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Review

Nutritional Support for Gastrointestinal Cancer Patients: New (and Old) Frontiers in Management, a Narrative Review

by
Nazanin Khajoueinejad
1,
Christina Santiago
2,
Kea Turner
3,4 and
Jose M. Pimiento
1,*
1
Department of Gastrointestinal Surgery, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
2
Department of Nutrition Therapy, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
3
Division of Health Systems, Policy, and Innovation, The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC 27599, USA
4
Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
*
Author to whom correspondence should be addressed.
Nutrients 2025, 17(24), 3917; https://doi.org/10.3390/nu17243917
Submission received: 2 November 2025 / Revised: 20 November 2025 / Accepted: 9 December 2025 / Published: 14 December 2025
(This article belongs to the Special Issue Perioperative Enteral and Parenteral Nutritional Therapies)
Review Reports Versions Notes

Abstract

Malnutrition in patients with gastrointestinal (GI) cancers can be the result of functional and/or anatomical changes in the alimentary tract, secondary to malignancy or oncologic therapies. Understanding the underlying mechanisms of malnutrition in these patients is imperative in providing appropriate interventions that can not only improve quality of life for these individuals, but also improve their tolerance of oncologic treatment and progression towards remission or cure. In this narrative review, we address common nutritional deficiencies associated with GI malignancies, including pancreatic, biliary, and hepatic cancers. Furthermore, we address common issues related to these deficiencies and causes of nutrition barriers as they relate to organ malfunction or surgical alterations of anatomy. Recommendations for counseling, dietary modifications, nutritional supplements, and pharmacologic interventions are provided based on individual barriers and the vital role of multidisciplinary care is highlighted. Additionally, we highlight novel techniques, such as the role of psychosocial care, prehabilitation, digital health, and machine learning, which can improve nutritional outcomes, provide patient-directed care, and improve risk stratification for this complex and multifaceted issue that faces patients diagnosed with GI cancers.

1. Introduction

Gastrointestinal (GI) cancers, taken as a whole, correspond to the second cause of cancer death in the United States [1,2]. These malignancies include esophagus, gastric, liver, bile duct, small bowel, pancreas, colon, rectal, and anal cancer [1]. The incidence and prevalence of malnutrition depend on the site of cancer and the anatomic and metabolic alterations that result from it (Table 1).
As has been extensively described, GI malignancies can affect the usual alimentary processes [8,9], alterations of the usual central regulation systems of satiety and hunger [10], nutrient intake, digestion, intestinal transit, absorption, and waste elimination [8,9,11,12]. Anticancer therapies used for the treatment of these malignancies are associated with multiple side effects that further impact the patient’s nutritional status [8,13]. This is true for chemotherapy, immunotherapy, cell therapies, radiation, and surgery [8]. Conversely, the nutritional status significantly impacts outcomes for cancer treatment [14,15,16,17].
In this narrative, scoping review, we highlight the most common micro- and macronutrient alterations impacting gastrointestinal cancer patients, provide recommendations for therapeutic clinical strategies for addressing these alterations, and discuss novel pharmaceutical and interventional approaches to identifying patients who are at risk of malnutrition.

2. Methods

PubMed, Medline, and Cochrane Review databases were queried for randomized clinical trials, meta-analyses, and systematic reviews focusing on micronutrient and macronutrient deficiencies in patients with gastrointestinal malignancies, management of symptoms, and clinical and pharmaceutical interventions. Similarly, the same approach was utilized to identify novel approaches to addressing nutritional deficits in cancer patients.

3. Nutritional Challenges Based on Cancer Site and Cancer Treatment

Individuals diagnosed with GI cancers can experience a myriad of nutritional challenges. Jacobson et al. provide a taxonomy of the long-term nutrition challenges associated with operations for GI cancers, based on the anatomic (restrictive or malabsorptive) or functional consequences of such procedures [8]. This taxonomy is a useful framework for the acute nutritional challenges associated with tumors located in the GI tract, based on their location and organ involvement.
In this context, tumors can cause anatomic alterations, such as mechanical complete or partial obstruction, functional impairment (i.e.,; pancreatic malabsorption), and what one can call central or systemic alterations (i.e.,; anorexia, cancer cachexia, or diabetes) [18,19,20]. Similarly, antineoplastic treatment can cause or worsen these alterations [21,22,23,24]. The following table (Table 2) presents common nutrition challenges and impactful symptoms for the five most prevalent GI cancers by anatomic location: pancreatic, gastroesophageal, colorectal, and liver cancers [25].

4. Therapeutic Strategies

4.1. Specialized Evaluation

Throughout their oncologic journey, patients diagnosed with GI cancers can present with increased nutrient requirements. Additionally, oncologic therapies present a host of nutritional barriers that are specific not just to the type of treatment, but to each individual patient [8,35,36]. Therefore, specialized evaluation by a registered dietitian (RD) is a critical step in addressing these barriers to maintaining appropriate nutrition during initial diagnosis, treatment, and surveillance. An RD can perform a comprehensive nutritional evaluation and can develop individualized nutrition plans to address intake requirements while managing nutrition impact symptoms [37,38]. The following basic recommendations are part of the national and international guidelines [18,35,36,37]:
  • Adult oncology patients should undergo regular malnutrition risk screening and nutrition assessment should be completed by an RD.
  • RD evaluation and personalized treatment plans for GI cancer patients can help improve nutrition-related outcomes.
  • Continued RD assessment is required, as treatment side effects and cancer symptoms may change over time and nutrition recommendations should be adjusted as needed to improve patients’ outcomes [18].
  • Incorporating other specialties, such as case management, social work, physical therapy, and genetics, among others, is necessary for completing a comprehensive evaluation and developing a management plan to address factors such as patients’ access to food, patients’ support system or lack thereof, individual dietary preferences, genetic concerns, and physical limitations, including challenges with activities of daily living.

4.2. Identifications of Barriers to Nutrition and Recommended Dietary Modifications

Patients with GI cancers may require nutrition guidance from RDs and dietary modifications to minimize the effects of nutrition-impact symptoms and other nutrition challenges (e.g., malabsorption) on nutrient intake, digestion, and absorption. Below, we summarize the most common nutrition barriers experienced by GI cancer patients and the recommended approaches for nutrition counseling and dietary modifications (Table 3).
  • Malabsorption/essential fatty acid deficiency [39]
    ○
    Patients who have undergone significant bowel resection, those on long term fat-restricted diets due to chyle leaks, or those who have pancreatic insufficiency are at risk of essential fatty acid deficiency [40]. Physical manifestations include a dry, scaly rash, hair loss, and poor wound healing [39]. Identifying the underlying cause is important for developing an appropriate nutrition plan.
    ○
    Providing at least 10% of total calories from fat prevents the development of this alteration [39].
    ○
    For patients with a fat-free diet, assuring supplementation of essential fatty acids is necessary.
  • Exocrine pancreatic insufficiency (EPI)
    ○
    EPI is frequently seen in patients with chronic pancreatitis with atrophy, pancreatic duct obstruction, bypass surgery, or after major pancreatic surgeries. EPI may occur due to a decrease in exocrine cells to secrete digestive enzymes, inadequate bicarbonate production causing inactivation of enzymes by stomach acid, or a mismatch between enzyme release and chyme transit. Inadequate fat digestion can limit the absorption of fat-soluble vitamins A, D, E, and K, as well as influence malnutrition, osteopenia, and sarcopenia [40].
    ○
    Many EPI symptoms are heterogeneous and common with oncological treatment. Regular screening for at-risk patients and comparing symptoms with a diet recall can help identify EPI. A fecal elastase test or qualitative fecal fat test can provide insight. However, these tests may not identify EPI in patients with adequate enzyme production and mismatched timing with chyme.
    ○
    Weight-based dosing of pancreatic enzyme replacement is the treatment of choice and resources online can help tailor personalized plans [28,40,41].
  • Poor appetite/anorexia [42,43,44]
    ○
    Poor appetite is routinely reported as a major side effect from cancer treatment and risk factors include chemotherapy and surgery.
    ○
    Anorexia can be multifactorial: contributing factors include tumor-related inflammatory markers and side effects of oncology treatment (i.e., chemotherapy, targeted therapies, immunotherapy and radiation).
    ○
    Alterations in the mood (i.e., depression and anxiety) related to cancer diagnosis can also cause suppression of the appetite [45]. Pharmacological agents such as progesterone analogs, corticosteroids, and antipsychotics may provide appetite stimulation. There is also new evidence to suggest that targeted therapy for stress-associated cytokines can provide benefits for weight gain [46].
  • Dysgeusia/hypogeusia [47,48]
    ○
    Taste changes are very individualistic and predominantly occur with chemotherapy or major surgical interventions such as cytoreductive surgery, pancreatic resection, extensive colorectal resections, or gastroesophageal interventions.
    ○
    Patients can experience a lack of taste, over-accentuated taste, or “off” flavors. Patients may prefer salty or sweet flavors or find that food has no flavor. Management involves an assessment of current acceptable flavors and individualized nutrition recommendations.
  • Nausea/vomiting [49,50]
    ○
    Appropriate use of anti-emetics and diet modification can help manage symptoms.
    ○
    Foods that are warm, greasy, or high in fiber might exacerbate nausea.
    ○
    Specific algorithms for the pharmacologic management of nausea and vomiting are found in the societal guidelines for nutritional support of cancer patients [49,50].
  • Diarrhea [51,52]
    ○
    Diarrhea can be seen with chemotherapy, radiation therapy, immunotherapy, and following surgical resection of various parts of the GI tract. Excessive fluid losses may lead to renal injury, hypotension, and cardiovascular concerns. Pharmacologic approaches, along with dietary management, can lessen symptoms and improve quality of life (QOL).
    ○
    An accurate picture of the frequency and volume of stooling should be obtained to evaluate treatment effectiveness.
    ○
    Temporary lactose intolerance can be seen with many chemotherapy agents [53], including 5-FU regimens, and may be reversed upon discontinuation of treatment. Short-term avoidance or choosing low-lactose products can improve symptoms.
    ○
    Etiology of diarrhea can be vast and may be a direct result of treatment or due to side effects from treatment. Identifying the cause of diarrhea can help to target management of symptoms.
    ○
    Intake of oral rehydration solutions can improve fluid absorption in the setting of diarrhea. Patients should be instructed to sip electrolyte-balanced fluids throughout the day.
  • Delayed gastric emptying [8]
    ○
    Delayed gastric emptying may be seen in oncology patients with diabetes mellitus or following pancreatic, gastric, or esophageal resections.
    ○
    Symptoms may include nausea, vomiting, bloating, early satiety, or abdominal pain.
    ○
    Dietitians should monitor weight changes in addition to dietary history to identify eating habits that may exacerbate symptoms of delayed emptying. This should include a review of symptoms, portion sizes of food and beverages, meal frequency, timing of food and fluids, and use of any supplements that may lead to delayed emptying.
    ○
    Prokinetics have been used for its management [54,55], but careful evaluation for mechanical bowel obstruction before initiating therapy is necessary.
  • Dumping syndrome [8,56]
    ○
    Dumping syndrome can be identified as early dumping or late dumping [8]. Early dumping syndrome is seen 10–30 min after eating and occurs when hyperosmolar chyme flows through the bowel; this results in excess luminal fluid secretion, which minimizes the osmolarity of chyme. This is followed by rapid intestinal transit that leads to symptoms which include diarrhea, bloating, nausea, abdominal pain, dehydration, and vasomotor symptoms. Late dumping syndrome occurs 1–3 h after eating. Symptoms are often due to excess insulin secretion from the rapid transit of concentrated carbohydrates through the small bowel. Symptomatic hypoglycemia is characterized by flushing, dizziness, heart palpitations, and sudden fatigue.
    ○
    Timely identification and intervention of dumping syndrome can alleviate discomfort and fear around eating.
    ○
    There are specific diagnostic criteria and algorithmic management strategies for this entity [56].
  • Risk of bowel obstruction
    ○
    Intestinal strictures can occur from adhesions, bowel ischemia, or tumor proliferation and can increase the risk of bowel obstructions.
    ○
    Significant adhesions or recurrent obstructions indicate a need for a stricter low-fiber diet.
    ○
    Patients may overly restrict their diet out of fear of symptom recurrence, which may lead to malnutrition. Proper assessment and intervention by a registered dietitian can inform adequate oral intake.
  • Micronutrient deficiency
    ○
    Micronutrients are absorbed in various locations throughout the gastrointestinal tract, and deficiencies may be related to prior surgical resection, poor oral intake, or malabsorption syndromes [8,57].
    ○
    The dietitian should review typical intake and assessment of dietary quality.
    ○
    Supplementation of Vitamin B12 is recommended for patients after total gastrectomy or total colectomy. This can be supplemented orally at a high enough dose to achieve similar results when compared to parenteral supplementation [58,59].
    ○
    Iron deficiency can be seen in patients with small bowel resections involving the duodenum and proximal jejunum, which are primary sites for iron absorption [60]. As such, patients who have undergone a Roux-en-Y reconstruction after resections are at increased risk of iron deficiency anemia. Additionally, the loss of gastric acid after a partial or total gastrectomy may limit the bioavailability of iron for absorption [60].
    ○
    Following an esophagectomy, patients are at increased risk of vitamin B12, vitamin D, and iron deficiency, and these deficiencies may persist for up to 24 months [61,62].
    ○
    Calcium is absorbed throughout the small intestine, with active absorption primarily occurring in the duodenum and proximal jejunum and passive absorption seen primarily in the jejunum [63]. Surgical resections, including ileostomy formation, Whipple, esophagectomy, and total gastrectomy, may affect calcium absorption. Vitamin D deficiency may also influence calcium deficiency, as vitamin D is involved in the intracellular transit of calcium.
    ○
    Research demonstrates an association between higher calcium intake and reduced incidences of colorectal cancer [64]. Moreover, vitamin D supplementation has been shown to improve survival in cancer patients [65] and specifically in colorectal cancer patients [66]. There is very limited high-quality data on micronutrient needs in patients with cancer diagnosis and undergoing oncologic management.

