The Challenge of Nutritional Maintenance in Cancer Patients
Document Sample
Refer to: Drasin H, Rosenbaum EH, Stitt CA, et al: The chal-
lenge of nutritional maintenance in cancer patients. West
J Med 130:145-152, Feb 1979
The Challenge of Nutritional
Maintenance in Cancer Patients
HARRY DRASIN, MD, and ERNEST H. ROSENBAUM, MD, San Francisco
CAROL A. STITT, RD, Houston, and ISADORA R. ROSENBAUM, San Francisco
Weight loss and cachexia frequently accompany malignant disease and its
treatment. Semistarvation is common in patients in hospital and in patients
with cancer as well. Adequate nutrition is essential in treatment of malignant
conditions. Patients and families as well as the medical community should use
a comprehensive approach to improving the caloric and protein intake of
patients who are still able to benefit from oral intake and further therapy.
MANY VOLUMES of published data affirm the hyperalimentation, or total parenteral nutrition
benefits of good nutrition in cancer patients. Often (TPN), and elemental (chemically defined) diets
there are multiple causes of malnutrition, usually in maintaining nutritional balance.
related to the cancer itself or to systemic effects The important role of nutrition in cancer man-
of the cancer. Treatment with chemotherapy, ir- agement is evident in the increased ability of pa-
radiation and surgery, as well as psychological tients to complete radiation therapy and chemo-
difficulties, are also aggravating factors. therapy, to suffer fewer complications during
Physicians must be attuned to the nutritional treatment and to achieve better surgical healing.
problems of patients for several reasons. First, This work has been done primarily with TPN and
they can foster in patients an awareness of the elemental diets.
importance of adequate protein and calorie in- It is hoped that similar benefits can be obtained
take. In addition, physicians can reinforce the idea with oral diets if attention to calorie and protein
that adequate nutrition is an integral part of anti- balance is maintained from the very beginning
cancer therapy without which other treatment and malnutrition-induced changes in gastrointes-
modalities are less likely to succeed. They can tinal function are thus prevented." Otherwise
stress that it is the responsibility of the patients anorexia, nausea, vomiting and bloating gradu-
and their families to carry out this aspect of their ally develop when absorptive function of the
care. gastrointestinal tract diminishes as malnutrition
Recent attention has centered on the use of progresses, a process very difficult to reverse.
Efforts must be made to prevent these changes
From the Division of Medical Oncology, Zellerbach Saroni
Tumor Institute (Dr. Drasin); Department of Medicine (Dr.
caused by malnutrition.
Rosenbaum); and Department of Dietetics (Mrs. Stitt), Mount This is, however, a difficult task to accomplish.
Zion Hospital and Medical Center, San Francisco. Mrs. Stitt is
now at M. D. Anderson Hospital, Houston. The importance of nutrition must be discussed
Supported in part by ACS Grant CF 3922A, from the American frankly with patients, with a reminder that it is
Cancer Society.
Submitted, revised, May 18, 1978. their effort that will make the difference. While it
Reprint requests to: Harry Drasin, MD, Mount Zion Hospital is primarily the responsibility of the patient,
and Medical Center, P.O. Box 7921, San Francisco, CA 94120.
THE WESTERN JOURNAL OF MEDICINE 145
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
family and friends to maintain an adequate diet for ten days before surgery for upper gastroin-
for the former, the medical profession must also testinal malignancies experienced-minimal post-
increase its efforts to help patients achieve a nu- operative morbidity and mortality, fewer wound
tritious dietary program. Physicians can do this infections and dehiscences, less postoperative
by discussing diet with patients, by providing pneumonia and shorter hospital stays.6
written dietary instructions, by consulting with A group of 39 nutritionally depleted patients
dietitians skilled in helping patients and physi- with a variety of malignancies received radiation
cians to solve nutritional difficulties, and by pro- therapy and TPN, and 95 percent of these patients
viding tape-recorded or video-taped discussions were able to complete the planned radiation
on nutrition. Doctors are responsible for educat- therapy.7 There was a positive correlation between
ing patients in nutritional maintenance. tumor response and nutritional status. It is criti-
cally important therefore to maintain protein and
Parenteral Nutrition calorie intake from the beginning of treatment.
Much current information concerning the effect Nutrition also plays an essential role in the
of nutritional maintenance on anticancer therapy maintenance of immunological function.8 Of 17
and its complications come from studies in pa- cancer patients who initially had negative results
renteral nutrition. Several excellent reviews detail of skin tests of delayed hypersensitivity, 13 con-
the method and results of hyperalimentation in verted to positive test results after an average of
cancer patients and others.2-4 While these methods 11.4 days of TPN, and only the converters re-
have contributed substantially to the ability to sponded to chemotherapy; those for whom results
maintain nutrition and prevent starvation in can- of skin tests remained negative (4 of 17) did not
cer patients, as well as enabling the use of greater respond to chemotherapy.9 After surgical opera-
amounts of chemotherapy or fewer interruptions tions, patients who had positive results of skin
of radiation therapy, they will be mentioned only tests experienced uncomplicated postoperative
briefly in this discussion of oral nutritional main- recoveries. Since malnutrition does play a part in
tenance. Basically, oral nutrition and parenteral immune incompetence, immunologic dysfunction
nutrition work toward the same goal. The main- in cancer patients could be corrected if its cause
tenance of adequate caloric and nitrogen status is malnutrition.
by either method should achieve the same result One critical factor in the implementation of
provided that the amounts of calories, amino more intensive forms of alimentation is the poten-
acids, fats, carbohydrates, vitamins and minerals tial for palliation or cure available through specific
are adequate and that significant diarrhea, steator- tumor-related therapy, be it chemotherapy, radi-
rhea or malabsorption is not present. ation therapy or surgery. Attempts at heroic
Copeland treated 175 patients with TPN and measures of nutritional repletion seem unreason-
recorded an average 2.5-kg (5.6-pound) weight able in patients whose tumors are not responsive
gain during chemotherapy, a time when many to available agents. While vigorous, refeeding
patients lose weight.5 There was a correlation be- seemingly might stimulate tumor growth,'0 this
tween adequate nutritional status and response to effect has not been seen by most researchers who
chemotherapy. Those without TPN received 3.8 have observed patients who received intensive
grams total dose of 5-fluorouracil and 10 percent nutritional supplementation.5 Speculatively, how-
responded, compared with 7.4 grams total dose ever, although growth of a tumor during refeeding
and a 31 percent response rate in patients treated might theoretically seem detrimental to a patient,
with TPN. With nutritional support as an adjunct refeeding might stimulate more cells of a therapy-
to surgery, a group of 100 patients gained an sensitive tumor to divide actively and enter the
average of 1.8 kg (4.2 pounds) in a period of cell cycle, thereby decreasing the number of cells
24.2 days. Weight gain, increase in strength and in the Go, or resting, stage and increasing cell
return of immunocompetence were much easier susceptibility to drug kill."
to accomplish when TPN was given preoperatively
instead of postoperatively. This result underscores Elemental Diets
the need to prevent incipient starvation and its Elemental diets that contain amino acids and
related systemic effects. other easily absorbable nutrients also have a place
Heatley and Hughes, in England, reported that in nutritional therapy. They are commercially
a group of patients who were treated with TPN available under the names of Vivonex, Vivonex
146 FEBRUARY 1979 * 130 * 2
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
HN, Flexical (all registered trade names) and Radiation Therapy Problems
others (Tables 1 and 2). These diets can provide Radiation therapy to the head and neck area
1,500 or more calories daily, and they have high results in loss of taste, dry mouth, stomatitis and
nutritional value. Discussions of elemental diets consequent anorexia. Irradiation destroys taste
are found in papers by Russell12 and by Freeman buds and decreases saliva secretion. It is extremely
and co-workers.13 difficult to prepare food that will appeal to people
In patients with advanced metastatic cancer, who have undergone such treatment. The graphic
elemental diets decreased the number of rectal description of the difficulties encountered after
lesions induced by 5-fluorouracil treatment in radiation therapy to the head and neck area
human beings and helped patients maintain their written by MacCarthy-Leventhal should be read
weight.14 by all who treat patients with these tumors.21 To
Bounous and associates found that, in rats, stimulate appetite, food aromas and visually en-
drug toxicity was decreased by the use of ele- ticing foods must be substituted for foods that
mental diets before and after the administration formerly tasted good. Patients who have under-
of 5-fluorouracil.15 These researchers felt that gone radiation therapy often need continual en-
the diet helped to protect mucosal integrity, thus couragement to eat, even though they are not
shielding animals from 5-fluorouracil-induced hungry and find that swallowing is painful.
