2021ESPEN肿瘤营养治疗实践指南
导读
2021年3月15日，欧洲临床营养与代谢协会（European Society for Clinical Nutrition and Metabolism, ESPEN）在其官方杂志Clinical Nutrition上在线发布了最新版的肿瘤患者营养治疗实践指南（ESPEN practical guideline: Clinical Nutrition in cancer）。该指南从临床实用性出发，对2017年ESPEN肿瘤患者营养治疗指南进行缩减，从肿瘤患者营养治疗的总体原则到特殊类型肿瘤患者的个体化营养治疗，总计给出43条推荐（内容没有变化），并添加了流程图，更加便于临床医师、营养师及护士等在临床实践中使用。
图1. ESPEN肿瘤患者营养治疗实践指南概要
一、总体原则
1.1 筛查与评估
推荐1
To detect nutritional disturbances at an early stage, we recommend to regularly evaluate nutritional intake, weight change, and body mass index (BMI), beginning with cancer diagnosis and repeated depending on the stability of the clinical situation. (Recommendation B1-1; strength of recommendation strong – level of evidence very low – strong consensus)
为早期发现营养失衡，推荐从肿瘤确诊开始就常规评估患者的营养摄入量、体重变化与身体质量指数（body mass index，BMI），并依据病情反复评估。（推荐B1-1；推荐强度强-证据水平极低-强烈同意）
推荐2
In patients with abnormal screening, we recommend objective and quantitative assessment of nutritional intake, nutrition impact symptoms, muscle mass, physical performance and the degree of systemic inflammation. (Recommendation B1-2; strength of recommendation strong – level of evidence very low – consensus)
建议对营养筛查有异常的患者进行营养摄入量、营养相关症状、肌肉质量、体格检查及全身炎症反应进行客观的定量评估。（推荐B1-2；推荐强度强-证据水平极低-同意）
1.2 能量与底物需求
推荐3
We recommend that the total energy expenditure (TEE) of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30kcal/kg/day. (Recommendation B2-1; strength of recommendation strong – Level of evidence low – consensus)
肿瘤患者的总能量消耗（total energy expenditure，TEE）若无法个体化测量，推荐其与健康人相似，一般为25-30kcal/kg。（推荐B2-1；推荐强度强-证据水平低-同意）
推荐4
We recommend that protein intake should be above 1g/kg/day and, if possible up to 1.5g/kg/day. (Recommendation B2-2; strength of recommendation strong – Level of evidence moderate – strong consensus)
推荐每日蛋白质摄入量应大于1g/kg ，有条件者增加至1.5g/kg以上。（推荐B2-2；推荐强度强-证据水平中等-强烈同意）
推荐5
We recommend that vitamins and minerals be supplied in amounts approximately equal to the recommended daily allowance and discourage the use of high-dose micronutrients in the absence of specific deficiencies. (Recommendation B2-4; strength of recommendation strong – Level of evidence low – strong consensus)
推荐维生素与矿物质的供给量大约等于每日营养推荐量，若没有特殊情况不建议使用高剂量微量营养素。（推荐B2-4；推荐强度强-证据水平低-强烈同意）
推荐6
In weight-losing cancer patients with insulin resistance, we recommend to increase the ratio of energy from fat to energy from carbohydrates. This is intended to increase the energy density of the diet and to reduce the glycemic load. (Recommendation B2-3; strength of recommendation strong – Level of evidence low – consensus)
对体重下降并存在胰岛素抵抗的患者，推荐增加脂肪在能量供给中所占的比例，以增加饮食的能量密度并降低葡萄糖负荷量。（推荐B2-3；推荐强度强-证据水平低-同意）
图2.肿瘤患者营养治疗总体原则：筛查与评估；能量与底物需求
1.3 营养治疗
推荐7
We recommend nutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms), and offering oral nutritional supplements (ONS). (Recommendation B3-1; strength of recommendation strong – Level of evidence moderate – consensus)
对能经口进食的营养不良或存在营养不良风险的肿瘤患者，推荐进行营养治疗来增加经口饮食，包括给予膳食建议、治疗影响进食的相关症状以及提供口服营养补充（oral nutritional supplements ，ONS）。（推荐B3-1；推荐强度强-证据水平中等-同意）
推荐8
We recommend not to use dietary provisions that restrict energy intake in patients with or at risk of malnutrition. (Recommendation B3-2; strength of recommendation strong – Level of evidence low – strong consensus)
推荐不要使用膳食保健品，这会限制营养不良或营养不良风险患者的能量摄入。（推荐B3-2；推荐强度强-证据水平低-强烈同意）
推荐9
