Ms Tah Pei Chien

Clinical Dietitian
University Malaya Medical Centre
(Chairperson of MNT Cancer
Guidelines)

Medical Nutrition Therapy

Cancer Guidelines Update
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MDA Scientific Conference 2013 Sunway Putra Hotel
MNT Guidelines for Cancer in Adults
Working Group Committee
Gaik
Lian Suraiya Shafurah
Li Yin Firdaus

Wai
Hong Hidayah Shariza
Pei
Chien
Zalina

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2010 2013 (3 years)
21 meetings 3
 Outline
Introduction
Objectives of the MNT guidelines
Contents of MNT guidelines
Nutrition recommendation for cancer
patients

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 New Cancer Cases Diagnosed (2007)

Cancer
-most common
death in Malaysia 44.6%
-3rd in MOH
Hospital

New cases
registered
2007- 18,219
5

Source: Malaysian National Cancer Registry 2011

The Most Common Cancer In Malaysia

12.3% 5.2%

18.1% 10.2% 4.6%

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Source: Malaysian National Cancer Registry 2007

 Gender Differences In
Sites Of Cancer

5.5%
Lympho 16.3%
ma/ Lung
Liver
6.2% 14.6%
Prostat colorect
e gland al
8.4%
NPC

7
Source: Malaysian National Cancer Registry 2007
 GENDER
DIFFERENCES IN
SITES OF CANCER

32.1%
breast
10.0%
Colorectal
8.4%
Cervix
uteri
6.5%
Ovary
5.4%
Trachea,
Bronchus
& lung

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Source: Malaysian National Cancer Registry 2007
 Introduction
Depletion of nutrient stores, anorexia, weight loss and poor nutritional
status are found in many individuals at the time of diagnosis (Goldman
et al. 2006).

Malnutrition in cancer patients can have a significant adverse effect impact on

clinical, cost and patient centred outcomes such as complications (infections),
treatment response, treatment interuptions, unplanned admission, length of
stay and quality of life (Schattner & Shike 2006; COSA 2011).

The prevalence of malnutrition in cancer patients ranges from 8-84%

depending on tumour site, stage and treatment (Maarten von
Meyenfeldt 2005, Brown et al. 2008).

Considering the implications of malnutrition, it is important to initiate early

intervention to help prevent or reverse malnutrition and to improve prognosis
of cancer patients.

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 Aim of the Guidelines
To provide evidence-based
recommendations while taking into
account the importance of an
individualised approach in assisting
dietitians to provide medical nutrition
therapy to adult cancer patients.

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Objectives of Nutrition Management
For individual who is at pre-cancer treatment or
pre-surgery
To maintain or prevent declining (or further
decline) in nutritional status and improve overall
nutritional status and its associated outcomes in
adults at risk of or with malnutrition

For individual who is ongoing radiotherapy or/and

systemic therapy
To minimise a further decline in nutritional
status, maintain quality of life (QoL) and for
adequate symptom management.

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 Contents of the MNT
Nutrition Screening
Nutrition Assessment
Estimated requirement:
Macronutrient
Fluid
Micronutrients
Eicosapentaenoic acid (EPA)
Nutrition Diagnosis

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 Content of the MNT
Algorithm of nutrition support
Nutrition Intervention
Sample menu
Nutrition counseling/ education
Coordination of care
Physical activity & cancer
Nutrition monitoring & evaluation
Nutrition & cancer resources for health care
professionals
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Nutrition Screening and NCP
Flowchart

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 MST

SGA &
PGSGA

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Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011
Nutrition Screening

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 Evidence Statement of Nutrition Screening
Evidence Statement Grade References
MST is an effective and validated B DAA, 2006
screening tool for identifying risk of COSA, 2011
malnutrition in cancer patients
Malnutrition screening should be B COSA, 2011
undertaken in all patients at diagnosis to
identify those at nutritional risk and
should be repeated at intervals through
each stage of treatment (e.g. surgery,
radiotherapy / chemotherapy and post
treatment). If identified at high risk, do
refer to the dietitian for early intervention.
All HNC patients receiving radiation A
therapy should be referred to dietitian for COSA, 2011
nutrition support intervention

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 Malnutrition Screening Tool (MST)
1. Have you lost weight recently without trying?

If no (0)
If unsure( 2)
If yes, how much weight (kg) have you lost?
0.55.0 ( 1)
>5.010.0 (2)
>10.015.0 (3)
>15.0 (4)
2. Have you been eating poorly because of a decreased appetite?

