Nutrition for Patients during

Radiotherapy in Nasopharyngeal
Cancer

Ririn H
Dharmais Cancer Hospital
2010
Cancer: An Epidemy Potency
Disease
 Cancer is a leading cause of death worldwide: it
accounted for 7.4 millions death ( 13% deaths) in
2004
 Death from cancer worldwide are projected to
continue rising  12 million deaths in 2030
Incidence
million 20
15.5
15 11.3
11.5 “45% Increase in cancer
10
7.9 deaths from 2007 to
5
2007 2030
2030”- WHO
Mortality
0 WHO.Cancer Fact Sheet.2007.www.who.int
WHO Projection WHO Online Q&A.2008.www.who.int
 Top 10 Most Diagnosed Cancer in
Dharmais Hospital, 2007
Type of Cancer Frequency Percentage
(%)
Breast 437/1348 32.4
Cervical 254/1348 18.8
Colorectal 121/1348 9.0
Lung 113/1348 8.4
Nasopharyng 104/1348 7.7
Liver 76/1348 5.6
Limphoma 62/1348 4.6
Leukemia 62/1348 4.6
Thyroid 62/1348 4.6
Ovarium 57/1348 4.2
Data Internal RS Dharmais
Nutritional Problem
Among Cancer Patients
 Weight loss and malnutrition are one of
most common features observed in cancer
patients
 Cancer associated malnutrition 40-80%
 IndonesiaSurvey in Dharmais Hospital,
2008
 30.9% has malnutrition
 42.9% reported weight loss in 6 mo.
Nutritional Problem
Among Cancer Patients
Especially occur in patients with
 head and neck cancerincluding
nasoparyngeal cancer
 Upper gastrointestinal cancer
 Pancreas Cancer
 Chemoradiotherapy

Severe malnutrition in Cancer  Cachexia

Cancer
 Incidence of Weight Loss
in Several Types of Cancer

Laviano A et al. Nature Clin Prac Oncol 2006;2:158-64

Malnutrition vs Cachexia
Cancer

 Cancer cachexia Malnutrition (Undernutrition)

 Malnutrition a state of nutrition in which a
imbalance of energy, protein, and other nutrients
causes measurable adverse effects on
tissue/body form (body shape, size and
composition) and function, and clinical outcome

Muscaritoli M et al. Clin Nutr 2010;29:154–9

 Cachexia Cancer
Definition of cachexia:1
 Complex metabolic syndrome associated with underlying
illness and characterized by loss of muscle with/without loss
of fat mass
Definition of Cachexia Cancer:2
 Multi organ syndrome charactrized by:
 Weight loss (at least 5%)
during the previous 3-6 mo.
 Muscle and adipose wasting
 Inflammation
often associated with ANOREXIA, include
the abnormalities of metabolism
1.Evans WJ dkk. Clin Nutr 2008;27:793-9
2. Argiles JM dkk. Cancer Management Res 2010;2:27-38
 Etiology of Cachexia
Cancer
 Remain unclear
 Multifactorial:1
 Tumor Factors 
1. Mechanical Obstructivefood intake 
2. Tumor metabolite product: lipid
mobilizing factor/LMF dan proteolysis-
inducing factor/PIF  metabolism and
 energy expenditure

Fietkau R. Cancer & Nutrition: Prevention and treatment. Switzerland: Nestle Ltd.
2000. 225-35
Etiology of Cachexia
Cancer
 Patient Factors :
 Psychological
 Non psychological Anorexia, smoking,
alcohol, poor oral higiene
 Cancer treatment Factors: surgery,
Chemotherapy, and radiotherapy
Nutritional Consequences Of
Cancer Therapy

Mechanism:
a. Directly interfere with metabolism
b. Indirectly affect nutrient intake (nausea,
vomiting, diarrhea, changes in taste
sensation, anorexia & food aversions)
Side Effect of
Radiotherapy
 Early effect the most common, can be
anticipated and limited duration.
 Severity of side effect depends on: type of
irradiation, body region, volume of irradiation
and combination with other therapy
(chemotheray).
Nutritional Consequences:
Radiotherapy
 Head and Neck Dysosmia

Caries Dentis

Stomatitis

Esophagitis Xerostomia
Outcomes Associated with
Cancer-induced Weight Loss
 ↓ Quality of Life  Unscheduled
 ↓ Functional Status hospitalization
 ↓ Response to therapy  ↑ Complications /
Infections
 Change in body image
 ↓ Survival
 ↑ Hospital Length of Stay

“Progressive wasting is common

and one of the most important
factors leading to early death in
cancer patients”
- Inui, Akio.Cancer Research.1999;59.4493-501 -
 The Importance
Nutritional Support
 All cancer patients especially who are
high risk to get nutritional problems

Nasopharyngeal
Cancer
Chemo-radiotherapy

Early Nutritional
Screening & Assessment Support
Nutritional Screening and
Assessment
SCREENING
Modality:
 History
 Physical Examination
 Laboratory data ASSESSMENT
Nutritional Assessment
 Aim: identify patients at risk for complication
and create options aimed at decreasing
morbidity and mortality
 Body Composisition  anthropometri
 Biochemical data
 Clinical Assessmenttools:
 SGA
(Subjective Global Assessment)
 PG-SGA (Patient-Generated Subjective Global
Assessment)
Subjective Global
Assessment
Recommended by ESPEN for the assessment of
nutritional status
Subjective Global
Assessment
 What Is The Role Of Nutrition Therapy
For Cancer Patients ?

 To help maintain body weight and strength

 To prevent body tissue from breaking down & rebuild it
 To fight infection
 To prevent or reverse nutrient deficiencies
 Help patients better tolerate treatments.
 To minimize nutrition-related side effects and
complications.

Maximize Quality of Life

Being well-nourished has been linked to a

better prognosis - National Cancer Institute.2009
 NUTRITION
REQUIREMENT IN
CANCER PATIENT

Tailored to the patients status

and treatment modalitites
Nutrition Requirement in Cancer
Patients

 Calorie requirement :
 The Harris-Benedict equation
 Estimates : severely stressed; have malabsorption :
35 kkal/kg
 Protein requirement :
 Cancer patient  negative nitrogen balance
 Daily protein requirement :
 non stress cancer patients : 1 – 1.2 g/kg
 hypercatabolic : 1.2 – 1.6 g/kg
 severely stress : 1.5 – 2.5 g/kg
 hematopoietic stem cell transplant pt : 1.5 – 2 g/kg

Grant, B.Krause’s, Nutrition & Diet Therapy 2007

 Nutrition Requirement in Cancer
Patients
 Fat requirement :
30% of total energy content
 Micronutrient requirement and Specific
Nutrition :
Difficulty in eating / anorexia

Need vitamin, mineral & specific

nutrition supplementation

Sobotka Basic in Clinical Nutrition.2007

 Specific Nutrients for
Cancer Patients

 Nutrition Elements that Have Impacts

for Cancer

a.Omega 3 Fatty Acid

b.BCAA
c.Antioxidant: SE, Vit C, Vit E
 Specific Nutrients for Cancer
Patients
Omega 3 :
  COX-2 in tumors   proliferation &
differentiation of cancer cells and angiogenesis
  nuclear factor-B activation and bcl-2
expression apoptosis of cancer cells
  production of inflammatory and chemotatic derivatives
  cancer-induced cachexia

“The available evidences indicate that increasing the

amount of omega 3 will be beneficial to cancer survival”
– The Journal of Nutrition.2002.3508S-12S -

Journal of the National Cancer Institute.1993;85(21).1743-7 Nutrition in Clinical

Nutrition in Clinical Practice 2005;20:394–9 Practice 2007;22:74-88
 Specific Nutrition for Cancer
Patients
Eicosapentaenoic Acid (EPA) :
 EPA : long chain PUFA
 Decrease weight loss, promote weight gain, and
increase survival in cancer cachexia patients
 May activate caspase-3  apoptosis
 May inhibit COX-2  reducing inflammatory process
 In cancer cachexia patients, EPA significantly reduce
the serum concentration of CRP (marker of inflammation)
(11.0 +/- 4.8 mg/l before, compared with 0.8 +/- 0.8 mg/l after 4
weeks of EPA, P < 0.05)

National Cancer Institute.Eicosapentaenoic Acid.www.cancer.gov

SJ, Wigmore; et al.Clin Sci.1997;92(2).215-21
I, Bayram; et al.Pediatr Blood Cancer.2009;52(5).571-4
Ryan, Aoife; et al.Annals of Surgery.2009;249(3).355-63
 Branched Chain Amino Acids

 BCAAValin, Isoleucine, Leucine

 Essential amino acid needed for normal cellular function
 Improve morbidity and QOL
 Improve immune system
 Improve nitrogen balance and protein synthesis
  appetite   caloric intake
• Decreament of anorexia : n=25 cancer pt
BCAA vs placebo : 55% vs 16%; p<0,05

