Current Challenges in Digital Representation of Variation in Cancer Care.

Advances in cancer treatment have improved patient outcomes and survival in recent decades. Increased complexity, duration, and individualisation of treatment protocols present an important challenge for care teams monitoring adherence to best-practice care. A rigid rules-based system for flagging outliers is not fit for purpose, as there are sound reasons for deviating from baseline protocols, such as the management of treatment side effects to a tolerable degree, however the methods for determining the bounds of appropriateness for variation are not well studied or understood. The development of digital representations to inform cancer care delivery in a timely and continuing manner is crucial. This scoping review seeks to identify gaps in current methods and propose a novel approach to digitally represent patient journeys in clinically meaningful visual and computational forms. These methods can be combined to produce real-time, clinically applicable tools such as group-level business-intelligence dashboards (are processes and resources adequate to ensure that patients are being treated according to best practice?) as well as individual-level decision support (what is the likely outcome for this patient if treatment is stopped early based on prior data?) and day to day clinical workflows (what has happened to this patient so far?).

Poor nutrition status associated with low patient satisfaction six months into treatment for head and neck/esophageal cancer treatment: A prospective multicenter cohort study.

BACKGROUND: Patient-reported outcome measures have been associated with survival in oncology patients. Altered intake and malnutrition are common symptoms for patients treated for head and neck cancer and esophageal cancer (HNC/EC). The purpose of this study was to examine the relationship between patient-reported satisfaction with medical care and nutrition status. METHODS: This prospective cohort study collected data from 11 international cancer care sites. RESULTS: One hundred and sixtythree adult patients (n = 115 HNC; n = 48 EC) completed a patient satisfaction questionnaire (the Canadian Health Care Evaluation Project Lite) and were included. HNC/EC patient global satisfaction with medical care was 88.3/100 ± 15.3 at baseline and remained high at 86.6/100 ± 16.8 by 6 months (100 max satisfaction score). Poor nutrition status, as defined by the Patient-Generated Subjective Global Assessment Short Form, was associated with lower patient satisfaction with overall medical care, relationship with doctors, illness management, communication, and decision-making 6 months into treatment (P < 0.01). There was no difference in global satisfaction between patients who did and did not report swallowing difficulty (P = 0.99) and patients with and without feeding tube placement (P = 0.36). Patients who were seen by a dietitian for at least one nutrition assessment had global satisfaction with care that was 16.7 percentage points higher than those with no nutrition assessment (89.3 ± 13.8 vs 72.6 ± 23.6; P = 0.005) CONCLUSION: In HNC/EC patient-centered oncology care, decreasing malnutrition risk and providing access to dietitian-led nutrition assessments should be prioritized and supported to improve patient satisfaction and standard of care. Feeding tube placement did not decrease patient satisfaction with medical care.

Quantifying the severity of sarcopenia in patients with cancer of the head and neck.

BACKGROUND & AIMS: Existing skeletal muscle index (SMI) thresholds for sarcopenia are inconsistent, and do not reflect severity of depletion. In this study we aimed to define criterion values for moderate and severe skeletal muscle depletion based on the risk of mortality in a population of patients with head and neck cancer (HNC). Additionally, we aimed to identify clinical and demographic predictors of skeletal muscle depletion, evaluate the survival impact of skeletal muscle depletion in patients with minimal nutritional risk or good performance status, and finally, benchmarking SMI values of patients with HNC against healthy young adults. METHODS: Population cohort of 1231 consecutive patients and external validation cohorts with HNC had lumbar SMI measured by cross-sectional imaging. Optimal stratification determined sex-specific thresholds for 2-levels of SMI depletion (Class I and II) based on overall survival (OS). Adjusted multivariable regression analyses (tumor site, stage, performance status, age, sex, dietary intake, weight loss) determined relationships between 2-levels of SMI depletion and OS. RESULTS: Mean SMI (cm2/m2) was 51.7 ± 9.9 (males) and 39.8 ± 7.1 (females). The overall and sex-specific population demonstrated an increased risk of mortality associated with decreasing SMI. Sex-specific SMI (cm2/m2) depletion thresholds for 2-levels of muscle depletion determined by optimal stratification for males and females, respectively (male: 45.2-37.5, and <37.5; female: 40.9-34.2, and <34.2). In the overall population, Normal SMI, Class I and II SMI depletion occurred in 65.0%, 24.0%, and 11.0%, respectively. Median OS was: Normal SMI (114 months, 95% CI, 97.1-130.8); Class I SMI Depletion (42 months, 95% CI, 28.5-55.4), and Class II SMI Depletion (15 months, 95% CI, 9.8-20.1). Adjusted multivariable analysis compared with Normal SMI (reference), Class I SMI Depletion (HR, 1.49; 95% CI, 1.18-1.88; P < .001), Class II SMI Depletion (HR, 1.91; 95% CI, 1.42-2.58; P < .001). CONCLUSIONS: Moderate and severe SMI depletion demonstrate discrimination in OS in patients with HNC. Moderate and severe SMI depletion is prevalent in patients with minimal nutrition risk and good performance status. Benchmarking SMI values against healthy young adults exemplifies the magnitude of SMI depletion in patients with HNC and may be a useful method in standardizing SMI assessment.

A Multi-Site, International Audit of Malnutrition Risk and Energy and Protein Intakes in Patients Undergoing Treatment for Head Neck and Esophageal Cancer: Results from INFORM.

Patients with foregut tumors are at high risk of malnutrition. Nutrition care focuses on identifying individuals at risk of malnutrition and optimizing nutrient intake to promote the maintenance of body weight and lean body mass. This multi-center prospective, longitudinal study audited nutrition care practices related to screening for risk of malnutrition (Patient-Generated Subjective Global Assessment Short Form; PG-SGA SF), and nutrition interventions prescribed (route; adequacy of energy and protein intakes). Audits occurred at four time periods: baseline (before treatment) and at 2, 4, and 6 months after starting cancer treatment; 170 patients (esophageal (ESO; n = 51); head and neck (HN; n = 119)) were enrolled. Nutrition risk (PG-SGA SF score ≥ 4) was prevalent at every time period: HN (baseline: 60%; 6 months 66%) and ESO (77%; 72%). Both groups had significant (p < 0.001) weight losses over the 6 month audit period (HN = 13.2% ESO = 11.4%). Enteral nutrition (EN) was most likely to be prescribed at 2 months for HN and at 4 and 6 months for ESO. Target prescribed energy and protein intakes were not met with any nutrition intervention; although adequacy was highest for those receiving EN. Nutrition care practices differed for HN and ESO cancers and there may be time points when additional nutrition support is needed.

Mapping ongoing nutrition intervention trials in muscle, sarcopenia, and cachexia: a scoping review of future research.

Muscle loss alone, or in the context of sarcopenia or cachexia, is a prevalent condition and a predictor of negative outcomes in aging and disease. As adequate nutrition is essential for muscle maintenance, a growing number of studies has been conducted to explore the role of specific nutrients on muscle mass or function. Nonetheless, more research is needed to guide evidence-based recommendations. This scoping review aimed to compile and document ongoing clinical trials investigating nutrition interventions as a strategy to prevent or treat low muscle mass or function (strength and physical performance), sarcopenia, or cachexia. ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform were searched up to 21 April 2021 for planned and ongoing trials. Randomized controlled trials with ≥20 participants per arm were included based on intent to explore the effects of nutrition interventions on muscle-related outcomes (i.e. muscle mass or strength, physical performance, or muscle synthesis rate) in both clinical and non-clinical conditions (i.e. aging). Two reviewers independently screened records for eligibility, and a descriptive synthesis of trials characteristics was conducted. A total of 113 trials were included in the review. Most trials (69.0%) enroll adults with clinical conditions, such as cancer (19.5%), obesity and metabolic diseases (16.8%), and musculoskeletal diseases (10.7%). The effects of nutrition interventions on age-related muscle loss are explored in 31% of trials. Although nutrition interventions of varied types were identified, food supplements alone (48.7%) or combined with dietary advice (11.5%) are most frequently reported. Protein (17.7%), amino acids (10.6%), and ß-hydroxy-ß-methylbutyrate (HMB, 6.2%) are the top three food supplements' nutrients under investigation. Primary outcome of most trials (54.9%) consists of measures of muscle mass alone or in combination with muscle strength and/or performance (as either primary or secondary outcomes). Muscle strength and physical performance are primary outcomes of 38% and 31.9% of the trials, respectively. These measurements were obtained using a variety of techniques. Only a few trials evaluate muscle synthesis rate either as a primary or secondary outcome (5.3%). Several nutrition studies focusing on muscle, sarcopenia, and cachexia are underway and can inform future research in this area. Although many trials have similar type of interventions, methodological heterogeneity may challenge study comparisons, and future meta-analyses aiming to provide evidence-based recommendations. Upcoming research in this area may benefit from guidelines for the assessment of therapeutic effects of nutrition interventions.

Evaluation of the agreement, adoption, and adherence to the evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians.

AIM: Evidence-based guideline translation to practice can improve outcomes but is often impaired by poor implementation. This project aimed to evaluate the implementation of the Evidence-based guidelines for the nutritional management of adult patients with head and neck cancer among Australian dietitians providing clinical care to this population. METHODS: A questionnaire was developed, with face and content validity confirmed by an expert panel (n = 13), to gauge participant perceptions of the guidelines against an implementation evaluation framework. Dietitians were identified through Dietitians Australia and by contacting experts in the field. Eligibility was determined by questionnaire completion and prior guideline awareness. Responses were provided using a 5-point Likert scale. Results were analysed using descriptive statistics; with inferential analysis to determine if demographic information could reveal trends in guideline use and perception. RESULTS: Of the 43 initial respondents, n = 28 completed the questionnaire, with n = 24/28 (86%) meeting full eligibility criteria for analysis. Median (range) scores for all four domains were high: awareness (4.0 [3.2-4.8]), agreement (4.4 [4.1-4.7]), adoption (3.5 [3.1-3.9]), and adherence (4.3 [4.1-4.9]). However, perception of guideline awareness and use among multidisciplinary team colleagues was low (mean 3.2/5.0 and 3.1/5.0, respectively). Dietitians with <10 years' experience had significantly higher perceptions of the guidelines' ability to positively influence practice; support evidence-based practice; and enhance dietitian credibility (P = 0.04) vs dietitians with ≥10 years' experience. CONCLUSION: Dietitians demonstrated high rates of guideline implementation and positive perceptions for its use in clinical practice. Future implementation strategies and evaluation should expand to engage the wider multidisciplinary team and more experienced clinicians.

Nutritional outcomes in patients undergoing transoral robotic surgery for head and neck cancers compared to conventional open surgery. Systematic review.

This systematic review examined nutritional outcomes in patients undergoing transoral robotic surgery (TORS), compared to open surgery (OS) for head and neck cancer. PUBMED, CINAHL, and Web of Science were systematically reviewed. Target nutritional outcomes included: weight, nutritional status, use of enteral feeding, swallowing function/ability, and time to oral diet. Risk of bias was assessed using the risk of bias in non-randomized studies tool, and certainty of evidence was assessed using grading of recommendations, assessment, development, and evaluation (GRADE). Eight studies were included (total n = 608). Compared to OS, TORS probably reduces short- and long-term enteral feeding use or duration (GRADE "moderate" certainty), may reduce time to full swallow ability (GRADE "low" certainty), but it remains uncertain whether TORS reduces long-term patient reported swallowing function or time to oral feeding (GRADE "very-low" certainty). No studies examined nutritional status or weight. There is limited body of evidence examining nutrition outcomes following TORS. Further studies are warranted, which may improve the certainty of evidence and assist in determining the optimal nutrition care for these patients.

Optimal frequency of individualised nutrition counselling in patients with head and neck cancer receiving radiotherapy: A systematic review.

BACKGROUND: Head and neck cancers (HNC) are strongly associated with malnutrition. This systematic review aimed to investigate the optimal frequency of individualised nutrition counselling (INC) pre-, peri- and post-treatment for patients with HNC. METHODS: Pubmed, EMBASE, Cinahl and Scopus were searched from inception through to April 2020 to identify randomised controlled trials (RCTs) that focused on the INC frequency for adult patients with HNC (Registration no. 178868). The outcomes assessed were nutritional status, dietary intake, weight change, treatment interruptions, unplanned hospital admissions, quality of life, complications and morbidity. Certainty of evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). RESULTS: Four RCTs were identified with five papers (n = 500 total participants). The certainty of evidence was 'high' for nutritional status and quality of life, 'moderate' for treatment interruptions and unplanned hospital admissions, and 'low' for percentage weight change, complications/morbidity and dietary intake. Compared to control groups, there were consistent improvements for nutritional status, quality of life, treatment interruptions, unplanned hospital admissions, dietary intake, percentage weight change and morbidity when weekly INC was provided peri-treatment and fortnightly INC was provided post-treatment. No statistical significance was found for treatment interruptions, dietary intake and weight change when INC was provided fortnightly peri-treatment only. There were no RCTs in the current review that offered INC pre-treatment. CONCLUSIONS: This systematic review shows beneficial effects with weekly INC peri-treatment and fortnightly INC post-treatment for patients with HNC in all outcomes studied. Future research should focus on models of care to address the optimal frequency of pre-treatment INC as well as the duration of post-treatment INC.

Computed tomography (CT)-defined sarcopenia and myosteatosis are prevalent in patients with neuroendocrine neoplasms (NENs) treated with peptide receptor radionuclide therapy (PRRT).

BACKGROUND/OBJECTIVES: Neuroendocrine neoplasms (NEN) may predispose patients to malnutrition. CT-defined sarcopenia and myosteatosis are common in other tumour types and recognized adverse prognostic factors. However, the prevalence and prognostic impact of sarcopenia and myosteatosis remain undetermined in NEN patients to date. METHODS: A retrospective study of NEN patients treated with peptide receptor radionuclide therapy (PRRT) at a tertiary institution from 2012 to 2017. Patients with PET/CT imaging at baseline and follow-up were included. The L3 slice of the co-localizing CT was analysed using the Alberta Protocol. Skeletal muscle cross-sectional area and muscle attenuation were measured and compared with pre-defined cut-offs. The primary endpoint was the prevalence of sarcopenia and myosteatosis according to previously published cut-offs. RESULTS: Fourty-nine patients (median age 64 (range 26-80) years) were included. The most common primary sites of tumour were the small bowel (51%) and pancreas (26%). Baseline sarcopenia was prevalent in 67% of patients and myosteatosis in 71%. Forty-five percent of patients gained weight over the course of PRRT. The presence of baseline sarcopenia was not associated with progression-free survival (20.8 mo vs. 20.7 mo, HR 0.86, p = 0.70) nor overall survival. Similarly, baseline myosteatosis (PFS 19.5 mo vs. 20.8 mo, HR 0.77, p = 0.47) was not significantly associated with survival outcomes. The mean (SD) age of those with myosteatosis was 60.8 ± 11.6 years compared to 49.7 ± 12.7 years for those without (p = 0.003). CONCLUSIONS: Body composition analysis is feasible using routinely acquired PET/CT data for patients with NEN. CT-defined sarcopenia and myosteatosis are prevalent in NEN patients, although myosteatosis is more common with increasing age. These findings were not associated with worsened overall or progression-free survival in the current study.

Comparison of prophylactic percutaneous endoscopic gastrostomy with reactive enteral nutrition in patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy: A systematic review.

