Nutrition Therapy in the Management of Gynecologic Malignancies: Addendum
Fredric V. Price
Table Of Contents
Fredric V. Price, MD
DEVELOPMENTS IN NUTRITION THERAPY FOR GYNECOLOGIC CANCER PATIENTS|
Two factors have arisen in the last decade that limit the use of nutritional therapy in the population of women with gynecologic malignancies. The more significant has been the drive to reduce medical costs by attaching more significance to “evidence-based” clinical care. The accrual of evidence of benefit of nutritional therapy in most situations has been slow and unconvincing. Older evidence described in this chapter leads to the conclusion that supplemental nutrition benefits only a minority of malnourished gynecologic cancer patients. The second most important influence on the utilization of nutritional therapy is the improvement in palliative alternatives such as hospice care and treatment of terminal bowel obstruction by nonsurgical means. Coupled with this improvement in the practice of palliative care has been a new acceptance of the concept of futility in terminal care. More patients, families, and clinicians accept that the best way to maintain quality of life in the final months may be to limit high-tech interventions such as parenteral nutrition.
|DEVELOPMENTS IN NUTRITION THERAPY FOR GYNECOLOGIC CANCER PATIENTS|
The prevalence of malnutrition in gynecologic oncology patients remains high. Santoso and coworkers1 studied nutritional parameters in 67 consecutive gynecologic oncology patients at Parkland Memorial Hospital using standardized criteria. The study included indigent patients with tumors from various primary sites (58% had cervical cancer) and early as well as advanced stages of disease; the prevalence of malnutrition was 54% overall. The analysis of the effects of malnutrition showed that the adverse effects of malnutrition were limited to women who were admitted for surgery. The effects were independent of age, extent of disease, or primary tumor. Malnourished women had a 50% longer length of hospital stay (6 versus 9 days). Serum albumin levels correlated well with clinical malnutrition and was inversely correlated with length of hospital stay.
The concept of prolonged bowel rest with nasogastric suction following extensive abdominal surgery has been challenged by general and intestinal surgeons. A meta-analysis published by Cheatham and associates2 demonstrated that nasogastric suction was useful only for a tiny minority of patients. In addition, several well-executed studies are looking at groups of women undergoing gynecologic cancer surgery.47,48 The result of this change in philosophy is that patients are resuming oral calorie intake sooner. The change in utilization of nasogastric suction has been one influence on the observed decrease in hospital stay. It has also undoubtedly reduced the indication for parenteral nutrition owing to prolonged bowel rest. Schilder and colleagues3 reported that reductions in hospital stay were seen, with no significant increase in gastrointestinal complications. In fact, as noted by Kelly and Stanhope,4 many gastrointestinal surgeons place needle catheter jejunostomies as (described previously) for postoperative feeding beginning immediately postoperatively.
Peripherally inserted central venous catheters have gained acceptance in centers in which interventional radiologists are skilled in implanting them. The advantages are fewer complications at insertion, lower cost, and improved cosmetic result. These catheters can be used for blood and chemotherapy infusions and have achieved a degree of acceptance in the gynecologic oncology community.5
Nutritional therapy remains controversial in the context of treatment of gynecologic cancer. Evidence-based criteria exist for only a small subset of patients. As in the noncancer population, treatment is most effective for patients with self-limited nutritional problems. Nutritional therapy can also be justified when chronic pre-existing nutritional problems render curative therapy difficult. In addition, some patients will suffer intestinal injuries, such as fistulas or obstruction from radiation and surgery, and may have an indication for nutritional support for that reason as an adjunct to effective repair. Supplementation is not generally useful as a palliative component of terminal care.