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