Nutritional assessment and approach in cancer Flashcards
How does cancer impact nutritional status
Cancer impacts nutritional status via:
1) Presence of tumor
2) Host response to tumour
3) Anti-cancer treatment
Consequences of compromised status
reduced intake + altered metabolism lead to -> Malnutrition + Weight loss
All this leads to:
1) Decreased Quality of life
2) ↓ Response to treatment (may have to stop/delay treatment)
3) ↓ Survival
Benefits of assessing nutrition
• Early identification of patients at risk, or experiencing malnutrition allows for early intervention
• Helps design appropriate nutritional support
• Improves patient wellbeing, survival, immune function and
reduced morbidity
• Improves eligibility and response to treatment
Define screening
Define assessment
Screening: process of identifying characteristics known to be associated with nutritional problems
Assessment: process of assessment of body compartments and analysis of structure and function of organ systems and their effects on metabolism
Goals and process of screening vs goal and process of assessment
Screening:
• To detect nutritional disturbances at an early stage,
• Should be !!repeated!! as clinical condition changes
• Tool should be easy to use, cost effective, valid, reliable, sensitive
Assessment
• Most often performed by dietitian
• Includes medical and dietary history, physical examination, anthropometric measurements and analysis of biochemical and functional status. Specific to cancer: !!! review of symptoms with nutrition impact!!!
Name nutritional screening tools
- NRS: Nutritional Risk Screening-
- MUST: Malnutrition Universal Screening Tool
- MNA: Mini-Nutritional Assessment
* Both screening (short form) and assessment (long form) for the elderly
how to calculate % weight loss
% weight loss = (Initial weight – current weight)/Initial weight X 100
What is the most powerful independent variable that predicts mortality in cancer?
unintentional weight loss measure
What is the prime clinical manifestation of cachexia
unintentional weight loss
unintentional weight loss cut-offs for classification of cachexia, based on weight loss in previous 6 months
- Moderate > 5%
- Severe > 10%
- Very severe > 15%
What is the correction that should be made when measuring weight loss
Weight should be corrected for excessive fluid loads (pleural effusion, ascites, edema)
% weight loss that is determined as Significant loss or Severe loss in 1 week 1 month 3 months 6 months Unlimited
1 week: Significant loss: 1-2%; Severe loss: >2%
1 month: Significant loss: 5%; Severe loss: >5%
3 months: Significant loss: 7.5%; Severe loss: >7.5%
6 months: Significant loss: 10%; Severe loss: >10%
Unlimited: Significant loss: 10-20%; Severe loss: >20%
What are the components of dietary assessment in cancer patients?
- Energy and protein intake: 24h recall or rapid estimation
- Changes in food and fluid intake
- Adequacy of nutrient intake
- Changes in type, texture or temperature of foods or liquids: aversion to food groups? e.g. meat as it often tastes metallic
- Use of medical food supplements
- Changes in meal or snack patterns
- Intake from enteral or parenteral nutrition
- Natural health products, alternative medicine products, medications; natural health products may have interactions and impact on weight
- Factors affecting access to food: e.g. doing groceries, ability to cook
Loss of muscle mass: assessment tools
arranged in the order from those used in clinic conditions to research conditions
Clinic-> research
• Anthropometry: mid-upper arm muscle area: not sensitive; <15% is cut- off for low measure
• Creatinine/height index
• 3-methylhistidine excretion: has been shown to be a reliable index of muscle protein breakdown
• Bioelectrical impedence (BIA)
• DXA: appendicular muscle mass index
• Imaging techniques: CT scan, MRI
• Densitometry: hydro- or air displacement • Stable isotope dilution
• Total body potassium counting
How is MAMA calculated? What is the cut-off value?
Mid-upper arm muscle area (MAMA)
• Calculated from mid-arm circumference and triceps skinfold
• Bone correction has to be included
• Low MAMA : < 15th percentile for age and sex
What is Urinary creatinine and how is it used as an indicator of muscle mass?
Urinary creatinine is a metabolite of creatine phosphate, mainly found in skeletal muscle: index of muscle mass
• Creatinine / height ratio
What is 3-methylhistidine and how is it used as an indicator of muscle mass?
3-methylhistidine is released from actin and myosin degradation → marker of myofibrillar protein degradation (account for ~ 90% skeletal muscle protein)
• 3-MH/creatinine ratio
What are the limitations of Urinary creatinine and
3-methyl-histidine as assessment tools?
• Wide day-to-day variation
• Both techniques require 24 h-urine collections and 3 day-meat free diet prior
thus, these are not used often
WHat is Bioelectrical impedance?
- Estimation of fat-free mass (body fat by difference)
* based on body water, 2-compartment model
What are the models of Bioelectrical impedance measures? Are they good or bad?
Foot-to-foot (not recommended) and 4-electrode models:
• Instruments accessible, affordable (
Limitations of Bioelectrical impedance measures
- Reliable only if hydration status is normal
* Built-in equations are not validated for malnourished or sick persons
What is DXA?
METHOD OF CHOICE TO MEASURE MUSCLE MASS
Dual energy X-ray absorptiometry (DXA)
• Imaging technique, based on different tissue density
• Measures bone, lean soft and fat tissues → total lean body mass and
appendicular muscle mass
What are the diagnostic cut-offs for dexa?
AMM/height2 identifies sarcopenia: <7.25 kg/m2 in men, <5.45 kg/m2 in women
DEXA limitations and advantages
• Expensive but increasingly accessible in research settings
• Minimal exposure to radiation
• Assumes normal hydration status
• Does not account for tumour, metastasis, organ enlargement
- cannot detect enlarged organs-> increased lean mass results
What can CT scan be used for?
Opportunistic use of oncology imaging for assessment of tissue volume
What is the test to measure muscle strength?
Cut-offs?
- + and -
Handgrip strength
• Measured with a dynamometer
• Cut-offs for low strength:
• men <33 kg women <20 kg (Tessier AJ et al. 2019)
• Correlates with whole-body muscle strength
- doesn’t reflect strength of the whole body
+ good indicator of recovery after surgery
What do functional tests measure?
strength, endurance and balance
Describe functional tests
Gait speed
• Walking speed <0.8 m/s in the 4-m walking test- > cut off; less than these= increased risk of morbidity and mortality
Chair rise
• Time to rise 5 times from a chair without help from the arms
• Test leg strength and power
6-min walking test
• Distance walked during 6 minutes
• Endurance test
• Predicts recovery after surgery, cancer treatment and general functional status
Balance test
• More general test
• Time standing on one foot, or one foot in front of the other
What is the best predictive marker of morbidity and mortality in older adults ?
Gait speed test
Albumin
What would cause high and low values? Consequences?
high values: dehydration
low values (more frequent): inflammation, protein deficiency, sepsis, hyperhydration
Consequences: Useful as morbidity tool, not useful as a marker of nutritional support
Vit B12
What would cause high and low values? Consequences?
high values: leukemia, liver metastasis
low values: gastrectomy (intrinsic factor is not produced in sufficient quantities)
Consequences: If high: do not restrict B12 intake; if low: IM injections
Calcium
What would cause high and low values? Consequences?
high values: some mets, lymphomas, parathyroid tumor (high values in such conditions due to deregulation of PTH)
low values: n/a
Consequences: do not restrict Ca intake, stop vit. D supplements
Folate
What would cause high and low values? Consequences?
high values: n/a
low values: some drugs (methotrexate)- some drugs lower folate a it accelerates the enzymatic system that metabolizes folate -> faster degradation
supplement only if intake is insufficient
Consequences: supplements not useful unless dietary intake is insufficient
Glucose
What would cause high and low values? Consequences?
high values: corticosteroids pancreatic CA
low values: n/a
Consequences: Avoid concentrated sugars
hemoglobin
What would cause high and low values? Consequences?
high values-
low values: Radio and chemo-Tx, blood losses, leukemia, lymphoma, Hodgkin
Consequences: If hypochromic anemia: may respond to iron supplement
If megaloblastic anemia: folate or B12 supplements
If normochromatic anemia: blood transfusion
potassium
What would cause high and low values? Consequences?
high values
low values : Tx with cisplatin (chemotherapy drug)
Consequences: Supplements if dietary intake insufficient
Lymphocyte count
What would cause high and low values? Consequences?
