Cancer

Rachel Cox, Sarah Kunz, Asia Camara, and Kayli Cummings

CANCER

Cancer•Disease involving abnormal division and reproduction of the cells that can spread throughout the body

•100 distinct types of cancer

•Cost is $48 billion annually

Cancer•13.7 million Americans with a history of cancer were alive in January 1, 2012

•Lifetime risk= probability that an individual will develop or die from cancer•Men= slightly less than a 1 in 2 lifetime risk of developing cancer•Women= slightly more than 1 in 3.

•The second most common cause of death in the US• 1 of every 4 deaths

•5-year survival rate• All cancers diagnosed between 2001-2007: 67%• All cancers diagnosed between 1975-1977- 49%

1,660,290 new cases expected in 2013

*excluding in situ cancer or basal cell or squamous cell

skin cancers

580,350 Americans expected to die from cancer in 2013

Including risk factorsETIOLOGY

•Tobacco/ cigarette smoking•Alcohol •Alcoholism and malnutrition•Excess energy •Calorie restriction•BMI (gastric surgery) • Insulin Resistance (IGF-1)• Carbohydrate intake

•Fats•Protein

External Risk Factors

External Risk Factors Continued• Infectious organisms•Hepatitis B, HPV, HIV, H. Pylori•Radiation/ UV rays•Limited fruit, vegetable, and fiber consumption•Chemicals/ Carcinogens•N-nitroso compounds (NOC)• Polycyclic aromatic hydrocarbons (PAH) •Bisphenol A (BP-A)• others

77% of all cancers are diagnosed in people over 55 years old

Internal Risk Factors•Genetic damage• Inherited mutations (5%)•Hormones• Immune conditions•Mutations in metabolism

•Most mutations occur during life

Gene Variants and Cancer•Detoxification system•Cytochrome P450 isozymes (CYPs)•Glutathione S-transferases (GSTs)• Superoxide dismutases (SODs) • Codes for proteins that dismantle reactive Oxygen species

•Each if affected by Nutrition • Lots of research on this relationship

Cancer Incidence and Death Rates by Site, Race, and Ethnicity, US, 2005-2009*All sites per 100,000 Americans, age adjusted

Incidence White African American

Asian American or Pacific Islander

American Indian or Alaska Native

Hispanic/ Latino

Male 543.1 619.7 327.5 423.2 418.7

Female 424.0 396.8 286.2 360.3 333.2

Mortality White African American

Asian or American or Pacific Islander

American Indian or Alaska Native

Hispanic/ Latino

Male 222.0 295.3 134.7 190.0 149.1Female 152.8 177.7 94.1 138.4 101.5

1/3 cancer deaths in the U.S. could be linked to diet and physical activity, including obesity

PREVENTION

American Cancer Society Recommendations•Achieve and maintain a healthy weight throughout life•Avoid excess weight gain•Be as lean as possible without being underweight•Be physically active• Limit sedentary behavior•Adults: 150 minutes of moderate intensity or 75 minutes of vigorous intensity activity a week•Children and teens: 1 hour of moderate or vigorous intensity activity each day with vigorous activity 3 days a week

ACS Recommendations Cont.•Eat a healthy diet with an emphasis on plant foods•Choose foods and drinks to maintain healthy weight• Limit processed meat and red meat• Eat at least 2 ½ cups of vegetables and fruits a day•Choose whole grain products•Watch portion control

ACS Recommendations Cont.•Limit alcohol intake• 1 drink/day for women, 2 drinks/day for men•Community Action• Increase access to affordable and healthy foods• Provide safe, enjoyable, and accessible places for physical activity

Prevention•Antioxidants• Vitamins A,C,E, carotenoids, selenium, zinc•Protein/ fat source• Omega 3: Omega 6 ratio• Leaner cuts of red meat and smaller portions or other meat

sources•Calcium and Vitamin D• Conflicting studies on calcium supplementation or increased

dairy intake• Vitamin D possibly preventative from colorectal cancer• Vitamin D may increase risk for aggressive prostate cancer• High serum levels associated with lower risk of many cancers•Folate and Folic Acid•Soy and Phytoestrogens

Phytochemicals•Mechanisms:•Detoxification of enzymes• Inhibition of nitrosamine formation• Provision of substrate for formation of chemotherapy agents•Dilution and binding of carcinogens in GI tract•Alteration of hormone metabolism•Antioxidant effects

Polyphenols (Phytochemicals)•Carotenoids •Flavonoids• Isoflavones•Lignans•Organosulfides•Phenolic compounds•monoterpenes

• Sources:– Fruits and vegetables• Nonstarchy vegetables-

green and yellow• Grapes and berries-

resveratrol – Tea and Coffee– Curry• Curcumin

PATHOPHYSIOLOGY

Classification and Nomenclature•Carcinomas: malignant epithelial tumors•Adenocarcinoma: cancer tumor from ductal or glandular structures•Adenoma - benign tumor in similar location•Sarcomas: malignant connective tissue (non-epithelial) tumors •Lymphomas: cancers of lymphatic tissue•Leukemias: cancers of blood-forming cells

Benign vs. Malignant Tumors

Benign MalignantGrows slowly Grows rapidlyWell-defined capsule Not encapsulatedNot invasive InvasiveWell differentiated Poorly differentiatedLow mitotic index High mitotic indexDoes not metastasize Can spread distantly

Differentiation

Differentiation

Anaplasia = absence of differentiation

Carcinogenesis•Initiation•Transformation of cells in response to carcinogenic agents•May be years from initial damage to detectable cancer

•Promotion•Neoplasm formed through failure of protective mechanisms

•Progression • Tumor formation•Metastasis• Angiogenesis

Pathophysiology•Proto-oncogene: normal gene that codes for cellular growth• ras•Oncogene: mutated proto-oncogenes• Promote tumor growth•Change programmed cell death (apoptosis)•Tumor suppressor genes• Encode proteins that negatively regulate proliferation• P53 (common one)

Initiation•Self-sufficiency in growth signals• Autocrine stimulation• increased growth factor receptors/ increased sensitivity of growth factor receptors •Mutation in caretaker genes• Insensitivity to antigrowth signals•Evading apoptosis•Limitless replicative potential•Sustained angiogenesis•Tissue invasion and metastasis •Over activity of Telomerase

Telomeres and Immortality•Telomeres: protective caps on each chromosome •Maintained by telomerase•Become smaller with each cell division•Cells can only divide a limited number of times

• If telomerase over active, cell becomes immortal

Mutations•Point mutations•Changes in one or a few nucleotide base pairs•Chromosome translocation • Piece on one chromosome is transferred to another

•Gene amplification•Duplication of a small piece of chromosome over and over•Can result in an increased expression of an oncogene

Carcinogenesis• Initiation• Transformation of cells in response to carcinogenic agents•May be years from initial damage to detectable cancer

•Promotion•Neoplasm formed through failure of protective mechanisms

•Progression • Tumor formation•Metastasis• Angiogenesis

Carcinogenesis• Initiation• Transformation of cells in response to carcinogenic agents•May be years from initial damage to detectable cancer

•Promotion•Neoplasm formed through failure of protective mechanisms

•Progression •Tumor formation•Metastasis• Angiogenesis

Mechanisms of Tumor Spread•Direct invasion of contiguous organs• Local spread•Metastasis to distant organs•Mechanical pressure • Lytic enzymes• Lymphatics and blood

Invasion!•Tumor cell attachment• Fibronectin• Laminin•Degradation or dissolution of the matrix• Enzymes (proteases, collagenases)•Locomotion into the matrix• Invadopodia

STAGING OF CANCER

Staging•Used to identify how much a cancer has spread throughout the body•Used as a strong predictor for survival•Used as a reference for the most effective treatment•Classified as Stage I, Stage II, Stage III, or Stage IV• Stage I being the least amt of disease and Stage IV being the most advanced.

Staging 1, 2, 3, 4• Involves the size of the tumor, degree to which it has invaded, and the extent to which it has spread•Stage 1•Cancer is confined to its organ of origin•Stage 2•Locally invasive•Stage 3•Regional structures•Stage 4•Distant sites

Staging- TNM•Tumor-node-metastasis• T- stands for the size of the tumor•N- stands for the nodes or whether it has spread into the lymph nodes•M- stands for metastasis (whether the cancer has spread to distant organs)

Tumor

Primary Tumor (T)

TX Primary tumor cannot be evaluated

T0 No evidence of primary tumorTis Carcinoma in situ (CIS)-

abnormal cells are present but have not spread to neighboring tissue

T1, T2, T3, T4 Size and/or extent of the primary tumor

NodesRegional Lymph Nodes (N)

NX Regional lymph nodes cannot be evaluated

N0 No regional lymph node involvement

N1, N2, N3Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread)

MetastasisDistant Metastasis (M)

MX Distant metastasis cannot be evaluated

M0 No distant metastasisM1 Distant metastasis is present

Staging

Classification terms• In situ: Abnormal cells are present only in the layer of cells in which they developed.•Localized: Cancer is limited to the organ in which it began, without evidence of spread.•Regional: Cancer has spread beyond the primary site to nearby lymph nodes or organs and tissues.•Distant: Cancer has spread from the primary site to distant organs or distant lymph nodes.•Unknown: There is not enough information to determine the stage.

Grading 1, 2, 3, 4*not to be confused with staging•Grading refers to the cancer cell differentiation •GX- Grade cannot be assessed (Undetermined grade)•G1- Well-differentiated (Low grade)•G2- Moderately differentiated (Intermediate grade)•G3- Poorly differentiated (High grade)•G4- Undifferentiated (High grade)

DIAGNOSING CANCER

Early DiagnosisC.A.U.T.I.O.N.•Change in bowel or bladder habits•A sore that does not heal•Unusual bleeding or discharge•Thickening or lumping in breast or elsewhere• Indigestion or difficulty in swallowing or chewing•Obvious change in a wart or mole•Nagging cough or hoarseness

Laboratory tests•Blood, urine, and other body fluids•Tumor markers- hormones, enzymes, genes, antigens, antibodies•Malignant tests•Histopathologic examinations, flow cytometry, immunohistochemistry and cytogenetics

•Oxidative damage to lipids, proteins and DNA

Other signs

General Signs•Anorexia• Fatigue•Weight loss• Fever•Sweating•Anemia

• Pain• Enlarged lymph nodes or body organs•Cough with or without hemoptysis•Bone pain w/ or w/o fracture•Neurological symptoms

Metastatic cancer

Cancer Images•CT Scan- (radiographic procedure which takes pictures at multiple angles)- evaluates for abnormalities in areas such as the head, chest, abdomen or pelvis•MRI Scan (radio waves and a magnet linked to a computer)- images produced show differences in normal and cancerous tissue. Mostly used in the brain, spinal cord and liver•PET Scan (follows radioactive glucose)- looks for ‘hot spots’ of high glycolysis in cancerous cells

PET scan of the body

CT scan of the abdomen MRI of the

brain

PROGNOSIS

Factors to Determine a Prognosis•Type of cancer (liquid vs solid)•Location of the cancer •Stage of the cancer (1, 2, 3, or 4)•Grade of the tumor (1, 2, 3, or 4)•Age of the patient•General health of the patient•Response to treatment•For liquid cancers (ie leukemia and lymphoma), the presence of chromosomal abnormalities and abnormalities in the patient’s complete blood count (CBC)

Prognosis Comparison•Breast cancer- 5 year survival rates• Stage 1 has a 88% survival rate• Stage 2 has a 81% survival rate• Stage 3 has a 67% survival rate• Stage 4 has a 15% survival rate•Lung cancer (non small cell)- 5 year survival rates• Stage 1 has a 49% survival rate• Stage 2 has a 30% survival rate• Stage 3 has a 14% survival rate• Stage 4 has a 1% survival rate

ALTERNATIVE MEDICINES

Alternative Medicines•Dietary supplements- main use is for symptom management (ie ginseng)•Metabolic therapies- detoxification, strengthening of the immune, and use of special methods to attack cancer.•Macrobiotic diet- grain based diet (natural means of healing – deficent in CA and vit B12)•Orthomolecular medicine- based on the theory that by correcting imbalances and deficiencies, the body will regain health

Alternative Therapies•Acupuncture•Naturopathic medicine•Mind-body therapies•Massage

Chemotherapy, Radiation, Surgery

TREATMENTS

Goals of treatment

Cure: complete response to treatment

Control: extend life of pt. when cure is not possible

Palliative: help pt. be as comfortable as possible.relieve and manage symptoms

Treatment Process•Gather information on the type of cancer• Stage, treatment options, places that offer treatment, caregivers

•Health care team•Doctors, nurses, dietitian, support team, family members

•Feel comfortable with the health care team•Be an active team member by remembering appointments, medications, and report side effects

