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The nutritional needs of older cancer survivors

Open AccessPublished:December 11, 2021DOI:https://doi.org/10.1016/j.jgo.2021.12.007

      1. Introduction

      Over the last 20 years, the number of cancer survivors in the United States has more than doubled, with approximately 17 million cancer survivors today []. Moreover, nearly two-thirds of cancer survivors (64%) are 65 years or older [
      • American Cancer Society
      Cancer facts and figures 2019.
      ]. Current projections show steady incidence rates, and cancers such as breast cancer, Hodgkin lymphoma, and prostate cancer have 5-year survival rates greater than 89% [
      • American Cancer Society
      Cancer facts and figures 2019.
      ]. Herein, we define cancer survivorship as starting at a diagnosis of cancer and following the person through treatment (if any) and the rest of their life [
      • Marzorati C.
      • Riva S.
      • Pravettoni G.
      Who is a Cancer survivor? A systematic review of published definitions.
      ]. Therefore, this definition encompasses individuals undergoing active treatment (e.g., chemotherapy) either in the curative-intent or advanced disease (e.g., palliative intent) stages, as well as those who have completed active therapy. While receiving cancer therapy, and after completion of active treatment, many cancer survivors live with persistent symptoms or side effects of their treatment. The growing field of supportive care in cancer is addressing these persistent ailments by integrating curative models of care and palliative care. Emerging evidence suggests that nutrition is a powerful and underutilized tool that cancer survivors can leverage to meet their supportive care needs [
      • Presley C.J.
      • Dotan E.
      • Soto-Perez-de-Celis E.
      • Jatoi A.
      • Mohile S.G.
      • Won E.
      • et al.
      Gaps in nutritional research among older adults with cancer.
      ].
      Nutrition is especially important among older cancer survivors to attenuate common issues of aging, many of which are exacerbated by the cancer experience. For example, cachexia—loss of lean and fat mass resulting from cancer or another chronic disease—and sarcopenia—the loss of lean muscle mass—are common and detrimental aging-related concerns. Malnutrition, as defined by insufficient acquisition of nutrients, is particularly worrisome among older cancer patients due to its high prevalence (25% to 85%) [
      • D’Almeida C.A.
      • Peres W.A.F.
      • de Pinho N.B.
      • Martucci R.B.
      • Rodrigues V.D.
      • Ramalho A.
      Prevalence of malnutrition in older hospitalized Cancer patients: a multicenter and multiregional study.
      ] and association with all-cause mortality [
      • Zhang X.
      • Tang T.
      • Pang L.
      • Sharma S.V.
      • Li R.
      • Nyitray A.G.
      • et al.
      Malnutrition and overall survival in older adults with cancer: a systematic review and meta-analysis.
      ]. It can be caused by low food intake, poor nutrient uptake, and insufficient digestive organ function. Obesity, or excess body fat, is equally as prevalent (e.g., 55% in the Cancer Prevention Study-II Nutrition Cohort in the United States [
      • Maliniak M.L.
      • Patel A.V.
      • McCullough M.L.
      • Campbell P.T.
      • Leach C.R.
      • Gapstur S.M.
      • et al.
      Obesity, physical activity, and breast cancer survival among older breast cancer survivors in the Cancer prevention study-II nutrition cohort.
      ]). Obesity can mask signs of clinical malnutrition, and can increase risk of many other aging-related conditions. Indeed, sarcopenic obesity, or the combined burden of obesity and sarcopenia, is associated with negative clinical outcomes in patients with cancer, including higher risk of chemotherapy dose-limiting toxicities, surgical complications, physical disability, and shorter survival [
      • Carneiro I.P.
      • Mazurak V.C.
      • Prado C.M.
      Clinical implications of Sarcopenic obesity in Cancer.
      ].
      Nutrition is important in long-term survivorship for older adults for many reasons [
      • National Comprehensive Cancer Network (NCCN)
      NCCN Clinical Practice Guidelines in Oncology: Survivorship.
      ]. For one, nutritional issues during cancer treatment tend to be underdiagnosed and not addressed [
      • Presley C.J.
      • Dotan E.
      • Soto-Perez-de-Celis E.
      • Jatoi A.
      • Mohile S.G.
      • Won E.
      • et al.
      Gaps in nutritional research among older adults with cancer.
      ,
      • Liposits G.
      • Orrevall Y.
      • Kaasa S.
      • Osterlund P.
      • Cederholm T.
      Nutrition in cancer care: a brief, practical guide with a focus on clinical practice.
      ], and these problems can persist for years into survivorship. Second, cancer and its treatments can cause long-term side effects that affect the ability to eat such as persistent diarrhea and trouble swallowing. In fact, treatment for several types of cancers entail significant alternations to the gastrointestinal tract, and patients need help managing these issues. Third, patients are often interested in behavioral strategies such as diet to reduce the risk of cancer recurrence. Lastly, good nutrition can help manage comorbidities such as diabetes and hypertension and generally promote health. Accordingly, the Institute of Medicine recommends that nutritional services are provided throughout a patients' cancer experience, and especially as they complete adjuvant cancer treatment [
      • The National Research Council
      From Cancer patient to Cancer survivor: Lost in transition.
      ]. However, unfortunately, nutritional issues are often not discussed—in fact, 0/26 survivorship care plan templates from NCI-designated comprehensive cancer centers across the United States mentioned nutritional services in a meta-analysis by Salz et al. [
      • Salz T.
      • Oeffinger K.C.
      • McCabe M.S.
      • Layne T.M.
      • Bach P.B.
      Survivorship care plans in research and practice.
      ]. This perspective is not meant to be a comprehensive guide to nutritional practices around substantial procedures (e.g., complete surgical resection of the pancreas for curative treatment of pancreatic cancer); clinicians are encouraged to follow evidence-based recommendations to promote nutritional status before and after these procedures. The goal of this perspective is to briefly summarize the nutritional needs of older cancer survivors, describe validated approaches to identify malnutrition and obesity, and provide current evidence-based and experience-based nutritional recommendations to improve the nutritional status of this population.

