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Browsing by Author "Ravasco, Paula"

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  • Aspects of taste and compliance in patients with cancer
    Publication . Ravasco, Paula
    Taste alterations are common in patients with cancer, and can be the result of the disease itself and/or its treatment(s). Specifically, chemotherapy and/or radiotherapy to the head and neck area have been shown to induce significant taste changes. Alterations in taste are distressing for patients and can lead to food aversions, a reduction in food intake and nutritional deficits. Ultimately, this can lead to weight loss and, in severe cases, malnutrition, which has been associated with poor patient outcomes, including a negative effect on survival. Dietary counselling and advice tailored to the individual can improve nutritional status, and several effective strategies are available to accommodate taste changes and increase nutritional intake. Oral supplements may provide additional nutritional support when dietary intake is insufficient. The success of supplementation depends, however, on the product acceptability and on patient compliance over the long term. Patient compliance is linked to perceived supplement taste, which may be affected by a variety of taste changes reported by patients both before and after therapy, or as a consequence of disease progression. Supplements which offer a variety of flavours are likely to prove beneficial by helping to prevent taste fatigue. In addition, individuals appear to exhibit distinct preferences for particular flavours at different time points during treatment.
    2005Journal article Restricted access Show more
  • Body composition changes in patients with head and neck cancer under active treatment : a scoping review
    Publication . Ferrão, Bárbara; Neves, Pedro Miguel; Santos, Teresa; Capelas, Manuel Luís; Mäkitie, Antti; Ravasco, Paula
    Background Head and neck cancer patients have the second highest malnutrition prevalence, when compared with other oncological patients. They experience significant weight loss before diagnosis, during and after treatment, and even during the first year of follow-up. However, the prognostic value of weight loss depends on body mass index, and this may be associated with low skeletal muscle mass, masking its loss. Thus, weight loss itself poorly predicts outcome in head and neck cancer patients when compared with depleted skeletal muscle mass, illustrating the inadequacy of body mass index as an accurate method to reflect nutritional status. A synthesis is needed of the body composition changes occurring in head and neck cancer patients during treatment, as well as of the methods to assess it. Objective The aim of this scoping review is to examine and map the body composition changes in head and neck cancer patients under oncological treatment with curative intent. A further objective is to determine which methods are used to assess body composition in these patients. Inclusion criteria Types of participants: The current review considered head and neck cancer patients, aged 18 years or older. Concept: This scoping review considered all studies that focused on the body composition changes. Context: This scoping review considered the studies that evaluated the body composition changes in the context of treatment with curative intent. Surgical treatment approach was excluded to avoid excess heterogeneity in the data. Types of sources: This scoping review considered only published studies, with abstract available. Search strategy: A three-step search strategy was undertaken. This review was limited to studies published in English, Spanish, and Portuguese during 2000–2019. Data extraction The data extracted included author(s)/year of publication, aims and purpose of the study, sample size, study design, type of treatment, measurement points and component(s) of body composition evaluated, body composition assessment methods, and main results/findings. Presentation of results Head and neck cancer patients suffer from serious loss of lean body mass, skeletal muscle, or free fat mass, after treatment compared with baseline. Further, nutritional deterioration is evident and occurs up to 8–12 months after treatment. Bioelectrical impedance analysis is one of the body composition assessment tools that has the great advantage for being available on a regular basis for assessment of body composition in head and neck cancer patients. However, it cannot be recommended for clinical decision making until further validation. Conclusion Head and neck cancer patients experience a significant depletion of lean body mass, fat-free mass, and skeletal muscle, accompanied by body fat mass, while undergoing (chemo)radiotherapy. This can be demonstrated either by triceps skinfold thickness, bioelectrical impedance analysis, dual-energy x-ray absorptiometry, or computed tomography. This loss has a remarkable impact on their survival, on their quality of life, and on the risk for post-operative complications and may result in a reduced response to cancer treatment. Thus, body composition assessment should become an integral component of the care of head and neck cancer patients, beyond weight and body mass index, and should be carried out at different times throughout treatment.
