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aa 442 > lecture 18 > Flashcards

lecture 18 Flashcards

1
Q

What is Cancer?

A

Disorder of cell growth and proliferation
– Unregulated proliferation of cells
– Prominent properties
• Lack of differentiation of cells
• Local invasion of adjoining tissues
• Metastasis à spread to distant sites through bloodstream or lymphatic system
– Will not occur in all cancers
• Umbrella term for a collection of > 200 related diseases

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2
Q

• Carcinoma:

A

Most common type of cancer
– Formed by epithelial cells (that cover inside/outside surfaces of the body)
– Those that begin in different epithelial cell types have specific names
• Adenocarcinoma: cancer that forms in epithelial cells that produce fluid or mucus
»Most common: breast, colon, prostate
• Basal cell carcinoma: cancer that begins in the lower or basal (base) layer of the epidermis
(outer layer of skin)
• Squamous cell carcinoma: epithelial cells that lie just beneath outer surface of the skin or
line organs
»i.e. stomach, intestines, lungs, bladder, kidneys
• Transitional cell carcinoma: cancer that forms in transitional epithelium (made up of many
layers of epithelial cells that can get bigger/smaller)
»i.e. bladder, ureters, parts of kidneys

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3
Q

• Sarcoma:

A

Form in bone and soft tissues (muscle, fat, blood and lymph vessels,
fibrous tissues)

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4
Q

Multiple myelomas:

A

Begins in plasma cells (type of immune cell).
– Abnormal plasma cells (myeloma cells) build up in bone marrow forming tumours in
bones and throughout body

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5
Q

Melanoma: C

A

: Cancer that begins in cells that make melanin

– Most form on skin; can form in other pigmented tissues, i.e. eye

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6
Q

• Germ cell tumours:

A

begin in cells that give rise to sperm or eggs

i.e. ovarian, testicular

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7
Q

• Neuroendocrine tumours:

A

from from cells that release hormones

into the blood in response to a signal from the CNS

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8
Q

• Carcinoid tumours:

A

type of neuroendocrine tumour.
– Slow growing, usually found in GIT
– May secrete substances such as serotonin or PG’s causing carcinoid
syndrome

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9
Q

Key Factors Influencing Nutritional State and Delivery of

MNT in Individuals with Cancer

A 
Site / type / stage of cancer
– Where patient is at in the trajectory of illness (pre/during/post-treatment)
• Metabolic alterations
– Tumour induced
– Treatment induced
• Side effects related to specific treatment modalities
– Physiological
– Psychological
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10
Q

Cancer classified based on:

A

– Size and/or extent of original (primary) tumour
– Whether the cancer has spread
• Staging assists with:
– Treatment plans
– Estimating prognosis
– Identifying ongoing clinical trials a patient may be eligible for

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11
Q

TNM (Tumour Node Metastasis) Cancer Staging System

A

• TMN staging examples:
– Prostate cancer T2 N0 M0
• Tumor located in prostate that has not spread to lymph nodes or elsewhere in the body
– “X” (i.e. TX, NX, MX) means can’t be measured/evaluated
• These combinations correspond to stages of cancer

T:

1: less than 3cm
2: more than 2cm
3: any size but near airway
4: in airwqay

N:

0: no lymph nodes are affected
1: spread to nearby nodes on same side of the body
2: nodes further away but on same side of body
3: nodes on other side of body

M:

1: no metastasis
2: has spread to other regions on teh body

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12
Q

Nutritional Implications of Cancer

A

• Cancer patients are at high risk for malnutrition
• Prevalence of malnutrition is __20-70%____ in hospitalized pt’s with CA • Highest risk of malnutrition associated with cancers of:
– GI- stomach, intestine, pancreatic, ETC.
– Head and neck
– liver
– lung
• Malnutrition associated with poor outcomes
– ↑ hospital LOS, hospital costs, surgical site infections, antibiotic use, mortality
– ↓ chemotherapy tolerance, QOL
– Significant implications for advocacy of more aggressive nutrition therapies

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13
Q

Disease-Related Malnutrition (DRM)

A 
•	Disease related malnutrition (DRM)
o	A condition that results from activation of systemic inflmamtion by an underlying disease such as cancer
•	Inflmamtory response results in:
o	Anorexia
o	(lean and fat) tissue breakdown
•	Leads to 
o	Signid=ficant weight loss 
o	Alterations in body compositions
o	Declining physical function
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14
Q

Cancer Cachexia

A

“Multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.
The pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism”

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15
Q

Precachexia

A

Weight loss <5%

anorexia and metabolic changes

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16
Q

Cachexia

A 
Weight loss >5% or BMI <20 and weight loss >2%
or sarcopenia and weight
loss >2%
Often reduced food intake/
systemic inflammation
17
Q

Refractory cachexia

A 
Variable degree of cachexia
Cancer disease both procatabolic
and not responsive to anticancer
treatment
Low performance score
<3 months expected surviva
18
Q

Definition of Sarcopenia in the Context of

Diagnosing Cancer Cachexia

A

• Mid upper-arm muscle area à TESTED HOW?
– Men <32 cm2;women <18 cm2)
• Appendicular skeletal muscle index à TESTED HOW?
– Men <7.26 kg/m2; women <5.45 kg/m2)
• Lumbar skeletal muscle index à TESTED HOW?
– Men <55 cm2/m2; women <39 cm2/m2)
• Whole body fat-free mass index à TESTED HOW?
– FFM / height2
– Men <14.6 kg/m2; Women <11.4 kg/m2)

19
Q

Relationship Between Systemic Inflammation in

Cancer and DRM

A

anorexia, weight loss, fatigue and pain, depression

20
Q

Anorexia, Cachexia and Sarcopenia in Cancer:

