Development of Clinical Practice Guidelines (CPGs) in Oncology Nutrition

1. Development of Clinical Practice Guidelines (CPGs) in Oncology Nutrition Charitini Orphanidou, MSc, RDN Regional Professional Practice Leader Nutrition Services - BCCA Centre for the Southern Interior

2. BACKGROUND • Mandate by CSCC, HC, and CAPCA for health disciplines in oncology care to develop Standards of Practice (SOPs) and Clinical Practice Guidelines (CPGs) • In 2003, a national working group of the Oncology Nutrition Network of Dietitians of Canada developed National Oncology Nutrition SOPs • A project was conducted from Jan-April 2003, to provide background for the development of National Oncology Nutrition CPGs

3. CPGs National Working Group • Charitini Orphanidou Co-Chair BC • Karen Biggs Co-Chair ONT • Satnam Sekhon Member BC • Angela Martens Member MAN • Donna Danelon Member ONT • Catherine Morley Contract Work BC

4. CPGs - What are they? • Systematically developed statements that inform practitioners and patients about the best available research evidence that pertains to the management of a specific clinical condition.

5. CPGs - Why do we need them? • Growing evidence of unexplained and inappropriate variations in clinical practice patterns. • Concern that further limitations in resources will affect the delivery of high quality health care. • Clinicians have difficulty assimilating evolving scientific evidence into practice.

6. The Practice Guidelines Development Cycle update 1. Select/Frame clinical problem 8. Scheduled Review 7. Adopt guideline, policies 2. Generate evidence-based-recommendation (EBR) 6. Negotiate practice policies 3. Ratify EBR 4. Formulate practice guideline 5. Independent review

7. LEVELS OF EVIDENCE • Level I Evidence • Review of all relevant RCTs • Level II Evidence • At least one properly designed RCT • Level III Evidence • Evidence obtained from well-designed controlled trials without randomization • Level IVA Evidence • Evidence from descriptive studies of provider practices, patient behaviors/knowledge/attitudes • Level IVB Evidence • Opinions of respected authorities

8. CPGs for Oncology Nutrition • How do we start? • Where do we focus? • What is important?

9. PURPOSE OF PROJECT • To identify key clinical issues in oncology nutrition care from the perspectives of dietitians working in cancer centres and community settings in order to: • establish priorities for CPG development • suggest other resources required to support oncology nutrition practice • inform future CPG development research projects

10. FUNDING SOURCES • Lynn Stevenson, BCCA Provincial Practice Leader for Nursing • Oncology Nutrition Network of Dietitians of Canada • Supportive Care Department, Hamilton Regional Cancer Centre

11. OBJECTIVES • Identify key oncology nutrition clinical issues in cancer centre and community settings requiring CPG development • Recommend directions on study submitted to CFDR • Identify and recommend practice resource needs in oncology nutrition care • Recommend approaches to enhance CPG uptake and use • Recommend a CPG dissemination plan • Identify and report any unanticipated findings

12. DATA COLLECTION AND ANALYSIS • Interviews and discussion groups with BC dietitians • 14 BCCA dietitians • 14 dietitians working in acute care hospitals and community settings • Written survey to Ontario oncology dietitians • Review of BCCA Nutrition Services report from Partners in Cancer Care conference, Nov 2002

13. DATA COLLECTION AND ANALYSIS • Interviews and discussion groups focused on the assessment, intervention, monitoring/outcomes components of care • Use of a modified Delphi Process (present earlier findings to subsequent respondents to more clearly articulate the issues)

14. FINDINGS

15. KEY CLINICAL ISSUES REQUIRING CPG DEVELOPMENT • NUTRITION RISK SCREENING • optimal approaches to screening • review of available tools • diagnostic vs predictive role • use in initial assessment and in evaluation of nutrition intervention outcomes

16. KEY CLINICAL ISSUES REQUIRING CPG DEVELOPMENT • OPTIMAL ENTERAL NUTRITION SUPPORT (esp. pertaining to oral and esophageal cancers and dual modality treatments) - Types of enteral support - Diagnoses that would most benefit - Prophylactic or reactive initiation - Duration of enteral support

