Nutrition Support In Cancer<br />
Incidence and Prevalence of Cancer<br />No. of deaths<br />% of all deaths<br />Rank<br />Cause of Death<br />1.	Heart Dis...
Rate Per 100,000<br />1950<br />2002<br />HeartDiseases<br />CerebrovascularDiseases<br />Pneumonia/Influenza<br />Cancer<...
Nutritional Alterations in Cancer*<br />Early Satiety<br />Dysphagia<br />Nausea Vomiting<br />Chemo-therapy<br />Mucositi...
Cancer Cachexia<br />
Cytokines modulate gastric motility and emptying either directly or via brain<br />TNF suppresses lipoprotein lipase activ...
Metabolic Alterations<br />1.Metabolic responses to tumour disease and progression: tumour–host interactionClinical Nutrit...
Micronutrient Deficiencies3<br />Reduced Levels of <br />Vit A in Colorectal & Esophageal Cancer and pretreatment pediatri...
Electrolyte Disturbances3<br />Tumor Lysis Syndrome<br />Hyperkalemia, Hyperphosphatemia & Hypocalcemia<br />Drug Induced<...
Nutritional Assessment<br />Screening<br />Early assessment of nutritional risk and serial reassessments through out cance...
Physical Examination<br />Body weight<br />&gt;45% of hospitalized adult cancer patients (&gt;10%) weight loss3<br />Weigh...
Physical Examination<br />Evaluation for <br />Edema<br />Ascites<br />Muscle wasting<br />Temporal wasting (Hallmark of C...
Biochemical and laboratory tests<br />Viceral Proteins<br />Use to evaluate nutritional status but reliability is question...
Biochemical and laboratory tests<br />Low Albumin and Prealbumin<br />Poor nutrition status<br />Infection<br />Overhydrat...
Quality Of Life (QOL)<br />Patient’s willingness to eat<br />Depressed Psychological State<br />Poor Attitude<br />Financi...
Nutrotional Considerations for Chemo, Radiation and immuno therapy<br />Nausea, Vomiting, Diarrhea, Constipation<br />Muco...
Criteria for Intervention4 (Adults)<br />Preoperative tube-feeding or PN provided for 7-14 days may benefits moderately an...
Goals of therapy<br />Maintenance of Nutritional status or Reversal of PCM<br />Calories to prevent/minimize catabolism wi...
Decreased morbidity, improved survival, and improved QOL<br />NS may improve QOL<br />Use of HPN also improved QOL<br />So...
Criteria For Intervention (Pediatrics) 3<br />Relapse rate is high in malnourished patients in ALL and solid tumors.<br />...
Indication for NS (American Academy of pediatrics)5<br />NS must be provided to patients to support normal growth who cann...
Indication for NS (American Academy of pediatrics)<br />Serum Albumin  &lt; 3.2mg/dL<br />Triceps skinfold  &lt; 5th perce...
Goals5<br />Body weight &gt; IBW<br />Arm Fat Area &gt; 10th percentile for age and sex<br />Serum Albumin &gt; 3.2mg/dL<b...
Pharmacological<br />Nausea & Vomiting<br />Serotonin receptor antagonists (e.g. Granisteron, Ondasteron)<br />Phenothiazi...
Pharmacological<br />Prevention and Rx of Mucositis<br />Salt and soda rinse<br />Chlorhexidine rinse<br />Mouthwash (diph...
Pharmacological<br />Bowel Medications<br />Stool Softeners (docusate)<br />Bulk Laxatives (Psyllium, Methylcellulose)<br ...
Nutritional<br />Nausea and Vomiting<br />Small & Frequent Meals<br />Eat slowly<br />Cold and non-odorous food<br />Light...
Nutritional<br />Mucositis<br />Choose blend, cold soft drinks<br />Moisten dry foods<br />Cut food into small pieces or p...
Nutritional<br />Constipation<br />Obtain Adequate Fluid intake<br />Increase insoluble fiber consumption<br />Drink hot b...
Nutritional<br />Diarrhea<br />Extra Fluid and K rich food sources<br />Increase soluble fiber and decrease insoluble fibe...
Nutritional<br />Neutropenia<br />Food containing less bacterial load<br />Wash fruits and vegetables well<br />Avoid unpa...
