Cancer Flashcards
What is the definition of cancer?
growth of abnormal cells beyond their usual boundaries that can then invade adjoining parts of the body and/or spread to other organs
what impact does malnourishment have on cancer outcomes? (1)
- lower rate of response to treatment
What is the main cause of weight loss in cancer patients?
- anorexia
- cancer cachexia
because of prolonger production of cytokines (high inflammatory markers)
What are the consequences of malnutrition in cancer patients? (5)
- impaired immune response
- reduced tolerance of treatment
- reduced muscle strength and function
- increased apathy and depression
- post-operative complications, prolonger recovery and poor wound healing
What is NICE CG32 definition of malnutrition?
Deficiency of nutrients such as energy, protein, vitamins or minerals which causes measurable adverse effects on body composition, function or clinical outcome.
It is a cause and consequence of ill health
What weight changes and BMI cut offs would identify someone as malnourished? (3)
- BMI <18.5 kg/m2
- unintentional weight loss >10% in 3-6 months
- BMI <20 kg/m2 AND unintentional weight loss >5% in 3-6 months
What recent eating pattern would indicate malnutrition risk?
have eaten little or nothing for >5 days and/or are likely to eat little for the next 5 days or longer
What physiological signs indicate a malnutrition risk in a patient? (3)
- poor absorptive capacity
- increased nutrient losses
- increased nutritional needs because of catabolism
Name 3 nutritional screening tools used to identify malnutrition (3)
- MUST screening tool
- Subjective Global Assessment (SGA)
- Nutrition screening tool 2002
In ESPEN 2021 guideline on Clinical Nutrition in Cancer, what are the recommendations for other HCPs to regularly observe/record to identify malnutrition risk/need for dietetic intervention? (3)
- nutritional intake
- weight change
- BMI at diagnosis and repeated depending on stability of clinical situation
What will the dietitian assess in those identified at risk of malnutrition? (5)
- objective and quantitative assessment of nutritional intake
- nutrition impact symptoms
- muscle mass (and changes of)
- physical performance (functional)
- the degree of systemic inflammation
What is the definition of Cancer Cachexia? (3)
a multifactoral syndrome defined by:
1. ongoing loss of skeletal muscle mass (with or without loss of fat mass)
2. it cannot be reversed with conventional nutritional support
3. leads to progressive functional impairment
What is the pathophysiology of cancer cachexia characterised by? (3)
- a negative protein and energy balance
- caused by reduced food intake
AND - abnormal metabolism due to high cytokines (inflammation)
Why can cancer related weight loss not be simply defined as malnutrition? (main cause and 4 mechanisms of action)
because it is caused by abnormal metabolism causing aggravation of weight loss due to systemic inflammation and catabolic factors, resulting in:
- elevated resting metabolic rate
- insulin resistance
- lipolysis
- proteolysis
Can be host or tumor derived.
What symptoms identify pre-cachexia (3)
- weight loss ≤5%
- anorexia
- metabolic change
What symptoms identify cachexia? (4)
- weight loss ≥ 5%
OR - BMI <20 kg/m2 AND weight loss >2%
- often reduced food intake
- systemic inflammation is present
What symptoms identify refractory cachexia? Can nutritional support help? (4)
Nutritional support = ineffective
- Variable degree of cachexia
- Cancer = pro-catabolic AND non-responsive to anti-cancer treatment
- low performance score
- < 3 months survival
Why does refractory cancer cachexia result in end of life care?
Because reversal of weight loss is no longer possible because of very advanced or rapidly progressing cancer that is unresponsive to anti-cancer treatment
What are the treatment goals for someone in refractory cancer cachexia? (3)
- reduce burden and risk of artificial nutrition support = outweighs benefits
- alleviate suffering by administering appetite stimulant and managing nausea
- alleviate eating related stress on patient and carers/family
List common side effects of cancer treatment that may affect nutritional intake (12)
- no appetite/anorexia
- early satiety
- pain
- taste change
- nausea
- dry mouth
- constipation
- vomiting
- diarrhea
- swallowing difficulties
- smells
- mouth sores
List common side effects of surgical treatment that may affect nutritional intake (4) - what determines extent of nutritional problems?
- eating difficulties
- absorption difficulties
- may need long term tube feeding
- may need long term modified texture diet
The extent of nutritional problems depends on site of tumor and extent of surgery.
List common side effects of chemotherapy treatment that may affect nutritional intake (9)
- nausea
- vomiting
- diarrhea
- constipation
- taste changes
- dry mouth
- sore mouth
- internal ulceration of mouth or GI tract
- malabsorption
List common side effects of radiotherapy treatment that may affect nutritional intake (7)
- burning sensation in throat or oesophagus
- loss of appetite
- taste changes
- teeth = damage or loss of
- abdominal cramping
- malabsorption
- diarrhea
- What long term effect can cancer treatment on bone health?