No ( 0)
Yes (1)
If score 0 or 1 not at risk of malnutrition
2 at risk of malnutrition

Ferguson M, Bauer J, Banks M, Capra S. 1999. Development

of a valid and reliable malnutrition screening tool for adult
acute hospital patients. Nutrition. 15: 458464. 18
Nutrition Assessment

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 Nutrition Assessment Criteria
Tools
- The Scored Patient GeneratedSubjective Global Assessment
(PG-SGA) - gold standard (Leuenberger et al., 2010)
- Subjective Global Assessment (SGA)

Assessment Parameters
- Medical history
- Anthropometric data
- Biochemical assessment
- Clinical assessment
- Dietary Information
- Functional status and QoL

The use of combination method (Tools and Assessment

Parameters) is best suggested for nutritional assessment
(Grade C). (Davies, 2005)
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 Energy
Requirement

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 Guidelines Review
Guidelines Energy Requirement

DAA 2005 120 KJ/kg/day (29 kcal/kg/d)

ESPEN 2006 (EN) - Ambulant patients: 30-35 kcal/kgBW/day
- Bedridden patients: 20-25 kcal/kgBW/day
ADA 2006 Equation:
- Harris Benedict, 1919
- Mifflin-St Jeor, 1990
- Ireton-Jones, 1992
Based on actual body weight
European Oncological In excess of 120KJ/kg/day
Disease 2007
DAA 2008 125 KJ/kg/day (30 kcal/kg/d)

ESPEN 2009 (PN) - Ambulant patients: 25-30 kcal/kgBW/day

- Bedridden patients: 20-25 kcal/kgBW/day
COSA 2011 (HNC) at least 125kJ/kg/day (30kcal/kg/day)
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 Energy Requirement Estimation in MNT CA
Table 3 Formulas for Calculation of Energy Requirement

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 PROTEIN
REQUIREMENT

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 Guidelines Review
Guidelines Protein Requirement

DAA 2005 1.4 g/kg/day

ESPEN 2006 (EN) - Minimum: 1 g/kgBW/day
- Target: 1.2-2 g/kgBW/day
ADA 2006 Nitrogen balance = (Protein Intake/6.25) (UUN+4)
: Positive 4 6 g/day is desirable
: Negative consideration to increase protein intake
Grams of protein per kilogram of body weight
formulas (consider of renal and/or hepatic dysfunction)
Protein needs for nutrition support: kilocalorie-to-
nitrogen ratio of 125:1
European Oncological In excess of 1.4g/kg/day
Disease 2007
DAA 2008 1.2 g/kg/day

ESPEN 2009 (PN) - Minimum: 1 g/kgBW/day

- Target: 1.2-2 g/kgBW/day
COSA 2011 (HNC) at least 1.2g/kg/day 28
 Protein Requirement in MNT CA
Table 4: Estimating Daily Protein Needs in Cancer Patients

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 Table 5: Estimating Fluid Needs in Cancer
Patients

Age (years) Fluid Requirement, ml/kg

16-30, active 40
31-55 35
56-75 30
76 or older 25
These recommendations are just for maintenance needs. Fluid
requirement in fluid overload or dehydration patients need to
be adjusted.
Source: ADA, 2000

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Algorithm of Nutrition Support
for Cancer Patients

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 32
Ref: ESPEN, 2006; FESEO, 2008
 Nutrition Diagnosis
Identification and labelling of the specific
nutrition problem that dietetic professionals
are responsible for treating independently.
A nutrition diagnosis may be temporary,
altering as the patient progresses
or responses to the intervention.

Source: ADA (2011) Third edition, International dietetics &

nutrition terminology (IDNT) reference manual. 33
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 Nutrition
Intervention and
Recommendation

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 Diet and Counseling
Recommendation Grade References

Intensive dietary counselling and ONS are able to A ESPEN, 2006;

increase dietary intake and to prevent therapy- FESEO, 2008;
associated weight loss and interruption of radiation DAA, 2008
therapy in patients undergoing radiotherapy of
gastrointestinal or head and neck areas
Dietitian should be part of the multidisciplinary team A DAA, 2008
and frequent dietitian contact has been shown to COSA, 2011
improve patients nutrition outcomes and quality of
life
At low nutritional risk patients (MST = 0-1) C Bauer, 2007;
-Recommend a well balanced diet FESEO, 2008
-Recommend healthy traditional diet
according to needs, preferences and
symptomatology
-Healthy, balanced, assorted, appetizing and
adequate amount of food and nutrients
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 Diet and Counseling
Recommendation Grade References

At moderate nutritional risk patients (MST = 2) C Bauer, 2007

- Recommend high protein-energy diet
- High protein and high energy diet
- Try 6 smaller meals/snacks per day
- Include 3-4 servings of energy and protein
rich foods or drinks daily
- Oral nutritional supplements 2-3 servings per
day
At high nutritional risk patients (MST = 3-5) C Bauer, 2007
- Recommend high protein high energy diet
- Recommend high protein high energy
supplements 2-3 times per day
- Consider intensive nutrition support

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 Enteral Nutrition (General)
Recommendation Grade References

Standard formula are recommended C ESPEN,

for EN of cancer patients 2006
EN should be started if an C ESPEN,
inadequate food intake ( <60% of 2006
EEE) is anticipated for more than 10
days
EN reduces morbidity in selected A FESEO,
malnourished patients. 2008

