ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology

SummaryParenteral nutrition offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake is inadequate and enteral nutrition is not feasible, is contraindicated or is not accepted by the patient.These guidelines are intended to provide evidence-based recommendations for the use of parenteral nutrition in cancer patients. They were developed by an interdisciplinary expert group in accordance with accepted standards, are based on the most relevant publications of the last 30 years and share many of the conclusions of the ESPEN guidelines on enteral nutrition in oncology.Under-nutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis and, per se, responsible for excess morbidity and mortality. Many indications for parenteral nutrition parallel those for enteral nutrition (weight loss or reduction in food intake for more than 7–10 days), but only those who, for whatever reason cannot be fed orally or enterally, are candidates to receive parenteral nutrition. A standard nutritional regimen may be recommended for short-term parenteral nutrition, while in cachectic patients receiving intravenous feeding for several weeks a high fat-to-glucose ratio may be advised because these patients maintain a high capacity to metabolize fats. The limited nutritional response to the parenteral nutrition reflects more the presence of metabolic derangements which are characteristic of the cachexia syndrome (or merely the short duration of the nutritional support) rather than the inadequacy of the nutritional regimen. Perioperative parenteral nutrition is only recommended in malnourished patients if enteral nutrition is not feasible. In non-surgical well-nourished oncologic patients routine parenteral nutrition is not recommended because it has proved to offer no advantage and is associated with increased morbidity. A benefit, however, is reported in patients undergoing hematopoietic stem cell transplantation. Short-term parenteral nutrition is however commonly accepted in patients with acute gastrointestinal complications from chemotherapy and radiotherapy, and long-term (home) parenteral nutrition will sometimes be a life-saving maneuver in patients with sub acute/chronic radiation enteropathy. In incurable cancer patients home parenteral nutrition may be recommended in hypophagic/(sub)obstructed patients (if there is an acceptable performance status) if they are expected to die from starvation/under nutrition prior to tumor spread.Summary of statements: Non-surgical OncologySubjectRecommendationsGradeNumberNutritional statusNutritional assessment of all cancer patients should begin with tumor diagnosis and be repeated at every visit in order to initiate nutritional intervention early, before the general status is severely compromised and chances to restore a normal condition are fewC1.1Total daily energy expenditure in cancer patients may be assumed to be similar to healthy subjects, or 20–25 kcal/kg/day for bedridden and 25–30 kcal/kg/day for ambulatory patientsC1.4The majority of cancer patients requiring PN for only a short period of time do not need a special formulation. Using a higher than usual percentage of lipid (e.g. 50% of non-protein energy), may be beneficial for those with frank cachexia needing prolonged PN (Grade C)C1.5IndicationsTherapeutic goals for PN in cancer patients are the improvement of function and outcome by:C2.1
•  preventing and treating under-nutrition/cachexia,
•  enhancing compliance with anti-tumor treatments,
•  controlling some adverse effects of anti-tumor therapies,
•  improving quality of lifePN is ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failureA2.1PN is recommended in patients with severe mucositis or severe radiation enteritisC2.1Nutritional provisionSupplemental PN is recommended in patients if inadequate food and enteral intake (<60% of estimated energy expenditure) is anticipated for more than 10 daysC2.2PN is not recommended if oral/enteral nutrient intake is adequateA2.2In the presence of systemic inflammation it appears to be extremely difficult to achieve whole body protein anabolism in cancer patients. In this situation, in addition to nutritional interventions, pharmacological efforts are recommended to modulate the inflammatory responseC2.3Preliminary data suggest a potential positive role of insulin (Grade C). There are no data on n-3 fatty acidsC2.4Peri-operative carePeri-operative PN is recommended in malnourished candidates for artificial nutrition, when EN is not possibleA3.1Peri-operative PN should not be used in the well-nourishedA3.1During non-surgical therapyThe routine use of PN during chemotherapy, radiotherapy or combined therapy is not recommendedA3.2If patients are malnourished or facing a period longer than one week of starvation and enteral nutritional support is not feasible, PN is recommendedC3.2Incurable patientsIn intestinal failure, long-term PN should be offered, if (1) enteral nutrition is insufficient, (2) expected survival due to tumor progression is longer than 2–3 months),(3) it is expected that PN can stabilize or improve performance status and quality of life, and (4) the patient desires this mode of nutritional supportC3.3There is probable benefit in supporting incurable cancer patients with weight loss and reduced nutrient intake with “supplemental” PNB3.4Hematopoietic stem cell transplantation (HSCT)In HSCT patients PN should be reserved for those with severe mucositis, ileus, or intractable vomitingB3.5No clear recommendation can be made as to the time of introduction of PN in HSCT patients. Its withdrawal should be considered when patients are able to tolerate approximately 50% of their requirements enterallyC3.6HSCT patients may benefit from glutamine-supplemented PNB3.7Tumor growthAlthough PN supplies nutrients to the tumor, there is no evidence that this has deleterious effects on the outcome. This consideration should therefore have no influence on the decision to feed a cancer patient when PN is clinically indicatedC4.1Full-size tableTable optionsView in workspaceDownload as CSV