欧洲肠外肠内营养学会癌症患者营养指南（三）
前情提要
第三章、特定患者类型相关干预
C1、手术
C1-1、术后加速康复（ERAS）管理
对所有接受根治性或姑息性手术的癌症患者，我们推荐术后加速康复（ERAS）管理方案，在这个方案中，每个患者都应筛查营养不良，如果被认为存在风险，应给予额外的营养支持。
推荐强度：强
证据级别：高
有待研究：肿瘤患者ERAS方案中营养供给包含的最佳组成成分，上消化道癌症患者按ERAS路径管理时免疫营养（精氨酸、n-3脂肪酸、核苷酸）的作用，富含n-3脂肪酸的口服补充剂/肠内营养对维持上消化道癌症患者的瘦体重及优化其脏器功能的作用。
共识
C1-2、手术：肿瘤综合治疗路径
对接受再次手术作为肿瘤综合治疗路径一部分的患者，我们推荐每次手术都进行ERAS管理。
推荐强度：强
证据级别：低
有待研究：多通道康复在长期肿瘤治疗中的作用
共识
C1-3、术后和出院后管理
对存在营养不良风险或已出现营养不良的癌症手术患者，我们推荐在住院期间及之后出院都进行适当的营养支持。
推荐强度：强
证据级别：中等
有待研究：实施ERAS管理的患者术后最佳方案包括正常食物±口服营养补充剂的种类、准备和获取方法
共识
C1-4、围手术期的免疫营养（精氨酸、n-3脂肪酸、核苷酸）
对进行手术切除的上消化道癌症患者，在传统的围手术期管理下，我们推荐口服或肠内免疫营养。
推荐强度：强
证据级别：高
有待研究：详述免疫营养方案中各组成成分的作用
高度共识
C2、放疗
C2-1、放疗：确保充足的营养摄入
我们推荐在放疗（RT）期间——特别注意头颈部、胸部和胃肠道肿瘤放疗—应确保充足的营养摄入，主要是通过个体化的营养咨询建议和/或使用口服营养补充剂（ONS），以避免营养状况恶化，保持摄入量，避免干扰放疗。
推荐强度：强
证据级别：中等
有待研究：营养支持对临床结局包括生存率的影响
高度共识
C2-2、放疗：使用管饲
我们推荐对严重的放射性口腔黏膜炎或头颈部或胸部阻塞性肿瘤患者采用经鼻胃管或经皮喂养管（如PEG）进行肠内喂养。
推荐强度：强
证据级别：低
有待研究：预防性/早期肠内营养对临床结局的影响，专用肠内营养配方对营养状况及临床结局的影响
高度共识
C2-3、放疗：维持吞咽功能
我们推荐对吞咽困难进行筛查和管理，并鼓励和教育患者在肠内营养期间如何维持他们的吞咽功能。
推荐强度：强
证据级别：低
有待研究：吞咽训练对肠内营养患者吞咽困难的影响
高度共识
C2-4、放射性腹泻：谷氨酰胺
尚无足够一致的临床数据资料推荐使用谷氨酰胺预防放射性肠炎/腹泻、口腔炎、食管炎或皮肤毒性。
推荐强度：—
证据级别：低
有待研究：谷氨酰胺对口腔/食管黏膜炎和皮肤毒性的影响
高度共识
C2-5、放射性腹泻：益生菌
尚无足够一致的临床数据资料推荐使用益生菌以减少放射性腹泻。
推荐强度：—
证据级别：低
有待研究：益生菌对放射性腹泻和治疗完成率的影响
高度共识
C2-6、放疗：使用肠外营养
我们不推荐肠外营养（PN）作为放疗时的一般治疗，除非足够的经口/肠内营养不可能达到，如严重的放射性肠炎或严重的吸收不良。
推荐强度：强
证据级别：中等
有待研究：比较需要人工营养的患者使用肠内与肠外营养的可行性和疗效
共识
C3、肿瘤内科：治愈性或姑息性抗癌药物治疗
C3-1、肿瘤内科：确保充足的营养
在抗癌药物治疗期间我们推荐确保充足的营养摄入并保持身体活动。
推荐强度：强
证据级别：非常低
有待研究：在使用抑制细胞生长和针对治疗耐受性、治疗反应和总体存活率的疗法期间营养干预的效果
高度共识
C3-2、肿瘤内科：使用肠内和肠外营养
对接受治愈性抗癌药物治疗的患者，如果经口食物摄入不足，尽管有咨询建议和口服营养补充剂（ONS），我们推荐使用补充性肠外营养，若经口摄入不足或不可能，推荐使用肠外营养。
推荐强度：强
证据级别：非常低
有待研究：对正接受治愈性抗癌药物治疗、营养摄入不足的患者：人工营养对治疗耐受性、治疗完成情况、复发率和总体生存率的影响，肠内与肠外营养对并发症、治疗完成情况、复发率和总体生存率的影响
共识
C3-3、肿瘤内科：使用谷氨酰胺