      2. Screening for and Addressing Malnutrition and Obesity

      Older adults ought to be screened for malnutrition and obesity upon a diagnosis of cancer and regularly throughout survivorship, especially at major cancer treatment- and health-related milestones and events (Table 1) [
      • Anderson A.S.
      • Martin R.M.
      • Renehan A.G.
      • Cade J.
      • Copson E.R.
      • Cross A.J.
      • et al.
      Cancer survivorship, excess body fatness and weight-loss intervention-where are we in 2020?.
      ]. Malnutrition, when diagnosed early, can be addressed with diet to prevent or treat sarcopenia, especially as part of a multimodal intervention with exercise [
      • Cruz-Jentoft A.J.
      • Kiesswetter E.
      • Drey M.
      • Sieber C.C.
      Nutrition, frailty, and sarcopenia.
      ]. Additionally, obesity is a risk factor for poorer cancer outcomes [
      • World Cancer Research Fund
      • American Institute for Cancer Research
      Diet, nutrition, physical activity, and Cancer: A global perspective.
      ] as well as many other diseases of aging [
      • Frasca D.
      • Blomberg B.B.
      • Paganelli R.
      Aging, obesity, and inflammatory age-related diseases.
      ]. Importantly, malnutrition and obesity can co-occur, and malnutrition and sarcopenia are often overlooked in the presence of obesity [
      • Baracos V.E.
      • Arribas L.
      Sarcopenic obesity: hidden muscle wasting and its impact for survival and complications of cancer therapy.
      ].
      Table 1Identifying malnutrition and obesity.
      Measure of nutritional status or body compositionPurpose of measureCriteria for concern
      Recent weight lossTo identify malnutrition>10% unintentional weight loss in the last 6 months
      Mini-Nutritional Assessment-Short FormTo identify malnutritionA score of 0–7 points (“malnourished” or 8–11 points (“at risk for malnutrition”)
      Body mass index (BMI; [weight in kg]/[height in m]2)To identify excess body fat≥25 kg/m2
      To identify low body fat<18.5 kg/m2
      To identify malnutrition in older cancer survivors, the Geriatric Assessment, which is recommended by the National Comprehensive Cancer Network [
      • Mohile S.G.
      • Velarde C.
      • Hurria A.
      • Magnuson A.
      • Lowenstein L.M.
      • Pandya C.
      • et al.
      Geriatric assessment-guided care processes for older adults: a Delphi consensus of geriatric oncology experts.
      ,
      • National Comprehensive Cancer Network (NCCN)
      NCCN Clinical Practice Guidelines in Oncology: Older Adult Oncology.
      ] and the International Society of Geriatric Oncology [
      • Wildiers H.
      • Heeren P.
      • Puts M.
      • Topinkova E.
      • Janssen-Heijnen M.L.
      • Extermann M.
      • et al.
      International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer.
      ], includes a nutrition domain that comprises recent weight loss and the Mini-Nutritional Assessment-Short Form (MNA-SF) [
      • Rubenstein L.Z.
      • Harker J.O.
      • Salva A.
      • Guigoz Y.
      • Vellas B.
      Screening for undernutrition in geriatric practice: developing the short-form Mini-nutritional assessment (MNA-SF).
      ]. The MNA-SF is a brief, six-item questionnaire completed by the clinical care team that captures changes in food intake, recent weight loss, mobility, the presence of psychological problems, and body mass index (BMI). Specifically, if a person has unintentionally lost more than 10% of their body weight in the previous 6 months and/or scores 11 points or less on the MNA-SF (indicating they are at risk for malnutrition or malnourished), they will be flagged as having nutritional impairment on the Geriatric Assessment.
      If a person is identified as being malnourished, it is important to investigate the cause of the malnutrition so that treatments can be targeted. The quantity (total calories) and quality (nutrient density) of diet patterns are both important. For patients with unintentional loss of lean mass, sufficient protein intake can slow or reverse this loss, especially in combination with physical activity. Patients might have symptoms that hinder food intake including low appetite, mucositis (mouth sores), xerostomia (dry mouth), nausea, vomiting, diarrhea, and/or constipation; these symptoms can often be treated with medication. Additionally, these symptoms may be side effects from cancer treatment or other supportive therapy medications, so careful medication review is important to determine potential contributors and guide potential treatment modifications.
      To identify obesity, BMI ([weight in kg] / [height in m]2) is a common tool—those with a BMI ≥25 kg/m2 are considered overweight and those with a BMI ≥ 30 kg/m2 are considered obese. While BMI is designed to easily identify excess body fat, it can inaccurately categorize people with high muscle mass into the overweight or obese categories despite low body fat. In these cases, more accurate measures of body composition are indicated including skin fold, bioelectric impedance analysis (BIA), or dual x-ray absorptiometry (DXA).
      For patients who are overweight or obese, low-calorie diets can decrease excess body fat, especially in combination with exercise. If a person is undergoing active treatment, it is especially important for weight loss to occur under the supervision of an oncology dietitian to avoid malnutrition.

