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- Impact of nutrition on outcome : a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapyPublication . Ravasco, Paula; Monteiro Grillo, Isabel; Marques-Vidal, Pedro; Camilo, Maria ErmelindaBackground: We aimed to determine the effect of dietary counseling or oral supplements on outcome for patients with cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and 3 months after radiotherapy. Methods: Seventy-five patients with head and neck cancer who were referred for radiotherapy (RT) were randomized to the following groups: group 1 (n = 25), patients who received dietary counseling with regular foods; group 2 (n = 25), patients who maintained usual diet plus supplements; and group 3 (n = 25), patients who maintained intake ad lib. Nutritional intake (determined by diet history) and status (determined by Ottery's Subjective Global Assessment), and QOL (determined by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire version 3.0 [EORTC QLQ-C30]) were evaluated at baseline, at the end of RT, and at 3 months. Results: Energy intake after RT increased in both groups 1 and 2 (p < or = .05). Protein intake also increased in both groups 1 and 2 (p < or = .006). Both energy and protein intake decreased significantly in group 3 (p < .01). At 3 months, group 1 maintained intakes, whereas groups 2 and 3 returned to or below baseline levels. After RT, >90% of patients experienced RT toxicity; this was not significantly different between groups, with a trend for reduced symptomatology in group 1 versus group 2/group 3 (p < .07). At 3 months, the reduction of incidence/severity of grade 1+2 anorexia, nausea/vomiting, xerostomia, and dysgeusia was different: 90% of the patients improved in group 1 versus 67% in group 2 versus 51% in group 3 (p < .0001). After RT, QOL function scores improved (p < .003) proportionally with improved nutritional intake and status in group 1/group 2 (p < .05) and worsened in group 3 (p < .05); at 3 months, patients in group 1 maintained or improved overall QOL, whereas patients in groups 2 and 3 maintained or worsened overall QOL. Conclusions: During RT, nutritional interventions positively influenced outcomes, and counseling was of similar/higher benefit; in the medium term, only counseling exerted a significant impact on patient outcomes.
- Anal canal plasmacytoma : an uncommon presentation sitePublication . Antunes, Maria Inês; Bujor, Laurentiu; Monteiro Grillo, IsabelBackground: Extramedullary plasmacytomas (EMP) are rare plasma cell tumors that arise outside the bone marrow. They are most often located in the head and neck region, but may also occur in the other locations. The lower gastrointestinal EMP represents less than 5% of all cases, and location in the anal canal is exceedingly rare. Aim: We present an exceedingly rare case of anal canal plasmacytoma, aiming to achieve a better understanding of this rare entity. Methods: We report a case of a 61-year-old man with a bulky mass in the anal canal. The lesion measured about 6 cm and invaded in all layers of the anal canal wall. The biopsy was performed and revealed a round and plasmocitoid cell population with a solid growth pattern and necrosis. The tumoral cells have express CD79a and CD138 with lambda chains. There was no evidence of disease in other locations and these features were consistent with the diagnosis of an extra-osseous plasmacytoma. The patient was submitted to conformal radiotherapy 50.4 Gy total dose, 1.8 Gy per fraction. After 24 months, the patient is asymptomatic and the lesion has completely disappeared. Conclusions: EMP accounts for approximately 3% of plasma cell malignancies. The median age is about 60 years, and the majority of patients are male. The treatment of choice for extramedullary plasmacytoma is radiation therapy in a dosage of about 50 Gy. Patients should be followed-up for life with repeated bone marrow aspiration and protein studies to detect the development of multiple myeloma.
- Psychosocial effect of mastectomy versus conservative surgery in patients with early breast cancerPublication . Monteiro Grillo, Isabel; Marques-Vidal, Pedro; Jorge, MaríliaPurpose: To compare the quality-of-life (QoL) and psychosocial changes in a group of patients with early breast cancer who underwent conservative surgery (BCS) or modified radical mastectomy(MRM). Methods: Self-administered questionnaire assessing body image perception, social habits, sexual attraction and self-consciousness with relatives/friends, was randomly assigned to 125 patients (61 BCS, 64 MRM; aged 53 +/- 8 and 50 + 9 years, respectively, p = NS). Results: MRM patients reported a significantly higher frequency of changes in body image perception and other related social behaviour such as avoiding going to the beach or using low-cut clothes, and reticence with friends. Conversely, no differences were found regarding sexuality, denial of the disease by the husband/partner, or concealing the disease from family members. Also, no significant differences were found between patients above and below the age of 50 years, for all variables studied after adjustment for surgical procedure. Conclusions: Modified radical mastectomy has a negative effect on body image perception and in social behaviour patterns of patients and with a concomitant decrease in QoL. The sexuality of the patient is not significantly affected.
