C. McGough

Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial

BACKGROUND Weight loss in patients with cancer is common and associated with a poorer survival and quality of life. Benefits from nutritional interventions are unclear. The present study assessed the effect of dietary advice and/or oral nutritional supplements on survival, nutritional endpoints and quality of life in patients with weight loss receiving palliative chemotherapy for gastrointestinal and non-small cell lung cancers or mesothelioma. METHODS Participants were randomly assigned to receive no intervention, dietary advice, a nutritional supplement or dietary advice plus supplement before the start of chemotherapy. Patients were followed for 1 year. Survival, nutritional status and quality of life were assessed. RESULTS In total, 256 men and 102 women (median age, 66 years; range 24-88 years) with gastrointestinal (n = 277) and lung (n = 81) cancers were recruited. Median (range) follow-up was 6 (0-49) months. One-year survival was 38.6% (95% confidence interval 33.3-43.9). No differences in survival, weight or quality of life between groups were seen. Patients surviving beyond 26 weeks experienced significant weight gain from baseline to 12 weeks, although this was independent of nutritional intervention. CONCLUSIONS Simple nutritional interventions did not improve clinical or nutritional outcomes or quality of life. Weight gain predicted a longer survival but occurred independently of nutritional intervention.

Small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy : An observational study

INTRODUCTION Loose stool affects up to 80% of all patients during pelvic radiotherapy and faecal incontinence may occur. Several causes for diarrhoea have been defined, though few oncologists target these causes in affected patients and most treat symptomatically only. It is not known whether small bowel bacterial overgrowth, a frequent cause of gastrointestinal symptoms in other contexts, occurs during radiotherapy. The frequency of new-onset lactose intolerance during pelvic radiotherapy is also not clear. AIMS AND METHODS To perform an observational pilot study to estimate the incidence of small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy. Before treatment started and at weeks 4-5 of pelvic radiotherapy, a glucose hydrogen breath test and lactose tolerance test were performed. Gastrointestinal symptoms were assessed using the Vaizey incontinence questionnaire and the Radiation Therapy Oncology Group scoring system. RESULTS Twenty two men and 17 women (median age 61, range 42-81) were recruited, four were treated for gastrointestinal, 17 were treated for gynaecological and 18 for urological cancers. Thirty-eight patients underwent glucose hydrogen breath tests and 26 patients underwent lactose breath tests at both time points. Ten patients (26%) were positive for the glucose hydrogen breath test: 60% of these developed new or worsening faecal incontinence during treatment and 60% had worsening bowel frequency. Four patients (15%) developed lactose intolerance. Of these 1 developed worsening faecal incontinence during treatment, 2 (50%) developed new-onset increase in bowel frequency or a change in the quality of bowel habit. CONCLUSION Small bowel bacterial overgrowth and lactose intolerance may occur during radical pelvic radiotherapy and are likely to contribute to gastrointestinal symptoms in some patients.

Can biological markers act as non-invasive, sensitive indicators of radiation-induced effects in the gastrointestinal mucosa?

Background  Reliable, non‐invasive biological markers of the severity of radiotherapy‐induced damage to the gastrointestinal tract are not available. Clinicians continue to use symptom scores as surrogate indicators of toxicity.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy

Background  Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one‐third of total calories for 3 weeks.

Clinical trial: efficacy of a low or modified fat diet for the prevention of gastrointestinal toxicity in patients receiving radiotherapy treatment for pelvic malignancies

