July 2005

Dear Readers: Here's the Article for this Month:

Name of article:

Should patients with advanced, incurable cancers ever be sent home with total parenteral nutrition?

A single Institution’s 20-year experience.

Author(s): Hoda D, Jatoi A, Burnes J, Loprinzi C, Kelly D.
Abstract:  Cancer 2005; 103:863-8

This article is not an randomized clinical trial (RCT) on the use of Total Parenteral Nutrition (TPN) in advanced cancer patients, but it is the Mayo Clinic’s 20-year experience of their patients with incurable metastatic disease who had TPN initiated in the hospital and who continued to received it in the out-patient setting.

The role of TPN in advanced cancer patients is still controversial. Because of RCTs which did not reveal the expected benefits of TPN in advanced cancer patients, the American College of Physicians took a stand by publishing a consensus statement. This statement advised that the routine use of parenteral nutrition should be discouraged in patients undergoing chemotherapy and that when it is used in cancer patients with malnutrition, physicians should consider the possibility of increased risks (Ann Intern Med 1989;110:734-6). However, in daily clinical practice, TPN is sometimes begun in advanced patients during hospitalization and then continued at home.

The Authors identified all patients with any type of incurable cancer, cared for at Mayo Clinic from 1979 to 1999 and thoroughly reviewed the clinical charts of the patients on TPN at home. In fact, patients followed at home permit identification of long-term survivors and excluded patients in the terminal phase who received TPN for a short period during their stay in hospital. The Authors evaluated: 1. what was the clinical situation which brought about the initial use of TPN? 2. what was the interval between diagnosis of metastatic disease and initiation of TPN? 3. what was the survival rate of these patients? and 4. How many patients survived one year or more? They tried to identify factors which would predict a longer survival among TPN treated patients (for example, were they patients with low-grade tumours or not painful cancer, or were they patients on CH, H, RT that were considered to live longer with respect to other patients with dyspnea or pain at the time of TPN initiation?).

372 adult patients with incurable cancer were identified during the period under investigation and 52 of them (median age 56 years, 30 women) received TPN at home. Most of these patients had GI cancers, ovarian cancer, carcinoid and amyloidosis. The most common reasons for TPN initiation was malabsorption, obstruction of the alimentary tract or fistulas.

Seventy-one percent of the patients had lost > 4.5 Kg before TPN initiation and in 48% of the patients the surgical service initiated TPN in consultation with the home TPN service.

Thirty two patients (62%) initiated TPN less than 1 year from the time of the diagnosis of metastatic cancer, while 19 patients the interval was greater than 1 year. Thirteen patients had symptoms of pain or dyspnea at the time of TPN initiation. Seventeen patients were on oncological therapies (15 CH, 1 RT, 1 H).

The median time from initiation of TPN to death was 5 months (range 1-154 months). Sixteen patients survived > 1 year. For most of the patients, TPN was stopped because of death. Five patients lived from 1 to 3 years after TPN cessation (1 pt with sarcoma, 1 with amyloidosis, 1 with ovarian cancer, 1 with pancreatic cancer, and 1 with esthesioneuroblastoma). The potential predictive variables examined (tumour grade, the interval between diagnosis of metastatic disease and TPN start , the presence of severe symptoms, and the administration of cancer therapy after TPN) were not associated with overall survival. TPN related complications included 18 catheter infections (1 per 2.8 catheter-years), 4 central venous thromboses, 3 pneumothoraces, and 2 episodes of TPN-related liver disease.

Why I chose this article

The use of TPN in advanced cancer patients with incurable cancer is still a controversial issue in both the oncological as well as in the palliative care settings. This study is the largest retrospective study of patients with metastatic incurable cancer who received TPN after a careful evaluation.

The results of the study demonstrat that, in selected patients with rare tumoural pathologies such as carcinoid/islet cell tumours, amyloidosis, abdominal tumours which cause malabsorption or mechanical GI problems, even though they have incurable cancer, TPN may be beneficial and they can live many months with acceptable TPN-related complications.

The results of this study cannot be applied to all patients with incurable cancer and nutritional problems.

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC