What the Tumor Does to Nutrition and
What Poor Nutrition Does to the Patient
and Treatment Outcomes
Columbus Chapter Oncology Nursing Society
26th Annual Spring Conference
Kaleidoscope of Oncology Care
March 26, 2015
Anne Coble Voss, PhD, RDN, LD
Associate Research Fellow, Abbott Nutrition R&D
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Disclosure
The speaker is an Associate Research Fellow in
Adult Nutrition Science at Abbott Nutrition but will
not be discussing Abbott products.
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Presentation Objectives
1. Identify the impact the tumor and anti-cancer treatments
have on nutrition status in the adult oncology patient
2. Determine the effect of lean body mass loss on treatment
outcomes in the adult oncology patient
3. Characterize the effect of cancer and its treatment on
outcomes
4. Recognize national/international guidelines and
recommendations
5. Develop early nutrition screening and intervention plan
.
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MALNUTRITION
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Historic definitions of malnutrition
marasmus • kwashiorkor • protein-energy undernutrition
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GL, et al. JPEN J Parenter Enteral Nutr. 2009;33:710-716.
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What is malnutrition?
A state of nutrition in which a deficiency, excess, or imbalance of
energy, protein, and other nutrients causes measurable adverse
effects on body function and clinical outcome.1
Up to 1 in 2 adults admitted to hospital or
care homes is or at risk of malnutrition.
– Somanchi M, et al. JPEN. Mar 2011;35(2):209-216
Estimated up to 80% of advanced patients
with cancer have malnutrition.
– Poole K, Froggatt K. Palliative medicine. 2002;16(6):499-506
1. Elia M, ed. Guidelines for Detection and Management of Malnutrition: A Report of the Malnutrition Advisory Group.
6 Maidenhead, UK: British Association for Parenteral and Enteral Nutrition (BAPEN); 2000.
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Malnutrition and weight loss are common in cancer
patients
• At cancer diagnosis,
approximately 50% of patients
present with some nutritional
issues1
• In certain cancers, up to 85% of
patients will develop
malnutrition/weight loss2,3 during
treatment
• Involuntary weight loss of just 5%
results in decreased survival5
Most common secondary diagnosis
for cancer patients is malnutrition4
1. Halpern-Silveira D, et al. Support Care Cancer. 2010;18(5):617-625; 2. Laviano A, Mequid MM. Nutrition. 1996;12(5):358-371; 3. Bozzetti F. Nutrition support in
patietns with cancer. In: Payne-James J, Grimble G, Silk D, eds. Artificial Nutrition Support in Clinical Practice. 2nd ed. London: GMM; 639-680; 4. National Cancer
Institute. Nutrition in Cancer Care. www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page1. 5. Dewys WD, et al. Am J Med 1980;69(4):491-7
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Malnutrition in the Adult Oncology Patient
• Weight loss and malnutrition are
common in the oncology patient
• In a classic paper by Dewys 1980
malnutrition ranged from 31% to 87%1
• Recent paper by Hebuterne 2014
40% of hospitalized oncology patients
were malnourished2
This concept is similar to hospital malnutrition
and “The Skeleton in the Hospital Closet” 3
1. Dewys Am J Med 1980; 2. Hebuterne JPEN 2014; Butterworth Today’s Dietitian 1974
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Malnutrition & Weight Loss
• Oncology nutrition risk studies show:
• 32% outpatients mixed tumor types
were malnourished1
• 34% malnourished, 42% at nutrition
risk advanced colorectal cancer2
• 88% pancreatic cancer3
• 58% GI tumors4
• 45% of GI cancer patients were
malnourished by Patient Generated
–Subjective Global Assessment
(PG-SGA)5
• 49% med oncology patients by PGSGA6
1. Bozzetti Supp Care Cancer 2012; 2. Thoresen Clin Nutr 2013; 3. La Torre J Surg Onc 2013; 4. Poziomyck Nutr Cancer 2012;
