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Nutrition assessment & support in esophageal cancer

Nutrition assessment & support in esophageal cancer. 實習生：林廷駿 指導老師：陳燕慈營養師 報告日期： 2012/12/25. Introduction. Stahl et al., 2005 Schneider et al., 2007 Bedenne et al., 2007. Treatment & Esophageal cancer. radiotherapy. chemotherapy. Only 30% to 40% of patients. surgery.

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Nutrition assessment & support in esophageal cancer

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  1. Nutrition assessment & support in esophageal cancer 實習生：林廷駿 指導老師：陳燕慈營養師 報告日期：2012/12/25

  2. Introduction

  3. Stahl et al., 2005 Schneider et al., 2007 Bedenne et al., 2007 Treatment & Esophageal cancer radiotherapy chemotherapy Only 30% to 40% of patients surgery

  4. Malnutrition & Esophageal cancer Immune functions Survival Performance status Malnutrition (60~85%) Response to chemotherapy Muscle function Quality of life Van Cutsem et al., 2005 Mariette et al., 2012

  5. Malnutrition enhances the chance of postoperative complications in patients with esophageal cancer. Kelsen et al., 1998 Senesse et al., 2008 Garth et al., 2010 Mariette et al., 2012 • Postoperative complications delay postoperative recovery and impair quality of life. Viklund et al., 2005 • Nutritional support can improve postoperative outcome in patients with gastrointestinal cancer. Postoperative complications

  6. The preoperative physiological status of the patient is known to influence postoperative mobidity and mortality. Lund et al., 1990 Law et al., 1994 • Pretreatment nutritional support to maintain body weight throughout treatment could possibly decrease postoperative complications. Preoperative nutritional condition

  7. Nutritional Status as a Risk Factor in Esophageal Surgery I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran, H.W. Tilanus Dig Surg 2006; 23: 159-163

  8. Purpose Nutritional risk index(NRI) Weight loss Prognostic nutritional index(PNI) Preoperative nutritional condition Body mass index(BMI) Postoperative morbidity

  9. In total, 400 patients with an esophageal malignancy undergoing esophageal resection and gastric tube reconstruction between 1996 and 2003. Patients

  10. Methods PNI NRI • Borderline mild: > 97.5 • Moderate: 83.5-97.5 • Severe: < 83.5 Weight loss None, < 5%, 5-10%, > 10% BMI < 18.5, 18.5-24.9, 25-29.9, > 30

  11. Data were obtained on postoperative infectious complications, length of hospital stay and postoperative mortality. • Data analysis: • Chi-square test • Mann-Whitney’s test • Logistic regression Methods

  12. Results

  13. Results P value for trend = 0.01

  14. Results

  15. Results

  16. Results

  17. The ROC curve shows that PNI and NRI do not make sensitive tests for predicting infectious complications. • No correlation was found between the degree of preoperative weight loss and BMI and the incidence of postoperative infectious complication rate. Discussion

  18. Takagi et al. evaluated the relationship between preoperative immunosuppression and morbidity and demonstrated a higher BMI in patients with postoperative complications. • They concluded that not the nutritional state but depression of cell-mediated immunity was related to the complication rate in patients who received preoperative nutritional support. Discussion

  19. Preoperative nutritional status established by PNI, NRI, BMI and weight loss has no predictive value on postoperative infectious complications in patients with an esophageal malignancy. Conculsion

  20. Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani, C. Schumacher, P. Dufour, J.-E. Kurtz, G. Noel Dis Esophagus 2012 Oct 26 doi: 10.1111/j.1442-2050.2012.01441.x

  21. Purpose

  22. Study population: between 2003 and 2006 Materials and Methods 143 esophageal cancer patients Treated by definitive Concurrent radiochemotherapy • Surgery • Raditherapy without chemotherapy • Distant metastasis Excluded

  23. Pretreatment evaluation: • Medical history • Clinical examination • Routine blood tests • Cancer staging system: 2002 Union for International Cancer Control (UICC) TNM classification Materials and Methods

  24. Nutritional factors: • Weight loss • BMI • Serum albumin level • Nutritional Risk Index (NRI) • Treatment: • Three-dimensional conformal radiotherapy • Concurrent cisplatin and 5-fluorouracil (5-FU) chemotherapy Materials and Methods

