importance of nutrition in the oncology setting€¦ · cancer nutrition therapy importance of...

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Cancer Nutrition Therapy

Importance of Nutrition in the Oncology Setting

North Carolina Dietetic Association

Greensboro, North Carolina

May 15, 2015

Anne Coble Voss, PhD, RDN, LD

Associate Research Fellow

Abbott Nutrition Global Research & Development

2



Presentation Objectives

1. Identify the impact of the tumor and anti-cancer treatments

on nutrition status in the adult oncology patient

2. Determine the effect of lean body mass (LBM) loss on

treatment outcomes in the adult oncology patient

3. Recognize national/international guidelines and

recommendations for the adult oncology patient

.

3



MALNUTRITION

4



Historic definitions of malnutrition

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

marasmus • kwashiorkor • protein-energy undernutrition

5



MALNUTRITION

“Malnutrition is an independent cause of poor outcomes

and is detected under different conditions. Malnutrition

caused by famine is observed during natural disasters or

political strife and can be successfully prevented and

managed by increasing access to a balanced diet.

Hospital-acquired malnutrition, on the other hand is

universally present.”1

Ochoa Gautier J. JPEN J Parenteral Ent Nutr 2015.

• Superficial similarities between malnutrition caused

by the different conditions such as famine and cancer

associated malnutrition and weight loss

• Tempts clinicians to jump into proposing overly

simplified solutions

• Malnutrition for different conditions require different

solutions

6



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

7



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. Nutrition support in patietns with cancer. 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 diagnosis

for cancer patients is malnutrition4

http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page1

8



• Severe wasting accounts for 30-50%

of deaths in patients with GI cancer1

• In a classic paper by Dewys 1980

malnutrition ranged from 31% to 87%2

• Recent paper by Hebuterne 2014

40% of hospitalized oncology patients

were malnourished3

Malnutrition and Weight Loss

1. Bachmann J Bastro Surg 2008; 2. Dewys Am J Med 1980; 3. Hebuterne JPEN 2014; 4. Butterworth Today’s Dietitian 1974

This concept is similar to hospital malnutrition

and “The Skeleton in the Hospital Closet” 4

9



• 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 Patient Generated

–Subjective Global Assessment

(PG-SGA)5

• 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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• 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


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

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• Pancreatic surgery patients

• 88% medium-severe nutrition risk by

Nutrition Risk Index (NRI)

• 83% medium to high risk by

Malnutrition Universal Screening Tool

(MUST)1

• 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


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

12



Fre

qu

en

cy

Fre

qu

en

cy

Body mass index (kg/m2)

Malnutrition and BMI Distribution

Images: Gallagher D, DeLegge M, JPEN 2011

BMI <18.5

kg/m2

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• Nutrition screening for oncology patients

improves outcomes1,2 • Screening Tools should be quick, easy to

use, valid and reliable

• Out Patient/Ambulatory Setting:

• Malnutrition Screening Tool (MST)

• Patient Generated Subjective Global

Assessment (PGSGA)

• In Patient Setting

• MST

• PGSGA

• Malnutrition Universal Screening Tool

(MUST)

• Malnutrition Screening Tool for

Cancer (MSTC)

Screening for Risk of Malnutrition in Oncology

1. Thompson KL, Elliott L, Fuchs V, Levin R, Voss AC, Ziegler P, Wolfram T, Piemonte T. Nutrition care improves outcomes for adult oncology patients: an evidence-based review. J Acad Nutr Diet 2015 (in press). 2. Academy Nutrition and Dietetics Evidence Analysis Library http://andevidencelibrary.com/topic.cfm?format_tables=0&cat=5067. Accessed March 28, 2015.

http://andevidencelibrary.com/topic.cfm?format_tables=0&cat=5067

14



Team Approach to Patient Care Improves Outcomes

“Thousands of patients are annually starved in the

midst of plenty from want of attention to the ways

which make it possible for them to take food” Florence Nightingale 1859

Using MST over 2 months, 47% of patients were identified at nutrition

risk. Routine screening with RNs and RDs working together promoted:

1. Earlier detection of a patient’s malnutrition risk

2. Improved communication and collaboration between dietitians and

nurses

3. Prioritization of patients requiring further nutritional assessment

Fierini D, et al. Dietitians and nurses working together to assess malnutrition in oncology

patients. Asia-Pac J Clin Onc 2014;10:222

15



Causes of Malnutrition in Cancer Patients

• Decreased dietary intake

• Increased nutrient requirements

• Impaired nutrient digestion / absorption

• Increased losses of nutrients

16



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.

* *

17



Cancer Patients Often Experience 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

malnourished

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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

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

21



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

Lean Body Mass (LBM) or Fat Free Mass (FFM)

– All tissue that is not adipose or fat (including bone)

23



Definitions

• Weight loss and malnutrition in oncology patients:

• Clinical Consequences:

• Weight loss

• Loss of muscle mass

• Inflammation

• Decreased performance status

Cancer Cachexia Defined:

“a multifactorial syndrome characterized by an ongoing

loss of skeletal muscle mass (with or without loss of

fat mass) that cannot be fully reversed by

conventional nutritional support and leads to

progressive functional impairment.”1

Fearon, et al. Lancet Oncology 2011

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Definitions

• Weight loss and malnutrition in oncology patients:

• Clinical Consequences:

• Weight loss

Fearon, et al. Lancet Oncology 2011

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Disease, Age, Inactivity Increase Loss of Muscle

Healthy Older Adults

(67 years of age) 10 Days’

Inactivity3

Healthy Young (26-46 years of age)

28 Days’ Inactivity2

Lo

ss

of

Le

an

Le

g M

as

s (

lbs

) all

measure

ments

re

pre

sent le

g loss

Elderly Inpatients

(≥65 years of age)

3 Days’

Hospitalization4

–2.0

–1.5

–1.0

0

–2.5

–0.5

1. Yancik R. Cancer J 2005;11:437-441. 2. Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004. 3. Kortebein P, et al. JAMA. 2007 4.. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH.

