ESMO Commentary: Specialised staff required for the nutrition and family teams in supportive care

VIENNA, Austria – Cancer is distressing for patients and families, and supportive care is today an important part of therapy. Attention has grown among allied healthcare professionals about the role of nutritional and family-oriented supportive programmes and their potential benefits in terms of clinical outcomes and quality of life. However, it is still difficult to integrate such programmes into routine clinical practice. According to Professor Gabriella Pravettoni, Director of the Applied Research Unit for Cognitive and Psychological Science at the European Institute of Oncology (IEO) in Milan, Italy, these obstacles can be overcome by means of multidisciplinary collaboration.

What is the situation in Europe in terms of nutritional and family-oriented supportive programmes?  

Pravettoni: Ideally, supportive programmes should be provided from the time of diagnosis, be adaptive and flexible to the needs of cancer patients and their families during their illness trajectory, and be integrated into the existing healthcare system at all levels of care, including community and home-based. However, the real situation in Europe is different from the ideal one. As emerged from recent results presented at the European Cancer Congress (ECC) 2015 in Vienna, today malnutrition is not routinely monitored during or after cancer treatment and staff need more guidance on how to support children and partners of patients with cancer after diagnosis. A different approach is required, involving oncologists, nurses, dietitians and psychologists, but there are limitations in building up such a multidisciplinary team.

In order to respond to cancer priority needs and make optimal use of scarce resources, supportive services should be strategically linked to cancer prevention, early detection and treatment services. Another important issue in this context is that of evidence-based practice. We live in a time in which no intervention can be promoted and sustained unless its usefulness in terms of health outcomes and quality of life can be clearly and unequivocally demonstrated. More research is needed showing that supportive programmes improve patients’ quality of life and clinical outcomes before such programmes will be adopted more widely. 

What is the impact of malnutrition during and after cancer in terms of clinical outcomes and quality of life?

Pravettoni: Today it is clear that malnutrition in cancer is a very complex and multifactorial issue. Cancer-related malnutrition can result from local effects of the tumour, from the host response to the tumour and from anticancer therapies, and it is associated with increased morbidity after surgery, impaired quality of life, mortality, length of hospital stay, and medical costs. 

In addition, malnutrition renders treatment less effective and makes it harder for patients to endure chemotherapy or radiation therapy, resulting in longer treatment periods and increased susceptibility to infection and to patient dropout.

The prevalence of malnutrition among cancer patients has been estimated to range from 9% in breast cancer to 80% in oesophageal. It has been shown to be related to such factors as tumour location, whether the patient is older and female, pre-existing obesity (body mass index [BMI] >30) and whether there is a head and neck and upper digestive primary tumour site. It is very hard to take in enough nutrients to stay healthy and malnutrition can often occur, particularly when the head, neck, oesophagus, stomach, or intestines are affected by the cancer treatment. In hospitalised patients, the prevalence of malnutrition has been found to be higher in male patients with a longer hospital stay and in liver and lung cancer patients.

How do medical and clinical oncologists assess nutritional status before, during and after cancer treatment?

Pravettoni: Malnutrition is assessed by less than 50% of medical and clinical oncologists before cancer therapy, 29% during treatment, and just 11% after treatment (abstract 1606). Cost and lack of clear guidelines are the most frequent barriers to nutritional screening. More than eight in ten oncologists (86%) say educational activities are needed around nutritional supportive care in cancer. These include clinical practice guidelines, scientific meetings focused on nutritional aspects, and simple clinical practice tools.

Nutritional screening should be performed at the time of the diagnosis, possibly before starting the specific anticancer treatments, and regularly re-assessed later in the illness trajectory. Validated tools include the scored Patient-Generated Subjective Global Assessment (PG-SGA), the Malnutrition Screening Tool and the Mini Nutritional Assessment Short Form Revised. Proactive nutritional interventions should form an integral part of cancer therapy, with the aim of improving clinical outcomes and quality of life.

What can a scientific society do in terms of editing recommendations and guidelines?

Pravettoni: Scientific societies have a key role in promoting effective strategies such as editorial material and guidelines to implement supportive care in oncology for nutritional aspects. The catchment area of societies is vast and communication with healthcare professionals can be simply and extensively achieved. 

Since 2011 ESMO has published the ESMO handbook series that includes the ESMO Handbook on Nutrition and Cancer. The handbook thoroughly deals with nutritional and cancer issues from the basic concepts of nutrition and nutritional assessment, to the role of nutrition in cancer prevention and in cancer care through different stages of illness. It also considers the psychological and health economics perspectives promoting a multidisciplinary approach. 

Are family-oriented supportive programmes still complex to implement despite increased awareness of family needs after cancer diagnosis? 

Pravettoni: Yes, they are. When a family member receives a cancer diagnosis the entire system is affected. Today it is mandatory to address the effect of cancer diagnosis on the partners and children of patients. In some cases such as in stages of advanced disease, cancer patients’ partners suffer from higher levels of psychological distress than the patients themselves (38.9% vs. 23%) (Braun M, 2007) and have a higher risk of depression. When cancer occurs in young couples, it often interrupts life projects and narrows perspectives.

