Cancer and Nutrition - Prevention

Transcription

1 MALNUTRITION RISK IN CANCER PATIENTS: SUGGESTIONS FOR IMPROVEMENT IN NUTRITIONAL CARE by Grant H. Cefalo A report submitted in partial fulfillment of the requirements for the degree of MASTER OF DIETETIC ADMINISTRATION in The Department of Nutrition, Dietetics, and Food Sciences Nedra Christensen Megan Bunch Noreen Schvaneveldt Janette Smith UTAH STATE UNIVERSTIY Logan, Utah 2009

2 ii Copyright Grant H. Cefalo 2009 All Rights Reserved

3 iii ABSTRACT Malnutrition Risk in Cancer Patients: Suggestions for Improvement in Nutrition Care by Grant H. Cefalo, Master of Dietetic Administration Utah State University, 2009 Major Professor: Megan Bunch Department: Nutrition, Dietetics, and Food Sciences Cancer is diagnosed in 1.2 million Americans annually and is the second leading cause of death in the United States, second only to cardiovascular disease. Cancer causes one in four deaths nationwide. Treatment options for patients with cancer include surgery, radiation, chemotherapy, and immunotherapy. Nutrition complications can occur before, during and after treatment. Inadequate nutritional intake or altered absorption can lead to malnutrition. Malnutrition prior to treatment can cause it to be less effective. This quality assessment was designed to identify how many patients receiving treatment at McKay-Dee Hospital Center were at risk for malnutrition. Fifty-six patients were screened using the subjective global assessment

4 iv (SGA). The patients were categorized into three groups: SGA-A (well nourished), SGA-B (moderate malnourished), and SGA-C (malnourished). SGA-A (n=33) accounted for 59% of the patients, SGA-B (n=12) accounted for 21% of patients and SGA-C (n=11) accounted for 20% of patients. Identifying those at risk for malnutrition can help prevent nutrition-related complications during cancer treatment. Early nutrition interventions and education plays an important role in improving the nutrition status and quality of life of cancer patients. The SGA is an effective tool for screening cancer patients for malnutrition.

5 v ACKNOWLEDGEMENTS I would like to thank my committee members, Megan Bunch, Nedra Christensen, Noreen Schvaneveldt, and Janette Smith for supporting me during the completion of a Master Degree. I would like to thank Megan Bunch for her countless hours of helping me through this process. I would like to thank Janette Smith for arranging classes that allowed me to continue to work fulltime. I would like to thank all committee members for their patience during these last few years. I also want to thank my family, friends and coworkers for their support, help and understanding that allowed for the completion of this document. Grant H. Cefalo

6 vi CONTENTS ABSTRACT iii ACKNOWLEDGEMENTS.. v LIST OF FIGURES.....vii LIST OF ABBREVIATIONS.viii CHAPTER I. INTRODUCTION... 1 REVIEW OF LITERATURE Abstract...3 Surgery Chemotherapy Radiation Weight Loss Cancer Cachexia...22 Nutrition Support Nutrition Screening CHAPTER II STUDY METHODS, DESIGN, AND RESULTS Introduction Current Practices at McKay Dee Hospital Center Methods Results Discussion...36 CONCLUSIONS AND IMPLICATIONS

7 vii Areas for Further Research My Recommendations.. 41 Conclusions REFERENCES APPENDIX.. 49

8 LIST OF FIGURES AND TABLES Potential contributions to unintentional weight loss Figures ,

9 2 LIST OF ABBREVIATIONS ECF EN DNA FAMTX NG NJ PEG PEJ PN SGA Epirubicin, Cisplatin, Fluorouracil Enteral Nutrition Dioxynucleic Acid Fluorouracil, Doxorubicin and Methotrexate Nasogastric Nasojejunal Percutaneous Endoscopic Gastrostomy Percutaneous Endoscopic Jejunostomy Parenteral Nutrition Subjective Global Assessment

10 3 CHAPTER I PROBLEM, LITERARTURE REVIEW, AND OBJECTIVES Problem Cancer is diagnosed in 1.2 million Americans annually and is the second leading cause of death in the United States, second only to cardiovascular disease. Cancer causes one in four deaths nationwide. Even though deaths attributed to cardiovascular disease have decreased over the last 50 years, deaths from cancer have remained constant. Lung cancer has the highest mortality rate among all cancers in men and women. In men, the second leading cause of cancer death is prostate followed by colon. In women, the second leading cause of cancer death is breast followed by colon (1,2). Cancer is defined as uncontrolled cellular proliferation. There are external and internal factors that can lead to cancer. External factors include: environmental exposures, tobacco use and radiation. Internal factors include: hormones, immunosuppression, genetics, and mutations of metabolism (2). If the cancer is detected early, prognosis is generally good and the need for cancer treatment is minimized. However, cancer is often detected at more advanced stages where cancer treatment may be needed to help induce remission. The five-year survival rate of patients with all types of cancer, irrespective of the treatment modality, is 65% (3). Treatment options for patients with cancer include surgery, radiation, chemotherapy, and immunotherapy. These therapies can be used alone or in

11 4 combination. Treatment options depend on the location, size, stage and type of cancer. All cancer treatment options carry nutrition risk and may lead to malnutrition and poor patient outcomes over time. To complicate matters, malnutrition can then lead to decreased treatment effectiveness. For example, inadequate nutrient intake during treatment can cause chemotherapy and radiation to be less effective (4-7). Thus, it is critical to identify cancer patients at risk for malnutrition in order to improve patient outcomes. Objectives The study objectives were to assess the current nutrition referral system for cancer patients at McKay-Dee Hospital Center, identify cancer patients at risk for malnutrition and discuss ways to improve outcomes related to malnutrition. Hypothesis Early detection of malnutrition improves cancer treatment. The subjective global assessment (SGA) is an adequate screening tool for identifying malnutrition among cancer patients. Literature Review Surgery Surgery is often the first line of treatment for cancer and can play an important role in determining what type or even if additional treatment(s) will be required. Excision of malignant cells can be curative at times if negative margins are achieved. Negative margins are defined as removal of all cancerous tissue. On the contrary,

12 5 positive margins are defined as cancerous tissue present with the potential for further tumor growth and metastasis (6-7). Chemotherapy and/or radiation therapy may be required when positive margins are detected as a method of inducing apoptosis. Furthermore, upon completion of chemotherapy and/or radiation therapy, additional surgeries may be warranted, which could possibly be followed by more chemotherapy and/or radiation therapy (8-9) Similar to non-cancer related surgeries, cancer patients have an increased need for calories, protein, and micronutrients in order to promote postoperative healing (6-10). Yet, postoperative oral intake can be compromised due to pain, pain medications, and nausea. Inadequate oral intake postoperatively increases the risk for infection, causes wound dehiscence and increases hospital length of stay. Additional factors that reduce healing time include age, medications and glycemic control (7). The type of surgery determines the healing time. Surgeries of the gastrointestinal tract often result in postoperative ileuses and decreased nutrient absorption, which can compromise nutritional status (9-10). The type and location of the surgery dictates what type of feeding method is appropriate and when oral feedings can be resumed. For example, bowel surgery can take approximately five to seven days postoperatively to regain adequate function (6,8-9). Lumley et al. (11) found that laparoscopic techniques lower the risk of developing a postoperative small bowel obstruction. Only 6 of 108 patients who underwent a laparoscopic procedure developed an adhesion or small bowel obstruction postoperatively (11). Braga et al. (12) compared open surgery to

13 6 laparoscopic surgery and reported decreased morbidity with the laparoscopic technique. Morbidity was 6.9% compared to 14.9% in open surgery (12). Although advancements in surgical techniques allow for smaller incisions and shorter healing times, bowel resections are not without nutritional consequences. Bowel resections can alter nutrient absorption; lifelong supplementation of nutrients may be necessary as a result depending on the site of resection. As previously mentioned, patients who have recently undergone a bowel resection are in need of increased energy and protein to promote healing (10). Thus, it is challenging for the patient to obtain adequate nutrition as a result of malabsorption and increased nutrient needs. A Veterans Affairs study reported that 39% of patients with cancer deemed candidates for surgery were considered to be malnourished (13). This is of great concern as surgical outcomes are compromised when patients are malnourished, and in some instances, the patient may no longer be considered a candidate for surgery because of his/her malnourished state. Furthermore, as much as fifty percent of patients develop malnutrition postoperatively (13). Thus, preoperative screening tools must be used to determine the degree of malnutrition, as defined by visceral protein status and weight loss, to improve pre- and postoperative outcomes and prevent and/or minimize the occurrence of malnutrition (10,13). Insufficient oral intake requires the use of nutrition support to provide adequate nutrition. There are two different methods of feeding when oral nutrition is contraindicated. Enteral nutrition (EN) requires the placement of a feeding tube into the stomach or small bowel. Tubes are often placed in the nasal cavity and threaded

14 7 into the stomach (nasogastric (NG)) or small bowel (nasojejunal (NJ)) when nutritional support is anticipated to be used for four weeks or less. Longer-term enteral nutrition requires surgical placement of a feeding tube through the abdominal wall and directly into the stomach (percutaneous endoscopic gastrostomy (PEG)) or small bowel (percutaneous endoscopic jejunostomy (PEJ)). Enteral formulas vary in nutrient composition depending on the purported use of the product. There are standard formulas, immune enhancing formulas, high protein formulas, and specialty formulas (e.g. impaired absorption, renal and liver formulas) (10,14). Parenteral nutrition (PN) is the administration of nutrients directly into the blood stream. PN usually requires placement of a central line, generally the vena cava, because of the high rate of blood flow. As a result, there is an increased risk of infection with use of PN (10,14). Nutrition support can be used both pre- and postoperatively. Enteral nutrition is preferred over parenteral nutrition due to a lower risk of infection, decreased cost, and its ability to maintain gut integrity (10,14). As such, enteral nutrition has been shown to improve patient outcomes. In contrast, pre-operative parenteral nutrition has not been shown to be effective and has been proven to increase morbidity and mortality. As previously mentioned, parenteral nutrition has a higher risk of infection, but it can also induce hyperglycemia and cause electrolyte imbalances. Moreover, in the malnourished population, parenteral nutrition increases the risk of refeeding syndrome, a potentially deadly syndrome that involves an intracellular shift of

