Critical Evaluation of Nutrition Screening Tools Recommended for Oncology Patients

Nutritional screening in a cancer prehabilitation programme: A cohort study

BACKGROUND

Cancer patients are often malnourished pre-operatively. Study aims were to establish if current screening was appropriate for use in prehabilitation and investigate any association between nutritional risk, functionality and quality of life (QoL).

METHODS

This cohort study used routinely collected data from September 2020 to August 2021 from patients in a Prehab4cancer programme. Included patients were aged >18 years, had colorectal, lung or oesophago-gastric cancer and were scheduled for surgery. Nutritional assessment included patient generated subjective global assessment (PG-SGA) short-form and QoL with a sit-to-stand test. Association between nutritional risk and outcomes were analysed using adjusted logistic regression.

RESULTS

From 928 patients referred to Prehab4Cancer service over 12-months, data on nutritional risk were collected from 526 patients. Pre-operatively, 233 out of 526 (44%) patients were at nutritional risk (score ≥2). During prehabilitation, 31% of patients improved their PG-SGA and 74% of patients maintained or improved their weight. Odds ratios (OR) with confidence intervals (CI) showed that patients with better QoL using EuroQol-5 Dimensions (OR 0.05, 95% CI 0.01, 0.45, P=0.01), EuroQol Visual Analogue Scale (OR 0.96, 95% CI 0.93, 1.00, p=0.04) or sit-to-stand (OR 0.96, 95% 0.93, 1.00, p=0.04) were less likely to be nutritional at risk.

CONCLUSION

Nearly half of patients in Prehab4Cancer programme assessed using PG-SGA were at risk of malnutrition. However, almost half of the sample did not have their risk assessed. Patients at risk of malnutrition were more likely to have a poorer QoL and sit-to-stand test than those who were not at risk. This article is protected by copyright. All rights reserved.

Malnutrition Screening and Assessment in the Cancer Care Ambulatory Setting: Mortality Predictability and Validity of the Patient-Generated Subjective Global Assessment Short form (PG-SGA SF) and the GLIM Criteria

Background: A valid malnutrition screening tool (MST) is essential to provide timely nutrition support in ambulatory cancer care settings. The aim of this study is to investigate the validity of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) and the new Global Leadership Initiative on Malnutrition (GLIM) criteria as compared to the reference standard, the Patient-Generated Subjective Global Assessment (PG-SGA). Methods: Cross-sectional observational study including 246 adult ambulatory patients with cancer receiving in-chair intravenous treatment at a cancer care centre in Australia. Anthropometrics, handgrip strength and patient descriptive data were assessed. Nutritional risk was identified using MST and PG-SGA SF, nutritional status using PG-SGA and GLIM. Sensitivity (Se), specificity (Sp), positive and negative predictive values and kappa (k) were analysed. Associations between malnutrition and 1-year mortality were investigated by Cox survival analyses. Results: A PG-SGA SF cut-off score ≥5 had the highest agreement when compared with the PG-SGA (Se: 89%, Sp: 80%, k = 0.49, moderate agreement). Malnutrition risk (PG-SGA SF ≥ 5) was 31% vs. 24% (MST). For malnutrition according to GLIM, the Se was 76% and Sp was 73% (k = 0.32, fair agreement) when compared to PG-SGA. The addition of handgrip strength to PG-SGA SF or GLIM did not improve Se, Sp or agreement. Of 100 patients who provided feedback, 97% of patients found the PG-SGA SF questions easy to understand, and 81% reported that it did not take too long to complete. PG-SGA SF ≥ 5 and severe malnutrition by GLIM were associated with 1-year mortality risk. Conclusions: The PG-SGA SF and GLIM criteria are accurate, sensitive and specific malnutrition screening and assessment tools in the ambulatory cancer care setting. The addition of handgrip strength tests did not improve the recognition of malnutrition or mortality risk.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Nutrition therapy for the management of cancer-related fatigue and quality of life: a systematic review and meta-analysis

Cancer-related fatigue (CRF) is one of the most commonly reported disease- and treatment-related side effects that impede quality of life. This systematic review and meta-analysis describes the effects of nutrition therapy on CRF and quality of life in people with cancer and cancer survivors. Studies were identified from four electronic databases until September 2017. Eligibility criteria included randomised trials in cancer patients and survivors; any structured dietary intervention describing quantities, proportions, varieties and frequencies of food groups or energy and macronutrient consumption targets; and measures of CRF and quality of life. Standardised mean differences (SMD) were pooled using random-effects models. The American Dietetic Association's Evidence Analysis Library Quality Checklist for Primary Research was used to evaluate the methodological quality and risk of bias. A total of sixteen papers, of fifteen interventions, were included, comprising 1290 participants. Nutrition therapy offered no definitive effect on CRF (SMD 0·18 (95 % CI -0·02, 0·39)) or quality of life (SMD 0·07 (95 % CI -0·10, 0·24)). Preliminary evidence indicates plant-based dietary pattern nutrition therapy may benefit CRF (SMD 0·62 (95 % CI 0·10, 1·15)). Interventions using the patient-generated subjective global assessment tool and prescribing hypermetabolic energy and protein requirements may improve quality of life. However, the heterogeneity seen in study design, nutrition therapies, quality-of-life measures and cancer types impede definitive dietary recommendations to improve quality of life for cancer patients. There is insufficient evidence to determine the optimal nutrition care plan to improve CRF and/or quality of life in cancer patients and survivors.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

A pilot study comparing the neutropenic diet to a non-neutropenic diet in the allogeneic hematopoietic stem cell transplantation population

BACKGROUND

Historically, dietary restrictions imposed on patients undergoing hematopoietic stem cell transplantation (HSCT) were severe and limited to prevent exposure to foodborne organisms. With improvements in supportive care and anti-infective agents, the necessity of the neutropenic diet for this population has been in question.

OBJECTIVES

This study aimed to determine whether the incidence of infection differs and to analyze the nutritional status in patients undergoing myeloablative allogeneic HSCT with a neutropenic diet as compared to those with a diet without restrictions.

METHODS

This study was a randomized, controlled prospective pilot study beginning within the first 24 hours of the start of the conditioning regimen. Patients were randomized to receive a neutropenic diet or a diet without restrictions. All patients received care in a high-efficiency particulate air-filtered room on the inpatient adult blood and marrow transplantation unit (ABMTU). All patients received antibacterial and antifungal prophylaxis. Patients were followed until the end of neutropenia (defined as absolute neutrophil count of greater than 500 for three days) or until discharge from the inpatient ABMTU.

FINDINGS

In 46 evaluable patients, no significant difference was found between infection rates or nutritional status. The neutropenic diet did not offer a protective effect against infection in patients undergoing myeloablative allogeneic HSCT. No differences were found in nutritional status between the two groups.

Clinical evaluation and optimal management of cancer cachexia

Cancer anorexia-cachexia syndrome (CACS) is a complex metabolic syndrome, different from malnutrition and sarcopenia, which is very common in cancer patients. Treatment for CACS is based on nutritional support and CACS pathophysiology-modulating drugs. The most commonly used are megestrol acetate (MA) and corticosteroids. The efficacy of MA has been confirmed by multiple clinical trials and meta-analyses. Glucocorticoids are also effective but should only be used for short periods and in selected cases. Future strategies should include intensified research into potentially effective drugs (ω-3 fatty acids, thalidomide, cannabinoids, ghrelin, bortezomib, and COX-2 inhibitors), combined treatment and new drugs (anti-IL-6 monoclonal antibodies, melanocortin, β-2 antagonists, and androgen receptor-modulating analogues). We propose a review based on the literature on the pathophysiology of CACS, the diagnostic criteria and treatment, and future strategies.

Pretreatment weight status and weight loss among head and neck cancer patients receiving definitive concurrent chemoradiation therapy: implications for nutrition integrated treatment pathways

PURPOSE

The purpose was to examine the effect of pretreatment weight status on loco-regional progression for patients with squamous cell carcinoma of the head and neck (SCCHN) after receiving definitive concurrent chemoradiation therapy (CCRT).

METHODS

In an expanded cohort of 140 patients, we retrospectively reviewed weight status and loco-regional progression of SCCHN patients treated with CCRT between 2004 and 2010.

RESULTS

Pretreatment ideal body weight percentage (IBW%) was statistically significantly different for patients with disease progression than for those without progression (p = 0.02) but was not an independent predictor of progression. Median pretreatment IBW% was 118 (72-193) for the progression-free group and was 101.5 (73-163) for the group with progression. Both groups suffered clinically severe weight loss of approximately 9 % from baseline to end treatment.

