Oncology

ONC: Executive Summary of Recommendations (2013)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics Oncology (ONC) Evidence-Based Nutrition Practice Guideline 2013. View the Guideline Overview from the Introduction section. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers under the Major Recommendations section. 

To see a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.

The ONC 2013 Recommendations are listed below. [Note: If you mouse-over underlined acronyms and terms, a definition will pop up.]

  • Screening and Referral
    ONC: Malnutrition Screening Tools for Adult Oncology Patients
    Adult oncology patients should be screened using a malnutrition screening tool validated in the setting (inpatient or ambulatory/outpatient) in which the tool is intended for use.  Research indicates that the following tools are valid and reliable for identifying malnutrition risk in oncology patients. The following have been shown to be valid and reliable for identifying malnutrition risk in adult oncology patients in the inpatient setting:
    • Malnutrition Screening Tool (MST)
    • Malnutrition Screening Tool for Cancer Patients (MSTC)
    • Malnutrition Universal Screening Tool (MUST)
    The following has been shown to be valid and reliable for identifying malnutrition risk in adult oncology patients in the ambulatory/outpatient setting:
    • MST.
     
    Strong
    Imperative
    ONC: Screening for Malnutrition Risk and Re-Screening of Adult Oncology Patients
    All adult patients should be screened for malnutrition risk on entry into oncology services. Early identification and management of malnutrition risk improves and protects nutrition status and quality of life (QoL), which leads to improved outcomes. Re-screening should be repeated routinely throughout treatment to facilitate referral as needed.   
    Consensus
    Imperative
    ONC: Referral of Adult Oncology Patients Identified at Malnutrition Risk to the RDN
    If an adult oncology patient has been identified at screening to be at risk for malnutrition, the patient should be referred to a registered dietitian nutritionist (RDN) for evaluation. If indicated, the RDN conducts a nutrition assessment and provides medical nutrition therapy (MNT) including the nutrition care process: Nutrition assessment, nutrition diagnosis, nutrition intervention, nutrition monitoring and evaluation. Management of malnutrition risk improves and protects nutrition status and quality of life (QoL), which leads to improved outcomes. 
    Consensus
    Conditional
    ONC: Medical Nutrition Therapy (MNT) in Adult Oncology Patients Undergoing Chemotherapy or Radiation Treatment
    If an adult oncology patient is undergoing chemotherapy or radiation treatment, the registered dietitian nutritionist (RDN) should provide medical nutrition therapy (MNT). MNT has been shown to be effective in improving multiple treatment outcomes in patients undergoing chemotherapy, radiation or chemoradiotherapy in ambulatory or outpatient and inpatient oncology settings.
    Strong
    Conditional
    ONC: Medical Nutrition Therapy (MNT) As Part of Multi-modal Therapy in Adult Oncology Patients Undergoing Chemotherapy or Radiation Treatment
    The RDN should be a member of the interdisciplinary team providing multi-modal therapy to adult oncology patients undergoing chemotherapy or radiation treatment. Multi-modal therapy includes coordinated interventions from a variety of health care disciplines. Multi-modal therapy that includes MNT demonstrates positive outcomes.
    Fair
    Conditional
  • Nutrition Assessment
    ONC: Nutrition Assesssment Tools for Adult Oncology Patients
    The registered dietitian nutritionist (RDN) should use an assessment tool validated in the setting (inpatient or ambulatory/outpatient) in which the tool is intended for use as part of the complete nutrition assessment. Research indicates that the following tools have been shown to elicit valid and reliable data as part of a comprehensive nutrition assessment of adult oncology patients in ambulatory and acute care settings:
    • Patient-Generated Subjective Global Assessment (PG-SGA)
    • Subjective Global Assessment (SGA).
     
