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Percentage of lung patients
Dual Modality Lung Nutrition Study
Orphanidou C, MSc, RD; Cosby C, MSc, RD; Brockman R, BSc, RD; Fimrite A, BSc, RD;
1
Levy-Milne R, PhD, RD, BC Cancer Agency Dietitians
Introduction
Lung cancer is one of the most prevalent types of cancer and
is associated with the greatest mortality for both men and
women. In recent years, there has been an increase in lung
patients receiving aggressive, curative treatment using
concurrent chemotherapy and radiation (dual modality),
placing these patients at high nutritional risk. Prior to
August 2006 dual modality lung cancer patients were
referred to a dietitian if they were identified to be at high
risk for malnutrition due to the severity of nutrition-related
symptoms. This process may have led to some patients
"falling through the cracks.” In phase 1 of this research, a
retrospective study was conducted during which 98 charts of
lung cancer patients who received dual modality treatment
were reviewed to examine past Oncology Nutrition care
practice and how patients fared via evaluation of a series of
outcome parameters. From August 2006-October 2006,
phase 2 of the study was conducted during which 35 dual
modality lung cancer patients were routinely referred to
Oncology Nutrition for intensive nutrition intervention. As
well as data that was collected in phase 1, phase 2 also
evaluated the effect of proactive Oncology Nutrition
intervention on outcome parameters.
Project Purpose
Cancer Agency, Vancouver, B.C.
Results- Phase 1
Retrospective Study
Of the 98 patient in phase 1:
• 98% were on the LUPE protocol,
• 83% on ECIS
• 68% were on 4 chemotherapy cycles
• 59% had 5-6 weeks of radiation,
• 30% had 3-4 weeks of radiation
After 4 weeks on treatment (n=46) (Figure 1R);
• 46% (21/46) had 2% or more weight loss with 30.4%
(14/46) having 2% or more weight gain from
baseline.
Number of times patients saw a
dietitian:
• 50% (5/10) who did not receive nutrition counseling
had a weight loss of 2% or more;
Results- Phase 2
Prospective Study
Of the 35 patients in phase 2:
15
• 94% were on the LUPE protocol, with
• 80% on ECIS
•78% were on 4 chemo cycles
•23% had 3-4 weeks radiation, 77% had
5-7 weeks radiation
After 4 weeks on treatment (n=21) (Figure 1P);
• 52.3% (11/21) had 2% or more weight loss
with 23.8% (5/21) having 2% or more weight
gain from baseline.
To examine the impact of nutrition intervention on selected
outcomes in dual modality lung patients, including weight,
treatment interruptions, and symptoms such as anorexia,
Nausea, and esphagitis.
Phase 2: prospective study. Evaluation of the selected
outcomes of dual modality lung patients receiving
nutrition intervention on a routine basis over a period of
3 months ( August 2006-October 2006).
Methods- Phase 1
Retrospective Study
We determined the number of dual modality lung cancer
patients that were seen at the four cancer centres over an 18
month period ending May 31, 2006. To ensure equal
representation from each of the four centres, we employed a
stratified randomized sampling methodology and selected a
total of 100 patient charts to review (about 25 charts from
each centre). For data collection purposes, we developed an
excel spreadsheet that included treatment protocol, nutrition
intervention and follow-up, patient generated-subjective
global assessment (PG-SGA) score, weight, three symptoms
(ie, anorexia, nausea, and esophagitis), treatment
interruptions, and intravenous (IV) hydration during
treatment. Descriptive statistics of the data was conducted to
observe the frequency of the selected outcomes.
60
N=46
N=46
40
20
2% or more
weight gain
maintained
weight
2% or more
weight loss
2
4
Weeks of treatment
N=15
2% or more
weight gain
maintained
weight
2% or more
weight loss
N=21
60
N=23
40
20
N=93
4
6
Weeks of treatment
Figure 1P. In the prospective study, percentage of lung cancer patients
maintaining weight, experiencing 2% or more weight gain or 2% or
more weight during treatment (total possible n=35).
100
N=93
N=16
60
0 (no anorexia)
40
1 (yes anorexia)
20
0
Pretx
2
4
N=22
N=25
N=18
80
0 (no nausea)
1
2
3
60
40
20
0
Pretx
6
Weeks of treatment
Figure 2R. In the retrospective study, percentage of lung cancer
patients experiencing anorexia during treatment (total possible n=98).
N=24
2
4
6
Weeks of treatment
Figure 2P. In the prospective study, percentage of lung cancer patients
experiencing nausea according to NCIC criteria during treatment (total
possible n=35).
