COSA Cancer-related malnutrition and sarcopenia position statement: Implementation toolkit
In 2020 the Clinical Oncology Society of Australia (COSA) published a position statement on cancer-related malnutrition and sarcopenia. The document outlines the position of COSA on the role of health professionals and health services in recognising and treating patients with cancer-related malnutrition and sarcopenia.
This toolkit provides practical resources and guidance to support the implementation of the COSA position statement recommendations on cancer-related malnutrition and sarcopenia, into practice.
Toolkit purpose
This toolkit is intended for use by clinicians and health services to train clinicians, develop the services required and advocate for resources to support optimal management of cancer-related malnutrition and sarcopenia.
How the toolkit was developed
The toolkit was developed by members of the COSA cancer-related malnutrition and sarcopenia working group.
Resources were iteratively developed and refined over a number of workshops with working group members and clinicians. Once developed, the toolkit underwent usability and acceptability testing with multidisciplinary clinicians from across Australia.
The toolkit was funded by an educational grant from Abbott Australasia.
How to use the toolkit
The toolkit can be downloaded as a PDF document below. In addition, each section of the toolkit has been broken up and individual resources can be accessed directly from the links below.
The toolkit
Position statement recommendations:
All people with cancer should be screened for malnutrition in all healthcare settings at diagnosis and repeated as the clinical situation changes, using a screening tool that is valid and reliable in the setting in which it is intended.
All people with cancer should be screened for sarcopenia at diagnosis and repeated as the clinical situation changes, using the validated screening tool SARC-F or SARC-F in combination with calf-circumference.
Which screening tools to use
Malnutrition
Malnutrition Screening Tool (MST)
Malnutrition Universal Screening Tool (MUST)
Malnutrition Screening Tool for Cancer Patients (MSCT)
Patient-Generated Subjective Global Assessment short form (PG-SGA SF)
Sarcopenia
SARC-F in combination with calf-circumference (SARC-CalF)
Exemplars of evidence-based care in practice
Raising awareness of malnutrition and sarcopenia in your organisation
Incorporating malnutrition or sarcopenia screening into existing supportive care screening processes
Improving your model of care to ensure timely identification of sarcopenia
Implementing self-screening for malnutrition risk
Improving completion rates for malnutrition screening
What is the role of oncologists?
Patient case studies
Case study 1 - prehabilitation
Case study 2 - haematology inpatient
Relevant resources
Online interactive MST - (Translated and culturally adapted into 10 languages other than English)
Position statement recommendations:
All people with cancer identified as being 'at risk' of malnutrition following appropriate screening or with a cancer diagnosis or treatment plan known to lead to high risk of malnutrition should have comprehensive nutrition assessment using a tool validated in the oncology population.
All people with cancer identified as being 'at risk' of sarcopenia following appropriate screening should have a comprehensive evaluation of muscle status using a combination of assessments for muscle mass, muscle strength and function.
Interpretation of diagnostic criteria for sarcopenia should be applied recognising that:
a. Threshold values for assessing muscle mass, muscle strength and physical performance are variable.
b. Care should be taken to determine the appropriate cut-off values in the population in which they are being applied.
c. Most data regarding muscle strength and performance comes from older populations.
d. The applicability of diagnostic criteria in different ethnicities is uncertain.
Diagnostic Criteria
Malnutrition
Global Leadership initiative on Malnutrition (GLIM)
Sarcopenia
European Working Group on Sarcopenia in Older People (EWGSOP1)
European Working Group on Sarcopenia in Older People updated definition (EWGSOP2)
Foundation for the National Institutes of Health biomarkers consortium sarcopenia project (FNIH)
Cancer specific CT image analysis
How to complete assessment
Malnutrition
Patient Generated Subjective Global Assessment (PG-SGA)
Subjective Global Assessment (SGA)
Muscle mass
PG-SGA physical exam (see above guides)
Calf-circumference how to guide
Calf-circumference instructional video
Bioelectric impedance analysis how to guide
Bioelectric impedance analysis instructional video 1
Bioelectric impedance analysis instructional video 2
Bioelectric impedence spectroscopy analysis how to guide
Bioelectric spectroscopy analysis instructional video
Muscle strength
Handgrip strength how to guide
Handgrip strength instructional video 1
Handgrip strength instructional video 2
Chair stand test instructional video
Performance
Short physical performance battery how to guide
Short physical performance battery instructional video 1
Short physical performance battery instructional - chair stand test
Short physical performance battery instructional - gait speed test
Short physical performance battery instructional - balance test
Timed up & go instructional video 1
Timed up & go instructional video 2
4m walk test instructional video
400m walk test instructional video
Exemplars of evidence-based care in practice
Assessment of skeletal muscle via CT
Nutrition care pathway for upper GI cancer surgery
Prehabilitation program for patients undergoing GI surgery
Advocating with the MDT for a business case to establish a new clinical service
How to train clinicians in new assessment measures
Patient case studies
[Content to be added in phase 2 of project]
[Content to be added in phase 2 of project]
Audit tool
AACTT framework day therapy units
AACTT framework radiotherapy outpatients
AACTT framework rural / community
Generic pathway
Generic pathway (editable version)
Generic pathway (worked example)
Example clinical indicators
Checklist to identify and address barriers to screening and assessment
Implementation theories, models and frameworks
Making sense of implementation theories, models and frameworks
Process models describing the process of translating research into practice
Understanding or explaining what influences implementation outcomes
Consolidated framework for implementation research (CFIR)
Theoretical domains framework (TDF)
Evaluating Implementation
Proctor’s outcomes for implementation research
Frameworks to define implementation strategies
Proctor’s recommendations for specifying and reporting implementation strategies
Next steps
This project forms stage 1 of a larger planned staged implementation process to develop a toolkit to support implementation of the COSA position statement on cancer-related malnutrition and sarcopenia and evaluate the outcomes of implementation.
