Aktuelle Ernährungsmedizin 2016; 41(02): 88-94
DOI: 10.1055/s-0042-102127
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Ernährungsprobleme unter Radiotherapie (RT) und Radiochemotherapie (RCT)

Post-(chemo)radiotherapy Nutritional Side Effects and their Management
H. Bertz
1   Klinik für Innere Medizin I, Hämatologie, Onkologie und Stammzelltransplantation und Sektion Ernährungsmedizin Universitätsklinikum Freiburg
,
Th. Brunner
2   Klinik für Strahlenheilkunde, Department für Radiologische Diagnostik und Therapie, Universitätsklinikum Freiburg
› Author Affiliations
Further Information

Publication History

Publication Date:
11 April 2016 (online)

Zusammenfassung

Radio- und Radiochemotherapie sind die dritte Therapiesäule für zahlreiche Karzinome sowohl im kurativen und auch palliativen Therapiekonzept. Die Strahlentherapie führt bei vielen Tumorpatienten, die häufig schon bei Erstdiagnose mangelernährt sind und durch die Tumorerkrankung nicht ausreichend essen können, zu weiteren ernährungsmedizinischen Problemen. Speziell Tumore im Hals-, Nasen-, Ohrenbereich sowie des Ösophagus gehören zu dieser Gruppe. Auch die Strahlentherapie der Lungenkarzinome beeinflusst das Gewebe des oberen Gastrointestinaltrakts mit Beeinträchtigung der Nahrungsaufnahme. Der untere Gastrointestinaltrakt wird durch die Bestrahlung gynäkologischer Tumore, das Rektum-, Anal-, Blasen- und Prostatakarzinom beeinträchtigt mit der möglichen Folge einer Radioenteritis.

Durch neuere Techniken werden diese Nebenwirkungen immer geringer, sind aber vielfältig und bedürfen eines interdisziplinären Behandlungskonzepts unter der Behandlung und in der Langzeitnachsorge. Prophylaxe und ernährungstherapeutische Therapien unter der Radiotherapie werden dargestellt, auch mit dem Schwerpunkt, ob die Ernährungstherapie zu einer Verbesserung des Überlebens nach Strahlentherapie führt. Die Nebenwirkungen akute und chronische Radioenteritis treten häufiger auf und werden ausführlich bzgl. Prophylaxe, Therapie und Langzeitbetreuung dargestellt.

Ernährungsmedizinische Diagnostik, Betreuung und Interventionen (mittels orale Trinknahrung, enteraler und parenteraler Ernährung) müssen frühzeitig in das multimodale Therapiekonzept dieser Tumore integriert werden. Nur so ist es möglich, wie bei der Chemotherapie, Komplikationen zu vermeiden, das Tumoransprechen und speziell die Lebensqualität des Patienten zu verbessern.

Abstract

Radiotherapy, together with chemoradiotherapy, is one of the three main pillars of solid cancer therapy in both, curative and palliative, therapeutic concepts. Often tumour patients already initially present with malnutrition and they are compromised to eat normally due to the cancer. In such cases radiotherapy often contributes to further nutritional problems. This is especially true for head and neck cancer and oesophageal cancer. Furthermore, radiotherapy of lung cancer frequently causes upper gastrointestinal side effects by oesophagitis making difficulty in swallowing. But radiotherapy can also lead to radiation enteritis when it is administered to pelvic disease for gynaecologic tumours, rectal cancer, anal cancer, bladder cancer and prostate cance.

Modern radiotherapy techniques help to reduce the frequency of GI side effects but they are still a diagnostic and a therapeutic challenge. These side effects are manifold and they require an interdisciplinary therapeutic concept both, during radiotherapy and during continued follow-up. Here we present prophylactic measures and nutritional therapies during radiotherapy and we also take into account the question whether nutritional therapy can lead to longer survival after radiotherapy. Since acute and chronic radiation enteritis take an important place, we describe these in more detail regarding prophylaxis, therapy and long-term follow-up.

Nutritional medicine diagnostics, care and interventions have to be integrated early on during the course of multimodal therapeutic concepts in the form of high calorie drinks, enteral and parenteral feeding. This is a prerequisite to avoid complications, to improve tumour response and importantly to improve quality of life much in parallel to what we know from chemotherapeutic treatment concepts.

