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    Jane Hopkinson PhD, RGN

    Macmillan Post Doctoral Fellow

    Faculty of Health Sciences, University of Southampton, UK

    NUTRITIONAL ISSUES IN

    CANCER

    What is nutritional care?

    Del Fabbro E, Baracos V, Demark-Wahnefried W, Bowling T, Hopkinson J, Bruera E. (2010) Nutrition and the cancer patient. Oxford University Press, Oxford.

    Learning objectives

    qTo understand contributory factors to compromised nutritional status in cancer patients

    q To describe three psychosocial factors that can impact the dietary intake of cancer patients

    q To identify ways that nurses can help cancer patients and their family members live with weight loss- and eating-related problems

  • Helping people with advanced cancer and their families live with the symptoms of

    cancer cachexia syndrome

    Macmillan weight and eating studies

    6

    Phase I

    Literature review

    Phase II

    Exploratory work

    Phase IIIDevelop MAWE

    exploratory trial

    Phase III

    Develop family intervention

    exploratory trialMedical Research Council Health Services and Public Health Record Board. A

    framework for development and evaluation of RCTs for complex interventions to improve health. 2000. London, Medical Research Council.

    What do you eat?

    What does someone with cachexia eat?

  • Number and percentage of participants reporting weight loss, eating less and concern about the symptoms

    n (%) 95%CI

    Weight loss (n=199) 156 (79%) 73%-85%

    Eating less (n=199) 151 (76%) 70%-82%

    Concern about weight loss or eating less (n=199)

    87 (52%) 44%-60%

    Hopkinson J.B.; MacDonald J.; Wright D.N.M.; Corner J.L. (2006) The prevalence of concern about weight loss and change in eating habits in people with advanced cancer. Journal of Pain and Symptom Management. 32(4) 322-331

    What is cachexia?

    Cachexia is a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass. The prominent clinical feature of cachexia is weight loss in adults (corrected for fluid retention) or growth failure in children (excluding endocrine disorders). Anorexia, inflammation, insulin resistance and increased muscle protein breakdown are frequently associated with wasting disease. Wasting disease is distinct from starvation, age-related loss of muscle mass, primary depression, malabsorption and hyperthyroidism and is associated with increased morbidity

    Evans WJ, Morley JE, Argiles J, et al. Cachexia: A new definition. Clinical Nutrition 2008, 27:793-799.

    TertiarySecondaryPrimary

    Cancer cachexia syndrome

    Hopkinson JB; Wright DNM; Foster C (2008) Management of anorexia and weight loss. Annals of Oncology. 19(7) vii289-vii293

    Weight loss and anorexia

    Primary cachexia

    Cancer

    Tumour products

    Immune system

    Metabolic abnormalities

    Protein loss

    LipolysisAnorexia

    Cachexia

  • The solution: pharmacology

    Progestins

    Megestrol acetate: 23 studies, 3436 patients

    Positive dose response 480-800mg/d but minimal measurable benefit on qol

    Corticosteroids

    6 studies, 647 patients

    Improved appetite and qol

    Systematic review of RCTs, Yavuzsen et al. (2005)

    The future:

    On going trials e.g. multimodal therapies

    Future trials e.g. Muscle growth stimulating agents

    TertiarySecondaryPrimary

    Metabolic change

    Treat

    Cancer cachexia syndrome

    Weight loss and anorexia

    Secondary cachexia

    Nutritional impact symptoms (the eating obstacle course)

    Nausea and vomiting

    Localised pain e.g. mouth

    Taste and smell abnormalities

    Diarrhoea/constipation

    Fatigue

    Mechanical obstruction

    The solution: nutritionNutritional counselling, for example:

    Poor appetite - small meals & snacks high in protein and energy.

    Sore mouth choose soft, moist foods and avoid hot and spicy foods/ drinks

    Taste changes if food lacks taste add herbs, spices, try sharp tasting foods

    Enriched/fortified foods, for example:

    Fortify full cream milk with milk powder

    Grate hard cheese onto vegetables, rice, noodles, potato, soups, casseroles and sauces

    Use cream in cereals, soups, puddings, sauces

    Nutritional supplements

    Tube feeding

    The future:

    On going trials e.g. nutraceuticals

    Future trials ?cancer control diets

  • TertiarySecondaryPrimary

    Metabolic change

    Treat

    Malnutrition

    Feed

    Cancer cachexia syndrome

    Weight loss and anorexia

    Eating well

    Im not eating vegetables, Im not eating fruit. It

    scares me.. I feel that, as well as the cancer, Im abusing my body. (Stella)

    Hopkinson J.B.; Corner J.L. (2006) Helping patients with advanced cancer live with concerns about eating: A challenge for palliative care professionals. Journal of Pain and Symptom Management. 31 (4) 293-305.

    Can nurses help cancer patients to

    Eat well for someone with a small appetite and weight loss?

  • Healthy eating

    I ate an apple today.First one for ages. I managed it! (Craig)

    Eating well

    I have gone on to tinned fruit, which is easy. I like blackberry and apples.I can eat a whole bowl full of that. (Craig)

    Food and identity

    To be honest I've got to the stage that I would rather (eat alone) because they are all tucking away at full sized meals. The size I had before and I am there with this 3 year olds portion and they were getting the full meal into the stomach and I was still messing around with this 3 year olds meal and it was embarrassing in a way. (Frank)

  • Burns GW. (2001) 101 Healing Stories. New York: John Wiley& Sons.

    Can nurses help cancer patients to manage the challenge to identity?

    The PRO approach to therapeutic story telling:

    Problem

    Resources

    Outcomes

    She wont try to eat.

    Im forced to eat.I dont want the things you dish up.

    Its only porridge like you had in the hospice!

    Conflict over food

    Mum, will go through, would you like this? Or would you like that? The end product is that it is even harder for me to try and stomach something. (Emma)

    Hopkinson JB (2008) Carers influence on diets of people with advanced cancer. Nursing Times, 104(12) 28-29.

    Youve got to make the people around you understand what your limitations areso that they can understand what you are going through.

    Interviewer: How have you done that?

    I had to sit down with (my family) and explain. (Steven)

    Can nurses help cancer patients to manage the response of others?

    Hopkinson JB (2007) How people with advanced cancer manage change in eating habits. Journal of Advanced Nursing, 59(5) 454-462

  • Healthy eating messages

    +

    Challenge to identity

    +

    Conflict over food

    =

    Socially constructed obstacles to eating well with advanced cancer

    TertiarySecondaryPrimary

    Metabolic change

    Treat

    Malnutrition

    Feed

    Distress

    Support

    Cancer cachexia syndrome

    Hopkinson JB; Wright DNM; Foster C (2008) Management of anorexia and weight loss. Annals of Oncology. 19(7) vii289-vii293

    Weight loss and anorexia

    The Macmillan Approach to Weight and Eating (MAWE): a complex psychosocial intervention

    Breaking Breaking through through

    the the weight weight

    loss loss tabootaboo

    Telling Telling healing healing storiesstories

    Managing Managing conflictconflict

    Eating Eating wellwell

    Support Support for for

    selfself--actionaction

    http://learnzone.macmillan.org.uk/

  • i/ deliverable by CNSs

    ii/ acceptable to patients

    iii/ may mitigate weight- and eating-related distress.

    The findings warrant further investigation, but any follow-on study should be of revised design

    The exploratory trial of MAWE found that it was

    Hopkinson JB, Fenlon D, Wright DNM, Okamoto I, Scott I, Addington-Hall J and Foster C (2010) The deliverability, acceptability and perceived effect of the Macmillan Approach to Weight loss and Eating difficulties (MAWE): Phase II cluster randomised exploratory trial of a psychosocial intervention for weight- and eating-related distress in people with advanced cancer. Journal of Pain and Symptom Management. Published on-line 3rd August.

    QUESTIONS

    Can tertiary cachexia present across the whole cancer journey?

    Can intervention for tertiary cachexia relieve suffering and save lives?

    Should the management of weight loss and anorexia in people with advanced cancer differ from people receiving active treatment?

    The solution: pharmacology

    Progestins

    Megestrol acetate: 23 studies, 3436 patients

    Positive dose response 480-800mg/d but minimal measurable benefit on qol

    Corticosteroids

    6 studies, 647 patients

    Improved appetite and qol

    Systematic review of RCTs, Yavuzsen et al. (2005)

    The future:

    On going trials e.g. multimodal therapies

    Future trials e.g. Muscle growth stimulating agents

    TertiarySecondaryPrimary

    Metabolic change

    Treat

    Cancer cachexia syndrome

    Weight loss and anorexia

  • Secondary cachexia

    Nutritional impact symptoms (the eating obstacle course)

    Nausea and vomiting

    Localised pain e.g. mouth

    Taste and smell abnormalities

    Diarrhoea/constipation

    Fatigue

    Mechanical obstruction

    The solution: nutritionNutritional counselling, for example:

    Poor appetite - small meals & snacks hi