ONCOLOGY NUTRITION IN 2020: THE INTERSECTION OF EVIDENCE, GUIDELINES AND CLINICAL PRACTICE July 22, 2020 12:00 – 1:00 pm EST
ONCOLOGY NUTRITION IN 2020:THE INTERSECTION OF EVIDENCE, GUIDELINES AND CLINICAL PRACTICE
July 22, 202012:00 – 1:00 pm EST
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WEBINAR OBJECTIVES
• Review current evidence on the benefits of nutrition intervention for improving muscle mass and strength in oncology patients.
• Highlight nutrition care guidelines for oncology patients.
• Explain how to implement nutrition guidelines into clinical practice to improve patient outcomes.
OUR SPEAKERS TODAY
CARLA PRADO PhD, RD Director, Human Nutrition
Research Unit Professor/CAIP Chair
Nutrition, Food & Health University of Alberta Edmonton, Canada
SUZANNE DIXON MPH, MS, RD Research Consulting Lead
Humana Portland, OR, USA
RHONE LEVIN MEd, RD, CSO, LD, FAND
Oncology Dietitian Duke University Hospital
Durham, NC, USA
WEBINAR AGENDA
Topic Speaker
Update on new evidence on nutrition intervention improving outcomes in patients with oncology
Carla Prado, PhD, RD
Update on current nutrition guidelines Suzanne Dixon, MPH, MS, RD
Implementing evidence and guidelines into clinical practice to improve care Rhone Levin, MEd, RD, CSO, LD, FAND
Q&A
UPDATE ON NEW EVIDENCE ON NUTRITION INTERVENTION IMPROVING OUTCOMES IN PATIENTS WITH ONCOLOGY
7/20/2020
Carla Prado, PhD, RDProfessor & CAIP Chair in Nutrition, Food & HealthDirector, Human Nutrition Research UnitDepartment of Agricultural, Food and Nutritional ScienceUniversity of Alberta, Canadawww.drcarlaprado.com
DISCLOSURES
• The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional
• This educational event is supported by Dietitian Connection and Abbott Nutrition Health Institute, Abbott Nutrition
• Dr. Prado’s disclosures include Abbott Nutrition, Nutricia, Almased.
OUTLINE
Summarize how cancer influences nutritional status and its impact on oncology outcomes
Examine new evidence on nutrition interventions, including those that impact muscle mass, in oncology patients.
Review and identify gaps and opportunities in the current evidence for nutrition interventions in clinical practice
MALNUTRITION IN CANCER
Take Home Message # 1: Patients with cancer are one of the largest hospital patient groups with malnutrition
MALNUTRITION PREVALENCE BY TUMOR GROUP
• The study included 1677 patients in 2012 (17 sites) and 1913 patients in 2014 (27 sites).
61
40 37 34 33 30 29 26
14
48
36 3327 24
3127
2113
2012 2014
31% overall 26% overall
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Par
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mFr
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ages
Prev
alen
ce (%
)
Marshall KM, et al. Clin Nutr. 2019;38(2):644-651.
10 TO 20% OF DEATH ATTRIBUTED TO MALNUTRITION RATHER THAN TO THE MALIGNANCY
ITSELF
ESPEN GUIDELINES CLIN NUTR 2017;36:1187-1196
Arends J, et al. Clin Nutr. 2017;36(5):1187-1196
MALNUTRITION IN CANCER: TUMOR & INFLAMMATION-RELATED CATABOLISM
“Studies of the body composition of patients with cancer reveal that it is specifically the loss of skeletal muscle- with or without loss of fat – which is the main aspect of cancer-associated malnutrition that predicts risk of physical impairment, post-operative complication, chemotherapy toxicity and survival”.
Arends J, et al. Clin Nutr. 2017;36(1):11-48.
LOW MUSCLE MASS IS A DEFINING FEATURE OF MALNUTRITION IN CANCER
Take Home Message # 2:Low muscle mass is prevalent in cancer. It occurs at any body weight, cancer type, stage and age and worsens prognosis.
LOW MUSCLE MASS IS A HIDDEN CONDITION PREVALENT ACROSS BODY WEIGHTS
Prado CM, et al. Ann Med. 2018;50:675-693.
