Line Oldervoll

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Exercise reduces fatigue in chronic fatigued Hodgkins disease survivors—results from a pilot study

The aims of this pilot study were to compare aerobic capacity in non-fatigued and fatigued Hodgkins disease survivors (HDS) and to assess the feasibility of an exercise-programme and its effects upon fatigue, physical functioning and aerobic capacity in chronic fatigued HDS. 53 HDS (85%) of originally 62 survivors treated at the Trondheim University Hospital in the period 1987-1997 completed a questionnaire including the Fatigue Questionnaire (FQ). 18 subjects were identified with chronic fatigue. 15 non-fatigued HDS matched for gender and age were drawn as controls. Both groups were invited to medical examination and exercise tests. All 15 fifteen non-fatigued HDS showed up to the medical examination. 12 of the 18 patients with chronic fatigue completed the tests and nine agreed to enter a home-based exercise intervention. Outcome measures were aerobic capacity, fatigue and physical functioning. No significant difference in aerobic capacity was found between the chronic fatigued HDS and the controls. Fatigue, physical functioning and maximal aerobic capacity were significantly improved after the intervention. Aerobic exercise had a positive effect upon chronic fatigue in HDS. However, the study is a pilot study and needs confirmation in a larger group of subjects. The intervention was well accepted, and the majority of the patients adhered to the programme.

Psychosocial interventions as part of breast cancer rehabilitation programs? Results from a systematic review

Objective: This systematic review aimed to determine the effectiveness of psychoeducation, cognitive behavioural therapy (CBT) and social support interventions used in the rehabilitation of breast cancer (BC) patients.

Assessing physical functioning: a systematic review of quality of life measures developed for use in palliative care:

Background : Physical decline is experienced by all palliative care patients and affects most aspects of life. Physical functioning (PF) is therefore a crucial domain for quality of life (Qol) assessments. The purpose of this study was to review how PF assessments are performed in Qol instruments developed for palliative care Methods : For identification of instruments, Medline searches up to April 2005 were performed using the terms (palliative care OR end of life care OR terminal care) AND quality of life AND (assessment OR instrument OR questionnaire). A total of 1326 hits were screened. Named QoL instruments were extracted from 240 abstracts and 46 relevant reports. Items assessing PF were then identified and classified according to activity domains as described by the WHO International Classification of Functioning Disability and Health. Results : Of 224 different instruments detected, 39 were identified as developed for palliative care. Of these, 11 included original PF assessments. Two were comprehensive performance status measures made for staff assessment, 9 were multidimensional tools including 2—7 PF items. The content and phrasing of items varied considerably. All instruments included some aspects of self-care, whereas the coverage of mobility, domestic, work — and leisure activities was inconsistent. Interpretation : Despite its importance, PF assessment seems to be a minor part of palliative care QoL instruments. Clear definitions and conceptualization of PF are needed, as well as a consensus on relevant aspects to include in improved instruments. Performance scales already developed should be further explored with regard to content, validity and psychometric properties. Palliative Medicine 2007; 21 : 673—682

Are palliative cancer patients willing and able to participate in a physical exercise program

OBJECTIVE The primary aim of the present article was to identify palliative care patient populations who are willing to participate in and able to complete a group exercise/physical training program designed specifically for the individual patient. METHOD We conducted a prospective phase II intervention study examining the willingness and ability of palliative care cancer patients to participate in a group exercise physical training program. Patients who were diagnosed with incurable cancer and had a life expectancy of less than 1 year at two outpatient clinics were invited to participate in an exercise program in the hospitals. The groups met twice a week over a 6-week period. RESULTS One hundred one consecutive patients were asked for inclusion. Sixty-three patients agreed to participate. Sixteen (25%) of the 63 patients dropped out after consent was given, but before the program started due to medical problems, social reasons, or death. Thus, 47 patients started the exercise program. Thirteen patients withdrew during the program due to sudden death, medical problems, or social reasons. The most frequent reasons for withdrawal were increased pain or other symptoms. Thirty-four patients completed the exercise program. SIGNIFICANCE OF RESULTS A high proportion of incurable cancer patients were willing to participate (63%) in a structured exercise program. The attrition rate was high, but despite being severely ill, 54% of the patients completed the exercise period. This shows that a physical exercise program tailored to the individual patient is feasible in this population.

Age and gender differences of endothelial function in 4739 healthy adults: the HUNT3 Fitness Study:

Aims: Endothelial dysfunction is an important marker for prognosis in patients with coronary heart disease. However, there are no reference values for endothelial function in a healthy population. Our aim was to determine the distribution of flow-mediated dilation (FMD) values by gender and age in healthy adults. Methods: FMD was measured by ultrasound during reactive hyperaemia in the brachial artery of 4739 adults aged 20–89 years, who were free from self-reported cardiovascular or pulmonary disease. Differences in FMD across age and gender were analysed by multiple linear regression. Results: Total mean ± SD FMD was 4.8 ± 4.2%, with corresponding estimates of 4.3 ± 3.9% for men and 5.3 ± 4.5% for women (p < 0.001). In total, 17% had FMD ≤0%, indicating endothelial dysfunction. FMD decreased with increasing age in both genders up to 70 years for men and 80 for women (p < 0.001). In women, age-related decline in FMD was steepest after age 45; in men, a steady decline after age 30. In men 80 years and older, FMD was higher than in men aged 50–79 years. Conclusions: The distribution of FMD in this study is representative of the respective age and gender groups of a healthy population and may be a useful reference for future studies. The high proportion of endothelial dysfunction came as a surprise. Its age and gender distribution suggest that FMD ≤0% precedes cardiovascular disease and that it may be a powerful non-invasive biomarker for identifying high-risk individuals.

