2021年，欧洲临床营养与代谢协会(European Society for Clinical Nutrition and Metabolism, ESPEN)在其官方杂志Clinical Nutrition上发布了最新版的肿瘤患者营养治疗实践指南(ESPEN practical guideline: Clinical Nutrition in cancer)，该版本在2017年ESPEN肿瘤患者营养治疗指南进行缩减，在内容没有变化的43条建议中添加了流程图，更加便于临床医师、营养师及护士等在临床实践中使用。
肿瘤特定全营养是继普通全营养、糖尿病特定全营养的的第三大全营养品类，受到众多的关注；ESPEN的肿瘤患者营养治疗实践指南是业界权威指南。从明华教授和吴国豪教授分别对指南进行了专业的解读，小编在两位教授的解读上做了综合编辑，以飨读者。此外，推荐水平、证据水平以及共识水平强的做了标红。
一、肿瘤患者营养治疗通则
To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change, and body mass index (BMI), beginning with cancer diagnosis and repeated depending on the stability of the clinical situation. (Recommendation B1-1; strength of recommendation strong – level of evidence very low – strong consensus)为早期发现营养失衡，建议从肿瘤确诊就定期评估患者的营养摄入量、体重变化与身体质量指数(BMI)，并依据病情反复评估。(强推荐、证据水平很低、强共识)In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, muscle mass, physical performance and the degree of systemic inflammation. (Recommendation B1-2; strength of recommendation strong – level of evidence very low – consensus)对对营养筛查有异常的患者，建议进行进行客观、定量的评估：营养摄入量、营养相关症状、肌肉质量、体能及全身炎症程度。(强推荐、证据水平很低、共识)We recommend that the total energy expenditure (TEE) of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30kcal/kg/day. (Recommendation B2-1; strength of recommendation strong – Level of evidence low – consensus)肿瘤患者的总能量消耗(TEE)若无法个体化测量，推荐其与健康人相似，一般为25-30kcal/kg/d。(强推荐、证据水平低、共识)We recommend that protein intake should be above 1g/kg/day and, if possible up to 1.5g/kg/day. (Recommendation B2-2; strength of recommendation strong – Level of evidence moderate – strong consensus)蛋白质摄入量每日应大于1g/kg ，有条件者增加至1.5g/kg以上。(强推荐、证据水平中等、强共识)We recommend that vitamins and minerals be supplied in amounts approximately equal to the recommended daily allowance and discourage the use of high-dose micronutrients in the absence of specific deficiencies. (Recommendation B2-4; strength of recommendation strong – Level of evidence low – strong consensus)维生素与矿物质的供给量应大致等于每日营养推荐量，若没有特别缺乏不建议使用高剂量微量营养素。(强推荐、证据水平低、强共识)In weight-losing cancer patients with insulin resistance, we recommend to increase the ratio of energy from fat to energy from carbohydrates. This is intended to increase the energy density of the diet and to reduce the glycemic load. (Recommendation B2-3; strength of recommendation strong – Level of evidence low – consensus)体重丢失且患有胰岛素抵抗的患者，推荐增加脂肪相对碳水化合物在能量供给中所占的比例，以增加饮食的能量密度并降低葡萄糖负荷量。(强推荐、证据水平低、共识)
We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms), and offering oral nutritional supplements (ONS). (Recommendation B3-1; strength of recommendation strong – Level of evidence moderate – consensus)对能经口进食的营养不良或存在营养不良风险的肿瘤患者，推荐进行营养干预来增加经口饮食，包括给予膳食建议、治疗影响进食的相关症状和紊乱，以及提供口服营养补充(ONS)。(强推荐、证据水平中等、共识)We recommend not to use dietary provisions that restrict energy intake in patients with or at risk of malnutrition. (Recommendation B3-2; strength of recommendation strong – Level of evidence low – strong consensus)我们建议不要在营养不良或有营养不良风险的患者中使用限制能量摄入的饮食规定。(强推荐、证据水平低、强共识)If a decision has been made to feed a patient, we recommend EN if oral nutrition remains inadequate despite nutritional interventions (counseling, ONS), and PN if EN is not sufficient or feasible. (Recommendation B3-3; strength of recommendation strong – Level of evidence moderate – strong consensus)如果进行了营养干预(咨询,ONS)，但口服营养仍然不足，建议EN；如果EN不充足或不可行，建议PN。(强推荐、证据水平中等、强共识)If oral food intake has been decreased severely for a prolonged period, we recommend to increase (oral, enteral or parenteral) nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome. (Recommendation B3-4; strength of recommendation strong – Level of evidence low – consensus)对经口进食量长期严重下降患者，推荐营养摄入量(经口补充，肠内营养或肠外营养)在几天内缓慢增加，并采取额外措施以防止再喂养综合征。