Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey

A theoretical explanation for how a nutrition counseling and medically tailored meal delivery program benefitted participants living with lung cancer

PURPOSE

The purpose of this study was to assess participants' perceptions and experiences while participating in a Food is Medicine medically tailored meal plus intensive nutrition counseling intervention to create a theoretical explanation about how the intervention worked.

METHODS

This interpretive qualitative study included the use of semi-structured interviews with active participants in a randomized controlled trial aimed at understanding how a medically tailored meal plus nutrition counseling intervention worked for vulnerable individuals with lung cancer treated at four cancer centers across the USA. During the 8-month long study, participants in the intervention arm were asked to be interviewed, which were recorded, transcribed verbatim, and analyzed using conventional content analysis with principles of grounded theory.

RESULTS

Twenty individuals participated. Data analysis resulted in a theoretical explanation of the intervention's mechanism of action. The explanatory process includes three linked and propositional categories leading to patient resilience: engaging in treatment, adjusting to diagnosis, and active coping. The medically tailored meals plus nutrition counseling engaged participants throughout treatment, which helped participants adjust to their diagnosis, leading to active coping through intentional self-care, behavior change, and improved quality of life.

CONCLUSIONS

These findings provide evidence that a Food is Medicine intervention may buffer some of the adversity related to the diagnosis of lung cancer and create a pathway for participants to experience post-traumatic growth, develop resilience, and change behaviors to actively cope with lung cancer. Medically tailored meals plus intensive nutrition counseling informed by motivational interviewing supported individuals' adjustment to their diagnosis and resulted in perceived positive behavior change.

Exploring relationships with food after dietary intervention in patients with colorectal cancer: a qualitative analysis from the Protein Recommendations to Increase Muscle (PRIMe) trial

PURPOSE

Patients with cancer often experience nutritional challenges and are vulnerable to muscle mass loss. While substantial research is directed towards understanding how nutritional interventions affect clinical outcomes, insights into patients' personal experiences during these trials remain limited. This qualitative study aimed to gain a deeper understanding of how participation in the Protein Recommendations to Increase Muscle (PRIMe) trial affected patients' relationships with food.

METHODS

A subset of patients who completed a minimum of one follow-up visit in the PRIMe trial participated in a semi-structured interview about their experience implementing dietary modifications to increase protein intake. Data from 26 patients with a recent diagnosis of stage II-IV colorectal cancer (non-cachectic) were included. Interviews were audio recorded, transcribed verbatim, and qualitative content analysis was applied.

RESULTS

Most patients were male (65.4%) with stage II or III (69.2%) colorectal cancer and were a mean age of 57 ± 10 years. Five key themes emerged to provide a deeper understanding of patients' relationship with food after the PRIMe trial: (1) new positive perspectives on nutrition and coping with a cancer diagnosis; (2) embracing a comprehensive approach to food and nutrition; (3) facilitators promoting adherence to the intervention; (4) barriers challenging adherence to the intervention; and (5) shaping future dietary intake.

CONCLUSION

This qualitative study explored the emotional and psychological effects of a clinical nutrition trial on patients, focusing on their relationship with food. It underscored the trial's comprehensive intervention and its enduring influence on patients, extending beyond the immediate intervention phase. The role of current perspectives, motivation, and knowledge acquisition on ability to adhere to dietary changes to increase protein intake were emphasized by patients and are key considerations for both clinicians and researchers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02788955; registration posted on 2016-06-02.

Nutritional impairment, psychological health and quality of life among older adults with advanced cancer: A secondary analysis of a randomized clinical trial

BACKGROUND

Nutritional impairment is associated with treatment toxicity and worse overall survival in patients with cancer. We aimed to (1) evaluate the association of nutritional impairment with psychological health and quality of life (QOL) and (2) examine which measures of nutrition had the strongest association with psychological health and QOL among older adults receiving cancer treatment with palliative intent.

METHODS

This secondary analysis was performed on baseline data from a nationwide cluster randomized clinical trial (ClinicalTrials.gov identifier: NCT02107443; PI: Mohile). Adults age ≥70 with advanced cancer and ≥1 geriatric assessment (GA) impairment were enrolled from 2014 to 2017. In line with geriatric oncology standards, we defined nutritional impairment as Mini Nutritional Assessment Short Form (MNA-SF) ≤11, body mass index (BMI) <21 kg/m2, or >10% involuntary weight loss in the past 6 months. We conducted multivariable linear regressions to evaluate the association of nutritional impairment with each measure of psychological health and QOL: Geriatric Depression Scale (GDS-15, range 0-15), Generalized Anxiety Disorder-7 (GAD-7, range 0-21), NCCN Distress Thermometer (NCCN DT, range 0-10), and Functional Assessment of Cancer Therapy-General (FACT-G, range 0-108). Analyses were adjusted for patient demographics, clinical characteristics, and GA.

RESULTS

Among 541 patients, the mean age was 77 (range 70-96) and 60% had nutritional impairment. Mean baseline scores: GDS-15 3.1 (SD 2.7), GAD-7 2.9 (SD 4.0), NCCN DT 2.9 (SD 2.7), and FACT-G 80 (SD 15). In the adjusted model, compared to those with no nutritional impairment, older adults with nutritional impairment had greater depression (β = 0.79, 95% CI 0.36-1.23) and anxiety severity (β = 0.86, 95% CI 0.19-1.53), and worse QOL (β = -6.31, 95% CI -8.62 to -4.00). Of the measures of nutrition, MNA-SF ≤11 demonstrated the strongest associations with depression, anxiety, distress, and QOL.

CONCLUSION

Nutritional impairment is associated with impaired psychological health and worse QOL. Clinicians should use the MNA-SF to screen older adults for nutritional impairment and offer tailored supportive interventions.

National Implementation of an Artificial Intelligence-Based Virtual Dietitian for Patients With Cancer

PURPOSE

Nutritional status is an established driver of cancer outcomes, but there is an insufficient workforce of registered dietitians to meet patient needs for nutritional counseling. Artificial intelligence (AI) and machine learning (ML) afford the opportunity to expand access to guideline-based nutritional support.

METHODS

An AI-based nutrition assistant called Ina was developed on the basis of a learning data set of >100,000 expert-curated interventions, peer-reviewed literature, and clinical guidelines, and provides a conversational text message-based patient interface to guide dietary habits and answer questions. Ina was implemented nationally in partnership with 25 advocacy organizations. Data on demographics, patient-reported outcomes, and utilization were systematically collected.

RESULTS

Between July 2019 and August 2023, 3,310 users from all 50 states registered to use Ina. Users were 73% female; median age was 57 (range, 18-91) years; most common cancer types were genitourinary (22%), breast (21%), gynecologic (19%), GI (14%), and lung (12%). Users were medically complex, with 50% reporting Stage III to IV disease, 37% with metastases, and 50% with 2+ chronic conditions. Nutritional challenges were highly prevalent: 58% had overweight/obese BMIs, 83% reported barriers to good nutrition, and 42% had food allergies/intolerances. Levels of engagement were high: 68% texted questions to Ina; 79% completed surveys; median user retention was 8.8 months; 94% were satisfied with the platform; and 98% found the guidance helpful. In an evaluation of outcomes, 84% used the advice to guide diet; 47% used recommended recipes, 82% felt the program improved quality of life (QoL), and 88% reported improved symptom management.

