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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 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 • • • • • 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 • • • • • • • 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 • • • • 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 • • • • • • • 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 • • • • • • 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 • • • • •