European Dietitians in Oncology: The Future

Transcription

1 European Dietitians in Oncology: The Future Carolina Bento Clare Shaw Julia Lobenwein 1 2 Oncology Workshop Introduction to the committee Clare Shaw (United Kingdom) Carolina Bento (Portugal) Julia Lobenwein (Austria) What are the important issues for oncology patients Who should we feed? When, what and why? Clare Shaw What do oncology patients ask? Carolina Bento What about ketogenic diets? Julia Lobenwein Therapeutic and individual factors that influence oncology nutrition efficiency in breast cancer patients Diana Artene Discussion about the future and plans of the Oncology Committee in EFAD 1

2 Clare Shaw, Consultant Dietitian, PhD RD The British Dietetic Association Oncology Group 291 members 2 newsletters each year 1 annual study day Good network 4 sub groups Opinions / comments on national documents Projects outcomes in oncology 2

3 Julia Lobenwein, BSc Innsbruck, Austria Julia Lobenwein, BSc Clinical practice University Hospital Innsbruck Education Lectures at the HEI for health education Fields of work Austrian Association of Dietitians Leading the working group Nutrition and Oncology Others Presentations, articles, EFAD... Julia Lobenwein, BSc 3

4 Clinical Practice No#standards#for#advising#oncological#pa1ents# in#austria# Depending#on#organisa1on#of#hospital#and# mo1va1on#of#die11an# Julia Lobenwein, BSc In Innsbruck: Implementing screening tool to realize malnutrition as soon as possible Caring of outpatients and inpatients Following the nutrition care process: Intervention (dietary advice for patients suffering from side effects of therapy, planning enteral/parenteral nutrition, homecare...) Julia Lobenwein, BSc 4

5 Education 5#HEI s#for#die11ans#in#austria# In#Innsbruck#app.#15#students#every#two#years# Lectures#on# Nutri1on#and#Oncology #and# Nutri1on#and#Dysphagia #(18#units#in#the#4th# term)# Lectures#on# Nutri1on#and#Oncology #also#for# speech#therapists#and#further#educa1on#of#nurses# Julia Lobenwein, BSc Austrian Association of Dietitians Leading#die11an#of#the#working#group# Nutri1on#and# Oncology # ####K#network#of#die11ans#specialized#in#oncology# ####K#planning#several#projects# ####K#organisa1on#of#further#educa1on# ####K#public#rela1ons...# Presenta1ons#at#congresses,#mee1ngs...# Wri1ng#ar1cles# Interna1onal#work#(EFAD)...# Julia Lobenwein, BSc 5

6 11 What are the important issues for oncology patients 12 Patients with metastatic GI cancer receiving chemotherapy Those with no weight loss compared to those with weight loss at presentation (Andreyev 1998 Eur J Cancer) 6

7 Weight loss and effect on radiotherapy outcome Langius et al, Are we looking at the right parameters? Prado et al,

8 15 Are we looking at the right parameters? Prado et al, How do chemotherapy and radiotherapy affect nutrition? 8

9 17 Symptoms that affect nutritional status Study of 219 medical oncology patients commenced chemotherapy in previous month Proportion of patients with one nutrition impact symptom 79% at 1 month, 72% at 6 months and 46% at 12 months Higher number of symptoms associated with lower QoL Patients experiencing more symptoms were more likely to have poorer quality of life and lower performance status More symptoms = more likely to lose weight Tong et al, 2009 Tong et al, 2009 Acute gastrointestinal effects of radiotherapy! Cellular damage:! Tissue damage: Repeated insults Mucosa and sub-mucosa! Functional impairment: Secretion and absorption Bowel motility Wound healing! Normal secretions potentiate damage Hovdenak)et)al)2000)IJROBP)48:111187) 9

10 19 Effects on patient and cancer treatment Morbidity and mortality eg. due to diarrhoea, sepsis Potential dose reduction (? Effect outcome) Influence performance status and quality of life Influence nutritional status Social isolation Andreyev et al, 2014 Andreyev et al, Dietary counselling during chemotherapy and radiotherapy 10

11 21 Chemotherapy and nutritional support ESPEN: Routine enteral nutrition during chemotherapy has no effect on tumour response to chemotherapy or on chemotherapy-associated unwanted effects and, therefore, is not considered useful. (Arends, 2006) ASPEN: Nutrition support therapy should not be used routinely as an adjunct to chemotherapy. (August et al, 2009) 22 Oral nutritional support during chemotherapy 358 patients with GI cancer (256) and lung cancer (102) randomised to No intervention Dietary advice Nutritional supplement Dietary advice and nutritional supplement 6 week intervention Followed up for 1 year Survival, nutritional status and quality of life Baldwin et al, 2011 Baldwin et al,

12 23 Oral nutritional support during chemotherapy Baldwin et al, Oral / enteral nutritional support during chemotherapy Normally nourished patients commencing chemotherapy prior to Autologous stem cell transplantation Randomised to standard care or early enteral nutrition Measured weight, weight loss, time to haemopoietic recovery and length of stay Kiss et al,

13 25 Oral / enteral nutritional support during chemotherapy Normally nourished patients commencing chemotherapy prior to Autologous stem cell transplantation Randomised to standard care or early enteral nutrition Measured weight, weight loss, time to haemopoietic recovery and length of stay Both groups experienced significant weight loss although intervention group lost less than the control group No difference in time to haemopoietic recovery, QoL or length of stay Patients in intervention group were fed for longer Kiss et al, 2014 Kiss et al, Malnourished patients with cancer 13

14 Radiotherapy: Nutrition counselling and outcome Mortality Toxicity Ravasco et al, Can nutrition affect treatment related symptoms? 14

15 29 Bile acid malabsorption in lenalidomide treatment Lenalidomide, novel treatment for myeloma 12 consecutive patients referred to the Royal Marsden Gastrointestinal and Nutrition Team clinic (GIANTs) Dose of lenalidomide Bristol Stool chart Mean Frequency per day Mean 25 mg mg Pawlyn et al, 2014 Blood 30 Bile acid malabsorption in lenalidomide treatment Lenalidomide, novel treatment for myeloma 12 consecutive patients referred to the Royal Marsden Gastrointestinal and Nutrition Team clinic (GIANTs) Dose of lenalidomide Bristol Stool chart Mean Frequency per day Mean 25 mg mg SeHCAT scan results 9 patients severe bile acid malabsorption 2 patients moderate bile acid malabsorption 1 patient mild bile acid malabsorption Pawlyn et al, 2014 Blood 15

16 Dietary Interventional strategies in radiotherapy Wedlake et al, Summary 16

17 33 Summary Cancer patients high risk of malnutrition which impacts on tolerance to treatment Toxicity of treatment contributes to decreased nutritional status Nutritional support is effective at maintaining or improving nutritional status during treatment Nutrition may influence symptoms and long term outcomes Preventing and treating undernutrition Enhancing anti-tumour treatment effects Reducing adverse effects of anti-tumour therapies Improving quality of life 34 References 17

18 EFAD /4/15 35 References 36 References Wedlake L, Shaw C, Whelan K, Andreyev HJN. Systematic review: the efficacy of nutritional interventions to counteract acute gastrointestinal toxicity during therapeutic pelvic radiotherapy. Aliment Phamacology Therapy. 2013;37: