gds_80000_title_v1 1 cancer nutrition therapy oncology and nutrition care: importance of nutrition...

GDS_80000_Title_v1 1

Cancer Nutrition Therapy

Oncology and Nutrition Care:Importance of Nutrition in the

Oncology SettingWestchester Rockland Dietetic Association

December 4, 2014

Anne Coble Voss, PhD, RD, LDNAssociate Research Fellow, Abbott Nutrition

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Support for the program is provided by Abbott Nutrition

The speaker is an Associate Research Fellow in Adult Nutrition Science at Abbott Nutrition

Disclosure

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Presentation Objectives

1. Identify the impact the tumor and anti-cancer treatments have on nutrition status in the adult oncology patient

2. Determine the effect of lean body mass loss on treatment outcomes in the adult oncology patient

3. Characterize the effect of cancer and its treatment on outcomes

4. Recognize national/international guidelines and recommendations

5. Develop early nutrition screening and intervention plan.

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MALNUTRITION

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Historic definitions of malnutrition

Jensen GL, et al. JPEN J Parenter Enteral Nutr. 2009;33:710-716.

marasmus • kwashiorkor • protein-energy undernutrition

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What is malnutrition?

A state of nutrition in which a deficiency, excess, or imbalance of energy, protein, and other nutrients causes measurable adverse

effects on body function and clinical outcome.1

1. Elia M, ed. Guidelines for Detection and Management of Malnutrition: A Report of the Malnutrition Advisory Group. Maidenhead, UK: British Association for Parenteral and Enteral Nutrition (BAPEN); 2000.

Up to 1 in 2 adults admitted to hospital or care homes is or at risk of malnutrition.

– Somanchi M, et al. JPEN. Mar 2011;35(2):209-216

Estimated up to 80% of advanced patients with cancer have malnutrition.

– Poole K, Froggatt K. Palliative medicine. 2002;16(6):499-506

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Malnutrition and weight loss are common in cancer patients

1. Halpern-Silveira D, et al. Support Care Cancer. 2010;18(5):617-625; 2. Laviano A, Mequid MM. Nutrition. 1996;12(5):358-371; 3. Bozzetti F. In: Payne-James J, Grimble G, Silk D, eds. Artificial Nutrition Support in Clinical Practice. 2nd ed. London: GMM; 639-680; 4. National Cancer Institute. Nutrition in Cancer Care. www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page1. 5. Dewys WD, et al. Am J Med 1980;69(4):491-7

• At cancer diagnosis, approximately 50% of patients present with some nutritional issues1

• In certain cancers, up to 85% of patients will develop malnutrition/weight loss2,3 during treatment

• Involuntary weight loss of just 5% results in decreased survival5

Most common secondary diagnosisfor cancer patients is malnutrition4

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•Weight loss and malnutrition are common in the oncology patient

•In a classic paper by Dewys 1980 malnutrition ranged from 31% to 87%1

•Recent paper by Hebuterne 2014 40% of hospitalized oncology patients were malnourished2

Malnutrition in the Adult Oncology Patient

1. Dewys Am J Med 1980; 2. Hebuterne JPEN 2014; Butterworth Today’s Dietitian 1974

This concept is similar to hospital malnutritionand “The Skeleton in the Hospital Closet” 3

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•Oncology nutrition risk studies show:• 32% outpatients mixed tumor types

were malnourished1

• 34% malnourished, 42% at nutrition risk advanced colorectal cancer2

• 88% pancreatic cancer3

• 58% GI tumors4

• 45% of GI cancer patients were malnourished by PG-SGA5

• 49% med oncology patients by PG-SGA6

Malnutrition & Weight Loss

1. Bozzetti Supp Care Cancer 2012; 2. Thoresen Clin Nutr 2013; 3. La Torre J Surg Onc 2013; 4. Poziomyck Nutr Cancer 2012; 5. Dias do Prado 2013 6. Isenring Nutr Cancer 2010.

