Ms Tah Pei Chien - MNT Cancer Guidelines - Changes in guidelines
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Transcript of 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%
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The Most Common Cancer In Malaysia
Source: Malaysian National Cancer Registry 2007
Gender Differences In
Sites Of Cancer
Source: Malaysian National Cancer Registry 2007
16.3%
Lung
14.6%
colorectal
8.4% NPC
6.2% Prostate gland
5.5% Lympho
ma/ Liver
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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
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
12
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
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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.
18
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)
20
21
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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
26
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
34
Nutrition
Intervention and
Recommendation
35
36
37
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
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
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
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
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
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
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
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
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
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
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
Sample
Menu
49
50
Nutrition Education
& Counselling
51
52
Physical Activity
& Cancer
53
54
Nutrition Monitoring
& Evaluation
55
56
Nutrition And Cancer
Resources For Health Care
Professionals
57
58
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
MNT Babies
60
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
THANK YOU
62