(Health Times reporter Xu Shiyu Qiao Jingfang) "When the concept of tumor nutrition was first promoted, many doctors and even nutrition experts found it incredible. Now that the oncology nutrition ward has been built, the survival rate of patients has improved, which is the best proof. Shi Hanping, director of the Tumor Nutrition and Metabolism Center of Beijing Shijitan Hospital and director of the Fourth Department of General Surgery, told the Health Times reporter.
The "Standardized Tumor Nutrition Demonstration Ward" was initiated by the Cancer Nutrition Professional Committee of the Chinese Anti-Cancer Association in 2016. At that time, there were only 10 standardized tumor nutrition demonstration wards set up, and as of July 2024, the number has reached 379, covering 29 provinces, municipalities and autonomous regions.
On the morning of July 2, Shi Hanping, director of the Cancer Nutrition and Metabolism Center and director of the Fourth Department of General Surgery of Beijing Shijitan Hospital, checked the nutritional status of the patients. Niu Hong super-photographed
Only when nutrition is replenished can we dare to talk about the "quality of life" of cancer patients
On July 1, Shi Hanping on the operating table appeared cautious. Lying on the operating table is 48-year-old Li Ping (pseudonym), whose abdominal tumor is lying tightly like an octopus on her rectum, ureters, iliac arteries, uterine appendages and retroperitoneum.
Shi Hanping's every knife was carefully avoided, and the operation lasted more than 6 hours, the blood loss was only 600 ml, and the huge tumor was finally removed, weighing 6.3 kilograms. After the tumor was removed, Li Ping weighed less than 40 kilograms.
In October 2023, Li Ping was diagnosed with colon cancer with liver metastases after going to the hospital for examination due to severe abdominal pain. Chemotherapy failed to suppress the growth of the tumor, and in March 2024, the tumour grew like a weed and lodged in her abdominal cavity. She developed typical symptoms of intestinal obstruction, and her intestinal lumen narrowed until she could no longer eat at all.
In June this year, Li Ping, who had just arrived at the cancer nutrition demonstration ward of Beijing Shijitan Hospital, failed to pass the first round of nutritional assessment: she showed severe malnutrition, cachexia, hypoproteinemia, severe anemia and multiple electrolyte imbalances. Entering the operating room with extreme nutritional deficiencies, severe anemia, and multiple electrolyte imbalances means that Li Ping will most likely not survive.
Nutrition therapy was initiated quickly. Initially, enteral nutrition was supplemented with a combination of parenteral nutrition, and then parenteral nutrition was used for maintenance with complete intestinal obstruction. When the nutritional status improved, the protein index increased, the energy increased, the coagulation function increased, and the possibility of complications during and after the operation decreased, Shi Hanping decided to "gamble" on Li Ping through surgery.
After the tumor was removed, Li Ping was left with only a 2.3-meter small intestine. The small intestine of a normal person is 4.5 to 5 meters long, while Li Ping only has half of the small intestine of an ordinary person, and the damaged intestinal function needs more time to recover. Nutritional support is still necessary after surgery. The energy is carefully calculated, and in order to boost the nutrients, Li Ping needs about 1,000 kcal of energy per day. The doctor first administers parenteral nutrition to the patient, and after the intestinal absorption and compensatory function are gradually restored, the patient slowly transitions to enteral nutrition, and finally resumes to daily diet.
It's a long game. At the beginning, nutritional diagnosis was carried out through the analysis of human metabolic components, blood draw results, and immune indicators, and then nutritional therapy was carried out according to the nutritional status score. "Once you lose more than 6 percent of your body weight, there are concerns about malnutrition and an increased risk of death." Wang Lin, Li Ping's bedside doctor, said that nutritional therapy should become the first-line therapy throughout the treatment of tumors.
During the ward rounds, Li Ping was already able to eat independently, and she was like a child who had tasted the delicious food of the world for the first time: "Doctor Shi, I haven't eaten for three or four months. It's just the most ordinary home-cooked food, and it's so delicious. "Raw, it is continued with the first bite of food. In Shi Hanping's view, when nutrition is replenished, surgeons have the opportunity and leeway to intervene, and only then do they dare to talk about the "quality of life" that cancer patients really need.
