Palliative management of cancer of the oesophagus – opportunities for dietetic intervention

Introduction: Cancer of the oesophagus develops insidiously and when patients present with symptoms such as dysphagia to solids/semi‐solids and in some cases liquids, the disease is often advanced and patients are frequently poorly nourished and cachectic ( Angorn, 1981 ; Larrea, 1992 ). In our own unit we were aware that patients were only referred to the dietitian once an oesophageal stent was inserted or radiotherapy commenced, thereby possibly missing opportunities to treat or prevent malnutrition earlier. We therefore evaluated the nutritional status and care pathways of patients diagnosed with cancer of the oesophagus in whom palliative treatment was the only option, with the aim of assessing the extent of malnutrition and identifying opportunities for earlier dietetic intervention to prevent or slow the development of malnutrition. Method: Data were collated on all patients referred to the hospital's dysphagia clinic and diagnosed with inoperable cancer of the oesophagus. Height, weight, body mass index, degree of dysphagia, period of dysphagia, percentage weight loss (data collected as standard practice in the dysphagia clinic) and time to stent insertion/radiotherapy and survival time was collected from the medical notes. Results: Data were available on 58 patients, 33 male, 25 female, mean age 75 years (range 49–92 years). The mean length of survival was 10.2 months (0–24 months). At diagnosis, 47% experienced dysphagia with solids, 33% with semi‐solids and 16% experienced a degree of dysphagia with liquids. The period of dysphagia was 1 month to 2 years. Eighty‐three per cent of patients had lost weight at diagnosis. Mean percentage weight loss per individual was 13% (range 0–45%). Thirty‐five per cent had a BMI <20 kg/m². Median time from diagnosis to radiotherapy (n = 8) was 2 months with range, 1–6 months. Median time from diagnosis to the placement of the oesophageal stent (n = 12) was 1 month with range, 0–7 months. Discussion: These data illustrate that malnutrition remains a significant problem in this patient group. These results demonstrate that dysphagia and malnutrition, as indicated by weight loss, is developing in the community before diagnosis. Opportunities for earlier dietetic intervention exist between diagnosis and date at which other treatments commence, i.e. stent insertion. Further opportunities exist to educate community health professionals on treating and preventing malnutrition when dysphagia presents. Survival times support the need for dietetic follow‐up. In our unit the results of this audit helped to improve care pathways for patients with cancer of the oesophagus. In response to the above findings, a nutritional screening tool is now completed by a nurse specialist at the first clinic attended. This has enabled appropriate and timely advice to be given on modified texture and fortification of food to optimize nutritional intake at diagnosis.     

Stenting in the oesophagus

Self-expanding metallic stents have assumed increasing importance in the palliative treatment of malignant dysphagia in recent years. This is most commonly the result of inoperable oesophageal cancer, but may also be the result of extrinsic compression on the oesophagus by other malignant masses. Stents are also occasionally used as a last resort in benign disease.     

Palliative treatment in patients with oesophagus carcinoma

More than 50% of patients with oesophageal carcinoma will undergo palliative treatment because of distant metastases or local tumour ingrowth into surrounding organs. The majority of these patients have symptoms ofdysphagia. If metastases from oesophageal carcinoma are present, the most commonly used treatment modalities for dysphagia in The Netherlands are placement of a self-expanding stent or intraluminal radiotherapy (brachytherapy). If the life expectancy of patients is longer than 3 months, brachytherapy is sometimes combined with external radiotherapy. If patients with metastases are in a good condition, chemotherapy may be considered. If there is local tumour ingrowth but no metastases, chemotherapy in combination with radiation therapy (chemoradiation) is an option. These treatments should preferably make up part of well-designed studies. Quality of life is an important endpoint to consider in the palliative treatment of patients with oesophageal cancer. Well-established standardized and validated questionnaires are available for this purpose.     

Palliative treatment of esophageal cancer with dysphagia: more favourable outcome from single-dose internal brachytherapy than from the placement of a self-expanding stent; a multicenter randomised study

OBJECTIVE: To compare the results of single-dose internal irradiation (brachytherapy) and self-expanding metal stent placement in the palliation of oesophageal obstruction due to cancer of the oesophagus. DESIGN: Randomised trial. METHOD: In the period from December 1999-Jun 2002, 209 patients with dysphagia due to inoperable carcinoma of the oesophagus were randomised to placement of an Ultraflex stent (n = 108) or single-dose (12 Gy) brachytherapy (n = 101). Primary outcome was relief of dysphagia; secondary outcomes were complications, persistent or recurrent dysphagia, health-related quality of life, and costs. Patients were followed up by monthly home visits from a specialised nurse. RESULTS: Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. Stent placement resulted in more complications than did brachytherapy (36/108 (33%) versus 21/101 (21%); p = 0.02), due mainly to an increased incidence of late haemorrhage in the stent group (14 versus 5; p = 0.05). The groups did not differ with regard to the incidence of persistent or recurrent dysphagia or median survival (p > 0.20). In the long term, quality-of-life scores were higher in the brachytherapy group. Total medical costs were also similar for both treatments: Euro 8,215 for stent placement and Euro 8,135 for brachytherapy. CONCLUSION: Brachytherapy provided better long-term relief of dysphagia than did stent placement and also produced fewer complications. Brachytherapy is therefore recommended as the preferred treatment for the palliation of dysphagia due to oesophageal cancer.     

