Non-Hodgkin’s Lymphoma

1. Non-Hodgkin’s Lymphoma Lauren Boutwell MS, RD, LDN Ming Cheung MS, RD, LDN

2. Agenda • Lymphoma Overview - L • Nutritional Changes due to Lymphoma - M • Treatment Options - L • Case Study - M • Nutrition Therapy General - L • Nutrition Therapy Case Study - M • Questions • Conclusion - M

3. Objectives • Understand basic information about cancer and lymphoma • Learn about the different treatments for cancer • Understand the nutritional impact of cancer and cancer treatment • Understand the RD’s role in treatment • Understand the nutritional needs of cancer patients

4. Lymphoma • Cancer of the lymph cells (lymphatic system), which is the body’s disease fighting network • Systemic • The lymphatic system includes blood, spleen, thymus gland, and bone marrow • Lymphocytes act abnormally by either dividing faster than normal or living longer than usual

5. Types of Lymphoma • There are several types of lymphomas, classified by origin • Two main groups: • Hodgkin’s lymphoma is characterized by the presence of Reed-Sternberg cells2 • Non-Hodgkin’s lymphoma is classified by the absence of Reed-Sternberg cells3 • Non-Hodgkin’s lymphoma more common • Tumor develops from lymphocytes3 • The most common sub-type of non-Hodgkin’s lymphoma is diffuse large B-cell lymphoma3 • Classification of the type of lymphoma is important because it can affect treatment and prognosis

7. Symptoms of Lymphoma Common symptoms include: • Swollen lymph nodes in the neck, armpits or groin • Abdominal pain or swelling • Chest pain, coughing or trouble breathing • Fatigue • Fever • Night sweats • Weight loss (usually unexplained weight loss and as much as 10% or more of their body weight) • Loss of appetite

8. Lymphoma Staging

9. Nutritional Changes Due to Lymphoma

10. General • Fevers • Fatigue • Anorexia • Anemia • Changes in taste • Cancer cachexia • Biological Alterations

11. AA are not spared as in simple starvation Muscle wasting: increased protein breakdown (hypercatabolism) decreased protein synthesis Occurrence of both results in intense muscular atrophy Changes in taste and smell perception plays an important role in the severity Cancer Cachexia Characterized by: • Involuntary weight loss • Tissue wasting • Inability to perform daily activities • Metabolic alterations

12. Alterations in lipid metabolism5 Increased lipid metabolism Decreased lipogenesis Decreased activity of lipoprotein lipase (LPL) Lipid-mobilizing factor (LMF) produced by tumor or host tissue Biological Changes in Malignancy • Carbohydrate abnormalities • Insulin resistance • Increased glucose synthesis • Gluconeogenesis • Increased Cori cycle activity • Decreased glucose tolerance and turnover

13. Lymphoma Treatment Options

14. Chemotherapy • Systemic treatment • Powerful chemicals to kill fast-growing/rapidly dividing cells • Chemotherapeutic agents travels throughout the body to reach cancer cells • Cannot differentiate between normal reproducing cells and cancer cells • Interrupts cell DNA, RNA or protein synthesis of the cell cycle • Different chemo agents interrupt cell proliferation at different stages • Combination therapy is common - enhance the effectiveness & minimize overall toxicity • Normal cells are damaged as well as the cancer cells

15. Radiation Therapy • Localized treatment used to shrink tumors, kill cancer cells and prevent their growth • X-rays, gamma rays, and charged particles most common types • External-beam radiation therapy - delivered by a machine • Brachytherapy - radioactive material placed near cancer cells • Systemic radiation therapy - radioactive substances (i.e. radioactiveiodine) travel in blood • Often used in conjunction with other therapies

16. Other Options • Surgery • Biological Therapy • Bone Marrow Transplant

17. Case Study: Lymphoma

18. Patient Introduction • Denise Mitchell (DM) • DOB: 2/18 • 21 yowf • College student • Religion: Methodist • Adm for evaluation of viral illness • Experienced night sweats, fevers, and weight loss • CXR indicates a possible mass

19. Physical Exam • General appearance: thin, pale, appears tired • Vitals • T: 100.5°F, RR: 18 bpm, B/P: 95/70 mm Hg, HR: 85 bpm • HEENT: • Head: Normocephalic • Eyes: EOMI; wears glasses for myopia; fundi grossly normal bilaterally • Ears: Tympanic membranes normal • Nose: Dry mucous membranes without lesion • Throat: Slightly dry mucous membranes without exudates or lesions; abnormal lymph nodes

20. Physical Exam cont. • Extremities: Normal muscular tone with normal ROM, nontender • Skin: warm and dry without lesions • Chest/lungs: Respirations are shallow; dullness present to percussion • WNL: Genitalia, Heart, Neurological tests, Abdomen, Peripheral vasculature • CC/HPI: “I don’t seem to have ever gotten over the flu that I had several weeks ago. I still have a fever sometimes, and the cough won’t go away.”

21. Patient History • NKA • Previous Hospitalization: Tonsillectomy – age 5 • Medication: • Dimetapp, OTC (2 tsp, occ) • Tylenol, OTC (400mg, occ) • Cold in past two weeks • Non-smoker • FH: (non-contributory)

22. Anthropometrics • Ht: 5’6” • Wt: 120 lbs • UBW: 130 lbs • %UBW: 92.31% • BMI: 19.34 – normal range • % unintentionalwt loss: 7.69% over the last 2-3 months, significant loss

23. Usual dietary intake AM: Cold cereal, toast or doughnut, skim milk, juice Lunch: (in college cafeteria) sandwich or salad, frozen yogurt, chips or pretzels, soda PM: Meat (eats only chicken and fish), 1-2 vegetables including a salad, iced tea, or skim milk Snack: Popcorn, occasionally pizza, soda, juice, iced tea Nutritional Hx • General • Appetite decreased • No N/V, constipation, or diarrhea • Food allergies/intolerances/aversions: NKA • Previous nutrition therapy: None • Vitamin/mineral intake: None • Food purchase/prep: Self, parents, college cafeteria

24. 24-Hour Recall • AM: 1 slice dry toast, plain hot tea • Lunch: ½ c ice cream, ¼ c fruit cocktail, few bites of other foods on tray • PM: Few bites of chicken (1 oz), 2 tbsp mashed potatoes, ½ c Jell-O, plain hot tea

25. Tx plan: Chemotherapy – cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) Prednisone administered orally on first 5 days of each 21-day cycle Other chemotherapeutic meds given intravenously on first day of cycle Radiotherapy planned to begin 3 wks after third cycle of CHOP Diagnosis and Treatment Plan • Dx: • Chest CT, MRI, and bone marrow and lymph node biopsy • Stage II diffuse large B-cell lymphoma w/ mediastinal disease and positive lymph node involvement • Bone marrow and other organs show no indication of disease • Discharged for outpatient therapy on hospital day 5

26. What Symptoms is Denise Experiencing? • Night sweats • Fevers • Loss of appetite • Unexplained weight loss • Coughing • Fatigue/lack of energy • Abnormal lymph nodes

27. CHOP & What To Expect

28. Nutritionally Related Labs

29. Nutrition Diagnosis • Malnutrition • Altered nutrition related laboratory values (albumin) • Unintended weight loss (involuntary weight loss) • Inadequate oral food/beverage intake • Increased energy expenditure • Inadequate energy intake • Hypermetabolism (Increased nutrient needs)

30. Nutrition Therapy

31. Nutritional Goals for Lymphoma • Prevent or reverse poor nutrition • Manage symptoms • Maintain or improve weight and strength • Maximize quality of life

32. Dietary and Weight Changes after Treatments for Lymphoma Russell NC, et al. Nutrition and Cancer. 2007; 57(2): 168–176 • Retrospective/cross-sectional study • Focused on current BMI • Post-treatment therapy longer than other cancers • No association b/w BMI and recurrence/death • Challenging to detect diet and BMI associations - many complications • Dietary counseling important - choosing foods that alleviate symptoms • Encouraging healthy choices can lead to weight gain

33. Keys to Nutritional Therapy • Careful screening & assessment • Symptoms/side-effects vary with pt • Individualization (Plan & Recommendations) • Severity of malabsorption, • Increase/decrease protein synthesis • Lipid metabolism changes • Appetite changes • Some pts do not need additional calories • Wt gain during/after treatment associated with worse outcome & higher relapse rates

34. Nutrition Therapy: General Side Effects

35. Nutrition Therapy: Chemotherapy Side Effects

36. Radiation Side Effects

37. Radiation Side Effects Cont.

38. DM’s Nutritional Needs

39. Energy Requirement Formula for patients who need to gain weight, are anabolic, or slightly hypermetabolic: 30 – 35 kcal/kg5 Her energy needs is between 1,637 kcal and 1,909 kcal Since she has unintentional weight loss, her energy requirement to be closer to 1,909 kcal

40. Protein DM does not appear to be very stressed Protein guidelines: Non-stressed cancer patient: 1.0 – 1.5 g/kg5 Her protein needs would be between 54.55g and 81.83g Experiencing some unintentional weight loss PE indicates that she looks thin Her protein needs would be closer to 1.5 g/kg to help her increase her energy intake and prevent protein losses due to cancer Her protein need is approximately 76 – 82g (1.4g/kg and 1.5g/kg).

41. Fluid Needs 35 mL/kg (night sweats & diarrhea) 35mL/kg x 54.5 kg = 1,907 mL Approximately 1.9 - 2 Liters of fluids per day

42. DM’s Nutrition Plan Calculated Goal/Recs • 1,900 Kcal/d • 82 gms Protein/d • 2 L fluids/d • Symptoms • Diarrhea • Early satiety • Esophagitis Recommendations • eat small, frequent meals throughout the day • consume nutrient-dense beverages/shakes • consume mild/non-acidic foods • try to consume balanced diet, but primarily whatever is tolerated to meet needs

43. Supplements • No definitive data • No regulation of herbal supplements • Contaminants - harmful with depressed immune status • High doses of antioxidants can actually work against the action of chemo thereby decreasing efficacy • Individual basis

44. Questions and Concerns from Family • Family has been asking questions about different diets... • Family support is great • Encourage questions • Don’t judge!

45. Reputable Sources for Information • Lots of recommendations for alternative treatments for lymphoma • Not all researched based Good Sources of Information • Dana Farber’s (www.danafarber.org/nutrition) • National Cancer Institute (www.cancer.gov) • American Cancer Society (www.cancer.org) • National Institute of Health (www.nih.gov) • Massachusetts General Hospital Cancer Center (www.massgeneral.org/cancer/) • The Leukemia and Lymphoma Society (www.lls.org)

46. Follow-Up/Evaluation • Food journal (what, where, when, and how much; also mood and symptoms she was experiencing) • Weight measured and recorded every day (preferably at the same time everyday), assess compliance and identify any necessary modifications to plan • This may be too much while she is not feeling well and undergoing chemo • I/O, prealbumin, CRP, hospital generated calorie count if she's not feeling well enough to manage it

47. Soluble fiber for diarrhea Common food and drug interactions All the instructional material should be given before the symptoms occur21. Low microbial diet Review safe food handling & clean technique (Dining In/Out) Nutrition Education • Proper record keeping (food journal) • Symptoms • Importance of obtaining adequate energy and nutrient intake during the treatment • List of foods and recommendations for common symptoms • Meal replacements • Mouth care

48. Sensitivity Understand this is a stressful time Education is important Be careful to not overwhelm Be sensitive to patient needs

49. Questions • Is it recommended that all cancer patients consume more calories? • Is too much weight gain bad? • What if the pt refuses to eat? • What about conflicting advice?

50. Conclusion • Nutritional care is important in conjunction medical treatment • Good nutrition can lead to better outcome & tolerance of cancer treatment • There are metabolic changes that can occur with lymphoma • Goal is to prevent malnutrition, treat symptoms, and improve QOL • RDs can make a big difference