Faculty of Science and Technology, University of Westminster, 115 New Cavendish Street, London W1W 6UW, United KingdomUnited Kingdom
Assistant Professor, Department of Onco-Anesthesiology and Palliative Medicine, Dr BRAI- RCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, IndiaIndia
Also available as PDF (figures and tables appear in the PDF).
Palliative care is of paramount importance for patients suffering from life threaten-ing incurable diseases such as AIDS, cancer, end stage renal disease and end stage chronic illnesses.1 In the Indian healthcare system, palliative care is a developing area and is not well represented in the health.
th Palliative care is of paramount importance for patients suffering from life threaten- Received: February 9 , 2016 st ing incurable diseases such as AIDS, cancer, end stage renal disease and end stage chronic Accepted: March 21 , 2016 1 st illnesses. In the Indian healthcare system, palliative care is a developing area and is not well Published: March 21 , 2016 represented in the health sector. Medical advancements, cancer survivors are leading a longer
and better quality of life but still there is a gap between availability of palliative care centers
Citation and assistance from healthcare professionals.2
Kapoor N, Garg R, Tewfik I. Pal-
liative nutritional care for can-
cer patients. Palliat Med Hosp
Care Open J. 2016; 2(1): e1-e6.
doi: 10.17140/PMHCOJ-2-e002 International Agency for Research on Cancer (GLOBOCAN project, 2012) reported
approximately 14.1 million new cancer cases and 8.2 million cancer deaths worldwide. Out
of these there were 1015,000 cancer cases and 683,000 cancer deaths in India.3 It has been
predicted that the number of cancer deaths in India will rise from 683,000 in 2012 to 1.2 million
by 2035.3 The World Health Organization (WHO) estimates 1 million new cancer patients
yearly in India with approximately 750,000 of them requiring palliative care.1
In cancer, with disease progression, a patients’ nutritional status is progressively im-
pacted. The multiple metabolic changes and nutritional depletion may affect body composition,
functional capability, psychological state and response to cancer treatment.4 Gastrointestinal
and head and neck cancers are widely associated with cachexia. However the same tumor site
may exhibit cachexia of varying grade or be absent in different patients. Approximately 50% of
cancer patients progress to cachexia.5
Cancer cachexia was defined as “a multifactorial syndrome defined by an ongoing loss
of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by con-
ventional nutritional support and leads to progressive functional impairment. Its pathophysiol-
ogy is characterized by a negative protein and energy balance driven by a variable combination
of reduced food intake and abnormal metabolism”.6 There are three stages of cancer cachexia:
pre-cachexia, cachexia and refractory cachexia. In the precachexia stage patients experience
less than 5% pre-treatment weight loss whilst once they progress to refractory cachexia stage
mortality is foreseen in approximately three months.
©2016 Garg R. This is an open ac-
cess article distributed under the During cancer, patients nutritional status is hindered due to tumor induced altera- Creative Commons Attribution 4.0 7
International License (CC BY 4.0), tions in metabolism. Patients also suffer from tumor related problems and chemo-radiotherapy
which permits unrestricted use, induced dysphagia, mucositis, xerostomia, nausea, vomiting, sometimes chewing and swal-
distribution, and reproduction in 8 lowing difficulties. The capacity to endure chemo-radiotherapy treatment and fight the disease any medium, provided the original 9 is adversely affected by cachexia. Alongside the minimum 10% increased in basal metabolic work is properly cited. 10 11
rate, anorexia is one of the key factors among cachexia patients leading to weight loss. Body
weight loss during cachexia is due to skeletal muscle as well as adipose tissue wasting.12 The wasting of skeletal muscle leads to
deranged immune system and mobility issues.13 As weight loss progress to 30% of pre treatment body weight, death becomes inevi-
table.14
Malnutrition is described as a clinical condition of imbalance of energy, protein, and other nutrients. This leads to signifi-
cant negative impact on body composition, function, and clinical treatment. Malnutrition has been documented globally among
17-19 30-80% of cancer patients. The consequences of malnutrition may include an increased risk of morbidity, decreased response
and tolerance to treatment, a decline in quality of life, higher health-care costs and reduced survival. Reported dietary intake of
advanced cancer patients suggests that their total calorie intake is 1610+686 kcal/d which is 4-53 kcal/kg body weight/d.23 Kumar et
al also documented a calorie deficit of approximately 250-400 kcal/d among weight losing cancer patients.18 Anemia is commonly
reported in advanced cancer patients, leading to altered energy homeostasis and reduction in physical activity.24 Advanced cancer
patients have deficiency of essential micronutrients like zinc, selenium, vitamin C and vitamin E, which support body’s immune
25-28 response.
Nutritional screening and body weight measurements assists in nutritional status evaluation of cancer patient’s non-inva-
sively.29 It helps to identify malnourished patients or those who are at risk of developing malnutrition. Patients’ nutritional status
can be monitored and a nutritional care plan can be developed. Body composition machine can be used to assess the body weight,
body fat percentage and muscle mass of ambulatory patients.30 A range of subjective and objective measures have been used for
nutritional screening like 24-hour dietary recall, food frequency questionnaire (FFQ), Patient Generated-Subjective Global Assess-
ment (PG-SGA). FFQ and 24 hour dietary recall help to record patients’ frequency of individual foods consumption and information
31 32 on eating patterns.31 PG-SGA questionnaire aids to determine the deterioration or improvement in their nutritional status.32 It has
been recommended as the nutrition assessment tool for patients with cancer by Oncology Nutrition Dietetic practice group of the
American Dietetic Association.32
Cancer and treatment-induced changes in metabolism can lead to alterations in physiological and psychological functions.