15 8 electrolytes. Thus, enteral nutrition is the preferred method of feeding when oral intake is inadequate pre- and post-operatively (6,10,14). However, parenteral nutrition is recommended if a trial of enteral nutrition has failed even after placement of a small bowel feeding tube in cases of gastrointestinal dysfunction, or if high output intestinal fistula(s) are present. PN should be initiated between day five and day ten postoperatively if an oral diet or EN is not feasible (10). Preoperative enteral nutrition may be a means to improve nutrition status in the malnourished patient if the surgery can be safely postponed for seven to ten days (6). Improving overall nutrition status preoperatively can improve post-operative healing. This decreases the length of stay required in the hospital. The majority of cancer patients that require nutrition support have recently undergone a surgical procedure and are in need of high protein formulas and have been unable to meet their protein needs orally. Provision of 1.5 grams of protein per kilogram of body weight is recommended to promote healing (7). In addition, early initiation of enteral nutrition in the post-operative period for upper GI surgeries has been shown to decrease hospital length of stay and healing time (15). Furthermore, immune enhancing enteral formulas have been shown to decrease length of hospital stay in surgical patients and should be considered as the enteral formula of choice in this patient population (10,14). Chemotherapy The three goals of chemotherapy are to cure, control and palliate. Chemotherapy is most effective when used in combination with surgery and/or

16 9 radiation (6). Chemotherapy agents interfere with dioxynucleic acid (DNA) synthesis. This can slow down and/or stop tumor growth. Chemotherapy targets rapidly dividing cells, malignant or nonmalignant. As such, the integumentary and gastrointestinal systems are affected. For example, hair growth is affected as well as the mucosa of the small bowel (6,9,16). Neoadjuvant therapy is chemotherapy that is given preoperatively. The goal of neoadjuvant therapy is to reduce the size of the tumor and prevent metastasis since malignancy causes inflammation of the surrounding tissues, which makes it difficult to determine the extent of the malignancy. Therefore, shrinking the tumor can help with the surgical removal of the tumor without damage to the surrounding tissues (6). Neoadjuvant therapy is not effective with all types of cancer but is often used for breast and colon cancers (16). Advancements in chemotherapy are ever occurring, but additional research is needed to determine its effectiveness. There are numerous reports that cite the relative effectiveness or ineffectiveness of chemotherapy. For example, Hartgrink et al. (17) found that there was no benefit of using neoadjuvant therapy using fluorouracil, doxorubicin and methotrexate (FAMTX) as treatment for stomach cancer (17). However, Cunningham et al. (18) found that epirubicin, cisplatin, and infused fluorouracil (ECF) is beneficial in reducing gastric or lower esophageal tumors. If nothing else, these trials show that not all chemotherapy agents are effective in all cancers. Thus, further research is warranted.

17 10 One option for additional research is clinical trials. Clinical trials allow patients to receive experimental treatments for cancer. Participation in clinical trials is voluntary. The findings of clinical trials assist in the development of chemotherapy protocols (16,19). Chemotherapy protocols are necessary to help prescribe the appropriate drug regimen for the individual patient. Adjuvant therapy is chemotherapy that is given postoperatively when surgical treatment was not successful at eradicating the tumor. Adjuvant therapy, like neoadjuvant, works best when combined with radiation therapy (6). Unfortunately, not all cancers respond to chemotherapy (6,16). Side effects of chemotherapy are similar with both neoadjuvant and adjuvant therapy. As aforementioned, the mucosal lining of the gastrointestinal tract is affected by chemotherapy. Atrophy of the mucosal lining can lead to malabsorption and diarrhea, which results in the loss of nutrients (9). Diarrhea can lead to dehydration, poor appetite and fatigue (6). Ensuring adequate fluid intake is essential to the prevention of dehydration. Adequate hydration after each episode of diarrhea is necessary (16). This can be accomplished by the use of sports drinks, for example. Avoidance of spicy, fried, greasy and sweet foods is also recommended. Though research findings are not conclusive as to whether lactobacillus may help alleviate diarrhea, it is often used as an antidiarrheal agent among the cancer population (3). As previously stated, malabsorption of nutrients can lead to weight loss and malnutrition. Moreover, avoidance of whole grains, fruits and vegetables can lead to an inadequate intake of vitamins and minerals (9). Both of these occurrences are

18 11 common among cancer patients, which exacerbate the risk for malnutrition. A multivitamin and mineral supplement should be consumed as a result (6-7,9). Nausea and vomiting are common side effects of chemotherapy and if left untreated, can result in inadequate oral intake, weight loss, electrolyte imbalance, and malabsorption of nutrients (16). Similar to diarrhea and malabsorption, uncontrolled nausea and vomiting can lead to malnutrition over time (20). Antiemetic agents may help alleviate nausea and vomiting. Medications can be taken on a routine basis as prophylaxis against nausea and vomiting (16). Dietary modifications such as consuming small and frequent meals, consuming bland foods and avoiding food with strong odors may help alleviate nausea (6-7,16). Some cancer patients will develop intolerance to dairy products; therefore, assessing tolerance to dairy products is recommended (6). Glutamine is one of the most abundant amino acids in the plasma and a major component of skeletal muscle (10,21). Commercial glutamine supplements are available over-the-counter and are often touted as a remedy for cancer. Numerous studies have shown that oral glutamine supplementation can be beneficial in chemotherapy-induced stomatitis (21-24). Glutamine plays a role in the metabolic processes of lymphocytes, macrophages, and enterocytes. Cancer causes stress on the body and during times of stress, glutamine may become conditionally essential (6). Glutamine has also been associated with maintaining fat-free mass during treatment (22).

19 12 Ulceration or inflammation of the throat and mouth (stomatitis and mucositis) is also a common side effect of chemotherapy. In such cases, eating can be very painful; therefore, oral intake often decreases as a direct result. Nutrition interventions to improve stomatitis and mucositis include eating soft textured foods, drinking through a straw and rinsing the mouth thoroughly after eating or drinking (9,16). Rough textured foods, spicy foods and acidic foods should be avoided. Use of numbing agents prior to eating may also improve intake. Furthermore, oral supplements like Boost or Ensure, are usually well tolerated and can aid in meeting nutritional needs (6,16). As previously mentioned, glutamine may help in healing stomatitis and mucositis (23). Cancer patients can experience taste changes during chemotherapy. The most common taste changes are a metallic taste and a heightened sensitivity to sweet foods. Meats are often avoided due to its metallic taste. Using different marinades on meat products can help mask the flavor of meat and make it more palatable. Plastic utensils may also help decrease the metallic taste. Gum, mints or lemon drops can be used between meals to decrease the metallic taste. If foods taste too sweet, diluting sweetened liquids with water or consuming foods that are more acidic may help. Caution should be used when eating acidic foods if mouth sores are present. Similar to mucositis, proper oral hygiene is essential in order to minimize the effects of taste alterations. For example, rinsing the mouth before eating or drinking can help minimize metallic taste changes (6,16).

20 13 Xerostomia, or dryness of the mouth, can result in secretion of viscous saliva and decreased quality of life for cancer patients. Xerostomia can make wearing dentures difficult as it can cause dental and gum disease. Nutrition recommendations to minimize the effects of xerostomia include adding sauces and gravies to foods, consuming foods in liquid form, and gargling with ginger ale if mucus sticks to the throat. Club soda and lemon juice can be used as a mouthwash, and artificial saliva products are available if needed. Eating smaller meals more often may also be beneficial. Keeping the mouth moist by drinking water or sucking on ice chips can help make meal times more meaningful as the patient may consume more food as a result (6,16). Constipation during cancer treatment can be multifactorial. Chemotherapy, use of pain medications, inadequate intake of fiber and fluids, and inactivity all contribute to constipation (16). Therefore, increasing fluid intake, engaging in physical activity, and consuming more fiber can help prevent constipation. Stool softeners, enemas and laxatives can also be used when nutrition therapy is not enough to alleviate the constipation. It is important to note that bowel obstructions can develop if constipation is not treated effectively and in a timely manner (6,16). Esophagitis can develop as a result of chemotherapy and it significantly impacts the ability to eat. Sore throat can lead to early satiety and reflux. Soft foods are usually well tolerated and accepted by patients with esophagitis. Pureed foods can also be used as tolerated. Fortified milk and oral supplements can be used as protein sources if meat products are not tolerated (6,16). In addition, glutamine

21 14 supplementation may be helpful in treating esophagitis (23). If oral intake is not sufficient or not possible, nutrition support may be needed. However, NG and NJ tubes are not recommended in cases of severe esophagitis due to possible esophageal perforation. Therefore, parenteral nutrition may be indicated for short-term therapy (10). Severe esophagitis can lead to dysphagia. Nutrition recommendations depend on the severity of the dysphagia. To determine the stage of dysphagia, patients should be evaluated by a speech therapist. Barium swallow evaluations are often preformed to assess the extent of the swallowing dysfunction, which are categorized into three levels of dyshpagia. Level I consists of a blenderized or pureed diet. Level II consists of a minced or mechanical diet. Level III consists of an advanced or chopped diet (9). Alterations in the consistency of liquids may also be needed in those with swallowing dysfunction. Liquids can be nectar, honey or spoon thick. Commercial thickening agents can be used to alter the consistency of liquids (9). Nectar thick liquids are more palatable than spoon thick liquids. Although dysphagia diets are beneficial, the palatability of such a diet is lacking. Multivitamin and mineral supplementation can be provided if there is a decrease in consumption of fruits and vegetables. If severe dysphagia is present, enteral nutrition may be used to meet nutritional needs (6-7,10,16). In summary, chemotherapy can compromise oral intake or alter the absorption of nutrients. As previously mentioned, inadequate oral intake during treatment can lead to decreased overall efficacy of treatment(s). Moreover, the side effects of

22 15 chemotherapy can compromise intake, which can ultimately lead to malnutrition over time (6,9,25). Treatment side effects of radiation therapy Similar to that of chemotherapy, radiation therapy can lead to malnutrition. The prevalence of malnutrition depends on the tumor location, the region irradiated, the dose, the length of treatment, the volume irradiated, and adjunct cancer treatments (6-7). For example, the small bowel is responsible for the absorption of fat, carbohydrates, protein, vitamins, minerals and bile salts. Thus, radiation enteritis, a side effect of radiation to the small bowel, can lead to malabsorption, bowel obstruction and diarrhea (6,26). Unlike acute enteritis, radiation enteritis can be chronic in nature. Damage to the bowel can affect the entire thickness of the bowel wall, not just the mucosa. Mucosal damage leads to fibrosis and ischemia. Ischemia and fibrosis can lead to small bowel obstructions. Fibrosis decreases the absorptive capacity of the small bowel (26). Over time, both ischemia and fibrosis can lead to malnutrition. The colon and rectum can also be affected by pelvic radiation. Radiation to the pelvic region can cause a decrease in the colonic re-absorption of fluid and nutrients. It can also impair bowel motility. Furthermore, constipation and diarrhea are common side effects of pelvic radiation. Similar to chemotherapy induced diarrhea, adequate fluid intake is necessary to prevent constipation when loss of fluid is high due to the diarrhea. Increasing fiber intake can also help minimize constipation. It is recommended to consume grams of fiber per day (9). Foods high in fiber include fresh fruits, vegetables and whole grains. Fiber supplements can

23 16 also be used to supplement dietary fiber intake. Stool softeners may also be required in cases of severe bowel injury (6). Radiation to the head and neck region is especially deleterious on nutritional status. Head and neck radiation can often result in a sore mouth and throat, dysphagia, mouth sores, fatigue and loss of appetite. Swallowing difficulty can lead to inadequate oral intake, which may result in weight loss and malnutrition over time (6-7,9). Thus, prophylactic placement of a feeding tube may be beneficial in patients receiving radiation therapy to the head and neck region. Research has shown that such measures minimize weight loss during radiation treatment (26-29). Paccagnella et al. (27) compared thirty-three head and neck cancer patients that received early nutrition intervention to thirty-three patients that did not receive nutritional intervention. After the fourth week of treatment, the control group lost on average, 4.70 kg compared to 1.72 kg in the nutrition intervention group. It was also noted that weight loss near the end of treatment was more common in both groups; however, the nutrition intervention group was more likely to regain the lost weight. The control group continued to lose weight up to six months after treatment was completed (27). Tongue and neck cancers can lead to mouth sores. Mouth sores can be treated with glutamine supplementation (23). Current research is not conclusive as to whether glutamine supplementation is actually effective against mouth sores, but the results are promising and glutamine supplementation should be considered as a possible treatment option (31). Treatment of mucositis should be done as a multidisciplinary approach with involvement from the physician, nurse, dietitian, and pharmacist.

24 17 Similar to mucositis associated with chemotherapy, proper oral hygiene is essential. Tolerance of foods can vary greatly from only tolerating pureed foods to tolerating regular diets. Oral supplements, like Boost, Ensure or fortified milk, can be beneficial in meeting protein and energy needs when nutrition status is compromised. Medications including anesthetic gels can numb the mouth and facilitate oral intake (6). Radiation enteritis can occur with radiation to the abdomen, pelvis, or lumbar regions. Acute enteritis is classified as diarrhea that occurs for 3 months or less (26). Yet, chronic enteritis can occur as well; diarrhea can last months to years after treatment, which can compromise nutrition status long-term. Even mild to severe diarrhea can decrease the amount of nutrients absorbed (9). Symptoms include nausea, vomiting, abdominal pain and secretory diarrhea. Patients may benefit from a low lactose, low fiber, and low fat diet as a result (6-7). Dehydration becomes a concern with severe diarrhea and hydration therapy may be required. Antidiarrheal agents can be used in severe cases and nutrition support may be necessary (7). As previously mentioned, a trial of enteral nutrition should be conducted prior to initiation of parenteral nutrition (10). Additional recommendations include small and frequent meals, vitamin and mineral supplementation and replacement of electrolytes (6). Nausea and vomiting are common side effects of radiation to the central nervous system as well as the pelvic region, as previously mentioned. Techniques to minimize nausea and vomiting include consuming small and frequent meals, drinking

25 18 before and/or after meals instead of with meals, and avoiding foods with strong odors. (6,10). Antiemetics can be given on a scheduled basis in an attempt to reduce nausea and vomiting (6). If nausea and vomiting are persistent, and nutrition status is compromised as a result, enteral nutrition administered to the small bowel can be initiated. Slow advancements in volume and rate to goal can improve tolerance (10). Alterations in taste can occur during radiation therapy. Even though dysgeusia and ageusia are common, the etiology is unknown. However, it is likely a combination of factors including xerostomia, poor hydration, mucositis and medications. An oral examination to assess for candidiasis and education on proper oral hygiene should be conducted. Techniques to promote proper oral hygiene include rinsing the mouth before meals and incorporating sauces and gravies into meals. Zinc sulfate may also be helpful in expediting return of taste after head and neck irradiation (32). Ensuring adequate oral intake is also beneficial. In addition, fresh fruits and vegetable may taste better than canned or frozen products (6). Fatigue can develop over time with radiation therapy, and it is multifactorial in nature. Treatment-related fatigue has been reported in 78% of patients during the course of their radiation therapy (6). Symptoms include weakness, lethargy, dizziness, sadness, depression, frustration, irritability, decreased appetite and decreased cognitive ability. Management of fatigue includes promoting adequate rest and relaxation, engaging in physical activity, supplementing with vitamins and minerals, and taking medications as prescribed (6-7,9).

26 19 Radiation therapy can compromise oral intake and also prevent adequate absorption of nutrients. Nutrition support may be needed in extreme cases and as previously mentioned, should be considered for all patients undergoing treatment of the head and neck. All of the aforementioned side effects can lead to a compromised nutrition status and malnutrition (25). Weight Loss As previously mentioned, weight loss can occur at any stage of cancer, from the time of diagnosis to the completion of cancer therapy (6). Some of the possible causes of unintentional weight loss in cancer patients are outlined in Table 1. Identifying the reason(s) for weight loss allows for more patient specific nutritional interventions (5,33-34).

27 20 Table 1 Mattox TW. Treatment of Unintentional Weight Loss in Patients with Cancer. Nutrition in Clinical Practice. 2005;20: Potential contributions to unintentional weight loss in cancer patients Nutrition Consequences of malignancy o Obstruction/perforation of GI tract o Intestinal secretory abnormalities o Malabsorption o Intestinal dysmotility o o Fluid/electrolyte abnormalities Anorexia Altered taste Learned food aversion Depression Altered peripheral hormone metabolism Leptin Ghrelin Altered neuropeptide metabolism Melanocortin Neuropeptide Y Nutrition consequences of treatment o Chemotherapy Anorexia Nausea, vomiting Mucositis, enteritis Ileus o o o Surgery Malabsorption, diarrhea Adhesion-induced obstruction Fluid/electrolyte abnormalities Vitamin/mineral abnormalities Radiation Anorexia Altered taste Mucositis, enteritis Xerostomia, dysphagia Obstruction Perforation Stricture Other Opioid-induced constipation GI tract abnormalities associated with Fungal, viral or bacterial infections Altered Metabolism o Tumor-induced changes in energy expenditure o Cory cycling/gluconeogenesis o Nitrogen trap o Altered fat metabolism o Tumor-induced secretions of host mediators Tumor necrosis factor, interleukin-1, interleukin-6, Proteolysis-induced factor(pif)

28 21 Currently, there is no single medication that treats unintentional weight loss. However, there are several medications that have been proven to be effective in the treatment of unintentional weight loss including anticytokine agents, anabolic agents, metabolic inhibitors and appetite stimulants (35). For example, progestational agents, a type of appetite stimulant, have been shown to be effective in promoting weight gain. However, for some patients weight gain will not be possible even with use of a stimulant. In such cases, the goal is to prevent further weight loss (6,34). Initiation of appetite stimulants should be based on the treatment goals of the patient, his/her current medical and nutritional status, and the patient s desire. Megestrol acetate and Medroxyprogesterone are appetite stimulants that are often used among cancer patients (6,10). Patients taking progestational agents have been found to be twice as likely to gain weight when compared to a placebo group. This is promising, as malnutrition and weight loss are common among cancer patients. It should be noted that the risk for adverse side effects with use of appetite stimulants is increased if the agents are taken for less than twelve weeks (34). Aside from the effects of cancer and its associated treatments, some with cancer may have a distorted perception of weight loss during treatment. Weight loss may be viewed as beneficial as the cancer patient may have been unable to lose weight prior to initiation of cancer treatment. Yet, weight loss increases risk of death in those with cancer regardless of body weight before cancer diagnosis (33-34). Those who lose more than 10% of their body weight during cancer treatment have a higher mortality rate (6). Thus, nutrition intervention is warranted in order to promote

29 22 adequate nutrition during treatment and prevent malnutrition (35). Brown and Radke (36) found that even though nutrition assessments were conducted in 97% of patients in their study, only 60% of patients had received nutrition interventions and only 44% of those that received nutrition interventions, received any follow-up assessments (36). Nutrition assessment is the first step in the nutritional treatment of cancer patients, but adequate follow-up is essential to prevent unintentional weight loss and malnutrition. Regardless of the cause(s) of weight loss in cancer patients, the end result is often malnutrition and a poor prognosis. This poor prognosis can largely be attributed to cachexia (33-38). Cancer Cachexia Cachexia is a Greek derivative meaning, bad condition, and is a form of malnutrition as a result of starvation-induced lipid and protein catabolism, which is associated with a high risk of mortality (33-38). Starvation and cachexia are similar but in starvation, adipose stores are depleted and protein stores are spared; neither protein nor adipose is spared in cachexia. Cachexia prevents chemotherapy from being as effective as it otherwise could have been (37). Unfortunately, cancer patients are at risk for cancer cachexia. It has been estimated that 20% of deaths from cancer are caused by cachexia versus the actual malignancy (5). Yet, the prevalence of malnutrition can vary as much as 31-87% among cancer patients, depending on the type and location of cancer, degree of metastasis, and nutrition status at diagnosis (39). Risk factors for cachexia include:

30 23 anorexia, nausea, vomiting, diarrhea, dysgeusia and early satiety. Signs of cachexia include: profound weight loss, muscle weakness, fatigue and anemia (33-38). The best treatment for cancer cachexia is to cure the cancer, but this is not always feasible; therefore, increased nutrient intake is recommended in an attempt to offset weight and nutrient losses (33). As previously mentioned, parenteral and enteral nutrition can promote an increase in nutrient intake. Similar to that of unintentional weight loss, there is no single medication or treatment option that can cure cachexia (33-38). Therefore, appropriate nutritional interventions should occur as long as cachexia is present. Prevention of cachexia is done by promoting optimal nutrition and preventing malnutrition. Studies have found that nutrition intervention can lead to a better response to cancer treatment and may prevent weight loss (40). Nutrition interventions include providing appropriate and timely nutrition education, promoting high calorie, high protein intake, and initiating nutrition support when indicated. All of the aforementioned interventions have been proven to decrease the degree of weight lost (8,33-38). Use of oral supplements and fortified dairy products can assist in meeting nutritional needs (6,9). However, some patients have a heightened sensitivity to sweet foods and do not tolerate such foods well. Unfortunately, oral supplements are often considered sweet to the taste, and may not be tolerated by cancer patients. Incorporating the supplements into recipes, like soups, may circumvent this problem and is a way to increase the caloric content of the food product (6).

31 24 Because cachexia is associated with an increased risk of mortality and it is difficult, if at all possible, to correct once present, it is of the upmost importance to prevent cachexia (34,37-39). Nutrition Support If a patient undergoing cancer treatment cannot achieve adequate nutrition to prevent weight loss by an oral diet alone, nutrition support can be used to help prevent weight loss and improve treatment outcomes. Antoun and Baracos (41) have suggested that enteral nutrition be initiated if oral intake has decreased by the third week of cancer treatment (41). As mentioned previously, enteral nutrition is superior to parental nutrition and should be trialed before initiation of parenteral nutrition (10). As such, enteral nutrition has been shown to improve patient outcomes. For example, early initiation of enteral nutrition for those with head and neck cancer has been shown to reduce morbidity (42). Prophylactic placement of a percutaneous endoscopic gastrostomy (PEG) tube is recommended; however, the push method should be used instead of the pull method (43). The pull method requires the use of an endoscope, which often leads to malignant cells being relocated to the PEG site. The pull method is not without benefits; however, it has been proven to have a lower rate of complications, such as tube clogging, tube leaks and cellulitis. Major complications of the pull method include necrosis, abscess and PEG site metastasis (43-44). The push method does not require an endoscope; rather, an incision is made through the abdominal wall and into the stomach. A guide wire is placed into the

32 25 stomach and the tract is dilated. The feeding tube is placed through the incision and into the stomach. The tube is held in place by a saline or water inflated balloon. The site of malignancy can be bypassed, which decreases the risk of cancer seeding (43). Historically, patients were not fed following a GI surgery. Often, oral diets were not resumed until five to seven days postoperative. Braga et al. (15) conducted a nine-year study on early enteral nutrition. Of the 650 patients fed enteral nutrition postoperative, only 58 needed to be switched from enteral to parenteral nutrition as the majority of the patients favored well on enteral nutrition in part due to the early initation of the enteral feeding. Early enteral nutrition in the postoperative period for upper GI surgeries has been shown to decrease length of stay and healing time (10,15). There has also been evidence to suggest that modulars, nutrients sometimes added to enteral formulas, may have a beneficial effect. One study showed that supplementation with β-hydroxy-β methylbutyrate, arginine and glutamine, promoted weight gain and an increase in fat free mass (22). Such findings are promising as patient outcomes and overall mortality are improved when nutrition status and body weight are optimal. Cancer treatment is complex and can affect nutrition status in many different ways. Early nutrition intervention not only improves treatment outcomes but can also enhance quality of life. Prevention of cancer cachexia may decrease the number of deaths from cancer (33-34). Identification of those at risk for developing malnutrition will allow for improvements in cancer treatment and its outcomes (3-4,38-39).

33 26 Nutrition Screening Nutrition screening of cancer patients can help identify those at risk for cachexia and malnutrition. Multiple screening tools have been used to identify those at risk for such complications (47-49). Screening parameters can include, but are not limited to, weight changes, dietary habits, type of cancer, location and stage of cancer, activities of daily living and side effects related to cancer treatment (46-47). Optional nutrition is necessary to prevent malnutrition in cancer patients. For example, nutrition intervention has proven beneficial for patients receiving radiation therapy for gastrointestinal and head and neck cancers (45). The amount of weight lost during treatment is strongly correlated with deterioration of nutrition status. Consequently, it has been recommended that close supervision of patients at risk for malnutrition should be routine practice. If inadequate staffing is a barrier, a referral system for high-risk patients should be implemented (45-46). Nutrition screening of cancer patients has been proven to be an effective way to identify high-risk patients. The Subjective Global Assessment (SGA) (see Appendix) is one of the screening tools available. Previous studies have validated its use in the cancer population (47-48). The SGA addresses weight history, presence of symptoms, food intake, and functional capacity. Patients are assigned as well nourished (SGA-A), moderately nourished or suspected malnourished (SGA-B), or severely malnourished (SGA-C) (48). Improved cancer survival rates have been found in those classified as SGA-A versus SGA-C (48-49). Patients classified in the SGA-B and SGA-C categories are not that uncommon. For example, in a study conducted by Gupta et al.

34 27 (49), 50% of patients were classified as SGA-A, 26.5% were classified as SGA-B and 23.5% were classified as SGA-C. These findings indicate moderate to severe malnutrition could be present in up half of all cancer patients (49). Gupta et al. (49) also found that the SGA score correlated to the survival rate of ovarian cancer patients. The SGA-A, or well nourished group, had a mean survival of 43.5 months compared to the SGA-B group that had a mean survival rate of 18.9 months and SGA-C group that had a mean survival rate of 6.7 months. The lower survival rate among the SGA-B and SGA-C groups could in part be attributed to malnutrition. Thus, the SGA is effective at identifying the nutrition status of some cancer patients and therefore, can be used as a routine screening tool in order to identify those at risk for malnutrition, which often have poor patient outcomes (49).

35 28 CHAPTER II STUDY METHODS, DESIGN, AND RESULTS Introduction Cancer is diagnosed in 1.2 million Americans annually and is the second leading cause of death in the United States, second only to cardiovascular disease. Cancer causes one in four deaths nationwide. Even though deaths attributed to cardiovascular disease have decreased over the last 50 years, deaths from cancer have remained constant. Lung cancer has the highest mortality rate among all cancers in men and women. In men, the second leading cause of cancer death is prostate followed by colon. In women, the second leading cause of cancer death is breast followed by colon (1,2). Cancer is defined as uncontrolled cellular proliferation. There are external and internal factors that can lead to cancer. External factors include: environmental exposures, tobacco use and radiation. Internal factors include: hormones, immunosuppression, genetics, and mutations of metabolism (2). If the cancer is detected early, prognosis is generally good and the need for cancer treatment is minimized. However, cancer is often detected at more advanced stages where cancer treatment may be needed to help induce remission. The five-year survival rate of patients with all types of cancer, irrespective of the treatment modality, is 65% (3). Treatment options for patients with cancer include surgery, radiation, chemotherapy, and immunotherapy. These therapies can be used alone or in combination. Treatment options depend on the location, size, stage and type of cancer. All cancer treatment

36 29 options carry nutrition risk and may lead to malnutrition and poor patient outcomes over time. To complicate matters, malnutrition can then lead to decreased treatment effectiveness. For example, inadequate nutrient intake during treatment can cause chemotherapy and radiation to be less effective (4-7). Thus, it is critical to identify cancer patients at risk for malnutrition in order to improve patient outcomes. Prevention of malnutrition is easier than treating cancer cachexia. The objectives of this study were to assess the current nutrition referral system for cancer patients at McKay-Dee Hospital Center, identify cancer patients at risk for malnutrition using the subjective global assessment (SGA) and discuss ways to improve outcomes related to malnutrition. Current Practices at McKay-Dee Hospital Center Currently, patients at McKay-Dee Hospital Center in Ogden, Utah are not screened using a validated screening tool. In the outpatient setting, a registered dietitian upon physician referral provides nutrition assessment and interventions. Physician referral is variable depending on the physician and there is no set criteria used to determine which patient is at risk of malnutrition.furthermore, the referral often occurs after the patient has already experienced a significant decline in nutrition status and may be too late to prevent malnutrition and/or cachexia from occurring. In addition, it is likely that some patients who are at risk for malnutrition may never be referred to a registered dietitian. In such cases, it is reasonable to assume that their nutrition status will continue to be poor or perhaps worsen, leading to poor patient outcomes. In some cases, malnourished patients are admitted for nutrition treatment

37 30 in the inpatient setting but at this point, their overall decline in nutrition status is too great to correct and/or overcome and the end result is often death. Patients admitted to McKay-Dee Hospital Center are screened based on percent body weight, diagnosis, serum albumin and the diet order within the first 24 hours of admission. Patients are assigned as a level one, two or three. These levels correlate to the likelihood of the patient being malnourished, at risk for malnutrition or nutritionally compromised. The registered dietitian will assess a level three patient within 48 hours, a level two patient within 72 hours and a level one patient within 5 days of admit. Cancer patients are automatically screened as a level two meaning that they would be assessed by a registered dietitian within 72 hours of admission. Unfortunately, many patients are not hospitalized for 72 hours, and as such, they would not be assessed by the dietitian and receive appropriate nutritional intervention. Thus, it is likely that in some cases, unintentional weight loss and malnutrition will remain undetected. Because of the average length of stay in the inpatient setting and the likelihood that the registered dietitian was not able to treat the cancer patient as a result, nutrition intervention must take place in the outpatient setting before malnutrition is present. Because of the current referral system in the outpatient setting at McKay-Dee Hospital Center, a screening tool must be used to identify those at risk for malnutrition. Subjective Global Assessment and Monitoring

38 31 The SGA is an appropriate screening tool used to identify malnutrition and would help increase the overall number of nutrition assessments and interventions given to cancer patients (48-49). Furthermore, patients that are deemed malnourished receive more frequent follow-up from a registered dietitian because of the high mortality rate associated with cancer cachexia (50). Follow-up guidelines for those cancer patients classified as malnourished are as follows: patients in the inpatient setting are monitored daily to every other day, and patients in the outpatient setting are considered more nutritionally stable and can be monitored twice weekly. Both inand outpatient assessments include collecting anthropometric, biochemical and clinical data such as: body weights, laboratory testing, signs of dehydrations, and presence of gastrointestinal symptoms. Nutrition intervention is aimed at reducing or eliminating such symptoms in an attempt to prevent the occurrence of malnutrition. Education about what nutrition changes can be made to help alleviate side effects of cancer should be given (see Appendix). For example, a patient that has a decreased appetite is encouraged to consume small meals throughout the day and increase his/her protein intake. Verbal and written nutrition information is given to the patient along with the contact information of the dietitian should questions arise (48-50). Regardless of the nutrition interventions and protocol currently practiced at McKay-Dee Hospital Center, it is possible that cancer patients at risk for malnutrition are not currently being identified and are consequently not receiving proper nutrition intervention. Thus, this study was designed to determine the prevalence of malnutrition in this population and discus how to improve nutritional services in the

39 32 future. Methods This study took place at McKay-Dee Hospital Center, Ogden, Utah, in collaboration with Utah State University, Logan. Patients (n=56) receiving treatment for cancer at the Huntsman-Intermountain and Northern Utah Hematology and Oncology Clinics were screened using the Subjective Global Assessment (SGA) to identify risk for malnutrition. The lead Medical Oncology Dietitian on staff at McKay-Dee Hospital Center, conducted all SGAs at the cancer clinics. For the purposes and scope of this study, the SGA was performed as cancer treatment was first initiated (initial screening) only. Previous studies have validated the SGA as a screening tool (48-49). The population studied was thought to have received no nutrition interventions in regards to cancer in the past. Data was collected based on the SGA and no patient identification data was collected. All patients were categorized as SGA-A, SGA-B, or SGA-C based on the degree of malnutrition. Prior to initiation of this study, Institution Review Board approval was obtained. Although, actual nutrition intervention was beyond the scope of this study, patients (n=15) identified at high or moderate risk for malnutrition received follow-up consultations weekly to twice weekly, in an attempt to improve patient outcomes. Further research could include completing an SGA during the course of treatment to quantify the rate of malnutrition during treatment. The focus of this study was to identify those at risk for developing malnutrition before cancer treatment.