ms tah pei chien - mnt cancer guidelines - changes in guidelines

Medical Nutrition Therapy

Cancer Guidelines Update

Ms Tah Pei Chien

Clinical Dietitian

University Malaya Medical Centre

(Chairperson of MNT Cancer

Guidelines)

MDA Scientific Conference 2013 – Sunway Putra Hotel

1

MNT Guidelines for Cancer in Adults

Working Group Committee Gaik

Lian Suraiya

Firdaus

Wai

Hong Hidayah Shariza

Pei

Chien

Shafurah

Li Yin

Zalina

2

2010 – 2013 (3 years)

21 meetings 3

Outline

• Introduction

• Objectives of the MNT guidelines

• Contents of MNT guidelines

• Nutrition recommendation for cancer

patients

4

New Cancer Cases Diagnosed (2007)

44.6%

5

Source: Malaysian National Cancer Registry 2011

•Cancer

-most common

death in Malaysia

-3rd in MOH

Hospital

•New cases

registered

2007- 18,219

18.1%

12.3%

10.2%

5.2%

4.6%

6

The Most Common Cancer In Malaysia


Gender Differences In

Sites Of Cancer


16.3%

Lung

14.6%

colorectal

8.4% NPC

6.2% Prostate gland

5.5% Lympho

ma/ Liver

7

8

32.1% breast

10.0% Colorectal

8.4%

Cervix

uteri 6.5% Ovary

5.4% Trachea,

Bronchus & lung

GENDER DIFFERENCES IN

SITES OF CANCER


Introduction

Depletion of nutrient stores, anorexia, weight loss and poor nutritional status are found in many individuals at the time of diagnosis (Goldman et al. 2006).

Malnutrition in cancer patients can have a significant adverse effect impact on clinical, cost and patient centred outcomes such as complications (infections), treatment response, treatment interuptions, unplanned admission, length of stay and quality of life (Schattner & Shike 2006; COSA 2011).

The prevalence of malnutrition in cancer patients ranges from 8-84% depending on tumour site, stage and treatment (Maarten von Meyenfeldt 2005, Brown et al. 2008).

Considering the implications of malnutrition, it is important to initiate early intervention to help prevent or reverse malnutrition and to improve prognosis of cancer patients.

9

Aim of the Guidelines

• To provide evidence-based

recommendations while taking into

account the importance of an

individualised approach in assisting

dietitians to provide medical nutrition

therapy to adult cancer patients.

10

Objectives of Nutrition Management

For individual who is at pre-cancer treatment or pre-surgery

• To maintain or prevent declining (or further decline) in nutritional status and improve overall nutritional status and its associated outcomes in adults at risk of or with malnutrition

For individual who is ongoing radiotherapy or/and systemic therapy

• To minimise a further decline in nutritional status, maintain quality of life (QoL) and for adequate symptom management.

11

Contents of the MNT

• Nutrition Screening

• Nutrition Assessment

– Estimated requirement:

• Macronutrient

• Fluid

• Micronutrients

• Eicosapentaenoic acid (EPA)

• Nutrition Diagnosis

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Content of the MNT

• Algorithm of nutrition support

• Nutrition Intervention

• Sample menu

• Nutrition counseling/ education

• Coordination of care

• Physical activity & cancer

• Nutrition monitoring & evaluation

• Nutrition & cancer resources for health care professionals

13

Nutrition Screening and NCP

Flowchart

14

MST

SGA &

PGSGA

Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011

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Nutrition Screening

16

Evidence Statement of Nutrition Screening

Evidence Statement Grade References

MST is an effective and validated

screening tool for identifying risk of

malnutrition in cancer patients

B DAA, 2006

COSA, 2011

Malnutrition screening should be

undertaken in all patients at diagnosis to

identify those at nutritional risk and

should be repeated at intervals through

each stage of treatment (e.g. surgery,

radiotherapy / chemotherapy and post

treatment). If identified at high risk, do

refer to the dietitian for early intervention.

