MedicalNutritionTherapyforanAdvancedPancreaticCancerPatient:ACaseStudy

TaylorPalm

NFS562

February18,2017

Email:Taylor.palm@yahoo.com
 Abstract:Pancreaticcancer(PC)occurswhenthereisanabnormalgrowthofcells

establishedinthepancreas,anorganthatplaysavitalroleinbloodglucoseregulationand

digestion.1Duetocanceritself,itslocationinthepancreas,andtreatmentlikechemotherapy,

nutritionstatuscanbeimpactedinavarietyofways.13Thiscasestudydescribesthemedical

nutritiontherapyforanadvancedPCpatientexperiencingnutritionrelatedsymptomssuchas

poorappetite,significantweightloss,anddysgeusia.ImplementationoftheNutritionCare

Processbyregistereddietitians(RDs)resultedinimprovedoutcomesincludingimproved

dysgeusiaaswellasincreasedenergyandproteinintake.

CasePresentation:Theoncologypatientinthiscasestudyisan86yearoldmale.Heis

66in,or167.64cm,and133#,or60.45kg,hisBMIis21.5.Hisusualbodyweightis145#.His

weighthistoryincludesasignificant12#(8.3%)lossin3months.Heismarriedwith2adult

daughters,retiredandliveswithhiswifewhocooksandfoodshops.Hehasnohistoryof

smokingordrinking.Pastmedicalhistoryincludeshypertension,hyperlipidemia,myocardial

infarction(2001),andanemiawithnopastsurgicalhistory.Thepatientwasrecentlydiagnosed

withStageIVadenocarcinomaofthetailofthepancreaswithmetastasestothelymphnodes.He

isbeingfollowedbyaninterdisciplinaryteamatanoutpatientcancercenter.Heoptednotto

undergosurgeryduetosuspectedprolongedrecoveryanddecreasedqualityoflife.Instead,he

andhisoncologistchosetopursuepalliativechemotherapyofGemzarandAbraxane.Thepatient

iscurrentlyoncycle1.

ThepatientmeetswithRDsatthecancercenter.Afterthefirstweekofchemotherapy,he

complainsofpoorappetiteanddysgeusia.Hedenieschangesinbowelhabits.Heisonthe
followingmedications:Coreg,Prinivil,withZofranandCompazineprescribedPRN.Labresults

showedalowH/H(10.2g/dL/32.7%)withhighMCV(99.1fl)likelyduetohishistoryofanemia

andpancreaticcancer(PC).Also,AST(39u/L)andALKPhos(136IU/L)werehigh,likelydue

toPC.4Thepatientdoesnothaveanynotedallergies.

Thepatientfollowsaregulardietbutlimitsexcesssodiumduetohispastmyocardial

infarction.A2dayfoodrecordfound,day1thepatienthad:1cupwholemilk,banana,and1

wholeorangeforbreakfast,6ozfatfreeGreekyogurtwithcupgranolaforlunch,and2pieces

ofwholewheattoastwith2TBofbutterfordinner.Day2,hehad1cupshreddedwheatcereal

with1cupwholemilkforbreakfast,agranolabarforlunch,andasliceofmeatloafwithcup

ofmashedpotatoesfordinner.Estimatedintakewas:1036kcaland47g/proteinday1,and718

kcaland35g/proteinday2.

UsingtheMalnutritionScreeningTool(MST),hereceiveda2forrecentweightlossand

poorappetite,meaningheisatriskformalnutrition.5UponfurtherevaluationwithASPEN

guidelines,hereceivedaseveremalnutritiondiagnosismeetingcriteriafor>7.5%weightlossin

3months,reportedeating<75%ofmealsfor>1month,andmildmuscularandfatwastingnoted

intheorbital,temporalandclavicularregions.Ahanddynamotorassessmentwasnotperformed

andedemawasnotnoted.6Thepatientsweightlossandmuscularwastingmeetthediagnostic

criteriaofcancercachexia,aproteinenergymalnutritionwithwasting.7 Forthesereasons,the

patientsenergyandproteinneedsareincreased.Hisenergyneedswereestimatedas18142116

kcal/day(3035kcal/kg).Proteinneedswereestimatedas7390g/day(1.21.5g/kg).Thepatients

idealbodyweightis142#,heiscurrently93.6%ofIBW.
 Forthenutritiondiagnosis,theassessmentresultedinthefollowingPESstatement:

