ReviewNutritional Support in Lung Cancer Patients: The State of the Art
Introduction
Lung cancer (LC), with over 2 million new cases in 2018, represents the most commonly diagnosed neoplasm worldwide for both sexes and remains the leading cause of cancer mortality with more than 18% of total cancer deaths.1 LC is a heterogeneous neoplasm and is classified into small-cell LC, representing 10% to 15% of the total, and non–small-cell LC (NSCLC), which comprises squamous-cell disease, adenocarcinoma, and other histotypes.2 LC treatment, which is strictly dependent on the tumor, node, metastasis classification system (TNM) assigned to the primary neoplasm, is represented by surgery for resectable diseases and, in selected cases, by a combination of radiotherapy (RT) and chemotherapy (CHT) for locally advanced/metastatic disease.2 In the last few years, a significant improvement in the understanding of the multiple biochemical pathways involved in the LC molecular pathogenesis has dramatically changed the landscape of its management, with the development of different treatment strategies targeting molecular alterations and their activated pathways, like checkpoint inhibitors, both in front-line therapy and in later lines of advanced therapy.3, 4, 5
Although these newer targeted and personalized therapies are generally more effective and better tolerated compared to standard CHT, maintaining good performance status and adequate nutritional condition could represent a further improvement for LC treatment.
Malnutrition is a well-determined clinical condition defined as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition ..., decreased fat-free mass, and body cell mass, leading to diminished physical and mental function and impaired clinical outcome from disease.”6 This clinical condition can increase the risk of developing complications and even decrease the response to therapies.7 Different aspects contribute to develop cancer-related malnutrition: inadequate caloric intake, metabolic derangements, depression, fatigue, CHT-induced toxicity leading to loss of skeletal muscle mass and systemic inflammation syndrome, in which acute phase proteins, such as C-reactive protein, serum albumin levels (ALB), and white blood cell count are altered.8 Traditionally, ALB has been used to assess malnutrition rates in different clinical settings,9 and in LC patients, lower ALB has also been associated with a higher incidence of CHT-induced toxicity10,11 and a worse overall survival (OS).12,13 Other biochemical parameters, like higher platelet-to-lymphocyte ratios, C-reactive protein, and serum interleukin-6 levels, have been related to worse OS in LC patients,14 and a recent meta-analysis reported a high predictive role of ALB-to-globulin ratio for OS and disease-free survival in the same setting.15 Prognostic nutritional index, obtained by ALB and total lymphocyte count in peripheral blood, represents an interesting parameter that should be evaluated in LC patients.16,17 Indeed, a recent review and meta-analysis conducted on 21 studies found that NSCLC patients with a low prognostic nutritional index, obtained by ALB and total lymphocyte count in peripheral blood, had shorter OS [hazard ratio (HR) = 1.59; 95% confidence interval (CI), 1.28-1.96; P = .001], disease-free survival (HR = 1.74; 95% CI, 1.08-2.80; P = .017), and progression-free survival (PFS) (HR = 1.52; 95% CI, 1.26-1.83; P = .002).18 Similar conclusions were obtained in another meta-analysis, in which a lower prognostic nutritional index was associated with a worse OS (HR = 1.61; 95% CI, 1.44-1.81; P < .001).19
Data from the literature show that cancer-related malnutrition is still an underrecognized and undertreated burden in clinical practice.20 As a result of the multiple aspects of cancer-related malnutrition, multimodal therapeutic strategies should be used to prevent and treat malnutrition in LC patients, aiming to improve clinical and survival outcomes.21
The aim of this review was to identify the rate of malnutrition, the burden of body composition (BC) changes, and the impact of different nutritional strategies in LC patients.
Section snippets
Materials and Methods
This review was conducted on Medline, from inception to 2020, using the term “lung neoplasm” linked with:
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“Nutrition” or “malnutrition” for “Nutritional Screening in Lung Cancer Patients.”
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“Weight loss” or “body composition” or “bioimpedentiometric analysis” or “muscle mass” for “Weight Loss and Body Composition Changes in Lung Cancer Patients.”
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“ERAS” or “lung surgery” for “Nutrition in Surgical Lung Cancer Patients.”