Eosinophilic oesophagitis: a frequently missed cause of dysphagia

Oesophageal dysphagia is the subjective feeling that there is a problem with the passage of solids or liquids through the oesophagus. The differential diagnosis of dysphagia is long and can be divided into mechanical and motility disorders. Dysphagia is an alarming symptom which requires short-term endoscopic evaluation. An emerging cause of dysphagia is eosinophilic oesophagitis. The typical eosinophilic oesophagitis patient is a young adult man, often with an atopic constitution, who has intermittent symptoms of dysphagia. The diagnosis of 'eosinophilic oesophagitis' is based on characteristic histological findings in the oesophagus, seen in a fitting clinical context. Best evidence for the effects of treatment of eosinophilic oesophagitis is available for topical glucocorticoids.     

Esophageal tumors at our outpatient clinic

INTRODUCTION: In the 1984-1997 period 1179 tumorous patients presented themselves at the oesophagus consultation of the Ist. Department of Surgery of Semmelweis University. The authors examined the changes in the characteristic features of these patients and the task of supply. OBJECT: The aim of analysis was estimating of the place and importance of the therapeutic methods applicable to ambulatory patients. METHODS: Essential task of the outpatients service was to summarize the diagnostic results and to supply the lacks for the therapeutic plan of the patients. Having possession of the results they had to make decisions of the necessary and possible method of therapy. From the 1179 patients it was necessary the ward admittance of 787 patients, in 512 cases in hope of resective operation, and in 275 cases in order to carry out palliative intervention under hospitalized circumstances. 392 patients were treated as outpatients. To outpatients in 296 cases tube endoprosthesis was implanted by endoscopic method for palliative purposes, there were made 14 dilating nasogastric tube treatments, in 2 cases percutaneous endoscopic gastrostomy, and in the case of 116 patients there were collaborations in intraluminal after-loading irradiation treatments. RESULTS: It appeared from the age-characteristics of the patients that the incidence in the examined period increased in the younger age-groups. The patients' main complaint was dysphagia, their average anamnesis-time was 4.03 months and it did not change during the 13 years. The incidence of the oesophago-respiratory fistula was 11.1% in the patient-population, and the incidence of reflectory dysphagia was 13.2%. There was an improvement in respect of the medical check-up of patients and the verification by histological examination of the tumorous process. In the case of 597 patients it was observed dysphagia requiring palliation and in 482 cases it succeeded to perform it by implanting endoprosthesis. There were 36 unsuccessful implantation attempts and in the case of 79 patients there were no conditions of intervention. CONCLUSIONS: In the treatment of oesophageal tumorous patients the interventions made in favour of the palliative improvement of agglutination were executable within the frame of the outpatient service, from among of which the implantation of endoscopic tube appeared to be the method improving the patients' quality of life and survival with the best result. In the course of years palliative treatments were made more and more in the frame of outpatient service. The authors feel it necessary to consider all the condition-ameliorating treatment possibilities and applications, which may not be alternatives of each other but complementaries.     

Acute dysphasia: often there is a readily treatable cause

Three patients, one woman aged 45 years and two men aged 40 and 62 years, presented with acute dysphagia due to oesophageal obstruction by a piece of food. In the woman symptoms of oesophageal perforation developed after the piece of food was removed by rigid endoscopy; she recovered after treatment with a stent, antibiotics and acid inhibitors. The younger man had a stricture of the oesophagus that was dilated. The older man had a Barrett's oesophagus and also oesophagcal adenocarcinoma; he was free of symptoms three years after resection of the oesophagus and the creation of a tubular stomach. In adults, 60% of acute oesophageal obstructions are caused by food impaction, which is associated with a high incidence of secondary pathologic findings in the oesophagus (75-97%). Evaluation of the oesophagus by flexible endoscopy contributes to an adequate diagnosis. Moreover, it can be used to treat the cause of the obstruction. If dilation therapy is started early after detecting a benign stricture in the oesophagus, it reduces the likelihood of recurrence. The detection of early-stage oesophageal malignancies may improve the prognosis of patients with this disorder.     

