Intervention Review

You have free access to this content

Perioperative nutrition interventions for women with ovarian cancer

  1. Hazel A Billson1,*,
  2. Cathrine Holland2,
  3. Janet Curwell1,
  4. Valerie L Davey1,
  5. Laura Kinsey1,
  6. Lianna J Lawton1,
  7. Alison J Whitworth1,
  8. Sorrel Burden3

Editorial Group: Cochrane Gynaecological Cancer Group

Published Online: 11 SEP 2013

Assessed as up-to-date: 31 JUL 2013

DOI: 10.1002/14651858.CD009884.pub2


How to Cite

Billson HA, Holland C, Curwell J, Davey VL, Kinsey L, Lawton LJ, Whitworth AJ, Burden S. Perioperative nutrition interventions for women with ovarian cancer. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009884. DOI: 10.1002/14651858.CD009884.pub2.

Author Information

  1. 1

    Manchester Royal Infirmary, Dietetic Department, Platt 2 Rehabilitation, Manchester, UK

  2. 2

    Central Manchester NHS Trust, Gynaecological Oncology, Manchester, UK

  3. 3

    University of Manchester, School of Nursing, Midwifery and Social Work, Manchester, UK

*Hazel A Billson, Dietetic Department, Platt 2 Rehabilitation, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. Hazel@billson.org. Hazel.Billson@cmft.nhs.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 11 SEP 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of the condition

Based on worldwide statistics, ovarian cancer is the seventh most frequent cancer for both incidence and mortality with age-standardised rates (ASR) respectively of 6.3 and 3.8 per 100,000 women. Within these rates is significant geographical variation with an ASR of incidence of 9.3 per 100,000 in more developed regions and 4.9 per 100,000 in less developed regions of the world (GLOBOCAN 2008). Approximately 90% of ovarian cancers originate in the epithelial (or surface) layers of the ovary; other types of ovarian cancer can occur in the sex cord-stroma (inner structure of the ovary) and in the germ cells (where the eggs develop).  

The presenting symptoms of ovarian cancer are often of a non-specific nature such as abdominal pain, abdominal bloating, changes in bowel habit, extreme fatigue or back pain and may be attributed to other reasons. As a consequence, patients may often be found to have advanced disease at the time of diagnosis. The treatment and prognosis of ovarian cancer are indicated by the staging of the disease classified using the International Federation of Gynecology and Obstetrics (FIGO) system (Benedet 2000). Staging may be evaluated from ultrasound, computerised tomography (CT) or other scanning techniques or from the finding of malignant cells in ascites (abnormal fluid collection in the abdomen); staging is confirmed when surgery occurs. The surgical treatment of ovarian cancer diagnosed at an early stage entails the removal of one or both ovaries and the uterus, depending on the extent of the disease and the need to preserve fertility. Where abnormal tissue is more widespread, for example in other pelvic organs, cytoreductive surgery is used with the aim of surgically removing all visible tumour tissue (optimal cytoreduction). If optimal cytoreductive surgery cannot be undertaken as a primary treatment, due to the presence of disease at inaccessible sites or poor performance status, chemotherapy may be commenced (neoadjuvant chemotherapy), prior to subsequent surgical reduction of the tumour (interval debulking) (Tangitgamol 2010). Surgical intervention may also be indicated where intestinal obstruction occurs as a complication of the disease.

Causes of malnutrition and weight loss in people with cancer have been described and these may include: tumour-induced anorexia; catabolic effects of the tumour; abnormal metabolism of nutrients; physical obstruction of the gastrointestinal tract by a tumour; reduced food intake as a side effect of radiotherapy or chemotherapy and diminished intake due to pain, anxiety or depression (Henry 2011). Specifically in ovarian cancer, common presenting symptoms include abdominal discomfort or pain, abdominal distension, nausea, dyspepsia, early satiety and constipation (Brooks 1994). In one UK study, more than 50% of 35 women recruited were reported to have a visibly distended abdomen due to ascites or ovarian mass (Balogun 2011).These factors are liable to influence food intake and consequently nutritional status within this patient group. Malnutrition in association with ovarian cancer has been identified as a problem for many years particularly in women with advanced cancer (FIGO stages III and IV) (Tunca 1983). Within a group of 33 women with ovarian cancer requiring an operation for a bowel obstruction, 75% were identified as having severe nutritional deprivation (Larson 1989).

A variety of methods have been used to identify malnutrition. Subjective global assessment (SGA) is a method of evaluating nutrition status combining weight change, diet history and physical examination. In a Brazilian study of women with gynaecological cancers, SGA identified malnutrition in four out of 14 (28%) women with ovarian cancer (Zorlini 2008), while the same method found 50% of 132 women with ovarian cancer in a US study were malnourished (Gupta 2008). In Australia, using the patient-generated SGA (PG-SGA), malnutrition was identified in two-thirds of 48 women with ovarian cancer in comparison with 12% of women with other gynaecological cancers. The mean body mass index (BMI) of the malnourished women (27.4 kg/m2) indicated that some women were overweight although their mean BMI was significantly lower than the mean BMI of well-nourished patients. Therefore, it was noted that the use of BMI and weight alone would not be sufficient to detect malnutrition in this patient group (Laky 2008).

Evidence of malnutrition in women with ovarian cancer has been related to outcomes from surgery. When surgery has been required for intestinal obstruction, poor nutritional status (identified either by weight loss, low serum albumin or low lymphocyte count) was a factor that significantly correlated with poor surgical outcome (Krebs 1983), poor postoperative survival (Clarke-Pearson 1988) and an increased incidence of postoperative infectious complications (Donato 1992). In a study of older women (aged 75 years or over) with ovarian and primary peritoneal cancer, serum albumin was used as a surrogate measure for nutritional status and was significantly associated with lower rates of optimal cytoreduction. Women with sub-optimal cytoreductive surgery had a lower median survival time in comparison with the women who underwent optimal cytoreduction (17 months versus 62 months) (Alphs 2006). Although serum albumin may reflect chronic protein deficiency, it is also an indicator of acute clinical stress, hydration status, liver dysfunction and inflammation, so requires careful evaluation. In a study where prealbumin was used as a nutrition assessment marker, a significant relationship was shown between low serum prealbumin and the risk of complications after primary radical cytoreductive surgery for ovarian cancer, with significantly greater risk of blood loss, morbidity and mortality where serum prealbumin was lower than 10 mg/dL (Geisler 2007).

