EONS 2012

Potential of supplements and nutrition during cancer treatment

Professor Federico Bozzetti – University of Milan, Italy


I understand that you have a really big bone of contention, for you, is that people disregard the importance of nutrition in cancer. Can you justify that statement?

First, I think that oncologists mainly focus on their target which is the cancer and how to kill the cancer. So they use chemotherapy, radiotherapy, they combine both; they use, of course surgery combined with other treatments but when they are losing the game and the patient has an aggressive disease which cannot be controlled for a long time and the patient is losing weight, they become not so interested in this field. One of the reasons is probably they do not have the know-how to manage these patients.

There isn’t a lot of data on it, is there?

There are many data, there are many data, many data, for instance data on the prevalence of weight loss and malnutrition in cancer patients, both in in-patients and also in out-patients.

Data on what you need to do to correct that?

I think the oncologists must be sensitised that the weight loss is a prognostic negative index for quality of life, for compliance with oncological therapy, for final outcome of this patient. We have a lot of people demonstrating that if you support enterally or parenterally a patient is more able to face aggressive chemotherapy. So it’s very important for them to be in a good condition when the oncological treatment is very aggressive.

Now the rules about nutrition may be different for a patient who has cancer as compared with a patient who is healthy and does not want to get cancer. So the epidemiological evidence about diet may not point to the same diet.

We are moving towards the best nutritional regimen for a patient with an advanced cancer because, besides the under-nutrition, there are a lot of problems of metabolic problems. So we are using nutrition in a pharmacological way to better control the alteration in metabolism, not only giving food, nutrients, calorie and protein but which kind of calorie, which kind of protein? And this is quite important in the advanced stage of disease, but in the vast majority of the patients they would need, if they are losing weight, just more calories, more protein, not a specialised diet, specialised food but just eat more because they quite often are anorexic, they have a feeling of early satiety. So it’s important to maintain a high calorie importing regimen.

Now you’ve been working on this with the European Society for Clinical Nutrition and Metabolism and there are guidelines, so can you tell me what some of those are?

I was the Chairman of all the projects of the guidelines in the hospitalised patients and especially I was involved in the guideline in non-surgical oncological patients. What we stressed is the need that patients at nutritional risk, that is patients so malnourished that their nutritional status can increase the risk of a complication when they receive any therapy, medical or radiotherapy or surgical, there should be an effort to identify these patients. There are a variety of methods to screen in a very simple, very quick way, the nutritional status of the patients.

Could you give me some examples of how you spot this poor nutritional statement and examples of what you can do about it, simple measures, and how much difference that makes?

There are many questionnaires made both in Europe and in the United States, many of them rely on simple questions like: have you lost weight in the last month or in the last six months? What about your appetite? What is your BMI? What is the oral intake of food compared to the period when you were in a healthy status? Then we can score these answers in some way and have, in fact, a number which quantifies the risk. At this point it is important to intervene with a nutritional approach, with a nutritional treatment.

And you were saying that nutritional intervention can be powerful, rather like a drug or rather like any other treatment. How much difference can it make?

Yes. I think that in the beginning, in an early phase the patient is a bit anorexic, is losing weight but there are not so many alterations in the weight, in metabolic patterns, what is important is to give to the patient, for instance, some supplements. There are supplements very rich with a high energy density and rich also in protein and they can be prescribed during the oncological examination. I think that the oncologist should prescribe such kind of easy nutritional support in a bundle, as when he prescribes chemotherapy he prescribes also pain killers or anti-emetic drugs, he should include in this bundle also supplements if he realises that the patient is losing weight.

So what do you want to happen to make that possible?

It’s a cultural problem, it’s a cultural problem. You know in the Nutritional Society we speak about nutritional problems which include, of course, also cancer and many other diseases of course. This is a separate entity from the oncology so I think that perhaps the oncology should be with the clinical guideline for nutrition or in their meeting they should include more room for discussing nutritional issues.

I think you’ve been addressing, for instance, some different areas because there’s the perioperative nutrition, that’s one thing, and then there’s the nutrition after that period and also at home as well. There are different phases, does that make a difference?

Yes, you’re perfectly right. We had the same problem with the surgeons. At the beginning we had to convince the surgeons that it’s better to operate on patients if the patient is not in a bad nutritional status. Now many surgeons are convinced, they’re quite convinced, of this. Many surgeons know that before an operation the patient should not be kept in a starving situation, they could eat at least until eight hours before general anaesthesia and possibly in the days preceding the operation, one week before, they could receive some immune enriched nutrients which have been demonstrated in randomised clinical trials which decrease the rate of complications in the postoperative state. Many surgeons now are convinced of this. We should also do the same with the oncologists.

So when patients are receiving chemotherapy, for example, they may need to have a carefully considered diet.

Not every patient receiving chemotherapy but if the patient, for instance for oesophageal cancer, he has obviously a stenosis in the oesophagus so their oral intake is diminished as compared to before. He’s receiving radiation or radiation combined with chemotherapy and this causes mucositis which impairs swallowing which causes trouble in eating, in swallowing. These patients, some of these patients have to interrupt the treatment because of this; if these patients can be nourished by vein or by nasal gastric tube or by percutaneous gastrostomy this is a way to prolong the therapy and avoiding the negative effect of chemotherapy.

So what would you sum up this in a few words? How would you advise people to consider this overall question, very briefly?

I think that, for instance, the most simple thing should be weigh the patients and report the weight of the patient in the chart and a small enquiry about their food intake, if it’s decreased or not. If there is a small problem they can intervene with this supplement or there are also some drugs which increase appetite. If the problem is higher, the patient is totally lethargic they should call a nutritionist, a dietician or a physician specialist who can perform a percutaneous gastrostomy or put a catheter in the vein. Many of these patients already have a catheter in the vein, if the patient has a catheter in the central vein, this patient can be nourished for many, many years through the vein. We have an experience with the home parenteral nutrition of a woman surviving many years and having been pregnant with a finally healthy child despite her nutrition was totally by vein. So these are very simple things that can be applied to the patients if they are starving.

And it’s necessary to take them all very seriously.

Yes. Yes it is.

Thank you very much.