ONC: Medical Nutrition Therapy and Nutrition Intervention in Adult Oncology Patients (2011)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

This study examined the effect of regular and long-term nutritional counseling on dietary intake, anthropometric measurements, response rate and overall survival rate and quality of life in patients with cancer of the breast, ovary or lung (small cell) undergoing chemotherapy with curative intent.

Inclusion Criteria:

All patients had:

  1. Histologically-verified small-cell lung cancer. Ovarian cancer or breast cancer.
  2. Measurable or assessable disease
  3. Life expectancy of longer than three months
  4. Eastern Cooperative Oncology Group (ECOG) performance status of two or better
  5. All patients agreed to enter a chemotherapeutic treatment protocol.
Exclusion Criteria:
  • Prior chemotherapy (except adjuvant chemotherapy in breast cancer)
  • Current or planned hormonal therapy (including therapy with anticatrogens and progesterone derivatives
  • Major surgery within the last month
  • Presence of ascities or clinically-detectable edema, malabsorption or other diseases (unrelated to cancer) that would necessitate dietary intervention
  • Metastasis to the central nervous system.
Description of Study Protocol:

Recruitment

Not described.

Design

  • Longitudinal study
  • All patients in the study were stratified according to primary disease, extent of weight-loss in the preceding three months and Eastern Cooperative Oncology Group performance status
  • A random number table and a system of sealed envelopes to receive either regular and frequent nutrition counseling from the start of the chemotherapy were utilized
  • Over the five-month time-frame, the Intervention Group was counseled by the study dietitian, while the Control Group received nutritional support (education) at the discretion of the assigned physician.

Blinding Used

Blinding was not discussed.

Intervention

  • A three-day food diary was utilized to evaluate the dietary intake of the Counseled and Control Groups
    • Prior to randomization, each patient was instructed by the study dietitian to weigh and measure foods, utilizing scales and measuring cups
    • Each patient received instructions to record their food intake for three consecutive days (including one weekend day) six times during the five-month period by the study dietitian.
  • Both groups were encouraged to take one vitamin-mineral tablet per day, which met the recommended allowance of micronutrients. The same dietitian counseled all patients randomized to receive nutritional intervention before the start of chemotherapy and twice monthly during the five months of the study. Counseling by the dietitian were also available upon the request.
    • The goal was to meet or exceed the Nordic Recommended Allowance for protein and energy requirements. These were daily energy intakes in the range of 1.5 to 1.7 basal energy (BEE), calculated from the Harris Bendict equation and protein intake of 1.0g to 1.2g per kg body weight.
    • Based on the diaries and nutrition-related symptoms, patients were counseled on an individual basis, according to advocated recommendations
    • Counseled patients were offered supplementation with commercial liquid diets, protein supplements or maltodextrin, if indicated
    • The subjects were given their preference among several commercial diets, in a choice of different flavors, (Salvimulsin, Ercopharm, Kvistgird, Denmark, Standard Top Up, Novo Nordisk, Copenhagen, Denmark, Nutrition Standard, Nutricia, Bagsvard, Denmark).
  • Patients who submitted less than four food diaries had the data excluded from the analysis. The Cox's test was used to test differences in survival distribution. Survival curves were plotted using the method of Kaplan and Meier.

Baseline Nutritional Data
(Preceding the onset of chemotherapy)

 

Counseled
(N=57)

Control
(N=48)

Energy Intake   MJ per day

7.7±1.9

7.5±2.3

MJ/BEE per day

1.4±0.3

1.3±0.4

Protein Intake Grams per day

61±18

58±19

g/kg per day

0.9±0.3

0.9±0.3

Weight (kg)

  66.7±12.5

65.8±12.6

Triceps skinfold (mm)

18.4±7.4

18.6±7.4

Arm muscle area (cm2)

32.1±9.8

32.0±9.8

FFM (kg)

44.9±8.1

44.4±8.0

Fat mass (kg)

21.8±6.5

 21.4±7.0

Plasma albumin (mcmol/L)

571±73

562±73

[Note: Values are mean ±SD.]

