Therapeutic Nutrition In the Oncology Population

Therapeutic Nutrition In the Oncology Population

Suzanne Dixon, MPH, MS, RD

Oncology Nutrition Specialist & Epidemiologist

Cancer Nutrition Info, LLC

www.cancernutritioninfo.com


Why is Nutrition Such a Battleground?

May be the only aspect of care with which family & friends feel they can help

May be the only thing over which the individual with cancer still feels a sense of control

People want to help & everyone ‘knows’ nutrition

These conflicting agendas cause much anxiety and tension


Why Should We Care About Nutrition?

20 to 40% of cancer patient deaths are related to cancer-induced or treatment related malnutrition

Site of treatment:

– GI tract and/or pelvic region: diarrhea, lactose intolerance, malabsorption, weight loss

– Head & Neck: xerostomia, superficial ulceration in the field of radiation, bleeding, pain, mucositis, weight loss

Mucositis during chemotherapy ~ 40%, Mucositis during chemoradiation ~ 100% Effect of symptoms on dietary intake profound: ~ 60% of

H&N & GI patients lose weight upon beginning treatment


Nutrition Intervention Works!

The Good News…

Getting Help With Nutrition WORKS!! Recent study comparing usual care with intensive diet intervention (seeing a dietitian) showed that people who see a dietitian do better!1

Population: GI & H&N

1 British Journal of Cancer 2004;91:447-452.


Cachexia vs. Anorexia

Anorexia: ‘Lack of Appetite’ & ‘Involuntary Decline in Food Intake’

٠ Anorexia is EFFECT rather than CAUSE of Cachexia

Cachexia is term to describe the disordered metabolism of diseases including (but not limited to):

٠ Cancer ٠ HIV/AIDS ٠ Sepsis٠ Other chronic infections ٠ Other Inflammatory Conditions

Cytokines Responsible for Metabolic Alterations

Metabolic Alteration Cytokines InvolvedCarbohydrate MetabolistmIncreased hepatic gluconeogenesis IL-6Increased Cori cycle activity TNFIncreased glucose turnover TNFDecreased muscle insulin-estimated glucose uptake TNF

Lipid MetabolistmHyperlipidemia TNF, IL-1, LIF, IFN-g

Decreased WAT LPL activity TNF, IL-1, LIF, IFN-g

Increased WAT lipolysis TNF, IL-1, IFN-a,b ,g

Increased BAT thermogenesis TNF

Protein MetabolistmIncreased whole body protein turnover TNFIncreased hepatic protein synthesis TNF, IL-1, LIF, IL-6, IFN-g

Changes in circulating amino acid pattern TNFIncreased muscle protein degradation TNFDecreased msucle amino acid uptake TNFIncreased BCAA turnover TNF, IL-1

Hormonal changesInsulin resistance TNFIncreased counter-regulatory hormones TNF, IL-1

Disordered MetabolismFat Breakdown

Lipid Mobilizing Fat Factors Anorexia

PBMC HypothalamusIncreasedEnergy

Cytokines Expenditure

Liver AcutePhase

Adrenal B Proteins Cells

Tumor Insulin Cortisol Glucagon

Protein Breakdown

Skeletal Muscle


Adequate Education of Family & Care Givers Key

May be a fundamental lack of understanding among family members & care givers

• Symptoms• Physical sensations of ‘starving’

Forcing the issue is often counterproductive

Must be addressed before the crisis point


Treatment Nutrition Goals

Phase 1: Getting Through Treatment (Primary Goals)

– Prevent or correct nutritional deficiencies– Minimize short-term and long-term treatment side effects – Improve tolerance to treatment– Enhance quality of life during treatment– Help achieve and maintain optimal body weight– Educate family members about special nutrition needs– Evaluate the risks and benefits of nutrition-related CAM

(supplements, vitamins, minerals, herbs); consider medication interaction issues!