4.3. Medical Nutrition Interventions

Evidence-based approaches to decreasing the development of malnutrition during the different periods of the continuum of cancer care have been published [18,36,37]. They include some of the aforementioned dietary-based interventions to address the common challenges and symptoms associated with cancer and its therapies [36]. The European Society for Clinical Nutrition and Metabolism (ESPEN) has performed a very thorough review of the evidence for medical nutrition recommendations for cancer patients, using the GRADE method to achieve the recommendation level based on strength or recommendation (weak to strong), level of evidence (low to high), and degree of consensus, with a strong consensus denoted when reaching at least 80% of the panel. The following table (Table 4) summarizes the medical therapy recommendations for cancer patients [36].

5. Pharmacological Interventions

An important factor of malnutrition in cancer patients is anorexia and cachexia, which occur both as a result of treatment side effects and central/systemic alterations related to the underlying malignancy. Counteracting these syndromes can reduce the burden of malnutrition in GI cancer patients.
Intense interest in pharmacological agents to address anorexia and cachexia in cancer patients has been commonplace, with various medications to stimulate appetite and offset anorexia associated with underlying malignancies or with the treatment side effects of oncologic therapies having been studied in preclinical or small clinical settings [42,43,44,67]. Until recently, only two medications were recommended for utilization for appetite stimulation in cancer patients. Recent advances in understanding the physiopathology of anorexia and cachexia highlight a potential role for the use of antipsychotics and targeted monoclonal antibodies to combat cancer-related cachexia, which inevitably leads to malnutrition [53,68].

5.1. Historically Used Mediations: Megestrol and Corticosteroids

Until recently, megestrol and corticosteroids were the most common medications used to address appetite loss in cancer patients.
Megestrol, a synthetic progestogen, was first introduced for the treatment of hormonal-associated cancers and was observed to demonstrate a side effect of weight gain in these treated patients [69]; as such, it was then studied as a potential pharmacological tool for the alleviation of poor appetite in cancer patients in the late 1980s [69,70]. To date, multiple randomized controlled trials and meta-analyses have evaluated the benefit of progesterone analogs for the management of cachexia and have shown improvement in appetite and quality of life [71,72,73,74]. The benefits of megestrol, however, must be weighed against its known complications. Patients treated with megestrol are at higher risk of developing dyspnea, peripheral edema, thromboembolic events, and potentially death. These side effects raise concerns for prolonged use of this hormonal therapy [67]. Based on these results, the most recent American Society of Clinical Oncology (ASCO) guidelines provide moderate strength recommendations in favor of the short-term use of progesterone analogs [71].
In a landmark randomized double blinded study of patients with advanced cancer published in 1974, patients who received dexamethasone reported an improvement in their appetite [75]. The benefit for appetite stimulation was further supported by a systemic review of multiple randomized controlled studies [67]. Despite the benefit to appetite stimulation, the ideal dosing, timing, and duration of the treatment is still not clearly defined. Even more, the benefit to weight gain has not been consistently demonstrated. Based on these results, the ASCO guidelines on the management of cancer cachexia support a short-term course of this medication in cancer patients for appetite stimulation [71].
While megestrol and dexamethasone remain the two most used medications for appetite stimulation in cancer patients, the two had not been compared head-to-head until recently. A phase III double blinded clinical trial comparing megestrol, dexamethasone, and a placebo daily did not demonstrate a statistically significant difference in appetite scores between the three study arms. Of note, the study was only able to evaluate one week of data, given its failure to increase appetite scores more than 25% from the baseline [76]. With this new data and existing historical evidence, the use of megestrol and steroids come into question.

5.2. Antipsychotic Medications: Olanzapine

The use of olanzapine for treatment of psychiatric disorders was associated with unexpected weight gain. This side effect has led to the utilization of the anti-psychotic for use in patients with anorexia nervosa [77]. Additionally, a short course of treatment is also used to treat chemotherapy-related nausea in cancer patients [77,78].
Recently, a randomized double-blinded placebo-controlled study of olanzapine in patients with chemotherapy-related anorexia and diagnosis of locally advanced or metastatic gastric, HPB, or lung cancer demonstrated a statistically significant improvement in weight gain in the study arm. Patients in the study received olanzapine 2.5 mg daily for 12 weeks, with the first dose being received on the first day of systemic therapy. Patients receiving Olanzapine demonstrated a significantly decreased incidence of severe malnutrition at study completion (14% vs. 39%; p: 0.01), and significant weight gain compared to the placebo (60% vs. 9%; p < 0.001). The study arm also demonstrated improvements in appetite at 12 weeks, improved nutrition scores, higher daily calories, and overall, minimal adverse events were demonstrated [79].
Based on the promising results of this study, the ASCO guidelines for the management of cancer cachexia were updated in 2023 to recommend the use of low-dose olanzapine for addressing poor appetite and improving weight gain in patients with advanced cancers [46,71]. A phase III clinical trial is currently recruiting patients to compare the effects of olanzapine to megestrol in addressing appetite loss (NCT04939090).

5.3. Targeted Therapy—Ponsegromab

Targeted therapies against molecules that play a role in cancer-related cachexia and malnutrition hold a promising future in the treatment of cancer patients [80]. A recent phase II study has demonstrated promising results for the blockage of a stress-induced cytokine, Growth differentiation factor 15 (GDF-15), with a humanized monoclonal antibody [68,80,81].
Growth differentiation factor 15 is a stress-induced cytokine that has demonstrated a correlation with weight loss and loss of skeletal muscle mass [80,81]. Ponsegromab is a highly selective humanized monoclonal antibody that inhibits GDF-15 in circulation and has demonstrated reduction in weight loss and skeletal muscle loss in translational models of cancer-related cachexia [68]. A phase-2 randomized double blinded placebo-controlled trial compared three doses of the study drug to placebo [68]. More than half of the participants in this study were diagnosed with GI cancers, including pancreatic and colorectal cancers (61%). Patients in the study arm experienced a dose-dependent increase in their weight compared to the placebo at 12 weeks. Specifically, patients in the highest dose group, 400 mg, gained back more than 5% of their body weight [68]. Beyond these objective improvements, subjects reported improved appetite and physical activity. This outcome was consistent across different cancer types, and exposure to platinum chemotherapy, as well as the baseline inflammatory state, as evaluated by CRP and albumin [68]. The results of this trial demonstrate a promising future for more targeted therapies in addressing the complex physiopathology of cancer-related cachexia and malnutrition [81].