CONCLUSIONS

Pretreatment weight status, a very crude indicator of nutrition status, may have prognostic value in patients with SCCHN undergoing definitive CCRT. Inadequate nutritional status in these patients has been associated with poor clinical outcomes and decreased quality of life. Based on this report and others, the best next steps include routine validated malnutrition screening and the testing of evidence-based nutrition care protocols with the goals of minimizing weight loss and improvement of quality of life.

Validation of the Head and Neck Patient Symptom Checklist as a nutrition impact symptom assessment tool for head and neck cancer patients

PURPOSE

The purpose of this study was to test the validity of the Head and Neck Patient Symptom Checklist (HNSC).

METHODS

Three hundred and sixty-eight treatment-naive individuals with head and neck cancer prospectively completed the HNSC and the Patient-Generated Symptom Global Assessment (PG-SGA). The predictive validity was determined by comparing the HNSC symptoms interference scores to the PG-SGA scores. Multivariate logistic regression was used to determine the HNSC symptoms scores associated with reduced dietary intake, ≥ 5 % weight loss over 6 months, and reduced functional performance (FP).

RESULTS

HNSC sensitivity (79-98 %), specificity (99-100 %), positive predictive value (92-100 %), and negative predictive value (94-100 %) were excellent, and the Cronbach's alpha coefficient was 0.92. The multivariate logistic regression showed that advanced tumor stage, pain, loss of appetite (LOA), and difficulty swallowing significantly predicted dietary intake. Advanced tumor stage, LOA, and difficulty swallowing were also significant predictors of ≥ 5 % weight loss over 6 months. LOA, difficulty swallowing, feeling full, and lack of energy were significant predictors of reduced FP.

CONCLUSIONS

The HNSC appears to be a valid tool for determining symptoms interfering with dietary intake of head and neck cancer (HNC) patients. This instrument may aid in early identification of symptoms that place HNC patients at risk for reductions in dietary intake, weight, and functional performance.

Mini-nutritional assessment predicts functional status and quality of life of patients with hepatocellular carcinoma in Taiwan

This study aimed to determine the possibility of using the Mini-Nutritional Assessment (MNA) to evaluate the quality of life and functional status in patients with hepatocellular carcinoma (HCC). The study recruited 300 outpatients with HCC from a teaching hospital in Central Taiwan to serve as subjects. All subjects were interviewed with a structured questionnaire for rating the nutritional status with the MNA (long-form and short-form), and for evaluating quality of life and functional status with Global Quality of Life (GQL) and Global Functional Status (GFS), respectively, of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 version-3. Cancer staging and liver cirrhosis indicators, blood biochemical indicators, and self-rated health status and mobility were used as reference standards. Results showed that based on the strength of the correlation and association with the reference standards, both the long-form and short-form of the MNA performed better than GQL and GFS in predicting quality of life and functional status of patients with HCC. These results suggest that the MNA is suitable for identifying the risk of deteriorating quality of life or functional status, in addition to identifying the risk of malnutrition, in patients with HCC.

Comparison of the prevalence of malnutrition diagnosis in head and neck, gastrointestinal, and lung cancer patients by 3 classification methods

BACKGROUND

Malnutrition is prevalent among patients within certain cancer types. There is lack of universal standard of care for nutrition screening and a lack of agreement on an operational definition and on validity of malnutrition indicators.

OBJECTIVE

In a secondary data analysis, we investigated prevalence of malnutrition diagnosis with 3 classification methods using data from medical records of a National Cancer Institute-designated comprehensive cancer center.

METHODS

Records of 227 patients hospitalized during 1998 with head and neck, gastrointestinal, or lung cancer were reviewed for malnutrition based on 3 methods: (1) physician-diagnosed malnutrition-related International Classification of Diseases, Ninth Revision codes; (2) in-hospital nutritional assessment summaries conducted by registered dietitians; and (3) body mass indexes (BMIs). For patients with multiple admissions, only data from the first hospitalization were included.

RESULTS

Prevalence of malnutrition diagnosis ranged from 8.8% based on BMI to approximately 26% of all cases based on dietitian assessment. κ coefficients between any methods indicated a weak (κ = 0.23, BMI and dietitians; and κ = 0.28, dietitians and physicians)-to-fair strength of agreement (κ = 0.38, BMI and physicians).

