The importance of nutrition in patients with cancer
Updates from ESPEN 2017

MS SALLY SHI-PO POON Registered Dietitian (UK) Accredited Practising Dietitian (Australia)

Malnutrition in patients with cancer

Multiple disease- and treatment-related factors combine to increase the risk of malnutrition in patients with cancer, including impaired food intake, increased energy and protein requirements and altered metabolism.1

Malnutrition is common in patients with cancer, with prevalence ranging from 20% to 70%, depending on age, cancer type and cancer stage, and is associated with adverse health outcomes, including1:

  • Weight and muscle loss

  • Higher risk of infections

  • Psychological stress

  • Reduced quality of life

  • Treatment toxicity

  • Increased risk of death

In fact, an estimated 10–20% of cancer patient deaths can be attributed to malnutrition rather than the cancer itself.1

Furthermore, cancer-related malnutrition is also linked to longer hospital stays and increased healthcare costs to the patient and the system.1

Nutrition is clearly an important aspect of cancer care, yet it is under-recognized by both patients and healthcare professionals and, therefore, under-addressed.1 Hence, many patients with cancer and at risk of malnutrition do not receive adequate, or any, nutritional support, increasing their risk of the associated high health and financial costs.

FIGURE 1. In patients with cancer, systemic inflammation is associated with the patient’s innate immune response and with clinical symptoms. Reproduced from Arends J, et al. 20171

BOX 1. Benefits of immunonutrients in cancer patients

Immunonutrients are defined as nutrients capable of modifying the immune system’s response.4 Substrates such as omega-3 fatty acids, the non-essential amino acid arginine, and nucleotides, have shown some beneficial outcomes in cancer patients, particularly malnourished patients undergoing major cancer surgery.1,3,5–13

  • Omega-3 fatty acids have been shown to improve appetite, oral intake, lean body mass, body weight, physical function and quality of life.1,5–7
  • Arginine, a non-essential amino acid, may become essential during catabolic states, such as those caused by major surgery.4 It is suggested to restore depressed immune responses and promote wound healing in surgical patients.4,8
  • Nucleotides are biologically active substances involved in many essential cellular processes and their demand is increased to support immune function under conditions of physiological stress.14

There is limited evidence on the study of individual nutrients, but results for nutritional supplements combining multiple immunonutrients show a number of benefits.1,3,9–13 Enteral supplements containing immunonutrients have been shown to enhance immune response in cancer patients.9,10 Peri- and postoperative intake of immunonutrient-enriched supplements have also been found to reduce infection rates and length of hospital stay following major cancer surgery, compared to standard nutritional supplements.1,3,11–13 While benefits have been observed in both under-nourished and adequately-nourished cancer patients, malnourished patients appear to benefit most.3,12,13

While further research is needed for definitive results and recommendations, immunonutrients in cancer patients is a promising area of nutritional research.1

Nutritional interventions

Nutritional intervention is tailored to meet the needs of the patient and will vary depending on the patient’s medical history, appetite, type and stage of cancer, and response to treatment.1 ESPEN generally recommends a step-wise approach to interventions, starting with nutritional counselling.2

Nutritional counselling provides patients and carers with a thorough understanding of nutrition that can lead to lasting changes in eating habits, as maintaining or improving nutritional intake with normal foods is preferred.1 However, it is often difficult to maintain adequate nutrition in cancer patients with normal foods alone and nutritional supplements are required.2

Immunonutrition is supported by ESPEN guideline

A further consideration in patients with cancer is the composition of nutritional supplements. Systemic inflammation in cancer patients impedes utilization of nutrients and promotes catabolism, which leads to muscle loss and the associated deleterious consequences (Figure 1).1 Fortification of normal foods, even with standard oral nutritional supplements, does not reduce systemic inflammation and, thus, the updated ESPEN guidelines suggest considering nutritional supplements containing anti-catabolic and anti-inflammatory ingredients in cancer patients.1 Nutritional formulas enriched with immunonutrients (arginine, omega-3 fatty acids, nucleotides) are also recommended peri- or at least postoperatively in malnourished patients undergoing major cancer surgery.3


References: 1. Arends J, et al. Clin Nutr 2017;36:1187-1196. 2. Arends J, et al. Clin Nutr 2017;36:11-48. 3. Weimann A, et al. Clin Nutr 2017;36:623-650. 4. Klek S, et al. Module 7.3 Immunonutrition substrates for enteral and parenteral nutrition. In ESPEN LLL Programme 2014. 5. Camargo Q, et al. Nutr Cancer 2016;68:70-76. 6. Sanchez-Lara K, et al. Clin Nutr 2014;33:1017-1023. 7. van der Meij BS, et al. Eur J Clin Nutr 2012;66:399-404. 8. Engelen MPKJ, et al. Clin Nutr 2017 Aug 5. doi: 10.1016/j.clnu.2017.07.019. [Epub ahead of print]. 9. Talvas J, et al. Clin Nutr 2015;34:810-817. 10. Song GM, et al. Medicine (Baltimore) 2015;94:e1311. 11. Osland E, et al. JPEN J Parenter Enteral Nutr 2014;38:53-69. 12. Braga M, et al. Arch Surg 2002;137:174-180. 13. Klek S, et al. World J Surg 2014;38:803-812. 14. Hess JR & Greenberg NA. Nutr Clin Pract 2012;27:281-294.