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Complete
Summary
GUIDELINE TITLE
Cancer. Nutrition management for older adults.
BIBLIOGRAPHIC SOURCE(S)
Barrocas A, Purdy D, Brady P, Troutman D. Cancer. Nutrition
management for older adults. Washington (DC): Nutrition
Screening Initiative (NSI); 2002. 19 p. [28 references]
GUIDELINE STATUS
This is the current release of the guideline.
** REGULATORY ALERT **
FDA WARNING/REGULATORY ALERT
Note from the National Guideline Clearinghouse: This guideline
references a drug(s) for which important revised regulatory
information has been released.
On April 7, 2005, after concluding that the overall risk
versus benefit profile is unfavorable, the FDA requested
that Pfizer, Inc voluntarily withdraw Bextra (valdecoxib)
from the market. The FDA also asked manufacturers of all
marketed prescription nonsteroidal anti-inflammatory drugs
(NSAIDs), including Celebrex (celecoxib), a COX-2 selective
NSAID, to revise the labeling (package insert) for their
products to include a boxed warning and a Medication Guide.
Finally, FDA asked manufacturers of non-prescription (over
the counter [OTC]) NSAIDs to revise their labeling to include
more specific information about the potential gastrointestinal
(GI) and cardiovascular (CV) risks, and information to assist
consumers in the safe use of the drug. See the FDA Web site
for more information.
Subsequently, on June 15, 2005, the FDA requested that sponsors
of all non-steroidal anti-inflammatory drugs (NSAID) make
labeling changes to their products. FDA recommended proposed
labeling for both the prescription and over-the-counter
(OTC) NSAIDs and a medication guide for the entire class
of prescription products. All sponsors of marketed prescription
NSAIDs, including Celebrex (celecoxib), a COX-2 selective
NSAID, have been asked to revise the labeling (package insert)
for their products to include a boxed warning, highlighting
the potential for increased risk of cardiovascular (CV)
events and the well described, serious, potential life-threatening
gastrointestinal (GI) bleeding associated with their use.
FDA regulation 21CFR 208 requires a Medication Guide to
be provided with each prescription that is dispensed for
products that FDA determines pose a serious and significant
public health concern. See the FDA Web site for more information.
COMPLETE SUMMARY CONTENT
** REGULATORY ALERT **
SCOPE
METHODOLOGY - including Rating Scheme and Cost Analysis
RECOMMENDATIONS
EVIDENCE SUPPORTING THE RECOMMENDATIONS
BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
IMPLEMENTATION OF THE GUIDELINE
INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY
REPORT CATEGORIES
IDENTIFYING INFORMATION AND AVAILABILITY
DISCLAIMER
SCOPE
DISEASE/CONDITION(S)
Cancer
Cancer anorexia
Cancer cachexia
GUIDELINE CATEGORY
Counseling
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
CLINICAL SPECIALTY
Family Practice
Geriatrics
Internal Medicine
Nutrition
Oncology
Preventive Medicine
INTENDED USERS
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
GUIDELINE OBJECTIVE(S)
To provide nutrition screening and intervention strategies
for cancer and cancer anorexia/cachexia that will enhance
disease management and health care outcomes and that will
positively impact individual health and quality of life
of older adults
TARGET POPULATION
Elderly individuals who are at increased risk of developing
cancer; individuals with a cancer that interferes with food
and nutrient intake; and individuals on anti-neoplastic
regimens that have an impact on nutritional status
INTERVENTIONS AND PRACTICES CONSIDERED
Assessment and Management of Cancer Cachexia
1. Assessment tools including the "patient-generated
subjective global assessment" (PG-SGA)
2. Pharmaconutrition management
Appetite stimulants
Anti-metabolic and anti-catabolic agents
Anabolic agents
Appropriate nutrition
Nutrition Screening for Cancer
Risk Assessment
1. Measurement of body weight and height
2. Evaluation of food and nutrient intake
3. Evaluation of physical activity and functional status
4. Evaluation of current medication, smoking habits, and
alcoholic beverage use
Evaluation in Patients Diagnosed with Cancer
