Merran Findlay | The University of Sydney (original) (raw)

Papers by Merran Findlay

Research paper thumbnail of Evaluation of the agreement, adoption, and adherence to the evidence‐based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians

Nutrition & Dietetics

AIM Evidence-based guideline translation to practice can improve outcomes but is often impaired b... more AIM Evidence-based guideline translation to practice can improve outcomes but is often impaired by poor implementation. This project aimed to evaluate the implementation of the Evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians providing clinical care to this population. METHODS A questionnaire was developed, with face and content validity confirmed by an expert panel (n = 13), to gauge participant perceptions of the guidelines against an implementation evaluation framework. Dietitians were identified through Dietitians Australia and by contacting experts in the field. Eligibility was determined by questionnaire completion and prior guideline awareness. Responses were provided using a 5-point Likert scale. Results were analysed using descriptive statistics; with inferential analysis to determine if demographic information could reveal trends in guideline use and perception. RESULTS Of the 43 initial respondents, n = 28 completed the questionnaire, with n = 24/28 (86%) meeting full eligibility criteria for analysis. Median (range) scores for all four domains were high: awareness (4.0 [3.2-4.8]), agreement (4.4 [4.1-4.7]), adoption (3.5 [3.1-3.9]), and adherence (4.3 [4.1-4.9]). However, perception of guideline awareness and use among multidisciplinary team colleagues was low (mean 3.2/5.0 and 3.1/5.0, respectively). Dietitians with <10 years' experience had significantly higher perceptions of the guidelines' ability to positively influence practice; support evidence-based practice; and enhance dietitian credibility (P = 0.04) vs dietitians with ≥10 years' experience. CONCLUSION Dietitians demonstrated high rates of guideline implementation and positive perceptions for its use in clinical practice. Future implementation strategies and evaluation should expand to engage the wider multidisciplinary team and more experienced clinicians.

Research paper thumbnail of Mapping ongoing nutrition intervention trials in muscle, sarcopenia, and cachexia: a scoping review of future research

Journal of Cachexia, Sarcopenia and Muscle, 2022

Muscle loss alone, or in the context of sarcopenia or cachexia, is a prevalent condition and a pr... more Muscle loss alone, or in the context of sarcopenia or cachexia, is a prevalent condition and a predictor of negative outcomes in aging and disease. As adequate nutrition is essential for muscle maintenance, a growing number of studies has been conducted to explore the role of specific nutrients on muscle mass or function. Nonetheless, more research is needed to guide evidence‐based recommendations. This scoping review aimed to compile and document ongoing clinical trials investigating nutrition interventions as a strategy to prevent or treat low muscle mass or function (strength and physical performance), sarcopenia, or cachexia. ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched up to 21 April 2021 for planned and ongoing trials. Randomized controlled trials with ≥20 participants per arm were included based on intent to explore the effects of nutrition interventions on muscle‐related outcomes (i.e. muscle mass or strength, physical performa...

Research paper thumbnail of Response to comment: Evaluating sarcopenia in cancer patients: The role of muscle strength

Research paper thumbnail of Letter to the Editor – Response to Comment: “Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer?” A meta-analysis

Research paper thumbnail of Support group preferences for patients with head and neck cancer: cross-sectional survey

Cancers arising from the head and neck represents the seventh most common cancer site in Australi... more Cancers arising from the head and neck represents the seventh most common cancer site in Australia (1), accounting for over 700,000 (over 5%) new cancer diagnoses worldwide and an estimated 450,000 (4.8%) deaths each year (2). The demographics and prognosis of patients with head and neck cancer are diverse and continually changing. In contrast to tobacco-related mucosal cancer, human papilloma virus (HPV)-related oropharyngeal cancers are common in younger males (3). HPV associated tumours have a much more favourable prognosis than smoking associated mucosal cancers (4). Several new treatments are emerging, such as immunotherapy, which are prolonging the lives of many patients with head and neck cancer. Improved survival means a larger cohort of patients are living with the long-term effects of the cancer and its treatment on their quality of life (QOL) (5). These patients live with the physical and emotional consequences of Original Article

Research paper thumbnail of Optimal frequency of individualised nutrition counselling in patients with head and neck cancer receiving treatment

Clinical Nutrition ESPEN, 2020

Patients undergoing Head and Neck Cancer (HNC) treatment had better clinical outcomes with more f... more Patients undergoing Head and Neck Cancer (HNC) treatment had better clinical outcomes with more frequent Individualised nutrition counselling: The optimal frequency of individualised nutrition counselling (INC) was weekly throughout treatment and fortnightly post-treatment for up to 6 weeks, or as clinically indicated. Improvements were seen in nutritional status (PG-SGA score), quality of life, treatment interruptions, unplanned hospital admissions and morbidity compared to control groups who received less frequent counselling. A systematic review was conducted in April 2020: The aim was to investigate the optimal frequency of INC pre-, periand post-treatment for patients with HNC. The authors hypothesized that more frequent counselling in line with current guidelines would produce the most beneficial clinical outcomes for patients. Four Randomised Controlled Trials (RTCs) (n=500), published in five manuscripts were included: Three RCT's delivered INC weekly and one RCT delivered INC fortnightly throughout treatment. Two RCT's delivered fortnightly INC post-treatment, two RCT's did not offer post-treatment INC, and nil offered INC pre-treatment. Compared to control groups, patients receiving weekly INC during treatment (three RCT's) and fortnightly post-treatment (two RCT's) demonstrated positive consistent findings for nutritional status, quality of life, treatment interruptions, unplanned hospital admissions and morbidity.