Research presented at ECC 2015 shows that one year after cancer diagnosis, partners had significantly more mood disorders, reactions to severe stress, and ischaemic heart disease than they had the year before the diagnosis (abstract 1707). In addition, cancer affects the relational and sexual life of couples and while patients are on the road to recovery, undergoing demanding treatment regimens, partners often feel uncomfortable about raising the intimacy and sexuality issue, this being a source of distress. 

How would family needs regarding dependent children be assessed throughout the cancer trajectory?

Pravettoni: Childhood distress seems to be related to the age and sex of the child and the sex of the patient, with adolescent girls whose mothers have cancer being the most significantly distressed. Targeted education programmes would help specialised staff to better communicate with dependent children of different ages about cancer and to assess their needs throughout the cancer trajectory (abstract 1708).

Education initiatives would be helpful for patients, too. Female patients in particular experience stress around how to communicate with their offspring about the disease and it is often the case that before embarking upon a consultation they decide not to tell their children about the illness.

How could the psychological impact on children and partners be reduced?

Pravettoni: There is a need for awareness-raising educational initiatives to be implemented about the issue and healthcare services, for instance, are showing an increasing awareness of the consequences of having a relative who has been diagnosed with cancer including psycho-social consequences, such as absence from work, costs related to caregiving, and costs related to caring for the relative (e.g. transportation).

In general, it is difficult to properly address psycho-social issues in a healthcare setting and difficulties are directly proportional with how far patients live from the hospital. On the other hand, specialist staff require more support on assessing psycho-social needs and this includes empowerment on communication strategies and access to up-to-date resources and referral pathways in the community setting. Healthcare professionals also recognise the presence of personal barriers in addressing these issues such as, for example, being in the same life situation as patients (abstract 1708) such as having young children or being just married.

What is important to start from, reflecting upon the familial effects of cancer, is that even today, too many patients still believe that having cancer, and the psychological side effects that arise from and accompany it, are something for which they deserve blame. 

Notes

Abstracts presented at ECC 2015, held 25–29 September in Vienna, Austria:

P377 - 1606: Nutritional support in cancer – more formal recommendations are required. F. Strasser, Switzerland. P377 - Sunday 27th September 2015 – 16:45-18:45 Poster Session HALL C

1707: The effects of cancer diagnosis on the health of the patient’s partner: A population-based register study of cancer in Sweden. M.L. Mollerberg, Sweden. Monday 28th September 2015 – 09:00-10:50 Proffered Paper Session HALL A2

1708: How do specialist oncology staff ‘think family’ and support patients with advanced cancer who have dependent children?. A. Arber, UK. Monday 28th September 2015 – 09:00-10:50 Proffered Paper Session HALL A2

Malnutrition references:

Haehling S, Anker SD. Cachexia as a major underestimated and unmet medical need: facts and numbers.J Cachexia Sarcopenia Muscle. 2010;1:159–167. doi: 10.1007/s13539-010-0012-4.

Santarpia L, Contaldo F, Pasanisi F. Nutritional screening and early treatment of malnutrition in cancer patients (2011).J Cachexia Sarcopenia Muscle. 2011; 2(1):27–35. 

Gyung-Ah Wie, Yeong-Ah Cho, So-Young Kim, Soo-Min Kim, Jae-Moon Bae, Hyojee Joung. Prevalence and risk factors of malnutrition among cancer patients according to tumor location and stage in the National Cancer Center in Korea. Nutrition (2010) Volume 26, Issue 3, 263–268 

Chima CS, Barco K, Dewitt ML, Maeda M, Teran JC, Mullen KD. Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service.J Am Diet Assoc. 1997;97:975–978.

Ma L, Poulin P, Feldstain A, Chasen MR. The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer.Curr Oncol. 2013; 20(6):e554–e560.

Allison SP. Malnutrition, disease and outcome.Nutrition. 2000;16:590–593.

Wie GA, Cho YA, Kim SY, Kim SM, Bae JM, Joung H. Prevalence and risk factors of malnutrition among cancer patients according to tumor location and stage in the National Cancer Center in Korea.Nutrition. 2010;26:263–268.

Pressoir M, Desné S, Berchery D,et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres.British Journal of Cancer. 2010;102:966–971. doi:10.1038/sj.bjc.6605578 

References for impact of cancer on families:

Braun M, Mikulincer M, Rydall A, Walsh A, Rodin G. Hidden morbidity in cancer: spouse caregivers.J Clin Oncol. 2007;25(30):4829–4834.

Compas BE, Worsham NL, Epping-Jordan JE, Grant KE, Mireault G, Howell DC, Malcarne VL. When mom or dad has cancer: markers of psychological distress in cancer patients, spouses, and children.Health Psychol. 1994;13(6):507–515.

Reference on barriers to implementing supportive programmes:

Ristevski E, Breen S, Regan M. Incorporating supportive care into routine cancer care: the benefits and challenges to clinicians' practice.Oncol Nurs Forum. 2011;38(3):E204–211. doi: 10.1188/11.ONF.E204-E211.

Information contained in this commentary was provided by the interviewee.