Nutritional<br />Taste Changes<br />Choose flavorful foods as tolerated<br />Loss of appetite<br />Small frequent meals<br...
Special Aspects of enteral nutrition<br />Aggressive EN should be considered in patients who are unable to attain oral int...
Special Aspects of enteral nutrition<br />Monitoring<br />Aspiration risk and GI tolerance<br />Pre-existing Rx related Na...
Special Aspects of enteral nutrition<br />Nasoenteric feeding tube may be contraindicated in<br />sever thrombocytopenia<b...
Special Aspects of enteral nutrition3<br />Safety of fish oil has not been well studies in children<br />In case of diarrh...
Special Aspects of PN<br />PN is recommended in patients who need aggressive NS when <br />Tube feeding is unsuccessful<br...
Special Aspects of PN<br />Pediatrics<br />Adequate calories to support growth along NCHS Growth charts<br />Catch Up grow...
Minimization of Metabolic disturbances<br />Glucose &lt; 180mg/dL<br />Triglycerides &lt; 300mg/dL<br />Avoidance of Refee...
Monitoring<br />Catheter Complication<br />Hemothorax<br />Infection at site of infection<br />Hematoma<br />Sepsis<br />R...
Monitoring<br />
Metabolic complication<br />Hyperglycemia<br />Hypophosphatemia<br />Electrolyte disturbances<br />Increased liver functio...
Drug Nutrient Interaction<br />Neutropenic diet<br />Educate patient & care giver about feeding methods<br />Nutrition sid...
American Cancer society www.cancer.org<br />American Institute of cancer research www.aicr.org<br />Cancer centers www.can...
Nutrition Support In Cancer
Nutrition Support In Cancer
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Nutrition Support In Cancer

  1. 1. Nutrition Support In Cancer<br />
  2. 2. Incidence and Prevalence of Cancer<br />No. of deaths<br />% of all deaths<br />Rank<br />Cause of Death<br />1. Heart Diseases 696,947 28.5<br />2.Cancer 557,271 22.8<br />3. Cerebrovascular diseases 162,672 6.7<br />4. Chronic lower respiratory diseases 124,816 5.1<br />5. Accidents (Unintentional injuries) 106,742 4.4<br />6. Diabetes mellitus 73,249 3.0<br />7. Influenza and pneumonia 65,681 2.7<br />8. Alzheimer disease 58,866 2.4<br />9. Nephritis 40,974 1.7<br />10. Septicemia 33,865 1.4 <br />US Mortality, 2002<br />Source: US Mortality Public Use Data Tape 2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2004. www.cancer.com (cancer statistics)<br />
  3. 3. Rate Per 100,000<br />1950<br />2002<br />HeartDiseases<br />CerebrovascularDiseases<br />Pneumonia/Influenza<br />Cancer<br />* Age-adjusted to 2000 US standard population.<br />Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.<br />2002 Mortality Data: US Mortality Public Use Data Tape, 2002, NCHS, Centers for Disease Control and Prevention, 2004. www.cancer.com (cancer statistics 2005) <br />Change in the US Death Rates* by Cause, 1950 & 2002<br />
  4. 4. Nutritional Alterations in Cancer*<br />Early Satiety<br />Dysphagia<br />Nausea Vomiting<br />Chemo-therapy<br />Mucositis<br />TNF<br />Food Intake<br />Taste/smell Alteration<br /> Catabolism<br />AA<br />FA<br />Anorexia<br />Weight Loss<br />GI Malabsorption<br />Radiation Therapy<br />Glucose<br />MalnutritionCachexia<br />*A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005<br />
  5. 5. Cancer Cachexia<br />
  6. 6. Cytokines modulate gastric motility and emptying either directly or via brain<br />TNF suppresses lipoprotein lipase activity<br />TNF play a role in cancer cachexia, weight loss was reversed with TNF neutralizing antibodies in mice.3<br /> IL-1 associated with anorexia by blocking neuropeptide Y (NPY) induced feeding.<br />IL-1 & TNF increases corticotropin hormone which decreases food intake<br />Hormonal & Cytokine Alterations<br />3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154<br />
  7. 7. Metabolic Alterations<br />1.Metabolic responses to tumour disease and progression: tumour–host interactionClinical Nutrition, Volume 19, Issue 6, December 2000, Pages 459-465<br />
  8. 8. Micronutrient Deficiencies3<br />Reduced Levels of <br />Vit A in Colorectal & Esophageal Cancer and pretreatment pediatric leukemia & Lymphoma<br />Vit E, Vit C, Beta Carotene in lung, gastric, pancreatic, oral & thyroid cancer<br />Vit D (and Calcium) in Colon Cancer<br />Metabolic Alterations<br />3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154<br />
  9. 9. Electrolyte Disturbances3<br />Tumor Lysis Syndrome<br />Hyperkalemia, Hyperphosphatemia & Hypocalcemia<br />Drug Induced<br />Hyponatremia – cyclophosphamide & Vincristine<br />Hypocalcemia, Hypomagnesemia and hypophosphatemia – platinum containing therapy<br />Metabolic Alterations<br />
  10. 10. Nutritional Assessment<br />Screening<br />Early assessment of nutritional risk and serial reassessments through out cancer patient’s course.<br />Patient-Generated Subjective Global Assessment (PG-SGA)<br />Outcome based assessment tool developed specifically for cancer patients<br />Easily Applicable<br />Capture Short term changes in nutritional status.<br />
  11. 11. Physical Examination<br />Body weight<br />&gt;45% of hospitalized adult cancer patients (&gt;10%) weight loss3<br />Weight loss correlates with complications and mortality<br />Body weight must be evaluated against normal or usual <br /> weight and not a reference standard<br />Nutritional Assessment<br />3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154<br />
  12. 12. Physical Examination<br />Evaluation for <br />Edema<br />Ascites<br />Muscle wasting<br />Temporal wasting (Hallmark of Cachexia)<br />Functional Assessment <br />Assessment of muscle function (Grip Strength)<br />Nutritional Assessment<br />
  13. 13. Biochemical and laboratory tests<br />Viceral Proteins<br />Use to evaluate nutritional status but reliability is questionable<br />Predictive of morbidity and mortality<br />Pre-Albumin Provides better Identification of nutritional status and its recovery during NS<br />Nutritional Assessment<br />
  14. 14. Biochemical and laboratory tests<br />Low Albumin and Prealbumin<br />Poor nutrition status<br />Infection<br />Overhydration<br />Decreased synthesis due to Cytotoxics agents<br />Nutritional Assessment<br />
  15. 15. Quality Of Life (QOL)<br />Patient’s willingness to eat<br />Depressed Psychological State<br />Poor Attitude<br />Financial constraints<br />Ability to eat<br />Weakness and fatigue<br />Nutrition counseling for symptom management improves nutrient intake and QOL<br />Nutritional Assessment<br />
  16. 16. Nutrotional Considerations for Chemo, Radiation and immuno therapy<br />Nausea, Vomiting, Diarrhea, Constipation<br />Mucositis<br />Neutropenia<br />Change in taste<br />Loss of appetite<br />Dry mouth<br />Fatigue<br />Criteria for Interventions & Goals Of Therapy<br />
  17. 17. Criteria for Intervention4 (Adults)<br />Preoperative tube-feeding or PN provided for 7-14 days may benefits moderately and severely malnourished cancer patients.<br />Specialized nutrition support is indicated in selected patients who are receiving cancer treatment and who are either severely malnourished or unable to consume and/or absorb an adequate oral diet for an extended period of time.<br />Criteria for Interventions & Goals Of Therapy<br />4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.<br />
  18. 18. Goals of therapy<br />Maintenance of Nutritional status or Reversal of PCM<br />Calories to prevent/minimize catabolism without overfeeding<br />In general 25-35 Kcals/kg is a reasonable estimate<br />Protein 1.2-1.5gm/kg (varies with degree of catabolism)<br />Criteria for Interventions & Goals Of Therapy<br />4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.<br />
  19. 19. Decreased morbidity, improved survival, and improved QOL<br />NS may improve QOL<br />Use of HPN also improved QOL<br />Some nutrients like glutamine, arginine and essential fatty acids and nucleic acids have been evaluated for their specific beneficial biologic effects on the tumor and the host.<br />Criteria for Interventions & Goals Of Therapy<br />4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.<br />