    2020Journal article Restricted access Show more
  • Cancer : disease and nutrition are key determinants of patients' quality of life
    Publication . Monteiro Grillo, Isabel; Marques-Vidal, Pedro; Camilo, Maria; Ravasco, Paula
    Goals of work: The aims of this study were (1) to evaluate quality of life (QoL), nutritional status and dietary intake taking into account the stage of disease and therapeutic interventions, (2) to determine potential interrelationships, and (3) to quantify the relative contributions of the cancer, nutrition and treatments on QoL. Patients and methods: In this prospective cross-sectional study conducted in 271 head and neck, oesophagus, stomach and colorectal cancer patients, the following aspects were evaluated: QoL (EORTC-QLQ C30), nutritional status (percent weight loss over the previous 6 months), usual diet (comprehensive diet history), current diet (24-h recall) and a range of clinical variables. Main results: Usual and current intakes differed according to the site of the tumour ( P=0.02). Patients with stage III/IV disease showed a significant reduction from their usual energy/protein intake ( P=0.001), while their current intakes were lower than in patients with stage I/II disease ( P=0.0002). Weight loss was greater in patients with stage III/IV disease than in those with stage I/II disease ( P=0.001). Estimates of effect size revealed that QoL function scores were determined in 30% by cancer location, in 20% by nutritional intake, in 30% by weight loss, in 10% by chemotherapy, in 6% by surgery, in 3% by disease duration and in 1% by stage of disease. Likewise in the case of symptom scales, 41% were attributed to cancer location, 22% to stage, 7% to nutritional intake, 7% to disease duration, 4% to surgery, 1% to weight loss and 0.01% to chemotherapy. Finally for single items, 30% were determined by stage, 20% by cancer location, 9% by intake, 4% by surgery, 3% by weight loss, 3% by disease duration and 1% by chemotherapy. Conclusions: Although cancer stage was the major determinant of patients' QoL globally, there were some diagnoses for which the impact of nutritional deterioration combined with deficiencies in nutritional intake may be more important than the stage of the disease process.
    2004Journal article Restricted access Show more
  • Cancer : metabolic dysfunction, nutrition and quality of life
    Publication . Ravasco, Paula; Camilo, Maria Ermelinda, 1943-
    Cancer is a major cause of morbidity and mortality worldwide. Cancer is the second most frequent cause of death and is becoming the leading cause of death in an ageing population, as most cancers occur in older adults; of note, cancer-related malnutrition is the immediate cause of death of 20% of the patients with cancer. Notwithstanding that different cancer types or locations may display different nutritional patterns, there is some inconsistency between studies in what concerns nutritional status assessment and cancer/treatment-related variables. A thorough analysis of their interaction is long due, in order to step forward the eagerly awaited evidence to foster the integration of appropriate nutritional therapy. Moreover, although 8 to 84% of cancer patients may present some degree of nutritional deterioration, which has been associated with functional impairment, the interaction between nutritional status and intake, symptoms and other disease/treatment-related factors, is a complex combination which may dictate patients’ Quality of Life (QoL). Nevertheless, the multitude of interactions between cancer location and stage, treatments, nutritional status and intervention, morbidity and QoL has never been thoroughly explored. The evidence for these interactions will be demonstrated in this thesis, which results from the collision of data from several prospective studies conducted in cancer patients. The present Thesis is structured into five sections. 1. Section 1 comprises Chapter 1 and Chapter 2. Chapter 1 describes the aims and the outline of the thesis. Chapter 2 consists of a general introduction reviewing the main concepts relevant to the studies’ design and analyses undertaken in the work ascribed to this thesis; specifically the multifactorial nature of cancer-related malnutrition, its impacts on the patients’ disease progress as well as the interactions between nutrition, morbidity and Quality of Life. 2. In Section 2, a pilot study conducted in a heterogeneous cancer patient population referred for radiotherapy is presented, which includes a critical analysis of different methods to measure QoL and the effect of nutritional intervention on nutritional parameters and QoL: • Chapter 3. Patients submitted to radiotherapy (RT), particularly of the head and neck or the gastrointestinal tract, are at higher risk of malnutrition, aggravated by the therapy induced