Nutritional Interventions for Patients with Cancer, Part 2: Return on Investment for All Stakeholders

Sheryl A. Riley, RN, OCN, CMCN
Managing Partner
Clarion, LLC
Bernardsville, NJ

Last month, I discussed the barriers to obtaining nutritional support for patients with cancer. This second article is focused on the return on investment to all stakeholders from ensuring nutritional support for patients with cancer. During the 2015 American Association of Managed Care Nurses preconference meeting, approximately 100 nurse care managers of various payers’ groups (private and public) attended my presentation on the economic impact of nutritional interventions.

Before I began my presentation, I asked how many of the nurse care managers screened for malnutrition risk—only a handful raised their hands. When asked why they were not assessing for this, most attendees stated that they do not have a good tool or a process to do so. They need something easy that can fit within their current assessment procedures and does not take too long. I have since confirmed this with patients and their families, who identified that their physicians or office staff rarely ask about weight loss, food intake, or any diet.

Tools for Assessing Nutritional Risk

There are many comprehensive and simple tools for assessing nutritional risk. The most often used tools include:

  • The Short Nutritional Assessment Questionnaire
  • The Malnutrition Screening Tool
  • The Malnutrition Universal Screening Tool
  • The Mini Nutritional Assessment–Short Form
  • Nutritional status as assessed by the Subjective Global Assessment, Mini Nutritional Assessment.
These tools can be easily integrated into current assessments, so that they do not create a burden for nurses and are not time-consuming for patients.

The Evidence

As stated last month, the implementation of nutritional supplements has been associated with improved clinical outcomes, because patients are able to maintain treatment with less breaks in their treatment cycle. Nutritional supplements help to reduce weight loss, as well as the number of hospital admissions and the length of stay during the treatment course; they also improve the patient’s tolerance of the planned treatment.

In a February 2015 review of a study by Dewys and colleagues on the impact of weight loss before chemotherapy on patients with cancer, Abbott Laboratories stated, “Weight loss of as little as 5% of body weight is shown to worsen prognosis.”1,2 The review also notes that the study by Dewys and colleagues showed that patients with cancer who maintained their weight demonstrated longer survival rates compared with patients with weight loss in a variety of cancer types, including1,2:

  • Colon cancer, 51% increased survival
  • Prostate cancer, 48%
  • Stomach cancer, 33%
  • Small-cell lung cancer, 20%
  • Non–small-cell lung cancer, 30%
  • Pancreatic cancer, 14%.

Current Recommendations for Nutritional Support

Nutritional support and supplements are recommended for the following groups of patients with cancer:
  • Patients with these types of tumor: head and neck, esophageal, colon, lung, pancreatic, and liver
  • Patients who receive treatments that oncology providers know will lead to weight loss, malnutrition, and decreased treatment tolerance, because these treatments affect the patient’s ability to eat
  • Patients receiving chemoradiation.
Any patients falling into one of these groups should undergo a proactive nutritional assessment by a specialist, such as an oncology dietitian or a nutritionist, during the initial presentation, and should receive appropriate nutritional support and follow-up within the multidisciplinary cancer care team.

Return on Investment to All

The use of oral supplements has a return on investment for all stakeholders, especially for patients seeking improved quality and extension of life; however, the coverage by Medicare, Medicaid, and commercial health plans is limited.

Although malnutrition and failure to thrive are covered diagnoses, health plans have very specific rules for coverage, and oral or nutritional supplements are least covered. For oral supplements to be covered, they must be a special-formula mix that is considered a meal replacement and not a supplement. In addition, the patient has to have lost >10% of his or her body weight, which is not a rational requirement, considering that once patients lose 5% of their body weight they begin to have poorer quality of life and poor outcomes, as well as lower tolerance to cancer treatment.

By increasing the screening for and early identification of poor nutrition, we can increase the requests for nutritional support to providers and to payers, which may be the trigger to obtaining better coverage. I focus on oral supportive nutrition for patients with cancer, because the evidence is overwhelming that patients who maintain their weight tolerate their treatment better, and have improved overall clinical outcomes. We need to raise the education level and awareness of this need among practice managers, nurses, social workers, navigators, patient advocates, and patients and their families.

To get the coverage of oral supplements raised from 0% to at least 50%, we need to increase the screening level from 60% to 100%, and begin to identify the nutritional needs of our patients. I challenge all practice managers and nurses who work with patients with cancer to begin this quest—not for us, but for our patients, who deserve the best we can give.


I wish to thank Cortney Bozack, BS, DPT, for her help with the writing of this article (part 1 and 2).


  1. Abbott Laboratories. Prognostic effect of weight loss on survival in multiple cancer types. February 2015. Accessed March 8, 2016.
  2. Dewys WD, Begg C, Lavin PT, et al; for the Eastern Cooperative Oncology Group. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Am J Med. 1980;69:491-497.

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