Current guidelines recommend the use of nutrition screening in hospital to identify individuals at risk of malnutrition. Identification of patients found to be malnourished or at risk of malnutrition should be linked to further assessment and implementation of an appropriate nutrition care plan, which may include nutrition support (ASPEN 2011; Kondrup 2003; NICE 2006). Women with ovarian cancer may have co-existing excess weight or obesity with or without ascites, therefore appropriate screening and assessment methods are required to ensure that malnutrition is identified and treated.

 

Description of the intervention

In this context, nutrition interventions include nutrition screening, nutrition assessment or nutrition advice, which may be combined with nutrition support (additional or alternative provision of nutrients), with the intention to improve or maintain nutrient intake. Nutrition support may be provided as supplementary foods and drinks, fortified foods or oral nutrition supplements; also nutrition formulations given by tube into the gastrointestinal tract (enteral feeding) or given by infusion intravenously (parenteral feeding or PN). Nutrition support may compensate in part or in full for inadequate food consumption. In this review, nutrition interventions do not include the use of nutrition formulations given routinely in 'Enhanced Recovery after Surgery (ERAS)' programmes, which have been recently reviewed in the context of gynaecological oncology (Lv 2010). Nutrition interventions may occur at any stage in the perioperative period with the intention to identify, prevent or treat malnutrition. It is important that the risk of adverse effects associated with the provision of nutrition support are considered. Risks associated with nutrition support interventions may range from minor effects such as taste dislike or nausea to life-threatening effects such as PN catheter-related sepsis.

 

How the intervention might work

Nutrition screening and assessment may identify women at risk of malnutrition and enable nutrition support to be implemented. Nutrition support may improve the nutrient intake of women undergoing surgical intervention for the investigation or treatment of ovarian cancer or associated complications. The nutrition intervention may prevent further nutritional losses at a time of increased metabolic requirements due to the stresses of surgery and the requirement for postoperative wound healing.

Nutrition interventions may improve quality of life (QoL) as perceived by the patient. In other patient groups undergoing radiotherapy for cancer treatment, randomised controlled trials (RCTs) have shown that nutrition counselling improved nutrition intake, nutritional status and QoL (Ravasco 2005; Ravasco 2005a).  

Nutrition interventions may reduce the length of hospital stay. Malnutrition has been identified as a factor contributing to prolonged length of stay following surgery for gynaecological cancer (Laky 2010).

Nutrition interventions may affect clinical outcome by reducing postoperative complications. Parenteral nutrition has been successfully used to raise prealbumin levels above 10 mg/dL in women with ovarian cancer; this reduced the incidence of surgical complications, which occurred in women when prealbumin levels were lower than 10 mg/dL. Prealbumin levels were subsequently used to determine the prescription of nutritional support and the timing of surgical intervention (Geisler 2007).

Women who are unable to eat due to ovarian cancer-related intestinal obstruction can be given nutrients by an alternative route (PN) either pre- or perioperatively (Rubin 1989). Nutrition support techniques may be used as an alternative to normal food intake where gastroparesis has occurred as a side effect of cytoreductive surgery in ovarian cancer (Caprino 2006).

The identification of malnutrition may provide useful prognostic information. Mean survival time has been shown to be longer in well-nourished women than in malnourished women with similar cancer staging (Gupta 2008). Nutrition status can improve. Some women with ovarian cancer identified as being malnourished at diagnosis, were subsequently noted to be nourished three months later and they had a median survival time similar to that of women who were identified as well nourished both at diagnosis and at three months. Nutritional interventions may have contributed to improved nutritional status (Gupta 2010).

 

Why it is important to do this review

Malnutrition has been shown to be a significant risk in women with ovarian cancer and therefore requires purposeful identification and treatment. Nutrition interventions may positively improve clinical outcomes, nutritional status or QoL measures in women with ovarian cancer. There is a need to develop practical guidance on the use of nutrition interventions derived from a systematic review of high quality studies undertaken in this patient group.  

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Primary objective

  • To assess the effects of nutrition interventions in the perioperative period for women with ovarian cancer.

 

Secondary objectives

  • To evaluate whether the effects are modified by nutritional status at baseline or by type of nutrition intervention.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Only RCTs were included.

 

Types of participants

Adult women (aged 18 years and over) in the perioperative phase of surgical treatment for ovarian cancer. Although the perioperative period may be considered to extend from the time when the patient is admitted to hospital for surgery until they are discharged, the term can also cover the period of time in which a patient is prepared physically (and psychologically) for surgery (i.e. from the time that surgery is planned as a treatment for ovarian cancer). The latter broader time period was considered for inclusion. Studies could include surgery at any stage in the treatment of ovarian cancer including recurrent cancer.

If studies included patients with cancer other than ovarian cancer, such as other gynaecological cancers, we only included studies where all patients were being surgically treated for cancer and where at least 75% of participants were women with ovarian cancer. No studies were found where information was reported by separate types of cancer and where data on ovarian cancer only could be extracted.

 

Types of interventions

We examined trials where any type of nutrition interventions was provided at any stage in the perioperative period where surgery was used as a treatment for ovarian cancer. Nutrition interventions were defined as any of the following: nutrition screening/assessment, nutrition counselling/advice, supplementary foods or drinks, fortified foods, oral nutrition supplements, enteral or parenteral feeds. Nutrition support would include a mixture of nitrogen and non-nitrogen energy with vitamins and minerals and be either supplementary to the usual food and drink provision or be the sole source of nourishment. Nutrition interventions were considered in comparison with no nutrition intervention or were comparisons of alternative types of nutrition intervention.

