Download Nutrition and the Oncology patient

Oncology Programme for Nurses
Nutrition and the Oncology patient
Arún Fenton MINDI
28th February 2012
[email protected]
Overview of presentation
Cancer Cachexia
An International consensus
Identification of
Pre‐cachexia and cachexia
Weight
Interpretation, % loss, BMI
Nutrition support
Cancer Cachexia
• Profound wasting syndrome characterised by severe weight loss, fatigue, anorexia due to tumour‐related metabolic changes
• It is estimated that 20% of patients with cancer die from effects of malnutrition rather than direct effects of neoplastic disease
Definition and Classification of Cancer Cachexia
An international Consensus
Fearon et al. 2011
Malnutrition Screening Tool
MST
Ferguson et al. 1999
1.
Have you lost weight recently without trying?
No Unsure
2.
3.
If yes, how much weight in kilos have you lost?
1‐5
6‐10
11‐15
greater than 15
unsure
0
2
1
2
3
4
2
Have you been eating poorly because of decreased appetite?
No
Yes
Score of 2 or more and patient is at risk of malnutrition
0
2
% Weight Loss
% weight loss = previous weight – current weight x 100
previous weight Significant weight loss Severe weight loss One week
Less than 1‐2 %
> 2 %
One month
5 %
> 5 %
3 months
7.5 %
> 7.5 %
6 months
10 %
> 10 %
Blackburn et al. Weight interpretation Ascites
Peripheral oedema
Mild
2.2 Kgs
1 Kgs
Moderate
6 Kgs
5 Kgs
Severe
14 Kgs
10 Kgs
Weight
? Has patient oedema
? Has patient ascites
? Was the patient an inpatient recently; maybe he or she has actually gained weight since discharge?
? Was last weight checked on different scales
? With or without outdoor shoes, coats etc. ? What is the pattern of weight loss, consistent gradual weight loss vs dramatic weight loss
• Sarcopenic obesity
• Weight loss can be very upsetting
• Mealtimes can be a cause of family conflict etc. • Redefining goals; rate of weight loss
Cancer‐induced Weight Loss v. Other Types of Weight Loss
Body weight
Lean body mass
Body fat
Caloric intake
Resting Energy Expenditiure (REE)
Protein degradation
Cancer‐
induced
Caloric Deficiency
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Thought to be due to acute phase response and pro-inflammatory cytokines
which induce Proteolysis Inducing Factor (PIF) and Lipid Mobilising Factor
BMI
Outcomes of Cancer‐induced Weight Loss
Weight loss of >10% will affect outcomes, including:
•Reduced functional status
•Reduced response to therapy
•Greater hospital length of stay
•Increased risk of complications / infections
•Decreased quality of life
Rate of Weight Loss
Associated with Cancer
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Pancreatic
Oesophageal Gastric
Head and neck
Colorectal
72%
69%
67%
57%
34%
Based on a study of 1555 patients attending a GI oncology service in UK, all were receiving chemotherapy
Andreyev et al. (1998) Eur J Cancer
Rationale for Nutrition Support
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Increased muscle strength and improved mobility
Decreased rate of infection
Reduced risk of pressure sores
Improved wound healing
Reduced length of hospital stay
Improved quality of life
Improved response to antineoplastic treatment
Which patients to refer to Clinical Nutriton?
• Patients experiencing weight loss or reduced appetite or reduced intake
• Patients with dysphagia or oesophageal stents or oesophageal dilatations
• Patients on chemotherapy with gastrointestinal side effects, e.g. nausea, altered taste, sore mouth, • Patients with short bowel or high output stoma (>1500ml/day)
• Patients with steroid‐induced diabetes
• Patients requiring dietary advice for weight reduction
• Patients that are not taking adequate diet or NPO and require nutrition support (enteral or parenteral nutrition)
• Patients with malabsorption, e.g. post‐gastrectomy or pancreatic cancer, (steatorrhoea; are stools pale, difficult to flush or greasy?
• Etc....
Aims of Nutrition Support
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To achieve and maintain desirable body weight
To prevent or improve nutritional deficiencies
To enhance wellbeing and quality of life
To prevent or minimise side‐effects of antineoplastic treatment
Implementation of a
nutrition care plan
• Albumin
Is not a good indicator of nutritional status
• Milk
does not cause diarrhoea
is not constipating
does not cause mucous production
• Sugar
Does not ‘feed’ the cancer cells
• Oral nutritional supplements or enteral feeds
recent taste improvements
generally do not cause diarrhoea, Side Effects of Chemotherapy
Impact on Nutrition
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Nausea and vomiting
Mucositis
Diarrhoea and constipation
Anorexia
Taste changes, dry mouth
Ileus and malabsorption
Nephro‐ and hepatotoxicity
Side Effects of Radiotherapy
Impact on Nutrition
Dependent on site of radiation
• Odynophagia
• Dysphagia
• Xerostomia
• Taste changes
• Mucositis, oesophagitis, enteritis
• Diarrhoea and malabsorption
• Nausea and vomiting
Causes of Malnutrition
Reduced Intake
• Mechanical obstruction of ingestion
 Tumour obstruction of GI tract
 External impingement on GI tract
• Treatment‐induced side effects
• Psychological issues
Metabolic alterations • Due to metabolic abnormalities initiated by the tumour itself, e.g. proinflammatory cytokines, proteolysis‐inducing factor, lipid mobilising factor
• Complex pathophysiology with net result of weight loss
Side Effects of Surgery
Impact on Nutrition
• Problems with ingestion, e.g. post‐surgery for tumours of head and neck, oesophagus, stomach
• Maldigestion and malabsorption, e.g. post‐
small bowel resection, prolonged ileus
• Prolonged fasting associated with surgical procedures
Dietary Advice
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Suitable consistency
Appropriate food choices & quantity
Nourishing drinks & snacks
Meal frequency
Symptom Control
Nutritional adequacy
Oral Nutritional Supplements
• Sip Feeds Milk‐based, juice‐based, yoghurt‐style
Suitable for specific conditions, e.g. DM, renal
Nutritionally complete v. non‐nutritionally complete
• Energy & Protein Supplements
Calogen, Maxijul, Maxipro, Procal, Polycal
Enteral Nutrition
• Routes: NG, NJ, PEG, RIG, Jejunostomy
• Required where adequate oral intake is not possible, e.g. post‐operative, mechanical problems with ingestion
• Home enteral nutrition is a safe and effective means of providing nutrition in the community to those patients who cannot achieve adequate oral intake and would otherwise require a prolonged stay in hospital
Contraindications to Enteral Feeding
• Malfunctioning Gastrointestinal Tract
– Insufficient absorptive capacity (Short Bowel Syndrome)
– Mechanical obstruction of GIT
– Prolonged ileus
– Severe diarrhoea
– Severe vomiting
– Severe enterocolitis
– High output GI fistula (>500ml / day)
Indications for Home Parenteral Nutrition
“Home parenteral nutrition support should be used in patients who cannot meet their nutritional requirement by enteral intake, and who are able to receive therapy outside an acute care setting”
ESPEN 2009
HPN Database Ireland
NSIG 2006‐2011
Case Study Intestinal Failure
Case Study; Intestinal Failure • 55 Yr female, lives with husband and 2 adult children
• Primary peritoneal cancer diagnosed in September 2010 and commenced chemotherapy
• History of connective tissue disorder resulting in oesophageal stricturing
frequent dilatation necessary
• November 2010 admitted to oncology with
– high output ileostomy, up to 3000mls/day, – severe (20 %) weight loss over 3 months, – Intestinal failure; short bowel syndrome. • December 2010 discharged on HPN
Case Study ‐ Intestinal Failure • History of connective tissue disorder resulting in oesophageal stricturing
frequent dilatation necessary
• November 2010 admitted to oncology with
– high output ileostomy, up to 3000mls/day, – severe (20 %) weight loss over 3 months, – Intestinal failure; short bowel syndrome. • December 2010 discharged on HPN
Case Study ‐ Intestinal Failure Line used for HPN PICC
Indication HPN
High output stoma, weight loss
Stoma
550mls (min)
1930mls (mean)
3300mls (max)
High risk of obstruction; low dose antimotility agents, octreotide. oral rehydration solutions were unsuccessful
420 days to date
Intestinal failure medications
HPN episode duration
Case Study –Weight History
Date
Weight (Kg)
BMI (KgM‐2) Comment
Usual Weight
52‐53 18.2
Known to service (OPD) HPHC mod consistency diet
9/8/10
57.3 (?fluid)
? < 18
On admission
22/10/10
45 15.6
On discharge (post GI surgery x 2)
12/11/10
43.1
14.9
Admitted oncology commenced TPN
31/12/10 47
16.3
HPN 7 days /wk on d/c
March 2011
49‐50
17.1
on HPN 7 days/wk
July 2011
50‐52
17.6
on HPN 7 days/wk
August 2011
52‐53
18.2
HPN reduced to alternate days
Quality of Life and HPN
Heterogeneous group of patients receive HPN
QOL is difficult to define
Literature is difficult to interpret
QOL in most studies made solely by clinicians
Cozzaglio et al. (1997) and Bozzetti et al. (2002) improved or stabilised QOL for patients surviving longer than 3 months
• Effects of the underlying disease v HPN • Only the individual living the life can assess the quality
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