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Graves JP, Daher GS, Bauman MMJ, Moore EJ, Tasche KK, Price DL, Van Abel KM. Association of sarcopenia with oncologic outcomes of primary treatment among patients with oral cavity cancer: A systematic review and meta-analysis. Oral Oncol 2023; 147:106608. [PMID: 37897858 DOI: 10.1016/j.oraloncology.2023.106608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/22/2023] [Accepted: 10/23/2023] [Indexed: 10/30/2023]
Abstract
GOAL We performed a systematic review of the literature and meta-analysis to determine how radiographic sarcopenia assessment methods and the presence of pre-treatment sarcopenia impact oncologic outcomes in patients with oral cavity cancer. INTRODUCTION Pre-treatment sarcopenia has been associated with poor outcomes in many different malignancies, including head and neck cancers. However, the impact sarcopenia has on outcomes for oral cavity cancer patients is not well understood. RESULTS Twelve studies met our inclusion criteria, totaling 1007 patients. 359 (36%) of these patients were reported as sarcopenic. The most commonly utilized sarcopenia assessment methods were L3 skeletal muscle index (n = 5) and C3 skeletal muscle index to estimate L3 skeletal muscle index (n = 5). The majority of studies established their sarcopenia cutoffs as the lowest quartile skeletal muscle index in their patient cohorts. Five studies were included in our meta-analysis, totaling 251 sarcopenic and 537 non-sarcopenic patients. Compared to non-sarcopenic patients, sarcopenic patients were found to have significantly poorer overall survival (univariate: HR = 2.24, 95% CI: 1.71-2.93, I2 = 0%; multivariate: HR = 1.93, 95% CI: 1.47-2.52, I2 = 0%) and disease-free survival (univariate: HR = 2.10, 95% CI: 1.50-2.92, I2 = 0%; multivariate: HR = 1.79, 95% CI: 1.29-2.47, I2 = 10%). CONCLUSIONS Over one-third of oral cavity cancer patients may present with sarcopenia. Pre-treatment sarcopenia is associated with significantly worse overall and disease-free survival.
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Affiliation(s)
- Jeffrey P Graves
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ghazal S Daher
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Eric J Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kendall K Tasche
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Daniel L Price
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
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Martinovic D, Tokic D, Puizina Mladinic E, Usljebrka M, Kadic S, Lesin A, Vilovic M, Lupi-Ferandin S, Ercegovic S, Kumric M, Bukic J, Bozic J. Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review. Nutrients 2023; 15:nu15081864. [PMID: 37111081 PMCID: PMC10144914 DOI: 10.3390/nu15081864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.
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Affiliation(s)
- Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Daria Tokic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, 21000 Split, Croatia
| | - Ema Puizina Mladinic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Mislav Usljebrka
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sanja Kadic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Antonella Lesin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marino Vilovic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Slaven Lupi-Ferandin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sasa Ercegovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Josipa Bukic
- Department of Pharmacy, University of Split School of Medicine, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
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Impact of sarcopenia and myosteatosis on survival outcomes for patients with head and neck cancer undergoing curative-intent treatment. Br J Nutr 2023; 129:406-415. [PMID: 35152926 PMCID: PMC9876810 DOI: 10.1017/s0007114522000435] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malnutrition and sarcopenia are prevalent in patients with head and neck squamous cell carcinoma (HNSCC). Pre-treatment sarcopenia and adverse oncological outcomes in this population are well described. The impact of myosteatosis and post-treatment sarcopenia is less well known. Patients with HNSCC (n = 125) undergoing chemoradiotherapy, radiotherapy alone and/or surgery were assessed for sarcopenia and myosteatosis, using cross-sectional computed tomography (CT) imaging at the third lumbar (L3) vertebra, at baseline and 3 months post-treatment. Outcomes were overall survival (OS) at 12 months and 5 years post-treatment. One hundred and one participants had a CT scan evaluable at one or two time points, of which sixty-seven (66 %) participants were sarcopenic on at least one time point. Reduced muscle attenuation affected 93 % (n = 92) pre-treatment compared with 97 % (n = 90) post-treatment. Five-year OS favoured those without post-treatment sarcopenia (hazard ratio, HR 0·37, 95 % CI 0·16, 0·88, P = 0·06) and those without both post-treatment myosteatosis and sarcopenia (HR 0·33, 95 % CI 0·13, 0·83, P = 0·06). Overall, rates of myosteatosis were high at both pre- and post-treatment time points. Post-treatment sarcopenia was associated with worse 5-year OS, as was post-treatment sarcopenia in those who had myosteatosis. Post-treatment sarcopenia should be evaluated as an independent risk factor for decreased long-term survival post-treatment containing radiotherapy (RT) for HNSCC.
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Sulo S, Brunton C, Drawert S, Watson G, Hegazi R, Bastasch M. Increased Emergency Department Utilization and Costs for Medicare Cancer Patients with Malnutrition Diagnoses. J Nutr Health Aging 2022; 26:786-791. [PMID: 35934823 DOI: 10.1007/s12603-022-1826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Malnutrition or its risk affects up to 70% of cancer patients. Compared to adequately nourished oncology patients, those with malnutrition experience more complications and have poorer prognoses, thus higher needs for healthcare. We compared utilization of emergency department (ED) services and costs for Medicare-covered cancer patients with or without a malnutrition diagnosis. METHODS We used the Centers for Medicare and Medicaid Services (CMS) Standard Analytic File to identify fee-for-service beneficiaries who had a cancer diagnosis, and had one or more outpatient claims in 2018. We totaled individual claims and costs for ED visits per beneficiary, then calculated mean per-person claims and costs for malnourished vs non-malnourished patients. RESULTS Using data from over 2.8 million claims of patients with cancer diagnoses, the prevalence of diagnosed malnutrition was 2.5%. The most common cancer types were genitourinary, hematologic/blood, and breast. Cancer patients with a malnutrition diagnosis, compared to those without, had a significantly higher annual total number of outpatient claims (21.4 vs. 11.5, P<.0001), including a 2.5-fold higher rate of ED visits (1.43 vs. 0.56, p<.0001). As result, such patients incurred more than 2-fold higher mean ED claim costs than did their adequately nourished counterparts ($10,724 vs. $4,935, P<.0001). CONCLUSIONS Our results suggest that malnutrition in cancer patients imposes a high outpatient burden on resource utilization and costs of care in terms of ED use. We propose that nutritional interventions can be used to improve health outcomes for people with cancer and to improve economic outcomes for patients and providers.
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Affiliation(s)
- S Sulo
- Suela Sulo, PhD, MSc, Abbott Nutrition, 100 Abbott Park Rd, Abbott Park, IL 60064, Office: 224-668-1377, Fax: 224-668-8355, E-mail:
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Muthanandam S, Muthu J. Understanding Cachexia in Head and Neck Cancer. Asia Pac J Oncol Nurs 2021; 8:527-538. [PMID: 34527782 PMCID: PMC8420913 DOI: 10.4103/apjon.apjon-2145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/21/2021] [Indexed: 01/06/2023] Open
Abstract
One of the major comorbidities of cancer and cancer therapy is posing a global health problem in cancer cachexia. Cancer cachexia is now considered a multifactorial syndrome that presents with drastic loss of body weight, anorexia, asthenia, and anemia. Head and neck cancer (HNC) patients are at a greater risk for development and severity of cachexia syndrome as there is direct involvement of structures associated with nutritional intake. Yet, the scientific evidence, approach, and management of cachexia in HNCs are yet to be largely explored. The article aims to succinctly review the concepts of cancer cachexia with relevance to HNCs and summarizes the current findings from recent research.
