May 26, 2024

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ASPEN 2024: Nutritional Therapy Strategies for Cancer and Critically Ill Patients

ASPEN 2024: Nutritional Therapy Strategies for Cancer and Critically Ill Patients



ASPEN 2024: Nutritional Therapy Strategies for Cancer and Critically Ill Patients

The American Society for Parenteral and Enteral Nutrition (ASPEN) is one of the most influential academic organizations in the field of clinical nutrition. ASPEN holds an annual scientific meeting, the ASPEN Nutrition Science & Practice Conference, to disseminate basic clinical nutrition knowledge, share the latest advances in clinical nutrition, guide clinical practice, and promote the continuous development of clinical nutrition.

The 2024 ASPEN Annual Meeting opened in March in Tampa, Florida, bringing together thousands of clinical nutrition and related field experts and scholars from around the world through both online and offline participation. The conference provided new advances and strategies in nutritional therapy for the global academic community. Among them, the nutritional therapy strategies for cancer and critically ill patients have always been one of the topics of great concern for clinical doctors.

To provide an in-depth interpretation of this topic at the conference, we invited Professor Shi Yongmei, Director of Clinical Nutrition Department at Ruijin Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. Next, we will share Professor Shi Yongmei’s detailed exposition on the main content and hot issues of this topic, hoping to bring enlightenment and gains to our colleagues.

ASPEN 2024: Nutritional Therapy Strategies for Cancer and Critically Ill Patients


I. Nutritional Therapy Strategies for Cancer Patients

Cancer is the second leading cause of death worldwide. Both the cancer itself and anti-cancer treatments (surgery, chemotherapy, radiotherapy, etc.) can lead to a high incidence of malnutrition in cancer patients, greatly affecting their quality of life and treatment outcomes. Studies have shown that about 10%~20% of cancer patients die from malnutrition rather than the cancer itself. Therefore, nutritional therapy plays a crucial role in the comprehensive management of cancer treatment. When cancer is diagnosed, the patient’s nutritional status should be assessed, and nutritional therapy should be provided during anti-cancer treatment and cancer rehabilitation. However, currently, malnutrition related to cancer is not given enough attention and proper treatment in clinical practice worldwide.

Professor Pimiento from the Moffitt Cancer Center’s Gastrointestinal Oncology Department shared a literature review on nutritional therapy for cancer at this year’s ASPEN conference, revealing new advances and strategies in nutritional therapy for cancer in recent years. Professor Pimiento first shared a study on “Does Surgery for Malignant Bowel Obstruction Improve Quality of Life and Nutrition?” In clinical practice, malignant bowel obstruction, caused by tumor invasion of the intestinal wall, blocking the intestinal lumen, leads to poor prognosis and often accompanied by various complications. However, whether surgery improves the quality of life and nutrition of patients is still under debate in the academic community. The S1316 clinical study explored the impact of surgery versus non-surgical treatment on the 91-day survival, hospitalization days, treatment complications, and quality of life of patients with intra-abdominal or retroperitoneal primary tumors. The results showed no significant differences in survival days, hospitalization days, or overall survival between surgical and non-surgical treatment, but patients who underwent surgery had a higher quality of life. Based on these results, Professor Pimiento believes that the nutrition support team needs to develop a nutritional therapy plan for patients based on understanding the impact of surgical and non-surgical treatment on patients with malignant bowel obstruction. In addition, patient willingness for surgery should also be an important factor in influencing treatment strategies, as patient willingness for surgery has a minimal impact on postoperative outcomes.

Subsequently, Professor Pimiento shared a study on “Compliance with Cancer Prevention Lifestyle Recommendations Before, During, and After Chemotherapy in High-Risk Breast Cancer Patients and its Association with Disease Recurrence and Mortality.” In this prospective cohort study involving 1340 breast cancer patients, strict adherence to the American Cancer Society and American Cancer Research Institute’s cancer prevention lifestyle recommendations reduced the risk of breast cancer recurrence by 37% (HR 0.63; p=0.01) and the risk of death by 58% (HR 0.42; p=0.01); strict adherence to recommendations regarding smoking, physical activity, fruit and vegetable intake, and sugar-sweetened beverage intake was significantly associated with reduced recurrence and mortality rates. These results suggest that following healthy lifestyle recommendations can reduce cancer recurrence and mortality rates.

