Abstract
Background/Aim: Cancer and its treatments often lead to patient malnutrition. The aim of the study was to identify the difficulties that cancer patients face in relation to their nutrition, to determine the importance of nutrition in their daily lives and to identify the reasons for their weight loss. In addition, the study aimed to capture the perspectives of the healthcare professionals and determine how the nutritional status of the individual patients plays a role in everyday clinical practice.
Patients and Methods: Using an interview guide with open questions, structured interviews were conducted with ten patients who had suffered unintentional weight loss of more than 5% in the last three to six months, five nurses, and five doctors on an oncology ward in Bad Hersfeld hospital. Responses were analysed qualitatively using Mayring’s content analysis method.
Results: All patients reported diet-related symptoms. The main causes cited were side effects of treatment. All patients had questions about their nutrition. Healthcare professionals indicated that the patients considered the problem of malnutrition to be high, but that there was no uniform treatment concept or general screening. Perceptions of interdisciplinary communication were mixed. There was a lack of information regarding sources of information and counselling services among both professional groups.
Conclusion: Standardised interviews should be conducted as part of treatment to identify individual patient problems. As there has been no standardised approach to detection, prevention and treatment, an interdisciplinary reassessment and discussion of treatment issues is required to understand and address the complex problem of malnutrition.
Introduction
Nutrition plays a central role in the treatment of cancer patients because these patients have an increased risk of malnutrition. Reasons why cancer patients often struggle with malnutrition and weight loss can be reduced food intake due to cancer or treatment-related side effects. Moreover, increased metabolic performance due to various inflammatory reactions also plays a role (1). This leads to poorer quality of life and a worse prognosis (2-4). Tumor cachexia can be a serious consequence of malnutrition and often occurs during cancer treatment, but it also plays an important role in other diseases. Untreated tumor cachexia weakens the patients due to loss of weight and muscle mass (5). This loss of muscle mass and weight then exacerbates side effects and complications associated with cancer treatment. As a result, morbidity and mortality of patients increase. In contrast, early nutritional intervention may not only improve the well-being and quality of life of patients but can also improve their prognosis (6).
There is a high prevalence of malnutrition in oncology wards. One study has shown that approximately 31% of cancer patients are malnourished (7). Nevertheless, the majority of malnourished patients remain undetected and therefore untreated in everyday clinical practice (8). One reason for this undertreatment is thought to be the insufficient assessment of nutritional status and the lack of knowledge among medical and nursing staff on appropriate screening procedures and adequate measures to be taken in case of malnutrition (9, 10). This may also be the reason why less than a third of patients are offered nutritional counselling (11).
The aim of this study was to take a closer look at nutrition-related problems in cancer patients in order to treat them as effectively and individually as possible and thus reduce the occurrence of malnutrition. The structured interviews should also reveal exactly which measures the patients benefit from, which resources are particularly useful to them both during their inpatient stay and in the outpatient area, and which social structures are important to them. In addition, the study should also provide insights into the measures taken by nursing staff. What is important here is the extent to which the individual professional groups react to the problem of malnutrition and how often the problem occurs in everyday clinical practice. The interviews with the healthcare professionals should provide an insight into how they assess the problem of malnutrition. Is it underestimated or do their views coincide with the findings already described in the literature? Problems in interprofessional co-operation should be uncovered and the structured interviews should help to clarify what actions should be undertaken by the staff to combat malnutrition. Through interviews with patients, nursing staff, and physicians, the study aimed to provide a holistic picture of the complex problem of malnutrition in oncological patients in order to better understand the heterogeneous problems in care and thus close gaps in care.
Patients and Methods
A medical student conducted the interviews in the oncology ward of a hospital located in Hesse, Germany. The participants were interviewed in person and conversations were initially recorded on a dictaphone for transcription purposes. The transcription was carried out by the interviewer. The transcripts were anonymised and analysed anonymously. The study participants gave their written consent to the anonymous processing of their data, which they could revoke at any time.
