Nutrition Care Process for Cancer Patients

1
Nutrition Care Process for Cancer Patients

• Presentation by Marie Molde

2
Objectives

• Understand medical nutrition therapy in oncology.
• Become familiar with nutrition implications in
  cancer treatment.
• Understand nutrition screening and assessment in
  oncology.
• Address ethical issues in cancer treatment

3
Definition

• Cancer a class of diseases characterized by
  uncontrolled cell division and the ability of
  these cells to invade other tissues, either by
  direct growth into adjacent tissue or by
  migration of cells to distant sites (metastasis).

• We are continually faced with great
  opportunities which are brilliantly disguised as
  unsolvable problems.
• -Margaret Mead, anthropologist

4
Cancer Pathophysiology

• In a cancer cell, an enzyme is secreted that
  breaks down the telomere, leading to the loss of
  the cells internal clock.

5
Cancer Progression

• Conditions must be conducive for the neoplasm to
  grow.
• Neoplasm new growth an abnormal mass of
  tissue, the growth of which exceeds and is
  uncoordinated with that of normal tissue.
• Metastasis spread of cancer from the primary
  site to nearby or distant areas through the blood
  or lymph.

6
Nutrition Therapy

• In the oncology setting, health care
  professionals consider nutrition screening to be
  the identification of cancer-related malnutrition
  and cachexia and/or associated nutrition impact
  symptoms.
• Primary goal is to prevent malnutrition.

7
Cancer

• Cancer patients experience changes in CHO, lipid,
  and protein metabolism that can contribute to
  fluid imbalance, acid-base imbalance, and changes
  in the concentration of electrolytes, vitamins,
  and minerals.

8
Cancer-Related Cachexia

• Occurs in approximately 2/3 of patients
• Is inversely correlated with length of survival
  and implies a poor prognosis.
• Degree of malnutrition is not explained by level
  of energy intake.
• Loss of muscle and fat occurs before decline in
  intake of food.

9
Cachexia

• Profound destructive process characterized by
  skeletal muscle wasting and harmful abnormalities
  in fat, CHO, and protein metabolism in spite of
  adequate caloric and nutrient intake.
• Involuntary weight loss, tissue wasting
  (particularly lean body mass and adipose tissue),
  inability to perform daily activities, and
  metabolic alterations.
• Pathophysiology is not completely understood.

10
Metabolic Effects of Cachexia

• Difficult to reverse with traditional nutritional
  support because the weight loss is not the result
  of starvation.
• Cachexia vs. Starvation
• Starvation loss of body fat and preservation of
  muscle mass
• Cachexia equal loss of fat and muscle, a loss of
  adipose tissue, and increased energy expenditure.

11
Cachexia

• Best option is treating underlying disease if
  this cannot be achieved, then specialized
  nutritional support should be developed that aims
  at maintaining body weight, in particular lean
  body mass, by counteracting the negative effects
  on metabolism and eating behavior by the
  increased inflammatory response.
• Pharmacologic agents, such as the steroid
  megestrol acetate, have been used to increase
  appetite but are associated with fat gain rather
  than increase in lean body mass.

12

• It appears advisable to use a hypercaloric
  (30-35kcal/kg body wt), high-protein diet rich in
  BCAAs (50 leucine), and EPA for patients with
  cachexia who can tolerate oral feeding.

13
Nutrition Support for Cachexia

• Early, intensive and individualized nutritional
  counseling has consistently been shown to be
  effective in preserving body weight and physical
  function in cancer patients.
• The efficacy of nutritional counseling in cancer
  patients relies on the presence of a well-trained
  and specialized nutrition support team.

14
Strategies to fight cachexia

• Therapeutic strategies are currently based on
  blocking cytokine synthesis and/or mechanism of
  action.
• Cause normal cells to produce additional
  cytokines which continue the cancer process.
• Cytokines affect gastric motility and emptying by
  altering the signals which regulate satiety.

15
Whey Protein Cancer Therapy

• Whey protein may play a role in both protecting
  against cancer and also in sensitizing cells to
  chemotherapy.
• A study conducted by Tsai et. al (2000)
  demonstrated that a whey protein isolate had an
  enhancing effect on the cytotoxicity of
  baicalein, a potential anticancer drug, when
  applied to a human cell line.

16
Anticancer Components of Whey

• Whey contains enzymes that catalyze
  detoxification compounds and fasten to mutagens
  and carcinogens, facilitating their elimination
  from the body.
• Induction of apoptosis in tumor cells and the
  regulation of growth factors involved in cell
  differentiation.

17
Nutritional Requirements

• Protein-energy malnutrition is the most common
  secondary diagnosis in individuals with cancer.
• The most effective intervention leading to
  improved nutritional status is to increase energy
  and protein intake.

18
Determining Nutrient Requirements

• Provide adequate kcals
• Harris-Benedict, Mifflin-St. Jeor (stress
  factors)
• Meet protein needs
• Normal protein needs 0.8-1.0g/kg
• Non-stressed cancer patients 1.0-1.5g/kg
• Bone marrow transplant patients 1.5g/kg
• Increased protein needs (protein-losing
  enteropathy, hypermetabolism, extreme wasting)
  1.5-2.5g/kg
• Hepatic or renal compromise including BUN
  approaching 100mg/dL or elevated ammonia
• 0.5-0.8g/kg

19
Nutrient Requirements

• Cancer patients at heightened risk for
  dehydration
• Especially those receiving chemotherapeutic
  agents that damage the GI mucosa and cause
  diarrhea also those receiving radiation to the
  head and neck.
• Signs and symptoms
• 30-35 mL/kg (those without renal disease)
• Vitamin and Mineral Deficiencies
• Common deficiencies Folate, Cu, Zn, Fe, Ca, Mg,
  Vitamins A, C, D.
• Use of a daily multivitamin that contains lt150
  of the DRI may be beneficial

20
Abnormalities in Nutrient Metabolism

• CHO metabolism
• Increased gluconeogenesis from amino acids and
  lactate
• Increased glucose synthesis
• Decreased glucose tolerance and turnover
• Insulin resistance
• Increased Cori cycle activity

21
Changes in Metabolism

• Lipid metabolism
• Increased lipolysis, decreased lipogenesis
• May see increased lipid metabolism and decreased
  activity of lipoprotein lipase.
• Elevated Triglycerides

22
Changes in Metabolism

• Protein Metabolism
• Muscle wasting is caused by increased protein
  breakdown and decreased protein synthesis.
• Nitrogen depletion/abnormal plasma AA levels
• Increased whole-body protein turnover, increased
  liver and tumor protein synthesis

23
How Treatment May Affect Nutrition

• Surgery
• Increased need for calories
• The malnourished have compromised wound healing
  and increased morbidity and mortality.
• The intent of nutrition support is to minimize
  weight loss and prevent nutrient deficiencies.

24
How Treatment May Affect Nutrition

• Radiation therapy
• Early occurring problems irritation of the
  mouth, tongue, and throat, milk intolerance,
  nausea, vomiting, diarrhea
• Later occurring problems dry mouth, stricture
  or narrowing of the esophagus, malabsorption of
  nutrients, abdominal discomfort, diarrhea,
  constipation.

25
How Treatment May Affect Nutrition

• Chemotherapy
• Interferes with cells as they divide and
  reproduce.
• Can cause a variety of side-effects.

26
Nutritional Implications in Cancer Treatment

• Cancer patients may experience anemia,
  constipation, diarrhea, fatigue, nausea and
  vomiting, poor appetite/early satiety, sore or
  dry mouth (xerostomia), mucositis, taste and
  smell alterations (dysguesia), and weight gain or
  loss, among others.

27
Constipation

• Difficulty passing stools or decrease in normal
  frequency of bowel movements.
• Can lead to nausea, bloating, anorexia, wt loss
• Try to prevent before it occurs
• Have meals at regular intervals each day
• Drink plenty of water and other liquids
• Eat a good breakfast and ingest warm foods such
  as oatmeal and tea.

28
Diarrhea

• Can lead to dehydration, electrolyte imbalances,
  malabsorption, anorexia, wt loss
• Encourage to drink small amounts of fluid
  frequently throughout the day, increase overall
  fluid intake.
• Avoid excessive amounts of sweetened beverages
  which may contribute to osmotic diarrhea.
• Possible increase in foods high in soluble fiber,
  limit/avoid insoluble fiber.
• If diarrhea is severe, increase K and Na intake.