尚无足够一致的临床数据资料推荐在常规细胞毒性或靶向治疗期间补充谷氨酰胺。
推荐强度：—
证据级别：低
有待研究：谷氨酰胺对药物性神经病变的影响
高度共识
C4、肿瘤内科：大剂量化疗和造血干细胞移植（HCT）
C4-1、大剂量化疗和HCT：确保充足的营养和身体活动
在强化化疗期间和干细胞移植后，我们推荐保持身体活动并确保充足的营养摄入。这可能需要肠内和/或肠外营养。
推荐强度：强
证据级别：非常低
有待研究：身体活动对临床结局的影响
高度共识
C4-2、大剂量化疗和HCT：肠内和肠外营养
如果经口营养摄入不足，我们建议首选肠内管饲而不是肠外营养，除非有严重的黏膜炎、顽固性呕吐、肠梗阻、严重的吸收不良、长期腹泻或移植物抗宿主病（GvHD）有胃肠道症状。
推荐强度：弱
证据级别：低
有待研究：比较肠内与肠外营养对临床结局和并发症发生率的效果
高度共识
C4-3、大剂量化疗和HCT：细菌含量低的饮食
尚无足够一致的临床数据资料推荐同种异体移植超过30天的患者采用细菌含量低的饮食。
推荐强度：—
证据级别：低
有待研究：确定可预测细菌含量低的饮食带来益处的影响因素，比较食品安全指南与中性白细胞减少症饮食的益处
高度共识
C4-4、大剂量化疗和HCT：谷氨酰胺
尚无足够一致的临床数据资料推荐使用谷氨酰胺以改善接受大剂量化疗和造血干细胞移植患者的临床结局。
推荐强度：—
证据级别：低
有待研究：谷氨酰胺对黏膜炎、腹泻、临床感染、移植物抗宿主病和恶性肿瘤复发率的影响
高度共识
C5、癌症生存者
C5-1、癌症生存者：身体活动
我们推荐癌症生存者定期进行身体活动。
推荐强度：强
证据级别：低
有待研究：身体活动对癌症生存者身体功能、复发和生存的影响
共识
C5-2、癌症生存者：体重和生活方式
对癌症生存者，我们推荐维持健康体重（BMI：18.5～25kg/m²）和健康的生活方式，包括积极的身体活动及以蔬菜、水果和全谷物为主，饱和脂肪、红肉和酒精少的饮食。
推荐强度：强
证据级别：低
有待研究：健康的饮食对代谢综合征、生活质量、癌症复发率和总体生存率的影响
高度共识
C6、无法接受抗癌治疗的晚期癌症患者
C6-1、晚期癌症：筛查和评定
我们推荐对所有晚期癌症患者营养摄入不足、体重下降和体重指数低进行常规筛查，如果发现存在风险，为可治疗的受营养影响的表现和代谢紊乱进一步对这些患者进行评定。
推荐强度：强
证据级别：低
有待研究：营养不良筛查联合多学科干预对晚期癌症患者生活质量的影响
共识
C6-2、晚期癌症患者的营养支持
我们推荐对晚期癌症患者只有在综合考虑其恶性疾病的预后、营养干预预计对生活质量和生存带来的好处以及营养诊疗相关负担之后再提供和实施营养干预。
推荐强度：强
证据级别：低
有待研究：营养诊疗对晚期癌症患者生活质量的影响
共识
C6-3、非常晚期的终末阶段
对临终患者，我们推荐治疗应基于舒适。人工水化和营养不可能为大多数患者提供任何好处。但在急性精神错乱状态，我们建议使用短期有限的水化排除脱水是直接原因。
推荐强度：强
证据级别：低
有待研究：预测急性精神错乱状态的可逆性
高度共识
Chapter C: Interventions Relevant to Specific Patient Categories
Section C1: Surgery
C1-1 Enhanced recovery after surgery (ERAS) care
Strength of recommendation: STRONG
For all cancer patients undergoing either curative or palliative surgery we recommend management within an enhanced recovery after surgery (ERAS) program; within this program every patient should be screened for malnutrition and if deemed at risk, given additional nutritional support.
Level of evidence: High
Questions for research: optimal components including nutrition of ERAS protocol for oncology patients. The role of immunonutrition (arginine, n-3 fatty acids, nucleotides) when upper GI cancer patients are managed within an ERAS pathway. The role of n-3 enriched oral supplements/enteral nutrition in upper GI cancer patients for preservation of lean body mass and optimisation of organ function.
Consensus
C1-2 Surgery: Multimodal oncological pathway
Strength of recommendation: STRONG
For a patient undergoing repeated surgery as part of a multimodal oncological pathway, we recommend management of each surgical episode within an ERAS program.
Level of evidence: Low
Questions for research: role of multimodal rehabilitation during prolonged oncological therapy
Consensus
C1-3 Postsurgical care and care after hospital discharge
Strength of recommendation: STRONG
In surgical cancer patients at risk of malnutrition or who are already malnourished we recommend appropriate nutritional support both during hospital care and following discharge from hospital.
Level of evidence: Moderate
Questions for research: The optimal post-operative regimen in terms of type, preparation and access to normal food +/- oral nutritional supplements for patients managed within an ERAS pathway.
Consensus
C1-4 Immunonutrition (arginine, n-3 fatty acids, nucleotides) in perioperative care
Strength of recommendation: STRONG
In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care we recommend oral/enteral immunonutrition.
Level of evidence: High
Questions for research: Specifying the role of the individual constituents of immunonutrition regimens
Strong consensus
Section C2: Radiotherapy
C2-1 Radiotherapy: Ensuring adequate nutritional intake
Strength of recommendation: STRONG
We recommend that during radiotherapy (RT)-with special attention to RT of the head and neck, thorax and gastrointestinal tract - an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of oral nutritional supplements (ONS), in order to avoid nutritional deterioration, maintain intake and avoid RT interruptions
Level of evidence: Moderate
Questions for research: Effect of nutritional support on clinical outcome including survival
Strong consensus
C2-2 Radiotherapy: Use of tube feeding
Strength of recommendation: STRONG
We recommend enteral feeding using naso-gastric or percutaneous tubes (e.g. PEG) in radiation-induced severe mucositis or in obstructive tumors of the head-neck or thorax.
Level of evidence: Low
Questions for research: Effect of prophylactic/early enteral feeding on clinical outcome. Effect of specialized enteral formula on nutritional status and clinical outcome.
Strong consensus
C2-3 Radiotherapy: Maintaining swallowing function
Strength of recommendation: STRONG
We recommend to screen for and manage dysphagia and to encourage and educate patients on how to maintain their swallowing function during enteral nutrition.
Level of evidence: Low
Questions for research: Effect of swallowing exercise on dysphagia in patients receiving enteral feeding
Strong consensus
C2-4 Radiation-induced diarrhea: glutamine
Strength of recommendation: -
There are insufficient consistent clinical data to recommend glutamine to prevent radiation-induced enteritis/diarrhea, stomatitis, esophagitis or skin toxicity.
Level of evidence: Low
Questions for research: Effect of glutamine on oral/esophageal mucositis and skin toxicity
Strong consensus
C2-5 Radiation-induced diarrhea: probiotics
Strength of recommendation: -
There are insufficient consistent clinical data to recommend probiotics to reduce radiation-induced diarrhea.
Level of evidence: Low
Questions for research: Effect of probiotics on radiation-induced diarrhea and treatment completion rate
Strong consensus
C2-6 Radiotherapy: Use of parenteral nutrition
Strength of recommendation: STRONG
We do not recommend parenteral nutrition (PN) as a general treatment in radiotherapy but only if adequate oral/enteral nutrition is not possible, e.g. in severe radiation enteritis or severe malabsorption
Level of evidence: Moderate
Questions for research: Comparing feasibility and efficacy of enteral vs parenteral nutrition in patients requiring artificial nutrition
Consensus
Section C3: Medical oncology: Curative or palliative anticancer drug treatment
C3-1 Medical oncology: Ensuring adequate nutrition
Strength of recommendation: STRONG
During anticancer drug treatment we recommend to ensure an adequate nutritional intake and to maintain physical activity.
Level of evidence: Very low
Questions for research: Effects of nutritional intervention during cytostatic and targeted therapies on treatment tolerance, response to treatment and overall survival
Strong consensus
C3-2 Medical oncology: Use of enteral and parenteral nutrition
Strength of recommendation: STRONG
In a patient undergoing curative anticancer drug treatment, if oral food intake is inadequate despite counselling and oral nutritional supplements (ONS), we recommend supplemental enteral or, if this is not sufficient or possible, parenteral nutrition.
