rd61 nutrition in cancer treatment: continuum of carenutrition in cancer treatment 4 accreditation...

Nutrition in Cancer Treatment

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RD61 Nutrition in Cancer Treatment:

Continuum of Care

3rd Edition • Revised April 2012

By Barbara L. Grant, RD, CSO, LD, MS


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RD61 Nutrition in Cancer Treatment:

Continuum of Care

3rd Edition • Revised April 2012

By Barbara L. Grant, RD, CSO, LD, MS About the Author About the Author: Barbara L. Grant, RD, CSO, LD, MS, is the outpatient registered dietitian at the Saint Alphonsus Cancer Care Center in Boise and Caldwell, Idaho. With more than 30 years of experience working with people diagnosed with cancer, she is a founding member and past chair of the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She was a contributing editor to the Academy’s Clinical Guide to Oncology Nutrition and co-author of Management of Nutrition Impact Symptoms in Cancer and Educational Handouts, among her many patient and professional publications. Her education includes: BS, Washington State University; MS, University of Idaho; Dietetic Internship, University of Minnesota Hospitals and Clinics.

Publisher 's note : The first edition of Nutrition in Cancer Treatment was written by Paula Davis McCallum, RD, LDN, MS. The second and third editions have been extensively revised, but they include some of her work. EXPIRATION DATE: Students of all professions must submit this course for credit no later than October 31, 2015. Credit will not be awarded for this course after that date.

Course ID Code: RD61 This course approved for:

RD 12 CPEU DTR 12 CPEU

CDM 12 Clock Hours © 1989 – 2012 Nutrition Dimension/Gannett Education No part of this course may be reproduced, duplicated or copied in any way without the written permission of the copyright holder.


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How to Earn Continuing Education Credit

1. Read the Learning Objectives. Read or watch the course material. Don’t forget to review the course objectives and take note of course tools available to you. The objectives provide specific learning goals and an overview of the course. Read the material in the order presented. If you need help with the material, please e-mail [email protected] with your specific question. We will forward your inquiry to the author, so allow adequate time for a reply.

2. CE credit will not be awarded for this course after October 31, 2015.

3. If you have an account on Nurse.com, TodayinPT.com, or TodayinOT.com, or NutritionDimension.com, please use that account username and password to sign in on ContinuingEduation.com. If you don’t already have one, please sign up for a user account. Click “sign up” or “login” in the upper right hand corner of any page on ContinuingEducation.com. If you have a CE Direct login ID and password (generally provided by your employer), please log in as you normally would at lms.nurse.com and search for this topic title.

4. Go to the “my courses” section of “my account.” Click on the title of the course you want to complete and then on “start course.”

5. Click “start test” to begin the exam. To earn contact hours, you must achieve a score of 75% on your multiple-choice exam for most courses. For webinar courses, you will need to achieve a score of 100%. You may retake the test as many times as necessary to pass. Clues are not provided on the exam. Certificates will be date/time stamped with the time and date of the day the user passes the test (Eastern Time, U.S.).

6. After successfully completing your exam click, “complete required survey.” To complete the test process and receive your certificate of completion, you must take a few moments to answer a brief survey about the course material.

7. After completing the survey, you will be taken to your transcript. Under Courses Completed, you can view, print, or e-mail your certificate.

8. Three months after you complete a course, you will receive an e-mail asking you to complete a follow-up survey. This is vital to our educational requirements so we can report our quality outcomes and effectiveness.

A Word About Copyrights We encourage health professionals to use material from this course in their practice. Please follow these guidelines: • Credit the author, Nutrition Dimension/Gannett Education and any referenced source. • Course material may not be sold, published, or made part of any program for which a fee is

charged, without written permission from Nutrition Dimension/Gannett Education. • Inform Nutrition Dimension/Gannett Education by letter if you wish to make significant use of

material from this course (e.g., if you wish to duplicate Appendix pages for a training session or patient handout).


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Accreditation Information

Gannett Education is a Continuing Professional Education (CPE) Accredited Provider (#GD001) with the Commission on Dietetic Registration (CDR). This is a Level 3 course. Suggested CDR learning codes: 2000, 2070, 3000, 3020, 3060, 5000, 5150, 5010, 5030, 5390, 5410, 5430, 5440

Gannett Education is also accredited by the Florida Council of Dietetics and Nutrition (provider # FBN 50-1489).

This course is approved for continuing education clock hours by the Certifying Board for Dietary Managers (CBDM).


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Table of Contents 5 Introduction 8 Chapter One: Understanding Cancer: Statistics, Diagnosis and Treatment Cancer incidence • Cancer survival • Cancer prevention: 2015 challenge goals • Signs and symptoms of

cancer • Diagnostic methods • Treatment goals and tumor response • References 16 Chapter Two: Overview of Cancer and its Treatment Oncology healthcare team • Modalities of cancer therapy • Categories of cancer • Leukemia • Lymphoma

• Carcinoma • Sarcoma • Summary • References • Resources 32 Chapter Three: Cancer and Metabolic Response Carbohydrate metabolism • Protein metabolism • Lipid metabolism • Metabolic adaptation to starvation •

Metabolic changes associated with cancer • Cancer cachexia syndrome • Summary • Case study • References

40 Chapter Four: Nutrit ion Screening and Assessment and Nutrit ion Diagnosis in the

Oncology Setting Standardized tools • Scored PG-SGA: a comprehensive review • Scoring the PG-SGA • Other assessment

tools • Oncology-related nutrition diagnoses • Nutrition diagnosis: PES statements • Summary • References

52 Chapter Five: Determining Nutrit ion Requirements for Adults with Cancer Energy requirements • Predictive equations for calculating energy requirements • Protein requirements •

Fluid requirements • Micronutrient requirements • Dietary supplementation • Summary • Case study • References

62 Chapter Six: Modalit ies of Cancer Treatment: Surgery, Radiation Therapy, Chemotherapy,

Biotherapy, Hormone Therapy and Antiangiogenic Agents Medical nutrition therapy • Surgery • Nutritional implications: surgery • Radiation therapy • Nutritional

implications: radiation therapy • Chemotherapy • Nutritional implications: chemotherapy • Hormone therapy • Biotherapy • Management of nutrition-related side effects • Summary • Case studies • References

78 Chapter Seven: Hematopoietic Cell Transplantation Hematopoietic cell transplants • HCT process • Nutritional implications of HCT • Side effects and

complications of HCT • Food safety and the neutropenic diet • Summary • Case study • References 88 Chapter Eight: Surviving Cancer: Nutrit ional Care What is a survivorship care plan? • Recovery from treatment • Nutrition counseling • Physical activity •

Lifestyle guidelines • Chronic/late effects of treatment • Summary • References


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96 Chapter Nine: Advanced Cancer and Pall iative Care Palliative care and hospice delivery systems • Prevalent symptoms • Paraneoplastic syndromes • Symptoms

and complications • Nutrition support in advanced cancer • As death becomes imminent • Summary • Case study • References

106 Chapter Ten: Nutrit ion Support Therapy Nutrition support therapy • Oral intake • Enteral nutrition support • Parenteral nutrition support • NST

safety and ethical considerations • Summary • References 116 Chapter Eleven: Management of Cancer-Related Nutrit ion Impact Symptoms Nutrition impact symptoms • Alterations: taste and smell • Anorexia • Cancer cachexia syndrome and

weight loss • Constipation • Diarrhea • Dysphagia • Early satiety • Fatigue • Lactose intolerance • Malabsorption • Mucositis and esophagitis • Myelosuppression • Nausea and vomiting • Treatment of nausea and vomiting • Oral infections and candidiasis • Pain • Xerostomia and thick saliva • Summary • References

130 Appendices Appendix 1: Diet Guidelines for Gastrointestinal Diet 1 and Diet 2 Appendix 2: Diet Guidelines for Immunosuppressed Patients Appendix 3: Nestle Mini Nutritional Assessment Appendix 4: Scored Patient-Generated Subjective Global Assessment

Appendix 5: Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms Appendix 6: Pharmacological Agents for the Management of Chemotherapy-induced Nausea and

Vomiting Appendix 7: Pharmacological Agents for the Management of Anorexia and Cachexia

Appendix 8: Pharmacological Agents for the Management of Constipation Appendix 9: Pharmacological Agents for the Management of Diarrhea Appendix 10: Pharmacological Agents for the Management of Oral Mucositis and Esophagitis Appendix 11: Pharmacological Agents for the Management of Pain Appendix 12A, 12B and 12C: Nutritional Implications of Chemotherapy, Nutritional Implications of

Hormone Therapy and Nutritional Implications of Biotherapy and Antiangiogenic Agents Appendix 13: Nutritional Implications of Surgical Oncology Appendix 14: Complications of Enteral Feeding Appendix 15: General Formulary Information for Oral and Enteral Nutritionals 172 Appendix 16/Glossary 182 Exam


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Learning Objectives

• List the four most common types of cancer for men and for women in the United States • Describe the risk factors for three different types of cancer • Explain two types of metabolic alterations that can occur secondary to cancer • Describe two different validated tools that are used to screen and assess for malnutrition

and nutritional risk for an individual diagnosed with cancer • Describe two different methods of how to calculate the energy, protein or fluid

requirements for an individual diagnosed with cancer • List how one of the modalities of cancer therapy can affect a cancer patient’s nutritional

status • State three different foods that should be avoided by an immunocompromised individual

undergoing hematopoietic cell transplantation • List the four phases of cancer survivorship • Describe two different paraneoplastic syndromes associated with advanced cancer • List two of the guideline recommendations for the use of nutrition support therapy in

adults undergoing anticancer treatment or hematopoietic cell transplantation • Describe two different eating strategies to manage a specific cancer-related nutrition

impact symptom • Identify three different pharmacological agents used to manage a specific cancer-related

nutrition impact symptom


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Introduction

he intent of Nutrition in Cancer: Continuum in Treatment is to educate and inform dietetic professionals working directly with patients who are diagnosed with cancer or with an interest in the area of oncology nutrition. Dietetic professionals seeking to specialize in the care and

treatment of cancer patients will find that completing this course enhances their professional credential and standing among their peers.

This course covers the role of nutrition throughout the continuum of cancer care. Nutrition is an integral component of cancer care from diagnosis, through treatment, recovery from treatment, survivorship, and throughout end-of-life care. There are many cancer treatments but no single cure for “cancer,” which is in quotation marks here because “cancer” comprises more than 100 diseases, all of which have in common abnormal growth of cells, but which are more different than alike in many important ways. Some cancers are, indeed, curable; many are not. Some cures are highly dependent on early detection and diagnosis.

This course focuses primarily on the nutritional care for individuals diagnosed with cancer and undergoing cancer treatment. Another Gannett course, Cancer Risk Reduction, assesses dietary risk factors and preventive nutrition strategies.

How do nutrition and dietetic professionals fit into the continuum of cancer care? First and foremost, as nutrition and dietetic professionals, we put the science of oncology nutrition

into action. We manage nutrition-related symptoms of cancer and treatment side effects and provide guidelines to minimize cancer risk through diet, using the latest evidence-based and “best clinical” practice. We are the nutrition experts.

Second, nutrition and dietetic professionals are educators. We provide the latest information about cancer prevention to healthy people and cancer survivors, and we help optimize the nutritional well-being of those recovering from cancer. We educate individuals about the effects of their disease and treatment on their nutritional status and overall health, and we teach the healthcare team about the role of nutrition in health and disease. We also provide sound scientific advice to patients and families, who may be exposed to nutrition and cancer misinformation.

Lastly, we are there to support patients, families and the healthcare team in the fight against cancer. We do this by maximizing the nutrition status of our patients, providing guidance and emotional support for their families, and reinforcing the overall plan of care.

This course is designed to heighten awareness of cancer and its treatment, as well as its impact on nutrition. Definitions to cancer-related terms used throughout the course can be found in the glossary. Additional professional resources for nutrition professionals working with patients diagnosed with cancer are available from the Academy of Nutrition and Dietetics at www.eatright.org or 800-877-1600. These oncology nutrition resources are The Clinical Guide to Oncology Nutrition, Oncology Toolkit and Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. In 2008, the Commission on Dietetic Registration (CDR) began administering and granting a board certification for registered dietitians specializing in oncology nutrition and working in the cancer care setting. This credential is known as “CSO,” or certified specialist in oncology nutrition. Additional information regarding the CSO credential can be obtained from the CDR’s website at:

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http://www.cdrnet.org/certifications/spec/oncology.cfm. Registered dietitians working in oncology nutrition will find the recent publication of the Standards

of Practice and Standards of Professional Performance for RDs in Oncology Nutrition Care a valuable resource for the further development and enhancement of their skills, competencies and knowledge for the safe and effective nutrition care for individuals diagnosed with cancer. 1

Reference 1. Robien K, Bechard L, Elliott L, et al. Academy of Nutrition and Dietetics: standards of practice and

standards of professional performance for registered dietitians (generalist, specialty, and advanced) in oncology nutrition care. J Am Diet Assoc. 2010;110(2):310-317.


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Chapter One: Understanding Cancer: Statistics,

Diagnosis and Treatment This chapter presents cancer-related statistics pertaining to incidence, death and survival rates, trends and prevention. It also reviews methods for cancer diagnosis and staging, and provides an introduction to the modalities of cancer treatment and the importance of proactive nutritional care. A glossary of the cancer-related terms used throughout this continuing education course is provided in the appendices.

ancer is the uncontrolled division and reproduction of abnormal cells that can spread throughout the body to adjacent normal structures and organs, and metastasize to lymph nodes and other organs. Often regarded as a single disease, cancer encompasses more than 100

diseases caused by nearly 300 different growths. Cancer can be caused by numerous external and internal factors.

Causes of Cancer1,2 External Factors

Lifestyle

Exposure to tobacco products Alcohol abuse Diet: poor nutrition, pesticides, contaminants, preservatives Contributing factors: physical inactivity and obesity

Infectious agents/Viruses

Helicobacter pylori (H. pylori) Hepatitis B (HVB) Hepatitis C (HVC) Human immunodeficiency virus (HIV) Human papillomavirus (HPV)

Environmental

Radiation: solar, radon, X-rays Chemical compounds: asbestos, heavy metals, ozone

Internal Factors Hormones

Immune conditions Inherited or metabolic mutations

These factors acting together or in sequence can to lead to the initiation, promotion and

progression of cancer. Ten or more years can pass between exposure to external factors and the presence of detectable cancer.3

Everyone is at risk for developing cancer. The American Cancer Society (ACS) predicts that the lifetime risk for developing cancer in the United States is slightly less than one in two for men and a little more than one in three for women.3

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Understanding Cancer: Statistics, Diagnosis and Treatment

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Carcinogenesis, the origin or development of cancer, is thought to be a biological, multistage process brought about by malfunctions of genes (oncogenes) that control normal cell growth and division. Tumor suppressor genes are the opposite of oncogenes; they can become deactivated in cancer cells. The loss of function of tumor suppressor genes leads to unregulated cell growth and, ultimately, cancer. Examples of tumor suppressor genes are breast cancer antigen 1 (BRCA-1) and BRCA-2, and adenomatous polyposis coli (APC).

Cancer Incidence

The ACS estimated that more than 1.6 million cases of cancer will be diagnosed in 2012. Current statistics show that 77% of all cancers are diagnosed in people 55 years and older.3 In the United States, the most common sites of new cancer in men are prostate, lung, colon/rectum and bladder. In the United States, the most common sites of new cancer in women are breast, lung, colon/rectum and uterus.

Leading Sites of New Cancers, 2012 Estimates2 Cancer Site Male Female

Prostate 241,740 (29%) N/A* Breast ** 226,870 (29%) Lung and bronchus 116,470 (14%) 109,690 (14%) Colon and rectum 73,420 (9%) 70,040 (9%) * not applicable ** not a leading site of new cancer for men

Cancer experts believe that the differences in cancer incidence rates observed in racial and ethnic

groups are due to health disparities and socioeconomic factors such as poverty, living in an inner city or rural community, lack of health insurance or education, cultural beliefs, language barriers and racial stereotypes. Other factors include equal access to cancer prevention efforts, early detection and quality treatment, and increased prevalence of risk factors for cancer such as obesity and use of tobacco products.3

Incidence of Cancer from 2004–2008*3 White African-

American Asian-American/ Pacific Islander

Native American/ Alaska Native

Hispanic/ Latino**

Male 545.0 626.2 332.4 427.8 423.4 Female 420.8 394.2 284.0 362.1 333.5 * Figures are per 100,000, age-adjusted to the 2000 U.S. standard population ** Hispanic is not mutually exclusive from other races and ethnic groups Note: Small sample sizes may create statistical errors; therefore, further research is needed regarding the etiology of cancer in these diverse populations.

Cancer is the second-leading cause of death in the United States, exceeded only by heart disease. Annually, cancer is the reason for almost one out of every four deaths, causing the death of more than a half million Americans.3 Evidence suggests that one third of cancer deaths can be attributed to nutrition and lifestyle behaviors such as overweight and obesity, poor diet, alcohol use and physical inactivity.


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Leading Sites of Cancer Deaths, 2012 Estimates2 Cancer Site Male Female Lung and Bronchus 87,750 (29%) 72,590 (26%) Colon and Rectum 26,470 (9%) 25,220 (9%) Breast * 39,510 (14%) Prostate 28,170 (9%) N/A** * Not a leading site of cancer death in men ** Not applicable

Cancer Survival The ACS defines anyone living with a diagnosis of cancer as a “cancer survivor.”4 It is estimated

that in 2012 there were nearly 12 million Americans who had been diagnosed with cancer and were living cancer-free, had evidence of disease or were undergoing cancer treatment.3 This large number of cancer survivors is due in part to cancer prevention efforts, improvements in the early detection of cancer and the development of new and often more aggressive cancer therapies.

Cancer has been shown to be a disease of aging, with 60% of cancer survivors being older than 65 years.5 In addition, cancer survivors represent one of the largest groups of Americans living with a chronic illness. According to recent reports, almost 75% of older Americans have at least one chronic and/or comorbid disease such as diabetes, cardiovascular disease, osteoporosis and cancer.

Despite the broad definition of “cancer survivor,” survival is typically referred to as an individual being alive five years post-diagnosis, whether cancer-free, in remission, undergoing cancer treatment or with evidence of disease. Survival longer than five years is commonly defined as long-term survival or cure. The five-year survival rate for all cancers diagnosed between 2001 and 2007 is 67%, up from 49% between 1975 and 1977.3 Cancer diagnosed at an earlier stage helps to increase the likelihood of successful treatment and improved survival.

Survival by Stage at Diagnosis3 Five-year Relative Survival Rates (%) by Stage at Diagnosis 2001–2007 All Stages Local Regional Distant Breast (female) 89 99 84 23 Colon and rectum 64 90 69 12 Esophagus 17 37 18 3 Kidney 70 91 63 11 Larynx 61 77 42 33 Liver 14 27 9 4 Lung and bronchus 16 52 24 4 Melanoma of the skin 91 88 61 15 Oral cavity and pharynx 61 82 56 34 Ovary 44 92 72 27 Pancreas 6 22 9 2 Prostate 99 100 100 29 Stomach 26 62 28 4 Urinary/bladder 78 71 35 5 Uterine/cervix 69 91 57 19


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Cancer Prevention: 2015 Challenge Goals

In 1999, the ACS developed the 2015 Challenge Goals to help focus the nation’s cancer prevention and survival efforts.6 The objectives of the 2015 Challenge aim to prevent cancer by addressing tobacco use, nutrition, physical activity levels, sun protection, and early screening and detection.

Specifically, the goals are as follows:

• Tobacco use : To reduce by 12% the proportion of all adults using tobacco products. • Nutrit ion: To increase to 75% the proportion of all Americans consuming at least five

servings of vegetables and fruits each day. • Physical act ivity : To increase by 60% the proportion of all adults regularly engaging in

physical activity to prevent obesity and promote healthy lifestyles. • Sun protection: To increase by 75% the proportion of all ages reducing their risk of skin

cancer by avoiding the sun between 10 a.m. and 4 p.m. by wearing sun protective clothing when exposed to sunlight, using sunscreen with SPF 15 or higher and avoiding artificial sources of ultraviolet light (e.g., sun lamps and tanning beds or booths).

• Early detection: To increase the proportion of cancer screening using the ACS guidelines for cancer detection (e.g., breast, 90% of women 40 years and older; colorectal, 75% of all Americans 50 years and older; and prostate, 90% of men 50 years and older).

By the year 2015, the 2015 Challenge hopes to achieve a 50% reduction in age-adjusted cancer

mortality rates; a 25% reduction in age-adjusted cancer incidence rates; a measurable improvement in quality of life (physical, psychological, social and spiritual), from time of diagnosis and for balance of life of all cancer survivors; and elimination of disparities in the cancer burden among different segments of the U.S. population in terms of socioeconomic status.

Signs and Symptoms of Cancer Assessing symptoms of cancer is critical to timely diagnosis. For cancer treatment to be the most

effective, the detection of cancer at its earliest stage is vital for improving survival and treatment outcomes. The ACS’s seven early warning signs (CAUTION) of cancer are:

Change in bowel or bladder habits. A sore that does not heal. Unusual bleeding or discharge. Thickening or lump in breast or elsewhere. Indigestion or difficulty in swallowing or chewing. Obvious change in wart or mole. Nagging cough or hoarseness.

Many symptoms of cancer or metastatic disease can affect a person’s ability to eat, as well as

normal digestion and absorption. Signs and symptoms of cancer can have a direct effect on nutritional status. Constitutional signs and symptoms include anorexia, fatigue, weight loss, fever, sweating and anemia.3 Signs and symptoms of metastatic cancer include pain, bone pain with or without fracture, enlarged lymph nodes or body organs, neurological symptoms and cough with or without hemoptysis.3


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Diagnostic Methods

A cancer diagnosis can be determined by several different methods. Diagnostic methods include clinical assessment of an individual’s medical history and physical examination; radiographic imaging studies (e.g., CT, MRI or PET scan), ultrasound or endoscopy; pathology using cytology studies or tumor biopsy of body tissue, sputum or fluids; or analysis of tumor markers from blood and body fluids. Examples of commonly used tumor markers to identify the possible presence of cancer or cancer recurrence include:

• Alpha-fetoprotein (AFP) for liver cancer • BRCA-1 or BRCA-2 for breast cancer • Cancer antigen 125 (CA 125) for ovarian cancer • Cancer antigen 19-9 (CA 19-9) for pancreatic cancer • Prostate-specific antigen (PSA) for prostate cancer • Carcinoembryonic antigen (CEA) for colon cancer

Cancer Staging The extent of disease at the time of diagnosis is determined by cancer staging. The stage of a cancer

is based on the presentation of the primary tumor and if the cancer has spread to different parts of the body. Cancer staging is used by physicians to determine an individual’s prognosis and the most effective treatment for his or her specific disease. The ACS classifies cancer stages as local, regional and distant.

Cancer is considered local if an invasive malignancy is confined entirely to the organ of origin. Cancer is considered regional if a malignancy extends beyond the limits of the organ of origin directly into surrounding organs or tissues, involves regional lymph nodes by way of the lymphatic system, and exhibits both regional extension and involvement of regional lymph nodes. Cancer is considered distant if a malignancy has spread to parts of the body remote from the primary tumor either by direct extension or by discontinuous metastasis to distant organs, tissues or via the lymphatic system to distant lymph nodes.

There are several different staging systems for classifying tumors. A commonly used staging system is TNM, which describes cancer by the extent of the tumor size (T); absence or presence of nodal involvement (N); and absence or presence of metastases (M).7 Once the TNM has been determined, a cancer stage of I, II, III or IV is assigned. Stage I disease is early stage and stage IV is considered advanced disease.

Tumor differentiation is another way that physicians classify tumors. Understanding how a cancer grows helps physicians in determining a person’s prognosis and the most effective treatment. Typically, a well-differentiated cancer grows more slowly and is less aggressive, while a poorly differentiated cancer tends to be more aggressive and faster growing, leading to a worse prognosis.

• Grade I : a well-differentiated cancer that looks like the normal tissue or organ from which the cancer arises.

• Grade II : a moderately differentiated cancer that slightly resembles the site of cancer origin.

• Grade III : a poorly differentiated or undifferentiated cancer that does not resemble normal tissue or organs.


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TNM Staging System7 Tumor

T0: No evidence of disease Tis: Carcinoma in situ or cancer that has not spread to surrounding tissue T1: Tumor is not palpable or visible by imaging T2: Tumor is confined to the primary cancer site T3: Tumor extends to neighboring tissue T4 :There is metastatic disease

Node

N0: No involvement of the lymph nodes N1: Metastasis to local lymph nodes

Metastasis

M0: No metastasis M1: Distant metastasis

Treatment Goals and Tumor Response The goals of cancer treatment are cure, control and palliation. Cure seeks to eradicate measurable, discernible malignant disease and obtain a complete response

to treatment. Control seeks to extend the length of life when a cure is not possible, prevent the growth of cancer cells without complete elimination of disease, obscure microscopic metastases after tumors are surgically removed and shrink tumors before surgery or radiation therapy. Palliation seeks to provide support and comfort when cure or control is not possible; improve quality of life; and reduce or relieve cancer-related symptoms and side effects, including pain.

Response to cancer treatment is defined as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). CR is the absence of all signs and symptoms of cancer for at least one month, demonstrating a complete response to the chosen cancer therapy. PR is at least a 50% reduction in measurable disease without the development of tumor mass for at least two months. SD is the reduction in tumor mass of less than 50% or less than 25% increase in tumor growth. PD is 25% growth of tumor mass or development of new tumors; essentially, the cancer keeps growing.

Factors that affect a person’s response to cancer treatment include tumor burden and rate of tumor growth. Tumor burden is the idea that the smaller the tumor (or fewer number of tumor cells), the greater the response to treatment; rate of tumor growth means that cancer treatments are typically more effective in cancers that are rapidly growing. References 1. Laughlin EH. Coming to Terms with Cancer: A Glossary of Cancer-Related Terms. Atlanta, GA: The

American Cancer Society; 2002. 2. National Comprehensive Cancer (NCCN) Clinical Practice Guidelines in Oncology, 2012. NCCN Web site.

http://nccc.org/clincal.org. Accessed July 17, 2012. 3. American Cancer Society. Cancer Facts & Figures, 2012. American Cancer Society Web site.

http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2012. Accessed July 17, 2012.

4. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.

5. Horner MJ, Ries LAG, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2006. National Cancer Institute Web site. http://seer.cancer.gov/csr/1975_2006/. Accessed July 17, 2012.

6. Byers T, Mouchawar J, Marks J, et al. The American Cancer Society challenge goals. How far can cancer rates decline in the U.S. by the year 2015? Cancer. 1999;86(4):715-727.

7. American Joint Committee on Cancer. What is cancer staging? American Joint Committee on Cancer Web site. http://www.cancerstaging.org/mission/whatis.html. Accessed July 17, 2012.


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Chapter Two:

Overview of Cancer and Its Treatment This chapter will familiarize the reader with types of cancer commonly seen in care settings, including brief descriptions, pertinent risk factors, signs/symptoms, diagnoses, treatments and survival.

ncology is the study of cancer, and oncologists are physicians who specialize in cancer. A tumor (or neoplasm) is an abnormal mass of tissue. Tumors are frequently called “solid” cancers or hematological (blood-related) cancers, the latter of which are often referred to as

“liquid” cancers. Tumors can be benign, which means they are non-progressing and not life-threatening; or malignant, which means they are progressing and life-threatening. Metastasis is the spread of malignant cells from an original or primary location in the body to distant tissues or organs. Oncology Healthcare Team

Cancer treatment is a highly specialized type of medical care. The oncology healthcare team is comprised of medical oncologists, radiation oncologists, surgical oncologists, nurses, pharmacists, social workers, chaplains, radiation therapists and dieticians. Some of the specific responsibilities include:

• Medical Oncologists are physicians with special training in the use of chemotherapy drugs and biotherapy agents to kill tumor cells.

• Radiation Oncologists are physicians with special training in the use of high-energy X-rays and other radioactive substances to destroy cancer cells.

• Surgical Oncologists are physicians with special training in how to remove malignant tissues from the body using surgical operations or procedures.

• Nurses , pharmacists , social workers , chaplains and radiation therapists • Registered diet i t ians (RDs) working in oncology can become specialty board certified

in oncology nutrition (CSO) through the Commission on Dietetic Registration (CDR). (For more information about the CSO credential, visit the CDR’s website at http://www.cdrnet.org/certifications/spec/oncology.cfm.)

Modalities of Cancer Therapy

Guidelines for cancer treatment by specific cancer site; cancer prevention, detection and risk reduction; and supportive cancer care in are guided by evidence-based standards known as the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.1 The website states that it is a not-for-profit alliance of 21 of the world’s leading cancer centers, and its goal is to improve the quality and effectiveness of care provided to people with cancer so they can live better lives.

Methods of conventional cancer treatment include surgery, chemotherapy, biotherapy, anti-angiogenic agents, hormonal therapy and radiation therapy. These agents can be used alone or in combination:

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Overview of Cancer and Its Treatment

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• Surgery is the surgical removal of cancerous tissue. • Chemotherapy is the use of chemical agents or medications to treat cancer systemically. • Biotherapy uses biological agents to produce anticancer effects indirectly as stimulators

of the person’s own natural immune defense system, or as cytotoxic agents via the administration of natural substances.

• Antiangiogenic agents inhibit the formation of new blood vessels required by cancers; to prevent cancer’s growth, invasion and spread.

• Hormone therapy is a systemic therapy for the treatment of hormone-sensitive cancers (e.g., prostate, breast or ovarian) by blocking or reducing the source of a hormone or its receptor site.

• Radiation therapy uses high energy (ionizing radiation) in multiple, fractionated doses to cure, control or palliate cancer cells.

• Hematopoietic cel l transplant (HCT) uses a combination of cancer therapy modalities to treat solid tumors and hematologic malignant diseases such as leukemia, lymphoma and multiple myeloma.

The types of cancer therapy include:

• Chemoprevention is the use of specialized pharmaceuticals to reduce the risk of cancer in high-risk individuals.

• Adjuvant therapy is cancer treatment given after the first treatment, such as chemotherapy and/or radiation therapy after a cancer surgery. Adjuvant therapy is given to enhance the effect of the initial treatment.

• Neo-adjuvant therapy is defined as cancer treatment given before the primary treatment, such as chemotherapy given before cancer surgery. Neo-adjuvant therapy is most commonly used to shrink a large tumor and make it more manageable before surgery and to reduce the likelihood of micrometastases.

• Myeloablation is the obliteration of bone marrow in preparation for an HCT. Oncologists develop a person’s treatment plan by determining the specific type of cancer, location

in the body, growth properties, invasion of other tissues and stage of disease at diagnosis. Other factors that help guide the treatment plan include the patient’s health status, medical history, life plans and preferences of care.

Categories of Cancers

It is usually accepted that there are three general categories of malignancies that develop in three different types of tissues.

Leukemias , myelomas and lymphomas are “liquid” cancers of the immune system. Specifically, leukemias most frequently arise from the white blood cells of the bone marrow; myelomas originate from the plasma cells of the bone marrow; and lymphomas develop in the lymphatic system, its glands and organs.

Carcinomas are “solid” cancers that develop in tissues that cover the surfaces or the linings of the body’s organs and epithelium.

Sarcomas are “solid” cancers that originate in the soft tissues or bones.


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Leukemia Leukemia is a group of hematologic diseases of the bone marrow and lymph tissue. It is

characterized by the uncontrolled proliferation of white blood cells, called leukocytes, and is categorized as acute, which means it is fast-growing; or chronic, which means it is slow-growing. If left untreated, all normal blood-forming elements can be depressed, which is known as pancytopenia.

Risk Factors . There is no known cause of leukemia other than increased occurrence observed after exposure to atomic radiation (e.g., atomic bomb survivors). The only risk factor has been linked to cigarette smoking.

Signs and Symptoms. Signs and symptoms of leukemia include pallor, generalized weakness, fevers, bruising and abnormal bleeding due to decreased platelets (thrombocytopenia), and anemia due to decreased production of red blood cells. Individuals diagnosed with leukemia often experience frequent infections due to a depression of the WBC and neutrophils (neutropenia). In acute leukemia these symptoms can often occur suddenly; chronic leukemia symptoms typically progress slowly with few signs or symptoms, and the disease is often diagnosed as a result of routine blood tests and not through any specific symptom.

Other symptoms of leukemia are dependent upon the organs that are involved. Infiltration of malignant cells into organs can cause enlargement of the spleen, liver and lymph nodes. Of concern for healthcare professionals is that people with leukemia may be completely free of symptoms, and their disease may only be discovered by a routine physical examination.

Diagnosis . Leukemia is diagnosed through physical examination; laboratory analysis using complete blood count, with differential, liver function and blood clotting evaluation; and bone marrow aspiration and biopsy. Pathological evaluation often includes monoclonal antibody studies and flow cytometry.

Types of Leukemia. Whether acute or chronic, leukemias are classified by the two major types of white blood cell that are involved: non-granulocytic (lymphoid) or granulocytic (myeloid). Other less common diseases of blood-forming cells include hairy cell leukemia, myelodysplastic syndrome, polycythemia vera, aplastic anemia and the malignant proliferation of plasma cells known as multiple myeloma.

Acute Lymphocytic Leukemia Acute lymphocytic leukemia (ALL), also known as acute childhood leukemia, is characterized by

large numbers of immature white blood cells that resemble lymphoblasts. These white blood cells lack cytoplasmic granules and comprise about 20% to 50% of total WBC. ALL accounts for approximately 90% of the childhood leukemias and occurs most commonly in children 3 to 7 years old. ALL can also occur in adults and accounts for about 20% of adult leukemias.

Individuals diagnosed with ALL frequently present with an enlarged liver and spleen, bruising and abnormal bleeding. A CBC with differential usually indicates an abnormal WBC, anemia and thrombocytopenia. A definitive diagnosis requires a bone marrow aspiration and biopsy. The result of the biopsy exhibits hypercellularity and an increased number of lymphoblasts.

Central nervous system involvement is a common complication. ALL is most commonly treated with a combination of chemotherapeutic agents divided into three phases: induction, CNS prophylaxis and maintenance. Cranial radiation and/or intrathecal chemotherapy may be included in CNS prophylaxis.

Children generally fare better than adults with ALL, with about 95% complete remission, although children who relapse after a short initial remission typically have a poor prognosis. Adults usually


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achieve about an 80% complete remission for an average of 15 months. Adults who relapse after initial remission are not expected to survive for more than a year. Long-term survival is about 50% to 60% in children and 30% to 50% in adults. If untreated, survival is only about three months. People who relapse or fail to respond to standard treatment may be eligible for an HCT (discussed in Chapter Seven).

Acute Myelogenous Leukemia Acute myelogenous leukemia (AML) may also be referred to as acute non-lymphocytic leukemia,

splenomedullary leukemia, acute myeloid leukemia, splenomyelogenous leukemia, acute granulocytic leukemia or acute myeloblastic leukemia. It is characterized by the proliferation of immature WBCs called granular leukocytes. AML can occur in children, but is most common among older adults.

Individuals diagnosed with AML typically present with an enlarged liver, spleen and lymph nodes. A CBC with differential usually indicates anemia, low reticulocyte counts and thrombocytopenia. The result of a bone marrow aspiration and biopsy exhibits hypercellularity. As with ALL, CNS involvement is a concern.

Treatment is given to control bone marrow and systemic disease, as well as CNS disease (if present). AML is treated with combination chemotherapy in two phases: induction and maintenance/consolidation. First, the induction chemotherapy is administered. Then, immediately after remission is achieved, or nine months after remission, maintenance chemotherapy is administered.

Complete remission occurs in about 60% to 70% of cases following induction. Long-term survival is achieved in about 20% to 30% of those who have received curative therapies.

Chronic Lymphocytic Leukemia Chronic lymphocytic leukemia (CLL) is characterized by slow proliferation of lymphocytes in the

blood and bone marrow. It results in immunosuppression, bone marrow failure and infiltration of malignant cells into organs. It is the most common type of leukemia in the United States. CLL is a disease of the elderly, with 90% of its incidence in people older than 50.

People with CLL are at risk for secondary cancers, autoimmune hemolytic anemia and hypogamma-globulinemia (a condition characterized by decreased antibodies, leading to increased risk for infections). Individuals who are diagnosed with CLL typically present with an enlarged liver, spleen and lymph nodes and exhibit symptoms of fatigue, bone pain, bruising, night sweats, anorexia and weight loss. A CBC with differential usually indicates an elevated WBC, anemia and thrombocytopenia.

Treatment ranges from “watch and wait,” with supportive care such as blood products and antibiotics, as needed; to combination chemotherapy; biotherapy; and HCT. As suggested by its name, CLL is a slow, progressive disease with a five-year survival rate of 60%.

Chronic Myelogenous Leukemia Chronic myelogenous leukemia (CML) also known as chronic myelocytic leukemia or chronic

granulocytic leukemia, is characterized by rapid growth of myeloid cells (large cells that are precursors of leukocytes) in the bone marrow, peripheral blood and body tissues. If left untreated, it can eventually convert into AML. CML is most common in middle-age adults and is rare in children. It is associated with a chromosomal abnormality called the Philadelphia chromosome. Like CLL, CML is characterized by initial slow disease progression (chronic phase). After about five years, however, patients frequently


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enter a blastic phase, or blast crisis. This occurs when there is a very high count of immature white cells, and it becomes difficult to treat.

Those diagnosed with CML typically present with an enlarged spleen, fatigue, night sweats, low-grade fever (without infection), bruising and abnormal bleeding, and bone pain. A CBC with differential usually indicates an increased WBC and additional testing reveals the Philadelphia chromosome.

CML is treated either with single agents or with combination chemotherapy and/or biotherapy; HCT may be used for specific individuals. Median survival is about four to six years in treated individuals, with about 50% of individuals receiving transplant achieving long-term survival.

Myelodysplast ic Syndrome Myelodysplastic syndrome (MDS) is considered a pre-leukemia disease. It can occur in patients

who have received chemotherapy and/or radiation therapy for a previously diagnosed malignancy. Increased incidence is also observed after exposure to toxic substances such as chemicals or radiation. Diagnosis is confirmed by bone marrow aspiration and biopsy, and hematological evaluation. Signs and symptoms of MDS include fatigue, increases in WBC, thrombocytopenia and progressive anemia. MDS, in almost all instances, progresses to acute leukemia. Treatment can include frequent blood transfusions, hematopoietic growth factors and chemotherapy agents.

Aplast ic Anemia Aplastic anemia may occur secondary to an autoimmune process, previous chemotherapy, exposure

to radiation, toxins, drugs, pregnancy, congenital disorders or systemic lupus erythematosus. The disease results from an injury to the stem cell (precursor to other types of blood cells). The result is pancytopenia.

Aplastic anemia presents with enlarged spleen, tenderness of the sternum and irregular heart rate. Additionally, CBC reveals low hemoglobin and hematocrit, low WBC, low reticulocyte count and thrombocytopenia. Bilirubin levels are elevated and sugar-water/hemolysis test shows fragile red cells. As with leukemia, weakness, fatigue, infections and abnormal bleeding are hallmarks of the disease.

Mild cases are treated with palliative, or supportive, care with blood products (platelets and transfusions). People younger than 30 years with severe cases may be considered for HCT. Adults older than 40 years or those who do not have a matched bone marrow donor may receive antithymocyte globulin, a horse serum containing antibodies against human T-cells that is used to suppress the body’s immune system. The theory is that the bone marrow, once suppressed, will resume its blood-generating function. Other immunosuppressants, such as cyclosporine (Sandimmune) and cyclophosphamide (Cytoxin) may be used to the same end, as well as corticosteroids and androgens.

If aplastic anemia is left untreated, death is imminent. Long-term survival in young people who have undergone HCT is about 80%, whereas the survival rate in older adults is 40% to 70%.

Multiple Myeloma Multiple myeloma (MM) is also known as myelomatosis, plasma cell myeloma, malignant

plasmacytoma and multiple plasmacytoma of the bone. It is a cancer of the bone marrow where plasma cells grow abnormally, crowding the bone marrow and interfering with the growth of red blood cells. Malignant plasma cells produce an abnormal immunoglobulin called monoclonal immunoglobin or M-


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protein that can be detected in the blood or urine. Risk factors include exposure to petroleum products, dioxin and atomic radiation. MM generally occurs in adults older than 60 years.

MM can present with bone pain, pathological fractures (from the destruction of normal bone) and back pain. Many individuals are prone to lytic lesions, which are caused by the skeletal involvement and bony destruction brought about by the accumulation of plasma cells in bony areas. Pallor, abnormal bleeding and myelosuppression of bone marrow are common and are evident by disease-related neutropenia, anemia and thrombocytopenia. Individuals diagnosed with MM may also develop renal complications due to disease-related hypercalcemia, hyperuricemia and dehydration.

Currently, there is no known cure for MM and treatment is largely palliative. Chemotherapy is often started when patients begin to experience symptoms. However, many new treatments are under investigation, including high-dose chemotherapy with HCT in healthy, younger individuals. Radiation therapy is used to treat painful bony lesions.

Once symptoms develop, the median survival of individuals without treatment is seven months. With treatment, survival can be extended to two to three years.

Lymphoma

Lymphoma is cancer of the lymphoid system. The lymphoid system comprises lymph nodes (glands) and lymphatic tissue and is similar to the circulatory system, but it contains lymph cells (lymphocytes), rather than blood. The lymphocytes circulate throughout the bloodstream and lymphatic channels, or are arranged in clusters in the neck, armpit, groin, and abdomen. Cancers that develop in the lymphoid system are found wherever the lymphocytes travel. Lymphomas can occur in isolated lymph nodes, clusters of lymph nodes, organs (e.g., stomach or intestines), lungs, bones, skin or a combination of these sites.

There are two main classifications of lymphoma: Hodgkin’s disease (also called Hodgkin’s lymphoma) and non-Hodgkin’s lymphoma. HD accounts for about 15% of all lymphomas and most frequently occurs in adolescents and young adults. NHL is seven to eight times more common than HD, and more than 95% of cases are diagnosed in adults. Lymphomas are classified into many subtypes.

Signs and symptoms. Both types of lymphoma (HD and NHL) may present with painless swelling of the lymph nodes, fatigue, and shortness of breath or coughing. Lymphomas that have a larger tumor burden typically exhibit “B-cell” type symptoms (B symptoms) that include unexplained weight loss, unexplained fever or drenching night sweats.

Diagnosis . Diagnosis involves surgical biopsy of involved tissue, a detailed physical examination with evaluation of all nodal areas and documentation of history, including the presence or absence of B symptoms. Additional diagnostic tests may include bone marrow aspiration and biopsy, imaging studies (e.g., chest X-ray; CT scans of the chest, abdomen and pelvis), surgical biopsy of organs, flow cytometry and molecular genetic testing, and hematological and biochemistry studies (e.g., CBC with differential, liver and kidney function tests). HD is distinguished from NHL by two distinctive characteristics: the presence of Reed-Sternberg cells in the lymph nodes (theses cells are not found in NHL), and the orderly spread of the disease from one lymph node group to another.

Treatment . Treatment regimens vary according to the specific stage, grade and type of disease. All lymphomas are staged according to the Ann Arbor Staging System (I, II, III and IV). Classifying lymphoma can be very confusing because there are different classification systems, as well as many different types of the disease. The Working Formulation classifies lymphoma as low grade, intermediate grade and high grade. A classification method called the Revised European American Lymphoma (REAL) System was developed recently to classify lymphomas not previously included in the Working


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Formulation. Most treatments consist of a combination of surgery, chemotherapy, biotherapy and radiation therapy.

Hodgkin ’s Disease HD occurs most often in people between the ages of 15 and 40 years and is characterized by the

presence of Reed-Sternberg cells in the lymph node biopsy. There are four types of Hodgkin’s disease. Lymphocyte Predominance: Lymph nodes comprise lymphocytes and malignant cells, which

have a “popcorn-like” appearance and very few of the Reed-Sternberg cells. LP accounts for 5% to 10% of total cases and is more common in men than women.

Nodular Sclerosis : Lymph nodes in the lower neck, chest and collarbone usually contain normal and reactive lymphocytes and Reed-Sternberg cells separated by a band of scar-like tissues. NS accounts for 30% to 60% of all cases.

Mixed Cel l : Lymph nodes usually contain Reed-Sternberg cells, as well as inflammatory cells. MC accounts for about 20% to 40% of total cases.

Lymphocyte Depleted: Two variations of LD exist; one with sheets of differing malignant cells, and the other with few Reed-Sternberg cells and lymphocytes with scar-like tissue.

HD is one of the most curable forms of cancer and is treated with surgery to remove any affected lymph nodes, radiation therapy, chemotherapy or a combination of radiation/chemotherapy, depending on the grade and stage of disease. One-year and five-year survival rates for HD are 92% and 84%, respectively. Mortality from a second malignancy (secondary to treatment for HD) is greater after five years than the total mortality from HD itself.

Non-Hodgkin ’s Lymphoma There are about 30 different types of NHL, a disease of the immune system that most commonly

involves B-cell lymphocytes and occasionally T-cell lymphocytes. People with suppressed immune systems following an organ transplant and those with human immunodeficiency virus (HIV) are at a greater risk for developing NHL. The predominant types of AIDS-related lymphomas are high-grade B-cell NHLs (e.g., Burkitt’s lymphoma or small, non-cleaved lymphoma). NHL occurs most frequently in people ranging in age from 30 to 70 years. Burkitt’s lymphoma is associated with the Epstein-Barr virus. NHL that exhibits B symptoms is often diagnostic of “bulky” or more aggressive and advanced disease.

The treatment regimen for NHL may include radiation therapy, chemotherapy, biotherapy (e.g., highly specific monoclonal antibodies directed at lymphoma cells or antibodies linked to radioactive atoms), removal of any affected lymph node or HCT. The effects of radiation therapy and chemotherapy are not inconsequential, placing patients at significantly greater risk for secondary cancers for up to 20 years post-diagnosis.

Survival for NHL varies widely by cell type and stage of disease. The overall one- and five-year survival is 81% and 67%, respectively. Carcinoma

Carcinomas are the most common type of cancer in adults. This type of cancer originates in the epithelial tissue (e.g., tissue that covers or lines internal organs and passageways) and has the propensity to metastasize to other tissues through the circulatory or lymphatic systems. Virtually every organ is susceptible to carcinomatous metastasis. Common classifications are:


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Adenocarcinomas form in glands or gland-like tissues such as the lung, breast, ovary, pancreas, colon and rectum.

Basal cel l carcinomas are a common type of skin cancer. They are often benign and generally slow to progress. They are commonly found on the face and upper extremities, particularly in the elderly, and if left untreated, can invade surrounding tissue, including the bone.

Papil lomas include a variety of warts, polyps and condylomas. Papillomas are benign, but can be precursors to malignancies. An example is the condyloma virus, or genital wart, that can increase the risk of cervical cancer. Treatment may include surgical excision or cryotherapy. In the case of condyloma, close monitoring with yearly Papanicolaou (Pap) tests is essential.

Squamous cel l carcinomas are found in normal tissues of the skin, the lining of the nasopharynx, larynx, esophagus, anus, genitourinary tract and cervix.

The most common types of new cancer cases diagnosed in adults in the United States are prostate, lung, colorectal and bladder cancer in men; and breast, lung, colorectal, and uterine cancer in women—all of which are carcinomas.

Bladder Cancer

Bladder cancer is the most frequently diagnosed cancer of the urinary system and occurs with greater frequency in older men. Ninety percent of all bladder cancers are transitional cell carcinomas that arise in the cells that line the bladder.

Risk Factors . Risk factors for bladder cancer include cigarette smoking, carcinogens in the urine, exposure to chemical compounds (e.g., aniline dyes), and chronic irritation of the bladder related to infection.

Survival . When bladder cancer is diagnosed at an early, localized stage, the five-year survival rate is 97%. If the cancer is diagnosed after it has spread regionally and metastasized to the colon, rectum, prostate or vagina, the five-year survival rate drops to 35%.

