Evidence based statements.

The evidence based statements are listed under headings based on the nutrition care process.

Access to Appropriate Care

Nutrition Screening

Clinical question

How should patients be identified for referral to the dietitian in order to maximise nutritional intervention opportunities?

Evidence statement                           Level of evidence

The Malnutrition Screening Tool (MST) is an  Level III-3 (6)
  effective screening tool for identifying
  nutritional risk in cancer patients

Nutrition Assessment

Clinical question

How should nutritional status be assessed?

Evidence statement                                     Level of evidence

Subjective Global Assessment (SGA) is a valid method   IV (7)
  of assessing nutritional status in patients with
  cancer cachexia
The scored Patient-Generated Subjective Global         III-3 (7,8)
  Assessment (PG-SGA) is a valid method of assessing
  nutritional status in patients with cancer cachexia
Bioelectrical impedance analysis is not suitable for   III-3 (9,10)
  body composition measurement in individual patients
  with cancer cachexia

Quality Nutrition Care

Nutrition Intervention

Establishing goals

Clinical question

What are the goals of nutrition intervention for patients with cancer cachexia?

Evidence statement                                     Level of evidence

Weight-losing patients with cancer cachexia who        III-2 (11)
  stabilise their weight have greater quality of life
  and survival duration than those who continue to
  lose weight

Nutrition Prescription

Clinical question

What is the nutrition prescription to achieve these goals?

Evidence statement                                     Level of evidence

Energy and protein requirements for weight             III-2 (11)
  stabilisation are approximately 120 kJ/kg/d and
  1.4g protein/kg/d in patients with cancer cachexia
  receiving supportive care
Energy and protein requirements for weight             IV (7)
  stabilisation are approximately 120 kj/kg/d and
  1.4g protein/kg/d in patients with cancer cachexia
  receiving chemotherapy
Weight stable patients have higher energy intake than  III-2 (11)
  weight losing patients in patients with cancer
  cachexia receiving supportive care
Well-nourished patients with advanced cancer have      IV (12)
  higher energy and protein intakes compared to
  malnourished patients with advanced cancer

Clinical question

Should EPA be included in the prescription in patients with cancer cachexia?

Evidence statement                            Level of evidence

The prescription of EPA improves outcomes in  Level C (7,11,13-20)
  patients with cancer cachexia
                                              Body of evidence provides
                                              some support for
                                              recommendation but care
                                              should be taken in its
                                              application

Implementation

Clinical question

What are effective methods of implementation to ensure positive outcomes?

Evidence statement                                     Level of evidence

Compliance with a nutrition prescription of 1.5        III-2 (20)
  cans/d of a high protein energy III-220 supplement
  [+ or -]EPA does not reduce total food intake in
  patients with cancer cachexia receiving supportive
  care
Consumption of a high protein energy supplement        IV (7)
  enriched with EPA does not reduce total food intake
  in patients with cancer cachexia receiving
  chemotherapy
Frequent clinician contact (minimum fortnightly)       III-3 (7,18)
  improves clinical outcomes in patients with cancer
  cachexia

Nutrition Monitoring and Evaluation

Measure and Evaluate Outcomes

Clinical question

Does nutrition intervention improve outcomes in patients with cancer cachexia?

Evidence statement                        Level of evidence

Nutrition intervention improves outcomes  Level C (7,11,13-20)
  in patients with cancer cachexia
                                          Body of evidence provides some
                                            support for recommendation
                                            but care should be taken in
                                            its application

A summary of recommendations for the nutritional management of cancer cacheia is presented in Table 1.

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APPENDIX I: BACKGROUND TO EVIDENCE STATEMENTS AND TIPS

The majority of cancer patients experience weight loss as their disease progresses and in general, weight loss is a major prognostic indicator of poor survival and impaired response to cancer treatment. (21) The incidence of malnutrition amongst patients with cancer has been estimated at between 40% and 80%. (22,23) The prevalence of malnutrition depends on the tumour type, location, stage and treatment. (24) The consequences of malnutrition may include an increased risk of complications, decreased response and tolerance to treatment, a lower quality of life, reduced survival and higher health-care costs. (25-27) Cancer cachexia has been implicated in the deaths of 30-50% of all cancer patients, as many die from the wasting associated with the condition. (28)

The causes of weight loss in patients with cancer are multifactorial and may be due to symptoms reducing intake, treatment related or mechanical obstruction, or cachexia. Symptoms such as anorexia, depression, anxiety, fatigue, early satiety and pain can result in a decreased appetite and food intake. Cancer treatment may result in weight loss, for example surgery (malabsorption), radiotherapy (nausea, pain, diarrhoea, mucositis), and chemotherapy (nausea, vomiting, diarrhoea, mucositis). Weight loss may be due to mechanical obstruction caused by the cancer itself, such as obstruction of the oesophagus causing swallowing problems and reduced intake. Appropriate nutrition support provided during radiotherapy can help to overcome some of the nutrition impact symptoms and help patients to maintain weight compared with standard practice where patients continued to lose weight during radiotherapy treatment. (29) However if the weight loss is due to cachexia, it may not be reversible because host intermediary metabolism (carbohydrate, protein and lipid metabolism) is abnormal, limiting the success of nutrition intervention. (30)

Numerous drug therapies (e.g. megestrol, steroids) have been trialled in patients with cancer cachexia to stimulate appetite or attenuate metabolic changes. Several trials with synthetic progesterone agents have demonstrated a beneficial influence on weight, however, this is largely due to an increase in fat mass. (31-33) Evaluation of pharmacotherapies is beyond the scope of these guidelines.

The term cancer cachexia is derived from the Greek words kakos and hexis meaning poor condition. Cachexia has been defined as a syndrome characterised by the progressive loss of lean tissue and body fat, and losses are often in excess to that explained by the associated anorexia. There are often additional metabolic derangements, including anaemia, acute phase protein response and alterations in plasma lipid profile. (34) The development of cachexia is common in people with solid tumours such as pancreatic, lung, gastric and colorectal cancer.

Weight loss in cancer cachexia is different from the weight loss of starvation or anorexia. This is due to accelerated loss of skeletal muscle in relation to adipose tissue, presence of pro-inflammatory cytokines and prolonged acute phase protein response (APPR) that contributes to increased resting energy expenditure and weight loss. (35) Patients with cancer cachexia experience anorexia, early satiety, weakness, muscle wasting, fatigue, anaemia and severe weight loss. In starvation more than three-quarters of the weight lost is from body fat and only a small amount from muscle. In cancer cachexia, weight loss arises equally from loss of muscle and fat. (36)

There are no definitive methods for diagnosis of cancer cachexia. Clinical signs of anorexia, muscle wasting and weight loss of [greater than or equal to] 5% over 6 months in patients diagnosed with cancer would be expected but clinical judgement is required. Weight loss due to mechanical obstruction, treatment or side-effects, which would be expected to resolve once the obstruction is bypassed/removed or treatment ceased should not be classified as cachexia. These patients still require nutrition intervention but the focus of these guidelines is on cancer cachexia.

The patient target group encompasses any adult patient with cancer fulfilling the diagnostic criteria for cachexia.

Appropriate Access to Care

Nutrition Screening

In Australia, hospital inpatients are generally seen by dietitians as a result of referrals by medical or nursing staff. (37) Studies have found the prevalence of malnutrition to be similar between those patients who were referred to a dietitian by medical staff and those who were not referred. (38,39) It is recommended that in addition to referrals by medical staff, nutrition screening be performed on admission to hospital or in the outpatient setting during the planning stages of commencing anticancer therapies.

Nutrition screening is the process of identifying patients with characteristics commonly associated with nutrition problems that may require comprehensive nutrition assessment (American Dietetic Association (ADA). (40) The purpose of nutrition screening is to quickly identify clients who are malnourished or at risk of becoming malnourished who would benefit from nutrition support and prioritise resources to those clients who most need nutrition support. According to the ADA, (40) an effective nutrition screening tool should be:

* Simple, quick, reliable, valid and inexpensive

* Easily administered with minimal nutritional expertise

* Applicable to most patients and designed to incorporate only routine data and tests available on admission

Many nutrition screening tools have been developed to identify clients at risk of malnutrition in the acute care setting and the community Problems identified with numerous published nutrition screening tools include requiring specialised nutrition knowledge, bio-chemical parameters that may not be immediately available, requiring complex calculations or not being evaluated in terms of reliability or validity. (37,41) A number of reliable and valid nutrition screening tools have been recently published:

* Malnutrition Screening Tool (6,42)

* Malnutrition Universal Screening Tool (43)

* Mini Nutrition Assessment-Short Form (44)

* Nutrition Risk Screening (45)

When selecting an appropriate nutrition screening tool, it is imperative that the tool has been validated in the client population in which it is to be applied. The Malnutrition Screening Tool (MST) is a valid screening tool for identifying nutrition risk in patients with cancer (Appendix II) (6,42) No studies have been identified that report nutrition screening in patients with cancer cachexia.

Clinical question

How should patients be identified for referral to the dietitian in order to maximise nutritional intervention opportunities?

Evidence statement                                     Level of evidence
The Malnutrition Screening Tool (MST) is an effective  Level III-3 (6)
  screening tool for identifying nutritional risk in
  patients with cancer

Practice Recommendation

Identify 'at risk' patients in oncology wards and outpatient clinics using a nutrition screening tool such as the Malnutrition Screening Tool that has been validated for oncology patients

Practice Tips:

1 Nutrition assistants, administration or nursing staff may implement the MST.

2 The MST can be incorporated into admission forms or patient information sheets.

3 Repeat nutrition screening during treatment at least fortnightly for patients initially screened at low risk.

4 If a patient has been referred to the dietitian by other methods, e.g. direct referral from medical oncologist, nutrition screening is unnecessary--proceed to nutrition assessment.

Nutrition Assessment

Nutrition assessment is a comprehensive approach to defining nutritional status using medical, nutrition and medication histories, physical examination, anthropometric measurements and laboratory data. (40) Nutrition assessment parameters may be affected by non-nutritional factors resulting in poor sensitivity and specificity. (46) No single parameter is sufficiently sensitive and specific to determine nutritional status and a combination of parameters should be used. (47) Several nutrition assessment tools have been published which use a combination of parameters.

Subjective global assessment

Subjective global assessment (SGA) determines nutritional status on the basis of a medical history (weight change, dietary intake change, presence of gastrointestinal symptoms that have persisted for greater than two weeks, functional capacity) and physical assessment (evidence of loss of subcutaneous fat, muscle wasting, oedema or ascites). The features are combined subjectively into an overall or global assessment where patients are rated as being well nourished (SGA A), moderately or suspected of being malnourished (SGA B) or severely malnourished (SGA C). (48)

Scored Patient-Generated Subjective Global Assessment

The scored Patient-Generated Subjective Global Assessment (PG-SGA) is an adaptation of SGA specifically developed for use in the cancer population (Appendix III). (49) It contains additional questions regarding short-term weight loss, a more extensive range of nutrition impact symptoms and for each component of the PG-SGA, points (0-4) are awarded depending on the impact on nutritional status. Typical scores range from 0 to 47 with a higher score reflecting a greater risk of malnutrition. The PG-SGA score has been correlated with a number of objective parameters (% weight loss, body mass index (BMI)), measures of morbidity (survival, length of stay, quality of life), has a high degree of interrater reproducibility and high sensitivity and specificity when compared with other validated nutritional assessment tools. (8,26,50-53) A change in score of approximately nine points is required to move one global rating category. (53) The PG-SGA score may be more sensitive than the global rating to demonstrate improvement or deterioration in nutritional status. (52) The scored PG-SGA has been recommended as the nutrition assessment tool for patients with cancer by the Oncology Nutrition Dietetic practice group of the American Dietetic Association. (54) In patients with cancer cachexia, two studies report nutritional status based on the global categorisation and the PG-SGA score. (7,8)

Biochemistry assessment

Biochemistry may be influenced by disease and treatment and therefore it is important to use clinical judgement when interpreting values. For example, serum albumin may be low due to the acute phase protein response. However, serum albumin has been shown to be an independent prognostic variable for survival in patients with cancer. (55) Patients with raised serum C-reactive protein levels have lower energy intake than those with normal levels (56) and there is some evidence that resting energy expenditure may be increased in these patients. (57)

Anthropometric assessment

A variety of techniques are available to measure body composition such as Dual Energy X-ray Absortiometry (DEXA), anthropometric measurements (e.g. triceps skinfold thickness (TSF); corrected arm muscle area (CAMA)), deuterium and bioelectrical impedance analysis (BIA). DEXA and deuterium are expensive methods that are impractical in the clinical setting but may be of use in research studies. Serial anthropometric measurements may be useful to monitor change however, accredited training in anthropometry is recommended. BIA measures tissue conductivity and can be used to assess total body water (TBW) from which fat free mass (FFM) can be calculated. It is important that a BIA prediction equation is used that has been validated in the population under study. (58) Studies examining the validation of BIA in cancer patients are limited (9,10,59-62) and no equation has been developed or validated in patients with cancer cachexia. At a group level, these equations are suitable to predict TBW in patients with cancer cachexia but for an individual, they are unsuitable for use. (10)

Functional assessment

Tools used to assess functional status include Karnofsky Performance Status and Eastern Cooperative Oncology Group (ECOG). A variety of tools have been developed and validated to measure quality of life such as the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30, (63) Functional Assessment of Cancer Therapy (FACT) (64) and the Short Form Health Survey (SF 36). (65) In patients with cancer, the PG-SGA score has been shown to be associated with quality of life (EORTC-QLQC30), and therefore can be used to predict the direction and magnitude of change in quality of life. (53)

Clinical question

How should nutritional status be assessed?

Evidence statement                                     Level of evidence
Subjective Global Assessment (SGA) is a valid method   IV (7)
  of assessing nutritional status in patients with
  cancer cachexia
The scored Patient-Generated Subjective Global         III-3 (7,8)
  Assessment (PG-SGA) is a valid method of assessing
  nutritional status in patients with cancer cachexia
Bioelectrical impedance analysis is not suitable for   III-3 (9,10)
  body composition measurement in individual patients
  with cancer cachexia

Practice Recommendation

Use the scored Patient Generated--Subjective Global Assessment. (PG-SGA) as the nutrition assessment tool in patients with cancer cachexia.

Practice Tips:

A summary of nutrition assessment practice tips are contained in Table 2.

Quality Nutrition Care

Nutrition Intervention

Nutrition intervention is the second stage of the clinical judgements made in the nutrition care process. The key aspects of intervention are establishing the goals of treatment, determining the nutrition prescription and the implementation of the nutrition care. The success or otherwise of nutrition intervention depends equally on these components. (66)

Establishing goals

Having identified the nutrition problem by assessing and interpreting the evidence and data collected about the patient, a judgement about the goals of treatment must be made. Established goals provide the criteria to be measured in the outcome evaluation step, where effectiveness of the nutrition intervention is evaluated. (4)

When discussing nutrition intervention options with patients and carers, it is important to present realistic potential outcomes. The goals and outcomes of nutrition intervention will be dependent on patient's diagnosis and prognosis. If goal requirements cannot be achieved with oral intake, alternative means of nutrition support should be considered. Refer to guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients from the American Society of Parenteral and Enteral Nutrition. (67)

Traditionally, treatment has focused on weight gain as the goal of nutrition intervention. Some studies have failed to show a positive effect of nutrition intervention when weight gain was the outcome. (16,17,55) Other studies using weight stabilisation as an outcome of nutrition intervention have shown positive effects. Weight losing patients with advanced gastrointestinal and non-small cell lung cancer whose weight stabilises have a longer survival and improved quality of life than those who continue to lose weight. (11,68,69) Weight stabilisation is an appropriate goal for weight losing cancer patients provided that life expectancy is at least two months. (11)

Continue to reassess stage of treatment and disease, and whether any change to palliative care status. Determine level of support from the patients General Practitioner, carer and palliative care team. When a patient is having palliative treatment or palliative supportive care at end stage of disease, intensity of dietary intervention may need to be adapted. Liaise with patient/family/carers and medical team to determine level of intervention required. Unnecessary dietary restrictions can be relaxed (e.g. cholesterol lowering modifications). Discuss treatment with patient for indication of satisfaction with intensity of care.

If end stage, the dietitian may advocate for patient with carer or family to reduce intensity of dietary treatment. The desired outcomes are maximising patient comfort and maintaining quality of life. In many cases this may mean a patient will not meet full nutrition requirements, for example if tube feeding is refused or supplement drinks are not liked. Each case should be assessed individually and with full discussion with the team to determine new goals of care. Patients in the final weeks of life are unlikely to be able to maintain their lean body mass. Any weight gain that does occur at this time is likely to be due to fluid retention. For comfort measures refer to DAA paper: Nutrition priorities in palliative care of oncology patients. (70)

Clinical question

What are the goals of nutrition intervention for patients with cancer cachexia?

Evidence statement                                     Level of evidence
Weight-losing patients with cancer cachexia who        III-2 (11)
  stabilise their weight have greater quality of life
  and survival duration than those who continue to
  lose weight

Practice Recommendation

Weight stabilisation is an appropriate goal for patients with cancer cachexia

Practice Tips:

Nutrition intervention goals should be individualised taking into consideration prognosis, psychosocial issues and the patient's wishes (Table 3).

Nutrition prescription

* Protein and energy requirements

Measurement of energy expenditure via indirect calorimetry is the most accurate method for determining individuals' energy requirements. Energy expenditure of patients with cancer has been shown to vary greatly. (71-73) Treatment and disease stage may alter metabolic requirements over time. Energy intakes in excess of 120 kJ/kg/day have been needed for weight maintenance in some studies of patients with cancer. (7,11,22) Protein intake is often reduced as the result of taste alterations, poor appetite and fatigue. Protein requirements for advanced cancer patients have not been elucidated. However protein intake in excess of 1.4 g/kg/day have been required for weight maintenance in some studies of cancer patients. (7,11)

* Eicosapentaenoic acid

A novel approach to the nutrition intervention in patients with cancer cachexia has been the prescription of pharmacological doses of eicosapentaenoic acid (EPA), an omega-3 polyunsaturated fat. The major dietary sources of EPA in Australia are marine oils, seafood, meat and eggs with the average Australian intake at 0.056 g per day. (74) Studies in both animals and humans have indicated that EPA supplementation reduces production of pro-inflammatory cytokines such as interleukin-6, interleukin-1 and tumour necrosis factor and in cultured cancer cell lines increases cell death rate. (14,75-77) Appendix IV summarises studies in relation to EPA supplementation (EPA capsules and oral nutrition supplements) in patients with cancer.

The results of studies of supplementation with EPA either in the form of capsules or high protein energy supplements enriched with EPA, are inconsistent. Although positive changes have been demonstrated in outcomes (improving energy and protein intake, body composition, performance status, quality of life) in patients with cancer cachexia receiving high protein energy supplements enriched with EPA in open trials (Level IV studies), in general these results have not been confirmed in randomised trials (Level II studies). Issues such as compliance with the prescription, (13) duration of intervention, (17) appropriate end points (16) and the treatment group (supportive care/chemotherapy/mixed therapy) are important to consider when evaluating study outcomes. A common weakness of the four randomised controlled trials investigating EPA is the limited discussion of dietetic involvement. Therefore whether or not patients received dietary counselling, the recommendations and frequency of contact were not documented and could also limit the efficacy of EPA or fish oil. Further studies in different patient groups with cancer are required.

A Cochrane review of the role of EPA in cancer cachexia was scheduled for release in 2005. The guideline steering committee produced evidence based statements regarding EPA and outcomes (Appendix V). The body of evidence in relation to EPA and cancer cachexia was assessed using NHMRC additional levels of evidence and grades for recommendations for developers of guidelines--Pilot Program 2005. (3)

Potential risks EPA

The draft Nutrient Reference Values for Australia and New Zealand recommend acceptable macronutrient distribution ranges to reduce chronic disease whilst still ensuring adequate micronutrient status. (81) The lower to upper ends of the recommended intake range for omega 3 fats (DHA : EPA : DPA) are 190 mg/day to 610 mg/day for men and 90 mg/day to 430 mg/day for women, where the upper end of the range is based on 90th percentile of current intake. (81) The United States Food and Drug Administration has concluded that fish oil concentrate is Generally Recognised As Safe (GRAS) provided that combined intake of EPA and DHA from all added sources does not exceed 3 g/person/day. (82) Cancer patients consuming 6 g EPA/d have reported no adverse effects on platelet counts. (80) No studies, however, have been conducted specifically on EPA in cancer patients who are using anticoagulants. It is therefore advisable to exercise caution with the use of EPA supplements in cancer patients on anticoagulant therapies such as warfarin. Use in such situations should be with the knowledge and approval of the patient's doctor. Large dose of fish oil can cause gastrointestinal side-effects. (14,19) Cod liver and halibut liver oil are not suitable sources of EPA as the doses required could provide excess levels of Vitamin A. Dioxin and dioxin like polychlorinated biphenyls are environmental contaminates that accumulate in lipid. Fish oils are potentially a significant source, so fish oil supplements are purified to meet European commission maximum standards for dioxin. (83) The main concerns with these toxins relate to long-term accumulation, as well as the effect on the foetus or breastfed infant. High short-term intakes in adults are unlikely to significantly increase total body burden. (83) Fish oil products and supplements are not a major source of dietary mercury and no recommendation has been made to restrict consumption because of mercury. (83,84)

Complimentary and alternative therapy

Australian studies have shown that between 22% and 52% of patients with cancer use complimentary or alternative therapy with up to $2.3 billion spent in 2000. (85-87) Evaluation of complimentary or alternative therapy is beyond the scope of these guidelines--refer to The Cancer Council Australia's 2005 Position Statement on Complementary & Alternative Therapies. (88)

Clinical questions

What is the nutrition prescription to achieve these goals?

Should ercosapentaenoic acid be included in the prescription?

Evidence statement                             Level of evidence

Energy and protein requirements for weight     III-2 (11)
  stabilisation are approximately 120 kJ/kg/d
  and 1.4 g protein/kg/d in patients with
  cancer cachexia receiving supportive care
Energy and protein requirements for weight     IV (7)
  stablisation are approximately 120 kJ/kg/d
  and 1.4 g protein/kg/d in patients with
  cancer cachexia receiving chemotherapy
Weight stable patients have higher energy      III-2 (11)
  intake than weight losing patients in
  patients with cancer cachexia receiving
  supportive care
Well-nourished patients with advanced cancer   IV (12)
  have higher energy and protein intakes
  compared to malnourished patients with
  advanced cancer
The prescription of EPA improves outcomes in   Level C (7,11,13-20)
  patients with cancer cachexia                Body of evidence provides
                                                 some support for
                                                 recommendation but care
                                                 should be taken in its
                                                 application

Practice Recommendations

1 Improving energy and protein intake remains the first step in nutrition intervention for weight losing cancer patients

2 If indirect calorimetry is unavailable, aim for an energy intake of approximately 120 kJ/kg/day.

3 Aim for a protein intake of approximately 1.4 g/kg/day

4 EPA can be considered as a component of nutrition intervention in cancer cachexia but patients should first be assessed for suboptimal symptom control or inadequate intake. If using EPA, aim for an intake of 1.4-2 g EPA/day which needs to be consumed for at least four weeks to achieve clinical benefit.

Practice Tips:

1 An individuals energy requirements are best determined by measurement of energy expenditure (e.g. indirect calorimetry), however, in practice this is rarely available. Due to high variation in energy expenditure, use clinical judgement with respect to energy requirements taking into consideration age, treatment and treatment goals. Regular monitoring of intake and weight will determine whether energy needs are being met.

2 Prior to commencing nutrition support, assess the patient for risk of refeeding syndrome.

3 EPA: Potential sources include dietary intake, capsules or a high protein energy supplement enriched with EPA. To achieve 1.4-2 g EPA/day patients need to consume at least 8-11 capsules of fish oil (180 mg EPA/capsule), 300-400 g oily fish, 310-445 mL of a high protein energy supplement enriched with EPA (0.45 g EPA/100 mL) or combination of these.

Implementation

The implementation of dietetic care involves counselling of the patient and/or carers to maximise food intake and facilitation of optimal symptom control. Counselling, especially in conjunction with high protein energy supplements, has been shown to increase intake and attenuate weight loss in a range of cancer patients. (22,29,89-92) A concern expressed by many patients is that consumption of high protein energy supplements may reduce their meal intake. In patients with cancer, high protein energy supplements have been shown to increase intake without negatively impacting on spontaneous food intake. (7,20,90) Prognosis, economic circumstances and client preferences need to be considered in decisions regarding supplement usage.

Nutrition counselling is effective both during phases of active treatment (chemotherapy and radiotherapy) and supportive care. Recommended time for initial consultation is 45-60 minutes and review consultation 15-30 minutes. (93) Recent studies in patients with cancer have demonstrated effective clinical outcomes with weekly to fortnightly dietetic intervention. (7,13,18,29,91,92) Dietetic practice regarding the implementation of medical nutrition therapy in clients with cancer, however, varies considerably, often depending on resources available. Further research regarding innovative methods of nutrition implementation such as telephone counselling is required.

Clinical questions

What are effective methods of implementation to ensure positive outcomes?

Evidence statement                                     Level of evidence

Compliance with a nutrition prescription of 1.5 cans/  III-2 (20)
  d of a high protein energy supplement [+ or -] EPA
  does not reduce total food intake in patients with
  cancer cachexia receiving supportive care
Consumption of a high protein energy supplement        IV (7)
  enriched with EPA does not reduce total food intake
  in patients with cancer cachexia receiving
  chemotherapy
Frequent clinician contact (minimum fortnightly)       III-3 (7,18)
  improves clinical outcomes in patients with cancer
  cachexia

Practice Recommendations

1 Nutrition counselling assists cancer patients to optimise their intake.

2 High protein and energy supplements play a valuable role in improving intake and do not simply take the place of usual meals.

3 Regular nutrition intervention improves clinical outcomes

Practice Tips:

1 Implementation of high protein, high energy dietary advice:

* Discuss good sources of protein in the diet--meat, fish and poultry, and encourage with at least one serve a day If vegan/vegetarian ensure adequate alternative sources of protein.

* If protein intake is reduced due to taste changes emphasise good oral hygiene, encourage with alternative sources of protein--eggs, dairy, legumes and nuts, suggest marinating meats in juice or wine to disguise a bitter taste;

* For patients with chewing and swallowing difficulties, ensure protein is adequate in texture modified diets, e.g. minced meats, pureed meat/chicken/fish, scrambled or poached eggs, mashed beans, peanut paste, lentil/bean soups;

* Encourage patients to consider high protein/energy supplements as an essential component of treatment.

* Assess need for alternative nutrition support if oral intake inadequate and liaise with medical team regarding options available and discuss with patient.

2 Compliance issues with EPA to consider in implementation:

* Decreased appetite and nutrition impact symptoms [right arrow] difficult to consume adequate quantities of fish, capsules or supplements;

* Capsules--number required, large size, side-effects (burping, fishy aftertaste, tolerance);

* High protein energy nutrition supplements enriched with EPA--ensure adequate quantity consumed each day, consider taste, consider cost;

* Need to develop gastrointestinal tolerance to fish orl and high protein energy supplements enriched with EPA--gradually increase dose.

3 Use the PG-SGA to identify barriers to food intake and facilitate optimal symptom control:

* Nausea, constipation, vomiting, diarrhoea, mouth sores, pain--liaise with medical and support team and instigate appropriate medical and nutrition treatment;

* Taste changes, early satiety, aversion to smells--use strategies to manage these;

* Dry mouth and/or swallowing problems--modify texture as required and liaise with other allied health professional support, e.g. speech pathology.

* The Cancer Councils in each state provide valuable patient resources describing the management of nutrition impact symptoms.

4 If patient is using complimentary or alternative therapies, provide appropriate information.

Nutrition Monitoring and Evaluation

Measure and Evaluate Outcomes--Intermediate and Clinical/Cost/Patient

Nutrition intervention may lead to a variety of outcomes. Intermediate outcomes include changes in dietary intake, symptoms, biochemistry, anthropometric measures or nutrition status. These changes will then impact upon and result in clinical, cost and patient outcomes. This includes morbidity and mortality, length of hospital stay, functional capacity or quality of life. (94) A variety of outcomes have been demonstrated in nutrition intervention studies in patients with cancer. To date, in cancer cachexia, intervention studies have focused on using fish oil or EPA supplements in management of outcomes. Weight stabilisation may improve length and quality of life in patients with cancer cachexia. (11) The body of evidence has been evaluated using the NHMRC additional levels of evidence and grades for recommendations for developers of guidelines--Pilot Program 2005. (3) The evidence based statement in relation to outcomes of nutrition intervention is below.

Clinical question

Does nutrition intervention improve outcomes in patients with cancer cachexia?

Evidence statement                        Level of evidence
Nutrition intervention improves outcomes  Level C (7,11,13-20)
  in patients with cancer cachexia        Body of evidence provides some
                                            support for recommendation
                                            but care should be taken in
                                            its application.

Practice Recommendations

1 A range of outcomes can be measured in patients with cancer cachexia including protein and energy intake, appetite, weight, lean body mass, functional status, quality of life and survival.

2 Consumption of high protein energy supplement enriched with EPA over a period of at least 8 weeks improves intake, total energy expenditure and physical activity level and attenuates weight loss in patients with cancer cachexia.

3 There is conflicting evidence about whether EPA supplementation can improve quality of life, appetite, lean body mass, and survival. This may be due to studies not being conducted for long enough (at least 4 weeks) or because improvement rather than attenuation was the outcome goal.

APPENDIX II: THE MALNUTRITION SCREENING TOOL[c]

Have you lost weight recently without trying?

  If no       0
  If unsure   2
  If yes, how much weight (kg) have you lost?
  0.5-5.0     1
  >5.0-10.0   2
  >10.0-15.0  3
  >15.0       4
  Unsure      2

Have you been eating poorly because of a decreased appetite?

  No   0
  Yes  1

If score 0 or 1                    not at risk of malnutrition
score [greater than or equal to]2  at risk of malnutrition

Reprinted from Ferguson M, Bauer J, Banks M, Capra S. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15: 458-64. Copyright (1999), with permission from Elsevier.

APPENDIX III: THE PATIENT GENERATED SUBJECTIVE GLOBAL ASSESSMENT (PG-SGA)

Scored Patient-Generated Subjective Global Assessment (PG-SGA)

History (Boxes 1-4 are designed to be completed by the patient.)

[GRAPHIC OMITTED]

Worksheets for PG-SGA Scoring

Boxes 1-4 of the PG-SGA are designed to be completed by the patient. The PG-SGA numerical score is determined using 1) the parenthetical points noted in boxes 1-4 and 2) the worksheets below for items not marked with parenthetical points. Scores for boxes 1 and 3 are additive with each box and scores for boxes 2 and 4 are based on the highest scored item checked off by the patient.

[GRAPHIC OMITTED]

APPENDIX IV: SUMMARY OF STUDIES OF ROLE OF EICOSAPENTAENOIC ACID IN PATIENTS WITH CANCER CACHEXIA

                    Level of
Author Year         evidence and     Patient cancer
Country             study design     type and number     Method

Wigmore et          Level IV         18 weight losing    Dose escalation
  al. (14)          Observational      pancreatic          escalation
1996                  study 12 wks     cancer patients     study to 16 g
UK                                                         fish oil/d
                                                           max (Max-EPA)
Gogos et al. (19)   Level II         64 patients with    18 g fish oil
1998                RCT                mixed solid         (Max-EPA--
Greece                                 tumour types        3.06 g EPA +
                                                           2.07 g DHA)
                                                           or placebo
                                                           daily
Burns et al. (78)   Level IV         22 weight losing    Dose escalation
1999                Observational      cancer patients     study of fish
USA                   study                                oil
Barber et al. (79)  Level IV         20 weight losing    High protein,
1999                Observational      pancreatic          energy
UK                    study 7 wks      cancer patients     supplement
                                                           with 2.18 g
                                                           EPA
Wigmore et          Level IV         26 weight losing    Dose escalation
  al. (80)          Observational      pancreatic          study of fish
2000                  study 12 wks     cancer patients     oil to 6 g/d
UK                                                         EPA (95%
                                                           pure)
Fearon et al. (13)  Level II RCT 8   200 weight losing   Randomised to
2003                  wks              untreated           high protein
Multinational                          pancreatic          and energy
                                       cancer patients     supplement
                                                           [+ or -] EPA
Bruera et al. (17)  Level II RCT 2   60 cachectic        Randomised to
2003                  wks              cancer patients     fish oil
USA                                                        capsules or
                                                           placebo (mean
                                                           dose EPA
                                                           1.8 g)
Jatoi et al. (16)   Level II RCT 3   421 weight losing   Randomised to
2004                  mths             cancer patients     EPA sup v meg
USA                                                        ace + control
                                                           v meg ace +
                                                           EPA sup
Moses et al. (18)   Level II RCT 8   24 weight losing    Randomised to
2004                  wks              pancreatic          high protein
UK                                     cancer patients     and energy
                                                           supplement
                                                           [+ or -] EPA
                                                           for 8 wks
                                                         Doubly labelled
                                                           water to
                                                           assess PAL.
Davidson et         Level III-2      107 pts wt losing   High protein
  al. (11)            Post hoc         (>1 kg) or wt       and energy
2004                  analysis RCT     stable untreated    supplement
Australia             8 wks            pancreatic          [+ or -] EPA
                                       cancer patients
Bauer & Capra (7)   Level IV         8 weight losing     High protein
2005                  Observational    pancreatic and      and energy
Australia             study 8 wks      non-small cell      supplement
                                       lung cancer pts     [+ or -] EPA
                                       receiving
                                       chemotherapy
Persson et          Level II RCT 8   24 weight losing    Randomised to
  al. (15)            wks              untreated           fish oil
2005                                   advanced            (4.9 g EPA)
Sweden                                 gastrointestinal    or Melatonin
                                       cancer pts          (18 mg/d) 4
                                                           wks, both
                                                           treatments
                                                           additional 4
                                                           wks
Bauer et al. (20)   Level III-2      200 untreated       Compliance (C)
2005                  Post hoc         pancreatic          with 1.5
Australia             analysis RCT     cancer patients     cans/d high
                      8 wks                                protein and
                                                           energy
                                                           supplement
                                                           [+ or -] EPA
                                                           compared to
                                                           non-compliant
                                                           (NC)

Author Year
Country             Results                            Comment

Wigmore et          Energy intake--N                   Demonstrated
  al. (14)          Protein intake--NA                   attenuation of
1996                Weight--[down arrow] 2.9 kg/mth      weight loss in
UK                    prestudy, [up arrow] 0.3 kg/mth    cancer cachexia
                      3 mths
                    LBM--NA
                    Functional capacity--NA
                    Quality of life--NA
                    Survivall--NA
                    Other--patients tolerated median
                      of 12 Max-EPA daily
                    (2.2 g EPA + 1.4 g DHA).
                    No serious toxicity--25%
                      steatorrhoea, some taste
                      aberrations or transient
                      diarrhoea
                    Changes in weight accompanied by
                      a temporary sig [down arrow]
                      APPR and stabilisation REE
Gogos et al. (19)   Energy intake--NA                  Demonstrated high
1998                Protein intake--NA                   doses of omega
Greece              Weight--ns improvement               3 PUFA given
                    LBM--NA                              with
                    Functional capacity--[up arrow]      antioxidant
                      KPS after 40 d in malnourished     supplementation
                      patients receiving fish oil        --prolonged
                      only                               survival in
                    Quality of life--NA                  patients with
                    Survival--doubled in patients        cancer--
                      receiving fish oil only            [up arrow] KPS
                    Other--no effect of fish oil on      in malnourished
                      albumin or transferrin             cancer patients
                    No toxicity of fish oil except
                      for mild abdominal discomfort
                      and transient diarrhoea
Burns et al. (78)   Energy intake--NA                  Demonstrated
1999                Protein intake--NA                   maximum
USA                 Weight--NA                           tolerated dose
                    LBM--NA                              EPA
                    Functional capacity--NA
                    Quality of life--NA
                    Survival--NA
                    Other--maximum tolerated dose
                      0.3 g/kg/d fish oil = 21 x 1 g
                      capsules/d containing 7.9 g EPA
                      + 5.2 g
                    DHA for a 70 kg male. Dose
                      limiting toxicity was
                      gastrointestinal--diarrhoea.
Barber et al. (79)  Energy intake--[up arrow] 372      First study to
1999                  kcals                              demonstrate
UK                  Protein intake--NA                   positive
                    Weight--[down arrow] 3.2 kg/mth      outcomes
                      prestudy; [up arrow] 1 kg 3        (weight gain,
                      wks, [up arrow] 2.5 kg 7 wks       LBM, KPS,
                    LBM--[up arrow] LBM 1 kg 3 wks;      energy) with a
                      [up arrow] 1.9 kg 7 wks            combination of
                    Functional capacity--KPS             EPA and
                      [up arrow] 10 3 wks; [up arrow]    protein/energy
                      10 7 wks
                    Quality of life--NA
                    Survival--NA
                    Other--median consumption
                      supplement 1.9 cans/d
Wigmore et          Energy intake--NA                  Confirmed
  al. (80)          Protein intake--NA                   previous
2000                Weight--[down arrow] 2 kg/mth        studies that
UK                    prestudy; [up arrow] 0.5 kg/mth    doses of EPA to
                      4 wks;                             6 g well
                    16 patients weight stable or         tolerated
                      gained weight 12 wks             Confirmed EPA was
                    LBM--NA                              the active
                    Functional capacity--NA              ingredient in
                    Quality of life--NA                  fish oil
                    Survival--NA                         capsules
                    Other--no change in total body
                      water, MAMC, TSF
                    APPR stable. EPA supplement well
                      tolerated--some patients had
                      nausea and/steatorrhoea
Fearon et al. (13)  Energy intake--[up arrow] 224      Both E and C
2003                  kcal E v 68 kcal C, ns; Sig        supplements
Multinational         [up arrow] E baseline to 8 wks     attenuated
                      only                               weight loss.
                    Protein intake--[up arrow] 15 g E    [up arrow] LBM
                      v 6 g C, ns; Sig [up arrow] E      in E only.
                      baseline to 8 wks only           Non-compliance
                    Weight-- -0.37 kg E v -0.25 kg C,    with protocol
                      ns; Sig change baseline to 8       in both groups
                      wks E & C; Wt [up arrow]         High dropout rate
                      correlated with intake cans E      due to death
                      only
                    LBM--[up arrow] 0.27 E v 0.12 kg
                      C, ns; [up arrow] LBM
                      correlated intake cans E only
                    Functional capacity--NA
                    Quality of life--Global E v C,
                      ns; Post hoc analysis
                      [up arrow] QoL and [up arrow]
                      wt E only
                    Survival--142 d E v 128 d C, ns
                    Other
Bruera et al. (17)  Energy intake--[up arrow] 51       No effect of fish
2003                  kcals E v [down arrow] 57 C        oil on outcomes
USA                   kcals ns                           but only 2 wks
                    Protein intake--NA                   of treatment
                    Weight--[up arrow] 0.03 kg E v     Non-compliance
                      [down arrow] 0.89 kg C ns          with protocol
                    LBM--NA                              in both groups
                    Functional capacity--KPS             10% controls
                      [up arrow] 10.0 E v                high EPA levels
                      [down arrow] 6.9 C ns              High dropout
                    Quality of life--NA                  rate due to
                    Survival--NA                         intolerance of
                    Other--appetite, tiredness,          fish oil
                      nausea, well being ns
Jatoi et al. (16)   Energy intake--NA                  No better effect
2004                Protein intake--NA                   of EPA
USA                 Weight--[up arrow] 10%: EPA 6% v     supplement
                      Meg + c 18% v Meg + EPA 11% Ns     compared to
                      EPA v Meg + c P = 0.004            megace on
                    Any [up arrow]: EPA 37% Meg 39%      outcome Outcome
                      Meg + EPA 45% ns                   of 10% weight
                    LBM--NA                              gain in cancer
                    Functional capacity--NA              patients
                    Quality of life--ns                  unrealistic
                    Survival--ns
                    Other--appetite [up arrow] EPA 63
                      Meg 69 Meg + epa 66
Moses et al. (18)   Energy intake--E 474 kcals v C     First study to
2004                  166 kcals ns; Baseline change E    demonstrate
UK                    P < 0.05 only                      improvement in
                    Protein intake--Sig [up arrow] E     functional
                      27 g v C 4 g                       outcomes with a
                    Weight--E 0.0 kg v C [down arrow]    combination of
                      0.2 kg ns                          EPA and
                    LBM--E 0.3 kg v C 0.6 kg ns          protein/energy
                    Functional capacity--TEE and PAL
                      ns; [up arrow] PAL baseline--8
                      wks E only
                    Quality of life--NA
                    Survival--NA
                    Other
Davidson et         Energy intake--WL 107 kJ/kg/d v    Demonstrated that
  al. (11)            WS125 P < 0.001                    weight
2004                Protein intake--NA                   maintenance
Australia           Weight--NA                           suitable goal
                    LBM--NA                              for patents
                    Functional capacity--ns              with cancer
                    Quality of life--WS 55 v WL 47.1     cachexia and is
                      P = 0.037                          associated with
                    Survival--WS 259 d v WL 164 P =      [up arrow]
                      0.019                              survival and
                    Other                                QoL
Bauer & Capra (7)   Energy intake--[up arrow] 36 kJ/   Demonstrated
2005                  kg/d                               improvement in
Australia           Protein intake--[up arrow] 0.3 g/    outcomes
                      kg/d                               (dietary
                    Weight--[up arrow] 2.3 kg            intake, QoL,
                      clinically sig                     KPS) in
                    LBM--[up arrow] 4.4 kg clinically    cachectic
                      sig                                patients
                    Functional capacity--KPS             receiving
                      [up arrow] 10                      chemotherapy
                    Quality of life--[up arrow] 16.7     and combination
                    Survival--NA                         of EPA/protein/
                    Other--[up arrow] nutritional        energy Small
                      status PG-SGA score 9              number patients
                    No change in meal protein or
                      energy intake over
                    8 wks
Persson et          Energy intake--[down arrow] 65     Weight
  al. (15)            kcal 4 wks, [down arrow] 196 8     stablisation
2005                  wks FO;
Sweden              MLT [up arrow] 187 kcal 4 wks,
                      [up arrow] 19 kcal 8 wks (no
                      stats provided)
                    Protein intake--NA
                    Weight--38% stable or gain FO;
                      27% MLT; 63% FO and MLT
                    LBM--NA
                    Functional capacity--KPS stable
                      FO and MLT; ns between groups
                    Quality of life--stable FO and
                      MLT, ns between groups
                    Survival--ns
                    Other--no biochemical/cytokine
                      changes; [up arrow] plasma
                    EPA levels
Bauer et al. (20)   Energy intake--30.3 C v 23.0 NC    Compliance with
2005                  kcal/kg/d                          prescription
Australia           Protein intake--1.26 C v 0.90 NC     1.5 cans/d
                      g/kg/d                             supplement no
                    Weight--1.7 kg difference (P =       effect on meal
                      0.052)                             intake
                    LBM--44.1 v 43.6 kg ns
                    Functional capacity--NA
                    Quality of Life--56.8 v 52.4 ns
                    Survival--NA
                    Other--no change in meal protein
                      or energy intake over 8 wks

C = control product; E = experimental product; KPS = Karnofsky
Performance Status; LBM = lean body mass; NA = Not assessed; ns = not
significant; PAL = physical activity level; QoL = quality of life.

APPENDIX V: EVIDENCE BASED STATEMENTS IN RELATION TO EPA AND OUTCOMES IN CANCER CACHEXIA

                                                           Level of
Evidence statement                                         evidence

Intermediate outcomes
Consumption of a high protein energy supplement enriched   II (13)
with EPA for 8 weeks increases protein and energy intake
(meals + supplements). Consumption of a standard high
protein energy supplement for 8 weeks increases protein
and trends towards increasing energy intake in patients
with cancer cachexia compared with baseline
Consumption of a high protein energy supplement [+ or -]   II (13)
EPA for 8 weeks attenuates loss of weight and lean body
mass in patients with cancer cachexia receiving
supportive care
Supplementation with EPA capsules or fish oil for at       III-3 (14,15)
least 4 weeks attenuates weight loss in patients with
cancer cachexia receiving supportive care
Consumption of a high protein energy supplement enriched   IV (7)
with EPA for 8 weeks protein and energy intake and
attenuates loss of weight and lean body mass in patients
with cancer cachexia receiving chemotherapy
A higher intake of a high protein energy supplement        III-2 (13)
enriched with EPA is associated with increases in body
weight and LBM in patients with cancer cachexia receiving
supportive care
Consumption of a high protein energy supplement enriched   II (16)
with EPA [+ or -] megestrol acetate (median 12 weeks)
does not improve weight ([greater than or equal to]10%
baseline) or appetite better than megesterol acetate
alone in patients with cancer cachexia receiving
supportive care/chemotherapy/radiotherapy.
Supplementation with fish oil for 2 weeks does not         II (17)
improve appetite, energy intake, weight, or fat-free mass
compared with placebo in patients with cancer cachexia
receiving supportive care/chemotherapy.

Clinical/cost/patient outcomes
Consumption of a high protein energy supplement enriched   II (18)
with EPA improves total energy expenditure and physical
activity level in patients with cancer cachexia receiving
supportive care
Supplementation with fish oil for at least 4 weeks         III-2 (19)
improves performance status in malnourished patients with
cancer cachexia receiving supportive care
Supplementation with fish oil for at least 4 weeks         II (19)
improves survival in patients with cancer cachexia
receiving supportive care
Supplementation with fish oil for 2 weeks does not         II (17)
improve physical function compared with placebo in
patients with cancer cachexia receiving supportive care/
chemotherapy
Consumption of a high protein energy supplement enriched   II (16)
with EPA used alone or in combination with megestrol
acetate (median 12 weeks) does not improve quality of
life or survival in patients with cancer cachexia
receiving supportive care/chemotherapy/radiotherapy
Consumption of a high protein energy supplement [+ or -]   II (13)
EPA for 8 weeks does not improve quality of life or
survival in patients with cancer cachexia receiving
supportive care
Weight-losing patients with cancer cachexia who stabilise  III-2 (11)
their weight have greater quality of life and survival
duration than those who continue to lose weight
Weight gain in patients consuming a high protein energy    III-2 (13)
supplement enriched with EPA is associated with
improvements in quality of life in patients with cancer
cachexia receiving supportive care
Consumption of a high protein energy supplement enriched   IV (7)
with EPA for 8 weeks improves nutritional status,
performance status and quality of life in patients with
cancer cachexia receiving chemotherapy

Table 1 Summary of recommendations for the nutritional management of
cancer cachexia

Point of referral          Anorexia, weight loss
                             [greater than or equal to]5% in 6 months
                             and MST [greater than or equal to]2
Time for consultation      45-60 minutes initially, 15-30 minutes
                             follow-up
Biochemistry and clinical  Albumin, blood glucose (for persons with
                             diabetes), Hb, CRP medications including
                             supplements
Nutrition assessment       Weight, PG-SGA, protein/energy intake
                             assessment
Nutrition intervention     Prescription
                           Promote high protein (>1.4 g/kg/day) and
                             energy (>120 g/kg/day) intake [+ or -]EPA
                             (1.4-2.0 g/day)
                           Implementation
                           Counselling [+ or -] supplements, symptom
                             management, meal planning and modification,
                             self monitoring
Support                    Liaise with medical and palliative care team,
                             carers and family
Monitoring                 Weight, PG-SGA, protein/energy intake minimum
                             fortnightly Frequency of monitoring will
                             vary as treatment goals change towards end
                             stage.

Table 2 Recommended nutrition assessment parameters for patients with
cancer cachexia

Nutrition       PG-SGA: Record both the global rating (SGA-A well
  assessment      nourished, SGA-B moderately malnourished, SGA-C
  tool            severely malnourished) and the PG-SGA score (1-47),
                  which need to be determined independently. The
                  diagnosis of malnutrition is based on the global
                  rating. Nutrition impact symptoms are a major
                  component of the PG-SGA score.
                Some clients with cancer may have a high score due to
                  presence of multiple nutrition impact symptoms yet
                  still be well nourished. The score is more sensitive
                  than the global rating to demonstrate improvement or
                  deterioration in nutritional status and hence can be
                  used when the global rating has not changed. The lower
                  the PG-SGA score, the better the clients nutritional
                  status.
Anthropometry   Record height, body weight, body mass index (BMI)
                Due to the prevalence of overweight and obesity, clients
                  with cachexia may have a BMI >25 kg/[m.sup.2] yet
                  still be moderately or severely malnourished due to
                  weight loss, reduced intake, functional capacity
                  presence of nutrition impact symptoms, etc.
                Determine lean body mass if technology available--
                  deuterium, DEXA, bioelectrical impedance (BIA)--group
                  level only
                Record anthropometric measurements--TSF, CAMA
Dietary intake  Assess dietary intake, especially energy and protein,
                  quantitatively
                Determine use of vitamin/mineral supplements and
                  complementary medicines
                Assess dietary restrictions and beliefs, texture of diet
                  and other barriers to food intake, hydration
Symptoms/       GI symptoms (nausea, vomiting, constipation, diarrhoea,
side-effects      steatorrhoea, early satiety)
                Appetite and taste changes
                Presence of pain
                Mood change
Functional      Determine functional status and level of fatigue, using
  status and      PG-SGA, Karnofsky Performance Scale or Eastern
  quality of      Co-operative Oncology Group.
  life          PG-SGA score can be used as surrogate measure of quality
                  of life
Biochemistry    Determine: Serum albumin
                           C reactive protein
                           Haemoglobin
                           Blood glucose
Medications     Review medications and note if patients is taking
                  analgesics, enzymes, laxatives, antiemetics,
                  alternative therapies

Table 3 Goals of nutrition intervention for patients with cancer
cachexia

Measure                                 Goal

PG-SGA                                  Reduce or maintain PG-SGA score
Anthropometry:                          Stabilise weight and lean body
                                          mass
* Weight
* Skin folds, CAMA (if accredited in
  measuring skin folds)
* DEXA, deuterium (if available)
Dietary intake                          Achieve appropriate current
                                          energy and protein intake
Symptoms or side-effects identified     Minimise symptoms which impact
  in the PG-SGA                           on nutritional intake and
                                          status
Karnofsky Performance Scale or ECOG     Improve or maintain functional
                                          status score
PG-SGA as surrogate measure of          Improve or maintain quality of
  quality of life                         life
Biochemistry                            Use to interpret current
                                          clinical condition
* Serum albumin
* C reactive protein
* Haemoglobin
* Blood glucose
Medications                             Ensure symptoms are being
                                          medically managed
Other
* Assess need for texture modification  Ensure appropriate nutrition
  of diet or alternative nutrition        support is provided
  support
* Assess social situation and need for  Meet energy and protein
  education of carers/family/other        requirements
  social support, e.g. Meals-on-Wheels