Professor Shi Yongmei added that the conclusion that adherence to healthy lifestyle recommendations reduces cancer recurrence and mortality rates among breast cancer patients also indirectly demonstrates the importance of nutritional intervention for cancer patients. Evidence from patient groups such as breast cancer and prostate cancer has shown that a diet high in fat, low in fruits and vegetables, and overweight/obesity increase the risk of cancer recurrence, while reducing saturated fat and increasing intake of various micronutrients can help reduce the risk of cancer recurrence; on the other hand, cancer patients often have metabolic diseases, so maintaining appropriate weight and metabolic status and reducing complications of metabolic diseases are also important for health.

A retrospective cohort study on “The Impact of Adipose Tissue Distribution, Sarcopenia, and Nutritional Status on the Clinical Outcomes of Patients Receiving CD19 Chimeric Antigen Receptor T Cell Therapy (CD19 CAR-T)” showed that patients with refractory B-cell lymphoma who received CD19 CAR-T therapy had better overall survival (OS) and progression-free survival (PFS) when they had higher total fat and visceral fat, while sarcopenia was associated with lower OS and PFS. This indicates that the baseline nutritional status of cancer patients affects the response and survival of exogenous immune cells, so before CD19 CAR-T therapy, patients need to be provided with rehabilitation training and nutritional intervention to avoid the adverse effects of malnutrition and sarcopenia on patient outcomes.

In addition, many patients who require high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT) are malnourished upon admission, and adverse reactions such as high-dose chemotherapy and nausea, vomiting, mucositis, diarrhea, and infections further affect oral intake. Therefore, Professor Shi Yongmei believes that for hospitalized patients with hematologic tumors, nutritional screening and assessment should be carried out upon admission, and reasonable nutritional interventions, including enteral nutrition and/or parenteral nutrition therapy, should be implemented, while maintaining moderate physical activity to avoid or reduce the decline in body weight and total body cell mass.


II. Nutritional Therapy Strategies for Critically Ill Patients

Critically ill patients are at high risk of malnutrition due to high metabolism and breakdown in severe trauma, infections, and other stress states. In addition, the metabolic and hormonal changes in critically ill patients can lead to muscle wasting and ICU-acquired weakness, which can last for several years. Since both underfeeding and overfeeding in the ICU can have adverse consequences, the timing, route, and dose of nutritional therapy remain focal points of attention.

At this year’s ASPEN conference, Professor Lee from the Samsung Medical Center’s Nutrition Department in South Korea shared a clinical study by his team on “Nutritional Malnutrition Diagnosed According to GLIM Criteria in Mechanically Ventilated Critically Ill Patients: Correlation between Nutritional Intake over Time and Clinical Outcomes.” The study found that among the 595 ICU patients included in the study based on the Global Leadership Initiative on Malnutrition (GLIM) criteria, the prevalence of malnutrition was 61%, and the 90-day mortality rates for the well-nourished and malnourished groups were 45% and 58%, respectively (P<0.001). There were no differences in mortality rates among

different energy intake groups in the early and late acute phases of patient care, but in the recovery phase, patients with high energy intake (>20 kcal/kg/d) had a lower mortality rate (HR 0.602; 95% CI 0.413-0.877; P=0.008); there were no differences in mortality rates among different protein intake groups in the early and late acute phases of patient care, but in the recovery phase, patients with moderate protein intake (0.8-1.2 g/kg/d) had a lower mortality rate (HR 0.770; 95% CI 0.599-0.990; P=0.041). The study results showed that energy and protein intake during the recovery phase after ICU admission were associated with mortality, especially in malnourished patients. Therefore, determining nutritional intake based on nutritional status may be crucial for optimizing nutritional support strategies for ICU patients.

