June/July 2022 Issue
Malnutrition in Cancer Patients
By Whitney Christie, MS, RD, CSO, CNSC
Today’s Dietitian
Vol. 24, No. 5, P. 32
Learn what screening tools outpatient oncology dietitians are using to diagnose and improve nutrition status in this vulnerable population.
Malnutrition continues to be a pervasive problem that often is underdiagnosed and undertreated. It’s common in a variety of hospital inpatient and outpatient populations and is especially prevalent among those diagnosed with cancer. According to the European Society for Clinical Nutrition and Metabolism, 20% to 70% of cancer patients worldwide will experience malnutrition, “the inability to consume, digest, and absorb essential nutrition and hydration,” in the inpatient and outpatient settings before, during, and after treatment.1
A complex diagnosis, malnutrition may stem from many cancer-related factors, such as inflammation, cancer cachexia, and disease progression/metastases, as well as side effects from chemotherapy, immunotherapy, radiation, stem cell transplantation, or targeted or combination therapies. Malnutrition can prolong hospital stays, lead to poor surgical outcomes, decrease physical functioning, delay or reduce treatment options due to intolerance, and increase disease severity and mortality risk. It also can impact the health care system, requiring greater staffing and resources to care for these patients.
New Screening and Diagnosis Standard
The American College of Surgeons Commission on Cancer (CoC) 2020 accreditation standards—which went into effect in January 2020 but were updated in April 2022—include a new requirement for the screening and diagnosis of malnutrition in cancer patients under the Oncology Nutrition Service Standard 4.7. This standard states that oncology nutrition services should incorporate nutrition assessment and screening for malnutrition and other nutrition-related concerns, as well as overweight and obesity.2
The CoC establishes quality standards and accredits cancer programs based on those standards. More than 1,500 CoC-accredited cancer programs in the United States and Puerto Rico must comply with the new requirements.2
Protocols, screening tools, and nutrition-focused physical exams that meet the CoC standards are used to diagnose and develop treatment plans for malnutrition in the inpatient and outpatient hospital settings. Unlike inpatient settings, maintaining proper nutrition among outpatients undergoing cancer treatment can be challenging due to the difficulty of patient follow-up. Oncology dietitians often practice in a variety of locations and health care settings and may not have access to oncology EMRs. Moreover, malnutrition isn’t reimbursable for outpatients and screening tools vary among health care facilities.
In this article, Today’s Dietitian discusses the screening tools more commonly used in the outpatient setting that meet the new standards, including the Patient-Generated Subjective Global Assessment (PG-SGA); its short form, PGSGA SF; the Malnutrition Screening Tool (MST); and NUTRISCORE, and shares the experiences of a few dietitians who use these tools regularly at their health care institutions.
Outpatient Screening Tools
PG-SGA
The PG-SGA was developed more than 25 years ago by surgical oncologist Faith Ottery, MD, PhD, FACN, executive medical director of Astellas Pharma US and president of Ottery & Associates, LLC, in the Chicago area. The patient-completed portion, or the short form, of the PG-SGA is a nutrition assessment tool that includes questions about weight, food intake, symptoms, and activities and is considered a valid and reliable screening tool for outpatient oncology populations.3-6 Patients’ answers are factored into a flow sheet to complete the PG-SGA SF scoring. A physician, nurse, or dietitian completes the second portion of the PG-SGA to add points to the final score based on diagnosis, age, metabolic stress, and physical examination (eg, presence of subcutaneous fat loss or muscle wasting, edema, or ascites). The tool provides triage recommendations for scores above 2, requiring intervention by a health care professional.
Joy Heimgartner, MS, RDN, LD, an assistant professor of nutrition at Mayo Clinic in Rochester, Minnesota, works with outpatients receiving blood and bone marrow transplants. Since 2018, she has spearheaded a project through her institution’s Oncology Nutrition Subcommittee to have the PG-SGA embedded as a live tool in its Epic EMR system, and the tool debuted in December 2021. Epic is one of the largest EMR systems, containing the medical records of 45% of the US population. More than 250 health care organizations in the United States and globally use the system.7
Ottery, the developer and copyright holder of the PG-SGA, gave Epic permission to implement the tool for Mayo Clinic in collaboration with Heimgartner and wanted her to share it with any Epic-enabled institution for free. Health care facilities can request the PG-SGA tool as a turbo package through an Epic technical specialist. “We wanted a tool that could do more,” says Heimgartner, who believes the PG-SGA SF can better streamline clinical processes to optimize the quality of patient interaction.
This tool identifies all areas of malnutrition as defined by the American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism and can detect anabolic competence, or a state in which factors related to exercise, hormones, and nutrition line up to create optimal body composition and physiological function.8,9 Existing malnutrition and characteristics that may lead to malnutrition also can be detected.10,11
Moreover, PG-SGA can be used for patients with sarcopenic obesity, a patient population often overlooked for malnutrition screening. Characterized by a loss of muscle mass and strength or physical performance, sarcopenic obesity can lead to poor surgical outcomes, poor quality of life, and higher risk of mortality.12-18
All cancer patients can receive and fill out the PG-SGA SF questionnaire online through their patient portal or moments before their appointment. A 2019 study of hospitalized head and neck cancer patients found that it took patients two minutes and 41 seconds to complete the PG-SGA SF. The study also showed patients’ knowledge of malnutrition risk increased after completing the form.19
Heimgartner says it’s recommended that patients undergoing radiation and chemotherapy complete the PG-SGA SF every one to two weeks and every two to four weeks, respectively.
The PG-SGA SF also includes scores for nutrition impact syndromes, factors that may impede a patient’s ability to take in adequate nutrition, such as changes in taste and smell, constipation, abdominal pain, dysphagia, and epigastric pain.20 This information helps identify more patients at risk of malnutrition. Unlike the full PGSGA, there are no defined interventional triage recommendations for the PG-SGA SF, so it’s up to health care institutions to decide what to do with the scores from the patient-generated screening portion.21
Heimgartner adds that certain scores or the use of this nutrition screening tool shouldn’t increase patient visits or always require full nutrition assessments by dietitians. “We need to get out of that mindset and become inventive on how we manage patients.” Perhaps with more specific patient-reported information, clinicians can provide more targeted information or services that better meet patients’ needs.
MST
The MST was developed in 1999 by Maree Ferguson, PhD, MBA, AdvAPD, RD, FAND, founder and managing director of Dietitian Connection, a worldwide community of dietitians that offers professional development, job opportunities, resources, and connections, and director of the Healthy Kids Association in Sydney, Australia. The MST is well known for being a quick and easy and reliable screening tool. It contains just two questions related to appetite and weight loss, and it can be completed by a health care professional or patient. RDs usually triage patients with a score higher than 2, which indicates the need for a dietitian referral.
In 2020, the Academy of Nutrition and Dietetics released its position paper on malnutrition screening for all adults stating the MST should be used to screen adults for malnutrition regardless of age, medical history, or setting.22
Mary Washington Healthcare’s Regional Cancer Center in Fredericksburg, Virginia, implemented the MST to meet the new CoC standards. Its community hospital has three radiation centers and a small infusion center.
The tool was piloted in the center’s smaller radiation satellite locations in December 2020 and rolled out to the main locations in February 2021. The staff embedded the questionnaire into the radiation center’s EMR. Once the MST was implemented, a dietitian taught nurses how to use it. The nurses provided feedback about the MST while a dietitian audited it for three months. A reminder task was added to the nurses’ frequently used documents to improve the rate of completion.
The dietitian performed a six-month audit of 290 patients’ charts to assess how often nurses completed the MST questionnaire after their initial consultation with patients. The results showed a 67% completion rate. The highest completion rate was 79% in one month with the lowest being 59%. Average questionnaire completion rates among nurses in current studies range from 30% to 81%.23,24
In the future, the cancer center plans to test a screening tool to be completed on a tablet by the patient before consultations. The information then will go to nursing for dietitian referrals. It’s anticipated that this step will raise the rate of completing the MST to 100%.
Initiatives such as these build relationships, improve communication between nurses and dietitians, and increase understanding of when to refer a patient to a dietitian.
NUTRISCORE
Lorena Arribas, MSc, RD, at Catalan Institute of Oncology in L’Hospitalet de Llobregat, Barcelona, Spain, developed NUTRISCORE in 2017. This screening tool is newer and less frequently used than the PG-SGA and MST, but it has unique features. NUTRISCORE takes 25 seconds to complete and is a cancer-specific malnutrition assessment tool, unlike the PG-SGA and MST. However, weight loss and appetite over three months are scored and taken into account as they are in the PG-SGA and MST. Cancer location and treatment type are factored into the final score, and points are calculated for patients with high-risk cancers and who are undergoing combined chemoradiation, hyperfractionated radiotherapy, and hematopoietic stem cell transplantation. Metastasis, tumor stages, and the number of courses of chemotherapy received aren’t considered.