6. Future Directions in Addressing Malnutrition in Cancer Patients

6.1. Prehabilitation—The Need for Standardization

Prehabilitation programs that provide nutrition support as a standalone intervention or multi-modal support (e.g., nutrition and exercise) have demonstrated effectiveness for improving nutritional outcomes for GI cancer patients preparing for surgery. Prehabilitation can improve nutritional status (e.g., PG-SGA score) and dietary intake and minimize losses in weight and body mass [82,83,84]. These interventions may have the greatest impact on patients with moderate or severe malnutrition at baseline [85]. Prehabilitation programs can also lead to improvements in functional capacity and quality of life for GI cancer patients receiving surgery [84,86], outcomes highly correlated with nutritional outcomes. Despite the promising evidence base for nutrition prehabilitation, there are notable research gaps that need to be addressed [87].
Across nutrition prehabilitation studies, the ‘nutrition’ intervention component is often poorly defined [88], making it difficult to discern which nutrition interventions lead to improvements in patient outcomes. Nutritional prehabilitation could include a combination of nutrition interventions, such as dietary counseling, patient education, oral nutrition supplements, immunonutrition, and energy intake monitoring [88]. Many of these interventions have failed to measure the impact of the intervention on nutrition outcomes or failed to use validated malnutrition assessments [88]. A recent review found that most prehabilitation studies in oncology (two-thirds) do not measure nutritional outcomes [88]. When nutritional outcomes are measured, there is heterogeneity in what is measured [87] and a limited study of long-term outcomes, such as survival. All these factors highlight the need for standardizing how nutrition prehabilitation interventions are defined and what outcomes are measured.
Research is also needed to examine the delivery and implementation of nutrition prehabilitation programs for GI cancer patients. Given how many components can be included in nutrition prehabilitation, there is a need for comparative effectiveness research to determine which components are most effective at improving patient outcomes. Second, there is a need for intervention delivery research to determine the optimal timing, dosage, and duration of nutritional interventions. For example, studies suggest that nutrition counseling delivered before or at the start of cancer treatment may be more effective at improving nutritional outcomes compared with nutrition counseling that is provided after treatment is already well underway [89,90,91,92]. Well-designed clinical trials are needed to definitively establish the ideal timing of nutrition prehabilitation interventions, how much intervention is needed, and for how long.
Studies suggest that adherence to nutrition prehabilitation varies considerably across studies and is inconsistently measured and reported [33,87,93,94,95]. Studies report several patient barriers that may affect adherence to nutrition prehabilitation. Patients’ physical or mental health may make it difficult to participate in nutrition prehabilitation (e.g., symptom burden, mobility, cognition, depression, anxiety) [96,97]. Patients and their caregivers may also lack awareness about nutrition prehabilitation [97], or have difficulty with logistics (e.g., scheduling, time commitment) [96]. Social determinants of health (e.g., transportation barriers, food insecurity, financial hardship) [98,99] can also affect participation. Similarly, healthcare settings may vary in their capacity to provide nutrition prehabilitation due to insufficient dietitian staffing (e.g., patient-to-dietitian ratios), availability of dietitians with specialized expertise in GI cancer, and inadequate insurance reimbursement for oncology nutrition services [41,100,101]. Innovation is needed to determine what strategies can be used to reduce patient barriers to nutrition prehabilitation and promote equitable access to nutrition prehabilitation across settings.

6.2. Behavioral Science and Role of Psychosocial Care

Behavioral science is increasingly being applied to cancer prehabilitation research to optimize patient engagement and overcome barriers to patient participation and adherence [102]. Recent studies have used behavior change techniques such as self-monitoring, goal setting, social support, and motivational messaging to support the behavior changes that are required in prehabilitation programs [102,103,104,105,106,107]. Because the application of behavioral science to cancer prehabilitation is still limited, there is limited evidence on what behavioral change techniques may be most effective in prehabilitation, how behavior change should be sequenced (e.g., implementing multiple changes simultaneously or sequentially), or what approaches are most effective at promoting long-term behavior change beyond prehabilitation [102].
Psychosocial care has been integrated into cancer prehabilitation to support patient behavior changes. Prehabilitation programs have included mindfulness, stress management, cognitive-behavioral strategies, resilience training, and return-to-work support [108,109,110,111,112]. Integration of psychosocial care into prehabilitation can improve patient outcomes, such as anxiety, depression, and fatigue [109,110,111], determinants that can also affect nutrition. Prior reviews suggest that psychosocial care may be more commonly integrated into prehabilitation for other cancer types (e.g., gynecological cancers) and less commonly used in prehabilitation programs for GI cancer [113,114,115]. Given that individuals with GI cancer experience higher rates of anxiety, depression, and fatigue, compared with many other cancer types [116,117], there is a need to test the integration of psychosocial care into GI prehabilitation programs. Researchers could evaluate, for example, if there is a synergistic effect between psychosocial care and nutrition care that leads to improved patient outcomes.

6.3. Digital Health

Digital health is being tested as a strategy to improve access to and the delivery of nutrition prehabilitation. Studies have tested telemedicine as a method for delivering nutrition counseling before surgery, either through telephone or videoconference. Telemedicine-delivered nutrition prehabilitation has demonstrated feasibility and acceptability and improved access to nutrition care for certain GI cancer patients (e.g., rural residents) [61,118,119,120]. Tele-prehabilitation has also demonstrated a preliminary effect for improving nutritional outcomes, such as nutritional status, dietary intake, and weight maintenance, and related outcomes (e.g., quality of life) [121,122] in GI cancer, but the available evidence is limited to small pilot studies. Additionally, flexibility in delivery mode can improve patient adherence and satisfaction with prehabilitation programs [94,102,123,124].
Digital health technologies, such as mobile apps, web-based platforms, and wearable devices, are being tested to support nutrition prehabilitation delivery. For example, studies have used mobile apps, web-based platforms, and wearable devices to deliver nutrition education, track dietary intake, and assess nutritional status and symptoms, and preliminary studies suggest that these technologies are feasible [118,125,126,127,128]. Digital technology utilization in addressing nutritional prehabilitation holds a promising future but work is necessary to (1) establish the impact of digital health technologies on nutritional outcomes; (2) determine which strategies are most effective at overcoming barriers to technology use; (3) address the usability issues of existing technologies through human-centered and human factors research; and (4) test digital technologies in real-world settings and populations to gather evidence on implementation.

6.4. Machine Learning

Commonly used nutritional assessment tools and surveys are often limited by their subjective nature and poor performance, capturing the complex and multifaceted nature of cancer-related malnutrition and cachexia [129]. Machine learning models introduce a new frontier that allows for incorporation of clinically available data, including molecular markers, patient-reported symptoms, and even imaging to predict the presence of malnutrition and cancer-related cachexia and, in doing so, introduces the opportunity for more prompt and patient-tailored interventions [130,131,132,133].
Deep machine learning algorithms have demonstrated an enhanced predicting ability to correctly identify malnutrition in patients with gastric cancer when utilizing imaging features such as psoas muscle at the third lumbar vertebrate and clinical prognostic features such as BMI and albumin and lymphocyte count [134]. Large retrospective studies support the use of machine learning in predicting the presence of cachexia in a broad range of cancer diagnoses, even when the electronic health record (EHR) lacks information about weight loss [132,133]. This finding is very appealing, as weight loss is one of the most commonly used tools in identifying patients at risk of developing cachexia and the implementation of machine learning models has demonstrated the ability to accurately predict cachexia in cancer patients, even when this vital measurement is absent [132,133]. These models take advantage of other important clinical factors, such as changes in appetite, clinical lab values, and changes in muscle mass to predict malnutrition. This innovative approach can serve as a vital tool to identify at-risk individuals who otherwise would not be able to be assessed for malnutrition, given the missing clinical data points [132,133].
Perhaps the more critical application of machine learning models is for the identification of patients at risk of progression to developing malnutrition or cancer-related cachexia [131,135]. Retrospective data have demonstrated a promising ability to utilize machine learning to identify patients with pre-cachexia with high accuracy. Furthermore, it provides a valuable tool for more individualized risk stratification of patients that may not be feasible with the existing clinical screening tools [131]. This important prognostication tool can allow for more individualized goal-directed care, intervention, and follow up.

7. Conclusions

Nutrition complications in patients with gastrointestinal cancers are a serious and common problem; accurate diagnosis of the nutritional challenge and associated symptomatology is paramount for developing a personalized dietary recommendation. Novel technologies will help in identifying patients who are at risk of developing these devastating problems. A comprehensive multidisciplinary evaluation is necessary early and often to address these complications; therapeutic pharmacological advances and technological innovations in delivery of care should pave the way to decrease the incidence and clinical impact of malnutrition on gastrointestinal cancer patients.

Author Contributions

Conceptualization, J.M.P. and N.K.; data curation, N.K., K.T., C.S. and J.M.P.; writing—original draft preparation, N.K., K.T., C.S. and J.M.P.; writing—review and editing, N.K., K.T., C.S. and J.M.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Acknowledgments

We would like to thank the Noznesky Family for their generous contributions that allowed this manuscript to be completed and to their support of the Noznesky Family Gastroesophageal Research Fund.

Conflicts of Interest

J.M.P. discloses participation with Consulting Ferranova, Consulting Astrazeneca, and Consulting Alcresta. The authors declare no conflict of interest.

