I am fortunate enough to work at a cancer center that has a cancer supportive services team to address the unique needs of patients with cancer. The team consists of several social workers, a nutritionist and dietitian (myself), and a symptom management physician. The staff helps patients address a spectrum of concerns occurring throughout their treatment timelines. As for my role, nutritional consultations are a much-needed benefit to our patients, who may obtain nutritional advice and counseling before, during, and after treatment. Nutrition intervention is a valuable service that, especially when initiated early in treatment, can optimize nutritional status and improve outcomes. Additionally, nutrition education is an extremely helpful means for patients and their families to actively participate in their care. In oncology centers without staff dietitians, patients should be screened and receive general nutrition advice from RNs and other healthcare practitioners.

This article provides an overview of what to look for when screening patients for nutritional risk, how to evaluate the need for nutritional supplementation, and when to refer patients for in-depth nutritional counseling with dietitians and nutritionists.

Screening

Screening patients will reveal their nutritional risk levels and can help staff determine how to prioritize nutritional needs (see Figure 1). Nurses, who have primary and continued contact with patients, have the opportunity to optimize nutrition through interventions. Nutrition interventions can help patients maintain optimal weight, facilitate tolerance and healing from treatment, minimize symptoms, maintain or improve quality of life, and decrease morbidity.

Having cancer can affect nutritional status in a variety of ways, even prior to treatment interventions such as surgery, chemotherapy, and radiation. Weight loss and its associated morbidity are a multifactorial problem not easily solved by getting patients to "eat more." For the sake of simplicity, this article will focus on nutritional status in patients undergoing radiation treatment (RT) (although it is never that simple).

Diagnosis

Cancer diagnoses and treatment fields can send up "red flags" for patients who will receive RT to the head and neck, mediastinum, abdomen, or colorectal regions, given the organs affected. The long list of potential nutritional problems starts with the head and neck and works its way through the digestive tract for this patient population, who should be closely monitored for symptoms arising throughout treatment. Many patients with head and neck cancers come to treatment with preexisting weight loss or oral intake issues because of previous surgeries, dysphagia, or other swallowing difficulties. Some patients with head and neck cancers already have feeding tubes in place to facilitate adequate nutrition where compromised oral routes exist. Such patients require specialized care from their healthcare teams regarding nutritional support.

Tolerance to foods can be hindered significantly in patients receiving RT to the mediastinum because of refluxing, heartburn, and, in severe cases, esophagitis. RT to the abdominal region, colon, and rectum may result in moderate to severe gastrointestinal distress in the form of nausea, gas, pain, bloating, dysmotility, malabsorption, enteritis, and diarrhea. Patients must be made aware of the normal symptoms they may experience and receive tools to minimize them, such as appropriate diets or medications. Nutritional and medical management should be implemented to minimize symptoms as they occur to prevent diminished oral intake, gastrointestinal irritation, and diarrhea. RNs can pick up on such symptoms during their daily interactions with patients or during weekly status checks. My center uses a weekly "distress thermometer" checklist on which patients record any symptoms or psychosocial concerns; the tool then is routed to appropriate staff members (e.g., nurses, social workers, nutritionists) for follow-up.

Weight

Weight alterations appear to have more to do with the type of cancer rather than any cancer diagnosis. When evaluating patients' weight, look for stable adult weight or other patterns that suggest trends over time. Significant, unintentional weight loss is categorized as 5% or more loss in one month or 10% or more loss in six months. Significant weight loss with underweight status, associated with loss of appetite and decreased lean body mass, can be considered cachexia and diminishes treatment response while increasing morbidity and mortality. For patients with significant weight loss, the immediate priority is to stabilize their weight during treatment for the sake of improving treatment outcomes (see Figure 2). Some patients may present with a history of recent weight loss and others with longstanding obesity, but both situations require nutritional interventions. Correcting weight loss or staving off further depletion in high-risk patients is an immediate priority. Patients with obesity, however, could be directed toward nutritional counseling and exercise programs after RT is completed.

Food Recall

A time-efficient way to reveal inferior or inadequate intakes is to ask patients what they usually consume in an average day. I usually have patients go through a "normal" day, from breakfast through evening snack. Suboptimal amounts of protein, calories, or nutrients usually can be detected with this method. It also reveals eating patterns, cooking frequency, and overall quality of food consumption such as empty calories (e.g., pastries, donuts) versus nutrient-rich foods (e.g., fruits, vegetables, lean proteins, good fats). If patients report difficulty purchasing or cooking foods, they can be referred to social workers or to food programs such as Meals-on-Wheels, as appropriate.