The Perfect Storm for DRM

A

a

21
Q

Types of Cancer Therapies

A 
Surgery
• Systemic treatments
– Chemotherapy
– Hormone therapy
– Biologic therapy (i.e. immunotherapy)
• Radiation therapy (XRT)
• Transplantation (i.e. bone marrow)
Types of Cancer Therapies
Therapies can be given in combination / multiple therapies
administered over the course of treatment
22
Q

• Neoadjuvant

A

– Treatment given as first step to shrink the tumor prior to primary treatment: ie. Neoadjuvant chemotherapy given prior to surgery

23
Q

• Adjuvant

A

– Treatment given after the primary treatment to lower the risk that cancer will come back
▪ May include cancer, chemo, XRT, hormone , targeted, biological therapy

24
Q

Cancer Therapy: Surgery
Removal of the tumour
– May be the only treatment required or adjuvant
• Tumour debulking

• Palliative surgery

A

• Tumour debulking
– Surgical removal of as much of a tumor as possible (I.E. IF CANCER has metastasized)
▪ May increase chance chemo +/- XRT will kill all the tumor cells
• Palliative surgery
– Ameliorate disease or treatment related symptoms
– Ie. Resection of a tumor causing spinal cord compression
– Not curative

25
Q

Cancer Therapy: Chemotherapy

A 
Systemic treatment used to:
– Eradicate the cancer
– Control its size/spread
– Alleviate symptoms
• Can be given orally or via IV
• Class of medications that interrupt different stages of cell cycle replication
(Nelms Table 23.5)
• Combination chemotherapy
– Co-administration of several drugs
– Used to achieve additive effect
26
Q

Cancer Therapy: Radiation Therapy (XRT)

A

The use of high-energy radiation from x-rays, gamma rays, neutrons,
protons, and other sources to kill cancer cells and shrink tumors.
– External-beam radiation therapy
• Radiation comes from a machine outside the body
– Internal radiation therapy or brachytherapy
• Radioactive material placed in the body near cancer cells
• Causes alterations in cell DNA from high energy x-rays
• Chemotherapy may be given at the same time to “radiosensitize” the
cancer cells.

27
Q

Cancer Therapies: Biological & Targeted

A

Immunological
– Antibodies bind to specific antigens expressed by cancer cells
stimulating an immune response that destroys cancer cells
• Cytokines
– i.e. interferons (INF) and interleukins (IL)
– Mediate and regulate immune responses; may inhibit growth of
cancer cells, promote cellular apoptosis

28
Q

Goals of Nutritional Therapy for Patients Undergoing

Cancer Treatment

A
  1. adress current cancer- and treatment related concerns
  2. minimize treatment-related side effects
  3. anticipate and manage acute, delayed, and late-occuring side effects of cancer and/or cancer treatment
29
Q

Individualization of Nutrition Goals

A 
•	Goals should be based on:
–	Pts’ current nutrition status
–	Type and stage of disease
–	Comordib conditions
–	Overall medical treatment plan

• Best approach for nutrition therapies informed by:
– Symptom severity
– Function of the GI tract
– Patient preference

30
Q

Energy & Protein Requirements in Cancer Patients

A 
•	Requirements in General
– Vary based on:
•	Type of tumour
•	Types of treatment(s)
•	Co-morbidities
•	Individual variables (i.e. activities/exercise)
31
Q

Daily Energy Requirements

A

• Key considerations
– Predictive equations have limitations (i.e. HBE)
– REE tends to ↑ with advanced cancer
• But total energy expenditure (TEE) may ↓ d/t fatigue, ↓ physical activity
• Preferred: indirect calorimetry
– Increased trend to assess TEE using wearable devices (i.e. Sensewear ® armband)
• If REE/TEE not available:
– Target __25-30k kcal/kg (ESPEN 2017; low grade evidence)

– ___30-35___ kcal/kg
• Clear hypermetabolism
• Or if Goal is weight gain (use ideal body weight – BMI of 25)

32
Q

Daily Protein Requirements

A

• Protein requirement (ESPEN 2017)
– General recommendation: 1.2-2 g/kg
– Target: 1.5 g/kg if possible
– Do not go below 1.0 g/kg
• For chronically ill older adults, do not go below 1.2 g/kg
• Moderate level of evidence
– ↑ protein intake shown to promote protein anabolism in CA pt’s

33
Q

Nausea & Vomiting

A
  • BRAT diet (Banana, Rice, Apple sauce, Toast)
  • Small frequent meals
  • Sip liquids throughout the day
  • Avoid eating in rooms with odours
  • Choose cold foods with less odours
  • Use clud soda or salt rinse ac/pc meals
  • Anti-emetics and/or motility agents (most effective given 30 minutes before meals)( speak with physicians, pharmacist)
34
Q

Xerostomia +/- Thick Saliva

A
  • Ensure adequate fluid intake
  • Sip on cold water, club soda: ice chips
  • Moisten foods with sauces/gravies
  • Slightly acid foods/beverages (lemon juice may increase salivary glands)
  • Avoid dry foods, crumbly
  • Avoid highly acid foods – caffeine, alcohol
  • Try mouth rinses, artificial saliva, or saliva stimulants
35
Q

Mucositis

A
  • Soft, bland, moist foods
  • Avoid alcohol, highly acidi foods
  • Straws -> decreased contact of liquids with mouth
  • Mouth rinses and topical anesthetics as rx’d
  • Sevre: full fluid diets, EN, PN
36
Q

Dysphagia

A

Modified texture diet

EN if necessary

37
Q

Diarrhea

A

Increase fluids- electrolytes, avoid laxative effect- prune juice- coffee
Add soluble fiber, reduce insoluble fibre
Reduce lactase in meals

aa 442 (17 decks)

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