NUTRICIÓN Y METABOLISMO EN EL PACIENTE ONCOLÓGICO
Palabras clave:
cancer, estado nutricional, terapia médica nutricional, tumor, caquexia, fortificación, nutrición entérica, nutrición parenteralResumen
El cáncer afecta seriamente el estado nutricional del paciente. La pérdida de peso, y principalmente de masa libre de grasa, puede ser de gran magnitud, como sucede cuando afecta órganos sólidos. Asimismo, se producen anormalidades metabólicas que impiden la adecuada utilización de los nutrientes, por lo cual es necesario ajustar, en forma individual, el plan de alimentación. Los efectos secundarios generados por los medicamentos anticancerosos dificultan aún más una alimentación adecuada. Un pobre estado nutricional limita el tratamiento, sea de quimioterapia o de radioterapia, pues aumenta la intolerancia, lo cual impide la administración de las dosis usuales o su aumento en magnitud o frecuencia. También el estado de desnutrición significa un mayor reconocido riesgo cuando se emprende un tratamiento quirúrgico.
La implementación del tratamiento médico nutricional (evaluación, diagnóstico, intervención, vigilancia y seguimiento) es fundamental para el manejo multimodal que requieren estos pacientes. La selección del tipo de soporte nutricional debe ser personalizada y su principal objetivo también debe estar encaminado a mejorar la calidad de vida. En muchos casos la fortificación de los alimentos, especialmente con proteína de alto valor biológico, logra mejorar el estado nutricional. Cuando esta no es suficiente, o sea aquella que cubre menos del 60% del requisito proteico-calórico diario, se deben considerar alternativas, como la nutrición entérica por sonda o la parenteral suplementaria.
Cuando el pronóstico de supervivencia es mayor de tres meses o cuando la localización del tumor o las alteraciones gastrointestinales impiden el empleo de la vía entérica, se sugiere la nutrición parenteral total, la cual, idealmente, debería ser ambulatoria. Hoy en día se considera que la nutrición y el ejercicio son factores fundamentales en el manejo de estos pacientes, y que no hay bases para considerar que alimentar al individuo es alimentar el tumor.
Biografía del autor/a
Patricia Savino Lloreda, Academia Nacional de Medicina de Colombia
ND, MBA. Miembro Asociado Academia Nacional de Medicina, Bogotá, D.C. Colombia
Referencias bibliográficas
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6. Mir O, Coriat R, Blanchet B, Durand J, Boudou-Rouquetee P, Michels J, et al. Sarcopenia predicts early dose-limiting toxicities and pharmacokinetics of sorafenib in patients with hepatocellular carcinoma. PLoS One. 2012; 7: e37563.
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25. Anandavadivelan P, Brismar TB, Nilsson M, Johar AM, Martin L. Sarcopenic obesity: A probable risk factor for dose limiting toxicity during neo-adjuvant chemotherapy in oesophageal cancer patients. Clin Nutr. 2016;35:72430.
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27. Bossola M, Pacelli F, Rosa F, Tortorelli A, Doglietto GB. Does nutrition support stimulate tumor growth in humans? Nutr Clin Pract. 2011;26:174-80.
28. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14:542- 59.
29. Bozzetti F. Tailoring the nutritional regimen in the elderly cancer patient. Nutrition. 2015;31:612-4.
30. Winter A, Macadams J, Chevalier S. Normal protein anabolic response to hyperaminoacidemia in insulinresistant patients with lung cancer caquexia. Clin Nutr. 2012;31:765-73.
31. Cano N, Fiaccadori E, Tesinky P, Toigo G, Druml W, DGEM (German Society for Nutritional Medicine), et al. ESPEN guidelines on enteral nutrition: Adult renal failure. Clin Nutr. 2006;25:295-310.
32. Kuhn K, Muscaritoli M, Wischmeyer P, Stehle P. Glutamine as indispensable nutrient in oncology: experimental and clinical evidence. Eur J Nutr. 2010;49:197-210.
33. Pytlyck R, Bebes P, Patorková, Chocenska E, Gregora E, Procházka B, et al. Stantardized parenteral alanylglutamine dipeptide supplementation is not beneficial in autologous transplant patients: a randomized, doubleblind, placebo controlled study. Bone Marrow Transplant. 2002;30:953-61.
