Nutri&on support of the pa&ent with cancer

Transcription

1 Nutri&on support of the pa&ent with cancer Dr Liz Isenring, AdvAPD Clinical Academic Fellow, Princess Alexandra Hospital Conjoint Senior Lecturer University of Queensland, Australia

2 Nutritional issues in cancer Weight loss due to: treatment Nutrition impact symptoms mechanical barriers depression, anxiety pain Provision of energy and protein usually results in weight gain " Cachexia metabolic abnormalihes + energy intake energy expenditure

3 AND/ASPEN e&ology- based malnutri&on defini&ons (White et al 2012)

4 Malnutri&on prevalence 30-70% depending on nutrihonal assessment, stage, tumour type associated with negahve clinical outcomes $$$$ (Baldwin Cur Opin Support Palliat Care : 29-36; Bozze[ J GerOnc 2011; ; Isenring Nutr Cancer 2010; 62:220-28)

5 Oncology pa&ents at increased nutri&onal risk O D D S R A T I O Malnourished Consumed 50% food Readmissions

6 Evidence- based Guidelines Enteral Nutrition/Parenteral 2006 ESPEN 2009 ASPEN Clinical Nutrition 25 ( ) Clinical Nutrition 25 ( ) JPEN 33 ( ) Surgery, Organ Transplantation. Non-Surgical Oncology. Adult Anticancer Treatment Cancer Cachexia 2006 DAA Nutrition and Dietetics 63 (Suppl.2): S3-32 or Nutritional management of cancer cachexia. Radiotherapy/ Chemotherapy 2008 DAA Nutrition and Dietetics 65 (Suppl.1): S1-S20 or Nutritional management of patients receiving radiation therapy DAA Nutrition and Dietetics- early view Update of radiation therapy guidelines, including chemotherapy hfp://wiki.cancer.org.au/australia/ COSA:Head_and_neck_cancer_nutriHon_g uidelines Head and Neck Cancer topic.cfm?cat=1058 Specific questions Head and Neck Cancer 2011 COSA Broad Oncology Groups AND & PEN

7 NHMRC Evidence hierarchy Level I: systemahc review of all RCTs Level IV: evidence obtained from case studies, either post- test or pre- test Grades of Recommenda&on Level A: body of evidence can be trusted to guide prachce Level B: in most situahons Level C: some support for recommendahon(s) but care should be taken in its applicahon Level D: weak, apply with cauhon

8 Evidence for prac&ce Gold standard = highest level of evidence (I). E.g. meta analysis of RCTs Omen very difficult, if not impossible to achieve in nutrihon intervenhons i.e. considerahon is given to strong study design, strength of effect, minimising bias and relevance (Isenring et al NutriHon and DieteHcs 65 (Sup 1) S1-20).

9 Available Nutri*on and Diete*cs Early View: 29 JAN 2013 DOI: / Acknowledgement: DAA Small Grant

10 AIMS To update the Evidence- Based Prac*ce Guidelines for the Nutri*onal Management of Radiotherapy and broaden the scope to include chemotherapy pahents. Consolidate with Evidence Based PracHce Guidelines for the NutriHonal Management of Adult pahents with Head and Neck Cancer to move towards one central set of oncology guidelines

11 hfp://wiki.cancer.org.au/australia/cosa:head_and_neck_cancer_nutrihon_guidelines DieHHan Steering Commifee Acknowledge Cancer Australia, COSA

12 !

13 METHODS- update Search strategy: Cochrane Database of SystemaHc Reviews, CENTRAL, MEDLINE (via Ebscohost), EMBASE, CINAHL (Ebscohost), Web of Science, Health Source: Nursing/Academic EdiHon and PubMed Date limits: Radiotherapy ; Chemotherapy: no date limits N=47 arhcles reviewed by at least 2 members of the steering commifee: assigned a Level of Evidence (NHMRC) and quality rahng (AND Evidence Analysis Manual)

14 Appropriate Access to Care Nutri&on Screening Nutri&on Assessment *How should patients be identified for referral to the dietitian in order to maximise nutritional intervention opportunities? *How should nutritional status be assessed? Quality Nutrition Care *What are the goals of nutrition intervention for patients receiving radiotherapy treatment? Nutrition intervention *What is the nutrition prescription to achieve these goals? - Establishing goals - Nutrition prescription - Implementation *What are effective methods of implementation to ensure positive outcomes? *Is nutrition intervention beneficial in radiation enteritis? Nutrition Monitoring and Evaluation Measure and Evaluate Outcomes - Intermediate - Clinical/Cost/Patient *Does nutrition intervention improve outcomes in patients receiving radiotherapy treatment? *What nutritional follow-up should patients receiving radiotherapy receive?

15 RESULTS No new nutrihon intervenhons in radiotherapy (non HNC) from Feb Evidence remains strong A/B N=12 nutrihon intervenhons in chemotherapy (all dates) 5 RCTs (4 + quality) Some found improvements in intermediate outcomes (dietary intake, weight) but most found no benefit for quality of life or survival. Most had limitahons including methods of nutrihon intervenhon rarely reported in detail and few involved intense or frequent diehhan contact or standardised nutrihon counselling. Treatment differences between RT and chemotherapy. RT tends to follow predictable, defined treatment period; chemotherapy large differences

16 " Aim for weight maintenance (or at the very least minimise weight loss) during treatment " Manage nutrihon- related symptoms as a mulhdisciplinary team " NutriHonal management may include texture modificahon, high energy and protein dietary modificahons, supplements and/or tube feeding if inadequate dietary intake. " In some cases may require parenteral nutrihon if inadequate intake and GIT not funchoning.

17 Dietary counselling " Dietary counselling (+/- sups) improves dietary intake in pahents receiving radiahon therapy (RT) NHMRC grade of recommenda&on: A " Dietary counselling (+/- sups) improves QoL and physical funchon during & post radiahon in pahents with oesophageal and HNC. NHMRC grade of recommenda&on: B

18 Nutri&on Interven&on 2008 Radiotherapy Guidelines (Isenring et al 2008) Updated Radiotherapy &/or Chemotherapy Guidelines (Isenring et al 2013) How should patients be screened and referred to the dietitian? All patients receiving radiotherapy to HN or GIT should be referred to the dietitian. Other patients screened with validated tool eg MST. Grade B All pts receiving radiotherapy to HN or GIT should be referred to the dietitian. Other pts at nutritional risk (eg receiving chemotherapy) should be screened with validated tool eg MST. Grade A Validated nutrition assessment tools eg PGSGA, SGA should be used to assess nutritional status in patients receiving radiotherapy. Grade B Validated nutrition assessment tools eg PG-SGA, SGA should be used to assess nutritional status in patients receiving radiotherapy and/or chemotherapy. Level B

19 Nutri&on Interven&on 2008 Radiotherapy Guidelines (Isenring Updated Radiotherapy &/or Chemotherapy et al 2008) Guidelines (Isenring et al 2013) Does nutrition intervention improve outcomes? Regular nutrition intervention (dietary counselling +/- supplements) improves energy & protein intake & nutritional status during radiotherapy. Grade A Nutrition intervention (dietary counselling +/supplements) during & post radiotherapy improves patient-centred outcomes (QoL, physical fn, satisfaction). Grade B Radiotherapy- Grade A Nutrition intervention (dietary counselling +/-supplements) increases dietary intake & weight in chemotherapy patients but not patient-centred outcomes. Grade A Nutrition intervention (dietary counselling +/-supplements) does not improve survival in patients undergoing chemotherapy or radiotherapy with curative intent. Level B There is insufficient evidence to support use of antioxidant supplements during radiotherapy and/or chemotherapy treatment Grade A Some evidence lower SEs but concerns over interactions Grade C

20 Should EPA be included in the nutrition prescription? Courtesy Aaron Burton Meij B et al., 2013; Bauer et al 2006,

21 Role of EPA inflammatory response pro-inflammatory cytokine production attenuates APPR leading to reduced REE level/activity of proteolysis-inducing factor (PIF) attenuates cachexia slows tumour growth

22 Diete&c interven&on Limited discussion in most published trials? Dietetic counselling? Nutrition recommendations? Dietary Intake? Frequency of contact

23 Should EPA be included in the nutrition prescription? A B C D Body of evidence can be trusted to guide prachce Body of evidence can be guided to trust prachce in most situahons Body of evidence provides some support for recommendahon but care should be taken in its applicahon Body of evidence is weak and recommendahon must be applied with cauhon Isenring E: Nutrition & Pharmacy

24 Should EPA be included in the nutrition prescription? Practice Recommendation EPA can be considered as a component of nutrition intervention in cancer cachexia but patients should first be assessed for suboptimal symptom control or inadequate intake. If using EPA, aim for an intake of g EPA/day which needs to be consumed for at least four weeks to achieve clinical benefit.

25 Areas to watch - EPA - Amino acids e.g. arginine, glutamine, carnihne - managing NIS (ginger, anhoxidants) - Vitamin D - NutriHon & exercise programs - Automated screening

26 Summary MalnutriHon is common in oncology pahents Early access to appropriate nutrihon care is important to maintain or minimise deteriorahon in nutrihonal status & QOL Several sets of guidelines present best available evidence for nutrihonal recommendahons including this update of radiotherapy (chemotherapy). Further research is required in the area of nutrihon and chemotherapy As anhcancer treatment conhnues to evolve so to should the nutrihonal management of these condihons.

27 References