Abstract: We read with interest the review article by Moffat et al,1 in which the authors proposed supportive management strategies for patients diagnosed with pancreatic ductal adenocarcinoma (PDAC). We agree with the underscored need for the early integration of supportive care into routine cancer care, but we would like to point out that the management of nutritional support in patients with this disease deserves a more relevant and specific approach. We believe that weight loss should not be considered among symptoms and the treatment of malnutrition cannot be limited to the suggested simple dietary modifications. As the authors state, malnutrition and sarcopenia are factors acknowledged to be strongly associated with a limited tolerance for chemotherapy, postsurgical complications, short survival, and poor quality of life in patients with PDAC.1-3 Hence, prompt and appropriate nutritional support is mandatory in all patients with pancreatic cancer beginning with the early phases of the disease. To guarantee the best possible effectiveness, appropriate and well-timed multidisciplinary management by professionals with specific skills and training (ie, dietitians and clinical nutritionists), also involving artificial nutrition, are required as soon as indicated.4 Despite the robust evidence demonstrating an association between nutritional status and clinical outcomes, attitudes toward nutritional care still vary considerably among oncologists and surgeons, and therefore a significant percentage of patients do not receive adequate nutritional assessment and treatment.5 Early recognition of nutritional problems is the first key point for appropriate management. Different tools for nutritional screening have been validated within the oncologic setting and effectively allow for the identification of patients at nutritional risk who are likely to benefit from nutritional treatment.6 Unfortunately, they still are used only rarely.7 However, considering that the prevalence of nutritional derangements in patients with pancreatic cancer is among the highest,2, 8 it may appear advisable to refer every patient with PDAC to clinical nutrition specialists for the implementation of prophylactic nutritional monitoring and/or counseling. Nutritional counseling is the first line of treatment in malnourished patients with cancer or in those at nutritional risk due to its proven efficacy in increasing protein calorie intake and body weight and improving body composition.4 In patients with PDAC, early nutritional counseling was proven to be beneficial not only with regard to nutritional status but also for survival.9 The complexity of effective dietary interventions in patients with this cancer type is amplified by the presence of pancreatic exocrine insufficiency, which represents a major contributor to the development and/or worsening of nutritional derangements.10 In this context, together with personalized dietary counseling, pancreatic enzyme replacement therapy is the cornerstone of nutritional treatment, the aim of which is to relieve maldigestion-related symptoms and to preserve and/or improve nutritional status.10, 11 As a general rule, diet should be as normal as possible, and fat restriction and very high-fiber diets should be avoided. Small, frequent, high-energy meals generally are recommended because they are easier to digest compared with large meals in patients with reduced pancreatic secretion.10 Oral protein calorie nutritional supplements are required in patients who cannot meet their nutritional requirements despite dietary intervention.4, 11 In recent years, calorie-restricted dietary regimens and compounds such as vitamins, curcumin, green tea extracts, and aloe have attracted attention for their potential anticancer effects. Although definitive conclusions cannot be drawn in this field due to the lack of clinical evidence, many patients adopt complementary antitumor therapies with the objective of improving the efficacy or reducing the toxicity of chemotherapy, with uncertain benefits and the risk of additional toxicities or antagonistic interactions with standard therapies. Hence, dietary advice should be tailored to the individual patient and "hypocaloric alternative anticancer diets" and "natural nutrients" that are not supported by clinical evidence should be avoided.4 In patients who are unable to tolerate sufficient oral food intake (due to anorexia, gastrointestinal symptoms, or physical obstructions, among other reasons), prompt artificial nutrition is recommended, starting in the surgical setting.12 Enteral nutrition should be preferable over parenteral nutrition due to lower costs and potential complications,4 but the latter may be found to be more tolerable for patients and more effective.11, 13, 14 Prompt and appropriate nutritional support and/or monitoring should be guaranteed to all patients with PDAC beginning in the early phases of the disease to improve clinical outcomes. Nutritional treatment should be integrated into early supportive care and should be managed by professionals with specific skills and training in clinical nutrition within the oncologic setting. No specific funding was disclosed. Riccardo Caccialanza has received personal fees from Akern, Angelini, BBraun, Boehringer Ingelheim, Eli Lilly, Fresenius Kabi, and Ipsen and grants and personal fees from Baxter, Nestle Health Science, and Nutricia for work performed outside of the current study. Paolo Pedrazzoli has received grants and personal fees from Baxter for work performed outside of the current study. The other authors made no disclosures.