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Affiliation(s)
- Sivaramakrishnan Muthanandam
- Department of Oral and Maxillofacial Pathology and Oral Microbiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be) University, Puducherry, India
| | - Jananni Muthu
- Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be) University, Puducherry, India
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Findlay M, White K, Lai M, Luo D, Bauer JD. The Association Between Computed Tomography-Defined Sarcopenia and Outcomes in Adult Patients Undergoing Radiotherapy of Curative Intent for Head and Neck Cancer: A Systematic Review. J Acad Nutr Diet 2021; 120:1330-1347.e8. [PMID: 32711854 DOI: 10.1016/j.jand.2020.03.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 03/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor in patients with cancer; however, its influence on outcomes for patients with head and neck cancer (HNC) has not been established. OBJECTIVE This review synthesizes current knowledge regarding the association between CT-defined sarcopenia and outcomes for adult patients undergoing radiotherapy with or without other treatment modalities of curative intent for HNC. METHODS A systematic review of the literature published between January 2004 and June 2019 was conducted in Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and PubMed. Empirical studies of CT-defined sarcopenia in adult patients (≥18 years) with HNC who had completed radiotherapy of curative intent with or without other treatment modalities were included. Outcomes reported included survival, prolonged radiotherapy breaks, and chemotherapy toxicity. Study quality was assessed using the American Academy of Nutrition and Dietetics Quality Criteria Checklist. Synthesis of outcomes and clinical relevance was performed using the Grading of Recommendations Assessment, Development, and Evaluation system. RESULTS Of 11 studies (n = 3,461) identified, 3 were positive and 8 were neutral quality. Studies were heterogeneous in HNC diagnosis, ethnicity, definition of sarcopenia, CT level of evaluation, and skeletal muscle index threshold value. Eight definitions for sarcopenia were identified with pretreatment prevalence of 6.6% to 70.9% and posttreatment prevalence of 12.4% to 65.8%. Pretreatment sarcopenia was independently associated with reduced: overall survival (OS), 3-year OS, disease-free survival, prolonged radiotherapy breaks, and chemotherapy-related toxicities. Posttreatment sarcopenia was independently associated with reduced OS and 5-year OS. The overall certainty of evidence according to Grading of Recommendations Assessment, Development and Evaluation criteria was low for OS; 3-year, 5-year, and 10-year OS; locoregional control; locoregional failure; progression-free survival; metastasis-free survival, disease-specific survival; and disease-free survival and very low for distant metastasis, prolonged radiotherapy breaks, and chemotherapy toxicity-related outcomes. CONCLUSIONS CT-defined sarcopenia is independently associated with reduced OS and treatment completion in patients with HNC and holds a clinically meaningful prognostic value. The certainty of the evidence requires strengthening with further research. Understanding the impact sarcopenia has on outcomes for these patients has implications for informing potential nutrition interventions and facilitating individualized care.
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Richards J, Arensberg MB, Thomas S, Kerr KW, Hegazi R, Bastasch M. Impact of Early Incorporation of Nutrition Interventions as a Component of Cancer Therapy in Adults: A Review. Nutrients 2020; 12:nu12113403. [PMID: 33167544 PMCID: PMC7694504 DOI: 10.3390/nu12113403] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022] Open
Abstract
Malnutrition is prevalent among oncology patients and can adversely affect clinical outcomes, prognosis, quality of life, and survival. This review evaluates current trends in the literature and reported evidence around the timing and impact of specific nutrition interventions in oncology patients undergoing active cancer treatment. Previous research studies (published 1 January 2010–1 April 2020) were identified and selected using predefined search strategy and selection criteria. In total, 15 articles met inclusion criteria and 12/15 articles provided an early nutrition intervention. Identified studies examined the impacts of nutrition interventions (nutrition counseling, oral nutrition supplements, or combination of both) on a variety of cancer diagnoses. Nutrition interventions were found to improve body weight and body mass index, nutrition status, protein and energy intake, quality of life, and response to cancer treatments. However, the impacts of nutrition interventions on body composition, functional status, complications, unplanned hospital readmissions, and mortality and survival were inconclusive, mainly due to the limited number of studies evaluating these outcomes. Early nutrition interventions were found to improve health and nutrition outcomes in oncology patients. Future research is needed to further evaluate the impacts of early nutrition interventions on patients’ outcomes and explore the optimal duration and timing of nutrition interventions.
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Affiliation(s)
- Julie Richards
- Abbott Nutrition, Bob Evans Farms, Columbus, OH 43212, USA
- Correspondence: ; Tel.: +1-740-497-7708
| | - Mary Beth Arensberg
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA; (M.B.A.); (S.T.); (K.W.K.); (R.H.)
| | - Sara Thomas
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA; (M.B.A.); (S.T.); (K.W.K.); (R.H.)
| | - Kirk W. Kerr
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA; (M.B.A.); (S.T.); (K.W.K.); (R.H.)
| | - Refaat Hegazi
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA; (M.B.A.); (S.T.); (K.W.K.); (R.H.)
