Nutritional strategies to prevent gastrointestinal toxicity during pelvic radiotherapy

Abstract

Radiotherapy-induced damage to non-cancerous gastrointestinal mucosa has effects on secretory and absorptive functions and can interfere with normal gastrointestinal physiology. Nutrient absorption and digestion may be compromised. Dietary manipulation is an attractive option with sound rationale for intervention. The aim of this review was to synthesise published evidence for the use of elemental formulae, low or modified fat diets, fibre, lactose restriction and probiotics, prebiotics and synbiotics to protect the bowel from gastrointestinal side effects during long-course, radical pelvic radiotherapy. Thirty original studies (recruiting n 3197 patients) were identified comprising twenty-four randomised controlled trials, four cohort studies and two comparator trials. Endpoints varied and included symptom scales (Inflammatory Bowel Disease Questionnaire, Common Technology Criteria for Adverse Events, Radiation Therapy Oncology Group) and Bristol Stool Scale. Dietary and supplement interventions were employed with many studies using a combination of interventions. Evidence from RCT was weak for elemental, low or modified fat and low-lactose interventions and modestly positive for the manipulation of fibre during radiotherapy. Evidence for probiotics as prophylactic interventional agents was more promising with a number of trials reporting positive results but strength and strains of interventions vary, as do methodologies and endpoints making it difficult to arrive at firm conclusions with several studies lacking statistical power. This consolidated review concludes that there is insufficient high-grade evidence to recommend nutritional intervention during pelvic radiotherapy. Total replacement of diet with elemental formula could be effective in severe toxicity but this is unproven. Probiotics offer promise but cannot be introduced into clinical practice without rigorous safety analysis, not least in immunocompromised patients.

Association of Patient-Reported Outcomes and Nutrition with Body Composition in Women with Gynecologic Cancer Undergoing Post-Operative Pelvic Radiotherapy: An Observational Study

“…Pelvic radiotherapy is associated with GI toxicity and deterioration of the nutritional status of patients [ 10 , 11 , 12 ]. We found that the PG-SGA score at the end of radiotherapy was associated with the PRO-CTCAE score but not physician-reported CTCAE.…”

“…Pelvic radiotherapy is associated with gastrointestinal (GI) toxicities, including diarrhea, abdominal pain, food intolerance, and fecal incontinence [ 6 ]. GI toxicities are burdensome to patients, interfere with the quality of life, and can lead to nutritional status deterioration and muscle loss [ 7 , 8 , 9 , 10 , 11 , 12 ]. Muscle loss can, in turn, affect outcome and quality of life in women with gynecologic cancer [ 10 , 11 , 12 , 13 , 14 , 15 ].…”

“…GI toxicities are burdensome to patients, interfere with the quality of life, and can lead to nutritional status deterioration and muscle loss [ 7 , 8 , 9 , 10 , 11 , 12 ]. Muscle loss can, in turn, affect outcome and quality of life in women with gynecologic cancer [ 10 , 11 , 12 , 13 , 14 , 15 ]. Accurate assessment of GI toxicities and nutritional status may help predict muscle loss and enable potential intervention to maintain muscle mass during pelvic radiotherapy [ 16 ].…”

Gastrointestinal Toxicity of Pelvic Radiotherapy: Are We Letting Women Down?

“…Elemental diet reduces pancreatic and biliary secretions that may aggravate radiotherapy-induced mucosal inflammation [92]. Many find it unpalatable and compliance with an elemental diet is generally poor, especially if started when most likely to be effective, before symptoms develop [93e96].…”

Management of diet in gastrointestinal cancer

“…Pelvic radiotherapy causes damage to non-cancer gastrointestinal mucosa and has an effect on secretory and absorptive functions (51,52) . A review of dietary interventions to manage symptoms highlighted weak evidence for some dietary changes including elemental, low or modified fat and low lactose interventions (53) . The use of probiotics was more promising with four out of five studies suggesting that some symptoms benefit from their use although variations in the strength and strains and study methodologies make firm recommendations difficult.…”