Screening for nutritional status should be done during the first visit to the hospital for outpatient consultation and within 24 hours (or) at the earliest opportunity for inpatients as it helps identify patients at risk of becoming malnourished. 18

Screening should be done by consulting doctors or the outpatient department (OPD) nurse in the outpatient setting or by trained RMO/ health care professionals.

Patients found to be at risk should be referred to the Clinical Nutrition Therapist for comprehensive nutritional assessment.

Nutritional assessment should be repeated during the course of treatment. 16, 18, 19, 20, 21, 22 Malnutrition Universal Screening Tool (MUST), Nutritional Risk Screening-2002 (NRS-2002) and Mini Nutritional Assessment (MNA) are considered suitable tools for screening. 19, 20, 23, 24, 25

Subjective Global Assessment (SGA) and Patient Generated-Subjective Global Assessment (PG-SGA- For literate population) are validated tools for nutritional assessment of adult oncology patients. 18, 21, 26

SGA should be complemented with Biochemical parameters.

Imaging techniques help detect loss of muscle mass and fatty infiltration. 2 In patients at risk for malnutrition, sarcopenia and cachexia, muscle mass can be assessed using dual X-ray absorptiometry (DEXA), computed tomography scans at the level of the 3rd vertebra or bio- impedance analysis (BIA). 16, 19

More simple assessment tools can be included such as handgrip strength assessment, gait- speed test and nutrition focused physical examination.

Nutritional assessment should be performed for the stages of cachexia, as nutritional intervention is most effective in the stages of pre-cachexia. 11

Nutritional assessment can include inflammatory markers such C-reactive protein, serum albumin, hyperglycemia and symptoms such as anorexia.

Patients’ medical history, age, type and stage of cancer, and response to treatment, determine nutritional intervention.

For Patients who can eat and have a functional gastrointestinal tract, nutritional counseling, with or without oral nutritional supplement (ONS) should be the foremost intervention. 16, 17, 2

Nutritional counselling is the first priority to improve nutrition intake. In case of inadequacy, ONS should be recommended.

If oral nutrition is not possible or is inadequate, artificial nutrition should be considered. 16, 17, 19, 20, 21, 22

Choice of enteral nutrition (EN) or parenteral nutrition (PN) must take into account the extent of GUT availability, the amount of oral food intake, tolerance, symptoms, tumor site, its extent and complications, treatment plan and intent, prognosis, and patient’s overall physical status and the duration of the nutritional support. 16, 17, 19, 20, 21, 22, 27

EN should be preferred in patients with preserved GI functions in order to maintain gut integrity, reduce bacterial translocation and to reduce infectious complications. 16, 17, 19, 20, 21, 28 EN is recommended in severely undernourished patients with compromised volitional intake or inadequate food intake is anticipated. 16, 20, 22, 29, 30 Routine use of artificial nutrition during chemotherapy is not recommended. 16, 17, 19, 20, 21

In radiation-induced severe mucositis or in obstructive tumors of the head-neck, thorax and upper GI either PEG (percutaneous endoscopic gastrostomy) or nasogastric tube are recommended. 16, 17

If EN is insufficient, a combination of EN and PN or PN alone should be considered. PN should be initiated early whenever indicated. 16, 19, 20, 21

In case of GI failure, macronutrient and micronutrient’ requirements can only be fulfilled via the parenteral route long term artificial nutrition as home parenteral nutrition (HPN) is the standard recommendation. 16, 27, 31, 32

Refeeding Syndrome (RS) prevention is recommended when BMI is <16kg/m² or in the presence of unintentional weight loss of >15% within the last 3 to 6 months or whenever there is little or no nutritional intake for more than 2 to 3 days or if there are decreased levels of potassium, phosphorus, thiamine or magnesium prior to feeding.

The recommended protein intake is 1.2–1.5 g/kg/day. 35

Amino acid supplementations have been tested in cancer, further research is needed to clarify potential benefits. 35

Lack of good quality protein during cancer treatment can lead to sarcopenia, and associated complications, and impact Qol and survival. 36, 37, 38

Whey protein isolate (WPI) supplementation has been reported to benefit the nutritional status and immunity parameters, QoL, functional status, and muscle strength. 39, 40, 41

WPI supplementation can improve protein synthesis, due to their faster digestion, leading to a more rapid increase in plasma amino acid levels, particularly in essential amino acids. 42

Intervention studies have shown that protein supplementation with exercise/ physical activities improves muscle mass and function among sarcopenic older adults, and preserves muscle mass during intentional weight loss in obese older adults. 43, 44, 45

Whey Protein also contain high levels of other essential amino acids, such as leucine, which makes them an important food source for sustaining muscle protein anabolism and function. 42

EPA supplementation inhibits catabolic stimuli by checking the production of pro-inflammatory cytokines and enhancing insulin sensitivity leading to protein synthesis. 46

EPA improves calorie and protein intake, reduces inflammation, and can modulate body composition. 47, 48

Studies suggest n−3 fatty acids can inhibit cancer cell proliferation and decrease Chemotherapy (CT) toxicity without significant side effects. 16, 49, 50

Micronutrient supplementation can be considered in severely malnourished patients with inadequate food intake even after nutritional intervention with (or) without ONS and in conditions where micronutrient deficiency is established through investigations.

Micronutrient supplementation is recommended in all patients receiving TPN.