Malnutrition is a huge threat to many cancer patients
Cancer treatment mainly relies on surgery, radiotherapy, chemotherapy and other methods. In 2005, Shi Hanping found that although the way of cancer treatment is different, patients show a series of similar characteristics: skinny, severe hair loss, many people often vomit and cannot eat during treatment, nutritional problems are worrying, and the consequences of malnutrition are fatal: tolerance to radiotherapy, chemotherapy, and surgery is reduced, sensitivity is reduced, the risk of death is increased, and the survival time is shortened.
Malnutrition is a huge threat to many cancer patients. In 2012, the Cancer Nutrition Therapy Committee of the China Anti-Cancer Association launched a large-scale survey involving 18 cancer types, covering nearly 80,000 cancer patients, and found that the incidence of total malnutrition in mainland cancer patients was as high as 80.4%, and the incidence of moderate and severe malnutrition was 58.2%. Malnutrition increased the risk of death by more than 45%, but at that time, 68.78% of cancer patients and 55.03% of severely malnourished cancer patients in mainland China did not receive any nutritional treatment.
Behind every piece of data is a living life. This means that more than half of the cancer patients who are severely malnourished are "starved" to death.
Why is malnutrition common among cancer patients? Shi Hanping explained: First of all, cancer patients are in a state of high metabolic consumption due to the disease itself, which is easy to cause malnutrition, anorexia and early satiety; The second is the toxic side effects brought about by treatment, surgery can lead to the occurrence of negative nitrogen balance and malnutrition, which is mostly manifested as insufficient or lack of energy or nutrients, resulting in serious loss of body weight and muscle, resulting in increased mortality. Cognitive misunderstandings such as "taboos" in cancer patients also cause further obstacles.
"At first, many doctors thought that cancer patients should be hungry and that it was normal to be thin. Some cancer patients lose 10 kg or 20 kg of weight, but doctors think it is normal, and only know about chemotherapy and radiotherapy until many patients' bodies completely collapse, and do not think that weight loss should be reversed. Zhang Zhanzhi, chief physician of the hospital's tumor nutrition and metabolism center, told the Health Times reporter that before the establishment of the tumor nutrition demonstration ward, doctors still had a vague concept of nutrition, and enteral nutrition and parenteral nutrition were mostly used as temporary means of adjuvant treatment.
In order to make the concept of nutrition therapy deeply rooted in the hearts of the people, Shi Hanping has been running for nearly 20 years. During this period, Shi Hanping founded the Department of Cancer Nutrition in China, actively carried out tumor nutrition training and nutrition education, completed the country's largest tumor cohort study, lifestyle intervention study, nutrition KAP (Knowledge, Belief and Action) cohort study, established a database of nutritional status of cancer patients, formulated expert consensus and guidelines covering the whole process of nutrition diagnosis and treatment, and founded the Journal of Nutritional Oncology and Precision Nutrition, Medical Information Newspaper - Nutrition Channel, Electronic Journal of Tumor Metabolism and Nutrition, four authoritative nutrition journals......
In 2023, Shi Hanping led the team to conduct a survey on the construction status of the tumor nutrition therapy demonstration ward, involving 94 units, and found that "the demonstration ward project has effectively benefited patients, which is manifested in the increase in the total nutrition treatment rate of cancer patients by 13.5%, the incidence of malnutrition by 11.5%, the 30-day mortality rate by 24.6%, and the inpatient medical expenses by 13.4%. When nutrition becomes the first-line treatment for cancer patients, the "roadblocks" caused by malnutrition caused by patients who do not want to eat, cannot eat, have indigestion, and are not fully absorbed are removed, and they do not need to go hungry while fighting the disease, and the "quality of life" has been really improved.
"Nutritional diagnosis" is the first link, which should be listed as a routine item for admission
On July 2, Professor Shi Hanping walked through the corridor outside the tumor nutrition demonstration ward of Beijing Shijitan Hospital. Niu Hong super-photographed
The Oncology Nutrition Demonstration Ward is not a place for surgeons to work alone, but needs to have a nutrition support team composed of clinicians (including dietitians), dietitians (technicians), nurses, and clinical pharmacists. At the same time, according to the specific situation of the hospital, a multidisciplinary comprehensive diagnosis and treatment work model can be established.
