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Mrs. Anjali Nair Chief Dietician Tata Memorial HospitalShe is recepient of many awards including one from Smt Lilavati MunshiFoundation for a project on Diet in Cancer Tube Feeding Formulation.Shehas been part of research team of Food Technology Department of BARC fordeveloping Goods for Foods for Immuno-compromised patients and othertarget groups-using radiation technology.She has also been involved in various publications in the area of Nutritionand Cancer and has shared her experience on practical approaches inNutrition and Cancer in various conferences and seminars at National andInternational levels .Mrs. Nair is also involved in guiding post graduate andresearch students in dessertations and has been playing a lead role incarrying out nutrition related educational activities for Oncology &Enterostomal Nurses along with Nutrition students.As a part of herresponsibilities at Tata Memorial Hospital , she is running many nutritionalcounselling programmes for Communities-Breast/Uterine group,Head andNeck Cancer,General Medicine and Palliative Care Patients.
NUTRITION IN HEAD AND NECK CANCER Mrs. Anjali B. Nair Chief Dietician Tata Cancer Hospital
Annually, over 3,00,000 new cases of oral cancer are diagnosed all overthe world where the majority are diagnosed in the advanced stages III orIV. Such data make the oral cancer an important public health matterwhich is responsible for 3% to 10% of cancer mortality worldwide.
Head and neck cancer refers to a groupof biologically similar cancersoriginating from the upper aerodigestive tract including lip, oral cavity,nasal cavity, paramucosal sinuses,pharynx, larynx, oropharynx andHypopharynx
Cancer of lip Cancer of tongue Cancer of hard palateCancer of bucal mucosa Cancer of mandible
An “At Risk” Population Alcohol use/abuse Tobacco use Up to 40% of newly diagnosed head and neck cancer patients are malnourished. Malnutrition has significant impact on morbidity, mortality and quality of life for cancer patients Physicians often do not address this issue
Presenting ComplaintsChange in voiceChange in facial appearanceNon healing ulcersIll-fitting dentures, loosening teethLesions
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
Increased Nutrient Losses Vomiting DiarrheaIncreased 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
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
SWALLOWING PROBLEMS IN HEAD AND NECK CANCER.HNCA Reduced pre-treatment swallowing function. Reduced post-treatment swallowing function. Surgery Chemotherapy Radiation MALNUTRITIONSwallowing problems Worse swallowing function &Dysphagia Aspiration IMPAIRED Less variety of food consistency QUALITY OFXerostomia Mucositis LIFE.Nasal regurgitation. Less nutrition through oral route
Treatment related complication Surgery Negative nitrogen balance Inability to chew Agluttion (inability to Chemotherapy swallow) Nausea Dysphagia Vomiting Communication impairment Diarrhea Aspiration Cheilosis GlossitisRadiotherapy PharyngitisMucositis EsophagitisXerostomia ( dry mouth) anorexiaOdynophagia ( pain in swallowing)Dysguesia ( loss of taste)Dental caries associated with xerostomia Table 7.3 - Nutritional management of cancer patient
Clinical Manifestations of CancerPainNutritional implication- Cancer Cachexia Disturbances in water and electrolyte metabolism. Anorexia Progressive impairment of vital functions. Weight loss and depletion Abnormal taste- Hypogeusia , dysguesia Alteration in body compartments Dysphagia
Carbohydrates gluconeogenesis from Acetic acid , lactate and glycerol. glucose disappearance and recycling. Glucose intolerance Insulin resistance
Altered lipid metabolism Increased Lipolysis Increased Glycerol and fatty acid turnover. Lipid oxidation non – inhibited by glucose. Decreased lipoprotein lipase activity. Increase in serum lipids and fatty acids.
Altered Protein metabolism Increased Muscle Protein catabolism Increased whole body protein turnover Increased liver protein synthesis. Decreased muscle protein synthesis.
Gastrointestinal DysfunctionAbnormalities in the mouth and the digestive tract, either as a result of a disease or its treatment, May interfere with food ingestion Changes in taste and smell . Changes in taste and smell correlate with decreased nutrient intake, a poor response to therapy, and tumor progression, including metastasis .Zinc-deficiency, alterations in brain neuro-transmitters such as NPY, that affect taste and nutrient selection .
