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Oncology

ONC: Nutrition Assessment for Adult Oncology Patients (2013)

An adult oncology nutrition assessment should characterize and document the presence of (or expected potential for) altered nutrition status and nutrition impact symptoms that may result in a measurable adverse effect on body composition, function, QoL or clinical outcome and may also include indicators of malnutrition.
 

Nutrition impact symptoms are those symptoms that impede intake, digestion or absorption. They include (but are not limited to) anorexia, nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, dysphagia, alterations in taste and smell, pain, depression, anxiety and fatigue. They can be caused by the cancer itself or the oncology treatment.1,2,3 
 

Laboratory values currently suggested to be a part of a nutrition assessment include glucose, white blood cell (WBC) and C-reactive protein (CRP). Careful interpretation may be required in oncology patients, as they can experience wide variations in glucose and WBC values due to type and timing of treatment. An elevated CRP may indicate inflammation. Other lab values determined to be outside of normal may indicate a need for diet modification of nutrients.
 

In order to evaluate the clinical characteristics used to document malnutrition, it is important to identify any presence and degree of inflammation. This information is used to differentiate between chronic disease related malnutrition (lung, pancreatic and GI cancer, sarcopenic obesity and organ failure) and acute disease and injury-related malnutrition (major infection and surgery). Determining the presence and degree of inflammation determines the significance of any patient weight loss.4,5  The etiology-based malnutrition definitions are located at this link: Etiology-Based Malnutrition Definitions.4
 

While there is no universally accepted approach to the diagnosis and documentation of adult malnutrition, the AND/ASPEN consensus document attempts to provide evidence-based guidance. See Clinical Characteristics to Document Malnutrition.5  The working group has provided additional interpretations specific to the diagnosis of malnutrition in oncology patients:

  • Insufficient energy intake5
  • Unintended weight loss5
    • For the purposes of the Oncology EAL, any weight loss has potential significance, as oncology patients often experience weight loss prior to admission to oncology services. Because weight loss is demonstrated to lead to poor outcomes, it is important to accurately determine a baseline weight.
    • Weight loss or change should be defined as current weight compared to baseline weight. Baseline weight* is defined as:
      • Usual body weight from medical records
      • Weight taken when admitted to oncology service or, if not available:
        • Self-report of recent healthy weight
        • Consider rate of weight loss over specified time frame4
          • *Include presence of under- or over-hydration.
    • Because the presence and degree of inflammation determines the significance of any patient weight loss, first assess markers of inflammation such as an elevated* CRP,4,5 then refer to etiology-based malnutrition definition flowchart located at this link: Etiology-Based Malnutrition Definitions.4
      • *Note: Past interpretation of >10mg/L CRP has been used to indicate inflammation.6 However, further research will elucidate more specific markers for use.
Interpretation of Weight Loss5
 
Time Acute Illness or Injury
(Major infection and surgery)

Chronic Illness
(Lung, pancreatic and GI cancer, sarcopenic obesity and organ failure)

Social or Environmental Circumstances
Moderate Malnutrition Severe Malnutrition Moderate Malnutrition Severe Malnutrition Moderate Malnutrition Severe Malnutrition
% Weight Loss Over Time        1 week
1-2
>2
 
 
 
 
1 month
5
>5
5
>5
5
>5
3 months
7.5
>7.5
7.5
>7.5
7.5
>7.5
6 months
-
-
10
>10
10
>10
1 year
-
-
20
>20
20
>20
  • Weight loss in elderly patients may have additional impact. Usual adult cutoff is BMI of 18.5kg/m2, however studies of the elderly support an association between increased mortality and underweight (BMI under 20kg/m2 or current weight compared with usual or desired body weight ) or UWL (5% in 30 days or any further weight loss after meeting this criteria).7,8,9
  • Loss of muscle mass 5,10
    • Low muscle mass is a common and independent predictor of immobility and mortality,11 is a particularly adverse prognostic indicator in obese patients9 and is associated with greater toxicities of chemotherapy leading to treatment interruptions including dose reductions, treatment delays and treatment termination.8,10,12,13,14,15,16 
    • As 50% of patients with advanced cancer have frank sarcopenia,16 and the shortest survival times are among obese patients with sarcopenia,9 reducing weight at the possible expense of lean muscle mass, in obese cancer patients should not be a priority.


Body weight has been used as an outcome in clinical trials in cancer-induced weight loss and only recently has research begun to focus on LBM as a primary outcome. Existing computerized tomography (CT) images used to diagnose and monitor disease progression are readily available and provide an opportunistic means for body composition analysis. Although this type of analysis is relatively new, its use will be common in the near future and offers the dietitian the ability to demonstrate value. Other methods of measuring muscle mass are bioelectrical impedence analysis (BIA), dual-energy X-ray absorptiometry (DXA) and anthropometry. Patients with loss of muscle mass experience greater treatment toxicity and shorter survival.13,17

  • Loss of subcutaneous fat:5,9,16 With the increase in obesity in Western society and patients with cancer in particular, reducing fat tissue should not be a priority. The important problem remains low muscle mass, since up to 50% of patients with advanced cancer have frank sarcopenia.16 The shortest survival times are among obese patients with sarcopenia.9
  • Localized or generalized fluid accumulation (that may mask weight loss)5
  • Reduced grip strength* or diminished functional status, as measured by Karnofsky score5
    • Consult normative standards per device manufacturer.

The following tools have been found to be valid and reliable in assessing the nutritional status of adult oncology patients in ambulatory and acute care settings:

  • PG-SGA
  • SGA.

The MNA was found to have the sensitivity to diagnose oncology patients with malnutrition in the ambulatory setting, but was only moderately specific in identifying malnutrition when compared with the PG-SGA. The MNA was not evaluated in the acute care setting.  Click this link for the Nutrition Assessment Tool summary.

References

1. American Cancer Society: Nutrition for the Person with Cancer: A Guide for Patients and Families. Atlanta, Ga: American Cancer Society, Inc., 2000.

2. 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.

3. Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues. 17 (2): 15-17, 2002.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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): 6,973-6,979. Epub 2009 Nov 3. PMID: 19887488.

10. 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): 2,920-2,926. Epub 2009 Apr 7. PMID: 19351764.

11. Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, Baracos VE. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008 Jul;9 (7): 629-635. Epub 2008 Jun 6. PMID: 18539529.

12. Prado CM, Baracos VE, McCargar LJ, Mourtzakis M, Mulder KE, Reiman T, Butts CA, Scarfe AG, Sawyer MB. Body composition as an independent determinant of 5-fluorouracil-based chemotherapy toxicity. Clin Cancer Res. 2007 Jun 1; 13 (11): 3,264-3,268. PMID: 17545532.

13. 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.

14. 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.

15. 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.

16. Fearon KC. Cancer cachexia and fat-muscle physiology. N Engl J Med. 2011 Aug 11; 365 (6): 565-567. No abstract available. PMID: 21830971.

17. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinkov√° 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):412-423. doi: 10.1093/ageing/afq034. Epub 2010 Apr 13. PMID: 20392703. 

 

See Nutrition and the Adult Oncology Patient and Screening Adult Oncology Patients for Malnutrition Risk.