Nutrition in Advanced Cancer
Advanced cancer is often associated with cachexia.[1,2,3,4] Individuals diagnosed with cancer may develop new, or worsening, nutrition-related side effects as cancer becomes more advanced. The most prevalent symptoms in this population are the following:[1,2,3]
As defined by the World Health Organization, palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. The goal of palliative care is to give relief of symptoms that are bothersome to the patient. Although some of the symptoms listed above can be effectively treated, anorexia, though common, is a symptom that is often not noted as problematic for most terminally ill patients but is distressing to most family members; this distress may vary according to cultural factors. Several studies have demonstrated that terminally ill patients lack hunger, and of those who did experience hunger, the symptom was relieved with small amounts of oral intake.
Decreased intake, especially of solid foods, is common as death becomes imminent. Individuals usually prefer and tolerate soft-moist foods and refreshing liquids (full and clear liquids). Those who have increased difficulty swallowing have less incidence of aspiration with thick liquids than with thin liquids.
Dietary restriction is not usually necessary, as intake of prohibited foods (e.g., sweets in the diabetic patient) is insufficient to be of concern. As always, food should continue to be treated and viewed as a source of enjoyment and pleasure. Eating should not just be about calories, protein, and other macronutrient and micronutrient needs.
Diet restrictions are sometimes appropriate, however.[6,7] For example, people with pancreatic cancer, gynecologic cancer, abdominal carcinomatosis, pelvic masses, or retroperitoneal lymph node masses may have bowel obstruction less frequently when adhering to a prophylactic soft diet (i.e., no raw fruits and vegetables, no nuts, no skins, no seeds). Any restriction should be considered in terms of quality of life and the patient's wishes.
Decisions regarding nutritional support should be made with the following considerations:
- Will quality of life be improved?
- Do the potential benefits outweigh the risks/costs?
- Is there an advance directive?
- What are the wishes and needs of the family?
The benefit of home parenteral nutrition in patients with advanced cancer is often debated, and evidence-based data regarding its use are lacking. For patients who still have good quality of life but also have mechanical or physiologic barriers to achieving adequate nourishment and hydration orally (e.g., head and neck cancer), prolonged survival may be achieved with the use of enteral or parenteral nutrition. In a qualitative study, 13 patients and 11 family members perceived some benefits with home parenteral nutrition. The most salient positive feature of home parenteral nutrition was a sense of relief and security that nutritional needs were met. In this study, patients were also able to take oral nutrition, and the administration of total parenteral nutrition was often described as a complement to the patients' oral intake. This contradicts the traditional indication for TPN, i.e., that its use be reserved for times when nourishment via the gastrointestinal tract is not possible. Patients in this study also had regular visits by home health care providers, which could have had a positive impact on their physical, social, and psychological well-being.