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•Oncology nutrition risk studies show:• 66% advanced H&N by >10%

weight loss in 6 months; 26% had BMI <20 at 6 month1

• 32% of patients with GI cancer had mild to moderate and 16% had severe malnutrition by SGA2

Malnutrition & Weight Loss

1. Silander Laryngosope 2013; 2. Garth J Hum Nutr Diet 2010

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•Oncology nutrition risk studies show:• Pancreatic surgery patients

• 88% medium-severe nutrition risk by Nutrition Risk Index

• 83% medium to high risk by MUST1

• 35% of patients with lung cancer were malnourished by BMI < 18.5, weight loss > 10% or BMI <20 and weight loss > 5%2

• 25% of patients with gynecological cancer were malnourished by PG-SGA3

Malnutrition in the Adult Oncology Patient

1. La Torre J Surg Onc 2013; 2. Percival Resp Med 2013; 3. Laky BMC Cancer 2010

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Causes of Malnutrition in Cancer Patients

• Decreased dietary intake

• Increased nutrient requirements

• Impaired nutrient digestion / absorption

• Increased losses of nutrients

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Common Treatment-related Side Effects Negatively Impact Nutritional Status

Symptom Chemo Radiation Surgery

Weight loss

Fatigue

Nausea/Vomiting

Taste alterations

Oral mucositis

Constipation

Diarrhea

Dry mouth

Loss of appetite

*Occurs as a result of pain medication.

**

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Cancer Patients Often suffer from Multiple Side Effects that Impact Nutritional Status

PG-SGA=Patient Generated-Subjective Global Assessment (Ottery 2000). Isenring E, et al. Nutr Cancer. 2010;62(2):220-228.

Number of Symptoms

Medical Oncology Patients (N=191)

Percentage of patients

who are malnourishe

d

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• Cancer induced weight loss has no direct relationship with the weight of the tumor, presence of metastases and its anatomic localization

• Cancer induced weight loss can be present when the tumor weighs < than 0.01% of the host’s body weight

• Bigger tumors might not cause cancer induced weight loss

• Cancer induced weight loss has no direct relationship with the weight of the tumor, presence of metastases and its anatomic localization

• Cancer induced weight loss can be present when the tumor weighs < than 0.01% of the host’s body weight

• Bigger tumors might not cause cancer induced weight loss

Tisdale MJ. Physiology 2005; 20:340-8.

Cancer Induced Weight Loss and the Tumor

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Quiz #1

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Quiz: which statement is not correct?

• Consider weight loss and malnutrition in oncology patients:

– Patients with cancer have greater rates of malnutrition than patients without cancer

– Oncology patients rarely have weight loss prior to diagnosis– Malnutrition is the second most common diagnosis in patients with

cancer– Patients with breast and prostate are less likely to experience

weight loss

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Quiz: which statement is not correct?

• Consider weight loss and malnutrition in oncology patients:

– Patients with cancer have greater rates of malnutrition than patients without cancer

– Oncology patients rarely have weight loss prior to diagnosis– Malnutrition is the second most common diagnosis in patients with

cancer– Patients with breast and prostate are less likely to experience

weight loss

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LEAN BODY MASS

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Bed Rest, Age, and Disease Increase Loss of Muscle

Healthy Older Adults

(67 years of age)10 Days’ Inactivity2

Healthy Young (26-46 years of age)

28 Days’ Inactivity1

Lo

ss o

f L

ean

Leg

Ma

ss (

lbs)

al

l mea

sure

men

ts r

epre

sent

sin

gle

leg

loss

Elderly Inpatients (≥65 years of age)

3 Days’ Hospitalization3

–2.0

–1.5

–1.0

0

–2.5

–0.5

1. Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004

2. Kortebein P, et al. JAMA. 2007 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH.

Approx

2.2 lbs

Approx

1.0 lb

Approx

2.2 lbs

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Type of Weight Loss is Critical to Outcomes and Survival in Cancer Patients

Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; 2002.

Muscle mass functions include:•Skin integrity•Immune function•Healing/Repair•GI integrity/Digestion

Malnutrition

Weight Loss

Muscle Mass Loss

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Progressive Muscle Loss Can Be Associated with Severe Complications

Demling RH. Eplasty. 2009;9:65-94.

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Effects of Loss of LBM in Patients with Cancer

• Low muscle mass is common and independent predictor of immobility and mortality 1

• Low muscle mass is an independent adverse prognostic indicator in obese patients 2

• Patients with sarcopenia seem prone to toxic effects during chemotherapy3,4,5 requiring dose reductions and treatment delays5

1. Prado, et al. Lancet Oncol. 2008;9:629-635.2. Tan, et al. Clin Cancer Res 2009;15:6973-79.3. Prado, et al. Curr Opino Support Palliat Care 2009;3:269-275.4. Prado, et al. Clin Cancer Res 2007;13:3264-3268.5. Prado, et al. Clin Cancer Res 2009;15:2920-2926.

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Loss of Lean Body Mass

• Patients with muscle mass loss have greater toxicity and shorter survival1

• Shortest survival times are among obese patients with sarcopenia2

• Median survival of patients with low muscle density was compared to high muscle density:– 14 vs. 20 months (p=0.001)2

1. Tan, et al. Clin Ca Res 2009;15:6973-6379. 2. Antoun, et al. Cancer 2013;19:3377-3384.

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BMI is a False Indicator of Loss of Muscle Mass

Image: Fearon et al., Nature 2013, 1. Davidson W, et al. Oncol Nurs Forum. 2012;39:E340-E345.

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One study found that 79% of patients identified as malnourished were normal weight, overweight, or obese.1

BMILBM

Cachectic17

Equal

Normal25

Equal

Obese38

Equal

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Impact of Lean Body Mass

• LBM determinant of epirubicin toxicity in pts with breast cancer1

– Same BSA but wide variation in LBM– Low LBM predicts toxicity p=0.002– LBM positively correlated with neutropenia nadir r=0.05, p=0.023Capecitabine Tx of metastatic breast cancer2

– Low LBM is determinant of CT toxicity and time to progression

1. Prado, et al. Cancer Chemother Pharmacol 2011;67:93-1012. Prado, et al. Clin Cancer Res 2009;15:2920-26

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• Sorafenib’s common toxic effects limit patient’s ability to receive full-dose treatment and account for:

– dose reductions in 13% of patients – treatment termination in 21% of patients

• BMI < 25 kg/m2 with decreased muscle mass is a significant predictor of toxicity in metastatic RCC patients treated with sorafenib.

Antoun S, et al. Annals of Oncology 2010 doi:10/1093/annoc/md605

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• Mayo Clinic regimen 5-FU/leucovorin CRC– 35% had toxicity resulting in dose reduction, Tx discontinuation, hosp, death– Dose based on Body Surface Area (BSA)– 20mg 5-FU/kg LBM cut point for developing toxicities p=0.005– 56% had dose reductions or Tx delays– Toxicities febrile neutropenia, fatigue, diarrhea, N&V

5FU/BSA or 5FU/kg B Wt not predictive


Prado, et al. Clin Cancer Research 2007;13:3264-68

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Chemotherapy, Toxicity and Malnutrition

• Greater toxicity in patients with lower LBM but also in malnourished patients

• N=100 patients

• Malnutrition and hypoalbuminemia were associated with chemotherapy toxicity

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Quiz # 2

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Quiz: which answer is not correct

• Loss of lean body mass in oncology patients is associated with:

– Greater toxicities of chemotherapy– Loss of strength, performance and activity– Increased leg strength – Poorer outcomes in obese patients

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Quiz: which answer is not correct

• Loss of lean body mass in oncology patients is associated withn:

– Greater toxicities of chemotherapy– Loss of strength, performance and activity– Increased leg strength – Poorer outcomes in obese patients

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Patient-centered outcomes

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Nutrition awareness

• Among medical practitioners, nutritional awareness is low– Not considered important by many medical practitioners– Little or no nutrition education in medical school– “I’ll cure the cancer and the nutrition problem will go away.”

• Patients and families do worry

• Use of herbs, supplements, potions, pills, devices, treatments is high

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Awareness of Patient Reported Outcomes

• In a recent prospective study in patients with NSCLC, survival was correlated with Patient Reported Outcomes.1

• How applicable are Patient Reported Outcomes for predicting quality of life in your practice?

• 51% not or only slightly applicable2

1. Gralla, et al. J Clin Oncol 2013 2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014

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Nutrition Intervention Improves Outcomes in CIWL

• Nutritional status and intake are independent determinants of QoL as much as stage of disease, location of the cancer and treatment regimen in some types of cancer1

• Intensive nutrition therapy including ONS shown to improve2

– Body weight and LBM– Hand grip strength– Physical activity3

– Performance status– Dietary intake

1%

30%

20%

3%

10%

6%

30%

StageLocationIntakeWeight loss

DurationChemotherapySurgery

1. Ravasco P, et al. Supp Care Cancer 2004;12:246-25212. Von Meyenfeldt M, et al. Am Soc Clin Onc 20023. Moses A, et al. Br J Cancer 2004;90:996-1002

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Nutrition Intervention Can Help Improve Quality of Life

Baldwin C, et al. J Natl Cancer Inst. 2012;104(5):371-378.

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SURVIVAL AND NUTRITION

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Weight loss has a significant impact on survival

Patients with pancreatic, gastric cancer and lung had the highest frequency of weight loss (83-87%) and tumor types less likely to produce weight loss breast, prostate, sarcoma. DeWys WD et al. Amer J Med 1980; 69: 491-497

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Weight Loss is Associated with Worse Outcomes

Andreyev HJN, et al. Eur J Cancer. 1998;34(4):503-509.

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Weight Loss Impacts Survival in Colorectal Cancer

Andreyev HJN, et al. Eur J Cancer. 1998;34(4):503-509.

0

Time Since Treatment (Years)

100

80

60

40

20

0 1 2 3 4 5

Pe

rce

nta

ge

Weight Loss(n=246)

No Weight Loss (n=472)

P<.00001

Results

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Nutrition Intervention in Weight Losing Patients Unresectable Pancreatic Cancer

• Dietary counseling and Oral Nutrition Supplements over 8 weeks n=107

• Weight stabilization– Longer survival– Improved QoL (EORTC)

• Improved dietary intake

Davidson W, et al. Clin Nutr 2004;23:239-247

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Early Supportive Care in Patients with NSCLC Improves Survival• Early Supportive Care vs. Standard Care n=151

– Improved Quality of Life (p=0.04)– Longer survival 1.6 vs. 8.9 mos (p=0.02)

Improved QoL (EORTC)

Temel J, et al. N Eng J Med 2010;363:733-742

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Early Intervention for Cancer Cachexia• Early palliative care correlates with longer survival in patients

with NSCLC.1 How early should an intervention start for cancer anorexia-cachexia?

• (69%) With any weight loss or patients most likely at risk for developing weight loss.2

1. Temel, et al. N Engl J Med 2010;363:733-742. 2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014

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NUTRITION INTERVENTIONS

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Appropriate nutrition can support cancer treatment goals

Goals of cancer treatment

•Be effective

•Be well tolerated

•Minimize complications

•Maximize quality of life

•Allow for healing and recovery

Levin RM. Oncology Issues. Nutrition: The 7th Vital Sign. November/December 2010:32-35. accc-cancer.org/oncology_issues/articles/NovDec2010/ND10-Levin.pdf. Accessed March 26, 2012.

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Early nutrition intervention has been shown to improve outcomes in cancer patients

Nutrition intervention started as early as possible can result in:

Nutritional status Performance status Quality of life (QOL) Response and tolerance to treatment

Rate of complications Morbidity

Marín Caro MM, et al. Clin Nutr. 2007;26(3):289-301.

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Patients Treated with a Nutrition Pathway Experienced Improved Outcomes and Treatment Tolerance1

1. Odelli C et al. Clinical Oncology 2005; 17: 639-625.

Results

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EXPERT GUIDELINES

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Experts Have Recognized the Importance of Ongoing Nutrition Intervention in Oncology Patients

• Evaluation process starting in 2015

• “The cancer committee develops and implements a process to provide a comprehensive treatment summary and follow-up plan to patients who are completing treatment; the process is monitored, evaluated, and reported to the cancer committee each year.”

• Continued care that considers the big picture: Cancer recurrence and… other chronic disease

1. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered Care. Chicago, IL: American College of Surgeons. 2011.

The American College of Surgeons Commission on Cancer 2012

Cancer Survivorship Standards1

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Society Guidelines Support Proactive Nutrition Intervention Across the Cancer Continuum

1. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered Care. Chicago, IL: American College of Surgeons; 2011. 2. McCallum PD. In: Elliott L, Molseed LL, Davis P, Grant B, (eds). The Clinical Guide to Oncology Nutrition. 2nd ed. Washington, DC: Oncology Nutrition Dietetic Practice Group, American Dietetic Association; 2006:44-53. 3. The Association of Community Cancer Centers Cancer Nutrition Services: A Practical Guide for Cancer Programs, 2012.

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A Simple and Effective Plan to Ensure Consistency of Care

“Nutritional care is a fundamental aspect of nursing practice and nurses are ideally placed to play an essential role in the early

detection and screening of malnutrition in patients with cancer.”1

1. Davies M. Eur J Oncol Nurs. 2005;9(suppl 2):S64-S73.

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Make Nutrition Part of Your Oncology Patient Care Plan

• Early nutrition screening and intervention requires a multidisciplinary approach

– Integrate into existing pathways or protocols, especially for high-risk cancers

– DO NOT WAIT for serious nutrition concerns

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What did she say?

1. Cancer induced weight loss results in:• Decreased quality of life• Increased complications• Poorer response to therapy

2. Type of weight loss is important• LBM is predominant type of tissue lost• Over weight patients have greater LBM loss and poorer survival

3. Nutritional impact of treatment-related side effects• LBM loss contributes to greater treatment associated toxicities • Dose reductions and treatment delays

.

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THANK YOU!

QUESTIONS?

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