Acute dysphagia of oncological origin. Therapeutic management

Dysphagia is one of the most frequent syndromes in patients with tumours of the head and neck, and the oesophagus. This can be the initial symptom or, more frequently, related to the oncological treatment. We review the most important therapeutic and physio-pathological aspects of acute dysphagia of oncological origin. Deglutition is a complex process in which numerous muscular-skeletal structures intervene under the neurological control of different cranial nerves. The complex neuro-muscular coordination needed for a correct deglutition can be affected by numerous situations, both from the effect of the tumours and from their treatment, basically surgery or radiotherapy. In conclusion, it can be affirmed that for a suitable treatment of oncological dysphagia, a correct initial evaluation and an active treatment are required, since not only the patient's quality of life but, on numerous occasions, the possibility of continuing the treatment and thus maintaining the possibilities of a cure depend on control of the dysphagia.     

Granular cell tumor of the esophagus

Granular cell tumor is a relatively rare, mostly benign lesion, that can be found in almost every organ, however, only 2% of the cases is oesophageal. It is named after the eosinophilic S-100 protein positive granula in the cytoplasm of the tumor cells. Since patients with oesophageal granular cell tumor are mostly symptomless, the tumor is usually found accidentally. Even in patients with dysphagia, contrast radiograph and gastroscopy show an atypical picture, therefore, the diagnosis is based on the histological examination. Therapy is usually conservative, but surgical treatment might be necessary sometimes. A patient with severe dysphagia is reported here. She was diagnosed with a granular cell tumor in the oesophagus, and the tumor was surgically removed.     

Belching (ructus)

Accumulation of air in the stomach increases the gastric volume, which activates receptors in the gastric wall. This results in a reflex that relaxes the lower oesophageal sphincter, whereby the intragastric air can escape through the oesophagus. Ventilation of the stomach via the oesophagus is known as belching (ructus). Belching often occurs in combination with reflux symptoms and dyspepsia. In these cases, other symptoms are often more predominant, and it is advisable to treat these first. In patients with aerophagia, belching is the most common reason for medical consultation. These patients belch frequently, up to 20 times per minute, and often during consultation. Aerophagia results from air being sucked into the oesophagus or injected by pharyngeal contraction, after which it is expelled immediately. In contrast to the described gastric belching, aerophagia is therefore a form of supragastric belching. Aerophagia is a behavioural disorder, and behavioural therapy or logopedics appears to be most common therapeutic approach.     

Gastrojejunostomy versus endoscopic stent placement as palliative treatment for a malignant constriction of the duodenum: the SUSTENT-study

Gastric-outlet obstruction often results from inoperable distal stomach, periampullary (pancreatic or cholangio-), or duodenal carcinoma. Gastrojejunostomy and stent placement are standard palliative treatments. An advantage of gastrojejunostomy is the long-term efficacy; a disadvantage is the prolonged postoperative recovery time. The advantage of stent placement is the rapid ability to consume a soft diet; a disadvantage is that around 20% of the patients require re-intervention because of recurrent symptoms. A randomised multicentre study was started in January 2006 in the Netherlands in which gastrojejunostomy is compared with stent placement in the palliative treatment of malignant gastroduodenal obstruction: 'Surgery versus stent for malignant gastroduodenal obstruction', the SUSTENT-study. The primary-outcome measurement is survival adjusted for the time patients are not able to consume (soft) food. Other outcome measurements are medical effects (complications, re-interventions), quality of life, cost and cost-effectiveness. This study aims to provide individualised recommendations for effective palliative treatment of patients with malignant gastroduodenal obstruction.     

The nutritional effects of endoscopic intubation for carcinoma of the oesophagus or cardia

The nutritional status in 17 patients with unresectable carcinoma of the oesophagus or cardia was assessed before and one month after endoscopic intubation by measurement of body weight, triceps skinfold thickness, midarm circumference and serum albumin concentration. There was a significant increase in dietary energy intake and weight loss was arrested in 10 patients. A weight gain of 3 kg or more was recorded in six cases of which two put on 8.4 and 9.4 kg respectively with concommitant increases in midarm circumference. It is concluded that endoscopic intubation of carcinoma of the oesophagus or cardia commonly benefits nutritional status by relieving dysphagia.     

The Role of Nutritional Support for Cancer Patients in Palliative Care

The role of nutritional support for cancer patients in palliative care is still a controversial topic, in part because there is no consensus on the definition of a palliative care patient because of ambiguity in the common medical use of the adjective palliative. Nonetheless, guidelines recommend assessing nutritional deficiencies in all such patients because, regardless of whether they are still on anticancer treatments or not, malnutrition leads to low performance status, impaired quality of life (QoL), unplanned hospitalizations, and reduced survival. Because nutritional interventions tailored to individual needs may be beneficial, guidelines recommend that if oral food intake remains inadequate despite counseling and oral nutritional supplements, home enteral nutrition or, if this is not sufficient or feasible, home parenteral nutrition (supplemental or total) should be considered in suitable patients. The purpose of this narrative review is to identify in these cancer patients the area of overlapping between the two therapeutic approaches consisting of nutritional support and palliative care in light of the variables that determine its identification (guidelines, evidence, ethics, and law). However, nutritional support for cancer patients in palliative care may be more likely to contribute to improving their QoL when part of a comprehensive early palliative care approach.     