- Which treatments have this effect? (4)
- What health behaviours can support bone health long term? (4)
- Can cause thinning
- Chemotherapy
- steroid medicines
- hormonal therapy
- radiation therapy - avoid smoking
- diet high in calcium and vitamin D
- exercise (weight bearing)
- limit alcohol intake
Name some late effects of cancer treatment- where affected and how so (7)
- Lungs
- Joints
- brain
- lymphoma - mobility issues
- sexual health
- early menopause
- weight gain (esp patients who have been on steroids)
Why can steroid treatment increase the risk of secondary cancers?
suppressed immune system
Name lower GI effects of late effects from cancer treatment (16)
- bleeding
- bloating
- change in bowel habit
- constipation - evacuation difficulty
- diarrhea - frequency of defamation
- flatulence
- incontinence and soiling leakage
- loss of rectal sensation
- mucu excess
- nausea
- nocturnal defamation
- abdo pain
- back pain
- steatorrhea
- vomiting
- weight loss
Name upper GI effects of late effects from cancer treatment (17)
- anorexia
- acid reflux
- burping
- dysphagia
- dry/painful mouth or teeth
- early satiety
- gastric stasis
- hypersalivation
- heartburn/indigestion
- jaundice
- nausea
- odynophagia (swallowing pain)
- back pain
- chest pain
- regurgitation of food
- vomiting
- weight loss
Describe the difference between: radical treatment and palliative care/end of life in dietetic care for cancer patients.
Radical treatment = intensive nutritional support
Palliative care/end of life = treatment needs to focus on symptomatic support and quality of life including alleviating hunger and thirst
How much higher and lower is REE in cancer patients? There is a fair bit of variation.
10% higher or less than normal, depends on cancer location and severity.
When is REE likely to be higher in cancer patients?
when newly diagnosed - likely to reduce after treatment i.e. surgery/chemo but data = inconsistent
Why is TEE assumed to be similar to healthy subjects in cancer patients?
Metabolic stress increases energy expenditure however, reduced physical activity likely nulls this effect
How would you estimate energy and protein requirements for a cancer patient?
PENG x PAL
Use alongside clinical judgement and monitoring.
Name 4 therapies used to manage cancer associated malnutrition
- nutrition counselling (changing eating habits, food fortification and ONS)
- Artificial nutrition (EN or PN)
- Drug therapy (appetite stimulants, decrease hyper-catabolism and increase muscle mass)
- physical therapy (increase muscle mass, daily functioning activities)
What are the 3 main nutritional goals in cancer patients?
- Prevent and treat under-nutrition - CATCH IT EARLY to try avoid severe malnutrition
- Provide dietary advice, treatment of symptoms and derangements impairing food intake
- improve quality of life
List some potential dietary interventions used in cancer patients (8)
- high calories, high protein diets for underweight patients or those with unintentional weight loss
- ONS
- Modified texture diets for pts with obstruction, stents or dysphagia
- modified fibre diet
- PERT
- Specific advice tailored to symptoms, i.e. constipation ,diarrhoea, nausea, dry mouth
- Neutropenic diet
- Managing high output stomas
When should you assume insulin resistance in cancer patients?
Those with pre-cachexia or cachexia who:
- persistently losing weight
How would you treat persistent weight loss in pre-cachexia or cachexia patients with suspected insulin resistance? why?
increase the ratio of energy from fat to energy from carbohydrate
- in creases energy density of diet and reduces glycemic load
IN a food first approach what would you recommend to modify diet in cancer patients? (3)
- increased protein and energy fortification
- Alter eating pattern to little and often
- Texture modification if required
What ONS options are there when normal food intake is insufficient in meeting requirements? What do you need to consider?
- tolerance
- monitoring
- adjust to meet needs
Need to choose appropriate ON for needs and symptoms
What is mucositis? How could you manage this symptom? (9)
Mucositis = sore swelling of cells in and around the mouth
- moist, soft meals or chilled/frozen nourishing drinks/ ONS
- Avoid spicy or salty food
- Avoid acidic food and drink i.e. citrus and vinegar
- drink through a straw
- only use dentures when eating
- avoid hot or frozen foods - may hurt
- avoid dry/rough textured foods
- crushes, ice and lollies can help
- oral mouth care/hygiene
How could you manage dry mouth symptoms? (4)
- moist, soft diet (add sauce, gravy etc)
- avoid foods that stick in mouth i.e. peanut butter
- take small bites, chew thoroughly
- stimulate saliva; suck lemon or pineapple sweets, ice cubes, saliva, grapefruit (if no mucositis); brush teeth before eating; regular mouthwash
How could you. manage nausea and vomiting symptoms? (8)
- sip cold or chilled fluids throughout day
- replace lost salts from vomiting with sports drink, electrolyte drinks (salty and sweet)
- fizzy drinks, peppermint tea, ginger
- plain foods may be easier to digest
- salty food can help
- focus on eating when nausea is less
- avoid eating 1-2 hours before chemo/radiotherapy
- Avoid strong food smells, and eat somewhere more well ventilated
How could you manage taste change symptoms?
