Video transcript
Innovations in Radiation Therapy Part C
Julie McCrossin
Merran Findlay, Executive Research Lead Nutrition & Oncology Specialist Dietician, Royal prince Alfred Hospital, Sydney Local Health District & Chris O’Brien Lifehouse.
Julie McCrossin
Well welcome back to this video on innovations in care and treatment in radiation therapy for the head and neck cancer patient. So far we’ve been talking to a radiation oncologist and a speech pathologist, and now another utterly critical member of the team, a life saving member of the team, the dietitian Merran can you introduce yourself and explain your role with head and neck cancer?
Merran Findlay
Sure. My name is Merran Findley, I’m an advanced accredited practicing dietitian. I have specialized in the field of hidden neck cancer for close to 20 years. I’m currently employed as the executive research lead for cancer nutrition at Royal Prince Alfred Hospital in Sydney Local Health District, and in that role, we partner with Chris O’Brien Lifehouse Cancer Center to provide the best possible cancer care to our patients with head and neck cancer.
Julie McCrossin
Look, we’re here to talk about innovation, but I’m always mindful. There could be a person watching this has just been diagnosed with head and neck cancer and they haven’t met their dietitcian, yet. I referred to you as life saving. That’s not an overstatement. Is it? Why are you a life saving profession for the head and neck cancer patient?
Merran Findlay
Absolutely. I’m glad to hear you say that, Julie. I mean, basically, the fundamentals of human physiology dictate that we require nutrition in order to optimally function in order to go about our lives and do the things that we want to do. So, you know, when nutrition is, is something so fundamental to maintaining good health, it makes so much sense that it’s actually even more vital in times of when we are, in periods when we’re unwell, and that we need to be in the best shape possible to get through cancer treatment.
Julie McCrossin
And we’ve heard from Dr. Forstner and also from Therese Dodds that the radiation can impact quite significantly on the capacity to swallow. So can you give us an understanding of how you assist the head and neck cancer patients, who’s affected by the radiation therapy, to basically keep taking in nutrition?
Merran Findlay
Absolutely. So the dietitians role in amongst the multidisciplinary team is to provide support to patients and their caregivers for family members, in order to optimize a person’s nutrition.
Julie McCrossin
What does that mean optimize a person’s nutrition?
Merran Findlay
So our goals usually are to encourage as much nutrition as possible in order to meet that person’s requirements, to prevent any unintentional weight loss, and because unplanned weight loss is actually quite a concern in this particular setting. Losing weight dramatically through side effects of cancer care is not what we’re aiming for.
There’s a practical reason for that in the sense that the masks that Dieon showed us earlier is performing an important function of fitting a person and that is actually targeting the appropriate treatment area. But also, you know, adequate nutrition means that you preserve your lean muscle stores. That’s where your strength and function is. And there’s a number of different strategies that we use in order to help people meet their nutritional requirements.
Julie McCrossin
I’ve managed to keep swallowing, but I lost a lot of weight. Can you explain why is it important that we don’t lose too much weight, and the different ways you try to get food into us, even as our swallowing gets harder and harder to manage?
Merran Findlay
The thing that a lot of people find it hard to understand is that malnutrition is actually very prevalent in patients with his neck cancer, and that is regardless of their body weight. You don’t have to be underweight to be malnourished. And what we do know is that people who are malnourished are less likely to get through treatment, they’re less likely to recover weill, they’re more likely to need hospital admission. And there’s a lot of roll on effects of loss of function and ability to do the day to day tasks in when someone becomes malnourished.
So the ways that we manage that, in order to really give people the best chance of getting through treatment and recovering, first line is to look at what we can do with dietary strategies for people eating by mouth. And that will be things like maybe modifying the texture of the foods, making them softer, more moist.
They might need to be on a texture modified diet that we usually work with, in consultation with our speech pathology colleagues, in order to know what the recommendation should be for that person. So that when they’re swallowing the foods going down the right way, going down the food partpipe, not the wind pipeart. And so things like maybe minced mashed or pureed foods for those people.
The second line is really fortifying foods so that we’re adding additional energy or additional protein. So that’s a way that we can make really every mouthful count, so that everything someone is swallowing is having the most effect in terms of nutritional benefit.
And then for people that are really struggling with the intake orally and they’re becoming malnourished, they’re losing weight. And we know that about 5% body weight is actually what we call critical weight loss where it does potentially impact on a person’s outcomes.
