Parenteral Nutrition Techniques Improve Cancer Patients’ Status

PHILADELPHIA—For too long, the nutritional needs of cachectic cancer patients have been ignored, Stanley J. Dudrick, MD, said at the 5th International Congress of the Society for Nutritional Oncology Adjuvant Therapy.

Dr. Dudrick, who pioneered the development of total parenteral nutrition, delivered the 2000 NOAT Green Ribbon Award lecture. He talked about attitudes toward nutrition in advanced cancer, his early efforts to feed patients intravenously, and what he calls the needless near starvation of cancer patients.

“I think a cancer patient deserves any kind of radiotherapy, chemotherapy, combination therapy, or experimental therapy we can give them, but they also deserve optimal nutritional support during that time,” said Dr. Dudrick, professor of surgery, Yale University.

He emphasized that physicians “cannot expect cells to function optimally when we are exposing them to various chemicals, surgery, and other immunologic insults. If you want optimal results, you have to incorporate nutrition and nutritional therapy into their care.”

A patient with a large nutritional functional reserve capacity may be able to withstand cancer therapy without nutritional intervention, he said, “but when a debilitated, underweight, cachectic, hypoproteinemic patient receives cancer therapy, you’re really accelerating death rather than accelerating a cure.”

Dr. Dudrick was first drawn to the field of nutrition when serving as chief general surgery resident at the University of Pennsylvania in the early 1960s, where he worked with Jonathan Rhoads, MD, chairman of general surgery.

“At that time, chemotherapy and radiation therapy were just starting to be used in cancer patients. It was an era of great discovery and technical development,” he said. But these therapies caused nausea and vomiting, which led to increased cachexia, “and when a patient died, we weren’t sure whether it was from the cancer, the treatment, starvation, or all of the above.”

In an effort to improve patients’ nutritional status, Drs. Dudrick and Rhoads first tried infusing feeding solutions into the peripheral vein, “although that meant irritation of the blood vessel and pain due to hypertonicity,” he said. They also found that the 10% to 15% solutions they were able to infuse provided insufficient nutritional supplementation.

About that time, intravenous Diuril (chlorothiazide), one of the first intravenous diuretics, became available. “Now we were in business, because by adding IV diuretics, we could give a larger infusion using twice as much water, 5 L instead of 2.5 L,” he said.

With the “5-L program,” Dr. Dudrick said, “it was like pushing a bottle of water into the sponge and squeezing the sponge. We didn’t have indwelling catheters, but we had an ‘indwelling’ resident, and that was usually me,” he quipped.

Using this labor-intensive process, the researchers were able to get 39 of 49 cancer patients into slightly positive nitrogen balance or nitrogen equilibrium. “In 2 or 3 days, those patients began to open like a flower,” he said.

Bedridden patients began to get up and sit in a chair, read, and watch television. Women began to comb their hair again, and the men began to shave. “When women stop washing their hair and men stop shaving, you know you’ve got a problem,” he said. “You may not have a positive culture yet or an elevated white count, but you have trouble. And when you get them doing just the opposite, you know they are getting better.”

One patient, a 52-year-old man with fistulas and wounds, weighed 49 lb and was dying. “We fed him for 9 weeks, and he completely healed,” Dr. Dudrick said. “Nine of 13 fistulas closed, and we operated and closed the other 4. We discharged him from the hospital, and he gained 100 lb.”

After treating 49 cancer patients, there was no way, Dr. Dudrick said, that he could go on feeding more and more people via peripheral vein infusions. “We had to find some other way,” he said.

Working with Dr. Rhoads, he showed in experiments with beagle puppies that normal growth and development were possible with intravenous feeding. The first use of IV feeding in a human infant came in 1967 when Dr. Dudrick was asked to help feed a 1-month-old baby born with almost no small bowel. With central vein feeding, the baby lived for 22 months.

Dr. Dudrick concluded that the use of enteral and parenteral feeding is “beyond the horse and buggy stage, but we have just barely touched the surface. We want to know how to achieve the maximum benefit for the available cells, and total body cell mass, to allow them to perform the functions for which they were optimally designed—which is my intuitive clinical definition of health.”