Chapter 37. Medical Nutrition Therapy for Cancer. 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 (2/3 rd in persons over age 65) - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
CancerCancer Abnormal cell division and reproduction Abnormal cell division and reproduction
that can spread throughout the bodythat can spread throughout the body
Major cause of mortality in the U.S., Major cause of mortality in the U.S., second only to cardiovascular diseasesecond only to cardiovascular disease
Most cases occur in older individuals Most cases occur in older individuals (2/3(2/3rdrd in persons over age 65) in persons over age 65)
Rates vary by ethnicity: African Rates vary by ethnicity: African American men higher rates than white American men higher rates than white men. African American women have men. African American women have lower incidence rates but higher mortality lower incidence rates but higher mortality rates than white womenrates than white women
Multistep process in which normal cells Multistep process in which normal cells are transformed into cancer cellsare transformed into cancer cells
Causes: exposure to carcinogens, Causes: exposure to carcinogens, genetics, nutritiongenetics, nutrition
1/31/3rdrd of deaths attributed to diet and of deaths attributed to diet and exercise and 1/3exercise and 1/3rdrd attributed to cigarettes attributed to cigarettes
Normal body cells have closely regulated Normal body cells have closely regulated growthgrowth
Cellular growth is partly controlled by a Cellular growth is partly controlled by a counting system based on telomeres.counting system based on telomeres.
Telomeres are end pieces of Telomeres are end pieces of chromosomes that become shorter after chromosomes that become shorter after each cell divisioneach cell division
When the telomere shortens to a specific When the telomere shortens to a specific length, the cell will stop dividinglength, the cell will stop dividing
Pathophysiology cont.Pathophysiology cont. Cancer cells produce at an uncontrolled Cancer cells produce at an uncontrolled
raterate
Cancer cells become autonomous from Cancer cells become autonomous from the normal growth signals and genetic the normal growth signals and genetic control and may even secrete their own control and may even secrete their own growth factorgrowth factor
An enzyme is secreted that destroys the An enzyme is secreted that destroys the telomere, leading to loss of the celltelomere, leading to loss of the cell’’s s internal clock & counting system which internal clock & counting system which controls replicationcontrols replication
Pathophysiology cont.Pathophysiology cont. The cell may take on other traits: The cell may take on other traits:
nucleus/cytoplasm may be enlarged or nucleus/cytoplasm may be enlarged or misshapen, mitosis rate becomes higher, misshapen, mitosis rate becomes higher, derangements in chromosome sequencederangements in chromosome sequence
Three stagesThree stages
– Initiation: transformation of cellInitiation: transformation of cell
– Promotion: multiplication of cellsPromotion: multiplication of cells
– Tumor progression, includes metastasisTumor progression, includes metastasis
Response to treatment is complete, Response to treatment is complete, partial, stable, or progressivepartial, stable, or progressive
ChemotherapyChemotherapy: systemic – affects all : systemic – affects all body systems. Interrupts stages of cell body systems. Interrupts stages of cell replication. Affects rapidly dividing cells replication. Affects rapidly dividing cells such as the GI tract. Ptsuch as the GI tract. Pt’’s experience s experience nausea and other GI problems during nausea and other GI problems during treatment. Hair loss is also a side affect. treatment. Hair loss is also a side affect. Pt may experience neutropenia and Pt may experience neutropenia and anemia because bone marrow cells are anemia because bone marrow cells are affected.affected.
– Most the normal cells in the body are in a Most the normal cells in the body are in a resting stage and are somewhat protected resting stage and are somewhat protected from the effectsfrom the effects
Use of chemical agents or medications to treat Use of chemical agents or medications to treat cancercancer
Anemia, fatigue, nausea, vomiting, loss of Anemia, fatigue, nausea, vomiting, loss of appetite, mucositis, changes in taste and small, appetite, mucositis, changes in taste and small, xerostomia, dysphagia, diarrhea, constipationxerostomia, dysphagia, diarrhea, constipation
Severity of side effects depend on specific Severity of side effects depend on specific agents used, dosage, duration, number of agents used, dosage, duration, number of treatments, current health status.treatments, current health status.
