Preventing and Treating Malnutrition in Cancer Patients

Research suggests that malnutrition may affect 30% to 85% of cancer patients, and it may account for 10% to 20% of deaths in these patients.¹ 

Malnutrition in cancer has been associated with fewer treatment options, reduced response to treatment, greater treatment-related toxicity, longer hospitalization, and worse prognosis.²

“Malnutrition is a major concern for our patients, especially those undergoing intense treatments,” said Katie Roberts, MPH, RD, CSO, LD, clinical dietitian at The University of Texas MD Anderson Cancer Center in Houston. 

The highest prevalence of malnutrition occurs with upper gastrointestinal, head and neck, lung, hematologic, gynecologic, and colorectal cancers, added Edelina “Ede” Bustamante Cohen, MS, RD, CDN, CDCES, clinical nutrition manager at NYU Langone’s Perlmutter Cancer Center in New York, New York.³ 

Screening for Malnutrition in Cancer Patients

The National Cancer Institute (NCI) recommends that cancer patients undergo standard nutrition screening and assessment.¹ Screening tools that have been validated for use in cancer patients include the Malnutrition Screening Tool, Patient-Generated Subjective Global Assessment, and NUTRISCORE tool.

The NCI recommends assessing patients’ nutrition status before they start cancer treatment and continuing assessments throughout treatment.

Research has shown that even minimal weight loss before the start of cancer treatment is associated with worse prognosis, said Ginger Carney, MPH, RDN, LDN, IBCLC, RLC, FILCA, FAND, director of clinical nutrition at St Jude Children’s Research Hospital in Memphis, Tennessee.^4,5

During cancer treatment, patients may experience a wide range of issues that can contribute to malnutrition and sarcopenia, Cohen added. This includes treatment-related side effects such as nausea, vomiting, diarrhea, altered taste, and loss of appetite. 

Patients who are at risk of malnutrition should be referred to a registered dietician (RD) or registered dietitian nutritionist (RDN) for “a comprehensive nutrition assessment, including a nutrition-focused physical exam,” advised Kerry McMillen, MS, RD, CSO, FAND, manager of medical nutrition therapy services at Fred Hutchinson Cancer Center in Seattle. 

This exam involves evaluation of muscle mass and subcutaneous fat, fluid accumulation, and nutritional deficiencies.¹

Treating and Preventing Malnutrition

Nutrition support has important implications for the success of cancer treatment and the effects of cancer therapies on patients’ overall health, said Julie Bosworth, RD, LDN, senior dietitian on the Nutrition Services Team at Dana-Farber Cancer Institute in Boston. 

“While chemotherapy, radiation therapy, and many medications used in cancer care result in side effects that are catabolic to the body, food and fluids rebuild the body, readying it to receive the next step of treatment,” Bosworth explained.

Studies have linked nutritional interventions to a range of benefits for cancer patients.^1,2,6 Nutritional interventions have been shown to help patients complete cancer treatment, reduce treatment-related toxicity, decrease the duration of hospitalization, and improve survival, quality of life, and physical function. 

In the oncology setting, RDs or RDNs provide medical nutrition therapy to help “manage treatment-related symptoms, proactively support patients in maintaining strength and healthy body tissue, maintain or improve energy and protein intake, reduce the risk of treatment intolerance, mitigate metabolic perturbations, and improve quality of life for patients,” McMillen explained.

“Loss of skeletal muscle — with or without fat loss — is the main aspect of malnutrition that predicts the risk of physical impairment, postoperative complications, treatment toxicity, and mortality in individuals with cancer,” McMillen said. “For these reasons, it’s important to ensure that the patient’s lean body mass is preserved and to collaborate with RD and rehab professionals to prevent and treat sarcopenia.”

In determining each patient’s specific nutrition needs and appropriate interventions, the RD/RDN collaborates with the oncology treatment team and creates dietary recommendations based on the patient’s medical condition, treatment regimen, and nutrition status, as well as the patient’s food preferences and financial implications, Cohen explained. 

“If a patient is not able to take in the needed amounts of calories and nutrients orally during therapy, enteral feeding may be recommended,” Carney noted. “If the patient is unable to digest and absorb enteral nutrition, the RDN may recommend total parenteral nutrition along with appropriate levels of macronutrients” until the patient improves and gut function returns. 

Cohen noted that patients with head and neck cancers, for example, require close monitoring for the need to start nutrition support via oral nutrition supplement or enteral nutrition. Patients with gastrointestinal cancers also need extensive monitoring for the need to start nutrition support or pancreatic enzymes, Cohen said. 

“Involving the dietitian as part of the care team and providing frequent follow-up throughout the treatment process can help keep patients on track nutritionally to avoid malnutrition,” Roberts said.

“Dietitians also provide dietary guidance for prevention of recurrence or the development of a primary cancer,” Roberts added. “Touching base with patients after treatment is over or being part of the cancer prevention team can help educate patients on ways to reduce their risk.”

Post-treatment or survivorship nutrition care is also important for the prevention of other diseases such as diabetes, heart disease, and stroke, Cohen noted.