Choudry, HA; et a.The Journal of Nutrition.2006;136.314S-318S

Calder, Philip.American Society for Nutrition.2006;136.288S-293S
Cangiano, C; et al.Journal of the National Cancer Institute.1996;88(8).550-1
Branched-chain amino acids
(BCAA)
 Mechanism of BCAA to  appetite
 Block tryptophan  serotonin appetite
 BCAAs IMPROVE
NITROGEN BALANCE AND PROTEIN SYNTHESIS

J. Nutr. 2006 136: 314S–8S

 Specific Nutrition for Cancer
Patients
SELENIUM
Protects against oxidative tissue damage
May modulate carcinogenesis by inhibiting damaged
DNA
and by enhancing host immune response
Selenium induce cancer cell death via COX-2/PGE2
signaling pathway
Descriptive geographic studies have shown an
inverse relationship between cancer mortality and
incidence rates and selenium availability
Mark, Steven D; et al.Journal of the National Cancer Institute.2000;92(21).1753-63
Peters, Ulrike; et al.Cancer Epidemiol.2006;15.315-20
Jiang, W; et .Molecular Cancer Therapeutics.2009;1(8)
Hwang, JT; et al.Cancer Research.2006;66(20).p10057-63
 Specific Nutrition for Cancer
Patients
VITAMIN C
 Vitamin C deficiency is common in patients with
advanced cancer
 Vitamin C helps induce apoptosis in various
human cancer cell lines :
 Induce G2-M arrest
 augment TNF-related apoptosis
 Patients with low plasma concentrations of
vitamin C have a shorter survival.

Mayland, CR; et al.Palliative Medicine.2005;19(1).17-20

 Specific Nutrition for Cancer
Patients

Vitamin E :
- Help recover electrophysiology and evoked
potential of neuron cell  Help protect form
chemotherapy-induced neuropathy.
- Omega3 and high level of antioxidant can
reverse severe weight loss

Morani, AS: Bodhankar, SL.Neuroanatomy.2008;7.33-7

Marcus R; Coulston.Goodman & Gilman’s The Pharmacological Basis of Therapeutics 10th
ed.2001.McGraw-Hill.
Pace, A; et al.J Clin Oncol.2003;21(5).924-31
J of Clin Oncology 2005;23(24):5805-13.
Grimble, RF.Gut.2003;52.1391-2
 Specific Nutrition for Cancer
Patients
Zinc :
 Reduced serum-zinc concentrations are well
known as typical laboratory characteristics in
advanced head and neck cancer.
 Zinc supplementation improved survival for
patients with Stages III-IV disease.
 Zinc sulfate useful for patients with
hypogeusia due to radiation/chemotherapy

Buntzel, J; et al.International Institute of Anticancer Research.2007

L Lin, etal. Int J of Rad Oncology Biol & Physics. 69 (3):S466-S466
A M Nally: http://www.nutraingredients.com
Silverman JE et al. J Oral Med 38 (1): 14-6, 1983 Jan-Mar
 Route of Nutritional Support
Nutrition can be delivered by:
 Oral
 Enteral
 Parenteral

Choosing nutritional route depend on:

 Gastrointestinal tract function
 Ability of patient’s food intake
 Route of Nutritional Support

Oral

Parenteral

Enteral
 Oral Nutrition
 Preferred modality in patients who are able to
eat
 Should modified based on the physiologic and
anatomic constraints of the disease process 
loss appetite, dry mouth, nausea-vomiting,
swallow difficulties, taste/smell alteration
 Oral Nutrition
 Frequent small meals
 Increase caloric and protein density of foods,
avoid excessive fat
 Avoid strong odors
 Select soft, moise foods; add sauce/gravy
 Limit liquids at mealtime
 Provide a pleasant mealtime atmosphere
 Enteral Nutrition
Enteral nutrition 
 If oral intake is not adequate
 Preferred to parenteralpreserves the gastrointestinal
architecture & prevents bacterial translocation 
fewer complication
Type
•Short term:
•nasoenteral tube
•Long term:
•Gastrostomy
•jejunostomy
Enteral Nutrition

 Tube feeding:
 obstruction of head or neck or esophageal
cancer interferes with swallowing
 Severe local mucositis
 percutaneous gastrostomy (PEG):
 radiation induced oral and esophageal
mucositis
 Enteral Nutrition

Recommendation
 Enteral nutrition if an inadequate food intake (<
60% of estimated energy expenditure for > 10
days) is anticipated (C)
 Enteral nutrition should be provided to improve
or maintain nutritional status in weight losing
patients due to insufficient nutritional intake (B)
Routine enteral nutrition is not indicated during radiation
Therapy or chemotherapy  as long as food intake is adequate
by oral
 Parenteral Nutrition

 unsuitable for oral or enteral nutritional

support
 Indication :
- Gastrointestinal tract can be used
ionperable cancer
- Side effect of radiotherapy: malabsorbsion,
enteritis
Parenteral Nutrition
 Route
- Perifer Based on patient’s
needed & condition
- Central
 Recommendations
 Patients with expectation having inadequate oral
or enteral nutrition intake for >10 to 14 days
 Severe malnutrition perioperative parenteral
nutrition
 Bone marrow transplant recipients
Sore mouth / throat
Possible causes : mucositis radiation and/or
chemotherapy
• Mucositis  cancer treatments break down the
rapidly divided epithelial cells lining the GIT particularly
in oral cavity, leaving the mucosal tissue open to
ulceration and infection
• Oral mucositis the most common

20-40% chemotherapy alone

> 50%  combination (chemo-radiotherapy)

consequences : hypovolemia, electrolyte abnormalities

& malnutrition
Sore mouth / throat
Mucositis should be treated as early as possible
Adequate education on proper nutrition and oral
hygiene is essential
Management
- Give intensive mouth care to prevent bacterial
infection or mouth lesions
- Eat soft, bland foods
- Try eating cold, odorless foods
- Avoid eating too hot or cold food
- Drink through a straw to bypass mouth sores
- Avoid irritating spices such as pepper, chili
- Eat high-protein foods to speed healing
 Sore mouth / throat
Management (continue)
• Drink high-calorie liquid nutritional supplements to
help maintain adequate calorie intake
• Avoid alcohol, tobacco  irritate mucous
membranes
• Begin use of tube feedings
• Puree / liquefy food in blender easier to swallow
• Avoid rough, dry or coarse foods which can scratch
an irritated mouth or throat
Dry mouth
Possible causes  saliva production from radiation
or surgery
Xerostomia  minor complication  significant for
long time

Subjective sensation of dryness and is usually

associated with hypo-salivation

excessive dry mouth  discomfort, taste sensation,

interferes with eating

oral intake and subsequent nutritional deficiencies

Dry mouth
• Xerostomia

Change the oral Ph  conductive to dental

decay

• Medical management
- Fluoride treatment
- oral hygiene
- saliva substitute
- saliva stimulant
 Dry mouth
Managements
- Regular mouth care to keep mouth clean and reduce risk for oral
lesion and infection
- Drink 8-12 cups of liquid a day
- In general, foods that are cold and have no odor
- Eat soft, moist foods that are cool or at room temperature
- Try eating fruit purees, soft cooked
- Use fluids other than water, such as non-acidic juice, to aid
with hydration and increase calorie intake
- Avoid caffeinated foods and beverage
- Avoid dry foods
Swallowing difficulty
Possible causes
• tumor location
• inflammation / pain in throat or mouth due to surgery
• radiation / chemotherapy
• nerve damage from surgery or radiation

Patients with dysphagia need advice on food

consistencies and teaching in swallowing techniques to
prevent risk for aspiration
Swallowing difficulty
Management
• Drink 6 – 8 cups of fluid each day and thicken the
fluid to the right consistency
• coughing or chocking while eating especially with
fever should be reported
• Eat small, frequent, soft, moist meals and snacks
• Drink high-calorie liquid nutritional supplements
several times per day especially if there is disability to
eat regular foods
 Change in smell and taste
Possible causes :
• inflammation and mucous membrane changes from
radiation or taste change from chemotherapy
• lack of smell because nasopharyngeal cancer

Management
• Seasoning foods with tart flavors, such as lemon, citrus
fruits, to overpower bad or off tastes
• Suck on sugar-free lemon candy or mints to get rid of
unpleasant taste
• Flavor foods with natural ingredients
• Rinse mouth before eating to help to clear taste buts
• Eat foods cold or room temperature to decrease food
flavor and odor
Summary
 Malnutrition in cancer is common especially in
head and neck cancer, including
nasopharyngeal cancer
 Radiotherapy cause the worsening nutritional
problem  sore throat, dry mouth, swallowing
difficulty, change in smell and taste
 Nutritional support is needed since malnutrition
has bad impact to cancer outcome
 Oral and enteral nutrition route is preferred
than parenteral