CANCER AND NUTRITION (Case V)

Group 5:
Bersaba, IC I.
Bognot, Atmavriana Angela R.
Cababa Kanji C.
Camalig Emely B.

March 11, 2020

OBJECTIVES:

1. Discuss the Basic Pathology of Cancer and its correlation to nutrition.

2. Discuss the dietary and nutritional factors of specific cancers.
3. Describe the nutrition implications of cancer therapies.
4. Discuss the nutritional suggestions for symptom management in cancer therapy.
5. Enumerate the methods of nutrition care.

CANCER- it is a large group of diseases characterized by the growth of abnormal cells beyond
their usual boundaries that can invade adjoining parts of the bodies and spread to the other
organs.
-it can affect any part of the body, and it has many anatomic and molecular subtypes that each
of them required specific management strategies.
-is one of the four non-communicable diseases or life-style related diseases: CARDIOVASCULAR
DISEASES, DIABETES MELLITUS, CHRONIC RESPIRATORY DISEASES.

SIGNIFICANCE OF MALNUTRITION IN CANCER:

• associated with longer hospitalization
• reduced responses to anti-cancer therapies
• Increased complications from anti-cancer therapies.
o Worsened functional performances status.
o Decreased survival.

• Involuntary weight loss >10% (if rapid <6 months), becomes an independent risk factor for
survival.
-On a physical level, malnutrition can cause a loss of muscle and fat mass, reduced respiratory
muscle and cardiac function, and atrophy of visceral organs. It has been shown that an
unintentional 15% loss of body weight causes steep reductions in muscle strength and
respiratory function, while a 23% loss of body weight is associated with a 70% decrease in
physical fitness, 30% decrease in muscle strength and a 30% rise in depression. At a
psychological level, malnutrition is associated with fatigue and apathy, which in turn delays
recovery, exacerbates anorexia and increases convalescence time.
MALIGNANCIES INDUCED ADVERSE CHANGES IN NUTRITION STATUS:

✓ Multifactorial
✓ Usually assessed through unexplained and involuntary weight loss.

1.Loss of Appetite

❖ The exact cause of loss of appetite is unknown, but it may due to the cancer itself, side
effects of cancer treatment (e.g nausea, fatigue), or to feeling upset.
❖ Emerging evidence from some studies suggests that omega-3 fatty acids may have specific
benefits for cancer patients, such as reducing cachexia, improving quality of life, and perhaps
enhancing the effects of some forms of treatment. However, these findings are not conclusive,
and more research is needed. Foods that are rich in omega-3 fatty acids (e.g. fish, walnuts) are
associated with a lower risk for cardiovascular diseases and a lower overall mortality rate, and
are therefore recommended for cancer patients.

Some strategies to manage appetite loss:

1. Small meals eaten more often may be easier to manage. Try to eat every 2–3 hours during
the day. Serve small food portions.
2. Drink after and between meals. Avoid drinking fluids half an hour before meals and during
mealtimes – they tend to fill you up, so that you eat less.
3. Try liquid or powdered meal replacements, a useful option if you find it very difficult to eat.
4. Choosing a variety of different foods may help increase your appetite. For example, you may
choose whole fresh fruit, mixing fruit into a milkshake, or canned fruit.

2. Impaired Nutrient Intake

❖ Malnutrition seen in hospitalized patients is often a combination of cachexia (disease-

related) and malnutrition (inadequate consumption of nutrients) as opposed to malnutrition
alone. Malnutrition adopted refers to the complex interplay between underlying disease,
disease-related metabolic alterations and the reduced availability of nutrients (because of
reduced intake, impaired absorption and/or increased losses or a combination of these) which
is a combination of cachexia and malnutrition.
❖ Malnutrition has been shown to cause impairment at a cellular, physical and psychological
level. This impairment is dependent on many factors, including the patient’s age, gender, type
and duration of illness, and current nutritional intake. On a cellular level, malnutrition impairs
the body’s ability to mount an effective immune response in the face of infection, often making
infection harder to detect and treat. It also increases the risk of pressure ulcers, delays wound
healing, increases infection risk, decreases nutrient intestinal absorption, alters
thermoregulation and compromises renal function.
3. Metabolic Alterations
❖ Since tumor tissue takes up glucose, the decreased disappearance of glucose observed in the
tolerance test must be sought in metabolic alterations in the host tissues associated with
cancer development.

ALTERATIONS OF METABOLISM IN CANCER:

• Carbohydrates, Proteins, Lipids, Minerals, Vitamins, Hormones.

