Of the estimated 400,000 annual incident cases of cancer in children 0 to 14 years of age worldwide, more than 80% of those diagnosed live in low- and middle-income countries (LMICs). In Brazil, an upper-middle-income country, there are approximately 12,500 new patients each year among 1- to 19-year-olds, and cancer currently represents the leading cause of death by disease in this age group. With an increasing pediatric population undergoing treatment for cancer, the need for timely supportive care, including nutritional interventions, is of considerable importance.
The impact of poor nutritional status, both undernutrition and overnutrition, on clinical outcomes (including survival) is well recognized. Such conditions can increase treatment-related morbidities and mortality, as well as health care costs and abandonment of therapy. Moreover, studies in children with acute lymphoblastic leukemia (ALL) have demonstrated that the remediation of compromised nutritional status during treatment can improve survival, which supports the hypothesis that nutritional status is a modifiable risk factor for adverse outcomes. However, there is a significant gap in the literature regarding high-quality research on the relationship between nutrition and cancer in children in LMICs, including in Brazil, which creates obstacles to determining the optimal standards of nutritional care for this patient population and remains a barrier to setting educational and research priorities, thereby preventing the field from advancing. The purpose of this review was to describe published nutrition-related data in children and adolescents diagnosed with cancer in Brazil.
The objective of this systematic review was to describe nutrition-related publications on children and adolescents diagnosed with cancer in Brazil.
The methodology followed that of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Medline, LILACS (the Latin American & Caribbean Health Sciences Literature), and Embase were searched in April 2019, and data extraction and rating of methodologic study quality (according to the National Institutes of Health quality score assessment) were performed independently by reviewers.
Twenty-seven studies met the inclusion criteria, reporting on 3,509 patients from 1994 to 2018. Most of the studies (74%) were of poor quality in methodology and reporting. Different cancer diagnoses were included in 52% of studies, whereas acute leukemia was the exclusive focus in 41%. The majority of the articles (70%) were from institutions in the Southeast Region of Brazil, mainly the state of São Paulo (74%); no publications were from the North Region of the country. Twelve studies addressed nutritional status and body composition, reporting an abundance of malnourished patients in the Brazilian population of children and adolescents with cancer. Six studies on micronutrients pointed to possible deficiencies in this population, with a yet unclear but promising role for supplementation during treatment.
In conclusion, the authors identified a requirement in Brazil to focus on and invest in high-quality research in the field of nutrition in pediatric oncology. There is a particular need to engage in multicentric/national studies that will help establish research priorities and better planned clinical interventions, as well as educational strategies, tailored and adapted to each region of the country. In 2017, a partnership was established between the Brazilian Society of Pediatric Oncology and International Society of Paediatric Oncology through a nutrition task force, aiming to bridge that gap. 54 The support from such organizations is pivotal in improving nutrition research in pediatric oncology in Brazil, as well as implementing nutritional evaluations nationally at systematic time points. Some suggestions for specific research that could be undertaken are:
- Prospective cohorts of patients with a single diagnosis or diagnoses that make clinical sense to group, especially solid tumors, to better understand how nutritional variables behave during treatment;
- Prospective national diet quality and nutrient intake study, representative of different states and cultures;
- Longitudinal multicentric trial on early nutrition therapy intervention in patients with selected diagnoses, such as medulloblastoma and osteosarcoma; and
- Clinical trials focusing on specific nutrition interventions, such as protein intake, and their impact on body composition and outcomes.
Overall, it is critical to increase the representation from the under-represented regions in the literature. This may be the way to advance studies of nutrition in children with cancer, not only in Brazil but also in other LMICs.
Brazilthe largest Latin American country and the largest Portuguese speaking country in the world; located in the central and northeastern part of South America; world’s leading coffee exporterMore (Definitions, Synonyms, Translation)