Approx

2.2 lbs

Approx

1.0 lb

56% of new cancers occur in people > 65 years1

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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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.

Sarcopenia: loss of muscle mass and

function usually associated with normal aging

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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.

29



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.

29

One study found that 79% of patients identified as

malnourished were normal weight, overweight, or obese.1

BMI

LBM

Cachectic

17

Equal

Normal

25

Equal

Obese

38

Equal

30



c1 c2 c3

Variation in fat and muscle within body mass index

BMI = 30.0 kg/m2

31



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=0.023

• Capecitabine Tx of metastatic breast cancer2

– Low LBM is determinant of CT toxicity

and time to progression

1. Prado, et al. Cancer Chemother Pharmacol 2011;67:93-101

2. 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

34



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

35



Loss Of Lean Body Mass Can Seriously Impact Patient Outcomes

10% Loss

20% Loss

30% Loss

40% Loss

% loss of total

lean body mass Associated complications

Impaired immunity

(infections)

Decreased healing,

weakness, infections

Too weak to sit,

wounds (such as

pressure ulcers),

pneumonia, no healing

Death (usually from

pneumonia)

Associated

Mortality

(%)

10

30

50

100

36



Quiz # 2

37



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

38



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

39



Patient-centered outcomes

40



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

41



Pharmacological Interventions for Cancer Induced Weight Loss

• Altered response in cancer

– Ghrelin: hormone from stomach and intestines signal the brain for satiety or hunger

– Leptin: peptide released by adipocytes (fat cells) to signal nutrient deficiency and increase appetite

• Megace®

– Claim is to stimulate appetite; increase in weight is fat and water retention

– Side effects

• Impotence

• Deep vein thrombosis

• Ghrelin analogue – Anamorelin by Helsinn

• Selective Androgen Receptor Modulator – enobosarm (Ostarine®) by GTX

• Novartis

43



Nutrition Intervention Improves Outcomes in Cancer Induced Weight Loss

• 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 Oral Nutrition Supplements improve2

– Body weight and LBM

– Hand grip strength

– Physical activity3

– Performance status

– Dietary intake

1%

30%

20%

3%

10%

6%

30%

Stage

Location

Intake

Weight loss

Duration

Chemotherapy

Surgery

1. Ravasco P, et al. Supp Care Cancer 2004;12:246-2521

2. Von Meyenfeldt M, et al. Am Soc Clin Onc 2002

3. Moses A, et al. Br J Cancer 2004;90:996-1002

44



Nutrition Intervention Can Help Improve Quality of Life: Meta-Analysis

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

45



Weight Loss is Associated with Worse Outcomes

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

46



SURVIVAL AND NUTRITION

47



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

48



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

49



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

50



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

52



NUTRITION INTERVENTIONS

53



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.

54



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.

55



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

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

Results

Control Group Treatment Group

(Nutrition Pathway)

P Value

Patients receiving enteral nutrition 33% 54% 0.05

Weight change during treatment (%) -8.9 ± 5.9% -4.2 ± 6.4% 0.003

Patients who had a chemotherapy

dose reduction (%) 42% (n=10) 29% (n=7) 0.34

Patients who completed radiation (%) 50% (n=12) 92% (n=22) 0.001

Patients who experienced radiation

therapy breaks (for those who

completed treatment)

33% 27% 0.71

Patients who had an unplanned

hospital admission (%) 75% (n=18) 46% (n=11) 0.04

Total length of stay for all unplanned

hospital admissions (days) 13.5 ± 14.1 days 3.2 ± 5.4 days 0.002

56



Using St. Vincent numbers in Odelli’s study

57



EXPERT GUIDELINES

58



Society Guidelines Support Proactive Nutrition Intervention

Academy of Nutrition and Dietetics Adult Guideline states All patients

should be screened for malnutrition risk on entry into oncology services. Early

identification and management of malnutrition risk leads to improved outcomes.

Re-screening should be repeated routinely throughout treatment to facilitate

referral as needed. Imperative recommendation 2015 Academy Nutrition and Dietetics Evidence analysis Library

http://andevidencelibrary.com/topic.cfm?format_tables=0&cat=5067

:

The American College of Surgeons Commission on Cancer 2012 Program Standards indicate an optimal cancer program encompasses nutrition services, including screening and education across the cancer

continuum American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered

Care. Chicago, IL: American College of Surgeons; 2011

“The Association of Community Cancer Centers 2012 Cancer Program

Guidelines recommend nutrition screening to identify patients at nutrition risk,

patient-specific nutrition assessment, and intervention and education through

the cancer treatment process.”

The Association of Community Cancer Centers Cancer Nutrition Services: A Practical Guide for Cancer Programs, 2012.

http://andevidence/

61



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

63



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

.

64



THANK YOU!

QUESTIONS?

importance of nutrition in the oncology setting€¦ · cancer nutrition therapy importance of...

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