Improving Patient Outcomes with Nutrition Services: What a Dietitian Can Do for Your Cancer Center

March is National Nutrition Month. ACCCBuzz has invited guest blogger Colleen Gill, MS, RD, CSO, to share her perspectives on the value dietitian services can bring to cancer care services. Ms. Gill is a clinical dietitian with the University of Colorado Cancer Center. She is also serves on the ACCC Board of Trustees.

Although 90 percent of cancer treatment occurs in clinics, dietitian services have not been universally available in the outpatient setting. While for inpatients some level of coverage for dietitian services exists, the focus is rarely on issues patients encounter after discharge from the hospital and while undergoing anticancer treatment.

In 2012, the American College of Surgeons Commission on Cancer (ACOS CoC) added a standard to address nutrition (Eligibility Requirement 12), stating: “a policy or procedure is in place to access nutrition services either on site or by referral.” This is a step in the right direction; however, the process is left up to each center, which can result in token efforts without administrative endorsement of supportive oncology services.

Over the past five years, staffing surveys have found that many more cancer centers have added nutrition services and, more significantly, have noted improved patient and staff satisfaction that has led to hiring of additional dietitians. A study is currently being funded by the Institutes of Medicine (IOM) to identify optimal staffing based on patient need rather than current practice. The IOM Planning Committee on Assessing Nutrition Care in Outpatient Oncology is hosting a one-day workshop on Monday, March 14, which will be open for the public to watch as a webcast. Event details and registration information is available here.

The Role of Nutrition Support for Patients with Cancer

Discussion of the role of nutrition support for cancer patients has a long history. In 1980, DeWys and colleagues published ECOG data showing that weight loss was associated with poor outcomes in cancer patients. In 1998, Andreyev and colleagues identified increased toxicities and shorter treatment duration as outcomes of weight loss, and noted this resolved with stabilization of weight. Since then research has found that nutrition support helps manage symptoms, improving intake and thus stabilizing weight, nutrition and hydration status, normalizing bowel patterns. This keeps patients on treatment pathways without interruptions related to failure to thrive and hospital admissions for dehydration. Across the continuum of cancer care, nutrition support is associated with improved quality of life (QOL), better maintenance of muscle mass and functional status, and improved tolerance of treatment with better outcomes. Eating also allows patients to sustain social connections, while minimizing conflicts around eating that can arise from family concerns and pressures.

Five Basic Steps for Starting a Nutrition Program

For cancer programs interested in starting a nutrition program, five basic steps include:

1. Screening.

• Criteria are now well defined* and include assessment of any losses in muscle mass and evaluation of the rate of weight loss. Interestingly, obesity is actually a predictor of higher rates of malnutrition, though with delayed recognition.

*Consensus papers on the assessment of malnutrition were published in ASPEN and the Journal of Nutrition and Dietetics in 2012. In 2013, Jensen, Compher, Sullivan and Mullin followed with a summary of strategies to implement a multidisciplinary team approach to identifying patients at risk.

• Screening should be done at least monthly, as therapies can and do change over time and create new barriers to eating. Identifying and addressing changes and new symptoms proactively will lessen their impact and the likelihood the patient will become malnourished.
• In a recent review of screening tools (Skipper A, et al., 2012), the Malnutrition Screening Tool (MST), which uses unintentional weight loss and reduced appetite, was found to have the greatest validity and reliability. In some cancer centers, screening is implemented with a simple question that includes these factors; the screening question is added to the list that the medical assistant reviews with the patient at each visit. For example, asking patients: “Are you experiencing any difficulties with eating that limit your ability to maintain your weight?”

2. Initiation of interventions in patients at nutrition risk, by diagnosis, weight/muscle loss.

3. Staff and patient education activities.

• Identifying or creating materials needed to address symptom management issues
• Educating staff where appropriate, i.e., enzyme dosing for malabsorption, bowel regimens, TPN monitoring/support
• Support group lectures
• Supervising nutrition rotations for local internship programs, medical school electives

4. Involvement in outreach activities that increase the visibility of nutrition support services.

• For example, through outreach activities with Living Beyond Breast Cancer, Lymphoma and Leukemia Society, or similar support groups
• Community lectures on complementary/integrative nutrition topics. Sample topics might include:  Limiting the adoption of extremely restrictive diets that are not evidenced based; helping patients integrate nutrition without creating a new stress in their lives; and addressing issues such as supplementation, weight management, and exercise.
• Cooking classes
• PR requests from local media

5. Hiring carefully. Find candidates with a passion for oncology and a desire to make a difference. A registered dietitian nutritionist (RD/RDN) with 2,000 hours of oncology experience can take a certification exam to become a board certified specialist in oncology (CSO).

Here are some resources to help get you started:

American Institute on Cancer Research: www.aicr.org

• The plate model as a visual guide for a healthy diet
• Continuous Update Reports on specific cancers and diet
• Symptom management materials:  HEAL Well: A Cancer Nutrition Guide

Association of Community Cancer Centers: Cancer Nutrition Provider Resources

• A Quality Improvement Nutrition Program. Oncology/Issues (July/August 2013)
• Building a Nutrition Program within a New Comprehensive Cancer Center. Oncology Issues (November/December 2010)
• Nutrition the 7^th Vital Sign. Oncology Issues (November/December 2010)

The Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics;      FAQs www.oncologynutrition.org/erfc/healthy-nutrition-now/foods/  Materials to address questions on juicing, sugar and cancer, soy, etc.

ACS Nutrition and Physical Activity Guidelines for Cancer Survivors, 2012.