Medical Nutrition Therapy for Cancer

1. Chapter 37 Medical Nutrition Therapy for Cancer

2. Cancer Abnormal cell division and reproduction that can spread throughout the body Major cause of mortality in the U.S., second only to cardiovascular disease Most cases occur in older individuals (2/3rd in persons over age 65) Rates vary by ethnicity: African American men higher rates than white men. African American women have lower incidence rates but higher mortality rates than white women

3. Etiology Multistep process in which normal cells are transformed into cancer cells Causes: exposure to carcinogens, genetics, nutrition 1/3rd of deaths attributed to diet and exercise and 1/3rd attributed to cigarettes

4. Pathophysiology Normal body cells have closely regulated growth Cellular growth is partly controlled by a counting system based on telomeres. Telomeres are end pieces of chromosomes that become shorter after each cell division When the telomere shortens to a specific length, the cell will stop dividing

5. Pathophysiology cont. Cancer cells produce at an uncontrolled rate Cancer cells become autonomous from the normal growth signals and genetic control and may even secrete their own growth factor An enzyme is secreted that destroys the telomere, leading to loss of the cell’s internal clock & counting system which controls replication

6. Pathophysiology cont. The cell may take on other traits: nucleus/cytoplasm may be enlarged or misshapen, mitosis rate becomes higher, derangements in chromosome sequence Three stages Initiation: transformation of cell Promotion: multiplication of cells Tumor progression, includes metastasis Response to treatment is complete, partial, stable, or progressive

7. Treatment Chemotherapy: systemic – affects all body systems. Interrupts stages of cell replication. Affects rapidly dividing cells such as the GI tract. Pt’s experience nausea and other GI problems during treatment. Hair loss is also a side affect. Pt may experience neutropenia and anemia because bone marrow cells are affected. Most the normal cells in the body are in a resting stage and are somewhat protected from the effects

8. Chemotherapy cont. Use of chemical agents or medications to treat cancer Anemia, fatigue, nausea, vomiting, loss of appetite, mucositis, changes in taste and small, xerostomia, dysphagia, diarrhea, constipation Severity of side effects depend on specific agents used, dosage, duration, number of treatments, current health status. Intestinal mucosa and digestive processes are affected which alter digestion and absorption of some nutrients Watch for drug nutrient interactions

9. Treatment cont. Radiation: used alone is the most common treatment for certain cancers of the head and neck. May cure some cancers such as Hodgkins, thyroid carcinoma, localized cancers of the head and neck. Ionizing radiation breaks the strands of the DNA helix, leading to cell death. Toxicity of radiation is localized to the region being treated

10. Radiation Therapy (site specific) Radiation to head and neck: Sore mouth Altered taste & smell Dysphagia & odynophagia Mucositis Xerostomia Anorexia Fatigue Weight loss Need aggressive enteral nutrition

11. Cancer Treatment and Nutritional Implications–cont’d Hematopoietic stem cell transplantation (treatment for leukemia, lymphoma) Nausea, vomiting, anorexia, dysgeusia, stomatitis, oral and esophageal mucositis, fatigue, and diarrhea Dietary precautions with neutropenia: food safety (avoid undercooked meats, unpasteurized beverages). Serve primarily cooked foods. Graft versus host disease (GVHD): donar stem cells react against the tissues of the forein host Sinusoidal obstructive syndrome (SOS): chemo or radiation therapy damage to the hepatic venules

12. Severe Oral Mucositis Following Marrow Transplantation

13. Surgery After surgery, patients may experience fatigue, changes in appetite and bowel function, pain. Require additional energy and protein for wound healing. Head & neck cancer: impaired mastication and chewing due to tumor mass- usually rely on enteral nutrition Stomach cancer – surgery is most common treatment. Malabsorption, deficiency of iron, folate & B12 Pancreatic cancer: Whipple procedure Delayed gastric emptying, early satiety, glucose intolerance, bile acid insufficiency, diarrhea, fat malabsorption Usually need pancreatic enzyme replacement and low fat diet

14. Nutrition in the Etiology of Cancer Nutrition may modify carcinogenic process at any stage: carcinogen metabolism, cellular and host defense, cell differentiation, and tumor growth Nutrition is adversely affected by cancer itself, treatment (radiation therapy, chemotherapy, and surgery), and current health and nutritional status One third of all cancer deaths attributed to diet, nutrition, and lifestyle behaviors such as poor diet, physical inactivity, overweight and obesity, and alcohol use; another third related to cigarette and tobacco use

15. Types of Epidemiologic Studies of Cancer

16. Nutrition in the Etiology of Cancer– cont’d Complex relationship Dietary carcinogens: naturally occurring and added in food preparation and preservation Inhibitors of carcinogenesis: antioxidants, phytochemicals Enhancers of carcinogenesis: fat in red meat, compounds formed when meat is grilled at high temperatures Latency period between initiation and promotion