| | - Michael Bastasch
- Department of Medicine and Division of Radiation Oncology, University of Texas East Health, Athens, TX 75751, USA;
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Curtin P, Akbar A, Kramer H, Iqbal A, Markossian T. The Status of Nutritional Management Guidelines for Head and Neck Cancer Patients. Cureus 2020; 12:e11309. [PMID: 33163316 PMCID: PMC7641487 DOI: 10.7759/cureus.11309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction Head and neck cancer (HNC) is the seventh leading cause of cancer worldwide. Approximately 35%-60% patients with HNC are malnourished from the disease onset, malnutrition being associated with worsened health outcomes among these patients. This study aimed to review and synthesize existing guidelines regarding nutritional interventions in HNC patients and assess providers’ knowledge, opinions, and practice of guidelines for the nutritional management of HNC patients. Methods This is a multimethod study that includes a systematic review of guidelines for nutritional intervention in HNC patients and a providers’ survey regarding their knowledge and opinions regarding nutrition therapy guidelines for HNC patients. Results Our review yielded seven guidelines. Of the seven guidelines reviewed, all were specific to cancer patients, however, only three were specific for HNC patients. Three of the guidelines recommended using a nutritional screening tool, however, only two mentioned a specific screening tool. Out of 193 surveys included in our analysis, the highest percentage of respondents were physicians (52.4%), followed by registered nurses (33.5%). The majority of respondent (77.5%) worked in a hospital-based practice, while 18.8% worked in clinic-based practice. A large proportion (46.6%) of respondents were not aware of nutritional guidelines for HNC patients; with 23.6% not aware of any, and 23.0% aware of their existence but not aware of their content. The majority (81.5%) of respondents said that a more detailed guideline should be available for HNC patient with regards to nutrition. Conclusion Nutritional deficiencies in HNC patients continue to cause significant complications in treatment and recovery. Existing practice guidelines are limited and lack specific recommendations. A universal standard of care with regard to addressing nutrition in HNC patients is needed to improve healthcare outcomes among NHC patients.
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Affiliation(s)
| | - Aelia Akbar
- Internal Medicine, Loyola University Medical Center, Chicago, USA
| | - Holly Kramer
- Nephrology, Loyola University Medical Center, Chicago, USA
| | - Aqsa Iqbal
- Cardiology, University of Illinois at Chicago, Chicago, USA
| | - Talar Markossian
- Epidemiology and Public Health, Loyola University Medical Center, Chicago, USA
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Rossi R, Serra P, Suzzi M, Guerra D, Bilotta S, Ricci M, Pallotti MC, Ibrahim T, Frassineti GL, Zavoiu V, Nanni C, Altini M, Maltoni M. The challenge for nutritional care in a cancer center: The need for integration between clinical nutritionist, oncologist, and palliative care physician. Curr Probl Cancer 2020; 44:100618. [PMID: 32684290 DOI: 10.1016/j.currproblcancer.2020.100618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/25/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Patrizia Serra
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy.
| | - Monia Suzzi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Debora Guerra
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Stefania Bilotta
- Medical Oncology Department, Santa Maria della Scaletta Hospital, Imola, Italy
| | - Marianna Ricci
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Maria Caterina Pallotti
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Venetia Zavoiu
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Cristina Nanni
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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Einarsson S, Laurell G, Tiblom Ehrsson Y. Mapping the frequency of malnutrition in patients with head and neck cancer using the GLIM Criteria for the Diagnosis of Malnutrition. Clin Nutr ESPEN 2020; 37:100-106. [PMID: 32359730 DOI: 10.1016/j.clnesp.2020.03.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/07/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Patients with head and neck cancer are defined as high-risk patients for malnutrition, but the inconsistent practice of diagnosing malnutrition is a barrier in comparing studies and in assessing patients in clinical practice. The aim of the study was to describe the frequency of malnutrition over time in patients treated for head and neck cancer using the GLIM Criteria for the Diagnosis of Malnutrition. METHODS Data from a prospective observational study on patients with head and neck cancer were used (n = 210). Patients were assessed for malnutrition using the combination of one phenotypic and one etiologic criterion. The following phenotypic criteria for malnutrition were used: body weight loss (either >5% within the past six months or >10% beyond six months), body mass index (<20 kg/m2 if <70 years or <22 kg/m2 if ≥70 years), and fat free mass index measured by bioelectrical impedance analysis (<17 FFM/m2 for males and <15 FFM/m2 for females). The following etiologic criteria for malnutrition were used: reduced food intake (partial or no food intake with the need for artificial nutrition) and C-reactive protein (>5 mg/L). RESULTS For all eight possible combinations of GLIM, the frequency of malnutrition reached its highest point at seven weeks after the start of treatment. A total of 32% of the patients fulfilled the criteria for malnutrition using weight loss >5% within the past six months (phenotypic) in combination with C-reactive protein >5 mg/L (etiologic). CONCLUSIONS GLIM Criteria for the Diagnosis of Malnutrition can be used to assess malnutrition in patients with head and neck cancer during treatment. Using the same criteria to define malnutrition in nutritional research will make it possible to produce multiple lines of evidence on malnutrition in head and neck cancer and its adverse effects on treatment, prognosis, and survival.
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Affiliation(s)
- Sandra Einarsson
- Department of Food, Nutrition and Culinary Science, Umeå University, SE-901 87, Umeå, Sweden.
| | - Göran Laurell
- Department of Surgical Sciences, Section of Otorhinolaryngology and Head & Neck Surgery, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Ylva Tiblom Ehrsson
- Department of Surgical Sciences, Section of Otorhinolaryngology and Head & Neck Surgery, Uppsala University, SE-751 85, Uppsala, Sweden.
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Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey. JOURNAL OF ONCOLOGY 2019; 2019:7462940. [PMID: 31885583 PMCID: PMC6893237 DOI: 10.1155/2019/7462940] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/12/2019] [Accepted: 10/03/2019] [Indexed: 01/07/2023]
Abstract
Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Medical nutrition therapy (MNT) optimizes clinical outcomes, yet registered dietitian nutritionists (RDNs), the healthcare professionals specifically trained in MNT, are not routinely employed in outpatient cancer centers where over 90% of all cancer patients are treated. The objective of this study was to evaluate RDN staffing patterns, nutrition services provided in ambulatory oncology settings, malnutrition screening practices, and referral and reimbursement practices across the nation in outpatient cancer centers. An online questionnaire was developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics and distributed via the ON DPG electronic mailing list. Complete data were summarized for 215 cancer centers. The mean RDN full-time equivalent (FTE) for all centers was 1.7 ± 2.0. After stratifying by type of center, National Cancer Institute-Designated Cancer Centers (NCI CCs) employed a mean of 3.1 ± 3.0 RDN FTEs compared to 1.3 ± 1.4 amongst non-NCI CCs. The RDN-to-patient ratio, based on reported analytic cases, was 1 : 2,308. Per day, RDNs evaluated and counseled an average of 7.4 ± 4.3 oncology patients. Approximately half (53.1%) of the centers screened for malnutrition, and 64.9% of these facilities used a validated malnutrition screening tool. The majority (76.8%) of centers do not bill for nutrition services. This is the first national study to evaluate RDN staffing patterns, provider-to-patient ratios, and reimbursement practices in outpatient cancer centers. These data indicate there is a significant gap in RDN access for oncology patients in need of nutritional care.
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Vittayakasemsont K, Klaitong C, Phukosi K, Chavasit V, Sinthusek T, Trachootham D. Association Between Pretreatment Dietary Preference and Weight Loss after Radiation Therapy in Head and Neck Cancer Patients: A Pilot Study. Nutr Cancer 2019; 71:230-239. [DOI: 10.1080/01635581.2019.1578393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Kanoknun Vittayakasemsont
- Division of Nutrition and Dietetics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonsanee Klaitong
- Department of Radiation Oncology, Maha Vajiralongkorn Thanyaburi Hospital, Pathum Thani, Thailand
| | - Kulachatr Phukosi
- Department of Radiation Oncology, Maha Vajiralongkorn Thanyaburi Hospital, Pathum Thani, Thailand
| | - Visith Chavasit
- Institute of Nutrition, Mahidol University, Nakhon Pathom, Thailand
| | - Tanadej Sinthusek
- Department of Radiation Oncology, Maha Vajiralongkorn Thanyaburi Hospital, Pathum Thani, Thailand
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Translation and Cultural Adaptation of the Scored Patient-Generated Subjective Global Assessment: An Interdisciplinary Nutritional Instrument Appropriate for Dutch Cancer Patients. Cancer Nurs 2018; 41:450-462. [DOI: 10.1097/ncc.0000000000000505] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Carvalho-Salemi J, Salemi JL, Wong-Vega MR, Spooner KK, Juarez MD, Beer SS, Canada NL. Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011. J Acad Nutr Diet 2018; 118:40-51.e7. [DOI: 10.1016/j.jand.2017.02.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/16/2017] [Indexed: 01/13/2023]
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Leung JSL, Seto A, Li GKH. Association Between Preoperative Nutritional Status and Postoperative Outcome in Head and Neck Cancer Patients. Nutr Cancer 2017; 69:464-469. [PMID: 28287316 DOI: 10.1080/01635581.2017.1285406] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Head and neck cancer patients treated with surgery often experience significant postoperative morbidities. Administering preoperative nutritional intervention may improve surgical outcomes, but there is currently a paucity of data reviewing the association between preoperative nutritional status and postoperative outcome. It is therefore of importance to investigate this association among head and neck cancer patients. To assess the association between preoperative nutritional status and postoperative outcome in head and neck cancer patients treated with surgery, a retrospective study of 70 head and neck cancer patients who were surgically treated between 2013 and 2014 in a tertiary referral head and neck surgery center in Hong Kong was conducted. Clinical data regarding preoperative nutritional status and postoperative outcome were retrieved from a computer record system. Logistic and linear regressions were used to analyze the appropriate parameters. A higher preoperative albumin level was associated with lower rates of postoperative complications and better wound healing (P < 0.05). In contrast, preoperative body mass index, hemoglobin level, and absolute lymphocyte count did not demonstrate significant associations with postoperative outcome. As high albumin levels are associated with better surgical outcome in head and neck cancer patients, preoperative intervention strategies that boost albumin levels could be considered for improving surgical outcome.
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Affiliation(s)
- John S L Leung
- a Li Ka Shing Faculty of Medicine , The University of Hong Kong , Pokfulam, Hong Kong SAR , China
| | - Alfred Seto
- a Li Ka Shing Faculty of Medicine , The University of Hong Kong , Pokfulam, Hong Kong SAR , China
| | - George K H Li
- a Li Ka Shing Faculty of Medicine , The University of Hong Kong , Pokfulam, Hong Kong SAR , China
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16
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Kapucu S. Nutritional Issues and Self-care Measures Adopted by Cancer Patients Attending a University Hospital in Turkey. Asia Pac J Oncol Nurs 2017; 3:390-395. [PMID: 28083557 PMCID: PMC5214873 DOI: 10.4103/2347-5625.196500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to assess the nutritional status of cancer patients and the self-care measures they adopted as a response to nutritional problems. Methods: This descriptive study included seventy cancer patients staying in the oncology and internal disease clinics of a university hospital in Turkey. Data were collected using a questionnaire with 29 questions. Results: The mean age of participants was 40.2 ± 1.82 years. Approximately, 62.9% of the patients ate only half of the meals offered to them, 65.7% experienced weight loss, and 45.7% had difficulty eating their meals on their own. Moreover, 47.1% of the patients received nutritional support and nutritional problems were observed in 71.4% of the patients; 80% were unable to eat hospital food, 54.3% had an eating disorder related to a special diet, 30% suffered from loss of appetite, 27% had nausea, and 14.3% had difficulty swallowing. Furthermore, 48.5% of patients responded that they ate home-cooked food or ordered food from outside when questioned about the self-care measures taken to avoid the aforementioned nutritional problems. Conclusions: Most of the cancer patients had serious nutritional problems and ate home-cooked food and used nutritional supplements to overcome these problems. Oncology nurses are responsible for evaluating the nutritional status of cancer patients and eliminating nutritional problems.
