Nutritional Aspects of Cancer Care

1. Nutritional Aspects of Cancer Care Helen Webster Oncology Dietitian NHS Tayside

2. Aims • Malnutrition • Causes • MUST • Management • Cancer Cachexia • Management • EPA supplements • Alternative diets/supplements • Case studies • Conclusion • Questions • References

3. What is Malnutrition? • “A state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse affects on tissue/body form, function and clinical outcome” • DOH, 2002 • 1 in 4 adults admitted to hospital or care homes at risk of Malnutrition. Bapen 2007 • Estimated up to 80% of advanced ca pts have malnutrition.Poole & Froggatt, 2002

4. Causes of malnutrition? Four main causes: • Decreased dietary intake • Increased requirements • Increased losses of nutrients • Impaired nutrient digestion / absorption.

5. Causes of decreased intake • Reduced appetite due to cachexia / depression / anxiety • Symptoms of illness – N&V, sore mouth, abdo distension, diarrhoea. • Treatment side effects • Tumour / ascites pressing on GI Tract reducing volume available and causing early satiety • Taste changes • Constipation

6. Causes of decreased intake • Social isolation, significant life change, mental illness • Repeatedly NBM for investigations / biopsies • Difficulty with eating / chewing e.g. ill fitting dentures, poor oral hygiene / dysphagia • Difficulty with self feeding

7. Causes of Increased Requirements • Cachexia • SOB e.g. lung ca, PE, • Infection • Wound healing • Post op pts • Fractures

8. Loss of nutrients • Vomiting • Diarrhoea • Renal losses • Haemorrhage • Wound • Fistula

9. Impaired digestion / absorption • Lack of digestive enzymes e.g. ca pancreas, pancreatitis, CF • Loss of surface area for absorption e.g. pts with resections, coeliac disease • Radiation enteritis

10. Impact: • Weight loss • Vitamin Deficiency • Impaired immune function • Delayed wound healing • Higher risk of pressure sores • Muscle wasting and weakness – impairing respiratory function, cardiac function, mobility

11. Impact Cont… • Increased risk of post op complications. • Apathy and depression – vicious circle. • Lethargy, tiredness, weakness. • Est. 20% people with cancer die from effects of malnutrition rather than cancer itself.

12. Management of Malnutrition • Early intervention improves outcome. • Ward can screen with MUST, start fortified diets, food charts, weight checks, provide assistance. • Clinics – weight, height, BMI, weight history, recent food intake, consider planned treatments. • Refer to dietitian using MUST score > 2, anything less should be managed at ward level.

14. Management of malnutrition • Treat side effects restricting intake • Treat depression if present • Mouth care – be proactive! • Modify diet • Consider supplements • Consider artificial nutrition if appropriate

15. Nutritional Supplements • Ensure plus – 330 kcal, 13 g protein. • Ensure plus juce – 330 kcal, 10 g protein. • Enshake – 600 kcal, 15 g protein. • Calogen - 405 kcal in 3 x 30 ml doses. • Procal liquid – 300 kcal, 6 g protein in 3 x 30 ml doses. • Procal powder – 100 kcal, 2 g protein. • Want to try some? • Which do you prefer? • Others available.

16. Enteral Feeding • Various routes: NG, NJ, PEG, RIG, PEJ, Surg Jej. • Used to meet full / part nutritional requirements. • Various feeds. • Emergency feeding regimen for out of hours.

17. Refeeding Syndrome • Refeeding syndrome – “severe fluid and electrolyte shifts and related metabolic complications in malnourished pts undergoing refeeding.” • During starvation the body adapts to save energy. • On refeeding: increased insulin release leads to uptake of glucose, Phos and K+ into cells.

18. Refeeding Continued… • Magnesium is used as a co-factor for cellular pump activity • Reactivation of the Na/K+membrane pump leads to more K+ moving into cells • Reduced phosphate causes increased magnesium excretion (urine) • Stimulation of protein synthesis leads to increased demand for phos, K+ and glucose by the cells • Increased thiamine use – cofactor in CHO metabolism

19. Parenteral Nutrition • Intravenous nutrition • If the gut works – USE IT! • Used to meet patients requirements where the gut is not working • Short and long term indications e.g. enterocutaneous fistulae, post-op ileus, severe mal-absorption, short bowel syndrome, radiation enteritis etc • Requested via the nutrition team

20. Cancer Induced Weight loss (Cachexia) • Weight not maintained despite normal diet • Complex combination of metabolic abnormalities. • Particularly prevalent with solid tumours. • Adequate nutrition has little or no effect • Early visible sign of deterioration • Associated with Anorexia and Early satiety

21. Aetiology of cachexia • Many different factors • Cytokine involvement • Pro-inflammatory cytokines implicated in metabolic disturbances • TNF, IL-1, IL-6, IL-8 and LIF • Mediate acute phase protein response (APPR) • Causes increased synthesis of proteins by the liver e.G. CRP • Req. Amino acids from lean body tissue causing weight loss • CRP elevated in 45 % of ca panc pts at diagnosis. Falconer et al. 1994

22. Glucose Production/ turnover Metabolically Inefficient Recycling of glucose Whole body Protein turnover APPR Protein catabolism REE Lipogenesis Protein synthesis Lipoprotein lipase Metabolic changes causing REE PIF REE = resting energy expenditure PIF = proteolysis inducing factor APPR: Acute phase protein response

23. Summary of Cachexia

24. Management of Cachexia • Team approach. • Cure the cancer – not always possible. • Increase nutritional intake – diet and supplements to meet the deficit. • Reduce effects of factors listed previously through cancer treatments, pharmacology, dietary interventions, involvement of other AHPs etc. • Improve nutritional status. • Improve quality of life.

25. EPA Supplements • High fish oil content providing patient with mega-dose of eicosapentaenoic acid (EPA) • Proven to reduce inflammatory response • Reduce further weight loss • Improve quality of life • Limited evidence, small studies. • 2 available: Prosure (any cachexic pt) and Forticare (licensed only for ca pancreas) • Not widely used as other supplements tend to be more appropriate/palatable when pts diagnosed. • Cost implications: Ensure plus = 3 p on contract (in hospital) Forticare = £1.80 Prosure = £2.70 Wigmore et al, 1996

26. Alternative Diets/ Supplements • Many different types • Vulnerable/desperate patients seeking help / advice • Not evidence based • Tend to cut out/restrict good sources of calories and protein • Tend to encourage lots of f&v >10 portions, bulky, low in kcals and protein • Some claim to cure cancers • Some promote weight loss as part of the healing process

27. Bristol Cancer Diet • Well publicised. • It recommends: • High intake of fresh veg & fruit, high in whole grains beans and pulses on a regular basis. • It rules out: • Sugar and refined carbohydrates, dairy products, red meat, processed foods, smoked/cured foods, caffeine, alcohol, salt .

28. Problems With The Bristol Cancer Diet • Cancer patients commonly have poor appetite and early satiety • Eating bulky foods such as raw veg, brown rice and pasta, lentils and pulses – not tolerated. • People fill up on these quickly. • Therefore unable to meet calorie and protein requirements and lose weight. • Limited evidence. • Where appropriate Healthy eating advice should be given by a dietitian and tailored to the individual e.g. in a weight gaining breast ca pt.

29. Gerson Diet • Claims a 50% recovery rate if followed – no evidence to support those claims • Strictly based on organic fruit and veg – juiced • Therefore entirely vegan • Coffee enemas, thyroid hormones and liver extract used • Very expensive, time consuming and pts lose weight dramatically Gerson institute, 2006

30. Metabolic Therapy • Claims to boost the immune system • Uses Lætrile (vit B17) a derivative of bitter almonds/apricot kernels • Also uses coffee enemas and liver extract and mega doses of vits and mins • Scientific studies showed no effect on outcome for patients • Demonstrated higher levels of cyanide from Lætrile in blood stream of those taking part National Cancer Institute, 2006

31. Immuno-augmentative Therapy • Iscador – extract of mistletoe • Said to boost immune function • Studies have shown rise in WBC • Seen to affect growth of ca cells in laboratories • Limited evidence – mechanism not fully understood. Weleda, 2006

32. Shark Cartilage Extract • Claim that sharks don’t get cancer. • Cartilage thought to prevent angiogenesis. • One major study showed no effect. • However phase 3 trial using Neovastat in USA underway (renal ca and NSCLCa). • £20 for 100 capsules online. • ? Dosage. Cancerhelp, 2008.