BACKGROUND & AIMS: Nutrition support is frequently indicated in patients with head and neck cancer (HNC). However, the optimal timing of enteral tube placement and feeding commencement is unknown. This review aims to compare the outcomes for patients with HNC undergoing curative intent radiotherapy (RT) or chemoradiotherapy (CRT) receiving either prophylactic percutaneous endoscopic gastrostomy (pPEG) tube placement/feeding or reactive enteral nutrition (rEN). METHODS: A literature search was conducted in March 2020 across PubMed, CINAHL, Embase, Web of Science, and Scopus. Randomized controlled trials (RCTs) of patients (≥18 years) with HNC who had received either pPEG or rEN were included. Outcomes examined were weight change, nutritional status, body mass index, treatment interruptions, quality of life (QoL), disease-free survival and overall survival. Study quality and certainty of evidence were assessed using the Cochrane Risk-of-bias Tool for Randomized Trials Version 2 and the Grading of Recommendations Assessment, Development and Evaluation system, respectively. RESULTS: Five studies (three RCTs) (n = 298) were included and definitions of pPEG and rEN were heterogenous. pPEG was associated with a clinically important reduction in short-term critical weight loss (>10% weight loss), and significantly improved short-term QoL in patients with HNC. The timing of nutrition support commencement had no effect on all other outcomes. The overall certainty of evidence was 'moderate' for: nutritional status; treatment interruptions; short-term QoL; disease-free survival; and 'low' for all other outcomes. CONCLUSIONS: Patients with HNC undergoing RT or CRT receiving pPEG tube feeding/placement were less likely to experience short-term critical weight loss and have improved short-term QoL compared to rEN. Further well-designed RCTs with consistent definitions of tube feeding protocols and the use of validated tools to evaluate nutritional status, will assist to increase the certainty of evidence and confirm the beneficial effects observed.

Nutritional status and skeletal muscle status in patients with head and neck cancer: Impact on outcomes.

BACKGROUND: Computed tomography (CT)-defined skeletal muscle depletion and malnutrition are demonstrated as poor prognostic factors in patients with head and neck cancer (HNC), however to date, have only been explored in isolation. We aimed to describe body composition profile and examine the impact of nutritional status as well as independently and concurrently occurring body composition features on overall survival, treatment completion, unplanned admissions and length of stay (LOS) in patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT) of curative intent for HNC. METHODS: This work is a retrospective, observational study of patients who had completed treatment of curative intent for HNC. Scored Patient-Generated Subjective Global Assessment (PG-SGA) was used to determine nutritional status. Tissue-density data were derived at the third lumbar vertebra (L3) with sarcopenia and myosteatosis defined by published, sex-specific threshold values stratified by body mass index for skeletal muscle index (cm2 /m2 ) and skeletal muscle radiodensity (SMR, Hounsfield Unit). RESULTS: Pre-treatment data (n = 277: 78% male, mean (SD) age 60 (13) years) revealed the prevalence of malnutrition (24.9%), sarcopenia (52.3%), myosteatosis (82.3%), and concurrently occurring sarcopenia and myosteatosis (39.7%). Malnutrition was independently associated with reduced OS for patients with moderate [hazard ratio (HR) 2.57; 95% confidence interval (CI) 1.45-4.55, P = 0.001] and severe (HR 3.19; 95% CI 1.44-7.07, P = 0.004) malnutrition on multivariable analysis but not sarcopenia (HR 1.09; 95% CI 0.70-1.71), P = 0.700 or myosteatosis (HR 1.28; 95% CI 0.57-2.84), P = 0.500). Malnutrition was associated with treatment discontinuation (P < 0.001), not completing RT as planned (P < 0.001), unplanned hospital admission (P = 0.021), and greater LOS (P < 0.001). Skeletal muscle status features were associated with unplanned hospital admissions for those with no features (32%), with sarcopenia only (50%), myosteatosis only (25%), and concurrent sarcopenia and myosteatosis (50%), P < 0.001. Similarly, a clinically relevant greater median (Q1, Q3) LOS was observed for those with sarcopenia only [5 (3, 32)], myosteatosis only [10 (5, 30)], concurrent sarcopenia, and myosteatosis [14 (4, 33)] days vs. those with no features [3 (2, 11)] days, P = 0.2. CONCLUSIONS: Malnutrition was a more powerful prognostic indicator than CT-defined skeletal muscle depletion and was independently associated with reduced OS in patients undergoing RT or CRT of curative intent for HNC. CT-defined skeletal muscle depletion studies should recognize the multifaceted nature of human body composition and also measure nutritional status using validated methods in order to move towards developing a typology of high risk criteria for this complex patient group.

The effect of timing of enteral nutrition support on feeding outcomes and dysphagia in patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy: A systematic review.