  25. Follow-up: Every 3 months for the first year, every 6 months for the second year, and yearly thereafter. • Statistical analysis: • Kaplan-Meier method and Log-rank test • Cox regression • Hazards ratios (HR), and within 95% confidence interval (CI) • Log-minus-log plots and Schoenfeld residuals • IBM SPSS Statistics v20 (IBM Inc., Armonk, NY, USA) Materials and Methods

  26. Results

  27. Results

  28. Results P=0.0098

  29. In the study, NRI is described as an independent prognostic factor for both DFS and OS, which emphasizes the major impact of nutrition on the outcome of esophageal cancer patients. • Several previous studies have shown that weight loss, serum albumin level, BMI, performance status (PS) were able to be identified as independent prognostic factors. Discussion

  30. This study found a major impact of baseline nutritional status on the outcome of esophageal cancer patients treated by definitive radiochemotherapy. • NRI was an independent prognostic factor of both DFS and OS. Conclusion

  31. Dietician-delivered intensive nutritional support is associated with adecrease in severe postoperative complications after surgery in patientswith esophageal cancer G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S. Buskermolen, C. P. Earthman, H. M. W. Verheul, E. S. M. de Lange- de Klerk, S. J. B. van Weyenberg, D. L. van der Peet Dis Esophagus 2012 Dec 13 doi: 10.1111/dote.12008

  32. To evaluate the effect of an intensive nutritional support (INS) program under the guidance of a dietician on postoperative outcome in patients with esophageal cancer. Purpose

  33. Patients 37 patients who underwent an esophagectomy between January 2006 and February 2009 were included in the control group. 65 patients with esophageal cancer 28 patients who underwent an esophagectomy between March 2009 and April 2010 were included in the INS intervention group.

  34. INS group Nutritional treatment

  35. Nutritional treatment

  36. Results

  37. Preoperative weight change Results P=0.048 unadjusted Adjusted: non-significant With NAT P=0.002 unadjusted P=0.009 adjusted

  38. Results The adjusted odds ratioafter surgerywas 0.23 (95%CI: 0.05–0.97; P=0.045) The adjusted odds ratioundergoing NATwas 0.14 (95% CI: 0.23–0.89; P=0.037)

  39. Results Patients undergoing NAT ICU/MCU stay: P=0.049 Hospital stay: P=0.04

  40. Dietary intervention is especially beneficial in patients who received NAT. • The longer time between diagnosis and surgery may have been to the advantage of the INS group. • The prevention of preoperative weight loss mayalso be an explanation for the observed effect of INSon postoperative complications in patients receivingNAT. Discussion

  41. In the present study, patients in the INS group were intensively guided by a dietitian without the use of immune system modulating nutrients. • This result suggests that a lot is to gain with plain improvement of energy and protein intake. Discussion

  42. This study shows that INS by a dietician is associated with preoperative weight preservation and less severe short-term postoperative complications in patients with esophageal cancer. Conclusion

  43. Nutritional status such as NRI, weight loss, serum albumin, and performance status can be independent prognostic factors in patients with esophageal cancer and lead to an early specific nutritional support. Summary

  44. Patients with esophageal cancer should have dietary counseling once every two week, whether in preoperative stage or in postoperative stage. As well as the most important thing is that patients with NAT is a high risk group that is most likely to suffer from malnutrition, however, treating them with INS can evidently improve their nutritional condition, then it finally affect prognosis positively and rise survival rate. Summary

  45. I.J.M. Han-Geurts, W.C. Hop, T.C.K. Tran, H.W. Tilanus.Nutritional Status as a Risk Factor in Esophageal Surgery. Dig Surg 2006; 23: 159-163 • J.-B. Clavier, D. Antoni, D. Atlani, M. Ben Abdelghani, C. Schumacher, P. Dufour, J.-E. Kurtz, G. Noel. Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer. Dis Esophagus 2012 Oct 26 doi: 10.1111/j.1442-2050.2012.01441.x • G. C. Ligthart-Melis, P. J. M. Weijs, N. D. te Boveldt, S. Buskermolen, C. P. Earthman, H. M. W. Verheul, E. S. M. de Lange- de Klerk, S. J. B. van Weyenberg, D. L. van der Peet. Dietician-delivered intensive nutritional support is associated with a decrease in severe postoperative complications after surgery in patients with esophageal cancer. Dis Esophagus 2012 Dec 13 doi: 10.1111/dote.12008 Reference

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