The Cancer Nutrition Network for Texans presents:

1. The Cancer Nutrition Network for Texans presents: Creating Cancer Care Teams: A workshop for Cancer Patients and their Family Caregivers The CNNT is funded by the University of Texas Medical Branch and the Texas Cancer Council Contract # 08-94

2. Information for Patients Your Survivorship Journey

3. Objectives Patient and Caregiver will: • Name the common cancer therapies • Explain the importance of nutrition during your survivorship journey • Identify several symptom management techniques • Describe the importance of exercise and physical activity

4. The diagnosis of cancer. • You’re not alone – 84,530 Texans are diagnosed each year with cancer. • It’s not a death sentence – 9.5 million people in the US are cancer survivors. • Strong emotions are normal – help, helps. • Be informed – understand your diagnosis, your treatment, ask questions.

5. Surgery Radiation Chemotherapy Immunotherapy Complementary and alternative therapy These can be used as single mechanisms. Commonly these are used in combinations. Often additional therapy, adjuvant, is also possible – e.g., tamoxifen for early stage breast cancer. All produce side-effects! Common Cancer Therapies

6. Nausea Vomiting Diarrhea Constipation Mouth Sores Swallowing Early Satiety Loss of Appetite Change in tastes Sensitivity to smells Managing Side EffectsThat Impair Nutrition

7. Nutrition and Cancer • Nutrition (key nutrients) • Vitamins, minerals, protein, calories, carbohydrates, fat and water • Treatment causes symptoms that may interfere with nutrition • Treatment also may affect other senses that interfere with nutrition

8. The diet is an important part of cancer treatment. Eating the right kinds of foods before, during, and after treatment can help the patient feel better and stay stronger. To ensure proper nutrition, a person has to eat and drink enough of the foods that contain key nutrients (vitamins,minerals,protein,carbohydrates, fat, and water). Nutrition Advice during Treatment

9. Treatment Symptoms For many patients, some side effects of cancer and cancer treatments make it difficult to eat well. Symptoms that interfere with eating include nausea,vomiting,diarrhea,constipation, mouth sores, trouble with swallowing and pain. Appetite, taste, smell, and the ability to eat enough food or absorb the nutrients from food may be affected.

10. Important Nutrition Fact Malnutrition (lack of key nutrients) can result, causing the patient to be weak, tired, and unable to resist infections or withstand cancer therapies. Eating too little protein and calories is the most common nutrition problem facing many cancer patients. Protein and calories are important for healing, fighting infection, and providing energy.

11. Special Concerns Hydration Although a good rule of thumb is to drink 8 glasses of water per day, proper hydration helps flush toxins. You should drink 1/2 ounce of water for each pound of your body weight. For example, if you weigh 150 pounds, you should drink 75 ounces or about nine 8 ounce glasses a day. Supplement drinks and bars Supplements - are intended as “occasional” substitutes and should be selected carefully: •Bars should be well-balanced with equal portions of carbs, proteins, and sugars •Bars should provide 3 to 5 grams fiber •Bar fortified but does not oversupply Recommended Daily Allowance of vitamins & minerals (~35%) •Bar supplies no more than 150 calories per serving • Vitamin and mineral supplements • Herbal preparations – biologically active • Myths and realities – symptoms • Habits – junk foods, alcohol and smoking • Comorbidity

12. Herbal Preparations • Be cautious as they can interfere with treatment and/or produce side-effects • Method of preparation can determine effectiveness • Not regulated by FDA, so need to be careful with selection • Recommend taking bottles in to family physician/oncologist • Avoid during protected period • Antioxidants – can repair the cellular oxidative damage to cancer cells caused by treatments such as radiotherapy and chemotherapy

13. Managing Side EffectsThat Impair Physical Function Lymphedema Neuropathy

14. Lymphedema • Swelling due to localized fluid build up • Caused by damage or removal of the lymphatic tree • Most notably in breast cancer due to nodal dissection • Lymphatic system • Often referred to as the body's "second" circulatory system • Collects and filters the interstitial fluids • May develop months or even years after therapy has concluded • Lower-limb lymphedema have been associated with the use of Tamoxifen

15. Lymphedema:Symptoms & Complications • Heavy, swollen limb or localized fluid accumulation • Stagnant, protein-rich fluid causes tissue channels to increase in size & number - reducing the availability of oxygen • Discoloration of the skin overlying the lymphedema • Impaired wound healing due to lack of oxygen/nutients • Bacterial growth can result in infections: cellulitis, lymphangitis, lymphadenitis, and in severe cases, skin ulcers • Eventually deformity (elephantiasis) • Infections common and recurrent, in addition to their inherent danger, further damage the lymphatic system and set up a vicious circle

16. Stage 0 (latent): Transport capacity is still sufficient for the amount of lymph being removed. No lymphedema. Stage 1 (spontaneously reversible): Tissue is still at the "pitting" stage. Usually upon waking in the morning, the limb or affected area is normal or almost normal in size. Stage 2 (spontaneously irreversible): The tissue now has a spongy consistency and is "non pitting". Fibrosis - hardening of the limbs and increasing size begin to persist. Stage 3 (lymphostatic elephantiasis): At this stage, the swelling is irreversible and usually the limb(s) or affected area is very large. The tissue is hard (fibrotic) and unresponsive. Grade 1 (mild edema): Lymphedema is in distal parts of the affected area. The difference in circumference is less than 4 centimeters – no other tissue changes are present. Grade 2 (moderate edema): Lymphedema involves whole area. Difference in circumference is more than 4 but less than 6 centimeters. Tissue changes, such as pitting, are apparent. Grade 3 (severe edema): Lymphedema is present in one limb. The difference in circumference is greater than 6 centimeters. Significant skin alterations. Grade 4 (gigantic edema): Also known as elephantiasis where affected extremities are huge due to almost complete blockage of the lymph channels. Lymphedema:Staging & Grading