toxicity that may further compromise nutrition and functional status. Since patients’ QoL reflects functional status, psychosocial well being, health perceptions and disease/treatment-related symptoms, the patients’ nutritional status, nutritional intake and symptoms are thus likely to assume a significant role in their QoL. We investigated: 1) the patients’ nutritional status, nutrient intake and QoL at the onset and at the end of RT, 2) whether individualised nutritional counselling, despite RT-induced symptoms, was able to enhance nutrient intake over time and whether the latter influenced the patient’s QoL and 3) which symptoms may have anticipated poorer QoL and/or reduced nutritional intake. This study showed that in patients prone to develop nutritional problems and to report the worst QoL during RT, an individualised nutritional counselling did improve nutritional intake which was identified as central to a better QoL. Additionally, from the two QoL instruments tested, the non-specific EUROQOL should be used routinely because its completion is less time consuming; the more comprehensive cancer-specific EORTC QLQ C-30 instrument covers more items and scales, identifies more domains and specific complaints, and although time consuming provides the accuracy required for research. Both instruments were able to assess patients’ QoL and both revealed the relevance of nutrition care. 3. Section 3. • Chapter 4. Based on this background, gathering validated objective data on nutritional status and its evolution throughout the disease course is of prime concern. Thus, we conducted a prospective study in head and neck, oesophageal, stomach and colorectal cancer patients, aiming to explore the intricate construct of various disease-related and diet-related factors potentially implicated in the patients’ nutritional deterioration. The disease extent was hypothesized as key to current nutritional status, which was assessed by three different methods, further compared in order to disclose their reliability. Regardless of the nutritional assessment method used, nutritional depletion was a multifactorial outcome determined by cancer and diet-related factors, all of which were simultaneously evaluated in a general linear model. Advanced cancer stage showed by far the most significant association with worse nutritional status; cancer locations, duration of the disease, protein and energy intake, and previous surgery or chemotherapy, were also significantly associated. Besides the identification of valid nutrition assessment tools, this study provided novel clinical evidence of the complex interactions between cancer and/or treatment-related variables and diet modifications, all of which exerted a combined effect on the patients’ nutritional deterioration. Cancer location was the dominant factor influencing the pattern and/or progression of nutritional deterioration; though the tumour burden for the host was of major importance. Our results were consistent with the hypothesized relations between progressive disease and wasting, which purportedly exacerbate every organ/systemic physiological derangement. • Chapter 5. It then became necessary to explore the potential interaction(s) between various disease-related and diet-related factors likely to be implicated in the patients’ QoL. A prospective cross-sectional study was thus conducted in head and neck, oesophageal, stomach and colorectal cancer patients; the specific aims were to evaluate patients’ nutritional status, nutrient intake and QoL, taking into account the disease stage and previous therapeutic interventions, to determine the potential inter-relations, and to quantify the relative impact of cancer/treatments and/or nutrition-related factors on patients’ QoL. This study provided objective evidence that cancer, diet deficits, nutritional deterioration and therapeutic interventions are determinants of the patients’ QoL, but with distinct relative weights. Whilst chemotherapy and surgery were perceived by the patients as of minor relevance, nutritional deficits and/or deterioration were intrinsic to the cancer location and stage, to reduced energy/protein intake and to weight loss, which were independent determinants of QoL. These results concur with seminal landmark data which revealed that semi-starvation impairs functional and psychological abilities, and in addition corroborated our previous study demonstrating the relationship between progressive disease and wasting. 