If a decision has been made to feed a patient, we recommend EN if oral nutrition emains inadequate despite nutritional interventions (counseling, ONS), and PN if EN is not sufficient or feasible. (Recommendation B3-3; strength of recommendation strong – Level of evidence moderate – strong consensus)
营养治疗推荐首选营养咨询和口服营养补充，若营养咨询和口服营养补充无法满足营养需求，使用肠内营养（enteral nutrition，EN），若EN无法实施或仍不能满足营养需求，则使用肠外营养（parenteral nutrition，PN）。（推荐B3-3；推荐强度强-证据水平中等-强烈同意）
推荐10
If oral food intake has been decreased severely for a prolonged period, we recommend to increase (oral, enteral or parenteral) nutrition only slowly over several days and to take additional precautions to prevent a refeeding syndrome. (Recommendation B3-4; strength of recommendation strong – Level of evidence low – consensus)
对经口进食量长期严重下降患者，推荐营养摄入量（经口补充，肠内营养或肠外营养）在几天内缓慢增加，并警惕再喂养综合征的发生。（推荐B3-4；推荐强度强-证据水平低-同意）
推荐11
In patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home EN or PN in suitable patients. (Recommendation B3-5; strength of recommendation strong – Level of evidence low – strong consensus)
对长期膳食摄入不足和/或顽固性吸收不良患者，推荐对合适的患者进行家庭EN或PN。（推荐B3-5；推荐强度强-证据水平低-强烈同意）
1.4 运动
推荐12
We recommend maintenance or an increased level of physical activity in cancer patients to support muscle mass, physical function, and metabolic pattern. (Recommendation B4-1; strength of recommendation strong – Level of evidence high – consensus)
推荐肿瘤患者坚持或增加运动以维持肌肉质量、机体功能及代谢状态。（推荐B4-1；推荐强度强-证据水平高-同意）
推荐13
We suggest individualized resistance exercise in addition to aerobic exercise to maintain muscle strength and muscle mass. (Recommendation B4-2; strength of recommendation weak – Level of evidence low – strong consensus)
推荐在有氧运动外基础上制定个体化抗阻训练以维持肌肉力量和质量。（推荐B4-2；推荐强度弱-证据水平低-强烈同意）
图3.肿瘤患者营养治疗总体原则：营养治疗的选择；运动
1.5 药物治疗
推荐14
We suggest considering corticosteroids to increase the appetite of anorectic cancer patients with advanced disease for a restricted period (1-3 weeks) but to be aware of side effects (e.g. muscle wasting, insulin resistance, infections). (Recommendation B5-1; strength of recommendation weak – Level of evidence high – consensus)
对有厌食的进展期肿瘤患者，推荐短期内（1-3周）使用糖皮质激素以增加食欲，但需警惕肌肉丢失、胰岛素抵抗及感染等副作用。（推荐B5-1；推荐强度弱-证据水平高-同意）
推荐15
We suggest considering progestins to increase the appetite of anorectic cancer patients with advanced disease but to be aware of potentially serious side effects (e.g. thromboembolism). (Recommendation B5-2; strength of recommendation weak – Level of evidence high – consensus)
对有厌食的进展期肿瘤患者，推荐对使用黄体酮以增加食欲，但需注意血栓形成等副作用。（推荐B5-2；推荐强度弱-证据水平高-同意）
推荐16
In patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished, we suggest using supplementation with long-chain N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass, and body weight. (Recommendation B5-7; strength of recommendation weak – Level of evidence low – strong consensus)
对化疗或存在体重丢失及营养不良风险的进展期肿瘤患者，推荐补充长链N-3脂肪酸或鱼油来保持或改善食欲、进食量、瘦组织群及体重。（推荐B5-7；推荐强度弱-证据水平低-强烈同意）
推荐17
In patients complaining about early satiety, after diagnosing and treating constipation, we suggest to consider prokinetic agents, but to be aware of potential adverse effects of metoclopramide on the central nervous system and domperidone on cardiac rhythm. (Recommendation B5-8; strength of recommendation weak – Level of evidence moderate – consensus)
