Transcript M11-CancerHIV - E-Learning Faculty Modules

Chapter 37
Medical Nutrition
Therapy for Cancer
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Severe Oral Mucositis Following
Marrow Transplantation
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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
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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
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Types of Epidemiologic Studies
of Cancer
Case Control Studies
The diets of individuals with cancer are compared with
those of cancer-free controls matched for age, sex, and
other key factors.
Cohort Studies
The diets of different groups of subjects are determined
before cancer onset, and the incidences of developing
cancers in each group are compared.
Cross-sectional Studies
The diets of different groups of subjects are compared,
using the same measures at a single point in time.
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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
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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
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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
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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
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Color Code System of Vegetables
and Fruits
Color
Phytochemical
Vegetables and Fruits
Red
Lycopene
Red/purple
Anthocyanins,
polyphenols
Tomatoes and tomato
products, pink grapefruit,
watermelon
Berries, grapes, red wine,
prunes
Orange
α-, β-carotene
Carrots, mangoes,
pumpkin
Orange/yellow
β-cryptoxanthin,
flavonoids
Yellow/green
Lutein, zeaxanthin
Green
Sulforaphanes, indoles
White/green
Allyl sulphides
Cantaloupe, peaches,
oranges, papaya,
nectarines
Spinach, avocado,
honeydew, collard and
turnip greens
Cabbage, broccoli,
Brussels sprouts,
cauliflower
Leeks, onion, garlic,
chives
Data from Heber D: Vegetables, fruits and phytoestrogens in the prevention of diseases, F Postgrad Med 50:145, 2004.
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Guidelines for Cancer Prevention
1. Choose a diet rich in a variety of plant-based foods.
2. Eat plenty of vegetables and fruits.
3. Maintain a healthy weight and be physically active.
4. Drink alcohol only in moderation, if at all.
5. Select foods low in fat and salt.
6. Prepare and store food safely.
And always remember . . . Do not use tobacco in any form.
From American Institute for Cancer Research: Simple steps to prevent cancer, Washington, DC, 2000, AICR.
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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
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Factors That Affect Appetite
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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
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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
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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
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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
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Energy and Protein Requirements
 Energy
– Standardized equations, indirect calorimetry
– Should be 25-35 kcal/kg to maintain and 3545 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
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Daily Protein Requirements for
Patients with Cancer
RDA for adults: 0.8 g/kg
Normal maintenance: 0.8 to 1 g/kg
Nonstressed cancer patient: 1 to 1.2 g/kg
Hypercatabolic cancer patient: 1.2 to 1.6 g/kg
Severely stressed cancer patient: 1.5 to 2.5
g/kg
Hematopoietic stem cell transplant patient:
1.5 to 2 g/kg
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.
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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.
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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
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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
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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
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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
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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
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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 sugarfree hard candies may increase the flow
of saliva
 Chewing gum may be effective
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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
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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
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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 sitespecific effects
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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
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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
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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.
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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
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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
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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
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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.
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