Transcript Esophageal Cancer Treated with Surgery and Radiation

Kimberly Morris
Stevie Arroyo
Esophageal Cancer
 Cancer that forms in tissues
lining the esophagus, two
main types:
 Squamous cell carcinoma -
cancer that begins in flat
cells lining the esophagus
 Adenocarcinoma - cancer
that begins in cells that
make and release mucus
and other fluids
Incidence/Prevalence
 Incidence: 4.6 per 100,000 men and women
diagnosed per year (2001-2005)
 Prevalence : Estimated new cases in 2008:


New cases: 16,470 (12,970 men and 3,500
women)
Deaths: 14,280
(http://seer.cancer.gov/statfacts/html/esoph.html)
Signs/symptoms
 Dysphagia (difficulty swallowing )
 Unintentional weight loss
 Pain in the throat , mid-chest area
 Hoarseness, hiccups
 vomiting of blood
Diagnosis
 Barium swallow →
 Endoscopy
 Biopsy
The following stages are used for
diagnosis of esophageal cancer:
Risk Factors
 Age 65 or older
 Being male
 Smoking
 Heavy drinking
 Diet
 Obesity
 Acid reflux
 Abnormal cells in the esophagus
Treatment
 When esophageal cancer is found very early,
there is a better chance of recovery.
 At later stages, esophageal cancer can be
treated but rarely can be cured.
 Esophageal cancer is generally treated with
surgery to remove the cancer
 Treatment often includes minimizes discomfort
caused by GERD and dysphagia.
(www.cancer.gov)
Treatment
 Patients with moderate-to-severe dysphagia require a
team approach involving nutritional support, physical
therapy, speech rehabilitation, pain management,
and psychological counseling. (Nguyen N., et. al.,
2005)
 Treatment varies depending on severity but dietary
modification is a key component
Treatment
 In 2002 the ADA established a national dysphagia
diet with four different levels of treatment:
 NDD Level 1: Pureed - homogenous, very cohesive,
pudding-like, requiring very little chewing ability.
 NDD Level 2: Mechanical Altered - cohesive, moist,
semisolid foods, requiring some chewing.
 NDD Level 3: Advanced - soft foods that require
more chewing ability.
 Regular - all foods allowed.
Treatment
 Nutritional factors are believed to aggravate
acidic reflux either by delaying gastric emptying
or diminishing pressure of the LES (Holtmann G.
2007)
 Decrease gastric discomfort by eating smaller
meals with fluid in between
 Avoid foods and activities that cause discomfort
and irritation (smoking, alcohol, spicy and acidic
foods)
Treatment
 Surgery is usually paired with radiation therapy for
optimal results.
 Results for radiotherapy studies showed a 13%
absolute improvement in survival at two years
(Gebski V, et. al. 2007)
 Typical side effects or radiation therapy include:
 Trouble swallowing
 heartburn
 fatigue
 loss of appetite
Treatment - MNT Radiation
 Try to eat something at least 60 minutes before
treatment.
 Bring snacks or nutrition supplements with you on
the ride to and from treatment
 Eat small frequent meals with fluids
 Be sure to drink plenty of water and other liquids
 Ask friends and family members to help by
shopping for groceries and preparing meals.
Nick Seyer
 Age: 58
 Sex: Male
 Occupation:
Contractor
 Ethnic Background:
Caucasian
Assessment - Medical History
 Drugs: TUMS, Alka-Seltzer, Pepcid consistently for
past year
 Noted 30Ib weight loss in last several months
 Patient is a smoker and regular drinker
 Family History: Mother had liver cancer, passed
at age 58
Assessment - Medical History
 Chief complaints:
 Significant heartburn for previous year
 Patient has recurrent cough at night
 Unable to eat due to heartburn pain, has difficulty
swallowing foods with texture
 Onset of disease: Dysphasia x 3-4 months,
odynophagia x 5-6 months
Assessment - Medications/Drug
Interactions
 Tums- treats upset stomach, vomiting heartburn,
and indigestion
Side effects: Constipation and gas
Drug interactions: may decrease absorption of
drugs like tetracycline antibiotics and biphosphates.
Do not use if you have stomach/intestinal blockage,
hypocalcaemia
(www.WebMD.com)
Assessment - Medications/Drug
Interactions
 Alka-Seltzer- Used to treat indigestion and low
calcium in blood
Side effects: taste problems, incomplete or
infrequent bowel movements.
Drug interactions: phosphate supplements/antacid
use can cause less absorption of phosphates, low
phosphate levels in body
(www.WebMD.com)
Assessment - Medications/Drug
Interactions
 Pepcid- helps relieve heartburn and acid indigestion
Side effects- persistent nausea, vomiting, stomach
and abdominal pains
Drug interactions- Aspirin/NSAIDS can cause stomach
irritation/ulcers.
Do not take similar acid blockers at the same time.
Consult doctor of other medication uses
(www.WebMD.com)
Assessment – Anthropometrics
Ht: 75”
BMI: 24.7
Wt: 198
UBW: 230
IBW: 196
%IBW: 101% normal
%UBW: 86% mildly depleted energy stores
Assessment – Physical Exam
Temperature: 98.3° F
Blood Pressure: 132/92 mm Hg
Heart Rate: 88 bpm
Resting Rate: 13 bpm
Nose/throat: dry mucus membranes
Assessment - Lab Values
NORMAL
Albumin
3.1 L
3.5-5
Total Protein
5.7 L
6-8
Pre-albumin
15 L
16-35
WBC
5.2
4.8-11.8
RBC
4.2 L
4.5-6.2 (men)
HGB
13.5 L
14-17 (men)
HCT
38 L
40-54 (men)
Assessment – Medical Diagnosis
 Doctor required patient to undergo chest x-ray,
endoscopy, biopsy, and CT scan
 Doctor diagnosed patient with stage IIB
adenocarcinoma of the esophagus
 Patient underwent a trans-hiatal esophagectomy
and received pre and postoperative external
beam radiation therapy
 During surgery patient was given a jejunal tube
feed and prescribed Isosource HN 1.5 kcal at
75ml/hr x 24hrs
Assessment – Nutrition Needs
 Energy needs: BEE
66.5 + (13.8 x 198/2.2) + (5 x (75x2.54)) – (6.8 x 58)
= 1866.6 x 1.2 (bed rest) x 1.2 (surgery)
= 2687.9 kcal/d
 Kcals from Isosource HN 1.5
75 x 24= 1800ml/d 1.5kcal x 1800ml/d= 2700 kcal
 Protein needs:
198 lb / 2.2 kg/lb = 90 kg.
90 kg x 1.0 g/kg/d = 90 g/d
Assessment – Nutrition History
USUAL DIETARY INTAKE
AM
Used to eat eggs, bacon and toast
every morning but has not eaten this
for at least a month. Recently has
had just coffee and cereal
LUNCH
Previously ate cold packed lunch;
sandwich, cold meat or other
leftovers, fruit, cookies, and tea
DINNER
All meats, pasta or rice, 2-3
vegetables, 1-2 beers
SNACKS
Ice cream, popcorn, or homemade
dessert
Assessment – Nutrition History
24 HOUR RECALL
AM
1 packet of instant oatmeal; sips of
coffee
LUNCH
6 oz. tomato soup with 2-4 crackers
DINNER
Macaroni and cheese – homemade
½ cup
SNACKS
1 scoop of chocolate ice cream
Diagnosis – PES Statement
 Inadequate oral food/beverage intake (NI- 2.1)
related to patients pre-surgical esophageal
discomfort, and current tube feed placement
as evidence by depleted protein stores and
reported weight loss of 30 pounds over several
months
Intervention – Goals
 Short term
Ensure patient is tolerating advancement to soft
diet prior to discharge
Education patient on diet changes he can
make to minimize discomfort of eating
 Long term
Goal for patient is to maintain healthy body
weight through proper nutrition
Intervention – Diet Order
Recommendations
 After clearance by physician and speech
pathologist; Discontinue enteral or parenteral
nutrition (ND-2)
 If patient tolerates jejunal tube feeding (5-7 days
post-surgery) start on clear liquid diet and
advance diet as tolerated : mechanical soft to
soft. (Mackenzie, et. al., 2005)
Intervention – Diet Order
Recommendations
 Fruits
 Soft, canned or fresh
fruit with pits and skin
removed.
 Applesauce,
bananas, peaches,
melons (no seeds).
 Fruit juices.
 Avoid crisp or stringy
fruits such as green
apples and rhubarb.
 Vegetables
 Soft, cooked
vegetables with
seeds and skin
removed
 Vegetable juice
 Avoid raw, tough, or
stringy vegetables
http://www.bmc.org/thoraciconcology/pdf/esophogealsurgery.pdf
Intervention – Diet Order
Recommendations
 Meat & Alternatives
 Minced or ground
meat
 Soups prepared with
soft foods
 Cooked eggs, omelets
 Soft cheeses
 Tofu
 Avoid overcooked or
dry and stringy meats.