5. Dias do Prado 2013 6. Isenring Nutr Cancer 2010.
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Malnutrition & Weight Loss
• Oncology nutrition risk studies show:
• 66% advanced H&N by >10%
weight loss in 6 months; 26% had
BMI <20 at 6 month1
• 32% of patients with GI cancer
had mild to moderate and 16%
had severe malnutrition by SGA2
1. Silander Laryngosope 2013; 2. Garth J Hum Nutr Diet 2010
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Malnutrition in the Adult Oncology Patient
• Oncology nutrition risk studies show:
• Pancreatic surgery patients
• 88% medium-severe nutrition risk by
Nutrition Risk Index (NRI)
• 83% medium to high risk by
Malnutrition Universal Screening Tool
(MUST)1
• 35% of patients with lung cancer were
malnourished by BMI < 18.5, weight loss
> 10% or BMI <20 and weight loss > 5%2
• 25% of patients with gynecological
cancer were malnourished by PG-SGA3
1. La Torre J Surg Onc 2013; 2. Percival Resp Med 2013; 3. Laky BMC Cancer 2010
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Causes of Malnutrition in Cancer Patients
• Decreased dietary intake
• Increased nutrient
requirements
• Impaired nutrient digestion /
absorption
• Increased losses of
nutrients
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Common Treatment-related Side Effects Negatively
Impact Nutritional Status
Symptom
Chemo
Radiation
Surgery
Weight loss
Fatigue
Nausea/Vomiting
Taste alterations
Oral mucositis
Constipation
*
*
Diarrhea
Dry mouth
Loss of appetite
*Occurs as a result of pain medication.
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Cancer Patients Often suffer from Multiple Side
Effects that Impact Nutritional Status
Medical Oncology Patients (N=191)
Percentage
of patients
who are
malnourished
Number of Symptoms
PG-SGA=Patient Generated-Subjective Global Assessment (Ottery 2000).
14 Isenring E, et al. Nutr Cancer. 2010;62(2):220-228.
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Cancer Induced Weight Loss and the Tumor
• Cancer induced weight loss has no direct relationship
with the weight of the tumor, presence of metastases
and its anatomic localization
• Cancer induced weight loss can be present when the
tumor weighs < than 0.01% of the host’s body weight
• Bigger tumors might not cause cancer induced weight
loss
Tisdale MJ. Physiology 2005; 20:340-8.
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Identification of Oncology Patients at Risk of
Developing Malnutrition
• Nutrition Screening tools identify patients at risk of
developing cancer associated malnutrition and/or
unintentional weight loss
• Nutrition Screening Tools found to be valid and
reliable for oncology patients
– Outpatient:
• Malnutrition Screening Tool
• Patient Generated Subjective Global Assessment
– In Patient:
• f
Add references
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Quiz #1
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Quiz: which statement is not correct?
• Consider weight loss and malnutrition in oncology patients:
– Patients with cancer have greater rates of malnutrition than patients
without cancer
– Oncology patients rarely have weight loss prior to diagnosis
– Malnutrition is the second most common diagnosis in patients with
cancer
– Patients with breast and prostate are less likely to experience
weight loss
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Quiz: which statement is not correct?
• Consider weight loss and malnutrition in oncology patients:
– Patients with cancer have greater rates of malnutrition than patients
without cancer
– Oncology patients rarely have weight loss prior to diagnosis
– Malnutrition is the second most common diagnosis in patients with
cancer
– Patients with breast and prostate are less likely to experience
weight loss
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LEAN BODY MASS
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Bed Rest, Age, and Disease Increase
Loss of Muscle
Loss of Lean Leg Mass (lbs)
all measurements represent single leg loss
Healthy Young
(26-46 years of age)
28 Days’
Inactivity1
Elderly Inpatients
(≥65 years of age)
3 Days’
Hospitalization3
0
–0.5
–1.0
Approx
–1.5
1.0 lb
–2.0
–2.5
1.
2.
Healthy Older
Adults
(67 years of age)
10 Days’
Inactivity2
Approx
2.2 lbs
Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004
Kortebein P, et al. JAMA. 2007 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference;
June 23-25, 2009; Columbus, OH.
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Approx
2.2 lbs
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Type of Weight Loss is Critical to Outcomes and
Survival in Cancer Patients
Malnutrition
Weight Loss
Muscle Mass Loss
Muscle mass functions include:
• Skin integrity
• Immune function
• Healing/Repair
• GI integrity/Digestion
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Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; 2002.
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Progressive Muscle Loss Can Be Associated with
Severe Complications
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Loss of Total Muscle
Mass (%)
Complications
Associated
Mortality (%)
10
Decreased immunity,
increased infections
10
20
Decreased healing,
weakness, infections
30
30
Too weak to sit,
pressure ulcers,
pneumonia, no
healing
50
40
Death, usually from
pneumonia
100
Demling RH. Eplasty. 2009;9:65-94.
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Effects of Loss of LBM in Patients with Cancer
• Low muscle mass is common and independent predictor of immobility
and mortality 1
• Low muscle mass is an independent adverse prognostic indicator in
obese patients 2
• Patients with sarcopenia seem prone to toxic effects during
chemotherapy3,4,5 requiring dose reductions and treatment delays5
1. Prado, et al. Lancet Oncol. 2008;9:629-635.
2. Tan, et al. Clin Cancer Res 2009;15:6973-79.
3. Prado, et al. Curr Opino Support Palliat Care 2009;3:269-275.
4. Prado, et al. Clin Cancer Res 2007;13:3264-3268.
5. Prado, et al. Clin Cancer Res 2009;15:2920-2926.
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Loss of Lean Body Mass
• Patients with muscle mass loss have greater toxicity
and shorter survival1
• Shortest survival times are among obese patients with
sarcopenia2
• Median survival of patients with
low muscle density was compared
to high muscle density:
– 14 vs. 20 months (p=0.001)2
1. Tan, et al. Clin Ca Res 2009;15:6973-6379. 2. Antoun, et al. Cancer 2013;19:3377-3384.
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BMI is a False Indicator of Loss of Muscle Mass
BMI
LBM
Cachectic
17
Equal
Normal
25
Equal
Obese
38
Equal
One study found that 79% of patients identified as
malnourished were normal weight, overweight, or obese.1
Image: Fearon et al., Nature 2013, 1. Davidson W, et al. Oncol Nurs Forum. 2012;39:E340-E345.
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Impact of Lean Body Mass
•
LBM determinant of epirubicin toxicity in pts with breast cancer1
– Same BSA but wide variation in LBM
– Low LBM predicts toxicity p=0.002
– LBM positively correlated with
neutropenia nadir
r=0.05, p=0.023
Capecitabine Tx of metastatic breast cancer2
– Low LBM is determinant of CT toxicity
and time to progression
1. Prado, et al. Cancer Chemother Pharmacol 2011;67:93-101
2. Prado, et al. Clin Cancer Res 2009;15:2920-26
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Impact of Lean Body Mass
•
Sorafenib’s common toxic effects limit patient’s ability to
receive full-dose treatment and
account for:
– dose reductions in 13% of patients
– treatment termination in 21% of
patients
•
BMI < 25 kg/m2 with decreased
muscle mass is a significant
predictor of toxicity in metastatic
RCC patients treated with
sorafenib.
