Diet – what helps? Lindsey Allan

Macmillan Oncology Dietitian

Royal Surrey County Hospital, Guildford

Diet and cancer…

Diet and cancer…

Nutrition research

Lack of funding

RCTs

Low quality

Small sample sizes

Heterogenous populations

Various treatment types and intent

Dietary management

NOT a cure!

Supportive

Reduce delays in treatment

Dependent on:

Site of tumour

Cancer symptoms

Treatment side effects

Reduced intake

MALNUTRITION

Malnutrition: definition

‘a state of nutrition in which a deficiency or excess (or

imbalance) of energy, protein and other nutrients causes

measurable adverse effects on tissue / body form (body

shape, size and composition) and function and clinical

outcome’.

(BAPEN, 2016)

‘lack of proper nutrition, caused by not having enough to

eat, not eating enough of the right things, or being unable

to use the food that one does eat.’

(Oxford English Dictionary)

Cancer related malnutrition: definition

Reduced intake

Metabolic derangements

Increased resting energy expenditure

Can affect 50% patients

Increased in certain tumour sites

Insulin resistance

Disordered fat and protein breakdown

Associated with inflammation and catabolism

CANCER CACHEXIA

Lack of response to standard nutritional interventions

Dysphagia

Diarrhoea Constipation

Fatigue

Nausea & vomiting

Malabsorption

Surgical interventions

Taste changes

Anorexia

Pain

Medication

Restricted diets

Cancer associated malnutrition: causes

Cancer related malnutrition: incidence

Tumour site Prevalence of malnutrition as % of total patient cohort

Pancreas 80-85

Stomach 65-85

Head and neck 65-75

Oesophagus 60-80

Lung 45-60

Colon/rectum 30-60

Urological 10

Gynaecological 15

(Stratton et al, 2003)

Cancer related malnutrition: incidence

-40.00

-35.00

-30.00

-25.00

-20.00

-15.00

-10.00

-5.00

0.00

5.00

10.00

15.00

1

12

23

34

45

56

67

78

89

100

111

122

133

144

155

166

177

188

199

210

221

232

243

254

265

276

287

298

309

320

331

342

353

364

375

386

397

408

419

430

441

452

% weight change at referral to the dietitian

5%

Median weight change: - 9.3%

76%: >5% weight loss

= cachectic 24%: < 5%

weight loss

(Fearon et al, 2011, Hug et al, 2016)

Cancer related malnutrition:

consequences

Impaired response to chemotherapy

Reduced quality of life

Increased chemotherapy-induced toxicity

Chemotherapy dose reductions

Stop or delay to treatment

Post-operative complications

Shorter overall survival and mortality rates

Cancer related malnutrition:

consequences

-40.00

-35.00

-30.00

-25.00

-20.00

-15.00

-10.00

-5.00

0.00

5.00

10.00

15.00

1

12

23

34

45

56

67

78

89

100

111

122

133

144

155

166

177

188

199

210

221

232

243

254

265

276

287

298

309

320

331

342

353

364

375

386

397

408

419

430

441

452

Weight loss from usual body weight to referral

5%

OS: 299 days OS: 199 days

Unpublished data from RSCH audit

ESPEN Guidelines on nutrition in

cancer patients

Identify, prevent and treat reversible malnutrition in adult

cancer patients

ALL cancers

Nutritional therapy

Physical therapy

Drug management

Strong recommendations

low level of evidence

Areas for future research

(Arends et al, 2016)

Screening

Early identification

Fast, cheap and sensitive

Recommendation

BMI, weight loss history and nutritional intake

Body Mass Index (BMI)

Height to weight ratio

Healthy range: 19.5-25 kg/m2

Lacks sensitivity

Fluid shifts

Obesity and malnutrition

Lung audit: median BMI 23 kg/m2

BMI

Screening

Weight loss history

Major cause of morbidity and mortality (Andreyev et al, 1998)

Accurate indicator of malnutrition

Reliance on personal recall

Nutritional intake

Under / over reporting

Fear of delays

Challenging with treatment cycles

Screening tools

Not mandatory in the UK

No consensus

Most not validated in oncology

MUST

BMI, weight loss, acute disease score

PG-SGA

Validated in oncology outpatients

Weight loss, symptoms AND side effects

No correlation between MUST and PG-SGA

Screening: what works?

Weight loss history

At diagnosis

Repeated during treatment

Subjective assessment

Check symptoms and side effects

Ask questions

Nutrition support: aims

Meet nutritional requirements

Improve nutritional status

When to initiate?

Consensus (Fearon et al, 2011)

On identification

As early as possible post diagnosis

Severe malnutrition / cachexia are irreversible

Nutrition support

Determining route of nutrition:

oral +/- oral nutritional supplements

enteral feeding

parenteral nutrition

Ensuring nutritional needs are met

Food fortification

Texture modification

Timing of meals

Dietary counselling

Treatment of symptoms and side effects

Nutrition support: recommendation

‘nutritional intervention to increase oral intake in cancer patients

who are able to eat but who are malnourished or at risk of

malnutrition. This includes dietary advice, the treatment of

symptoms and derangements impairing food intake (nutrition

impact symptoms) and offering oral nutritional supplements.’

(Arends, 2016)

Start artificial nutrition

No food > 1 week

<60% intake for > 1-2 weeks

Nutrition support

“Can you eat to beat cancer with the best cancer diet

and cancer nutrition?

And is it the sugar-ladened, cheeseburger, cake, biscuits

and milkshake diet that NHS dieticians, Cancer Research

UK and Macmillan suggest?”

Cancer Active

Oral Nutritional Supplements: evidence

Oral nutritional supplements (ONS)

Effective in severe malnutrition only

ONS and enteral feeding

No evidence to improve outcomes

Enteral feedingyyy in head & neck, oesophageal

RCTs are unethical

Observational studies

Reduced weight loss

Delays in treatment

Hospitalization

Parenteral nutrition: evidence

Bowel obstruction / peritoneal carcinomatosis

Expensive

Risks outweigh benefits

Observational study (Fan, 2007)

Malignant GI obstruction, n=115

No oral intake, Home PN

Median survival: 6.5 months

N=11: > 1yr, n=2: > 4 years

Prognosis < 2 months: home PN not recommended

No evidence to improve QoL

Dietary counselling: evidence

Systematic review (Baldwin et al, 2012)

nutritional counselling +/-ONS vs routine care

13 RCTs, n=1414

Mixed results

Increase in body weight, QoL

No impact on overall survival

Dietary counselling: evidence

RCT n=61 (Poulsen et al, 2014)

Intensive counselling by a dietitian vs ad-hoc input from nursing staff

gynaecological, gastric and oesophageal cancer

Weight loss 38% in intervention group, 72% in control

QoL: no difference

RCT n=58 (Uster et al, 2013)

Intensive counselling by a dietitian vs standard care

Increased protein and energy intake

no improvement in QOL, functional status or nutritional status

Dietary counselling: evidence

Systematic review (Lee et al, 2016)

Counselling, ONS and counselling, ONS, tube feeing

11 RCTs, n=1017

Lung, stomach, head & neck, colorectal

Counselling improved energy and protein intake and QoL

No improvements with ONS and tube feeding

No evidence?

Reduction in energy intake or fasting

Ketogenic diets

Cannabis to improve taste changes or appetite

Steroids to increase muscle mass

corticosteroids to aid anorexia

improves dietary intake and quality of life. (Yavuzsen et al, 2005)

No evidence?

Omega-3 fish oils to treat cancer cachexia

weak evidence: fish oil supplements can increase appetite,

energy intake, total body weight and lean muscle mass

(Sanchez-Lara et al, 2014)

Probiotics to reduce the effects radiotherapy-induced

diarrhoea – YET

Inconclusive studies to date

May improve symptoms

Cancer survivors: recommendations

Cancer prevention

1/3 of 13 most common cancers (WCRF)

1 in 10 cancers (Cancer Research UK)

Cancer survivors = cancer prevention (WCRF, Arends et al, 2016)

Healthy body weight with a BMI of 18.5-25 kg/m2

Healthy lifestyle

Physical activity

Healthy diet high in fruit, vegetables, whole grains and low in saturated fat, red meat and alcohol

Cancer survivors: evidence

Lack of evidence

Obesity and metabolic syndrome: independent risk factors of recurrence

breast cancer (Azrad & Demark-Wahnefried, 2014)

gastric cancers post gastrectomy (Kim et al, 2014)

Motivation for behaviour change

Observational study (n=16,282)

cancer survivors: ↑fruit and vegetables, ↓ physical activity (Wang et al, 2014)

Cross-sectional study (n=63,662)

Prostate cancer survivors: ↑fruit and vegetables, → obesity, physical activity (Rogers et al, 2008)

Living with and beyond

Healthy eating, healthy weight

Physical activity

but

Nutrition support

Weight loss

Dysphagia

Enteral feeding

Late effects

Summary

Strong recommendations

Low level evidence

Screening

Early identification

Timely, appropriate nutrition support

Dietary counselling

Meet nutritional requirements

Resolve symptoms and side effects

Prevent deferral of treatment

BUT…..

Cancer is not just physical

Psychological effects

Emotional responses

Reduced food intake is about MORE than just malnutrition

Loss of appetite leads to

loss of control

change in appearance

depression, anxiety

Frailty

Conflict

social isolation

Poor QOL

Remember…

Food is HOPE

Food is CONTROL

What is our responsibility?

Support patients’ beliefs

In spite of lack of evidence

Individualized advice

Address expectations

listen to priorities