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Enteral and parenteral nutrition in cancer patients, a comparison of complication rates: an updated systematic review and (cumulative) meta-analysis

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A Correction to this article was published on 31 December 2019

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Abstract

Introduction

Weight loss in cancer patients is a worrisome constitutional change predicting disease progression and shortened survival time. A logical approach to counter some of the weight loss is to provide nutritional support, administered through enteral nutrition (EN) or parenteral nutrition (PN). The aim of this paper was to update the original systematic review and meta-analysis previously published by Chow et al., while also assessing publication quality and effect of randomized controlled trials (RCTs) on the meta-conclusion over time.

Methods

A literature search was carried out; screening was conducted for RCTs published in January 2015 up until December 2018. The primary endpoints were the percentage of patients achieving no infection and no nutrition support complications. Secondary endpoints included proportion of patients achieving no major complications and no mortality. Review Manager (RevMan 5.3) by Cochrane IMS and Comprehensive Meta-Analysis (version 3) by Biostat were used for meta-analyses of endpoints and assessment of publication quality.

Results

An additional seven studies were identified since our prior publication, leading to 43 papers included in our review. The results echo those previously published; EN and PN are equivalent in all endpoints except for infection. Subgroup analyses of studies only containing adults indicate identical risks across all endpoints. Cumulative meta-analysis suggests that meta-conclusions have remained the same since the beginning of publication time for all endpoints except for the endpoint of infection, which changed from not favoring to favoring EN after studies published in 1997. There was low risk of bias, as determined by assessment tool and visual inspection of funnel plots.

Conclusions

The results support the current European Society of Clinical Nutrition and Metabolism guidelines recommending enteral over parenteral nutrition, when oral nutrition is inadequate, in adult patients. Further studies comparing EN and PN for these critical endpoints appear unnecessary, given the lack of change in meta-conclusion and low publication bias over the past decades.

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Change history

  • 31 December 2019

    The appendices were incorrectly numbered in the original article. Please see below correcct appendices

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Conflict of interest

The authors declare that they have no competing interests.

Author information

Authors and Affiliations

  1. Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada

    Ronald Chow

  2. Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

    Ronald Chow, Leonard Chiu, Nicholas Chiu, Stephanie Chan, Henry Lam & Carlo DeAngelis

  3. London Health Sciences Centre, University of Western Ontario, 800 Commissioners Road East, London, ON, Canada, N6A 5W9

    Ronald Chow, Tian Yi Tang & Michael Lock

  4. University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Eduardo Bruera

  5. University of Freiburg, Freiburg, Germany

    Jann Arends

  6. Levine Cancer Institute, Charlotte, NC, USA

    Declan Walsh

  7. Cantonal Hospital, St. Gallen, Switzerland

    Florian Strasser

  8. Bond University, QLD, Robina, 4226, Australia

    Elisabeth Isenring

  9. Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA

    Egidio G. Del Fabbro

  10. Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR

    Alex Molassiotis

  11. Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA

    Monica Krishnan

  12. Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada

    Carlo DeAngelis

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  1. Ronald Chow
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Correspondence to Ronald Chow.

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The original version of this article was revised. The appendices was numbered incorrectly.

Appendices

Appendix 1. Search Strategy

Database: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed

Citations, Daily and Versions(R) <1946 to December 20, 2018 > Search Strategy:

figure a
figure b
figure c

Appendix 2. PRISMA Flow Diagram

figure d

Appendix 3

No mortality for enteral nutrition (EN) and parenteral nutrition (PN) patients. 3.1 Analyses by EN—tube feeding and standard care. 3.2 Analyses by nutrition status—protein energy

Appendix 3.1

figure e

Appendix 3.2

figure f

Appendix 3.3

figure g

Appendix 4

No mortality for enteral (EN) and parenteral nutrition (PN) patients, over time

figure h

Appendix 5

Assessment of risk of bias

figure i

Appendix 6

Assessment of publication bias for endpoint “No infection” 6.1 Assessment by enteral nutrition (EN) – tube feeding and standard care 6.2 Assessment by nutrition status – protein energy malnutrition (PEM) and PEM 6.3 Assessment by age of population – children and adults

Appendix 6.1

figure j

Appendix 6.2

figure k

Appendix 6.3

figure l

Appendix 7

Assessment of publication bias for endpoint “No nutrition support complications” 7.1 Assessment by enteral nutrition (EN) – tube feeding and standard care 7.2 Assessment by nutrition status – protein energy malnutrition (PEM) and PEM 7.3 Assessment by age of population – children and adults

Appendix 7.1

figure m

Appendix 7.2

figure n

Appendix 7.3

figure o

Appendix 8

Assessment of publication bias for endpoint “No major complications” 8.1 Assessment by enteral nutrition (EN) – tube feeding and standard care 8.2 Assessment by nutrition status – protein energy malnutrition (PEM) and PEM 8.3 Assessment by age of population – children and adults

Appendix 8.1

figure p

Appendix 8.2

figure q

Appendix 8.3

figure r

Appendix 9

Assessment of publication bias for endpoint “No mortality” 9.1 Assessment by enteral nutrition (EN) – tube feeding and standard care 9.2 Assessment by nutrition status – protein energy malnutrition (PEM) and PEM 9.3 Assessment by age of population – children and adults

Appendix 9.1

figure s

Appendix 9.2

figure t

Appendix 9.3

figure u

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Chow, R., Bruera, E., Arends, J. et al. Enteral and parenteral nutrition in cancer patients, a comparison of complication rates: an updated systematic review and (cumulative) meta-analysis. Support Care Cancer 28, 979–1010 (2020). https://doi.org/10.1007/s00520-019-05145-w

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