CHEMOTHERAPY•Chemical agents or medications to treat cancer

•Travel via:•Oral: capsule, pill• Intravenous: vein• Intraperitoneal: abdominal cavity• Intravesicular: bladder• Intrathecal: lumbar puncture

CHEMOTHERAPY•The goal of chemo is to stop or slow the growth of cancer cells

•Mostly effects the cells that divide and grow rapidly• Cancer cells, bone marrow, hair follicles, and digestive tract

• The rate and duration of chemo is based on the type and severity of the cancer

• Chemo is administered and then Followed by a time of rest in order to let the body compensate

CHEMOTHERAPY•Side Effects:

•Hair Loss

•Nausea/Vomiting

•Bone marrow destruction

CHOP•Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone

•R-CHOP: introduction of Rituxan

• Intense dose of chemo drugs to quickly kill cancer cells

•21 days, 6-8 times

CHOP•Side Effects: mouth sores, nausea, vomiting, infections, hair loss, fatigue, fever, infection, fatigue, constipation

•Many negative nutritional implications

RADIATION•Delivered externally into the body from a machine or by placing a radioactive source in or near the tumor to deliver a highly localized dose

•Radiation only affects the tumor and surrounding area

•Can be paired with chemo. Side effects are more intense.

RADIATION• Internal radiation therapy• Implants are placed in the body • Implants give off radiation for weeks to months

•External beam radiation therapy• 5 days a week for 1-10 weeks• Lay under a radiation machine• Process takes about 15-30 minutes each time

RADIATION•Since radiation affects the surrounding tissue it is best to•Use a precise spot, spread out treatment, use low and effective doses, use medication

•Takes days or weeks for the cancer cells to begin dying, they continue to die weeks or months after treatment

RADIATION•Kills cancer cells by damaging their DNA

•Goal is to shrink tumors and kill cancer cells

•Side effects: nausea, vomiting, loss of appetite, damage to bowels, fibrosis, infertility

Mucositis Xerostomia

Stomatitis

SURGERY•Often the greatest chance for a cure of cancer is surgery, if the cancer has not spread throughout the body

•Surgery can be used as a prevention mechanism•Breast removal is a common preventative measure if a woman has a high risk of breast cancer due to family history

•Surgery is often used in order to discover the stage of the cancer

SURGERY•Curative surgery is conducted when the cancer is localized in one area. It is often coupled with radiation or chemotherapy.

•Palliative surgery is used to correct a problem that is causing discomfort or disability within the patient. Palliative care is only used to make the patients life easier, it is never used as a cure.

•Reconstructive surgery is used in order to improve the physical features of the patient after cancer.

HEMATOPOIETIC CELL TRANSPLANT•Bone marrow transplantation to restore stem cells that were destroyed through chemo, radiation, or the cancer itself•Carry oxygen, fight infection, prevent bleeding

•Stem cells come from marrow, peripheral blood, and umbilical cord blood

•The donated cells may be better at killing the cancer cells

HCT•Transplants:•Autologous: pts own stem cells• Syngeneic: stem cells from identical twin•Allogenic: relative, or unrelated donor• Most often used

HCT•Procedure: • derived from the pelvic bone or breastbone. Procedure takes about an hour to “harvest” the marrow.

•Cells are received intravenously like a blood transfusion

HCT•Risky procedure

•Pts are placed on many immunosuppressive drugs that may cause serious side effects•N/V, anorexia, stomastitis, fatigue, diarrhea• PN is a standard component of care

Hematopoietic Cell Transplant (HCT)

Autologous donor HSCT• Infusion of patient’s healthy stem cells previously harvested•Bone marrow: high [stem cells]•Requires multiple aspirations from iliac crest

•Peripheral blood•Found in mononuclear fraction of WBC•Collected by leukapheresis of donor’s blood after chemotherapy

Allogeneic transplant• Infusion of stem cells harvested from an HLA compatible donor•Usually bone marrow•Peripheral blood stem cells—may increase risk of GVHD

TBI= cytotoxicChemotherapy w/ or w/o TBI

(at very high doses) and immunosuppressivedrugs to destroy immunesystem and kill malignant

Cells.4-8 days

Infusion ofBone

Marrow(250-750 ml)