Another clinical trial shared by Professor Lew from the Nutrition Department of Tan Tock Seng Hospital in Singapore on the “Impact of Malnutrition and High Protein Infusion on the Prognosis of Critically Ill Patients” found that while malnutrition upon admission was associated with poor outcomes, higher protein intake was not related to better outcomes except for patients with a body mass index (BMI) <18.5 kg/m2; compared to normal protein intake, higher protein intake was associated with shorter time to discharge alive (TTDA) and higher discharge rates. However, due to the small sample size of patients with low BMI, further research is needed to confirm this finding.

A retrospective cohort study by Professor Araujo from the Alberta Health Services Center in Canada on “Protein Adequacy and its Relationship with Functional and Activity Results in Ventilated Critically Ill Patients: Pro-Move” showed that patients who were fed 1.2-1.5 g/kg/d protein were significantly associated with functional capacity at ICU discharge compared to patients fed <0.8, 0.8-1.19, and >1.5 g/kg/d protein doses. This suggests that protein intake between 1.2-1.5 g/kg/d may have a mediating effect on improving functional capacity.

Professor Shi Yongmei added that the recommended protein supplementation range in international critical care nutrition guidelines is 1.2~2.0 g/kg/d, which is higher for obese patients, burn patients, and trauma patients, at 2.0~2.5 g/kg/d. However, there is currently insufficient research evidence on the optimal dose of protein supplementation for critically ill patients during the course of their illness. Recent studies have shown that compared to supplementing with conventional doses of protein, supplementing with higher doses of protein for critically ill patients at high nutritional risk does not shorten the TTDA of patients. Moreover, supplementing with high-dose protein may worsen clinical outcomes for patients with acute kidney injury and higher organ failure scores. Therefore, personalized nutritional therapy plans tailored to critically ill patients are crucial throughout the entire ICU treatment and recovery phase.

Additionally, Professor Garcia Grimaldo from the Food and Nutrition Science Institute at the National Institute of Respiratory Diseases in Mexico shared a clinical study on “ICU-Acquired Weakness and its Association with Post-extubation Dysphagia in Critically Ill Patients with Respiratory System Diseases.” The study found that among 54 ICU patients, 35.2% were diagnosed with post-extubation dysphagia and 59.3% were diagnosed with ICU-acquired weakness.

Patients with post-extubation dysphagia had lower phase angle values (PhA, a comprehensive indicator of cell health), lower Medical Research Council (MRC) values, and lower handgrip strength at extubation. In univariate logistic regression analysis, PhA at extubation, diagnosis of ICU-acquired weakness, and duration of invasive mechanical ventilation (MV) were associated with post-extubation dysphagia; in multivariate regression analysis, only MV duration and diagnosis of ICU-acquired weakness were independently associated with post-extubation dysphagia.

This study suggests that duration of invasive mechanical ventilation and diagnosis of ICU-acquired weakness are predictors of post-extubation dysphagia. Based on this study, Professor Shi Yongmei believes that for critically ill patients, a comprehensive nutritional therapy strategy should be adopted to prevent ICU-acquired myopathy and its serious consequences, thereby improving post-extubation clinical outcomes and quality of life.


Conclusion

Nutritional therapy has been proven to be a safe, effective, and feasible basic treatment for most cancer and critically ill patients. In the process of nutritional therapy, how to optimize nutritional therapy strategies, ensure the effectiveness of nutritional therapy, and maximize the nutritional therapy benefits for patients still needs continuous exploration.

At this ASPEN conference, professors from clinical nutrition and related fields in different countries and regions worldwide shared new research and strategies on nutritional therapy for cancer and critically ill patients, and it is believed that colleagues can gain valuable experience and insights from them.

ASPEN 2024: Nutritional Therapy Strategies for Cancer and Critically Ill Patients


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