Cancer patients often suffer from weight loss, muscle wasting and reduced physical function at diagnosis, and this is especially prevalent in pancreatic and other hepatobiliary (HPB) cancers. Sarcopenia, defined as a decreased muscle mass independent of fat mass, is a feature of the cachexia associated with pancreatic cancer. In patients undergoing surgery sarcopenia and malnutrition have been associated with increased rates of complications and worse survival. Treatment is difficult but includes nutritional support and pancreatic enzyme replacement therapy (PERT) aimed at reducing malabsorption, alongside physical activity.
In 2016 we received Macmillan funding for my role, a full time HPB specialist dietitian, working alongside a physiotherapist to tackle the problem outlined above. The process of enhancing functional capacity of an individual before an operation to enable him or her to withstand the stress of surgery has been termed Prehabilitation.
Prehabilitation is a multimodal therapeutic regimen aimed at improving the overall physical condition of patients prior to surgery with the intention of reducing the incidence of perioperative complications. Emerging evidence suggests that exercise prior to surgery for high risk patients scheduled to undergo major abdominal surgery improves aerobic capacity and can reduce the incidence of perioperative complications.
All HPB cancer patients that were deemed to have resectable disease were eligible for our project and the aim was to provide support throughout the four phases of their treatment pathway; Prehabilitation, Enhanced recovery after surgery, Recovery and reablement, and Living with and beyond cancer.
Baseline assessments are completed at an initial prehabilitation appointment and individualised treatment plans are advised depending on the patients’ needs. This often includes a tailored home exercise programme, pancreatic enzyme replacement therapy, symptom control, meal advice and nutritional supplements as indicated. Patients are subsequently reviewed over the telephone or have the opportunity to attend gym sessions with the physiotherapist. Measurements are repeated within one week of surgery to evaluate progress.
Weight history, body mass index (BMI), Patient Generated Subjective Global Assessment Short Form (PG-SGA SF) ©FD Ottery 2015 v3.22.15, Handgrip strength (HGS) and a modified Gastro-intestinal Symptom Rating Scale (GSRS) are the main outcome measures used for dietetic assessment.
During our first year 54 patients met criteria to be included in our data, with median prehabilitation duration of 34 days (Range 14-165 days). Baseline assessment showed malnutrition was prevalent with 70% losing ≥5% and 33% losing ≥10% of their weight leading up to diagnosis. Short PG-SGA score was 7, with triage recommendations suggesting a score ≥4 requires dietetic intervention. A HGS of ≤85% of normal has been reported as suggesting protein malnutrition, and this was found in 43% of our patients.
At review assessment all nutritional outcomes had improved. Median weight change improved from -6.9% to +1.9%, and only 4% of patients lost ≥5% of their weight. Median handgrip improved from 26.4 to 30.6kg, with only 19% now scoring ≤85% of normal. Median Short PG-SGA reduced to 0 from 7 and GSRS improved from 12.5 at baseline to 5 at review, suggesting malabsorption symptoms were better controlled.
Subjective patient data was also collected along the pathway using the Nutrition and Dietetic Patient Outcomes Questionnaire, as shown in the graphs below.
After treatment patient interviews were conducted to gain further feedback and a summary of comments are shown below.
The project has been very well received and achievements during our first year included presenting at several national conferences, chosen as best project at a trust innovation event and supported in Manchester Cancer Action Plan for delivering world class care published 2017. This resulted in further funding for a second year and we aim to complete our final data analysis over the coming months. Our long term aim is for this service to be embedded into standard patient care, allowing all high risk patients to receive appropriate AHP support throughout their surgical treatment pathway.
Written by: Neil Bibby, Macmillan Specialist HPB Dietitian
References
- Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clin Cancer Res. 2009;15(22):6973-9.
- Pecorelli N, Carrara G, De Cobelli F, Cristel G, Damascelli A, Balzano G, et al. Effect of sarcopenia and visceral obesity on mortality and pancreatic fistula following pancreatic cancer surgery. Br J Surg. 2016;103(4):434-42.
- Carrara G, Pecorelli N, De Cobelli F, Cristel G, Damascelli A, Beretta L, et al. Preoperative sarcopenia determinants in pancreatic cancer patients. Clin Nutr. 2017;36(6):1649-53.
- Choi Y, Oh DY, Kim TY, Lee KH, Han SW, Im SA, et al. Skeletal Muscle Depletion Predicts the Prognosis of Patients with Advanced Pancreatic Cancer Undergoing Palliative Chemotherapy, Independent of Body Mass Index. PLoS One. 2015;10(10):e0139749.
- Harimoto N, Shirabe K, Yamashita YI, Ikegami T, Yoshizumi T, Soejima Y, et al. Sarcopenia as a predictor of prognosis in patients following hepatectomy for hepatocellular carcinoma. Br J Surg. 2013;100(11):1523-30.
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