ONCOLOGY NUTRITION IN 2020: THE INTERSECTION OF … · 2020. 7. 22. · oncology nutrition in 2020:...

ONCOLOGY NUTRITION IN 2020:THE INTERSECTION OF EVIDENCE, GUIDELINES AND CLINICAL PRACTICE

July 22, 202012:00 – 1:00 pm EST

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WEBINAR OBJECTIVES

• Review current evidence on the benefits of nutrition intervention for improving muscle mass and strength in oncology patients.

• Highlight nutrition care guidelines for oncology patients.

• Explain how to implement nutrition guidelines into clinical practice to improve patient outcomes.

OUR SPEAKERS TODAY

CARLA PRADO PhD, RD Director, Human Nutrition

Research Unit Professor/CAIP Chair

Nutrition, Food & Health University of Alberta Edmonton, Canada

SUZANNE DIXON MPH, MS, RD Research Consulting Lead

Humana Portland, OR, USA

RHONE LEVIN MEd, RD, CSO, LD, FAND

Oncology Dietitian Duke University Hospital

Durham, NC, USA

WEBINAR AGENDA

Topic Speaker

Update on new evidence on nutrition intervention improving outcomes in patients with oncology

Carla Prado, PhD, RD

Update on current nutrition guidelines Suzanne Dixon, MPH, MS, RD

Implementing evidence and guidelines into clinical practice to improve care Rhone Levin, MEd, RD, CSO, LD, FAND

Q&A

UPDATE ON NEW EVIDENCE ON NUTRITION INTERVENTION IMPROVING OUTCOMES IN PATIENTS WITH ONCOLOGY

7/20/2020

Carla Prado, PhD, RDProfessor & CAIP Chair in Nutrition, Food & HealthDirector, Human Nutrition Research UnitDepartment of Agricultural, Food and Nutritional ScienceUniversity of Alberta, Canadawww.drcarlaprado.com

DISCLOSURES

• The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional

• This educational event is supported by Dietitian Connection and Abbott Nutrition Health Institute, Abbott Nutrition

• Dr. Prado’s disclosures include Abbott Nutrition, Nutricia, Almased.

OUTLINE

Summarize how cancer influences nutritional status and its impact on oncology outcomes

Examine new evidence on nutrition interventions, including those that impact muscle mass, in oncology patients.

Review and identify gaps and opportunities in the current evidence for nutrition interventions in clinical practice

MALNUTRITION IN CANCER

Take Home Message # 1: Patients with cancer are one of the largest hospital patient groups with malnutrition

MALNUTRITION PREVALENCE BY TUMOR GROUP

• The study included 1677 patients in 2012 (17 sites) and 1913 patients in 2014 (27 sites).

61

40 37 34 33 30 29 26

14

48

36 3327 24

3127

2113

2012 2014

31% overall 26% overall

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Par

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ages

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)

Marshall KM, et al. Clin Nutr. 2019;38(2):644-651.

10 TO 20% OF DEATH ATTRIBUTED TO MALNUTRITION RATHER THAN TO THE MALIGNANCY

ITSELF

ESPEN GUIDELINES CLIN NUTR 2017;36:1187-1196

Arends J, et al. Clin Nutr. 2017;36(5):1187-1196

MALNUTRITION IN CANCER: TUMOR & INFLAMMATION-RELATED CATABOLISM

“Studies of the body composition of patients with cancer reveal that it is specifically the loss of skeletal muscle- with or without loss of fat – which is the main aspect of cancer-associated malnutrition that predicts risk of physical impairment, post-operative complication, chemotherapy toxicity and survival”.

Arends J, et al. Clin Nutr. 2017;36(1):11-48.

LOW MUSCLE MASS IS A DEFINING FEATURE OF MALNUTRITION IN CANCER

Take Home Message # 2:Low muscle mass is prevalent in cancer. It occurs at any body weight, cancer type, stage and age and worsens prognosis.

LOW MUSCLE MASS IS A HIDDEN CONDITION PREVALENT ACROSS BODY WEIGHTS

Prado CM, et al. Ann Med. 2018;50:675-693.