    Strong
    Imperative
    ONC: Assessment of Food/Nutrition-related History of Adult Oncology Patients
    The registered dietitian nutritionist (RDN) should assess the food, beverage and nutrient intake and related history of adult oncology patients including, but not limited to the following:
    • Energy and protein intake
    • Changes in food and fluid/beverage intake
    • Adequacy and appropriateness of nutrient intake or nutrient administration
    • Actual daily intake from enteral nutrition (EN) and parenteral nutrition (PN) and other nutrient sources
    • Changes in type, texture, or temperature of food and liquids
    • Use of medical food supplements (MFS)
    • Food avoidance and intolerances
    • Meal or snack pattern changes
    • Prescription medications, over-the-counter medications, herbal preparations and complementary or alternative medicine products 
    • Factors affecting access to food.
    Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    ONC: Assessment of Anthropometric Measurement in Adult Oncology Patients
    The RDN should assess the following anthropometric measurements in adult oncology patients:
    • Height and weight
    • Weight change
    • Body Mass Index (BMI).
    Any weight loss that is unintended in adult oncology patients has potential significance, as oncology patients often experience weight loss prior to admission to oncology services. Low muscle mass is a common and independent predictor of immobility and mortality, is a particularly adverse prognostic indicator in obese patients and is associated with greater toxicities of chemotherapy leading to treatment interruptions including dose reductions, treatment delays and treatment termination. Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.
    Consensus
    Imperative
    ONC: Assessment of Biochemical Data, Medical Tests, and Procedures on Adult Oncology Patients
    The RDN should evaluate available data and recommend as indicated: Biochemical data, medical tests and procedures of adult oncology patients. Examples include:
    • Glucose
    • White blood cell (WBC)
    • Nutritional anemia profile (hemoglobin, hematocrit, folate, B12, iron)
    • Electrolyte and renal profile
    • Liver function
    • Inflammatory profile, including C-reactive protein (CRP)
    • Gastrointestinal (GI) function tests (i.e., swallowing study, abdominal films, gastric emptying, transit time).
    Assessment of these factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.
    Consensus
    Imperative
    ONC: Assessment of Nutrition-Focused Physical Findings and Client History of Adult Oncology Patients
    The RDN should evaluate available data regarding the nutrition-focused physical findings and client history of adult oncology patients including, but not limited to: Nutrition-focused physical findings:
    • Age greater than 65 years
    • Loss of muscle mass 
    • Loss of subcutaneous fat
    • Presence of pressure ulcers or wounds
    • Nutrition impact symptoms including but not limited to: Nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, alterations in taste and smell and anxiety
    • Changes in appetite
    • Vital signs
    • Functional indicators (i.e., Karnofsky score, grip strength)
    • Localized or generalized fluid accumulation.
    Client history:
    • Patient/Family/Client Medical/Health history:
      • Nutrition impact symptoms including but not limited to: Dysphagia, depression and pain fatigue
      • Medical treatment or therapy
      • Other diseases, conditions and illnesses including cancer cachexia.
    Social history: Psychological/socioeconomic factors (e.g., social support). Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.
    Consensus
    Imperative
    ONC: Nutrition Assessment for the Stages of Cancer Cachexia in Adult Oncology Patients
    As part of the nutrition assessment, in patients with lung, pancreatic or head and neck and gastrointestinal (GI) cancers or those who are at high risk for weight loss or have experienced unintended weight loss, the registered dietitian nutritionist (RDN) should assess for nutrition impact symptoms, markers of inflammation [e.g., elevated C-reactive protein (CRP)] and other signs of wasting, which may indicate pre-cachexia or cancer cachexia. The presence of cachexia does not always indicate end of life or need for hospice. Therefore, the identification of cachexia leading to intervention can positively impact clinical outcomes. 
    Consensus
    Conditional
  • Nutrition Diagnosis
    ONC: Nutrition Diagnosis of Malnutrition in Adult Oncology Patients
    The registered dietitian nutritionist (RDN) should use clinical judgment in interpreting nutrition assessment data to diagnose malnutrition in adult oncology patients. Early identification and diagnosis of malnutrition leading to intervention can positively impact body composition, function, quality of life (QoL), treatment tolerance and clinical outcomes. The presence of two or more of the following criteria or characteristics supports a nutrition diagnosis of malnutrition in the adult oncology patient (See Clinical Characteristics to Document Malnutrition).  
    • Insufficient energy intake
    • Unintended weight loss
    • Loss of subcutaneous fat
    • Loss of muscle mass 
    • Localized or generalized fluid accumulation (that may mask weight loss)
    • Reduced grip strength.
    Consensus
    Imperative
  • Nutrition Intervention
    ONC: Nutrition Intervention of Adult Oncology Patients with Cancer Cachexia
    In adult oncology patients who have been identified to have pre-cachexia or cancer cachexia, prompt and aggressive intervention to address nutrition impact symptoms and preserve or prevent loss of lean body mass (LBM) and weight should be initiated by the registered dietitian nutritionist (RDN). Early rather than later intervention to prevent weight loss in this population is more likely to be effective. The metabolic derangements in cancer cachexia that promote wasting can lead to loss of weight and LBM and poor outcomes.
    Consensus
    Conditional
    ONC: Dietary Supplements Containing Fish Oil for the Adult Oncology Patient
    If sub-optimal symptom control or inadequate dietary intake has been addressed and the adult oncology patient is still experiencing loss of weight and lean body mass (LBM), the registered dietitian nutritionist (RDN) may consider use of dietary supplements containing eicosapentaenoic acid (EPA) as a component of nutrition intervention. Research indicates that dietary supplements containing fish oil (actual consumption, 0.77g to 6.0g of EPA per day), resulted in weight gain or weight stabilization and improvement or preservation of LBM in adult oncology patients with weight loss.
       
    Strong
    Imperative
    ONC: Medical Food Supplements Containing Fish Oil for the Adult Oncology Patient
    If sub-optimal symptom control or inadequate dietary intake has been addressed and the adult oncology patient is still experiencing loss of weight and LBM, the RDN may consider use of a medical food supplement (MFS) containing EPA as a component of nutrition intervention. Research indicates that MFS containing fish oil (actual consumption, 1.2g to 2.2g of EPA per day) resulted in weight gain or weight stabilization and improvement or preservation of LBM in adult oncology patients with weight loss.


     
    Strong
    Imperative
    ONC: Glutamine and Oral Mucositis in Adult Oncology Patients with Solid Tumors and Hematological Malignancies
    If use of parenteral glutamine is proposed to prevent or treat oral mucositis in oncology patients with solid tumors, the registered dietitian nutritionist (RDN) should advise that its use may or may not be beneficial. Limited research in head and neck and stem cell transplantation patients receiving parenteral glutamine has not established the effectiveness of L-Alanyl-L-Glutamine in treating or preventing oral mucositis. Enteral or oral provision of glutamine was not evaluated.
    Weak
    Conditional
    ONC: Parenteral Glutamine and Hematopoietic Cell Transplantation (HCT) in Adult Oncology Patients
    When parenteral nutrition (PN) is required for patients undergoing hematopoietic cell transplantation (HCT), the registered dietitian nutritionist (RDN) may or may not recommend parenteral glutamine (GLN) in doses ranging from 0.2g to 0.5g per kg per day. Research indicates parenteral GLN should be initiated early in the treatment course. Parenteral GLN is associated with improved nitrogen balance and decreased morbidity. However, decreased hospital length of stay (LOS) was found only when data from allogeneic and autologous transplants were combined.
    Fair
    Conditional
    ONC: Nutrition Substances and Chemotherapy-Induced Peripheral Neuropathy
    If an adult oncology patient is at risk for or has chemotherapy-induced peripheral neuropathy (CIPN), the registered dietitian nutritionist (RDN) should advise the patient that the use of nutrition substances (vitamin E, calcium and magnesium infusions, acetyl-L-carnitine, glutamine, glutathione) may or may not be beneficial as a means of preventing or improving CIPN. Research indicates that these substances have had only limited success in preventing or improving CIPN in oncology patients receiving specific chemotherapeutic agents.
    Weak
    Conditional
    ONC: Neutropenic Dietary Precautions for Adult Oncology Patients with Neutropenia (non-Bone Marrow Transplant)
    If an adult oncology patient has neutropenia, the registered dietitian nutritionist (RDN) should provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution. Research has not demonstrated the effectiveness of low-microbial diets.
    Fair
    Conditional
    ONC: Neutropenic Dietary Precautions for Adult Oncology Patients Undergoing Bone Marrow Transplant
    If an adult oncology patient is undergoing bone marrow transplant, the RDN should provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution. There is conflicting research regarding the effectiveness of neutropenic diets in the bone marrow transplant population.
    Weak
    Conditional
  • Nutrition Monitoring and Evaluation
    ONC: Monitoring and Evaluation of Adult Oncology Patients
    Following the nutrition intervention, to check progress, the registered dietitian (RDN) should monitor and evaluate the following components of adult oncology patients at each visit and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. This may include, but is not limited to: Anthropometric measurements:
    • Weight change 
    • BMI
     Food/Nutrition-related history:
    • Energy and protein intake
    • Changes in food and fluid/beverage intake
    • Adequacy and appropriateness of nutrient intake/nutrient administration 
    • Actual daily intake from enteral nutrition (EN) and parenteral nutrition (PN) and other nutrient sources
    • Changes in type, texture, or temperature of food and liquids
    • Use of medical food supplements (MFS)
    • Food avoidance and intolerances
    • Meal/snack pattern changes
    • Prescription medications, over-the-counter medications, herbal preparations and complementary alternative medicine products 
    • Factors affecting access to food
    • Feeding method or need for placement (e.g., oral, enteral or parenteral)
    Biochemical data, medical tests and procedures:
    • Biochemical indices
    • Implications of diagnostic tests and therapeutic procedures 
    Nutrition-focused physical findings:
    • Vital signs
    • Loss of muscle mass 
    • Loss of subcutaneous fat
    • Nutrition impact symptoms including but not limited to: Nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, alterations in taste and smell, and anxiety
    • Presence of pressure ulcers or wounds
    • Functional indicators (i.e., Karnofsky score, grip strength) 
    • Localized or generalized fluid accumulation
    Client history:
    • Patient/Family/Client Medical/Health History:
      • Nutrition impact symptoms including but not limited to: Dysphagia, depression and pain fatigue
      • Medical treatment/therapy
      • Other diseases, conditions and illnesses including cancer cachexia
    Social history:
    • Psychological/socioeconomic issues (e.g., social support)
    Monitoring and evaluation of the above factors is needed to correctly/effectively diagnose nutrition problems that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    ONC: Monitoring and Evaluating Adult Oncology Patients with Cancer Cachexia
    As part of monitoring and evaluation, in patients with lung, pancreatic or head and neck and gastrointestinal (GI) cancers, or those who are at high risk for weight loss or have experienced unintended weight loss, the registered dietitian nutritionist (RDN) should monitor and evaluate nutrition impact symptoms, markers of inflammation [e.g., elevated C-reactive protein (CRP)] and other signs of wasting, which may indicate pre-cachexia or cancer cachexia.   

     
    Consensus
    Conditional
  • Outcomes Management
    ONC: Nutrition Status and Outcomes in Adult Oncology Patients
    The registered dietitian nutritionist (RDN) should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that the evaluation of nutrition status is a key component of the adult oncology patient care process. Research indicates that poor nutrition status is associated with higher rates of hospital admissions or re-admissions, increased length of hospital stay (LOS), lower quality of life (QoL) and mortality in adult oncology patients. Poor nutrition status is also associated with decreased tolerance to chemotherapy and radiation treatment in adult oncology patients undergoing these therapies.
    Strong
    Imperative