Lecture 19: Oncology Flashcards
prominent properties of cancer:
lack of differentiation of cells, local invasion of adjoining tissues, metastasis thru blood/lymph
abnormal cell / tissue change progression:
normal–>hyperplasia–>dysplasia–>cancer
most common type of cancer:
carcinoma
carcinomas formed by ____ cells
epithelial
cancer that forms in epithelial cells that produce fluid or mucus
adenocarcinoma
cancer that starts in lower/basal layer of epidermis
basal cell carcinoma
epithelial cells lie just beneath outer surface of skin/line organs
squamous cell carcinoma
other types of cancer?
sarcoma (bone/soft tissue), leukemia (bone marrow), multiple myelomas (plasma cell), melanoma (melanin producing cells), germ cell, neuroendocrine, carcinoid
carcinoid tumours are a type of ____ tumour that are usually found in ____ and are slow growing
neuroendocrine; GIT
carcinoid tumours may secrete these substances:
serotonin, PG’s causing carcinoid syndrome
most common cancers:
prostate, breast, lung, colorectal
leading cause of cancer death?
lung cancer
key factors influencing nutr state and delivery of MNT for cancer:
site/type/stage of cancer, metabolic alterations (tumour or treatment induced), side effects related to specific treatment modalities (physio or psych)
how to diagnose cancer?
biochem markers, med imaging, invasive techniques (biopsy, laparoscopy, cytologic aspiration)
types of biomarkers?
blood and tumour markers
cancer staging based on:
size/extent of original primary tumour, whether cancer has spread
cancer staging assist with:
treatment plan, estimating prognosis, identify clinical trials pt eligible for
TNM cancer staging system based on:
tumour size, lymph nodes, metastases
X in staging means:
can’t be measured/evaluated
what is stage 0 cancer?
group of abnormal cells that may develop into cancer later but not yet
S/S of cancer?
unexplained wt loss, fever, fatigue, pain, skin changes
highest risk of malnutrition associated with cancers of :
GIT, head and neck, liver, lung
malnutrition associated with these poor outcomes:
^ LOS, costs, infections, antibiotic use, mortality; v chemo tolerance, QOL
condition that results from activation of systemic inflammation by an underlying disease such as cancer
disease related malnutrition
inflam response results in:
anorexia, lean and fat tissue breakdown –> wt loss, altered body comp, v phys function
multifactorial syndrome characterized by ongoing loss skel muscle mass that cannot be fully reversed by nutr support and lead to progressive functional impairment
cancer cachexia
wt loss = __% is precachexic
5
wt loss > __% or BMI < ___ and wt loss > __% or sarcopenia and wt loss >__% is cachexic
5; 20; 2; 2
refractory cachexia is characterized by:
cancer disease both procatabolic and not responsive to anticancer treatment, low performance score, <3 months survival (palliative)
sarcopenia characterized by:
low muscle mass, loss of fxn, fatigue common, decreased strength
implications of sarcopenia for cancer pt?
impact ability live independently, v QOL
sarcopenia diagnosed by measuring:
mid upper arm muscle area, appendicular skel muscle index (DEXA), lumbar skel muscle index (ct), whole body fat free mass index (BIA)
why fat depletion in cancer?
^ lipolysis and impaired lipogenesis
tumour releases inflamm mediators and signalling metabolites that cause:
CNS signals anorexia, muscle wasting, liver metabolism changes, fat use and depletion
types of cancer therapies:
surgery, systemic treatments, radiation therapy, transplantation
types of systemic treatments:
chemo, hormone therapy, biologic therapy (immunotherapy)
this is given to shrink a tumour before the primary treatment
neoadjuvant
treatment given after primary treatment to lower risk that cancer will come back
adjuvant
surgical removal of as much tumour as possible is called:
tumour debulking
chemotherapy can be administered either __ or via ____
orally; IV
class of meds that interrupt diff stages of cell cycle replication:
chemotherapy
combo chemo referred to as:
cocktails
what is radiation therapy?
use of high energy radiation from x-rays, gamma rays, neutrons, protons, to kill cancer cells and shrink tumours
how does radiation therapy work?
