Summary of the Informal Discussionof Nutritional Management1

Dr. George L. Blackburn opened the discussion of Dr. Giovanni Costa's paper (2). Dr. Blackburn felt that it was not necessary to determine with ultrafine precision the exact type and degree of malnutrition in cancer patients but that such patients couldinsteadbe grouped intothreeor four categories of nutritional status that might be clinically use ful. While admitting that currently the measurements and standards for clinically evaluating nutritional status are rather rough, he felt that they are adequate for the current state of the art. He emphasized that the malnourished can cen patients in his series benefited greatly from their nutni tional rehabilitation, showing improved responses to chem otherapy, radiotherapy, and surgery. Dr. Blackburn noted that, just as indirect calorimetry by measurement of oxygen consumption correlates directly but not exactly with direct calorimetry, the simple indices of nutritional status that he used correlate with nitrogen balance and protein turnover. He thought that patients with cancer could be grouped into three or four nutritional-status categories based on availa ble anthropometnic and simple biochemical anameters and that the patients could be followed serially with these simple and inexpensive indices as they progressed on re gressedduringtherapy. Dr. Costa expressed the viewpoint that most malnutrition in cancer patients, especially in extreme categories, could be identified by inspection if simplicity was desirable at the expense of objectivity. He noted that the margin of error in determining foodconsumptiononrequirements mightbeas great as 30 to 50%. Although this is not a great problem in a single patient, it becomes astronomical when one applies this magnitude of error to food consumption by all human beings on earth. Thus, it is necessary to have the capacity precisely to determine nutrient requirements in a scientific manner. Dr. Costa acknowledged that common sense and ingenuity are very important aspects of the practice of medi cine, especially when trying to feed starving patients. How ever, he emphasized that we should be attempting to evolve from that subjective state of the art to one of more consist ent and reproducible objectivity. Dr. Blackburn asked Dr. Costa if he thought that simply looking at a patient is sufficient to determine the degree of malnutrition. He made the parallel observation that it is not nearly enough merely to note that a patient is jaundiced or burned. In such cases, it is helpful and necessary to mea sure the serum bilirubin level to determine the degree and extent of the burn injury. Dr. Costa countered that his plea was for increased preci sion in the establishment of as many nutritional aname tens as possible. He advocated a series of sophisticated and possibly expensive experiments to answer the many nutri