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MALNUTRITION RISK IN CANCER PATIENTS: SUGGESTIONS FOR

IMPROVEMENT IN NUTRITIONAL CARE

by

Wasim Akram

A report submitted in partial fulfillment of


the requirements for the degree

of
Bachelors of Biological Science

in
The Department of Biological Science

UNIVERSITY OF CALCUTTA
Kolkata, West Bengal India
2012

ABSTRACT

Malnutrition Risk in Cancer Patients:


Suggestions for Improvement in Nutrition
Care
by
Wasim Akram
Bachelor Of Biological Science
University of Calcutta, 2012

Major Professor: Iman Hazra Mam


Department:
Biological Science

Cancer is diagnosed in 1.2 million Indian annually and is the third


leading cause of death in India, second only to cardiovascular disease.
Cancer causes one in four deaths nationwide. Treatment options for patients with
cancer include surgery, radiation, chemotherapy, and immunotherapy. Nutrition
complications can occur before, during and after treatment. Inadequate nutritional
intake or altered absorption can lead to malnutrition. Malnutrition prior to treatment
can cause it to be less effective. This quality assessment was designed to identify how
many patients receiving treatment at Tata Medical Centre and Cancer Research at risk for

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malnutrition. Fifty-six Patients were screened using the subjective global assessment.
(SGA). The patients were categorized into three groups: SGA-A (well nourished),
SGA-B (moderate malnourished), and SGA-C (malnourished). SGA-A (n=33)
accounted for 59% of the patients, SGA-B (n=12) accounted for 21% of patients and
SGA-C (n=11) accounted for 20% of patients. Identifying those at risk for
malnutrition can help prevent nutrition-related complications during cancer treatment.
Early nutrition interventions and education plays an important role in improving the
nutrition status and quality of life of cancer patients. The SGA is an effective tool for
screening cancer patients for malnutrition.

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ACKNOWLEDGEMENTS

I would like to thank my committee members, Abhishek Das, Zeeshan Ahmed, Rohit Shaw, and Puja
Sharma for supporting me during the completion of a Bachelor Degree.
I would like to thank Iman Hazra Mam, Major Professor of Biology for her countless hours of helping
me through this process.
I would like to thank Debashis Mondal, Head of the Department of Microbiology for arranging
classes that allowed me to continue to work full-time.
I would like to thank all committee members for their patience during these periods of my
research
I also want to thank my family, friends and coworkers for their support, help and understanding that
allowed for the completion of this document.

Wasim Akram

CONTENTS

ABSTRACT..... ....ii-iii
ACKNOWLEDGEMENTS ..iv
LIST OF FIGURES......vi
LIST OF ABBREVIATIONS.vii

CHAPTER I.
INTRODUCTION................1
REVIEW OF LITERATURE..... 2
Abstract...3
Surgery .......2-3
Chemotherapy.....7
Radiation ......13
Weight Loss..........17
Cancer Cachexia.......20
Nutrition Support..........22
Nutrition Screening ......................24

CHAPTER II

STUDY METHODS, DESIGN, AND RESULTS


Introduction

Current Practices at Tata Medical Centre......27

Results .....31
Discussion ...37
Areas for Further Research...39
My Recommendations..41
Conclusions...41
REFERENCES.....45
APPENDIX..50

vi

LIST OF FIGURES AND TABLES

Potential contributions to unintentional weight loss................18


Figures
1

..32

..33

......34

..,...35

..36

..37

vii

LIST OF ABBREVIATIONS

ECF

Epirubicin, Cisplatin, Fluorouracil

EN

Enteral Nutrition

DNA

Dioxynucleic Acid

FAMTX

Fluorouracil, Doxorubicin and Methotrexate

NG

Nasogastric

NJ

Nasojejunal

PEG

Per-cutaneous Endoscopic Gastrostomy

PEJ

Per-cutaneous Endoscopic Jejunostomy

PN

Parenteral Nutrition

SGA

Subjective Global Assessment

CHAPTER I
PROBLEM, LITERARTURE REVIEW, AND OBJECTIVES
Problem
Cancer is diagnosed in 1.2 million Indian annually and is the third
leading cause of death in India, second only to cardiovascular disease.
Cancer causes one in four deaths nationwide. Even though deaths attributed to
cardiovascular disease have decreased over the last 50 years, deaths from cancer have
remained constant. Lung cancer has the highest mortality rate among all cancers in
men and women. In men, the second leading cause of cancer death is prostate
followed by colon. In women, the second leading cause of cancer death is breast
followed by colon (1,2).
Cancer is defined as uncontrolled cellular proliferation. There are external and
internal factors that can lead to cancer. External factors include: environmental
exposures, tobacco use and radiation. Internal factors include: hormones,
Immuno-suppression, genetics, and mutations of metabolism (2). If the cancer is
detected early, prognosis is generally good and the need for cancer treatment is
minimized. However, cancer is often detected at more advanced stages where cancer
treatment may be needed to help induce remission. The five-year survival rate of
patients with all types of cancer, irrespective of the treatment modality, is 65% (3).
Treatment options for patients with cancer include surgery, radiation,
chemotherapy, and immunotherapy. These therapies can be used alone or in

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combination. Treatment options depend on the location, size, stage and type of
cancer. All cancer treatment options carry nutrition risk and may lead to malnutrition
and poor patient outcomes over time. To complicate matters, malnutrition can then
lead to decreased treatment effectiveness. For example, inadequate nutrient intake
during treatment can cause chemotherapy and radiation to be less effective (4-7).
Thus, it is critical to identify cancer patients at risk for malnutrition in order to
improve patient outcomes.
Objectives
The study objectives were to assess the current nutrition referral system for
cancer patients at Tata Medical Centre and Cancer Research, identify cancer patients at risk for
malnutrition and discuss ways to improve outcomes related to malnutrition.
Hypothesis
Early detection of malnutrition improves cancer treatment. The subjective
global assessment (SGA) is an adequate screening tool for identifying malnutrition
among cancer patients.

Literature Review
Surgery
Surgery is often the first line of treatment for cancer and can play an important
role in determining what type or even if additional treatment(s) will be required.
Excision of malignant cells can be curative at times if negative margins are achieved.
Negative margins are defined as removal of all cancerous tissue. On the contrary,

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positive margins are defined as cancerous tissue present with the potential for further
tumor growth and metastasis (6-7). Chemotherapy and/or radiation therapy may be
required when positive margins are detected as a method of inducing apoptosis.
Furthermore, upon completion of chemotherapy and/or radiation therapy, additional
surgeries may be warranted, which could possibly be followed by more chemotherapy
and/or radiation therapy (8-9)
Similar to non-cancer related surgeries, cancer patients have an increased need
for calories, protein, and micro-nutrients in order to promote postoperative healing (610). Yet, postoperative oral intake can be compromised due to pain, pain
medications, and nausea. Inadequate oral intake postoperatively increases the risk for
infection, causes wound dehiscence and increases hospital length of stay. Additional
factors that reduce healing time include age, medications and glycemic control (7).
The type of surgery determines the healing time. Surgeries of the gastrointestinal tract
often result in postoperative ileuses and decreased nutrient absorption, which can
compromise nutritional status (9-10).
The type and location of the surgery dictates what type of feeding method is
appropriate and when oral feedings can be resumed. For example, bowel surgery can
take approximately five to seven days postoperatively to regain adequate function
(6,8-9). Lumley et al. (11) found that laparoscopic techniques lower the risk of
developing a postoperative small bowel obstruction. Only 6 of 108 patients who
underwent a laparoscopic procedure developed an adhesion or small bowel
obstruction postoperatively (11). Braga et al. (12) compared open surgery to

