Nutritional Assessment and Intervention in Cancer Flashcards
How does cancer impact nutritional status?
- Presence of tumor
- Host response
- Anti-cancer treatment
What are the impacts of low nutritional status in cancer?
-Reduced intake
-Altered metabolism
Leading to malnutrition and weight-loss
Disadvantages to malnutrition and weight loss?
-Decrease quality of life, response to treatment and survival
In addition to decrease response to treatment, how else will malnutrition and weight loses affect treatment?
- May have increased wait time to receive treatment in the first place
- Malnutrition will also increase toxicity to treatments
Benefits of assessing nutrition?
- Early ID of pts at risk
- Help design nutritional support
- Improves patients wellbeing, survival and improved eligibility and response to treatment
% weight loss?
IBW - CBW /IBW x 100
Most powerful independent variable that predict mortality in CA?
unintentional weight loss
What is the primary clinical manifestation of cachexia?
Unintentional weight loss
Important to consider about % weight loss in the presence of pleural effusion, ascites or edema?
Weight should be corrected but difficult to be precise
1 week 1-2% weight loss?
Significant
1 week >2% weight loss?
Severe
1 month 5% weight loss?
Significant
1 month >5% weight loss?
Severe
3 months 7.5% weight loss?
Significant
3 months >7.5% weight-loss?
Severe
6 months 10% weight loss?
Significant
6 months >10% weight-loss?
Severe
What is MAMA?
Mid-upper arm muscle area
What does MAMA calculate?
Calculated from mid-arm circumference and triceps skinfold
Low MAMA?
Less than 15th percentile for age and sex
What can 3-methyhistidine and urinary creatinine excretion measure?
Loss of muscle mass -
Urinary creatinine?
Metabolite of creatine phosphate, mainly found in skeletal muscle and index of muscle mass (creatinine/height ratio)
3-methylhistidine?
Released from actin and myosin degradation and marker of myofibrillar protein degradation
Relationship between 3-MH and Creatine?
3-MH/Creatinine ratio
Limitations of UC and 3-MH?
- Wide day-to-day variation
- Both techniques require 24-hour urine collections and 3day meat free diet prior
What is muscle strength indicative of?
- Muscle mass
- Functional status and survival
What is the BEST predictive marker of morbidity and mortality?
Gait speed
Having a walking speed of of less than ___ in the 4-m walking test is indicative of low gait speed, and low functional capacity
0.8 m/s
What are examples of functional tests?
- Gait speed
- Chair rise
- 6-min walking test
- Balance test
What does the chair rise test assess?
- Time to rise 5 times from chair w/o arms
- Test leg strength and power
What is the 6-min walking test?
Endurance test, distance walked during 6 mins (<400m)
What is the balance test?
Time standing on one food, or one foot in front of the other
High albumin?
Dehydaration
Low albumin?
- Inflammation
- Protein deficiency
- Sepsis
- Hyper-hydration
Albumin is useful as a morbidity tool but NOT a useful marker of ___
Nutritional support
High B12?
- Leukemia
- Liver mets
Low B12?
-Gastrectomy (partial removal of stomach, less intrinsic factor)
If B12 is high, should we restrict intake?
No
If low B12, should we supplement?
No - Intramuscular injections (especially if gastrectomy)
High calcium?
- mets
- Lymphoma
- PTH tumor
High calcium guidelines?
do not restrict Ca intake, but stop vit. D supplements
Low folate?
May be due to methtrexate (accelerate metabolism of folate in the liver)
When are supplements of folate useful?
Only when dietary intake is insufficient
High glucose?
- Corticosteroids
- Pancreatic CA
High glucose recommendation?
Avoid concentrated sugars
Low hmg?
- Radio/chem blood losses
- Cancer
Hypochromic anemia?
Suggest iron supplementation
Megoblastic anemia?
Suggest folate or B12 supplementation
Norochromatic anemia?
Suggest blood transfusion
Low K+?
Assoicated with cisplatine
Low lymphocyte?
- Radio/Chemo
- Leukemia
- Corticosteroids
Low lymphocyte recommendation
May respond to increased protein intake
High levels of which values are indicative of dehydration?
- Blood electrolytes
- BUN
- Creatinine
- CBC:hematocrit
- Specific gravity
Clinical signs of dehydration?
-Low BP, rapid heart rate, skin dryness/loss of elasticity, dry mouth/lips, confusion and thirst
What is the Glasgow Prognostic Score based on?
