Nutritional Support in Patient Undergoing Induction Therapy for Esophageal Cancer

Esophageal cancer is highly lethal. In Ontario in 2020, an estimated 900 patients were diagnosed with esophageal cancer, while 860 died from it. In Canada, the figures are 2400 diagnoses and 2260 deaths. The incidence of esophageal cancer in Canada is projected to increase over time, especially in males who are more likely to be obese and to suffer from reflux disease.

Esophageal cancer is the malignancy associated with the highest risk for malnutrition. Before their diagnosis, 80% of all patients with esophageal cancer have over 10-15% unintentional weight loss. Strategies to palliate malnutrition in cancer patients and its consequences on outcomes have been developed. In patient with severe nutritional risk, use of nutritional support for at least 10-14 days has been recommended in a non-surgical, oncology population. The European Society for Clinical Nutrition and Metabolism have recommended preoperatively enteral nutrition for 5-7 days in cancer patients undergoing major abdominal surgery. In addition, dietary counselling and oral nutritional supplement were suggested to prevent weight loss and interruption of radiotherapy on patients undergoing radiation treatments for head/neck or gastrointestinal malignancies. Routine enteral nutrition was not suggested during chemotherapy-only treatments.

The type of supplements administered may have an impact on recovery. It was shown that esophageal cancer patients receiving enriched glutamine, fibers and oligosaccharide perioperative enteral supplementation had a shorter systemic inflammatory response syndrome postoperatively and less surgical stress, which could in turn lead to reduced postoperative immunosuppressive conditions. A recent retrospective study from Taiwan did show a slightly improved 4-year overall survival rate and less mucositis on patients supported by enteral feeding tubes with esophageal squamous cell carcinoma and undergoing neoadjuvant therapy.

However, there is still equipoise in the literature and most centers in Canada have moved away from feeding tubes. At LHSC, feeding tubes were historically placed on every patient during their induction treatment. Efforts are being made to spare patients from unnecessary procedure, but patient selection is variable. Standardization of this practice is needed. A recent retrospective study evaluating the effect of surgical enteral access prior to induction treatment did not show nutritional or perioperative benefit. There was no difference in postoperative complication rates and weight loss was similar. In fact, dysphagia is felt to be significantly relieved after a single cycle of chemotherapy. Percutaneous feeding tubes may not be required on all patients during induction therapy for esophageal cancer.

Those feeding tubes are associated with high morbidity. Kidane et al have shown that 39.3% of visits to the ED after an esophagectomy are due to feeding tubes problems (dislodgement, blockage, infection). Of those ED visits for feeding tubes issues, 17% resulted to an admission. Small bowel obstruction is also associated to percutaneous feeding tube placement and selective use has been recommended. Perioperative use of feeding jejunostomy in gastroesophageal cancer has been associate with a complication rate as high as 44%. Given the related-morbidity, guidelines now recommend selective use of feeding tubes on high-risk patients after esophagectomy. When patients undergoing chemotherapy present to the emergency department with fever or infectious signs, data from the Ontario Cancer Registry show that 46% are admitted, increasing healthcare burden. At baseline, patients undergoing chemotherapy are at high risk of presenting to the emergency department or having unplanned visit to the cancer center, this figure going as high as 49% within 4 weeks of initiation of chemotherapy in comparable jurisdictions. Efforts must be made to save an already strained system.