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Nutrition in Cancer Treatment

RD61
Nutrition in Cancer Treatment:
Continuum of Care
3rd Edition Revised April 2012

By Barbara L. Grant, RD, CSO, LD, MS

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Nutrition in Cancer Treatment

RD61
Nutrition in Cancer Treatment:
Continuum of Care
3rd Edition Revised April 2012

By Barbara L. Grant, RD, CSO, LD, MS

About the Author

About the Author: Barbara L. Grant, RD, CSO, LD, MS, is the outpatient registered dietitian at the
Saint Alphonsus Cancer Care Center in Boise and Caldwell, Idaho. With more than 30 years of
experience working with people diagnosed with cancer, she is a founding member and past chair of the
Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She was a
contributing editor to the Academys Clinical Guide to Oncology Nutrition and co-author of
Management of Nutrition Impact Symptoms in Cancer and Educational Handouts, among her many
patient and professional publications. Her education includes: BS, Washington State University; MS,
University of Idaho; Dietetic Internship, University of Minnesota Hospitals and Clinics.

Publisher's note: The first edition of Nutrition in Cancer Treatment was written by Paula Davis McCallum,
RD, LDN, MS. The second and third editions have been extensively revised, but they include some of her work.

EXPIRATION DATE: Students of all professions must submit this course for credit no later than October 31,
2015. Credit will not be awarded for this course after that date.

Course ID Code: RD61


This course approved for:
RD 12 CPEU
DTR 12 CPEU
CDM 12 Clock Hours

1989 2012 Nutrition Dimension/Gannett Education


No part of this course may be reproduced, duplicated or copied in any way without the written permission of the
copyright holder.

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How to Earn
Continuing Education Credit
1. Read the Learning Objectives. Read or watch the course material. Dont forget to review the
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We encourage health professionals to use material from this course in their practice. Please follow
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Credit the author, Nutrition Dimension/Gannett Education and any referenced source.
Course material may not be sold, published, or made part of any program for which a fee is
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Nutrition in Cancer Treatment

Accreditation Information
Gannett Education is a Continuing Professional Education (CPE) Accredited Provider
(#GD001) with the Commission on Dietetic Registration (CDR). This is a Level 3
course. Suggested CDR learning codes: 2000, 2070, 3000, 3020, 3060, 5000, 5150,
5010, 5030, 5390, 5410, 5430, 5440

Gannett Education is also accredited by the Florida Council of Dietetics and Nutrition (provider #
FBN 50-1489).

This course is approved for continuing education clock hours by the Certifying Board for Dietary
Managers (CBDM).

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Nutrition in Cancer Treatment

Table of Contents
5 Introduction

8 Chapter One: Understanding Cancer: Statistics, Diagnosis and Treatment


Cancer incidence Cancer survival Cancer prevention: 2015 challenge goals Signs and symptoms of
cancer Diagnostic methods Treatment goals and tumor response References

16 Chapter Two: Overview of Cancer and its Treatment


Oncology healthcare team Modalities of cancer therapy Categories of cancer Leukemia Lymphoma
Carcinoma Sarcoma Summary References Resources

32 Chapter Three: Cancer and Metabolic Response


Carbohydrate metabolism Protein metabolism Lipid metabolism Metabolic adaptation to starvation
Metabolic changes associated with cancer Cancer cachexia syndrome Summary Case study
References

40 Chapter Four: Nutrition Screening and Assessment and Nutrition Diagnosis in the
Oncology Setting
Standardized tools Scored PG-SGA: a comprehensive review Scoring the PG-SGA Other assessment
tools Oncology-related nutrition diagnoses Nutrition diagnosis: PES statements Summary
References

52 Chapter Five: Determining Nutrition Requirements for Adults with Cancer


Energy requirements Predictive equations for calculating energy requirements Protein requirements
Fluid requirements Micronutrient requirements Dietary supplementation Summary Case study
References

62 Chapter Six: Modalities of Cancer Treatment: Surgery, Radiation Therapy, Chemotherapy,


Biotherapy, Hormone Therapy and Antiangiogenic Agents
Medical nutrition therapy Surgery Nutritional implications: surgery Radiation therapy Nutritional
implications: radiation therapy Chemotherapy Nutritional implications: chemotherapy Hormone
therapy Biotherapy Management of nutrition-related side effects Summary Case studies
References

78 Chapter Seven: Hematopoietic Cell Transplantation


Hematopoietic cell transplants HCT process Nutritional implications of HCT Side effects and
complications of HCT Food safety and the neutropenic diet Summary Case study References

88 Chapter Eight: Surviving Cancer: Nutritional Care


What is a survivorship care plan? Recovery from treatment Nutrition counseling Physical activity
Lifestyle guidelines Chronic/late effects of treatment Summary References

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96 Chapter Nine: Advanced Cancer and Palliative Care


Palliative care and hospice delivery systems Prevalent symptoms Paraneoplastic syndromes Symptoms
and complications Nutrition support in advanced cancer As death becomes imminent Summary
Case study References

106 Chapter Ten: Nutrition Support Therapy


Nutrition support therapy Oral intake Enteral nutrition support Parenteral nutrition support NST
safety and ethical considerations Summary References

116 Chapter Eleven: Management of Cancer-Related Nutrition Impact Symptoms


Nutrition impact symptoms Alterations: taste and smell Anorexia Cancer cachexia syndrome and
weight loss Constipation Diarrhea Dysphagia Early satiety Fatigue Lactose intolerance
Malabsorption Mucositis and esophagitis Myelosuppression Nausea and vomiting Treatment of
nausea and vomiting Oral infections and candidiasis Pain Xerostomia and thick saliva Summary
References

130 Appendices
Appendix 1: Diet Guidelines for Gastrointestinal Diet 1 and Diet 2
Appendix 2: Diet Guidelines for Immunosuppressed Patients
Appendix 3: Nestle Mini Nutritional Assessment
Appendix 4: Scored Patient-Generated Subjective Global Assessment
Appendix 5: Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms
Appendix 6: Pharmacological Agents for the Management of Chemotherapy-induced Nausea and
Vomiting
Appendix 7: Pharmacological Agents for the Management of Anorexia and Cachexia

Appendix 8: Pharmacological Agents for the Management of Constipation


Appendix 9: Pharmacological Agents for the Management of Diarrhea
Appendix 10: Pharmacological Agents for the Management of Oral Mucositis and Esophagitis
Appendix 11: Pharmacological Agents for the Management of Pain
Appendix 12A, 12B and 12C: Nutritional Implications of Chemotherapy, Nutritional Implications of
Hormone Therapy and Nutritional Implications of Biotherapy and Antiangiogenic Agents
Appendix 13: Nutritional Implications of Surgical Oncology
Appendix 14: Complications of Enteral Feeding
Appendix 15: General Formulary Information for Oral and Enteral Nutritionals

172 Appendix 16/Glossary

182 Exam

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Learning Objectives
List the four most common types of cancer for men and for women in the United States
Describe the risk factors for three different types of cancer
Explain two types of metabolic alterations that can occur secondary to cancer
Describe two different validated tools that are used to screen and assess for malnutrition
and nutritional risk for an individual diagnosed with cancer
Describe two different methods of how to calculate the energy, protein or fluid
requirements for an individual diagnosed with cancer
List how one of the modalities of cancer therapy can affect a cancer patients nutritional
status
State three different foods that should be avoided by an immunocompromised individual
undergoing hematopoietic cell transplantation
List the four phases of cancer survivorship
Describe two different paraneoplastic syndromes associated with advanced cancer
List two of the guideline recommendations for the use of nutrition support therapy in
adults undergoing anticancer treatment or hematopoietic cell transplantation
Describe two different eating strategies to manage a specific cancer-related nutrition
impact symptom
Identify three different pharmacological agents used to manage a specific cancer-related
nutrition impact symptom

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Nutrition in Cancer Treatment

Introduction

T
he intent of Nutrition in Cancer: Continuum in Treatment is to educate and inform dietetic
professionals working directly with patients who are diagnosed with cancer or with an interest in
the area of oncology nutrition. Dietetic professionals seeking to specialize in the care and
treatment of cancer patients will find that completing this course enhances their professional credential
and standing among their peers.
This course covers the role of nutrition throughout the continuum of cancer care. Nutrition is an
integral component of cancer care from diagnosis, through treatment, recovery from treatment,
survivorship, and throughout end-of-life care. There are many cancer treatments but no single cure for
cancer, which is in quotation marks here because cancer comprises more than 100 diseases, all of
which have in common abnormal growth of cells, but which are more different than alike in many
important ways. Some cancers are, indeed, curable; many are not. Some cures are highly dependent on
early detection and diagnosis.
This course focuses primarily on the nutritional care for individuals diagnosed with cancer and
undergoing cancer treatment. Another Gannett course, Cancer Risk Reduction, assesses dietary risk
factors and preventive nutrition strategies.

How do nutrition and dietetic professionals fit into the continuum of cancer care?

First and foremost, as nutrition and dietetic professionals, we put the science of oncology nutrition
into action. We manage nutrition-related symptoms of cancer and treatment side effects and provide
guidelines to minimize cancer risk through diet, using the latest evidence-based and best clinical
practice. We are the nutrition experts.
Second, nutrition and dietetic professionals are educators. We provide the latest information about
cancer prevention to healthy people and cancer survivors, and we help optimize the nutritional well-
being of those recovering from cancer. We educate individuals about the effects of their disease and
treatment on their nutritional status and overall health, and we teach the healthcare team about the role
of nutrition in health and disease. We also provide sound scientific advice to patients and families, who
may be exposed to nutrition and cancer misinformation.
Lastly, we are there to support patients, families and the healthcare team in the fight against cancer.
We do this by maximizing the nutrition status of our patients, providing guidance and emotional
support for their families, and reinforcing the overall plan of care.
This course is designed to heighten awareness of cancer and its treatment, as well as its impact on
nutrition. Definitions to cancer-related terms used throughout the course can be found in the glossary.
Additional professional resources for nutrition professionals working with patients diagnosed with
cancer are available from the Academy of Nutrition and Dietetics at www.eatright.org or 800-877-
1600. These oncology nutrition resources are The Clinical Guide to Oncology Nutrition, Oncology
Toolkit and Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. In 2008,
the Commission on Dietetic Registration (CDR) began administering and granting a board certification
for registered dietitians specializing in oncology nutrition and working in the cancer care setting. This
credential is known as CSO, or certified specialist in oncology nutrition. Additional information
regarding the CSO credential can be obtained from the CDRs website at:

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http://www.cdrnet.org/certifications/spec/oncology.cfm.
Registered dietitians working in oncology nutrition will find the recent publication of the Standards
of Practice and Standards of Professional Performance for RDs in Oncology Nutrition Care a valuable
resource for the further development and enhancement of their skills, competencies and knowledge for
the safe and effective nutrition care for individuals diagnosed with cancer. 1

Reference
1. Robien K, Bechard L, Elliott L, et al. Academy of Nutrition and Dietetics: standards of practice and
standards of professional performance for registered dietitians (generalist, specialty, and advanced) in
oncology nutrition care. J Am Diet Assoc. 2010;110(2):310-317.

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Chapter One:
Understanding Cancer: Statistics,
Diagnosis and Treatment
This chapter presents cancer-related statistics pertaining to incidence, death and survival rates, trends and
prevention. It also reviews methods for cancer diagnosis and staging, and provides an introduction to the
modalities of cancer treatment and the importance of proactive nutritional care. A glossary of the cancer-
related terms used throughout this continuing education course is provided in the appendices.

C ancer is the uncontrolled division and reproduction of abnormal cells that can spread
throughout the body to adjacent normal structures and organs, and metastasize to lymph nodes
and other organs. Often regarded as a single disease, cancer encompasses more than 100
diseases caused by nearly 300 different growths. Cancer can be caused by numerous external and
internal factors.

Causes of Cancer1,2
External Factors
Lifestyle Exposure to tobacco products
Alcohol abuse
Diet: poor nutrition, pesticides,
contaminants, preservatives
Contributing factors: physical inactivity
and obesity
Infectious agents/Viruses Helicobacter pylori (H. pylori)
Hepatitis B (HVB)
Hepatitis C (HVC)
Human immunodeficiency virus (HIV)
Human papillomavirus (HPV)
Environmental Radiation: solar, radon, X-rays
Chemical compounds: asbestos, heavy
metals, ozone
Internal Factors
Hormones Immune conditions
Inherited or metabolic mutations

These factors acting together or in sequence can to lead to the initiation, promotion and
progression of cancer. Ten or more years can pass between exposure to external factors and the
presence of detectable cancer.3
Everyone is at risk for developing cancer. The American Cancer Society (ACS) predicts that the
lifetime risk for developing cancer in the United States is slightly less than one in two for men and a
little more than one in three for women.3

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Understanding Cancer: Statistics, Diagnosis and Treatment

Carcinogenesis, the origin or development of cancer, is thought to be a biological, multistage


process brought about by malfunctions of genes (oncogenes) that control normal cell growth and
division. Tumor suppressor genes are the opposite of oncogenes; they can become deactivated in
cancer cells. The loss of function of tumor suppressor genes leads to unregulated cell growth and,
ultimately, cancer. Examples of tumor suppressor genes are breast cancer antigen 1 (BRCA-1) and
BRCA-2, and adenomatous polyposis coli (APC).

Cancer Incidence
The ACS estimated that more than 1.6 million cases of cancer will be diagnosed in 2012. Current
statistics show that 77% of all cancers are diagnosed in people 55 years and older.3 In the United
States, the most common sites of new cancer in men are prostate, lung, colon/rectum and bladder. In
the United States, the most common sites of new cancer in women are breast, lung, colon/rectum and
uterus.

Leading Sites of New Cancers, 2012 Estimates2


Cancer Site Male Female
Prostate 241,740 (29%) N/A*
**
Breast 226,870 (29%)
Lung and bronchus 116,470 (14%) 109,690 (14%)
Colon and rectum 73,420 (9%) 70,040 (9%)
*
not applicable
**
not a leading site of new cancer for men

Cancer experts believe that the differences in cancer incidence rates observed in racial and ethnic
groups are due to health disparities and socioeconomic factors such as poverty, living in an inner city
or rural community, lack of health insurance or education, cultural beliefs, language barriers and racial
stereotypes. Other factors include equal access to cancer prevention efforts, early detection and quality
treatment, and increased prevalence of risk factors for cancer such as obesity and use of tobacco
products.3

Incidence of Cancer from 20042008*3


White African- Asian-American/ Native American/ Hispanic/
American Pacific Islander Alaska Native Latino**
Male 545.0 626.2 332.4 427.8 423.4
Female 420.8 394.2 284.0 362.1 333.5
*
Figures are per 100,000, age-adjusted to the 2000 U.S. standard population
**
Hispanic is not mutually exclusive from other races and ethnic groups
Note: Small sample sizes may create statistical errors; therefore, further research is needed regarding the
etiology of cancer in these diverse populations.

Cancer is the second-leading cause of death in the United States, exceeded only by heart disease.
Annually, cancer is the reason for almost one out of every four deaths, causing the death of more than a
half million Americans.3 Evidence suggests that one third of cancer deaths can be attributed to nutrition
and lifestyle behaviors such as overweight and obesity, poor diet, alcohol use and physical inactivity.

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Nutrition in Cancer Treatment

Leading Sites of Cancer Deaths, 2012 Estimates2


Cancer Site Male Female
Lung and Bronchus 87,750 (29%) 72,590 (26%)
Colon and Rectum 26,470 (9%) 25,220 (9%)
*
Breast 39,510 (14%)
Prostate 28,170 (9%) N/A**
*
Not a leading site of cancer death in men
**
Not applicable

Cancer Survival
The ACS defines anyone living with a diagnosis of cancer as a cancer survivor.4 It is estimated
that in 2012 there were nearly 12 million Americans who had been diagnosed with cancer and were
living cancer-free, had evidence of disease or were undergoing cancer treatment.3 This large number of
cancer survivors is due in part to cancer prevention efforts, improvements in the early detection of
cancer and the development of new and often more aggressive cancer therapies.
Cancer has been shown to be a disease of aging, with 60% of cancer survivors being older than 65
years.5 In addition, cancer survivors represent one of the largest groups of Americans living with a
chronic illness. According to recent reports, almost 75% of older Americans have at least one chronic
and/or comorbid disease such as diabetes, cardiovascular disease, osteoporosis and cancer.
Despite the broad definition of cancer survivor, survival is typically referred to as an individual
being alive five years post-diagnosis, whether cancer-free, in remission, undergoing cancer treatment or
with evidence of disease. Survival longer than five years is commonly defined as long-term survival or
cure. The five-year survival rate for all cancers diagnosed between 2001 and 2007 is 67%, up from
49% between 1975 and 1977.3 Cancer diagnosed at an earlier stage helps to increase the likelihood of
successful treatment and improved survival.

Survival by Stage at Diagnosis3


Five-year Relative Survival Rates (%) by Stage at Diagnosis
20012007 All Stages Local Regional Distant
Breast (female) 89 99 84 23
Colon and rectum 64 90 69 12
Esophagus 17 37 18 3
Kidney 70 91 63 11
Larynx 61 77 42 33
Liver 14 27 9 4
Lung and bronchus 16 52 24 4
Melanoma of the skin 91 88 61 15
Oral cavity and pharynx 61 82 56 34
Ovary 44 92 72 27
Pancreas 6 22 9 2
Prostate 99 100 100 29
Stomach 26 62 28 4
Urinary/bladder 78 71 35 5
Uterine/cervix 69 91 57 19

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Understanding Cancer: Statistics, Diagnosis and Treatment

Cancer Prevention: 2015 Challenge Goals


In 1999, the ACS developed the 2015 Challenge Goals to help focus the nations cancer
prevention and survival efforts.6 The objectives of the 2015 Challenge aim to prevent cancer by
addressing tobacco use, nutrition, physical activity levels, sun protection, and early screening and
detection.
Specifically, the goals are as follows:

Tobacco use: To reduce by 12% the proportion of all adults using tobacco products.
Nutrition: To increase to 75% the proportion of all Americans consuming at least five
servings of vegetables and fruits each day.
Physical activity: To increase by 60% the proportion of all adults regularly engaging in
physical activity to prevent obesity and promote healthy lifestyles.
Sun protection: To increase by 75% the proportion of all ages reducing their risk of skin
cancer by avoiding the sun between 10 a.m. and 4 p.m. by wearing sun protective clothing
when exposed to sunlight, using sunscreen with SPF 15 or higher and avoiding artificial
sources of ultraviolet light (e.g., sun lamps and tanning beds or booths).
Early detection: To increase the proportion of cancer screening using the ACS
guidelines for cancer detection (e.g., breast, 90% of women 40 years and older; colorectal,
75% of all Americans 50 years and older; and prostate, 90% of men 50 years and older).

By the year 2015, the 2015 Challenge hopes to achieve a 50% reduction in age-adjusted cancer
mortality rates; a 25% reduction in age-adjusted cancer incidence rates; a measurable improvement in
quality of life (physical, psychological, social and spiritual), from time of diagnosis and for balance of
life of all cancer survivors; and elimination of disparities in the cancer burden among different segments
of the U.S. population in terms of socioeconomic status.

Signs and Symptoms of Cancer


Assessing symptoms of cancer is critical to timely diagnosis. For cancer treatment to be the most
effective, the detection of cancer at its earliest stage is vital for improving survival and treatment
outcomes. The ACSs seven early warning signs (CAUTION) of cancer are:

Change in bowel or bladder habits.


A sore that does not heal.
Unusual bleeding or discharge.
Thickening or lump in breast or elsewhere.
Indigestion or difficulty in swallowing or chewing.
Obvious change in wart or mole.
Nagging cough or hoarseness.

Many symptoms of cancer or metastatic disease can affect a persons ability to eat, as well as
normal digestion and absorption. Signs and symptoms of cancer can have a direct effect on nutritional
status. Constitutional signs and symptoms include anorexia, fatigue, weight loss, fever, sweating and
anemia.3 Signs and symptoms of metastatic cancer include pain, bone pain with or without fracture,
enlarged lymph nodes or body organs, neurological symptoms and cough with or without hemoptysis.3

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Nutrition in Cancer Treatment

Diagnostic Methods
A cancer diagnosis can be determined by several different methods. Diagnostic methods include
clinical assessment of an individuals medical history and physical examination; radiographic imaging
studies (e.g., CT, MRI or PET scan), ultrasound or endoscopy; pathology using cytology studies or
tumor biopsy of body tissue, sputum or fluids; or analysis of tumor markers from blood and body fluids.
Examples of commonly used tumor markers to identify the possible presence of cancer or cancer
recurrence include:

Alpha-fetoprotein (AFP) for liver cancer


BRCA-1 or BRCA-2 for breast cancer
Cancer antigen 125 (CA 125) for ovarian cancer
Cancer antigen 19-9 (CA 19-9) for pancreatic cancer
Prostate-specific antigen (PSA) for prostate cancer
Carcinoembryonic antigen (CEA) for colon cancer

Cancer Staging

The extent of disease at the time of diagnosis is determined by cancer staging. The stage of a cancer
is based on the presentation of the primary tumor and if the cancer has spread to different parts of the
body. Cancer staging is used by physicians to determine an individuals prognosis and the most
effective treatment for his or her specific disease. The ACS classifies cancer stages as local, regional and
distant.
Cancer is considered local if an invasive malignancy is confined entirely to the organ of origin.
Cancer is considered regional if a malignancy extends beyond the limits of the organ of origin directly
into surrounding organs or tissues, involves regional lymph nodes by way of the lymphatic system, and
exhibits both regional extension and involvement of regional lymph nodes. Cancer is considered
distant if a malignancy has spread to parts of the body remote from the primary tumor either by direct
extension or by discontinuous metastasis to distant organs, tissues or via the lymphatic system to
distant lymph nodes.
There are several different staging systems for classifying tumors. A commonly used staging system
is TNM, which describes cancer by the extent of the tumor size (T); absence or presence of nodal
involvement (N); and absence or presence of metastases (M).7 Once the TNM has been determined, a
cancer stage of I, II, III or IV is assigned. Stage I disease is early stage and stage IV is considered
advanced disease.
Tumor differentiation is another way that physicians classify tumors. Understanding how a cancer
grows helps physicians in determining a persons prognosis and the most effective treatment. Typically,
a well-differentiated cancer grows more slowly and is less aggressive, while a poorly differentiated
cancer tends to be more aggressive and faster growing, leading to a worse prognosis.
Grade I: a well-differentiated cancer that looks like the normal tissue or organ from which
the cancer arises.
Grade II: a moderately differentiated cancer that slightly resembles the site of cancer
origin.
Grade III: a poorly differentiated or undifferentiated cancer that does not resemble
normal tissue or organs.

