Dietetic Interventions in the Management of Lung Cancer: A Journey from Diagnosis to End of Life Care Samantha Morris S

1. Dietetic Interventions in the Management of Lung Cancer: A Journey from Diagnosis to End of Life Care Samantha Morris Senior Dietitian North Tees & Hartlepool NHS Foundation Trust

2. Aim & Objectives Aim: To provide an insight into the dietetic management of lung cancer patients throughout the cancer journey Objectives: To summarise the service provided at University Hospital of North Tees as part of the MDT To outline the key factors influencing nutritional status of lung cancer patients Discuss the aims of the dietetic management of Lung Cancer patients To explain and demonstrate how dietetic interventions change throughout the lung cancer care pathway

3. Background-Lung Cancer Lung cancer is the second most common cancer diagnosed in the UK In 2006, around 39,000 people were diagnosed with lung cancer in the UK, that�s 107 people every day Lung cancer is the second most common cancer in men after prostate cancer More than 16,600 women were diagnosed with lung cancer in the UK in 2006, making it the third most common cancer in women after breast and bowel cancer. Lung cancer is the most common cancer in the world with 1.3 million people diagnosed in 2002. (Cancer Research UK)

4. Diagnosis & Symptoms Chest X-ray is often the initial step. Followed by a bronchoscopy and CT scan +/- biopsy Symptoms: Dyspnoea (shortness of breath) Haemoptysis (coughing up blood) Chronic coughing or change in regular coughing pattern Wheezing Chest pain or pain in the abdomen Cachexia (weight loss), fatigue and anorexia Dysphonia (hoarse voice) Clubbing of the fingernails (uncommon) Dysphagia (difficulty swallowing). (Hamilton, 2005)

5. Histology Approximately 20% are small cell lung cancers (SCLC) and the remainder are non-small cell lung cancers (NSCLC). The main types of NSCLC are, squamous cell carcinoma, adenocarcinoma and large cell carcinoma, which account for approximately 35%, 27% and 10% of all lung cancer cases respectively in the UK (NICE 2005). Mesothelioma is a type of cancer that can develop in the tissues lining the lungs (pleura) or the abdomen. About two thirds or three quarters of mesotheliomas occur in the chest (67 to 75%).

6. LUCADA LUCADA data for 2008 for University Hospital North Tees - total registered was 177 patients

7. Background- My Role Based at University Hospital of North Tees Established in 1999 Acute & community based Work as an integral part of the MDT

8. Referrals In-patient: Consultant, junior doctors, nursing staff, patient or via screening tool Clinic: Consultant, Lung MacMillan nurses, clinic nurses (prompted by screening) or MacMillan physiotherapist Community: Lung MacMillan nurses, MacMillan physiotherapist/OT, chemotherapy nurses, district nurses or GPs

9. MDT at North Tees

10. The team at North Tees Hospital has developed the lung cancer service in line with the National Cancer Survivorship Initiative (DOH 2008), enabling people who have been diagnosed with lung cancer to lead as healthy, active life as possible for as long as possible.

11. Benefits of nutrition support Improve mental well being and quality of life May enable more intensive treatment Can reduce complications such as pressure sore and infections It can play a part in symptom management Address patient/ carer concerns re weight loss (Hawkins et al, 2000, 36 % patients concerned re anorexia but 87 % of carers)

12. Key Factors Affecting Nutritional Status of Lung Cancer Patients

13. LUCADA

14. Reason for Referral

15. Goals of Dietetic Management Early palliative care (Diagnosis, undergoing palliative treatment): Assess nutritional status Assess any concerns or wishes of the patient/ family relating to nutrition Proactively aim to meet nutritional requirements Improve nutritional status or minimise weight loss/ malnutrition Advise on symptoms/ side effects of treatment Monitor progress

16. Dietetic Interventions- Post lobectomy / during chemotherapy Diagnosis: NSCLC Treatment: Lobectomy, chest wall resection, Adjuvant chemotherapy (vincristine) Presenting problems: Anorexia, nausea, bloating, taste changes, anxiety Anthropometrics: Weight: 58 kg BMI: 21(healthy) Weight loss: 8 %

17. Case Study 1- continued Aims: To improve nutritional status and meet requirements To minimise weight loss during treatment To advise re symptoms Interventions: High calorie/ protein diet Commence an energy dense oral nutritional supplement Advice on eating pattern re anorexia, bloating & nausea Advice on nausea Advice on taste changes Discussed bowels re bloating

18. Case Study 1- continued Initial Review (June 09) Further weight loss (54 kg) Problems tolerating initial supplement re taste Advised on a juice tasting product Nausea settled and coping with altered taste Appetite still reduced Second Review (August 09,) Weight increase (58.2 kg) Appetite good Dietary intake good

19. Dietetic Interventions-Post Radiotherapy Diagnosis: NSCLC Treatment: Initial chemotherapy (Carboplatin &Gemcitibine), followed by radical radiotherapy Presenting Problems: Severe oesphagititis, swallowing difficulties, minimal dietary intake and poor tolerance of nutritional supplements Anthropometrics: Weight 72 kg BMI: 22 (healthy) Weight loss: 17 % (clinically significant)

20. Case Study 2 Aims: To improve nutritional status and meet requirements To minimise further weight loss To advise re oesphagitis Interventions: Advice on high calorie / high protein soft diet Review of oral nutritional supplements- Trial of supplement desserts. Continue energy supplement Advice re oesphagitis � temperature of foods & drinks, foods to avoid / best choices

21. Case Study 2 - continued Initial Review (Oct 09) Ongoing dysphagia, oesphagitis persisting Reported weight stable Food intake improving but still poor Patient very anxious to eat due to pain Patient advised by oncologist to aim at 8 supplement desserts daily (1,600 kcals, 96 g protein) Discussed goal with supplements Reiterated advise re diet, to promote dietary intake

22. Case Study 2- continued Second Review (Oct 09) Weight stable (72 kg) Patient tolerating 8 supplement desserts and calorie supplement Symptoms improving Diet- now managing a greater variety of soft foods inc ready meals Advised to reduce supplement dessert to 6 daily. Continue energy supplement

23. Case Study 2 - Continued Third Review (Oct 09) Weight increased 76 kg Symptoms significantly improved Diet- Managed full English breakfast! To reduce dessert supplements to 4 � 6 daily Plan Ongoing review Further reduction in nutritional supplements and to promote normal diet Promote further weight gain

24. Goals of Dietetic Management Late Palliative Care (Deterioration in patient�s condition/progression of the disease, end of life care) Optimise nutritional intake Assess factors affecting nutritional intake and focus on their management eg anorexia, fatigue, bowel problems Improve well being and quality of life by agreeing patient led/ realistic goals Follow up as appropriate

25. End Stage Palliative Care Diagnosis: Extensive small cell lung cancer, brain mets Treatment: Previous excellent response to chemotherapy, followed by radiotherapy. Anti-emetic therapy Presenting Problems: In-patient, admitted c/o nausea and weakness. Referred re nausea and poor intake. Reluctant re supplements Anthropometrics: Weight 52 kg BMI: 22.5

26. Case study 3 - continued Aims: To advise re nausea To promote improved oral intake, considering patient�s wishes Interventions: Discuss with patient options re diet therapy Trial of juice tasting supplement in small volumes Patient on IV fluids and anti-emetics (Nozinan) Advise re best food choices re nausea Discussed with nursing staff and catering re very small portions

27. Case Study 3 - continued Initial Review (4 days later) Refusing supplement drink too sweet Agreed not for further supplements given advancing disease and patient�s wishes Dietary intake negligible but patient keen to attempt food Discuss again with nursing staff re portion sizes Nausea still not well controlled Second Review ( 4 days later) Nausea controlled, end stage of illness Patient enjoying small volumes of fluids

28. References Hawkins C (2000) Anorexia and anxiety in advadvanced malignancy: the relative problem. J Hum Nutr Dietet, 13, 113 � 117 Hamilton W (2005) What are the clinical features of lung cancer before the diagnosis is made? A population based control study. Thorax, 60, (12): 1,059 � 1065 National Cancer Survivorship Initiative . DOH 2008. Lung Cancer � The diagnosis and treatment of Lung Cancer (Clinical guideline 24) NICE, 2005.

29. Any Questions ?