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Oncology

ONC: Introduction (2013)

Guideline Overview

Guideline Title

Oncology (2013) Evidence-Based Nutrition Practice Guideline

Guideline Narrative Overview

The focus of this guideline is on oncology nutrition practice during the treatment of adult patients with cancer. Cancer is a complex group of multifactoral diseases that develops from interactions between genetics and environment. Screening for malnutrition risk and performing a comprehensive nutrition assessment are required to identify intervention to maximize adequate intake. The goals of nutrition care are to identify nutrition impact symptoms,  to prevent or reverse nutrient deficiencies, and intervene early if cancer cachexia is identified, preserve lean body mass (LBM),  minimize nutrition-related side effects and complications in order to help patients better tolerate treatments.

This edition lays the foundation to establish the need for Medical Nutrition Therapy (MNT) in the adult oncology population, since nutrition plays a key role in all cancers and cancer treatments. The aim of this guideline is to document the areas where more evidence exists in order to strengthen the rationale for MNT. Thus, the workgroup chose to principally target:

  1. malnutrition screening and nutrition assessment using tools validated in this population,
  2. the association between nutrition status and morbidity and mortality outcomes,
  3. the effect of MNT on patients undergoing chemotherapy and radiation treatment, and
  4. cancer cachexia and the effect of the interventions of dietary supplements and medical food supplements containing fish oil (EPA) on LBM and weight.

This Oncology Guideline edition focuses on analysis where the recent literature pool was concentrated: screening, assessment and outcomes. To further expand the recommendation set, evidence-based guidelines published by external organizations were reviewed and included where appropriate.

The articles evaluated for the Academy’s analysis in this edition were not concentrated on one particular type of cancer or therapy treatment. It is acknowledged that this is a departure from the first edition of the Oncology guideline, which presented evidence-based interventions for oncology patients with specific types of cancers and treatments. This change in organization highlights specific key topics where the stronger bodies of evidence exist.

Guideline Development

This guideline outlines the most current information on nutrition support practice in adults with cancer. The recommendations developed in this guideline were based upon a systematic review of the literature in multiple practice areas. A summary of the evidence analysis is below:

Topics  include:

  • ONC: Nutrition Status and Outcomes of Adult Oncology Patients (hospital admissions or re-admissions, length of hospital stay (LOS), quality of life (QoL), tolerance to chemotherapy and radiation treatment and mortality)
  • ONC: Screening for Malnutrition Risk and Referral of Adult Oncology Patients
  • ONC: Malnutrition Screening Tools for Adult Oncology Patients
  • ONC: MNT in Adult Oncology Patients Undergoing Chemotherapy or Radiation Therapy
  • ONC: Nutrition Assessment Tools for Adult Oncology Patients
  • ONC: Nutrition Assessment Criteria for Adult Oncology Patients
  • ONC: Nutrition Assessment for the Stages of Cancer Cachexia in Adult Oncology Patients
  • ONC: Nutrition Diagnosis of Malnutrition in Adult Oncology Patients
  • ONC: Nutrition Intervention of Adult Oncology Patients with Cancer Cachexia 
  • ONC: Fish Oil, LBM and Weight in Adult Oncology Patients 
  • ONC: Glutamine and Oral Mucositis in Adult Oncology Patients 
  • ONC: Parenteral Glutamine and Hematopoietic Cell Transplantation (HCT) in Adult Oncology Patients
  • ONC: Neutropenic Dietary Precautions for Adult Oncology Patients 
  • ONC: Nutrition Substances and Chemotherapy-Induced Peripheral Neuropathy 
  • ONC: Nutrition Monitoring and Evaluation of Adult Oncology Patients  

The number of supporting documents for these topics is below:

  • Recommendations: 22
  • Conclusion Statements: 16
  • Evidence Summaries: 16
  • Article Worksheets: 95

At the time of this publication, the majority of research has been completed in the adult population. This guideline was developed for adult oncology patients; therefore, clinical judgment is crucial in the application of these guidelines for individuals in other age groups and settings.

Application of the Guideline

This guideline will be accompanied by a set of companion documents (i.e., a toolkit) to assist the practitioner in applying the guideline. The toolkit will contain materials such as the Medical Nutrition Therapy protocol, documentation forms, outcomes management tools, client education resources and case studies. The toolkit is currently under development and will undergo pilot-testing through the A.N.D.'s Dietetic Practice-Based Research Network prior to publication.

Revision

Academy guidelines are revisited every five years. An expert workgroup will be convened by the Evidence-based Practice Committee to determine the need for new and revised recommendations based on the available science. The process includes:   

  • Literature searches to identify new research published since the previous searches were completed. Updated inclusion/exclusion criteria and search terms may be warranted.
  • Review to determine if the update will include modification to all, some or no recommendations compared to the earlier version(s) of the guideline, or development of new recommendations.
  • Creation of a table comparing the new guideline and the older version of the guideline. The document will indicate which recommendations remained unchanged; updated; new; or not reviewed.

Using the Academy's EAL Methodology, an unbiased and transparent systematic review will be completed and the updated guidelines published on the EAL.

Medical Nutrition Therapy and Cancer

Scientific evidence supports the effectiveness of nutrition therapy to increase effectiveness of oncology therapy and to reduce nutrition impact symptoms among individuals who have cancer. Scientific evidence also supports the importance of the registered dietitian nutritionist (RDN) as a member of the interdisciplinary team caring for adult oncology patients.

The RDN plays an integral role on the interdisciplinary care team by determining the optimal nutrition prescription and developing the nutrition care plan for oncology patients in all phases of illness. Based on the patient’s clinical status, plan for treatment, and comorbidities, the RDN monitors and evaluates the effectiveness of the nutrition care plan in promoting the patient’s nutritional health and QoL. The dietitian adjusts the nutrition care plan as necessary to achieve desired outcomes.

New research may warrant a revision to a specific question or recommendation prior to the full project or guideline revision. Once identified, information is gathered and the EAL oversight committee will make a decision on the appropriate action.

Populations to Whom This Guideline May Apply

This guideline applies to adult cancer patients prior to, during or immediately after cancer therapy.

Other Guideline Overview Material

For more details on the guideline components, see the following within the Introduction on the left:

  • Scope of Guideline
  • Statement of Intent and Patient Preference
  • Guideline Methods
  • Implementation of the Guideline
  • Benefits and Harms of Implementing the Recommendations

Clinical judgment is critical. Careful consideration should be given to the application of these guidelines for patients receiving hospice, palliative care, or those with significant medical co-morbidities.