33. Alternative Diets/supplements • The weird and the wacky. • Used by the very vulnerable / desperate people as well as the sensible. • Can be avoided if given appropriate advice early on. • Tread carefully. • Allow the patient to make an informed choice. • And allow the dietitian to support their choice without detriment to their health.

34. Case Study 1 • 76 yr old male. • Admitted with SOB, recurrent chest infections. • Recently found to have lung ca on CT and pleural effusion. • C/O poor appetite. • Mouth “like the Sahara desert.” • Gets fatigue from SOB. • Lost approx 7 kg (1 stone) over last 4-6 weeks.

35. Case Study 1 • What steps can be taken to improve this pt’s nutritional intake? • What can be done at ward level? • What other proactive measures would help prevent a worsening of his nutritional intake? • What other meds are likely to be used that will help his appetite anyway?

36. Case Study 2 • 72 yr old male pt adm to oncology unit with oesophagitis, dry, sore mouth, dysphagia and pain on eating and swallowing. • Has been receiving radiotherapy for oesophageal cancer • Minimal dietary intake • Unable to wear dentures • Epigastric pain, particularly at night.

37. Case Study 2 • What has caused the oesophagitis? • How can we reduce the pain on eating and at night? • What sort of mouthcare might you recommend? • What dietary steps / advice may be useful? • What steps can the ward take?

38. Conclusion • No quick fix to nutrition support for patients. • Not necessarily about pt gaining weight. • Aiming to improve quality of life for the pt and reassure anxious relatives. • Proactive approach is best. • Early referral and intervention improves outcome for the patient.

39. Conclusion • Oncology Dietitians available for patients on ward 32 east, west and day pt area • MUST scoring with common sense and proactive thinking • Refer other ward’s patients to local dietitians • Food first approach • Not just about supplements – lots of other issues we can address as a team to improve a patient’s oral intake and in turn their quality of life.

40. Thanks for listening • Any questions?

41. References: • DOH. Nutrition screening in quality of care 2002. • McWhirter J.P., Pennington C.R., Incidence & recognition of malnutrition in hospital. Br MED J 1994:308:945-948. • Poole K, Frogatt K, weight loss in advanced cancer – a literature review. Macmillan cancer relief, 2002. • Tisdale MJ, biology of cachexia, J Natl cancer inst 1997:23: 1763-73. • Falconer JS, Plester CE, et al. Cytokines, the acute-phase response, and resting energy expenditure in cachexic patients with pancreatic cancer. Ann surg 1994;219(4): 325-31. • Tisdale MJ, metabolic abnormalities in cachexia and anorexia. Nutrition 2000;6:d164-74. • Billingsley KG, Alexander HR. The pathophysiology of cachexia in advanced cancer and AIDS. In: Bruera E and Higginson I, Cachexia – anorexia in cancer patients: NY: oxford university press, 1996. P1-22.

42. References • Wigmore SJ et al. The effect of polyunsaturated fatty acids on the progress of cachexia on the progress of cachexia in patients with pancreatic cancer. Nutrition, 1996;12. • Bristol cancer help, 2006 www.bristolcancerhelp.org.uk. • Gerson institute, 2006 www.gerson.org. • National cancer institute, 2006 http://www.cancer.gov/cancertopics/pdq/cam/laetrile. • Weleda, 2006 www.iscador.com. • Cancerhelp, 2008 http://www.cancerhelp.Org.uk/help/default.Asp?Page=31060.