Nutrition: The Forgotten Ingredient in Cancer Care
Presentation Provided by The Cancer Nutrition Network for Texans
TCC #00-78
Burden of Cancer in Texas
2000
77,100 New Cases 34,400 Deaths
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Malnutrition and Cancer
Diminished tolerance of therapy Lower survival rates Diminished quality of life Longer hospitalizations
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Weight Loss and Survival
Median Survival (Weeks)
Total # Patie nts 111 179 138 307 289 78 189 590 436 290 311 129 No We ight Los s 14 41 18 43 70 46 46 20 34 0 107 8 Any We ight Los s 12 27 16 21 45 24 25 14 27 138 55 4 Tum or Type / Location Pancreas Gastric Nonmeasureable Measureable Colon Breast Prostate Sarcoma Lung Nonsmall Cell Small Cell Hodgkin's Disease Favorable Unf avorable Acute Nonlymphocytic Leukemia 0.01 0.01 ns 0.01 0.05 0.05 ns 0.01 0.01 0.05 0.01 p* ns
Adapted f rom DeWys, WD; Begg, C; Lavin, PT; et al.: Prognotis ef f ect of w eight loss prior to chemotherapy in cancer patients. Am J Med, 68:683-690, 1980.
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Nutritional Issues in Cancer
Systemic Effects of Cancer on Nutrition Localized Tumor Effects Nutritional Problems of Therapy Nutrition Intervention and Tumor Growth Efficacy of Nutritional Support Guidelines for Nutritional Support Unproven Diet and Nutrition Claims
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Cancer-related Defects in Carbohydrate Metabolism
Glucose intolerance Insulin resistance Abnormal insulin secretion Delayed glucose clearance Increased glucose production Increased glucose turnover Variably increased Cori cycle activity
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Cancer-related Defects in Fat Metabolism
Excess body fat depletion relative to protein loss Decreased lipolysis, free fatty acids, and glycerol turnover Hyperlipidemia Failure of glucose to suppress oxidation of free fatty acids Decreased serum lipoprotein lipase activity despite normal insulin
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Cancer-related Defects in Protein Metabolism
Increased whole-body protein turnover Increased protein fractional synthetic rates in liver Reduced fractional synthetic rates in muscle Increased hepatic protein synthesis Persistent muscle protein breakdown Decreased plasma branched-chain amino acids
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Radiation-related Problems
Oropharyngeal Area Loss of taste Xerostomia & odynophagia Teeth loss Lower Neck & Mediastinum Esophagitis with dysphagia Fibrosis with esophageal stricture Abdomen & Pelvis Bowel-damage syndromes (acute or chronic) with diarrhea, malabsorption, stenosis & obstruction, fistulization
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Surgery-related Problems
Radical Resection of Oropharyngeal Area
Chewing & swallowing difficulties
Gastric stasis & hypochorhydria secondary to vagotomy Steatorrhea secondary to vagotomy Diarrhea secondary to vagotomy Premature satiety Regurgitation Dumping syndrome Malabsorption Achlorhydria & lack of intrinsic factor and R protein Hypoglycemia Premature satiety
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Esophagectomy
Gastrectomy (high subtotal or total)
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Surgery-related Problems
Intestinal Resection - Jejunum & Ileum
Decreased absorption efficiency including fat Vitamin deficiency with fat-soluble vitamin malabsorption Bile salt losses with diarrhea or steatorrhea Hyperoxaluria & renal stones Calcium & magnesium depletion Life-threatening malabsorption Malnutrition Metabolic acidosis Dehydration w/wo salt & water balance problems Vitamin B12 Malabsorption Malabsorption Diabetes
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Massive Bowel Resection
Blind Loop Syndrome
Pancreatectomy
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Drug-related Problems*
*Noncytotoxic agents
Corticosteriods
Fluid & electrolyte problems Nitrogen & calcium losses Hyperglycemia
Fluid retention Nausea Megesterol acetate - glucocorticoid effects
Sex hormone analogues
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Immunotherapy Problems*
* Prevalence Ranking
Tumor necrosis factor Fluid Retention Hypotension Interleukin-2 Interferons
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Nausea & Vomiting Diarrhea
Azotemia
Anorexia
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Chemotherapy & Symptoms
Che mothe ra pe utic Age nts
M ethotr exa te 6-M er ca ptopur i ne P entosta ti n 5-Fl uor our a ci l Str eptozoci n Cyta r a bi ne Aza ci ti di ne Fl uor our a ci l Hydr oxyur ea Hexa nethyl mel a mi ne Chl or a mbuci l Cycl ophospha mi de Da ca r ba zi ne Ci spl a ti n Ca r musti ne (BCNU) Doxor ubi ci n/Ida r ubi ci n Da cti nomyci n Bl eomyci n P r oca r ba zi ne Etoposi de/Teni posi de Amsa cr i ne Aspa r a gi na se Vi nbl a sti ne Vi ncr i sti ne Ta xol
Nutritiona l Effe cts
A+,N+,P ,M 2,U,D2+ A+,N2+,M 2+,D+ A+,N3+ A,N+,M 2+,D2+ A+,N3+,U,CT A+,N2+,M + A2+,N2+,D3+ A,N2+,M +,D+ A,N+,M + A,N3+ A,N+ A,N3+ A,N3+,D A,N3+,M g A,N3+ A,N+,M + A,N3+,M ,D M 3+,D,N+ A,N2+ N+,M ,D A2+,M 2+,CT A2+,N2+ C,M ,N,D C3+,P A,M ,N,D,O
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What can be done about Nutritional Support?
Step 1 - Assessment
History Labs
Step 2 - Planning
Nutritional requirements Setting achievable goals
Step 3 - Intervention
Symptom Management Nourishment
Step 4 - Evaluate
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Assess - Ask!
Ask about:
Appetite - good/poor Grazing or snacking Special diets/ practices Food likes/dislikes Quantity - calories in Symptoms - mouth pain or difficulties with chewing or swallowing Vitamin/herb use
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Beware of: Living arrangements
Alone? Housebound? Vigor?
Income level Alcohol use Mental status
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Assess - Look for signs!
Hair - dull, brittle, dry or falls out easily Swollen glands in the neck Skin - dry, rough, spotty, or sandpapery feel Sores and delayed wound healing Muscle wasting (decreased size & strength) Edema of the lower extremities Abnormal heart rate, rhythm, & blood pressure Enlarged liver or spleen Loss of balance or coordination
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Assess - Regular weighing!
Criteria Weight Standard Ideal Body Weight (BMI) Men: 106 lbs. For the first 5' of height plus 6 lbs. For each additional inch. Women: 100 lbs. For the first 5' of height plus 5 lbs. For each additional inch. Percent Amount of weight change Weight divided by usual weight x 100 Change Interpretation >120 % IBW is obese 110% - 120% IBW is over weight 90% - 110% IBW is normal range 80% - 90% IBW is mildly underweight <80% IBW is moderately underweight
BMI (Body Mass Index)
Significant weight loss is greater than: 1% - 2% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months Weight (kg)/height squared (m) < 20 = malnutrition possible < 18 = malnutrition likely
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Assess - Know lab results!
Albumin (3.5-5 g/dL)
Mild depletion (2.8-3.4 g/dL) Moderate depletion (2.1-2.7 g/dL) Severe depletion (<2.1g/dL)
Total lymphocyte count (2500 mm3)
TLC (mm3) = WBC (mm3) x % lymphocytes Mild depletion (<1500 mm3) Moderate depletion (<1200 mm3) Severe depletion (<800 mm3)
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Plan and Set Achievable Goals
Rule-of-Thumb Guidelines
Cardinal principle: Individualize to needs of patient Short-term goal: Improve nutritional status Long-term goal: Normalize Nutrient Intake and alleviate disease symptoms
Calories per day Normal: 30 cal/kg (for adults) - average activity levels 28 cal/kg in starvation - due to slowed metabolism & decreaed calorie needs 32 cal/kg in elective surgery - mildly increased needs 40 cal/kg in polytrauma; significantly increased needs 50 cal/kg in sepsis or severe stress; highly increased needs Normal: 0.8 g/kg (for adults) - average activity levels 1.5 - 2 g/kg with fever, fracture, infection, wound healing 1.5 - 2 g/kg for protein repletion 1.5 - 3 g/kg for cachexia or burns If ablbumin is 3.5 g/dL, protein requirement is 0.8 g/kg If ablbumin is 2.8 - 3.5 g/dL, protein requirement is 1 - 1.2 g/kg If albumin is 2.1 - 2.7 g/dL, protein requirement is 1.2 -1.5 g/dL If albumin is<2.1g/dL, protein requirement is 1.5 - 2 g/dL
Protein per day
Protein required per day based on albumin level
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Symptom Management
Strategies for Patients (Handout)
Patient teaching Trial and error pragmatism
Pharmacological Interventions Supplements Coping Strategies
Spiritual Support Groups Exercise
Total Parenteral Nutrition (TPN)
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Drug Therapy & Symptom Control
Common Problems
Early Satiety
Common Agents
Metoclopramide (Reglan) Megestrol (Megace) Dexamethasone (Decadron, Hexadrol) Fluoxymesterone (Android-F, Halotestin) Pilocarpine (Ocusert) Benzocaine (Americaine, Anbesol) Dyclonine (Dyclone) Lidocaine (Xylocaine) Perphenazine (Trilafon) Prochlorperazine (Compazine) Dolasetron mesylate (Anzemet) Granisetron (Kytril) Ondansetron (Zofran) Diphenoxylate HCL (Lomotil) Kaolin/pectin (Kaopectate) Loperamide HCL (Imodium) Octreotide acetate (Sandostatin) Bisacodyl (Dulcolax) Lactulose (Evalose) Senna (Senokot, Senolax)
Action
Increases gastric emptying and transit time Appetite Stimulant Appetite Stimulant Anabolic steriod Increases salivation Analgesic Analgesic Analgesic Moderate emetogenic Moderate emetogenic
Dry mouth
Nausea and Vomiting
Serotonin antagonists with moderate to high emetogenicity Antidiarrheal
Diarrhea
Constipation
Bowel Motility
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Evaluation
Cardinal principle:
Individualize to needs of patient
Short-term goal:
Improve nutritional status
Long-term goal:
Normalize Nutrient Intake Alleviate disease symptoms
Outcomes???
Better Quality of life / Vigor Fewer Crisis / Improved Treatment Response
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Chemoprevention Trials
Cooperative Groups Subtractive vs. Additive Concerns - dosage determination, toxicity evaluation, efficacy testing, end-points Threats to validity - compliance, ‘cross-over’, surrogate measures, costs & time
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Recently Completed Trials
Vitamin A - Oral cavity, lung, cervix, skin, Vitamins C & E w/wo Calcium - Colon Vitamin B12 - Bronchial epithelium Beta Carotene - Skin China - Beta Carotene, Vitamin E, Selenium Finland - Alpha-tocopherol, Beta Carotene CARET - Alpha-tocopherol, Beta Carotene
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Promising Clinical Trials
Planned: Calcium supplementation in colorectal adenoma Vitamin E & Selenium in prostate intraepithelial neoplasia Retinoids in: Smokers with bronchial dysplasia Women with hyperplastic breast lesions People with oral leukoplakia Women with cervical intraepithelial neoplasia People with Barrett's esophagus People with skin lesions Underway: WINS (The Women's Nutrition Intervention Study) NOAT (Society of Nutrition Oncology Adjuvant Therapy)
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Many areas of traditional and complementary medicine have been utilized to explore the connection between nutrition and cancer, but the full potential of nutritional oncology to impact the survival of the cancer patient has not been realized.
Preface - Nutritional Oncology (AP, 1999) David Heber, George L. Blackburn, Vay Liang W. Go
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Cancer Nutrition Network for Texans Webpage:
www.homestead.com/NSIGHTS
Address:
CNNT 301 University Blvd. Galveston, Texas 77555-1147
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