Often TPN For 3 months

to rest the gut

Signs of Malnutrition in HSCT•> 5% weight loss in < 1 month•< 90% ideal body weight•Overt muscle wasting•> 7 days of inadequate nutrition intake (<50% of needs)•>5 days of little or no nutrition intake (<25% of nutrition needs)

Graft-Versus-Host Disease•Symptoms:• can be severe individuals may experience gastroenteritis, ab pain, nausea, vomit, diarrhea

•Treat:• 1st Phase: immunosuppressive medications, Total bowel rest and the use of PN until diarrhea subsides. Nitrogen replacement • 2nd phase: reintroduce oral feedings of beverages that are isomotic, low-residue, and lactose free.. • 3rd phase: if they are tolerated reintroduce solids that contain low levels of lactose, fiber, fat, and total acidity and no gastric irritants . • 4th phase: dietary restrictions progressively reduced as foods are gradually introduced and tolerance is established.• 5th phase: resumption of regular diet.

Acute GVHD•Occurs 7-10 days post BMT•At risk for up to 3 months•May resolve or become a chronic GVHD•Treatment: immunosuppressants, steroids, inflammatory cytokine inhibitors (cyclosporine, tacrolimus, prednisone, etanercept)•MNT: Low fat, lactose free, low fiber as tolerated, NPO with significant gut involvement

Sinusoidal Obstructive SyndromeAnother transplant related complication. • Right upper quadrant discomfort, hepatomegaly, fluid

retention and jaundice. • Severe: hepatic liver failure leading to multiple-organ

system failure. • MNT: concentrated PN, monitor fluid, electrolytes,

nutrients.• Protein tolerance: Branched chain amino acids

PALLIATIVE CARE•Also known as supportive care

•Palliative – relieving symptoms of a disease with treatments not intended to cure the disease itself

•Can be given throughout treatment, or when treatment is no longer working

•Studies have shown that patients who receive palliative care often report less symptoms•Better quality of life, less pain, less depression, less nausea

DRUGS•Imuran• Immunosuppressant commonly used to RA. •Weakens the bodys immune system• Long term use increases risk for skin cancer and lymphoma

DRUGS•Thalidomide•Used to treat multiple myeloma, a type of bone marrow cancer• Immunosuppressant•Reduced to formation of blood vessels that feed tumors•Must be on two types of birth control due to the high risk of birth defects• Taken as a capsule once a day• Side effects: dizziness, drowsiness, increased risk for infection, rash, and fatigue

Drugs•Prednisone•Used to treat some leukemias, and lymphomas•Used to treat side effects of chemo such as nausea and vomiting, and increase appetite•Corticosteroid•May initiate apoptosis of cancerous white blood cells

•Cyclophosphamide•Used to treat leukemia, lymphoma, multiple myeloma, and cancers of the breast and ovaries•Belongs to a group of chemotherapy drugs• Stops cancer cells from growing, which causes them to die

Small amounts of weight loss before treatment is associated with a poorer prognosis and decreased quality of life, thus reinforcing the importance of early MNT.

MEDICAL NUTRITION THERAPY

Nutritional Screening and Assessment•Conduct a nutritional assessment throughout the patients continuum of care: at the time of diagnosis and reevaluated throughout treatment. •Nutrition focused physical exam• Survey of the body•Review vital signs•Anthropometrics• Fat stores•Muscle Mass • Fluid Status.

Subjective Global Assessment• Considers history(weight loss,

dietary intake, gastrointestinal symptoms, and functional capacity), metabolic demands• Subjective global assessment: is

adapted for use with cancer patients: • Weight history• Food Intake• Symptoms• Functioning• A dietitian will analyze: weight loss,

disease, metabolic stress, and include a nutrition-focused physical examination.• Scored Patient-Generated Subject

Global Assessment.

Additional Tools•Activities of Daily Living (ADL)•PedsQL Measurement Model•Common Toxicity Criteria(CTC) •Karnofsky Performance Scale(KPS)• In-depth Assessments

Nutrition Intervention• Intervention goals should be specific, achievable, and individualized•Minimize the effects of nutrition impact systemsOral Nutrition Management• Ideal to feed orally if possible.

Energy Requirements•Metabolism varies significantly among cancer patients. • In 200 hospitalized cancer patients, 33% were hypometabolic, 41% were normometabolic and 26% were hypermetabolic.•Harris Benedict Equation• Estimating body needs based on weight• Indirect Calorimetry.

