Nutrition Screening and Counseling in Patients With Lung Cancer in an Outpatient Setting SUSAN SNIGHT MORELAND, DNP, CRNP
From The Catholic University of America, Washington, DC Author’s disclosures of potential conflict of interest are found at the end of this article. Correspondence to: Susan Snight Moreland, DNP, CRNP, 620 Michigan Avenue NE, Washington, DC 20064. E-mail: [email protected]
© 2012 Harborside Press®
J Adv Pract Oncol 2012;3:191–193
alnutrition is evident in 30% to 90% of patients with cancer at some point during their disease course (Molina, Yang, Cassivi, Schild, & Adjei, 2008; Nitenberg & Raynard, 2000; Read et al., 2005). Significant weight loss (> 10% of body weight) increases the risk of morbidity and mortality in individuals with cancer (Bozzetti, 2009; Dewys et al., 1980; Nitenberg & Raynard, 2000; Ottery, 1996). At diagnosis, at least one third of patients exhibit weight loss of > 5%, but this number is significantly higher in those with advanced disease (Ottery, 1996). Along with this weight loss, there are also changes in protein and albumin status that indicate progressive deterioration of nutritional status and propensity for cachexia (Esper & Harb, 2005). Thus, it is important to recognize those patients who are at risk for malnutrition or who are already malnourished at diagnosis. In an outpatient private practice, a dietitian or nutritionist may not be available for nutrition counseling; thus, this important step becomes an essential component of the oncology advanced practitioner’s role. In this article, an intervention developed at a suburban outpatient practice to address the problem of malnutrition in lung cancer patients is described. A synopsis of the screening and counseling program is given. AdvancedPractitioner.com
Initial Office Visit
At the first office visit, newly diagnosed lung cancer patients were approached to participate in the pilot study. Seven patients (four males, three females) consented to participate. One participant had stage II disease, three had stage III disease, and three had stage IV disease. Participants ranged in age from 45 to 83 years and all were either current (six patients) or former (one patient) smokers. Six of the participants had a diagnosis of non–small cell lung cancer and one had small-cell lung cancer. During the first visit, baseline bloodwork was ordered: complete blood cell (CBC) count with differential, comprehensive metabolic panel, and C-reactive protein (CRP). The CRP was added because evidence shows that there is elevation of the acute proinflammatory humoral response in patients who are at risk for malnutrition and cachexia (J. Brown, personal communication, April 2, 2009; Esper & Harb, 2005; Nitenberg & Raynard, 2000; Slaviero, Read, Clarke, & Rivory, 2003). Each patient made an appointment for an individualized counseling session during the next week.
Initial Individualized Nutrition Counseling Session
Each individualized nutrition counseling session with the patient and family members included an explanation of the nutrition screening,
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setting of individual goals for the intervention, bloodwork Answer questions review, explanation and comfrom patient/family pletion of required screening Discuss individual Discuss reasons tools, and discussion of nutrigoals of intervention for screening tion information. During the first session, the project goal Nutrition was explained to the patient counseling session and family members as being Discuss cancer the successful screening for Review bloodwork pathology nutritional deficiencies, the evaluation of any deficiencies, Expand and the provision of counselknowledge/give Complete QOL and ing and support during therapy suggestions PG-SGA tools (diet sheets) to mitigate any deficiencies. The patient and family members also shared their goals for study participation. See Figure Figure 1. Components of the first individualized nutrition 1 for a flow chart depicting the counseling session. QOL = quality of life; PG-SGA = Patientcomponents of the first indiGenerated Subjective Global Assessment. vidualized nutrition counseling session. tributed and reviewed. During the session, the The baseline bloodwork review highlighted patient completed the Scored Patient-Generated areas of concern. In particular, the CBC and other Subjective Global Assessment (PG-SGA) tool indices that are important in evaluating for nutri(Ottery, 1996). tion deficiencies (WBC count, hemoglobin, hemaThe PG-SGA tool evolved from the Subjectocrit, and platelet count) were explained to the tive Global Assessment, which was first used in patient and family members. The nurse practitiothe 1980s to determine a hospitalized patient’s ner investigator discussed albumin and its role as nutrition status (Baker et al., 1982). In 1996, the an indicator of nutrition status. The patient’s CRP PG-SGA tool was modified, by Faith Ottery at Fox level was noted, and its significance as it pertains Chase Cancer Center, to reflect the particular to nutrition was explained. A pamphlet on nuconcerns related to oncology patients. The instrutrition information from the American Institute ment has a 98% specificity and an 82% sensitivity. for Cancer Research (2007), entitled Nutrition of The top section is completed by the patient and/ the Cancer Patient: Special Population Series, was or family member with regard to weight changes, distributed. This series of pamphlets focuses on amount of food intake, symptoms caused by cancancer patients in active treatment and is brocer or therapy, and current activity level. In the ken down into understanding the side effects of lung cancer study, the nurse practitioner investitherapy, treating them at home, and avoiding the gator completed the remainder of the tool. The complications in the future. Information sheets worksheet is made up of categories that score for with suggestions on increasing caloric intake weight loss, criteria or condition (other comorthrough shakes and protein-rich foods were disbidities), metabolic stress, physical examination, and global assessment. The investigator’s and patient’s scores are combined to obtain an overall assessment score. The patient and/or family member also completed a quality-of-life tool for the study, but this is outside the scope of this arUse your smartphone to view the scoresheet for the PG-SGA ticle and will not be discussed. nutrition screening tool. This counseling process was repeated 6 and 12 weeks after starting therapy and coincided with SEE PAGE XXX SEE PAGE 150 follow-up scans for determination of response to J Adv Pract Oncol
NUTRITION SCREENING AND COUNSELING
therapy. The patients and their family members were also given the nurse practitioner investigator’s contact information for any questions that might arise between counseling sessions.