dipeptidase deficiencies. Elemental diets also sig- Foods such as citrus juices that may irritate
nificantly improved survival in mice following sore mouths should be avoided. Patients are most
irradiation by enabling a faster recovery from comfortable with food taken at room temperature
radiation-induced intestinal lesions and by limit- or slightly chilled. Highly seasoned foods may be
ing the initial effects on absorptive cells.16 irritating to the mouth and throat and do nothing
to heighten taste that has been destroyed by
Diet Methods for Cancer Patients therapy. Food sticking may be a problem, and
Discussions of standard diets may be found in swallowing can be difficult because of decreased
the Mayo Clinic Diet Manual,17 in Iowa State saliva secretion.' Meats and vegetables' should be
University's Recent Advances in Therapeutic moistened with gravies and sauces to permit easier
Diets,18 in Goodhart and Shils' Modern Nutri- swallowing. A pureed diet may be tolerated better
tion in Health and Disease'! and in the Diet Man- than a soft diet, depending on the degree of
ual from Massachusetts General Hospital's dietary dysphagia present. Small frequent feedings are
department.20 Some additions and changes in generally better accepted than are the customary
these diets are necessary for the special problems three meals each day. High-protein, high-calorie,
of cancer patients, which include complications liquid supplements such as milk shakes, eggnog,
from cancer therapy. Meritene, Sustagen and Carnation Instant Break-
TABLE 1.-Overview of Nutritional Supplements
Chemically
Milk Lactose- Defined Low Special
Supplement* Base Free (Elemental) Residue Supplements
1"Mir.;tain
erLLiene ........ IV
A
Sustacal ......... x
Sustagen ........ x
Nutri-1000 ...... x
Carnation Instant
Breakfast ...... x
Ensure ..........
Flexical ......... x xi x
Precision LR and
Precision HN x x
Vivonex and
Vivonex HN ... x x x
Citrotein ........ x .. x x
Portagen ........ x .. X x
MCT ........... x .. .. x
*AU registered trade names.
THE WESTERN JOURNAL OF MEDICINE 147
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
S4
tt 0 % %00
0~~~~~~~~~~~~~
0
4) ~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ "
',A 40
0 ow >~~0>
0~~"
~
0'~~~~~~~
0~ 0 0ca :
0 >~~~
*~~~~~~~~~~~~~~~~~~C
040
00 00~~~~~~O. 0 0 -
0~~~~~~
I~~~~~5b1 ~ gzr 0% - Sf5~~~~~~~~~~~
0~~~~
'0 '00 Sf
'0~~~~~
0 ~~~~~~~00 u0 0
- "4 "4~~~V "44
so0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~i
"
0~~~~~~~~~~~~~~~~~~~
0 ~~~~~~~~~~~~~~~~~~~~~~o.
