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I Understanding the Disease and Pathology

1. What type of cancer is lymphoma?

Lymphoma is a type or cancer involving the lymphatic system. It is a

group of cancers that affect the cells that are involved with immunity.
Lymphoma is a malignant transformation of either lymphocytes B or T
cells. Lymphocytes are cells involved in immunity. As the disease
spreads, the cells multiply and invade surrounding tissues. This in turn
forms a tumor. Lymphoma travels throughout the lymph system and can
invade other organs. This is called extrandal disease.

The two types of categories are Hodgkin lymphoma and all other
lymphomas(non-hodgkins) spreads through the B lymphocytes and non-
hodgkins in either B or T cells. Lymphoma is the most common type of
blood cancer in the US. It is the 6th most prevalent cancer in the US with
about 54,000 new cases each year. 24,000 people die from non-hodgkins
each year. Generally the risk of NHL increases with advancing age.

There are no known causes of nonhodgkins, however diseases that

compromise the immune system such as HIV, Hepatitis B or Hepatitis C
weaken the immune system leaving it vulnerable to nonhodgkins.
Exposure to chemicals such as pestisides and herbicides are also thought
to contribute. Black hair dye used over 20 years is suspected as well.

2. Which symptoms found in Ms. Mitchell’s diagnosis history and

physical are consistent with the classic symptoms of

Her lab values indicate anemia. This is consistent with Lymphoma. Her
WBC count is high, which is also a sign of Lymphoma. Her physical
indicated she had been experiencing night sweats and recuring fever.
This is a classic symptom of lymphoma. She is also pale and tired
exhibiting flu like symptoms for an extended period. Her weight has
dropped with no effort on her part and she has no appetite.

3. Ms. Mitchell’s diagnosis stated that she had Stage II

lymphoma. What does Stage II mean, and how does her
physical examination support this?
Ms. Mitchell’s stage II lymphoma is more advanced than some, but is not
at the most advanced stage. The most advanced stage is stage IV. The
stage assigned indicates the size and level of invasion of nearby
structures. Her stage II diagnosis indicates she has a tumor on her lung.
The physical showed evidence of this with shallow respirations and
dullness present to percussion.

4. Generally, patients with cancer are treated with surgery,

radiation, chemotherapy, biological therarpy, bone marrow
transplant etc What medical plan indicates that she will have
both chemotherapy and radiation therapy?

Chemotherapy works systemically which is ideal for lymphoma which is

systemic. Chemotherapy acts by interrupting different stages of cell
replication. It is most lethal to cells in constant proliferation. There are
different classifications for chemicals used in chemotherapy. They work
in different ways and are usually combined in treatment

Radiation pinpoints a target and works solely on that area. The tumor in
her chest is best tion. RT is delivered with electromagnetic rays and
charged particles. It destroys cancer cells by altering cellular and nuclear
material, especially DNA. The goal of RT is to destroy a specific target
without affecting the surrounding tissues.

5. Radiation and chemotherapy may also affect healthy tissues.

A. What other cells in the body may be affected by either or
both of these treatments?

Chemotherapy works on proliferating cells in the body, not resting.

Because most normal cells in the body are in resting a resting stage,
they are somewhat protected from the lethal chemotherapy. However,
cells that frequently divide are more susceptible such as red blood cells,
epithelial cells of the gastrointestinal tract, and hair line cells.

B. What symptoms may the patient experience as a result of

the destruction of these cells?

The destruction of epithelial cells in the GI tract may result in nausea,

diarrhea, early satiety and anorexia,dysgeusia, mucositis, constipation,
and general abdominal discomfort. Destruction of RBC’s may result in
anemia and destruction of hair cells will result in loss of hair.
8. For each symptom of treatment, describe the nutrition
therapy appropriate.

For GI disturbances, patient needs to be monitored for dehydration due

to the effects of diarrhea. A multivitamin <150% DRI may be beneficial
as nutrients may be depleted from tumors, cytokine effects, and
chemotherapy and radiation.