References

  1. GI Cancer Alliance. Gastrointestinal Cancers: An Urgent Need; GI Cancer Alliance: Central Square, NY, USA, 2018. [Google Scholar]
  2. Sherman, R.L.; Firth, A.U.; Henley, S.J.; Siegel, R.L.; Negoita, S.; Sung, H.; Kohler, B.A.; Anderson, R.N.; Cucinelli, J.; Scott, S.; et al. Annual Report to the Nation on the Status of Cancer, featuring state-level statistics after the onset of the COVID-19 pandemic. Cancer 2025, 131, e35833. [Google Scholar] [CrossRef]
  3. Davies, S.J.; West, M.A.; Rahman, S.A.; Underwood, T.J.; Marino, L.V. Oesophageal cancer: The effect of early nutrition support on clinical outcomes. Clin. Nutr. ESPEN 2021, 42, 117–123. [Google Scholar] [CrossRef] [PubMed]
  4. Garth, A.K.; Newsome, C.M.; Simmance, N.; Crowe, T.C. Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer. J. Hum. Nutr. Diet. 2010, 23, 393–401. [Google Scholar] [CrossRef] [PubMed]
  5. Muscaritoli, M.; Lucia, S.; Farcomei, A.; Lorusso, V.; Saracino, V.; Barone, C.; Plastino, F.; Gori, S.; Magarotto, R.; Carteni, G.; et al. Prevalence of malnutrition in patients at first medical oncology visit: The PreMiO study. Oncotarget 2017, 8, 79884–79896. [Google Scholar] [CrossRef]
  6. Matsui, R.; Rifu, K.; Watanabe, J.; Inaki, N.; Fukunaga, T. Impact of malnutrition as defined by the GLIM criteria on treatment outcomes in patients with cancer: A systematic review and meta-analysis. Clin. Nutr. 2023, 42, 615–624. [Google Scholar] [CrossRef]
  7. Meissner, C.; Tiegges, S.; Broehl, M.; Otto, R.; Ridwelski, K. International study on the prevalence of malnutrition in centralized care for colorectal cancer patients. Innov. Surg. Sci. 2023, 8, 83–92. [Google Scholar] [CrossRef] [PubMed]
  8. Jacobson, R.; Gurd, E.N.; Pimiento, J.M. Long-term nutrition alterations after surgery for gastrointestinal cancers. Nutr. Clin. Pract. 2023, 38, 721–730. [Google Scholar] [CrossRef]
  9. Zhang, L.; Lu, Y.; Fang, Y. Nutritional status and related factors of patients with advanced gastrointestinal cancer. Br. J. Nutr. 2014, 111, 1239–1244. [Google Scholar] [CrossRef]
  10. Zhang, H.; Zhang, Y.; Tang, X.; Zhang, S.; Man, C.; Gong, D.; Fan, Y. The Prevalence and Prognostic Impact of Cancer Cachexia on Overall Survival in Patients with Gastrointestinal Cancer: A Meta-Analysis. Nutr. Cancer 2025, 77, 590–599. [Google Scholar] [CrossRef]
  11. Saeed, S.M.; Fontaine, J.P.; Dam, A.N.; Hoffe, S.E.; Cameron, M.; Frakes, J.; Mehta, R.; Gurd, E.; Pimiento, J. Is Preoperative G-Tube Use Safe for Esophageal Cancer Patients? J. Am. Coll. Nutr. 2020, 39, 301–306. [Google Scholar] [CrossRef]
  12. Marín Caro, M.M.; Laviano, A.; Pichard, C. Impact of nutrition on quality of life during cancer. Curr. Opin. Clin. Nutr. Metab. Care 2007, 10, 480–487. [Google Scholar] [CrossRef] [PubMed]
  13. Brudno, J.N.; Kochenderfer, J.N. Current understanding and management of CAR T cell-associated toxicities. Nat. Rev. Clin. Oncol. 2024, 21, 501–521. [Google Scholar] [CrossRef] [PubMed]
  14. Reece, L.; Dragicevich, H.; Lewis, C.; Rothwell, C.; Fisher, O.M.; Carey, S.; Alzahrani, N.A.; Liauw, W.; Morris, D.L. Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann. Surg. Oncol. 2019, 26, 2622–2630. [Google Scholar] [CrossRef]
  15. Cucchiaro, B.; Davies, N.A.; Weekes, C.E.; O’Reilly, M.; Roddie, C.; Slee, A. Malnutrition and cachexia are associated with poor CAR T-cell therapy outcomes including survival. Clin. Nutr. ESPEN 2024, 62, 206–215. [Google Scholar] [CrossRef] [PubMed]
  16. Hirano, Y.; Konishi, T.; Kaneko, H.; Itoh, H.; Matsuda, S.; Kawakubo, H.; Uda, K.; Matsui, H.; Fushimi, K.; Daiko, H.; et al. Weight loss during neoadjuvant therapy and short-term outcomes after esophagectomy: A retrospective cohort study. Int. J. Surg. 2023, 109, 805–812. [Google Scholar] [CrossRef]
  17. Zhang, Y.; Li, Z.; Jiang, L.; Xue, Z.; Ma, Z.; Kang, W.; Ye, X.; Liu, Y.; Jin, Z.; Yu, J. Impact of body composition on clinical outcomes in people with gastric cancer undergoing radical gastrectomy after neoadjuvant treatment. Nutrition 2021, 85, 111135. [Google Scholar] [CrossRef]
  18. Pimiento, J.M.; Evans, D.C.; Tyler, R.; Barrocas, A.; Hernandez, B.; Araujo-Torres, K.; Guenter, P.; ASPEN Value Project Scientific Advisory Council. Value of nutrition support therapy in patients with gastrointestinal malignancies: A narrative review and health economic analysis of impact on clinical outcomes in the United States. J. Gastrointest. Oncol. 2021, 12, 864–873. [Google Scholar] [CrossRef]
  19. Alzoubi, Z.; Loman, B.R. Nutrition Interventions in the Treatment of Gastrointestinal Symptoms during Cancer Therapy: A Systematic Review and Meta-analysis. Adv. Nutr. 2025, 16, 100485. [Google Scholar] [CrossRef]
  20. Cencioni, C.; Trestini, I.; Piro, G.; Bria, E.; Tortora, G.; Carbone, C.; Spallotta, F. Gastrointestinal Cancer Patient Nutritional Management: From Specific Needs to Novel Epigenetic Dietary Approaches. Nutrients 2022, 14, 1542. [Google Scholar] [CrossRef]
  21. McQuade, R.M.; Stojanovska, V.; Abalo, R.; Bornstein, J.C.; Nurgali, K. Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments. Front. Pharmacol. 2016, 7, 414. [Google Scholar] [CrossRef]
  22. Stein, A.; Voigt, W.; Jordan, K. Review: Chemotherapy-induced diarrhea: Pathophysiology, frequency and guideline-based management. Ther. Adv. Med. Oncol. 2010, 2, 51–63. [Google Scholar] [CrossRef] [PubMed]
  23. Nakayama, T.; Haratani, K.; Kurosaki, T.; Tanaka, K.; Nakagawa, K. Gastroparesis as a significant gastrointestinal adverse event during intensive chemotherapy for solid caner: A case report. Transl. Cancer Res. 2022, 11, 1824–1828. [Google Scholar] [CrossRef]
  24. 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. [Google Scholar] [CrossRef]
  25. Arnold, M.; Abnet, C.C.; Neale, R.E.; Vignat, J.; Giovannucci, E.L.; McGlynn, K.A.; Bray, F. Global Burden of 5 Major Types of Gastrointestinal Cancer. Gastroenterology 2020, 159, 335–349.e15. [Google Scholar] [CrossRef]
  26. Hendifar, A.E.; Petzel, M.Q.B.; Zimmers, T.A.; Denlinger, C.S.; Matrisian, L.M.; Picozzi, V.J.; Rahib, L. Precision Promise Consortium. Pancreas Cancer-Associated Weight Loss. Oncologist 2019, 24, 691–701. [Google Scholar] [CrossRef]
  27. Bartel, M.J.; Asbun, H.; Stauffer, J.; Raimondo, M. Pancreatic exocrine insufficiency in pancreatic cancer: A review of the literature. Dig. Liver Dis. 2015, 47, 1013–1020. [Google Scholar] [CrossRef]
  28. Tseng, D.S.; Molenaar, I.Q.; Besselink, M.G.; van Eijck, C.H.; Borel Rinkes, I.H.; van Santvoort, H.C. Pancreatic Exocrine Insufficiency in Patients with Pancreatic or Periampullary Cancer: A Systematic Review. Pancreas 2016, 45, 325–330. [Google Scholar] [CrossRef] [PubMed]
  29. National Guideline Alliance (UK). Oesophago-Gastric Cancer: Assessment and Management in Adults; National Institute for Health and Care Excellence: London, UK, 2018. [Google Scholar]
  30. Kang, M.K.; Lee, H.-J. Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer. Ann. Gastroenterol. Surg. 2024, 8, 534–552. [Google Scholar] [CrossRef] [PubMed]
  31. Akad, F.; Filip, B.; Preda, C.; Zugun-Eloae, F.; Peiu, S.N.; Akad, N.; Crauciuc, D.V.; Vatavu, R.; Gavril, L.C.; Sufaru, R.F.; et al. Assessing Nutritional Status in Gastric Cancer Patients after Total versus Subtotal Gastrectomy: Cross-Sectional Study. Nutrients 2024, 16, 1485. [Google Scholar] [CrossRef]
  32. Dunne, R.F.; Crawford, J.; Smoyer, K.E.; McRae, T.D.; Rossulek, M.I.; Revkin, J.H.; Tarasenko, L.C.; Bonomi, P.D. The mortality burden of cachexia or weight loss in patients with colorectal or pancreatic cancer: A systematic literature review. J. Cachexia Sarcopenia Muscle 2024, 15, 1628–1640. [Google Scholar] [CrossRef]
  33. Beukers, K.; Franssen, R.F.W.; Beijaard, K.; van de Wouw, A.J.; Havermans, R.C.; Janssen-Heijnen, M.L.G. Nutritional intervention during a teleprehabilitation pilot study in high-risk patients with colorectal cancer: Adherence, motivators, and barriers. Support. Care Cancer 2024, 32, 710. [Google Scholar] [CrossRef]
  34. Ruiz-Margáin, A.; Román-Calleja, B.M.; Moreno-Guillén, P.; González-Regueiro, J.A.; Kúsulas-Delint, D.; Campos-Murguía, A.; Flores-García, N.C.; Macías-Rodríguez, R.U. Nutritional therapy for hepatocellular carcinoma. World J. Gastrointest. Oncol. 2021, 13, 1440–1452. [Google Scholar] [CrossRef]
  35. Arends, J.; Bachmann, P.; Baracos, V.; Barthelemy, N.; Bertz, H.; Bozzetti, F.; Fearon, K.; Hütterer, E.; Isenring, E.; Kaasa, S.; et al. ESPEN guidelines on nutrition in cancer patients. Clin. Nutr. 2017, 36, 11–48. [Google Scholar] [CrossRef]
