Oncology Dietitians Research Articles

Management of inoperable malignant bowel obstruction using the 4-step BOUNCED diet.

Malignant bowel obstruction (MBO) presents with multiple symptoms. The 4-step BOUNCED diet educates patients to self-manage oral intake according to symptoms. It includes clear fluids, thin liquids, purée and soft, sloppy foods, which are low in fibre. This mixed methods single-arm feasibility study aimed to establish if the diet could reduce MBO symptoms in patients with inoperable colorectal and gynaecological malignancies. The secondary objectives were to investigate if it was easily followed, improved quality of life (QOL) and reduced hospital admissions. Patients able to tolerate an oral diet with one or more symptoms (pain, bloating, early satiety, nausea and vomiting) were eligible. Following informed consent, an oncology dietitian took a diet history and determined which step of the diet they needed to follow using a detailed patient information leaflet. Patients remained on the trial for 28 days. Symptom and QOL data were collected on Days 1 and 28 using the Memorial Symptom Assessment Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) questionnaires. Thirty patients (24 female, 6 male) aged 18-85 years consented from March 2021 to November 2022. Twenty-six participants completed the trial and 25 found the diet very easy or easy to understand. There was a significant reduction in pain from 96% on Day 1 to 63% on Day 28 (p = 0.004). The mean increase of EORTC global health status/QOL was 23.5 points, 95% CI (12.4-32.5) (p ≤ 0.001). There was a significant difference between number of admissions (p = 0.018) and bed days (p = 0.004) in the 28 days prior to consent compared to the trial period. A modified consistency low-fibre diet is easily followed, may reduce symptoms of MBO, admissions to hospital and improve QOL.

Pediatric oncology nutritional practices in high-income countries: A survey from the International Society of Paediatric Oncology (SIOP).

Optimal nutrition in pediatric oncology can influence cancer-related outcomes. To establish an understanding of nutrition practice and perceptions of best practice, we queried nutrition providers practicing in pediatric oncology care centers in high-income countries. An electronic, multidisciplinary, cross-sectional survey of nutrition practices was conducted among pediatric oncology nutrition practitioners. Final analysis included 110 surveys from 71 unique institutions and included practitioners from Europe, the United States, Canada, Australia/New Zealand, South America, and the Middle East/Asia. The majority of institutions (97%) reported having dietitians; 72% had designated oncology dietitians. Approximately half of the practitioners (47%) reported feeling their institutions were inadequately staffed. The majority (78%) of institutions completed nutrition risk screening, but there was no consensus on specific screening practices. Half (50%) of the institutions that screened for nutrition risk did so in both inpatient and outpatient settings. The majority (80%) of institutions completed a nutrition assessment close to the time of diagnosis. Those that did not cite lack of staff and/or lack of time, lack of standardized approach, and consult only level of nutritional care as primary barriers. The most common topic of nutrition education provided to patients/families was nutrition-related symptom management (68%). While most institutions reported having pediatric oncology dietitians, we found a lack of standardized practice and perceived inadequate staffing. In addition, what providers perceived to be best practice did not always align with day-to-day clinical practice. Ongoing efforts are needed to develop evidence-based guidelines, including staffing recommendations, to support specialized care in this population.

Integrating diabetes care into an oncology practice: A patient-centric model of care delivery at a safety-net health system.

