My goal has been to develop a programme to identify early nutritional issues, nutritional problems, and try to treat these problems before they become irreversible. Particularly in elderly patients we know that at least 60% of elderly cancer patients are malnourished and the real possibility of helping those patients to, first of all, receive cancer treatment but also enjoy a good quality of life, a good opportunity to remain in their homes, is really to address nutritional problems.
The first step is really to screen these patients for those nutritional problems and we have many tools available but I would say that the Abridged Patient-Generated Subjective Global Assessment, a tool that has been developed initially in Canada and further refined in the States, is nowadays probably the tool of choice as a screening tool for malnutrition as well as a possible diagnostic tool for malnutrition and potentially a way to monitor patients over time while they are receiving treatment, whether they are treatments related to their disease or treatments related to their problem with nutrition. Aside from or in addition to screening tools we need also a specific programme to address the problem of malnutrition and we have developed the Cancer Rehabilitation Programme at McGill University Centre which essentially includes four streams – a pre-habilitation programme or stream which treats patients prior to receiving cancer treatments; the supportive stream which treats patients during cancer treatment; then we have the cachexia clinic or cachexia stream which looks at patients who with advanced disease have developed an important problem with weight loss and lack of appetite. Finally we have a restorative stream for cancer patients who have completed their cancer treatment and they are essentially trying to return to their normal life. So the problem of nutrition is common across all those streams but also the approach common is the interdisciplinary approach. That means that we cannot just target nutrition we have also to address functional issues of these patients and most of the time also provide support to these patients by psychological support or other types of support which could be, for instance, from occupational therapy support and ways, in other words, to maximise their performance.
Particularly in the elderly it’s important to address also problems with cognition, problems with social isolation which allows the intervention specific for nutrition and exercise to be really feasible but also to be practical. Therefore we are working also with psychosocial oncology and with social workers in order to help elderly patients to benefit the most from specific nutritional or exercise intervention.
So, in summary, malnutrition is very common in elderly cancer patients, it’s important to identify it early through screening tools of which we have identified with the Abridged Patient-Generated Subjective Global Assessment, the tool of choice, and in order to address the malnutrition in terms of intervention we need to have an interdisciplinary approach that could or should start as soon as possible, even before the oncological treatment starts.
What is the next step in this area?
There is still a lot to learn, primarily to identify again the mechanism by which malnutrition takes place in elderly cancer patients. One of these, again, is the problem of cachexia which is essentially the malnutrition syndrome that cannot be reversed simply by feeding the patient but is the syndrome which is characterised by metabolic abnormalities and that is particularly important because of a loss of muscle. We know how that is important for elderly cancer patients to maintain their autonomy so this would be one area, along with not just the problem related to the tumour but along with the side effects of the cancer treatment, particularly the targeted treatments, which although they allow patients to survive longer but they also have an important nutritional impact. Therefore, in the future prevention and care of the survivors will become more and more important in terms of winning the battle with cancer and its consequences.