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Jenny Turcott



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    IASLC Pre-Conference School of Nursing (ID 3)

    • Event: LALCA 2019
    • Type: Invited Speaker Session
    • Track:
    • Presentations: 1
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      PC3.12 - Nutritional Support of the Lung Cancer Patient (ID 37)

      09:00 - 15:30  |  Author(s): Jenny Turcott

      • Abstract
      • Slides

      Lung cancer (LC) has the most lethal mortality rate between all the cancer types. In newly diagnosed LC patients the 5-year survival is estimated in 5-16%. Malnutrition is considered as a pivotal to decrease quality of life, prognosis and survival in LC. At the time of diagnosis, malnutrition can be observed in at least 45% of the patients and this proportion increase as the disease progression. LC patients present a considerable symptom burden, and are at a high risk of involuntary weight loss. Anorexia, dysgeusia and cachexia are among the main factors that affect nutritional status. Over one half of the patients diagnosed with advanced LC experience anorexia (loss of appetite) and 35% of treatment naïve Non Small Cell Lung Cancer (NSCLC) patients reported disgeusia (taste alteration), proportion increased until 56% in patients treated with chemotherapy and 66% in patients treated with radiotherapy. Anorexia and dyspepsia are directly related with lower energy and nutrimental consumption and contribute to the development of cachexia. Cachexia is mainly characterized by the loss of muscle mass induced by cancer associated inflammatory response. Early assessment of nutritional status, including the determination of anorexia, dysgeusia and risk of cachexia in LC patients is imperative in order to timely treat them to improve prognosis. Nutritional support should be focused individualizing the nutritional risks confronting each patient, including mainly the energy balance of the diet, achieve energy needs, assess the need of nutritional supplements consumption or alternative ways of feeding.

      There are recently available tools for an easy and fast assessment of nutritional risk in LC patients. The nutritional risk evaluation of LC patients should include the anorexia cachexia scale (ACS) section from the Functional Assessment of Anorexia–Cachexia Therapy (FAACT). ACS has been validated in LC patients identifying a cutoff value of ?32 (sensitivity: 80.3% and specificity: 85%) for the determination of anorexia with the propose of consider an stimulant of appetite to achieve the energy requirements. Dysgeusia can be defined as a taste alteration and can be perceived as a distortion of taste (dysgeusia), absence of taste (ageusia), decreased detection sensitivity (hypogeusia), or increased sensitivity to any or all tastes (hypergeusia). But disgeusia is closely related with quality of life because obstruct the pleasure of eat. So the identification of the magnitude of dysgeusia is the annoyance that represent for the LC patient. One of the most widely used tests is the taste and smell survey (TSS), which is a 16-item questionnaire that can help guide the taste alteration complain and give advice to improve the sense of taste making the eating process a more pleasant experience. Moreover, a cachexia grading system which takes into consideration body mass index (BMI) and weight loss to stratify patients into 5 risk categories (0 [pre-cachexia] - 4 [refractory cachexia]) was performed from a data set population of 8,160 heterogeneous cancer patients, with significant impact on survival according to the risk grade category.

      After 8-weeks of treatment, patients who received Nabilone increased their caloric-intake (342-kcal) compared to patients receiving placebo (p = 0.040). However it was discontinued in Mexico. Another option considered to improve appetite is mirtazapina, available in Mexico and with preliminary reported improvement of appetite. Moreover, there is a current randomized clinical trial running in Instituto Nacional de Cancerología of Mexico comparing mirtazapine versus placebo in NSCLC-patients for the evaluation of improvement of appetite, energy-intake and quality-of-life. On the other hand, since dysgeusia is presented before treatment, nutritional-advice should start at LC diagnosis to prevent or improve the taste disturbances. Preparing food with-reduced or absence altogether of condiments, choosing foods with a milder flavor, with a cold or warm temperature which could be more enjoyable to the patients. Additionally, LC patients classified with cachexia-grading system showed those with low-risk had a significantly longer survival compared with intermediate or high risk (Figure-1).

      The highlights after the opportune nutritional risk evaluation of LC patients are concentrated in reach an optimums proportion of proteins, carbohydrate and lipids in the caloric intake including if is necessary oral nutritional supplements (ONS). Cancer patients consuming two ONS per day during 8 weeks after their first cycle of chemotherapy showed increment in body weight, fat-free mass, skeletal muscle mass, body cell mass, and fat mass compared to those without ONS. Once the cachexia is evident, a multitargeted approach seems essential for its treatment, including combination of nutritional support, appetite stimulants drugs and a suitable program of pulmonary rehabilitation and/or physical exercises. The food plan should be centralized in the complete symptoms burden and be promoting the enjoyment of eating. It is important to start as early as possible for avoid progression of cachexia stage even before weight loss can be presented.The continuous follow up of patients should be approximately every 3 weeks. The future of the multidisciplinary approach to the management of LC patients must therefore not overlook the important role of nutrition in the quality of life and clinical outcomes.

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