Download Nutrition and upper GI cancers - G-Care

GP Masterclass May 11th 2015
Fiona Brown. Cancer Care Specialist Dietitian.
Nutrition and upper GI cancers
Aim
• To identify nutritional issues which can be dealt with in primary care and when to refer a patient
into the Dietetic service
Objectives
• Nutritional challenges for patients and implications
• Intervention
• Dietetic roles and intervention
General Overview of Malnutrition in UK
Greater use of healthcare and costs associated with malnutrition means: (Mind the hunger Gap 2012)
• 65% more GP visits; 82% more hospital admissions; 30% longer hospital stay.
Costs
Saving opportunities
•
Malnourished patients visiting their GP
 Screening and early intervention could result in
incur an additional health care cost of
a net saving of £71,800 per 100,000 of the
£1449 per patient in the year following
population (National Institute for Health &
diagnosis (Guest et al, 2011;
Care Excellence, 2012).
Malnutrition Task Force, 2013).
 Regular screening and monitoring all people in
The estimated costs of malnutrition in the UK
care homes has been shown to cost half that
range from :
of treating those who are malnourished
• £5bn for direct health care costs (Guest
(Meijers et al, 2011).
et al, 2011: Malnutrition Task Force,
 Appropriate use of Oral Nutritional
2013)
Supplements (ONS) in hospitals has been
• To £13bn for associated health and social
found to save £849 per patient based on
care expenditure in 2007
length of stay and reduce GP attendances (Elia
(Elia & Russell for BAPEN, 2009)
& Stratton, 2009).
Malnutrition prevalence for upper GI cancers
• Lung, oesophageal, stomach, pancreatic, colonic, rectal and head and neck cancers carry the
greatest presentation of weight loss/nutritional challenges (Capra 2001)
• upper GI cancer patients malnourished = 52% (Segura et al, 2005)
Screening of nutritional status in 1000 patients (mixed diagnoses) Nutritional risk highest in upper GI
cancer patients. Oesophageal cancer patients mean weight loss 16.3 % (16 to 40%). Over half had
lost 10% of their weight. Where anorexia is a symptom then the risk of weight loss is higher. When
weight loss was more than 10% anorexia occurred in 50% of patients (Bozzetti et al, 2010)
Percentages patients severe malnutrition at cancer site were Oesophagus 62.5% Stomach 43.7%
Pancreas 54.3% (Bozzetti et al, 2012)
Significance of Malnutrition
•
Poor prognosis
• Problems related to nutrition have been
•
Reduced response to anticancer therapy
identified as the most important factor
•
Increased side effects of treatment
in affecting a sense of wellbeing…’
•
Weakness, fatigue
(Padilla et al 1983)
•
Reduced quality of life
• ‘Short term nutritional support can
•
Increased mortality rate
improve well being and quality of life.’
•
Increased hospital stay
(Holmes and Dickerson 1991)
•
Treatment may have to be delayed or stopped
(De Wys 1980, Andreyev 1998, Marin 2007, Holmes 1996), Nayel 1992, Isering 2004, Bauer 2005,
Odelli 2005, Braunschweig 2000, Pressoir 2010)
Aims of Nutritional Treatments
 Preventing and treating undernutrition
 Enhancing anti-tumour treatment effects
 Reducing adverse effects of anti-tumour therapies
 Improving quality of life.
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GP Masterclass May 11th 2015
Fiona Brown. Cancer Care Specialist Dietitian.
Nutrition intervention needs to be;
Timely (early), Appropriate, Include suitable monitoring and recognised that some patients will
require specialist intervention and support perhaps using artificial tube feeding ?parenteral feeding
Pathways
Rehabilitation throughout the treatment pathway delivered by Allied Health Professionals is
recognised by NICE,NCAT,Macmillan etc. at;
•
Pre diagnosis
• Pre diagnosis
•
Diagnosis and care-planning
• Assessment and Diagnosis
•
Treatment
• Treatment (pre/post XRT, chemo, surgery)
•
Post Treatment
• Survivorship
•
Monitoring and Survivorship
(AHP Cancer care toolkit. A guide for
•
Palliative Care
Healthcare Commissioners)
•
End of Life
(NCAT Rehabilitation Care Pathway 2009)
NICE guidance suggests a screening tool should be based on:
• Measurement of weight and weight history
• Has there been a normal and varied diet in the last few weeks?
• Unintentional weight loss?
• Any swallowing problems?
• Metabolic stress eg. Wound healing
• Excessive losses eg. vomiting, diarrhoea
• Global assessment eg. Any signs of loose fitting clothes/watch
• Can patient meet their requirements with voluntary choice from the food available
• Acknowledging that those with High BMI are at risk of malnutrition.
• Example of screening tool – MUST
(National Collaborating Centre for Acute Care, 2006)
Local Pathway
Prescribing Sip feeds in Adults (2013) GHNHSFT in conjunction this Gloucestershire Clinical
Commissioning Group – available on-line at Gloucestershire ‘CCG Live’ intranet in the section:
Clinical support/medicines management/prescribing guidance.
This pathway is based on regular monitoring and assessment;
1. Nutritional Screening (MUST) including percentage weight loss
2. Assessing and investigating any underlying causes/barriers to patient maintaining good
nutritional status. E.g. underlying medical cause, disease states with nutritional implications, Oral
health/swallowing problems, altered taste and smell, reduced mobility, poor positioning, social
situation, psychological wellbeing, poly-pharmacy. Refer directly to Dietitians if required
3. ‘Food First Approach’=first line dietary advice to use; small frequent meal, increase milk intake if
possible and fortify/enrich milk and other foods.
4. Agree and Document goals of treatment
5. Prescribing Oral Nutritional sip feeds. Fresubin powder initially then 1.5kcal/ml ready to drink
feeds dependant on preference.
6. Refer to other service e.g. Dietitians
Role of Dietitians
• Nutritional assessment
• Dietary counselling
• Advise on specific diets in line with underlying diagnosis(s) and treatment(s)
• Experts on Prescribed/non-prescribed nutritional supplements, enteral and
parenteral feeds
• Deliver nutritional care in line with treatment side effects including gastric
paresis, alterations in digestion, malabsorption of nutrients/bile acids,
hyperglycaemia, fluid and electrolyte imbalance, dumping syndrome, and
vitamin and mineral deficiencies etc.
• Provide advice and support with alternative or complementary diets
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GP Masterclass May 11th 2015
Fiona Brown. Cancer Care Specialist Dietitian.
Benefits of Rehabilitation throughout the pathway
(NCAT (2013) Cancer Rehabilitation, making excellent cancer care possible )
Evidence based information for patients available at:
British Dietetic Association
Food fact sheets (online) https://www.bda.uk.com/foodfacts/MalnutritionFactSheet
Macmillan
Nutritional support (enteral tube feeds) http://www.macmillan.org.uk/information-andsupport/coping/side-effects-and-symptoms/eating-problems/types-of-nutritional-support.html
Eating problems http://www.macmillan.org.uk/information-and-support/coping/side-effects-andsymptoms/eating-problems
Build up diet http://be.macmillan.org.uk/be/p-20052-the-building-up-diet.aspx
Healthy eating http://www.macmillan.org.uk/information-and-support/coping/maintaining-ahealthy-lifestyle/healthy-eating
Recipe booklet – contact Macmillan by phone
Cancer research
Managing Diet http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/copingphysically/diet/managing/
Oesophageal Patients association
On-line talks on nutrition http://www.opa.org.uk/resources.html
Pancreatic cancer UK
Has on-line details and support on diet at varying stages of the treatment pathway
http://www.pancreaticcancer.org.uk/information-and-support/managing-dietary-symptoms/
Please make any Dietetic referrals to:
The Nutrition and Dietetic Dept,
Cheltenham General Hospital
GHNHSFT Tel: 0300422 3460
The Nutrition and Dietetic Dept,
Beacon House
Gloucestershire Royal Hospital
GHNHSFT Tel: 0300422 5506
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GP Masterclass May 11th 2015
Fiona Brown. Cancer Care Specialist Dietitian.
References and Bibliography
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Macmillan (2010) Grimes C. Guidance for the Nutritional Management of Cancer Patients
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