alter cell DNA
chemo given at same time sometimes to _____ cancer cells
radiosensitize
how does immunological therapy work?
antibodies bind to specific antigens expressed by cancer cells stimulating immune response that destroys cancer cells
these mediate and regulate immune response, may inhibit growth of cancer cells and promote cell apoptosis
cytokines (INF, IL)
biological targets include:
estrogen receptor, signal transduction inhibitors, modify enzymes that regulate gene expression, induce apoptosis, block angiogenesis, target immune sys, monoclonal antibodies, cytokines, hematopoietic growth factors
goals of nutr therapy for cancer treatment?
1) address current cancer and treatment related concerns
2) minimize treatment related side effects
3) anticipate and manage acute, delayed, late occurring side effects of cancer and/or cancer treatment
goals of nutr should be based on:
current nutr status, type/stage of disease, comorbidities, overall med treatment plan
best approach for nutr therapies informed by:
symptom severity, fxn of GIT, pt preference
nrg/pro requirements vary based on:
type of tumour, type of treatment, comorbidities, individual variables
REE _____ with advanced cancer but TEE may ____
increases; decreases
assess TEE with ___ (Preferred) or ____ (practice)
indirect calorimetry; wearable devices
if REE/TEE not available, use target of ____ kcal/kg and _____ kcal/kg for clear hypermetabolism and goal of wt gain
25-30; 30-35
general pro requirement:
1.2-2g/kg (not below 1, try 1.5+)
why more protein?
promote protein anabolism
nutr strategies for nausea/vomiting?
dry starchy foods (BRAT diet), sip liquids throughout day, avoid eating in rooms with odours, choose cold foods with less odours, eat upright, use club soda/salts, meds to address nausea
causes of nausea/vomiting?
chemo, XRT to CNS/abdomen/pelvis, other meds, GI obstruction, dysmotility, intracranial lesions/edema
causes of xerostomia +/- thick saliva
chemo, XRT to head/neck, salivary gland tumours, mouth surgery, meds
nutr strategies for xerostomia?
ensure adequate fluids, sip on cold water/club soda/ice chips, moisten food with sauce/gravy, slightly acidic foods/bev, avoid dry/crumbly food, mouth rinses/artificial saliva/saliva stim, avoid highly acidic/caffeine/alcohol
mucositis caused by:
chemo, XRT head and neck, oral candidiasis infection, weakened immune fxn and decreased salivary function
chemo induced mucositis occur within __ days of beginning treatment, peaking within ___ days
3; 7-10
XRT induced mucositis peaks at ____
completion of treatment
nutr strategies for mucositis:
soft/bland/moist food, avoid alcohol/acidic/tart/spicy foods and extreme temps, straws, mouth rinses
if mucositis severe, consider :
full fluid diet, EN, PN
if develop c difficile, consider ___ until resolved
PN
causes of diarrhea:
chemo, XRT to ab and pelvis, various meds, infections , anxiety, lactose intolerance
causes of constipation:
meds (pain/opioids), tumours around bowel, v food/fluid, v mobility, neuro dysfunction
preeminent interdisciplinary pt assessment tool in oncology
PG-SGA
purpose of ECOG performance status?
scales/criteria used assess pt disease progression, assess ADLs, determine appropriate treatment/prognosis
common oncology nutr diagnoses?
inadequate pro/energy intake, chronic disease related malnutrition, ^ energy expenditure, altered GI fxn, unintended wt loss
what is diff between inadequate pro/energy intake and inadequate oral intake?
specific nutr lower than needed vs. set a goal “rate” but not getting enough
nutr relevant risk factors for breast cancer?
overwt/obese, not physically active
treatment for breast cancer to reduce risk of recurrence:
hormone therapy (ER + BrCA: presence of estrogen promotes cell growth)
tamoxifen is example of ____ drug
anti-estrogen
metabolic side effect of tamoxifen?
^ TG
metabolic side effects of aromatase inhibitors?
