Diet what helps? Lindsey Allan Macmillan Oncology Dietitian Royal Surrey County Hospital, Guildford

Diet and cancer

Nutrition research Lack of funding RCTs Low quality Small sample sizes Heterogenous populations Various treatment types and intent

Dietary management NOT a cure! Supportive Reduce delays in treatment Dependent on: Site of tumour Cancer symptoms Treatment side effects Reduced intake MALNUTRITION

Malnutrition: definition a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition) and function and clinical outcome. (BAPEN, 2016) lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat. (Oxford English Dictionary)

Cancer related malnutrition: definition Reduced intake Metabolic derangements Increased resting energy expenditure Can affect 50% patients Increased in certain tumour sites Insulin resistance Disordered fat and protein breakdown Associated with inflammation and catabolism CANCER CACHEXIA Lack of response to standard nutritional interventions

Cancer associated malnutrition: causes Taste changes Medication Dysphagia Nausea & vomiting Pain Anorexia Malabsorption Restricted diets Fatigue Surgical interventions Constipation Diarrhoea

Cancer related malnutrition: incidence Tumour site Prevalence of malnutrition as % of total patient cohort Pancreas 80-85 Stomach 65-85 Head and neck 65-75 Oesophagus 60-80 Lung 45-60 Colon/rectum 30-60 Urological 10 Gynaecological 15 (Stratton et al, 2003)

1 12 23 34 45 56 67 78 89 100 111 122 133 144 155 166 177 188 199 210 221 232 243 254 265 276 287 298 309 320 331 342 353 364 375 386 397 408 419 430 441 452 Cancer related malnutrition: incidence 15.00 10.00 5.00 % weight change at referral to the dietitian Median weight change: - 9.3% 0.00-5.00-10.00-15.00-20.00-25.00-30.00 76%: >5% weight loss = cachectic 24%: < 5% weight loss -35.00-40.00 5% (Fearon et al, 2011, Hug et al, 2016)

Cancer related malnutrition: consequences Impaired response to chemotherapy Reduced quality of life Increased chemotherapy-induced toxicity Chemotherapy dose reductions Stop or delay to treatment Post-operative complications Shorter overall survival and mortality rates

1 12 23 34 45 56 67 78 89 100 111 122 133 144 155 166 177 188 199 210 221 232 243 254 265 276 287 298 309 320 331 342 353 364 375 386 397 408 419 430 441 452 Cancer related malnutrition: consequences 15.00 Weight loss from usual body weight to referral 10.00 5.00 0.00-5.00-10.00-15.00-20.00 OS: 199 days OS: 299 days -25.00-30.00-35.00-40.00 5% Unpublished data from RSCH audit

ESPEN Guidelines on nutrition in cancer patients Identify, prevent and treat reversible malnutrition in adult cancer patients ALL cancers Nutritional therapy Physical therapy Drug management Strong recommendations low level of evidence Areas for future research (Arends et al, 2016)

Screening Early identification Fast, cheap and sensitive Recommendation BMI, weight loss history and nutritional intake Body Mass Index (BMI) Height to weight ratio Healthy range: 19.5-25 kg/m 2 Lacks sensitivity Fluid shifts Obesity and malnutrition Lung audit: median BMI 23 kg/m 2

BMI

Screening Weight loss history Major cause of morbidity and mortality (Andreyev et al, 1998) Accurate indicator of malnutrition Reliance on personal recall Nutritional intake Under / over reporting Fear of delays Challenging with treatment cycles

Screening tools Not mandatory in the UK No consensus Most not validated in oncology MUST BMI, weight loss, acute disease score PG-SGA Validated in oncology outpatients Weight loss, symptoms AND side effects No correlation between MUST and PG-SGA

Screening: what works? Weight loss history At diagnosis Repeated during treatment Subjective assessment Check symptoms and side effects Ask questions

Nutrition support: aims Meet nutritional requirements Improve nutritional status When to initiate? Consensus (Fearon et al, 2011) On identification As early as possible post diagnosis Severe malnutrition / cachexia are irreversible

Nutrition support Determining route of nutrition: oral +/- oral nutritional supplements enteral feeding parenteral nutrition Ensuring nutritional needs are met Food fortification Texture modification Timing of meals Dietary counselling Treatment of symptoms and side effects

