GP Masterclass May 11Th 2015 Fiona Brown. Cancer Care Specialist Dietitian

GP Masterclass May 11th 2015 Fiona Brown. Cancer Care Specialist Dietitian.

Nutrition and upper GI cancers

Aim

•  To identify nutritional issues which can be dealt with in primary care and when to refer a patient into the Dietetic service

Objectives

•  Nutritional challenges for patients and implications

•  Intervention

•  Dietetic roles and intervention

General Overview of Malnutrition in UK

Greater use of healthcare and costs associated with malnutrition means: (Mind the hunger Gap 2012)

•  65% more GP visits; 82% more hospital admissions; 30% longer hospital stay.

Malnutrition prevalence for upper GI cancers

•  Lung, oesophageal, stomach, pancreatic, colonic, rectal and head and neck cancers carry the greatest presentation of weight loss/nutritional challenges (Capra 2001)

•  upper GI cancer patients malnourished = 52% (Segura et al, 2005)

Screening of nutritional status in 1000 patients (mixed diagnoses) Nutritional risk highest in upper GI cancer patients. Oesophageal cancer patients mean weight loss 16.3 % (16 to 40%). Over half had lost 10% of their weight. Where anorexia is a symptom then the risk of weight loss is higher. When weight loss was more than 10% anorexia occurred in 50% of patients (Bozzetti et al, 2010) Percentages patients severe malnutrition at cancer site were Oesophagus 62.5% Stomach 43.7% Pancreas 54.3% (Bozzetti et al, 2012)

Significance of Malnutrition

(De Wys 1980, Andreyev 1998, Marin 2007, Holmes 1996), Nayel 1992, Isering 2004, Bauer 2005, Odelli 2005, Braunschweig 2000, Pressoir 2010)

Aims of Nutritional Treatments

·  Preventing and treating undernutrition

·  Enhancing anti-tumour treatment effects

·  Reducing adverse effects of anti-tumour therapies

·  Improving quality of life.

Nutrition intervention needs to be;

Timely (early), Appropriate, Include suitable monitoring and recognised that some patients will require specialist intervention and support perhaps using artificial tube feeding ?parenteral feeding

Pathways
Rehabilitation throughout the treatment pathway delivered by Allied Health Professionals is recognised by NICE,NCAT,Macmillan etc. at;

NICE guidance suggests a screening tool should be based on:

•  Measurement of weight and weight history

•  Has there been a normal and varied diet in the last few weeks?

•  Unintentional weight loss?

•  Any swallowing problems?

•  Metabolic stress eg. Wound healing

•  Excessive losses eg. vomiting, diarrhoea

•  Global assessment eg. Any signs of loose fitting clothes/watch

•  Can patient meet their requirements with voluntary choice from the food available

•  Acknowledging that those with High BMI are at risk of malnutrition.

•  Example of screening tool – MUST (National Collaborating Centre for Acute Care, 2006)

Local Pathway

Prescribing Sip feeds in Adults (2013) GHNHSFT in conjunction this Gloucestershire Clinical Commissioning Group – available on-line at Gloucestershire ‘CCG Live’ intranet in the section: Clinical support/medicines management/prescribing guidance.

This pathway is based on regular monitoring and assessment;

1.  Nutritional Screening (MUST) including percentage weight loss

2.  Assessing and investigating any underlying causes/barriers to patient maintaining good nutritional status. E.g. underlying medical cause, disease states with nutritional implications, Oral health/swallowing problems, altered taste and smell, reduced mobility, poor positioning, social situation, psychological wellbeing, poly-pharmacy. Refer directly to Dietitians if required

3.  ‘Food First Approach’=first line dietary advice to use; small frequent meal, increase milk intake if possible and fortify/enrich milk and other foods.

4.  Agree and Document goals of treatment

5.  Prescribing Oral Nutritional sip feeds. Fresubin powder initially then 1.5kcal/ml ready to drink feeds dependant on preference.

6.  Refer to other service e.g. Dietitians

Role of Dietitians

Evidence based information for patients available at:

British Dietetic Association

Food fact sheets (online) https://www.bda.uk.com/foodfacts/MalnutritionFactSheet

Macmillan

Nutritional support (enteral tube feeds) http://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/eating-problems/types-of-nutritional-support.html

Eating problems http://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/eating-problems

Build up diet http://be.macmillan.org.uk/be/p-20052-the-building-up-diet.aspx

Healthy eating http://www.macmillan.org.uk/information-and-support/coping/maintaining-a-healthy-lifestyle/healthy-eating

Recipe booklet – contact Macmillan by phone

Cancer research

Managing Diet http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/diet/managing/

Oesophageal Patients association

On-line talks on nutrition http://www.opa.org.uk/resources.html

Pancreatic cancer UK

Has on-line details and support on diet at varying stages of the treatment pathway http://www.pancreaticcancer.org.uk/information-and-support/managing-dietary-symptoms/

Please make any Dietetic referrals to:

References and Bibliography

3