Signs and Symptoms. Signs and symptoms of bladder cancer include painless blood in the urine and changes in normal urination such as increased frequency, urgency or dysuria (painful urination).

Diagnosis . Diagnostic methods include cystoscopy, abdominal CT scan, laboratory analysis (including urinalysis and blood tests for kidney function), and mapping and biopsy of bladder tissue.

Treatment . Treatment of early stage disease involves surgical resection of tumors using cystoscopy, and instillation of chemotherapy agents such as Bacillus Calmette-Guérin (TheraCys BCG) or thiotepa (Thioplex) into the bladder (intravesical administration). More advanced disease is treated with radiation therapy and cystectomy (removal of the bladder), or combinations of therapies that may include hormones and chemotherapy.

Breast Cancer

Breast cancer is most frequently diagnosed in women, and is more prevalent in older women than

younger women. Approximately 10% to 11% of American women will be diagnosed with breast cancer in their lifetime. Survival decreases when the size of the breast tumor is large or if the cancer has spread to the lymph nodes under the arm (axilla). The majority of breast cancers arise in the milk-ducts or the milk-producing lobules (glands). When diagnosed at an early stage, ductal cancer of the breast is referred to as ductal cancer in situ (DCIS) and lobular cancer of the breast is known as lobular cancer in situ (LCIS). Breast cancer that grows into surrounding breast tissue is referred to as infiltrating


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cancer. In situ breast cancer never metastasizes, but infiltrating breast cancer can spread to the lymph nodes and other organs such as the bone, brain, liver and ovaries. Inflammatory breast cancer, while rare, is a rapidly growing breast cancer characterized by redness, swelling and tenderness of the breast. ACS screening guidelines recommend that women begin yearly screening mammograms at age 40; those with a family history of breast cancer should be screened earlier.

Risk Factors . Risk factors associated with breast cancer are family history of breast cancer, increasing age, obesity, high-fat diets, oral contraceptive use, physical inactivity, alcohol use (one or more drinks per day), having a first child after age 30, menstruating before age 12, having menopause after age 50, use of postmenopausal hormone therapy and previous chest irradiation.

Survival . The five-year survival rate for early stage (localized) breast cancer is 99%. If the cancer has spread to the surrounding lymph nodes the five-year survival rate is 84%. If a woman is diagnosed with distant metastases (e.g., cancer has traveled to the bone or brain) the five-year survival rate is 23%. In addition, studies reveal that being overweight adversely affects survival for postmenopausal women with breast cancer.

Signs and Symptoms. The most common symptom of breast cancer is a painless lump in the breast. Other symptoms can include nipple pain or retraction, discharge from the nipple other than breast milk, tenderness, swelling, thickening, dimpling or redness of the breast.

Diagnosis . Breast cancer is most commonly diagnosed by a mammogram, although a negative mammogram does not always indicate the breast is free from cancer. Other diagnostic measures include breast ultrasound, digital mammography, breast MRI and biopsy of suspicious tissue. Biopsy procedures are performed by inserting a needle into the lump, core biopsy, vacuum-assisted biopsy, excisional biopsy or by surgically removing the entire breast lump. Pathological analysis of the breast tissue is performed to determine estrogen-receptor (ER) and progesterone-receptor (PR) status, HER2/neu expression and S-phase status.

Treatment . Treatment considerations for breast cancer include the type of tumor, location, stage of disease, receptor status and Oncotype DX testing, as well as patient’s age, health status and personal preferences. Effective treatment consists of the surgical removal of the tumor by either lumpectomy, which is removal of the tumor and a narrow margin around the tumor; or mastectomy, which is removal of the entire breast; as well as lymph node biopsy with or without radiation therapy, chemotherapy or hormonal manipulation. Biotherapy with trastuzumab (Herceptin) is used in patients whose cancers test positive for HER2/neu expression, and lapatinib (Tykerb) for those with advanced disease. Hormone therapy is indicated for women whose cancers express ER or PR positivity, as receptive positive tumors are generally responsive to endocrine therapies such as ER modulators (e.g., tamoxifen [Nolvadex]) and aromatase inhibitors (e.g., letrozole [Femara], anastrozole [Arimidex], or exemestane [Aromasin]).

Colorectal Cancer

Adenocarcinomas account for 98% of colon cancers and 95% of rectal cancers. More than 90% of

colorectal cancers are diagnosed in individuals older than 50 years. The ACS screening guidelines recommend that all Americans have colorectal examinations beginning at age 50.

Risk Factors . Risk factors for colorectal cancer include increasing age, positive family history for colorectal cancer; history of inflammatory bowel disease or polyps; obesity; physical inactivity; and diets high in fat, well-cooked meat and alcohol.

Survival . When colorectal cancer is diagnosed at an early, localized stage, the five-year survival


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rate is 90%. If the cancer is diagnosed at a stage where it has spread regionally to the lymph nodes or adjacent organs, the five-year survival rate falls to 69%.

Signs and Symptoms. Signs and symptoms of colorectal cancer do not usually manifest in early stage disease. Depending upon the location of the tumor, patients may report vague abdominal pain, increased bowel gas or cramping, or changes in normal bowel habits. Commonly experienced symptoms of later stage disease include blood in the stool or rectal bleeding (either bright red or very dark), bowel pain, anemia with weakness and fatigue, and bowel obstruction.

Diagnosis . Diagnosis of colorectal cancer is commonly made with double-contrast barium enema, colonoscopy and tissue biopsy. Other methods used to diagnose colorectal cancer are fecal occult blood tests, digital rectal examination and flexible sigmoidoscopy.

Treatment . Treatment considerations for colorectal cancer include the type of tumor, location, stage of disease, as well as patient’s age, health status, and personal preferences. Surgical resection is the primary treatment for all stages of colorectal cancer. Chemotherapy or chemotherapy with radiation therapy is often given before or after surgery depending upon the stage, location and spread of the disease. Biotherapy using the antiangiogenic agent bevacizumab (Avastin) is indicated for patients with metastatic disease.

Lung and Bronchus Cancer

Lung cancer is the leading cause of cancer-related death in American men and women. Lung cancer

is classified into two general histological types: non–small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). NSCLC accounts for 80% of all lung cancers, and it has three subtypes (adenocarcinoma, squamous cell and large cell). SCLC or oat cell cancer is a rapidly growing lung cancer that can quickly spread to other organs, especially the brain. Other common sites of lung cancer metastases are liver, adrenal glands and bones.

Risk Factors . Cigarette smoking is the most significant risk factor. Other risk factors include non-smokers exposed to second-hand smoke, and occupational or environmental exposure to asbestos, radon, arsenic, benzene or air pollution.

Survival . When lung cancer is diagnosed at an early, localized stage, the five-year survival rate is 52% (only 15% of all lung cancers are diagnosed at this stage). The five-year survival rate for SCLC is 6%, and the five-year survival rate for NSCLC is 17%.

Signs and Symptoms. Early stage lung cancer frequently has few symptoms. Persistent cough, hemoptysis, dyspnea, wheezing, enlarged lymph nodes in the neck, recurring pneumonia or bronchitis, and chest or shoulder pain are often signs and symptoms of more advanced disease. Systemic symptoms of lung cancer are unexplained weight loss, anorexia and fatigue. Headaches or seizures are usually indicative of metastasis to the brain.

Diagnosis . Commonly used diagnostic methods for lung cancer are chest X-ray; bronchoscopy with washing, brushing and biopsy; cytological analysis of malignant cells in the sputum or fluid drained from the lung; and chest and abdominal CT scan. CT scan of the brain is often ordered to evaluate the presence of brain metastasis.

Treatment . Treatment includes surgery for localized tumors. Depending upon type, stage and location of disease, it can include a combination of radiation therapy, chemotherapy and biotherapy using targeted biological agents.

Melanoma


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Melanomas are malignant tumors that develop in the pigment-producing cells (melanocytes),

which give color to the skin, hair and eyes. Melanomas can spread horizontally as well as vertically, into layers of the skin and tissues. This spread can lead to lymph node involvement and metastasis to any organ of the body, especially the brain, lung or liver.

Risk Factors . Melanomas are linked to sun exposure, particularly severe sunburn. They occur more often in light-skinned people; on the extremities in women; and on the trunk, head and neck in men. They are most often found in adults. Avoiding sun exposure during mid-day hours (10 a.m. through 4 p.m.) and the use of sunscreen with sun protection factor (SPF) 15 should be used to help prevent this malignancy.

Survival . Prognosis depends on the stage of the disease. Melanomas generally considered curable are thin lesions that have not spread beyond the original site or invaded beyond the papillary dermis.

Signs and Symptoms. Moles that change color, size, or shape or become itchy are suspicious for melanomas. Later signs include ulceration and bleeding.

Diagnosis . Diagnosis is made by excisional biopsy. There are several subtypes of melanoma, including superficial spreading, nodular, lentigo maligna and acral lentiginous. Staging of melanoma is based on its thickness (Breslow’s classification) and/or the anatomic level of local invasion (Clark’s classification).

Treatment . Treatment of localized melanoma is surgical excision. More advanced stages of the disease are treated with adjuvant chemotherapy or biotherapy.

Pancreatic Cancer Cancer of the pancreas most commonly arises from both exocrine parenchyma and endocrine islet

cells. Sites of metastases are adjacent lymph nodes, lung, bone and brain. There are no widely used methods for early detection at this time.

Risk Factors . Risk factors include cigarette and cigar smoking, obesity, high-fat diet, physical inactivity, chronic pancreatitis, diabetes and cirrhosis.

Survival . Even when pancreatic cancer is diagnosed at an early, localized stage, the five-year survival rate is only 22%. More than half of people with pancreatic cancer are diagnosed with advanced disease; their five-year survival rate is only 2%.

Signs and Symptoms. Rarely diagnosed in its early stages, symptoms of pancreatic cancer can be vague and not cause suspicion until the disease is well advanced. Symptoms most often include weight loss, abdominal pain and discomfort, jaundice, nausea, vomiting, anorexia or the sudden onset of diabetes.

Diagnosis . The only definitive diagnosis of pancreatic cancer is biopsy of the involved pancreatic tissue.

Treatment . Treatment varies according to type, stage and location of disease. Surgical resection is the treatment of choice in operable tumors. The Whipple procedure (pancreatoduodenectomy) is the only potentially curative approach when the tumor is located in the head of the pancreas. Therefore, surgery, radiation therapy and chemotherapy, as well as biotherapy, are treatment options used to extend survival or to palliate and relieve symptoms.


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Prostate Cancer

Prostate cancer is the most frequently diagnosed cancer in men. It is usually slow growing and

typically occurs in men older than 50. The ACS screening guidelines recommend that men begin yearly PSA evaluation and digital rectal examination (DRE) at 50 years, or at 45 years for African-Americans.

Risk Factors . Risk factors for prostate cancer include increasing age, family history and ethnicity (e.g., African-American). Other risk factors are obesity and diets high in fat, red meat and animal fat.

Survival . The majority of prostate cancers are diagnosed in local and regional stages, and the five-year survival rate is nearly 100%. If a man is diagnosed with cancer that has distant metastasis (e.g., the cancer has traveled to the bone), the five-year survival rate is 33%. Improved survival has come about through improvements in early detection and treatment.

Signs and Symptoms. Early stage prostate cancer rarely has any symptoms. Symptoms of more advanced disease may include difficulty starting or stopping urination, pain or discomfort with urination, or urinary frequency, especially at night. Other symptoms are erectile dysfunction, painful ejaculation or blood in the urine. Pain in the lower back, legs and thighs may be a sign of metastatic disease.

Diagnosis . Diagnosis is most frequently determined by the presence of an evaluated level of the blood tumor marker (PSA) and/or the discovery of a mass or lump on the prostate gland found during a DRE. A thorough work-up usually includes abdominal CT scan, bone scan and a core biopsy of the prostate gland.

Treatment. Treatment for prostate cancer is dependent upon the stage of the disease at diagnosis. Types of treatment for earlier stage disease include careful observation known as “watch and wait,” surgical removal of the prostate gland, external beam radiation therapy, brachytherapy (radioactive seed implantation into the prostate gland), or hormonal therapy (androgen deprivation therapy to block the action of androgenic hormones). Metastatic disease is treated with radiation therapy to painful bony areas, hormonal therapy, chemotherapy, or a combination of these therapies.

Sarcoma

Sarcomas are malignancies of the connective tissue, bone, cartilage or striated muscle. Because connective and supportive tissues are found throughout the body, sarcomas can occur anywhere. Sarcomas can spread by extension into neighboring tissue or by way of the circulatory system. They are divided into soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas are classified according to tissue type involved, such as fibrosarcoma and liposarcoma. Soft tissue sarcomas most frequently metastasize to the lungs, bone and liver. Bone sarcomas include osteosarcomas, Ewing’s sarcoma and malignant fibrous histiocytoma of the bone.

Symptoms of sarcomas include local pain, soft tissue swelling and palpable masses. Common diagnostic methods include CT scans and MRIs of the affected area and open biopsy. Treatment is specific to the type of sarcoma diagnosed.

Adult Soft Tissue Sarcomas Soft tissue sarcomas arise from mesodermal tissues of the extremities, trunk, retroperitoneum, and

head and neck. They are more commonly seen in patients with neurofibromatosis, Gardner syndrome, Werner syndrome, tuberous sclerosis, basal cell nevus syndromes and Li-Fraumeni syndrome kindreds. Types of soft tissue sarcomas include:


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• Alveolar soft-part sarcomas • Angiosarcoma • Dermatofibrosarcoma protuberans • Epithelioid sarcoma • Extraskeletal chondrosarcoma • Extraskeletal osteosarcoma • Fibrosarcoma • Leiomyosarcoma • Liposarcoma (accounting for 25% of all adult soft tissue sarcomas) • Malignant fibrous histiocytomas (accounting for 40% of total adult soft tissue sarcomas) • Malignant hemangiopericytoma • Malignant mesenchymoma • Malignant schwannoma • Malignant peripheral nerve sheath tumor • Rhabdomyosarcoma • Synovial sarcoma

Treatment . Treatment is determined by the staging of the tumor (e.g., size, histologic grade and

presence of local spread to nodes or distant metastases). Treatment is multimodal, with either pre- or post-operative radiation therapy, usually depending on the physician’s philosophy. Ideally, surgery leaving clean margins and maintaining functionality for the patient is desirable. Patients with metastases may be considered for adjuvant chemotherapy.

Prognosis . Prognosis is related to the site and stage of the sarcoma. Localized tumors that are easily and completely resected are generally the most responsive to treatment. Retroperitoneal tumors, particularly high-grade tumors, can be difficult to resect fully, thus these patients tend to have poorer prognoses.

Pediatr ic Soft Tissue Sarcomas This type of sarcoma originates in the primitive mesenchymal tissue. It accounts for about 7% of all

childhood tumors. Included in this group are: • Leiomyosarcoma • Fibromatosis • Malignant fibrous histiocytoma • Liposarcoma • Angiosarcoma • Hemangiopericytoma • Synovial sarcoma • Malignant schwannoma • Extraskeletal osteosarcoma • Extraskeletal mesenchymal chondrosarcoma • Extraskeletal myxoid chondrosarcoma • Malignant mesenchymoma

Tumor biopsies are differentiated through careful examination using immunocytochemical tests

and electron microscopy. Many of these tumors are characterized by chromosomal abnormalities.


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A combination of surgery and radiation therapy generally yields good tumor control in about 80% of patients. As with many childhood cancers, the long-term effects of the therapies are not inconsequential (e.g., secondary cancers due to radiation exposure) and require careful consideration and individualization.

Childhood rhabdomyosarcoma is a soft tissue tumor of the striated muscle. It accounts for about 3.5% of all cancers in children up to the age of 14 and 2% of the cases in children 15 to 19. The most common sites of rhabdomyosarcoma are the head and neck, genitourinary tract and the extremities. Less common sites include the trunk, the intrathoracic region and perineum.

Treatment . Treatment is generally multimodal. Surgical resection, followed by chemotherapy is standard. Some children require a “second look” surgery if they had residual disease before chemotherapy. Radiation therapy may be administered before or after surgery, depending upon the physician’s philosophy.

Prognosis . Prognosis depends on the site, extent and histopathology of the disease. It is a curable disease in children who receive optimal therapy, with more than 60% surviving five years after diagnosis. Primary sites with the most favorable outcome are the orbit and nonparameningeal head and neck, and the nonbladder/nonprostate genitourinary region (especially the paratesticular and vaginal regions). The extent of the disease and its surgery are also factors in outcome. Those with no residual disease or microscopic residual disease had five-year survival rates of 90% and 80%, respectively, while those with gross residual disease had only a 70% five-year survival rate.

Osteosarcoma Osteosarcoma is a bone tumor that occurs most often in adolescents and young adults, with a peak

incidence around the adolescent growth spurt. Approximately 5% of all childhood tumors are osteosarcomas. About 20% of patients have radiographically detectable metastases at the time of diagnosis.

Treatment . Osteosarcoma is resistant to radiation therapy. Therefore, chemotherapy followed by surgery is the standard treatment.

Prognosis . The site of the primary tumor is a big factor in survival. Tumors of the craniofacial area, or other flat bones, have favorable survival rates when the entire bone can be removed. Only 20% of patients receiving surgical intervention alone for localized tumors survive disease-free. Patients whose tumors respond favorably to pre-surgical chemotherapy have more favorable prognoses.

Ewing’s Sarcoma Ewing’s sarcoma is a group of childhood tumors including Ewing’s sarcoma of the bone,

extraosseous Ewing’s sarcomas, primitive neuroectodermal tumors and Askin’s tumor (a primitive neuroectodermal tumor of the chest wall). These tumors all evolve from the same type of stem cell. Ewing’s tumors are more common in the second decade of life, and affect boys slightly more often than girls. Ewing’s sarcoma of the bone accounts for about 60% of Ewing’s tumors. Its sites of origin include the extremities, pelvis, chest, spine and skull. Extraosseous Ewing’s sarcomas are found in the trunk, extremities, head and neck, and retroperitoneum. Primitive neuroectodermal tumors (including Askin’s tumors) occur in the trunk, extremities and retroperitoneum.

Treatment . Treatment may include surgery, radiation and/or chemotherapy, depending of the extent of the disease. Retroperitoneal sites pose the most difficulties in surgical resection due to the potential to leave residual tumor to spare vital tissues.


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Prognosis . Prognosis and treatment are based on the site, tumor volume and presence of metastases. More localized tumors in the extremities have the most favorable outcomes. Younger children fare better than adolescents and young adults.

Summary

Cancer is not one disease, or even “the big four” (breast, lung, prostate and colorectal cancers), but rather a group of diseases with multiple primary sites and hundreds of pathologies. While there are great similarities among hematology and oncology diagnoses, there are many differences as well.

References 1. National Comprehensive Cancer (NCCN) Clinical Practice Guidelines in Oncology, 2012. NCCN Web site.

http://nccc.org/clincal.org. Accessed July 18, 2012. Resources American Cancer Society. Cancer Facts and Figures, 2012. Atlanta, GA: The American Cancer Society; 2012. Gates RA, Fink RM. Oncology Nursing Secrets, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2006. Laughlin EH. Coming to terms with cancer: A glossary of cancer-related terms. Atlanta, GA: American Cancer

Society; 2002. National Cancer Institute. (NCI) Common types of cancer. http://www.cancer.gov/cancertopics/commoncancers

NCI Web site. Accessed July 18, 2012. Taber CW. Taber’s Cyclopedic Medical Dictionary, 21st ed. Philadelphia, PA: F.A. Davis Company; 2009.

Cancer and Metabolic Response

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33

Chapter Three:


To enhance the understanding of the metabolic changes that occur in the presence of cancer, this chapter includes a review of normal metabolism and metabolic pathways responsible for basal metabolism and energy expenditure; a discussion of the metabolic changes associated with starvation; and alterations in metabolism associated with cancer and cancer cachexia syndrome. The bulk of the chapter will be presented as facts and figures with the intention of simplifying the content for providing nutrition care for patients diagnosed with cancer.

ancer alters metabolism. To understand the metabolic changes that occur in the presence of cancer, an understanding of normal metabolism and metabolic pathways responsible for basal metabolism and energy expenditure is needed.

Carbohydrate Metabolism Carbohydrates are absorbed as monosaccharides (glucose, galactose and fructose), which are

transported to the liver, where galactose and fructose are converted to glucose enzymatically. Glucose may be used or stored.

C


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Use and Storage of Consumed Carbohydrates Dietary CHO

Blood Gloucose

Glucose is transported to the body’s cells for use as energy. Glucose must go through glycolysis to yield its energy to biological systems. Glycolysis takes each glucose molecule through a series of reactions, producing two molecules of adenosine triphosphate (ATP), two molecules of hydrogen, one molecule of pyruvate and one molecule of lactic acid.

Glycolysis takes place in the cytoplasm of the cell under anaerobic conditions. Energy inside ATP is used as a source of “system maintenance.” Pyruvate spills into another pathway, called the tricarboxylic acid cycle (TCA), or Krebs cycle.

(glycogenesis) (lipogenesis) Liver and Liver and Muscle glycogen adipose lipid

STOR

AG

E Immediate Use

Body cells for energy


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The TCA cycle takes place in the cell mitochondria under aerobic conditions, generating another

34 ATP molecules, along with carbon dioxide as a byproduct. Clinical and dietetic practitioners should have a good understanding of this metabolic process, as ventilator-dependent patients produce CO2 as a byproduct of metabolism. Extra glucose beyond that which the body needs for maintenance is stored in the muscle and liver as glycogen. Some glucose may be converted into nonessential amino acids by either transanimation, or by the addition of a nitrogen-containing molecular group in the liver. When the glycogen storage is at capacity, extra glucose is converted to and stored as fat (fatty acids and triglycerides).

If the body requires glucose for energy at a time when it is unavailable from the diet, it can convert


36

stored glucose (glycogen in liver and muscle), or can convert fat to glucose via lipolysis. Here is a summary of normal carbohydrate metabolism:

• Glycogen in the liver is converted via glycogenolysis to glucose, which is transported to the rest of the body for energy.

• Protein from the liver and muscle can be converted to glucose via gluconeogenesis (creation of glucose from a non-carbohydrate source). This process is called the Cori cycle.2

• Stored fat can be converted to fatty acids and glycerol, from which glycerol can be converted to glucose in a process called lipolysis, another type of gluconeogenesis.

Protein Metabolism

The following provides a summary of normal protein metabolism.1 • Protein is absorbed in the form of amino acids and transported to the liver, which regulates

its function. • Protein forms the basis of enzymes, hormones, toxins and antibodies, and is needed for the

transport and storage of substrates. • Proteins serve as structural tissue in the form of cartilage, tendons and bone. • The primary function of protein is tissue synthesis. • All cells synthesize and break down protein on a continual basis (protein turnover). • Dietary amino acids, as well as those derived from protein breakdown, are used to create

proteins needed by the body for growth, repair or replacement of tissue (e.g., bone, muscle, wound repair, skin, hair and nails) under the direction of ribonucleic acid (RNA).

• Protein may also be used for energy when carbohydrates and lipids are insufficient. • Amino acids lose their nitrogen groups, leaving carbon skeletons, which are degraded to

pyruvate or other intermediates in the Krebs cycle. • Excess amino acids are converted to pyruvate and acetyl-CoA, and synthesized to fatty

acids, which combine with glycerol to form triglyceride for storage.

Lipid Metabolism The following provides a summary of normal lipid metabolism.1


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• Lipid metabolism is directed by the liver and adipose tissue and is triggered by lipotropic factors, hormones and enzymes.

• Lipotropic factors tell the body what to do when there is excess lipid in the liver, when lipid can be stored and when it needs to be mobilized for energy.

• When the liver has more than enough lipid, the excess is synthesized into triglycerides in a process called lipogenesis.

• Triglycerides, in turn, are transported by lipoproteins to adipose tissue for storage and future use as energy.

• Lipolysis also occurs in the liver, breaking down triglycerides into fatty acids and glycerol when the body signals a need for circulating lipid.

• Lipid stored in adipose tissue can be mobilized and converted to fatty acids and glycerol for energy as well.

• Hormones, like glucagon and epinephrine, trigger lipase enzymes to start the breakdown of stored triglycerides into fatty acids and glycerol.

• Free fatty acids are bound to albumin and transported to other tissues for use as energy in a process known as β-oxidation.

Metabolic Adaptation to Starvation

Acute starvation or dietary deprivation is characterized by a loss of body fat and preservation of muscle mass.3 Inadequate dietary carbohydrate intake leads to mobilization of triglycerides from adipose tissue, as mentioned previously. Triglycerides are broken down into glycerol and free fatty acids, the latter of which are used for energy by most of the body’s cells. As lipid mobilization is accelerated, the balance of lipogenesis and lipolysis is upset and free fatty acids are released into the blood. The liver (and to some degree the kidneys) converts the free fatty acids to acetyl-CoA, which is converted to energy in the TCA cycle. The problem with the use of free fatty acids is that too much acetyl-CoA is formed and any excess that cannot be processed by the TCA cycle is used to produce ketone bodies.

The heart and skeletal muscles are able to use the ketones as energy. After a period of time, even the brain adapts and is able to convert ketones into ATP, but the liver cannot. During starvation, the plasma ketone concentration increases, as the production of ketones surpasses the level at which the heart and skeletal muscle can oxidize them.

Metabolic Changes Associated with Cancer

Energy metabolism is related intimately to carbohydrate, protein and lipid metabolism, all of which are affected by tumor growth. Alterations in metabolism when cancer is present can impair nutritional status by depleting the body’s protein, fat, water, and vitamin and mineral stores.3,4 This is evidenced by the way some tumors can exert a constant demand for glucose. Of note, more recent studies using indirect calorimetry have shown that the long-held belief that all patients with cancer have increased energy expenditures are simply not valid.5 Results from these studies reveal that changes in energy expenditures are more varied, do not occur with all tumor types and can range from 60% to 150% of expected energy expenditure.6-8

Malignant cells can exhibit a high rate of anaerobic metabolism, which yields lactate as the end product. This lactic acid pool requires an increased rate of host gluconeogenesis via Cori cycle activity, which is increased in some cancer patients, but not others. Both protein breakdown and lipolysis take place at increasing rates to maintain high rates of glucose synthesis.


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Additionally, metabolism may be affected by hormones or substances produced by the tumor or by the body in response to the tumor.

Altered Carbohydrate Metabolism in Cancer Some possible metabolic scenarios associated with cancer-related alterations in carbohydrate

metabolism include the following.3,9 • Increased glucose synthesis • Decreased glucose turnover • Increased gluconeogenesis • Increased Cori cycle activity • Increased peripheral glucose uptake • Decreased glucose tolerance or insulin resistance • Increased glucose consumption by the tumor • Production of insulin or insulin-like substances by the tumor

Altered Protein Metabolism in Cancer Possible alterations in protein metabolism associated with cancer include the following.3-10

• Increased rate of whole-body protein turnover • Decreased protein synthesis • Increased skeletal tissue degradation • Increased synthesis of non-skeletal muscle protein • Increased hepatic synthesis of acute-phase reactants (as in trauma or sepsis) • Increased hepatic and tumor protein synthesis • Decreased plasma concentrations of gluconeogenic amino acids • Abnormal serum proteins, similar to kwashiorkor or protein-calorie malnutrition

Altered Lipid Metabolism in Cancer Possible alterations in lipid metabolism associated with cancer include the following.3-10

• Increased glycerol and fatty acid turnover • Increased plasma levels of free fatty acids • Increased lipid mobilization • Decreased lipogenesis and fat storage • Decreased lipoprotein lipase activity • Elevated triglycerides • Decreased high-density lipoproteins • Increased venous glycerol • Decreased plasma glycerol clearance • Increased lipid oxidation • Possible tumor dependence on specific fatty acids (linoleic and arachidonic acids) • Increased use of fatty acids as energy by host tissue in the presence of certain tumors • Impaired suppression of lipid mobilization, in the presence of glucose administration • Increased metabolic rate secondary to increased gluconeogenesis from glycerol


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Cancer Cachexia Syndrome A common secondary diagnosis in patients with advanced cancer is a variant of protein-energy

malnutrition. This syndrome is called cancer cachexia and is characterized by progressive weight loss, anorexia, generalized wasting and weakness, immunosuppression, altered basal energy expenditure, and abnormalities in fluid and energy metabolism.11,12

In contrast to starvation, individuals with cancer cachexia can experience a loss in adipose and skeletal muscle mass while visceral muscle mass is preserved, weight loss not reversed with increases in nutrition intake alone and weight loss despite increased intake of nutrients.13

The etiology of cancer cachexia is not clearly understood and can manifest in patients with metastatic disease, as well as those with localized disease. Recent work has focused on the role of cytokines, which through broad physiological actions, produce metabolic changes and wasting in tumor-bearing hosts that are similar but not identical to changes seen in patients with sepsis and inflammation.4

Cytokines are soluble proteins, peptides or glycoproteins, produced predominately by immune cells, that mediate interactions between cells and regulate cellular and tissue function.3,9,10,14 These substances are found in the blood, ascites, pleural effusions and urine of cancer patients and are believed to play a major role in the biological responses that lead to the wasting seen in cancer cachexia.12,15

Examples of specific cytokines related to cancer cachexia are:16 • Tumor necrosis factors (TNF-α and TNF-β) • Cachectin • Interleukin-1 (IL-1) • Interleukin-6 (IL-6) • Interferon-γ (INF-γ)

Abnormalities in the body’s hormones are also believed to be associated with cancer cachexia and

include: • Increased cortisol • Decreased insulin • Decreased insulin resistance • Decreased testosterone

Animal studies have shown that proteolysis-inducing factor (PIF) and lipid-mobilizing factor

(LMF) may also contribute to cancer cachexia.12,15 PIF is directed by tumor cells to induce protein breakdown in skeletal muscle, decrease protein synthesis and increase cytokines.12

LMF found in the sera of cancer patients has been shown to be proportional to the extent of weight loss. It appears that eicosapentaenoic acid (EPA) found in fish oil can inhibit LMF.9,14 Other fatty acids, such as docosahexaenoic acid (DHA), also found in fish oil and flaxseed, gamma linoleic acid (GLA) and linoleic acid (LA) were ineffective in inhibiting LMF. There may also be a protein-mobilizing factor (PMF) present in weight-losing cancer patients. A proteoglycan, 24Kda, has been shown to induce muscle protein degradation. Interestingly, EPA was found to decrease protein degradation, as well as LMF-related weight loss 9,14

Summary

The etiology of cancer-associated weight loss and cachexia is multifactorial. Decreased food intake


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alone does not account for the wasting and impaired nutritional status observed in some cancer patients. Cancer-related metabolic changes cannot be explained in a simple manner. It is likely that the etiology is specific to tumor type and is influenced by alterations in substrate metabolism. Additional factors like hormones, cytokines and other catabolic factors contribute to weight loss in some patients.

References 1. Berg JM, Tymoczko JL, Stryer L. Biochemistry. 5th ed. New York NY: WH Feeman, 2002. 2. Cori CF. The glucose-lactic acid cycle and gluconeogenesis. Curr Top Cell Regul. 1981;18:377-387. 3. Trujillo E, Nebeling L. Changes in carbohydrate, protein and fat metabolism in cancer. In: The Clinical

Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: The American Dietetic Association; 2006:17-27.

4. Tisdale MJ. Pathogenesis of cancer cachexia. J Support Oncol. 2003;1(3):159-168. 5. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Clinical Nutrition for Oncology

Patients. Marian M, Roberts S, eds. Sudbury, MA: Jones & Bartlett Publishers; 2010:21-44. 6. Khalid U, Spiro A, Baldwin C, et al. Symptoms and weight loss in patients with gastrointestinal and lung

cancer at presentation. Support Care Cancer. 2007;15(1):39-46. 7. Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the

diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059-1065. 8. Bosaeus I, Daneryd P, Lundholm K. Dietary intake, resting energy expenditure, weight loss and survival in

cancer patients. J Nutr. 2002;132(suppl 11):3465S-3466S. 9. Tisdale MJ. Cancer cachexia: metabolic alterations and clinical manifestations. Nutrition. 1997;13(1):1-7. 10. Keller U. Pathophysiology of cancer cachexia. Support Care Cancer. 1993;1(6):290-294. 11. Barber MD, Ross JA, Fearon KC. Cancer cachexia. Surg Oncol. 1999;8(3):133-141. 12. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2(11):862-871. 13. Huhmann MB, August D. Surgical Oncology. In: Clinical Nutrition for Oncology Patients. Marian M, Roberts

S, eds. Sudbury, MA: Jones & Bartlett Publishers; 2010:101-136. 14. Tisdale MJ. Biology of cachexia. J Natl Cancer Inst. 1997;89(23):1763-1773. 15. Dunlop RJ, Campbell CW. Cytokines and advanced cancer. J Pain Symptom Manage. 2000;20(3):214-232. 16. Argiles VM, Busquets S, Lopez-Soriano FJ. Cytokines in the pathogenesis of cancer cachexia. Curr Opin

Nutr Metab Care. 2003;6(4):401-406.


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Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

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Chapter Four: Nutrition Screening, Assessment

and Diagnosis in the Oncology Setting

This chapter will explore nutrition screening and assessment tools that are commonly used in oncology care setting, such as the Scored Patient-Generated Subjective Global Assessment (PG-SGA) along with other assessment tools. The PG-SGA includes nutrition screening, triage and assessment components and has been validated for use in the oncology population. Examples of commonly used nutrition diagnosis statements indentified in the Academy of Nutrition and Dietetics Evidence Analysis Library’s Oncology Toolkit will be provided.

For supplemental information to this chapter, please review the following appendices: Appendix 3 Nestlé Mini Nutritional Assessment (MNA®) Appendix 4 Scored Patient-Generated Subjective Global Assessment (PG-SGA)

n 2003, the Academy of Nutrition and Dietetics (AND) adopted the Nutrition Care Process (NCP) as a four-step, systematic framework for dietetic professionals to provide nutrition care in a variety of care settings.1 Nutrition assessment is the first step of the four-step NCP and provides an

organized method for obtaining, verifying and interpreting information needed to identify nutrition-related problems, their causes and significance.2 The second step is nutrition diagnosis, where dietetic professionals use standardized language to identify and label specific nutrition problems for the healthcare team. The remaining two steps of the NCP include nutrition intervention, and nutrition monitoring and evaluation.

With the continued shift of healthcare from the hospital setting to the ambulatory setting, nutrition screening and assessment are critical components of patient care in the oncology setting. In a review by Huhmann and August, the incidence of weight loss and malnutrition in adults with cancer was 31% to 100%, depending on tumor site, stage and treatment.3 Malnutrition is common and has been shown to be the cause of death in about 20% of patients with cancer.4,5 It is associated with increased morbidity and mortality, decreased response to therapy, increased healthcare costs and a negative force in activities of daily living and quality of life.6 Proactive nutrition screening and risk assessment are the cornerstones of success in preventing such outcomes in the oncology patient care setting.7-9

Early nutrition intervention is essential for optimal patient care. Nutrition screening is used to identify individuals at nutritional risk. Screening for nutrition-related problems should be multidisciplinary, instituted at the time of diagnosis and monitored throughout the continuum of cancer treatment and care.10,11 The Joint Commission and Centers for Medicare and Medicaid services (CMS) require that nutrition screening be performed in all healthcare settings, with each facility establishing its own nutrition-screening process for indentifying nutritional risks. Nutrition-screening criteria commonly includes height, weight, body mass index (BMI), unintentional change in weight, change in appetite, diet, diagnosis, alterations in chewing and swallowing, bowel habits and laboratory

I


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data.12 Effective screening tools should be simple, easy-to-use and able to be completed by any qualified member of the oncology healthcare team.

Once nutrition screening has been conducted to identify nutrition risk and malnutrition, a thorough nutrition assessment is needed. The NCP defines nutrition assessment as the timely collection of pertinent patient data that is analyzed and interpreted with evidence-based standards to determine nutrition status and need for nutrition intervention. Charney and Marian state that “the nutrition assessment process uses information gathered during screening and adds more in-depth, comprehensive data, as well as interpretation of those data, to determine the presence and degree of nutrient deficiency.”12

Nutrition screening and assessment parameters include patient history, food/nutrition history, biochemical data, anthropometric data and nutrition-focused physical examination.

Nutrition Assessment: Key Components12 Patient History Food/Nutrition History Pertinent medical and social history Cultural and ethnic practices Medication and supplement use Socioeconomic status

Meal and snack patterns Adequacy of intake Food availability Food/nutrient tolerance Physical activity

Biochemical Data Anthropometric Data Albumin/prealbumin CBC with differential Electrolytes Lipid panel Micronutrient levels

Height Weight Weight history BMI Weight-to-hip ratio

Nutrition-focused Physical Examination General appearance Overall muscle stores Adipose stores Oral cavity Hair, skin, nails

Through a comprehensive nutrition assessment process, dietetic professionals can then determine

the most appropriate nutrition diagnosis and subsequent nutrition interventions.

Standardized Tools A number of nutrition screening and assessment tools have evolved over the years. Although not

every one is specific to the oncology population, the following tools have practical applications in the oncology setting as evidenced by their use in cited oncology nutrition literature.

The Mini Nutrit ional Assessment (MNA®) was developed as a quick and efficient tool to screen and assess for the risk of malnutrition in the elderly ages 65 and older).13,14 Although this tool has been used frequently with oncology patients, it has not been specifically validated for use in oncology patients.


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While there are no laboratory values included, the MNA® does consider anthropometric measurements, including BMI. There are a number of questions that relate to nutritional intake, but none that consider symptoms affecting nutritional status. The MNA® includes screening and assessment components, both of which are scored, indicating level of nutrition risk. However, there are no intervention guidelines.

The benefits of using the MNA® are that it is based on multiple parameters and is easy to use.13,15 Limitations include its use is indicated only in the geriatric population, the absence of nutrition impact symptoms and other oncology-specific factors that may affect metabolic demand, and lack of validation for use in oncology patients.

The Malnutrit ion Screening Tool (MST) is a measure that uses the following criteria to identify patients at nutritional risk: unintentional weight loss, percentage weight loss and decreased appetite. It is validated for use with adults in acute-care settings and the cancer population (it has been validated for use in patients receiving radiation therapy).16

The Malnutrit ion Universal Screening Tool (MUST) is a measure that uses the following criteria to identify patients at nutritional risk: BMI, percentage of unintentional weight loss and acute disease effect. It was developed for use with adults in the acute-care setting.17

The 7 th Vita l Sign is an outpatient oncology nutrition-screening tool that incorporates two criteria — unintentional weight loss and a decrease in appetite — to identify cancer patients at nutritional risk.18 As the name implies, “the 7th Vital Sign” screening for the risk of malnutrition is an important consideration when performing a comprehensive patient care assessment (the other six vital signs are temperature, blood pressure, pulse, respirations, oxygenation and pain).

Subjective Global Assessment (SGA) was originally developed by Jeejeebhoy and colleagues in the 1980s.19 The SGA has been used in a number of patient populations and has been shown to have superior sensitivity and specificity to more traditional measures of nutrition assessment, such as albumin.19-21

The SGA is comprised of history (weight loss, dietary intake, gastrointestinal [GI] symptoms and functional capacity), metabolic demands of the underlying disease and a nutrition-related physical exam.22 The subjective physical examination considers patients’ loss of subcutaneous fat and presence of muscle wasting, edema and/or ascites.

As the name suggests, the rating of nutritional status is subjective and based on the global picture of nutrition status as evidenced by the sum of the parameters, with A = well nourished; B = moderately malnourished, or at risk; and C = severely malnourished.

Scored Patient-Generated Subjective Global Assessment (PG-SGA). In the mid-1990s, Ottery adapted the SGA to meet the needs of the oncology population by increasing the GI symptom section to include common nutrition impact symptoms found in patients with cancer.6 The history section of the tool has evolved to become “patient-generated” to streamline the process and to involve patients and patient caregivers.

With further refinement, a scoring and triage component was added and the assessment tool has evolved into the latest version. The Scored PG-SGA has been validated as a nutrition-assessment tool in patients diagnosed with cancer and receiving cancer treatment.16,23,24 Researchers have also found that the Scored PG-SGA correlates with quality of life in cancer patients undergoing radiation therapy.25


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Benefits and Limitations of the Scored PG-SGA16,23,26-29 Benefits • Multiple parameters, inclusive of cancer-related nutrition impact symptoms • Quick to complete (takes a trained oncology healthcare clinician about five minutes) • Validated in oncology setting • Cost effective, no costly laboratory analyses • Non-invasive • Includes triage guidelines • Consistent means of identifying patients at risk • High degree of inter-rater agreement • Score can be used sequentially to track patient outcomes Limitations • Nurses often perceive the assessment tool as additional work • Resistance to implement the physical examination • May identify more patients “at risk” than nursing and nutrition staff can accommodate

Scored PG-SGA: A Comprehensive Review The patient and/or family member complete quadrants 1 through 4 on the history portion of the

PG-SGA. A member of the oncology healthcare team (e.g., nurse, dietitian, dietetic technician, physician or physician’s assistant) completes quadrants 5 and 6. A physical exam completes the assessment portion of the PG-SGA. The oncology healthcare team member then scores the PG-SGA, using the tables and worksheets found on the second page/reverse side of the form.

The tables and worksheets for scoring are self-explanatory; however, the physical exam requires training. Training must be done with patients and an experienced clinician and/or the PG-SGA Training Video produced by the Academy of Nutrition and Dietetics.11

Overview of the Nutrit ion-related Physical Examination Assessment of subcutaneous fat . Loss of subcutaneous fat suggests an energy deficit and may

be assessed by observing the areas where adipose tissue is typically stored. The PG-SGA examines the fat pads under the eye, which is one of the first places that adipose

losses will be evident. Another area to note is the fat pad over the triceps area. Finally, the fat stores over the lower anterior ribs are examined.

Each site is ranked as either 0 = no deficit, 1+ = mild deficit, 2+ = moderate deficit, and 3+ = severe deficit. An overall rating of fat stores is based on the “average” ranking for all of the sites examined.

Assessment of muscle stores . Assessment of muscle stores should include an evaluation of the muscle volume, as well as tone and functionality. There are some differences with respect to sex, which are reviewed and depicted in the PG-SGA Training Video.11 It is important to note that the muscles of the upper body are more susceptible to depletion secondary to nutritional deprivation, while the depletion of the muscles of the lower body may be secondary to inactivity (which may also be due to malnutrition).

One of the first, subtle changes that may be observed in a mildly or moderately malnourished patient is hollowing of the temples, which is due to wasting of the temporalis muscle, one of the sites


46

evaluated during the physical exam. Other sites to be examined for muscle wasting include the pectoral and deltoid muscles surrounding the clavicle and shoulders, the interosseous muscle between the thumb and forefinger, the trapezius and deltoid muscles surrounding the scapula, the quadriceps of the thigh and the gastrocnemius muscle of the calf.

Each site that is examined is ranked, just as the sites for fat stores were ranked (0 = no deficit, 1+ = mild deficit, 2+ = moderate deficit, 3+ = severe deficit), with the “average” or overall ranking serving as the global rating for muscle stores.

Assessment of f luid status . Lastly, fluid status must be assessed, as severe malnutrition often causes edema due to oncotic pressure changes. Weight can be skewed due to presence of ascites and/or edema. Patients are examined for pedal (foot and ankle) edema, as well as sacral edema in the chair or bed-bound patient. Finally, the presence of ascites is noted. Again, ranking is noted for each site, as well as the global or overall fluid status, using the 0, 1+, 2+ and 3+ system.

Scoring the physical exam. The score for the entire physical exam is global in nature, and muscle wasting is weighted more heavily than fat loss or fluid overload. The score is not the sum of the three body compartments, but an overall picture of the patient’s nutriture. The score for this section is 0 = no deficit, 1 = mild deficit, 2 = moderate deficit or 3 = severe deficit. The greatest possible score for the physical exam section is 3 points.

Scoring the PG-SGA

The score of the PG-SGA is the sum of boxes A, B, C and D, as outlined in the “Tables and Worksheets for Scoring.” Guidelines for the triage of nutrition intervention are provided at the bottom of the first page of the form. The PG-SGA ratings (A = well nourished; B = moderately malnourished, or at risk; C = severely malnourished) are based on the global picture painted by the entire PG-SGA.

Simply mark the appropriate responses to weight, intake, nutrition impact symptoms, functioning and physical exam categories in Table 5, found in Appendix 4. Wherever the preponderance of responses lies, there is the assessment rating. Whenever in doubt, it is best to err toward the middle.

Also, the history data weighs more heavily than the physical exam, as these symptoms may occur before physical changes. It is important to note that progress in the history data obtained in subsequent evaluations may occur before improvements in the physical exam can be appreciated.

What is the dif ference between the “Score” and the “Rating?” Although related, they are independent triage and assessment systems. In general, higher scores

correlate with “C,” or severely malnourished patients. Patients seen for follow-up may still have a fairly high score, but with non-fluid weight gain, may be rated an “A,” or anabolic. Ideally, positive outcomes measures would include decreased PG-SGA score and improved rating. These measures could be tied to incidence of nutrition-related complications and associated costs, as well as treatment cessation for treatment-related nutritional toxicity (weight loss and unmanaged nutrition impact symptoms).


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Scored Patient-Generated Subjective Global Assessment (PG-SGA) History (Boxes 1-4 are designed to be completed by the patient.) 1. Weight (See worksheet 1, next page) In summary of my current and recent weight: I currently weigh about ___175____ lb I am about ____5_____ feet _____10___ inches tall. One month ago I weighed about __182_____ lb Six months ago I weighed about __190______ lb During the past two weeks my weight has: decreased (1) not changed (0) increased (0) Box 1: 3 points 2. Food Intake: As compared to my normal intake, I would rate my food intake during the past month as: unchanged (0)

more than usual (0)

less than usual (1) I am now taking: normal food but less than normal amount (1)

little solid food (2)

only liquids (3)

only nutritional supplements (3) very little of anything (4) n only tube feedings or only nutrition by vein (0) Box 2: 3 points 3. Symptoms: I have had the following problems that have kept me from eating enough during the past

two weeks (check all that apply): no problems eating (0)

no appetite, just did not feel like eating (3)

nausea (1) vomiting (3)

constipation (1) diarrhea (3) mouth sores (2) dry mouth (1)

things taste funny or have no taste smells bother me (1)

problems swallowing (2) feel full quickly (1)

pain (3): where? ______________ other (1)* ____________________

no problems eating (0) *examples: depression, money, or dental problems Box 3: 5 points 4. Activities and Function: Over the past month, I would generally rate my activity as: normal with no limitations (0)

not my normal self, but able to be up and about with fairly normal activities (1) not feeling up to most things, but in bed or chair less than half the day (2) able to do little activity and spend most of the day in bed or chair (3) pretty much bedridden, rarely out of bed (3) Box 4: 1 point


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Additive Score of the Boxes 1-4: 12 A The remainder of this form will be completed by your doctor, nurse or therapist. Thank you. 5. Disease and its relation to nutritional requirements (See Worksheet 2) All relevant diagnoses (specify) ______Esophageal cancer____________________________ Primary disease stage (circle if known or appropriate) I II I II IV Other ______________________ Age ____62_____ Numerical score from Worksheet 2 B 6. Metabolic Demand (See Worksheet 3) Numerical score from Worksheet 3 C 7. Physical (See Worksheet 4) Numerical score from Worksheet 4 D Global Assessment (See Worksheet 5) Well-nourished or anabolic (SGA-A)

Moderate or suspected malnutrition (SGA-B)

Severely malnourished (SGA-C) Total PG-SGA score _____________________ (Total numerical score of A+B+C+D above) (See triage recommendations below) Clinician Signature _______________ RD RN PA MD DO Other _______ Date ___________

Nutritional Triage Recommendations: Additive score is used to define specific nutritional interventions including patient and family education, symptom management including pharmacologic intervention, and appropriate nutrient intervention (food, nutritional supplements, enteral, or parenteral triage). First line nutrition intervention includes optimal symptom management. 0-1 : No intervention required at this time. Re-assessment on routine and regular basis during treatment. 2-3 : Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as indicated by symptom survey (Box 3) and laboratory values as appropriate. 4-8 : Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms survey (Box 3). ≥9 : Indicates a critical need for improved symptom management and/or nutrient intervention options.