^ bone loss and risk of osteoporosis, wt gain?
used for treatment of breast cancer in premenopausal women
ovarian suppression
types of ovarian suppression?
surgical (oophorectomy) and luteinzing hormone-releasing hormone agonists
nutr considerations for breast cancer?
during treatment don’t promote wt loss and monitor for common nutr-related side effects; recovery wt gain is common
why recovery wt gain
reduced metabolism related to estrogen suppression, reductions in PA, diet quality more fat than recommended
diet recommendations post-treatment:
reduce risk of recurrence by managing other comorbidities, ^ V and F, v fat (<30% kcal), minimize cured/pickled/smoked foods, limit alcohol, healthy wt
common therapy in head and neck cancers?
chemoradiation, particularly toxic antineoplastic regimen
chemoradiation in head and neck cancer commonly result in:
xerostomia, dysgeusia, dysphagia, nausea, early satiety, fatigue, odynophagia, severe mucositis
v nutr status lead to:
treatment toxicities, v QOL, interruptions/delays in treatments
nutr considerations fro HNC:
prophylactic PEG (at surgical resection or initiation of XRT)
why prophylactic PEG?
v rate ER visits, v hospitalizations, v interruptions in treatment, v wt loss
malnourished pt undergoing tumour resection should receive ___ days preop EN because ___
7-10; v morbidity and ^ QOL
predictors for need of preop EN?
recent heavy alcohol use, tongue base involvement, surgery, XRT, tumour size
strategies to limit mucositis:
good oral hygiene, opiate analgesics, nutr support therapy providing adequate pro for wound healing
nutr impact symptoms of esophageal cancer:
anorexia, dysphagia, odynophagia, heartburn, N/V, diarrhea, mucositis
nutr issues after esophagectomy?
early satiety, gastroparesis, dysphagia, dysmotility, dumping
post-esophagectomy nutr recommendations:
eat slowly , small frequent meals on schedule, chew well, avoid foods poorly tolerated, anti dumping diet
symptoms of ovarian ca
stomach/pelvic pain, early satiety, involuntary wt loss, ab swelling
malignant obstructions in ovarian ca related to:
tumour location, radiation enteritis, carcinomatosis, disease progression (need intestinal surgery 30-50% of time)
conservative management of malignant bowel obstructions of advanced CA:
NG suction, bowel rest, symptom management, IV fluids
process that involves IV infusion of hematopoietic stem cells collected from bone marrow, peripheral blood or placental cord blood into pt after treatment with cytoreductive conditioning system
hematopoietic stem cell transplantation
purpose of cytoreduction?
kill cancer cells, immune cells (to avoid transplant rejection), bone marrow cells to make room for new blood forming stem cells
types of HSCT:
autologous (infuse pt own stem cells), allogenic (infusion from histocompatible donor)
HSCT pt receive ________ regimen
pre transplant conditioning
adverse effects/complications of HSCT develop dependent on:
conditioning regimen, age, presence of comorbidities, time between treatment and followup
non-infectious complications fo HSCT?
fluid/electrolyte abnormalities, sinusoidal obstruction syndrome, kidney injury, compromised cardiopulmonary fxn, graft-vs-host disease
S/S of sinusoidal obstruction syndrome
ab pain/swelling, evidence of portal HTN, ^ liver enzymes, jaundice
clinical presentation of graft vs host disease?
derangements in skin, liver, GIT
s/s related to GIT for graft vs host disease;
N/V, ab cramps, diarrhea, anorexia, xerostomia, mucositis, altered nutr rqts
nutr therapy for HSCT
low microbial diet for oral diet
what is low microbial diet?
well washed foods, exclude unpasteurized milk/raw meat/herbal products/aged cheese/unwashed V and F, safe food handling
if autologous, low microbial diet for ___ months after transplant, if allogenic, up to ___ yr(s) + if remain on immunosuppressive therapies
3; 1
why no iron?
cuz risk iron overload
NG probs?
increase infectious risk, mucosal bleeding, worsen GI symptoms
HSCT energy requirements for severely malnourished is ____ and for non severe malnourished is ____
3-5x BEE or 30-35 kcal/kg; 25-30 kcal/kg
protein rqts for HSCT first 1-3 months after transplant:
1.5-2g/kg