Nutritional intervention and quality of life in adult oncology patients

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.     

Phase Angle of Bioelectrical Impedance Analysis as Prognostic Factor in Palliative Care Patients at the National Cancer Institute in Mexico

Patients with advanced cancer often experience symptoms of disease and treatment that contribute to distress such as weight loss, which is present in up to 85% of cancer patients. Palliative care in these patients focuses on care aimed at improving quality of life. Phase angle (PA) is obtained by bioelectric impedance analysis (BIA) and is associated with cellular function. It is considered a reliable marker of malnutrition. A low PA may suggest deterioration of the cell membrane, which in palliative patients may result in a short-term survival. The aim of this study was to associate PA and survival in palliative patients of the National Cancer Institute of Mexico. We included 452 patients (women, 56.4%); the average PA was 4.0°. The most frequent disease was gastric cancer (39.2%). Mean body mass index (BMI) was 22.84. The average survival of patients with PA ≤ 4° was 86 days, while in the group with PA > 4°, it was 163 days (P > 0.0001). PA showed significant positive correlation with survival time and BMI. Our results corroborate the reliability of PA in Mexican population, as an indicator of survival in palliative care patients compared to the reported literature in other countries.     

Palliation in patients with metastatic breast cancer often better with antitumour treatment than with only symptomatic treatment

Two women, aged 57 and 55 years, with metastatic breast cancer were admitted for uncontrolled pain due to bone metastases. Despite the fact that progressive disease was evident, a change in antitumour therapy had not been recommended. The pain control was optimised in both patients. In one patient, palliative chemotherapy was installed, combined with trastuzumab because of HER2/neu overexpression. She was still alive after one and a half year of treatment. The other patient could not adjust mentally to the fact that her palliative therapy was changed to antitumour therapy; she died one month later. It is important to be aware of the various kinds of therapy in metastatic breast cancer because palliative treatment is more than just symptomatic treatment. Systemic antitumour therapy includes hormone therapy, chemotherapy and targeted therapy. Furthermore, in patients with bone metastases, radiotherapy combined with bisphosphonates results in pain relief and can reduce skeletal complications. Because of the ensuing complexity of the treatment of metastatic breast cancer, these patients should be regularly managed by a breast-cancer care team in order to improve the quality of care.     

Analysis of the surgical treatment of pancreas head and peri-ampullary carcinoma in 236 patients

Between 1978 and 1987, 236 patients were admitted for cancer in the pancreas or periampullary region. In 93 patients a resection of curative intent was performed, while 88 patients underwent a palliative procedure and 55 patients no operation. The operative mortality was 9%. In the complete group of patients, age above 70 years and preoperative jaundice were of prognostic significance. A tumour size greater than 3.5 cm after resection implies a better prognosis than tumours less than 3.5 cm. The 1-, 3- and 5-year survival rates of the resected patients with pancreatic head cancer were 59%, 12% and 8% respectively, those of patients with periampullary cancer 90%, 49% and 30% respectively. After a palliative procedure or only a laparotomy survival was significantly lower (p less than 0.001), with 1-year survival of 16% and 2-year survival of 4%. After resection of curative intent for cancer of the head of the pancreas 21 cases still had microscopical remnants of tumour (T3, N1b). Survival of these patients was not significantly different from that of patients with a curative resection. Surgical resection for cancer of the head of the pancreas has to be considered as a mainly palliative treatment, but given low operative mortality (less than 10%) it is still the treatment of choice to gain longer survival and in some cases definitive cure.     

Reinstituting oral feeding in tube-fed adult patients with dysphagia.

Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding. With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients.     

Importance of oesophageal manometry in the diagnosis of oesophageal motility disorders. Report of two cases.

Two cases of dysphagia, in which radiology led to an incorrect diagnosis, are described. In case I the X-ray barium swallow showed only minor oesophageal dilatation with no apparent delay in emptying or abnormality of the cardias, yet achalasia was diagnosed by oesophageal manometry. In case 2, although the barium swallow strongly suggested achalasia, manometry showed a less severe motility disorder characterized by lower oesophageal sphincter dysfunction and normal peristalsis. Correct diagnosis obtained with manometry was supported by the different clinical course of the two patients during a 2 year follow up. Oesophageal manometry should always be performed when radiology and/or the patient's history suggest the presence of a motility disorder of the oesophagus since a correct diagnosis is essential for appropriate treatment and follow-up.