# Parenteral Nutrition in Patients with Incurable Cancer: Exploring the Heterogenous and Non-Randomised Clinical Landscape

## TL;DR

This study explores how parenteral nutrition is used in real-world palliative care for patients with incurable cancer, highlighting varied practices and the need for individualized treatment.

## Contribution

The study provides real-world insights into PN use in incurable cancer patients, often excluded from clinical trials.

## Key findings

- Most patients received PN due to eating difficulties or digestive obstructions.
- PN doses were often below estimated needs and required frequent adjustments.
- Many patients did not receive anticancer treatment while on PN.

## Abstract

Parenteral nutrition (PN) is a controversial and understudied topic in palliative care. Few studies explore how PN is administered to patients with incurable cancer, and strict patient selection in clinical trials often excludes those commonly treated in real-world practice. This multicentre study provides valuable insights into the everyday clinical use of PN. Common reasons for initiating PN were eating difficulties or obstructions in the digestive tract, with PN doses often administered below estimated needs and requiring frequent adjustments. Few patients received anticancer treatment, though some used PN as a bridge to future therapies; however, overall survival was short. This study highlights the importance of individualised PN treatment, carefully and safely managed to meet the patients’ palliative care situation.

Background: There is an insufficient knowledge base for optimal parenteral nutrition (PN) use for patients with incurable cancer, leading to vague guidelines and varied practices. The aim of the study is to describe the practices and actual outcomes of PN in patients with incurable cancer at Norwegian hospitals. Methods: This multicentre study retrospectively reviewed 507 deceased patients (>18 years) receiving PN between 2011 and 2017. Data were collected from PN initiation until death, and analyses were descriptive. Results: Fifty-one percent had upper and lower gastrointestinal cancers, and the main PN indications were insufficient intake (75%) and gastrointestinal malfunction (47%). Sixty-seven percent received no anticancer treatment. Forty-three (8%) received PN as temporary bridging to anticancer treatment, of whom fifteen (35%) resumed or initiated treatment. The median PN dose corresponded to 53% of estimated energy requirements, and 94% of the patients had complementary energy intake. The most common reason for discontinuation was expected imminent death (47%). While common symptoms during PN were nausea (52%), vomiting (46%), and oedema (37%), 15% reported improved wellbeing. Conclusions: In this real-world cohort, up to 80% of the patients would not meet the eligibility criteria of previous trials due to cancer diagnosis and treatment, gastrointestinal tract function, weight loss criteria or complications such as ascites. This study highlights the heterogeneity in how patients with incurable cancer receive PN, and emphasises the importance of individualised PN treatment, carefully and safely managed to meet the patients’ palliative care situation. Future real-world pragmatic patient-centred protocols bridging the gap between clinical trials and patients in clinical practice are warranted.