4. Section 4. Based on the knowledge that in the above mentioned cancer patients, the location and stage of the disease as well as nutritional aspects are major determinants of patients’ QoL, it remained to be proven whether nutritional intervention might influence outcomes; therefore two prospective randomised controlled trials of nutritional therapy were conducted: 1) in colorectal cancer or 2) head and neck cancer outpatients, in order to address the potential role of adjuvant oral nutritional support on patients’ outcomes. • Chapter 6. The study herewith summarised was designed to test the hypothesis of a causal pathway between nutritional therapy and functional/clinical outcomes. A prospective randomised controlled trial, in colorectal cancer patients referred for radiotherapy, was designed to investigate whether, and to what degree, total oral intake was affected by dietary counselling or ad libitum intake supplemented with commercial supplements, both provided during RT. Furthermore the impact of nutritional intake on predefined outcomes, nutritional status and QoL, during treatment and 3 months later was examined. Despite the expected and experienced detrimental effects of RT, concurrent nutrition care integrated in the overall patient management allowed proper assessment of nutritional status and nutritional requirements, dietary counselling, education and monitoring of diet compliance and timely management of symptoms. Nutrition intervention was central to the improvement of colorectal cancer patients’ nutritional as well as non-nutritional outcomes: nutritional intake and status, QoL and lessened morbidity even in the medium term. Adding oral nutritional supplements to the diet did not appear to be as effective as dietary counselling. The control group showed a progressive deterioration in all items. • Chapter 7. Within a similar framework, with the same goals and an identical study design as in Chapter 6, the results of a prospective randomised controlled trial of nutritional therapy in head and neck cancer patients, referred for radiotherapy, are presented. The results were similar to those registered in colorectal cancer patients: nutritional counselling was indeed central to the improvement of a diversity of patient outcomes in such patients: nutritional intake, nutritional status, QoL and lessened morbidity, even in the medium term, after treatment completion. Adding oral nutritional supplements to the diet did not appear to be as effective as dietary counselling. Indeed, concurrent individualized dietary counselling based on regular foods, was the most effective means of improving patients’ nutritional intake, status and QoL during RT which are sustained 3 months after its completion, thereby lessening RT induced morbidity. The control group showed a progressive deterioration in all items. 5. Finally, Section 5 comprises Chapter 8 in which results of the studies ascribed to this thesis are discussed and some guidelines for potential future research are also suggested.
    2006Doctoral thesis Open access Show more
  • Cancer wasting and quality of life react to early individualized nutritional counselling!
    Publication . Ravasco, Paula; Monteiro Grillo, Isabel; Camilo, Maria
    To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients' expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients' quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients' outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.
    2007Journal article Restricted access Show more
  • A critical approach to nutritional assessment in critically ill patients
    Publication . Ravasco, Paula; Camilo, M. E.; Oliveira, Antonio; Adam, S.; Brum, G.
    Background and aims: Nutritional assessment enhances quality of nutritional care, however, its practice bemuses professionals. This prospective study aimed to identify a feasible/informative nutritional parameter in intensive care. Methods: 44 patients (APACHE II: 23.8+/-10.1), age 58.4+/-18.6 years, were evaluated at admission: clinical data, height, weight, body mass index (BMI), tricep skinfold thickness, mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), albumin, total protein and lymphocyte count. Anthropometric parameters' performance was evaluated isolated or assembled according to Blackburn and McWhirter criteria. Results: Oedema increased %IW and BMI (P<0.01); muscle depletion was frequent and agreed with MAC or MAMC ranked by both criteria, P=0.02. %IW and BMI overestimated well-nourished/overweight patients, whilst arm anthropometry, mostly MAC/MAMC, shifted towards +/-50% malnutrition. Patients were not equally ranked by both criteria; McWhirter's by using percentiles clarified the distribution and showed agreement between MAC and MAMC, P=0.007, unlike Blackburn's. Mortality was higher in patients with MAC<5th percentile, P=0.003; MAC;<15th percentile was able to predict mortality and major complications. In invasive ventilated patients, severe muscle depletion was associated with mortality, P=0.05. Conclusion: In intensive care most nutritional assessment methods are useless; MAC is simple, feasible and if classified by percentiles may prove functional with prognostic value.
