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Nutrition in Head & Neck Cancer

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Nutrition in Head & Neck Cancer

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Nutrition in Head & Neck Cancer

  1. 1. www.nutritionistsrepublic.comWorld’s First Online Networking Platformexclusively for Nutritionists & Dieticians
  2. 2. brings you a chance to listen to the Experts through interactiveNutrinaRs Benefits•Interact with Experts•Enhance your knowledge and learn new skills•Request Topics you may be interested•Post and get your questions answered.
  3. 3. 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.
  4. 4. NUTRITION IN HEAD AND NECK CANCER Mrs. Anjali B. Nair Chief Dietician Tata Cancer Hospital
  5. 5. 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.
  6. 6. 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
  7. 7. Cancer of lip Cancer of tongue Cancer of hard palateCancer of bucal mucosa Cancer of mandible
  8. 8. 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
  9. 9. Presenting ComplaintsChange in voiceChange in facial appearanceNon healing ulcersIll-fitting dentures, loosening teethLesions
  10. 10. 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
  11. 11. 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
  12. 12. 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  
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Macronutrient metabolism
  17. 17. Carbohydrates  gluconeogenesis from Acetic acid , lactate and glycerol.  glucose disappearance and recycling.  Glucose intolerance  Insulin resistance
  18. 18. 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.
  19. 19. Altered Protein metabolism Increased Muscle Protein catabolism Increased whole body protein turnover Increased liver protein synthesis. Decreased muscle protein synthesis.
  20. 20. 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 .
  21. 21. 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.
  22. 22.  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.
  23. 23. 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.
  24. 24. 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
  25. 25. 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.
  26. 26.  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 )
  27. 27.  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.
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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.
  32. 32.  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
  33. 33. 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
  34. 34. ROUTES OF FEEDING
  35. 35. SELECTION OF FORMULA Functional capacity of gut Intubations site Patients metabolic status Cost Convenience considerations
  36. 36. COMPARISION BETWEEN PRODUCTSRESOURCE HIGH PROTEIN ACTIBASE NEUTRAL(100gms) (100gms)ENE 374kcals 338 kcalsPRO 41gms 45 gmsNa 500mg 360mgK 800mg 546mgCost Rs 215 Rs 240
  37. 37. Case Studies
  38. 38. 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
  39. 39. HT: 151CMSWEIGHT: 60KGSBMI:26KG/M2GRADE I OBESEENERGY: 30X46(IBW)=1380+STRESS FACTOR=1450KCALSPROTEINS: 1.5 GM/KG IBW=69GMSCHO:65%=227 GMSFAT:22%=34 GMS
  40. 40. HOSPITAL DIET DAY1(1/6) DAY2(2/6) DAY3(3/6)ENERGY 432 906 1157PROT 7.2 27.1 48.2FATS 9 20.7 21.6CHO 75 128 125Na 134 128 143 GIVEN 1GM SALTREMARKS SEVERELY NAUSEA INTAKE NAUSEATED REDUCED IMPROVED WITH FEELING
  41. 41. PT DISCHARGED ON 4/6/10ON RT FEEDS+ORAL LIQUIDS ON ACTIBASE NEUTRALWEIGHT MAINTAINED SO CONTINUED WITH SAME DIET.
  42. 42. MRS.SINGH 40/ F CA LATERAL BORDER OF TONGUE—T3NOMO SYMP: PAIN WHILE EATING FOOD ADMITTED TO TMH 27/4/10BIOCHEMICAL NORMAL EXCEPT FOR FLUCTUATING Na OPERATED ON 31/5/10 RT FEEDS STARTED ON 1/6/10
  43. 43. HT: 161 CMSWEIGHT:82KGBMI:31.66KG/M2GRADE II OBESEENERGY:25KCALS/KG= 1400PROTEINS: 1.3GM/KG= 73 GMSCHO 65%= 228GMSFATS 15%= 23 GMS
  44. 44. 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
  45. 45.  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
  46. 46. 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.
  47. 47. Questions & AnswersTo submit a question for Mrs.Anjali Nair,please message Akash Srivastava via the chat
  48. 48. Closing Remarks

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