29
Nausea and Vomiting

• Can lead to anorexia, wt loss, dehydration,
  electrolyte imbalances
• Thorough assessment of the causes will help with
  treatment.
• Avoid food odors and eat frequent small meals
  throughout the day.

30
Poor Appetite/Early Satiety

• Can lead to anorexia, wt loss, cachexia,
  electrolyte imbalances, bloating, nausea
• Caused primarily by delayed gastric emptying.
• Consumption of raw vegetables and other
  high-fiber foods should be avoided.
• Eat small meals, avoid food odors, drink liquids
  between meals, eat favorite foods any time of day.

31
Sore or Dry Mouth

• Difficulty chewing/swallowing, decreased intake
• Soften food, use a straw, focus on liquid, drink
  8-12 cups of fluid per day, try to eat at times
  of day when mouth pain is less intense.
• Xerostomia use of artificial saliva and other
  mouth-moisturizers
• Chewing gum or sour hard-candy may also be useful.

32
Dysgeusia

• No taste (Ageusia)
• Metallic taste, commonly from the
  chemotherapeutic agent cisplatin
• Heightening of certain tastes (especially sweet)
• Incorporate other high-protein foods besides
  meat, highly spiced and flavored foods, non-sweet
  supplements

33
Mucositis

• Irritation and inflammation of the epithelial
  cells of the mucosal membranes lining the GI
  tract that can occur at any point from the mouth
  to the anus.
• Encourage to eat soft, non-fibrous or acidic
  foods
• Use a straw

34
Weight Loss/Anorexia

• Prevalence of anorexia is estimated at 50
• Etiologies circulating cytokines, hormones,
  depression, therapy, learned food aversions,
  fatigue, and certain medications.
• Exercise may be helpful, if able.
• Pharmacologic interventions
• Megestrol acetate
• Corticosteroids

35
Weight Gain

• Weight gain of even 5-10 poses risk of
  recurrence
• May occur due to lack of exercise, hormonal and
  medical treatments, or eating more than you need
  in response to stress.
• Eat breakfast, eat more fiber, drink more water,
  New American Plate, think positively.

36
Nutrition Assessment

• Traditional nutrition assessment
• Historical data
• Medical, diet, and weight histories
• Biochemical data
• Visceral protein indexes (albumin, transferrin,
  pre-albumin, retinol binding protein), total
  lymphocyte count, Hgb, Hct, Nitrogen balance
  studies, lipid profiles, and blood glucose level.
• Anthropometric data
• Weight, height, midarm circumference, BMI

37
Nutrition Assessment

• Subjective Global Assessment (SGA)
• Valid assessment based on features of medical
  history (weight change, nutrient intake changes,
  GI symptoms)
• Scored Patient Generated SGA (PG-SGA)
• Has been validated for use in oncology patients.
• Includes calculations of change in body weight
  and a nutrition-related physical exam

38
Other Useful Assessments

• IBW, UBW, unplanned weight loss
• If weight loss occurs, it should be determined
  whether voluntary or involuntary
• Edema
• Ability to consume adequate nutrients to prevent
  deficiencies weight loss
• C-reactive protein (useful for measuring
  inflammation)

39
Ethical Issues

• Role of the RD in palliative care
• To understand the symptoms and complications
  associated with advanced cancer.
• To manage symptoms and/or treatment side effects
• To implement appropriate MNT to prevent further
  morbidity
• To maintain optimal quality of life and, when
  possible, provide sufficient dietary intake to
  maintain energy and strength.

40
Ethical Issues

• RDs decisions regarding artificial nutrition
  and hydration may be guided by many aspects,
  including advanced directives, case law, and
  ethical and legal issues in nutrition, hydration,
  and feeding.

41
Ethical Issues

• ADA states that the RD, as a member of the
  healthcare team, has the responsibility to
  identify the nutritional and hydration needs of
  each individual patient. Development of ethical
  guidelines for when feeding may or may not be in
  the patients best interest can help the patient
  and the health care team implement appropriate
  therapy.

42

• Thanks for listening! Questions?