# Symptom Burden and Dietary Changes Among Older Adults with Cancer: A Cross-Sectional Study
## 4 Discussion
Interestingly, we did not observe a significant difference in malnutrition risk rates when comparing patients with aggressive hematological neoplasms (aggressive lymphoma/acute leukemia) to patients with more chronic/indolent hematological disease (indolent lymphoma/chronic leukemia/MDS/MPN). The lower malnutrition risk rate in patients undergoing cellular immunotherapy compared to the overall population and patients with hematological neoplasms is probably due to a selection bias--only patients in good health with low comorbidities are considered for cellular immunotherapy [26]. Neither the aforementioned GLIM criteria [21] nor the NRS-2002 [10] take into account, that cancer patients may change their diet during oncological treatment. Cancer diets are a controversy [27, 28, 29], and oncologists are aware that cancer diets often diverge from official dietary guidelines such as the American Cancer Society or the American Institute for Cancer Research/World Cancer Research Fund [28]. Cancer diets are not only restricted to regimes offered by alternative medicine. During recent years, data showed that dietary restrictions prescribed by conventional medicine such as a neutropic diet do not have a positive impact on infection rates in patients undergoing stem cell transplantation [30]. Fortunately, recent data from a German study showed that only a small minority of cancer patients follow a specific cancer diet [12], which fits the observation we made in our study. However, avoiding or preferring certain foods as well as using nutritional supplements may also influence nutritional status. To close this information gap, our group previously proposed a four-item questionnaire assessing cancer diet/dietary changes and the intake of micronutrients [14]. A pilot trial revealed that up to a third of cancer patients showed dietary changes after being diagnosed with cancer [12]. In this study, we observe that older patients are more prone to avoiding specific food (41%) compared to the younger cohort of [PERSON] et al. (27%, [12]). Overall, abstaining from hard food or preferring soft/pureed nutrition seems to be a recurring topic. The latter could be interpreted as an adaption to the side effects of cancer therapy (e.g., no hard foods--oral mucositis, dysphagia, or odynophagia). These symptoms are often interconnected in patients undergoing radio(chemo)therapy. If a change of dietary habits is caused by therapy and thus influences nutritional status, we should (1) be aware of the side effects in order to (2) ameliorate supportive care and alleviate symptom burden. Further, a lower symptom burden also affects quality of life independent of weight loss [31], and supportive care provides patients with relief regardless of disease stage [32]. Following this rationale, we added a symptom burden questionnaire to our survey. In doing so, we aimed to identify the individual needs of patients, enabling oncological staff to ensure a patient-centered multimodal supportive therapy. Surprisingly, patients' chief complaints were xerostomia, loss of appetite, and dysgeusia. While this could be partly explained by treatment modality (radio(chemo)chemotherapy), treatment modality alone does not explain the high percentage of symptom burden. However, xerostomia is known to be more common in older people. Additionally, therapies such as radiation therapy but also chemo- or immunotherapy further decrease the salivation rate. Dysgeusia in turn often accompanies xerostomia, and sufficient salivation also aids digestion [33]. Digestion troubles of the upper gastrointestinal tract are not always a clear-cut symptom, and patients tend to describe the symptom as a \"loss of appetite\" or abdominal discomfort. Recognizing and addressing xerostomia is important, as we were able to observe a significant association between xerostomia and patients at risk of malnutrition. In addition to these symptoms, which are common in both patients with solid tumors or hematological neoplasm, we also observed specific symptom patterns in these groups.