Fig. 1:The scheme depicts the way we envision multifactorial cancer cachexia in 2015, involving
reciprocal compounding interactions between the tumor and the organism, which result in
inflammatory and metabolic changes distant from the pathological sites of tumor growth.

Carbohydrate intolerance in cancer patients has long been noted (Rohdenburg et al. 1919).
While fasting blood sugar concentration between control and cancer groups did not differ
significantly, intravenous glucose tolerance tests showed significantly decreased disappearance
of glucose in cancer patients. Since tumor tissue takes up glucose, the decreased disappearance
of glucose observed in the tolerance test must be sought in metabolic alterations in the host
tissues associated with cancer development. Either increased hepatic glucose production or a
decrease in peripheral utilization could account for the reduced glucose tolerance observed in
cancer patients. Despite decreased hepatic glycogen stores, endogenous glucose production is
increased in cachectic patients due to increased hepatic glucose recycling via lactate, a
phenomenon termed the Cori cycle.

Cancer and Changes of Taste and Appetite

 - Proinflammatory cytokines and neuropeptides contribute to diminished appetite with
cancer, up to 50% of CA patients experience unpleasant alterations of taste and smell.
- Chemotherapheutic agents have been linked to changes in taste (cisplatin, carboplatin,
cyclophosphamide, doxuribicin, 5-fluorouracil, levamisole and methotrexate). Delivery
of nutrition can be impaired depending on types of CA.

Importance of Nutrition in the Cancer Patient

• Diets is the key to successful treatment of CA.

• Providing the CA patient with proper diet as important as the cancer treatments.
Nutrition requirements must be created depending on type of cancer involved

Malnutrition

• Results from taking unbalanced diet in which certain nutrients are taken in excess,
lacking, or in the wrong proportions.
• Common problem in cancer patients often coexisting with significant weight loss
(loss >10% of body weight in 6 months) -> Increase morbidity & mortality, decrease
quality of life.
Most closely assiciated with cancers of GIT and cancers in the head and neck.
Cachexia
• Progressive wasting syndrome evidenced by:
-Weakness
-Marked and progressive loss of body weight, fat, and muscle.
-Immediate cause of death in 20-40% of CA patients.
- Due to cytokines with direct catabolic effect (TNF-a, IL-1, IL-6, INF-y) altered fat,
protein,carbohydrate metabolism

Goals of Nutritional Therapy:

• Prevent or reverse nutrient deficiency

• Preserve lean body mass
• Help patient better tolerate the treatment
• Maintain strength and energy
• Protect immune function-> decreasing risk of infection
• Aid in recovery and healing and maximize quality of life

1.) Head and Neck Cancer:

• 3 % of adult malignancies in adult (US)

• Frequent Sites: Oral cavity, oropharynx, larynx
• Most occur in >50 years old
• 90% are squamous cell carcinoma
• 52%: 5 year survival rate
-Tumor obstruction of food passage leads to significant weight loss and malnutrition
Risk Factors

•Chronic alcohol intake → Malnutrition

•Smoking
•Sun exposure
•Occupational carcinogens (nickel, chromium)

Effects of Treatment

•Radiation - Mucositis, loss of taste and xerostomia

•Surgery- Difficulty in chewing and swallowing, risk of aspiration
•Chemotherapy - Anorexia, alterations in taste, N/V, early satiety, diarrhea and constipation

Nutritional Support
a.) Surgery
•Prophylactic enteral tube placement
•Enteral tube feeding immediately post-op
•Percutaneous endoscopic gastrostomies for tube feeding
•Tip of tube is placed in the small bowel and nutrients are supplied via slow drip if there is a risk
of chronic aspiration

b) Degree of Dysphagia
Mild to moderate

•Foods with pleasant aroma

•Foods with high caloric content

Significant
•Endoscopic gastrotomy tubes (feeding is 3-4x a day)

2.)Esophageal Cancer
- Most common: squamous cell carcinoma
•Occurs in the upper 2/3
•Tobacco and alcohol use
•Most prevalent in USA is adenocarcinoma
•GERD
•Barret’s esophagus
- 5 year survival: 11%
Risk Factors
•Chronic alcohol intake → Malnutrition
•Smoking
Clinical Manifestations
•Progressive dysphagia (present in 90%), Malnutrition, Significant weight loss, Chest pain
(mediastinal spread), Odynophagia, Pulmonary aspiration, Hoarseness, Hypercalcemia,
Infrequent bleeding.
Effects of Treatment
•Surgery- Complications (anastomotic leak, stricture, dysmotility, early satiety, regurgitation,
vomiting, diarrhea and steatorrhea)
•Radiation - Esophagitis
•Chemotherapy- Systemic effects (anorexia, alterations in taste, nausea, vomiting, early satiety,
diarrhea and constipation)
Basic Principles of Nutritional Support
•Enteral nutrition is advocated- distal GIT is functional; absence of contraindications.
•Mild dysphagia- Well-planned meals and liquid formulas.
•Moderate-severe dysphagia- Special oral or enteral feedings.
•Following resumption of oral intake- Frequent small meals; High carbohydrate and Adequate
protein and fats.
•In the presence of post-op strictures- Tube-fed liquid formulas.