Treatment Nutrition Goals

Phase 2: Cancer Fighting Nutrition For Life (Secondary Goals)

– Maintain healthy weight

– Incorporate healthy nutrition habits for long-term health

– Maximize cancer preventive potential of the diet (minimize recurrence risk)

– Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!


Addressing Primary Clinical Nutrition Intervention Goals


Screening Vs. Assessment

SCREENING To detect possibility of nutrition risk Provide information to determine if follow-up is required All oncology patients in all settings require screening Screen must be simple & self-administered Screen determines whether patient is referred to specialist (RD) If screening detects need for more intensive assessment &

intervention, arrange for this immediately If referral unnecessary, document screen & re-screen at follow-up

ASSESSMENT More intensive & thorough Includes intervention, follow-up, intervention, follow-up, etc.


The Who & How of Screening

Generally, nursing staff performs screen: In-home & Outpatient May simply provide & collect form to/from patient & return it to the office

for screening score & further intervention planning

Different clinics & home care companies use different methods for patient referral– Forms handed to dietitian prior to scoring– Forms scored & referrals made by nursing/medical staff

Referral must be made if patient is classified at risk

Dietitian may keep & store screening forms, but it will need to be in permanent medical record

Best Tool: Patient-Generated Subjective Global Assessment (PG-SGA)


Screening Tool Fundamentals

SCREENING TOOL PG-SGA = Patient Generated Subjective Global Assessment Despite the name, PG-SGA is a good screening tool PG-SGA is validated for use in oncology populations Easy to administer & score

ITEMS ON A NUTRITION SCREEN Weight History & Percent Weight Change Food Intake: Has It Changed? Symptoms Functional Status Disease & stage Metabolic demand Physical exam


PG-SGA Scoring & Optimal InterventionPG-SGA Score Guides Nutrition Intervention

Not At Risk: Additive Score = 0 to 1– No intervention required at this time; continue to screen at follow up

visits Stage A/Low Risk: Additive Score = 2 to 3

– Well nourished, but may still be at risk; intervention includes education by dietitian or nurse, with pharmacologic nurse or physician triage as indicated by symptom survey

Stage B/Moderately Malnourished: Additive Score = 4 to 8– Moderately malnourished, requires dietitian intervention working in

conjunction with nurse, physician, and medical care team as indicated by the symptom check-off for pharmacologic management

Stage C/Severely Malnourished: Additive Score = 9 or greater– Critical need for symptom mgmt and other nutrition intervention.

Requires interdisciplinary team discussion to address all aspects affecting nutritional status and discussion of non-oral nutrition options including enteral or parenteral nutrition as dictated by gut function


From Screening To Assessment

AFTER SCREEN INDICATES RISK, FULL ASSESSMENT:

Weight History & Percent Weight Change; Consider IBW Appearance, behavior, mental health Age & Gender Functional status (Karnofsky Score, ECOG Score, etc.) GI, oral cavity, head & neck region, cancer type & location Intake: Diet History & 24-Hour Recall

– FFQ generally NOT appropriate in the clinical setting – Diet records are impractical

Biochemical parameters: Albumin, Prealbumin, Transferrin, Hematocrit, Hemoglobin, RBP, glucose, CRP, Serum Creatinine

Medications & Planned Treatment Psychosocial?? Financial??


Symptoms Affecting Nutrition Status

DiarrheaSore MouthDry MouthAltered Taste/SmellConstipationLack of Appetite

Fullness/Early FullnessFluid status (ascites, edema)Dumping SyndromeNausea/VomitingOther Pain


Nutrition Can Help Manage Symptoms

KEY: START EARLY

Specific Diet Modifications Will Help Minimize Nutrition-Related Side Effects

Each Side Effect Has Numerous Approaches for Mgmt

Nutrients/Food will PROFOUNDLY Affect The Body

Written Materials Alone May Not Be Sufficient


Some Patients Must Have Enteral Support

Nutrition ‘tricks’ (and there are dozens) may be useful for non-acute patients

For others, enteral support is a must

Screening & Assessment will help identify those requiring more aggressive intervention

Some populations need enteral support preemptively (H&N, Stomach, other GI…)


When Is Initiation of Enteral Nutrition Indicated?