2 Background: Oncologic treatments can disrupt glycemic control in people with diabetes and induce dysglycemia in individuals without diabetes through the use of steroids and/or targeted therapies. Severe hyperglycemia can result in delay/interruption of oncologic care and emergency department (ED) utilization. Here we report on an integrated model of diabetes care at a safety-net system, where patients commonly use the ED for their care. Methods: Parkland Health is an academic-affiliated safety-net system, primarily providing care for the un-/under-insured patients in Dallas County. An advanced nurse practitioner specializing in diabetes care (DM-ANP), supervised by an endocrinologist, was embedded in oncology clinics. Patients were referred to the DM-ANP by their oncology provider, or through an automated process if they had a recent hemoglobin A1c >8.0% or a random blood sugar > 250mg/dL. Patient education was provided by a trained nurse educator. Nutrition consult was available through an oncology dietitian. An acute hyperglycemia management protocol was developed to manage patients in the infusion center and prevent unnecessary ED visits. Results: Between March 2021 and March of 2024, the DM-ANP provided 4,276 visits to 797 distinct patients (average, 1425 visits per year). Breast cancer was the most common malignancy among patients seen in the integrated clinic. DM-ANP visits were coupled with oncology visits (clinic or infusion) or via telehealth, thereby increasing access and decreasing number of days patients had to come to clinic to receive care. Telehealth visit rate was highest in 2021 (27.5%) reflecting the impact of the pandemic, and subsequently dropped to 10.1% in 2023. Patients who were seen by the DM-ANP had an overall lower number of ED visits. Comparing prior vs post establishing care with the DM-ANP, the total number of ED visits by patients with diabetes significantly reduced in 2021-2022 (2021: 970 vs. 241, p <0.01; 2022: 796 vs. 501, p<0.01) before equilibrating in 2023-2024; (2023: 426 vs. 468, p=0.24). On average, patients had 1.2 less ED visits after receiving care from the DM-ANP. Since in-person visits were coupled with other oncology visits, the no-show rate for DM-ANP mirrored the rates for oncology clinics/infusion visits. Conclusions: Integrating diabetes/glycemic management into our oncology practice provided a patient-centric model of care delivery, improved visit adherence compared to an off-site model, reduced the time-toxicity by having fewer clinic visit days. Future directions include comparing oncologic outcomes in patients who had DM-ANP management to those who were managed by primary care.

Nutrition and Selected Lifestyle Elements as a Tertiary Prevention in Colorectal Cancer Patients.

Nutrition and lifestyle elements can significantly support the therapeutic process in colorectal cancer (CRC) patients, which is the basis for tertiary prevention. The study aimed to assess the nutritional strategies and lifestyle of CRC patients and to determine differences in these behaviors depending on gender and age. The study group included 202 CRC patients. The research was carried out in two hospitals and using the snowball method. The research tool was an original questionnaire. Data were processed in statistical programs. p < 0.05 was considered statistically significant. Patients reported many behavioral-nutritional side effects. Half of them did not use a therapeutic diet (n = 101; 50.0%). The majority of patients declared that they ate three meals a day (57.4%). Fruits and vegetables were mainly eaten raw (69.3%). Almost a quarter of patients were not physically active at all (22.3%). Men chose to fry meat significantly more often than women (27.7% vs. 19.3%) (p = 0.003). The elderly consumed fast food significantly less often than middle-aged (88.5% vs. 72.3%) (p = 0.03). Patients showed both pro- and anti-health activities. The findings revealed several noteworthy disparities in dietary habits and lifestyle choices based on gender and age, indicating that these factors can significantly influence the health management of CRC patients. The patients' behaviors should be constantly monitored and intensified, especially through regular consultations and educational meetings with an oncology dietitian for nutritional tertiary prevention of chronic disease.

Belief About App Effectiveness Is a Significant Predictor of App Interest, but Not Use, in Oncology Dietitians in Oncology Dietitians

Belief About App Effectiveness Is a Significant Predictor of App Interest, but Not Use, in Oncology Dietitians in Oncology Dietitians

National implementation of an AI-based virtual dietitian for patients with cancer.

1500 Background: Nutritional status is an established key driver of cancer outcomes and patient experience. However, the workforce of oncology dietitians is unable to meet the needs of the population, and 80% of patients seek but do not receive nutrition support. Advances in artificial intelligence (AI) and machine learning (ML) capabilities afford the opportunity to expand reach and rapidly hone in on clinical and contextual needs to deliver evidence-based nutritional guidance. Methods: To address this unmet need, an AI-based nutrition expert-platform was developed. Interventions were curated by oncology-nutrition experts based on peer-reviewed literature and clinical guidelines to facilitate self-management of cancer side effects and optimize nutrition. A growing database of over 114,000 evidence-based interventions powers Ina, a text-message based virtual nutrition assistant. Interventions are continually enhanced and refined using AI and ML applied to an extensive learning dataset. The tool was implemented nationally in partnership with 25 cancer advocacy organizations. Data on demographics, patient-reported outcomes, and utilization were systematically collected. Results: Between July 2019 and August 2023, 3,310 users from all 50 states registered for the virtual nutrition platform. Based on self-report, users were 73% female; mean age 57 years (18-91); most common cancer types were GU (22%), Breast (21%), Gyn (19%), GI (14%), and Lung (12%), representing nearly 90% of users. Users were medically complex, with 50% reporting Stage 3-4 disease, 64% with metastases, and 50% with 2+ chronic conditions. Nutritional challenges were highly prevalent: 58% were overweight/obese by BMI, 83% reported barriers to good nutrition, and 42% had food allergies/intolerances. Levels of engagement were high: 68% of users texted queries to Ina, 79% completed surveys, and median user retention duration was 8.8 months. Overall, 94% of users reported being satisfied with the platform and 98% found the guidance to be helpful. In an evaluation of outcomes, 84% reported actively using the nutrition advice to guide their diets, 47% used the recommended recipes, and 82% felt the program improved their quality of life. In this cohort with high symptom burden, 88% reported Ina helped them manage their symptoms and 34% noted improved symptom control during participation. Conclusions: Implementation of an evidence-based AI virtual dietitian is feasible, and is reported by patients to be beneficial on diet, quality of life, and symptom control. Ongoing evaluations are assessing impact on other outcomes.

