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An Interdisciplinary Approach to Manage Cancer Cachexia Clara Granda-Cameron, MSN, CRNP, AOCN®, Debra DeMille, MS, RD, CSO, Mary Pat Lynch, CRNP, MSN, AOCN®, Christine Huntzinger, MPT, CCI, Theresa Alcorn, BA, Joan Levicoff, MA, Carly Roop, RD, LDN, and David Mintzer, MD Cancer cachexia occurs in about 33% of newly diagnosed patients with cancer and may lead to delayed, missed, or decreased treatments. An interdisciplinary team approach to manage cancer cachexia may result in fewer missed treatments and improved outcomes. The palliative care program of an urban community cancer center developed an interdisciplinary clinic to treat cancer cachexia with the goal of using an interdisciplinary approach to improve symptom management, nutrition, function, and quality of life (QOL) for patients with cancer at high risk for malnutrition. The Cancer Appetite and Rehabilitation Clinic team completes medical, nutritional, speech, swallowing, and physical therapy evaluations and then develops an individualized program directed to meet patients’ needs and improve overall QOL. Patient outcomes are measured by symptom management and nutritional and functional parameters. Early intervention and aggressive symptom management may improve performance status and overall QOL. Results from this project will be used to expand this innovative program. The process of developing and implementing this clinic may help oncology nurses and other healthcare professionals to improve management of cancer cachexia and overall cancer care.

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ancer cachexia is defined as a decrease in baseline weight by 5%–10% or more in six months or 5% in one month (Bruera, 1997). Cancer cachexia is common; 50%–75% of patients with cancer experience some degree of cachexia (Slaviero, Read, Clarke, & Rivory, 2003; Takudar & Bruera, 2004). Stewart, Skipworth, and Fearon (2006) stated that cancer cachexia represents a wasting syndrome involving loss of muscle and fat caused directly by tumor factors and/or indirectly by abnormal response to tumor presence. Cachexia most commonly develops in the following tumor types: gastric, 85%; pancreatic, 83%; non-small cell lung, 61%; small cell lung, 57%; prostate, 57%; and colon, 54% (DeWys et al., 1980). The pathophysiology of cancer cachexia is complex, and its various causes can be grouped into two classes: primary anorexia cachexia and secondary anorexia cachexia (Strasser & Bruera, 2002). Primary anorexia cachexia is a metabolic syndrome directly caused by cancer. The interaction between cancer cells and the host produces a series of immune alterations which lead to anorexia, early satiety, asthenia, muscle wasting, and loss of fat (Strasser & Bruera, 2002). Secondary anorexia cachexia represents a combination of several contributing factors: malnutrition caused by impaired oral intake and impaired gastrointestinal absorption mostly caused by treatment and/or tumor-related symptoms; catabolic conditions nonrelated to cancer, such as chronic diseases or infections; 72

and the loss of muscle mass as a result of prolonged inactivity (Strasser & Bruera, 2002). Wasting and malnutrition have long been recognized as predictive of poor outcomes in patients with cancer. Significant weight loss at the time of diagnosis was correlated with decreased survival and impaired response to chemotherapy in 1980 by the Eastern Cooperative Oncology Group (DeWys et al., 1980). Patients with cancer cachexia have poor appetites and significant weight loss, leading to weakness and fatigue

Clara Granda-Cameron, MSN, CRNP, AOCN®, is a palliative care nurse practitioner at the Philadelphia Veterans Affairs Medical Center; Debra DeMille, MS, RD, CSO, is a nutrition counselor in the Joan Karnell Cancer Center at Pennsylvania Hospital; Mary Pat Lynch, CRNP, MSN, AOCN®, is the administrator in the Joan Karnell Cancer Center at Pennsylvania Hospital; Christine Huntzinger, MPT, CCI, is the lead therapist of inpatient rehabilitation services at Good Shepherd Penn Partners; Theresa Alcorn, BA, is a cancer center assistant in the Joan Karnell Cancer Center at Pennsylvania Hospital; Joan Levicoff, MA, is a site manager and speech-language pathologist at Good Shepherd Penn Partners; Carly Roop, RD, LDN, is a nutrition counselor in the Joan Karnell Cancer Center at Pennsylvania Hospital; and David Mintzer, MD, is a medical director of the Pain and Supportive Care Program at Pennsylvania Hospital, all in Philadelphia, PA. (First submission April 2009. Revision submitted May 2009. Accepted for publication June 14, 2009.) Digital Object Identifier: 10.1188/10.CJON.72-80

