Oncology and Nutrition Care: Importance of Nutrition in the Oncology Setting

1. Oncology and Nutrition Care:Importance of Nutrition in theOncology Setting Westchester Rockland Dietetic Association December 4, 2014 Anne Coble Voss, PhD, RD, LDN Associate Research Fellow, Abbott Nutrition

2. Disclosure Support for the program is provided by Abbott Nutrition The speaker is an Associate Research Fellow in Adult Nutrition Science at Abbott Nutrition

3. Presentation Objectives Identify the impact the tumor and anti-cancer treatments have on nutrition status in the adult oncology patient Determine the effect of lean body mass loss on treatment outcomes in the adult oncology patient Characterize the effect of cancer and its treatment on outcomes Recognize national/international guidelines and recommendations Develop early nutrition screening and intervention plan .

4. MALNUTRITION

5. Historic definitions of malnutrition marasmus • kwashiorkor • protein-energy undernutrition Jensen GL, et al. JPENJ Parenter Enteral Nutr. 2009;33:710-716.

6. What is malnutrition? A state of nutrition in which a deficiency, excess, or imbalance of energy, protein, and other nutrients causes measurable adverse effects on body function and clinical outcome.1 Up to 1 in 2 adults admitted to hospital or care homes is or at risk of malnutrition. – Somanchi M, et al. JPEN. Mar 2011;35(2):209-216 Estimated up to 80% of advanced patients with cancer have malnutrition. – Poole K, Froggatt K. Palliative medicine. 2002;16(6):499-506 1. Elia M, ed. Guidelines for Detection and Management of Malnutrition: A Report of the Malnutrition Advisory Group. Maidenhead, UK: British Association for Parenteral and Enteral Nutrition (BAPEN); 2000.

7. Malnutrition and weight loss are common in cancer patients • At cancer diagnosis, approximately 50% of patients present with some nutritional issues1 • In certain cancers, up to 85% of patients will develop malnutrition/weight loss2,3during treatment • Involuntary weight loss of just 5% results in decreased survival5 Most common secondary diagnosis for cancer patients is malnutrition4 1. Halpern-Silveira D, et al. Support Care Cancer. 2010;18(5):617-625; 2. Laviano A, Mequid MM. Nutrition. 1996;12(5):358-371; 3. Bozzetti F. In: Payne-James J, Grimble G, Silk D, eds. Artificial Nutrition Support in Clinical Practice. 2nded. London: GMM; 639-680; 4. National Cancer Institute. Nutrition in Cancer Care. www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page1. 5. Dewys WD, et al. Am J Med 1980;69(4):491-7

8. Malnutrition in the Adult Oncology Patient • Weight loss and malnutrition are common in the oncology patient • In a classic paper by Dewys 1980 malnutrition ranged from 31% to 87%1 • Recent paper by Hebuterne 2014 40% of hospitalized oncology patients were malnourished2 This concept is similar to hospital malnutrition and “The Skeleton in the Hospital Closet” 3 1. Dewys Am J Med 1980; 2. Hebuterne JPEN 2014; Butterworth Today’s Dietitian 1974

9. Malnutrition & Weight Loss • Oncology nutrition risk studies show: • 32% outpatients mixed tumor types were malnourished1 • 34% malnourished, 42% at nutrition risk advanced colorectal cancer2 • 88% pancreatic cancer3 • 58% GI tumors4 • 45% of GI cancer patients were malnourished by PG-SGA5 • 49% med oncology patients by PG-SGA6 1. Bozzetti Supp Care Cancer 2012; 2. Thoresen Clin Nutr 2013; 3. La Torre J Surg Onc 2013; 4. Poziomyck NutrCancer 2012; 5. Dias do Prado 2013 6. Isenring Nutr Cancer 2010.