  20. 20. Criteria For Intervention (Pediatrics) 3<br />Relapse rate is high in malnourished patients in ALL and solid tumors.<br />Tolerance to drug therapy is lower in malnourished patients as compared to well nourished patients.<br />Criteria for Interventions & Goals Of Therapy<br />
  21. 21. Indication for NS (American Academy of pediatrics)5<br />NS must be provided to patients to support normal growth who cannot meet requirements via oral intake.<br />Weight loss &gt; 5% of preillness body weight<br />Weight &lt; 90% of ideal body weight<br />Weight for height &lt; 10th percentile <br />Criteria for Interventions & Goals Of Therapy<br />5. Mauer AM, Burgess JB, Donaldson SS, et al. Special nutritional needs of children with malignancies: a review. J ParenterEnteralNutr. 1990;14(3):315–324.<br />
  22. 22. Indication for NS (American Academy of pediatrics)<br />Serum Albumin &lt; 3.2mg/dL<br />Triceps skinfold &lt; 5th percentile for age and sex<br />Oral Intake &lt; 70% of that needed for growth for more than 5 days in well nourished patient.<br />Expected GI dysfunction &gt; 5 days in well nourished patients<br />Criteria for Interventions & Goals Of Therapy<br />
  23. 23. Goals5<br />Body weight &gt; IBW<br />Arm Fat Area &gt; 10th percentile for age and sex<br />Serum Albumin &gt; 3.2mg/dL<br />Vitamin and mineral deficiency should be prevented<br />Decreased morbidity <br />Improved survival<br />Improved QOL<br />Criteria for Interventions & Goals Of Therapy<br />5. Mauer AM, Burgess JB, Donaldson SS, et al. Special nutritional needs of children with malignancies: a review. J ParenterEnteralNutr. 1990;14(3):315–324.<br />
  24. 24. Pharmacological<br />Nausea & Vomiting<br />Serotonin receptor antagonists (e.g. Granisteron, Ondasteron)<br />Phenothiazines (e.g., promethazine)<br />Antihistamine (e.g. Diphenhydramine)<br />Benzodiazepines (e.g. Lorazepam)<br />Steroids (e.g. Dexamethasone)<br />Nutritional Management<br />
  25. 25. Pharmacological<br />Prevention and Rx of Mucositis<br />Salt and soda rinse<br />Chlorhexidine rinse<br />Mouthwash (diphenhydramine +antacid+Lidocain)<br />Nutritional Management<br />
  26. 26. Pharmacological<br />Bowel Medications<br />Stool Softeners (docusate)<br />Bulk Laxatives (Psyllium, Methylcellulose)<br />Lubricants (Mineral Oil)<br />Osmotic Agents (Glycerin, Lactulose)<br />Stimulants (Bisacodyl)<br />Antidiarrheal (loperamide, Kaolin/Pectin)<br />Nutritional Management<br />
  27. 27. Nutritional<br />Nausea and Vomiting<br />Small & Frequent Meals<br />Eat slowly<br />Cold and non-odorous food<br />Light, starchy & low fat food<br />Avoid Very sweet or spicy food<br />Rest & sit up after eating<br />Nutritional Management<br />
  28. 28. Nutritional<br />Mucositis<br />Choose blend, cold soft drinks<br />Moisten dry foods<br />Cut food into small pieces or puree<br />Use straw with fluids<br />Coordinate eating with analgesic use<br />Nutritional Management<br />
  29. 29. Nutritional<br />Constipation<br />Obtain Adequate Fluid intake<br />Increase insoluble fiber consumption<br />Drink hot beverages prior to the usual time of bowel movements<br />Incorporate physical activity as permitted by medical team<br />Nutritional Management<br />
  30. 30. Nutritional<br />Diarrhea<br />Extra Fluid and K rich food sources<br />Increase soluble fiber and decrease insoluble fiber<br />Avoid Lactose & Sugar Alcohols<br />Low fat food<br />Consume food and beverages at room temperature<br />Nutritional Management<br />
  31. 31. Nutritional<br />Neutropenia<br />Food containing less bacterial load<br />Wash fruits and vegetables well<br />Avoid unpasteurized products<br />Follow safe handling, storage and cooking procedures for meat, fish, poultry and eggs<br />Nutritional Management<br />