B COSA, 2011

All HNC patients receiving radiation

therapy should be referred to dietitian for

nutrition support intervention

A

COSA, 2011

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1. Have you lost weight recently without trying?

If no (0)

If unsure( 2)

If yes, how much weight (kg) have you lost?

0.5–5.0 ( 1)

>5.0–10.0 (2)

>10.0–15.0 (3)

>15.0 (4)

2. Have you been eating poorly because of a decreased appetite?

No ( 0)

Yes (1)

If score 0 or 1 not at risk of malnutrition

≥ 2 at risk of malnutrition

Ferguson M, Bauer J, Banks M, Capra S. 1999. Development

of a valid and reliable malnutrition screening tool for adult

acute hospital patients. Nutrition. 15: 458–464.

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Malnutrition Screening Tool (MST)

Nutrition Assessment

19

Nutrition Assessment Criteria • Tools

- The Scored Patient Generated–Subjective Global Assessment (PG-SGA) - gold standard (Leuenberger et al., 2010)

- Subjective Global Assessment (SGA)

• Assessment Parameters

- Medical history

- Anthropometric data

- Biochemical assessment

- Clinical assessment

- Dietary Information

- Functional status and QoL

• The use of combination method (Tools and Assessment Parameters) is best suggested for nutritional assessment (Grade C). (Davies, 2005)

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Energy

Requirement

23

Guidelines Review Guidelines Energy Requirement

DAA 2005 120 KJ/kg/day (29 kcal/kg/d)

ESPEN 2006 (EN)

- Ambulant patients: 30-35 kcal/kgBW/day

- Bedridden patients: 20-25 kcal/kgBW/day

ADA 2006 • Equation:

- Harris Benedict, 1919

- Mifflin-St Jeor, 1990

- Ireton-Jones, 1992

• Based on actual body weight

European Oncological

Disease 2007 In excess of 120KJ/kg/day

DAA 2008 125 KJ/kg/day (30 kcal/kg/d)

ESPEN 2009 (PN)

- Ambulant patients: 25-30 kcal/kgBW/day

- Bedridden patients: 20-25 kcal/kgBW/day

COSA 2011 (HNC) at least 125kJ/kg/day (30kcal/kg/day) 24

Energy Requirement Estimation in MNT CA

Table 3 Formulas for Calculation of Energy Requirement

25

PROTEIN

REQUIREMENT

27

Guidelines Review Guidelines Protein Requirement

DAA 2005 1.4 g/kg/day

ESPEN 2006 (EN)

- Minimum: 1 g/kgBW/day

- Target: 1.2-2 g/kgBW/day

ADA 2006 • Nitrogen balance = (Protein Intake/6.25) – (UUN+4)

: Positive 4 – 6 g/day is desirable

: Negative – consideration to increase protein intake

• Grams of protein per kilogram of body weight

formulas (consider of renal and/or hepatic dysfunction)

• Protein needs for nutrition support: kilocalorie-to-

nitrogen ratio of 125:1

European Oncological Disease 2007

In excess of 1.4g/kg/day

DAA 2008 1.2 g/kg/day

ESPEN 2009 (PN)

- Minimum: 1 g/kgBW/day

- Target: 1.2-2 g/kgBW/day

COSA 2011 (HNC) at least 1.2g/kg/day 28

Protein Requirement in MNT CA

Table 4: Estimating Daily Protein Needs in Cancer Patients

29

Age (years) Fluid Requirement, ml/kg

16-30, active 40

31-55 35

56-75 30

76 or older 25

These recommendations are just for maintenance needs. Fluid

requirement in fluid overload or dehydration patients need to

be adjusted.

Table 5: Estimating Fluid Needs in Cancer

Patients

Source: ADA, 2000

30

Algorithm of Nutrition Support

for Cancer Patients

31

32 Ref: ESPEN, 2006; FESEO, 2008

Nutrition Diagnosis

• Identification and labelling of the specific

nutrition problem that dietetic professionals

are responsible for treating independently.

• A nutrition diagnosis may be temporary,

altering as the patient progresses

or responses to the intervention.

Source: ADA (2011) Third edition, International dietetics &

nutrition terminology (IDNT) reference manual. 33

Nutrition

Intervention and

Recommendation

35

Diet and Counseling

38

Recommendation Grade References

• Intensive dietary counselling and ONS are able to

increase dietary intake and to prevent therapy-

associated weight loss and interruption of radiation

therapy in patients undergoing radiotherapy of

gastrointestinal or head and neck areas

A ESPEN, 2006;

FESEO, 2008;

DAA, 2008

• Dietitian should be part of the multidisciplinary team

and frequent dietitian contact has been shown to

improve patients’ nutrition outcomes and quality of

life

A DAA, 2008

COSA, 2011

• At low nutritional risk patients (MST = 0-1)

-Recommend a well balanced diet

-Recommend healthy traditional diet

according to needs, preferences and

symptomatology

-Healthy, balanced, assorted, appetizing and

adequate amount of food and nutrients

C

Bauer, 2007;

FESEO, 2008

Diet and Counseling

39


• At moderate nutritional risk patients (MST = 2)

- Recommend high protein-energy diet

- High protein and high energy diet

- Try 6 smaller meals/snacks per day

- Include 3-4 servings of energy and protein

rich foods or drinks daily

- Oral nutritional supplements 2-3 servings per

day

C Bauer, 2007

• At high nutritional risk patients (MST = 3-5)

- Recommend high protein high energy diet

- Recommend high protein high energy

supplements 2-3 times per day

- Consider intensive nutrition support

C

Bauer, 2007

Enteral Nutrition (General)

40


• Standard formula are recommended

for EN of cancer patients

C ESPEN,

2006

• EN should be started if an

inadequate food intake ( <60% of

EEE) is anticipated for more than 10

days

C ESPEN,

2006

• EN reduces morbidity in selected

malnourished patients.

A FESEO,

2008

Enteral Nutrition (Perioperative)

41

Recommendation Grade Reference

s

• Patients with severe nutritional risk

should be given nutritional support for 10–

14 days prior to major surgery even if

surgery has to be delayed

A ESPEN,

2006;

FESEO,

2008

• Perioperative nutrition support therapy

may be beneficial in moderate or severely

malnourished patients if administered for

7-14 days preoperatively but the potential

benefits of nutrition support must be

weighed against the potential risks of the

nutrition support therapy itself and of

delaying the operation

A ASPEN,

2009

Enteral Nutrition (Perioperative)

42


• In all cancer patients undergoing

major abdominal surgery preoperative

EN preferably with immune modulating

substrates (arginine, Ω-3 fatty acids

and nucleotides) is recommended for 5–

7 days independent of their nutritional

status

A ESPEN,

2006

ASPEN,

2009

• EN should be started during first 24

hours after surgery for patients

undergoing head and neck surgery or

upper GIT and also in seriously

malnourished Individuals

A FESEO,

2008

Enteral Nutrition During Chemo / Radiotherapy

43


• NST is indicated in patients receiving active

cancer treatment who are malnourished and who

are anticipated to be unable to ingest and/or

absorb adequate nutrients for a prolonged period

of time

B ASPEN,

2009

• Tube feeding should be used to improve protein

and energy intake for HNC patients when oral

intake is inadequate

B COSA, 2011

Nasogastric tube (NGT) and percutaneous

endoscopic gastrostomy (PEG) feeding are

effective in achieving higher protein and energy

intakes and weight maintenance in HNC patients

undergoing radiation therapy compared with oral

intake alone

B

A

DAA, 2008

ADA, 2007

Parenteral Nutrition (PN)