CONCLUSION

Implementation of an evidence-based AI virtual dietitian is feasible and is reported by patients to be beneficial on diet, QoL, and symptom management. Ongoing evaluations are assessing impact on other outcomes.

The nutrition-related adverse events associated with immune checkpoint inhibitor treatment for patients with non-small cell lung cancer: A systematic review

AIMS

Immune checkpoint inhibitor therapy used for lung cancer has significantly changed response and survival rates, however, the impact on patients' nutritional status remains largely unexplored. This review aims to identify common adverse events that increase nutrition risk induced in non-small cell lung cancer patients treated with immune checkpoint inhibitor therapy and assess impact on nutritional status.

METHODS

PubMed, Medline and CINAHL were systematically searched in September 2023 for randomised controlled trials comparing immune checkpoint inhibitor treatment of non-small cell lung cancer to a control group. Treatment-related adverse events that increased nutrition impact symptoms identified in the patient-generated subjective global assessment and clinical guidelines were extracted and qualitatively analysed. Risk of bias was assessed using Cochrane Risk of Bias tool 2.

RESULTS

Eleven eligible randomised controlled trial studies were identified and analysed. The data demonstrated immune checkpoint inhibitor treatment was associated with a lower percentage of reported nutrition impact symptoms, for example, decreased appetite, nausea, vomiting, compared to chemotherapy treatment. Conversely, immune checkpoint inhibitor treated patients recorded a greater percentage of immune-related adverse events that alter metabolism or nutrient absorption.

CONCLUSION

Non-small cell lung cancer patients treated with immune checkpoint inhibitors still experience nutrition impact symptoms but less frequently than patients treated with chemotherapy. This combined with unique nutrition-related consequences from colitis and thyroid disorders induced by immune checkpoint inhibitor therapy indicates patients should be screened, assessed and interventions implemented to improve nutrition.

E-PROOF: E-intervention for protein intake and resistance training to optimize function: A study protocol

BACKGROUND

Accounting for more than 60% of cancer survivors, older (≥65 years) cancer survivors have a 2- to 5-fold risk of physical function impairment, compared to cancer-free peers. One strategy to improve physical function is dietary and resistance training interventions, which improve muscle strength and mass by stimulating muscle protein synthesis. The E-PROOF (E-intervention for Protein Intake and Resistance Training to Optimize Function) study will examine the feasibility, acceptability, and preliminary efficacy of a 12-week randomized controlled trial of an online, tailored nutritional and resistance training education and counseling intervention to improve physical function and associated health outcomes (muscle strength, health-related quality of life (HRQoL), self-efficacy, and weight management).

METHODS

In this study, 70 older cancer survivors will be randomized to one of two groups: experimental (receiving remote behavioral counseling and evidence-based education and resources), and control (general survivorship education). We will examine the intervention effects on physical function, muscle strength, HRQoL, self-efficacy, weight, and waist circumference during a 12-week period between the experimental and control groups. Three months following the end of the intervention, we will conduct a follow-up assessment to measure physical function, muscle strength, and HRQoL.

SIGNIFICANCE AND IMPACT

This study is the first synchronous, online protein-focused diet and resistance training intervention among older cancer survivors. This novel study advances science by promoting independent health behaviors among older cancer survivors to improve health outcomes, and provide foundational knowledge to further address this growing problem on a wider scale through online platforms.

Bridging gaps in cancer cachexia Care: Current insights and future perspectives

Cachexia is characterized by severe weight loss and skeletal muscle depletion, and is a threat to cancer patients by worsening their prognosis. International guidelines set indications for the screening and diagnosis of cancer cachexia and suggest interventions (nutritional support, physical exercise, and pharmacological treatments). Nevertheless, real-life experience not always aligns with such indications. We aimed to review the current state of the field and the main advancements, with a focus on real-life clinical practice from the perspectives of oncologists, nutrition professionals, and radiologists. Pragmatic solutions are proposed to improve the current management of the disease, emphasizing the importance of increasing awareness of clinical nutrition's benefits, fostering multidisciplinary collaboration, promoting early identification of at-risk patients, and leveraging available resources. Given the distinct needs of patients who are receiving oncologic anti-cancer treatments and those in the follow-up phase, the use of tailored approaches is encouraged. The pivotal role of healthcare professionals in managing patients in active treatment is highlighted, while patient and caregiver empowerment should be strengthened in the follow-up phase. Telemedicine and web-based applications represent valuable tools for continuous monitoring of patients, facilitating timely and personalized intervention through effective communication between patients and healthcare providers. These actions can potentially improve the outcomes, well-being, and survival of cancer patients with cachexia.

Effectiveness of a Digital Decision Aid for Nutrition Support in Women with Gynaecological Cancer: A Comparative Study

This study aimed to examine the effects of an animated Patient Decision Aid (PtDA) about dietary choices on decisional conflict and decision regret. A prospective, observational, two-group comparative effectiveness study was conducted with patients (n = 90) from a southern Taiwan oncology inpatient unit. Data included the Malnutrition Universal Screening Tool (MUST), laboratory results, 16-item Decisional Conflict Scale (sf-DCS), and 5-item Decision Regret Scale (DRSc). Data were collected at admission (T0), after the first-cycle of chemotherapy but before discharge (T1), and after the six-cycle chemotherapy protocol (T2) (around 3 months). Group A received standardized nutrition education and a printed brochure, while Group B watched a 10-minute information video during a one-on-one inpatient consultation and engaged in a values clarification exercise between T0 and T1. The percentage of women with a MUST score ≧1 in Group A sharply increased over time, but not in Group B. Decision aid usage significantly increased patients' hemoglobin and lymphocyte values over time (p < 0.05). The digital PtDA contributed to less decisional conflict and decision regret in at-risk patients and improved their nutritional well-being. Decision-aids help patients make healthcare decisions in line with their values, and are sustainable for use by busy clinicians.

How a Medically Tailored Meal Intervention with Intensive Nutrition Counseling Created Active Coping with Behavior Change for Vulnerable Patients with Lung Cancer

Purpose

The purpose of this study was to assess participants' perceptions and experiences while participating in a Food is Medicine medically tailored meal plus nutrition counseling intervention to create a theoretical explanation about how the intervention worked.

Methods

This interpretive qualitative study included the use of semi-structured interviews with active intervention participants. Purposeful sampling included vulnerable (uninsured, rural zip code residency, racial/ethnic minority, 65 years old, and/or low-income) individuals with lung cancer treated at four cancer centers across the United States. Interviews were recorded, transcribed verbatim, and analyzed using conventional content analysis with principles of grounded theory.

Results

Twenty individuals participated. Data analysis resulted in a theoretical explanation of the intervention's mechanism of action. The explanatory process includes 3 linked and propositional categories leading to patient resilience: engaging in treatment, adjusting to diagnosis, and active coping. The medically tailored meals plus intensive nutrition counseling engaged participants throughout treatment, which helped participants adjust to their diagnosis, leading to active coping through intentional self-care, behavior change, and improved quality of life.

Conclusions

These findings provide evidence that a food is medicine intervention may buffer some of the adversity related to the diagnosis of lung cancer and create a pathway for participants to experience post-traumatic growth, develop resilience, and change behaviors to actively cope with lung cancer. Medically tailored meals plus intensive nutrition counseling informed by motivational interviewing supported individuals' adjustment to their diagnosis and resulted in perceived positive behavior change.

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

The association of the Affordable Care Act with nutrient consumption in adults in the United States

The Patient Protection and Affordable Care Act, more commonly known as the ACA, was legislation passed in the United States in 2010 to expand access to health insurance coverage for millions of Americans with a key emphasis on preventive care. Nutrition plays a critical role in overall wellness, disease prevention and resilience to chronic illness but prior to the ACA many Americans did not have adequate health insurance coverage to ensure proper nutrition. With passage of the ACA, more individuals received access to nutritional counseling through their primary care physicians as well as prescription vitamins and supplements free of charge. The objective of this study was to evaluate the impact of a national health insurance reform on nutrient intake among general population, including more vulnerable low-income individuals and patients with chronic conditions. Using data from the National Health and Nutrition Examination Survey (NHANES), we identified 8,443 adults aged 21 years and older who participated in the survey before (2011-2012) and after the ACA (2015-2016) implementation and conducted a subgroup analysis of 952 respondents who identified as Medicaid beneficiaries and 719 patients with a history of cancer. Using pre-post study design and bivariate and multivariable logistic analyses, we compared nutrient intake from food and supplementation before and after the ACA and identified risk factors for inadequate intake. Our results suggest that intake of micronutrients found in nutrient-dense foods, mainly fruit and vegetables, has not changed significantly after the ACA. However, overall use of nutritional supplements increased after the ACA (p = 0.05), particularly magnesium (OR = 1.02), potassium (OR = 0.76), vitamin D (both D2, and D3, OR = 1.34), vitamin K (OR = 1.15) and zinc (OR = 0.83), for the general population as well as those in our subgroup analysis Cancer Survivors and Medicaid Recipients. Given the association of increased use of nutritional supplements and expansion of insurance access, particularly in our subgroup analysis, more research is necessary to understand the effect of increasing access to nutritional supplements on the overall intake of micro- and macronutrients to meet daily nutritional recommended allowances.

Nutritional status associated with clinical outcomes in children with solid tumors: A retrospective cohort study from China

OBJECTIVE

To investigate the long-term changes in nutritional status in children with solid tumors during treatment and the relationship between nutritional status and clinical outcomes.

METHODS

This study was a retrospective medical records review of data from children who were diagnosed with solid tumors and followed up for more than 3 months from January 2016 to December 2021 in China. Patient demographics and clinical information, including nutritional status, parenteral nutrition use, intensive care unit (ICU) transfers, infection during hospitalization, hospitalization frequency, length of stay, hospitalization costs and antibiotic costs, were collected to analyze the nutritional status of children with different types of solid tumors, the dynamic changes in nutritional status during treatment, and the relationship between nutritional status and clinical outcomes.

RESULTS

Among the 764 patients (383 males (50.1%); 381 females (49.9%); mean age: 2.58 years), 41.6% of the solid tumors were neuroblastomas, 17.1% were hepatoblastomas, and Wilms tumors as the third most common solid tumors (8.9%). The median follow-up duration was 6 months (range: 3-40 months). At diagnosis, the proportion of children who were undernourished (underweight and wasting) versus overweight or obese were 26.71% versus 5.21% (25.86% vs. 2.89% in the third month; 29.77% vs. 2.28% in the sixth month; 24.77% vs. 3.27% in the 12th month). The body mass index Z scores decreased from the initial values after the first month (-0.56 (-1.47, 0.23) vs. -0.44 (-1.29, 0.41)) but improved later and decreased again at 6 months. The children in the undernutrition group had longer hospital stays (p < 0.001), higher hospitalization costs (p < 0.001), higher antibiotic costs (p < 0.001), a higher risk of neutropenia (OR = 4.781 (95% CI: 1.571-14.553), p = 0.006), and a higher risk of ICU transfers (OR = 1.498 (95% CI: 1.010-2.224), p = 0.044). No significant differences in those associations by malnutrition and infection, ICU duration, or length of parenteral nutrition were observed.

CONCLUSION

There is a considerable prevalence of malnutrition in children with solid tumors. Malnutrition is related to adverse clinical outcomes and increases in total hospital expenses and antibiotic costs.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes

Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

A comparative analysis of outpatient nutrition clinic scheduling outcomes based on in-person and telehealth patient care delivery modalities☆

During the start of the global COVID-19 pandemic in March 2020, patient care modalities changed from in-person to telehealth to comply with physical distancing guidelines. Our study uniquely examines operations data from three distinct periods: before the transition to telehealth, early transition from in-person care to telehealth, and the eventual adoption of telehealth. We present a comparative analysis of outpatient nutrition clinic scheduling outcomes based on care delivery modality. We used descriptive statistics to report means and variance and frequencies. We used inferential statistics to make comparisons: categorical data were compared using chi- square analysis with post-hoc comparisons using a z-test with alpha at 0.05. Means of continuous variables were compared using ANOVA with Tukey HSD post-hoc analysis. We found patient demographics remained widely unchanged across the three distinct periods as the demand for telehealth visits increased, with a notable rise in return patient visits, signaling both adaptability across the patient population and acceptance of the telehealth modality. These analyses along with evidence from the included literature review point to many the benefits of telehealth, thus telehealth as a healthcare delivery modality is here to stay. Our work serves as a foundation for future studies in this field, provides information for decision-makers in telehealth-related strategic planning, and can be utilized in advocacy for the extension of telehealth coverage.

Barriers and Facilitators to Adherence to a Mediterranean Diet Intervention during Chemotherapy Treatment: A Qualitative Analysis

Patients undergoing chemotherapy are at risk for malnutrition and a high symptom burden, and nutritional interventions can address clinical and supportive care outcomes. Herein, we identified barriers and facilitators to adhering to a Mediterranean Diet (MedDiet) intervention during chemotherapy. Patients with cancer (any type) who were undergoing chemotherapy were enrolled into a clinical trial testing the effects of an 8-week MedDiet intervention on cancer-related fatigue. Participants were randomized 2:1, MedDiet:control. The intervention entailed food provision, education, a cookbook, a session with a nutritionist, and weekly check-ins. Post-intervention, all participants completed semi-structured exit interviews. The interviews were transcribed and open coding was conducted to describe the facilitators and barriers to MedDiet adherence. Participants (n = 29, n = 21 in the intervention group) were 51.0 ± 15.1 years old and 93.1% had breast cancer. Educational materials and convenient food delivery were the highest reported facilitators. Many patients offered that changing their diet gave a sense of control and empowerment. Barriers to adherence were that the frozen food was unappetizing, participants' (or their spouse/children's) food preferences did not align with the MedDiet, and chemotherapy-induced side effects that prevented food consumption (eg, mouth sores, lack of appetite). This project helps understand the patient experience within nutritional interventions to optimize dietary programs during chemotherapy treatment.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

GLIM criteria as a valid tool for nutrition assessment and mortality prediction in treatment-naïve patients with cancer

BACKGROUND

Clinical care of patients with cancer mostly focuses on medical management with less attention on disease-related malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) released new criteria for diagnosing malnutrition, but the validation of these criteria in treatment-naïve patients with cancer is not well documented. This study aimed to investigate the application of the GLIM criteria in nutrition assessment and mortality prediction in treatment-naïve patients with cancer.