 
  • Literatur

  • 1 Williams MV, Drinkwater KJ. Radiotherapy in England in 2007: modelled demand and audited activity. Clin Oncol (R Coll Radiol) 2009; 21: 575-590
  • 2 Palma D, Visser O, Lagerwaard FJ et al. Impact of introducing stereotactic lung radiotherapy for elderly patients with stage I non-small-cell lung cancer: a population-based time-trend analysis. J Clin Oncol 2010; 28: 5153-5159
  • 3 Bonner JA, Harari PM, Giralt J et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med 2006; 354: 567-578
  • 4 Bernier J, Domenge C, Ozsahin M et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004; 350: 1945-1952
  • 5 van Hagen P, Hulshof MC, van Lanschot JJ et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012; 366: 2074-2084
  • 6 Cooper JS, Guo MD, Herskovic A et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. JAMA 1999; 281: 1623-1627
  • 7 Douillard JY, Rosell R, De Lena M et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB-IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol 2006; 7: 719-727
  • 8 Palma DA, Senan S, Oberije C et al. Predicting esophagitis after chemoradiation therapy for non-small cell lung cancer: an individual patient data meta-analysis. Int J Radiat Oncol Biol Phys 2013; 87: 690-696
  • 9 Spiro SG, Tanner NT, Silvestri GA et al. Lung cancer: progress in diagnosis, staging and therapy. Respirology 2010; 15: 44-50
  • 10 Smalley SR, Benedetti JK, Haller DG et al. Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. J Clin Oncol 2012; 30: 2327-2333
  • 11 Mukherjee S, Hurt CN, Bridgewater J et al. Gemcitabine-based or capecitabine-based chemoradiotherapy for locally advanced pancreatic cancer (SCALOP): a multicentre, randomised, phase 2 trial. Lancet Oncol 2013; 14: 317-326
  • 12 Brunner TB, Eccles CL. Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma. Strahlenther Onkol 2010; 186: 672-680
  • 13 Golcher H, Brunner TB, Witzigmann H et al. Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: Results of the first prospective randomized phase II trial. Strahlenther Onkol 2015; 191: 7-16
  • 14 Sauer R, Becker H, Hohenberger W et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351: 1731-1740
  • 15 Rose PG, Bundy BN, Watkins EB et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 1999; 340: 1144-1153
  • 16 Morris M, Eifel PJ, Lu J et al. Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer. N Engl J Med 1999; 340: 1137-1143
  • 17 Tans L, Ansink AC, van Rooij PH et al. The role of chemo-radiotherapy in the management of locally advanced carcinoma of the vulva: single institutional experience and review of literature. Am J Clin Oncol 2011; 34: 22-26
  • 18 Sasse S, Klimm B, Gorgen H et al. Comparing long-term toxicity and efficacy of combined modality treatment including extended- or involved-field radiotherapy in early-stage Hodgkin's lymphoma. Ann Oncol 2012; 23: 2953-2959
  • 19 Basch E, Prestrud AA, Hesketh PJ et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29: 4189-4198
  • 20 Barthelemy N, Streel S, Donneau AF et al. Screening for malnutrition in lung cancer patients undergoing radiotherapy. Support Care Cancer 2014; 22: 1531-1536
  • 21 Webb GJ, Brooke R, De Silva AN. Chronic radiation enteritis and malnutrition. J Dig Dis 2013; 14: 350-357
  • 22 Theis VS, Sripadam R, Ramani V et al. Chronic radiation enteritis. Clin Oncol (R Coll Radiol) 2010; 22: 70-83
  • 23 Sauer R, Becker H, Hohenberger W et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351: 1731-1740
  • 24 Abayomi J, Kirwan J, Hackett A. The prevalence of chronic radiation enteritis following radiotherapy for cervical or endometrial cancer and its impact on quality of life. Eur J Oncol Nurs 2009; 13: 262-267
  • 25 Galland RB, Spencer J. The natural history of clinically established radiation enteritis. Lancet 1985; 1: 1257-1258
  • 26 Henson CC, Burden S, Davidson SE et al. Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy. Cochrane Database Syst Rev 2013; 11 Cd009896
  • 27 Ravasco P, Monteiro-Grillo I, Camilo M. Individualized nutrition intervention is of major benefit to colorectal cancer patients: long-term follow-up of a randomized controlled trial of nutritional therapy. Am J Clin Nutr 2012; 96: 1346-1353
  • 28 Alshadwi A, Nadershah M, Carlson ER et al. Nutritional considerations for head and neck cancer patients: a review of the literature. J Oral Maxillofac Surg 2013; 71: 1853-1860
  • 29 Dechaphunkul T, Martin L, Alberda C et al. Malnutrition assessment in patients with cancers of the head and neck: a call to action and consensus. Crit Rev Oncol Hematol 2013; 88: 459-476
  • 30 Fearon K, Strasser F, Anker SD et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol 2011; 12: 489-495
  • 31 Langius JA, Zandbergen MC, Eerenstein SE et al. Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: a systematic review. Clin Nutr 2013; 32: 671-678
  • 32 Irune E, Dwivedi RC, Nutting CM et al. Treatment-related dysgeusia in head and neck cancer patients. Cancer Treat Rev 2014; 40: 1106-1117
  • 33 Nutting CM, Morden JP, Harrington KJ et al. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicentre randomised controlled trial. Lancet Oncol 2011; 12: 127-136
  • 34 Jawad H, Hodson NA, Nixon PJ. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1. Br Dent J 2015; 218: 65-68
  • 35 Awan MJ, Mohamed AS, Lewin JS et al. Late radiation-associated dysphagia (late-RAD) with lower cranial neuropathy after oropharyngeal radiotherapy: a preliminary dosimetric comparison. Oral Oncol 2014; 50: 746-752
  • 36 Fietkau R, Thiel H, Iro H et al. Comparison between oral nutrition and enteral nutrition using a percutaneous endoscopically guided gastrostomy (PEG) in patients undergoing radiotherapy for head and neck tumors. Strahlenther Onkol 1989; 165: 844-851
  • 37 Kramer S, Newcomb M, Hessler J et al. Prophylactic versus reactive PEG tube placement in head and neck cancer. Otolaryngol Head Neck Surg 2014; 150: 407-412
  • 38 Clavel S, Fortin B, Despres P et al. Enteral feeding during chemoradiotherapy for advanced head-and-neck cancer: a single-institution experience using a reactive approach. Int J Radiat Oncol Biol Phys 2011; 79: 763-769
  • 39 Ravasco P, Monteiro-Grillo I, Marques Vidal P et al. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck 2005; 27: 659-668
  • 40 Bossola M. Nutritional Interventions in Head and Neck Cancer Patients Undergoing Chemoradiotherapy: A Narrative Review. Nutrients 2015; 7: 265-276
  • 41 Trachootham D, Songkaew W, Hongsachum B et al. Nutri-jelly may improve quality of life and decrease tube feeding demand in head and neck cancer patients. Support Care Cancer 2015; 23: 1421-1430
  • 42 van den Berg MG, Kalf JG, Hendriks JC et al. Normalcy of food intake in head and neck cancer patients supported by combined dietary counseling and swallowing therapy: A randomized clinical trial. Head Neck 2015; June epub
  • 43 Pai PC, Chuang CC, Tseng CK et al. Impact of pretreatment body mass index on patients with head-and-neck cancer treated with radiation. Int J Radiat Oncol Biol Phys 2012; 83: e93-e100
  • 44 Werner-Wasik M, Yorke E, Deasy J et al. Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys 2010; 76: S86-93
  • 45 Servagi-Vernat S, Ali D, Roubieu C et al. Dysphagia after radiotherapy: State of the art and prevention. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 132: 25-29
  • 46 Fietkau R, Lewitzki V, Kuhnt T et al. A disease-specific enteral nutrition formula improves nutritional status and functional performance in patients with head and neck and esophageal cancer undergoing chemoradiotherapy: results of a randomized, controlled, multicenter trial. Cancer 2013; 119: 3343-3353
  • 47 Bittner MI, Grosu AL, Brunner TB. Comparison of toxicity after IMRT and 3D-conformal radiotherapy for patients with pancreatic cancer – A systematic review. Radiother Oncol 2015; 114: 117-121
  • 48 Naumann P, Habermehl D, Welzel T et al. Outcome after neoadjuvant chemoradiation and correlation with nutritional status in patients with locally advanced pancreatic cancer. Strahlenther Onkol 2013; 189: 745-752
  • 49 Brunner TB, Scott-Brown M. The role of radiotherapy in multimodal treatment of pancreatic carcinoma. Radiat Oncol 2010; 5: 64