Managing the nutritional status of people with oesophagogastric cancer: a literature review
Intended for healthcare professionals
Evidence and practice    

Managing the nutritional status of people with oesophagogastric cancer: a literature review

Stella Watson Community staff nurse, HCRG Care Group, Farnham, England
Tanya Andrewes Senior lecturer, Department of Nursing Science, Bournemouth University, Bournemouth, England

Why you should read this article:
  • To recognise the nutritional issues that patients may experience following treatment for oesophagogastric cancer

  • To learn about the latest research on patients’ experiences following an oesophagectomy

  • To understand the role of nurses in providing nutritional support and optimising quality of life

Following an oesophagectomy for oesophagogastric cancer, patients can experience significant issues such as dysphagia, weight loss and malnutrition, which means that they require nutritional support. This article details a literature review that sought to explore the experience of patients who had undergone an oesophagectomy, as well as investigating how nurses might enhance the management of patients’ nutritional status. Analysis of data from six primary qualitative research studies led to the identification of three themes: feelings associated with eating and maintaining nutritional status; social disengagement and isolation; and managing bodily impairments. Nurses should initiate early discussions with patients with oesophagogastric cancer to assess their nutritional needs, ensure prompt referral to a dietitian and/or clinical nurse specialist in nutrition, and signpost patients to appropriate support services.

Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1829

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@AndrewesTanya

Correspondence

tandrewes@bournemouth.ac.uk

Conflict of interest

None declared

Watson S, Andrewes T (2022) Managing the nutritional status of people with oesophagogastric cancer: a literature review. Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1829

Published online: 08 November 2022

OESOPHAGOGASTRIC CANCER is the ninth most common cancer in UK males, with around 6,400 new cases per year, and the 15th most common in UK females, with around 2,800 new cases per year (Cancer Research UK 2022). However, people are living with oesophagogastric cancer for longer. The latest survival data, from 2013-17, indicated that 12% of people in England and Wales with oesophagogastric cancer survive for ten years or more, which has been attributed to earlier diagnosis, enhanced surgical techniques and the efficacy of neoadjuvant treatment (Cancer Research UK 2022).

An oesophagectomy is the surgical removal of part of the oesophagus to treat the cancer at an early stage (Macmillan Cancer Support 2019). Following an oesophagectomy, patients may be affected by dysphagia (swallowing difficulties), weight loss and malnutrition, so it is essential for healthcare professionals to provide effective nutritional support to improve their quality of life.

While enhanced recovery programmes after surgery focus on the early introduction of enteral nutrition following an oesophagectomy, in some cases – for example where patients with oesophageal cancer are malnourished at diagnosis – enteral nutrition is required preoperatively to ensure adequate nutritional support (Berkelmans et al 2017). Following an oesophagectomy, patients are commonly discharged from hospital with a feeding tube in situ to support their nutritional intake and the maintenance of a healthy body weight (Macmillan Cancer Support 2019). This can be either a nasogastric tube or a gastrostomy tube. In some cases, nasoenteric tubes (from the nose to jejunum or duodenum) may be used where nasogastric tube placement fails. Sometimes oral nutrition is introduced alongside enteral nutrition post-operatively or when the patient returns home.

Interprofessional working is important in supporting nutritional care for people with oesophagogastric cancer. Dietitians are instrumental in developing individual meal plans to address issues for patients such as dysphagia, changes in taste, dry mouth, oesophagogastric sores, nausea, vomiting and constipation, all of which can affect patients’ nutritional intake. Interventions from dietitians can assist patients to manage these side effects and improve their energy levels, thus supporting the healing process following an oesophagectomy (OncoLink 2022).

Nurses have significant contact with hospital patients so are well placed to monitor their nutritional status and discuss their nutritional experiences and challenges. In addition, nurses have a vital role in supporting communication between patients and members of the multidisciplinary team including the dietitian, which is a fundamental aspect of providing the safe, effective and personalised care required by the Nursing and Midwifery Council (NMC) (2018).

Historically, most research about nutritional status in patients with oesophagogastric cancer has been quantitative, with a focus on understanding weight loss and the effect of nutritional interventions on disease and treatment outcomes. Deftereos et al’s (2020) systematic review into the effects of preoperative nutrition noted that despite some evidence to support the positive effect of preoperative nutrition on wound infection rates, length of hospital stay and hospital costs, there was no clear evidence on the optimal method of nutritional support for patients about to undergo oesophagectomy. Therefore, the authors undertook a literature review to explore this area further.

