|
前情提要
第二章、癌症患者治疗总论
B1、筛查和评定 B1-1、筛查 B1-2、评定 B2、能量和底物需求 B2-1、能量需求 B2-2蛋白质需求 B2-3、供能底物的选择 B2-4、维生素和微量元素 B3、营养干预 B3-1、营养干预效果 B3-2、潜在有害的饮食 B3-3、营养供给方式：何时调整 B3-4、再喂养综合征 B3-5、家庭人工营养 B4、运动 B4-1、运动联合营养 B4-2、推荐的运动类型 B5、药理营养素和具有药理作用的物质 B5-1、使用糖皮质激素增加食欲 B5-2、使用孕激素增加食欲 B5-3、使用大麻酚类改善食欲 B5-4、使用雄激素增加肌肉含量 B5-5、使用氨基酸增加去脂体重 B5-6、使用非甾体抗炎药物（NSAID）增加体重 B5-7、使用脂肪酸改善食欲和体重 B5-8、使用促胃动力药物改善早饱 翻译：肖慧娟（天津市第三中心医院营养科）
Chapter B: General Concepts of Treatment Relevant to All Cancer Patients Section B1: Screening and Assessment B1-1 Screening To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change and BMI, beginning with cancer diagnosis and repeated depending on the stability of the clinical situation. Strength of recommendation: STRONG Level of evidence: Very low Questions for research: relationship of screening to assessment, Interventions and clinical outcomes Strong consensus
B1-2 Assessment In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, muscle mass, physical performance and the degree of systemic inflammation. Strength of recommendation: STRONG Level of evidence: Very low Questions for research: Linking outcomes from current and future intervention trials with appropriate screening and assessment tools Consensus
Section B2: Energy and substrate requirements B2-1 Energy requirements We recommend, that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day. Strength of recommendation: STRONG Level of evidence: Low Questions for research: improve prediction of energy requirements in the individual patient Consensus
B2-2 Protein requirement We recommend that protein intake should be above 1 g/kg/day and, if possible up to 1.5 g/kg/day Strength of recommendation: STRONG Level of evidence: Moderate Questions for research: effect on clinical outcome of increased supply (1-2 g/kg/day) and composition of protein/amino acids Strong consensus
B2-3 Choice of energy substrates In weight-losing cancer patients with insulin resistance we recommend to increase the ratio of energy from fat to energy from carbohydrates. This is intended to increase the energy density of the diet and to reduce the glycemic load. Strength of recommendation: STRONG Level of evidence: Low Questions for research: effect of a high fat diet on clinical outcome in patients with systemic inflammation/insulin resistance effect of varying the fat composition Consensus
B2-4 Vitamins and trace elements We recommend that vitamins and minerals be supplied in amounts approximately equal to the RDA and discourage the use of high-dose micronutrients in the absence of specific deficiencies. Strength of recommendation: STRONG Level of evidence: Low Questions for research: Assessment of micronutrient status in cancer patients and effect of supplementation Strong consensus
Section B3: Nutrition Interventions B3-1 Efficacy of nutritional intervention We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms), and offering oral nutritional supplements. Strength of recommendation: STRONG Level of evidence: Moderate Questions for research: effect of dietary advice and ONS on clinical outcome Consensus
B3-2 Potentially harmful diets We recommend to not use dietary provisions that restrict energy intake in patients with or at risk of malnutrition. Strength of recommendation: STRONG Level of evidence: Low Questions for research: Effects of fasting or fasting mimicking diets on wanted and unwanted effects of anticancer agents Strong consensus
B3-3 Modes of nutrition: when to escalate If a decision has been made to feed a patient, we recommend enteral nutrition if oral nutrition remains inadequate despite nutritional interventions (counselling, ONS), and parenteral nutrition if enteral nutrition is not sufficient or feasible. Strength of recommendation: STRONG Level of evidence: Moderate Questions for research: effect of EN or PN or combinations on clinical outcome in patients with inadequate food intake Strong consensus
B3-4 Refeeding syndrome If oral food intake has been decreased severely for a prolonged period of time, we recommend to increase (oral, enteral or parenteral) nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome. Strength of recommendation: STRONG Level of evidence: Low Questions for research: Assessment of phosphate, potassium and magnesium levels in malnourished cancer patients and response to artificial feeding Consensus
B3-5 Home artificial nutrition In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home artificial nutrition (either enteral or parenteral) in suitable patients Strength of recommendation: STRONG Level of evidence: Low Questions for research: Effect of long-term EN and PN on clinical outcome Strong consensus