Exploring dietitians' practice and perspectives on the role of dietary patterns during cancer treatment: A qualitative study.

Dietitians are nutrition professionals equipped with specialised skills required to prevent and treat malnutrition in cancer. Optimisation of dietary intake is recommended as the primary nutrition strategy for the treatment of cancer-related malnutrition. However, it is unclear whether dietary patterns, described as the combination, quantity, and frequency of food consumption, are considered. This study examined dietitians' current food-based management of malnutrition; explored dietitians' awareness of dietary patterns and assessed barriers and enablers to the use of dietary patterns in clinical practice. This qualitative study consisted of semi-structured interviews with oncology dietitians. Dietitians were recruited through national nutrition societies, social media, and professional networks. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. Fourteen oncology dietitians from across four Australian states and territories participated. Three themes were identified: (i) principles to guide nutritional care, (ii) dietary patterns as a gap in knowledge and practice, and (iii) opportunities for better care with systems as both a barrier and enabler. Dietetic practice was food-focussed, encouraging energy and protein-rich foods consistent with nutrient-focussed evidence-based guidelines. Dietitians encouraged one of two nutrition-related approaches, either encouraging intake of 'any tolerated food' or 'foods supportive on longer-term health'. Dietitians were generally unaware of dietary patterns and questioned their relevance in certain clinical situations. A multidisciplinary team approach, adequate food service and dissemination of dietary patterns research and education were identified as opportunities for better patient care. Recommendations for the treatment of malnutrition vary between oncology dietitians and uncertainty exists regarding dietary patterns and their relevance in clinical practice. Further exploration into the role of dietary patterns to treat cancer-related malnutrition and education for dietitians are required prior to implementation of a dietary patterns approach into clinical practice.

Effectiveness of the nutrition referral system in a multidisciplinary pancreatic cancer clinic.

Proactive nutrition screening and intervention is associated with improved outcomes for patients with pancreatic adenocarcinoma (PDAC). To better optimize nutrition amongst our PDAC population, we implemented systematic malnutrition screening in the Johns Hopkins pancreas multidisciplinary clinic (PMDC) and assessed the effectiveness of our nutrition referral system. This was a single institution prospective study of patients seen in the PMDC, screened for malnutrition using the Malnutrition Screening Tool (MST) (score range=0 to 5, score > 2 indicates risk of malnutrition), and offered referrals to the oncology dietitian. Patients that requested a referral but did not attend a nutrition appointment were contacted by phone to assess barriers to seeing the dietitian. Univariate (UVA) and multivariable (MVA) analyses were carried out to identify predictors of referral status and appointment completion status. A total of 97 patients were included in the study, of which 72 (74.2%) requested a referral and 25 (25.8%) declined. Of the 72 patients who requested a referral, 31 (43.1%) attended an appointment with the oncology dietitian. Data on information session attendance was available for 35 patients, of which 8 (22.9%) attended a pre-clinic information session in which the importance of optimal nutrition was highlighted. On MVA, information session attendance was significantly associated with requesting a referral (OR: 11.1, 95% CI 1.12-1.0E3, p=0.037) and successfully meeting with the oncology dietitian (OR: 5.88, 95% CI 1.00-33.3, p=0.049). PMDC teams should institute educational initiatives on the importance of optimal nutrition in order to increase patient engagement with nutrition services.

Is virtual nutritional counseling efficacious for cancer patients during the COVID-19 pandemic?

This study investigates the outcomes of virtual nutritional counseling (VNC) for oncology patients during the Covid-19 pandemic. Our study evaluated the nutritional status data of cancer patients at the baseline and after VNC. An oncology dietitian evaluated the patients by video calling each patient via WhatsApp and sent an individual nutrition diet plan and recommendations via e-mail. Patient-Generated Subjective Global Assessment (PG-SGA) was used as a screening and evaluation tool to assess nutritional status. A total of 157 patients with a mean age of 55.8 ± 14.7 (r = 19–89) were included in the study. Researchers detected at least one nutrition-related sign in 77.7% of patients. After the VNC and based on the final PG-SGA assessments, 62.2% of the patients whose baseline PG-SGA Score-B improved to Score-A, 12.5% with a baseline PG-SGA Score-C improved to Score-A and 54.2% with a baseline Score-C improved to a Score-B (χ2 = 55,000, P < 0.001). Based on the number of VNCs, the improvement in malnutrition status following two sessions and three or more sessions was found to be 17.6% and 35.7%, respectively (P < 0.001). Our results confirm that VNC can improve the nutritional status of cancer patients. Hence, nutritional counseling should be an integral part of oncological treatment.

OA08.05 A Quality Improvement Project Determining if Dietitian Input with the UHS Lung Oncology Team Improved Patient Outcomes.

Unintentional weight loss is common in lung cancer, with 40-60% of patients presenting with this at diagnosis. Weight loss and depleted nutritional status have been identified as negative prognostic variables for survival and directly impact the effectiveness of cancer treatments. The Lung Oncology team at the University Hospital Southampton (UHS) received external funding from Bionical Solutions and AstraZeneca for a part time oncology Dietitian to join the team in treating this patient group. The aim was to determine if specialist Dietitian input improves patients’ nutritional outcomes in those diagnosed with Stage III Non-Small Cell Lung Carcinomas (NSCLC) undergoing radical treatment.

Cognitive behavioral therapy for weight management in gynecologic oncology (288)

<b>Objectives:</b> Obesity is an epidemic in gynecologic oncology, leading to an increased risk of surgical complications and poor cancer outcomes. Cognitive-behavioral therapy (CBT) is an effective weight loss strategy. We aimed to determine whether group CBT is an effective weight loss tool when offered in an outpatient gynecologic oncology setting. <b>Methods:</b> We established a CBT-based weight management intervention for gynecologic oncology patients at an NCI-designated cancer center. The intervention was a 12-week group-based weight loss program offered to patients from the gynecologic oncology clinic with body mass indices (BMI) between 25-50 kg/m². Sessions were free of charge, led by a psychologist and dietitian, and transitioned from in-person to tele-visits due to the COVID-19 pandemic. The program combined nutritional education, lifestyle changes, and CBT approaches, with 12 weekly group visits followed by three monthly individual follow-up visits. Each participant was given a goal weight loss of 7% total body weight (TBW). Retrospective data were collected from patients enrolled in the intervention from September 2019 through March 2021. Paired t-tests were performed to compare the pre-program and ending weights for all participants. Weight loss data were tested for normality using the Shapiro-Wilk test. <b>Results:</b> A total of 29 patients were enrolled in four cohorts during the study timeframe. Fifty-nine percent of participants were White, 38% were Black. The mean age among participants was 56 years, and the mean BMI was 41 kg/m². Most participants had a history of endometrial hyperplasia or malignancy (58%) and had stage I disease (59%). Among the participants, 22 (76%) completed the program. The average weight loss among all participants during the 12-week program was 5.6 pounds (CI: -8.9- -2.1, p=0.002), equivalent to an average 2% change in TBW. Among the 22 participants who completed the program, the average weight loss was 7.4 pounds (CI: -11.1- -3.8, p <0.001), equivalent to an average 3% change in TBW. Weight loss was sustained at the 6-month mark, with an average change in TBW of 2-3% when comparing weight at 6 months to pre-program weight. <b>Conclusions:</b> This CBT-based weight loss intervention was feasible and acceptable to gynecologic oncology patients. While the average weight loss fell short of the goal of 7% TBW, the 2-3% change in TBW achieved on average with this intervention was stable over six months. Additionally, retention within the intervention was high and maintained during COVID-19 with tele-visits. Given that weight loss plateaued when transitioning from weekly to monthly sessions, our findings suggest that longer, more intensive treatment may be needed to promote sustainable weight loss among gynecologic oncology patients. Collaboration between psychologists, oncology dietitians, and gynecologic oncologists, with continued support for psychologists and dieticians at cancer centers, is critical to the success of such programs. CBT is a feasible behavioral intervention to add further multidisciplinary efforts to tackle the complexity of obesity in cancer survivors. Table 1