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Other Assessment Tools

Standardized symptom and activity scales are tools used across the continuum of cancer care by oncology healthcare professionals to assess and evaluate patients’ cancer-related symptoms; cancer treatment-related side effects; and psychosocial, socioeconomic, functional and behavioral status.

Examples of these scales include: • National Cancer Institutes’ Common Terminology Criteria for Adverse Events (CTCAE),

version 4.03, which assesses acute toxicities related to cancer and its treatment30 • Activities of Daily Living (ADL), which assesses routine activities, such as eating, bathing,

dressing, toileting and transferring31 • Karnofsky Performance Scale (KPS), which assesses functional status/impairment32

Oncology-related Nutrition Diagnoses

As outlined in the NCP, nutrition diagnosis is divided into three general domains: intake, clinical and behavioral/environmental.2

Common Oncology-related Nutrition Diagnoses33 Intake Domain Inadequate energy intake Excessive energy intake Inadequate oral intake Excessive oral intake Inadequate enteral (EN) or parenteral

(PN) infusion Excessive EN or PN infusion Less than optimal EN or PN infusion Inadequate fluid intake Excessive fluid intake Inadequate bioactive substance intake Excessive bioactive substance intake Excessive alcohol intake

Increased nutrient needs Malnutrition Inadequate protein-energy intake Imbalance of nutrients Inadequate protein intake Excessive fat intake Excessive carbohydrate intake Inadequate fiber intake Excessive fiber intake Inadequate vitamin or mineral intake

(specify) Excessive vitamin or mineral intake

(specify) Clinical Domain Swallowing difficulty Chewing or biting difficulty Altered GI function Impaired nutrient use Altered nutrition-related laboratory values (specify) Food-medication interaction Underweight Unintentional weight loss Overweight/obesity Unintentional weight gain Behavioral Domain Food- and nutrition-related knowledge deficit


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Harmful beliefs/attitudes about food- or nutrition-related topics Not ready for diet/lifestyle change Limited adherence to nutrition-related recommendations Physical inactivity Impaired ability to prepare foods/meals Intake of unsafe food Limited access to food or water Limited access to nutrition-related supplies

Nutrition Diagnosis: PES Statements The nutrition diagnosis “PES” statement is composed of three distinct components: the problem

(P), the etiology (E), and the signs and symptoms (S).2 The PES statement describes a specific nutrition problem, its root or contributing causes, and the data obtained from the nutrition assessment that supports the nutrition diagnosis.

The PES statement framework is outlined as follows: ___________________ related to ________________ as evidenced by __________________. Nutrition Diagnosis Label Etiology or Risk Factors Measurable Symptom or Sign

Oncology-related Nutrition Diagnosis: PES Statements33 Intake Domain • Inadequate energy intake related to anxiety and sleeplessness as evidenced by

weight loss more than 10% in two months. • Inadequate oral intake related to improper administration of pain medication

as evidenced by nausea, vomiting, anorexia and continued weight loss in the past week.

• Inadequate intake from enteral nutrition support related to target goal not achieved as evidenced by weight loss of 4 lb in the past two weeks.

• Inadequate fluid intake related to uncontrolled diarrhea from pelvic radiation as evidenced by more than 5% weight loss in the past two weeks, poor skin turgor, thickened saliva and hypernatremia.

• Inadequate fiber intake related to prolonged intake of liquids only as evidenced by low stool volume and constipation for the past five days.

Clinical Domain • Swallowing difficulty related to presence of an esophageal tumor as evidenced

by regurgitation of food, vomiting and weight loss of more than 5% in the past month.

• Altered GI function related to s/p Whipple Procedure as evidenced by weight loss of more than 5% in the past three weeks, steatorrhea and an episode of emergency IV hydration.

• Overweight/obesity related to psychological stress, excessive energy intake and sedentary lifestyle as evidenced by BMI of 37 (obesity grade II).

Behavioral Domain • Inability to manage self-care related to learning disability, lack of supportive


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care and caregivers as evidenced by not using feeding tube, and continued weight loss to 89% of usual body weight.

• Impaired ability to prepare foods/meals related to increased fatigue and living alone as evidenced by progressive weight loss to 90% of pre-treatment body weight.

• Limited access to food related to failure to participate in federal food programs as evidenced by continued weight loss of 5 lb in the past two weeks during cancer treatment.

Summary

Consistent and timely nutrition screening and assessment is difficult in today’s healthcare environment where dietetic professionals, nurses and other oncology healthcare team members are spread thin. Yet, as evidence suggests, with proactive screening and assessment, patients at risk for developing malnutrition may be identified and treated early, improving quality of life and decreasing healthcare costs in many cases. Nutrition assessment is best achieved with a tool that does not rely on single parameters, but rather the sum of a variety of factors. Oncology nutrition assessment must consider hydration, comorbid diseases and immune function along with the patient’s dietary, medical, social, functional and weight history. The Scored PG-SGA is well suited to the oncology setting, providing screening, triage and nutrition assessment components, and works well in a multidisciplinary setting. Optimum patient care can be achieved with this consistent means of identifying cancer patients at risk for malnutrition.

Nutrition diagnosis is based on the results of a thorough nutrition assessment, dietetic professionals’ clinical judgment, and the likelihood the nutrition intervention or treatment can help to resolve or improve patients’ signs and symptoms. Nutrition diagnoses are not medical diagnoses, but identify nutrition-related problems that affect nutritional status and health.

Case Study

WC, a 62-year-old male, has distal esophageal cancer. He is scheduled to begin neoadjuvant chemotherapy and radiation therapy in 10 days, followed by a surgical resection of the affected portion of the gastroesophagus junction.

Pertinent nutrition assessment data includes: • Height: 5’10” (177.8 cm) ; Weight: 175 lb (79.5 kg) • Usual Weight (six months ago): 190 lb; Weight one month ago: 182 lb • Albumin: 3.2 g/dL • Food intake: less than usual, avoidance of some dry, scratchy foods • Complaints: anorexia, dysphagia, food sticking and early satiety • Functional capacity: not normal; still able to work, but easily fatigued with exertion • Afebrile • Medications: do not include steroids • Physical exam: normal fat stores, mildly depleted muscle stores, no edema or ascites

PG-SGA Score = 12 (triage recommendations: score ≥ 9 indicates need for improved symptom

management and/or nutrition intervention options). • Weight: 3 points (2 points for weight loss of 4% over one month + 1 point

for weight loss over the past two weeks)


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• Food Intake: 1 point (for normal diet, but less intake) • Symptoms: 5 points (3 for anorexia, 1 for problems swallowing and 1 for early satiety) • Activities/Function: 1 point (not normal, but up and about) • Diagnosis: 1 point (for cancer diagnosis) • Metabolic Demand: 0 points (afebrile and not on steroids) • Physical Exam: 1 point (for mildly depleted muscle stores)

PG-SGA Rating = B (moderately malnourished, or suspected of malnutrition) See PG-SGA worksheet for Global Assessment Categories, which place WC’s assessment largely in

the Stage B rating in worksheet 5. In weight and functioning, WC’s rating was between Stage A and B, because the patient exhibits greater than Stage A and is approaching Stage B, and is noted with an “x.”

Note: The Prognostic Nutritional Index (PNI) did not identify this man as malnourished, yet the PG-SGA caught the early signs and risk factors for malnutrition, allowing for earlier intervention.

NCP PES Statement for WC: Inadequate oral intake related to esophageal cancer as evidenced by dysphagia, early satiety

anorexia, and 7 lb weight loss in the preceding month.

References 1. Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and

outcomes. J Am Diet Assoc. 2003;103(8):1061-1072. 2. Academy of Nutrition and Dietetics. International Dietetics & Terminology: Reference Manual, Standardized

Language for the Nutrition Care Process. 3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2010. 3. Huhmann MB, August D. Surgical oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology

Patients. Sudbury, MA: Jones & Bartlett; 2010:101-136. 4. Stepp L, Pakiz TS. Anorexia and cachexia in advanced cancer. Nurs Clin North Am. 2001;36(4):735-744, vii. 5. Ottery FD. Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract. 1994;2(2):123-

131. 6. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology.

Nutrition. 1996;12(1 Suppl): S15-S19. 7. Ottery FD. Supportive nutrition to prevent cachexia and improve quality of life. Semin Oncol. 1995;22(2

Suppl 3):98-111. 8. Lees J. Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment

at a regional oncology center. Eur J Cancer Care. 1999;8(3):133-136. 9. Ferguson ML, Bauer J, Gallagher B, et al. Validation of a malnutrition screening tool for patients receiving

radiotherapy. Australas Radiol. 1999;43(3):325-327. 10. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Marian M, Roberts S, eds.

Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones & Bartlett; 2010:21-44. 11. McCallum PD, Polisena CG, eds. Patient-Generated Subjective Global Assessment video. Chicago:

American Dietetic Association, 2001. 12. Charney P, Marian M. Nutrition screening and risk assessment. In: Charney P, Malone A, eds. ADA’s Pocket

Guide to Nutrition Assessment. 2nd ed. Chicago: American Dietetic Association; 2009:1-19. 13. Vellas B, Guigoz Y, Baumgartner M, et al. Relationships between nutritional markers and the mini-nutritional

assessment in 155 older persons. J Am Geriatr Soc. 2000;48(10):1300-1309. 14. MNA Mini Nutritional Assessment (MNA): user’s guide and MNA video. Nestle Nutrition Institute Web site.

http://www.mna-elderly.com/user_guide.html. Accessed July 18, 2012.


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15. Schneider SM, Hebuterne X. Use of nutritional scores to predict clinical outcomes in chronic diseases. Nutr Rev. 2000;58(2 Pt 1):31-38.

16. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464.

17. Malnutrition Universal Screening Tool (MUST). British Association for Parenteral and Enteral Nutrition Web site.http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must. Accessed July 18, 2012.

18. Levin RM. The 7th vital sign: implementing a malnutrition screening tool at a community cancer center. Oncol Nutr Connect. 2010;18(3):10-14.

19. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN. 1987;11(1):8-13.

20. Enia G, Sicuso C, Alati G, Zoccali C. Subjective global assessment of nutrition in dialysis patients. Nephrol Dial Transplant. 1993;8(10):1094-1098.

21. McLeod RS, Taylor BR, O’Connor BL, et al. Quality of life, nutritional status, and gastrointestinal profile following Whipple procedure. Am J Surg. 1995;169(1):179-185.

22. McCallum PD. Nutrition screening and assessment in oncology. In: The Clinical Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic Association; 2006:44-53.

23. 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(8):779-785.

24. Ottery FD, Kasenic S, De Bolt S, et al. Volunteer network accrues > 1900 patients in 6 months to validate standardized nutritional triage. Proc ASCO. 1998;17:Abstract 282.

25. Bauer J, Capra S, Isenring E. 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(8):779-785.

26. Persson C, Sjoden PO, Glimelius B. The Swedish version of the patient-generated subjective global assessment of nutritional status: gastrointestinal vs urological cancers. Clin Nutr. 1999;18(2):71-77.

27. Capra S, Ferguson M, Ried K. Cancer: impact of nutrition intervention outcome – nutrition issues for patients. Nutrition. 2001;17(9):769-772.

28. Sacks GS, Dearman K, Replogle WH, et al. Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents. J Am Coll Nutr. 2000;19(5):570-577.

29. Thoresen L, Fjeldstad I, Krogstad K, Kaasa S, Falkmer UG. Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool. Palliat Med. 2002;16(1):33-42.

30. Common Terminology Criteria for Adverse Events (CTCAE) v 4.03. National Cancer Institute Web site. http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf. Accessed July 18, 2012.

31. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.

32. Karnofsky Performance Status Scale Definitions Rating (%) Criteria. Hospice Patients Alliance Web site. http://hospicepatients.org/karnofsky.html. Accessed July 18, 2012.

33. Academy Oncology Evidence-based Nutrition Practice Guideline. Academy of Nutrition and Dietetics Web site. https://www.adaevidencelibrary.com/store.cfm?category=1. Accessed July 18, 2012.


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Chapter Five: Determining Nutrition Requirements

for Adults with Cancer

This chapter examines energy, protein, fluid and micronutrient requirements of adults, as well as reviews methods for calculating nutrition needs in the clinical setting.

etermining the nutrition requirements for people diagnosed with cancer is a challenging and complex task. Cancer and its treatment can significantly influence the nutritional status of individuals undergoing and recovering from treatment. Those demands coupled with the

presence of nutrition impact symptoms can adversely affect the ability to eat.1 Other important factors that affect nutritional well-being include nutrition status at the time of

cancer diagnosis, presence of comorbid diseases, current medications, age, sex and performance status. Nutritional needs can change dramatically during the course of cancer treatment; thus, it is imperative that dietetic professionals regularly assess individuals throughout the continuum of cancer care. The overall goals of nutrition management for people diagnosed with cancer are:

• To prevent or reverse nutrient deficiencies • To preserve body cell mass • To manage nutrition-related side effects • To maximize quality of life

Energy Requirements

The metabolic changes that occur in cancer are not consistent, nor are they simple to explain. A common belief among oncology clinicians is that all patients diagnosed with cancer are hypermetabolic; however, a study conducted in 200 hospitalized cancer patients illustrates energy metabolism varies significantly from patient to patient.2 The study found 33% of the patients evaluated were hypometabolic, 41% were normometabolic and only 26% were hypermetabolic. Additional evidence demonstrating that a patient’s site of cancer or tumor type does not accurately predict his or her resting energy requirements or overall energy needs is consistently supported in the literature.3-5 Dietetic professionals should make careful estimates of each patient’s energy requirements using established methods along with clinical judgment.

Indirect calorimetry is a validated, evidenced-based method of accurately determining energy expenditure in critically ill hospitalized patients.6,7 Its use requires a measurement cart or device, and can be impractical and expensive in the ambulatory setting where the majority of oncology care is provided. Guidelines for using and interpreting of measurements derived from indirect calorimetry are well documented in the literature and professional nutrition reference texts.7-9

Predictive Equations: Calculating Energy Requirements The Harris-Benedict formula is an established predictive equation that estimates basal or resting

D

Determing Nutrition Requirements for Adults With Cancer

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energy expenditure (REE).10 Used by dietetic professionals for decades, this simple mathematical calculation takes into consideration a person’s sex, age, height and weight.

When compared with indirect calorimetry and other predictive equations, the Harris-Benedict formula has been shown to overestimate the energy needs of healthy, obese and critically ill patients.11,12 Validation studies have shown the Mifflin-St. Jeor formula more accurately estimates the REE of obese and non-obese individuals.11,13

Estimating Adult Energy Requirements10,13

Harris-Benedict Formula Mifflin–St. Jeor Formula

Men: REE = 66 + 13.7W + 5H – 6.8A Men: REE = 10W + 6.25H – 5A + 5

Women: REE = 655 + 9.6W + 1.7H – 4.7A Women: REE = 10W + 6.25H – 5A – 161

REE = resting energy expenditure in kcal/day W = weight in kg H = height in cm A = age in years

Calculat ing Energy Requirements of Obese Patients

To avoid the risk of overfeeding, there are a variety of validated methods for estimating the energy

requirements of obese individuals with BMI between 30 and 50.9,14 The Mifflin-St. Jeor formula has been validated to be an accurate method for estimating the REEs for both the obese and non-obese. Predictive equations and methods for calculating the energy requirements of obese persons without renal or hepatic dysfunction are provided below.

Calculating Energy Requirements of Obese Adults (BMI > 30) Method 1: Mifflin-St. Jeor Formula11,13 See formula in Chart 1 Method 2: Hypocaloric Regimen for Obese Individuals9 Use 22 kcal/kg of ideal body weight Method 3: Adjusted Harris-Benedict Formula14,15 Use the Harris-Benedict formula and the person’s average weight in kg* multiplied by a stress factor of 1.3 (no activity factor is used) * Average weight (kg) = desired body weight (kg) + 50% of excess body weight (kg)

Total Energy Expenditure

REE can be multiplied by stress and activity factors to determine an individual’s total energy needs

or expenditure (TEE). Combined with clinical judgment, other important considerations for estimating TEE include a person’s current health and weight history, planned therapy, and performance status.

There are a number of commonly used stress and activity factors. Published standardized stress factors of 1.1 to 1.45 for cancer diagnoses are general guidelines and are likely based on cancers known to be hypermetabolic.14


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Stress and Activity Factors9,14,16-18 Stress Factors Factor Mild starvation 0.85 – 1.0 Elective surgery 1.05 – 1.15

Cancer (based on severity of illness) 1.1 – 1.45 Cancer (weight maintenance) 1.15 – 1.3

Hematopoietic cell transplant (baseline) 1.3 – 1.4

Hematopoietic cell transplant (stress) 1.5 – 1.6 Cancer (nutritional repletion/weight gain) 1.5

Ventilator dependent (catabolic) 1.5 Activity Factors Factor Ventilator dependent 1.0 – 1.1 Bedridden/immobile 1.2 Ambulatory 1.3 TEE = REE x stress factor x activity factor

Quick Methods for Calculating Total Energy Needs When indirect calorimetry is not available to determine energy needs, the following methods can be used to estimate the total energy quickly using a person’s body weight. While these methods lack evidenced-based validation, they are frequently used by dietetic professionals to make quick estimates of energy needs. A person’s actual body weight in kg is multiplied by his or her current condition to determine daily energy needs.

Estimating Total Energy Needs Based on Body Weight3,14,16 Condition Estimated Energy Needs Cancer (no stress) 25 kcal/kg/day – 30 kcal/kg/day Cancer (nutritional repletion, weight gain) 30 kcal/kg/day – 35 kcal/kg/day* Cancer (hypermetabolic, stressed) 35 kcal/kg/day Sepsis 25 kcal/kg/day – 30 kcal/kg/day Hematopoietic Cell Transplant 30 kcal/kg/day – 35 kcal/kg/day Obesity 21 kcal/kg/day – 25 kcal/kg/day** *more than 35 kcal/kg/day may be required to maintain or promote weight gain in some individuals and situations **when weight maintenance is the goal; energy needs may be increased when nutritional status is deteriorating

In summary, the energy requirements of people with cancer are as varied as the many cancer

diagnoses themselves. Therefore, it is important for dietetic professionals to remember that calculations of energy requirements are simply estimates, and follow-up and re-evaluation of each patient’s nutrition status and nutrition care plans are essential for quality patient care.


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Protein Requirements Many patients with cancer experience some kind of altered protein metabolism, such as increased

whole-body protein turnover, increased muscle wasting, decreased muscle synthesis and negative nitrogen balance.

Important factors that need to be considered when estimating protein needs include the extent of disease, current nutritional status, planned cancer treatment, performance status and the patient’s ability to metabolize and use protein.9

For the body to use protein effectively, adequate energy (calories) should be provided to ensure protein is used for tissue synthesis, rather than as a fuel source. As with energy requirements, follow-up and re-evaluation of the estimated protein requirement is essential for optimal nutrition.

Different methods are used to estimate daily protein requirements for adults diagnosed with cancer and other medical conditions.14

Estimating Protein Requirements in Adults3,9,14

Cancer-related Conditions Estimated Protein Needs Cancer (no stress) 1.0 g/kg/day – 1.2 g/kg/day Cancer (moderate stress) 1.2 g/kg/day – 1.5 g/kg/day Cancer (hypermetabolic) 1.5 g/kg/day – 2.5 g/kg/day Hematopoietic stem cell transplant 1.5 g/kg/day – 2.0 g/kg/day Other Conditions Estimated Protein Needs Normal (maintenance, no stress) 0.8 g/kg/day – 1.0 g/kg/day Older adults 1.0 g/kg/day Acute renal failure (no stress) 0.6 g/kg/day – 0.8 g/kg/day Acute renal failure (stress and hemodialysis) 1.0 g/kg/day – 1.4 g/kg/day Hepatic failure 1.0 g/kg/day – 1.5 g/kg/day Hepatitis (acute or chronic) 1.0 g/kg/day – 1.5 g/kg/day* End stage liver disease with encephalopathy 0.6 g/kg/day – 0.8 g/kg/day* Cirrhosis without encephalopathy 1.0 g/kg/day – 1.2 g/kg/day* Critical illness (severe stress) 1.5 g/kg/day – 2.0 g/kg/day *Dry weight

Current best practice suggests providing metabolically stressed patients with energy to meet

metabolic demand, and assuming adequate organ function, the provision of no more than 1.5 g of protein per kg of body weight per day.9 With the exception of certain situations, Russell and Malone report providing more than this amount does not normally improve nitrogen balance.9

Adequacy of protein intake can be evaluated via nitrogen balance studies, although this isn’t generally practical in the ambulatory oncology setting. Nitrogen balance studies compare patients’ nitrogen (protein) intake with their nitrogen (protein) output by measuring the urea that is excreted in their urine over a 24-hour period. A positive nitrogen balance reflects that adequate protein is being provided and a negative balance indicates protein intake should be increased. When a collected urine sample is not feasible or available, computing g of protein per kg of body weight provides general guidelines for estimating specific protein needs.


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Determining Nitrogen Balance Nitrogen balance can be used as an index of protein requirements.

Nitrogen balance = (24 hr protein intake/6.25) – (UUN/4*) * A factor of 4 is added to the urine urea nitrogen (UUN) to account for non-urea nitrogen losses such as stool and skin.

Interpretation • A positive nitrogen balance of 4 g/day to 6 g/day is sufficient for anabolism and

wound healing. • A negative nitrogen balance indicates the need for increasing daily protein intake.

Serum protein values obtained from laboratory analyses have often been used as a way of assessing and monitoring malnutrition risk and response to nutrition intervention. However, non-nutritional factors such as disease processes, inflammation, treatments, medications, hydration status and other acute and chronic medical conditions can significantly alter laboratory values.19 Therefore, albumin and prealbumin are no longer considered good markers of nutritional status and instead are considered markers of inflammation.17 In 2012, practitioners are turning toward nutrition-focused physical assessment, weight changes and poor meal intake (components of the PG-SGA) as a way to evaluate nutritional status.18

Fluid Requirements

Ensuring adequate hydration is a vital component of the nutritional care plan for patients diagnosed with cancer who are undergoing treatment. The current recommendation for daily water intake from all beverages and foods for adults ages 19 to 70 is 3.7 L (125 oz) for men and 2.7 L (90 oz) for women.19 There are several methods for determining specific fluid needs.

Fluid status should be monitored routinely by dietetic professionals with consideration of measured losses (e.g., urine, stool or drainage), alterations in fluid balance due to metabolic or treatment-induced changes (e.g., fever, vomiting or diarrhea), and medications and supportive care therapies (e.g., diuretics or infusion of IV fluids).9

In the oncology setting, patients are at risk for dehydration secondary to reduced fluid intake and/or fluid loss associated with treatment-related toxicities including anorexia, nausea, vomiting and diarrhea. Over-hydration or fluid overload can occur because of the infusion of large volumes of IV fluids, such as hydration fluids (e.g., D5W, normal saline), chemotherapy agents, parenteral nutrition and blood products (examples of calculating fluid needs are included in the case study).

Estimating Fluid Needs Method 1: RDA Method9 Fluid Needs = 1 mL fluid per 1 kcal of estimated energy needs Method 2: Body Surface Area (BSA) Method9 Fluid Needs = 1,500 mL/m2 or BSA x 1,500 mL Method 3: Age-Specific Method14 16 to 30 years (active): 40 mL/kg 31 to 55 years: 35 mL/kg 56 to 75 years: 30 mL/kg 76 years or older: 25 mL/kg


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Micronutrient Requirements The National Academy of Sciences’ Food and Nutrition Board (part of the Institutes of Medicine)

periodically published Recommended Dietary Allowances (RDA) from 1941 until 1989. RDA were intended to be used as guidelines for nutrient intake and were estimated to meet the needs of nearly all people (about 98%).

The RDA have now evolved into a combination of recommendations called the Dietary Reference Intakes (DRI), which take into consideration scientific evidence regarding nutrient intake required to prevent classic deficiencies (i.e., scurvy, rickets, pellagra), as well as intakes related to the prevention and treatment of diseases, such as cancer, cardiovascular disease and osteoporosis.20 These recommendations include Estimated Average Requirement (EAR), RDA, Adequate Intake (AI), and Tolerable Upper Intake Level (UL).

Ideally, micronutrients should come from eating a healthful diet that includes a variety of foods and sufficient energy intake to ensure adequate nutritional status and weight maintenance. This is not always possible for everyone who is diagnosed with cancer and undergoing treatment.

Micronutrient deficiencies can occur not only from the presence of cancer, but from effects of cancer treatment, such as alterations in digestion and absorption, anorexia, dehydration, vomiting and diarrhea. Other patients may present with existing nutritional deficiencies because of poor diet and lifestyle choices. Dietetic professionals should refer to the DRI/RDA recommendations when determining and recommending intake levels of micronutrients for patients during and after cancer treatment.20

Other important factors for making micronutrient recommendations above or below DRI/RDA levels include assessment of current nutritional status (e.g., need for iron supplementation secondary to iron deficiency anemia or calcium supplementation for osteoporosis prevention), medical history (including presence of comorbid diseases), laboratory analyses and current medications (e.g., vitamin K restriction secondary to anticoagulation therapy).

Dietary Supplementation

Various studies report that 25% to 80% of those diagnosed with cancer take some type of dietary supplements, including vitamins, minerals and other micronutrients.20-22 There is growing public interest in the use of these supplements in both the prevention and treatment of cancer.

Oncology clinicians and patients alike are inundated with an abundance of information in the literature from popular and professional peer-reviewed sources that pertains to cancer and micronutrients. Health experts and organizations, including the American Cancer Society, conclude that there is benefit from a standard multiple vitamin and mineral supplement that contains no more than 100% of the daily value, since it may be difficult during and after cancer treatment to consume a diet that contains adequate amounts of micronutrients.20,23

Dietetic professionals should ask patients if they are using dietary supplements and help guide them in making informed decisions about proper use, as well as alerting them to potential nutrient–drug interactions.

Summary

Determining the nutrient requirements of persons with cancer is not an exact science. Cancer and its treatment can significantly affect the ability to eat, as well as normal digestion and absorption. Energy expenditure varies with disease, age, sex, activity, body composition and inflammatory response. Estimates can be made based on a variety of published, evidence-based calculations; however, it is


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important for dietetic professionals to provide regular follow-up to determine the adequacy of those estimates.

The same holds true for protein requirements. Estimates of protein requirements are based on standard calculations, but follow-up evaluation or nitrogen balance studies are necessary to evaluate the adequacy of estimated recommendations.

Fluid status changes are common, and it is important to monitor a patient’s fluid intake and output routinely to provide adequate daily fluids based on situation and need.

Micronutrients are best obtained via a varied plant-based diet, rich in fruits and vegetables. However, some people with cancer are unable to consume an ideal diet due to treatment or disease-related side effects. In these cases, supplementation with the DV/RDA/DRI level, and not exceeding UL levels, is acceptable practice.

Case Study

MJ is a 55-year-old female with a diagnosis of colon cancer. She has undergone colon surgery and has recently completed chemotherapy. Her goal is to regain 31 lbs, as well as her strength and energy.

• Height: 5’3” (160 cm) • Current Weight: 87 lbs (39.5 kg) • Ideal Body Weight: 115 lbs (52.3 kg) • Usual Weight (6 months ago): 128 lbs (58.2 kg)

Activity Level : MJ is housebound and spends most of the day in a chair or resting, but she is

able to care for herself and perform a few chores. Continuing Nutrit ion Impact Symptoms: She continues to struggle with fatigue and

occasional episodes of diarrhea. 1 st s tep: Determine REE by using Mifflin–St. Jeor formula: REE = (10 x weight) + (6.25 x height) – (5 x age) – 161 REE = (10 x 39.5 kg) + (6.25 x 160) – (5 x 56) – 161 REE = 954 kcal 2nd step: Determine TEE by using the following formula: TEE = REE x stress factor x activity factor TEE = 954 x 1.5 x 1.3 TEE = 1860 kcal/day Estimated Daily Energy Requirement using 35 kcal /kg : 35 x 39.5 kg = 1393 kcal Estimated daily energy requirement = 1393 calories Estimated Protein Requirement using 1.5 g/kg : 1.5 g protein/kg Ideal Body Weight (IBW) 1.5 g x 52.3 kg = 78.5 g/day Estimated Fluid Requirements : Method 1: RDA/Caloric Intake-Based: 1 mL/calorie/day 1860 mL (using REE)


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Method 2: BSA-based: 1500 mL/m2

BSA = square root of 160 x 39.5 ÷ 3,600 = 1.32 Fluid requirement = 1500 x 1.32 = 1980 mL/day Method 3: Weight-based: 35 mL/kg IBW 35 x 52.3 kg = 1830 mL/day Note : Considering that MJ is still experiencing occasional episodes of diarrhea, she should be

encouraged to drink at least 240 mL or 1 cup of fluid for each diarrhea stool. The range in calorie and fluid requirements illustrates further the fact that these calculations are

merely estimates.

References 1. Schattner M, Shike M. Nutrition support of the patient with cancer. In: Shils ME, Shike M, Ross AC,

Caballero B, Cousins RJ, eds. Modern Nutrition in Health and Disease. 10th ed. Philadelphia PA: Lippincott Williams & Wilkins; 2006:1291-1313.

2. Knox LS, Crosby LO, Feurer ID, et al. Energy expenditure in malnourished cancer patients. Ann Surg. 1983;197(2):152-162.

3. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones & Bartlett; 2010:21-44.

4. Merrick HW, Long CL, Grecos GP, Dennis RS, Blakemore WS. Energy requirements for cancer patients and the effect of total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1988;12(1):8-14.

5. Hansell DT, Davis JW, Burns HJ. The relationship between resting energy expenditure and weight loss in benign and malignant disease. Ann Surg. 1986;203(3):240-245.

6. Boullata J, Williams J, Cottrell F, Hudson L, Compher C. Accurate determination of energy needs in hospitalized patients. J Am Diet Assoc. 2007;107(3):393-401.

7. Porter C, Cohen NH. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results. J Am Diet Assoc. 1996;96(1):49-57.

8. Ireton-Jones CS, Jones JD. Should predictive equations or indirect calorimetry be used to design nutrition support regimens? Predictive equations should be used. Nutr Clin Pract. 1998;13(3):141-143.

9. Russell M, Malone AM. Nutrient requirements. In: Charney P, Malone AM, eds. Nutrition Assessment. 2nd ed. Chicago, Il: Academy of Nutrition and Dietetics; 2009:167-191.

10. Harris JA, Benedict FG. A Biometric Study of Basal Metabolism in Men. Washington, D.C.: Carnegie Institute of Washington; 1919:Publication 279.

11. Frankenfield DC, Rowe WA, Smith JS, Cooney RN. Validation of several established equations for resting metabolic rate in obese and nonobese people. J Am Diet Assoc. 2003;103(9):1152-1159.

12. McClave S, Snider HL. Use of indirect calorimetry in clinical nutrition. Nutr Clin Prac. 1992;7(5):207-221. 13. Mifflin MD, St Jeor ST, Hill LA, et al. A new predictive equation for resting energy expenditure in healthy

individuals. Am J Clin Nutr. 1990;51(2):241-247. 14. Hurst JD, Gallagher AL. Energy, macronutrient, micronutrient and fluid requirements. In: Elliott L, Molseed

LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, Il: American Dietetic Association; 2006:54-71.

15. Glynn CC, Greene GW, Winkler MF, Albina JE. Predictive versus measured expenditure using limits-of-agreement analysis in hospitalized, obese patients. JPEN J Parenter Enteral Nutr. 1999;23(3):147-154.


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16. Alberda C, Snowden L, McCargar L, Gramlich L. Energy requirements in critically ill patients: how close are our estimates? Nutr Clin Prac. 2002;17(1):38-42.

17. Barbosa-Silva MC. Subjective and objective nutritional assessment methods: what do they really assess? Curr Opin Nutr Metab Care. 2008;11(3):248-254.

18. Marcason W. Malnutrition: Where do we stand in acute care? J Acad Nutr Dietetics. 2012;112(1):200. 19. Institute of Medicine. Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate.

Washington, D.C.: National Academies Press; 2005. 20. Food and Nutrition. Institute of Medicine Web site. http://www.iom.edu/Global/Topics/Food-

Nutrition.aspx. Accessed July 18, 2012. 21. Doyle C, Kushi LH, Courneya KS, et al. Nutrition and physical activity during and after cancer treatment: an

American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353. 22. Rock CL, Neuman VA, Neuhouser ML, Major J, Barnett MJ. Antioxidant use in cancer survivors and the

general public. J Nutr. 2004;134(11):3194S-3195S. 23. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA.

2002;287(23):3127-3129.


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Chapter Six: Modalities of Cancer Treatment:

Surgery, Radiation Therapy, Chemotherapy, Biotherapy, Hormone Therapy and Antiangiogenic Agents

This chapter will discuss the goals of therapies and how they are used to treat cancer. Depending on the site of the cancer and the treatment modalities prescribed, the nutrition side effects can vary considerably. This chapter will also examine the potential side effects of these therapies on nutritional status.

For supplemental information to this chapter, please review the following appendices:

Appendix 5 Nutrition Intervention for Nutrition Impact Symptoms Appendix 6 Pharmacological Management of Chemotherapy-Induced Nausea and Vomiting Appendix 7 Pharmacological Management of Anorexia and Cancer Cachexia Appendix 8 Pharmacological Management of Constipation Appendix 9 Pharmacological Management of Diarrhea Appendix 10 Pharmacological Management of Mucositis and Esophagitis (includes enteral and

parenteral nutrition) Appendix 11 Pharmacological Management of Pain Appendix 12A, 12B and 12C

Nutritional Implications of Chemotherapy, Nutritional Implications of Hormone Therapy and Nutritional Implications of Biotherapy and Antiangiogenic Agents

Appendix 13 Nutritional Implications of Surgical Oncology

onventional modalities of cancer treatment include surgery, radiation therapy, chemotherapy, hormonal therapy, biotherapy, and antiangiogenic agents. In the United States, cancer treatment is guided by evidence-based standards known as the National Comprehensive Cancer

Network (NCCN) Practice Guidelines in Oncology.1 These treatment guidelines provide oncologists (surgeons, radiation oncologists and medical oncologists) and the oncology healthcare team with cancer regimens specific to each cancer. Depending on the site of the cancer and the treatment modality(s) prescribed, the nutrition side effects can vary considerably.

Medical Nutrition Therapy

Oral nutrition is the preferred route of nutrition care; however, when mechanical obstructions to oral feeding exist or when oral intake is suboptimal, enteral nutrition support is often necessary and should be implemented early in the postoperative period.6 Only when enteral feeding is not tolerated in five to 10 days post-surgery or its use is impossible due to GI obstruction or dysfunction, is parenteral nutrition indicated to restore and maintain nutrition status.16

C

Modalities of Cancer Treatment

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Progression of an oral diet should be advanced as tolerated. A good resource for evidence-based “best practice” for providing nutrition care, including preoperative through postoperative diet progression, is the American Society of Parenteral and Enteral Nutrition’s published guidelines for the use of specialized nutrition support in hospitalized patients and guidelines for nutrition support therapy during adult cancer treatment and in hematopoietic cell transplantation17,18 These guidelines provide specific recommendations for oral, enteral and parenteral nutrition in surgical oncology patients.

Surgery Surgery can be used as the sole modality of cancer treatment, or it can be combined with

preoperative (neoadjuvant) or postoperative (adjuvant) chemotherapy and/or radiation therapy. In particular, the surgical resection or removal of any part of the oral cavity, esophagus or gastrointestinal (GI) tract — as well as the malignant process itself — can significantly impair normal digestion and absorption.

After surgery, patients commonly experience fatigue and temporary changes in appetite and bowel function caused by anesthesia and surgery-related pain. Often, additional dietary energy and protein is needed for wound healing and recovery. Most side effects are temporary and dissipate after a few days following surgery; however, some surgical interventions can have long-lasting nutritional implications. Nutritional Implications: Surgery

Identifying patients at nutrition risk and providing timely nutrition assessment and intervention before and after surgery can help reduce surgical-related morbidity and mortality, and help prevent deteriorations in nutritional status (a variety of nutrition screening and risk assessment tools were discussed in detail in Chapter Four).2 Specifically, preoperative nutrition assessment to identify patients with malnutrition or patients who are at greater risk for developing malnutrition is essential for improving surgical outcomes.3-5

McClave, et al. found that anywhere from five to 10 days of preoperative nutrition support significantly reduced postoperative complications in surgical patients.4 Provision of nutrition support in the postoperative period has also proved effective in reducing infections, length of stay and healthcare costs, as well as improving nutritional status.6 As evidenced by numerous studies, cancer patients with optimal nutritional status have been shown to experience decreased incidence of surgery-related mortality and postoperative morbidity versus patients with poor nutritional status.7-9

Nutrition implications vary with the type of surgery performed. Some cancer-related surgeries have significant impact on nutritional status immediately after surgery, as well as long-term effects.

It is important to remember that cancer is often treated with multiple modalities to achieve the most effective response to therapy.

Resumption of normal eating can sometimes be challenging for those preparing for and recovering from cancer-related surgeries. Poor appetite, weight loss and nutrient deficiencies before surgery can impact nutritional status, wound healing and immune function post-surgery. Fatigue is a common problem in all cancer surgeries. Fatigue can lead to decreased appetite (no activity to stimulate eating), as well as an inability to prepare food, which is an important issue for those recovering from surgery and cancer treatment.


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Brain Surgery There are several different types of brain tumors in adults. The most common types of brain

cancers are gliomas, including astrocytomas and glioblastoma multiformes; and non-gliomas, such as meningiomas, medulloblastomas, and neuromas. Surgery, chemotherapy and radiation therapy are used in the treatment of these tumors. There is little information in the literature addressing nutrition issues following surgery for brain tumors.

Generally, patients with brain tumors are prescribed corticosteroids to reduce swelling, intracranial pressure, nausea and vomiting.19,20 Extended use of corticosteroids can lead to weight gain, hyperglycemia, gastritis, GI bleeding and immunosuppression.21 Corticosteroids can be catabolic when taken for extended periods of time; therefore, attention to maintenance of lean body mass and functional status is important. Optimal protein intake, along with physical therapy, may help reduce symptoms of myopathy.

Cancer-related and treatment-related nausea, vomiting, loss of appetite, weight gain, GI symptoms and hyperglycemia are all issues dietetic professional should be aware of and manage accordingly. As with any surgery, optimal nutrition is essential for postoperative healing and may help to combat fatigue. Radiation therapy to the brain and the effects of chemotherapy agents such as temozolomide (Temodar) may also contribute to symptoms of nausea, vomiting, decreased appetite and fatigue 22-25

Head and Neck Surgery

Like brain tumors, head and neck cancers can involve several diagnoses and treatments. Cancers of

the oral cavity and neck include oropharyngeal, pharyngeal, base of the tongue, buccal mucosa, and upper esophagus and can include the removal of involved lymph nodes.23 Even before treatment, these cancers can present with symptoms of dysphagia, odynophagia, anorexia and weight loss. Conversely, some people may have suspicious tumors or enlarged lymph nodes discovered by a dentist or physician during a routine oral examination and may not present with any eating-related concerns.

Patients diagnosed with cancers of the head and neck who undergo cancer-related surgeries commonly experience treatment-related dysphagia, odynophagia, alterations in chewing and swallowing, xerostomia, alterations in taste and smell, impaired wound healing, anorexia, weight loss and fatigue.23,26

In addition, radiation therapy to the head and neck region and the effects of chemotherapy agents can significantly contribute to the severity and duration of side effects.23-25 Radiation therapy may be administered pre-, post- or in lieu of surgery, depending on the extent of the disease and preference of the prescribing physician.

There are many nutrition problems associated with radiation therapy of the head and neck, including the production of copious and/or thick saliva, xerostomia, taste changes, dysphagia, odynophagia, mucositis and esophagitis.25

Chemotherapy is now commonly given with radiation therapy to treat specific types of head and neck cancers before surgery. Combined therapies are administered to provide the best possible disease response and with less morbidity, and may even help to lessen the need for surgery.22,27,28 Side effects are dependent on the particular chemotherapy regimen and include, but are not limited to, nausea, vomiting, mucositis, esophagitis, diarrhea, taste changes and anorexia.29-31


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Thoracic Surgery Thoracic surgery includes procedures for cancers of the esophagus and lung, as well as removal of

involved lymph nodes. There are different implications for each of these types of surgeries.

Esophagus

Esophageal cancer can present with esophageal obstruction, dysphagia, odynophagia, reflux and subsequent weight loss. Surgery is common treatment with lower stage disease. The esophagogastrectomy involves the removal of the diseased portion of the esophagus and adjacent tissue. Surgery may lead to problems with dumping syndrome, as the stomach is typically brought up and attached to the esophageal remnant, creating a decrease in the stomach reservoir capacity.32,33 Patients almost always require jejunostomy feedings, at least temporarily while the surgical anastomoses heal.

Additionally, post-surgery, patients may experience dysphagia, odynophagia, reflux, early satiety, wound healing and fatigue. Chemotherapy is often offered as either neoadjuvant therapy (before surgery to reduce the size of the tumor) or as adjuvant therapy (after the surgery). As with chemotherapy in head and neck cancer, side effects are dependent on the treatment regimen prescribed and can include nausea, vomiting, anorexia, diarrhea, mucositis and esophagitis.29,34

Pulmonary

Depending on the type of lung cancer, its location within the lung, course of treatment, stage of

disease, comorbid conditions and control of symptoms, people with lung cancer can present with a number of nutrition impact symptoms.35 Weight loss is common, along with nausea, vomiting, anorexia and cachexia.35 Early satiety is also a problem, although often lumped together with anorexia, both in diagnosis and treatment.

Surgery causes fewer direct mechanical issues involving nutrition, although wound healing, fatigue and dyspnea are concerns.23 Therefore, postoperative healing may be problematic unless nutrition is addressed early in the perioperative phase. An additional, but rare, complication is chylothorax or chyle leak, which is a leakage of lymphatic fluid into the pleural space.8

Breast Surgery

Although one of the more common cancers, breast cancer doesn’t always present with the “typical”

nutrition-related symptoms usually associated with cancer, such as anorexia and weight loss. Symptoms are dependent on the stage of the disease, sites of metastasis, course of treatment, comorbid conditions and menopausal status of the patient.

Treatment for breast cancer commonly consists of the surgical removal of the tumor by either lumpectomy (removal of the tumor and a narrow margin around the tumor) or mastectomy (removal of the entire breast) and lymph node biopsy. To provide the most effective treatment regimen depending upon the stage of the disease, surgical intervention can be combined with radiation therapy, chemotherapy and/or hormonal manipulation.

Weight gain is frequently reported during and after breast cancer and treatment, most likely due to altered hormonal status, the effects of combined multimodality therapy, increased eating (to manage


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nausea), fatigue and physical inactivity.36-38 Demark-Wahnefried found that weight gain was more often associated with premenopausal status; positive lymph node biopsies; and higher dose, longer duration and multi-agent chemotherapy regimens.36 Maintenance of optimal nutrition, support of postoperative healing, and achieving and maintaining an optimal weight is the focus of nutrition intervention for breast cancer survivors (refer to Chapter Eight for additional information).39

Advanced breast cancer can often pose more challenging nutrition-related concerns. Bone metastases can be painful and can lead to decreased mobility and physical activity (refer to Chapter Nine for additional information).

GI Surgeries

Surgery is often the primary treatment for the majority of GI cancers. Types of GI cancers include

stomach, pancreas, liver, gall bladder, bile duct, small intestine and colorectal. Wound healing, changes in bowel habits, decreased appetite and fatigue are concerns following any of these surgeries.23

Gastr ic . Surgery is the most common treatment for lower-stage gastric cancer. To improve disease control and survival, surgery is combined with preoperative or postoperative chemotherapy and radiation therapy. Gastric surgery can lead to dumping syndrome, early satiety, maldigestion, malabsorption and subsequent nutrient deficiencies.40 Other complications include lactose intolerance, anemia, gastroparesis and osteoporosis.41

Pancreatic . The most commonly used surgery to treat cancer of the pancreas is the Whipple procedure or the pancreaticoduodenectomy. The Whipple procedure involves the removal of the head of the pancreas, a portion of the bile duct, the distal stomach and the duodenum. While surgery offers the best likelihood for cure, only 20% of patients are surgical candidates. Pancreatic surgery often requires the use of jejunostomy feedings for several weeks postoperatively. Resultant surgical complications include gastroparesis; fat malabsorption; hyperglycemia; malabsorption of vitamins A, D, E, K and B-12; and calcium, iron and zinc.42-44

Hepatic . Liver cancer resulting in hepatic resection is associated with high rates of morbidity and mortality and can cause problems with hyperglycemia, hypertriglyceridemia, encephalopathy and nutrient deficiencies.45

Gal lbladder and bi le duct . Cancer of the gallbladder is rare. Surgery can cause early satiety, malabsorption, diarrhea, steatorrhea, hyperglycemia and nutrient deficiencies.

Cholangiocarcinoma (bile duct cancer) is also rare. Surgery usually involves removal of portions of the liver and pancreas because of the bile duct’s proximity to these organs. Surgery can lead to early satiety, malabsorption, steatorrhea, diarrhea, hyperglycemia and nutrient deficiencies.

Small intest ine. Cancer of the small intestine is rare, although metastasis from other abdominal organs such as colon, pancreas, stomach, liver, ovary and appendix are more common. Surgery can cause problems with early satiety, malabsorption, hyperglycemia and nutrient deficiencies.

Colorectal . Colorectal cancer is most associated with GI symptoms.35 Presenting symptoms frequently include abdominal pain, change in bowel function, weight loss, nausea and vomiting.46 Depending on the location and extent of the tumor, bowel obstruction is not uncommon.35

Surgery is the primary treatment for cancers of the colon and rectum. Surgical treatment for colorectal cancer often requires a colostomy, depending on the location and extent of the tumor.35 If the disease has spread, chemotherapy and/or radiation therapy may be prescribed, causing additional GI problems, which may include nausea, anorexia, mucositis, esophagitis, diarrhea, constipation and taste changes.22,29,47

Immune-enhancing nutrit ional support . Of interest is the use of immune-enhancing or


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enteral nutrition support formulas for patients undergoing GI surgery in the cancer care setting.10 Immune-enhancing nutrients found in specific enteral formulas include arginine, glutamine, omega-3 fatty acids and nucleic acids. The inclusion of these nutrients in enteral nutrition formulas has been shown to reduce postoperative morbidity, reduce infections, decrease length of hospital stay and reduce patient costs.11-14

Sax reported that the use of immune-enhancing formulas was indicated orally for five to seven days before surgery and then for a minimum of five days enterally after surgery to reduce postoperative complications.12 Of note, van Bokhorst-de van der Schueren found that nine days of preoperative enteral feeding, both with and without arginine in the solution, did not significantly improve nutritional status or clinical outcome in severely malnourished head and neck cancer patients.15 They did, however, find that cancer patients given the arginine-enhanced formula tended to live longer.

Prostate Surgery For prostate cancers, new and different methods of prostate-sparing surgery are being used with or

without radiation therapy (e.g., external beam and/or brachytherapy) to lessen the complications of altered bladder, rectal and sexual function.47

Nutrition-related problems prevalent in prostate cancer are most often secondary to treatment.48,49 Of note, radical prostatectomy (removal of the entire prostate gland, seminal vesicles and portion of the bladder neck) can cause significant incontinence issues and loss of sexual potency. Diarrhea secondary to radiation therapy is not uncommon. Urinary and stool incontinence can lead to decreased food and fluid intake, as the patient attempts to decrease embarrassing situations.