Level of evidence: Very low
Questions for research: In patients with inadequate nutritional intake, who are undergoing curative anticancer drug treatment:
Effect of artificial nutrition on treatment tolerance, treatment completion, relapse rate and overall survival
Effect of enteral vs parenteral nutrition on complications, treatment completion, relapse rate and overall survival
Consensus
C3-3 Medical oncology: Use of glutamine
Strength of recommendation: -
There are insufficient consistent clinical data to recommend glutamine supplementation during conventional cytotoxic or targeted therapy.
Level of evidence: Low
Questions for research: Effect of glutamine on drug-induced neuropathy
Strong consensus
Section C4: Medical oncology: High-dose chemotherapy and hematopoietic stem cell transplantation (HCT)
C4-1 High-dose chemotherapy and HCT: Ensuring adequate nutrition and physical activity
Strength of recommendation: STRONG
During intensive chemotherapy and after stem cell transplantation we recommend to maintain physical activity and to ensure an adequate nutritional intake. This may require enteral and/or parenteral nutrition.
Level of evidence: Very low
Questions for research: Effects of physical actvity on clinical outcome
Strong consensus
C4-2 High-dose chemotherapy and HCT: Enteral and parenteral nutrition
Strength of recommendation: WEAK
If oral nutrition is inadequate we suggest preferring enteral tube feeding to parenteral nutrition, unless there is severe mucositis, intractable vomiting, ileus, severe malabsorption, protracted diarrhea or symptomatic gastrointestinal graft versus host disease (GvHD).
Level of evidence: Low
Questions for research: Comparing efficacy of enteral vs parenteral nutrition on clincal outcome and complication rates
Strong consensus
C4-3 High-dose chemotherapy and HCT: Low bacterial diet
Strength of recommendation: -
There are insufficient consistent clinical data to recommend a low bacterial diet for patients more than 30 days after allogeneic transplantation
Level of evidence: Low
Questions for research: Definition of factors predicting beneficial effects of a low bacterial diet. Comparing benefits of food safety guidelines vs neutropenic diet
Strong consensus
C4-4 High-dose chemotherapy and HCT: Glutamine
Strength of recommendation: -
There are insufficient consistent clinical data to recommend glutamine to improve clinical outcome in patients undergoing high-dose chemotherapy and hematopoetic stem cell transplantation.
Level of evidence: Low
Questions for research: Effect of glutamine on mucositis, diarrhea, clinical infections, graft versus host disease and malignancy relapse rate
Strong consensus
Section C5: Cancer survivors
C5-1 Cancer survivors: Physical activity
Strength of recommendation: STRONG
We recommend that cancer survivors engage in regular physical activity.
Level of evidence: Low
Questions for research: Effects of physical activity on physical function, recurrence and survival in cancer survivors
Consensus
C5-2 Cancer survivors: Body weight and lifestyle
Strength of recommendation: STRONG
In cancer survivors we recommend to maintain a healthy weight (BMI 18.5-25 kg/m²) and to maintain a healthy lifestyle, which includes being physically active and a diet based on vegetables, fruits and whole grains and low in saturated fat, red meat and alcohol.
Level of evidence: Low
Questions for research: Effects of a healthy diet on metabolic syndrome, quality of life, cancer relapse rates and overall survival
Strong consensus
Section C6: Patients with advanced cancer receiving no anticancer treatment
C6-1 Advanced cancer: Screening and assessment
Strength of recommendation: STRONG
We recommend to routinely screen all patients with advanced cancer for inadequate nutritional intake, weight loss and low body mass index, and if found at risk, to assess these patients further for both treatable nutrition impact symptoms and metabolic derangements.
Level of evidence: Low
Questions for research: Effects of malnutrition screening programs combined with multidisciplinary interventions on quality of life in cancer patients with advanced disease
Consensus
C6-2 Nutrition support in patients with advanced cancer
Strength of recommendation: STRONG
We recommend offering and implementing nutritional interventions in patients with advanced cancer only after considering together with the patient the prognosis of the malignant disease and both the expected benefit on quality of life and potentially survival as well as the burden associated with nutritional care.
Level of evidence: Low
Questions for research: Effects of nutritional care on quality of life in patients with advanced cancer
Consensus
C6-3 Very advanced terminal phase
Strength of recommendation: STRONG In dying patients, we recommend that treatment be based on comfort. Artificial hydration and nutrition are unlikely to provide any benefit for most patients. However, in acute confusional states, we suggest to use a short and limited hydration to rule out dehydration as precipiting cause.
Level of evidence: Low
Questions for research: Predicting reversibilty in acute confusional states
Strong consensus