Nutritional Needs

Not all patients present with weight loss or malnutrition; therefore, determining nutritional needs is a dynamic process. At the very least, patients need adequate calories and protein to facilitate weight maintenance and healing. Healthcare providers should encourage patients to maintain their usual intakes of food; however, the need for adequate protein, nutrients, and fluid also must be a consideration. If cancer itself induces a hypermetabolic state, RT may further increase the body's need for calories and protein. Estimated nutritional needs are based on higher-than-normal needs for protein and calories. Sometimes, meeting such needs can be as easy as adding 500 calories per day to a patient's normal intake. Of course, dieting during RT and recovery is discouraged because it may hinder treatment outcomes (see Figure 3).

Nutritional Supplements

Most cancer centers have a multitude of oral meal-replacement drinks to provide to patients, such as Ensure^® (Abbott Laboratories, Abbott Park, IL), Boost^® (Novartis Nutrition Corporation, East Hanover, NJ), and Carnation Instant Breakfast™ (Nestlé Corporation, Glendale, CA). Most standard supplements have 250-375 calories and 9-15 grams of protein per can. I encourage patients to test different brands and flavors for tolerance and palatability. If a supplement is too dense, it can be thinned with liquid or blended into a milkshake. Patients may augment with supplements between meals or use them as meal replacements. Indications for augmenting the diet with nutritional supplements are considerable.

• Weight loss
• Nutritionally inferior diet (e.g., inadequate calories, protein, or nutrients)
• Poor appetite
• Inability to tolerate solid foods
• Time constraints (long travel time to treatment)
• Fatigue (no energy to shop or prepare foods at home)

Premade nutritional meal replacements are a quick and convenient method to maximize nutrition. Many other options exist, however, depending upon patient or caregiver ability and motivation level. I provide handouts with easy, quick, and nutritious food ideas such as savory soups, drinkable yogurts, and high-protein fruit smoothies. Most grocery stores also carry a large variety of premade pure fruit juice blends or protein-based drinks, which can contain as many calories and protein as commercial supplements.

• Cancer Nutrition Info, LLC: www.cancernutritioninfo.com
• Eat Well—Stay Nourished: A Recipe and Resource Guide for Coping With Eating Challenges by Support for People With Oral and Head and Neck Cancer, Inc.
• Eating Hints for Cancer Patients Before, During, and After Treatment by the National Cancer Institute (25 free per facility per month; call 1-800-4-CANCER)
• The Cancer Survival Cookbook: 200 Quick and Easy Recipes With Helpful Eating Hints by Donna L. Weihofen
• The I-Can't-Chew Cookbook: Delicious Soft-Diet Recipes for People With Chewing, Swallowing, and Dry-Mouth Disorders (2nd ed.) by J. Randy Wilson

A piece of paper is not sufficient for patients who require one-on-one nutritional counseling with a registered dietician or nutritionist. If your center does not have an in-house dietitian, you can easily find one through the American Dietetics Association's Web site at www.eatright.org. Click on "Find a Nutrition Professional" and search by zip code and specialty.

Clinical evidence shows that early nutritional intervention is fundamental for success in patients undergoing treatment for cancer. Nutritional intervention is a dynamic process for patients receiving RT, and healthcare providers must closely monitor how symptoms affect what or how much patients eat. Ongoing nutritional and medical management works synergistically to minimize symptoms while maximizing intakes. When patients and families are aware that good nutrition improves energy and promotes healing, they are motivated to make positive changes. The results will improve treatment outcomes and, perhaps more importantly, patients' quality of life.

Bibliography

Fouladiun, M., Korner, U., Bosaeus, I., Daneryd, P., Hyltander, A., & Lundholm, K.G. (2006). Body composition and time course changes in regional distribution of fat and lean tissue in unselected cancer patients on palliative care—Correlations with food intake, metabolism, exercise capacity, and hormones. Cancer, 103, 2189–2198.

Larsson, M., Hedelin, B., & Athlin, E. (2003). Lived experiences of eating problems for patients with head and neck cancer during radiotherapy. Journal of Clinical Nursing, 12, 562–570.

Laviano, A., Meguid, M.M., Inui, A., Muscaritoli, M., & Rossi-Fanelli, F. (2006). Therapy insight: Cancer anorexia-cachexia syndrome—When all you can eat is yourself. Nature Clinical Practice: Oncology, 2(3), 158–165.

