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Guideline Summary
Guideline Title
A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation.
Bibliographic Source(s)
August DA, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-500. [184 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Cancer

Guideline Category
Counseling
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Nutrition
Oncology
Surgery
Intended Users
Advanced Practice Nurses
Dietitians
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To examine the literature and develop guidelines only for nutrition support therapy (NST) in adult cancer patients (during anticancer treatment and in hematopoietic cell transplantation)

Note: Nutrition and cancer prevention or alternative medicine approaches using nutritional supplements in the treatment of cancer is beyond the scope of the guideline.

Target Population

Adult cancer patients receiving anticancer treatments and/or hematopoietic cell transplantation

Interventions and Practices Considered

Nutrition Support Therapy During Anticancer Treatment

  1. Nutrition screening
  2. Formal nutrition assessment
  3. Development of a nutrition care plan
  4. Nutrition support therapy (as indicated)
  5. ω-3 Fatty acid supplementation
  6. Immune enhancing enteral formulas containing mixtures of arginine, nucleic acids, and essential fatty acids

Nutrition Support Therapy in Hematopoietic Cell Transplantation

  1. Nutrition screening
  2. Formal nutrition assessment
  3. Development of a nutrition care plan
  4. Nutrition support therapy (as indicated)
  5. Enteral nutrition
  6. Parenteral glutamine
  7. Dietary counseling regarding foods which may pose infectious risks and safe food handling
  8. Nutrition support therapy for patients who develop moderate to severe graft-vs-host disease
Major Outcomes Considered
  • Morbidity
  • Mortality
  • Length of stay
  • Complications
  • Nutrition parameters/indicators

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The best available literature was obtained and carefully reviewed. Chapter author(s) completed a thorough literature review using Medline®, the Cochrane Central Registry of Controlled Trials, the Cochrane Database of Systematic Reviews, and other appropriate reference sources. This paper includes older as well as current research related to the use of nutrition support therapy (NST) in individuals with cancer. Dates prior to 1990 were not excluded from the analyses, as there are no obvious trends over time to suggest that more modern practice has had an impact on outcome.

Published literature through January 1, 2007 was searched and reviewed.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

I Large randomized trials with clear-cut results; low risk of false-positive (alpha) and/or false-negative (beta) error
II Small, randomized trials with uncertain results; moderate to high risk of false-positive (alpha) and/or false-negative (beta) error
III Nonrandomized cohort with contemporaneous controls
IV Nonrandomized cohort with historical controls
V Case series, uncontrolled studies, and expert opinion
Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The system used to categorize the level of evidence for each study or article used in the rationale of the guideline statement and to grade the guideline recommendation is outlined in Table 1 of the original guideline document (see the "Rating Scheme for the Strength of Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

These Clinical Guidelines were developed under the guidance of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors.

These clinical guidelines were created in accordance with Institute of Medicine recommendations as "systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances."

These clinical guidelines are formatted to promote the ability of the end user of the document to understand the strength of the literature used to grade each recommendation. Each guideline recommendation is presented as a clinically applicable definitive statement of care and should help the reader make the best patient care decision.

The results of the literature search and review formed the basis of an evidence-based approach to the Clinical Guidelines. Chapter editors worked with the authors to ensure compliance with the authors' directives regarding content and format.

Rating Scheme for the Strength of the Recommendations

Grading of Guidelines

A Supported by at least two level I investigations
B Supported by one level I investigation
C Supported by at least one level II investigation
D Supported by at least one level III investigation
E Supported by level IV or V evidence
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The initial draft is reviewed internally to ensure consistency with the other American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Guidelines and Standards and reviewed externally (either by experts in the field within the organization and/or outside of the organization) for appropriateness of content. The final draft is then reviewed and approved by the A.S.P.E.N. Board of Directors.

Recommendations

Major Recommendations

Grades of recommendation (A-E) and levels of evidence (I-V) are defined at the end of the "Major Recommendations" field.

