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Cancer Research (2013) estimated that there were 352,197 cases of cancer

diagnosed in the UK in 2013 with breast, prostate, lung and bowel cancers together accounting for over half (53%) of all new cases. This presents a challenge to the NHS across primary, secondary and tertiary care settings, however, within the UK in 2015, 89% of patients rated their treatment as excellent (Cancer Research UK, 2013).

Once cancer has developed, it can present with a variety of nutritional problems including the interaction of metabolic and nutritional changes that can change the body’s composition, for example, patients with cancer may experience a prolonged catabolic (a set of metabolic pathways that break molecules into smaller units) response to the presence of the tumour resulting in weight loss and in particular muscle wasting. The body’s performance status, psychological state and the ability to tolerate and withstand cancer treatments such as chemotherapy, radiotherapy and surgery can also be affected.

These changes are directly linked to patients’ quality of life and their close family and carers, but also the mortality and morbidity risk for the

The provision of nutritional advice in patients with cancer

individual. When considering the impact on quality of life, community nurses should consider the reduction in strength and energy levels as a result of weight loss and muscle wasting and the impact this has on the patient’s ability to maintain their independence with activities of daily living. The side effects of treatment can often be pronounced and debilitating, including loss of appetite, taste changes, nausea, vomiting, constipation or diarrhoea, which can further impact on energy levels and accelerate weight loss and loss of muscle mass. Therefore, nutrition plays a very important role and it is vital that the patient’s nutritional needs are considered at all stages of the development and management of cancer.

NUTRITION AND CANCER

The negative impact of poor nutrition on cancer patients was identified as far back as the 1980s (DeWys et al, 1980). While there have been significant medical advances in the area of oncology, in particular in targeted treatments and anti-tumour therapies, the clinical evidence continues to demonstrate that poor nutritional status remains a negative prognostic factor for survival and tolerance of both surgery (Tewari et al, 2007) and chemotherapy (Meyerhardt et al, 2004).

Recent years have also seen an increase in the number of cancer

While cancer treatment can be debilitating enough in itself, one of the lesser known side-effects is the impact it has on patients’ nutrition, including reduced appetite, nausea and changes in taste. This article takes an in-depth look at the elements that community nurses need to be aware of when managing patients undergoing treatment for cancer.

KEYWORDS:Nutrition Cancer Quality of life Oral nutritional supplements

Edel McGinley

Edel McGinley, nutrition support service manager, Ealing Community, London North West Healthcare NHS Trust

patients presenting as obese, although obesity seems to confer protection against treatment-associated toxicity. However, a negative prognostic factor remains for those presenting with a body mass index (BMI) of more than 35kg/m² (classified as severely obese) (Dignam et al, 2006).

When considering the cause of weight loss and malnutrition in cancer patients, a review of the literature suggests that the causes are multifactorial. The site and extent of the tumour, any cancer treatment and/or medication, and the curative or palliative intent of treatment can determine the presence and extent of any malnutrition. When a patient is offered palliative treatment, the focus is on relieving symptoms which are arising as a result of the cancer and any nutritional problems can be harder to manage as the disease progresses, e.g. a tumour of the oesophagus will cause increasing swallowing difficulties. In comparison, those patients receiving curative treatment will find their nutritional intake and body composition improves with time following treatment. The possible causes for weight loss and malnutrition in cancer are presented in Table 1.

The effect of weight loss on cancer patients has been well-documented in the past and is associated with lower survival, poor response to treatment, decreased tolerance to therapies, longer hospital stays and increased healthcare costs (Nitenberg and Raynard, 2000). It is also important to consider the other known consequences of malnutrition and how they impact on the cancer patient, e.g. reduced muscle mass, increased risk of infection, need for polypharmacy, and decreased immune function. The effects of malnutrition in patients receiving surgical intervention

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62 JCN 2016, Vol 30, No 5

NUTRITION

symptoms including: Nausea: encourage patients to

choose cold rather than hot foods; try to avoid the smell of cooking; avoid strong spicy flavours

Taste changes: many patients with cancer experience a metallic taste; advice includes rinsing the mouth with lemon juice before eating (not in patients experiencing a sore mouth or mouth ulcers).

Nausea Nausea can occur in 4–44% of cancers (Naeim et al, 2008), and is dependent of the site of the tumour and stage of the disease. In the author’s experience, it is better to address nausea with appropriate antiemetic medications alongside ensuring adequate fluid intake and resumption of normal dietary intake once symptoms have been controlled. The evidence base for dietary change in cases of nausea — in particular the addition of ginger — is lacking, although patients may benefit from practical suggestions around avoiding nausea triggers, including choosing cold foods and avoiding cooking odours, e.g. avoiding sitting in the kitchen.

for cancer have been extensively studied and these patients often experience longer recovery times and a higher risk of postoperative infection, which can then delay plans for additional post surgical treatments, e.g. chemotherapy/radiotherapy (Bozzetti et al, 2007).

SCREENING

It is vital that community nurses are able to recognise cancer patients who require support with nutrition to prevent or mediate the effects of malnutrition. Within the UK, the screening tool widely used to screen for malnutrition is the Malnutrition Screening Tool (MUST) (British Association for Parenteral and Enteral Nutrition [BAPEN], 2016). However, this particular tool has not been validated for use within oncology.

It is essential that community nurses are aware that although widely used, MUST has limitations in terms of sensitivity in recognising patients at risk of malnutrition when attending oncology services, mainly because the tool does not account for decreased nutritional intake or nutrition-related side effects from treatment (Roulston and McDermott, 2008).

MUST still has an important role to play, but it is important to consider the impact of treatment and side-effects when considering referral to dietitians for specialist advice and support, especially when MUST identifies a low risk of malnutrition. In the author’s experience, a referral in the early stages of the patient’s cancer pathway produces better outcomes than waiting for a medium-to-high MUST score.

SYMPTOMS

Within a community setting, clinicians will often be supporting patients — with medication, counselling, support and also dietary advice — in managing symptoms they experience as a result of cancer treatment. Khalid et al (2007) identified that the most common symptom is loss of appetite, followed by early satiety (feeling of fullness after eating small amounts). Khalid et al (2007) also identified that symptoms can vary between tumour groups, with lung cancer patients experiencing greater loss of appetite than gastrointestinal cancer patients, for example (other symptoms are presented in Table 2).

Reduced appetiteOne of the commonest symptoms experienced by patients with cancer is a loss of appetite (anorexia) and Thoresen et al (2002) reported that patients can often only manage small portions of food compared to their usual intake. When this occurs, and when the patient is not supported or educated around diet, they may not be aware that they have to supplement their diet with between-meal snacks or choosing higher energy foods. As a result, patients often do not meet their energy requirements, resulting in weight loss. It is important that weight loss is recognised early in oncology patients and that they are advised to change their approach, choosing higher calorie foods or adding extra calories to smaller portions (food fortification).

When a person with a reduced appetite presents with other symptoms (such as those outlined in Table 2), this can be difficult for community nurses to manage without dietetic assessment and support. However, while they wait for a dietitian referral, community nurses can still help patients with first-line advice as well as specific advice for

Table 1: Possible causes of weight loss and malnutritionInadequate intake due to tumour-induced anorexia (loss of appetite)

Reduced food intake due to treatment side effects, e.g. nausea, constipation, diarrhoea

Physical obstruction of the tumour, e.g. bowel obstruction

Obstruction as a consequence of treatment, e.g. radiotherapy to the pharynx causes dysphagia (difficulty swallowing)

Pain, anxiety and/or depression as a result of the diagnosis and/or treatment

Table 2: Common symptoms that affect dietary intake

Loss of appetitePain Taste changes Nausea / vomiting Dry mouth Constipation

Diarrhoea Difficulties with swallowing Fatigue Sore mouth Thickened saliva secretions

Red Flag Obesity

Research confirms that that being obese increases the risk of various cancers, with the The World Health Organization (WHO, 2003) stating that being overweight and obesity are the most important avoidable causes of cancer after tobacco. One large study into links between excess weight and cancer examined the GP records of more than five million people and found a link between weight and 10 different types of cancer, including bowel, kidney and cervical cancer (Bhaskaran, et al, 2014).

Source: www.cancerresearchuk.org

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64 JCN 2016, Vol 30, No 5

NUTRITION

Taste changes Taste changes are problematic for cancer patients, with 75% of those undergoing chemotherapy reporting an issue (Bernhardson et al, 2007). In 2009, Karaman et al examined the type of taste changes experienced by patients and found them described as ‘bitter’, ‘metallic’, ‘sour’ and ‘salty’. This can have a significant impact on quality of life and causes considerable distress to patients. The dietary advice for patients with taste changes has been summarised in Table 3.

Oral mucositis Oral mucositis (a painful inflammation and ulceration of the mucous membranes of the mouth) can impact significantly on patients’ food intake. It can present as erythema (superficial reddening of the skin) and ulceration, which can cause difficulty speaking, swallowing and oral pain, resulting in compromised dietary and fluid intake.

Oral mucositis is particularly associated with chemotherapy, with an estimated 75% of patients on high dose chemotherapy regimens experiencing symptoms. It can occur in people with head and neck cancers as a result of radiotherapy and is often experienced alongside xerostomia (dry mouth). It is important to manage oral mucositis with advice and support with oral hygiene and analgesia, and dietary advice often centres around practical measures, e.g. avoiding acidic or spicy food; not adding salt to food or choosing salty foods; and recommending soft and cold foods that may be easier to tolerate than hot food.

CHANGING DIET

Often, one of the hardest challenges for healthcare staff is the change in cancer patients’ relationship with food following a diagnosis and managing this to ensure malnutrition does not develop. In 2005, Pinto and Trunzo identified that over half of patients who have been diagnosed with cancer will make changes to their diet, varying from excluding foods such as dairy, sugar or meat, to increasing consumption of fruit, vegetables and organic foods (Beagan and Chapman, 2004; Adams and Glanville, 2005).

The extent that a patient may change their diet can vary depending on the stage of their cancer ‘journey’. In the treatment phase, research has shown that food can be used as a means of control, either to manage the disease and/or control the side-effects of the treatment (McGrath, 2002; Adams and Glanville, 2005). It is important that those patients who have chosen to exclude a particular food group are given the support to ensure that no consequences arise as a result of their choice. For example, in the author’s experience, excluding dairy can compromise the patient’s protein intake, which is important for weight and muscle maintenance during and post cancer treatment, as well as reducing their calcium content.

One patient group that demonstrates the effects of the changing relationship with food and drinks are those with head and neck cancer. Due to the nature of their condition and the tumours involved, these patients are often supported through treatment with a gastrostomy tube and enteral nutrition. Once treatment is completed, the side effects of treatment can be prolonged, which can mean: Ongoing swallowing difficulties Regular mouth care and

swallowing exercises (usually taught by a speech and language therapist)

Sore mouth and neck with accompanying swelling

Dry mouth Thick salvia secretions Risk of aspiration (food or liquid

entering the airway) due to impaired swallowing mechanism.

In the author’s experience, patients are often scared to eat or drink after treatment due to the above side effects, and may feel more comfortable on a liquid diet, e.g. soups, smoothies and milkshakes, which can be nutritionally inadequate, however. As well as often being resistant to trialling other textures of food, patients may find they have to drink a lot of water alongside meals to manage their dry mouth and as a result feel uncomfortable and bloated. They can become reliant on artificial nutrition and be non-concordant with swallowing advice and exercises resulting in chest infections, which can further reduce their confidence with diet and swallowing.

The author would encourage community nurses to counsel the patient to take small measurable steps to increase their diet, for example taking one milk-based drink per day or adding bread to soups, and gradually reduce their reliance on enteral nutrition alongside regular reviews with the dietitian.

It is also importance to support patients with swallowing exercises, discussing oral care practices and encouraging them to try their own dietary changes. It is very important that a multidisciplinary approach is taken in the community to support the patient’s rehabilitation, including community nurses, GPs, hospital staff, community dietitians, and speech and language therapists (Talwar, 2010; Talwar and Findaly, 2012).

Oral nutritional support (ONS)Taking into account the symptoms discussed above, which occur in the majority of cancer patients, the management of nutrition is challenging at any point in the diagnosis and treatment pathway and across all different tumour groups. Often, the patient’s nutritional needs, in particular with regards to weight and muscle mass, cannot be managed through diet alone and the use of oral nutrition support (ONS) supplements to support patients in maintaining an adequate nutritional status is common.

Similar to patients in other disease groups such as chronic obstructive pulmonary disease (COPD), the

Table 3: Advice for managing changing taste Cold meats may taste better served with pickle or chutney

Recommend marinating meat in fruit juices or wine, or cook it in strong sauces such as curry or sweet and sour

Cold foods may taste better than hot foods

Sharp-tasting foods like fresh fruit, fruit juices and bitter boiled sweets can be refreshing

If the patient no longer likes tea or coffee, recommend lemon tea, or perhaps an ice-cold fizzy drink such as lemonade

Recommend seasoning food with spices and herbs such as pepper, cumin or rosemary to add flavour

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Which one would you choose?

SUPPORTING YOU TO SUPPORT YOUR PATIENTS

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Fearon KCH, von Meyenfeldt MR, Moses AGW, et al (2003) Effect of protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut 52: 1479–86

Karaman N, Vardar H, Dogan L, et al (2009) Taste and smell changes in patients receiving chemotherapy for breast cancer. European Journal of Cancer Supplements 7(2): 304

Khalid U, Spiro A, Baldwin C, et al (2007) Symptoms and weight loss in patients with gastrointestinal and lung cancer at presentation. Support Care Cancer 15(1): 39–46

McGrath P (2002) Reflections on nutritional issues associated with cancer therapy. Cancer Practice 10(2): 94–101

Meyerhardt JA, Tepper JE, Niedzwiecki D, et al (2004) Impact of body mass index on outcomes and treatment related toxicity in patients with stage 1 & 3 rectal cancer: findings from intergroup trial 0114. J Clin Oncol 22: 648–57

Naeim A, Lorenz K, Sanati H, et al (2008) Evidence-based recommendations for cancer nausea and vomiting. J Clin Oncol 26(23): 3903–10

Nitenberg G, Raynard B (2000) Nutritional support of cancer patient, issues and dilemmas. Critical Reviews in Oncology/Haematology 34(3): 137–68

Pinto B, Trunzo J (2005) Health behaviours during and after a cancer diagnosis. Cancer Nutrition 21(4): 355–61

Roulston F, McDermott R (2008) Comparison of three validated nutritional screening tools in the oncology setting. Clinical Nutrition 3(Suppl 1): 107–8

Thoresen L, Fjeldstad I, Krogstad K, et al (2002) Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool. Palliative Medicine 16(1): 33–42

Tewari N, Martin-Ucar AE, Black E, et al (2007) Nutritional status affects long-term survival after lobectomy for lung cancer. Lung Cancer 57: 389–94

Talwar B (2010) Head and neck cancer. In: Shaw C (ed). Nutrition and Cancer. Oxford University Press, Oxford: 188–220

Talwar B, Findaly M (2012) When is the optimal time for placing a gastrostomy in patients undergoing treatment for head and neck cancer? Current Opinion in Supportive and Palliative Care 6: 41-53

WHO (2003) Report of a Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases. Available online: www.who.int (accessed September 4, 2016)

evidence shows that patients who take ONS alongside dietary counselling have an improved nutritional status (Arends et al, 2006). This reinforces the importance of dietary advice, including first-line support from nursing and other allied health staff, but, more importantly, dietary counselling provided by dietitians.

Patient are prescribed ONS for a variety of reasons: To increase protein intake

and prevent further decline in muscles mass

To increase overall nutritional intake of calories, protein and micronutrients (vitamins and minerals)

Because their diet is limited, e.g. those requiring puree diet due to swallowing problems, tumour location or following surgery

To meet their full nutritional requirements for a short period, e.g. because a gastrostomy (surgical opening into the stomach from the abdominal wall for the introduction of food) placement operation was not indicated at diagnosis or tolerated, therefore, the patient may have to take an estimated 5-6 bottles of ONS per day.

There is a large variety of types of ONS, including juice- and milk-based preparations, powders made with milk, yoghurt drinks, savoury soups, fat-based ‘shot’ supplements, and small volume milk-based (compact/mini) versions. In the author’s experience, patients should ideally be encouraged to aim for at least 600kcals and 25g of protein per day from ONS, which may mean consuming at least two bottles per day.

Community nurses can support patients to tolerate ONS by offering first-line advice, e.g. freezing the ONS into ice ‘lollies’; heating coffee-flavoured ONS in the microwave (for no more than 15 seconds); blending with ice to make an iced-coffee/chocolate drink; blending with fresh fruit and ice; or take in small amounts, e.g. a medicine cupfull of 30–40mls every couple of hours.

CONCLUSION

The role of nutrition in cancer is a large

and varied area, especially if specific tumour groups are considered, and it is important that each patient’s needs are assessed on an individual basis and first line advice is offer to support them, their carers and their family. Subsequently, it is important that consideration is given to community nutrition and dietetics in the early stages of a patient’s cancer journey, especially in response to identification and assessment of symptoms such as changing taste and nausea. JCN

REFERENCES

Adams C, Glanville T (2005) The meaning of food to breast cancer survivors. Canadian Journal of Dietetic Practice and Research 66(2): 62–6

Arends J, Bodoky G, Bozetti F, et al (2006) ESPEN guidelines on enteral nutrition: non-surgical oncology. Clinical Nutrition 25(2): 245–59

BAPEN (2016) Malnutrition Universal Screening Tool. Available online: www.bapen.org.uk/screening-and-must/must-calculator (accessed September 4, 2016)

Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L (2014) Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5-24 million UK adults. Lancet 384(9945): 755–65

Beagan B, Chapman G (2004) Eating after breast cancer: influences on women’s actions. Journal of Nutrition Education and Behaviour 36(4): 181–8

Bernhardson B, Tishelman C, Rutqvist L (2007) ORAL impact of cancer chemotherapy related taste and smell changes on daily life. Eur J Cancer Suppl 5(4): 435

Bozzetti F, Gianotti L, Braga M, et al (2007) Postoperative complications in gastrointestinal cancer patients, the joint role of the nutritional status and nutritional support. Clinical Nutrition 26: 698–709

Cancer Research UK (2013) Cancer statisitcs for the UK. Available online: www.cancerresearchuk.org (accessed 12 October, 2016

DeWys WD, Begg C, Lavin PT, et al (1980) Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 69: 491-7

Dignam JJ, Polite BN, Yothers G, et al (2006) Body mass index and outcomes in patients who receve adjuvant chemotherapy for colon cancer. J Natl Cancer Inst 98: 1647–54

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