The Effect of Nutritional Supplementation Consisting Locally Available Food Along With Micronutrients to Improve Cancer Cachexia in Bangladesh: A Quasi-experimental Study.

Cancer is one of the major societal, public health, and economic problems of the 21st century. It encompasses a diverse group of diseases characterized by uncontrolled proliferation of abnormal cells, which can invade surrounding tissues and metastasize to distant organs. Despite advances in diagnostic modalities and therapeutic interventions, the burden of cancer continues to rise, particularly in low- and middle-income countries (LMICs). The global burden of cancer presents a formidable challenge to public health in the 21st century. According to the International Agency for Research on Cancer, the world witnessed approximately 20 million new cancer cases and 9.7 million deaths attributed to cancer in 2022 . In the South-East Asia region cancer also poses a significant public health challenge. In 2022, World Health Organization (WHO) reported approximately 2.37 million new cancer cases and 1.53 million deaths attributed to the disease in the South-East Asia region. Moreover, the burden of cancer is projected to rise, with an increase of new cases by 85.7% by 2050. According to estimates from the World Health Organization (WHO), the leading causes of cancer-related mortality worldwide in 2020 were lung cancer (1.80 million deaths), followed by colorectal cancer (916,000 deaths), liver cancer (830,000 deaths), stomach cancer (769,000 deaths), and breast cancer (685,000 deaths). Solid tumors accounts for approximately 90% of adult human cancer. Surgery is often the primary treatment for solid tumors, especially in early stages. It is estimated that by 2030 annually 45 million surgical procedures will be needed worldwide.

With a population of 171.2 million, Bangladesh is the world's eighth most populous country. The Global Cancer Observatory reported 156,775 new cancer cases and 108,990 cancer-related deaths occurred in Bangladesh in 2020. The age-standardized rates of 106.2 and 75.3 per 100,000 for cancer incidence and mortality, respectively.

As cancer prevalence increases, so does the incidence of cancer-associated complications, among which cancer cachexia is one of the most significant.

Cancer cachexia is a multifactorial syndrome characterized by progressive weight loss, skeletal muscle wasting and metabolic dysregulation in patients with cancer. It has been reported that conventional nutritional supplementation alone is not enough to combat cancer cachexia. Recent research has highlighted the potential role of specialized nutritional strategies in mitigating the impact of cancer cachexia. A positive protein balance is required to increase skeletal muscle mass. A recent study showed that patients with low serum albumin level had markedly poorer prognosis than those in the high serum marker group. Consistent with this, the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend a daily protein intake should be 1.0-1.5 gm/kg. In terms of multivitamin, vitamin B complex plays a crucial role in managing cancer cachexia. Vitamin B particularly B3 (niacin), B6, and B12, are essential cofactors for various enzymes involved in energy production and metabolism. Studies showed that decreased levels of B vitamin-related enzymes in the liver, along with alterations in one-carbon metabolism, are hallmarks of cancer cachexia.

The National Institute of Cancer Research & Hospital (NICRH) is a 500-bed tertiary specialized located in Dhaka, Bangladesh. NICRH is the only government hospital, dedicated to comprehensive cancer care, education, and research. They offer a comprehensive range of specialties including surgical oncology, radiation oncology, medical oncology, cytopathology, histopathology. The department of surgical oncology provides surgical interventions for various cancers. Surgical patients typically stay in the hospital for 15 to 20 days. These patients often present after prolonged periods of inadequate nutritional intake, frequently with hypoalbuminemia. In the context of limited access to advanced nutritional support, many patients at NICRH infrequently consume rice water mixed with egg as a locally available nutritional supplement. This low-cost locally developed nutritional formula improve energy intake and protein status. Rice starch water is culturally accepted, low cost, easily digestible source of complex carbohydrate. Unlike milk, rice-based water avoids lactose intolerance and is less likely to provoke nausea/vomiting. It also provides hydration and a slow-release energy source critical for cachectic patients with poor appetite. Moreover, the effectiveness of this combination remains uncertain, particularly in terms of essential micronutrients. The purpose of this study is to analyse the role of evidence-based nutritional interventions in cancer cachexia with an affordable cost.