An Evaluation of the Quality of Commercial Nutrition Apps for Cancer Survivors

ObjectivesMobile nutrition apps have the potential to address gaps within the cancer care continuum by providing nutrition education to shape one's knowledge. Few studies evaluate the quality of these cancer nutrition apps and the degree of clinician agreement on app quality. Thus, we investigated the quality of four cancer nutrition apps with knowledge shaping features.MethodsDuring December 2019, an initial search was conducted in the Apple App Store using keywords relevant to cancer and nutrition. Apps were chosen if they provided free cancer-specific nutrition education (i.e., knowledge shaping) regardless of accuracy (e.g., “anti-cancer” foods, recipes) and had a ≥3-star rating. Four apps with knowledge shaping features were evaluated: Eat AntiCancer, Get Well Soon, Untire, and Vegan Soul Belly. Five oncology dietitians used the validated App Quality Evaluation (AQEL) to rate apps in several domains, such as: knowledge shaping (knowledge acquisition, skill development) and app design (functionality, appropriateness for cancer survivorship). Domain scores ranged from 0 -10 (score ≥8 represented high quality). Interclass correlation coefficient (ICCs) analyses determined the interrater reliability between dietitians. An ICC ≥0.90 represented excellent agreement; 0.75 to < 0.90 as good; 0.50 to <0.75 as moderate; and <0.50 as poor. Fixed effects models were used to examine domain score differences between apps, adjusting for the rater. Statistical significance threshold was set at P <0.05.ResultsAll apps had good agreement with AQEL scores among the dietitians (ICC range = 0.75–0.82). When examining differences in AQEL scores among apps, Untire had the highest AQEL scores in the knowledge acquisition (mean: 8.0 ± 1.2; p = 0.02). There were no differences in skill development and app design between the cancer apps (p > 0.05). Only Untire scored highly in the knowledge acquisition, function, and appropriate for cancer survivorship domains (all AQEL ≥8). None of the apps received a high-quality score for skill development (AQEL <8).ConclusionsUntire received high-quality scores for knowledge acquisition and app design. None of the apps scored highly in skill development. Future cancer nutrition apps should consider including effective skill development features to assist with shaping knowledge for behavior change.Funding SourcesNo funding sources.

Evaluating an AI-based nutrition expert platform delivered via SMS-text to support patients with cancer.

1569 Background: Interventions incorporating nutritional strategies can prevent and manage nutrition-related symptoms, however, due to a shortage of oncology dietitians (RD CSO) combined with healthcare access disparities, many patients do not receive the support they need, resulting in poor outcomes and quality of life (QoL). High rates of cell phone utilization among all demographics offers a unique opportunity to provide interventions using mobile technology. Methods: Launched to select groups in 2019, Ina (trademarked by Savor Health LLC) is a virtual nutrition assistant powered by an artificial intelligence (AI)-enabled expert platform, to facilitate self-management of cancer treatment side effects. The platform combines evidence, expertise, and unique patient data to deliver the personalized guidance patients would receive from an RD CSO, “on-demand” via text. This study applied the RE-AIM framework to evaluate the intervention from five dimensions. Results: Reach: The program reached 1,706 users as of 2021. Based on self-report among 1209 users, 78% are patients, 18% are caregivers, and 5% are healthcare professionals with 66% female and 34% male. Ina supports all cancer types, and top diagnoses among users are genitourinary (28%), lung (20%), gynecologic (16%), gastrointestinal (15%), and breast (11%). Disease burden is high, with 62% of users reporting they are experiencing nutrition-addressable symptoms at any given time. Effectiveness: Based on weekly patient reported outcome (PRO) surveys, 87% of respondents report Ina helps them manage symptoms, and 80% report that using Ina has improved their QoL. The cumulative likelihood to recommend is 4.1 on a 5-point scale. Adoption: Users are from over 18 cancer organizations, proving the feasibility and accessibility of this intervention. Implementation: Ina is accessible 24/7 via text, and is offered to patients in a B2B2C model. Users typically receive responses to nutrition-related questions within seconds from the AI platform (or 1-3 minutes with live RD oversight). Each active user (one that engages at least once in a given month) asks an average of 2.8 questions per month. Maintenance: The median time users remain on the platform is 156 days (range 0-884) and 57% of evaluable users stayed on the platform 6 months or longer. The platform’s database, which includes over 54,000 referenced interventions, grows daily via supervised machine learning supported by RD CSOs. When surveyed on future feature development, respondents are most interested in tele-nutrition (57%), mental health (65%), and stress management (62%). Conclusions: Initial data suggests this is a feasible and accessible tool to support cancer patients’ unique nutrition and symptom-management needs. Clinical trials are needed to validate feasibility and assess impact on clinical and QoL outcomes. Product development to integrate language and cultural preferences is ongoing.

