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      Effects of Immunonutrition in Head and Neck Cancer Patients Undergoing Cancer Treatment – A Systematic Review

      systematic-review

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          Abstract

          Background and Aims

          Malnutrition is prevalent among head and neck cancer (HNC) patients and leads to undesirable outcomes such as reduced treatment response and increased treatment-related side effects. This systematic review summarizes the recent evidence regarding the effect of immunonutrition in HNC patients undergoing radiotherapy and chemotherapy.

          Methods

          A literature search was conducted of the CENTRAL, ProQuest, MEDLINE, EBSCOhost, Web of Science and CINAHL databases; and further supplemented with internet and manual searches. Studies published between January 2011 and May 2021 were identified, screened, retrieved, and data extraction was performed.

          Results

          Twenty studies involving 1535 patients were included, 15 were randomized controlled trials (RCTs), three were retrospective study and two were comparative cohort studies. Five out of seven studies reported improvement or maintenance of nutrition status with continuous supplementation using immunonutrient-enriched formula. Three studies reported functional status as an outcome, with one study reporting significant improvement, one study reporting maintenance, and another study reporting no difference in the functional status of patients supplemented with immunonutrient-enriched formulas. Supplementation with glutamine did not reduce the overall incidence of mucositis but delayed the onset of oral mucositis and had significantly less incidence of severe oral mucositis.

          Conclusion

          Supplementation with immunonutrient-enriched formulas in HNC patients during radiotherapy and chemotherapy may improve or maintain nutrition status. Supplementation with glutamine during HNC radiotherapy and chemotherapy may delay the onset of oral mucositis and reduce incidences of severe oral mucositis. Further investigations are required, focusing on the timing, dosage, and duration of immunonutrition.

          Systematic Review Registration: PROSPERO, identifier CRD42021241817.

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          Most cited references50

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          Assessing the quality of reports of randomized clinical trials: is blinding necessary?

          A. Jadad, R Moore, D. Carroll … (1996)
          It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.
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            Glutamine: Metabolism and Immune Function, Supplementation and Clinical Translation

            Vinicius Cruzat, Marcelo Macedo Rogero, Kevin Noel Keane … (2018)
            Glutamine is the most abundant and versatile amino acid in the body. In health and disease, the rate of glutamine consumption by immune cells is similar or greater than glucose. For instance, in vitro and in vivo studies have determined that glutamine is an essential nutrient for lymphocyte proliferation and cytokine production, macrophage phagocytic plus secretory activities, and neutrophil bacterial killing. Glutamine release to the circulation and availability is mainly controlled by key metabolic organs, such as the gut, liver, and skeletal muscles. During catabolic/hypercatabolic situations glutamine can become essential for metabolic function, but its availability may be compromised due to the impairment of homeostasis in the inter-tissue metabolism of amino acids. For this reason, glutamine is currently part of clinical nutrition supplementation protocols and/or recommended for immune suppressed individuals. However, in a wide range of catabolic/hypercatabolic situations (e.g., ill/critically ill, post-trauma, sepsis, exhausted athletes), it is currently difficult to determine whether glutamine supplementation (oral/enteral or parenteral) should be recommended based on the amino acid plasma/bloodstream concentration (also known as glutaminemia). Although the beneficial immune-based effects of glutamine supplementation are already established, many questions and evidence for positive in vivo outcomes still remain to be presented. Therefore, this paper provides an integrated review of how glutamine metabolism in key organs is important to cells of the immune system. We also discuss glutamine metabolism and action, and important issues related to the effects of glutamine supplementation in catabolic situations.
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              ESPEN expert group recommendations for action against cancer-related malnutrition

              J. Arends, V Baracos, H Bertz … (2017)
              Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.
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                Author and article information

                Contributors
                Journal
                Journal ID (nlm-ta): Front Nutr
                Journal ID (iso-abbrev): Front Nutr
                Journal ID (publisher-id): Front. Nutr.
                Title: Frontiers in Nutrition
                Publisher: Frontiers Media S.A.
                ISSN (Electronic): 2296-861X
                Publication date (Electronic): 25 February 2022
                Publication date Collection: 2022
                Volume: 9
                Electronic Location Identifier: 821924
                Affiliations
                [1] 1Centre for Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya , Kuala Lumpur, Malaysia
                [2] 2Ministry of Health , Putrajaya, Malaysia
                [3] 3Department of Clinical Oncology, University of Malaya Medical Centre , Kuala Lumpur, Malaysia
                [4] 4Department of Nutrition, Faculty of Public Health, Airlangga University , Surabaya, Indonesia
                Author notes

                Edited by: Paula Ravasco, Santa Maria Hospital, Portugal

                Reviewed by: Daniela Caetano Gonçalves, Federal University of São Paulo, Brazil; Philip Calder, University of Southampton, United Kingdom

                *Correspondence: Hazreen Abdul Majid hazreen@ 123456ummc.edu.my

                This article was submitted to Clinical Nutrition, a section of the journal Frontiers in Nutrition

                Article
                DOI: 10.3389/fnut.2022.821924
                PMC ID: 8961436
                SO-VID: dd56a6e6-9a3f-4cb5-8176-61b85b5dbcfb
                Copyright © Copyright © 2022 Tan, Abdul Satar and Majid.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                Date received : 25 November 2021
                Date accepted : 01 February 2022
                Page count
                Figures: 2, Tables: 5, Equations: 0, References: 50, Pages: 17, Words: 8575
                Funding
                Funded by: Universiti Malaya, doi 10.13039/501100004386;
                Categories
                Subject: Nutrition
                Subject: Systematic Review

                Keywords: immunonutrition,glutamine,arginine,omega 3 fatty acid,radiotherapy,cancer treatment,head and neck (h&n) cancer
                Data availability:
                Keywords: immunonutrition, glutamine, arginine, omega 3 fatty acid, radiotherapy, cancer treatment, head and neck (h&n) cancer

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