Low muscle mass

Physical impairment /

disability

Greater length of hospital stay

Need for rehabilitation

Post-operative complicationsPoor QofL

Tumorprogression /

toxicity

Shorter survival

The goals of nutritional and metabolic therapy,therefore, must place considerable emphasis on

maintenance or gain of muscle mass.

1) Xiao et al. In press. JAMA Surgery; 2)Caan BJ, et al. JAMA Oncol. 2018;4(6):798-804; 3)Prado CM, et al. Ann Med. 2018;50:675-693; 4) Caan BJ, et al. Cancer Epidemiol Biomarkers Prev. 2017;26(7):1008-1015; 5) Sachar SS, et al. Eur J Cancer. 2016;57:58-67; 6) Prado CM, et al. Lancet Oncology. 2008;9(7):P629-635

NUTRITION INTERVENTIONS: NEW EVIDENCE & FOCUS ON MUSCLE HEALTH

Take Home Message # 3:The quality and quantity of nutrients is essential to sustain nutritional status, hence improving outcomes in cancer

Geethanjali - Cartoons

Winter A, et al. Clin Nutr. 2012;31(5):765-773.

Deutz NE, et al. Clin Nutr. 2011;30(6):759-768.

Prado CM, et al. Am J Clin Nutr. 2013;98(4):1012-1019.

MacDonald AJ, et al. Clin Cancer Res. 2015;21(7):1734-1740.

Engelen MP, et al. Curr Opin Clin Nutr Metab Care. 2016;19(1):39-47.

Aging

Hormonal changes/ Imbalances

Altered energy expenditure

Low dietary intake

Inactivity

Inflammation

Energy needs25-30 kcal/d

Protein1.2-2.0 g/kg/d

AAs and derivativesLeucine: 2 g/d; HMB: 3 g/d;

Glutamine: 0.3g/kg/d; Carnitine: 4-6 g/d; Creatine: 0.03-0.5g/kg/d

Fish oil/EPA2.0-2.2 g/d EPA

1.5 g/d DHA

Vitamins/minerals800-1000 IU/d

+multivitamin/mineral

Multimodal interventionsNutrition, exercise, pharmaceutical,

psychosocial

NUTRIENTS UNDER CONSIDERATION FOR TREATMENT OF LOW MUSCLE MASS IN CANCER

Prado CM, et al.. 2020;11(2):366-380.

PROTEIN INTAKE GUIDELINES


Protein Requirement to Increase Muscle

http://primestudy.ualberta.ca/ClinicalTrials.gov Identifier: NCT02788955

o Test the efficacy of diets of different protein levels

o12 week Randomized Controlled Trial, CRC (non cachectic)

1 g/kg/day vs. 2 g/kg/d

ENERGY INTAKE GUIDELINES


ENERGY NEEDS ARE HIGHLY VARIABLE AND NOT CAPTURED BY CURRENT RECOMMENDATIONS

Mea

sure

d TE

E, k

cal/k

g bo

dy w

eigh

t

Each point is a patient. The blue box represents current recommendations of 25-30 kcal/kg body weight.

Energy recommendations based on body weight alone were poor assessments of energy requirements

25 kcal/kg: 1613 kcal/d (or 48.5%) under-prediction 30 kcal/kg: 968 kcal/d (or 46.9%) over-prediction

Errors related to weight, body composition, and physicalactivity.

Purcell SA, et al. Am J Clin Nutr. 2019;110(2):367-376.

https://www.cosmed.com/en/products/indirect-calorimetry/q-nrg Quick: 10-15 minutes measurement

MobileAffordable

https://www.cosmed.com/en/products/indirect-calorimetry/q-nrg

GAPS & OPPORTUNITIES

Take Home Message # 4:Nutrition as a powerful metabolic therapy

ARE ENERGY AND PROTEIN RECOMMENDATIONS ADEQUATE?

Prado CM, et al. Ann Med. 2018;50:675-693.

Gaps & Opportunities

Guidelines evidence?