METHODS

A total of 267 patients newly diagnosed with different types of cancer were enrolled. Nutrition status was assessed with the Patient-Generated Subjective Global Assessment (PG-SGA) at outpatient clinic admission during the data collection period. Furthermore, after the GLIM criteria publication, nutrition status was assessed retrospectively using the GLIM criteria in the same cohort to assess validity. The agreement between the tools was calculated using kappa statistics, and the association of malnutrition according to each tool and mortality was analyzed using logistic regression analysis.

RESULTS

The mean age of the patients was 58.06 ± 12.6 years, and 42.7% were women. The prevalence of malnutrition was 60.3% with GLIM criteria and 53.6% with PG-SGA. Agreement between tools was moderate (κ = 0.483, P < 0.001). During a median follow-up period of 23.6 months, 99 deaths occurred. Both GLIM-defined and PG-SGA-defined malnutrition was independently associated with 2-year mortality after adjusting for age, sex, presence of comorbidities, and stage of cancer.

CONCLUSIONS

Our findings support the validation of GLIM in diagnosing malnutrition and predicting 2-year mortality among treatment-naïve patients with cancer.

Food Insecurity Among People With Cancer: Nutritional Needs as an Essential Component of Care

A cancer diagnosis can upend work and family life, leading patients to reallocate resources away from essentials such as food. Estimates of the percentage of people navigating a cancer diagnosis and food insecurity range between 17% and 55% of the cancer patient population. The complexity of addressing food insecurity among those diagnosed with cancer during different phases of treatment is multifactorial and often requires an extensive network of support throughout each phase. This commentary explores the issue of food insecurity in the context of cancer care, explores current mitigation efforts, and offers a call to action to create a path for food insecurity mitigation in the context of cancer. Three programs that address food insecurity among those with cancer at various stages of care are highlighted, drawing attention to current impact and actionable recommendations to make programs like these scalable and sustainable. Recommendations are grounded in the National Academies of Sciences, Engineering, and Medicine social care framework through 5 essential domain areas: awareness, adjustment, assistance, alignment, and advocacy. This commentary seeks to highlight opportunities for the optimization of cancer care and reframe food access as an essential part of treatment and long-term care plans.

A large, multi-centre prospective study demonstrating high prevalence of malnutrition associated with reduced survival in ambulatory systemic anti-cancer therapy patients

BACKGROUND & AIMS

The nutritional status of cancer patients is highly variable, and known to impact on clinical outcomes. To date, no large study evaluating the nutritional status of Irish cancer patients has been reported. The aim of this study was to describe the nutritional status, using gold standard methods, of a large cohort of ambulatory oncology patients receiving Systemic Anti-Cancer Therapy and to assess the impact of abnormal body composition phenotypes on survival.

METHODS

A prospective study in adults undergoing Systemic Anti-Cancer Therapy for solid tumours enrolled patients between 2012 and 2016. Baseline details were collected incorporating demographics, cancer pathology, lifestyle, body composition (by computed tomography (CT), and inflammatory status. Skeletal muscle index (SMI) and mean muscle attenuation (MA) were obtained from CT images and categorised to low muscle mass and low MA using previously published sex specific cut points. Survival was monitored for a median of 25 months [IQR:10-46 months]. Survival analyses were conducted using multivariate Cox Proportional Hazards Models.

RESULTS

Of 1015 patients recruited, 940 patients with an evaluable CT were included in this analysis. Median age was 64 years [IQR 55-71] and 56% were male. Colorectal cancer (28%) and gastro-oesophageal (16%) were the most common diagnoses and 58% of patients had stage IV disease. Despite 56% being overweight or obese (BMI >25 kg/m²), 52% were weight losing and 17% had lost >10% body weight. Cancer Cachexia (CC) was present in 42%, 39% had low muscle mass (MM) (sarcopenia) and 45% had low MA. Overall, 73% of patients exhibited an abnormal body composition (BC) phenotype (≥1 of CC, low MM/MA). Overall survival was significantly lower in those with abnormal BC phenotype, independent of site, stage, sex, ECOG and mGPS (HR: 1.416 [95% CI: 1.069-1.875], p = 0.015).

CONCLUSIONS

Malnutrition and abnormal body composition phenotypes are common in cancer, but are often masked by adiposity. Appropriate screening and diagnostic tools should consider this co-presentation of overweight and obesity, alongside muscle depletion. Given that abnormal body composition phenotypes detectable only via CT are associated with reduced survival, these should be more widely employed to identify patients at risk of poor prognosis, and allow potentially more effective, early intervention.

"What Should I Eat?"-Addressing Questions and Challenges Related to Nutrition in the Integrative Oncology Setting

PURPOSE OF REVIEW

This review aims to assess how nutrition can be addressed in the integrative oncology setting, taking into account cancer patients' unmet needs as they relate to nutrition in cancer care and the evidence-based information that is available on this topic.

RECENT FINDINGS

During and after cancer treatment, nutrition is an important component of supportive care, for patients and their family members. Current scientific data consistently show that poor nutrition can reduce survival and decrease adherence to cancer treatments. Unfortunately, the limited availability of dietitians makes access to individualized nutrition counseling challenging, and many cancer patients still do not receive adequate nutritional support. As a result, one of the main unmet needs of patients and their families through the whole cancer trajectory is accessible and up-to-date evidence-based nutritional counseling that emphasizes basic healthy nutrition. The popularity of complementary and integrative medicine among patients with cancer makes the integrative oncology setting an excellent avenue for providing such support. A suggested simple approach that utilizes World Cancer Research Fund/American Institute for Cancer Research and American Cancer Society basic information is described. This approach can be easily incorporated into integrative oncology settings, while reserving the role for the registered dietician to address underweight patients, patients with malnutrition, and patients with more complicated dietary situations. The integrative oncology setting is in a unique place in oncology that can be utilized for enhancing dissemination of healthy nutrition information and addressing the unmet needs expressed by patients and families.

Malnutrition management in oncology: An expert view on controversial issues and future perspectives

Cancer and anticancer treatments can lead to several negative side effects, including malnutrition. Despite the recognized need for adequate nutritional support in cancer patients, in daily clinical practice, nutrition is still not considered one of the first aspects to be considered. Malnutrition negatively affects the clinical outcomes, treatment response, and overall survival of cancer patients. In this study, three of the most controversial issues related to malnutrition, which emerged during an Italian Consensus Conference, were addressed specifically for patients with head and neck as well as gastrointestinal cancer. The timing of nutritional evaluation and intervention, extension of the Enhanced Recovery after Surgery (ERAS^®) protocols, and cost-effectiveness of nutritional interventions have been considered. This study aimed to illustrate the state-of-the art of each issue and hypothesize future perspectives and actions to be taken, trying to suggest a new nutritional management model for cancer patients in Italy that overcomes the critical issues encountered. Of note, the timely diagnosis of nutritional issue appears to be essential to ensure the correct management of malnourished cancer patients as well as those who are at high risk of malnutrition. Standardized protocols, screening tests, and the inclusion of nutritional parameters in patient medical records would help to achieve good clinical outcomes. Finally, appropriate nutritional support is also associated with cost savings, and it seems necessary to promote its clinical and economic value to obtain improvements in both outcomes and management costs.

