The nutrition status of patients with cancer can vary at presentation and through the continuum of cancer care. Many patients experience unintentional weight loss leading to a diagnosis of cancer.[
Emerging evidence supports that loss of lean body mass (sarcopenia) in patients with cancer is an independent risk factor for poorer outcomes, and that in the setting of obesity, unlike in other diseases where weight loss may be welcomed, inappropriate loss of weight may lead to loss of muscle mass and poorer outcomes.[
The leading nutrition societies of the United States and Europe have developed consensus guidelines regarding standardized definitions of malnutrition, and the U.S. societies have developed criteria for assessment of malnutrition including weight loss.[
In 2010, the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism published their proposed etiology-based definitions of malnutrition. These have been accepted by both groups and the Academy of Nutrition and Dietetics (the Academy).[
Etiology-based definitions of malnutrition include the following:
In 2012, ASPEN and the Academy released a joint statement regarding assessment of malnutrition.[
Significant Weight Loss
Weight loss is often used as a surrogate for malnutrition. It has been correlated with adverse outcomes, including increased incidence and severity of treatment side effects and increased risk of infection, thereby reducing chances for survival.[
The major nutrition societies in the United States have published criteria for the evaluation of weight loss over time and classifications as moderate or severe [
|Time||% Weight Loss for Non-Severe (Moderate) Malnutrition||% Weight Loss for Severe Malnutrition|
| a Adapted from White et al.[
Anorexia and Cachexia
Anorexia, the loss of appetite or desire to eat, is typically present in 15% to 25% of all patients with cancer at diagnosis and may also occur as a side effect of treatments or related to the tumor itself. In an observational study of patients in outpatient clinics, anorexia was reported by 26% of patients receiving chemotherapy.[
Anorexia can hasten the course of cachexia,[
Sarcopenia is the condition of severe muscle depletion.[
Sarcopenic obesity is the presence of sarcopenia in individuals with a high BMI (≥25 kg/m2), often precipitated by the loss of skeletal muscle and gain of adipose tissue. Sarcopenic obesity is an independent risk factor for poor prognosis.[
It is important to identify and anticipate malnutrition and other nutrition impact symptoms early. (Nutrition impact symptoms are a range of side effects of cancer and cancer treatment that impede oral intake, e.g., alterations in taste and smell, mucositis, dysphagia, stomatitis, nausea, vomiting, diarrhea, constipation, malabsorption, pain, depression, and anxiety.) Nutrition intervention improves outcomes by helping a patient do the following:[
It is suggested that the treating clinician assess baseline nutrition status (refer to the Nutrition Screening and Assessment section of this summary for more information) and be aware of the possible implications of the various therapies. Patients receiving aggressive cancer therapies typically need aggressive nutrition management.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Influences on nutrition status and risk of malnutrition include the following:[
Treatment approaches, including surgery, chemotherapy, and radiation therapy, can have a direct (mechanical) negative effect and/or an indirect (metabolic) negative effect on nutrition status. The success of anticancer therapy is affected by the patient's nutrition status before and during treatment, which influences the patient's ability to tolerate therapy.
Oral intake is impeded by the following nutrition impact symptoms:[
Preexisting comorbidities may also play a role in the development of cancer, e.g., alcohol abuse (head and neck cancer) and obesity (breast or prostate cancer), or may increase the risk of malnutrition at presentation.[
Tumor-Induced Effects on Nutrition Status
Tumors may have systemic or local effects that affect nutrition status, including hypermetabolism, malabsorption, dysmotility, and obstructions.[
Nutrition complications are usually most notable and severe with tumors involving the digestive tract or head and neck, owing to mechanical obstruction or dysfunction. Refer to Table 2 for common side effects of tumor locations.
|Common Side Effects||Tumor Location|
| a Adapted from McGuire,[
|Head/Neck||Esophagus, Stomach||Pancreas, Liver, Small Intestine||Large Intestine|
Nutrition status can be compromised in direct response to tumor-induced alterations in metabolism (i.e., cachexia). Tumor-induced weight loss occurs frequently in patients with solid tumors of the lung, pancreas, and upper gastrointestinal (GI) tract and less often in patients with breast cancer or lower GI cancer. Cachexia is also more common with more-advanced disease.
In 2011, an international group of experts developed a consensus definition of cachexia as "a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass...that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment."[
Although anorexia may also be present, the energy deficit alone does not explain the pathogenesis of cachexia. The etiology of cancer cachexia is not entirely understood, but several factors have been proposed.[
Altered metabolism of fats, proteins, and carbohydrates is evident in patients with cancer cachexia. Tumors may impair glucose uptake and glucose oxidation, leading to an increased glycolysis.[
Treatment-Induced Effects on Nutrition Status
Cancer treatments may cause acute and chronic effects. Nutrition intervention is based on symptom management. Patients who maintain good nutrition are more likely to tolerate the side effects of treatment. Adequate calories and protein can help maintain patient strength and prevent body tissues from further catabolism. Side effects of cancer treatments vary among patients, depending on the type, length, and dose of treatments and the type of cancer being treated (refer to Table 3). Cancer treatment has toxic effects on the GI tract, including the following:
| a Adapted from Grant[
|Chemotherapy||Radiation Therapy||Biotherapy||Hormone Therapy||Surgery|
Chemotherapy and hormone therapy
Chemotherapy and hormone therapy can be used as single agents or in combination, depending on the disease type and patient's health condition.[
Common nutrition-related side effects include the following:
Because cancer and the side effects of chemotherapy can greatly affect nutrition status, health care providers must anticipate possible problems and formulate a plan with the patient to prevent malnutrition and weight loss (refer to the Nutrition Screening and Assessment section of this summary for more information). Malnutrition and weight loss can affect a patient's ability to regain health and acceptable blood counts between chemotherapy cycles; this can directly affect the patient's ability to stay on treatment schedules, which is important for achieving a successful outcome. (Refer to the Behavioral strategies for symptom management section in the Nutrition Therapy section of this summary for more information.)
Patients receiving hormone suppression therapies are at risk of weight gain rather than weight loss. These patients may benefit from directed education to minimize weight gain and help reduce the risk of developing comorbidities associated with excess body weight.[
Radiation therapy causes localized symptoms. Some of the common nutrition-related side effects caused by irradiation include the following:[
The side effects of radiation therapy depend on the area that is irradiated, total dose, fractionation, duration, and volume irradiated (refer to Table 4). Most side effects are acute, begin around the second or third week of treatment, and diminish 2 or 3 weeks after radiation therapy has been completed. Some side effects can be chronic and continue or occur after treatment has been completed.[
Nutrition support during radiation therapy is vital. The effect of radiation therapy on healthy tissue in the treatment field can produce changes in normal physiologic function that may ultimately diminish a patient's nutrition status by interfering with ingestion, digestion, or absorption of nutrients.
Many nutrition-related side effects result from radiation therapy. Quality of life and nutrition intake can be improved by managing these side effects through appropriate medical nutrition therapy and dietary modifications. For example, medications such as pilocarpine (Salagen) may be useful in treating the xerostomia that accompanies radiation therapy targeting the head and neck.[
| a Adapted from Grant (tables 11-14–11-16),[
|Xerostomia, mucositis, taste changes||Dysphagia, odynophagia, esophagitis||Nausea, vomiting||Diarrhea||Other acute||Late side effects|
|Brain||X||X||Loss of appetite||Dysphagia|
|Head and neck||X||X||Thick saliva||Trismus, dysphagia, xerostomia|
|Chest||X||X||Loss of appetite||Esophageal stenosis, fibrosis, or necrosis|
|Abdomen||X||X||Chronic enteritis/colitis, intestinal stricture or obstruction|
|Pelvis and rectum||X||X|
For patients with most types of solid tumors, surgery is the only chance for a cure.[
Surgical treatment can increase occurrence of or worsen malnutrition. Common side effects of surgery, especially to the GI tract or head and neck, include decreased appetite, decreased ability to take food by mouth, and early satiety, all of which can lead to worsening preexisting malnutrition or may cause previously adequately nourished patients to become malnourished after surgery.[
Depending on the procedure, surgery can cause mechanical or physiologic barriers to adequate nutrition, such as a short gut that results in malabsorption after bowel resection.[
(Refer to the Nutrition support subsection in the Nutrition Therapy section of this summary for more information about approaches to nutrition intervention and the appropriate use of enteral and parenteral nutrition support.)
Biotherapy is treatment to boost the immune system to help enhance the body's own response against cancer or to help repair normal cells damaged as a side effect of treatment.[
Hemopoietic cell transplantation (HCT)
Patients receiving HCT can have special nutrition requirements. Before cell transplant, patients receive high-dose chemotherapy and may be treated with total-body irradiation.[
The goal of nutrition support is to maintain adequate nutrition status and protein stores. The American Society for Parenteral and Enteral Nutrition recommends that patients undergoing HCT who are malnourished and expected to be unable to ingest or absorb adequate nutrients for a prolonged period of time (>7–14 days) receive nutrition support; if a patient has a functioning GI tract, enteral nutrition is recommended.[
In addition, transplant patients are at very high risk of neutropenia, an abnormally small number of neutrophils in the blood that increases susceptibility to multiple infections. To reduce the risk of infections related to HCT, patients can receive dietary counseling regarding safe food handling and avoidance of foods that may pose an infection risk.[
Optimizing nutrition for patients with cancer involves early detection of malnutrition or risk of malnutrition so that intervention may be initiated in the early stages of disease or treatment. The goal of nutrition screening is to rapidly identify patients who are at risk of developing malnutrition and refer them to a health care professional, ideally a registered dietitian, who can perform a complete nutrition assessment and implement a nutrition care plan.[
There are no standard definitions or indices of malnutrition. Historically, loss of weight or body mass index (BMI), low BMI, and low serum protein (e.g., albumin) have been used to identify patients with malnutrition. Without more context, these characteristics are not acceptable measures by which to determine malnutrition.[
A growing body of literature examines the prevalence of malnutrition in obese cancer patients. In a study of clinical data obtained from 1,469 patients with metastatic primary cancers, 41.9% were identified as overweight or obese.[
Obesity has been shown to increase the risk of cancer recurrence, and it negatively impacts overall survival.[
Early recognition of nutrition-related issues is necessary for appropriate nutrition management of cancer patients. Nutrition screening can be performed with a validated tool before treatment begins and at regular intervals over the course of treatment.
Nutrition screening can be a simple process that may be completed by hospital staff or members of the community/ambulatory health care team, with the goal of early identification of individuals with or at risk of malnutrition.[
In the outpatient oncology setting, it is recommended that patients be screened initially before treatment begins and rescreened at planned intervals. Screening can most often coincide with the patient's treatment schedule, such as weekly during radiation therapy and as frequently as every 2 to 3 weeks during chemotherapy, before surgery, and at follow-up visits after completion of treatment or surgical recovery.[
The following five screening tools are validated for use in oncology:[
Only the MST and the PG-SGA have been validated for use in both inpatient and outpatient oncology settings. Several studies have validated use of the abridged PG-SGA (abPG-SGA) or short-form PG-SGA (PG-SGAsf), each of which is simply the section of the PG-SGA completed by the patient.[
The Nutrition Risk Screening-2002 has not been validated in the oncology setting, but it has been used in several studies of oncology patients. Scores are correlated to general outcomes associated with malnutrition, such as hospital length of stay, complications, and mortality.[
The NUTRISCORE tool utilizes the MST as a base but has additional items, including tumor location and treatment, that help improve sensitivity (97.3% vs. 84%) and specificity (95.9% vs. 85.6%). The authors used the PG-SGA as the reference for validation in the outpatient oncology setting, also finding that it took less time to complete the NUTRISCORE than it did to complete the PG-SGA.[
The MST is a short questionnaire comprising two questions. Depending on the answers, patients are stratified into two categories: at risk or not at risk.[
In screening, it is important to use a validated tool and to consider the needs of the clinical practice. In centers where a registered dietitian is available, the MST may be the screening tool of choice because it is quick and can be performed by many members of the office and practice staff. Patients found to be at risk may be referred to the dietitian for further assessment.
