Nutrition Care: Managing Symptoms From Cancer

Nutrition Care: Managing Symptoms From Cancer Patricia A. Wilkes, MS, RD, LDN, and Deborah H. Allen, PhD, FNP-BC, AOCNP ABSTRACT

More than 20% of cancer diagnoses can be linked to an unhealthy diet and weight. Cancer patients are at risk for sustained malnutrition beyond treatment completion. This article describes how nurse practitioners can anticipate and screen for nutritional issues their patients may face over their cancer trajectory. In addition, specific evidence-based strategies to manage nutritional issues that patients may experience across their cancer trajectory are discussed. Keywords: cancer, malnutrition, nutrition, prevention screening Ó 2018 Elsevier Inc. All rights reserved.

INTRODUCTION

T

here were an estimated 1.7 million cases of cancer newly diagnosed in 2017.1 Although this is a daunting number, technological advances in cancer screening, early detection, and treatment have substantially reduced the annual number of cancer deaths to only 600,920 in 2017. Thus, the diagnosis of cancer has become one that reflects a diagnosis of chronicity for many survivors.1,2 To address survivorship issues, there has been an increasing focus for research to address acute and long-term symptoms experienced through the cancer trajectory.3 The focus of this article is to guide nurse practitioners to anticipate specific nutritional problems that their patients with cancer may experience, promote routine nutritional assessments across the cancer trajectory using validated evidencebased screening tools and identify at-risk patients to implement appropriate standard-of-care strategies.

HEALTHY NUTRITIONAL GUIDELINES

A healthy diet is essential to good health throughout our life trajectory. The exact makeup of a diversified, balanced, and healthy diet vary depending on individual needs (eg, gender, lifestyle, physical activity) and availability of local foods.4 Unhealthy diets have been associated with predisposing chronic illnesses, including cancer.5 More than 20% of all cancer diagnoses can be linked to an unhealthy diet, limited physical activity, excessive alcohol ingestion and an www.npjournal.org

unhealthy weight (body mass index [BMI]
25 kg/m2). Individuals who maintain an unhealthy weight are at greater risk for developing specific cancers, such as endometrial, esophageal, colorectal, postmenopausal breast, and prostate cancer.3,5 A recent meta-analysis with > 40,000 individuals who were followed over a 10- to 18-year time frame illustrated that BMIs
25 kg/m2 had increased risk for developing any obesity-related cancer (hazard ratio 1.11; 95% confidence interval 1.00e1.32).6 While examining the role nutrition may play to prevent or reduce risk of prostate cancer, Lin and colleagues7,8 found that maintaining a healthy body weight and a diet rich in antioxidant fruits and vegetables, and low in animal fats and refined carbohydrates, warrant recommendation to patients. Box 1 summarizes the American Cancer Society Guidelines for nutrition to prevent cancer and integrate general guidelines for a healthy diet, as well as evidence-based nutritional recommendations to prevent cancer and chronic illnesses.9 CANCER AND NUTRITION

The goal of cancer treatment is individualized to cure, control, or palliate, whereas the role of nutritional care throughout the cancer trajectory is individualized to their needs and treatment goals.1,2,9 All cancer patients are at risk for developing malnutrition since time of diagnosis.10,11 Malnutrition is present in 15%e20% of all cancer patients at time of diagnosis, The Journal for Nurse Practitioners - JNP

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Box 1. American Cancer Society Cancer Prevention Recommendations9 1. Achieve and maintain a healthy weight throughout life. Normal weight: 18.45e24.9 kg/m2 Overweight: 25e29.9 kg/m2 Obese: >30>kg/m2 2. Adopt a physically active lifestyle. Adults should participate in at least 150 minutes of moderate exercise, preferably throughout the week, eg, 30 minutes 5 days a week. 3. Consume a healthy diet with emphasis on plant-based foods. Consume at least 21/2 cups colorful vegetables and fruits daily. Select whole grain foods. Limit processed and red meats (beef, pork, lamb) consumed per week. 4. Limit alcohol consumption. No more than 1 drink for women or 2 per day for men. One drink equivalent: 1.5 oz. 80 proof distilled spirits, 5 oz. wine, or 12 oz. beer

80% of patients with advanced cancer, and 85%e90% of patients in terminal stages.12,13 Malnutrition in cancer patients is associated with a negative impact on quality of life, reduced response to chemotherapy, and high mortality.14,15 Malnutrition and cancer cachexia have been associated with 20%e30% of all cancer deaths.12,13 Weight loss of 5% before diagnosis/initiation of treatment has been predictive of early death regardless of cancer stage.15 Malnutrition

In 2012, the Academy of Nutrition of Dietetics and American Society of Parenteral and Enteral Nutrition defined malnutrition as meeting
2 of the following 6 characteristics: decreased energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized/generalized fluid accumulation, and decreased functional status by hand-grip strength (measured by a dynamometer).2 Several factors contribute to the risk for malnutrition and can be summarized as cancer, patient, and treatment factors.12,13 Cancer. Cancer induces hypermetabolic changes from release of catabolic hormones and inflammatory cytokines that hinder protein synthesis and prevent increasing lean body mass (eg, acute-phase proteins, interleukin-6, and ubiquitin-proteasome complex).12,13,16,17 Depending on the type of cancer, 2

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functional and mechanical issues may affect the ability to eat or absorb nutrients (eg, head and neck or gastrointestinal cancers).13,18 Patient. These factors include eating habits, appetite, cultural perspectives on food, and perceptions of taste.19 In addition, patients’ baseline nutritional health before diagnosis contributes significantly because they may require additional macronutrients (carbohydrates, protein, and fats) and micronutrients (iron, zinc, selenium, and vitamins A, B and C) before and during treatment. For example, higher baseline intake of soy protein, omega-3 fatty acids, green tea, tomatoes, and Zyflamend (New Chapter Inc, Brattleboro, VT) herbal blend have been associated with reducing cancer risk, whereas higher animal fat and beta-carotene intake increases risk.8 Treatment. Treatment modalities may include surgery, chemotherapy, radiation, hormone therapy, immunotherapy, biological therapy, target therapy, transplantation, or any combination thereof. In general, treatment-specific effects may affect appetite, taste, absorption, and loss of nutrients. Risk of developing malnutrition is exacerbated by treatment side effects, such as mucositis, nausea/vomiting, and diarrhea or constipation. To illustrate, Kerby and colleagues20 found that pediatric patients who Volume

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underwent allogeneic hematopoietic stem cell transplantation and became malnourished with BMIs below 25th or 5th percentiles were more likely to develop severe graft-versus-host disease in the subsequent 30 days and had a higher risk of death. Cachexia

Recently, the National Comprehensive Cancer Network developed a Palliative Care Guideline in which cancer cachexia and anorexia haves been included as a problematic palliative care concern.11 Cancer cachexia is an insidiously progressive syndrome involving systemic inflammation, ongoing loss of skeletal muscle mass (with or without loss of fat mass), and negative protein/energy balance.15 Cancer cachexia includes anorexia and associated weight loss in its symptomology and cannot be fully reversed by conventional nutritional support.11,15 Ultimately, cachexia leads to generalized weakness, as well as cardiorespiratory weakness, delayed wound healing, deterioration of the immune system, and progressive functional impairment.13,15,21 Cancer cachexia is a continuum, with 3 stages of clinical relevance: precachexia, cachexia, and refractory cachexia.14,21 Precachexia. Characterized by anorexia, metabolic abnormalities (protein, carbohydrate, and lipid metabolism), and weight loss
5% over the previous 6 months.21 Cachexia. Diagnosed by meeting 1 of the following parameters: (1) weight loss
5%, (2) BMI < 20 with weight loss > 2%, or (3) sarcopenia with weight loss >2%.12 Refractory cachexia. Characterized by the patient’s low performance status (eg, Karnofsky Performance Status), unresponsiveness to cancer treatment, and life expectancy of < 3 months.21 NUTRITIONAL SCREENING

With most cancer care transitioning to ambulatory settings, nutritional screening should be of high priority at time of diagnosis and performed routinely through the cancer continuum to prevent malnutrition. Nutritional screening needs to be feasible, easy, quick, inexpensive, and noninvasive,12 and ideally it should be performed by a registered dietitian or trained clinician.22 Nutritional intervention is at least partially effective and can improve clinical outcomes www.npjournal.org

in certain cancer types (eg, head and neck) or treatments (eg, chemoradiotherapy) where reduced food intake is prevalent and not accompanied by severe metabolic derangements.2,16 To assist identification of patients at risk for malnutrition, a validated screening tool is recommended.2,13 Two widely used nutritional assessment tools are the Nutrition-Focused Physical Examination (NFPE)22 and Scored Patient Generated-Subjective Global Assessment (PGeSGA).16,23 NFPE

An NFPE requires a systematic head-to-toe examination of a patient, including physical appearance and functional status, to determine nutritional status.24 The next step requires the clinician to identify signs of malnutrition, nutrient deficiencies, or nutrient toxicities. The combined scores identify whether criteria for severe or nonsevere malnutrition are met. PG-SGA

The Scored PG-SGA tool16,23 has become the recommended standard of practice from the Academy of Nutrition Oncology Dietetics Practice Group. This revision was specifically designed to measure the impact of symptoms commonly experienced by cancer patients.16,23 The PG-SGA consists of 2 parts: Part 1 is patient-reported and Part 2 requires clinician assessment. Part 1 focuses on 4 components: dietary intake, weight loss, symptom impact, and functional ability. These components assess: weight history, food intake, symptoms (nausea, vomiting, constipation, and diarrhea, swallowing ability, swallowing ability, dry mouth, mouth sores, fatigue, or pain), physical function, and ability to perform daily activities. Part 2 assesses cancer-related metabolic demands, nutritional requirements, and current physical examination. Combining scores from each section, the PG-SGA scores range from 0 to 9 and classifies patients as nourished, at risk for malnourishment, moderately malnourished, or severely malnourished; higher scores indicate worse nutritional status. Recommendations for nutritional intervention are based on the following scores: score 0e1, “nourished,” requires no current intervention; score 2-3, “at risk,” requires patient and family education by a dietitian or trained clinician; score The Journal for Nurse Practitioners - JNP