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laparoscopic surgery and reported decreased morbidity with the laparoscopic
technique. Morbidity was 6.9% compared to 14.9% in open surgery (12). Although
advancements in surgical techniques allow for smaller incisions and shorter healing
times, bowel resections are not without nutritional consequences. Bowel resections
can alter nutrient absorption; lifelong supplementation of nutrients may be necessary
as a result depending on the site of resection. As previously mentioned, patients who
have recently undergone a bowel resection are in need of increased energy and
protein to promote healing (10). Thus, it is challenging for the patient to obtain
adequate nutrition as a result of malabsorption and increased nutrient needs.
A Veterans Affairs study reported that 39% of patients with cancer deemed
candidates for surgery were considered to be malnourished (13). This is of great
concern as surgical outcomes are compromised when patients are malnourished, and
in some instances, the patient may no longer be considered a candidate for surgery
because of his/her malnourished state. Furthermore, as much as fifty percent of
patients develop malnutrition postoperatively (13). Thus, preoperative screening tools
must be used to determine the degree of malnutrition, as defined by visceral protein
status and weight loss, to improve pre- and postoperative outcomes and prevent
and/or minimize the occurrence of malnutrition (10,13).
Insufficient oral intake requires the use of nutrition support to provide
adequate nutrition. There are two different methods of feeding when oral nutrition is
contraindicated. Enter-al nutrition (EN) requires the placement of a feeding tube into
the stomach or small bowel. Tubes are often placed in the nasal cavity and threaded

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into the stomach (nasogastric (NG)) or small bowel (nasojejunal (NJ)) when
nutritional support is anticipated to be used for four weeks or less. Longer-term
Eternal nutrition requires surgical placement of a feeding tube through the abdominal
wall and directly into the stomach (per-cutaneous endoscopic gastrostomy (PEG)) or
small bowel (per-cutaneous endoscopic jejunostomy (PEJ)). Enteral formulas vary in
nutrient composition depending on the purported use of the product. There are
standard formulas, immune enhancing formulas, high protein formulas, and specialty
formulas (e.g. impaired absorption, renal and liver formulas) (10,14).
Parenteral nutrition (PN) is the administration of nutrients directly into the
blood stream. PN usually requires placement of a central line, generally the vena
cava, because of the high rate of blood flow. As a result, there is an increased risk of
infection with use of PN (10,14).
Nutrition support can be used both pre- and postoperatively. Enteral nutrition
is preferred over parenteral nutrition due to a lower risk of infection, decreased cost,
and its ability to maintain gut integrity (10,14). As such, enteral nutrition has been
shown to improve patient outcomes. In contrast, per-operative Parenteral nutrition has
not been shown to be effective and has been proven to increase morbidity and
mortality. As previously mentioned, Parenteral nutrition has a higher risk of infection,
but it can also induce hyperglycemia and cause electrolyte imbalances. Moreover, in
the malnourished population, parenteral nutrition increases the risk of re-feeding
syndrome, a potentially deadly syndrome that involves an intracellular shift of

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electrolytes. Thus, enteral nutrition is the preferred method of feeding when oral
intake is inadequate pre- and post-operatively (6,10,14).
However, Parenteral nutrition is recommended if a trial of enteral nutrition has
failed even after placement of a small bowel feeding tube in cases of gastrointestinal
dysfunction, or if high output intestinal fistula(s) are present. PN should be initiated
between day five and day ten postoperatively if an oral diet or EN is not feasible (10).
Preoperative enteral nutrition may be a means to improve nutrition status in
the malnourished patient if the surgery can be safely postponed for seven to ten days
(6). Improving overall nutrition status preoperatively can improve post-operative
healing. This decreases the length of stay required in the hospital. The majority of
cancer patients that require nutrition support have recently undergone a surgical
procedure and are in need of high protein formulas and have been unable to meet
their protein needs orally. Provision of 1.5 grams of protein per kilogram of body
weight is recommended to promote healing (7). In addition, early initiation of enteral
nutrition in the post-operative period for upper GI surgeries has been shown to
decrease hospital length of stay and healing time (15). Furthermore, immune
enhancing enteral formulas have been shown to decrease length of hospital stay in
surgical patients and should be considered as the enteral formula of choice in this
patient population (10,14).
Chemotherapy
The three goals of chemotherapy are to cure, control and palliate.
Chemotherapy is most effective when used in combination with surgery and/or

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radiation (6). Chemotherapy agents interfere with deoxynucleic acid (DNA) synthesis.
This can slow down and/or stop tumor growth. Chemotherapy targets rapidly dividing
cells, malignant or nonmalignant. As such, the integumentary and gastrointestinal
systems are affected. For example, hair growth is affected as well as the mucosa of
the small bowel (6,9,16).
Neoadjuvant therapy is chemotherapy that is given preoperatively. The goal of
neoadjuvant therapy is to reduce the size of the tumor and prevent metastasis since
malignancy causes inflammation of the surrounding tissues, which makes it difficult
to determine the extent of the malignancy. Therefore, shrinking the tumor can help
with the surgical removal of the tumor without damage to the surrounding tissues (6).
Neoadjuvant therapy is not effective with all types of cancer but is often used for
breast and colon cancers (16).
Advancements in chemotherapy are ever occurring, but additional research is
needed to determine its effectiveness. There are numerous reports that cite the relative
effectiveness or ineffectiveness of chemotherapy. For example, Hartgrink et al. (17)
found that there was no benefit of using neoadjuvant therapy using fluorouracil,
doxorubicin and methotrexate (FAMTX) as treatment for stomach cancer (17).
However, Cunningham et al. (18) found that epirubicin, cisplatin, and infused
fluorouracil (ECF) is beneficial in reducing gastric or lower esophageal tumors. If
nothing else, these trials show that not all chemotherapy agents are effective in all
cancers. Thus, further research is warranted.

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One option for additional research is clinical trials. Clinical trials allow
patients to receive experimental treatments for cancer. Participation in clinical trials is
voluntary. The findings of clinical trials assist in the development of chemotherapy
protocols (16,19). Chemotherapy protocols are necessary to help prescribe the
appropriate drug regimen for the individual patient.
Adjuvant therapy is chemotherapy that is given postoperatively when surgical
treatment was not successful at eradicating the tumor. Adjuvant therapy, like
neoadjuvant, works best when combined with radiation therapy (6). Unfortunately,
not all cancers respond to chemotherapy (6,16). Side effects of chemotherapy are
similar with both neoadjuvant and adjuvant therapy.
As aforementioned, the mucosal lining of the gastrointestinal tract is affected
by chemotherapy. Atrophy of the mucosal lining can lead to malabsorption and
diarrhea, which results in the loss of nutrients (9). Diarrhea can lead to dehydration,
poor appetite and fatigue (6). Ensuring adequate fluid intake is essential to the
prevention of dehydration. Adequate hydration after each episode of diarrhea is
necessary (16). This can be accomplished by the use of sports drinks, for example.
Avoidance of spicy, fried, greasy and sweet foods is also recommended. Though
research findings are not conclusive as to whether lactobacillus may help alleviate
diarrhea, it is often used as an antidiarrheal agent among the cancer population (3).
As previously stated, malabsorption of nutrients can lead to weight loss and
malnutrition. Moreover, avoidance of whole grains, fruits and vegetables can lead to
an inadequate intake of vitamins and minerals (9). Both of these occurrences are

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common among cancer patients, which exacerbate the risk for malnutrition. A
multivitamin and mineral supplement should be consumed as a result (6-7,9).
Nausea and vomiting are common side effects of chemotherapy and if left
untreated, can result in inadequate oral intake, weight loss, electrolyte imbalance, and
malabsorption of nutrients (16). Similar to diarrhea and malabsorption, uncontrolled
nausea and vomiting can lead to malnutrition over time (20). Antiemetic agents may
help alleviate nausea and vomiting. Medications can be taken on a routine basis as
prophylaxis against nausea and vomiting (16). Dietary modifications such as
consuming small and frequent meals, consuming bland foods and avoiding food with
strong odors may help alleviate nausea (6-7,16). Some cancer patients will develop
intolerance to dairy products; therefore, assessing tolerance to dairy products is
recommended (6).
Glutamine is one of the most abundant amino acids in the plasma and a major
component of skeletal muscle (10,21). Commercial glutamine supplements are
available over-the-counter and are often touted as a remedy for cancer. Numerous
studies have shown that oral glutamine supplementation can be beneficial in
chemotherapy-induced stomatitis (21-24). Glutamine plays a role in the metabolic
processes of lymphocytes, macro-phages, and enterocytes. Cancer causes stress on the
body and during times of stress, glutamine may become conditionally essential (6).
Glutamine has also been associated with maintaining fat-free mass during treatment
(22).

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Ulceration or inflammation of the throat and mouth (stomatitis and mucositis)
is also a common side effect of chemotherapy. In such cases, eating can be very
painful; therefore, oral intake often decreases as a direct result. Nutrition
interventions to improve stomatitis and mucositis include eating soft textured foods,
drinking through a straw and rinsing the mouth thoroughly after eating or drinking
(9,16). Rough textured foods, spicy foods and acidic foods should be avoided. Use of
numbing agents prior to eating may also improve intake. Furthermore, oral
supplements like Boost or Ensure, are usually well tolerated and can aid in
meeting nutritional needs (6,16). As previously mentioned, glutamine may help in
healing stomatitis and mucositis (23).
Cancer patients can experience taste changes during chemotherapy. The most
common taste changes are a metallic taste and a heightened sensitivity to sweet foods.
Meats are often avoided due to its metallic taste. Using different marinades on meat
products can help mask the flavor of meat and make it more palatable. Plastic utensils
may also help decrease the metallic taste. Gum, mints or lemon drops can be used
between meals to decrease the metallic taste. If foods taste too sweet, diluting
sweetened liquids with water or consuming foods that are more acidic may help.
Caution should be used when eating acidic foods if mouth sores are present. Similar
to mucositis, proper oral hygiene is essential in order to minimize the effects of taste
alterations. For example, rinsing the mouth before eating or drinking can help
minimize metallic taste changes (6,16).

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Xerostomia, or dryness of the mouth, can result in secretion of viscous saliva
and decreased quality of life for cancer patients. Xerostomia can make wearing
dentures difficult as it can cause dental and gum disease. Nutrition recommendations
to minimize the effects of xerostomia include adding sauces and gravies to foods,
consuming foods in liquid form, and gargling with ginger ale if mucus sticks to the
throat. Club soda and lemon juice can be used as a mouthwash, and artificial saliva
products are available if needed. Eating smaller meals more often may also be
beneficial. Keeping the mouth moist by drinking water or sucking on ice chips can
help make meal times more meaningful as the patient may consume more food as a
result (6,16).
Constipation during cancer treatment can be multifactorial. Chemotherapy,
use of pain medications, inadequate intake of fiber and fluids, and inactivity all
contribute to constipation (16). Therefore, increasing fluid intake, engaging in
physical activity, and consuming more fiber can help prevent constipation. Stool
softeners, enemas and laxatives can also be used when nutrition therapy is not enough
to alleviate the constipation. It is important to note that bowel obstructions can
develop if constipation is not treated effectively and in a timely manner (6,16).
Esophagitis can develop as a result of chemotherapy and it significantly
impacts the ability to eat. Sore throat can lead to early satiety and reflux. Soft foods
are usually well tolerated and accepted by patients with esophagitis. Pureed foods can
also be used as tolerated. Fortified milk and oral supplements can be used as protein
sources if meat products are not tolerated (6,16). In addition, glutamine

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supplementation may be helpful in treating esophagitis (23). If oral intake is not
sufficient or not possible, nutrition support may be needed. However, NG and NJ
tubes are not recommended in cases of severe esophagitis due to possible esophageal
perforation. Therefore, parenteral nutrition may be indicated for short-term therapy
(10).
Severe esophagitis can lead to dysphagia. Nutrition recommendations depend
on the severity of the dysphagia. To determine the stage of dysphagia, patients should
be evaluated by a speech therapist. Barium swallow evaluations are often preformed
to assess the extent of the swallowing dysfunction, which are categorized into three
levels of dyshpagia. Level I consists of a blenderized or pureed diet. Level II consists
of a minced or mechanical diet. Level III consists of an advanced or chopped diet (9).
Alterations in the consistency of liquids may also be needed in those with swallowing
dysfunction. Liquids can be nectar, honey or spoon thick. Commercial thickening
agents can be used to alter the consistency of liquids (9). Nectar thick liquids are
more palatable than spoon thick liquids. Although dysphagia diets are beneficial, the
palatability of such a diet is lacking. Multivitamin and mineral supplementation can
be provided if there is a decrease in consumption of fruits and vegetables. If severe
dysphagia is present, enteral nutrition may be used to meet nutritional needs (67,10,16).
In summary, chemotherapy can compromise oral intake or alter the absorption
of nutrients. As previously mentioned, inadequate oral intake during treatment can
lead to decreased overall efficacy of treatment(s). Moreover, the side effects of

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chemotherapy can compromise intake, which can ultimately lead to malnutrition over
time (6,9,25).
Treatment side effects of radiation therapy
Similar to that of chemotherapy, radiation therapy can lead to malnutrition.
The prevalence of malnutrition depends on the tumor location, the region irradiated,
the dose, the length of treatment, the volume irradiated, and adjunct cancer treatments
(6-7). For example, the small bowel is responsible for the absorption of fat,
carbohydrates, protein, vitamins, minerals and bile salts. Thus, radiation enteritis, a
side effect of radiation to the small bowel, can lead to malabsorption, bowel
obstruction and diarrhea (6,26). Unlike acute enteritis, radiation enteritis can be
chronic in nature. Damage to the bowel can affect the entire thickness of the bowel
wall, not just the mucosa. Mucosal damage leads to fibrosis and ischemia. Ischemia
and fibrosis can lead to small bowel obstructions. Fibrosis decreases the absorptive
capacity of the small bowel (26). Over time, both ischemia and fibrosis can lead to
malnutrition. The colon and rectum can also be affected by pelvic radiation. Radiation
to the pelvic region can cause a decrease in the colonic re-absorption of fluid and
nutrients. It can also impair bowel motility. Furthermore, constipation and diarrhea
are common side effects of pelvic radiation. Similar to chemotherapy induced
diarrhea, adequate fluid intake is necessary to prevent constipation when loss of fluid
is high due to the diarrhea. Increasing fiber intake can also help minimize
constipation. It is recommended to consume 25-30 grams of fiber per day (9). Foods
high in fiber include fresh fruits, vegetables and whole grains. Fiber supplements can

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also be used to supplement dietary fiber intake. Stool softeners may also be required
in cases of severe bowel injury (6).
Radiation to the head and neck region is especially deleterious on nutritional
status. Head and neck radiation can often result in a sore mouth and throat, dysphagia,
mouth sores, fatigue and loss of appetite. Swallowing difficulty can lead to
inadequate oral intake, which may result in weight loss and malnutrition over time (67,9). Thus, prophylactic placement of a feeding tube may be beneficial in patients
receiving radiation therapy to the head and neck region. Research has shown that such
measures minimize weight loss during radiation treatment (26-29). Paccagnella et al.
(27) compared thirty-three head and neck cancer patients that received early nutrition
intervention to thirty-three patients that did not receive nutritional intervention. After
the fourth week of treatment, the control group lost on average, 4.70 kg compared to
1.72 kg in the nutrition intervention group. It was also noted that weight loss near the
end of treatment was more common in both groups; however, the nutrition
intervention group was more likely to regain the lost weight. The control group
continued to lose weight up to six months after treatment was completed (27).
Tongue and neck cancers can lead to mouth sores. Mouth sores can be treated
with glutamine supplementation (23). Current research is not conclusive as to whether
glutamine supplementation is actually effective against mouth sores, but the results
are promising and glutamine supplementation should be considered as a possible
treatment option (31). Treatment of mucositis should be done as a multidisciplinary
approach with involvement from the physician, nurse, dietitian, and pharmacist.

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Similar to mucositis associated with chemotherapy, proper oral hygiene is essential.
Tolerance of foods can vary greatly from only tolerating pureed foods to tolerating
regular diets. Oral supplements, like Boost, Ensure or fortified milk, can be
beneficial in meeting protein and energy needs when nutrition status is compromised.
Medications including anesthetic gels can numb the mouth and facilitate oral intake
(6).
Radiation enteritis can occur with radiation to the abdomen, pelvis, or lumbar
regions. Acute enteritis is classified as diarrhea that occurs for 3 months or less (26).
Yet, chronic enteritis can occur as well; diarrhea can last months to years after
treatment, which can compromise nutrition status long-term. Even mild to severe
diarrhea can decrease the amount of nutrients absorbed (9). Symptoms include
nausea, vomiting, abdominal pain and secretory diarrhea. Patients may benefit from a
low lactose, low fiber, and low fat diet as a result (6-7). Dehydration becomes a
concern with severe diarrhea and hydration therapy may be required. Antidiarrheal
agents can be used in severe cases and nutrition support may be necessary (7). As
previously mentioned, a trial of enteral nutrition should be conducted prior to
initiation of parenteral nutrition (10). Additional recommendations include small and
frequent meals, vitamin and mineral supplementation and replacement of electrolytes
(6).
Nausea and vomiting are common side effects of radiation to the central
nervous system as well as the pelvic region, as previously mentioned. Techniques to
minimize nausea and vomiting include consuming small and frequent meals, drinking

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before and/or after meals instead of with meals, and avoiding foods with strong odors.
(6,10). Antiemetics can be given on a scheduled basis in an attempt to reduce nausea
and vomiting (6). If nausea and vomiting are persistent, and nutrition status is
compromised as a result, enteral nutrition administered to the small bowel can be
initiated. Slow advancements in volume and rate to goal can improve tolerance (10).
Alterations in taste can occur during radiation therapy. Even though dysgeusia
and ageusia are common, the etiology is unknown. However, it is likely a
combination of factors including xerostomia, poor hydration, mucositis and
medications. An oral examination to assess for candidiasis and education on proper
oral hygiene should be conducted. Techniques to promote proper oral hygiene include
rinsing the mouth before meals and incorporating sauces and gravies into meals. Zinc
sulfate may also be helpful in expediting return of taste after head and neck
irradiation (32). Ensuring adequate oral intake is also beneficial. In addition, fresh
fruits and vegetable may taste better than canned or frozen products (6).
Fatigue can develop over time with radiation therapy, and it is multifactorial
in nature. Treatment-related fatigue has been reported in 78% of patients during the
course of their radiation therapy (6). Symptoms include weakness, lethargy, dizziness,
sadness, depression, frustration, irritability, decreased appetite and decreased
cognitive ability. Management of fatigue includes promoting adequate rest and
relaxation, engaging in physical activity, supplementing with vitamins and minerals,
and taking medications as prescribed (6-7,9).

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Radiation therapy can compromise oral intake and also prevent adequate
absorption of nutrients. Nutrition support may be needed in extreme cases and as
previously mentioned, should be considered for all patients undergoing treatment of
the head and neck. All of the aforementioned side effects can lead to a compromised
nutrition status and malnutrition (25).
Weight Loss
As previously mentioned, weight loss can occur at any stage of cancer, from
the time of diagnosis to the completion of cancer therapy (6). Some of the possible
causes of unintentional weight loss in cancer patients are outlined in Table 1.
Identifying the reason(s) for weight loss allows for more patient specific nutritional
interventions (5,33-34).

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Table 1 Mattox TW. Treatment of Unintentional Weight Loss in Patients with Cancer. Nutrition in
Clinical Practice. 2005;20:400-410.
Potential contributions to unintentional weight loss in cancer patients
Nutrition Consequences of malignancy
o Obstruction/perforation of GI tract
o Intestinal secretory abnormalities o
Malabsorption
o Intestinal dysmotility
o Fluid/electrolyte abnormalities
o Anorexia
Altered taste
Learned food aversion
Depression
Altered peripheral hormone metabolism
Leptin
Ghrelin
Altered neuropeptide metabolism
Melanocortin
Neuropeptide
Y Nutrition consequences of treatment
o Chemotherapy
Anorexia
Nausea, vomiting
Mucositis, enteritis
Ileus
o Surgery
Malabsorption, diarrhea
Adhesion-induced obstruction
Fluid/electrolyte abnormalities
Vitamin/mineral abnormalities
o Radiation
Anorexia
Altered taste
Mucositis, enteritis
Xerostomia, dysphagia
Obstruction
Perforation
Stricture
o Other
Opioid-induced constipation
GI tract abnormalities associated with Fungal, viral or bacterial
infections
Altered Metabolism
o Tumor-induced changes in energy expenditure
o Cory cycling/gluconeogenesis
o Nitrogen trap
o Altered fat metabolism
o Tumor-induced secretions of host mediators
)

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Currently, there is no single medication that treats unintentional weight loss.
However, there are several medications that have been proven to be effective in the
treatment of unintentional weight loss including anticytokine agents, anabolic agents,
metabolic inhibitors and appetite stimulants (35). For example, pro-gestational agents,
a type of appetite stimulant, have been shown to be effective in promoting weight
gain. However, for some patients weight gain will not be possible even with use of a
stimulant. In such cases, the goal is to prevent further weight loss (6,34).
Initiation of appetite stimulants should be based on the treatment goals of the
patient, his/her current medical and nutritional status, and the patients desire.
Megestrol acetate and Medroxyprogesterone are appetite stimulants that are often
used among cancer patients (6,10). Patients taking progestational agents have been
found to be twice as likely to gain weight when compared to a placebo group. This is
promising, as malnutrition and weight loss are common among cancer patients. It
should be noted that the risk for adverse side effects with use of appetite stimulants is
increased if the agents are taken for less than twelve weeks (34).
Aside from the effects of cancer and its associated treatments, some with
cancer may have a distorted perception of weight loss during treatment. Weight loss
may be viewed as beneficial as the cancer patient may have been unable to lose
weight prior to initiation of cancer treatment. Yet, weight loss increases risk of death
in those with cancer regardless of body weight before cancer diagnosis (33-34).
Those who lose more than 10% of their body weight during cancer treatment have a
higher mortality rate (6). Thus, nutrition intervention is warranted in order to promote

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adequate nutrition during treatment and prevent malnutrition (35). Brown and Radke
(36) found that even though nutrition assessments were conducted in 97% of patients
in their study, only 60% of patients had received nutrition interventions and only 44%
of those that received nutrition interventions, received any follow-up assessments
(36). Nutrition assessment is the first step in the nutritional treatment of cancer
patients, but adequate follow-up is essential to prevent unintentional weight loss and
malnutrition.
Regardless of the cause(s) of weight loss in cancer patients, the end result is
often malnutrition and a poor prognosis. This poor prognosis can largely be attributed
to cachexia (33-38).
Cancer Cachexia
Cachexia is a Greek derivative meaning, bad condition, and is a form of
malnutrition as a result of starvation-induced lipid and protein catabolism, which is
associated with a high risk of mortality (33-38). Starvation and cachexia are similar
but in starvation, adipose stores are depleted and protein stores are spared; neither
protein nor adipose is spared in cachexia. Cachexia prevents chemotherapy from
being as effective as it otherwise could have been (37).
Unfortunately, cancer patients are at risk for cancer cachexia. It has been
estimated that 20% of deaths from cancer are caused by cachexia versus the actual
malignancy (5). Yet, the prevalence of malnutrition can vary as much as 31-87%
among cancer patients, depending on the type and location of cancer, degree of
metastasis, and nutrition status at diagnosis (39). Risk factors for cachexia include:

21
anorexia, nausea, vomiting, diarrhea, dysgeusia and early satiety. Signs of cachexia
include: profound weight loss, muscle weakness, fatigue and anemia (33-38).
The best treatment for cancer cachexia is to cure the cancer, but this is not
always feasible; therefore, increased nutrient intake is recommended in an attempt to
offset weight and nutrient losses (33). As previously mentioned, parenteral and
enteral nutrition can promote an increase in nutrient intake. Similar to that of
unintentional weight loss, there is no single medication or treatment option that can
cure cachexia (33-38). Therefore, appropriate nutritional interventions should occur
as long as cachexia is present.
Prevention of cachexia is done by promoting optimal nutrition and preventing
malnutrition. Studies have found that nutrition intervention can lead to a better
response to cancer treatment and may prevent weight loss (40). Nutrition
interventions include providing appropriate and timely nutrition education, promoting
high calorie, high protein intake, and initiating nutrition support when indicated. All
of the aforementioned interventions have been proven to decrease the degree of
weight lost (8,33-38).
Use of oral supplements and fortified dairy products can assist in meeting
nutritional needs (6,9). However, some patients have a heightened sensitivity to
sweet foods and do not tolerate such foods well. Unfortunately, oral supplements are
often considered sweet to the taste, and may not be tolerated by cancer patients.
Incorporating the supplements into recipes, like soups, may circumvent this problem
and is a way to increase the caloric content of the food product (6).

22
Because cachexia is associated with an increased risk of mortality and it is
difficult, if at all possible, to correct once present, it is of the upmost importance to
prevent cachexia (34,37-39).
Nutrition Support
If a patient undergoing cancer treatment cannot achieve adequate nutrition to
prevent weight loss by an oral diet alone, nutrition support can be used to help
prevent weight loss and improve treatment outcomes. Antoun and Baracos (41) have
suggested that enteral nutrition be initiated if oral intake has decreased by the third
week of cancer treatment (41). As mentioned previously, enteral nutrition is superior
to parental nutrition and should be trialed before initiation of parenteral nutrition (10).
As such, enteral nutrition has been shown to improve patient outcomes. For example,
early initiation of enteral nutrition for those with head and neck cancer has been
shown to reduce morbidity (42). Prophylactic placement of a percutaneous
endoscopic gastrostomy (PEG) tube is recommended; however, the push method
should be used instead of the pull method (43). The pull method requires the use of an
endoscope, which often leads to malignant cells being relocated to the PEG site. The
pull method is not without benefits; however, it has been proven to have a lower rate
of complications, such as tube clogging, tube leaks and cellulitis. Major
complications of the pull method include necrosis, abscess and PEG site metastasis
(43-44).
The push method does not require an endoscope; rather, an incision is made
through the abdominal wall and into the stomach. A guide wire is placed into the

23
stomach and the tract is dilated. The feeding tube is placed through the incision and
into the stomach. The tube is held in place by a saline or water inflated balloon. The
site of malignancy can be bypassed, which decreases the risk of cancer seeding (43).
Historically, patients were not fed following a GI surgery. Often, oral diets
were not resumed until five to seven days postoperative. Braga et al. (15) conducted a
nine-year study on early enteral nutrition. Of the 650 patients fed enteral nutrition
postoperative, only 58 needed to be switched from enteral to parenteral nutrition as
the majority of the patients favored well on enteral nutrition in part due to the early
initation of the enteral feeding. Early enteral nutrition in the postoperative period for
upper GI surgeries has been shown to decrease length of stay and healing time
(10,15).
There has also been evidence to suggest that modulars, nutrients sometimes
added to enteral formulas, may have a beneficial effect. One study showed that
supplementation with -hydroxy- methylbutyrate, arginine and glutamine,
promoted weight gain and an increase in fat free mass (22). Such findings are
promising as patient outcomes and overall mortality are improved when nutrition
status and body weight are optimal.
Cancer treatment is complex and can affect nutrition status in many different
ways. Early nutrition intervention not only improves treatment outcomes but can also
enhance quality of life. Prevention of cancer cachexia may decrease the number of
deaths from cancer (33-34). Identification of those at risk for developing malnutrition
will allow for improvements in cancer treatment and its outcomes (3-4,38-39).

24
Nutrition Screening
Nutrition screening of cancer patients can help identify those at risk for
cachexia and malnutrition. Multiple screening tools have been used to identify those
at risk for such complications (47-49). Screening parameters can include, but are not
limited to, weight changes, dietary habits, type of cancer, location and stage of
cancer, activities of daily living and side effects related to cancer treatment (46-47).
Optional nutrition is necessary to prevent malnutrition in cancer patients. For
example, nutrition intervention has proven beneficial for patients receiving radiation
therapy for gastrointestinal and head and neck cancers (45). The amount of weight
lost during treatment is strongly correlated with deterioration of nutrition status.
Consequently, it has been recommended that close supervision of patients at risk for
malnutrition should be routine practice. If inadequate staffing is a barrier, a referral
system for high-risk patients should be implemented (45-46). Nutrition screening of
cancer patients has been proven to be an effective way to identify high-risk patients.
The Subjective Global Assessment (SGA) (see Appendix) is one of the
screening tools available. Previous studies have validated its use in the cancer
population (47-48). The SGA addresses weight history, presence of symptoms, food
intake, and functional capacity. Patients are assigned as well nourished (SGA-A),
moderately nourished or suspected malnourished (SGA-B), or severely malnourished
(SGA-C) (48). Improved cancer survival rates have been found in those classified as
SGA-A versus SGA-C (48-49). Patients classified in the SGA-B and SGA-C
categories are not that uncommon. For example, in a study conducted by Gupta et al.

25
(49), 50% of patients were classified as SGA-A, 26.5% were classified as SGA-B and
23.5% were classified as SGA-C. These findings indicate moderate to severe
malnutrition could be present in up half of all cancer patients (49).
Gupta et al. (49) also found that the SGA score correlated to the survival rate
of ovarian cancer patients. The SGA-A, or well nourished group, had a mean survival
of 43.5 months compared to the SGA-B group that had a mean survival rate of 18.9
months and SGA-C group that had a mean survival rate of 6.7 months. The lower
survival rate among the SGA-B and SGA-C groups could in part be attributed to
malnutrition. Thus, the SGA is effective at identifying the nutrition status of some
cancer patients and therefore, can be used as a routine screening tool in order to
identify those at risk for malnutrition, which often have poor patient outcomes (49).

26
CHAPTER II
STUDY METHODS, DESIGN, AND RESULTS
Introduction
Cancer is diagnosed in 1.2 million Indian annually and is the third
leading cause of death in India, second only to cardiovascular disease.
Cancer causes one in four deaths nationwide. Even though deaths attributed to
cardiovascular disease have decreased over the last 50 years, deaths from cancer have
remained constant. Lung cancer has the highest mortality rate among all cancers in
men and women. In men, the second leading cause of cancer death is prostate
followed by colon. In women, the second leading cause of cancer death is breast
followed by colon (1,2).
Cancer is defined as uncontrolled cellular proliferation. There are external and
internal factors that can lead to cancer. External factors include: environmental
exposures, tobacco use and radiation. Internal factors include: hormones,
immunosuppression, genetics, and mutations of metabolism (2). If the cancer is
detected early, prognosis is generally good and the need for cancer treatment is
minimized. However, cancer is often detected at more advanced stages where cancer
treatment may be needed to help induce remission. The five-year survival rate of
patients with all types of cancer, irrespective of the treatment modality, is 65% (3).
Treatment options for patients with cancer include surgery, radiation, chemotherapy,
and immunotherapy. These therapies can be used alone or in combination. Treatment
options depend on the location, size, stage and type of cancer. All cancer treatment

27
options carry nutrition risk and may lead to malnutrition and poor patient outcomes
over time. To complicate matters, malnutrition can then lead to decreased treatment
effectiveness. For example, inadequate nutrient intake during treatment can cause
chemotherapy and radiation to be less effective (4-7). Thus, it is critical to identify
cancer patients at risk for malnutrition in order to improve patient outcomes.
Prevention of malnutrition is easier than treating cancer cachexia. The objectives of
this study were to assess the current nutrition referral system for cancer patients at
Tata Medical Centre and Cancer Research, identify cancer patients at risk for malnutrition using
the subjective global assessment (SGA) and discuss ways to improve outcomes
related to malnutrition.
Current Practices Tata Medical Centre & Cancer Research
Currently, patients at Tata Medical Centre and Cancer Research in Kolkata, India are not
screened using a validated screening tool. In the outpatient setting, a registered
dietitian upon physician referral provides nutrition assessment and interventions.
Physician referral is variable depending on the physician and there is no set criteria
used to determine which patient is at risk of malnutrition.Furthermore, the referral
often occurs after the patient has already experienced a significant decline in nutrition
status and may be too late to prevent malnutrition and/or cachexia from occurring. In
addition, it is likely that some patients who are at risk for malnutrition may never be
referred to a registered dietitian. In such cases, it is reasonable to assume that their
nutrition status will continue to be poor or perhaps worsen, leading to poor patient
outcomes. In some cases, malnourished patients are admitted for nutrition treatment

28
in the inpatient setting but at this point, their overall decline in nutrition status is too
great to correct and/or overcome and the end result is often death.
Patients admitted to Tata Medical Centre and Cancer Research are screened based on
percent body weight, diagnosis, serum albumin and the diet order within the first 24
hours of admission. Patients are assigned as a level one, two or three. These levels
correlate to the likelihood of the patient being malnourished, at risk for malnutrition
or nutritionally compromised. The registered dietitian will assess a level three patient
within 48 hours, a level two patient within 72 hours and a level one patient within 5
days of admit. Cancer patients are automatically screened as a level two meaning that
they would be assessed by a registered dietitian within 72 hours of admission.
Unfortunately, many patients are not hospitalized for 72 hours, and as such, they
would not be assessed by the dietitian and receive appropriate nutritional intervention.
Thus, it is likely that in some cases, unintentional weight loss and malnutrition will
remain undetected.
Because of the average length of stay in the inpatient setting and the
likelihood that the registered dietitian was not able to treat the cancer patient as a
result, nutrition intervention must take place in the outpatient setting before
malnutrition is present. Because of the current referral system in the outpatient setting
at Tata Medical Centre and Cancer Research, a screening tool must be used to identify those at
risk
for malnutrition.
Subjective Global Assessment and Monitoring

29
The SGA is an appropriate screening tool used to identify malnutrition and
would help increase the overall number of nutrition assessments and interventions
given to cancer patients (48-49). Furthermore, patients that are deemed malnourished
receive more frequent follow-up from a registered dietitian because of the high
mortality rate associated with cancer cachexia (50). Follow-up guidelines for those
cancer patients classified as malnourished are as follows: patients in the inpatient
setting are monitored daily to every other day, and patients in the outpatient setting
are considered more nutritionally stable and can be monitored twice weekly. Both inand outpatient assessments include collecting anthropometric, biochemical and
clinical data such as: body weights, laboratory testing, signs of dehydrations, and
presence of gastrointestinal symptoms. Nutrition intervention is aimed at reducing or
eliminating such symptoms in an attempt to prevent the occurrence of malnutrition.
Education about what nutrition changes can be made to help alleviate side effects of
cancer should be given (see Appendix). For example, a patient that has a decreased
appetite is encouraged to consume small meals throughout the day and increase
his/her protein intake. Verbal and written nutrition information is given to the patient
along with the contact information of the dietitian should questions arise (48-50).
Regardless of the nutrition interventions and protocol currently practiced at
McKay-Dee Hospital Center, it is possible that cancer patients at risk for malnutrition
are not currently being identified and are consequently not receiving proper nutrition
intervention. Thus, this study was designed to determine the prevalence of malnutrition
in this population and discus how to improve nutritional services in the future