The PG-SGA is the most commonly accepted tool for screening and assessment, backed by many studies and validated in both inpatient and outpatient oncology settings.[
The remainder of the PG-SGA is completed by a health care practitioner, accounting for information about disease and metabolic demand and the completion of a physical examination. The abPG-SGA and PG-SGAsf use only the section completed by the patient. Responses are then scored, and patients are stratified into the following four nutrition triage categories:[
The benefit of the PG-SGA (PG-SGAsf) is that it collects clinical information that can be helpful in the nutrition assessment. The drawback is that the PG-SGA takes more time to administer and requires a trained health care practitioner to complete the physical assessment portion. With validation of the short form, the need for physical examination is eliminated, and the practitioner's administration time is reduced.
In practices where a registered dietitian is not available, the PG-SGAsf may be more appropriate because it helps better determine which patients may receive sufficient information from the nurse, advanced-practice provider, or physician and which patients would best be referred to a registered dietitian for more in-depth assessment and intervention.
Nutrition assessment is a comprehensive approach to evaluating and diagnosing nutrition problems and designing interventions.[
The assessment of anthropometric measurements evaluates weight loss, takes into account the time frame of weight loss, and is considered in the context of physical findings such as dehydration or fluid retention. Evaluation of food- and nutrition-related history ideally involves a dietitian obtaining a diet history and comparing intake with the patient's calculated energy needs.[
Subcutaneous fat loss
Subcutaneous muscle loss
Within the nutrition assessment, the following factors are considered in diagnosing malnutrition:[
In addition to the issues described above, the oncology nutrition assessment also takes into account the following:[
The goal of an oncology nutrition assessment is to collect the information necessary to determine current or anticipated nutrition issues and to formulate a plan with the patient, caregivers, and other members of the health care team involved with nutrition interventions. Additionally, this multidisciplinary team approach may also include metabolic, pharmacologic, and functional interventions to address and prevent the identified or anticipated nutrition issues.[
Goals of Nutrition Therapy
The goals of medical nutrition therapy are to do the following:[
Goals must be individualized for each patient on the basis of the following:
Decisions about the best approach for therapy are informed by symptom severity and function of the gastrointestinal (GI) tract. Treatment could include multiple strategies based on these factors.
Nutrition goals during and after cancer therapy are integrated with goals related to nutrition status and the presence of malnutrition.[
A healthy diet with an emphasis on plant-based foods, regular physical activity, and achievement of a healthy weight has been recommended for all patients after cancer treatment on the basis of extensive reviews of the evidence.[
|Weight/Nutrition Status||During Treatment|
| a Adapted from Hamilton et al.,[
|Healthy weight and nutrition status||Maintain lean body mass|
|Maintain healthy weight|
|– Acute disease related||Support vital organ function|
|Preserve host response though acute episode|
|May have increased energy and protein requirements|
|– Chronic disease related||Maintain and improve lean body mass and fat|
|Obesity (no malnutrition)||Maintain lean body mass|
|Consider modest weight reduction (≤2 lbs/wk)|
Methods of Nutrition Therapy
Prompt and aggressive nutrition intervention is required for patients with precachexia or cancer cachexia. Intervention is more likely to be effective when started early. Interventions include an individualized approach to oral, enteral, and parenteral nutrition using evidence-based recommendations, guidelines, and program and regulatory standards.
The dietitian works with the patient, caregivers, and members of the health care team to (1) improve compliance and the effectiveness of pharmacotherapy interventions prescribed to manage cancer and cancer treatment–related symptoms; and (2) counsel patients about behavioral strategies to alleviate nutrition impact symptoms.[
Counseling by a registered dietitian
The registered dietitian/nutritionist is an integral member of the oncology team in hospital and ambulatory settings. The Association of Community Cancer Centers Cancer Program Guidelines [
The registered dietitian does the following:[
Registered dietitians also serve as a resource for patients and communities, providing education related to reducing cancer risk and the risk of recurrence.[
A systematic review of randomized controlled trials led to the recommendation that patients be referred for nutrition counseling because of strong evidence of its beneficial effects on the prevention and reduction of malnutrition.[
A randomized controlled trial of 328 patients at a single institution in China assessed the inclusion of a dietitian and psychologist as part of the interdisciplinary team versus the standard of care. The standard of care team included the medical oncologist and oncology nurse, with referral, as needed, to a dietitian and/or psychologist. The patients in the intervention group met with the interdisciplinary team before starting chemotherapy and had follow-up visits at defined intervals throughout treatment until the time of death. Nutrition intervention (diet counseling and side-effect management, with or without oral nutrition supplements and tube feeding) and follow-up by the dietitian was standardized, based on initial nutrition risk screening scores. All participants received chemotherapy per standardized guidelines (including National Comprehensive Cancer Network), and there were no significant differences in patient demographics. Improvement in overall survival (median, 14.8 months vs. 11.9 months) occurred despite no statistically significant difference in progression-free survival. Secondary analysis also showed significant improvements in nutrition assessment scores at 9 weeks.[
In a study of patients with unresectable pancreatic adenocarcinoma, participants had a weekly phone call with a registered dietitian for 8 weeks to discuss diet and management of disease-related side effects. They were also given oral nutritional supplements. Median survival was found to be significantly longer in weight-stable versus weight-losing subjects (8.6 months vs. 5.5 months).[
Despite consensus that referral for nutrition intervention should be early,[
Behavioral strategies for symptom management
Cancer and cancer treatment result in a range of side effects, described as nutrition impact symptoms, that impede oral intake. While some patients experience few of these effects, others may have multiple symptoms, including:
These symptoms can result in a decline in nutrition status and quality of life. Behavioral strategies are essential for alleviating the impact of these symptoms and promoting adequate nutrient intake; pharmacologic interventions may be used in combination with these strategies to minimize symptom severity.
