Lessons in Supportive Care, V: Nutritional Therapy
Special Feature
Lessons in Supportive Care, V: Nutritional Therapy
By Thomas J. Smith, MD
Is it better to die fat and happy?
Case: R.N. is a 43 year old carpenter with slowly progressive pancreatic cancer and intestinal obstruction. His performance status is still ECOG 1, and he wants to finish the house he is building for his family. Your managed care organization (MCO) will allow total parental nutrition (TPN), but the funds will come out of the internal medicine budget (yours!). It will mean that someone else does not get care, like an anti-arrhythmic or cholecystectomy. Do you give TPN?This case is not from St. Paul or Sacramento, 1997; it is from the Indian Health Service, North Dakota 1982 where I was in general practice. Besides making house calls on snow shoes and delivering babies, I got invaluable experience in working in under-funded MCOs. The controversy about appropriate use of nutrition has continued even here, to the land of poor ice fishing. (Archer SB, et al. Adv Surg 1996;29:165-89; Gallagher-Allred CR, et al. J Am Diet Assoc 1996;96:361-366, 369; Ottery FD. Semin Oncol 1995;22:98-111. Tchekmedyian NS. Oncology (Huntingt) 1995;9(11 Supp):79-84.)
Nutrition therapy accounts for an unknown amount of health care dollars, as much is out of pocket. Interventions cost from $52/month (make your own) to $8,400/month for TPN. (Tchekmedyian NS. Op cit.] What do we get from these expenditures? In oncology, we use two strategies to keep people fat and happy:
• making people eat with megesterol or prednisone, or
• increasing calories with enteral or total parenteral nutrition (TPN).
What is the evidence that these work? This topic has been the subject of recent reviews and some well -designed studies.
Do cancer patients lose weight?
Yes. More than half of lung and colon cancer patients lose weight. And it is a bothersome symptom.Is there evidence that reversing weight loss with nutrition gives better survival?
There’s the rub. The new and comprehensive review by Souba is very helpful. (Souba WW. N Engl J Med 1997;336:41-48.] The short answer is yes and no, as outlined in Table 1.These answers are remarkably similar to the findings of a meta-analysis and national expert consensus panel of internists in 1989. (American College of Physicians. Ann Intern Med 1989;110:734-736. Klein S, et al. Cancer 1986;58:1378-1386.)
The limited positive evidence for bone marrow transplant (BMT) is surprising in its impact. For instance, TPN was associated with longer survival (21 months vs 7 months) as well as improved nutritional status. (Weisdorf SA, et al. Transplantation 1987;43:833-838.) A study of enteral vs. TPN feedings in BMT concluded that both were effective, but that many enteral feeding patients would eventually require TPN. (Szeluga DJ, et al. Cancer Res 1987;47:3309-3316.) However, this study was done in the pre-hematopoietic growth factor (CSF) era, and the shorter length of neutropenia and hospital stay at present would tend to minimize the differences.
Table 1
Indications of Weight Loss Reversal for Better Survival
Outcomes improved enough Indication to warrant useBone marrow transplant Yes Improves survival outcomes
Patients unable to eat for Yes > 10-14 days Preserves pre-morbid nutritional status
Patients unable to eat for No < 10 days
Routine cancer treatment No Possible but unproven exceptions are those patients who cannot eat for > 10 days, whose disease is controlled and whose only impediment is nutritio
AIDS care No Possible but unproven effects
There is also a lot of nutrition therapy being used for questionable indications. Souba reviews the evidence for nutrition therapy and finds no proof of efficacy in the treatment of AIDS, routine surgery except as above, liver and renal failure, and critically ill non-trauma patients. He notes that surrogate outcomes such as protein levels or weight can be misleading, as has been noted in other types of clinical trials. (Fleming TR, DeMets DL. Ann Intern Med 1996;125:605-613.) (Take this review to your next internal medicine staff meeting, and investigate the practices of your GI, renal, and ID colleagues!)
Can we improve anorexia?
Yes. The available data, well known to oncologists, is that one-third to one-half of patients will improve their appetite with megesterol acetate. (Tchekmedyian NS, et al. Cancer 1992;69:1268-1274; Loprinzi CL, et al. J Clin Oncol 1993;11:762-767.) This relief of anorexia is often welcomed by patients, care givers and health care providers, and has manageable side effects (in my practice, mostly fluid retention.) It is unclear from the published studies how long the relief of anorexia lasts, but anecdotally, it is usually weeks or months until the disease progresses.Does improving anorexia make a difference in cancer treatment outcomes?
Survival is the same. Patient well-being is improved in AIDS patients (Von Roenn JH, et al. Ann Intern Med 1994;121:393-399; Oster MH, et al. Ann Intern Med 1994;121:400-408.), and in cancer patients. (Loprinzi CL, et al. Op cit.) The improvements with lower doses, such as 160 mg daily, may be nearly as substantial as with doses of 800 mg daily.Other outcomes such as costs and cost-effectiveness have not been reported. The cost-effectiveness ($/year of life gained) of a nutritional supplement would be immeasurably high since it does not add any survival in years (like any palliative medicine, even narcotics.) The only way that nutritional treatments would fit the economic mold would be for the quality-of-life increment to be very high, but a formal cost-utility analysis has not been reported.
The costs of different types of megesterol acetate at my local pharmacy are listed in Table 2. In the absence of cost-effectiveness data, a reasonable compromise would be to use 160 mg suspension or tablets daily for 7-14 days as a trial, and continue only if the patient felt better and gained non-edema weight. A two-week trial, or 120 mL of suspension, would cost only $30.
Table 2
Costs of Megesterol Acetate
Megesterol Product Cost for one month supplytablets 40 mg qid. $132
suspension 800 mg daily $298
suspension 400 mg daily $149
What if we used nutritional supplements and treated anorexia, together?
There is no data to suggest this is or is not helpful.Take-out message
We can improve survival outcomes in bone marrow transplant patients, and others with controlled disease who will not eat for more than 10 days, with nutritional interventions. For all others, we do not have proof that nutritional interventions improve any standard survival outcome. In many cases, such as some GI and small-cell lung cancer, we have proof that nutritional therapy does not work. In these cases, nutritional therapy cannot be recommended. Feelings of anorexia can be helped with low doses of megestrol acetate.Nutritional or hydration therapy cannot be recommended in the dying patient unless it will help symptoms. There is no medical or ethical obligation to provide food or water when it will not change outcome, just as there is no obligation to provide ineffective bone marrow transplantation or cardiac surgery.
Anorexia symptoms can occasionally be relieved by the use of megesterol acetate, with no change in survival outcomes. A cost-conscious approach would be to give 160 mg suspensions or tablet (whichever is cheaper and more convenient for the patient) for a two-week trial, discontinue it in the half of patients for whom it does not work, and discontinue it for the others when it stops working.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.