34. Sykorova A, Horacek J, Zak P, Kmonicek M, Bucak J, Maly J. A randomized, double blind comparative study of
prophylactic parenteral nutrition support with or without glutamine in autologous stem cell transplantation for hematological malignancies --three years’ follow up. Neoplasma. 2005;52:476-82.
35. Bozzetti F, Zupec-Kania B. Toward a cancer-specific diet. Clin Nutr. 2016;35:1188-95.
36. Seyfried TN, Shelton LM, Mukherjee P. Does the existing standard of care increase glioblastoma energy metabolism? Lancet Oncol. 2010;11:811-3.
37. Seyfried TN. Cancer as a metabolic disease: on the origin, management, and prevention of cancer. Hoboken, NJ: Wiley; 2012. pp. 57-60
38. Klein S, Wolfe RR. Carbohydrate restriction regulates the adaptive response to fasting. Am J Physiol. 1992;262(5 Pt. 1):E631-6.
39. Burt ME, Norton JA, Brennan MF. The human tumorbearing limb: An ex vivo model. Surgery. 1980;87:12832.
40. Norton JA, Burt ME, Brennan MF. In vivo utilization of substrate by human sarcoma-bearing limbs. Cancer. 1980;45:2934-9.
41. Greschner M, Saeger HD, Barth H, Leweling H, Holm E. Balances of energy yielding substrates across malignant gastric tumours in man. Clin Nutr. 1991;10(Suppl.):12.
42. Holm E, Hagmüller E, Staedt U, Schlickeiser G, Günther HJ, Leweling H, et al. Substrate balances across colonic carcinomas in humans. Cancer Res. 1995;55:1373-8.
43. Derr RL, Ye X, Islas MU, Desideri S, Saudek CD, Grossman SA. Association between hyperglycemia and survival in patients with newly diagnosed glioblastoma. J Clin Oncol. 2009;27:1082-6. http://dx.doi.org/10.1200/ JCO.2008.19.1098 [Epub 2009 Jan 12].
44. Kubicek GJ, Champ C, Fogh S, Wang F, Reddy E, Intenzo C, et al. FDG-PET staging and importance of lymph node SUV in head and neck cancer. Head Neck Oncol. 2010; 2:19. doi: 10.1186/1758-3284-2-19
45. Chung HH, Kwon HW, Kang KW, Park NH, Song YS, Chung JK, et al. Prognostic value of preoperative metabolic tumor volume and total lesion glycolysis in patients with epithelial ovarian cancer. Ann Surg Oncol. 2012;19:1966-72.
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48. Rous P. The influence of diet on transplanted and spontaneous mouse tumors. J Exp Med. 1914;20:433-51.
49. Fearon K, von Meyenfeldt MF, Mose AG, van Greene R, Roy A, Gouma DJ, et al. Effect of a protein and energy dense N-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: A randomised double blind trial. Gut. 2003;52:1479-86.
50. Norman HA, Butrum RR, Feldman E, Heber D, Nixon D, Picciano MF, et al. The role of dietary supplements during cancer therapy. J Nutr. 2003;133(Suppl.1):3794-9S.
51. Thompson K, Elliot L, Fuchs-Tarlovsky V, Levin RM, Voss AC, Piemonte T. Oncology evidence-based nutrition practice guideline for adults. J Acad Nutr Diet. 2017;117:297-310.
52. Savino P. Knowledge of constituent ingredients in enteral nutrition formulas can make a difference in patient response to enteral feeding Nut Clin Pract 2018; 33(1): 90 -98.
53. Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A, Allison SP, et al. Nutrition in clinical practice-the refeeding syndrome: Illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr. 2008;62:68794.
54. Ferriolli E. Physical activity monitoring: A responsive and meaningful patient-centered outcome for surgery, chemotherapy, or radiotherapy? J Pain Symptom Manage. 2012;43:1025-35.
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57. Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr. 2016;35:54556. http://dx.doi.org/10.1016/j.clnu.2016.02.006
58. Fan BG. Parenteral nutrition prolongs the survival of patients associated with malignant gastrointestinal obstruction. J Parenter Enter Nutr. 2007;31:508-10.