The following lists describe behavioral strategies to help alleviate nutrition-related symptoms of cancer treatment. The information is based on the National Cancer Institute's (NCI's) Eating Hints: Before, During, and After Cancer Treatment and AICR's Dealing with Treatment Side Effects. Additional information about nutrition strategies during treatment is available from oncology-focused organizations such as ACS and AICR.[
Oral nutrition supplements
Commercially available oral nutrition supplements (e.g., Boost, Ensure) are often used to improve the adequacy of nutrient intake.[
Patients with cancer need adequate protein to maintain and rebuild lean body mass. A systematic review of multinutrient, high-protein oral nutrition supplements found significant improvement in total energy and protein intake and reduced incidence of complications.[
Although supplements containing fish oil alone do not seem to be beneficial in cachexia or surgery recovery, studies of immune-enhancing (IE) formulas containing fish oil, as well as arginine and nucleotides, suggest benefit for individuals undergoing GI surgery. A 2012 Cochrane review found significant reduction in postoperative complications and infections when IE oral supplements or enteral feeding were given before GI surgery.[
There is concern that long-term use of oral nutrition supplements can result in taste fatigue and decreased compliance with recommendations. A systematic review of compliance with oral nutrition supplements suggested that compliance is good, especially with higher-energy-density supplements.[
When oral supplements do not achieve nutrition goals, enteral and/or parenteral nutrition can be considered in the context of a patient's nutrition status and the overall medical treatment plan.[
Nutrition support is the delivery of nutrition that bypasses oral intake. Every measure is employed to sustain patients and improve their condition through oral intake before nutrition support is considered.
The use of enteral and parenteral nutrition in the oncology population may be indicated when oral nutrition strategies are not possible or fail because of tumor location or severe side effects. Although nutrition support is not recommended as standard treatment, it may be beneficial for patients who are malnourished and expected to become unable to take in adequate nutrition by mouth for an extended period of time.[
Enteral nutrition is preferred over parenteral nutrition in most instances. Enteral nutrition continues to use the gut, is associated with fewer infectious complications, is often easier to administer, and is more cost-effective than parenteral nutrition.[
Indications for nutrition support include the following:[
Providing nutrition support routinely to patients undergoing chemotherapy or radiation therapy is not recommended; rather, nutrition support is reserved for patients who meet any of the criteria listed above. It is sometimes difficult to know which patients will have a prolonged period of inadequate oral intake or malabsorption and will benefit from nutrition support.[
Although aggressive nutrition support has been shown to improve quality of life in patients with advanced cancer,[
Investigators have suggested the following additional criteria for withholding nutrition support in patients with advanced disease:[
Enteral route and administration
Several effective methods for the delivery of enteral nutrition exist. Factors affecting a choice of the enteral route include the following:
Assessment of need is best performed early. If a malnourished patient requires surgery for an unrelated event, a feeding tube may be placed at that time to avoid an additional procedure.
For short-term feeding (<2 weeks), a nasoenteric tube may be best. The risk of aspiration is considered in the determination of the proper termination point of the tube, as follows:
Tubes are constructed of silicone or polyurethane and can vary in length from 30 to 43 inches, with the shorter tubes used for nasogastric feedings. Diameters range from 5F catheters to 16F catheters. Tubes may have weighted tips to help passage through the gut. If a patient with cancer is at very high risk of aspiration, enteral nutrition may be contraindicated, and parenteral nutrition can be considered. Immunocompromised patients with mucositis, esophagitis, and/or herpetic, fungal, or candidiasis lesions in the mouth or throat may not be able to tolerate the presence of a nasoenteric tube.[
For longer-term feeding (>4 weeks), direct enteral access is recommended. Percutaneous tubes may be placed endoscopically, surgically, or with fluoroscopy by interventional radiology.
Percutaneous tube placement has a number of advantages, including the following:[
Conversion to a skin-level button gastrostomy or jejunostomy may also be considered when longer-term support is anticipated.[
Infusion methods and formulas
Administration methods vary depending on where in the GI tract the tube terminates and may be affected by treatment side effects.
For tubes terminating in the stomach, a bolus or intermittent (gravity) drip may be possible and is preferable because it mimics normal feeding, requires less time and equipment, and offers greater flexibility to the patient. For tubes terminating in the duodenum or jejunum, an infusion pump is required because a slower administration rate is necessary. Feedings via a pump may be administered cyclically (<24 hours per day) or continuously.[
The following lists summarize infusion methods and considerations for initiation and administration of enteral nutrition.[
Bolus and Intermittent Feeding
Continuous or Cyclic Drip Feeding
Enteral formulas vary in nutrient composition and source. Most commercially available formulas are lactose free, kosher, and halal. Standard/polymeric formulations are appropriate for most patients. Semi-elemental and elemental formulas are available for patients with malabsorption who do not or will not tolerate standard formulas. In some cases, disease-specific (renal, pulmonary, and diabetic) formulas may be appropriate but in general are not necessary unless the patient has a demonstrated "failure" with standard formulas.
The use of whole-food blenderized formulas is gaining in popularity. Some products are commercially available, and there are published recipes for home-made formula. It is important for a dietitian to thoroughly review the nutrient content of these home-blenderized formulas to ensure adequacy.[
For patients in the perioperative setting, evidence supports the use of IE formulas. The most widely studied formula in this category contains a combination of arginine, omega-3 fatty acids, and nucleotides.[
Parenteral route and administration
If parenteral nutrition is determined to be beneficial and appropriate, it can be administered via central or peripheral venous access. Many patients with cancer already have central IV catheters to accommodate multiple IV therapies. For patients who do not already have central line access or will not have it for a period of time, a peripheral catheter can be placed; however, care must be taken to avoid overuse of the peripheral IVs, as this can result in vessel sclerosis. To minimize venous complications, the use of peripheral parenteral nutrition is limited.[
Parenteral nutrition is a combination of dextrose (carbohydrate), amino acids (protein), and lipid emulsions (fat) with added electrolytes, vitamins, and trace elements. It is recommended that parenteral nutrition management include clinicians with expertise in nutrition support and be made up of a multidisciplinary team, including a registered dietitian and clinical pharmacist.[
Parenteral nutrition is typically initiated as a 24-hour infusion. After tolerance is established and generally after daily macronutrient goals are achieved, parenteral nutrition may be cycled (typically to an infusion time of 10–14 hours). For patients who will receive home parenteral nutrition, a cyclic infusion is preferred.[
Pharmaceutical management of cancer-associated cachexia and weight loss
Many treatments have been suggested for cachexia-anorexia syndrome (CAS), but few of these treatments have resulted in consistent improvement, probably because of the multifactorial mechanisms involved.[
The first widely studied treatment issue has been anorexia associated with CAS. The use of agents that improve appetite and resultant caloric intake have been widely studied; these agents include corticosteroids, progesterone analogs, androgens, cannabinoids, and cyproheptadine.
