No difference No difference

15 NA NA

16 NA No difference 21 NA Better

64 No difference No difference

Note: NA = not available.

Source: From Cancer: Principles and Practice of Oncology, 5th ed., Lippincott-Raven, 1997, p.2849. With permission.

radiation-induced reactions are usually of limited duration and, for this reason, tend to interfere with the nutritional status to a lesser extent than the permanent chronic consequences of irradiation. Weight loss and malnutrition tend to develop particularly in patients in whom segments of the gastrointestinal tract are subjected to irradiation.

The use of aggressive nutritional support in patients undergoing radiation therapy has been most extensively studied in individuals who have aero digestive cancers, because such patients tend to have mechanical difficulties with deglutition, they have a high prevalence of substantial malnutrition,117 and radiation therapy is a commonly used modality of treatment in this cancer population. Table 12.6 lists the results of prospective randomized trials examining the role of nutritional support in cancer patients treated with radiation therapy. These trials do not demonstrate any consistent significant benefit in terms of survival or treatment toxicity. In patients with head and neck cancers, nutritional support has also been shown to significantly improve objective indicators of the quality of life,118 which may be enough to justify its use for these types of patients.

recommendations for nutritional support in cancer patients

A thorough review of the literature of nutritional support in cancer patients has only served to demonstrate the inconsistency and methodologic flaws of various well-intentioned clinical trials. Most of the data for these studies come from the use of parenteral and enteral nutrition in the perioperative period. However, the increasing role of multimodality therapy also brings chemotherapy and radiation therapy into the equation. The following recommendations come from an attempt to combine the conclusions from the aforementioned reports with a realistic commonsense desire to provide the cancer patient with the best chance for a successful intervention, whatever the modality.

For cancer patients undergoing elective major oncologic surgery, perioperative nutritional support is indicated in the following situations:

1. When no oral intake is anticipated for 7 to 10 d postoperatively, enteral feedings should be initiated 2 to 3 d after the operation. This can be accomplished through a nasoduodenal feeding tube or a feeding jejunos-tomy placed at the time of operation. If the risk of aspiration is low, and there are no surgical anastomotic concerns, a nasogastric or surgical gastrostomy tube can be used as well. If the gut cannot be used, then parenteral feedings should be initiated postoperatively.

2. If after 7 d the patient cannot take oral nutrition when it was originally thought he or she would be able to, then parenteral nutrition should be initiated at that time. A nasogastric or nasoduodenal feeding tube can then be inserted and enteral feedings started at the same time. It usually takes 3 to 4 d to reach caloric goals, and the TPN can then be decreased as the enteral feedings are increased.

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