 Dairy & Misc.
 Yogurt
 Ice cream
 Pudding
 Whole milk
 Nutrition Supplements
such as ensure or
carnation instant
breakfast
http://www.bmc.org/thoraciconcology/pdf/esophogealsurgery.pdf
Intervention – Education
 Nutrition education including textured modified,
high protein/energy diet and/or managing
nausea/vomiting and fluid intake (Odelli C, et. al.,
2005)
 Education should include:
 Use of Protein supplements, high-energy foods, and
a soft dysphasia diet
 Sit upright, chew slowly, and eat more than 3 hours
before bedtime
Intervention – Education cont.
 6 to 8 small frequent meals each day
 Avoid foods that cause discomfort for example
very hot or cold beverages and spicy foods
 Avoid alcohol and smoking
 Educate wife on cooking techniques and food
selection
Monitoring and Evaluation
 While patient is still in the hospital monitor weight
and food intakes
 Check labs every 3 days, ordered by physician
 Once patient is discharged provide handouts
and resources on nutrition
 Patient may need additional nutrition
counseling in the future; if he is having trouble
eating he should ask to be referred to a RD
References
 “Cancer of the Esophagus Risk Factors.” National Cancer Institute. 01 Apr.




2009 <http://www.cancer.gov/cancertopics/wyntk/esophagus
/page5 >.
“ Diagnosis of Esophageal Cancer.” National Cancer Institute. 01 Apr
2009 < http://www.cancer.gov/cancertopics/wyntk/esophagus/
page7>.
“Drugs & Medication- Alka-Seltzer Antacid Oral.” WebMD. 2005-2009. 01
Apr 2009 < http://www.webmd.com/drugs/drug-13879-Alka
Seltzer+Antacid+Oral.aspx?drugid=13879&drugname=AlkaSeltzer+Antacid+Oral>.
“Drugs & Medication- Pepcid AC Oral. WebMD. 2005-2009. 01 Apr 2009 <
http://www.webmd.com/drugs/mono-250-FAMOTIDINE+10+MG++ORAL.aspx?drugid=16241&drugname=Pepcid+AC+Oral>.
“Drugs & Medication- Tums Oral.” WebMD . 2005-2009. 01 Apr 2009
<http://www.webmd.com/drugs/mono-2123-CALCIUM+CARBONATE
+ANTACID+-+ORAL.aspx?drugid=9574&drugname=Tums+Oral
References
 “Esophageal Cancer.” Mayo Clinic Online. 11 May 2007. 01 Apr. 2009

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< http://www.mayoclinic.com/print/esophageal-cancer/DS00500
/METHOD=print&DSECTION=all>.
“SEER Stat Fact Sheet- Cancer of the Esophagus.” National Cancer
Institute . 01 Apr. 2009 <http://seer.cancer.gov/statfacts/html/esoph.
html>.
Shaleen, Nicholas and David Ransohoff. “Gastroesophageal Reflux,
Baretts Esophagus, and Esophageal Cancer. “ Journal of the American
Medical Association. 2002; 287: 1972-1981
“Radiation Therapy.” American Cancer Society .13 Apr. 2009
http://www.cancer.org/docroot/MBC/content/MBC_6_2X_When_You_Ha
ve_Radiation_Therapy.asp?sitearea=MBC
Holtmann, G. GERD: How to Have a Better Day. Journal of Clinical
Gastroenterology. July 2007; 41: 204-208.
References
 Odelli C, Burgess D, Bateman L, Hughes A, Ackland S, Gillies J, Collins
CE. Nutrition support improves patient outcomes, treatment tolerance
and admission characteristics in esophageal cancer. Journal of
Clinical Oncology. 2005;17:639-645.
 Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J;
Australasian Gastro-Intestinal Trials Group.Survival benefits from
neoadjuvant chemoradiotherapy or chemotherapy in esophageal
carcinoma: a meta-analysis. Lancet Oncol. 2007 Mar;8(3):226-34
 Nguyen N., Moltz F., Vos C., Smith P., Karlsson H., Dutta U., Midyett S.,
Barloon A., Sallah J., Sabah F. Impact of dysphagia on quality of life
after treatment of head-and-neck cancer. International Journal of
Radiation Oncology, Biology, Physics; Mar2005, Vol. 61 Issue 3, p772778, 7p