Mahan, L.K., & Escott-Stump, S. (2000). Krause's food, nutrition, and diet therapy (10th ed.). Philadelphia: Saunders.

Muscaritoli, M., Bossola, M., Aversa, Z., Bellantone, R., & Rossi Fanelli, F. (2006). Prevention and treatment of cancer cachexia: New insights into an old problem. European Journal of Cancer, 42(1), 31–41.

von Meyenfeldt, M. (2006). Cancer-associated malnutrition: An introduction. European Journal of Oncology Nursing, 9(Suppl. 2), S35–S38.

ONS Members Conduct Pilot Study to Clinically Evaluate a Gel Product for Radiodermatitis

The Role of Nurses in a Cyberknife^® Department

The role of radiation nurses evolves with each advancement in radiation technology. The Radiation Therapy Department at St. Joseph's Hospital in St. Paul, MN, added a Cyberknife^® (CK) (Accuray, Sunnyvale, CA) in October 2003. The institution has treated more then 500 patients with CK. This paper describes CK treatment and nurses' role in that setting.

Stereotactic radiosurgery is a noninvasive and extremely precise method to deliver higher doses of radiation in a shorter period of time. CK delivers stereotactic radiosurgery from a lightweight linear accelerator mounted on a robotic arm. Fixation frames are unnecessary thanks to real-time imaging via x-ray. Consequently, treatment can be fractionated, resulting in greater safety and applicability.

Precise targeting capabilities allow CK to be used for malignancies, some benign tumors, and several neurologic anomalies. Malignancies include previously irradiated tumors, solitary lung or brain lesions, and dangerously located tumors (e.g., liver, pancreatic, other abdominal masses). Neurologic problems such as acoustic neuromas, trigeminal neuralgia, meningiomas, and arterio venous malformations are among the other conditions treated with CK.

Although CK originally was developed to treat intracranial lesions, both intra- and extracranial applications have been developed. Outside the skull, lesions must be marked with fiducial markers. Fiducial markers are tiny gold seeds implanted in soft tissues or tiny screws in the spine for localization prior to the planning scans and process. Software is available to negate the need for spine fiducials.

Treatment planning is a multistep process. Fiducial placement, when necessary, is performed. Next, immobilization devices (facemasks or body molds) are created, followed by computed tomography (CT) scanning, magnetic resonance imaging (MRI), or either of those procedures with angiography (CT/A and MRI/A). CT/A and MRI/A are used more commonly with vascular anomaly. Images are contoured, and physics planning follows. Our department uses radiation oncologists and surgeons. The surgeons contour treatment areas, and the physics staff plans treatments. The planning process can take as long as two weeks to allow healing time after fiducials and to achieve agreement between physics staff members and physicians.

CK treatments are generally fractionated, spanning three to seven days, and fractions average 60 minutes. Patients are encouraged to take lorazepam before each fraction to foster relaxation, and they are required to take dexamethasone 4 mg after each fraction to reduce treatment-induced inflammation. Some patients receiving intracranial radiation are prescribed antiseizure medication, which is continued for at least three weeks after treatment.

Providing education and support and monitoring patient status before, during, and after CK treatment are the primary roles for nursing in the CK department, as in other stereotactic radiosurgery specialties. CK treatments are a specific kind of stereotactic radiosurgery. Refer to the article in the bibliography for more information regarding stereotactic radiosurgery for intracranial tumors.

Nurses ensure that patients and families understand CK planning and procedures at the time of consultation. Issues regarding claustrophobia, use of anticoagulants, and allergies to antiseizure and IV contrast agents are addressed. Education includes teaching about fiducials and pre- and post-treatment medications. On treatment days, patients are monitored for safety, and comfort measures are taken as necessary, primarily related to immobilization. Discharge teaching includes side effect management and criteria for medical intervention. Follow-up phone calls are made on post-treatment days 1 and 7. Patients are seen for follow-up 3, 6, and/or 12 months after CK.

CK treatments offer advanced technology for patients. CK challenges radiation nurses with a rewarding application of knowledge and a chance to acquire new skills.

Bibliography

Witt, M.E., Haas, M., Marrinan, M.A., & Brown, C.N. (2003). Understanding stereotactic radiosurgery for intracranial tumors, seed implants for prostate cancer, and intravascular brachytherapy for cardiac restenosis. Cancer Nursing, 26, 494–502.

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