So nutrition support can take the form of tube feeding where a nasal gastric tube is put through the nose down through into the stomach, and that people are able to administer a medical nutrition formula that goes through that and also hydration, and also medications.
So the…they’re the three things that we would put down a tube if someone is unable to swallow. And the other type of tube is a gastrostomy tube which is tends to be used in a sort of more medium, longer term type arrangement. And that really depends on the person’s circumstances as to what their care team might recommend,
Julie McCrossin
And what is the gastrostomy tube?
Merran Findlay
So a gastrostomy tube is used for slight medium to longer term use and it’s placed, it can be placed either endoscopically, radiologically, or surgically. So there’s different medical procedures involved with your their insertion. But essentially, it’s something that sits underneath your clothing. It’s not visible while you’re going about your day to day life, but you can actually use it to administer nutritional formula, especially for those people who are unable to eat enough to maintain their nutrition.
Julie McCrossin
And is it always achieved through your tummy?
Merran Findlay
In most, if gastrostomy is is into the stomach, yes,
Julie McCrossin
In my case, I was able to keep swallowing throughout my treatment, but I have friends in different parts of Australia and different parts of the world, where the practice within their cancer team was to insert a tube in the tummy or a PEG tube, right from the word go in my observation theres varied practices in varied locations is that is it basically something that you you talk to your team about and and see what they say thinik?
Merran Findlay
We do look at the evidence around this and we do know that preventing people from deteriorating in terms of the nutrition will help them in the long run. But ultimately, what type of nutrition support is in your best interest? That’s the decision that’s best made, discussing with the care team, your dietitian, his your speech pathologists to treating oncologists and surgeons and collectively help you arrive at a decision that’s right for you.
Julie McCrossin
I want to ask you about any current or recent research that gives us insight into the nutritional needs of the head and neck cancer patient in relation to radiation therapy or more broadly. Before I do that, is there any other aspect of care from a dietitcians point of view that you’d like to mention?
Merran Findlay
One of the things that we have worked very hard on here in Australia is to look at the best available evidence. In fact, we’ve led the development and dissemination of internationally endorsed guidelines for the nutritional management of adult patients with head and neck cancer.
And we were lucky enough to do that in partnership with the Clinical Oncology Society of Australia and Cancer Council Australia. So those guidelines are available on a wiki platform. And essentially what they really highlight that access, early access to a specialist dietitian, who is a core member of the MDT and at that frequent dietary dietetic intervention counseling before, during, and after treatment is actually essential to optimizing outcomes for patients.
Julie McCrossin
Okay, so if people take nothing else from this video, if they’re a patient, make sure you see a dietitian before, during and after treatment.
Merran Findlay
Absolutely. And that’s particularly often people who are newly coming to our center with a new diagnosis, they’re often feeling well, eating and drinking well without any problems, and may wonder why on earth do I need to see a dietitian? Why do I need to see a speech pathologist? and you know, those are the people that we really want to make sure that we see early. Advise them on what the possibilities are in terms of the toxicities or side effects of treatment, and really have that early chance to optimize nutrition, because with nutrition prevention is better than cure.
Julie McCrossin
And some people struggle to regain anything near their pretreatment weight. Why is that?
Merran Findlay
Probably some of the factors around their ability to eat as well as they had previously. And I think following the speech pathologist and dietitian’s advice during treatment sets you up into the best possible scenario for maximizing your recovery.
And what we call swallowing and nutrition rehabilitation is that post treatment period where we’re really trying to optimize people’s intake, swallowing function, and, you know, getting people or off feeding tubes who have happened to require one, and returning them to as normal diet as possible.
Julie McCrossin
And it’s that process of coming off a tube, something that you really do need supervision and management to help you do it?
Merran Findlay
Absolutely. And in fact, we have a duty of care. A as long as someone has a feeding tube, we really need to make sure that they are being looked after appropriately, receiving the appropriate guidance and advice on how to ween their feeds without compromising their nutrition and maximizing the variety in their diet. And of course, nutritional adequacy, and weight maintenance are all important parts about removing a feeding tube.
Julie McCrossin
And do you go through a period where you’re taking food in orally and you’re having the feeding tube?
Merran Findlay
The two are not mutually exclusive. We always encourage where possible for people to keep swallowing. And as a speech pathologist colleagues have said today that it’s really important to keep those swallowing muscles working in order to maximize function.
Julie McCrossin
If you had to sum up two or three key messages for patients watching this today, what are they? What do you want them to remember from an from a dietitcians point of view?