- Inflammation based on CRP and Albumin
- Indicative of poor outcomes that may follow
Low CRP and normal albumin?
GPS= 0 - No cachexia
Low CRP and albumin?
GPS = 0 - undernourished
High CRP and normal albumin?
GPS = 1 - pre-cachexia
High CRP and low albumin?
GPS = 2 - refractory cachexia
When is CRP low? high?
<10 mg/L
>10 mg/L
When is albumin low? High?
<35 mg/L
>/= 35 g/L
How may performance status be evaluated?
ECOG, assessing on a scale of 0-5
ECOG 0?
Fully active
ECOG 1?
Restricted in physically strenuous activity, OK for other lighter activity
ECOG 2?
Ambulatory and capable of self care, but no work activities. Up and about for 50% of waking hours
ECOG 3?
Only self-care. Confined to bed/chair more than 50% of waking hours
ECOG 4?
Completely disabled, confined to bed.chair and no self-care
ECOG 5?
Death
What does PG-SGA stand for?
Patient-generated Subjective Global Assessment
PG-SGA may be used for both screening and ?
Assessment
What does PG-SGA do?
Will have patients complete on side, and will then be evaluated by healthcare professional
What are the 4-boxes on the patient side of the PG-SGA?
1) Weight
2) Food intake
3) Symptoms
4) Activities and Function (same as ECOG)
What is included on the HCP side of PG-SGA?
1) Weight scoring
2) Disease
3) Metabolic demands
4) Physical exam (muscle, fat and fluid status)
When is PG-SGA indicative of dietetic education? Dietetic intervention?
Education: 2-3
Intervention: 4-8 (more common)
What is the baseline nutritional assessment for patients with cancer?
- Dietary assessment
- Weight-loss history
- Body composition
- PG-SGA
- Biochemical data (GPS)
- Muscle strength
- Physical examination
Possible nutrition diagnosis in cancer?
- Involuntary weight loss
- Malnutrition
- Dehydration
What could be an etilogy of malnutrition?
Some patients may have unsupported beliefs and attitudes about food - especially in relation to cancer
Goals of nutritional intervention?
1) Preventative
2) Adjuvant
3) Palliative
Describe prevention nutritional intervention
In prevision of treatment that will affect nutritional status/pre-cachexia
Describe adjuvant nutritional intervention
To improve nutritional status to initiate and support anti-cancer treatments (or in cachexia)
Descrive palliative nutritional intervention
To improve or maintain the quality of life when anti-cancer treatments have stopped (refractory cachexia )
Key points in nutritional counselling?
- Individual
- Provide adequate energy and protein
- Consider multi-vitamin/mineral supplements
- Adapt diet to therapy, appetite
- Encourage PA
Goals of nutritional approach?
- Increase lean mass
- Predispose to better response to treatment
- Increase immunocompetence
- Symptom management
- Improve perception of well-being
Why should we encourage PA in CA?
Beneficial for increasing mood and energy, improved quality of life and potentiate the nutritional support
If we are dealing with a cachexia patient in active weight loss, should we focus on increasing lean mass or weight stabilization?
Weight stabilization as going from a catabolic to anabolic state is extremely difficult
Why may energy prediction equations NOT be appropriate to use in cancer patients?
As REE either increases or decreases in patients (which we cannot determine) and REE may vary according to treatment
What is used to predict E in CA?
- Rule of thumb
- 25-30 kcal/kg/day and depends on performance status (assumes more sedentary)
- 35 if more active
What is important when determining energy requirement?
Establish current intake (i.e. 24 hour recall) and then recommend increases to avoid severe weight-loss
Obese patients may not need more energy, however may need what?
More protein
If we feed the patient, do we feed the tumor?
NO evidence that this is the case, but is shown in animal models.
Should we provide a certain ratio of CHO:Fat?
Not much evidence, but if there is insulin resistance we can increase ratio of fat:CHO and decrease simple CHO
Protein in CA?
Above 1.0 to 1.5 g/kg/day
Protein if inactivity an systemic inflammation?
1.2-2.0 g/kg/day
Protein if kidney disease?
1.0-1.2 g/kg/day
Why do protein needs increase in cancer?
Cancer therapy can increase cell turnover and cell death and we need protein to support
(T/F) Micronutrient or mineral supplements should be recommended as dosages much greater than DRIs
False - but can be recommended in amount close to DRis
Recommendations on micronutrient/mineral supplementation?
