Medical Nutrition Therapy for Cancer!

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Cancer!
• Cancer damages the DNA of the cells of the body. The damage accumulates over time. !
• Tumor Classification: based on tissue of origin, growth properties, invasion of other tissues.!
• Malignant neoplasm growth usually destroys surrounding tissues and may spread to surrounding
tissues and organs (metastasis)!
• Leukemias and lymphomas, tumors of the immune system, occur in both adults and children. !
• Stages of carcinogenesis: initiation, promotion, and tumor progression.!
• Initiation - transformation of the cell produced by the interaction of chemicals, radiation, or
viruses with the cellular DNA. Rapid transformation but cell is dormant until activated by
promoting agent.!
• Promotion - initiated cells multiply to form a tumor!
• Progression - formation of a fullt malignant neoplasm!
• Goals of treatment: cure, control, palliation, or adjuvant therapy!
• Treatment response: complete, partial, stable or progressive !
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Nutrition for Cancer!
• Nutrition can modify the carcinogenic process at any stage, including carcinogen metabolism,
cellular and host defense, cell differentiation, tumor growth !
• Nutrition is affected by the cancer and its treatment: can affect digestion, absorption, and
metabolism (nausea and vomitting, change in taste and smell, bowel changes, dysphagia,
anorexia, pain, fatigue) !
• Nutrition for cancer addresses the causes and consequences of cancer and its treatment. !
• Nutritional Management: Prevent or correct nutritional deficiencies, Minimize weight loss!
• Nutrition Goals: Prevent or reverse nutrient deficiencies, preserve lean body mass,
minimize nutrition related side effects, maximize quality of life, minimize effects of
nutrition impact symptoms and to maximize the patient’s nutritional parameters !
• 1/3 of cancer deaths can be attributed to nutrition and other lifestyle factors as seen in migration
between cultures.!
• Diet is difficult to plane because a diet contains both inhibitors and enhancers of carcinogenesis.
When one component of the diet is altered, other changes take place simultaneously. Thus,
effects cannot be clearly associated with a single factor. Many cancers have a long latency
period meaning the diet at the time of cancer diagnosis may not be the same as cancer initiation
or promotion. !
• But for sure it’s related because various nutritional manipulations influence the occurrence of
tumors in animals !
• The adverse nutritional effects of cancer can be severe and may be compounded by the effects
of the treatment regimens and the psychological impact of cancer. The result is often a profound
depletion of nutrient stores. Significant weight loss and poor nutritional status at time of diagnosis
are associated with lower quality of life scores. Even small amounts of weight loss before therapy
are associated with poor prognosis thus reinforcing the importance of early nutritional
assessment and intervention as a preventive measure. !
• Relationship between nutritional status and the outcome of malignant disease!
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Cancer Cachexia !
• Cancer Cachexia - A common secondary diagnosis in patients with advanced neoplastic disease
is a variant of protein energy malnutrition. !
• Progressive weight loss, anorexia, generalized wasting, immunosuppression, altered basal
metabolic rate, and abnormalities in fluid and energy metabolism. !
• Happens in both patients with localized disease and metastasis. !
• No exact etiology but related to cytokines. !
• Cachexia is one of the most common causes of death among patients with cancer, and is
present in 80% at death.17 The word “cachexia” was used by a Roman physician to describe a
state!
of “marked emaciation and severe malaise that frequently accompanies chronic, severe, and often
lethal diseases.”!
• Cachexia is characterized by involuntary weight loss, tissue wasting (particularly lean body mass!
and adipose tissue), inability to perform daily activities, and metabolic alterations. These alterations
in glucose, amino acid/protein, and lipid metabolism can have an impact on the patient’s nutritional
and medical status with a subsequent impact on quality of life, morbidity, and mortality.!
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Anorexia!
• Eat smaller, more frequent meals.!
• Maximize your intake when appetite is most normal.!
• Limit fl uid with meals to avoid feeling of fullness.!
• Keep favorite foods readily available at all times.!
• Mild exercise, as tolerated (check with physician).!
• Eat meals in a pleasant environment.!
• A glass of wine before a meal may help to stimulate the appetite (check!
with the physician fi rst).!
• Avoid noxious odors; ventilate eating area.!
• Find a liquid nutritional supplement that is appealing and drink only!
2–4 ounces at a time (to avoid a feeling of fullness); keep unopened!
beverage in the refrigerator.!
• Try relaxation exercises before mealtimes.!
• Consider pharmacologic agents/appetite stimulants.!
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Severe Oral Mucositis !
• Because patients become immunocompromised, supportive therapy including medications and
dietary changes is essential to prevent infection!
• Food safety practices: avoidance of food containing unsafe levels of bacteria (raw meat, spoiled
or moldy food, unpasteurized beverages), thorough handwashing, special handling of raw meats,
poultry eggs, utensils, cutting boards, and countertops, storage of food at appropriate
temperatures (below 40 degrees F and above 140 degrees F)!
• Neutropenic diet: low microbial or low bacteria diet !
• Serve cooked food and avoid fresh, raw, or uncooked food and unpasteurized beverages !
• Serve soft or liquefied, moderate or room temperature !
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Sensory Changes !
• Alteration in taste and smell can contribute to anorexia!
• Taste alterations associated with disease, antineoplastic agents, irradiation, or surgery!
• Chemotherapy induced learned taste aversions !
• Heightened sense of smell that results in the sensitivity to food preparation odors. -> Serve food
cold instead of hot!
• Altered taste acuity (dysgeusia, hypogeusia, ageusia) = increased use of flavorings and
seasonings !
• Meat aversions = remove red meat because it has strong flavor and substitute with other protein
alternatives!
• Taste changes that occur include a metallic taste (usually due to the chemotherapeutic agent
cisplatin), no taste sensation (aguesia), a heightening of certain tastes (especially sweets), or
aversions to foods the patient liked to eat in the past.!
Patients who experience a metallic taste in their mouth should be advised to avoid metal utensils
and instead use plastic utensils. If nutritional supplements are consumed, they should be poured
into a glass first, as often the metal container may also be off ensive. Meats are often not tolerated.
To ensure an adequate protein intake, the patient should be encouraged to incorporate other high-
protein foods into the diet, including peanut butter, cottage cheese, cheese, poultry, and soy meat
substitutes. Patients with aguesia should be encouraged to use more highly spiced and fl avorful
foods, such as marinated foods. Sweet foods often taste too sweet to individuals undergoing
cancer therapy. Many homemade drinks and nutritional beverages may be too sweet for these
patients.!
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Fatigue and Early Satiety!
• One of the most common symptoms reported by patients with cancer!
• Physical tiredness, mental slowness, lack of emotional resilience!
• Consume small frequent feeding, emphasizing morning feeding, easy to prepare food that’s easy
to consume. Serve nutrient rich beverages in between meals to avoid feeling of fullness!
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Pain!
• Affects appetite and ability to eat !
• Result of the tumor itself or treatment !
• Can have a psychological component !
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Food Aversions !
• when specific food are associated with unpleasant symptoms such as nausea and vomiting and
psychological stimuli such as anxiety!
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Chemotherapy!
• Chemotherapy is a systematic therapy that affects the whole body !
• Target is not just the malignant tissues but also affects normal cells especially cells in the body
with rapid turnover such as bone marrow, hair follicles, mucosa of the alimentary tract!
• Effects: myelosuppression, fatigue, nausea, comiting, loss of appetite, mucositis, changes in
taste and smell, xerostomia, dysphagia, changes in bowel function, taste abnormalities: diarrhea,
constipation, adynamic ileus (inhibition of bowel motility) !
• Corticosteroids can cause tissue breakdown and cause urinary loss of protein, potassium,
calcium. Intestinal mucosa and digestive processes are affected thus altering digestion and
absorption, protein, energy and vitamin metabolism may be impaired !
• Total lymphocyte count is depressed !
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Radiation !
• Radaition therapy only affects the tumor and surrounding area !
• Loss of appetite, skin changes, hair loss in area being treating !
• Sore mouth, altered taste and smell, dysphagia, odynophagia, mucositis, xerostomia!
• anorexia, fatigue, weight loss!
• Late effects: dental carries, permanent xerostomia, trismus or lockjaw, osteoradionecrosis!
• Radiation near the thorax can cause heartburn, acute esophagitis, dysphagia, odynophagia !