  32. 32. Nutritional<br />Taste Changes<br />Choose flavorful foods as tolerated<br />Loss of appetite<br />Small frequent meals<br />Save beverages for the end of meal<br />High calorie and Protein-nutrient dense foods<br />Nutritional Management<br />
  33. 33. Special Aspects of enteral nutrition<br />Aggressive EN should be considered in patients who are unable to attain oral intake<br />Small bowel resection and mucosal injury pateint may benefit from EN<br />Aim is to meet requirements of<br />Macronutrients<br />Micronutrients<br />Fluid needs with acceptable GI tolrance<br />Nutritional Management<br />
  34. 34. Special Aspects of enteral nutrition<br />Monitoring<br />Aspiration risk and GI tolerance<br />Pre-existing Rx related Nausea, vomiting may be exacerbated during EN<br />Postoperatively ileus may preclude tolerance<br />Mechanically Ventilated patients may have poor perfusion<br />Nutritional Management<br />
  35. 35. Special Aspects of enteral nutrition<br />Nasoenteric feeding tube may be contraindicated in<br />sever thrombocytopenia<br />Significant mucositis<br />Recent extensive neck resection<br />Immune-suppressed patient should be educated for careful tube feeding technique<br />Nutritional Management<br />
  36. 36. Special Aspects of enteral nutrition3<br />Safety of fish oil has not been well studies in children<br />In case of diarrhea and mal-absorption <br />Use low osmolar nutrient supplements that contain MCT, hydrolized carbohydrates and proteins.<br />Increase prealbumin by 1mg/dL per day<br />Nutritional Management<br />
  37. 37. Special Aspects of PN<br />PN is recommended in patients who need aggressive NS when <br />Tube feeding is unsuccessful<br />GI Tract is not appropriate(e.g. Obstruction, High output Fistula)<br />In Cachectic patients, the goal may be to minimize wasting rather than to nutritionally replete patient.<br />Nutritional Management<br />
  38. 38. Special Aspects of PN<br />Pediatrics<br />Adequate calories to support growth along NCHS Growth charts<br />Catch Up growth-if patient has PCM<br />Prealbumin Level-1mg/dL per day increase<br />Replacement of minerals and electrolytes (Zn in diarrohea)<br />Nutritional Management<br />
  39. 39. Minimization of Metabolic disturbances<br />Glucose &lt; 180mg/dL<br />Triglycerides &lt; 300mg/dL<br />Avoidance of Refeeding Syndrome<br />Repleting Mineral and electrolyte level prior to start PN<br />Initiating PN slowly in case of severe malnutrition<br />Nutritional Management<br />
  40. 40. Monitoring<br />Catheter Complication<br />Hemothorax<br />Infection at site of infection<br />Hematoma<br />Sepsis<br />Rate of infection varies on the nutrition status of patient6<br />Nutritional Management<br />6. A clinical trial of hyperalimentation in children with metastatic malignancies <br />J. Van Eys, E. M. Copeland, A. Cangir, G. Taylor, B. Teitell-Cohen, P. Carter, C. OrtizMedical and Pediatric Oncology Volume 8, Issue 1 , Pages63 - 73<br />
  41. 41. Monitoring<br />
  42. 42. Metabolic complication<br />Hyperglycemia<br />Hypophosphatemia<br />Electrolyte disturbances<br />Increased liver function test & bilirubin<br />Nutritional Management<br />
  43. 43. Drug Nutrient Interaction<br />Neutropenic diet<br />Educate patient & care giver about feeding methods<br />Nutrition side effects commonly experienced with cancer therapy and how to minimize it.<br />Patient & Caregiver Education Internet Resources<br />
  44. 44. American Cancer society www.cancer.org<br />American Institute of cancer research www.aicr.org<br />Cancer centers www.cancerlinksusa.com<br />Cancer research and prevention foundation www.preventioncancer.org<br />Diet guidelines for immunosuppressed patients www.fhcrc.org/clinical/ltfu/<br />National Cancer Institute www.cancer.gov<br />Oncolinkhttp://www.oncolink.upenn.edu/<br />Oncology dietetic Practice group www.oncologynutrition.org<br />Patient & Caregiver Education Internet Resources<br />

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