对主诉有早饱感的患者，在诊断并治疗便秘后，推荐使用促动力药，但需注意胃复安对中枢神经系统的副作用以及多潘立酮对心率的影响。（推荐B5-8；推荐强度弱-证据水平中等-同意）
推荐18
There are insufficient consistent clinical data to recommend the supplementation with branched-chain or other amino acids or metabolites to improve fat-free mass. (Recommendation B5-5; strength of recommendation none – Level of evidence low – strong consensus)
目前尚缺乏足够的临床数据支持推荐补充支链氨基酸或其他氨基酸或代谢产物来增加去脂体重。（推荐B5-5；推荐强度无-证据水平低-强烈同意）
推荐19
There are insufficient consistent clinical data to recommend non-steroidal anti-inflammatory drugs to improve body weight in weight-losing cancer patients. (Recommendation B5-6; strength of recommendation none – Level of evidence low – strong consensus)
对体重下降的肿瘤患者，目前尚缺乏足够的临床数据支持推荐使用非甾体类抗炎药来改善体重。（推荐B5-6；推荐强度无-证据水平低-强烈同意）
推荐20
There are insufficient consistent clinical data to recommend cannabinoids to improve taste disorders or anorexia in cancer patients. (Recommendation B5-3; strength of recommendation none – Level of evidence low – consensus)
目前尚缺乏足够的临床数据支持推荐使用大麻类制剂来改善肿瘤患者的味觉障碍或厌食。（推荐B5-6；推荐强度无-证据水平低-强烈同意）
推荐21
There are insufficient consistent clinical data to recommend currently approved androgenic steroids to increase muscle mass. (Recommendation B5-4; strength of recommendation none – Level of evidence low – consensus)
目前尚缺乏足够的临床数据支持推荐使用雄激素类固醇来增加肌肉质量。（推荐B5-4；推荐强度无-证据水平低-同意）
图4. 肿瘤患者营养治疗总体原则：药物治疗
二、特殊类型肿瘤患者的营养治疗
2.1 手术治疗
推荐22
For all cancer patients undergoing either curative or palliative surgery, we recommend management within an enhanced recovery after surgery (ERAS) program; within this program, every patient should be screened for malnutrition and if deemed at risk, given additional nutritional support. (Recommendation C1-1; strength of recommendation strong – Level of evidence high – consensus)
无论是根治性手术还是姑息性手术的患者，均推荐按照加速术后康复（enhanced recovery after surgery，ERAS) 原则进行围手术期管理。ERAS实施过程中，应对每位患者进行营养不良筛查，若存在营养不良风险，则给予相应的营养治疗。（推荐C1-1；推荐强度强-证据水平高-同意）
推荐23
For a patient undergoing repeated surgery as part of a multimodal oncological pathway, we recommend the management of each surgical episode within an ERAS program. (Recommendation C1-2; strength of recommendation strong – Level of evidence low – consensus)
对需要多次手术作为肿瘤多模式治疗一部分的患者，推荐每次手术的围手术期处理均遵循ERAS原则。（推荐C1-2；推荐强度强-证据水平低-同意）
推荐24
In surgical cancer patients at risk of malnutrition or who are already malnourished, we recommend appropriate nutritional support both during hospital care and following discharge from the hospital. (recommendation C1-3; strength of recommendation strong Level of evidence moderate – consensus)
对存在营养不良风险或已经存在营养不良的外科肿瘤患者，推荐住院期间与出院后使用合适的营养治疗。（推荐C1-3；推荐强度强-证据水平中度-同意）
推荐25
In upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care, we recommend oral/enteral immunonutrition (arginine, n-3 fatty acids, nucleotides). (Recommendation C1-4; strength of recommendation strong – Level of evidence high – strong consensus)
对采用传统围术期管理的上消化道肿瘤手术患者，推荐使用口服或肠内免疫营养（如精氨酸、n-3脂肪酸、核苷酸）。（推荐C1-4；推荐强度强-证据水平高-强烈同意）
图5.手术患者的营养治疗
2.2 放疗
推荐26
We recommend that during radiotherapy – with special attention to radiotherapy of the head and neck, thorax and GI tract - an adequate nutritional intake should be ensured primarily by individualized nutritional counseling and/or with use of ONS, in order to avoid nutritional deterioration, maintain intake and avoid radiotherapy interruptions. (Recommendation C2-1; strength of recommendation strong – Level of evidence moderate – strong consensus)
