The nursing contribution to nutritional care in cancer cachexia.

Cancer cachexia is a complex syndrome. Its defining feature is involuntary weight loss, which arises, in part, because of muscle atrophy and is accompanied by functional decline. International expert consensus recommends that nutritional support and counselling is a component of multimodal therapy for cancer cachexia, as poor nutritional intake can contribute to progression of the syndrome. The present paper focuses on what is presently known about the nursing contribution to nutritional care in cancer cachexia. There is potential for nurses to play an important role. However, obstacles to this include lack of a robust evidence base to support their nutritional care practices and unmet need for education about nutrition in cancer. The nursing role's boundaries and the outcomes of nurse-delivered nutritional care in cancer cachexia are both uncertain and should be investigated.

Novel intervention with acupuncture for anorexia and cachexia in patients with gastrointestinal tract cancers: a feasibility study.

PURPOSE/OBJECTIVES: To investigate the feasibility of using acupuncture as a complementary intervention to existing treatments and to evaluate the efficacy of acupuncture in improving appetite and slowing weight loss with patients with gastrointestinal (GI) tract cancers. 
 DESIGN: One-group pre- and postintervention feasibility study. 
 SETTING: Outpatient clinic for patients with cancer and a community setting, both in Florida. 
 SAMPLE: A convenience sample of seven adults with GI cancer.
 METHODS: Eight acupuncture sessions were provided during eight weeks. Data were collected using the visual analog scale (VAS) for appetite, Simplified Nutritional Appetite Questionnaire (SNAQ), Karnofsky Performance Status, and bioelectrical impedance analysis. 
 MAIN RESEARCH VARIABLES: Appetite, weight, attrition rate.
 FINDINGS: Seven patients with a mean age of 61 years completed the intervention. Acupuncture was well accepted, feasible, and safe without any reported side effects. Appetite showed improvement, with an average score of 3.04 on the VAS and 4.14 on SNAQ compared to the preintervention scores. The average weight loss was 1.32% compared to the baseline during an eight-week period. 
 CONCLUSIONS: The acupuncture intervention was feasible and indicated positive outcomes. Because of the small sample size and lack of a control group, statistical significance of effectiveness was not determined. Acupuncture seemed to improve appetite and slow weight loss in patients with GI cancers, so additional studies with a larger sample size and a variety of cancers are warranted. 
 IMPLICATIONS FOR NURSING: Oncology nurses are uniquely able to equip patients with information about complementary therapy modalities, such as acupuncture, which is a promising way to improve appetite and slow weight loss in patients with GI cancers.


Evaluation of a psychoeducational intervention for patients with advanced cancer who have cachexia and their lay carers (EPACaCC): study protocol.

AIM: To evaluate a psychoeducational intervention for patients with advanced cancer who have cachexia and their lay carers. BACKGROUND: Cachexia is a frequent and devastating syndrome of advanced cancer. It has an impact on patients biologically, psychologically and socially and has profound impact on their lay carers. Prior research has predominately focused on the biological components of cachexia and associated potential treatment modalities. At present, there is no standardized supportive healthcare intervention in current practice that targets the psychosocial impact of this syndrome. DESIGN: A pragmatic multicentre randomized controlled trial. METHODS: Patient/carer dyads (n = 200) will be recruited into a randomized controlled trial of a DVD intervention for cachexia management. The sample will be recruited from two urban hospices in the UK. The primary outcome measure will be the General Health Questionnaire-12. Additional questionnaires focusing on distress, readiness to give care and coping skills will be used as secondary outcome measures. In addition, lay carers in the intervention group will be asked to participate in semi-structured interviews following the death of their loved one. Both Office for Research Ethics Committee approval and local governance approval at both hospices have been obtained as of February 2013. DISCUSSION: This is the first time that a psychoeducational DVD has been tested in a randomized controlled trial in this population. Dissemination of findings will make a significant contribution to international knowledge and understanding in this area. Findings will inform education, practice and policy.

Healthcare professionals' response to cachexia in advanced cancer: a qualitative study.