Merran Findlay
I would say that nutrition is a vital part of your overall care. Think of it as a form of treatment. Take your advice from your care team and look for information from reliable evidence based sources, places like Bbeyond five Five from Cancer Council, because there’s a lot of information on the internet, there’s equally a lot of misinformation and certainly when it comes to nutrition, there’s a lot of misleading things that that aren’t necessarily appropriate or suitable for someone with a hidden head and neck cancer diagnosis.
Julie McCrossin
And one of the things that can be very hard for people is they lose taste. I certainly lost the capacity to taste food for quite some time. For most people will look a passage to taste food comeback?
Merran Findlay
For a lot of people it does improve. It is in relation to things like chemotherapy that can cause a taste changes in a short term period. And it’s often as Dion would have mentioned, the radiation therapy causing a longer term dry mouth.
The newer radiation techniques are designed to minimize the impact of that. But if you do have a dry mouth, it will impact taste because saliva is partly what helps us register flavor.
So staying well hydrated is also important. Maintaining moist food if your mouth is dry, it’s far more comfortable to maneuver that around the mouth and swallow. And those sorts of things can actually be useful tips carrying your water bottle. Those sorts of things.
Julie McCrossin
Just finally from my point of view. We’ve briefly mentioned the impact on your teeth in a conversation with a radiation oncologist, that the the impact on saliva is bad for your teeth, and we do have a video in this series, where we look in depth at the oral needs and the dental needs of head and neck cancer patients, but is that something you as a dietitian, supervising someone after treatment might say, look, make sure you get yourself to the dentist? Is that does that come within your frame?
Merran Findlay
Absolutely. I mean, dietitcians take a very whole person view to nutrition assessment and intervention, it’s physical aspects, including dentition. So if someone has problems with their teeth, it is a very immediate barrier to them being able to bite, chew, swallow well, and it can have a big impact on the variety of foods they’re able to actually consume, and therefore nutritional adequacy can become an issue for those people.
Julie McCrossin
And that’s so important, isn’t it? Because some patients need to have quite a few teeth extracted prior to radiation treatment because it can be a challenge to have extractions after radiation treatment. So you would be dealing quite often with patients who’ve lost quite a few teeth?
Merran Findlay
Yes, absolutely. And they will often still have sore gums while their mouth is healing and they’re limited in what they can manage. And that’s really a time that we need to ramp up, modifying the texture of the foods, adding extra sources sauces and gravies to make the food more moist, fortifying with higher energy or calories and additional protein.
Julie McCrossin
Just before I let you go, is there any current or recent research that you think it’s important to alert both patients and members of the multidisciplinary team who are watching this to know what’s happening that’s important.
Merran Findlay
Some of the work we’ve done in our center has been around implementation of nutrition care evidence into practice. Through that we developed a supportive care- lead pre treatment clinic so that was run by a specialist dietitian and specialist nurse. And through that innovation, we’ve been able to demonstrate that those patients had greater access to specialist care early, in line with best available evidence.
It also meant that those patients had less treatment breaks both radiation and chemotherapy and we’re less likely to be admitted to hospital. So there were benefits to patients and also the healthcare system in terms of a cost reduction with those avoided unplanned admissions.
Julie McCrossin
And have you been able to continue that pre treatment clinic or was it only for a research purpose?
Merran Findlay
it was initiated as a pilot in response to us interviewing our patients and caregivers to find out what they needed from their nutrition care. But it was such a successful pilot that that now has been incorporated into standard care in our center.
Julie McCrossin
One issue that’s been raised in these videos is that sometimes really good work is done as part of research, but it doesn’t necessarily get funded or integrated into the system. So that’s a wonderful success, isn’t it?
Merran Findlay
Yes. It was said to me, can we afford to continue this? And my pushback was then can we afford not to? Malnutrition is insidious. It costs the patient greatly in terms of function and getting through treatment and it costs the healthcare system enormously.
Julie McCrossin
Look Merran can I just say as a head and neck cancer patient aware of your work, thank you so much for your dedication, your professionalism, your focus on evidence gathering, and disseminating because this is an area that needs it so much and we are truly grateful.
Thank you for having me, Julie.
And so, ladies and gentlemen, that is the final of our three interviews looking at innovations in treatment and care in relation to radiation therapy.
And remember that 13 11 20 is the Cancer Council number information and support line 13 11 20 and as we’ve mentioned https://www.beyondfive.org.au is a fantastic website. And thank you so much for taking interest in head and neck cancer.
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