Intestinal mucosa and digestive processes are Intestinal mucosa and digestive processes are affected which alter digestion and absorption of affected which alter digestion and absorption of some nutrientssome nutrients
Watch for drug nutrient interactionsWatch for drug nutrient interactions
RadiationRadiation: used alone is the most : used alone is the most common treatment for certain cancers of common treatment for certain cancers of the head and neck. May cure some the head and neck. May cure some cancers such as Hodgkins, thyroid cancers such as Hodgkins, thyroid carcinoma, localized cancers of the head carcinoma, localized cancers of the head and neck.and neck.
– Ionizing radiation breaks the strands of the Ionizing radiation breaks the strands of the DNA helix, leading to cell death.DNA helix, leading to cell death.
– Toxicity of radiation is localized to the Toxicity of radiation is localized to the region being treatedregion being treated
Cancer Treatment and Nutritional Cancer Treatment and Nutritional Implications–contImplications–cont’’dd Hematopoietic stem cell transplantationHematopoietic stem cell transplantation
(treatment for leukemia, lymphoma)(treatment for leukemia, lymphoma)
– Nausea, vomiting, anorexia, dysgeusia, Nausea, vomiting, anorexia, dysgeusia, stomatitis, oral and esophageal mucositis, stomatitis, oral and esophageal mucositis, fatigue, and diarrheafatigue, and diarrhea
– Graft versus host disease (GVHD): donar stem Graft versus host disease (GVHD): donar stem cells react against the tissues of the forein hostcells react against the tissues of the forein host
– Sinusoidal obstructive syndrome (SOS): chemo Sinusoidal obstructive syndrome (SOS): chemo or radiation therapy damage to the hepatic or radiation therapy damage to the hepatic venulesvenules
SurgerySurgery After surgery, patients may experience fatigue, After surgery, patients may experience fatigue,
changes in appetite and bowel function, pain.changes in appetite and bowel function, pain.
Require additional energy and protein for wound Require additional energy and protein for wound healing.healing.
Head & neck cancer: impaired mastication and chewing Head & neck cancer: impaired mastication and chewing due to tumor mass- usually rely on enteral nutritiondue to tumor mass- usually rely on enteral nutrition
Stomach cancer – surgery is most common treatment.Stomach cancer – surgery is most common treatment.
– Malabsorption, deficiency of iron, folate & B12 Malabsorption, deficiency of iron, folate & B12
Nutrition in the Etiology of CancerNutrition in the Etiology of Cancer Nutrition may modify carcinogenic process at Nutrition may modify carcinogenic process at
any stage: carcinogen metabolism, cellular and any stage: carcinogen metabolism, cellular and host defense, cell differentiation, and tumor host defense, cell differentiation, and tumor growthgrowth
Nutrition is adversely affected by cancer itself, Nutrition is adversely affected by cancer itself, treatment (radiation therapy, chemotherapy, and treatment (radiation therapy, chemotherapy, and surgery), and current health and nutritional status surgery), and current health and nutritional status
One third of all cancer deaths attributed to diet, One third of all cancer deaths attributed to diet, nutrition, and lifestyle behaviors such as poor nutrition, and lifestyle behaviors such as poor diet, physical inactivity, overweight and obesity, diet, physical inactivity, overweight and obesity, and alcohol use; another third related to cigarette and alcohol use; another third related to cigarette and tobacco useand tobacco use
Types of Epidemiologic Studies Types of Epidemiologic Studies of Cancerof Cancer
Case Control StudiesThe 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 StudiesThe diets of different groups of subjects are compared, using the same measures at a single point in time.