    2002Journal article Restricted access Show more
  • Dairy products : is there an impact on promotion of prostate cancer? A review of the literature
    Publication . Vasconcelos, Alexandra; Santos, Teresa; Ravasco, Paula; Neves, Pedro Miguel
    This review of the literature aims to study potential associations between high consumption of milk and/or dairy products and prostate cancer (PC). Literature is scarce, yet there is a direct relationship between mTORC1 activation and PC; several ingredients in milk/dairy products, when in high concentrations, increase signaling of the mTORC1 pathway. However, there are no studies showing an unequivocal relationship between milk products PC initiation and/or progression. Three different reviews were conducted with articles published in the last 5 years: (M1) PC and intake of dairy products, taking into account the possible mTORC1signaling mechanism; (M2) Intake of milk products and incidence/promotion of PC; (M3) mTORC1 activation signaling pathway, levels of IGF-1 and PC; (M4) mTORC pathway and dairy products. Of the 32 reviews identified, only 21 met the inclusion criteria and were analyzed. There is little scientific evidence that directly link the three factors: incidence/promotion of PC, intake of dairy products and PC, and PC and increased mTORC1 signaling. Persistent hyper-activation of mTORC1 is associated with PC promotion. The activity of exosomal mRNA in cellular communication may lead to different impacts of different types of milk and whether or not mammalian milks will have their own characteristics within each species. Based on this review of the literature, it is possible to establish a relationship between the consumption of milk products and the progression of PC; we also found a possible association with PC initiation, hence it is likely that the intake of dairy products should be reduced or minimized in mens' diet.
    2019Journal article Open access Show more
  • The diversity of nutritional status in cancer : new insights
    Publication . Chaves, Mariana Ramos; Boléo-Tomé, Carolina; Monteiro-Grillo, Isabel; Camilo, Maria; Ravasco, Paula
    Objective. Nutritional status in cancer has been mostly biased toward undernutrition, an issue now in dispute. We aimed to characterize nutrition status, to analyze associations between nutritional and clinical/cancer-related variables, and to quantify the relative weights of nutritional and cancer- elated features. Methods. The cross-sectional study included 450 nonselected cancer patients (ages 18 –95 years) at referral for radiotherapy. Nutritional status assessment included recent weight changes, body mass index (BMI) categorized by World Health Organization's age/sex criteria, and Patient-Generated Subjective Global Assessment (PG-SGA; validated/specific for oncology). Results. BMI identified 63% as >25 kg/m2 (43% overweight, 20% obese) and 4% as undernourished. PG-SGA identified 29% as undernourished and 71% as well nourished. Crossing both methods, among the 319 (71%) well- nourished patients according to PG-SGA, 75% were overweight/obese and only 25% were well nourished according to BMI. Concordance between BMI and PG-SGA was evaluated and consistency was confirmed. More aggressive/ advanced stage cancers were more prevalent in deficient and excessive nutritional status: in 83% (n = 235/ 282) of overweight/obese patients byBMIand in 85% (n = 111/131) of undernourished patients by PG-SGA. Results required adjustment for diagnoses: greater histological aggressiveness was found in overweight/obese prostate and breast cancer; undernutrition was associated with aggressive lung, colorectal, head-neck, stomach, and esophageal cancers (p < .005). Estimates of effect size revealed that overweight/obesity was associated with advanced stage (24%), aggressive breast (10%), and prostate (9%) cancers, whereas undernutrition was associated with more aggressive lung (6%), colorectal (6%), and head-neck (6%) cancers; in both instances, age and longer disease duration were of significance. Conclusion. Undernutrition and overweight/obesity have distinct implications and bear a negative prognosis in cancer. This study provides novel data on the prevalence of overweight/obesity and undernutrition in cancer patients and their potential role in cancer histological behavior.
