Malnutrition in patients with gynaecological cancer
Malnutrition in cancer patients is very common can arise through the patient’s inability to ingest or absorb food. In our research, between 20-53% of gynaecological cancer patients present with at least mild malnutrition at cancer diagnosis.
In patients requiring surgery, Queensland Centre of Gynaecological Cancer (QCGC) research has found the impact of malnutrition is associated with low quality of life, a high risk of treatment-related adverse events such as wound infections and also longer hospital stay. Many patients may not achieve an adequate nutritional intake in the days following surgery, and for a patient who undergoes surgery in a malnourished state this may increase their likelihood of worse treatment outcomes.
Malnutrition is most common in patients with ovarian cancer. In a 2007 study by QCGC of 145 patients with suspected or proven gynaecological cancer, patients with ovarian cancer were 19 times more likely to present with malnutrition to the gynaecology oncology clinic compared to patients with benign conditions.
My research team and I recently published a review in the journal Gynaecologic Oncology on this topic. We summarised evidence from randomised clinical trials previously conducted that aimed to provide an update on this research area. We looked at studies in the gynaecological cancer setting that aimed to reduce the risk of malnutrition, enhance recovery after surgery, and achieve a return to normal diet as early as possible.
After searching medical journal databases, we found seven clinical trials to review. All seven studies evaluated interventions for improving nutritional recovery in gynaecological cancer patients across a number of countries including Australia, Canada, China, Italy, Turkey and the USA. The number of participants in the studies ranged from 40 to 245.
All seven clinical trials tested non-conventional feeding interventions against traditional usual care in the control (placebo) groups. The purpose of the intervention groups was to allow patients to have caloric intake as soon as tolerable. The studies hypothesised the intervention group would have improved quality of life and a reduced hospital stay. The interventions involved early oral postoperative feeding (1 trial assessed clear fluid diet; 1 trial assessed semiliquid diet; 3 trials assessed regular diet), enteral feeding (1 trial) and immune-enhanced enteral feeding (1 trial). Enteral feeding is receiving nutrients via a tube inserted through the nose to the stomach).
Across all the studies, early clear liquid diet, semiliquid diet, regular diet or immune-enhanced enteral diets were all found to be safe d did not increase a patient’s risk of complications. Overall, four of seven studies reported a quicker intestinal recovery or resumption back to normal diet, within the intervention group.
Five of the studies reviewed found nutritional interventions to improve intestinal recovery, reduce hospital stay or postoperative complications. The remaining two clinical trials of the seven reviewed found no benefit of enteral nutrition or administering a clear liquid diet as opposed to a normal diet postoperatively. One study found early intake of a semiliquid diet reported significantly higher nausea in the early feeding group.
Overall early oral intake with progressive advancement from a liquid diet to a normal diet was safe and well tolerated following surgery in gynaecological cancer patients. Compared to patients who received traditional oral feeding postoperatively, length of hospital stay was significantly shorter in the early feeding group. However, postoperative complications, particularly infections were found to be higher in the control groups.
From my daily practice, I do acknowledge that patients often are not keen on eating after surgery. Most patients simply are not hungry. I see my role to inform patients and encourage them to have a spoon of this and a bite of that. As surgeons we want patients eating as soon as possible after surgery because it helps with the recovery form surgery.
A little tip for my surgical colleagues who might read this article – Sometimes when patients are not hungry I try chewing gum or sour drops. WORKS WONDERS to wake up the bowels!
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