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Structured Abstract
Objective:
To understand the evidence base for nutrition interventions delivered prior to or during cancer treatment for preventing and treating negative cancer and cancer treatment–related outcomes among individuals with or at risk for malnutrition. The primary purpose was to inform the National Institutes of Health (NIH) Pathways to Prevention workshop Nutrition as Prevention for Improved Cancer Health Outcomes, held July 26–28, 2022.
Data sources:
We searched Ovid Medline®, Ovid Embase®, and Cochrane Central Register of Controlled Trials to identify studies from 2000 through July 2022. We conducted grey literature searches to identify additional resources relevant to the associated costs or value (e.g., cost-effectiveness, cost-benefit) of nutrition interventions.
Review methods:
The review was guided by a set of Key Questions established by the NIH planning committee for the Nutrition as Prevention for Improved Cancer Health Outcomes workshop. We searched for studies that evaluated a broad range of nutrition interventions (e.g., dietary supplements, nutrition support, nutrition counseling) for preventing and treating negative outcomes of cancer and cancer-related treatment. Eligible studies included randomized controlled trials (RCTs) with enrollment ≥50 participants. We extracted basic study information from all eligible studies, then grouped studies by broad intervention and cancer types. We provide a detailed evidence map for all included studies, but conducted risk of bias and additional qualitative descriptions of outcomes for only those intervention and cancer types with a larger volume of literature.
Results:
We identified 9,798 unique references, with 206 studies from 219 publications reporting RCTs of nutrition interventions to potentially improve negative outcomes of cancer and cancer-related treatment. Two decades of randomized trial evidence on nutrition interventions for adults prior to and/or during cancer treatment primarily focused on dietary supplements, nutrition support (including oral nutrition supplements), and the route or timing of nutrition interventions for gastrointestinal and head and neck cancers in the inpatient setting. Most studies evaluated changes in body weight/composition, adverse events, length of hospital stay, and quality of life. Few studies were conducted within the U.S. setting. Among intervention and cancer types with a high volume of literature (n=114), which predominantly included studies in dietary supplements and nutrition support in gastrointestinal and head and neck cancers, 11 percent (n=12) were rated as low risk of bias (higher quality), 40 percent (n=46) medium risk of bias, and 49 percent (n=56) high risk of bias (lower quality). Low and medium risk-of-bias studies reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes. Although the evidence map shows a large volume of studies evaluating nutrition interventions and outcomes, these studies showed high heterogeneity across study populations, interventions, and outcomes (measure definitions, timing of measurements), even within nutrition intervention categories; as a result, we could not aggregate results. While studies enrolled individuals from multiple cancer types, treatments, and stages, across the lifespan, with varying degrees of muscle wasting, and in those with a range of comorbid conditions, no eligible studies specifically evaluated whether the effects of nutrition interventions on preventing negative outcomes varied across these characteristics.
Among studies included in our Key Questions, we found that few (4%, n=8) published cost or value (e.g., cost-effectiveness, cost-benefit) information related to the intervention. In our grey literature search of additional studies examining cost or value of nutrition interventions, we found few studies that conducted cost-effectiveness or cost-benefit analyses; among those that did, we found the studies were conducted in non-U.S. health systems and demonstrated mixed results on the value of nutrition interventions.
Conclusions:
Although overall RCT evidence focused on a wide range of nutrition interventions, studies were concentrated in use of dietary supplements, nutrition support, and the route or timing of nutrition interventions within gastrointestinal and head and neck cancers in inpatient settings. Among interventions with the highest volume of literature, the majority of studies were rated as high risk of bias. Our findings point to the need for rigorous new research to bolster the evidence base. Specifically, the field needs a more detailed future evaluation of a subset of nutrition interventions contained in this evidence map that focuses on priorities most relevant to specific stakeholders (e.g., oncologists, patients, dietitians, researchers, policymakers). Further, studies should be specifically designed to evaluate the main outcomes of interest for clinical practice. Future research would also benefit from creation of standardized taxonomies for interventions and outcomes as well as more rigorous design and reporting of nutrition interventions. As mentioned, heterogeneity of populations, interventions, comparators, and outcomes precluded aggregation. Currently, the quality and heterogeneity of the studies limit translation of findings into clinical practice or guidelines. In order to inform development of these guidelines, coordinated efforts are required to develop detailed conceptual frameworks for mechanisms of nutrition interventions most relevant to clinical care providers and patients. Such frameworks would help inform priorities for future research as well as guide practice and policy.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Chapter 1. Introduction
- Chapter 2. Methods
- Chapter 3. Search Results
- Chapter 4. Overview of Nutrition Interventions
- Chapter 5. Nutrition Interventions Prior to Cancer Treatment
- Chapter 6. Nutrition Interventions Prior to and Including the Initiation of Cancer Treatment
- Chapter 7. Nutrition Interventions After Cancer Treatment Began
- Chapter 8. Effect of Nutrition Interventions on Symptoms
- Chapter 9. Effect of Nutrition Interventions Intended for Body Weight Loss
- Chapter 10. Cost-Effectiveness of Nutrition Interventions
- Chapter 11. Discussion
- References
- Abbreviations and Acronyms
- Appendixes
- Appendix A. Methods
- Appendix B. Studies Excluded at Full Text
- Appendix C. Evidence Tables for Chapter 5
- Appendix D. Evidence Tables for Chapter 6
- Appendix E. Evidence Tables for Chapter 7
- Appendix F. Evidence Tables for Chapter 8
- Appendix G. Evidence Tables for Chapter 9
- Appendix H. References for Appendixes C–G
Suggested citation:
Parsons HM, Forte ML, Abdi H, Brandt S, Claussen AM, Wilt TJ, Klein M, Ester E, Landsteiner A, Shaukut A, Sibley SD, Slavin J, Sowerby C, Ng W, Butler M. Nutrition as Prevention for Improved Cancer Health Outcomes. Comparative Effectiveness Review No. 260. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 75Q80120D00008.) AHRQ Publication No. 23-EHC004. Rockville, MD: Agency for Healthcare Research and Quality; May 2023. DOI: https://doi.org/10.32970/AHRQEPCCER260. Posted final reports are located on the Effective Health Care Program search page.
This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00008). The report was commissioned and funded by the National Institutes of Health (NIH) Office of Disease Prevention to inform a Pathways to Prevention Workshop. The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or NIH. Therefore, no statement in this report should be construed as an official position of NIH, AHRQ, or the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (research, clinical or patient education, quality improvement projects) in the United States, and do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for sale, incorporation into software, incorporation into for-profit training courses) or for use outside of the United States. If organizational policies require permission to adapt or use these materials, AHRQ will provide such permission in writing.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
A representative from AHRQ served as a Contracting Officer’s Representative and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis, interpretation of data, or preparation or drafting of this report.
AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Nutrition as Prevention for Improved Cancer Health Outcomes, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).
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