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POM > Nutrition and Cancer > Flashcards

Nutrition and Cancer Flashcards

1
Q

Considerations in managing a cancer patient

A

• Site of cancer (foot vs mouth cancer differ in effect on nutrition) (metastises)
• Type
• Stage of cancer
• Multi-modality treatment i.e. chemotherapy, radiotherapy, surgery & biological therapies
• Side effects of treatment & disease
• Co-morbidities
• Age of patient (able to tolerate treatment)
(ehtical to intervene? -palliative care)
• Social circumstances i.e. alcohol / drug & nicotine dependency
• Cachexia syndrome

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2
Q

Weight loss: Patients with cancer

A

Hall mark of cancer when considering treatment
-good predictor of cancer status and tumour stages
-significant predicter of survival
% of weight loss
-caused by majority of cancers
-Larger % of weight loss = Larger likelihood of morbidity/mortality
-Greatest % of weight loss in patients with GI cancers (+ pancreatic cancers)
CI and pancreatic cancers have greater % of weight loss and greater amount loss in 6 months

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3
Q

Adverse clinical consequences of weight loss in cancer: case-control and prospective cohort tria

A

Outcomes:

  1. Diminished survival
  2. Decreased response to chemoRx and XRT (radiotherapy)
    - drug treatments less effective if lost large amount of lean body mass (try retain weight and lean body mass)
  3. Increased perioperative morbidity
  4. Worse quality of life
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4
Q

Treatment Side effects

A

Nearly all treatments cause some increase in nutritional requirements/cause a side effect that interferes with dietary intake
Chemo: weightloss- due to nausea, vomiting, fatigue, oral mucositis (sore mouth), taste alterations, constipation
Radiation (head and neck): Weight loss, fatigue, nausea/vomiting, oral mucositis, Taste alterations
Surgery (esp GI): Weight-loss, fatigue, Nausea/vomiting
Immunotherapy: Weight loss, fatigue and Oral Mucositis

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5
Q

Cancer Cachexia

A

• Extreme on the continuum of weight loss and anorexia (loss of apetite)
-weightloss mediated by tumour, tumour secretions, inflammatory response to having tumour
• Seen in cancer, cardiac disease & chronic infection
• Due to a systemic inflammatory response (mediated by tumour istelf and cancer state in body)
• Mediated through cytokines
-unique to cancer. also HIV, arthritis (due to inflammatory) , renal patients

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6
Q

Pathology of Cancer-induced Weight loss (cacehia)

A

Tumour:
1. Lipid mobilizing Factor –> Fat –> Fat breakdown
(used for energy to drive body into catabolic state)
2. Cytokines –>
a) Hypothalamus –> anorexia (inhibition of neurotranmistters) + Increased Energy expenditure (metbaolism
b) Liver (catbaolic products)–> Inflammatory Response
3. Hormonal Changes –> Skeletal muscle –> Liver –> Inflammatory response
4. Proteolysis Inducing Factor –> skeletal muscle –> Protein Breakdown (a/acid breakdown –> increased a/acid production utilised for energy)
-alot of these processes cannot be stopped - tumour continues to produce these substances and inflammatory response. Makes it very difficult to reverse the catabolism. Patients require very intensive nutritional interventation.
-Some drugs/steroids help produce inflammatory response itself

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7
Q

Difficulties associated with Cancerous Cachexia

A
  • alot of these processes cannot be stopped - tumour continues to produce these substances and inflammatory response. Makes it very difficult to reverse the catabolism. Patients require very intensive nutritional interventation.
  • Some drugs/steroids help produce inflammatory response itself
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8
Q

Metabolic Alterations in Starvation V. Cancer Cachexia – CHO Metabolism

A

Similarities:
Glucose tolerance and Insulin sensitivity decreased in both
Differences:
Glucose turnover:
-decreased in starvation, to try maintain equilibrium and reduce weightloss. results in decreased serum glucose and insulin
-increased in cancer cachexia due to cytokines in inflammatory state produced by cancer. results in unchanged Serum glucose and insulin
Lactate:
Cori Cycle activity and Serum Lactate increase in Cancer Cachexia. Become acidotic
-unchanged in starvation

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9
Q

Metabolic Alterations in Starvation V Cancer Cachexia – Fat Metabolism

A

Lipolysis increased in both
-for energy production
Lipoprotein lipase activity decreased in Cancer- drive/induced lipolysis (unchanged in starvation)
Serum Triglyceride level: Increase in cancer, unchanged in starvation

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10
Q

Metabolic Alterations in Starvation V Cancer Cachexia – Protein Metabolism

A

Negative Nitrogen Balance in both
Urinary nitrogen excretion decreased in starvation (unchanged in cancer)
Protein turnover and Skeletal muscle catabolism increased in Cancer Cachexia (decreased in starvation as are trying to contain and reserved skeletal muscle at expense of fat)
Challenge: try to feed cancer cachexia patient, but no matter how much protein you feed them, they’re burning it up and increasing body’s output of nitrogen

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11
Q

Challenge re Metabolism Alteration and Protein metabolism

A

Challenge: try to feed cancer cachexia patient, but no matter how much protein you feed them, they’re burning it up and increasing body’s output of nitrogen

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12
Q

Other factors that contribute to the development of protein-energy malnutrition in the cancer patient
-Physical impairment of swallowing

A

Physical impairment of swallowing (neck type tumours)
 effects on chewing or swallowing mechanisms (mouth/oesophagus tumour)
 reduction in saliva production –xerostomia (treatment to shrink tumour damages other cells, decreases amount of salive produced)
 radiation- or chemotherapy-induced mucositis (treatment to shrink tumour damages other cells)
 surgical interruption of swallowing mechanism
e.g. Severe Oral Mucositis Following Marrow Transplantation- huge ulcers. -common for people who had radiotherapy/chemotherapy treatments for head and neck type treatments

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13
Q

Other factors that contribute to the development of protein-energy malnutrition in the cancer patient
-alterations in physiology

A

 malabsorption/maldigestion due to tumour or to therapy (where tumour is/ how much GI tract has been resected)
 constipation/gastrointestinal dysmotility (drugs/surgery type/cancer type)

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14
Q

Other factors that contribute to the development of protein-energy malnutrition in the cancer patient
-insufficient dietary intake

A

 Suppression of appetite (depression)
 Food aversion (chemo therapy causes nausea and causing vomiting. become food averse/phobic due to unpleasant vomiting after every time you eat)
Be aware of strong beliefs re diet/nutrition and cancer
-self diagnosed treatment from google. difficult to support their beliefs in conjunction with traditional medical paradigm
-think that by starving tumour will be positive (remove glucose). Isnt good long term- as long term will be less able to tolerate treatment

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15
Q

Cancer - Aims of Nutritional Support

A

•Improve the subjective quality of life (QoL)
-nutrition intervention sometime intensive but needs to consider quality of life
•Enhance anti-tumour treatment effects
•Reduce the adverse effects of anti-tumour therapies
•Prevent & treat under nutrition

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16
Q

Be aware of strong beliefs re diet/nutrition and cancer

A

Be aware of strong beliefs re diet/nutrition and cancer

  • self diagnosed treatment from google. difficult to support their beliefs in conjunction with traditional medical paradigm
  • think that by starving tumour will be positive (remove glucose). Isnt good long term- as long term will be less able to tolerate treatment
17
Q

People with cancer need extra nutrition

A 
1. Healthy individual:
Energy: 25 –30 kcal/kg
Protein: 0.8 g/kg
Energy Intake/day: 2262 kcal/day1
2. Individual with cancer:
Energy:
a) Maintenance: 25 –35 kcal/kg 
b) Gain: 35 –50 kcal/kg
Protein:
a) Maintenance: 1–1.5 g/kg 
b) Gain: 1.5 –2.0 g/kg
Energy Intake/day: 1429 kcal/day1 
-low physical activity
-increased requirement based on type of tumour and how advanced it is
18
Q

Nutritional Therapy

A

This can be achieved by:
• Supplemental feeding
-cannot get nutrition from diet alone
-Oral: Sip feeds/milky drinks high in energy and nutrients presribed to consume daily, so dont have to drink large volumes (some meal replacements)
-sweet, flavour fatigue. Therefore use dietician to come up with sustainable regime
• Support/Advice
• Pharmacological agents to combat anorexia, wasting and nausea (halt inflammatory response)
• Nutraceutical agents to enhance immunity and anabolism (reduce cetabolism or a/acids anf fatty acids)
-ingredients within supplemental feeds

19
Q

Enternal Acess

A
  1. Feeding via Nose :
    a) Naso gastric(–> Stomach):
    - bolus feeding (12 hrs) or continuous feed (24hrs)
    b) Nasoduodenal:
    - vomitting alot
    c) Jejunal
  2. Gastrostomy: PEG
    - “Percutaneous Endoscopic Gastrostomy”
    - significant issues with nausea/vomiting.
    - Long term support
    - tube is passed through small opening in abdominal wall straight into stomach. bypasses oesophagus and nose - more comfortable than having a tube through
    - simple procedure. under endoscopy. wound has to be looked after.
    - immediate PEG is standardised treatment for patients prior to having head/neck radiotherapy. recognise they will have significant weight loss.
  3. Jejunosotomy “Percutaneous Endoscopic Jejunosotomy”
20
Q

Standardised procedure for patients having Head/neck Radiotherapy?

