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前情提要
第三章、特定患者类型相关干预 C1、手术 C1-1、术后加速康复（ERAS）管理 C1-2、手术：肿瘤综合治疗路径 C1-3、术后和出院后管理 C1-4、围手术期的免疫营养（精氨酸、n-3脂肪酸、核苷酸） C2、放疗 C2-1、放疗：确保充足的营养摄入 C2-2、放疗：使用管饲 C2-3、放疗：维持吞咽功能 C2-4、放射性腹泻：谷氨酰胺 C2-5、放射性腹泻：益生菌 C2-6、放疗：使用肠外营养 C3、肿瘤内科：治愈性或姑息性抗癌药物治疗 C3-1、肿瘤内科：确保充足的营养 C3-2、肿瘤内科：使用肠内和肠外营养 C3-3、肿瘤内科：使用谷氨酰胺 C4、肿瘤内科：大剂量化疗和造血干细胞移植（HCT） C4-1、大剂量化疗和HCT：确保充足的营养和身体活动 C4-2、大剂量化疗和HCT：肠内和肠外营养 C4-3、大剂量化疗和HCT：细菌含量低的饮食 C4-4、大剂量化疗和HCT：谷氨酰胺 C5、癌症生存者 C5-1、癌症生存者：身体活动 C5-2、癌症生存者：体重和生活方式 C6、无法接受抗癌治疗的晚期癌症患者 C6-1、晚期癌症：筛查和评定 C6-2、晚期癌症患者的营养支持 C6-3、非常晚期的终末阶段 Chapter C: Interventions Relevant to Specific Patient Categories Section C1: Surgery C1-1 Enhanced recovery after surgery (ERAS) care Strength of recommendation: STRONG For all cancer patients undergoing either curative or palliative surgery we recommend management within an enhanced recovery after surgery (ERAS) program; within this program every patient should be screened for malnutrition and if deemed at risk, given additional nutritional support. Level of evidence: High Questions for research: optimal components including nutrition of ERAS protocol for oncology patients. The role of immunonutrition (arginine, n-3 fatty acids, nucleotides) when upper GI cancer patients are managed within an ERAS pathway. The role of n-3 enriched oral supplements/enteral nutrition in upper GI cancer patients for preservation of lean body mass and optimisation of organ function. Consensus
C1-2 Surgery: Multimodal oncological pathway Strength of recommendation: STRONG For a patient undergoing repeated surgery as part of a multimodal oncological pathway, we recommend management of each surgical episode within an ERAS program. Level of evidence: Low Questions for research: role of multimodal rehabilitation during prolonged oncological therapy Consensus
C1-3 Postsurgical care and care after hospital discharge Strength of recommendation: STRONG In surgical cancer patients at risk of malnutrition or who are already malnourished we recommend appropriate nutritional support both during hospital care and following discharge from hospital. Level of evidence: Moderate Questions for research: The optimal post-operative regimen in terms of type, preparation and access to normal food +/- oral nutritional supplements for patients managed within an ERAS pathway. Consensus
C1-4 Immunonutrition (arginine, n-3 fatty acids, nucleotides) in perioperative care Strength of recommendation: STRONG In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care we recommend oral/enteral immunonutrition. Level of evidence: High Questions for research: Specifying the role of the individual constituents of immunonutrition regimens Strong consensus
Section C2: Radiotherapy C2-1 Radiotherapy: Ensuring adequate nutritional intake Strength of recommendation: STRONG We recommend that during radiotherapy (RT)-with special attention to RT of the head and neck, thorax and gastrointestinal tract - an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of oral nutritional supplements (ONS), in order to avoid nutritional deterioration, maintain intake and avoid RT interruptions Level of evidence: Moderate Questions for research: Effect of nutritional support on clinical outcome including survival Strong consensus
C2-2 Radiotherapy: Use of tube feeding Strength of recommendation: STRONG We recommend enteral feeding using naso-gastric or percutaneous tubes (e.g. PEG) in radiation-induced severe mucositis or in obstructive tumors of the head-neck or thorax. Level of evidence: Low Questions for research: Effect of prophylactic/early enteral feeding on clinical outcome. Effect of specialized enteral formula on nutritional status and clinical outcome. Strong consensus
C2-3 Radiotherapy: Maintaining swallowing function Strength of recommendation: STRONG We recommend to screen for and manage dysphagia and to encourage and educate patients on how to maintain their swallowing function during enteral nutrition. Level of evidence: Low Questions for research: Effect of swallowing exercise on dysphagia in patients receiving enteral feeding Strong consensus
C2-4 Radiation-induced diarrhea: glutamine Strength of recommendation: - There are insufficient consistent clinical data to recommend glutamine to prevent radiation-induced enteritis/diarrhea, stomatitis, esophagitis or skin toxicity. Level of evidence: Low Questions for research: Effect of glutamine on oral/esophageal mucositis and skin toxicity Strong consensus
C2-5 Radiation-induced diarrhea: probiotics Strength of recommendation: - There are insufficient consistent clinical data to recommend probiotics to reduce radiation-induced diarrhea. Level of evidence: Low Questions for research: Effect of probiotics on radiation-induced diarrhea and treatment completion rate Strong consensus
C2-6 Radiotherapy: Use of parenteral nutrition Strength of recommendation: STRONG We do not recommend parenteral nutrition (PN) as a general treatment in radiotherapy but only if adequate oral/enteral nutrition is not possible, e.g. in severe radiation enteritis or severe malabsorption Level of evidence: Moderate Questions for research: Comparing feasibility and efficacy of enteral vs parenteral nutrition in patients requiring artificial nutrition Consensus
Section C3: Medical oncology: Curative or palliative anticancer drug treatment C3-1 Medical oncology: Ensuring adequate nutrition Strength of recommendation: STRONG During anticancer drug treatment we recommend to ensure an adequate nutritional intake and to maintain physical activity. Level of evidence: Very low Questions for research: Effects of nutritional intervention during cytostatic and targeted therapies on treatment tolerance, response to treatment and overall survival Strong consensus
C3-2 Medical oncology: Use of enteral and parenteral nutrition Strength of recommendation: STRONG In a patient undergoing curative anticancer drug treatment, if oral food intake is inadequate despite counselling and oral nutritional supplements (ONS), we recommend supplemental enteral or, if this is not sufficient or possible, parenteral nutrition. Level of evidence: Very low Questions for research: In patients with inadequate nutritional intake, who are undergoing curative anticancer drug treatment:
Effect of artificial nutrition on treatment tolerance, treatment completion, relapse rate and overall survival Effect of enteral vs parenteral nutrition on complications, treatment completion, relapse rate and overall survival
C3-3 Medical oncology: Use of glutamine Strength of recommendation: - There are insufficient consistent clinical data to recommend glutamine supplementation during conventional cytotoxic or targeted therapy. Level of evidence: Low Questions for research: Effect of glutamine on drug-induced neuropathy Strong consensus
Section C4: Medical oncology: High-dose chemotherapy and hematopoietic stem cell transplantation (HCT) C4-1 High-dose chemotherapy and HCT: Ensuring adequate nutrition and physical activity Strength of recommendation: STRONG During intensive chemotherapy and after stem cell transplantation we recommend to maintain physical activity and to ensure an adequate nutritional intake. This may require enteral and/or parenteral nutrition. Level of evidence: Very low Questions for research: Effects of physical actvity on clinical outcome Strong consensus
C4-2 High-dose chemotherapy and HCT: Enteral and parenteral nutrition Strength of recommendation: WEAK If oral nutrition is inadequate we suggest preferring enteral tube feeding to parenteral nutrition, unless there is severe mucositis, intractable vomiting, ileus, severe malabsorption, protracted diarrhea or symptomatic gastrointestinal graft versus host disease (GvHD). Level of evidence: Low Questions for research: Comparing efficacy of enteral vs parenteral nutrition on clincal outcome and complication rates Strong consensus
C4-3 High-dose chemotherapy and HCT: Low bacterial diet Strength of recommendation: - There are insufficient consistent clinical data to recommend a low bacterial diet for patients more than 30 days after allogeneic transplantation Level of evidence: Low Questions for research: Definition of factors predicting beneficial effects of a low bacterial diet. Comparing benefits of food safety guidelines vs neutropenic diet Strong consensus
C4-4 High-dose chemotherapy and HCT: Glutamine Strength of recommendation: - There are insufficient consistent clinical data to recommend glutamine to improve clinical outcome in patients undergoing high-dose chemotherapy and hematopoetic stem cell transplantation. Level of evidence: Low Questions for research: Effect of glutamine on mucositis, diarrhea, clinical infections, graft versus host disease and malignancy relapse rate Strong consensus
Section C5: Cancer survivors C5-1 Cancer survivors: Physical activity Strength of recommendation: STRONG We recommend that cancer survivors engage in regular physical activity. Level of evidence: Low Questions for research: Effects of physical activity on physical function, recurrence and survival in cancer survivors Consensus
C5-2 Cancer survivors: Body weight and lifestyle Strength of recommendation: STRONG In cancer survivors we recommend to maintain a healthy weight (BMI 18.5-25 kg/m²) and to maintain a healthy lifestyle, which includes being physically active and a diet based on vegetables, fruits and whole grains and low in saturated fat, red meat and alcohol. Level of evidence: Low Questions for research: Effects of a healthy diet on metabolic syndrome, quality of life, cancer relapse rates and overall survival Strong consensus
Section C6: Patients with advanced cancer receiving no anticancer treatment C6-1 Advanced cancer: Screening and assessment Strength of recommendation: STRONG We recommend to routinely screen all patients with advanced cancer for inadequate nutritional intake, weight loss and low body mass index, and if found at risk, to assess these patients further for both treatable nutrition impact symptoms and metabolic derangements. Level of evidence: Low Questions for research: Effects of malnutrition screening programs combined with multidisciplinary interventions on quality of life in cancer patients with advanced disease Consensus
C6-2 Nutrition support in patients with advanced cancer Strength of recommendation: STRONG We recommend offering and implementing nutritional interventions in patients with advanced cancer only after considering together with the patient the prognosis of the malignant disease and both the expected benefit on quality of life and potentially survival as well as the burden associated with nutritional care. Level of evidence: Low Questions for research: Effects of nutritional care on quality of life in patients with advanced cancer Consensus
C6-3 Very advanced terminal phase Strength of recommendation: STRONG In dying patients, we recommend that treatment be based on comfort. Artificial hydration and nutrition are unlikely to provide any benefit for most patients. However, in acute confusional states, we suggest to use a short and limited hydration to rule out dehydration as precipiting cause. Level of evidence: Low Questions for research: Predicting reversibilty in acute confusional states Strong consensus
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