Effect of Early and Intensive Telephone or Electronic Nutrition Counselling Delivered to People with Upper Gastrointestinal Cancer on Quality of Life: A Three-Arm Randomised Controlled Trial

BACKGROUND

Delay in dietetic service provision for upper gastrointestinal cancer exacerbates disease-related malnutrition and consequently increases morbidity and mortality. Dietetic services are usually referral-based and provided face-to-face in inpatient or outpatient settings, which can delay the commencement of nutrition care. The aim of this study was to provide intensive dietetic intervention close to the time of diagnosis for upper gastrointestinal cancer and assess the effect on quality-adjusted life years.

METHODS

A three-arm randomised controlled trial of adults newly diagnosed with upper gastrointestinal cancer was performed. A behavioural-based, individually tailored, symptom-directed nutrition intervention was provided in addition to usual care, delivered by a dietitian using a telephone (synchronously) or a mobile application (asynchronously) for 18 weeks, compared with a usual care control group. Data were collected at baseline, three, six, and twelve months post-randomisation. The primary outcome was quality-adjusted life years (EQ-5D-5L quality of life assessment tool). Data were analysed using linear mixed models.

RESULTS

One hundred and eleven participants were randomised. Quality-adjusted life years were not different in the intervention groups compared with control (telephone: mean (95% CI) 0.04 (0.43, 2.3), p = 0.998; App: -0.08 (-0.18, 0.02), p = 0.135) after adjustment for baseline, nutrition risk status, age, and gender. Survival was similar between groups over 12 months. The asynchronous mobile app group had a greater number of withdrawals compared with the telephone group.

CONCLUSION

Early and intensive nutrition counselling, delivered at home, during anticancer treatment did not change quality-adjusted life years or survival over 12 months compared with usual care. Behavioural counselling alone was unable to achieve nutritional adequacy. Dietetic services delivered asynchronously using a mobile app had low acceptance for patients undergoing anticancer treatment.

TRIAL REGISTRATION

27 January 2017 Australian and New Zealand Clinical Trial Registry, ACTRN12617000152325.

Diet-microbiome interactions in cancer treatment: Opportunities and challenges for precision nutrition in cancer

Dietary patterns contribute to cancer risk. Separately, microbial factors influence the development of several cancers. However, the interaction of diet and the microbiome and their joint contribution to cancer treatment response needs more research. The microbiome significantly impacts drug metabolism, immune activation, and response to immunotherapy. One of the critical factors affecting the microbiome structure and function is diet. Data demonstrate that the diet and microbiome composition affects the immune response. Moreover, malnutrition is a significant confounder to cancer therapy response. There is little understanding of the interaction of malnutrition with the microbiome in the context of cancer. This review aims to address the current knowledge of dietary intake patterns and malnutrition among cancer patients and the impact on treatment outcomes. Second, this review will provide evidence linking the microbiome to cancer treatment response and provide evidence of the potentially strong effect that diet could have on this interaction. This review will formulate critical questions that will need further research to understand the diet-microbiome relationship in cancer treatment response and directions for future research to guide us to precision nutrition therapy to improve cancer outcomes.

Implementation and Feasibility of an Electronic Health Record-Integrated Patient-Reported Outcomes Symptom and Needs Monitoring Pilot in Ambulatory Oncology

PURPOSE

Describe the feasibility and implementation of an electronic health record (EHR)-integrated symptom and needs screening and referral system in a diverse racial/ethnic patient population in ambulatory oncology.

METHODS

Data were collected from an ambulatory oncology clinic at the University of Miami Health System from October 2019 to January 2021. Guided by a Patient Advisory Board and the Exploration, Preparation, Implementation, and Sustainment model, My Wellness Check was developed to assess physical and psychologic symptoms and needs of ambulatory oncology patients before appointments to triage them to supportive services when elevated symptoms (eg, depression), barriers to care (eg, transportation and childcare), and nutritional needs were identified. Patients were assigned assessments at each appointment no more than once in a 30-day period starting at the second visit. Assessments were available in English and Spanish to serve the needs of the predominantly Spanish-speaking Hispanic/Latino population.

RESULTS

From 1,232 assigned assessments, more than half (n = 739 assessments; 60.0%) were initiated by 506 unique patients. A total of 65.4% of English and 49.9% of Spanish assessments were initiated. Among all initiated assessments, the majority (85.1%) were completed at home via the patient portal. The most common endorsed items were nutritional needs (32.9%), followed by emotional symptoms (ie, depression and anxiety; 27.8%), practical needs (eg, financial concerns; 21.7%), and physical symptoms (17.6%). Across the physical symptom, social work, and nutrition-related alerts, 77.1%, 99.7%, and 78.8%, were addressed, respectively, by the corresponding oncology health professional, social work team member, or nutritionist.

CONCLUSION

The results demonstrate encouraging feasibility and initial acceptability of implementing an EHR-integrated symptom and needs screening and referral system among diverse oncology patients. To our knowledge, this is the first EHR-integrated symptom and needs screening system implemented in routine oncology care for Spanish-speaking Hispanics/Latinos.

American Cancer Society nutrition and physical activity guideline for cancer survivors

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

Optimizing the Nutrition Support Care Model: Analysis of Survey Data

BACKGROUND

Malnutrition is under-recognized and under-diagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low, despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models.

METHODS

This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth.

RESULTS

Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p-value <0.0001). Most responding physicians (80.7%) reported being a member of NSTs, compared with 56.5% of dietitians. Of those not practicing in NSTs (N = 81, 34.4%), 12.3% reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (48.9%), followed by leadership (30.6%), and healthcare professional (HCP) interest (23.4%). A majority (73.6%) of all respondents wanted additional training in nutrition, but reported insufficient protected time, ability to travel, or support from administrators or other HCPs.

CONCLUSION

Core actions resulting from this survey focused on formalizing physician roles, increasing inter-disciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

CLINICAL RELEVANCY STATEMENT

Physician engagement in nutrition support continues to remain low despite the increasing prevalence of malnutrition. This problem, and the working solution, is in the context of decreased engagement of other healthcare professionals in nutrition support, as well as declining Nutrition Support Team utilization. To address these issues, the ASPEN Physician Engagement Committee (PEC) conducted a survey of healthcare professionals (HCPs) involved in nutrition support. Key findings include: (1) lack of financial support and physician champions with financial knowledge; (2) inadequate valuation of physicians and other nutrition support HCPs and NSTs, and their impact on clinical outcomes; and (3) significant barriers to primary and supplementary training for physicians in nutrition. Accordingly, the PEC recommends: (1) development of cost-effective screening and intervention for malnutrition; (2) expansion of nutrition support care models appropriately scaled to the available resources and expertise; and (3) development of a knowledge translation platform to foster transmission of novel breakthroughs while addressing research, knowledge, and practice gaps. This article is protected by copyright. All rights reserved.

Nutritional education and counseling program for adult cancer patients during radiotherapy: a cluster-randomized clinical trial

PURPOSE

Nutrition education andcounseling is the first-line approach in nutritional support for adult cancer patients; however, it is not well implemented in many clinical settings. This study aims to determine the effect of an evidence-based nutrition education and counseling (NEC) program on nutrition status among cancer patients receiving radiotherapy.

SUBJECTS/METHODS

This cluster-randomized clinical trial enrolled cancer patients receiving radiotherapy from ten radiotherapy units in three hospitals. Randomization was conducted at the unit level (five units into the NEC group and five units into the usual care group). The primary outcome was nutrition status after radiotherapy measured by the Patient-Generated Subjective Global Assessment (PG-SGA). Secondary outcomes included nutrition-related blood biomarkers after radiotherapy and the use of artificial nutrition and treatment interruption during radiotherapy.

RESULTS

A total of 468 patients were enrolled (241 in the NEC and 227 in the usual care group); 196 patients were female with a mean age (SD) of 59.8 (11.9). No difference was found between the NEC and usual care groups in nutrition status and blood biomarkers at baseline. After radiotherapy, patients in the NEC group had lower PG-SGA scores (5.6 vs 6.9; MD = -1.3, p < 0.001) and lower malnutrition rate (56.0% vs 70.5%; OR = 0.5; p = 0.004) compared with the usual care group. The usages of artificial nutrition and treatment interruption during radiotherapy and the level of blood biomarkers after radiotherapy did not differ between groups.

CONCLUSIONS

Nutrition education and counseling is an effective approach in reducing malnutrition and can be generalized to multiple radiotherapy settings. REGISTERED UNDER CLINICALTRAILS.

GOV IDENTIFIER NO

None.

Increased Emergency Department Utilization and Costs for Medicare Cancer Patients with Malnutrition Diagnoses

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.

Identification of Malnutrition Risk Using Malnutrition Screening Tool in an Ambulatory Pancreas Clinic

OBJECTIVES

The aim of this project was to assess malnutrition risk in a well-defined cohort of pancreatic diseases.

METHODS

We performed a retrospective, cross-sectional study of 401 subjects with available malnutrition screening tool scores who received care at a single outpatient pancreas clinic during a 6-month study period. Univariate analyses were performed to compare demographic, anthropometric, symptoms/diseases, and risk for malnutrition characteristics across 3 strata of diseases: acute pancreatitis (n = 141), chronic pancreatitis (n = 193), and other pancreatic diagnoses (n = 67).

RESULTS

A total of 18% of subjects were identified as at risk for malnutrition, including 25% who reported involuntary weight loss and/or decreased appetite. Subjects categorized as at risk for malnutrition were more likely to have gastrointestinal symptoms. Although the nutrition consultation rates were higher in subjects at risk for malnutrition (P = 0.03), 66% did not receive a clearly indicated dietary evaluation or management recommendations. One fifth of all patients in an ambulatory pancreas clinic are identified as at risk for malnutrition using a simple, validated tool.

CONCLUSIONS

The majority of patients at increased risk for nutritional complications did not receive nutritional recommendations.

When Reality and Research Collide: Guidelines Are Essential for Optimal Nutrition Care in Pediatric Oncology

Nutritional problems are common in pediatric oncology due to the side effects of the disease and treatment. Nutrition intervention can be challenging, and little is known about the current clinical practice of registered dietitian nutritionists. An online questionnaire emailed to members of the pediatric, oncology nutrition, and clinical manager practice groups of the Academy of Nutrition and Dietetics, consisted of items related to current nutrition practice. Our questionnaire results suggest that the field of pediatric oncology is employed with relatively new dietitians (62% had <5 y of experience). Many registered dietitian nutritionists (60%) are providing care across the cancer care continuum (standard therapy, transplant, and survivorship) versus specializing in a particular area. Approximately half (52%) felt that their center had inadequate staffing, many reporting little in the outpatient setting. Barriers to providing optimal patient care included inadequate staffing, lack of time for research initiatives, and lack of evidence-based guidelines. Future studies should determine follow-up guidelines and appropriate staffing ratios for nutrition care in pediatric oncology. Approaches should be developed to support less experienced dietitians. Collaboration between dietitians at different facilities will likely be key in developing essential evidence-informed guidelines.

Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery

Background

Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery.

Methods

Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes.

Results

All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7).

Conclusions

This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial.

Trial registration

Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165.

Identifying Knowledge and Practices regarding Cancer Patient Malnutrition: A Survey Study among Oncologists

Malnutrition is one of the most common complications of cancer and its treatments with a prevalence of up to 80% among cancer patients. Thus, standardized and target-oriented attitudes of oncologists toward nutritional management are particularly important. This study aims to report the questionnaire-based evaluation of different views toward medical nutrition among medical and radiation oncologists with the purpose to underline the problems and requirements of cancer nutrition. A national web-based survey composed of 26 multiple choice questions about participant demographics, level of knowledge about cancer nutrition, and approaches to malnutrition were completed by 247 oncologists. The survey was answered by a total of 247 (34%) radiation and medical oncologists. The majority of the oncologists (77%) were working at the University Hospitals and Education & Research Hospitals. Most of them were specialists with 5-10 years of experience. Nutritional status was routinely assessed in oncology units of 84% of (206) oncologists. However, only 50% reported nutritional evaluation follow-ups without waiting for a patient's declaration and 5 (2%) oncologists reported the absence of nutritional evaluation in their unit. Additionally, more than 79% of participants reported that their knowledge was not enough about enteral and parenteral nutrition while 8% were skeptical about the benefits of medical nutrition. Although the role of nutrition as an essential part of cancer care is widely recognized, the availability of limited high-quality evidence, problems of accessibility, lack of routine nutritional evaluation, and varying indicators for malnutrition are some of the problems preventing standardized nutritional management. Therefore, there are a variety of approaches and barriers to the implementation of guidelines. Further studies are needed to identify areas of improvement, as well as strategies to implement nutritional therapy in cancer care.

Diet Quality and the Number of Comorbidities Are Associated with General Health Among Older Female Cancer Survivors

Objective: We aimed to investigate the associations between diet quality, general health, and comorbidities among older female cancer survivors. Methods: Participants (n = 171) completed one-time surveys to assess health-related quality of life (RAND-36), diet quality (Healthy Eating Index (HEI-2015)), and number of comorbidities. Additional demographic and clinical variables were collected. Descriptive statistics, analysis of covariance, correlations, and linear regressions were utilized. Results: A positive correlation was found between HEI-2015 and general health subscale scores (r = .26, p = .002). A negative correlation was found between the number of comorbidities and general health (r = -.21, p = .02). Being white (β = -.24, p = .02) and having fewer comorbidities (β = -.22, p = .04) were significantly associated with higher general health. Being unmarried (β = .24, p = .02) and having higher education (β = .32, p = .002) were significantly associated with higher HEI-2015 scores. Discussion: Healthcare providers should seek guidance from registered dietitian nutritionists for nutritional education to promote optimal nutritional status, thus contributing to improved general health among this growing population.

Examining guidelines and new evidence in oncology nutrition: a position paper on gaps and opportunities in multimodal approaches to improve patient care

Malnutrition, muscle loss, and cachexia are prevalent in cancer and remain key challenges in oncology today. These conditions are frequently underrecognized and undertreated and have devastating consequences for patients. Early nutrition screening/assessment and intervention are associated with improved patient outcomes. As a multifaceted disease, cancer requires multimodal care that integrates supportive interventions, specifically nutrition and exercise, to improve nutrient intake, muscle mass, physical functioning, quality of life, and treatment outcomes. An integrated team of healthcare providers that incorporates societies' recommendations into clinical practice can help achieve the best possible outcomes. A multidisciplinary panel of experts in oncology, nutrition, exercise, and medicine participated in a 2-day virtual roundtable in October 2020 to discuss gaps and opportunities in oncology nutrition, alone and in combination with exercise, relative to current evidence and international societies' recommendations. The panel recommended five principles to optimize clinical oncology practice: (1) position oncology nutrition at the center of multidisciplinary care; (2) partner with colleagues and administrators to integrate a nutrition care process into the multidisciplinary cancer care approach; (3) screen all patients for malnutrition risk at diagnosis and regularly throughout treatment; (4) combine exercise and nutrition interventions before (e.g., prehabilitation), during, and after treatment as oncology standard of care to optimize nutrition status and muscle mass; and (5) incorporate a patient-centered approach into multidisciplinary care.

