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Perspectives from a dietitian: case studies
Oonagh Griffin RD, MINDIResearch Dietitian – HRB Research FellowDepartment of Surgery, Trinity College DublinNational Surgical Centre for Pancreatic Cancer – St Vincent’s University Hospital
Trinity College Dublin, The University of Dublin
Oncology dietetics
• Nutritional assessment and support throughout treatment
• Identifying and addressing nutrition impact symptoms
• Survivorship: secondary prevention, dealing with long term side effects of treatment
Trinity College Dublin, The University of Dublin
Dietetic clinic list this evening….
Brigid
Michael
Louisa
Trinity College Dublin, The University of Dublin
Brigid
50 year old widow, 4 grown up children, 12 grandchildren
Med Hx: nil, ?previous alcohol excess
Presented with jaundice, subsequently diagnosed with resectablepancreatic cancer
Declined surgery in favour of natural therapies
12/52 later under pressure from family returns to SVUH
Staging laparoscopy reveals disease progression – now borderline resectable disease requiring neo-adjuvant therapy
Dietetic referral at 3rd cycle Folfirinox – 10% weight loss (5kg) requiring dose reduction
Trinity College Dublin, The University of Dublin
Nutritional Assessment
50kg, BMI 19kg/m², pre-illness weight 72kg – 30% weight loss over 5 months
Following own natural regimen: vegan no sugar diet (40% protein, 65% energy requirements)
High dose anti-oxidants and plant-based enzymes
Drinking 2-3 glasses wine daily
“I’m only doing this chemotherapy to keep them happy”
Trinity College Dublin, The University of Dublin
Issues
Weight loss and malnutrition – limiting treatment
Steattorhoea and PEI
Drug nutrient interactions
Alcohol excess
Recent falls – unclear cause
Trinity College Dublin, The University of Dublin
Dietary practices - ? New ? Rationale for avoidance
Priorities
1. Weight loss and impact on treatment, function
2. Address drug nutrient interactions
Trinity College Dublin, The University of Dublin
Agreed goals
Increase protein: Agreed to reintroduce fish and organic meat, butter and cheese (no milk, no eggs)
Agreed to discuss supplements with oncologist
Not agreeable to PERT
Not agreeable to discussion regarding alcohol
Trinity College Dublin, The University of Dublin
Review
2.5 kg increase, chemo resumed
Consented to physio referral
PO intake improved – achieving 75% protein intake
New onset steattorhoea – still declining PERT but took literature regarding same
Telephone call one week later requesting prescription for Creon.
Trinity College Dublin, The University of Dublin
Treatment outcome
Completed 6 cycles Folfirinox
Restaging CT revealed good response – referred for short course RT
Patient declined RT or surgery
Family meeting: community palliative care referral
RIP 5/12 later
Trinity College Dublin, The University of Dublin
Reflection
Control – patient priorities vs healthcare professionals goals
Family dynamics/frustration
Common ground
Priorities
Trinity College Dublin, The University of Dublin
Michael
68 year old bachelor farmer
Recently bereaved (96 year old mother RIP 4/12 ago)
Med Hx: Type 2 DM (10 years), hypertension, high cholesterol, A fib, Obesity (BMI ~44)
Routine GP attendance – 3 stone weight loss, offered bereavement counselling, improvements in lipids and HbA1c praised
6/52 later – brought to A&E by concerned neighbours – jaundiced, frail, further weight loss
ERCP and stent, CT & referral to SVUH
Subsequent CT TAP – 5 cm HOP mass with liver mets
Referred by surgeons following discussion of diagnosis/prognosis
Trinity College Dublin, The University of Dublin
Nutritional Assessment
93 kg, BMI 30kg/m², 32% weight loss over 6 months
Minimal intake: tea and dry toast
Pain & steattorhoea: post prandial, 1 episode of incontinence
Erratic blood sugars; 5-16 mmol/L
Fearful of eating
“Can’t be bothered when it’s only me”
Trinity College Dublin, The University of Dublin
Goals
PERT – treat malabsorption
High protein, high calorie diet – relax previous restrictions
Contacted GP - Community palliative care referral
Contacted by patient a week later
1. Tolerating diet with PERT
2. Attending day care centre for meals
3. “Was I sure he was allowed to have dessert?”
RIP in local hospice 9/52 later
Trinity College Dublin, The University of Dublin
Reflection
Timing of referral
Need to consider previous dietary information/restrictions and address
Role in supportive care
1. Symptom control
2. Barriers to nutrition
3. QOL
Trinity College Dublin, The University of Dublin
Louisa
50 year married teacher, 11 year old twins
Medical Hx: nil
Cruise holiday for 50th birthday: developed abdominal distension and faeculent vomiting
Airlifted back to UK – CT abdo revealed ovarian Ca and bowel obstruction
Referred for PN on arrival in RMH, ngt draining 4L/day
Initial goal – feed/hydrate, commence chemo to reduce tumour bulk
Trinity College Dublin, The University of Dublin
PN dependent for 9/52, stopped following 2nd cycle of chemo
Slow resumption of po intake – intermittent vomiting, early satiety, fear of eating.
D/c home following 3rd cycle – to continue as outpatient
Advised HPHC diet, and importance of weight maintenance throughout
Contact details provided and advised to contact if any weight loss
Trinity College Dublin, The University of Dublin
9 months later
Referred by surgeons prior to attempted resection/debulking, 8kg weight loss noted post RT
Severe diarrhoea following long course RT
Following internet search – patient avoiding wheat and dairy to control symptoms
Resolution of symptoms 2/52 later, still following restricted diet
Trinity College Dublin, The University of Dublin
Explained specific treatment related side effect rather than new dietary intolerance
Need to resume HPHC diet
4kg regained pre-op; debulking only, change to second line chemotherapy
Trinity College Dublin, The University of Dublin
Reflection
Changing needs throughout treatment
Need to ensure patients aware of role regarding symptom management, not just weight maintenance
Review on request?
Trinity College Dublin, The University of Dublin
Reflection
Patient priorities vs family/MDT
Family dynamics and insight into disease/prognosis
Trinity College Dublin, The University of Dublin
Challenges - Summary
• Timing and environment of assessment/referral
• Dietetic capacity
• Food versus Nutrition
• Managing (mis)information
• Patient control and choice
Trinity College Dublin, The University of Dublin
Thank you