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Nutrition in Head and Neck Cancer

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  • 1. Mrs. Anjali B. Nair Chief Dietician Tata Cancer Hospital NUTRITION IN HEAD AND NECK CANCER
  • 2. Oral cancer is the sixth most common cancer in the world
  • 3. Head and neck cancer refers to a group of biologically similar cancers originating from the upper aero digestive tract including lip, oral cavity, nasal cavity, paramucosal sinuses, pharynx, larynx, oropharynx and Hypopharynx
  • 4. Cancer of lip Cancer of tongue Cancer of hard palate Cancer of bucal mucosa Cancer of mandible
  • 5. Presenting complaints
    • Change in voice
    • Change in facial appearance
    • Non healing ulcers
    • Ill-fitting dentures, loosening teeth
    • Lesions
  • 6. Mode of treatment
    • Surgery: primary mode of treatment. It can include:
    • Total or partial glossectomy
    • Removal of certain portion of hard or soft palate.
    • Neck dissections.
    • Radiation: Indications for radiotherapy include a bulky tumor with significant risk of recurrence.
    • Chemotherapy: systemic therapy which affects whole body.
  • 7.
    • Causes of Malnutrition 
    • Diminished nutrient intake
    • Increased nutrient demand not matched by intake
    • Tumor-induced derangements
    • Diminished Nutrient Intake 
    • Alcohol & Tobacco
    • Poor dentition
    • Partial or complete obstruction of aerodigestive tract
    • Post-surgical functional and anatomic impairments of chewing and swallowing
    • mucositis, dysgeusia, xerostomia
    • Chemotherapy-induced nausea, vomiting  
  • 8.
    • Increased Nutrient Losses  
    • Vomiting
    • Diarrhea
    • Increased Nutrient Demand 
    • Acute metabolic stresses caused by surgery, RT, chemotherapy
    • Duration and intensity of stresses depend on intensity and duration of treatment as well as complications  
    • Tumor-induced Metabolic Abnormalities 
    • Abnormal metabolism of carbohydrates, lipids, and protein
    • Abnormal levels of neurotransmitters leading to anorexia
    • Increased basal metabolic rate
    • Cytokines appear to mediate these abnormalities
    • Tumor necrosis factor, IL-1, IL-6
  • 9.
    • Impact of Malnutrition  
    • Immunocompetence
      • Decreased cell-mediated immunity
      • Depressed T-cell proliferation, NKC cytotoxicity, macrophage cytotoxicity
    • Inability to tolerate antineoplastic treatments
      • Toxicities more severe—treatment delays, higher costs
    • Postoperative complications
      • Wound infection, healing—quality of life, cost      
  • 10. NUTRITIONAL CARE
    • Weight loss and altered nutritional status are evident in 50% of the patient with cancer at time of diagnosis and therefore nutritional support can improve overall patient performance status.
    • Nutrition therapy recommendation may vary throughout the continuum of care. Maintenance of adequate intake is important, whether the patient on active therapy, recovering from cancer therapy or in remission and striving to avoid cancer re-occurrence.
  • 11.
    • The goals of nutritional therapy:
    • Prevent or reverse nutritional deficiencies
    • Preserve lean body mass
    • Help patient better tolerate treatment
    • Minimize nutrition related side effects and complication
    • Maintain strength and energy
    • Protect immune function and decrease the rush of infection
    • Aid in recovery and healing
    • Maximize the quality of life
  • 12. Dietary guidelines
    • Macro nutrients:
    • Energy: 15-20 kcals/kg PBW/day to prevent re-feeding syndrome
    • 25-35 kcals/kg PBW for maintenance
    • 39-40kcals/kg PBW/day. for weight gain:
    • Proteins: 1-1.5gm/kg PBW/day for maintenance
    • 1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain patients.
  • 13.
    • Micronutrients :
    • 1. Sodium: hyponatrimia due to
    • SIADH.
    • Dehydration
    • Drains
    • 2. Zinc: common deficiency, results in:
    • decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood.
    • Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations
    • iii. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. AJCN (Vol. 17, No. 5, 409-418 (1998 )
  • 14.
    • Water: 30-40ml/kg PBW/day
    • Prevent dehydration
    • Prevent respiratory distress due to drying of secretions.
    • Arginine: (controversial)
    • Shown to increases fistula and wound complications
    • Glutamine:
    • Decreases the risk and severity of stomatitis
    • Helps in wound healing after surgery
    • Reduced the side effects of chemo drugs like doxorubicin etc.
    • Contraindicated: shown to stimulate growth of cancer cells.
  • 15. Avoid cooking smell and food with strong odors Have dry meals with drinks taken separately Biscuits, dry toast and cold foods Avoid very sweet and fatly foods Nausea Frequent small quantity and variation in meals Nutritious snacks and drinks between meals Supplementation of high calorie and proteins Anorexia Dietary intervention Symptoms
  • 16. Avoid food that worsen the unpleasant taste mainly because of zinc deficiency Altered taste Small frequent feed with soft and liquid diets with nutritious drinks after food Difficulty in swallowing (Dysphasia) Dietary intervention Symptoms
  • 17. Eat foods that are easy to chew and swallow with cool temperature and soft fruits like bananas stewed apple and peach, cottage cheese, mashed potatoes, scramble eggs, cooked cereals, and milk shakes Mouth sores Eat moist foods with extra sauces, butter or margarine and avoid liquids and food that contain lots of sugars and dry fruit nectar instead of juice Dry Mouth Dietary intervention Symptoms
  • 18.
    • Strategies for modifying nutrient intake depend on specific feeding problem and the extent of depletion.
    • Oral route is preferred mode of feeding but may be resisted by patient experiencing nausea , altered sensation and dysphagia.
    • In patients with head and neck cancer the cancer lesions in the oral cavity makes difficult to consume food orally.
    Few considerations
  • 19.
    • Dysphagia due to oral lesions can be lessened with intake of soft and liquefied foods served at moderate and room temperature.
    • Patients with Xerostomia should be encouraged to have plenty of fluids(25-30ml/kgbdwt) and eat moist foods with extra gravies and butter.
    • Patients with chemotherapy complain of decreased ability to eat as the day progresses. Thus morning can be the best time for eating.
    • This is an attribute to sluggish digestion and gastric emptying as a result of GI mucosal atrophy and gastric muscle atrophy
  • 20. Approach to nutrition support PRETREATMEN T -Nutrition screening, History( weight loss), Physical examination( BMI) , Lab studies(Serum albumin) Malnourished Is therapy intensive Oral supplements NO Moderately or severely malnourished Aggressive nutritional support Is GI tract functional Oral supp or Enteral tube feeding Parenteral nutrition YES NO
  • 21. ROUTES OF FEEDING
  • 22. SELECTION OF FORMULA
    • Functional capacity of gut
    • Intubations site
    • Patient's metabolic status
    • Cost
    • Convenience considerations
  • 23. COMPARISION BETWEEN PRODUCTS Rs 240 Cost Rs 215 546mg K 800mg 360mg Na 500mg 45 gms PRO 41gms 338 kcals ENE 374kcals ACTIBASE NEUTRAL (100gms) RESOURCE HIGH PROTEIN (100gms)
  • 24. Case studies
  • 25. MRS RKT 43 YR/F CA UPPER LIP --- T4 N0 M0 STAGE IV COMPLAINED OF SWELLING IN UPPER LIP ADMITTED TO TMH---24/5/10 DIAG: SPINDLE CELL CARCINOMA BIOCHEMICAL NORMAL EXCEPT FOR Na OPERATED ON 31/5/10 PT ON RT FEEDS SINCE 1/6/10
  • 26. HT: 151CMS WEIGHT: 60KGS BMI:26KG/M2 GRADE I OBESE ENERGY: 30X46(IBW)=1380 +STRESS FACTOR=1450KCALS PROTEINS: 1.5 GM/KG IBW=69GMS CHO:65%=227 GMS FAT:22%=34 GMS
  • 27. HOSPITAL DIET 143 128 GIVEN 1GM SALT 134 Na INTAKE IMPROVED NAUSEA REDUCED WITH FEELING OF FULLNESS SEVERELY NAUSEATED REMARKS 125 128 75 CHO 21.6 20.7 9 FATS 48.2 27.1 7.2 PROT 1157 906 432 ENERGY DAY3(3/6) DAY2(2/6) DAY1(1/6)
  • 28.
    • PT DISCHARGED ON 4/6/10
    • ON RT FEEDS+ORAL LIQUIDS ON ACTIBASE NEUTRAL
    • WEIGHT MAINTAINED SO CONTINUED WITH SAME DIET.
  • 29. MRS.SINGH 40/F CA LATERAL BORDER OF TONGUE—T3NOMO SYMP: PAIN WHILE EATING FOOD ADMITTED TO TMH 27/4/10 BIOCHEMICAL NORMAL EXCEPT FOR FLUCTUATING Na OPERATED ON 31/5/10 RT FEEDS STARTED ON 1/6/10
  • 30. HT: 161 CMS WEIGHT:82KG BMI:31.66KG/M2 GRADE II OBESE ENERGY:25KCALS/KG= 1400 PROTEINS: 1.3GM/KG= 73 GMS CHO 65%= 228GMS FATS 15%= 23 GMS
  • 31. HOSPITAL DIET 134 -- 134 Na INTAKE PROPER COCONUT WATER=SWEETLIME JUICE SO LESS OF BLEND FEEDS TAKEN ½ RT FEEDS AS NAUSEATED REMARKS 171 141 57 CHO 44 38.5 20 FATS 72 68 32.6 PROT 1541 1278 554 ENERGY DAY3(3/6) DAY2(2/6) DAY1(1/6)
  • 32.
    • LOW HB WAS BEFORE SURGERY 10GMS(25/5)
    • 3/6: HB FURTHER REDUCED TO 9.70GMS DUE TO BLOOD LOSS DURING SURGERY
    • DISCHARGED ON SAME DIET WITH ADDITION OF RAGI PORRIDGE AND ½ BOILED EGG ADDED TO THE RT FEEDS
  • 33. Conclusion
    • Head and neck cancer and disease induced dysphagia can adversely affect a patient’s ability to eat and thus its QOL.
    • Dysphagia has serious emotional and social consequences.The inability to participate in eating , one of the life’s most social occasion generates a lot of frustration , anxiety and depression.
    • Quality of life assessment is important for patients with neoplasm of head and neck.
    • Apart from the treatment modalities, the type of cancer carries a significant influence on the physical , functional , social , emotional and a global wellbeing of the patients.
  • 34.  

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