When we treat Cancer-Associated Malnutrition (CAM), it is important to not only look at solving the physical symptoms of malnutrition in cancer patients but also to address the patient’s quality of life in their emotions and thoughts. Here is a quick summary of what CAM is, and what the causes are.
Palliative and Curative Care: What are the differences and why do they matter when treating CAM?
Treating cancer-associated malnutrition, and treating cancer in general, can often be categorized into palliative and curative care. The difference between the two lies in the overall purpose of the strategy. The goal of palliative care is to relieve as much pain and discomfort as possible, often when the patient is fully cured is no longer an option. In contrast, curative care works to solve the direct problem of the disease while not necessarily focusing on the patient’s pain levels.
CAM treatment fits into both of these strategies. In palliative care, it is important for CAM treatment to combat mental hardships the patient may be going through; this includes food aversions and taste changes, as well as weakness from an increased resting energy expenditure. In curative care, CAM treatment improves the effectiveness of other anti-cancer treatments by building up body strength through nutrition. Whether the treatment is focused on the surface of the problem or the underlying core of the disease, it is important to include treatment of CAM in all stages of the illness. CAM treatment not only works towards improving QoL but betters the patient’s nutritional status to cope with other anti-cancer treatments.
Different Treatments for CAM
Dietary counseling
Dietary counseling is an effective treatment for cancer-associated malnutrition because it focuses on knowledge as the solution. The effectiveness of this strategy depends on the ability of the nutritional counselor to gear their efforts towards each patient; if a nutritional counselor can dedicate time and individualized planning to give each patient a unique and specific treatment protocol, the person will have the best outlook (Caro). By going to a dietary counselor, patients can understand what exactly is happening to their bodies and why the way they think about food is changing. Side effects of anti-cancer treatments normally include a lower food intake, not only in amount but also in the quality of food the patient consumes (Laviano). Having a nutritional counselor reassures the patient they are not alone and gives them an answer to why the way they think about food is changing. If a patient understands the disease they have, treatments and specific diets prescribed to them make more sense and will encourage the patient to follow the treatment strategy, ultimately improving their quality of life.
Studies have also looked at and shown the benefits of dietary counseling. In a study that worked to improve the quality of life of cancer patients, nutritional counseling was the only method examined that significantly improved patients’ clinical status during a three month time period post-radiation treatment (Laviano). In addition, a study was done by Ravasco et al. in 2005 on 75 head and neck cancer patients compared the effectiveness of dietary counseling and oral supplementation. They concluded that not only does the quality of life of cancer patients improve proportionally with improved quality of food intake, but that nutritional counseling had a significant impact on the outcomes of the patients (Caro). This is not to say that oral supplementation, enteral nutrition, or total parenteral nutrition are not good treatment options, but rather stresses the importance of understanding the food that patients eat and why they’re making certain choices about what they eat.
Oral Supplementation
Oral supplements can be an effective form of treatment because they provide the exact nutrient that the patient needs. In addition, these supplements focus on improving the immune system and metabolism. They often contain immunomodulating nutrients, such as polyunsaturated fatty acids, arginine, and nucleotides. Including these compounds in the supplements has shown to improve the immune system, gastrointestinal system, and reduce inflammatory response (Caro).
Another integral benefit of oral supplements is their effect on weight gain. A study done on pancreatic cancer patients with cachexia, which is characterized by lean muscle loss and muscle weakness, showed that diets with enriched in N-3 fatty acids were able to stop weight loss and in some cases also caused weight gain, although more studies on the specifics of the benefits of the fatty acids are needed (Caro). N-3 fatty acids are effective in stopping weight loss because they are able to inhibit pathways associated with tumor growth (Laviano). Weight gain or continuity is crucial for patients as it allows them to maintain a decent quality of life in their food intake and exercise, and the fact that supplements build up lean muscle mass allows for greater patient functioning. In addition, patients taking nutritional supplements that originally had a BMI of 20 kg/m2 or less had more beneficial effects in terms of functioning and weight gain (Laviano). Overall, supplements should be used as a secondary form of treatment to nutritional counseling, but directly help to improve the quality of life of the patient through weight gain and daily functioning.
Enteral Nutrition (EN) and Total Parenteral Nutrition (TPN)
In cases where the disease has advanced to a stage where patients can no longer take in nutrients orally, enteral nutrition or total parental nutrition methods are used. The main difference between the two is that enteral nutrition uses feeding tubes into the gastrointestinal tract to transport nutrients, while total parenteral nutrition uses an intravenous infusion to bring nutrients directly to the bloodstream, usually through a central line that accesses a vein to go straight to the heart. Because using TPN is a vulnerable and high-risk situation for the patient, EN is the standard strategy of care for non-oral nutrient provision.
In enteral nutrition, using the parts of the body already related to digestion and food intake keeps the process more natural. In patients undergoing surgery, using TPN had less gastrointestinal symptoms postoperatively. However, patients using EN had significantly shorter hospital stays and fewer complications after their surgeries (Laviano). Total parenteral nutrition should only be reserved for very high-risk cases and special circumstances where it is the only option for feeding the patient. An example of this is when the patient has solid tumors or cancer that began in blood-forming tissue, such as bone marrow, and needs a bone marrow transplant (Laviano). Other cases include when the gastrointestinal tract is completely blocked and food cannot be processed through the digestive system and must be put directly in the bloodstream.
A combination of oral supplements (arginine, n-3 fatty acids, and nucleotides) and EN or TPN also proved to be much more beneficial to the patient than standard nutrition given by EN or TPN. In a study done in 2006 by Shang et al. on patients with varied cancers, TPN combined with supplements had potential to reduce weight loss, gain lean muscle mass, and improve appetite (Caro & Laviano). In addition, gastric or pancreatic patients with surgeries that had parts of their gastrointestinal tract resected, this combination of supplements and EN reduced the infection rate by 50% and lowered dangerous consequences of infections that did occur (Laviano). Overall, enteral nutrition carries less risk of complication and improves quality of life for the patient more than total parent nutrition, but the vulnerable nature of both treatments can be improved significantly when combined with other malnutrition treatments like enriched oral supplements.
The Effectiveness of Treatment for Malnutrition in Cancer Patients
For any CAM treatment to be the most effective, it is necessary to integrate it as part of the holistic curative and palliative strategy for the patient as soon as possible. It is important to recognize that these treatments aim to improve the patient physically and mentally, which is directly connected to increase their quality of life. Increased weight gain and lean muscle mass not only improves metabolism and provides a more effective foundation for anti-cancer treatments to be successful, but also makes the patient feel better. Increased physical function to carry out day to day tasks and a healthier looking body can improve the patient’s mental health, increasing chances for a full recovery.
As a study done by Ravasco et al. in 2005 showed, the group of patients that received dietary counseling improved their nutritional status better than the group with oral supplementation, while both groups did better than groups with no nutritional aid (Caro). This study suggests that giving patients agency, when feasible, over their own eating sets them up for better physical results than resorting to more pills or medicine. It is important to consider that patients will want to resort back to a sense of normality as much as possible when their quality of life is much lower than their lives before cancer. Dietary counseling gives them the knowledge to create their own routines and own food preferences. Food is so integral to daily life; any sense of normalcy surrounding it will be an improvement for the patient’s general wellbeing. Ultimately, every patient’s needs are different; each treatment plan should be geared specifically to their background and current needs in order to improve their quality of life as much as possible.