Most cancer patients who are being treated with chemotherapy and
radiation will experience nausea/vomiting. Care must be taken to avoid
noxious odors. Ways to do this is by cooking with a microwave,
opening windows when cooking, and avoid perfumes. The patient
should avoid eating large meals. To provide kcals and maintain
hydration, consumption of electrolyte-fortified nutritional fruit
beverages such as Resource should be encouraged. Anti-emetics
should be encouraged.

Early satiety is a common complaint. Small and nutrient dense foods

are encouraged. Raw vegetables and salad are discouraged.

Mucositis can be a painful side effect. Patients are encouraged to eat

only soft, non-fibrous, non-acidic foods. Hot foods and liquids should be
avoided. High-kcalorie, high-protein milkshakes may be useful if

Diarrhea should be managed by having patient drink small amounts of

fluid frequently to avoid dehydration. Large amounts of fructose should
be avoided.

Dysguesia can be managed by avoiding metal utensils. Meats are often

not tolerated. Protein needs must be monitored by incorporating other
high-protein foods into the diet. Peanut butter, cottage cheese, poultry,
and soy meat substitutes are good.

Anorexia is challenging. Small, frequent meals are encouraged. Eat

when hungry. Limit fluids at meal times, and take appetite stimulents.
E. Behavioral-Environmental Domain

24. How would you advise patient on adherence of cleansing “anti-

cancer” diet? What steps would you suggest for them as they
research on making appropriate decisions for care? Why may
cancer patients be vulnerable to nutrition and medical quackery?

The decision to use alternative or complementary methods is an important

one, and it is the decision of the patient. It is not in the scope of a licensed
RD to assist with such programs. I would urge the client to consider the side
effects she is experiencing already. Anything that would potentially cause
more distress would be discouraged. It is more important to get adequate
nutrition at this time.

The American Cancer Society has compiled the following guidelines and
information to help you think through the issues and make the most
informed and safest decision possible. She may want to discuss with her
oncologist as well. Some questions she should consider looking into for the
diet are;

• What claims are made for the treatment? Does it claim to cure cancer?

• Is it supposed to help your medical treatment work better or to relieve

symptoms or side effects?

• What are the credentials of those supporting the treatment? Are they
recognized experts in cancer treatment?

• Have scientific studies or clinical trials been done to find out whether this
treatment works?

Cancer patients are more susceptible to quackery as the conventional

treatments have so many side effects. The treatment often makes them
sicker than the cancer.

IV. Nutrition diagnosis

25. Select two PES statements that you have written, establish an
ideal goal (based on signs and symptoms) and an appropriate
intervention (based on the etiology)

Inadequate iron intake(P) related to low iron food choices (E) as evidenced
by iron intake of 13mg and lowered Hct, Mgb, MCHC, and Ferritin lab values.


Inadequate energy intake (P) related to decreased appetite (E) as evidenced

by recent weight loss and energy intake meeting 40% of estimated

V. Nutrition Intervention

For each PES statements, establish an ideal goal (based on signs

and symptoms) and an appropriate intervention (based on the



Increase iron consumption to meet DRI of 18mg and increase Ferritin levels
to normal range of 20-120mg/ml. Educate and provide the patient with a
form of iron supplement to meet requirements.


Increase energy intake to recommended 1890 kcals to maintain current




Provide the patient with recommendations of daily sources of iron.

Incorporate plenty of iron-containing foods into the diet. Foods rich in iron
include red meat, seafood, poultry and eggs and are all heme sources. These
are recommended over non-heme sources. Plant based foods rich in iron
include iron-fortified cereals, breads and pastas, beans ,peas, raisins, nuts,
and seeds. The patient should focus on foods that are appealing and if at all
possible consume non-heme sources with vitamin C to maximize absorption.
Iron supplementation will be needed to ensure that iron intake is adequate to
maintain recommended serum levels due to anorexia and to prevent further
loss due to treatment. Iron deficient females are prescribed 15mg-60mg iron
per day. Ferrous sulfate and ferrous gluconate are better absorbed than
other chelates. Weekly high doses are better tolerated than lower daily
doses. The patient will need to be monitored to ensure adequate levels. If
diet and supplementation do not increase iron levels a intramuscular
injection may be called for.


Provide feedback on ways to increase appetite to avoid Cachexia. Instruct

patient to eat small, frequent meals at times when appetite is normal. Limit
fluid with meals, keep favorite foods with her, avoid noxious odors, and
include mild exercise if physician approved. Pharmacologic interventions
may be considered. Megestrol acetate and corticoseteroids are commonly
used. The patient is going to be taking prednisone as part of her treatment
plan. Prednisone is also an appetite stimulant. Other stimulants include
growth hormone, insulin-like growth factor, and testosterone analogues.
Increase energy intake to maintain weight of 54kg.

VI. Nutrition monitoring and evaluation

27. How would you follow up or evaluate the interventions you have
determined? For iron deficient anemia, another set of labs would be
needed to determine if the mild case of anemia has been resolved. If the
values for HGB, HCT, and HCMC are within normal ranges then the
intervention has worked. If the patient’s protein levels and weight remain
close to normal limits and cachexia is avoided, the intervention has worked.
Follow-up counseling sessions may be needed as treatment commences.

28. What kinds of nutrition education would you provide Denise?

When would it be appropriate to provide this education? What
factors might interfere with patient’s reception of nutrition

Denise is only beginning her treatment. She has not had to endure the side
effects of the treatment. These side effects include nausea, vomiting, satiety,
dysguesia, diarrhea, mucositis, xerostoma, constipation, weight loss, and
anemia. In addition to the side effects of her treatment, Denise is
experiencing abnormalities in macronutrient metabolism as a result of her
illness. In malignancy, several biochemical changes occur. Denise has
already experienced anorexia and weight loss before her treatment. It is
essential that she be made aware of the nutritional implications and risk of
cachexia. Ideally, this should be discussed prior to her first treatment.

Denise may be unreceptive to nutritional education if she is already

experiencing side effects from the treatment. Cancer patients often
experience depression and anxiety. She may not be receptive to any
additional changes at times in the course of her treatment.

29. What is a low-microbial diet? Why may Denise need to follow

food safety guidelines during immunosuppression? Patients
undergoing cytotoxic chemotherapy may develop severe neutropenia,as
defined by an absolute neutrophil count of less than 500/microliter. These
patients should be advised to maintain a low microbial diet for the expected
duration of neutropenia. Microbes such as bacteria and fungi are found in
foods and liquids. In most processed foods (e.g. canned foods, cooked foods)
microbes have been eliminated, reducing the risk of food-borne illness.
These “low microbial” foods are safer to eat than raw, fresh or unprocessed
foods (e.g. untreated fresh fruits and vegetables, raw or undercooked meats
or tap water) which – if not handled properly – have a greater potential for
causing infection and food-borne illness. Items to be avoided are self-serve
type beverages, including the icefrom an ice machine, in the cafeteria or a
restaurant, self-serve foods that could be potentially touched with
barehands, no cold delicatessen meats or cheeses are allowed unless heated
to steaming hot. Uneaten portions of fresh cooked foods should be promptly
refrigerated, and may only be eaten/reheated within 24-48 hours of

30. What is glutamine? What is the rationale for its use? Glutamine
is the most abundant amino acid in the bloodstream. Under extreme physical
stress the demand for glutamine exceeds the body's ability to make it. Most
glutamine in the body is stored in muscles followed by the lungs, where
much of the glutamine is manufactured. Glutamine is important for removing
excess ammonia. Several types of important immune cells rely on glutamine
for energy. Without glutamine, the immune system would not function
appropriately. Glutamine also appears to be necessary for normal brain
function and digestion.
Adequate amounts of glutamine are generally obtained through diet alone
because the body is also able to make glutamine on its own. Certain medical
conditions, including injuries, surgery, infections, and prolonged stress, can
deplete glutamine levels, however. In these cases, glutamine
supplementation may be helpful.

Glutamine is low in many cancer patients. It is though that glutamine

supplementation is beneficial for malnourished cancer patients undergoing
radiation and chemotherapy treatments. It is also used to protect the lining
of the small and large intestines which can be damaged by cancer