Don’t push foods that were once enjoyed because they could develop a long term aversion to the food.
Metallic taste:
1. add strong flavoured snacks and spices o foods.
2. disguise meats with strong flavours - opt for chiles, fish, egg, cheese and pulses instead
Bland taste:
3. use strong food flavour options
4. cold meats, spicy sausage, marmite
5. strong flavour savoury foods
6. sweets or mints
If food tastes sweeter than normal:
7. opt for sharp flavour foods
8. Luke warm/chilled foods can be more palatable
How could you manage symptoms of early satiety? (6)
- small meals and snacks more often
- avoid greasy/fatty or rich foods
- chew food thoroughly and slowly
- avoid having drinks with meals
- supplements/nourishing drinks between meals
- make meal times relaxing
How could you manage symptoms of constipation? (5)
- increase fibre in diet
- can use laxatives
- adequate fluid intake
- warm drink in the morning can help
- report to MDT = possible bowel obstruction
How could you manage symptoms of diarrhoea? (3)
- reduce dietary fibre intake
- adequate fluid intake and replace electrolytes
- low fat/low fibre diet can help but not to be continued long term.
What is the aim of PERT?
- To manage pancreatic exocrine insufficiency
- Required to digest and absorb nutrients
Which cancer patients are more likely to need PERT treatment?
- pancreatic cancers
- surgical removal of all or some of the pancreas
- those who have had gastric/duodenal surgical intervention
What do you need to consider when administering PERT?
- dosage
- timings
- tailor dose according to dietary fat intake and symptoms
When is someone classified as Neutropenic? What precautions need to be taken?
Neutropenia = levels of neutrophils < 1.0 X 10^9/L
- strict food hygiene needed
- poor ability to fight food borne infections
- Various high risk foods to avoid whilst on neutropenic diet
What can cause someone to need a neutropenic diet?
high dose chemotherapy or patients having total body irritation for stem cell transplant
What dairy food need to be avoided on neutropenic diet? (6)
- unpasteurised dairy products
- soft cheeses; feta, brie
- homemade or deli paneer
- mould ripened cheese: brie, camembert, goats cheese
- blue cheese
- probiotic foods i.e. yogurts
What meat products need to be avoided on neutropenic diet? (3)
- raw and undercooked meat, poultry or fish i.e. pink in the middle or sushi
- smoked meats i.e. salami 3. unpasteurised pate (meat or vegetable)
What fish products need to be avoided on neutropenic diet? (5)
- smoked salmon
- raw sushi
- caviar
- oysters
- lightly cooked shellfish
What egg products need to be avoided on a neutropenic diet? (3)
- raw or undercooked eggs (dippy eggs)
- products made using undercooked/raw egg, i.e. homemade mayonnaise, homemade ice cream, mousse, egg-nog, meringue, hollandaise sauce
- dressings containing raw egg i.e. caesar dressing
How could you manage symptoms of early satiety? (6)
- small meals and snacks more often
- avoid greasy/fatty or rich foods
- chew food thoroughly and slowly
- avoid having drinks with meals
- supplements/nourishing drinks between meals
- make meal times relaxing
What dietetic advice would you offer to a cancer patient prehab (before treatment to get people as well as possible to improve recovery outcomes) (2)
- may require weight gain before treatment
- healthy eating advice to improve outcomes/survivorship
In which patients would you not recommend supplementation with long-chain N3 fatty acids or fish oil?
Diabetic patients with cancer
What are some of the benefits of supplementing cancer patients with long-chain N3 fatty acids? (5)
- improved appetite
- improved weight
- reduced post surgical morbidity
- quality of life
- conservation of body composition
Which cancers most likely to require EN feeding?
head, neck and oesophageal cancers.
Can be inserted prophylactically pre/post surgery if highly likely to have problems.
Describe radical treatment for oesophagi-gastric cancer patients
- offer nutritional assessment, before, during and after radical treatments
- offer immediate EN or PN after surgery for people having radical surgery for oesophageal and gastro-oesophageal junctional cancers
What are contraindications for EN feeding? (5)
- gastrointestinal obstruction - opt for PN
- severe vomiting
- severe mucositis
- graft versus host disease of the gut
- unable to tolerate sufficient nutrition from EN (use EN + PN)