PURPOSE/OBJECTIVES: To explore healthcare professionals' experience, understanding, and perception of the needs of patients with cachexia in advanced cancer. RESEARCH APPROACH: A qualitative approach based on symbolic interactionism. SETTING: A regional cancer center in a large teaching hospital in the United Kingdom. PARTICIPANTS: 34 healthcare professionals who had experience providing care to patients with cachexia in advanced cancer. METHODOLOGIC APPROACH: Data collection consisted of two phases: focus group and semistructured interviews. Interviews were digitally recorded and transcribed verbatim for analysis. This article reports on findings from the second phase of data collection. FINDINGS: Analysis revealed that professional approaches to cachexia were influenced by three overarching and interthinking themes: knowledge, culture, and resources. Healthcare professionals commonly recognized the impact of the syndrome; however, for nonpalliative healthcare professionals, a culture of avoidance and an overreliance on the biomedical model of care had considerable influence on the management of cachexia in patients with advanced cancer. CONCLUSIONS: Cachexia management in patients with advanced cancer can be difficult and is directed by a variable combination of the influence of knowledge, culture of the clinical area, and available resources. Distinct differences exist in the management of cachexia among palliative and nonpalliative care professionals. INTERPRETATION: This study presented a multiprofessional perspective on the management of cachexia in patients with advanced cancer and revealed that cachexia is a complex and challenging syndrome that needs to be addressed from a holistic model of care. KNOWLEDGE TRANSLATION: Cachexia management in patients with advanced cancer is complex and challenging and is directed by a combination of variables. An overreliance on the biomedical model of health and illness occurs in the management of cachexia in patients with advanced cancer. Cachexia needs to be addressed from a holistic model of care to reflect the multidimensional needs of patients and their families.

Outcomes evaluation of a weekly nurse practitioner-managed symptom management clinic for patients with head and neck cancer treated with chemoradiotherapy.

PURPOSE/OBJECTIVES: To determine whether improved monitoring through close follow-up with a nurse practitioner (NP) could enhance treatment compliance and decrease frequency of hospitalizations. DESIGN: Retrospective chart review. SETTING: An academic National Cancer Institute-designated comprehensive cancer center. SAMPLE: 151 patients aged 45-65 years diagnosed with stage III or IV oropharyngeal cancer. METHODS: Patients were nonrandomized to one of two groups: a prechemotherapy clinic group and a weekly NP-led clinic group. After examination of descriptive statistics, multiple linear and logistic regressions were used to compare groups across patient outcomes. MAIN RESEARCH VARIABLES: Hospitalization, chemotherapy dose deviations, and chemotherapy treatment completion. FINDINGS: The average number of visits during traditional treatment was three and, after initiation of the NP-led clinic, the number was six. The hospitalization rate was 28% in the traditional clinic group compared to 12% in the NP-led group. The rate of chemotherapy dose deviations was 48% in the traditional clinic group compared to 6% in the NP-led clinic group. Forty-six percent of patients in the traditional clinic group received the full seven scheduled doses of chemotherapy compared to 90% of patients seen in the NP-led clinic group. CONCLUSIONS: A weekly NP-led symptom management clinic reduces rates of hospitalization and chemotherapy dose deviations and increases chemotherapy completion in patients receiving intensive chemoradiotherapy for oropharyngeal cancer. IMPLICATIONS FOR NURSING: Patients receiving chemoradiotherapy benefit from close monitoring for toxicities by NPs to successfully complete their treatment and avoid hospitalization. KNOWLEDGE TRANSLATION: Early interventions to manage toxicities in patients with head and neck cancer can improve outcomes. NPs are in a key position to manage these toxicities and, when symptoms are controlled, costs are reduced.

A literature review of end-stage renal disease and cachexia: understanding experience to inform evidence-based healthcare.

INTRODUCTION: Cachexia is a major cause of morbidity and mortality in people who have end-stage renal disease (ESRD). The majority of research into cachexia in ESRD has focused on the biological aspects of the syndrome and potential treatment modalities. While this research is necessary, it predominately focuses on the physical impact of cachexia in ESRD. The multi-dimensional psychosocial ramifications of this syndrome have been highlighted in other end-stage illness trajectories, but have not been systematically explored in persons who have ESRD. AIM: This paper discusses why this research is necessary, alongside further studies to help define the pathophysiology of this syndrome. CONCLUSION: The rich insightful data gained from understanding the patients' illness experience will positively contribute to the limited knowledge base available and inform future holistic patient-centred care delivery which recognises and responds to not only the biological but also the psychosocial impact of cachexia.

Providing nutritional support for patients with cancer cachexia.

Malnutrition is the single most common secondary diagnosis for patients with advanced cancer, and can affect up to 85% of patients. Anorexia and weight loss affect up to 80% of patients and are responsible for death in up to 20% of cases. Cancer cachexia is a feature of advanced cancer characterised by anorexia and a progressive loss of body weight, reduced immune response, poor treatment response, and poor quality of life. Providing effective nutritional support for patients who experience cancer cachexia at the end of life is very challenging and requires a multidisciplinary team approach to consider the implications beyond the patient's dietary needs being met. Evidence suggests that health professionals have limited understanding of cachexia and are often at a loss as to how to manage patients who experience this severe form of weight loss. The purpose of this article is to examine the quality of life of patients with advanced cancer who experience cachexia. The article covers the aetiology and management of the condition as well as current treatment methods and management strategies. In particular, it emphasises the advantages of the Macmillan approach to weight and eating. This approach focuses on the social aspects of eating and weight gain, indicating the importance of considering the effects of malnutrition on both the patient and the carer.

Cancer cachexia care: the contribution of qualitative research to evidence-based practice.

BACKGROUND: Despite its prevalence and prognostic impact, primary cachexia is not well understood. Its potential to cause considerable psychological stress indicates the need for qualitative research to help understand the perspectives of those affected. OBJECTIVE: The aims of this study were to describe the perspectives of patients with primary cachexia, of their relatives, and of the healthcare professionals involved in their care and to demonstrate how this evidence can be applied in practice at 4 different levels of application ranging from empathy to coaching. METHODS: A review of the qualitative literature and empirical qualitative investigation was used to understand the experiences of patients and relatives and the perspectives of professionals. RESULTS: The main worries expressed by patients and relatives concerned appetite loss, changing appearance, prognosis, and social interaction. We also describe their coping responses and their views of professionals' responses. The main concerns of professionals related to poor communication, lack of clinical guidance, and lack of professional education. CONCLUSIONS: Understanding patients', families', and professionals' perspectives, and mapping that understanding onto what we know about the trajectory and prognosis of the condition, provides the evidence base for good practice. Qualitative research has a central role to play in providing the knowledge base for the nursing care of patients with cachexia. IMPLICATIONS FOR PRACTICE: The evidence provided can improve nurses' insight and assist them in assessment of status, the provision of guidance, and coaching. There is a need for the development of a holistic, information-based integrated care pathway for those with cancer cachexia and their families.

Nutrition in the care of patients with cancer cachexia.

Cancer cachexia, a progressive wasting syndrome experienced by approximately 80% of patients, is characterized by loss of adipose tissue and lean body mass. This complex metabolic process reflects both reduced nutrient availability and increased nutritional demand. Though cachexia is most commonly associated with particular tumours, no patient or tumour are excluded. This article provides an overview of cachexia and its pathophysiology and the factors contributing to its development before considering its impact on individuals. Emphasis is placed on the nutritional aspects of its management.

Understanding cachexia in patients with cancer.

Cancer cachexia is a progressive wasting syndrome characterised by loss of both adipose tissue and lean body mass. It is a complex metabolic process common in patients with cancer and responsible for death. Consideration of this syndrome is important because of its prevalence and its significant effect on morbidity, mortality and nutritional and psychological status.

The deliverability, acceptability, and perceived effect of the Macmillan approach to weight loss and eating difficulties: a phase II, cluster-randomized, exploratory trial of a psychosocial intervention for weight- and eating-related distress in people with advanced cancer.

CONTEXT: Up to 80% of people with cancer will develop weight loss and anorexia during the advanced stages of the disease. The Macmillan Weight and Eating Studies (2000-2009) have used the Medical Research Council complex interventions framework to develop the first psychosocial intervention for weight- and eating-related distress (WRD and ERD) in people with advanced cancer and their carers: The Macmillan Approach to Weight and Eating (MAWE). OBJECTIVES: This article reports the findings of a Phase II trial of MAWE that investigated its deliverability, acceptability, and patient-perceived effect on WRD and ERD. METHODS: The Phase II trial, conducted in 2006-2007, was of cluster-randomized design, with two community palliative care teams randomized to different arms. It used mixed methods to compare an intervention group (n=25), the MAWE group, which was supported by MAWE-trained clinical nurse specialists, with a group that received usual care (n=25), the control group. RESULTS: MAWE was deliverable in clinical practice and acceptable to patients. Unplanned exposure of the MAWE group to the intervention before an initial measure of WRD and ERD proved problematic to the trial process. Despite this, quantitative and qualitative analyses indicate that MAWE does not exacerbate WRD and ERD and may help patients with advanced cancer live with the weight loss and anorexia that are the symptoms of cancer cachexia syndrome. CONCLUSION: A follow-on randomized controlled trial of MAWE is warranted but should be of a revised design.

