The Key Role of Patient Empowerment in the Future Management of Cancer-Related Malnutrition

Malnutrition is a common condition in cancer patients. It is associated with poor clinical outcomes and higher healthcare costs, with approximately 20–30% of patients dying because of its consequences rather than cancer. The prevalence of cancer-related malnutrition depends on disease stage and localization, ranging from 15% to 40% at diagnosis, and up to 80% in later stages. Patients affected by gastrointestinal tract tumors and advanced-stage disease present the highest rates of malnutrition [1,2]. Nutritional support helps improving clinical outcomes and lowering the risk of mor tality in many settings, including patients with head and neck, gastrointestinal, respiratory, and genitourinary cancer. Therefore, all efforts should be made to include nutritional interventions in multimodal oncologic care since diagnosis, even when patients are not severely malnourished [3]. Although it is known that nutritional status impairment affects the efficacy of anti cancer treatment and increases the risk of adverse outcomes, cancer-related malnutrition is still under-recognized and under-treated. In fact, the collaboration between oncologists and nutritionists seems to be suboptimal in current clinical practice, as clinical nutrition is often considered as a non-essential part of multimodal cancer care [4]. According to the most recent international guidelines and recommendations [1,5], malnourished patients and patients at risk of malnutrition should be recognized early using nutritional risk screening tools. A comprehensive assessment of nutritional status including anthropometry, body composition, oral intake and inflammatory status evaluation is mandatory to implement an appropriate and timely nutritional support plan. Dietary counseling (DC) is the first-line intervention in malnourished cancer patients. Through the optimization of oral food intake, it acts on mitigating metabolic derangements, maintaining body weight and improving body composition through skeletal muscle mass preservation. DC was demonstrated to improve survival, reduce the risk of modification of planned anticancer treatments, and improve quality of life of cancer patients. If necessary, DC may also include the administration of oral nutritional supplements (ONS). ONS are medical nutrition products used to counteract cancer-related malnutrition when normal food consumption is not sufficient to maintain or increase energy intake. Since ONS have different textures and flavors, they can be easily incorporated into the usual diet and adapted to personal preferences of patients. In case of insufficient energy intake through the oral route, artificial nutrition can be administered through an enteral access (i.e., nasogastric tube, nasojejunal tube, or percutaneous gastrostomy) or through the parenteral route by a central or peripheral venous access [5]. Despite scientific and clinical evidence, many issues remain to be addressed. For instance, no clear indication is available on how to manage patients with a pre served nutritional status at diagnosis. In this population, there is a high risk of overlooking the development of malnutrition during the illness trajectory. This is more frequent in some cancer types (i.e., gastrointestinal, head and neck and lung cancer), in advanced disease stage and in case of aggressive treatment modalities, which are likely to worsen nutritional status even in non-previously malnourished patients [5]. In case of treatment toxicities, the early identification and management of nutrition impact symptoms (i.e., nausea, vomiting, anorexia, dysphagia, dysgeusia and diarrhea) can increase survival rates, as seen in patients with metastatic esophagogastric cancer [6]. A critical problem is the marked hetero