Malnutrition is common in cancer patients, affecting 60% of general cancer patients and up to 80% of patients with advanced cancers. Nutrition is negatively impacted by the cancer itself as well as side effects of cancer treatments like chemotherapy and radiotherapy. Parenteral or enteral nutrition may be needed if oral intake is insufficient. Nutrition therapy aims to maintain nutritional status, quality of life, treatment efficacy and reduce complications by addressing issues like appetite loss, nausea, taste changes and providing adequate calories and protein. Specific diets high in calories, fat and protein may help minimize tumor growth while feeding the patient. Supplements like omega-3 fatty acids, glutamine and other agents may also help reduce cachexia and support the body's

1. ROLE OF NUTRITION
IN RADIOTHERAPY
By
Dr. Ayush Garg, PG JR II
Moderator: Dr. Pavan Kumar

2. Malnutrition In Cancer Patients
• Reduction of food intake is a common manifestation of
cancer, presenting in 15-40% of patients and up to
80% of those with advanced malignancy
• More than 80% of all patients suffers from: Anorexia,
Nausea, and Emesis
• 85% of patients with pancreatic or stomach cancer had
lost weight at the time of diagnosis, and in 30% the
loss was severe.
• Autopsies have shown that malnutrition is one of the
most common causes of death, accounting for 10–20%

3. Incidence Of Malnutrition In
Different Tumor Sites
Tumor Site % Malnutrition
General Cancer Patients 60%
Oesophagus 79%
Breast 9%
Gastric 83%
Lung (small cell) 50%
Head and Neck 72%
(Adapted from Freeman 2004)

4. Frequency/severity of weight loss
associated with cancer

5. Nutrition Problems During
Radiotherapy
Dept. Digestive Diseases and
Clinical Nutrition
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
74
60
82 82
65
88 93
26
40
18 18
35
12 7
Present Absent

6. Nutrition Problems During
Chemotherapy
Dept. Digestive Diseases and
Clinical Nutrition
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
70 74
82
74
55
72 70
30 26
18
26
45
28 30
Present Absent

7. Prevention of
Malnutrition
through Nutrition
Malnutrition
with
progressive
tumor growth
Malnutrition as a
risk factor for
anticancer
therapy
Surgery,
Radiotherapy,
Chemotherapy
Malnutrition as
consequence/
complication of
therapies
Mucositis,
infections
Malnutrition in
advanced
incurable cancer
Terminal care
Nutritional Issues Throughout
The Course Of Cancer Illness

8. Causes Of Anorexia In Cancer
Patients
• Pain,
• Nausea, vomiting
• Abnormal taste,
• Abnormal smell,
• Loss appetite,
• Depression,
• Weakness,
• GI disturbance/ Obstruction

9. Cancer Cachexia
• Debilitating and life-threatening condition, characterized by
negative protein and energy balance
• Present in 50% of cancer patients, more prevalent in GI and
Lung Cancer
• Characterized by:
• Progressive weight loss
• Anorexia
• Asthenia
• Metabolic alterations
• Depletion in lipid stores
• Severe loss of skeletal muscle protein

11. Cancer Cachexia Starvation
Body weight
Lean body mass
Body fat
Total energy expenditure
Resting energy expenditure
Protein degradation
Cancer Cachexia
Vs
Simple Starvation

12. Cancer Cachexia Causes And
Effects
Acute Phase
Response
( CRP)
Appetite
depression
Cachexia with weight loss, inflammation, fat depletion, muscle wasting,
Poor clinical outcomes
Body’s Immune response to tumor
Cytokine production elicits local
and systemic inflammatory response
 Proteolysis- inducing
Factor (PIF)
 Food Intake Loss of
Lean Body Mass
Alteration in
Macronutrient
Metabolism
 Resting
Metabolic
Rate
Release of tumor factors

13. Consequences of Malnutrition
• Impaired immunological function
• lymphocyte count and function ↓,
• macrophage / B- ,T-, and NK cell function ↓,
• chemotaxis / migration of neutrophils ↓
• Increased complications
• Chemotherapy/Radiotherapy
induced toxicity ↑
REF: Concise Manual of Hematology and Oncology; D.P.Berger, M.Engelhardt, H.Henb, R.Mertelsmann; Springer-Verlag Berlin
Heidelberg 2008
Duration
Of
Hospital
Stay ↑
Costs
↑
Quality
Of Life
↓
Mortality
↑

14. Chemotherapy
• Chemotherapy can result in the following nutritional
problems:
nausea, anorexia, vomiting, diarrhoea, constipation,
taste changes, mucositis, internal ulceration,
malabsorption
• Multiple combinations of cytotoxic drugs can increase
side effects
• Normal and malignant cells can be damaged
• Intake often decreases with each cycle of
chemotherapy and food aversions occur in up to 74%
of patients

15. Radiotherapy
• Nutritional problems may arise depending on:
– Area exposed
– Duration and total radiation dose
• Radiotherapy can result in:
– burning sensation to the throat, loss of appetite, taste
alterations, sore mouth, dry mouth, damage or loss of teeth,
abdominal cramping, nausea, fatigue, malabsorption or
diarrhoea
• More than 10% of patients lose over 10% of their usual weight
when radiotherapy continues for a period of 6-8 weeks

16. Emotional and social effects
• Loss of employment - loss of role in life, loss of income
• Anxiety - about diagnosis, about treatment, possible
recurrence
• Body Image - weight loss, loss of hair
• Fear - about the future, about dying, about their family
• Depression
• All of these can have an impact on nutrition even before
treatment begins.