Antoun S, et al. Annals of Oncology 2010 doi:10/1093/annoc/md605
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Impact of Lean Body Mass
•
Mayo Clinic regimen 5-FU/leucovorin CRC
– 35% had toxicity resulting in
dose reduction, Tx discontinuation, hosp, death
– Dose based on Body Surface Area (BSA)
– 20mg 5-FU/kg LBM cut point for
developing toxicities p=0.005
– 56% had dose reductions or Tx delays
– Toxicities febrile neutropenia,
fatigue, diarrhea, N&V
5FU/BSA or 5FU/kg B Wt not predictive
Prado, et al. Clin Cancer Research 2007;13:3264-68
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Chemotherapy, Toxicity and Malnutrition
• Greater toxicity in patients with lower
LBM but also in malnourished patients
• N=100 patients
• Malnutrition and hypoalbuminemia were associated with
chemotherapy toxicity
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Quiz # 2
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Quiz: which answer is not correct
• Loss of lean body mass in oncology patients is associated with:
–
–
–
–
Greater toxicities of chemotherapy
Loss of strength, performance and activity
Increased leg strength
Poorer outcomes in obese patients
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Quiz: which answer is not correct
• Loss of lean body mass in oncology patients is associated withn:
–
–
–
–
Greater toxicities of chemotherapy
Loss of strength, performance and activity
Increased leg strength
Poorer outcomes in obese patients
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Patient-centered outcomes
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Nutrition awareness
• Among medical practitioners, nutritional awareness is low
– Not considered important by many medical practitioners
– Little or no nutrition education in medical school
– “I’ll cure the cancer and the nutrition problem will go away.”
• Patients and families do worry
• Use of herbs, supplements, potions, pills, devices, treatments is
high
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Awareness of Patient Reported Outcomes
• In a recent prospective study in patients with NSCLC, survival
was correlated with Patient Reported Outcomes.1
• How applicable are Patient Reported Outcomes for predicting
quality of life in your practice?
• 51% not or only slightly applicable2
1. Gralla, et al. J Clin Oncol 2013
2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014
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Nutrition Intervention Improves Outcomes in CIWL
• Nutritional status and intake are independent determinants of
QoL as much as stage of disease, location of the cancer and
treatment regimen in some types of cancer1
• Intensive nutrition therapy including ONS shown to improve2
–
–
–
–
–
Body weight and LBM
Hand grip strength
Physical activity3
Performance status
Dietary intake
6%
1%
10%
30%
3%
Stage
Location
Intake
Weight loss
Duration
Chemotherapy
Surgery
30%
1. Ravasco P, et al. Supp Care Cancer 2004;12:246-2521
2. Von Meyenfeldt M, et al. Am Soc Clin Onc 2002
3. Moses A, et al. Br J Cancer 2004;90:996-1002
20%
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Nutrition Intervention Can Help Improve Quality
of Life
38
Baldwin C, et al. J Natl Cancer Inst. 2012;104(5):371-378.
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SURVIVAL AND NUTRITION
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Weight loss has a significant impact on survival
Patients with pancreatic, gastric cancer and lung had the highest frequency of weight
loss (83-87%) and tumor types less likely to produce weight loss breast, prostate,
sarcoma.
DeWys WD et al. Amer J Med 1980; 69: 491-497
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Weight Loss is Associated with Worse Outcomes
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Andreyev HJN, et al. Eur J Cancer. 1998;34(4):503-509.
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Weight Loss Impacts Survival in Colorectal Cancer
Results
100
Percentage
80
60
No Weight Loss (n=472)
40
Weight Loss
(n=246)
20
P<.00001
0
0
1
2
3
4
5
Time Since Treatment (Years)
Andreyev
HJN, et al. Eur J Cancer. 1998;34(4):503-509.
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Nutrition Intervention in Weight Losing
Patients Unresectable Pancreatic Cancer
• Dietary counseling and Oral Nutrition Supplements
over 8 weeks n=107
• Weight stabilization
– Longer survival
– Improved QoL (EORTC)
• Improved dietary intake
Davidson W, et al. Clin Nutr 2004;23:239-247
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Early Supportive Care in Patients with NSCLC
Improves Survival
• Early Supportive Care vs. Standard Care n=151
– Improved Quality of Life (p=0.04)
– Longer survival 1.6 vs. 8.9 mos
(p=0.02)
Improved QoL (EORTC)
Temel J, et al. N Eng J Med 2010;363:733-742
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Early Intervention for Cancer Cachexia
• Early palliative care correlates with longer survival in patients
with NSCLC.1 How early should an intervention start for cancer
anorexia-cachexia?