- Tamoxifen in breast cancer ipse dixit in uterine malignant mixed Müllerian tumor and sarcoma : a report of 8 cases and review of the literaturePublication . Vasconcelos, Ana Luisa Cardoso; Nunes, Beatriz; Duarte, Catarina; Mendonça, Vera; Ribeiro, Joana; Jorge, Marília; Monteiro Grillo, IsabelAim: Report the outcome of 8 patients (pts) with breast cancer (BC) treated with Tamoxifen (TAM) that developed malignant mixed Müllerian tumor (MMMT) and rare uterine sarcoma (RUS). Patients and methods: Retrospective study based on data collected from the department medical records between April 1999 and September 2010 among 583 pts with endometrial cancer, 36 pts with MMMT and RUS histopathology. Among them, 8 pts underwent TAM between 4 and 10 years due to a previous diagnosis of BC; all pts were post-menopausal with regular gynecological surveillance; 6 pts (75%) with abnormal uterine bleeding. The diagnosis of 6 pts (MMMT) and 2 pts (RUS) occurred at median interval of 8 years (range 4–12) after initial BC treatment. Pts underwent surgical treatment and were staged as stage I (3pts), IIIA (3pts) and IIIC (2 pts) (FIGO 1988); followed by whole pelvis irradiation (50 Gy) and intracavitary HDR brachytherapy boost (24 Gy). Two pts underwent chemotherapy (CT). Overall and disease free survival was calculated by Kaplan Meier method. Results: With a median follow-up of 47 months (range 17–130), 3 pts remain alive recurrencefree of BC and RUS. Four pts died with distant metastasis within the first follow-up year, without BC. One pt died from non-related cancer cause. No evidence of local recurrence was found in the whole group of pts. At two years, DFS and OS were 40% and 80%, respectively. Conclusion: As reported in the literature, TAM administration and causal effect on MMMT and RUS in BC pts is still unknown. No reports about outcome from these specific pts were found.
- Nutritional risks and colorectal cancer in a Portuguese populationPublication . Ravasco, Paula; Monteiro Grillo, isabel; Marques-Vidal, Pedro; Camilo, MariaBackground: Food and nutrition as major causes of colorectal cancer (CRC) are still debatable. Aim of the study: This cross-sectional study in a Portuguese population aimed to characterize and identify "high-risk" diets/life-styles and explore their associations with colorectal cancer. Methods: In 70 colorectal cancer patients and 70 sex, age-matched subjects without cancer history, we evaluated: diet history and detailed nutrient intake (DIET-PLAN5 2002, UK), alcohol (amount, type, years), smoking (number packages/year, years), physical activity, co-morbidities and body mass index. Age-adjusted Relative Risks were calculated, Proportional Hazards models adjusted the analysis for multiple risk factors. Results: Smoking was a risk factor (1.90). Increased colorectal cancer risk regarding the lowest vs the highest intake quartile emerged for: vitamin B12 (3.41), cholesterol (3.15), total fat (2.87), saturated fat (1.98), animal protein (1.95), energy (1.85), alcohol (1.70), iron (1.49), refined carbohydrates (1.39). Reduced colorectal cancer risk for the highest vs the lowest intake quartile was found for: n-3 fatty acids (0.10), insoluble fiber/folate (0.15), flavonoids/vitamin E (0.25), isoflavones/beta-carotene (0.30), selenium (0.36), copper (0.41), vitamin B6 (0.46). Conclusion: Our results corroborated well-established risk factors and identified emergent nutrients. Prolonged excessive intake of macronutrients and some micronutrients concurrent with marked deficits of fiber and protective compounds were dominant in colorectal cancer and more significant than alcohol and smoking. The interaction diet-colorectal cancer is consistent and the relevance of new nutrients is emerging.
- Cancer wasting and quality of life react to early individualized nutritional counselling!Publication . Ravasco, Paula; Monteiro Grillo, Isabel; Camilo, MariaTo 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.
- Cancer : disease and nutrition are key determinants of patients' quality of lifePublication . Monteiro Grillo, Isabel; Marques-Vidal, Pedro; Camilo, Maria; Ravasco, PaulaGoals 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.
- Qual o perfil nutricional e de estilos de vida do doente oncológico? Estudo transversalPublication . Rolão, Andreia; Monteiro Grillo, Isabel; Camilo, Maria; Ravasco, PaulaBackground: Cancer aetiology is multifactorial and risk factors include: obesity, central adiposity, sedentarism, excessive or deficient intake of foods and/or nutrients with pro-carcinogenic effects vs protective ones. Objectives: To evaluate the pattern of nutritional status, life styles, physical activity and diet in a cohort of cancer patients. Methods: This pilot cross-sectional study was conducted in 64 patients referred for radiotherapy at the Radiotherapy Department of the University Hospital of Santa Maria (CHLN). Evaluations were: waist circumference associated with potential cardio-metabolic risk, body composition by Tetrapolar Bioimpedance Analysis (XITRON®), Body Mass Index, dietary intake pattern with a short food frequency questionnaire, physical activity with Jackson questionnaire. Results: The most frequent diagnosis were breast and colorectal cancers; 53% of patients were overweight/obese, and there was a significant correlation between this nutritional pattern and weight gain in comparison with usual weight (p<0.005). There were 78% of patients with a waist circumference above the maximum cut-off limit, indicating moderate/ high cardio-metabolic risk, and most were female patients (87%). The great majority of patients (61%) had excessive fat mass highly above the maximum recommended cut-off value, especially male patients (74%). The dietary pattern was poor in vegetables (55%) and excessive in meat and simple carbohydrates (78%); physical activity was low with a high prevalence of sedentarism. Conclusions: This population presented excessive body weight, excessive fat mass, high cardio-metabolic risk, sedentarism and an unbalanced diet poor in protective foods/nutrients. This population's life styles and nutritional pattern, may be considered of risk in oncology disease. The elevated and growing incidence of cancer in Portugal, reinforces the need for further research in order to identify nutritional factors involved in the etiology/evolution and probably prognosis of cancer.
- Does nutrition influence quality of life in cancer patients undergoing radiotherapy?Publication . Ravasco, Paula; Monteiro Grillo, Isabel; Camilo, MariaPurpose: 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.
- Qualidade de vida em doentes com cancro gastrintestinal : qual o impacto da nutrição?Publication . Ravasco, Paula; Monteiro Grillo, isabel; Marques-Vidal, Pedro; Camilo, Maria ErmelindaIntroduction: Nutrition and Quality of Life (QoL) are key issues. Aims: 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 inter-relations, 3) to quantify the relative contributions of cancer/nutrition/treatments on QoL. Methods: In 184 oesophagus, stomach and colon/rectum cancer patients, the following were evaluated: QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire), nutritional status (% weight loss over the previous 6 months), usual diet (diet history), current diet (24 hr recall) and a range of clinical variables. Results: Stage III/IV patients showed a significant reduction from their usual energy/protein intake (p=0.001), worse in oesophagus (p=0.02), while current intakes were lower than in stage I/II patients (p=0.0002). Weight loss was greater in stage III/IV (p=0.001). Different diagnoses and cancer stages presented different patterns of QoL function scales (p=0,03), significantly and independently associated with nutritional factors (p=0,05). Patients in stage III/IV had increased symptomatology (p=0,003); symptom scales and single items were strongly associated with stage III/IV (p=0,04). Patients with stomach cancer presented the worst global QoL not significantly different from oesophagus, vs colon/rectum, p=0,02. Conclusions: In oesophageal, stomach and colon/rectum cancer, nutritional deterioration depends of diet intake, the latter is mainly determined by cancer location and stage. Patients' QoL was determined by cancer or nutrition-related factors with distinct relative weights. Due to this multidimensional construct, in which nutrition plays a major role, nutritional therapy must be integrated in early stages of the overall treatment.