Ethical approval. The research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. All procedures performed in the study complied with the ethical standards of the Ethics Committee of the University Hospital Jena, Reg. No.: 2022-2646_1-Bef and the Hessian State Medical Association Procedure No.: 2022-3017-zvBO. Participation in the interviews was voluntary and had no influence on the oncological treatment of the patients. All patients gave their written consent to participate in the study and to the anonymous analysis of the data.
Inclusion criteria of patients. Inclusion criteria for the patients were a cancer diagnosis, sufficient knowledge of the German language and unintentional weight loss since the onset of the disease. The weight loss should be more than 5% of their initial weight in the last six months. No distinction was made regarding the type of cancer diagnosed in the patients. The patients were accommodated in the oncology department of the Hessian hospital.
Inclusion criteria of healthcare professionals. Inclusion criteria for healthcare professionals were occupation on a cancer ward and work with cancer patients. The staff was employed in the oncology department of the Hessian Hospital.
Development of interview guidelines. First, a literature search was carried out on the topic of malnutrition in cancer patients and on interventions by healthcare professionals. Based on this literature research, overarching topics were identified in order to determine which changes and problems in nutrition are associated with an oncological disease. The overarching topics included the patients’ social situation, eating habits before and after illness, prior knowledge about nutrition, and restrictions in their daily lives. The topics for the questions asked to healthcare professionals were also developed on the basis of the literature research. However, the focus was placed on professional experience, the discussion of malnutrition during training and studies, measures taken to prevent and treat malnutrition and the assessment of the relevance of the topic in everyday clinical practice. The aim was to determine the extent to which the problems described in the literature occur in everyday clinical practice and whether evidence-based findings on the prevention and treatment of malnutrition are being actively applied. Open-ended questions were used to allow patients and staff to respond freely and describe their everyday lives as accurately as possible, enabling a more comprehensive presentation of their individual actions and experiences. Participants were interviewed using a semi-structured interview, which was recorded using a dictaphone. A detailed transcript of each interview was then prepared.
The exact content of the interviews can be found in the following text under “Interview with patients”, “Interview with nursing staff” and “Interview with physicians”.
The detailed structure of the interviews can be found in the interview guide in the attached supplementary material.
Interview with patients. Patients were asked to report their weight before treatment and their current weight. At the beginning, general information such as age, height, type of neoplasm and onset of the disease was obtained. The interview was structured as follows:
Introductory question
Social status (current housing situation, family situation, family support).
Key questions
Pre-illness dietary behavior (meal times, meal preparation, diet, nutritional education, cultural restrictions);
Dietary behavior during treatment (side effects, loss of appetite, changes in taste, restrictions in hospital, changes in diet);
Information about nutrition in oncology (sources of information, advice at the hospital, coping with weight loss, hospital interventions);
Restrictions in daily life (digestive problems, hobbies, performance, sports activities).
Final question
Summary and important additions.
Interviews with healthcare professionals. The survey was also conducted as a semi-structured interview. Interviews were structured as follows:
Interview with nursing staff.
Introductory question
Professional background (time in nursing, time with cancer patients)
Key questions
Topic of nutrition in education (continuing education, designated contacts, additional qualifications, guidelines);
Recognition of malnutrition (weight checks, Body Mass Index, assessment tools, e.g., the WHO scale of general wellbeing, reassessment);
Nursing interventions for malnutrition (information sharing, sources of information, symptom management, oral nutritional supplements);
Interdisciplinary collaboration (counselling services, team meetings);
Relevance of malnutrition in cancer patients (perception of the problem, occupational group differences, relevance to patients).
Final question
Summary and important additions.
Interview with physicians
Introductory question
Professional background (time as a physician, time with cancer patients)
Key questions
Topic of nutrition in education (continuing education, scientific studies, guidelines);
Recognition of malnutrition (assessment tools, indicators);
Medical interventions for malnutrition (enteral and parenteral nutrition, symptom management, micronutrient administration);
Interdisciplinary collaboration (counselling services, team meetings, information on cost coverage, commissioning of nutritional counselling);
Relevance of malnutrition in cancer patients (perception of the problem, professional differences, relevance for patients, working according to guidelines).
