Nutrition Care Process for Oncology

1. Nutrition Care Process for Oncology Ingrid Jorud Concordia College Moorhead, MN

2. Objectives • Identify who is most at risk of developing cancer. • Define what cancer is and what nutritional deficiencies may develop. • Identify the nutrition maladies associated with cancer. • Identify the types of treatment and side effects involved in each. • Learn what nutrition care can be given in each case. • Discuss the Nutrition Care Process for Cancer.

3. Objectives (cont.) • Identify the ethical issues regarding nutrition with cancer patients • Outline some prevention guidelines

4. What is cancer? • Disease of disordered cell growth and replication. • Uncontrolled cellular division • Ability to invade other tissues, either by direct growth or migration to distant cells.

5. Cancer Cell Growth • Normal cellular growth is controlled by genetic factors, hormones, and growth substances secreted by distant cells. • Telomeres in cell shorten and stop cell growth after a certain point - cancer cells secrete enzymes to destroy telomere. • Cell’s internal clock is destroyed, cell differentiation may change, cell may take on other traits and become misshapen, replicate at a faster rate than normal.

6. What can put a person at high risk? • Genetics - heredity only plays a small role • Diet and physical activity habits • Fat content and type (Omega 3 and 6 are better) • Low consumption of fruit and vegetables • Low intake of whole grains • Obesity - BMI > 40 risk of cancer and death more than doubles • Environmental/behavioral • Smoking • Work and chemical exposure

7. Men 33% Prostate 13% Lung and bronchus 10% Colon and rectum 27% include: Urinary bladder, Melanoma of skin, Non-Hodgkin Lymphoma, Kidney, Leukemia, Oral Cavity, Pancreas 17% Other sites Women 32% Breast 12% Lung and bronchus 11% Colon and rectum 6% Uterine corpus 18% Non-Hodgkin lymphoma, Melanoma of skin, Ovary, Thyroid, Urinary bladder, Pancreas 21% Other sites Most Common Cancers

8. Leading Mortality • Lung and bronchus • Prostate and Breast • Colon and Rectum • Pancreas • Ovary • Leukemia

9. Treatments • Chemotherapy • Antineoplastics - inhibit and combat development of tumors • Radiation therapy • Use of radiation to control malignant cancer cells • Surgery • Physical removal of the cancer tumor or organ involved

10. Factors Contributing to Malnutrition • Treatments • Chemotherapy • Drugs and severity of types that are used • Radiation • Depending on the location of the cancer and radiation site • Surgery • Location of tumor to determine surgical location and nutritional status • Tumor and abnormal cell growth

11. Affects of Disease State on Nutrition • Tumor • Malignant tumors cause changes in energy expenditure and basal metabolic rates. • Altered enzyme activity • Immune system

12. Carbohydrate Insulin resistance Increased glucose synthesis Gluconeogenesis Increased Cori cycle activity Decreased glucose tolerance Protein Increased protein catabolism Decreased protein synthesis Fat Increased lipid metabolism Decreased lipogenesis Decreased activity of lipoprotein lipase (LPL) Changes the occur in Metabolism

13. Nutritional Assessment of Cancer Patient • Anthropometric Measurements • AMC < 60% of standard are consistent with protein depletion • BMI < 22, based on UBW and % weight loss is often considered for depletion • BIA (Bioelectric Impedance Analysis) - resistance to low intensity electric current by fat and lean tissue • Lab values • Not always the most accurate for assessment when viewed alone • Prognostic Nutritional Index (PNI)

14. PNI Prognostic Nutritional Index measures the risk that a patient has of developing a complication such as sepsis or death related to malnutrition. PNI% = 158 – 16.6A - .78TSF – 0.2TFN – 5.8DH A indicates albumin (g/dL); TSF –tricep skinfold (mm); TFN – transferrin (mg/dL); DH delayed hypersensitivity skin testing reaction to a recall antigen <40: low risk; 40-49.99: intermediate risk; ≥ 50: high risk

15. Basic Nutrition Requirements • Harris-Benedict or Mifflin-St. Jeor • Kcalorie • Obese patients: 21-25 kcal/kg • Non-ambulatory/sedentary adults: 25-30 kcal/kg • Sepsis: 25-35 kcal/kg • Slightly hypermetabolic or those in need of weight gain or those with stem cell transplant: 30-35 kcal/kg • Hypermetabolic or severely stressed: ≥35 kcal/kg

16. Basic Nutrition Requirements (cont.) • Protein • Normal or Maintenance: 0.8-1.0 g/kg • Non-stressed cancer patient: 1.0-1.5 g/kg • Bone marrow transplant or HSCT patients: 1.5 g/kg • Increased protein needs: 1.5-2.5 g/kg • Hepatic or renal compromised or elevated ammonia: 0.5-0.8 g/kg