CONCLUSIONS

Available methods to identify patients with malnutrition in a National Cancer Institute-designated comprehensive cancer center resulted in varied prevalence of malnutrition diagnosis. A universal standard of care for nutrition screening that uses validated tools is needed.

IMPLICATIONS FOR PRACTICE

The Joint Commission on the Accreditation of Healthcare Organizations requires nutritional screening of patients within 24 hours of admission. For this purpose, implementation of a validated tool that can be used by various healthcare practitioners, including nurses, needs to be considered.

Effects of nutritional counselling on anthropometric measures in adult patients with cancer undergoing treatment and their perception and satisfaction level: a comprehensive systematic review

BACKGROUND

Patients with cancer undergoing treatment often develop malnutrition. Malnutrition can lead to multiple complications. In view of the potential complications, it is important for the patients to maintain good nutritional status. One method to maintain a good nutritional status is to provide frequent nutritional support such as nutritional counselling. The effectiveness of nutritional counselling is commonly indicated by anthropometric measures. Other than anthropometric measures, the value of patients' perception and satisfaction levels towards nutritional counselling are important as well.

OBJECTIVES

The objectives of this systematic review were: (1) to examine the effect of nutritional counselling based on anthropometric measures in adult patients with cancer undergoing treatment, and (2) to determine patients' perceptions and satisfaction levels towards nutritional counselling.

INCLUSION CRITERIA

Types of participants This review considered adult patients with cancer aged 18 years or over. Patients were at various stages of the disease. Patients were undergoing treatment.Types of intervention This review considered all types of nutritional counselling given to patients with cancer.Types of outcomes The outcome of interest were anthropometric measures, patients' subjective perceptions and patients' satisfaction level.Types of studies This review considered studies that examined the effectiveness of nutritional counselling on anthropometric measures in adult patients with cancer undergoing treatment, as well as their perception and satisfaction levels towards nutritional counselling.

SEARCH STRATEGY

A comprehensive search strategy was developed using all identified MeSH headings and key words for quantitative and qualitative studies.

METHODOLOGICAL QUALITY

Both quantitative and qualitative papers selected for review for methodological validity were assessed by two independent reviewers prior to inclusion in the review. The review was then carried out using the standardised critical appraisal instruments.

DATA COLLECTION/EXTRACTION

Following the critical appraisal, data were extracted from the included study using data extraction tools developed by JBI.A total of 11 articles were included in this systematic review, 6 were randomised controlled trials, 3 were comparable cohort studies and 2 qualitative studies.

DATA ANALYSIS

Narrative summary was presented for the quantitative studies as statistical pooling was not possible. For qualitative studies, findings were presented in meta-synthesis form.

RESULTS

From the presented quantitative studies, some patients with cancer were clinically benefited from the effect of nutritional counselling through the improvement or minimisation of the deterioration of body weight and fat free mass at particular time or chemotherapy cycle. Overall, patients were satisfied with the nutritional counselling they received. Patients feel that the ability to eat is important however, patients with cancer developed eating inability as a result of disease process and treatment side effects From the qualitative findings, most participants expressed that counseling was beneficial but highlighted the need for understanding of the individual food preferences when giving nutritional counselling.

CONCLUSIONS

Lastly, from the quantitative finding, no absolute conclusion can be drawn on the effect of nutritional counselling on anthropometric measures. The findings of patients' perceptions and satisfaction levels towards nutritional counselling can provide an improved framework to help health care professionals in implement better nutritional counselling session.

IMPLICATIONS FOR PRACTICE -

The quantitative findings support the use of individualized and intensive nutritional counselling for patients with cancer to improve body weight and fat free mass measurement. Patient satisfaction with nutritional counselling should be conducted regularly in the clinical area. The qualitative findings highlight the need for minimising eating inability related to treatment side effects and disease process. Furthermore, the qualitative findings indicated the need for more individualized nutritional counselling in the clinical area, taking into account individual dietary differences, concerns, and needs.

IMPLICATIONS FOR RESEARCH -

There is a need for further research to assess the effectiveness of nutritional counselling based on anthropometric measures, patients' perception and satisfaction.