Low muscle mass
Physical impairment /
disability
Greater length of hospital stay
Need for rehabilitation
Post-operative complicationsPoor QofL
Tumorprogression /
toxicity
Shorter survival
The goals of nutritional and metabolic therapy,therefore, must place considerable emphasis on
maintenance or gain of muscle mass.
1) Xiao et al. In press. JAMA Surgery; 2)Caan BJ, et al. JAMA Oncol. 2018;4(6):798-804; 3)Prado CM, et al. Ann Med. 2018;50:675-693; 4) Caan BJ, et al. Cancer Epidemiol Biomarkers Prev. 2017;26(7):1008-1015; 5) Sachar SS, et al. Eur J Cancer. 2016;57:58-67; 6) Prado CM, et al. Lancet Oncology. 2008;9(7):P629-635
NUTRITION INTERVENTIONS: NEW EVIDENCE & FOCUS ON MUSCLE HEALTH
Take Home Message # 3:The quality and quantity of nutrients is essential to sustain nutritional status, hence improving outcomes in cancer
Geethanjali - Cartoons
Winter A, et al. Clin Nutr. 2012;31(5):765-773.
Deutz NE, et al. Clin Nutr. 2011;30(6):759-768.
Prado CM, et al. Am J Clin Nutr. 2013;98(4):1012-1019.
MacDonald AJ, et al. Clin Cancer Res. 2015;21(7):1734-1740.
Engelen MP, et al. Curr Opin Clin Nutr Metab Care. 2016;19(1):39-47.
Aging
Hormonal changes/ Imbalances
Altered energy expenditure
Low dietary intake
Inactivity
Inflammation
Energy needs25-30 kcal/d
Protein1.2-2.0 g/kg/d
AAs and derivativesLeucine: 2 g/d; HMB: 3 g/d;
Glutamine: 0.3g/kg/d; Carnitine: 4-6 g/d; Creatine: 0.03-0.5g/kg/d
Fish oil/EPA2.0-2.2 g/d EPA
1.5 g/d DHA
Vitamins/minerals800-1000 IU/d
+multivitamin/mineral
Multimodal interventionsNutrition, exercise, pharmaceutical,
psychosocial
NUTRIENTS UNDER CONSIDERATION FOR TREATMENT OF LOW MUSCLE MASS IN CANCER
Prado CM, et al.. 2020;11(2):366-380.
PROTEIN INTAKE GUIDELINES
Arends J, et al. Clin Nutr. 2017;36(1):11-48.
Protein Requirement to Increase Muscle
http://primestudy.ualberta.ca/ClinicalTrials.gov Identifier: NCT02788955
o Test the efficacy of diets of different protein levels
o12 week Randomized Controlled Trial, CRC (non cachectic)
1 g/kg/day vs. 2 g/kg/d
ENERGY INTAKE GUIDELINES
Arends J, et al. Clin Nutr. 2017;36(1):11-48.
ENERGY NEEDS ARE HIGHLY VARIABLE AND NOT CAPTURED BY CURRENT RECOMMENDATIONS
Mea
sure
d TE
E, k
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g bo
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eigh
t
Each point is a patient. The blue box represents current recommendations of 25-30 kcal/kg body weight.
Energy recommendations based on body weight alone were poor assessments of energy requirements
25 kcal/kg: 1613 kcal/d (or 48.5%) under-prediction 30 kcal/kg: 968 kcal/d (or 46.9%) over-prediction
Errors related to weight, body composition, and physicalactivity.
Purcell SA, et al. Am J Clin Nutr. 2019;110(2):367-376.
https://www.cosmed.com/en/products/indirect-calorimetry/q-nrg Quick: 10-15 minutes measurement
MobileAffordable
GAPS & OPPORTUNITIES
Take Home Message # 4:Nutrition as a powerful metabolic therapy
ARE ENERGY AND PROTEIN RECOMMENDATIONS ADEQUATE?
Prado CM, et al. Ann Med. 2018;50:675-693.
Gaps & Opportunities
Guidelines evidence?