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“Diet” or “nutritional advice” or “nutritional support” or “medical nutrition”
Nutritional Screening in Lung Cancer Patients
Today, the most accurate way to detect the risk of malnutrition and eventually to assess its presence is to conduct multimodal tests. The most widely used for screening is the Nutrition Screening Risk 2002 (NRS-2002), while the Mini Nutritional Assessment test (MNA), the Subjective Global Assessment (SGA), and the Patient-Generated Subjective Global Assessment (PG-SGA) are generally used for diagnosis.22, 23, 24, 25
In 2019, Global Leadership Initiative on Malnutrition (GLIM) criteria for the
Weight Loss and Body Composition Changes in Lung Cancer Patients
WL and BC changes are frequently experienced by LC patients during the therapeutic process.51, 52, 53 BC can be assessed through various methods: bioimpedance analysis (BIA), dual-energy X-ray absorptiometry, and computed tomographic (CT) scan.54,55
Nutrition in Surgical Lung Cancer Patients
It is well known that a patient’s body weight before surgery may affect surgical outcomes of patients with resectable LC. A large French study, performed using the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, evaluated data from 19,635 patients who had undergone a lobectomy for a primary LC between 2005 and 2011. The authors showed that underweight patients (BMI < 18.5 kg/m2) presented more surgical (air leakages and bronchial dehiscence) and
Nutritional Intervention in Lung Cancer Patients
According to the European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines, nutritional counseling should represent the first and most important way to manage malnourished neoplastic patients by prescribing a personalized diet.21,111
Kiss et al112 performed a pilot study of 24 LC patients during RT who were randomized to receive intensive nutritional counseling or standard nutritional care; they found greater general satisfaction, higher weight and fat-free mass gain, and more
Conclusion
LC is one of the most common cancers worldwide; however, although malnutrition is frequent in LC patients, this aspect is underestimated and thus undertreated.131 In the modern setting of highly personalized cancer therapies, it is desirable that the maintenance of a good nutritional status becomes a key achievement in the oncologic pathway, allowing the oncologist to use all the potential CHT lines and RT treatments against LC.
Although this review of the current literature does not allow us to
Disclosure
E.B. has received speaker and travel fees from MSD, Astra-Zeneca, Celgene, Pfizer, Helsinn, Eli-Lilly, BMS, Novartis, and Roche; has received consultant fees from Roche and Pfizer; and has received institutional research grants from AstraZeneca and Roche. The other authors have stated that they have no conflict of interest.
Acknowledgments
E.B. is currently supported by the Associazione Italiana per la Ricerca sul Cancro (AIRC) under investigator grant IG20583; and is currently supported by Institutional funds of Università Cattolica del Sacro Cuore (UCSC-project D1-2018/2019). G.T. is supported by AIRC, IG18599, and AIRC 5x1000 21052. The authors thank Philip Egger for his English-language editorial work.
References (131)
- et al.
Lung cancer: biology and treatment options
Biochim Biophys Acta Rev Cancer
(2015) - et al.
Molecular biology of lung cancer: clinical implications
Clin Chest Med
(2011) - et al.
ESPEN guidelines on definitions and terminology of clinical nutrition
Clin Nutr
(2017) - et al.
ESPEN guidelines on nutrition in cancer patients
Clin Nutr
(2017) - et al.
Subjective global assessment (SGA) score could be a predictive factor for radiation pneumonitis in lung cancer patients with normal pulmonary function treated by intensity-modulated radiation therapy and concurrent chemotherapy
Clin Lung Cancer
(2018) - et al.
Clinical significance of preoperative serum albumin level for prognosis in surgically resected patients with non–small cell lung cancer: comparative study of normal lung, emphysema, and pulmonary fibrosis
Lung Cancer
(2017) - et al.
Prognostic value of pretreatment albumin to globulin ratio in lung cancer: a meta-analysis
Nutr Cancer
(2020) - et al.
Predictive impact for postoperative recurrence using the preoperative prognostic nutritional index in pathological stage I non–small cell lung cancer
Lung Cancer
(2016) - et al.
Pretreatment prognostic nutritional index as a prognostic factor in lung cancer: review and meta-analysis
Clin Chim Acta
(2018) - et al.