Estimated Energy Needs Based on Body Weight

Condition Present Energy Needs, kcal/kg

Cancer, nutritional repletion, weight gain

30-35

Cancer, nonambulatory, inactive

25-30

Cancer, hypermetabolic, stressed

35

Sepsis 25-35

Stem cell transplant

30-35

Protein• Increased whole-body protein turnover• Increased muscle wasting•Decreased serum protein levels• Increased liver protein synthesis •Decreased muscle protein synthesis•Negative nitrogen balance

Medical Condition

Estimated Protein Needs, g/kg

Normal 0.8-1.0

Nonstressed cancer patient

1.0-1.2

Hypercatabolism

1.2-1.6

Severe Stress 1.5-2.5

Nutrition support

1.6-2.0

Fluid RequirementsAltered fluid balance: Ascites, edema, fistulas, profuse vomiting or diarrhea, multiple concurrent intravenous therapies, impaired renal function, or medications such as diuretics.•Closely monitor fluid intakes for dehydration: • S/S: fatigue, weight loss, hypernatremia, poor skin turgor, dry oral mucosa, dark urine, decreased urine output

• Fluid needs 30-35 mL/kg/day • 1 mL fluid per 1 kcal of estimated calorie needs. • IV fluid hydration may be needed.

Vitamin and Mineral Supplementation•Vitamins and Minerals•American Cancer institute: don’t use dietary supplements for cancer prevention. High doses of supplementation can have cancer promoting effects•Multivitamin no more than 100% of DRI’s is considered safe. •Controversy on if vit A, C, E, B-carotene, zinc, and selenium actually inhibits or enhances the antitumor effects of radiation therapy or chemotherapy.•Avoid antioxidant supplements: get a variety of antioxidants from food sources: naturally occurring, health-promoting, phytonutrients, vitamins and minerals.

Nutrition Impact SymptomsNausea & Vomiting: Anorexia, weight loss, dehydration, electrolyte imbalance. • Small frequent meals & liquids between meals•Room temperature or cold foods• Eat dry, starchy and salty foods• Light exercise•Avoid sweet, rich, greasy, or spicy foods•Avoid strong odors•Avoid eating favorite foods when nauseated to decrease potential aversions

Cachexia/Weight LossProtein Energy Malnutrition• Progressive weight loss caused by protein energy malnutrition, anorexia, generalized wasting and weakness, immunosuppression, altered basal metabolic rate, electrolyte imbalances and energy metabolism. • Increase in lipolysis = loss of fat• Increase lipid-mobilizing factor & proteolysis-inducing factor= fat and

muscle loss. • Cytokines: metabolic changes and wasting • TNF: overlapping effects. • REE is elevated• Treatment• Eat nutrient dense meals and snacks frequently• Add protein and calories to favorite food• Capitalize on the times that are best

Alterations in Taste/ Early SatietyAlterations in taste: Anorexia, decreased intake of food, weight loss• Try marinades and spices • Use plastic utensils • Try a different protein source• Eat foods at room temperature• Rinse mouth frequently• Try fresh or frozen foods

Early Satiety : Anorexia, cachexia, weight loss, electrolyte imbalances, bloating, nausea• Eat small frequent nutrient dense meals and snacks• Add protein and calories to foods• Drink nutrient dense liquids• Avoid fried, greasy, or rich foods which take longer to digest• Avoid gaseous foods which can cause bloating• Try light exercise

Diarrhea & Constipation Diarrhea:• Add soluble fiber/limit insoluble fiber• Eat small frequent meals and snacks• Avoid foods that make diarrhea worse• Drink only clear liquids for 12-14 hours after a sudden attack of diarrhea• Eat foods high in sodium and potassium• Drink plenty of fluidsConstipation• Drink plenty of liquids especially hot liquids• Eat high fiber foods• Incorporate Exercise

MouthXerostoma (Dry Mouth)• Sip water throughout the day• Eat or drink sweet/tart foods and drinks• Chew gum or suck on hard candy, popsicles, and ice chips• Moisten food with sauce gravy or salad dressingOral Candidiasis (Sore Mouth) • Choose foods that are easy to chew• Cut food into small pieces and use a small spoon• Drink with a straw• Suck on ice chips• Avoid certain foods and drinks when your mouth is sore