Gynecological Surgery Gynecological cancer surgeries can lead to long-term problems such as bloating, gas, cramping,

constipation, ileus and bowel obstruction. Gynecological cancer treatment regimens commonly include pre- or postoperative radiation therapy and chemotherapy.22,47 Radiation Therapy

Radiation therapy uses high-energy rays (ionizing radiation) to cure, control or palliate tumor cells.47 The amount of radiation that a patient receives is measured in units called centigrays (cGys). Formerly, the term was “RADs,” for radiation-absorbed doses. In the United States, radiation therapy is usually given five days a week. Depending on the area of the body receiving treatment and the dosage required, the scheduled course of treatment is given in daily “fractions” over two to eight weeks.

Both normal cells and cancer cells are affected by radiation. Energy released from the therapeutic radiation damages the cells’ genetic material, thus stopping the growth of the targeted tissue. Side effects experienced are generally limited to the specific site or treatment field being irradiated. The reason radiation oncologists prescribe and deliver multiple treatment fractions over an extended period of time instead of giving a single treatment is to achieve maximum tumor cell kill while sparing, protecting and preserving healthy tissue.47

Most types of cancers are susceptible to radiation, although some are radioresistent. Typically, cells that are rapidly dividing are most sensitive to radiation therapy, such as cells found in tumors, bone marrow, hair follicles and the mucosal lining of the GI tract.35 To improve radiosensitivity, chemotherapy agents may be given in combination with radiation to produce a radiation-enhancing effect. Patients receiving multimodality therapy often experience more toxic side effects sooner.


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Types of radiation therapy used in cancer treatment include radiotherapy, brachytherapy and radiopharmaceutical therapy.

External Beam Radiation Therapy External beam megavoltage machines precisely deliver radiation therapy into the body in multiple

fractionated doses. Examples of radiation therapy machines include linear accelerators that generate X-rays or photons and electrons, cyclotrons that generate protons or neutrons, or cobalt-60 units that generate gamma rays. Recent advances in technology to deliver radiation therapy with extreme accuracy to a tumor (e.g., brain or spinal cord) while limiting exposure to normal tissue are stereotactic radiosurgery (also called Gamma knife) and intensity-modulated radiation therapy (IMRT).50,51

Brachytherapy Brachytherapy involves the use of sealed radioactive sources or implants (that emit beta particles or

gamma rays) directly in or near the treatment site to deliver highly localized doses of radiation.52 Examples of brachytherapy are interstitial implantation of permanent radioactive seeds for men with prostate cancer and removable intercavitary implants for women with gynecological cancer.

Radiopharmaceutical Therapy Radiopharmaceutical therapy involves the use of unsealed liquid radioactive sources that are

injected, ingested or instilled into the body.47 Examples of radiopharmaceuticals are oral iodine-131 to treat thyroid disease; IV infusions of strontium-89 or samarium-153 to treat painful bony metastases; and radioimmunotherapy, which uses injections of radiolabeled monoclonal antibodies to selectively deliver radiation therapy directly to tumor cells.

Nutritional Implications: Radiation Therapy

When used alone, acute side effects of radiotherapy generally manifest around the second or third week of treatment and usually resolve within two to four weeks after the radiation therapy has been completed. Late effects of treatment may occur several weeks, months or years after treatment. Regardless of the specific area being irradiated, common side effects of treatment include fatigue, loss of appetite, skin changes and loss of hair in the area being treated.25,53 There are, however, typical side effects experienced for the specific areas of the body being irradiated.


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Side Effects Associated with Radiation Therapy25,46,54-58

Site of Radiation Therapy Acute Effects Late Effects Central Nervous System

Brain Spinal cord

Nausea Vomiting Loss of appetite Hyperglycemia due to steroid administration Fatigue

Headache Lethargy

Head and Neck

Tongue Larynx Pharynx Oropharynx Nasopharynx Tonsils Salivary Glands

Mucositis Stomatitis Dysphagia Odynophagia Xerostomia Loss of taste Alterations of taste/smell Fatigue Loss of appetite

Salivary glands: xerostomia, fibrosis Mucosal: atrophy, dryness, ulceration Trismus Dental caries Osteoradionecrosis

Thorax Esophagus Lung Breast (if treatment field includes esophagus)

Dsyphagia Odynophagia Heartburn/reflux Fatigue Loss of appetite

Esophageal: fibrosis, stenosis, necrosis Pulmonary: dyspnea, dry cough, fibrosis, pneumonitis, Cardiac: angina upon effort, pericarditis

Abdomen/ Pelvis

GI tract GI organs Colon/rectum Reproductive organs

Nausea Vomiting Changes in bowel function: diarrhea, cramping, gas Changes in urinary function Acute colitis or enteritis Lactose intolerance Fatigue Loss of appetite

Diarrhea Malabsorption Intestinal: stricture, ulceration, obstruction, perforation, fistula Urinary: hematuria, cystitis

Chemotherapy

Chemotherapy is the use of chemical agents or medications to treat cancer. Whereas surgery and radiation are used to treat localized tumors, chemotherapy is a systemic therapy that can affect the whole body. Chemotherapy is also known as cytotoxic (cell-killing) or antineoplastic (anticancer) treatment. Chemotherapy (chemo) may be given to cure cancer, control the rate of cancer growth or to palliate symptoms of advanced disease. Chemotherapy can be used as the following:22

• A primary treatment in hematological cancers, such as leukemia and lymphoma • Single agent or in combination with other agents to achieve maximum cell kill for each

drug within a tolerated range of toxicity • An adjuvant treatment to decrease the risk of recurrence after surgery, primarily in

breast and colorectal cancer • A neoadjuvant treatment (before surgery) to improve the possibility of optimal surgery,

most commonly used in breast and colorectal cancers


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• A myeloablation treatment to obliterate bone marrow in preparation for hematopoietic cell transplant

• A radiosensitizer to enhance the response to radiation therapy • A palliative treatment for patients with incurable disease • A chemopreventive treatment to prevent cancer in high-risk people

Nutritional Implications: Chemotherapy

The action of chemotherapy is not limited to malignant cells; it affects normal cells as well. Cells of the body with rapid turnover such as bone marrow, hair follicles, mucosa of the oral cavity, esophagus and GI tract are typically the most affected. Side effects of chemotherapy are varied and depend on the treatment regimen and the patient’s stage of disease and health status. The most common nutrition-related side effects are myelosuppression, anemia, fatigue, nausea, vomiting, diarrhea, anorexia, mucositis, esophagitis, alterations in smell and taste, constipation, and early satiety or bloating.

Types and Classi f icat ions of Chemotherapy Agents Chemotherapy is the term used to describe a type of cytotoxic agent (medications that are cell

killers) used in cancer treatment.22,56 Cytotoxics kill actively reproducing cells, both normal and abnormal. These agents are classified according to their pharmacological action at various phases of the cell cycle.

Cell Cycle Phases Phase Description Duration

G0 Resting phase G1 Increased production of RNA and proteins 18–30 hours S DNA replication in preparation for cell division 18–20 hours G2

Period immediately preceding cell division/RNA and proteins are formed

2–10 hours

M Cell division 30–60 minutes


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Cytotoxic Agents Classification

Description Cell Phase Specificity

Examples

Alkylating Agents

Works on DNA to prevent cell division

Not phase-specific

Busulfan (Myleran), cisplatin (Platinol), cyclophosphamide (Cytoxan), dacarbazine (DTIC), ifosfamide (Ifex), mechlorethamine (Mustargen), melphalan (Alkeran)

Nitrosoureas

Inhibit enzymes needed in DNA repair

Not phase-specific

Carmustine (BCNU), lomustine (CeeNU)

Antimetabolites Interfere with DNA and RNA growth

S phase 5-fluorouracil (Adrucil), methotrexate (Rheumatrex), gemcitabine (Gemzar), cytarabine (Cyostar-U), fludarabine (Fludara)

Antitumor Antibiotics

• Antimicrobial/ cytotoxic • Inhibit enzymes needed in DNA

repair • Inhibit mitosis

by altering cellular

membranes

Not phase-specific

Bleomycin (Bleonoxane), dactinomycin (Cosmegen), daunorubicin (Cerubidine), doxorubicin (Adriamycin), idarubicin (Idamycin PFS)

Mitotic Inhibitors

• Plant alkaloids and natural products • Inhibit mitosis • Inhibit enzymes needed for cell reproduction

M phase

Paclitaxel (Onxol), docetaxel (Taxotere), etoposide (Etopophos), vinblastine (Velban), vincristine (Oncovin), vinorelbine (Navelbine)

Hormone Therapy Hormone therapy interferes with the body’s hormone production or action. Tumors that grow

more rapidly in the presence of certain hormones can be suppressed with the administration of anti-hormonal agents.22 Examples of cancers whose growth is under hormonal control are prostate, breast and ovarian.

Ablative hormone therapy is the surgical removal of hormone-producing glands or medical eradication, such as surgical or medical castration to treat advanced prostate cancer.

Addit ive hormone therapy, such as tamoxifen (Nolvadex) or anastrozole (Arimidex), is an anti-estrogen agent given to block estrogen to treat estrogen receptor-positive breast cancer, altering the effects of the hormone.


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Biotherapy

Biotherapy agents, biologics, biological response modifiers and immunotherapy are treatments with agents that stimulate a person’s own immune system to fight cancer. They also act as cytotoxic agents via the administration of natural substances.22,59 Biotherapy agents are often used as an adjuvant to the main therapy. Lymphocytes (B cells, T cells, natural killer cells) work with antigen-presenting cells (macrophages and dendritic cells) to attack cancer cells, much the same way antibodies fight infection or foreign substances in our bodies.

Examples of biotherapy agents include α-interferon that is used to treat hairy-cell leukemia and interleukin-2 that is used in the treatment of malignant melanoma and renal cell carcinoma. Like cytotoxics, biotherapy agents fall into different categories.

Antiangiogenic agents . Antiangiogenic agents are a type of biotherapy. These agents inhibit the development of new blood vessels needed by tumors’ vasculature. Their actions prevent tumor growth, invasion and spread, as well as help maximize the efficacy of other therapies.22

Biotherapy Agents Classification Mechanism of Action Medication Name Hemopoietic Growth Factor Stimulates growth and

differentiation of stem cells in bone marrow to increase production of red blood cells

Darbepoetin (Aranesp) Erythropoietin (Procrit)

Granulocyte Colony-Stimulating Factor (G-CSF)

Promotes proliferation and differentiation of neutrophils and enhances functional properties of mature neutrophils

Filgrastim (Neupogen) Pegfilgrastim (Neulasta)

Interferon Mechanisms of action are not clearly understood

Interferon alfa-2A Interferon alfa-2B

Binds to CD20 on B cells resulting in activation of complement-dependent cytotoxicity as well as antibody-dependent cellular toxicity dependent cytotoxicity as well as antibody-dependent cellular toxicity

Rituximab (Rituxan)

Binds to the extracellular domain of HER2, resulting in mediation of antibody-dependent cellular toxicity against cells that overproduce HER2

Trastuzumab (Herceptin)

Monoclonal Antibodies

Binds to CD20 on pre-B and mature lymphocytes and has iodine-131 attached for additional cell death

Tositumomab (Bexxar)

Tyrosine Kinase Inhibitor (TKI)

Inhibits intracellular phosphorylation of tyrosine kinase associated with EGRF with EGRF

Erlotinib (Tarceva)

Antiangiogenic Agent Inhibits development of new blood vessels

Bevacizumab (Avastin)

Management of Nutrition-related Side Effects

Chemotherapy, including hormone therapy, biotherapy, and antiangiogenic agents, can be given in combination. Side effects of combination therapies are additive, although not necessarily potentiated (see Chapter 11 for more information).


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Summary

Dietetic professionals need to understand the principles of surgery, radiation therapy, chemotherapy and biotherapy, as well as the potential nutrition-related side effects that may occur secondary to these cancer treatments before initiating nutrition intervention.

Case Studies The two case studies presented below demonstrate how nutrition intervention can be an integral

part of an individual’s cancer treatment and care. Case Study No. 1 AB is a 61-year-old female with a diagnosis of metastatic colon cancer. She underwent resection of

the affected area of the colon, not requiring a permanent ostomy. She then began FOLFOX chemotherapy (5-FU [Fluorouracil], leucovorin [Trexall], and oxaliplatin [Eloxatin]) with bevacizumab. After five cycles (10 weeks of therapy), her treatment was interrupted, and she was admitted to the hospital with uncontrollable diarrhea and dehydration.

A nutrition consult was initiated upon admission. Subsequent nutrition assessment revealed that AB had lost 10 lbs (9.4% of her pre-treatment body weight) in the past two weeks. She reported a very poor appetite, and she was afraid to eat anything for fear of having diarrhea.

The nutrition care plan included a soft diet, emphasizing intake of soluble fibers and avoiding insoluble fibers and high-fat foods. Foods with water soluble fiber content (i.e., oatmeal, bananas, cooked carrots, mashed potatoes and applesauce) were recommended in small quantities spread throughout the day (about six servings). AB was advised to avoid excess amounts of fruit juice and sugary drinks that could contribute to osmotic diarrhea. She was also advised to drink an additional cup of water for each diarrheal stool to maintain adequate hydration.

She received IV fluids, was given instructions to use anti-diarrheals and was discharged to home with follow-up with the dietitian one week after discharge. Chemotherapy was resumed after a one-week interruption. Follow-up revealed that AB was tolerating her treatment much better with the modification in diet.

Case Study No. 2

LB is a 48-year-old male with a diagnosis of human papillomavirus (HPV)-associated cancer of the

oropharynx. He had consumed two to three beers a day and smoked for more than 28 years, although he reported that he quit smoking and drinking on the day he received his cancer diagnosis. His usual weight is 170 lbs. At diagnosis, his weight was 155.5 lbs, about a 9% weight loss in the three months before his diagnosis due to difficulty with chewing and swallowing and a poor appetite. His treatment regimen consisted of concurrent head and neck radiation therapy and chemotherapy (cisplatin [Platinol-AQ]). He met with the dietitian before treatment and adamantly refused a feeding tube when offered before beginning his therapy.

The dietitian continued to meet with LB once a week during his seven-week cancer treatment to help him transition from a soft, high-calorie/high-protein diet to a full liquid, high-calorie/high-protein diet. After two and a half weeks of treatment, he was experiencing mucositis, taste changes, xerostomia


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and dysphagia. The dietitian continued to provide nutrition interventions for improving his calorie and protein intake. At three and a half weeks he was complaining of thick, ropey saliva and severe oral mucositis and odynophagia. His oral intake consisted of about two cups of raspberry sherbet per day, plus sips of ice water. He had lost another 10 lbs (weight, 145.5 lbs), bringing his total weight loss to 15% of his pre-treatment weight.

Despite his painful oral cavity and throat, WC agreed to have a percutaneous gastrostomy (PEG) feeding tube placed as an outpatient in the endoscopy department. He was started on a standard 1.5 kcal per cc enteral formula at 240 cc over six feedings per day (2,500 kcal and 100 g protein/day). Two weeks after placement of the feeding tube, WC was tolerating his feedings well and his weight stabilized. After four weeks, he had gained 1 lb. The enteral feedings were continued until WC could consume 75% of his needs orally. The dietitian continued to contact the patient after his therapy to provide nutrition recommendations. Three months after completion of cancer treatment, WC was able to meet his nutritional needs orally and the PEG tube was removed. He continued to take one to two cans of a 1.5 kcal per cc liquid meal replacement to supplement his diet.

References 1. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, 2012. NCCN

Web site. http://www.nccn.org. Accessed July 18, 2012. 2. Huhmann MB, August D. Surgical oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology

Patients. Sudbury, MA: Jones & Bartlett; 2010:101-136. 3. Corish CA. Pre-operative nutritional assessment. Proc Nutr Soc. 1999;58(4):821-829. 4. McClave SA, Snider HL, Spain DA. Preoperative issues in clinical nutrition. Chest. 1999;115(5 Suppl):64S-

70S. 5. Corish CA. Pre-operative nutritional assessment in the elderly. J Nutr Health Aging. 2001;5(1):49-59. 6. Braga M, Gianotti L, Gentilini O, et al. Early postoperative enteral nutrition improves gut oxygenation and

reduces costs compared with total parenteral nutrition. Crit Care Med. 2001;29(2):242-248. 7. Synderman CH, Kachman K, Molseed L, et al. Reduced postoperative infections with an immune-enhancing

nutritional supplement. Laryngoscope. 1999;109(6):915-921. 8. Jagoe RT, Goodship TH, Gibson GJ. The influence of nutritional status on complications after operations

for lung cancer. Ann Thorac Surg. 2001;71(3):936-943. 9. Jagoe RT, Goodship TH, Gibson GJ. Nutritional status of patients undergoing lung cancer operations. Ann

Thorac Sur. 2001;71(3):929-935. 10. Imoberdorf R. Immuno-nutrition: designer diets in cancer. Support Care Cancer. 1997;5(5):381-386. 11. Senkal M, Kemen M, Homann HH, et al. Modulation of postoperative immune response by enteral nutrition

with a diet enriched with arginine, RNA, and omega-3 fatty acids in patients with upper gastrointestinal cancer. Eur J Surg. 1995;161(2):115-122.

12. Sax HC. Effect of immune enhancing formulas (IEF) in general surgery patients. JPEN Parenter Enteral Nutr. 2004;25(2 Suppl):S19-S22.

13. Braga M, Gianotti L. Preoperative immunonutrition: cost-benefit analysis. JPEN Parenter Enteral Nutr. 2005;29(1 Suppl):S57-S61. Review.

14. Gianotti L, Braga M, Nespoli L, et al. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology. 2002;122(7):1763-1770.

15. van Bokhorst-De Van Der Schueren MA, Quak JJ, von Blomberg-van der Flier BM, et al. Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients. Am J Clin Nutr. 2001;73(2):323-332.


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16. Barrera R. Nutrition support in cancer patients. JPEN Parenter Enteral Nutr. 2002;26(5 Suppl ):S63-S71. Review.

17. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adults and pediatric patients. JPEN Parenter Enteral Nutr. 2002;26(1 Suppl):1SA-138SA.

18. August D, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN Parenter Enteral Nutr. 2010;33(5):472-500.

19. Herrstedt J, Aapro MS, Smyth JF, Del Favero A. Corticosteroids, dopamine antagonists and other drugs. Support Care Cancer. 1998;6(3):204-214.

20. Newton HB, Newton C, Pearl D, Davidson T. Swallowing assessment in primary brain tumor patients with dysphagia. Neurology. 1994;44(10):1927-1932.

21. Koehler PJ. Use of corticosteroids in neuro-oncology. Anticancer Drugs. 1995;6(1):19-33. 22. Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and Biotherapy Guidelines and Recommendations

for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009. 23. Thomas S. Nutrition implications of surgical oncology. In: Elliott L, Molseed LL, McCallum PD, Grant B, eds.

The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:94-109. 24. Grant BL. Nutritional implications of chemotherapy. In: Elliott L, Molseed LL, McCallum, PD, Grant B, eds.

The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:72- 87. 25. Luthringer SL. Nutritional implications of radiation therapy. In: Elliott L, Molseed LL, McCallum, PD, Grant B,

eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:88-93.

26. Minisian A, Dwyer JT. Nutrition implications of dental and swallowing issues in head and neck cancer. Oncology. 1998;12(8):1155-1162; discussion, 1162-1169.

27. Gokhale AS, Lavertu P. Surgical salvage after chemoradiation of head and neck cancer: complications and outcomes. Curr Oncol Rep. 2001;3(1):72-76.

28. Adelstein DJ. Integration of chemotherapy into the definitive management of squamous cell head and neck cancer. Curr Oncol Rep. 1999;1(2):97-98.

29. Karch AM, ed. Lippincott’s Nursing Drug Guide. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001. 30. Teh BS, Monga U, Thornby J, et al. Concurrent chemotherapy and “concomitant boost” radiotherapy for

unresectable head and neck cancer. Am J Otolaryngol. 2000;21(5):306-311. 31. Urba SG, Wolf GT, Bradford CR, et al. Neoadjuvant therapy for organ preservation in head and neck

cancer. Laryngoscope. 2000;110(12):2074-2080. 32. McLarty AJ, Deschamps C, Trastek VF, et al. Esophageal resection for cancer of the esophagus: long-term

function and quality of life. Ann Thorac Surg. 1997;63(6):1568-1572. 33. Metzger J, Degen L, Beglinger C, von Flüe M, Harder F. Clinical outcome and quality of life after gastric

and distal esophagus replacement with an ileocolon interposition. J Gastrointest Surg. 1999;3(4):383-388. 34. I lson DH, Forastiere A, Arquette M, et al. A phase II trial of paclitaxel and cisplatin in patients with advanced

carcinoma of the esophagus. Cancer J. 2000;6(5):316-323. 35. Berkow R, ed. The Merck Manual of Medical Information. New York: Pocket Books; 2000. 36. Demark-Wahnefried W, Rimer BK, Winer EP. Weight gain in women diagnosed with breast cancer. J Am

Diet Assoc. 1997;97(5):519-526. 37. Harvie MN, Campbell IT, Baildam A, Howell A. Energy balance in early breast cancer patients receiving

adjuvant chemotherapy. Breast Cancer Res Treat. 2004;83(3):201-210. 38. Herman DR, Ganz PA, Petersen L, Greendale GA. Obesity and cardiovascular risk factors in younger breast

cancer survivors: The Cancer Menopause Study (CAMS). Breast Cancer Res Treat. 2005;93(1):13-23.


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39. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.

40. Koike H, Misu K, Hattori N, et al. Postgastrectomy polyneuropathy with thiamine deficiency. J Neurol Neurosurg Psychiatry. 2001;71(3): 357-362.

41. Takahashi S, Maeta M, Mizusawa K, et al. Long-term postoperative analysis of nutritional status after limited gastrectomy for early gastric cancer. Hepatogastroenterology. 1998;45(21):889-894.

42. Martignoni ME, Friess H, Sell F, et al. Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection. Am J Surg. 2000;180(1):18-23.

43. Ong HS, Ng EH, Heng G, Soo KC. Pancreaticoduodenectomy with pancreaticogastrostomy: assessment of patients nutritional status, quality of life and pancreatic exocrine function. Aust N Z J Surg. 2000;70(3):199-203.

44. Sugiyama M, Atomi Y. Pylorus-preserving total pancreatectomy for pancreatic cancer. World J Surg. 2000;24(1):66-70.

45. Wong PW, Enriquez A, Barrera R. Nutrition support in critically ill patients with cancer. Crit Care Clin. 2001;17(3):743-767.

46. Majumdar SR, Fletcher RH, Evans AT. How does colorectal cancer present? Symptoms, duration, and clues to location. Am J Gastroenterol. 1999;94(10):3039-3045.

47. Watkins Bruner D, Haas ML, Gosselin-Acomb TK, eds. Manual for Radiation Oncology Nursing Practice and Education. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2005.

48. Adolfsson J, Hegalson AR, Dickman P, Steineck G. Urinary and bowel symptoms in men with and without prostate cancer: results form an observational study in the Stockholm area. Eur Urol. 1998;33(1):11-16.

49. Beard CJ, Lamb C, Buswell L, et al. Radiation-associated morbidity in patients undergoing small-field external beam irradiation for prostate cancer. Int J Radiat Oncol Biol Phys. 1998;41(2):257-262.

50. Boyer AL, Mok E, Luxton G, et al. Quality assurance for treatment planning dose delivered by 3DRTP and IMRT. In: General Practice of Radiation Oncology Physics in the 21st Century. Shui AS, Mellenberg DE, eds. Madison, WI: Medical Physics Publishing; 2000:187-230.

51. Wulf J, Hadinger U, Oppitz U, Olshausen B, Flentje M. Stereotactic radiotherapy of extrcranial targets: CT-simulation and accuracy of treatment in the stereotactic body frame. Radiother Oncol. 2000;57(2):225-236.

52. Van Dyk J. The Modern Technology of Radiation Oncology. Madison, WI: Medical Physics Publishing, 1999. 53. Minsky BD, Cohen AM. Minimizing the toxicity of pelvic radiation therapy in rectal cancer. Oncology.

1988;2(8):21-25, 28-29. 54. Backstrom I, Funegard U, Anderson I, Franzén L, Johansson I. Dietary intake in head and neck irradiated

patients with permanent dry mouth symptoms. Eur J Cancer B Oral Oncol. 1995;31B(4):253-257. 55. Donner CS. Pathophysiology and therapy of chronic radiation-induced injury to the colon. Dig Dis.

1998;16(4):253-261. 56. Grant BL, Hamilton KK. Medical nutrition therapy for cancer prevention, treatment, and recovery. In: Mahan

LK, Escott-Stump S, Raymond JL, eds. Krause’s Food and the Nutrition Care Process. 13th ed. Chicago, IL: Elsevier; 2012:832-863.

57. Husebye E, Hauer-Jensen M, Kjorstad K, Skar V. Severe late radiation enteropathy is characterized by impaired motility of proximal small intestine. Dig Dis Sci. 1994;39(11):2341-2349.

58. Zimmerman FB, Geinitz J, Feldman HJ. Therapy and prophylaxis of acute and late radiation-induced sequelae of the esophagus. Strahlenther Onkol. 1998;174(Suppl 3):78-81.

59. Baquiran DC, Gallaher J. Cancer Chemotherapy Handbook. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

Hematopoietic Cell Transplantation Overview and Nutritional Care

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Chapter Seven:


This chapter will discuss the hematopoietic cell transplantation process, nutrition management, acute treatment-related side effects and complications, and long-term side effects and complications.

For supplemental information to this chapter, please review the following appendices: Appendix 1 Diet Guidelines for Gastrointestinal Diet 1 and Diet 2 Appendix 2 Diet Guidelines for Immunosuppressed Patients Appendix 14 Complications of Enteral Feeding

ematopoietic cell transplantation (HCT) is the IV infusion of healthy hematopoietic stem cells that have been harvested from the peripheral blood or bone marrow into the person receiving the transplant. The goal of HCT is to replace malignant and defective marrow and to restore

normal hematopoiesis and immunologic function. HCT is a common treatment modality for hematologic malignancies such as leukemia, lymphoma, multiple myeloma and nonmalignant blood diseases including aplastic anemia, and autoimmune, congenital, and immunological disorders.

Hematopoietic Cell Transplants

There are four different types of bone marrow transplants: autologous (self) transplant or autograft, allogeneic transplant or allograft, reduced-intensity stem cell transplant (nonmyeloablative), and syngeneic transplant.

Autologous (sel f) transplant or autograft : Patients receive a transplant of their own stem cells.

Al logeneic transplant or a l lograft : Patients receive stem cells from a related family member, unrelated donor or cord blood unit. Donor cells are matched as closely to the patient’s as possible to decrease the likelihood of rejection. Individuals have different sets of proteins called human leukocyte-associated antigens (HLA) on the surface of their cells. This set of cells determines a person’s HLA type, which can be identified through a blood test. Siblings and parent-child HLA types usually make the closest matches, but unrelated donors are also used in allografts. To locate suitable unrelated donors or cord blood units for patients requiring transplants without compatible related family members, the National Marrow Donor Program operates a marrow and blood cell registry.1

Reduced intensity stem cel l transplant (nonmyeloablative) : Currently under investigation in clinical trials, this type of transplant is very similar to an allogeneic transplant where stem cells are harvested from a healthy individual; however, the chemotherapy or radiation therapy

H


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given is reduced. This type of transplant may be a better option for individuals who may not be able to tolerate more intensive types of allogeneic transplants, such as older adults, people with comorbid diseases and people with less aggressive cancers.2

Syngeneic transplant : Individuals receive stem cells from a genetically identical twin.

HCT Process

Harvest of Stem Cells Stem cells are obtained from bone marrow or peripheral blood. If stem cells are collected from the

bone marrow, the cells are harvested under general or local anesthesia. A large bore needle is inserted to aspirate marrow, usually in the hip bone. The procedure takes about an hour, and there are no significant problems for the donor with the exception of soreness at the harvest site and fatigue. The donor’s bone marrow is replenished by his or her own body within a few weeks after the procedure.

After harvesting, the bone marrow is processed to remove blood and bone fragments and then put into a preservative and, in some cases, frozen for later use. When patients donate their own marrow (autograft), the marrow is “purged” or treated with anticancer drugs to rid it of any potential cancerous cells.3

Stem cells can also be harvested from the bloodstream. A process called apheresis (or leukapheresis) is used to obtain stem cells from peripheral blood, where the supply is not nearly as plentiful as in bone marrow. For four or five days prior to apheresis, the donor is given medications to increase the number of stem cells in the bloodstream. In apheresis, blood is removed via a central venous catheter or peripheral line in a large vein in the arm.4 The blood goes through a machine that removes the stem cells and then is returned to the patient. The process takes about four to five hours and causes little discomfort, although lightheadedness, chills, numbness around the lips, and cramping in the hands may be experienced. Medication given prior to apheresis may cause bone and muscle aches, headaches and difficulty sleeping, although these usually subside within a few days of the last dose of the medication.

As with stem cells taken from bone marrow, peripheral blood stem cells are put into a preservative and may be frozen for later use. Stem cells that are used for an autograft are “purged” with anticancer drugs. There is some evidence to suggest that there may be advantages to peripheral blood stem cell transplants (PBSCT) over bone marrow transplants (BMT), in that blood cell recovery may be quicker and there may be less incidence of leukemia relapse.5 Umbilical cord blood can be obtained after birth; these stem cells are separated and can be frozen for later use.

Preparation for Transplant Prior to the infusion of donated or “purged” stem cells, the patient’s own diseased bone marrow

must be destroyed. Two types of preparative regimens or conditioning regimens are used to ablate bone marrow:6,7

• Myeloablative : An HCT conditioning regimen that involves several days of chemotherapy with or without total body irradiation (TBI).

• Nonmyeloablat ive : An HCT conditioning regimen where the patient receives lower and less toxic doses of chemotherapy with or without radiation therapy (also called mini-transplant, transplant-lite, or mixed chimera).8-12


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There is increasing use of nonmyeloablative transplants, which are typically used for patients who are older or unable to withstand the more intense treatments.8-12 Although lower dosages of chemotherapy and radiation therapy may leave some malignant cells behind, the therapeutic rationale is that the donor’s white blood cells will more effectively attack and kill the cancer cells. Infusions of the donor’s white blood cells can magnify this reaction or even put a relapsed patient back into remission. This phenomenon is referred to as the graft-versus-leukemia or graft-versus-tumor effect and is more often seen in slowly progressing diseases, such as chronic myelogenous leukemia, low-grade lymphoma, chronic lymphocytic leukemia and multiple myeloma.3

The effects of conditioning regimens range from mild to severe and commonly include many medical and nutritional concerns such as tumor lysis, nausea, vomiting, diarrhea, hair loss, fatigue, bladder irritation, loss of appetite and mouth sores.13

Transplantation and Engraftment A few days after chemotherapy and radiation therapy have been administered, the stem cells are

infused, very much like a blood transfusion, through a venous access device (e.g., port-a-cath). The patient is closely monitored for signs of fever, chills, hives and chest pains during the infusion. Those who receive allografts are given immunosuppressive drugs to help prevent rejection of the donor cells. In addition, they also receive supportive therapy such as total parenteral nutrition, antibiotics, antifungal agents, red blood cell transfusions and platelet transfusions during the first several weeks to combat the side effects of the treatment.

Engraftment occurs after the newly transplanted stem cells find their way into the patient’s bone marrow and begin to produce new white blood cells, followed by platelets and, later, red blood cells. If a patient has received a peripheral stem cell transplant, engraftment usually occurs within the first two weeks after the transplant.13 For a patient receiving a transplant with stem cells taken from the bone marrow, engraftment usually takes place within two to four weeks after transplant.

Patients are often kept in protective isolation and may be placed in rooms with special ventilation/filtration of air due to treatment-related neutropenia and immunosuppression. White blood cell counts are monitored frequently post-transplant to monitor for signs of engraftment.3

Nutrition assessment should begin during the pretransplant period and then continue throughout the transplantation and recovery process.14 Charuhas states that the nutrition assessment should include a comprehensive evaluation of the patient’s nutrition history, anthropometric parameters, functional and performance status, blood chemistries, comorbidities, prior therapy and current medications (see Chapter Five for more information).15

Nutritional Implications of HCT

Oral intake is the preferred route of nutrition care; however, enteral nutrition support is indicated

for those unable to consume adequate oral intake, or for patients who are malnourished.14 Enteral nutrition is often given to those undergoing nonmyeloablative conditioning regimens to ensure that estimated nutritional needs are being met.

Parenteral nutrition (PN) support is commonly given immediately post-transplant for patients receiving more rigorous myeloablative conditioning regimens where more intense and acute oral, GI and organ-toxic side effects are anticipated; and energy, protein and fluid requirements are increased.16,17 The Academy of Nutrition and Dietetics’ Evidence Analysis Library guidelines for PN


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following HCT recommends this route of nutrition support only be used in select patients because of the lack of significant improvement in nutritional status, and the increased risks of complications and increased costs.18 The American Society of Parenteral and Enteral Nutrition’s evidence-based clinical guidelines for nutrition support during adult cancer treatment and in HCT also recommend that nutrition support is appropriate for those who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrition for a prolonged period of time.14 These clinical guidelines also state that when PN is used, it should be discontinued as soon as treatment-related toxicities have resolved after HCT (see Chapter Ten for more information). Side Effects and Complications of HCT

Conditioning regimens and stem cell transfusions have considerable oral, GI, infectious or organ-

toxic side effects that can affect oral intake and nutritional status.15 Side effects can be immediate and short-term, while others are late-occurring and/or chronic.

Acute Side Effects and Complications of HCT15,19-26

Oral and GI Complications Mucositis • Taste alterations • Candidiasis

Infectious Complications Immunosuppression, specifically, neutropenia (decreased white blood cell count) puts patients at greater risk of infection (e.g., bacterial, viral, fungal). Individuals should be instructed to follow a diet for immunosuppressed patients to reduce risk of foodborne illness. Handwashing and safe food handling, preparation and storage are imperative.

Organ Toxicity Liver Complications Sinusoidal obstructive syndrome (SOS), also known as veno-

occlusive liver disease, is a common problem in the first month posttransplant. The blood vessels in the liver become swollen and obstructed, impairing the liver’s ability to remove toxins and waste from the bloodstream. It can cause fluid retention in the liver, abdomen and extremities; a swollen, tender liver; or in severe cases, encephalopathy.

Renal Complications Impaired renal function can be related to the conditioning regimens, medications, hemolytic syndromes, SOS and sepsis

Other Organ System Complications

Respiratory Cardiac Urinary

Other long-term side effects and complications include chronic hypomagnesia, chronic viral

hepatitis, fungal liver disease, cataracts, infertility, bone damage and respiratory complications.26


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Graft-versus-Host Disease Graft-versus-host disease (GVHD) is the result of the donor’s white blood cells (graft) recognizing

the cells in the recipient’s body (host) as foreign and attacking the tissues and organs. GVHD can manifest in two ways: acute GVHD, which develops in the first three months after transplant; and chronic GVHD, which develops approximately 70 days post-transplant.13,27 GVHD can affect the skin, eyes, GI tract, lungs and liver. Although anti-rejection drugs are helpful in treating GVHD, their side effects can be severe and even life-threatening.28,29 A “benefit” of GVHD is that the donor’s cells will also attack any cancerous cells remaining after chemotherapy and radiation therapy. It is often said on the nursing floor that if a patient can survive severe GVHD, the chances of long-term survival are greatly improved.

Because corticosteroids are used long term to treat chronic GVHD, some patients may develop osteoporosis.15,30 Patients are advised to supplement with calcium and vitamin D to prevent and/or manage this late effect of transplant.

GVHD of the gut may affect any or all of the alimentary tract or the liver, where it attacks the small bile ducts, interfering with the flow of bile from the liver to the intestines.31 The role of the dietetic professional is very important in the care of the patient with GVHD affecting the alimentary tract. Mucositis and diarrhea can prevent patients from having an adequate oral intake. In fact, patients with severe diarrhea are unable to take anything by mouth and receive all of their nutrition parenterally. Nutrition-related consequences include weight gain, weight loss, oral sensitivity, xerostomia, stomatitis, anorexia, reflux and diarrhea.16,32

The GVHD diet, like the neutropenic diet, varies from institution to institution, but is based on research and best clinical practice at Seattle Cancer Care Alliance (SCCA), formerly the Fred Hutchinson Cancer Research Center. Initially, patients are given nothing by mouth and receive parenteral nutrition, which allows the gut to rest. When diarrhea resolves, patients may begin the Gastrointestinal (GI) 1 diet. Foods are added slowly (i.e., one new food per feeding, as tolerated). If able to progress through the GI 1 Diet, patients may advance to the GI 2 diet, as tolerated individually. GI 1 diet begins with the typical BRAT (bananas, rice, applesauce and toast) diet with low osmolality beverages and gradually progresses to the GI 2 diet, which includes small, frequent feedings of a low-fat, low-fiber, low-lactose diet that is low in GI irritants.

Food Safety and the Neutropenic Diet

Patients who are neutropenic or have low WBC — specifically an absolute neutrophil count (ANC) of less than 500 mm — are at risk for infection from normally harmless bacteria found in and on foods. Neutropenic precautions include thorough handwashing, good personal hygiene and protective protocols eliminating potential sources of infection. To highlight the importance of good hygiene, the Oncology Nursing Society’s evidence-based guidelines for improving oncology patient outcomes state that one of the most effective measures for helping to prevent infection for people with cancer at risk for neutropenia is good hand hygiene using soap and water or an antiseptic hand rub.33

To help prevent infection, a neutropenic “safe food” or low microbial diet is used in most institutions, although exact guidelines vary from institution to institution.

The SCCA is considered one of the world’s leading centers in HCT; many institutions pattern their nutrition care practices after SCCA. In general, the diet eliminates potential sources of dietary pathogens.


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The “Safe Food” or Neutropenic Diet24 Do NOT eat the following foods • Unpasteurized dairy products

• Cheeses from delis • Cheeses with mold (e.g., bleu, Roquefort or gorgonzola) • Mexican-style soft cheeses (e.g., queso fresco or queso blanco) • Raw or undercooked meats, eggs • Meats or cold cuts from delis • Uncooked seafood (e.g., lox, smoked, jerky or kippered) or pickled fish

• Unwashed raw fruits and vegetables • Unpasteurized fruit and vegetable juices • Raw vegetable sprouts (e.g., alfalfa, mung bean or any others)

• Salads from delis • Salad dressings from the grocer's refrigerator case • Raw or non-heat treated honey • Raw grain products (e.g., raw oats) not baked or cooked • Unrefrigerated cream-filled pastry products (not shelf-stable) • Unroasted nuts or nuts in the shell • All miso products • Uncooked brewer’s yeast • Untested and unboiled well water • Sun tea or yerba mate tea • All herbal and dietary supplements (without physician approval)

Summary

Stem cells may be transplanted from an HLA-matched donor, preferably a sibling, parent or child, or from the patient’s own cells that have been treated with ablative drugs to rid them of cancerous cells. HCT from bone marrow or from peripheral blood can be a life-saving procedure, but has serious and life-threatening side effects and possible long-term complications. Nonmyeloablative transplants offer specific patients good results with fewer and/or milder side effects than traditional transplants using high-dose chemotherapy and radiation therapy. Nonetheless, caring for patients receiving HCT can be a challenge for dietetic professionals.

Resources The Leukemia and Lymphoma Society, Inc. www.leukemia.org The National Cancer Institutes’ Physician Data Query (PDQ) www.cancer.gov/cancerinfo/pdq/treatment

Case Study

HH is a 32-year-old female with acute lymphocytic leukemia. She achieved remission after induction chemotherapy and then relapsed. The second course of treatment included high-dose marrow ablative chemotherapy followed by allogeneic stem cell rescue. HH required hospitalization after receiving her chemotherapy secondary to severe neutropenia.


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Side effects from the high-dose marrow ablative chemotherapy included myelosuppression, severe nausea and vomiting, anorexia, mucositis, esophagitis and xerostomia. Calorie counts revealed that HH was only taking about 150 kcal/day and, therefore, total parenteral nutrition (TPN) was initiated one week after initiation of conditioning chemotherapy regimen. HH preferred “not to see food,” so she did not receive the Diet for Immunosuppressed Patients typically given to patients who are neutropenic.

After about three weeks she wanted to try to eat again so a mechanical soft/low microbial diet was started (her mouth and throat were still a little tender), and continuous calorie counts were recorded. About six weeks post-transplant, her oral intake met about 50% of her needs and TPN was cut in half. One week later TPN was stopped (she was meeting 70% of her needs orally). She was meeting about 75% of her needs orally when discharged a week later.

Her weight never appreciably decreased during hospitalization (it initially increased due to hydration accompanying chemotherapy). As she was weaned from TPN and resumed normal hydration by mouth, her weight decreased about 5 lbs (4% of her usual weight).

Her two-week follow-up appointment revealed that her oral intake was increasing gradually, and she was consuming more protein than she had been previously. Her weight had decreased another 2 lbs. She was interested in liquid nutritional supplements, so she was provided with several samples, as well as tips to boost calories and protein in the foods she was able to eat.

At her next follow-up two weeks later, she had nearly resumed her normal intake, and her weight had stabilized. She wanted to regain strength and tone more than the weight she had lost during treatment. A consultation for strength training with the physical therapist was ordered, and HH continued her current diet.

References 1. National Marrow Donor Program. National Marrow Donor Program Web site. www.marrow.org. Accessed

July 19, 2012. 2. Stem cell transplantation. Leukemia and Lymphoma Society Web site.

www.lls.org/#/diseaseinformation/managingyourcancer/treatmentnextsteps/typesoftreatment/stemcelltransplantation/. Accessed July 19, 2012.

3. Physician Data Query (PDQ) Cancer Information Summaries: Adult Treatment. National Cancer Institute Web site. www.cancer.gov/cancerinfo/pdq/treatment. Accessed July 19, 2012.

4. Johansson E, Sollen Hansson A, Nilsson AS, Engervall P. Vascular access devices used during harvest of peripheral blood stem cells: high complication rate in patients with a long-term dialysis central venous catheter. Bone Marrow Transplant. 1999;24(7):793-797.

5. Ke X, Yang Y, Zhao X, Wang L. Autologous peripheral blood stem cell transplantation in the patients with hematologic malignancies and solid tumors. Chin Med J. 2001;114(2):196-199.

6. Gopal R, Ha CS, Tucker SL, et al. Comparison of two total body irradiation fractionation regimens with respect to acute and late pulmonary toxicity. Cancer. 2001;92(7):1949-1958.

7. Gutierrez-Delgado F, Maloney DG, Press OW, et al. Autologous stem cell transplantation for non-Hodgkin’s lymphoma: comparison of radiation-based and chemotherapy-only preparative regimens. Bone Marrow Transplant. 2001;28(5):455-461.

8. Bhatia V, Porter DL. Novel approaches to allogeneic stem cell therapy. Expert Opin Biol Ther. 2001;1(1):3-15.

9. Feinstein L, Sandmaier B, Maloney D, et al. Nonmyeloablative hematopoietic cell transplantation. Replacing high-dose cytotoxic therapy by the graft-versus-tumor effect. Ann N Y Acad Sci. 2001;938:328-337; discussion 337-339.

10. Mossad SB, Avery RK, Longworth DL, et al. Infectious complications within the first year after


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nonmyeloablative allogeneic peripheral blood stem cell transplantation. Bone Marrow Transplant. 2001;28(5):491-495.

11. Khoury H, Adkins D, Brown R, et al. Low incidence of transplantation-related acute complications in patients with chronic myeloid leukemia undergoing allogeneic stem cell transplantation with a low-dose (550 cGy) total body irradiation conditioning regimen. Biol Blood Marrow Transplant. 2001;7(6):352-258.

12. McSweeney PA, Niederwieser D, Shizuru JA, et al. Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood. 2001;97(11):3390-3400.

13. Stronach K, Dohan MC. Survivor’s guide to bone marrow transplantation. In: Rosenbaum EH, Rosenbaum I. Everyone’s Guide to Cancer Supportive Care: A Comprehensive Handbook for Patients and Their Families. Kansas City, MO: Andrews McMeel Publishing; 2005:51-80.

14. August D, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenteral Enteral Nutr. 2009;33(5):472-500.

15. Charuhas PM. Medical nutrition therapy in hematopoietic cell transplantation. In: Elliott L, Molseed LL, McCallum PD, Grant B. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:126-137.

16. Robien K. Hematological malignancies. In: Marian M, Roberts S. Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones & Bartlett; 2010:297-319.

17. Seattle Cancer Care Alliance. Hematopoietic Stem Cell Transplantation Nutrition Care Criteria. 2nd ed. Seattle, WA: Seattle Cancer Care Alliance; 2002.

18. American Dietetic Association. Oncology Evidence-based Nutrition Practice Guideline. Chicago, IL: American Dietetic Association; 2007.

19. Herget-Rosenthal S, Uppenkamp M, Beelen D, Kohl D, Kribben A. Renal complications of high-dose chemotherapy and peripheral blood stem cell transplantation. Nephron. 2000;84(2):136-141.

20. Jules-Elysee K, Stover DE, Yahalom J, White DA, Gulati SC. Pulmonary complications in lymphoma patients treated with high-dose therapy autologous bone marrow transplantation. Am Rev Respir Dis. 1992;146(2): 485-491.

21. Koc S, Hagglund H, Ireton RC, et al. Successful treatment of severe hemorrhagic cystitis with cystectomy following matched donor allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 2000;26(8):899-901.

22. Nieto Y, Cagnoni PJ, Bearman SI, et al. Cardiac toxicity following high-dose cyclophosphamide, cisplatin, and BCNU (STAMP-I) for breast cancer. Biol Blood Marrow Transplant. 2000;6(2A):198-203.

23. NosariA, Oreste P, Cairoli R, et al. Invasive aspergillosis in haematological malignancies: clinical findings and management for intensive chemotherapy completion. Am J Hematol. 2001;68(4):231-236.

24. Diet guidelines for immunosuppressed patients. Seattle Cancer Care Alliance Web site. http://www.seattlecca.org/client/documents/practical-emotional-support%5CHSC-Diet-Immunosuppressed-Patients-032508.pdf. Accessed July 19, 2012.

25. Takahata M, Hashino S, Izumiyama K, et al. Cyclosporin A-induced encephalopathy after allogeneic bone marrow transplantation with prevention of graft-versus-host disease by tacrolimus. Bone Marrow Transplant. 2001;28(7):713-715.

26. Trisolini R, Stanzani M, Agli L, et al. Delayed non-infectious lung disease in allogeneic bone marrow transplant recipients. Sarcoidosis Vasc Diffuse Lung Dis. 2001;18(1):75-84.

27. Stewart BL, Storer B, Storek J, et al. Duration of immunosuppressive treatment for chronic graft-versus-host disease. Blood. 2004;104:3501-3506.


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28. Nash RA, Antin JH, Karanes C, et al. Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors. Blood. 2000;96(6):2062-2068.

29. Mollee P, Morton AJ, Irving I, et al. Combination therapy with tacrolimus and anti-thymocyte globulin for the treatment of steroid-resistant acute graft-versus-host disease developing during cyclosporine prophylaxis. Br J Haematol. 2001;113(1):217-223.

30. Stern JM, Chesnut CH III, Bruemmer B, et al. Bone density loss during treatment of chronic GVHD. Bone Marrow Transplant. 1996;17(3):395-400.

31. Hill GR, Ferrara JL. The primacy of the gastrointestinal tract as a target organ of acute graft-versus-host disease: rationale for the use of cytokine shields in allogeneic bone marrow transplantation. Blood. 2000;95(9):2754-2759.

32. Lenssen P, Sherry ME, Cheney CL, et al. Prevalence of nutrition-related problems among long-term survivors of allogeneic marrow transplantation. J Am Diet Assoc. 1990;90(6):835-842.