high values
low values : Radio and chemo-Tx, leukemia, corticosteroids
Consequences: May respond to increased protein intake (make sure that its not due to protein insufficiency; if its the case-> is the treatment)
what can albumin be used for to evaluate?
albumin can be used to evaluate the degree of inflammation and perhaps nutritional status
Can you give B12 supplements in gastrectomy?
b12 supplements will not be helpful, since there is no intrinsic factor for absorption
Solution: injections are done once in 3-4 months as B12 can be stored
What should be done when calcium is high
do not restrict calcium as it is not the cause of high calcium
stop vit D
Why should we control for the hydration status?
For valid interpretation of lab results
What are the indicators of dehudration?
High blood concentrations of: • Blood electrolytes • Blood urea nitrogen (BUN) • Creatinine • CBC: hematocrit
• Urine specific gravity
• Clinical signs:
Low blood pressure especially orthostatic; rapid heart rate, skin dryness and lack of elasticity, dry mouth and lips, confusion, thirst
How is inflammation usually measured
Many inflammatory/catabolic markers may be present but usually measured as:
• C-reactive protein (CRP)- high
• Albumin- low
Describe a scoring method used to measure inflammation
Glasgow Prognostic Score: combines CRP and albumin together to predict the mortality state better
Based on
• CRP: low <10 mg/L or high >10 mg/L
• Albumin: low < 35 g/L or normal ≥35 g/L
• Highly predictive of morbidity and mortality
What are the conditions for GLasgow score for 0, 1, 2?
GPS: 0 = No cachexia
CRP is low
Albumin is normal
0= undernourished
CRP is low
Albumin is low
1= pre-cachexia (moderate inflammation)
CRP is high
Albumin is normal
2=refractory cachexia (high inflammation)
CRP is high
Albumin is low (we don’t know why albumin is low
Which test is used for performance status
ECOG
GRADE=0 Fully active, able to carry on all pre-disease performance without restriction
GRADE=1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
GRADE=2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours
GRADE=3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
GRADE=4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair
GRADE=5 Dead
Describe PG-SGA
Patient-Generated – Subjective Global Assessment
(PG-SGA)
• Adapted from the SGA (Detsky Index) for oncology patients
• May be used for both screening and assessment
• 2 sections: one filled by patient, one by health-care professional
• Numerical score: useful for triage to initiate intervention
• Has been validated against objectives measures
• May be used to assess improvements/deteriorations of nutritional status
What are the components of SGA that are filled out by the patient?
- weight
- Food intake (changes)
- Symptoms; changes occur quickly- assessed form past 2 weeks
- Activities and function
What are the components of SGA that are filled out by the doctor?
- disease and it’s relation to nutrient requirement
- MEtabolic demand
- Physical exam
Which age limit adds an additional point to SGA-PG?
age of 65+
Is it hard to get a high score on SGA-PG?
no
Based on available resources, nutritional assessment of patients with cancer should include:
- Dietary assessment (usual and 24 h-food recall)
- Weight loss history
- Muscle mass: anthropometry (MAMA), BIA or DXA
- Nutrition impact symptoms: PG-SGA box 3
- Inflammation: serum CRP
- Biochemical data: albumin, prealbumin, hemoglobin, others if suspected nutrient deficiencies (+dehydration/edema)
- Muscle strength
- Physical performance: PG-SGA or functional tests
- Physical examination: pre-albumin is less affected by inflammation; not always measured
What are the 2 recommended functional tests
6-min walking speed or gate
Possible causes of Involuntary weight loss
• Increased energy and protein demands • Reduced food intake due to: - Difficulty swallowing, chewing - Taste aversions - Impaired ability to prepare foods
Possible causes of Malnutrition
- Altered GI function
- Reduced food intake
- Unsupported beliefs/attitudes about foods
Possible causes of dehydration
Insufficient fluid intake
Nutritional Intervention:
preventative, adjuvant and pallitative
- Preventive: In prevision of treatment that will affect nutritional status (or
pre-cachexia); but can also be with developed cachexia - Adjuvant (during the treatment): To improve nutritional status to initiate and support anti-cancer
treatments (or in cachexia) - Palliative: To improve or maintain quality of life when anti-cancer treatments have stopped (refractory cachexia)
Adapt dietary strategy according to
- Appetite
- Rounds of therapy
- Symptoms (provide practical tips)
- Accessible route of feeding (oral, enteral, parenteral)
components/characteristics of Nutritional counseling
- Should be individual
- Provide adequate energy and protein (next slide)
- Consider multivitamin/mineral supplements, omega-3 fatty acids?
