惡性腫瘤患者的營(yíng)養(yǎng)治療專家共識(shí)

惡性腫瘤患者的營(yíng)養(yǎng)治療專家共識(shí)CSCO養(yǎng)治療專家共識(shí)1 險(xiǎn)篩查及評(píng)定 4 8 12 16 20附表1：NCCN證據(jù)和共識(shí)的分類和牛津推薦意見分級(jí)(OCEBM)對(duì)照 23 附表3：病人提供-主觀全面評(píng)定(PG-SGA)評(píng)定量表 24CSCO委員會(huì)名單 26養(yǎng)治療專家共識(shí)21前言惡性腫瘤治療技術(shù)和治療方法的不斷進(jìn)步，延長(zhǎng)了惡性腫瘤患者的生存時(shí)間，使得惡性腫瘤逐步成為一種可控可治的慢性疾病，因此，重視患者的生存質(zhì)量應(yīng)該成為現(xiàn)代腫瘤學(xué)的重要領(lǐng)域。適合腫瘤患者的營(yíng)養(yǎng)風(fēng)險(xiǎn)和營(yíng)養(yǎng)狀況的評(píng)常代惡性腫瘤患者的營(yíng)養(yǎng)治療已成為惡性腫瘤多學(xué)科綜合治療的重要組成部分。為了規(guī)范對(duì)腫瘤患O學(xué)會(huì)(原為腸外腸內(nèi)營(yíng)養(yǎng)學(xué)會(huì)，ESPEN)、美國(guó)腸外腸內(nèi)營(yíng)養(yǎng)學(xué)會(huì)(ASPEN)最新腫瘤營(yíng)養(yǎng)治療指南，從而1)營(yíng)養(yǎng)治療(nutritionaltherapy)：一般認(rèn)為包括經(jīng)口、腸內(nèi)或腸外途徑為患者提供較全面營(yíng)養(yǎng)素，蛋白)型和小分子聚合物(氨基酸、短肽)型。3)腸外營(yíng)養(yǎng)(parenteralnutrition，PN)：是經(jīng)靜脈為無(wú)法經(jīng)胃腸攝取和利用營(yíng)養(yǎng)素的患者提供包括4)營(yíng)養(yǎng)不良(malnutrition)：因能量、蛋白質(zhì)及其他營(yíng)養(yǎng)素缺乏或過(guò)度，對(duì)機(jī)體功能乃至臨床結(jié)局造5)營(yíng)養(yǎng)不足(nutritionalinsufficiency)：通常指蛋白質(zhì)-能量缺乏型營(yíng)養(yǎng)不良(protein-energymalnutritionPEM。6)營(yíng)養(yǎng)風(fēng)險(xiǎn)(nutritionalrisk)：指現(xiàn)存的或潛在的營(yíng)養(yǎng)和代謝狀況對(duì)疾病或手術(shù)相關(guān)的臨床結(jié)局(感染有關(guān)的并發(fā)癥、住院日等)發(fā)生負(fù)面影響的可能。7)營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查(nutritionalriskscreening)：是臨床醫(yī)護(hù)人員用來(lái)判斷腫瘤病人是否需要進(jìn)一步8)營(yíng)養(yǎng)評(píng)定(nutritionalassessment)：由營(yíng)養(yǎng)專業(yè)人員對(duì)患者的營(yíng)養(yǎng)代謝、機(jī)體功能等進(jìn)行全面檢9)惡液質(zhì)(cachexia)：是一種在癌癥患者中存在的表現(xiàn)復(fù)雜的綜合征，其特點(diǎn)為慢性、進(jìn)行性、不知養(yǎng)治療專家共識(shí)3[1]AugustDA,HuhmannMB.A.S.P.E.N.clinicalguidelines:nutritionsupporttherapyduringadultanticancertreatmentandinhematopoieticcelltransplantation[J].JPENJParenterEnteralNutr,2009,33(5):472-500.[2]BozzettiF,ArendsJ,LundholmK,etal.ESPENGuidelinesonParenteralNutrition:non-surgicaloncology[J].ClinNutr,2009,28(4):445-454.[3]BragaM,LjungqvistO,SoetersP,etal.ESPENGuidelinesonParenteralNutrition:surgery[J].ClinNutr,2009,28(4):378-386.[4]WeimannA,BragaM,HarsanyiL,etal.ESPENGuidelinesonEnteralNutrition:Surgeryincludingorgantransplantation[J].ClinNutr,2006,25(2):224-244.[5]ArendsJ,BodokyG,BozzettiF,etal.ESPENGuidelinesonEnteralNutrition:Non-surgicaloncology[J].ClinNutr,2006,25(2):245-259.[6]FearonK,StrasserF,AnkerSD,etal.Definitionandclassificationofcancercachexia:aninternationalconsensus[J].LancetOncol,2011,12(5):489-495.養(yǎng)治療專家共識(shí)42腫瘤患者的營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查及評(píng)定(超重)，營(yíng)養(yǎng)不足主要以患者體重指數(shù)(BMI)＜18.5kg/m2，并結(jié)合臨床情況作為判定標(biāo)準(zhǔn)；第二，營(yíng)養(yǎng)發(fā)癥、費(fèi)用和住院天數(shù)等)發(fā)生不利影響的風(fēng)險(xiǎn)，并非發(fā)生營(yíng)養(yǎng)不良(不足)的風(fēng)險(xiǎn)。