The tool was validated when compared with the PG-SGA and the MST in a Spanish study conducted by Arribas.25 Several other studies also have evaluated NUTRISCORE’s efficacy. One found that 21% of patients with upper digestive tract or head and neck cancers had malnutrition; 76% were diagnosed with moderate malnutrition and 12% with severe malnutrition. A Turkish study showed that NUTRISCORE had the highest sensitivity and specificity compared with the MST and European Diagnostic Criteria. However, another study found low sensitivity in cancer patients in China when compared with the MST and PG-SGA.26-28
Joseph Dowdell, RDN, LD, an outpatient oncology dietitian at Cleveland Clinic Taussig Cancer Institute in Ohio, who works with head and neck cancer, bone marrow transplant, lung cancer, sarcoma, and melanoma patients, asked Arribas for permission to implement the tool in Cleveland Clinic’s Epic EMR system. The nursing staff completes the NUTRISCORE questionnaire weekly. Dowdell says the tool has good sensitivity with high-risk populations (eg, patients with head and neck and gastrointestinal cancers and bone marrow transplants) and enough specificity to equally evaluate each cancer group. Dowdell says NUTRISCORE is increasing in popularity, noting there are several other cancer centers in the country using it.
Improving Nutrition Before, During, and After Treatment
The steps taken to treat malnutrition before, during, and after cancer treatment vary from institution to institution. Patients diagnosed with malnutrition before cancer therapy may enter a prehabilitation program, in which they receive nutrition counseling and a step-by-step care plan to improve their nutrition status before beginning treatment.
Prehabilitation in oncology nutrition is an evolving area that prepares patients for cancer therapies. At this time in their cancer journey, patients often are busy with appointments, procedures, and tests and may not have time for in-person dietitian visits. The good news is that prehabilitation can occur remotely through telehealth, which can relieve patients of added stress and offer them flexibility.
During routine follow-up visits and malnutrition screening throughout treatment, dietitians focus on developing dietary strategies to help manage side effects from various cancer therapies to optimize nutrition. Dietitians may recommend small, frequent meals and bland foods for patients dealing with nausea. They may suggest bumping up the flavor of foods by marinating meats or using different herbs and spices for those struggling with taste and smell changes. RDs may encourage patients grappling with fatigue to prepare and freeze foods ahead of time or rely on others to help them with meal preparation. And they may recommend nutritional drinks, homemade smoothies, and nutrient-dense foods to help those with loss of appetite.
Other strategies used to improve nutrition in cancer patients may include oral nutritional supplements, enteral or parenteral nutrition, vitamin/mineral supplementation, IV hydration, appetite stimulants, and medication adjustments. These interventions can be incorporated throughout treatment from a variety of health care providers.
After cancer treatment ends, dietitians still should advocate use of the screening tools to identify patients continuing to battle malnutrition. The tools will continue to identify the need for additional referrals for nutrition counseling based on patients’ weight loss, symptoms, or decline in physical function.
Recommendations for RDs
The implementation of malnutrition screening tools beginning with the patient’s initial hospital visit and during and after treatment offers a more standardized way to identify and improve malnutrition in the outpatient oncology setting.
Dietitians play an important role in the implementation and monitoring of malnutrition screening tools. To that end, RDs should take an interdisciplinary approach to selecting the tool, be involved in determining who completes the tool, note how long it will take and how referrals to dietitians will be handled. RDs should consider monitoring the tool as a quality improvement initiative to identify any gaps in knowledge and needed improvements. To be sure, with cancer care becoming more complex and individualized, malnutrition screening tools will help dietitians develop the knowledge and skills to provide optimal supportive care to improve nutrition status in the cancer patient population.
— Whitney Christie, MS, RD, CSO, CNSC, is an outpatient oncology dietitian at Mary Washington Healthcare’s Regional Cancer Center in Fredericksburg, Virginia. She works for Compass Group/Morrison’s Healthcare. She lives in King George, Virginia, with her husband and two children.
References
1. Arends J, Baracos V, Bertz H, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. 2017;36(5):1187-1196.
2. American College of Surgeons, Commission on Cancer. Optimal resources for cancer care: 2020 standards. https://www.facs.org/media/whmfnppx/2022_ca_coc_standards_april-2022_v03.pdf. Updated April 2022.
3. Carriço M, Guerreiro CS, Parreira A. The validity of the Patient-Generated Subjective Global Assessment Short-form© in cancer patients undergoing chemotherapy. Clin Nutr ESPEN. 2021;43:296-301.
4. Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy AL, Isenring E. Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a valid screening tool in chemotherapy outpatients. Support Care Cancer. 2016;24(9):3883-3887.
5. Ruan X, Nakyeyune R, Shao Y, et al. Nutritional screening tools for adult cancer patients: a hierarchical Bayesian latent-class meta-analysis. Clin Nutr. 2021;40(4):1733-1743.