- Encourage physical exercise
Goals of the approach
• Increase lean body mass (or weight stabilisation ?)
- change to anabolic conditions
- more energy and protein should be provided
• Predispose to a better response to radio- or chemo-therapy
• Increase immunocompetence: ensure sufficient nutritional status; provide enough protein, Vit A, minerals and zinc
• Symptom management
• Improve perception of well-being
Nutritional needs: ESPEN guidelines about energy
• Prediction equations may not be appropriate: REE is increased in many
patients, but not all; REE may vary according to treatment.
• Estimated with 25-30 kcal/kg/d, depending on performance status (low level
of evidence)
• Ideally: REE should be measured by indirect calorimetry and physical activity with wearable devices. (stage, treatment and type of cancer influences REE; accurate REE can only be measured
• Best to determine current intakes and recommend increased intakes when severe weight loss; if with current intake the patient is loosing weight-> intake has to be increased
• Obese patients may not need more energy but do need more protein
• * No evidence that providing adequate nutritional support increases tumor; thus no need to limit calories
growth in humans
• Energy composition: because of insulin resistance, recommended to increase the ratio of energy from fat/carbohydrates
Nutritional needs: ESPEN guidelines about protein
- Should be above 1.0 and up to 1.5 g/kg/d (moderate level of evidence)
- 1.2 -2.0 g/kg/d if inactivity and systemic inflammation are present
- Safe with normal kidney function; 1.0-1.2 g/kg/d with kidney disease
Nutritional needs: ESPEN guidelines about micronutrients
supplements are recommended only if the DRI cannot be reached through oral intake due to it beeing too low
multivitamin/mineral supplements may be recommended in amounts close to DRIs
• consider prior and current diet and oral supplement use
• avoid mega-doses of single nutrients in absence of specific deficiencies
what is the Efficacy of nutritional intervention?
Increase oral intake in cancer patients who are able to eat but are malnourished or at risk through: dietary advice, treatment of symptoms impairing food intake and offering oral nutritional supplements (moderate level of evidence)
- these methods are effective
Potentially harmful diets
Do not recommend diets that restrict energy intake in patients with or at risk of malnutrition (low level of evidence)
• “keto” diets : interesting results on tumor growth in animals, no clinical evidence in cancer patientsàmay lead to weight loss
• Fasting: short-term fasting around time of anti-cancer treatment suggested to increase efficacy of treatmentànot recommended now but trials are ongoing
approach for symptom management: N/V
- Patients are often prescribed antiemetics to control nausea and vomiting. Antiemetics should be taken at least 30–45 minutes before a meal
Nausea from cooking odors can be minimized by using a microwave oven, opening windows when cooking, taking a walk when meals are being cooked, and avoiding frying of foods, which emits more odors than most other forms of cooking. - Patients should ask friends and family members to avoid perfumes when they are visiting.
Recommended nutrition therapy for emesis is to eat a small, low-fat meal the morning of the first treatment and to avoid fried, greasy, and favorite foods for several days follow- ing the treatment. A clear liquid diet for the first 24 hours after therapy may be indicated. To provide energy and main- tain hydration, consumption of electrolyte-fortified beverages and non-acidic fruit drinks (apple and grape juice, nectars) should be encouraged.
Prokinetics may also be prescribed to minimize vomiting.
approach for symptom management: early saitety
to eat small, frequent meals that are nutrient dense. Beverages should also contain nutrients and should be consumed between meals rather than with meals so as not to add to the feeling of fullness. Consumption of raw vegetables, such as salads, and other high-fiber foods should be avoided. Proki- netics, medications that increase gastric emptying, may be useful
approach for symptom management Mucositis, mouth sores
Mucositis, also known as stomatitis, is irritation and inflammation of the epithelial cells of the mucosal membranes lining the gastrointestinal tract that can occur at any point in the GI tract from the mouth to the anus
Mucositis may be severe enough to cause the patient to completely forgo any food or fluids, which can lead to dehydration and acute weight loss. Good oral hygiene is important for the patient with oral mucositis in order to prevent infection.
