Q3. How should patients be screened and referred to the dietitian?

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Q3. How should patients be screened and referred to the dietitian?

Summary

The Evidence Based Practice Guidelines for Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care state that validated tools appropriate for your patient population should be used for screening [1]. The Malnutrition Screening Tool (MST) has been validated for use in the cancer population and is recommended in the Evidence Based Practice Guidelines for Nutritional Management of Patients Receiving Radiation Therapy [2] and the Evidence Based Practice Guidelines for the Nutritional Management of Cancer Cachexia [3]. The tool consists of two questions relating to weight history and appetite, and is quick and simple to use. It can be administered by clinical staff such as nursing, radiation therapists, or cancer care coordinators, or by non-clinical staff such as administration support officers. It is a more efficient use of resources to provide training to other staff on screening so that dietetic resources can be targeted to the assessment and implementation of a nutrition care plan of those patients identified at risk [1].

There is limited good quality evidence for screening tools specifically for patients with head and neck cancer. Two level II studies, one positive quality [4] and one negative quality [5], identified predictive factors for malnutrition during radiotherapy which could be used to assist with screening and referral criteria. A level III-2, neutral quality paper [6] describes a validated tool to assess and screen for symptoms to target management interventions.

An older study [7] (level IV neutral quality) also described a tool to assess for symptoms to determine nutritional risk, which is similar to the nutrition assessment tool – the scored Patient-Generated Subjective Global Assessment (PG-SGA) [8]. One level IV, positive quality study [9] identified several biochemical factors which could be associated with identifying malnourished patients at baseline. Four other level IV studies of lower quality (neutral or negative quality) also identify factors which could be used to predict malnutrition at baseline [10][11][12][13]. There is some evidence of predictive validity of single parameters such as C-reactive protein, prealbumin, haemoglobin and selenium in identifying malnutrition in patients with head and neck cancer, however, screening tools with at least two parameters are recommended as they have higher sensitivity and specificity of predicting nutritional status [14].

There are currently no validated tools to assist in the identification of patients who are predicted to have future high nutritional risk. Evidenced based suggestions for patient groups to consider are discussed in Q15 and Q25.

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Recommendation Grade
Use a validated nutrition screening tool (e.g. Malnutrition Screening Tool) for identifying malnutrition risk in cancer patients.
B

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References

  1. 1.0 1.1 Watterson C, Fraser A, Banks M, Isenring E, Miller M, Silvester C, et al. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutrition & Dietetics 2009 Dec;66(Suppl 3):1-34. Abstract available at http://www.clinicalguidelines.gov.au/search.php?pageType=2&fldglrID=1617&.
  2. Isenring E. Evidence based practice guidelines for the nutritional management of patients receiving radiation therapy. Nutrition & Dietetics 2008;65:1-20. Abstract available at http://www.clinicalguidelines.gov.au/search.php?pageType=2&fldglrID=1256&.
  3. Bauer JD, Ash S, Davidson WL, et al. Evidence based practice guidelines for the nutritional management of cancer cachexia. Nutrition & Dietetics 2006;63:3-32. Abstract available at http://onlinelibrary.wiley.com/doi/10.1111/j.1747-0080.2006.00099.x/abstract.
  4. Britton B, Clover K, Bateman L, Odelli C, Wenham K, Zeman A, et al. Baseline depression predicts malnutrition in head and neck cancer patients undergoing radiotherapy. Support Care Cancer 2012 Feb;20(2):335-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21234608.
  5. Qiu C, Yang N, Tian G, Liu H. Weight loss during radiotherapy for nasopharyngeal carcinoma: a prospective study from northern China. Nutr Cancer 2011;63(6):873-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21714687.
  6. Murphy BA, Dietrich MS, Wells N, Dwyer K, Ridner SH, Silver HJ, et al. Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: a tool to assess symptom burden in patients treated with chemoradiation. Head Neck 2010 Jan;32(1):26-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19626644.
  7. Macqueen CE, Frost G.. Visual analog scales: a screening tool for assessing nutritional need in head and neck radiotherapy patients. J Hum Nutr Diet 1998;11:115-24. Abstract available at http://onlinelibrary.wiley.com/doi/10.1046/j.1365-277X.1998.00088.x/abstract.
  8. Ottery FD. Patient generated-subjective global assessment. In: McCallum PD, Polisena CG, editors. The clinical guide to oncology nutrition. Chicago: The American Dietetic Association 2000;11-23.
  9. Capuano G, Gentile PC, Bianciardi F, Tosti M, Palladino A, Di Palma M. Prevalence and influence of malnutrition on quality of life and performance status in patients with locally advanced head and neck cancer before treatment. Support Care Cancer 2010 Apr;18(4):433-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19562384.
  10. Munshi A, Pandey MB, Durga T, Pandey KC, Bahadur S, Mohanti BK. Weight loss during radiotherapy for head and neck malignancies: what factors impact it? Nutr Cancer 2003;47(2):136-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15087265.
  11. Sanz Ortiz J, Moreno Nogueira JA, García de Lorenzo y Mateos A. Protein energy malnutrition (PEM) in cancer patients. Clin Transl Oncol 2008 Sep;10(9):579-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18796375.
  12. Bertrand PC, Piquet MA, Bordier I, Monnier P, Roulet M. Preoperative nutritional support at home in head and neck cancer patients: from nutritional benefits to the prevention of the alcohol withdrawal syndrome. Curr Opin Clin Nutr Metab Care 2002 Jul;5(4):435-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12107380.
  13. Yadav SP, Gera A, Singh I, Chanda R. Serum selenium levels in patients with head and neck cancer. J Otolaryngol 2002 Aug;31(4):216-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12240756.
  14. Gibson RS. Principles of Nutritional Assessment. 2nd Edition. New York: Oxford University Press 2005 Abstract available at http://www.oup.com/us/catalog/he/subject/Nutrition/?view=usa&ci=9780195058383.

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