Standards of care to be followed Early nutrition support. Total calorie intake should be restricted to 1500-2000 kcals/day. Main substrates providing calories should be Carbohydrates and lipids. Protein intake determined by severity of catabolism. Assessment of nutritional status based on SGA. Enteral nutrition should be the choice.
Parenteral nutrition if needed , certain recommendation should be followed. Timing of nutritional support to be studied. Specific diseased stated may require certain modifications. Immuno-nutrition Preventive nutritional support with primary treatment to be considered.
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.
The Goals of Nutritional Therapyc. Prevent or reverse nutritional deficienciesd. Preserve lean body masse. Help patient better tolerate treatmentf. Minimize nutrition related side effects and complicationg. Maintain strength and energyh. Protect immune function and decrease the rush of infectioni. Aid in recovery and healingj. Maximize the quality of life
Dietary Guidelines Macro nutrients:Energy: 15-20 kcals/kg PBW/day to prevent re-feeding syndrome25-35 kcals/kg PBW for maintenance39-40kcals/kg PBW/day. for weight gain:Proteins: 1-1.5gm/kg PBW/day for maintenance1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain patients.
Micronutrients1. Sodium: hyponatrimia due to3. SIADH.4. Dehydration5. Drains2. Zinc: common deficiency, results in:vii. decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood.viii.Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizationsiii. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. AJCN (Vol. 17, No. 5, 409-418 (1998 )
Water: 30-40ml/kg PBW/day2. Prevent dehydration3. Prevent respiratory distress due to drying of secretions. Arginine: (controversial)Shown to increases fistula and wound complications Glutamine:9. Decreases the risk and severity of stomatitis10. Helps in wound healing after surgery11. Reduced the side effects of chemo drugs like doxorubicin etc. Contraindicated: shown to stimulate growth of cancer cells.
Symptoms Dietary interventionAnorexia Frequent small quantity and variation in meals Nutritious snacks and drinks between meals Supplementation of high calorie and proteinsNausea 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
Symptom Dietary interventionsDifficulty Small frequent feed with soft andin liquid diets with nutritious drinks afterswallowin foodg(Dysphasia)Altered Avoid food that worsen the unpleasanttaste taste mainly because of zinc deficiency
Sympto Dietary interventionmsDry Eat moist foods with extra sauces, butter or margarine and avoid liquidsMouth and food that contain lots of sugars and dry fruit nectar instead of juiceMouth Eat foods that are easy to chew and swallow with cool temperature and softsores fruits like bananas stewed apple and peach, cottage cheese, mashed potatoes, scramble eggs, cooked cereals, and milk shakes
Few Considerations 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.
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
Approach to Nutrition SupportPRETREATMENT-Nutrition Moderately or severelyscreening, History( weight loss), malnourishedPhysical examination( BMI) ,Lab studies(Serum albumin) Aggressive nutritional support Malnourished Is GI tract functional Is therapy YES NO intensive NO Oral supp or Parenteral Enteral tube nutrition Oral supplements feeding
MRS RKT 43 YR/F CA UPPER LIP --- T4 N0 M0 STAGE IVCOMPLAINED 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
HOSPITAL DIET DAY1(1/6) DAY2(2/6) DAY3(3/6)ENERGY 554 1278 1541PROT 32.6 68 72FATS 20 38.5 44CHO 57 141 171Na 134 -- 134REMARKS ½ RT FEEDS COCONUT INTAKE AS WATER=SWE PROPER NAUSEATED ETLIME JUICE SO LESS OF
LOW HB WAS BEFORE SURGERY 10GMS(25/5) 3/6: HB FURTHER REDUCED TO 9.70GMS DUE TO BLOOD LOSS DURING SURGERYDISCHARGED ON SAME DIET WITH ADDITION OF RAGI PORRIDGE AND ½ BOILED EGG ADDED TO THE RT FEEDS
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.
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