Neutropenia Abnormally low levels of neutrophils. Causing a greater risk for developing serious infections.•Was hand frequently and keep kitchen surfaces clean• Do not eat undercooked or raw animal products: such as meat pork game, poultry, eggs, and fish•When in doubt throw it out. No old or moldy. • Discard leftovers stored at room temperature longer than 2 hours • Use only clean eating utensils • All raw meat should be cooked thoroughly to an internal temperature of 185 degrees Fahrenheit • Avoid cross-contamination by using separate cutting boards for produce and meats• Do not drink directly from cans; wash can before opening and then pour into cup

Other Side EffectsLactose Intolerance• Choose low lactose or lactose free products.

Neutropenia• Was hand frequently and keep kitchen surfaces clean• Do not eat undercooked or raw animal products• When in doubt throw it out.

Thickened Saliva• Sip on liquids such as club soda seltzer water or papaya nectar.• Use a mist humidifier.

Sore Throat • Eat soft moist foods with extra sauce• Avoid dry foods, alcohol, citrus, caffeine, tomatoes, vinegar• Experiment with temperatures of food.

MedicationsAnti-emeticsAppetite stimulants • Megase• MarinolUpper GI stimulants (stimulate gastric emptying) • metoclopramide (reglan)Immunosuppressants• Cyclosporine• Imuran (azathioprine) • PrednisoneAnti-Cachexics (Anabolics)• Growth Hormone• Oxandrolone• testosterone derivatives

JUVEN• Juven is a blend of Revigor, Arginine, and Glutamine and is clinically shown to begin to support tissue building. •Revigor helps produce new tissue by slowing muscle breakdown and enhancing protein synthesis•Arginine is an amino acid that promotes nutrient rich blood flow and is a building block for proteins which can contribute to healing•Glutamine is an amino acid that helps cells produce the building blocks needed for new tissue

•Helps build new tissue after injury, surgery and wounds

Nutrition SupportBiotherapy• Side Effects: Hematopoietic growth factors may cause fatigue, chills, fever, and flulike symptoms.

Radiation Therapy• Side effects: fatigue, loss of appetite, skin changes, hair loss

Surgery• Fatigue, temporary changes in appetite and bowel function caused by anesthesia, and pain. • Requires additional energy and protein for wound healing and recovery.• Its important to understand which part of the alimentary tract has been affected or surgically removed so the appropriate nutrition intervention can be recommended.

Hematopoietic Cell Transplantation•Greatly Effects nutritional status. Side Effects:• Acute toxicities of immunosuppression, nausea, vomiting, anorexia, dysgeusia, stomatitis, oral and esophageal mucositis, fatigue, and diarrhea.

• Individuals typically have little or no oral intake and the GI tract is compromised during the first few weeks following transplant. • PN vs Enternal Feeding•Carefully monitor and use more concentrated solutions• Low white blood cell count • Neutropenic Diet

Pediatric Cancer• Psychogenic food refusal in children requires intervention to address underlying psychological issues• Efforts to minimize psychological effects of fear, unpleasant hospital routines, unfamiliar foods learned food aversions, and pain

•Nutrition requirements similar: adjust for activity •Stress maximum intake of favorite foods, nutrient-dense foods during time when intake is best.• EN for children who are unable to cooperate and who have functional GI tracts• PN for children receiving intense treatment associated with severe GI toxicity and for malnourished children

•Best indicator of nutrition is growth.

CASE STUDY Non-Hodgkin Lymphoma: is a cancer that starts in the lymphocytes, which are part of the body's immune system. The four main histologic subtypes of Hodgkin's disease include the following:• Treatment includes multimodal therapy with radiation, chemotherapy,

and may include bone marrow transplant for relapsed patients.Symptoms and Signs• Lymphadenopathy• Fever• Night sweats• Weight loss• Pruritus• Alcohol-induced pain• Anemia• Lymphopenia• Serum protein depletion

CASE STUDY•Stage 2 diffuse large B-cell lymphoma with mediastinal disease and positive lymph nodes• Treatment: • Chemotherapy regimen and radiation therapy. • Treatment may can cause mucositis, nausea, vomiting, diarrhea, and constipation. Taste abnormalities that lead to anorexia and decreased oral intake.

• Food and Drug interaction: may require B12 supplement

Sample Diet for Case Study•Class discussion