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 Enteral Nutrition (Perioperative)
Recommendation Grade Reference
s
Patients with severe nutritional risk A ESPEN,
should be given nutritional support for 10 2006;
14 days prior to major surgery even if FESEO,
surgery has to be delayed 2008
Perioperative nutrition support therapy A ASPEN,
may be beneficial in moderate or severely 2009
malnourished patients if administered for
7-14 days preoperatively but the potential
benefits of nutrition support must be
weighed against the potential risks of the
nutrition support therapy itself and of
delaying the operation
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 Enteral Nutrition (Perioperative)
Recommendation Grade References
In all cancer patients undergoing A ESPEN,
major abdominal surgery preoperative 2006
EN preferably with immune modulating ASPEN,
substrates (arginine, -3 fatty acids 2009
and nucleotides) is recommended for 5
7 days independent of their nutritional
status
EN should be started during first 24 A FESEO,
hours after surgery for patients 2008
undergoing head and neck surgery or
upper GIT and also in seriously
malnourished Individuals
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 Enteral Nutrition During Chemo / Radiotherapy
Recommendation Grade References

NST is indicated in patients receiving active B ASPEN,

cancer treatment who are malnourished and who 2009
are anticipated to be unable to ingest and/or
absorb adequate nutrients for a prolonged period
of time
Tube feeding should be used to improve protein B COSA, 2011
and energy intake for HNC patients when oral
intake is inadequate

Nasogastric tube (NGT) and percutaneous B DAA, 2008

endoscopic gastrostomy (PEG) feeding are A ADA, 2007
effective in achieving higher protein and energy
intakes and weight maintenance in HNC patients
undergoing radiation therapy compared with oral
intake alone
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 Parenteral Nutrition (PN)
Recommendation Grade References

PN should be started if an inadequate food C ASPEN,

intake and/or EN(<60% of estimated energy 2009
expenditure) is anticipated for more than 10 days

A higher than usual % of lipid (e.g. 50% of non- C ESPEN

protein energy), may be beneficial for those with 2009
frank cachexia needing prolonged PN
PN is ineffective and probably harmful in A ESPEN,
oncological patients without swallowing difficulty 2009
and gastrointestinal failure
Perioperative PN should not be used in well nourished A ESPEN,
cancer patients 2009
Perioperative PN starting 710 days pre-operatively A ESPEN,
and continuing into the post-operative period is 2009
recommended in malnourished candidates for
artificial nutrition, when EN is not possible
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Nutrition During Transplantation of Hematopoietic
Precursor Cells
Recommendation Grade References

Patients should receive dietary C ASPEN,

counselling regarding foods which may 2009
pose infectious risks and safe food
handling during the period of neutropenia
Not to recommend the enteral C ESPEN,
administration of glutamine or EPA in 2006
patients undergoing haematopoietic stem
cell transplantation (HSCT) due to
inconclusive data
Glutamine supplemented PN should be B ESPEN,
used in HSCT patients for possible health 2009
benefit
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Nutrition During Transplantation of Hematopoietic
Precursor Cells
Recommendation Grade References

PN should be reserved for those with B ESPEN,

severe mucositis, ileus, or intractable 2009
vomiting
In addition, if oral intake is decreased, C ESPEN,
the increased risk of haemorrhage, and 2006
infections associated with enteral tube
placement in immuno-compromised
and thrombocytopenic patients has to be
considered; in certain situations,
therefore (e.g. allogeneic HSCT)
parenteral nutrition (PN) may be
preferred to TF
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 Nutrition During Terminal Illness
Recommendation Grade References

The palliative use of NST in terminally ill B ASPEN,

cancer patients is rarely indicated 2009
EN should be provided in order to minimize C ESPEN,
weight loss, as long as the patient consents 2006
and the dying phase has not started
When the end of life is very close, most B ESPEN,
patients only require minimal amounts of 2006
food and little water to reduce thirst and
hunger
Supplemental PN should be used in B ESPEN,
supporting incurable cancer patients with 2009
weight loss and reduced nutrient intake

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 Dietary Guidelines for Immunosuppressed
Patients Neutropenic Diet

The use and effectiveness of neutropenic diet is

not scientifically proven.
Neutropenic diets are not standardized.
Further research is needed to better evaluate
the benefit of neutropenic diet (Steven, 2011).
Food safety education and high risk foods
restriction is needed when handling
immunosuppressed patients (ADA, 2006).

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Sample
Menu

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Nutrition Education
& Counselling

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Physical Activity
& Cancer

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Nutrition Monitoring
& Evaluation

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 Nutrition And Cancer
Resources For Health Care
Professionals

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 Summary and Conclusion
This medical nutrition therapy is developed to guide
dietitians toward a standardised dietary management
along the nutrition care process for cancer patients in
order to improve patients outcomes.

Guidelines are just that, Guidelines

Not dogma, not absolute, not rules, No guarantees

Clinical judgment and expertise always takes
precedent over guidelines

Guidelines will change with ongoing trials, keep

an open mind
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MNT Babies

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 Acknowledgement
We would like to extend out gratitude and appreciation to
the following for their contributions:

Dietetic Department of University Malaya Medical Centre

for the use of the meeting room
The Peer Reviewers for their time and professional
expertise
Healthcare Nutrition Division of Nestle Products Sdn. Bhd.
for the refreshments
Wyeth Nutrition (M) Sdn. Bhd (formerly know as Wyeth
(M) Sdn Bhd) for the printing of the Cancer MNT book

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THANK YOU

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