Actual or anticipated inability to meet 50% of needs for 7 or more days

Contributes to Quality/Length of life in meaningful way Can improve tolerance to treatment and/or ultimate outcome Patient wants it A functioning gut (to some degree) is present Is not contraindicated

– Obstruction?– Gastroparesis?

May be able to by-pass with a J-tubeIs there hypomotility of the small intestine as well?

– Nausea/Vomiting?Often can get around this if using a J-tube


Beginning Enteral Feeding

Use HBE to determine Calorie NeedsMales: BEE = 66.5+(13.7xW{kg})+(5.0xH{cm})-(6.8xA{yrs})Females: BEE = 655+(9.6xW{kg})+(1.9xH{cm})-(4.7xA{yrs})(Quick & Easy: 35-50 kcal/kg for hypermetabolic patients)

Protein Needs1.3 to 1.5 grams/kg body weight (IBW or Adjusted IBW)Adjusted IBW = (Actual BW - IBW) x (0.25 to 0.4) + IBWIBW: Males = 106 lbs + 6 lbs/inch + 10%; Females = 100 lbs + 5

lbs/inch + 10%

Fluid Needs1500 mL for first 20 kg of body weight + 20 mL per kg foreach kg over 20 kg


Basic Points For Enteral Feeding

SELECT FORMULA CONSIDERING: Osmolality (280 to 350 mOsm ideal for J-feeds); Albumin?? Calories per cc Malabsorption (Specialty Formulas, MCT oil) Account for free water & supplement liberally as needed

ROUTE OF ADMINISTRATION Will G-Tube Be Tolerated? Is J-Tube Necessary? (can bypass nausea & high obstructions) Begin slowly; always, Always, ALWAYS use pump with J-Tubes Gravity Feed/Bolus

– Bolus feeding: 250 - 300 mL over 15 minutes, followed by 25-60 mL water; at least 3 hours b/w each bolus feeding

Trouble Shooting for Enteral Feeding Problems

Problem Possible Cause SolutionsFeeding tube clog Inadequate flushing of tube Attempt to flush tube with a 30 cc

before & after administering syringe of warm water; if unsuccessfulNOTE: Do NOT try to clear feedings and/or medications fill half of syringe with water; moveblockage by inserting an object plunger back and forth several timesinto the tube as this could until tube clears; avoid excessive forcedamage the tube or injure the when flushing tube. If unsuccessful, stomach lining; DO NOT use call your home care nurse, doctor, or RDcranberry juice, meat tenderizer or carbonated beverages tounplug tube; acidic productscause the protein in TF formulato form more clogs

Leakage around the tube Improper positioning Sit at least 45 degrees upright duringfeeding & for 1 hour post-feeding

Too rapid feeding rate Decrease rate of feedingBlocked Tube See aboveTube out of position Measure length of tube or look for mark

If tube is longer or mark is further out, stop feeding & contact your doctor;tube may need to be replaced

Diarrhea Too rapid feeding rate Decrease rate of feedingToo high osmolality of formula Switch to isotonic formulaNot enough fiber Switch to fiber containing formula or

switch at least half of feedings to fibercontaining formula


Addressing Secondary Clinical Nutrition Intervention Goals


Healing 101: No Judging

Why judge? It should be clear why a client is doing a specific approach!

Don’t take it personally!

Compliment client on initiative - Do NOT indicate disdain

Don’t forget the power of ‘self-help’


Healing 102: Everyone is Unique

The story of the medical student and loss of compassion

Use science but be compassionate

Don’t betray your own principles but DO be flexible

Never say never!


Healing 103: Nocebo Effect

What about YOUR expectations?

Your power is greater than you believe or know

Don’t betray your own principles but DO be honest & compassionate

Never say never!