  1. Nutrition Support Therapy During Anticancer Treatment
    1. Patients with cancer are nutritionally-at-risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (D)
    2. Nutrition support therapy should not be used routinely in patients undergoing major cancer operations. (A)
    3. Perioperative nutrition support therapy may be beneficial in moderately or severely malnourished patients if administered for 7-14 days preoperatively, but the potential benefits of nutrition support must be weighed against the potential risks of the nutrition support therapy itself and of delaying the operation. (A)
    4. Nutrition support therapy should not be used routinely as an adjunct to chemotherapy. (B)
    5. Nutrition support therapy should not be used routinely in patients undergoing head and neck, abdominal, or pelvic irradiation. (B)
    6. Nutrition support therapy is appropriate in patients receiving active anticancer treatment who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time (see Guideline 6 Rationale in the original guideline document for discussion of "prolonged period of time"). (B)
    7. The palliative use of nutrition support therapy in terminally ill cancer patients is rarely indicated. (B)
    8. Omega-3 Fatty acid supplementation may help stabilize weight in cancer patients on oral diets experiencing progressive, unintentional weight loss. (B)
    9. Patients should not use therapeutic diets to treat cancer. (E)
    10. Immune-enhancing enteral formulas containing mixtures of arginine, nucleic acids, and essential fatty acids may be beneficial in malnourished patients undergoing major cancer operations. (A)
  1. Nutrition Support Therapy in Hematopoietic Cell Transplantation
    1. All patients undergoing hematopoietic cell transplantation with myeloablative conditioning regimens are at nutrition risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (D)
    2. Nutrition support therapy is appropriate in patients undergoing hematopoietic cell transplantation who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time (see Guideline 6 Rationale in the original guideline document for discussion of "prolonged period of time"). When parenteral nutrition is used, it should be discontinued as soon as toxicities have resolved after stem cell engraftment. (B)
    3. Enteral nutrition should be used in patients with a functioning gastrointestinal tract in whom oral intake is inadequate to meet nutrition requirements. (C)
    4. Pharmacologic doses of parenteral glutamine may benefit patients undergoing hematopoietic cell transplantation.* (C)
    5. Patients should receive dietary counseling regarding foods which may pose infectious risks and safe food handling during the period of neutropenia. (C)
    6. Nutrition support therapy is appropriate for patients undergoing hematopoietic cell transplantation who develop moderate to severe graft-vs-host disease accompanied by poor oral intake and/or significant malabsorption. (C)

*Parenteral glutamine is not available by the usual FDA-approved manufacturer process but rather as a prescription prepared by a compounding pharmacy in the U.S. Glutamine appears on the FDA List of Bulk Drug Substances That May Be Used in Pharmacy Compounding (see Federal Register 1999;64:996-1003).

Definitions:

Levels of Evidence

I Large randomized trials with clear-cut results; low risk of false-positive (alpha) and/or false-negative (beta) error
II Small, randomized trials with uncertain results; moderate to high risk of false-positive (alpha) and/or false-negative (beta) error
III Nonrandomized cohort with contemporaneous controls
IV Nonrandomized cohort with historical controls
V Case series, uncontrolled studies, and expert opinion

Grading of Guidelines

A Supported by at least two level I investigations
B Supported by one level I investigation
C Supported by at least one level II investigation
D Supported by at least one level III investigation
E Supported by level IV or V evidence
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence ranges from prospective randomized trials to expert opinion/consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Improvement in nutritional status in cancer patients, positively affecting quality of life and sense of well-being.
  • Reduction in malnutrition and weight loss in cancer patients.
Potential Harms
  • Enthusiasm for the use of nutrition support therapy (NST) in cancer patients has historically been tempered by concern that provision of nutrients may stimulate tumor growth and metastasis, as observed in animal studies and cell culture. There are few relevant clinical studies. Most recently, a study of parenteral nutrition (PN) in malnourished gastric cancer patients indicated no significant difference in tumor cell proliferation with administration of PN preoperatively. Absent any overt effects, it is reasonable to ignore this theoretical consideration when contemplating the use of NST in patients.
  • Although the adverse events caused by PN may actually worsen quality of life and overall palliative care of some patients, home PN may lengthen survival and improve quality of life in carefully selected patients.

Qualifying Statements

Qualifying Statements

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guidelines are based upon general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, the professional judgment of the attending health professional is the primary component of quality medical care. Because guidelines cannot account for every variation in circumstances, the practitioner must always exercise professional judgment in their application. These Clinical Guidelines are intended to supplement, but not replace, professional training and judgment.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
August DA, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009 Sep-Oct;33(5):472-500. [184 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Sep-Oct
Guideline Developer(s)
American Society for Parenteral and Enteral Nutrition - Professional Association
Source(s) of Funding

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: David Allen August, MD; Maureen B. Huhmann, DCN, RD, CSO; and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors

Financial Disclosures/Conflicts of Interest

Financial disclosure: none declared

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Journal of Parenteral and Enteral Nutrition Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on January 16, 2013. The information was verified by the guideline developer on February 1, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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