Can people living with and beyond colorectal cancer make lifestyle changes with the support of health technology: A feasibility study.

Rates of cancer survival are increasing, with more people living with and beyond cancer. Lifestyle recommendations for cancer survivors are based largely on extrapolation from cancer prevention recommendations. This feasibility study was designed to investigate diet and physical activity variables linked to primary prevention and digital behaviour change interventions in cancer survivors and delivered by an oncology dietitian to plan for future research. In this 2-month feasibility study, participants who had completed treatment for colorectal cancer were invited to complete online food diaries, underwent physical activity assessment, attended fortnightly telephone consultations with an oncology dietitian and completed an evaluation form. The baseline food diaries were used to help participants pick two lifestyle changes to focus on throughout the intervention. Demographic and clinical data were analysed using descriptive statistics. In total, 996 patients were screened for eligibility; of these, 78 were eligible to approach and 69 were approached, resulting in 20 participants consenting to take part. Overall, the intervention was acceptable with 65% of participants completing an online food diary and 70% engaging with the dietitian over the telephone. The intervention received good feedback, with 100% of those completing the evaluation form reporting they felt supported and found it helpful. The present study offers preliminary evidence that a lifestyle intervention delivered by an oncology dietitian using digital behaviour change interventions (DBCIs) to cancer survivors is feasible and accepted by participants and providers.

Nutritional interventions in patients with head and neck cancer undergoing chemoradiotherapy: Current practice at the Dutch Head and Neck Oncology centres.

ObjectiveTo assess variations in nutritional interventions during chemoradiotherapy (CRT) among the Dutch Head and Neck Oncology centres (HNOCs).MethodsAn online questionnaire about nutritional interventions and dietetic practices was sent to 14 oncology dietitians of the HNOCs.ResultsThe response rate was 93%. The number of scheduled dietetic consultations varied from two to seven during CRT. Most centres (77%) reported using a gastrostomy for tube feeding in the majority of patients. Gastrostomies were placed prophylactically upon indication (39%) or in all patients (15%), reactive (15%), or both (31%). For calculating energy requirements, 54% of the dietitians used the Food and Agriculture Organization/World Health Organization and United Nations University (FAO/WHO/UNU) formula and 77% uses 1.2–1.5 g/kg body weight for calculating protein requirements. Almost half of the centres (46%) reported to remove the gastrostomy between 8 and 12 weeks after CR. Most centres (92%) reported to end dietary treatment within 6 months after CRT.ConclusionThis study shows substantial variation in dietetic practice, especially in the use of a gastrostomy for tube feeding, between the HNOCs. There is a need for concise dietetic guidelines.

OA04.03 Feasibility of Prospective Dietetic Assessment and Intervention of Patients Receiving Chemo-Radiotherapy for Lung Cancer