Narcotic analgesics may be required for pain.
Patients with oral mucositis may need nutrition education to provide guidelines for eating until the mucositis resolves. The patient should be encouraged to eat only soft, non-fibrous, non-acidic foods. Hot foods should be avoided as they can burn the mucosa. Liquids should be encouraged to prevent dehydration; non-acidic juices such as nectars may be helpful. High-kcalorie, high-protein milk- shakes or nutritional supplements may be beneficial at this time
approach for symptom management for Diarrhea
encouraged to drink small amounts of fluid frequently throughout the day.
Large amounts of fruit juices should be avoided as excessive fructose can exacerbate diarrhea.
Clear liquid nutritional beverages and other oral rehydration fluids are recommended.
Increase intake of foods high in soluble fiber may help with the treatment of diarrhea; however, often these patients have a poor appetite and may have a difficult time increasing their intake of foods in general.
approach for symptom management for Dysgeusia
avoid metal utensils and instead use plastic utensils. If nutritional supplements are consumed, they should be poured into a glass first, as often the metal container is also offensive. Meats are often not tolerated. To ensure an adequate protein intake, the patient should be encouraged to incorporate other high-protein foods includ- ing peanut butter, cottage cheese, cheese, poultry, and soy meat substitutes into the diet. Patients with ageusia should be encouraged to use more highly spiced and flavorful foods, such as marinated foods. Sweet foods often taste too sweet to individuals undergoing cancer therapy.
approach for symptom management for anorexia
- Eat smaller, more frequent meals.
- Maximize your intake when appetite is most normal.
- Limit fluid with meals to avoid feeling of fullness.
- Keep favorite foods readily available at all times.
- Mild exercise, as tolerated (check with physician).
- Eat meals in a pleasant environment.
- A glass of wine before a meal may help to stimulate the appetite (check with the physician first).
- Avoid noxious odors; ventilate eating area.
- Find a liquid nutritional supplement that is appealing and drink only 2–4 oz at a time (to avoid a feeling of fullness); keep unopened beverage in the refrigerator.
- Try relaxation exercises before mealtimes.
- Consider pharmacologic agents/appetite stimulants.
Oral Route of nutritional administration
best for patients who are able to eat
Normal diets can be enriched and modified in texture Commercial liquid diets may be helpful
Food restrictions should be eliminated e.g low sodium diets as person is eating less -> less sodium will be consumed
Take advantage of circadian patterns of appetite }Identify sensory changes: food odours, taste aversions
Enteral Route of nutritional administration
Used when unable to ingest/digest foods for a prolonged period of time due to obstructions, surgery, radio or chemo Tx or when oral intake is insufficient
}Preserves GI architecture, barrier, immune function and gut permeability (GI architecture is damaged when GI is not used )
Whis is tube that doesn’t go through the skin is better?
tube that goes though the nose is less invasive than the one that goes thorough the skin which is used when all upper GI tract is not accessible
the tube that goes through skin increases the risk of infection
Should we immediately switch to tube feeding?
always try supporting eating orally before switching to tube
try increasing the density, without increasing the volume-> enrichment
Parenteral Route of nutritional administration
- When enteral route not accessible, perioperatively in severe
malnourished patients, head and neck CA with multiple treatments - Not recommended in advanced cancer patients receiving chemotherapy (parenteral nutrition increases the risk of infection
this risk are higher than benefits sometimes) - Should be based on expected survival in the order of months
-> Not when close to death (<3 months)
-> Difficulty of accurately predicting survival is recognized as the main challenge for choosing the right patients for TPN
Nutr Interventions for Hematopoietic Cell Transplantation
• Nutrition support is appropriate in patients undergoing hematopoietic cell transplantation who are malnourished and who are anticipated to be unable to ingest and/
or absorb adequate nutrients for a prolonged period of time. When parenteral nutrition is used, it should be discontinued as soon as toxicities have resolved after stem cell engraftment.