ESPEN expert group recommendations for action against cancer-related malnutrition
Clin Nutr
(2017)
Subjective global assessment of nutritional status—a systematic review of the literature
Clin Nutr
Clinically relevant determinants of body composition, function and nutritional status as mortality predictors in lung cancer patients
Lung Cancer
ESPEN guidelines for nutrition screening, 2002
Clin Nutr
Evaluation of nutritional status in non–small-cell lung cancer: screening, assessment and correlation with treatment outcome
ESMO Open
Serum antioxidant levels and nutritional status in early and advanced stage lung cancer patients
Nutrition
Baseline nutritional evaluation in metastatic lung cancer patients: Mini Nutritional Assessment versus weight loss history
Ann Oncol
Mini Nutritional Assessment (MNA) and biochemical markers of cachexia in metastatic lung cancer patients: interrelations and associations with prognosis
Lung Cancer
Muscle derangement and alteration of the nutritional machinery in NSCLC
Crit Rev Oncol Hematol
Five-year survival and prognostic factors according to histology in 6101 non–small-cell lung cancer patients
Respir Med Res
The effect of weight change during treatment with targeted therapy in patients with metastatic renal cell carcinoma
Clin Genitourin Cancer
Prediagnosis weight loss, a stronger factor than BMI, to predict survival in patients with lung cancer
Lung Cancer
Premorbid body mass index and mortality in patients with lung cancer: a systematic review and meta-analysis
Lung Cancer
Bioelectrical impedance analysis—part I: review of principles and methods
Clin Nutr
Bioelectrical impedance analysis—part II: utilization in clinical practice
Clin Nutr
Assessment of preoperative nutritional status using BIA-derived phase angle (PhA) in patients with advanced ovarian cancer: correlation with the extent of cytoreduction and complications
Gynecol Oncol
Malnutrition is a prognostic factor in patients with hepatocellular carcinoma (HCC)
Clin Nutr
Altered tissue electric properties in lung cancer patients as detected by bioelectric impedance vector analysis
Nutrition
Association between low muscle mass and survival in incurable cancer patients: a systematic review
Nutrition
Muscle mass, assessed at diagnosis by L3-CT scan as a prognostic marker of clinical outcomes in patients with gastric cancer: a systematic review and meta-analysis
Clin Nutr
Skeletal muscle radiodensity is prognostic for survival in patients with advanced non–small cell lung cancer
Clin Nutr
Clinical implications of sarcopenia in patients undergoing complete resection for early non–small cell lung cancer
Lung Cancer
Effect of adipose tissue volume on prognosis in patients with non–small cell lung cancer
Clin Imaging
Cachexia—sarcopenia as a determinant of disease control rate and survival in non–small lung cancer patients receiving immune-checkpoint inhibitors
Lung Cancer
The prognostic value of early onset, CT derived loss of muscle and adipose tissue during chemotherapy in metastatic non–small cell lung cancer
Lung Cancer
Prediction of 90 day and overall survival after chemoradiotherapy for lung cancer: role of performance status and body composition
Clin Oncol
Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries
CA Cancer J Clin
Molecular biology of lung cancer
J Thorac Dis
Immunotherapies for NSCLC: are we cutting the Gordian helix?
Anticancer Res
The role of malnutrition and muscle wasting in advanced lung cancer
Curr Oncol Rep
Nutritional laboratory markers in malnutrition
J Clin Med
Association of nutritional status and serum albumin levels with development of toxicity in patients with advanced non–small cell lung cancer treated with paclitaxel-cisplatin chemotherapy: a prospective study
BMC Cancer
Impact of malnutrition in advanced non–small cell lung cancer
Tunis Med
Association of nutrition parameters including bioelectrical impedance and systemic inflammatory response with quality of life and prognosis in patients with advanced non–small-cell lung cancer: a prospective study
Nutr Cancer
Postoperative prognostic nutritional index as a prognostic factor after non–small cell lung cancer surgery
Gen Thorac Cardiovasc Surg
Prognostic value of pretreatment prognostic nutritional index in non–small cell lung cancer: a systematic review and meta-analysis
Int J Biol Markers
Unmet needs in clinical nutrition in oncology: a multinational analysis of real-world evidence
Ther Adv Med Oncol
Assessing nutritional status in cancer: role of the patient-generated subjective global assessment
Curr Opin Clin Nutr Metab Care
Risk, prevalence, and impact of hospital malnutrition in a tertiary care referral university hospital: a cross-sectional study
Intern Emerg Med
GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community
J Parenter Enter Nutr
Evaluation of the global leadership initiative on malnutrition criteria using different muscle mass indices for diagnosing malnutrition and predicting survival in lung cancer patients
J Parenter Enter Nutr
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2022, NutritionCitation Excerpt :Their consequences are prolonged hospitalization, higher incidence and severity of treatment-related toxicity and postsurgical complications, reduced response to cancer treatment, impaired quality of life (QoL), and worse overall prognosis [2]. These effects have been reported also in people with lung cancer (LC) [3–5], in whom the prevalence of nutritional derangements is relevant after diagnosis [6,7]. Over the past two decades, the availability of innovative therapeutic strategies, such as targeted therapy and immunotherapy, has substantially contributed to changing the treatment paradigm in non–small cell lung cancer (NSCLC), as well as improving prognosis and life expectancy [8].
The prognostic value of skeletal muscle index on clinical and survival outcomes after cytoreduction and HIPEC for peritoneal metastases from colorectal cancer: A systematic review and meta-analysis
2022, European Journal of Surgical OncologyCitation Excerpt :BC assessment, obtained from the analysis of a single L3 slice by CT scan, is considered the gold standard in the oncological setting, due to the images routinely available for tumor staging [40]. Furthermore, different studies showed that low SMI correlated with poorer survival outcomes and higher chemotherapy-induced toxicity [41,42]. As remarked by the PSOGI group at the 11th International Congress on Peritoneal Surface Malignancies, a preoperative malnutrition screening, a plan of nutritional prehabilitation and an early nutritional intervention after surgery is recommendable [39].
Short-term Nutritional Support of Abalone Muscle Proteinon Lewis Lung Cancer Chemotherapy Mice
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