Final question
Summary and important additions.
Evaluation. A content analysis according to Mayring, which is a structured method for evaluating interviews, was carried out and presented in a mind map for each group of participants. The three mind maps created based on the interviews can be found in the supplementary material under the titles “evaluation of interviews with physicians” (Figure 1), “evaluation of interviews with nurses” (Figure 2), and “evaluation of patient interviews” (Figure 3). This evaluation process is rule-based, which means a fixed procedure and predefined steps are followed for the analysis. The individual categories described in the text above were created based on the interviews, and statements were classified into the respective categories. The interviews of the three participant groups (patients, nursing staff and physicians) were analyzed separately. The available transcripts were initially collected under a pseudonym and later analyzed anonymously.
Evaluation of physician interviews. In the physician interviews, each color represents an overarching theme under which statements were systematically categorized. Yellow indicates interdisciplinary collaboration. Dark blue represents opportunities for continuing education. Light green refers to the consideration of scientific studies. Red denotes the use of clinical guidelines. Dark green reflects the assessment of the relevance of malnutrition. Dark pink highlights educational aspects. Light blue indicates interventions carried out by medical staff. Violet refers to professional career development.
Evaluation of nurse interviews. In the nurse interviews, each color represents an overarching theme under which statements were systematically categorized. Yellow signifies interdisciplinary collaboration. Light green refers to the identification of a contact person. Dark blue represents opportunities for continuing education. Light blue indicates specific nursing interventions. Dark green reflects the assessment of the relevance of malnutrition. Red denotes the use of clinical guidelines. Dark pink highlights educational aspects. Violet refers to professional career development.
Evaluation of patient interviews. In the patient interviews, each color represents an overarching theme under which statements were systematically categorized. Red indicates interventions carried out by medical staff. Light green reflects personal habits. Pink denotes weight loss. Light blue highlights limitations experienced in daily life. Turquoise blue refers to eating habits associated with the medical condition. Dark blue captures aspects of social inclusion. Violet describes the living situation. Dark pink represents eating habits prior to the onset of illness.
Results
Demographic data. From August 2022 to October 2022, ten patients with an underlying oncological disease participated in the qualitative interviews. Detailed demographic data are shown in Table I.
Demographic data of patients (N=10).
Of these ten patients, eight were female and two male, with a mean age of 75 years. The BMI was between 18.8 kg/m2 and 35.6 kg/m2 and the mean BMI was 25,4 kg/m2. The exact extent of weight loss in patients with underlying oncological disease can be seen in Table II.
Weight loss of patients (N=10).
On the same hematology/oncology ward, in addition, five members of the nursing staff and five physicians were interviewed. Four female and one male nurse were interviewed, as well as three male and two female doctors. The doctors’ work experience with oncological patients was between one month and 20 years. The nursing staff had between two and 28 years of work experience. Detailed demographic data are shown in Table III.
Demographic data of nurses (N=5) and physicians (N=5).
Analysis of the patient interviews. Dietary behavior before the disease. Six out of ten patients cooked for themselves before the onset of the disease. Almost all patients stated that they consumed home-cooked food, but paid attention to less meat. None of the patients had a vegetarian or vegan diet. Most of the patients had no previous education or special preoccupation with their diet. Three patients had dealt with nutritional restrictions for diabetes because they themselves or their partner had diabetes. One patient had a history of an eating disorder that had influenced eating behavior before the oncological disease.
Changes in diet with the disease. Nine out of ten patients said that their diet had changed somewhat or a lot. This was mainly due side effects of the treatment, but also to restrictions caused by the underlying cancer. Loss of appetite, changes in taste, nausea, vomiting, diarrhea, difficulty in swallowing and weakness or fatigue were reported as side effects and symptoms. There was no difference between male and female patients. Both had problems such as loss of appetite, nausea or physical weakness. Yet, problems increased with duration of treatment.