30

Methods
This study took place at Tata Medical Centre and Cancer Research, Kolkata, India, in
collaboration with University of Calcutta, India. Patients (n=56) receiving treatment
for cancer at the Apollo Cancer Hospital and Ruby Cancer Hospital, Kolkata and
Oncology Clinics were screened using the Subjective Global Assessment (SGA) to
identify risk for malnutrition. The lead Medical Oncology Dietitian on staff at
Tata Medical Centre and Cancer Research, conducted all SGAs at the cancer clinics.
For the purposes and scope of this study, the SGA was performed as cancer
treatment was first initiated (initial screening) only. Previous studies have validated
the SGA as a screening tool (48-49). The population studied was thought to have
received no nutrition interventions in regards to cancer in the past. Data was collected
based on the SGA and no patient identification data was collected. All patients were
categorized as SGA-A, SGA-B, or SGA-C based on the degree of malnutrition. Prior
to initiation of this study, Institution Review Board approval was obtained.
Although, actual nutrition intervention was beyond the scope of this study,
patients (n=15) identified at high or moderate risk for malnutrition received follow-up
consultations weekly to twice weekly, in an attempt to improve patient outcomes.
Further research could include completing an SGA during the course of treatment to
quantify the rate of malnutrition during treatment. The focus of this study was to
identify those at risk for developing malnutrition before cancer treatment.

31
Each follow-up assessment addressed all nutrition indices: anthropometrics,
biochemical, clinical and dietary factors. For example, laboratory testing was
analyzed, weight and dietary changes were assessed, swallowing problems were
addressed, and mouth sores and gastrointestinal symptoms were monitored. Verbal
education was given along with written information on ways to minimize side effects
associated with cancer therapy through dietary modification. Patients considered
malnourished were also educated on medical nutrition therapy during cancer
treatment based on Tata Medical Centre and Cancer Research protocol. Such patients were
also
assessed for appropriateness and feasibility of nutrition support as a way to improve
nutritional status.

Results
Fifty-six patients recently diagnosed with cancer were assessed using the SGA
to determine the degree of mal-nourishment. The majority of the patients had breast
cancer (n=24). Other types of cancer represented were as follows: prostate (n=13),
lymphoma (n=3), rectal/sigmoid (n=3), stomach (n=3), esophageal (n=2), ovarian
(n=2), brain (n=), liver (n=1), pancreatic (n=1), sarcoma (n=1), skin (n=1), and
uterine/cervical (n=1).
The majority of patients with breast cancer (83%) and prostate cancer (85%)
were categorized as SGA-A (Figure 1). The majority of patients with esophageal
cancer (100%), lymphoma (67%), and stomach cancer (100%) were categorized as
SGA-C. All patients (n=3) with rectal/sigmoid cancer were categorized as SGA-B.

32

Figure 1. SGA scores according to cancer

Ninety-eight percent of cancer patients who reported that their dietary habits
had not changed since the onset of symptoms also reported no weight loss or mild
weight loss (0%<5% of body weight) (Figure 2). Sixty percent of cancer patients who
reported a change in their dietary habits also experienced significant weight loss
(>10% of body weight) since onset of symptoms.

33

Figure 2. Comparison of weight change to dietary habits


Eighty-three percent of cancer patients who reported no functional
impairments reported that their dietary habits had not changed since onset of
symptoms (Figure 3).

34

Figure 3. Comparison of change in diet to functional impairment


Eighty-nine percent of cancer patients who reported moderate to severe
functional impairment also reported significant weight loss (<10% of body weight).
Functional impairment was defined as decreased ability to perform activities of daily

35
living, including meal preparation and mobility (Figure 4).

Figure 4. Functional impairment compared to weight loss


Ninety-five percent of cancer patients categorized as SGA-A reported no
weight loss or minimal weight loss (0<5 lbs) (Figure 5). All patients with greater than
20 pound weight loss were (n=5) categorized as SGA-C.

36

Figure 5: Comparison of malnutrition and weight loss


Eighty percent of breast cancer patients and 92% of prostate cancer patients
reported no weight or minimal weight loss (0<5 lbs) since onset of symptoms (Figure
5). All cancer patients with esophageal cancer (n=1), liver (n=1), lymphoma (n=3),
pancreatic (n=1), stomach (n=3), and uterine/cervical (n=1) had lost at least 15 lbs
since onset of symptoms.

37

Figure 6: Weight loss among cancer types


Limitations
There was no control group in this study; therefore, improvement comparisons
could not be made. Patient data was not tracked over time to view comparisons in
nutrition status before and after cancer therapy. Likewise, no comparison could be
made in nutrition status before and after nutrition intervention.

Discussion
Nutrition plays a vital role in cancer treatment and the risk of malnutrition is
high among some cancer populations. As anticipated, breast and prostate cancer had
the smallest degree of weight loss before treatment whereas cancers of the GI tract
had the highest degree of weight loss. The results of this study were similar to that of
Gupta et al. (49).

38
The cancer types that correlated with SGA-C classification were stomach,
pancreatic, esophageal, and liver. These findings were not entirely unexpected as the
aforementioned cancers are often diagnosed at advanced stages where malnutrition is
more common. Nutrition consultations should be ordered upon diagnosis for patients
with these cancer types as they are at high nutrition risk and are in need of close
monitoring by a registered dietitian to prevent the onset of malnutrition and cachexia
(9-10,37-38,41).
The patients that had the greatest changes in dietary habits also exhibited the
greatest amount of weight loss. Of concern is that the dietary changes were made
prior to initiation of treatment. Thus, it is possible that such patients could experience
additional weight loss due to decreased nutrient intake often observed during and
after cancer treatment (37-39). In other words, weight loss before cancer treatment
can lead to continual weight loss during treatment if appropriate nutrition
interventions are not implemented.
Functional impairment is defined as decreased ability to perform activities of
daily living. Functional impairment may prevent adequate nutrition for a myriad of
reasons including the inability to cook or purchase foods. Fatigue can also cause a
decrease in appetite (6,9). In this study, cancer patients with no functional impairment
were less likely to change their dietary habits and experienced less weight loss than
those with functional impairment. These findings could be in part due to age. As one
ages, functional ability decreases, which can lead to inadequate oral intake and weight
loss. Unfortunately, age was not accounted for in this study but likely contributed to

39
overall functionality. Other factors that could play a role are social situations, where
lack of social support is available, and lack of physical activity. Regardless of the
cause, those with less functional ability had lost more weight prior to cancer
treatment. Of concern is fatigue since it is often associated with decreased
functionality during cancer treatment and could lead to further weight loss (6,9,16).
All of the patients that were classified as SGA-C had experienced significant
weight loss. Specifically, 9% of patients had greater than a 20-pound weight loss
before initiation of cancer treatment. This is of concern since these patients are at
higher risk for developing malnutrition and experiencing further weight loss after
treatment. As previously mentioned, nutrition support may be needed to halt weight
loss. However, if treatment is palliative in nature, nutrition support is contraindicated.
To date, there have not been any studies that have found benefit in improving
outcomes with terminal patients (10).
Breast cancer and prostate cancer patients experienced less weight loss when
compared to all other patients in this study. Not surprisingly, the cancer types that
were associated with higher amounts of weight loss are those of the GI tract,
including stomach, esophageal, liver, and pancreatic. It should be noted that patients
with colon cancer may experience large or small amounts of weight loss depending
on the status of the patient, which was found to be true in this study also. As
previously mentioned, cancers affecting the GI tract not only increase nutritional
needs but also decrease nutrient absorption (6,9-10).

40
Moderate nutrition risk cancers include ovarian, brain, ovarian and
rectal/sigmoid. The likelihood of malnutrition developing in patients with these
cancer types during treatment is considerable. For example, treatment with radiation
can lead to malabsorption, maldigestion, nausea and vomiting. As previously
mentioned, inadequate intake and malabsorption can lead to malnutrition (6,10).
The prevalence of cancer continues to increase and the need for nutrition
intervention will continue to be essential to the successful treatment of the patient.
Proper screening of malnutrition is critical to improve patient outcomes and quality of
life. Currently, McKay-Dee Hospital Center does not have a screening process in
place to detect malnutrition in cancer patients; however, the SGA would be an
appropriate screening tool to use in this population due to its effectiveness and
relative ease in administration. Early identification of cancer patients at high risk for
malnutrition would allow for timely intervention and prevention of malnutrition. The
findings of this study validate the need for appropriate nutritional intervention in the
cancer population and support other studies that some cancer types have a higher risk
of malnutrition, and that weight loss is associated with poor outcomes, such as
functional impairment, that adversely affect oral intake increasing the risk or degree
of malnutrition (1-2,6,49).

CHAPTER III
CONCLUSIONS AND IMPLICATION
Screening tools for malnutrition are not one hundred percent accurate but can
help identify those at risk for developing malnutrition (49). Although additional
studies could be conducted to validate these screening tools even further, it would be
more beneficial to follow cancer patients who were initially assessed using a
screening tool, like the SGA, throughout their cancer treatments to determine the
incidence of malnutrition. In addition, because the SGA is generally conducted before
initiation of cancer treatment only, it is not useful in identifying those who develop
malnutrition due to the side effects of cancer treatment who were considered
nourished at the time the SGA was conducted (48-49). Thus, due to the deleterious
effects of cancer treatment, it seems likely that the number of malnourished patients
will increase during and after treatment. Therefore, it would be beneficial to conduct
the SGA periodically throughout the course of cancer treatment in an attempt to
identify at risk patients and intervene as appropriate to determine if the rate of
morbidity and mortality associated with malnutrition can be reduced (49).
Additional areas of research include the efficacy of nutrition counseling for
cancer patients in regards to malnutrition. Based on the results obtained, one could
adjust his/her counseling techniques to yield better outcomes. For example, nutrition
support is often disregarded as a viable treatment option for cancer patients (51).
From personal experience, some physicians believe that a feeding tube is a nuisance
to the alert patient and would not permit patients to be discharged using a NG or NJ
tube. Yet with some cancers, such as head and neck cancer, prophylactic placement of

41

42
feeding tubes could be beneficial and improve patient outcomes (27-30). One could
argue that prophylactic placement of feeding tubes could reduce the incidence of
malnutrition in some cancer populations. Gastric and pancreatic cancer patients
usually have a difficult time consuming adequate calories and weight loss is common
postoperatively. Jejunostomy tubes could be placed during surgery and be used until
adequate intake has been demonstrated. However, prophylactic placement of feeding
tubes in not routinely done. As this example indicates, specific nutritional
interventions should be researched to determine if they are of benefit in preventing
malnutrition. A practical method to determine the risk of malnutrition in these
instances would be to utilize the SGA as a screening tool for malnutrition. The SGA
could be considered best practice for nutrition screening among cancer patients in the
outpatient setting (15,48-49).
Clinical Practice Recommendations
In response to the findings of this research, it is recommended that all cancer
patients who are considering undergoing cancer treatment be introduced to a
registered dietitian and educated about the nutrition services available to them in their
treatment facility. All patients should have a SGA conducted at the initiation of
cancer treatment to determine malnutrition risk. At that point, nutritional care should
be tailored to the individual based on the results of the SGA. For example, all patients
with head and neck cancer should be evaluated for a feeding tube placement as an
option to help circumvent malnutrition in this high-risk subpopulation (42,45).

43
Patients do not always know about the nutrition services available to them. A
good example is the report of a patient that was admitted to Tata Medical Centre
who was undergoing treatment chemotherapy for breast cancer and had
experienced severe vomiting resulting in a 20-pound weight loss. This was of great
nutritional concern due to the poor outcomes associated with malnutrition (3-6). Over
time, her nutrition status had improved and her weight was more stable. Once her
condition began to improve, she wanted to know why she had not been informed of
the nutritional services available to her. Unfortunately, her case is not uncommon, as
nutrition services are often overlooked in importance. Thus, further research is
warranted to validate nutrition services as an integral component of cancer treatment
and as an essential factor in preventing malnutrition and improving patient outcomes.
Such results can be found by conducting the SGA throughout a patients cancer
treatment and by tailoring nutrition intervention according to the patients nutritional
status at any given time. Further research could include monitoring the frequency of
hospital admissions for malnutrition and then compare with historical data.
In general, because of the small amount of time allotted for an inpatient
dietitian to spend assessing and counseling cancer patients and the higher acuity level
and demands of many of the patients in the inpatient setting that the dietitian is also
responsible for in a given day, patients should be screened using the SGA by the
nursing staff. Additionally, the nursing staff is responsible for the initial paper work
of cancer patients starting treatment and therefore would be in contact with the patient
as treatment begins. Furthermore, nursing has more initial direct patient contact

44
compared to the dietitian. The nursing staff could then present the results of the SGA
to the outpatient dietitian. That way, the cancer patient would receive more
counseling and follow-up than an inpatient dietitian could provide, which would also
allow compensation for services. For example, at Tata Medical & Cancer Research,
nutrition services are currently offered as free to all cancer patients.
If the outpatient office submitted a bill to the insurance company and the
claim was denied, and if the patient could not pay for the services rendered, a charity
care application would be filled out that would allow the hospital to write off those
services. As a result, all cancer patients have access to nutrition services, which
should help reduce the risk of malnutrition in many cases.
Conclusions
Cancer will continue to affect the population. Nutrition interventions can
improve overall treatment outcomes and can enhance quality of life. Early
intervention is the key to preventing malnutrition. The goal of nutrition intervention it
to prevent malnutrition before hospital admission becomes necessary. The SGA is a
tool that can help identify those at risk for developing malnutrition and should be
used to identify those patients that would benefit from nutrition intervention (48-49).

45

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APPENDICES
APPENDIX A

Subjective Global Assessment


Scoring Sheet
Medical History
1. Weight Change
a. Overall Change in past 6 months: _______
b. Percent Change:
Gain or less than
5%
5-10% loss
More than 10% loss
c. Change in past 2 weeks:
_______
Increase
No
change
Decrease
2. Dietary Intake
a. Overall Change
No
Change
Change
b. Duration: _________
c. Type of Change
Suboptimal solid
diet Full liquid diet
Hypocaloric
diet Starvation
3. Gastrointestinal Symptoms (for greater than 2
weeks)
a. None
b. Nausea
c. Vomiting
d. Diarrhea
e. Anorexia

4. Functional Impairment
a. Overall
impairment
None

APPENDIX B

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