An interdisciplinary approach to manage cancer cachexia.

Cancer cachexia occurs in about 33% of newly diagnosed patients with cancer and may lead to delayed, missed, or decreased treatments. An interdisciplinary team approach to manage cancer cachexia may result in fewer missed treatments and improved outcomes. The palliative care program of an urban community cancer center developed an interdisciplinary clinic to treat cancer cachexia with the goal of using an interdisciplinary approach to improve symptom management, nutrition, function, and quality of life (QOL) for patients with cancer at high risk for malnutrition. The Cancer Appetite and Rehabilitation Clinic team completes medical, nutritional, speech, swallowing, and physical therapy evaluations and then develops an individualized program directed to meet patients' needs and improve overall QOL. Patient outcomes are measured by symptom management and nutritional and functional parameters. Early intervention and aggressive symptom management may improve performance status and overall QOL. Results from this project will be used to expand this innovative program. The process of developing and implementing this clinic may help oncology nurses and other healthcare professionals to improve management of cancer cachexia and overall cancer care.

An exploration of the experience of cancer cachexia: what patients and their families want from healthcare professionals.

The aim of this paper is to investigate the perceptions of patients and family members with regard to care received for cancer cachexia. A qualitative study recruited 27 participants, of which 15 were patients with advanced cancer who had primary cachexia and 12 were family members. Participants were recruited from a regional cancer centre in the UK. All participants took part in a domiciliary interview, which was transcribed verbatim for analysis. A major finding from analysis was 'lack of response from health care professionals' in relation to cancer cachexia management. This finding illuminated that patients and their family members wanted three things from healthcare professionals. They wanted their profound weight loss acknowledged, they wanted information about it and why it was happening and they wanted interventions to deal with it. This paper provides powerful messages for healthcare professionals and highlights the needs of patients and their family regarding cancer cachexia management. Patients and their families want this problem addressed by healthcare professionals. This client group requires supportive healthcare interventions, so that they can understand the nature and impact of this syndrome.

Fighting over food: patient and family understanding of cancer cachexia.

PURPOSE/OBJECTIVES: To investigate tensions over food that exist between patients with advanced cancer with cachexia and their families. RESEARCH APPROACH: Heideggerian phenomenologic inquiry using unstructured interviews. SETTING: A regional cancer center in the United Kingdom. PARTICIPANTS: 8 patients with advanced cancer living with cachexia and 8 family members. METHODOLOGIC APPROACH: Singular unstructured interviews were recorded digitally, transcribed verbatim, and analyzed using thematic and interpretative phenomenologic analysis. MAIN RESEARCH VARIABLES: Cachexia and advanced cancer. FINDINGS: A fine line existed between offering food to a patient and forcing a patient to eat; often, conflict arose as a result. Contributors to that conflict focused on reduced dietary intake by the patient and the reaction to food refusal by the family, which frequently led to patients eating to please. CONCLUSIONS: This study highlights the anxiety that surrounds eating and the distress it causes to patients and their families. This strain can escalate into arguments over food, causing negative repercussions for patients and their family members. INTERPRETATION: This is the first study to uncover tensions about eating as experienced by patients with advanced cancer and cachexia and their families. Nurses must consider this issue when designing and delivering effective care for this patient population.

Assessment and monitoring of nutritional status in patients with advanced cancer: part 1.

Using a qualitative approach, this study set out to explore nurses' management of patients with advanced cancer, weight loss and eating-associated problems. Extreme weight loss is commonly seen in patients with incurable solid tumour cancer and, to date, it has proved difficult to manage successfully. Currently, little is known about how nurses (often directly involved in the delivery of palliative care) assess weight loss and nutritional status in everyday practice in order to provide appropriate support. In this study, 14 semi-structured interviews were conducted with nurses from both hospital and community settings. The findings revealed that many nurses did not routinely provide early identification and assessment of nutritional status including weight loss, nor did they continue to monitor the patient's progress or deterioration. Many nurses were reluctant to initiate conversations with cancer patients about weight loss, but instead waited for patients and relatives to raise their concerns. As a result, it is likely that informal assessment may have resulted in the reactive style of nutritional management seen. However, nurses interviewed received limited training, but were keen to learn more about nutritional assessment and management.