InadequateoralintakerelatedtometastaticPCasevidencedbyaveragedailyintakeof877kcal

and41g/proteinper2dayfoodrecord,8.3%weightlossin3months,intake<75%ofmealsfor

3months,reportedpoorappetiteanddysgeusia.Theinterventionincluded:Verbalandwritten

educationoneatinghintsforcancerspecificallytipsforovercomingdysgeusiaandpoorappetite

aswellasfortifyingfoods/mealswithextracaloriesandprotein.Additionally,werecommended

anoralnutritionsupplement(ONS)atleastoncedailyandprovidedthepatientwithsamplesof

BoostPlus.Shorttermdietarygoalswere:Meetenergyandproteinneedsbyincreasingoral

intaketo>75%ofmealsandsupplementinganONSatleastoncedaily,preventfurtherlossof

weightandleanbodymass,reduceimpactofpoorappetiteanddysgeusia,andpatient

understandingofdieteducation.Longtermdietarygoalsincluded:adequateoralintake,weight

restorationandmaintenance,andpreventnutrientdeficiencies.Heandhiswifewerereceptiveto

nutritioneducationoneatingtipsforcancerandimprovinghisspecificsymptoms.Hetrieda

sampleofBoostPlusandremarkedthathelikedthechocolateflavor.Itislikelyhewilldrink

ONSathome.Hiswifeaskedanumberofquestionsregardingwaystoaddcaloriestohismeals

andaddflavorsforhisdysgeusia.Hisstrongsupportsystemindicateslikelycompliance.

Monitoringandevaluationinclude:oralintake,nutritionimpactsymptoms,weight

change,andlabs.Thoughthepatientdoesnotcomplainofnausea,vomitingorchangesinbowel

habits,signsofthesesymptomswillbemonitoredfor.TheRDswillcheckinonhimweeklyas

hecontinueschemotherapy.Unfortunately,theprognosisformetastaticPCispoor.Palliative

chemotherapywillhopefullyextendhislifeaslongaspossible.
 Discussion:Cancerischaracterizedbyanabnormalgrowthofcells.1Carcinogenesis

involvesthreephases:initiation,promotion,andprogression.1Inthefinalphase,afullyformed

malignantneoplasm,ortumor,isestablished.1Inmoreadvancedcancer,thetumorcan

metastasize,orspread,toothertissuesandorgans.1Cancercachexia,aproteinenergy

malnutritionwithmusclewasting,includessymptomssuchasweightlossandanorexia.1Itisa

resultofcytokinescausingchangesinmetabolismwhichresultsinincreasedrestingenergy

expenditure.1AccordingtotheEvidenceAnalysisLibrary(EAL),interventionsecondaryto

identifyingcachexiacanimproveclinicaloutcomes.8

Thelocationofatumor,inthiscase,thepancreas,canaffectapatientsnutritionalstatus.

Thepancreasisanimportantorganwithtwomajorroles.1Itsendocrinefunctionincludes

manufacturinginsulinandglucagonneededforbloodsugarcontrol.1Itsexocrinefunction

includessecretingdigestiveenzymesviathepancreaticductintothesmallintestineswhichare

requiredtobreakdowncarbohydrates,fats,andproteins.1Duetotheseroles,PCcancause

malabsorption,poorappetite,weightloss,nausea,vomiting,diarrhea,jaundiceandchangesin

bowelhabitssuchaspale,floating,oily,foulsmellingstools.3Theycanalsoaffectbloodsugar

regulation,thoughthepatientsbloodglucoseiswithinnormallimitsatthistime.3

Thepatientdoesnotreportchangesinbowelhabitsatthistimeandthereforedoesnot

appeartohavemalabsorption.However,thisshouldbemonitoredwithPCbecausetumorscan

blockorrestrictthepancreaticductresultingininsufficientdigestiveenzymesenteringthesmall

intestines.3Ifmalabsorptionisnoted,pancreaticenzymereplacementtherapy(PERT)wouldbe

initiated.3PERTprovidesenzymesatmealstoaiddigestionandincreasenutrientabsorption.3
 PCcanbetreatedwithanycombinationofsurgicalresection,chemotherapy,or

radiation.3Thepatientoptedforpalliativechemotherapy.Palliativecareisnotdonewithintent

tocurebuttomakepatientscomfortable,improvequalityoflifeandsymptoms,andreduce

pain.1Chemotherapyisasystemicwaytotreatcanceraffectingallcellswitharapidturnover

likethoseinbonemarrow,hairfollicles,andalimentarytractmucosa.1Poornutritionstatusis

correlatedwithareducedtolerancetochemotherapyaswellasincreasedinterruptionsof

treatment,infections,fatigueandhospitaladmissions.9Symptomsaffectingnutritionstatus

dependonthetypeofchemotherapy.ThispatientisonGemzarandAbraxane.Gemzar,an

antimetabolite,cancausevomiting,fatigue,myelosuppression,anorexia,nausea,diarrheaand

mucositis.1Abraxane,aplantalkaloid,cancauseanemia,nausea,vomiting,diarrhea,

dehydration,decreasedappetite,andconstipation.2Thepatientalsoreportsdysgeusia,ortaste

changes,whichareassociatedwithchemotherapyaswellaspoorqualityoflife.10

Thepatientisonafewmedicationsatthistime.Coreg,abetablockerfortreating

hypertension,maymaskhypoglycemicsymptomsorcauseweightgainordiarrhea.11Prinivil,an

ACEInhibitor,alsoforhypertension,maycauseabdominalpain,vomiting,nausea,ordiarrhea.11

Zofran,anantinauseaandantiemetic,maycauseconstipationordiarrhea.11Finally,

Compazine,anotherantiemetic,maybeeffectedbydiuretics,Warfarin,andalcohol.11

Apoornutritionstatusisassociatedwithmortalityandlowerqualityoflifeinadult

oncologypatients.9Itis,therefore,importanttoaddressissuesaffectingnutritionassoonas

possible.OnestudyfoundforPCpatients,thosewholoselessweighthaveimprovedoutcomes

posttreatment.12Anotherstudyfoundanutritionalinterventionconsistingofdietitian

counseling,foodfortificationandONS,leadtogreaterintakesofenergyandprotein,onaverage
379morecalories(p=0.007)and10.4moregramsofproteinaday(p=0.016).13Accordingtothe

EAL,medicalnutritiontherapybyanRDcanimprovetreatmentoutcomesinoncologypatients

gettingchemotherapy,liketheoneinthiscasestudy.9Inordertobesuccessful,anRDshouldbe

clearaboutnutritionalgoals,utilizeindividualizedapproachesandpayparticularattentiontothe

patientspsychosocialstatusduringtreatment.14Inaddition,RDsshouldconsidergoalslike

qualityoflifeandfunctionalcapacityintheirintervention.14

Thepatientsmainnutritionrelatedsymptomsarepoorappetite,dysgeusia,and

significantweightloss,allofwhichcanbeimprovedwithmedicalnutritiontherapy.Thereare

severalstrategiesanRDcaneducatepatientsontoimprovethesesymptoms.Fordysgeusia,

strategiesinclude:choosingthemostappealingfoods,marinadesandspices,plasticutensilsifa

metallictasteispresent,maintainingacleanmouth,andaddingextraflavors,sweetnessor

tartnesstoincreasepalatability.1,15Forappetiteandweightloss,strategiesinclude:choosing

nutrientdensefoods,smallfrequentmeals,drinkingONSwhenitisdifficulttoeat,fortifying

foods,andmakingthemostoftheperiodswhenfeelingbest.1,15Just1.5cansadayofONS,can

improvenutritionrelatedoutcomesinPCpatientswithoutaffectingmealintake.16

Conclusion:ThepatientisstillfollowedbyRDsduringchemotherapy.Hehasnochange

inbowelhabits,showingnoneedforPERTatthistime.Hisabnormallabvaluesremained,

however,theyarelikelyrelatedtohiscondition,notnutritionstatus.Hisappetitehasnot

improved.Forsimilarfuturepatients,Imayrecommendanappetitestimulanttothephysician.

HedoesreportdrinkingaBoostPlusaday.Anewfoodrecordindicatesanaverageintakeof

1550kcaland75gramsofproteinaday.Whileheisnowmeetinghisproteinneeds,heisstill
notmeetingcalorieneeds.AsecondBoostPlus,anextrasnackormorecalorieboostingwould

help.After2weeks,helost1#(0.8%),thoughnotsignificant,hisgoalisweightmaintenance.

Dietaryeducationwaseffectiveashiswifereportedaddingoliveoiltopotatoes,buying

fullfatyogurt,andaddingproteintoeverymeal.Sheisexperimentingwithseasoningslike

lemonpepper,garlic,andcurrytohelphisdysgeusia.Hereportsimprovementwiththelemon

pepperandgarlic,butnotcurry.Futureresearchshouldevaluatetheefficacyoffoodalterations

likespicesandacidityinreducingsymptomsincancerpatients.Thoughanecdotallythisstrategy

iseffective,thereisnocurrentevidencesupportingit.17Allinall,thepatientreportsincreased

proteinandcalorieintakeandimproveddysgeusiafollowingnutritioninterventions.Forfuture

patients,Iwillconsiderqualityoflifeasimportantasclinicaloutcomes.14Forthispatient,

prognosisispoor,maintainingthatqualityoflifewillbeoftheutmostimportanceinhiscare.

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