 

Types of outcome measures

 

Primary outcomes

  1. Overall survival (OS) recorded up to five years.
  2. Length of hospital stay.

 

Secondary outcomes

  1. Infective and non-infective complications that occurred subsequent to the surgery including haemorrhage, sepsis, wound breakdown, anastomatic leak, bowel obstruction, paralytic ileus, pulmonary embolism and deep vein thrombosis, chest infection and urinary infection. Complications were included in relation to the route of access (line infection, nasogastric tube misplacement) or in relation to the substrate (such as metabolic abnormalities). Details about whether complications were recorded prospectively or retrospectively and how they were defined were noted.
  2. Nutrition measures including nutrient intake, anthropometry (physical measures of the body), subjective global assessment (SGA) or other validated nutrition assessment tools or minor complications related to the nutrition including nausea, vomiting or diarrhoea.
  3. Functional measures such as change in performance status, hand grip strength or sit-to-stand time.
  4. QoL measures including patient-reported outcomes.
  5. Biochemical measures of nutritional status (blood tests), e.g. prealbumin, transferrin, retinol-binding protein, urinary nitrogen balance.

 

Search methods for identification of studies

 

Electronic searches

The following electronic databases were searched:

  • the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7) and DARE (2012, Issue 3) (Appendix 1),
  • Medline (1946 to July week 4 2012) (Appendix 2, Appendix 2)
  • Embase (1980 to 2012 week 31) (Appendix 3),
  • AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (1981 to April 2012)

All relevant articles were identified on PubMed and using the ‘related articles’ feature, a further search was carried out for newly published articles. Papers in all languages were sought and translations were carried out as necessary.

 

Searching other resources

 

Unpublished and grey literature

Metaregister (http://www.controlled-trials.com/rct), Physicians Data query (http://nci.nih.gov), http://www.clinicaltrials.gov and http://www.cancer.gov/clinicaltrials were searched for ongoing trials. An ongoing trial that had not been published was identified; we approached the principal investigator to ask for information concerning the protocol and likely date of publication of results. Conference proceedings and abstracts were searched through ZETOC (http://zetoc.mimas.ac.uk) and WorldCat Dissertations.

 

Handsearching

Handsearching was undertaken of the citation lists of included studies and a previous systematic review to identify further relevant trials.

 

Data collection and analysis

 

Selection of studies

All titles and abstracts retrieved by electronic searching were examined by two review authors to determine relevance and eligibility. Papers that did not meet the eligibility criteria were excluded. When there was insufficient information to make a decision based on the abstract and title, the full article was obtained in order to make a decision. Two review authors independently reviewed relevant references and discussed with the team of review authors to ensure they met the eligibility criteria. The reasons for exclusion of studies were documented.

 

Data extraction and management

A data collection form devised for the study to facilitate data collection from the included studies was piloted and modified. Data extraction was undertaken by review authors (JC, VLD, LK, LJL) independently with discrepancies discussed. The following information was recorded:

  • authorship, year of publication, country of origin and source of funding;
  • patient details, number of participants, age, inclusion and exclusion criteria;
  • cancer diagnosis including staging if indicated, type of surgery used, details of prior chemotherapy;
  • details of nutrition status of women including BMI, the proportion of malnourished women (and definition of malnutrition);
  • details of nutrition intervention (including type of food or nutrition support product, route of intervention, time period of intervention and quantity delivered);
  • details of primary and secondary outcomes including the time points when these were collected and reported.

Data on outcomes were extracted:

For dichotomous outcomes, we examined the number of women in each treatment arm who experienced the outcome of interest and the number of women assessed at endpoint, in order to estimate a risk ratio (RR).

For continuous outcomes, we recorded the final value and standard deviation (SD) of the outcome of interest and the number of women assessed at endpoint in each treatment arm at the end of follow-up, in order to estimate the mean difference (MD) between treatment arms and its standard error.

All data extracted were relevant to an intention-to-treat analysis, in which participants were analysed in the groups to which they were assigned.

 

Assessment of risk of bias in included studies

The risk of bias in included studies was assessed using The Cochrane Collaboration's tool (Higgins 2011). This included assessment of:

  • selection bias:
    • random sequence generation;
    • allocation concealment;
  • performance bias:
    • blinding of participants and personnel (women and treatment providers) - although blinding may not have been possible due to the nature of the interventions;
  • detection bias:
    • blinding of outcome assessment;
  • attrition bias:
    • incomplete outcome data: the proportion of participants whose outcomes were not reported at the end of the study was noted; a level of loss to follow-up for each outcome was coded as:
      • low risk of bias, if fewer than 20% of women were lost to follow-up and reasons for loss to follow-up were similar in both treatment arms;
      • high risk of bias, if more than 20% of women were lost to follow-up or reasons for loss to follow-up differed between treatment arms;
      • unclear risk of bias, if loss to follow-up was not reported;
  • reporting bias:
    • selective reporting of outcomes
  • other possible sources of bias.

The 'Risk of bias' tool was independently applied and differences resolved by discussion. Results were summarised in a 'Risk of bias' summary. Results of meta-analyses in future updates of the review will be interpreted in light of the findings with respect to risk of bias.

 

Measures of treatment effect

The following measures of the effect of treatment were used: for dichotomous outcomes RR was used and for continuous outcomes the MD between treatment arms.

 

Dealing with missing data

If missing data were identified, it had been planned to contact study authors to seek relevant information. There was no imputation of missing data for any outcome.

 

Sensitivity analysis

Sensitivity analyses were planned to be performed, excluding studies at high risk of bias

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

 

Results of the search

The results of the search are summarised in Figure 1. Following the initial review of titles and abstracts and after handsearching, it was noted that the search strategy had not been sufficiently broad to identify all available studies in this area, in some studies, patients with ovarian cancer were categorised as having 'gynaecological cancer'. The title search was therefore repeated to include the broader term of 'gynaecological cancer', when a further 2642 titles were examined for relevance. A total of 4092 titles were therefore screened. Fourteen papers were examined in detail to determine relevance where this could not be determined from the abstract. Thirteen studies were excluded as they did not meet the criteria of the protocol, one study met the protocol criteria and was included.

 FigureFigure 1. Study flow diagram.

 

Included studies

See Characteristics of included studies. In this RCT (Minig 2009a) a comparison was made of postoperative feeding regimens for women who were undergoing intestinal resection in conjunction with surgery for gynaecological malignancy; 88% of the women had ovarian cancer (n = 35); FIGO staging was not reported. This was a single-centre trial conducted in Milan, Italy with the aim of investigating the feasibility of early postoperative oral feeding in this patient group and evaluating whether this would result in a reduced length of hospital stay. Baseline characteristics of the women in the two comparison groups were similar; the median age of the women in the intervention and the control group was 54 and 58 years respectively. The nutritional intervention included nutritional assessment prior to surgery using a standardised subjective global assessment questionnaire that classified women as well nourished, moderately nourished or severely malnourished. This assessment was used to determine eligibility for the trial and women who were found to be severely malnourished were excluded. Postoperatively, the nutritional intervention comprised an early oral feeding (EOF) regimen in comparison with a "traditional" oral feeding regime (TOF) where nourishment was withheld until normal bowel function resumed, evidenced by bowel sounds and passage of flatus.

 

Excluded studies

See Characteristics of excluded studies. All of the excluded studies included some women with ovarian cancer. One RCT examined the provision of oral and parenteral nutrition supplementation in women with advanced ovarian cancer undergoing chemotherapy, however, the chemotherapy was given after the surgical phase of treatment rather than prior to surgery (Nuutinen 1982). The use of postoperative parenteral nutrition for women with advanced ovarian cancer was studied in a group of women in comparison with a similar group of women who did not receive parenteral nutrition, but the trial was excluded as there was no reported evidence of randomisation (Tan 2002). Two studies, which were not RCTs, examined early postoperative feeding as part of a new clinical pathway and compared data from the prospective trials with data extracted retrospectively on earlier patients (Gerardi 2008; Marx 2006). Four RCTs examining early postoperative oral feeding in contrast to traditional postoperative regimens in women undergoing major abdominal gynaecological surgery were not included, as the study groups included women with benign disease in addition to women with malignant disease and there was an insufficient proportion of women with ovarian cancer (Pearl 1998; Pearl 2002; Schilder 1997; Steed 2002). The effects of early postoperative feeding were also observed in three RCTs including only women with gynaecological cancer, the proportion of women with ovarian cancer ranged from 18% to 58%, this was lower than the protocol inclusion rate of 75% (Cutillo 1999; Feng 2008; Minig 2009b). An earlier RCT included an intervention group who were given postoperative elemental feeding via jejunostomy tube. Although all the women in the study had gynaecological malignancies, only half had ovarian cancer (Spirtos 1988). More recently perioperative enteral feeding using standard and immune-enhancing feeds was compared in an RCT of women with gynaecological cancers; this trial included 32% of patients with ovarian cancer (Celik 2009).

 

Risk of bias in included studies

See Risk of bias in included studies.

In the included study (see Characteristics of included studies), a web-based randomisation system was used (TENALEA 2013) where patient details were entered prior to the randomisation. Allocation to groups was made after surgery was completed and when it had been verified that no intraoperative exclusion criteria had occurred (exclusions were: if total or anterior pelvic exenteration had occurred or if intestinal bowel resection had not been performed). No information was reported concerning whether those who cared for the women, measured outcomes and analysed the data were aware of which intervention the women were receiving; due to the nature of the intervention, blinding may not have been possible. Postoperative exclusion from the trial was to occur if intensive care unit (ICU) admission equalled or exceeded 24 hours, or if the malignancy was found to be non-gynaecological. Eleven of 51 women (22%) were excluded from the trial postoperatively, with similar numbers and reasons in both study groups. It is reported that these women received the intervention, although it is unclear for what length of time. Post-randomisation exclusion may have increased the risk of bias and raises the possibility that the intervention may be associated with an outcome that resulted in exclusion from the trial. As the nutrition intervention is a supportive therapy rather than a primary treatment, the welfare of the patient undergoing prolonged ICU admission may not be compatible with the continuing administration of the intervention.

The authors reported both their primary and secondary end-points. Although it was noted that there was a significant difference in estimated blood loss (EBL), which was greater in the group receiving the traditional feeding regimen compared with those receiving early oral feeding, the authors state that EBL did not have a significant impact on length of hospital stay. FIGO stage was also reported as not being associated with length of hospital stay but details of FIGO staging were not reported. Although subjective global assessment score was evaluated, it was not reported so it is unclear if there were differences in nutritional status between the comparison groups.

 

Other potential sources of bias

There is a potential risk of bias associated with the small size of the study. The women in the study were carefully selected for inclusion in the RCT; although they all had gynaecological cancer, not all of them had ovarian cancer.

 

Effects of interventions

In the included study, most women in the early intervention group (78%, n = 14) were able to consume drinks within 24 hours of surgery and solid food one day after surgery, this was at least two days prior to those in the traditional feeding group. The primary outcome of the study was length of stay which was significantly shorter in the EOF group (9.1 ± 4.5 (mean days ± SD) compared to 6.9 ± 2.6 ). After adjustment for postoperative complications, the mean reduction in stay was 1.7 days. Overall survival was evaluated until 30 days following discharge from hospital. In this period, there was one death of a woman who had been in the group receiving traditional oral feeding (TOF), cause of death was not noted. The incidence of postoperative complications did not differ statistically between the groups, 44% of the patients in the EOF group had complications, none of which were infectious complications; in the TOF group, complications occurred in 55% of the patients of which a quarter had infectious complications. No complications were reported to result from the nutrition intervention. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Scores were similar between the two groups on the two health-related quality of life questionnaires used at 30 days after hospital discharge and overall postoperative satisfaction was noted to be similar in both groups. Half of the women in the TOF group reported a wish to eat sooner than was allowed by the protocol. Nutrient intake, anthropometric measures, functional and biochemical measures were not evaluated as outcomes in this study.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

Results from the included study showed evidence that a small group of women with ovarian cancer who were undergoing surgery including intestinal resection could tolerate an early introduction of oral fluids and foods postoperatively, and that this resulted in a reduced length of hospital stay and no difference in postoperative complication rates in comparison with women who had a traditional postoperative feeding regimen. One of the strengths of the study was that alternative feeding regimens were the only aspects of the perioperative management of the patients that differed between the randomised groups.