Section B4: Exercise B4-1 Exercise in combination with nutrition We recommend maintenance or an increased level of physical activity in cancer patients to support muscle mass, physical function and metabolic pattern. Strength of recommendation: STRONG Level of evidence: High Questions for research: effect of physical activity before, during and after anticancer treatment on clinical outcome, effect of combining an exercise program with nutritional support in curative and palliative settings Consensus
B4-2 Type of exercise recommended We suggest individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass. Strength of recommendation: WEAK Level of evidence: Low Questions for research: Differential and combined effects of resistance and endurance exercise on clinical outcome during anticancer therapy, in survivors and as a component of supportive and palliative care Strong consensus
Section B5: Pharmaconutrients and Pharmacological Agents B5-1 Corticosteroids to increase appetite We suggest considering corticosteroids to increase the appetite of anorectic cancer patients with advanced disease for a restricted period of time (1-3 weeks) but to be aware of side effects (e.g. muscle wasting, insulin resistance, infections). Strength of recommendation: WEAK Level of evidence: High Questions for research: Better define settings for a beneficial effect of corticosteroids Consensus
B5-2 Progestins to increase appetite Strength of recommendation: WEAK We suggest considering progestins to increase the appetite of anorectic cancer patients with advanced disease but to be aware of potential serious side effects (e.g. thromboembolism). Level of evidence: High Questions for research: Prospective studies to evaluate the combined effects of appropriate nutritional support and progestins Consensus
B5-3 Cannabinoids to improve appetite Strength of recommendation: - There are insufficient consistent clinical data to recommend cannabinoids to improve taste disorders or anorexia in cancer patients Level of evidence: Low Questions for research: Effects of cannabinoids on nutritional state in anorectic cancer patients with taste alterations Consensus
B5-4 Androgens to increase muscle mass Strength of recommendation: - There are insufficient consistent clinical data to recommend currently approved androgenic steroids to increase muscle mass Level of evidence: Low Questions for research: Mechanism and long term effects of SARMs in patients with cachexia. Consensus
B5-5 Amino acids to increase fat free mass Strength of recommendation: - There are insufficient consistent clinical data to recommend the supplementation with branched-chain or other amino acids or metabolites to improve fat free mass. Level of evidence: Low Questions for research: Effects of leucine or HMB (hydroxy methylbutyrate) in weight losing patients studied in large randomized trials Strong consensus
B5-6 Non steroidal antiinflammatory drugs (NSAID) to increase body weight Strength of recommendation: - There are insufficient consistent clinical data to recommend nonsteroidal antiinflammatory drugs to improve body weight in weight losing cancer patients. Level of evidence: Low Questions for research: Effect of NSAID on body composition and clinical outcome in cancer patients with systemic inflammation Strong consensus
B5-7 N-3 fatty acids to improve appetite and body weight Strength of recommendation: WEAK In patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished, we suggest to use supplementation with long-chain N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass and body weight. Level of evidence: Low Questions for research: Effect of long chain N-3 fatty acids on body composition and clinical outcome in cancer patients undergoing antineoplastic treatment. Effect of long chain N-3 fatty acids on quality of life and clinical outcome in patients with cancer cachexia. Strong consensus
B5-8 Prokinetic drugs to improve early satiety Strength of recommendation: WEAK In patients complaining about early satiety, after diagnosing and treating constipation, we suggest to consider prokinetic agents, but to be aware of potential adverse effects of metoclopramide on the central nervous system and of domperidone on cardiac rhythm Level of evidence: Moderate Questions for research: Effect of prokinetics on oral nutritional intake in the context of optimal nutritional counselling Consensus
|