100
N=22
N=24
N=25
0 (no nausea)
1
2
3
60
40
0
Pretx
2
4
Weeks of treatment
80
N=67
N=17
0 (no
esophagitis)
1 (yes
esophagitis)
20
Percentage of lung patients
N=94
40
6
N=25
N=27
4
2
4
Weeks of treatment
6
Figure 5. Patient-Generated Subjective Global Assessment (PG-SGA)
scores for lung cancer patients from the retrospective study (total
possible n=98) and the prospective study (total possible n=35) prior to
and during treatment.
Some inconsistency with data collection during both the
retrospective and prospective phases. The accuracy of the
assessment of Nutritional symptoms may have varied
between two phases, with increased accuracy and
consistency during the prospective phase. During the
prospective phase, patients were not always able to attend
the Oncology Nutrition sessions therefore in some cases,
there are gaps or incomplete data sets. Due to limited
staffing resources for conducting the prospective phase of
this study, data collection was limited to a 3 month period.
Statistical analysis for significance has not yet been
conducted for these data.
Discussion
6
Weeks of treatment
Figure 4R. In the retrospective study, percentage of lung cancer
patients experiencing esophagitis during treatment (total possible
n=98).
In past practice (referral to Oncology Nutrition prn basis),
a greater percentage of patients experienced weight gain
and/or weight maintenance at 4 weeks during treatment
than routine practice (weekly Oncology Nutrition sessions)
patients. However, at week 6 during treatment, this trend
reversed with the routine practice patients experiencing
greater weight gain and/or weight maintenance. Although
more past practice patients experienced less anorexia at
the start of treatment, the patients who received routine
practice experienced less anorexia between week2 and
week 4 of treatment. This trend is reversed at week 6 with
past practice patients experiencing less anorexia during
this period. The experience of both groups of patients with
nausea was similar with 80% not experiencing nausea
during the entire treatment period. A similar percentage of
both past practice and routine patients experienced
esophagitis at the start of treatment to week 4 during
treatment. At week 6 during treatment past practice
patients experienced less esophagitis than routine patients.
Conclusions
The Patient Generated Subjective Global Assessment score
is a rating of a patient’s overall risk of developing
malnutrition considering many symptoms. Overall, patients
receiving routine weekly Oncology Nutritional intervention
experienced similar PGSGA scores as compared to patients
who received past practice of Oncology Nutrition care
throughout the period they received dual modality
treatment for lung cancer.
N=25
60
N=17
40
0 (no esophagitis)
1
2
3
20
Pretx
0
2
Pretx
80
0
Pretx
0
20
100
100
60
3
80
N=93
Percentage of lung patients
All dual modality lung patients were referred to Oncology
Nutrition over a period of 3 months (August 2006-October
2006, n=35). These patients were followed weekly during
treatment. Data collected followed an identical model as for
phase 1. As in phase 1, the data collected included treatment
protocol, nutrition intervention and follow-up, patient
generated-subjective global assessment (PG-SGA) score,
weight, three symptoms (esophagitis, anorexia and nausea),
treatment interruptions, and intravenous (IV) hydration during
treatment. Descriptive statistics of the data was conducted to
observe the frequency of the selected outcomes.
PG-SGA
prospective
N=18
Figure 3P. In the prospective study, percentage of lung cancer patients
experiencing nausea according to NCIC criteria during treatment (total
possible n=35).
Methods- Phase 2
Prospective Study
6
2
N=66
100
9
0
6
Figure 1R. In the retrospective study, percentage of lung cancer
patients maintaining weight, experiencing 2% or more weight gain or
2% or more weight during treatment (total possible n=98).
80
80
Percentage of lung patients
basis with lung cancer patients receiving dual modality
treatment improves symptom outcomes.
N=37
0
Percentage of lung patients
Hypothesis: Nutrition intervention on a proactive, routine
80
Percentage of lung patients
Phase 1: retrospective chart review. Charts for dual
modality lung patients were reviewed over a period of
18 months (December 2004- May 2006) assessing the
selected outcomes.
100
Percentage of lung patients
Percentage of lung patients
100
PG-SGA
retrospective
Limitations
• 45% who saw a dietitian one or more times had a
weight loss of 2% or more while 34.5%
maintained
their weight during treatment.
This study was conducted in two phases;
12
PG-SGA scores
1B.C.
2
4
6
Weeks of treatment
Figure 4P. In the prospective study, percentage of lung cancer
patients experiencing esophagitis according to NCIC criteria during
treatment (total possible n=35).
References