 

Overall completeness and applicability of evidence

The most striking observation from this review concerns the absence of information on this topic. While it has been reported that the incidence of malnutrition in women with ovarian cancer may vary between 28% (Zorlini 2008) and 67% (Laky 2008) and may extend to 75% where there is associated bowel obstruction (Larson 1989), there are currently no published RCTs specifically addressing the treatment of malnutrition in women with ovarian cancer or investigating the use of nutrition assessment linked to preoperative nutritional interventions in this patient group. This situation will be partly addressed by a trial currently underway where randomisation to early postoperative enteral feeding is being trialled in women identified as being at nutritional risk (Characteristics of ongoing studies). The included study is of limited applicability to women with ovarian cancer, as the 35 women in the study with ovarian cancer were all undergoing surgery that included intestinal resection.

 

Quality of the evidence

Results from the included study indicate that women with ovarian cancer who are undergoing surgery with associated intestinal resection may be able to manage selected fluids within 24 hours of operation and solid foods on the following day. The small number of women with gynaecological cancer (n = 40) included in the study was calculated on the basis of demonstrating a significant difference in the length of hospital stay in relation to the feeding regimens. There was no reported quantification of the amount of foods consumed, information concerning the use of intravenous fluids or measurement of nutrition outcomes. The study was conducted in a single centre and therefore may not be generalisable. Additionally, there were several reasons why women were not eligible for the trial, including women with significant other presenting conditions including an ASA (American Society of Anesthesiologists) score of four or more, severe concomitant medical condition, metabolic disease such as type 1 diabetes, infection or intestinal obstruction. Women were also excluded if found to be severely malnourished, although this was reported to be determined only on the criteria of recent weight loss greater than 10%, an assessment which may not be applicable to women with ovarian cancer; within this study, 42% of the women (n = 17) were noted to have ascites, which may disguise significant weight loss. There is no evidence from the included trial that can be applied to women who have ovarian cancer in association with these exclusion criteria or who require surgery without intestinal resection.

 

Potential biases in the review process

We undertook to minimise bias in this review by the breadth of our search for relevant papers including handsearching and by repeating the electronic searches when it became evident that some studies, which included patients with ovarian cancer, were categorised as having 'gynaecological cancer'. Titles, abstracts and papers were all reviewed by at least two review authors. Bias in the review process may have been influenced by the decision to exclude studies where fewer than 75% of included patients had ovarian cancer in an attempt to secure information relevant to women with ovarian cancer. It became evident from our data selection process that most studies relevant to this topic include women with differing types of gynaecological cancer or where groups of women may have either a benign or malignant tumour and that data are not reported separately for differing types of disease. Although malnutrition has been noted in association with other types of gynaecological cancer, it is most prevalent in association with ovarian cancer and therefore, data were sought that was specific to women with ovarian cancer. If we had lowered the inclusion rate selected to include studies where a majority of the women in a mixed study (more than 50%) had ovarian cancer, this would only have resulted in the inclusion of one additional study.

 

Agreements and disagreements with other studies or reviews

Our review concurs with a recent systematic review which was unable to identify any RCTs that evaluated the use of nutrition supplementation or nutrition counselling in women with ovarian cancer (Balogun 2012). A Cochrane systematic review on the topic of early versus delayed oral fluids and food after major abdominal gynaecologic surgery included three studies including some patients undergoing surgery for ovarian cancer (Charoenkwan 2007). The conclusion of Charoenkwan 2007 was that early feeding after major abdominal gynaecologic surgery was safe even though associated with an increased risk of nausea, and that early feeding was associated with a reduced length of hospital stay.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

There is limited evidence from one small randomised controlled trial (RCT) that some women with ovarian cancer undergoing surgery, including bowel resection, may manage to commence oral fluids within 24 hours of surgery and may manage to eat normal foods on the following day without increasing the risk of postoperative complications.

 
Implications for research

Women with ovarian cancer may be at risk of malnutrition but there is an absence of research concerning the identification and treatment of malnutrition in this patient group. Studies are needed which examine whether nutrition interventions such as good quality nutrition counselling with or without the use of oral supplements following diagnosis and before and during the perioperative period may be efficacious in improving nutrition status, treatment outcomes and quality of life for women with ovarian cancer. Particular effort should be given to identifying, supporting and treating women identified as being most at risk of malnutrition.

Further analysis of data from RCTs, which include large sub-groups of women with ovarian cancer (such as RCTs where women with other types of gynaecological cancer are also included), could provide more information concerning the effect of nutrition interventions specific to this population group.

Replication of the early feeding intervention in a further RCT and with the inclusion of women who may have additional co-morbidities will confirm whether early oral fluids and foods should be recommended as standard practice for women with ovarian cancer undergoing surgery either with or without bowel surgery.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We thank Chris Williams and Jo Morrison for clinical and editorial advice, Jane Hayes for designing the search strategy and Gail Quinn and Clare Jess for their contribution to the editorial process. We additionally thank Janice Lui for study translation. Dr Sorrel Burden was supported by a Post Doctoral Fellowship Grant from Macmillan Cancer Support.