    2010Journal article Restricted access Show more
  • Does nutrition influence quality of life in cancer patients undergoing radiotherapy?
    Publication . Ravasco, Paula; Monteiro Grillo, Isabel; Camilo, Maria
    Purpose: To investigate in cancer patients referred for radiotherapy (RT): (1) quality of life (QoL), nutritional status and nutrient intake, at the onset and at the end of RT; (2) whether individualised nutritional counselling, despite symptoms, was able to enhance nutrient intake over time and whether the latter influenced the patient's QoL; and (3) which symptoms may anticipate poorer QoL and/or reduced nutritional intake. Material and methods: One hundred and twenty-five patients with tumours of the head-neck/gastrointestinal tract (high-risk: HR), prostate, breast, lung, brain, gallbladder, uterus (low-risk: LR) were evaluated before and at the end of RT. Nutritional status was evaluated by Ottery's Subjective Global Assessment, nutritional intake by a 24-h recall food questionnaire and QoL by two instruments: EUROQOL and the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30. Results: Baseline malnutrition was prevalent in HR vs. LR (P=0.02); nutritional intake was associated with nutritional status (P=0.007); the latter did not change significantly during RT. In LR, baseline energy intake was higher than EER (P=0.001), and higher than HR' intake (P=0.002); the latter increased (P<0.03), in spite of symptom increase anew and/or in severity (P=0.0001). According to both instruments, QoL was always better in LR vs. HR (P=0.01); at the end of RT, QoL improvement in HR was correlated with increased nutritional intake (P=0.001), both remained stable in LR. Conclusions: Individualised nutritional counselling accounting for nutritional status and clinical condition, was able to improve nutritional intake and patients' QoL, despite self-reported symptoms.
    2003Journal article Unknown Show more
  • Does nutrition play a role in the quality of life of patients under chronic haemodialysis?
    Publication . Raimundo, P.; Ravasco, Paula; Proença, V.; Camilo, M.
    Background: In patients with chronic renal failure under haemodialysis, we investigated the inter-relationships and relative contributions of disease, haemodialysis and of nutrition related factors on the patients' Quality of Life. Methods: Collected data in 60 adult patients comprised: co-morbidities (multiple medicines, other chronic diseases), duration of renal failure and of haemodialysis (in months), % weight loss since haemodialysis, nutrient intake derived from diet history analysis (DIETPLAN5 2003, UK). The EuroQoL instrument that includes 5 dimensions, mobility, self-care, activities, pain/discomfort, anxiety/depression, and an overall health visual analogue scale evaluated QoL. Results: Estimates of effect size attributed to each variable included in the general linear model revealed that 47% of patients' mobility/self-care scores were worsened by deficient protein/energy intake and 30% by weight loss =10%. Poor performance of usual activities was attributed in 45% to duration of haemodialysis and of disease, 70% to protein/energy/vitamin B12/zinc/iron deficits, and 20% to weight loss =10%. Pain/discomfort were worsened in 45% by the duration of haemodialysis and of disease, and in 15% by co-morbidities. Higher anxiety/depression were related in 43% to protein/energy/selenium & vitamin C deficits, in 40% to the duration of haemodialysis and of disease, in 10% to weight loss =10%, and in 3% to co-morbidities. Likewise, 47% of poor overall health was determined by protein/energy/vitamin B12/ zinc/selenium & vitamin C deficits, 25% by weight loss =10%, 10% by disease duration, and 7% by co-morbidities. Conclusion: Protein, antioxidants and key micronutrients involved in protein metabolism, did exert a major effect on patients' Quality of Life. Given the prevalence of nutrient deficits, the ensuing impaired functional capacity is likely to compromise QoL, timely nutrition is thus warranted.
    2006Journal article Unknown Show more