Oncology Nutritionists: Should cancer care teams include dietary experts?

According to the National Cancer Institute, early screening and comprehensive assessment of risk for malnutrition is increasingly recognized as imperative in the development of standards of quality of care in oncology practices.¹ Malnutrition is cited as a component in a large number of cancer deaths. Cachexia, a progressive wasting syndrome, is estimated to be the immediate cause of death in 20% to 40% of cancer patients.¹ Despite this evidence, a 2007 survey by the Oncology Nutrition Certification Work Group reported that an estimated 80% of all cancer patients in the United States do not consult with a nutritionist. This figure may decrease in the years to come, however, with the emergence of the oncology nutritionist as an integral part of the cancer care team.

What Is an Oncology Nutritionist?

The ideas of eating less sugar and more fiber, increasing antioxidant intake, eliminating foods that contain potentially carcinogenic ingredients, and drinking ginger tea to calm a queasy stomach might seem like common sense to some. But disseminating this kind of information is just one of the many tasks of the oncology nutritionist. Their work is wide-ranging, from helping a patient deal with mouth sores or nausea to teaching nutrient-dense recipes that can be made in a blender and ingested through a feeding tube to help keep up a patient’s strength during treatment.

Kim Robien, PhD, RD, CSO, Masonic Cancer Center, University of Minnesota, Minneapolis.

An oncology nutritionist is a registered dietitian who is a certified specialist in oncology (CSO), a credential received through the American Dietetic Association.² Certification for oncology nutritionists was introduced in 2008 and is administered by the Commission on Dietetic Registration. CSO candidates must have 2000 hours in practice and pass an exam.

In a discussion at the ASCO 2011 Annual Meeting, Kim Robien, PhD, RD, CSO, and Member, Cancer Outcomes and Survivorship Program, Masonic Cancer Center, University of Minnesota, Minneapolis, said there are currently 427 CSOs practicing in the United States and Canada. Other general nutritionists work with cancer patients, but many lack extensive training and experience in oncology.

Oncology nurses who do not have a CSO available at their hospital can refer patients to the “Find an Oncology Dietitian” section of the American Dietetic Association’s website for its Oncology Nutrition Dietetic Practice Group. The site also provides a wealth of other oncology nutrition resources.

Robin McConnell, MS, RD, CSO, clinical nutrition coordinator at the John Theurer Cancer Center.

The JTCC Experience

One institution that has integrated oncology nutritionists into its treatment program is the John Theurer Cancer Center (JTCC) at Hackensack University Medical Center in New Jersey.

Robin McConnell, MS, RD, CSO, is the clinical nutrition coordinator at the JTCC and 1 of 5 oncology nutritionists at the center who work with outpatients in all stages of treatment and recovery. As registered dietitian specialists certified in oncology nutrition, she and other staff members at the JTCC deal with challenges including depression, altered taste, anorexia, surgery, and the inability to process food. Their patients “have tremendous issues with eating,” she said, and the problem extends across the spectrum of cancers and cancer treatments.

While limited research data are available on the use of nutrition to help cancer patients, success is a powerful persuader. In recent years, “I have seen an increase in the number of patients referred” for counseling, McConnell said. “When you see results and action, you are more likely to refer patients.”

The earlier a patient gets counseling, the better, McConnell said. “The nutritionists are the point people” in the attack on cancer, she added, offering counseling before and during treatment in their role as part of the medical team that coordinates patients’ care. That team includes oncology nurses, who often make referrals. The decision to offer nutrition counseling to cancer patients without an extra charge puts the JTCC ahead of the curve; in the past, only hospitalized patients received nutrition counseling. For many, that was too late.

VIVIAN ROE was 36 years old and pregnant with her third child in 2006 when she underwent a right-breast mastectomy and began chemotherapy after her first trimester. The treatments made her ill and the medications to treat those side effects made her frightened for her unborn child.

So she made the radical choice to educate herself on how she could treat the side effects and help maintain her own health with food while discontinuing medications to alleviate side effects.

Her illness predated the creation of an oncology certification for registered dietitians, so she did her own research and created a plan for herself.