3.)Gastric Cancer
- Most common histologic type is adenocarcinoma
Risk factors :
•Diet of processed food high in preservatives and nitrosamines
Clinical manifestation
•Weight loss, Anorexia, Abdominal pain, Weakness
•5 year survival rate in USA
•Stage 1: 43%
•Stage 4: 20%
Effects of Treatment
-Surgery: Early satiety leading to weight loss, Dumping Syndrome, Fat malabsorption (Vitamin
A,D,E,K deficiency), Iron Deficiency, Calcium Deficiency, Pernicious anemia (due to low gastric
acidity, intrinsic factor and R protein).
Basic Principles of Nutritional Support
•Frequent small meals (5-6x/day)
•Diet
-High protein, Calorie dense, Adequate fats, Low carbohydrate and Low insoluble fiber
•Vitamin Deficiency
-Iron (oral) + Vitamin supplementation

-Monthly injection of 100mcg of Vitamin B12

•Lactose intolerance- consume lactase treated milk and yogurt
•Nocturnal enteral feeding via jejunum if with weight loss and dumping syndrome despite anti-
dumping diet
4.) Pancreatic Cancer
- An aggressive disease with no longer curative cure
•Most common location: head of pancreas
•5% year survival is 20%
•Associated with: Chronic alcohol intake, Smoking, Chronic Pancreatitis, PUD, Diet high in fat
and meat.
Clinical manifestations
•Abdominal pain, Nausea and vomiting, bile insufficiency due to tumor mass effects, Weight
loss, Digestive enzyme deficiency with pancreatic duct obstruction,anorexia.
Nutritional support
•Adequate amount of pancreatic enzyme with all meals
•Sufficient amounts of calories and nutrients
•Oligosaccharides rather than long chain carbohydrates
•Frequent small meals
•If nutritional demands are not met, nocturnal enteral feeding through jejunostomy tube.
5.) Colorectal Cancer
Risk factors:
•High calorie diet low in fiber
•High in animal fat
•Little to no weight loss
•5 year survival is 61%
•Treatment: adjuvant 5FU chemotherapy
Nutritional Support
•Infusion of salt solution containing short chain fatty acids.

Effects of Chemotherapy
-The mechanism for chemotherapy associated toxicities affecting nutrition depend upon the drugs
administered and their site of location. Chemotherapeutic agents adversely affect dietary intake. Some
of these drugs produce:

• Anorexia - causes an abnormality in taste

• Mucosal ulceration - presenting as mucositis, cheilosis, glossitis, stomatitis
• Esophagitis - painfully interfere with ingestion of nutrients
• Nausea, vomiting, and diarrhea - caused by neoplastic drugs
• Constipation or adynamic ileus may also occur
• Sodium and water retention, nitrogen and calcium loss - caused by corticosteroids
-Chemotherapeutic agents may also have a pronounced damaging effects on bone marrow and
renal tubules as well as hepatic, cardiac, pulmonary, and nerve cells. Negative nitrogen balance
- nitrogen equilibrium before starting vinblastine, cisplatin, and bleomycin changed to negative
balance, protein turnover, synthesis and catabolism decreased by 23, 34, and 30% respectively.

Effects of Radiation Therapy

Central Nervous System
- Tumors of the nervous system can produce somnolence, lethargy, confusion and
irritability which can lead to decreased oral intake. Increased ICP can cause headache,
nausea, and vomiting
 Head and Neck
- Mucosal surfaces of the head and neck are sensitive to radiation, and treatment induced
reactions often result in severe nutritional sequelae. Symptoms which occur acutely may
include sore-throat, pain on swallowing, dry mouth and lack of appetite.
Thorax
- Radiation given to organs in the thorax such as lung, mediastinum, or esophagus may
acutely create dysphagia because of local irritation to the mucosa of the pharynx and
esophagus.
Abdomen-Pelvis
- Stomach can tolerate radiation remarkably well. Asymptomatic radiation gastritis
accompanied by hyperemia, edema, microscopic hemorrhages and exudation may occur
after approximately 2 weeks of radiation.