mainly focusing on critically ill patient who are getting treatment in oncology and as well as palliative medicine .

1. NUTRITIONAL
SUPPORT IN CANCER
PATIENT
Presented by
Dr.S.M. Nazmul Alam
Resident, phase B
Department of oncology
BSMMU

2. Introduction
• Nutritional alteration is the major problem in cancer patients.
• >40 % patients develop sign of malnutrion during treatment
• 20% of oncology patients die from nutritional complications
rather than from their primary diagnosis.

3. Introduction
• Leads to
– prolonged hospitalization
– Increased degree of treatment-related toxicity
– Decrease Response to cancer treatment
– Decreased quality of life & worse over all prognosis.

5. Cancer Cachexia
• Nearly two-thirds of patients with cancer develop cancer
cachexia due to several metabolic effect of cancer cells.
• Different cytokines(TNF,IL1) release from host cell in
response to tumour and side effect of therapies.
• These can lead to unintentional weight loss and failure to
preserve muscle and fat tissue.

8. Metabolic Alteration
• Micronutrient Deficiencies
– Reduced Levels of
• Vit A in colorectal & oesophageal 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
A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005

9. Goal of Nutritional Support
 Prior, during & after anticancer treatment maintain &/or
improve nutritional status,function and outcome.
 Done by
 Prevent & treating malnutrition
 Preventing or reversing loss of weight.
 Minimizing adverse effect of anti tumour therapy
 Improving treatment efficacy & quality of life.

10. Organization of Nutrition Support
Screen
Recognise
Treat
Oral Enteral Parenteral
Monitor & Review

11. Screening for nutritional risk
• Should be mandatory
• Validated screening tools
1.Patient –Generated Subjective Global Assessment(PG-SGA)
2.Malutrtion Universal Screening Tool(MUST)
3.Nutritional Risk Screening(NRS)

13. Nutritional assessment
• Rate of weight change is the most useful parameter.
• An unintentional weight loss of
• >2% per week
• >5% per month
• >7.4% in 3 months or
• >10% in 6 months is associated with severe risk of
malnutrition.

14. Nutritional Requirements
• Estimates of Energy Requirments
patient/condition kilocalories
Acutely ill;obese 21kcl/kg
Cancer 25-30 kcl/kg
Hypermetabolism,malabsor
btion
35 kcl/kg
Stem cell transplant 30-35 kcl/kg

15. Nutritional Support
• Recommended protein intake for adults
Disease State Grams of protein /KG BW
Cancer 1-1.2
Cancer cachexia 1.2 -1.5
Haematopoietic stem cell transplant 1.5
Renal disease(GFR 26-55 ml/min) 0.8
Liver disease 1 – 1.5

16. Oral Nutritional Support
• Always the first method of choice.
• Energy intake varying between 20 -35Kcal/kg BW/day.
Patient characteristics Required energy
Mimimal hypermetabolism 20-25 Kcal/kg BW
Moderate hypermetabolism 25-30 Kcal/kg BW
Severe hypermetabolism 30-35 Kcal/kg BW

17. Oral Nutritional Support
• High energy & high protein diet provide adequate macro and
micronutrient.
• Goal >75% daily energy requiment
• Favorite food should offered to tempt the appetite
• Provide small,frequent feeding upto 6 times a day
• Treatment of Cancer related anorexia treated with progestrin
& corticosteriods,metoclopramide .

18. Indication for Enteral nutrition
 Functional GI tract but the patient is unable to eat orally for
more than 7 days.
 <60% of estimated caloric requirments >10 days
 Obstructing head & neck or oesophageal cancer interferes
swallowing or severe local mucositis

19. Enteral feeding
“If the gut works – use it”
• Nasogastric (NG)
• Nasojejunal (NJ)
• Percutaneous Endoscopic Gastrostomy (PEG)
• Percutaneous Endoscopic Jejunostomy (PEJ)
• Radiologically Inserted Gastrostomy (RIG)
• Surgical Gastrostomy
• Surgical Jejunostomy

21. Complicationof Enteral Feeding
• Diarrhoea
• Abdominal cramps
• High osmotic load
• PEG related tube blockage,dislodgement,local site infection.

22. Definition of TPN
• Provision of all nutritional requirements by the means
of intravenous
• And without the use of GI tract

23. Indications for Parenteral Nutrition
Short term:
• Severe pancreatitis
• Mucositis post-chemo with intolerance of enteral nutrition
• Prolonged nil by mouth (NBM) post major excisional surgery
• High output or enterocutaneous fistula
• Intractable vomiting
• Malnourished patient unable to establish enteral nutrition

24. Indications for Parenteral Nutrition
Long term:
• Radiation enteritis
• Subacute/chronic radiation enteropathy
• Extreme short bowel syndrome
• Chronic malabsorption
• Motility disorders

25. Routes of TPN
• Central (CPN)
– Long term >3 weeks
• Peripheral (PPN)
– Short term <3 weeks
– IV cannula

27. Calculation
• Step 1 - Non protein Calories Calculation
• Step 2 - Carbohydrate : Fat Ratio
• Step 3 - Protein in Grams(1.2 -1.5g/kg/day)
• Step 4 - Carbohydrate in Grams(400 calories/day or 100
g/day)
• Step 5 - Fat In Grams (Initial: 20% to 40 % of total
calories;maximum: 60% of total calories or 2.5 g/kg/day)

28. Calculation
• Step 6 - Water Requirement(Water-1500 ml/m2 ,35ml/kg or
1ml/kcal)
• Step 7 - Micronutrients
• Step 8 - Decide
– The Route
– Administrative System
– Near Match Commercial Preparation
• PeriKabiven
• Kabiven

29. Electrolytes (daily requirements for TPN):
• Na: 80-100 mEq
• K: 60-150 mEq
• Mg: 8-12 mEq (5 -10 ml MgSo4 20%)
• Ca: 2.5-5 mEq (10-20 ml Ca Gluconate 10%)
• P04: 15-30 mEq

30. • Vitamins:
A ,D, E, Water soluble vitamins.
• Trace Elements:
Zn,Cu, mg ,Cr , Mn.

31. Example
• 50 kg
• Energy – 50x30 = 1500kcal
• Water-1500 ml/m2 35ml/kg or 1ml/kcal
• Carb : Fat = 3:2
– Carb = 900kcal,
• 1g dextrose =3.4 kcal
– fat= 600kcal
• Protein:
– 1.5 X 50 = 75 g

32. Example
• CHO
– 1 g dextrose IV = 3.4 kcal
– 25% nutridex 500 ml = 125 g dextroseMinimum
• Fat
– 20% - 1ml = 2kcal
– 10% - 1ml = 1.1 kcal

33. Monitoring for TPN
• Baseline: Weight, Na+, K+, BUN, Cr, Ca++, P, Mg, CBC, PT,
INR, triglyderide, LFT,Glucose, Albumin,transferrin
• Daily: Wt, V/S, I-O, Na, K, BUN, Cr, Glu, Sign/Symptoms of
infection
• 2-3 times a week: CBC, Ca, P, Mg
• Weekly: Alb, LFT, INR, Nitrogen Balance.

34. Complications of TPN
• Refeeding syndrome
• Hypertriglyceridemia
• Parenteral nutrition associated liver disease
• Parenteral nutrition associated cholestasis

35. THANK YOU