional problems.
Individualized Dietary Counseling
According to Dr Kiss, individualized dietary counseling (medical nutrition therapy) has been the most effective intervention in other malignancies, but no studies have investigated this approach in patients with lung cancer receiving thoracic radiotherapy. She and her co-investigators designed a pilot randomized controlled trial to assess whether early and intensive dietary counseling maintains or improves outcomes in patients with lung cancer receiving thoracic radiotherapy.
A total of 24 patients were randomized to the intervention arm, which employed a care pathway to guide intensive, individualized dietary counseling, or to usual care, wherein patients received a nutrition intervention every 2 weeks during treatment, and a review 4 weeks posttreatment. The majority of patients had NSCLC and were receiving treatment with concurrent chemotherapy, and the proportion of well-nourished and malnourished patients in the 2 arms was relatively equal at baseline.
At the end of thoracic radiotherapy, 45% of patients in the usual-care arm were malnourished and 33% experienced a decline in nutritional status, compared with 11% malnourishment in the intervention arm and 0% experiencing a decline in nutritional status at any time point, Dr Kiss reported.
An overall fluctuation in weight and fat-free mass was seen in patients in the usual-care arm, compared with a steady increase in patients who received the intervention.
“These ranged from small to large effect sizes, but the results seem to indicate that the more frequent dietary counseling in the intervention group promoted weight and fat-free mass gain and prevented the fluctuations seen in the usual-care arm,” she said.
The participants in the intervention arm also maintained physical and functional well-being and overall quality of life over the duration of thoracic radiotherapy, whereas a decline was observed in each of these outcomes in the usual-care arm. No difference in symptoms, treatment interruptions, or unplanned admissions was seen between the 2 groups.
“The results of the pilot randomized controlled trial are promising for a benefit of early, intensive individualized dietary counseling on nutritional, fatigue, and functional outcomes,” said Dr Kiss. The researchers hope to test these results in a larger phase 3 trial.