4)
54 4)~~~~~
I
148 FEBRUARY 1979 * 130 * 2
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
o 0 0 0~~~c
_ e
01
Cu-~~~~~C
0 6
4)~~~~~~~~~~~~~~~~i.U
o 'Id o
~~ O~~C
_ q o*4
V U
~~ ~~ o,.~~t
co 00 No0co
'ij 0%~~~~~~~~ 0g*0
0'4 -~~~C4V-
0
0~~~~~~~~~~~~~~~~~0
o 0 ~~~~~~~~~ O0 10~10~~ ~ ~ ~v
c - -4 .W 1 4
>0 Is 75 '40 '0 ) '0
o 0 0 .~~~00
0
o 0.0
IUS 0 > '0
THE WESTERN JOURNAL OF MEDICINE 149
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
fast form an extraordinarily important part of the offsetIthe weight loss that occurs during therapy.
nutritional maintenance of these patients (Tables The treatment regimen for stomatitis is a diet
1 and 2). consisting of cream soups, cooked cereals, milk
Patients who receive irradiation to the pelvis shakes, eggnogs, custards, ice cream and juices.
and abdomen may suffer side effects of malab- Alcohol should be avoided and smoking should
sorption, diarrhea or obstruction. Low-residue be curtailed.
diets or elemental diet preparations are some- Some measures that often permit moderate oral
times indicated in order to keep fecal bulk at a intake in patients with stomatitis include mouth
minimum. Patients with obstruction may require care with salt and soda washes (made by adding
elemental diets or parenteral nutrition. Milk 1 or 2 tablespoons of baking soda and 1 teaspoon
products must be avoided if temporary lactase of salt to a quart of warm water) or lidocaine hy-
deficiency occurs, or Lact-Aid may be used to drochloride (Xylocaine) suspension taken orally;
convert the lactose to lactic acid and permit the treatment of complicating candida infections, and
use of milk. adequate analgesia. Foods are better tolerated at
The low-residue diet is similar to the standard room temperature or slightly chilled; and fruit
soft diet in food restrictions. Vegetable juices, nectars are more easily taken than are citrus
cooked whole beets, cooked whole carrots and juices, which may cause a burning sensation.
cooked asparagus tips are allowed. All other vege- Supplementing the diet with high-protein, high-
tables must be pureed. -If these measures are calorie liquids is important to the aim of main-
ineffective, low-residue diets such as Precision LR taining protein and calorie intake during the
and Vivonex* provide complete nutrition and time needed for healing and thus promoting the
require little digestion. Elemental preparations healing process by preventing the malnutrition
such as Flexical and Vivonex are generally poorly that would otherwise occur.
tolerated when taken by mouth, however, and Diarrhea should be controlled with proper
often require tube feeding. Some supplements are medication or by avoidance of milk in patients
better accepted by patients than others.22 Cost who are temporarily lactase-deficient following
and availability also vary (Table 2). therapy. For lactase deficiency Lact-Aid may also
be used to convert lactose to lactic acid. After
Chemotherapy Problems diarrhea has diminished, the patient can take
Chemotherapeutic drugs are an important part liquids and gradually start soft, bland foods.
of anticancer therapy. These agents frequently
cause side effects including nausea, vomiting, Dietary Supplements
anorexia, stomatitis, malabsorption and diarrhea, In addition to milk shakes and eggnogs, there
which lead to nutritional problems. are many commercial dietary supplements (Tables
Antinauseant medications' such as prochlor- I and 2), and new dietary pre'parations become
perazine can be given to reduce discomfort and available constantly. The limited number of prod-
are often effective if taken about half an hour ucts discussed in this report are those used most
before meals. frequently for patients treated in the Division of
Different drugs cause varying degrees of nausea Medical Oncology at Mount Zion Hospital and
and vomiting. Nausea occurs frequently with Medical Center.
nitrogen mustard, the nitrosoureas, adriamycin, Sustagen, Sustacal and Meritene are powdered
cis-platinum, mitomycin-C, vinblastine and strep- supplements that are available without prescrip-
tozotocin; commonly with procarbazine and cyclo- tion in most larger drugstores. They come in
phosphamide; more rarely with vincristine, pred- various flavors and mix with water or milk. Car-
nisone and methotrexate. nation Instant Breakfast, a powdered supplement
Chemotherapy may be given combined with available in grocery stores or supermarkets, comes
heavy sedation in the evening to decrease the side in a variety of flavors and can be mixed either
effects of nausea and vomiting, enabling the with milk or with half-and-half. Pharmacists can
patient to escape through sleep the peak hours of order other supplements that are not routinely
discomfort. Many patients increase oral nutri- stocked. The person who purchases supplements
tional intake before chemotherapy in order to will probably find the prices at larger pharmacies
are lower than those charged by small or hospital
*A1 nutritional supplements mentioned in this paper are regis-
tered trade names. pharmacies.
150 FEBRUARY 1979 * 130 * 2
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS-
TABLE 3.-Comparison of Nutritional Supplements one is found. Availability and cost also are factors
Supplement* Flavor Mean Ratingt in the choice of a supplement (Table 2), since
many of these preparations are not covered by
Ensure ...... Vanilla 3.19
Nutri-1000 ... Vanilla 2.93 standard medical insurance policies.
Sustagen ..... Vanilla 2.19
Meritene ..... Vanilla 2.15 Vitamin and Mineral Supplements
Vivonex ..... Orange 1.80 There is no conclusive evidence at this time to
Precision LR . . Orange 1.76
Flexical ...... Vanilla 1.19 indicate that decreased or excess amounts of any
*All registered trade names. specific vitamin have beneficial effects in the
t5 = excellent taste; 1 = very poor taste. treatment of cancer in human beings.23
Recent attention has focused on the role of
While all these products supplement the diet trace elements in cancer.24 Patients with malig-
with added nutrients, vitamins, calories and pro- nancies have decreased levels of zinc in serum,25
tein, the protein content of many of these drinks and zinc deficiency may possibly contribute to the
can be doubled by mixing with milk reinforced decreased sense of taste26'27 and the immunologic
by instant dry nonfat milk solids (a cup of milk dysfunction in these patients.28
solids to a quart of whole milk). This double- The source of vitamins and minerals for human
strength milk can be used in making cream soups, beings should be the food they eat, based on a
puddings, custards, milk shakes and many other properly planned diet. For patients who are un-
dishes, as well as in the preparation of supple- able to ingest a normal diet, a preparation con-
ments. taining B complex and C vitamins is generally
In a recent study that compared patient accept- recommended. Vitamin D is not routinely recom-
ance of various oral supplements, Meritene was mended, since many cancer patients suffer from
significantly preferred over elemental diet or hypercalcemia.
low-residue preparations such as Precision LR,
Vivonex HN and Standard and W-T Low Resi- Other Considerations
due food.22 When other preparations were com- Adequate analgesics are essential, since pain
pared, Ensure, Nutri-1000 and Sustacal rated contributes greatly to anorexia. Non-nauseating
significantly higher than Meritene or Vivonex analgesics should be used in adequate dosages
Standard. In a study we have recently conducted based upon individual tolerance.
21 physicians and dietitians participated in a If ascites is present, the patient may take pre-
taste test of various dietary supplements. All sup- scribed diuretics or undergo paracentesis to im-
plements were coded and blindly scored on a prove appetite.
scale from 1 (very poor taste) to 5 (excellent Individual eating habits, food preferences and
taste). Samples were freshly made and served at daily eating patterns should be followed as much
room temperature. Results are shown in Table 3. as possible. If the largest meal is eaten in the
Ensure and Nutri-1000 were significantly favored morning, this pattern should be continued, with
over Vivonex and Precision LR (P<.001). En- most of the calories taken at that time of day
sure was not ranked significantly different from (except perhaps on therapy days).
Nutri-1000 (P>.25), but was favored over all Mechanical factors such as obstruction have a
the others (P<.005). Nutri-1000 was not sig- significant nutritional impact, and malabsorption
nificantly different from Meritene (P>.25). Meri- should be noted early, before significant nutri-
tene was ranked superior to Precision LR (P< tional imbalance can occur.