First Do No Harm

Discouragement of a harmless or potentially beneficial intervention may constitute harm (must consider all aspects including psychological, emotional, socioeconomic, etc)

Nutrients & Food Have The Ability To PROFOUNDLY Affect Our Bodies, On Many Levels

For the Client, “Food & Nutrition Are POWER, And YOU Control That Power By Choices!”


Think About This

If you think you don’t need to think about this, you’re missing the boat

A Few Nutrients of Interest:– Capsaicin

– Coenzyme Q-10

– Eicosapentaenoic Acid (EPA) (Omega-3s)– Glutamine– Ginger

– Milk Thistle

– Probiotics

– Zinc


Weight loss and malnutrition have been shown to lead to:

Decreased treatment tolerance Longer hospital stays Decreased quality of life Reduced life expectancy

Regaining lost weight is difficult, so early nutritional intervention is critical

Useful interventions include omega-3 fats (EPA/DHA)

The Implications:

1 Andreyev, et al, 1998.2 Ottery 1996.3 O’Gorman P, et al, 1998, Andreyev, 1998.4 Albrecht and Canada 1996, Ottery 1995.


Early Intervention With Specialized Nutrition:Recent studies have shown that specialized ingredients help improve outcomes:

Omega-3 fatty acids (EPA/DHA)

Help prevent muscle and fat breakdown

Help improve appetite

Help restore metabolic balance

Standard supplements do not contain EPA/DHA or high levels of essential amino acids

Solutions:

1 Barber, et al, 2001; Tisdale, et al, 2003; Wigmore, et al, 1997.2 Borsheim, et al, 2002; Tipton, et al, 1999; Shaw, et al, 1988.

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Time Since Beginning Supplementation

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Weight Change Change in LBM

Omega-3 fatty acids (EPA/DHA) have been shown to reverse weight loss & increase LBM – may improve treatment tolerance

Weight and Lean Body Mass in Patients with Advanced Pancreatic Cancer Following Administration of an EPA-Enriched Nutritional Supplement

Source: Barber MD, et al, 1999. Prospective study completed in 20 pancreatic cancer patients experiencing weight loss. Patients consumed an average of 1.9 cans/day of a nutritional supplement containing 1.1g EPA/can in addition to normal food intake for 7 wks.

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Treatment Group

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82

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Baseline 3 Weeks 7 WeeksK

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Mean Change in Physical Activity Level Following 8 Weeks of Oral Supplementation

Karnofsky Performance Status Following Supplementation with EPA-Enriched Supplement

Source: Moses, et al, 2001 examined a subset of a large randomized trial conducted in pancreatic cancer patients and compared the intake of nutritional supplements with and without EPA (1.1g – 2.2g/day) and the effects on total energy expenditure and physical activity level.

Source: Barber MD, et al, 1999. Prospective study in 20 patients with pancreatic cancer experiencing ongoing weight loss. Patients consumed average 1.9 cans/day of a nutritional supplement containing 1.1g EPA/can along with normal intake for 7 weeks.

Nutritional supplements enriched with omega-3 fatty acids (EPA/DHA) have been shown to improve quality of life and performance status

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With EPA Supplement Without EPA Supplement

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Source: Voss AC, et al, 2003. Voss, et al, examined survival rates in pancreatic cancer patients from 2 different studies. In one study patients received an omega-3 fatty acid nutritional supplement containing 1.1g EPA/can and in the other a supplement containing no omega-3.

Impact of EPA Supplement on Survival

Nutritional supplements enriched with omega-3 fatty acids (EPA/DHA) have been shown to increase life expectancy


“Best Bet” Complementary Cancer Therapies

Eicosapentaenoic Acid (EPA) (Omega-3s)– Essential fatty acid with potential roles in inflammation,

immunity, cachexia– May help decrease cachexia– May improve chemotherapy effectiveness/enhance immune

functionDownside:

– May have anticoagulant activity so use with caution if platelets low or on coagulation therapy

– Generally well tolerated (up to 0.3 g EPA+DHA/kg body weight/day), but diarrhea possible

Dose:– Minimum dose of 2.2 mg EPA per day (best to avoid

coagulation complications)– Two new products on the market Prosure & Resource Support


What Is Glutamine?

Neutral, gluconeogenic nonessential amino acid Stored primarily in skeletal muscle (75%) and liver (25%) Nitrogen carrier between tissues Primary energy source for rapidly proliferating cells (e.g.

intestinal epithelium, activated lymphocytes, & fibroblasts) May be conditionally essential; depleted in stress states (e.g.

surgery, sepsis, & cancer) Appears to be synthesized in muscle tissue in substantial

amounts Plasma concentrations are quite high, second only to alanine Needed for renal acid-base balance


Why Glutamine For Oncology?

Neuropathy ArthralgiasMyalgiasDiarrhea Enteritis & GI Mucosal DamageStomatitisMuscle Mass Preservation??


Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action

Role in circulating nerve growth factor levels

– increased peripheral neuropathy concurrent with declining serum nerve growth factor concentrations

– animal models: glutamine up-regulates nerve growth factor mRNA

– ongoing studies are examining nerve growth factor concentrations in banked serum


Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action

Role in pain perception in the cerebral cortex

– glutamine is a precursor amino acid for excitatory neurotransmitters such as glutamate and GABA

– glutamine into astrocytes and converted to glutamate (glutamine synthetase), then released into synapse

– some glutamate in neurotransmitter capacity, but some used for neuronal energy requirements

– hypothesized that high systemic glutamine concentrations may down-regulate conversion of glutamine to glutamate


Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action

Role in metabolic stress states

– Glutamine freely released from skeletal muscles in states of metabolic distress

– Advanced malignant disease results in muscle glutamine depletion and weight loss

– Stress hormones induce decreased muscle glutamine concentrations, even in healthy adults

– Intracellular glutamine concentrations more than 50% under metabolic stress

– Glutamine is known to preserve glutathione concentrations; glutathione is needed for intracellular redox status


Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action

Role in metabolic stress states

– Previous research suggests that during periods of metabolic stress, approximately 15 to 35 grams of supplemental glutamine may be needed to preserve muscle glutamine concentrations, provide fuel for cells with rapid turnover, and improve overall nitrogen balance.

– Glutamine is vital as energy for rapidly proliferating cells, it may be extracted from muscles and supplied to other cells at the expense of muscle and connective tissue integrity

– Altered redox status and resultant oxidative damage may also play a role in pain syndromes


Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action

Role in provision of energy, nutrients, cellular building blocks to enterocytes

– Well-documented that glutamine is preferred fuel for GI tract– Three potential mechanisms through which glutamine

appears to exert positive effects on GI tissue:

1.Primary cellular fuel of enterocytes

2.Precursor for nucleotides needed for cell regeneration

3.Source of glutathione, an endogenous anti-oxidant system


Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action

Cell, Animal, & Human Studies Demonstrate:

– Glutamine is documented as preferential fuel for enterocytes, esp. during stress

– Controls glycogen synthesis in enterocytes– Decreases protein degradation in enterocytes– Demonstrated to enhance gut cell mass– Demonstrated to increase height of mucosal villi– Demonstrated to increase numbers of mucosal villi– Decreases bacterial translocation under stress


Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action

Role in weight loss for HIV/AIDS

– Loss of body cell mass (BCM) correlates with length of survival in this, and other, populations

– Hypothesized that glutamine, which is conditionally essential, may be rate-limiting for repletion of BCM

– Muscles synthesize glutamine & release into circulation


Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action

Role in weight loss for HIV/AIDS

– Tissues that consume glutamine extract as needed from circulation

– During stress and inflammation, consumption of glutamine exceeds ability of skeletal muscle to supply this amino acid

– Blood & muscle glutamine concentrations decrease and muscle breaks down to satisfy needs