Chemo-radiotherapy for lung cancer can be a morbid treatment, often in an older and co-morbid population. Our patients are not routinely seen by a dietitian. As a pilot project, all patients receiving either sequential or concurrent chemo-radiotherapy for lung cancer between May and November 2020, were identified by the lead lung radiographer and bookings team and referred to a specialist oncology dietitian. These patients were offered up to 3 routine fortnightly assessments on treatment. We recorded their symptoms (based on a standardised tool, PG-SGA) and weight during treatment. 15 patients were referred to the dietitian: 7 male, 8 female. All patients accepted dietetic review. The median age was 64 years old; mean age 63 years old (range 50-79). The mean average number of cycles of chemotherapy was 3.4. Concurrent chemo-radiotherapy was given to 11 patients, with the remaining 4 having sequential treatment. Of all patients, 1 had small cell lung cancer, 1 had a mixed adenocarcinoma and small cell. The remaining 13 were non-small cell lung cancers, and of these 6 were adenocarcinomas and 6 were squamous cell carcinomas and 1 mixed histology. All patients were reviewed at least twice whilst on treatment. The most complete data was for the review in weeks 3/4 of radiotherapy. All 15 patients had scores for this time point. Mean number of symptoms was 5.5 (range 3-9). The commonest symptoms were fatigue (100%), loss of appetite (67%), pain (67%) and dysphagia (60%). For 12 patients receiving 6 weeks of radiotherapy median symptom number increased from 5 in 1st 2 weeks, to 5.5 in weeks 2nd 2 weeks, to 6.5 in final 2 weeks. All patients in this group lost weight. Median weight loss during treatment was 6.6% (range 1.8-15.9%). All patients received food fortification advice throughout their treatment and advice on symptom management. The symptom management advice for 12 of the 15 patients either reinforced advice, or, made adjustments to the timing of medications prescribed by medical or nursing staff. The other 3 patients did not have an existing prescription, and so recommendations were made of medications to manage symptoms, e.g. oxcetacaine, anti-emetics and laxatives. Oral nutritional supplements (ONS) were recommended if patients were not meeting their estimated nutritional requirements from dietary assessment. Seven patients received ONS prescription in addition to the food fortification advice. One patient declined an ONS prescription. 1. Routine dietetic review during radical chemo-radiotherapy is feasible and occurred successfully during the COVID-19 pandemic. It led to some simple, but vital changes in practice such as weekly weighing of patients on treatment 2. Patients undergoing chemo-radiotherapy have a high symptom burden. 3. All patients receiving 6 weeks of radiotherapy lost weight during treatment. 4. We received positive feedback from patients.

Evaluating the impact of a nutrition-focused eras protocol in hepatobiliary and pancreatic surgery patients: a preliminary analysis

Presenter: Taylor Abraham MD | Bon Secours Mercy Health St. Elizabeth Youngstown Hospital Background: Nutritional status is an important independent predictor of clinical outcomes after surgery. Optimized surgical nutrition has been found to improve the clinical and health outcomes of surgical patients. A perioperative nutrition protocol was implemented to provide oral nutritional supplements to all eligible surgery patients in the perioperative period to optimize their nutritional status and improve their clinical outcomes. Methods: Between January 1, 2019 and November 1, 2020, patients scheduled to undergo major hepatobiliary or pancreatic surgery by a single surgeon at a single institution was seen by the registered oncology dietitian 1 week prior to surgery. During this visit, the patients were provided with 1 bottle of clear carbohydrate drink (Ensure Pre-Surgery), and 10 bottles of immunonutrition (Ensure Immunonutrition Surgery Shake). Patients also received an educational flyer outlining the benefits of nutritional supplements pre- and post-surgery as well as specific instructions and checklists to promote compliance. During the patient's hospital stay, the nutritional supplements were started per the surgical nutrition protocol and a 5-day supply of immunonutrition shakes (Ensure) or therapeutic nutrition powder for wound healing (Juven) were provided to take home and consume post-operatively. Outcomes of interest included length of hospital stay, 30-day readmissions and post-operative infectious complications. Outcomes of these patients were compared to those of historical controls - patients undergoing similar procedures between January and December of 2018, prior to the initiation of the nutrition protocol. Results: A total of 92 patients undergoing major hepatobiliary and pancreatic surgeries were included in the analysis of which 67 patients were given the perioperative nutrition protocol and 25 were historical controls. Overall, patients were mainly female (57%), on public insurance (57%) and had a mean age of 65. Comparative analysis showed improvements in favor of the perioperative nutrition protocol cohort in terms of reduced length of stay (8.54 vs. 7.89 days), 30-day readmissions (24% vs. 19%) and infectious complications (20% vs. 16.4%). Conclusion: The results of our analysis confirm the importance of perioperative nutrition protocols in optimizing the clinical outcomes of patients undergoing major hepatobiliary and pancreatic surgeries. The improvements observed can result in decreased financial burden for the patients and the institution. Future research is needed to validate the findings of our preliminary analysis.

A national survey of oncology survivors examining nutrition attitudes, problems and behaviours, and access to dietetic care throughout the cancer journey.