The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Gynaecological Cancer Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Appendix 1. CENTRAL/DARE search strategy

CENTRAL/DARE

#1 MeSH descriptor Perioperative Care explode all trees
#2 MeSH descriptor Perioperative Period explode all trees
#3 peri-operative or perioperative
#4 MeSH descriptor Surgical Procedures, Operative explode all trees
#5 Any MeSH descriptor with qualifier: SU
#6 surg* or operat* or procedure*
#7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6)
#8 MeSH descriptor Nutrition Therapy explode all trees
#9 MeSH descriptor Nutrition Disorders explode all trees
#10 MeSH descriptor Nutritional Status, this term only
#11 MeSH descriptor Nutrition Assessment, this term only
#12 MeSH descriptor Cachexia, this term only
#13 weight or underweight or cachexi* or malnutrition
#14 nutrition* or nutrient* or macronutrient* or micronutrient* or immunonutrition or immunonutrition
#15 MeSH descriptor Foodexplode all trees
#16 food* or feed* or supplement* or vitamin* or mineral* or protein* or fat* or carbohydrate* or calorie* or energy
#17 MeSH descriptor Dietexplode all trees
#18 Any MeSH descriptor with qualifier: DH
#19 diet*
#20 MeSH descriptor Fish Oils explode all trees
#21 MeSH descriptor Amino Acids explode all trees
#22 amino acid* or fatty acid* or fish oil* or omega 3 or glutamin* or arginine or novel substrate* or nitrogen
#23 MeSH descriptor Feeding Methods explode all trees
#24 enteral or parenteral of PN or TPN or naso-gastric or nasogastric or gastrostomy or jejunostomy
#25 (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24)
#26 MeSH descriptor Genital Neoplasms, Female explode all trees
#27 MeSH descriptor Ovarian Neoplasms explode all trees
#28 (gynaecologic* or gynecologic* or ovar*) near/5 (cancer* or tumor* or tumour* or malignan* or carcinoma* or adenocarcinoma*)
#29 (#26 OR #27 OR #28)
#30 (#7 AND #25 AND #29)

 

Appendix 2. Medline search strategy

Medline Ovid

1 exp Perioperative Care/
2 exp Perioperative Period/
3 (peri-operative or perioperative).mp.
4 exp Surgical Procedures, Operative/
5 surgery.fs.
6 (surg* or operat* or procedure*).mp.
7 1 or 2 or 3 or 4 or 5 or 6
8 exp Nutrition Therapy/
9 exp Nutrition Disorders/
10 Nutritional Status/
11 Nutrition Assessment/
12 Cachexia/
13 (weight or underweight or cachexi* or malnutrition).mp.
14 (nutrition* or nutrient* or macronutrient* or micronutrient* or immunonutrition or immuno-nutrition).mp.
15 exp Food/
16 (food* or feed* or supplement* or vitamin* or mineral* or protein* or fat* or carbohydrate* or calorie* or energy).mp.
17 exp Diet/
18 diet therapy.fs.
19 diet*.mp.
20 exp Fish Oils/
21 exp Amino Acids/
22 (amino acid* or fatty acid* or fish oil* or omega 3 or glutamin* or arginine or novel substrate* or nitrogen).mp.
23 exp Feeding Methods/
24 (enteral or parenteral or TPN or naso-gastric or nasogastric or gastrostomy or jejunostomy).mp.
25 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24
26 exp Genital Neoplasms, Female/
27 exp Ovarian Neoplasms/
28 ((gynaecologic* or gynecologic* or ovar*) adj5 (cancer* or tumor* or tumour* or malignan* or carcinoma* or adenocarcinoma*)).mp.
29 26 or 27 or 28
30 randomized controlled trial.pt.
31 controlled clinical trial.pt.
32 randomized.ab.
33 placebo.ab.
34 clinical trials as topic.sh.
35 randomly.ab.
36 trial.ti.
37 30 or 31 or 32 or 33 or 34 or 35 or 36
38 7 and 25 and 29 and 37˜
39 exp animals/ not humans.sh.
40 38 not 39

key:
mp=protocol supplementary concept, rare disease supplementary concept, title, original title, abstract, name of substance word, subject heading word, unique identifier
pt=publication type
ab=abstract
sh=subject heading
fs=floating subheading 

 

Appendix 3. Embase search strategy

1 perioperative period/
2 (peri-operative or perioperative).mp.
3 exp surgery/
4 su.fs.
5 (surg* or operat* or procedure*).mp.
6 1 or 2 or 3 or 4 or 5
7 exp diet therapy/
8 exp nutritional disorder/
9 exp nutritional status/
10 nutritional assessment/
11 cachexia/
12 (weight or underweight or cachexi* or malnutrition).mp.
13 (nutrition* or nutrient* or macronutrient* or micronutrient* or immunonutrition or immuno-nutrition).mp.
14 exp Food/
15 (food* or feed* or supplement* or vitamin* or mineral* or protein* or fat* or carbohydrate* or calorie* or energy).mp.
16 exp diet/
17 diet*.mp.
18 fish oil/
19 exp amino acid/
20 (amino acid* or fatty acid* or fish oil* or omega 3 or glutamin* or arginine or novel substrate* or nitrogen).mp.
21 exp food intake/
22 (enteral or parenteral or PN or TPN or naso-gastric or nasogastric or gastrostomy or jejunostomy).mp.
23 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22
24 exp female genital tract tumor/
25 exp ovary tumor/
26 ((gynaecologic* or gynecologic* or ovar*) adj5 (cancer* or tumor* or tumour* or malignan* or carcinoma* or adenocarcinoma*)).mp.
27 24 or 25 or 26
28 crossover procedure/
29 double-blind procedure/
30 randomized controlled trial/
31 single-blind procedure/
32 random*.mp.
33 factorial*.mp.
34 (crossover* or cross over* or cross-over*).mp.
35 placebo*.mp.
36 (double* adj blind*).mp.
37 (singl* adj blind*).mp.
38 assign*.mp.
39 allocat*.mp.
40 volunteer*.mp.
41 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40
42 6 and 23 and 27 and 41
43 (exp Animal/ or Nonhuman/ or exp Animal Experiment/) not Human/
44 42 not 43

[mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword] 

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Last assessed as up-to-date: 31 July 2013.


