Nutrition 31 (2015) 585–586

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Nutrition
journal homepage: www.nutritionjrnl.com

Special article

Evidence-based nutritional support of the elderly cancer patient

Federico Bozzetti M.D. *
Faculty of Medicine, University of Milan, Italy

a r t i c l e i n f o a b s t r a c t

Article history: The papers included in this section represent the effort of the Task Force on Nutrition of the
Received 18 November 2014 International Society of Geriatric Oncology to synthetize the evidence-based concepts on nutri-
Accepted 24 November 2014 tional support of the elderly cancer patients. In the attempt of presenting a comprehensive over-
view of the topic, the panel included experts from different specialties: basic researchers,
Keywords: nutritionists, geriatricians, nurses, dieticians, gastroenterologists, oncologists. Cancer in elderly
Nutritional support of the cancer patient
people is a growing problem. Not only in almost every country, the proportion of people aged over
Nutritional support of the elderly cancer
60 years is growing faster than any other age group, but cancer per se is also a disease of old adult-
patient
Nutritional supplementation of the elderly elderly people, hence the oncologists face an increasing number of these patients both now and in
cancer patient the next years. The are several studies on nutrition of elderly subjects and many other on nutrition
Tube feeding of the elderly cancer patient of cancer patients but relatively few specifically devoted to the nutritional support of the elderly
Parenteral nutrition of the elderly cancer cancer patients. However, the awareness that elderly subjects account for a high proportion of the
patient mixed cancer patients population, in some way legitimates us to extend some conclusions of the
literature also to the elderly cancer patients. Although the topics of this Experts’ Consensus have
been written by specialists in different areas of nutrition, the final message is addressed to the
oncologists. Not only they should be more directly involved in the simplest steps of the nutritional
care (recognition of the potential existence of a “nutritional risk” which can compromise the
planned oncologic program, use of some oral supplements, etc.) but, as the true experts of the
natural history of their cancer patient, they should also coordinate the process of the nutritional
support, integrating this approach in the overall multidisciplinary cancer care.
Ó 2015 Elsevier Inc. All rights reserved.

This document represents the effort of the International
Society of Geriatric Oncology Task Force on Nutrition, which I
have the privilege to chair, to synthetize the evidence-based
concepts on nutritional support of the elderly cancer patients
on the basis of a Consensus of an International Panel of Experts
on this topic. The panel includes M. Elia and J. Hopkinson (UK),
E. Isenring (Australia), P. Ravasco (Portugal), M. Sheffield
More (United States), Y. Orreval (Sweden), S. Schneider and X.
Hebuterne (France), C. Sieber (Germany), and A. Vigano  specialist is not necessary.
(Canada).
This Consensus is mainly addressed to the oncologists for
two reasons. First, as we will see, malnutrition is so common in
cancer patients that it appears difficult to delegate all the
nutritional approach to the nutritionist. Secondly, the onco-
logist knows better than anyone the natural history of the
* Corresponding author. Tel: þ39 3297655385; fax: þ39 0226410267.
E-mail address: dottfb@tin.it
http://dx.doi.org/10.1016/j.nut.2014.11.004
0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
disease and adverse effects of the oncologic treatments, hence
he/she may easily recognize the proper indication, advise the
potential duration of the treatment, and also the more suitable
route for feeding. Obviously, the exact formulations of the
admixtures to be administered enterally or parenterally belong
to the expertise of the nutritionists and dietitians, but the
prescription of nutritional supplements is so frequent and
their use so simple that probably the intervention of a
Cancer in elderly people is a growing problem. In almost
every country, the proportion of people aged over 60 y is growing
faster than any other age group. They were 841 million in 2013,
and it is forecast they will reach 2 billion by 2050 when they will
account for the 21.1% of all world population [1]. Cancer is pri-
marily a disease of older people [2] and epidemiologic studies
have shown [3] more than half of all newly diagnosed cancer
patients and 71% of cancer deaths are in subjects 65 y old and
older. In the United States, experts predict by 2030, adults 65 y
586 F. Bozzetti / Nutrition 31 (2015) 585–586
and older will account for 20% of the population and by 2050,
42% of the cancer population are predicted will be 75 y and older
[4]. Currently, in the UK, more than three out of five (63%) can-
cers are diagnosed in people ages 65 and over [2].
In the attempt of presenting a comprehensive overview of the
topic, the panel included experts from different specialties: basic
researchers, nutritionists, geriatricians, nurses, dietitians, gas-
troenterologists, and oncologists.
Although this approach represents an advantage because all
different issues of the nutrition of the elderly cancer patients are
covered by such a specialized panel of experts ranging from
biological-experimental to the curative and palliative areas,
there is always the risk that some statements reflect the specific
experience of a single area of research or a single clinical context
and cannot generalized to other contexts. Viewed in this
perspective, some discrepancies are probably more apparent
than real.
On the contrary, there is some overlapping. As a matter of fact,
I was more concerned to avoid contradictory statements than to
avoid repetitions, also because nutrition is a continuum and
despite the original fragmentation of the topics, some concepts
were necessarily recalled in different articles.
The reader will note that terminology is somewhat spurious,
sometimes suggesting different terms may mean the same thing
or, more rarely, different things are expressed through the same
word. This is because we preferred, in general, to maintain the
terms used in the original publications rather than to convey
them into a conventional definition.
The reader might be confused by the indifferent use of some
words, namely weight loss, malnutrition, and cachexia to define
the state of wasting of the cancer patients. Obviously, these
terms have different meaning: “malnutrition” would suggest
wasting is mainly caused by a poor intake of nutrients (hence
could be in some way reversed by an adequate nutritional sup-
port), “cachexia” would underline the role of a deranged meta-
bolism as a key factor for wasting (hence a poor response to
nutrition and the need for the use of specific anticachectic
agents), and finally, the term “weight loss” does not imply any
etiopathogenetic meaning and just reflects the clinical presen-
tation of the patient.
Unfortunately there is a paucity of randomized clinical trials
in this area and most of the suggestions simply rely on the
experience of professionals who have dedicated many years to
clinical nutrition or to laboratory research in elderly people and
in cancer patients.
Although there is an abundant literature on nutritional
aspects of cancer patients and elderly people, studies focusing
on nutrition of the elderly cancer patients are definitely scanty
[5]; however, because the proportion of elderly people in the
cancer series is very high, it is quite likely the findings achieved
from studies in mixed patients’ populations, may also apply to
the elderly cancer patients. We were careful to report in all
documents it some statements regarded healthy/sarcopenic
people, cancer patients, or, more rarely, elderly cancer
patients.
The document will follow in the different articles the chro-
nological sequence of an elderly cancer patient who may
potentially need a nutritional support. The first article [6] will
deal with the general issues of elderly cancer patients, nutrients’
intake and nutritional support, then the effect of “malnutrition”
on patient outcome [7], followed by a review of the main
nutritional screenings tools [8]. Then, we move to the nutritional
care with distinct but interrelated papers on the role of nurses
[9], the effects of the dietary counseling and oral supplementa-
tion on the clinical outcome [10] and on the metabolic response
[11], and the approach with the tube feeding [12] and parenteral
nutrition [13]. Finally, after an article on the optimization of the
nutritional support [14], the following contributions will deal
with parenteral [15] and enteral [16] nutrition in patients with
advanced and incurable cancer. The last article [17] will sum-
marize the difficulty of implementing the nutritional support in
elderly patients where coexistence of malignancy, malnutrition,
and frailty and polypharmacy pose a tremendous challenge to
the oncologist.
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