• Late effects: esophageal fibrosis !
• Radiation to abdomen: acute gastritis or enteritis accompanied by nausea, vomitting, diarrhea,
anorexia!
• Late effects: severe gastrointestinal damage = malabsorption of fat, disaccharides, electrolytes !
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Immunotherapy!
• fatigue, chills, fever, flulike symptoms, decreased food intake !
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Energy!
• Chronic restriction of food inhibits the growth of most experimentally induced cancers and the
growth of many spontaneous cancers. Caloric restriction during the progression phase is more
effective in inhibiting tumor growth.!
• May have increased Resting Energy Expenditure (REE) !
• Patients who maintain their body weight and nutrient stores may be better able to tolerate
treatment impact symptoms and recover more quickly from therapy !
• Weight loss during cancer therapy is usually caused by loss of muscle (lean body mass) rather
than fat stores !
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Fat!
• Omega-3 fatty acid supplementation may help stabilize weight in cancer patients on oral diets
experiencing progressive,unintentional weight loss.!
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Protein!
• Tumor development is suppressed by diets that contain levels of protein below that required for
optimal growth whereas it is enhanced by protein levels two or three times the amount required.
Attributed to specific amino acids, general effect of protein, or depressed protein intake. !
• Certain amino acid deficiencies inhibit some tumors - feeding amino acid deficient diets is a
possible form of cancer therapy!
• Alterations in protein metabolism appear to be directed toward providing adequate amino acids
for tumor growth. Loss of skeletal muscle protein. !
• A patient’s need for protein is increased during time of illness and stress. The additional protein is
required by the body to repair and rebuild tissues affected by cancer therapy and to maintain a
healthy immune system. For the body to most effectively use protein, adequate energy should be
provided or the body will use its protein reserves as a fuel source. !
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Fruits and Vegetables !
• Anticarcinogenic agents found in fruits and vegetables: antioxidants such as Vitamins C and E,
selenium, and phytochemicals such as carotenoids, flavonoids, plant sterols, allium compounds,
indoles, phenols, and terpenes. !
• What anticarcinogenic agents do: induction of detoxification enzymes, inhibition of nitrosamine
formation, provision of substrate for formation of antineoplastic agents, dilution and binding of
carcinogens in the digestive tract, alteration of hormone metabolism, and antioxidant effects!
• Consumption of fruits and vegetables provides a protective effect against cancers (stomach). !
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Vitamins and Minerals !
• Vitamin and mineral deficiencies can lead to DNA damage !
• Multivitamin supplements: vitamin b12, folic acid, vitamins A, E, K to prevent deficiencies !
• Many patients may have existing nutritional deficiencies when they are diagnosed with cancer
because of poor diet and lifestyle choices and the metabolic effects of the cancer itself and so
these effects may worsen as a result of cancer treatment and recovery !
• If patients are experiencing difficulty with eating and treatment related side effects, the use of a
multivitamin and mineral supplement that provides no more than 100% of the recommended
daily allowances is generally considered safe !
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Method of Food Preparation !
• Formation polycyclic aromatic hydrocarbons and hetrocyclic amines when high heat cooking
methods such as grilling, broiling, barbecuing, and smoking of meats are used. These toxic
substances are formed during combustion of carbon fuel and pyrolysis of protein. !
• Mutagenic activity in food after frying and charcoal broiling.!
• Healthier alternatives: boiling, poaching, stewing, steaming, braising, baking, microwaving, and
roasting !
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Carbohydrates!
• Tumors have a consistent demand for glucose -> High rate of anaerobic metabolism and yield
lactate as the end product -> Gluconeogenesis through Cori cycle -> lipolysis to maintain high
rates of glucose synthesis !
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Fluid and Electrolyte Imbalances !
• Hypercalcemia in bone metastasized cancers !
• When there is excessive vomitting or diarrhea !
• For those with low saliva production (xerostomia), serve plenty of fluids throughout the day with
meals Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry!
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Timing of Food Presentation !
• Patients with cancer often complain of a decreased ability to eat as the day progresses = the
morning is the best time for eating. May be due to sluggish digestion and gastric emptying as a
result of decreased production of digestive decretions, gastrointestinal mucosal atrophy and
gastric muscle atrophy. Treatment related fatigue. !
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