BACKGROUND & AIMS: Patients with head and neck cancer (HNC) often require enteral nutrition (EN). This systematic review reports the effect of EN timing in patients with HNC undergoing curative-intent and definitive or adjuvant radiotherapy or chemoradiotherapy on tube feeding duration, tube-related complications and dysphagia. METHODS: Randomised controlled trials (RCTs) published between January 2015-April 2020 were obtained from Medline, CINAHL and Embase. Study quality and certainty of evidence were assessed with Cochrane Risk-of-Bias and Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Two RCTs (n = 265) in five manuscripts were included. The risk of bias was moderate in one RCT and low in the other RCT. Timing of EN (prophylactic vs. reactive) may have little or no effect on tube feeding duration or complications, however, the effect on dysphagia was uncertain. Certainty of evidence was low for short-term and moderate for long-term tube feeding duration, low for tube-related complications and very low for dysphagia. There was imprecision due to small sample sizes, heterogeneity in the definitions and protocols for prophylactic and reactive EN, variations in time points for outcome assessment and indirect dysphagia measures. CONCLUSION: Larger well-designed trials are warranted to increase certainty of evidence regarding EN timing in patients with HNC.

"There's a lot of talent in the room but it's only really the medical talent that gets heard": a qualitative exploration of multidisciplinary clinicians' perspectives of optimal nutrition care of patients with head and neck cancer.

BACKGROUND: The high prevalence of malnutrition in patients with head and neck cancer (HNC) negatively impacts outcomes. The best-available evidence has been published in clinical nutrition guidelines; however, translation into practice has lagged. AIM: This project aimed to explore multidisciplinary team (MDT) clinicians' perspectives regarding barriers and enablers to best-practice nutrition care in order to inform the design of a new model of care. METHOD: Qualitative interviews were conducted with clinicians who were purposively sampled from a major HNC tertiary referral centre in Sydney, Australia. To elicit information regarding barriers and facilitators to change, a semi-structured interview schedule was developed, interviews were transcribed verbatim and analyzed employing an inductive thematic approach. The Consolidated Framework for Implementation Research (CFIR) was used to guide data analysis and interpretation of key themes identified. RESULTS: Nineteen participants (11 supportive care and eight medical clinicians) representing allied health, medical, and nursing disciplines participated. Five key themes were identified: (1) acknowledgement of dietetics expertise and access to resources to deliver nutrition care; (2) proactive versus reactive nutrition care; (3) integrated and coordinated care-"The One Stop Shop"; (4) MDT favours the medical model; and (5) leadership-within disciplines, within the MDT. CONCLUSIONS: MDT clinicians expressed similar views regarding delivering optimal nutrition care to this high nutritional risk patient group. However, perspectives differed at times between medical and supportive care clinicians, attributable to perceptions that current service structure favours the medical model. In order to design and deliver an evidence-based model of care, specific strategies will be required to ensure: early and ongoing access to expert nutrition care; nutrition care processes are proactive; integrated and coordinated care; and leadership, both intra- and inter-disciplinary. This novel exploration of MDT clinicians' views provides supporting evidence that multi-component implementation strategies comprising individual, team and system-level approaches will be essential to leverage sustainable change.

Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer? A meta-analysis.

INTRODUCTION: Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor for survival in patients with cancer, however, its impact in patients with head and neck cancer (HNC) has only recently been explored. This study aimed to determine the prognostic impact of CT-defined sarcopenia at the level of the third lumbar vertebra (L3) on overall survival in patients with HNC undergoing radiotherapy ± other treatment modality of curative intent. METHODS: A systematic review of the literature published between January 2004 and May 2020 was conducted in Medline, Embase, CINAHL, AMED and PubMed. Empirical studies in adults (≥18 years) who had completed radiotherapy of curative intent ± other treatment modalities that evaluated sarcopenia using the gold standard method at L3 and applied sex-specific cut-offs were included. Outcome of interest was overall survival. Study quality was assessed using the Quality In Prognosis Studies (QUIPS) tool. Hazard ratios with 95% confidence intervals derived from multivariate analysis were extracted directly from studies. Random-effects meta-analysis was used to determine the pooled hazard ratio for overall survival in patients with sarcopenia versus those without using RevMan (Version 5.3). The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS: A total of 6211 studies were identified and screened from which seven studies met the inclusion criteria with 1059 pooled patients. All studies defined sarcopenia as low muscle mass but varied in skeletal muscle index (SMI) threshold values applied and ethnicity. Sarcopenia prevalence ranged from 6.6 to 64.6% pre-treatment and 12.4 to 65.8% post-treatment. Pre-treatment sarcopenia was associated with reduced overall survival (HR 2.07; 95%CI, 1.47-2.92, p < 0.0001, I2 = 49%) with similar findings for post-treatment sarcopenia (HR 2.93; 95%CI, 2.00-4.29, p < 0.00001, I2 = 0%) with moderate to low heterogeneity exhibited amongst studies respectively. The certainty of evidence for overall survival according to GRADE was low for pre-treatment sarcopenia and moderate for post-treatment sarcopenia. CONCLUSIONS: CT-defined sarcopenia is independently associated with reduced overall survival in patients with HNC and holds a clinically meaningful prognostic value. Consensus regarding sarcopenia assessment and definitions is warranted in order to substantiate these findings and support implementation of body composition assessment as a clinically meaningful prognostic tool into practice.