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Perl G, Nordheimer S, Lando S, Benedict C, Brenner B, Perry S, Shmoisman G, Purim O, Amit L, Stemmer SM, Ben-Aharon I. Young patients and gastrointestinal (GI) tract malignancies - are we addressing the unmet needs? BMC Cancer 2016; 16:630. [PMID: 27519697 PMCID: PMC4983017 DOI: 10.1186/s12885-016-2676-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/04/2016] [Indexed: 01/11/2023] Open
Abstract
Background Recent epidemiological studies indicate the rate of gastrointestinal (GI) malignancies among younger patients is increasing, mainly due to colorectal cancer. There is a paucity of data regarding the magnitude of treatment-related symptoms, psychosocial issues and potential unmet needs in this population. We aimed to characterize the needs of this population to evaluate whether unmet needs could be targeted by potential intervention. Methods Female and male patients diagnosed with cancer of the gastrointestinal tract <40y retrospectively completed a questionnaire to evaluate symptoms, daily function and unmet needs at pre-treatment, during and post-treatment. Comparisons were made by gender, disease stage and treatment modality. Multiple linear regression models evaluated effects of demographics, symptoms and needs on multiple domains of health-related-quality-of-life (using Short-Form Health Survey-12 and CARES). Results Fifty patients were enrolled (52 % female) to a pilot study. Median age at diagnosis was 35.5y (range, 21-40y). The symptoms that significantly increased from baseline to during and post-treatment were: diarrhea (37 %), sleeping disorder (32 %) and sexual dysfunction (40 %). Patients also reported significant deterioration in occupational activities and coping with children compared with baseline. Female patients reported significant unmet need for nutritional counseling and psychosocial support compared to male patients (p < 0.05). Patients treated with multimodality-treatment presented higher rates of unmet needs (p = 0.03). Conclusions Young patients with GI cancers represent a group with unique characteristics and needs compared with published evidence on other young-onset malignancies. The distinctive symptoms and areas of treatment-related functional impairments indicate there are unmet needs, especially in the area of psychosocial support and nutritional counseling.
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Affiliation(s)
- G Perl
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel
| | - S Nordheimer
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel
| | - S Lando
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - C Benedict
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - B Brenner
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - S Perry
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - G Shmoisman
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel
| | - O Purim
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel
| | - L Amit
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel
| | - S M Stemmer
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - I Ben-Aharon
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Kaplan St, Petah-Tiqva, 49100, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
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Sealy MJ, Nijholt W, Stuiver MM, van der Berg MM, Roodenburg JL, van der Schans CP, Ottery FD, Jager-Wittenaar H. Content validity across methods of malnutrition assessment in patients with cancer is limited. J Clin Epidemiol 2016; 76:125-36. [DOI: 10.1016/j.jclinepi.2016.02.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 02/01/2016] [Accepted: 02/22/2016] [Indexed: 12/30/2022]
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Li X, Feng Y, Wang H, Song M, Jin J, Cui Z, Zheng Y. Nutritional status survey of aplastic anemia patients - a single center experience in China. Appl Nurs Res 2016; 30:142-7. [DOI: 10.1016/j.apnr.2015.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/30/2015] [Accepted: 09/06/2015] [Indexed: 10/23/2022]
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20
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Aktas A, Walsh D, Galang M, O'Donoghue N, Rybicki L, Hullihen B, Schleckman E. Underrecognition of Malnutrition in Advanced Cancer: The Role of the Dietitian and Clinical Practice Variations. Am J Hosp Palliat Care 2016; 34:547-555. [PMID: 27069100 DOI: 10.1177/1049909116639969] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Malnutrition (MN) often goes unrecognized due to ineffective screening techniques. Published standards for multidisciplinary care exist but no consensus on best nutritional assessment for hospitalized patients. Malnutrition is common in cancer and adversely affects clinical outcomes. The Cleveland Clinic Nutrition Therapy Department used in-house criteria to classify MN in hospitalized patients. This study aimed to evaluate the registered dietitian (RD)'s role, the use of these criteria in the acute care palliative medicine unit (ACPMU), and investigate MN prevalence and severity among admitted patients with cancer. METHODS Electronic medical records were reviewed for newly admitted patients with cancer to the ACPMU with a first time RD consult and completed nutritional therapy assessment. Physician (MD) assessments were derived from admission notes. Cox regression model assessed the association of MN prevalence and severity with survival. McNemar's test determined whether a prevalence difference existed between RD and MD. RESULTS Variations existed in criteria used to identify MN. Seventy percent had MN, with the majority (61%) classed as moderate to severe. Prevalence (hazard ratio [HR]: 1.88; P = .002) and severity (HR: 1.22; P = .006) were associated with significantly increased mortality. Evaluations by RD and MD were highly congruent, but MDs underrecorded nutritional status. CONCLUSION Malnutrition was prevalent and clinically important, even in those on nutritional support. Variations in MN identification were common. Physicians underrecorded MN but were accurate for prevalence and severity when recorded. The data confirm the RD's important role in MN assessment. Comparable clinical practice and better communication between physicians and dietitians should improve cancer care and optimize quality of life.