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At a Glance F Many patients with cancer experience some degree of cachexia caused either directly by the tumor or by the treatment. F Cancer cachexia may negatively impact the results of treatment through delayed or missed therapy sessions. F An interdisciplinary team approach may improve symptom management, function, nutrition, and quality of life in patients with cancer cachexia.

as well as potentially life-threatening metabolic disturbances. In addition, impaired nutritional status and protein deficiency can affect response to chemotherapy and increase toxicity to therapy, leading to increased morbidity and mortality (Langer, Hoffman, & Ottery, 2001; Mattox, 2005; Slaviero et al., 2003). Patients with cancer cachexia also may have decreased quality of life (QOL), particularly in physical, psychological, and social functioning (Brown, 2002). Patients with cancer cachexia experience symptoms associated directly with the cancer and/or the cancer treatment. Anorexia, or lack of appetite, the most common symptom in cancer cachexia, usually is associated with gastrointestinal symptoms (i.e., nausea, vomiting, and change in taste) and other symptoms (i.e., pain, dyspnea, and delirium) (Armes, Plant, Allbright, Silverstone, & Slevin, 1992; Davis, 2005). Impaired oral intake and impaired gastrointestinal absorption are caused by treatment and/or tumor-related symptoms. Cancer treatments (surgery, chemotherapy, radiation therapy), particulalry to the oral cavity and esophagus, may lead to mucositis, dysphagia, odynophagia, and xerostomia. Mechanical interference of the alimentary and gastrointestinal tracts caused by a malignant tumor may lead to poor oral intake and malnutrition (Perez, Newcomer, Moertel, Go, & Dimagno, 1983; Ramot, 1971). Other factors contributing to impaired oral intake are emotional distress, depression, and social and financial issues (Strasser & Bruera, 2002). The general approach to the management of cancer cachexia is based on the understanding of its multifactorial origin. Cancer cachexia originates from a combination of factors including reduced dietary intake, deficiency in the anabolic endocrine setting, hyperexpression of catabolic elements, lack of physical activity, and presence of comorbid conditions (Baracos, 2006). Unfortunately, no single agent has been found to be effective in treating cancer cachexia. Several authors have recommended implementation of a combination of modalities with an experienced interdisciplinary team (Ottery, Sljuka, & Hagan, 1995; Stewart et al., 2006; Strasser & Bruera, 2002). Patients with cancer cachexia should be enrolled in programs that address various aspects of patient care, including early detection of the issue; correction of secondary causes (physical and emotional symptoms); inclusion dietary counseling and other nutritional interventions; exercise to maintain muscle mass; and use of drug combinations that increase anabolism, reduce muscle proteolysis, and reverse the inflammatory state of cancer cachexia (MacDonald, 2007). This article describes the process of developing and implementing a cancer cachexia clinic at an urban cancer center. The clinic was initially developed as a pilot project that demonstrated

satisfactory patient outcomes and later became an established service to patients with cancer at high risk for or experiencing cachexia. One goal of this article is to show that this interdisciplinary clinic model could be replicated in other cancer care settings. This article also will demonstrate the importance of a multidisciplinary approach to the issue of cancer cachexia and the vital role that each individual team member plays in the success of the model.

Planning and Organization In 2007, the Palliative Care Program at the Joan Karnell Cancer Center (JKCC) at Pennsylvania Hospital in Philadelphia developed a cancer cachexia clinic called the Cancer Appetite and Rehabilitation (CARE) Clinic to diminish the effects of cancer cachexia and improve nutrition, function, symptom management, and QOL of patients with cancer. The goals of the CARE Clinic are to prevent or reverse the progressive weight loss in patients with cancer when possible; to prevent unnecessary loss of function and restore normal or near-normal function through an individualized rehabilitation program; to provide strategies to maximize safety, efficiency, and enjoyment of oral nutrition intake; to manage cancer-related fatigue; and to improve the QOL of patients by providing symptom management and psychological, social, and spiritual care. JKCC is an urban community cancer center with approximately 1,400 new cancer cases annually. The palliative care team noted that a large number of patients receiving cancer treatment experienced anorexia, cachexia, fatigue, dysphagia, and other symptoms that were difficult to address in one visit. Patients would need several referrals to multiple disciplines (i.e., speech and swallowing therapy, physical therapy, and nutrition) to manage their symptoms in a comprehensive manner. Some patients with transportation or financial issues would choose not to comply with their referral appointments, leading to an incomplete management of their symptoms. The cancer cachexia clinic was developed as a strategy to meet patients’ needs; patients would be evaluated by an interdisciplinary team in one coordinated, seamless visit.

• • • • • • • •



Involuntary weight loss greater than 5% within the past six months Increased fatigue Signs of cachexia, such as temporal wasting and clavicle prominence Difficulty with function and activities of daily living Patients at high risk for cancer cachexia, such as those with head and neck cancers, lung cancer, and gastrointestinal cancers Patients with cancer who have completed cancer treatment but have lost weight and are deconditioned For management of difficult or painful swallowing For report of coughing and choking or signs of “silent aspiration,” including shortness of breath, wet vocal quality, watery eyes, and runny nose during or after meals When speech becomes impaired by muscle weakness or change in structure

Figure 1. Quick Checklist for Referral to the Clinic Note. Based on information from Casper & Colton, 1993; Davis, 2005; DeWys et al., 1980; Ottery, 1996; Steele & Fong, 2003; Strasser & Bruera, 2002.

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During the process of implementing the CARE Clinic, proponents needed to consider the administrative and financial feasibility for this project. The cancer center administrator collaborated with the rehabilitation program manager at Pennsylvania Hospital, who agreed to assign a physical therapist and a speech and swallowing therapist to the clinic. The financial support came from a grant from a foundation and was used to pay the hourly rate of one physical therapist and one speech and swallowing therapist, the cost of parking for patients, and some nutritional supplements. In the second year of funding, a patient navigator was added to assist patients in completing forms and navigating the clinic system. The office visit was billed by the nurse practitioner or the physician. Additional costs for the nurse practitioner, nutritionist, program assistant, and other palliative care team members were covered by the cancer center as they are salaried employees.

Cancer Appetite and Rehabilitation Clinic Model The clinic’s interdisciplinary model includes a physician, a nurse practitioner, a nutritionist, a physical therapist, a speech

and swallowing therapist, a patient navigator, and a program assistant. The clinic is open to patients with any cancer diagnosis but prioritizes patients at high risk for cachexia and fatigue, such as those with head and neck cancer, lung cancer, and gastrointestinal cancer. Patients with cancer are referred to the CARE Clinic by any healthcare provider or are self-referred. The criteria for patient referral to the CARE Clinic are described in Figure 1. The organization of the clinic is critical to provide an effective service. The clinic runs one afternoon per week with a maximum of six patients per session. The duration of each clinic visit is 45–90 minutes. Patients are scheduled by the program assistant. The patient navigator assists patients with the completion of assessment tools and makes sure that the clinic runs smoothly. A medical assistant takes patients’ vital signs and blood work. Three examination rooms are available for the clinic, allowing three patients to be seen simultaneously by the physician, the nurse practitioner, the nutritionist, the physical therapist, and the speech therapist.

Table 1. Interdisciplinary Assessment and Treatment Goals Department

Assessment

Treatment Goals

Medical and nursing

General information: cancer diagnosis and stage, cancer treatment, and current medications Physical symptoms: gastrointestinal symptoms associated with cancer or treatment, pain, dyspnea, and fatigue Psychosocial issues: delirium, anxiety, depression, coping with changes in self-image, financial, and spiritual and religious Assessment: Edmonton Symptom Assessment Scale, performance status (Karnofsky), and complete physical examination and baseline laboratory tests for renal and liver function

To improve symptom management and quality of life by using various pharmacologic approaches, including orexigenic drugs (appetite stimulants), prokinetic drugs (improve bowel motility), and anabolic agents (enhance muscle growth and strength)

Nutrition

Weight history: usual body weight and weight changes Caloric or protein intake: 24-hour recall and indirect calorimetry Anthropometry: current weight and height, bioelectrical impedance analysis, mid-arm circumference, and skin-fold thickness (scapular, triceps, and biceps) Assessment: laboratory tests for nutritional parameters

To meet patient’s nutrition goals through food texture modification, alternative methods of nutrition support, and use of nutritional supplements when appropriate