      3. Nutritional Recommendations for all Older Cancer Survivors

      First and foremost, it is important for the clinic care team to communicate directly with survivors regarding concerns related to nutrition, including how treatment may impact dietary practices and body composition. Table 2 includes recommendations to address various nutritional concerns. Ideally, a nutritionist or dietitian is part of the clinical care team, preferably one who is familiar with the cancer trajectory. Registered Dietitians (RDs) can receive credentials for their specialization in oncology—“CSO” credentialing indicates Board Certified Specialist in Oncology Nutrition.
      Table 2Recommendations to address nutritional concerns among older cancer survivors.
      Nutritional concernPotential recommendations
      MalnutritionTry to identify the cause of malnutrition via discussion with the patient, caregiver(s), and the clinical care team
      Referral to a registered dietitian
      see oncologynutrition.org for board certified specialists in oncology by state.
      Unintentional weight lossNutritional supplements (e.g., Ensure®), small frequent meals, high protein/high calorie snacks
      Referral to a registered dietitian
      see oncologynutrition.org for board certified specialists in oncology by state.
      Low food intake due to low appetite, mucositis (mouth sores), xerostomia (dry mouth), nausea, vomiting, diarrhea, and/or constipationReview treatment plan and medication list to identify the cause. Weigh risks and benefits of medications.
      Excess body fatDiscuss barriers to healthy eating and/or exercise
      Provide handouts for weight loss (e.g., see the AICR website for up-to-date resources)
      Smartphone applications for weight loss, goal setting, or food logging (e.g., MyFitnessPal)
      Local social groups for weight loss or healthy lifestyles
      Poor dentition or denture issuesReferral to a dentist
      Speech or swallowing difficultiesReferral to an oral care specialist
      Need for extra support for grocery shopping or meal preparationHome-delivered meal programs from social services organizations (e.g., Meals on Wheels)
      Local grocery delivery services (e.g., Instacart)
      Local or nationwide meal delivery services (e.g., Blue Apron, Splendid Spoon)
      Desire for personal diet or nutrition counseling and/or accountabilityLocal social groups for weight loss or healthy lifestyles
      Provide handouts for nutrition in survivorship, weight loss, or weight gain (e.g., see the AICR website for up-to-date resources)
      Smartphone applications for weight loss, goal setting, or food logging (e.g., MyFitnessPal)
      Referral to a registered dietitian
      see oncologynutrition.org for board certified specialists in oncology by state.
      Abbreviations: AICR, American Institute for Cancer Research.
      low asterisk see oncologynutrition.org for board certified specialists in oncology by state.
      For general nutrition matters, the American Cancer Society (ACS) [
      • Rock C.L.
      • Doyle C.
      • Demark-Wahnefried W.
      • Meyerhardt J.
      • Courneya K.S.
      • Schwartz A.L.
      • et al.
      Nutrition and physical activity guidelines for cancer survivors.
      ] and the American Institute for Cancer Research (AICR) [
      • World Cancer Research Fund
      • American Institute for Cancer Research
      Diet, nutrition, physical activity, and Cancer: A global perspective.
      ] provide nutrition guidelines for cancer survivors with a focus on life post-adjuvant treatment. These recommendations entail staying hydrated, maintaining a healthy body weight, and consuming a diet high in fruits, vegetables, and whole grains; the ACS discourages red meat and processed foods and the AICR encourages beans [
      • World Cancer Research Fund
      • American Institute for Cancer Research
      Diet, nutrition, physical activity, and Cancer: A global perspective.
      ,
      • Rock C.L.
      • Doyle C.
      • Demark-Wahnefried W.
      • Meyerhardt J.
      • Courneya K.S.
      • Schwartz A.L.
      • et al.
      Nutrition and physical activity guidelines for cancer survivors.
