Nutritional interventions

From Cancer Guidelines Wiki


Malnutrition is common in patients with cancer due to a combination of the disease process, host response to tumour and anticancer treatments.[1]

Patients with colorectal cancer are more prone to malnutrition than non-GI cancers due to the direct effects of bowel obstruction and malabsorption.

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Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points were based on selected published evidence. See Guidelines development process.

ScreeningPerforming tests to identify disease in people before any symptoms appear. for malnutrition and assessment of nutritional status

Formal preoperative assessment of nutritional status in colorectal cancer patients has not been well investigated.

The measures commonly used to assess nutrition are hypoalbuminaemia, body weight loss and body mass index (BMI).

In a large study reporting on The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database, malnutrition, was most prevalent in colorectal cancer patients, compared with patients with other common types of cancer.[1] This was particularly evident when hypoalbuminaemia was used as a marker for malnutrition, with 27.3% of colorectal cancer patients demonstrating a low albumin.

The risk of malnutrition appears to be further compounded when combined with preoperative chemoradiation in rectal cancer patients. One study reported that 51% of their patients demonstrated malnutrition, as measured by body weight loss, at the completion of chemoradiation and 29% at the time of surgery.[2]

There appears to be a strong association between markers of malnutrition such as hypoalbuminaemia, body weight loss and BMI, and increased postoperative mortality, with hypoalbuminaemia being associated strongly even after multiple regression analysis with all postoperative complications.[1] In rectal cancer patients, malnutrition, as measured by body weight loss, was also associated with increased rates of anastomotic leakage.[2]

There are more effective and precise tools for screening for malnutrition and also for formally assessing nutritional status which have been well validated in cancer patients. The nutritional risk index (NRI) and the Malnutrition ScreeningPerforming tests to identify disease in people before any symptoms appear. Tool (MUST) can be used to screen for malnutrition in cancer patients.[3] MUST can also be used for formal assessment of nutritional status, however the Patient Generated-Subjective Global Assessment Tool (PG-SSA) is the most accurate and comprehensive tool for assessing nutrition in cancer patients. For practical purposes, the MUST tool appears to be the cheapest and easiest tool to use in screening and assessment of colorectal cancer patients for malnutrition.

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Nutritional support and intervention

In patients undergoing elective colorectal cancer surgery, nutritional support with supplements in the immediate preoperative period is a key component of enhanced recovery programs, with postoperative nutritional supplements also used in many programs.[4][5]

Preoperative correction of malnutrition in colorectal cancer patients has not been well studied. Similarly the medium and long term effects of nutritional interventions in colorectal cancer patients have not been evaluated systematically. One Portuguese study randomized 111 patients with colorectal cancer into three groups: a group receiving dietary counselling, a group receiving protein supplements, and those receiving standard care, whilst having preoperative radiotherapy for rectal carcinoma.[6] Both nutritional intervention groups had better intake, improved quality of life and fewer gastrointestinal symptoms than standard treatment patients at the completion of radiotherapy. With dietary counselling these changes were sustained at three months.[6] A more recent study with long term follow-up of this same group of patients demonstrated improved survival in the patients receiving nutritional counselling.[7]

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Patients undergoing elective surgery for colorectal cancer should be screened for malnutrition.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

If patients are found to be malnourished, nutritional interventions should be put in place.

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  1. Hu WH, Cajas-Monson LC, Eisenstein S, Parry L, Cosman B, Ramamoorthy S. Preoperative malnutrition assessments as predictors of postoperative mortality and morbidity in colorectal cancer: an analysis of ACS-NSQIP. Nutr J 2015 Sep 7;14:91 Abstract available at
  2. 2.02.1 Yamano T, Yoshimura M, Kobayashi M, Beppu N, Hamanaka M, Babaya A, et al. Malnutrition in rectal cancer patients receiving preoperative chemoradiotherapy is common and associated with treatment tolerability and anastomotic leakage. Int J ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2016 Apr;31(4):877-84 Abstract available at
  3. Håkonsen SJ, Pedersen PU, Bath-Hextall F, Kirkpatrick P. Diagnostic test accuracy of nutritional tools used to identify undernutrition in patients with colorectal cancer: a systematic review. JBI Database System Rev Implement Rep 2015 May 15;13(4):141-87 Abstract available at
  4. Gustafsson UO, Tiefenthal M, Thorell A, Ljungqvist O, Nygrens J. Laparoscopic-assisted and open high anterior resection within an ERAS protocol. World J Surg 2012 May;36(5):1154-61 Abstract available at
  5. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012 Dec;31(6):801-16 Abstract available at
  6. 6.06.1 Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol 2005 Mar 1;23(7):1431-8 Abstract available at
  7. Ravasco P, Monteiro-Grillo I, Camilo M. Individualized nutrition intervention is of major benefit to colorectal cancer patients: long-term follow-up of a randomized controlled trial of nutritional therapy. Am J Clin Nutr 2012 Dec;96(6):1346-53 Abstract available at
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