Perhaps the earliest agents studied for the management of cancer cachexia are dexamethasone and prednisolone. Used in cancer treatment for their anti-inflammatory, antimalignancy, and antiemetic properties, steroids have produced side effects such as increased appetite and weight gain, probably because of their effects on the hypothalamus.
Several large placebo-controlled studies have shown increases in appetite and weight gain associated with steroid use in this setting.[
Like steroids, progesterone antagonists are effective in improving appetite and weight in patients with AIDS-related cachexia and CAS.[
A placebo-controlled study looked at megestrol acetate at a dose of 7.5 mg/kg per day in 26 children with weight loss exceeding 5%. The megestrol group had a mean weight gain of 19.7% compared with weight loss of 1.2% (P = .003) in the placebo group.[
Interest in the use of cannabinoids in CAS is ongoing because of their effects on appetite and potential benefit in HIV-related cachexia.[
Cyproheptadine is a serotonin and histamine antagonist developed as an antihistamine. Side effects include increased appetite and weight gain.[
In a study of cyproheptadine use in children with CAS, one group of investigators evaluated 66 children with weight loss exceeding 5%.[
CAS is a multifactorial disorder that occurs in more than 50% of patients with advanced cancer. Increases in cytokines associated with cancer—including tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1—have been shown to be important in the etiology of this disorder.[
Specific targeted agents have also been studied. These include agents targeting TNF-alpha, such as etanercept, infliximab, and pentoxifylline, which, in small trials, have not had a significant impact.[
Several studies using thalidomide, a nonspecific antagonist to TNF, have been performed.[
Other agents of interest
There has been interest in several other agents for the management of CAS, including mirtazapine,[
Given the multifactorial etiology of, and multiple mechanisms involved in, the development of CAS, it is possible that combining agents with different mechanisms of action might result in greater efficacy.[
Researchers also looked at the combination of formoterol, an anabolic beta-2 adrenergic agonist, and megestrol acetate in 13 patients. Six of seven evaluable patients achieved a major response, with increases in muscle mass.[
Summary of pharmaceutical treatment strategies
CAS is a complex, multifactorial complication of cancer and its therapy, resulting in weight loss and decreased lean body mass. As understanding of the mechanisms of CAS improves and new agents that selectively target proposed pathways become available, more efficacious treatments are expected to become available. Trials of new agents must be able to compare similar groups of patients. In addition, treating preventively in high-risk patients, as opposed to treating patients already experiencing CAS, may have better outcomes. Further clinical trials are essential to determine the best possible therapies.
|Drug||Dose||Comments||Reference/Level of Evidence|
|bid = twice a day; EPA = eicosapentaenoic acid; qid = 4 times a day; tid = 3 times a day; VTE = venous thromboembolism.|
| a Adapted from Lexicomp Online[
|Megestrol acetate||160–800 mg daily (most-common dose: 400 or 800 mg)||Doses >160 mg/d associated with better weight gain; 800 mg may be optimal. More benefit seen than with dronabinol in comparative study. Addition of thalidomide to megestrol increased benefit.||[
|Medroxyprogesterone||500 mg bid||Improved appetite and stimulated weight gain. Notable for a VTE-related death.||[
|Dexamethasone||0.75 mg qid||Benefit similar to that seen with megestrol.||[
|Methylprednisolone||16 mg bid||Small trial (N = 40); increased appetite, but negligible change in weight.||[
|Prednisolone||5 mg tid||Provided short-term appetite improvement over placebo, with no increase in weight.||[
|Dronabinol||2.5 mg bid, maximum 20 mg daily||Given in divided doses; twice daily most common. No benefit seen when added to megestrol. One study showed as equal to placebo.||[
|Cyproheptadine||2 mg qid, maximum 16 daily||Has been used up to 24 mg daily. Enhances appetite but may not decrease weight loss in adults. Improved both appetite and weight gain in children.||[
|Mirtazapine||15–30 mg daily||24% of patients gained ≥1 kg.||[
|Olanzapine||20 mg daily||Dose escalation trial; modest effect on reducing weight loss.||[
|Melatonin||20 mg daily||Trial stopped for futility. Significantly fewer patients with >10% weight loss on melatonin vs. placebo.||[
|Omega-3 fatty acids||EPA, 1.09 g bid||No improvement in weight or appetite vs. megestrol vs. both.||[
|10 capsules daily (EPA, 1.8 g daily)||No improvement in appetite vs. placebo.||[
|EPA, 4.4 g daily||Poor compliance with treatment. Post-hoc dose-response analysis suggests improved lean body mass with EPA supplement.||[
|Pentoxifylline||400 mg tid||No effect on weight gain or arm circumference.||[
|No improvement in appetite.||[
|Thalidomide||100 mg daily||No significant difference vs. placebo.||[
|200 mg daily||At 8 wk, patients receiving thalidomide had lost significantly less weight than had patients receiving placebo.||[
|Oxandrolone||2.5–20 mg in divided doses, 2–4 times daily||Not studied in cancer patients.||[
|Fluoxymesterone||10 mg bid||Inferior to dexamethasone and megestrol acetate.||[
Patients with advanced disease often develop new or worsening nutrition-related side effects associated with disease progression, treatment, or both. In a large systematic review of symptom prevalence in patients with incurable cancer, the most common nutrition impact symptoms were the following:[
These symptoms were present in a large subset of patients receiving care in various settings and in a small subset of patients in their last 2 weeks of life. Other symptoms among advanced-cancer patients receiving care in inpatient palliative care units,[
In addition, advanced-cancer patients with pain and opioid-induced constipation (OIC) reported both physical and psychological distress related to the OIC.[
Clinically refractory cachexia develops as a result of very advanced cancer or rapidly progressive disease that is unresponsive to antineoplastic therapy. It is associated with active catabolism and weight loss that is unresponsive to nutrition therapy. At the end of life, patients often have severely restricted oral intake of food and fluids as part of the normal dying process.[
The primary objective of nutrition intervention in patients with advanced cancer is to conserve or restore the best possible quality of life and control any nutrition-related symptoms that cause distress.[
Goals of Nutrition Therapy in Advanced Cancer