How is the nutritional status of cancer patients managed? Shi Hanping divided nutrition therapy into three stages: nutrition diagnosis, nutrition therapy and efficacy evaluation. In his view, "nutritional diagnosis" is the first link, "all patients should receive nutritional diagnosis at the time of admission, and the investigation of nutritional status should be included in the routine items of patients entering the hospital." ”
In order to standardize nutrition therapy, Shi Hanping added the five-step principle of nutrition therapy to the standard of "tumor nutrition demonstration ward", which from bottom to top: diet + nutrition education, diet + oral nutrition supplementation, total enteral nutrition (oral or tube feeding), partial enteral nutrition + partial parenteral nutrition, and total parenteral nutrition. If you can eat normally, then eat normally according to your nutritional needs; If you can't get enough nutrition through eating, you need to start diet + oral nutrition supplementation (oral special medical food), and if it is not enough, enteral nutrition therapy through oral or tube feeding; Enteral nutrition is not sufficient, and intravenous parenteral nutrition is administered. In the specific implementation process, the principle of the five ladders is supplemented and refined and adjusted according to the different patient conditions, and is implemented one by one by relying on the nutrition support team in the ward.
When should nutritional interventions and treatments begin? "The sooner the better!" Shi Hanping said, "The traditional treatment thinking in clinical practice is that chemotherapy, radiotherapy, and surgery are used successively or in combination, and nutritional support is not enough. Now we advocate that nutritional therapy and anti-tumor should be carried out simultaneously, and the whole process should be involved. The large tumor nutrition database we compiled and collected shows that malnutrition can lead to early deterioration of the disease, and malnutrition in cancer patients occurs not only in the later stage, but also in the early stage, so it is necessary to intervene as soon as possible. ”
"In the tumor nutrition demonstration ward, with the foreshadowing of nutrition, many impossible things become possible." Shi Hanping lamented that most of the 379 tumor nutrition demonstration wards are located in large tertiary hospitals, but only tertiary hospitals are not enough. In the next step, we should deploy the construction of standardized nutrition treatment demonstration wards in primary medical institutions as soon as possible, explore the pilot project of continuous nutrition management in hospitals, communities and families, ensure and realize the continuous nutrition treatment and management of patients throughout the whole process, and realize the integration of disease prevention, diagnosis and treatment of patients.
"It is impossible to overemphasize the importance of nutrition to health, whether it is a patient or a normal person, we must be practitioners of balanced nutrition and the first person responsible for health." Shi Hanping wrote in his essay "The Doctor's Zen Heart": "The doctor's Zen heart is also the ordinary heart, and its core is benevolence, treating different patients with the same benevolent ordinary heart, maintaining the supremacy of life, and pursuing the ...... of perfection in treatment".
Related reading: Cancer patients should be supplemented with more high protein
The Guidelines for Nutritional Therapy for Patients with Malignant Tumors (2021 Edition) released by the Chinese Society of Clinical Oncology give specific suggestions on how to supplement nutrition for cancer patients:
1. Even cancer patients who eat normally may have insufficient food components and low total energy and protein intake. A diet high in energy and protein is the preferred way to maintain or improve nutritional status.
2. For patients who need nutritional therapy, oral feeding can still not meet the needs of the body, supplemental enteral nutrition is recommended, oral nutrition supplementation is preferred, and gavage feeding can be considered when the digestive tract function is basically normal and the intake is insufficient due to eating disorders and other reasons.
3. Enteral nutrition can be used during surgery, radiotherapy, chemotherapy and at home, and is generally supplemented between meals. It can also be used to improve appetite, digestion and absorption functions (such as megestrolone), supplement digestive enzymes, probiotics, micronutrients, etc.
4. When the nutrient needs cannot be met through oral feeding and enteral nutrition, enteral nutrition combined with parenteral nutrition is recommended. For example, supplemental parenteral nutrition should be considered when supplemental parenteral nutrition is indicated and 60% of the target requirement is not met after more than 7 days of enteral nutrition.
5. Severe intestinal obstruction, intestinal ischemia, intestinal bleeding, gastrointestinal fistula, shock, etc., are contraindications to enteral nutrition therapy. Once these conditions occur, enteral nutrition must be administered with caution. Of course, there are exceptions, for some stable and draining digestive tract fistulas, proper enteral nutrition, "eating and leaking" is also a reasonable and beneficial choice.