.0025). Sustagen, Meritene and Vivonex were The always-encouraging relatives and friends
not rated significantly different from each other should be told to avoid the entreaty of "just
(P>.05). Statistics were calculated by use of the one more bite," and to recognize the limits of the
one-tailed test. There are significant differences patient. If nutritional status can be maintained,
in taste between the various dietary supplements there may not be a progressive decrease in intake
tested. Ideally, the chemically defined products in many patients until shortly before death.
would be served as slush or ice or used in recipes It is important to recognize periods when
designed to improve acceptability to patients. It temporary nasogastric, peripheral vein or TPN
is important to recognize these taste differences feedings may be needed for a brief time to main-
!nd to switch supplements until an acceptable tain a patient during some stressful situation.
THE WESTERN JOURNAL OF MEDICINE 151
NUTRITIONAL MAINTENANCE IN CANCER PATIENTS
Weight can be maintained afterward by reinsti- tors can seek consultation with dietitians who are
tution of oral intake as appetite returns. skilled in the nutritional needs of cancer patients.
No difference or superiority has been shown As always, physicians should give patients sup-
for natural or organically grown foods when com- port, encouragement and feedback. We must strive
pared with crops grown under standard agricul- to prevent the starvation of patients with cancer
tural conditions with chemical fertilizers.29 The as long as there is still a chance for curative or
higher cost of the former may make them less palliative treatments.
desirable for cancer patients who may be bur- REFERENCES
dened financially. 1. Viteri FE, Schneider RE: Gastrointestinal alterations in pro-
tein-calorie malnutrition. Med Clin N Am 58:1487-1504, Nov 1974
Cooking with convenience foods may be ap- 2. Ghadimi H: Total Parenteral Nutrition-Premises and
preciated as a means to conserve time and Promises. New York, John Wiley & Sons, 1975
3. Copeland EM III, Dudrick SJ: Nutritional aspects of cancer,
energy for patients who live alone or who are In Hickey RC (Ed): Current Problems in Cancer-Vol 1, No 3.
Chicago, Year Book Medical Publishers, Inc, 1976, pp 1-51
unable to shop frequently and prepare food. 4. Fischer JE: Total Parenteral Nutrition. Boston, Little,
Frozen-food dinners, canned convenience foods, Brown and Company, 1976
5. Copeland EM III, MacFayden BV Jr, Dudrick SJ: Intra-
frozen leftovers and dishes adequate for several venous hyperalimentation in cancer patients. J Surg Res 16:241-
247, Mar 1974
meals that are prepared and kept in the freezer 6. Heatley RV, Hughes LE: Preoperative intravenous nutrition
in cancer patients (abst). Proceedings XI Int Cancer Congress,
until needed, all may help to increase protein and Florence, Italy, 4:874, 1974
calorie intake. Often the patient's family can help 7. Copeland EM III, MacFayden BV Jr, MacComb WS, et al:
Intravenous hyperalimentation in patients with head and neck
prepare a week's meals to be defrosted and cancer. Cancer 35:606-611, Mar 1975
8. Gross RL, Newberne PM: Malnutrition, the thymolymphatic
cooked as needed. system and immunocompetence, In Friedman H (Ed): The Re-
ticuloendothelial System in Health and Diseases. New York,
Plenum Press, 1976, pp 179-187
Conclusion 9. Copeland EM III, MacFayden BC Jr, Dudrick SJ: Effect of
intravenous hyperalimentation on established delayed hypersen-
Although efforts to maintain proper nutrition sitivity in the cancer patient. Ann Surg 184:60-64, Jul 1976
10. Terepka AR, Waterhouse C: Metabolic observations during
may not add significantly to survival, they cer- the forced feeding of patients with cancer. Am J Med 20:225-238,
Feb 1956
tainly improve the quality of life. Success depends 11. Steiger E, Oram-Smith J, Miller E, et al: Effects of nutri-
on improving the caloric and protein intake of tion on tumor growth and tolerance to chemotherapy. J Surg Res
18:455-461, Apr 1975
patients, often a nearly impossible task that re- 12. Russell RI: Progress report: Elemental diets. Gut 16:68-79,
Jan 1975
quires the cooperation of the patient, the patient's 13. Freeman JB, Egan MC, Millis BJ: The elemental diet. Surg
family and friends and the physician. Those Gynecol Obstet 142:925-932, Jun 1976
14. Bounous G, Gentile JM, Hugon J: Elemental diet in the
around the patient must constantly devise new management of the intestinal lesion produced by 5-fluorouracil in
man. Canad J Surg 14:312-324, Sep 1971
ways to add appetizing foods of moderate or high 15. Bounous G, Hugon J, Gentile JM: Elemental diet in the
management of the intestinal lesion produced by 5-fluorouracil in
caloric content as many times a day as possible. the rat. Canad J Surg 14:298-311, Sep 1971
Eventually, progressive tumor usually precludes 16. Hugon JD, Bounous G: Elemental diet in the management
of the intestinal lesions produced by radiation in the mouse.
