Principles and guidance for prehabilitation within the management and support of people with cancer
Lucy Eldridge RD is chair of BDA Oncology Specialist Group and Dietetic Team Leader at The Royal Marsden NHS Foundation Trust.
In autumn last year the Oncology Specialist group of the BDA (OSG) was invited to be a stakeholder in the development of Prehabilitation guidance. This project was led jointly by Macmillan Cancer Support, the NIHR Cancer and Nutrition Collaboration of the NIHR and The Royal College of Anaesthetists. It has three parts; Nutrition; Physical Activity and Psychological support.
Following an initial scoping there was an evidence review to establish the extent of current published research data in these three key areas. This information underpinned the discussion and expert group consensus process. A two day meeting was held with a group of 10 leading nutrition specialists from around the world who reviewed all the key research papers and texts and developed a series of consensus statements. Dr Clare Shaw, the Education and Research lead for the OSG was a co-chair of the Nutrition component.
Members of the Oncology Specialist group attended focus groups and took part in round table discussions. These statements were reviewed and commented on by the OSG. This guidance is launched on 2nd July 2019 at the World Congress for Prehabilitation. It highlights the essential role of nutrition and the dietitian.
Emerging evidence of prehabilitation indicates that people who are able to optimise their nutrition, physical activity and practice emotional self-care during cancer treatment have better tolerance to treatment. Further research is required regarding the impact of multi-modal interventions which combine nutrition, physical activity and psychological resilience. It is anticipated that these would be translated into improved outcomes such as improved completion rates of systemic anti-cancer treatment (SACT), a reduction in treatment toxicity and improved quality of life.
Prehabilitation – impact of poor nutritional status on outcome
The research recognises that poor nutritional status can impact on the individuals outcome to treatment. They are at greater risk of sarcopenia (loss of muscle mass), toxicity of treatment, poor performance status. By identifying patients at diagnosis, pre treatment allows for nutritional concerns to be addressed and thus aim to improve outcome from treatment. Research questions are highlighted in the Principles and Guidance and will be a key driver for future research studies.
Screening as part of prehabilitation and meeting individual needs
All patients with cancer should undergo nutritional screening as early as possible using validated screening tools. Nutrition screening (for undernutrition) in people with a cancer diagnosis should include evaluation of weight loss, poor intake, BMI and nutrition impact symptoms. It is also important to identify those who are overweight so that they can have tailored advice to support healthy lifestyle choices during treatment.
Once identified all high nutrition risk patients should be referred to a dietitian for a person-centered care plan that includes dietary advice, symptom management addressing barriers to adequate intake/absorption.
Outstanding research questions remain on the optimal approach to people who are overweight but are losing weight / have a reduced nutritional intake. Weight loss in this group is associated with a poorer outcome during treatment so should be addressed as for people who are malnourished or at risk of malnutrition.
Nutrition as part of a multi-modal intervention
Nutrition should be considered part of the treatment package, an essential component of care. It cannot be done in isolation and it is essential the person as a whole has all needs addressed including their physical and psychological wellbeing as well. Once screening and assessment has been undertaken then individual needs will be identified. Every person will require their own personal plan with appropriate targeted interventions and a personalised prehabilitation care plan (PPCP).
Developing services for prehabilitation
Funding needs to be available to embed the role of dietitians into all prehabilitation pathways. Services need to be flexible to meet the individual needs of the patients. They should be able to access written information, group facilities and 1:1 care as required.
Implications for education
It is important that all health professionals working with cancer patients are trained to recognise the importance of nutrition. They should be able to identify those at risk, give first line advice and refer on to trained professionals as required. Skills to motivate people to make a lifestyle change and ongoing skills support behaviour change will be essential to the prehabilitation workforce.
The guidance poses questions for research which provides an opportunity for dietitians to be involved in new models of care and testing the efficacy and cost effectiveness of multi-modal interventions.
You can access the guidance and associated outputs including the podcasts and the comprehensive evidence review at the link below: