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