AOCNP Nutrition, Cachexia, and Supportive Care in Oncology — Questions and Answers
Question 1: Which validated screening tool is most widely recommended for identifying nutritional risk in hospitalized oncology patients?
- BMI calculation alone
- NRS-2002 (Nutritional Risk Screening 2002) or MUST (Malnutrition Universal Screening Tool) (Correct answer)
- Serum albumin level as a sole indicator
- 24-hour dietary recall interview
Correct answer: NRS-2002 (Nutritional Risk Screening 2002) or MUST (Malnutrition Universal Screening Tool)
The NRS-2002 and MUST are validated, guideline-endorsed tools for systematic nutritional risk screening in hospitalized patients, including those with cancer. They account for BMI, recent weight loss, reduced intake, and disease severity. BMI alone misses patients with significant weight loss but normal BMI. Serum albumin reflects inflammation as much as nutrition and is no longer recommended as a sole nutritional marker. A 24-hour recall is an assessment tool, not a validated screening instrument.
Question 2: Cancer-associated cachexia is best characterized by which of the following pathophysiologic features?
- Pure caloric deficiency reversible solely through caloric supplementation
- Metabolic dysregulation with systemic inflammation causing loss of muscle and fat that is not fully reversible with nutrition alone (Correct answer)
- Isolated fat loss without muscle wasting driven by voluntary food restriction
- A temporary anorexic state that resolves upon completion of chemotherapy
Correct answer: Metabolic dysregulation with systemic inflammation causing loss of muscle and fat that is not fully reversible with nutrition alone
Cancer cachexia is a complex metabolic syndrome characterized by systemic inflammation (elevated IL-6, TNF-α, etc.), increased catabolism, and negative protein and energy balance. Critically, it is NOT simply starvation — aggressive caloric supplementation alone cannot fully reverse the muscle wasting because the underlying metabolic dysfunction persists. This distinguishes cachexia from malnutrition alone and explains why nutritional support must be multimodal.
Question 3: An oncology NP is advising a patient undergoing FOLFOX chemotherapy who wants to take high-dose St. John's Wort for depression. What is the primary clinical concern with this supplement?
- St. John's Wort causes additive myelosuppression when combined with oxaliplatin
- St. John's Wort is a potent CYP3A4 inducer that can significantly reduce plasma levels of chemotherapy and other co-administered drugs (Correct answer)
- St. John's Wort causes peripheral neuropathy that mimics oxaliplatin toxicity
- St. John's Wort directly inhibits cancer cell apoptosis, reducing chemotherapy efficacy
Correct answer: St. John's Wort is a potent CYP3A4 inducer that can significantly reduce plasma levels of chemotherapy and other co-administered drugs
St. John's Wort (Hypericum perforatum) is a potent inducer of CYP3A4 and P-glycoprotein, significantly increasing the metabolism and clearance of many drugs. In oncology patients, this can reduce plasma concentrations of chemotherapy agents, targeted therapies (including irinotecan's active metabolite SN-38), and other co-medications, potentially compromising treatment efficacy. This is a clinically significant and well-documented herb-drug interaction that the oncology NP must screen for.
Question 4: For a patient with head and neck cancer undergoing concurrent chemoradiation who cannot maintain adequate oral intake due to mucositis, which nutritional support route is most appropriate?
- Total parenteral nutrition (TPN) via central venous access
- Enteral nutrition via nasogastric or gastrostomy tube (Correct answer)
- High-calorie oral supplements alone with appetite stimulants
- Intravenous dextrose infusions to maintain caloric needs
Correct answer: Enteral nutrition via nasogastric or gastrostomy tube
When the GI tract is functional, enteral nutrition (via NG tube or prophylactic PEG/RIG) is the preferred route and is supported by ASPEN, ESPEN, and ASCO guidelines for patients who cannot maintain adequate oral intake. Enteral feeding maintains gut integrity, reduces infection risk, and is more physiologic than parenteral nutrition. TPN is reserved for patients with a non-functional GI tract. Oral supplements alone are insufficient if mucositis prevents adequate intake. IV dextrose provides calories but no protein or micronutrients.
Question 5: Which omega-3 fatty acid supplement has the most evidence supporting its use in cancer patients for attenuating weight loss and improving outcomes during chemotherapy?
- Evening primrose oil (GLA)
- EPA (eicosapentaenoic acid) from fish oil (Correct answer)
- Conjugated linoleic acid (CLA)
- Flaxseed oil (ALA)
Correct answer: EPA (eicosapentaenoic acid) from fish oil
Eicosapentaenoic acid (EPA), a long-chain omega-3 fatty acid found in fish oil, has the most evidence in oncology nutrition for its anti-inflammatory properties and potential to attenuate cancer cachexia, particularly in pancreatic and upper GI cancers. Multiple trials have examined EPA supplementation for preservation of lean body mass. Evening primrose oil, CLA, and flaxseed-derived ALA (which must be converted to EPA/DHA with limited efficiency) have significantly less evidence in this context.
Question 6: A patient with colorectal cancer reports taking high-dose antioxidant supplements (vitamins C and E, selenium) during chemotherapy. What is the evidence-based concern the oncology NP should communicate?
- High-dose antioxidants significantly increase chemotherapy-induced nephrotoxicity
- High-dose antioxidants may interfere with the oxidative mechanism by which some chemotherapy agents kill cancer cells, potentially reducing treatment efficacy (Correct answer)
- High-dose antioxidants directly cause hepatotoxicity when combined with fluorouracil
- High-dose antioxidants are safe and may protect normal tissue from chemotherapy side effects without any concerns
Correct answer: High-dose antioxidants may interfere with the oxidative mechanism by which some chemotherapy agents kill cancer cells, potentially reducing treatment efficacy
Many conventional chemotherapy agents (alkylating agents, anthracyclines, platinum compounds) and radiation exert cytotoxic effects partly through generation of reactive oxygen species (ROS). High-dose antioxidant supplementation during active treatment may theoretically neutralize these ROS, potentially reducing efficacy — a concern supported by mechanistic evidence and some observational data, leading ASCO and integrative oncology guidelines to recommend caution and avoidance of high-dose antioxidant supplements during active treatment.
AOCNP Nutrition, Cachexia, and Supportive Care in Oncology
Which validated screening tool is most widely recommended for identifying nutritional risk in hospitalized oncology patients?