Advertisement

The Efficacy of Dietary Fiber in Managing Gastrointestinal Toxicity Symptoms in Patients with Gynecologic Cancers undergoing Pelvic Radiotherapy: A Systematic Review

  • Author Footnotes
    ∗ APD = Accredited Practicing Dietitian (Australia).
    Emilie Croisier
    Correspondence
    Address correspondence to: Emilie Croisier, MDietSt, APD, Building 26B, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, QLD 4072, Australia.
    Footnotes
    ∗ APD = Accredited Practicing Dietitian (Australia).
    Affiliations
    School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia

    Department of Nutrition and Dietetics, The Royal Brisbane Women's Hospital, Herston, Queensland, Australia
    Search for articles by this author
  • Author Footnotes
    † AdvAPD = Advanced Accredited Practicing Dietitian (Australia).
    Teresa Brown
    Footnotes
    † AdvAPD = Advanced Accredited Practicing Dietitian (Australia).
    Affiliations
    School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia

    Department of Nutrition and Dietetics, The Royal Brisbane Women's Hospital, Herston, Queensland, Australia
    Search for articles by this author
  • Author Footnotes
    † AdvAPD = Advanced Accredited Practicing Dietitian (Australia).
    Judy Bauer
    Footnotes
    † AdvAPD = Advanced Accredited Practicing Dietitian (Australia).
    Affiliations
    School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia
    Search for articles by this author
  • Author Footnotes
    ∗ APD = Accredited Practicing Dietitian (Australia).
    † AdvAPD = Advanced Accredited Practicing Dietitian (Australia).
Published:October 28, 2020DOI:https://doi.org/10.1016/j.jand.2020.08.077

      Abstract

      Background

      Pelvic radiotherapy is a common part of treatment used in gynecologic malignancies. The side effects associated with treatment, such as gastrointestinal toxicity, can be acute and chronic. Previous studies have provided little clarity in regard to the best dietary intervention for management of symptoms.

      Objective

      The aim of this systematic review was to summarize the evidence on the efficacy of nutrition interventions involving fiber modification in patients with gynecologic cancers undergoing pelvic radiotherapy to prevent or alleviate gastrointestinal side effects, in comparison to standard care, placebo, or no intervention.

      Methods

      Studies, inclusive of any language and date, up to December 1, 2019, were selected from eight electronic databases: PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, Scopus, Science direct, Clinical Key, Web of Science, and Cochrane. Key study outcomes included gastrointestinal toxicity such as diarrhea/bowel changes, abdominal pain or bloating, and nausea; nutritional status; and quality of life. All studies underwent a quality appraisal using the Academy of Nutrition and Dietetics Quality Criteria Checklist and certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation criteria.

      Results

      Four studies were included (total number of participants = 89), with quality ratings of neutral or negative. Due to the risk of bias, inconsistency, indirectness, and imprecision, there was very low certainty of evidence that dietary fiber modifications improved these outcomes. Some positive trends regarding improvements in incidence and severity of diarrhea and bowel symptoms were reported; however, the body of evidence was insufficient to form specific recommendations for clinical practice. This is reflected in the Grading of Recommendations Assessment, Development, and Evaluation criteria rating (very low level of certainty) for quality of life and gastrointestinal toxicity outcomes.

      Conclusions

      This systematic review suggests that supplementary fiber modification during radiation therapy may have some potential benefits with improving gastrointestinal symptoms; however, more definitive evidence and further exploration of fiber in a therapeutic role is required to inform dietary practice.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • International Agency for Research on Cancer
        Latest global cancer data: Cancer burden rises to 18.1 million new cases and 9.6 million cancer deaths in 2018.
        (Accessed September 13, 2020)
        • Dasari P.
        • Vivekanandam S.
        • Raghava K.S.
        Radiation for gynaecological malignancies.
        Radiother. 2017; 63
        • Addley H.C.
        • Vargas H.A.
        • Moyle P.L.
        • Crawford R.
        • Sala E.
        Pelvic imaging following chemotherapy and radiation therapy for gynecologic malignancies.
        Radiograph. 2010; 30: 1843-1856
        • Zhang Y.
        • Yang Z.
        • Zhou Y.
        • Pan J.
        • Liu Y.
        Efficacy of concurrent single-agent chemotherapy using radiotherapy in patients with cervical cancer: A meta-analysis.
        Int J Clin Exp Med. 2015; 8: 8661
        • Morris M.
        • Eifel P.J.
        • Lu J.
        • et al.
        Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer.
        N Engl J Med. 1999; 340: 1137-1143
        • Maduro J.H.
        • Pras E.
        • Willemse P.H.
        • De Vries E.G.
        Acute and long-term toxicity following radiotherapy alone or in combination with chemotherapy for locally advanced cervical cancer.
        Cancer Treat Rev. 2003; 29: 471-488
        • Kirwan J.M.
        • Symonds P.
        • Green J.A.
        • Tierney J.
        • Collingwood M.
        • Williams C.J.
        A systematic review of acute and late toxicity of concomitant chemoradiation for cervical cancer.
        Radiother Oncol. 2003; 68: 217-226
        • Reed N.S.
        • Sadozye A.H.
        Update on radiotherapy in gynaecological malignancies.
        Obstet Gynaecol. 2017; 19: 29-36
        • Hymel R.
        • Jones G.C.
        • Simone II, C.B.
        Whole pelvic intensity-modulated radiotherapy for gynecological malignancies: A review of the literature.
        Crit Rev Oncol Hematol. 2015; 94: 371-379
        • Andreyev J.
        Gastrointestinal complications of pelvic radiotherapy: Are they of any importance?.
        Gut. 2005; 54: 1051-1054
        • Andreyev H.J.
        Gastrointestinal problems after pelvic radiotherapy: The past, the present, and the future.
        Clin Oncol. 2007; 19: 790-799
        • Theis V.S.
        • Sripadam R.
        • Ramani V.
        • Lal S.
        Chronic radiation enteritis.
        Clin Oncol. 2010; 22: 70-83
        • Gami B.
        • Harrington K.
        • Blake P.
        • et al.
        How patients manage gastrointestinal symptoms after pelvic radiotherapy.
        Aliment Pharmacol Ther. 2003; 18: 987-994
        • Andreye H.J.
        • Davidson S.E.
        • Gillespie C.
        • Allum W.H.
        • Swarbrick E.
        Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer.
        Gut. 2012; 61: 179-192
        • Arends J.
        • Baracos V.
        • Bertz H.
        • et al.
        ESPEN expert group recommendations for action against cancer-related malnutrition.
        Clin Nutr. 2017; 36: 1187-1196
        • McGough C.
        • Baldwin C.
        • Frost G.
        • Andreyev H.J.
        Role of nutritional intervention in patients treated with radiotherapy for pelvic malignancy.
        Br J Cancer. 2004; 90: 2278-2287
        • Laky B.
        • Janda M.
        • Bauer J.
        • Vavra C.
        • Cleghorn G.
        • Obermair A.
        Malnutrition among gynaecological cancer patients.
        Eur J Clin Nutr. 2007; 61: 642-646
        • Kennedy G.D.
        • Heise C.P.
        Radiation colitis and proctitis.
        Clin Colon Rectal Surg. 2007; 20: 64-72
        • Coles C.E.
        • Burgess L.
        • Tan L.T.
        An audit of delays before and during radical radiotherapy for cervical cancer—effect on tumour cure probability.
        Clin Oncol. 2003; 15: 47-54
        • Andreyev H.J.
        • Norman A.R.
        • Oates J.
        • Cunningham D.
        Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies?.
        Eur J Cancer. 1998; 34: 503-509
        • Dewys W.D.
        • Begg C.
        • Lavin P.T.
        • et al.
        Prognostic effect of weight loss prior to chemotherapy in cancer patients.
        Am J Med. 1980; 69: 491-497
        • van Eys J.
        Effect of nutritional status on response to therapy.
        Cancer Res. 1982; 42: 747s-753s
        • Henson C.C.
        • Burden S.
        • Davidson S.E.
        • Lal S.
        Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy.
        Cochrane Database Syst Rev. 2013; 11: CD009896
        • Wedlake L.J.
        • Shaw C.
        • Whelan K.
        • Andreyev H.J.
        Systematic review: The efficacy of nutritional interventions to counteract acute gastrointestinal toxicity during therapeutic pelvic radiotherapy.
        Aliment Pharmacol Ther. 2013; 37: 1046-1056
        • Flores-Cisneros L.
        • Castro-Eguiluz D.
        • Reyes-Barretero D.Y.
        • et al.
        Effects of dietary components during and after concomitant chemoradiotherapy, radiotherapy, or sequential chemoradiotherapy to the abdominopelvic area.
        Rev Invest Clin. 2018; 70: 126-129
        • Lawrie T.A.
        • Green J.T.
        • Beresford M.
        • et al.
        Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers.
        Cochrane Database Syst Rev. 2018; 1: CD012529
        • Wedlake L.J.
        Nutritional strategies to prevent gastrointestinal toxicity during pelvic radiotherapy.
        Proc Nutr Soc. 2018; 77: 357-368
        • Wedlake L.
        • Shaw C.
        • McNair H.
        • et al.
        Randomized controlled trial of dietary fiber for the prevention of radiation-induced gastrointestinal toxicity during pelvic radiotherapy.
        Am J Clin Nutr. 2017; 106: 849-857
        • Cunningham E.
        Are low-residue diets still applicable?.
        J Acad Nutr Diet. 2012; 112: 960
        • Gerassy-Vainberg S.
        • Blatt A.
        • Danin-Poleg Y.
        • et al.
        Radiation induces proinflammatory dysbiosis: transmission of inflammatory susceptibility by host cytokine induction.
        Gut. 2018; 67: 97-107
        • Nam Y.D.
        • Kim H.J.
        • Seo J.G.
        • Kang S.W.
        • Bae J.W.
        Impact of pelvic radiotherapy on gut microbiota of gynecological cancer patients revealed by massive pyrosequencing.
        PloS One. 2013; 8
        • Pandey K.R.
        • Naik S.R.
        • Vakil B.V.
        Probiotics, prebiotics and synbiotics—a review.
        J Food Sci Technol. 2015; 52: 7577-7587
        • Scott A.J.
        • Merrifield C.A.
        • Younes J.A.
        • Pekelharing E.P.
        Pre-, pro- and synbiotics in cancer prevention and treatment—a review of basic and clinical research.
        Ecancer Med Sci. 2018; 12
        • Isenring E.
        • Zabel R.
        • Bannister M.
        • et al.
        Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy.
        Nutr Diet. 2013; 70: 312-324
        • Arends J.
        • Bachmann P.
        • Baracos V.
        • et al.
        ESPEN guidelines on nutrition in cancer patients.
        Clin Nutr. 2017; 36: 11-48
        • Garibaldi C.
        • Jereczek-Fossa B.A.
        • Marvaso G.
        • et al.
        Recent advances in radiation oncology.
        Ecancer Med Sci. 2017; 11
        • Gandhi A.K.
        • Sharma D.N.
        • Rath G.K.
        • et al.
        Early clinical outcomes and toxicity of intensity modulated versus conventional pelvic radiation therapy for locally advanced cervix carcinoma: A prospective randomized study.
        Int J Radiat Oncol Biol Phys. 2013; 87: 542-548
        • Viswanathan A.N.
        • Lee L.J.
        • Eswara J.R.
        • et al.
        Complications of pelvic radiation in patients treated for gynecologic malignancies.
        Cancer. 2014; 120: 3870-3883
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
      1. Endnote X7 [computer program]. Clarivate Analytics, Philadelphia, PA2013
        • Bauer J.
        • Capra S.
        • Ferguson M.
        Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer.
        Eur J Clin Nutr. 2002; 56: 779-785
        • American Dietetic Association
        Evidence Analysis Manual: Steps in the Academy Evidence Analysis Process. Research and Strategic Business Development.
        American Dietetic Association, Chicago, IL2012
        • Guyatt G.
        • Oxman A.D.
        • Akl E.A.
        • et al.
        GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Lodge N.
        • Evans M.L.
        • Wilkins M.
        • Blake P.R.
        • Fryatt I.
        A randomized cross-over study of the efficacy of codeine phosphate versus ispaghula husk in patients with gynaecological cancer experiencing diarrhoea during pelvic radiotherapy.
        Eur J Cancer Care. 1995; 4: 8-10
        • Itoh Y.
        • Mizuno M.
        • Ikeda M.
        • et al.
        A randomized, double-blind pilot trial of hydrolyzed rice bran versus placebo for radioprotective effect on acute gastroenteritis secondary to chemoradiotherapy in patients with cervical cancer.
        J Evid Based Complementary Altern Med. 2015; 2015: 974390
        • Garcia-Peris P.
        • Velasco C.
        • Hernandez M.
        • et al.
        Effect of inulin and fructo-oligosaccharide on the prevention of acute radiation enteritis in patients with gynecological cancer and impact on quality-of-life: A randomized, double-blind, placebo-controlled trial.
        Eur J Clin Nutr. 2016; 70: 170-174
        • Salminen E.
        • Elomaa I.
        • Minkkinen J.
        • Vapaatalo H.
        • Salminen S.
        Preservation of intestinal integrity during radiotherapy using live Lactobacillus acidophilus cultures.
