A recently published multicentre study in the Clinical Nutrition ESPEN journal has drawn attention to the disparities in access to parenteral nutrition (PN) for cancer patients suffering from malignant bowel obstruction (MBO). The study, which retrospectively analyzed adult patients admitted to eight UK hospitals within a year and followed up for 1 year, sheds light on differences in nutritional care pathways and outcomes for patients based on their referral to a nutrition team for PN.
The Disquieting Disparity in Nutritional Support
Malignant bowel obstruction, a daunting complication often faced by patients with advanced cancers, particularly of gynecological and gastrointestinal origins, poses significant challenges in ensuring appropriate nutritional care. Despite recommendations for multi-disciplinary treatment approaches, including specialized nutrition support, the study found that only 1 in 3 MBO patient admissions resulted in a referral to a nutrition team for parenteral nutrition – a central component of managing intestinal failure in this patient group.
The research, involving 232 patients with 347 MBO admissions, revealed a median patient age of 66 years (with an interquartile range (IQR) of 55-74 years), and a majority being female (67%). Of these patients, 79 were referred for PN (R group). The remaining comprised the not referred (NR) group, who were discovered to be older, heavier upon admission, and more likely to receive conservative treatment compared to the R group.
DOI: 10.1016/j.clnesp.2023.11.018
The Crucial Role of Dieticians and Multi-disciplinary Teams
Highlighting the substantial role of dieticians and multi-disciplinary team (MDT) discussions in patient care, the study found that the R group patients were more likely to experience such interventions. For example, MDT discussions were more common in the R group, with 123 out of 347 admissions (27% vs. 7%, P = 0.001) having this feature, while dietetic contact occurred in 95% of the R group versus 39% of the NR group (P < 0.0001).
However, these findings also underscore a concerning gap – a considerable number of patients did not have the benefit of these discussions or dietetic reviews, potentially impacting the quality of their care and survival outcomes.
No Difference in Overall Survival
In terms of survival, the study reported no significant difference between the R and NR groups, with an overall median survival span of 150 days (126-232). This may suggest the necessity for further research to identify whether differing care pathways do indeed affect clinical outcomes beyond survival, such as quality of life, symptom management, and patient satisfaction.
Research and Care Implications
The study’s lead author, Pinal S Patel of the Intestinal Failure Unit at University College London Hospitals, and the other research contributors stress the need for further prospective research to explore the potential consequences of the identified differential care pathways on clinical outcomes and patients’ quality of life.
The findings also advocate for the standardization of care processes and increased awareness among healthcare providers, highlighting the need for routine referral to a nutrition team and dietetic evaluation for MBO patients requiring PN. The integration of dietetic assessment as part of the initial care management plan could pave the way for more tailored, proactive, and comprehensive care.
Competing Interests
The study declares a competing interest, noting that Pinal Patel’s research post was funded by companies involved in the production of parenteral nutrition solutions, which could bring potential biases into the interpretation of the findings.
Conclusion
The retrospective multi-centre study provides essential insights into the current state of nutritional care pathways for MBO patients in the UK and emphasizes the importance of addressing the variation in access to critical nutritional support services. The holistic well-being of these patients, compounded by the complexity of their underlying condition, requires that greater attention be given to ensuring equitable access to care resources, including parenteral nutrition, dietetic support, and multi-disciplinary team interventions.
Keywords
1. Malignant bowel obstruction
2. Parenteral nutrition cancer
3. Dietician in oncology care
4. Nutritional support in cancer
5. Multi-disciplinary team in cancer care
References
1. Patel, P. S., Fragkos, K. K., Keane, N., et al. (2024, February). Nutritional care pathways in cancer patients with malignant bowel obstruction: A retrospective multi-centre study. Clinical Nutrition ESPEN, 59, 118-125. doi: 10.1016/j.clnesp.2023.11.018
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