Nutrition in advanced cancer care : a clinical perspective

Sammanfattning: Adequate nutrition is an essential part in all stages of cancer care. By optimizing the nutrition care the benefits include increased tolerance to treatment as well as decreased mortality. Understanding how aspects of nutrition care in patients diagnosed with cancer, such as appetite, protein, albumin, and C-Reactive Protein (CRP), as well as body image, are intertwined are potentially important factors in clinical practice. All studies in the thesis were performed among patients diagnosed with advanced cancer admitted to Advanced Medical Home Care in Stockholm, Sweden. In men diagnosed with advanced cancer, who had lost weight since diagnosis, we found an inverse association between weight loss and “physical functioning”, as measured by the RAND-36 domain, β = -1.34 (95%CI: -2.44,- 0.24 (study I). In women, we found that weight loss was associated with improvement in the RAND-36 domain role “limitations due to physical health”; β = 2.02 (95%CI:0.63,3.41). Women reported a more distressed body image than men (p = 0.02), which remained significant when only women that had lost weight after diagnosis were included. Further, we found an association between weight loss in men and body image distress, β = 0.22 (95%CI:0.07,0.37). The aim of study II was to compare how high-protein parenteral nutrition (PN) affects the liver compared to standard PN. We found no significant difference in the proportion of patients with elevated liver enzymes in the high-protein PN group; OR 0.20 (95%CI:0.02,1.86). Patients that have received high-protein PN had a significantly higher weight at follow-up when compared to patients administered a PN containing standard amount of protein (p < 0.05). In study III we found a significant correlation in men between low appetite, measured by the Edmonton Symptom Assessment System (ESAS), and low albumin (r = 0.27, p < 0.001). In men, lower appetite was also correlated with a higher CRP (r = 0.27, p < 0.001). In regression analysis, adjusted for confounding factors, the results remained similar. In women, there was no correlation between appetite and albumin or CRP. In a cohort analysis (study IV) moderate and poor appetite were significantly associated with a higher mortality rate when compared to participants reporting a good appetite; HR 1.44 (95%CI:1.16,1.79) and HR 1.78 (95%CI:1.39,2.29), respectively (study IV). We also found that participants with low albumin levels (< 25 g/L), and participants in the highest tertile of CRP/albumin ratio, had higher mortality rates, HR 5.35 (95%CI:3.75,7.63) and HR 2.66 (95%CI:2.12,3.35), when compared to participants with high albumin levels (>36 g/L) and participants in the lowest tertile of CRP/albumin ratio. The associations were more pronounced in men than in women.