Oncology

ONC: Executive Summary of Recommendations (2007)

ADA Oncology Evidence-based Nutrition Practice Guideline

Executive Summary of Recommendations

Below are the major recommendations, and ratings for the Academy of Nutrition and Dietetics Oncology Evidence-Based Nutrition Practice Guideline.  To view the Guideline Overview, click the Introduction section. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers under Major Recommendations.

To see a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence) click here.

The Oncology and Nutrition Recommendations are organized by Type of Cancer.  (Note:  If you mouseover underlined acronyms and terms, a definition will pop-up.)

Breast Cancer and Oncology Nutrition

Chemotherapy

ONC: Breast Cancer: Chemotherapy Determination of Resting Energy Expenditure 2007

ONC: Breast cancer: Determination of REE and Chemotherapy

Use of indirect calorimetry to measure REE is more accurate than estimation in early stage and advanced metastatic breast cancer patients. If measurement of REE is not possible or not thought to be imperative, use the HBE to estimate calorie requirements. Limited evidence indicates that the mean estimated REE was comparable to measured REE in these populations. No research was available to compare HBE using individual error or to compare HBE with other predictive equations in these populations.


Weak
Imperative

ONC: Breast Cancer: Chemotherapy and Use of Arginine Oral Supplement 2007

ONC: Breast cancer: Arginine and Chemotherapy

Use of an oral arginine supplement to improve long-term clinical response for patients with breast cancer prior to the start of neoadjuvant chemotherapy is not currently recommended. Evidence is not available to evaluate the safety of arginine or its effect on cancer symptoms for patients with breast cancer receiving chemotherapy. One RCT demonstrated a statistically significant histopathological response in tumor sizes less than 6 cm, however there was no improvement in short-term clinical response.


Weak
Imperative

Auto-Hematopoietic cell transplant

ONC: Breast Cancer: Auto-HCT and Use of Parenteral Nutrition (PN) 2007

ONC: Breast cancer: Auto-HCT and PN

Parenteral nutrition (PN) should not be routinely recommended for breast cancer patients undergoing auto-HCT who are well-nourished prior to treatment. While PN may preserve nutritional status and lean body mass in these patients, it does not appear to affect LOS or survival, and may increase risk of infectious complications.


Weak
Imperative

Radiation

ONC: Breast Cancer: Radiation and Use of Antioxidant Vitamin E Oral Supplement 2007

ONC: Breast cancer: Vitamin E and Radiation

If vitamin E (alpha tocopherol, 670-1000 mg) oral supplement is proposed to promote tolerance or reduce late-effects of radiation, advise that no research is available on the impact of vitamin E supplementation to promote tolerance of radiation. Evidence is inconclusive on the benefit of vitamin E for treatment of chronic radiation-induced fibrosis. Vitamin E supplementation may have adverse effects such as nutrient-nutrient interactions, drug-nutrient interactions (e.g., anti-coagulant and anti-hypertensive medications/herbal supplements) and disease-related complications.


Weak
Conditional

Colorectal Cancer and Oncology Nutrition

ONC: Colorectal Cancer: Radiation and Medical Nutrition Therapy (MNT) 2007

ONC: Colorectal cancer: Radiation and MNT

Dietitians should provide weekly Medical Nutrition Therapy (MNT) that includes an individualized nutrition prescription and counseling for patients with colorectal cancer undergoing pelvic radiation. Individualized counseling with a focus on the consumption of regular foods may improve calorie and protein intake, nutrition status, quality of life (QOL) and reduce symptoms of anorexia, nausea, vomiting and diarrhea.


Fair
Imperative

Esophageal Cancer and Oncology Nutrition

Chemoradiation

ONC: Esophageal Cancer: Chemoradiation and Medical Nutrition Therapy (MNT) 2007

ONC: Esophageal cancer: Chemoradiation and MNT

The Dietitian should provide Medical Nutrition Therapy (MNT) consisting of a pre-treatment evaluation and weekly visits for six weeks during chemoradiation treatment for esophageal cancer to improve outcomes. MNT may reduce the amount of weight loss, unplanned hospitalizations, LOS, as well as improves tolerance to treatment and the likelihood of receiving prescribed radiation dose.


Weak
Imperative



ONC: Esophageal Cancer: Chemoradiation and Use of Enteral Nutrition 2007

ONC: Esophageal cancer: Chemoradiation and use of enteral nutrition

Enteral nutrition (EN) may be used to increase calorie and protein intake in esophageal cancer patients undergoing chemoradiation therapy. EN has been shown to maintain weight, however EN has not been shown to improve tolerance to therapy or survival.


Weak
Imperative

ONC: Esophageal Cancer: Chemoradiation and Use of Parenteral Nutrition 2007

ONC: Esophageal cancer: use of parenteral nutrition and chemoradiation

Use of parenteral nutrition (PN) to prevent weight loss or improve effectiveness of treatment for patients with esophageal cancer receiving chemoradiation therapy (CRT) is not recommended. PN has not been shown to prevent weight loss or improve effectiveness of treatment, even though patients were able to tolerate a higher dose of CRT. PN may have adverse effects such as complications related to refeeding syndrome, inadequate glycemic control and increased risk of infections.


Weak
Imperative

Head and Neck Cancer and Oncology Nutrition

Radiation

ONC: Head and Neck Cancer: Chemoradiation and Determination of Resting Energy Expenditure (REE) 2007

ONC: Head and neck cancer: Chemoradiation and Determination of REE

Use of indirect calorimetry to measure Resting Energy Expenditure (REE) is more accurate than estimation in patients with advanced head and neck cancer undergoing chemoradiation therapy. If measurement of REE is not possible or not thought to be imperative, use the Harris Benedict Equation (HBE) to estimate calorie needs. However, limited evidence indicates that HBE underestimates REE in this population.


Weak
Imperative

ONC: Head and Neck Cancer: Radiation Determination of Protein Needs 2007

ONC: Head and Neck Cancer: Determination of Protein Needs and Radiation

The protein needs for patients with head and neck cancer undergoing radiation therapy may be higher than the RDA. Limited evidence indicates patients consuming the RDA for protein experienced a significant decrease in weight and LBM during treatment. More defined protein intervention studies are needed.


Weak
Imperative

ONC: Head and Neck Cancer: Radiation and Use of Medical Food Supplement 2007

ONC: Head and neck cancer: Medical Food Supplements and Radiation

Dietitians should consider use of medical food supplements (MFS) to improve protein and calorie intake for patients with head and neck cancer undergoing radiation therapy. Use of MFS may be associated with fewer treatment interruptions, a reduction of mucosal damage, and may minimize weight loss.


Fair
Imperative

ONC: Head and Neck cancer: Radiation and Medical Nutrition Therapy (MNT) 2007

ONC: Head and neck cancer: MNT and radiation therapy

Medical Nutrition Therapy (MNT) that consists of nutrition assessment, intensive intervention, and ongoing monitoring and evaluation by an RD should be provided for patients with head/neck cancer being considered for radiation therapy. MNT has been shown to improve calorie and protein intake, maintain anthropometric measurements and improve quality of life (QOL).


Strong
Imperative

ONC: Head and neck cancer: MNT and pre-treatment evaluation

The Dietitian should provide MNT consisting of a pre-treatment evaluation and weekly visits during radiation treatment for head and neck cancer to improve outcomes.


Strong
Imperative

ONC: Head and Neck Cancer: Radiation and Use of Enteral Nutrition (EN) 2007

ONC: Head and neck cancer: Radiation and use of EN

Use enteral nutrition (EN) to increase calorie and protein intake for outpatients with stage III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of nutritional status by EN during radiation therapy may improve tolerance of therapy to promote better outcomes.


Strong
Imperative

ONC: Head and Neck Cancer: Radiation and Use of Honey 2007

ONC: Head and neck cancer: Use of honey and radiation

If the topical use of honey is proposed to prevent mouth sores caused by radiation treatment for patients with head and neck cancer, advise that its use may or may not be beneficial. Limited evidence shows that topical use of honey has been associated with decreased incidence of severe mucositis, weight gain and reduced treatment interruptions; however, the risks of interference with effectiveness of radiation treatment and infectious complications were not evaluated.


