Author:

Chloé McMurray, Specialist HPB Dietitian, South Tees Hospitals NHS Foundation Trust

The management of pancreatic cancer is complex and requires a multidisciplinary team (MDT) approach. Nutrition is crucial, with dietitians being a core member of the MDT. However, until recently, our Trust lacked dietetic input within the hepato-pancreato-biliary (HPB) MDT, with management limited to the medical team. Nutrition plays an essential role in patients with pancreatic cancer, making this an area of significant need. This project aimed to introduce a Specialist HPB Dietitian into the MDT and evaluate its impact on patient outcomes and MDT professionals in a District General Hospital (DGH). 

In January 2020, a joint dietetic and consultant clinic was established, initially unfunded. By October 2021, funding from the gastroenterology department enabled the dietitian role (0.4 full-time equivalent), leading to expanded clinic hours and MDT participation. The dietitian undertook a Non-Medical Prescribing course in 2021, allowing supplementary prescribing for nutritional supplements and pancreatic enzyme replacement therapy (PERT). This reduced prescription delays and errors. Consistent teaching and training, MDT working and conversations around pancreatic disease in both inpatient and outpatient settings has helped to demonstrate the importance of dietetics in this role.   

A Trust PERT guideline was developed jointly by dietitian and gastroenterologist, improving medication adherence and staff education, leading to improved symptom management. The collaboration also supported continuity of care, as all pancreatic patients were seen by the dietitian. Continuity of care between inpatient and outpatient settings has also benefited, as the HPB dietitian is able to see in both settings. 

Amongst others, the primary benefit from our joint HPB service has been a reduced number of appointments for patients to attend, which has also supported sustainability from an environmental and social perspective. This has additionally reduced delays in patients receiving dietetic support, which enables prehabilitation for cancer patients immediately at diagnosis, as they are seen jointly. Furthermore, the dietitian is able to offer more frequent and regular support to cancer patients and their families to support nutrition, symptoms and quality of life. 

The benefits and impact on both patient outcomes and professionals with the MDT in the DGH setting was evaluated.  Only 34% and 30% of patients diagnosed with pancreatic cancer in 2018 and 2019 respectively, were referred to a dietitian. From January 2020-August 2024, following the introduction of a specialist HPB Dietitian, 282 patients were diagnosed with pancreatic cancer and 229 patients (81%) were referred. 

Outcome data using the National Health Service outcomes framework was collected using a data collection tool from the British Dietetic Association Oncology Specialist Group. The primary outcomes measured were: 

1. Percentage of patients referred to dietitians  

2. Initiation of bespoke advice and management 

3. Nutritional status 

4. Symptom control 

During the 56 months that outcome measures were collected: 

• 100% of patients seen had achieved patient focused goals including bespoke verbal/written advice and support provided to manage condition/symptoms 
• 79% had achieved or partially achieved dietitian focused goals.  

Individual goals were set regarding nutritional status:  

• 60% of patients achieved or partially achieved the goal of maintaining their nutritional status 
• 60% of patients achieved or partially achieved the goal to minimise deterioration of their nutritional status 
• 76% of patients achieved or partially achieved the goal to manage their symptoms through dietetic intervention 
• 100% of patients achieved goals in relation to assessment, improving nutritional status, management at end of treatment and management at end of life 

Patient feedback was obtained through an electronic patient questionnaire was sent electronically with consent from July 2023-April 2024. 11/22 (50%) questionnaires were returned and indicated:  

• 8/11 (73%) had very good or good understanding of PERT prior to dietitian involvement, increasing to 11/11 (100%) after seeing the HPB dietitian  
• Only 5/11 (45%) patients were very confident or quite confident on PERT prior to dietitian involvement, increasing to 10/11 (91%) after seeing the HPB dietitian.  
• 9/9 (100%) patients found the PERT information booklet either very helpful or quite helpful  
• 11/11 (100%)  patients were either very satisfied or satisfied with the HPB dietetic service 
• 11/11 (100%) patients felt well supported by the HPB dietetic service 
• 10/11 (91%) patients would recommend HPB dietetic service to friends and family 

Comments were made how patients felt ‘supported’ ‘ fully informed’ listened to and ‘reassured’. One patient commented how questions were always ‘fully and simply answered’ and the right questions asked by the dietitian.  

The HPB dietetic service was also evaluated from a professional perspective through a web-based survey sent to 11 HPB MDT members (medical, surgical, and nursing staff). All 11 (100%) questionnaires were returned, indicating: 

• 5/11 (45%) were very likely or likely to refer pancreatic cancer patients to the dietetic service prior to the introduction of a HPB Dietitian, increasing to 11/11 (100%) post introduction. 
• 3/11 (27%) were very likely or likely to refer benign pancreatic patients to the dietetic service prior to the introduction of a HPB Dietitian, increasing to 10/11 (91%) post introduction. 
• 5/11 (45%) had very good or good understanding of PERT prior to a HPB Dietitian in the MDT, increasing to 11/11 (100%) post introduction.  
• 4/11 (36%) were very confident or confident in giving PERT advice and making alterations to dosage prior to a HPB Dietitian in the MDT, increasing to 11/11 (100%) post introduction.  
• 9/11 (82%) had looked at the HPB dietitian written Trust Guidelines on 'Pancreatic Enzyme Replacement Therapy (PERT) in Adults’, with 9/9 (100%) finding them very useful or useful.  
• 10/11 (91%) respondents found a Specialist HPB Dietitian sitting within the MDT clinics very beneficial or beneficial for them professionally, and 9/11 (82%) very beneficial or beneficial for the patients. 

Free text comments were made around how the ‘great service’ was ‘very professional and highly respected’ and provided ‘holistic approach to patient care’ having ‘positive outcome on wellbeing and improvement in patients symptoms’.  

The data shows that introducing a specialist HPB dietitian in the DGH has improved patient referrals and outcomes. Responders had a positive experience, recognising the importance of nutrition in HPB care. Despite partial funding, the project highlights the benefits of a full-time specialist role, which should be encouraged in all DGHs to support patient outcomes.