Chapter 3.4
Oesophageal cancer and nutrition
Orla Hynes and Saira Chowdhury
Guy’s and St Thomas’ NHS Trust, London, UK
Oesophageal cancer occurs predominantly in the older population, mainly after the age of 65 years, and is more prevalent in men [1]. It is associated with poor survival rates of up to 14% at 5 years [2]. The morbidity associated with the disease and its treatments, in an ageing population, is high. Disease location, treatment effects and anxiety challenge the nutritional well-being of this group of patients who are recognised to have high supportive care needs. Nutrition interventions play an important role across the cancer journey, from diagnosis through to survivorship and end-of-life care [3–7].
3.4.1 Aetiology
The past 40 years have seen a sharp rise in the incidence of the oesophageal adenocarcinoma subtype within Western countries. This has been linked to rising obesity levels. Principal risk factors for oesophageal adenocarcinoma are obesity, gastro-oesophageal reflux disease and subsequent Barrett’s oesophagus. Oesophageal squamous cell carcinoma risk is higher amongst smokers and those with a history of a high alcohol intake. Achalasia, the thermal effect of hot food and beverages, corrosive oesophageal injury, Plummer–Vinson syndrome and tylosis are also influential in the aetiology of the squamous cell carcinoma subtype [8,9].
3.4.2 Effects of disease on nutrition
Oesophageal cancer is usually advanced at diagnosis, with less than 60% having resectable disease [10]. Common presenting symptoms are dysphagia, which arises once less than 1.5 cm of the oesophageal lumen remains, weight loss and odynophagia with incidence at diagnosis of 74%, 57% and 20% respectively [11]. Sarcopenia is present in 57% of patients with oesophagogastric cancer prior to starting curative treatment with chemotherapy before surgery which is further exacerbated by treatment [12]. Advanced oesophageal cancers are associated with a high incidence of loss of appetite, early satiety and pain which may have a negative impact on quality of life and the prognostic indicators weight loss and Performance Status [13,14]. Performance status is a scale used in oncology to assess how well a person is able to undertake ordinary daily activities while living with cancer. It is also used to determine whether someone is fit to proceed with treatment and also as an indicator of how well they may be responding to treatment.
3.4.3 Treatment and nutrition
Multimodality treatment is standard practice in most early-stage cancers. It may last many months, combining chemotherapy, radiotherapy, surgery and oesophageal stenting. The cumulative effects of these treatments increase morbidity and impair quality of life. When combined with symptoms of disease, these result in nutritional compromise, warranting varying levels of nutritional intervention to improve treatment tolerance and preserve performance status.
Chemotherapy
Nutritional side-effects include stomatitis, taste changes, nausea and vomiting, anorexia, altered bowel habit and fatigue. Weight loss before treatment increases the incidence of severe treatment-related dose-limiting toxicities, failure to complete chemotherapy and unplanned hospital admissions [15]. Failure to complete the prescribed treatment can impair its efficacy and influence prognosis. The principles of nutritional management during chemotherapy are to minimise the risk of chemotherapy-related toxicity due to weight loss, enable the patient to complete treatment at the intended dose and regimen, preserve performance status and preserve quality of life. Oral nutritional support is suitable where intake is impaired to the extent that dietary counselling and oral supplements are adequate to maintain nutritional status. Introduction of enteral nutrition (EN) should be considered where significant weight loss has occurred and/or where treatment and disease-related morbidity cause significant difficulty with achieving dietary adequacy [16].
Patients receiving multimodality treatments are at a greater nutritional risk due to the cumulative side-effects and treatment duration. Therefore dietetic interventions should plan for and consider this to preserve performance status and avoid interruption to treatment. A centre placing prophylactic jejunostomy feeding tubes at diagnosis showed that 42% of patients require artificial feeding during neoadjuvant chemotherapy, leading to significant weight gain compared with those who did not feed [17].
Endoscopic gastrostomy tube insertion is not recommended in oesophageal cancer. This is due to the potential presence of an impassable oesophageal tumour, stomach infiltration of oesophagogastric junctional tumours and risk of introducing stoma metastasis. All types of gastrostomy tube placement should be avoided in surgical candidates prior to curative resection as there is a risk of compromising the use of the stomach as an oesophageal substitute at oesophagectomy [18]. A transnasal feeding tube can be placed safely where needed at any point through treatment. Nutritional difficulties and weight loss are common in the months following oesophageal cancer surgery and this may compromise continuing further treatment. A jejunostomy tube may be placed intraoperatively and has the advantage of providing nutrition support after discharge from hospital.
