Anna Boltong

A Prospective Cohort Study of the Effects of Adjuvant Breast Cancer Chemotherapy on Taste Function, Food Liking, Appetite and Associated Nutritional Outcomes

Background ‘Taste’ changes are commonly reported during chemotherapy. It is unclear to what extent this relates to actual changes in taste function or to changes in appetite and food liking and how these changes affect dietary intake and nutritional status. Patients and methods This prospective, repeated measures cohort study recruited participants from three oncology clinics. Women (n = 52) prescribed adjuvant chemotherapy underwent standardised testing of taste perception, appetite and food liking at six time points to measure change from baseline. Associations between taste and hedonic changes and nutritional outcomes were examined. Results Taste function was significantly reduced early in chemotherapy cycles (p<0.05) but showed recovery by late in the cycle. Ability to correctly identify salty, sour and umami tastants was reduced. Liking of sweet food decreased early and mid-cycle (p<0.01) but not late cycle. Liking of savory food was not significantly affected. Appetite decreased early in the cycle (p<0.001). Reduced taste function was associated with lowest kilojoule intake (r = 0.31; p = 0.008) as was appetite loss with reduced kilojoule (r = 0.34; p = 0.002) and protein intake (r = 0.36; p = 0.001) early in the third chemotherapy cycle. Decreased appetite early in the third and final chemotherapy cycles was associated with a decline in BMI (p = <0.0005) over the study period. Resolution of taste function, food liking and appetite was observed 8 weeks after chemotherapy completion. There was no association between taste change and dry mouth, oral mucositis or nausea. Conclusion The results reveal, for the first time, the cyclical yet transient effects of adjuvant chemotherapy on taste function and the link between taste and hedonic changes, dietary intake and nutritional outcomes. The results should be used to inform reliable pre-chemotherapy education.

Experiences and consequences of altered taste, flavour and food hedonics during chemotherapy treatment

PurposeSelf-reported taste alterations are common in people receiving chemotherapy; however, it is usually unclear whether these reports refer to changes to the sense of taste itself or to problems related to the broader phenomenon of flavour, or the hedonic experience of eating and drinking. The purpose of this study was to explore patient and carer descriptions, experiences and consequences of taste and flavour changes associated with oxaliplatin treatment.MethodsThis study utilised a grounded theory research design. Purposeful sampling was used to recruit eligible patients who had self-reported taste changes in relation to oxaliplatin-containing chemotherapy for colorectal cancer. Content analysis of interview data was performed using an analysis framework derived from previous sensory and nutritional sciences and supportive care research.ResultsTen patients and four carers participated in semi-structured interviews. The overarching theme identified from the data was reduced food enjoyment. In addition to changes to taste, participants described sensory and hedonic changes which influence overall flavour perception and food enjoyment. Reduced food enjoyment had dietary, social and emotional consequences for patients and carers.Conclusions‘Taste’ problems during oxaliplatin treatment mostly relate to the broader phenomena of flavour. This study has helped to unravel the major sensory determinants of the eating and drinking experience in the chemotherapy setting and has provided guidance regarding relevant and measurable endpoints of chemotherapy-related flavour changes. There remains a gap in knowledge between the pattern of flavour changes associated with chemotherapy treatment and how this influences dietary intake and nutritional status.

A matter of taste: making the distinction between taste and flavor is essential for improving management of dysgeusia

Dear Editor, Thank you for publishing a suite of systematic reviews of oral complications from cancer therapies, conducted by the Oral Care Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology [1–8]. These reviews were underpinned by a robust and transparent guiding protocol [9]. While the systematic review on dysgeusia [5] adds to the literature on the influence of cancer therapies on oral complications, it failed to accurately define the sense of taste. This means there is little chance for effective strategies to address taste changes in cancer and will lead to further confusion among clinicians. Taste is one component of flavor which also involves two other independent sensory systems, smell and touch [10]. The authors report that, “Dysgeusia is variably defined as an abnormal or impaired sense of taste, an unpleasant alteration of taste sensation, or a distortion or perversion of the sense of taste.” They then go on to write that, “Dysgeusia is closely linked to changes in olfaction as both taste and smell are involved in producing the sense of flavor.” In doing so, they correctly identify that taste is not synonymous with flavor. Indeed, it is taste sensitivity, not dysgeusia as the authors suggest, which is assessed by measuring the taste detection or recognition thresholds for the five basic tastes: sweet, salt, sour, bitter and umami [11]. They state that qualitative (taste) changes are “... reported through patient complaints, interviews and clinical observations.” We argue that such changes refer not to taste but are likely to be influenced by other factors such as the sense of smell and touch, emotional state of mind, and symptomatology of the person. Valid methods of measuring taste are via taste sensitivity and intensity testing [12]. Several published studies have examined the influence of cancer treatment on the sense of taste by measuring taste in this way [13–18]. The authors state in their methodology that, “Dysgeusia was assessed by the presence (Y/N) or grade when available.” It is our assumption then, that when screening papers for inclusion in this systematic review, the “presence of dysgeusia” concerned problems which were not related purely to the sense of taste. Of the 26 papers included in this systematic review, only one paper reports a study which measured taste via a validated method [19]. The other papers used a variety of self-report and observational tools which pertain to flavor and other domains and are therefore not appropriate for scoring taste disturbances although taste alterations are mentioned [20]. Brennan rightly states that well-developed, evidencebased management recommendations have the potential to enhance the appropriateness of clinical practice, improve the quality of oral health care, lead to better patient outcomes, improve cost-effectiveness, and identify areas of further research needs; but to get there, a deeper understanding of the epidemiology of each oral complication is needed [21]. We would argue that definitions of the complications need to be agreed and adhered to before we can explore the epidemiology accurately. Without appropriate categorization of specific problems affecting taste, A. Boltong (*) : S. K. Aranda Melbourne School of Health Sciences, The University of Melbourne, Level 4, 234 Queensberry Street, Carlton, VIC 3010, Australia e-mail: a.boltong@pgrad.unimelb.edu.au

Chemosensory Science in the Context of Cancer Treatment: Implications for Patient Care

IntroductionThis collaborative commentary brings together both clinical and sensory science perspectives in an effort to explain the mechanisms of cancer treatment and the ensuing implications for the sensorium.StrategyThis paper makes the distinction between food hedonics and true chemosensory effects in the cancer context and describes the adverse effects cancer and its treatment have on the eating and drinking experience, including gastronomic, nutritional and emotional implications. Results from a prospective breast cancer cohort study, conducted by an interdisciplinary team of nurses, medical oncologists, dietitians and sensory science researchers shed new light on specific sensory symptomatology associated with chemotherapy treatment and the implications this has for informing reliable pre-treatment patient education.FindingsTwo conceptual models are posed as frameworks for better understanding the determinants and consequences of altered eating and drinking experiences during chemotherapy, as well as the link between patient-reported symptoms and chemosensory or hedonic disturbances.DiscussionApplication of evidence of cancer treatment and its sensory effects in the patient treatment context continues to be a challenge for cancer clinicians, especially where standardised testing of taste and smell function are not able to be practically administered.ConclusionsRecommendations are made for further research and practice pursuits to underpin improved food enjoyment and dietary quality throughout the cancer trajectory. Clinician education of sensory science is also encouraged.

Self-guided interventions for managing psychological distress in people with cancer - a systematic review

OBJECTIVE People with cancer can experience psychological distress but do not always desire, or engage with, professional support to assist with managing distress. Interventions that are self-directed or guided by patients may hold promise as they allow patients to engage with interventions as they need. The objective of this review is to describe and appraise the evidence for effectiveness of self-guided interventions that aim to manage psychological distress in people with cancer. METHODS A systematic search of Medline, PsychInfo and CINAHL identified 15 relevant papers, reporting on 14 studies. RESULTS Of the interventions, three studies comprised hard-copy workbooks, six studies used resource packs, four were online resources and one was a brief multimedia resource. One study was adequately powered and demonstrated a positive effect. Almost all interventions required some level of facilitation. Distressed participants may benefit more from interventions. CONCLUSION Self-guided interventions represent a potentially efficient way of delivering support for people affected by cancer, however evidence supporting them is lacking. PRACTICE IMPLICATIONS There is a need to generate evidence to understand the impact of self-guided interventions for: i) the ideal delivery point in the disease trajectory, ii) patient groups, iii) intervention content and iv) type and mode of delivery.

Using webinars for the education of health professionals and people affected by cancer: processes and evaluation

Technology provides an opportunity to engage with a variety of audiences to provide cancer education, information and support. Webinars are one such format that allow live presentations by experts that can be accessed online, from people’s homes or other convenient locations. In 2015, Cancer Council Victoria (CCV) undertook a program of work to design and evaluate the effectiveness of a suite of webinars: four designed for people affected by cancer and two for health professionals. Webinars included a series of expert presentations, a panel discussion and an interactive component where participants posed questions to the panel. Evaluation included analysis of online metrics and a post-event survey covering experience and satisfaction with the webinar, self-reported changes in knowledge of key webinar concepts and confidence to discuss concepts with health professionals or patients. A total of 438 people participated in the webinars (41.5% of 1056 registrations), and 207 post-event surveys were completed by participants (47.3%). Overall, 90.1% indicated that webinar content was relevant to their interests and needs. Self-ratings of knowledge, awareness of resources and confidence to discuss webinar topics increased after the webinar. The majority (63.9%) had not participated in a webinar before, and 92.6% were interested in participating in future webinars. Over half of respondents (52.8%) had not accessed CCV resources before. This work provided a new opportunity to consolidate consistency of delivery and evaluation of webinars, demonstrating they are an effective, acceptable, accessible and sustainable vehicle for delivering information and support to health professionals and people affected by cancer.

To what extent is alcohol consumption associated with breast cancer recurrence and second primary breast cancer?: A systematic review

BACKGROUND The association between alcohol intake and breast cancer recurrence or development of second primary breast cancer in the survivor population is unclear. The aim of this systematic review was to evaluate the existing evidence to assess the extent to which alcohol consumption is associated with breast cancer recurrence and second primary breast cancer. METHODS Six databases (Cochrane Library, EMBASE, MEDLINE, PubMed, Scopus and Web of Science) were searched using the following search phrase: (breast cancer OR breast adenocarcinoma OR breast neoplasm OR breast tumour) AND (alcohol∗ OR alcohol intake OR alcohol consumption OR ethanol) AND (recurrence OR second primary). A narrative synthesis was conducted on studies meeting the inclusion criteria. RESULTS After screening, 16 studies met the inclusion criteria, of which 11 assessed breast cancer recurrence and 5 assessed second primary breast cancer. Considerable clinical and methodological heterogeneity was observed between studies. Approximately half of the included studies observed a modest, but significant, association between alcohol consumption and increased risk of breast cancer recurrence or development of a second primary breast cancer, with some studies observing associations from as little as six grams of alcohol intake per day. Two studies suggest this association was stronger in postmenopausal women. CONCLUSION There is some evidence that alcohol consumption increases the risk of breast cancer recurrence, particularly in postmenopausal women. The association between alcohol and development of a second primary breast cancer is less clear. Inconsistencies in methodology and results across studies complicate attempts to develop a cohesive interpretation of findings.

Integrating referral to community-based cancer information and support services in a hospital setting

PurposeTo implement and evaluate a hospital-based referral mechanism to increase patient uptake of community-based cancer information and support services. Feasibility and acceptability of the intervention and education program was evaluated. Changes in usage of Cancer Council Victoria’s cancer information and support telephone line were investigated.MethodsA 6-month study was conducted in one metropolitan and one regional cancer treatment hospital. Clinicians attended an education session regarding referral mechanisms to Cancer Council support services. Clinicians completed a questionnaire, and consenting patients participated in a semi-structured telephone interview for the project evaluation. The number of calls made from patients at study sites was monitored.ResultsFifty-two clinicians were trained and referred a total of 430 patients to the cancer information and support service during the study period. Calls from patients increased by up to 100% per month from baseline following the implementation of the referral mechanism. Staff evaluations showed support for the referral mechanism and its incorporation into routine practice. Interviews were conducted with 45 patients; most remembered receiving the referral and were positive towards the intervention. Common reasons patients gave for not acting on the referral included forgetting, lack of need, timing and burden of information.ConclusionsThere is preliminary evidence that this intervention increases awareness and uptake of community-based cancer information and support services. Ongoing clinician education and improvements in patient-clinician communication are important for effective translation from referral to service uptake. Consideration of the most appropriate time in a patients’ care trajectory to introduce a referral is warranted.

Translating Research into Community Practice: The Healthy Living after Cancer Partnership Project.

There is now considerable evidence for physical activity and,increasingly, for weight control interventions in survivors of themore prevalent cancers, especially breast cancer. However, inAustralia, as in most developed countries, such interventions are notincorporated into routine cancer care. The Healthy Living afterCancer (HLaC) project seeks to bridge this evidence-to-practicedivide. HLaC is an Australian National Health & Medical ResearchCouncil-funded Partnership Project involving collaboration betweenuniversity cancer researchers and four state-based Cancer Councils(cancer control advocacy and support organizations similar to theAmerican Cancer Society). The HLaC project, conducted from 2015to 2019, is evaluating the implementation of an evidence-based,6-month, telephone-delivered program targeting physical activity,healthy eating, and weight control among cancer survivors (of anycancer type following treatment with curative intent). The programis offered by the Cancer Councils free of charge via their telephone-based cancer support and information service. Cancer survivors canself-refer or be referred by a treating health professional. Screening,pre- and post-program assessment, and program delivery are all implemented by Cancer Council staff and nurses.In this phase IV dissemination and implementation study (single-group, pre-post design with assessments at baseline and 6 months)(1), primary outcomes relate to program implementation: adoption(referral sources), reach (number of participants) and retention, fidelity of implementation, participant and staff satisfaction, and fixed and recurrent costs of program delivery. Secondary outcomes are patient-reported and validated measures of physical activity and dietary intake/behavior, weight, quality of life, cancer-related side-effects, and fear of recurrence.To date, over 500 cancer survivors have been referred, with 89%screened as eligible and 91% consenting. Among the first 440 to complete the pre-program assessment, 88% were female (most with breast cancer); mean age was 55 years (SD 5 11); with meanBMI 5 29 kg/m2(SD 5 6). Among the first nearly 200 program completers (57% completion rate), significant (P < 0.05) and clinically meaningful improvements have been seen in all secondary patient-reported outcomes.This University-Cancer Council collaboration provides an opportunity for national dissemination of an evidence-based intervention to support healthy living among cancer survivors. Preliminary analysis of service-level outcomes suggests the program is feasible to deliver,with analysis of patient-reported outcomes showing it produces improvements in outcomes important to patients, clinicians, and public health. The end-of-program evaluation, including economic analysis, will provide the practice-based evidence needed to inform decisions regarding program sustainability.

Acceptability and utility of a telephone outcall program for carers of persons with cancer

A systematic review of randomized controlled trials studying the preventive effects of physical exercise, manual and behavioural treatments in acute low back pain and neck painIntroduction: The global financial crisis has left governments struggling to reduce their budget deficits. Loans and taxes are two important financial instruments for governments to close their budget gaps. According to models of temporal discounting and expected utility individuals should experience loans as a greater loss than taxes, depleting psychological resources and reducing individuals’ capacity to cope with stressors. The present research examined patterns of cardiovascular (CV) reactivity associated with exposure to loans or taxes. Methods: We randomised 73 students to one of three groups: loans, taxes, control (baseline). Participants in the experimental groups imagined finishing university with debts and having to repay the sums outstanding as a proportion of their salaried income over the next 30 years either via a loan repayment, or via taxes. Participants in the control group imagined finishing university, and then working in salaried employment over the next 30 years. All participants then performed a variant of the Trier Social Stress Test (TSST), whilst CV responses were monitored [BP (blood pressure), ECG (electrocardiogram), ICG (impedance cardiogram)]. Results: Compared to the control group, participants in the loan group exhibited maladaptive CV responses during the stress task (higher BP and higher total peripheral resistance [TPR]). Conversely, participants in the taxes group exhibited more adaptive CV responses and did not differ from the control group. Conclusions: Economic considerations have dominated debates surrounding macro-financial performance. The present research highlights the need to consider the psychological costs and benefits of tax-based and loan-based financial instruments.