Nutrition in the Etiology of Cancer– Nutrition in the Etiology of Cancer– contcont’’dd
Complex relationshipComplex relationship
Dietary carcinogens: naturally occurring and Dietary carcinogens: naturally occurring and added in food preparation and preservationadded in food preparation and preservation
Inhibitors of carcinogenesis: antioxidants, Inhibitors of carcinogenesis: antioxidants, phytochemicalsphytochemicals
Enhancers of carcinogenesis: fat in red meat, Enhancers of carcinogenesis: fat in red meat, compounds formed when meat is grilled at high compounds formed when meat is grilled at high temperaturestemperatures
Latency period between initiation and Latency period between initiation and promotionpromotion
Energy Intake, Body Weight, Energy Intake, Body Weight, Obesity, and Physical ActivityObesity, and Physical Activity
Energy restriction inhibits cancer and Energy restriction inhibits cancer and extends life span in animalsextends life span in animals
Positive associations between overweight Positive associations between overweight and cancers of the breast, endometrium, and cancers of the breast, endometrium, kidney, colon, prostate, and otherskidney, colon, prostate, and others
Overweight increases risk of cancer Overweight increases risk of cancer recurrence and decreases survivalrecurrence and decreases survival
Physical activity is inversely associated Physical activity is inversely associated with cancerwith cancer
Nutrition and Cancer EtiologyNutrition and Cancer Etiology Fat: positive associationFat: positive association
Protein: increased red meat intake associated Protein: increased red meat intake associated with colon and prostate cancerwith colon and prostate cancer
Soy and phytoestrogens: protective against Soy and phytoestrogens: protective against breast cancer. For women already dx, moderate breast cancer. For women already dx, moderate use of soy is recommended but avoid use of soy is recommended but avoid supplementssupplements
Carbohydrates: fiber, sugars, and glycemic Carbohydrates: fiber, sugars, and glycemic indexindex– Fiber protectiveFiber protective
– Simple sugars – may stimulate cancer cell growth Simple sugars – may stimulate cancer cell growth due to increased insulin productiondue to increased insulin production
Fruits and vegetables: protectiveFruits and vegetables: protective
Nonnutritive sweeteners: not a concernNonnutritive sweeteners: not a concern
Nutrition and Cancer Etiology– contNutrition and Cancer Etiology– cont’’dd Alcohol: associated with cancer of the mouth, Alcohol: associated with cancer of the mouth,
Coffee and tea: no significant relationshipCoffee and tea: no significant relationship
Methods of food preparation and preservation: Methods of food preparation and preservation: high heat cooking methods and processed high heat cooking methods and processed meats may be linkedmeats may be linked
Cancer chemoprevention: supplementation of Cancer chemoprevention: supplementation of nutrients such as betacarotene to prevent cancer nutrients such as betacarotene to prevent cancer – no statistical relatinship– no statistical relatinship
Cancer prevention recommendations: nutrition Cancer prevention recommendations: nutrition and physical activityand physical activity
Nutrition and physical activity Nutrition and physical activity recommendations for cancer survivors: Table recommendations for cancer survivors: Table 37-237-2
Color Code System of Vegetables Color Code System of Vegetables and Fruitsand FruitsColorColor PhytochemicalPhytochemical Vegetables and FruitsVegetables and Fruits
RedRed LycopeneLycopene Tomatoes and tomato Tomatoes and tomato products, pink grapefruit, products, pink grapefruit, watermelonwatermelon
Data from Heber D: Vegetables, fruits and phytoestrogens in the prevention of diseases, Data from Heber D: Vegetables, fruits and phytoestrogens in the prevention of diseases, F Postgrad MedF Postgrad Med 50:145, 2004. 50:145, 2004.
Guidelines for Cancer PreventionGuidelines 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: From American Institute for Cancer Research: Simple steps to prevent cancer,Simple steps to prevent cancer, Washington, DC, 2000, AICR. Washington, DC, 2000, AICR.
Adverse nutritional effects of cancer Adverse nutritional effects of cancer compounded by treatmentcompounded by treatment
Even small weight loss (<5% body Even small weight loss (<5% body weight) before treatment adversely affect weight) before treatment adversely affect prognosisprognosis
Cancer CachexiaCancer Cachexia Progressive weight loss. One of the most Progressive weight loss. One of the most
common causes of death among pts with cancer common causes of death among pts with cancer and is present in 80% at time of death.and is present in 80% at time of death.
Abnormalities in fluid and energy metabolismAbnormalities in fluid and energy metabolism
Mediated via cytokines, including tumor Mediated via cytokines, including tumor necrosis factor (TNFnecrosis factor (TNF and TNF and TNF), cachectin, ), cachectin, interleukin-1, interleukin-6, and interferon-interleukin-1, interleukin-6, and interferon-
Diagnosis stems from presenting signs and Diagnosis stems from presenting signs and symptomssymptoms
In cancer cachexia, amino acids are not spared In cancer cachexia, amino acids are not spared as they are during simple starvation and as they are during simple starvation and depletion of lean muscle mass occursdepletion of lean muscle mass occurs
Muscle wasting: increased protein catabolism Muscle wasting: increased protein catabolism and/or decreased protein synthesisand/or decreased protein synthesis
Nutrition support preserves lean body mass; Nutrition support preserves lean body mass; also benefits malignancyalso benefits malignancy
Metabolism and Tumor Growth Metabolism and Tumor Growth cont.cont.
Hypercalcemia in patients with bone Hypercalcemia in patients with bone metastasesmetastases
Fluid and electrolyte imbalances: cancers Fluid and electrolyte imbalances: cancers that promote excessive diarrhea or that promote excessive diarrhea or vomitingvomiting
Loss of appetite and sensory changes. Loss of appetite and sensory changes. Alterations in taste and smell are Alterations in taste and smell are commoncommon
Nausea, vomiting, early satiety, Nausea, vomiting, early satiety, mucositis, constipationmucositis, constipation
Nutritional Care of AdultsNutritional Care of Adults Goals: prevent or reverse nutrient Goals: prevent or reverse nutrient
deficiencies, preserve lean body mass, deficiencies, preserve lean body mass, minimize nutrition-related side effects, minimize nutrition-related side effects, maximize quality of lifemaximize quality of life
Nutritional screening and risk Nutritional screening and risk assessment: SGA considered reliableassessment: SGA considered reliable
Body weight: maintain body wt and Body weight: maintain body wt and nutrient stores. Wt loss not typically nutrient stores. Wt loss not typically recommended.recommended.
Antioxidants: controversy over whether Antioxidants: controversy over whether or not to take supplementsor not to take supplements
– Should be 25-35 kcal/kg to maintain and 35-Should be 25-35 kcal/kg to maintain and 35-45 kcal/kg to replenish. Add kcal if patient 45 kcal/kg to replenish. Add kcal if patient is febrile or septic.is febrile or septic.
– Some indicate that okay for obese patients to Some indicate that okay for obese patients to receive 21-25 kcal/kgreceive 21-25 kcal/kg
ProteinProtein
– Consider degree of malnutrition, extent of Consider degree of malnutrition, extent of disease, degree of stress, ability to disease, degree of stress, ability to metabolize and use proteinmetabolize and use protein
Daily Protein Requirements for Daily Protein Requirements for Patients with CancerPatients 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, 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: micronutrient, and fluid requirement. In Elliott L et al, editors: The clinical guide to oncology nutrition,The clinical guide to oncology nutrition, ed 2, ed 2, Chicago, 2006, American Dietetic Association.Chicago, 2006, American Dietetic Association.
– It is a cytokine protein that promotes It is a cytokine protein that promotes breakdown of both protein and fat stores to breakdown of both protein and fat stores to provide adequate energy for tumor cells.provide adequate energy for tumor cells.
– Insulin resistance occurs because of the Insulin resistance occurs because of the excessive fatty acid oxidation.excessive fatty acid oxidation.
– Glucose levels increase but the glucose and Glucose levels increase but the glucose and amino acids made available are used by the amino acids made available are used by the cancer cells.cancer cells.
Nauea/VomitingNauea/Vomiting Assess causeAssess cause
If odors contribute, take precautions to avoid If odors contribute, take precautions to avoid the odorsthe odors
Assess for early satiety: small frequent meals Assess for early satiety: small frequent meals may be helpfulmay be helpful
Many times, n/v is a result of medications Many times, n/v is a result of medications (chemotherapy most common)(chemotherapy most common)
– Eat small, low fat meal the mornin of the Eat small, low fat meal the mornin of the first treatment and avoid fried, greasy and first treatment and avoid fried, greasy and favorite foods for several days following the favorite foods for several days following the treatmenttreatment
– Encourage ptEncourage pt’’s to take anti-emetics as s to take anti-emetics as prescribedprescribed
Small, frequent meals that are nutrient Small, frequent meals that are nutrient densedense
Beverages should contain nutrients and Beverages should contain nutrients and consumed between meals rather than consumed between meals rather than with meals to avoid fullnesswith meals to avoid fullness
Avoid consumption of raw vegetables Avoid consumption of raw vegetables and other high fiber foodsand other high fiber foods
Medications that increase gastric Medications that increase gastric emptying may be usedemptying may be used
MucositisMucositis Associated pain is the main source of Associated pain is the main source of
cancer treatment-related paincancer treatment-related pain
– Pain can be severe enough that patients Pain can be severe enough that patients avoids food and drink which can lead to avoids food and drink which can lead to dehydration and weight lossdehydration and weight loss
