肿瘤患者营养疗法临床指南

指南 肿瘤内科· 肿瘤治疗与综合管理 · 中国抗癌协会

1 肿瘤患者的营养诊断

诊断是治疗的前提,没有规范营养诊断就没有科学营养治疗,如何规范营养诊断?中国抗癌协会提出了三级营养诊断原则[8]。

1.1 第一级营养诊断：营养筛查

营养筛查是营养诊断的第一步，目的是在全部患

吕家华等:肿瘤患者营养疗法临床指南

者中快速识别存在营养风险的患者,而不是发现需要营养治疗的患者.营养筛查的阳性结果是进一步营养诊断(营养评估)的指征,而不是营养治疗的适应证.营养筛查常用量表法,ESPEN指南推荐以下4种工具[9]:营养风险筛查200(nutritional risk screening 2002, NRS 2002)、微型营养评估简表(mini nutritional assessment-short form, MNA-SF)、营养不良通用筛查工具(malnutrition universal screening tool, MUST)和营养不良筛查工具(malnutrition screening tool, MST).其中,NRS 2002是目前最常用的营养筛查工具,NRS 2002评分≥3分与患者不良临床结局相关,包括生活质量更差、并发症发生率更高、死亡风险增加等[10,11].

中国抗癌协会肿瘤营养专业委员会发明了首个患者自我营养筛查工具——年龄、摄食、体重、步行(age, intake, weight, walk, AIWW)简易问卷[12],该问卷由四个问题组成(表1),操作简单,无需专业培训.研究发现, AIWW, NRS-2002和MST的敏感度分别为0.910, 0.531和0.285,特异度分别为0.768, 0.946和0.975, Kendall tau系数分别为0.588, 0.501和0.326, AUG分别为0.785, 0.739和0.630, 漏诊率分别为0.09%, 49.0%和73.2%. 该研究提示, AIWW作为肿瘤患者营养风险筛查工具,可能优于NRS2002和MST,但需要进一步验证.

1.2 第二级营养诊断：营养评估

营养评估也主要用量表法,目的是诊断营养不良并区分营养不良的严重程度.

患者主观整体评估patient generated-subjective global assessment, PG-SGA)是目前使用最广泛的肿瘤患者营养评估工具。改良患者主观整体评估(modified patient generated-subjective global assessment, mPG-SGA)[13,14]删除了体格检查及回答困难的问题,使问卷条目大幅度减少,调查难度显著降低。研究发现,mPG-SGA比PG-SGA有更好的外部效度、内部效度、重测信度和预测效度,尤其是能区分营养良好和轻度营养不良患者的生存,在预测肺癌患者生存方面的效能更好[15]。

全球领导人营养不良倡议(global leadership initiative on malnutrition, GLIM)是一种新型通用营养不良评估工具[16]. GLIM分两步实施,即先行营养筛查,再对存在营养风险的患者实施营养评估,其信度和效度

表 1 AIWW 问卷

Table 1 AIWW (age, intake, weight, walk) questionnaire

|编号|内容|问题|回答$^{a)}$| |---|---|---|---| |1|年龄|您有65岁吗?|是否| |2|摄食|过去1个月,您吃饭是否 非主动性减少?|是否| |3|体重|过去1个月,您的体重是否 非主动性减轻?|是否| |4|步行|过去1个月,您的步速是否 非主动性减慢?|是否|

a) 说明: 是, 得1分; 否, 得0分. 累计得分≥1分为有营养风险

得到多方面验证. Brown等人[17]系统分析了GLIM评估的营养不良与预后的相关性, 21项研究中的18项报告了营养不良与生存率下降相关, 6项发现营养不良与更长的住院时间相关, 5项报告营养不良可预测术后并发症的增加.

研究显示, GLIM在肿瘤患者中的应用有一些特殊性. 由于肿瘤患者本身就是营养风险人群, 无需前期营养筛查, 直接进入营养评估更好, 可显著减少营养不良漏诊率[18]. 同时, GLIM表型标准与病因标准的不同组合可导致营养评估结果的差异, 比较发现“体重丢失+肿瘤”是最佳组合[18]. 由于不同肿瘤患者的炎症负荷水平差异显著, 用实际炎症负荷水平代替病因标准“肿瘤”, 可以显著提高预后预测效能[19]. 根据GLIM不同条目权重赋分组成的量化GLIM(Scored-GLIM), 比常规定性GLIM有更好的预后预测作用, 而且操作更加简便[20].

乳腺癌的营养诊断具有显著的特殊性, PG-SGA和GLIM对乳腺癌患者存在明显的局限性,为此, INCOC项目组研发了乳腺癌患者特异性营养评估工具——胆固醇营养预后指数(cholesterol-modified prognostic nutritional index, CPNI),预后预测效能优于PG-SGA, GLIM, PNI, CONUT及NRI,但需要更多的验证[21].

1.3 第三级营养诊断：综合评价

中国抗癌协会肿瘤营养专业委员会推荐营养评估后进行综合评价(comprehensive investigation), 分析营养不良的原因、类型和后果, 由此形成了营养筛查、营养评估和综合评价的三级营养诊断体系, 综合评价重点从能耗水平、应激程度、炎症负荷及代谢状况4个维度进行分析, 明确患者是否需要综合治疗及其方

中国科学:生命科学 2026年 第56卷 第2期

案[8,22]。肿瘤患者营养不良具有显著不同于良性疾病营养不良患者的特征,如代谢紊乱、骨骼肌丢失、慢性炎症等,尤其需要三级诊断,重度营养不良肿瘤患者建议常规接受综合评价。

肿瘤患者能量消耗主要由年龄、性别、体重、荷瘤状态、体力活动及治疗情况6个因素决定.前3个因素是决定静息能量消耗(resting energy expenditure, REE)的基础,后3个因素是REE基础上影响每日总能量消耗(total daily energy expenditure, TDEE)的要素[23,24]。基于间接测热法测量REE的代谢车已经用于临床,计算法The Mifflin-St Jeor公式优于Harris-Benedict公式[24]。能量消耗随年龄、体重增加而降低,随体力活动、荷瘤数量增加而增加,手术>放疗>化疗>治疗间期,男性>女性。

反映应激状况的参数较多。由于胰岛素抵抗是所有代谢性疾病包括肿瘤的共同特征，因此胰岛素抵抗指数更为实用。INSCOC项目组构建的CRP、甘油三酯、葡萄糖指数(C-reactive protein, triglyceride, glucose index, CTI)的预后价值高于文献报告的其他胰岛素抵抗指数[25]。甘油三酯/葡萄糖(triglyceride/glucose，TyG)指数对女性生殖系统肿瘤患者预后预测更佳[26]。

肿瘤的本质是一种慢性炎症,炎症负荷是肿瘤患者的重要预后预测标志物,根据机体炎症负荷水平,可以将肿瘤分为高、中、低炎症负荷3类,炎症负荷水平越高,患者生存时间越短[27].炎症不仅是肿瘤营养不良的发病原因,也是肿瘤本身的发病原因,还是肿瘤营养不良区别于良性疾病营养不良的重要特征,更是影响肿瘤治疗、营养治疗效果的重要负面因素[28,29].与低炎症负荷者相比,高炎症负荷的营养不良患者死亡风险增加33.1%,恶液质患者死亡风险增加一倍[28].机体炎症水平可通过细胞因子,如TNF-α, IL-1, IL-6等判断,也可用炎症指数如中性粒细胞/淋巴细胞比值(neutrophil/lymphocyte ratio, NLR)、CRP与白蛋白比值(C-reactive protein/albumin ratio, CAR)等反映[27,28].炎症负荷指数(inflammatory burden index, IBI)具有最好的预测效能,优于目前文献报告的其他炎症指数[27-29].

代谢状况是器官功能状态的反映. 最新研究发现, 肿瘤患者代谢紊乱率高达96.0%, 代谢紊乱率最高的前3位指标分别为低密度脂蛋白胆固醇(45.7%)、总胆固醇(34.2%)、前白蛋白(30.0%); 代谢紊乱率最低的前

3位指标分别为高密度脂蛋白胆固醇(0.5%)、白蛋白(4.0%)、总蛋白(5.1%). 不同肿瘤类型、性别、年龄、TNM分期及治疗方式的肿瘤患者其代谢紊乱率有显著差异(P<0.05)[30].

2 肿瘤患者的营养治疗

营养治疗方法包括营养教育、医学营养治疗(肠内营养、肠外营养)及营养代谢调节治疗[31]。基本要求是满足肿瘤患者目标能量及营养素需求,最高目标是调节代谢、控制肿瘤、提高生活质量、延长生存时间。必须根据患者的营养诊断结果进行个体化治疗[32]。选择具体方法时,要遵循膳食优先、口服优先、营养教育优先和肠内营养优先的“四优先”原则[31,32]。既要保证肿瘤患者营养平衡,维护患者正常生理功能,又要选择性饥饿肿瘤细胞,从而抑制或减缓肿瘤进程。

2.1 分类营养治疗

肿瘤患者入院后应常规实施营养诊断,将患者分为无营养不良、轻度营养不良、中度营养不良及重度营养不良4类,进而依据营养诊断结果制订分类营养治疗原则并实施,无营养不良者,无需营养治疗,直接进行抗肿瘤治疗;轻度营养不良者,在营养教育的同时,实施抗肿瘤治疗;中度营养不良者,在医学营养治疗的同时,实施抗肿瘤治疗;重度营养不良者,应先进行医学营养治疗1~2周,然后在继续医学营养治疗的同时,进行抗肿瘤治疗,无论有无营养不良,所有患者在完成一个疗程的抗肿瘤治疗后,应重新进行营养诊断[4,31],见图1.

2.2 五阶梯营养治疗

营养不良的规范治疗应该遵循五阶梯治疗原则[4,32]. 首先选择营养教育, 然后依次向上逐级选择口服营养补充(oral nutritional supplements, ONS)、完全肠内营养(total enteral nutrition, TEN)、部分肠外营养(partial parenteral nutrition, PPN)和全肠外营养(total parenteral nutrition, TPN), 见图2. 根据患者病情不同阶梯可单独或联合使用. 规范的五阶梯治疗[33,34]对改善营养状况、提高治疗效果、减少并发症、提升生活质量、延长生存时间及节约医疗费用具有重要作用[35].

吕家华等:肿瘤患者营养疗法临床指南

![graph TD\n A1[肿瘤患者入院] --> A2[营养诊断]\n A2 --> A3[无营养不良]\n A2 --> A4[轻度营养不良]\n A2 --> A5[中度营养不良]\n A2 --> A6[重度营养不良]\n A3 --> A7[无需营养治疗抗肿瘤治疗]\n A4 --> A8[营养教育抗肿瘤治疗]\n A5 --> A9[医学营养治疗抗肿瘤治疗]\n A6 --> A10[医学营养治疗1~2周]\n A10 --> A11[医学营养治疗抗肿瘤治疗]\n](1/parseimages/figured4d50eaa3a2b4da98e918d334d66e279_0_1.png) 图1 分类营养治疗(基于营养不良严重程度)

Figure 1 Categorized nutritional therapy (based on malnutrition severity)

![graph TD\n A1[第5阶段全肠外营养] --> A2[第4阶段部分肠内营养+部分肠外营养]\n A2 --> A3[第3阶梯全肠内营养(口服及管饲)]\n A3 --> A4[第2阶梯膳食+口服营养补充]\n A4 --> A5[第1阶梯膳食+营养教育]\n](1/parseimages/figure7449f132c3424832ad3dc5d3ff4d9919_0_4.png) 图 2 五阶梯营养治疗 Figure 2 Five-ladder nutritional therapy protocol

五阶梯营养治疗的从下往上和从上向下的切换称为营养过渡[31,32]。可以进食的患者,首选第一阶梯。从下往上过渡,遵循60%原则,即当目前阶梯不能满足60%目标营养需求时,应选择上一阶梯,比如,营养教育不能满足60%目标营养需求时,应选择ONS;ONS不能满足60%目标营养需求时,应该选择全肠内营养;当全肠内营养不能满足60%目标营养需求时,应选择肠内营养+PPN;当肠内营养+PPN不能满足60%目标营养需求时,应选择TPN。

完全不能进食的患者,如消化道大手术、肠梗阻,首先从第五阶梯开始。根据病情,及时降阶,尽快转向更加符合生理的营养治疗方式。从上向下过渡,遵循

50%原则. 即当下一阶梯能够满足50%目标营养需求时, 可逐渐减少目前阶梯, 同时逐渐增加下一阶梯, 比如, 肠内营养可满足50%目标营养需求时, 可以逐渐减少肠外营养, 同时逐渐增加肠内营养; 口服营养可满足50%目标营养需求时, 可以逐渐减少管饲, 同时逐渐增加口服营养; 日常膳食可满足50%目标营养需求时, 可以逐渐减少医学营养, 同时逐渐增加日常膳食.

为了保证营养治疗的平稳过渡，国内外指南一致推荐营养过渡观察时间为：普通患者3~5天，危重患者2~3天。

2.3 营养需求与制剂选择

理想的肿瘤营养治疗应该实现两个达标,即能量达标、蛋白质达标[32]。单纯能量达标,而蛋白质未达标,不能降低病死率,能量和蛋白质均达标,可显著减少临床病死率[36-38]。

如前所述,肿瘤患者能量消耗主要由6个因素决定,其中年龄与性别是不变因素,其余4个是可变因素,也是决定肿瘤患者营养需求个体化差异的重要考虑因素,其中荷瘤状态(肿瘤部位、类型与分期)的影响最大[39].生理条件下的REE计算公式用于肿瘤患者时需要校正,其计算值与实际测得REE值误差较大,因此代谢车是预测肿瘤患者REE的理想方法[40].肿瘤增加了能量消耗,但同时消耗了体重、抑制了体力活动.所以,临床上肿瘤患者的能量供给可参照健康同龄人计算.从临床实用性和可及性考虑,推荐采用拇指法

中国科学:生命科学 2026年 第56卷 第2期

则(25~30 kcal/(kg d))计算能量需求。肿瘤患者蛋白质需求升高,蛋白质需要量应满足机体100%的需求,推荐量为1.2~1.5 g/(kg d),甚至2.0 g/(kg d) [9,31,32].

肿瘤患者的肠内营养制剂首选普通均衡型配方,荷瘤患者及严重代谢紊乱患者推荐疾病特异性配方.肠外营养制剂首选工业化多腔袋,小容量包装“全合一”制剂可有效避免浪费,卫生经济学效益更好.脂肪乳剂推荐中长链脂肪乳剂、鱼油制剂、橄榄油制剂及多种油制剂.无论肠内、肠外营养,富含ω-3多不饱和脂肪酸(poly unsaturated fatty acid, PUFA)制剂的益处得到越来越多的证据支持.荟萃分析发现,使用免疫营养,包括精氨酸、ω-3 PUFA或谷氨酰胺(存在肝、肾功能衰竭的重症患者,不推荐使用谷氨酰胺-双肽)等,可以显著降低术后总体并发症、感染并发症的发生率,缩短住院时间[41,42].

2.4 营养治疗方法

良好的营养方案、合理的临床应用、正确的制剂选择，可以提高患者生活质量，延长其生存时间。

日常膳食是所有人包括肿瘤患者的营养主要来源,建议遵循“选择多样、控制总量、提高质量、掌握时相”16字诀。病情允许情况下,摄入丰富多样的食物,每天至少20种,每周不少于30种;推荐增加抗炎食物,如深海鱼、蔬菜等的摄入,以降低炎症反应,减轻肿瘤相关的疼痛和其他不适症状[43]。结合病情,适当增加蛋白质、果蔬和全谷物的摄入量,每日要求摄入蔬菜和水果至少5份(2.5~3份蔬菜和1.5~2份水果),且要求色彩缤纷、种类繁多[44,45]。同时,要控制饱和脂肪酸、红肉及加工肉的摄入,避免过咸食物和含糖饮品等。建议在临床营养师指导下,为可以经口进食的肿瘤患者制定个性化的食物计划表,少量多餐,定时定量提供营养丰富的食物。同时,鼓励患者在愉悦的环境中享用制作精良、美味可口的食物,提高饮食的愉悦感和依从性。

营养教育是所有肿瘤患者必须常规接受的营养治疗方法,即使没有营养不良的患者,也应该在出院时进行摄食指导.营养教育也称营养咨询(nutrition counseling),但二者的中文意思有细微差别,营养教育是医务人员主动为患者提供的服务,而营养咨询是医务人员被动回应患者提出的问题.营养教育的内容不仅仅包括膳食建议、饮食强化,还强调生活方式调整,包括

戒烟限酒、保持充足睡眠、避免过度劳累、养成口服营养补充及体力活动习惯等。营养教育≥3次/月是手术后并发症减少的独立影响因素[46]。营养教育、合理膳食的重要性往往被患者、家属及医护人员忽略。Ueshima等人[47]汇总分析了晚期肿瘤患者营养教育的随机对照临床研究,发现营养教育可以显著改善患者能量和蛋白质摄入。

ONS是最简便的医学营养治疗方法,荷瘤患者推荐终身ONS,并建议以3(正餐)+3(ONS)模式实施.一项荟萃分析研究了ONS对放化疗头颈癌患者的影响,发现与单独的营养咨询相比,营养咨询加ONS可以增加患者的体重和无脂肪质[48]. Choi等人[49]系统总结了胃切除术后ONS对体重丢失的影响,发现与标准饮食相比,添加ONS可显著降低胃癌患者胃切除术后体重丢失.

管饲主要用于胃肠道功能正常但口服不能满足营养需求的患者,如头颈部手术或放射治疗导致吞咽困难的患者、食管胃手术后患者、食管黏膜损伤患者、严重昏迷患者、重度营养不良且食欲减退患者及抗肿瘤治疗导致食欲严重减退患者,与ONS相比,管饲营养达标率更高,管饲路径包括鼻胃管、鼻肠管、咽造口、胃造口、十二指肠或空肠造口等,经鼻置管方便、经济、无创,是短期肠内营养的首选途径,对于头咽部肿瘤、脑卒中及重型颅脑损伤等需要长期置管患者,和存在胃潴留、食管炎及吸入性肺炎风险的患者,推荐胃肠造口,上消化道(食管、胃、十二指肠、胰腺、胆道)肿瘤及腹部大手术推荐手术同时常规空肠造口。

部分肠外营养又称补充性肠外营养(supplementary parenteral nutrition, SPN),是对肠内营养不足部分的补充[9].肠内营养不能满足60%目标需要量超过3天时,应在24~48 h内实施SPN. SPN的用量取决于患者对肠内营养的耐受情况及营养负债差值.肠内营养禁忌或重度肠功能衰竭的患者,建议使用TPN.国内外指南均推荐采用“全合一”,即以全营养混合液(total nutrient admixture, TNA)形式实施SPN及TPN[50,51].

3 营养治疗疗效评价

营养治疗是一种整体治疗,其作用除营养状况本身外,还涉及生理、心理、行为、结构、功能及疾病等多个方面,因此,其疗效也需要综合评价,主要包括

吕家华等:肿瘤患者营养疗法临床指南

营养知识-态度-行为、摄食情况、营养状况、人体学测量、人体成分分析、体能评价与健康状况、实验室检查、心理及生活质量等多个方面。肿瘤患者还要对瘤灶体积、代谢活性、肿瘤标志物及生存时间进行特异性评价。考虑到营养治疗的临床效果出现较慢,建议以4周为一个疗程。营养治疗后不同参数对治疗产生反应的时间不一致,因此,不同参数评价(复查)的间隔时间也各不相同。根据反应时间长短将营养治疗的疗效评价指标分为三类。(i)快速变化指标:实验室参数,如血常规、电解质、肝功能、肾功能、炎症参数(IL-1, IL-6, TNF, CRP)、营养检测套餐(白蛋白、前白蛋白、转铁蛋白、视黄醇结合蛋白、游离脂肪酸)、血乳酸等,建议每周检测1次;(ii)中速变化指标:人体测量参数、人体成分、生活质量、体能、肿瘤病灶,建议每4~12周评估1次;(iii)慢速变化指标:生存时间,建议每年评估1次[52]。所有严重营养不良患者出院后均应定期到医院复诊或接受电话营养随访,至少每3个月一次。

由于肿瘤患者往往需要长期营养治疗,居家营养治疗时间远长于住院,因此,建议患者本人和照护者学习一些简便而有效的营养治疗疗效评价技术,实施自我营养治疗疗效评价.

体重是患者自我监测营养状况的最简便、最重要方法,远较BMI敏感.建议早晨起床、排空大小便、着单衣称重并记录,每1~2周一次.任何不明原因的体重丢失超过2%,均应咨询主管医师或到门诊就诊.体重过轻是肿瘤患者总生存期更差的独立危险因素,体重丢失>10%者死亡风险增高2倍[53]。基于西方人群数据的体重丢失分级系统(weight loss grading system, WLGS)不能有效预测我国肿瘤患者预后,INSCOC项目组改良的mWLGS能更好地评估我国肿瘤患者的营养状况,对肺癌和胃肠道肿瘤患者的预后预测能力更优[54,55]。INSCOC研究发现,中国肿瘤人群体重丢失(weight loss, WL)预测预后的最佳阈值为5.76%,不同肿瘤有不同最佳阈值,随BMI升高,WL临床阈值呈升高趋势,体重过低、正常、超重和肥胖肿瘤患者WL的临床预后阈值分别为4.21%,5.03%,6.33%和7.60%[56]。进一步研究发现,肿瘤患者存在显著的肥胖悖论现象[57],不同年龄段最优BMI有不同保护作用,肥胖对青年及中年患者仅见保护趋势,对老年患者则有显著保护作用,肥胖对老年患者的保护效果在全人群、肿

瘤患者及心血管患者中得到验证. 随着年龄升高, 适宜BMI区间逐渐扩大; BMI越高, 肿瘤全因死亡越低, 呈单向负相关, 而非U型. 但肿瘤发生本身及肝癌、胆管/胆囊癌、乳腺癌未见肥胖悖论现象. 因此, 肿瘤患者的体重管理应该个体化.

营养影响症状(nutrition impact symptoms, NIS)包括食欲减退、咀嚼困难、口干、唾液黏稠、疼痛、焦虑、便秘、早饱、抑郁、腹泻、口腔溃疡/嘴疼、乏力、恶心、气味改变、味觉改变、吞咽困难及呕吐等17个症状[58-60]。NIS不仅导致摄食减少、体重丢失,而且是导致机体功能障碍的关键决定因素,严重影响肿瘤患者临床结局及生存时间。NIS越多、积分越高,患者预后越差[59,60]。NIS负荷及评分应该成为肿瘤患者营养治疗效果自我评价的重要内容。制订标化NIS量表,每2周1次患者自我评价或照护者评价并记录NIS数量的变化,可以有效判断营养治疗效果,并预测预后。

体能是营养治疗效果的综合反映. 体能测试常用方法包括简易体能组合、日常步速试验、计时起走试验、爬楼试验、功能伸展试验及搬运测试等[61]. 其中日常步速试验最适合居家患者使用, 评价步速最简单的方法是计时步行特定的距离, 通常为6~20 m, 步速<0.8 m/s提示机体功能下降. 握力测试简单易行, 分别测量利手、非利手或非损伤手握力, 取最大值, 精确至0.1 kg. 握力分为绝对握力及相对握力, 研究发现, 相对握力的评价效果优于绝对握力, 握力/体重、握力/身高是反映相对握力的最常用形式[62]. 握力真实反映肌肉力量, 可有效预测肿瘤患者预后及营养治疗效果[63].

4 推荐意见

(1) 营养疗法是肿瘤患者的基础治疗、一线治疗和核心治疗,应常规整合到肿瘤患者的综合治疗中(A).

(2) 肿瘤患者的营养诊断推荐三级营养诊断,重度营养不良患者常规进行综合评价,关注肿瘤患者的炎症负荷水平及代谢紊乱(A).

(3) 肿瘤患者推荐按照营养诊断结果及营养不良严重程度实施分类和个体化营养治疗,并遵循五阶梯营养治疗原则(A).

(4) 营养治疗应该实现两个达标:能量达标和蛋

中国科学:生命科学 2026年 第56卷 第2期

白质达标, 要求能量达到25~30 kcal/(kg d), 蛋白质达到1.2~1.5 g/(kg d) (A).

(5) 营养教育是所有肿瘤患者应该常规接受的营养治疗方式. 日常饮食是肿瘤患者经口进食正常时的主要营养来源, ONS是胃肠功能正常患者接受肠内营养的首选途径(A).

(6) 肠内营养制剂首选均衡型配方,荷瘤患者及严重代谢紊乱患者推荐疾病特异性配方(A).

