Q5. What is the impact of the dietitian providing nutrition intervention as part of a multidisciplinary team?

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Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer > Q5. What is the impact of the dietitian providing nutrition intervention as part of a multidisciplinary team?

Summary

There are three level II positive quality studies [1][2][3] that demonstrate an improvement in patient-centred outcomes such as quality of life, and improved nutritional intake and nutritional status following dietetic counselling for head and neck patients receiving radiotherapy, both during and post treatment. A pseudo randomised controlled trial, level III-1 neutral quality [4] also reported similar findings with less weight loss and malnutrition following individual dietetic counselling compared to standard care. The UK National Institute for Health and Clinical Excellence publication “Guidance on Cancer Services: Improving Outcomes in Head and Neck Cancers –The Manual” recommends a specialist dietitian as a core member of the multidisciplinary team [5].

A level III-3 neutral quality study [6] found that patients undergoing an early nutrition intervention program, including dietetic contact pre, during and post radiotherapy, had improved outcomes in terms of less weight loss, fewer treatment interruptions and less unplanned admissions. One paper [7] (level III-3, neutral quality) describes the effect of an integrated care program including a dietitian role pre, during and post treatment, which resulted in an 82% increase in patients receiving nutrition support for oral and oropharyngeal cancers. A level III-3 neutral quality study describes the positive outcomes of when a dietitian is present in a multidisciplinary team i.e. patients are more likely to receive pre-treatment dietetic intervention, nutrition guidelines or recommendations are more likely to be followed and the patient is more likely to receive follow up post treatment [8]. Another level III-3 neutral quality study found that nutritional management in a dietitian-led clinic was associated with reduced nutrition-related admissions, fewer unplanned nasogastric tube insertions, improved transition to oral diet post-radiotherapy, and reduced need for medical follow-up during the immediate post-treatment period [9]. One level IV neutral quality qualitative paper [10] indicates that there is a patient need for intervention and support throughout the continuum of care. Another Level IV neutral quality paper [11] also supports the need to prepare patients for the post treatment phase and the slow recovery from side effects. The significance of eating problems needs to be acknowledged and the impact this has physically, emotionally and socially.

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Recommendation Grade
A dietitian should be part of the multidisciplinary team for treating patients with head and neck cancer throughout the continuum of care, as frequent dietitian contact has been shown to improve nutrition outcomes and quality of life.
A

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References

  1. 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.
  2. 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.
  3. 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.
  4. van den Berg MG, Rasmussen-Conrad EL, Wei KH, Lintz-Luidens H, Kaanders JH, Merkx MA. Comparison of the effect of individual dietary counselling and of standard nutritional care on weight loss in patients with head and neck cancer undergoing radiotherapy. Br J Nutr 2010 Sep;104(6):872-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20441684.
  5. National Institute for Health and Clinical Excellence.. Guidance on Cancer Services: Improving Outcomes in Head and Neck Cancers - The Manual. London: National Institute for Health and Clinical Excellence 2004 Abstract available at http://www.nice.org.uk/nicemedia/live/10897/28851/28851.pdf.
  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. Ouwens MM, Hermens RR, Hulscher MM, Merkx MA, van den Hoogen FJ, Grol RP, et al. Impact of an integrated care program for patients with head and neck cancer on the quality of care. Head Neck 2009 Jul;31(7):902-10 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19280664.
  8. Wood K. Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy. J Hum Nutr Diet 2005 Oct;18(5):343-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16150130.
  9. Kiss NK, Krishnasamy M, Loeliger J, Granados A, Dutu G, Corry J. A dietitian-led clinic for patients receiving (chemo)radiotherapy for head and neck cancer. Support Care Cancer 2012 Sep;20(9):2111-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22086406.
  10. Larsson M, Hedelin B, Athlin E. A supportive nursing care clinic: conceptions of patients with head and neck cancer. Eur J Oncol Nurs 2007 Feb;11(1):49-59 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17185036.
  11. McQuestion M, Fitch M, Howell D. The changed meaning of food: Physical, social and emotional loss for patients having received radiation treatment for head and neck cancer. Eur J Oncol Nurs 2011 Apr;15(2):145-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20864401.

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