44


• PN should be started if an inadequate food

intake and/or EN(<60% of estimated energy

expenditure) is anticipated for more than 10 days

C ASPEN,

2009

• A higher than usual % of lipid (e.g. 50% of non-

protein energy), may be beneficial for those with

frank cachexia needing prolonged PN

C ESPEN

2009

• PN is ineffective and probably harmful in

oncological patients without swallowing difficulty

and gastrointestinal failure

A ESPEN,

2009

• Perioperative PN should not be used in well nourished

cancer patients

A ESPEN,

2009

• Perioperative PN starting 7–10 days pre-operatively

and continuing into the post-operative period is

recommended in malnourished candidates for

artificial nutrition, when EN is not possible

A ESPEN,

2009

Nutrition During Transplantation of Hematopoietic

Precursor Cells

45


• Patients should receive dietary

counselling regarding foods which may

pose infectious risks and safe food

handling during the period of neutropenia

C ASPEN,

2009

• Not to recommend the enteral

administration of glutamine or EPA in

patients undergoing haematopoietic stem

cell transplantation (HSCT) due to

inconclusive data

C ESPEN,

2006

• Glutamine supplemented PN should be

used in HSCT patients for possible health

benefit

B ESPEN,

2009

Nutrition During Transplantation of Hematopoietic

Precursor Cells

46


• PN should be reserved for those with

severe mucositis, ileus, or intractable

vomiting

B ESPEN,

2009

• In addition, if oral intake is decreased,

the increased risk of haemorrhage, and

infections associated with enteral tube

placement in immuno-compromised

and thrombocytopenic patients has to be

considered; in certain situations,

therefore (e.g. allogeneic HSCT)

parenteral nutrition (PN) may be

preferred to TF

C ESPEN,

2006

47


• The palliative use of NST in terminally ill

cancer patients is rarely indicated

B ASPEN,

2009

• EN should be provided in order to minimize

weight loss, as long as the patient consents

and the dying phase has not started

C ESPEN,

2006

• When the end of life is very close, most

patients only require minimal amounts of

food and little water to reduce thirst and

hunger

B ESPEN,

2006

• ‘‘Supplemental’’ PN should be used in

supporting incurable cancer patients with

weight loss and reduced nutrient intake

B ESPEN,

2009

Nutrition During Terminal Illness

Dietary Guidelines for Immunosuppressed

Patients – Neutropenic Diet

• The use and effectiveness of neutropenic diet is

not scientifically proven.

• Neutropenic diets are not standardized.

• Further research is needed to better evaluate

the benefit of neutropenic diet (Steven, 2011).

• Food safety education and high risk foods

restriction is needed when handling

immunosuppressed patients (ADA, 2006).

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Sample

Menu

49

Nutrition Education

& Counselling

51

Physical Activity

& Cancer

53

Nutrition Monitoring

& Evaluation

55

Nutrition And Cancer

Resources For Health Care

Professionals

57

Summary and Conclusion This medical nutrition therapy is developed to guide dietitians toward a standardised dietary management along the nutrition care process for cancer patients in order to improve patients’ outcomes.

Guidelines are just that, Guidelines

• Not dogma, not absolute, not rules, No guarantees

Clinical judgment and expertise always takes precedent over guidelines

Guidelines will change with ongoing trials, keep an open mind

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MNT Babies

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Acknowledgement We would like to extend out gratitude and appreciation to

the following for their contributions:

•Dietetic Department of University Malaya Medical Centre

for the use of the meeting room

•The Peer Reviewers for their time and professional

expertise

•Healthcare Nutrition Division of Nestle Products Sdn. Bhd.

for the refreshments

•Wyeth Nutrition (M) Sdn. Bhd (formerly know as Wyeth

(M) Sdn Bhd) for the printing of the Cancer MNT book

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THANK YOU

62

ms tah pei chien - mnt cancer guidelines - changes in guidelines

Health & Medicine

common cancer

adult cancer patients

prognosis of cancer

precancer treatment

sites of cancer source

cancer patients b daa

nutrition support intervention

new cancer cases