Weak
Conditional

 

ONC: Head and Neck Cancer: Radiation 2007

ONC: Use of Antioxidant Vitamin E Oral Supplement 

Use of vitamin E oral supplements to enhance efficacy, improve tolerance and reduce late-effects of radiation therapy for patients with head/neck cancer is not recommended. While limited evidence supports the use of vitamin E oral supplements to reduce late effects (osteoradionecrosis), there is strong research reporting an increased risk for second primary cancers and decreased survival rate with use of vitamin E in doses greater than or equal to 400 IU (268mg).


Weak
Imperative

Surgery

ONC: Head and Neck Cancer: Surgery and Use of Arginine-Enhanced Medical Food Supplement or EN 2007

ONC: Head and neck cancer: Post-operative use of arginine

Post-operative use of arginine-enhanced medical food supplements (MFS) or enteral nutrition (EN) to improve outcomes for patients with head and neck cancer is not recommended. Arginine-enhanced versus non-arginine-enhanced MFS and EN did not produce significant changes in weight and body composition in either well-nourished or malnourished subjects. Most evidence shows there is no impact of arginine-enhanced MFS or EN on immune function. Limited research reported that arginine-enhanced EN can improve post-operative complications and LOS in malnourished patients.


Fair
Imperative

ONC: Head and neck cancer: Pre-operative use of arginine

Pre-operative use of arginine-enhanced EN to improve outcomes for patients with head and neck cancer is not recommended. No significant improvement in clinical outcomes, nutritional status, or surgery-induced immune suppression was observed among malnourished compared to patients receiving a non-enhanced EN, or those who did not receive EN.


Fair
Imperative

ONC: Head and Neck Cancer: Surgery and Use of EPA-Enhanced Medical Food Supplement 2007

ONC: Head and neck cancer: Surgery and EPA-enhanced medical food supplement

If the use of an EPA-enhanced MFS is proposed to decrease post-surgical complications (e.g., infections and weight loss) for oral and laryngeal cancer patients, advise inadequate evidence exists to show a benefit. While one study comparing EPA- versus arginine-enhanced MFS found that an EPA supplement led to an increase in weight, there were no differences in fat-free mass or infectious complications.


Weak
Conditional

Hematological Malignancies and Oncology Nutrition

 Chemotherapy 

ONC: Hematological: Chemotherapy and Medical Nutrition Therapy (MNT) 2008

ONC: HEM: Chemotherapy and MNT

Medical Nutrition Therapy (MNT) that consists of nutrition assessment, intensive intervention, and ongoing monitoring and evaluation by a registered dietitian may be of benefit to patients with acute leukemias undergoing chemotherapy. Daily monitoring of intake and incorporating patient preferences have been shown to increase nutrition intake which positively affects body weight and tumor-therapy side effects (e.g., fatigue and anorexia).


Weak
Imperative

Hematopoietic cell transplant

 ONC: Hematological Malignancies (HCT): Determination of Calorie Needs 2008

ONC: HCT: Determination of Calorie Needs

Use indirect calorimetry to measure REE for adult patients with hematologic malignancies undergoing allogeneic HCT. When indirect calorimetry is not available, limited evidence indicates that the estimated energy requirements are 30-35 kcal per kg per day during the first month post-transplant, and may be higher during acute GVHD and/or for patients receiving >75% of their total daily energy intake via PN.


Fair
Imperative

 ONC: Hematological Malignancies (HCT): Determination of Protein Needs 2008

ONC: HCT: Determination of Protein Needs

The protein needs for patients with hematologic malignancies undergoing allogeneic HCT are higher than the RDA. Limited evidence suggests that more than 2.2g protein per kg may be needed to maintain nitrogen balance. Further research is needed to define protein requirements in this population.


Fair
Conditional

ONC: Hematological Malignancies (HCT): Use of Oral Glutamine 2008

ONC: HCT: Use of oral glutamine

Use of oral glutamine to decrease incidence or severity of mucositis or to support recovery following hematopoietic cell transplantation for hematologic malignancies is not currently recommended. Glutamine supplementation did not show an effect on the incidence or severity of oral mucositis, diarrhea, oral intake or PN requirements among patients with hematologic malignancies receiving autologous or allogeneic HCT


Fair
Imperative

 ONC: Hematological Malignancies (HCT): Use of Parenteral Nutrition 2008

ONC: HCT: Use of Parenteral Nutrition (PN)

Parenteral nutrition (PN) should only be used in selected HCT patients due to increased risk of treatment complications, increased cost, and a lack of significant improvement in treatment outcomes.  Dietitians should regularly screen and monitor HCT patients for signs of malnutrition and prolonged periods of poor oral intake to identify patients who might benefit from PN.  Patients most likely to benefit from PN include patients receiving allogeneic transplants from mismatched donors.