Aim

To analyse the qualitative nutritional experiences of patients with oesophagogastric cancer. The authors also sought to develop an understanding of the nurse’s role in nutritional support, and to propose recommendations for nursing practice to enhance the nutritional experiences of patients with oesophagogastric cancer.

Key points

  • An oesophagectomy is the surgical removal of part of the oesophagus to treat oesophagogastric cancer

  • Following an oesophagectomy, patients may be affected by dysphagia, weight loss and malnutrition, so it is essential for healthcare professionals to provide effective nutritional support

  • This literature review sought to analyse the qualitative nutritional experiences of patients with oesophagogastric cancer

  • Three themes were identified from the data: feelings associated with eating and maintaining nutritional status, social disengagement and isolation, and managing physical impairments

Method

The literature review was undertaken in November 2021. The PEO framework was used to develop the research question, as follows:

  • Population – people with oesophageal cancer.

  • Exposure – nutritional interventions or problems.

  • Outcome – experiences or perceptions.

Literature searches were undertaken in the Directory of Open Access Journals, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, ScienceDirect, Academic Search Ultimate and PsycINFO databases. The key words used in the literature search were: ‘oesophagogastric cancer’ or ‘esophagogastric cancer’; ‘impact’ or ‘affect’ or ‘influence’; ‘artificial feed*’ or ‘nasogastric*’ or ‘enteral feed*’; ‘experience’ or ‘perspective’; and ‘qualitative research’. Boolean logic and truncation were used to broaden the search results. A proximity operator was applied within the search to limit results to terms that appeared within a specified number of words in a phrase.

Initially, 293 articles were identified from the search, with 148 remaining after duplicates were removed. At this stage, the authors filtered the articles to identify those that were most relevant to the review. Subsequently, a further 128 articles were excluded because they did not meet the inclusion and exclusion criteria outlined in Table 1. The remaining 20 articles were read in full by the authors to assess their eligibility and a further 14 were subsequently discarded because of their insufficient focus on the research aim. This left six primary research articles that were systematically analysed using the Understanding Health Research critical appraisal tool (Medical Research Council et al 2022). Each of them demonstrated suitable quality and focus for inclusion in the literature review.

Table 1.

Inclusion and exclusion criteria

Inclusion criteriaExclusion criteria
  • Adult patients with oesophagogastric cancer

  • Focus on nutrition

  • Primary, qualitative research

  • English language

  • Peer reviewed

  • Published within the past ten years (since 2011)

  • Not focused on experiences of patients with oesophagogastric cancer

  • Not peer reviewed

  • Not English language

Findings

Data from the six articles were entered into a summary of findings table, shown in Table 2. This formed the basis of the thematic analysis because it enabled the authors to identify themes more clearly.

Table 2.

Summary of findings table

cnp.2022.e1829_0002_tb1.jpg

The initial themes were tested in peer discussions and academic supervision, where they were explored and justified with evidence. Three themes were identified from the data:

  • Feelings associated with eating and maintaining nutritional status.

  • Social disengagement and isolation

  • Managing physical impairments.

Feelings associated with eating and maintaining nutritional status

The most prominent theme in the data was ‘feelings associated with eating and maintaining nutritional status’. Although slightly dated, the study by Jaromahum and Fowler (2010) was included to expand the amount of data available for the review. The researchers used a phenomenological approach to describe seven patients’ lived experiences of eating after oesophagectomy. Participants described various feelings about eating, ranging from happiness about being able to resume eating to fears about relying on family members and/or carers who would be supporting them, managing a feeding tube at home or managing nutrition. Although some participants were anxious about vomiting at home, they expressed determination to eat and become stronger (Jaromahum and Fowler 2010).

These findings were reflected in the work of Malmstro¨m et al (2013), who conducted focus group interviews with 17 patients who had undergone surgery for oesophagogastric cancer in the previous two to five years. Most of the participants described having lost weight, which was attributed to lack of appetite and changes in their sensation of taste following surgery. This caused them anxiety. Weight loss was not universal in this group, with some participants maintaining weight; however, even these participants described a fine balance between eating sufficient amounts to maintain weight but avoiding overeating, which could result in nausea (Malmstro¨m et al 2013).