Nutrition support: recommendation nutritional intervention to increase oral intake in cancer patients who are able to eat but who are malnourished or at risk of malnutrition. This includes dietary advice, the treatment of symptoms and derangements impairing food intake (nutrition impact symptoms) and offering oral nutritional supplements. (Arends, 2016) Start artificial nutrition No food > 1 week <60% intake for > 1-2 weeks

Nutrition support Can you eat to beat cancer with the best cancer diet and cancer nutrition? And is it the sugar-ladened, cheeseburger, cake, biscuits and milkshake diet that NHS dieticians, Cancer Research UK and Macmillan suggest? Cancer Active

Oral Nutritional Supplements: evidence Oral nutritional supplements (ONS) Effective in severe malnutrition only ONS and enteral feeding No evidence to improve outcomes Enteral feedingyyy in head & neck, oesophageal RCTs are unethical Observational studies Reduced weight loss Delays in treatment Hospitalization

Parenteral nutrition: evidence Bowel obstruction / peritoneal carcinomatosis Expensive Risks outweigh benefits Observational study (Fan, 2007) Malignant GI obstruction, n=115 No oral intake, Home PN Median survival: 6.5 months N=11: > 1yr, n=2: > 4 years Prognosis < 2 months: home PN not recommended No evidence to improve QoL

Dietary counselling: evidence Systematic review (Baldwin et al, 2012) nutritional counselling +/-ONS vs routine care 13 RCTs, n=1414 Mixed results Increase in body weight, QoL No impact on overall survival

Dietary counselling: evidence RCT n=61 (Poulsen et al, 2014) Intensive counselling by a dietitian vs ad-hoc input from nursing staff gynaecological, gastric and oesophageal cancer Weight loss 38% in intervention group, 72% in control QoL: no difference RCT n=58 (Uster et al, 2013) Intensive counselling by a dietitian vs standard care Increased protein and energy intake no improvement in QOL, functional status or nutritional status

Dietary counselling: evidence Systematic review (Lee et al, 2016) Counselling, ONS and counselling, ONS, tube feeing 11 RCTs, n=1017 Lung, stomach, head & neck, colorectal Counselling improved energy and protein intake and QoL No improvements with ONS and tube feeding

No evidence? Reduction in energy intake or fasting Ketogenic diets Cannabis to improve taste changes or appetite Steroids to increase muscle mass corticosteroids to aid anorexia improves dietary intake and quality of life. (Yavuzsen et al, 2005)

No evidence? Omega-3 fish oils to treat cancer cachexia weak evidence: fish oil supplements can increase appetite, energy intake, total body weight and lean muscle mass (Sanchez-Lara et al, 2014) Probiotics to reduce the effects radiotherapy-induced diarrhoea YET Inconclusive studies to date May improve symptoms

Cancer survivors: recommendations Cancer prevention 1/3 of 13 most common cancers (WCRF) 1 in 10 cancers (Cancer Research UK) Cancer survivors = cancer prevention (WCRF, Arends et al, 2016) Healthy body weight with a BMI of 18.5-25 kg/m 2 Healthy lifestyle Physical activity Healthy diet high in fruit, vegetables, whole grains and low in saturated fat, red meat and alcohol

Cancer survivors: evidence Lack of evidence Obesity and metabolic syndrome: independent risk factors of recurrence breast cancer (Azrad & Demark-Wahnefried, 2014) gastric cancers post gastrectomy (Kim et al, 2014) Motivation for behaviour change Observational study (n=16,282) cancer survivors: fruit and vegetables, physical activity (Wang et al, 2014) Cross-sectional study (n=63,662) Prostate cancer survivors: fruit and vegetables, obesity, physical activity (Rogers et al, 2008)

Living with and beyond Healthy eating, healthy weight Physical activity but Nutrition support Weight loss Dysphagia Enteral feeding Late effects

Summary Strong recommendations Low level evidence Screening Early identification Timely, appropriate nutrition support Dietary counselling Meet nutritional requirements Resolve symptoms and side effects Prevent deferral of treatment

BUT.. Cancer is not just physical Psychological effects Emotional responses Reduced food intake is about MORE than just malnutrition Loss of appetite leads to loss of control change in appearance depression, anxiety Frailty Conflict social isolation Poor QOL

Remember Food is HOPE Food is CONTROL What is our responsibility? Support patients beliefs In spite of lack of evidence Individualized advice Address expectations listen to priorities