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Spotlight on Supportive Care: The Oncology Dietitian

September 5, 2019
When most people think of cancer care, the work of clinicians such as oncologists, advanced practitioners, and nurses first come to mind. But since cancer and its treatment affect the whole person, quality oncology care must address a number of patient needs.

This requires the work of multiple professionals in supportive care roles—including social workers, dietitians, pharmacists, genetic counselors, financial navigators, psychotherapists, rehabilitation therapists, occupational therapists, physical therapists, massage therapists, acupuncturists, yoga instructors, and even artists, musicians, and hairstylists. In this series, we will interview one of these supportive care specialists each month and ask them how their profession contributes to comprehensive cancer care.

We are kicking off this series with Kelay E. Trentham, MS, RDN, CSO, FAND, an oncology dietitian at MultiCare Regional Cancer Center in Tacoma, Washington. Trentham is a past chair of the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She serves on the Editorial Board for Oncology Issues and on the ACCC Clinical Affairs Committee.

ACCCBuzz: How does one become an oncology dietitian?

Trentham: To be a registered dietitian nutritionist (RDN), you have to have a bachelor’s degree from an accredited dietetics program, complete 1,200 hours in internships, and sit for the board exam. When I began working in this field, there was not a specific credential that dietitians could earn to specialize in oncology. But, in more recent years, the Oncology Nutrition Dietetic Practice Group (ON-DPG) of the Academy of Nutrition and Dietetics collaborated with the Commission on Dietetic Registration to create a board certification credential for Registered Dietitian Nutritionists in Oncology Nutrition—the Certified Specialist in Oncology (CSO). In 2008, the first CSO exam was given, enabling dietitians to become certified specialists in the field. The CSO credential requires individuals to work as dietitians for two years and to have at least 2,000 hours of oncology experience before they can sit for the specialized board exam.

ACCCBuzz: How did you become interested in specializing in oncology?

Trentham: I have been a dietitian for more than 20 years. I was introduced to cancer care through my work on a hospice team, on which I helped care for many cancer patients. I really enjoyed my work, so when I moved to Seattle and began looking for a new position, I decided to specialize in oncology. For the past 15 years, I have served oncology patients in outpatient settings.

ACCCBuzz: What patient care services do oncology dietitians provide?

Trentham: In addition to community outreach and teaching cancer prevention through diet and exercise, we work individually with patients. We meet with patients to prepare them for treatment, teach them about the effects of different treatments on their nutritional status, and work with those who have become malnourished because of their treatment.

The side effects of some cancer treatments can affect a patient’s absorption of nutrients. Surgeries can also affect how a patient digests and absorbs food. We help people understand how to optimize their nutrition even though they may need to eat differently after their treatment.

A few specific cancers require the placement of a feeding tube at the outset of treatment, so we provide guidance to those patients throughout their treatment to maximize their nutrition. We also work with patients post-treatment by helping them try to prevent cancer from reoccurring by eating well and managing their weight.

ACCCBuzz: Why are your services important to cancer care?

Trentham: Approximately 50 percent of oncology patients will experience malnutrition during treatment. Unintentional weight loss results in decreased muscle mass, and this contributes to fatigue and difficulty performing daily activities.

Problems like this can lead to poorer treatment tolerance, resulting in unplanned pauses between treatments, or treatment regimens that end early. It’s important to help people understand what’s happening to their bodies and teach them how to work around side effects so they can maintain their weight and nutritional status and receive their full treatment regimen. This can help lessen hospital lengths of stay, reduce admissions, readmissions, and ER visits, and ultimately improve quality of life and treatment outcomes.

ACCCBuzz: Where do oncology dietitians work?

Trentham: Most dietitians are employed by health systems. In the past, cancer treatment was most often provided in the inpatient setting, which gave patients access to the dietitians who worked there. Over time, cancer treatment has moved to the ambulatory setting, and there is no requirement in those settings that dietitians be made available to patients. The majority of patients with cancer are older, and since Medicare does not cover nutrition care for these patients, many would not seek a dietitian’s services.

Today there is a hodgepodge of treatment settings that choose to employ dietitians. It largely depends on whether they see value or benefit or a competitive edge in having a dietitian on staff. In 2007, MultiCare Regional Cancer Center in Tacoma hired me as its first staff dietitian, and I have been working on developing cancer nutrition services here ever since. Today I am one of two dietitians in my healthcare system, serving four outpatient oncology clinics.

ACCCBuzz: How are oncology dietitians reimbursed for their services?

Trentham:  While some private payers cover nutrition services, Medicaid and Medicare have limited or no coverage for oncology nutrition counseling. For the populations without coverage, we need to think outside of the box in terms of funding our work. Often, services like nutritional counseling are revenue-driven; if we cannot prove the dollar value of our worth, health systems will not pay for our services.

We have to convince board members and hospital administration of our value as an essential part of the patient care team and request funding so that all who need nutrition care can receive it. For example, dietitians could serve as primary navigators for the patients who are most in need of our services (such as head and neck or esophageal cancer patients who require feeding tubes). Like nurse navigators, we would not provide all services a specific patient requires, but rather determine individual patient needs and outsource them to specialists. Engaging with philanthropy services to provide funding for registered dietitian nutritionists could also ensure that those at greatest risk receive the care they need whether or not they have coverage.

ACCCBuzz: What is the most concerning patient issue in your field of practice?

Trentham: I’m concerned about clinicians’ lack of knowledge about the prevalence of malnutrition in cancer patients and how important nutritional services are to patients. It is vital that other clinicians connect patients with dietitians and collaborate with us in patient care. Patients have a real challenge coordinating their all of their care, even with their primary care physicians, who often seem unaware of the importance of nutrition during cancer treatment. It can be difficult to get healthcare team members to understand that this lack of coordination is detrimental to a patient’s cancer care, that our services can help keep patients out of the hospital and on track with their treatment plans. In general, I’m concerned that some members of the healthcare team just don’t get the importance of patients receiving nutrition care from a nutrition expert.

ACCCBuzz: What future directions do you see for your profession?

Trentham: A big thing we’re working toward is raising awareness about the importance of screening for malnutrition in cancer patients. Since many of today’s patients are treated in the outpatient setting rather than as inpatients, there are not enough dietitians to serve them. That results in patients’ nutritional needs not always being noticed. If you don’t screen for malnutrition, you’re not aware that it is a problem. The hope is that if patients are screened, the healthcare team will see the degree to which patients are experiencing malnutrition and advocate to have a registered dietitian nutritionist—hopefully a certified specialist in oncology—available to their patients.

Listen to Kelay Trentham and her ACCC colleagues—Randall Oyer, MD, (Medical Director of Oncology Programs at Penn Medicine-Lancaster General Health) and Jeffrey Kendall, PsyD, LP, (Director of Oncology Support Services at University of Minnesota Cancer Care)—address the how cancer programs are finding ways to justify, implement, and fund supportive cancer care services like nutritional counseling in this episode of ACCC’s podcast, CANCER BUZZ.