(强推荐、证据水平低、共识)In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home EN or PN in suitable patients. (Recommendation B3-5; strength of recommendation strong – Level of evidence low – strong consensus)对长期膳食摄入不足和/或顽固性吸收不良患者，推荐对合适的患者进行家庭EN或PN。(强推荐、证据水平低、强共识)We recommend maintenance or an increased level of physical activity in cancer patients to support muscle mass, physical function, and metabolic pattern. (Recommendation B4-1; strength of recommendation strong – Level of evidence high – consensus)推荐肿瘤患者坚持或增加体力活动水平，以维持肌肉质量、机体功能及代谢状态。(强推荐、证据水平高、共识)We suggest individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass. (Recommendation B4-2; strength of recommendation weak – Level of evidence low – strong consensus)建议在有氧运动外基础上制定个体化抗阻训练以维持肌肉力量和质量。(弱推荐、证据水平低、强共识)
We suggest considering corticosteroids to increase the appetite of anorectic cancer patients with advanced disease for a restricted period (1-3 weeks) but to be aware of side effects (e.g. muscle wasting, insulin resistance, infections). (Recommendation B5-1; strength of recommendation weak – Level of evidence high – consensus)推荐短期内(1-3周)使用糖皮质激素以增加晚期厌食性肿瘤患者的食欲，但需注意副作用(如肌肉丢失、胰岛素抵抗及感染等)。(弱推荐、证据水平高、共识)We suggest considering progestins to increase the appetite of anorectic cancer patients with advanced disease but to be aware of potentially serious side effects (e.g. thromboembolism). (Recommendation B5-2; strength of recommendation weak – Level of evidence high – consensus)对有厌食的晚期肿瘤患者，推荐对使用黄体酮以增加食欲，但需注意血栓等副作用。(弱推荐、证据水平高、共识)In patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished, we suggest using supplementation with long-chain N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass, and body weight. (Recommendation B5-7; strength of recommendation weak – Level of evidence low – strong consensus)对化疗或存在体重丢失及营养不良风险的晚期肿瘤患者，建议补充长链N-3脂肪酸或鱼油来保持或改善食欲、进食量、瘦体重及体重。(弱推荐、证据水平低、强共识)In patients complaining about early satiety, after diagnosing and treating constipation, we suggest to consider prokinetic agents, but to be aware of potential adverse effects of metoclopramide on the central nervous system and domperidone on cardiac rhythm. (Recommendation B5-8; strength of recommendation weak – Level of evidence moderate – consensus)对主诉早饱的患者，在诊断并治疗便秘后，推荐使用促动力药，但需注意胃复安对中枢神经系统的副作用以及多潘立酮对心率的影响。(弱推荐、证据水平中、共识)There are insufficient consistent clinical data to recommend the supplementation with branched-chain or other amino acids or metabolites to improve fat-free mass. (Recommendation B5-5; strength of recommendation none – Level of evidence low – strong consensus)没有足够一致的临床数据支持推荐补充支链氨基酸或其他氨基酸或代谢产物来改善去脂组织质量。(推荐强度无、证据水平低、强共识)There are insufficient consistent clinical data to recommend non-steroidal anti-inflammatory drugs to improve body weight in weight-losing cancer patients. (Recommendation B5-6; strength of recommendation none – Level of evidence low – strong consensus)没有足够一致的临床数据支持推荐非甾体类抗炎药来改善体重丢失肿瘤患者的体重。(推荐强度无、证据水平低、强共识)There are insufficient consistent clinical data to recommend cannabinoids to improve taste disorders or anorexia in cancer patients. (Recommendation B5-3; strength of recommendation none – Level of evidence low – consensus)没有足够一致的临床数据支持推荐使用大麻类制剂来改善肿瘤患者的味觉障碍或厌食症。(推荐强度无、证据水平低、共识)There are insufficient consistent clinical data to recommend currently approved androgenic steroids to increase muscle mass. (Recommendation B5-4; strength of recommendation none – Level of evidence low – consensus)没有足够一致的临床数据支持推荐使用目前批准的雄激素类固醇来增加肌肉质量。(推荐强度无、证据水平低、共识)