Statistical Analysis

  • Categorical variables were analyzed by chi square test and quantitative variables by analysis of variance
  • The ANOVA model was a two-factor design with repeat measures on one factor
  • The researchers determined that approximately 50 patients in each group were required in order to detect differences in a weight of five kg, considered to be clinically significant, at a level of significance (two-sided) of 0.05 and a power of 0.8.
Data Collection Summary:

Timing of Measurements

  • All of the therapies were administered in repeating cycles, approximately every four weeks. Tumor responses were evaluated when patients completed three cycles (approximately two months) of protocol chemotherapy and again after six cycles (approximately five months).
  • The first food recording was before the onset of the first chemotherapeutic series and the following five recordings during the week before each of the subsequent scheduled series. For the Intervention Group, the diaries were analyzed upon receipt to determine appropriate changes in nutritional counseling. The diaries of the Control Group were analyzed at the end of the study.
  • Dietary counseling was standardized and performed by a trained dietitian two times per month during the five-month time frame of the research project
  • All patients underwent anthropometric and laboratory assessments six times prior to the beginning of chemotherapy and five additional times at delivery of dietary records, usually on days of chemotherapy
  • Patients answered the quality of life questionnaire three times. These included:
    • Before onset of chemotherapy
    • Before the fourth and sixth chemotherapeutic cycle, usually on the first day of a diet registration period.

Dependent Variables

  • Response to chemotherapy
  • All patients were staged according to running treatment protocols using physical and radiologic examinations; ultrasonic, radioisotopic and computed tomographic scan and needle biopsy cytology. All patients with ovarian cancer had a staging exploratory laparotomy. Various chemotherapeutic regimens were used:

  Chemotherapy Regimes
Lung Cancer

Combination therapy with cisplatin, vindesine, etoposide, vincristine, doxorubicin, tenoposide, cyclophosphamide, lomustine (CCNU) and hexamethylmelamine or monotherapy with tenoposide or etoposide

Ovarian Cancer Combination therapy with caboplatin, cisplatin and etoposide or with cyclophosphamide, doxorubicin and fluorouracil
Breast Cancer Combination therapy with cyclophosphamide, epirubicin and fluorouracil or monotherapy with epirubicin

  • In this study, treatment "Responders" were defined as patients with CR or PR, while "Nonresponders" were defined as patients with NC or PD
  • The patients with no response, assessed after three cycles of chemotherapy, had their chemotherapy regimes changed, whereas responders continued with the protocol treatment for at least another three cycles or until there was evidence of disease progression
  • The patients who died were considered non-responders
  • The response evaluation criteria was defined as follows:

 

Response Evaluation
Complete Remission (CR) Defined as the disappearance of all evidence (clinical, radiologic, biochemical and histologic) of tumor
Partial Remission (PR) A greater than 50% decrease in the product of cross-sectional diameters of measurable lesions
Progressive Disease (PD)

Defined as the appearance of of any new lesions or a 25% increase in the product of cross-sectional diameters of measurable lesions

Stable Disease or No Change (NC) Defined as changes less than PD or PR

Dietary Intake

Dietary data was coded and analyzed for energy and protein intake, utilizing a computerized version of Danish Food Composition Tables (Dankost, version 1.3 National Food Agency, Saborg, Denmark).

Anthropometric Measurements

  • Weight (light clothing), determined by weighing on a calibrated physician's scale. The patient's recalled weight, at least three months prior to the cancer diagnosis, was used to assess weight loss.
  • The mean values of triplicate measurements at four sites [triceps, biceps, subscapular and suprailiac (skinfolds)] were used to to calculate body density, using the equations reported by Durnin and Womersley
  • Triceps skinfold, measured to the nearest millimeter using a Harpenden skin caliper (John Bull, British Indicators Ltd., England)
  • Arm muscle area, measured using a non-stretchable tape
  • Fat-free mass (FFM), from the calculated body density, the fat-free mass was derived using the Sin's equation
  • Fat mass
  • Mid-arm muscle area (bone-free arm muscle area) was calculated from arm circumference and triceps skinfold measurements, according to the equation reported by Heymsfield et al.

Laboratory Values

  • Plasma albumin
    • The Quality of Life Index utilized to assess the quality of life of the cancer patients was a modified version of the QL-index developed by Spitzer et al. The questionnaire was chosen because it has been shown to be reliable and valid and because scores have been shown to be associated with degree of weight loss in a cancer population similar to the one under investigation. The QL index covers the following items:
      • Involvement in own occupation
      • Activities of daily living
      • Perception of own health and outlook on life (one question each)
      • Patient's appetite and pleasure of eating. Each item was scored categorically (zero, one or two). Each patient also completed a 100-mm linear analog scale (LAS) in answer to the question, How good is your quality of life? The answers on the LAS ranged from zero (extremely poor) to 100 (excellent).
  • Survival rate.

Independent Variables

  • Age (years)
  • Sex
  • Stage cancer (local:extensive)
  • Primary tumor site
  • Percent weight loss in prior three months.

Control Variables

Dietary counseling by a trained dietitian vs. no dietary counseling by a trained dietitian.

Description of Actual Data Sample:

Initial N

137.

Characteristics of 57 Patients Who Received Dietary Counseling and 48 Control Patients

Characteristics    
Counseled
Control
Age (years)   Mean

59

58

Range

29-80

22-80

Sex (female:male)

74:26

79:21

Stage (local:extensive percentage)*

56:44

63:37

Primary Tumor Site (percentage)   Breast

21

15

Ovarian

40

46

Lung

39

39

Weight Loss in Prior Three Months (percentage)   :5

49

50

>5

51

50

 *Presence of distant metastases (i.e., tumor-made metastasis classification of M) in breast and ovarian cancer patients and disease outside one hemitharax in small-cell lung cancer patients).

Attrition (Final N)

  • 105
  • 32 patients were not used in the analysis due to:
    • Early death or deteriorating functional status (N=13)
    • Rejected further participation within two months (N=11)
    • Delivery of insufficient number of dietary records (N=5)
    • Stopped protocol chemotherapeutic treatment (N=3).

Ethnicity

Not identified.

Location

Copenhagen, Denmark.

Summary of Results:

Changes From Initial (Preceding the Onset of Therapy) Energy and Protein Intakes In the Counseled (N=57) and Control (N=48) Groups

  Month

One

Two

Three

Four

Five

Energy Intake (MJ per day)      Counseled

1.1±2.6*

0.9±2.2*§
0.6±2.2*§
1.0±2.4*§
0.6±2.3*§
Control
0.3±2.7
-0.1±1.9
-0.3±2.0
-0.5±1.9
-0.3±2.0
Protein Intake (grams per day)      Counseled
12±23*§
11±20*§
11±19*§
14±21*§
8±21*§
Control
2±21

~1±14

-5±15
-5±17
-1±22

[Note: Values are mean ±SD]
*P<0.05 between months
§P<0.05 between groups.

Changes From Initial (Preceding the Onset of Therapy) Anthropometric Values in Counseled (N=57) and Control (N=48) Groups