Glutamine For Muscle Mass Maintenance:Research Evidence

Study Shabert et al. 1999

– 40 grams glutamine/day in divided doses– 26 patients total– Double-blind, placebo controlled (glycine as control)– Over 3 months: glutamine group gained 2.2 kg vs. 0.3 in

control (1.8 kg BCM vs. 0.4 kg BCM) Given common etiology between wasting seen in HIV/AIDS

and wasting seen in cancer cachexia, it may be possible to enhance lean body mass retention throughout cancer treatment with glutamine


“Best Bet” Complementary Cancer Therapies Glutamine

– Amino Acid– May help with diarrhea/GI symptoms & sore mouth/throat– May help decrease mucositis (5-FU)– May help decrease radiation enteritis– May help With Aching Muscles/Nerves (Taxol)

Downside:– No major side effects, some minor side effects– Do not take if you have poor kidney and/or liver function

Dose:– 10 grams glutamine powder, three times per day, dissolved

in liquid (research has been done with Cambridge Nutraceuticals-Baxter Pharmaceuticals & Glutasolve by Novartis)


Think About This

Looking at a summary of some other potentially important interventions:

A Few Nutrients of Interest:– Capsaicin

– Coenzyme Q-10

– Eicosapentaenoic Acid (EPA) (Omega-3s)– Glutamine– Ginger

– Milk Thistle

– Probiotics

– Zinc


Capsaicin Taffy Recipe (For Sore Mouth)

1 cup sugar3/4 cup light corn syrup2/3 cup water

1 tablespoon cornstarch

2 tablespoons butter or margarine

1 teaspoon salt

2 teaspoons vanilla

1 1/2 teaspoons cayenne pepper

Combine all ingredients except vanilla and cayenne pepper and cook over medium heat stirring constantly, to 256°F (use candy thermometer). Remove from heat, stir in vanilla and cayenne pepper. When cool enough to handle, pull taffy. When stiff, cut into strips, then pieces and wrap.

From: Journal of Pain and Symptom Management 1995;10(3): 245



Coenzyme Q10– Antioxidant – May protect heart muscle from damage during treatment

with certain chemotherapy regimens (adriamycin)Downside:

– Appears to be safe when used in reasonable dose– It acts as an antioxidant and some experts believe

antioxidants are counterproductive during radiation therapy; data is mixed concerning antioxidants during radiation therapy, but overall suggests moderate use is ok

Dose:– 30 mg two times daily



Ginger– Food spice that also has medicinal properties– Taken as tea or root may help alleviate nausea– Also try 'natural' ginger ales

Downside:– Can act as mild anti-coagulant– Use with caution if low platelets or are on anti-coagulant

medications (e.g. coumadin, heparin, etc.)

Dose:– Chopped/dried extracts for tea, taken 2-3 times daily– 940 mg once daily of powdered ginger root for nausea prevention

– 250 mg of powder taken 4 times daily for nausea mgmt



Milk Thistle– May help protect the liver from damaging effects of

chemotherapy; may protect kidney & other organs– May help the liver regenerate & recover after damage

Downside:– Appears very safe for use in cancer patients; not much data on

use in those with liver involvement– Mild nausea is a reported side effect– Mild anti-coagulant; use with caution if platelets are low– May reduce effectiveness of oral contraceptives

Dose:– 140 mg standardized to 70-80% silymarin, 3 times daily– Phosphatidylcholine-bound silymarin, 100 mg 3 to 4 times daily



Probiotics– “Healthy Bacteria” in yogurt & other fermented foods– May have selective immune modulating activity– May decrease rates of ‘opportunistic’ infections– May decrease diarrhea, mucositis, improve nutrient absorption

Downside:– Not many downsides however…– Dietary supplement products are poorly regulated and

contamination is possible (yogurt & other fermented dairy are good options)

– May need to be avoided in severe immune compromise (e.g. BMT populations)

