S3-Leitline der Deutschen Gesellschaft für Ernährungsmedizin e. V. (DGEM) in Kooperation mit der Deutschen Gesellschaft für Hämatologie und Onkologie e. V. (DGHO), der Arbeitsgemeinschaft „Supportive Maßnahmen in der Onkologie, Rehabilitation und Sozialmedizin“ der Deutschen Krebsgesellschaft (ASORS) und der Österreichischen Arbeitsgemeinschaft für klinische Ernährung (AKE)

Zusammenfassung

Fragestellung: Bei Tumorpatienten führen sowohl erkrankungs- als auch therapieassoziierte Belastungen häufig zu einer Mangelernährung. Zentrale klinische Probleme sind eine unzureichende Nahrungsaufnahme, eine Einschränkung der körperlichen Aktivität und Mobilität sowie katabole metabolische Veränderungen im Sinne einer systemischen Inflammationsreaktion, die oft gemeinsam vorliegen. Diese Leitlinie soll evidenzbasierte Empfehlungen zur Erkennung und ggf. multimodalen Behandlung von Ernährungs- und Stoffwechselstörungen bei Tumorpatienten geben.

Methodik: Es wurden eine systematische Literaturrecherche sowie eine Handsuche zu Literatur über Ernährungs- und Stoffwechelstörungen bei Tumorpatienten durchgeführt. Die Ergebnisse wurden in einer interdisziplinären Arbeitsgruppe aus Ärzten, Ernährungswissenschaftlern und Diätassistenten diskutiert und bewertet. Auf dieser Basis wurden von der Arbeitsgruppe Empfehlungen erarbeitet, die auf der Konsensuskonferenz am 18. und 19. Oktober 2013 vorgestellt, diskutiert, z. T. modifiziert und verabschiedet wurden.

Ergebnisse: Die Leitlinie enthält 48 Empfehlungen zur klinischen Ernährung in der Onkologie. Zur frühzeitigen Erfassung von Ernährungsstörungen sollen valide Screeningverfahren eingesetzt und bei Auffälligkeiten im Screening durch ein gezieltes Assessment ergänzt werden. Grundsätzlich soll eine ausreichende Energie- und Eiweißzufuhr gesichert werden. Hierzu eignen sich die Linderung ernährungsrelevanter Symptome sowie ein der individuellen Situation angemessener Einsatz professioneller Ernährungsberatung inkl. oraler bilanzierter Diäten (Trinknahrungen), Sondenernährung bzw. intravenöser Ernährung. Jede Ernährungsbetreuung sollte zum Aufbau der Muskelmasse von bewegungstherapeutischen Maßnahmen begleitet werden. Bei Patienten mit fortgeschrittener Erkrankung können medikamentöse Substanzen zur Steigerung des Appetits, zur Vergrößerung der Muskelmasse und zur Minderung der Inflammationsreaktion erwogen werden. Während einer Bestrahlung im Kopf-Hals-Bereich ist frühzeitig der Einsatz von Trinknahrungen und ggf. einer Sondenernährung in Betracht zu ziehen, um den Energiebedarf zu sichern und eine Unterbrechung der Bestrahlung zu verhindern. Während einer medikamentösen Tumorbehandlung gilt analog, dass eine ausreichende Nahrungszufuhr gesichert werden soll, ggf. unter Anwendung einer enteralen und/oder parenteralen Nahrungszufuhr. Nach kurativer Tumorbehandlung werden regelmäßige körperliche Aktivität sowie eine die Bedarfsdeckung nicht übersteigende Energiezufuhr empfohlen. Abhängig von der Erkrankungsprognose sollte auch bei unheilbar kranken Tumorpatienten auf eine ausreichende Nahrungsaufnahme geachtet werden, während in der Sterbephase die Zufuhr von Nahrung und Flüssigkeit allein symptomorientiert erfolgen soll.

Schlussfolgerung: Durchgehende Aufmerksamkeit für mögliche Ernährungsstörungen sowie eine der jeweiligen Situation angemessene Ernährungsbehandlung sollen Teil der Supportivbetreuung jedes Tumorpatienten sein, um die Körperreserven, die Therapietoleranz, den Erkrankungsverlauf und die Lebensqualität günstig zu beeinflussen.

Abstract

Aim: In cancer patients, tumor- and treatment-associated factors may promote malnutrition. Inadequate food intake, diminished physical activity and metabolic catabolic derangements (systemic inflammation) are major clinical problems; they are often present simultaneously. This guideline presents evidence-based recommendations for detection and multi-modal treatment of nutritional and metabolic problems in cancer patients.

Methods: This guideline is based on a systematic literature search and hand-searches of relevant literature by experts. Results were discussed and evaluated by a group of physicians, nutritionists and dieticians. Clinical recommendations derived by the group were presented, discussed, adapted and finally adopted during a consensus conference on 18 – 19 October 2013.

Results: This guideline is composed of 48 recommendations dealing with clinical nutrition in cancer patients. To detect nutritional problems early, we recommend screening for malnutrition in all cancer patients; abnormal screening should be followed by dedicated nutrition assessment. Generally, an adequate intake of energy and protein should be ensured. This may be achieved by treatment of nutrition impact symptoms and the appropriate and if necessary escalating use of nutrition counseling, oral nutritional supplements (ONS), tube feedings and/or intravenous nutrition. To improve muscle mass, nutritional care should always be accompanied by exercise training. In patients with advanced cancer, pharmacological agents may be considered to improve appetite, muscle mass and systemic inflammation. During radiotherapy of head and neck cancers the appropriate use of ONS or tube feedings should not be missed to ensure continuity of an adequate energy intake and to avoid interruptions of the treatment. Similarly, during anticancer drug treatment an adequate provision of energy should be ensured, if necessary by applying nutrition by enteral or parenteral routes. Cancer survivors should be physically active and balance energy intake with requirements. Depending on life expectancy, also in incurable cancer patients an adequate nutritional supply should be provided. However, during the dying phase nutrition and fluids should only be supplied as required to alleviate symptoms.

Conclusion: Supportive care of all cancer patients should always include continuous attention to potential nutritional problems and if necessary early and adequate nutritional support. This is aimed at improving body resources, the tolerance of anticancer treatments, the overall prognosis and the patients’ quality of life.

Schlüsselwörter

Tumor - Ernährung - Mangelernährung - Sarkopenie - Kachexie - Bestrahlung - Chemotherapie - Palliativbehandlung - Ernährungstherapie - Ernährungsberatung - Trinknahrung - künstliche Ernährung

Keywords

cancer - nutrition - malnutrition - sarcopenia - cachexia - radiotherapy - chemotherapy - palliative care - nutrition support - nutrition counseling - oral nutritional supplement - artificial nutrition

^* DGEM Steering Committee: Bischoff SC, Weimann A, Adolph M, Normann K, Plauth M, Ockenga J.

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