A First Step in the Development of an International Self-Report Instrument for Physical Functioning in Palliative Cancer Care: A Systematic Literature Review and an Expert Opinion Evaluation Study

Decline in physical functioning (PF) in progressive cancer increases risk of psychological problems, dependence, and distress, and it considerably affects quality of life. Despite this, assessment of PF has received little attention. Standardized, internationally endorsed assessment tools are needed that assess activities of relevance to palliative cancer patients from very low to high levels of PF. This study was done in cooperation with the European Association for Palliative Care Research Network. It was initiated to develop a computer-based symptom-assessment tool and aimed to 1) identify relevant existing PF-assessment instruments, 2) extract relevant items and classify them into meaningful subdimensions, and 3) construct unidimensional scales of selected PF domains. A systematic literature review was performed to detect relevant PF items from existing instruments. The International Classification of Functioning and Health was used to decide relevant subdimensions of PF, and expert panels within palliative cancer care were consulted to make decisions on activities to be included. One hundred and thirty-five instruments containing 743 items were included from the literature review. Two relevant PF subdimensions were revealed: Mobility (386 items representing 65 different activities) and Self-Care (143 items representing 30 different activities). The final PF tool consisted of two unidimensional scales: 24 hierarchically ranked Mobility items ranging from turning in bed to running, and 16 non-hierarchically ranked Self-Care items. Further testing of the instrument in a palliative cancer population is needed to develop the final PF instrument.

Computer-Based Assessment of Symptoms and Mobility in Palliative Care: Feasibility and Challenges

The aims of the study were to explore the ability of cancer patients who are primarily receiving palliative care to use a touchscreen computer for assessment of symptoms and mobility and to investigate which factors predicted the need for assistance during the assessment. Before the main data collection, a pilot study was conducted to explore the preferences of these patients toward using such a computerized assessment tool. Patients were recruited from nine different inpatient and outpatient palliative care and general cancer clinics in Norway. The patients responded to 60 items on symptoms and mobility directly on the computer. In the pilot study (n=20), 11 patients (55.0%) preferred computerized assessment over paper and pencil, whereas five (25.0%) had no preference. In the main data collection, 370 patients (52.7% men with mean age 62 years and mean Karnofsky Performance Status score of 70) completed the assessment. Eighty-six patients (23.2%) required assistance. Patients requiring assistance were significantly older, had worse performance status, and poorer cognitive function than those not requiring assistance. Predictors for requiring assistance were age (P<0.001) and performance status (P<0.001). Because higher age and worse performance status resulted in more need of assistance, assessment tools should be short and user-friendly to ensure good compliance in frail patients.

“The healthy me appears”: Palliative cancer patients' experiences of participation in a physical group exercise program

OBJECTIVE Tentative results from a pilot study showed that patients with advanced cancer were willing and able to take part in a group exercise intervention. Limited knowledge exists, though, about the meaning and significance of such programs. The purpose of the present study was to understand the meaning of such an intervention for the individual participant and thereby to provide knowledge for shaping future clinical practice. METHODS Thirty-four palliative cancer patients with a life expectancy of less than 1 year completed a 6-week group exercise program. Five randomly selected individuals were interviewed 7 months after completion. Results from a self-report evaluation questionnaire identified relevant themes that formed the basis of an interview guide. These were addressed in a semistructured interview. Verbatim transcripts were analyzed with a phenomenological-hermeneutical approach. RESULTS Two main themes emerged from the interviews: (1) perceptions of the group and (2) a secure and caring setting for the group. Themes identified regarding perception of the group were a sense of belonging and commitment. Themes identified regarding a secure and caring setting for the group were a life-empowering group as a setting for enhancing coping, the qualifications of those who led the group, and a public gym as an unsuitable setting. SIGNIFICANCE OF RESULTS Our study indicates that an individually adjusted group exercise program, with competent leaders, can provide a setting to enhance psychological well-being in cancer patients with life expectancy below 1 year. Small sample size, however, limits the possibility to generalize the findings.

Feasibility and changes in symptoms and functioning following inpatient cancer rehabilitation.

Abstract Aim. The aim was to assess feasibility of a 3 + 1 week inpatient rehabilitation program for cancer survivors, to explore characteristics of the attending participants and examine changes in work status, symptoms and functioning, level of fatigue, exercise and physical performance following rehabilitation. Methods. This was an open intervention study involving cancer survivors having completed primary cancer treatment. The multidisiplinary program consisted of physical training, patient education and group sessions. Participant were assessed at primary stay (T0), at follow-up stay 8–12 weeks later (T1), and six months after T1 (T2). Symptoms and functioning were assessed by the European Organization for Research and Treatment Core Quality-of-Life Questionnaire, physical fatigue by Fatigue Questionnaire, physical exercise by The Nord- Trøndelag Health Study Physical Activity Questionnaire and physical performance by aerobic capacity (VO2max), 30 second Sit-to-stand (STS) and Maximum Step Length (MSL). Linear mixed models were used in analyses. Results. One hundred and thirty-four of 163 included participants (82%) completed both rehabilitation stays and returned questionaires at T2. The majority of completers were females (81%), breast cancer survivors (60%), highly educated and with mean age of 52.8 years (SD of 8.1). Participants had higher level of symptoms and fatigue and lower functioning at admission compared to a Norwegian reference population. However, they reported higher physical exercise level and 47% reported improved work status from T0 to T2. Symptoms and functioning, fatigue, physical exercise and physical performance improved significantly from T0 to T1 and were maintained at T2. Conclusions. The rehabilitation program was feasible and symptoms and functioning normalized following rehabilitation. The program mainly recruited well-educated breast cancer survivors, reporting relative high level of physical exercise. More focus should be put on recruiting and selecting those who need comprehensive inpatient rehabilitation and also compare the effects of inpatient with outpatient rehabilitation programs.