Research paper thumbnail of Computed tomography (CT)-defined sarcopenia and myosteatosis are prevalent in patients with neuroendocrine neoplasms (NENs) treated with peptide receptor radionuclide therapy (PRRT)

European Journal of Clinical Nutrition, 2021

Neuroendocrine neoplasms (NEN) may predispose patients to malnutrition. CT-defined sarcopenia and... more Neuroendocrine neoplasms (NEN) may predispose patients to malnutrition. CT-defined sarcopenia and myosteatosis are common in other tumour types and recognized adverse prognostic factors. However, the prevalence and prognostic impact of sarcopenia and myosteatosis remain undetermined in NEN patients to date. A retrospective study of NEN patients treated with peptide receptor radionuclide therapy (PRRT) at a tertiary institution from 2012 to 2017. Patients with PET/CT imaging at baseline and follow-up were included. The L3 slice of the co-localizing CT was analysed using the Alberta Protocol. Skeletal muscle cross-sectional area and muscle attenuation were measured and compared with pre-defined cut-offs. The primary endpoint was the prevalence of sarcopenia and myosteatosis according to previously published cut-offs. Fourty-nine patients (median age 64 (range 26–80) years) were included. The most common primary sites of tumour were the small bowel (51%) and pancreas (26%). Baseline sarcopenia was prevalent in 67% of patients and myosteatosis in 71%. Forty-five percent of patients gained weight over the course of PRRT. The presence of baseline sarcopenia was not associated with progression-free survival (20.8 mo vs. 20.7 mo, HR 0.86, p = 0.70) nor overall survival. Similarly, baseline myosteatosis (PFS 19.5 mo vs. 20.8 mo, HR 0.77, p = 0.47) was not significantly associated with survival outcomes. The mean (SD) age of those with myosteatosis was 60.8 ± 11.6 years compared to 49.7 ± 12.7 years for those without (p = 0.003). Body composition analysis is feasible using routinely acquired PET/CT data for patients with NEN. CT-defined sarcopenia and myosteatosis are prevalent in NEN patients, although myosteatosis is more common with increasing age. These findings were not associated with worsened overall or progression-free survival in the current study.

Research paper thumbnail of Comparison of prophylactic percutaneous endoscopic gastrostomy with reactive enteral nutrition in patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy: A systematic review

Clinical Nutrition ESPEN, 2021

Summary Background & Aims Nutrition support is frequently indicated in patients with head and... more Summary Background & Aims Nutrition support is frequently indicated in patients with head and neck cancer (HNC). However, the optimal timing of enteral tube placement and feeding commencement is unknown. This review aims to compare the outcomes for patients with HNC undergoing curative intent radiotherapy (RT) or chemoradiotherapy (CRT) receiving either prophylactic percutaneous endoscopic gastrostomy (pPEG) tube placement/feeding or reactive enteral nutrition (rEN). Methods A literature search was conducted in March 2020 across PubMed, CINAHL, Embase, Web of Science, and Scopus. Randomized controlled trials (RCTs) of patients (≥18 years) with HNC who had received either pPEG or rEN were included. Outcomes examined were weight change, nutritional status, body mass index, treatment interruptions, quality of life (QoL), disease-free survival and overall survival. Study quality and certainty of evidence were assessed using the Cochrane Risk-of-bias Tool for Randomized Trials Version 2 and the Grading of Recommendations Assessment, Development and Evaluation system, respectively. Results Five studies (three RCTs) (n=298) were included and definitions of pPEG and rEN were heterogenous. pPEG was associated with a clinically important reduction in short-term critical weight loss (>10% weight loss), and significantly improved short-term QoL in patients with HNC. The timing of nutrition support commencement had no effect on all other outcomes. The overall certainty of evidence was ‘moderate’ for: nutritional status; treatment interruptions; short-term QoL; disease-free survival; and ‘low’ for all other outcomes. Conclusions Patients with HNC undergoing RT or CRT receiving pPEG tube feeding/placement were less likely to experience short-term critical weight loss and have improved short-term QoL compared to rEN. Further well-designed RCTs with consistent definitions of tube feeding protocols and the use of validated tools to evaluate nutritional status, will assist to increase the certainty of evidence and confirm the beneficial effects observed.

Research paper thumbnail of The Association Between Computed Tomography–Defined Sarcopenia and Outcomes in Adult Patients Undergoing Radiotherapy of Curative Intent for Head and Neck Cancer: A Systematic Review

Journal of the Academy of Nutrition and Dietetics, 2020

Background: Since information about macro-and micronutrient intake among vegans is limited we aim... more Background: Since information about macro-and micronutrient intake among vegans is limited we aimed to determine and evaluate their dietary and supplementary intake. Methods: Seventy 18-61 years old Danish vegans completed a four-day weighed food record from which their daily intake of macro-and micronutrients was assessed and subsequently compared to an age-range-matched group of 1 257 omnivorous individuals from the general Danish population. Moreover, the vegan dietary and supplementary intake was compared to the 2012 Nordic Nutrition Recommendations (NNR). Results: Dietary intake differed significantly between vegans and the general Danish population in all measured macro-and micronutrients (p < 0.05), except for energy intake among women and intake of carbohydrates among men. For vegans the intake of macro-and micronutrients (including supplements) did not reach the NNR for protein, vitamin D, iodine and selenium. Among vegan women vitamin A intake also failed to reach the recommendations. With reference to the NNR, the dietary content of added sugar, sodium and fatty acids, including the ratio of PUFA to SFA, was more favorable among vegans. Conclusions: At the macronutrient level, the diet of Danish vegans is in better accordance with the NNR than the diet of the general Danish population. At the micronutrient level, considering both diet and supplements, the vegan diet falls short in certain nutrients, suggesting a need for greater attention toward ensuring recommended daily intake of specific vitamins and minerals.

Research paper thumbnail of Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer? A meta-analysis

Clinical Nutrition, 2020

Introduction: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic facto... more Introduction: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor for survival in patients with cancer, however, its impact in patients with head and neck cancer (HNC) has only recently been explored. This study aimed to determine the prognostic impact of CT-defined sarcopenia at the level of the third lumbar vertebra (L3) on overall survival in patients with HNC undergoing radiotherapy ± other treatment modality of curative intent. Methods: A systematic review of the literature published between January 2004 and May 2020 was conducted in Medline, Embase, CINAHL, AMED and PubMed. Empirical studies in adults (!18 years) who had completed radiotherapy of curative intent ± other treatment modalities that evaluated sarcopenia using the gold standard method at L3 and applied sex-specific cutoffs were included. Outcome of interest was overall survival. Study quality was assessed using the Quality In Prognosis Studies (QUIPS) tool. Hazard ratios with 95% confidence intervals derived from multivariate analysis were extracted directly from studies. Random-effects meta-analysis was used to determine the pooled hazard ratio for overall survival in patients with sarcopenia versus those without using RevMan (Version 5.3). The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: A total of 6211 studies were identified and screened from which seven studies met the inclusion criteria with 1059 pooled patients. All studies defined sarcopenia as low muscle mass but varied in skeletal muscle index (SMI) threshold values applied and ethnicity. Sarcopenia prevalence ranged from 6.6 to 64.6% pre-treatment and 12.4 to 65.8% post-treatment. Pre-treatment sarcopenia was associated with reduced overall survival (HR 2.07; 95%CI, 1.47e2.92, p < 0.0001, I 2 ¼ 49%) with similar findings for post-treatment sarcopenia (HR 2.93; 95%CI, 2.00e4.29, p < 0.00001, I 2 ¼ 0%) with moderate to low heterogeneity exhibited amongst studies respectively. The certainty of evidence for overall survival according to GRADE was low for pre-treatment sarcopenia and moderate for post-treatment sarcopenia. Conclusions: CT-defined sarcopenia is independently associated with reduced overall survival in patients with HNC and holds a clinically meaningful prognostic value. Consensus regarding sarcopenia assessment and definitions is warranted in order to substantiate these findings and support implementation of body composition assessment as a clinically meaningful prognostic tool into practice.

Research paper thumbnail of Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes

Nutrients, 2020

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despit... more Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence–practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre–post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation...

Research paper thumbnail of “Completely and utterly flummoxed and out of my depth”: patient and caregiver experiences during and after treatment for head and neck cancer—a qualitative evaluation of barriers and facilitators to best-practice nutrition care

Supportive Care in Cancer, 2020

Background Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on ou... more Background Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on outcomes. Despite publication of best-practice nutrition care clinical guidelines, evidence-practice gaps persist. Aim This project aimed to understand the perspectives of patients and their caregivers about nutritional care and how their unmet supportive care needs can be better addressed in designing a new model of care (MOC). The results will contribute to documenting the barriers and enablers to implementing best practice nutrition care for patients with HNC. Method Qualitative interviews were conducted with patients who had completed radiotherapy with or without (+/−) other treatment modality (surgery and/or systematic therapy) of curative intent for HNC. Patients were purposively sampled from a major tertiary referral centre in Sydney, Australia. Patients’ primary caregivers were also invited to participate if both parties consented. A semi-structured interview schedule was developed to elicit information about barriers and facilitators to change and inform development of the new MOC. Interviews were transcribed verbatim then analysed using an inductive thematic approach. This study was one component of a mixed methods design to explore the barriers and facilitators to best-practice nutrition care in a head and neck oncology unit. Results Eleven participants (seven patients, four caregivers) took part in the interviews. Four key themes were identified with branching themes within each: (1) being ill-prepared for the impact of treatment, even when advised; (2) navigating complex systems to meet significant care needs; (3) depleted by overwhelming and prolonged suffering; and (4) information lost in translation. Conclusions This study highlights the unique and complex care needs of people with HNC and those caring for them. To design and successfully deliver a patient-centred MOC, specific strategies will be required to address: early and ongoing access to expert supportive care clinicians; integrated and coordinated care; individual information, education and support needs and; and education of MDT staff in accurate and consistent messaging, ensuring nutrition care is a collective responsibility. Nutrition care did not appear to be viewed separately to overall care from the patient perspective as the importance of nutrition ultimately became viewed as vital treatment.

Research paper thumbnail of Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice

Supportive Care in Cancer, 2020

Purpose Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to bench... more Purpose Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement. Methods A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia. Results Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding postoperatively; however, initiation within 24 h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions. Conclusions Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

Research paper thumbnail of The Importance of Nutrition during Treatment for Oesophageal Cancer—The Patient’s Perspective

Food and Nutrition Sciences, 2019

Background and Objectives: Nutritional issues are prevalent in patients with oesophageal cancer (... more Background and Objectives: Nutritional issues are prevalent in patients with oesophageal cancer (OC) across all aspects of treatment, including chemoradiotherapy (CRT) and surgery. There are limited studies investigating nutritional issues faced by people undergoing neoadjuvant or definitive CRT from the patient's perspective. This study aimed to explore the importance that people with OC place upon nutrition during their treatment which included neoadjuvant or definitive CRT, explore the nutritional issues faced in this patient group and identify areas for improvement of dietetic services. Methods and Study Design: Nine people who had undergone curative treatment for OC in the previous 2-25 months participated in semi-structured phone interviews. Interviews were tape-recorded and transcribed verbatim and analysed using an inductive thematic analysis approach. Results: Interviews revealed severe difficulties in food consumption during and following CRT and a period of struggling to adjust eating habits post oesophagectomy. There was significant difficulty in following nutrition advice and, despite participants expressing the importance of nutrition; this was not reflected in attitudes towards weight loss. The medical team significantly influenced the perceptions of some participants in regards to their weight loss. Conclusions: Implications for clinical practice include the need for dietetic services before, during and after treatment for OC, irrespective of treatment type. Patient education regarding detrimental effects of rapid weight loss and effects on body composition is crucial, and this should be consistent from all members of the healthcare team.