二、特殊类型肿瘤患者的营养治疗
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. (Recommendation C1-1; strength of recommendation strong – Level of evidence high – consensus)对于所有接受根治性手术还是姑息性手术的患者，均推荐按照加速术后康复(ERAS)原则进行围手术期管理：每个患者都应进行营养筛查；若存在营养不良风险，则给予额外的营养治疗。(强推荐、证据水平高、共识)For a patient undergoing repeated surgery as part of a multimodal oncological pathway, we recommend the management of each surgical episode within an ERAS program. (Recommendation C1-2; strength of recommendation strong – Level of evidence low – consensus)对需要多次手术作为肿瘤多模式治疗一部分的患者，推荐每次手术的围手术期管理均遵循ERAS原则。(强推荐、证据水平低、共识)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 the hospital. (recommendation C1-3; strength of recommendation strong – Level of evidence moderate – consensus)对存在营养不良风险或已经营养不良的外科肿瘤患者，推荐住院期间与出院后都给予适当的营养治疗。(强推荐、证据水平中、共识)In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care, we recommend oral/enteral immunonutrition (arginine, n-3 fatty acids, nucleotides). (Recommendation C1-4; strength of recommendation strong – Level of evidence high – strong consensus)对采用传统围术期管理的上消化道肿瘤手术患者，推荐使用口服或肠内免疫营养(如精氨酸、n-3脂肪酸、核苷酸)。(强推荐、证据水平高、共识强)
We recommend that during radiotherapy – with special attention to radiotherapy of the head and neck, thorax and GI tract - an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of ONS, in order to avoid nutritional deterioration, maintain intake and avoid radiotherapy interruptions. (Recommendation C2-1; strength of recommendation strong – Level of evidence moderate – strong consensus)在放疗期间，特别是头颈部、胸部及消化道放疗，为避免营养状况恶化，维持营养摄入量并避免放疗中断，推荐进行个体化营养咨询和/或使用ONS以保证充足的营养摄入。(强推荐、证据水平中等、强共识)We recommend to screen for and manage dysphagia and to encourage and educate patients on how to maintain their swallowing function during EN. (Recommendation C2-3; strength of recommendation strong – Level of evidence low – strong consensus)推荐对吞咽困难进行筛查和治疗，鼓励并教育患者在行EN时如何维持吞咽功能。(强推荐、证据水平低、强共识)We recommend enteral feeding using nasogastric or percutaneous tubes (e.g. percutaneous endoscopic gastrostomies (PEG)) in radiation-induced severe mucositis or obstructive tumors of the head-neck or thorax. (Recommendation C2-2; strength of recommendation strong – Level of evidence low – strong consensus)对放疗过程中所致的放射性黏膜炎或肿瘤所致的严重梗阻，推荐使用鼻胃管或经皮胃肠管(如经皮内镜下胃造瘘术，PEG)进行肠内营养。(强推荐、证据水平低、强共识)We do not recommend 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. (Recommendation C2-6; strength of recommendation strong – Level of evidence moderate – consensus)不建议将PN作为放疗的常规治疗方法，除非口服或肠内营养无法满足营养需求或无法实施，例如存在严重的放射性肠炎或严重的吸收不良等情况。(强推荐、证据水平中等、共识)There are insufficient consistent clinical data to recommend glutamine to prevent radiation-induced enteritis/diarrhea, stomatitis, esophagitis or skin toxicity. (Recommendation C2-4; strength of recommendation none – Level of evidence low – strong consensus)没有足够一致的临床数据支持推荐使用谷氨酸，来预防放疗导致的肠炎、腹泻、胃炎、食管炎或皮肤中毒。(推荐强度无、证据水平低、强共识)There are insufficient consistent clinical data to recommend probiotics to reduce radiation-induced diarrhea. (Recommendation C2-5; strength of recommendation none– Level of evidence low – strong consensus)没有足够一致的临床数据支持推荐使用益生菌来减少放疗导致的腹泻。(推荐强度无、证据水平低、强共识)