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4e8, “moderately malnourished,” requires intervention by a dietitian in conjunction with a nurse or physician; and score
9, “severely malnourished,” indicates a critical need for improved management or intervention. Screening should be repeated at routine intervals to determine change in nutritional status, assess the need for nutritional intervention, and monitor effectiveness of interventions deployed (eg, weekly, monthly, 3-months or 6-month intervals).13,16

the patient.11,13,17 Side effects from cancer treatment may substantially contribute to malnutrition and cause unpleasant side effects that can affect appetite, taste, and digestion processes and can persist well beyond treatment cessation (Table 2). Equally important components of a cancerspecific assessment are determinations of their estimated energy needs and hydration status; they are vital components for preventing malnutrition and cachexia in cancer patients.24

CANCER-SPECIFIC ASSESSMENT

Estimated Energy (Caloric) Needs

The NFPE or PG-SGA screening tools can be used in conjunction with an evidenced-based nutritional assessment. At minimum, if the NFPE or PG-SGA cannot be performed, the clinician’s nutritional assessment should include subjective and objective data displayed in Table 1. Additional assessments for cancer patients require the nurse practitioner to possess knowledge of the treatment administered to

Underlying the risk for malnutrition from cancer and cancer-related treatment is the increased demand for energy, which drives every biological reaction and all essential processes in the body, including cardiopulmonary and immune responses.2,12 Protein is the primary source of calories used for energy conversion. Because hypermetabolism usually occurs during stress and illness, additional protein is required.25 The

Table 1. Nutritional Assessment25,28,29 Assessment Parameter

4

Components

Subjective data: dietary history

24-hour dietary recall: food frequency, changes in appetite, food allergies and intolerances, oral supplements Gastrointestinal patterns Use of tobacco or alcohol Knowledge beliefs/attitudes Use of herbal supplements

Screening

Scored Patient Generated-Subjective Global Assessment and Nutrition-Focused Physical Examination

Objective data: biochemical indices

Glucose, electrolytes, blood urea nitrogen, creatinine, prealbumin, hemoglobin, hematocrit, transferrin, total protein, mean corpuscular volume, sodium, potassium, chloride, calcium, phosphorus Specific indicators: lipid profile (total cholesterol, high-density and low-density lipoprotein cholesterol, triglycerides), glycated hemoglobin, urinary protein

Anthropometry

Height Body mass index Weight: actual, % weight desirable body weight, usual body weight, Weight change: over 1 month, 3 months, or 6 months

Pertinent medications

Medications Drug nutrient intervention

Diagnostic tests/procedures

Hydration status Estimated energy needs Electrolytes, including calcium Complete blood count Liver and renal function tests C-reactive protein

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Table 2. Nutritional Interventions for Common Cancer Symptoms25,28,29 Symptoms

Definition

Nutrition Intervention

Nausea and vomiting

Nausea: unpleasant feeling that one is about to vomit; associated with altered physiologic activity, including the gastric hypomotility and increased parasympathetic tone that precede or accompany vomiting. Vomiting: a forceful expulsion of gastric contents produced by involuntary contractions of the abdominal musculature when the gastric fundus and lower esophageal sphincter are relaxed.

 Eat small meals (5e6/day). Avoid high fat meals with strong aroma.  Limit fluids to in between meals instead of with meals.  Elevate head for 30 minutes after meals.  Avoid strong-smelling scents: lotions, soaps, perfumes, air fresheners.  Take prescribed nausea medication (eg, dexamethasone, ondansetron, aprepitant).  Try ginger ale, ginger tea, ginger candies, or ginger capsules 500 mg 3 times daily.  Perform relaxation techniques.  For hydration: drink water and replace electrolytes as necessary; may consider appropriate electrolyte replacement drinks (without additional sugars and unnecessary additives)

Constipation

Less than 3 bowel movements per week or small bowel movements that are hard and difficult to pass.

 Consume at least 64 oz. noncaffeinated fluid (8 cups per day).  Drinking hot liquids.  Gradually increase fiber to 25e35 g per day by eating high-fiber foods (eg, hot cereals, pasta, lentils, hummus, almonds, bean soups).  Contact health care provider if no bowel movements in 3 days for laxative recommendations.

Diarrhea

Three or more loose, watery stools per day

 Consume small, frequent meals that are low-fat, low-fiber, and nonspicy foods.  Avoid caffeine and alcohol.  Try soluble fiber-containing foods/pectin (eg, oatmeal, bananas, rice, potatoes).

Dysgeusia (altered taste)

Loss of taste that may be general or more specific (ie, sweet, metallic, bitter of salty taste.)

 Encourage good oral care.  Brush teeth before eating.  Use oral rinse: 1 cup (see oral rinse recipe) 3e4 per day before meals. Oral rinse recipe: 3/4 tsp. salt, 1 tsp. baking soda, and 1 quart of water (4 cups)  Select fruit marinades for meats (eg, lemon, extra herbs and spices).  Use lemon drops and mints.  Use plastic utensils and glassware if metallic taste occurs.

Dysphagia/ odynophagia

Difficult swallowing that can be from a mechanical obstruction, neurological dysfunction, candidiasis, severe mucositis, or esophagitis.

 Practice good posture while eating.  Alter texture of foods (eg, mechanical, chopped or puree foods).  Encourage “double swallowing” to promote food movement through the esophagus.  Consider thickeners in foods to slow down fluid flow for safe swallowing and prevent aspiration.  Coordination of care: consult speech and language therapist for swallowing evaluation. continued

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Table 2. (continued) Symptoms Mucositis

Definition Painful inflammation with ulceration of the mucous lining/gastrointestinal tract

protein requirement for cancer patients should be based on the degree of malnutrition and induced stress response, their ability to utilize protein, and the extent of the disease.17,25 Most calculations for energy/caloric requirement for adults are estimates using current condition, particularly body weight. Normal estimated needs for healthy individuals range between 25 and 30 kcal /kg/day; individuals needing to gain weight gain require 30 to 40 kcal/kg/day, whereas obese individuals require 21e25 kcal/kg/day.13,25 Patients with hypermetabolic conditions, such as cancer or undergoing cancer treatment, require 35 kcal/kg/day.25 Fluid Balance

Fluid management is extremely important for electrolyte balance, maintaining normovolemia, and preventing dehydration.11,13 Routine monitoring of hydration status can be assessed through weight, intake/output, blood pressure, presence of edema, skin integrity, oral cavity, and respiratory status.24 Mild dehydration can cause fatigue, dry mouth, lightheadedness, constipation, and nausea—all of which worsen cancer and treatment-related side effects such as nausea and vomiting, diarrhea, ascites, and fever. In addition, elderly patients experience a normal physiological decrease in thirst mechanisms which can worsen dehydration.26 The simplest method for calculating fluid requirements is 30e35 ml/kg.21 INTERVENTION

Nutritional recommendations and interventions are based on cancer type and stage, as well as projected treatment.13,17 The 2 main goals of nutritional therapy are to (1) maintain adequate calories, protein and fluids, and overall nutrition status through monitoring and (2) prevent or manage nutritionerelated problems arising for cancer 6

Nutrition Intervention

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 Select low citrus acid and spicy foods  Choose foods soft in texture (eg, mashed potatoes, yogurt, soft eggs, pudding, cream soups).  Avoid alcohol, including mouthwashes that contain alcohol.

treatment or the cancer.3 Early nutritional intervention not only identifies patients at risk for malnutrition but can prevent nutritional deterioration as seen with cachexia.11 When possible, nurse practitioners should consider referring the patient for a nutritional consultation with a registered dietitian.11 A registered dietitian or registered dietitian nutritionist can help nurse practitioners to assess weight loss, perform body composition measurements to assess loss of muscle and subcutaneous tissues, and use a variety of evidence-based screening tools to identify patients at risk.3 If a referral system has not been identified or implemented at your facility/clinic, consult with a registered dietitian to develop the plan to implement a systematic assessment and nutritional protocol for referrals. Most electronic medical records can generate a consultation for a timely nutritional assessment, ease nutritional plan implementation, and provide some patient education.16,23 Patient education should also be provided verbally in clinic, during treatment (chemotherapy or radiation), or by phone so that questions can be answered and their understanding confirmed using a teach-back framework.19 At time of diagnosis, patients and their families should receive education about how cancer can affect their nutritional status, potential treatmentrelated side effects, and encouragement to use preventative strategies when indicated.11,19,27 For example, if a chemotherapy regimen induces mucositis, the patient should initiate diligent oral care before chemotherapy by implementing salt and baking soda oral rinses (recipe in Table 2). Table 2 provides common and practical strategies that nurse practitioners may recommend to patients to prevent or manage potential side effects from treatment that may affect their nutritional status. To illustrate the importance of educating patients Volume

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Table 3. Evidenced-based Resources Organization

Web Link

Synopsis

National Institute of Health/ National Institute of Diabetes and Digestive and Kidney Disease

http://www.niddk.nih.gov

Diagnosis and treatment of diseases affecting the gastrointestinal tract

Supertracker (App)

http://www.Supertracker.usda.gov

Personalized nutritional app to track food intake and physical activity

Academy of Nutrition and Dietetics

http://www.eatright.org or call 1-800-366-1655

“Find a Nutritional Professional” to locate a local Registered Dietitian

US Department of Agriculture

http://www.ChooseMyPlate.gov

Healthy eating with the 5 food groups (fruits, vegetables, whole grains, lean protein, dairy)

American Institute for Cancer Research

http://www.AICR.org

Research on diet and cancer prevention; also provides information on research grants and fellowship programs

National Cancer Society

http://www.cancer.org

Cancer information for patients, survivors, professionals.