Nutrition goals for a patient with advanced cancer may depend on the overall plan of care. These patients may be receiving anticancer therapy (with or without concurrent palliative care), may be receiving palliative care alone, or may be enrolled in hospice. Regardless of the care setting, patients are screened to determine the need for nutrition intervention. The Patient-Generated Subjective Global Assessment (PG-SGA) has been validated in cancer patients and addresses body weight history, food intake, symptoms, and functional status.[
As the focus of care shifts from cancer-modifying therapy to hospice or end-of-life care, nutrition goals may become less aggressive, with a shift toward comfort. Continued assessment and adjustment of nutrition goals and interventions is required throughout this continuum to meet the changing needs of the patient receiving palliative or hospice care services.[
Nutrition Intervention in Advanced Cancer
Ethical issues may arise when patients, families, or caregivers request artificial nutrition and hydration when there is no prospect of recovering from the underlying illness or benefiting appreciably from the intervention. When there is uncertainty about whether a patient will benefit from artificial nutrition, hydration, or both, a time-limited trial with clear, measurable endpoints may be useful. The caregiving team will explain that, as with other medical therapies, artificial nutrition and hydration can be stopped if the desired nutrition effects do not occur.[
Randomized controlled trials of enteral or parenteral nutrition in cancer patients receiving formal palliative care are lacking.[
If patients are to benefit from parenteral nutrition, they must be physically and emotionally capable of participating in their own care and have the following:[
Patients with a life expectancy shorter than 40 days may be palliated with home intravenous (IV) fluid therapy, although this practice is controversial.[
Nutrition Considerations for the End of Life
Patients and caregivers often consider the provision of food and fluids to be basic care. However, the use of artificial nutrition and hydration at the end of life is a complex and controversial intervention that is influenced by clinical, cultural, religious, ethical, and legal factors. Patients and families often believe these interventions will improve quality and length of life, but evidence of clear benefit is lacking.[
In addition, agitated or confused patients receiving artificial nutrition and hydration may need to be physically restrained to prevent them from removing a gastrostomy tube, nasogastric tube, or central IV line.[
Patients at the end of life who have increased difficulty with swallowing have less risk of aspiration with thick liquids than with thin liquids.[
For patients at the end of life, the goal of nutrition therapy is to alleviate symptoms rather than reverse nutrition deficits. The pleasure of tasting food and the social benefits of participating in meals with family and friends can be emphasized over increasing caloric intake.[
A well-designed randomized trial reported that hydration at 1 L/d for a week did not improve dehydration symptoms (fatigue, myoclonus, sedation, hallucinations) and provided no benefit in quality of life or survival.[
The American Academy of Hospice and Palliative Medicine suggests that providers facilitate respectful and informed discussions about the effects of artificial nutrition and hydration near the end of life among physicians, other health care professionals, patients, and families.[
Ethical, Cultural, and Religious Issues in Medically Assisted Nutrition and Hydration in Advanced Cancer
Decisions about whether to provide artificial nutrition and hydration to patients in the late stages of life are complex and influenced by ethical, cultural, and religious issues, as well as by legal issues, clinical considerations, and patient and family preferences. The event of death itself, the manner in which it occurs, and the patient's quality of life are significant matters that have spiritual and psychological consequences for each person involved.[
A number of organizations have published guidelines on the ethical considerations about whether to forgo or discontinue hydration and nutrition support, including the following:
These guidelines reflect judicial decisions that have supported the authority and liberty of the competent individual to refuse life-saving hydration and nutrition, the role of medical expertise, and respect for the dignity and values of the patient and family. (Refer to the Artificial Hydration and Artificial Nutrition sections in the PDQ summary Last Days of Life for more information.)
Religion and religious traditions provide a set of core beliefs about life events and an ethical foundation for clinical decision-making.[
To provide an optimal and inclusive healing environment, all palliative team members need to be aware of their own spirituality and how it may differ from that of fellow team members and the patients and families they serve.[
Religious beliefs are often closely related to cultural views. Individuals living in the midst of a particular tradition can continue to be influenced by it, even if they have stopped believing in or practicing it.[
Religious and cultural preferences about artificial nutrition and hydration are expressions of a patient's autonomy and, in many cases, may outweigh clinical considerations. When these values conflict with clinical judgment, practitioners may work with the patient and/or surrogate in consulting with faith leaders and the patient's ethnic community , as well as the institutional ethics committee, to facilitate resolution.[
The wide range of practices related to neutropenic diets reflects the lack of evidence regarding the efficacy of dietary restrictions in preventing infectious complications in cancer patients. Studies evaluating various approaches to diet restrictions have not shown clear benefit.
A meta-analysis and a systematic review of articles evaluating the effect of a neutropenic diet on infection and mortality rates in cancer patients found no superiority or advantage in using a neutropenic diet over a regular diet in neutropenic cancer patients.[
Other studies have demonstrated potential adverse effects of neutropenic diets. One group of investigators [
Without clinical evidence to define the dietary restrictions required to prevent food-borne infection in immunocompromised cancer patients, recommendations for food safety are based on general food safety guidelines and the avoidance of foods most likely to contain pathogenic organisms. The effectiveness of these guidelines depends on patient and caregiver knowledge about, and adherence to, safe food handling practices and avoidance of higher-risk foods. Leading cancer centers provide guidelines for HCT patients and information about food safety practices related to food purchase, storage, and preparation (e.g., the University of Pittsburgh Medical Center's Stem Cell Transplant Diet and Memorial Sloan Kettering Cancer Center's Neutropenic Diet). Patients can be educated to refer to FoodSafety.gov for up-to-date information about food recalls and alerts.
