September 2016, Vol. 5, No. 7

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Audit of Patients with Head and Neck Cancer Reveals Gaps in Nutritional Care

MASCC/ISOO

Patients with head and neck cancer (HNC) are at a high risk of malnutrition, but the implementation of a best practice model for nutritional support can improve health outcomes and address the many unmet needs in nutritional management, according to Merran Findlay, MSc, AdvAPD, Senior Oncology Dietitian at the Royal Prince Alfred Hospital in Sydney, Australia.

An audit of patients at her center revealed that almost half of unplanned hospital admissions were related to nutritional issues, and patients rarely saw a dietitian.

Evidence-based practice guidelines for the nutritional management of adult patients with HNC were published in 2011, “but we still have significant evidence practice gaps, and it’s still important to explore what the barriers and enablers are locally,” she said at the 2016 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology Annual Meeting on Supportive Care in Cancer.

She and her team of oncologists and investigators with translational research expertise sought to evaluate the nutrition care process—appropriate access to care, quality nutrition care, and nutrition monitoring and evaluation—in use for HNC patients undergoing radiation of curative intent with or without another treatment modality. They used a series of research questions to gauge barriers and enablers to nutritional care among patients and clinicians in order to implement an innovative best-practice dietetic model of care and also to minimize the detrimental sequelae of malnutrition among patients with HNC.

Nutritional Support and Admissions

The researchers audited 98 patients (75 male, 23 female) from 2013 to 2014 with a mean age of 61 years. The majority of patients underwent treatment with 2 or more modalities, and most were well nourished at baseline. In terms of nutritional support, close to 70% of patients required some form of tube feeding through their treatment. The unplanned admission rate overall was 45%, but of those admissions, 45% were for nutrition-related morbidity. The increased length of stay for nutrition-related morbidity was 28 median days versus 3 days for morbidity unrelated to nutrition, which also increased the intensity of dietetic resources (15 occasions of service in the inpatient setting vs 9 in the outpatient setting), she reported.

Patients were seen by a dietitian prior to treatment 20% of the time, “but that’s really only because they were in such a poor state that they were admitted to the hospital, and that’s when they were seen,” she added. “It wasn’t a dedicated outpatient service.”

During treatment, patients were seen weekly 55% of the time, but only about 12% of patients received reviews 2 weeks posttreatment. Nutritional status was recorded and evaluated with a validated tool 86% of the time at initial assessment, but this number dropped during posttreatment. “There is definitely room for improvement,” she said.

Qualitative Interviews

To assess barriers and enablers to nutritional care, the investigators conducted qualitative interviews with 19 participants from the study population. The interviews revealed that patients and caregivers would like to meet with their dietitian sooner, and, on the team level, the biggest unmet need was integrated and coordinated care. “They wanted a 1-stop shop, where everyone who needs to see a patient is in the same location at the same time,” Ms Findlay reported. “I found it absolutely fascinating that this was the number 1 wish.”

The researchers also identified a communication breakdown between nonmedical clinicians and physicians. “While the nonmedical clinicians in the room felt that nutrition care was important, the consensus was that the doctors may not think so, so [the nonmedical clinicians] didn’t want to speak up,” she said. “I found that particularly interesting, because if you speak to oncologists and surgeons, they’d actually welcome more information on nutrition that would facilitate decision-making in the multidisciplinary team.”

On the system level, the investigators identified issues around a proactive versus a reactive approach to nutrition care, and the general desire for a better system-level process that triages patients and identifies problems earlier.

Successful Implementation

Ms Findlay noted that implementation is undoubtedly a science, and effective implementation strategies are evidence based. Though it can be tempting to want to fix everything, she recommends focusing on a few starting points.

Based on the results of the study, she said the first implementation strategies likely to be employed at her institution include establishing a pretreatment clinic for early nutrition assessment and intervention, developing a nutrition care dashboard for integration into weekly multidisciplinary team discussions, and the development of a nutrition care kit for patients and caregivers.

She also stressed the importance of evaluating implementation outcomes. “If you have a failed implementation, you want to know if it’s because the implementation strategies weren’t appropriate, or because they just weren’t delivered as you planned,” Ms Findlay said. “But I think the obvious answer is to pick an implementation plan that makes sense to you and to the context in which you’re working.”

Reference

Findlay M. Implementing a best practice model of care for nutritional management of head and neck cancer: translating evidence into practice. Presented at: MASCC/ISOO Annual Meeting on Supportive Care in Cancer; June 23-25, 2016; Adelaide, Australia.
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