Physical therapy

History: previous and current level of function, fatigue pattern, and sleep pattern Occupation: home setup and equipment needs Physical examination: range of motion testing, manual muscle testing, postural assessment, gait analysis, and endurance testing Assessment: identifying impairments that can improve with physical therapy intervention

Plan and goals: fatigue management, improved muscle strength and tone, improved posture, improved range of motion, individualized home exercise program, and patient education on energy-conservation techniques and ways to safely increase activity

Speech and swallowing therapy

Evaluation components: detailed medical and social history; physical examination, including oromotor assessment, strength, coordination, and sensitivity; frequency and ease of spontaneous swallow; secretion management; respiratory support; laryngeal examination, including vocal quality, strength and length of phonation, strength of cough, dynamic range, and vocal intensity; functional assessment of swallow with trials of varying liquid viscosities and food textures; and use of instrumental testing as needed, such as the Modified Barium Swallow Study and Fiberoptic Examination of Swallowing Symptoms: xerostomia, odynophagia, dysphagia, dysarthria, dysphonia, aphonia, respiratory changes, gastro-esophageal reflux disease, taste loss, and food or texture aversions

Intervention strategies: alternative or augmentative communication, including alaryngeal communication, use of voice prosthesis, and heat moisture exchange systems Direct and indirect therapy: oropharyngeal strengthening, range of motion and/or coordination exercises, sensory stimulation, diet modification, positional modifications during nutritional intake, education regarding safety, aspiration risk factors, function, and oral care specific to cancer treatment Referrals: otorhinolaryngology, gastrointestinal, pulmonary, and support groups

Note. Based on information from Adams et al., 2009; American Physical Therapy Association, 2001; American Speech-Language-Hearing Association, 2000, 2004a, 2004b, 2005, 2006, 2007; Blom et al., 1998; Casper & Colton, 1993; Del Fabbro et al., 2006; Elliott et al., 2006; Fearon & Moses, 2002; MacDonald, 2007; National Comprehensive Cancer Network, 2009; Ottery et al., 1995; Portenoy & Itri, 1999; Stewart et al., 2006; Strasser & Bruera, 2002; Watson & Mock, 2004; Zinna & Yarasheski, 2003. 74

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Patient name: Date: Summary notes: Please see additional information provided for detailed recommendations. Pain and symptom management: Consultation: Prescriptions: Pain: Nausea: Appetite: Bowel management: Other: Nutritional therapy: Calories: Nutrition goals: Supplementation:

Protein:

Speech pathology: q Aspiration precautions q Reflux precautions Diet modification necessary? q No q Yes Compensatory strategies: q Required

Medical and Nursing Assessment The physician and/or the nurse practitioner perform a complete history and physical examination. Patient history includes the cancer diagnosis, current cancer treatment, current medications, prior cancer diagnosis, weight loss, anorexia, and any related symptoms. At each visit, a patient’s symptoms are measured by the Edmonton Symptom Assessment Scale (ESAS) to monitor any symptom changes (Chang, Hwang, & Feuerman, 2000). Functional status is measured by the Karnofsky performance status tool (Karnofsky, Abelmann, Craver, & Burchenal, 1948). On physical examination, cachetic patients may present with loss of muscle mass indicated by temporal wasting and poor muscle tone. Skin may be dry with poor turgor and nails may be brittle. An oral examination may reveal poor dentition, lesions, and dry mouth (Ottery, 1996). The treatment plan addresses symptom management by using various pharmacologic approaches.

