Nutritional Impacts of Cancer Treatment: Head and Neck & Breast Cancers (Week 7 Lecture 2)

Question 1

How does muscle loss differ in cancer types?

Answer 1

Muscle loss differs by disease site and treatment plan
* taxane based therapy almost no loss compared to pancreatic
* important to know where it is and what the treatment plan is, changes what happens

Question 2

Overview of head & neck cancers

Answer 2

essentially from bottom of neck to around nose
* Mostly stage III and IV at diagnosis
* Risk factors: smoking, alcohol, wood & chemical exposure, Epstein-Barr Virus, HPV (part of why there is currently a spike, but hopefully HPV will be reduced with vaccines but many 50 year olds did not get vaccinated as kids)
* Oral and oropharynx – increased incidence due to HPV
* Can have delay if lump in throat and thinking its just a cold

Question 3

How is head and neck cancer treated?

Answer 3

Surgery: with skin grafts, extra nutrition would be needed for healing
radiotherapy: radiation has mask made to hold on table and beam must go precisely where it needs to go. treatment is like a full time job; 30 min a day 5 days a week , intensive but not too much time
chemotherapy: Platin-based therapy weekly dose 7 days a week and may make mouth taste like muscle and normal cells that turnover quickly get hurt too like GI

Question 4

Prevalence and prognostic significance of malnutrition in patients with cancer of the head and neck

Answer 4

Shows risk of loss, depending on where you were to start
* 3 means weight loss really needs to be addressed and 4 is very bad, likely to die quickly
* With BMI over 28, if you have even over 6% it gets dangerous too

Question 5

How is weight loss grade associated with survival?

Answer 5

associated with reduced survival
* WL grade 1 is 50% greater chance of death
* WL grade 4 is huge, 164% higher

Question 6

Acute nutrition impacts of surgery

Answer 6

• Inability to eat or drink orally after surgery (unless surgery really small)
• Recovery from skin grafts
• Psychosocial impacts, loss of voice, loss of income

Question 7

Acute nutrition impact of Radiation +/- Chemotherapy

Answer 7

• multi-symptom assessment and management is required
• many symptoms persist for 6-12 weeks after treatment, or longer

Question 8

Head and Neck Symptom Checklist

Answer 8

An instrument to evaluate nutrition impact symptoms effect on energy intake and weight loss., Supportive Care in Cancer for head and neck patients which allows patients to say how long they have had symptoms and whether it is a problem for eating
* similar to SGA
* odenophagia: oral pain
* xerostomia: dry mouth
* anorexia: loss of appetite
* feeling full/ early satiety
* dysphagia: difficulty swallowing
* mucositosis (mostly oral but can also go throughout GI)
* dysguesia (taste changes)

Question 9

When does toxicity effects of radiation therapy peak?

Answer 9

most prevalent part peaks at week 7 because towards end of therapy

Question 10

Nutrition management for Dry mouth/ thick saliva +/- oral thrush

Answer 10

medical strategies
* xylitol tablets (promotes salivation, but only works if salivary gland is still around
* lemon drops (may cause dooth decay)
* oral rinsings, sprays

Food strategies (difficult to taste without saliva)
* fruits based smoothies (better than chocolate or vanilla because of acidity)
* soup/ stew
* soft pasta ++ sauce

Question 11

Nutrition management for oral pain

Answer 11

medical strategies
* opioids - often lots of liquid morphine which some dont want but that often changes within a week. constipation and feeling full is side effect

Food strategies
* soft/ moist foods
* fruit sauces
* fluids (ONS, milk, ice cream, sorbet)

Question 12

Nutrition management for chew/swallow difficulty, aspiration

Answer 12

medical intervention
* thickened liquids of required for safety

food strategies
* purees
* enteral nutrition (usually for fluids)

Question 13

Nutrition management for taste changes

Answer 13

• nutrition counseling related to coping/ framing
• FASS (fat, acid, salty, sweet)

Question 14

Describe FASS

Answer 14

Using fat acid salt and sweet to manage taste changes
* following the line may provide quick fixes on how to make a food taste better if there is too much of one taste or another (problem though if trouble cooking meals)
*

Question 15

factors that increase risk for breast cancer

Answer 15

• any amount of alcohol (pre- and post-menopausal BC)
• excess body fat (post-menopausal BC)

Question 16

Factors that decrease risk for breast cancer

Answer 16

• vigorous physical activity (probably linked to lower adiposity)
• decreased adiposity
• lactation

Question 17

What can impact breast cancer treatment plan?

Answer 17

Hormone receptor status impacts treatment plan (firs thing to look at)
* Estrogen receptor (ER), progesterone receptor (PR), HER2 positive/negative
* Triple-negative: ~15% of all cases
* These values determine treatment plan

Question 18

How is breast cancer treated?

Answer 18

• radiation doesnt really impact nutrition too much due to area
• neoadjuvent: chemo given before surgery to shrink tumour
• adjuvant: given chemo given after surgery in order to decrease risk of reoccurence
• palliative-intent: When patient cannot have surgery or has resurgence and is metastatic so still being treated to try and reduce growth, but is not to cure

Question 19

Acute impacts from breast cancer treatment

Answer 19

• Surgery: Reduced exercise due to fatigue, pain, lymphedema
• Radiation therapy: Few nutritional impacts if protein is adequate
• Hormone therapy: menopause-like symptoms; bone mineral density loss
• Chemotherapy/targeted therapy: Nutrition status can weaken throughout treatment (Anorexia, nausea, fatigue); Metastatic disease (anorexia +/- cachexia); Diarrhea, gut alterations
• Adipose gain, muscle loss is common throughout this journey (too tired to exercise)

Question 20

nutrition management for breast cancer

Answer 20

• Confusion, fear of food, restrictive diets: Myth-busting, breast-cancer specific nutrition education, supportive listening, educate the team
• Increased adiposity: Group fitness classes, resistance training, adequate protein
• Bone mineral density loss: Protein, calcium, vitamin D, weight-bearing exercise (Ca and vit D supplement reccomended)

Question 21

Breast cancer in the long term

Answer 21

• 90% of women with breast cancer survive 5 years
• Post-treatment motivation to change lifestyle is often high
• Muscle loss and adipose gain impact survivorship
• Counsel survivors to: avoid alcohol, reduce body fat. increase muscle mass with resistance training, engage in regular vigorous physical activity

Question 22

Body composition & treatment toxicity in breast cancer

Answer 22

• Sarcopenia: link between low muscle mass and chemo dose in breast cancer which is based on body surface area. So if people are larger but low muscle mass may get overdose of chemo and toxicity occurs.
• sarcopenia + obesity: sarcopenia obesity in breast cancer = highest risk of grade 3-4 toxiciy
• fat mass: higher absolute fat mass but not BMI or BSA associated with higher risk of toxicity-induced treatment modifications

Question 23

what is current reccomendations for chemo dosing based on body composition?

Answer 23

current state of reccomendations is still to give the full dose because we dont know if its muscle, sarcopenia and adiposity, or fat mass that is the factor to look at
* Reinforces ASCO 2012 recommendations for full weight-based dosing in obesity.
* Acknowledges the potential impact of sarcopenic obesity but cites lack of clear evidence from prospective studies.