McGill Cancer Nutrition – Rehabilitation Program

CANCER NUTRITION Dr. Martin Chasen Medical Oncologist/ Palliative Care Physician Clinical Director McGill Cancer Nutrition and Rehabilitation Program The McGill University Nutrition-Rehabilitation Programme www.mcgill.ca/cnr McGill Cancer Nutrition – Rehabilitation Program  Cancer rehabilitation is a process that assists the patient to obtain optimal physical, social, nutritional, psychological and vocational functioning within the limits created by the disease and its treatment McGill Cancer Nutrition – Rehabilitation Program (CNRP)  Organizational Structure McGill Department of Oncology  Division of Palliative Medicine  Departments of Medicine and Oncology MUHC    Origin 2003 with clinics at the Sir Mortimer B Davis-Jewish General Hospital and Department of Medicine MUHC 2006 Cancer Rehabilitation Program RVH Role of the Dietitian complete a thorough nutrition assessment  design a nutrition care plan tailored to the patient’s needs  provide counseling and information on optimizing food intake  provide counseling on symptom control such as nausea, vomiting, diarrhea, etc  ensure adequate food intake to optimize function and quality of life  American Society of Parenteral and Enteral Nutrition recommends that all patients undergo nutritional screening as a component of their initial assessment Nutritional Status is important: Predicts the risk associated with treatment Predicts response to treatment Predicts survival and Quality of Life    Cancer Cachexia Progressive weight loss  Early satiety  Generalized weakness  Decreased function  Progressive wasting  Nutritional Screening  Early recognition = Screening Height Weight Weight change Diagnosis, stage Co-morbidities 1. 2. 3. 4. 5. Nutritional Assessment  Registered Dietitian 1. 2. 3. 4. 5. Medical history Dietary history Physical examination Antropometric measurements Laboratory data To be effective    In routine clinical practice Patients screened at initial visit Early education PG-SGA  Weight   Present, one month ago, six months ago Weight in last 2 weeks: decreased, increased unchanged Unchanged, more than usual, less than usual   Food Intake  Symptoms  No problems eating, no appetite, taste changes, nausea, vomiting, diarrhea, constipation, mouth sores, dry mouth, swallowing problems, smells bothersome, feel full quickly, pain Normal with no limitations, not normal but able to be up and about with fairly normal activities, not feeling up to most things, able to do little activity , pretty much bedridden  Activities and Function  Use of Patient Generated Subjective Global Assessment Tool Dietary Counseling improves patient outcomes. A prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. Paula Ravasco, Isabel Monteiro-Grillo, Pedro Marques Vidal et al. JCO 23:1431-1438 March 1 2005 111 colorectal patients 45 stage I/II 66 Stage III/IV 37 – dietary counseling on regular foods  37 – protein supplements (2 cans/day)  37 – ad libitum intake  RAVASCO Evaluation  Nutritional Intake (diet history)  24 hour food recall questionnaire Anthropometric Data  PGSGA  QoL (EORTC – QLQ – C30  At end of RT  Group 1 – Energy intake increase of 555kcal/d (398 – 758) p = 0.002 Group 2 – Energy intake increase of 296 kcal/d (286 – 401) p = 0.04 Group 3 – Energy intake decreased - 285kcal/d (201 – 398) p < 0.1   Group 1 > Group 2 (p = 0.001) Baseline    15 malnourished in Group 1 14 malnourished in Group 2 13 malnourished in Group 3 At 3 month  Additional nutritional degeneration in G 2 and G3 relative to G1 (p < 0.001)  Quality of Life At 3 months: G1 patients maintained or improved QoL (p < 0.02) G2 patients maintained or worsened QoL (p < 0.03) G3 patients deteriorated (p< 0.004) CANCER REHAB TEAM Physician Nurse Psychologist Physiotherapist Occupational Therapist Dietician Nurse Educator Medical Secretary January - October 2006            136 new patient referrals Age Range: 18-84 yrs 71 male 65 female Diagnoses: Hepato-biliary -- 21 Breast –20 Gastro/Esophageal –28 Pancreatic – 10 Colorectal – 12 Lung –12 Gynecological- 10 Hematological – 15 Other – 9 Gastric Pacesetter and EGG Waves 3 EGG Procedure Visipace Electrogastrogram Analyzer 1. Baseline (10 min) 2. Water load 3. Test (30 min) 3 EGG Summary Report 3 Studies Carried out at MUHC Age Distribution (19-82 yrs) 2 Total number of Patients (n= 24) 10 14 male female 16 6 < 30 30 - 60 > 60 3 Studies Carried out at MUHC (cont’d) Patients' diagnoses 8 7 6 5 4 3 2 1 0 7 6 6 5 GI (esophageal, pancreatic, gastric, colon) lung breast + ovarian+ endometrial others (brain, leukemia, myeloma, multiple mets unknown primary) 3 100% Studies Carried out at MUHC 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% 87% 80% 73% 73% 60% 60% 53% 53% 47% 47% 47% 40% 40% 40% 40% 40% 33% Dyspepsia Symptoms of the Patients Fu ll fe Fr el eq in In g St ue ab af om nt ilit te y bu ac rm to rp h ea f in di in sc g ls ish pr om no be fo rm lch rt, al w in -s ith g ize ou d tp m ai ea n, ls af St te om rm ac ea ha ls ch e St Bl be om oa fo t in ac re g h m di ea st ls en or tio w n he St om n hu ac ng St ha ry om ch e ac at ha ni ch gh e t af Re te rm flu Bu x ea du rn ls rin in g g fe th el e in da g y Bu in th rp e in ch g Na wi es us th t Na ea bi tte us wh rf ea en lu id be w fo ak re e up m ea in ls th e Bu m or rn ni in Re ng g flu fe x el at in g ni in gh th t e st Na om us ac ea h af te rm ea ls Re tc hi ng 20% 3 EGG Result The result of the EGG test 10 9 8 7 6 5 4 3 2 1 0 9 7 2 1 3 2 bradygastria mixed dysrhythmiatending to bradygastria normal tachygastria mixed dysrhythmiatending to tachygastria mixed dysrthythmianonspecific 3 Top of the W O R L D !!!