Nutrition

The registered dietitian assesses a patient’s weight history based on the patient’s usual body weight. A weight loss of more than 10% over six months or weight Medications: q Take as indicated q Take medications with thick liquids or puree loss of more than 5% in one month places the patient q Crush q Therapeutic swallowing at nutritional risk. The patient’s body composition is Exercise: assessed with bioelectrical impedance analysis. This Voice recommendations: q Increase hydration q Vocal rest assessment uses an electrical current to distinguish the q Vocal amount of muscle, fat, and fluid in the body. Analysis can Exercise: be conducted in an office setting using a commercially Physical therapy: available analyzer. Laboratory values are obtained to q Home exercise program given for upper/lower extremity q Theraband given assess nutritional status and include serum albumin, preq Energy-conservation techniques q Walking diary albumin, testosterone, and vitamin D (Elliott, Molseed, q Increasing postural awareness & Davis McCallum, 2006). Pre-albumin has a half-life of Recommendations: 2–3 days, which makes it a better indicator of dietary q Outpatient physical therapy q Home physical therapy change than albumin, which shows overall nutritional q Occupational therapy q Lymphedema status. Fatigue, decreased libido, erectile dysfunction, Therapy: loss of muscle mass and muscle strength, and depresq Equipment sion may indicate low serum testosterone, which can be corrected (Wang et al., 2000). Needs: Vitamin D deficiency has been found to be extremely q Other: common because of low dietary intake and inadequate Return for a follow-up visit in ______ weeks. sun exposure or avoidance (Krueger & Binkley, 2006). Additional notes: Vitamin D deficiency is associated with conditions such as rickets and osteoporosis as well as muscle Figure 2. Cancer Appetite and Rehabilitation Clinic Evaluation weakness and an increase in falls. Ionized calcium and Form 1,25(OH)2D are involved locally in cell growth and cell Note. Reprinted with permission from the Joan Karnell Cancer Center at Pennsylvania differentiation. In the U.S., an increased prevalence Hospital. and/or mortality for 13 cancers (breast, colon, ovary, prostate, non-Hodgkin lymphoma, bladder, esophagus, kidney, lung, pancreas, rectum, stomach, and uterus) Interdisciplinary Assessment and Treatment Plan have been identified with low ultraviolet B exposure (Grant, 2002). In addition, vitamin D has demonstrated antiproliferaAt the CARE Clinic, patients with cancer undergo a compretive, proapoptotic, and antiangiogenetic effects on cancer cells. hensive symptom assessment followed by an individualized Therefore, patients are routinely tested for vitamin D deficiency treatment plan (see Table 1). Although patient assessment and repleted with high-dose vitamin D supplementation of categories may be similar among the disciplines with some 50,000 IU for three days per week for a month until patients are overlap, each discipline has distinctive assessment and treatat an optimal level of 50 ng/ml (Krueger & Binkley, 2006). ment points. q None required

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The registered dietitian then performs a 24-hour recall with the patient to review food choices and amounts. Indirect calorimetry is conducted to determine energy expenditure by measuring a subject’s oxygen consumption, carbon dioxide production, and minute ventilation. The patient’s intake is then compared to requirements and the reason for the weight loss is assessed (Elliott et al., 2006). Once the patient’s nutritional status has been assessed, the registered dietitian will strategize with the patient to meet estimated nutrition requirements. The goal is to manage patient side effects and replete malnourished patients through dietary change, nutritional supplements, or pharmacologic agents.

Physical Therapy The role of physical therapy in the CARE Clinic is to help patients regain their previous level of function by decreasing fatigue while building strength and overall endurance. The physical therapy initial evaluation consists of four different sections, including a thorough patient history, physical examination, assessment, and plan and goals (American Physical Therapy As-

Activities

sociation, 2001). The patient history section includes a detailed medical history along with the patient’s previous and current level of function, fatigue pattern, sleep pattern, occupational status, and home setup (Portenoy & Itri, 1999). The physical examination focuses on range of motion and manual muscle strength testing, including the upper and lower extremities as well as the spine. The patient’s posture and functional mobility also are assessed with a focus on gait analysis and endurance testing with a pulse oximeter. After all of this information is collected, an assessment is made to identify the patient’s functional impairments that can be improved with physical therapy intervention. The assessment also incorporates the patient’s personal goals. A plan of care then is determined by the physical therapist to work on these impairments (National Comprehensive Cancer Network, 2009; Watson & Mock, 2004). The main goals of physical therapy are to provide the patient with an individualized home exercise program, to educate the patient on ways to manage his or her fatigue by using energyconservation techniques and making simple lifestyle changes, to increase muscle strength and tone, to educate the patient on ways to safely increase his or her activity levels, and to educate the patient’s family on ways they can safely assist the patient on his or her Team Members rehabilitation program.

Speech and Swallowing Therapy

Patient arrival to CARE Clinic

• Complete Edmonton Symptom Assessment Scale questionnaire. • Blood work, including complete blood count, renal function, electrolytes, vitamin D, and testosterone • Vital signs • Patient in examination room

Patient navigator or nursing assistant

Interdisciplinary assessment and treatment plan

• Comprehensive patient assessment by each discipline • Ongoing communication among CARE Clinic team members after each patient assessment. Need for additional diagnostic tests is discussed (i.e., laboratory workup, barium swallow test, or chest x-ray). • CARE Clinic team rounds at the end of clinic to discuss treatment plan for each patient.