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2. Arends J, Bachman P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1): 11-48.
3. Laviano A, Molfino A, Rossi F. Cancer-treatment toxicity: can nutrition help? Nat Rev Clin Oncol. 2012;9: doi: 10.1038/nrclinonc.2012.99-c1. Epub 2012 Sep 25.
4. Laviano A, Rossi F. Toxicity in chemotherapy--when less is more. N Engl J Med. 2012;366:2319-20.
5. Prado C, Baracos V, McCargar L, Reiman T, Mourtzakis M, Tonkin K, et al. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009;15:2920-6.
6. Mir O, Coriat R, Blanchet B, Durand J, Boudou-Rouquetee P, Michels J, et al. Sarcopenia predicts early dose-limiting toxicities and pharmacokinetics of sorafenib in patients with hepatocellular carcinoma. PLoS One. 2012; 7: e37563.
7. World Health Organization. Cancer. WHO, 2017. Fecha de consulta: 17 de septiembre de 2017. Disponible en: http://www.who.int/cancer/en/.
8. World Health Organization. Colombia. WHO, 2014. Fecha de consulta: 17 de septiembre de 2017. Disponible en: https://www.google.com.co/url?sa=t&rct=j&q=&esrc=s&s ource=web&cd=2&cad=rja&uact=8&ved=0ahUKEwjVnP 3qnqzWAhXDNiYKHQ7fDBAQFggzMAE&url=http%3A% 2F%2Fwww.who.int%2Fnmh%2Fcountries%2Fcol_en.p df&usg=AFQjCNGN4MjjzjXTQzPvGZj3YbC2mkFwdQ.
9. PAHO. Colombia Cancer Profile. Colombia. Sociodemographic indicators. Fecha de consulta: 17 de septiembre de 2017. Disponible en: http://www.paho.org/hq/index. php?option=com_docman&task=doc_view&gid=22994 &Itemid=270&lang=en.
10. Ospina M, Huertas JA, Montaño J, Rivillas JC. Observatorio Nacional de Cancer Colombia. Rev Fac Nac SaludPública. 2015;33:262-76.
11. Bozzetti F. Basics in clinical nutrition: Nutritional support in cancer. e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism. 2010;5:e148-52. http://www.clinicalnutritionespen.com/article/S17514991(09)00065-1/pdf
12. Trujillo E, Nebeling L. Changes in carbohydrate, lipid, and protein metabolism in cancer. In: Elliot L, Molseed L, McCallum D, Grant B. editors. The Clinical Guide to Oncology Nutrition. Washington DC, Unite States of America: American Dietetic Association; 2006. p.17-27.
13. Ravasco P. Nutrition in cancer. In: Soeters P, Meir R, editors. The importance of nutrition as an integral part of disease management. Nestlé Nutr Inst Workshop Ser., vol 82, p. 91-102 (doi:10.1159/000382004. Nestec Ltd., Vevey/S.KargerAG, Basel, 2015. Ver: https://www.nestlenutrition-institute.org/docs/default-source/global-dcoument-library/publications/secured/e67b25a1e53b9b715d25e313de3d3070.pdf?sfvrsn=0
14. Dewys WD, Begg C, Lavin PT, Bennett JM, Band PR, Bertino JR, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980:69: 491-7.
15. Bozzetti F. Rationale and indications for preoperative feeding of malnourished surgical patients. Nutrition. 2002;18:953-9.
16. Huhmann M, August D. Surgical oncology. In Marian MS, Roberts S, editors. Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones and Barlett Publishers; 2010. p.101-36.
17. Goodwin WJ Jr, Torres J, The value of the prognostic nutritional index in the management of patients with advance carcinoma of the head and neck. Head Neck Surg. 1984;6:932-7.
18. Baracos V, Martin L, Korc M, Guttridge D, Fearon K. Cancer-associated cachexia. Nat Rev Dis Primers. 2018; 4:17105. doi:10.1038/nrdp.2017.105.Review. PMID:29345251.
19. Lacey K, Pritchett E. Nutrition Care Process and model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103:1061-72.
20. Splett P. Developing and validating evidence-bases guides for practice: A tool kit for dietetics professionals. Chicago, III: American Dietetic Association; 1999.
21. Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: Role of the Patient-Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care. 2017;20:322-9.
22. Davis P. Nutrition screening and assessment in oncology. . In: Elliot L, Molseed L, McCallum D, Grant B. editors. The Clinical Guide to Oncology Nutrition. Washington DC, Unite States of America: American Dietetic Association; 2006. p.44-53.
23. Planas M, Álvarez-Hernández J, León-Sanz M, CelayaPérez S, Araújo K, García A, et al. Prevalence of hospital malnutrition in cancer patients: A sub-analysis of the PREDyCES® study. Support Care Cancer. 2016; 24:429-35.
24. Gyan E, Raynard B, Durand JP, Lacau Saint Guily J, Gouy S, Movschin ML, et al. Malnutrition in patients with cancer: Comparison of perceptions by patients, relatives, and physicians-Results of the NutriCancer 2012 J Parenter Enteral Nutr. 2018: 42(1):255-60.
25. Anandavadivelan P, Brismar TB, Nilsson M, Johar AM, Martin L. Sarcopenic obesity: A probable risk factor for dose limiting toxicity during neo-adjuvant chemotherapy in oesophageal cancer patients. Clin Nutr. 2016;35:72430.
26. Bozzetti F, Mori V. Nutritional support and tumor growth in humans: A narrative review of the literature. Clin Nutr. 2009;28:226-30.
27. Bossola M, Pacelli F, Rosa F, Tortorelli A, Doglietto GB. Does nutrition support stimulate tumor growth in humans? Nutr Clin Pract. 2011;26:174-80.
28. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14:542- 59.
29. Bozzetti F. Tailoring the nutritional regimen in the elderly cancer patient. Nutrition. 2015;31:612-4.
30. Winter A, Macadams J, Chevalier S. Normal protein anabolic response to hyperaminoacidemia in insulinresistant patients with lung cancer caquexia. Clin Nutr. 2012;31:765-73.
31. Cano N, Fiaccadori E, Tesinky P, Toigo G, Druml W, DGEM (German Society for Nutritional Medicine), et al. ESPEN guidelines on enteral nutrition: Adult renal failure. Clin Nutr. 2006;25:295-310.
32. Kuhn K, Muscaritoli M, Wischmeyer P, Stehle P. Glutamine as indispensable nutrient in oncology: experimental and clinical evidence. Eur J Nutr. 2010;49:197-210.
33. Pytlyck R, Bebes P, Patorková, Chocenska E, Gregora E, Procházka B, et al. Stantardized parenteral alanylglutamine dipeptide supplementation is not beneficial in autologous transplant patients: a randomized, doubleblind, placebo controlled study. Bone Marrow Transplant. 2002;30:953-61.
34. Sykorova A, Horacek J, Zak P, Kmonicek M, Bucak J, Maly J. A randomized, double blind comparative study of
prophylactic parenteral nutrition support with or without glutamine in autologous stem cell transplantation for hematological malignancies --three years’ follow up. Neoplasma. 2005;52:476-82.
35. Bozzetti F, Zupec-Kania B. Toward a cancer-specific diet. Clin Nutr. 2016;35:1188-95.
36. Seyfried TN, Shelton LM, Mukherjee P. Does the existing standard of care increase glioblastoma energy metabolism? Lancet Oncol. 2010;11:811-3.
37. Seyfried TN. Cancer as a metabolic disease: on the origin, management, and prevention of cancer. Hoboken, NJ: Wiley; 2012. pp. 57-60
38. Klein S, Wolfe RR. Carbohydrate restriction regulates the adaptive response to fasting. Am J Physiol. 1992;262(5 Pt. 1):E631-6.
39. Burt ME, Norton JA, Brennan MF. The human tumorbearing limb: An ex vivo model. Surgery. 1980;87:12832.
40. Norton JA, Burt ME, Brennan MF. In vivo utilization of substrate by human sarcoma-bearing limbs. Cancer. 1980;45:2934-9.
41. Greschner M, Saeger HD, Barth H, Leweling H, Holm E. Balances of energy yielding substrates across malignant gastric tumours in man. Clin Nutr. 1991;10(Suppl.):12.
42. Holm E, Hagmüller E, Staedt U, Schlickeiser G, Günther HJ, Leweling H, et al. Substrate balances across colonic carcinomas in humans. Cancer Res. 1995;55:1373-8.
43. Derr RL, Ye X, Islas MU, Desideri S, Saudek CD, Grossman SA. Association between hyperglycemia and survival in patients with newly diagnosed glioblastoma. J Clin Oncol. 2009;27:1082-6. http://dx.doi.org/10.1200/ JCO.2008.19.1098 [Epub 2009 Jan 12].
44. Kubicek GJ, Champ C, Fogh S, Wang F, Reddy E, Intenzo C, et al. FDG-PET staging and importance of lymph node SUV in head and neck cancer. Head Neck Oncol. 2010; 2:19. doi: 10.1186/1758-3284-2-19
45. Chung HH, Kwon HW, Kang KW, Park NH, Song YS, Chung JK, et al. Prognostic value of preoperative metabolic tumor volume and total lesion glycolysis in patients with epithelial ovarian cancer. Ann Surg Oncol. 2012;19:1966-72.
46. Saigusa S, Toiyama Y, Tanaka K, Okugawa Y, Fujikawa H, Matsushita K, et al. Prognostic significance of glucose transporter-1 (GLUT1. gene expression in rectal cancer after preoperative chemoradiotherapy. Surg Today. 2012;42:460-9.
47. Erickson N,Boscheri A, Linke B, Huebner J. Systematic review: Isocaloric ketogenic dietary regimes for cancer patients. Med Oncol. 2017;34:72.
48. Rous P. The influence of diet on transplanted and spontaneous mouse tumors. J Exp Med. 1914;20:433-51.
49. Fearon K, von Meyenfeldt MF, Mose AG, van Greene R, Roy A, Gouma DJ, et al. Effect of a protein and energy dense N-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: A randomised double blind trial. Gut. 2003;52:1479-86.
50. Norman HA, Butrum RR, Feldman E, Heber D, Nixon D, Picciano MF, et al. The role of dietary supplements during cancer therapy. J Nutr. 2003;133(Suppl.1):3794-9S.
51. Thompson K, Elliot L, Fuchs-Tarlovsky V, Levin RM, Voss AC, Piemonte T. Oncology evidence-based nutrition practice guideline for adults. J Acad Nutr Diet. 2017;117:297-310.
52. Savino P. Knowledge of constituent ingredients in enteral nutrition formulas can make a difference in patient response to enteral feeding Nut Clin Pract 2018; 33(1): 90 -98.
53. Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A, Allison SP, et al. Nutrition in clinical practice-the refeeding syndrome: Illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr. 2008;62:68794.
54. Ferriolli E. Physical activity monitoring: A responsive and meaningful patient-centered outcome for surgery, chemotherapy, or radiotherapy? J Pain Symptom Manage. 2012;43:1025-35.
55. Jones LW, Alfano CM. Exercise-oncology research: Past, present, and future. Acta Oncol. 2013;52:195-215.
56. Bozzetti F, Santarpia L, Pironi L, Thul P, Klek S, Gavazzi C, et al. The prognosis of incurable cachectic cancer patients on home parenteral nutrition: A multi-centre observational study with prospective follow-up of 414 patients. Ann Oncol. 2014;25:487-93.
57. Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, et al. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr. 2016;35:54556. http://dx.doi.org/10.1016/j.clnu.2016.02.006
58. Fan BG. Parenteral nutrition prolongs the survival of patients associated with malignant gastrointestinal obstruction. J Parenter Enter Nutr. 2007;31:508-10.
59. Martin L, Watanabe S, Fainsinger R, Lau F, Ghosh S, Quan H, et al. Prognostic factors in patients with advanced cancer: Use of the patient-generated subjective global assessment in survival prediction. J Clin Oncol. 2010;28:4376-83.
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Cómo citar
[1]
Savino Lloreda, P. 2018. NUTRICIÓN Y METABOLISMO EN EL PACIENTE ONCOLÓGICO. Medicina. 40, 2 (jun. 2018), 208–225.
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2018-06-29
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