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Understanding Cancer: Statistics, Diagnosis and Treatment

TNM Staging System7


Tumor T0: No evidence of disease
Tis: Carcinoma in situ or cancer that has not spread to surrounding
tissue
T1: Tumor is not palpable or visible by imaging
T2: Tumor is confined to the primary cancer site
T3: Tumor extends to neighboring tissue
T4 :There is metastatic disease
Node N0: No involvement of the lymph nodes
N1: Metastasis to local lymph nodes
Metastasis M0: No metastasis
M1: Distant metastasis

Treatment Goals and Tumor Response


The goals of cancer treatment are cure, control and palliation.
Cure seeks to eradicate measurable, discernible malignant disease and obtain a complete response
to treatment. Control seeks to extend the length of life when a cure is not possible, prevent the growth
of cancer cells without complete elimination of disease, obscure microscopic metastases after tumors
are surgically removed and shrink tumors before surgery or radiation therapy. Palliation seeks to
provide support and comfort when cure or control is not possible; improve quality of life; and reduce or
relieve cancer-related symptoms and side effects, including pain.
Response to cancer treatment is defined as complete response (CR), partial response (PR), stable
disease (SD), and progressive disease (PD). CR is the absence of all signs and symptoms of cancer for at
least one month, demonstrating a complete response to the chosen cancer therapy. PR is at least a 50%
reduction in measurable disease without the development of tumor mass for at least two months. SD is
the reduction in tumor mass of less than 50% or less than 25% increase in tumor growth. PD is 25%
growth of tumor mass or development of new tumors; essentially, the cancer keeps growing.
Factors that affect a persons response to cancer treatment include tumor burden and rate of tumor
growth. Tumor burden is the idea that the smaller the tumor (or fewer number of tumor cells), the
greater the response to treatment; rate of tumor growth means that cancer treatments are typically more
effective in cancers that are rapidly growing.

References
1. Laughlin EH. Coming to Terms with Cancer: A Glossary of Cancer-Related Terms. Atlanta, GA: The
American Cancer Society; 2002.
2. National Comprehensive Cancer (NCCN) Clinical Practice Guidelines in Oncology, 2012. NCCN Web site.
http://nccc.org/clincal.org. Accessed July 17, 2012.
3. American Cancer Society. Cancer Facts & Figures, 2012. American Cancer Society Web site.
http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2012.
Accessed July 17, 2012.
4. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an
American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
5. Horner MJ, Ries LAG, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2006. National Cancer
Institute Web site. http://seer.cancer.gov/csr/1975_2006/. Accessed July 17, 2012.
6. Byers T, Mouchawar J, Marks J, et al. The American Cancer Society challenge goals. How far can cancer
rates decline in the U.S. by the year 2015? Cancer. 1999;86(4):715-727.
7. American Joint Committee on Cancer. What is cancer staging? American Joint Committee on Cancer Web
site. http://www.cancerstaging.org/mission/whatis.html. Accessed July 17, 2012.

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Chapter Two:
Overview of Cancer and Its Treatment
This chapter will familiarize the reader with types of cancer commonly seen in care settings, including
brief descriptions, pertinent risk factors, signs/symptoms, diagnoses, treatments and survival.

O ncology is the study of cancer, and oncologists are physicians who specialize in cancer. A
tumor (or neoplasm) is an abnormal mass of tissue. Tumors are frequently called solid
cancers or hematological (blood-related) cancers, the latter of which are often referred to as
liquid cancers. Tumors can be benign, which means they are non-progressing and not life-threatening;
or malignant, which means they are progressing and life-threatening. Metastasis is the spread of
malignant cells from an original or primary location in the body to distant tissues or organs.

Oncology Healthcare Team


Cancer treatment is a highly specialized type of medical care. The oncology healthcare team is
comprised of medical oncologists, radiation oncologists, surgical oncologists, nurses, pharmacists, social
workers, chaplains, radiation therapists and dieticians. Some of the specific responsibilities include:
M edical Oncologists are physicians with special training in the use of chemotherapy
drugs and biotherapy agents to kill tumor cells.
Radiation Oncologists are physicians with special training in the use of high-energy X-
rays and other radioactive substances to destroy cancer cells.
Surgical Oncologists are physicians with special training in how to remove malignant
tissues from the body using surgical operations or procedures.
Nurses, pharmacists, social workers, chaplains and radiation therapists
Registered dietitians (RDs) working in oncology can become specialty board certified
in oncology nutrition (CSO) through the Commission on Dietetic Registration (CDR).
(For more information about the CSO credential, visit the CDRs website at
http://www.cdrnet.org/certifications/spec/oncology.cfm.)

Modalities of Cancer Therapy


Guidelines for cancer treatment by specific cancer site; cancer prevention, detection and risk
reduction; and supportive cancer care in are guided by evidence-based standards known as the
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.1 The
website states that it is a not-for-profit alliance of 21 of the worlds leading cancer centers, and its goal
is to improve the quality and effectiveness of care provided to people with cancer so they can live better
lives.
Methods of conventional cancer treatment include surgery, chemotherapy, biotherapy, anti-
angiogenic agents, hormonal therapy and radiation therapy. These agents can be used alone or in
combination:

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Overview of Cancer and Its Treatment

Surgery is the surgical removal of cancerous tissue.


Chemotherapy is the use of chemical agents or medications to treat cancer systemically.
Biotherapy uses biological agents to produce anticancer effects indirectly as stimulators
of the persons own natural immune defense system, or as cytotoxic agents via the
administration of natural substances.
Antiangiogenic agents inhibit the formation of new blood vessels required by cancers;
to prevent cancers growth, invasion and spread.
Hormone therapy is a systemic therapy for the treatment of hormone-sensitive cancers
(e.g., prostate, breast or ovarian) by blocking or reducing the source of a hormone or its
receptor site.
Radiation therapy uses high energy (ionizing radiation) in multiple, fractionated doses
to cure, control or palliate cancer cells.
Hematopoietic cell transplant (HCT) uses a combination of cancer therapy
modalities to treat solid tumors and hematologic malignant diseases such as leukemia,
lymphoma and multiple myeloma.

The types of cancer therapy include:


Chemoprevention is the use of specialized pharmaceuticals to reduce the risk of cancer
in high-risk individuals.
Adjuvant therapy is cancer treatment given after the first treatment, such as
chemotherapy and/or radiation therapy after a cancer surgery. Adjuvant therapy is given to
enhance the effect of the initial treatment.
Neo-adjuvant therapy is defined as cancer treatment given before the primary
treatment, such as chemotherapy given before cancer surgery. Neo-adjuvant therapy is
most commonly used to shrink a large tumor and make it more manageable before surgery
and to reduce the likelihood of micrometastases.
M yeloablation is the obliteration of bone marrow in preparation for an HCT.

Oncologists develop a persons treatment plan by determining the specific type of cancer, location
in the body, growth properties, invasion of other tissues and stage of disease at diagnosis. Other factors
that help guide the treatment plan include the patients health status, medical history, life plans and
preferences of care.

Categories of Cancers
It is usually accepted that there are three general categories of malignancies that develop in three
different types of tissues.
Leukemias, myelomas and lymphomas are liquid cancers of the immune system.
Specifically, leukemias most frequently arise from the white blood cells of the bone marrow; myelomas
originate from the plasma cells of the bone marrow; and lymphomas develop in the lymphatic system,
its glands and organs.
Carcinomas are solid cancers that develop in tissues that cover the surfaces or the linings of the
bodys organs and epithelium.
Sarcomas are solid cancers that originate in the soft tissues or bones.

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Nutrition in Cancer Treatment

Leukemia
Leukemia is a group of hematologic diseases of the bone marrow and lymph tissue. It is
characterized by the uncontrolled proliferation of white blood cells, called leukocytes, and is categorized
as acute, which means it is fast-growing; or chronic, which means it is slow-growing. If left untreated, all
normal blood-forming elements can be depressed, which is known as pancytopenia.
Risk Factors. There is no known cause of leukemia other than increased occurrence observed
after exposure to atomic radiation (e.g., atomic bomb survivors). The only risk factor has been linked to
cigarette smoking.
Signs and Symptoms. Signs and symptoms of leukemia include pallor, generalized weakness,
fevers, bruising and abnormal bleeding due to decreased platelets (thrombocytopenia), and anemia due
to decreased production of red blood cells. Individuals diagnosed with leukemia often experience
frequent infections due to a depression of the WBC and neutrophils (neutropenia). In acute leukemia
these symptoms can often occur suddenly; chronic leukemia symptoms typically progress slowly with
few signs or symptoms, and the disease is often diagnosed as a result of routine blood tests and not
through any specific symptom.
Other symptoms of leukemia are dependent upon the organs that are involved. Infiltration of
malignant cells into organs can cause enlargement of the spleen, liver and lymph nodes. Of concern for
healthcare professionals is that people with leukemia may be completely free of symptoms, and their
disease may only be discovered by a routine physical examination.
Diagnosis. Leukemia is diagnosed through physical examination; laboratory analysis using
complete blood count, with differential, liver function and blood clotting evaluation; and bone marrow
aspiration and biopsy. Pathological evaluation often includes monoclonal antibody studies and flow
cytometry.
Types of Leukemia. Whether acute or chronic, leukemias are classified by the two major types
of white blood cell that are involved: non-granulocytic (lymphoid) or granulocytic (myeloid). Other less
common diseases of blood-forming cells include hairy cell leukemia, myelodysplastic syndrome,
polycythemia vera, aplastic anemia and the malignant proliferation of plasma cells known as multiple
myeloma.

Acute Lymphocytic Leukemia

Acute lymphocytic leukemia (ALL), also known as acute childhood leukemia, is characterized by
large numbers of immature white blood cells that resemble lymphoblasts. These white blood cells lack
cytoplasmic granules and comprise about 20% to 50% of total WBC. ALL accounts for approximately
90% of the childhood leukemias and occurs most commonly in children 3 to 7 years old. ALL can also
occur in adults and accounts for about 20% of adult leukemias.
Individuals diagnosed with ALL frequently present with an enlarged liver and spleen, bruising and
abnormal bleeding. A CBC with differential usually indicates an abnormal WBC, anemia and
thrombocytopenia. A definitive diagnosis requires a bone marrow aspiration and biopsy. The result of
the biopsy exhibits hypercellularity and an increased number of lymphoblasts.
Central nervous system involvement is a common complication. ALL is most commonly treated
with a combination of chemotherapeutic agents divided into three phases: induction, CNS prophylaxis
and maintenance. Cranial radiation and/or intrathecal chemotherapy may be included in CNS
prophylaxis.
Children generally fare better than adults with ALL, with about 95% complete remission, although
children who relapse after a short initial remission typically have a poor prognosis. Adults usually

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Overview of Cancer and Its Treatment

achieve about an 80% complete remission for an average of 15 months. Adults who relapse after initial
remission are not expected to survive for more than a year. Long-term survival is about 50% to 60% in
children and 30% to 50% in adults. If untreated, survival is only about three months. People who
relapse or fail to respond to standard treatment may be eligible for an HCT (discussed in Chapter
Seven).

Acute M yelogenous Leukemia

Acute myelogenous leukemia (AML) may also be referred to as acute non-lymphocytic leukemia,
splenomedullary leukemia, acute myeloid leukemia, splenomyelogenous leukemia, acute granulocytic
leukemia or acute myeloblastic leukemia. It is characterized by the proliferation of immature WBCs
called granular leukocytes. AML can occur in children, but is most common among older adults.
Individuals diagnosed with AML typically present with an enlarged liver, spleen and lymph nodes.
A CBC with differential usually indicates anemia, low reticulocyte counts and thrombocytopenia. The
result of a bone marrow aspiration and biopsy exhibits hypercellularity. As with ALL, CNS involvement
is a concern.
Treatment is given to control bone marrow and systemic disease, as well as CNS disease (if
present). AML is treated with combination chemotherapy in two phases: induction and
maintenance/consolidation. First, the induction chemotherapy is administered. Then, immediately after
remission is achieved, or nine months after remission, maintenance chemotherapy is administered.
Complete remission occurs in about 60% to 70% of cases following induction. Long-term survival
is achieved in about 20% to 30% of those who have received curative therapies.

Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is characterized by slow proliferation of lymphocytes in the


blood and bone marrow. It results in immunosuppression, bone marrow failure and infiltration of
malignant cells into organs. It is the most common type of leukemia in the United States. CLL is a
disease of the elderly, with 90% of its incidence in people older than 50.
People with CLL are at risk for secondary cancers, autoimmune hemolytic anemia and
hypogamma-globulinemia (a condition characterized by decreased antibodies, leading to increased risk
for infections). Individuals who are diagnosed with CLL typically present with an enlarged liver, spleen
and lymph nodes and exhibit symptoms of fatigue, bone pain, bruising, night sweats, anorexia and
weight loss. A CBC with differential usually indicates an elevated WBC, anemia and thrombocytopenia.
Treatment ranges from watch and wait, with supportive care such as blood products and
antibiotics, as needed; to combination chemotherapy; biotherapy; and HCT. As suggested by its name,
CLL is a slow, progressive disease with a five-year survival rate of 60%.

Chronic M yelogenous Leukemia

Chronic myelogenous leukemia (CML) also known as chronic myelocytic leukemia or chronic
granulocytic leukemia, is characterized by rapid growth of myeloid cells (large cells that are precursors
of leukocytes) in the bone marrow, peripheral blood and body tissues. If left untreated, it can eventually
convert into AML. CML is most common in middle-age adults and is rare in children. It is associated
with a chromosomal abnormality called the Philadelphia chromosome. Like CLL, CML is characterized
by initial slow disease progression (chronic phase). After about five years, however, patients frequently

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Nutrition in Cancer Treatment

enter a blastic phase, or blast crisis. This occurs when there is a very high count of immature white cells,
and it becomes difficult to treat.
Those diagnosed with CML typically present with an enlarged spleen, fatigue, night sweats, low-
grade fever (without infection), bruising and abnormal bleeding, and bone pain. A CBC with differential
usually indicates an increased WBC and additional testing reveals the Philadelphia chromosome.
CML is treated either with single agents or with combination chemotherapy and/or biotherapy;
HCT may be used for specific individuals. Median survival is about four to six years in treated
individuals, with about 50% of individuals receiving transplant achieving long-term survival.

M yelodysplastic Syndrome

Myelodysplastic syndrome (MDS) is considered a pre-leukemia disease. It can occur in patients


who have received chemotherapy and/or radiation therapy for a previously diagnosed malignancy.
Increased incidence is also observed after exposure to toxic substances such as chemicals or radiation.
Diagnosis is confirmed by bone marrow aspiration and biopsy, and hematological evaluation. Signs and
symptoms of MDS include fatigue, increases in WBC, thrombocytopenia and progressive anemia.
MDS, in almost all instances, progresses to acute leukemia. Treatment can include frequent blood
transfusions, hematopoietic growth factors and chemotherapy agents.

Aplastic Anemia

Aplastic anemia may occur secondary to an autoimmune process, previous chemotherapy, exposure
to radiation, toxins, drugs, pregnancy, congenital disorders or systemic lupus erythematosus. The
disease results from an injury to the stem cell (precursor to other types of blood cells). The result is
pancytopenia.
Aplastic anemia presents with enlarged spleen, tenderness of the sternum and irregular heart rate.
Additionally, CBC reveals low hemoglobin and hematocrit, low WBC, low reticulocyte count and
thrombocytopenia. Bilirubin levels are elevated and sugar-water/hemolysis test shows fragile red cells.
As with leukemia, weakness, fatigue, infections and abnormal bleeding are hallmarks of the disease.
Mild cases are treated with palliative, or supportive, care with blood products (platelets and
transfusions). People younger than 30 years with severe cases may be considered for HCT. Adults older
than 40 years or those who do not have a matched bone marrow donor may receive antithymocyte
globulin, a horse serum containing antibodies against human T-cells that is used to suppress the bodys
immune system. The theory is that the bone marrow, once suppressed, will resume its blood-generating
function. Other immunosuppressants, such as cyclosporine (Sandimmune) and cyclophosphamide
(Cytoxin) may be used to the same end, as well as corticosteroids and androgens.
If aplastic anemia is left untreated, death is imminent. Long-term survival in young people who
have undergone HCT is about 80%, whereas the survival rate in older adults is 40% to 70%.

M ultiple M yeloma

Multiple myeloma (MM) is also known as myelomatosis, plasma cell myeloma, malignant
plasmacytoma and multiple plasmacytoma of the bone. It is a cancer of the bone marrow where plasma
cells grow abnormally, crowding the bone marrow and interfering with the growth of red blood cells.
Malignant plasma cells produce an abnormal immunoglobulin called monoclonal immunoglobin or M-

21
Overview of Cancer and Its Treatment

protein that can be detected in the blood or urine. Risk factors include exposure to petroleum products,
dioxin and atomic radiation. MM generally occurs in adults older than 60 years.
MM can present with bone pain, pathological fractures (from the destruction of normal bone) and
back pain. Many individuals are prone to lytic lesions, which are caused by the skeletal involvement and
bony destruction brought about by the accumulation of plasma cells in bony areas. Pallor, abnormal
bleeding and myelosuppression of bone marrow are common and are evident by disease-related
neutropenia, anemia and thrombocytopenia. Individuals diagnosed with MM may also develop renal
complications due to disease-related hypercalcemia, hyperuricemia and dehydration.
Currently, there is no known cure for MM and treatment is largely palliative. Chemotherapy is
often started when patients begin to experience symptoms. However, many new treatments are under
investigation, including high-dose chemotherapy with HCT in healthy, younger individuals. Radiation
therapy is used to treat painful bony lesions.
Once symptoms develop, the median survival of individuals without treatment is seven months.
With treatment, survival can be extended to two to three years.

Lymphoma
Lymphoma is cancer of the lymphoid system. The lymphoid system comprises lymph nodes
(glands) and lymphatic tissue and is similar to the circulatory system, but it contains lymph cells
(lymphocytes), rather than blood. The lymphocytes circulate throughout the bloodstream and lymphatic
channels, or are arranged in clusters in the neck, armpit, groin, and abdomen. Cancers that develop in
the lymphoid system are found wherever the lymphocytes travel. Lymphomas can occur in isolated
lymph nodes, clusters of lymph nodes, organs (e.g., stomach or intestines), lungs, bones, skin or a
combination of these sites.
There are two main classifications of lymphoma: Hodgkins disease (also called Hodgkins
lymphoma) and non-Hodgkins lymphoma. HD accounts for about 15% of all lymphomas and most
frequently occurs in adolescents and young adults. NHL is seven to eight times more common than
HD, and more than 95% of cases are diagnosed in adults. Lymphomas are classified into many
subtypes.
Signs and symptoms. Both types of lymphoma (HD and NHL) may present with painless
swelling of the lymph nodes, fatigue, and shortness of breath or coughing. Lymphomas that have a
larger tumor burden typically exhibit B-cell type symptoms (B symptoms) that include unexplained
weight loss, unexplained fever or drenching night sweats.
Diagnosis. Diagnosis involves surgical biopsy of involved tissue, a detailed physical examination
with evaluation of all nodal areas and documentation of history, including the presence or absence of B
symptoms. Additional diagnostic tests may include bone marrow aspiration and biopsy, imaging studies
(e.g., chest X-ray; CT scans of the chest, abdomen and pelvis), surgical biopsy of organs, flow cytometry
and molecular genetic testing, and hematological and biochemistry studies (e.g., CBC with differential,
liver and kidney function tests). HD is distinguished from NHL by two distinctive characteristics: the
presence of Reed-Sternberg cells in the lymph nodes (theses cells are not found in NHL), and the
orderly spread of the disease from one lymph node group to another.
Treatment. Treatment regimens vary according to the specific stage, grade and type of disease. All
lymphomas are staged according to the Ann Arbor Staging System (I, II, III and IV). Classifying
lymphoma can be very confusing because there are different classification systems, as well as many
different types of the disease. The Working Formulation classifies lymphoma as low grade, intermediate
grade and high grade. A classification method called the Revised European American Lymphoma
(REAL) System was developed recently to classify lymphomas not previously included in the Working

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Nutrition in Cancer Treatment

Formulation. Most treatments consist of a combination of surgery, chemotherapy, biotherapy and


radiation therapy.

Hodgkins Disease

HD occurs most often in people between the ages of 15 and 40 years and is characterized by the
presence of Reed-Sternberg cells in the lymph node biopsy. There are four types of Hodgkins disease.
Lymphocyte Predominance: Lymph nodes comprise lymphocytes and malignant cells, which
have a popcorn-like appearance and very few of the Reed-Sternberg cells. LP accounts for 5% to 10%
of total cases and is more common in men than women.
Nodular Sclerosis: Lymph nodes in the lower neck, chest and collarbone usually contain normal
and reactive lymphocytes and Reed-Sternberg cells separated by a band of scar-like tissues. NS
accounts for 30% to 60% of all cases.
M ixed Cell: Lymph nodes usually contain Reed-Sternberg cells, as well as inflammatory cells. MC
accounts for about 20% to 40% of total cases.
Lymphocyte Depleted: Two variations of LD exist; one with sheets of differing malignant cells,
and the other with few Reed-Sternberg cells and lymphocytes with scar-like tissue.
HD is one of the most curable forms of cancer and is treated with surgery to remove any affected
lymph nodes, radiation therapy, chemotherapy or a combination of radiation/chemotherapy, depending
on the grade and stage of disease. One-year and five-year survival rates for HD are 92% and 84%,
respectively. Mortality from a second malignancy (secondary to treatment for HD) is greater after five
years than the total mortality from HD itself.

