A qualitative analysis of nutritional needs and dietary changes during cancer treatment in Ireland

INTRODUCTION

Cancer and its associated side effects can cause changes in dietary intakes of people with cancer due to a variety of nutrition impact symptoms. These symptoms can lead to suboptimal dietary intakes which negatively affect muscle mass and therefore survivorship. The aim of this qualitative study was to assess the nutrition needs and dietary changes made by cancer patients in Ireland.

METHODS

Online focus groups were completed with cancer patients and caregivers, and demographic information was collected via an online questionnaire. An inductive thematic analysis approach was utilised to derive themes and subthemes from the data.

RESULTS

Four online focus groups were held with cancer patients and caregivers (n = 15) which reflected 18 total cancer experiences. Novel themes identified from this research included that symptoms were varied and transient-coming and going rapidly-and that patients were not satisfied with dietetic and broader nutrition services provided by hospitals. Themes that aligned with previous research were the severity and variety of nutrition impact symptoms and the variety of both evidence-based and non-evidence-based nutrition strategies used by patients to overcome nutrition impact symptoms, as general coping strategies, and potentially due to the belief that nutrition can be curative.

CONCLUSION

Treatment of nutrition impact symptoms must be rapid and responsive. The development of responsive self-management resources such as booklets and apps for patients is likely to be valuable to ensure that patients can access support for their nutrition impact symptoms as-and when-they occur. Nutrition support must be integrated across the multi-disciplinary team to optimise trust in nutrition strategies.

Support Through Remote Observation and Nutrition Guidance (STRONG), a digital health intervention to reduce malnutrition among pancreatic cancer patients: A study protocol for a pilot randomized controlled trial

Background

Malnutrition is a common and distressing condition among pancreatic cancer patients. Fewer than a quarter of pancreatic cancer patients receive medical nutrition therapy (MNT), important for improving nutritional status, weight maintenance, quality of life and survival. System, provider, and patient level barriers limit access to MNT. We propose to examine the feasibility of a 12-week multi-level, digital health intervention designed to expand MNT access among pancreatic cancer patients.

Methods

Individuals with advanced pancreatic cancer starting chemotherapy (N = 80) will be 1:1 randomized to the intervention or usual care. The Support Through Remote Observation and Nutrition Guidance (STRONG) intervention includes system-level (e.g., routine malnutrition and screening), provider-level (e.g., dietitian training and web-based dashboard), and patient-level strategies (e.g., individualized nutrition plan, self-monitoring of dietary intake via Fitbit, ongoing goal monitoring and feedback). Individuals receiving usual care will be referred to dietitians based on their oncologists' discretion. Study assessments will be completed at baseline, 4-, 8-, 12-, and 16-weeks.

Results

Primary outcomes will be feasibility (e.g., recruitment, retention, assessment completion) and acceptability. We will collect additional implementation outcomes, such as intervention adherence, perceived usability, and feedback on intervention quality via an exit interview. We will collect preliminary data on outcomes that may be associated with the intervention including malnutrition, quality of life, treatment outcomes, and survival.

Conclusion

This study will advance our knowledge on the feasibility of a digital health intervention to reduce malnutrition among individuals with advanced pancreatic cancer. Trial registration: NCT05675059, registered on December 9, 2022.

Pilot study of a telehealth intervention for personalized self-management for eating symptoms after gastroesophageal cancer surgery

BACKGROUND AND OBJECTIVES

Following gastric and esophageal cancer surgery, patients often experience significant, prolonged eating-related symptoms. One promising approach to help patients improve their eating-related quality of life (QOL) is through self-management coaching to aid in diet modification. We performed a randomized pilot study of a nutritionist-led telehealth intervention for the self-management of eating after gastroesophageal cancer surgery.

METHODS

Patients who were within 30 days of resuming oral intake after undergoing surgery for gastric and/or esophageal cancer were consented and then randomized to the intervention or usual care. The intervention was performed by a nutritionist trained in self-management coaching and delivered in four telehealth sessions over 4 months. The following outcomes were measured at baseline and at 6 months after baseline: QOL (EORTC QLQC30), weight, body mass index, and sarcopenia.

RESULTS

Fifty-three patients were enrolled. 22/27 usual care and 21/26 intervention patients completed the study for a retention rate of 81%. Differences between the intervention and control groups were not statistically significant, but the intervention group had indications of greater improvements in overall QOL as measured by EORTC QLQC30 Summary Score (8.7 vs. 2.3, p = 0.17) as well as greater improvements in 4/5 functional domains (p > 0.3). The intervention group also had slightly more weight gain (6 kg vs. 3 kg, p = 0.3) and less sarcopenia (3/16 vs. 9/18, p = 0.07).

CONCLUSIONS

This pilot study demonstrated the feasibility and acceptability of a telehealth intervention for self-management of eating symptoms after gastroesophageal cancer surgery. There were trends toward improved overall QOL in the intervention group. A larger study is needed to validate the results.

Availability of cancer survivorship support services across the National Cancer Institute Community Oncology Research Program network

BACKGROUND

National cancer organizations recommend provision of nutrition, physical activity, and mental health supportive services to cancer survivors. However, the availability of these services across diverse community oncology settings remains unclear.

METHODS

The National Cancer Institute Community Oncology Research Program (NCORP) is a national network of community oncology practices engaged in cancer research. The 2022 NCORP Landscape Assessment (5UG1CA189824) assessed individual practices' establishment of survivorship clinics and nutrition, physical activity, and mental health services, resources, and/or referrals. Descriptive statistics summarized and logistic regression quantified the association between services, practice, and patient characteristics.

RESULTS

Of 46 NCORP community sites, 45 (98%) responded to the survey, representing 259 adult practice groups. A total of 41% had a survivorship clinic; 96% offered mental health, 94% nutrition, and 53% physical activity services, resources, and/or referrals. All 3 services were offered in various formats (eg, in-house, referrals, education) by 51% and in-house only by 25% of practices. Practices with advanced practice providers were more likely to have a survivorship clinic (odds ratio [OR] = 3.19, 95% confidence interval [CI] = 1.04 to 9.76). Practices with at least 30% Medicare patients (OR = 2.54, 95% CI = 1.39 to 4.66) and more oncology providers (OR = 1.02, 95% CI = 1.01 to 1.04) were more likely to have all 3 services in any format. Practices with at least 30% Medicare patients (OR = 3.41, 95% CI = 1.50 to 7.77) and a survivorship clinic (OR = 2.84, 95% CI = 1.57 to 5.14) were more likely to have all 3 services in-house.

CONCLUSIONS

Larger oncology practices and those caring for more survivors on Medicare provided more supportive services, resources, and/or referrals. Smaller practices and those without survivorship clinics may need strategies to address potential gaps in supportive services.

Health service nutrition practices and associations with clinical outcomes in patients undergoing resection for upper gastrointestinal cancer: results from the multi-centre NOURISH point prevalence study

BACKGROUND

This study aimed to investigate health service nutrition practices of sites providing care to patients undergoing surgery for upper gastrointestinal (UGI) cancer within Australia, including the provision of perioperative nutrition support services and outpatient clinics, and the use of evidence-based nutrition care pathways/protocols. Secondary aims were to investigate associations between the use of a nutrition care pathway/protocol and patient outcomes.

METHODS

Principal investigator dietitians for the sites (n=27) participating in the NOURISH point prevalence study participated in a purpose-built site-specific survey regarding perioperative nutrition practices and protocols. Data from the 200 patients who participated in the study (including malnutrition prevalence, preoperative weight loss and receipt of dietetics intervention, intraoperative feeding tube insertions, provision of nutrition support day one post surgery, length of stay and complications) were investigated using multivariate analysis to determine associations with the sites' use of a nutrition care pathway/protocol.

RESULTS

The majority of sites (>92%) reported having dietetics services available in chemotherapy/radiotherapy. Eighty-five percent of sites reported having some form of outpatient clinic service; however, a routine service was only available at 26% of sites preoperatively and 37% postoperatively. Most preoperative services were embedded into surgical/oncology clinics (70%); however, this was reported for only 44% of postoperative clinics. Only 44% had a nutrition care pathway/protocol in place. The use of a nutrition care pathway/protocol was associated with lower rates of malnutrition, and higher rates of preoperative dietetics intervention, intraoperative feeding tube insertions and ESPEN guideline compliant care day one post surgery.

CONCLUSIONS

The results of this study demonstrate varied perioperative outpatient nutrition services in this high-risk patient group. The use of nutrition care pathways and protocols was associated with improved patient outcomes. This article is protected by copyright. All rights reserved.

The Status of Nutritional Management Guidelines for Head and Neck Cancer Patients

Introduction

Head and neck cancer (HNC) is the seventh leading cause of cancer worldwide. Approximately 35%-60% patients with HNC are malnourished from the disease onset, malnutrition being associated with worsened health outcomes among these patients. This study aimed to review and synthesize existing guidelines regarding nutritional interventions in HNC patients and assess providers’ knowledge, opinions, and practice of guidelines for the nutritional management of HNC patients.

Methods

This is a multimethod study that includes a systematic review of guidelines for nutritional intervention in HNC patients and a providers’ survey regarding their knowledge and opinions regarding nutrition therapy guidelines for HNC patients.

Results

Our review yielded seven guidelines. Of the seven guidelines reviewed, all were specific to cancer patients, however, only three were specific for HNC patients. Three of the guidelines recommended using a nutritional screening tool, however, only two mentioned a specific screening tool. Out of 193 surveys included in our analysis, the highest percentage of respondents were physicians (52.4%), followed by registered nurses (33.5%). The majority of respondent (77.5%) worked in a hospital-based practice, while 18.8% worked in clinic-based practice. A large proportion (46.6%) of respondents were not aware of nutritional guidelines for HNC patients; with 23.6% not aware of any, and 23.0% aware of their existence but not aware of their content. The majority (81.5%) of respondents said that a more detailed guideline should be available for HNC patient with regards to nutrition.

Conclusion

Nutritional deficiencies in HNC patients continue to cause significant complications in treatment and recovery. Existing practice guidelines are limited and lack specific recommendations. A universal standard of care with regard to addressing nutrition in HNC patients is needed to improve healthcare outcomes among NHC patients. 

We report performance status in oncology-but not nutritional status?

Performance status (PS) scales are used routinely in clinical oncology to evaluate functional status and help direct treatment decisions. PS is also used to determine research protocol eligibility, indicate treatment response, and evaluate toxicity in oncology clinical trials. Malnutrition (like poor PS) is associated with adverse outcomes such as lower tolerance to anti-tumor treatment, poor quality of life, and decreased survival. Nutritional status is therefore arguably as important as PS for cancer outcomes. Despite well-documented adverse consequences for patients, malnutrition also often goes undiagnosed until severe depletion is evident. If the predictive importance of nutritional status is comparable to PS, why is nutritional status not routinely used along with PS to guide treatment decisions? There is compelling evidence to support the predictive abilities of both PS and nutritional status in cancer outcomes and treatment decision-making. Perhaps, PS may be a proxy for nutritional status. Nutritional status might also serve as an effective tool for patient selection and stratification in oncology trials. Together with PS, it might provide important and distinct prognostic information; we propose both should be routinely included in outcome studies. The extent to which impaired PS may be a surrogate for malnutrition warrants investigation. Given its comparable importance to PS, it is inexcusable that nutritional status is not given the prominence it deserves as a key patient-reported outcome.

Diet and nutrition information on nine national cancer organisation websites: A critical review

INTRODUCTION

National Cancer Organisations (NCO) provide web-based diet and nutrition information for patients with all types and stages of cancer. We examined diet and nutrition information provided by nine NCO in English-speaking countries.

METHODS

Diet and nutrition information was examined under four headings: disease phases, treatment modalities, nutrition impact symptoms and cancer primary sites. We also examined the degree of concordance between NCO websites and appraised the readability of materials.

RESULTS

Nine NCO websites from six English-speaking countries were included: Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States. All provided general healthy eating advice. Information at diagnosis and pre-treatment was inadequate, but well-addressed for survivorship. Specific treatment modalities such as biological and hormone therapy were largely ignored. Symptom management was well-addressed, with some exceptions. Cancer site-specific advice was readily available. All recommended consultation with a dietitian/healthcare professional for personalised guidance. Only one met the universal health literacy standard.

CONCLUSIONS

NCO websites provided important general diet and nutrition information for cancer patients. The information was reliable and safe, but more in-depth, evidence-based and health-literate information is required. There is an urgent need for an international consensus for consistent cancer diet and nutrition advice.

Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey

Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Medical nutrition therapy (MNT) optimizes clinical outcomes, yet registered dietitian nutritionists (RDNs), the healthcare professionals specifically trained in MNT, are not routinely employed in outpatient cancer centers where over 90% of all cancer patients are treated. The objective of this study was to evaluate RDN staffing patterns, nutrition services provided in ambulatory oncology settings, malnutrition screening practices, and referral and reimbursement practices across the nation in outpatient cancer centers. An online questionnaire was developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics and distributed via the ON DPG electronic mailing list. Complete data were summarized for 215 cancer centers. The mean RDN full-time equivalent (FTE) for all centers was 1.7 ± 2.0. After stratifying by type of center, National Cancer Institute-Designated Cancer Centers (NCI CCs) employed a mean of 3.1 ± 3.0 RDN FTEs compared to 1.3 ± 1.4 amongst non-NCI CCs. The RDN-to-patient ratio, based on reported analytic cases, was 1 : 2,308. Per day, RDNs evaluated and counseled an average of 7.4 ± 4.3 oncology patients. Approximately half (53.1%) of the centers screened for malnutrition, and 64.9% of these facilities used a validated malnutrition screening tool. The majority (76.8%) of centers do not bill for nutrition services. This is the first national study to evaluate RDN staffing patterns, provider-to-patient ratios, and reimbursement practices in outpatient cancer centers. These data indicate there is a significant gap in RDN access for oncology patients in need of nutritional care.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice

PURPOSE

Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities.

METHODS

This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted.

RESULTS

Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89).

CONCLUSIONS

Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

Patterns of Support Service, Emergency Department, and Hospital Utilization in Patients with Advanced Cancer: A Descriptive Study

Context:

Palliative care in oncology provides multiple benefits, however access to specialty palliative clinicians is limited in community cancer centers. Individual support services are more often available, but little is known on the utilization and impact of these services.

Objectives:

To describe the utilization of outpatient support services in the advanced cancer population and the association with ED and hospital use in a community setting.

Methods:

A retrospective chart review of 314 patients with advanced cancer of lung, gastrointestinal, genitourinary, and gynecologic origin was conducted. Data collected included demographics, descriptive data, type and number of support services (symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor) within 90 days of diagnosis and descriptions of ED visits/hospitalizations within 12 months of diagnosis. Support services were available to patients by referral.

Results:

29.6% of patients were deceased within 6 months and were considered to have severe disease. Patients with severe disease had a significantly greater mean number of support services than patients with non-severe disease (8.9 vs 6.0, p=0.001) and had a greater mean number of visits per year to the ED (6.4 vs 1.8, p<0.001). A greater proportion of patients with severe disease had palliative consultations (48.9% vs 21.7%, p<0.001), but 65.5% of palliative consultations occurred after an ED or hospital visit.

Conclusion:

Our data demonstrated that advanced cancer patients with severe disease had increased healthcare utilization in all areas measured. Despite high utilization, outpatient support services used in a reactive manner were not effective in reducing ED or hospital visits.

Young patients and gastrointestinal (GI) tract malignancies - are we addressing the unmet needs?

Background

Recent epidemiological studies indicate the rate of gastrointestinal (GI) malignancies among younger patients is increasing, mainly due to colorectal cancer. There is a paucity of data regarding the magnitude of treatment-related symptoms, psychosocial issues and potential unmet needs in this population. We aimed to characterize the needs of this population to evaluate whether unmet needs could be targeted by potential intervention.

Methods

Female and male patients diagnosed with cancer of the gastrointestinal tract <40y retrospectively completed a questionnaire to evaluate symptoms, daily function and unmet needs at pre-treatment, during and post-treatment. Comparisons were made by gender, disease stage and treatment modality. Multiple linear regression models evaluated effects of demographics, symptoms and needs on multiple domains of health-related-quality-of-life (using Short-Form Health Survey-12 and CARES).

Results

Fifty patients were enrolled (52 % female) to a pilot study. Median age at diagnosis was 35.5y (range, 21-40y). The symptoms that significantly increased from baseline to during and post-treatment were: diarrhea (37 %), sleeping disorder (32 %) and sexual dysfunction (40 %). Patients also reported significant deterioration in occupational activities and coping with children compared with baseline. Female patients reported significant unmet need for nutritional counseling and psychosocial support compared to male patients (p < 0.05). Patients treated with multimodality-treatment presented higher rates of unmet needs (p = 0.03).

Conclusions

Young patients with GI cancers represent a group with unique characteristics and needs compared with published evidence on other young-onset malignancies. The distinctive symptoms and areas of treatment-related functional impairments indicate there are unmet needs, especially in the area of psychosocial support and nutritional counseling.