During anticancer drug treatment, we recommend to ensure an adequate nutritional intake and to maintain physical activity. (Recommendation C3-1; strength of recommendation strong – Level of evidence very low – strong consensus)在使用抗肿瘤药物治疗期间，推荐确保充足的营养摄入并坚持体育锻炼。(强推荐、证据水平很低、强共识)In a patient undergoing curative anticancer drug treatment, if oral food intake is inadequate despite counseling and ONS, we recommend supplemental EN or, if this is not sufficient or possible, PN. (Recommendation C3-2; strength of recommendation strong – Level of evidence very low – consensus)在接受在疗效性抗肿瘤药物治疗的过程中，若给予营养咨询和ONS患者的经口食物摄入仍然不足，推荐补充EN，若仍不能满足患者营养需求，建议PN。(强推荐、证据水平很低、共识)There are insufficient consistent clinical data to recommend glutamine supplementation during conventional cytotoxic or targeted therapy. (Recommendation C3-3; strength of recommendation none – Level of evidence low – strong consensus)没有足够一致的临床数据支持，在传统的细胞毒性药物或靶向药物治疗期间，推荐补充添加谷氨酸。(推荐强度无、证据水平低、强共识)During intensive chemotherapy and after stem cell transplantation we recommend maintaining physical activity and to ensure an adequate nutritional intake. This may require EN and/or PN. (Recommendation C4-1; strength of recommendation strong – Level of evidence very low – strong consensus)在大剂量化疗期间或造血干细胞移植后，建议坚持体育活动并进行合适的营养摄入，必要时可进行EN和/或PN。(强推荐、证据水平很低、强共识)If oral nutrition is inadequate we suggest preferring EN to PN, unless there is severe mucositis, intractable vomiting, ileus, severe malabsorption, protracted diarrhea or symptomatic GI graft versus host disease. (Recommendation C4-2; strength of recommendation weak – Level of evidence low – strong consensus)若口服营养不足，建议首选EN而非PN，除非患者存在严重的黏膜炎、顽固性呕吐、肠梗阻、严重吸收不良、长期腹泻或症状性胃肠道移植物抗宿主疾病。(弱推荐、证据水平低、强共识)There are insufficient consistent clinical data to recommend a low bacterial diet for patients more than 30 days after allogeneic transplantation. (Recommendation C4-3; strength of recommendation none – Level of evidence low – strong consensus)对同种异体移植术后超过30天的患者，没有足够的临床数据支持推荐使用低细菌饮食。(推荐强度无、证据水平低、强共识)There are insufficient consistent clinical data to recommend glutamine to improve clinical outcome in patients undergoing high-dose chemotherapy and HSCT. (Recommendation C4-4; strength of recommendation none – Level of evidence low – strong consensus)对接受大剂量化疗和造血干细胞移植(HSCT)患者，没有足够一致的临床数据支持推荐使用谷氨酸来改善临床结局。(推荐强度无、证据水平低、强共识)
We recommend that cancer survivors engage in regular physical activity.(Recommendtion C5-1; strength of recommendation strong – Level of evidence low-consensus)推荐肿瘤幸存者定期进行体育锻炼。(强推荐、证据水平低、共识)In cancer survivors, we recommend maintaining 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. (Recommendation C5-2; strength of recommendation strong – Level of evidence low – strong consensus)对于肿瘤幸存者者，建议维持健康的体重水平(BMI 18.5-25 kg/m2)，并保存健康的生活方式，包括进行体育活动，以蔬菜、水果、全谷类食物为基础，低饱和脂肪酸、红肉和酒精摄入的饮食。(强推荐、证据水平低、强共识)We recommend to routinely screen all patients with advanced cancer for inadequate nutritional intake, weight loss, and low BMI, and if found at risk, to assess these patients further for both treatable nutrition impact symptoms and metabolic derangements. (Recommendation C6-1; strength of recommendation strong – Level of evidence low – consensus)建议所有晚期肿瘤患者常规筛查是否存在营养摄入不足、体重丢失及低BMI，对存在风险的患者进一步评估是否有可治疗的营养相关症状与代谢紊乱。(强推荐、证据水平低、共识)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. (Recommendation C6-2; strength of recommendation strong – Level of evidence low – consensus)对进展期肿瘤患者，推荐在综合评估患者恶性肿瘤预后、营养治疗对生活质量的获益、可能的生存时间以及营养治疗相关的负担后，再实施营养干预。(强推荐、证据水平低、共识)In dying patients, we recommend that treatment be based on comfort. Parenteral hydration and nutrition are unlikely to provide any benefit for most patients. However, in acute confusional states, we suggest using a short and limited hydration to rule out dehydration as precipitating cause. (Recommendation C6-3; strength of recommendation strong – Level of evidence low – strong consensus)对于临终患者，推荐治疗以舒适为主。大部分临终患者不能从肠外水化和肠外营养中获益。然而对急性精神错乱的患者，推荐使用短期限制性补水以排除脱水这个诱发因素。(强推荐、证据水平低、强共识)