De Vries et al (2016) reported on a qualitative study that explored chemosensory and food-related changes in 13 patients with advanced oesophagogastric cancer who were receiving palliative chemotherapy. The findings detailed the participants’ fears about not being able to swallow their food, in addition to panic they experienced about gastric reflux at night if they did not monitor what and when they ate (de Vries et al 2016).

Similar concerns were reinforced in Alberda et al’s (2017) descriptive qualitative study, which included eight males and two females who had undergone neoadjuvant chemotherapy and oesophagectomy. The researchers detailed increased levels of stress, fear and concern about swallowing difficulties that, along with associated pain, resulted in weight loss and reduced nutrition. In this study, data were collected close to the completion of the participants’ cancer treatment, by which time their eating difficulties may have become exacerbated (Alberda et al 2017).

A hermeneutic phenomenological study by Laursen et al (2019) included seven women and ten men who were receiving palliative chemotherapy. The findings reinforced a correlation between swallowing difficulties and fears about weight loss and altered appearance, with participants describing anxiety around mealtimes as being a ‘struggle for survival’. Missel et al’s (2018) phenomenological study was undertaken in the same centre as that used by Laursen et al (2019), but with eight male and two female participants. Missel et al (2018) described how the participants’ fear and anxiety around eating meant a loss of freedom to enjoy food without feelings of self-consciousness. The researchers also found that pre-discharge educational support from nurses was valuable for participants, while family members were acknowledged as being supportive in managing participants’ low moods, which were associated with fears about eating and maintaining nutritional status. It is unclear whether there was an overlap of participant data in the studies by Laursen et al (2019) and Missel et al (2018); however, different perspectives were offered in each study.

The data associated with this theme emphasised that participants’ feelings of eating and maintaining nutritional status were not universally negative; however, few patients reported positive feelings. Where positive experiences were reported, they arose when individuals could consume food again after a period of not being able to eat. Generally, participants across the studies felt anxious and fearful in relation to functional issues such as being able to physically swallow food. They described a fine balance between eating sufficiently to maintain nutrition but not so much that they would become physically uncomfortable or nauseous. Education from nurses was valued and family members and/or carers were important in providing support in response to patients’ fears and anxiety around eating.

Social disengagement and isolation

Feelings of social disengagement and isolation were evident across four of the studies (Malmstro¨m et al 2013, de Vries et al 2016, Alberda et al 2017 and Laursen et al 2019).

Participants in the studies by Alberda et al (2017) and Laursen et al (2019) described a loss of pleasure around eating, due in part to the need to plan what and when to eat to avoid pain and nausea, or to avoid the embarrassment of nausea and vomiting as a result of eating. A lack of energy due to the need to plan ahead when eating out, as well as the prolonged act of eating arising from treatment-related functional changes such as difficulties with chewing or digesting, also caused participants in some studies to withdraw from social opportunities (de Vries et al 2016, Alberda et al 2017).

Most participants in Laursen et al’s study (2019) referred to the social aspect of mealtimes being particularly challenging, with many feeling embarrassment and loss of dignity when eating around other people. Mealtimes were particularly challenging when patients were fed through a feeding tube. Participants in these four studies described feeling ‘hurt’ and ‘upset’ when they could not participate in family occasions in the way they used to. In addition, participants in Malmstro¨m et al’s (2013) study described a reduced social network leading to isolation due to their difficulties around eating. The lack of social contact was a ‘source of grief’ to them.

Not all participants avoided eating around other people. For example, some of those in Malmstro¨m et al’s (2013) study continued to socialise because they received valuable support from family members in the home, or from those who had invited them to eat out. However, they expressed feelings of anxiety about wasting food, or offending family members or their hosts if they could not finish a meal (Malmstro¨m et al 2013).

The challenges of eating also resulted in altered social roles in some cases. De Vries et al (2016) described how participants who were receiving chemotherapy withdrew from cooking to avoid unpleasant aromas that could contribute to loss of appetite. One solution was to become more engaged with shopping, enabling more choice and control over the food that was to be cooked.

The data associated with this theme reinforced a feeling of social isolation resulting from treatment for oesophagogastric cancer. While some participants maintained social activities around eating, most avoided eating with others at home and in public. A loss of spontaneity around eating, as well as physical challenges, led to participants eating slowly or not finishing meals to avoid the risk of aspiration or vomiting, which would have caused feelings of anxiety. A combination of these aspects often caused participants to withdraw from social situations and led to feelings of isolation.

