Identifying patients at high nutritional risk and assessing the feasibility of medical nutrition therapy in patients receiving radiotherapy for lung cancer
Document TypePhD thesis
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© 2014 Dr. Nicole Kerstin Kiss
Radiotherapy to the thoracic region is associated with acute toxicities including radiation-induced oesophagitis, anorexia and fatigue which may impact on the ability to achieve an adequate nutritional intake and subsequently lead to malnutrition. Malnutrition is associated with poorer quality of life, treatment interruptions, reduced functional capacity and is an independent prognostic indicator in patients with lung cancer. The aim of this thesis was to identify the factors associated with weight loss during radiotherapy for lung cancer and to assess the feasibility and preliminary effect of an intensive, individualised nutrition intervention on nutritional, functional and fatigue outcomes. The aims of the thesis were investigated over five studies. The first two studies retrospectively analysed the prevalence and predictors of greater than or equal to 5% weight loss in patients with non-small cell (NSCLC) and small cell lung cancer (SCLC) treated with radiotherapy in two patient cohorts. Two cohorts were studied due to the availability of different clinical parameters in each cohort. These studies identified that treatment with concurrent chemotherapy (NSCLC and SCLC patients), stage III or more disease (NSCLC patients), and multiple radiotherapy dosimetric factors (NSCLC patients) were associated with greater than or equal to 5% weight loss. Of the dosimetric factors, absolute and relative length of the oesophagus receiving 60Gy to the partial circumference, were more strongly related to weight loss. The three predictive variables identified in the retrospective studies were used in the third study, the pilot validation of a model to predict nutritional risk in NSCLC patients at the commencement of radiotherapy. In NSCLC patients treated with high dose palliative or radical intent radiotherapy, stage III or more disease (model 1) had 91% sensitivity and 41% specificity for predicting greater than or equal to 5% weight loss. While in patients treated with radical intent only, the combination of stage III or more disease and concurrent chemotherapy was able to predict greater than or equal to 5% weight loss with a sensitivity of 94% and specificity of 55%. Having established a high nutritional risk associated with thoracic radiotherapy, the fourth study involved a systematic review to determine the effective methods of nutrition intervention in this population. Systematic reviews have previously been completed investigating the effect of novel agents such as omega 3 fatty acids in patients with lung cancer with the results largely inconclusive. This systematic review therefore focused on dietary counselling or oral supplements, previously found to be effective in other tumour types, and identified that insufficient evidence was available regarding the effect of dietary counselling or oral supplements during radiotherapy for lung cancer. Therefore, the final study was a pilot randomised controlled trial to assess the efficacy and feasibility of intensive, individualised dietary counselling in lung cancer patients receiving radiotherapy. The intervention arm of the study demonstrated clinically important benefits at the end of radiotherapy for nutritional, functional and fatigue outcomes compared to patients receiving usual care. High patient satisfaction with the intervention supported the feasibility of the intervention, while acceptable recruitment, consent and attrition rates supported the feasibility of the study. The studies conducted within this thesis have provided evidence that a substantial proportion of patients with lung cancer are at high nutritional risk during radiotherapy. The factors predictive of weight loss during radiotherapy for lung cancer have been identified and supported the pilot validation of models to predict nutritional risk in both high dose palliative and radically treated NSCLC patients. In the pilot randomised trial, dietary counselling improved nutritional, fatigue and functional outcomes in lung cancer patients receiving radiotherapy which is consistent with previous randomised trials of a similar intervention in other tumour types. These studies have provided insight into the lung cancer patients at highest nutritional risk and indicate these patients should be prioritised for nutritional services along with other high risk tumour types. The results indicate that further research in a larger sample is warranted, including external validation of the predictive model and a phase III trial of the intensive nutrition intervention.
Keywordsnutrition; malnutrition; lung cancer; radiotherapy; weight loss
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