Nutrition for Pre- and Postoperative Patients With Cancer: Improve Nutritional Status to Help Improve Outcomes

TON - January/February 2014 Vol 7 No 1 - Supportive Care
Tiffany DeWitt, MS, MBA, RD, LD

Malnutrition impacts many patients with cancer, yet the clinical consequences of malnutrition are often overlooked. The prevalence of malnutrition varies depending on cancer type, ranging from as little as 9% in urologic cancers to up to 85% in pancreatic cancers.1,2 Many factors contribute to malnutrition, including nausea, vomiting, loss of appetite, diarrhea, and the catabolic effects of cancer. Common treatment practices such as keeping patients nil-by-mouth for tests and procedures can further contribute to the development of malnutrition and weight loss, putting patients at risk of poor outcomes. Weight loss in surgical pancreatic oncology patients was found to have a significant correlation with increased surgical site infections (P = .026) and longer hospital length of stay (LOS) (P = .035).3 Poor preoperative nutritional status, coupled with delayed and inadequate postoperative nutrition practices, has been associated with worse clinical outcomes among surgical oncology patients.3,4

Individuals who are malnourished prior to surgery may be at a disadvantage or ill-equipped to recover from the stress of surgery. Up to 50% of patients with cancer may present with some form of nutritional deficit at diagnosis.5 Patients are at further risk of developing malnutrition during cancer treatment because of a variety of other factors, such as increased energy requirements, decreased food intake resulting from adverse effects, and altered nutrient metabolism leading to reduced ability to process nutrients.6

A study by Garth and colleagues demonstrated the impact of malnutrition on clinical outcomes in surgical patients with gastrointestinal (GI) cancer.7 The study provided evidence for the relationship between preoperative malnutrition and postsurgical adverse outcomes. Additionally, the findings highlight the importance of nutrition screening to identify patients at risk of malnutrition, which would allow for nutritional intervention to help improve outcomes.


Table


Figure

The investigators examined select nutritional practices, such as preoperative nutritional status, postoperative intake, and number of days until soft diet commenced during the pre- and postoperative period, to determine any association with improvement in clinical outcomes in patients undergoing elective surgery for upper GI or colorectal cancer.7 A 2-part study design was used: the first part consisted of a retrospective medical record review of 95 patients (37 upper GI cancers and 58 colorectal cancers); the second part involved nutritional assessment using the validated Subjective Global Assessment tool prior to surgery in a subset of 25 patients.

The results support previously reported prevalence data on malnutrition, revealing that almost half (48%) of the patients were malnourished—32% were mild-moderately malnourished and 16% were severely malnourished.7 Mean hospital LOS was twice as long in the malnourished patients compared with the well-nourished patients, 15.8 days versus 7.6 days (P <.05); see the Table. In the retrospective medical record review, patients with either weight loss or low albumin levels prior to surgery had significantly longer LOS. Furthermore, a significant correlation was found between low preoperative albumin and LOS (r = –0.325; P <.05). Mean hospital LOS was longer in patients with significant preoperative weight loss compared with those without significant weight loss, 17 days versus 10 days (P <.05). The findings suggest that improving or maintaining the nutritional status of patients preoperatively can shorten hospital LOS. This is particularly relevant in today’s medical environment, which requires facilities to decrease LOS while continuing to improve quality of care.

Preoperative malnutrition was also associated with adverse postoperative clinical outcomes.7 Some of the common complications reported included wound dehiscence and prolonged postoperative ileus, as well as infections such as sepsis and wound and urinary tract infections. Compared with well-nourished patients, malnourished patients were 2 times more likely to develop one or more complications (41.7% vs 15.4%); however, this did not reach statistical significance (P = .20).

Inadequate postoperative nutrition intervention negatively affected clinical outcomes.7 The investigators examined the time it took for patients to achieve adequate nutritional status, defined as consuming >75% of daily energy requirements. Patients who took 7 days or more to achieve adequate nutrition were significantly more likely to experience at least one complication compared with those who achieved adequate nutrition in less than 7 days (52% vs 13%, respectively; P <.01).

The authors raise a concern that many patients are discharged soon after tolerating a soft diet but are not consuming adequate intake.7 In their study, 68% of the patients were consuming less than half of their daily energy requirements at the time of discharge. This is of particular concern in the current healthcare environment, in which facilities are at financial risk owing to preventable readmissions within 30 days of discharge. Readmissions were not measured in the study by Garth and colleagues, but it has been suggested that providing nutrition support to attain adequate nutrition can help reduce unplanned hospital admissions in oncology patients.8 Evidence supports the importance of identifying nutrition risk and intervening with appropriate nutrition to improve outcomes while decreasing healthcare cost, as shown in the Figure.2

For GI and colorectal surgical oncology patients, Garth and colleagues suggest that poor preoperative nutrition status and a delay in postoperative nutrition can result in worse clinical outcomes.7 This study adds to the evidence in support of identifying the risk of malnutrition early to provide proper intervention. Correcting preoperative malnutrition, limiting nil-by-mouth days, and properly advancing postoperative diets may improve clinical outcomes for surgical oncology patients. Providing nutritional intervention pre- and postoperatively to ensure patients consume adequate caloric intake can help correct malnutrition and maintain weight throughout cancer therapy.

References
1. Bozzetti F. Nutritional support of the oncology patient. Crit Rev Oncol Hematol. 2013;87(2):172-200.
2. Stratton RJ, Green CJ, Elia M, eds. Disease-Related Malnutrition: An Evidence-Based Approach to Treatment. Wallingford, UK: CABI Publishing; 2003.
3. La Torre M, Ziparo V, Nigri G, et al. Malnutrition and pancreatic surgery: prevalence and outcomes. J Surg Oncol. 2013;107(7):702-708.
4. Bruun LI, Bosaeus I, Bergstad I, et al. Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation. Clin Nutr. 1999;18(3):141-147.
5. Halpern-Silveira D, Susin LR, Borges LR, et al. Body weight and fat-free mass changes in a cohort of patients receiving chemotherapy. Support Care Cancer. 2010;18(5):617-625.
6. Heber D, Blackburn GL, Go VLW, eds. Nutrition Oncology. San Diego, CA: Academic Press; 1999.
7. Garth AK, Newsome CM, Simmance N, et al. Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet. 2010;23(4):393-401.
8. Odelli C, Burgess D, Bateman L, et al. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer. Clin Oncol (R Coll Radiol). 2005;17(8):
639-645.

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Last modified: March 14, 2014