教學研究服務教學 研究 服務 高雄醫學大學附設中和紀念醫院 Kaohsiung Medical University Chung-Ho Memorial Hospital ~ 實證醫學報告 ~ 營養介入對接受化放療頭頸癌病人之成效評估 營養部蘇郁婷營養師 101 年 3 月 19 日 1
病例 52yo male hypopharyngeal cancer ct2n2bmx,stage IVA 101.02.25 amitted for chemoradiotherapy. Symptoms: sore throat(+) odynophagia(+) dysphagia(+) 2
Nutritional Assessment Nutritional intervention: 101.02.27 Height: 168cm; 46kg; BMI:16.3; IBW: 62kg SGA score from nurse: 3 (BMI<18.5; 吞嚥困難 ; 癌症 ) High risk for malnutrition Dietary intake: 早餐午餐晚餐晚點 菠蘿麵包 1 個 麵包 1 個 牛肉湯麵 1 份 麵包 1 個 豆漿 240cc 豆漿 240cc 白開水 Calorie: 1456kcal; Protein: 47g(13%); Fat: 60g(37%); CHO: 163g(50%) Total SGA scores: 5 Severe malnutrition Weight loss >10% in 6 months (57.8kg 46kg: loss 20%) Depletion of fat store on 太陽穴. 虎口. 眼瞼
Nutrition problem & patient s question Nutrition problem: Inadequate calorie and protein intake Severe malnutrition 病人提出問題 最近吞嚥疼痛, 不想吃東西, 體重下降很多, 體力也變差 要怎麼做才能增加我的體重和營養? Weight (kg) 60.0 40.0 20.0 0.0 Weight & BMI Change 57.8 20.5 46.6 46.0 16.5 16.3 100.05.23 100.10.12 101.02.25 4
EBM step 1~ 臨床問題呈現 營養師的飲食介入對於頭頸癌症病人治療中及治療後是否真的有幫助? 熱量及蛋白質攝取狀況 營養狀況 體重變化 生活品質 5
EBM step 1~ PICO P Patient/Problem 52 歲, 男性, 口咽癌, 接受化學及放射治療, 吞嚥困難進食量減少, 體重減輕 I Intervention 營養師介入指導 C comparison 無營養師介入指導 O Outcome 體重變化 營養狀況 熱量及蛋白質攝取狀況 生活品質改善 6
EBM step 2~ 5S Information Resources Systems 實證系統 Summaries 綜結及概述 UpToDate, DynaMed Synopses 摘要性評述 EBM, ACP Journal club Syntheses 綜合性系統性回顧 Cochrane reviews Studies 原始研究文獻 PubMed 7
EBM step 3~ Appraise the evidences Grade of Recommendation A B Level of Evidence 1a 1b 1c 2a 2b 2c 3a 3b Therapy Systemic review of RCTs Single RCT All-or-none Systemic review of cohort studies Cohort study or poor RCT Outcomes research Systemic review of case-control studies Case-control study C 4 Case series D 5 Expert opinion, physiology, bench research 8
Searching evidences MeSH keywords: dietitian, nutrition intervention, dietary intervention head neck cancer, head neck neoplasm Databases: System/Summaries: UpToDate (1), DynaMed (0) Synopses: EBM (0), ACP Journal Club (0) Syntheses: Cochrane library (1/16) Studies: PubMed (3/12) 9
Up To Date The role of nutritional support in patients with cancer 10
Up To Date Head and neck cancer section Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy Head and Neck (2005) 27:659-668 Class A; 1b: Single RCT 11
Subjects and Methods Subjects 75 head and neck cancer patients undergoing radiotherapy Study Design Randomly assigned patients Dietary counseling with regular food; n=25 Usual diet plus supplements; n=25 Usual diet only; n=25 Nutrition Intervention Baseline Weekly for 6 weeks (Radiotherapy) End of radiotherapy Follow-up after 3 months 12
Improvements on intake and nutritional status 13
Improvements on quality of life and symptoms 14
Conclusions Nutrition intervention positively influenced outcome Nutritional intake Nutritional status (PG-SGA) Treatment related symptoms Quality of life (QOL) 15
The Cochrane Library Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area British Journal of Cancer (2004) 91,447-452 Class A; 1b: Single RCT
Subjects and Methods Subjects 60 patients with gastrointestinal or head and neck caner receiving radiotherapy Study Design Prospective, randomized-controlled Intensive nutrition intervention (NI); n=29 (male:female 24:5) Usual care (UC); n=31 (male:female 27:4) Nutritional Intervention Baseline (within 4 days of radiotherapy Weekly for 6 weeks (Radiotherapy) Fortnightly for 3 times till 12 weeks 17
Improvements on body weight, PG-SGA, quality of life and physical function 18
Conclusions Early and intensive nutrition intervention provides beneficial outcomes in ambulatory oncology patients receiving radiotherapy to the gastrointestinal or head and neck area minimizing weight loss minimizing the deterioration in nutritional status improving global QOL and physical function 19
PubMed 2004~2012; (3/12) Nutritional counseling and oral nutritional supplements in head and neck cancer patients undergoing chemoradiotherapy Journal of Human Nutrition and Dietetics. 2012 Class B; 2c: Outcome research A dietitian-led clinic for patients receiving (chemo)radiotherapy for head and neck cancer. Support Care Cancer. 2011 Nov 16 Class B; 3b: Case-control study Comparison of the effect of individual dietary counseling and of standard nutritional care on weight loss in patients with head and neck cancer undergoing radiotherapy. British Journal of Nutrition. 2010 Sep;104(6):872-7 Class A; 1b: Single RCT
Subjects and Methods Subjects 38 patients with head and neck cancer undergoing radiotherapy Study Design Prospective, randomized-controlled Individual dietary counseling by dietitian (IDC); n=20 Male:Female 14:6 Standard nutritional counseling by an oncology nurse (SC); n=18 Male:Female 8:10 Nutritional Intervention Baseline (Diagnosis) Weekly for 6 weeks (Radiotherapy) Weekly for 10 weeks (Rehabilitation)
Improvements on percentage weight change 22
Improvements on nutritional status
Conclusions Early and intensive individualized dietary counseling by a dietitian produces clinically relevant effects in patients with head and neck caner undergoing radiotherapy Decreasing weight loss Decreasing malnutrition 24
Summary~ PICO P I Head and neck cancer patients undergoing radiotherapy UpToDate Cochrane PubMed Baseline V V V (4 times) (Radiotherapy) Weekly for 6 wks V V V End of radiotherapy V V V Follow-up After 3 months Fortnightly for 6 weeks Weekly for 10 wks C No intervention Intervention by nurse Intervention by nurse O Weight change - V V Nutritional status V V V Nutritional intake V - - Treatment related symptoms V - - Physical function - V - Quality of life V V - 25
實證應用 ~ 回答病人問題 P (Patient / Problem) I (Intervention) C (comparison) O (Outcome) 將執行化放療的頭頸癌病人配合營養師的營養介入 - 於治療中 : 每週一次為期六週 - 於治療後 : 每週一次或每兩週一次為期 6~12 週沒有營養師的營養介入有效提升及改善 : - 體重 營養素攝取量 營養狀態 - 治療副作用 - 生活品質
EBM step 4&5~ 證據應用及效果評估 頭頸癌病人接受營養照護會診成效 台灣膳食營養學會雜誌 (2011) 3(1):25-36 Subjects 193 male head and neck cancer patient admitted for chemotherapy or radiotherapy Nutrition intervention 入院 48 小時由營養師訪視介入衛教 訪視 1~2 週後追蹤 1 次 27
Improvements on dietary intake
Improvements on biological markers and weight change
Study Limitation UpToDate Cochrane PubMed Our Article Study design Prospective RCT Prospective RCT Prospective RCT Retrospective Outcome study P Head and neck cancer patients undergoing radiotherapy Baseline V V V (4 times) 48hrs after admission I (Radiotherapy) Weekly for 6 wks V V V only 1 time End of radiotherapy V V V - Follow-up After 3 months Fortnightly for 6 weeks Weekly for 10 wks - C No intervention Intervention by nurse Intervention by nurse No comparison Weight change - V V V Nutritional status V V V - O Nutritional intake V - - V Symptoms V - - V Physical function - V - - Quality of life V V - - 30
Limitation No systemic review of RCTs or meta analysis on the topic of nutrition intervention and outcomes on head and neck cancer patients published recently 31
Thanks for your listening! 感謝營養部主任. 組長. 全體營養師 32