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S&P - Nutrition > Cancer > Flashcards

Cancer Flashcards

1
Q

Differentiate between high, medium and low risk cancers

A 
High Risk  
•	Head & Neck, Oesophago-gastric and Pancreatic Cancers
Medium Risk
•	Prostate, Colorectal, Lung
Low Risk 
•	Breast, Sarcomas and NHL
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2
Q

How does malnutrition affect the general population?

A
  • Reduced immunity
  • Impaired muscle function, weakness
  • Impairments to organ functions e.g. cardiac and respiratory
  • Delayed wound healing and skin integrity
  • Reduced mobility, loss of independence
  • QoL
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3
Q

How does weight loss predict outcome in lung Ca?

A
  • delivery of fewer cycles of chemotherapy
  • more treatment delays
  • more anaemia
  • more symptoms at presentation
  • less symptomatic benefit from chemotherapy
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4
Q

What assessment of ‘body composition’ do we make in clinical practice?

A 
•	Weight
•	BMI
•	BSA
•	Nutrition Screening
•	Visible signs of fat loss
o	Orbital, Triceps
•	Visible signs of muscle loss
o	Clavicle, Temporal
•	Fluid: oedema / ascites
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5
Q

Describe the link between sarcopenia and weight loss.

A

Syndrome of reduced muscle mass AND reduced muscle strength OR function. Frequently but not exclusively occurs in with ageing.
• Not restricted to thin or wasted individuals
• Sarcopenic obesity

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6
Q

Compare primary to secondary sarcopenia.

A

Primary sarcopenia: age related

Secondary: activity-related -
Resulting from bed rest, sedentary lifestyle and deconditioning.

Disease: Associated with malignancy, inflammatory disease or endocrine disease.

Nutrition:
Resulting from inadequate dietary intake of energy and/or protein, secondary to malabsorption or anorexia.

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7
Q

Toxicity aggravates loss of weight&muscle, and vice versa; what else did prado et al find muscle loss was linked to?

A

Muscle loss in cancer patients is associated with poor functional status, more treatment delays, dose reductions, termination of treatment and decreased survival
Prado et al, 2008, 2009, 2011

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8
Q

What did Collins et al and martin et al find was the link between lung cancer and weight?

A

Collins et al BMJ 2015 – Systematic review of lung cancer
Prevalent regardless of BMI
Associated with poorer functional status and survival
Important to evaluate loss of muscle mass and function rather than loss of weight alone

Martin et al J Clin Oncol 2013 – 1500 lung and GI cancer patients

}Muscle depletion results in poorer prognosis regardless weight loss or BMI

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9
Q

Why are lung cancer patients malnourished?

A
  • less food intake, greater energy expenditure
  • Iatrogenic causes of less intake
  • Inadequate symptom control
  • Tumour site
  • Cancer cachexia
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10
Q

Explain iatrogenic malnutrition

A

As a result of anticancer therapies e.g. surgery, radiotherapy, chemotherapy
(Where significant difficulties are anticipated, feeding tubes can be placed prophylactically before undergoing treatment )

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11
Q

Explain how general surgery affects nutrition

A
  • Fatigue, pain and loss of appetite
  • Nil-by-mouth pre / post surgery
  • Post op dietary restrictions or staged reintroduction of diet
  • Head and neck cancer surgery can alter a patient’s ability to speak, chew, salivate, swallow, smell, taste, and/or see
  • Potential background of alcohol excess
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12
Q

Explain how GI Surgery affects nutrition

A 
Gastrointestinal cancer surgery (e.g., oesophageal, gastric, pancreatic, liver, gallbladder, bile duct and small and large intestine):
•	Gastric paresis
•	Malabsorption of nutrients 
•	Hyperglycaemia
•	Fluid and electrolyte imbalance
•	Anastomotic and chyle leaks
•	Dumping syndrome
•	Vitamin and mineral deficiencies
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13
Q

Explain how chemotherapy affects nutrition.

A 
Most common nutrition-related side effects are :
Anorexia
early satiety,
Taste changes (dysgeusia)
Nausea, vomiting, 
Mucositis/ oesophagitis 
Diarrhoea and constipation 
Fatigue

Malnutrition and weight loss impact the ability to regain health and acceptable blood counts between chemotherapy cycles;; directly affecting the ability to stay on treatment schedules

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14
Q

Explain how radiotherapy affects malnutrition

A 
Odynophagia & dysphagia (pain or difficulty swallowing) 
Mucositis
Shortness of breath (from fibrosis)
Dysgeusia, 
Xerostomia, 
Pain 
Fatigue
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15
Q

Explain how Stem Cell Transplants

affect nutrition

A

Higher doses of chemo +- TBI result in more intense side effects
Anorexia, fatigue and depression can persist after treatment
Prolonged neutropenia and immunosuppression – theoretical risk
of food borne infection – dietary restrictions
Graft versus host disease can significantly increase requirements and / or result in large GI losses

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16
Q

Explain the symptoms of lung & GI cancer

A 
No appetite 38%
Early satiety 27%
Pain 23%
Taste changes 20%
Nausea 18%
Dry mouth 17%
Constipation 14%
Vomiting 11%
Diarrhoea 11%
Significant association with  number of symptoms & rate of weight  loss
17
Q

Describe agents used in the symptom management for nutrition

A 
Prokinetic agents
Antiemetic agents 
Antidiarrheal agents 
Pancreatic enzymes aka PERT. Laxatives 
Agents for oral care (e.g., saliva stimulants, cleansing agents, antifungal agents, topical anaesthetics, mouthwashes, and healing/coating agents). 
Analgesia
18
Q

Explain the effects of tumour site on malnutrtion

A

Functional and physiological causes of malnutrition:
GI function/ motility
Obstruction
Malabsorption

19
Q

}What is cancer cachexia?

A

Multifactorial syndrome, which leads to on-going loss of skeletal mass with or without the loss of fat mass, that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment

20
Q

Describe the Pathophysiology of Cachexia?

A

Abnormal metabolism (increased inflammatory response : CRP,
IL1, IL6, IL10 and TNF-alpha)
Increased anaerobic respiration
Increased protein utilisation

21
Q

How are glucose and fats and proteins metabolized in cachexia vs starvation?

A

Glucose – less in starvation more in cachexia
Fat – more in both
Protein – varies in starvation, more in cachexia

Energy expenditure decreases in starvation – causing slow weight loss, increases in cachexia – causing rapid weight loss

22
Q

How is CHO metabolism disturbed?

A

Metabolism of glucose to lactate –>
Lactate converted to pyruvate in liver–>
Pyruvate utilised in gluconeogenesis –>
Insulin resistance/impaired oral glucose tolerance test –mediated by inflammatory cytokines or gluco-regulatory hormones

23
Q

How is protein metabolism disturbed?

A

Overall whole-body protein turnover is ↑
↓synthesis (despite ↑acute phase proteins)
↑proteolytic pathways e.g.
ATP ubiquitin-proteasome proteolytic pathway
Lysosomal system

24
Q

How is lipid metabolism disturbed?

A

↑lipolysis and fat oxidation, dependant on stage of disease and extent of
malnutrition

25
Q

Describe how cachexia’s assessed clinically. What are the stages?

A 
Reduced food intake/anorexia
Catabolic Drivers (CRP, responsiveness to chemotherapy) Assessment of Muscle Mass
Assessmentof Muscle Strength
Functional Assessment (QLQ-C30)
Psychosocial Assessment (HNA)

Stages of Cancer Cachexia

  1. Pre-cachexia (weight loss less than 5%, anorexia and metabolic change)
  2. Cachexia(weight loss more than 5% or BMI<20 AND weight loss >2% or sarcopenia and weight loss >2%. Often reduced intake and systemic inflammation.
  3. Refractory Cachexia – variable degree. Cancer is procatabolic and not responsive to anticx tx, low performance score, <3 months expected survival)
26
Q

How are precachexia, cachexia and refractory cachexia managed?

A

Monitor and use preventative intervention in precachexia. Use multimodal management according to phenotype, with prioritization of reversible contributory factors).

Use symptom palliation, psychosocial support andethical discussion using nutritional support for refractory cachexia.

27
Q

What does multimodal therapy consist of?

A

Awareness.
Optimal oncological management. Nutritional support eg high protein ONS.
Exercise.
Anaemia therapy (eg EPO).
Anti inflammatory tx (eg NSAID, EPA). Best supportive care (tx secondary factors).
Early intervention.
MDT work.

28
Q

Why is nutritional screening used for early intervention?

A

Malnutrition can occur at any stage

Early identification of malnutrition and regular reassessment of weight and body composition is essential

29
Q

What form the goals of nutritional support?

A

Prevent cancer or treatment related malnutrition
↑treatment efficacy
Maintain muscle mass and strength
Promote physical activity / minimise inactivity
Maintain QoL:QoL scores in cancer pts determined by:
Tumour site (30%)
Weight loss (30%)
Intake (20%)
Ravasco et al. Supp Can Care 2004

30
Q

Name 3 “Oral Nutritional Interventions”?

A

Additional supplements, modifications of texture, flavours, temp. timings, small meals and snacks, food fortification.

Oral Interventions - Evidence Tailored advice and dietary counselling:
Increases nutritional intake
Improves nutritional status
Prevents/ minimises therapy associated weight loss
Reduces treatment interruption
Reduces late radiotherapy toxicity
Improves QoL

Fearon et al, 2003;; Ravasco et al, 2005 & 2012;; Hutton et al, 2006;; Starke et al, 2011

31
Q

When are ANS not indicated?

A

ANS = Artificial nutritional supplements.
An identifiable and reversible cause of weight loss is an indication for intensive nutrition. However it is not indicated as routine adjunct to surgery or chemo In terminally ill patients (usually)

ANS rarely results in significant lean weight gain or altered outcome in advanced cancer
ASPEN Clinical Guidelines: Nutrition Support Therapy During Adult Anticancer Treatment. JPEN 2009

32
Q

Whats the link between breast Cancer and Nutritional Status?

A

6/10 women gain weight post diagnosis. Harvie, et al Br J Cancer. 2005

This may be due to: 
Hormonal influence
Dysgeusia 
Increased appetite secondary to steroids
Reduced physical activity
33
Q

How does breast cancer affect body composition & outcome?

A

Poor prognosis in the obese:

Excess adiposity associated with 30% increased risk of mortality Patterson, 2010
33% increase in breast cancer mortality in obese versus non- obese women Protani, 2010

34
Q

What advice for diet would you give for breast cancer patients with regards to their diet?

A

Avoid exclusion of whole food groups unless known intolerance is
present. i.e. dairy, gluten free
High fibre, lower fat diet – Inhibit intestinal reabsorption of
oestrogen and ↓endogenous production
Where menopausal or aromatase inhibitors are in use, provide Calcium – dairy, alternative or supplement
Vitamin D –sunlight, diet or supplement
Alcohol >2 units /d = 40% increase risk

35
Q

What advice would you give wrt weight &physical activity?

A

Increase physical activity
Avoid weight gain
Aim for a BMI < 25 (post menopausal women)

36
Q

Compare breast cx to lung cx.

A

Breast:
Often well nourished
Treatable: goal is long term remission or cure
Aggressive nut support rarely needed
Lifestyle advice re early menopause & to reduce risk of recurrence

Vs lung
Often malnourished
Poor survival rate
Require nutritional support & care plan
Focus more on QoL & symptom control
Frequent cachexia – ANS not routinely used or effective

Regular screening and promotion of physical activity is essential for both groups

37
Q

Describe cx survivorship in the UK

A

Survival has doubled from 24% to 50% in 40 years

Survivorship rates vary according to tumour type

38
Q

What lifestyle advice would you give to cancer patients?

A

Systematic review of RCTs of nutritional and physical activity found improved phys and psych wellbeing, reduced tx risks, better self esteem, lower recurrence risks and improved survivial with a healthy lifestyle.

39
Q

What other dietary recommendations are there for survivorship?

A 
Decrease saturated fats 
Increase fish- aim for 2 portions of oily fish/week 
Variety: maximise essential vitamins &amp; minerals 
Eat the Rainbow - fruit and vegetables 
Decrease salt and processed meats 
Reduce red meats 
Minimise/ avoid alcohol 
Colorectal: ↑fibre

Certain tumour types may have lasting dietary alterations due to
cancer or treatment provided such as…
Late effects of Pelvic Radiation Disease
Stenosis and impaired swallow function
Trismus
Pancreatic Insufficiency
Vitamin and Mineral Deficiencies

S&P - Nutrition (13 decks)

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