Patient: “[…] Well, with the disease now, everything was just disgusting to me. When I think about it, for example, about lunch. I look at it and eat three forks full. But it can taste so good and it does taste good, but I can’t eat it. […]” (Interview 6)
Patient: “[…] I can’t do anything by myself. I am much too weak for that. I have no strength left. […]” (Interview 6) Interventions by healthcare professionals. Seven out of ten patients received supplementary nutrition either in the form of parenteral nutrition or high-calorie drinks. In addition, the patients reported oral care in case of dry mouth or mucositis and symptoms such as nausea, vomiting or diarrhea were mainly treated by drugs by the healthcare professionals and less often by additional dietary changes. Addressing weight loss, offering information and moral support from the staff were also important to the patients. Active enquiry about problems and empathetic care by healthcare professionals were particularly emphasized by the patients in the interviews and seemed to be a great support to them. By treating the side effects, gaining information and having access to additional nutritional offerings such as high-calorie drinks, the patients’ condition was stabilized or even improved during inpatient treatment, according to their own statements.
Patient: “[…] I receive artificial nutrition here. A bag like this overnight. It then runs for ten hours.[…]” (Interview 5)
Patient: “[…] A lot of support. Morally and this whole ward I would really like to emphasize. […]” (Interview 1)
But it was also apparent that weight checks and follow-ups regarding weight loss were performed irregularly.
Interviewer: “[…] Did anyone ask you about it (the weight loss) from the staff?”
Patient: “No, not that. […]” (Interview 10)
Social involvement. Eight patients lived together with their partners who supported them. Nine patients described that their partners supported them in performing daily tasks and had taken over many tasks since the onset of illness. In particular, support with chores around the house and with cooking or grocery shopping was mentioned. However, for all patients, emotional support from the partnership was especially important. The patients stated that they ate even though they often lacked the feeling of hunger and appetite, in particular because of shared meals. The fixed mealtimes with partner or family were important for the patients in the outpatient setting and they stated that they would have eaten significantly less without these.
Patient: “[…] Yes, we already have our fixed times. And that hasn’t changed much now. I always got up for meals. Never in bed even when it was difficult. […]” (Interview 2)
They also suggested that the weight loss would probably have been higher without the partner and family.
However, one interviewed patient stated that her husband was in need of care and that she had cared for him until she was admitted to hospital. There was a high level of stress in connection with the need for care and a significantly unhealthier eating behavior.
Patient: “[…] I have been eating less and less for some time. That’s why I lost weight. I simply wasn’t hungry. All the work and I also did the washing and ironing myself. […]” (Interview 8)
Nine patients stated that they had children and/or grandchildren. In particular when children lived nearby, but also when they lived far away, the support received from the patients’ children was emphasized. This also extended to help with everyday tasks, as well as financial and emotional support. Helping with the organization and attending of appointments, e.g., with doctors were especially mentioned as support provided by the children. Living nearby made it easier for relatives to recognize weight loss and to talk to patients about it. Only three patients stated that they used external help in the form of domestic help or nursing services.
It was clear from the interviews that family support was particularly important to the majority of patients, that they valued it highly and that they themselves would have estimated the weight loss to be greater than it was at the time of the interview without family support.
Restrictions in daily life. All patients reported that they had experienced some restrictions, in some cases a complete restriction, in everyday life, due to their disease.
Interviewer: “[…] Has your fitness level changed in the last few weeks? […]”
Patient: “Yes, very much. Well, I could hardly walk up and down stairs anymore and I was so tired and exhausted. I am normally very active. So, shopping and things like that were no longer possible. I just dragged myself from corner to corner […]”. (Interview 7)
The most common reason given was a significant decline in condition, often associated with weight loss. This limited the ability to pursue hobbies and maintain social contacts.
Analysis of the interviews with healthcare professionals. Professional background. Both professional groups were asked about their professional background and experience with cancer patients (Table I, Table II). Experienced colleagues in the nursing team or colleagues with an oncological specialist education were indicated as contact person for nutrition-related questions. All respondents stated that there was no fixed contact person within the team. It became apparent that team members experienced in dealing with cancer patients served as contact person for less experienced colleagues.
Nurse: “[…] No, there is no direct contact person. I would say that if you have any questions, you simply contact an experienced colleague. But yes, if I have specific questions, then I would go to the specialist nurse. […]” (Interview 11)
Respondents repeatedly stated that the topics of nutrition and malnutrition had played little or no role in their general professional education or studies. The topic of nutrition and malnutrition in cancer patients was dealt with in more detail only in specialized further education.
Interviewer: “[…] Ok, and to what extent was the topic of nutrition in general and malnutrition in cancer patients addressed in the education and in the specialized education?”
Nurse: “Not really at all during the education. In the further education more often. […]” (Interview 12)
Working according to guidelines. Regarding information about guidelines for patients with malnutrition, 80% of the nurses stated that they did not know any guidelines on this topic. One of the nurses interviewed stated that she had found a guideline on this topic after doing her own research on quality management, but other than that had never received any information about it. However, the nursing staff were aware of other guidelines on the topics of oral care or nutrition in the case of reverse isolation, and they also worked according to these.
Nurse: “[…] There is a guideline on the topic of oral care in cancer patients and actually also a guideline for malnutrition in cancer patients. I looked that up again beforehand. You can find it in the quality management section. But that was actually an own contribution, so there was never any information that there was something like that and where to find it. […]” (Interview 17)
Physicians were not aware of any guidelines and only one knew of scientific studies on the topic of malnutrition in patients with cancer.
Similarly, all staff members stated that there was no general screening or procedure for malnourished patients.
Specialist: “[…] Of course there are these screening sheets, but we don’t actually use them here. Of course, that’s bad, I know that, but that’s the way it is […].” (Interview 13)
This lack of information can lead to patients with malnutrition not being identified or being identified too late.
Interventions by healthcare professionals. The healthcare professionals focused on observing patients’ physical condition and eating behavior, physical examinations and discussions with patients and relatives to record nutritional status. Nursing staff also focused on nursing interventions such as eating and drinking protocols, positioning plans, oral care and skin protection measures.
Nurse: “[…] If the patients are very cachectic, we already look for skin defects. Especially if the patients are very weak and rather immobile, we pay a lot of attention to the skin. We position them and so on. Of course, they are then also placed in an anti-decubitus bed. […]” (Interview 12)
For physicians, laboratory checks, the search for the cause of malnutrition and the prescription of medication to alleviate the side effects of therapy were more important. Both professional groups saw the highest benefit in optimizing patient nutrition and increasing calorie intake with oral nutritional supplements, initially orally and later parenterally.
Specialist: “[…] First, we try to find out why the patient is losing weight. Whether it’s the side effects of the therapy, like nausea or loss of appetite. Or perhaps the tumor is not well controlled. That could lead to tumor cachexia. Or whether it is a local problem, for example, a stomach ulcer or whatever. And we try to find the cause of that first. Then if we see that we can’t optimize their own diet, then we first try to support the patient with high-energy drinkable food. If we see that this is not enough, we actually give parenteral nutrition directly. […]” (Interview 13)
Communication and consultation with patients, but also with their relatives, was an important point for the healthcare professionals. This gave them important information about the eating habits of the patients in the home environment. Our study showed that, during the corona pandemic, communication with relatives was severely restricted for staff and made patient care more difficult.
Nurse: “[…] Yes, very different conversations were possible. During the corona pandemic, it became even more important for us to question and look at the patients when they were admitted. In the past, the son, daughter or other relatives would say on the way to the bed that the patient is not eating enough. In this way, a lot of information is lost. Otherwise, the relatives were much more involved, also with information about nutrition. […]” (Interview 19)
Interdisciplinary collaboration. A particular focus of the survey was put on interdisciplinary collaboration between nurses and physicians, but also with other professions such as diabetes counsellors and dietitians. There were clear discrepancies between nursing staff and physicians. Both reported good collaboration between nurses and physicians. Good communication and information transfer were emphasized. Suggestions were also discussed among the team members and indications of malnutrition were passed on. This improved the quality of treatment for patients with malnutrition. However, while the nursing staff stated a good collaboration with diabetes and nutrition counsellors, physicians could not confirm this. They said that diabetes counselling was very present on the ward, but that nutrition counselling was hardly involved at all in the treatment.
Interviewer: “[…] Ok, and how does the interdisciplinary cooperation with the nutritionists work? Resident: “Here really not at all. In other hospitals where I have worked, it worked well. But here I haven’t seen them at all. I also think it’s partly due to the lack of staff. […]” (Interview 18)
For both professional groups, however, there was a large information gap regarding information and counselling services offered by the hospital. All interviewed staff members stated that both physicians and nurses see the topic of malnutrition as very present and relevant in everyday clinical practice and that there was still potential for improvement in the care of these patients.
Nurse: “[…] The topic of nutrition in general is a very big issue. Because of the tumor, which really needs a lot of energy, you have to make sure that the patients are not malnourished. You have to take countermeasures beforehand. […]” (Interview 12)
Discussion
In our study of patients and healthcare professionals, we were able to show that nutrition is a central issue from the patients’ point of view and professionals are also aware of this. However, due to time and personnel constraints, there is a lack of time, knowledge, or comprehensive examination of this topic.
It is noteworthy that the BMI of all interviewed patients ranged from the lower end of the normal spectrum (19 kg/m2) to the obesity range (36 kg/m2). Nevertheless, weight loss was dramatic in some cases. The minimal weight loss in our collective was 3 kg with an initial weight of 91 kg. At the time of the interview, the patient was receiving her first chemotherapy and was therefore still at the beginning of her treatment. The largest weight loss was 39 kg with an initial weight of 105 kg. This patient had a lung carcinoma that had been diagnosed a year ago and had already received significantly more treatment. In summary, our data show a gradual increase in weight loss with the duration and extent of treatment. Another patient with lung cancer lost 109 kg within three years. However, this weight loss was assessed as an outlier, as it was not possible to clearly define whether the extreme weight loss was due to a grief reaction caused by the man’s death or to the tumor disease that followed. Especially patients who previously have a BMI in the overweight or obese range are less attentive with respect to their weight loss and often not aware of how severe their weight loss is. This leads to the important finding that overweight patients are less likely to take a critical view of their own and the healthcare professionals often take action later with these patients. Neither patients nor staff had information about nutritional counselling and patients also stated that they were unaware of any resources for researching validated information. However, they often have nutrition-related questions and are open to suggestions on how to improve their nutritional status.
Identifying those at increased risk of losing body mass can be difficult due to the unequal distribution of losses across muscle and fat compartments. Especially people who suffer from obesity but still show clear signs of malnutrition have the greatest risk of adverse events and often remain undetected in everyday clinical practice. For this reason, various studies highlight the association of low body mass with a worse prognosis in patients with cancer (12).
In this study, the highest weight losses were recorded in two patients with lung carcer. Other studies primarily associate malnutrition with tumors and therapies that affect the gastrointestinal tract, on the one hand through their direct influence on nutrition, for example through reduced absorption, and on the other hand through the indirect influence of the therapy of these tumors (13). Even with cancers that are not related to the gastrointestinal tract, there is sometimes serious weight loss, as this study confirms existing studies. As an example, a study found that patients with lung cancer often suffer from malnutrition, especially in advanced stages of the disease, which worsens the outcome of the patients (14). The study by Büntzel et al. also describes significant differences in survival rates among patients with head and neck tumors depending on their nutritional status. Malnourished patients had a median survival time of 13.84 months, while patients of normal weight had a median survival time of 51.16 months (15). It appears that patients with tumors in the head and neck area in particular benefit significantly from good nutritional status. Especially in the case of tumors that can lead to restricted oral intake of food, good nutritional status appears to improve the prognosis.