Non-Hodgkins Lymphoma

There are about 30 different types of NHL, a disease of the immune system that most commonly
involves B-cell lymphocytes and occasionally T-cell lymphocytes. People with suppressed immune
systems following an organ transplant and those with human immunodeficiency virus (HIV) are at a
greater risk for developing NHL. The predominant types of AIDS-related lymphomas are high-grade B-
cell NHLs (e.g., Burkitts lymphoma or small, non-cleaved lymphoma). NHL occurs most frequently in
people ranging in age from 30 to 70 years. Burkitts lymphoma is associated with the Epstein-Barr
virus. NHL that exhibits B symptoms is often diagnostic of bulky or more aggressive and advanced
disease.
The treatment regimen for NHL may include radiation therapy, chemotherapy, biotherapy (e.g.,
highly specific monoclonal antibodies directed at lymphoma cells or antibodies linked to radioactive
atoms), removal of any affected lymph node or HCT. The effects of radiation therapy and
chemotherapy are not inconsequential, placing patients at significantly greater risk for secondary
cancers for up to 20 years post-diagnosis.
Survival for NHL varies widely by cell type and stage of disease. The overall one- and five-year
survival is 81% and 67%, respectively.

Carcinoma
Carcinomas are the most common type of cancer in adults. This type of cancer originates in the
epithelial tissue (e.g., tissue that covers or lines internal organs and passageways) and has the
propensity to metastasize to other tissues through the circulatory or lymphatic systems. Virtually every
organ is susceptible to carcinomatous metastasis. Common classifications are:

23
Overview of Cancer and Its Treatment

Adenocarcinomas form in glands or gland-like tissues such as the lung, breast, ovary, pancreas,
colon and rectum.
Basal cell carcinomas are a common type of skin cancer. They are often benign and generally
slow to progress. They are commonly found on the face and upper extremities, particularly in the
elderly, and if left untreated, can invade surrounding tissue, including the bone.
Papillomas include a variety of warts, polyps and condylomas. Papillomas are benign, but can be
precursors to malignancies. An example is the condyloma virus, or genital wart, that can increase the
risk of cervical cancer. Treatment may include surgical excision or cryotherapy. In the case of
condyloma, close monitoring with yearly Papanicolaou (Pap) tests is essential.
Squamous cell carcinomas are found in normal tissues of the skin, the lining of the
nasopharynx, larynx, esophagus, anus, genitourinary tract and cervix.
The most common types of new cancer cases diagnosed in adults in the United States are prostate,
lung, colorectal and bladder cancer in men; and breast, lung, colorectal, and uterine cancer in women
all of which are carcinomas.

Bladder Cancer

Bladder cancer is the most frequently diagnosed cancer of the urinary system and occurs with
greater frequency in older men. Ninety percent of all bladder cancers are transitional cell carcinomas
that arise in the cells that line the bladder.
Risk Factors. Risk factors for bladder cancer include cigarette smoking, carcinogens in the urine,
exposure to chemical compounds (e.g., aniline dyes), and chronic irritation of the bladder related to
infection.
Survival. When bladder cancer is diagnosed at an early, localized stage, the five-year survival rate
is 97%. If the cancer is diagnosed after it has spread regionally and metastasized to the colon, rectum,
prostate or vagina, the five-year survival rate drops to 35%.
Signs and Symptoms. Signs and symptoms of bladder cancer include painless blood in the
urine and changes in normal urination such as increased frequency, urgency or dysuria (painful
urination).
Diagnosis. Diagnostic methods include cystoscopy, abdominal CT scan, laboratory analysis
(including urinalysis and blood tests for kidney function), and mapping and biopsy of bladder tissue.
Treatment. Treatment of early stage disease involves surgical resection of tumors using
cystoscopy, and instillation of chemotherapy agents such as Bacillus Calmette-Gurin (TheraCys BCG)
or thiotepa (Thioplex) into the bladder (intravesical administration). More advanced disease is treated
with radiation therapy and cystectomy (removal of the bladder), or combinations of therapies that may
include hormones and chemotherapy.

Breast Cancer

Breast cancer is most frequently diagnosed in women, and is more prevalent in older women than
younger women. Approximately 10% to 11% of American women will be diagnosed with breast cancer
in their lifetime. Survival decreases when the size of the breast tumor is large or if the cancer has spread
to the lymph nodes under the arm (axilla). The majority of breast cancers arise in the milk-ducts or the
milk-producing lobules (glands). When diagnosed at an early stage, ductal cancer of the breast is
referred to as ductal cancer in situ (DCIS) and lobular cancer of the breast is known as lobular cancer
in situ (LCIS). Breast cancer that grows into surrounding breast tissue is referred to as infiltrating

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Nutrition in Cancer Treatment

cancer. In situ breast cancer never metastasizes, but infiltrating breast cancer can spread to the lymph
nodes and other organs such as the bone, brain, liver and ovaries. Inflammatory breast cancer, while
rare, is a rapidly growing breast cancer characterized by redness, swelling and tenderness of the breast.
ACS screening guidelines recommend that women begin yearly screening mammograms at age 40;
those with a family history of breast cancer should be screened earlier.
Risk Factors. Risk factors associated with breast cancer are family history of breast cancer,
increasing age, obesity, high-fat diets, oral contraceptive use, physical inactivity, alcohol use (one or
more drinks per day), having a first child after age 30, menstruating before age 12, having menopause
after age 50, use of postmenopausal hormone therapy and previous chest irradiation.
Survival. The five-year survival rate for early stage (localized) breast cancer is 99%. If the cancer
has spread to the surrounding lymph nodes the five-year survival rate is 84%. If a woman is diagnosed
with distant metastases (e.g., cancer has traveled to the bone or brain) the five-year survival rate is 23%.
In addition, studies reveal that being overweight adversely affects survival for postmenopausal women
with breast cancer.
Signs and Symptoms. The most common symptom of breast cancer is a painless lump in the
breast. Other symptoms can include nipple pain or retraction, discharge from the nipple other than
breast milk, tenderness, swelling, thickening, dimpling or redness of the breast.
Diagnosis. Breast cancer is most commonly diagnosed by a mammogram, although a negative
mammogram does not always indicate the breast is free from cancer. Other diagnostic measures include
breast ultrasound, digital mammography, breast MRI and biopsy of suspicious tissue. Biopsy
procedures are performed by inserting a needle into the lump, core biopsy, vacuum-assisted biopsy,
excisional biopsy or by surgically removing the entire breast lump. Pathological analysis of the breast
tissue is performed to determine estrogen-receptor (ER) and progesterone-receptor (PR) status,
HER2/neu expression and S-phase status.
Treatment. Treatment considerations for breast cancer include the type of tumor, location, stage
of disease, receptor status and Oncotype DX testing, as well as patients age, health status and personal
preferences. Effective treatment consists of the surgical removal of the tumor by either lumpectomy,
which is removal of the tumor and a narrow margin around the tumor; or mastectomy, which is
removal of the entire breast; as well as lymph node biopsy with or without radiation therapy,
chemotherapy or hormonal manipulation. Biotherapy with trastuzumab (Herceptin) is used in patients
whose cancers test positive for HER2/neu expression, and lapatinib (Tykerb) for those with advanced
disease. Hormone therapy is indicated for women whose cancers express ER or PR positivity, as
receptive positive tumors are generally responsive to endocrine therapies such as ER modulators (e.g.,
tamoxifen [Nolvadex]) and aromatase inhibitors (e.g., letrozole [Femara], anastrozole [Arimidex], or
exemestane [Aromasin]).

Colorectal Cancer

Adenocarcinomas account for 98% of colon cancers and 95% of rectal cancers. More than 90% of
colorectal cancers are diagnosed in individuals older than 50 years. The ACS screening guidelines
recommend that all Americans have colorectal examinations beginning at age 50.
Risk Factors. Risk factors for colorectal cancer include increasing age, positive family history for
colorectal cancer; history of inflammatory bowel disease or polyps; obesity; physical inactivity; and diets
high in fat, well-cooked meat and alcohol.
Survival. When colorectal cancer is diagnosed at an early, localized stage, the five-year survival

25
Overview of Cancer and Its Treatment

rate is 90%. If the cancer is diagnosed at a stage where it has spread regionally to the lymph nodes or
adjacent organs, the five-year survival rate falls to 69%.
Signs and Symptoms. Signs and symptoms of colorectal cancer do not usually manifest in early
stage disease. Depending upon the location of the tumor, patients may report vague abdominal pain,
increased bowel gas or cramping, or changes in normal bowel habits. Commonly experienced
symptoms of later stage disease include blood in the stool or rectal bleeding (either bright red or very
dark), bowel pain, anemia with weakness and fatigue, and bowel obstruction.
Diagnosis. Diagnosis of colorectal cancer is commonly made with double-contrast barium
enema, colonoscopy and tissue biopsy. Other methods used to diagnose colorectal cancer are fecal
occult blood tests, digital rectal examination and flexible sigmoidoscopy.
Treatment. Treatment considerations for colorectal cancer include the type of tumor, location,
stage of disease, as well as patients age, health status, and personal preferences. Surgical resection is the
primary treatment for all stages of colorectal cancer. Chemotherapy or chemotherapy with radiation
therapy is often given before or after surgery depending upon the stage, location and spread of the
disease. Biotherapy using the antiangiogenic agent bevacizumab (Avastin) is indicated for patients with
metastatic disease.

Lung and Bronchus Cancer

Lung cancer is the leading cause of cancer-related death in American men and women. Lung cancer
is classified into two general histological types: nonsmall-cell lung cancer (NSCLC) and small-cell lung
cancer (SCLC). NSCLC accounts for 80% of all lung cancers, and it has three subtypes
(adenocarcinoma, squamous cell and large cell). SCLC or oat cell cancer is a rapidly growing lung
cancer that can quickly spread to other organs, especially the brain. Other common sites of lung cancer
metastases are liver, adrenal glands and bones.
Risk Factors. Cigarette smoking is the most significant risk factor. Other risk factors include non-
smokers exposed to second-hand smoke, and occupational or environmental exposure to asbestos,
radon, arsenic, benzene or air pollution.
Survival. When lung cancer is diagnosed at an early, localized stage, the five-year survival rate is
52% (only 15% of all lung cancers are diagnosed at this stage). The five-year survival rate for SCLC is
6%, and the five-year survival rate for NSCLC is 17%.
Signs and Symptoms. Early stage lung cancer frequently has few symptoms. Persistent cough,
hemoptysis, dyspnea, wheezing, enlarged lymph nodes in the neck, recurring pneumonia or bronchitis,
and chest or shoulder pain are often signs and symptoms of more advanced disease. Systemic
symptoms of lung cancer are unexplained weight loss, anorexia and fatigue. Headaches or seizures are
usually indicative of metastasis to the brain.
Diagnosis. Commonly used diagnostic methods for lung cancer are chest X-ray; bronchoscopy
with washing, brushing and biopsy; cytological analysis of malignant cells in the sputum or fluid
drained from the lung; and chest and abdominal CT scan. CT scan of the brain is often ordered to
evaluate the presence of brain metastasis.
Treatment. Treatment includes surgery for localized tumors. Depending upon type, stage and
location of disease, it can include a combination of radiation therapy, chemotherapy and biotherapy
using targeted biological agents.

M elanoma

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Nutrition in Cancer Treatment

Melanomas are malignant tumors that develop in the pigment-producing cells (melanocytes),
which give color to the skin, hair and eyes. Melanomas can spread horizontally as well as vertically, into
layers of the skin and tissues. This spread can lead to lymph node involvement and metastasis to any
organ of the body, especially the brain, lung or liver.
Risk Factors. Melanomas are linked to sun exposure, particularly severe sunburn. They occur
more often in light-skinned people; on the extremities in women; and on the trunk, head and neck in
men. They are most often found in adults. Avoiding sun exposure during mid-day hours (10 a.m.
through 4 p.m.) and the use of sunscreen with sun protection factor (SPF) 15 should be used to help
prevent this malignancy.
Survival. Prognosis depends on the stage of the disease. Melanomas generally considered curable
are thin lesions that have not spread beyond the original site or invaded beyond the papillary dermis.
Signs and Symptoms. Moles that change color, size, or shape or become itchy are suspicious
for melanomas. Later signs include ulceration and bleeding.
Diagnosis. Diagnosis is made by excisional biopsy. There are several subtypes of melanoma,
including superficial spreading, nodular, lentigo maligna and acral lentiginous. Staging of melanoma is
based on its thickness (Breslows classification) and/or the anatomic level of local invasion (Clarks
classification).
Treatment. Treatment of localized melanoma is surgical excision. More advanced stages of the
disease are treated with adjuvant chemotherapy or biotherapy.

Pancreatic Cancer

Cancer of the pancreas most commonly arises from both exocrine parenchyma and endocrine islet
cells. Sites of metastases are adjacent lymph nodes, lung, bone and brain. There are no widely used
methods for early detection at this time.
Risk Factors. Risk factors include cigarette and cigar smoking, obesity, high-fat diet, physical
inactivity, chronic pancreatitis, diabetes and cirrhosis.
Survival. Even when pancreatic cancer is diagnosed at an early, localized stage, the five-year
survival rate is only 22%. More than half of people with pancreatic cancer are diagnosed with advanced
disease; their five-year survival rate is only 2%.
Signs and Symptoms. Rarely diagnosed in its early stages, symptoms of pancreatic cancer can
be vague and not cause suspicion until the disease is well advanced. Symptoms most often include
weight loss, abdominal pain and discomfort, jaundice, nausea, vomiting, anorexia or the sudden onset
of diabetes.
Diagnosis. The only definitive diagnosis of pancreatic cancer is biopsy of the involved pancreatic
tissue.
Treatment. Treatment varies according to type, stage and location of disease. Surgical resection is
the treatment of choice in operable tumors. The Whipple procedure (pancreatoduodenectomy) is the
only potentially curative approach when the tumor is located in the head of the pancreas. Therefore,
surgery, radiation therapy and chemotherapy, as well as biotherapy, are treatment options used to
extend survival or to palliate and relieve symptoms.

27
Overview of Cancer and Its Treatment

Prostate Cancer

Prostate cancer is the most frequently diagnosed cancer in men. It is usually slow growing and
typically occurs in men older than 50. The ACS screening guidelines recommend that men begin yearly
PSA evaluation and digital rectal examination (DRE) at 50 years, or at 45 years for African-Americans.
Risk Factors. Risk factors for prostate cancer include increasing age, family history and ethnicity
(e.g., African-American). Other risk factors are obesity and diets high in fat, red meat and animal fat.
Survival. The majority of prostate cancers are diagnosed in local and regional stages, and the five-
year survival rate is nearly 100%. If a man is diagnosed with cancer that has distant metastasis (e.g., the
cancer has traveled to the bone), the five-year survival rate is 33%. Improved survival has come about
through improvements in early detection and treatment.
Signs and Symptoms. Early stage prostate cancer rarely has any symptoms. Symptoms of more
advanced disease may include difficulty starting or stopping urination, pain or discomfort with
urination, or urinary frequency, especially at night. Other symptoms are erectile dysfunction, painful
ejaculation or blood in the urine. Pain in the lower back, legs and thighs may be a sign of metastatic
disease.
Diagnosis. Diagnosis is most frequently determined by the presence of an evaluated level of the
blood tumor marker (PSA) and/or the discovery of a mass or lump on the prostate gland found during a
DRE. A thorough work-up usually includes abdominal CT scan, bone scan and a core biopsy of the
prostate gland.
Treatment. Treatment for prostate cancer is dependent upon the stage of the disease at diagnosis.
Types of treatment for earlier stage disease include careful observation known as watch and wait,
surgical removal of the prostate gland, external beam radiation therapy, brachytherapy (radioactive seed
implantation into the prostate gland), or hormonal therapy (androgen deprivation therapy to block the
action of androgenic hormones). Metastatic disease is treated with radiation therapy to painful bony
areas, hormonal therapy, chemotherapy, or a combination of these therapies.

Sarcoma
Sarcomas are malignancies of the connective tissue, bone, cartilage or striated muscle. Because
connective and supportive tissues are found throughout the body, sarcomas can occur anywhere.
Sarcomas can spread by extension into neighboring tissue or by way of the circulatory system. They are
divided into soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas are classified according to
tissue type involved, such as fibrosarcoma and liposarcoma. Soft tissue sarcomas most frequently
metastasize to the lungs, bone and liver. Bone sarcomas include osteosarcomas, Ewings sarcoma and
malignant fibrous histiocytoma of the bone.
Symptoms of sarcomas include local pain, soft tissue swelling and palpable masses. Common
diagnostic methods include CT scans and MRIs of the affected area and open biopsy. Treatment is
specific to the type of sarcoma diagnosed.

Adult Soft Tissue Sarcomas

Soft tissue sarcomas arise from mesodermal tissues of the extremities, trunk, retroperitoneum, and
head and neck. They are more commonly seen in patients with neurofibromatosis, Gardner syndrome,
Werner syndrome, tuberous sclerosis, basal cell nevus syndromes and Li-Fraumeni syndrome kindreds.
Types of soft tissue sarcomas include:

28
Nutrition in Cancer Treatment

Alveolar soft-part sarcomas


Angiosarcoma
Dermatofibrosarcoma protuberans
Epithelioid sarcoma
Extraskeletal chondrosarcoma
Extraskeletal osteosarcoma
Fibrosarcoma
Leiomyosarcoma
Liposarcoma (accounting for 25% of all adult soft tissue sarcomas)
Malignant fibrous histiocytomas (accounting for 40% of total adult soft tissue sarcomas)
Malignant hemangiopericytoma
Malignant mesenchymoma
Malignant schwannoma
Malignant peripheral nerve sheath tumor
Rhabdomyosarcoma
Synovial sarcoma

Treatment. Treatment is determined by the staging of the tumor (e.g., size, histologic grade and
presence of local spread to nodes or distant metastases). Treatment is multimodal, with either pre- or
post-operative radiation therapy, usually depending on the physicians philosophy. Ideally, surgery
leaving clean margins and maintaining functionality for the patient is desirable. Patients with
metastases may be considered for adjuvant chemotherapy.
Prognosis. Prognosis is related to the site and stage of the sarcoma. Localized tumors that are
easily and completely resected are generally the most responsive to treatment. Retroperitoneal tumors,
particularly high-grade tumors, can be difficult to resect fully, thus these patients tend to have poorer
prognoses.

Pediatric Soft Tissue Sarcomas

This type of sarcoma originates in the primitive mesenchymal tissue. It accounts for about 7% of all
childhood tumors. Included in this group are:
Leiomyosarcoma
Fibromatosis
Malignant fibrous histiocytoma
Liposarcoma
Angiosarcoma
Hemangiopericytoma
Synovial sarcoma
Malignant schwannoma
Extraskeletal osteosarcoma
Extraskeletal mesenchymal chondrosarcoma
Extraskeletal myxoid chondrosarcoma
Malignant mesenchymoma

Tumor biopsies are differentiated through careful examination using immunocytochemical tests
and electron microscopy. Many of these tumors are characterized by chromosomal abnormalities.

29
Overview of Cancer and Its Treatment

A combination of surgery and radiation therapy generally yields good tumor control in about 80%
of patients. As with many childhood cancers, the long-term effects of the therapies are not
inconsequential (e.g., secondary cancers due to radiation exposure) and require careful consideration
and individualization.
Childhood rhabdomyosarcoma is a soft tissue tumor of the striated muscle. It accounts for about
3.5% of all cancers in children up to the age of 14 and 2% of the cases in children 15 to 19. The most
common sites of rhabdomyosarcoma are the head and neck, genitourinary tract and the extremities.
Less common sites include the trunk, the intrathoracic region and perineum.
Treatment. Treatment is generally multimodal. Surgical resection, followed by chemotherapy is
standard. Some children require a second look surgery if they had residual disease before
chemotherapy. Radiation therapy may be administered before or after surgery, depending upon the
physicians philosophy.
Prognosis. Prognosis depends on the site, extent and histopathology of the disease. It is a curable
disease in children who receive optimal therapy, with more than 60% surviving five years after
diagnosis. Primary sites with the most favorable outcome are the orbit and nonparameningeal head and
neck, and the nonbladder/nonprostate genitourinary region (especially the paratesticular and vaginal
regions). The extent of the disease and its surgery are also factors in outcome. Those with no residual
disease or microscopic residual disease had five-year survival rates of 90% and 80%, respectively, while
those with gross residual disease had only a 70% five-year survival rate.

Osteosarcoma

Osteosarcoma is a bone tumor that occurs most often in adolescents and young adults, with a peak
incidence around the adolescent growth spurt. Approximately 5% of all childhood tumors are
osteosarcomas. About 20% of patients have radiographically detectable metastases at the time of
diagnosis.
Treatment. Osteosarcoma is resistant to radiation therapy. Therefore, chemotherapy followed by
surgery is the standard treatment.
Prognosis. The site of the primary tumor is a big factor in survival. Tumors of the craniofacial
area, or other flat bones, have favorable survival rates when the entire bone can be removed. Only 20%
of patients receiving surgical intervention alone for localized tumors survive disease-free. Patients
whose tumors respond favorably to pre-surgical chemotherapy have more favorable prognoses.

Ewings Sarcoma

Ewings sarcoma is a group of childhood tumors including Ewings sarcoma of the bone,
extraosseous Ewings sarcomas, primitive neuroectodermal tumors and Askins tumor (a primitive
neuroectodermal tumor of the chest wall). These tumors all evolve from the same type of stem cell.
Ewings tumors are more common in the second decade of life, and affect boys slightly more often than
girls. Ewings sarcoma of the bone accounts for about 60% of Ewings tumors. Its sites of origin include
the extremities, pelvis, chest, spine and skull. Extraosseous Ewings sarcomas are found in the trunk,
extremities, head and neck, and retroperitoneum. Primitive neuroectodermal tumors (including Askins
tumors) occur in the trunk, extremities and retroperitoneum.
Treatment. Treatment may include surgery, radiation and/or chemotherapy, depending of the
extent of the disease. Retroperitoneal sites pose the most difficulties in surgical resection due to the
potential to leave residual tumor to spare vital tissues.

30
Nutrition in Cancer Treatment

Prognosis. Prognosis and treatment are based on the site, tumor volume and presence of
metastases. More localized tumors in the extremities have the most favorable outcomes. Younger
children fare better than adolescents and young adults.

Summary
Cancer is not one disease, or even the big four (breast, lung, prostate and colorectal cancers), but
rather a group of diseases with multiple primary sites and hundreds of pathologies. While there are
great similarities among hematology and oncology diagnoses, there are many differences as well.

References
1. National Comprehensive Cancer (NCCN) Clinical Practice Guidelines in Oncology, 2012. NCCN Web site.
http://nccc.org/clincal.org. Accessed July 18, 2012.

Resources
American Cancer Society. Cancer Facts and Figures, 2012. Atlanta, GA: The American Cancer Society; 2012.
Gates RA, Fink RM. Oncology Nursing Secrets, 3rd ed. Philadelphia, PA: Mosby Elsevier; 2006.
Laughlin EH. Coming to terms with cancer: A glossary of cancer-related terms. Atlanta, GA: American Cancer
Society; 2002.
National Cancer Institute. (NCI) Common types of cancer. http://www.cancer.gov/cancertopics/commoncancers
NCI Web site. Accessed July 18, 2012.
Taber CW. Tabers Cyclopedic Medical Dictionary, 21st ed. Philadelphia, PA: F.A. Davis Company; 2009.

31
Cancer and Metabolic Response

32
Nutrition in Cancer Treatment

Chapter Three:
Cancer and Metabolic Response
To enhance the understanding of the metabolic changes that occur in the presence of cancer, this chapter
includes a review of normal metabolism and metabolic pathways responsible for basal metabolism and
energy expenditure; a discussion of the metabolic changes associated with starvation; and alterations in
metabolism associated with cancer and cancer cachexia syndrome. The bulk of the chapter will be
presented as facts and figures with the intention of simplifying the content for providing nutrition care for
patients diagnosed with cancer.

C
ancer alters metabolism. To understand the metabolic changes that occur in the presence of
cancer, an understanding of normal metabolism and metabolic pathways responsible for basal
metabolism and energy expenditure is needed.

Carbohydrate Metabolism
Carbohydrates are absorbed as monosaccharides (glucose, galactose and fructose), which are
transported to the liver, where galactose and fructose are converted to glucose enzymatically. Glucose
may be used or stored.

33
Cancer and Metabolic Response

Use and Storage of Consumed Carbohydrates


Dietary CHO

Blood Gloucose

(glycogenesis) (lipogenesis)

STORAGE
Body cells
for energy
Liver and Liver and
Immediate Use Muscle glycogen adipose lipid

Glucose is transported to the bodys cells for use as energy. Glucose must go through glycolysis to
yield its energy to biological systems. Glycolysis takes each glucose molecule through a series of
reactions, producing two molecules of adenosine triphosphate (ATP), two molecules of hydrogen,
one molecule of pyruvate and one molecule of lactic acid.
Glycolysis takes place in the cytoplasm of the cell under anaerobic conditions. Energy inside ATP is
used as a source of system maintenance. Pyruvate spills into another pathway, called the tricarboxylic
acid cycle (TCA), or Krebs cycle.

34
Nutrition in Cancer Treatment

The TCA cycle takes place in the cell mitochondria under aerobic conditions, generating another
34 ATP molecules, along with carbon dioxide as a byproduct. Clinical and dietetic practitioners should
have a good understanding of this metabolic process, as ventilator-dependent patients produce CO2 as
a byproduct of metabolism. Extra glucose beyond that which the body needs for maintenance is stored
in the muscle and liver as glycogen. Some glucose may be converted into nonessential amino acids by
either transanimation, or by the addition of a nitrogen-containing molecular group in the liver. When
the glycogen storage is at capacity, extra glucose is converted to and stored as fat (fatty acids and
triglycerides).

If the body requires glucose for energy at a time when it is unavailable from the diet, it can convert

35
Cancer and Metabolic Response

stored glucose (glycogen in liver and muscle), or can convert fat to glucose via lipolysis. Here is a
summary of normal carbohydrate metabolism:
Glycogen in the liver is converted via glycogenolysis to glucose, which is transported to the rest
of the body for energy.
Protein from the liver and muscle can be converted to glucose via gluconeogenesis (creation of
glucose from a non-carbohydrate source). This process is called the Cori cycle.2
Stored fat can be converted to fatty acids and glycerol, from which glycerol can be converted to
glucose in a process called lipolysis, another type of gluconeogenesis.

Protein Metabolism
The following provides a summary of normal protein metabolism.1
Protein is absorbed in the form of amino acids and transported to the liver, which regulates
its function.
Protein forms the basis of enzymes, hormones, toxins and antibodies, and is needed for the
transport and storage of substrates.
Proteins serve as structural tissue in the form of cartilage, tendons and bone.
The primary function of protein is tissue synthesis.
All cells synthesize and break down protein on a continual basis (protein turnover).
Dietary amino acids, as well as those derived from protein breakdown, are used to create
proteins needed by the body for growth, repair or replacement of tissue (e.g., bone, muscle,
wound repair, skin, hair and nails) under the direction of ribonucleic acid (RNA).
Protein may also be used for energy when carbohydrates and lipids are insufficient.
Amino acids lose their nitrogen groups, leaving carbon skeletons, which are degraded to
pyruvate or other intermediates in the Krebs cycle.
Excess amino acids are converted to pyruvate and acetyl-CoA, and synthesized to fatty
acids, which combine with glycerol to form triglyceride for storage.

Lipid Metabolism
The following provides a summary of normal lipid metabolism.1

36
Nutrition in Cancer Treatment

Lipid metabolism is directed by the liver and adipose tissue and is triggered by lipotropic
factors, hormones and enzymes.
Lipotropic factors tell the body what to do when there is excess lipid in the liver, when
lipid can be stored and when it needs to be mobilized for energy.
When the liver has more than enough lipid, the excess is synthesized into triglycerides in a
process called lipogenesis.
Triglycerides, in turn, are transported by lipoproteins to adipose tissue for storage and
future use as energy.
Lipolysis also occurs in the liver, breaking down triglycerides into fatty acids and glycerol
when the body signals a need for circulating lipid.
Lipid stored in adipose tissue can be mobilized and converted to fatty acids and glycerol
for energy as well.
Hormones, like glucagon and epinephrine, trigger lipase enzymes to start the breakdown of
stored triglycerides into fatty acids and glycerol.
Free fatty acids are bound to albumin and transported to other tissues for use as energy in
a process known as -oxidation.

Metabolic Adaptation to Starvation


Acute starvation or dietary deprivation is characterized by a loss of body fat and preservation of
muscle mass.3 Inadequate dietary carbohydrate intake leads to mobilization of triglycerides from
adipose tissue, as mentioned previously. Triglycerides are broken down into glycerol and free fatty
acids, the latter of which are used for energy by most of the bodys cells. As lipid mobilization is
accelerated, the balance of lipogenesis and lipolysis is upset and free fatty acids are released into the
blood. The liver (and to some degree the kidneys) converts the free fatty acids to acetyl-CoA, which is
converted to energy in the TCA cycle. The problem with the use of free fatty acids is that too much
acetyl-CoA is formed and any excess that cannot be processed by the TCA cycle is used to produce
ketone bodies.
The heart and skeletal muscles are able to use the ketones as energy. After a period of time, even the
brain adapts and is able to convert ketones into ATP, but the liver cannot. During starvation, the
plasma ketone concentration increases, as the production of ketones surpasses the level at which the
heart and skeletal muscle can oxidize them.

Metabolic Changes Associated with Cancer


Energy metabolism is related intimately to carbohydrate, protein and lipid metabolism, all of which
are affected by tumor growth. Alterations in metabolism when cancer is present can impair nutritional
status by depleting the bodys protein, fat, water, and vitamin and mineral stores.3,4 This is evidenced by
the way some tumors can exert a constant demand for glucose. Of note, more recent studies using
indirect calorimetry have shown that the long-held belief that all patients with cancer have increased
energy expenditures are simply not valid.5 Results from these studies reveal that changes in energy
expenditures are more varied, do not occur with all tumor types and can range from 60% to 150% of
expected energy expenditure.6-8
Malignant cells can exhibit a high rate of anaerobic metabolism, which yields lactate as the end
product. This lactic acid pool requires an increased rate of host gluconeogenesis via Cori cycle activity,
which is increased in some cancer patients, but not others. Both protein breakdown and lipolysis take
place at increasing rates to maintain high rates of glucose synthesis.

37
Cancer and Metabolic Response

Additionally, metabolism may be affected by hormones or substances produced by the tumor or by


the body in response to the tumor.

Altered Carbohydrate M etabolism in Cancer

Some possible metabolic scenarios associated with cancer-related alterations in carbohydrate


metabolism include the following.3,9
Increased glucose synthesis
Decreased glucose turnover
Increased gluconeogenesis
Increased Cori cycle activity
Increased peripheral glucose uptake
Decreased glucose tolerance or insulin resistance
Increased glucose consumption by the tumor
Production of insulin or insulin-like substances by the tumor

Altered Protein M etabolism in Cancer

Possible alterations in protein metabolism associated with cancer include the following.3-10
Increased rate of whole-body protein turnover
Decreased protein synthesis
Increased skeletal tissue degradation
Increased synthesis of non-skeletal muscle protein
Increased hepatic synthesis of acute-phase reactants (as in trauma or sepsis)
Increased hepatic and tumor protein synthesis
Decreased plasma concentrations of gluconeogenic amino acids
Abnormal serum proteins, similar to kwashiorkor or protein-calorie malnutrition

Altered Lipid M etabolism in Cancer

Possible alterations in lipid metabolism associated with cancer include the following.3-10
Increased glycerol and fatty acid turnover
Increased plasma levels of free fatty acids
Increased lipid mobilization
Decreased lipogenesis and fat storage
Decreased lipoprotein lipase activity
Elevated triglycerides
Decreased high-density lipoproteins
Increased venous glycerol
Decreased plasma glycerol clearance
Increased lipid oxidation
Possible tumor dependence on specific fatty acids (linoleic and arachidonic acids)
Increased use of fatty acids as energy by host tissue in the presence of certain tumors
Impaired suppression of lipid mobilization, in the presence of glucose administration
Increased metabolic rate secondary to increased gluconeogenesis from glycerol

38
Nutrition in Cancer Treatment

Cancer Cachexia Syndrome


A common secondary diagnosis in patients with advanced cancer is a variant of protein-energy
malnutrition. This syndrome is called cancer cachexia and is characterized by progressive weight loss,
anorexia, generalized wasting and weakness, immunosuppression, altered basal energy expenditure, and
abnormalities in fluid and energy metabolism.11,12
In contrast to starvation, individuals with cancer cachexia can experience a loss in adipose and
skeletal muscle mass while visceral muscle mass is preserved, weight loss not reversed with increases in
nutrition intake alone and weight loss despite increased intake of nutrients.13
The etiology of cancer cachexia is not clearly understood and can manifest in patients with
metastatic disease, as well as those with localized disease. Recent work has focused on the role of
cytokines, which through broad physiological actions, produce metabolic changes and wasting in
tumor-bearing hosts that are similar but not identical to changes seen in patients with sepsis and
inflammation.4
Cytokines are soluble proteins, peptides or glycoproteins, produced predominately by immune cells,
that mediate interactions between cells and regulate cellular and tissue function.3,9,10,14 These substances
are found in the blood, ascites, pleural effusions and urine of cancer patients and are believed to play a
major role in the biological responses that lead to the wasting seen in cancer cachexia.12,15
Examples of specific cytokines related to cancer cachexia are:16
Tumor necrosis factors (TNF- and TNF-)
Cachectin
Interleukin-1 (IL-1)
Interleukin-6 (IL-6)
Interferon- (INF-)

Abnormalities in the bodys hormones are also believed to be associated with cancer cachexia and
include:
Increased cortisol
Decreased insulin
Decreased insulin resistance
Decreased testosterone

Animal studies have shown that proteolysis-inducing factor (PIF) and lipid-mobilizing factor
(LMF) may also contribute to cancer cachexia.12,15 PIF is directed by tumor cells to induce protein
breakdown in skeletal muscle, decrease protein synthesis and increase cytokines.12
LMF found in the sera of cancer patients has been shown to be proportional to the extent of
weight loss. It appears that eicosapentaenoic acid (EPA) found in fish oil can inhibit LMF.9,14 Other
fatty acids, such as docosahexaenoic acid (DHA), also found in fish oil and flaxseed, gamma linoleic
acid (GLA) and linoleic acid (LA) were ineffective in inhibiting LMF. There may also be a protein-
mobilizing factor (PMF) present in weight-losing cancer patients. A proteoglycan, 24Kda, has been
shown to induce muscle protein degradation. Interestingly, EPA was found to decrease protein
degradation, as well as LMF-related weight loss 9,14

Summary
The etiology of cancer-associated weight loss and cachexia is multifactorial. Decreased food intake

39
Cancer and Metabolic Response

alone does not account for the wasting and impaired nutritional status observed in some cancer
patients. Cancer-related metabolic changes cannot be explained in a simple manner. It is likely that the
etiology is specific to tumor type and is influenced by alterations in substrate metabolism. Additional
factors like hormones, cytokines and other catabolic factors contribute to weight loss in some patients.

References
1. Berg JM, Tymoczko JL, Stryer L. Biochemistry. 5th ed. New York NY: WH Feeman, 2002.
2. Cori CF. The glucose-lactic acid cycle and gluconeogenesis. Curr Top Cell Regul. 1981;18:377-387.
3. Trujillo E, Nebeling L. Changes in carbohydrate, protein and fat metabolism in cancer. In: The Clinical
Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: The
American Dietetic Association; 2006:17-27.
4. Tisdale MJ. Pathogenesis of cancer cachexia. J Support Oncol. 2003;1(3):159-168.
5. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Clinical Nutrition for Oncology
Patients. Marian M, Roberts S, eds. Sudbury, MA: Jones & Bartlett Publishers; 2010:21-44.
6. Khalid U, Spiro A, Baldwin C, et al. Symptoms and weight loss in patients with gastrointestinal and lung
cancer at presentation. Support Care Cancer. 2007;15(1):39-46.
7. Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the
diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059-1065.
8. Bosaeus I, Daneryd P, Lundholm K. Dietary intake, resting energy expenditure, weight loss and survival in
cancer patients. J Nutr. 2002;132(suppl 11):3465S-3466S.
9. Tisdale MJ. Cancer cachexia: metabolic alterations and clinical manifestations. Nutrition. 1997;13(1):1-7.
10. Keller U. Pathophysiology of cancer cachexia. Support Care Cancer. 1993;1(6):290-294.
11. Barber MD, Ross JA, Fearon KC. Cancer cachexia. Surg Oncol. 1999;8(3):133-141.
12. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2(11):862-871.
13. Huhmann MB, August D. Surgical Oncology. In: Clinical Nutrition for Oncology Patients. Marian M, Roberts
S, eds. Sudbury, MA: Jones & Bartlett Publishers; 2010:101-136.
14. Tisdale MJ. Biology of cachexia. J Natl Cancer Inst. 1997;89(23):1763-1773.
15. Dunlop RJ, Campbell CW. Cytokines and advanced cancer. J Pain Symptom Manage. 2000;20(3):214-232.
16. Argiles VM, Busquets S, Lopez-Soriano FJ. Cytokines in the pathogenesis of cancer cachexia. Curr Opin
Nutr Metab Care. 2003;6(4):401-406.

40
Nutrition in Cancer Treatment

41
Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

Chapter Four:
Nutrition Screening, Assessment
and Diagnosis in the Oncology Setting
This chapter will explore nutrition screening and assessment tools that are commonly used in oncology
care setting, such as the Scored Patient-Generated Subjective Global Assessment (PG-SGA) along with
other assessment tools. The PG-SGA includes nutrition screening, triage and assessment components and
has been validated for use in the oncology population. Examples of commonly used nutrition diagnosis
statements indentified in the Academy of Nutrition and Dietetics Evidence Analysis Librarys Oncology
Toolkit will be provided.

For supplemental information to this chapter, please review the following appendices:
Appendix 3 Nestl Mini Nutritional Assessment (MNA)
Appendix 4 Scored Patient-Generated Subjective Global Assessment (PG-SGA)

I
n 2003, the Academy of Nutrition and Dietetics (AND) adopted the Nutrition Care Process (NCP)
as a four-step, systematic framework for dietetic professionals to provide nutrition care in a variety
of care settings.1 Nutrition assessment is the first step of the four-step NCP and provides an
organized method for obtaining, verifying and interpreting information needed to identify nutrition-
related problems, their causes and significance.2 The second step is nutrition diagnosis, where dietetic
professionals use standardized language to identify and label specific nutrition problems for the
healthcare team. The remaining two steps of the NCP include nutrition intervention, and nutrition
monitoring and evaluation.
With the continued shift of healthcare from the hospital setting to the ambulatory setting, nutrition
screening and assessment are critical components of patient care in the oncology setting. In a review by
Huhmann and August, the incidence of weight loss and malnutrition in adults with cancer was 31% to
100%, depending on tumor site, stage and treatment.3 Malnutrition is common and has been shown to
be the cause of death in about 20% of patients with cancer.4,5 It is associated with increased morbidity
and mortality, decreased response to therapy, increased healthcare costs and a negative force in
activities of daily living and quality of life.6 Proactive nutrition screening and risk assessment are the
cornerstones of success in preventing such outcomes in the oncology patient care setting.7-9
Early nutrition intervention is essential for optimal patient care. Nutrition screening is used to
identify individuals at nutritional risk. Screening for nutrition-related problems should be
multidisciplinary, instituted at the time of diagnosis and monitored throughout the continuum of
cancer treatment and care.10,11 The Joint Commission and Centers for Medicare and Medicaid services
(CMS) require that nutrition screening be performed in all healthcare settings, with each facility
establishing its own nutrition-screening process for indentifying nutritional risks. Nutrition-screening
criteria commonly includes height, weight, body mass index (BMI), unintentional change in weight,
change in appetite, diet, diagnosis, alterations in chewing and swallowing, bowel habits and laboratory

42
Nutrition in Cancer Treatment

data.12 Effective screening tools should be simple, easy-to-use and able to be completed by any qualified
member of the oncology healthcare team.
Once nutrition screening has been conducted to identify nutrition risk and malnutrition, a
thorough nutrition assessment is needed. The NCP defines nutrition assessment as the timely
collection of pertinent patient data that is analyzed and interpreted with evidence-based standards to
determine nutrition status and need for nutrition intervention. Charney and Marian state that the
nutrition assessment process uses information gathered during screening and adds more in-depth,
comprehensive data, as well as interpretation of those data, to determine the presence and degree of
nutrient deficiency.12
Nutrition screening and assessment parameters include patient history, food/nutrition history,
biochemical data, anthropometric data and nutrition-focused physical examination.

Nutrition Assessment: Key Components12


Patient History Food/Nutrition History
Pertinent medical and social history Meal and snack patterns
Cultural and ethnic practices Adequacy of intake
Medication and supplement use Food availability
Socioeconomic status Food/nutrient tolerance
Physical activity
Biochemical Data Anthropometric Data
Albumin/prealbumin Height
CBC with differential Weight
Electrolytes Weight history
Lipid panel BMI
Micronutrient levels Weight-to-hip ratio
Nutrition-focused Physical Examination
General appearance
Overall muscle stores
Adipose stores
Oral cavity
Hair, skin, nails

Through a comprehensive nutrition assessment process, dietetic professionals can then determine
the most appropriate nutrition diagnosis and subsequent nutrition interventions.

Standardized Tools
A number of nutrition screening and assessment tools have evolved over the years. Although not
every one is specific to the oncology population, the following tools have practical applications in the
oncology setting as evidenced by their use in cited oncology nutrition literature.
The M ini Nutritional Assessment (MNA) was developed as a quick and efficient tool to
screen and assess for the risk of malnutrition in the elderly ages 65 and older).13,14 Although this tool
has been used frequently with oncology patients, it has not been specifically validated for use in
oncology patients.

