Nutritional assessment and intervention in cancer Flashcards
What are the factors that affect nutritional status of a person with cancer?
- presence of tumor
- host response
- anti-cancer treatment
What are the consequences of compromised status?
reduced intake + altered metabolism –>
malnutrition + weigh loss –>
decreased quality of life
decreased response to treatment
decreased survival
What are the benefits of assessing nutrition in cancer patients?
- 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
Nutritional screening vs assessment
Screening: process of identifying characteristics known to be associated with nutritional problems
- Purpose is to quickly identify individuals with nutritional risks
- Should be easy to use, cost effective, valid, reliable, sensitive
Assessment: process of assessment of body compartments and analysis of structure and function of organ systems and their effects on metabolism
- Most often performed by dietician
- Includes medical and dietary history, physical examination, anthropometric measurements and analysis of biochemical and functional status. Specific to cancer: review of symptoms.
What are some nutritional screening tools for cancer?
- NRI: Nutritional Risk Index (Busby)
Albumin x % ideal weight - MUST: Malnutrition Universal Screening Tool
- SNAQ: Short Nutritional Assessment Questionnaire
- NRS: Nutritional Risk Screening-2002
- MNA: Mini-Nutritional Assessment (short and long)
Both screening and assessment for the elderly
How is percent weight loss calculated?
initial weight-current weight/initial weight x100
How is unintentional weight loss classified?
- Most powerful independent variable that predicts mortality in CA
- Prime clinical manifestation of cachexia
- Classification of cachexia, based on weight loss in previous 6 mo: }
Moderate > 5%
Severe > 10%
Very severe > 15%
What is the severity of weight loss if I lost >2% in 1 week?
severe
What is the severity of weight loss if I lost 1-2% in 1 week?
significant loss
What is the severity of weight loss if I lost 5% in 1 month?
significant loss
What is the severity of weight loss if I lost >5% in 1 month?
severe
What is the severity of weight loss if I lost 7.5 % in 3 months?
significant loss
What is the severity of weight loss if I lost >7.5 % in 3 months?
severe
What is the severity of weight loss if I lost 10% in 6 months?
significant loss
What is the severity of weight loss if I lost >10% in 6 months?
severe
What is the severity of weight loss if I lost 10-20% in unlimited time?
significant loss
What is the severity of weight loss if I lost >20% in unlimited time?
severe
What are the assessment tools for muscle mass loss?
- Anthropometry: mid-upper arm muscle area
- Creatinine/height index
- 3-methylhistidine excretion
- 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
What is Mid-upper arm muscle area (MAMA) and how is it interpreted?
- Calculated from mid-arm circumference and triceps skinfold
- Low MAMA : < 15th percentile for age and sex
What is Urinary creatinine excretion?
Urinary creatinine is a metabolite of creatine phosphate, mainly found in skeletal muscle: index of muscle mass
- Creatinine / height ratio
What is 3-methyl- histidine excretion?
- 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 excretion?
- Wide day-to-day variation
- Both techniques require 24 h-urine collections and 3 day-meat free diet prior
What is Bioelectrical impedance and advantages of it?
- Estimation of fat-free mass (body fat by difference) based on body water, 2-compartment model
- Foot-to-foot (not recommended) and 4-electrode models: - Instruments accessible, affordable
What are the limitations of bioelectrical impedance?
- Reliable only if hydration status is normal
- Built-in equations are not validated for malnourished or sick persons
What is Dual energy X-ray absorptiometry (DXA) and what are its limitations?
- Imaging technique, based on different tissue density
- Measures bone, soft and fat tissues → total lean body mass and appendicular muscle mass
- AMM/height2 identifies sarcopenia:
<7.25 kg/m2 in men,
<5.45 kg/m2 in women
Limitations:
- Expensive but increasingly accessible in research settings
- Minimal exposure to radiation
- Assumes normal hydration status
- Does not account for tumour, metastasis, organ enlargement
How is muscle strength measured?
Handgrip strength - Measured with a dynamometer - Cut-offs for low strength: men <35 kg women <23 kg - Correlates with whole-body muscle strength
What are some other functional tests?
- Gait speed
Walking speed <0.8 m/s in the 4-m walking test
The best predictive marker of morbidity and mortality (Guralnik, Ferucci et al, 2000) - 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 - Balance test
Time standing on one foot, or one foot in front of the other
In what situations albumin is high and low in cancer?
high –> dehydration
low –> inflammation, protein deficiency, sepsis, hyperhydration
In what situations vitamin B12 is high and low in cancer?
high –> leukemia, liver mets
low –> gastrectomy
*** If high: do not restrict B12 intake;
if low: IM injections
In what situations calcium is high in cancer?
high –> some mets, lymphomas, parathyroid tumor
*** do not restrict Ca intake, stop vit. D supplements
In what situations folate is low in cancer?
low –> some drugs (methotrexate)
In what situations glucose is high in cancer?
high –> corticosteroids pancreatic CA
** avoid concentrated sugar
In what situations hemoglobin is low in cancer?
low –> Radio and chemo-Tx, blood losses, leukemia, lymphoma, Hodgkin
*** If hypochromic anemia: may respond to iron supplement
If megaloblastic anemia: folate or B12 supplements
If normochromatic anemia: blood transfusion
In what situations potassium is high in cancer?
Tx with cisplatine
*** Supplements if dietary intake insufficient
In what situations lymphocyte count is low in cancer?
Radio and chemo-Tx, leukemia, corticosteroids
*** May respond to increased protein intake
What are the indications of dehydration in cancer?
For valid interpretation of lab results Indication of dehydration: 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 performance status assessed?
0
Fully active, able to carry on all pre-disease performance without restriction
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
2
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5
Dead
What is subjective assessment?
Patient-Generated – Subjective Global Assessment
(PG-SG A)
- 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
Based on available resources, nutritional assessment of patients with cancer should include, at least:
- Dietary assessment (usual and 24 h-food recall)
- Weight loss history
- Body composition: anthropometry (MAMA), BIA or DXA
- PG-SGA (review of symptoms and level of function)
- Biochemical data: albumin, CRP, prealbumin, hemoglobin, others if suspected nutrient deficiencies (+dehydration/oedema)
- Muscle strength
- Physical examination
What are Possible Nutrition Diagnosis?
Involuntary weight loss
- Increased energy and protein demands
- Reduced food intake
- Difficulty swallowing, chewing
- Taste aversions
- Impaired ability to prepare foods
Malnutrition
- Altered GI function
- Reduced food intake
- Unsupported beliefs/attitudes about foods
Dehydration
- Insufficient fluid intake
What are the types of nutritional interventions
Preventive:
- In prevision of treatment that will affect nutritional status (or pre-cachexia)
Adjuvant:
- 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)
How should the nutrition counselling done?
- Should be individual
- Provide adequate energy and protein (next slide)
- Consider multivitamin/mineral supplements, omega-3 fatty acids?
- Adapt dietary strategy according to:
Ø Appetite
Ø Rounds of therapy
Ø Symptoms (provide practical tips)
Ø Accessible route of feeding (oral, enteral, parenteral)
Ø Encourage physical exercise
What are the Goals of the approach?
Ø Increase lean body mass (or weight stabilisation ?)
Ø Predispose to a better response to radio- or chemo-
therapy
Ø Increase immunocompetence
Ø Symptom management
Ø Improve perception of well-being
What is the AF and protein requirement of Chair/bed-ridden patient in maintenance? (including the stress factor)
1.2-1.3 x REE
≥1. 2 (g/kg/d)
What is the AF and protein requirement of active patient in maintenance? (including the stress factor)
1.3-1.7 X REE
≥ 1.2 (g/kg/d)
What is the AF and protein requirement of active patient in anabolism? (including the stress factor)
1.7-2.0 X REE
≥ 1.5 (g/kg/d)
What is the AF and protein requirement of Chair/bed-ridden patient in anabolism? (including the stress factor)
1.5-1.7 X REE
≥ 1.5 (g/kg/d)
What are the considerations in nutrition needs of cancer patients?
- Evaluate stress factor
- Best to determine current intakes and recommend increased intakes when severe weight loss
- Obese patients may not need more energy but do need more protein
- Micronutrients: multivitamin/mineral may be recommended
consider prior and current diet and oral supplement use } avoid mega-doses of single nutrients
What are the routes of nutritional administration?
Oral: best for patients who are able to eat
Enteral: unable to ingest/digest foods for a prolonged period of time due to obstructions, surgery, radio or chemo Tx
Parenteral: When enteral route not accessible, perioperatively in severe malnourished patients, head and neck CA with multiple treatments
Explain oral nutrition
- Normal diets can be enriched and modified in texture
- Commercial liquid diets may be helpful
- Food restrictions should be eliminated
- Take advantage of circadian patterns of appetite
- Identify sensory changes: food odours, taste aversions
Explain enteral nutrition
- Preserves GI architecture, barrier, immune function and gut permeability
Explain parenteral nutrition
- Not recommended in advanced cancer patients receiving chemotherapy
- 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
What is Hematopoietic stem cell transplantation? What are its complications
- Hematopoietic stem cell transplantation: treatment for
hematological cancers - Involves total body irradiation as a conditioning regimen: - Eradicate malignant cells
- Immunosuppression
Complications:
- infections associated with immunosuppression
- symptoms of toxicity from TBI graft-versus-host-disease: acute and long-term problems (skin rash, liver dysfunction, GI problems)
What is the Nutrition approach for 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.
What are some Promising nutrition therapies for cachexia?
- omega 3 fa
- The anabolic response to sufficient protein/amino acids is maintained in CA patients
- Specific amino acids
What are the benefits of omega 3?
- Anti-inflammatory properties,
- reduce chemotoxicity in animal models
- weight and LBM gain and improved quality of life
- maintenance of body weight, maintenance or gain in muscle mass, lesser intramuscular fat and improved chemo treatment efficacy in lung cancer
- May be recommended in most patients, since not harmful if <3 g/day
- NOT in patients receiving anti-coagulation therapy
What are the benefits of specific amino acids and what are they?
Ø Leucine stimulates protein synthesis and insulin secretion → may have anabolic properties
Ø Ingestion of formula enriched with Leu + ω-3 fatty acids in CA patients (+ inflammation) → ↑ muscle protein synthesis, but long term effects?
Ø 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
Ø Glutamine & arginine↑immune competence, help wound healing : could be beneficial pre and post-operatively
What are the recommendations on exercise and how is it beneficial?
- Inactivity induces muscle loss
- 1 0 days of bed rest in healthy older subjects –> ≈ one kg of leg muscle loss
- Resistance exercise + nutritional supplements = lean body mass and strength in elderly and in bed-ridden patients
- Exercise (resistance) is anabolic and potentiates the anabolic effect of nutrition: should be central to any anabolic therapy
- May increase appetite and well-being
- Exercise study in advanced CA patients:
- Feasible, improved physical performance and strength, no change in fatigue
What are the recommendations of exercise 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
What are the recommendations of exercise during recovery?
- Regular adapted program of exercise is essential to aid
recovery
What are the recommendations of exercise during long term survivalship?
In addition to known benefits of exercise, may reduce recurrence of cancer and increase survival (breast, prostate, colon, ovarian CA)