Synergistic vs additive
effect nutrients
Studies of longer
duration
Studies in all cancer
stagesRCT
Early & continuing
intervention
Multimodal approach
EXPLORATORY DIETARY APPROACHESDiet as a metabolic therapy
Fasting/caloric restriction can: inhibit tumor growth enhance chemotherapy efficacy reduce side effects of chemotherapy
ClinicalTrials.gov Identifier: NCT03795493
ClinicalTrials.gov Identifier NCT03131024
Oliveira CLP, et al. J Acad Nutr Diet. 2018;118(4):668-688.
EXPLORATORY DIETARY APPROACHESDiet as a metabolic therapy
Fasting/caloric restriction can: inhibit tumor growth enhance chemotherapy efficacy reduce side effects of chemotherapy
ClinicalTrials.gov Identifier: NCT03795493
ClinicalTrials.gov Identifier NCT03131024
Oliveira CLP, et al. J Acad Nutr Diet. 2018;118(4):668-688.
RECAP…
Take Home Message # 1:Patients with cancer are one of the largest hospital patient groups with malnutrition
Take Home Message # 4:Nutrition as a powerful metabolic therapy
Take Home Message # 3:The quality and quantity of nutrients is essential to sustain nutritional status, hence improving outcomes in cancer
Take Home Message # 2:Low muscle mass is prevalent in cancer. It occurs at any body weight, cancer type, stage and age and worsens prognosis.
NEWBODY COMPOSITION & HEALTH
ONLINE EDUCATIONAL MODULES
VISIT ANHI.ORG TO LEARN MOREDIRECT LINK: ANHI.ORG/EDUCATION/COURSE-CATALOG/BODY-
COMPOSITION-WITH-CARLA-PRADO
Use as Continuing Education Credits
NUTRITION CARE GUIDELINES FOR ONCOLOGY PATIENTS
SUZANNE DIXON, MPH, MS, RDN
DISCLOSURES
• The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional
• This educational event is supported by Dietitian Connection and Abbott Nutrition Health Institute, Abbott Nutrition
• I have no financial disclosures
OBJECTIVES
1. Review current evidence-based clinical nutrition guidelines for early nutrition screening and assessment in oncology patients.
2. Examine current recommendations on implementing nutrition interventions to address malnutrition and cancer cachexia in oncology practice.
3. Identify areas for future guideline development to improve nutrition care.
NUTRITION GUIDELINES FOR ONCOLOGY PATIENTS
• Past–EAL 2007, 2013–ASPEN 2009
• Present–NAS 2016–NCCN–ASCO–ESPEN 2016
• Future–Malnutrition Consensus
Project
EVIDENCE ANALYSIS LIBRARY: 2007 – 2013 ONCOLOGY NUTRITION UPDATE6 original questions, 95 articles, 16 conclusion statements and 15 recommendations.•Grade I: Good – the evidence consists of results from studies of strong design for answering the question addressed.
•Grade II: Fair – the evidence consists of results from studies of strong design
•Grade III: Limited numbers of studies
•Grade IV: Expert opinion only
•Grade V: Not assignable
Conclusion Statement
Grades 2007 vs 2013
EAL 2007 Grade 1 Grade 2 Grade 3 Grade 5 EAL 2013
Evidence Analysis Library Oncology Guideline 2013. https://www.andeal.org/vault/pq113.pdf. Accessed 7.12.20Evidence Analysis Library Oncology Guideline 2007. https://www.andeal.org/topic.cfm?cat=2819. Accessed 7.12.20
6%
EVIDENCE ANALYSIS LIBRARY: ONCOLOGY 2013
Poor nutrition status is associated with decreased toleranceto radiation treatment in adult oncology patients
Poor nutrition status is associated with decreased toleranceto chemotherapy treatment in adult oncology patients
Poor nutrition status is associated with increased length ofhospital stay (LOS) in adult oncology patients.
Poor nutrition status is associated with lower quality oflife (QoL) in adult oncology patients.
Poor nutrition status is associated with mortality inadult oncology patients.