43
Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

While there are no laboratory values included, the MNA does consider anthropometric
measurements, including BMI. There are a number of questions that relate to nutritional intake, but
none that consider symptoms affecting nutritional status. The MNA includes screening and
assessment components, both of which are scored, indicating level of nutrition risk. However, there are
no intervention guidelines.
The benefits of using the MNA are that it is based on multiple parameters and is easy to use.13,15
Limitations include its use is indicated only in the geriatric population, the absence of nutrition impact
symptoms and other oncology-specific factors that may affect metabolic demand, and lack of validation
for use in oncology patients.
The M alnutrition Screening Tool (MST) is a measure that uses the following criteria to
identify patients at nutritional risk: unintentional weight loss, percentage weight loss and decreased
appetite. It is validated for use with adults in acute-care settings and the cancer population (it has been
validated for use in patients receiving radiation therapy).16
The M alnutrition Universal Screening Tool (MUST) is a measure that uses the following
criteria to identify patients at nutritional risk: BMI, percentage of unintentional weight loss and acute
disease effect. It was developed for use with adults in the acute-care setting.17
The 7 th Vital Sign is an outpatient oncology nutrition-screening tool that incorporates two
criteria unintentional weight loss and a decrease in appetite to identify cancer patients at
nutritional risk.18 As the name implies, the 7th Vital Sign screening for the risk of malnutrition is an
important consideration when performing a comprehensive patient care assessment (the other six vital
signs are temperature, blood pressure, pulse, respirations, oxygenation and pain).
Subjective Global Assessment (SGA) was originally developed by Jeejeebhoy and colleagues
in the 1980s.19 The SGA has been used in a number of patient populations and has been shown to
have superior sensitivity and specificity to more traditional measures of nutrition assessment, such as
albumin.19-21
The SGA is comprised of history (weight loss, dietary intake, gastrointestinal [GI] symptoms and
functional capacity), metabolic demands of the underlying disease and a nutrition-related physical
exam.22 The subjective physical examination considers patients loss of subcutaneous fat and presence
of muscle wasting, edema and/or ascites.
As the name suggests, the rating of nutritional status is subjective and based on the global picture
of nutrition status as evidenced by the sum of the parameters, with A = well nourished; B = moderately
malnourished, or at risk; and C = severely malnourished.
Scored Patient-Generated Subjective Global Assessment (PG-SGA). In the mid-1990s,
Ottery adapted the SGA to meet the needs of the oncology population by increasing the GI symptom
section to include common nutrition impact symptoms found in patients with cancer.6 The history
section of the tool has evolved to become patient-generated to streamline the process and to involve
patients and patient caregivers.
With further refinement, a scoring and triage component was added and the assessment tool has
evolved into the latest version. The Scored PG-SGA has been validated as a nutrition-assessment tool
in patients diagnosed with cancer and receiving cancer treatment.16,23,24 Researchers have also found
that the Scored PG-SGA correlates with quality of life in cancer patients undergoing radiation
therapy.25

44
Nutrition in Cancer Treatment

Benefits and Limitations of the Scored PG-SGA16,23,26-29


Benefits
Multiple parameters, inclusive of cancer-related nutrition impact symptoms
Quick to complete (takes a trained oncology healthcare clinician about five minutes)
Validated in oncology setting
Cost effective, no costly laboratory analyses
Non-invasive
Includes triage guidelines
Consistent means of identifying patients at risk
High degree of inter-rater agreement
Score can be used sequentially to track patient outcomes
Limitations
Nurses often perceive the assessment tool as additional work
Resistance to implement the physical examination
May identify more patients at risk than nursing and nutrition staff can accommodate

Scored PG-SGA: A Comprehensive Review


The patient and/or family member complete quadrants 1 through 4 on the history portion of the
PG-SGA. A member of the oncology healthcare team (e.g., nurse, dietitian, dietetic technician, physician
or physicians assistant) completes quadrants 5 and 6. A physical exam completes the assessment
portion of the PG-SGA. The oncology healthcare team member then scores the PG-SGA, using the
tables and worksheets found on the second page/reverse side of the form.
The tables and worksheets for scoring are self-explanatory; however, the physical exam requires
training. Training must be done with patients and an experienced clinician and/or the PG-SGA Training
Video produced by the Academy of Nutrition and Dietetics.11

Overview of the Nutrition-related Physical Examination

Assessment of subcutaneous fat. Loss of subcutaneous fat suggests an energy deficit and may
be assessed by observing the areas where adipose tissue is typically stored.
The PG-SGA examines the fat pads under the eye, which is one of the first places that adipose
losses will be evident. Another area to note is the fat pad over the triceps area. Finally, the fat stores
over the lower anterior ribs are examined.
Each site is ranked as either 0 = no deficit, 1+ = mild deficit, 2+ = moderate deficit, and 3+ = severe
deficit. An overall rating of fat stores is based on the average ranking for all of the sites examined.
Assessment of muscle stores. Assessment of muscle stores should include an evaluation of the
muscle volume, as well as tone and functionality. There are some differences with respect to sex, which
are reviewed and depicted in the PG-SGA Training Video.11 It is important to note that the muscles of
the upper body are more susceptible to depletion secondary to nutritional deprivation, while the
depletion of the muscles of the lower body may be secondary to inactivity (which may also be due to
malnutrition).
One of the first, subtle changes that may be observed in a mildly or moderately malnourished
patient is hollowing of the temples, which is due to wasting of the temporalis muscle, one of the sites

45
Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

evaluated during the physical exam. Other sites to be examined for muscle wasting include the pectoral
and deltoid muscles surrounding the clavicle and shoulders, the interosseous muscle between the
thumb and forefinger, the trapezius and deltoid muscles surrounding the scapula, the quadriceps of the
thigh and the gastrocnemius muscle of the calf.
Each site that is examined is ranked, just as the sites for fat stores were ranked (0 = no deficit, 1+ =
mild deficit, 2+ = moderate deficit, 3+ = severe deficit), with the average or overall ranking serving as
the global rating for muscle stores.
Assessment of fluid status. Lastly, fluid status must be assessed, as severe malnutrition often
causes edema due to oncotic pressure changes. Weight can be skewed due to presence of ascites and/or
edema. Patients are examined for pedal (foot and ankle) edema, as well as sacral edema in the chair or
bed-bound patient. Finally, the presence of ascites is noted. Again, ranking is noted for each site, as well
as the global or overall fluid status, using the 0, 1+, 2+ and 3+ system.
Scoring the physical exam . The score for the entire physical exam is global in nature, and
muscle wasting is weighted more heavily than fat loss or fluid overload. The score is not the sum of the
three body compartments, but an overall picture of the patients nutriture. The score for this section is
0 = no deficit, 1 = mild deficit, 2 = moderate deficit or 3 = severe deficit. The greatest possible score for
the physical exam section is 3 points.

Scoring the PG-SGA


The score of the PG-SGA is the sum of boxes A, B, C and D, as outlined in the Tables and
Worksheets for Scoring. Guidelines for the triage of nutrition intervention are provided at the bottom
of the first page of the form. The PG-SGA ratings (A = well nourished; B = moderately malnourished, or
at risk; C = severely malnourished) are based on the global picture painted by the entire PG-SGA.
Simply mark the appropriate responses to weight, intake, nutrition impact symptoms, functioning
and physical exam categories in Table 5, found in Appendix 4. Wherever the preponderance of
responses lies, there is the assessment rating. Whenever in doubt, it is best to err toward the middle.
Also, the history data weighs more heavily than the physical exam, as these symptoms may occur
before physical changes. It is important to note that progress in the history data obtained in subsequent
evaluations may occur before improvements in the physical exam can be appreciated.

W hat is the difference between the Score and the Rating?

Although related, they are independent triage and assessment systems. In general, higher scores
correlate with C, or severely malnourished patients. Patients seen for follow-up may still have a fairly
high score, but with non-fluid weight gain, may be rated an A, or anabolic. Ideally, positive outcomes
measures would include decreased PG-SGA score and improved rating. These measures could be tied to
incidence of nutrition-related complications and associated costs, as well as treatment cessation for
treatment-related nutritional toxicity (weight loss and unmanaged nutrition impact symptoms).

46
Nutrition in Cancer Treatment

Scored Patient-Generated Subjective Global Assessment (PG-SGA)


History (Boxes 1-4 are designed to be completed by the patient.)
1. Weight (See worksheet 1, next page)
In summary of my current and recent weight:
I currently weigh about ___175____ lb
I am about ____5_____ feet _____10___ inches tall.
One month ago I weighed about __182_____ lb
Six months ago I weighed about __190______ lb
During the past two weeks my weight has:
decreased (1) not changed (0) increased (0)
Box 1: 3 points
2. Food Intake: As compared to my normal intake, I would rate my food intake during the past month as:
unchanged (0)
more than usual (0)
less than usual (1)
I am now taking:
normal food but less than normal amount (1)
little solid food (2)
only liquids (3)
only nutritional supplements (3)
very little of anything (4)
n only tube feedings or only nutrition by vein (0)
Box 2: 3 points
3. Symptoms: I have had the following problems that have kept me from eating enough during the past
two weeks (check all that apply):
no problems eating (0)
no appetite, just did not feel like eating (3)
nausea (1) vomiting (3)
constipation (1) diarrhea (3)
mouth sores (2) dry mouth (1)
things taste funny or have no taste smells bother me (1)
problems swallowing (2) feel full quickly (1)
pain (3): where? ______________
other (1)* ____________________
no problems eating (0)
*examples: depression, money, or dental problems
Box 3: 5 points
4. Activities and Function: Over the past month, I would
generally rate my activity as:
normal with no limitations (0)
not my normal self, but able to be up and about
with fairly normal activities (1)
not feeling up to most things, but in bed or chair
less than half the day (2)
able to do little activity and spend most of the day
in bed or chair (3)
pretty much bedridden, rarely out of bed (3)
Box 4: 1 point

47
Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

Additive Score of the Boxes 1-4: 12 A


The remainder of this form will be completed by your doctor, nurse or therapist. Thank you.
5. Disease and its relation to nutritional requirements (See Worksheet 2)
All relevant diagnoses (specify) ______Esophageal cancer____________________________
Primary disease stage (circle if known or appropriate) I II III IV Other ______________________
Age ____62_____Numerical score from Worksheet 2 B
6. Metabolic Demand (See Worksheet 3) Numerical score from Worksheet 3 C
7. Physical (See Worksheet 4) Numerical score from Worksheet 4 D
Global Assessment (See Worksheet 5)
Well-nourished or anabolic (SGA-A)
Moderate or suspected malnutrition (SGA-B)
Severely malnourished (SGA-C)

Total PG-SGA score _____________________


(Total numerical score of A+B+C+D above)
(See triage recommendations below)

Clinician Signature _______________ RD RN PA MD DO Other _______ Date___________


Nutritional Triage Recommendations: Additive score is used to define specific nutritional interventions including patient
and family education, symptom management including pharmacologic intervention, and appropriate nutrient intervention
(food, nutritional supplements, enteral, or parenteral triage). First line nutrition intervention includes optimal symptom
management.
0-1: No intervention required at this time. Re-assessment on routine and regular basis during treatment.
2-3: Patient & family education by dietitian, nurse, or other clinician with pharmacologic intervention as indicated by
symptom survey (Box 3) and laboratory values as appropriate.
4-8: Requires intervention by dietitian, in conjunction with nurse or physician as indicated by symptoms survey (Box 3).
9: Indicates a critical need for improved symptom management and/or nutrient intervention options.

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Nutrition in Cancer Treatment

Other Assessment Tools


Standardized symptom and activity scales are tools used across the continuum of cancer care by
oncology healthcare professionals to assess and evaluate patients cancer-related symptoms; cancer
treatment-related side effects; and psychosocial, socioeconomic, functional and behavioral status.
Examples of these scales include:
National Cancer Institutes Common Terminology Criteria for Adverse Events (CTCAE),
version 4.03, which assesses acute toxicities related to cancer and its treatment30
Activities of Daily Living (ADL), which assesses routine activities, such as eating, bathing,
dressing, toileting and transferring31
Karnofsky Performance Scale (KPS), which assesses functional status/impairment32

Oncology-related Nutrition Diagnoses


As outlined in the NCP, nutrition diagnosis is divided into three general domains: intake, clinical
and behavioral/environmental.2

Common Oncology-related Nutrition Diagnoses33


Intake Domain
Inadequate energy intake Increased nutrient needs
Excessive energy intake Malnutrition
Inadequate oral intake Inadequate protein-energy intake
Excessive oral intake Imbalance of nutrients
Inadequate enteral (EN) or parenteral Inadequate protein intake
(PN) infusion Excessive fat intake
Excessive EN or PN infusion Excessive carbohydrate intake
Less than optimal EN or PN infusion Inadequate fiber intake
Inadequate fluid intake Excessive fiber intake
Excessive fluid intake Inadequate vitamin or mineral intake
Inadequate bioactive substance intake (specify)
Excessive bioactive substance intake Excessive vitamin or mineral intake
Excessive alcohol intake (specify)
Clinical Domain
Swallowing difficulty
Chewing or biting difficulty
Altered GI function
Impaired nutrient use
Altered nutrition-related laboratory values (specify)
Food-medication interaction
Underweight
Unintentional weight loss
Overweight/obesity
Unintentional weight gain
Behavioral Domain
Food- and nutrition-related knowledge deficit

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Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

Harmful beliefs/attitudes about food- or nutrition-related topics


Not ready for diet/lifestyle change
Limited adherence to nutrition-related recommendations
Physical inactivity
Impaired ability to prepare foods/meals
Intake of unsafe food
Limited access to food or water
Limited access to nutrition-related supplies

Nutrition Diagnosis: PES Statements


The nutrition diagnosis PES statement is composed of three distinct components: the problem
(P), the etiology (E), and the signs and symptoms (S).2 The PES statement describes a specific nutrition
problem, its root or contributing causes, and the data obtained from the nutrition assessment that
supports the nutrition diagnosis.
The PES statement framework is outlined as follows:

___________________ related to ________________ as evidenced by __________________.


Nutrition Diagnosis Label Etiology or Risk FactorsMeasurable Symptom or Sign

Oncology-related Nutrition Diagnosis: PES Statements33


Intake Domain
Inadequate energy intake related to anxiety and sleeplessness as evidenced by
weight loss more than 10% in two months.
Inadequate oral intake related to improper administration of pain medication
as evidenced by nausea, vomiting, anorexia and continued weight loss in the
past week.
Inadequate intake from enteral nutrition support related to target goal not
achieved as evidenced by weight loss of 4 lb in the past two weeks.
Inadequate fluid intake related to uncontrolled diarrhea from pelvic radiation
as evidenced by more than 5% weight loss in the past two weeks, poor skin
turgor, thickened saliva and hypernatremia.
Inadequate fiber intake related to prolonged intake of liquids only as
evidenced by low stool volume and constipation for the past five days.
Clinical Domain
Swallowing difficulty related to presence of an esophageal tumor as evidenced
by regurgitation of food, vomiting and weight loss of more than 5% in the past
month.
Altered GI function related to s/p Whipple Procedure as evidenced by weight
loss of more than 5% in the past three weeks, steatorrhea and an episode of
emergency IV hydration.
Overweight/obesity related to psychological stress, excessive energy intake
and sedentary lifestyle as evidenced by BMI of 37 (obesity grade II).
Behavioral Domain
Inability to manage self-care related to learning disability, lack of supportive

50
Nutrition in Cancer Treatment

care and caregivers as evidenced by not using feeding tube, and continued
weight loss to 89% of usual body weight.
Impaired ability to prepare foods/meals related to increased fatigue and living
alone as evidenced by progressive weight loss to 90% of pre-treatment body
weight.
Limited access to food related to failure to participate in federal food
programs as evidenced by continued weight loss of 5 lb in the past two weeks
during cancer treatment.

Summary
Consistent and timely nutrition screening and assessment is difficult in todays healthcare
environment where dietetic professionals, nurses and other oncology healthcare team members are
spread thin. Yet, as evidence suggests, with proactive screening and assessment, patients at risk for
developing malnutrition may be identified and treated early, improving quality of life and decreasing
healthcare costs in many cases. Nutrition assessment is best achieved with a tool that does not rely on
single parameters, but rather the sum of a variety of factors. Oncology nutrition assessment must
consider hydration, comorbid diseases and immune function along with the patients dietary, medical,
social, functional and weight history. The Scored PG-SGA is well suited to the oncology setting,
providing screening, triage and nutrition assessment components, and works well in a multidisciplinary
setting. Optimum patient care can be achieved with this consistent means of identifying cancer patients
at risk for malnutrition.
Nutrition diagnosis is based on the results of a thorough nutrition assessment, dietetic
professionals clinical judgment, and the likelihood the nutrition intervention or treatment can help to
resolve or improve patients signs and symptoms. Nutrition diagnoses are not medical diagnoses, but
identify nutrition-related problems that affect nutritional status and health.

Case Study
WC, a 62-year-old male, has distal esophageal cancer. He is scheduled to begin neoadjuvant
chemotherapy and radiation therapy in 10 days, followed by a surgical resection of the affected portion
of the gastroesophagus junction.
Pertinent nutrition assessment data includes:
Height: 510 (177.8 cm); Weight: 175 lb (79.5 kg)
Usual Weight (six months ago): 190 lb; Weight one month ago: 182 lb
Albumin: 3.2 g/dL
Food intake: less than usual, avoidance of some dry, scratchy foods
Complaints: anorexia, dysphagia, food sticking and early satiety
Functional capacity: not normal; still able to work, but easily fatigued with exertion
Afebrile
Medications: do not include steroids
Physical exam: normal fat stores, mildly depleted muscle stores, no edema or ascites

PG-SGA Score = 12 (triage recommendations: score 9 indicates need for improved symptom
management and/or nutrition intervention options).
Weight: 3 points (2 points for weight loss of 4% over one month + 1 point
for weight loss over the past two weeks)

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Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

Food Intake: 1 point (for normal diet, but less intake)


Symptoms: 5 points (3 for anorexia, 1 for problems swallowing and 1 for early satiety)
Activities/Function: 1 point (not normal, but up and about)
Diagnosis: 1 point (for cancer diagnosis)
Metabolic Demand: 0 points (afebrile and not on steroids)
Physical Exam: 1 point (for mildly depleted muscle stores)

PG-SGA Rating = B (moderately malnourished, or suspected of malnutrition)


See PG-SGA worksheet for Global Assessment Categories, which place WCs assessment largely in
the Stage B rating in worksheet 5. In weight and functioning, WCs rating was between Stage A and B,
because the patient exhibits greater than Stage A and is approaching Stage B, and is noted with an x.
Note: The Prognostic Nutritional Index (PNI) did not identify this man as malnourished, yet the
PG-SGA caught the early signs and risk factors for malnutrition, allowing for earlier intervention.

NCP PES Statement for W C:


Inadequate oral intake related to esophageal cancer as evidenced by dysphagia, early satiety
anorexia, and 7 lb weight loss in the preceding month.

References
1. Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and
outcomes. J Am Diet Assoc. 2003;103(8):1061-1072.
2. Academy of Nutrition and Dietetics. International Dietetics & Terminology: Reference Manual, Standardized
Language for the Nutrition Care Process. 3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2010.
3. Huhmann MB, August D. Surgical oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology
Patients. Sudbury, MA: Jones & Bartlett; 2010:101-136.
4. Stepp L, Pakiz TS. Anorexia and cachexia in advanced cancer. Nurs Clin North Am. 2001;36(4):735-744, vii.
5. Ottery FD. Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract. 1994;2(2):123-
131.
6. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology.
Nutrition. 1996;12(1 Suppl): S15-S19.
7. Ottery FD. Supportive nutrition to prevent cachexia and improve quality of life. Semin Oncol. 1995;22(2
Suppl 3):98-111.
8. Lees J. Incidence of weight loss in head and neck cancer patients on commencing radiotherapy treatment
at a regional oncology center. Eur J Cancer Care. 1999;8(3):133-136.
9. Ferguson ML, Bauer J, Gallagher B, et al. Validation of a malnutrition screening tool for patients receiving
radiotherapy. Australas Radiol. 1999;43(3):325-327.
10. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Marian M, Roberts S, eds.
Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones & Bartlett; 2010:21-44.
11. McCallum PD, Polisena CG, eds. Patient-Generated Subjective Global Assessment video. Chicago:
American Dietetic Association, 2001.
12. Charney P, Marian M. Nutrition screening and risk assessment. In: Charney P, Malone A, eds. ADAs Pocket
Guide to Nutrition Assessment. 2nd ed. Chicago: American Dietetic Association; 2009:1-19.
13. Vellas B, Guigoz Y, Baumgartner M, et al. Relationships between nutritional markers and the mini-nutritional
assessment in 155 older persons. J Am Geriatr Soc. 2000;48(10):1300-1309.
14. MNA Mini Nutritional Assessment (MNA): users guide and MNA video. Nestle Nutrition Institute Web site.
http://www.mna-elderly.com/user_guide.html. Accessed July 18, 2012.

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15. Schneider SM, Hebuterne X. Use of nutritional scores to predict clinical outcomes in chronic diseases. Nutr
Rev. 2000;58(2 Pt 1):31-38.
16. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for
adult acute hospital patients. Nutrition. 1999;15(6):458-464.
17. Malnutrition Universal Screening Tool (MUST). British Association for Parenteral and Enteral Nutrition Web
site.http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must. Accessed July 18, 2012.
18. Levin RM. The 7th vital sign: implementing a malnutrition screening tool at a community cancer center.
Oncol Nutr Connect. 2010;18(3):10-14.
19. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN.
1987;11(1):8-13.
20. Enia G, Sicuso C, Alati G, Zoccali C. Subjective global assessment of nutrition in dialysis patients. Nephrol
Dial Transplant. 1993;8(10):1094-1098.
21. McLeod RS, Taylor BR, OConnor BL, et al. Quality of life, nutritional status, and gastrointestinal profile
following Whipple procedure. Am J Surg. 1995;169(1):179-185.
22. McCallum PD. Nutrition screening and assessment in oncology. In: The Clinical Guide to Oncology
Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago: American Dietetic
Association; 2006:44-53.
23. Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-
SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56(8):779-785.
24. Ottery FD, Kasenic S, De Bolt S, et al. Volunteer network accrues > 1900 patients in 6 months to validate
standardized nutritional triage. Proc ASCO. 1998;17:Abstract 282.
25. Bauer J, Capra S, Isenring E. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA)
as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56(8):779-785.
26. Persson C, Sjoden PO, Glimelius B. The Swedish version of the patient-generated subjective global
assessment of nutritional status: gastrointestinal vs urological cancers. Clin Nutr. 1999;18(2):71-77.
27. Capra S, Ferguson M, Ried K. Cancer: impact of nutrition intervention outcome nutrition issues for
patients. Nutrition. 2001;17(9):769-772.
28. Sacks GS, Dearman K, Replogle WH, et al. Use of subjective global assessment to identify nutrition-
associated complications and death in geriatric long-term care facility residents. J Am Coll Nutr.
2000;19(5):570-577.
29. Thoresen L, Fjeldstad I, Krogstad K, Kaasa S, Falkmer UG. Nutritional status of patients with advanced
cancer: the value of using the subjective global assessment of nutritional status as a screening tool. Palliat
Med. 2002;16(1):33-42.
30. Common Terminology Criteria for Adverse Events (CTCAE) v 4.03. National Cancer Institute Web site.
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf. Accessed July
18, 2012.
31. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily
living. Gerontologist. 1969;9(3):179-186.
32. Karnofsky Performance Status Scale Definitions Rating (%) Criteria. Hospice Patients Alliance Web site.
http://hospicepatients.org/karnofsky.html. Accessed July 18, 2012.
33. Academy Oncology Evidence-based Nutrition Practice Guideline. Academy of Nutrition and Dietetics Web
site. https://www.adaevidencelibrary.com/store.cfm?category=1. Accessed July 18, 2012.

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Nutrition Screening, Assessment and Diagnosis in the Oncology Setting

54
Nutrition in Cancer Treatment

Chapter Five:
Determining Nutrition Requirements
for Adults with Cancer
This chapter examines energy, protein, fluid and micronutrient requirements of adults, as well as reviews
methods for calculating nutrition needs in the clinical setting.

D etermining the nutrition requirements for people diagnosed with cancer is a challenging and
complex task. Cancer and its treatment can significantly influence the nutritional status of
individuals undergoing and recovering from treatment. Those demands coupled with the
presence of nutrition impact symptoms can adversely affect the ability to eat.1
Other important factors that affect nutritional well-being include nutrition status at the time of
cancer diagnosis, presence of comorbid diseases, current medications, age, sex and performance status.
Nutritional needs can change dramatically during the course of cancer treatment; thus, it is imperative
that dietetic professionals regularly assess individuals throughout the continuum of cancer care. The
overall goals of nutrition management for people diagnosed with cancer are:
To prevent or reverse nutrient deficiencies
To preserve body cell mass
To manage nutrition-related side effects
To maximize quality of life

Energy Requirements
The metabolic changes that occur in cancer are not consistent, nor are they simple to explain. A
common belief among oncology clinicians is that all patients diagnosed with cancer are hypermetabolic;
however, a study conducted in 200 hospitalized cancer patients illustrates energy metabolism varies
significantly from patient to patient.2 The study found 33% of the patients evaluated were
hypometabolic, 41% were normometabolic and only 26% were hypermetabolic. Additional evidence
demonstrating that a patients site of cancer or tumor type does not accurately predict his or her resting
energy requirements or overall energy needs is consistently supported in the literature.3-5 Dietetic
professionals should make careful estimates of each patients energy requirements using established
methods along with clinical judgment.
Indirect calorimetry is a validated, evidenced-based method of accurately determining energy
expenditure in critically ill hospitalized patients.6,7 Its use requires a measurement cart or device, and
can be impractical and expensive in the ambulatory setting where the majority of oncology care is
provided. Guidelines for using and interpreting of measurements derived from indirect calorimetry are
well documented in the literature and professional nutrition reference texts.7-9

Predictive Equations: Calculating Energy Requirements


The Harris-Benedict formula is an established predictive equation that estimates basal or resting

55
Determing Nutrition Requirements for Adults With Cancer

energy expenditure (REE).10 Used by dietetic professionals for decades, this simple mathematical
calculation takes into consideration a persons sex, age, height and weight.
When compared with indirect calorimetry and other predictive equations, the Harris-Benedict
formula has been shown to overestimate the energy needs of healthy, obese and critically ill
patients.11,12 Validation studies have shown the Mifflin-St. Jeor formula more accurately estimates the
REE of obese and non-obese individuals.11,13

Estimating Adult Energy Requirements10,13


Harris-Benedict Formula MifflinSt. Jeor Formula
Men: REE = 66 + 13.7W + 5H 6.8A Men: REE = 10W + 6.25H 5A + 5
Women: REE = 655 + 9.6W + 1.7H 4.7A Women: REE = 10W + 6.25H 5A 161
REE = resting energy expenditure in kcal/day
W = weight in kg
H = height in cm
A = age in years

Calculating Energy Requirements of Obese Patients

To avoid the risk of overfeeding, there are a variety of validated methods for estimating the energy
requirements of obese individuals with BMI between 30 and 50.9,14 The Mifflin-St. Jeor formula has
been validated to be an accurate method for estimating the REEs for both the obese and non-obese.
Predictive equations and methods for calculating the energy requirements of obese persons without
renal or hepatic dysfunction are provided below.

Calculating Energy Requirements of Obese Adults (BMI > 30)


Method 1: Mifflin-St. Jeor Formula11,13
See formula in Chart 1
Method 2: Hypocaloric Regimen for Obese Individuals9
Use 22 kcal/kg of ideal body weight
Method 3: Adjusted Harris-Benedict Formula14,15
Use the Harris-Benedict formula and the persons average weight in kg* multiplied by a
stress factor of 1.3 (no activity factor is used)
* Average weight (kg) = desired body weight (kg) + 50% of excess body weight (kg)

Total Energy Expenditure

REE can be multiplied by stress and activity factors to determine an individuals total energy needs
or expenditure (TEE). Combined with clinical judgment, other important considerations for estimating
TEE include a persons current health and weight history, planned therapy, and performance status.
There are a number of commonly used stress and activity factors. Published standardized stress
factors of 1.1 to 1.45 for cancer diagnoses are general guidelines and are likely based on cancers known
to be hypermetabolic.14

56
Nutrition in Cancer Treatment

Stress and Activity Factors9,14,16-18


Stress Factors Factor
Mild starvation 0.85 1.0
Elective surgery 1.05 1.15
Cancer (based on severity of illness) 1.1 1.45
Cancer (weight maintenance) 1.15 1.3
Hematopoietic cell transplant (baseline) 1.3 1.4
Hematopoietic cell transplant (stress) 1.5 1.6
Cancer (nutritional repletion/weight gain) 1.5
Ventilator dependent (catabolic) 1.5
Activity Factors Factor
Ventilator dependent 1.0 1.1
Bedridden/immobile 1.2
Ambulatory 1.3
TEE = REE x stress factor x activity factor

Quick Methods for Calculating Total Energy Needs

When indirect calorimetry is not available to determine energy needs, the following methods
can be used to estimate the total energy quickly using a persons body weight. While these
methods lack evidenced-based validation, they are frequently used by dietetic professionals to
make quick estimates of energy needs. A persons actual body weight in kg is multiplied by his
or her current condition to determine daily energy needs.

Estimating Total Energy Needs Based on Body Weight3,14,16


Condition Estimated Energy Needs
Cancer (no stress) 25 kcal/kg/day 30 kcal/kg/day
Cancer (nutritional repletion, weight gain) 30 kcal/kg/day 35 kcal/kg/day*
Cancer (hypermetabolic, stressed) 35 kcal/kg/day
Sepsis 25 kcal/kg/day 30 kcal/kg/day
Hematopoietic Cell Transplant 30 kcal/kg/day 35 kcal/kg/day
Obesity 21 kcal/kg/day 25 kcal/kg/day**
*
more than 35 kcal/kg/day may be required to maintain or promote weight gain in some individuals and
situations
**
when weight maintenance is the goal; energy needs may be increased when nutritional status is deteriorating

In summary, the energy requirements of people with cancer are as varied as the many cancer
diagnoses themselves. Therefore, it is important for dietetic professionals to remember that calculations
of energy requirements are simply estimates, and follow-up and re-evaluation of each patients nutrition
status and nutrition care plans are essential for quality patient care.

57
Determing Nutrition Requirements for Adults With Cancer

Protein Requirements
Many patients with cancer experience some kind of altered protein metabolism, such as increased
whole-body protein turnover, increased muscle wasting, decreased muscle synthesis and negative
nitrogen balance.
Important factors that need to be considered when estimating protein needs include the extent of
disease, current nutritional status, planned cancer treatment, performance status and the patients
ability to metabolize and use protein.9
For the body to use protein effectively, adequate energy (calories) should be provided to ensure
protein is used for tissue synthesis, rather than as a fuel source. As with energy requirements, follow-up
and re-evaluation of the estimated protein requirement is essential for optimal nutrition.
Different methods are used to estimate daily protein requirements for adults diagnosed with cancer
and other medical conditions.14

Estimating Protein Requirements in Adults3,9,14


Cancer-related Conditions Estimated Protein Needs
Cancer (no stress) 1.0 g/kg/day 1.2 g/kg/day
Cancer (moderate stress) 1.2 g/kg/day 1.5 g/kg/day
Cancer (hypermetabolic) 1.5 g/kg/day 2.5 g/kg/day
Hematopoietic stem cell transplant 1.5 g/kg/day 2.0 g/kg/day
Other Conditions Estimated Protein Needs
Normal (maintenance, no stress) 0.8 g/kg/day 1.0 g/kg/day
Older adults 1.0 g/kg/day
Acute renal failure (no stress) 0.6 g/kg/day 0.8 g/kg/day
Acute renal failure (stress and hemodialysis) 1.0 g/kg/day 1.4 g/kg/day
Hepatic failure 1.0 g/kg/day 1.5 g/kg/day
Hepatitis (acute or chronic) 1.0 g/kg/day 1.5 g/kg/day*
End stage liver disease with encephalopathy 0.6 g/kg/day 0.8 g/kg/day*
Cirrhosis without encephalopathy 1.0 g/kg/day 1.2 g/kg/day*
Critical illness (severe stress) 1.5 g/kg/day 2.0 g/kg/day
*
Dry weight

Current best practice suggests providing metabolically stressed patients with energy to meet
metabolic demand, and assuming adequate organ function, the provision of no more than 1.5 g of
protein per kg of body weight per day.9 With the exception of certain situations, Russell and Malone
report providing more than this amount does not normally improve nitrogen balance.9
Adequacy of protein intake can be evaluated via nitrogen balance studies, although this isnt
generally practical in the ambulatory oncology setting. Nitrogen balance studies compare patients
nitrogen (protein) intake with their nitrogen (protein) output by measuring the urea that is excreted in
their urine over a 24-hour period. A positive nitrogen balance reflects that adequate protein is being
provided and a negative balance indicates protein intake should be increased. When a collected urine
sample is not feasible or available, computing g of protein per kg of body weight provides general
guidelines for estimating specific protein needs.

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Nutrition in Cancer Treatment

Determining Nitrogen Balance


Nitrogen balance can be used as an index of protein requirements.
Nitrogen balance = (24 hr protein intake/6.25) (UUN/4*)
*
A factor of 4 is added to the urine urea nitrogen (UUN) to account for non-urea nitrogen losses such as stool
and skin.
Interpretation
A positive nitrogen balance of 4 g/day to 6 g/day is sufficient for anabolism and
wound healing.
A negative nitrogen balance indicates the need for increasing daily protein intake.

Serum protein values obtained from laboratory analyses have often been used as a way of assessing
and monitoring malnutrition risk and response to nutrition intervention. However, non-nutritional
factors such as disease processes, inflammation, treatments, medications, hydration status and other
acute and chronic medical conditions can significantly alter laboratory values.19 Therefore, albumin and
prealbumin are no longer considered good markers of nutritional status and instead are considered
markers of inflammation.17 In 2012, practitioners are turning toward nutrition-focused physical
assessment, weight changes and poor meal intake (components of the PG-SGA) as a way to evaluate
nutritional status.18

Fluid Requirements
Ensuring adequate hydration is a vital component of the nutritional care plan for patients
diagnosed with cancer who are undergoing treatment. The current recommendation for daily water
intake from all beverages and foods for adults ages 19 to 70 is 3.7 L (125 oz) for men and 2.7 L (90
oz) for women.19 There are several methods for determining specific fluid needs.
Fluid status should be monitored routinely by dietetic professionals with consideration of
measured losses (e.g., urine, stool or drainage), alterations in fluid balance due to metabolic or
treatment-induced changes (e.g., fever, vomiting or diarrhea), and medications and supportive care
therapies (e.g., diuretics or infusion of IV fluids).9
In the oncology setting, patients are at risk for dehydration secondary to reduced fluid intake
and/or fluid loss associated with treatment-related toxicities including anorexia, nausea, vomiting and
diarrhea. Over-hydration or fluid overload can occur because of the infusion of large volumes of IV
fluids, such as hydration fluids (e.g., D5W, normal saline), chemotherapy agents, parenteral nutrition
and blood products (examples of calculating fluid needs are included in the case study).

Estimating Fluid Needs


Method 1: RDA Method9
Fluid Needs = 1 mL fluid per 1 kcal of estimated energy needs
Method 2: Body Surface Area (BSA) Method9
Fluid Needs = 1,500 mL/m2 or BSA x 1,500 mL
Method 3: Age-Specific Method14
16 to 30 years (active): 40 mL/kg
31 to 55 years: 35 mL/kg
56 to 75 years: 30 mL/kg
76 years or older: 25 mL/kg

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Determing Nutrition Requirements for Adults With Cancer

Micronutrient Requirements
The National Academy of Sciences Food and Nutrition Board (part of the Institutes of Medicine)
periodically published Recommended Dietary Allowances (RDA) from 1941 until 1989. RDA were
intended to be used as guidelines for nutrient intake and were estimated to meet the needs of nearly all
people (about 98%).
The RDA have now evolved into a combination of recommendations called the Dietary Reference
Intakes (DRI), which take into consideration scientific evidence regarding nutrient intake required to
prevent classic deficiencies (i.e., scurvy, rickets, pellagra), as well as intakes related to the prevention and
treatment of diseases, such as cancer, cardiovascular disease and osteoporosis.20 These
recommendations include Estimated Average Requirement (EAR), RDA, Adequate Intake (AI), and
Tolerable Upper Intake Level (UL).
Ideally, micronutrients should come from eating a healthful diet that includes a variety of foods and
sufficient energy intake to ensure adequate nutritional status and weight maintenance. This is not
always possible for everyone who is diagnosed with cancer and undergoing treatment.
Micronutrient deficiencies can occur not only from the presence of cancer, but from effects of
cancer treatment, such as alterations in digestion and absorption, anorexia, dehydration, vomiting and
diarrhea. Other patients may present with existing nutritional deficiencies because of poor diet and
lifestyle choices. Dietetic professionals should refer to the DRI/RDA recommendations when
determining and recommending intake levels of micronutrients for patients during and after cancer
treatment.20
Other important factors for making micronutrient recommendations above or below DRI/RDA
levels include assessment of current nutritional status (e.g., need for iron supplementation secondary to
iron deficiency anemia or calcium supplementation for osteoporosis prevention), medical history
(including presence of comorbid diseases), laboratory analyses and current medications (e.g., vitamin K
restriction secondary to anticoagulation therapy).

Dietary Supplementation
Various studies report that 25% to 80% of those diagnosed with cancer take some type of dietary
supplements, including vitamins, minerals and other micronutrients.20-22 There is growing public
interest in the use of these supplements in both the prevention and treatment of cancer.
Oncology clinicians and patients alike are inundated with an abundance of information in the
literature from popular and professional peer-reviewed sources that pertains to cancer and
micronutrients. Health experts and organizations, including the American Cancer Society, conclude
that there is benefit from a standard multiple vitamin and mineral supplement that contains no more
than 100% of the daily value, since it may be difficult during and after cancer treatment to consume a
diet that contains adequate amounts of micronutrients.20,23
Dietetic professionals should ask patients if they are using dietary supplements and help guide
them in making informed decisions about proper use, as well as alerting them to potential nutrient
drug interactions.

Summary
Determining the nutrient requirements of persons with cancer is not an exact science. Cancer and
its treatment can significantly affect the ability to eat, as well as normal digestion and absorption.
Energy expenditure varies with disease, age, sex, activity, body composition and inflammatory response.
Estimates can be made based on a variety of published, evidence-based calculations; however, it is

60
Nutrition in Cancer Treatment

important for dietetic professionals to provide regular follow-up to determine the adequacy of those
estimates.
The same holds true for protein requirements. Estimates of protein requirements are based on
standard calculations, but follow-up evaluation or nitrogen balance studies are necessary to evaluate the
adequacy of estimated recommendations.
Fluid status changes are common, and it is important to monitor a patients fluid intake and output
routinely to provide adequate daily fluids based on situation and need.
Micronutrients are best obtained via a varied plant-based diet, rich in fruits and vegetables.
However, some people with cancer are unable to consume an ideal diet due to treatment or disease-
related side effects. In these cases, supplementation with the DV/RDA/DRI level, and not exceeding UL
levels, is acceptable practice.

Case Study
MJ is a 55-year-old female with a diagnosis of colon cancer. She has undergone colon surgery and
has recently completed chemotherapy. Her goal is to regain 31 lbs, as well as her strength and energy.
Height: 53 (160 cm)
Current Weight: 87 lbs (39.5 kg)
Ideal Body Weight: 115 lbs (52.3 kg)
Usual Weight (6 months ago): 128 lbs (58.2 kg)

Activity Level: MJ is housebound and spends most of the day in a chair or resting, but she is
able to care for herself and perform a few chores.
Continuing Nutrition Impact Symptoms: She continues to struggle with fatigue and
occasional episodes of diarrhea.

1 st step: Determine REE by using MifflinSt. Jeor formula:


REE = (10 x weight) + (6.25 x height) (5 x age) 161
REE = (10 x 39.5 kg) + (6.25 x 160) (5 x 56) 161
REE = 954 kcal

2 nd step: Determine TEE by using the following formula:


TEE = REE x stress factor x activity factor
TEE = 954 x 1.5 x 1.3
TEE = 1860 kcal/day

Estimated Daily Energy Requirement using 35 kcal/kg:


35 x 39.5 kg = 1393 kcal
Estimated daily energy requirement = 1393 calories

Estimated Protein Requirement using 1.5 g/kg:


1.5 g protein/kg Ideal Body Weight (IBW)
1.5 g x 52.3 kg = 78.5 g/day

Estimated Fluid Requirements:


Method 1: RDA/Caloric Intake-Based: 1 mL/calorie/day
1860 mL (using REE)

61
Determing Nutrition Requirements for Adults With Cancer

Method 2: BSA-based: 1500 mL/m2


BSA = square root of 160 x 39.5 3,600 = 1.32
Fluid requirement = 1500 x 1.32 = 1980 mL/day

Method 3: Weight-based: 35 mL/kg IBW


35 x 52.3 kg = 1830 mL/day

Note: Considering that MJ is still experiencing occasional episodes of diarrhea, she should be
encouraged to drink at least 240 mL or 1 cup of fluid for each diarrhea stool.
The range in calorie and fluid requirements illustrates further the fact that these calculations are
merely estimates.

References
1. Schattner M, Shike M. Nutrition support of the patient with cancer. In: Shils ME, Shike M, Ross AC,
Caballero B, Cousins RJ, eds. Modern Nutrition in Health and Disease. 10th ed. Philadelphia PA: Lippincott
Williams & Wilkins; 2006:1291-1313.
2. Knox LS, Crosby LO, Feurer ID, et al. Energy expenditure in malnourished cancer patients. Ann Surg.
1983;197(2):152-162.
3. Charney P, Cranganu A. Nutrition screening and assessment in oncology. In: Marian M, Roberts S, eds.
Clinical Nutrition for Oncology Patients. Sudbury, MA: Jones & Bartlett; 2010:21-44.
4. Merrick HW, Long CL, Grecos GP, Dennis RS, Blakemore WS. Energy requirements for cancer patients and
the effect of total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1988;12(1):8-14.
5. Hansell DT, Davis JW, Burns HJ. The relationship between resting energy expenditure and weight loss in
benign and malignant disease. Ann Surg. 1986;203(3):240-245.
6. Boullata J, Williams J, Cottrell F, Hudson L, Compher C. Accurate determination of energy needs in
hospitalized patients. J Am Diet Assoc. 2007;107(3):393-401.
7. Porter C, Cohen NH. Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting
results. J Am Diet Assoc. 1996;96(1):49-57.
8. Ireton-Jones CS, Jones JD. Should predictive equations or indirect calorimetry be used to design nutrition
support regimens? Predictive equations should be used. Nutr Clin Pract. 1998;13(3):141-143.
9. Russell M, Malone AM. Nutrient requirements. In: Charney P, Malone AM, eds. Nutrition Assessment. 2nd
ed. Chicago, Il: Academy of Nutrition and Dietetics; 2009:167-191.
10. Harris JA, Benedict FG. A Biometric Study of Basal Metabolism in Men. Washington, D.C.: Carnegie
Institute of Washington; 1919:Publication 279.
11. Frankenfield DC, Rowe WA, Smith JS, Cooney RN. Validation of several established equations for resting
metabolic rate in obese and nonobese people. J Am Diet Assoc. 2003;103(9):1152-1159.
12. McClave S, Snider HL. Use of indirect calorimetry in clinical nutrition. Nutr Clin Prac. 1992;7(5):207-221.
13. Mifflin MD, St Jeor ST, Hill LA, et al. A new predictive equation for resting energy expenditure in healthy
individuals. Am J Clin Nutr. 1990;51(2):241-247.
14. Hurst JD, Gallagher AL. Energy, macronutrient, micronutrient and fluid requirements. In: Elliott L, Molseed
LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, Il: American Dietetic
Association; 2006:54-71.
15. Glynn CC, Greene GW, Winkler MF, Albina JE. Predictive versus measured expenditure using limits-of-
agreement analysis in hospitalized, obese patients. JPEN J Parenter Enteral Nutr. 1999;23(3):147-154.

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16. Alberda C, Snowden L, McCargar L, Gramlich L. Energy requirements in critically ill patients: how close are
our estimates? Nutr Clin Prac. 2002;17(1):38-42.
17. Barbosa-Silva MC. Subjective and objective nutritional assessment methods: what do they really assess?
Curr Opin Nutr Metab Care. 2008;11(3):248-254.
18. Marcason W. Malnutrition: Where do we stand in acute care? J Acad Nutr Dietetics. 2012;112(1):200.
19. Institute of Medicine. Dietary Reference Intakes: Water, Potassium, Sodium, Chloride, and Sulfate.
Washington, D.C.: National Academies Press; 2005.
20. Food and Nutrition. Institute of Medicine Web site. http://www.iom.edu/Global/Topics/Food-
Nutrition.aspx. Accessed July 18, 2012.
21. Doyle C, Kushi LH, Courneya KS, et al. Nutrition and physical activity during and after cancer treatment: an
American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
22. Rock CL, Neuman VA, Neuhouser ML, Major J, Barnett MJ. Antioxidant use in cancer survivors and the
general public. J Nutr. 2004;134(11):3194S-3195S.
23. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA.
2002;287(23):3127-3129.

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Determing Nutrition Requirements for Adults With Cancer

64
Nutrition in Cancer Treatment

Chapter Six:
Modalities of Cancer Treatment:
Surgery, Radiation Therapy,
Chemotherapy, Biotherapy, Hormone
Therapy and Antiangiogenic Agents
This chapter will discuss the goals of therapies and how they are used to treat cancer. Depending on the
site of the cancer and the treatment modalities prescribed, the nutrition side effects can vary considerably.
This chapter will also examine the potential side effects of these therapies on nutritional status.

For supplemental information to this chapter, please review the following appendices:
Appendix 5 Nutrition Intervention for Nutrition Impact Symptoms
Appendix 6 Pharmacological Management of Chemotherapy-Induced Nausea and Vomiting
Appendix 7 Pharmacological Management of Anorexia and Cancer Cachexia
Appendix 8 Pharmacological Management of Constipation
Appendix 9 Pharmacological Management of Diarrhea
Appendix 10 Pharmacological Management of Mucositis and Esophagitis (includes enteral and
parenteral nutrition)
Appendix 11 Pharmacological Management of Pain
Appendix 12A, Nutritional Implications of Chemotherapy, Nutritional Implications of Hormone
12B and 12C Therapy and Nutritional Implications of Biotherapy and Antiangiogenic Agents
Appendix 13 Nutritional Implications of Surgical Oncology

C
onventional modalities of cancer treatment include surgery, radiation therapy, chemotherapy,
hormonal therapy, biotherapy, and antiangiogenic agents. In the United States, cancer
treatment is guided by evidence-based standards known as the National Comprehensive Cancer
Network (NCCN) Practice Guidelines in Oncology.1 These treatment guidelines provide oncologists
(surgeons, radiation oncologists and medical oncologists) and the oncology healthcare team with
cancer regimens specific to each cancer. Depending on the site of the cancer and the treatment
modality(s) prescribed, the nutrition side effects can vary considerably.

Medical Nutrition Therapy


Oral nutrition is the preferred route of nutrition care; however, when mechanical obstructions to
oral feeding exist or when oral intake is suboptimal, enteral nutrition support is often necessary and
should be implemented early in the postoperative period.6 Only when enteral feeding is not tolerated in
five to 10 days post-surgery or its use is impossible due to GI obstruction or dysfunction, is parenteral
nutrition indicated to restore and maintain nutrition status.16

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Modalities of Cancer Treatment

Progression of an oral diet should be advanced as tolerated. A good resource for evidence-based
best practice for providing nutrition care, including preoperative through postoperative diet
progression, is the American Society of Parenteral and Enteral Nutritions published guidelines for the
use of specialized nutrition support in hospitalized patients and guidelines for nutrition support
therapy during adult cancer treatment and in hematopoietic cell transplantation17,18 These guidelines
provide specific recommendations for oral, enteral and parenteral nutrition in surgical oncology
patients.

Surgery
Surgery can be used as the sole modality of cancer treatment, or it can be combined with
preoperative (neoadjuvant) or postoperative (adjuvant) chemotherapy and/or radiation therapy. In
particular, the surgical resection or removal of any part of the oral cavity, esophagus or gastrointestinal
(GI) tract as well as the malignant process itself can significantly impair normal digestion and
absorption.
After surgery, patients commonly experience fatigue and temporary changes in appetite and bowel
function caused by anesthesia and surgery-related pain. Often, additional dietary energy and protein is
needed for wound healing and recovery. Most side effects are temporary and dissipate after a few days
following surgery; however, some surgical interventions can have long-lasting nutritional implications.

Nutritional Implications: Surgery


Identifying patients at nutrition risk and providing timely nutrition assessment and intervention
before and after surgery can help reduce surgical-related morbidity and mortality, and help prevent
deteriorations in nutritional status (a variety of nutrition screening and risk assessment tools were
discussed in detail in Chapter Four).2 Specifically, preoperative nutrition assessment to identify patients
with malnutrition or patients who are at greater risk for developing malnutrition is essential for
improving surgical outcomes.3-5
McClave, et al. found that anywhere from five to 10 days of preoperative nutrition support
significantly reduced postoperative complications in surgical patients.4 Provision of nutrition support in
the postoperative period has also proved effective in reducing infections, length of stay and healthcare
costs, as well as improving nutritional status.6 As evidenced by numerous studies, cancer patients with
optimal nutritional status have been shown to experience decreased incidence of surgery-related
mortality and postoperative morbidity versus patients with poor nutritional status.7-9
Nutrition implications vary with the type of surgery performed. Some cancer-related surgeries have
significant impact on nutritional status immediately after surgery, as well as long-term effects.
It is important to remember that cancer is often treated with multiple modalities to achieve the
most effective response to therapy.
Resumption of normal eating can sometimes be challenging for those preparing for and recovering
from cancer-related surgeries. Poor appetite, weight loss and nutrient deficiencies before surgery can
impact nutritional status, wound healing and immune function post-surgery. Fatigue is a common
problem in all cancer surgeries. Fatigue can lead to decreased appetite (no activity to stimulate eating),
as well as an inability to prepare food, which is an important issue for those recovering from surgery
and cancer treatment.

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Nutrition in Cancer Treatment

Brain Surgery

There are several different types of brain tumors in adults. The most common types of brain
cancers are gliomas, including astrocytomas and glioblastoma multiformes; and non-gliomas, such as
meningiomas, medulloblastomas, and neuromas. Surgery, chemotherapy and radiation therapy are used
in the treatment of these tumors. There is little information in the literature addressing nutrition issues
following surgery for brain tumors.
Generally, patients with brain tumors are prescribed corticosteroids to reduce swelling, intracranial
pressure, nausea and vomiting.19,20 Extended use of corticosteroids can lead to weight gain,
hyperglycemia, gastritis, GI bleeding and immunosuppression.21 Corticosteroids can be catabolic when
taken for extended periods of time; therefore, attention to maintenance of lean body mass and
functional status is important. Optimal protein intake, along with physical therapy, may help reduce
symptoms of myopathy.
Cancer-related and treatment-related nausea, vomiting, loss of appetite, weight gain, GI symptoms
and hyperglycemia are all issues dietetic professional should be aware of and manage accordingly. As
with any surgery, optimal nutrition is essential for postoperative healing and may help to combat
fatigue. Radiation therapy to the brain and the effects of chemotherapy agents such as temozolomide
(Temodar) may also contribute to symptoms of nausea, vomiting, decreased appetite and fatigue 22-25

Head and Neck Surgery

Like brain tumors, head and neck cancers can involve several diagnoses and treatments. Cancers of
the oral cavity and neck include oropharyngeal, pharyngeal, base of the tongue, buccal mucosa, and
upper esophagus and can include the removal of involved lymph nodes.23 Even before treatment, these
cancers can present with symptoms of dysphagia, odynophagia, anorexia and weight loss. Conversely,
some people may have suspicious tumors or enlarged lymph nodes discovered by a dentist or physician
during a routine oral examination and may not present with any eating-related concerns.
Patients diagnosed with cancers of the head and neck who undergo cancer-related surgeries
commonly experience treatment-related dysphagia, odynophagia, alterations in chewing and
swallowing, xerostomia, alterations in taste and smell, impaired wound healing, anorexia, weight loss
and fatigue.23,26
In addition, radiation therapy to the head and neck region and the effects of chemotherapy agents
can significantly contribute to the severity and duration of side effects.23-25 Radiation therapy may be
administered pre-, post- or in lieu of surgery, depending on the extent of the disease and preference of
the prescribing physician.
There are many nutrition problems associated with radiation therapy of the head and neck,
including the production of copious and/or thick saliva, xerostomia, taste changes, dysphagia,
odynophagia, mucositis and esophagitis.25
Chemotherapy is now commonly given with radiation therapy to treat specific types of head and
neck cancers before surgery. Combined therapies are administered to provide the best possible disease
response and with less morbidity, and may even help to lessen the need for surgery.22,27,28 Side effects
are dependent on the particular chemotherapy regimen and include, but are not limited to, nausea,
vomiting, mucositis, esophagitis, diarrhea, taste changes and anorexia.29-31

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Modalities of Cancer Treatment

Thoracic Surgery

Thoracic surgery includes procedures for cancers of the esophagus and lung, as well as removal of
involved lymph nodes. There are different implications for each of these types of surgeries.

Esophagus

Esophageal cancer can present with esophageal obstruction, dysphagia, odynophagia, reflux and
subsequent weight loss. Surgery is common treatment with lower stage disease. The
esophagogastrectomy involves the removal of the diseased portion of the esophagus and adjacent
tissue. Surgery may lead to problems with dumping syndrome, as the stomach is typically brought up
and attached to the esophageal remnant, creating a decrease in the stomach reservoir capacity.32,33
Patients almost always require jejunostomy feedings, at least temporarily while the surgical anastomoses
heal.
Additionally, post-surgery, patients may experience dysphagia, odynophagia, reflux, early satiety,
wound healing and fatigue. Chemotherapy is often offered as either neoadjuvant therapy (before
surgery to reduce the size of the tumor) or as adjuvant therapy (after the surgery). As with
chemotherapy in head and neck cancer, side effects are dependent on the treatment regimen prescribed
and can include nausea, vomiting, anorexia, diarrhea, mucositis and esophagitis.29,34

Pulmonary

Depending on the type of lung cancer, its location within the lung, course of treatment, stage of
disease, comorbid conditions and control of symptoms, people with lung cancer can present with a
number of nutrition impact symptoms.35 Weight loss is common, along with nausea, vomiting,
anorexia and cachexia.35 Early satiety is also a problem, although often lumped together with anorexia,
both in diagnosis and treatment.
Surgery causes fewer direct mechanical issues involving nutrition, although wound healing, fatigue
and dyspnea are concerns.23 Therefore, postoperative healing may be problematic unless nutrition is
addressed early in the perioperative phase. An additional, but rare, complication is chylothorax or chyle
leak, which is a leakage of lymphatic fluid into the pleural space.8

Breast Surgery

Although one of the more common cancers, breast cancer doesnt always present with the typical
nutrition-related symptoms usually associated with cancer, such as anorexia and weight loss. Symptoms
are dependent on the stage of the disease, sites of metastasis, course of treatment, comorbid conditions
and menopausal status of the patient.
Treatment for breast cancer commonly consists of the surgical removal of the tumor by either
lumpectomy (removal of the tumor and a narrow margin around the tumor) or mastectomy (removal of
the entire breast) and lymph node biopsy. To provide the most effective treatment regimen depending
upon the stage of the disease, surgical intervention can be combined with radiation therapy,
chemotherapy and/or hormonal manipulation.
Weight gain is frequently reported during and after breast cancer and treatment, most likely due to
altered hormonal status, the effects of combined multimodality therapy, increased eating (to manage

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Nutrition in Cancer Treatment

nausea), fatigue and physical inactivity.36-38 Demark-Wahnefried found that weight gain was more often
associated with premenopausal status; positive lymph node biopsies; and higher dose, longer duration
and multi-agent chemotherapy regimens.36 Maintenance of optimal nutrition, support of postoperative
healing, and achieving and maintaining an optimal weight is the focus of nutrition intervention for
breast cancer survivors (refer to Chapter Eight for additional information).39
Advanced breast cancer can often pose more challenging nutrition-related concerns. Bone
metastases can be painful and can lead to decreased mobility and physical activity (refer to Chapter
Nine for additional information).

GI Surgeries

Surgery is often the primary treatment for the majority of GI cancers. Types of GI cancers include
stomach, pancreas, liver, gall bladder, bile duct, small intestine and colorectal. Wound healing, changes
in bowel habits, decreased appetite and fatigue are concerns following any of these surgeries.23
Gastric. Surgery is the most common treatment for lower-stage gastric cancer. To improve disease
control and survival, surgery is combined with preoperative or postoperative chemotherapy and
radiation therapy. Gastric surgery can lead to dumping syndrome, early satiety, maldigestion,
malabsorption and subsequent nutrient deficiencies.40 Other complications include lactose intolerance,
anemia, gastroparesis and osteoporosis.41
Pancreatic. The most commonly used surgery to treat cancer of the pancreas is the Whipple
procedure or the pancreaticoduodenectomy. The Whipple procedure involves the removal of the head
of the pancreas, a portion of the bile duct, the distal stomach and the duodenum. While surgery offers
the best likelihood for cure, only 20% of patients are surgical candidates. Pancreatic surgery often
requires the use of jejunostomy feedings for several weeks postoperatively. Resultant surgical
complications include gastroparesis; fat malabsorption; hyperglycemia; malabsorption of vitamins A, D,
E, K and B-12; and calcium, iron and zinc.42-44
Hepatic. Liver cancer resulting in hepatic resection is associated with high rates of morbidity and
mortality and can cause problems with hyperglycemia, hypertriglyceridemia, encephalopathy and
nutrient deficiencies.45
Gallbladder and bile duct. Cancer of the gallbladder is rare. Surgery can cause early satiety,
malabsorption, diarrhea, steatorrhea, hyperglycemia and nutrient deficiencies.
Cholangiocarcinoma (bile duct cancer) is also rare. Surgery usually involves removal of portions of
the liver and pancreas because of the bile ducts proximity to these organs. Surgery can lead to early
satiety, malabsorption, steatorrhea, diarrhea, hyperglycemia and nutrient deficiencies.
Small intestine. Cancer of the small intestine is rare, although metastasis from other abdominal
organs such as colon, pancreas, stomach, liver, ovary and appendix are more common. Surgery can
cause problems with early satiety, malabsorption, hyperglycemia and nutrient deficiencies.
Colorectal. Colorectal cancer is most associated with GI symptoms.35 Presenting symptoms
frequently include abdominal pain, change in bowel function, weight loss, nausea and vomiting.46
Depending on the location and extent of the tumor, bowel obstruction is not uncommon.35
Surgery is the primary treatment for cancers of the colon and rectum. Surgical treatment for
colorectal cancer often requires a colostomy, depending on the location and extent of the tumor.35 If
the disease has spread, chemotherapy and/or radiation therapy may be prescribed, causing additional
GI problems, which may include nausea, anorexia, mucositis, esophagitis, diarrhea, constipation and
taste changes.22,29,47
Immune-enhancing nutritional support. Of interest is the use of immune-enhancing or

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Modalities of Cancer Treatment

enteral nutrition support formulas for patients undergoing GI surgery in the cancer care setting.10
Immune-enhancing nutrients found in specific enteral formulas include arginine, glutamine, omega-3
fatty acids and nucleic acids. The inclusion of these nutrients in enteral nutrition formulas has been
shown to reduce postoperative morbidity, reduce infections, decrease length of hospital stay and reduce
patient costs.11-14
Sax reported that the use of immune-enhancing formulas was indicated orally for five to seven days
before surgery and then for a minimum of five days enterally after surgery to reduce postoperative
complications.12 Of note, van Bokhorst-de van der Schueren found that nine days of preoperative
enteral feeding, both with and without arginine in the solution, did not significantly improve nutritional
status or clinical outcome in severely malnourished head and neck cancer patients.15 They did, however,
find that cancer patients given the arginine-enhanced formula tended to live longer.

Prostate Surgery

For prostate cancers, new and different methods of prostate-sparing surgery are being used with or
without radiation therapy (e.g., external beam and/or brachytherapy) to lessen the complications of
altered bladder, rectal and sexual function.47
Nutrition-related problems prevalent in prostate cancer are most often secondary to treatment.48,49
Of note, radical prostatectomy (removal of the entire prostate gland, seminal vesicles and portion of the
bladder neck) can cause significant incontinence issues and loss of sexual potency. Diarrhea secondary
to radiation therapy is not uncommon. Urinary and stool incontinence can lead to decreased food and
fluid intake, as the patient attempts to decrease embarrassing situations.

Gynecological Surgery

Gynecological cancer surgeries can lead to long-term problems such as bloating, gas, cramping,
constipation, ileus and bowel obstruction. Gynecological cancer treatment regimens commonly include
pre- or postoperative radiation therapy and chemotherapy.22,47

Radiation Therapy
Radiation therapy uses high-energy rays (ionizing radiation) to cure, control or palliate tumor
cells.47 The amount of radiation that a patient receives is measured in units called centigrays (cGys).
Formerly, the term was RADs, for radiation-absorbed doses. In the United States, radiation therapy is
usually given five days a week. Depending on the area of the body receiving treatment and the dosage
required, the scheduled course of treatment is given in daily fractions over two to eight weeks.
Both normal cells and cancer cells are affected by radiation. Energy released from the therapeutic
radiation damages the cells genetic material, thus stopping the growth of the targeted tissue. Side
effects experienced are generally limited to the specific site or treatment field being irradiated. The
reason radiation oncologists prescribe and deliver multiple treatment fractions over an extended period
of time instead of giving a single treatment is to achieve maximum tumor cell kill while sparing,
protecting and preserving healthy tissue.47
Most types of cancers are susceptible to radiation, although some are radioresistent. Typically, cells
that are rapidly dividing are most sensitive to radiation therapy, such as cells found in tumors, bone
marrow, hair follicles and the mucosal lining of the GI tract.35 To improve radiosensitivity,
chemotherapy agents may be given in combination with radiation to produce a radiation-enhancing
effect. Patients receiving multimodality therapy often experience more toxic side effects sooner.

70
Nutrition in Cancer Treatment

Types of radiation therapy used in cancer treatment include radiotherapy, brachytherapy and
radiopharmaceutical therapy.

External Beam Radiation Therapy

External beam megavoltage machines precisely deliver radiation therapy into the body in multiple
fractionated doses. Examples of radiation therapy machines include linear accelerators that generate X-
rays or photons and electrons, cyclotrons that generate protons or neutrons, or cobalt-60 units that
generate gamma rays. Recent advances in technology to deliver radiation therapy with extreme accuracy
to a tumor (e.g., brain or spinal cord) while limiting exposure to normal tissue are stereotactic
radiosurgery (also called Gamma knife) and intensity-modulated radiation therapy (IMRT).50,51

Brachytherapy

Brachytherapy involves the use of sealed radioactive sources or implants (that emit beta particles or
gamma rays) directly in or near the treatment site to deliver highly localized doses of radiation.52
Examples of brachytherapy are interstitial implantation of permanent radioactive seeds for men with
prostate cancer and removable intercavitary implants for women with gynecological cancer.

Radiopharmaceutical Therapy

Radiopharmaceutical therapy involves the use of unsealed liquid radioactive sources that are
injected, ingested or instilled into the body.47 Examples of radiopharmaceuticals are oral iodine-131 to
treat thyroid disease; IV infusions of strontium-89 or samarium-153 to treat painful bony metastases;
and radioimmunotherapy, which uses injections of radiolabeled monoclonal antibodies to selectively
deliver radiation therapy directly to tumor cells.

Nutritional Implications: Radiation Therapy


When used alone, acute side effects of radiotherapy generally manifest around the second or third
week of treatment and usually resolve within two to four weeks after the radiation therapy has been
completed. Late effects of treatment may occur several weeks, months or years after treatment.
Regardless of the specific area being irradiated, common side effects of treatment include fatigue, loss of
appetite, skin changes and loss of hair in the area being treated.25,53 There are, however, typical side
effects experienced for the specific areas of the body being irradiated.

71
Modalities of Cancer Treatment

Side Effects Associated with Radiation Therapy25,46,54-58


Site of Radiation Therapy Acute Effects Late Effects
Central Brain Nausea Headache
Nervous Spinal cord Vomiting Lethargy
System Loss of appetite
Hyperglycemia due to
steroid administration
Fatigue
Head Tongue Mucositis Salivary glands: xerostomia,
and Neck Larynx Stomatitis fibrosis
Pharynx Dysphagia Mucosal: atrophy, dryness,
Oropharynx Odynophagia ulceration
Nasopharynx Xerostomia Trismus
Tonsils Loss of taste Dental caries
Salivary Glands Alterations of taste/smell Osteoradionecrosis
Fatigue
Loss of appetite
Thorax Esophagus Dsyphagia Esophageal: fibrosis,
Lung Odynophagia stenosis, necrosis
Breast (if treatment field Heartburn/reflux Pulmonary: dyspnea, dry
includes esophagus) Fatigue cough, fibrosis,
Loss of appetite pneumonitis,
Cardiac: angina upon effort,
pericarditis
Abdomen/ GI tract Nausea Diarrhea
Pelvis GI organs Vomiting Malabsorption
Colon/rectum Changes in bowel Intestinal: stricture,
Reproductive organs function: diarrhea, ulceration, obstruction,
cramping, gas perforation, fistula
Changes in urinary Urinary: hematuria, cystitis
function
Acute colitis or enteritis
Lactose intolerance
Fatigue
Loss of appetite

Chemotherapy
Chemotherapy is the use of chemical agents or medications to treat cancer. Whereas surgery and
radiation are used to treat localized tumors, chemotherapy is a systemic therapy that can affect the
whole body. Chemotherapy is also known as cytotoxic (cell-killing) or antineoplastic (anticancer)
treatment. Chemotherapy (chemo) may be given to cure cancer, control the rate of cancer growth or to
palliate symptoms of advanced disease. Chemotherapy can be used as the following:22
A primary treatment in hematological cancers, such as leukemia and lymphoma
Single agent or in combination with other agents to achieve maximum cell kill for each
drug within a tolerated range of toxicity
An adjuvant treatment to decrease the risk of recurrence after surgery, primarily in
breast and colorectal cancer
A neoadjuvant treatment (before surgery) to improve the possibility of optimal surgery,
most commonly used in breast and colorectal cancers

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Nutrition in Cancer Treatment

A myeloablation treatment to obliterate bone marrow in preparation for hematopoietic


cell transplant
A radiosensitizer to enhance the response to radiation therapy
A palliative treatment for patients with incurable disease
A chemopreventive treatment to prevent cancer in high-risk people

Nutritional Implications: Chemotherapy


The action of chemotherapy is not limited to malignant cells; it affects normal cells as well. Cells of
the body with rapid turnover such as bone marrow, hair follicles, mucosa of the oral cavity, esophagus
and GI tract are typically the most affected. Side effects of chemotherapy are varied and depend on the
treatment regimen and the patients stage of disease and health status. The most common nutrition-
related side effects are myelosuppression, anemia, fatigue, nausea, vomiting, diarrhea, anorexia,
mucositis, esophagitis, alterations in smell and taste, constipation, and early satiety or bloating.

Types and Classifications of Chemotherapy Agents

Chemotherapy is the term used to describe a type of cytotoxic agent (medications that are cell
killers) used in cancer treatment.22,56 Cytotoxics kill actively reproducing cells, both normal and
abnormal. These agents are classified according to their pharmacological action at various phases of the
cell cycle.

