Q27. How should patients be nutritionally assisted in the transition to survivorship?

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Q27. How should patients be nutritionally assisted in the transition to survivorship?

Summary

There is minimal evidence to support when patients should be assisted in the transition to survivorship and when it is appropriate to optimise healthy weight. The World Cancer Research Fund and American Institute for Cancer Research Expert Report, Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective advises that cancer survivors should follow cancer prevention dietary and physical activity advice unless contraindicated [1]. Although there is no guidance with respect to appropriate timing of when this should occur, it should be balanced with the patients’ current ability to eat adequately according to side effects from their treatment. In the post treatment setting there is one level IV neutral quality study [2]. The study monitored patients who were still being tube fed >1 year post treatment, and found that by controlling energy intake, optimisation of a healthy body weight/body mass index (BMI) could be achieved. Obese patients (BMI 27 to 30kg/m2) were prescribed an intake of 115kJ/kg/day (28kcal/kg/day) resulting in intentional controlled weight loss, patients requiring weight maintenance (BMI 22kg/m2) were prescribed an intake of 145kJ/kg/day (35kcal/kg/day) and underweight patients (BMI 16.5-19kg/m2) were prescribed a target intake of 185kJ/kg/day (44kcal/kg/day) to promote weight gain. Longer term feeding was required for a mean of 36 months.

One of the key issues for patients in the survivorship period is dental care. Although this topic is out of scope to be addressed fully in these guidelines, it is important to highlight the problems that patients receiving radiation therapy to the head and neck region can have long term. Hyposalivation (dry mouth) occurs when radiation therapy involves the salivary glands and it is associated with increased risk of dental caries (tooth decay) and dental erosion [3][4][5]. A link between cariogenic diet (high in simple sugars) and dental caries is well established [5]. Consumption of acidic foods is associated with dental erosion [4]. Dental extractions as a result of dental breakdown, place post radiation therapy patients at risk of serious complication - osteoradionecrosis (exposed irradiated bone that fails to heal) [6]. In light of this, it is important to minimize consumption of cariogenic and acidic foods in dentate patients, whilst at the same time considering the overall impact of dietary restrictions on patient’s nutritional status and how much the patient is compromised from other side effects, such as dysphagia, dysgeusia and odynophagia, which may impact food choices. It is therefore important to seek advice from a dentist who is experienced in the management of post radiation therapy patients, to assist in a suitable management programme to achieve long term oral health.

With regards to smoking and alcohol use, a level IV positive quality study [7], which compared survival and disease outcomes of a group of life long non smokers and drinkers to a group of continuing smokers and drinkers, found that overall survival was significantly worse in patients that continued to drink and smoke (although specific disease outcomes were no different). This supports general survivorship advice for patients to stop smoking and to reduce alcohol to the recommendations of the National Health and Medical Research Council (NHMRC) publication, Australian Guidelines to reduce health risks from drinking alcohol.[8]

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Recommendation Grade
Adjust dietary advice to cancer prevention diet and physical activity guidelines where appropriate depending on patient’s disease status and presence of late side effects post treatment.
D


Practice point
To achieve long term oral health and reduce the risk of dental complications and osteoradionecrosis, it is important to seek the advice of a dentist who is experienced in the management of post radiation therapy patients. Any dietary changes should be considered in the context of the patient’s nutritional status and presence of prolonged or late side effects post treatment.

Practice points – No systematic review conducted but rather a guidance point important to clinicians.

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References

  1. World Cancer Research Fund/American Institute for Cancer Research. Food, nutrition, physical activity and the prevention of cancer: a global perspective. 2007 Abstract available at http://www.dietandcancerreport.org/.
  2. Schattner MA, Willis HJ, Raykher A, Brown P, Quesada O, Scott B, et al. Long-term enteral nutrition facilitates optimization of body weight. JPEN J Parenter Enteral Nutr 2005;29(3):198-203 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15837780.
  3. Meurman JH, Grönroos L. Oral and dental health care of oral cancer patients: hyposalivation, caries and infections. Oral Oncol 2010 Jun;46(6):464-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20308007.
  4. 4.0 4.1 Magalhães AC, Wiegand A, Rios D, Honório HM, Buzalaf MA. Insights into preventive measures for dental erosion. J Appl Oral Sci 2009;17(2):75-86 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19274390.
  5. 5.0 5.1 Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard tissue ultrastructure. Dent Clin North Am 2010 Jul;54(3):455-67 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20630189.
  6. Madrid C, Abarca M, Bouferrache K. Osteoradionecrosis: an update. Oral Oncol 2010 Jun;46(6):471-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20457536.
  7. Farshadpour F, Kranenborg H, Calkoen EV, Hordijk GJ, Koole R, Slootweg PJ, et al. Survival analysis of head and neck squamous cell carcinoma: influence of smoking and drinking. Head Neck 2011 Jun;33(6):817-23 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20737489.
  8. National Health and Medical Research Council. NHMRC Australian Guidelines to reduce health risks from drinking alcohol. Commonwealth of Australia: National Health and Medical Research Council; 2009 Jan 1 Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf.

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