Recommendations support the use of safe food-handling procedures and avoiding consumption of foods that pose a high risk of infection, as noted in Table 7.
|Food Group||May Eat||Do Not Eat|
| a Adapted from Tomblyn et al.[
|b Although eating cooked soft cheese is not completely risk free, the risk of food-borne illness is low.|
|c Rinse under clean running water before use, including produce that is to be cooked or peeled, such as bananas, oranges, and melons.|
|d Shelf stable refers to unopened canned, bottled, or packaged food products that can be stored at room temperature before being opened; container may require refrigeration after being opened.|
|e Bring tap water to a rolling boil and boil for 15–20 minutes. Store boiled water in the refrigerator; discard unused water after 48 hours. Hematopoietic cell transplantation patients are advised not to use well water from private wells or from public wells in communities with limited populations because tests for bacterial contamination are performed too infrequently.|
|f Tap water from a city water service in a highly populated area that is tested >2 times/day for bacterial contamination. Listen for media alerts for a "boil water advisory," which means all tap water should be boiled >1 minute before being consumed. In addition, use a home water filter capable of removing particles >1 µm in diameter or filter by reverse osmosis to reduce risk of exposure toCryptosporidium.|
|g Bottled water can be used if it conforms to U.S. Food and Drug Administration standards and has been processed to removeCryptosporidium by reverse osmosis, distillation, or 1-μm-particulate absolute filtration. Contact the bottler directly to confirm which process is used. Contact information for water bottlers is available on the International Bottled Water Associationwebsite.|
|Dairy||All pasteurized grade "A" milk, milk products||Unpasteurized or raw milk|
|Dry, refrigerated, or frozen pasteurized whipped topping||Foods made from unpasteurized or raw milk|
|Commercially packaged hard and semisoft cheeses such as cheddar, mozzarella, Parmesan, Swiss, Monterey Jack||Cheeses from delicatessens|
|Cooked soft cheese such as brie, Camembert, feta, farmer'sb||Cheese containing chili peppers or other uncooked vegetables|
|Commercially sterile ready-to-feed and liquid-concentrate infant formulas||Cheeses with molds, such as blue, Stilton|
|Mexican-style soft cheeses such as queso fresco, queso blanco|
|Powdered infant formulas, if a ready-to-feed or liquid-concentrate alternative is available|
|Meat and meat substitutes||All meats, poultry, fish cooked to well-done (poultry >180°F; other meats >160°F)||Raw or undercooked meat, poultry, fish, game, tofu|
|Canned meats||Raw or undercooked (over easy, soft boiled, poached) eggs and unpasteurized egg substitutes|
|Eggs cooked until both white and yolk are firm||Meats & cold cuts from delicatessens|
|Pasteurized eggs and egg substitutes and powdered egg white (can be used undercooked)||Hard-cured salami in natural wrap|
|Commercially packaged salami, bologna, hot dogs, ham, other lunch meats (heated until steaming)||Refrigerated pâtés or meat spreads|
|Canned and shelf-stable smoked fish (refrigerate after opening)||Uncooked, refrigerated smoked seafood such as salmon or trout labeled nova-style, lox, kippered, smoked, or jerky|
|Pasteurized or cooked tofu||Pickled fish|
|Refrigerated smoked seafood such as salmon or trout if cooked to 160°F or contained in a cooked dish or casserole||Tempe (tempeh) products|
|Fruits and nuts||Well-washedc, raw, and frozen fruit, except berries||Unwashed raw fruits|
|Cooked, canned, and frozen fruit||Fresh or frozen berries|
|Pasteurized juices and frozen juice concentrates||Unpasteurized fruit and vegetable juices|
|Dried fruits||Fresh fruit salsa and unpasteurized raw-fruit–containing items found in grocery refrigerated case|
|Canned or bottled roasted nuts||Raw nuts|
|Shelled, roasted nuts and nuts in baked products||Roasted nuts in the shell|
|Commercially packaged nut butters (peanut, almond, soy nut)|
|Entrees and soups||All cooked entrees and soups||All miso products|
|Vegetables||Well-washedc raw and frozen vegetables||Unwashed raw vegetables or herbs|
|All cooked fresh, frozen, or canned vegetables, including potatoes||Fresh, unpasteurized vegetable salsa and unpasteurized raw-vegetable–containing items found in grocery refrigerated case|
|Shelf-stabled bottled salsa (refrigerate after opening)||All raw vegetable sprouts (alfalfa, clover, mung bean)|
|Cooked vegetable sprouts such as mung bean sprouts||Salads from delicatessens|
|Fresh, well-washedc herbs, dried herbs, and spices (added to raw or cooked foods)|
|Breads, grains, and cereal products||All breads, bagels, rolls, English muffins, muffins, pancakes, sweet rolls, waffles, French toast||Raw (not baked or cooked) grain products, such as raw oats|
|Potato chips, corn chips, tortilla chips, pretzels, popcorn|
|Cooked grains and grain products, including pasta and rice|
|All cereals, cooked and ready-to-eat|
|Beverages||Boiled well watere||Unboiled well water|
|Tap water and ice made from tap waterf||Cold-brewed tea made with warm or cold water|
|Commercially bottled distilled, spring, and natural watersg||Mate tea|
|All canned, bottled, and powdered beverages||Wine, unpasteurized beer (Note: all alcoholic beverages can be consumed if approved by physician.)|
|Instant and brewed coffee and tea; cold-brewed tea made with boiling water||Unpasteurized fruit and vegetable juices|
|Herbal teas brewed from commercially packaged tea bags||Powdered infant formulas, if a ready-to-feed or liquid-concentrate alternative is available|
|Commercial nutrition supplements, both liquid and powdered|
|Commercially sterile ready-to-feed and liquid-concentrate infant formulas|
|Desserts||Refrigerated commercial and homemade cakes, pies, pastries, and puddings||Unrefrigerated cream-filled pasty products (not shelf-stabled)|
|Refrigerated cream-filled pastries|
|Cookies, both homemade and commercially prepared|
|Shelf-stabled cream-filled cupcakes and fruit pies|
|Canned and refrigerated puddings|
|Ices, ice pops, and similar products|
|Fats||Vegetable oils and shortening||Fresh salad dressings (stored in grocery refrigerated case) containing raw eggs or cheeses listed as "Do Not Eat" under "Dairy"|
|Refrigerated lard, margarine, and butter|
|Commercial, shelf-stabled mayonnaise and salad dressings, including blue cheese and other cheese-based salad dressings (refrigerate after opening)|
|Cooked gravies and sauces|
|Other||Commercial pasteurized grade "A" honey||Raw honey, honey in the comb|
|Salt, granulated sugar, brown sugar||Herb and nutrient supplement preparations|
|Jams, jellies, syrups (refrigerate after opening)||Brewer's yeast, if uncooked|
|Catsup, mustard, barbecue sauce, soy sauce, other condiments (refrigerate after opening)|
|Pickles, pickle relish, olives (refrigerate after opening)|
Maintaining adequate nutrition while undergoing treatment for cancer is imperative because it can reduce treatment-related side effects, prevent delays in treatment, and help maintain quality of life.[
The sections below summarize the state of the science on some of the most popular diets and dietary supplements.