17. CPG DEVELOPMENT STEPS • Systematic review of the literature for each topic to be investigated • Definition of literature inclusion/exclusion criteria • Gather documents to review • Include published and unpublished materials (include manual searching) • Determination of document relevance relative to criteria • Summary preparation of available evidence

18. CHALLENGES • Evidence available in oncology nutrition care not comparable in volume to that for other disciplines • There are neither the number of researchers nor research funding sources available compared to other disciplines

19. PRACTICE RESOURCE NEEDSOF CANCER CENTRE RDNs • CPGs and/or evidence summaries • An oncology nutrition practice research program • A Foundations of Oncology Nutrition Care Manual

20. PRACTICE RESOURCE NEEDS OF RDNs IN COMMUNITY SETTINGS • Primary need is for a Foundations of Oncology Nutrition Care Manual • oncology nutrition care in community settings mostly involves symptom management for patients prior to cancer diagnosis, or rehabilitating following treatment • Perceived CPGs to be more relevant to cancer centre dietitians

21. ONCOLOGY NUTRITION PRACTICERESEARCH PROGRAM • For what cancer diagnoses and treatment does nutrition support make the most difference in morbidity and mortality? • What is the role of Nutrition Services in offering support to: - meet physiologic needs? - eating changes due to cancer treatment? - patients confused/overwhelmed about what to eat? - patients/families in palliative situations?

22. Oncology Nutrition Research Programcould be framed according to 4 outcome categories: • Biochemical / physical parameters • Performance / functional parameters • Financial considerations (including cost benefit/cost effectiveness assessment) • Client perceptions

23. FOUNDATIONS OF ONCOLOGY NUTRITION CARE MANUAL • contain evidence based information on best practices • contain information on issues / situations regarding beliefs, meaning of eating, suggestions to counselling approaches • articulate positions or evidence summaries about new and / or controversial aspects of oncology nutrition

24. DISSEMINATION AND USE OF CPGs • For community RDNs, CPGs simply need to be made available when ready (value BCCA dietitians and resources highly!) • For Cancer centre RDNs, developmental process must be inclusive and collaborative

25. BCCA RDNs inform decision making and planning promote consistent practice orient new staff educate and train interns, graduate students provide updates to RDNs in community facilitate research agenda COMMUNITY RDNs enhance patient care enhance communication with BCCA RDNs be kept up-to-date on developments educate and train interns POTENTIAL USES OF RESOURCES

26. UNANTICIPATED FINDINGSDIFFERING APPROACHES TO ONCOLOGY NUTRITION CARE: FOR CANCER CENTRE RDNs • Centrality of knowing tumour site and stage, treatment plans, and pre-existing conditions • Consideration of three components of nutritional assessment and intervention planning: - physiologic nutritional needs - beliefs, meanings of food/eating - nutrition education/counselling approaches • Assessment and planning/implementing interventions are intertwined; not discrete activities

27. UNANTICIPATED FINDINGSDIFFERING APPROACHES TO ONCOLOGY NUTRITION CARE: FOR COMMUNITY RDNs • Often did not know patient’s diagnosis • Did not have in-depth familiarity with different types of cancer, cancer treatment, and its implications • Nutrition care for cancer pts was only one of many conditions they tried to stay up-to-date • Hospital-based practice offers little/no opportunity for follow-up. Often arrange for BCCA RDNs to follow pts as there is little/no Home Care RDN support in BC

28. UNANTICIPATED FINDINGSRESOURCES USED TO INFORM PRACTICE • Resources used by BCCA dietitians related to the three components of nutritional assessment • With experience, practice became less dominated by textbook or manual type information • With experience, strive to find a balance between standards for care and personalized solutions • Monitor the medical and nutrition literature, consult with patients and families, and dietetic/medical colleagues

29. Where Are We Now? • Seeking input from other Nutrition specialty areas that have developed CPGs (eg. ICU Nutrition Support) • Forming partnerships with organizations that have the infrastructure to develop CPGs (eg. Cancer Care Ontario program in evidence based care) • Pursuing alternative funding sources