Attitudes of cancer survivors to nutrition and nutrition care have rarely been captured. A better understanding of their needs based on a review of their experiences would give voice to this patient group (which has rarely been captured) and allow for better planning of nutritional care. To conduct a national survey to determine: (1) survivors' experience in relation to nutrition and diet-related problems, (2) perceived importance of the role of nutrition to cancer survivors, (3) the experience of accessing dietetic support, (4) the sources where survivors get nutrition information, and (5) their use of alternative dietary strategies. Survivors (any adult ever diagnosed with cancer) who had been diagnosed with or treated for cancer in Ireland within the past 5 years, were asked to complete a 25-item paper-based survey at one of 20 different hospital sites in Ireland. The survey was also hosted online on the websites of major cancer charities. Descriptive statistics were used to examine quantitative data. In total, 1073 valid responses were received (63% female, mean age 57 years (range 18-88)). Breast cancer was the most common (n=362), followed by colorectal (n=121). One third of respondents had metastatic disease. Diet-related problems were reported by 45%. Weight loss was experienced by 44% and amongst those, 42% reported they were 'unhappy or worried' by this, while 27% reportedbeing 'delighted/happy' with their weight loss. Muscle loss was noted by 52%, with 20% reporting they had noticed 'a lot' of muscle loss. Nutrition was rated as 'very/extremely' important to cancer care by 89% of respondents, yet 58% reported being asked about dietary issues by their medical team only 'sometimes', 'rarely' or 'never'. Only 39% had been assessed/treated by a registered dietitian (RD) and 74% rated their advice/care as 'very/extremely' helpful. Worryingly, 39% of survivors with involuntary weight loss, and 29% of survivors on a texture modified diet had not received nutritional care from an RD. Overall, 57% of those who did not see an RD said they wanted more dietetic support (access to a helpline/dietitian/additional reliable information). Of concern, 37% of survivors were following or had tried alternative, unproven dietary strategies (e.g. restrictive diets, herbal remedies, juicing or detoxes), and 32% reported avoiding specific foods, e.g. processed meat or dairy. A majority (56%) felt confused by the often conflicting nutrition information available in the media and offered by people around them. While nutrition is considered highly important by cancer survivors and a high proportion experience potentially serious diet-related problems including weight and muscle loss, fewer than half surveyed had access to a dietitian. Over a third had used at least one alternative dietary strategy, and over half felt confused about nutrition. Comprehensive nutritional screening and referral programmes to oncology dietitians need to be implemented in the ambulatory setting in order to identify and facilitate early management of the nutritional concerns of cancer survivors.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice.

Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities. This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted. Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89). Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

Eating As Treatment (EAT): A Stepped-Wedge, Randomized Controlled Trial of a Health Behavior Change Intervention Provided by Dietitians to Improve Nutrition in Patients With Head and Neck Cancer Undergoing Radiation Therapy (TROG 12.03)

Malnutrition in head and neck cancer (HNC) treatment is common and associated with poorer morbidity and mortality outcomes. This trial aimed to improve nutritional status during radiation therapy (RT) using a novel method of training dietitians to deliver psychological techniques to improve nutritional behaviors in patients with HNC. This trial used a stepped-wedge, randomized controlled design to assess the efficacy of the Eating As Treatment (EAT) program. Based on motivational interviewing and cognitive behavioral therapy, EAT was designed to be delivered by oncology dietitians and integrated into their clinical practice. During control steps, dietitians provided treatment as usual, before being trained in EAT and moving into the intervention phase. The training was principles based and sought to improve behavior-change skills rather than provide specific scripts. Patients recruited to the trial (151 controls, 156 intervention) were assessed at 4 time points (the first and the final weeks of RT, and 4 and 12weeks afterward). The primaryoutcome was nutritional status at the end of RT as measured by the Patient-Generated Subjective Global Assessment. Patients who received the EAT intervention had significantly better scores on the primary outcome of nutritional status at the critical end-of-treatment time point (β=-1.53 [-2.93 to -.13], P=.03). Intervention patients were also significantly more likely than control patients to be assessed as well-nourished at each time point, lose a smaller percentage of weight, have fewer treatment interruptions, present lower depression scores, and report a higher quality of life. Although results were not statistically significant, patients who received the intervention had fewer and shorter unplanned hospital admissions. This trial is the first of its kind to demonstrate the effectiveness of a psychological intervention to improve nutrition in patients with HNC who are receiving RT. The intervention provides a means to ameliorate malnutrition and the important related outcomes and consequently should be incorporated into standard care for patients receiving RT for HNC.