- Consider prior and current diet and oral supplement use
- Avoid mega doses of single nutrient in absence of specific deficiencies
What kind of intervention would allow for the increased oral intake of cancer patients who are able to eat, but are malnourished or at risk?
-Dietary advice, treatment of symptoms impairing food intake, offering ONS
Diets that ____ should NOT be recommended to pts with or at risk of malnutrition
restrict energy
Describe the appeal of keto diets in cancer
Animal studies showed some decrease in tumor growth but no clinical evidence in cancer patients
-Keto diets eliminate foods and may lead to weight loss
Describe the appeal of fasting in cancer
Short-term fasting around the time of anti-cancer treatment suggested increased efficacy of treatment
Are keto and fasting completely rejected as treatments?
NO, cannot be currently recommended, but enough evidence to pursue clinical trials
If patients are able to eat what route is recommended?
ALWAYS oral
How can we potentiate success in oral-feeding routes?
- Enrich/modify texture
- Eliminate food restriction (i.e. no low salt diets)
- Take advantage of circadian patterns of appetite
- Identify sensory changes (food odours, taste aversions)
When should enteral nutrition be recommended?
- Unable to ingest/digest foods
- Surgery
- Radio/chemo
- Oral intake insufficient
- May be provided alongside oral intake
Advantages of enteral nutrition?
-Preserve GI architecture, barrier, immune function and gut permeability
When may parenteral nutrition be administered?
When enteral route not accessible, severely malnourished patients and head/neck CA w/ multiple treatments
When is parenteral nutrition NOT recommended?
In advanced cancer patients receiving chemotherapy
How should parenteral nutrition be based on? When is it not appropriate?
- Expected survival in order of months - not when close to death (<3 mo)
- Refractory cachexia
- Quality of life
What are risks in parenteral nutrition?
Infection, and CA patients are immunosuppressed
What is hematopoietic stem cell transplantation?
Treatment for hematological and lymphoid cancers, may be curative (previously known as bone marrow transplant)
What are the 3 sources of stem cells used in HSCT?
1) Donor (allogenic)
2) Genetically identical twin
3) Autologous
Which patients are at the highest risk of graft-versus host disease?
Thos undergoing allogenic HSCT
Discuss to HSCT procedure (breif)
Stem cells harvested, then body undergoes conditioning (high dose chemo/total body irradiation) which eradicates malignant cells and decrease rejection (immunosuppression), then stem cells are infused back in an
Complications with HSCT?
- Infections associated with immunosuppression
- Symptoms of toxicity of TBI
- Graft-versus-host disease, long-term problems
What are some symptom of toxicity from TBI?
Nausea, vomiting, mucositis, diarrhea, pancytopenia (deficiency of RBC, WBC and platelets)
Nutrition approach for HSCT?
- Avoid food at risk of infections, adopts safe food handling during neutropenia
- Provide supplementalEN
When is PN used in HSCT?
-Patients unable to ingest or absorb adequate nutrients for a prolonged period and those who develop severe GVHD
What are 2 promising nutrition therapies for cachexia?
Omega-3
Amino Acids
Omega-3 and cachexia?
- Anti-inflammatory, reduce chemotoxicity
- May be recommended in most pts, since not harmful if <3 g/day
When should omega-3s NOT be recommended?
In patients receiving anti-coagulation therapy
(T/F) The anabolic response to sufficient protein/AA is maintained in CA patients
True
Which AA have promise in CA?
- Leucine
- Glutamine and arginine
Leucine in CA?
Stimulates protein synthesis and insulin secretion, anabolic properties
-May be beneficial if consumed with omega-3,
Glutamine and arginine in CA?
Increase immune competence, help would healing, could benefit pre and post OP
10 days of bed rest in health, older subjects = ___ ofl eg muscle loss
1 kg
How can the LBM and strength in the elderly and bed-ridden patients improve?
Resistance exercise and nutritional supplement
Why does exercise improve nutrition?
Exercise is anabolic, and potentiate the effect of nutrition
-May increase appetite and well-being
(T/F) Exercise cannot be done during chemo TX
False, no interference but adapt to lower intensity/duration
When is exercise recommended?
- During active treatment
- During recovery
- Long-term survivorship
Key conclusion of CA?
- We must combine dietary, physical, exercise and pharmacological
- Individualized and early intervention
