Survival of the starving cancer patient: a food for thought for oncologists

Patients with untreated malignant bowel obstruction usually survive less than 1 month and death is accounted by 3 components: the tumour, the obstruction and the starvation. The potential benefit of total parenteral nutrition cannot be investigated, for ethical reasons, through RCT which would include a non-fed control arm. We hypothesized that if literature would consistently confirm that untreated malignant small bowel obstruction patients survive less than 1 month, there would be no need of randomised clinical trial to study the effect of total parenteral nutrition in these patients and such approach could potentially become part of the armamentarium of the oncologist. We reviewed the last 40 years of the literature on patients with malignant small bowel obstruction receiving a palliative care and distinguished 3 groups: Group I (20 studies), patients with untreated tumour, obstruction and starvation; Group II (27 studies), patients with treatment of the obstruction only, and Group III (25 studies), patients with total parenteral nutrition and some control of the obstruction. Median survivals were about 1, 1.5 and > 3 months in the 3 groups, respectively. Data suggest that total parenteral nutrition might benefit these patients being associated with a longer survival and sometimes allowing for further oncologic therapies. In conclusion, a timely intervention through parenteral nutrition should have a priority indication in a selected group of patients with malignant bowel obstruction before the occurrence of an irreversible nutritional deterioration, This would allow patients with spontaneous remission to survive longer or to be occasionally candidate for further oncologic therapies.