Research paper thumbnail of Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society

JAMA otolaryngology-- head & neck surgery, Jan 13, 2016

Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap... more Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction. Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral ...

Research paper thumbnail of Understanding nutritional issues in the older person with cancer

The prevalence of malnutrition in both older people and those with cancer is high. Risk of malnut... more The prevalence of malnutrition in both older people and those with cancer is high. Risk of malnutrition is compounded in the oncogeriatric population arising from the overlap of both age-related and cancer - induced aetiologies, leaving the older person particularly susceptible to the detrimental sequelae of disease and treatment-related morbidity. National evidence-based guidelines recommend implementation of routine malnutrition screening to identify at risk patients and facilitate early access to dietitians with expertise in nutritional management of this patient group for comprehensive nutritional assessment, intervention and monitoring. The multidisciplinary team can play a proactive role in addressing the nutritional needs of this group as part of comprehensive cancer care and improve patientcentred, clinical and cost outcomes.

Research paper thumbnail of Nutritional status and fitness in neoadjuvant chemoradiation for oesophagogastric cancer

Cancer Forum, 2011

The policy of Cancer Forum is to provide a forum for debate and the exchange of medical, scientif... more The policy of Cancer Forum is to provide a forum for debate and the exchange of medical, scientific, political, social and educational comment related to cancer research, treatment, prevention and control. Cancer Forum invites submissions of original research articles, reports and letters relating to these themes.

Research paper thumbnail of Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy

Nutrition & Dietetics, 2013

ABSTRACT AimsThe aim of this paper was to update the evidence-based practice guidelines for the n... more ABSTRACT AimsThe aim of this paper was to update the evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and broaden the scope to include chemotherapy. Methods The following databases were searched using a range of keywords: Cochrane Database, CENTRAL, MEDLINE (via Ebscohost), EMBASE, CINAHL (Ebscohost), Web of Science, Health Source: Nursing/Academic Edition and PubMed. Relevant papers (n = 47) were reviewed by at least two members of the steering committee and assigned a level of evidence and a quality rating. ResultsThere were no new published randomised controlled trials (RCTs) of nutrition intervention in radiation therapy. Most statements in the previous radiation therapy guidelines have strong evidence supporting nutrition intervention. There were 12 studies in chemotherapy including five RCTs. While these studies provided strong evidence that simple nutrition intervention improves nutritional outcomes such as dietary intake and weight, they did not find an improvement in quality of life or survival. Several RCTs found no benefits of nutrition support in patients undergoing chemotherapy. None of the RCTs in chemotherapy used medical nutrition therapy (MNT) as the intervention, but rather simple dietary advice and/or supplements. Conclusions The evidence to support nutrition intervention in patients receiving radiation therapy remains strong. However, the benefits of nutrition intervention in chemotherapy are less clear. Further studies are required to evaluate the impact of MNT as opposed to simple dietary advice in chemotherapy patients. This update contributes to a move towards comprehensive evidence-based guidelines for the nutritional management of patients with cancer.

Research paper thumbnail of Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer

Journal of Human Nutrition and Dietetics, 2013

The present study describes the development of evidence-based practice guidelines for the nutriti... more The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency. A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics. In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min. Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated.

Research paper thumbnail of When is the optimal time for placing a gastrostomy in patients undergoing treatment for head and neck cancer?

Current Opinion in Supportive & Palliative Care, 2012

Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for hea... more Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for head and neck cancer involves complex decision making and multifactorial analysis. Lack of high-quality studies with appropriate end points for nutritional outcomes and heterogeneity of patient, clinical and organizational factors makes determining best practice nutritional care challenging. This review provides a background rationale for gastrostomy placement and evaluates the relevant literature extending beyond the past 12 months due to limited numbers of published studies. Emerging concepts and controversies are highlighted to demonstrate that the decision to place a gastrostomy or not has eclipsed the significance of patients&#39; nutritional needs leading to much debate and inconsistencies in clinical practice. While the optimal method of tube feeding remains unclear due to challenges with study design, improved outcomes have been demonstrated with prophylactic tube feeding. Variation exists with selection criteria in the decision for gastrostomy placement based on clinical opinion rather than evidence-based practice. Gastrostomy use as a measure of swallowing outcomes and the presence of a feeding tube for quality of life (QOL) have led to the concept of gastrostomy dependency and a perceived association with poorer outcomes. The multidimensional contributors have been inadequately explored leaving this phenomenon poorly defined and misinterpreted. Best practice nutritional care incorporates malnutrition screening and nutritional assessment using validated tools, early referral to the dietitian and ongoing monitoring to optimize nutritional status throughout the patient&#39;s entire care pathway. The decision for timing of gastrostomy placement should be made at diagnosis given the benefits of prophylactic tube feeding. Accountability for insertion and removal of gastrostomies with alignment of services will facilitate risk assessment, appropriate placement, effective patient counselling and monitoring for major and minor complications. Nutritional outcomes need to be distinguished from swallowing and QOL measures and evaluated to include effects on nutritional status, gastrostomy complications, intensity and frequency of dietetic support and effect on survival.