33. Zitella L, Holmes B, O’Leary C. PEP card: prevention of infection. In: Eaton LH, Tipton JM, eds. Putting Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:267-283.


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Chapter Eight Surviving Cancer: Nutritional Care

This chapter will focus on patients who are recovering from cancer treatment and those who are living after recovery.

For supplemental information to this chapter, please review the following appendices: Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms

he American Cancer Society (ACS) defines a cancer survivor as “anyone who has been diagnosed with cancer, from the time of diagnosis through the rest of life.”1 This includes individuals just diagnosed and receiving cancer treatment, those recovering from treatment, those post-recovery

and disease-free, and those with advanced disease. As discussed in Chapter One, more than 12 million Americans are cancer survivors, and the survival rate for living more than five years after cancer diagnosis is now 67%.2 Cancer survivors represent one of the largest groups of people living with a chronic illness in the United States. The ACS describes cancer survivorship in the terms of four distinct phases: treatment, recovery from treatment, living after recovery and living with advanced cancer.3

What Is a Survivorship Care Plan?

The Institute of Medicine (IOM) Report, “From Cancer Patient to Cancer Survivor: Lost in Transition” recommends that every cancer survivor and his or her primary healthcare provider receive a written comprehensive care summary and follow-up plan once cancer treatment is completed.4 The National Coalition for Cancer Survivorship, the Lance Armstrong Foundation, the American Society of Clinical Oncology and the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics support the use of a survivorship care plan for identifying and addressing post-treatment needs, and for ultimately improving health and quality of life.

At a minimum, elements of a survivorship care plan should include: • The likely course of recovery from treatment toxicities, as well as the need for ongoing

health maintenance/adjuvant therapy. • Information on possible signs of late and long-term effects of treatment and symptoms

of such effects. • Information on possible signs of recurrence and second primary cancers. • Specific recommendations for healthy behaviors (e.g., diet, exercise, healthy weight,

osteoporosis prevention and smoking cessation). • Referrals to specific follow-up care providers, support groups and/or the primary

healthcare provider. The Academy of Nutrition and Dietetics’ Oncology Toolkit outlines survivorship care plan

templates for dietetic professionals working with survivors of breast, colorectal, esophageal, gastric,

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head and neck, hematologic malignancy, and prostate cancers.5 Each template provides a framework to document survivors’ medical nutrition therapy care summary, dietary supplement use, integrative therapy use, and nutrition and lifestyle goals.

Recovery from Treatment

After cancer treatment has been completed, the next phase of cancer survival is recovery. The symptoms and side effects of treatment that affect nutrition and physical well-being begin to diminish and resolve.3 Generally, most acute effects of treatment diminish within a few weeks after completing cancer therapy, while chronic effects may persist, and late effects may occur several weeks, months or even years after treatment.

During treatment, some cancer survivors experience loss of weight and lean body mass (muscle), while others gain weight and adipose tissue. Examples of lingering effects of cancer treatment that affect nutritional status and physical well-being include:

• Continued anorexia and poor nutrition intake • Continued taste and smell alterations • Continued myelosuppression and anemia • Persistent fatigue • Peripheral neuropathy (numbness and tingling of fingers and/or toes) that limits the

ability to be physically active The primary nutrition goals for recovery are to achieve/maintain a healthy body weight; replenish

lean body mass; improve strength and functional ability; stabilize and correct problems, such as anemia or impaired organ functioning; and most important, proactively manage treatment-related side effects.3 Many cancer survivors who are unable to consume adequate nutrition intake because of continuing side effects will require ongoing nutrition care and guidance (see Chapters Four and Eleven for more information).

Nutrition Counseling The emphasis of nutrition counseling should focus on strategies for not only preventing cancer

recurrence (secondary prevention), but guidance for preventing second primary cancers and other chronic diseases, as well as managing continuing and/or late effects of treatment.3

Convincing evidence exists that cancer survivors are at greater risk for developing secondary cancers, as well as chronic diseases such as cardiovascular disease, diabetes and osteoporosis.6-8 It is prudent to assist cancer survivors with making informed decisions regarding nutrition and lifestyle changes that include obtaining and maintaining an appropriate body weight, eating a healthful diet and engaging in regular physical activity.

Body Weight Implications Evidence supports that overweight and obesity are risk factors for developing cancer at specific

sites (e.g., postmenopausal breast, prostate, colorectal, esophagus, liver, pancreas, leukemia and lymphoma), thus many individuals are overweight or obese at the time of diagnosis.9 There is increasing evidence that being overweight or obese increases the risk of cancer recurrence and reduces the likelihood of survival after cancer diagnosis.10,11


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Body Mass Index (BMI) and Health Risk12 Risk Weight Classification BMI Range (kg/m2) — Underweight < 19

Minimal Normal Weight 19–24 Low to Moderate Overweight 25–30 High Obesity, Class I 30–34 Very High Obesity, Class II 35–39 Extremely High Extreme Obesity, Class III +40

Plant-based Diet

It is likely that the synergistic effect of the nutrients and phytochemicals in a low-fat, plant-based

diet provide protection from disease. It is prudent to advise survivors to get nutrients and phytochemicals from a variety of vegetables, fruits and grains, if possible, rather than from dietary supplements.3,13 A plant-based diet is generally low in fat, particularly saturated fat. Such a diet may provide protection against breast, colorectal and prostate cancers, although evidence is not conclusive.14,15 Nonetheless, a low-fat, plant-based diet helps prevent cardiovascular disease and obesity.

Dietary Supplement Use

Whether to feel better, to treat a symptom or even if it is medically directed to correct a

micronutrient deficiency (e.g., iron supplementation for iron deficiency anemia), evidence suggests that between 25% and 80% of all cancer survivors use dietary supplements.3,16,17

Cancer survivors benefit from a multiple vitamin and mineral supplement that contains no more than 100% of the Daily Value, as cancer treatment makes it difficult to consume a nutritionally adequate diet.3,18 Use of a multiple vitamin and mineral supplement can help ensure that micronutrient needs are met.

Physical Activity

Health guidelines developed for preventing chronic diseases are especially important for cancer survivors. Guidelines established by the ACS and Dietary Goals for Americans serve as the basis for healthy food choices and physical activity for all Americans, including long-term cancer survivors. The 2008 Physical Activity Guidelines for Americans issued by the U.S. Department of Health and Human Services includes the following information for survivors after cancer diagnosis:19

• Increased physical activity is linked with improved quality of life and increased fitness. • While the current public health guidelines of 30 to 60 minutes of moderate-intensity

aerobic exercise five times per week have not been studied systematically in cancer survivors, there is no reason to believe that following these guidelines would not also benefit survivors.

• Results also indicated that the particular physical, physiological and psychosocial effects of cancer and its treatment are positively affected by cardiovascular exercise, resistance training and flexibility training.


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How Cancer Treatment Affects Physical Activity19 Treatment Physical Changes Surgery Lung Decreased pulmonary function

Breast Altered lymphatic drainage and lymphedema

Radiation Therapy Mediastinum Decreased cardiac and pulmonary function

Chemotherapy Anthracyclines Decreased cardiac function

Taxanes Peripheral neuropathy Other Treatments Biotherapy Increased fat mass, myalgia and hypertension

Hormone Therapy Increased body weight, BMI and fat mass

Steroid Therapy Decreased muscle, bone loss, increased body weight, BMI and fat mass Lifestyle Guidelines The ACS has published Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices. This guide is based on scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer.3

The guidelines include recommendations on nutrition and physical activity for cancer prevention, as well as promote overall health, quality of life and longevity, with the goal of reducing the risk for developing cancer recurrence, secondary cancers and chronic diseases.


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ACS Nutrition and Physical Activity Guidelines for Cancer Prevention20

Achieve and maintain a healthy weight throughout life. • Be as lean as possible throughout life without being underweight. • Avoid excessive weight gain at all ages. For those who are currently overweight or

obese, losing even a small amount of weight has health benefits. • Engage in regular physical activity and limit consumption of high-calorie foods and

beverages as key strategies for maintaining a healthy weight.

Adopt a physically active lifestyle. • Adults should engage in at least 150 minutes of moderate-intensity activity or 75

minutes of vigorous-intensity activity each week, or an equivalent combination, preferably spread throughout the week.

• Children and adolescents should engage in at least one hour of moderate-to-vigorous-intensity activity each day, with vigorous-intensity activity occurring at least three days a week.

- Limit sedentary behavior such as sitting, lying down, watching television or other forms of screen-based entertainment.

- Doing some physical activity above usual activities, no matter what one’s level of activity, can have many health benefits.

Consume a healthy diet, with an emphasis on plant foods. • Choose foods and beverages in amounts that help achieve and maintain a healthy

weight. • Eat at least 2.5 cups of vegetables and fruits each day. • Choose whole grains instead of refined grain products. • Limit consumption of processed and red meats.

If you drink alcoholic beverages, limit consumption. • Drink no more than one drink per day for women or two drinks per day for men.


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The American Institute of Cancer Research has also issued recommendations on ways to attempt

to prevent cancer.

American Institute of Cancer Research’s Simple Steps to Prevent Cancer21

Lifestyle Choices Implications

Body Fatness Be as lean as possible within the normal range of body weight.

Physical Activity Be physically active as part of everyday life. Foods and Drinks that Promote Weight Gain

Limit consumption of energy-dense foods. Avoid sugary drinks.

Plant Foods Eat mostly foods of plant origin. Animal Foods Limit intake of red meat and avoid processed meat. Alcoholic Beverages Limit alcoholic beverages. Preservation, Processing, Preparation

Limit consumption of salt. Avoid moldy cereals (grains) and pulses (legumes).

Dietary Supplements Aim to meet nutritional needs through diet alone. Breastfeeding Mothers to breast feed, children to be breastfed.

Chronic/Late Effects of Treatment

Most side effects from cancer treatment are temporary and resolve after treatment completion, but some side effects may persist and become chronic. Late effects are toxicities caused by cancer treatment that appear weeks, months and even years later. Toxicities can be mild, severe or life-threatening.22

Acute effects of treatment most frequently occur in rapidly proliferating cells such as the bone marrow and mucosa cells that line the GI tract, while late effects manifest in slowly proliferating cells such as the heart and lung.22 Chronic or late effects may be exacerbated by the length of cancer treatment(s), specific drug(s), total amount of drug(s) administered over time, amount of radiation therapy delivered and specific treatment area(s), and the survivor’s age.23

After the completion of treatment, care must include both surveillance for cancer recurrence, as well as monitoring for chronic and/or late effects of cancer and its treatment.3,24 Follow-up visit intervals may vary, but it is recommended that follow-up monitoring should occur at least once a year for life.


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Chronic/Late Effects of Cancer Treatment System/Organ Treatment Effects of Treatment

Cardiovascular • Total body irradiation • Radiation therapy to the

mediastinum or a mantle field • Chemotherapy agents (e.g.,

anthracyclines, high-dose cyclophosphamide)

Arrhythmias or cardiomyopathy, resulting in congestive heart failure

Constitutional • Chemotherapy agents: high doses for extended periods of time

• Radiation therapy: especially bony metastases

Chronic fatigue and anorexia resulting in malnutrition and wasting

Esophagus • Esophageal surgery • Radiation therapy to the

esophagus and/or gastric-esophageal junction

Permanent esophageal stenosis and stricture, resulting in dysphagia, odynophagia, and malnutrition

Gastrointestinal • Surgery and/or resection of the GI tract

• Pelvic or abdominal radiation therapy

Chronic radiation enteritis, resulting in malabsorption, diarrhea, malnutrition and wasting

Oral Cavity • Head and neck surgery • Radiation therapy to the head

and neck

Permanent xerostomia, resulting in difficulty chewing and swallowing, taste alterations and increased risk of dental caries

Respiratory • Pulmonary surgery • Radiation therapy to the

mediastinum or a mantle field • Chemotherapy agents (e.g.,

bleomycin [Blenoxane], busulfan [Myleran], vinca alkaloids, alkylating agents)

Pulmonary fibrosis or pneumonitis, resulting in dyspnea and decreased pulmonary function

Second Primary Cancers

• Chemotherapy agents: high doses for extended periods of time

• Total body irradiation

Caused by damage from radiation therapy and/or chemotherapy to the body’s cellular DNA

Summary

It is important for healthcare professionals and cancer survivors to understand the goals of nutrition therapy during recovery and throughout long-term survival. Important nutrition and physical activity-related issues for long-term cancer survivors include avoiding obesity, increasing physical


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activity, making healthful food choices, increasing fruit and vegetable intake, appropriate use of dietary supplements and limiting alcoholic beverage use. Dietetic professionals need to help survivors navigate through the scientific and lay literature, weighing potential benefit to potential harm, thereby enabling them to make informed decisions to achieve recovery and survivorship goals, as well as help prevent a recurrence or a second primary cancer diagnosis.25

References 1. Glossary. American Cancer Society Web site. www.cancer.org. Accessed July 19, 2012. 2. American Cancer Society. Cancer Facts and Figures, 2012. Atlanta, GA: The American Cancer Society;

2012. 3. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an

American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353. 4. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition.

Washington, DC: The National Academies Press; 2005. 5. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition

Practice Guideline. Academy of Nutrition and Dietetics: Chicago, IL; 2010. 6. Oeffinger KC, Buchanan GR, Eshelman DA, et al. Cardiovascular risk factors in young adult survivors of

childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2001;23(7):424-430. 7. de Vos FY, Nuver J, Willemse PH, et al. Long-term survivors of ovarian malignancies after cisplatin-based

chemotherapy: cardiovascular risk factors and signs of vascular damage. Eur J Cancer. 2004;40(50:696-700. 8. Eyre HJ, Kahn R, Robertson RM, ACS/ADA/AHA Collaborative Writing Committee. Preventing cancer,

cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association. CA Cancer J Clin. 2004;54(4):190-207.

9. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625-1638.

10. Rock CL, Demark-Wahnefried W. Nutrition and survival after the diagnosis of breast cancer: a review of the evidence. J Clin Oncol. 2002;20(15):3302-3316.

11. Amling CL. The association between obesity and the progression of prostate and renal cell carcinoma. Urol Oncol. 2004;22(6):478-484.

12. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S.

13. E ichholzer M. Nutrition and cancer. Ther Umsch. 2000;57(3):146-151. 14. Saxe GA, Hebert JR, Carmody JF, et al. Can diet in conjunction with stress reduction affect the rate of

increase in prostate specific antigen after biochemical recurrence of prostate cancer? J Urol. 2001;166(6):2202-2207.

15. Hensrud DD, Heimburger DC. Diet, nutrients, and gastrointestinal cancer. Gastroenterol Clin North Am. 1998;27(2):325-346.

16. Rock CL, Neuman VA, Neuhouser ML, Major J, Barnett MJ. Antioxidant use in cancer survivors and the general public. J Nutr. 2004;134(11):3194S-3195S.

17. McDavid K, Breslow RA, Radimer K. Vitamin/mineral supplementation among cancer survivors: 1987 and 1992 Health Interview Surveys. Nutr Cancer. 2001;41(1-2):29-32.

18. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA. 2002;287(23):3127-3129.

19. Physical Activity Guidelines Advisory Committee report, 2008. To the Secretary of Health and Human Services. Part A: executive summary. Nutr Rev. 2009;67(2):114-20.


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20. Kushi LH, Doyle C, McCullough M, Rock CL, et al. American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012;62(1):30-67.

21. World Cancer Research Fund (WCRF)/American Institute for Cancer Research (ACIR). Food, nutrition, physical activity and the prevention of cancer: a global perspective. Washington, DC: WCRF/ACIR; 2007.

22. Ronk B. Organ toxicities and late effects: risks of treatment. In: Gates RA, Fink RM. Oncology Nursing Secrets. 2nd ed. Philadelphia, PA: Hanley & Belfus, Inc.; 2001:385-390.

23. Boice JD. Second malignancies after chemotherapy. In: Perry MC, ed. The Chemotherapy Source Book. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-24.

24. Polovich M, White JM, Kelleher LO. Chemotherapy and Biotherapy Guidelines and Recommendations. 2nd ed. Pittsburgh PA: Oncology Nursing Society; 2005.

25. Harpham WS. Alternative therapies for curing cancer: what do patients want? What do patients need? CA Cancer J Clin. 2001;51(2):131-136.


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Chapter Nine: Advanced Cancer and Palliative Care

This chapter discusses palliative and hospice care for patients with advanced cancer and the importance of creating and implementing a survivorship plan for these patients. For supplemental information to this chapter, please review the following appendices: Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms

espite improvements in cancer diagnosis and treatment, a cure is not always possible. As described by the American Cancer Society’s Survivorship Advisory Committee, one of the phases of survivorship in the cancer continuum is living with advanced cancer or a cancer that

cannot be cured.1 Palliative care can be defined as the active, complete care of a patient when curative measures are

no longer considered an option by either the healthcare team or the patient.2 Another definition describes palliative care as “treatment that is designed to ease symptoms of disease rather than attempting to cure it.”3 The term palliative care is often used interchangeably, though improperly so, with hospice. Hospice can be a component of palliative care, but palliative care is not necessarily hospice. Hospice care focuses on relieving symptoms and supporting those with a life expectancy of only months, and it encompasses all of the principles of palliative care.4

Palliative treatment and care, while usually provided to individuals with advanced cancer, can be given to people receiving curative cancer treatment or in the phase of long-term survival after anti-cancer treatment.

Quality of life and patient- and family-centered care are important aspects of care for people living with advanced cancer. Improved knowledge and application of the principles of palliative care will help healthcare professionals enhance the lives of their patients.5,6 The objectives of palliative care are to relieve physical symptoms; alleviate isolation, anxiety and fear associated with advanced disease; and maintain independence as long and as comfortably as possible.1,7

Palliative Care and Hospice Delivery Systems Palliative care services can be provided to individuals through a variety of healthcare delivery

systems. Institution-based palliative care programs may offer inpatient consultation services, inpatient primary care (which may or may not include a specialized palliative care nursing unit), and a range of outpatient services.

Hospice programs may provide free-standing residential care facilities, hospice/home care and inpatient respite care. Typically, persons must have a life expectancy of six months or fewer to enroll in hospice care.

As an outpatient, a patient might receive homecare services, such as enteral feedings, durable medical equipment and nursing visits. This type of arrangement, sometimes called “bridge services,” may be appropriate for those not yet ready for hospice or in cases where the hospice concept conflicts

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with patients or their families’ philosophy (e.g., belief that hospice means giving up hope for survival). Some palliative care outpatients do not require hospice or bridge services and return to the clinic for regular follow-up and continuity of care.8,9

Specific guidelines regarding Medical Nutrition Therapy (MNT) and management of nutrition impact symptoms are provided in Chapter Eleven and Appendices 3 through 11. It is important for dietetic professionals to be aware of the common symptoms and complications associated with advanced cancer, as well as their impact on nutritional status.1 Dietetic professionals should assess nutritional status, identify specific nutritional needs and nutrition impact symptoms, and implement an individualized nutrition care plan.10 Komurcu and colleagues make an interesting comment, that by simply “defining the relationship of the symptoms to the disease (we) can defuse fear and encourage a sense of control in patients and their families.”7

Prevalent Symptoms

Walsh and associates published a review of the symptoms of 1,000 patients upon their initial referral to palliative care service.11 The 10 most common symptoms identified were pain, easy fatigue, weakness, anorexia, lack of energy, dry mouth, constipation, early satiety, dyspnea and greater than 10% loss of weight.

Researchers have found the most common gastrointestinal (GI) symptoms of individuals with advanced cancer are anorexia, constipation, early satiety, xerostomia, nausea, taste changes, vomiting, bloating and weight loss. In general, nutrition symptoms tend to worsen with disease progression; however, many of these symptoms are manageable, further illustrating the need for greater education of healthcare professionals.

Nutrition-Related Symptoms in Advanced Cancer8,12,13

Symptom Advanced Cancer (N=1,000)

Advanced Metastatic Cancer (N=352)

Palliative Care (N=200)

Anorexia 66% 81% 59% Bloating 18% 43% 50% Constipation 52% 59% 39% Diarrhea 8% 24% 10% Early Satiety 51% 69% 49% Nausea 36% 49% 26% Taste Changes 28% 16% 32% Vomiting 23% 38% 11% Weight loss 50% 85% 54% Xerostomia 57% 69% 67%

Paraneoplastic Syndromes

Advanced cancer often leads to a variety of complications often described as paraneoplastic syndromes, some of which can have serious nutritional implications. Paraneoplastic syndromes are caused by substances secreted by the cancer, such as hormones and cytokines, which cause metabolic, nerve or muscular disorders.14,15 Common paraneoplastic syndromes with medical and nutritional implications include cancer cachexia syndrome, hypercalcemia, hypoglycemia, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and Lambert-Eaton syndrome.


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Cancer Cachexia Syndrome The etiology of cachexia is multifactorial, although tumor production of hormones and cytokines is

a factor. While there is no known treatment to reverse these effects, pharmacologic management and nutritional counseling have been shown to help improve patient outcomes and quality of life.16,17

Hypercalcemia Hypercalcemia of paraneoplastic disease and bony metastases is associated with metastatic breast

cancer and multiple myeloma, followed by cancers of the lung cancer, head and neck, and renal cell cancer.18-20 Humoral hypercalcemia can manifest from non-metastatic tumor cells that induce parathyroid hormone-like peptides. Hypercalcemia-associated bony metastases are caused by the osteolytic activity of tumor cells releasing calcium into the extracellular fluid.

Although restriction of dietary calcium is not a treatment for hypercalcemia, it is important to advise patients to avoid taking large amounts of exogenous calcium (e.g., dietary supplements, antacids or calcium-fortified foods and beverages). Hypercalcemia is treated with the infusion of IV fluids and the use of bisphosphonates and other antihypercalcemic agents.21

Hypoglycemia Hypoglycemia is most common in patients with insulin-secreting islet cell tumors, as well as

mesenchymal tumors, such as fibrosarcomas, leiomyomas, rhabdomyosarcomas, liposarcomas and mesotheliomas.18 Acute episodes of hypoglycemia can be treated with IV dextrose, while mild cases of ongoing hypoglycemia may respond to frequent, small feedings that emphasize protein, complex carbohydrates and fat at each feeding. Severe cases may benefit from the use of corticosteroids and/or glucagons (although these may cause vomiting).

SIADH SIADH is most often associated with small-cell lung cancer. Hyponatremia is the most common

symptom of SIADH, which is treated with diuretics, IV saline with potassium, and/or fluid restriction (usually 500 to 1000 cc/day).18

Lambert-Eaton Syndrome Lambert-Eaton syndrome, a neurological disorder similar to myasthenia gravis, is most often

associated with small-cell lung cancer. These patients can have problems with xerostomia and dysphagia, which can be managed with nutritional intervention (see Chapter Eleven for more information).18,22


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Symptoms and Complications

Additional symptoms and complications commonly seen in advanced cancer include: Bowel Obstructions and I leus Bowel obstructions and ileus are associated with pancreatic and gynecological cancers, abdominal

carcinomatosis, enlarged retroperitoneal nodes and pelvic masses. They are also a result of pelvic and/or abdominal radiation therapy and after surgical interventions to the GI tract.23-25

Patients with advanced cancer and bowel obstruction can be managed with medications, IV fluids and decompression.26 If the bowel obstruction or ileus can be resolved, patients should be transitioned from IV fluids to a clear liquid diet and then if tolerated, be instructed on a low-fiber diet.

Parenteral nutrition is in most instances inappropriate, although it may be used for some who are medically and emotionally stable and have a reasonable life expectancy (e.g., to improve quality of life, to assist in a patient’s desire to live to witness an important life event).27,28

Steroid-induced Hyperglycemia Patients with advanced cancer are often prescribed corticosteroids to manage disease-related

symptoms. A common side effect of steroid use is hyperglycemia, which is usually managed successfully with a “no added sugar/no concentrated sweets” diet and/or antihyperglycemic agents. Often patients are eating so poorly that diet is an insignificant contribution to blood glucose levels and, therefore, diet should be as liberal as possible to maximize quality of life.

Venous Thromboembolic Complications A variety of disease-related factors can lead to the development of deep vein thrombosis (DVT) or

pulmonary embolism (PE) in people with advanced cancer. Some individuals may be treated with intermittent pneumatic compression, compression stockings or vena cava filters, although pharmacological management with anticoagulants is common. Dosing of anticoagulants is based on the patient’s blood clotting time, which reflects his or her average vitamin K intake. Patients should be advised to consume a consistent amount of vitamin K-containing foods, rather than totally restrict vitamin K-rich foods from their diets.25

Spinal Cord Compression Spinal cord compression is considered an oncological emergency and is usually, but not exclusively,

due to extradural metastases occurring in the vertebral column.24 Treatment of cord compression is vital to prevent complete compression, resulting in paralysis and loss of bowel and bladder function/control. Cord compression is usually treated with radiation therapy, bisphosphonates and/or corticosteroids.

Nutritional issues concerning spinal cord compression include constipation secondary to opiates used for pain management, dehydration and poor dietary intake secondary to those wanting to avoid embarrassment of urinary or fecal incontinence due to the associated loss of bladder and bowel control, and physical inactivity. A multi-disciplinary healthcare team effort can help alleviate constipation and manage bowel and bladder function to help preserve the patient’s dignity and quality of life.


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Nutrition Support in Advanced Cancer Nutrition support (e.g., enteral or parenteral nutrition) for patients with advanced disease can be a

difficult and controversial issue.29 The American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) states in its evidence-based clinical guidelines for nutrition support during cancer treatment that the palliative use of nutrition support therapy in terminally ill patients is rarely indicated.30 The A.S.P.E.N. guidelines advise that decisions should be made on a case-by-case basis and include consideration of the patient’s and family’s wishes, potential risks and benefits, and the patient’s estimated survival. In some instances, nutrition support does have a place in the treatment of the advanced cancer patient. Enteral nutrition is appropriate in patients with mechanical barriers to achieving adequate oral intake wherein quality of life would suffer and death would be caused by malnutrition, rather than the underlying disease (i.e., head and neck cancer).31

Rationale for implementing parenteral nutrition, however, is less clear. Mercadante and others suggest that parenteral nutrition may be appropriate in cases where oral or enteral nutrition was not possible due to mechanical obstruction or malabsorption.31,32 However, Torelli and colleagues found that parenteral nutrition neither influenced the ultimate outcome nor improved quality of life and, therefore, conclude that there is little validity to administering parenteral nutrition to terminally ill cancer patients.33 The authors admit, however, that there may be subjective rationale to justify the use of parenteral nutrition, such as compassionate, religious, ethical or emotional reasons.

Parenteral nutrition may be appropriate for use in select patients who are medically and emotionally stable and have a reasonable life expectancy.27 Consideration of cost, burden on family members and potential complications must be weighed against any potential benefit derived from nutrition support, whether it is enteral or parenteral.29,34,35

Decisions regarding the provision of nutrition support and hydration may be guided by a variety of sources, including the 2008 Position Statement of the Academy of Nutrition and Dietetics: Ethical and Legal Issues in Nutrition, Hydration, and Feeding. The Academy’s position paper states:36

Each patient is unique, and the plan of care should be constantly reassessed for each individual. For the patient to accept, and perhaps enjoy, oral intake, previous dietary restrictions should be minimized or eliminated, depending on the physical consequences. Registered dietitians should work with the team to coordinate administration of pain medication to maximize enjoyment of food. Amelioration of symptoms such as nausea, vomiting, insomnia, and anxiety is an important objective. The actual or illusory source of strength, nurturing, comfort, and caring provided by food should be encouraged as well as family interaction and socialization.

The Academy position paper recommends the following four considerations be taken regarding

decisions about feeding: • Patient preference guides the decision-making process. • When the patient’s preference is not known, a substitute decision maker is guided by

the best interests of the patient. • Informed and shared decision-making is the best ethical practice. • All stakeholders are encouraged to collaborate in the decision-making process.

As Death Becomes Imminent Dietetic professionals should remain involved in patient care throughout the course of the disease

to serve as a resource to patients, family and the healthcare team for information regarding nutritional


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care of people with advanced and terminal disease. They should assist patients and the healthcare team in making informed decisions regarding nutrition support, educate patients and families regarding medical nutrition therapy interventions, and provide ongoing support throughout the course of the disease, especially for symptom control.

As death becomes imminent, dietetic professionals should remain available and supportive to the patient and family members, providing appropriate suggestions to maximize the comfort of the patient.

Working with Terminally Ill Patients and Families

Supportive guidance to family • “Let him give you the cues as to when and what he’s able to eat or drink.” • “Nature is our best guide, as the body’s needs change.” • “She may be more comfortable taking sips of cool liquids rather than meals.” • “Too much food or liquid can make her more uncomfortable, make her lungs more ‘wet’

and make breathing more difficult.” • “I know you feel helpless and like you’re not doing anything, but know that you are

doing what is best for her at this time. Your presence and your caring are what is important. You are doing a wonderful job, and she is so lucky to have you.”

Foods that might provide comfort • Cream soups (pureed, with uniform consistency to avoid aspiration) • Fruit-based shakes and smoothies (very small quantities, may be made with ginger ale or

lemon-lime soda to make them lighter and more refreshing) • Mashed or baked potatoes • Cream of wheat/oatmeal • Yogurt • Gelatin • Ice cream/sherbet/ices Liquids that might provide comfort* • Clear juices and nectars • Kool-Aid (sometimes patients prefer this diluted) • Dilute Gatorade or Powerade • Lemonade or limeade • Cranberry juice • Ginger ale or lemon-lime soda (can be mixed with juices or Kool-Aid) • Popsicles • Fruit ice • Water with lemon, lime or orange slices (remove slices to prevent aspiration, unless

patient is drinking through a straw) *Note: Patients who would never drink these items ordinarily may find them very soothing at this time.

It is important to note that as death approaches, most people stop taking solid food, and may even

take very little liquid.34 Provision of artificial hydration is controversial and should be taken on a case-by-case basis, similar to nutrition support.13,37 It is thought that dehydration at this point in the life cycle is not uncomfortable, but rather creates a kind of euphoric state.38 In fact, excess fluids may increase secretions, making breathing more difficult and disturbing to both the patient and family members.


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Summary

Palliative care is aggressive symptom management, including nutritional care. Patients with advanced cancer and their families and caregivers are faced with a wide range of nutrition-related problems, which may worsen with disease progression. It is important for dietetic professionals to be aware of potential disease symptoms and complications and their nutritional implications, and to work with the healthcare team to ensure optimum symptom management and quality of life. Nutritional counseling is needed throughout the course of disease to provide education and support to individuals and their families, as well as to help guide and navigate all stakeholders involved toward appropriate informed choices regarding nutritional care and nutrition support.

Case Study

NS was a 43-year-old female with advanced breast cancer, admitted to an inpatient hospice care facility. She had undergone a radical mastectomy followed by chemotherapy and hormone therapy and was presumed to be disease-free for six years when she was diagnosed with a recurrence of the disease. By this time, the disease had metastasized to her lung and bones. Her chief complaints were cough, shortness of breath, pain from the bone metastases, and constipation related to opioid use and physical inactivity.

Nutrition assessment revealed the patient to be within normal limits of her ideal and usual body weights, although she had lost 6 lbs in the previous month. Her physician had prescribed oxycodone/acetaminophen for pain while in the hospital one month before, but had not prescribed a prophylactic bowel regimen. Upon admission to hospice, NS had not had a bowel movement in five days.

Her care plan included an enema to relieve her constipation initially, followed by a daily prophylactic bowel regimen (stool softener three times daily and milk of magnesia at bedtime if no bowel movement during the day). The registered dietitian provided her with nutrition suggestions to help promote good bowel function (i.e., hot prune juice as a natural bowel stimulant). Additionally, the registered dietitian suggested she try soft, moist foods or liquids, which are easier to consume for people having difficulty with shortness of breath.

Three months later, NS was reaching the end stages of her disease and eating very little. Her teenage daughter wanted a tube feeding placed to “help her to get stronger.” NS did not want to receive tube feedings, but couldn’t discuss the matter with her daughter without breaking down into tears. The registered dietitian, nurse, social worker and attending physician held a family meeting. The patient’s wishes were reiterated to the family and alternative means of providing comfort and support were provided (i.e., cool, refreshing beverages). The family was able to discuss ways that they could help ease NS through her final days and seemed comforted by their new understanding of the disease process.

References 1. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an

American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353. 2. McCallum PD, Fornari A. Medical nutrition therapy in palliative care. In: Elliott L, Molseed LL, McCallum PD,

Grant D, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:201-207.

3. Markovitch H, ed. Black’s Medical Dictionary. 41st ed. Lanham, MD: Scarecrow Press; 2006:185-186. 4. What is hospice and palliative care? National Hospice and Palliative Care Organization Web site.


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http://www.nhpco.org/i4a/pages/index.cfm?pageid=4648. Accessed July 19, 2012. 5. Nelson KA, Walsh D, Abdullah O, et al. Common complications of advanced cancer. Semin Oncol.

2000;27(1):34-44. 6. LeGrand SB, Nelson K, Zhukovsky DS. Development of a clinical fellowship program in palliative medicine.

J Pain Symptom Manage. 2000;20(5):345-352. 7. Komurcu S, Nelson KA, Walsh D, et al. Common symptoms in advanced cancer. Semin Oncol.

2000;27(1):24-33. Review. 8. Walsh D. The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel

comprehensive integrated program. Am J Hosp Palliat Care. 2001;18(4):239-250. 9. Bruera E, Neumann CM. Respective limits of palliative care and oncology in the supportive care of cancer

patients. Support Care Cancer. 1999;7(5):321-327. 10. Trentham K. Palliative care. In: Marian M. Roberts S, eds. Clinical Nutrition for Oncology Patients. Sudbury,

MA: Jones & Bartlett; 2010:351-378. 11. Walsh D, Donnelly S, Rybicki L. The symptoms of advanced cancer: relationship to age, gender, and

performance status in 1,000 patients. Support Care Cancer. 2000;8(3):175-179. 12. Homsi J, Walsh D, Rivera N, et al. Symptom evaluation in palliative medicine: patient report vs systematic

assessment. Support Care Cancer. 2006;14(5):444-453. 13. Sarhill N, Walsh D, Nelson K, Davis M. Evaluation and treatment of cancer-related fluid deficits: volume

depletion and dehydration. Support Care Cancer. 2001;9(6):408-419. 14. Gerrard G. Paraneoplastic syndromes in advanced malignancy. Eur J Pall Care. 1996;3(2):51-53. 15. Nelson KA, Walsh D, Behrens C, et al. The dying cancer patient. Semin Oncol. 2000;27(1):84-89. 16. Ravasco P, Monterio-Grillo I, Camilo M. Cancer wasting and quality of life react to early, individualized

nutritional counseling! Clin Nutr. 2007;26(1):7-15. 17. Nelson KA. Modern management of the cancer anorexia-cachexia syndrome. Curr Pain Headache Rep.

2001;5(3):250-256. 18. Escalante CP, Manzullo E, Gollamudi SV, et al. Oncologic emergencies and paraneoplastic syndromes. In:

Padzur R, ed. Cancer Management: A Multidisciplinary Approach. 5th ed. Melville, NY: PRR; 2001:835-858. 19. McCloskey EV, Guest JF, Kanis JA. The clinical and cost considerations of bisphosphonates in preventing

bone complications in patients with metastatic breast cancer or multiple myeloma. Drugs. 2001;61(9):1253-1274.

20. Singer FR. Pathogenesis of hypercalcemia of malignancy. Semin Oncol. 1991;18(4 Suppl 5):4-10. 21. Pecherstorfer M, Brenner K, Zojer N. Current management strategies for hypercalcemia. Treat Endocrinol.

2003;2(4):273-292. 22. Levin KH. Paraneoplastic neuromuscular syndromes. Neurol Clin. 1997;15(3):597-614. 23. Thomas S. Nutritional implications of surgical oncology. In: Elliott L, Molseed LL, McCallum PD, Grant B,

eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association: 2006:94-109.

24. Watkins Bruner D, Hass ML, Gosselin-Acomb TK, eds. Manual for Radiation Oncology Nursing Practice and Education. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2005.

25. McCallum P, Walsh D, Nelson KA. Can a soft diet prevent bowel obstruction in advanced pancreatic cancer? Support Care Cancer. 2002;10(2):174-175.

26. Ripamonti C, Twycross R, Baines M, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer. 2001;9(4):223-233.

27. DeChicco RS, Steiger E. Parenteral nutrition in medical or surgical oncology. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:156-164.


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28. Hoda D, Jatoi A, Burnes J, Loprinzi C, Kelly D. Should patients with advanced, incurable cancer ever be sent home with total parenteral nutrition? A single institution’s 20-year experience. Cancer. 2005;103(4):863-868.

29. Sharp JW, Roncagli T. Home parenteral nutrition in advanced cancer. Cancer Pract. 1993;1(2):119-124. 30. August D, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of

Directors. A.S.P.E.N. clinical guidelines: Nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472-499.

31. Bachmann P, Marti-Massoud C, Blanc-Vincent MP, et al. Standards, options and recommendations: nutritional support in palliative or terminal care of adult patients with progressive cancer. Bull Cancer. 2001;88(10):985-1006.

32. Mercadante S. Parenteral nutrition at home in advanced cancer patients. J Pain Symptom Manage. 1995;10(6):476-480.

33. Torelli GF, Campos AC, Meguid MM. Use of TPN in terminally ill cancer patients. Nutrition. 1999;15(9):665-667.

34. Dunlop RJ, Ellershaw JE, Baines MJ, Sykes N, Saunders CM. On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far? A reply. J Med Ethics. 1995;21(3):141-143.

35. Pironi L, Ruggeri E, Tanneberger S, et al. Home artificial nutrition in advanced cancer. J R Soc Med. 1997;90(11):597-603.

36. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108(5):873-882.

37. Torsheim AK, Falkmer U, Kaasa S. Hydration of patients with advanced cancer—is subcutaneous infusion a good solution? Tidsskr Nor Laegeforen. 1999;119(19):2815-2817.

38. Bennett JA. Dehydration: hazards and benefits. Geriatr Nurs. 2000;21(2):84-88.


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Chapter Ten: Nutrition Support Therapy

This chapter will review three types of nutrition support therapy in the oncology care setting (oral intake, enteral nutrition and parenteral nutrition), and will provide a review of the various considerations that need to be addressed before implementing nutrition support in the oncology setting. For supplemental information to this chapter, please review the following appendices: Appendix 14 Complications of Enteral Feeding

egardless of which route of nutrition support therapy is used when caring for people with cancer, nutrition goals should be specific and achievable to provide optimal nutrition and compliance. Nutritional care involving the patient and his or her caregivers and family should

be initiated early in the course of treatment and should continue in conjunction with follow-up nutrition assessment and care. Being proactive and using evidence-based guidelines will help dietetic professionals maximize safety and clinical benefits of nutrition support while minimizing potential complications.1

Nutrition Support Therapy

The Academy of Nutrition and Dietetics’ Evidence Analysis Library includes evidence-based guidelines on oncology and nutrition. These guidelines recommend medical nutrition therapy with individualized nutrition assessment, diagnosis, intervention and counseling as an integral component of a cancer patient’s treatment and care.2 According to Wong and colleagues at Memorial Sloan-Kettering Cancer Center, the goals of nutrition support therapy are to minimize body cell mass depletion, prevent nutrient deficiencies, support or improve immune function, and to facilitate tissue repair and would healing.3

Nutrition support therapy for use in people with cancer remains a topic of controversy. There is concern that while enteral and parenteral nutrition support provides needed energy, protein and micronutrients — it may also stimulate cancer growth and metastases, as observed in cell culture and animal studies. Some believe nutrition support therapy is not appropriate for all people with cancer, such as those with advanced cancer or those who are terminally ill. To help guide appropriate use, the A.S.P.E.N. clinical guidelines provide evidence-based nutrition support therapy during adult cancer treatment and in hematopoietic cell transplant (HCT).4

R


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Nutrition Support Therapy During Adult Cancer Treatment and HCT4

Guideline Recommendations 1. Patients with cancer are nutritionally at risk and should undergo nutrition screening

to identify those who require formal nutrition assessment with development of a nutrition care plan.

2. Nutrition support therapy (NST) should not be used routinely in patients undergoing major cancer operations.

3. Perioperative NST may be beneficial in moderately or severely malnourished patients if administered for seven to 14 days preoperatively, but the potential benefits of NST must be weighed against potential risks of NST itself and of delaying the operation.

4. NST should not be used routinely as an adjunct to chemotherapy. 5. NST should not be used routinely in patients undergoing head and neck,

abdominal, or pelvic irradiation. 6. NST is appropriate in patients receiving active cancer treatment who are

malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time.

7. The use of NST in patients with terminal cancer is rarely indicated. 8. Omega-3 fatty acid supplementation may help stabilize weight in cancer patients

on oral diets experiencing progressive, unintentional weight loss. 9. Patients should not use therapeutic diets (alone) to treat cancer. 10. Immune-enhancing enteral formulas containing mixtures of arginine, nucleic acids

and essential fatty acid may be beneficial in malnourished patients undergoing major cancer operations.

11. All patients undergoing HCT with myeloablative conditioning regimens are at nutrition risk and should undergo nutrition screening to identify those who require formal nutrition assessment with the development of a nutrition care plan.

12. NST is appropriate in those undergoing HCT who are malnourished and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time. When parenteral nutrition is used, it should be discontinued as soon as toxicities have resolved after stem cell engraftment.

13. Enteral nutrition should be used in patients with a functioning gastrointestinal tract in whom oral intake is inadequate to meet nutrition requirements.

14. Pharmacological doses of parenteral glutamine may benefit patients undergoing HCT.

15. Patients should receive dietary counseling regarding foods that may pose infectious risks, as well as safe food handling during the period of neutropenia.

16. NST is appropriate for patients undergoing HCT who develop moderate-to-severe graft-versus-host disease accompanied by poor oral intake and/or significant malabsorption.


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Oral Intake Oral intake includes diet, nutritional supplements, and vitamin and mineral supplements. When

combined with nutrition counseling and appropriate pharmacological agents, it can be a cost-effective means of maintaining or improving nutriture.5,6 Because of lower cost and minimal risks associated with oral nutrition, it is the preferred means of nutrition support (see Chapter Five for more information).

Nutrit ional Supplements Nutritional supplements can be ready-to-use or “meal replacement” varieties; in liquid, pudding,

bars, powdered mixes, and high-protein clear liquid drinks; or modular additives that can be used in other supplements or added to food. In addition, there are a number of fortified soups, gelatins and hot cereal mixes on the market. Although commercially prepared formulas have been available for many years, companies regularly change formulations to improve the nutrition and palatability of their products. It’s a good idea to keep samples for patients to try, as well as the members of the healthcare team, to ensure truthful recommendations to others. Commonly used commercial liquid nutrition supplement products in the oncology setting include Ensure, Boost, Resource and Orgain (USDA certified organic).

Although modular supplements (e.g., protein powders, lipids, carbohydrates and fiber) are not always stocked at the grocery store, pharmacy or discount store, they can be a helpful way to add extra nutrients to an oral diet. Modulars, when added to foods, can boost calories and/or protein without significantly altering the flavor or volume. Several modular supplements can also be used to tailor commercially prepared enteral feeding formulas to meet the precise needs of those whose nutritional plans require more “fine tuning.”

Types of Supplements Protein Powders Non-fat dry milk

Egg white powder Soy powder Whey powder (Beneprotein)

Carbohydrate Modulars Polycose Benecalorie

Lipids Modulars Microlipid MCT Oil

Fiber Products Benefiber Metamucil Citrucel

Enteral Nutrition Support It is important that all avenues of oral nutrition support and symptom management be aggressively

pursued as a primary means of managing the effects of cancer and its treatment. However, when oral nutrition is not possible or is inadequate because of mechanical obstruction or nutrition impact symptoms such as dysphagia, anorexia, early satiety or pain, enteral nutrition (EN) is a viable option to help maintain or replete nutrition status.7,8 Although more expensive than oral nutrition, EN support is


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less expensive than parenteral nutrition and has far fewer potential complications. Potential complications of EN can be mechanical, metabolic or GI in nature. Complications

include tube displacement/migration, tube occlusion, high residuals/volume intolerance, aspiration, gastric retention, gastric reflux, nausea, vomiting, cramping, distension, bloating, hypermotility, diarrhea and constipation.

EN may be administered via nasogastric, nasoenteric or enterostomy tube. Generally speaking, nasogastric and nasoenteric tubes are used for short-term feeding, whereas the less visible enterostomy variations are more common for long-term feeding.8

Nasogastr ic /Nasoenteric Nasogastric (NG) and nasoenteric tubes vary in length, French size, material, weighted tips, and

opacity. While the distal tip of a NG tube is placed into the stomach (may be done at the bedside), nasoenteric tubes are advanced beyond the pyloric sphincter into the duodenum or further into the jejunum. This may require the use of endoscopy, fluoroscopy or prokinetic pharmacological agents. Nasoenteric tubes are intended for use in patients who are at greater risk for aspiration.

Smaller French sizes are used more frequently in children or for adults requiring NG tube placement for feeding during head and neck radiation therapy to decrease the possible pharyngeal irritation; however, the smaller the French size (diameter), the greater risk of obstruction due to the administration of medications through the tube or more viscous enteral formulas.

French Sizes of Feeding Tube Catheters9 Common External French Diameter (OD)

Size Mm 10 3.3 12 4.0 14 4.7 16 5.3

Enteric Feeding Enterostomies include gastrostomy and jejunostomy tubes and may be placed surgically or

laparoscopically under a general anesthetic (percutaneous endoscopic gastrostomy [PEG]), or endoscopically or radiologically under lighter anesthesia (percutaneous endoscopic jejunostomy [PEJ]).10 A jejunal extension tube (JET) may be placed through a PEG tube to allow for simultaneous gastric decompression and jejunal feeding when warranted.

The further the distal end of the tube is placed into the intestinal tract, the greater the potential risk of diarrhea/dumping. Therefore, nasojejunal, jejunostomy, PEJ and JET-PEG feedings need to be administered continuously via a pump. Feedings can be cycled overnight, as tolerated, to allow more freedom during the day. Gastric feedings may be administered as continuous or cycled feedings via pump, or more commonly intermittent gravity drip or bolus feedings. Duodenal feedings pose moderate potential for dumping, and feedings should be administered as tolerated by the individual.


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Enteral Formulas There is quite an array of commercially prepared formulas for EN support. Most patients will

tolerate standard formulas without problems. For those with volume intolerance, the concentrated formulas are good alternatives. It is important to note that concentrated formulas will require greater free water between feedings by mouth or via tube to ensure adequate hydration, unless the person is fluid restricted.

To determine the amount of free water required by a patient, take the percentage of free water/L of formula multiplied by the volume the individual receives. Subtract this number from the estimated daily fluid requirement. Individuals with constipation or diarrhea secondary to their cancer therapy may benefit from a fiber-containing formula, with adequate free water to ensure hydration.

Free Water Requirements for Enteral Feedings

Sample Calculation Formula “X” has 840 cc H2O/L, or 84% (0.84) Patient requires 1800 cc Formula “X”/day Patient requires 2200 cc fluid/day ____________________________________ 0.84 X 1800 cc Formula “X” = 1512 cc free water in 1800 cc Formula “X” 2200 cc fluid required/day – 1512 cc free water from Formula “X” ____________________________________ 688 cc additional free water/day

As indicated in the A.S.P.E.N. guideline recommendations, specialty formulas should be used on an individual basis, as supported by evidence-based practice.4 Immune-enhanced formulas have been shown to decrease infectious complications and length of hospital stay in surgical patients.11-13 However, the subject groups were fairly heterogeneous, and studies varied in length and time of administration of immune-enhancing formulas. The composition of these formulas are varied (e.g., various combinations of arginine, glutamine, nucleic acids and essential fatty acids) and the nutritional status of the evaluated subjects varied as well.

Similar to the immune-enhanced formulas are omega-3 fatty acid-containing formulas designed specifically for cancer patients with solid tumors. Animal and human studies have shown that these formulas can be an effective modulator of cancer cachexia.14-16 The amount of omega-3 fatty acids used to achieve weight stabilization or improvement varied from 2 g/day to 27 g/day, with the enteral product containing 1 g per 240 cc can. The only product with this formulation is no longer sold in the United States due to poor sales, as the price was more than $6 per can. Great Britain still sells this type of product.

Although research is not definitive as to the effects of omega-3 fatty acid-containing formulas on platelets, caution is advised for patients with thrombocytopenia, as supplemental omega-3 fatty acids will thin the blood. Clearly, more research is needed regarding the amount of EPA and tumor types that might benefit from supplementation, as well as its indications/contraindications for individuals with decreased platelets.


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Research is needed to further pinpoint population groups that may derive the greatest benefit from omega-3 fatty acid-containing formulas. Other needed areas of study include trials evaluating the influence of inflammatory response markers, as well as attenuation of weight loss, with the inclusion of omega-3 fatty acids. Inflammatory response markers may become part of the guidelines used to determine the appropriate use of these new formulas.

Parenteral Nutrition Support

The use of PN support in the oncology care setting should be determined by the patient’s disease and functional status, GI function, level of stress and degree of malnutrition.17,18 The benefit of PN should then be evaluated with regard to cost and potential adverse consequences. There are specific areas where PN support is appropriate and necessary, and it should be an adjuvant therapy to conventional cancer treatments.

Indications for PN in People With Cancer4,19 • Nonfunctional GI tract • Bowel rest (whether caused by the cancer or as a consequence

of treatment) • Severe diarrhea • Severe malabsorption • Radiation enteritis • Short bowel syndrome • Intractable nausea and or vomiting • Bowel obstruction • Ileus • Severe pancreatitis • Enterocutaneous fistula • Graft-versus-host-disease of the gut

PN may be administered via a peripheral vein (peripheral parenteral nutrition [PPN]) or central

venous catheter (total parenteral nutrition [TPN]). Peripheral PN Basic PN solutions contain 3% to 15% amino acids and 5% to 70% dextrose. These basic formulas

are used as the basis for all PPN and TPN. Essential fatty acid requirements can be met by providing at least 3% of the total calories as lipid.20 Lipids may be part of the daily admixture or lipid emulsions of 10% to 30% can be added to the PN regimen once, twice or three times/week. Vitamins, trace elements, electrolytes and medications (e.g., famotidine [Pepcid]) can be added to the solution daily.

Risks associated with PPN include phlebitis, sepsis and catheter infiltration. PPN should be limited to short-term use (no more than 14 days) because of the risk of phlebitis and limited venous access. Osmolarity of PPN solutions is limited to 600 mOsm/L to 900 mOsm/L, which limits the dextrose to no greater than 10%, and amino acids to 2.5% to 5%.21 Therefore, nutritional requirements cannot be met with PPN. Lipid added to PPN solutions decreases the risk for phlebitis and can contribute additional non-protein calories.


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TPN TPN solutions are much less limited than PPN in the nutrients that they provide and the duration

of nutrition support. From the base solution, TPN can be formulated to meet the calorie, protein and individual nutrient needs of a patient. Delivery can be done continuously, or in some cases, can be cycled on and off to give patients greater mobility.

Many patients with cancer already have central venous lines for treatment; therefore, the risks associated with central line placement are not increased. Risks associated with TPN fall into three categories: mechanical/technical, infectious and metabolic:

• Mechanical/technical complications have to do with placement, occlusion and breakage of catheters and thrombosis.

• Infectious complications arise from endogenous skin flora, contamination of the catheter hub, seeding of the device from a distant site and contamination of the solution.22

• Metabolic complications can be serious and life-threatening. Adequate monitoring and appropriate interpretation of laboratory values can prevent metabolic complications such as hyper- or hypoglycemia; hypophosphatemia; hypomagnesemia; and other nutrients, fluid and electrolyte imbalances.

NST Safety and Ethical Considerations

NST of critically ill and/or severely malnourished patients can result in serious complications. Refeeding syndrome can result in intracellular shifts of potassium, magnesium, phosphorus and calcium.23 Further metabolic complications of overfeeding include azotemia, fat-overload syndrome, hepatic steatosis, hypercapnia, hyperglycemia, hyperglycemic hyperosmolar nonketotic syndrome (HHNS), hypertonic dehydration, hypertriglyceridemia and metabolic acidosis.24 Continuous monitoring and re-evaluation of patients’ requirements and response to NST are essential.

Oral nutrition is the preferred means of nutrition support and requires the development of individualized nutrition care plans and proactive symptom management, as well as supportive care (e.g., pharmacologic agents and liquid supplements and meal replacements), to achieve adequate oral intake and maintenance of nutritional status. EN and PN support is appropriate in specific instances, particularly in severely malnourished individuals. Decisions regarding implementation of NST are best made on an individual basis using a multidisciplinary approach that includes the patients and their caregivers and families.25 Additionally, dietetics professionals should be familiar with the position statement of the Academy of Nutrition and Dietetics regarding ethical and legal issues in nutrition, hydration and feeding.25

Summary

NST may be accomplished via oral, enteral or parenteral means. EN is not without risk or added healthcare costs, but is preferred over PN in most cases. EN support may be appropriate in the malnourished perioperative patient or when the patient is unable to take adequate oral nutrition for more than seven to 10 days because of nutrition impact symptoms such as esophagitis, mucositis, obstruction of the upper GI tract (that does not preclude intestinal feeding), or dysphagia.

PN may be useful in patients who are unable to take adequate oral or enteral nutrition for more


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than seven to 10 days due to mechanical obstruction, radiation enteritis and/or treatment-related nutrition impact symptoms. Decisions regarding the implementation of nutrition support should be made on an individual basis in a multidisciplinary team setting.

References 1. Charney P, Malone A, eds. ADA Pocket Guide to Enteral Nutrition. Chicago, IL: American Dietetic

Association; 2006. 2. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition

Practice Guideline. Chicago, IL: Academy of Nutrition and Dietetics: 2010. 3. Wong PW, Enriquez A, Barrera R. Nutritional support in critically ill patients with cancer. Crit Care Clin.

2001;17(3):743-767. 4. August D, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of

Directors. A.S.P.E.N. clinical guidelines: Nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472-499.

5. Tchekmedyian NS. Pharmacoeconomics of nutritional support in cancer. Semin Oncol. 1998;25(2 Suppl 6):62-69.

6. Pille S, Bohmer D. Options for artificial nutrition of cancer patients. Strahlenther Onkol. 1998;174(Suppl 3):52-55.

7. Waldfahrer F, Iro H. Basic principles and concepts of enteral nutrition of ENT patients. HNO. 2002;50(3):201-208.

8. Robinson C. Enteral nutrition in adult oncology. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:138-155.

9. Nestle Nutrition. 2012 HealthCare Products Booklet. http://www.nestle-nutrition.com/Products. Accessed July 21, 2012.

10. Given MF, Lyon SM, Lee MJ. The role of the interventional radiologist in enteral alimentation. Eur Radiol. 2004;14(1):38-47.

11. Gentilini O, Braga M, Gianotti L. Rational base and clinical results of immunonutrition. Minerva Anestesiol. 2000;66(5):362-366.

12. Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg. 2002;137(2):174-180.

13. Wu GH, Zhang YW, Wu ZH. Modulation of postoperative immune and inflammatory response by immune-enhancing enteral diet in gastrointestinal cancer patients. World J Gastroenterol. 2001;7(3):357-362.

14. Whitehouse AS, Smith HJ, Drake JL, Tisdale MJ. Mechanism of attenuation of skeletal muscle protein catabolism in cancer cachexia by eicosapentaenoic acid. Cancer Res. 2001;61(9):3604-3609.

15. Wigmore SJ, Barber MD, Ross JA, et al. Effect of oral eicosapentaenoic acid on weight loss in patients with pancreatic cancer. Nutr Cancer. 2000;36(2):177-184.

16. Von Meyenfeldt, Ferguson M, Voss A, et al. Weight gain is associated with improved quality of life in patients with cancer cachexia consuming an energy and protein dense, high N-3 fatty acid oral supplement. Proc Am Soc Clin. Oncol 21: 2002 (abstr 1536).

17. Charney P, Malone A, eds. ADA Pocket Guide to Parenteral Nutrition. Chicago, IL: American Dietetic Association; 2007.

18. De Chicco RS, Steiger E. Parenteral nutrition in medical or surgical oncology. In: Elliott LL, Molseed L, McCallum PD. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:156-164.


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19. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adults and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1Suppl):S1A-138SA.

20. F rankenfield D. Energy and macrosubstrate requirements. In: Gottschlich MM, ed. The Science and Practice of Nutrition Support: A Case-based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:31-52.

21. Mirtallo JM. Introduction to parental nutrition. In: Gottschlich MM, ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:217.

22. Krzywda EA, Andris DA, Edmiston CE, et al. Parenteral access devices. In: Gottschlich MM, ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:230.

23. Hurst JD, Gallagher AL. Energy, macronutrient, micronutrient, and fluid requirements. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:54-71.

24. Klein CJ, Stanek GS, Wiles CE 3rd. Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc. 1998;98(7):795-806.

25. P osition of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108(5):873-882.


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Chapter Eleven: Management of Cancer-related

Nutrition Impact Symptoms

This chapter will review nutrition impact symptoms common to people with cancer, including etiologies of nutrition impact symptoms, medical nutrition therapy (MNT) and symptom management, and pharmacological agents used in symptom management.

For supplemental information to this chapter, please review the following appendices:

Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms Appendix 6 Pharmacological Agents for the Management of Chemotherapy-induced Nausea and

Vomiting Appendix 7 Pharmacological Agents for the Management of Anorexia and Cachexia Appendix 8 Pharmacological Agents for the Management of Constipation Appendix 9 Pharmacological Agents for the Management of Diarrhea Appendix 10 Pharmacological Agents for the Management of Oral Mucositis and Esophagitis Appendix 11 Pharmacological Agents for the Management of Pain

ancer, cancer treatment and recovery from treatment can significantly impact nutritional needs and can affect digestion, absorption, and metabolism. Symptoms that affect nutritional status include nausea and vomiting, changes in taste and smell, bowel changes, dysphagia, anorexia,

pain and fatigue.

Nutrition Impact Symptoms People diagnosed with cancer may experience a myriad of symptoms that have an impact on their

nutritional status. These “nutrition impact symptoms” impede or impact nutrition intake.1 Aggressive management of nutrition impact symptoms is essential to good patient care.2

Identification of nutrition impact symptoms and their etiologies allow for optimum management with medical nutrition therapy (MNT) and appropriate pharmacological agents.

It is important to remember that “cancer” does not present with one basic symptom profile. Symptoms vary from person to person, and depending upon the type of cancer, disease stage, treatment regimens, comorbid diseases, current health and functional status, and age. Each patient should receive individualized care, with respect to symptom identification and management. It is true, however, that there are commonalities in symptoms and management techniques. Experience shows that by listening to patients and working together, nutrition professionals can manage and overcome patients’ nutrition-related problems and concerns.

C

Management of Cancer-related Nutrition Impact Symptoms

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Alterations: Taste and Smell Alterations in taste, or dysgeusia, and alterations in smell can occur secondary to chemotherapy,

xerostomia, infection or psychological conditioning. Taste alterations secondary to chemotherapy are usually reversible, but may take several months to

resolve. Changes occurring with radiation therapy, however, can sometimes be permanent. People undergoing head and neck radiation therapy usually experience more difficulty with

depression or complete loss of taste sensation for sweet, sour, bitter and salty tastes. In contrast, those undergoing chemotherapy are more likely to complain of intolerance to meats (especially red meat), and increased bitter or sweet sensations, as well as strange tastes, such as metallic or “gamey” tastes, even between meals. They may also experience a heightened sense of smell that results in sensitivity to food preparation odors and aversions to nonfood items such as perfumes and soaps.

Nutrition interventions that decrease the aroma of food, such as serving food cold instead of hot, may be helpful. Patients should be encouraged to practice good oral hygiene including regular brushing, gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution will also help to keep the oral cavity clean, moist, and better tasting.

Zinc supplementation (220 mg zinc sulfate twice a day) has been used in cases of depressed taste acuity with some success; however, it is thought that this may only be helpful in patients whose zinc nutriture is suboptimal. Excessive and prolonged use of zinc supplementation may cause immunosuppression and diarrhea, as well as decreased copper and iron absorption.3

Anorexia

Anorexia is defined as the involuntary loss of appetite or the desire to eat, with subsequent reduction of food intake.4.5 It is most likely caused by physiological (e.g., pain, cytokines and fatigue) and psychological (e.g., depression and anxiety) changes caused by the cancer itself or its treatment.6

Anorexia is common among cancer survivors and nearly universal among those with advanced disease. In addition, anorexia may be secondary to other symptoms and side effects of treatment, or may be a unique and unrelated symptom. Nutrition-related factors contributing to anorexia can include alterations in taste and smell, alterations in gastrointestinal (GI) function and metabolic abnormalities.

Alleviation of anorexia is best achieved by treating all potential causes, such as pain, nausea/vomiting, constipation, diarrhea, taste changes and early satiety. If symptoms are treated satisfactorily and anorexia remains, a variety of pharmacological agents can stimulate appetite.

MNT management strategies include a thorough nutrition assessment and physical examination to identify risk for malnutrition and factors related to poor food intake. Patients should be encouraged to increase their intake of nutrient-dense foods, as well as consume small, frequent meals and snacks. In addition, the Oncology Nursing Society’s Putting Evidence into Practice (PEP) statement on anorexia states that individualized dietary counseling is likely to be effective to improve nutritional intake and quality of life.4

Cancer Cachexia Syndrome and Weight Loss

The etiology of cachexia and weight loss observed in cancer survivors is not entirely understood, although experts agree it is most likely multifactorial.7,8 Metabolic alterations and inadequate intake secondary to nutrition-related problems contribute to these symptoms of cancer and its treatment.9 Other factors include anorexia, nausea, vomiting, fatigue, taste and smell alterations, pain, early satiety, constipation, mucositis, diarrhea, xerostomia and malabsorption.10,11

Alleviation of weight loss is best achieved by proactive nutrition assessment, diagnosis, intervention


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and monitoring, as well as by identifying and treating its potential causes. There are several pharmacological agents, as well as liquid nutrition supplements, available to help patients increase their appetite and caloric intake to replenish lean body mass and to arrest weight loss.

Constipation

Constipation is defined as difficult defecation or infrequent defecation (fewer than three stools per week) associated with the passing of hard or dry fecal matter.4 Constipation is common among cancer survivors and can result from dehydration or mechanical changes from cancer.12 In addition, many instances of constipation are secondary to medications, such as opioids. Inadequate intake of fiber and fluid, as well as decreased physical activity, can be contributing factors. Severe constipation can lead to fecal impaction and obstruction.

Constipation should be managed prophylactically, and patients should be encouraged to increase fiber and fluid intake, and increase physical activity as able. These recommendations are supported by the Oncology Nursing Society’s PEP expert opinion on constipation that states that individualized bowel management programs for people experiencing constipation should include fluids, dietary fiber, activity and increased mobility as well as medications to offset constipating side effects of other medications.4

Diarrhea

Diarrhea is a common side effect of cancer treatment.13 Diarrhea is defined as the frequent passage of unformed, watery bowel movements. It can further be described as an increase (from usual) in number and/or liquidity of stools and may be accompanied by abdominal cramping.4 An exact number of stools does not define diarrhea; rather, patients’ diarrhea symptoms should be individually assessed and compared with their normal bowel habits.14 The consequences of diarrhea can be severe and include dehydration and electrolyte imbalances. Nutrition interventions can be very effective in managing diarrhea.

The etiology of diarrhea can be secondary to excess blood or mucus in the GI tract; malabsorption’ dysmotility; osmosis of water into the GI tract to dilute a concentrated substance; increased secretion of electrolytes and fluid (likely the mechanism of chemotherapy-induced diarrhea); or combinations thereof. Chemotherapy can cause diarrhea. Graft-versus-host disease of the gut following allogeneic stem cell transplantation can cause severe diarrhea. Damage to the GI tract from radiation therapy can cause radiation enteritis (acute or chronic).

People with advanced cancer may also experience diarrhea, although constipation is more prevalent among this population. Diarrhea is common among those with cancer diagnoses involving the GI tract such as cancers of the pancreas, gallbladder, colon, rectum, anus or neuroendrocrine cancer, such as carcinoid tumors. Surgeries or procedures that can contribute to diarrhea include celiac plexus block (often done to relieve pain associated with pancreatic cancer), cholecystectomy, esophagogastrectomy, gastrectomy, pancreaticoduodenectomy (Whipple procedure), intestinal resection and vagotomy.15 Radiation therapy involving the abdomen or pelvis or total body irradiation is also a common cause of diarrhea.

Medications, like antibiotics, can contribute to diarrhea, as can intestinal bacterial overgrowth, diet, psychological stress and fecal impaction.

In addition to pharmacological agents, probiotic supplements and water soluble fiber supplementation (e.g., Citrucel, Benefiber), can reduce the incidence and severity of radiation-induced diarrhea.4 Anecdotal reports of glutamine used during radiation therapy are far more favorable than the


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current literature suggests. The effectiveness of glutamine supplementation during chemotherapy may be dependent on the cytotoxic agent(s) used, as well as the timing of the glutamine dosing. Further documentation in the literature is needed in both chemotherapy and radiation therapy. Currently, the recommended dosage is 30 g glutamine/day in two or three doses. Glutamine works best in a powdered form, which is relatively unstable. Each dose should be mixed in water, juice or other soft-moist food and taken immediately.

Dysphagia

Dysphagia, or difficulty swallowing, is often vaguely defined. Pain with swallowing is often classified as dysphagia, while the technical term is odynophagia. Dysphagia refers to an aberration in one or more phases of the swallow, not simply painful swallowing. Logemann describes swallowing in four phases: preparatory, oral, pharyngeal and esophageal:16

• In the preparatory phase , food/drink (the bolus) enters the mouth and the lips, the jaws close and saliva is produced. This action is entirely voluntary.

• The oral phase is voluntary and involves further preparation of the bolus by chewing and mixing with saliva. The tongue propels the bolus to the back of the throat, or the pharynx.

• The pharyngeal phase of the swallow is involuntary and is triggered as the bolus passes the faucial pillars at the back of the mouth. The muscles of the pharynx contract, the nasopharynx is closed, the epiglottis closes, the larynx is raised and vocal cords come together, providing protection of the nasal passages and airway.

• The esophageal phase of the swallow is also an involuntary action. The upper esophageal sphincter relaxes, and peristalsis moves the bolus into the stomach.

Each phase can be affected by cancer and its treatment. Patients who are post-surgical resection for

a variety of oral cancers or those with xerostomia, oral candidiasis, mucositis, poor dentition and history of stroke; and those who are elderly, weak and debilitated, have a history of stroke or have advanced cancer may not be able to properly “prepare” a bolus of food for the pharyngeal phase of the swallow.

The esophageal phase of the swallow is most affected by strictures and esophagitis. Patients with esophageal cancer and those who have had esophageal resection are at greater risk for these types of problems. The elderly may also have increased esophageal transit time, which can cause further difficulties.

Management of Dysphagia It is extremely important for people with dysphagia to be evaluated by a speech pathologist and, if

needed, receive treatment from the speech pathologist. These professionals can provide valuable diagnostic information, as well as techniques for airway protection and recommendations for appropriate diet consistency that can prevent the need for enteral nutrition; they also determine when it is not safe to eat or drink due to risk of aspiration. The dietitian and speech pathologist work together as a team to coordinate the plan of care and patient education, and they should reinforce each other’s care guidelines whenever possible.

There are no medications that can treat dysphagia; however, there are numerous medications that are effective in treating problems such as xerostomia, odynophagia, oral candidiasis and mucositis that contribute to difficult or painful swallowing.


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Early Satiety

Although early satiety is a common symptom of cancer and its treatment, it is often lumped together with anorexia in its identification and treatment.17 Patients often describe feelings of fullness along with loss of appetite. It is often associated with reduced upper GI motility and can be effectively managed with MNT and pharmacological agents such as metoclopramide (Reglan).

Studies have shown that gastric emptying of solids occurs more quickly alone than when liquids are present; therefore, patients should be encouraged to take sips of liquids between meals, throughout the day.18 This recommendation can maximize the intake of energy- and protein-containing foods at meals and snacks rather than "filling up" on lower calorie-containing fluids (e.g., water and juice) at meal/snack time. It is a careful balance of intake of calorie/protein-containing foods and adequate hydration. If fluids are encouraged at meal time the concern is the desired/needed protein and energy intake will not be met: Patients will drink a big glass of juice and then have no room for other foods; thus the recommendation for foods at meal time and fluids between.

Metoclopramide for Management of Early Satiety10,19-21 Action GI stimulant Indication Early satiety Dosage 10 mg 30 minutes before each meal and at bedtime Side effects Restlessness, drowsiness, fatigue, lassitude, extrapyramidal effects,

nausea, diarrhea Comments

It takes about 2 weeks for desired effect; drug is often prescribed for “appetite” and patients expect improvement in appetite immediately. It is important to instruct patient on action of the drug and to take it exactly as ordered for at least two weeks to adequately evaluate efficacy.

Early satiety can also occur secondary to constipation. Many cancer survivors require a

prophylactic bowel regimen program to maintain regular bowel movements and decrease constipation-related symptoms, such as GI gas and bloating.

Fatigue

Fatigue is the most frequently reported and long-lasting side effect experienced by people with cancer.22 Cancer-related fatigue can be defined as distressing or persistent tiredness, as well as a subjective sense of physical, emotional and/or cognitive tiredness related to cancer or cancer treatment that interferes with usual functioning.4 Fatigue is commonly manifest as weakness, tiredness, dizziness, decreased motivation or interest, feelings of sadness, depression, frustration, irritability and decreased cognitive abilities.

Nutrition-related symptoms of fatigue include anorexia, poor nutrition intake, cancer cachexia, weight loss and anemia.23 Collaborative management includes energy conservation, stress management, rest and relaxation, and nutrition consultation to ensure that patients consume adequate dietary intake and hydration.5,24


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Lactose Intolerance Lactose intolerance is a form of malabsorption, caused by inadequate production of lactase, the

enzyme needed to metabolize lactose to glucose and galactose for absorption. People with lactose intolerance experience rumbling gas and/or diarrhea after consuming dairy products.

Symptoms vary depending on the amount of lactose present in the food or beverage. Individual tolerance varies considerably, but most lactose-intolerant people can tolerate up to 12 oz/day, in divided portions, without symptoms. Lactose intolerance approaches 100% in Native Americans and people of Asian descent; it is also common among African Americans and Latinos, affecting nearly 80% of their population. Lactose intolerance is present in about 15% of people of northern European descent.25

The prevalence of lactose intolerance as it relates to cancer and its treatment is not well documented. Some healthcare professionals believe that radiation therapy and chemotherapy can cause lactose intolerance, while others believe that such treatments can exacerbate symptoms in previously subclinical cases. Others believe that cancer patients may consume more dairy products (in the form of cream sauces, milk shakes, casseroles and puddings) than they normally do and experience symptoms related to an underlying lactose intolerance.

Lactase enzymes are sold over the counter under a variety of brand names, as well as generics or store brands. Additionally, lactose-free dairy products (e.g., milk and cottage cheese) that have been pretreated with lactase enzymes are available in most grocery stores in several different fat contents. Enzymes come in chewable tablets or caplets and range in strength from 3000 to 9000 FCC lactase units/tablet or caplet. Instructions to patients should include:

• Begin with one 3000 FCC lactase unit tablet or caplet with a serving of dairy and increase dosage until symptoms are relieved. Patients will learn how many caplets are needed for various foods such as milk, ice cream and cheese.

• Some people may find the lactase enzyme products ineffective and should then try lactose-free products or dairy alternatives such as almond, rice or soy milk products.

Malabsorption Patients with malabsorption may experience gas; abdominal pain; and frequent watery, frothy,

floating, greasy stools that may be malodorous. This is common among pancreatic cancer patients and can occur in patients with GI cancers, particularly after surgical resection.15 Malabsorption is a result of inadequate pancreatic enzymes lipase, protease and amylase.

However, rather than restrict intake in patients who may already have nutrition problems, it is best to treat malabsorption with supplemental pancreatic enzymes. A number of pancreatic enzyme preparations that contain lipase, protease and amylase are available by prescription. These preparations come in capsules, tablets and powders, and are available in a variety of strengths. Potential side effects from pancreatic enzymes include nausea, abdominal cramps and diarrhea.

Mucositis and Esophagitis

Mucositis is defined as inflammation and potentially ulcerative processes of the mucous membranes of the body of individuals receiving chemotherapy and radiation therapy.4 Mucositis can cause pain, which can be severe. Similarly, esophagitis is the inflammation of the esophageal mucosa. Both are common side effects from chemotherapy and radiation therapy. Chemotherapy-induced mucositis usually appears within three to 10 days following chemotherapy, and starts with burning, followed by ulceration of the mucosa. Mucositis or esophagitis secondary to radiation therapy usually


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develops about two weeks into treatment. Its severity depends on the amount of radiation delivered and the patient’s use of alcohol and tobacco, which exacerbate the situation.

Treatment interruptions or dose reductions in therapy may be needed because of severe mucositis or esophagitis; therefore, aggressive supportive care management is warranted. A number of pharmaceutical agents can be used in the supportive care plan. Additionally, glutamine has been investigated in the prevention and treatment of mucositis secondary to chemo- and radiotherapy.26-29

Results have been favorable, although more research is necessary to determine dosage and delivery for maximum benefit. Currently, the recommended dosage is 30 g glutamine/day in two or three doses.

Patients should be encouraged to practice good oral hygiene with regular brushing with an extra-soft tooth brush, gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution (e.g., 1 tsp salt, 1 tsp baking soda mixed into four cups of water, daily) can help to keep the oral cavity clean, moist and better tasting.

Myelosuppression

Myelosuppression refers to the suppression of bone marrow activity by the modalities of cancer treatment and is the most common dose-limiting toxicity of chemotherapy.5 The result of myelosuppression can be a reduction in the number of platelets, red blood cells and white blood cells.30

Thrombocytopenia Thrombocytopenia is a decrease in the number of platelets. Symptoms include petechiae (small tiny

red dots on the skin), excessive bleeding, enlarged liver and/or spleen, blood in the stool and prolonged menstruation. MNT management strategies should encourage patients to consume adequate protein-containing foods for megakaryocyte (a cell in the bone marrow necessary to produce platelets) production and to avoid dry, scratchy foods that could be irritating to the mucosa of the oral cavity and gut.31

Anemia Anemia is a decrease in the number of red blood cells and/or a reduced iron content of the red

blood cells. Symptoms vary depending upon the degree of anemia and include fatigue, weakness, pallor and shortness of breath. Patients with prolonged poor nutritional intake should be encouraged to improve overall energy and protein intake because available iron stores can be greatly diminished due to negative nitrogen stores, weight loss and chemotherapy-related toxicities.32 Management of anemia should include oral iron supplementation only for those with confirmed iron deficiency.

Tolerance to iron supplementation is most often not an "acute" problem or concern for people with cancer. "Nu-iron," an elemental iron that is an iron polysaccharide and has good GI tolerance, is routinely recommended for people not tolerating ferrous sulfate or ferrous gluconate. It is available over the counter. Liquid iron is often very difficult to tolerate, thus for people with treatment- or cancer-related decreased appetite, nausea or early satiety, it is not prescribed. For patients with profoundly low iron stores, IV iron should be administered.

Neutropenia Neutropenia is a decrease in the number of white blood cells, specifically neutrophils. Patients

with cancer who undergo hematopoietic cell transplantation, intensive chemotherapy, and/or radiation


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therapy are at significant risk for infection and neutropenia. When patients are immunosuppressed, neutropenic precautions should be used to minimize exposure to foreign bacteria to decrease the risk of infection and foodborne illness.33

Strategies to reduce risk of infection include hematopoietic growth factors, prophylactic treatment of infection, strict hand washing, and the restriction of foods and beverages that are potentially high in bacteria that could introduce foodborne pathogenic organisms into the GI tract.

Neutropenic precautions are commonly instituted when the absolute neutrophil count (ANC) drops below 1500 mm3, although standard guidelines vary greatly among institutions. Considerations for instituting a neutropenic or low-bacteria diet include the severity and duration of neutropenia, other nutrition-related nutrition impact symptoms, the patient’s nutritional status and prescribed cancer treatment.

Nausea and Vomiting

Nausea can be described as an unpleasant subjective experience or a feeling that arises in the stomach and/or the back of the throat that may or may not be accompanied by vomiting or retching.4 Nausea can occur with other related symptoms such as tachycardia, perspiration, lightheadedness, dizziness, pallor, excess salivation and weakness.5

Nausea is one of the more common symptoms experienced among cancer patients. As many as 50% of patients receiving chemotherapy experience some degree of nausea and vomiting. Chemotherapy-induced nausea and vomiting (CINV) is classified as follows:

• Acute: Occurs 24 hours or fewer after chemotherapy • Delayed: Occurs one to six days after chemotherapy • Anticipatory: Occurs within one week before the actual administration of chemotherapy Nausea and vomiting are controlled by the central nervous system. Nausea is mediated by the

autonomic nervous system, and vomiting is a result of the stimulation of any number of CNS pathways, including a chemoreceptor trigger zone; the cerebral cortex and limbic system response to sensory stimulation, psychological distress and pain; vestibular-labyrinthine apparatus of the inner ear (in response to motion); and peripheral stimuli from visceral organs and vasculature as a result of exogenous chemicals and endogenous substances that accumulate during inflammation, ischemia and irritation.5

Nausea and vomiting may also be secondary to hypercalcemia; volume depletion; water intoxication; tumor invasion of the GI tract, liver or CNS; constipation; medications, such as opioids; infection/septicemia; uremia; delayed gastric emptying; or anxiety.5

Acute nausea and vomiting is presumed to be a result of peripheral stimuli from visceral organs and vasculature, along with stimulation of the chemoreceptor trigger zone. In addition to chemotherapy, radiotherapy to the GI tract, liver and brain are associated with nausea and vomiting.

Chronic nausea and vomiting, not related the administration of chemotherapy, is observed in patients with advanced cancer, and its etiology is most likely due to in part to GI, cranial, metabolic, drug-induced, and chemo/radiation therapy-induced mechanisms.

Treatment of Nausea and Vomiting

Nausea and vomiting, as with all nutrition impact symptoms, should be managed according to its etiologies. The risk for developing CINV is related to specific chemotherapy agent(s) being administered, the dose prescribed and other patient factors.34 The onset and the duration of CINV can be highly variable.35


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To effectively control CINV, oncologists determine the emetogenic level of the chemotherapy agent prescribed and then select the appropriate antiemetic.

Emetogenic Potential of Chemotherapy Agents35,36

Level/Likelihood of Emesis (Vomiting) Individuals Experiencing Emesis (Vomiting) 5 (very high) > 90%

4 (high) 60% to 90% 3 (moderate) 30% to 60%

2 (low) 10% to 30% 1 (very low) < 10%

MNT for Nausea and Vomiting Until vomiting is under control, patients should be cautioned against taking in solid foods, as this

may perpetuate symptoms. Vomiting can lead to dehydration, if not managed proactively. Therefore, patients should contact their physician if nausea and vomiting persists and if they are unable to keep down liquids. Encourage patients to sip on water and clear, calorie-containing liquids such as fruit juices, sports drinks, gelatin and flat soft drinks to ensure adequate hydration.

Pharmacological Management of Nausea and Vomiting Anticipatory nausea and vomiting (ANV) is often difficult to control with pharmacological agents.

A variety of behavioral interventions such as guided imagery, hypnosis and systematic desensitization may be helpful with its management. ANV has been reported in up to 25% of patients as a result of classic conditioning from stimuli associated with chemotherapy.30 Risk factors that may increase the likelihood of ANV include being younger than 50 years, being female, having high levels of anxiety before and during chemotherapy administration, and having susceptibility to motion sickness.5 A referral to a mental health professional is often recommended in the management of ANV.

Acute and delayed nausea and vomiting related to cancer treatment, as well as chronic nausea and vomiting, can be treated with several different pharmacological agents. Combination antiemetic regimens are commonly prescribed for nausea and vomiting management. Generally, a combination regimen includes a dopamine antagonist and other agents that have no dopamine-blocking action.5

The National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines that guide oncologists in the effective management of cancer-related nausea and vomiting using various single and multiple antiemetic agent schemas.37

Oral Infections and Candidiasis Oral candidiasis is a fungal infection (the organism is Candida albicans) of the mouth,

characterized by red mucosa with white “cheesy” patches. It can cause decreased taste acuity, unpleasant mouth taste and mouth pain. It is more common in:

• Immunocompromised patients and those on antibiotic therapy, which destroys normal oral flora and allows for overgrowth of fungus.


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• Patients undergoing radiation therapy to the oral cavity. • Patients treated with corticosteroids.

Fungal infections can spread to the esophagus, causing odynophagia and/or dysphagia. Oral candidiasis can be managed by both MNT and pharmacological agents. Maintaining

optimum nutriture and immune status, as well as aggressive oral hygiene, helps to prevent fungal infections. Patients should be encouraged to practice good oral hygiene including regular brushing, gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution (e.g., 1 tsp salt, 1 tsp baking soda mixed into four cups of water, daily) will also help to keep the oral cavity clean, moist, and better tasting. There are a number of antifungal agents available for use in the oncology population.

Management of Oral Candidiasis4,10,19

Drug Dosage Side Effects Nystatin (Mycostatin)

Oral suspension: 400,000- 600,000 Units qid (half of dose in each side of mouth, retaining in the mouth as long as possible before swallowing) Troches (lozenges): Dissolve one to two tablets in mouth four to five times/day for up to 14 days

Nausea, vomiting, diarrhea

Clotrimazole (Lotrimin)

10 mg oral troches: Dissolve slowly in the mouth five times/day for 14 days (tid for prophylaxis)

Nausea, vomiting, abnormal liver function tests

Fluconazole (Diflucan)

Oral candidiasis: 200 mg PO or IV on the first day, followed by 100 mg qd, for at least two weeks Esophageal candidiasis: 200 mg PO or IV the first day, followed by 100 mg qd for at least three weeks (up to 400 mg/d may be used in severe cases)

Headache, nausea, vomiting, diarrhea, abdominal pain

Amphotericin B (Fungizone, Amphocin)

1 ml (100 mg) oral suspension qid (swish and hold for minute, then spit), for two weeks

None noted

Ketoconazole (Nizoral)

200 mg PO qd, up to 400 mg/d in severe cases, for three to six weeks

Nausea, vomiting

Pain

Pain is one of the most common symptoms of advanced cancer. One does not often associate pain as a nutrition impact symptom unless it is pain associated with eating, digestion or elimination. However, poorly controlled pain can have a profound impact on nutrition intake and nutrition status. Severe pain can cause anorexia, and nausea and vomiting. Poorly controlled pain can lead to a decreased oral intake, followed by loss of appetite, weight loss, fatigue and dehydration.

Xerostomia and Thick Saliva Xerostomia, or dry mouth, is a common nutrition impact symptom and may be acute or chronic. It

is characterized by abnormal dryness of the mouth that can be mild to severe. Scanty, thick, ropey saliva and xerostomia can result from certain chemotherapy agents,

medications, dehydration, oral infections and surgery of the head and neck. In addition, radiation


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therapy to the head and neck area can cause the salivary glands to atrophy and become fibrotic. Patients with xerostomia often experience dental and gum disease, difficulty with eating and/or talking, taste alterations, sleep disturbances due to dryness of the oral cavity and difficulty wearing dentures.

All these related symptoms can further impact nutritional status and patients’ ability to eat. Patients should be encouraged to practice good oral hygiene including regular brushing, gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution (e.g., 1 tsp salt, 1 tsp baking soda mixed into four cups of water, daily) will also help keep the oral cavity clean and moist. Patients should be advised to have a thorough dental examination and cleaning before undergoing cancer treatment.

Pharmaceutical products can stimulate saliva production; artificial saliva products and mouth moisturizers (e.g., Biotene, Salivart and Oasis) are also available. There are no negative side effects, although some patients choose not to use them as a matter of personal preference.

Prescription saliva stimulants, or sialagogues, stimulate production of saliva. Pilocarpine (Salagen) is the only U.S. FDA-approved drug for use as a saliva stimulant. It is given in 5 mg tablets three times daily; some patients may require 10 mg doses, three times a day. The most common side effect of pilocarpine is excessive sweating. In doses exceeding 5 mg, the following side effects may occur: nausea, chills, rhinorrhea, vasodilation, watery eyes, bladder pressure, dizziness, headache, diarrhea and dyspepsia. Saliva production usually increases within 30 minutes of ingesting pilocarpine and continual use maximizes the effect.

Summary

Nutrition impact symptoms are common in oncology practice. MNT interventions as well as pharmacological agents are helpful in managing nutrition impact symptoms. Proactive and aggressive symptom management is the first line of treatment in oncology nutrition. Multidisciplinary care provides the best means of symptom management, using the full complement of tools available.


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Resources for Nutrition Impact Symptoms The Academy of Nutrition and Dietetics’ (AND) Evidence Analysis Library publishes and

updates the Oncology Evidence-Based Nutrition Practice Guidelines.38 This professional reference provides dietetic practitioners with current evidence-based recommendations for managing symptoms and minimizing weight changes, as well as suggestions for maintaining optimal nutrition status before, during and after cancer treatment. Another evidence-based professional resource is the AND’s evidence-based Oncology Toolkit.38 The Toolkit details the benefit of MNT and nutrition counseling provided by dietetic professionals and contains MNT summary recommendations for various cancer sites, progress note documentation and outcome monitoring forms, and professional and patient resource lists.38

The Oncology Nursing Society’s Putting Evidence into Practice: Improving Oncology Patient Outcomes is another valuable professional resource for providing cancer care based on the best available evidence to affect the best possible patient outcomes.4 Cancer and nutrition-related topics and recommendations included in this resource include anorexia, constipation, diarrhea, fatigue, mucositis, nausea and vomiting, and the prevention of infection.

Dietetic professionals should also refer to the Academy of Nutrition and Dietetics’ Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Oncology Nutrition Care when caring for and working directly with individuals at risk for or diagnosed with malignant or pre-malignant conditions in a variety of healthcare settings.39 Free patient education pamphlets are available from the following organizations: National Cancer Institute: 800-4-CANCER

• Eating Hints: For Cancer Patients Before, During and After Treatment • Chemotherapy and You: A Guide to Self-Help During Cancer Treatment • Radiation Therapy and You: A Guide to Self-Help During Cancer Treatment • Home Care for Cancer Patients • Facing Forward: Life After Treatment Series

American Cancer Society: 800-ACS-2345 • Nutrition for the Person with Cancer • Living Smart: The American Cancer Society’s Guide to Eating Healthy & Being Active • Understanding Chemotherapy: A Guide for Patients and Families • Understanding Radiation Therapy: A Guide for Patients and Families • Caring for the Patient at Home: A Guide for Patients and Families

Nutrition and Cancer Treatment Resources for Consumers and Healthcare Professionals Academy of Nutrition and Dietetics: 800-877-1600

• Management of Nutrition Impact Symptoms in Cancer & Educational Handouts. Eldridge B, Hamilton KK. 2004.

• The Clinical Guide to Oncology Nutrition. 2nd edition. Elliott L, Molseed LL, McCallum PD, Grant B, eds. 2006.

American Cancer Society: 800-ACS-2345 • American Cancer Society’s Complete Guide to Complementary and Alternative

Cancer Methods. American Cancer Society. 2010. • American Cancer Society's Complete Guide to Nutrition for Cancer Survivors:

Eating Well, Staying Well During and After Cancer. Bloch AS, Grant BL, Hamilton KK, Thomson CA, eds. 2011.


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References 1. Wojaszek CA, Kochis LM, Cunningham RS. Nutrition impact symptoms in the oncology patient. Oncol

Issues. 2002;17:(2):15-17. 2. Grant B, Hamilton KK. Management of Nutrition Impact Symptoms in Cancer and Educational Handouts.

Chicago, IL: American Dietetic Association; 2004. 3. Riapmonti C, Zecca E, Brunelli F, et al. A randomized controlled clinical trial to evaluate effects of zinc

sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer. 1998;82(10):1938-1945.

4. Eaton LH, Tipton JM. Putting Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009.

5. Polovich M, Whitford JM, Kelleher LO. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 3nd ed. Pittsburgh, PA: Oncology Nursing Society, 2009.

6. Capra S, Ferguson M, Ried K. Cancer: Impact of nutrition intervention outcome--nutrition issues for patients. Nutr. 2001;17(9):769-722.

7. Barber MD. The pathophysiology and treatment of cancer cachexia. Nutr Clin Pract. 2002;17(4):203-209. 8. Plata-Salaman CR. Anorexia during acute and chronic disease. Nutrition. 1997;13(2):159-60. 9. Inui A. Cancer anorexia-cachexia syndrome: current issues in research and management. CA Cancer J Clin.

2002;52(2):72-91. 10. Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In:

Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:165-179.

11. Trujillo E, Nebeling L. Changes in carbohydrate, lipid, and protein metabolism in cancer. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:17-27.

12. Komurcu S, Nelson KA, Walsh D, et al. Common symptoms in advanced cancer. Semin Oncol. 2000;27(1): 24-33.

13. Engelking C. Diarrhea. In: Yarbro CH, Frogge MH, Goodman M, eds. Cancer Symptom Management. 3rd ed. Sudbury, MA: Jones & Bartlett; 2004:538-557.

14. Engelking C, Stuckey-Marshall L, Viele C. Nurse’s Pocket Guide: Assessment and Management of Cancer-related Diarrhea. New York, NY: Cancer Care; 2002.

15. Thomas S. Nutritional implications of surgical oncology. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:94-109.

16. Logemann JA. Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed Publishers; 1983. 17. Nelson K, Walsh D, Sheehan F. Cancer and chemotherapy-related upper gastrointestinal symptoms: the

role of abnormal gastric motor function and its evaluation in cancer patients. Support Care Cancer. 2002;10(6):455-461.

18. Thor PJ, Popiela T, Sobocki J, et al. Pancreatic carcinoma-induced changes in gastric myoelectric activity and emptying. Hepatogastroenterology. 2002;49(43):268-270.

19. Karch AM. 2003 Lippincott’s Nursing Drug Guide. Philadelphia PA: Lippincott Williams & Wilkins; 2003. 20. Ottery FD, Walsh D, Strawford A. Pharmacologic management of anorexia/cachexia. Semin Oncol.

1998;25(2 Suppl 6): 35-44. 21. Nelson KA. Modern management of the cancer anorexia-cachexia syndrome. Curr Pain Headache Rep.

2001;5(3):250-256. 22. Curt AG, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients: new findings

from the Fatigue Coalition. Oncologist. 2000;5(5):353-360.


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23. Nail LM. Fatigue. In: Yarbro CH, Frogge MH, Goodman M, eds. Cancer Symptom Management. 3rd ed. Sudbury, MA: Jones & Bartlett; 2004:47-60.

24. Nail LM. Fatigue in patients with cancer. Oncol Nurs Forum. 2002;29(3):537. Review. 25. S wargerty DL Jr, Walling AD, Klein RM. Lactose intolerance. Am Fam Physician. 2002;65(9):1845-1850. 26. Huang EY, Leung SW, Wang CJ, et al. Oral glutamine to alleviate radiation-induced oral mucositis: a pilot

randomized trial. Int J Radiat Oncol Biol Phys. 2000;46(3):535-539. 27. Anderson PM, Schroeder G, Skubitz KM. Oral glutamine reduces the duration and severity of stomatitis

after cytotoxic cancer chemotherapy. Cancer. 1998;83(7):1433-1439. 28. Decker-Baumann C, Buhl K, Frohmuller S, et al. Reduction of chemotherapy-induced side-effects by

parenteral glutamine supplementation in patients with metastatic colorectal cancer. Eur J Cancer. 1999;35(2):202-207.

29. Cockerham MB, Weinberger BB, Lerchie SB. Oral glutamine for the prevention of oral mucositis associated with high-dose paclitaxel and melphalan for autologous bone marrow transplantation. Ann Pharmacother. 2000;34(3):300-303.

30. Camp-Sorrell D. Chemotherapy: toxicity management. In: Yarbo CH, Frogge MH, Goodman M, Groenwald SL, eds. Cancer Nursing: Principles and Practice. 5th ed. Sudbury, MA: Jones & Bartlett; 2000:444-486.

31. Gobel B. Bleeding disorders. In: Yarbo CH, Frogge MH, Goodman M, Groenwald SL, eds. Cancer Nursing: Principles and Practice. 5th ed. Sudbury, MA: Jones & Bartlett; 2000:709-736.

32. Loney J, Chernecky C. Anemia. Oncol Nurs Forum. 2000;27(6):951-964. 33. Seattle Cancer Care Alliance. Hematopoietic Stem Cell Transplantation Nutrition Care Criteria. 2nd ed.

Seattle, WA: Seattle Cancer Care Alliance; 2002. 34. Ettinger DS. Preventing chemotherapy-induced nausea and vomiting: an update and review of emesis.

Semin Oncol. 1995;22(4 Suppl 10):6-18. 35. Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for classifying the acute emetogenicity of cancer

chemotherapy. J Clin Oncol. 1997;15(1):103-109. 36. Hesketh PJ. Potential role of NK1 receptor antagonists in chemotherapy-induced nausea and vomiting.

Support Care Cancer. 2001;9(5):350-354. 37. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Antiemesis.

www.nccn.org. NCCN Web site. Accessed July 21, 2012. 38. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition

Practice Guideline. Chicago, IL: Academy of Nutrition and Dietetics; 2010. 39. Robien K, Bechard L, Elliott L, et al. American Dietetic Association: revised standards of practice and

standards of professional performance for registered dietitians (generalist, specialty, and advanced) in oncology nutrition care. J Am Die Assoc. 2010;110:310-317, e1-23.


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Appendix 1: The Gastrointestinal Diet 1 and Gastrointestinal Diet 2

The Gastrointestinal Diet 1 (GI 1 diet) and Gastrointestinal Diet 2 (GI 2 diet) are designed to

reduce GI discomfort (such as abdominal pain, nausea, vomiting and diarrhea) after eating. The diets are based on the following guidelines:

• Low fat : Fats are hard to digest and can increase diarrhea. • Low fiber : Certain fibers (insoluble fibers, such as those in whole wheat products) can

increase diarrhea or gas; however, the fibers allowed in the GI 2 diet contain soluble fiber such as apples and pears that help to form stools.

• Low lactose : Dairy products contain a sugar called lactose that may be hard to digest during GI illness. Signs of poor digestion are bloating, gas, abdominal cramping and diarrhea. Lactose-free milk is available as a substitute for regular milk. Oral lactase enzyme tablets can be taken with other dairy products.

• Low acid and irr i tants : Foods that are high in acid or spicy can irritate the mouth, stomach or GI tract.

Start ing the GI 1 or GI 2 Diet The following are recommended when starting the GI diets:

• Carbohydrate-rich and protein-rich foods are easier for the body to digest than high-fat foods. Limit fatty foods to three servings each day at first.

• Limit meal size. Smaller, more frequent meals are easier to digest. • Try one new food at a time. Wait at least three hours before trying another new food. • If your GI symptoms (abdominal pain, nausea, vomiting or diarrhea) increase, do not eat

the most recently introduced food again. Notify the dietitian, nurse or physician about the symptoms.

Progressing on the GI 1 and GI 2 Diets The GI 1 diet does not provide all of the nutrients a person needs to remain healthy, as it is a

modified BRAT diet. If it is to be followed for longer than one week, other nutrition support should be considered. The GI 1 diet should be used to reintroduce easily digested foods and to assess a patient’s tolerance to these foods. The patient should start with the foods listed in the “Foods to Try First” table. Once the patient has tolerated the GI 1 beverages, cereals, starches and fruits for a few days, the foods in the “If Tolerated, Try These Foods” table should be tried, and tolerance of the items assessed. When the GI 1 diet has been tolerated without worsening GI symptoms, the patient may progress to the GI 2 diet. The GI 2 diet offers a greater variety of foods. It can provide adequate nutrition and so may be continued for a long period of time.

Each person is different. What may be best for one patient may not be best for another. The rate of progression from the GI 1 diet to the GI 2 diet and then to a general diet varies among people. The decision to advance the diets is based on each patient’s GI symptoms, and patients should work with a dietitian while progressing on the GI diets to help ensure that nutritional needs are met.

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Foods to Try First Beverages (1 cup)

• Tea, weak decaffeinated or brewed herbal, except peppermint • Gatorade • Rice milk • Lactaid 100% lactose-free milk • Apple juice (half-strength) • Kool-Aid or Tang (half-strength) • Cranberry drinks (half-strength)

Hot Cereals (½ cup), all made with water

• Cream of Rice • Cream of Wheat • Farina • Grits • Malt-o-Meal

Cold Cereals (½ cup)

• Puffed rice • Rice Krispies • Cheerios • Other: _________

Starches (allowed with 1 tsp margarine)

• White bread, plain bagel or English muffin (1 slice) • Pasta: macaroni, egg noodles or plain spaghetti (½ cup) • Potato (no skin), baked or mashed (½ medium or ½ cup) • Rice, white (½ cup) • Saltine crackers (2) • Pretzels (1 oz) • White dinner roll (1)

Fruits (½ cup)

• Applesauce, plain • Banana (½) • Peaches, canned in juice or light syrup • Pears, canned in juice or light syrup

Other

• Lifesavers • Lemon drops • Broth, beef or chicken (1 cup) • Popsicle

Miscellaneous

• Sugar: 1 packet or 1 tsp • Salt: as desired


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If Tolerated, Try These Foods Protein Sources (allowed with 1 tsp margarine or mayonnaise)

• Well-cooked chicken or turkey breast (no skin), baked, broiled or boiled (½ breast or 3 oz)

• Ham, lean (3 oz) • Egg, well cooked only (1) • Fish, baked or poached (3 oz) • Tuna, water packed (¼ cup) • Resource fruit beverage (½ cup) • Pediasure (½ cup) • Ensure, Boost High Protein (½ cup) • Other: _________

Other

• Chicken rice or chicken noodle soup (1 cup) • Sandwiches made with low-fat mayonnaise on white bread: egg salad,

tuna salad, chicken, turkey or lean ham (½ sandwich) • Vanilla wafers or graham crackers (2) • Animal crackers (4) • Angel food cake • Carrots, well cooked (½ cup) • Green beans, well cooked (½ cup) • Sweet potatoes (peeled and mashed) (½ cup)

Reference Introduction to Gastrointestinal Diets. Seattle Cancer Care Alliance Web site.

http://www.seattlecca.org/introduction-to-gastrointestinal-diets.cfm. Accessed July 21, 2012.

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Appendix 2: General Oncology Diet Guidelines “Safe Food” Diet

Diet Guidel ines for General Oncology Patients with Low White Blood Counts (Absolute Neutrophil Count Less Than 1,000) People with decreased immune function due to chemotherapy or radiation, or those receiving

therapy that affects the mouth, esophagus, stomach, intestines, colon or rectum are at increased risk for developing a food-related infection. Following these guidelines will help them protect themselves from infection by preparing food and drinks properly and by avoiding specific foods that are more likely to contain infection-causing organisms.

Milk and Dairy Products

• Eat or drink only pasteurized milk, yogurt, cheese or other dairy products (pasteurized, grade-A milk and milk products).

• Avoid soft mold-ripened and blue-veined cheese, including brie, camembert, Roquefort, stilton,

gorgonzola and blue cheese. • Avoid Mexican-style cheeses, such as queso blanco fresco, as they are frequently made from

unpasteurized milk and are associated with a higher rate of foodborne illness.

Eggs • Cook eggs until the yolk and white are solid, not runny. • Do not eat foods that may contain raw eggs, such as hollandaise sauce, raw cookie dough,

homemade mayonnaise, and Caesar salad dressing. If these foods are prepared at home, use a pasteurized egg product instead of eggs in the shell. (Pasteurized eggs can be found in the dairy case in the grocery store; Egg Beaters is one example.)

Meat, Poultry, Fish and Tofu • Use a food thermometer to ensure meat and poultry reach the proper temperature when cooked.

Red meat and ground beef should reach a minimum internal temperature of 160 degrees F. Ground poultry should reach an internal temperature of 165 degrees F, and whole poultry should reach an internal temperature of 180 degrees F. Casseroles should be cooked to an internal

temperature of 165 degrees F. Do not eat meat, poultry and fish that are spoiled, raw or undercooked.

• Do not eat raw or lightly cooked fish, shellfish, lox, sushi or sashimi. • It is recommended to heat until steaming all hot dogs and “ready-to-eat” luncheon meats, colds

cuts and other deli-style meats before eating. • Cut tofu into 1-inch cubes or smaller, and boil for five minutes in water or broth before eating or

using in recipes. (Note: This process is not necessary if using aseptically packaged, shelf-stable tofu, such as Mori-Nu silken tofu).

Fruits and Vegetables • Raw fruits and vegetables and fresh herbs are safe to eat if they are washed carefully under cold

running water. Special produce sprays are not necessary. Do NOT use soap to wash produce, as soap can cause diarrhea if not thoroughly rinsed off the food.

• Avoid fresh salsas and salad dressings found in the refrigerated section of the grocery store.

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Choose shelf-stable salsas and salad dressings instead. (Shelf-stable refers to unopened canned, bottled or packaged food products that can be stored at room temperature before opening; the

container may require refrigeration after opening.) • Do not eat any raw vegetable sprouts, such as alfalfa, radish, broccoli, mung bean or other

sprouts.

Bread, Grain and Cereal Products • Avoid “bulk bin” sources of cereals, grains or other foods. • Desserts and sweets

• Avoid unrefrigerated, cream-filled pastry products. (Shelf-stable items, such as Twinkies or Ding Dongs, are allowed.)

• Do not consume raw honey or honeycomb. Select commercial, grade-A, heat-treated honey.

Water • Drinking water from a home faucet is considered safe if the water is from a city water supply or a

municipal well serving highly populated areas. • Do not consume well water from a private or small community well unless it is tested at least

yearly and contains no coliforms. It is recommended to use distilled or bottled water if using a

water service other than city water service. • At home, safe water can be made by bringing tap water to a rolling boil for one minute. After

boiling, the water should be stored in a clean, covered container in the refrigerator. Discard

water not used within 72 hours. • Do not drink water straight from lakes, rivers, streams or springs. • Beverages

• Do not drink unpasteurized fruit or vegetable juices. • Do not drink sun tea. Make tea with boiling water, using commercially packaged tea bags.

Dining Out • Eat early to avoid crowds. • Ask that food be prepared fresh in fast-food establishments. (It may help to order the product

prepared slightly differently from standard offerings, such as without pickles.) • Ask if fruit juices are pasteurized. • Avoid raw fruits and vegetables when dining out; save these items for home, where you can wash

them thoroughly and prepare them safely. • Do not eat salsa or other condiments that are unrefrigerated and used by multiple people at a

restaurant. • Ask for single-serving condiment packages. Do not use public self-serve condiment containers. • Avoid salad bars, delicatessens, buffets, smorgasbords, potlucks and sidewalk vendors. These are

high-risk food sources due to potential improper food storage or holding temperature and poor

hygiene by food handlers. • Check the general condition of the restaurant. Are the plates, glasses and utensils clean? Are the

restrooms clean and stocked with soap and paper towels? How clean the restaurant looks may

tell the amount of care taken while preparing the food.

Reference General Oncology Diet Guidelines. Seattle Cancer Care Alliance Web site. http://www.seattlecca.org/general-

oncology-diet-guidelines.cfm. Accessed July 21, 2012.

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Appendix 3: Nestlé’s Mini Nutritional Assessment


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Appendix 4: Scored Patient-Generated Subjective Global Assessment (PG-SGA)

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Appendix 5: Medical Nutrition Therapy for Nutrition Impact Symptoms

Symptom Tips for Symptom Management Potential Secondary Problems

Nausea • Try small, frequent feedings • Try dry, starchy and/or salty foods (pretzels, saltines,

rice, noodles and dry cereals) • Avoid large amounts of liquids on an empty stomach • Sip on liquids between meals • Avoid sweet, rich, greasy and/or spicy foods • Avoid strong odors • Try room temperature, cool or cold foods • Try light exercise and cleansing breaths of fresh air • Try sips of ginger ale, ginger tea or candied dried

ginger • Avoid lying down for about an hour after eating • Avoid favorite foods when nauseated to decrease

potential aversions • Capitalize on the times when feeling best • Take anti-nausea medication as directed

Vomiting Anorexia Weight loss Dehydration Electrolyte imbalances

Vomiting

• If nausea precedes vomiting, try nausea management tips

• Once vomiting subsides, sip on fluids • Breathe deeply and slowly and get fresh air • Take anti-nausea medication as directed

Anorexia Weight loss Dehydration Electrolyte imbalances

Anorexia

• Eat nutrient-dense meals and snacks • Add protein and calories to favorite foods using extra

butter, margarine, olive oil, cheese and protein powder (whey, soy or non-fat dry milk)

• Drink nutrient-dense beverages between meals to avoid feeling too full with meals

• Try a small amount of wine, beer or aperitif to stimulate the appetite, if approved by physician

• Take meals and snacks in pleasant atmosphere • Keep nutrient-dense snacks close at hand and snack

frequently • Try light exercise to stimulate appetite • Capitalize on the times when feeling best (breakfast is

often the best meal of the day) • If prescribed, take appetite stimulant as directed

Weight loss Cachexia Dehydration Electrolyte imbalances

Weight Loss/Cachexia

• Determine cause of weight loss, if possible, and treat appropriately

• Eat small, frequent, nutrient-dense meals and snacks • Add protein and calories to favorite foods using extra

Electrolyte imbalances Impaired organ function Immunosuppression

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• Try a small amount of wine, beer or aperitif to stimulate the appetite, if approved by the physician

• Take meals and snacks in pleasant atmosphere • Keep nutrient-dense snacks close at hand and snack

frequently • Capitalize on the times when feeling best (breakfast is

often the best meal of the day) • If prescribed, take appetite stimulant as directed

Early satiety • Eat small, frequent, nutrient-dense meals and snacks • Add protein and calories to favorite foods using extra


• Take nutrient-dense liquids between meals to avoid feeling too full with meals

• Try a nutrient-dense liquid diet, which may be more quickly digested and absorbed than solid food

• Avoid fried, greasy or rich foods that take longer to digest

• Avoid gassy foods and carbonated beverages that can cause bloating

• Keep nutrient-dense snacks close at hand and snack frequently

• Capitalize on the times when feeling best (breakfast is often the best meal of the day)

• Try light exercise to help stimulate digestion • Consider a medication to help stimulate gastric

emptying

Anorexia Weight loss Cachexia Electrolyte imbalances Bloating Nausea

Constipation • Eat at regular intervals throughout the day • Increase fluid intake to eight to 10 cups/day • Avoid caffeine-containing beverages that can decrease

intestinal hydration and cause stools to be harder • Increase dietary fiber, if able to take adequate fluids • Try hot beverages as a bowel stimulant • Try prune juice as a bowel stimulant • Try hot prune juice for a “double whammy” effect • Try to increase physical activity, as able • Try to establish a schedule for having bowel

movements • Initiate and follow a daily bowel regimen (stool

softeners, stimulant or osmotic laxatives, medicinal fiber and polyethylene glycol)

Nausea Bloating Anorexia Weight loss

Diarrhea

• Add soluble fiber to diet at regular intervals throughout day

• Limit/avoid insoluble fiber

Dehydration Electrolyte imbalances Malabsorption


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• Eat foods containing probiotics (yogurt, kefir) or try a probiotic supplement

• Eat small, frequent meals and snacks throughout the day

• Avoid greasy, fried, spicy or very rich foods • Avoid alcoholic beverages • Avoid caffeine-containing beverages • If lactose intolerant, avoid dairy products or use a

lactase enzyme product • Avoid excessive amounts of sweetened beverages

(fruit drinks, soft drinks, sports drinks and sweet teas) and juices that might contribute to osmotic diarrhea

• Avoid foods, gum and candy that contains sugar alcohols (sorbitol, mannitol and xylitol)

• Increase fluid intake throughout the day • Increase consumption of high-potassium foods if

diarrhea is severe (peeled potatoes, pulp-free orange juice and bananas)

• Increase consumption of high-sodium foods if diarrhea is severe (commercially prepared broths and soups)

• Increase sources of pectin/soluble fiber (peeled apples and potatoes, applesauce, bananas, cooked carrots, white rice, corn or rice cereals)

• Take anti-diarrheal medication as prescribed

Anorexia Weight loss

Malabsorption • Eat several small, frequent meals throughout the day • Avoid fluids and foods that promote diarrhea (intake

and output should be monitored, along with the number, color and consistency of stools to determine which foods are problematic)

• Increase fluid intake throughout the day • Consider use of pancreatic enzymes

Nutrient deficiencies Steatorrhea Weight loss

Lactose Intolerance

• Try lactase enzyme supplement, to help lessen symptoms

• Try dairy products treated with lactase enzyme • Limit/avoid dairy products • Substitute milk with soy, almond or rice milk; or non-

dairy beverage • Increase consumption of non-dairy high calcium foods

Avoidance of dairy products without diet instruction or dietary supplementation could lead to calcium and vitamin D deficiencies

Xerostomia • Try tart foods to stimulate saliva • Sip on liquids or suck on ice chips throughout the day

(aim for eight to 10 cups fluid/day) • Try sipping non-sweetened liquids throughout the day • Rinse mouth frequently throughout the day with a

saline baking soda solution (1 tsp salt and 1 tsp baking soda in four cups of water)

• Avoid caffeine-containing beverages

Difficulty chewing and swallowing Decreased intake of food

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• Avoid alcohol-containing mouthwashes • Avoid alcoholic beverages and tobacco products • Try soft and/or moist foods with extra sauce, dressing,

gravy • Try sucking on sugar-free lemon drops, frozen grapes,

popsicles • Try using a cool mist humidifier when napping or sleeping

Taste Changes

• Try different protein sources such as poultry, fish, eggs, dairy products, beans or soy foods if red meat is unappealing

• Try marinades and spices to mask strange tastes • Use plastic utensils rather than metal to help alleviate

or lessen taste • Try to eat foods at room temperature or chilled • Add lemon, lime, vinegar or salt to foods that seem

too sweet • Try adding lemon, lime, instant decaffeinated coffee

powder, or mint to milkshakes or commercially prepared supplements that taste too sweet

• Rinse mouth frequently throughout the day with a saline baking soda solution (1 tsp salt and 1 tsp baking soda in four cups of water)

• Try sipping pleasant-tasting beverages, sucking popsicles or hard candy, or eating sherbet or sorbet to mask bad taste between meals

• Try fresh or frozen foods rather than canned

Anorexia Decreased intake of food Weight loss

Dysphagia

• Try soft, moist or pureed foods/uniform consistency is best, as opposed to chunky soups and stews

• Eat smaller, more frequent meals and snacks • Avoid breads, cakes, cookies and crackers; or soak in

milk, juice, gravy or sauce before eating • If indicated, follow instructions regarding diet

consistency and swallowing techniques provided by the speech pathologist

• If directed by a speech pathologist: try ice, sherbet/sorbet, or popsicles before a meal to stimulate swallow reflex

• If directed by a speech pathologist, use commercially prepared food thickeners, tapioca, flour, instant mashed potatoes, infant rice cereal and/or cornstarch to thicken liquids

• Consider using a mucosal protectant and/or topical anesthetic

Decreased intake Weight loss

Mucositis

• Try soft, moist foods with extra sauce, dressings and gravies (Use caution when eating acidic ingredients



148


like tomatoes, citrus or vinegar) • Use a straw to direct fluid away from painful parts of

mouth • Avoid alcoholic beverages, citrus, caffeine, tomatoes

and vinegar • Avoid dry, coarse or rough foods • Avoid spicy foods, pepper or hot peppers • Try foods at room temperature or chilled • Try sucking popsicles or ice chips to numb the mouth • Rinse the mouth frequently throughout the day with

saline baking soda solution (1 tsp salt and 1 tsp baking soda in four cups of water)

• Avoid alcohol-containing mouthwashes • Use a soft toothbrush that is replaced regularly • Consider using a topical anesthetic

Esophagitis

• Try soft, moist foods with extra sauce, dressings and gravies (Use caution when eating acidic ingredients like tomatoes, citrus or vinegar)

• Avoid alcohol, citrus, caffeine, tomatoes and vinegar • Avoid dry, coarse or rough foods • Avoid spicy foods, pepper and hot peppers • Try foods at room temperature or chilled • Try sucking popsicles or ice chips to numb the mouth • Rinse the mouth and gargle frequently throughout the

day with baking soda solution (1 tsp salt and 1 tsp baking soda in 4 cups of water)

• Avoid alcohol-containing mouthwashes • Consider using a mucosal protectant and/or topical

anesthetic


Thick Oral Secretions

• If gagging on oral secretions triggers vomiting: – Increase fluid intake to help thin secretions and

hydrate oral cavity – Rinse and gargle frequently throughout the day

with a saline baking soda solution (1 tsp salt and 1 tsp baking soda in four cups of water) to clean oropharynx and temporarily remove thick, ropey secretions

– Try pineapple or papaya to help thin oral and pharyngeal secretions

– Avoid alcohol-containing mouthwashes – Limit caffeine-containing beverages – Try using a cool mist humidifier while napping or

sleeping • Consider using a guaifenesin-containing medication to

help thin secretions

Decreased intake Nausea Vomiting Weight loss

Oral Candidiasis

• Try soft, moist foods with extra sauce, dressings and gravies (Use caution when eating acidic ingredients

Taste changes Sore mouth

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like tomatoes, citrus or vinegar) • Use a straw to direct fluid away from the painful parts

of the mouth • Avoid alcoholic beverages, citrus, caffeine, tomatoes,

vinegar • Avoid dry, coarse or rough foods • Avoid spicy foods, pepper or hot peppers • Try foods at room temperature or chilled • Try sucking popsicles or ice chips to numb the mouth • Rinse the mouth and gargle frequently throughout the

day with a saline baking soda solution (1 tsp salt and 1 tsp baking soda in four cups of water)

• Avoid alcohol-containing mouthwashes • Use a soft toothbrush that is changed regularly • Use anti-fungal medication as directed

Decreased intake Weight loss Can spread to the pharynx and esophagus, causing sore throat and dysphagia

Pain (not specific to alimentary tract)

• Try small frequent feedings • Avoid taking pain medications on an empty stomach • Try soft foods at room temperature or chilled • Try deep cleansing breaths of fresh air • Increase intake of hydrating liquids throughout the day • Initiate and follow a daily bowel regimen, including a

stool softener and laxative • Take pain medications as ordered (to avoid “catching up with the pain”)

Anorexia Nausea Vomiting Sedation Weight loss

References Eating Hints: Before, During, and After Cancer Treatment. National Cancer Institute Web site.

http://www.cancer.gov/cancertopics/coping/eatinghints/page2. Accessed July 21, 2012. Eaton LH, Tipton JM, eds. Putting Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA:

Oncology Nursing Society; 2009. Eldridge B, Hamilton K. Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago,

IL: American Dietetic Association; 2004. Elliott L, Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd edition. Chicago,

IL: American Dietetic Association; 2006. Grant BL, Bloch AS, Hamilton KK, Thomson CA. American Cancer Society Complete Guide to Nutrition for Cancer

Survivors: Eating Well, Staying Well During and After Cancer. Atlanta, GA: American Cancer Society; 2010.

Nutrition in Cancer Treatment: Continuum of Care

Appendix 6: Pharmacological Agents for the Management of Chemotherapy-Induced Nausea

and Vomiting Classificati

on Medicatio

n Route Indication Side Effects Site of

Action Ondansetron (Zofran)

Oral, injection

Prevention of nausea and vomiting associated with single-day highly emetogenic chemotherapy

Headache, fever, diarrhea, constipation, hypotension, transient elevation of liver function

CTZ PGSEC

Granisetron (Kytril)

Oral, injection, transdermal

Prevention of nausea and vomiting during chemotherapy at initial and repeated cycles

Headache, asthenia, diarrhea, constipation, fever, somnolence

CTZ PGSEC

Dolasetron (Anzemet)

Oral, injection

Prevention of CINV Headache, diarrhea, dizziness, fatigue, abnormal liver function

CTZ PGSEC

Serotonin receptor antagonist (5HT3)

Palonosetron (Aloxi)

Oral, injection

Prevention of acute CINV w/initial and repeated cycles of moderately and highly emetogenic chemotherapy; prevention of delayed CINV

Headache, constipation, pruritis, elevated liver enzymes

CTZ PGSEC

NK-1 receptor antagonist

Aprepitant (Emend)

Oral Prevention of acute and delayed CINV in combination w/other antiemetics

Constipation, hiccups, loss of appetite, diarrhea, fatigue, hair loss

CTZ

Corticosteroid

Dexamethasone (Decadron)

Oral, injection

Prevention of CINV caused by moderately emetogenic chemotherapy; prevention of delayed CINV

insomnia, euphoria, headache, anxiety, acne, hyperglycemia, weight gain, peptic ulcer, osteoporosis

Unknown

Dopamine antagonist

Metoclopramide (Reglan)

Oral, injection

Prevention of CINV caused by moderately emetogenic chemotherapy; prevention of

Sedation, extrapyramidal symptoms, dystonia, dizziness, orthostasis

CTZ

Appendices

151

Classification

Medication

Route Indication Side Effects Site of Action

delayed CINV Prochlorperazine (Compazine)

Oral, injection, rectal

Prevention of CINV caused by moderately emetogenic chemotherapy; prevention of delayed CINV


CTZ

Haloperidol (Haldol)

Oral, injection, rectal

Prevention of acute or delayed CINV


CTZ

Cannabanoid

Dronabinol (Marinol)

Oral Prevention of CINV caused by moderately emetogenic chemotherapy

Sedation, euphoria, dysphoria, dry mouth, orthostasis

CNS

Alprazolam (Xanax)

Oral, injection

Prevention of anticipatory nausea and vomiting; used in combination w/other antiemetics as needed for acute or delayed CINV

Sedation, physical dependence

CNS Benzodiazepine

Lorazepam (Ativan)

Oral, injection

Prevention of anticipatory nausea and vomiting; used in combination w/other antiemetics as needed for acute or delayed CINV

Sedation, dependence

CNS

CINV = chemotherapy-induced nausea and vomiting; CNS = central nervous system; CTZ = chemoreceptor trigger zone; PGSEC = peripheral gastrointestinal stimulation to emetic center.

References Chu E, DeVita VT Jr. Physician’s Cancer Chemotherapy Drug Manual 2011. Sudbury, MA: Jones & Bartlett;

2011. Friend PJ, Johnston MP, Tipton JM, et al. ONS PEP resource: chemotherapy-induced nausea and vomiting. In:

Eaton LH, Tipton JM, eds. Putting Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:71-83.

Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009.

Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: Elliott L, Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetics Association; 2006:165-179.

Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones & Bartlett; 2011.

Nutrition in Cancer

152

Appendices

153

Appendix 7: Pharmacological Agents for the Management

of Anorexia and Cancer Cachexia

Classification Medication Name

Route Indication Side Effects Action

Antidepressant

Mirtazapine (Remeron)

Oral

Appetite stimulant; weight gain

Sedation, decreased mental alertness and physical coordination, hypotension, edema

Stimulates appetite

Cannabinoid Dronabinol (Marinol)

Oral capsule

Appetite stimulant; weight gain; antiemetic

Sedation, euphoria, nervousness, dysphoria, dry mouth, orthostasis

Stimulates appetite, leading to improved body weight and mood

Corticosteroid

Methylprednisolone (Prednisolone) Dexamethasone (Decadron)

Oral, injection

Appetite stimulant; antiemetic

Insomnia, euphoria, headache, fluid retention, osteoporosis, hyperglycemia

Stimulates appetite

Dietary supplement

beta-hydroxy-beta-methylbutyrate (HMB) (Juven)

Oral Appetite stimulant and weight gain

Headache, diarrhea, dizziness, fatigue, abnormal liver function

Shown to decrease protein breakdown

Eicosapentaenoic acid (EPA); fish oil

Oral

Weight gain for patients with non-hormone-based solid tumors

Nausea, steatorrhea, “fishy” burps

Appears to affect potential mediators of cachexia, anti-inflammatory effect

Dopamine antagonist

Metoclopramide hydrochloride (Reglan)

Oral, injection

Enhances gastric emptying; antiemetic

Sedation, extrapyramidal symptoms, diarrhea, dizziness, dry mouth, hypotension

Stimulates upper gastrointestinal motility, increasing gastric emptying

Nutrition in Cancer

154


Route Indication Side Effects Action

Synthetic progestin

Megestrol acetate (Megace)

Oral (pill or liquid)

Appetite stimulant and weight gain

Headache, fever, diarrhea, constipation, hypotension, transient elevation of liver function

Appears to stimulate appetite/weight gain in cancer cachexia directly or indirectly by antagonism of tumor necrosis factor (TNF)

References Adams LA, Cunningham RS. ONS PEP resource: anorexia. In: Eaton LH, Tipton JM, eds. Putting Evidence Into

Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:31-34. Chu E, DeVita VT Jr. Physician’s Cancer Chemotherapy Drug Manual 2011. Sudbury, MA: Jones & Bartlett;

2011. Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: Elliott L,

Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetics Association; 2006:165-179.



Appendix 8: Pharmacological Agents for the Management of Constipation

Classification Medication

Name Route Side Effects Mechanism

of Action Medicinal fiber

Psyllium (Metamucil, Citrucel) Wheat dextrin (Benefiber)

Oral powder, chewable wafer, liquid

Diarrhea, abdominal cramping, constipation, bowel obstruction

Absorbs water from intestine, bulk expansion stimulates peristalsis

Hyperosmotic laxatives

Glycerin Rectal suppository or enema

Chronic use alters normal bowel function (lazy bowel), vomiting, dizziness, excessive diarrhea

Local irritant with hyperosmotic action, stimulates evacuation

Lactulose (Cholac)

Oral or rectal solution

Flatulence, abdominal pain and distension, alterations in fluid, electrolyte imbalance, diarrhea

Delivers osmotically active molecules to the intestine, stimulates peristalsis

Lubricant Mineral Oil Oral solution; rectal enema

Excessive diarrhea, headache, vomiting; chronic use alters normal bowel function, impaired absorption of fat soluble vitamins, lipid pneumonitis if reclined

Lubricates intestine, water retention distends colon, stimulates peristalsis and evacuation

Osmotic cathartic

Polyethylene glycol (Miralax)

Oral powder/solution

Chronic use alters normal bowel function, alterations in fluid and electrolyte balance, excessive diarrhea

Osmotic agent that pulls water into the stool, softens stool and causes peristalsis and evacuation

Saline laxatives Magnesium hydroxide (Milk of Magnesia)

Oral tablet or solution

Abdominal cramping, excessive diarrhea; muscle weakness, hypotension, chronic use alters normal bowel function

Draws water into small intestine lumen, stimulates peristalsis and evacuation

Magnesium citrate

Oral solution

Abdominal cramping, excessive diarrhea; chronic use alters normal bowel function

Draws water into small intestine lumen, stimulates peristalsis and evacuation

Stimulant laxatives

Bisacodyl (Dulcolax)

Oral capsule; rectal suppository


Stimulates/irritates smooth muscle of the intestine, increases peristalsis

Senna (Senokot) Oral capsule; rectal suppository


Stimulates/irritates smooth muscle of the intestine, increases peristalsis

Stool softener Docusate (Colace) Oral Abdominal cramping, Reduces surface tension


156


Route Side Effects Mechanism of Action

capsule, syrup, solution

excessive diarrhea; chronic use alters normal bowel function

of the stool, allowing for softening

Opioid receptor antagonist

Methylnaltrexone (Relistor)

Injection

Flatulence, abdominal pain, nausea

Treats opioid-induced constipation in advanced disease, where laxatives have not been effective

References Bisantz AK, Woolery MJ. Constipation. In: Eaton LH, Tipton JM. Putting Evidence Into Practice: Improving

Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:85-104. Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: The

Clinical Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: American Dietetic Association; 2006:165-179.

Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones and Bartlett Publishers; 2011.

GI and mucosal side effects. In: Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009:174-182.

Appendices

157

Appendix 9: Pharmacological Agents for the Management of Diarrhea


Name Route Side Effects Mechanism

of Action Antimotility agents

Diphenoxylate/ atropine (Lomotil)

Oral capsule or liquid

Rash, nausea, blurred vision, vomiting, dry mouth, abdominal cramping, constipation

Inhibits peristalsis, prolongs transit time

Bismuth subsalicylate (Kaopectate)

Oral chewable tablet or liquid

Transient constipation, tinnitus, black stools and tongue

Acts as an absorbent and protectant, decreases stool fluidity

Loperamide hydrochloride (Imodium)

Oral capsule or liquid

Rash, nausea, vomiting, dry mouth, abdominal cramping, constipation

Inhibits peristalsis, prolongs transit time

Tincture of opium (Laudanum)

Oral liquid Nausea, vomiting

Increases GI smooth muscle tone and inhibits GI motility, delays movement of intestinal contents

Medicinal fiber

Psyllium (Metamucil, Citrucel) Wheat dextrin (Benefiber)

Oral powder, chewable wafer, liquid

Diarrhea, abdominal cramping, constipation, bowel obstruction

Absorbs water from intestine, bulk expansion stimulates peristalsis

Miscellaneous antidiarrheals

Octreotide acetate (Sandostatin)

Intramuscular injection (intragluteally)

Rash, flushing, edema, fatigue, headache, dizziness, increased liver function tests, transient hypo- or hyperglycemia, gallbladder problems

Mimics somatostatin, lengthens transit time of intestinal contents, stimulates fluid and electrolyte absorption from GI tract

Cholestyramine (Questran, Questran Light)

Oral powder or chewable bar

Constipation, bloating, gas, nausea, vomiting, heartburn, steatorrhea, indigestion, diarrhea; may decrease absorption of fat-soluble vitamins: A, D, E and K

Acts as a bile acid sequestrant, indicated for individuals after ileal resection

Pancrelipase (Creon, Zenpep,

Oral capsule Constipation, nausea, abdominal cramps, diarrhea

Digestive enzyme, aids in fat, protein and carbohydrate


158


Route Side Effects Mechanism of Action

Pancreaze) absorption GI = gastrointestinal. References Chu E, DeVita VT. Physician’s Cancer Chemotherapy Drug Manual: 2011. Sudbury, MA: Jones & Bartlett; 2011. Muehlbauer P, Thorpe D. Diarrhea. In: Eaton LH, Tipton JM. Putting Evidence Into Practice: Improving

Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:119-134. Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: The

Clinical Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: American Dietetics Association; 2006:165-179.

Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones and Bartlett; 2011.


Appendix 10: Pharmacological Agents for the Management of Oral Mucositis and

Esophagitis Classification Medication

Name Route Side Effects Mechanism of

Action Anti- inflammation agent (corticosteroid)

Prednisone (Deltasone) Elixir (Dexamethasone)

Oral tablets or solution

Headache, electrolyte and fluid retention, increased appetite, peptic ulcer disease, osteoporosis, hyperglycemia

Reduces inflammation of mucosa

Bland rinses Glutamine Oral swish and swallow

Gritty solution that may cause discomfort while swishing in mouth

Emerging evidence suggests reduction of severity and duration of mucositis; may help to reduce oral pain

Saline/baking soda rinse (four cups of water + 1 tsp salt + 1 tsp baking soda)

Oral swish, then spit

None other than aversion to salty taste of solution

Soothes and keeps oral mucosa clean

Cryotherapy Ice chips

Oral cavity, suck on ice five minutes before and 25 minutes after 5-fluorourcil bolus

Oral discomfort secondary to cold

Produces temporary vasoconstriction of oral mucosa; reduces local drug delivery 5-fluorouracil

Topical analgesic coating agent

Gelclair gel Oral viscous gel Oral discomfort Temporarily reduces oral pain

Mucosal protectant/ coating agent

Hydroxypropyl cellulose film

Oral swish and swallow

Burning, stinging, tenderness, swelling, tissue irritation

Adheres to inflamed mucosa and provides a protective coating; helps reduce pain

Sucralfate suspension (Carafate)

Oral swish and swallow

Burning, stinging, tenderness, tissue irritation

Adheres to inflamed mucosa and provides a protective coating; helps reduce pain

Capsaicin

Oral “candy” dissolves in mouth

Burning, stinging or pain

Temporarily reduces oral pain

Lidocaine Oral swish, then spit


Topical anesthetics

BMX solution: Benadryl/Maalox/ Viscous xylocaine (1:1:1 ratio)

Oral swish, then spit



160

References Harris DJ, Eilers JI, Eaton LH. Mucositis. In: Eaton LH, Tipton JM. Putting Evidence into Practice: Improving

Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:193-213. Wilkes GM, Barton-Burke M. Oncology Nursing Drug Handbook: 2010. Sudbury, MA: Jones & Bartlett; 2010. Yarbo CH, Frogge MH, Goodman H. Cancer Symptom Management. 3rd ed. Sudbury, MA: Jones & Bartlett;

2005.

Appendices

161

Appendix 11: Pharmacological Agents for the Management of Pain


Name Route Side Effects

Codeine

Oral, IV

Sedation, headache, dizziness, nausea, vomiting, constipation, paralytic ileus, dry mouth, anorexia, hypotension

Acetaminophen + Codeine (Tylenol + Codeine)

Oral

Sedation, headache, dizziness, nausea, vomiting, constipation, paralytic ileus, dry mouth, anorexia, hypotension

Fentanyl (Duragesic)

Transdermal patch

Sedation, headache, dizziness, nausea, vomiting, constipation, dry mouth, anorexia

Hydrocodone + Acetaminophen (Vicodin)

Oral


Hydromorphone (Dilaudid)

Oral


Morphine sulfate (MS Contin, MSIR, Roxanol, Oramorph)

Oral, oral sustained release, intramuscular, IV, epidural, intrathecal, suppository


Oxycodone (Percodan)

Oral, oral sustained release


Opioid narcotic

Oxycodone + Acetaminophen (Percocet)

Oral


Choline magnesium trisalicylate (Trilisate)

Oral

Diarrhea, nausea, GI bleed, platelet inhibition

Ibuprofen (Advil, Nuprin)

Oral

Headache, dizziness, somnolence, nausea, dyspepsia, GI pain, diarrhea, vomiting, flatulence, constipation, GI bleed, platelet inhibition

Naproxen (Aleve)

Oral Headache, dizziness, somnolence, nausea, dyspepsia, GI pain, diarrhea, vomiting, flatulence, constipation, platelet inhibition

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Salsalat (Disalcid)

Oral

Headache, dizziness, somnolence, nausea, dyspepsia, GI pain, diarrhea, vomiting, flatulence, constipation, platelet inhibition

Acetaminophen (Tylenol)

Oral or rectal suppository

More than 4 g/day increases hepatic toxicity, do not exceed 2.5 g/day in people who drink 2 oz of alcohol daily, nausea, vomiting

Non-opioid analgesics

Tramadol Oral Sedation, dizziness/vertigo, headache,


162


Route Side Effects

(Ultram) hypotension, nausea, vomiting, constipation, flatulence

References Aiello-Laws LB, Ameringer SW. Pain. In: Eaton LH, Tipton JM. eds. Putting Evidence into Practice: Improving

Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:215-234. Wilkes GM, Barton-Burke M. Oncology Nursing Drug Handbook: 2010. Sudbury, MA: Jones & Bartlett; 2010.

Appendices

163

Appendix 12A: Nutritional Implications of Chemotherapy

Chemotherapy/

Cytotoxics

Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia

Mucositis/

Stomatitis

Diarrhea Other

Asparaginase (Elspar)

ALL Moderate Yes

Yes Weight loss, fever, hyperglycemia, abdominal pain

Azacitidine (Vidaza)

MDS

Mild to moderate

Mild

Yes Yes Yes

Elevated creatinine, hypokalemia, fever

Bleomycin (Blenoxane)

Head and neck, NHL, HD, cervical, testicular

Mild Very low

Yes

Yes

Weight loss, xerostomia, pulmonary fibrosis

Busulfan (Myleran)

CML, HCT preparation

Mild to Moderate

High to very high

Yes

Yes

Pulmonary fibrosis, alopecia, if oral take on empty stomach to decrease nausea and vomiting

Capecitabine (Xeloda)

Breast, met. colon

Moderate Very low Yes Yes Yes

Hand and foot syndrome, fever

Carboplatin (Paraplatin)

Ovarian, lung, testicular

Moderate to severe

High

Yes

Ototoxicity, taste alterations

Carmustine (BCNU )

HD, NHL, CNS tumors

Moderate to severe

High to very high

Yes

Yes

Pulmonary toxicity

Chlorambucil (Leukeran)

CLL, HD, NHL Mild to moderate

Very low Yes Pulmonary fibrosis

Cisplatin (Plantinol-AQ, DDP)

Lung, ovarian, testicular, head and neck, HD, NHL

Mild to moderate

High to very high

Yes

Yes

Decreased serum Mg, K, Zn; taste changes, ototoxicity, adequate hydration to prevent renal toxicity

Cyclophosphamide (Cytoxan)

Breast, ovarian, lymphomas, leukemias

Moderate to severe

Low to moderate

Yes

Yes

Xerostomia, abdominal pain, pulmonary fibrosis, if oral


164

Chemotherapy/ Cytotoxics

Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia

Mucositis/

Stomatitis

Diarrhea Other

encourage fluid intake, hematuria

Cytarabine (Cytosar-U, Ara-C)

Leukemias, lymphomas

Moderate to severe

Moderate to very high

Yes Yes

Yes

Flu-like symptoms, CNS toxicity

Dacarbazine (DTIC) Melanoma, sarcomas, HD

Moderate Very high Yes

Yes

Yes

Taste changes, flu-like symptoms

Dactinomycin (Actinomycin)

Sarcoma, testicular

Moderate to severe

Very high Yes

Yes

Yes

Xerostomia, taste changes, radiation recall

Daunorubicin hydrochloride (Daunomycin)

ALL

Moderate to severe

Moderate to high

Yes

Yes

Yes

Xerostomia, taste changes, cardiotoxicity

Docetaxel (Taxotere)

Breast, lung, head and neck, met. ovarian

Severe

Low

Yes Yes

Yes

Neuropathy, risk for acute allergic reaction during infusion Hair loss

Doxorubicin hydrochloride (Adriamycin)

Breast, HD, NHL, ovarian, lung, ALL, AML, thyroid

Moderate to severe

Low to high

Yes

Yes

Yes

Xerostomia, alopecia, hand and foot syndrome, cardiotoxicity

Epirubicin (Ellence)

Breast

Moderate Low to high Yes

Yes

Yes

Alopecia, cardiotoxicity

Etoposide (Vepesid, VP-16)

Lung, ALL, HD, NHL, testicular

Moderate Low

Yes

Yes

Yes

Hypertension, fever

Fludarabine phosphate (Fludara)

CLL, lymphomas

Moderate to severe

Very low

Yes

Yes

Yes Neurotoxicity

Fluorouracil (5-FU)

Colorectal, esophageal, head and neck, stomach

Moderate Low

Yes

Yes

Taste alterations, hand and foot syndrome, ice chips pre/post IV bolus to reduce mucositis

Gemcitabine hydrochloride (Gemzar)

Pancreas, bladder, lung, ovarian

Mild to moderate

Low

Yes

Yes

Fever, rash, dyspnea , hematuria

Hydroxyurea (Hydrea)

CML, melanoma

Moderate Very low Yes

Yes

Yes

Severe anemia

Idarubicin (Idamycin PFS)

ALL

Mild to moderate

Moderate Yes

Yes

Cardiotoxicity, alopecia

Ifosfamide (Ifex) Lung, NHL, testicular, sarcomas

Moderate Moderate Yes

Yes

Yes

Cystitis, CNS toxicity, hair loss

Appendices

165


Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia

Mucositis/

Stomatitis

Diarrhea Other

Irinotecan (Camptosar)

Met. colorectal Moderate to severe

High Yes

Yes

Fever, abdominal pain

Mechlorethamine (Nitrogen mustard)

Severe

Very high Yes

Yes

Yes

Taste changes, fever

Melphalan (Alkeran)

Myeloma, ovarian, melanoma, sarcomas

Moderate

Very low Yes

Yes

Yes

If oral take on empty stomach

Mercaptopurine (Purinethol)

ALL, AML, CML, NHL

Moderate

Very low

Yes

Yes

Yes

Biliary stasis, pancreatitis, rash

Methotrexate sodium (Trexall)

HD, breast, lymphomas, leukemias

Moderate

Low to high Yes

Yes

Yes

Folic acid containing vitamins should be avoided, taste changes

Mitomycin (Mutamycin)

Pancreas, stomach, lung

Severe

Low

Yes Yes

Yes

Alopecia, hypercalcemia

Mitoxantrone (Novantrone)

Breast, prostate, lymphomas

Mild to moderate

Moderate Yes

Yes

Blue discoloration of urine

Oxaliplatin (Eloxatin)

Met. colorectal Mild to moderate

Moderate Yes Yes Yes

Avoid exposure to cold food and drinks for four days after infusion

Paclitaxel (Taxol)

Breast, ovarian, lung, head and neck

Moderate to severe

Low Yes Neuropathy, fatigue

Pemetrexed (Alimta)

Mesothelioma, met. lung

Moderate to severe

Low Yes Yes Yes To reduce hematologic toxicity supplement with folic acid and vitamin B-12 , dysnea

Procarbazine (Matulane)

HD, brain Moderate to severe

High Yes

Yes

Yes

MAO inhibitor (low tyramine diet indicated)

Streptozotocin (Zanosar)

Carcinoid, pancreas

Moderate

High

Yes

Hyperglycemia, proteinuria

Temozolomide (Temodar)

Brain

Moderate

Moderate Yes

Yes Headache, fatigue

Thiotepa (Thioplex)

Bladder, brain, lymphomas

Moderate

Very low Yes

Yes

Renal toxicity

Topotecan (Hycamtin)

Met. ovarian, lung

Severe

Low

Yes

Yes

Fever

Vinblastine sulfate (Velban)

Testicular, HD

Moderate

Moderate Yes

Yes

Jaw pain, peripheral


166


Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia

Mucositis/

Stomatitis

Diarrhea Other

neuropathy, paralytic ileus, constipation

Vincristine sulfate (Oncovin)

Lymphomas, sarcomas, breast, lung

Mild

Very low Yes

Yes

Peripheral neuropathy, constipation, jaw pain, paralytic ileus

Vinorelbine tartrate (Navelbine)

Lung, breast, ovarian, HD

Moderate to severe

Low Yes Yes Neuropathy, constipation

ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic lymphocytic leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI = gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkin’s disease; HER2/neu + = human epidermal growth factor receptor 2 positive; MAO = monoamine oxidase MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-Hodgkin’s lymphoma.

Appendices

167

Appendix 12B: Nutritional Implications of Hormone Therapy

Hormone Therapy

Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia

Mucositis/ Stomatitis

Diarrhea Other

Anastrozole (Arimidex)

ER+ breast Low

Hot flashes, headaches , mood changes

Bicalutamide (Casodex)

Prostate

Low

Yes

Hot flashes, decreased libido, impotence, back pain

Exemestane (Aromasin)

ER+ advanced breast, post-menopausal

Low

Yes

Hot flashes, fatigue, increased appetite, increased sweating , depression

Flutamide (Eulexin)

Met. prostate Low Yes

Hypertension, hot flashes, impotence, edema, gynecomastia

Fulvestrant (Faslodex)

ER+ met. breast, postmenopausal

Low

Yes

Yes

Yes

Myalgia, flu-like symptoms, hot flashes, constipation, edema, bone pain, insomnia

Goserelin (Zoladex)

Prostate, breast, endometriosis

Low Yes Gynecomastia, hot flashes, impotence, bone pain, headache

Letrozole (Femara)

Breast, postmenopausal

Low Yes Bone pain, hot flashes, arthralgia, dyspnea, fatigue, constipation, headache, chest pain

Leuprolide (Lupron)

Prostate, breast, endometriosis

Low Yes Gynecomastia, hot flashes, impotence, bone pain, sodium retention, headache

Tamoxifen (Nolvadex)

ER+ breast Low Edema, menstrual irregularities, hot flashes, hypercalcemia

Toremifene (Fareston)

Met. breast, postmenopausal

Low

Hot flashes, sweating, vaginal changes, edema, dizziness

ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic


168

lymphocytic leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI = gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkin’s disease; HER2/neu + = human epidermal growth factor receptor 2 positive; MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-Hodgkin’s lymphoma.

Appendices

169

Appendix 12C: Nutritional Implications of Biotherapy and Antiangiogenic Agents

Biotherapies

Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia


Diarrhea Other

Monoclonal antibodies Bevacizumab (Avastin)

Met. colorectal

Mild

Moderate Yes Moderate Yes

Hypertension, hemorrhage, proteinuria

Bortezomib (Velcade)

Multiple myeloma

Moderate Low Moderate Yes Yes

Peripheral neuropathy, hypotension, fatigue, blurred vision

Cetuximab (Erbitux)

Met. colorectal, head and neck (wild-type KRAS)

Mild

Low

Yes

Yes

Rash, hypotension, fever, malaise

Erlotinib (Tarceva)

Advanced or met. lung

Moderate Yes Yes Yes Rash, abnormal liver function test, GI bleeding, conjunctivitis

Ibritumomab Tiuxetan (Zevalin)

Non-Hodgkin’s lymphoma

Moderate

Allergic reaction during infusion, fever, chills, headache, dyspnea

Imatinib mesylate (Gleevec)

CML

Moderate

Low Yes

Edema, fluid retention, GI irritation, hepatotoxicity

Lenalidomide (Revlimid)

Multiple myeloma, MDS

Moderate

Yes

Rash, dyspnea, peripheral edema, dizziness, headache, muscle cramps

Rituximab (Rituxan)

NHL (CD20+)

Moderate

Moderate Moderate Fever, chills, rash, angioedema, abd pain, back pain, arthralgia, dyspnea

Tositumomab I-131 (Bexxar)

NHL (CD20+)

Moderate

Low Yes Yes

Anaphylaxis, hypothyroidism, fever, infection, MDS

Trastuzumab (Herceptin)

HER2/neu + met. breast

Moderate

Moderate Yes Yes Chills, fever, rash, vague pain sensation, cardiomyopathy, headache

Panitumumab (Vectibix)

Met. colorectal

Moderate

Moderate to high

Yes

Yes

Rash, fatigue, Itching, hypomagnesemia


170

Biotherapies

Indication (Cancer)

Myelo-suppression

Nausea/ Vomiting

Anorexia


Diarrhea Other

Miscellaneous Agents Interferon Alfa-2B (Intron A)

Leukemia, melanoma, chronic hepatitis

Moderate to high

Moderate Yes Fever, chills, malaise, myalgia, headache, fatigue, pancreatitis, renal toxicity

Interleukin, Aldesleukin (Proleukin, IL-2)

Renal cell, melanoma

Moderate Yes

Yes Yes

Fever, rigors, malaise, hypotension, anemia, capillary leak syndrome, dizziness

Hemopoietic Growth Factors Darbepoetin (Aranesp)

Increase red blood cells

Mild Moderate Moderate Pain at injection site, hypertension, myalgia

Erythropoietin (Procrit, Epogen)

Increase red blood cells

Pain at injection site, hypertension, myalgia

Granulocyte-colony-stimulating Factors Filgrastim (Neupogen)

Promote neutrophils

Bone pain, flu-like symptoms

Pegfilgrastim (Neulasta)

Promote neutrophils

Moderate Mild Mild Bone pain, flu-like symptoms

Romiplostim (Nplate)

Platelet booster

Mild

Mild Mild Increase risk of blood clots, headache, joint pain, myalgia, abdominal pain, dizziness

Antiangiogenic Agents Bevacizumab (Avastin)

Colorectal, lung

Moderate

Mild Mild Yes

Weakness, vague pain, hemorrhage, hypertension, proteinuria, CHF, headache, GI perforation, wound healing

ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic lymphocytic leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI = gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkin’s disease; HER2/neu + = human epidermal growth factor receptor 2 positive; MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-Hodgkin’s lymphoma.

