ESPEN expert group recommendations for action …

1 ReviewESPEN expert group recommendations for action against cancer-related malnutritionJ. Arendsa,b,*, V. Baracosc, H. Bertza,b, F. Bozzettid, Caldere, Deutzf,N. Ericksong, A. Lavianoh, Lisantii, Loboj, McMillank, M. Muscaritolih,J. Ockengal, M. Pirlichm, F. Strassern, M. de van der Schuereno,p, A. Van Gossumq,P. Vaupelr, A. WeimannsaDepartment of Medicine I, Medical CentereUniversity of Freiburg, Freiburg, GermanybFaculty of Medicine, University of Freiburg, Freiburg, GermanycDepartment of Oncology, University of Alberta, Edmonton, CanadadFaculty of Medicine, University of Milan, Milan, ItalyeFaculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS FoundationTrust and University of Southampton, Southampton, UKfCenter for Translational Research in Aging&Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, TX, USAgComprehensive Cancer Center, Ludwig-Maximilian-University Hospital, Munich.

2 GermanyhDepartment of Clinical Medicine, Sapienza University, Rome, ItalyiDepartment of Translational Medicine, University of Salford, Salford, UKjGastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre,Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UKkDepartment of Surgical Science, University of Glasgow, Glasgow, UKlDepartment of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, GermanymDepartment of Internal Medicine, Elisabeth Protestant Hospital, Berlin, GermanynDepartment Internal Medicine and Palliative Care Centre, Cantonal Hospital St Gallen, St Gallen, SwitzerlandoDepartment of Nutrition and Dietetics, VU University Medical Center, Amsterdam, The NetherlandspDepartment of Nutrition and Health, HAN University of Applied Sciences, Nijmegen.

3 The NetherlandsqGastroenterology Service, H^opital Erasme, University Hospitals of Brussels, Brussels, BelgiumrDepartment of Radiation Oncology and Radiotherapy, Klinikum rechts der Isar, Technical University, Munich, GermanysDepartment of General, Visceral, and Oncological Surgery, Hospital St Georg, Leipzig, Germanyarticle infoArticle history:Received 15 June 2017 Accepted 15 June 2017 Keywords:CancerMalnutritionSarcopeniaCac hexiaAnorexiaNutritional interventionsummaryPatients with cancer are at particularly high risk for malnutrition because both the disease and itstreatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlookedor under-treated by clinicians, patients, and their families.

4 The European Society for Clinical Nutritionand Metabolism ( ESPEN ) recently published evidence-based guidelines for nutritional care in patientswith cancer. In further support of these guidelines, an ESPEN oncology expert group met for aCancer andNutrition Workshopin Berlin on October 24 and 25, 2016. The group examined the causes and conse-quences of cancer-related malnutrition, reviewed treatment approaches currently available, and built therationale and impetus for clinicians involved with care of patients with cancer to take actions thatfacilitate nutrition support in practice. The content of this position paper is based on presentations anddiscussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care forpeople with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care,regardless of body mass index and weight history; (2) expand nutrition-related assessment practices toinclude measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure,and physical function; (3) use multimodal nutritional interventions with individualized plans, includingcare focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, andincreasing physical activity.

5 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.*Corresponding author. University of Freiburg, Department of Medicine I, Hematology, Oncology, and Stem Cell Transplantation, Hugstetter Str. 55,79106 Freiburg, Arends).Contents lists available atScienceDirectClinical Nutritionjournal homepage: 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights Nutrition 36 (2017) 1187e11961. IntroductionPatients with cancer are at particularly high risk for malnutritionbecause boththe disease and its treatments threaten their nutritionalstatus. It is estimated that the deaths of 10e20% of patients withcancer can be attributed to malnutrition rather than to the malig-nancy itself[1e3].

6 Thus, nutrition is an important aspect of multi-modal cancer care. Yet, recent studies in European hospitals foundthat only 30%e60% of patients with cancer who were at risk ofmalnutrition actually received nutritional support ( , oral supple-ments and/or parenteral nutrition and/or enteral nutrition)[4,5].Inanother European study, physicians misclassified the severity ofcancer-relatedmalnutritionin40%ofcases ;asa result, manyseverelymalnourishedpatientsdidnotge tnecessarynutritionalinterventions[6]. Even when physicians recognized cancer-related malnutrition,the patients and their relatives often underestimated its presence[7].To address cancer-related malnutrition in contemporary prac-tice, the European Society for Clinical Nutrition and Metabolism( ESPEN ) recently published evidence-based guidelines for nutritioncare in patients with cancer[8].

7 In further support of these guide-lines, an ESPEN oncology expert group met for aCancer andNutrition Workshopin Berlin on October 24 and 25, 2016. Here, theyexamined the causes and consequences of cancer-related malnu-trition, reviewed currently available treatment approaches, andbuilt the rationale and impetus for clinicians involved with care ofthe patient with cancer to take actions that facilitate nutrition carein practice. The content of this position paper is based on pre-sentations and discussions at the Berlin Talking about cancer and nutrition: the terminologyCritically important work has been done to build universallyaccepted definitions for malnutrition, cachexia, and definitions are intended to help clinicians identify and treatthe underlying metabolic and nutritional issues associated withboth aging and with chronic or acute diseases, including cancer(Fig.)

8 1)[9,10]. Despite efforts to clearly differentiate these condi-tions, there is some overlap in the working definitions, as there issome overlap in the conditions themselves. Notably, the need to beabsolute on the definitions is surpassed by the necessity of recog-nizing the negative impact of cancer on nutrition. While definitionsare important, this paper focuses on identifying and treating themetabolic and nutritional alterations that impede recovery andsurvival of patients with malnutritionhas been defined as a conditionthat results from the activation of systemic inflammation by anunderlying disease such as cancer[9]. The inflammatory responsecauses anorexia and tissue breakdown that can, in turn, result insignificant loss of body weight, alterations in body composition,and declining physical function[9].

9 Cachexiais a multifactorial wasting syndrome characterized byinvoluntary weight loss with ongoing loss of skeletal muscle masswith or without loss of fat mass; such wasting cannot be reversedby conventional nutrition care and may lead to functional impair-ment[10e14].Inprecachexia, early clinical and metabolic signs precedeextensive involuntary loss of weight and muscle. Risk for cachexiaand its worsening depends on factors such as cancer type and stage,extent of systemic inflammation, and degree of response to anti-cancer therapy[10,13].Sarcopeniais low lean body mass (mostly muscle); fatigue iscommon, strength may be lessened, and physical function limited[11,13]. As functionality is lost, patients with cancer may no longerbe able to live independently, and they often report lower quality oflife[8,13].

10 Sarcopenic obesityis low lean body mass in obese individuals[9]. In such patients, clinicians frequently overlook muscle loss dueto the presence of excess fat and extracellular water[12]. In fact, thepresence of sarcopenic obesity is an important predictor of adverseoutcome, which can be further worsened by surgical interventions[15].2. The high prevalence of malnutrition in patients withcancerPatients with cancer are more likely to be malnourished thanpatients treated in many other specialties[13]. The prevalence ofmalnutrition in patients with cancer has been reported to rangefrom about 20% to more than 70% in worldwide studies, with dif-ferences related to patient age, cancer type, and cancer stage(Table 1).