Translating Evidence-Based Guidelines into Practice-Are We Getting It Right? A Multi-Centre Prospective International Audit of Nutrition Care in Patients with Foregut Tumors (INFORM).

Malnutrition is highly prevalent in patients with foregut tumors comprising head and neck (HNC) and esophageal (EC) cancers, negatively impacting outcomes. International evidence-based guidelines (EBGs) for nutrition care exist; however, translation of research evidence into practice commonly presents considerable challenges and consequently lags. This study aimed to describe and evaluate current international nutrition care practices compared with the best-available evidence for patients with foregut tumors who are at high risk of malnutrition. A multi-centre prospective cohort study enrolled 170 patients commencing treatment of curative intent for HNC (n = 119) or EC (n = 51) in 11 cancer care settings in North America, Europe and Australia between 2016 and 2018. Adherence criteria were derived from relevant EBG recommendations with pooled results for participating centres reported according to the Nutrition Care Model at either system or patient levels. Adherence to EBG recommendations was: good (≥80%) for performing baseline nutrition screening and assessment, perioperative nutrition assessment and nutrition prescription for energy and protein targets; moderate (≥60 to 80%) for utilizing validated screening and assessment tools and pre-radiotherapy dietitian consultation; and poor (60%) for initiating post-operative nutrition support within 24 h and also dietetic consultation weekly during radiotherapy and fortnightly for 6 weeks post-radiotherapy. In conclusion, gaps in evidence-based cancer nutrition care remain; however, this may be improved by filling known evidence gaps through high-quality research with a concurrent evolution of EBGs to also encompass practical implementation guidance. These should aim to support multidisciplinary cancer clinicians to close evidence-practice gaps throughout the patient care trajectory with clearly defined roles and responsibilities that also address patient-reported concerns.

Clinical Oncology Society of Australia: Position statement on cancer-related malnutrition and sarcopenia.

This position statement describes the recommendations of the Clinical Oncology Society of Australia (COSA) regarding management of cancer-related malnutrition and sarcopenia. A multidisciplinary working group completed a review of the literature, focused on evidence-based guidelines, systematic reviews and meta-analyses, to develop recommendations for the position statement. National consultation of the position statement content was undertaken through COSA members. All people with cancer should be screened for malnutrition and sarcopenia in all health settings at diagnosis and as the clinical situation changes throughout treatment and recovery. People identified as "at risk" of malnutrition or with a high-risk cancer diagnosis or treatment plan should have a comprehensive nutrition assessment; people identified as "at risk" of sarcopenia should have a comprehensive evaluation of muscle status using a combination of assessments for muscle mass, muscle strength and function. All people with cancer-related malnutrition and sarcopenia should have access to the core components of treatment, including medical nutrition therapy, targeted exercise prescription and physical and psychological symptom management. Treatment for cancer-related malnutrition and sarcopenia should be individualised, in collaboration with the multidisciplinary team (MDT), and tailored to meet needs at each stage of cancer treatment. Health services should ensure a broad range of health care professionals across the MDT have the skills and confidence to recognise malnutrition and sarcopenia to facilitate timely referrals and treatment. The position statement is expected to provide guidance at a national level to improve the multidisciplinary management of cancer-related malnutrition and sarcopenia.