She gave birth to a healthy daughter and today is a 5-year breast cancer survivor.

Today, Roe not only continues to follow a cancer prevention eating plan, but is cofounder of TherapEase Cuisine, an online guide that debuted in 2009, and uses oncology dietitians to craft individual nutritional plans for cancer patients.

On TherapEase Cuisine’s website, patients provide their basic treatment and physical information and receive customized food and nutritional recommendations, plus the ability to send email questions to a dietitian. Customized recommendations are tailored to each subscriber’s diagnosis, medications, side effects, treatments, and food-drug interactions.

Vivian Roe, breast cancer survivor and cofounder, TherapEase Cuisine, with her daughter.

Personalized Treatment

Robien and McConnell both endorse the idea that each patient requires a personalized nutrition plan. “There is a much stronger need for individualized treatment,” Robien said at ASCO.

With treatment, “there is the potential for dry mouth, painful swallowing, or thick mucus,” McConnell said. Some suffer loss of taste, fatigue, pain, nausea, vomiting, or mouth sores. Oncology nutritionists craft plans to deal with each of these.

To build a plan, the oncology nutritionist assesses the patient’s needs and ability to meet those needs, McConnell said. She begins with evaluating food intake, including calorie, protein, and nutrient. Depending on the cancer treatment, she might take steps such as adding fiber or cutting back on sugar. “There are so many places where nutrition can make an impact,” she said.

Educating patients to meet their own nutritional needs might include teaching them how to use a blender or a food processor and giving them recipes they can make in their own kitchen. If a feeding tube has been temporarily inserted, the blender may become a necessity.

While some foods can specifically target side effects, the overall intent of treatment is wellness. Robien said the goals are to maintain lean body mass, prevent nutrient deficiencies, and minimize the impact of side effects. This is in keeping with the American Cancer Society (ACS) 2006 recommendations for cancer prevention.³ Those include eating ≥5 servings of vegetables and fruits each day, choosing whole grains over refined grains, limiting consumption of processed and red meats, and limiting alcoholic drinks to 1 per day for women and 2 per day for men.

Advocating for Nutritional Intervention

Oncology nutritionists strongly advocate for the efficacy of nutritional intervention in cancer care. Robien is the lead author of the article, “Evidence- Based Nutrition Guidelines for Cancer Survivors: Current Guidelines, Knowledge Gaps, and Future Research Directions,” which appeared in the March issue of the Journal of the American Dietetic Association. “Data support the hypothesis that nutrition interventions are not only likely to help with cancer outcomes, but can also be important in preventing and managing some of the chronic health conditions that can occur after cancer treatment, such as cardiovascular complications, weight gain, diabetes and other endocrine disorders, functional impairment, osteopenia, and osteoporosis,” Robien said.

McConnell’s advocacy goes a step further. “I firmly believe patients can be healthier after a diagnosis of cancer than before,” said McConnell. With nutrition counseling, “Everything ties together,” McConnell added, “It’s really a remarkable opportunity to have people see the big picture. It’s not just about treatment, it’s about prevention and wellness.”

Looking Ahead

In their article in the Journal of the American Dietetic Association, Robien and her collaborators wrote that the ACS will update its nutrition and physical activity guidelines this year using a panel of experts who look at available scientific evidence. The current guidelines focus on cancer prevention, as do guidelines set by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR).

Meanwhile, registered dietitians are intervening as early as possible to provide hope and practical advice. “Patients fear pain, nausea, and weight loss,” McConnell said. “They feel like their disease is out of control.” Working with a dietitian’s plan, they feel like they can regain some of that. “Knowledge is power,” she said, “and can take away fear.”

References

• National Cancer Institute. Nutrition in Cancer Care (PDQ®). http://1. usa.gov/od0mn3. Accessed August 17, 2011.
• The American Dietetic Association: The Oncology Nutrition Dietetic Practice Group. www.oncologynutrition.org. Accessed August 17, 2011.
• The American Cancer Society. http://bit.ly/pfFzAv. Accessed August 17, 2011.