Dose:– Unknown



Zinc– May help restore sense of taste during radiation therapy to

head/neck region– May take up to 1 month for noticeable effect

Downside:– Short term use improves immune function, long term use

may suppress immune function– DO NOT USE if on cisplatin as zinc may increase toxicity

Dose:– 30 - 50 mg daily elemental zinc daily (~135 - 220 mg zinc

sulfate, divided into three doses)


Use the Resources That Are Available To Evaluate CAM

Herbal/Supplement Resources (websites):– http://www.cancernutritioninfo.com– http://www.tnp.com– http://www.mcp.edu/herbal/– http://www.herbmed.org– http://www.naturaldatabase.com/– http://ods.od.nih.gov (http://ods.od.nih.gov/databases/ibids.html) – http://my.webmd.com/medical_information/drug_and_herb/drugs/default.htm– http://www.mskcc.org/aboutherbs– http://www.consumerlabs.com– http://www.quackwatch.org– http://vm.cfsan.fda.gov/~djw & http://www.cfsan.fda.gov/~dms/supplmnt.html– http://www.ncbi.nlm.nih.gov/pubmed– http://www.herbalgram.org– http://www.ars-grin.gov/duke/index.html– http://www.herbs.org– http://dietary-supplements.info.nih.gov– http://nccam.nih.gov


Use the Resources That Are Available To Evaluate CAM

Look at the Herbal/Supplement Resources (books):– Mosby’s Handbook of Herbs & Natural Supplements

– German Commission E Monographs

– The Health Professional’s Guide to Popular Dietary Supplements

– The Honest Herbal & Herbs of Choice

– Herbal Drugs and Phytopharmaceuticals

– The Encyclopedia of Medicinal Plants

– Integrative Medicine: Your Quick Reference Guide

– PDR for Herbal Medicines

– Herbal Medicinals: A Clinician’s Guide

– H erbal Medicines: A Guide for Healthcare Professionals

– The American Pharmaceutical Association Practical Guide to Natural Medicines

– Rational Phytotherapy: A Physican’s Guide to Herbal Medicine

– Many, many journals also available


Does Nutrition Matter for Survival?


Findings of Special Interest

Body Weight, ER status & Risk of Death After Breast Cancer:

– 1997 Int J Epidemiol: 1169 early stage breast cancer cases

– Lower # estrogen receptors assoc w/ hazard ratio of 1.8

– Highest BMI vs. lowest BMI (quartiles) assoc w/ a hazard ratio of 2.5!!

Diet & Body Weight & Risk of Death After Breast Cancer: – 1998 Breast Cancer Res Treat: 472 early stage breast cancer cases,

diet data collected & patients followed

– Higher consumption of butter, margarine, lard, beer, red meat, liver, bacon increases likelihood of dying AFTER diagnosis of breast cancer

– HIGHER body weight (as measured by BMI) assoc w/ higher risk of death AFTER diagnosis of breast cancer



Zinc Supplements For Taste Changes:

– 1998 Cancer: 20 head and neck cancer cases randomized to 45 mg zinc sulfate, 3 times daily or placebo

– Those receiving zinc supplement: less worsening sense of taste when compared to placebo

– Those receiving zinc recovered their sense of taste faster after treatment

Saturated Fat & Risk of Death After Prostate Cancer:

– 1999 Eur Urol: 384 confirmed prostate cancer cases

– Diet data collected & patients followed

– Higher consumption of saturated fat increases likelihood of dying AFTER diagnosis of prostate cancer



Diet & Risk of Death After Stomach Cancer Diagnosis:

– 2000 Nutr Cancer: 877 confirmed stomach cancer cases

– Diet data collected & patients followed

– Higher consumption of tofu & raw vegetables decreases likelihood of dying AFTER diagnosis of stomach cancer

Processed Tomato Products & Prostate Cancer:

