Perspectives from a dietitian: case studies

Oonagh Griffin RD, MINDIResearch Dietitian – HRB Research FellowDepartment of Surgery, Trinity College DublinNational Surgical Centre for Pancreatic Cancer – St Vincent’s University Hospital

Trinity College Dublin, The University of Dublin

Oncology dietetics

• Nutritional assessment and support throughout treatment

• Identifying and addressing nutrition impact symptoms

• Survivorship: secondary prevention, dealing with long term side effects of treatment

Trinity College Dublin, The University of Dublin

Dietetic clinic list this evening….

Brigid

Michael

Louisa

Trinity College Dublin, The University of Dublin

Brigid

50 year old widow, 4 grown up children, 12 grandchildren

Med Hx: nil, ?previous alcohol excess

Presented with jaundice, subsequently diagnosed with resectablepancreatic cancer

Declined surgery in favour of natural therapies

12/52 later under pressure from family returns to SVUH

Staging laparoscopy reveals disease progression – now borderline resectable disease requiring neo-adjuvant therapy

Dietetic referral at 3rd cycle Folfirinox – 10% weight loss (5kg) requiring dose reduction

Trinity College Dublin, The University of Dublin

Nutritional Assessment

50kg, BMI 19kg/m², pre-illness weight 72kg – 30% weight loss over 5 months

Following own natural regimen: vegan no sugar diet (40% protein, 65% energy requirements)

High dose anti-oxidants and plant-based enzymes

Drinking 2-3 glasses wine daily

“I’m only doing this chemotherapy to keep them happy”

Trinity College Dublin, The University of Dublin

Issues

Weight loss and malnutrition – limiting treatment

Steattorhoea and PEI

Drug nutrient interactions

Alcohol excess

Recent falls – unclear cause

Trinity College Dublin, The University of Dublin

Dietary practices - ? New ? Rationale for avoidance

Priorities

1. Weight loss and impact on treatment, function

2. Address drug nutrient interactions

Trinity College Dublin, The University of Dublin

Agreed goals

Increase protein: Agreed to reintroduce fish and organic meat, butter and cheese (no milk, no eggs)

Agreed to discuss supplements with oncologist

Not agreeable to PERT

Not agreeable to discussion regarding alcohol

Trinity College Dublin, The University of Dublin

Review

2.5 kg increase, chemo resumed

Consented to physio referral

PO intake improved – achieving 75% protein intake

New onset steattorhoea – still declining PERT but took literature regarding same

Telephone call one week later requesting prescription for Creon.

Trinity College Dublin, The University of Dublin

Treatment outcome

Completed 6 cycles Folfirinox

Restaging CT revealed good response – referred for short course RT

Patient declined RT or surgery

Family meeting: community palliative care referral

RIP 5/12 later

Trinity College Dublin, The University of Dublin

Reflection

Control – patient priorities vs healthcare professionals goals

Family dynamics/frustration

Common ground

Priorities

Trinity College Dublin, The University of Dublin

Michael

68 year old bachelor farmer

Recently bereaved (96 year old mother RIP 4/12 ago)

Med Hx: Type 2 DM (10 years), hypertension, high cholesterol, A fib, Obesity (BMI ~44)

Routine GP attendance – 3 stone weight loss, offered bereavement counselling, improvements in lipids and HbA1c praised

6/52 later – brought to A&E by concerned neighbours – jaundiced, frail, further weight loss

ERCP and stent, CT & referral to SVUH

Subsequent CT TAP – 5 cm HOP mass with liver mets

Referred by surgeons following discussion of diagnosis/prognosis

Trinity College Dublin, The University of Dublin

Nutritional Assessment

93 kg, BMI 30kg/m², 32% weight loss over 6 months

Minimal intake: tea and dry toast

Pain & steattorhoea: post prandial, 1 episode of incontinence

Erratic blood sugars; 5-16 mmol/L

Fearful of eating

“Can’t be bothered when it’s only me”

Trinity College Dublin, The University of Dublin

Goals

PERT – treat malabsorption

High protein, high calorie diet – relax previous restrictions

Contacted GP - Community palliative care referral

Contacted by patient a week later

1. Tolerating diet with PERT

2. Attending day care centre for meals

3. “Was I sure he was allowed to have dessert?”

RIP in local hospice 9/52 later

Trinity College Dublin, The University of Dublin

Reflection

Timing of referral

Need to consider previous dietary information/restrictions and address

Role in supportive care

1. Symptom control

2. Barriers to nutrition

3. QOL

Trinity College Dublin, The University of Dublin

Louisa

50 year married teacher, 11 year old twins

Medical Hx: nil

Cruise holiday for 50th birthday: developed abdominal distension and faeculent vomiting

Airlifted back to UK – CT abdo revealed ovarian Ca and bowel obstruction

Referred for PN on arrival in RMH, ngt draining 4L/day

Initial goal – feed/hydrate, commence chemo to reduce tumour bulk

Trinity College Dublin, The University of Dublin

PN dependent for 9/52, stopped following 2nd cycle of chemo

Slow resumption of po intake – intermittent vomiting, early satiety, fear of eating.

D/c home following 3rd cycle – to continue as outpatient

Advised HPHC diet, and importance of weight maintenance throughout

Contact details provided and advised to contact if any weight loss

Trinity College Dublin, The University of Dublin

9 months later

Referred by surgeons prior to attempted resection/debulking, 8kg weight loss noted post RT

Severe diarrhoea following long course RT

Following internet search – patient avoiding wheat and dairy to control symptoms

Resolution of symptoms 2/52 later, still following restricted diet

Trinity College Dublin, The University of Dublin

Explained specific treatment related side effect rather than new dietary intolerance

Need to resume HPHC diet

4kg regained pre-op; debulking only, change to second line chemotherapy

Trinity College Dublin, The University of Dublin

Reflection

Changing needs throughout treatment

Need to ensure patients aware of role regarding symptom management, not just weight maintenance

Review on request?

Trinity College Dublin, The University of Dublin

Reflection

Patient priorities vs family/MDT

Family dynamics and insight into disease/prognosis

Trinity College Dublin, The University of Dublin

Challenges - Summary

• Timing and environment of assessment/referral

• Dietetic capacity

• Food versus Nutrition

• Managing (mis)information

• Patient control and choice

Trinity College Dublin, The University of Dublin

Thank you