Implications of nutritional issues in the older cancer patient
Prof Matti Aapro - Clinique de Genolier, Vaud, Switzerland
When you have older patients with cancer nutrition, I’m gathering from your presentations here in Prague, could be quite an important issue. Why are you focussing on nutrition?
Nutrition is one of many aspects in the general support of cancer patients that plays a very, very important role that we haven’t really focussed on but we should really focus on because there is sufficient data among our colleagues in geriatrics to show that patients that are at home present in maybe 20-30% of the cases signs of malnutrition. Patients that are already in nursing homes will present in 50-70% of the cases malnutrition and malnutrition equals many more problems. These many more problems will, at the end, equate to less tolerability of surgery and less tolerability of chemotherapy.
What sort of things are going wrong because doctors understand drugs and treatments very well but, from what you’re saying, the dietary input could be crucial.
Dietary input is crucial, not in the short term, but many elderly patients, for various reasons, don’t have an adequate dietary input. They already have, because of the aging process, a process of loss of muscle mass called sarcopenia and when you put on top of that insufficient quality of nutrition you can have quite a few issues. Let’s take a simple example – patients will have insufficient intake of calcium and vitamin D, after 5-10 years they will develop a demineralisation of the bone. In other words they will have osteopenia and osteopenia will then become osteoporosis then we’ll have a fracture and after the fracture they will have a pulmonary embolism and they will die. So this is short, undramatic way of representing that malnutrition can be a very serious condition.
Can this be corrected by using supplements or do you have to work out a whole dietary package?
I believe that adequate nutrition does not need for a majority of the patients special supplements except in patients that have insufficient mineralisation of the bones. Before using calcium and vitamin D we should think of exercise and then we can add drugs like the bisphosphonates and denosumab. For patients that have malnutrition and weight loss, the first thing is to try to see what are the dietary habits. So some patients it will be necessary to add supplements and some patients have malnutrition because they have no appetite and we do have some promising new agents that have not yet been approved that might modify the situation in some cancer patients undergoing cancer treatment.
You mentioned exercise there and nutrition and exercise go together. What do you recommend patients? Clearly if you have cancer you might not be feeling well enough to take a lot of exercise.
You are putting the finger right on one of the issues which is that there is universal recommendation to increase the level of exercise, not only because of cancer but because of cardiovascular issues also. It was a unanimous vote at the adjuvant treatment of breast cancer meeting in St Gallen a few years ago that exercise should be suggested. In the adjuvant setting when the patients have been operated for a cancer it’s relatively easy, especially breast cancer situations, not like bowel cancer where it’s a little bit more difficult to start immediately exercise. But you’re right, in advanced cancer it’s somewhat more difficult but even there there’s sufficient indication that, for example, the fatigue that patients have can be best controlled if we can increase their level of exercise. It doesn’t need to be strenuous exercise, what I personally call the chambers of torture which are those places in hotels where they have all these machines that you go to and hotels will say, ‘We have a nice room for this,’ I say, ‘Yes, you have a nice chamber of torture.’ You don’t need that, you just have to convince the patient if only possible to have a brisk walk for fifteen minutes a day carrying a couple of kilograms, not more than that, and that not after one week, not after two weeks but after two months will make a difference.
Can you tell me about the G8 screening tool that you’re using?
The G8 screening tool is one of many screening tools that are available in order to understand whether an elderly patient is at a risk of having a relatively short lifespan or a much longer lifespan. In this tool several of the items, it’s G8 because there are eight items and several of these items are related to the patient’s nutritional status and to the patients capability of exercising and moving around, showing how important these factors are in establishing the general health of the person and potentially the fact that these people might tolerate some of the cancer treatments better. It’s not ideal at all for the evaluation of tolerability of chemotherapy but it’s a very nice discriminating tool in order to then go further with the help of geriatricians and better evaluate these patients and also to evaluate them for tolerability of chemotherapy and of anaesthesia and surgery with other tools.
So what do you think are the main messages coming out of this for cancer doctors in nutrition and exercise?
There is a very simple tool which is the MNA, which is the minimal nutritional assessment. It’s very simple to apply but already looking at a very simple factor, patient’s weight. If you have in your chart as a GP your patient’s weight and your patient was, let’s say, 75kg last year, presents with some cancer symptoms and has lost 10kg you know this patient is going to be very poorly. It might not be related to the fact that the patient is not eating well any more, it may be related to a changed metabolism but nevertheless this is a very important indicator. Then asking the patient on their general dietary habits what do they have for breakfast, lunch and dinner and you’ll realise that many elderly patients have an insufficient intake and then you realise that actually you ask them, ‘Oh yes, my weight was 80kg five years ago now it is 70kg.’ it’s not usually a good sign. Sometimes it can be when they were at 95kg and now they’re at 85kg it’s probably better but going from 80kg to 70kg for a gentleman who is 185cm might not be ideal.
So in a few words what should doctors be doing, a call to action?
A call to action – ask your patients about their weight and ask your patients about what are they eating and how do they compare their appetite compared to people around them. If they say, ‘I don’t eat as much as…’ that’s a sign that maybe something is wrong.