Cancer in Ireland

Up to 70% of cancer patients unintentionally lose weight, and it is estimated that the deaths of 10-20% of patients with cancer can be attributed to malnutrition rather than to the malignancy itself. Despite this, studies have shown that only 30-60% of patients with cancer who are at risk of malnutrition receive nutritional support². This is due in part to the fact that many cancer patients do not look visibly malnourished, and many may even be categorised as overweight despite the presence of significant cachexia and sarcopenia³.

Unintentional weight loss in cancer patients can have a devastating impact on health outcomes. Malnutrition in cancer is associated with decreased performance status, reduced quality of life, increased morbidity and mortality, poorer response to cancer treatment and decreased survival⁴. Both a low body weight and amount of weight loss independently predict overall survival⁴.

The first step to managing malnutrition in cancer is early identification of risk which should be done by performing nutritional screening of each cancer patient early in his/her cancer treatment². Assessment should include identification of signs or symptoms of anorexia, cachexia and sarcopenia and this should be done as early as possible.

There is no one size fits all management for malnutrition in cancer.  The form of nutritional intervention depends on the patients’ medical history, appetite, type of cancer, stage of cancer, and his/her response to treatment.  

Nutritional counselling should address the presence and severity of symptoms such as anorexia, nausea, mucositis, dysphagia, and gastrointestinal symptoms². Oral nutritional support includes regular food and fortified foods as meals or snacks and/or oral nutritional supplements (ONS) to increase nutritional intake. The European Society of Clinical Nutrition and Metabolism (ESPEN) have concluded that ONS, used in combination with dietary advice, can prevent therapy-associated weight loss and interruption of therapy, as well as enhance quality of life⁴.

It is difficult to give exact guidance on which ONS is most suitable for cancer patients, as requirements will be determined by a range of factors including:

• Type of cancer (tumour site/stage/prognosis)
• Appetite/ability to tolerate large volumes (patients often experience early fullness and may only tolerate a "little and often" approach)
• Intake of normal food (are they eating quite well and only need an energy boost, or has their intake of normal foods declined significantly?)
• Taste preference (patients may experience taste changes associated with their treatment)
• Age of the patient

Nutritional intervention plans should be individualised to increase nutritional intake, and should ideally be combined with optimal medical and oncological strategies to minimise cancer cachexia^5,6.

A 50% reduction in complications and improved patient outcomes has been observed among cancer patients who used medical nutrition preoperatively⁷.

Cancer patients who are initiated on ONS have, on average, a shorter hospital stay post-operatively than those who are not prescribed ONS, resulting in reduced healthcare costs⁸.

1.  Cancer Fact Sheet. National Cancer Registry Ireland. [Internet].[cited 28 February 2019]. Available from: https://www.ncri.ie/sites/ncri/files/factsheets/Factsheet%20all%20cancers.pdf
2.  Arends J et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr 2017; 36; 1187-1196.
3.  Prado CM et al. Sarcopenia and cachexia in the era of obesity: clinical and nutritional impact. Proc Nutr Soc 2016; 75(2): 188-198
4.  Arends J et al. ESPEN Guidelines on nutrition in cancer patients. Clin Nutr 2016; 36(1):11-48.
5.  Elia M et al. Enteral (oral or tube administration) nutritional support and eicosapentaenoic acid in patients with cancer: a systematic review. Int J Oncol 2006; 28: 5–23.
6.  Fearon KCH et al. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut 2003; 52: 1479-86.
7.  Kabata et al. Preoperative nutritional support in cancer patients with no clinical signs of malnutrition – prospective randomised control trial. Support Cancer Care 2015; 23(2): 365-70.
8.  Manasek et al. Perioperative oral nutritional support in colorectal cancer patients may improve clinical and health economics outcomes. Ann Oncol 2015; 26(suppl 4): 1-100.