Nutritional screening and assessment tools and methods

There is no consensus on which method or tools to use for assessment of needs for nutritional rehabilitation in HNC survivors in Denmark or internationally.

In the disease-specific follow-up programme, it is recommended that nutritional status and dietary intake should be assessed at the beginning of treatment and weekly during treatment, but there is no

recommendation on posttreatment assessment. The generic follow-up programme recommends that nutritional status should be assessed with focus on potential weight loss or weight gain, but no further recommendations are provided the assessment.

Several different tools and methods have been developed for nutritional screening and assessment. In Danish hospitals, the Nutritional Risk Screening 2002 (NRS 2002) is the recommended screening method, and it has been developed and validated to identify patients who will benefit from nutritional

interventions¹⁰⁷. It includes information on body weight history, dietary intake (amount consumed versus requirement), disease severity, and age in the assessment of nutritional risk. However, NRS 2002 has primarily been validated in admitted patients¹⁰⁷ who could possibly be assumed to be more affected by disease severity than curatively head and neck cancer survivors. Hence, it may be assumed that the recommended cut-offs of NRS 2002, will leave HNC survivors with needs of nutritional rehabilitation unidentified. In a study assessing the value of NRS 2002 as a nutritional risk screening method in pretreatment HNC patients, authors conclusively suggested that a cut-off value of 2 points instead of 3 should be used in this population¹⁰⁸.

In their guidelines on nutrition in cancer patients, ESPEN state that for nutrition risk screening, body mass index (BMI), weight loss, information on food intake may be obtained directly or through validated screening tools e.g. NRS 2002, Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool, or Mini Nutritional Assessment Short Form Revised¹³. In their 2002 guideline on nutritional risk screening, NRS 2002 is recommended for screening at hospitals, while MUST is recommended in community settings¹⁰⁹. Hence, MUST could potentially be more relevant in the assessment of HNC survivors’ needs for nutritional rehabilitation in the Danish municipalities. To my knowledge, no previous studies have assessed whether NRS 2002 or MUST can be used to identify HNC survivors who will benefit from posttreatment nutritional rehabilitation services. In the guideline on nutrition in cancer patients, ESPEN concludes, that further research linking outcomes from current and future clinical trials with appropriate screening and assessment tools is needed¹³.

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Since nutrition impact symptoms are so frequent in HNC survivors, screening and assessment tools that include nutrition impact symptoms in their assessment may be more relevant than tools that merely focus on body weight changes and quantitative changes dietary intake. The Scored Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) further include presence of nutrition impact symptoms and performance in the assessment, and is widely used as a screening tool in cancer patients¹¹⁰. But while the tool has been found feasible and valid in HNC patients during treatment^111,112, evidence is limited on its applicability after treatment completion.

Tools specifically developed to assess nutrition impact symptoms could also be relevant to consider in the assessment of needs for nutritional rehabilitation. For the initial assessment of dysphagia in HNC patients and HNC survivors, the disease-specific follow-up programme from the Danish Health Authority¹⁰ suggests body weight changes and M.D. Anderson Dysphagia Inventory (MDADI)¹¹³ or Eating

Assessment Tool (EAT-10)¹¹⁴. While EAT-10 is a symptom-specific outcome instrument for dysphagia, MDADI has been developed to assess dysphagia-specific QOL in terms of the physical, functional, and emotional impact of dysphagia in HNC¹¹³. Since neither MDADI or EAT-10 are typically being

categorised as nutrition screening or assessment tools, their potential as such has not been explored.

To summarise, NRS 2002, MUST, PGSGA SF, MDADI, and EAT-10 could potentially all be relevant in the assessment of needs for nutritional rehabilitation in HNC survivors, but their potential has not yet been explored. The tools and methods are presented more detailed in Table 2.

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Table 2: Overview of tools and methods that could potentially be relevant in the assessment of needs for nutritional rehabilitation in head and neck cancer survivors

Tool/method Purpose Description Domains/subscales Range Interpretation

NRS 2002¹⁰⁷

Identify patients at nutritional risk

Screening system developed for use by health professionals

In secondary screening:

A-score for malnutrition, B-score for disease severity, age-adjustment if aged 70 years or above

A-score: 0-3 B-score: 0-3 Age-adjustment: 1

A higher score indicates greater nutritional risk.

A score of ≥ 3 defines nutritional risk, and nutritional support should be initiated.

MUST¹¹⁵

Identify adults, who are malnourished/at risk of

malnutrition (undernutrition), or obese

Screening system developed for use by health professionals

BMI score, weight loss score, acute disease effect score (or if there has been or likely will be no nutritional intake for >5 days)

BMI score: 0-2 Weight loss score: 0-2 Acute disease effect score: 2

0: Low risk: Routine clinical care

1: Medium risk: Observe (and increase nutritional intake if inadequate)

≥2: High risk: Treat (refer to dietitian, nutrition support team etc.)

Obesity (BMI>30): Underlying acute conditions are generally controlled before treating obesity

PG-SGA SF¹¹⁰

Assess nutritional risk and nutritional deficit

Self-administered one-page instrument (validated in Danish¹¹⁶)

Overall score based on weight changes, changes in dietary intake (amount or consistency), nutrition impact symptoms and performance status

Overall score:

0-36

A higher score indicates higher malnutrition risk.

Nutrition triage recommendations*:

- Score of 4-8: Intervention by dietitian and nurse/physician as indicated by symptoms - Score ≥ 9: Critical need for intervention

MDADI¹¹³

Assess dysphagia-specific QOL in head and neck cancer

Self-administered 20-item questionnaire (+4 extra items in Danish version¹¹⁷) (validated in Danish¹¹⁷)

4 subscales: Global, emotional, functional and physical.

1 composite score: Weighted average of the emotional functional and physical subscales.

Subscales and composite score:

20-100

A higher score indicates a higher degree of functioning.

Suggested cut-offs for composite score¹¹⁸:

≥ 80: Optimal swallowing function

≥60 - <80: Adequate swallowing function

<60: Poor swallowing function

EAT-10¹¹⁴

Symptom-specific outcome instrument for dysphagia

Self-administered 10-item questionnaire (validated in Danish)

Overall score based on the 10 items Overall score:

0-40

A higher score indicates higher degree of dysphagia.

A score of ≥ 3 is suggested to define abnormal swallowing function

EAT-10: Eating Assessment Tool, MDADI: M. D. Anderson Dysphagia Inventory, NRS 2002: Nutritional Risk Screening 2002, PG-SGA SF: The Scored Patient Generated Subjective Global Assessment Short Form, QOL: Quality of life

*The nutrition triage recommendations are based on the full PG-SGA, not the short-form.

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