Fluid and Micronutrient Fluid and Micronutrient RequirementsRequirements FluidFluid
– Body surface area: 1500 mL/mBody surface area: 1500 mL/m22 or BSA × 1500 or BSA × 1500 mLmL
– Daily requirements method: 1 mL fluid per 1 Daily requirements method: 1 mL fluid per 1 kcal of estimated needskcal of estimated needs
– Holliday-Seger method: >20 kg of body weight Holliday-Seger method: >20 kg of body weight = 1500 mL + 20 mL/kg for each kg >20 kg= 1500 mL + 20 mL/kg for each kg >20 kg
– Age based method: <55 year of age – 30 to 40 Age based method: <55 year of age – 30 to 40 mL/kg, 55 to 65 years of age – 30 mL/kg, >65 mL/kg, 55 to 65 years of age – 30 mL/kg, >65 years of age – 25 mL/kgyears of age – 25 mL/kg
MicronutrientsMicronutrients– High-dose supplements commonHigh-dose supplements common– Pre-existing deficienciesPre-existing deficiencies– Recommend supplement with 100% DRIRecommend supplement with 100% DRI
Fatigue is most common side effectFatigue is most common side effect
– Consume frequent, small feedingsConsume frequent, small feedings
– Emphasis on Emphasis on morning feedingmorning feeding when energy when energy is betteris better
– Easy to eat foodsEasy to eat foods
– Foods with low preparation timeFoods with low preparation time
– Avoid favorite foods when undergoing Avoid favorite foods when undergoing treatment – may develop negative aversions treatment – may develop negative aversions to the foods if they are associated with to the foods if they are associated with unpleasant symptomsunpleasant symptoms
Parenteral NutritionParenteral Nutrition Used when oral and enteral feeding is not Used when oral and enteral feeding is not
toleratedtolerated
May use when severe diarrhea or May use when severe diarrhea or malabsortion occursmalabsortion occurs
Usually, patients are severely Usually, patients are severely malnourished with GI malfunctionsmalnourished with GI malfunctions
Intense monitoring and specialized care Intense monitoring and specialized care is requiredis required
Used for pts with reasonable prognosis. Used for pts with reasonable prognosis. Not appropriate for terminal patients.Not appropriate for terminal patients.
Provide for quality of lifeProvide for quality of life
Diet as desired by individualDiet as desired by individual
Goal is to alleviate negative symptoms Goal is to alleviate negative symptoms (ex: pain, weakness, constipation, nausea, (ex: pain, weakness, constipation, nausea, loss of appetite, dry mouth)loss of appetite, dry mouth)
Emphasize pleasurable aspects of eating Emphasize pleasurable aspects of eating without concern for quantity or without concern for quantity or nutrient/energy contentnutrient/energy content
Nutritional Care of ChildrenNutritional Care of Children
Families and caregivers often have Families and caregivers often have extreme preoccupation with eating and extreme preoccupation with eating and weightweight
Creativity in feedingCreativity in feeding
Enteral nutrition supportEnteral nutrition support
Focal PointsFocal Points Nutrition plays an important role throughout the continuum of Nutrition plays an important role throughout the continuum of
cancer care—from helping to reduce cancer risk, to caring for cancer care—from helping to reduce cancer risk, to caring for patients undergoing cancer treatment, to promoting healthy patients undergoing cancer treatment, to promoting healthy lifestyles for cancer survivors. lifestyles for cancer survivors.
Patients have different needs and challenges with regard to their Patients have different needs and challenges with regard to their nutrition management, and providing individualized nutritional nutrition management, and providing individualized nutritional guidance is an essential component of their care. guidance is an essential component of their care.
Prompt and appropriate nutrition management may help to improve Prompt and appropriate nutrition management may help to improve patientspatients’’ tolerance of treatment, minimize nutrition impact tolerance of treatment, minimize nutrition impact symptoms, and maximize quality of life. symptoms, and maximize quality of life.
Cancer patients should be encouraged to actively participate in their Cancer patients should be encouraged to actively participate in their care and to communicate with their health care providers. care and to communicate with their health care providers.
When patients are inundated with nutrition-related CAM therapy When patients are inundated with nutrition-related CAM therapy choices, food and professionals can provide sound guidance for choices, food and professionals can provide sound guidance for informed decision making.informed decision making.