17. Energy Intake, Body Weight, Obesity, and Physical Activity Energy restriction inhibits cancer and extends life span in animals Positive associations between overweight and cancers of the breast, endometrium, kidney, colon, prostate, and others Overweight increases risk of cancer recurrence and decreases survival Physical activity is inversely associated with cancer

18. Nutrition and Cancer Etiology Fat: positive association Protein: increased red meat intake associated with colon and prostate cancer Soy and phytoestrogens: protective against breast cancer. For women already dx, moderate use of soy is recommended but avoid supplements Carbohydrates: fiber, sugars, and glycemic index Fiber protective Simple sugars – may stimulate cancer cell growth due to increased insulin production Fruits and vegetables: protective Nonnutritive sweeteners: not a concern

19. Nutrition and Cancer Etiology– cont’d Alcohol: associated with cancer of the mouth, pharynx, larynx, esophagus, lung, colon, rectum, liver, breast Coffee and tea: no significant relationship Methods of food preparation and preservation: high heat cooking methods and processed meats may be linked Cancer chemoprevention: supplementation of nutrients such as betacarotene to prevent cancer – no statistical relatinship Cancer prevention recommendations: nutrition and physical activity Nutrition and physical activity recommendations for cancer survivors: Table 37-2

20. Color Code System of Vegetables and Fruits Data from Heber D: Vegetables, fruits and phytoestrogens in the prevention of diseases, F Postgrad Med 50:145, 2004.

21. Guidelines for Cancer Prevention From American Institute for Cancer Research: Simple steps to prevent cancer, Washington, DC, 2000, AICR.

22. Nutritional Implications of Cancer Goal: prevent malnutrition Adverse nutritional effects of cancer compounded by treatment Even small weight loss (<5% body weight) before treatment adversely affect prognosis

23. Factors That Affect Appetite

24. Cancer Cachexia Progressive weight loss. One of the most common causes of death among pts with cancer and is present in 80% at time of death. Characterized by: anorexia, involuntary weight loss, tissue wasting, inability to perform ADLs, altered BMR. Abnormalities in fluid and energy metabolism Mediated via cytokines, including tumor necrosis factor (TNFa and TNFb), cachectin, interleukin-1, interleukin-6, and interferon-a Diagnosis stems from presenting signs and symptoms

25. Metabolism and Tumor Growth Energy needs are variable Protein, fat, and carbohydrate: tumors exert consistent demand for glucose CHO abnormalifies: insulin resistance, increased glucose synthesis, gluconeogenesis, decreased glucose tolerance In cancer cachexia, amino acids are not spared as they are during simple starvation and depletion of lean muscle mass occurs Muscle wasting: increased protein catabolism and/or decreased protein synthesis Nutrition support preserves lean body mass; also benefits malignancy

26. Metabolism and Tumor Growth cont. Hypercalcemia in patients with bone metastases Fluid and electrolyte imbalances: cancers that promote excessive diarrhea or vomiting Loss of appetite and sensory changes. Alterations in taste and smell are common Nausea, vomiting, early satiety, mucositis, constipation

27. Nutritional Care of Adults Goals: prevent or reverse nutrient deficiencies, preserve lean body mass, minimize nutrition-related side effects, maximize quality of life Nutritional screening and risk assessment: SGA considered reliable Body weight: maintain body wt and nutrient stores. Wt loss not typically recommended. Antioxidants: controversy over whether or not to take supplements

28. Energy and Protein Requirements Energy Standardized equations, indirect calorimetry Should be 25-35 kcal/kg to maintain and 35-45 kcal/kg to replenish. Add kcal if patient is febrile or septic. Some indicate that okay for obese patients to receive 21-25 kcal/kg Protein Consider degree of malnutrition, extent of disease, degree of stress, ability to metabolize and use protein

29. Daily Protein Requirements for Patients with Cancer Data from Charuhas PM et al: Medical nutrition therapy in bone marrow transplantation: energy, protein, micronutrient, and fluid requirement. In Elliott L et al, editors: The clinical guide to oncology nutrition, ed 2, Chicago, 2006, American Dietetic Association.

30. Contributor to Anorexia Cachectin: Tumor necrosis factor It is a cytokine protein that promotes breakdown of both protein and fat stores to provide adequate energy for tumor cells. Insulin resistance occurs because of the excessive fatty acid oxidation. Glucose levels increase but the glucose and amino acids made available are used by the cancer cells.

31. Nauea/Vomiting Assess cause If odors contribute, take precautions to avoid the odors Assess for early satiety: small frequent meals may be helpful Many times, n/v is a result of medications (chemotherapy most common) Eat small, low fat meal the mornin of the first treatment and avoid fried, greasy and favorite foods for several days following the treatment Encourage pt’s to take anti-emetics as prescribed

32. Early Satiety Small, frequent meals that are nutrient dense Beverages should contain nutrients and consumed between meals rather than with meals to avoid fullness Avoid consumption of raw vegetables and other high fiber foods Medications that increase gastric emptying may be used

33. Mucositis Associated pain is the main source of cancer treatment-related pain Pain can be severe enough that patients avoids food and drink which can lead to dehydration and weight loss Good oral hygeine Narcotic analgesics Soft, non-fibrous, non-acidic foods; Avoid hot foods Liquids to prevent dehydration; high kcal/high protein milkshakes helpful

34. Diarrhea • Antineoplastic agents target cells that have the highest replication ate and often cause diarrhea • When mucositis is present in the oral mucosa, it can be assumed that it may also be present in the stomach and intestines, resulting in diarrhea • Monitor for dehydration • Small amts of fluid frequently • Avoid large amts of fruit juice (excessive fructose can increase diarrhea) • Use anti-diarrheal meds as prescribed • Increasing soluble fibers may help but poor appetite may make it difficult

35. Dysgeusia • Alterations in taste: due to tumors or treatment options • Metallic taste: • avoid metal utensils • drink supplements from glass, not can • use high protein non-meat sources (peanut butter, cheese, soy, poultry) • Use more highly spiced and flavorful foods

36. Xerostomia • Dry mouth: common side-effect of head and neck radiation and chemotherapy • Use artificial saliva and/or mouth moisturizers • Sugar-free gum and sour-flavored sugar-free hard candies may increase the flow of saliva • Chewing gum may be effective

37. Anorexia • Lack of appetite • Prevalence in cancer pts is estimated at 50% of patients • Can lead to weight loss and increase the development of cancer cachexia • Manipulation of diet does little to help improve a poor appetite • Exercise may help but many pts are unable to tolerate increased activity • Appetite stimulants: Megestrol acetate & corticosteroids agents

38. Fluid and Micronutrient Requirements Fluid Body surface area: 1500 mL/m2 or BSA × 1500 mL Daily requirements method: 1 mL fluid per 1 kcal of estimated needs Holliday-Seger method: >20 kg of body weight = 1500 mL + 20 mL/kg for each kg >20 kg Age based method: <55 year of age – 30 to 40 mL/kg, 55 to 65 years of age – 30 mL/kg, >65 years of age – 25 mL/kg Micronutrients High-dose supplements common Pre-existing deficiencies Recommend supplement with 100% DRI

39. Cancer Treatment and Nutritional Implications Chemotherapy Immunotherapy Biologic agents used to kill cancer cells Fatigue, chills, fever, flu-like symptoms, decreased food intake Radiation therapy Fatigue, loss of appetite, skin changes, and site-specific effects

40. Fatigue Fatigue is most common side effect Consume frequent, small feedings Emphasis on morning feeding when energy is better Easy to eat foods Foods with low preparation time Avoid favorite foods when undergoing treatment – may develop negative aversions to the foods if they are associated with unpleasant symptoms

41. Enteral Nutrition Preferred if gut is functional Associated with fewer postoperative complications and shorter stays Nasogastric and nasojejunal feeding tubes most commonly used for short term Gastrostomy or jejunostomy feeding tubes for longer term enteral nutrition

42. Parenteral Nutrition Used when oral and enteral feeding is not tolerated May use when severe diarrhea or malabsortion occurs Usually, patients are severely malnourished with GI malfunctions Intense monitoring and specialized care is required Used for pts with reasonable prognosis. Not appropriate for terminal patients.

43. Palliative Care Provide for quality of life Diet as desired by individual Goal is to alleviate negative symptoms (ex: pain, weakness, constipation, nausea, loss of appetite, dry mouth) Emphasize pleasurable aspects of eating without concern for quantity or nutrient/energy content Hospice care

44. Nutritional Care of Children Families and caregivers often have extreme preoccupation with eating and weight Creativity in feeding Enteral nutrition support Individualize requirements Requirements for growth and development

45. Complementary and Alternative Therapies Whole medical systems Traditional Chinese Medicine, ayurvedic medicine, homeopathy, naturopathy Mind-body interventions Mindfulness, meditation Biologically based therapies Botanicals, dietary supplements, vitamins, minerals Manipulative and body-based methods Massage, yoga, reflexology Energy therapies Veritable and measurable – sound, light, energy Putative such as biofields

46. Focal Points Nutrition plays an important role throughout the continuum of cancer care—from helping to reduce cancer risk, to caring for patients undergoing cancer treatment, to promoting healthy lifestyles for cancer survivors. Patients have different needs and challenges with regard to their nutrition management, and providing individualized nutritional guidance is an essential component of their care. Prompt and appropriate nutrition management may help to improve patients’ tolerance of treatment, minimize nutrition impact symptoms, and maximize quality of life. Cancer patients should be encouraged to actively participate in their care and to communicate with their health care providers. When patients are inundated with nutrition-related CAM therapy choices, food and professionals can provide sound guidance for informed decision making.