为避免营养状况恶化，维持营养摄入并避免放疗中断，推荐在放疗期间进行个体化营养咨询和/或使用ONS以保证充足的营养摄入，尤其是行头颈部、胸部及消化道放疗的患者。（推荐C2-1；推荐强度强-证据水平中等-强烈同意）
推荐27
We recommend to screen for and manage dysphagia and to encourage and educate patients on how to maintain their swallowing function during EN. (Recommendation C2-3; strength of recommendation strong – Level of evidence low – strong consensus)
推荐对吞咽困难进行筛查和治疗，鼓励并指导患者在行EN时如何锻炼吞咽功能。（推荐C2-3；推荐强度强-证据水平低-强烈同意）
推荐28
We recommend enteral feeding using nasogastric or percutaneous tubes (e.g. percutaneous endoscopic gastrostomies (PEG)) in radiation-induced severe mucositis or obstructive tumors of the head-neck or thorax. (Recommendation C2-2; strength of recommendation strong – Level of evidence low – strong consensus)
放疗过程中若出现放射性黏膜炎或肿瘤所致的严重梗阻，推荐使用鼻胃管或经皮导管（如经皮内镜下胃造瘘术）进行肠内营养。（推荐C2-2；推荐强度强-证据水平低-强烈同意）
推荐29
We do not recommend PN as a general treatment in radiotherapy but only if adequate oral/enteral nutrition is not possible, e.g. in severe radiation enteritis or severe malabsorption. (Recommendation C2-6; strength of recommendation strong – Level of evidence moderate – consensus)
放疗过程中不常规推荐使用PN，除非口服或肠内营养无法满足营养需求或无法实施，例如存在严重的放射性肠炎或严重的吸收不良等情况。（推荐C2-6；推荐强度强-证据水平中等-同意）
推荐30
There are insufficient consistent clinical data to recommend glutamine to prevent radiation-induced enteritis/diarrhea, stomatitis, esophagitis or skin toxicity. (Recommendation C2-4; strength of recommendation none – Level of evidence low – strong consensus)
目前尚缺乏足够的临床数据支持推荐使用谷氨酸来预防放疗导致的肠炎、腹泻、胃炎、食管炎或皮肤中毒。（推荐C2-4；推荐强度无-证据水平低-强烈同意）
推荐31
There are insufficient consistent clinical data to recommend probiotics to reduce radiation-induced diarrhea. (Recommendation C2-5; strength of recommendation none– Level of evidence low – strong consensus)
目前尚缺乏足够的临床数据支持推荐使用益生菌来减少放疗导致的腹泻。（推荐C2-5；推荐强度无-证据水平低-强烈同意）
图6.放疗患者的营养治疗
2.3 肿瘤内科：根治或姑息性抗肿瘤药物治疗
推荐32
During anticancer drug treatment, we recommend to ensure an adequate nutritional intake and to maintain physical activity. (Recommendation C3-1; strength of recommendation strong – Level of evidence very low – strong consensus)
推荐在使用抗肿瘤药物治疗期间保持合适的营养摄入并坚持体育锻炼。（推荐C3-1；推荐强度强-证据水平极低-强烈同意）
推荐33
In a patient undergoing curative anticancer drug treatment, if oral food intake is inadequate despite counseling and ONS, we recommend supplemental EN or, if this is not sufficient or possible, PN. (Recommendation C3-2; strength of recommendation strong – Level of evidence very low – consensus)
患者在有效的抗肿瘤药物治疗过程中，若给予营养咨询和ONS患者的经口食物摄入仍然不足，推荐补充EN，若仍不能满足患者营养需求，可用PN。（推荐C3-2；推荐强度强-证据水平极低-同意）
推荐34
There are insufficient consistent clinical data to recommend glutamine supplementation during conventional cytotoxic or targeted therapy. (Recommendation C3-3; strength of recommendation none – Level of evidence low – strong consensus)
传统的细胞毒性药物或靶向药物治疗期间，目前尚缺乏足够的临床数据支持推荐补充添加谷氨酸。（推荐C3-3；推荐强度无-证据水平低-强烈同意）
2.4 肿瘤内科：大剂量化疗与造血干细胞移植
推荐35
During intensive chemotherapy and after stem cell transplantation we recommend maintaining physical activity and to ensure an adequate nutritional intake. This may require EN and/or PN. (Recommendation C4-1; strength of recommendation strong – Level of evidence very low – strong consensus)
大剂量化疗期间或造血干细胞移植后，推荐患者坚持体育锻炼并进行合适的营养摄入，必要时可进行EN和/或PN。（推荐C4-1；推荐强度强-证据水平极低-强烈同意）
推荐36