Radiotherapy
Side-effects of radiotherapy are dependent on treatment dose. High-dose radiotherapy is usually combined with chemotherapy (chemoradiation) with a curative intent. The most common side-effects are oesophagitis causing pain, exacerbation of dysphagia and weight loss. This, combined with the aforementioned side-effects of chemotherapy and the duration of chemoradiation, leads to significant nutritional risk. Australian guidelines on dietetic intervention for radiotherapy recommend the following goals of nutritional intervention: to minimise weight loss, maintain quality of life and provide symptom control [19]. All patients receiving radiotherapy to the GI tract, including the oesophagus, should be referred to the dietitian (Grade A) and should receive at least fortnightly intensive dietary counselling with combined oral supplementation for patients during radiotherapy with follow-up continuing for at least 6 weeks after treatment completion [16,19].
Enteral nutrition (EN) is needed in almost three-quarters of patients undergoing oesophageal chemoradiation [20]. Preservation of nutritional status can improve treatment tolerance and reduce unplanned hospital admission [19]. This may be facilitated by placement of a prophylactic feeding tube [21,22]. Current guidelines recommend EN if an obstructing tumour results in dysphagia and causes difficulty with dietary adequacy [16,19]. Odelli et al. suggest gastrostomy placement prior to embarking on oesophageal chemoradiation in patients with weight loss of at least 10%, a Body Mass Index (BMI) less than 18 or when a patient is only able to swallow a purée consistency or less [22].
The side-effects of dysphagia and oesophagitis may last up to several weeks or a few months after completing treatment and so regular dietetic review remains important. Late effects of this treatment are benign oesophageal stricturing and stenosis due to tissue fibrosis. Management is usually with a series of oesophageal dilations and sometimes oesophageal stent placement with artificial feeding being required in the interim.
Surgery
The surgical resection of the malignant oesophageal tumour remains the principal curative treatment [5,23]. This may be on its own or as part of a multimodality treatment plan. Oesophagectomy is carried out for mid to lower oesophageal cancers and some oesophagogastric junction tumours. It may also be performed in rare cases where definitive chemoradiotherapy has failed.
Enhanced recovery after surgery
The enhanced recovery after surgery (ERAS) approach to pre-, peri- and postoperative care has major benefits for many patients in relation to quicker recovery following major surgery and shorter hospital stay, with no increase in readmission rates. Enhanced recovery after surgery is becoming standard practice for most patients undergoing major surgery in the UK.
Postoperative major surgery-related complications are a predictor of reduced quality of life after oesophageal resection, and any measures that can reduce the risk of complications can decrease the negative impact on quality of life [24].
Early identification and treatment of undernutrition
Preoperative weight loss is an independent risk factor for the onset of postoperative complications in patients with GI cancer [25]. All patients with oesophageal cancer should be screened using a validated nutritional screening tool. Guidelines recommend that patients with severe nutritional risk receive nutritional support, preferably using the enteral route for 10–14 days prior to major surgery, even if surgery has to be delayed [5,26].
Immunonutrition
Immunonutrition refers to EN which contains substrates that are postulated to ameliorate the postoperative immune response, modulate the postoperative inflammatory response and upregulate GI microperfusion and oxygen metabolism. An immunonutrition enteral formula commonly used in upper GI malignancies is enriched with omega-3 fatty acids, arginine, ribonucleic acid and soluble fibre. A prospective, randomised, double-blind study was performed on 206 elective surgery patients with cancer of the stomach, pancreas, colon and rectum. Patients receiving perioperative immunonutrition experienced a significantly lower rate of postoperative infections and had a shorter length of stay compared to the control group who received perioperative isonitrogenous, isocaloric liquid feed. Interestingly, the benefits were seen in both well-nourished and undernourished patients [27]. Similar findings are reflected in another study where patients with GI cancer undergoing surgery received pre- and perioperative immunonutrition compared with no nutritional support. Length of hospital stay was shorter in the pre- and perioperative groups. Interestingly, there was no statistical difference between the preoperative and perioperative groups which suggests that preoperative immunonutrition is sufficient in inferring the benefits [28].
Immunonutrition has been shown to be cost-effective in well-nourished patients [29]. A meta-analysis of all randomised clinical trials using immunonutrition identified an optimum dosage of 0.5–1 L/day. Supplementation for 5 days before surgery contributed to reduced morbidity in elective surgical patients, particularly those undergoing GI surgery [30]. European guidelines give a Grade A recommendation for the use of immunonutrition for 5–7 days preoperatively, independent of nutritional risk [26].
Preoperative carbohydrate loading
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