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Lorton CM, Griffin O, Higgins K, Roulston F, Stewart G, Gough N, Barnes E, Aktas A, Walsh TD. Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice. Support Care Cancer 2019; 28:2351-2360. [PMID: 31485981 DOI: 10.1007/s00520-019-05042-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/12/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities. METHODS This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted. RESULTS Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89). CONCLUSIONS Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.
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Affiliation(s)
- Cliona M Lorton
- Academic Department of Palliative Medicine, Our Lady's Hospice & Care Services, Harold's Cross, Dublin, D6W EV82, Ireland.
- Trinity College Dublin, Dublin, Ireland.
| | - O Griffin
- Trinity College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - K Higgins
- Tallaght University Hospital, Dublin, Ireland
| | - F Roulston
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - G Stewart
- St Vincent's Private Hospital, Dublin, Ireland
| | - N Gough
- Mater Private Mid-Western Radiation Oncology Centre, Limerick, Ireland
| | - E Barnes
- St Vincent's University Hospital, Dublin, Ireland
| | - A Aktas
- Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - T D Walsh
- Academic Department of Palliative Medicine, Our Lady's Hospice & Care Services, Harold's Cross, Dublin, D6W EV82, Ireland
- Trinity College Dublin, Dublin, Ireland
- Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
- University College Dublin, Dublin, Ireland
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Abstract
Cachexia is a metabolic syndrome driven by inflammation and characterized by loss of muscle with or without loss of fat mass. In cancer cachexia, the tumor burden and host response induce increased inflammation, decreased anabolic tone, and suppressed appetite leading to the clinical presentation of reduced body weight and quality of life (QOL). There is no approved treatment for cancer cachexia, and commonly used nutritional and anti-inflammatory strategies alone have proven ineffective for management of symptoms. Several other pharmacological agents are currently in development and have shown promise as a clinical strategy in early-phase trials. Recently, it has been proposed that multimodal strategies, with an anabolic focus, initiated early in the disease/treatment progression may provide the most therapeutic potential for symptom management. Here we review the data from recent clinical trials in cancer cachexia including pharmacological, exercise, and nutritional interventions.
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Affiliation(s)
- Lindsey J Anderson
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, Seattle, WA, 98108, USA
| | - Eliette D Albrecht
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, Seattle, WA, 98108, USA.,Yale University, New Haven, CT, 06520, USA
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Health Care System, Seattle, WA, 98108, USA. .,Department of Medicine, Division of Gerontology & Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Differential Associations Between Delirium and Mortality According to Delirium Subtype and Age: A Prospective Cohort Study. Psychosom Med 2015; 77:903-10. [PMID: 26397939 DOI: 10.1097/psy.0000000000000239] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study investigated the differential associations between delirium and mortality in terminally ill patients according to delirium subtype and age. METHODS This was a prospective cohort study of terminally ill patients. Delirium was diagnosed using the confusion assessment method. Delirium subtypes were defined based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria and the Delirium Rating Scale-98-R. A multivariate Cox proportional hazards regression analysis was used to examine predictors of mortality. RESULTS Of the 322 cases, 98 patients (30.4%) were diagnosed as having delirium. The median (interquartile range) number of survival days after admission was 17.0 (10.0-36.0) days for patients with delirium and 28.0 (16.0-57.0) days for patients without delirium (p = .002). A multivariate analysis revealed that patients with hypoactive and mixed subtypes of delirium survived for shorter periods compared with patients without delirium (hazard ratio [HR] = 1.65 [95% confidence interval {CI} = 1.05-2.59, p = .029] and HR = 2.30 [95% CI = 1.44-3.69, p = .001], respectively). The hypoactive and mixed delirium subtypes exhibited significant interactions with age: younger age was associated with shorter periods of survival in patients with hypoactive and mixed subtype delirium (HR = 0.95 [95% CI = 0.93-0.98, p < .001] and HR = 0.97 [95% CI = 0.93-1.00, p = .038], respectively). CONCLUSIONS The hypoactive and mixed subtypes of delirium were associated with shorter survival periods in terminally ill patients, and these associations interacted significantly with age. These findings support the clinical and academic value of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition specifiers that differentiate the diagnoses of delirium subtypes.
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Gallagher EJ, LeRoith D. Obesity and Diabetes: The Increased Risk of Cancer and Cancer-Related Mortality. Physiol Rev 2015; 95:727-48. [PMID: 26084689 DOI: 10.1152/physrev.00030.2014] [Citation(s) in RCA: 442] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Obesity and type 2 diabetes are becoming increasingly prevalent worldwide, and both are associated with an increased incidence and mortality from many cancers. The metabolic abnormalities associated with type 2 diabetes develop many years before the onset of diabetes and, therefore, may be contributing to cancer risk before individuals are aware that they are at risk. Multiple factors potentially contribute to the progression of cancer in obesity and type 2 diabetes, including hyperinsulinemia and insulin-like growth factor I, hyperglycemia, dyslipidemia, adipokines and cytokines, and the gut microbiome. These metabolic changes may contribute directly or indirectly to cancer progression. Intentional weight loss may protect against cancer development, and therapies for diabetes may prove to be effective adjuvant agents in reducing cancer progression. In this review we discuss the current epidemiology, basic science, and clinical data that link obesity, diabetes, and cancer and how treating obesity and type 2 diabetes could also reduce cancer risk and improve outcomes.
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Affiliation(s)
| | - Derek LeRoith
- Icahn School of Medicine at Mount Sinai, New York, New York
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Delirium in adult patients receiving palliative care: A systematic review of the literature. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rpsmen.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bausewein C, Simon ST. Shortness of breath and cough in patients in palliative care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:563-71; quiz 572. [PMID: 24069091 DOI: 10.3238/arztebl.2013.0563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 06/19/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Shortness of breath and cough are common, disturbing symptoms in patients receiving palliative care. They arise in 10% to 70% of patients with advanced cancer and in 60% to nearly 100% of patients with non-malignant underlying diseases, depending on the type of disease. METHODS This review is based on a selective literature search in the Medline, Embase, and PsycInfo databases and on current recommendations from Germany and other countries, as well as on the authors' personal experience. RESULTS Some general measures to address these problems are reassurance, development of an emergency plan, physical activity, and relaxation exercises. Supportive non-pharmacological measures may include the use of a rollator (level of evidence [LoE] 1-), a cool draft of air as from a handheld fan (LoE 1-), physiotherapy, and respiratory therapy. There is good evidence (LoE 1+) to support the administration of opioids as the medications of choice; benzodiazepines are often used, but a meta-analysis did not reveal any statistically significant benefit (LoE 1+). Expectorants can help patients who cough with marked sputum formation. Antitussants suppress the cough reflex both peripherally and centrally (LoE 1+ to 3). Opioids, including morphine (LoE 1-) and dextromethorphan (LoE 1-), are effective antitussants with low toxicity. CONCLUSION In most patients, shortness of breath and cough can be relieved by a series of therapeutic measures.
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Sánchez-Román S, Beltrán Zavala C, Lara Solares A, Chiquete E. Delirium in adult patients receiving palliative care: a systematic review of the literature. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2013; 7:48-58. [PMID: 23911280 DOI: 10.1016/j.rpsm.2013.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/23/2013] [Accepted: 05/14/2013] [Indexed: 11/25/2022]
Abstract
Delirium in palliative care patients is common and its diagnosis and treatment is a major challenge. Our objective was to perform a literature analysis in two phases on the recent scientific evidence (2007-2012) on the diagnosis and treatment of delirium in adults receiving palliative care. In phase 1 (descriptive studies and narrative reviews) 133 relevant articles were identified: 73 addressed the issue of delirium secondarily, and 60 articles as the main topic. However, only 4 prospective observational studies in which delirium was central were identified. Of 135 articles analysed in phase 2 (clinical trials or descriptive studies on treatment of delirium in palliative care patients), only 3 were about prevention or treatment: 2 retrospective studies and one clinical trial on multicomponent prevention in cancer patients. Much of the recent literature is related to reviews on studies conducted more than a decade ago and on patients different to those receiving palliative care. In conclusion, recent scientific evidence on delirium in palliative care is limited and suboptimal. Prospective studies are urgently needed that focus specifically on this highly vulnerable population.
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Affiliation(s)
- Sofía Sánchez-Román
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Cristina Beltrán Zavala
- Clínica del Dolor y Cuidados Paliativos, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Argelia Lara Solares
- Clínica del Dolor y Cuidados Paliativos, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Erwin Chiquete
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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Utech AE, Tadros EM, Hayes TG, Garcia JM. Predicting survival in cancer patients: the role of cachexia and hormonal, nutritional and inflammatory markers. J Cachexia Sarcopenia Muscle 2012; 3:245-51. [PMID: 22648739 PMCID: PMC3505579 DOI: 10.1007/s13539-012-0075-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/13/2012] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Cancer can lead to weight loss, anorexia, and poor nutritional status, which are associated with decreased survival in cancer patients. METHODS Male cancer patients (n = 136) were followed for a mean time of 4.5 years. Variables were obtained at baseline: cancer stage, albumin, hemoglobin, tumor necrosis factor alpha (TNF-α), interleukin (IL)-6, bioavailable testosterone, appetite questionnaire, and weight change from baseline to 18 months. Primary statistical tests included Kaplan-Meier survival analysis and Cox proportional hazard regression (PHREG). RESULTS Univariate PHREG showed that cancer stage, albumin, hemoglobin, TNF-α, IL-6, and weight change were each significantly associated with mortality risk (P < 0.05), but bioavailable testosterone was not. Multivariate PHREG analysis established that weight change and albumin were jointly statistically significant even after adjusting for stage. CONCLUSION In this sample of male oncology patients, cancer stage, serum albumin, and weight loss predicted survival. High levels of inflammatory markers and hemoglobin are associated with increased mortality, but do not significantly improve the ability to predict survival above and beyond cancer stage, albumin, and weight loss.
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Affiliation(s)
- Anne E Utech
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX, USA
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Hwang IC, Choi CH, Kim KK, Lee KS, Suh HS, Shim JY. Predictability of Impending Events for Death within 48 Hours in Terminal Cancer Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.14475/kjhpc.2011.14.1.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- In-Cheol Hwang
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Chung-Hyun Choi
- Clinical Trial Center, Yonsei University Health System, Korea
| | - Kyoung-Kon Kim
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Kyoung-Shik Lee
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Heuy-Sun Suh
- Department of Family Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Jae-Yong Shim
- Department Family Medicine, Yonsei University College of Medicine, Seoul, Korea
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