Ms Tah Pei Chien - MNT Cancer Guidelines - Changes in guidelines

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Ms Tah Pei Chien - MNT Cancer Guidelines - Changes in guidelines

  1. 1. 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
  2. 2. MNT Guidelines for Cancer in Adults Working Group Committee Gaik Lian Suraiya Firdaus Wai Hong Hidayah Shariza Pei Chien Shafurah Li Yin Zalina 2
  3. 3. 2010 – 2013 (3 years) 21 meetings 3
  4. 4. Outline • Introduction • Objectives of the MNT guidelines • Contents of MNT guidelines • Nutrition recommendation for cancer patients 4
  5. 5. 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
  6. 6. 18.1% 12.3% 10.2% 5.2% 4.6% 6 The Most Common Cancer In Malaysia Source: Malaysian National Cancer Registry 2007
  7. 7. Gender Differences In Sites Of Cancer Source: Malaysian National Cancer Registry 2007 16.3% Lung 14.6% colorect al 8.4% NPC 6.2% Prostat e gland 5.5% Lympho ma/ Liver 7
  8. 8. 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 Source: Malaysian National Cancer Registry 2007
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Contents of the MNT • Nutrition Screening • Nutrition Assessment – Estimated requirement: • Macronutrient • Fluid • Micronutrients • Eicosapentaenoic acid (EPA) • Nutrition Diagnosis 12
  13. 13. 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
  14. 14. Nutrition Screening and NCP Flowchart 14
  15. 15. MST SGA & PGSGA Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011 15
  16. 16. Nutrition Screening 16
  17. 17. 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 17
  18. 18. 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. 18 Malnutrition Screening Tool (MST)
  19. 19. Nutrition Assessment 19
  20. 20. 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) 20
  21. 21. 21
  22. 22. 22
  23. 23. Energy Requirement 23
  24. 24. 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
  25. 25. Energy Requirement Estimation in MNT CA Table 3 Formulas for Calculation of Energy Requirement 25
  26. 26. 26
  27. 27. PROTEIN REQUIREMENT 27
  28. 28. 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
  29. 29. Protein Requirement in MNT CA Table 4: Estimating Daily Protein Needs in Cancer Patients 29
  30. 30. 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
  31. 31. Algorithm of Nutrition Support for Cancer Patients 31
  32. 32. 32 Ref: ESPEN, 2006; FESEO, 2008
  33. 33. 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
  34. 34. 34
  35. 35. Nutrition Intervention and Recommendation 35
  36. 36. 36
  37. 37. 37
  38. 38. 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
  39. 39. Diet and Counseling 39 Recommendation Grade References • 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
  40. 40. Enteral Nutrition (General) 40 Recommendation Grade References • 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
  41. 41. 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
  42. 42. Enteral Nutrition (Perioperative) 42 Recommendation Grade References • 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
  43. 43. Enteral Nutrition During Chemo / Radiotherapy 43 Recommendation Grade References • 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
  44. 44. Parenteral Nutrition (PN) 44 Recommendation Grade References • 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
  45. 45. Nutrition During Transplantation of Hematopoietic Precursor Cells 45 Recommendation Grade References • 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
  46. 46. Nutrition During Transplantation of Hematopoietic Precursor Cells 46 Recommendation Grade References • 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. 47. 47 Recommendation Grade References • 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
  48. 48. 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). 48
  49. 49. Sample Menu 49
  50. 50. 50
  51. 51. Nutrition Education & Counselling 51
  52. 52. 52
  53. 53. Physical Activity & Cancer 53
  54. 54. 54
  55. 55. Nutrition Monitoring & Evaluation 55
  56. 56. 56
  57. 57. Nutrition And Cancer Resources For Health Care Professionals 57
  58. 58. 58
  59. 59. 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 59
  60. 60. MNT Babies 60
  61. 61. 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 61
  62. 62. THANK YOU 62

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