A
  • immediate PEG is standardised treatment for patients prior to having head/neck radiotherapy. recognise they will have significant weight loss.=
    Gastrostomy: PEG
    -“Percutaneous Endoscopic Gastrostomy”
    -significant issues with nausea/vomiting.
    -Long term support
    -tube is passed through small opening in abdominal wall straight into stomach. bypasses oesophagus and nose - more comfortable than having a tube through
    -simple procedure. under endoscopy. wound has to be looked after.
21
Q

Solution for patient who you cannot feed someone orally, large amounts of GI tract resected/isnt functioning well

A

Venous Sites from which the Superior Vena Cava may be accessed
Parental nutrition :via vein
Enteral: via digestive system
-use large vein e.g. Superior Vena cava, to feed patients through, due to the osmotic pressure
-can use peripheral veins but is difficult to get nutrition in via that way
-everything has to be completely digested, as skipping digestive system (pure a/acids, fatty/acids, glucose, vitamins, minerals) (end points of digestion and absorption)
-last resort
-should always try keep feeding gut, as gut will only maintain functioning if it is fed

22
Q 
• Male- Mr X
• 52yrs
• Diagnosis- T4N3M0 SCC Left Floor of Mouth (FOM)
• PMH-CABGx3& Hypertension
• Social History
– Lives alone above a pub
– Alcohol intake approx. 63 units/week
– Smokes 50g tobacco/week
– Security Guard
A

Nutrition Assessment
• Weight on referral- 62 kg 17/05/10 (lost alot of weight)
• Usual weight- 70 kg
• BMI- 17 kg/m2
• Diet History
– 4 strong black coffee’s each with 2 sugars
– 1 meal daily, early evening, takeaway Meat Pie & chips
– Approx. 5 pints strong lager +/- 2-3 double vodkas per night (getting alot of his energy/nutrition from alcohol)

23
Q

Male X Treatment

A

Treatment
• 23/05/10 resection of FOM with DCIA flap (Deep Circumflex Iliac Flap, resection and then reconfigure artery bone into Jawbone shape)
• Left radical neck dissection
• Right neck dissection
• Dental clearance
• Nil by mouth & tracheostomy in situ
• 13/06/10 debridement of DCIA flap
• 15/06/10 PEC major flap after failure of DCIA flap
• 04/08/10 post surgery 6/52 radiotherapy
**-had poor nutrition and poor dietary intake due to surgery and tumour location
** Increased risk of poor nutrition due to treatment

24
Q

Male X Nutrition Support

A
  • Requirements calculated using 10% stress factor (SF) & 20% activity factor (AF) – approx. 2000 kcal, 60-70g Protein
  • Fed 2000ml Nutrison Multi fibre (2000kcal, 80g Protein)
  • Weight increased 61.2kg- oedematous, 5 days later 55.3kg
25
Q

What happened to Male X

A

• Changed feed 1000ml Nutrision Energy Multi Fibre & boluses 2 x 200ml Fortisip (agitated due to withdrawl from alcohol)
• Not meeting requirements due to compliance issues
• Flap failure & need for further surgery
• Remains NBM & PEG placed 19/07/10 (Peg more comfortable)
• Weight 52.1kg (2.9kg (5%) weight loss in 2/12)
2. What happened next
• Commenced radiotherapy 04/08/10 • Weight 49.5kg
• Remained an inpatient
• Refusing pump feeding – bolus only

26
Q

What actually happened to Male X

A

• Energy requirements were calculated approx. 1800kcal, 50-60g Protein
• Feed regimen 6 x 200ml Fortisip bolused daily – provides 1800kcal, 72g protein
• Only taking 4 x 200ml Fortisip daily- provided 1200kcal, 48g protein (tried to take orally, to get off PEG)
• Weight 07/09/10 47.5kg
Mr X was discharged home post radiotherapy, his weight dropped to 47kg & his requirements re-calculated.

27
Q

Mr X after discharged home

A

• Energy requirements were calculated using a PAL factor (1.5 – moderately active in a light occupation)
***• Feed switched to 4 x 237ml cans of Two CalHN bolus in an attempt to meet requirements in a minimum volume (2 cal per ml + high amount of nitrogen)
• Oral diet resumed
-shows how nutritional intervention is required and so important

28
Q

Summary

A

•PEM is common amongst cancer patients. GIand, head & neck cancers have the poorer outcomes.
•The cause of the malnutrition is multifactorial
•Nutrition support in cancer patients improves quality of life.
• The provision of aggressive nutritional support will improve outcomes in patients.
-important for tolerance and effectiveness of treatment (chemo, radio and immune therapy)

POM (33 decks)

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