6. De Groot LM, Lee G, Ackerie A, van der Meij BS. Malnutrition screening and assessment in the cancer care ambulatory setting: mortality predictability and validity of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) and the GLIM criteria. Nutrients. 2020;12(8):2287.
7. Why Epic. Johns Hopkins Medicine website. https://www.hopkinsmedicine.org/epic/why_epic/. Accessed March 17, 2022.
8. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-283.
9. Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - an ESPEN consensus statement. Clin Nutr. 2015;34(3):335-340.
10. Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017;36(1):11-48.
11. Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care. 2017;20(5):322-329.
12. Fattouh M, Chang GY, Ow TJ, et al. Association between pretreatment obesity, sarcopenia, and survival in patients with head and neck cancer. Head Neck. 2019;41(3):707-714.
13. Nishigori T, Obama K, Sakai Y. Assessment of body composition and impact of sarcopenia and sarcopenic obesity in patients with gastric cancer. Transl Gastroenterol Hepatol. 2020;5:22.
14. Mintziras I, Miligkos M, Wächter S, Manoharan J, Maurer E, Bartsch DK. Sarcopenia and sarcopenic obesity are significantly associated with poorer overall survival in patients with pancreatic cancer: systematic review and meta-analysis. Int J Surg. 2018;59:19-26.
15. Stangl-Kremser J, Mari A, Lai LY, et al. Sarcopenic obesity and its prognostic impact on urological cancers: a systematic review. J Urol. 2021;206(4):854-865.
16. Mizuno S, Seishima R, Okabayashi K, Shigeta K, Matsui S, Kitagawa Y. Sarcopenic obesity is a postoperative prognostic factor for stage II and III colorectal cancer. J Gastrointest Surg. 2021;25(11):2951-2953.
17. Zhang WT, Lin J, Chen WS, et al. Sarcopenic obesity is associated with severe postoperative complications in gastric cancer patients undergoing gastrectomy: a prospective study. J Gastrointest Surg. 2018;22(11):1861-1869.
18. Dikova TS, Zatsepina AY, Fedorinov DS, Lyadov VK. The impact of sarcopenic obesity on treatment outcomes in gastrointestinal cancer: a systematic review. Clin Nutr ESPEN. 2022;47:135-146.
19. Jager-Wittenaar H, de Bats HF, Welink-Lamberts BJ, et al. Self-completion of the Patient-Generated Subjective Global Assessment Short Form is feasible and is associated with increased awareness on malnutrition risk in patients with head and neck cancer. Nutr Clin Pract. 2020;35(2):353-362.
20. Omlin A, Blum D, Wierecky J, Haile SR, Ottery FD. Nutrition impact symptoms in advanced cancer patients: frequency and specific interventions, a case-control study. J Cachexia Sarcopenia Muscle. 2013;4(1):55-61.
21. FAQ. Pt-Global website. https://pt-global.org/faq/. Accessed March 17, 2022.
22. Skipper A, Coltman A, Tomesko J, et al. Position of the Academy of Nutrition and Dietetics: malnutrition (undernutrition) screening tools for all adults. J Acad Nutr Diet. 2020;120(4):709-713.
23. Trujillo EB, Shapiro AC, Stephens N, et al. Monitoring rates of malnutrition risk in outpatient cancer centers utilizing the malnutrition screening tool embedded into the electronic health record. J Acad Nutr Diet. 2021;121(5):925-930.
24. Castillo-Martínez L, Castro-Eguiluz D, Copca-Mendoza ET, et al. Nutritional assessment tools for the identification of malnutrition and nutritional risk associated with cancer treatment. Rev Invest Clin. 2018;70(3):121-125.
25. Arribas L, Hurtós L, Sendrós MJ, Peiró I, Sánchez-Migallón JM. NUTRISCORE: a new nutritional screening tool for oncological outpatients. Nutrition. 2017;33:297-303.
26. Álvaro Sanz E, Garrido Siles M, Rey Fernández L, Villatoro Roldán R, Rueda Domínguez A, Abilés J. Nutritional risk and malnutrition rates at diagnosis of cancer in patients treated in outpatient settings: early intervention protocol. Nutrition. 2019;57:148-153.
27. Ak E, Demirel B, Atasoy BM, Yumuk PF. Translation, validity, and reliability of NUTRISCORE: the nutrition risk assessment screening test for Turkish cancer patients [published online December 3, 2021]. Nutr Clin Pract. doi: 10.1002/ncp.10804.
28. Kang J, Li H, Shi X, Ma E, Chen W. Validation of the efficacy of the NUTRISCORE for the nutritional screening of cancer patients in China. BMC Cancer. 2022;22(1):43.