Nurse practitioner, physician, nutritionist, physical therapist, speech and swallow therapist

Patient and family education

A summary treatment form is provided to patient and family.

Patient navigator, nurse practitioner, physician, nutritionist, physical therapist, speech and swallow therapist

Follow-up visit

A follow-up appointment is scheduled based on a patient’s needs.

Palliative care assistant

Figure 3. Cancer Appetite and Rehabilitation (CARE) Clinic Pathway 76

According to the American SpeechLanguage-Hearing Association ([ASHA], 2007), the overall objective of speechlanguage pathology services is to optimize an individual’s ability to communicate and swallow, thereby improving QOL. Evaluation by a speech therapist begins with completion of medical and social history, as well as a thorough discussion of the individual’s chief complaints. This communication enables the therapist to evaluate a patient’s safety and function while ensuring that intervention will meet the unique needs of each patient. The evaluation includes symptom assessment, oromotor assessment, laryngeal examination, and functional assessment of swallow. Therapeutic intervention frequently is initiated during this visit. Together, the individual and therapist develop a plan of care which targets the individual’s needs and addresses concerns. Often symptom management becomes a primary goal and discussion of long-term modifications begin.

Interdisciplinary Treatment Plan The interdisciplinary treatment plan includes pharmacologic and nonpharmacologic approaches to symptom

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Table 2. Administration Evaluation Obstacle

Patients waiting too long in the waiting room

Actions

Inform patients in advance about the duration of the clinic. Meet with medical assistants to make the blood draw and vital signs process more efficient. Use a card system in examination rooms during clinic to identify who has seen the patient.

No written information to patients

Give folder with written information for new patients. Provide treatment summary form to patients at each visit.

Patients referred too late

Meet with oncologists, nurse practitioners, and nurses to promote clinic. Advertise clinic to patients and families.

Patients not completing assessment tools

Have a clinic navigator available to help patients complete the form.

Patients not compliant

Satisfaction survey

management, nutrition, physical therapy, and speech or swallowing therapy. The pharmacologic treatment may include progestational agents, glucocorticoids, canabinoids, antidepressants, prokinetic agents, and anabolic steroids. Nonpharmacologic treatments may include exercise programs, mouth and swallowing exercises, and nutrition counseling (Adams et al., 2009; Fearon & Moses, 2002; Gagnon & Bruera, 1998; MacDonald, 2007; Mattox, 2005; Orr & Fiatarone, 2004; Osei-Hyiaman, 2007; Ottery et al., 1995; Stewart et al., 2006; Strasser & Bruera, 2002; Tisdale, 2006; Zinna & Yarasheski, 2003). Occasionally, patients are referred to other palliative care disciplines for psychosocial counseling. A summary treatment form is provided to the patient explaining his or her individualized treatment plan (see Figure 2). The patient’s family is always involved in the teaching process. The CARE Clinic is a unique process because of the length of the visit and the number of providers involved; therefore, it requires constant communication and coordination among the team members to meet the patient’s needs in an efficient and timely manner. This process is described in Figure 3. Coordination of patient care is accomplished by the constant communication among the CARE Clinic team throughout the duration of the clinic and by “CARE Clinic rounds,” which is an interdisciplinary meeting at the end of the day where the plan of care of each patient seen at the clinic is discussed. The care plan is shared with the referring physician or nurse practitioner, primary oncology team, and other care providers requested by the patient through the shared electronic medical record and a letter to the providers.

Clinic Evaluation The CARE Clinic was initiated in April 2007 as a nine-month pilot project. The project evaluation was performed on a regular basis throughout 2007, and a final report was produced

at the nine-month benchmark. The evaluation reviewed the clinic’s various aspects, including administration, clinic characteristics, patient outcomes, and patient satisfaction. Given the favorable results of the pilot project, the CARE Clinic was funded and fully implemented. The CARE Clinic currently is one of the palliative care services offered to patients attending the cancer center.

Administration A number of administrative and logistical obstacles were identified during the clinic’s implementation process, including long waits, patients referred too late to benefit from the clinic (many appropriate for hospice referral), burden on patients to complete the symptom and QOL assessment tools, and patients’ noncompliance in keeping appointments. Corrective actions had already taken place by the end of the nine months (see Table 2). Additional funding was sought and obtained through a local foundation, enabling the hiring of a clinic navigator to assist patients and improve the efficiency of the clinic visit.

Demographics From April 2007–April 2009, 96 patients were seen at the CARE Clinic. Patient characteristics are summarized in Table 3. Most patients were male (64%), Caucasian (73%), and within the 50–59 age range (42%). The main cancer types included head and neck, gastrointestinal, and lung. Current clinic activity shows that 21 patients are active (attending clinic), 39 are inactive (reasons include return to work, health improved, transportation, insurance, financial issues, noncompliance, or too ill), and 35 patients are deceased.

Table 3. Sample Characteristics Characteristic

Age (years) 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 Gender Male Female Ethnicity Caucasian African Hispanic Indian Cancer type Head and neck Lung Gastrointestinal Noncancers Gynecologic Others

n

1 – 4 16 40 24 8 3 61 35 70 22 3 1 33 12 14 2 13 22

N = 96

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Patient Outcomes

Changes in weight

Patient Satisfaction

Weight (pounds)

200 150 100 50 0

1

2

3

4

5 6 7 8 Patient Number

Weight at visit 1

9

10

11

Weight at visit 4

Changes in body cell mass (BCM) 120 100 80 60

1

2

3

4

5 6 7 Patient Number

BCM at visit 1

8

9

10

BCM at visit 4

Implications for Oncology Nurses Malnutrition is associated with increasing morbidity and mortality in patients with cancer (Andreyev, Norman, Oates, & Cunningham, 1998). An interdisciplinary cancer cachexia clinic is a strategy to improve symptoms and QOL of patients with cancer at high risk for malnutrition. Given that cancer cachexia has a multifactorial etiology, a multimodality approach should be used to address such a complex syndrome. Although the CARE Clinic is led by an advanced oncology nurse practitioner, it does highlight the importance of collaboration among disciplines. Each member of the interdisciplinary team is critical for the CARE Clinic to succeed, as each discipline offers specific assessment skills and treatment strategies. Oncology nurses play a key role in the management of cancer cachexia by understanding the significance of this cancer symptom and by identifying patients with nutritional issues at an early stage. Oncology nurses who work directly with patients on a daily basis, including chemotherapy nurses and oncology nurse

Edmonton Symptom Assessment Scale

Changes in anorexia

A CARE Clinic patient satisfaction survey was conducted through a telephone interview at the end of the nine-month pilot project. The project-developed tool is a 20-item questionnaire based on a four-point Likert scale rating scheduling appointments, contact with reception staff, ease in completing symptom assessment forms, evaluation and intervention by each team member, and communication or recommendations provided at the clinic. To view the questionnaire, see Appendix A in the online version of this article at http://ons.metapress.com/content/1092-1095. Twenty-five patients completed the interview. Overall, most patients felt that the CARE Clinic was a worthwhile experience and all patients said they would recommend the clinic to a friend.

78

250

BCM (%)

Data collection to measure patient outcomes was completed at each clinic visit. Parameters to measure patient outcomes included symptom assessment using the ESAS; performance status using the Karnofsky performance scale; nutrition using weight, body cell mass (BCM), and caloric goal; and laboratory tests (complete blood count, renal function, liver function, albumin, pre-albumin, testosterone level, and vitamin D level). The primary goal of data collection was to evaluate the effectiveness of treatment plans on an individual basis rather than to conduct clinical research. During the pilot project, the authors looked at nutritional parameters (weight and BCM) and symptom distress (ESAS) for the group of patients with cancer who attended the CARE Clinic at least four times (N = 11). At each visit, patients were asked to rate their symptoms from 0 (no symptom) to 10 (worst symptom) by using the ESAS instrument. Although not statistically significant, a trend for improvement was observed between visit 1 and visit 4 in weight, BCM, and appetite levels (see Figure 4). Additional research with randomized, controlled trials is necessary to identify the patient groups who would benefit most from the CARE Clinic, measure patient outcomes, and determine the effectiveness of the interdisciplinary interventions provided at the CARE Clinic.

10 9 8 7 6 5 4 3 2 1 0

1

2

3

4 5 6 Patient Number

Anorexia at visit 1

7

8

9

Anorexia at visit 4

Note. N = 11, with one patient not reporting information for changes in BCM and two patients not reporting information for changes in anorexia.

Figure 4. Changes Between Visit 1 and Visit 4 in Patients Attending the Cancer Appetite and Rehabilitation Clinic

practitioners, are particularly well positioned to impact the issue of cancer cachexia. This article has demonstrated that implementation of a cancer cachexia clinic initiative is appropriate and achievable by oncology nurses in collaboration with colleagues from nutrition and physical medicine. Proactive, multimodality interventions to address cancer cachexia are an integral part of cancer therapy with the aim of improving clinical outcomes and QOL.

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Case Study The following case study describes the interdisciplinary assessment and interventions at the Cancer Appetite and Rehabilitation (CARE) Clinic. V.T. was a 50-year-old Caucasian man who presented to the CARE Clinic in October 2007. He admitted to rare cigarette use and one or two drinks daily. He was married with no children and employed as a research laboratory supervisor in a university hospital. No significant history of cancer existed in the family. He had a history of stage IVb squamous cell carcinoma of the base of the tongue with bulky bilateral cervical node metastases and pulmonary embolism. His completed treatments were induction chemotherapy with cisplatin, docetaxel, and 5-fluorouracil, followed by concurrent chemoradiotherapy. All therapies were completed in October 2007. V.T. participated in the CARE Clinic for four visits from October 2007–January 2008. His primary goal was to become reconditioned enough to return to work on a part-time basis. He accomplished this goal early in November. He was back to work full-time by the end of December with marked improvement in his level of fatigue and appetite. First visit, week 1: V.T. presented with dysphagia, mucositis, persistent cough, anorexia, and weight loss. He received about 50% of his nutrition via a percutaneous endoscopic gastrostomy (PEG) tube and experienced nausea and early satiety after each feeding. He was assessed to be severely malnourished with an 18% weight loss, 90% lean muscle mass (per bioelectrical impedance analysis), and deconditioning. To address the oral pain and thick mucus, the patient was started on liquid morphine and guifenesin. He was already using viscous lidocaine. He was instructed to follow intensive oral care (mouth rinses). To help him achieve 100% of his nutrition needs via tube feeding, metoclopramide was started prior to feedings. The patient was educated on fatigue management and energy-conservation techniques,

The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Author Contact: Clara Granda-Cameron, MSN, CRNP, AOCN®, can be reached at [email protected], with copy to editor at CJONEditor @ons.org.

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February 2010 • Volume 14, Number 1 • Clinical Journal of Oncology Nursing

We hope your participation in the CARE Clinic was a worthwhile experience. We are committed to providing you with the best service possible. Your honest assessment of the CARE Clinic will help ensure the continued high quality of our program. The information you provide will not become part of your clinical record. Patient name: Visit date(s):

Very Satisfied

Somewhat Satisfied

Somewhat Dissatisfied

Very Dissatisfied

Strongly Agree

Agree

Disagree

Strongly Disagree

Scheduling appointments 1. Helpfulness of scheduling coordinator 2. Ease in setting up appointments 3. Waiting time to schedule appointments Contact with cancer center reception staff 4. Helpfulness of reception staff 5. Ease in checking in for appointments 6. Waiting time to see professional staff after checking in Ease or difficulty in completing quality-of-life questionnaires 7. Length of questionnaires 8. Ease in filling out questionnaire and understanding questions 9. Nutritional evaluation and intervention 10. Physical therapy evaluation and intervention 11. Occupational therapy evaluation and intervention 12. Swallowing therapy evaluation and intervention 13. Symptom assessment and intervention by nurse practitioner 14. Symptom assessment and intervention by physician

15. Professional staff was able to communicate information in a clear and meaningful way. 16. Attention was focused on my concerns during appointments. 17. There was enough time to ask questions and get answers from professional staff. 18. My participation in the CARE Clinic has been a worthwhile experience. 19. I would recommend the CARE Clinic to a friend. 20. Any additional comments and/or suggestions:

Appendix A. Cancer Appetite and Rehabilitation (CARE) Clinic Evaluation Form Note. Reprinted with permission from the Joan Karnell Cancer Center at Pennsylvania Hospital.

Clinical Journal of Oncology Nursing • Volume 14, Number 1 • An Interdisciplinary Approach to Manage Cancer Cachexia