1. Integrating nutritional support into the care pathway for colorectal cancer patients Dr Sorrel Burden Lead Dietitian & Macmillan/NIHR Fellow

2. Research projects Exploratory work TNM staging/nut status RCT Validation of anthropometry Reliability of definitions complications

3. Nutritional status 86 CRC patients were recruited Undertook nutritional measurement BMI % weight loss hand grip strength Body composition

4. Lean body mass & fat in pts with wt loss Percentage weight loss <10% Mean (SD) >10% mean(SD) Kolmogorov -smirnov test P value 95% C.I Lean muscle mass (kg) 51.9(12.1)39.7(13.5)0.910.0015.3 to19 Fat (kg)25.0(7.8)22.7(10.2)0.690.314-2.3 to 7 * Independent Student t-tests, C.I confidence intervals.

5. Nutritional & Functional Assessment 12 14 11 15 6 7 n=80 48 weight losing 43 low handgrip 47 overweight BMI >25 4

6. Research Question for RCT Does preoperative sip feeding decrease postoperative complication in colorectal cancer patients?

7. Trial Design  Pragmatic randomized control trial to determine effectiveness  Intervention preoperative sip feeding Control Intervention Dietary advice Sip feeds (Fortisip ) & dietary advice

8. Recruitment Patients were recruited from colorectal clinics over a 16M period. Patients were recruited at the point a tumour was suspected. They were visited at home by a Dietitian. Signed consent was given by all patients. 3 sites

9. Trial observations Sample characteristics Anthropometry Bioelectrical Impedance Hand grip strength Post operative complications QOL Questionnaires

10. Recruitment

11. Patient characteristics at baseline

12. Site of tumour

13. Length of time prior to surgery patients had sip feeds

14. Energy intake pre & post op

15. Treatment Group (Sip feeds) Control (Advice) Chi- square P value Wound infections9 (16)17 (27)2.120.145 Chest infections8 (15)14 (22)1.540.125 UTI8 (15)6 (9)0.1250.724 Total No patients with one or more infection 20 (37)27 (43)1.210.271 ITT- Infectious complications CDC

16. Treatment n46 Control n37 Chi-squareP value CDC wound5103.610.05* CDC chest7101.930.16 Buzby wound5108.40.03* Buzby chest681.90.37 Sub group analysis ITT (Including 71% patients 83 patients)

17. Cost implications of 1 minor complication cost of one minor complication £161 James (2005) Cost of wound infections in treatment group £805 Cost of same infections in the control group is £1610 Cost of sip feeds daily cost 10p

18. Recommendation Patients should be given sip feeds if weight losing prior to surgery Trial specific to colorectal cancer patients Patients should be identified in the preop period if weight losing.

19. Further developments Exploratory work to ask patients view’s & experience of food Evaluate more patient centered outcomes for nutritional support interventions Look at prehabiliation Look at rehabilitation Further RCT

20. Relationship between context, problem definition, intervention and evaluation for complex interventions Campbell N et al. Designing and evaluating complex interventions to improve health care. BMJ 2007;334;455-459