This may lead to low quality of life and consequently adversely influence patients’ nutritional status.33 Various tools for quality of
life assessment have been developed; European Organization for Research and Treatment of Cancer quality-of-life core question-
naires (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-General (FACT-G), Functional Living Index cancer
questionnaire (FLIC), Spitzer Quality of Life Index (QLI), Rotterdam Symptom Check List (RSCL), the Medical Outcome Study
36-item short form (MOS SF-36), EuroQol (EQ-5D), the Cancer Rehabilitation Evaluation System (CARES) and the Symptom Dis-
tress Scale.34 The European Organization for Research and Treatment of Cancer-Quality of Life (EORTC QLQC30) questionnaire is
a validated self assessment instrument used for assessing quality of life in patients with cancer and most widely used tool. Studies
involving malnourished cancer patients suggest a strong association between body weight loss and fatigue with poor quality of life,
36,37 functional impairment and early mortality.
Development of cachexia may lead to decline in daily motor activities and increased fatigue. Endurance activity has been
noted to decrease self reported cancer related fatigue.38 Clinical Practice Guidelines on Cancer Cachexia in Advanced Cancer Pa-
tients by European Palliative Care Research Collaborative 2010 strongly recommends physical activity in the management of cancer
39 40 related cachexia.39 It may help to enhance the immune function and reduce inflammatory responses.40 Physical activity questionnaire
like Global Physical Activity Questionnaire (GPAQ) and Karnofsky Performance Score (KPS) are reliable tools to assess patients
41,42 physical functioning. A study on 188 advanced palliative cancer patients who were enrolled under a 12-week physical activity
program (mainly walking) observed strong improvement in fatigue levels and maintenance of body weight.43 Another study, observ-
ing daily physical activity of advanced cancer patients showed significant correlation between activity levels and different domains
of quality of life.44
Oral Nutritional Supplements (ONS) containing protein, fat, carbohydrates, vitamins and minerals can provide a convenient 15,16
20-22 34,35
28.7-34 kcal/kg ideal body weight/day and protein intake of 1.4 g/kg ideal body weight/day in cancer cachexia patients can help in
45,46 weight maintenance. Patients experiencing weight-loss due to cancer cachexia can have better quality of life if their weight is
stabilized compared to weight losing patients.47
For management of cachexia patients, a multimodal therapy approach has been proposed.39 A multimodal therapy involves
nutritional support, anti-inflammatory and anemia therapy, encouraging physical activity, oral nutritional supplement intake and
multidisciplinary teamwork approach in order to improve nutritional status of the patient.48 According to a recent systematic review,
malnourished cancer patients, receiving nutritional counseling along with or without ONS resulted in nutritional status improve-
49 50 ments.49 Body weight increase in cancer patients consuming ONS leads to maintenance of lean body mass and better quality of life50.
Better nutritional status among head and neck as well as gastrointestinal tract cancer patients consuming ONS compared to patients
receiving standard care has been reported earlier.51 A recent nutritional intervention study among low socio-economic malnourished
head & neck patients, reported increased percentage body weight and improved biochemical indices compared to control patients
on daily diets.8 The patients were given a diet chart consisting of locally available and acceptable low cost nutritional food items,
which could be easily adhered with.8 Another ongoing intervention study is testing the acceptability and impact of a natural nutri-
tional flour mix (IAtta) on improving nutritional status of cachexic female cancer patients.52 Educating caregivers about employing
affordable nutritious local foods among malnourished cancer patients could help in correcting their nutritional status with minimal
training. This is irrespective of their financial status as well as their area of residence.52 Baldwin et al, in the past concluded that nu-
tritional intervention among advanced malnourished patients was significantly correlated with better quality of life.53 Furthermore,
nutritional supplements containing protein, fat, carbohydrates, vitamins and minerals can provide a convenient and practical way of
compensating their inadequate daily diets. Dieticians should be actively involved in providing patients’ individualized nutritional
counseling keeping their preferences, ethnicity and cultural restrictions in mind.54 During nutritional counseling sessions, attention
should be paid to the kind of treatment patient is undergoing as chemo-radiotherapy side effects impact food intake. Enteral, parent-
ral, total parentral nutrition feeding techniques should be considered in patients who are unable to take oral foods.54 Oncologists and
clinical nutrition experts need to work in collaboration to optimally manage malnutrition among cancer patients.
Therefore, palliative cancer patients’ nutritional status should be regularly monitored and supplementation should be
recommended to compensate deficit calorie intake. We can then manage body weight loss and predict improved treatment outcome
leading to a better quality of life. Patients in palliative care should be counseled for nutritional intake according to their individual
needs and food preferences.
The authors declare that they have no conflicts of interest.