Managing physical impairments

Physical challenges identified in this literature review included participants requiring a feeding tube and/or experiencing physical difficulties in swallowing food, changes in taste and loss of appetite, pain, bloating, nausea or diarrhoea and weight loss, all of which required management.

Where feeding tubes were used, two participants in Jaromahum and Fowler’s (2010) study expressed anxiety about managing the tubes themselves, or with the support of partners. In addition, the requirement to plan nutrition in advance – such as the appropriate time, type of food and preparation – caused some participants to feel that eating was a task they were obligated to undertake (Malmstro¨m et al 2013), and reduced the pleasure associated with eating (Alberda et al 2017).

Missel et al (2018) found that advice given by nurses assisted participants and their families to prepare for managing their nutrition at home, while diet plans were described as being useful for managing nutrition and enabled family members to give patients support with meal planning.

In some cases, oesophagogastric cancer treatment resulted in participants having an altered sense of self, attributed to the changes in their body. For example, where patients had a feeding tube, it became a visible indicator of ill health, which resulted in participants’ withdrawal from social situations to avoid people asking questions (Laursen et al 2019). Other participants described changing their eating patterns to avoid gastric reflux at night (de Vries et al 2016), while participants in Malmstro¨m et al’s (2013) study described avoiding leaving home altogether, due to uncertainty about managing nausea and diarrhoea.

Only Missel et al’s (2018) study referred to nursing support specifically. It emphasised the benefits of education provided by nurses on how patients could manage the impairments that arose from oesophagogastric cancer and its treatment, including regular meal planning to ensure sufficient nutritional intake.

The data in this theme reinforced the challenges of managing patients’ physical impairments so that they could maintain adequate nutrition. This was predominantly portrayed as a burden that affected the spontaneity and pleasure of eating, including the social aspects of eating.

Discussion

The findings of this literature review emphasised the biopsychosocial effects on nutrition for patients with oesophagogastric cancer, arising from the disease and/or its treatment. Preoperative and post-operative malnutrition poses a significant challenge for patients with oesophagogastric cancer and is correlated with a suboptimal prognosis (Anandavadivelan et al 2021).

Role of early nutritional support

Dietitians have a fundamental role in providing nutritional support for patients with oesophagogastric cancer, which should focus on regular contact with patients to promote assessment and dietary planning, and is aimed at enhancing nutritional status throughout their cancer journey. While the provision of post-operative nutritional support from dietitians is well established, preoperative support is typically only offered to those patients with oesophageal cancer who are malnourished at diagnosis (Anandavadivelan et al 2021).

In their retrospective review of 151 patients with oesophageal cancer who had undergone oesophagectomy, Davies et al (2021) found a correlation between patients who had experienced a weight loss of ≥10% before surgery and higher mortality rates. The data revealed that patients who received early nutritional intervention via supplements during neoadjuvant chemotherapy had a significant reduction in weight loss at 12 months post-surgery compared with those patients who received nutritional supplements only after surgery. This represented positive evidence for early nutritional intervention in patients undergoing oesophagectomy.

A similar review, using data from a nationwide prospective study of 675 Swedish patients undergoing an oesophagectomy, explored the effect of preoperative support from a dietitian (Anandavadivelan et al 2021). In this review, the data indicated that early intervention by a dietitian resulted in reduced weight loss for some patients at one-year post-surgery, but this was not statistically significant overall. Of the original sample of 675 people undergoing oesophagectomy, 164 died, 85 were not reachable and two were excluded due to cognitive impairments, meaning only 424 patients were eligible for the one-year follow-up.

A total of 245 participants (58%) consented and contributed to data collection, so a skewing of the findings was likely. The small percentage of patients who did demonstrate a reduction in weight loss at one-year post-surgery was in part attributed to effective malnutrition screening practices and routine early nutritional intervention in Sweden (Anandavadivelan et al 2021). Further research is recommended to develop the evidence base for early nutritional intervention in this patient group.

