Background: Malnutrition is highly prevalent in the oncology population and is associated with poor treatment outcomes.
Objectives: This study aimed to implement a malnutrition screening process using a validated tool in three outpatient cancer centers.
Methods: Nursing and nutrition department leaders collaborated to establish malnutrition screening. The Malnutrition Screening Tool (MST) was embedded in the electronic health record. Based on the MST, a score of 2 or greater is considered at risk for malnutrition. Nurses were educated on screening all patients completing their first cycle of infusion chemotherapy. Data were collected for six months.
Findings: Interprofessional collaboration established a process to implement malnutrition screening. Twenty-eight percent of patients with cancer were at risk for malnutrition. Fifty-three percent were at risk for malnutrition based on MST scores of 2. Compliance with the MST at first infusion visit was 30%–81% across the three cancer centers.
Malnutrition affects 40%–80% of the oncology population (Lee et al., 2016). Among patients seen in acute care, the prevalence of malnutrition is highest in the oncology setting (Hettiarachchi et al., 2018). Many factors are associated with malnutrition; in patients with cancer, it is often diagnosed at the same time the patient is initially diagnosed (Lee et al., 2016). The metabolic activity of the disease and presence of inflammation are some of the mechanisms associated with a high prevalence of malnutrition in the oncology population. Severe and persistent inflammation can result in loss of lean body mass, which is one clinical characteristic of malnutrition (Mueller et al., 2011). Impaired nutrition because of the side effects of chemotherapy, radiation therapy, or surgery can also contribute to poor nutrition status. Anorexia, changes in activities of daily living, and psychological changes also play a role in malnutrition (Lee et al., 2016).
Patients with cancer can have increased nutritional requirements because of higher resting energy expenditures (REE). Individuals with higher REE require significantly more energy to maintain body weight and functions. Higher REE increase calorie, protein, and micronutrient needs (Cao et al., 2010). Patients with esophageal, gastric, pancreatic, and non-small cell lung cancers are at higher risk for malnutrition because they can have higher REE.
Malnutrition can significantly affect patients with cancer, including poor prognosis and treatment outcomes, reduced functional status and quality of life, and increased risk of chemotherapy-induced toxicity and postsurgical complications (Lee et al., 2016). Disease-related malnutrition is attributed to 20% of cancer mortality rates (Hettiarachchi et al., 2018). Patient malnutrition can contribute to poor clinical outcomes and decreased performance status, potentially increasing inpatient hospitalization rates and healthcare costs (Lee et al., 2016). Patients who lose as much as 20% of their body weight during cancer treatment have 50% or greater inpatient readmission rates (Capuano et al., 2008).
Measurements and Evaluation
Unintentional weight loss is a metric that suggests malnutrition. A loss of greater than 20% of body weight is associated with a greater risk of treatment interruptions, infections, and early mortality (Capuano et al., 2008). Weight loss during cancer treatment is more likely to be a loss of lean body mass rather than of adipose tissue. Loss of lean body mass is associated with toxicities from chemotherapy and radiation therapy (Cespedes Feliciano et al., 2017). Hill et al. (2011) reported a strong correlation between malnutrition risk scores and weight loss in a sample of 73 patients with gastrointestinal cancer undergoing radiation therapy. Patients who required unplanned treatment breaks had experienced greater weight loss than those without treatment breaks (Hill et al., 2011). As Capuano et al. (2018) reported, when patients pause or stop cancer treatment, they may have lost an estimated 4%–20% of body weight.
Early screening, identification, and intervention are effective strategies in managing malnutrition (Leser et al., 2018). Early intervention can reduce weight loss, reduce hospital admissions, and improve quality of life (Lee et al., 2016). Unrecognized or untreated malnutrition may evolve to cancer cachexia, which is characterized by irreversible progressive muscle wasting (Lee et al., 2016).