營(yíng)養(yǎng)風(fēng)險(xiǎn)的概念有兩方面內(nèi)涵:(1)有營(yíng)養(yǎng)風(fēng)險(xiǎn)的患會(huì)。續(xù)的過(guò)程，不能混為一談。前者的主要目的是發(fā)現(xiàn)已發(fā)生營(yíng)養(yǎng)不良(營(yíng)養(yǎng)不足)或存在營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者，養(yǎng)不良(營(yíng)養(yǎng)不足)引起的并發(fā)癥，估計(jì)營(yíng)養(yǎng)需要量，制定營(yíng)養(yǎng)治療計(jì)劃，評(píng)估營(yíng)養(yǎng)治療療效等。.營(yíng)養(yǎng)風(fēng)險(xiǎn)的篩查GlobeAssessment，SGA)、病人自評(píng)主觀全面評(píng)定量表(Patient-GeneratedSubjectiveGlobalAssessmentPGSGAMiniNutritionalAssessmentMNA篩查工ening于接受過(guò)專門訓(xùn)練的專業(yè)人員使用，而不是作為大醫(yī)院常規(guī)營(yíng)養(yǎng)篩查工具。PG-SGA則是根據(jù)SGA修改選的首選方法。會(huì)多學(xué)科營(yíng)養(yǎng)不良咨詢小組于2000年發(fā)布，主要用于蛋白質(zhì)-能量營(yíng)養(yǎng)不良及其發(fā)養(yǎng)風(fēng)險(xiǎn)篩查。主要包括3方面內(nèi)容：①營(yíng)養(yǎng)狀況受損評(píng)分(0~3分)；②疾病的嚴(yán)重程度評(píng)分(0~3分)；養(yǎng)治療專家共識(shí)5NRS查并判斷是否需要營(yíng)養(yǎng)治療是可行的[9]。究開展時(shí)間多為上世紀(jì)70~90年代，其對(duì)惡性腫瘤患者的治療與當(dāng)今規(guī)范化的多學(xué)科的綜合治療理念存NRS02中關(guān)于疾病嚴(yán)重程度的評(píng)價(jià)將手術(shù)臨床制定營(yíng)養(yǎng)治療計(jì)劃，然而，存在營(yíng)養(yǎng)風(fēng)險(xiǎn)患者中僅有46%接受了營(yíng)養(yǎng)治療。營(yíng)養(yǎng)不良(不足)和營(yíng)養(yǎng)進(jìn)一步綜合營(yíng)養(yǎng)評(píng)定養(yǎng)治療專家共識(shí)6生活方式、醫(yī)療保障、宗黏膜等，有助于評(píng)價(jià)能量和蛋白質(zhì)缺乏的嚴(yán)重程度。并非只有消瘦才是營(yíng)養(yǎng)不良(營(yíng)養(yǎng)不足)，很多患者同(4)機(jī)體測(cè)量：動(dòng)態(tài)監(jiān)測(cè)體重是最方便、最直接的臨床指標(biāo)，但易受干擾，如液體潴留、患者昏迷、圍(AC)、肱三頭肌皮褶厚度(TSF)、上臂肌圍(AMC)等，反應(yīng)脂肪、骨骼肌儲(chǔ)備等。(5)機(jī)體功能及機(jī)體組成的測(cè)定：機(jī)體功能及組成變化可為營(yíng)養(yǎng)狀況評(píng)價(jià)提供參考。的改善和抗腫瘤治療耐受性的提高上。養(yǎng)狀態(tài)、免疫功能、總生.推薦意見NRS于個(gè)體化的營(yíng)養(yǎng)計(jì)劃，給予營(yíng)養(yǎng)以養(yǎng)治療專家共識(shí)7[1]DetskyAS,McLaughlinJR,BakerJP,etal.Whatissubjectiveglobalassessmentofnutritionalstatus?[J]J[2]GuigozY.TheMiniNutritionalAssessment(MNA)reviewoftheliterature--Whatdoesittellus?[J]JNutrHealthAging,2006,10(6):466-485.[3]StrattonRJ,KingCL,StroudMA,etal.MalnutritionUniversalScreeningToolpredictsmortalityandlengthofhospitalstayinacutelyillelderly[J].BrJNutr,2006,95(15):325-330.KondrupJRasmussenHHHambergOetalNutritionalriskscreening(NRS2002):anewmethodbasedonananalysisofcontrolledclinicaltrials[J].ClinNutr,2003,22(3):321–336.PENGuidelinesfornutritionscreeningJClinNutr22(5):415-417.19.[7]LiangX,JiangZM,NolanMT,etal.ComparativesurveyonnutritionalriskandnutritionalsupportbetweenBeijingandBaltimoreteachinghospitals[J].Nutrition,2008,24(10):969-976.,2008,16(4):349-351.[9]陳偉,蔣朱明,張?jiān)伱?等.歐洲營(yíng)養(yǎng)風(fēng)險(xiǎn)調(diào)查方法在中國(guó)住院患者的臨床可行性研究[J].中國(guó)臨床[10]JiangZM,ChenW,ZhanWH,etal.Parenteralandenteralnutritionapplicationinwest,middleandeastChina:amulticenterinvestigationfor15098patientsin13metropolitansusingnutritionalriskscreeningnNutrSuppl養(yǎng)治療專家共識(shí)83非終末期手術(shù)腫瘤患者的營(yíng)養(yǎng)治療術(shù)死；而不適當(dāng)?shù)臓I(yíng)養(yǎng)治療同樣會(huì)給患術(shù)腫瘤患者營(yíng)養(yǎng)治療的目標(biāo)和效果對(duì)于中、重度營(yíng)養(yǎng)不良(不足)的大手術(shù)患者，術(shù)前10~14天的營(yíng)養(yǎng)治療能降低手術(shù)并發(fā)癥的發(fā)生態(tài)正常的患者無(wú)這種作用[2]。有證據(jù)表明術(shù)前2~3小時(shí)進(jìn)食流食并不增加反流與誤吸的風(fēng)險(xiǎn)，因此，許多國(guó)家的麻醉學(xué)會(huì)已將擇期手保護(hù)心肌[6]。結(jié)直腸手術(shù)患者術(shù)后早期進(jìn)食或腸內(nèi)營(yíng)養(yǎng)有益。有證據(jù)表明術(shù)后早期進(jìn)食或腸內(nèi)營(yíng)養(yǎng)(包括術(shù)后1~2患者的術(shù)后早期進(jìn)食或腸內(nèi)營(yíng)養(yǎng)的開始時(shí)間直接停用與逐步停用腸外營(yíng)養(yǎng)對(duì)患者的血糖水平的影響沒有差異[8]。目前沒有證據(jù)可以證實(shí)腫瘤細(xì)胞飲食獲取足夠營(yíng)充對(duì)患者的營(yíng)養(yǎng)改善，并發(fā)癥減少有益[10]。手術(shù)腫瘤患者營(yíng)養(yǎng)治療的指證，養(yǎng)治療專家共識(shí)9院時(shí)間都較接受腸內(nèi)的熱量需要)時(shí)，多數(shù)專家認(rèn)為可以考慮聯(lián)合應(yīng)用腸外營(yíng)養(yǎng)。方式和特殊成份、飼喂養(yǎng)，在術(shù)后24小時(shí)內(nèi)可進(jìn)行管飼喂養(yǎng)管飼營(yíng)養(yǎng)的患者(如嚴(yán)重頭頸部外傷患者)，如無(wú)需腹部手術(shù)，可考慮經(jīng)皮內(nèi)鏡下胃造瘺置管。由于腸道耐受力有限，應(yīng)以較低的滴速(如l0~20ml/h)開始管飼營(yíng)養(yǎng)，可能需5~7天才能達(dá)到足量營(yíng)養(yǎng)攝入。腫瘤患者能量與蛋白質(zhì)需求與健康者相差不大，故可以20-25kcal/kg/天來(lái)估算臥床患者，25-30養(yǎng)治療[16]。標(biāo)準(zhǔn)的大分子聚合物(整蛋白)配方適合大部分患者的腸內(nèi)營(yíng)養(yǎng)治療。薈萃分析表明因腫瘤接受頸部大手術(shù)(喉切除術(shù)、咽部分切除術(shù))患者、腹部腫瘤大手術(shù)(食管切除術(shù)、胃切除術(shù)和胰十二指-3脂肪酸和核苷酸)的腸內(nèi)營(yíng)養(yǎng)可減少術(shù)能反元素維生素和微量元素[19]。能有益[20]。見(1類)腸切除)3)有重度營(yíng)養(yǎng)不足風(fēng)險(xiǎn)的患者，大手術(shù)前應(yīng)給予10~14天的營(yíng)養(yǎng)治療。圍手術(shù)期有重度營(yíng)養(yǎng)不足的患養(yǎng)治療專家共識(shí)5)對(duì)接受大型的頸部手術(shù)和腹部手術(shù)的患者可考慮圍手術(shù)期應(yīng)用含有免疫調(diào)節(jié)成分(精氨酸、ω-3脂肪[1]HeylandDK,MontalvoM,MacDonaldS,etal.Totalparenteralnutritioninthesurgicalpatient:a[2]BragaM,GianottiL,GentiliniO,etal.Feedingthegutearlyafterdigestivesurgery:resultsofanine-yearexperienceJ].ClinNutr,2002,21(1):59-65.reoperativefastinganupdateJAnaesthesist[4]SoopM,NygrenJ,ThorellA,etal.Preoperativeoralcarbohydratetreatmentattenuatesendogenousglucoserelease3daysaftersurgery[J].ClinNutr,2004,23(4):733-741.[5]HenriksenMG,HessovI,DelaF,etal.Effectsofpreoperativeoralcarbohydratesandpeptidesonpostoperativeendocrineresponse,mobilization,nutritionandmusclefunctioninabdominalsurgery[J].Actaand[6]BreuerJP,vonDossowV,vonHeymannC,etal.PreoperativeoralcarbohydrateadministrationtoASAnesthAnalg[7]FeoCV,RomaniniB,SortiniD,etal.Earlyoralfeedingaftercolorectalresection:arandomizedcontrolledstudyJANZJSurg4,74(5):298-301.NirulaR,YamadaK,WaxmanK.Theeffectofabruptcessationoftotalparenteralnutritiononserumglucose:arandomizedtrialJAmSurg2000,66(9):866-869.[9]ChinTY,HuWY,ChuangRB,eta1.Terminalcancerpatients’wishesandinfluencingfactorstowardtheprovisionofartificialnutritionandhydrationinTaiwanJJPainSymptomManage2004,27(3):206-214.[10]UlanderK,JeppssonB,GrahnG.Postoperativeenergyintakeinpatientsaftercolorectalcancersurgery[J].[11]CorreiaMI,CaiaffaWT,daSilvaAL,etal.Riskfactorsformalnutritioninpatientsundergoinggastroenterologicalandherniasurgery:ananalysisof374patients[J].NutrHosp,2001,16(2):59-64.[12]TheVeteransAffairsTotalParenteralNutritionCooperativeStudyGroup.Perioperativetotalparenteralnutritioninsurgicalpatients[J].NEnglJMed,1991,325(8):525-532.[13]WeimannA,BragaM,HarsanyiL,etal.ESPENguidelinesonenteralnutrition:surgeryincludingorgantransplantation[J].ClinNutr,2006,25(2):224-244.[14]TakagiK,YamamoriH,MorishimaY,etal.Preoperativeimmunosuppression:itsrelationshipwithhighbidityandmortalityinpatientsreceivingthoracicesophagectomyJNutrition[15]BragaM,LjungqvistO,SoetersP,etal.ESPENguidelinesonparenteralnutrition:surgery[J].ClinNutr,2009,28(4):378-386.DrumlWNutritionalmanagementofacuterenalfailureJAmJKidneyDis,2001,37(Suppl.2):89-94.[17]BragaM,GianottiL,VignaliA,etal.Preoperativeoralarginineandn-3fattyacidsupplementationimprovestheimmunometabolichostresponseandoutcomeaftercolorectalresectionforcancer[J].Surgery,2002,養(yǎng)治療專家共識(shí)5-814.[18]江華,蔣朱明,羅斌,等.免疫腸內(nèi)營(yíng)養(yǎng)用于臨床營(yíng)養(yǎng)支持的證據(jù)：中英文文獻(xiàn)的系統(tǒng)評(píng)價(jià)[J].中國(guó)醫(yī)學(xué)科學(xué)院學(xué)報(bào),2002,24(6):552-558.[19]BergerMM,ShenkinA.Vitaminsandtraceelements:practicalaspectsofsupplementation[J].Nutrition,2006,22(9):952-955.[20]LundholmK,KornerU,GunneboL,eta1.Insulintreatmentincancercachexia:effectsonsurvival,metabolism,andphysicalfunctioning[J].ClinCancerRes,2007,13(9):2699-2706.養(yǎng)治療專家共識(shí)4非終末期化療腫瘤患者的營(yíng)養(yǎng)治療非終末期化療腫瘤患者營(yíng)養(yǎng)治療的目標(biāo)和效果性與依從性；3)控制化療的副反應(yīng)；4)改善生活質(zhì)量?；颊唢@提升血清轉(zhuǎn)鐵蛋白及白蛋白水平[9]。都RCT不同帶來(lái)的影。養(yǎng)治療專家共識(shí)魚油多不飽和脂肪酸(EPA)在動(dòng)物腫瘤模型中有積極作用[20]，體外研究亦證實(shí)EPA對(duì)腫瘤細(xì)胞有抑道腫EPA加鼠的的同等效應(yīng)還有待時(shí)日。III。AA[1]AndreyevHJ,NormanAR,OatesJ,etal.Whydopatientswithweightlosshaveaworseoutcomewhen養(yǎng)治療專家共識(shí)undergoingchemotherapyforgastrointestinalmalignancies?[J].EurJCancer,1998,34(4):503-509.[2]AslaniA,SmithRC,AllenBJ,etal.Thepredictivevalueofbodyproteinforchemotherapy-inducedtoxicity[J].Cancer,2000,88(4):796-803.[3]BauerJD,CapraS.Nutritioninterventionimprovesoutcomesinpatientswithcancercachexiareceivingchemotherapy--apilotstudy[J].SupportCareCancer,2005,13(4):270-274.[4]ShangE,WeissC,PostS,etal.Theinfluenceofearlysupplementationofparenteralnutritiononqualityoflifeandbodycompositioninpatientswithadvancedcancer[J].JPENJParenterEnteralNutr,2006,30(3):222-230.[5]GramignanoG,LussoMR,MadedduC,etal.Efficacyofl-carnitineadministrationonfatigue,nutritionalstatus,oxidativestress,andrelatedqualityoflifein12advancedcancerpatientsundergoinganticancerition[6]HasenbergT,EssenbreisM,HeroldA,etal.Earlysupplementationofparenteralnutritioniscapableofimprovingqualityoflife,chemotherapy-relatedtoxicityandbodycompositioninpatientswithadvancedcolorectalcarcinomaundergoingpalliativetreatmentResultsfromaprospective,randomizedclinicaltrial[J].e[7]McCarthyD,WeihofenD.Theeffectofnutritionalsupplementsonfoodintakeinpatientsundergoingradiotherapy[J].OncolNursForum,1999,26(5):897-900.[8]ArnoldC,RichterMP.Theeffectoforalnutritionalsupplementsonheadandneckcancer[J].IntJRadiat[9]ElkortRJ,BakerFL,VitaleJJ,etal.Long-termnutritionalsupportasanadjuncttochemotherapyforbreastcancer[J].JPENJParenterEnteralNutr,1981,5(5):385-390.[10]DeCM,PanarelloG,FantinD,etal.Parenteralnutritionincancerpatientsreceivingchemotherapy:effectsontoxicityandnutritionalstatus[J].JPENJParenterEnteralNutr,1993,17(6):513-518.[11]BozzettiF,ArendsJ,LundholmK,etal.ESPENGuidelinesonParenteralNutrition:non-surgicaloncology[J].ClinNutr,2009,28(4):445-454.[12]ValdiviesoM,FrankmannC,MurphyWK,etal.Long-termeffectsofintravenoushyperalimentationadministeredduringintensivechemotherapyforsmallcellbronchogeniccarcinoma[J].Cancer,1987,59(2):362-369.[13]BrardL,WeitzenS,Strubel-LaganSL,etal.TheeffectoftotalparenteralnutritiononthesurvivalofallyillovariancancerpatientsJGynecolOncol[14]JonesL,WatlingRM,WilkinsS,etal.Nutritionalsupportinchildrenandyoungpeoplewithcancerundergoingchemotherapy[J].CochraneDatabaseSystRev,2010,(7):CD003298.[15]MartenA,WenteMN,OseJ,etal.AnopenlabelrandomizedmulticentrephaseIIIbtrialcomparingparenteralsubstitutionversusbestsupportivenutritionalcareinsubjectswithpancreaticadenocarcinomareceiving5-FUplusoxaliplatinas2ndorhigherlinechemotherapyregardingclinicalbenefit-PANUSCO[J].BMCCancer,2009,9:412.[16]AugustDA,HuhmannMB.A.S.P.E.N.clinicalguidelines:nutritionsupporttherapyduringadultanticancertreatmentandinhematopoieticcelltransplantation[J].JPENJParenterEnteralNutr,2009,33(5):472-500.養(yǎng)治療專家共識(shí)[17]ScolapioJS,FlemingCR,KellyDG,etal.Survivalofhomeparenteralnutrition-treatedpatients:20yearsofexperienceattheMayoClinic[J].MayoClinProc,1999,74(3):217-222.[18]deVriesEG,MulderNH,HouwenB,etal.EnteralnutritionbynasogastrictubeinadultpatientstreatedwithteleukemiaJAmJClinNutr[19]KoretzRL,LipmanTO,KleinS.AGAtechnicalreviewonparenteralnutrition[J].Gastroenterology,2001,[20]FiniL,PiazziG,CeccarelliC,etal.HighlypurifiedeicosapentaenoicacidasfreefattyacidsstronglysuppressespolypsinApcMinmiceJClinCancerRes010,16(23):5703-5711.[21]SchleyPD,JijonHB,RobinsonLE,etal.Mechanismsofomega-3fattyacid-inducedgrowthinhibitioninreastcancercellsJBreastCancerResTreat[22]DeweyA,BaughanC,DeanT,etal.Eicosapentaenoicacid(EPA,anomega-3fattyacidfromfishoils)forthetreatmentofcancercachexia.CochraneDatabaseSystRev,2007,(1):CD004597.[23]JatoiA,RowlandK,LoprinziCL,etal.Aneicosapentaenoicacidsupplementversusmegestrolacetateversusbothforpatientswithcancer-associatedwasting:aNorthCentralCancerTreatmentGroupandNationalCancerInstituteofCanadacollaborativeeffort[J].JClinOncol,2004,22(12):2469-2476.[24]SzymanskiKM,WheelerDC,MucciLA.Fishconsumptionandprostatecancerrisk:areviewand[25]GogosCA,GinopoulosP,SalsaB,etal.Dietaryomega-3polyunsaturatedfattyacidsplusvitaminErestoreimmunodeficiencyandprolongsurvivalforseverelyillpatientswithgeneralizedmalignancy:arandomizedcontroltrial[J].Cancer,1998,82(2):395-402.[26]XueH,LeRS,SawyerMB,etal.Singleandcombinedsupplementationofglutamineandn-3polyunsaturatedfattyacidsonhosttoleranceandtumourresponsetocilchemotherapyinratsbearingWardcolontumourJBrJNutr009,102(3):434-442.[27]NgK,MeyerhardtJA,ChanJA,etal.MultivitaminuseisnotassociatedwithcancerrecurrenceorsurvivalinpatientswithstageIIIcoloncancer:findingsfromCALGB89803[J].JClinOncol,2010,28(28):4354-4363.養(yǎng)治療專家共識(shí)5非終末期放療腫瘤患者的營(yíng)養(yǎng)治療在整個(gè)病程中會(huì)接受放療。腫瘤患為非食欲下降、惡心、嘔吐、腹瀉等反應(yīng)從而導(dǎo)致攝入不足或吸收障礙。放療患者這些副反應(yīng)約在放療的第3~4周出現(xiàn)，并可降低的放療患者，飲食指導(dǎo)和經(jīng)口營(yíng)養(yǎng)補(bǔ)充(oralnutritionalsupplements，ONS)可預(yù)防體重下降和放療非終末期腫瘤放療患者的營(yíng)養(yǎng)治療目標(biāo)是：①評(píng)估、預(yù)防和治療營(yíng)養(yǎng)不良/惡病質(zhì)；②提高患者抗腫依從性；③控制某些抗腫瘤治療的不良反應(yīng)；④提高生活質(zhì)量[2,3]。腫瘤患者營(yíng)養(yǎng)治療的目標(biāo)和效果頭頸部腫瘤和食管癌患者在放化療期間伴隨的黏膜炎可導(dǎo)致體重下降已被廣泛接受[4-7]，而這種丟失及時(shí)給予營(yíng)養(yǎng)干預(yù)可以有效減少體重丟失、防止?fàn)I養(yǎng)狀態(tài)惡化、提高生活質(zhì)量[9]。Bozzetti[10]等的研究表營(yíng)養(yǎng)腫瘤患者營(yíng)養(yǎng)治療的指證有養(yǎng)治療專家共識(shí)后口腔黏膜反應(yīng)養(yǎng)加用腸外營(yíng)養(yǎng)較單純腸內(nèi)營(yíng)養(yǎng)在提高患者食欲及生活質(zhì)量評(píng)分方面有優(yōu)勢(shì)[25]。方式性頭頸部腫瘤和食管癌導(dǎo)致吞咽困1)對(duì)放療患者的營(yíng)養(yǎng)評(píng)估應(yīng)在腫瘤診斷或入院時(shí)就進(jìn)行(特別是放療前和放療過(guò)程中)，并在后續(xù)的每2)放療患者的每日消耗和正常人相似，放療患者的一般狀況要求為KPS60以上，故以25~30kcal/kg/的：預(yù)防和治療營(yíng)養(yǎng)不良/惡吞咽功能者，腸內(nèi)營(yíng)養(yǎng)應(yīng)經(jīng)管給予(2B類)。腸外營(yíng)養(yǎng)推薦用于：不能耐受腸內(nèi)營(yíng)養(yǎng)、且需要營(yíng)養(yǎng)治PolisenaCGWadeVRCancerpatientsneedreferralstodietitiansJJAmDietAssoc976.[2]ArendsJ,BodokyG.,BozzettiF,etal.ESPENGuidelinesonEnteralNutrition:Non-surgicaloncology[J].ClinNutr,2006,25(2):245-259.[3]BozzettiF,ArendsJ,LundholmK,etal.ESPENGuidelinesonParenteralNutrition:non-surgicaloncology[J].ClinNutr,2009,28(4):445-454.[4]DalyJM,WeintraubFN,ShouJ,etal.EnteralnutritionduringmultimodalitytherapyinuppergastrointestinalcancerpatientsJAnnSurg,1995,221(4):327-338.[5]FietkauR,IroH,SailerD,etal.Percutaneousendoscopicallyguidedgastrostomyinpatientswithheadandneckcancer[J].RecResCancerRes,1991,121:269-282.[6]ThielHJ,FietkauR,SauerR.Malnutritionandtheroleofnutritionalsupportforradiationtherapypatients[J].RecResCancerRes,1988,108:205-226.[7]LangiusJA,DoornaertP,SpreeuwenbergMD,etal.Radiotherapyonthenecknodespredictssevereweightlossinpatientswithearlystagelaryngealcancer[J].RadiotherOncol,2010,97(1):80-85.[8]CollinsMM,WightRG,PartridgeG..Nutritionalconse-quencesofradiotherapyinearlylaryngeal養(yǎng)治療專家共識(shí)carcinomaJAnnRoyalCollSurg1999,81(6):376-381.[9]IsenringEA,CapraS,BauerJD.Nutritioninterventionisbeneficialinoncologyoutpatientsreceivingradiotherapytothegastrointestinalorheadandneckarea[J].BrJCancer,2004,91(3):447-452.[10]vandenBergMG,Rasmussen-ConradEL,WeiKH,etal.Comparisonoftheeffectofindividualdietarycounsellingandofstandardnutritionalcareonweightlossinpatientswithheadandneckcancerundergoingradiotherapy[J].BrJNutr,2010,104(6):872-877.[11]RavascoP,Monteiro-GrilloI,VidalPM,etal.Dietarycounselingimprovespatientoutcomes:aprospective,randomized,controlledtrialincolorectalcancerpatientsundergoingradiotherapy[J].JClinOncol,2005,[12]LeeJH,MachtayM,UngerLD,etal.Prophylacticgastrostomytubesinpatientsundergoingintensiveirradiationforcanceroftheheadandneck[J].ArchOtolaryngolHeadNeckSurg,1998,124(8):871-875.[13]MarcyPY,MagneN,BensadounRJ,etal.Systematicpercutaneous?uoroscopicgastrostomyforconcomitantradiochemotherapyofadvancedheadandneckcancer:optimizationoftherapy[J].SuppCareCancer,2000,8(5):410-413.[14]TyldesleyS,SheehanF,MunkP,etal.TheuseofradiologicallyplacedgastrostomytubesinheadandneckpatientsreceivingradiotherapyJIntJRadiatOncolBiolPhys[15]BeerKT,KrauseKB,ZuercherT,etal.Earlypercutaneousendoscopicgastrostomyinsertionmaintainsnutritionalstateinpatientswithaerodigestivetractcancer[J].NutrCancer,2005,52(1):29-34.[16]MangarS,SlevinN,MaisK,etal.Evaluatingpredictivefactorsfordeterminingenteralnutritioninpatientsreceivingradicalradiotherapyforheadandneckcancer:aretrospectivereview[J].RadiotherOncol,2006,[17]RabinovitchR,GrantB,BerkeyBA,etal.Impactofnutritionsupportontreatmentoutcomeinpatientswithlocallyadvancedheadandnecksquamouscellcancertreatedwithdefinitiveradiotherapy:asecondaryanalysisofRTOGtrial-03[J].HeadNeck,2006,28(4):287-296.[18]ScolapioJS,TarrosaVB,StonerGL,etal.Auditofnutritionsupportforhematopoieticstemcelltransplantationatasingleinstitution[J].MayoClinProc,2002,77(7):654-659.[19]PaccagnellaA,MorelloM,DaMostoMC,etal.Earlynutritionalinterventionimprovestreatmenttoleranceandoutcomesinheadandneckcancerpatientsundergoingconcurrentchemoradiotherapy[J].SupportCareCancer2010,18(7):837-845.[20]KoretzRL,LipmanTO,KleinS.AGAtechnicalreviewonparenteralnutrition[J].Gastroenterology,2001,FreedmanBEquiposeandtheethicsofclinicalresearchJNEnglJMed,1987,317(3):141-145.[22]LoiudiceTA,LangJA.Treatmentofradiationenteritis:acomparisonstudy[J].AmJGastroenterol,1983,78(8):481-487.[23]ScolapioJS,FlemingCR,KellyDG,etal.Survivalofhomeparenteralnutrition-treatedpatients:20yearsofexperienceattheMayoClinic[J].MayoClinProc,1999,74(3):217-222.iFHomeparenteralnutritionCABInternationalPubl[25]ShangE,WeissC,PostS,etal.Theinfluenceofearlysupplementationofparenteralnutritiononqualityoflifeandbodycompositioninpatientswithadvancedcancer[J].JPENJParenterEnteralNutr,2006,30(3):222-230.[26]StrangP.Theeffectofmegestrolacetateonanorexia,weightlossandcachexiaincancerandAIDSpatients[J].AnticancerRes,1997,17(1B):657-662.養(yǎng)治療專家共識(shí)6終末期腫瘤患者的營(yíng)養(yǎng)治療終末期惡性腫瘤患者往往伴隨有嚴(yán)重的惡液質(zhì)。惡液質(zhì)是存在于癌癥患者中的一種表現(xiàn)復(fù)雜的綜合生的腫瘤脂質(zhì)活動(dòng)因子(LMF)和蛋白分解誘導(dǎo)因子(PIF)等。這些因子均會(huì)向機(jī)體傳遞加強(qiáng)分解代謝的KennethFearon，將惡液質(zhì)診斷度蛋白質(zhì)-能量缺乏型營(yíng)養(yǎng)不良、惡液質(zhì)患者中單純的營(yíng)養(yǎng)治療既不能保持機(jī)體無(wú)脂體重，也未提高患者下仍在決策仍缺乏高標(biāo)準(zhǔn)的循證醫(yī)學(xué)依據(jù)。醫(yī)反而會(huì)加重患者的代謝負(fù)擔(dān)，影響其生活質(zhì)量[4]。養(yǎng)治療專家共識(shí)和生存期延長(zhǎng)[5]?；蚰c調(diào)節(jié)劑，目前使用藥物包括魚油不飽和脂肪酸(EPA)、二十二碳六烯酸(DHA)和非甾體類抗炎藥沙立度胺等[7-10]。異常的問題，更容易發(fā)生代謝性并發(fā)癥[11]：血癥。注意血鉀濃度監(jiān)測(cè)和補(bǔ)充鉀離子。制既不能保持機(jī)體無(wú)脂體重，也未提養(yǎng)治療專家共識(shí)的代[1]FearonKC,VossAC,HusteadDS.Definitionofcancercachexia:effectofweightloss,reducedfoodintake,flammationonfunctionalstatusandprognosisJClinNutrLundholmK,DanerydP,BosaeusI,etal.Palliativenutritionalinterventioninadditiontocyclooxygenaseanderythropoietintreatmentforpatientswithmalignantdisease:effectsonsurvival,metabolism,andfunction[J].J營(yíng)養(yǎng)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