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Affiliation(s)
- Aynur Aktas
- 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.,2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Declan Walsh
- 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.,2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA.,3 Faculty of Health Sciences, Trinity College, Dublin 2, Ireland
| | - Marianne Galang
- 4 Section of Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Niamh O'Donoghue
- 3 Faculty of Health Sciences, Trinity College, Dublin 2, Ireland
| | - Lisa Rybicki
- 5 Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Barbara Hullihen
- 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.,2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ellen Schleckman
- 1 Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA.,2 The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA
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21
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Sensitivity and Specificity of Malnutrition Screening Tools Used in the Adult Hospitalized Patient Setting. TOP CLIN NUTR 2015. [DOI: 10.1097/tin.0000000000000046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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22
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Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES® study. Support Care Cancer 2015; 24:429-435. [DOI: 10.1007/s00520-015-2813-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
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23
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Phillips W. Accurate Documentation of Malnutrition Diagnosis Reflects Increased Healthcare Resource Utilization. Nutr Clin Pract 2015; 30:604-8. [DOI: 10.1177/0884533615589372] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Platek ME, Johnson J, Woolf K, Makarem N, Ompad DC. Availability of Outpatient Clinical Nutrition Services for Patients With Cancer Undergoing Treatment at Comprehensive Cancer Centers. J Oncol Pract 2015; 11:1-5. [DOI: 10.1200/jop.2013.001134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Comprehensive cancer centers rely on referral-based clinical nutrition services, which are not always a part of multidisciplinary care. An in-depth comparison of clinical nutrition services among other approaches to cancer care is needed.
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Patel V, Romano M, Corkins MR, DiMaria-Ghalili RA, Earthman C, Malone A, Miller S, Sabino K, Wooley J, Guenter P. Nutrition Screening and Assessment in Hospitalized Patients. Nutr Clin Pract 2014; 29:483-490. [PMID: 24993585 DOI: 10.1177/0884533614535446] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Vihas Patel
- Metabolic Support Service, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Mark R. Corkins
- Le Bonheur Children’s Hospital/University of Tennessee Health Sciences Center, Memphis, Tennessee
| | | | | | | | - Sarah Miller
- University of Montana Skaggs School of Pharmacy, Missoula, Montana
| | - Kim Sabino
- St Francis Hospital and Medical Center, Hartford, Connecticut
| | | | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
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Couch ME, Dittus K, Toth MJ, Willis MS, Guttridge DC, George JR, Barnes CA, Gourin CG, Der-Torossian H. Cancer cachexia update in head and neck cancer: Definitions and diagnostic features. Head Neck 2014; 37:594-604. [DOI: 10.1002/hed.23599] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/21/2013] [Accepted: 01/07/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Marion E. Couch
- Division of Otolaryngology - Head and Neck Surgery; Department of Surgery; Vermont Cancer Center; University of Vermont, College of Medicine; Burlington Vermont
| | - Kim Dittus
- Division of Hematology - Oncology; Department of Medicine; Vermont Cancer Center; University of Vermont, College of Medicine; Burlington Vermont
| | - Michael J. Toth
- Department of Molecular Physiology and Biophysics; University of Vermont, College of Medicine; Burlington Vermont
| | - Monte S. Willis
- Department of Pathology and Laboratory Medicine; McAllister Heart Institute; University of North Carolina; Chapel Hill North Carolina
| | - Denis C. Guttridge
- Department of Molecular Virology; Immunology; and Medical Genetics; Ohio State University; Columbus Ohio
| | - Jonathan R. George
- Department of Otolaryngology - Head and Neck Surgery; University of California; San Francisco California
| | - Christie A. Barnes
- Division of Otolaryngology - Head and Neck Surgery; Department of Surgery; Vermont Cancer Center; University of Vermont, College of Medicine; Burlington Vermont
| | - Christine G. Gourin
- Department of Otolaryngology - Head and Neck Surgery; Johns Hopkins University; Baltimore Maryland
| | - Hirak Der-Torossian
- Division of Otolaryngology - Head and Neck Surgery; Department of Surgery; Vermont Cancer Center; University of Vermont, College of Medicine; Burlington Vermont
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The use of hand grip strength as a predictor of nutrition status in hospital patients. Clin Nutr 2014; 33:106-14. [DOI: 10.1016/j.clnu.2013.03.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 02/25/2013] [Accepted: 03/04/2013] [Indexed: 11/18/2022]
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28
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:109-25. [DOI: 10.1097/spc.0b013e328350f70c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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