Nurses’ role

The themes identified in this literature review demonstrate that the challenges with nutrition experienced by patients may become established over time, often following their discharge from hospital. This emphasises the importance of nurses becoming involved in this aspect of patient care both preoperatively and post-operatively, and to begin specific discussions about nutritional support. Nurses are instrumental in providing person-centred education and care, which supports patients to manage the changes they will experience due to cancer (Eriksson et al 2018).

Nurses are also responsible for establishing a therapeutic relationship with patients and their family members, to ‘hear their story’ and learn about their individual needs and wishes, and assist them to access relevant information and support (NMC 2010). Making Every Contact Count is a powerful health-promotion approach that optimises brief interactions between healthcare professionals and patients to identify how they can improve their health. Brief interactions can comprise short conversations that enable the nurse to ascertain the extent of the patient’s knowledge about their condition, as well as their wishes and plans (National Institute for Health and Care Excellence 2021, Health Education England 2022).

Understanding patients’ concerns in relation to nutritional care enables nurses to provide tailored education around nutrition, which might include advice on meal planning, referral to a dietitian, and signposting to charities and support groups.

For nurses, multidisciplinary working with allied health professionals is also important in providing optimal support for patients and their families and/or carers. Hazzard et al’s (2021) Australian study explored the effect of an interprofessional clinic for people with head and neck cancer. The researchers found that integrated support from a dietitian, cancer nurse specialist and speech therapist reinforced the importance of early discussions about nutrition, preparing patients for future nutritional challenges and encouraging them to access the support available (Hazzard et al 2021).

Nurses can also discuss strategies such as meal planning in partnership with the multidisciplinary team, particularly the dietitian, as part of a person-centred plan of care. Of particular importance is the need for professional support with nutrition when patients are discharged home after surgery, which can involve regular reviews with the multidisciplinary team, including nurse specialists and dietitians.

Quality of life and well-being

Reduced quality of life was not directly stated as an effect in any of the studies included in this literature review; however, the substantial efforts required by participants in the various studies in planning what to eat and with whom, and attempting to avoid pain, nausea or causing offence to hosts, could result in patients and their families avoiding eating out with others and in some cases eating in the home. This can have a significant negative effect on socialisation and connection with and support from others, which are important factors in promoting well-being and enhancing patients’ quality of life (Michaelson 2013).

Practice recommendations

Based on the findings of this literature review, the authors recommend that nurses use any early opportunities for brief interactions with patients to initiate conversations about the future nutritional challenges they may experience (Health Education England 2022). This is challenging, since there is a fine balance between providing realistic information to patients about potential nutritional challenges and maintaining hope for the future when they are diagnosed with cancer.

In the authors’ clinical experience, a lack of confidence on the part of the nurse can lead them to avoid initiating such sensitive discussions early in the cancer journey, when they might have a positive effect on the patient’s long-term nutrition. However, these conversations are important because raising awareness of potential issues such as social disengagement or physical impairment means that patients with oesophagogastric cancer and their families are less likely to be taken by surprise when they arise.

Clinical nurse specialists (CNSs) in nutrition not only have a fundamental role in supporting patients (Hazzard et al 2021), but they are also a source of expert knowledge and educational support for other nurses. Junior or inexperienced nurses can increase their confidence in initiating sensitive nutritional discussions by observing how the CNS manages these discussions with patients, and through practical strategies such as role-playing clinical scenarios with the CNS.

Given the focus on optimising quality of life, prompt referral to a CNS in nutrition for every patient with oesophagogastric cancer will ensure effective ongoing support for the patient and their family post-discharge, which is when the challenges in maintaining nutrition and weight tend to present (Missel et al 2018).

Limitations

The limited qualitative data available for this literature review led to one slightly dated study being included (Jaromahum and Fowler 2010). The studies by Missel et al (2018) and Laursen et al (2019) appeared to originate from one centre and there was not a clear indication as to whether or not the data overlapped. De Vries et al (2016) stated that their study was funded by a public-private partnership on precompetitive research in food and nutrition, so its findings should be viewed with caution.

Conclusion

Nutritional status has a direct effect on mortality in patients with oesophagogastric cancer. The three themes identified in this literature review reflected the psychosocial responses of patients and their family members to the challenges of maintaining weight and nutrition after treatment for oesophagogastric cancer. Nurses can optimise quality of life for patients with oesophagogastric cancer through the early provision of education, information and psychosocial support, as well as referral to a dietitian and CNS in nutrition where available.

References

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