Return on Investment with Nutritional Support for Patients with Cancer, Part 1

Sheryl A. Riley, RN, OCN, CMCN
Chief Nursing Officer
Beacon Advocates
St. Petersburg, FL

Last year, I presented at the 2015 American Association of Managed Care Nurses (AAMCN) preconference on “Managed Care Nurses and the Clinical and Economic Impact of Nutritional Interventions in Patient Outcomes.” The focus of the conference was disease-related malnutrition. In my more than 20 years as a clinician, I have always prided myself on my attention to the value of proper nutrition and exercise for all patients.

I was under the impression that most nurse care managers, regardless of their practice setting, would have the same mind-set. Nutritional care is an essential aspect of nursing practice: we are uniquely situated to play a crucial role in early detection and screening for malnutrition in patients with cancer.

However, my research for my presentation showed that 60% of patients are never screened for malnutrition risk. This finding was very disconcerting and a wake-up call. This prompted me to dig deeper to ascertain where the problems lie, and what we can do to correct this oversight. Based on the dearth of screening and appropriate tools to do so, as a profession, we have to diligently educate healthcare providers and payers, provide appropriate malnutrition screening tools, and improve the outcomes.

Evidence shows that malnutrition is the most common comorbidity in patients with cancer.1 In her 2012 book, Dr Kumar notes that 30% to 87% of patients with cancer are diagnosed with malnutrition, and 30% to 60% of those patients are diagnosed with protein calorie malnutrition.1

Specifically, the rate of malnutrition among patients with esophageal cancer is 80%, and 67% among women with ovarian cancer.1 Endometrial cancer boasts the lowest rate (6%) of malnutrition. The incidence of malnutrition is 81% in patients receiving palliative care. Among all patients with cancer, up to 95% report ≥1 gastrointestinal tract symptoms that contribute to their malnutrition.1

Barriers to Eliminating Malnutrition

Because malnutrition is such a frequent manifestation of cancer, it is not surprising that it is a significant contributor to morbidity and mortality. Furthermore, because up to 85% of all patients with cancer suffer from clinical malnutrition, the negative consequences are profound, including poorer response to therapy, increased incidence of treatment-related side effects, and decreased overall survival.2

Consequently, malnutrition should have a proper place in the assessment and treatment of patients with cancer (and other catastrophic diseases).

The first step is to identify the barriers to successful outcomes. These barriers include:

  • Lack of education for healthcare professionals and for payers
  • Inadequate tools for healthcare providers to assess and manage malnutrition
  • Insufficient sharing of information and outcomes.

As cancer care providers, we need to educate care managers on the importance of screening every patient, and the value of early detection.

Educating Providers and Patients

We need to provide malnutrition screening tools to nurses and care managers in hospitals, skilled facilities, rehabilitation centers, nursing homes, and physician practices. We need to provide education and tools regarding weight and appetite loss before, during, and after treatment to patients and caregivers. We also need to encourage patients to self-screen, and urge them to report back to their nurse or oncologist regularly.

Providers must realize the value of good nutrition before, during, and after treatment and use screening tools in their practices.

Early Intervention Improves Outcomes

Early identification of patients who are malnourished or who are at risk for malnutrition will promote their recovery and improve their prognosis. Being proactive and utilizing screening and assessment tools for malnutrition are essential steps to effectively improving outcomes for patients with cancer.

Not surprising, early nutritional in­tervention is cost-effective and can:

  • Reduce complication rates
  • Decrease emergency department visits
  • Decrease hospital admission
  • Reduce the length of hospital stay.

The aim of nutritional screening is to identify patients who are malnourished or those who are at risk for malnutrition. Once a patient is identified, it is important to refer the patient to a dietitian or to a nutrition specialist for a comprehensive nutritional assessment. This assessment should include an examination of medical, dietary, psychosocial, environment, physical/functional, cognitive, anthropometry, and biochemical testing. This will give a clearer picture of the patient’s malnutrition, assist in identifying the etiology of the problem, and begin to build a plan of care for the patient, the patient’s family, and the care team.

Tailoring Your Intervention to the Individual Patient

It is important that all interventions are tailored to the individual, taking into consideration the patient’s cancer type, treatment regimen, lifestyle, physical and cognitive functions, environment, support, and prognosis.

The plan must include proactive interventions that support the patient and family before the onset of weight loss and malnutrition; once the patient loses ≥5% of the overall body mass, it is very difficult to gain it back. Wellness, nutrition, and exercise are not always areas of education and discussion with patients when reviewing their treatment options, medication regimens, and side effects, but they should be.

In my more than 20 years of patient care, I’ve learned that keeping patients as healthy and as active as possible during treatment improves treatment tolerance, decreases side effects, decreases depression, and enhances quality of life.

Assessing Nutritional Risk in Oncology

During the initial consultation, the oncologist or the oncology nurse should evaluate the patient’s nutritional status before starting cancer treatment. Some patients may have already lost a significant amount of weight, depending on the cancer they have and how long it took to get diagnosed.

This is the perfect time to complete a nutritional risk assessment and to introduce the possible use of oral nutritional supplements. Educate the patient and the family immediately about the dangers of weight loss, decreased activity level, treatment tolerance, and side effects.

Obtain a baseline weight and functional status, so the patient and the family have a starting point and can monitor changes. Reassess nutritional risk each time the patient comes for treatment and/or an office visit. Instruct the patient on what to look for, and when to call if there are changes.

One of the reasons oncologists, care managers, and oncology nurses are not assessing nutritional risk may be the cost to the patient and/or the family. Similarly, knowing that health plans fall short in their coverage of nutritional oral supplements, there is a reluctance to add more expenses to patients and their families.

However, there are ways to obtain these supplements through grants, coupons, and discount programs from nutritional supplement manufacturers, hospital programs, and cancer support organizations, among others. This could also be another reason for a lack of coverage; because health plans have identified that patients with cancer have strong support through national, regional, and local organizations, they have less incentive to provide coverage for nutritional supplements.

In my experience, medical directors are not hearing much from their clinical staff about oral nutritional supplements for patients with cancer. There may not be enough push from clinical staff, care managers, pharmacists, and dietitians, and if they are not screening for risk up front, no one is going to know it is an issue. In addition, your nurses may not be oncology nurses, or they may not have been educated on the importance of nutritional assessment for patients with cancer and the downside of poor nutrition.

With the growing cost of cancer treatments and patients’ possible inability to work during treatment, patients may go without treatment before burdening their families with additional costs. Often, patients must decide between paying their rent or mortgage, purchasing their medicines, and going for follow-up tests; copays and out-of-pocket costs also have a negative effect on patients’ ability to have a positive treatment process.


  1. Kumar NB. Nutritional Management of Cancer Treatment Effects. Berlin, Germany: Springer-Verlag; 2012.
  2. Sauer AC. Malnutrition in patients with cancer: an often overlooked and undertreated problem. Oncol Nurse. 2013;6:23-24.

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