10. Malnutrition & Weight Loss • Oncology nutrition risk studies show: • 66% advanced H&N by >10% weight loss in 6 months; 26% had BMI <20 at 6 month1 • 32% of patients with GI cancer had mild to moderate and 16% had severe malnutrition by SGA2 1. Silander Laryngosope 2013; 2. Garth J Hum Nutr Diet 2010

11. Malnutrition in the Adult Oncology Patient • Oncology nutrition risk studies show: • Pancreatic surgery patients • 88% medium-severe nutrition risk by Nutrition Risk Index • 83% medium to high risk by MUST1 • 35% of patients with lung cancer were malnourished by BMI < 18.5, weight loss > 10% or BMI <20 and weight loss > 5%2 • 25% of patients with gynecological cancer were malnourished by PG-SGA3 1. La Torre J Surg Onc 2013; 2. Percival Resp Med 2013; 3. Laky BMC Cancer 2010

12. Causes of Malnutrition in Cancer Patients • Decreased dietary intake • Increased nutrient requirements • Impaired nutrient digestion / absorption • Increased losses of nutrients

13. Common Treatment-related Side Effects Negatively Impact Nutritional Status * * *Occurs as a result of pain medication.

14. Cancer Patients Often suffer from Multiple Side Effects that Impact Nutritional Status Medical Oncology Patients (N=191) Percentage of patients who are malnourished Number of Symptoms PG-SGA=Patient Generated-Subjective Global Assessment (Ottery 2000). Isenring E, et al. Nutr Cancer. 2010;62(2):220-228.

15. Cancer Induced Weight Loss and the Tumor • Cancer induced weight loss has no direct relationship with the weight of the tumor, presence of metastases and its anatomic localization • Cancer induced weight loss can be present when the tumor weighs < than 0.01% of the host’s body weight • Bigger tumors might not cause cancer induced weight loss Tisdale MJ.Physiology 2005; 20:340-8.

16. Quiz #1

17. Quiz: which statement is not correct? • Consider weight loss and malnutrition in oncology patients: • Patients with cancer have greater rates of malnutrition than patients without cancer • Oncology patients rarely have weight loss prior to diagnosis • Malnutrition is the second most common diagnosis in patients with cancer • Patients with breast and prostate are less likely to experience weight loss

18. Quiz: which statement is not correct? • Consider weight loss and malnutrition in oncology patients: • Patients with cancer have greater rates of malnutrition than patients without cancer • Oncology patients rarely have weight loss prior to diagnosis • Malnutrition is the second most common diagnosis in patients with cancer • Patients with breast and prostate are less likely to experience weight loss

19. LEAN BODY MASS

20. 0 –0.5 –1.0 –1.5 –2.0 –2.5 Bed Rest, Age, and Disease Increase Loss of Muscle Healthy Older Adults (67 years of age) 10 Days’ Inactivity2 Elderly Inpatients (≥65 years of age) 3 Days’ Hospitalization3 Healthy Young (26-46 years of age) 28 Days’ Inactivity1 Loss of Lean Leg Mass (lbs) all measurements represent single leg loss Approx 1.0 lb Approx2.2 lbs Approx 2.2 lbs • Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004 • Kortebein P, et al. JAMA. 2007 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH.

21. Type of Weight Loss is Critical to Outcomes and Survival in Cancer Patients Malnutrition Weight Loss Muscle Mass Loss • Muscle mass functions include: • Skin integrity • Immune function • Healing/Repair • GI integrity/Digestion Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; 2002.

22. Progressive Muscle Loss Can Be Associated with Severe Complications Demling RH. Eplasty. 2009;9:65-94.

23. Effects of Loss of LBM in Patients with Cancer • Low muscle mass is common and independent predictor of immobility and mortality 1 • Low muscle mass is an independent adverse prognostic indicator in obese patients 2 • Patients with sarcopenia seem prone to toxic effects during chemotherapy3,4,5 requiring dose reductions and treatment delays5 • 1. Prado, et al. Lancet Oncol. 2008;9:629-635. • 2. Tan, et al. Clin Cancer Res 2009;15:6973-79. • 3. Prado, et al. Curr Opino Support Palliat Care 2009;3:269-275. • 4. Prado, et al. Clin Cancer Res 2007;13:3264-3268. • 5. Prado, et al. Clin Cancer Res 2009;15:2920-2926.

24. Loss of Lean Body Mass Patients with muscle mass loss have greater toxicity and shorter survival1 Shortest survival times are among obese patients with sarcopenia2 Median survival of patients with low muscle density was compared to high muscle density: 14 vs. 20 months (p=0.001)2 • Tan, et al. Clin Ca Res 2009;15:6973-6379. 2. Antoun, et al. Cancer 2013;19:3377-3384.

25. BMI is a False Indicator of Loss of Muscle Mass Cachectic 17 Equal Normal 25 Equal Obese 38 Equal BMI LBM One study found that 79% of patients identified as malnourished were normal weight, overweight, or obese.1 Image: Fearon et al., Nature 2013, 1. Davidson W, et al. Oncol Nurs Forum. 2012;39:E340-E345. 25

26. Impact of Lean Body Mass LBM determinant of epirubicin toxicity in pts with breast cancer1 Same BSA but wide variation in LBM Low LBM predicts toxicity p=0.002 LBM positively correlated with neutropenia nadir r=0.05, p=0.023 Capecitabine Tx of metastatic breast cancer2 Low LBM is determinant of CT toxicity and time to progression 1. Prado, et al. Cancer Chemother Pharmacol 2011;67:93-101 2. Prado, et al. Clin Cancer Res 2009;15:2920-26

27. Impact of Lean Body Mass Sorafenib’s common toxic effects limit patient’s ability to receive full-dose treatment and account for: dose reductions in 13% of patients treatment termination in 21% of patients BMI < 25 kg/m2 with decreased muscle mass is a significant predictor of toxicity in metastatic RCC patients treated with sorafenib. Antoun S, et al. Annals of Oncology 2010 doi:10/1093/annoc/md605

28. Mayo Clinic regimen 5-FU/leucovorin CRC 35% had toxicity resulting in dose reduction, Tx discontinuation, hosp, death Dose based on Body Surface Area (BSA) 20mg 5-FU/kg LBM cut point for developing toxicities p=0.005 56% had dose reductions or Tx delays Toxicities febrile neutropenia, fatigue, diarrhea, N&V 5FU/BSA or 5FU/kg B Wt not predictive Impact of Lean Body Mass Prado, et al. ClinCancer Research 2007;13:3264-68

29. Chemotherapy, Toxicity and Malnutrition • Greater toxicity in patients with lower LBM but also in malnourished patients • N=100 patients • Malnutrition and hypoalbuminemia were associated with chemotherapy toxicity

30. Quiz # 2

31. Quiz: which answer is not correct • Loss of lean body mass in oncology patients is associated with: • Greater toxicities of chemotherapy • Loss of strength, performance and activity • Increased leg strength • Poorer outcomes in obese patients

32. Quiz: which answer is not correct • Loss of lean body mass in oncology patients is associated withn: • Greater toxicities of chemotherapy • Loss of strength, performance and activity • Increased leg strength • Poorer outcomes in obese patients

33. Patient-centered outcomes

34. Nutrition awareness • Among medical practitioners, nutritional awareness is low • Not considered important by many medical practitioners • Little or no nutrition education in medical school • “I’ll cure the cancer and the nutrition problem will go away.” • Patients and families do worry • Use of herbs, supplements, potions, pills, devices, treatments is high

35. Awareness of Patient Reported Outcomes • In a recent prospective study in patients with NSCLC, survival was correlated with Patient Reported Outcomes.1 • How applicable are Patient Reported Outcomes for predicting quality of life in your practice? • 51% not or only slightly applicable2 1. Gralla, et al. J Clin Oncol 2013 2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014

36. Nutrition Intervention Improves Outcomes in CIWL Nutritional status and intake are independent determinants of QoL as much as stage of disease, location of the cancer and treatment regimen in some types of cancer1 Intensive nutrition therapy including ONS shown to improve2 Body weight and LBM Hand grip strength Physical activity3 Performance status Dietary intake 1. Ravasco P, et al. Supp Care Cancer 2004;12:246-2521 2. Von Meyenfeldt M, et al. Am Soc Clin Onc 2002 3. Moses A, et al. Br J Cancer 2004;90:996-1002

37. Nutrition Intervention Can Help Improve Quality of Life Baldwin C, et al. J Natl Cancer Inst. 2012;104(5):371-378.

38. SURVIVAL AND NUTRITION

39. Weight loss has a significant impact on survival Patients with pancreatic, gastric cancer and lung had the highest frequency of weight loss (83-87%)and tumor types less likely to produce weight loss breast, prostate, sarcoma. DeWys WD et al. Amer J Med 1980; 69: 491-497

40. Weight Loss is Associated with Worse Outcomes Andreyev HJN, et al. Eur J Cancer. 1998;34(4):503-509.

41. Weight Loss Impacts Survival in Colorectal Cancer Results 100 80 60 Percentage No Weight Loss (n=472) 40 20 Weight Loss (n=246) P<.00001 0 0 1 2 3 4 5 Time Since Treatment (Years) Andreyev HJN, et al. Eur J Cancer. 1998;34(4):503-509.

42. Nutrition Intervention in Weight Losing Patients Unresectable PancreaticCancer Dietary counseling and Oral Nutrition Supplements over 8 weeks n=107 Weight stabilization Longer survival Improved QoL (EORTC) Improved dietary intake Davidson W, et al. Clin Nutr 2004;23:239-247

43. Early Supportive Care in Patients with NSCLC Improves Survival Early Supportive Care vs. Standard Care n=151 Improved Quality of Life (p=0.04) Longer survival 1.6 vs. 8.9 mos (p=0.02) Improved QoL (EORTC) Temel J, et al. N Eng J Med 2010;363:733-742

44. Early Intervention for Cancer Cachexia • Early palliative care correlates with longer survival in patients with NSCLC.1 How early should an intervention start for cancer anorexia-cachexia? • (69%) With any weight loss or patients most likely at risk for developing weight loss.2 1. Temel, et al. N Engl J Med 2010;363:733-742. 2. NCCN Trends™ Highlights: Cancer Anorexia-Cachexia 6/19/2014

45. NUTRITION INTERVENTIONS

46. Appropriate nutrition can support cancer treatment goals Goals of cancer treatment • Be effective • Be well tolerated • Minimize complications • Maximize quality of life • Allow for healing and recovery Levin RM. Oncology Issues. Nutrition: The 7th Vital Sign. November/December 2010:32-35. accc-cancer.org/oncology_issues/articles/NovDec2010/ND10-Levin.pdf. Accessed March 26, 2012.

47. Early nutrition intervention has been shown to improve outcomes in cancer patients Nutrition intervention started as early as possible can result in: • Nutritional status • Performance status • Quality of life (QOL) • Response and tolerance to treatment • Rate of complications • Morbidity Marín Caro MM, et al. Clin Nutr. 2007;26(3):289-301.

48. Patients Treated with a Nutrition Pathway Experienced Improved Outcomes and Treatment Tolerance1 Results Odelli C et al. Clinical Oncology 2005; 17: 639-625.

49. EXPERT GUIDELINES

50. Experts Have Recognized the Importance of Ongoing Nutrition Intervention in Oncology Patients • Evaluation process starting in 2015 • “The cancer committee develops and implements a process to provide a comprehensive treatment summary and follow-up plan to patients who are completing treatment; the process is monitored, evaluated, and reported to the cancer committee each year.” • Continued care that considers the big picture: Cancer recurrence and… other chronic disease The American College of Surgeons Commission on Cancer 2012 Cancer SurvivorshipStandards1 American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered Care. Chicago, IL: American College of Surgeons. 2011.