Malnutrition risk at solid tumor diagnosis: the malnutrition screening tool in a large US cancer institute

BACKGROUND

In cancer, malnutrition is common and negatively impacts tolerance and outcomes of anti-tumor therapies. The aim of this study was to evaluate the prevalence of malnutrition risk and compare the clinicodemographic features between those with high malnutrition screening tool (MST) scores (i.e., ≥ 2 of 5 = high risk for malnutrition, H-MST) to low scores (L-MST).

METHODS

A cohort of 3585 patients (May 2017 through December 2018), who completed the MST at least once at the time of diagnosis of any stage solid tumor, were analyzed. Logistic regression tested for associations between clinicodemographic factors, symptom scores, and H-MST prevalence.

RESULTS

The median age was 64 years (25-75 IQR, 55-72), with 62% females and 81% White. Most common tumor primary sites were breast (28%), gastrointestinal (GI) (21%), and thoracic (13%). Most had non-metastatic disease (80%). H-MST was found in 28%-most commonly in upper (58%) and lower GI (42%), and thoracic (42%) tumors. L-MST was most common in breast (90%). Multivariable regression confirmed that Black race (OR 1.9, 95% CI 1.5-2.4, p =  < 0.001), cancer primary site (OR 1.6-5.7, p =  < 0.001), stage IV disease (OR 1.8, 95% CI 1.4-2.2, p =  < 0.001), low BMI (OR 4.2, 95% CI 2.5-6.9 p =  < 0.001), and higher symptom scores were all independently associated with H-MST.

CONCLUSIONS

Twenty-eight percent of solid tumor oncology patients at diagnosis were at high risk of malnutrition. Patients with breast cancer rarely had malnutrition risk at diagnosis. Significant variation was found in malnutrition risk by cancer site, stage, race, and presence of depression, distress, fatigue, and trouble eating/swallowing.

Unique Features of a Web-Based Nutrition Website for Childhood Cancer Populations: Descriptive Study

Background

Children with cancer experience a myriad of nutritional challenges that impact their nutrition status during treatment and into survivorship. Growing evidence suggests that weight at diagnosis impacts cancer outcomes, but provider guidance on nutrition and diet during treatment varies. Nutrition literacy and culinary resources may help mitigate some common nutritional problems; however, many patients may face barriers to accessing in-person classes. Along with dietitian-led clinical interventions, web-based resources such as the newly updated electronic cookbook (e-cookbook) created by The University of Texas MD Anderson Cancer Center, @TheTable, may facilitate access to nutrition and culinary education during treatment and into survivorship.

Objective

We sought to define and describe the features and content of the @TheTable e-cookbook and compare it with analogous resources for a lay audience of patients with childhood cancer and childhood cancer survivors as well as their families.

Methods

We evaluated freely available web-based resources via a popular online search engine (ie, Google). These searches yielded three web-based resources analogous to @TheTable: the American Institute for Cancer Research’s Healthy Recipes, The Children’s Hospital of San Antonio’s Culinary Health Education for Families Recipe for Life, and Ann Ogden Gaffney and Fred Hutchinson Cancer Research Center’s Cook for Your Life. These sites were analyzed for the following: number of recipes, search functionality, child or family focus, cancer focus, specific dietary guidance, videos or other media, and miscellaneous unique features.

Results

Cook for Your Life and Culinary Health Education for Families Recipe for Life were the most comparable to @TheTable with respect to cancer focus and family focus, respectively. Healthy Recipes is the least user-friendly, with few search options and no didactic videos.

Conclusions

The @TheTable e-cookbook is unique in its offering of child- and family-focused content centered on the cancer and survivorship experience.

Commentary: Quality nutrition care is integral to the Oncology Care Model

The Oncology Care Model (OCM) is a US Centers for Medicare & Medicaid Services (CMS) specialty model implemented in 2016, to provide higher quality, more highly coordinated oncology care at the same or lower costs. Under the OCM, oncology clinics enter into payment arrangements that include financial and performance accountability for patients receiving chemotherapy treatment. In addition, OCM clinics commit to providing enhanced services to Medicare beneficiaries, including care coordination, navigation, and following national treatment guidelines. Nutrition is a component of best-practice cancer care, yet it may not be addressed by OCM providers even though up to 80% of patients with cancer develop malnutrition and poor nutrition has a profound impact on cancer treatment and survivorship. Only about half of US ambulatory oncology settings screen for malnutrition, registered dietitian nutritionists (RDNs) are not routinely employed by oncology clinics, and the medical nutrition therapy they provide is often not reimbursed. Thus, adequate nutrition care in US oncology clinics remains a gap area. Some oncology clinics are addressing this gap through implementation of nutrition-focused quality improvement programs (QIPs) but many are not. What is needed is a change of perspective. This paper outlines how and why quality nutrition care is integral to the OCM and can benefit patient health and provider outcomes.

Matched pair analysis to evaluate weight loss during radiation therapy for head and neck cancer as a prognostic factor for survival

Background

One frequent consequence of radiation therapy (RT) for head and neck cancer (HNC) is weight loss (WL). HNC patients reportedly lose about 9% of their weight during treatment, regardless of pre-treatment WL and nutritional support. We investigated whether high WL during RT has an association with overall (OS) and cancer-specific survival (CSS).

Methods

We retrospectively reviewed weight during RT in HNC patients treated at Roswell Park Comprehensive Cancer Center between 2003 and 2017. High WL was defined as greater than or equal to the median WL. Logistic regression analysis was performed to identify predictors for WL during RT. Multivariate Cox regression and Kaplan-Meier analyses were used to estimate survival outcomes. Propensity score matching was performed to obtain balanced matched-pairs and compare survival outcomes.

Results

A total of 843 patients received either definitive (71%) or post-operative (29%) RT. Median follow-up was 53.6 months [interquartile range (IQR) 35.7–88.9]. Median WL was 5.8% (IQR 0.24–10.6) from baseline weight. Patients with high WL had better OS [hazard ratio (HR) 0.75, 95% confidence interval (CI), 0.61–0.93, P=0.01] and CSS (HR 0.71, 95% CI, 0.55–0.93, P=0.01). 258 matched-pairs were analyzed. Median follow-up was 54.8 months (IQR 35.8–90.4). Median OS was 39.2 months (IQR 21.4–75.7) for high WL versus 36.7 months (IQR 14.6–61.7) for low WL cohorts (P=0.047).

Conclusions

Different from previous reports, this study shows that patients with less WL have worse OS. WL during RT may not be a reliable marker for worse prognosis. A better way to evaluate malnutrition in patients undergoing RT is warranted.

Implementation of malnutrition quality improvement reveals opportunities for better nutrition care delivery for hospitalized patients

BACKGROUND

Gaps in hospital-based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services.

