Parenteral Nutrition in Oncological Patients in Current ESPEN Recommendations

The Importance of Nutritional Care in Oncology

Malnutrition is a common phenomenon in oncological patients and can be a consequence of the cancer itself or pharmacological or surgical treatment. Malnutrition negatively affects the course of therapy, quality of life, and in 10–20% of patients, it is the cause of death from cancer. Although nutrition plays a crucial role in the multimodal care of oncological patients, malnutrition is still an underestimated and inadequately addressed problem in clinical practice.

General Guidelines for Oncological Patients

Nutritional issues need to be identified as early as possible, so food intake assessment and monitoring of weight and body mass index (BMI) should be initiated in the early stages of the disease in cancer patients. If the nutritional status worsens, a more detailed assessment of nutrition-related parameters is necessary. The total energy expenditure in oncological patients should generally be similar to that of healthy individuals, ranging between 25 and 30 kcal/kg/day. Protein intake should exceed 1 g/kg/day, and if possible, reach up to 1.5 g/kg/day. Vitamin and mineral intake should correspond to the recommended daily allowance, and they should not be administered in high doses unless there is a deficiency of specific vitamins and other substances.

Circumstances for Using Parenteral Nutrition

According to ESPEN recommendations, oncological patients at risk of malnutrition or with proven malnutrition should undergo nutritional intervention aimed at increasing oral food intake, including the administration of oral nutritional supplements (ONS). If artificial nutrition is necessary, the ESPEN guidelines recommend starting with enteral nutrition, and only if this type of artificial nutrition is not possible or sufficient for the patient, parenteral nutrition is considered.

For cancer patients who are unable to take in food orally or have an affected upper gastrointestinal tract, enteral nutrition is appropriate. Conversely, for individuals with severe intestinal damage associated with radiation colitis, intestinal obstruction, short bowel syndrome, or peritoneal carcinomatosis, parenteral nutrition is suitable to meet nutritional needs. The clinical practice, contraindications, complications, and monitoring of the administration process of enteral and parenteral nutrition do not differ between oncological patients and those with benign conditions. However, the risks of parenteral nutrition are considered significantly higher than its benefits in oncological patients with a prognosis of 2 months or less.

ESPEN experts do not recommend the routine administration of parenteral nutrition in patients undergoing radiotherapy. This type of nutrition should only be considered if oral or enteral nutrition is not possible, does not ensure sufficient energy intake, or if patients suffer from severe malabsorption. Parenteral nutrition is pertinent, for example, in patients with severe nausea, vomiting, abdominal pain, or diarrhea.

During intensive chemotherapy and post-stem cell transplantation, enteral or parenteral nutrition may be necessary according to ESPEN guidelines to ensure sufficient energy intake and to prevent body weight and lean body mass loss. Many patients undergoing autologous and especially allogeneic stem cell transplantation are already malnourished at the start of the therapy, and parenteral nutrition provides the necessary nutrition with mixtures containing all essential nutrients.

Nutrition After Cancer

The guidelines issued by ESPEN in 2021 also include nutritional recommendations for patients who have undergone cancer treatment. Their body mass index (BMI) should range between 18.5 and 25 kg/m^2, their diet should include all essential nutrients, and they should avoid burdening the body with overweight or obesity. Obesity and metabolic syndrome can be risk factors for cancer recurrence and shorter survival in patients who have undergone, among others, breast or stomach cancer.

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Source: Muscaritoli M., Arends J., Bachmann P. et al. ESPEN practical guideline: Clinical nutrition in cancer. Clin Nutr 2021 May; 40 (5): 2898–2913, doi: 10.1016/j.clnu.2021.02.005.