effective oral nutritional maintenance. Canad J Surg 15:23-26, Jan 1972
17. Committee on Dietetics of Mayo Clinic: Mayo Clinic Diet
Profound systemic metabolic changes occur in Manual. 4th Ed. Philadelphia, WB Saunders Company, 1971
many patients with cancer and lead to increased 18. Staff of Department of Nutrition, University of Iowa: Re-
cent Advances in Therapeutic Diets, 2nd Ed. Ames, Iowa, Iowa
energy requirements and cachexia. Nutritional State University Press, 1973
19. Goodhart RS, Shils ME: Modern Nutrition in Health and
maintenance is an integral part of the treatment Disease-Dietotherapy, 5th Ed. Philadelphia, Lea & Febiger, 1973
20. Massachusetts General Hospital Dietary Department: Diet
of malignancies. The patient must maintain caloric Manual. Boston, Little, Brown and Company, 1976
and protein requirements in order to benefit from 21. MacCarthy-Leventhal EM: Post-radiation mouth blindness.
Lancet 2:1138-1139, Dec 19, 1959
surgical, medical or radiation treatments. As 22. DeWys WC, Herbst SH: Oral Feedings in the nutritional
food intake becomes more deficient, it becomes management of the cancer patient. Cancer Res 37:2429-2431, Jul
1977
increasingly difficult to maintain proper nutrition, 23. Basu TK: Significance of vitamins in cancer. Oncology 33:
183-187, Jul 1976
and starvation occurs. In cachectic patients, the 24. Schwartz MK: Role of trace elements in cancer. Cancer
Res 35:3481-3487, Nov 1975
approach we have described will not be effective, 25. Falchuk KH: Effect of acute disease and ACTH on serum
and tube feedings or total parenteral nutrition will zinc proteins. N Engl J Med 296:1129-1134, May 19, 1977
26. Henkin RI, Schechter PJ, Hoye R, et al: Idiopathic hypo-
be required. geusia with dysgeusia, hyposmia, and dysosmia. JAMA 217:434-
440, Jul 26, 1971
Physicians, nurses and dietitians can provide 27. DeWys WD, Walters K: Abnormalities of taste sensation
in cancer patients. Cancer 36:1888-1896, Nov 1975
printed materials, present audio tapes and video 28. McMahon LJ, Montgomery DW, Guschewsky A, et al: In
tapes of discussions about nutrition and conduct vitro effects of zinc chloride on spontaneous sheep red blood cell
(E) rosette formation by lymphocytes from cancer patients and
diet classes for patients to strengthen further the normal subjects. Immunological Communications 5:53-67, Jan 1976
29. Barness LA: Nutritional aspects of vegetarianism, health
educational approach to diet maintenance. Doc- foods and fad diets. Pediatrics 59:460 464, Mar 1977
152 FEBRUARY 1979 * 130 * 2