The Malnutrition Screening Tool (MST) was designed by Ferguson et al. (1999) as a way to identify patients at risk for malnutrition. This validated instrument has demonstrated rigor for its use in the outpatient adult oncology setting (Ferguson et al., 1999). The MST consists of two questions pertaining to recent unintentional weight loss and decrease in appetite. The MST is scored from 0 to 7 points, and a score of 2 or greater is considered being at risk for malnutrition. Isenring et al. (2006) found the MST to be “appropriate to use in patients with cancer” (p. 1,155). The MST was found to be a strong predictor of nutritional risk relative to the other tools. Reports of sensitivity and specificity of the MST vary in the research. In a study of 50 patients, the MST had 100% sensitivity and 92% specificity (Isenring et al., 2006). Shaw et al. (2015) found the MST has been validated against the Subjective Global Assessment (SGA) and Patient-Generated SGA (PG-SGA) for use in the outpatient oncology setting. The PG-SGA is often considered to be the gold standard in oncology screening, but it is very intricate and time-consuming (Isenring et al., 2006). The study by Shaw et al. (2015) reviewed patient data from 128 diverse patients in a single tertiary cancer center. The sensitivity and specificity were found to be 66% and 83%, respectively. The evidence indicates that using a validated screening tool is a best practice at the start of treatment. The MST is advantageous over other commonly used screening tools, including the Malnutrition Universal Screening Tool (MUST) (Stratton et al., 2004), the Mini-Nutrition Assessment–Short Form (Shaw et al., 2015), and Nutrition Risk Screening (Isenring et al., 2006), because it does not require any calculations, is quick and easy to use, and can be completed by a variety of clinical and nonclinical staff (Isenring et al., 2006). Nurses have reported that the MST is easy and not complicated to use as compared to the MUST (Raja et al., 2008).
Patients who screen positive for malnutrition risk should be referred to a registered dietitian who is a certified specialist in oncology (RD-CSO) for further evaluation. An RD-CSO has completed two years of clinical practice and 2,000 clinical hours working with the oncology population. For at-risk patients, a comprehensive nutrition assessment includes a food and nutrition history, anthropometric measurements and calculations (e.g., current body weight, ideal body weight, usual body weight, percentage weight change over monthly time frame), biochemical data, and evaluation of nutrition impact symptoms (e.g., anorexia, mucositis, nausea). The purpose of this detailed nutrition evaluation is to confirm the presence and extent of malnutrition. It is vital for the RD-CSO to assess anthropometric measures because reviewing body weight or body mass index in isolation may mask sarcopenic obesity (an increase in fat mass with a loss of muscle mass). To determine the extent of muscle and/or fat loss, the RD-CSO assessment includes a physical examination.
Based on a comprehensive assessment, the RD-CSO drafts a care plan, which includes interprofessional interventions. The goal of the care plan is to provide patients with individualized interventions to improve nutritional status and manage factors contributing to malnutrition. Gupta et al. (2010) reported that patients who received a nutrition intervention with effective improved nutritional status at three months had an increased survival rate. Malnourished patients who received a care plan and were subsequently well nourished had a median survival of 18.5 months. Patients whose nutrition status did not improve had a median survival of three to nine months. Individualized interventions include suggestions for food or nutrient intake and nutrition education. If a patient has lost a significant amount of weight, the RD-CSO may suggest use of oral nutrition supplements, homemade nutrient-dense smoothies, or nutrient-dense snacks. The RD-CSO also may provide patient education about increasing the intake of nutrient-dense foods.
This study took place at three National Cancer Institute–designated cancer centers within Mount Sinai, a tertiary medical center in New York, New York, that has been recognized by the Commission on Cancer. This medical center uses a collaborative interprofessional approach to diagnosing and treating cancer. The cancer centers provide outpatient care for patients with solid tumor and blood disorders. A combined 200 patients are seen per day in areas of office practice, radiation, imaging, and infusion. The medical center provides a comprehensive range of advanced, interprofessional clinical services (e.g., nutrition, social work, massage, yoga, family support groups, psychology, psychiatry, genetic counseling) for patients with all cancer diagnoses.
Nutrition Screening Process
The goal of this initiative was to implement a nutrition screening process for patients at the start of chemotherapy. Historically, a screening tool had been built into the electronic health record (EHR) in the nursing flowsheets but was not being used routinely. There was an opportunity to create and implement a clinical standard of practice and processes to ensure malnutrition screening of all new patients receiving chemotherapy treatment.
The first step in developing this quality improvement project required interprofessional collaboration and agreement on the importance of malnutrition screening. Leaders from the nutrition and nursing departments met to discuss how to approach electronic malnutrition screening. The clinical staff at the point of care reviewed the proposed quality improvement project and shared their thoughts and ideas for implementation. It was determined that one of the three cancer centers would test the electronic screening process in a pilot program. A reminder within the EHR, called a best practice alert (BPA), was built with the goal to increase screening compliance. Building the BPA and receiving approval for including it in the EHR was achieved through weekly meetings with leadership from nutrition, nursing, administration, and EHR departments. In these weekly meetings, key design decisions were made, such as the appropriate timing, design, and verbiage of the BPA. Nursing leadership determined that the BPA should fire upon release of treatment orders on the patient’s initial infusion visit. The implementation of the new screening process was endorsed by all the members of the team. The BPA appeared in a yellow box within the EHR and stated, “Reminder: Complete malnutrition screen.” The MST was also housed within the EHR.
The pilot program ran from November 2018 to January 2019. Data from the pilot were presented at a system-wide interprofessional quality improvement committee meeting. There was endorsement from system-wide leadership to expand the malnutrition screening protocol to the other two cancer centers within the medical center. The first site kept the BPA within the EHR, whereas the two other sites did not implement the electronic reminder. Compliance was encouraged through the RD-CSO tracking compliance and providing a monthly compliance update to the nurse manager, who discussed it with the infusion nurses in staff meetings and in-services for infusion RNs. The RD-CSO conducted daily huddles to provide malnutrition-specific education to the nursing team. Informational tip sheets were created as a resource for the nurses on how to complete the MST. Best practices were completing the MST during the first patient chemotherapy infusion visit. Flyers were disseminated to support the electronic screening process. Ongoing education took place via in-service meetings at all sites in partnership with the RD-CSO and nurse manager.
The EHR team generated an automatic weekly report sent to the RD-CSO with the MST data. The report contained patient identification numbers, medical diagnoses, and MST scores. All patients at risk for malnutrition were referred to the RD-CSO for assessment. A comprehensive individualized care plan was created for patients at risk for malnutrition. Medical nutrition therapy, which is evidence-based nutrition suggestions to manage side effects of cancer treatment, was used as the main intervention. The RD-CSO provided nutrition education sheets developed by the Oncology Practice Group, a subgroup of the Academy of Nutrition and Dietetics, on the appropriate nutrition impact symptoms (Elliott et al., 2013). These guides include information on managing side effects (e.g., nausea and vomiting, loss of appetite, constipation) and a detailed list of foods to eat and avoid. Other common interventions included managing body weight changes through education on high-calorie and high-protein food or oral nutrition supplements, if appropriate. The oncology RNs relied on the RD-CSO’s consultation notes and the MST score to reinforce the patients’ care continuously during treatment. To effectively monitor and advise patients, all members of the interprofessional team worked closely together to reinforce the care plan.
MST data were collected for six months from November 2018 to May 2019 across three outpatient cancer centers. In total, 325 patients receiving infusion chemotherapy were screened for malnutrition risk (see Table 1). Of the sample, 240 patients were female and 85 were male. The average age was 60.8 years old. The prevalence of patients at risk for malnutrition was 28% (n = 91). The at-risk patients were of various cancer types (see Table 2). Patients with ovarian, lung, and breast cancers made up the highest numbers of patients at risk for malnutrition. These data represent the most common cancer diagnoses for patients treated at the cancer centers in the current study.
No patients had a score greater than 5 within this sample. The patients who scored 5 were diagnosed with head and neck cancer or lymphoma. The patients who scored 4 had diagnoses of prostate, gastric, or ovarian cancer. A high incidence of malnutrition is commonly seen in patients with head and neck, lung, and colorectal cancers (Argilés, 2005), which is consistent with the current study’s findings of a high risk for malnutrition.
Across the three cancer centers, compliance (defined as completion of MST at first infusion visit) varied. At the center that used the BPA within the EHR, compliance averaged 81%. At the other two centers, compliance ranged from 30%–68%. The authors have identified that using an electronic reminder is one way to improve compliance with a new malnutrition screening policy.
All patients screened for malnutrition and determined to be at risk (28%, n = 91) were referred to the RD-CSO for a comprehensive nutrition assessment. Appropriate nutrition and medical interventions were recommended and reinforced by the RD-CSO, oncology nurse, and other members of the medical team.
Malnutrition screening is a simple, noninvasive strategy to support patients with cancer at risk for malnutrition (Reber et al., 2019). Because of the high percentage of patients who are malnourished at the time of their cancer diagnosis, early recognition and nutrition intervention has been established as an effective strategy to reduce the degree and effects of malnutrition (Leser et al., 2018).
Studies of MST use in the oncology outpatient population are limited. Using the MST, the current study identified that 28% of patients were at risk for malnutrition. The prevalence of malnutrition in patients with cancer is estimated to be higher, at 40%–80% (Lee et al., 2016). However, the prevalence and level of malnutrition will depend on the setting (inpatient versus outpatient), screening tool used, and age and diagnoses within a study sample (Arends et al., 2017; Shaw et al., 2015; Stratton et al., 2004). Because patients seen in the outpatient setting are ambulatory, a lower percentage of malnutrition is to be expected in the current sample (Stratton et al., 2004). In this study, many patients were diagnosed with breast cancer, which is not considered a high-risk diagnosis for or commonly associated with malnutrition (Shaw et al., 2015). In the Shaw et al. (2015) study, using the MST, 52% of inpatients with cancer (n = 126, average age = 59 years) were at risk for malnutrition. Most of the patients in the Shaw et al. (2015) study sample were diagnosed with hematologic or gastrointestinal cancer, which are highly correlated with poor nutrition. Inpatients, who have more acute conditions, can be at higher risk for malnutrition than outpatients (Shaw et al., 2015).
Access to nutrition services is a barrier in outpatient oncology care (Trujillo et al., 2019). Cancer programs may not have an RD-CSO on staff, or the dietitian may not be able to see all referrals because of the volume of patients. If adequate nutrition services are limited, the clinical team may refer patients to speak with a dietitian outside of the facility. Social workers may assist patients to find nutrition services elsewhere, and oncology nurses can intervene with at-risk patients by providing guidance on medical interventions for nutrition impact symptoms of cancer treatment. Another barrier to malnutrition screening is lack of education and lack of value placed on the topic (Lorton et al., 2019). Clinical staff may lack knowledge on how to categorize clinically significant weight loss and the risks of weight loss in obese patients (Lorton et al., 2019). A survey of oncology nurses’ views of the MST in the inpatient setting by Raja et al. (2008) reported that, although 85%–89% of nurses had attended a nutrition screening training and the MST was required, compliance with the screening policy was 3%–4%. The primary reasons for low compliance were competing nursing duties and a sense of professional judgment being adequate to determine nutrition risk. Oncology nurses did not consider the risks of sarcopenic obesity in obese patients because of body weight and body mass index.
Limitations of this study exist. The sample size was small (n = 325), and the project included only patients receiving infusion chemotherapy. Patients who received oral treatment, injection treatment, radiation therapy, or surgery were not included in this sample. In addition, it is possible to receive a false positive score on the MST. A score of 2 or greater triggers a patient to be at risk for malnutrition. If the first question is marked as “unknown,” this triggers a score of 2 points, deeming a patient at risk for malnutrition. This reinforces the need for a detailed assessment by the RD-CSO.
Implications for Nursing and Research
Oncology nurses have frequent contact with patients during treatment, so they are key in collaborating with RD-CSOs in managing malnutrition. Oncology nurses can provide guidance on medical management of nutrition impact symptoms. RD-CSOs and oncology nurses may refer to social workers or psychotherapists for emotional support if depression and/or anxiety are contributing to malnutrition. An interprofessional approach is vital in preventing and treating malnutrition.
Future research is necessary to determine a national oncology standard for malnutrition screening in the ambulatory oncology setting. No conclusive guidelines from nursing or nutrition organizations exist that require malnutrition screening or recommend the best practice guidelines (Trujillo et al., 2019). According to Oncology Nutrition for Clinical Practice, it may be beneficial to screen patients in radiation therapy weekly and patients in chemotherapy every two to three weeks and at each follow-up visit (Leser et al., 2018). Many patients present with malnutrition at diagnosis, but for those who do not, side effects of cancer treatment or progression of disease may contribute to malnutrition developing at a later time (Sauer, 2013). Therefore, rescreening should be part of the larger malnutrition screening program. There is no standard set of malnutrition interventions, but research shows improved survival in those who receive nutritional education and use of oral nutrition supplements (Gupta et al., 2010). Future research may also include determining the most effective nursing and nutrition interventions for varying degrees of malnutrition.
Patients with cancer are at risk for malnutrition because of a multitude of factors, even upon diagnosis. Among the available validated screening tools in the outpatient oncology setting, the MST shows validity and ease of implementation. In the current study, the addition of a BPA resulted in better compliance. Nutrition interventions have been found to improve nutritional status and positively affect outcomes related to cancer treatment. A collaborative approach should be taken in executing a malnutrition screening process in the ambulatory setting.
About the Author(s)
Chelsey K. Schneider, MS, RD, CSO, CDN, is a nutrition supervisor/oncology nutritionist in the Blavatnik Family–Chelsea Medical Center, and Toby Bressler, PhD, RN, OCN®, is the director of nursing for oncology and clinical quality and an assistant professor of medical oncology in the Icahn School of Medicine, both at Mount Sinai Health System in New York, NY. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Schneider can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org. (Submitted September 2019. Accepted January 13, 2020.)
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