1. Evaluation of serum albumin, serum cholesterol
2. Identification of type of cancer treatment
3. Evaluation of addition anthropomorphic indices of nutritional
status
4. Evaluation of physical signs/symptoms of nutritional
deficiency
Nutrition Interventions for Cancer
Interventions to Reduce Risk of Cancer
1. Maintenance of reasonable weight
2. Making appropriate food choices (e.g., plants sources,
limiting fats, increasing fiber)
3. Moderation/elimination of alcohol
4. Minimizing intake of salt-cured, salt-pickled, smoked
foods
5. Smoking cessation
6. Physical activity
MAJOR OUTCOMES CONSIDERED
Impact of nutritional status on cancer incidence, progression,
prognosis, and health outcomes
Effect of pharmaconutrition on cancer cachexia and/or
anorexia
METHODOLOGY
METHODS USED TO COLLECT/SELECT EVIDENCE
Searches of Electronic Databases
DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE
EVIDENCE
Not stated
NUMBER OF SOURCE DOCUMENTS
Not stated
METHODS USED TO ASSESS THE QUALITY AND STRENGTH
OF THE EVIDENCE
Not stated
RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE
Not applicable
METHODS USED TO ANALYZE THE EVIDENCE
Review
DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE
Not stated
METHODS USED TO FORMULATE THE RECOMMENDATIONS
Informal Consensus
DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS
Professionals with expertise in nutrition, medicine, and
allied disciplines served as authors and reviewers.
The information in A Physicians Guide to Nutrition in Chronic
Disease Management for Older Adults-Expanded Version is
derived from The Role of Nutrition in Chronic Disease Care,
a 1997 Nutrition Screening Initiative (NSI) publication.
The authors updated their 1997 work through an extensive
review of the literature, using evidence-based data where
possible and consensus-based information when definitive
outcomes were not available.
RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS
Not applicable
COST ANALYSIS
The benefits of implementing low cost, low tech nutritional
screening and intervention to reduce cancer risk are significant.
It is currently estimated that about 32% of cancers may
be avoidable by changes in diet, with 20 to 42% of cancer
deaths avoidable by dietary change. Some evidence has accumulated
to suggest that differences in activity patterns may account
for some of the risk reduction formerly attributed to nutritional
factors. However, recent data suggest that in addition to
reductions in meat and fat consumption, the protective effects
of as yet unidentified substances in fruits and vegetables
are primary factors that contribute to these estimates of
risk reduction.
Patients with cancer, particularly those receiving radiation
or chemotherapy or those with advanced disease, often experience
anorexia, decreased food intake, fatigue, weight loss, muscle
wasting, and a decline in functional status. The provision
of appropriate nutritional support often affords these patients
a better quality, if not longer, life. From a health care
provision standpoint, an intervention may be indicated and
considered cost effective when the combination of its effects
on length and/or quality of life warrant its use and support
the required expense. Criteria useful in making decisions
to refer patients for nutrition intervention are shown in
Figure 4 of the original guideline document. Conservative
cost estimates for nutrition interventions range from $52.00/month
for home prepared supplements to $8,400/month for home parenteral
nutrition support. The estimated yearly national cost for
home enteral nutrition and home parenteral nutrition services
are $357 million and $780 million, respectively. The majority
of these services are generated in meeting the nutritional
needs of patients with cancer. At times, the use of life
sustaining measures may not be in the patient's best interest.
See Fig. 5 of the original guideline document to facilitate
such decisions.
METHOD OF GUIDELINE VALIDATION
External Peer Review
DESCRIPTION OF METHOD OF GUIDELINE VALIDATION
An interdisciplinary advisory committee of nationally recognized
practitioners in medicine, nutrition, and geriatrics reviewed
the chapter related to their area of expertise.
RECOMMENDATIONS
MAJOR RECOMMENDATIONS
Nutrition Screening Guidelines for Cancer (CA)
At a minimum, nutrition screening for individuals at risk
of developing CA should include:
Measure body weight at each office visit, calculate body
mass index (BMI)
Measure height (annually in those age 65 and older)
Evaluate food and nutrient intake
Evaluate physical activity level and functional status
Evaluate current medications use
Evaluate smoking habits
Evaluate alcoholic beverage use
In addition to the elements listed above, screening in individuals
who have been diagnosed with CA should include:
Evaluate serum albumin level (>3.5 mg/dl)
Evaluate serum cholesterol level (160 to 200 mg/dl, note
precipitous drop)
Identify type of cancer treatment utilized (i.e., radiation,
surgery, chemotherapy, immunotherapy)
Evaluate additional anthropometric indices of nutritional
status if indicated (e.g.,
triceps skinfold, arm muscle circumference)
Evaluate possible physical signs/symptoms of nutritional
deficiency
Use of the Nutrition Screening Initiative's (NSI 1992) DETERMINE
Your Nutritional Health Checklist and Level II Screen provide
a structured approach in assessing the majority of the elements
listed above. The Level II Screen is an invaluable initial
resource in the identification and treatment of nutritional
risk factors associated with CA development and in the initial
assessment of patients with cancer. (See the appendices
of the original guideline document for these tools.)
Nutrition Intervention Guidelines for CA
Nutrition intervention to reduce risk of CA development
should include:
Maintain a reasonable weight (body mass index [BMI] 22
to 27)
Choose the majority of foods from plant sources
>5 servings of fruit and vegetables daily
>6 to 11 servings from the cereals and grain group
Increase consumption of dried beans and peas as protein
sources, especially soy
beans/soy products
Limit intakes of high fat foods, especially those from
animal sources. Choose:
Low fat foods
Low fat dairy products
Lean cuts of meat, poultry without skin
Low fat cooking methods
Increase dietary fiber intakes to 20 to 30 g/day (upper
limit 35 g/day)
Moderate consumption/elimination of alcoholic beverages
Minimize intake of salt-cured, salt-pickled, or smoked
foods
Stop smoking
Be physically active
Nutrition intervention for patients undergoing definitive
therapy for cancer is highly individualized and should be
based upon risks associated with the provision of nutritional
support and expected benefits to be accrued. An excellent
publication of the National Cancer Institute (NCI 1992),
Eating Hints: Recipes & Tips for Better Nutrition During
Cancer Treatment, offers practical suggestions regarding
food intake for patients with cancer and their families.
When patients are unable to meet their nutritional needs
via the oral route, the services of a Registered Dietitian
(RD) should be enlisted to assist the patient in maintaining
optimal achievable nutritional status.
Assessment and Management of Cancer Cachexia
The early identification of patients at risk for or with
cancer cachexia is of paramount importance in successful
outcomes. A variety of tools and tests are available. One
particular assessment tool which has been validated and
continues to gain acceptance is the patient-generated subjective
global assessment (PG-SGA) developed by The Society for
Nutritional Oncology Adjuvant Therapy (NOAT) and adopted
by The American Dietetic Associations Oncology Dietetic
Practice Group. Developed in 1993 from the original SGA
of Detsky et al., in 1987, this simple-to-administer tool
is able to classify the risks of malnutrition and cachexia
from information available directly from the patient or
a surrogate. The PG-SGA has been available in Spanish since
1998.
The pharmaconutrition management of cancer cachexia has
four components:
Appetite stimulants (orexigenic). Agents include progestational
agents (e.g., megestrol acetate), tetrahydrocannabinol (THC)-related
agents (e.g., dronabinol, marijuana), corticosteroids (e.g.,
prednisolone acetate, dexamethasone), cyproheptadine, periactin,
and ethanol. While these agents can increase appetite and
weight, they do not prevent the decline in somatic and visceral
protein that is so devastating to the cancer patient.
Anti-metabolic and anti-catabolic agents. These are employed
with the hopes of down-regulating the pro-inflammatory cascade
that leads to anorexia and/or cachexia. These include pentoxifylline,
hydrazine sulfate, thalidomide, melatonin, and others including
steroids and non-steroidal auto inflammatory agents, such
as ibuprofen. In addition, alteration in the composition
of dietary fats to increase levels of the less inflammatory
prostaglandins precursors eicosapentaenoic acid (EPA) and
fish oils have also been proposed. The majority of studies
using these modalities have not demonstrated consistent
benefits. However, recent reports using combinations (i.e.,
ibuprofen, fish oil, megestrol acetate) appear promising.
Anabolic agents. Though often fraught with undesirable
side effects, anabolic agents have been shown to improve
the protein status in selected patients. These agents include
testosterone, nandrolone, oxandrolone, growth hormone, and
others.
Appropriate nutrition. In addition to utilizing the three
previous modalities, appropriate nutrition, preferably through
the oral route, is recommended. In general, 25 to 30 calories/kg
per day and 1.5 to 2.0 g of protein/kg per day is recommended,
if tolerated, for the moderately/severely stressed cachectic
cancer patient.
These four modalities provide appetite stimulation, reduce
inflammatory response, increase anabolic signals, and provide
the necessary macro and micronutrients. When these methods
are combined with attempts to reduce or eliminate inflammatory
nidus through tumor excision or debulking, they offer the
optimal approach to reduce cancer cachexia.
CLINICAL ALGORITHM(S)
Algorithms for "Nutrition Intervention in Cancer Anorexia"
and "Decision to Forego Life Sustaining Measures"
are provided in the original guideline document.
EVIDENCE SUPPORTING THE RECOMMENDATIONS
TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of supporting evidence is not specifically stated
for each recommendation.
BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
POTENTIAL BENEFITS
Benefits of Nutrition Management to Patients
Implementation of nutritional screening and risk reduction
strategies in older people can help to prevent or delay
the development of cancer in otherwise healthy individuals.
The benefits of such low cost, low tech interventions are
obvious.
Oral, enteral, or parenteral nutrition support methodologies
may not always be effective in retarding tumor growth or
in the prevention of cancer recurrence after definitive
therapy (e.g. radiation, surgery, chemotherapy, immunotherapy).
However, many patients report significant improvement in
the quality of life indices of gastrointestinal discomfort,
nausea, vomiting, fatigue level, morale, and social interactions
during the course of nutrition intervention. Nutrition interventions
are also frequently provided during definitive cancer therapy
in an attempt to improve outcome or ameliorate toxicity.
They facilitate the optimum delivery of either curative
or palliative therapy at lower risk.
Recognition of the significant alterations in metabolism
that occur in individuals with cancer has led to the development
of newer enteral/parenteral formulations that may be of
benefit in counteracting derangements in host metabolism
experienced by patients with cancer (e.g. various combinations
of amino acids, carnitine supplementation). These types
of products show promise in the amelioration of malnutrition
and perhaps reduction in tumor growth rates in people with
this dreaded disease. However, they are of unproven efficacy
at this time.
POTENTIAL HARMS
Not stated
IMPLEMENTATION OF THE GUIDELINE
DESCRIPTION OF IMPLEMENTATION STRATEGY
Health care professionals must decide how best to implement
these recommendations in multiple settings and in patients
with diverse needs. It is essential to develop a habitual
approach to the nutrition screening and assessment of nutritional
status in older adults, and develop policies, protocols,
and procedures to ensure the implementation of disease-specific
nutritional interventions. The reader should refer to other
Nutrition Screening Initiative (NSI) materials for additional
information and to facilitate a systematic approach to nutritional
care. NSI screening tools are included as appendices of
the original guideline document --
DETERMINE Your Nutritional Health Checklist
and Levels I and II Screens. The Checklist was developed
as a self-administered tool designed to increase public
awareness of the importance of nutritional status to health
and to encourage older people to discuss their own nutritional
status with their primary provider. Based on this guided
discussion, the provider can decide if additional screening
or assessment is indicated. The Level I Screen was designed
for administration by non-physician health care providers
in community settings while Level II requires administration
by physicians and physician-extenders that have the ability
to order and interpret laboratory parameters indicative
of nutritional health.
Evaluation Criteria to Document Improved Health
Outcomes
Evaluation criteria useful in documenting the impact of
nutrition screening and intervention on health status are
consistent with the goals of nutrition screening and intervention
to reduce cancer risk, and include:
Maintenance of a reasonable weight (body mass index [BMI]
22 to 27 for those age 65 years and older, or a weight within
the desirable range on standard weight-for-height tables)
Consumption of minimum number of recommended servings
from vegetable, fruit, and grain groups
Consumption of dried beans and peas as protein sources,
especially soy beans/soy products
Limited intake of high fat foods, especially those from
animal sources
Increased dietary fiber intakes to 20 to 30 g/day (upper
limit 35 g/day)
Moderate consumption/eliminate alcoholic beverages
Limited intake of salt-cured, salt-pickled, or smoked
foods
Stop smoking
Increased physical activity consistent with age and ability
In individuals with established cancer, evaluation criteria
useful in documenting the impact of nutrition screening
and intervention on health status include, in addition to
maintenance of a reasonable weight, when possible, factors
related to quality of life such as:
Reduced gastrointestinal discomfort
Improved ability to swallow
Improved food taste
Reduced mouth dryness
Increased food/nutrient intake
Decreased nausea and/or vomiting
Enhanced energy level
Improved functional status
Improved emotional and/or cognitive status
Improved morale
Increased social interaction
Evaluation Criteria to Document the Impact of Nutrition
Management on the Health Care System
In addition to the evaluation criteria listed above, the
following may be used to assess the impact of nutrition
screening and intervention for cancer on the delivery of
health care. Reductions or improvements in these indicators
could be used to document a positive impact of nutrition
screening and intervention in individuals at increased risk
of developing cancer or those with established cancer to
whom routine and appropriate nutritional care is made available.
Incidence of diet-related cancers in the population served
Tolerance for cancer treatment prescribed
Incidence/improvement in nutritional comorbidities commonly
seen in patients with cancer
Type, quantity, or number of doses of medication needed
to manage the nutrition-related side effects of cancer therapy
Number of visits to the health care provider needed to
successfully manage nutritional comorbidities associated
with cancer and/or its treatment
Rates of admission, readmission, or length of stay in
acute or long-term care settings for the management of cancer
and/or its nutrition-related consequences
IMPLEMENTATION TOOLS
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the "Availability
of Companion Documents" and "Patient Resources"
fields below.
INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE
QUALITY REPORT CATEGORIES
IOM CARE NEED
End of Life Care
Living with Illness
Staying Healthy
IOM DOMAIN
Effectiveness
Patient-centeredness
IDENTIFYING INFORMATION AND AVAILABILITY
BIBLIOGRAPHIC SOURCE(S)
Barrocas A, Purdy D, Brady P, Troutman D. Cancer. Nutrition
management for older adults. Washington (DC): Nutrition
Screening Initiative (NSI); 2002. 19 p. [28 references]
ADAPTATION
Not applicable: The guideline was not adapted from another
source.
DATE RELEASED
2002
GUIDELINE DEVELOPER(S)
American Academy of Family Physicians - Medical Specialty
Society
American Dietetic Association - Professional Association
Nutrition Screening Initiative - Professional Association
GUIDELINE DEVELOPER COMMENT
The Nutrition Screening Initiative (NSI) is a partnership
of the American Academy of Family Physicians (AAFP) and
the American Dietetic Association (ADA). It is funded in
part through a grant from Ross Products Division, Abbott
Laboratories.
Additional information can be obtained from the AAFP Web
site and the ADA Web site.
SOURCE(S) OF FUNDING
The Nutrition Screening Initiative (NSI) is funded in part
through a grant from Ross Products Division, Abbott Laboratories.
GUIDELINE COMMITTEE
Not stated
COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE
Primary authors: Albert Barrocas, MD, FACS (Vice President
Medical Affairs and Medical Director of Nutrition Support
and Home Health Services, Pendleton Memorial Methodist Hospital,
New Orleans, LA); Dana Purdy, RD, LDN (Consultant Dietitian,
Nutri Pro Inc., New Orleans, LA); Patrick Brady, RN, BSN,
OCN, CPT (Community Nurse Educator, Wellspring Coordinator,
Pendleton Memorial Methodist Hospital, New Orleans, LA);
Debra Troutman, RN, OCN (Patient Care Coordinator, Radiation
Therapy, Cancer Center, Pendleton Memorial Methodist Hospital,
New Orleans, LA)
FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST
Not stated
GUIDELINE STATUS
This is the current release of the guideline.
GUIDELINE AVAILABILITY
Electronic copies: Available from the American Academy of
Family Physicians (AAFP) Web site and to members only from
the American Dietetic Association (ADA) Web site.
Print copies: Not available
AVAILABILITY OF COMPANION DOCUMENTS
The following is available:
Nutrition Screening Initiative (NSI). A physicians guide
to nutrition in chronic disease management for older adults.
Washington (DC): Nutrition Screening Initiative (NSI); 2002.
18 p.
Electronic copies available in Portable Document Format
(PDF) from the American Academy of Family Physicians (AAFP)
Web site and the American Dietetic Association (ADA) Web
site.
Electronic copies also available for download in Personal
Digital Assistant (PDA) format from the American Academy
of Family Physicians (AAFP) Web site.
Print copies: Available from Ross Educational Service Materials;
Phone: (800) 986-8503; Web site: www.Ross.com/nsi.
PATIENT RESOURCES
The following is available:
Managing chronic disease. Food tips if you need extra
nutrients. In: Nutrition Screening Initiative (NSI). A physicians
guide to nutrition in chronic disease management for older
adults. Washington (DC): Nutrition Screening Initiative
(NSI); 2002. 4 p.
Electronic copies available in Portable Document Format
(PDF) from the American Academy of Family Physicians (AAFP)
Web site and the American Dietetic Association (ADA) Web
site.
Electronic copies also available for download in Personal
Digital Assistant (PDA) format from the American Academy
of Family Physicians (AAFP) Web site.
Print copies: Available from Ross Educational Service Materials;
Phone: (800) 986-8503; Web site: www.Ross.com.
Please note: This patient information is intended to provide
health professionals with information to share with their
patients to help them better understand their health and
their diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide specific
medical advice for particular patients. Rather we urge patients
and their representatives to review this material and then
to consult with a licensed health professional for evaluation
of treatment options suitable for them as well as for diagnosis
and answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for health care professionals included on NGC by the authors
or publishers of that original guideline. The patient information
is not reviewed by NGC to establish whether or not it accurately
reflects the original guideline's content.
NGC STATUS
This summary was completed by ECRI on April 16, 2004. The
updated information was verified by the guideline developer
on June 21, 2004. This summary was updated on May 3, 2005
following the withdrawal of Bextra (valdecoxib) from the
market and the release of heightened warnings for Celebrex
(celecoxib) and other nonselective nonsteroidal anti-inflammatory
drugs (NSAIDs). This summary was updated by ECRI on June
16, 2005, following the U.S. Food and Drug Administration
advisory on COX-2 selective and non-selective non-steroidal
anti-inflammatory drugs (NSAIDs).
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which
is subject to the guideline developers copyright restrictions.
For reprint permissions, please contact Marti Andrews, Ross
Products Division, at (614) 624-3381, e-mail: marti.andrews@abbott.com.
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