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Nutritional Support in Terminal Cancer Patients

      To the Editor:
      I read with interest the paper by Winter,
      • Winter SM
      Terminal nutrition: framing the debate for the withdrawal of nutritional support in terminally ill patients.
      and I agree with the author's conclusion if, for “terminally ill” he means “imminently dying/moribund” patients, because artificial nutrition has no role in these situations. Unfortunately, the definition of “terminally ill” has never been scientifically coded, and the author considers within the same term “oncologically” terminal patients who survived longer than 1 year,
      • Clamon GH
      • Feld R
      • Evans WK
      • et al.
      Effect of adjuvant central iv hyperalimentation on the survival and response to treatment of patients with small cell lung cancer: a randomized trial.
      and “biologically” terminal patients who were expected to die within 3 months.
      • McCann RM
      • Hall WJ
      • Groth-Juncker A
      Comfort care for terminally ill patients. The appropriate use of nutrition and hydration.
      This is ambiguous because some oncologically terminal patients could sometimes succumb prior from starvation/malnutrition rather than from tumor progression and hence, they could potentially benefit from artificial nutrition. As summarized in a recent paper,
      • Bozzetti F
      Parenteral nutrition.
      (hypo)aphagic incurable cancer patients survive few weeks without nutritional support but could survive months if receiving parenteral nutrition.
      • Bozzetti F
      • Cotogni P
      • Lo Vullo S
      • et al.
      Development and validation of a nomogram to predict survival in incurable cachectic cancer patients on home parenteral nutrition.
      A further source of misunderstanding is the reference to meta-analyses and randomized controlled trials of the past millennium: Clamon et al
      • Clamon GH
      • Feld R
      • Evans WK
      • et al.
      Effect of adjuvant central iv hyperalimentation on the survival and response to treatment of patients with small cell lung cancer: a randomized trial.
      enrolled nonmalnourished patients, administering IV for 1 month 40-56 Kcal/Kg/d, in addition to the oral intake. Such a glucose-based regimen would be defined nowadays as extremely toxic by any expert. Current parenteral nutrition regimens are much better balanced and, if properly administered for a limited period of time, many of the complications reported in the table of Winter's paper
      • Winter SM
      Terminal nutrition: framing the debate for the withdrawal of nutritional support in terminally ill patients.
      simply do not exist. Many “terminal” cancer patients still harbor a central venous catheter originally placed for chemotherapy, are familiar with its care, or more recently, they may receive a peripherally introduced catheter with minimal risk.
      Finally, I accept the objective criteria of futility reported by Schneiderman et al;
      • Schneiderman LJ
      • Jecker NS
      • Jonsen AR
      Medical futility: its meaning and ethical implications.
      however, it is well known that quality-of-life priorities recognized by the carers often do not parallel those of the patients. Hence, I would prefer a more patient-centered approach that also considers the eventual will of the patient to be discharged home while continuing to receive nutritional support.
      In conclusion, I think it is difficult to keep a rigid position about what to do or not to do in a gray area like this; however, any choice should rely on the real-world experience, that is, the practice and the potential of artificial nutrition is not that of 30 years ago, and incurable cancer is becoming a chronic disease where sometimes malnutrition/starvation, more than tumor progression, affects the outcome.

      References

        • Winter SM
        Terminal nutrition: framing the debate for the withdrawal of nutritional support in terminally ill patients.
        Am J Med. 2000; 109: 723-726
        • Clamon GH
        • Feld R
        • Evans WK
        • et al.
        Effect of adjuvant central iv hyperalimentation on the survival and response to treatment of patients with small cell lung cancer: a randomized trial.
        Cancer Treat Rep. 1985; 69: 167-177
        • McCann RM
        • Hall WJ
        • Groth-Juncker A
        Comfort care for terminally ill patients. The appropriate use of nutrition and hydration.
        JAMA. 1994; 272: 1263-1266
        • Bozzetti F
        Parenteral nutrition.
        Nutrition. 2019; 66: 101-107
        • Bozzetti F
        • Cotogni P
        • Lo Vullo S
        • et al.
        Development and validation of a nomogram to predict survival in incurable cachectic cancer patients on home parenteral nutrition.
        Ann Oncol. 2015; 26: 2335-2340
        • Schneiderman LJ
        • Jecker NS
        • Jonsen AR
        Medical futility: its meaning and ethical implications.
        Ann Intern Med. 1990; 112: 949-954