rhone levin
Rhone Levin, MEd, RDN, CSO, LD, is a board-certified oncology registered dietician at the Dell Children’s Blood and Cancer Center in Austin, TX.

Nutrition impact symptoms (NIS) involve any barrier to a patient’s nutritional status. Cancer and its treatments often lead to complex side effects that develop rapidly and change in character and intensity throughout treatment. Barriers to eating and drinking, digesting, and absorbing nutrients lead to negative clinical outcomes for patients with cancer, including malnutrition. Prompt assessment and interventions are key to helping patients avoid treatment holidays and dose reductions while also promoting the best possible quality of life during their cancer journey. In fact, a weight loss of just 5% is an indicator that a patient will likely not receive all of his or her prescribed cancer treatment.

Malnutrition is associated with poor outcomes and high cost of care in patients with cancer. Despite malnutrition’s known effects, few patients who present with an increased risk are identified or treated in practice. Cancer diagnoses associated with the highest risk for malnutrition include head and neck, esophageal, gastric, pancreatic, lung, and metastatic disease. Patients on emetogenic chemotherapy regimens, radiation therapy to the head and neck, concomitant treatments, and transplant regimens are also likely to become malnourished.

Early intervention to prevent and treat malnutrition is key to successful oncology care. Managing the condition early allows patients to tolerate and receive their optimal treatment plan by reducing the need for dose modifications or delays. The oncology registered dietitian/nutritionist (RDN) is trained to provide medical nutrition therapy to prevent and address NIS’s modifiable aspects. Clinical dietitians are experts at providing successful nutrition support, including enteral nutrition and total parenteral nutrition. Patients who require tube feeding or hyperalimentation in the home can also benefit from intensive nutrition surveillance and prompt problem solving.

Out of all the cancer care team members, oncology nurses have the most consistent contact with patients. Nurses are in a key position to collaborate with RDN colleagues by routinely screening for NIS. They can also provide early nutrition intervention for anorexia, early satiety, nausea and vomiting, constipation, diarrhea, dysgeusia, dysphagia, xerostomia, mucositis, esophagitis, and gastroparesis. Nurses can create a culture of nutrition by assessing patients regularly for issues with eating, drinking, and weight change. They can also encourage other oncology providers to provide nutrition surveillance and report the presence and severity of NIS. The symptoms are much easier to treat and control when they are identified early, before they’ve derailed treatment protocols.

As part of a culture of nutrition, nurses can implement a validated oncology malnutrition screening tool that can be used across all diagnoses at each provider visit to help identify malnutrition at its earliest and most treatable stage. Some validated tools include the Malnutrition Screening Tool, abridged Patient Generated Subjective Global Assessment (aPG-SGA), and NUTRISCORE. Electronic medical records may be configured to provide automatic malnutrition screening based on weight loss for patients, too. Nurses should advocate for adequate RDN hours, ideally requiring nutrition services in the cancer center itself or by setting up a rapid referral process to an outpatient nutrition clinic.

Ultimately, nutrition therapy should be included in comprehensive cancer treatment. Oncology nurses can routinely screen and assess for nutrition issues and ensure they are addressed by being prepared to adequately provide nutrition interventions and refer patients with progressive malnutrition to an RDN.