Q7. Does nutrition intervention improve outcomes? - Radiotherapy and chemotherapy

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Q7. Does nutrition intervention improve outcomes? - Radiotherapy and chemotherapy

Summary

There are two level I positive quality studies [1][2], both systematic reviews of nutrition intervention for patients receiving radiotherapy and chemotherapy. The first study reported on results for 10 randomised controlled trials (RCT’s). The majority of these studies were radiotherapy alone, compared to concurrent chemoradiotherapy. Nutritional status was maintained/improved with dietary counselling (5 RCT's), and prophylactic tube feeding (1 RCT). The second study (10 RCT’s) included patients receiving a mixture of radiotherapy alone or in combination with chemotherapy[2]. Dietary counseling was found to convey benefit to nutritional status and quality of life (4 RCT’s), while nasogastric tube feeding was of greater benefit to nutritional status than oral intake alone (1 RCT) but less effective than gastrostomy (1 RCT). Prophylactic gastrostomy was not found to be superior to tube feeding as required (2 RCT’s).

There are three level II positive quality studies [3][4][5] and two level II neutral quality studies [6][7] looking at the impact of dietary counselling. Improvements were seen with nutritional intake/nutritional status [5][3][4] and quality of life [3][4]. There are also two level II neutral quality studies looking at tube feeding compared to oral diet [8][9], which found the tube fed group had increased energy and protein intakes and less weight loss, but no impact on treatment response or survival. There were two level II papers, one positive and one neutral quality, which examined that impact of prophylactic gastrostomy use. The positive quality paper reported improved quality of life at six months post treatment in the prophylactic gastrostomy group, and a trend toward reduced malnutrition prevalence (not significant)[10]. The neutral quality paper found no significant difference in energy and protein intakes between groups, although the prophylactic gastrostomy group tended to be higher[11]. There is one level III-1 neutral quality study which demonstrates improvements in weight and nutritional status following dietetic counselling footnote[12].

There are four level III-2 studies: one positive quality [13], one negative quality [14] and two neutral quality [15][16]. The first study found that prophylactic gastrostomy was associated with fewer unplanned inpatient days, but not reduced weight loss [13]. The negative quality study demonstrated that presence of a gastrostomy resulted in less weight loss and conveyed a reduction in set up variation in daily treatment [14]. Another neutral quality study supported that tube feeding results in higher energy and protein intakes than oral diet and/or supplements [15]. The final neutral quality study reported that prophylactic gastrostomy resulted in reduced hospital admissions[16].

There is one level III-3 positive quality study [17] and seven level III-3 neutral quality studies [18][19][20][21][22][23][24]. Two of these examined the effect of nutrition intervention incorporating supplement provision with reductions noted in both weight loss [19][22] and the number of gastrostomy insertions [19]. Increased intensity of dietetic supervision was evaluated in three studies with improved outcomes including: less weight loss [21][18], fewer treatment interruptions and unplanned admissions [18], less nutrition-related admissions and unplanned nasogastric tube insertions, improved transition to oral diet post-radiotherapy, and reduced need for medical follow-up during the immediate post-treatment period [23]. One study describing a set of nutritional guidelines also found that there was less weight loss and fewer admissions [20]. Two studies examined prophylactic tube feeding which was found to convey reduced hospital admissions and/or LOS [17][24], fewer treatment interruptions, and improved maintenance of baseline nutritional status [24]. No difference was observed regarding survival or tumour recurrence rates [24].

There are five level IV positive quality studies [25][26][27][28][29], and fourteen level IV neutral quality studies [29][30][31][32][33][34][35][36][37][38][39][40][41][42] looking at various patient tumour/treatment groups and different outcomes. One study found no survival difference between those that received nasogastric tube feeding and those that didn't [40]. A post hoc analysis of an RCT [43] (level IV neutral quality), demonstrated positive outcomes in terms of less weight loss and less mucositis, however patients that received baseline nutrition support were also more likely to have reduced loco-regional control and survival. Limitations of this study are that it was not designed to measure outcomes of nutrition support interventions, and it could be argued that patients who received baseline nutrition support were those who required it due to more severe weight loss/dysphagia as a consequence of more advanced disease, and were therefore more likely to have poorer clinical outcomes. Another study showed a non significant reduction in the rate of severe oral mucositis was reduced in patients whose adherence with an oral immune modulating formula was high (≥75% consumed) compared to lower adherence [41]. Similarly, a study examining the impact of prophylactic gastrostomy showed that patients with weak adherence exhibited a significant reduction in weight during chemoradiotherapy, while there was no significant weight change and higher completion rate of concurrent chemotherapy (70% versus 44%) in those with high adherence [42].  

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Recommendation Grade
Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves/maintains nutritional status.
A
Nutrition intervention (dietary counselling and/or supplements and/or tube feeding) improves patient-centred outcomes (quality of life, physical function and patient satisfaction).
B
Tube feeding can improve protein and energy intake when oral intake is inadequate.
B
Tube feeding may reduce unplanned hospital admissions and reduced disruptions to treatment compared to oral intake alone.
C

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References

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