17. Basic Nutrition Requirements (cont.) • Adequate fluid and hydration • Vitamins • Folate • Vitamin C • Retinol • Minerals • Magnesium • Zinc • Copper • Iron

18. Fluid Requirements • 16-30 years, active: 40 mL/kg • 31-55 years: 35 mL/kg • 56-75 years: 30 mL/kg • 76 years or older: 25 mL/kg • 1 mL/kcal of estimated energy needs

19. Nutritional Complications and Symptoms That Cause Them (Diagnosis) • Anorexia • Cachexia • Dysphasia • Nausea and Vomiting • Constipation/Diarrhea/Malabsorption • Oral Manifestations • Xerostomia

20. Anorexia • Imbalance between caloric intake and metabolic needs due to a lack or loss of appetite for food, leading to weight loss, cachexia, dehydration, and electrolyte imbalances • Causes • Alterations in Taste • Decreased threshold for bitter taste • Decreased like for beef, pork, chocolate, coffee, or tomatoes • Metallic or medicinal taste

21. Anorexia (causes cont.) • Taste abnormalities may lead to decrease in digestive enzymes causing delay in digestion • Alterations in GI function • Ulceration of the mucous membranes may produce mucositis or diarrhea, which interferes with ingestions, digestion, or absorption • Metabolic Abnormalities • Glucose Metabolism • Increased circulation of amino acids or lactic acid • Increased free fatty acids • All cause early satiety

22. Anorexia (causes cont.) • Psychological abnormalities • Effects of tumor • Release of cytokines • Cytokines may raise metabolic rate and increase protein catabolism and skeletal muscle protein metabolism • Wound healing • Decreased ability to heal due to tumor growth and tumor utilization of nutrients

23. Appetite stimulant Megestrol acetate Corticosteroids agents Exercise may increase appetite Eat small, frequent high protein high calorie meals. Eat when appetite is normal Limit fluid with meals to avoid early satiety Keep favorite foods handy Glass of wine before a meal may help to stimulate appetite Avoid strong food odors Find a liquid nutritional supplement that is appealing Treatment of Anorexia in Cancer Patients

24. Cachexia • Wasting syndrome that causes: weakness and loss of weight, fat, and muscle, electrolyte imbalances, impaired organ function, and immunosuppression • Common with lung, pancreas, upper GI tract cancers • Less common in breast and lower GI cancer • Caused by malabsorption, anorexia, and other factors contributing to nutrient deficiencies • Not related to tumor size or type. • Increased nutrient needs • Due to metabolic rate changes or demands • Alterations in GI function

25. Types of Cachexia • Primary • Anorexia • Decrease in Nutrients • Changes in Metabolic Pathways • Secondary • Weight loss due to mechanical factors limiting intake

26. Nutritional Deficiencies due to Cachexia • Carbohydrate Metabolism • Cori cycle increases so that glucose usage is greater than conversion and to keep up with demand, amino acid is used • Impairment of insulin sensitivity or glucose tolerance • Lead to hyperglycemia • Protein Metabolism • Used when energy stores of glycogen are decreased • Decrease in protein synthesis that may be due to decreased intake or decreased albumin production by liver

27. Nutritional Deficiencies due to Cachexia (cont.) • Fat Metabolism • Normal and Abnormal Metabolism • Stimulated by insulin resistance leading to hyperlipidemia and decreased fat stores. http://www.biologyclass.net/cori.jpg

28. Treatment of Cachexia in Cancer Patients • Treat initial causes • Replenish body with protein, carbohydrates, fats, vitamins, and minerals • Enteral or parenteral nutrition

29. Dysphasia • Difficult and painful swallowing • Resulting from tumor and/or treatment: • Chemotherapy, Radiation, or Surgery

30. Treatment of Dysphasia in Cancer Patients • Therapeutic approaches • Swallowing therapy • Pain management • Oromotor exercises - muscle control for swallowing • Altered postural strategies • Food Consistencies • Semisolid foods, soft foods, medium to thick liquids, dense sticky/bulky foods, and thin and thick liquids.

31. Nausea and Vomiting • Secondary to treatments, progressive disease states, and other therapies. • Often involves the cerebral cortex, mediated by the autonomic nervous system.

32. Treatment for Nausea and Vomiting in Cancer Patients • Parenteral support in cases of greater than 10 episodes in 24 hours. • Control of symptom management • Pharmacologic Management • Serotonin antagonist • Dopamine Antagonists • Corticosteroids • Benzodiazepines • Cannabinoid

33. Treatment for Nausea and Vomiting in Cancer Patients • Nonpharmacologic Interventions • Behavior Interventions • Acupressure • Dietary interventions • Individualized to each patient • Eating cold or room temperature foods • Avoiding high fat foods which delay gastric emptying • Avoid favorite foods on treatment days • Ginger

34. Constipation/ Diarrhea/ Malabsorption • GI dysfunction caused by drugs, endocrine tumors, malabsorption, chemotherapy, radiation therapy, and other concurrent diseases • Diarrhea • Carbohydrate malabsorption • Inability to properly absorb salt • Bacteria infection

35. Constipation/ Diarrhea/ Malabsorption (cont.) • Malabsorption- ineffective absorption of nutrients • Intestinal resection • Bile salt deficiency • Reduced activity or transport mechanisms • Insufficient enzymes • Short Bowel Syndrome • Antibiotics • Signs - Steatorrhea; Caloric Deprivation; Folate, Vitamin B12, Calcium, Magnesium, Vitamin D, and Iron deficiencies

36. Constipation/ Diarrhea/ Malabsorption (cont.) • Constipation - extremely common in cancer patients • Medication induced • Tumor location • Hypercalcemia, hypokalemia, and/or uremia • Diabetes • Inadequate food/fiber intake • Poor liquid intake • Bowel surgery

37. Treatment of GI Dysfunction in Cancer Patients • Diarrhea • Binders of osmotically active substances - pectin • Avoid cold meals, milk, fiber rich vegetables, fatty meats and fish, alcohol, and coffee. • Rehydration - solutions containing glucose, electrolytes, and water; intravenously • Antibiotics

38. Treatment of GI Dysfunction in Cancer Patients • Malabsorption - Correct deficiencies • Enzyme replacement • Bicarbonate supplements • Vitamins • Calcium, Magnesium, and Iron • Low fat and high protein diet • Parenteral nutrition postoperative

39. Treatment of GI Dysfunction in Cancer Patients • Constipation • Increase fluid intake • High fiber foods • Laxatives • Reversal of hypercalcemia and hypokalemia

40. Oral Manifestations • Xerostomia - abnormal dryness of mouth • Results most commonly from radiation therapy to the head and neck region, surgical excisions, and Sjogren’s syndrome. • May be impossible to prevent

41. Treatment of Oral Manifestations in Cancer Patients • Frequent oral rinses and sips of water or juice • Moist, soft foods; prepare foods with sauces or gravies. • Alcoholic and carbonated beverages may inflame mucosa • Sucking on hard sugarless candy or gum to stimulate saliva secretion • Fine mist of water sprayed into the mouth from a spray bottle • Foods and drinks that are very sweet or tart to stimulate saliva production

42. Enteral Nutrition • Nasogastric - nose to stomach, short term • Gastrostomy & Jejunostomy - stoma placed into stomach or jejunum, long-term use • Patients with low body weight • Inability to eat or drink by mouth for more than five days • Moderate or high nutritional risk

43. Advantages for Enteral Nutrition • Food in liquid form • Keeps the stomach and intestines working normally • Fewer complications than parenteral • Nutrients used more easily by the body • Can be administered at home

44. Parenteral Nutrition • Nutrients delivered directly into the blood via catheter inserted into the subclavian (CVC) or other larger peripheral vein. • Stomach and intestines not working correctly or have been removed • Severe nausea or vomiting • Fistulas in stomach or esophagus • Loss of body weight and muscle with enteral nutrition.

45. Complications Associated with Parenteral Nutrition • Hypoglycemia • Hyperglycemia • Hypokalemia • Blood clots • Infection as site of insertion • Elevated liver enzymes

46. Inadequate oral food/beverage intake Inadequate fluid intake Inadequate bioactive substance intake Hypermetabolism Increase nutrient needs Swallowing difficulty Chewing difficulty Altered GI function Altered nutrition-related laboratory values Food-medication interaction Involuntary weight loss Food, nutrition, nutrition-related knowledge deficit Diagnostic Labels

47. Monitoring of Patients • During and after treatment • Improvement • Maintenance • Risk assessments • Disease progression • Recovery • Following health lifestyle

48. Ethical Issues • Care of Dying Patient • Autonomy and beneficence • Seek decisions of recognized authorities or religious codes, professional guidelines of legal ruling • Nutrition and hydration - continuation of nutrition support or voluntary refusal

49. Cancer Prevention • Healthful Diet • Five or more servings of various fruits and vegetables each day • Limit high fat and fried products • Choose whole grains • Limit consumption of red meats, especially high fat and processed • Watch your portions

50. Cancer Prevention (cont.) • Physical Activity • At least 30 min 5 days a week, 45 min is even better • Healthy Weight • Balance caloric intake with physical activity • Limit Alcohol Consumption • Limit to 1 drink/day for women and 2 drinks/day for men.