METHODS

Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019.

RESULTS

Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001).

CONCLUSIONS

The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.

Modification of systemic anti-cancer therapies and weight loss, a population-level real-world evidence study

Background:

Involuntary weight loss may occur during systemic anti-cancer therapy (SACT), causing treatment disruption and poorer prognoses. There remain gaps in clinical awareness as to which patients may benefit from nutritional interventions that aim to prevent unintended weight loss during SACT.

We utilised England’s population-level cancer registry data, conducting a pan-cancer assessment of patient weight loss during SACT. We aimed to identify cancers with weight loss-associated treatment modifications, potential beneficiaries of nutritional intervention.

Methods:

This cross-sectional study used England’s Cancer Analysis System database, including SACT-treated adults with one tumour and ⩾2 weight recordings between 2014 and 2018. Binary weight loss (threshold: 2.5%) was derived from patients’ most negative weight change from first SACT weight recording. The Martin et al. body mass index-adjusted weight loss grading system (BMI-WLG) was assigned. We describe binary weight loss, BMI-WLG and treatment modification status by cancer. Multivariate logistic regression models of weight loss (binary and BMI-WLG) and a composite outcome of patient treatment-modification status by cancer were produced.

Results:

Our study population contained 200,536 patients across 18 cancers; 28% experienced binary weight loss during SACT. Weight loss patients were more likely to have multiple types of treatment modifications recorded across all cancers. Regression analyses included 86,991 patients. Binary weight loss was associated (p < 0.05) with higher likelihood of treatment modification in; colon [Odds Ratio (OR) = 1.72, 95% confidence interval (CI): 1.42, 2.07]; gynaecologic (excl. ovarian) (OR = 1.48, 95% CI: 1.08, 2.01); stomach (OR = 1.6, 95% CI: 1.04, 2.06); lung (OR = 1.38, 95% CI: 1.21, 1.58); leukaemia (OR = 1.30, 95% CI: 1.09, 1.55); head and neck (OR = 1.30, 95% CI: 1.02, 1.65) and oesophageal (OR = 1.29, 95% CI: 1.01, 1.64) cancers. In lung, colon, and grouped gastro-intestinal cancers, association between BMI-WLG and treatment modification increased by WLG.

Discussion:

Our study is a wide assessment of weight loss during SACT using England’s cancer registry data. Across different cancers we found patients have weight loss-associated treatment modifications during SACT, a precursor to poorer prognoses. Our findings highlight cancers that may benefit from improved nutritional intervention during SACT.

eHealth Practices in Cancer Survivors With BMI in Overweight or Obese Categories: Latent Class Analysis Study

Background

eHealth technologies have been found to facilitate health-promoting practices among cancer survivors with BMI in overweight or obese categories; however, little is known about their engagement with eHealth to promote weight management and facilitate patient-clinician communication.

Objective

The objective of this study was to determine whether eHealth use was associated with sociodemographic characteristics, as well as medical history and experiences (ie, patient-related factors) among cancer survivors with BMI in overweight or obese categories.

Methods

Data were analyzed from a nationally representative cross-sectional survey (National Cancer Institute’s Health Information National Trends Survey). Latent class analysis was used to derive distinct classes among cancer survivors based on sociodemographic characteristics, medical attributes, and medical experiences. Logistic regression was used to examine whether class membership was associated with different eHealth practices.

Results

Three distinct classes of cancer survivors with BMI in overweight or obese categories emerged: younger with no comorbidities, younger with comorbidities, and older with comorbidities. Compared to the other classes, the younger with comorbidities class had the highest probability of identifying as female (73%) and Hispanic (46%) and feeling that clinicians did not address their concerns (75%). The older with comorbidities class was 6.5 times more likely than the younger with comorbidities class to share eHealth data with a clinician (odds ratio [OR] 6.53, 95% CI 1.08-39.43). In contrast, the younger with no comorbidities class had a higher likelihood of using a computer to look for health information (OR 1.93, 95% CI 1.10-3.38), using an electronic device to track progress toward a health-related goal (OR 2.02, 95% CI 1.08-3.79), and using the internet to watch health-related YouTube videos (OR 2.70, 95% CI 1.52-4.81) than the older with comorbidities class.

Conclusions

Class membership was associated with different patterns of eHealth engagement, indicating the importance of tailored digital strategies for delivering effective care. Future eHealth weight loss interventions should investigate strategies to engage younger cancer survivors with comorbidities and address racial and ethnic disparities in eHealth use.

A national survey of oncology survivors examining nutrition attitudes, problems and behaviours, and access to dietetic care throughout the cancer journey

BACKGROUND

Attitudes of cancer survivors to nutrition and nutrition care have rarely been captured. A better understanding of their needs based on a review of their experiences would give voice to this patient group (which has rarely been captured) and allow for better planning of nutritional care.

AIMS

To conduct a national survey to determine: (1) survivors' experience in relation to nutrition and diet-related problems, (2) perceived importance of the role of nutrition to cancer survivors, (3) the experience of accessing dietetic support, (4) the sources where survivors get nutrition information, and (5) their use of alternative dietary strategies.

METHODS

Survivors (any adult ever diagnosed with cancer) who had been diagnosed with or treated for cancer in Ireland within the past 5 years, were asked to complete a 25-item paper-based survey at one of 20 different hospital sites in Ireland. The survey was also hosted online on the websites of major cancer charities. Descriptive statistics were used to examine quantitative data.

RESULTS

In total, 1073 valid responses were received (63% female, mean age 57 years (range 18-88)). Breast cancer was the most common (n = 362), followed by colorectal (n = 121). One third of respondents had metastatic disease. Diet-related problems were reported by 45%. Weight loss was experienced by 44% and amongst those, 42% reported they were 'unhappy or worried' by this, while 27% reportedbeing 'delighted/happy' with their weight loss. Muscle loss was noted by 52%, with 20% reporting they had noticed 'a lot' of muscle loss. Nutrition was rated as 'very/extremely' important to cancer care by 89% of respondents, yet 58% reported being asked about dietary issues by their medical team only 'sometimes', 'rarely' or 'never'. Only 39% had been assessed/treated by a registered dietitian (RD) and 74% rated their advice/care as 'very/extremely' helpful. Worryingly, 39% of survivors with involuntary weight loss, and 29% of survivors on a texture modified diet had not received nutritional care from an RD. Overall, 57% of those who did not see an RD said they wanted more dietetic support (access to a helpline/dietitian/additional reliable information). Of concern, 37% of survivors were following or had tried alternative, unproven dietary strategies (e.g. restrictive diets, herbal remedies, juicing or detoxes), and 32% reported avoiding specific foods, e.g. processed meat or dairy. A majority (56%) felt confused by the often conflicting nutrition information available in the media and offered by people around them.

CONCLUSIONS

While nutrition is considered highly important by cancer survivors and a high proportion experience potentially serious diet-related problems including weight and muscle loss, fewer than half surveyed had access to a dietitian. Over a third had used at least one alternative dietary strategy, and over half felt confused about nutrition. Comprehensive nutritional screening and referral programmes to oncology dietitians need to be implemented in the ambulatory setting in order to identify and facilitate early management of the nutritional concerns of cancer survivors.

Impact of Early Incorporation of Nutrition Interventions as a Component of Cancer Therapy in Adults: A Review

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.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.