17. • Grading of Malnutrition:
Body weight loss
< 10% wt. loss :- Mild Malnutrition
10 – 20% wt. loss :- Moderate Malnutrition
> 30% wt. loss :- Severe Malnutrition
Subjective global assessment, group C
• Using dietary history or nutrition protocols.
• Starvation = daily oral energy intake < 500 kcal
• Insufficient energy intake = daily oral energy intake <
60% of required intake
Diagnosis of Malnutrition in
Cancer Patients

19. Objectives of Nutrition Therapy
o Maintenance / improvement of nutritional status
o Maintenance / improvement of subjective quality of life
o Increase in treatment efficacy
o Reduction of treatment related side effects and complications
o Preserve lean body mass
o Maintain strength and energy
o Protect immune function, decreasing the risk of infection
o Aid in recovery and healing
o Improvement of prognosis, prevention of treatment breaks or
delays

20. Strategies in Nutrition Therapy
o Appetite Stimulants
o Drugs which are capable of inhibiting the synthesis and/or release
of cytokines
E.g. COX inhibitors, Non-steroidal anti-inflammatory drugs,
pentoxifylline, thalidomide, melatonin, statins, ACE inhibitors
o Agents which promote skeletal muscle anabolism
e.g. Anabolic androgenic steroid
Metabolic intervention:
To optimize patient’s nutritional status but minimize tumor
nourishment
Substrate intervention:
To modulate effects of mediators & control inflammatory
response

21. Metabolic Intervention
• High caloric density feeding
• Improve lean body mass
• Low carbohydrate content
• “Starve the tumor, feed the patient”
• Suggested composition:
• High energy >1.2 – 1.5 kcal /ml
• High fat 45 - 50 % and low CHO
• High protein 18 - 20 %
(50% - Fat, 20% - Protein, 30% - CHO)

22. Specific Metabolic Changes In The
Tumor Host
• Tumor hosts reveal abnormalities of:
• Lipid metabolism
• Increased lipolysis
• Increased oxidation of fatty acids
• Carbohydrate metabolism
• Increased glucose turnover
• Impaired peripheral glucose disposal
• Caused by insulin resistance
• Protein degradation , nitrogen depletion,
muscle protein synthesis 

23. Calculation of required Nutrition
(per Kg of normal weight / ideal weight and day)

24. Indications for Parenteral
Nutrition in Oncology
• Individual need depending on:
• Nutritional status
• Co-morbidities (concomitant diseases)
• Type of anti-neoplastic treatment
• Patient’s performance status
• Parenteral nutrition is indicated when:
• Oral / enteral nutrition < 500 Kcal/d expected for at least
5 days
• Oral / enteral nutrition < 60% of the calculated
nutritional needs expected for at least 10 days

25. ASPEN Guidelines: Oncology
Parenteral & Enteral nutrition 2009
• Omega 3 FA supplementation may help in
• Decrease rate of weight loss
• Maintain lean body mass
• Improve appetite
• Improve quality of life
• Inhibit progress of cachexia in cancer
• Inhibit Proteolysis-inducing factor
• Decrease fatigue
• Cytotoxic to variety of tumor cells
• May reduce adverse effects of chemotherapy

26. Glutamine: Beneficial Effects In
Cancer
• Supports immune, muscle, gut function
• Enhances activity of NK lymphocytes
• Improves tolerence to adjuvant treatment
• Inhibits tumor growth, enhances response
• Corrects host depletion, improves nitrogen retention, &
reverses impairement of intestinal integrity associated with
cancer.
• Reduces 6-months mortality
• Shortens hospital stay

27. Can Nutrition Treatment Maintain Or Improve
Nutritional Status In Cancer Patients?
Nutrition therapy in oncology is required to
improve prognosis and reduce the cancer-
related decline in nutritional status.
In surgical oncology, it reduces the
postoperative symptoms, lessens the
hospital stay and improved tolerance to
treatments.
In palliative care, the nutritional therapy
focuses on symptoms associated with weight
loss, thus improving the quality of life.

28. Summary
• Early focused assessment - “proactive”
• Clear and realistic definition of goals
• Manipulation of nutrient intake
• The overall nutritional goal is to optimally feed the host
and to minimise any nourishment of tumour tissue
Integrate Nutrition
into the overall treatment plan

29. Thanks