Vegetarian or vegan diet
A vegetarian diet is popular, is easy to implement, and, if followed carefully, does not result in nutritional deficiencies. There is strong evidence that a vegetarian diet reduces the incidence of many types of cancer, especially cancers of the gastrointestinal (GI) tract.[
One pilot study suggested that following a plant-based diet can prevent tumor progression in men with localized prostate cancer.[
A macrobiotic diet varies according to a person's sex, their level of activity, and the climate (and season) where they live, among other variables. It is a high-carbohydrate, low-fat, plant-based diet stemming from philosophical principles promoting a healthy way of living. The diet consists of 35% to 50% (by weight) whole grains, 25% to 35% vegetables, 5% to 10% soup, 5% to 10% cooked vegetables and sea vegetables, and 5% to 10% fish.
Although there are anecdotal reports of the effectiveness of a macrobiotic diet as an alternative cancer therapy, none has been published in peer-reviewed, scientific journals. No clinical trials, observational studies, or pilot studies have examined the diet as a complementary or alternative therapy for cancer. In fact, two reviews of the diet concluded that there is no scientific evidence for the use of a macrobiotic diet in cancer treatment.[
A ketogenic diet has been well established as an effective alternative treatment for some cases of epilepsy and has gained popularity for use in conjunction with standard treatments for glioblastoma. The theory behind the diet as cancer treatment is that reducing glucose availability to a tumor can reduce tumor activity, and that this reduction can be achieved through entering a state of ketosis via the ketogenic diet's increased fat intake and restriction of carbohydrates.
The ketogenic diet can be difficult to follow and relies more on exact proportions of macronutrients (typically a 4:1 ratio of fat to carbohydrates and protein) than other complementary and alternative medicine (CAM) diets.
Most studies have focused on the diet's feasibility, tolerability, and safety, all of which have been shown for patients with glioblastoma at various stages of the disease.[
Similarly, findings from a study that compared the acceptability and adverse effects of a ketogenic diet to the American Cancer Society's high-fiber, low-fat diet among women with ovarian or endometrial cancer found no differences between groups over 12 weeks. Further, the findings indicated that the ketogenic diet was both safe and acceptable.[
Refer to the PDQ summary Intravenous Vitamin C for more information about the use of intravenous vitamin C as a treatment for people with cancer.
The use of probiotics has become prevalent within and outside of cancer therapy. Strong research has shown that probiotic supplementation during radiation therapy, chemotherapy, or both is well tolerated and can help prevent radiation- and chemotherapy-induced diarrhea, especially in those receiving radiation to the abdomen.[
Melatonin is a hormone produced endogenously that has been used as a CAM supplement (along with chemotherapy or radiation therapy) for targeting tumor activity and for reducing treatment-related symptoms, primarily for solid tumors.
Several studies have shown tumor response to, or disease control with, chemotherapy alongside oral melatonin, as opposed to chemotherapy alone. One study has shown tumor response with melatonin in conjunction with radiation therapy.[
Melatonin taken in conjunction with chemotherapy may help reduce or prevent some treatment-related side effects and toxicities that can delay treatment, reduce doses, and negatively affect quality of life. Melatonin supplementation has been associated with significant reductions in neuropathy and neurotoxicity, myelosuppression, thrombocytopenia, cardiotoxicity, stomatitis, asthenia, and malaise.[
Overall, several small studies show some evidence supporting melatonin supplementation alongside chemotherapy, radiation therapy, or both for solid tumor treatment, aiding tumor response, and reducing toxicities. Negative side effects for melatonin supplementation have not been found. Therefore, it may be appropriate to provide oral melatonin in conjunction with chemotherapy or radiation therapy to a patient with an advanced solid tumor.
Glutamine is an amino acid that is especially important for GI mucosal cells and their replication. Chemotherapy and radiation therapy often damage these cells, causing mucositis and diarrhea, which can lead to treatment delays and dose reductions and severely affect quality of life. Some evidence suggests that oral glutamine can reduce both of those toxicities by aiding in faster healing of the mucosal cells and entire GI tract.
For patients receiving chemotherapy who are at high risk of developing mucositis, either because of previous mucositis or having received known mucositis-causing chemotherapy, oral glutamine may reduce the severity and incidence of mucositis.[
For patients receiving radiation therapy to the abdomen, oral glutamine may reduce the severity of diarrhea and can lead to fewer treatment delays.[
In addition to reducing GI toxicities, oral glutamine may also reduce peripheral neuropathy in patients receiving the chemotherapy agent paclitaxel.[
Oral glutamine is a safe, simple, and relatively low-cost supplement that may reduce severe chemotherapy- and radiation-induced toxicities.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Basic Principles of Nutrition in Patients With Cancer
Added text to state that malnutrition increases treatment toxicities, diminishes quality of life, and accounts for 10% to 20% of mortality in patients with cancer (cited Muscaritoli et al. as reference 5 and level of evidence IV).
Added text about evidence suggesting that dietitian-led intervention is associated with increased survival in patients with cancer (cited Lu et al. [level of evidence: I] and Davidson et al. as references 12 and 13, respectively).
Added text about a randomized controlled trial of 328 patients at a single institution in China that assessed the inclusion of a dietitian and psychologist as part of the interdisciplinary team versus the standard of care. Improvement in overall survival occurred despite no statistically significant difference in progression-free survival. Secondary analysis also showed significant improvements in nutrition assessment scores at 9 weeks.
Added text about a study of patients with unresectable pancreatic adenocarcinoma who had a weekly phone call with a registered dietitian for 8 weeks to discuss diet and management of disease-related side effects. They were also given oral nutritional supplements. Median survival was found to be significantly longer in weight-stable versus weight-losing subjects.
This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about nutrition before, during, and after cancer treatment. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Nutrition in Cancer Care are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Nutrition in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389293]
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Last Revised: 2022-03-23
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