Grade I
Grade I
Grade I
Grade I
Grade I
Evidence Analysis Library Oncology Guideline 2013. https://www.andeal.org/vault/pq113.pdf. Accessed 7.12.20
ASPEN (2009) GUIDELINE DEVELOPMENT CRITERIA
Grading of GuidelinesA Supported by at least two level I investigationsB Supported by one level I investigationC Supported by at least one level II investigationsD Supported by at least one level III investigationsE Supported by level IV or V evidence
Levels of EvidenceI Large randomized trials with clear‐cut results; low risk of
false‐positive(alpha) and/or false‐negative (beta) errorII Small, randomized trials with uncertain results; moderate‐to‐high
risk of false‐positive (alpha) and/or false‐negative (beta) errorIII Nonrandomized cohort with contemporaneous controlsIV Nonrandomized cohort with historical controlsV Case series, uncontrolled studies, and expert opinion
August DA, et al. JPEN J Parenter Enteral Nutr. 2009;33(5):472-500.
ASPEN 2009 ONCOLOGY NUTRITION GUIDELINE EXAMPLES
• Patients with cancer are nutritionally‐at‐risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (D)
• Nutrition support therapy is appropriate in patients receiving active anticancer treatment who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time (see Guideline 6 Rationale for discussion of prolonged period of time”). (B)
• The palliative use of nutrition support therapy in terminally ill cancer patients is rarely indicated. (B)
• ω‐3 Fatty acid supplementation may help stabilize weight in cancer patients on oral diets experiencing progressive, unintentional weight loss. (B)
• Immune‐enhancing enteral formulas containing mixtures of arginine, nucleic acids, and essential fatty acids may be beneficial in malnourished patients undergoing major cancer operations. (A)
August DA, et al. JPEN J Parenter Enteral Nutr. 2009;33(5):472-500.
NATIONAL ACADEMY OF SCIENCES (NAS – IOM) 2016 WORKSHOP REPORT
National Academies of Sciences, Engineering, and Medicine. 2016. Examining access to nutrition care in outpatient cancer centers: Proceedings of a workshop. Washington, DC: The National Academies Press. www.nationalacademies.org/oncologynutrition
WORKSHOP GOALS
1. Describe the potential benefits of outpatient nutritional care on morbidity, mortality, and long-term survival
2. Describe the current status of nutritional care for oncology outpatients including the availability of data during treatment and long-term survivorship
3. Describe the barriers to achieving an ideal care setting and the information resources available to patients
4. Describe the ideal care setting, including models of care within and outside of the United States
5. Describe the issues relating to cost benefit assessment for both recent diagnosis and post-treatment care
NUTRITIONAL STATUS, NUTRITIONAL INTERVENTION AND CANCER MORBIDITY & MORTALITY
Malnutrition adversely affects outcomes
Certain sub-populations of cancer survivors can make positive lifestyle changes,
including weight loss
Nutrition intervention improves morbidity,
mortality, health outcomes
• Data strong
• Data relatively strong
• Data mixed
NAS 2016 WORKSHOP REPORT: BARRIERS
• The average ratio of RDNs to patients in outpatient cancer care programs is 1:2,308. Barriers to screening:
• Lack of a referral process (46.9%)• Little-to-no administrative support (46.9%)• Time constraints (45.3%)• No identified screening tool (31.3%)• Little-to-no nursing support (29.7%)• No agreement on which screening tool to use among other
disciplines (25%)
Trujillo EB, et al. J Oncol. 2019;2019:7462940.
NAS 2016 WORKSHOP REPORT: IDEAL CARE
Pre-treatment Treatment Post-treatment
• Determine baseline nutritional status, replete nutrient deficiencies as needed
• Discuss potential treatment related side-effects, and nutritional strategies for minimizing the side effects
• Review food safety guidelines
• Monitor changes in nutritional status as the treatment course progresses, modify nutrition plan as needed
• Identify appropriate foods (e.g. taste, texture, temperature) to optimize dietary intake as treatment-related side effects develop
• Review safe food handling procedures during neutropenia
Prevent weight gain, nutrition-related late effects, chronic diseases
MOVING FORWARD…
BUILDING ALLIANCES: INTEGRATING NUTRITION INTO GLOBAL ONCOLOGY TREATMENT GUIDELINES
• NCCN: Registered dietitian referral added to specific treatment guides:
– Pancreatic, Head and Neck, Esophageal
• ASCO
“Recommendation 1.1. Clinicians may refer patients with advanced cancer and loss of appetite and/or body weight to a registered dietitian for assessment and counseling, with the goals of providing patients and caregivers with practical and safe advice for feeding; education regarding high-protein, high-calorie, nutrient-dense food; and advice against fad diets and other unproven or extreme diets (Type of recommendation: informal consensus; Evidence quality: low; Strength of recommendation: moderate).”
Roeland EJ, et al. [published online ahead of print, 2020 May 20]. J Clin Oncol. 2020;JCO2000611.
2016 ESPEN GUIDELINES ON NUTRITION IN CANCER PATIENTSScreening Assessment Intervention Screening/Assessment
• Nutritional management as proposed by the guideline will require screening for malnutrition in all and further assessment and treatment in a relevant fraction of cancer patients.
• Nutrition counselling by a health care professional is regarded as the 1st line of nutrition therapy. Professional counselling, as distinct from brief and casual nutritional “advice”, is a dedicated and repeated professional communication process...
• Theoretical arguments that nutrients “feed the tumor” are not supported by evidence related to clinical outcome and should not be used to refuse, diminish, or stop feeding.
• We recommend, that total energy expenditure of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day
• We recommend that protein intake should be above 1 g/kg/day and, if possible up to 1.5 g/kg/day
Arends J, et al. Clin Nutr. 2017;36(1):11-48.
Future: Malnutrition Consensus Project
• Oncology Nutrition Dietetic Practice Group, Academy of Nutrition and Dietetics
• National Academies of Sciences, Engineering and Medicine’s Health and Medicine Division
• American Society of Nutrition
• American Society for Parenteral and Enteral Nutrition
• Academy of Oncology Nurse and Patient Navigators
• Oncology Nursing Society
• American Institute for Cancer Research
• American Cancer Society
• Association of Community Cancer Centers
• American College of Surgeons’ Commission on Cancer
• American Society of Clinical Oncology
• American Society of Radiation Oncology
THANK YOU.
IMPLEMENTING EVIDENCE AND GUIDELINES INTO CLINICAL PRACTICE TO IMPROVE CARE
RHONE M. LEVIN, M.ED., RDN, LDN, CSO
DISCLOSURES
7/20/2020
• The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional
• This educational event is supported by Dietitian Connection and Abbott Nutrition Health Institute, Abbott Nutrition
OBJECTIVE: HOW TO IMPLEMENT EVIDENCE AND GUIDELINES INTO CLINICAL PRACTICE TO IMPROVE CARE
• Translate new evidence and current guidelines to improve oncology patient outcomes.
• Propose strategies for clinical practice based on current evidence and guidelines to improve direct patient care interventions.
• Identify future opportunities for updating current nutrition practice.
7/20/2020
7/20/2020
TRANSLATE NEW EVIDENCE AND CURRENT GUIDELINES TO IMPROVE PATIENT OUTCOMES –
WHAT WE KNOW WORKS
Arends J, et al. Clin Nutr. 2017;36(5):1187-1196.
ESPEN KEY STEPS: WHAT WE KNOW WORKS(1) NUTRITION SCREENING
7/20/2020
Choose a validated tool(s) for your setting
Common tool characteristics:
Weight change/ timeReduction in appetiteNutrition impact symptomsBMIHigh risk diagnosis
Apply malnutrition screening for all patients through out treatment, at regular intervals
Include the malnutrition screening results in the EMR
Arends J, et al. Clin Nutr. 2017;36(5):1187-1196.
ESPEN KEY STEPS: WHAT WE KNOW WORKS(2) EXPAND NUTRITION-RELATED ASSESSMENT PRACTICES
7/20/2020
• Expand nutrition –related assessment practices to include measures of:• Anorexia• Body composition• Inflammatory biomarkers• Resting energy expenditure• Physical function
Arends J, et al. Clin Nutr. 2017;36(5):1187-1196.
ESPEN KEY STEPS: WHAT WE KNOW WORKS(3) MULTIMODAL NUTRITIONAL INTERVENTIONS
7/20/2020
Arends J, et al. Clin Nutr. 2017;36(5):1187-1196. Muscaritoli M, et al. Ther Adv Med Oncol. 2019;11:1758835919880084.
• Multimodal nutritional interventions1
• Individualized nutrition plans
• Care focused on increasing nutritional intake
• Lessening of inflammation and hypermetabolic stress
• Increasing physical activity
Task2 Health Care Specialist
Food Intake Dietitian
Dysphagia Speech therapist, ENT, dentist, surgeon, neurologist
Gastrointestinal problems
Dietitian, Gastroenterologist, surgeon
Chronic Pain Pain expert
Psychosocial distress Psychologist, social worker, palliative care specialist
Muscle loss, fatigue, inactivity
Dietitian, PT, Exercise physiologist
STRATEGIES TO IMPROVE DIRECT PATIENT INTERVENTIONS
• (2013)– written for inpatient but can be adapted to outpatient services
• Summary of Alliance’s Nutrition Care Recommendations• 1. Create institutional culture• 2. Redefine clinician’s roles to include nutrition• 3. Recognize and diagnose all patients at risk• 4. Rapidly implement interventions and continue
monitoring• 5 Communicate nutrition care plans• 6. Develop discharge nutrition care and education plans
Tappenden KA, et al. J Acad Nutr Diet. 2013;113(9):1219-1237.
STRATEGIES FOR CLINICAL PRACTICE TO IMPROVE DIRECT PATIENT CARE INTERVENTIONS
• “Harmonize” with standardized care pathways/algorithms• National Comprehensive Cancer Network (NCCN) – Nutrition for Cancer Survivors• Clinical Oncology Society of Australia (COSA) - Head and Neck Guidelines• Multinational Association of Supportive Care in Cancer (MASCC)• Academy of Nutrition – Oncology EAL
• Standardize care among nutrition staff• NFPE• Nutrition assessment• Malnutrition diagnosis and coding• MNT interventions: provide individualized nutrition interventions
• Nutrition education and nutrition counseling• Food and nutrient delivery
• Energy / nutrient dense• Enteral/parenteral nutrition
7/20/2020
• Get nutrition into care plans, discharge instructions, survivorship plans
• Use of technology to provide education and resources that frees up RDN time for direct patient interventions
• e.g. Use social media to create education for immediate access:
• Information for patients new to treatment (e.g. “try this first”), common questions, de-bunking, cancer prevention, Survivorship
• Training materials for other disciplines triaging nutrition distress
Connecting Kitchen - Meryl Hunt - used with permission
STRATEGIES FOR CLINICAL PRACTICE TO IMPROVE DIRECT PATIENT CARE INTERVENTIONS
IDENTIFY FUTURE OPPORTUNITIES FOR UPDATING THE CURRENT NUTRITION GUIDELINES TO IMPROVE ONCOLOGY
NUTRITION CLINICAL PRACTICE
7/20/2020
• Oncology organizations need to create nutrition guidelines• Requirement for nutrition screening for all oncology patients
applied through out treatment • Start with consensus project!
• Incorporate “Symptom Tracking” into documentation• accurate capture of the patient experience (timing, severity,
intensity and resolution)• leading to real time symptom management
• Requirement utilization of Malnutrition Diagnosis and coding as documented by RDNs
IDENTIFY FUTURE OPPORTUNITIES FOR UPDATING THE CURRENT NUTRITION GUIDELINES TO IMPROVE ONCOLOGY
NUTRITION CLINICAL PRACTICE
7/20/2020
• RDNs participate in research • if you are involved in a research – get the terminology that a “RDN provided MNT” into the
description of the study
• Tools to measure and capture the effectiveness of RDN interventions• Learn something from other disciplines (applied care / RN vs. measured
progress SLP/PT)
The Academy: • Update the Oncology EAL• Oncology nutrition benchmarking to officially address how much work is possible • Improve national standards for oncology nutrition documentation• Reimbursement for efficacious nutrition therapy• Volunteer with the Oncology Nutrition – DPG!
SUMMARY
• There are nutrition organizations that continue to work to improve the current oncology care guidelines and direct patient care:
• Oncology Nutrition – DPG, Academy of Nutrition and Dietetics, American Society of Parenteral and Enteral Nutrition, ESPEN, MASCC, ONS, ASCO, NCCN, COSA, COG
-Screening-Nutrition assessment -Creating a multi-modal team -Pathways to offer improvements to your facility as well as within your nutrition team
THANK YOU
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