17. Manage your risks: Adequate diet - protein rich Proper weight Within normal BMI range Be physically active Manage other conditions diabetes, hypertension, kidney or heart disease, or phlebitis (inflammation of the veins) Drugs – generally not helpful and may harm Avoid antibiotics, diuretics & anticoagulants Manage your treatments: Physical Manipulation Support the arm or leg in a raised position. Manual lymphatic drainage (a specialized form of very light massage that helps to move fluid from the end of the limb to the body). Wear compression garments that are custom-fitted and apply controlled pressure around the affected limb. TENS for pain Lymphedema:Keys to Comfort

18. Neuropathy • Usually short for peripheral neuropathy • Mainly affects the feet and legs • Common in cancer • Direct result of the cancer on peripheral nerves (e.g., compression by a tumor), • Side effect of many chemotherapy drugs • Electrical energy damage of radiation • Results in tingling, numbness, or pain

19. Neuropathy Treatment • Prevention – vigilance, avoidance, assistive devices • Drugs – alone or in combinations • opioid analgesics such as morphine, codeine, heroin, oxycodone or methadone • tricyclic antidepressants such as amitriptyline (Elavil®) • anticonvulsants such as gabapentin (Neurontin®), pregabalin (Lyrica®), or carbamazepine (Tegretol®) and oxcarbazepine (Trileptal®),

20. Myths and Realities • Habits – lifestyle affects prevention, treatment, and survivorship •Balanced diet will maximize treatment, minimize symptoms, and increase survivorship •Smoking – Don’t do it •Alcohol – Intake should be moderate if not avoided. Advice should be tailored to cancer type, stage, treatment, risk factors and comorbidities.

21. General Principles • Maintain energy balance (functionality) • Prevent excessive weight changes (loss) • Plan ahead is important (nutritionist/dietician) • What is your current nutritional status? (differs from prevention) • Normal dietary consumption is the best means for acquiring adequate nutrition!

22. Exercise and Physical Activity • Studies show that physical activity helps: • Energy Balance • Appetite - expenditure of calories help increase appetite • Muscle Mass – sometimes affected adversely by treatments • Vitality & emotional balance • Symptom Management Exercise as frequently as possible and it will enhance physical and functional well-being as well as improve your overall quality of life.

23. Exercise and Physical Activity Individualize your physical activity to your personal preferences and condition. • Assess your condition – begin at lower intensity and progress at slower pace if undergoing active therapy • Pay careful attention to balance to reduce injuries - Exercise in the presence of a caregiver or exercise professional (helpful if they have special training or certification) (Tip: Request a Physical Therapy referral) • Take into consideration other issues such as arthritis or peripheral neuropathies • If you exercised prior to diagnosis you should maintain as much activity as possible. • Always inform physician about your exercise program

24. ACS Recommendations for Increasing Physical Activity • Use stairs instead of elevator • If you can, walk or bike instead of drive • Exercise with your family, friends, and coworkers. • Plan active vacations instead of driving trips • Take an exercise break to stretch or take a quick walk. • Use a stationary bicycle while watching TV • Plan your exercise routine to gradually increase days per week and minutes per session.

25. Warnings and Cautions • Survivors: • with severe anemia should delay exercise, other than activities of daily living, until the anemia is improved: minimum of 10 micro-deciliters • with compromised immune function should avoid public gyms and other public places until their white blood cell counts return to safe levels. Survivors who have completed a bone marrow transplant are usually advised to avoid exposure to public places with risk for microbial contamination, such as gyms, for 1 year after transplantation. • suffering from severe fatigue (physical rather than emotional) - from their therapy may not feel up to an exercise program, so they may be encouraged to do 10 minutes of stretching exercises daily. A good guideline for determining fatigue is shortness of breath after common daily activities (test – if after walking 10 feet, patient has shortness of breath- they have severe fatigue) • undergoing radiation should avoid chlorine exposure to irradiated skin (eg, swimming pools). Patients with inflammatory responses or lesions – bad sunburn, puffiness, cracked skin should also avoid chlorine and other skin irritants. • with indwelling catheters should avoid water or other microbial exposures that may result in infections as well as resistance training of muscles in the area of the catheter to avoid dislodgment. • with significant peripheral neuropathies may have a reduced ability to perform exercises that use the affected limbs because of weakness or loss of balance. They may do better with a stationary reclining bicycle. For example: patients will know if they are experiencing peripheral neuropathy (if it’s numb, hurts, and they experience loss of control)

26. It may seem odd to be encouraged to exercise in one sentence, and encouraged to conserve your energy in the next. The idea is to achieve an appropriate energy balance. Tips for Energy Conservation

27. Tips for Energy Conservation • Sit to bathe and dry off (wear a robe) • Install grab rails in shower • Organize to avoid rushing • Stop working before becoming tired • Use easy to prepare foods/prepare double and freeze extra • Delegate chores when possible

28. Complementary and Alternative Medicine Remember:Dietary supplements can be marketed without proof of safety or effectiveness, likewise anyone can publish on internet. Be sure to research complementary and alternative medicine thoroughly, as well as being careful to research information providers well. • Reputable information sites: • http://cam.utmb.edu/default.asp • www.nccam.nih.gov • www.mdanderson.org/departments/CIMER • Caution – Health food stores - beware of advice from employees. They may mean well, but not qualified to act as a physician and will not understand the degree/components of the individualized treatment (or the combination of co-morbidities)

29. For more information please visit us as: www.utmb.edu/nsights