• Enteral nutrition should be used in patients with a functioning GI tract for whom oral intake is inadequate to meet nutrition requirements.
• Pharmacologic doses of parenteral glutamine may benefit patients undergoing hematopoietic cell transplantation.
• Avoid foods at risk of causing infections and adopt safe food handling during period of neutropenia
• Provide enteral nutrition when GI tract is intact and oral intake is inadequate
• Parenteral nutrition for patients unable to ingest or absorb adequate nutrients for a prolonged period and those who develop severe GVHD.
When is Hematopoietic stem cell transplantation used?
Hematopoietic stem cell transplantation: treatment for
hematological cancers
What does Hematopoietic stem cell transplantation involve?
stem cells are taken from the patient
the stem cells are irradiated to kill all the malignant cells
cells are transplanted back into the patient
transplant can come from other non-cancer patient;
with this method there’s risk of graft rejection
Involves total body irradiation as a conditioning regimen:
• Eradicate malignant cells
• total Immunosuppression
Complications of Hematopoietic stem cell transplantation
- infections associated with immunosuppression
- symptoms of toxicity from Total body irradiation (TBI)
- graft-versus-host-disease: acute and long-term problems (skin rash which is very, liver dysfunction, GI problems-> diarrhea)
Promising nutrition therapies for cachexia: omega-3
• Anti-inflammatory properties, reduce chemotoxicity in animal models
• Two recent systematic reviews of >1.5 g n-3 FA/day: 1) improved appetite, body weight, quality of life in weight-losing patients and 2)
conservation of body composition in chemo and/or radio Tx
• Trial with supplement of 2.2 g EPA/day during 10 weeks in lung CA patients, compared to standard care during chemoTx: maintenance of body weight, maintenance or gain in muscle mass, lesser intramuscular fat and improved chemo treatment efficacy
• May have protective effects on chemo-induced toxicities, neuroprotective effects
• Well-tolerated, mild GI side effects, fishy aftertaste
- May be recommended in most patients, since not harmful if <5 g/da
Promising nutrition therapies for cachexia
Amino acids
• The anabolic response to sufficient protein/amino acids is maintained in CA patients (Chevalier & Winter, Curr Opin Clin Nutr Metab Care 2014)
• Specific amino acids:
• Leucine stimulates protein synthesis and insulin secretion → may have anabolic properties
• Ingestion of formula enriched with Leu + ω-3 fatty acids in CA patients (+ inflammation) → ↑ muscle protein synthesis, but long term effects?
• In CA patients with weight loss: mixture of Gln + Arg + Leu metabolite (HMB) = lean body mass in 4 weeks (vs. loss in control group), no reported side effects
• Glutamine & arginine ↑immune competence, help wound healing : could be beneficial pre and post-operatively
have to provide sufficient amount of protein to have an anabolic response
What is the effect of inactivity?
Inactivity induces muscle loss
• 10 days of bed rest in healthy older subjects-> one kg of leg
muscle loss
Resistance exercise + nutritional supplements = __ in _
Resistance exercise + nutritional supplements = increased lean body mass and
strength in elderly and in bed-ridden patients
What should be central to any anabolic therapy?
Exercise (resistance) is anabolic and potentiates the anabolic effect of nutrition: should be central to any anabolic therapy
• May increase appetite and well-being
What are the potential effects of exercise in cancer patients?
- May increase appetite and well-being
- May help lower inflammation
- RCTs (in early stages) showed improvements in aerobic capacity, muscle strength, health-related quality of life, and self-esteem, and with reduction in fatigue and anxiety
Exercise recommendations in advanced CA patients, during active treatment, during recover
- RCT in advanced CA patients: feasible & safe, improved physical performance and strength, no change in fatigue (Oldervoll, Oncologist 2011)
- During active treatment
- Safe, feasible, may improve functioning and quality of life
- No interference with chemoTx
- Adapt program: lower intensity and duration • Avoid during severe Tx side effects
- During recovery
- Regular adapted program of exercise is essential to aid recovery
Long-term survivorship and exercise
In addition to known benefits of exercise, may reduce recurrence of cancer
and increase survival (breast, prostate, colon, ovarian CA)