Research paper thumbnail of Evaluation of the agreement, adoption, and adherence to the evidence‐based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians

Nutrition & Dietetics

AIM Evidence-based guideline translation to practice can improve outcomes but is often impaired b... more AIM Evidence-based guideline translation to practice can improve outcomes but is often impaired by poor implementation. This project aimed to evaluate the implementation of the Evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians providing clinical care to this population. METHODS A questionnaire was developed, with face and content validity confirmed by an expert panel (n = 13), to gauge participant perceptions of the guidelines against an implementation evaluation framework. Dietitians were identified through Dietitians Australia and by contacting experts in the field. Eligibility was determined by questionnaire completion and prior guideline awareness. Responses were provided using a 5-point Likert scale. Results were analysed using descriptive statistics; with inferential analysis to determine if demographic information could reveal trends in guideline use and perception. RESULTS Of the 43 initial respondents, n = 28 completed the questionnaire, with n = 24/28 (86%) meeting full eligibility criteria for analysis. Median (range) scores for all four domains were high: awareness (4.0 [3.2-4.8]), agreement (4.4 [4.1-4.7]), adoption (3.5 [3.1-3.9]), and adherence (4.3 [4.1-4.9]). However, perception of guideline awareness and use among multidisciplinary team colleagues was low (mean 3.2/5.0 and 3.1/5.0, respectively). Dietitians with <10 years' experience had significantly higher perceptions of the guidelines' ability to positively influence practice; support evidence-based practice; and enhance dietitian credibility (P = 0.04) vs dietitians with ≥10 years' experience. CONCLUSION Dietitians demonstrated high rates of guideline implementation and positive perceptions for its use in clinical practice. Future implementation strategies and evaluation should expand to engage the wider multidisciplinary team and more experienced clinicians.

Research paper thumbnail of Mapping ongoing nutrition intervention trials in muscle, sarcopenia, and cachexia: a scoping review of future research

Journal of Cachexia, Sarcopenia and Muscle, 2022

Muscle loss alone, or in the context of sarcopenia or cachexia, is a prevalent condition and a pr... more Muscle loss alone, or in the context of sarcopenia or cachexia, is a prevalent condition and a predictor of negative outcomes in aging and disease. As adequate nutrition is essential for muscle maintenance, a growing number of studies has been conducted to explore the role of specific nutrients on muscle mass or function. Nonetheless, more research is needed to guide evidence‐based recommendations. This scoping review aimed to compile and document ongoing clinical trials investigating nutrition interventions as a strategy to prevent or treat low muscle mass or function (strength and physical performance), sarcopenia, or cachexia. ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched up to 21 April 2021 for planned and ongoing trials. Randomized controlled trials with ≥20 participants per arm were included based on intent to explore the effects of nutrition interventions on muscle‐related outcomes (i.e. muscle mass or strength, physical performa...

Research paper thumbnail of Response to comment: Evaluating sarcopenia in cancer patients: The role of muscle strength

Research paper thumbnail of Letter to the Editor – Response to Comment: “Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer?” A meta-analysis

Research paper thumbnail of Support group preferences for patients with head and neck cancer: cross-sectional survey

Cancers arising from the head and neck represents the seventh most common cancer site in Australi... more Cancers arising from the head and neck represents the seventh most common cancer site in Australia (1), accounting for over 700,000 (over 5%) new cancer diagnoses worldwide and an estimated 450,000 (4.8%) deaths each year (2). The demographics and prognosis of patients with head and neck cancer are diverse and continually changing. In contrast to tobacco-related mucosal cancer, human papilloma virus (HPV)-related oropharyngeal cancers are common in younger males (3). HPV associated tumours have a much more favourable prognosis than smoking associated mucosal cancers (4). Several new treatments are emerging, such as immunotherapy, which are prolonging the lives of many patients with head and neck cancer. Improved survival means a larger cohort of patients are living with the long-term effects of the cancer and its treatment on their quality of life (QOL) (5). These patients live with the physical and emotional consequences of Original Article

Research paper thumbnail of Optimal frequency of individualised nutrition counselling in patients with head and neck cancer receiving treatment

Clinical Nutrition ESPEN, 2020

Patients undergoing Head and Neck Cancer (HNC) treatment had better clinical outcomes with more f... more Patients undergoing Head and Neck Cancer (HNC) treatment had better clinical outcomes with more frequent Individualised nutrition counselling: The optimal frequency of individualised nutrition counselling (INC) was weekly throughout treatment and fortnightly post-treatment for up to 6 weeks, or as clinically indicated. Improvements were seen in nutritional status (PG-SGA score), quality of life, treatment interruptions, unplanned hospital admissions and morbidity compared to control groups who received less frequent counselling. A systematic review was conducted in April 2020: The aim was to investigate the optimal frequency of INC pre-, periand post-treatment for patients with HNC. The authors hypothesized that more frequent counselling in line with current guidelines would produce the most beneficial clinical outcomes for patients. Four Randomised Controlled Trials (RTCs) (n=500), published in five manuscripts were included: Three RCT's delivered INC weekly and one RCT delivered INC fortnightly throughout treatment. Two RCT's delivered fortnightly INC post-treatment, two RCT's did not offer post-treatment INC, and nil offered INC pre-treatment. Compared to control groups, patients receiving weekly INC during treatment (three RCT's) and fortnightly post-treatment (two RCT's) demonstrated positive consistent findings for nutritional status, quality of life, treatment interruptions, unplanned hospital admissions and morbidity.

Research paper thumbnail of Computed tomography (CT)-defined sarcopenia and myosteatosis are prevalent in patients with neuroendocrine neoplasms (NENs) treated with peptide receptor radionuclide therapy (PRRT)

European Journal of Clinical Nutrition, 2021

Neuroendocrine neoplasms (NEN) may predispose patients to malnutrition. CT-defined sarcopenia and... more Neuroendocrine neoplasms (NEN) may predispose patients to malnutrition. CT-defined sarcopenia and myosteatosis are common in other tumour types and recognized adverse prognostic factors. However, the prevalence and prognostic impact of sarcopenia and myosteatosis remain undetermined in NEN patients to date. A retrospective study of NEN patients treated with peptide receptor radionuclide therapy (PRRT) at a tertiary institution from 2012 to 2017. Patients with PET/CT imaging at baseline and follow-up were included. The L3 slice of the co-localizing CT was analysed using the Alberta Protocol. Skeletal muscle cross-sectional area and muscle attenuation were measured and compared with pre-defined cut-offs. The primary endpoint was the prevalence of sarcopenia and myosteatosis according to previously published cut-offs. Fourty-nine patients (median age 64 (range 26–80) years) were included. The most common primary sites of tumour were the small bowel (51%) and pancreas (26%). Baseline sarcopenia was prevalent in 67% of patients and myosteatosis in 71%. Forty-five percent of patients gained weight over the course of PRRT. The presence of baseline sarcopenia was not associated with progression-free survival (20.8 mo vs. 20.7 mo, HR 0.86, p = 0.70) nor overall survival. Similarly, baseline myosteatosis (PFS 19.5 mo vs. 20.8 mo, HR 0.77, p = 0.47) was not significantly associated with survival outcomes. The mean (SD) age of those with myosteatosis was 60.8 ± 11.6 years compared to 49.7 ± 12.7 years for those without (p = 0.003). Body composition analysis is feasible using routinely acquired PET/CT data for patients with NEN. CT-defined sarcopenia and myosteatosis are prevalent in NEN patients, although myosteatosis is more common with increasing age. These findings were not associated with worsened overall or progression-free survival in the current study.

Research paper thumbnail of Comparison of prophylactic percutaneous endoscopic gastrostomy with reactive enteral nutrition in patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy: A systematic review

Clinical Nutrition ESPEN, 2021

Summary Background & Aims Nutrition support is frequently indicated in patients with head and... more Summary Background & Aims Nutrition support is frequently indicated in patients with head and neck cancer (HNC). However, the optimal timing of enteral tube placement and feeding commencement is unknown. This review aims to compare the outcomes for patients with HNC undergoing curative intent radiotherapy (RT) or chemoradiotherapy (CRT) receiving either prophylactic percutaneous endoscopic gastrostomy (pPEG) tube placement/feeding or reactive enteral nutrition (rEN). Methods A literature search was conducted in March 2020 across PubMed, CINAHL, Embase, Web of Science, and Scopus. Randomized controlled trials (RCTs) of patients (≥18 years) with HNC who had received either pPEG or rEN were included. Outcomes examined were weight change, nutritional status, body mass index, treatment interruptions, quality of life (QoL), disease-free survival and overall survival. Study quality and certainty of evidence were assessed using the Cochrane Risk-of-bias Tool for Randomized Trials Version 2 and the Grading of Recommendations Assessment, Development and Evaluation system, respectively. Results Five studies (three RCTs) (n=298) were included and definitions of pPEG and rEN were heterogenous. pPEG was associated with a clinically important reduction in short-term critical weight loss (>10% weight loss), and significantly improved short-term QoL in patients with HNC. The timing of nutrition support commencement had no effect on all other outcomes. The overall certainty of evidence was ‘moderate’ for: nutritional status; treatment interruptions; short-term QoL; disease-free survival; and ‘low’ for all other outcomes. Conclusions Patients with HNC undergoing RT or CRT receiving pPEG tube feeding/placement were less likely to experience short-term critical weight loss and have improved short-term QoL compared to rEN. Further well-designed RCTs with consistent definitions of tube feeding protocols and the use of validated tools to evaluate nutritional status, will assist to increase the certainty of evidence and confirm the beneficial effects observed.

Research paper thumbnail of The Association Between Computed Tomography–Defined Sarcopenia and Outcomes in Adult Patients Undergoing Radiotherapy of Curative Intent for Head and Neck Cancer: A Systematic Review

Journal of the Academy of Nutrition and Dietetics, 2020

Background: Since information about macro-and micronutrient intake among vegans is limited we aim... more Background: Since information about macro-and micronutrient intake among vegans is limited we aimed to determine and evaluate their dietary and supplementary intake. Methods: Seventy 18-61 years old Danish vegans completed a four-day weighed food record from which their daily intake of macro-and micronutrients was assessed and subsequently compared to an age-range-matched group of 1 257 omnivorous individuals from the general Danish population. Moreover, the vegan dietary and supplementary intake was compared to the 2012 Nordic Nutrition Recommendations (NNR). Results: Dietary intake differed significantly between vegans and the general Danish population in all measured macro-and micronutrients (p < 0.05), except for energy intake among women and intake of carbohydrates among men. For vegans the intake of macro-and micronutrients (including supplements) did not reach the NNR for protein, vitamin D, iodine and selenium. Among vegan women vitamin A intake also failed to reach the recommendations. With reference to the NNR, the dietary content of added sugar, sodium and fatty acids, including the ratio of PUFA to SFA, was more favorable among vegans. Conclusions: At the macronutrient level, the diet of Danish vegans is in better accordance with the NNR than the diet of the general Danish population. At the micronutrient level, considering both diet and supplements, the vegan diet falls short in certain nutrients, suggesting a need for greater attention toward ensuring recommended daily intake of specific vitamins and minerals.

Research paper thumbnail of Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer? A meta-analysis

Clinical Nutrition, 2020

Introduction: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic facto... more Introduction: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor for survival in patients with cancer, however, its impact in patients with head and neck cancer (HNC) has only recently been explored. This study aimed to determine the prognostic impact of CT-defined sarcopenia at the level of the third lumbar vertebra (L3) on overall survival in patients with HNC undergoing radiotherapy ± other treatment modality of curative intent. Methods: A systematic review of the literature published between January 2004 and May 2020 was conducted in Medline, Embase, CINAHL, AMED and PubMed. Empirical studies in adults (!18 years) who had completed radiotherapy of curative intent ± other treatment modalities that evaluated sarcopenia using the gold standard method at L3 and applied sex-specific cutoffs were included. Outcome of interest was overall survival. Study quality was assessed using the Quality In Prognosis Studies (QUIPS) tool. Hazard ratios with 95% confidence intervals derived from multivariate analysis were extracted directly from studies. Random-effects meta-analysis was used to determine the pooled hazard ratio for overall survival in patients with sarcopenia versus those without using RevMan (Version 5.3). The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results: A total of 6211 studies were identified and screened from which seven studies met the inclusion criteria with 1059 pooled patients. All studies defined sarcopenia as low muscle mass but varied in skeletal muscle index (SMI) threshold values applied and ethnicity. Sarcopenia prevalence ranged from 6.6 to 64.6% pre-treatment and 12.4 to 65.8% post-treatment. Pre-treatment sarcopenia was associated with reduced overall survival (HR 2.07; 95%CI, 1.47e2.92, p < 0.0001, I 2 ¼ 49%) with similar findings for post-treatment sarcopenia (HR 2.93; 95%CI, 2.00e4.29, p < 0.00001, I 2 ¼ 0%) with moderate to low heterogeneity exhibited amongst studies respectively. The certainty of evidence for overall survival according to GRADE was low for pre-treatment sarcopenia and moderate for post-treatment sarcopenia. Conclusions: CT-defined sarcopenia is independently associated with reduced overall survival in patients with HNC and holds a clinically meaningful prognostic value. Consensus regarding sarcopenia assessment and definitions is warranted in order to substantiate these findings and support implementation of body composition assessment as a clinically meaningful prognostic tool into practice.

Research paper thumbnail of Best Evidence to Best Practice: Implementing an Innovative Model of Nutrition Care for Patients with Head and Neck Cancer Improves Outcomes

Nutrients, 2020

Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despit... more Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting outcomes. Despite publication of nutrition care evidence-based guidelines (EBGs), evidence–practice gaps exist. This study aimed to implement and evaluate the integration of a patient-centred, best-practice dietetic model of care into an HNC multidisciplinary team (MDT) to minimise the detrimental sequelae of malnutrition. A mixed-methods, pre–post study design was used to deliver key interventions underpinned by evidence-based implementation strategies to address identified barriers and facilitators to change at individual, team and system levels. A data audit of medical records established baseline adherence to EBGs and clinical parameters prior to implementation in a prospective cohort. Key interventions included a weekly Supportive Care-Led Pre-Treatment Clinic and a Nutrition Care Dashboard highlighting nutrition outcome data integrated into MDT meetings. Focus groups provided team-level evaluation...

Research paper thumbnail of “Completely and utterly flummoxed and out of my depth”: patient and caregiver experiences during and after treatment for head and neck cancer—a qualitative evaluation of barriers and facilitators to best-practice nutrition care

Supportive Care in Cancer, 2020

Background Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on ou... more Background Malnutrition is prevalent in patients with head and neck cancer (HNC), impacting on outcomes. Despite publication of best-practice nutrition care clinical guidelines, evidence-practice gaps persist. Aim This project aimed to understand the perspectives of patients and their caregivers about nutritional care and how their unmet supportive care needs can be better addressed in designing a new model of care (MOC). The results will contribute to documenting the barriers and enablers to implementing best practice nutrition care for patients with HNC. Method Qualitative interviews were conducted with patients who had completed radiotherapy with or without (+/−) other treatment modality (surgery and/or systematic therapy) of curative intent for HNC. Patients were purposively sampled from a major tertiary referral centre in Sydney, Australia. Patients’ primary caregivers were also invited to participate if both parties consented. A semi-structured interview schedule was developed to elicit information about barriers and facilitators to change and inform development of the new MOC. Interviews were transcribed verbatim then analysed using an inductive thematic approach. This study was one component of a mixed methods design to explore the barriers and facilitators to best-practice nutrition care in a head and neck oncology unit. Results Eleven participants (seven patients, four caregivers) took part in the interviews. Four key themes were identified with branching themes within each: (1) being ill-prepared for the impact of treatment, even when advised; (2) navigating complex systems to meet significant care needs; (3) depleted by overwhelming and prolonged suffering; and (4) information lost in translation. Conclusions This study highlights the unique and complex care needs of people with HNC and those caring for them. To design and successfully deliver a patient-centred MOC, specific strategies will be required to address: early and ongoing access to expert supportive care clinicians; integrated and coordinated care; individual information, education and support needs and; and education of MDT staff in accurate and consistent messaging, ensuring nutrition care is a collective responsibility. Nutrition care did not appear to be viewed separately to overall care from the patient perspective as the importance of nutrition ultimately became viewed as vital treatment.

Research paper thumbnail of Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice

Supportive Care in Cancer, 2020

Purpose Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to bench... more Purpose Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement. Methods A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia. Results Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding postoperatively; however, initiation within 24 h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions. Conclusions Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

Research paper thumbnail of The Importance of Nutrition during Treatment for Oesophageal Cancer—The Patient’s Perspective

Food and Nutrition Sciences, 2019

Background and Objectives: Nutritional issues are prevalent in patients with oesophageal cancer (... more Background and Objectives: Nutritional issues are prevalent in patients with oesophageal cancer (OC) across all aspects of treatment, including chemoradiotherapy (CRT) and surgery. There are limited studies investigating nutritional issues faced by people undergoing neoadjuvant or definitive CRT from the patient's perspective. This study aimed to explore the importance that people with OC place upon nutrition during their treatment which included neoadjuvant or definitive CRT, explore the nutritional issues faced in this patient group and identify areas for improvement of dietetic services. Methods and Study Design: Nine people who had undergone curative treatment for OC in the previous 2-25 months participated in semi-structured phone interviews. Interviews were tape-recorded and transcribed verbatim and analysed using an inductive thematic analysis approach. Results: Interviews revealed severe difficulties in food consumption during and following CRT and a period of struggling to adjust eating habits post oesophagectomy. There was significant difficulty in following nutrition advice and, despite participants expressing the importance of nutrition; this was not reflected in attitudes towards weight loss. The medical team significantly influenced the perceptions of some participants in regards to their weight loss. Conclusions: Implications for clinical practice include the need for dietetic services before, during and after treatment for OC, irrespective of treatment type. Patient education regarding detrimental effects of rapid weight loss and effects on body composition is crucial, and this should be consistent from all members of the healthcare team.

Research paper thumbnail of Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society

JAMA otolaryngology-- head & neck surgery, Jan 13, 2016

Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap... more Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction. Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral ...

Research paper thumbnail of Understanding nutritional issues in the older person with cancer

The prevalence of malnutrition in both older people and those with cancer is high. Risk of malnut... more The prevalence of malnutrition in both older people and those with cancer is high. Risk of malnutrition is compounded in the oncogeriatric population arising from the overlap of both age-related and cancer - induced aetiologies, leaving the older person particularly susceptible to the detrimental sequelae of disease and treatment-related morbidity. National evidence-based guidelines recommend implementation of routine malnutrition screening to identify at risk patients and facilitate early access to dietitians with expertise in nutritional management of this patient group for comprehensive nutritional assessment, intervention and monitoring. The multidisciplinary team can play a proactive role in addressing the nutritional needs of this group as part of comprehensive cancer care and improve patientcentred, clinical and cost outcomes.

Research paper thumbnail of Nutritional status and fitness in neoadjuvant chemoradiation for oesophagogastric cancer

Cancer Forum, 2011

The policy of Cancer Forum is to provide a forum for debate and the exchange of medical, scientif... more The policy of Cancer Forum is to provide a forum for debate and the exchange of medical, scientific, political, social and educational comment related to cancer research, treatment, prevention and control. Cancer Forum invites submissions of original research articles, reports and letters relating to these themes.

Research paper thumbnail of Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy

Nutrition & Dietetics, 2013

ABSTRACT AimsThe aim of this paper was to update the evidence-based practice guidelines for the n... more ABSTRACT AimsThe aim of this paper was to update the evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and broaden the scope to include chemotherapy. Methods The following databases were searched using a range of keywords: Cochrane Database, CENTRAL, MEDLINE (via Ebscohost), EMBASE, CINAHL (Ebscohost), Web of Science, Health Source: Nursing/Academic Edition and PubMed. Relevant papers (n = 47) were reviewed by at least two members of the steering committee and assigned a level of evidence and a quality rating. ResultsThere were no new published randomised controlled trials (RCTs) of nutrition intervention in radiation therapy. Most statements in the previous radiation therapy guidelines have strong evidence supporting nutrition intervention. There were 12 studies in chemotherapy including five RCTs. While these studies provided strong evidence that simple nutrition intervention improves nutritional outcomes such as dietary intake and weight, they did not find an improvement in quality of life or survival. Several RCTs found no benefits of nutrition support in patients undergoing chemotherapy. None of the RCTs in chemotherapy used medical nutrition therapy (MNT) as the intervention, but rather simple dietary advice and/or supplements. Conclusions The evidence to support nutrition intervention in patients receiving radiation therapy remains strong. However, the benefits of nutrition intervention in chemotherapy are less clear. Further studies are required to evaluate the impact of MNT as opposed to simple dietary advice in chemotherapy patients. This update contributes to a move towards comprehensive evidence-based guidelines for the nutritional management of patients with cancer.

Research paper thumbnail of Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer

Journal of Human Nutrition and Dietetics, 2013

The present study describes the development of evidence-based practice guidelines for the nutriti... more The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency. A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics. In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min. Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated.

Research paper thumbnail of When is the optimal time for placing a gastrostomy in patients undergoing treatment for head and neck cancer?

Current Opinion in Supportive & Palliative Care, 2012

Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for hea... more Determining the optimal timing for placing a gastrostomy in patients undergoing treatment for head and neck cancer involves complex decision making and multifactorial analysis. Lack of high-quality studies with appropriate end points for nutritional outcomes and heterogeneity of patient, clinical and organizational factors makes determining best practice nutritional care challenging. This review provides a background rationale for gastrostomy placement and evaluates the relevant literature extending beyond the past 12 months due to limited numbers of published studies. Emerging concepts and controversies are highlighted to demonstrate that the decision to place a gastrostomy or not has eclipsed the significance of patients&#39; nutritional needs leading to much debate and inconsistencies in clinical practice. While the optimal method of tube feeding remains unclear due to challenges with study design, improved outcomes have been demonstrated with prophylactic tube feeding. Variation exists with selection criteria in the decision for gastrostomy placement based on clinical opinion rather than evidence-based practice. Gastrostomy use as a measure of swallowing outcomes and the presence of a feeding tube for quality of life (QOL) have led to the concept of gastrostomy dependency and a perceived association with poorer outcomes. The multidimensional contributors have been inadequately explored leaving this phenomenon poorly defined and misinterpreted. Best practice nutritional care incorporates malnutrition screening and nutritional assessment using validated tools, early referral to the dietitian and ongoing monitoring to optimize nutritional status throughout the patient&#39;s entire care pathway. The decision for timing of gastrostomy placement should be made at diagnosis given the benefits of prophylactic tube feeding. Accountability for insertion and removal of gastrostomies with alignment of services will facilitate risk assessment, appropriate placement, effective patient counselling and monitoring for major and minor complications. Nutritional outcomes need to be distinguished from swallowing and QOL measures and evaluated to include effects on nutritional status, gastrostomy complications, intensity and frequency of dietetic support and effect on survival.