The project is planned to be a staged implementation process conducted over three stages:
Stage 1: Develop and disseminate toolkit content to support screening and assessment of cancer-related malnutrition and sarcopenia
Stage 2:Develop and disseminate toolkit content to support treatment and transition of care of cancer-related malnutrition and sarcopenia
Stage 3: Evaluate implementation of the toolkit via a pilot test in 2-3 health services and a survey of cancer clinicians
Feedback from users
We welcome feedback from toolkit users. If you have any comments or suggestions to improve the toolkit please email [email protected].
COSA would like to thank the Cancer-Related Malnutrition and Sarcopenia Working Group members for their outstanding contribution and acknowledge the Chair, Ms Jenelle Loeliger and project dietitian Ms Jane Stewart for leading this project.
COSA also thanks the oncology clinicians and stakeholders who contributed to the development and review of the toolkit and gratefully acknowledges the feedback provided during the end-user review.
Project Team members
Ms Jenelle Loeliger AdvAPD- Chair
COSA Nutrition Group Chair, Manager Nutrition and Speech Pathology, Peter MacCallum Cancer Centre
Ms Jane Stewart APD - Project Dietitian
Clinical Lead Dietitian, Peter MacCallum Cancer Centre
Prof Judy Bauer
Professor Nutrition, Dietetics and Food, Department of Nutrition, Dietetics and Food, Monash University
A/Prof Merran Finlay
Executive Research Lead, Cancer Nutrition, Royal Prince Alfred Hospital
A/Prof Nicole Kiss
Victorian Cancer Agency Clinical Research Fellow Co-lead, Exercise and Nutrition for Cancer Research Group, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University
Project Steering Committee members:
Ms Jenelle Loeliger - Chair
Ms Jane Stewart - Project Dietitian
Prof Judy Bauer
A/Prof Merran Finlay
A/Prof Nicole Kiss
Dr Brenton Baguley
Lecturer in Dietetics, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University
A/Prof Steve Fraser
Discipline Lead Clinical Exercise, Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University
Prof Sandra Hayes
Senior Research Fellow, Menzies Health Institute Queensland, Griffith University
Ms Catherine Johnson
Cancer Nurse Coordinator, Calvary Mater Newcastle
Dr Chris Lomma
Medical Oncologist, Fiona Stanley Hospital
Dr Carolyn McIntyre
Senior Lecturer, Exercise Medicine Research Institute, School of Medical and Health Science, Edith Cowan University
Ms Tracey Nicholls
ENT Nurse Practitioner, Flinders Medical Centre
Dr Lina Pugliano
Medical Oncologist, Northern Cancer Institute / Cancer Fit Australia
A/Prof Tina Skinner
Senior Lecturer in Clinical Exercise Physiology, School of Human Movement and Nutrition Sciences, University of Queensland
Instructional video working group members:
Ms Jane Stewart - Co-facilitator
A/Prof Nicole Kiss – Co-facilitator
A/Prof Steve Fraser
Ms Tracey Nicholls
Ms Amy Bowman
Senior Clinical Physiotherapist, Peter MacCallum Cancer Centre
Ms Megan Sanders
Clinical Oncology Dietitian, Peter MacCallum Cancer Centre
Generic pathway and audit tool working group members:
Ms Jane Stewart - Co-facilitator
Ms Jenelle Loeliger - Co-facilitator
Prof Sandra Hayes
Dr Chris Lomma
Mr Shane McAuliff APD
Oncology/Research Dietitian, Chris O'Brien Lifehouse
Ms Louise Moody AdvAPD
Director Dietetics, Allied Health & Clinical Support Services, Mackay Hospital and Health Service
Case studies and tips to overcome barriers working group members:
Ms Jane Stewart - Co-facilitator
Prof Judy Bauer - Co-facilitator
A/Prof Merran Finlay - Co-facilitator
Dr Brenton Baguley
Ms Catherine Johnson
Dr Carolyn McIntyre
Dr Lina Pugliano
Ms Manelle Challita
Physiotherapist, Chris O'Brien Lifehouse
Ms Carol Chan
Physiotherapist in Continence and Pelvic Floor Disorder, Cancer Rehabilitation, Digestive Pelvic Floor Centre
Dr Ashfaq Chauhan
Postdoctoral Research Fellow and Patient Safety Movement Foundation Fellow, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University
Ms Tiffany Jones
Oncology Dietitian, Calvary Mater Newcastle
Dr Michael Krasovitsky
Medical Oncologist, The Kinghorn Cancer Centre
Conjoint Senior Lecturer, University of New South Wales
Ms Marina Nguyen APD
Clinical Oncology Dietitian, Nutrition and Dietetics Department, Alfred Health