Undernutrition in elderly patients with cancer: Target for diagnosis and intervention

doi:10.1016/j.critrevonc.2008.04.005

Critical Reviews in Oncology/Hematology

Volume 67, Issue 3, September 2008, Pages 243-254

https://doi.org/10.1016/j.critrevonc.2008.04.005 Get rights and content

Abstract

In recent years, geriatricians and oncologists have worked together to evaluate elderly patients with cancer before and during treatment, to estimate the balance between the efficacy and safety of chemotherapy and to upgrade treatment in this population according to their comorbidity and physiological status. The clinical and biological factors of this population need to be assessed in multidisciplinary comprehensive geriatric assessment (CGA) in order to optimize treatment without inducing major adverse effects. We reviewed the nutritional aspects of this evaluation that highlight the impact of undernutrition on poor survival. In this paper we briefly describe tumoral cachexia (molecular and physiological), the impact of undernutrition on cancer prognosis (predictive factors), therapeutic effects of cancer on nutritional status, nutritional indicators (biological, anthropometric) and undernutrition in the elderly (specific needs of this population). The potential for nutritional intervention in geriatric oncology with regard to CGA is explored.

Introduction

The number of elderly patients older than 70 years in France and in the industrialized world is steadily increasing. In 2002, the average life expectancy at 75 years was 12 years for both males and females. At that time in Aquitaine, France, 273,741 individuals were over 75 years and represented 9.2% of the population. The incidence of cancer at this age was 72,000 new cases per year in France in 2000. Older subjects (>70 years) represent more than 40% of patients with cancer [1]. Diagnosis and treatment of older patients is one of the priorities of the cancer campaign set up by the French government. Despite the difficulties of physicians to evaluate the ratio between risk and benefits, the fears of patients and their families, studies focusing on elderly patients have been conducted in recent years [2], [3]. The few oncologic therapeutic studies conducted in this older population have shown excellent results with tolerable toxicities [4], [5], [6] despite the presence of comorbidity (cardio-vascular diseases, diabetes, hypertension, etc.).

Undernutrition is frequent after 70 years of age due to inadequate dietary intake and particularly protein intake [7]. It is now considered as one of the criteria of frailty in older patients due to the major association of undernutrition with altered cognition, mobility, mood, physiological status and quality of life in environmental, social and familial contexts [8]. Nutritional prognostic factors during medical treatments are poorly understood. No simple specific undernutrition marker is available in daily practice. Furthermore, independently of tumor specificity, central anorexia was noted to differing degrees associated with hypothalamic dysfunction interfering via an inflammatory process with serotoninergic systems or neuropeptides that control dietary intake. Interactions between inflammatory mediators, nutritional status, tumor course, chemotherapy-related events and survival are likely.

We aimed to describe the influence of undernutrition in elderly patients with cancer on cancer course and prognosis and to explore any positive effects of nutritional interventions in geriatrics.

Section snippets

Tumoral cachexia

Cancer is generally associated with undernutrition, particularly in advanced stages. Cancer cachexia is characterized by a slow weight loss consequence of abnormal metabolic activity and anorexia, altered immune function, modified prognosis, and decreased efficacy of chemotherapy regimens (Table 1) [9], [10].

The cancer process involves extensive tissue remodeling including modulation of numerous cellular activities and tissue functions [11]. Cytokine expression (Il-1β, Il-2, Il-6, TNFα, IFNγ,

Impact of undernutrition on neoplastic pathology prognosis

The notion of nutritional status involves the association of several markers (Table 2). Anthropometric parameters include weight, weight changes expressed as percent of initial body mass, BMI (body mass index weight (kg/m²)), skin fold and calculation of muscle area. The most widely used anthropometric measures are BMI and percent of recent weight loss. When baseline weight or healthy weight is not known, it is possible to refer to ideal body weight determined with the Lorentz formulae. Dietary

Undernutrition and elderly patients

Undernutrition in the elderly may result from various causes including inactivity, cachexia from other pathologies, physical inabilities, cancer and cancer treatments. Frail elderly patients are characterized by decreasing functional, psychological and social capacities as attested by progressive decline in functional, cognitive and social activities. Decreased dietary intake that is not identified by relatives is common in such subjects. All these modifications lead to a lower nutritional

Cancer treatment effects

Standard therapeutic measures may contribute to undernutrition and must be considered in any decision about nutrition. Surgery, chemotherapy [71] and radiotherapy [72] alone or associated can induce different acute or delayed toxicities at different levels of the digestive tract. Nausea and vomiting are more frequent events during chemotherapy cycles and anti-emetics are prescribed preventively [73]. Several drugs can induce mucositis, a frequently reported event. Although this disorder can

Nutritional intervention in cancerology

Oral, enteral and parenteral nutritional interventions have been studied in trials with small numbers of patients. The impact of renutrition in patients with severe loss of weight (>10%) was demonstrated pre- and postoperatively [54], but few studies have examined non-surgical treatment in cancer pathology.