References Grant B, Byron J. Nutritional implications of chemotherapy. In: The Clinical Guide to Oncology Nutrition. 2nd ed.

Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: American Dietetic Association; 2006:72-87. Angiogenesis and antiangiogenic agents. In: Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and

Biotherapy Guidelines: Recommendations for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009:34-72.



Appendix 13A: Nutritional Implications of Surgical Oncology

Symptom Bile

Duct

Brain

Breast

Colorectal

Esophagus

Gallbladder

Gastric

GYN

Altered taste Bloating X Bowel obstruction/ileus

X X

Chyle leak X X X Constipation Dehydration X X Diarrhea X X X X X Difficulty chewing

Dumping syndrome

X X

Dysphagia X Early satiety X X X X Esophagitis Fatigue X X X X X X X X Fluid/electrolyte imbalance

X X X X

Gas X X X Gastritis X X Gastrointestinal bleed

X X X

Hyperglycemia X Malabsorption X X X X Maldigestion X X X Nausea and vomiting

X X X X

Nutrient deficiencies

B-12, A,

D, E, K,

Ca, Fe, Zn

B-12 B-12, A, D, E, K, Ca, Fe,

Zn

B-12, D, Fe,

Ca

Odynophagia X Steatorrhea X X X X Urinary changes

Weight gain X X Weight loss X X X Wound healing X X X X X X X X


172

Appendix 13B: Nutritional Implications of Surgical Oncology

Symptom Head/Ne

ck Hepatic Lung Pancreas Prostat

e Small

Intestine

Amputation

Altered taste X Bloating Bowel obstruction/ileus

X

Chyle leak X X X X Constipation Dehydration X Diarrhea X X X Difficulty chewing X Dumping syndrome

X

Dysphagia X X X Early satiety X X X Esophagitis X Fatigue X X X X X X X Fluid/electrolyte imbalance

X X X

Gas Gastritis Gastrointestinal bleed

Hyperglycemia X X Malabsorption X X X Maldigestion X X Nausea and vomiting

X

Nutrient deficiencies

B-12, A, D, E, K, Mg, Zn,

Folic Acid

B-12, A, D, E, K,

Ca, Fe, Zn

B-12, A, D, E, K, Ca, Fe,

Zn

Odynophagia X Steatorrhea X X Urinary changes X Weight gain Weight loss X X X X X X X Wound healing X X X X X X X

References Thomas S. Nutritional implications of surgical oncology. In: Elliott L, Molseed LL, McCallum PD, Grant B, eds.

The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:94-109. Huhmann MB, August D. Surgical oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology

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Patients. Sudbury, MA: Jones & Bartlett; 2010:101-136.


174

Appendix 14: Complications Secondary to Enteral Feeding

Complication Possible Causes Treatment/Prevention

Tube Displacement/ Migration

Coughing, vomiting, uncooperative patient

Replace tube and confirm placement

Crushed medications Thoroughly crush medications; use liquid medications whenever possible

Incompletely dissolved formula

Mix formulas thoroughly

Tube Occlusion

Failure to irrigate Flush adequately Irrigation with

inappropriate substance (i.e., cranberry juice, cola)

Flush only with clear water (saline or plain club soda, as appropriate)

High Residuals

Decreased gastric motility

↑ head of bed 30 degrees

Prokinetic agents Check residuals frequently Duodenal or jejunal feedings

Aspiration Altered gastric motility or gag reflex

Continuous infusion; check residuals often; prokinetic agents

Vomiting Concentrated formula; antiemetics; decrease feeding rate

Gastric Reflux Patient not upright or at an incline

↑ head of bed 30 degrees

Displaced tube Monitor tube placement; distal end of tube should be beyond ligament of Treitz

Nausea/Vomiting Formula administration Advance rate and concentration gradually; continuous infusion; decrease rate and/or concentration

Cramping Lactose intolerance; cold formula

Use lactose-free formula; formula at room temperature

Distention/Bloating Volume sensitivity Concentrated formula; decrease rate; prokinetic agent

Hypermotility Antibiotic therapy Fiber-containing formula; anti-motility agents Diarrhea

Formula administration

Advance rate and concentration gradually; continuous infusion; decrease rate and/or concentration

Overfeeding Reduce excess caloric intake Lactose intolerance Lactose-free formula Hypoalbuminemia

malnutrition Elemental diet initially; administer albumin

Malabsorption Pancreatic enzymes Bacterial contamination Use clean administration technique; change

solutions frequently; hang feeding for four hours or less

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Complication Possible Causes Treatment/Prevention

Constipation Inadequate fluid Increase free water Decreased gastric motility

Fiber-containing formula; prune juice

(preceded and followed by adequate tube flushing with clear water)

Inadequate bulk Fiber-containing formula Medications Daily stool softeners; laxatives as needed Inadequate activity Increase activity, as able

References Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Enteral Nutrition. Chicago, IL:

American Dietetic Association; 2006. Robinson CA. Enteral nutrition in adult oncology. In: The Clinical Guide to Oncology Nutrition. 2nd ed. Elliott

LL, Molseed LL, McCallum PD, Grant BL, eds. Chicago, IL: American Dietetic Association; 2006:138-155.


176

Appendix 15: General Formulary Information for Oral and Enteral Nutritionals

Category Caloric

density (kcal/cc)

Protein Density

Osmolality (mOsm/kg H2O)

Characteristics

Possible usage

Standard, Ready-to-use, oral and/or enteral

1.0–1.25

8.8–10 g/240

cc

270–670

Flavored or unflavored; some products designed for oral or enteral use, while others are only for enteral use

Uncomplicated oral supplementation or tube feeding

Clear liquid “Juice” drink

0.67–1.25

6.5–0 g/240

cc

750–990

Available in a variety of fruit flavors

For patients requiring clear liquid diet, or preferring lighter, “non-milky” supplements

Concentrated

1.5–2.0

13–21.3 g/240

cc

680–870

Same as standard formulas

Patients with volume intolerance, higher calorie and/or protein needs

Fiber-containing

1.06–1.25

40–68 g/L

300–650

Same as standard Formulas

Patients requiring regulation of bowel function

Fructooligo-saccaride-containing

1.0–1.2

35.2–55.5 g/L

450–500 1.0 g FOS/240 cc

To promote healthy bacterial growth and intestinal tract health

High protein

0.95–1.5

44–60 g/L

300–610

Same as standard Formulas

For patients requiring greater protein without greater calories

Elemental/semi-elemental

1.0–1.5

21–94 g/L

320–630

Usually unflavored, but flavor packets may be available

• Inflammatory bowel disease

• Short-gut syndrome • Transition from TPN to

enteral therapy • Non-specific

malabsorptive/maldigestive states

• Need for postoperative feeding

Disease-specific

1.0–2.0

30–75 g/L

665–700

High branched-chain amino acids in hepatic formulas

Acute or chronic renal failure; predialysis, hepatic failure

Immune- 1.0–1.5 56–84 375–630 May contain Pre- and/or perioperatively

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Category Caloric density (kcal/cc)

Protein Density

Osmolality (mOsm/kg H2O)

Characteristics

Possible usage

enhanced g/L

arginine, glutamine, RNA, and EPA

EPA-containing 1.27–1.5

16–21 g/240

cc

635–800

1 g EPA/240 cc; 480 cc/day recommended as an oral supplement or as part of an enteral feeding plan; may contain 3 g fiber/240 cc

Solid tumors, especially with suspected hypermetabolism and/or inflammatory process

EPA = eicosapentaenoic acid; FOS = fructooligosaccaride; RNA = ribonucleic acid; TPN = total parenteral nutrition.

References Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Enteral Nutrition. Chicago, IL:

American Dietetic Association; 2006. Robinson CA. Enteral nutrition in adult oncology. In: The Clinical Guide to Oncology Nutrition. 2nd ed. Elliott

LL, Molseed LL, McCallum PD, Grant BL, eds. Chicago, IL: American Dietetic Association; 2006:138-155.

Appendices

Appendix 16

Glossary

Abdominal carcinomatosis: widespread dissemination of carcinoma throughout the abdomen.

Acute lymphocytic leukemia: acute onset of unrestrained growth of nongranular leukocytes, more common in children.

Acute myelogenous leukemia (acute myeloid leukemia, acute nonlymphocytic leukemia, granulocytic leukemia, myeloblastic leukemia, splenomedullary leukemia, splenomyelogenous leukemia): acute onset of unrestrained growth of particular subtypes of myelocytes, or leukocyte precursors.

Adjuvant: that which assists, hastens or increases the action of a principal ingredient.

Allogeneic transplant (allograft): stem cell transplant wherein related or unrelated donor’s HLA matched cells are transplanted into the recipient.

Alveolar soft-part sarcoma: malignant tumor arising from vascular tissue; a variant of rhabdomyosarcoma; see also sarcoma.

Anaphylactic reaction: a life-threatening allergic reaction.

Angiosarcoma: malignant tumor arising from vascular tissue; see also sarcoma.

Anorexia: loss of appetite.

Antineoplastic: preventing the development, growth or proliferation of malignant cells.

Antithymocyte globulin: a potent immunosuppressive agent.

Apheresis: a process in which blood is drawn from a donor or patient and a component (stem cells, platelets, plasma or white blood cells) is separated out, with the remaining blood components being returned to the body.

Aplastic anemia: a rare bone marrow disorder characterized by decreased function of the bone marrow, which results in abnormally low levels of all the cellular elements of the blood (pancytopenia). In some cases, the disorder may affect primarily single cell lines (i.e., red blood cells, white cells or platelets).

Autologous transplant (autograft): a stem cell transplant where the patient’s own stem cells are transplanted, after being purged of cancerous cells.

Basal cell carcinoma: skin cancer with low incidence of metastasis and is common among the elderly; accounts for more than 90% of all skin cancer in the United States; secondary to sun exposure.

Benign: description of a non-cancerous tumor; it is also used to describe a mild or non-life threatening illness or medical condition.

Biotherapy (biological response modifiers, immunologicals): a broad term encompassing the use of various agents, most of which occur naturally, to induce or enhance the patient’s own immune responses to disease.

Bolus: a soft mass of chewed food; a dose of enteral formula administered fairly rapidly, as opposed to administration via continuous or gravity drip.


179

Glossary

Brachytherapy: radiation treatment given by placing radioactive material directly in or near a target.

Buccal mucosa: the inner lining of the cheeks and lips.

Cancer cachexia syndrome: wasting; decreased body weight characterized by significant loss of both adipose tissue and muscle mass.

Candidiasis: overgrowth of the Candida albicans yeast, usually found in moist, warm areas of skin (i.e., vagina, mouth/throat); thrush (a condition characterized by patches of white inside the mouth and/or throat); tends to develop when the normal balance of bacterial flora in the area is upset, as with antibiotic use.

Carcinoma: a malignant tumor occurring in epithelial tissue.

Carcinomatosis: widespread dissemination of carcinoma.

Chemoprevention: the use of natural or synthetic substances to reduce the risk of developing cancer or to reduce the risk of recurrence.

Chemotherapy: chemical/drug treatment; see also CNS prophylaxis, consolidation, induction, intrathecal and maintenance.

Chronic lymphocytic leukemia: chronic disease with abnormal proliferation of lymphocytes.

Chronic myelocytic leukemia (chronic myelogenous leukemia, chronic granulocytic leukemia): chronic disease of the bone marrow that causes rapid growth of the blood-forming cells (myeloid precursors) in the bone marrow, peripheral blood, and body tissues.

Chylothorax (chyle leak, chylous leak): fluid consisting of a mixture of lymphatic fluid (lymph) and chylomicrons that has entered the pleural cavity.

Central nervous system (CNS) prophylaxis: preventive therapy using intrathecal and/or high-dose systemic chemotherapy to the CNS to kill leukemia cells present there or to prevent the spread of cancer cells to the brain and spinal cord even if cancer has not been detected there.

Consolidation: high-dose chemotherapy, following induction, to attempt to kill any remaining leukemia cells.

Cori Cycle: the metabolic cycle of reactions in which glycogen is broken down and resynthesized; muscle glycogen » blood glucose » liver glycogen » blood glucose » muscle glycogen.

Cytokine: substance released by T-cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells; cytokines include interleukins, lymphokines and cell signal molecules, such as tumor necrosis factor and the interferons, which trigger inflammation and respond to infections.

Cytotoxic: destructive to cells.

Deep vein thrombosis (DVT): a blood clot (thrombus) in a vein of the deep system (veins within the muscle); DVT can lead to pulmonary embolism.

Deltoid: the muscle covering the shoulder prominence.

Dendritic cell: (branched like a tree); a special type of cell that is a key regulator of the immune system, acting as a professional antigen-presenting cell capable of activating naïve T cells and stimulating the growth and differentiation of B cells; dendritic cells are found in the lymph

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Glossary nodes and spleen.

Dermatofibrosarcoma protuberans: fibrohistiocytic tumor found on the skin, predominantly on the trunk and proximal areas of extremities; see also sarcoma.

Dysgeusia: change in taste; unusual taste sensation.

Dyspepsia: vague description of abdominal discomfort, which may include heartburn, bloating, abdominal pain, nausea, belching and indigestion.

Dysphagia: difficulty or inability to swallow.

Dyspnea: air hunger; difficult or labored breathing.

Early satiety: the feeling of being full prematurely (sooner than normal or after eating less than usual).

Endoscopy: a flexible tube and an optical system introduced through the mouth (or rectum) to view gastrointestinal tract; may be used to assist in placing enteral feeding tubes.

Enteral nutrition: nutrition support via the gastrointestinal tract.

Epidermoid carcinoma: cancer of the epidermis, or outer layer of skin; see also basal cell carcinoma, squamous cell carcinoma and papillomatous carcinoma.

Epithelial tissue: the basic tissue that covers surface areas: the spaces, surfaces and the cavities of the body; three types of epithelial tissues: covering and lining, glandular, sensory.

Epithelioid sarcoma: slow-growing malignant soft tissue tumor, usually occurring in adults; “pseudo-capsule” or poorly circumscribed mass often attached to tendons, tendon sheath, or joint capsule; predisposition for fingers, hands and forearm; most common soft tissue sarcoma of the hand; see also sarcoma.

Erythrocytes: red blood cells.

Esophagitis: inflammation of the esophagus; may be painful; may cause odynophagia and/or dysphagia.

Ewing’s sarcoma: family of tumors of the bone and soft tissue; the second most common type of bone cancer; frequently found in the flat bones, such as the pelvis and ribs, as well as the bones of the arms and legs; commonly spreads to bones, lungs and bone marrow; usually occurs in those between ages 10 and 20; see also sarcoma.

Ewing’s sarcoma of the bone: bone cancer that forms in the middle (shaft) of large bones; most often affects the hip bones and the bones of the upper arm and thigh; see also sarcoma.

External beam radiation: uses a machine located outside the body to aim high-energy rays at a tumor.

Extraskeletal mesenchymal chondrosarcoma: rare soft tissue tumors that are related to chondrosarcomas of the bone by a similar histopathology; majority are classified as myxoid chondrosarcomas; the majority of tumors present in extremities, though various organs around the body have reported cases; see also sarcoma.

Extraskeletal myxoid chondrosarcoma: resembles chordoma; accounts for less than 2% of all soft-tissue sarcomas; usually affects men in fifth decade of life; frequently arises in deep soft tissues, especially of lower extremity and frequently the foot; see also sarcoma.


181

Glossary

Extraskeletal osteosarcoma: a primary tumor arising in the somatic soft tissue with all of the features of classic osteosarcoma; see also sarcoma.

Extraosseous Ewing’s sarcoma: Ewing’s sarcoma occurring in soft tissue; see also sarcoma.

Fibromatosis: infiltrative proliferation of fibroblasts and myofibroblasts; see also sarcoma.

Fibrosarcoma: spindle-celled sarcoma containing much connective tissue; see also sarcoma.

Fistula: an abnormal passageway in the body; may go from the body surface into a blind pouch or into an internal organ, or go between two internal organs.

Flatulence: excessive gas in the stomach and intestines.

Fluoroscopy: observing the internal structure of opaque objects (as the living body) by means of the shadow cast by the object examined upon a fluorescent screen when placed between the screen and a source of X-rays; used chiefly for diagnostic purposes.

Fructooligosaccharides: probiotics, which are beneficial to the growth of desirable intestinal bacterial flora.

Gardner’s syndrome: familial polyposis of the colon; high risk for colon cancer.

Gastrocnemius muscle: calf muscle.

Gastroparesis: paralysis of the stomach by a disease of either the stomach muscle itself or the nerves controlling the muscle; food and secretions do not empty normally from the stomach; may result in early satiety, bloating, nausea and vomiting.

Gluconeogenesis: formation of glucose from non-carbohydrate sources.

Glycogenesis: formation of glycogen from glucose.

Glycogenolysis: breakdown of glycogen to glucose.

Glycolysis: a multistep reaction that converts glucose to two pyruvate during which two ATP are produced via substrate level phosphorylation; hydrolysis of glucose (catalyzed by enzymes).

Graft-versus-host disease: donated stem cells respond to and attack the patient’s own tissue as if it were a foreign body.

Hemangiopericytoma: a rare tumor arising in the cells that form part of the blood vessel walls of small capillaries; accounts for about 3% of all soft tissue sarcomas in children; can be malignant or benign; can occur in any part of the body, but most often occurs in the lower extremities; also occurs in adults and very rarely in infants; see also sarcoma.

Hematology: medical specialty dealing with disorders of the blood and blood-forming tissues.

HLA type: a pattern of human leukocyte antigens found in each person’s cells; HLA matching helps to ensure engraftment and acceptance of donated stem cells.

Hodgkin’s lymphoma: cancer of the lymphatic system characterized by painless swelling in the lymph nodes in the neck, underarm or groin, as well as fevers, night sweats, tiredness, weight loss or itching skin; distinguished from other types of lymphoma by the presence of one characteristic type of cell, known as the Reed-Sternberg cell.

Hormone therapy: blocks endogenous hormones that lead to cancer proliferation.

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Glossary

Hospice: a concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments; neither prolongs life nor hastens death.

Hypercalcemia: higher-than-normal level of calcium in the blood.

Hypermetabolic: greater energy expenditure than normal or calculated.

Hypogammaglobulinemia: a condition in which the levels of the gamma fraction of serum globulin are abnormally low.

Hypometabolic: lower energy expenditure than normal or calculated.

Immune therapy (biologics, biological response modifiers): a broad term encompassing the use of various agents, most of them naturally occurring, to induce or enhance the patient’s own immune responses to disease.

Immunosuppression: Lowering the immune response.

Immunotherapy: a broad term encompassing the use of various agents, most of them naturally occurring, to induce or enhance the patient’s own immune responses to disease.

Indirect calorimetry: the determination of metabolic rate from the measure of oxygen consumption.

Induction: the first stage of chemotherapy for leukemia; the purpose of induction therapy is to kill as many leukemia cells as possible and force the disease into remission.

In situ: localized.

Interosseous muscle: the muscle located between the forefinger and thumb.

Intrathecal: treatment with drugs that are injected into the fluid surrounding the brain and spinal cord (cerebrospinal fluid).

In vitro: outside the living body and in an artificial environment.

In vivo: in the living body of a plant or animal; real life situation.

Invasive cancer: malignancy with a tendency to spread.

Krebs cycle: a complicated series of reactions involving the oxidative metabolism of pyruvate and the production of energy; primary metabolic pathway for energy production in the body; see also tricarboxylic acid cycle.

Lambert-Eaton syndrome: an autoimmune disease characterized by weakness and fatigue of the proximal muscles (those near the trunk), particularly the muscles of the pelvic girdle (the pelvis and hips) and the thighs, with relative sparing of eye and respiratory muscles; associated in 40% of cases with cancer, most often with small cell cancer of the lung and less often with other tumors; due to insufficient release of the neurotransmitter acetylcholine by nerve cells.

Laparoscopy: the use of a slender illuminated optical or fiber-optic instrument that is inserted through an incision in the abdominal wall and used to examine visually the interior of the peritoneal cavity.

Leiomyosarcoma: rare malignant tumor consisting of smooth muscle cells and small cell sarcoma tumor; see also sarcoma.


183

Glossary

Leukapheresis: a process in which blood is drawn from a donor or patient and white blood cells are separated out, the remaining blood components being returned to the body; see also apheresis.

Leukocyte: white blood cell.

Leukocytosis: increased white blood cell count.

Li-Fraumeni syndrome: a rare, autosomal dominant cancer predisposition syndrome that is remarkable for the wide variety of cancer types involved, the young age at onset of malignancies and the potential of multiple primary sites of cancer during the lifetime of affected people.

Linear accelerator: machine used to deliver radiation therapy.

Lipogenesis: the formation or deposition of body fat; the transformation of carbohydrates or protein into body fat.

Lipolysis: breakdown of fat into glycerol and free fatty acids.

Lipoma: a fatty tumor; frequently appears in multiples, but is not malignant.

Liposarcoma: malignant fatty tumor; see also sarcoma.

Lumpectomy: excision of a breast tumor with a limited amount of associated tissue.

Lymphoma: cancer of the lymphatic system that results when a lymphocyte (a type of white blood cell) undergoes a malignant change and begins to multiply, eventually crowding out healthy cells and creating tumors, which enlarge the lymph nodes and other sites in the body; see also Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.

Macrophage: type of white blood cell that ingests foreign material; key player in the immune response to foreign invaders such as infectious microorganisms.

Malignancy: describes a cancer that has the ability to invade into adjacent tissues or spread (metastasize) into lymph nodes, body organs or distant sites.

Malignant fibrous histiocytoma: the most common malignant sarcoma of older adults; tends to occur in the deep soft tissue of the extremities and the retroperitoneum, though it has been described in nearly every organ of the body; see also sarcoma.

Malignant mesenchymoma: a tumor containing a combination of mesenchymal tissues; see also sarcoma.

Malignant peripheral nerve sheath tumor: the malignant counterpart to benign soft tissue tumors such as neurofibromas and schwannomas; this term is preferred to older designations such as malignant schwannomas and neurofibrosarcomas; most common in deep soft tissue, usually in close proximity of a nerve trunk; most common sites include sciatic nerve, brachial plexus, sacral plexus; see also sarcoma.

Malignant schwannoma: tumors derived from schwann cells, which produce myelin, insulating nerves and facilitating neural transmission; has been associated with neurofibromatosis; see also sarcoma.

Maintenance: chemotherapy given for several years after consolidation to maintain remission.

Melanoma: a form of skin cancer that arises in melanocytes, the cells that produce pigment.

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Glossary

Mesenchymal tissue: cells capable of differentiating into a variety of soft tissues, such as blood, blood vessels and the lymphatic system.

Mesothelioma: a malignant tumor of the mesothelium, the thin lining on the surface of the body cavities and the organs contained within them; most mesotheliomas begin as one or more nodules that progressively grow to form a solid coating of tumor surrounding the lung, abdominal organs or heart; most commonly occurs in the chest cavity and is associated with exposure to asbestos in up to 90% of cases.

Metastasis: the spread of cancer from an original site or location to a remote location of the body. Common sites of cancer metastasis include the lymph nodes, liver, bone, brain and lungs.

Micronutrient: an organic compound (as a vitamin or mineral) essential in minute amounts.

Mini-transplant (nonmyeloablative transplant, mixed chimera transplant): stem cell transplant wherein smaller doses of chemotherapeutic agents and radiation are used than in a traditional transplant; goal is to lessen side effects and take advantage of the graft-versus-tumor effect; used more frequently in older or frailer patients.

Modular supplement: macronutrient supplements that can be added to foods or other nutritional supplements.

Monoclonal antibody: an antibody derived from a single cell, synthesized in large quantities for use against a specific antigen (as a cancer cell); currently being investigated as a form of cancer treatment.

Mucositis: an inflammation and ulceration of the lining of the mouth, throat or gastrointestinal tract most commonly associated with chemotherapy or radiotherapy.

Multiple myeloma: a malignancy of plasma cells (a form of lymphocyte) that typically involves multiple sites within the bone marrow; also called plasma cell myeloma.

Myeloid cells: precursors to phagocytes, which include neutrophils, eosinophils and monocytes; group of non-lymphocyte white blood cells.

Nadir: lowest point in white cell, red cell and platelet counts following chemotherapy or radiation; patients are often cautioned to be extra careful with exposure to infection and avoid anything that could cause bleeding during this time.

Natural killer (NK) cells: a type of non-antigen-specific lymphocyte.

Neoplasm: a new and abnormal formation of tissue; grows at the expense of healthy tissue.

Nephropathy: abnormally functioning kidney(s).

Neurofibromatosis-1: an inherited disorder characterized by formation of neurofibromas (tumors involving nerve tissue) in the skin, subcutaneous tissue, cranial nerves and spinal root nerves; see also neurofibromatosis-2 and sarcoma.

Neurofibromatosis-2: von Recklinghausen neurofibromatosis; a neurocutaneous disorder similar to neurofibromatosis-1, but associated with the presence of acoustic neuromas; see also neurofibromatosis-1 and sarcoma.

Neuropathy: an abnormal and usually degenerative state of the nervous system or nerves.

Neutropenia: marked decrease in the number of neutrophils, white blood cells produced in the bone marrow that ingest bacteria.


185

Glossary

Non-Hodgkin’s lymphoma: a diverse group of cancers with the distinctions between types based on the characteristics of the cancerous cells; groups are often classified as indolent or aggressive; or low, intermediate and high grade; usually progress in a far less systematic and predictable manner than Hodgkin’s disease.

Odynophagia: pain when swallowing.

Oncogene: a normal gene that has been transformed into a gene that promotes the growth of cancer.

Oncology: study of cancer.

Osteoradionecrosis: death of bony tissue following radiation therapy.

Osteosarcoma: the most common malignant bone tumor in children; average age of diagnosis is 15 years; boys and girls have a similar incidence of this tumor until late adolescence, at which time more boys are affected than girls; see also sarcoma.

Palliative care: the active total care of patients whose disease is not responsive to curative treatment, including control of pain, symptoms and psychological, social and spiritual problems; goal is best possible quality of life for patients and their families.

Pancytopenia: abnormally low levels of all blood constituents: platelets, white and red blood cells.

Papillomatous carcinoma: benign tumor featuring hypertrophied papillae covered by epithelium; includes warts, condylomas and polyps.

Paraneoplastic syndrome: a group of signs and symptoms caused by a substance produced by a tumor or in reaction to a tumor.

Parenteral nutrition: nutrients provided via peripheral or central venous access.

Perioperative: the time before, during and after surgery.

Philadelphia chromosome: chromosome abnormality found in chronic myeloid leukemia (CML).

Phlebitis: inflammation of a vein.

Primitive neuroectodermal tumors (PNET): different morphological expression of the Ewing’s tumor type; in general, Ewing’s sarcoma arises within the bone while PNET arises within soft tissues; also known as peripheral neuroepithelioma; see also sarcoma.

Prokinetic agent: pharmacological agent used to promote gastric motility.

Pulmonary embolism: a blood clot in the arteries of the lung.

Quadriceps: a large extensor muscle of the front of the thigh divided above into four parts that include the rectus femoris, vastus lateralis, vastus intermedius and vastus medialis.

Radiation therapy: use of high-energy rays to damage cancer cells, stopping them from growing and dividing; local treatment that affects cancer cells only in the treated area; see also external beam radiation, brachytherapy and stereotaxis.

Reed-Sternberg cells: abnormal cells that are usually associated with Hodgkin’s lymphoma.

Reticuloendothelial system: diffuse system of phagocytic cells associated with the connective tissue framework of the liver, spleen, lymph nodes and other serous cavities; a group of cells, including macrophages or macrophage precursors, specialized endothelial cells lining the

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Glossary sinusoids of the liver, spleen, and bone marrow, and reticular cells of lymphatic tissue (macrophages) and of bone marrow (fibroblasts); also called the mononuclear phagocyte system.

Reticulocyte: immature red blood cell, precursor to the erythrocyte.

Rhabdomyosarcoma: malignant, soft tissue tumor found in children; most common sites are the structures of the head and neck, the genitourinary tract, and the arms or legs; see also sarcoma.

Sarcoma: type of cancer that starts in bone or connective tissue; see also alveolar soft-part sarcoma, angiosarcoma, dermatofibrosarcoma protuberans, epithelioid sarcoma, extraskeletal mesenchymal chondrosarcoma, extraskeletal myxoid chondrosarcoma, extraskeletal osteosarcoma, Ewing’s sarcoma, Ewing’s sarcoma of the bone, fibromatosis, fibrosarcoma, hemangiopericytoma, leiomyosarcoma, liposarcoma, malignant fibrous histiocytoma, malignant mesenchymoma, malignant peripheral nerve sheath tumor, malignant schwannoma, neurofibromatosis, osteosarcoma, primitive neuroectodermal tumors, rhabdomyosarcoma and synovial sarcoma.

Scapula: shoulder blade.

Sepsis: a toxic condition resulting from the spread of bacteria or their byproducts from a focus of infection.

Squamous cell carcinoma: found in the tissue that forms the surface of the skin, the lining of the hollow organs of the body, and the passages of the respiratory and digestive tracts; can metastasize; can occur secondary to exposure to sun, alcohol and tobacco.

Stem cell: a “generic” cell that can make exact copies of itself indefinitely; has the ability to produce specialized cells for various tissues in the body, such as heart muscle, brain tissue and liver tissue; embryonic stem cells are obtained from either aborted fetuses or fertilized eggs that are left over from in vitro fertilization; “adult” stem cells are found in adults and children and are not as versatile for research purposes because they are specific to certain cell types, such as blood, intestines, skin and muscle, while embryonic stem cells are non-specific.

Stenosis: constriction or narrowing of a passage or orifice.

Stereotaxis: use of a number of precisely aimed beams of ionizing radiation, each coming from different directions and meeting at a specific point, to deliver radiation treatment to that spot.

Stomatitis: inflammation of the mouth.

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH): disorder of fluid and electrolyte balance caused by excessive release of antidiuretic hormone.

Syngeneic transplant: stem cell transplant between identical twins.

Synovial sarcoma: soft-tissue sarcoma that usually emerges in adolescence or young adulthood; usually arises near a joint (particularly the knee joint), and comprises cells similar to the synovial cells that normally line a joint; see also sarcoma.

Temporalis: a large muscle in the temporal fossa (where the temple piece of eyeglasses rests).

Thrombocytes: platelets.

Thrombocytopenia: abnormally low platelet count; risk for bleeding.

Thromboembolism: blood clot blocking a blood vessel.


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Glossary

Thrombophlebitis: inflammation of a vein with formation of a thrombus (clot).

Trapezius: a large, flat, triangular superficial muscle on each side of the upper back and lower neck.

Tricarboxylic acid cycle: a complicated series of reactions involving the oxidative metabolism of pyruvate and the production of energy; primary metabolic pathway for energy production in the body; see also Krebs cycle.

Trismus: tonic contraction of the muscles of mastication; can occur secondary to radiation therapy.

Tuberous sclerosis: a group of two genetic disorders characterized by problems with the skin, brain/nervous system, kidneys and a predisposition to tumors; named after a characteristic abnormal growth in the brain in the shape of a tuber.

Tumor: a solid cancer in the form of a distinct lump or mass.

Veno-occlusive liver disease: blockage of the small- or medium-sized hepatic veins due to nonthrombotic subendothelial edema, which may progress to fibrosis.

Werner syndrome: an autosomal recessive disorder that causes premature aging in adults, characterized by sclerodermal skin changes, cataracts, subcutaneous calcification, muscular atrophy, a tendency to diabetes mellitus, aged appearance of the face, baldness and a high incidence of neoplastic disease.

Xerostomia: dry mouth. Sources for Glossary HONsearch section for medical professionals. http://www.hon.ch/HONsearch/Pro/index.html.

Health on the Net Foundation Web site. Accessed July 22, 2012.

MedicineNet. http://www.medicinenet.com/script/main/hp.asp. MedicineNet Web site. Accessed July 22, 2012.

Medical Encyclopedia. http://www.nlm.nih.gov/medlineplus/encyclopedia.html. MedlinePlus Web site. Accessed July 22, 2012.

Types of Cancer. www.nci.nih.gov/cancer_information/. National Cancer Institute Web site. Accessed July 22, 2012.

Venes D, ed. Taber’s Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: FA Davis Co.; 2009.

Examination

188

Examination 1. According to the American Cancer Society, which of the following signs and symptoms are early warnings of cancer?

a. Change in sleeping habits b. Voluntary loss of weight c. Headaches d. Muscle achiness e. Obvious change in a wart or mole

2. Which of the following cancer diagnostic methods is a tumor marker? a. Computed tomography (CT) b. Magnetic resonance imaging (MRI) c. Prostate-specific antigen (PSA) d. Positron emission tomography (PET) e. Prostate ultrasound (US)

3. According to 2012 statistics compiled by the American Cancer Society, the four most common cancer diagnoses in the United States are:

a. Leukemia, liver, breast and prostate b. Lung, breast, prostate and pancreatic c. Lung, breast, colorectal and pancreatic d. Lung, breast, colorectal and prostate e. Pancreatic, liver, breast and prostate

4. The American Cancer Society’s 2012 guidelines on nutrition and physical activity for cancer prevention provide Americans with recommendations to reduce cancer risk. What nutrition strategy can assist adults in reducing cancer risk?

a. Increase intake of omega-3 fatty acid dietary supplements b. Increase intake of calcium-containing dietary supplements c. Decrease carbohydrate intake d. Achieve and maintain a healthy body weight e. Decrease fiber intake

5. JB is a 63-year-old man with lung cancer. His cancer treatment will include chemotherapy and radiation therapy to his mediastinum. Which of the following treatment-related nutrition impact symptoms will JB most likely experience?

a. Diarrhea b. Dysuria c. Esophagitis d. Colitis e. Myalgia


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6. CH is a 73-year-old man diagnosed with prostate cancer and will receive hormone therapy (leuprolide [Lupron]) for treatment. Which side effect will CH most likely experience as result of his therapy?

a. Peripheral neuropathy b. Hot flashes c. Nausea and vomiting d. Mucositis e. Anorexia

Mini-Case Study for Questions 7 and 8 Before beginning cancer therapy, a 55-year-old man with tongue cancer has been referred for nutrition counseling. His cancer treatment will include head and neck radiation therapy and concurrent chemotherapy. During the past three months he has lost 20 lbs due to dysphagia; his body mass index is 22.

7. Anticipating treatment-related side effects, which of the following routes of nutrition support therapy should be recommended by the dietitian to support this patient nutritionally?

a. Daily parenteral IV fluids b. Total parenteral nutrition c. Enteral nutrition using a percutaneous endoscopic gastrostomy (PEG) feeding tube d. Plant-based, cancer-prevention diet e. Ad-lib diet

8. Which side effect is commonly experienced by patients undergoing radiation therapy for treatment of oral cancer?

a. Esophageal reflux b. Xerostomia c. Peripheral neuropathy d. Hiccups e. Dysuria

9. Which side effect is commonly experienced by patients after undergoing a partial gastrectomy for treatment of stomach cancer?

a. Weight gain b. Xerostomia c. Steatorrhea d. Constipation e. Dumping syndrome

10. Which side effect is commonly experienced by patients after undergoing a surgical resection for treatment of colorectal cancer?

a. Hyperglycemia b. Diarrhea c. Dysgeusia d. Gastritis e. Mucositis

Examination

190

Mini-Case Study for Questions 11 and 12 RH is a 33-year-old man diagnosed with acute lymphocytic leukemia. As an inpatient, he is undergoing conditioning high-dose chemotherapy in preparation for a hematopoietic cell transplant. RH reports a very poor appetite, and his weight has decreased 5 lbs during the last three days. He has an absolute neutrophil count of 150.

11. Which of the following terms describes the condition a patient with an absolute neutrophil count of 150 is experiencing?

a. Neutropenia b. Thrombocytopenia c. Microcytic anemia d. Pernicious anemia e. Cytopenia

12. Which treatment-related side effect most likely explains RH's recent weight loss? a. Side effects from engraftment of stem cells b. Side effects from graft-versus-host disease of the gut c. Nausea and vomiting secondary to his high-dose conditioning chemotherapy d. Taste alterations secondary to his high-dose conditioning chemotherapy e. Constipation secondary to his high-dose conditioning chemotherapy

13. According to the American Institute for Cancer Research’s Simple Steps to Prevent Cancer, the lifestyle goals for long-term cancer survival should include which recommendation?

a. Regaining weight that was lost during treatment b. Obtaining and maintaining a healthy body weight c. Decreasing carbohydrate intake d. Increasing protein intake e. Increasing intake of dietary supplements

14. According to the American Cancer Society’s Nutrition and Physical Activity Guidelines for Cancer Survivors, which of the following lifestyle strategies should be recommended for long-term cancer survivors?

a. Consume an "all natural," organic diet and be physically active. b. Take dietary supplements to boost and strengthen the immune system. c. Eat a plant-based diet and be physically active. d. Take herbal supplements to boost and strengthen the immune system. e. Eat a high-protein, low-carbohydrate diet and be physically active.

15. Which symptoms commonly occur in people with advanced cancer? a. Weight gain, constipation and nausea b. Anorexia, early satiety and constipation c. Pain, fatigue and sleep disturbances d. Anorexia, early satiety and sleep disturbances e. Weight loss, constipation and sleep disturbances


191

16. Which of the following treatment strategies are used to manage hypercalcemia observed in patients with advanced cancer and bony metastases?

a. Fluid restriction and calcium binder agents b. IV fluids and antihypercalcemic agents c. IV fluids and calcium channel blockers d. Calcium-restricted diet e. High phosphate diet

17. Which of the following cancer diagnoses pose the greatest risk for patients developing bowel obstruction after receiving chemotherapy and pelvic radiation therapy?

a. Colon cancer and stomach cancer b. Pancreatic cancer and liver cancer c. Pancreatic cancer and prostate cancer d. Colon cancer and ovarian cancer e. Pancreatic cancer and stomach cancer

Mini-Case Study for Questions 18 and 19 KL is a 72-year-old man with advanced prostate cancer receiving hospice care. Medical history includes hypercholesterolemia, hypertension and adult onset diabetes mellitus. He has tried to follow a cardiac and carbohydrate controlled diet for more than 20 years. His cancer has metastasized to several bony areas. KL reports chronic bone pain, poor appetite, continued weight loss and constipation.

18. Which of the following diets should KL follow to manage his cancer-related symptoms?

a. Continue carbohydrate-controlled diet b. Continue cardiac diet c. High-fiber diet d. Ad-lib diet e. High-calorie, high-protein diet

19. Which of the following pharmacological agents could alleviate KL’s constipation? a. Take stool softeners daily b. Take anti-motility agents regularly c. Take Kaopectate daily d. Take milk of magnesia daily e. Take megestrol acetate (Megace) regularly

20. Which statement defines cancer cachexia? a. A multifactorial process thought to be caused by the suppression of bone marrow activity b. A common secondary diagnosis observed in patients diagnosed with early stage cancer and is

characterized by progressive weight loss, anorexia, and generalized wasting and weakness c. A multi-factorial process thought to be caused by direct or indirect damage to the central nervous

system, peripheral nervous system, cranial nerves or any combination of the three d. A common secondary diagnosis observed in patients with advanced cancer and is characterized

by progressive weight loss, anorexia, and generalized wasting and weakness e. A multifactorial process thought to be caused by alterations in the cell cycle of both normal and

malignant cells

Examination

192

21. Which of the following nutrition screening tools is well suited for the outpatient oncology setting, and why?

a. Weight history and albumin, because it is used for nutrition screening in most institutions b. Patient-Generated Subjective Global Assessment (PG-SGA), because it is validated, quick,

inexpensive and provides consistent reliable identification of oncology patients at risk c. Prognostic Nutrition Index (PNI), because it is a validated predictor of negative outcomes

related to malnutrition in surgical oncology and labs are readily available and covered by insurance d. Mini Nutritional Assessment (MNA), because it is quick and easy, inexpensive, based on

multiple parameters and is validated in the oncology population e. Subjective Global Assessment (SGA), because it is quick, inexpensive, validated in the oncology

population and includes an action plan

Mini-Case Study for Questions 22, 23 and 24 NC is a 45-year-old woman with an astrocytoma. She has undergone surgical resection and is currently receiving daily dexamethasone (Decadron) and temozolomide (Temodar) chemotherapy, and concurrent whole brain radiation therapy. She is 5’6”, and her current weight is 138 lbs; her usual body weight is 145 lbs.

22. Which of the following side effects will NC most likely experience as a result of her combined modality cancer therapy?

a. Diarrhea b. Peripheral neuropathy c. Mucositis d. Fatigue e. Dyspnea

23. Which condition is NC at risk for developing while undergoing cancer therapy? a. Acute renal failure b. Hyperglycemia c. Hyperlipidemia d. Hepatic toxicity e. Hypercalcemia

24. What is the purpose of a “safe food” or neutropenic diet? a. To decrease foods that could further irritate the oral and gastric mucosa b. To control diarrhea caused by graft-versus-host disease or conditioning chemotherapy regimen c. To eliminate foodborne pathogens that could cause an infection in immunocompromised

patients d. To enhance immune function in patients who are neutropenic e. To add immune-enhancing supplements to reduce potential infectious complications


193

25. A patient is interested in taking vitamin and mineral supplements to boost his immune system during cancer treatment. According to the literature cited in this course, which of the following recommendations should be provided by the dietitian regarding vitamin and mineral supplementation during therapy?

a. Dietary Reference Intakes provide Estimated Average Requirements (EAR) that meet nearly 100% of the nutrients required by all people at all times.

b. Health experts conclude that taking a vitamin and mineral supplement containing no more than 100% of the Daily Value (DV) is considered safe for patients during cancer treatment.

c. Health experts conclude that water-soluble vitamins are harmless at any dosage, so megadoses of the Recommended Dietary Allowance (RDA) are not considered harmful for patients desiring greater protection.

d. The Dietary Reference Intake Average Intake (AI) is the highest amount of a nutrient that can be taken safely at any time.

e. Health experts conclude that the RDA meets 100% of the needs of most patients and should never be exceeded.

Mini-Case Study for Questions 26, 27 and 28 CR is a 55-year-old patient, newly diagnosed with esophageal cancer. CR’s recommended treatment plan includes chemotherapy and gastroesophageal radiation therapy followed by an esophagectomy. He has an almost complete obstruction of the esophagus and documented dysphagia with aspiration. He is 5’9”, and his current weight is 138 lbs; his usual body weight is 170 lbs, and one month ago he weighed 155 lbs.

26. Which route of nutrition support therapy is recommended for patients undergoing this treatment regimen?

a. Percutaneous endoscopic jejunostomy b. Peripheral parenteral nutrition c. Nasogastric feeding tube d. Ad-lib diet e. Plant-based, cancer-prevention diet

27. Which side effect is most frequently experienced by patients undergoing an esophagectomy? a. Constipation b. Dumping syndrome c. Peripheral neuropathy d. Dysgeusia e. Alopecia

28. Which side effects are most frequently experienced by patients undergoing CR’s planned chemotherapy and radiation therapy?

a. Diarrhea and malabsorption b. Constipation and bloating c. Esophagitis and dysphagia d. Xerostomia and taste changes e. Mucositis and stomatitis

Examination

194

29. In which scenario would the use of parenteral nutrition be indicated for a patient diagnosed with cancer?

a. When a patient’s oral intake is inadequate and results in weight loss while undergoing chemotherapy for her breast cancer

b. When a hospice patient with advanced cancer is unable to eat due to bowel obstruction c. When a patient receiving head and neck radiation therapy refuses the placement of a PEG

feeding tube d. When a patient receiving chemotherapy experiences episodes of diarrhea between cycles of

chemotherapy e. When a patient with acute graft-versus-host disease experiences severe diarrhea after receiving

an allogeneic stem cell transplant

30. Which of the following foods should be recommended for a patient experiencing nausea after receiving a highly emetogenic chemotherapy?

a. A large glass of warmed milk b. A mug of hot coffee c. A serving of pretzels d. A serving of a favorite food e. A dish of ice cream

31. Which of the following medications is prescribed for the management of anticipatory nausea before the administration of chemotherapy?

a. Prochlorperazine (Compazine) b. Aprepitant (Emend) c. Lorazepam (Ativan) d. Metoclopramide (Reglan) e. 5-HT3 antagonists (e.g., ondansetron [Zofran])

32. Which of the following pharmacological agents has been shown to be effective for improving appetite in people with cancer?

a. Megestrol acetate (Megace) b. Polyethylene glycol (Miralax) c. Bisacodyl (Dulcolax) d. Amifostine (Ethyol) e. Prochlorperazine

33. Which of the following nutrition interventions should be recommended for a patient with prostate cancer experiencing acute radiation enteritis during pelvic irradiation?

a. Consume a high-fiber, low-fat diet b. Consume a low-fiber, low-fat diet c. Consume a low-fiber, high-fat diet d. Consume a high-fiber, high-fat diet e. Consume an ad-lib diet


195

34. MF is a 58-year-old woman with pancreatic cancer undergoing chemotherapy. She complains of abdominal bloating, steatorrhea and early satiety. Which pharmacological agents could be prescribed?

a. Corticosteroids b. Antiemetics c. Cathartics d. Pancreatic enzymes e. Mucosal protectant agents

35. JT is a 16-year-old boy diagnosed with Hodgkin’s disease. He has undergone chemotherapy and is now receiving radiation therapy to a para-aortic field. Which of the following side effects will JT most likely experience as a result of his radiation therapy?

a. Headaches and hearing changes b. Xerostomia and dysgeusia c. Odynophagia and heartburn d. Nausea and diarrhea e. Oral and esophageal mucositis

36. Which of the following oral care suggestions should be recommended for management of radiation therapy-induced oral mucositis?

a. Spraying the oral cavity with a saliva stimulant b. Spraying the oral cavity with an artificial saliva c. Rinsing the oral cavity with a saline/baking soda rinse throughout the day d. Sucking on lemon drops or peppermint candy throughout the day e. Rinsing the oral cavity with a mouthwash (e.g., Listerine) throughout the day

37. According to the American Cancer Society’s 2012 guidelines for nutrition and physical activity for cancer prevention, which of the following physical activity recommendations should be discussed to assist adults with reducing their cancer risk?

a. Engage in at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity each week

b. Engage in at least 75 minutes of moderate-intensity activity or 150 minutes of vigorous-intensity activity each week

c. Physical activity does not affect cancer risk d. Engage in at least one hour of vigorous-intensity activity each day, with moderate-intensity

activity occurring at least three days a week e. Engage in at least one hour of moderate- or vigorous-intensity activity each day, with vigorous-

intensity activity occurring at least three days a week

38. A patient undergoing head-and-neck radiation therapy presents to the clinic with a reddened oral mucosa and white “cheesy” patches on his tongue, soft palate and oropharynx. Which treatment-related side effect is this patient experiencing?

a. Esophageal fibrosis b. Neutropenia c. Candidiasis d. Cholelithiasis e. Esophageal stenosis

Examination

196

39. Which of the following interventions could be recommended by the dietitian for a patient experiencing chronic dysgeusia related to cancer treatment?

a. Magnesium supplementation b. Zinc supplementation c. Calcium supplementation d. Folic acid supplementation e. Iron supplementation

40. A patient is experiencing constipation, loss of appetite and a feeling of fullness. Which of the following pharmacological agents could be recommended to alleviate this patient’s symptoms?

a. Metoclopramide b. Prochlorperazine c. Ondansetron d. Bisacodyl e. Senna (Senokot)

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