标准流程指引下的肿瘤营养治疗（完结篇）

 本文作者：丛明华（中国医学科学院肿瘤医院　综合科，北京　100021）

3　疗效评价

营养治疗方案实施后，要密切监测治疗效果，并实时调整，以达到良好的治疗效果。中国肿瘤营养指南推荐[28]： 不同参数对治疗发生反应的时间不一致，因此，不同参数复查的间隔时间也各不相同。根据时间长短分为 3 类 ： ①快速反应参数 ： 如体重、实验室检查、摄食量、代谢率等，每周检测1 ～ 2 次 ； ②中速反应参数 ： 如人体学测量、人体成分分析、影像学检查、肿瘤病灶体积、器官代谢活性、生活质量、体能及心理变化，每 4 ～ 12 周复查 1 次； ③慢速反应参数 ： 生存时间，每年评估1 次。考虑营养干预的临床效果出现较慢，建议以4 周为一疗程。所有严重营养不良患者出院后均应定期（至少每 3 个月 1 次）到医院营养门诊复查或接受电话营养随访。恶性肿瘤患者营养不良的发生率在所有住院患者中最高，其发生情况取决于肿瘤类型、分期和治疗手段[38] 。于康等 [39]研究表明，恶性肿瘤住院患者营养不足发生率为 26.35%，营养风险发生率为45.56%。Pan 等[40]研究表明，初次评估的营养不足发生率为 19.7%，住院治疗后再次评估，营养不足发生率升高至 26.8%，初次筛查营养风险发生率为 24.6%，再次筛查发生率为 40.2%。而标准的肿瘤营养治疗理念尚未被广大临床医师接受，临床营养治疗的过度和不足仍然普遍存在[10,40] ，因此推荐普及标准流程指引下的肿瘤营养治疗。

 

参考文献

[1]  中国营养学会．营养科学词典 [M]．北京： 中国轻工业出版社，2013．

[2]  Ukleja A, Freeman KL, Gilbert K, et al.Standards for nutrition support: adult hospitalized patients[J]. Nutr ClinPract, 2010,25(4):403-414.

[3]  石汉平．肿瘤营养疗法 [J]．中国肿瘤临床， 2014， 41（18）：1141-1145．

[4]  The Veterans Affairs Total ParenteralNutrition Cooperative Study Group. Perioperative total parenteral nutrition insurgical patients[J]. N Engl J Med, 1991, 325(8):525-532.

[5]  Kondrup J, Rasmussen HH, Hamberg O, et al.Nutritional risk creening (NRS 2002): a new method based on an analysis ofcontrolled clinical trials[J]. Clin Nutr, 2003, 22(3):321-336.

[6]  American Dietetic Association. Identifyingpatients at risk:ADA's definitions for nutrition screening and nutritionassessment[J]. J Am Diet Assoc, 1994, 94(8):838-839.

[7]  Dewys WD, Begg C, Lavin PT, et al. Prognosticeffect of weight loss prior to chemotherapy in cancer patients. EasternCooperative Oncology Group[J]. Am J Med, 1980, 69(4):491-497.

[8]  Ottery FD. Cancer cachexia: Prevention, earlydiagnosis and management[J]. Cancer Pract, 1994, 2(2):123-131.

[9]  Kondrup J, Allison SP, Elia M, et al. ESPENguidelines for evaluating nutrition screening 2002[J]. Clin Nutr, 2003,22(4):415-421.

[10]  蒋朱明，陈伟，朱赛楠，等．我国东、中、西部大城市三甲医院营养不良（不足）、营养风险发生率及营养支持应用状况调查 [J]．中国临床营养杂志，2008，16（6） ： 335-337．

[11]  Gazzotti C, Albert A, Pepinster A, et al.Clinical usefulness of the mini nutritional assessment (MNA) scale in geriatricmedicine[J]. J Nuit Health Aging, 2000, 4(3):176-181.

[12]  Orrevall Y, Tishelman C, Permert J, et al.Nutritional supp-ortand risk status among cancer patients in palliative homecare services[J]. Support Care Cancer, 2009, 17(2):153-161.

[13]  Haldun G, Eren E, Recep A, et al. Evaluationof nutritional risk on admission to the general surgery department[J]. BratislLek Listy, 2008, 109(2):57-60.

[14]  Elkan AC, Engvall IL, Tengstrand B, et al.Malnutrition in women with rheumatoid arthritis is not revealed by clinicalanthropometrical measurements or nutritional evaluation tools[J]. Eur J ClinNutr, 2008, 62(10):1239-1247.

[15]  Sorensen J, Kondrup J, Prokopowicz J, et al.EuroOOPS: an international, multi-centre study to implement nutritional riskscreening and evaluate clinical outcome[J]. Clin Nutr, 2008,27(3):340-349.

[16]  Sehiesser M, Mtiller S, Kirchhof P, et al.Assessment of anovel screening score for nutritional risk in predictingcomplications in gastro-intestinal surgery[J]. Clin Nutr, 2008, 27(4):565-570.

[17]  Martins CP, Correia JR, Amaral TF.Undernutrition risk scre-ening and length of stay of hospitalized elderly[J]. JNutr Elder,2005, 25(2):5-21.

[18]  Amaral TF, Matos LC, Tavares MM, et al. Theeconomicimpact of disease-related malnutrition at hospital admission[J]. Clin Nutr,2007, 26(6):778-784.

[19]  Ottery FD. Rethinking nutritional support ofthe cancer patient:the new field of nutritional oncology[J]. Semin Oncol, 1994,21(6):770-778.

[20]  Ek A, Unosson M, Larsson J, et al. Interratervariability and validity in subjective nutritional assessment of elderly patients[J].Scand J Caring Sci, 1996, 10(3):163-168.

[21]  Barritta de Defranchi RL, Bordalejo A,Ca?ueto I, et al.Evolution of nutritional status in patients with autologousand allogeneic hematopoietic stem cell transplant[J]. Support Care Cancer,2015, 23(5):1341-1347.

[22]  Rodrigues CS,Chaves GV.Patient-Generated SubjectiveGlobal Assessment in relation to site,stage of the illness,reason for hospital admission, and mortality in patientswith gynecological tumors[J]. Supportive Care Cancer, 2015, 23(3):871-879.

[23]  Detsky AS, McLaughlin JR, Baker JP, et al.What is subjective global assessment of nutritional status?[J]. JPEN J ParenterEnteral Nutr, 1987, 11(1):8-13.

[24]  Ferguson M, Capra S, Bauer J, et al.Development of avalid and reliable malnutrition screening tool for adultacutehospital patients[J]. Nutrition, 1999, 15(6):458-464.

[25]  Ottery FD. Patient-Generated SubjectiveGlobal Assessment. In: The Clinical Guide to Oncology Nutrition[M]. Chicago:TheAmerican Dietetic Association, 2000.

[26]  Laky B, Janda M, Cleghorn G, et al.Comparison of different nutritional assessments and body-compositionmeasurements in detecting malnutrition among gynecologic cancer patients[J]. AmJ Clin Nutr, 2008, 87(6):1678-1685.

[27]  Segura A, Pardo J, Jara C, et al. Anepidemiological evaluation of the prevalence of malnutrition in Spanishpatients with locally advanced or metastatic cancer[J]. Clin Nutr, 2005,24(5):801-814.

[28]  中国抗癌协会肿瘤营养与支持治疗委员会．中国肿瘤营养治疗指南 [M]．北京 ： 人民卫生出版社，2015．

[29]  Andreyev HJ, Norman AR, Oates J, et al. Whydo patients with weight loss have a worse outcome when undergoingchemotherapyfor gastrointestinal malignancies[J]. Eur J

Cancer,1998, 34(4):503-509.

[30]  Persson C, Glimelius B. The relevance ofweight loss forsurvival and quality of life in patients with advancedgastroint-estinal cancer treated with palliative chemotherapy[J]. Antica-ncerRes, 2002, 22(6B):3661-3668.

[31]  石汉平，许红霞．李苏宜，等．营养不良的五阶梯治疗[J]．肿瘤代谢与营养电子杂志，2015，2（1） ： 29-33．

[32]  Ravasco P, Monteiro-Grillo I, Vidal PM, etal. Dietary couns-eling improves patient outcomes: a prospective, random ized,controlledtrial in colorectal cancer patients under going radioth-erapy[J]. J Clin Oncol,2005, 23(7):1431-1438.

[33]  Rock CL. Dietary counseling is beneficial forthe patient with cancer[J]. J Clin Oncol, 2005, 23(7):1348-1349.

[34]  Milne AC, Potter J, Vivanti A, et al. Proteinand energy suppl-ementation in elderly people at risk from malnutrition[J].Coc-hrane Database Syst Rev, 2009, 15(2):CD003288.

[35]  Philipson TJ, Snider JT, Lakdawalla DN, etal. Impact of oral nutritional supplementation on hospital outcomes[J]. Am JManagCare, 2013, 19(2):121-128.

[36]  丛明华，程国威，李淑娈，等．管饲营养支持对于食管癌放化疗患者作用的研究 [J]．中国肿瘤，2014，23（12） ：1029-1033．

[37]  Arends J, Bodoky G, Bozzetti F, et al. ESPENGuidelines on Enteral Nutrition: Non-surgical oncology[J]. Clin Nutr, 2006,25(2):245-259.

[38]  Shike M. Nutrition therapy for the cancerpatient[J]. Haematol Oncol Clin North Am, 1996, 10(1):221-234.

[39]  于康，周晓容，郭亚芳．恶性肿瘤住院患者营养风险和营养不足发生率及营养支持应用状况调查 [J]．肿瘤学杂志，2011，17（6） ： 408-411．

[40]  Pan H, Cai S, Ji J, et al. The impact of nutritionalstatus,nutritional risk, and nutritional treatment on clinical outcome of2248hospitalized cancer patients: a multi-center, prospectivecohort study inChinese teaching hospitals[J]. Nutr Cancer,2013,65(1):62-70.

康爱营养医学研究院

图片来源：MSN中文网