Nutritional intervention in undernourished patients with cancer seems to improve their nutritional status, quality of life and prognosis. Enteral or parenteral intervention modalities have

Conclusion

To date, no biological marker or single clinical diagnostic marker of nutritional status in oncology or CGA has been identified. A combination of markers easily used in, routine screening such as MNA, NRI or GNRI could allow better access to care. Moreover, undernourished patients with cancer could suffer from increased mortality compared with well-nourished patients, even if they are progression-free. The qualitative and quantitative benefits of nutrition in elderly patients with or without

Conflict of interest

There is no conflict of interest.

Reviewers

Dr. Nathalie Jacquelin-Ravel, Clinique de Genolier, 1 route du Muids Genolier 1272, Switzerland.

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Christele Blanc-Bisson graduated on 16th September 2002 in biology at University Victor Segalen Bordeaux 2 (France) and University of Liege (Belgium). She studied metalloproteinase activity produced by myofibroblasts from stroma in breast and liver cancer. Since May 2002, she has participated in geriatric oncology research in Aquitaine, south-west France and onco-hematology research at the Institut Bergonie cancer center in Bordeaux (Director Pr P Soubeyran). In January 2007, she joined the geriatric department of the University Hospital of Bordeaux to take part in the INOGAD clinical trial, which investigates the effect on survival of nutritional support in elderly cancer patients at risk of undernutrition (main investigator Pr Bourdel-Marchasson).

Marianne Fonck (physician in oncology), Muriel Rainfray (Professor in geriatrics) and Pierre Soubeyran (Professor in onco-hematology) are founders of the oncogeriatric group in Aquitaine and Isabelle Bourdel-Marchasson (Professor in geriatrics), who is involved in nutritional research in gerontology, is the main INOGAD investigator.

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Undernutrition in elderly patients with cancer: Target for diagnosis and intervention

Abstract

Introduction

Section snippets

Tumoral cachexia

Impact of undernutrition on neoplastic pathology prognosis

Undernutrition and elderly patients

Cancer treatment effects

Nutritional intervention in cancerology

Conclusion

Conflict of interest

Reviewers

Crit Rev Oncol Hematol

Clin Geriatr Med

Eur J Oncol Nurs

Mol Cancer

J Hepatol

Am J Clin Nutr

Clin Nutr

Clin Nutr

Eur J Oncol Nurs

Am J Clin Nutr

Am J Med

Am J Clin Nutr

Cytokine

Med Hypotheses

Am J Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Lung Cancer

Gastrointest Endosc

Cytokine

Eur J Cancer

Leuk Res

Am J Clin Nutr

Nutrition

Clin Nutr

Clin Nutr

Clin Nutr

Cancer Treat Rev

Semin Oncol Nurs

J Am Diet Assoc

Am J Clin Nutr

Gastroenterology

Clin Nutr

Eur J Cancer

Clin Nutr

J Clin Epidemiol

J Psychiatr Res

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study

J Clin Oncol

Pharmacokinetic considerations of oral chemotherapy in elderly patients with cancer

Drugs Aging

Palliative chemotherapy for advanced colorectal cancer: systematic review and meta-analysis

BMJ

Treatment of advanced non-small-cell lung cancer in the elderly: results of an international expert panel

J Clin Oncol

Caring the elderly diabetic patient with respect to concepts of successful aging and frailty

Diabetes Metab

The cancer cachexia syndrome: a review of metabolic and clinical manifestations

Nutr Clin Pract

Interleukin-1 in renal fibrosis

Kidney Int Suppl

Expression of IL6 and TNF-alpha in normal and pathological kidney

C R Seances Soc Biol Fil

Insulin-like growth factor mediated stromal-epithelial interactions in human breast cancer

Breast Cancer Res Treat

Nutrition: a major factor influencing immunity in the elderly

J Nutr Health Aging

Nutritional factors and immunological ageing

Proc Nutr Soc

Nutrition and immunity in the elderly

Proc Nutr Soc