DateEventDescription

11 February 2015AmendedContact details updated.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The protocol and review was drafted by HAB who also co-ordinated the review and undertook data entry. CH provided specialist advice that the focus of the review should be on women with ovarian cancer and provided a clinical perspective to the review and to the interpretation of data. JC was involved in designing the review, screening search results and screening retrieved papers for eligibility, VLD was involved in designing the review, screening retrieved papers, extracting data from papers and appraising the quality of papers. LK was involved in designing the review, screening retrieved papers for eligibility, liaison with the interpreter, extracting data from papers and appraising the quality of papers, LJL was involved in designing the review, screening retrieved papers for eligibility, the design of data extraction forms, liaison with the interpreter, extracting data from papers and appraising the quality of papers, AJW was involved in the design of the review and the design of data extraction forms. SB supervised HAB, conceived and initiated the review to examine the nutritional requirements of patients with gynaecological cancer, screened retrieved papers and provided methodological perspective to the review. All authors reviewed both the draft protocol and draft review, which was subsequently amended to reflect their comments.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • This work was supported by the NIHR Manchester Biomedical Research Centre, UK.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Some minor clarification of methods was made at the request of reviewers which did not affect how the present review was undertaken but would be incorporated into future updates of this review. Due to time constraints, some tasks were undertaken by different authors than originally planned. As only one study was identified for inclusion, it was not necessary to use some statistical analysis as detailed in the protocol. If we had obtained further studies, then the following elements of the protocol would have been used and these will be incorporated in future updates as appropriate

 

Assessment of heterogeneity  

We planned to assess heterogeneity between studies by visual inspection of forest plots, by estimation of the percentage heterogeneity between trials that could not be ascribed to sampling variation (Higgins 2003), by a formal statistical test of the significance of the heterogeneity (Deeks 2001) and, if possible, by subgroup analyses (Subgroup analysis and investigation of heterogeneity).  If there was evidence of substantial heterogeneity, we planned to investigate and report the possible reasons for this.

 

Assessment of reporting biases  

We intended to examine funnel plots corresponding to meta-analysis of the primary outcome to assess the potential for small-study effects such as publication bias. If these plots suggested that treatment effects were not sampled from a symmetric distribution, as assumed by the random-effects model, we would have performed further meta-analyses using fixed-effect models.

 

Data synthesis  

If sufficient, clinically similar studies were available, their results would have been pooled in meta-analyses.

For time-to-event data, we planned to pool hazard ratios (HRs) using the generic inverse variance facility of RevMan 5.

For any dichotomous outcomes, the RR would have been calculated for each study and these were then to be pooled. 

For continuous outcomes, we planned to pool the mean differences between the treatment arms at the end of follow-up if all trials measured the outcome on the same scale, otherwise standardised mean differences would have been used. 

If any trials had multiple treatment groups, the ‘shared’ comparison group would have been divided into the number of treatment groups and comparisons between each treatment group and the split comparison group would have been treated as an independent comparison.

We planned to use random-effects models with inverse variance weighting for all meta-analyses (DerSimonian 1986) if data allowed.

If possible, studies making different comparisons would have been synthesised using the methods of Bucher 1997.

 

Subgroup analysis and investigation of heterogeneity  

We planned to undertake subgroup analysis on studies if data allowed grouping the trials by:

  • malnourished versus non-malnourished; trials conducted before and after 1990 (since when there have been significant developments in artificial feeding and nutrition support);

  • factors such as age, stage, type of intervention, length of follow-up, adjusted/unadjusted analysis were planned to be considered in the interpretation of any heterogeneity.

