EAL

Recommendations Summary

ONC: Nutrition Monitoring and Evaluation of Adult Oncology Patients 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

Recommendation(s)
ONC: Monitoring and Evaluation of Adult Oncology Patients

Following the nutrition intervention, to check progress, the registered dietitian (RDN) should monitor and evaluate the following components of adult oncology patients at each visit and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. This may include, but is not limited to:

Anthropometric measurements:
- Weight change
- BMI
Food/Nutrition-related history:
- Energy and protein intake
- Changes in food and fluid/beverage intake
- Adequacy and appropriateness of nutrient intake/nutrient administration
- Actual daily intake from enteral nutrition (EN) and parenteral nutrition (PN) and other nutrient sources
- Changes in type, texture, or temperature of food and liquids
- Use of medical food supplements (MFS)
- Food avoidance and intolerances
- Meal/snack pattern changes
- Prescription medications, over-the-counter medications, herbal preparations and complementary alternative medicine products
- Factors affecting access to food
- Feeding method or need for placement (e.g., oral, enteral or parenteral)
Biochemical data, medical tests and procedures:
- Biochemical indices
- Implications of diagnostic tests and therapeutic procedures
Nutrition-focused physical findings:
- Vital signs
- Loss of muscle mass
- Loss of subcutaneous fat
- Nutrition impact symptoms including but not limited to: Nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, alterations in taste and smell, and anxiety
- Presence of pressure ulcers or wounds
- Functional indicators (i.e., Karnofsky score, grip strength)
- Localized or generalized fluid accumulation
Client history:
- Patient/Family/Client Medical/Health History:
  - Nutrition impact symptoms including but not limited to: Dysphagia, depression and pain fatigue
  - Medical treatment/therapy
  - Other diseases, conditions and illnesses including cancer cachexia
Social history:
- Psychological/socioeconomic issues (e.g., social support)
Monitoring and evaluation of the above factors is needed to correctly/effectively diagnose nutrition problems that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Rating: Consensus
Imperative

ONC: Monitoring and Evaluating Adult Oncology Patients with Cancer Cachexia

As part of monitoring and evaluation, in patients with lung, pancreatic or head and neck and gastrointestinal (GI) cancers, or those who are at high risk for weight loss or have experienced unintended weight loss, the registered dietitian nutritionist (RDN) should monitor and evaluate nutrition impact symptoms, markers of inflammation [e.g., elevated C-reactive protein (CRP)] and other signs of wasting, which may indicate pre-cachexia or cancer cachexia.

Rating: Consensus
Conditional
- Risks/Harms of Implementing This Recommendation
  There are no potential risks or harms associated with the application of this recommendation.
- Conditions of Application
  - RDNs should be appropriately trained to conduct a nutrition-focused physical exam
  - If necessary data are not available, the RDN should use professional judgment to request or obtain additional data.
- Potential Costs Associated with Application
  Accessibility and costs of additional laboratory testing should be considered.
- Recommendation Narrative
  Frequent monitoring and evaluation should be performed to document the presence of (or expected potential for) altered nutrition status, nutrition impact symptoms or measurable adverse effects on body composition, function, QoL or clinical outcomes. Appropriate MNT interventions can lead to improvement in clinical outcomes.
  
  Monitoring should include the six indicators of malnutrition (energy intake, interpretation of weight loss, body fat, muscle mass, fluid accumulation, reduced grip strength), laboratory values, nutrition impact symptoms, and planned oncology treatments.
- Recommendation Strength Rationale
  Consensus.
- Minority Opinions
  None.

Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
- References
- References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
  American Cancer Society.: Nutrition for the Person with Cancer: A Guide for Patients and Families. Atlanta, Ga: American Cancer Society, Inc., 2000.
  
  Antoun S, Baracos VE, Birdsell L, Escudier B, Sawyer MB. Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Ann Oncol. 2010 Aug; 21 (8): 1, 594-1, 598. Epub 2010 Jan 20. PMID: 20089558.
  
  Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M; European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul;39(4):412-23. doi: 10.1093/ageing/afq034. Epub 2010 Apr 13. PMID: 20392703
  
  Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. 2013 Feb; 10 (2): 90-99. doi: 10.1038/nrclinonc.2012.209. Epub 2012 Dec 4. PMID: 23207794.
  
  Fearon KC. Cancer cachexia and fat-muscle physiology. N Engl J Med. 2011 Aug 11; 365 (6): 565-567. No abstract available. PMID: 21830971.
  
  Fearon KC, Voss AC, Hustead DS; Cancer Cachexia Study Group. Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr. 2006 Jun; 83(6): 1, 345-1, 350. PMID: 16762946.
  
  Grabowski DC and Ellis JE. High body mass index does not predict mortality in older people: analysis of the Longitudinal Study of Aging. J Am Geriatr Soc. 2001 Jul; 49 (7): 968-979. PMID: 11527490.
  
  Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter Enteral Nutr. 2012 May; 36 (3): 267-274. Epub 2012 Mar 8.
  
  Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, Harris J, Scrimger R, Parliament M, Baracos VE. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck. 2010 Mar; 32 (3): 290-300. doi: 10.1002/hed.21174. PMID: 19626639.
  
  Prado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, Mackey JR, Koski S, Pituskin E, Sawyer MB. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009 Apr 15; 15 (8): 2, 920-922, 926. Epub 2009 Apr 7. PMID: 19351764.
  
  Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009 Dec; 3 (4): 269-275. Review. PMID: 19667996.
  
  Prado CM, Lima IS, Baracos VE, Bies RR, McCargar LJ, Reiman T, Mackey JR, Kuzma M, Damaraju VL, Sawyer MB. An exploratory study of body composition as a determinant of epirubicin pharmacokinetics and toxicity. Cancer Chemother Pharmacol. 2011 Jan; 67 (1): 93-101. Epub 2010 Mar 5. PMID: 20204364.
  
  Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clin Cancer Res. 2009 Nov 15; 15 (22): 6, 973-976, 979. Epub 2009 Nov 3. PMID: 19887488.
  
  White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group, A.S.P.E.N. Malnutrition Task Force, A.S.P.E.N. Board of Directors. J Acad Nutr Diet. 2012 May; 112 (5): 730-738. Epub 2012 Apr 25.
  
  Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues 17 (2): 15-17, 2002.