In addition to maintaining patients’ physical health and maximizing treatment outcomes and survival, nutrition care can provide psychosocial benefits to patients, according to Bosworth.

“Food and eating have strong social components and are often among the only ways that a patient has any control over their life during cancer treatment,” Bosworth said. “Nutrition care and meeting with an oncology dietitian allow the patient and family to participate in their care and set goals for themselves during treatment and beyond.”

Special Considerations

Dietitians must consider each patient’s social and cultural circumstances when creating nutrition recommendations, Bosworth said. 

McMillen emphasized the importance of addressing “social determinants of health by screening for food insecurity, as this can drastically impact a patient’s nutrition choices and status.” 

McMillen also advised that all providers assess whether they have an implicit weight bias that may influence their perception of a patient’s nutritional needs, as the risk of malnutrition affects patients of all weights and may be overlooked in higher-weight patients.¹ 

Carney cited the need for special considerations in dietary planning for pediatric cancer patients, who face the added challenge of maintaining adequate growth along with nutritional demands during treatment.⁷ 

“Malnutrition can have long-term side effects with childhood cancer treatment that can profoundly impact growth,” Carney explained. “Compromised bone health, eating disorders, and decreased quality of life are also unfortunate possibilities during pediatric cancer treatment.”

Ongoing Challenges and Needs

Research has suggested that patients’ nutritional needs may be overlooked during cancer care, despite patients’ interest in receiving evidence-based nutritional guidance from their health care team.⁸

RD/RDN understaffing may be one of the reasons support is not available to all cancer patients with or at risk of malnutrition. In a survey of 215 outpatient cancer centers in the US, researchers found a dietitian-to-patient ratio of 1:2308, when a ratio of 1:120 would be needed to address malnutrition in all patients.⁹ 

“Advocating for RD positions at outpatient oncology centers is critical to ensure patients have access to food and nutrition experts that are trained in oncology to address malnutrition, nutrition-impact symptoms, and misinformation,” McMillen said.

She added that variability in insurance coverage for oncology nutrition services is another barrier to care. McMillen noted that Fred Hutchinson Cancer Center addresses this issue by removing cost as a barrier to access and making medical nutrition therapy available to all patients. 

“Having varied ways to connect with patients, such as telehealth, also increases access by removing transportation as a barrier,” McMillen added.

Improving cultural competency is an ongoing need in the field of dietetics in general, according to Cohen. 

“As the US population grows more diverse, the dietetics profession, including oncology RDs, also need to keep up with the changing population to provide more personalized nutrition care,” Cohen said. “The Academy of Nutrition and Dietetics has provided RDs with extensive cultural competency resources and is working on strategies to increase diversity by increasing access to and improving affordability of undergraduate studies and training so that RDs can deliver nutrition services to people with different racial and ethnic backgrounds.”¹⁰ 

Disclosures: All interviewees said they have no relevant disclosures.

References

1. Nutrition in cancer care (PDQ®): Health professional version. National Cancer Institute. Updated June 22, 2023. Accessed July 6, 2023. 

2. Vitaloni M, Caccialanza R, Ravasco P, et al. The impact of nutrition on the lives of patients with digestive cancers: A position paper. Support Care Cancer. 2022;30(10):7991-7996. doi:10.1007/s00520-022-07241-w

3. Bossi P, Delrio P, Mascheroni A, Zanetti M. The spectrum of malnutrition/cachexia/sarcopenia in oncology according to different cancer types and settings: A narrative review. Nutrients. 2021;13(6):1980. doi:10.3390/nu13061980

4. Gannavarapu BS, Lau SKM, Carter K, et al. Prevalence and survival impact of pretreatment cancer-associated weight loss: A tool for guiding early palliative care. J Oncol Pract. 2018;14(4):e238-e250. doi:10.1200/JOP.2017.025221

5. Zhang S, Tan Y, Cai X, Luo K, Wu Z, Lu J. Preoperative weight loss is associated with poorer prognosis in operable esophageal cancer patients: A single-center retrospective analysis of a large cohort of Chinese patients. J Cancer. 2020;11(7):1994-1999. doi:10.7150/jca.40344

6. Ravasco P. Nutrition in cancer patients. J Clin Med. 2019;8(8):1211. doi:10.3390/jcm8081211

7. Tripodi SI, Bergami E, Panigari A, et al. The role of nutrition in children with cancer. Tumori. 2023;109(1):19-27. doi:10.1177/03008916221084740

8. Keaver L, Yiannakou I, Folta SC, Zhang FF. Perceptions of oncology providers and cancer survivors on the role of nutrition in cancer care and their views on the “NutriCare” program. Nutrients. 2020;12(5):1277. doi:10.3390/nu12051277

9. Trujillo EB, Claghorn K, Dixon SW, et al. Inadequate nutrition coverage in outpatient cancer centers: Results of a national survey. J Oncol. 2019;2019:7462940. doi:10.1155/2019/7462940

10. Academy of Nutrition and Dietetics. Inclusion, diversity, equity, and access. Accessed July 6, 2023.