        Clin Radiol. 1988; 39: 435-437
        • Raker J.M.
        • Blake M.R.
        • Whelan K.
        PTH-246 Can we trust reports of stool consistency? the validity and reliability of the Bristol stool form scale.
        2015: A518-A519
        • US National Institutes of Health
        Common Toxicity Criteria, Version 20.
        National Institutes of Health, National Cancer, Institute, Bethesda, MD1999
        • Fayers P.
        • Aaronson N.K.
        • Bjordal K.
        • Sullivan M.
        EORTC QLQ–C30 scoring manual.
        European Organisation for Research and Treatment of Cancer, Brussels, Belgium1995
        • Basch E.
        • Abernethy A.P.
        • Mullins C.D.
        • et al.
        Recommendations for incorporating patient-reported outcomes into clinical comparative effectiveness research in adult oncology.
        J Clin Oncol. 2012; 30: 4249-4255
        • Gotay C.C.
        • Kawamoto C.T.
        • Bottomley A.
        • Efficace F.
        The prognostic significance of patient-reported outcomes in cancer clinical trials.
        J Clin Oncol. 2008; 26: 1355-1363
        • Thompson K.L.
        • Elliott L.
        • Fuchs-Tarlovsky V.
        • Levin R.M.
        • Voss A.C.
        • Piemonte T.
        Oncology evidence-based nutrition practice guideline for adults.
        J Acad Nutr Diet. 2017; 117: 297-310
        • Marchesi J.R.
        • Adams D.H.
        • Fava F.
        • et al.
        The gut microbiota and host health: A new clinical frontier.
        Gut. 2016; 65: 330-339
        • Touchefeu Y.
        • Montassier E.
        • Nieman K.
        • et al.
        Systematic review: The role of the gut microbiota in chemotherapy- or radiation-induced gastrointestinal mucositis—current evidence and potential clinical applications.
        Aliment Pharmacol Ther. 2014; 40: 409-421
        • Claesson M.J.
        • Jeffery I.B.
        • Conde S.
        • et al.
        Gut microbiota composition correlates with diet and health in the elderly.
        Nature. 2012; 488: 178-184
        • Aziz Q.
        • Doré J.
        • Emmanuel A.
        • Guarner F.
        • Quigley E.M.
        Gut microbiota and gastrointestinal health: Current concepts and future directions.
        Neurogastroenterol Motil. 2013; 25: 4-15
        • Doron S.
        • Snydman D.R.
        Risk and safety of probiotics.
        Clin Infect Dis. 2015; 60: S129-S134
        • Vassiliou V.
        • Charalambous H.
        Curative intent versus palliative intent radiation oncology.
        Radiat Oncol Palliat Cancer Care, 2013: 31
        • US Dept of Health and Human Services
        Dietary guidelines for Americans 2015-2020, eighth edition.
        (Accessed September 13, 2020)
        • National Health and Medical Research Council (Australia)
        Nutrient reference values for Australia and New Zealand: Including recommended dietary intakes.
        (Accessed September 13, 2020)
        • McGill C.R.
        • Victor 3rd, L.F.
        • Devareddy L.
        Ten-year trends in fiber and whole grain intakes and food sources for the United States population: National Health and Nutrition Examination Survey 2001–2010.
        Nutrients. 2015; 7: 1119-1130
        • Fayet-Moore F.
        • Cassettari T.
        • Tuck K.
        • McConnell A.
        • Petocz P.
        Dietary fibre intake in Australia. Paper II: Comparative examination of food sources of fibre among high and low fibre consumers.
        Nutrients. 2018; 10: 1223
        • Bates B.
        • Lennox A.
        • Prentice A.
        • Bates C.
        • Swan G.
        National diet and nutrition survey. Headline results from Years 1, 2 and 3 (combined) of the Rolling Programme (2008/2009–2010/11).
        Department of Health, London, United Kingdom2012
        • Slavin J.
        Fiber and prebiotics: mechanisms and health benefits.
        Nutrients. 2013; 5: 1417-1435
        • Lacey K.
        • Pritchett E.
        Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
        J Acad Nutr Diet. 2003; 103: 1061-1072
        • Academy of Nutrition and Dietetics
        Nutrition Terminology Reference Manual (eNCPT): Dietetics language for nutrition care.
        (Accessed December 5, 2019)
        • Ravasco P.
        • Monteiro-Grillo I.
        • Vidal P.M.
        • Camilo M.E.
        Dietary counseling improves patient outcomes: A prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy.
        J Clinical Oncol. 2005; 23: 1431-1438

      Biography

      E. Croisier is a doctoral degree candidate, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia; and Department of Nutrition and Dietetics, The Royal Brisbane Women’s Hospital, Herston, Queensland, Australia.

      Biography

      T. Brown is an Assistant Director of Nutrition and Dietetics at the Royal Brisbane and Women’s Hospital, Queensland Health, Queensland, Australia.

      Biography

      J. Bauer is an associate professor, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Queensland, Australia.