needed on the best way to empower these complicated patients with the information and tools necessary to sustain their nutrition during the disease process. As advanced practitioners, we need to do our part to collect this evidence and incorporate it into our practice patterns.
Results Based on analysis of aggregate data from phone conversations with patients and family members, results from the pilot study indicate that the patients and their family members felt that both undergoing individualized counseling and being assigned a designated contact person were beneficial. There was a correlation between CRP level and physical well-being. Patients with a higher CRP level, indicating greater inflammation, reported lower scores for physical well-being and vice versa. The serum albumin levels ranged from 2.4 to 4.6 mg/L, with a mean of 3.657 mg/L and a standard deviation of 0.76. In all cases, serum albumin levels either remained stable or rose during the 12 weeks of the study. Recorded patient contacts to the nurse practitioner investigator were high in the first and last intervals. There was a direct correlation between PG-SGA score, or nutrition status, and the number of telephone questions. These data indicated that even though nutrition scores did improve over time, the participants felt that having the contact person as a resource was a positive experience. Due to the patients’ acuity and the study duration, there were only seven participants, one of whom died before completing the study. Thus, it is difficult to generalize the findings from this pilot study.
The author has no conflicts of interest to disclose. REFERENCES American Institute for Cancer Research. (2007). Nutrition of the Cancer Patient: Special Population Series. Retrieved from http://preventcancer.aicr.org/site/ PageServer?pagename=pub_nutrition_cp Baker, J. P., Detsky, A. S., Wesson, D. E., Wolman, S. L., Stewart, R. N., Whitewell, J.,…Jeejeebhoy, K. N. (1982). Nutritional assessment—A comparison of clinical judgment and objective measurements. New England Journal of Medicine, 306, 969–972. http://dx.doi.org/10.1056/ NEJM198204223061606 Bozzetti, F. (2009). Screening the nutritional status in oncology: A preliminary report on 1,000 outpatients. Supportive Care in Cancer, 17, 279–284. http://dx.doi.org/ 10.1007/s00520-008-0476-3 DeWys, W. D., Begg, C., Lavin, P. T., Band, P. R., Bennett, J. M., Bertino, M. R.,...Tormey, D. C. (1980). Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. American Journal of Medicine, 69(4), 491–497. http://dx.doi. org/10.1016/S0149-2918(05)80001-3 Esper, D. H., & Harb, W. A. (2005). The cancer cachexia syndrome: A review of the metabolic and clinical manifestations. Nutrition in Clinical Practice, 20, 369–376. http://dx.doi.org/10.1177/0115426505020004369 Molina, J. R., Yang, P., Cassivi, S. D., Schild, S. E., & Adjei, A. A. (2008). Non-small cell lung cancer: Epidemiology, risk factors, treatment, and survivorship. Mayo Clinic Proceedings, 83, 584–594. http://dx.doi. org/10.4065/83.5.584 Nitenberg, G., & Raynard, B. (2000). Nutritional support of the cancer patient: Issues and dilemmas. Critical Reviews in Oncology Hematology, 34, 137–168. http:// dx.doi.org/10.1016/S1040-8428(00)00048-2 Ottery, F. D. (1996). Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition, 12(1 suppl), S15–S19. Read, J. E., Crockett, N., Volker, D. H., Maclennan, P., Choy, S. B., Beale, P., & Clarke, S. J. (2005). Nutritional assessment in cancer: Comparing the Mini-Nutritional Assessment (MNA) with the Scored Patient-Generated Subjective Global Assessment (PG-SGA). Nutrition and Cancer, 53(1), 51–56. http://dx.doi.org/10.1207/ s15327914nc5301_6 Slaviero, K. A., Read, J. A., Clarke, S. J., & Rivory, L. P. (2003). Baseline nutritional assessment in advanced cancer patients receiving palliative chemotherapy. Nutrition and Cancer, 46, 148–157. http://dx.doi.org/10.1207/ S15327914NC4602_07
Implications for the Oncology Advanced Practitioner
Monitoring the nutrition status of oncology patients is vital to their continued well-being. Oncology advanced practitioners play a unique role, which allows them to screen and counsel these patients during their treatment. The pilot study results discussed in this article describe positive effects from an intervention conducted by an advanced practice clinician in an outpatient clinic setting. Because patients are frequently in the office for an appointment, it is an easy way to maintain contact and manage any side effects from treatment before they can cause major problems. However, further research is
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