Nutrition in cancer should be higher up the policy agenda

By Marc Abraham and Dr Was Mansoor, The Christie Hospital, Manchester, UK.

Oesophagogastric (OG) cancers are aggressive and sadly, outcomes remain poor with many patients not being considered fit for second line treatment. Improving survival is a key priority and there is a much-needed focus to develop new therapies to achieve this goal. However, preserving quality of life is fundamental in a disease that can have severe physical and nutritional consequences for patients. Nutrition is part of the discussion when it comes to cancer prevention, but it is rarely given the right value when it comes to treatment outcomes. Education on its benefits needs to form a more central part of health policy and guidelines to improve patient outcomes in cancer, driving change across the health system overall.

Far less attention is given to advanced and metastatic OG cancer patients. Strip back the consultation in clinic and behind the patient’s persona it is commonplace to hear the words of patients and their carers; ‘muscle wasting’, ‘no interest in food’ and ‘he’s not half the man he was’. This is a disease that epitomises the devastating effects of malnutrition. Nutritional screening and assessment are often overlooked by clinicians, perhaps due to inconsistent assessment methodology and reporting, poor understanding and low clinical priority.

Consequently in the real world, nutritional management is usually based on a reactive approach, often following catastrophic weight loss that may be refractory. As a result, most nutrition interventions are too late to have a clinical impact. In order to change this, we need an enabling policy environment and a multi-stakeholder approach. 

There is a growing interest in how quality of life may influence survival in advanced and metastatic OG cancers. At the recent ESMO 2018 symposium “Maximising Patient Outcomes through Evidence-Based Decision-Making in Advanced Gastric and GEJ Cancer” it was highlighted that early identification of sarcopenia (low muscle mass) and anorexia (reduced appetite) before starting chemotherapy; and weight loss during chemotherapy were all predictors of survival. Body mass index has been shown to be a less useful as a tool for predicting clinical outcome in patients receiving palliative chemotherapy.

Although anorexia in cancer patients is widely reported in the literature, identifying patients at risk remains a challenge due to the subjective nature of a patient describing anorexia in consultation. More research is required to understand the relationship between anorexia, weight loss and muscle wasting.

Metastatic OG cancer is incurable but treatable and emphasis has to be on optimising the patient’s quality of life. Baseline nutritional screening with ongoing surveillance is fundamental to identify potentially reversible factors that may affect the patient’s ability to receive chemotherapy and ultimately, survival. One avenue to tackle is to review how we nutritionally assess our patients using methodology that links with survival rather than the standard surrogates of weight and body mass index.

In this way, we can consider a more proactive approach as ‘patient preservation’ at the start of the chemotherapy journey if we are more likely to improve clinical outcomes. No one clinician can achieve this goal and bringing together oncologists, dietitians, nurses, patients and their families/guardians to tackle what is one of our biggest challenges with OG cancer patients, can only be a positive thing.

 

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