If oral nutrition is inadequate we suggest preferring EN to PN, unless there is severe mucositis, intractable vomiting, ileus, severe malabsorption, protracted diarrhea or symptomatic GI graft versus host disease. (Recommendation C4-2; strength of recommendation weak – Level of evidence low – strong consensus)
对口服营养补充不足的患者，推荐优先使用EN而非PN，除非患者存在严重的黏膜炎、难治性呕吐、肠麻痹、严重吸收不良、长期腹泻或有症状的胃肠道移植物抗宿主疾病。（推荐C4-2；推荐强度弱-证据水平低-强烈同意）
推荐37
There are insufficient consistent clinical data to recommend a low bacterial diet for patients more than 30 days after allogeneic transplantation. (Recommendation C4-3; strength of recommendation none – Level of evidence low – strong consensus)
对同种异体移植术后超过30天的患者，目前尚缺乏足够的临床数据支持推荐使用低细菌饮食。（推荐C4-3；推荐强度无-证据水平低-强烈同意）
推荐38
There are insufficient consistent clinical data to recommend glutamine to improve clinical outcome in patients undergoing high-dose chemotherapy and HSCT. (Recommendation C4-4; strength of recommendation none – Level of evidence low – strong consensus)
对大剂量化疗和造血干细胞移植（Hematopoietic Stem Cell Transplantation，HSCT）患者，目前尚缺乏足够的临床数据支持推荐使用谷氨酸来改善临床结局。（推荐C4-4；推荐强度无-证据水平低-强烈同意）
图7.肿瘤内科患者的营养治疗
2.5 肿瘤幸存者
推荐39
We recommend that cancer survivors engage in regular physical activity.（Recommendtion C5-1; strength of recommendation strong – Level of evidence low-consensus)
推荐肿瘤幸存者常规进行体育锻炼。（推荐C5-1；推荐强度强-证据水平低-同意）
推荐40
In cancer survivors, we recommend maintaining a healthy weight (BMI 18.5-25 kg/m2) and to maintain a healthy lifestyle, which includes being physically active and a diet based on vegetables, fruits, and whole grains and low in saturated fat, red meat, and alcohol. (Recommendation C5-2; strength of recommendation strong – Level of evidence low – strong consensus)
建议肿瘤幸存者体重维持在健康水平（BMI 18.5-25 kg/m2），并养成健康的生活习惯，包括参与身体锻炼，日常饮食包含蔬菜、水果、全谷类食物，并减少饱和脂肪酸、红肉和酒精的摄入。（推荐C5-2；推荐强度强-证据水平低-强烈同意）
2.6 行姑息治疗的进展期肿瘤患者
推荐41
We recommend to routinely screen all patients with advanced cancer for inadequate nutritional intake, weight loss, and low BMI, and if found at risk, to assess these patients further for both treatable nutrition impact symptoms and metabolic derangements. (Recommendation C6-1; strength of recommendation strong – Level of evidence low – consensus)
推荐对所有进展期肿瘤患者常规筛查是否存在营养摄入不足、体重丢失及低BMI，对存在风险的患者进一步评估是否存在可治疗的营养相关症状与代谢紊乱。（推荐C6-1；推荐强度强-证据水平低-同意）
推荐42
We recommend offering and implementing nutritional interventions in patients with advanced cancer only after considering together with the patient the prognosis of the malignant disease and both the expected benefit on quality of life and potentially survival as well as the burden associated with nutritional care. (Recommendation C6-2; strength of recommendation strong – Level of evidence low – consensus)
对进展期肿瘤患者，推荐在综合评估患者恶性肿瘤预后、营养治疗对生活质量的获益、可能的生存时间以及营养治疗相关的负担后再实施营养干预。（推荐C6-2；推荐强度强-证据水平低-同意）
推荐43
In dying patients, we recommend that treatment be based on comfort. Parenteral hydration and nutrition are unlikely to provide any benefit for most patients. However, in acute confusional states, we suggest using a short and limited hydration to rule out dehydration as precipitating cause. (Recommendation C6-3; strength of recommendation strong – Level of evidence low – strong consensus)
临终患者的治疗推荐以舒适为主。大部分临终患者不能从肠外水化和肠外营养中获益。然而对急性精神错乱的患者，推荐使用短期限制性水化以排除脱水这个诱发因素。（推荐C6-3；推荐强度强-证据水平低-强烈同意）
图8.肿瘤幸存者与肿瘤进展期行姑息治疗患者的营养治疗