      ]. The ACS and AICR recommendations are based on thorough systematic reviews for cancer prevention as well as secondary cancer prevention, though they do not address clinical nutrition issues that older survivors face as a direct result of cancer treatment, issues in supportive care, or specific comorbidities that many older individuals sustain. A healthy diet can promote a healthy gut and digestion, facilitate efficient metabolism and physiology, achieve or maintain a healthy body composition, reduce chronic inflammation, minimize oxidative stress, and prevent insulin resistance. Indeed, physiological changes occur with aging and make these processes especially vulnerable to cancer- and cancer treatment-induced impairments. In addition, comorbidities such as type II diabetes and hypertension can be managed with diet. There are many barriers to healthy eating, and open discussions can help identify and address these barriers. For example, discussions regarding healthy eating should include patients' access to fresh fruit and vegetables, their ability to prepare food on their own, and with whom they tend to consume meals. Provide relevant handouts that educate patients on good nutritional practices, malnutrition, and/or weight loss. Also, familiarize yourself with smartphone apps that may be helpful for your population (e.g., MyFitnessPal for logging diet and exercise, Instacart for food delivery, Headspace for meditation).
      For older adults, specifically, side effects of cancer can be compounded by natural aging. For patients with metabolic comorbidities (e.g., diabetes, hypertension), contact with the primary care provider is crucial to ensure that plans to address nutritional concerns are in place. The Geriatric Assessment may reveal pertinent domains that contribute to nutritional concerns. For example, older patients with impaired Instrumental Activities of Daily Living (IADL; e.g., transportation, meal preparation) and limited social support may have more barriers related to access to healthy food. Changes in eating patterns and food consumption are also more common in older adults with advanced cognitive impairment [
      • Ikeda M.
      • Brown J.
      • Holland A.J.
      • Fukuhara R.
      • Hodges J.R.
      Changes in appetite, food preference, and eating habits in frontotemporal dementia and Alzheimer's disease.
      ,
      • Morris C.H.
      • Hope R.A.
      • Fairburn C.G.
      Eating habits in dementia. A descriptive study.
      ]. Patients might have problems with dentition, dentures, chewing, or swallowing, which may have existed prior to the cancer or which was exacerbated by the cancer and its treatments. In this case, consider referring the individual to a dentist or oral care specialist. For patients who have limited access to local services, fortunately phone- and internet-based services are becoming much more accessible. It is recommended that clinicians have handouts that can connect patients with local social groups, a registered dietitian (local or remote), and other services based on their community, mobility, etc., starting with the organizations listed in Table 2.
      In addition to general nutrition advice, survivors may need help managing long-term side effects that affect their ability to eat. For example, patients who underwent surgery for colon cancer may have an ostomy, and patients who had radiation to the gut may experience intolerances to fiber, fat, or other nutrients. Patients will need a relationship with an accessible clinician to advise them on portion sizes, meal frequency, medications, meal replacement products, use of exogenous enzymes, ostomy management, and other specific and ever-changing concerns.
      Many survivors also deal with persistent issues of supportive care such as cancer-related fatigue and chemotherapy-induced neuropathy. Healthy dietary patterns that include fruits, vegetables, whole grains, and omega-3 fatty acids are often associated with fewer and less severe symptoms as well as higher quality of life [
      • Baguley B.J.
      • Skinner T.L.
      • Wright O.R.L.
      Nutrition therapy for the management of cancer-related fatigue and quality of life: a systematic review and meta-analysis.
      ,
      • Inglis J.E.
      • Lin P.J.
      • Kerns S.L.
      • Kleckner I.R.
      • Kleckner A.S.
      • Castillo D.A.
      • et al.
      Nutritional interventions for treating Cancer-related fatigue: a qualitative review.
      ]. Thus, introducing strategies to improve overall diet quality are warranted until more targeted nutrition therapies are available.
      Many patients are interested in what supplements can help reduce the risk of cancer recurrence. Unfortunately, due to the large heterogeneity of the survivor population, there is not enough evidence to recommend any supplements for secondary cancer prevention at this time; the AICR recommends following guidelines for primary cancer prevention [
      • World Cancer Research Fund
      • American Institute for Cancer Research
      Diet, nutrition, physical activity, and Cancer: A global perspective.
      ].