  Month

One

Two

Three

Four

Five

Weight (kg) Counseled
-0.7±2.7
-0.5±3.7
-0.5±4.0
0.4±4.7
1.0±5.6
Control
-0.6±2.6
-0.3±3.1
-0.4±3.6
0.2±3.9
0.1±4.7
Arm Muscle Area (cm2) Counseled
0.6±3.4
-0.9±4.6
-0.3±4.1
0.1±4.0
0.2±4.5
Control
-0.3±3.2
-0.2±4.7
-0.1±3.8
0±5.5
0±5.0
Triceps Skinfold (cm) Counseled
-0.7±2.8
-0.3±3.5
0±4.1
0.6±4.8
1.3±5.4*
Control
-0.3±2.5
-0.3±3.4
-0.2±3.5
0.2±4.0
0.4±4.2
FFM (kg) Counseled
0.3±1.4
-0.2±1.8
0.1±1.6
0.2±1.8
0.3±2.0
Control
-0.3±1.3
-0.1±1.6
-0.2±1.9
-0.1±1.7
-0.1±2.0
Fat Mass (kg) Counseled
-0.5±1.5
-0.4±2.7
-0.4±3.0
0.1±3.5
0.7±4.3
Control
-0.4±1.7
-0.1±2.0
-0.1±2.4
0.3±2.8
0.3±3.2
Plasma Albumin (mcmol/L) Counseled
0±65
12±64
8±56
17±76
17±74
Control
5±62
14±56
17±55
20±65
17±69

[Note: Values are mean ±SD.]
*P<0.05 between months

Overall tumor response rate was not significantly different in the Counseled and Control Groups.

Patient Responses in the Counseled (N=58) and Control (N=47) Groups After Three Months of Chemotherapy

  Three Months* Five Months¶
Responders (CR+PR)

Non-responders (NC+PD)

Responders (CR+PR)

Non-responders (NC+PD)

Counseled Number
37

20

36
21
Percentage
65
35
63
37
Control Number
33
15
22
26
Percentage
69
31
46
54
Total Number
70
35
58
47
Percentage
67
33
55
45

*P=0.83 difference between groups
¶P=0.11 difference between groups

 

Baseline

Three Months

Five Months

LAS (mm) Counseled

73±21

68±26

72±28

Control

70±17

68±25

68±26

QL-Index Counseled

7.0±2.2

7.6±2.4

8.1±2.1*

Control

6.6±2.2

8.0±2.1*

7.9±2.6*

[Note: Values are mean ±SD.]
*P<0.05 between months

Other Findings

There were no significant differences in the overall survival rate in the Counseled Group, compared with the Control Group.

The cumulative proportion surviving were:

 

Counseled

Controlled

Year One

69%

72%

Year Two

39%

32%

Analysis by Nutritional Status

  • Subset of patients nutritionally depleted (greater than 5% weight loss) at baseline
  • No benefit from MNT above control
  • Similar intake to weight-stable patients
  • Higher QOL tools in weight-stable patients.
Author Conclusion:

Frequent and professional dietary counseling targeted to recommended intake levels resulted in increased food intake during the five months' time-frame of the study in patients undergoing chemotherapy. However, no effect on weight, response rate, survival duration or quality of life could be demonstrated.

Funding Source:
Not-for-profit
0
Foundation associated with industry:
Reviewer Comments:
  • The researchers appeared to adhere to the protocols for their study design. The longitudinal design focus on a population or sub-group, some members of which are exposed to or experience certain events over time, while others will not. Data are collected at more than one point in time and the reference period is prospective. The researchers look to the future in describing and explaining the occurrence of the characteristics of interest. 
  • The author did not note the possibility of "recall basis" in relationship to the patients' report of weight prior to the beginning of the research study. It was noted that the patient's recalled weight, at least three months prior to the cancer diagnosis, was used to assess weight loss.
  • Even after attrition, the number of patients remained very close to the parameters established (57 Counseled and 48 Control) in the statistical analysis. The researchers determined that the chance of detecting differences in weight of five kilograms, considered to be clinically significant, required at a level of significance (two-sided) of 0.05 and a power of 0.8, would require approximately 50 patients in each group.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? ???
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) ???
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) ???
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? ???
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? ???
5. Was blinding used to prevent introduction of bias? ???
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? ???
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? ???
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? ???
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? ???
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? ???
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? ???
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? ???
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? ???
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? ???
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? ???
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  7.7. Were the measurements conducted consistently across groups? ???
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? ???
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? Yes
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes