Q2. When should patients be screened and referred to the dietitian?

From Cancer Guidelines Wiki

Q2. When 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 recommends routine malnutrition screening in the acute care setting [1]. The Evidence Based Practice Guidelines for Nutritional Management of Patients Receiving Radiation Therapy and the Updated Evidence-Based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy and/or Chemotherapy recommend all patients receiving radiation therapy to the head and neck area should be referred to the dietitian for nutrition support [2]. Three level II positive quality studies [3][4][5] support all head and neck patients receiving radiotherapy are at high nutritional risk and should be referred to the dietitian. A level III-3 neutral quality study suggests all patients receiving chemoradiotherapy should be referred prior to commencement of treatment [6].

There is limited evidence on when screening should be undertaken at other points in the continuum of care. A high prevalence of malnutrition or unintentional weight loss at baseline has been reported prior to commencing treatment, with one level III-2 neutral quality study and one level IV neutral quality study both reporting rates of 57% [7][8], and a further level IV neutral quality study reporting rates of 18-25% [9]. Therefore, screening should take place at diagnosis, as well as at frequent intervals across the treatment continuum, to account for various stages of treatment taking place at different centres. A number of studies have highlighted certain clinical and treatment factors which may also elevate a patient’s risk of malnutrition during and post treatment. These groups of patients would also benefit from early referral and intervention, and this is explained in more detail in Q15 and Q25.

Back to top

Recommendation Grade
Malnutrition screening should be undertaken on all patients at diagnosis to identify those at nutritional risk and then repeated at intervals through each stage of treatment (e.g. surgery, radiotherapy/chemotherapy, and post treatment). If identified at high risk refer to the dietitian for early intervention.
B
All patients receiving radiation therapy to the head and neck area should be referred to the dietitian for nutrition support.
A
Patients who are not malnourished at baseline, but are identified as having future high nutritional risk, should be referred to the dietitian prior to the commencement of treatment for assessment and consideration of appropriate nutrition support.
C

Back to top

References

  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. Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. Br J Cancer 2004 Aug 2;91(3):447-52 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15226773.
  4. Ravasco P, Monteiro-Grillo I, Marques Vidal P, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy. Head Neck 2005 Aug;27(8):659-68 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15920748.
  5. Isenring EA, Bauer JD, Capra S. Nutrition support using the American Dietetic Association medical nutrition therapy protocol for radiation oncology patients improves dietary intake compared with standard practice. J Am Diet Assoc 2007 Mar;107(3):404-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17324657.
  6. Paccagnella A, Morello M, Da Mosto MC, Baruffi C, Marcon ML, Gava A, et al. Early nutritional intervention improves treatment tolerance and outcomes in head and neck cancer patients undergoing concurrent chemoradiotherapy. Support Care Cancer 2010 Jul;18(7):837-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19727846.
  7. Lees J. Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment at a regional oncology centre. Eur J Cancer Care (Engl) 1999 Sep;8(3):133-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10763643.
  8. Langius JA, Bakker S, Rietveld DH, Kruizenga HM, Langendijk JA, Weijs PJ, et al. Critical weight loss is a major prognostic indicator for disease-specific survival in patients with head and neck cancer receiving radiotherapy. Br J Cancer 2013 Sep 3;109(5):1093-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23928661.
  9. Nugent B, Parker MJ, McIntyre IA. Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer. J Hum Nutr Diet 2010 Jun;23(3):277-84 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20337841.

Back to top