Nutrition Care for Oncology PatientsProf Liz Isenring

CRICOS CODE 00017B

2.966

2.48

2.71

1.12

1.33

1.05

1.8 1.81.7

0

0.5

1

1.5

2

2.5

3

3.5

Malnourished Consumed ≤ 50% food Readmissions

1.8 1.71.8

Agarwal Clin Nutr 2012; 31: 41-7 Acknowledgment: AuSPEN

Oncology patients at increased nutritional risk

ODDS

RATIO

CREDIBILITY

Evidence-based GuidelinesEnteral Nutrition/Parenteral

2006, 17

2009

ESPEN

ASPEN

1. Clinical Nutrition 25 (224-244)

2. Clinical Nutrition 25 (245-259)

JPEN 33 (472-500)

1. Surgery, Organ Transplantation.

2. Non-Surgical Oncology.

Adult Anticancer Treatment

Cancer Cachexia

2006 DAA Nutrition and Dietetics 63

(Suppl.2): S3-32 or www.daa.asn.au

Nutritional management of cancer cachexia.

Radiotherapy/ Chemotherapy

2008

2013

DAA

DAA

Nutrition and Dietetics 65 (Suppl.1):

S1-S20 or www.daa.asn.au

Nutrition and Dietetics- early view

Nutritional management of patients receiving

radiation therapy.

Update of radiation therapy guidelines,

including chemotherapy

Head and Neck Cancer

2011 COSA http://wiki.cancer.org.au/australia/COSA:Head_and_neck_cancer_nutrition_guidelines

Head and Neck Cancer

Broad Oncology Groups

AND &

PEN

http://www.adaevidencelibrary.com/t

opic.cfm?cat=1058

Specific questions

Oncology patient models of care

• Dependent on tumour type

• Treatment regimen

• Health care services

• Financial / insurance considerations

Example of Australian Model of Care

• Screen-IT Laurelie Wall et al

• Patients with head and neck cancer and their carers

• Patient and carer complete data each visit and triage

of care is based on results

• Focuses on nutrition, swallowing & distress outcomes

• Team approach with dietetics, speech pathology,

oncology, psychology, counselling & nursing.

ScreenIT Triage Pathways (IMPLEMENTATION TRIAL PHASE)

Patient identified as

“High-risk”

Patient identified as

“Low-risk”

Patient identified as

“Medium-risk”

Scheduled SP/DN session is NOT

required that week

Scheduled SP/DN session

continues as planned

Clinicians to use ScreenIT

summary report to guide session

Scheduled SP/DN session is

NOT required that week

Scheduled SP/DN session continues

as planned in the following week

UNLESS

Patient/Carer identified as “Low-risk”

through ScreenIT summary report in

following week

Carer identified as

“High-risk”

Carer identified as

“Low-risk”

Carer identified as

“Medium-risk”

EfficacyReview of

mechanisms and clinical trials

In Silico Investigation of

mechanismsRCT

Safety Review of safety data

HPLC study

Feasibility Review of clinical trial protocols

RCT Survey

Bench to beside: Ginger studies

Impact on patient

Lachaine et al. Supportive Cancer Therapy.2005

Davidson et al. Oncology Nursing Forum. 2012Bloechl-Daum et al. J Clin Oncol. 2006

CINV

Highly distressing

Associated with

malnutrition and fatigue

Further complications

Quality of life

Economic burden

Prevalence

Total participants: 1714Number of studies: 8

Total nausea and vomiting

Acute

27%

Nausea

38%

Vomiting

16%

Delayed

39%

Nausea

51%

Vomiting

27.5%

Molassiotis et al. Support Care CancerBloechl-Daum et al. J Clin Oncol. 2006

• 5HT-3 Antagonists

• NK-1 Antagonists

• Metoclopramide

Standard therapy

Proposed Adjuvant Therapies

• Acupuncture

• Exercise

• Progressive muscle relaxation

Mind & body interventions

• Ginger

• Peppermint oil

Dietary supplements

• Gabapentin

• OlanzapineMedication

Hawkins et al. J Clin Nurs. 2009 Haniadka et al. Integr Cancer Ther

High level of clinical and public interest

Molassiotis. Support Care Cancer

Effective for other types of nausea and vomiting

2

3

5

Marx et al. Crit Rev Food Sci Nutr.2015Impact factor: 5.548

4

3. Anti-inflammatory• Contributor delayed

CINV• Ginger ↓

inflammation, NF-kB, COX-2

4. Anti-histaminergic• ↑ CINV severity and

risk• Ginger ↓ motion

sickness in humans• In vitro studies show

receptor antagonism

1

2

3

4

1. Reduction in cell damage• Key initiator in CINV• Ginger may protect

specific cells from injury2. Serotonin antagonism• Mechanism of

standard anti-emetics• Ginger may interact

with same receptors3. Substance P antagonism• Mechanism of new

class of anti-emetics• Ginger compounds

have demonstrated antagonism

1

1. Modulation of gastric emptying• Delayed by

chemotherapy agents• May reduce GI

distress

2. Modulation of vasopressin• May contribute to

CINV• Ginger ↓ plasma

levels

Study #1. Molecular Docking

TMD

ECD

Serotoni

n

binding

site

Propose

d

allosteri

c site

M2 TM

helices (pore

lining)

ICD

(C)

R21

9

F22

2

K54

P27

4

I139

Y14

0

(B

)

(A

)

Submitted to Bioorganic & Medicinal Chemistry Letters

Author Sample Size

Ginger type

Dose (g)

Chemotherapy regimen

Result

Panahi et al. (2012)

78 Powder

1.5 HEC ↓ Acute nausea

Pillai et al. (2011)

58 Powder

1 HEC ↓ Acute and delayed nausea and vomiting

Ryan et al. (2011)

576 Extract

0.5, 1, 1.5

Not specified ↓ Acute nausea

Fahimi et al. (2010)

36 Powder

1 HEC No effect

Zick et al. (2009)

129 Extract

1, 2 LEC, MEC,HEC

No effect

Manusirivithaya et al.(2004)

43 Powder

1 HEC Delayed CINV equal to metoclopramide

Sontakke et al. (2003)

50 Powder

2 MEC, HEC Acute CINV equal to

Marx et al. Nut Rev. 2013;71(4):245-54.

Limited additional measures reported Assess effect on nutrition status, quality of life, and chemotherapy-related fatigue

Inconsistent use of validated questionnaires and standardised extracts

•Use of validated tool that assess all relevant domains. •Use of standardised extracts

Lack of control for predisposing factors •Recruit chemotherapy-naive patients•Record individual risk factors and provide statistical analysis

Inadequate dosing regimen Consumed four times daily, every 4 hours

Inappropriate comparator drugs Include sites with new generation anti-emetics

Primary limitations & Novel additions

Study design

Method

Intervention

Population

Outcomes

Measures

Time frame

Inclusion criteria Exclusion criteria

• Chemotherap

y-naive

patients

receiving

chemotherapy

of moderate

or severe

emetogenicity

.

• >18 years old

• Life

expectancy >3

months

• Baseline

Karnofsky

score >60

• Patients requiring concurrent radiotherapy

• Pregnant or lactating

• Concurrent use of other ginger-containing

supplements and ingestion of large quantities

of ginger (consumption of >1 ginger product

more 4+ days in the past week)

• History of adverse reactions to ginger

• Patients with malignancies of gastrointestinal

tract/ gastrointestinal diseases or nausea and

vomiting due to reasons other than

chemotherapy

• Severe thrombocytopenia or likely to

experience severe thrombocytopenia (platelets

<50 x 10^9/L)

• Prescribed warfarin or on anti-coagulant

therapy

• Concurrent neoplasms or illness that induces

nausea independent of chemotherapy

• Self-prescribed nausea therapies or

complementary products

• Previously undergone chemotherapy

treatment.

The Functional Living Index –

Emesis – 5 Day Recall. (FLIE-5DR)

Nausea and vomiting- related

impact on QoL

Rhodes Inventory of Nausea,

Vomiting and Retching (INVR)

Nausea: frequency, distress,

and duration.

Vomiting: frequency, distress,

and volume

Retching: frequency, distress,

and duration

Edmonton Symptom Assessment

System (ESAS)

Severity of common symptoms

experienced by cancer patients

including pain, anxiety and

drowsiness.

Patient Generated - Subjective

Global Assessment (PG-SGA)

Nutritional status

Functional Assessment of Cancer

Therapy- General (FACT-G)

General QoL (physical,

social/family, emotional, and

functional well-being)

Functional Assessment of Chronic

Illness Therapy (FACIT) - Fatigue

Scale

Patient-reported fatigue

Adherence questionnaire Patient consumption of study

medications in accordance

with study protocol.

CINV susceptibility questionnaire Individual prognostic factors

for CINV (e.g. alcohol intake,

previous motion sickness)

Primary: CINV-related quality of life

Secondary: • The frequency and severity of acute and

delayed vomiting• The frequency and severity of acute and

delayed retching• The frequency, severity, duration of acute

and delayed nausea• Change in ratings of cancer-related fatigue• Change in nutrition status• Incidence and severity of symptoms

associated with treatment• Change in quality of life• Influence of previously identified factors

that affect the generation of CINV

• 1.2g (4x300mg) Standardised ginger extract (5% gingerol content)

• Consumed 4 times per day for 5 days, starting on the day of chemotherapy.

Double-blinded randomised placebo-controlled trial

Marx et al. BMC Complement Altern Med. 2014Impact factor=2.08

Followed for first three cycles of chemotherapyWithin each cycle• Questionnaires commence 3 days pre-chemotherapy• Supplements commenced on day of chemotherapy

Patient demographics Variable Total

Intervention Group

Control Group

n 52 25 27

Age (mean±sd, years) 58±12 57±14 59±11

Gender (n, %female)33

(63) 17 (68) 16 (59)

Race (n, %Caucasian)43

(82) 19 (76) 24 (88)

Primary diagnoses

Breast 13 7 6

Colon 15 6 9

Lymphoma 9 4 5

Other 15 7 8

Chemotherapy Emetogenicity

HEC 8.0 4.0 4.0

MEC 44.0 21.0 23.0

Receiving aprepitant 18.0 7.0 11.0

Nutrition status

SGA (n, % well nourished)40

(76) 22 (81) 18 (91)

PG-SGA (mean±sd) 5±3 4±3 5±4

CINV-risk factors

Alcohol consumption above guidelines (n, % yes) 4.0 2 (8) 3 (11)

History of motion sickness (n, % yes) 17.0 6 (24) 11 (40)

History of morning sickness (n, %

ResultsCycle 1 Cycle 2 Cycle 3

n41

3733

CINV-relatedQuality of life

p=0.043 0.916 0.931

CINV - - -

Global Qualityof life

p=0.001 p=0.075 0.040

Fatiguep=0.001 0.231 0.013

Adverseeffects

<0.05 <0.05 <0.05

Nutrition status

0.371 0.500 0.622

Cycle 1 Cycle 2 Cycle 3

Placebo

31.48±8.6 30.36±8.6 27.95±6.4

Ginger 28.3±8.6 29.2±8.6 28.93±7.9

?!

HPLC

12mg (Ryan et al. 2012)

Implications• Future studies need to

• Standardize their formulation

• Control for dietary ginger intake

Clinically,

• Food products could be used therapeutically

• May exert unwanted side-effects (e.gthrombocytopenia)

Evidence 27

Implementation 590

Where to from here?

Summary

• Patients with cancer and their carers have significant nutritional issues.

• Chronic condition; nutritional requirements change over continuum of care.

• Several sets of guidelines present best available evidence for nutritional

recommendations.

• There are examples of models of care from around the world; team approach.

• As treatment continues to evolve so to should the nutritional management of

these conditions for best patient and carer care.

Supportive Care Makes Excellent Cancer Care Possible

https://www.maggiebeerfoundation.org.au/