BACKGROUND Inflammatory responses to pelvic radiotherapy can result in severe changes to normal gastrointestinal function with potentially severe long-term effects. Reduced or modified fat diets may confer benefit. METHODS This randomised controlled trial recruited patients with gynaecological, urological or lower gastrointestinal malignancy due to receive radical radiotherapy. Patients were randomised to a low fat (20% total energy from long chain triglycerides), modified fat (20% from long chain triglycerides and 20% from medium chain triglycerides) or normal fat diet (40% total energy from long chain triglycerides). The primary outcome was a difference in change in Inflammatory Bowel Disease Questionnaire--Bowel (IBDQ-B) score, from the start to end of radiotherapy. RESULTS A total of 117 patients with pelvic tumours (48% urological; 32% gastrointestinal; 20% gynaecological), with mean (SD) age: 65 (11.0) years, male:female ratio: 79:38, were randomised. The mean (SE) fall in paired IBDQ-B score was -7.3 (0.9) points, indicating a worsening toxicity. Differences between groups were not significant: P = 0.914 (low versus modified fat), P = 0.793 (low versus normal fat) and P = 0.890 (modified versus normal fat). The difference in fat intake between low and normal fat groups was 29.5 g [1109 kJ (265 kcal)] amounting to 11% (of total energy intake) compared to the planned 20% differential. Full compliance with fat prescription was only 9% in the normal fat group compared to 93% in the low fat group. CONCLUSIONS A low or modified fat diet during pelvic radiotherapy did not improve gastrointestinal symptom scores compared to a normal fat intake. An inadequate differential in fat intake between the groups may have confounded the results.

The NUT study: the effect of dietetic and oral nutritional interventions on survival and quality of life in patients with weight loss undergoing palliative chemotherapy for gastrointestinal (GI) or lung malignancy, a randomised controlled trial

Weight loss in patients with GI and lung cancers is common and is associated with shorter survival and poorer quality of life. Oral nutritional interventions to manage weight loss in a range of clinical conditions improve outcomes but data in cancer patients on the clinical benefits of nutritional intervention are inadequate. The aim of this study was to assess the effect of dietary advice and/or oral nutritional interventions on survival and quality of life of patients with weight loss and advanced GI and lung cancers. Patients with weight loss, in whom radical therapy was not possible and who were instead to receive palliative chemotherapy for histologically proven GI or non-small-cell lung cancer or mesothelioma were randomly assigned to receive (1) no intervention (ad libitum food intake), (2) a nutritional supplement (240 ml, 2510 kJ/d) and a vitamin supplement, (3) dietary advice (an additional 2510 kJ/d) and (4) dietary advice plus a nutritional and vitamin supplement (additional 2510 kJ/d from food plus 2510 kJ from a supplement) for 6 weeks beginning before the start of chemotherapy. EORTC-C30 was used to assess quality of life at 6 weeks and 26 weeks. Patients were followed for 1 year. Five centres recruited 358 patients between 2002 and 2006, 256 men and 102 women (age median 66 (range 24–88) years). A total of 254 had GI cancer (oesophago-gastric, n 71; pancreas, n 72; lower GI, n 111) eighty-one non-small-cell lung cancer or mesothelioma (fourteen other). Ninety-six patients were randomised to group 1, eighty-six to group 2, ninety to group 3 and eighty-six to group 4. The groups were balanced for baseline characteristics. Median follow up for all patients was 6.8 (range 0–50) months. The 1-year survival for all patients combined was 37.8% (95% CI 32.2,43.4). There was no significant difference in survival between the intervention groups.

The impact of radical pelvic radiotherapy on nutrient intake

Malignancy in the gynaecological, urological or lower gastrointestinal tract is responsible for 27% of all newly diagnosed cancer cases in the UK. Pelvic radiotherapy (PRT) is a cornerstone of current treatment, but in more than 90% of patients induces acute bowel symptoms, such as diarrhoea, faecal incontinence, abdominal discomfort and bloating due to underlying changes in intestinal physiology. This prospective, observational study aimed to characterise quantitative changes in nutrient intake and nutritional status at baseline and following the conclusion of 4–5 weeks of adjuvant or radical PRT in outpatients with pelvic malignancies. At baseline (week 0) and at 4–5 weeks patients completed a non-weighed, 3-d food diary. Gastrointestinal symptoms were assessed using validated scoring tools and anthropometry was measured. Food diaries were analysed using Dietplan 6 software (see Table). In total, twenty-three males and twenty-one females (mean age 61.3 (range 42–81) years) completed food diaries at both time points. Although at no nutritional risk at baseline (based on BMI), twenty-six patients (59.1%) lost weight during treatment, with a mean weight loss of 0.61 (SD 1.83) kg (P=0.03).