(7) 肿瘤患者的肠外营养首选工业化多腔袋, 输注方式推荐”全合一”, 小包装全合一制剂可以有效避免

浪费. 脂肪乳剂推荐中长链脂肪乳剂、鱼油制剂、橄榄油制剂及多种油制剂(A).

(8) NGT/NIT是短期管饲肠内营养的首选途径,管饲肠内营养超过3~4周时推荐胃肠造口途径(A).

(9) 若EN 3天及以上均低于目标需要量的60%时, 推荐在随后的24~48 h内实施PPN, 而对EN存在禁忌证或重度肠功能衰竭的患者, 则推荐实施TPN (A).

(10) 营养治疗的疗效需要根据对治疗发生反应的时间进行综合评价,体重、NIS及体能是肿瘤患者自我评价营养疗效的有效参数(A).

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吕家华等:肿瘤患者营养疗法临床指南

Clinical guidelines for nutritional therapy in cancer patients

LYU JiaHua$^{1}$†, ZHENG Xuan$^{2}$†, LIU Jie$^{3}$†, CHEN JunQiang$^{4}$, LI ZengNing$^{5}$, LIU Ming$^{6}$, LI Tao$^{1}$, LI Wei$^{7}$, CUI JiuWei$^{7}$, BA Yi$^{8}$, CHEN JinFei$^{9}$, CHEN YuePing$^{10}$, CHEN YongYi$^{11}$, GUO ZengQing$^{12}$, LIU Bo$^{13}$, MIAO MingYong$^{14}$, QIN BaoLi$^{15}$, QIN LiQiang$^{16}$, XING LiGang$^{13}$, SHEN ShengRong$^{17}$, TENG LiSong$^{18}$, WEI WenQiang$^{19}$, YU Zhen$^{20}$, HUANG He$^{21}$, ZHOU FuXiang$^{22}$, CONG MingHua$^{19}$, ZHANG XiaoTian$^{23}$, ZHUANG ZeHao$^{24}$, WU XiangHua$^{4}$, YAO QingHua$^{25}$, JIN Xi$^{26}$, LIU LingXiang$^{27}$, ZHUANG ChengLe$^{20}$, YAO Ying$^{28}$, SONG ChunHua$^{29}$, CHEN XiaoFeng$^{27}$, LIANG TingTing$^{7}$, WENG Min$^{30}$, ZHOU ChunLing$^{6}$, ZHENG XiaoDong$^{31}$, XU Jun$^{32}$, ZHOU JianPing$^{33}$, XU ShuFang$^{34}$, ZHANG Feng$^{35}$, WANG Hui$^{11}$, LI Yong$^{36}$, XU HongXia$^{37}$, SHI HanPing$^{9,38,39}$ & Chinese Anti-Cancer Association

$^{1}$ Sichuan Cancer Hospital, Chengdu 610041, China $^{2}$ Shanghai Hospital, Naval Medical University, Shanghai 200433, China $^{3}$ Chongqing Thirteenth People's Hospital, Chongqing 400053, China $^{4}$ The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China $^{5}$ Hospital of Stomatology Hebei Medical University, Shijiazhuang 050017, China $^{6}$ The Fourth Affiliated Hospital of Harbin Medical University, Harbin 150001, China $^{7}$ The First Hospital of Jilin University, Changchun 130021, China $^{8}$ Peking Union Medical College Hospital, Beijing 100005, China $^{9}$ The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China $^{10}$ Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning 530011, China $^{11}$ Hunan Cancer Hospital, Changsha 410013, China $^{12}$ Fujian Cancer Hospital, Fuzhou 350014, China $^{13}$ Shandong Cancer Hospital/Shandong First Medical University Affiliated Cancer Hospital, Jinan 250117, China $^{14}$ Naval Medical University, School of Basic Medical Science, Shanghai 200433, China $^{15}$ Liaoning Cancer Hospital, Shenyang 110042, China $^{16}$ School of Public Health, Soochow University, Suzhou 215123, China $^{17}$ School of Biosystem Engineering & Food Science of Zhejiang University, Hangzhou 310058, China $^{18}$ The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China $^{19}$ Cancer Hospital, Chinese Academy of Medical Sciences, Beijing 100021, China $^{20}$ The Tenth People's Hospital of Tongji University, Shanghai 200072, China $^{21}$ The First Hospital of Shanxi Medical University, Taiyuan 030001, China $^{22}$ Zhongnan Hospital of Wuhan University, Wuhan 430071, China $^{23}$ Peking University Cancer Hospital, Beijing 100142, China $^{24}$ The Second Affiliated Hospital of Fujian Medical University, Fuzhou 362000, China $^{25}$ The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310022, China $^{26}$ The First Hospital of Zhejiang University, Hangzhou 310006, China $^{27}$ Jiangsu Provincial People's Hospital, Nanjing 210029, China $^{28}$ Tongji Hospital, Tongji Medical College, Huahong University of Science and Technology, Wuhan 430030, China $^{29}$ Zhengzhou University/Henan Key Laboratory of Cancer Epidemiology, Zhengzhou 450001, China $^{30}$ The First Affiliated Hospital of Kunming Medical University, Kunming 650032, China $^{31}$ Chongqing University Cancer Hospital, Chongqing 400030, China $^{32}$ Beijing Tiantan Hospital, Capital Medical University/Guiyang Second People's Hospital, Beijing 100070, China $^{33}$ The First Affiliated Hospital of China Medical University, Shenyang 110001, China $^{34}$ Shenzhen Qianhai Taikang Hospital, Shenzhen 518052, China $^{35}$ Affiliated Hospital of Jiangnan University, Wuxi 214122, China $^{36}$ The Fourth Hospital of Hebei Medical University, Shijiahuang 050011, China $^{37}$ Daping Hospital, Army Medical University, Chongqing 400042, China $^{38}$ Department of Clinical Nutrition, Capital Medical Medical University, Beijing 100038, China $^{39}$ Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China † Contributed equally to this work * Corresponding author, E-mail: shihp@ccmu.edu.cn

Cancer Nutritional Therapy is a process involving the planning, implementation, and evaluation of nutritional interventions to treat

中国科学:生命科学 2026年 第56卷 第2期

tumors, their complications, or physical conditions, thereby improving the prognosis of cancer patients. It encompasses three stages: nutritional diagnosis, nutritional treatment, and efficacy evaluation. Nutritional therapy serves as the foundational, first-line, and core treatment for cancer patients. The nutritional diagnosis for cancer patients is conducted in three tiers: nutritional screening, nutritional assessment, and comprehensive evaluation. Patients with severe malnutrition routinely undergo comprehensive evaluation, with particular attention paid to their inflammatory burden and metabolic disorders. Based on the nutritional diagnosis and severity of malnutrition, categorized and individualized nutritional treatment is implemented. This follows the “Four Priority” principles: diet first, oral intake first, nutrition education first, and enteral nutrition first. It also adheres to the five-step nutritional treatment protocol: nutrition education, oral nutritional supplements (ONS), total enteral nutrition (TEN), partial parenteral nutrition (PPN), and total parenteral nutrition (TPN). Adjustments are made according to the patient’s specific condition to ensure a smooth nutritional transition. Daily dietary intake is the primary source of nutrition for cancer patients. Nutrition education is a mandatory routine treatment for all cancer patients, while ONS is the simplest form of medical nutritional therapy. The fundamental requirements of nutritional therapy are to ensure patients meet energy and protein targets: 25–30 kcal/(kg d) and 1.2–1.5 g/(kg d), respectively. For enteral nutrition formulas, balanced formulations are preferred for cancer patients, while disease-specific formulas are recommended for those with tumors or severe metabolic disorders. For parenteral nutrition, industrialized multi-chamber bags administered in an “all-in-one” format are the first choice. The efficacy of nutritional therapy should be comprehensively evaluated based on the response time. Weight, nutrition impact symptoms (NIS), and physical performance are effective self-assessment parameters for monitoring nutritional outcomes in cancer patients.

tumor, nutritional therapy, guidelines

doi: 10.1360/SSV-2024-0374

表 1 AIWW 问卷
编号内容问题回答$^{a)}$
1年龄您有65岁吗?是否
2摄食过去1个月,您吃饭是否 非主动性减少?是否
3体重过去1个月,您的体重是否 非主动性减轻?是否
4步行过去1个月,您的步速是否 非主动性减慢?是否

相关指南

引用 / 出处

中国抗癌协会. 肿瘤患者营养疗法临床指南[S/OL]. .