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Recommendations Summary

ONC: Nutrition Status and Outcomes 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: Nutrition Status and Outcomes in Adult Oncology Patients

    The registered dietitian nutritionist (RDN) should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that the evaluation of nutrition status is a key component of the adult oncology patient care process. Research indicates that poor nutrition status is associated with higher rates of hospital admissions or re-admissions,  increased length of hospital stay (LOS),  lower quality of life (QoL) and mortality in adult oncology patients. Poor nutrition status is also associated with decreased tolerance to chemotherapy and radiation treatment in adult oncology patients undergoing these therapies.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no potential risks or harms associated with the application of this recommendation.

    • Conditions of Application

      There are no conditions which may limit the application of this recommendation.

    • Potential Costs Associated with Application

      Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions including collaboration with other healthcare professionals, are essential for improved outcomes.

    • Recommendation Narrative

      A total of 45 studies were included in the evidence analysis for this recommendation:  

      • Six positive-quality randomized controlled trials (RCT) [Barlow et al, 2011; Braga et al, 1998; Hyltander et al, 2005; Ionescu et al, 2009; Ravasco et al, 2005 (Head and Neck); Ravasco et al, 2005 (J Clin Oncology.)] 
      • Six positive-quality prospective cohort studies (Fearon et al, 2006; Hill et al, 2011; Laky et al, 2010; Ross et al, 2004; Sorensen et al, 2008; Tan et al, 2009)
      • Three positive-quality diagnostic, validity or reliability studies (Amaral et al, 2008; Correia et al, 2007; Gioulbasanis et al, 2011)
      • Three positive-quality case-control studies (Alexandre et al, 2003; Carey et al, 2011; Horsley et al, 2005)
      • Two postive-quality retrospective cohort studies (Gupta et al, 2010; Yoon et al, 2011)
      • Two positive-quality prospective cohort studies (Pressior et al, 2010; Prado et al, 2007)
      • Two postive-quality cross-sectional studies (Isenring et al, 2003; Nourissat et al, 2008)
      • One positive-quality prospective before-and-after study (Ravasco et al, 2003)
      • Five neutral-quality prospective cohort studies (Martin et al, 2010; Martin and Lagergren, 2009; Prado et al, 2008; Prado et al, 2009; Prado et al, 2011)
      • Two neutral-quality diagnostic, validity or reliability studies (Phippen et al 2011; Persson et al, 1999)
      • Two neutral-quality non-controlled trials (Bauer et al, 2005; Capuano et al, 2008)
      • Two neutral-quality prospective cohort studies (Antoun et al, 2009; Iversen et al, 2010)
      • Two neutral-quality RCTs (Ollenschlager et al, 1992; Robinson et al, 2008)
      • Two neutral-quality cross-sectional studies (Dewys et al, 1980; Shahmoradi et al, 2009)
      • Two neutral-quality retrospective cohort studies (Eriksson et al, 1998; Kathiresan et al, 2011)
      • One neutral-quality descriptive study (Hammerlid et al, 1998)
      • One neutral-quality retrospective chart review (Odelli et al, 2005)
      • One neutral-quality non-randomized controlled trial (Piquet et al, 2002).

      Nutrition Status and Hospital Admissions or Re-admissions

      • Five of six studies provide evidence that poor nutrition status is associated with higher rates of hospital admissions or re-admissions in adult oncology patients.
        • Five studies found that a decreased nutrition status is associated with greater numbers of hospital admissions. 
        • A sixth study (Barlow et al, 2011) showed the same effect, but was not statistically significant.
      • Evidence is based on the following studies: Barlow et al, 2011; Capuano et al, 2008; Hill et al, 2011; Kathiresan et al, 2011; Odelli et al, 2005; and Piquet et al, 2002.

      Nutrition Status and Hospital LOS

      • Ten of eleven studies provide evidence that poor nutrition status is associated with increased length of hospital stay (LOS) in adult oncology patients.
        • Ten studies found that a decreased nutrition status is associated with longer LOS. 
        • One study (Hyltander et al, 2005) found no statistical difference between groups.
      • Evidence is based on the following studies: Amaral et al, 2008; Antoun et al, 2009; Barlow et al, 2011; Braga et al, 1998; Horsley et al, 2005; Hyltander et al, 2005; Ionescu et al, 2009; Laky et al, 2010; Odelli et al, 2005; Pressoir et al, 2010; and Sorensen et al, 2008.

      Nutrition Status and QOL

      • Thirteen of 14 studies provide evidence that poor nutrition status is associated with lower quality of life (QoL) in adult oncology patients.
        • Thirteen studies found that a decreased nutrition status is associated with a lower QoL.
          • All eight of the studies utilizing the Patient-Generated Subjective Global Assessment (PG-SGA) found that a higher score (higher nutrition risk) was associated with a lower QoL in oncology patients.
        • Only one study (Hammerlid et al, 1998) found minimal correlation between nutrition status and QoL.
      • Evidence is based on the following studies: Bauer et al, 2005; Carey et al, 2011; Correia et al, 2007; Fearon et al, 2006; Hammerlid et al, 1998; Hyltander et al, 2005; Isenring et al, 2003; Iversen et al, 2010; Nourissat et al, 2008; Ollenschlager et al, 1992; Ravasco et al, 2003; Ravasco et al, 2005 (J Clin Oncology); Ravasco et al, 2005 (Head and Neck); and Shahmoradi et al, 2009.

      Nutrition Status and Radiation Treatment Tolerance 

      • Six studies provide evidence that poor nutrition status is associated with increased radiation treatment intolerance in adult oncology patients undergoing radiotherapy.
        • All six studies found positive associations between nutrition status and two or more of the following: Reduced treatment interruptions, unplanned hospital admissions, treatment toxicity, PG-SGA score over time and QoL.
      • Evidence is based on the following studies: Capuano et al, 2008; Hill et al, 2011; Odelli et al, 2005; Ravasco et al, 2003; Ravasco et al, 2005 (J Clin Oncology); Ravasco et al, 2005 (Head and Neck)

      Nutrition Status and Chemotherapy Treatment Tolerance

      • Ten of eleven studies provide evidence that poor nutrition status is associated with increased chemotherapy treatment intolerance in adult oncology patients undergoing chemotherapy. 
        • Ten studies found positive associations in one or more of the following: Treatment interruptions, infections,  unplanned hospital admissions, treatment toxicity, including dose-limiting treatment toxicity, neutropenic fever,  fatigue and severe thrombocytopenia.
        • One study (Odelli, 2005) showed a similar trend toward fewer dose reductions, but the difference was NS. 
      • Evidence is based on the following eleven studies: Alexandre et al, 2003; Capuano et al, 2008; Eriksson et al, 1998; Hill et al, 2011; Odelli et al, 2005; Phippen et al, 2011; Prado et al, 2007; Prado et al, 2009; Prado et al, 2011; Robinson et al, 2008; and Ross et al, 2004

      Nutrition Status and Mortality

      • Sixteen of seventeen studies provide evidence that poor nutrition status is associated with mortality in adult oncology patients. 
        • Sixteen studies found positive associations among one or more of the following and mortality: weight loss, malnutrition, poor scores on validated malnutrition and quality of life screening tools, sarcopenia, cachexia, and fatigue. 
        • One study (Hyltander et al, 2005) did not find a relationship between nutrition status and mortality.
      • Evidence is based on the following seventeen studies: Capuano et al, 2008; Dewys et al, 1980; Fearon et al, 2006; Gioulbasanis et al 2011; Gupta et al, 2010; Hammerlid et al, 1998; Hyltander et al, 2005; Martin and Lagergren, 2009; Martin et al, 2010; Persson et al, 1999; Prado et al, 2008; Pressoir et al, 2010; Robinson et al, 2008; Ross et al, 2004; Sorensen et al, 2008; Tan et al, 2009; Yoon et al, 2011

    • Recommendation Strength Rationale

      • The conclusion statement for the relationship between nutrition status and hospital admissions or re-admissions is Grade II
      • The conclusion statement for the relationship between nutrition status and hospital LOS is Grade I
      • The conclusion statement for the relationship between nutrition status and QoL is Grade I
      • The conclusion statement for the relationship between nutrition status and radiation treatment tolerance is Grade I
      • The conclusion statement for the relationship between nutrition status and chemotherapy treatment tolerance is Grade I
      • The conclusion statement for the relationship between nutrition status and mortality is Grade I.

    • Minority Opinions

      None.