  36. Muscaritoli, M.; Arends, J.; Bachmann, P.; Baracos, V.; Barthelemy, N.; Bertz, H.; Bozzetti, F.; Hütterer, E.; Isenring, E.; Kaasa, S.; et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin. Nutr. 2021, 40, 2898–2913. [Google Scholar] [CrossRef] [PubMed]
  37. Trujillo, E.B.; Kadakia, K.C.; Thomson, C.; Zhang, F.F.; Livinski, A.; Pollard, K.; Mattox, T.; Tucker, A.; Williams, V.; Walsh, D.; et al. Malnutrition risk screening in adult oncology outpatients: An ASPEN systematic review and clinical recommendations. J. Parenter. Enteral Nutr. 2024, 48, 874–894. [Google Scholar] [CrossRef]
  38. Kenny, E.; Touger-Decker, R.; August, D.A. Structured Review of the Value Added by the Registered Dietitian to the Care of Gastrointestinal Cancer Patients. Nutr. Clin. Pract. 2021, 36, 606–628. [Google Scholar] [CrossRef] [PubMed]
  39. Mogensen, K.M. Essential Fatty Acid Deficiency. Pract. Gastroenterol. 2017, 41, 37–44. [Google Scholar]
  40. Murray, G.; Ramsey, M.L.; Hart, P.A.; Roberts, K.M. Fat malabsorption in pancreatic cancer: Pathophysiology and management. Nutr. Clin. Pract. 2024, 39, S46–S56. [Google Scholar] [CrossRef]
  41. Phillips, M.E.; McGeeney, L.M.; Griffin, O.; Freeman, K.; Dann, S.; Duggan, S.N.; Committee Members of the Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland. Training 1200 dietitians: An evaluation of a training course for non-specialist dietitians on the management of pancreatic exocrine insufficiency. Clin. Nutr. Open Sci. 2022, 44, 155–162. [Google Scholar] [CrossRef]
  42. Bruera, E. ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ 1997, 315, 1219–1222. [Google Scholar] [CrossRef]
  43. Laviano, A.; Meguid, M.M.; Rossi-Fanelli, F. Cancer anorexia: Clinical implications, pathogenesis, and therapeutic strategies. Lancet Oncol. 2003, 4, 686–694. [Google Scholar] [CrossRef] [PubMed]
  44. Ezeoke, C.C.; Morley, J.E. Pathophysiology of anorexia in the cancer cachexia syndrome. J. Cachexia Sarcopenia Muscle 2015, 6, 287–302. [Google Scholar] [CrossRef]
  45. Mercadante, S.; Napolitano, D.; Lo Cascio, A.; Mancin, S.; Casuccio, A. Poor Appetite and Survival in Patients Admitted to an Acute Palliative Care Unit for Comprehensive Palliative Care. Nutrients 2025, 17, 1882. [Google Scholar] [CrossRef]
  46. Roeland, E.J.; Bohlke, K.; Baracos, V.E.; Smith, T.J.; Loprinzi, C.L. Cancer Cachexia Expert Panel. Cancer Cachexia: ASCO Guideline Rapid Recommendation Update. J. Clin. Oncol. 2023, 41, 4178–4179. [Google Scholar] [CrossRef]
  47. Elterman, K.G.; Mallampati, S.R.; Kaye, A.D.; Urman, R.D. Postoperative alterations in taste and smell. Anesth. Pain Med. 2014, 4, e18527. [Google Scholar] [CrossRef]
  48. Welchman, S.; Hiotis, P.; Pengelly, S.; Hughes, G.; Halford, J.; Christiansen, P.; Lewis, S. Changes in taste preference after colorectal surgery: A longitudinal study. Clin. Nutr. 2015, 34, 881–884. [Google Scholar] [CrossRef]
  49. Hesketh, P.J.; Kris, M.G.; Basch, E.; Bohlke, K.; Barbour, S.Y.; Clark-Snow, R.A.; Danso, M.A.; Dennis, K.; Dupuis, L.L.; Dusetzina, S.B.; et al. Antiemetics: ASCO Guideline Update. J. Clin. Oncol. 2020, 38, 2782–2797. [Google Scholar] [CrossRef]
  50. Herrstedt, J.; Clark-Snow, R.; Ruhlmann, C.H.; Molassiotis, A.; Olver, I.; Rapoport, B.L.; Aapro, M.; Dennis, K.; Hesketh, P.J.; Navari, R.M.; et al. 2023 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting. ESMO Open 2024, 9, 102195. [Google Scholar] [CrossRef]
  51. Benson, A.B., 3rd; Ajani, J.A.; Catalano, R.B.; Engelking, C.; Kornblau, S.M.; Martenson, J.A., Jr.; McCallum, R.; Mitchell, E.P.; O’Dorisio, T.M.; Vokes, E.E.; et al. Recommended Guidelines for the Treatment of Cancer Treatment-Induced Diarrhea. J. Clin. Oncol. 2004, 22, 2918–2926. [Google Scholar] [CrossRef] [PubMed]
  52. Sanz-Paris, A.; Martinez-Trufero, J.; Lambea-Sorrosal, J.; Calvo-Gracia, F.; Milà-Villarroel, R. Clinical and Nutritional Effectiveness of a Nutritional Protocol with Oligomeric Enteral Nutrition in Patients with Oncology Treatment-Related Diarrhea. Nutrients 2020, 12, 1534. [Google Scholar] [CrossRef] [PubMed]
  53. Tamayo-Torres, E.; Garrido, A.; de Cabo, R.; Carretero, J.; Gómez-Cabrera, M.C. Molecular mechanisms of cancer cachexia. Role of exercise training. Mol. Aspects Med. 2024, 99, 101293. [Google Scholar] [CrossRef] [PubMed]
  54. Staller, K.; Parkman, H.P.; Greer, K.B.; Camilleri, M.; Altayar, O. AGA Clinical Practice Guideline on Management of Gastroparesis. Gastroenterology 2025, 169, 828–861. [Google Scholar] [CrossRef] [PubMed]
  55. Zhang, Y.-J.; Wu, S.-P. Therapeutic effect of Wendan Decoction combined with mosapride on gastroesophageal reflux disease after esophageal cancer surgery. World J. Clin. Cases 2024, 12, 2194–2200. [Google Scholar] [CrossRef]
  56. Scarpellini, E.; Arts, J.; Karamanolis, G.; Laurenius, A.; Siquini, W.; Suzuki, H.; Ukleja, A.; Van Beek, A.; Vanuytsel, T.; Bor, S.; et al. International consensus on the diagnosis and management of dumping syndrome. Nat. Rev. Endocrinol. 2020, 16, 448–466. [Google Scholar] [CrossRef]
  57. Nejatinamini, S.; Kubrak, C.; Álvarez-Camacho, M.; Baracos, V.E.; Ghosh, S.; Wismer, W.V.; Mazurak, V.C. Head and Neck Cancer Patients Do Not Meet Recommended Intakes of Micronutrients without Consuming Fortified Products. Nutr. Cancer 2018, 70, 474–482. [Google Scholar] [CrossRef] [PubMed]
  58. Pimiento, J.M. Feasibility of Oral Vitamin B12 Supplementation After Total Gastrectomy: Single Institution Cohort. J. Surg. Res. Pract. 2025, 6, 1–6. [Google Scholar] [CrossRef]
  59. Namikawa, T.; Maeda, M.; Yokota, K.; Iwabu, J.; Munekage, M.; Uemura, S.; Maeda, H.; Kitagawa, H.; Kobayashi, M.; Hanazaki, K. Enteral Vitamin B12 Supplementation Is Effective for Improving Anemia in Patients Who Underwent Total Gastrectomy. Oncology 2021, 99, 225–233. [Google Scholar] [CrossRef]
  60. DeLoughery, T.G.; Jackson, C.S.; Ko, C.W.; Rockey, D.C. AGA Clinical Practice Update on Management of Iron Deficiency Anemia: Expert Review. Clin. Gastroenterol. Hepatol. 2024, 22, 1575–1583. [Google Scholar] [CrossRef]
  61. Franssen, R.F.W.; Bongers, B.C.; Vogelaar, F.J.; Janssen-Heijnen, M.L.G. Feasibility of a tele-prehabilitation program in high-risk patients with colon or rectal cancer undergoing elective surgery: A feasibility study. Perioper. Med. 2022, 11, 28. [Google Scholar] [CrossRef]
  62. Janssen, H.J.B.; Fransen, L.F.C.; Ponten, J.E.H.; Nieuwenhuijzen, G.A.P.; Luyer, M.D.P. Micronutrient Deficiencies Following Minimally Invasive Esophagectomy for Cancer. Nutrients 2020, 12, 778. [Google Scholar] [CrossRef]
  63. Emkey, R.D.; Emkey, G.R. Calcium Metabolism and Correcting Calcium Deficiencies. Endocrinol. Metab. Clin. N. Am. 2012, 41, 527–556. [Google Scholar] [CrossRef]
  64. Zouiouich, S.; Wahl, D.; Liao, L.M.; Hong, H.G.; Sinha, R.; Loftfield, E. Calcium Intake and Risk of Colorectal Cancer in the NIH-AARP Diet and Health Study. JAMA Netw. Open 2025, 8, e2460283. [Google Scholar] [CrossRef]
  65. Bjelakovic, G.; Gluud, L.L.; Nikolova, D.; Whitfield, K.; Krstic, G.; Wetterslev, J.; Gluud, C. Vitamin D supplementation for prevention of cancer in adults. Cochrane Database Syst. Rev. 2014, 2014, CD007469. [Google Scholar] [CrossRef] [PubMed]
  66. Vaughan-Shaw, P.G.; Buijs, L.F.; Blackmur, J.P.; Theodoratou, E.; Zgaga, L.; Din, F.V.N.; Farrington, S.M.; Dunlop, M.G. The effect of vitamin D supplementation on survival in patients with colorectal cancer: Systematic review and meta-analysis of randomised controlled trials. Br. J. Cancer 2020, 123, 1705–1712. [Google Scholar] [CrossRef]
  67. Yavuzsen, T.; Davis, M.P.; Walsh, D.; LeGrand, S.; Lagman, R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J. Clin. Oncol. 2005, 23, 8500–8511. [Google Scholar] [CrossRef]
  68. Nielsen, R.L.; Houlind, M.B.; Andersen, A.L. Ponsegromab for the Treatment of Cancer Cachexia. N. Engl. J. Med. 2025, 392, 1035–1036. [Google Scholar] [PubMed]
  69. Sikic, B.I.; Scudder, S.A.; Ballon, S.C.; Soriero, O.M.; Christman, J.E.; Suey, L.; Ehsan, M.N.; Brandt, A.E.; Evans, T.L. High-dose megestrol acetate therapy of ovarian carcinoma: A phase II study by the Northern California Oncology Group. Semin. Oncol. 1986, 13, 26–32. [Google Scholar] [PubMed]
  70. Aisner, J.; Tchekmedyian, N.S.; Tait, N.; Parnes, H.; Novak, M. Studies of high-dose megestrol acetate: Potential applications in cachexia. Semin. Oncol. 1988, 15, 68–75. [Google Scholar]
  71. Roeland, E.J.; Bohlke, K.; Baracos, V.E.; Bruera, E.; Del Fabbro, E.; Dixon, S.; Fallon, M.; Herrstedt, J.; Lau, H.; Platek, M.; et al. Management of Cancer Cachexia: ASCO Guideline. J. Clin. Oncol. 2020, 38, 2438–2453. [Google Scholar] [CrossRef]
  72. Simons, J.P.; Aaronson, N.K.; Vansteenkiste, J.F.; ten Velde, G.P.; Muller, M.J.; Drenth, B.M.; Erdkamp, F.L.; Cobben, E.G.; Schoon, E.J.; Smeets, J.B.; et al. Effects of medroxyprogesterone acetate on appetite, weight, and quality of life in advanced-stage non-hormone-sensitive cancer: A placebo-controlled multicenter study. J. Clin. Oncol. 1996, 14, 1077–1084. [Google Scholar] [CrossRef]
  73. Beller, E.; Tattersall, M.; Lumley, T.; Levi, J.; Dalley, D.; Olver, I.; Page, J.; Abdi, E.; Wynne, C.; Friedlander, M.; et al. Improved quality of life with megestrol acetate in patients with endocrine-insensitive advanced cancer: A randomised placebo-controlled trial. Australasian Megestrol Acetate Cooperative Study Group. Ann. Oncol. 1997, 8, 277–283. [Google Scholar] [CrossRef]
  74. Ruiz-García, V.; Juan, O.; Pérez Hoyos, S.; Peiró, R.; Ramón, N.; Rosero, M.A.; García, M.A. [Megestrol acetate: A systematic review usefulness about the weight gain in neoplastic patients with cachexia]. Med. Clin. 2002, 119, 166–170. [Google Scholar] [CrossRef]
  75. Moertel, C.G.; Schutt, A.J.; Reitemeier, R.J.; Hahn, R.G. Corticosteroid therapy of preterminal gastrointestinal cancer. Cancer 1974, 33, 1607–1609. [Google Scholar] [CrossRef]
  76. Currow, D.C.; Glare, P.; Louw, S.; Martin, P.; Clark, K.; Fazekas, B.; Agar, M.R. A randomised, double blind, placebo-controlled trial of megestrol acetate or dexamethasone in treating symptomatic anorexia in people with advanced cancer. Sci. Rep. 2021, 11, 2421. [Google Scholar] [CrossRef] [PubMed]
  77. Kishi, T.; Kafantaris, V.; Sunday, S.; Sheridan, E.M.; Correll, C.U. Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systematic review and meta-analysis. J. Clin. Psychiatry 2012, 73, e757–e766. [Google Scholar] [CrossRef]
  78. Navari, R.M.; Pywell, C.M.; Le-Rademacher, J.G.; White, P.; Dodge, A.B.; Albany, C.; Loprinzi, C.L. Olanzapine for the Treatment of Advanced Cancer–Related Chronic Nausea and/or Vomiting. JAMA Oncol. 2020, 6, 895. [Google Scholar] [CrossRef] [PubMed]
  79. Sandhya, L.; Devi Sreenivasan, N.; Goenka, L.; Dubashi, B.; Kayal, S.; Solaiappan, M.; Govindarajalou, R.; Kt, H.; Ganesan, P. Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients with Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer. J. Clin. Oncol. 2023, 41, 2617–2627. [Google Scholar] [CrossRef] [PubMed]
  80. Breit, S.N.; Tsai, V.W. Metabolic Messenger: Growth differentiation factor 15. Nat. Metab. 2025, 7, 1732–1744. [Google Scholar] [CrossRef]
  81. Filippini, D.M.; Romaniello, D.; Carosi, F.; Fabbri, L.; Carlini, A.; Giusti, R.; Di Maio, M.; Alfieri, S.; Lauriola, M.; Pantaleo, M.A.; et al. The Multifaceted Role of Growth Differentiation Factor 15 (GDF15): A Narrative Review from Cancer Cachexia to Target Therapy. Biomedicines 2025, 13, 1931. [Google Scholar] [CrossRef]
  82. van Exter, S.H.; Drager, L.D.; van Asseldonk, M.J.M.D.; Strijker, D.; van der Schoot, N.D.; van den Heuvel, B.; Verlaan, S.; van den Berg, M.G.A. Adherence to and Efficacy of the Nutritional Intervention in Multimodal Prehabilitation in Colorectal and Esophageal Cancer Patients. Nutrients 2023, 15, 2133. [Google Scholar] [CrossRef]
  83. Gillis, C.; Fenton, T.R.; Sajobi, T.T.; Minnella, E.M.; Awasthi, R.; Loiselle, S.È.; Liberman, A.S.; Stein, B.; Charlebois, P.; Carli, F. Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass: A pooled analysis of randomized controlled trials. Clin. Nutr. 2019, 38, 1053–1060. [Google Scholar] [CrossRef]
  84. Minnella, E.M.; Awasthi, R.; Loiselle, S.E.; Agnihotram, R.V.; Ferri, L.E.; Carli, F. Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial. JAMA Surg. 2018, 153, 1081–1089. [Google Scholar] [CrossRef] [PubMed]
  85. Gillis, C.; Fenton, T.R.; Gramlich, L.; Keller, H.; Sajobi, T.T.; Culos-Reed, S.N.; Richer, L.; Awasthi, R.; Carli, F. Malnutrition modifies the response to multimodal prehabilitation: A pooled analysis of prehabilitation trials. Appl. Physiol. Nutr. Metab. 2022, 47, 141–150. [Google Scholar] [CrossRef]
  86. Allen, S.K.; Brown, V.; White, D.; King, D.; Hunt, J.; Wainwright, J.; Emery, A.; Hodge, E.; Kehinde, A.; Prabhu, P.; et al. Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial. Ann. Surg. Oncol. 2022, 29, 1839–1850. [Google Scholar] [CrossRef] [PubMed]
  87. Molenaar, C.J.; van Rooijen, S.J.; Fokkenrood, H.J.; Roumen, R.M.; Janssen, L.; Slooter, G.D. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst. Rev. 2022, 5, CD013259. [Google Scholar]
  88. Gillis, C.; Davies, S.J.; Carli, F.; Wischmeyer, P.E.; Wootton, S.A.; Jackson, A.A.; Riedel, B.; Marino, L.V.; Levett, D.Z.H.; West, M.A. Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review. Front. Nutr. 2021, 8, 644723. [Google Scholar] [CrossRef]
  89. Dijksterhuis, W.P.M.; Latenstein, A.E.J.; van Kleef, J.J.; Verhoeven, R.H.A.; de Vries, J.H.M.; Slingerland, M.; Steenhagen, E.; Heisterkamp, J.; Timmermans, L.M.; de van der Schueren, M.A.E.; et al. Cachexia and Dietetic Interventions in Patients with Esophagogastric Cancer: A Multicenter Cohort Study. J. Natl. Compr. Cancer Netw. 2021, 19, 144–152. [Google Scholar] [CrossRef]
  90. Trestini, I.; Carbognin, L.; Sperduti, I.; Bonaiuto, C.; Auriemma, A.; Melisi, D.; Salvatore, L.; Bria, E.; Tortora, G. Prognostic impact of early nutritional support in patients affected by locally advanced and metastatic pancreatic ductal adenocarcinoma undergoing chemotherapy. Eur. J. Clin. Nutr. 2018, 72, 772–779. [Google Scholar] [CrossRef]
  91. Richards, J.; Arensberg, M.B.; Thomas, S.; Kerr, K.W.; Hegazi, R.; Bastasch, M. Impact of Early Incorporation of Nutrition Interventions as a Component of Cancer Therapy in Adults: A Review. Nutrients 2020, 12, 3403. [Google Scholar] [CrossRef] [PubMed]
  92. Tanaka, N.; Takeda, K.; Kawasaki, Y.; Yamane, K.; Teruya, Y.; Kodani, M.; Igishi, T.; Yamasaki, A. Early Intensive Nutrition Intervention with Dietary Counseling and Oral Nutrition Supplement Prevents Weight Loss in Patients with Advanced Lung Cancer Receiving Chemotherapy: A Clinical Prospective Study. Yonago Acta Med. 2018, 61, 204–212. [Google Scholar] [CrossRef]
  93. Tweed, T.T.T.; Sier, M.A.T.; Van Bodegraven, A.A.; Van Nie, N.C.; Sipers, W.M.W.H.; Boerma, E.G.; Stoot, J.H.M.B. Feasibility and Efficiency of the BEFORE (Better Exercise and Food, Better Recovery) Prehabilitation Program. Nutrients 2021, 13, 3493. [Google Scholar] [CrossRef] [PubMed]
  94. St-Pierre, J.; Coca-Martinez, M.; Drummond, K.; Minnella, E.; Ramanakumar, A.V.; Ferri, L.; Carli, F.; Scheede-Bergdahl, C. Multimodal prehabilitation to enhance functional capacity of patients with esophageal cancer during concurrent neoadjuvant chemotherapies-a randomized feasibility trial. Dis. Esophagus 2024, 37, doae087. [Google Scholar] [CrossRef]
  95. Wang, Q.C.; Yuan, H.; Chen, Z.M.; Wang, J.; Xue, H.; Zhang, X.Y. Barriers and Facilitators of Adherence to Oral Nutritional Supplements Among People Living with Cancer: A Systematic Review. Clin. Nurs. Res. 2023, 32, 209–220. [Google Scholar] [CrossRef]
  96. Barnes, K.; Hladkowicz, E.; Dorrance, K.; Bryson, G.L.; Forster, A.J.; Gagné, S.; Huang, A.; Lalu, M.M.; Lavallée, L.T.; Saunders, C.; et al. Barriers and facilitators to participation in exercise prehabilitation before cancer surgery for older adults with frailty: A qualitative study. BMC Geriatr. 2023, 23, 356. [Google Scholar] [CrossRef]
  97. Watts, T.; Courtier, N.; Fry, S.; Gale, N.; Gillen, E.; McCutchan, G.; Patil, M.; Rees, T.; Roche, D.; Wheelwright, S. Access, acceptance and adherence to cancer prehabilitation: A mixed-methods systematic review. J. Cancer Surviv. 2024, 19, 1895–1923. [Google Scholar] [CrossRef] [PubMed]
  98. Piché, A.; Santa Mina, D.; Lambert, S.; Doré, I. Assessing real-world implementability of a multimodal group-based tele-prehabilitation program in cancer care: A pragmatic feasibility study. Front. Oncol. 2023, 13, 1271812. [Google Scholar] [CrossRef] [PubMed]
  99. Clemons, J.; Zhou, Z.; Hoy, S.A.; Gerber, S.; Nambiar, A.; Kwon, A.; Kin, C. No thanks and not for me: A qualitative study of barriers to prehabilitation participation. Surgery 2024, 176, 1697–1702. [Google Scholar] [CrossRef]
  100. Trujillo, E.B.; Claghorn, K.; Dixon, S.W.; Hill, E.B.; Braun, A.; Lipinski, E.; Platek, M.E.; Vergo, M.T.; Spees, C. Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey. J. Oncol. 2019, 2019, 7462940. [Google Scholar] [CrossRef]