In the interviews, the patients stated that they ate less than before their illness and that their food intake was reduced especially during hospitalization. They reported that this reduced food intake even continues after returning home. In another study, it was also confirmed that over 50% of the patients did not eat the full meal they received from the hospital and even a larger proportion ate only 25% of their meals. Yet they did not receive any support in the form of additional artificial feeding (16). It has also been noted that often problems with oral intake of food and the toxicity of cancer treatment cause patients to lose weight (17). This also means that patients who lose weight must pause or stop treatments because they cannot continue treatment due to side effects. To ensure long-term therapy, side effects need to be adequately managed and patients with cancer need to receive a nutritional assessment followed by individualized nutritional counselling.
In our interviews, half of the patients stated that they often felt overwhelmed with questions regarding their nutrition during the disease and therapy. This can be confirmed with other studies in which more than half of cancer patients, irrespective of weight loss, have questions regarding their diet (18). These numbers demonstrate the high information need, which should be considered in the clinical care of patients with cancer.
One key point of our study is that almost none of the patients actively ask questions concerning nutrition. Despite that, patients are open for advice on nutrition and would like to receive counselling on how to improve their nutritional status, even if they do not actively ask for it. They hardly know any sources of information, and they rarely use the few they know. A lack of realization of the nutrition problem by the affected patients themselves was already shown in another study (19). This could be one of the explanations for patients not actively seeking information. Another study has also shown that patients value advice from health professionals and act on it if they agree with the suggestions and they find them useful (20). This can be used as an opportunity to supply important information and suggestions through adequate counselling to patients for improving their nutritional status.
Especially symptoms like loss of appetite, changes in taste and side effects like nausea and vomiting played a role in a large number of patients in this study, as already shown by previous studies (21). Our study also shows that reducing the side effects of therapy is not enough to reduce weight loss. In the interviews, the patients said that they benefitted greatly from the relief of symptoms, but that weight loss often cannot be prevented. In order to counteract this, patients should additionally be offered regular nutritional advice to improve their nutritional status in the clinical and outpatient settings. In addition, the study by Sambataro et al. showed that functional inflammation parameters can also indicate an increased risk of malnutrition. In combination with the Mini Nutritional Assessment screening test, patients who need nutritional support can be identified (22).
However, this study also showed that patients lose weight in the home setting and regain weight in inpatient care, often through enteral or parenteral supplementary nutrition. Parenteral feeding is an effective means in the clinical setting and may also be done at home. However, it imposes an additional burden on the patients and goes along with losses in quality of life. Moreover, invasive methods should only there are no other means and never are a substitute for counselling.
Our study demonstrated that patients and their relatives try to improve the patients’ nutritional status in order to alleviate the side effects or improve the prognosis. Unfortunately, many patients often receive not scientifically based information with unproven benefits for patients. In this context, it is also important to provide patients with scientifically correct information so that they do not resort to dubious information from the internet (23).
Patient: “[…] He [her husband] tried a lot to make me eat more. Especially lots of carrots and the superfoods. I think it comes from Germany. It’s supposed to help like antibiotics. […]” (Interview 3)
Our study showed that family and acquaintances play a crucial role in the treatment of patients. Especially in the context of nutrition in the outpatient area, the family plays a major role. Relatives are aware of patients’ dietary habits and address issues when patients do not. Further studies confirm that the family and acquaintances are very important for all patients. They play an important role for patients in the course of the disease and during oncological therapy (24). As described in the previous text, our study indicated that during the corona pandemic, communication with relatives was severely restricted for staff and made patient care more difficult.
Study limitations. Patients were only interviewed once. Furthermore, the representativeness of the groups is questionable due to the small size of the interviewed groups. As a result, the evidence of the results is limited. In order to determine the relevance of the individual findings, a larger group of patients and staff at different clinics should be interviewed. The weight loss of the patients could only be estimated based on their reported weight at the time of diagnosis and their current weight. For this reason, the information on the exact amount of weight loss may be inaccurate. In order to correct this, further studies should take care of the patients from the first admission, if possible, and observe their weight during the treatment. In addition, only patients who presented signs of malnutrition or cachexia were selected. However, it was not possible to determine whether the weight loss was due to the loss of muscle mass, fat mass or both. This can be relevant for prognosis but also influences patient limitations and the success of measures taken by staff. Further studies could use measurements such as bioelectrical impedance analysis to measure the proportion of muscle mass in the body during treatment. It was also not possible to precisely determine at what point during weight loss patients began to experience limitations in their physical fitness or their ability to manage daily activities. Often, the patients could not name a point in time, and it was difficult for them to assess their weight loss. Patients could be given a questionnaire from the start to assess their performance.
Conclusion
The interviews with healthcare professionals show that a uniform approach to patients with signs of malnutrition is crucial for the quality of care. Since malnutrition in patients leads to a variety of problems, close interdisciplinary and uniform cooperation and procedures between nutritionists, physicians and nurses are important to achieve good results in nutritional medicine in the oncological setting (25). To achieve this, an interdisciplinary case presentation and discussion of nutritional problems and measures would be a conceivable solution.
Nutritional therapy should become an integral part of the treatment of patients with cancer (11, 25). A standardized screening for malnutrition in patients with cancer can be established upon admission and re-evaluated upon re-admission to achieve this. The holistic and interdisciplinary treatment of patients can be summarized as improved nutritional management.
The advice given to patients with cancer by healthcare professionals is based more on experience-based knowledge in dealing with nutritional problems and less on studies on this topic. This reduces the quality of information. One reason for this is that the topic of nutrition is a secondary topic in professional education and further education, and staff often lacks an evidence-based information basis for the care of malnourished patients. For this reason, the topic of malnutrition must be integrated into the curricula for initial and further training in order to raise awareness of the problem of malnutrition and enable evidence-based treatment.
To ensure that health professionals provide the best possible care for these patients, education in the Nutrition Pathway and a comprehensive nutritional screening programme can help. Physicians and nurses can find information, for example, in the ESPEN guideline (European Society for Clinical Nutrition and Metabolism) or in the S3 guideline of the German Society for Nutritional Medicine (DGEM) (25, 26). As a standard, all patients with cancer should receive individualized nutrition counselling at the start of treatment by a dietician. As an alternative, nurses with specific education in nutrition could be involved in the therapy as a constant contact person or nutritionist. In addition, a questionnaire should be given to patients to answer screening questions independently as part of their treatment in everyday clinical practice. This could be modelled on the Scored Patient-Generated Subjective Global Assessment questionnaire. This provides an initial assessment of the nutritional status (27). However, to obtain an individualized assessment of the patient’s problems, a much more intensive discussion would be necessary, which is often not possible in everyday clinical practice due to the significantly limited time per patient. As all healthcare professionals stated that malnutrition is important in oncological patients but there is no standardized approach, there is a risk that the problem will not be addressed in everyday clinical practice. As malnutrition has a significant impact on patients’ quality of life, as the interviews with patients revealed, this topic should be given a much greater attention in treatment. Unfortunately, both in teaching and in everyday clinical practice, this important topic is often merely addressed superficially and not approached in a consistent or systematic manner. This must be improved significantly in the future to ensure that patients receive holistic care.
Acknowledgements
The Authors are deeply grateful to the patients, nurses, and physicians who participated in the interviews and contributed their time and insights to this study.
Footnotes
Authors’ Contributions
Ms Armbrust and Prof. Dr. Hübner had the idea for this study. They developed the method of the study and Ms Armbrust conducted the interviews. Ms Armbrust drafted the article and wrote the final manuscript after the critical review of Prof. Dr. Hübner, Ms Mathies and Ms von Grundherr. Mr. Prof. Dr. Metzelder and Mr. Vasilev accompanied the study on the oncology ward and supported the finalization of the manuscript. They also provided the patients and medical staff on the ward.
Conflicts of Interest
The Authors declare that there is no conflict of interest within the meaning of the guidelines of the International Committee of Medical Journal Editors.
Funding
The study was not funded.
Artificial Intelligence (AI) Disclosure
No artificial intelligence (AI) tools, including large language models or machine learning software, were used in the preparation, analysis, or presentation of this manuscript.
- Received June 6, 2025.
- Revision received September 19, 2025.
- Accepted September 30, 2025.
- Copyright © 2025 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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