Nutrition and Cancer Care – American and European Context Free

Abstract from Arensberg MB, Besecker B, Weldishofer L, Drawert S. Commentary: Quality nutrition care is integral to the Oncology Care Model. Support Care Cancer. 2021;29(12):7139–7142.

In 2020, cancer was responsible for almost 1 in 6 deaths, a leading cause of death in the world according to data from the World Health Organisation [1]. Nonetheless, significant prevention, diagnosis, and treatment advancements are expected to substantial increase survival rates. Many cases of cancer could be prevented by adopting a healthful lifestyle which includes a healthy dietary pattern [1‒3]. While historically there have been insufficient effective treatments such as radiotherapy, chemotherapy, or local therapies in oncology patients, the therapy paradigm has been revolution­ised in the last decade by the introduction of systemic therapies and lately with next-generation targeted therapies [4, 5].

Diet-related unmet care needs, including poor appetite and gas­trointestinal symptoms, are common among those with cancer [6]. Malnutrition is common in cancer patients and is caused by an impaired ingestion or assimilation of nutrients, which is connected either to the cancer itself or its specific treatments [4]. Cachexia, a multifactorial syndrome characterised by a continuous loss of skeletal muscle mass (frequently sarcopenia) with or without loss of fat mass is also common [3, 4, 7, 8]. Malnutrition can negatively impact tolerance to treatment, quality of life, and survival [9]. Nutrition screening, support, and intervention are therefore important for all those with cancer.

There is currently a gap in the provision of nutrition care within oncology ambulatory settings in the United States (US) [10]. Malnutrition screening occurs in only half of these settings, there is a lack of registered dietitian nutritionists, and nutrition care is often not reimbursed [11]. The Oncology Care Model (OCM) was introduced in the US in 2016 to provide better quality and more coordinated care [12]. Although nutrition is a component of best care practice, it is not always addressed by OCM providers.

This paper outlined how nutrition is integral to the OCM. OCM clin­ics are required to provide 4 types of enhanced service, all of which could include nutrition aspects. These are outlined here: 1) There is a focus on eliminating barriers to care – many individuals with cancer experience nutrition impact symptoms, e.g. oral or gastrointestinal issues, that can act as a barrier to adequate nutrition intake and ultimately treatment tolerance [13]; 2) Nutrition aligns with many elements of the Institute of Medicine (IOM) Care Management Plan 13 components which are often used to develop care plans; 3) Clinicians can access the medical records of patients freely, however even though nutrition care plans are part of these records, they are often not readily available; and 4) Treatment should be consistent with national guidelines [14]. Despite the fact that there are nutrition-specific oncology guidelines and an inclusion of nutrition within oncology guidelines, the care plan often lacks a focus on nutrition. Finally, the Centres for Medicare & Medic­aid Services use 6 quality measures to evaluate practices. Nutrition can potentially impact all 6 of these quality measures, thus addressing malnutrition could improve the quality of care being provided.

Similarly to the US, issues with access to nutrition advice are also being reported in Europe. The European Cancer Patient Coalition found significant gaps in the nutrition care and provision of nutrition information to oncology patients in a survey in 10 European countries [15]. The European Society for Parenteral and Enteral Nutrition called for the improvement of nutritional care for cancer patients in a 2020 congress [16], while The European Union Health Policy Platform chose “Integrated Nutrition Cancer Care” as a thematic network to focus on for 2021/2022 [17].

Committees and networks such as the European Specialist Dietetic Network (ESDN) for Oncology Committee and the European Cancer Patient Coalition are all working to improve patient outcomes and integrate nutrition into cancer care as standard practice.

This work highlights the importance of healthcare professionals being familiar with and confident about including nutrition in standard oncology care. The commentary indicates ways in which nu­trition can be integrated as part of the OCM model. Previous work has shown that while healthcare professionals (non-dietetic) report positive attitudes towards nutrition [18, 19], they also report a lack of competency and confidence in providing nutrition advice [20, 21]. It will therefore be important to also address this barrier to help tackle the clear deficit of nutrition advice provision to oncology patients.

Lack of access to nutrition support and registered dietitian nutri­tionists is a problem globally. This commentary outlined ideas on how nutrition can be integrated in line with OCM priorities to help address this issue in the US. Similar attention should be paid to integrating nutrition into models of care in Europe and across the world. Overcoming barriers such as a lack of competence and confidence of healthcare professionals in providing nutrition support and advice would be of benefit.

We hereby declare that there are no conflicts of interest with regard to this commentary.