      4. Including Nutritional Recommendations in the Survivorship Care Plan

      The survivorship visit at the completion of adjuvant treatment and the survivorship care plan are an excellent time and place to provide patients with information on resources to address long-term nutritional issues. Individualized survivorship care plans provide patients and their caregivers a guide to effectively transition from curative cancer treatment to extended survivorship [
      • The National Research Council
      From Cancer patient to Cancer survivor: Lost in transition.
      ]. Indeed, survivors have indicated their desire for dietary advice as part of a survivorship care plan [
      • Krok-Schoen J.L.
      • Naughton M.J.
      • Noonan A.M.
      • Pisegna J.
      • DeSalvo J.
      • Lustberg M.B.
      Perspectives of survivorship care plans among older breast cancer survivors: a pilot study.
      ] and, therefore, it is recommended to develop the survivorship care plan in accordance with a nutritionist [
      • Hershman D.L.
      • Greenlee H.
      • Awad D.
      • Kalinsky K.
      • Maurer M.
      • Kranwinkel G.
      • et al.
      Randomized controlled trial of a clinic-based survivorship intervention following adjuvant therapy in breast cancer survivors.
      ].

      5. Conclusions

      In summary, nutritional needs for older cancer survivors are often overlooked and not addressed. It behooves clinicians caring for older adults with cancer and the clinical care team to formally screen for nutritional impairments, have established relationships with a registered dietitian or nutritionist, and have recommendations on hand for survivors to meet their nutritional needs and overcome barriers to healthy eating.

      Author contributions

      Both authors contributed to the writing of this perspective and read and approved the final manuscript.

      Funding

      This work was supported by the National Institutes of Health (NIH) National Cancer Institute (NCI) under grant numbers UG1CA189961 , T32CA102618 , K76AG04394 , and R01CA249467 .

      Declaration of Competing Interest

      Neither AK nor AM have any conflicts of interest.

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