• (69%) With any weight loss or patients most likely at
risk for developing
weight loss.2
1. Temel, et al. N Engl J Med 2010;363:733-742.
2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014
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NUTRITION INTERVENTIONS
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Appropriate nutrition can support cancer treatment
goals
Goals of cancer treatment
• Be effective
• Be well tolerated
• Minimize complications
• Maximize quality of life
• Allow for healing
and recovery
Levin RM. Oncology Issues. Nutrition: The 7th Vital Sign. November/December 2010:32-35.
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accc-cancer.org/oncology_issues/articles/NovDec2010/ND10-Levin.pdf.
Accessed March 26, 2012.
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Early nutrition intervention has been shown to
improve outcomes in cancer patients
Nutrition intervention started as early as possible
can result in:
 Nutritional status
 Performance status
 Quality of life (QOL)
 Response and tolerance to treatment
 Rate of complications
 Morbidity
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Marín Caro MM, et al. Clin Nutr. 2007;26(3):289-301.
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Patients Treated with a Nutrition Pathway Experienced
Improved Outcomes and Treatment Tolerance1
Results
Control Group
Treatment Group
(Nutrition Pathway)
33%
54%
0.05
Weight change during treatment (%)
-8.9 ± 5.9%
-4.2 ± 6.4%
0.003
Patients who had a chemotherapy
dose reduction (%)
42% (n=10)
29% (n=7)
0.34
Patients who completed radiation (%)
50% (n=12)
92% (n=22)
0.001
33%
27%
0.71
Patients receiving enteral nutrition
Patients who experienced radiation
therapy breaks (for those who
completed treatment)
Patients who had an unplanned
hospital admission (%)
Total length of stay for all unplanned
hospital admissions (days)
49
75% (n=18)
46% (n=11)
0.04
13.5 ± 14.1 days
3.2 ± 5.4 days
0.002
1. Odelli C et al. Clinical Oncology 2005; 17: 639-625.
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P Value
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EXPERT GUIDELINES
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Experts Have Recognized the Importance of
Ongoing Nutrition Intervention in Oncology Patients
The American College of Surgeons
Commission on Cancer 2012
Cancer Survivorship Standards1
• Evaluation process starting in 2015
• “The cancer committee develops and implements a process to
provide a comprehensive treatment summary and follow-up
plan to patients who are completing treatment; the process is
monitored, evaluated, and reported to the cancer committee
each year.”
• Continued care that considers the big picture: Cancer
recurrence and… other chronic disease
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1. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered
Care. Chicago, IL: American College of Surgeons. 2011.
Cancer
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Society Guidelines Support Proactive Nutrition
Intervention Across the Cancer Continuum
1. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered Care. Chicago, IL: American
College of Surgeons; 2011. 2. McCallum PD. In: Elliott L, Molseed LL, Davis P, Grant B, (eds). The Clinical Guide to Oncology Nutrition. 2nd ed.
Washington, DC: Oncology Nutrition Dietetic Practice Group, American Dietetic Association; 2006:44-53. 3. The Association of Community Cancer Centers
Cancer Nutrition Services: A Practical Guide for Cancer Programs, 2012.
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A Simple and Effective Plan to Ensure
Consistency of Care
“Nutritional care is a fundamental aspect of nursing practice and
nurses are ideally placed to play an essential role in the early
detection and screening of malnutrition in patients with cancer.”1
53 1. Davies M. Eur J Oncol Nurs. 2005;9(suppl 2):S64-S73.
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Make Nutrition Part of Your Oncology
Patient Care Plan
• Early nutrition screening and intervention requires a
multidisciplinary approach
– Integrate into existing pathways or protocols, especially for highrisk cancers
– DO NOT WAIT for serious nutrition concerns
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What did she say?
1.
Cancer induced weight loss results in:
•
•
•
2.
Type of weight loss is important
•
•
3.
Decreased quality of life
Increased complications
Poorer response to therapy
LBM is predominant type of tissue lost
Over weight patients have greater LBM loss and poorer survival
Nutritional impact of treatment-related side effects
•
•
LBM loss contributes to greater treatment associated toxicities
Dose reductions and treatment delays
.
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THANK YOU!
QUESTIONS?
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