Colorectal cancer patients deserve better diet advice

New research from the Uni­ver­si­ty of Sheffield has high­light­ed nutri­tion­al sup­port must be improved for patients liv­ing with bow­el, colon and rec­tal can­cer. Some 69 per cent of peo­ple sur­veyed said they had not received any diet and can­cer advice or sup­port from their health­care team at any stage of their care, through­out diag­no­sis, and dur­ing and after treat­ment.

Treat­ment for col­orec­tal can­cer can involve a par­tial resec­tion, or a tem­po­rary or per­ma­nent stoma, all of which affects bow­el func­tion. Con­se­quent­ly, most patients will encounter a num­ber of nutri­tion­al dif­fi­cul­ties, includ­ing being unsure what to eat and expe­ri­enc­ing diar­rhoea, con­sti­pa­tion, appetite loss as well as changes to taste and smell.

Nutrition has a huge role to play

Research find­ings come as no sur­prise to char­i­ty Bow­el Can­cer UK. “With­in our online com­mu­ni­ty, there’s always a lot of dis­cus­sion about nutri­tion and what to eat, and we know there is a gap in the pro­vi­sion of this advice,” says Lau­ren Wig­gins, direc­tor of ser­vices at Bow­el Can­cer UK.

“Around 268,000 peo­ple in the UK are liv­ing with bow­el can­cer and that’s a lot of lives to be affect­ed by the long-term con­se­quences of treat­ment. When your bow­el is affect­ed by dis­ease, nutri­tion has a huge role to play. It’s a part of the treat­ment and care pack­age that is so impor­tant.”

Nation­al Insti­tute for Health and Care Excel­lence guid­ance con­curs. Its guide­lines rec­om­mend col­orec­tal can­cer patients should be offered com­pre­hen­sive advice on man­ag­ing the effects of treat­ment on their bow­el func­tion. This includes infor­ma­tion on diet, foods that can cause or con­tribute to bow­el prob­lems, along­side advice on weight man­age­ment, phys­i­cal activ­i­ty and healthy lifestyle choic­es, such as quit­ting smok­ing and reduc­ing alco­hol con­sump­tion.

Identifying evidence-based advice online

When patients are unsure of what to eat, they tend to go online to seek advice. Bow­el Can­cer UK and Macmil­lan Can­cer Sup­port were the main sources accessed by the Sheffield Uni­ver­si­ty study’s respon­dents. Bow­el Can­cer UK has an Eat­ing Well with Bow­el Can­cer guide and Macmil­lan has Eat­ing Prob­lems with Can­cer guid­ance. Both are pop­u­lar with peo­ple look­ing for evi­dence-based gen­er­al infor­ma­tion about diet and can­cer.

“When patients look online for diet and col­orec­tal can­cer advice, the wor­ry is they risk com­ing across inac­cu­rate infor­ma­tion,” says Dr Bernard Corfe, lead author of the study and senior lec­tur­er in oncol­o­gy at Sheffield Uni­ver­si­ty. “If we could intro­duce a kitemark or an evi­dence-based stan­dard to online infor­ma­tion, this could help peo­ple to access only reli­able nutri­tion­al advice sources.”

There is an obvi­ous need for indi­vid­ual advice about diet and can­cer because what some­one is able to eat at dif­fer­ent stages of their treat­ment will change. Also, every­one is dif­fer­ent and expe­ri­ences will vary from one per­son to the next. For exam­ple, a young patient liv­ing with a stoma will require very dif­fer­ent diet and lifestyle advice to an old­er per­son who has been treat­ed for advanced bow­el can­cer.

Working out what you can eat

Any­one liv­ing with a long-term con­di­tion that affects the diges­tive sys­tem will most like­ly find out what foods work best for them via a process of tri­al and error. A food diary can help peo­ple to keep track of how they react to cer­tain exclu­sions and rein­tro­duc­tions in their diet.

“Peo­ple will ask what they should be eat­ing and when I check whether they’ve received any advice from their health­care team, almost every­one will say they haven’t been told any­thing spe­cif­ic,” says Kel­lie Ander­son, nutri­tion­al advis­er at Maggie’s can­cer care cen­tres. “They are just advised to eat what they fan­cy. For a lim­it­ed num­ber of peo­ple that might be OK. But for the vast major­i­ty, par­tic­u­lar­ly when they have had col­orec­tal surgery, they will have issues.”

While eat­ing a bal­anced diet that includes lean pro­tein, lim­it­ed red meat, whole­grains and plen­ty of fruit and veg­eta­bles is impor­tant for our gen­er­al well­be­ing, and as part of can­cer pre­ven­tion, healthy eat­ing can look quite dif­fer­ent for peo­ple hav­ing treat­ment for col­orec­tal can­cer.

“They may need to include food in their diet that you wouldn’t describe as nutri­tious or as nutri­ent filled, but it’s good for them espe­cial­ly when they are recov­er­ing from surgery,” says Ander­son. “This includes hav­ing white bread and rice instead of brown, ensur­ing the peel is removed from veg­eta­bles, exclud­ing high-fibre foods for a short peri­od and avoid­ing any­thing that’s spicy or too greasy.

They may need to include food that you wouldn’t describe as nutri­tious, but it’s good for them

“That’s why a low-fibre diet is often rec­om­mend­ed by some­one like myself and I would hope a bow­el team might advise this too. The ear­li­er the inter­ven­tion is, as far as when nutri­tion­al advice is giv­en, the bet­ter a person’s recov­ery is gen­er­al­ly.”

What’s need­ed to improve nutri­tion­al sup­port?

Under­stand­ing why there is dis­par­i­ty between the nutri­tion­al sup­port that peo­ple receive could help to ensure it’s offered more equi­tably going for­ward.

“You may find the rea­sons dif­fer depend­ing on geo­graph­i­cal area, the avail­abil­i­ty of local dieti­cian ser­vices or it may be the resources are just not there,” says Wig­gins at Bow­el Can­cer UK. “Anoth­er issue could be the resources are there, but patients don’t know about them and aren’t aware they can ask for a refer­ral to a dieti­cian, for example.”Corfe feels part of the prob­lem is that nutri­tion is some­times seen as a bolt-on to care. “Train­ing and pay­ing for enough dieti­cians to offer this advice to patients isn’t prob­a­bly some­thing that’s fea­si­ble with­in the NHS at the moment. But offer­ing basic nutri­tion train­ing through con­tin­u­ing pro­fes­sion­al devel­op­ment cours­es could help to improve the dietary advice pro­vid­ed to patients by GPs.

“There’s also a con­cern that there is insuf­fi­cient nutri­tion in the med­ical cur­ricu­lum at all stages. I think the bot­tom line is there needs to be more train­ing offered to bet­ter inform GPs.”

Changing the conversation around diet and cancer

In addi­tion, GPs could ben­e­fit from sup­port to enable them to pro­vide infor­ma­tion about diet to patients liv­ing with can­cer.

“We need to be giv­ing GPs the tools to be able to have these con­ver­sa­tions and sign­post the right places where patients can get expert sup­port,” says Wig­gins.

Bring­ing GPs into the care path­way for col­orec­tal can­cer is impor­tant because they will be see­ing those patients a lot more reg­u­lar­ly than their hos­pi­tal teams.

“The impact of treat­ment on the bow­el is one of the longer-term con­se­quences of treat­ment for this type of can­cer and it can have a sig­nif­i­cant impact on a person’s qual­i­ty of life. It’s vital that nutri­tion is addressed as part of the care path­way.”

Alter­na­tive­ly, gen­er­al prac­tices could cre­ate a list of evi­dence-based resources to pro­vide to patients, such as infor­ma­tion on diet and can­cer from Bow­el Can­cer UK, Macmil­lan Can­cer Sup­port and Maggie’s. This would help to pre­vent patients com­ing across online diet and can­cer advice from unre­li­able sources. Ander­son also offers nutri­tion and can­cer advice via her web­site Food to Glow and this resource is used by a num­ber of hos­pi­tal teams.

How­ev­er, evi­dence-based online advice is not a sub­sti­tute for a more per­son­alised approach to how diet and nutri­tion advice is pro­vid­ed.

“The Bow­el Can­cer UK web­site has lots of infor­ma­tion about diet, but this gen­er­al infor­ma­tion should be viewed only as a good start­ing point for a con­ver­sa­tion,” says Wig­gins. “It should not be con­sid­ered as the end of the con­ver­sa­tion. Tai­lored infor­ma­tion is real­ly impor­tant.”

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