Should patients with advanced, incurable cancers ever be sent home with total parenteral nutrition? A single institution's 20-year experience

Background: Home total parenteral nutrition (TPN) can be lifesaving and life sustaining for some patients. However, in patients with advanced, incurable cancer, its role is controversial. A retrospective study was conducted to explore whether home TPN was associated with long-term survival (>or=1 year) in patients with metastatic disease and to identify predictive factors to enable its judicious use.

Methods: The records of all adult patients with incurable cancer were identified between 1979 and 1999. Records were reviewed in depth for survival from TPN initiation to death and for a variety of demographic and clinical factors.

Results: Fifty-two patients were identified. Their median age was 56 years (range, 18-83 years), and 30 (58%) were women. Malignant diagnoses included carcinoid/islet cell tumor (n=10), ovarian carcinoma (n=6), amyloidosis/multiple myeloma (n=6), colorectal carcinoma (n=5), sarcoma (n=5), pancreatic carcinoma (n=4), gastric carcinoma (n=3), lymphoma (n=2), pseudomyxoma peritonei (n=2), and other (n=9). TPN was initiated for the following reasons (indications are not mutually exclusive): alimentary tract obstruction (n=20), short bowel syndrome/malabsorption (n=16), fistula (n=11), dysmotility (n=3), nausea/emesis (n=2), anorexia (n=2), and mucositis (n=1). The median time from initiation of TPN to death was 5 months (range, 1-154 months). Sixteen patients survived >or=1 year. TPN-related complications included 18 catheter infections (1 per 2.8 catheter-years), 4 thromboses, 3 pneumothoraces, and 2 episodes of TPN-related liver disease. Tumor grade, the interval between diagnosis of metastatic disease and initiation of TPN, the presence of prominent cancer symptoms, and the administration of cancer therapy after TPN were not associated in any way with overall survival.

Conclusions: The initiation of home TPN can be associated with long-term survival in very select patients with incurable cancer, and complication rates with its use appear acceptable. However, the judicious use of home TPN in this setting requires careful clinical assessment on a patient-by-patient basis.