Home parenteral nutrition therapy for patients with incurable malignancy and intestinal failure

Abstract

In the UK, the prevalence of home parenteral nutrition (HPN) for patients with incurable palliative malignancy has historically been lower than countries with comparable health economies, but there is evidence to suggest a significant increase in the prevalence within the UK. Despite this increase, there has been lack of clarity regarding patient survival and quality of life, optimisation of patient selection and associated health economics.

This thesis examined the complex issues involved in the use of HPN for Intestinal Failure in the palliative phase of malignancy deriving information from: a systematic review of the existing medical literature on these topics; novel data generated through meta-analysis of survival data; a national questionnaire of clinician’s attitudes to PN use in this context; analysis of a retrospective case series from University Hospital Southampton; identification of patient factors which effect survival; validation of newly developed survival prognostic tools; and a health economic assessment of this therapy.

Meta-analysis of survival data for palliative malignancy patients treated with HPN showed that survival was short, 55% and 74% mortality at 3- and 6-months respectively, with only 2% of patients alive at one year. There were insufficient and poor quality data on quality of life (QoL), although the available data indicate a probable positive impact of HPN treatment in this highly symptomatic patient group. The attitudes of UK based IF clinicians are increasingly positive towards HPN therapy for palliative malignancy, with an emphasis of treatment for improving QoL. Patient performance status at commencement of HPN is the best predictor of survival. Newly developed survival prognostication tools lack sensitivity and specificity. The cost of HPN treatment in the palliative malignancy patient group is high, with low cost effectiveness (£176,587 per quality adjusted life year), although comparable to HPN treatment for non-malignancy patients. The cost effectiveness dramatically improves when patient selection favours better performance status with consequent longer survival, at a higher QoL.

The results presented in this thesis provide clinically relevant information that can help with informed decision making by clinicians and patients when considering commencing HPN therapy during the palliative phase of malignant disease. This thesis also presents the first health economic assessment of this treatment, which can aid commissionaires when planning funding of services to meet the increasing demands for this treatment.

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