  101. Prado, C.M.; Laviano, A.; Gillis, C.; Sung, A.D.; Gardner, M.; Yalcin, S.; Dixon, S.; Newman, S.M.; Bastasch, M.D.; Sauer, A.C. Examining guidelines and new evidence in oncology nutrition: A position paper on gaps and opportunities in multimodal approaches to improve patient care. Support. Care Cancer 2022, 30, 3073–3083. [Google Scholar] [CrossRef]
  102. Grimmett, C.; Bradbury, K.; Dalton, S.O.; Fecher-Jones, I.; Hoedjes, M.; Varkonyi-Sepp, J.; Short, C.E. The Role of Behavioral Science in Personalized Multimodal Prehabilitation in Cancer. Front. Psychol. 2021, 12, 634223. [Google Scholar] [CrossRef]
  103. Voss, M.L.; Brick, R.; Padgett, L.S.; Wechsler, S.; Joshi, Y.; Ammendolia Tomé, G.; Arbid, S.; Campbell, G.; Campbell, K.L.; El Hassanieh, D.; et al. Behavior change theory and behavior change technique use in cancer rehabilitation interventions: A secondary analysis. Eur. J. Phys. Rehabil. Med. 2024, 60, 1036–1050. [Google Scholar] [CrossRef]
  104. Paterson, C.; Nguyen, J.; Fraser, G.; Pranavan, G.; Rammant, E. Effect of Prehabilitation Interventions in People Affected by Bladder Cancer on Long-Term Physical, Clinical, and Patient-Reported Outcome Measures: A Systematic Review. JCO Oncol. Pract. 2025, 21, 1583–1600. [Google Scholar] [CrossRef]
  105. Toohey, K.; Hunter, M.; McKinnon, K.; Casey, T.; Turner, M.; Taylor, S.; Paterson, C. A systematic review of multimodal prehabilitation in breast cancer. Breast Cancer Res. Treat. 2023, 197, 1–37. [Google Scholar] [CrossRef]
  106. Fong, M.; Kaner, E.; Rowland, M.; Graham, H.E.; McEvoy, L.; Hallsworth, K.; Cucato, G.; Gibney, C.; Nedkova, M.; Prentis, J. The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses. PLoS ONE 2023, 18, e0286757. [Google Scholar] [CrossRef]
  107. Wade-Mcbane, K.; King, A.; Urch, C.; Jeyasingh-Jacob, J.; Milne, A.; Boutillier, C.L. Prehabilitation in the lung cancer pathway: A scoping review. BMC Cancer 2023, 23, 747. [Google Scholar] [CrossRef] [PubMed]
  108. Shen, C.; Gu, L.; Li, N.; Wang, R.; Yang, X.; Chu, Z. Attitudes and perceptions of cancer patients and healthcare providers towards prehabilitation: A thematic synthesis. Br. J. Health Psychol. 2024, 29, 395–429. [Google Scholar] [CrossRef] [PubMed]
  109. Treanor, C.; Kyaw, T.; Donnelly, M. An international review and meta-analysis of prehabilitation compared to usual care for cancer patients. J. Cancer Surviv. 2018, 12, 64–73. [Google Scholar] [CrossRef] [PubMed]
  110. Scriney, A.; Russell, A.; Loughney, L.; Gallagher, P.; Boran, L. The impact of prehabilitation interventions on affective and functional outcomes for young to midlife adult cancer patients: A systematic review. Psychooncology 2022, 31, 2050–2062. [Google Scholar] [CrossRef]
  111. Tsimopoulou, I.; Pasquali, S.; Howard, R.; Desai, A.; Gourevitch, D.; Tolosa, I.; Vohra, R. Psychological Prehabilitation Before Cancer Surgery: A Systematic Review. Ann. Surg. Oncol. 2015, 22, 4117–4123. [Google Scholar] [CrossRef]
  112. Chen, Y.; Ahmad, M. Effectiveness of adjunct psychotherapy for cancer treatment: A review. Future Oncol. 2018, 14, 1487–1496. [Google Scholar] [CrossRef]
  113. Mareschal, J.; Hemmer, A.; Douissard, J.; Dupertuis, Y.M.; Collet, T.H.; Koessler, T.; Toso, C.; Ris, F.; Genton, L. Surgical Prehabilitation in Patients with Gastrointestinal Cancers: Impact of Unimodal and Multimodal Programs on Postoperative Outcomes and Prospects for New Therapeutic Strategies—A Systematic Review. Cancers 2023, 15, 1881. [Google Scholar] [CrossRef]
  114. Briggs, L.G.; Parke, S.C.; Beck, K.L.; Sinha, D.; Gill, V.; Van Ligten, M.J.; Bain, P.A.; Tyson, M.D., 2nd; Abdul-Muhsin, H.M.; Quillen, J.K.; et al. A Prehabilitative/rehabilitative exercise, nutrition, and psychological support for bladder cancer: A scoping review of randomized clinical trials. Cancer 2025, 131, e35608. [Google Scholar] [CrossRef] [PubMed]
  115. Dhanis, J.; Keidan, N.; Blake, D.; Rundle, S.; Strijker, D.; van Ham, M.; Pijnenborg, J.M.A.; Smits, A. Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity? Cancers 2022, 14, 3448. [Google Scholar] [CrossRef] [PubMed]
  116. Zamani, M.; Alizadeh-Tabari, S. Anxiety and depression prevalence in digestive cancers: A systematic review and meta-analysis. BMJ Support. Palliat. Care 2023, 13, e235–e243. [Google Scholar] [CrossRef]
  117. Kang, Y.E.; Yoon, J.H.; Park, N.H.; Ahn, Y.C.; Lee, E.J.; Son, C.G. Prevalence of cancer-related fatigue based on severity: A systematic review and meta-analysis. Sci. Rep. 2023, 13, 12815. [Google Scholar] [CrossRef]
  118. Lin, Y.C.; Pimiento, J.M.; Milano, J.; Riccardi, D.; Mckinnie, N.; Hume, E.; Sprow, O.; Diaz-Carraway, S.; Budnetz, M.; Hagen, R.; et al. Feasibility trial of STRONG: A digital intervention to improve nutritional management for individuals with esophageal and gastroesophageal junction cancer. Contemp. Clin. Trials Commun. 2025, 43, 101421. [Google Scholar] [CrossRef] [PubMed]
  119. Waterland, J.L.; Chahal, R.; Ismail, H.; Sinton, C.; Riedel, B.; Francis, J.J.; Denehy, L. Implementing a telehealth prehabilitation education session for patients preparing for major cancer surgery. BMC Health Serv. Res. 2021, 21, 443. [Google Scholar] [CrossRef]
  120. Wu, F.; Rotimi, O.; Laza-Cagigas, R.; Rampal, T. The Feasibility and Effects of a Telehealth-Delivered Home-Based Prehabilitation Program for Cancer Patients during the Pandemic. Curr. Oncol. 2021, 28, 2248–2259. [Google Scholar] [CrossRef]
  121. Kim, J.Y.; Love, M.; Woo, Y.; Campos, B.; Yu, A.; Chang, J.; Erhunmwunsee, L.; Krouse, R.S.; Melstrom, L.; Sun, V. Pilot study of a telehealth intervention for personalized self-management for eating symptoms after gastroesophageal cancer surgery. J. Surg. Oncol. 2024, 129, 728–733. [Google Scholar] [CrossRef]
  122. Brennan, L.; Sadeghi, F.; O’Neill, L.; Guinan, E.; Smyth, L.; Sheill, G.; Smyth, E.; Doyle, S.L.; Timon, C.M.; Connolly, D.; et al. Telehealth Delivery of a Multi-Disciplinary Rehabilitation Programme for Upper Gastro-Intestinal Cancer: ReStOre@Home Feasibility Study. Cancers 2022, 14, 2707. [Google Scholar] [CrossRef]
  123. Driessen, E.J.; Peeters, M.E.; Bongers, B.C.; Maas, H.A.; Bootsma, G.P.; van Meeteren, N.L.; Janssen-Heijnen, M.L. Effects of prehabilitation and rehabilitation including a home-based component on physical fitness, adherence, treatment tolerance, and recovery in patients with non-small cell lung cancer: A systematic review. Crit. Rev. Oncol. Hematol. 2017, 114, 63–76. [Google Scholar] [CrossRef]
  124. Avancini, A.; Borsati, A.; Baldo, E.; Ciurnelli, C.; Trestini, I.; Tregnago, D.; Belluomini, L.; Sposito, M.; Insolda, J.; Auriemma, A.; et al. A Feasibility Study Investigating an Exercise Program in Metastatic Cancer Based on the Patient-Preferred Delivery Mode. Oncologist 2024, 29, e828–e836. [Google Scholar] [CrossRef] [PubMed]
  125. Moorthy, K.; Halliday, L.J.; Noor, N.; Peters, C.J.; Wynter-Blyth, V.; Urch, C.E. Feasibility of Implementation and the Impact of a Digital Prehabilitation Service in Patients Undergoing Treatment for Oesophago-Gastric Cancer. Curr. Oncol. 2023, 30, 1673–1682. [Google Scholar] [CrossRef] [PubMed]
  126. Steffens, D.; Denehy, L.; Solomon, M.; Koh, C.; Ansari, N.; McBride, K.; Carey, S.; Bartyn, J.; Lawrence, A.S.; Sheehan, K. Consumer Perspectives on the Adoption of a Prehabilitation Multimodal Online Program for Patients Undergoing Cancer Surgery. Cancers 2023, 15, 5039. [Google Scholar] [CrossRef] [PubMed]
  127. Timmers, T.G.; Groen, L.C.; Schreurs, H.; Bruns, E.R. Development and implementation of a home-based prehabilitation app for older patients undergoing elective colorectal cancer surgery. A Prospective Cohort Study. Digit. Health 2025, 11, 20552076251317760. [Google Scholar] [CrossRef]
  128. Tay, S.S.; Zhang, F.; Neo, E.J.R. The use of technology in cancer prehabilitation: A systematic review. Front. Oncol. 2024, 14, 1321493. [Google Scholar] [CrossRef]
  129. Cao, Z.; Zhao, K.; Jose, I.; Hoogenraad, N.J.; Osellame, L.D. Biomarkers for Cancer Cachexia: A Mini Review. Int. J. Mol. Sci. 2021, 22, 4501. [Google Scholar] [CrossRef]
  130. Janssen, S.M.; Bouzembrak, Y.; Tekinerdogan, B. Artificial Intelligence in Malnutrition: A Systematic Literature Review. Adv. Nutr. 2024, 15, 100264. [Google Scholar] [CrossRef]
  131. Wu, H.F.; Yan, J.P.; Wu, Q.; Yu, Z.; Xu, H.X.; Song, C.H.; Guo, Z.Q.; Li, W.; Xiang, Y.J.; Xu, Z.; et al. Discovery of distinct cancer cachexia phenotypes using an unsupervised machine-learning algorithm. Nutrition 2024, 119, 112317. [Google Scholar] [CrossRef]
  132. Yin, L.; Cui, J.; Lin, X.; Li, N.; Fan, Y.; Zhang, L.; Liu, J.; Chong, F.; Wang, C.; Liang, T.; et al. Identifying cancer cachexia in patients without weight loss information: Machine learning approaches to address a real-world challenge. Am. J. Clin. Nutr. 2022, 116, 1229–1239. [Google Scholar] [CrossRef]
  133. Wu, T.; Xu, H.; Li, W.; Zhou, F.; Guo, Z.; Wang, K.; Weng, M.; Zhou, C.; Liu, M.; Lin, Y.; et al. The potential of machine learning models to identify malnutrition diagnosed by GLIM combined with NRS-2002 in colorectal cancer patients without weight loss information. Clin. Nutr. 2024, 43, 1151–1161. [Google Scholar] [CrossRef] [PubMed]
  134. Huang, W.; Wang, C.; Wang, Y.; Yu, Z.; Wang, S.; Yang, J.; Lu, S.; Zhou, C.; Wu, E.; Chen, J.; et al. Predicting malnutrition in gastric cancer patients using computed tomography(CT) deep learning features and clinical data. Clin. Nutr. 2024, 43, 881–891. [Google Scholar] [CrossRef] [PubMed]
  135. Chen, Y.; Liu, C.; Zheng, X.; Liu, T.; Xie, H.; Lin, S.Q.; Zhang, H.; Shi, J.; Liu, X.; Wang, Z.; et al. Machine learning to identify precachexia and cachexia: A multicenter, retrospective cohort study. Support. Care Cancer 2024, 32, 630. [Google Scholar] [CrossRef] [PubMed]
Table 1. Reported incidence of malnutrition per cancer type.
Table 1. Reported incidence of malnutrition per cancer type.
Cancer LocationIncidence of MalnutritionReferences
Esophageal22–73%[3,4,5]
Gastric10–50%[6]
Pancreatic9–52%[5,6]
Liver7–20%[5]
Colorectal23%[7]
Table 2. Nutritional challenges and various nutrition impact symptoms that patients may experience, based on cancer site.
Table 2. Nutritional challenges and various nutrition impact symptoms that patients may experience, based on cancer site.
Disease SiteNutrition ChallengesNutrition Impact Symptoms
Pancreatic [26,27,28]Exocrine insufficiency
Fat-soluble vitamin deficiencies
Protein and micronutrient deficiencies
Weight loss, sarcopenia, cachexia
Bone health complications
Gastric outlet obstruction		Fatty stools (steatorrhea)
Chronic diarrhea
Abdominal pain and bloating
Feeling full early (early satiety)
Fatigue
Loss of appetite (anorexia)
Nausea
Constipation
Distress
Cold dysesthesia
Esophageal and Gastric [8,29,30,31]Esophageal obstruction
Gastric outlet obstruction
Vitamin deficiencies (folate, B12, iron)
Pernicious anemia
Malabsorption
Dehydration
Sarcopenia		Dysphagia
Odynophagia
Nausea
Vomiting
Early satiety
Abdominal pain and bloating
Reflux
Anorexia
Cold dysesthesia
Colorectal [8,32,33]Malabsorption
Diarrhea
Iron deficiency anemia
Malignant obstruction		Anorexia
Abdominal pain and bloating
Early satiety
Nausea/vomiting
Diarrhea
Constipation
Obstipation
Cold dysesthesia
Liver [34]Fat malabsorption in setting of hyperbilirubinemia
Sarcopenia
Malnutrition related to underlying cirrhosis or fatty liver disease
Cachexia
Dehydration and electrolyte imbalances in setting of hepatorenal syndrome		Anorexia
Abdominal pain, bloating
Ascites
Early satiety
Table 3. Common nutrition barriers in GI cancer patients and recommended nutrition counseling and dietary modifications.
Table 3. Common nutrition barriers in GI cancer patients and recommended nutrition counseling and dietary modifications.
Barrier to IntakeRecommended Nutrition Strategy
Malabsorption—Fatty Acid Deficiency
-
Ensure ~10% of total calorie intake from fat.
-
Encourage nut butters, vegetable oils, nuts, seeds, avocados, and condiments.
Malabsorption—Exocrine Pancreatic Insufficiency
-
Weight-based pancreatic enzyme replacement.
-
If EPI symptoms continue despite appropriate enzyme use, consider a lower-fat diet.
-
Smaller portions incorporating grains, fruits, and high protein diet.
Poor Appetite
-
Follow an eating schedule to not skip meals.
-
Add in calorie- and protein-dense options to all meals and snacks.
-
Choose calorie- and protein-containing fluids, as tolerated.
-
Consider pharmacologist interventions.
Dysgeusia/Hypogeusia
-
Identify foods that are palatable or unpleasant.
-
Trial seasonings or acidic options, as tolerated.
-
Limit metallic cups or utensils if foods taste metallic.
Nausea/Vomiting
-
Choose small, frequent meals that are room temperature or cold.
-
Consider anti-emetics before oral intake.
-
Limit greasy, fried, or spicy foods.
Diarrhea
-
Choose small, frequent meals.
-
Sip most fluids between meals.
-
Include complex carbohydrates with meals (potatoes, rice, pasta, etc.).
-
Consider a trial of lactose-free dairy.
-
Limit greasy, fried foods, large volumes of insoluble fibers, and concentrated sweets.
Delayed Emptying
-
Eat small, frequent meals and chew foods well.
-
Limit large portions of high-fiber foods and high-fat foods.
-
Liquids may be better tolerated than solids later in the day.
-
Consider enteral nutrition support if unable to increase and maintain consistent oral intake.
Dumping Syndrome
-
Include fat and protein foods with all meals and limit simple sugars.
-
Eat small, frequent meals.
-
Minimize liquid intake at mealtime.
Risk of Bowel Obstruction
-
Eat small, frequent meals and chew foods well.
-
Limit large portions of fiber-rich foods.
-
Limit gas-forming foods.
Table 4. Medical therapy recommendation in cancer patients modified from the ESPEN guidelines [36].
Table 4. Medical therapy recommendation in cancer patients modified from the ESPEN guidelines [36].
Topic/Strength of RecommendationRecommendationLevel of Evidence
Energy requirement/strongRecommend that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally range between 25 and 30 kcal/kg/day.Low/Consensus
Protein requirement/strongRecommend that protein intake should be above 1 g/kg/day and, if possible, up to 1.5 g/kg/day.Moderate/Strong Consensus
Efficacy of nutrition intervention/strongNutritional intervention to increase oral intake in cancer patients who are able to eat but are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms), and offering oral nutritional supplements (ONS).Moderate/Consensus
Specialized diets in cancer patients/strongRecommend not to use dietary provisions that restrict energy intake in patients with or at risk of malnutrition. Recommendation B3-2; strength of recommendation is strong; level of evidence low; strong consensus.Low/Strong Consensus
Mode of nutritional therapy when to
escalate/strong		If a decision has been made to feed a patient, we recommend enteral nutrition (EN) if oral nutrition remains inadequate despite nutritional interventions (counseling, ONS), and parenteral nutrition (PN) if EN is not sufficient or feasible.Moderate/Strong Consensus
Refeeding syndrome/strongIf oral food intake has been decreased severely for a prolonged period, we recommend increasing (oral, enteral, or parenteral) nutrition slowly over several days and to take additional precautions to prevent a refeeding syndrome.Low/Consensus
Home artificial nutrition/strongIn patients with chronic insufficient dietary intake and/or uncontrollable malabsorption, we recommend home EN or PN for suitable patients.Low/Strong Consensus
Role of immunonutrition/strongIn upper GI cancer patients undergoing surgical resection in the context of traditional perioperative care, we recommend oral/enteral immunonutrition.High/Strong Consensus
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Khajoueinejad, N.; Santiago, C.; Turner, K.; Pimiento, J.M. Nutritional Support for Gastrointestinal Cancer Patients: New (and Old) Frontiers in Management, a Narrative Review. Nutrients 2025, 17, 3917. https://doi.org/10.3390/nu17243917

AMA Style

Khajoueinejad N, Santiago C, Turner K, Pimiento JM. Nutritional Support for Gastrointestinal Cancer Patients: New (and Old) Frontiers in Management, a Narrative Review. Nutrients. 2025; 17(24):3917. https://doi.org/10.3390/nu17243917

Chicago/Turabian Style

Khajoueinejad, Nazanin, Christina Santiago, Kea Turner, and Jose M. Pimiento. 2025. "Nutritional Support for Gastrointestinal Cancer Patients: New (and Old) Frontiers in Management, a Narrative Review" Nutrients 17, no. 24: 3917. https://doi.org/10.3390/nu17243917

APA Style

Khajoueinejad, N., Santiago, C., Turner, K., & Pimiento, J. M. (2025). Nutritional Support for Gastrointestinal Cancer Patients: New (and Old) Frontiers in Management, a Narrative Review. Nutrients, 17(24), 3917. https://doi.org/10.3390/nu17243917

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