EAL

ONC: Medical Nutrition Therapy and Nutrition Intervention in Adult Oncology Patients (2011)

Citation:

Pituskin E, Fairchild A, Dutka J, Gagnon L, Driga A, Tachynski P, Borschneck JA, Ghosh S. Multidisciplinary team contributions within a dedicated outpatient palliative radiotherapy clinic: A prospective descriptive study. Int J Radiat Oncol Biol Phys 2010; 78 (2): 527-532.

PubMed ID: 20100640

Study Design:

Prospective Cohort Study

Class:

B - Click here for explanation of classification scheme.

Quality Rating:

NEUTRAL: See Quality Criteria Checklist below.

Research Purpose:

To describe the feasibility and results of multidisciplinary assessment of consecutive patients with painful bone metastases attending the first year of the Rapid Access palliative Radiotherapy program (RAPRP) and describe the resulting non-physician recommendations.

Inclusion Criteria:

Cancer patients attending the RAPRP clinic between January 1 and December 31, 2007.

Exclusion Criteria:

All patients were eligible unless they were inpatients at another facility, or had received recent palliative consultation. Clinical Nutrition and Social Work assessments were not started until March 2007, so patients seen between January and March did not have the option of these assessments.

Pharmacist assessment; reasons patients not assessed:
- Inpatient status at another facility
- Recent palliative consultation
- Staffing issues
Occupational therapist assessments; reasons patients not assessed:
- Inpatient status at another facility
- Recent palliative consultation
- Already receiving community OT services
- No OT-related needs identified
- Patient refusal
Clinical nutrition assessments; reasons patients not assessed:
- CN-related needs not identified by patient-generated subjective global assessment (PG-SGA)
Social work assessments; reasons patients not assessed:
- SW-related needs not identified on the multi-disciplinary team Edmonton Symptom Assessment system (ESAS).

Description of Study Protocol:

Recruitment

All patients attending the RAPRP clinic in 2007

Design

Patients were screened to determine the number and discipline of team members best suited to meet self-identified needs, with the exception of pharmacy, who performed a personal assessment on all outpatients. Patients were contacted by phone four weeks later to determine if recommendations by the multi-disciplinary team resulted in improvement in symptoms.

Blinding used

Not applicable

Intervention

Recommendations by MDT members (pharmacy, occupational therapy, clinical nutrition, and/or social work) for relief of individual symptoms.

Statistical Analysis

Demographic information, disease characteristics, treatment outcomes and types of multidisciplinary recommendations were prospectively collected in a computerized database. Analysis was performed using SPSS version 15.0. Descriptive statistics were used to collate responses. Chi-squared tests were used for exploration of association for categorical variables. A two-tailed paired t-test was used to compare baseline vs. four-week symptom scores, with P<0.05 considered significant.

Data Collection Summary:

Timing of Measurements

January 1-December 31, 2007

Dependent Variables

Baseline and follow-up determined by Edmonton Symptom Assessment System symptom scores
Pain
Tiredness
Nausea
Depression
Anxiety
Drowsiness
Appetite
Well-being
Shortness of breath.

Independent Variables

Multi-disciplinary team recommendations

Pharmacist recommendations (n=71)
- Adaptation of bowel regimen (n=46)
- Change of analgesic (n=46)
- Adjustments of supportive medication (n=39)
Occupational therapist recommendations (n=51)
- Adaptive equipment (n=37)
- Energy conservation (n=32)
- Occupational therapist service education (n=17)
- Durable medical equipment (n=14)
Registered Dietitian recommendations (n=24)
- Weight loss or gain counseling (n=21)
- Nutritional education (n=21)
- Tips on symptom management (n=16)
- Physical problems limiting intake (n=9)
Social worker recommendations (n=12)
- supportive counseling (n=9)
- Care assistance (n=8)
- Financial support (n=8)
- Advance directives (n=2).

Control Variables

Age
Type of cancer.

Description of Actual Data Sample:

Initial N:
- 82 individual patients
- 51 (62%) male
- 71 received initial pharmacy assessment
Attrition (final N): 23 (48 of 71 initially assessed not available for four-week follow-up)
Age: Median age 70 years (range, 40 to 88 years)
Ethnicity: Not identified
Other relevant demographics:
- Patients were from Canada, 98% resided in Alberta, 2% in neighboring provinces
- Patients lived an average of 110km away from clinic (range, five to 1,237km)
- Cancer diagnosis, an average of 3.9 years prior to being seen at RAPRP clinic, with bone metastases an average of 7.8 months prior to clinic visit
- Original cancer diagnoses:
  - 43% prostate cancer
  - 18% breast cancer
  - 17% non-small-cell lung carcinoma
  - 21% other malignancies
Anthropometrics: Not reported
Location: Edmonton, Alberta, Canada.

Summary of Results:

Key Findings

A total of 106 clinic visits by 82 individual patients occurred. As determined by screening form responses, the clinical Pharmacist, Occupational Therapist, Registered Dietitian and Social Worker were consulted to provide assessments and recommendations within the time constraints presented by one-day palliative RT delivery.
In addition to pain relief, significant improvements in tiredness, depression, anxiety, drowsiness and overall well-being were reported at four weeks.

Variables	Symptom Score Baseline Score and CI	Symptom Score Four-week Follow-up Score and CI	Statistical Significance P value
Pain	6.08±2.73	2.96±3.01	0.001
Tiredness	5.27±2.51	3.52±2.98	0.00
Nausea	1.53±2.57	0.66±1.91	0.196 Not sig
Depression	2.80±3.05	1.09±1.72	0
Anxiety	3.78±2.88	1.24±1.70	0.000
Drowsiness	3.91±3.07	2.07±2.42	0.022
Appetite	4.67±3.10	3.65±3.65	0.062 Not sig
Well-being	4.55±2.72	3.10±3.13	0.035
Shortness of breath	2.54±3.17	1.30±2.93	0.383 Not sig

Other Findings

Author Conclusion:

Multidisciplinary assessment in the setting of a dedicated outpatient palliative rapid access Radio Therapy program is feasible and time neutral. Routine screening for symptoms and needs, when undertaken by Pharmacists, Occupational Therapists, Social Workers and Registered Dietitians is associated with a high number of recommendations. These early interventions are associated with decreased symptom distress, and may be instrumental in preserving function and maintaining patients in their preferred care setting. Our findings lend strong support for the routine assessment by multiple supportive care professionals to patients with advanced cancer being considered for palliative radiotherapy.

Funding Source:

University/Hospital:

Cross Cancer Institute, University of Alberta

Reviewer Comments:

This study suggests that multidisciplinary assessment and recommendations in an outpatient palliative care RT clinic can result in improved quality of life for patients. Problems with this study include:

Less than half of the patients who received multidisciplinary screening and subsequent recommendations were contacted at four weeks
Registered Dietitians and Social Workers were not included on the multidisciplinary team until three months into the study; this limited the effects of their recommendations. It is difficult to know whether the results might have been changed if all of the patients had access to all of the disciplines.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	No
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		No
	4.1.	Were follow-up methods described and the same for all groups?	N/A
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	No
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	No
	4.4.	Were reasons for withdrawals similar across groups?	???
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		N/A
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	N/A
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	N/A
	7.7.	Were the measurements conducted consistently across groups?	N/A
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes