Nutrition Care Process for Oncology

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Nutrition Care Process for Oncology

• Ingrid Jorud
• Concordia College
• Moorhead, MN

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Objectives

• Identify who is most at risk of developing
  cancer.
• Define what cancer is and what nutritional
  deficiencies may develop.
• Identify the nutrition maladies associated with
  cancer.
• Identify the types of treatment and side effects
  involved in each.
• Learn what nutrition care can be given in each
  case.
• Discuss the Nutrition Care Process for Cancer.

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Objectives (cont.)

• Identify the ethical issues regarding nutrition
  with cancer patients
• Outline some prevention guidelines

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What is cancer?

• Disease of disordered cell growth and
  replication.
• Uncontrolled cellular division
• Ability to invade other tissues, either by direct
  growth or migration to distant cells.

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Cancer Cell Growth

• Normal cellular growth is controlled by genetic
  factors, hormones, and growth substances secreted
  by distant cells.
• Telomeres in cell shorten and stop cell growth
  after a certain point - cancer cells secrete
  enzymes to destroy telomere.
• Cells internal clock is destroyed, cell
  differentiation may change, cell may take on
  other traits and become misshapen, replicate at a
  faster rate than normal.

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What can put a person at high risk?

• Genetics - heredity only plays a small role
• Diet and physical activity habits
• Fat content and type (Omega 3 and 6 are better)
• Low consumption of fruit and vegetables
• Low intake of whole grains
• Obesity - BMI gt 40 risk of cancer and death more
  than doubles
• Environmental/behavioral
• Smoking
• Work and chemical exposure

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Most Common Cancers

• Men
• 33 Prostate
• 13 Lung and bronchus
• 10 Colon and rectum
• 27 include Urinary bladder, Melanoma of skin,
  Non-Hodgkin Lymphoma, Kidney, Leukemia, Oral
  Cavity, Pancreas
• 17 Other sites

• Women
• 32 Breast
• 12 Lung and bronchus
• 11 Colon and rectum
• 6 Uterine corpus
• 18 Non-Hodgkin lymphoma, Melanoma of skin,
  Ovary, Thyroid, Urinary bladder, Pancreas
• 21 Other sites

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Leading Mortality

• Lung and bronchus
• Prostate and Breast
• Colon and Rectum
• Pancreas
• Ovary
• Leukemia

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Treatments

• Chemotherapy
• Antineoplastics - inhibit and combat development
  of tumors
• Radiation therapy
• Use of radiation to control malignant cancer
  cells
• Surgery
• Physical removal of the cancer tumor or organ
  involved

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Factors Contributing to Malnutrition

• Treatments
• Chemotherapy
• Drugs and severity of types that are used
• Radiation
• Depending on the location of the cancer and
  radiation site
• Surgery
• Location of tumor to determine surgical location
  and nutritional status
• Tumor and abnormal cell growth

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Affects of Disease State on Nutrition

• Tumor
• Malignant tumors cause changes in energy
  expenditure and basal metabolic rates.
• Altered enzyme activity
• Immune system

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Changes the occur in Metabolism

• Carbohydrate
• Insulin resistance
• Increased glucose synthesis
• Gluconeogenesis
• Increased Cori cycle activity
• Decreased glucose tolerance

• Protein
• Increased protein catabolism
• Decreased protein synthesis
• Fat
• Increased lipid metabolism
• Decreased lipogenesis
• Decreased activity of lipoprotein lipase (LPL)

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Nutritional Assessment of Cancer Patient

• Anthropometric Measurements
• AMC lt 60 of standard are consistent with protein
  depletion
• BMI lt 22, based on UBW and weight loss is often
  considered for depletion
• BIA (Bioelectric Impedance Analysis) - resistance
  to low intensity electric current by fat and lean
  tissue
• Lab values
• Not always the most accurate for assessment when
  viewed alone
• Prognostic Nutritional Index (PNI)

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PNI
Prognostic Nutritional Index measures the risk
that a patient has of developing a complication
such as sepsis or death related to malnutrition.
PNI 158 16.6A - .78TSF 0.2TFN 5.8DH A
indicates albumin (g/dL) TSF tricep skinfold
(mm) TFN transferrin (mg/dL) DH delayed
hypersensitivity skin testing reaction to a
recall antigen lt40 low risk 40-49.99
intermediate risk 50 high risk
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Basic Nutrition Requirements

• Harris-Benedict or Mifflin-St. Jeor
• Kcalorie
• Obese patients 21-25 kcal/kg
• Non-ambulatory/sedentary adults 25-30 kcal/kg
• Sepsis 25-35 kcal/kg
• Slightly hypermetabolic or those in need of
  weight gain or those with stem cell transplant
  30-35 kcal/kg
• Hypermetabolic or severely stressed 35 kcal/kg

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Basic Nutrition Requirements (cont.)

• Protein
• Normal or Maintenance 0.8-1.0 g/kg
• Non-stressed cancer patient 1.0-1.5 g/kg
• Bone marrow transplant or HSCT patients 1.5
  g/kg
• Increased protein needs 1.5-2.5 g/kg
• Hepatic or renal compromised or elevated ammonia
  0.5-0.8 g/kg

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Basic Nutrition Requirements (cont.)

• Adequate fluid and hydration
• Vitamins
• Folate
• Vitamin C
• Retinol
• Minerals
• Magnesium
• Zinc
• Copper
• Iron

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Fluid Requirements

• 16-30 years, active 40 mL/kg
• 31-55 years 35 mL/kg
• 56-75 years 30 mL/kg
• 76 years or older 25 mL/kg
• 1 mL/kcal of estimated energy needs

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Nutritional Complications and Symptoms That Cause
Them (Diagnosis)

• Anorexia
• Cachexia
• Dysphasia
• Nausea and Vomiting
• Constipation/Diarrhea/Malabsorption
• Oral Manifestations
• Xerostomia

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Anorexia

• Imbalance between caloric intake and metabolic
  needs due to a lack or loss of appetite for food,
  leading to weight loss, cachexia, dehydration,
  and electrolyte imbalances
• Causes
• Alterations in Taste
• Decreased threshold for bitter taste
• Decreased like for beef, pork, chocolate, coffee,
  or tomatoes
• Metallic or medicinal taste

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Anorexia (causes cont.)

• Taste abnormalities may lead to decrease in
  digestive enzymes causing delay in digestion
• Alterations in GI function
• Ulceration of the mucous membranes may produce
  mucositis or diarrhea, which interferes with
  ingestions, digestion, or absorption
• Metabolic Abnormalities
• Glucose Metabolism
• Increased circulation of amino acids or lactic
  acid
• Increased free fatty acids
• All cause early satiety

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Anorexia (causes cont.)

• Psychological abnormalities
• Effects of tumor
• Release of cytokines
• Cytokines may raise metabolic rate and increase
  protein catabolism and skeletal muscle protein
  metabolism
• Wound healing
• Decreased ability to heal due to tumor growth and
  tumor utilization of nutrients

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Treatment of Anorexia in Cancer Patients

• Appetite stimulant
• Megestrol acetate
• Corticosteroids agents
• Exercise may increase appetite
• Eat small, frequent high protein high calorie
  meals.
• Eat when appetite is normal
• Limit fluid with meals to avoid early satiety

• Keep favorite foods handy
• Glass of wine before a meal may help to stimulate
  appetite
• Avoid strong food odors
• Find a liquid nutritional supplement that is
  appealing

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Cachexia

• Wasting syndrome that causes weakness and loss
  of weight, fat, and muscle, electrolyte
  imbalances, impaired organ function, and
  immunosuppression
• Common with lung, pancreas, upper GI tract
  cancers
• Less common in breast and lower GI cancer
• Caused by malabsorption, anorexia, and other
  factors contributing to nutrient deficiencies
• Not related to tumor size or type.
• Increased nutrient needs
• Due to metabolic rate changes or demands
• Alterations in GI function

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Types of Cachexia

• Primary
• Anorexia
• Decrease in Nutrients
• Changes in Metabolic Pathways
• Secondary
• Weight loss due to mechanical factors limiting
  intake

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Nutritional Deficiencies due to Cachexia

• Carbohydrate Metabolism
• Cori cycle increases so that glucose usage is
  greater than conversion and to keep up with
  demand, amino acid is used
• Impairment of insulin sensitivity or glucose
  tolerance
• Lead to hyperglycemia
• Protein Metabolism
• Used when energy stores of glycogen are decreased
• Decrease in protein synthesis that may be due to
  decreased intake or decreased albumin production
  by liver

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Nutritional Deficiencies due to Cachexia (cont.)

• Fat Metabolism
• Normal and Abnormal Metabolism
• Stimulated by insulin
• resistance leading to
• hyperlipidemia and
• decreased fat stores.

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Treatment of Cachexia in Cancer Patients

• Treat initial causes
• Replenish body with protein, carbohydrates, fats,
  vitamins, and minerals
• Enteral or parenteral nutrition

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Dysphasia

• Difficult and painful swallowing
• Resulting from tumor and/or treatment
• Chemotherapy, Radiation, or Surgery

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Treatment of Dysphasia in Cancer Patients

• Therapeutic approaches
• Swallowing therapy
• Pain management
• Oromotor exercises - muscle control for
  swallowing
• Altered postural strategies
• Food Consistencies
• Semisolid foods, soft foods, medium to thick
  liquids, dense sticky/bulky foods, and thin and
  thick liquids.

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Nausea and Vomiting

• Secondary to treatments, progressive disease
  states, and other therapies.
• Often involves the cerebral cortex, mediated by
  the autonomic nervous system.

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Treatment for Nausea and Vomiting in Cancer
Patients

• Parenteral support in cases of greater than 10
  episodes in 24 hours.
• Control of symptom management
• Pharmacologic Management
• Serotonin antagonist
• Dopamine Antagonists
• Corticosteroids
• Benzodiazepines
• Cannabinoid

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Treatment for Nausea and Vomiting in Cancer
Patients

• Nonpharmacologic Interventions
• Behavior Interventions
• Acupressure
• Dietary interventions
• Individualized to each patient
• Eating cold or room temperature foods
• Avoiding high fat foods which delay gastric
  emptying
• Avoid favorite foods on treatment days
• Ginger

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Constipation/ Diarrhea/ Malabsorption

• GI dysfunction caused by drugs, endocrine tumors,
  malabsorption, chemotherapy, radiation therapy,
  and other concurrent diseases
• Diarrhea
• Carbohydrate malabsorption
• Inability to properly absorb salt
• Bacteria infection

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Constipation/ Diarrhea/ Malabsorption (cont.)

• Malabsorption- ineffective absorption of
  nutrients
• Intestinal resection
• Bile salt deficiency
• Reduced activity or transport mechanisms
• Insufficient enzymes
• Short Bowel Syndrome
• Antibiotics
• Signs - Steatorrhea Caloric Deprivation Folate,
  Vitamin B12, Calcium, Magnesium, Vitamin D, and
  Iron deficiencies

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Constipation/ Diarrhea/ Malabsorption (cont.)

• Constipation - extremely common in cancer
  patients
• Medication induced
• Tumor location
• Hypercalcemia, hypokalemia, and/or uremia
• Diabetes
• Inadequate food/fiber intake
• Poor liquid intake
• Bowel surgery

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Treatment of GI Dysfunction in Cancer Patients

• Diarrhea
• Binders of osmotically active substances - pectin
• Avoid cold meals, milk, fiber rich vegetables,
  fatty meats and fish, alcohol, and coffee.
• Rehydration - solutions containing glucose,
  electrolytes, and water intravenously
• Antibiotics

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Treatment of GI Dysfunction in Cancer Patients

• Malabsorption - Correct deficiencies
• Enzyme replacement
• Bicarbonate supplements
• Vitamins
• Calcium, Magnesium, and Iron
• Low fat and high protein diet
• Parenteral nutrition postoperative

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Treatment of GI Dysfunction in Cancer Patients

• Constipation
• Increase fluid intake
• High fiber foods
• Laxatives
• Reversal of hypercalcemia and hypokalemia

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Oral Manifestations

• Xerostomia - abnormal dryness of mouth
• Results most commonly from radiation therapy to
  the head and neck region, surgical excisions, and
  Sjogrens syndrome.
• May be impossible to prevent

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Treatment of Oral Manifestations in Cancer
Patients

• Frequent oral rinses and sips of water or juice
• Moist, soft foods prepare foods with sauces or
  gravies.
• Alcoholic and carbonated beverages may inflame
  mucosa
• Sucking on hard sugarless candy or gum to
  stimulate saliva secretion
• Fine mist of water sprayed into the mouth from a
  spray bottle
• Foods and drinks that are very sweet or tart to
  stimulate saliva production

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Enteral Nutrition

• Nasogastric - nose to stomach, short term
• Gastrostomy Jejunostomy - stoma placed into
  stomach or jejunum, long-term use
• Patients with low body weight
• Inability to eat or drink by mouth for more than
  five days
• Moderate or high nutritional risk

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Advantages for Enteral Nutrition

• Food in liquid form
• Keeps the stomach and intestines working normally
• Fewer complications than parenteral
• Nutrients used more easily by the body
• Can be administered at home

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Parenteral Nutrition

• Nutrients delivered directly into the blood via
  catheter inserted into the subclavian (CVC) or
  other larger peripheral vein.
• Stomach and intestines not working correctly or
  have been removed
• Severe nausea or vomiting
• Fistulas in stomach or esophagus
• Loss of body weight and muscle with enteral
  nutrition.

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Complications Associated with Parenteral Nutrition

• Hypoglycemia
• Hyperglycemia
• Hypokalemia
• Blood clots
• Infection as site of insertion
• Elevated liver enzymes

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Diagnostic Labels

• Inadequate oral food/beverage intake
• Inadequate fluid intake
• Inadequate bioactive substance intake
• Hypermetabolism
• Increase nutrient needs
• Swallowing difficulty
• Chewing difficulty

• Altered GI function
• Altered nutrition-related laboratory values
• Food-medication interaction
• Involuntary weight loss
• Food, nutrition, nutrition-related knowledge
  deficit

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Monitoring of Patients

• During and after treatment
• Improvement
• Maintenance
• Risk assessments
• Disease progression
• Recovery
• Following health lifestyle

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Ethical Issues

• Care of Dying Patient
• Autonomy and beneficence
• Seek decisions of recognized authorities or
  religious codes, professional guidelines of legal
  ruling
• Nutrition and hydration - continuation of
  nutrition support or voluntary refusal

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Cancer Prevention

• Healthful Diet
• Five or more servings of various fruits and
  vegetables each day
• Limit high fat and fried products
• Choose whole grains
• Limit consumption of red meats, especially high
  fat and processed
• Watch your portions

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Cancer Prevention (cont.)

• Physical Activity
• At least 30 min 5 days a week, 45 min is even
  better
• Healthy Weight
• Balance caloric intake with physical activity
• Limit Alcohol Consumption
• Limit to 1 drink/day for women and 2 drinks/day
  for men.

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Summary

• Definition of cancer
• Cancer Treatments
• Basic Nutrient Requirements
• Contributors to nutritional deficiencies
• Treatment and disease symptoms
• Treatment of symptoms
• Ethical Issues
• Prevention

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