Synergistic vs additive

effect nutrients

Studies of longer

duration

Studies in all cancer

stagesRCT

Early & continuing

intervention

Multimodal approach

EXPLORATORY DIETARY APPROACHESDiet as a metabolic therapy

Fasting/caloric restriction can: inhibit tumor growth enhance chemotherapy efficacy reduce side effects of chemotherapy

ClinicalTrials.gov Identifier: NCT03795493

ClinicalTrials.gov Identifier NCT03131024

Oliveira CLP, et al. J Acad Nutr Diet. 2018;118(4):668-688.

RECAP…

Take Home Message # 1:Patients with cancer are one of the largest hospital patient groups with malnutrition

Take Home Message # 4:Nutrition as a powerful metabolic therapy

Take Home Message # 3:The quality and quantity of nutrients is essential to sustain nutritional status, hence improving outcomes in cancer

Take Home Message # 2:Low muscle mass is prevalent in cancer. It occurs at any body weight, cancer type, stage and age and worsens prognosis.

THANK YOU

[email protected]

@DRCARLAPRADO

NEWBODY COMPOSITION & HEALTH

ONLINE EDUCATIONAL MODULES

VISIT ANHI.ORG TO LEARN MOREDIRECT LINK: ANHI.ORG/EDUCATION/COURSE-CATALOG/BODY-

COMPOSITION-WITH-CARLA-PRADO

Use as Continuing Education Credits

NUTRITION CARE GUIDELINES FOR ONCOLOGY PATIENTS

SUZANNE DIXON, MPH, MS, RDN

DISCLOSURES



• I have no financial disclosures

OBJECTIVES

1. Review current evidence-based clinical nutrition guidelines for early nutrition screening and assessment in oncology patients.

2. Examine current recommendations on implementing nutrition interventions to address malnutrition and cancer cachexia in oncology practice.

3. Identify areas for future guideline development to improve nutrition care.

NUTRITION GUIDELINES FOR ONCOLOGY PATIENTS

• Past–EAL 2007, 2013–ASPEN 2009

• Present–NAS 2016–NCCN–ASCO–ESPEN 2016

• Future–Malnutrition Consensus

Project

EVIDENCE ANALYSIS LIBRARY: 2007 – 2013 ONCOLOGY NUTRITION UPDATE6 original questions, 95 articles, 16 conclusion statements and 15 recommendations.•Grade I: Good – the evidence consists of results from studies of strong design for answering the question addressed.

•Grade II: Fair – the evidence consists of results from studies of strong design

•Grade III: Limited numbers of studies

•Grade IV: Expert opinion only

•Grade V: Not assignable

Conclusion Statement

Grades 2007 vs 2013

EAL 2007 Grade 1 Grade 2 Grade 3 Grade 5 EAL 2013

Evidence Analysis Library Oncology Guideline 2013. https://www.andeal.org/vault/pq113.pdf. Accessed 7.12.20Evidence Analysis Library Oncology Guideline 2007. https://www.andeal.org/topic.cfm?cat=2819. Accessed 7.12.20

6%

EVIDENCE ANALYSIS LIBRARY: ONCOLOGY 2013

Poor nutrition status is associated with decreased toleranceto radiation treatment in adult oncology patients

Poor nutrition status is associated with decreased toleranceto chemotherapy treatment in adult oncology patients

Poor nutrition status is associated with increased length ofhospital stay (LOS) in adult oncology patients.

Poor nutrition status is associated with lower quality oflife (QoL) in adult oncology patients.

Poor nutrition status is associated with mortality inadult oncology patients.

Grade I

Grade I

Grade I

Grade I

Grade I

Evidence Analysis Library Oncology Guideline 2013. https://www.andeal.org/vault/pq113.pdf. Accessed 7.12.20

ASPEN (2009) GUIDELINE DEVELOPMENT CRITERIA

Grading of GuidelinesA Supported by at least two level I investigationsB Supported by one level I investigationC Supported by at least one level II investigationsD Supported by at least one level III investigationsE Supported by level IV or V evidence

Levels of EvidenceI Large randomized trials with clear‐cut results; low risk of

false‐positive(alpha) and/or false‐negative (beta) errorII Small, randomized trials with uncertain results; moderate‐to‐high

risk of false‐positive (alpha) and/or false‐negative (beta) errorIII Nonrandomized cohort with contemporaneous controlsIV Nonrandomized cohort with historical controlsV Case series, uncontrolled studies, and expert opinion

August DA, et al. JPEN J Parenter Enteral Nutr. 2009;33(5):472-500.

ASPEN 2009 ONCOLOGY NUTRITION GUIDELINE EXAMPLES

• Patients with cancer are nutritionally‐at‐risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (D)

• Nutrition support therapy is appropriate in patients receiving active anticancer treatment who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time (see Guideline 6 Rationale for discussion of prolonged period of time”). (B)

• The palliative use of nutrition support therapy in terminally ill cancer patients is rarely indicated. (B)

• ω‐3 Fatty acid supplementation may help stabilize weight in cancer patients on oral diets experiencing progressive, unintentional weight loss. (B)

• Immune‐enhancing enteral formulas containing mixtures of arginine, nucleic acids, and essential fatty acids may be beneficial in malnourished patients undergoing major cancer operations. (A)

August DA, et al. JPEN J Parenter Enteral Nutr. 2009;33(5):472-500.

NATIONAL ACADEMY OF SCIENCES (NAS – IOM) 2016 WORKSHOP REPORT

National Academies of Sciences, Engineering, and Medicine. 2016. Examining access to nutrition care in outpatient cancer centers: Proceedings of a workshop. Washington, DC: The National Academies Press. www.nationalacademies.org/oncologynutrition

WORKSHOP GOALS

1. Describe the potential benefits of outpatient nutritional care on morbidity, mortality, and long-term survival

2. Describe the current status of nutritional care for oncology outpatients including the availability of data during treatment and long-term survivorship

3. Describe the barriers to achieving an ideal care setting and the information resources available to patients

4. Describe the ideal care setting, including models of care within and outside of the United States

5. Describe the issues relating to cost benefit assessment for both recent diagnosis and post-treatment care

NUTRITIONAL STATUS, NUTRITIONAL INTERVENTION AND CANCER MORBIDITY & MORTALITY

Malnutrition adversely affects outcomes

Certain sub-populations of cancer survivors can make positive lifestyle changes,

including weight loss

Nutrition intervention improves morbidity,

mortality, health outcomes

• Data strong

• Data relatively strong

• Data mixed

NAS 2016 WORKSHOP REPORT: BARRIERS

• The average ratio of RDNs to patients in outpatient cancer care programs is 1:2,308. Barriers to screening:

• Lack of a referral process (46.9%)• Little-to-no administrative support (46.9%)• Time constraints (45.3%)• No identified screening tool (31.3%)• Little-to-no nursing support (29.7%)• No agreement on which screening tool to use among other

disciplines (25%)

Trujillo EB, et al. J Oncol. 2019;2019:7462940.

NAS 2016 WORKSHOP REPORT: IDEAL CARE

Pre-treatment Treatment Post-treatment

• Determine baseline nutritional status, replete nutrient deficiencies as needed

• Discuss potential treatment related side-effects, and nutritional strategies for minimizing the side effects

• Review food safety guidelines

• Monitor changes in nutritional status as the treatment course progresses, modify nutrition plan as needed

• Identify appropriate foods (e.g. taste, texture, temperature) to optimize dietary intake as treatment-related side effects develop

• Review safe food handling procedures during neutropenia

Prevent weight gain, nutrition-related late effects, chronic diseases

MOVING FORWARD…

BUILDING ALLIANCES: INTEGRATING NUTRITION INTO GLOBAL ONCOLOGY TREATMENT GUIDELINES

• NCCN: Registered dietitian referral added to specific treatment guides:

– Pancreatic, Head and Neck, Esophageal

• ASCO

“Recommendation 1.1. Clinicians may refer patients with advanced cancer and loss of appetite and/or body weight to a registered dietitian for assessment and counseling, with the goals of providing patients and caregivers with practical and safe advice for feeding; education regarding high-protein, high-calorie, nutrient-dense food; and advice against fad diets and other unproven or extreme diets (Type of recommendation: informal consensus; Evidence quality: low; Strength of recommendation: moderate).”

Roeland EJ, et al. [published online ahead of print, 2020 May 20]. J Clin Oncol. 2020;JCO2000611.

2016 ESPEN GUIDELINES ON NUTRITION IN CANCER PATIENTSScreening Assessment Intervention Screening/Assessment

• Nutritional management as proposed by the guideline will require screening for malnutrition in all and further assessment and treatment in a relevant fraction of cancer patients.

• Nutrition counselling by a health care professional is regarded as the 1st line of nutrition therapy. Professional counselling, as distinct from brief and casual nutritional “advice”, is a dedicated and repeated professional communication process...

• Theoretical arguments that nutrients “feed the tumor” are not supported by evidence related to clinical outcome and should not be used to refuse, diminish, or stop feeding.

• We recommend, that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day

• We recommend that protein intake should be above 1 g/kg/day and, if possible up to 1.5 g/kg/day


Future: Malnutrition Consensus Project

• Oncology Nutrition Dietetic Practice Group, Academy of Nutrition and Dietetics

• National Academies of Sciences, Engineering and Medicine’s Health and Medicine Division

• American Society of Nutrition

• American Society for Parenteral and Enteral Nutrition

• Academy of Oncology Nurse and Patient Navigators

• Oncology Nursing Society

• American Institute for Cancer Research

• American Cancer Society

• Association of Community Cancer Centers

• American College of Surgeons’ Commission on Cancer

• American Society of Clinical Oncology

• American Society of Radiation Oncology

THANK YOU.

IMPLEMENTING EVIDENCE AND GUIDELINES INTO CLINICAL PRACTICE TO IMPROVE CARE

RHONE M. LEVIN, M.ED., RDN, LDN, CSO

DISCLOSURES

7/20/2020



OBJECTIVE: HOW TO IMPLEMENT EVIDENCE AND GUIDELINES INTO CLINICAL PRACTICE TO IMPROVE CARE

• Translate new evidence and current guidelines to improve oncology patient outcomes.

• Propose strategies for clinical practice based on current evidence and guidelines to improve direct patient care interventions.

• Identify future opportunities for updating current nutrition practice.

7/20/2020

7/20/2020

TRANSLATE NEW EVIDENCE AND CURRENT GUIDELINES TO IMPROVE PATIENT OUTCOMES –

WHAT WE KNOW WORKS


ESPEN KEY STEPS: WHAT WE KNOW WORKS(1) NUTRITION SCREENING

7/20/2020

Choose a validated tool(s) for your setting

Common tool characteristics:

Weight change/ timeReduction in appetiteNutrition impact symptomsBMIHigh risk diagnosis

Apply malnutrition screening for all patients through out treatment, at regular intervals

Include the malnutrition screening results in the EMR


ESPEN KEY STEPS: WHAT WE KNOW WORKS(2) EXPAND NUTRITION-RELATED ASSESSMENT PRACTICES

7/20/2020

• Expand nutrition –related assessment practices to include measures of:• Anorexia• Body composition• Inflammatory biomarkers• Resting energy expenditure• Physical function


ESPEN KEY STEPS: WHAT WE KNOW WORKS(3) MULTIMODAL NUTRITIONAL INTERVENTIONS

7/20/2020

Arends J, et al. Clin Nutr. 2017;36(5):1187-1196. Muscaritoli M, et al. Ther Adv Med Oncol. 2019;11:1758835919880084.

• Multimodal nutritional interventions1

• Individualized nutrition plans

• Care focused on increasing nutritional intake

• Lessening of inflammation and hypermetabolic stress

• Increasing physical activity

Task2 Health Care Specialist

Food Intake Dietitian

Dysphagia Speech therapist, ENT, dentist, surgeon, neurologist

Gastrointestinal problems

Dietitian, Gastroenterologist, surgeon

Chronic Pain Pain expert

Psychosocial distress Psychologist, social worker, palliative care specialist

Muscle loss, fatigue, inactivity

Dietitian, PT, Exercise physiologist

STRATEGIES TO IMPROVE DIRECT PATIENT INTERVENTIONS

• (2013)– written for inpatient but can be adapted to outpatient services

• Summary of Alliance’s Nutrition Care Recommendations• 1. Create institutional culture• 2. Redefine clinician’s roles to include nutrition• 3. Recognize and diagnose all patients at risk• 4. Rapidly implement interventions and continue

monitoring• 5 Communicate nutrition care plans• 6. Develop discharge nutrition care and education plans

Tappenden KA, et al. J Acad Nutr Diet. 2013;113(9):1219-1237.

STRATEGIES FOR CLINICAL PRACTICE TO IMPROVE DIRECT PATIENT CARE INTERVENTIONS

• “Harmonize” with standardized care pathways/algorithms• National Comprehensive Cancer Network (NCCN) – Nutrition for Cancer Survivors• Clinical Oncology Society of Australia (COSA) - Head and Neck Guidelines• Multinational Association of Supportive Care in Cancer (MASCC)• Academy of Nutrition – Oncology EAL

• Standardize care among nutrition staff• NFPE• Nutrition assessment• Malnutrition diagnosis and coding• MNT interventions: provide individualized nutrition interventions

• Nutrition education and nutrition counseling• Food and nutrient delivery

• Energy / nutrient dense• Enteral/parenteral nutrition

7/20/2020

• Get nutrition into care plans, discharge instructions, survivorship plans

• Use of technology to provide education and resources that frees up RDN time for direct patient interventions

• e.g. Use social media to create education for immediate access:

• Information for patients new to treatment (e.g. “try this first”), common questions, de-bunking, cancer prevention, Survivorship

• Training materials for other disciplines triaging nutrition distress

Connecting Kitchen - Meryl Hunt - used with permission

STRATEGIES FOR CLINICAL PRACTICE TO IMPROVE DIRECT PATIENT CARE INTERVENTIONS

IDENTIFY FUTURE OPPORTUNITIES FOR UPDATING THE CURRENT NUTRITION GUIDELINES TO IMPROVE ONCOLOGY

NUTRITION CLINICAL PRACTICE

7/20/2020

• Oncology organizations need to create nutrition guidelines• Requirement for nutrition screening for all oncology patients

applied through out treatment • Start with consensus project!

• Incorporate “Symptom Tracking” into documentation• accurate capture of the patient experience (timing, severity,

intensity and resolution)• leading to real time symptom management

• Requirement utilization of Malnutrition Diagnosis and coding as documented by RDNs

IDENTIFY FUTURE OPPORTUNITIES FOR UPDATING THE CURRENT NUTRITION GUIDELINES TO IMPROVE ONCOLOGY

NUTRITION CLINICAL PRACTICE

7/20/2020

• RDNs participate in research • if you are involved in a research – get the terminology that a “RDN provided MNT” into the

description of the study

• Tools to measure and capture the effectiveness of RDN interventions• Learn something from other disciplines (applied care / RN vs. measured

progress SLP/PT)

The Academy: • Update the Oncology EAL• Oncology nutrition benchmarking to officially address how much work is possible • Improve national standards for oncology nutrition documentation• Reimbursement for efficacious nutrition therapy• Volunteer with the Oncology Nutrition – DPG!

SUMMARY

• There are nutrition organizations that continue to work to improve the current oncology care guidelines and direct patient care:

• Oncology Nutrition – DPG, Academy of Nutrition and Dietetics, American Society of Parenteral and Enteral Nutrition, ESPEN, MASCC, ONS, ASCO, NCCN, COSA, COG

-Screening-Nutrition assessment -Creating a multi-modal team -Pathways to offer improvements to your facility as well as within your nutrition team

THANK YOU

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ONCOLOGY NUTRITION IN 2020: THE INTERSECTION OF … · 2020. 7. 22. · oncology nutrition in 2020:...

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