National Comprehensive Cancer Network

http://www.nccn.org

Alliance of 27 US cancer centers Promotes implementation of evidencebased cancer guidelines for providers; patient education for patients

regarding nutrition-related symptoms, da Costa Marinho and colleagues found several concerning symptoms across the treatment continuum in breast cancer patients: changes in taste, increase in nausea, decline in meal enjoyment, and appetite changes toward salty and spicy food.19 Likewise, a systematic review of 12 studies reported 3 themes related to nutritional symptoms in adults with head and neck cancer: impact of symptoms, change in social networks and support, and nutritional concerns and strategies.27 The symptoms that negatively affected their quality of life the greatest were dysphagia, dysgeusia, mucositis, and xerostomia; these symptoms do not occur in isolation and often persist beyond treatment completion. MAINTAINING A GOOD NUTRITIONAL STATUS

Sustaining a good nutritional status across the cancer trajectory is equally important as preventing malnutrition.13 Healthy eating with adequate protein intake and maintenance of a normal fluid status, as well as performing physical activity for the recommended 150 minutes of moderate activity per week, are www.npjournal.org

essential components for long-term survivorship.17 For those malnourished at treatment completion, it is important to ensure that they consume adequate protein calories.13,27 This may be best met by eating 6 small meals through the day for better tolerance and adequate hydration. For those who are not meeting their nutritional requirements, traditional oral supplements (eg, Boost, Ensure, Carnation Instant Breakfast Essentials, Glucerna, Boost Control) may not be advised because of their high fructose content and the gastrointestinal effect of carrageenan.22,25 An organic supplement, such as Orgain, has a lower sugar content, is carrageenan free, and may provide greater benefit as a protein source. Protein can be added to the diet easily through pea protein, hemp, or whey supplements.13,17 Performing routine nutritionfocused physical assessments, monitoring weight, appetite, any gastrointestinal changes (nausea, vomiting, diarrhea, mucositis, constipation) and eating ability is essential through the cancer trajectory.13 Some patients express interest in foods that may cure their cancer. These discussions should be geared The Journal for Nurse Practitioners - JNP

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toward healthy eating, maintaining adequate energy/ protein, and prevention of muscle atrophy and deconditioning.19,27 Although it is imperative to explain that diet has not been shown to prevent or cure cancer, some research has shown diet reduces the risk of some cancers and chronic diseases (eg, heart disease, diabetes) such as the Plant-Based Diet.4-8 This diet recommends consuming a rainbow color of fruit, vegetables, nuts, legumes, whole grains, herbs, and spices. These foods are rich in antioxidants (vitamins A, C, E) that may help to prevent cancer and damage to cells. Care is warranted, however, because there is concern that antioxidants may decrease some cancer treatment effectiveness.16 It is recommended to discuss antioxidant use with the oncologist before use. Not all patients with cancer experience weight loss during treatment. Some patients have baseline obesity and may continue to gain weight. Obesity, particularly abdominal, increases the risk of cervical, colon, rectal, endometrial, esophageal, pancreatic, renal, and post-menopausal breast cancer.3,7 Abdominal obesity is associated with insulin resistance (cells ineffectively use glucose), which elevates insulin production to thereby increases cancer risk. Because obesity is a key concern in the development of comorbidities or secondary cancers, a weight loss diet may be recommended.3 Weekly weight loss goal is 2 pounds maximum, and patients require vigilant monitoring as they balance their body’s nutrient needs while losing weight and having cancer treatment; approval from the medical and oncology teams should be obtained. IMPLICATIONS FOR PRACTICE

Nutrition plays a vital role in maintaining our health. Cancer presents a unique challenge as nutritional demands exceed usual intake, due to cancer metabolism. Additional biochemical responses from cancer induce symptoms that reduce nutritional intake. The progression of cachexia in cancer patients is irreversible and can result in death. Initial nutritional screening should be conducted at time of diagnosis to guard against malnutrition and alleviate nutrition-related symptoms. Early nutritional interventions have been associated with successful benefits, such as preventing treatment delays that occur from severe symptoms. 8

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It is recommended that nurse practitioners implement a screening protocol within their clinical setting to identify patients at risk for malnutrition. The Scored PG-SGA and NFPA are widely used evidence-based screens that offer a quick yet accurate method to identify signs of malnutrition. By executing an individualized plan of care that includes routine nutritional screening across the illness trajectory, persistent or recurring symptoms can be managed. Nutrition recommendations should be reinforced at each encounter and with each intervention. Partnering with Registered Dietitians or Registered Dietitian Nutritionists for early consultations can promote prompt nutritional interventions. Table 3 lists resources that can be used to educate and guide patients about the role that a healthy diet plays to prevent illness, including cancer, as well as regain health through cancer survivorship. The online supplementary case study exemplifies how a nurse practitioner may perform nutritional screening and consultation with a registered dietitian for nutritional recommendations. SUPPLEMENTARY DATA

Supplementary material associated with this article can be found in the online version at https://doi.org/ 10.1016/j.nurpra.2018.01.011. References 1. Siegel R, Miller K. Jemal A. Cancer statistics, 2017. CA Canc J Clin. 2017;67(1):7-30. 2. Arends J, Bachmann P, Baracos V, et al. ESPEN Guidelines on nutrition in cancer patients. Clinical Nutr. 2017;36(1):11-48. 3. Leser M, Ledesma N, Bergerson S, Trujillo E. Oncology Nutrition for Clinical Practice. Chicago, IL: Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics; 2013. 4. American Cancer Society. Nutrition and physical activity and cancer prevention. 2017. http://www.cancer.org. Accessed 07.15.2017. 5. Grosso G, Micek A, Godos J, et al. Health risk factors associated with meat, fruit and vegetable consumption in cohort studies: a comprehensive metaanalysis. PLoS ONE. 2017;12(8), e0183787. https://doi.org/10.1371/journal .pone.0183787. 6. Freisling H, Arnold M, O’Doherty MG, et al. Comparison of general obesity and measure of body fat distribution in older adults in relation to cancer risk: meta-analysis of individual participant data of seven prospective cohorts in Europe. BJC. 2017;116(11):1486-1497. https://doi.org/10.1038/bjc.2017.016. 7. Lin PH, Aronson W, Freedland SJ. Nutrition, dietary interventions and prostate cancer: the latest evidence. BMC Med. 2015;133:3. https://doi.org/ 10.1186/s12916-014-0234-y. 8. Lin PH, Aronson W, Freedland SJ. An update of research evidence on nutrition and prostate cancer. Urol Oncol. 2017;17(suppl 2):1078-1439. https:// doi.org/10.1016/j.urolonc.2017.10.006. 9. Kushi LH, Doyle C, McCullourgh M, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012;62(1):30-67. 10. Feinberg J, Nielsen EE, Korang SK, et al. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev. 2017;5, CD011598. https://doi.org/10.1002/14651858.CD011598.pub2.

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11. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology, Palliative Care, version 1.2018. 2018. https://www.nccn.org/ professionals/physician_gls/pdf/palliative.pdf. Accessed January 5, 2018. 12. Suhag V, Sunita BS, Sarin AK, Singh AK. Cancer, malnutrition and cachexia: we must break the triad. Clin Eng Rad Oncol. 2015;12(4):64-70. 13. Virizuela JA, Camblor-Alvarez M, Luengo-Perez LM, et al. Nutritional support and parenteral nutrition in cancer patients: an expert consensus report [published online ahead of print]. Clin Transl Oncol. 2017. https://doi.org/10 .1007/s12094-017-1757-4. 14. Nelm L, Sucher KP, Lacey K. Nutrition Therapy and Pathophysiology. 3rd ed. Boston, MA: Cengage Learning; 2016. 15. Aoyagi T, Terracina KP, Raza A, Matasubara H, Takabe K. Cancer cachexia, mechanism and treatment. World J Gastrointest Oncol. 2015;7(4):17-29. https://doi.org/10.4251/wjgo.v7.i4.17. 16. Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care. 2017;20(5):322-329. https://doi.org/10.1097/MCO.0000000000000389. 17. Del Ferraro C, Grant M, Koczywas M, Dorr-Uyemura L. Management of anorexia-cachexia in late stage lung cancer patients. J Hosp Palliat Nurs. 2012;14(6):1-12. https://doi.org/10.1097/NJH.0b013e31825f3470. 18. Mitchell S, Williams JP, Bhatti H, et al. A retrospective matched cohort study evaluating the effects of percutaneous endoscopic gastrostomy feeding tubes on nutritional status and survival in patients with advanced gastroesophageal malignancies undergoing systemic anti-cancer therapy. PLoS ONE. 2017;12(11):e0188628. https://doi.org/10.1371/journal.pone.0188628. 19. da Costa Marinho EC, Custodio IDD, Ferreira IB, et al. Impact of chemotherapy on perceptions related to food intake in women with breast cancer: a prospective study. PLoS ONE. 2017;12(11), e0187573. https://doi.org/10.1371/ journal.pone.0187573. 20. Kerby EH, Li Y, Getz KD, et al. Nutritional risk factors predict severe acute graft-versus-host deisease and early mortality in pediatric allogeneic hematopoietic stem cell transplantation. Pediatr Blood Cancer. 2018;65(2):e26853. https://doi.org/10.1002/pbc.26853. 21. Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12(5):489-495. https://doi.org/10.1016/S1470-2045(10)70218-7. 22. White D, Guenter P, Jensen G, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and

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documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738. https://doi.org/10.1016/j.jand.2012.03.012. Ottery F. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutr. 1996;12(suppl 1):S15-S19. Dennett C. Nutrition-Focused Physical Exams. Today’s Dietitian. 2016;18:36. Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012. Shah M, Workeneh B, Taffet G. Hypernatremia in the geriatric population. Clin Interv Aging. 2014;9:1987-1992. https://doi.org/10.2147/CIA.S65214. Bressan V, Bagnasco A, Aleo G, et al. The life experience of nutrition impact symptoms during treatment for head and neck cancer patients: a systematic review and meta-synthesis. Support Care Cancer. 2017;25(5):1699. https://doi. org/10.1007/s00520-017-3618-7. The Merck Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2011. Department of Health and Human Services, Nutrition Institute of Health. Eating hint: before, during and after treatment. January 2011. http://www .pubs.cancer.gov/ncipl.detail.aspx?. Accessed July 15, 2017.

Patricia A. Wilkes, MS, RD, LDN, Oncology Dietitian, Duke Cancer Institute, Durham, NC. She is available at [email protected]. Deborah H. Allen, PhD, FNP-BC, AOCNP, Director of Nursing Research and Evidence-based Practice, Duke University Health System, Durham, NC. In compliance with national ethical guidelines, the author reports no relationship with business or industry that would pose a conflict of interest. 1555-4155/18/$ see front matter © 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2018.01.011

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Nutritional Case Study Part 1: Nurse Practitioner Evaluation

ML is a 52-year-old woman with history of hypertension and recent diagnosis of stage III ovarian cancer. Cancer treatment thus far has been total abdominal hysterectomy and bilateral salpingooophorectomy and recent chemotherapy initiation. She presents to her primary care clinic with complaints of poor appetite, weight loss, nausea, bloating, constipation, and nonspecific taste changes. She also reports depression related to her illness. Treatment Chemotherapy: Cisplatin with magnesium supplementation during infusion; received 1 cycle of treatment and preparing for second cycle Medications: Dexamethasone 5 mg oral 30 minutes before chemotherapy Ondansetron 8 mg tablets; take 1 every 8 hours as needed for maximum of 24 mg in a 24-hour period Prochloroperazine 10 mg tablets—take 1 every 6 hours as needed Item

Assessment

Amlodipine 5 mg orally per day Anthropometrics: Height: 170 cm Current weight: 218 lbs. (99 kg) One month ago: 228 lbs. (103.6 kg) Six months ago: 235 lbs. (106.8 kg) Labs: (7/20/17) Potassium 3.0 (3.5e5.0 mg/dL) Magnesium 1.5 (1.7e2.2 mg/dL) Albumin 2.8 (3.0e5.0 g/dL) Blood urea nitrogen 30 (8e24 mg/dL) Creatinine 1.4 (0.6e1.1 g/dL) Hemoglobin 9.5 (12e16 g/dL) Hematocrit 27 (37%e46%) Nutritional Screening Step 1: Using the Scored Patient GeneratedSubjective Global Assessment (PG-SGA) Self-reported items 1e4 completed by ML during the encounter. Clinician Review Items 5e7 completed by the clinic nurse during the encounter. Scoring

ML Score

Patient Self-Report 1

Weight

 % weight lost in 1 month or 6-month interval ¼ 1e4 points  Decrease in weight over 2 weeks ¼ 1 point

1 point

2

Food intake

 Decreased intake ¼ 1 point  Intake change of solids, liquids, nutritional supplements, or tube feedings ¼ 1e4 points

1 point

3

Gastrointestinal symptoms

4

Activities and function

3 points

Total points for every symptom that applies:  Nausea, constipation, xerostomia, dysgeusia, bothersome odors, quickly satiated, fatigue, other issues ¼ 1 point  Mucositis, dysphagia ¼ 2 points  Pain, emesis, diarrhea ¼ 3 points  % decline in mobility and functional status ¼ 1e3 points

1 point

Clinician Review 5

Disease relation to nutrition

1 point for each: cancer, AIDS, pulmonary or cardiac cachexia, presence of wounds/decubiti/ulcerations, trauma, age >65 years, chronic renal insufficiency

2 points

6

Metabolic demands

Range of 1e3 points for degree of stress, fever, fever duration, and corticosteroid use

1 point

7

Physical examination

Range of 1e3 points for body composition deficits and presence of edema

1 point 10 points TOTAL

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The Scored PG-SGA total was 10 points, indicating a critical need for improved symptoms and nutritional intervention options. Step 2: Performing the Nutrition Focus Physical Examination (NFPE) NFPE was performed by the nurse practitioner after reviewing the Scored PG-SGA. ML met only 1 indicator for malnutrition, that of energy intake. Patients need to have 2 or more indicators to be diagnosed with malnutrition. On the basis of the findings from the Scored PG-SGA

Item

and NFPE and knowing that further nutritional decline may occur through treatment and her survivorship trajectory, the nurse practitioner made a nutritional referral to a registered dietician specializing in nutritional counseling for cancer survivors. Follow-up: After ML met with the registered dietitian, the primary care nurse practitioner received the recommendations and scheduled a 2-week follow-up appointment with ML to follow her weight, anthropometrics, and nutritional status.

ML Assessment

Malnutrition Indicators

1. Physical assessment Energy intake

< 50% for > 1 month

Weight loss

Past 1 month: e4.6 kg (e10 lbs.) ¼ e4.4% Past 6 months: e7.8 kg (e17 lbs.) ¼ e7%

—

1. Fluid accumulation

þ 1 edema

—

3. Grip strength

22, which is normal for her age and gender

—

Met

Met 1 indicator

Nutritional Case Study Part 2: Registered Dietitian Consultation Note

Reason for Referral: Poor appetite and weight loss per RN screening assessment. ML is a 52-year-old female with stage III ovarian cancer. She started chemotherapy (cisplatin) 3þ weeks ago. Past Medical History: Obesity, hypertension. Past Surgical History: Status postetotal abdominal hysterectomy and bilateral salpingo-oophorectomy. Anthropometrics: Height: 67 inches (170 cm) Current weight: 218 lbs. (99 kg) One month ago: 228 lbs. (103.6 kg) Six months ago: 235 lbs. (106.8 kg) Desirable body weight (DBW): 135 lbs. (61.3 kg) Body mass index (BMI): 34.2 kg/m2 % Weight change: e4.6 kg/e10 lbs./e4.4%  1 month and e7.8 kg/e17 lbs./e7.3%  6 months Pertinent Biochemical Data: albumin 2.8, K 3.0, Mg 1.6, hemoglobin 9.5, hematocrit 27

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Pertinent Medications: prochlorperazine, ondansetron, amlodipine besylate, dexamethasone Physical Findings: Appearance: ambulatory, complaints of fatigue and weakness Skin: 1 cm surgical wound dehiscence (abdomen) GI: bloating, constipation (last bowel movement 5 days ago), nausea, but no vomiting Oral: dysgeusia, no reported mucositis Typical Nutritional Intake: Food allergies: NKFA (No none food allergies) Intolerance: lactose Dietary history: currently living with sister, who prepares meals; she reports eating < 50% of meals served; tries to consume 3 meals/day but seldom consumes lunch Breakfast: oatmeal, scrambled egg, white toast with butter, coffee with sugar and creamer Lunch: seldom consumes this meal Dinner: baked chicken, mashed potatoes, green beans, fruit cocktail, and water

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Snacks: applesauce, yogurt, chips, Oreos Oral nutrition supplements: none Nutritional Diagnoses: Nutrition Code Process, Nutrition Clinical—3.2 Unintended weight loss related to poor appetite, dysgeusia, and gastrointestinal distress as evidenced by e4.4% weight loss  1 month and e7.3% weight change  6 months, coupled by nausea, constipation, and change in taste of food. Nutrition Code Process, Nutrition Intake—1.2 Increased energy needs related to increased metabolic changes with cancer as evidenced by increased protein and energy needs for maintenance and repletion therapy. Estimated Nutritional Needs: Energy: 21 kcal/kg/day ¼ 2079 kcal/day Protein: 1.5 g/kg DBW (61 kg) ¼ 92 g/day Fluids: 30 mL/kg/day ¼ 2970 mL/day Assessment: Two screening tools were used to assess this patient’s nutritional status, the Scored Patient Generated-Subjective Global Assessment (PGSGA) and the Nutrition-Focused Physical Examination (NFPE). The Scored PG-SGA identified ML as moderately malnourished, based on progressive weight loss and decreased energy intake. The total PG-SGA score ¼ 10, which indicated a critical need for symptom management and nutrient intervention. The NFPE revealed that ML did not meet malnutrition criteria. ML has weight loss of e4.4%  1 month and e7.3% weight change  6 months. Current BMI is 34.2, indicative of class I obese. Patient reported poor appetite, coupled with abdominal bloating, nausea, constipation, and nonspecific dysgeusia (taste changes). Dietary recall revealed ML was eating < 50% of meals for > 1 month; she also has limited fruit and vegetable and fluid intake. Low-fiber diet, inadequate fluid intake, and nausea are contributors to constipation. Low potassium level most likely

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related to poor diet. Low Mg levels related to chemotherapy side effects. To address constipation, the provider prescribed stool softener (docusate) and laxative (MiraLax) during recent encounter. Educated ML regarding high-fiber, high-protein diet, with focus on potassium-, magnesium-, and iron-enriched foods. Advised ML to consume 6 smaller meals/day for better tolerance. Encouraged adequate fluid with various fluid options. Provided tips and strategies to help manage taste changes and nausea. Discussion with patient to take prescribed antinausea medication (ondansetron, prochlorperazine) as scheduled to manage nausea. As ML was not at risk for digestive or glycemic issues that may be associated with some supplements, she was encouraged to use oral nutritional supplements, such as Ensure/Boost, for additional calories. She is agreeable to plan of care and routine nutritional follow-up. Nutritional Recommendations and Intervention: 1. High-protein, high-fiber foods enriched with potassium, magnesium, and iron 2. Provided strategies to help manage constipation and nausea 3. Encouraged increased fluid intake and laxative therapy 4. Reinforced prescribed nausea medication compliance 5. Trial of oral nutritional supplement: Boost/ Ensure twice daily 6. Provider to consider appetite stimulant 7. Provide contact information of RD future contact Nutritional Goals: Weight and bowel management, enhance energy and protein intake with tolerance to oral diet, and maintain electrolyte and fluid balance. Coordination of Care: Recommend social worker consult for stress management.

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