Fair
Imperative

ONC: HCT: Use of Lipid-Based PN Formulations

Patients receiving PN while undergoing HCT should receive 25-30% of energy as lipids.  Provision of lipids is necessary to prevent fatty acid deficiency, and may improve blood glucose control.


Fair
Conditional

ONC: HCT: Use of Glutamine-Enhanced PN Formulations

Use of parenteral glutamine to decrease incidence or severity of mucositis or diarrhea following hematopoietic cell transplantation for hematologic malignancies is not currently recommended.  No clear evidence indicates that use of parenteral glutamine alters incidence or duration of mucositis or diarrhea. In addition, parenteral glutamine has not been shown to decrease LOS, time to engraftment or the number of infectious complications. 


Fair
Imperative

Lung Cancer and Oncology Nutrition

Chemotherapy

ONC: Non-Small Cell Lung Cancer: Chemotherapy and Determination of Resting Energy Expenditure 2007

ONC: Lung Cancer: Chemotherapy and Determination of REE

Use of indirect calorimetry to measure REE is more accurate than estimation in patients with non-small cell lung cancer (NSLC) cancer undergoing chemotherapy. If measurement of REE is not possible or not thought to be imperative, use HBE to estimate calorie needs. However, limited evidence indicates that the HBE may underestimate energy needs by an average of 12-13%.


Weak
Imperative

ONC: Lung Cancer: Chemotherapy and Use of Antioxidant Vitamins C, E and Beta-Carotene Oral Supplements 2007

ONC: Lung cancer: Chemotherapy and use of Antioxidant Supplements

The use of antioxidants (vitamin C, vitamin E, beta-carotene, selenium) above the tolerable upper intake level to improve treatment outcomes in patients with advanced non-small cell lung cancer undergoing chemotherapy is not recommended. In this population, use of high-dose multiple oral antioxidants did not significantly influence response to treatment, survival, survival time and toxicity. More studies are needed.


Weak
Imperative

ONC: Small-cell lung Cancer: Chemotherapy and Medical Nutrition Therapy 2007

ONC: Lung cancer: MNT and Chemotherapy

Medical Nutrition Therapy (MNT) that consists of nutrition assessment, intensive intervention, and ongoing monitoring and evaluation by an RD may be of benefit to patients with small cell lung cancer undergoing chemotherapy. Providing MNT may improve protein and calorie intake, which has been shown to improve weight status and QOL.


Weak
Imperative

Pancreatic Cancer and Oncology Nutrition

ONC: Pancreatic Cancer: Use of Omega-3 Fatty Acid-Enhanced Medical Food Supplement or Oral Supplement 2007

ONC: Pancreatic cancer: Use of omega-3 supplements for weight loss

Use of omega-3 fatty acids to alter the prolonged acute-phase response is not recommended for pancreatic cancer patients. Consumption of an omega-3 fatty acid-enhanced medical food supplement (mean dose 2.2g daily) or an oral supplement (2g EPA daily) for pancreatic cancer patients experiencing weight loss has not been shown to reduce serum CRP concentrations after 12 weeks of EPA supplementation and there are potential drug-nutrient interactions (e.g., anti-coagulant and anti-hypertensive medications/herbal supplements).


Fair
Imperative

ONC: Pancreatic cancer: Use of omega-3 supplements for anticachetic effects

Use of supplemental omega-3 fatty acids for anticachetic effects leading to changes in body composition (e.g., increase in LBM, weight gain or weight stabilization) is not recommended for patients with pancreatic cancer. EPA as a capsule or in a medical food supplement was not associated with an increase in LBM. Evidence that fish oil supplements stabilize weight or produce weight gain is inconclusive. There are potential drug-nutrient interactions (e.g., anti-coagulant and anti-hypertensive medications/herbal supplements).


Strong
Imperative