– 2001 JNCI: 32 men w/ prostate cancer fed 3/4 cup tomato sauce daily for 3 weeks; serum & prostate lycopene concentrations, PSA, oxidative damage assessed pre- and post-intervention

– Post-intervention: serum & prostate lycopene significantly increased; oxidative damage & PSA significantly decreased



Fasting Insulin & Breast Cancer Recurrence Risk:– 2002 Journal of Clin Onc: 512 women with early stage breast cancer

(T1-T3, N0-N1, M0) w/o known diabetes followed prospectively– Highest vs. Lowest quartile had twice the risk of distant recurrence &

death– Insulin associated w/ BMI and BMI a known risk factor

AHCC® & Hepatocellular Carcinoma (HCC)– 2002 J Hepatol: 222 people with confirmed HCC– By self choice: assigned to surgical resection vs. surgical resection

plus AHCC® and followed for a time ranging between 2 months to 10 years

– Intervention vs. Normal Care: – 34% vs. 66% recurrence– 80% vs. 53% survival


Findings of Special Interest Avemar® & Colorectal Cancer

– 2003 Br J Cancer: 176 people, Dukes A-D colorectal cancer diagnosis– By self choice: assigned to regular treatment vs. regular treatment plus

Avemar® and followed for 30-34 months– Intervention vs. Normal Care: – 3% vs. 17% recurrence– 7% vs. 23% new metasases– 31% vs. 64% progression– 75% vs. 54% survival

Lycopene & Advanced Prostate Cancer– 2003 BJU Int: 54 men randomized to orchidectomy or orchidectomy +

lycopene and followed for 2+ years– PSA of 78% of supplemented group returned to normal vs. only 40% in

orchidectomy alone group– Normal bone scans in 25% of supplemented group vs only 15% of

orchidectomy alone group having normal scans– 2 years after intervention: 87% of supplemented group alive vs. 78% of

orchidectomy alone group



Diet, Insulin & Risk of Death After Breast Cancer: – 2004 Cancer Epidemiol Biomarkers Prev: 603 women with breast

cancer asked about diet & had blood samples collected

– Higher level of insulin = worse survival

– Higher protein & lower fat = better survival

– Higher intake of sweets and sugar = worse survival

Breast Cancer & Health Behavior Changes– 2004 Eur J Clin Nutr: 354 Finnish & Australian women diagnosed

with breast cancer surveyed about experiences & choices

– One-third reported changing diet & exercise habits

– Both populations reported high need for diet & lifestyle counseling

– Both populations reported this need as unrecognized by physicians


Nutrition For Prevention of Recurrence:Fantasy or Reality?

Consider the research and there is A LOT of it!!

So many things are not in our control, encourage your clients to take advantage of the things that are!

Nutrition & Diet are powerful tools that one can use in the journey to regain and maintain health after a cancer diagnosis.


Remember This Truth…

Nutrients & Food Have The Ability To PROFOUNDLY Affect Our Bodies, On Many Levels

Food Is POWER Over Disease Risk, And WE Control It!


Let Food Be Your Medicine And Medicine Be Your Food

- Hippocrates, 337 BC


References

1. Isenring E, Bauer J, Capra S. The scored Patient-generated Subjective Global Assessment (PG-SGA) and its association with quality of life in ambulatory patients receiving radiotherapy. Eur J Clin Nutr. 2003;57: 305-9.

2. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Nutritional deterioration in cancer: the role of disease and diet. Clin Oncol (R Coll Radiol). 2003;15:443-50.

3. Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56:779-85.

4. Capra S, Ferguson M, Ried K. Cancer: impact of nutrition intervention outcome--nutrition issues for patients. Nutrition. 2001;17:769-72.

5. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12:S15-9.

6. FD Ottery, Patient-generated subjective global assessment of nutritional status. Nutritional Oncology. 1996;2(8-9).

7. Decker G, Bagyi JJ. Nutrition Interventions to Impact Clinical Practice (monograph). Minneapolis, MN: Novartis Nutrition, 2003.


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