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
Minig 2009a {published data only}
  • Minig L, Biffi R, Zanagnolo V, Attanasio A, Beltrami C, Bocciolone L, et al. Early oral versus "traditional" postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial. Annals of Surgical Oncology 2009;16(6):1660-8.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
Celik 2009 {published data only}
  • Celik JB, Gezginc K, Ozcelik K, Celik C. The role of immunonutrition in gynecologic oncologic surgery. European Journal of Gynaecological Oncology 2009;30(4):418-21. [PUBMED: 19761135]
Cutillo 1999 {published data only}
  • Cutillo G, Maneschi F, Franchi M, Giannice R, Scambia G, Benedetti-Panici P. Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: a randomized study. Obstetrics and Gynecology 1999;93(1):41-5. [PUBMED: 9916954]
Feng 2008 {published data only}
Gerardi 2008 {published data only}
  • Gerardi MA, Santillan A, Meisner B, Zahurak ML, Diaz Montes TP, Giuntoli RL 2nd, et al. A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers. Gynecologic Oncology 2008;108(2):282-6. [PUBMED: 18023851]
Marx 2006 {published data only}
Minig 2009b {published data only}
  • Minig L, Biffi R, Zanagnolo V, Attanasio A, Beltrami C, Bocciolone L, et al. Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial. Annals of Surgical Oncology 2009;16(11):3101-10. [PUBMED: 19760046]
Nuutinen 1982 {published data only}
  • Nuutinen LS, Kauppila A, Ryhänen, Niinimäki A, Kivinen S, Saarela M, et al. Intensified nutrition as an adjunct to cytotoxic chemotherapy in gynaecological cancer patients. Clinical Oncology 1982;8:107-12.
Pearl 1998 {published data only}
  • Pearl ML, Valea FA, Fischer M, Mahler L, Chalas E. A randomized controlled trial of early postoperative feeding in gynecologic oncology patients undergoing intra-abdominal surgery. Obstetrics and Gynecology 1998;92(1):94-7. [PUBMED: 9649101]
Pearl 2002 {published data only}
  • Pearl ML, Frandina M, Mahler L, Valea FA, DiSilvestro PA, Chalas E. A randomized controlled trial of a regular diet as the first meal in gynecologic oncology patients undergoing intraabdominal surgery. Obstetrics and Gynecology 2002;100(2):230-4. [PUBMED: 12151142]
Schilder 1997 {published data only}
  • Schilder JM, Hurteau JA, Look KY, Moore DH, Raff G, Stehman FB, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecologic Oncology 1997;67(3):235-40. [PUBMED: 9441769]
Spirtos 1988 {published data only}
  • Spirtos NM, Ballon SC. Needle catheter jejunostomy: a controlled, prospective, randomized trial in patients with gynecologic malignancy. American Journal of Obstetrics and Gynecology 1988;158(6 Pt 1):1285-90. [PUBMED: 3132853]
Steed 2002 {published data only}
  • Steed HL, Capstick V, Flood C, Schepansky A, Schulz J, Mayes DC. A randomized controlled trial of early versus "traditional" postoperative oral intake after major abdominal gynecologic surgery. American Journal of Obstetrics and Gynecology 2002;186(5):861-5. [PUBMED: 12015496]
Tan 2002 {published data only}
  • Tan WH, Wu J, Tai S, Che JH, Chi Q. The use of parenteral nutrition in postoperative patients with advanced ovarian cancer [(Published in Chinese)]. Parenteral & Enteral Nutrition 2002;9(4):218-20.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
Alphs 2006
  • Alphs HH, Zahurak ML, Bristow RE, Diaz-Montes TP. Predictors of surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer. Gynecologic Oncology 2006;103(3):1048-53.
ASPEN 2011
  • Mueller C, Compher C, Ellen DM and the American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: nutrition screening, assessment and intervention in adults. Journal of Parenteral and Enteral Nutrition 2011;35:16-24.
Balogun 2011
  • Balogun N, Forbes A, Widschwendter M, Lanceley A. Changes in nutritional status of women diagnosed and treated for ovarian cancer. Proceedings American Institute for Cancer Research annual research meeting on food, nutrition, physical activity and cancer; 2011 Nov 3-4; Washington, DC. 2011.
Balogun 2012
  • Balogun N, Forbes A, Widschwendter M, Lanceley A. Noninvasive nutritional management of ovarian cancer patients: beyond intestinal obstruction. International Journal of Gynecological Cancer 2012;22(6):1089-95. [PUBMED: 22688964]
Benedet 2000
  • Benedet JL, Bender H, Jones H 3rd, Ngan HY, Pecorelli S. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. FIGO Committee on Gynecologic Oncology. International Journal of Gynaecology and Obstetrics 2000;70(2):209-62.
Brooks 1994
Bucher 1997
  • Bucher HC, Guyatt GH, Griffith LE, Walter SD. The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials. Journal of Clinical Epidemiology 1997;50(6):683-91.
Caprino 2006
Charoenkwan 2007
Clarke-Pearson 1988
  • Clarke-Pearson DL, DeLong ER, Chin N, Rice R, Creasman WT. Intestinal obstruction in patients with ovarian cancer. Variables associated with surgical complications and survival. Archives of Surgery 1988;123(1):42-5. [PUBMED: 3337655]
Deeks 2001
  • Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG editor(s). Systematic Reviews in Health Care: Meta-Analysis in Context. 2nd Edition. London: BMJ Publication Group, 2001:285-312.
DerSimonian 1986
Donato 1992
  • Donato D, Angelides A, Irani H, Penalver M, Averette H. Infectious complications after gastrointestinal surgery in patients with ovarian carcinoma and malignant ascites. Gynecologic Oncology 1992;44(1):40-7. [PUBMED: 1730424]
EORTC QLQ-C30
  • Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute 1993;85(5):365-76. [PUBMED: 8433390]
EORTC QLQ-OV28
  • Greimel E, Bottomley A, Cull A, Waldenstrom AC, Arraras J, Chauvenet L, et al. An international field study of the reliability and validity of a disease-specific questionnaire module (the QLQ-OV28) in assessing the quality of life of patients with ovarian cancer. European Journal of Cancer (Oxford, England : 1990) 2003;39(10):1402-8. [PUBMED: 12826043]
Geisler 2007
  • Geisler JP, Linnemeier GC, Thomas AJ, Manahan KJ. Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer. Gynecologic Oncology 2007;106(1):128-31. [PUBMED: 17466363]
GLOBOCAN 2008
  • Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008, cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr (accessed 2nd July 2013).
Gupta 2008
  • Gupta D, Lammersfeld CA, Vashi PG, Dahlk SL, Lis CG. Can subjective global assessment of nutritional status predict survival in ovarian cancer?. Journal of Ovarian Research 2008;1(1):5. [PUBMED: 19014661]
Gupta 2010
Henry 2011
  • Henry C. Effect of malnutrition on cancer patients. In: Shaw C editor(s). Nutrition and Cancer. Wiley-Blackwell, 2011:45-82.
Higgins 2003
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Kondrup 2003
Krebs 1983
Laky 2008
  • Laky B, Janda M, Cleghorn G, Obermair A. Comparison of different nutritional assessments and body-composition measurements in detecting malnutrition among gynecologic cancer patients. American Journal of Clinical Nutrition 2008;87(6):1678-85. [PUBMED: 18541556]
Laky 2010
  • Laky B, Janda M, Kondalsamy-Chennakesavan S, Cleghorn G, Obermair A. Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study. BioMed Central Cancer 2010;10:232. [PUBMED: 20497581]
Larson 1989
  • Larson JE, Podczaski ES, Manetta A, Whitney CW, Mortel R. Bowel obstruction in patients with ovarian carcinoma: analysis of prognostic factors. Gynecologic Oncology 1989;35(1):61-5. [PUBMED: 2477316]
Lv 2010
  • Lv D, Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database of Systematic Reviews 2010, Issue 6. [DOI: 10.1002/14651858.CD008239.pub2]
NICE 2006
  • National Collaborating Centre for Acute Care. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute Care, London. Available from http://www.nice.org.uk/CG32 February 2006. [: Commissioned by the National Institute for Clinical Excellence Available from www.rcseng.ac.uk]
Ravasco 2005
  • Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Dietary counselling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. Journal of Clinical Oncology 2005;23(7):1431-8. [PUBMED: 15684319]
Ravasco 2005a
Rubin 1989
Tangitgamol 2010
TENALEA 2013
  • Trans European Network for Clinical Trials Services. https://nl.tenalea.net/amc/ALEA (accessed 2nd July 2013).
Tunca 1983
  • Tunca JC. Nutritional evaluation of gynecologic cancer patients during initial diagnosis of their disease. American Journal of Obstetrics and Gynecology 1983;147(8):893-6. [PUBMED: 6418009]
Zorlini 2008
  • Zorlini R, Akemi Abe Cairo A, Salete Costa Gurgel M. Nutritional status of patients with gynecologic and breast cancer. Nutricion Hospitalaria 2008;23(6):577-83. [PUBMED: 19132266]