Experiences and expectations of (mal)nutrition by oncology patients at Auckland City Hospital

Abstract

Background Malnutrition is prevalent in oncology patients at 30 to 40% (1), with even higher prevalence in those with head and neck cancer (HNC), upper gastrointestinal (UGI) and lung cancers. Identification and treatment of malnutrition can reduce morbidity and mortality (2-6). Nutrition screening tools identify malnutrition; they have been endorsed globally within each guideline, protocol or recommendation dedicated to nutrition in oncology patients (2, 3, 5, 7, 8). The benefit to District Health Boards (DHB) is the reduction in the associated cost of malnutrition (9, 10) and even a valuable revenue stream for DHBs (11). Aim Audit: identify weight change before and during active treatment in 300 patients with HNC, UGI or lung cancers at Auckland City Hospital (ACH). Questionnaire: characterise malnutrition, cancer and treatment-related side effects, nutrition behaviours, beliefs and sources of nutrition information; through a questionnaire and analysed using qualitative approaches. Design and participants Audit: a quantitative study using a retrospective audit of weight change in 200 patients (100 in each tumour group) for UGI or lung cancer and a prospective audit for 100 patients with HNC, all receiving treatment at the Regional Cancer and Blood Services, ACH. Questionnaire: following a pilot trial of the questionnaire and adaptation, a prospective observational study with a qualitative questionnaire was offered to any patient receiving cancer treatment at ACH. The questionnaire was available as a paper copy from receptions or treatment staff or as an online version with access from a quick response (QR) code or a Uniform Resource Locator (URL) (bit.ly/NutritionHaveUrSay) for a one-month timeframe. It contained 16 questions, with a combination of closed-ended and open-ended questions depending on the information and level of detail required. Malnutrition was assessed, in part, using the Patient Generated-Subjective Global Assessment (PG-SGA). Main findings Those with UGI cancer had an overall weight loss during treatment of 17%, which was 2-3 fold higher than seen in patients with HNC and lung cancer. Overall weight loss was 6% and 8% for patients with HNC and lung cancer, respectively. Weight loss was likely minimised in the HNC group with weekly nutritional intervention from a dietitian for all patients; for UGI cancer patients, 34 received dietitian intervention and 16 patients in those with lung cancer at ACH. Responses from the questionnaire (n=290) confirmed that malnutrition levels were similar to the peer-reviewed literature, with 53% of patients considered well-nourished, and 47% malnourished (SGA score B+C). The levels of nutrition impact symptoms showed 40% having multiple side effects likely to impact food intake and contribute to weight loss. Over half of the patients (58%) changed their diet due to these side effects. Nutrition and awareness of malnutrition is everyone’s responsibility. Oncology patients receive their nutrition advice primarily from their oncology doctors (47%) followed by nursing staff at 29%, then dietitians within the hospital and community settings (27%) along with family and friends (27%). Nearly a third of cancer patients change their diet to improve their overall health outcomes (32%). Conclusion Malnutrition is underdiagnosed and undertreated for oncology patients at ACH. Nutrition screening should be completed for all patients at each clinic review. Ideally, an electronic screening tool will reduce staff burden and allow for an audit of success with the implementation of malnutrition screening. For those who screen at high-risk for malnutrition, there should be access to timely nutritional intervention. Patients with HNC, UGI and lung cancer should have a routine nutritional intervention. A website dedicated to nutrition for cancer patients could allow patients to manage treatment side effects and evidence-based advice to improve health outcomes.