Cell Cycle Phases


Phase Description Duration
G0 Resting phase
G1 Increased production of RNA and proteins 1830 hours
S DNA replication in preparation for cell division 1820 hours
G2 Period immediately preceding cell division/RNA and proteins 210 hours
are formed
M Cell division 3060 minutes

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Modalities of Cancer Treatment

Cytotoxic Agents
Classification Description Cell Phase Examples
Specificity
Alkylating Works on DNA to Not phase- Busulfan (Myleran), cisplatin
Agents prevent cell specific (Platinol),
division cyclophosphamide (Cytoxan),
dacarbazine (DTIC), ifosfamide
(Ifex),
mechlorethamine (Mustargen),
melphalan (Alkeran)
Nitrosoureas Inhibit enzymes Not phase- Carmustine (BCNU), lomustine
needed in DNA specific (CeeNU)
repair
Antimetabolites Interfere with S phase 5-fluorouracil (Adrucil),
DNA and RNA methotrexate (Rheumatrex),
gemcitabine (Gemzar), cytarabine
growth
(Cyostar-U), fludarabine (Fludara)
Antitumor Antimicrobial/ Not phase- Bleomycin (Bleonoxane),
Antibiotics cytotoxic specific dactinomycin (Cosmegen),
Inhibit enzymes daunorubicin (Cerubidine),
needed in DNA doxorubicin (Adriamycin), idarubicin
repair (Idamycin PFS)
Inhibit mitosis
by altering
cellular
membranes
Mitotic Plant alkaloids M phase Paclitaxel (Onxol), docetaxel
Inhibitors and natural (Taxotere), etoposide (Etopophos),
products vinblastine (Velban), vincristine
Inhibit mitosis (Oncovin), vinorelbine (Navelbine)
Inhibit enzymes
needed for cell
reproduction

Hormone Therapy
Hormone therapy interferes with the bodys hormone production or action. Tumors that grow
more rapidly in the presence of certain hormones can be suppressed with the administration of anti-
hormonal agents.22 Examples of cancers whose growth is under hormonal control are prostate, breast
and ovarian.
Ablative hormone therapy is the surgical removal of hormone-producing glands or medical
eradication, such as surgical or medical castration to treat advanced prostate cancer.
Additive hormone therapy, such as tamoxifen (Nolvadex) or anastrozole (Arimidex), is an
anti-estrogen agent given to block estrogen to treat estrogen receptor-positive breast cancer, altering the
effects of the hormone.

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Nutrition in Cancer Treatment

Biotherapy
Biotherapy agents, biologics, biological response modifiers and immunotherapy are treatments with
agents that stimulate a persons own immune system to fight cancer. They also act as cytotoxic agents
via the administration of natural substances.22,59 Biotherapy agents are often used as an adjuvant to the
main therapy. Lymphocytes (B cells, T cells, natural killer cells) work with antigen-presenting cells
(macrophages and dendritic cells) to attack cancer cells, much the same way antibodies fight infection
or foreign substances in our bodies.
Examples of biotherapy agents include -interferon that is used to treat hairy-cell leukemia and
interleukin-2 that is used in the treatment of malignant melanoma and renal cell carcinoma. Like
cytotoxics, biotherapy agents fall into different categories.
Antiangiogenic agents. Antiangiogenic agents are a type of biotherapy. These agents inhibit the
development of new blood vessels needed by tumors vasculature. Their actions prevent tumor growth,
invasion and spread, as well as help maximize the efficacy of other therapies.22

Biotherapy Agents
Classification Mechanism of Action Medication Name
Hemopoietic Growth Factor Stimulates growth and Darbepoetin (Aranesp)
differentiation of stem cells in bone Erythropoietin (Procrit)
marrow to increase production of red
blood cells
Granulocyte Colony- Promotes proliferation and Filgrastim (Neupogen)
Stimulating Factor differentiation of neutrophils and Pegfilgrastim (Neulasta)
(G-CSF) enhances functional properties of
mature neutrophils
Interferon Mechanisms of action are not clearly Interferon alfa-2A
understood Interferon alfa-2B
Monoclonal Antibodies Binds to CD20 on B cells resulting in Rituximab (Rituxan)
activation of complement-dependent
cytotoxicity as well as antibody-
dependent cellular toxicity dependent cytotoxicity as w
Binds to the extracellular domain of Trastuzumab (Herceptin)
HER2, resulting in mediation of
antibody-dependent cellular toxicity
against cells that overproduce HER2
Binds to CD20 on pre-B and mature Tositumomab (Bexxar)
lymphocytes and has iodine-131
attached for additional cell death
Tyrosine Kinase Inhibitor Inhibits intracellular phosphorylation of Erlotinib (Tarceva)
(TKI) tyrosine kinase associated with EGRF with EGRF
Antiangiogenic Agent Inhibits development of new blood Bevacizumab (Avastin)
vessels

Management of Nutrition-related Side Effects


Chemotherapy, including hormone therapy, biotherapy, and antiangiogenic agents, can be given in
combination. Side effects of combination therapies are additive, although not necessarily potentiated
(see Chapter 11 for more information).

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Modalities of Cancer Treatment

Summary
Dietetic professionals need to understand the principles of surgery, radiation therapy,
chemotherapy and biotherapy, as well as the potential nutrition-related side effects that may occur
secondary to these cancer treatments before initiating nutrition intervention.

Case Studies
The two case studies presented below demonstrate how nutrition intervention can be an integral
part of an individuals cancer treatment and care.

Case Study No. 1

AB is a 61-year-old female with a diagnosis of metastatic colon cancer. She underwent resection of
the affected area of the colon, not requiring a permanent ostomy. She then began FOLFOX
chemotherapy (5-FU [Fluorouracil], leucovorin [Trexall], and oxaliplatin [Eloxatin]) with bevacizumab.
After five cycles (10 weeks of therapy), her treatment was interrupted, and she was admitted to the
hospital with uncontrollable diarrhea and dehydration.
A nutrition consult was initiated upon admission. Subsequent nutrition assessment revealed that
AB had lost 10 lbs (9.4% of her pre-treatment body weight) in the past two weeks. She reported a very
poor appetite, and she was afraid to eat anything for fear of having diarrhea.
The nutrition care plan included a soft diet, emphasizing intake of soluble fibers and avoiding
insoluble fibers and high-fat foods. Foods with water soluble fiber content (i.e., oatmeal, bananas,
cooked carrots, mashed potatoes and applesauce) were recommended in small quantities spread
throughout the day (about six servings). AB was advised to avoid excess amounts of fruit juice and
sugary drinks that could contribute to osmotic diarrhea. She was also advised to drink an additional
cup of water for each diarrheal stool to maintain adequate hydration.
She received IV fluids, was given instructions to use anti-diarrheals and was discharged to home
with follow-up with the dietitian one week after discharge. Chemotherapy was resumed after a one-
week interruption. Follow-up revealed that AB was tolerating her treatment much better with the
modification in diet.

Case Study No. 2

LB is a 48-year-old male with a diagnosis of human papillomavirus (HPV)-associated cancer of the


oropharynx. He had consumed two to three beers a day and smoked for more than 28 years, although
he reported that he quit smoking and drinking on the day he received his cancer diagnosis. His usual
weight is 170 lbs. At diagnosis, his weight was 155.5 lbs, about a 9% weight loss in the three months
before his diagnosis due to difficulty with chewing and swallowing and a poor appetite. His treatment
regimen consisted of concurrent head and neck radiation therapy and chemotherapy (cisplatin
[Platinol-AQ]). He met with the dietitian before treatment and adamantly refused a feeding tube when
offered before beginning his therapy.
The dietitian continued to meet with LB once a week during his seven-week cancer treatment to
help him transition from a soft, high-calorie/high-protein diet to a full liquid, high-calorie/high-protein
diet. After two and a half weeks of treatment, he was experiencing mucositis, taste changes, xerostomia

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Nutrition in Cancer Treatment

and dysphagia. The dietitian continued to provide nutrition interventions for improving his calorie and
protein intake. At three and a half weeks he was complaining of thick, ropey saliva and severe oral
mucositis and odynophagia. His oral intake consisted of about two cups of raspberry sherbet per day,
plus sips of ice water. He had lost another 10 lbs (weight, 145.5 lbs), bringing his total weight loss to
15% of his pre-treatment weight.
Despite his painful oral cavity and throat, WC agreed to have a percutaneous gastrostomy (PEG)
feeding tube placed as an outpatient in the endoscopy department. He was started on a standard 1.5
kcal per cc enteral formula at 240 cc over six feedings per day (2,500 kcal and 100 g protein/day). Two
weeks after placement of the feeding tube, WC was tolerating his feedings well and his weight
stabilized. After four weeks, he had gained 1 lb. The enteral feedings were continued until WC could
consume 75% of his needs orally. The dietitian continued to contact the patient after his therapy to
provide nutrition recommendations. Three months after completion of cancer treatment, WC was able
to meet his nutritional needs orally and the PEG tube was removed. He continued to take one to two
cans of a 1.5 kcal per cc liquid meal replacement to supplement his diet.

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79
Hematopoietic Cell Transplantation Overview and Nutritional Care

80
Nutrition in Cancer Treatment

Chapter Seven:
Hematopoietic Cell Transplantation
Overview and Nutritional Care

This chapter will discuss the hematopoietic cell transplantation process, nutrition management, acute
treatment-related side effects and complications, and long-term side effects and complications.

For supplemental information to this chapter, please review the following appendices:
Appendix 1 Diet Guidelines for Gastrointestinal Diet 1 and Diet 2
Appendix 2 Diet Guidelines for Immunosuppressed Patients
Appendix 14 Complications of Enteral Feeding

H ematopoietic cell transplantation (HCT) is the IV infusion of healthy hematopoietic stem cells
that have been harvested from the peripheral blood or bone marrow into the person receiving
the transplant. The goal of HCT is to replace malignant and defective marrow and to restore
normal hematopoiesis and immunologic function. HCT is a common treatment modality for
hematologic malignancies such as leukemia, lymphoma, multiple myeloma and nonmalignant blood
diseases including aplastic anemia, and autoimmune, congenital, and immunological disorders.

Hematopoietic Cell Transplants


There are four different types of bone marrow transplants: autologous (self) transplant or autograft,
allogeneic transplant or allograft, reduced-intensity stem cell transplant (nonmyeloablative), and
syngeneic transplant.
Autologous (self) transplant or autograft: Patients receive a transplant of their own stem
cells.
Allogeneic transplant or allograft: Patients receive stem cells from a related family member,
unrelated donor or cord blood unit. Donor cells are matched as closely to the patients as possible to
decrease the likelihood of rejection. Individuals have different sets of proteins called human leukocyte-
associated antigens (HLA) on the surface of their cells. This set of cells determines a persons HLA type,
which can be identified through a blood test. Siblings and parent-child HLA types usually make the
closest matches, but unrelated donors are also used in allografts. To locate suitable unrelated donors or
cord blood units for patients requiring transplants without compatible related family members, the
National Marrow Donor Program operates a marrow and blood cell registry.1
Reduced intensity stem cell transplant (nonmyeloablative): Currently under
investigation in clinical trials, this type of transplant is very similar to an allogeneic transplant where
stem cells are harvested from a healthy individual; however, the chemotherapy or radiation therapy

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Hematopoietic Cell Transplantation Overview and Nutritional Care

given is reduced. This type of transplant may be a better option for individuals who may not be able to
tolerate more intensive types of allogeneic transplants, such as older adults, people with comorbid
diseases and people with less aggressive cancers.2
Syngeneic transplant: Individuals receive stem cells from a genetically identical twin.

HCT Process

Harvest of Stem Cells

Stem cells are obtained from bone marrow or peripheral blood. If stem cells are collected from the
bone marrow, the cells are harvested under general or local anesthesia. A large bore needle is inserted
to aspirate marrow, usually in the hip bone. The procedure takes about an hour, and there are no
significant problems for the donor with the exception of soreness at the harvest site and fatigue. The
donors bone marrow is replenished by his or her own body within a few weeks after the procedure.
After harvesting, the bone marrow is processed to remove blood and bone fragments and then put
into a preservative and, in some cases, frozen for later use. When patients donate their own marrow
(autograft), the marrow is purged or treated with anticancer drugs to rid it of any potential cancerous
cells.3
Stem cells can also be harvested from the bloodstream. A process called apheresis (or
leukapheresis) is used to obtain stem cells from peripheral blood, where the supply is not nearly as
plentiful as in bone marrow. For four or five days prior to apheresis, the donor is given medications to
increase the number of stem cells in the bloodstream. In apheresis, blood is removed via a central
venous catheter or peripheral line in a large vein in the arm.4 The blood goes through a machine that
removes the stem cells and then is returned to the patient. The process takes about four to five hours
and causes little discomfort, although lightheadedness, chills, numbness around the lips, and cramping
in the hands may be experienced. Medication given prior to apheresis may cause bone and muscle
aches, headaches and difficulty sleeping, although these usually subside within a few days of the last
dose of the medication.
As with stem cells taken from bone marrow, peripheral blood stem cells are put into a preservative
and may be frozen for later use. Stem cells that are used for an autograft are purged with anticancer
drugs. There is some evidence to suggest that there may be advantages to peripheral blood stem cell
transplants (PBSCT) over bone marrow transplants (BMT), in that blood cell recovery may be quicker
and there may be less incidence of leukemia relapse.5 Umbilical cord blood can be obtained after birth;
these stem cells are separated and can be frozen for later use.

Preparation for Transplant

Prior to the infusion of donated or purged stem cells, the patients own diseased bone marrow
must be destroyed. Two types of preparative regimens or conditioning regimens are used to ablate bone
marrow:6,7
M yeloablative: An HCT conditioning regimen that involves several days of
chemotherapy with or without total body irradiation (TBI).
Nonmyeloablative: An HCT conditioning regimen where the patient receives lower and
less toxic doses of chemotherapy with or without radiation therapy (also called mini-
transplant, transplant-lite, or mixed chimera).8-12

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Nutrition in Cancer Treatment

There is increasing use of nonmyeloablative transplants, which are typically used for patients who
are older or unable to withstand the more intense treatments.8-12 Although lower dosages of
chemotherapy and radiation therapy may leave some malignant cells behind, the therapeutic rationale
is that the donors white blood cells will more effectively attack and kill the cancer cells. Infusions of the
donors white blood cells can magnify this reaction or even put a relapsed patient back into remission.
This phenomenon is referred to as the graft-versus-leukemia or graft-versus-tumor effect and is more
often seen in slowly progressing diseases, such as chronic myelogenous leukemia, low-grade lymphoma,
chronic lymphocytic leukemia and multiple myeloma.3
The effects of conditioning regimens range from mild to severe and commonly include many
medical and nutritional concerns such as tumor lysis, nausea, vomiting, diarrhea, hair loss, fatigue,
bladder irritation, loss of appetite and mouth sores.13

Transplantation and Engraftment

A few days after chemotherapy and radiation therapy have been administered, the stem cells are
infused, very much like a blood transfusion, through a venous access device (e.g., port-a-cath). The
patient is closely monitored for signs of fever, chills, hives and chest pains during the infusion. Those
who receive allografts are given immunosuppressive drugs to help prevent rejection of the donor cells.
In addition, they also receive supportive therapy such as total parenteral nutrition, antibiotics,
antifungal agents, red blood cell transfusions and platelet transfusions during the first several weeks to
combat the side effects of the treatment.
Engraftment occurs after the newly transplanted stem cells find their way into the patients bone
marrow and begin to produce new white blood cells, followed by platelets and, later, red blood cells. If a
patient has received a peripheral stem cell transplant, engraftment usually occurs within the first two
weeks after the transplant.13 For a patient receiving a transplant with stem cells taken from the bone
marrow, engraftment usually takes place within two to four weeks after transplant.
Patients are often kept in protective isolation and may be placed in rooms with special
ventilation/filtration of air due to treatment-related neutropenia and immunosuppression. White blood
cell counts are monitored frequently post-transplant to monitor for signs of engraftment.3
Nutrition assessment should begin during the pretransplant period and then continue throughout
the transplantation and recovery process.14 Charuhas states that the nutrition assessment should
include a comprehensive evaluation of the patients nutrition history, anthropometric parameters,
functional and performance status, blood chemistries, comorbidities, prior therapy and current
medications (see Chapter Five for more information).15

Nutritional Implications of HCT

Oral intake is the preferred route of nutrition care; however, enteral nutrition support is indicated
for those unable to consume adequate oral intake, or for patients who are malnourished.14 Enteral
nutrition is often given to those undergoing nonmyeloablative conditioning regimens to ensure that
estimated nutritional needs are being met.
Parenteral nutrition (PN) support is commonly given immediately post-transplant for patients
receiving more rigorous myeloablative conditioning regimens where more intense and acute oral, GI
and organ-toxic side effects are anticipated; and energy, protein and fluid requirements are
increased.16,17 The Academy of Nutrition and Dietetics Evidence Analysis Library guidelines for PN

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Hematopoietic Cell Transplantation Overview and Nutritional Care

following HCT recommends this route of nutrition support only be used in select patients because of
the lack of significant improvement in nutritional status, and the increased risks of complications and
increased costs.18 The American Society of Parenteral and Enteral Nutritions evidence-based clinical
guidelines for nutrition support during adult cancer treatment and in HCT also recommend that
nutrition support is appropriate for those who are malnourished and who are anticipated to be unable
to ingest and/or absorb adequate nutrition for a prolonged period of time.14 These clinical guidelines
also state that when PN is used, it should be discontinued as soon as treatment-related toxicities have
resolved after HCT (see Chapter Ten for more information).

Side Effects and Complications of HCT

Conditioning regimens and stem cell transfusions have considerable oral, GI, infectious or organ-
toxic side effects that can affect oral intake and nutritional status.15 Side effects can be immediate and
short-term, while others are late-occurring and/or chronic.

Acute Side Effects and Complications of HCT15,19-26


Oral and GI Complications Mucositis
Taste alterations
Candidiasis

Infectious Complications Immunosuppression, specifically, neutropenia (decreased


white blood cell count) puts patients at greater risk of
infection (e.g., bacterial, viral, fungal). Individuals should be
instructed to follow a diet for immunosuppressed patients
to reduce risk of foodborne illness. Handwashing and safe
food handling, preparation and storage are imperative.
Organ Toxicity
Liver Complications Sinusoidal obstructive syndrome (SOS), also known as veno-
occlusive liver disease, is a common problem in the first
month posttransplant. The blood vessels in the liver
become swollen and obstructed, impairing the livers ability
to remove toxins and waste from the bloodstream. It can
cause fluid retention in the liver, abdomen and extremities;
a swollen, tender liver; or in severe cases, encephalopathy.
Renal Complications Impaired renal function can be related to the conditioning
regimens, medications, hemolytic syndromes, SOS and
sepsis
Other Organ System Respiratory
Complications Cardiac
Urinary

Other long-term side effects and complications include chronic hypomagnesia, chronic viral
hepatitis, fungal liver disease, cataracts, infertility, bone damage and respiratory complications.26

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Nutrition in Cancer Treatment

Graft-versus-Host Disease

Graft-versus-host disease (GVHD) is the result of the donors white blood cells (graft) recognizing
the cells in the recipients body (host) as foreign and attacking the tissues and organs. GVHD can
manifest in two ways: acute GVHD, which develops in the first three months after transplant; and
chronic GVHD, which develops approximately 70 days post-transplant.13,27 GVHD can affect the skin,
eyes, GI tract, lungs and liver. Although anti-rejection drugs are helpful in treating GVHD, their side
effects can be severe and even life-threatening.28,29 A benefit of GVHD is that the donors cells will
also attack any cancerous cells remaining after chemotherapy and radiation therapy. It is often said on
the nursing floor that if a patient can survive severe GVHD, the chances of long-term survival are
greatly improved.
Because corticosteroids are used long term to treat chronic GVHD, some patients may develop
osteoporosis.15,30 Patients are advised to supplement with calcium and vitamin D to prevent and/or
manage this late effect of transplant.
GVHD of the gut may affect any or all of the alimentary tract or the liver, where it attacks the small
bile ducts, interfering with the flow of bile from the liver to the intestines.31 The role of the dietetic
professional is very important in the care of the patient with GVHD affecting the alimentary tract.
Mucositis and diarrhea can prevent patients from having an adequate oral intake. In fact, patients with
severe diarrhea are unable to take anything by mouth and receive all of their nutrition parenterally.
Nutrition-related consequences include weight gain, weight loss, oral sensitivity, xerostomia, stomatitis,
anorexia, reflux and diarrhea.16,32
The GVHD diet, like the neutropenic diet, varies from institution to institution, but is based on
research and best clinical practice at Seattle Cancer Care Alliance (SCCA), formerly the Fred
Hutchinson Cancer Research Center. Initially, patients are given nothing by mouth and receive
parenteral nutrition, which allows the gut to rest. When diarrhea resolves, patients may begin the
Gastrointestinal (GI) 1 diet. Foods are added slowly (i.e., one new food per feeding, as tolerated). If able
to progress through the GI 1 Diet, patients may advance to the GI 2 diet, as tolerated individually. GI 1
diet begins with the typical BRAT (bananas, rice, applesauce and toast) diet with low osmolality
beverages and gradually progresses to the GI 2 diet, which includes small, frequent feedings of a low-
fat, low-fiber, low-lactose diet that is low in GI irritants.

Food Safety and the Neutropenic Diet


Patients who are neutropenic or have low WBC specifically an absolute neutrophil count
(ANC) of less than 500 mm are at risk for infection from normally harmless bacteria found in and
on foods. Neutropenic precautions include thorough handwashing, good personal hygiene and
protective protocols eliminating potential sources of infection. To highlight the importance of good
hygiene, the Oncology Nursing Societys evidence-based guidelines for improving oncology patient
outcomes state that one of the most effective measures for helping to prevent infection for people with
cancer at risk for neutropenia is good hand hygiene using soap and water or an antiseptic hand rub.33
To help prevent infection, a neutropenic safe food or low microbial diet is used in most
institutions, although exact guidelines vary from institution to institution.
The SCCA is considered one of the worlds leading centers in HCT; many institutions pattern their
nutrition care practices after SCCA. In general, the diet eliminates potential sources of dietary
pathogens.

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Hematopoietic Cell Transplantation Overview and Nutritional Care

The Safe Food or Neutropenic Diet24


Do NOT eat the following foods
Unpasteurized dairy products
Cheeses from delis
Cheeses with mold (e.g., bleu, Roquefort or gorgonzola)
Mexican-style soft cheeses (e.g., queso fresco or queso blanco)
Raw or undercooked meats, eggs
Meats or cold cuts from delis
Uncooked seafood (e.g., lox, smoked, jerky or kippered) or pickled fish
Unwashed raw fruits and vegetables
Unpasteurized fruit and vegetable juices
Raw vegetable sprouts (e.g., alfalfa, mung bean or any others)
Salads from delis
Salad dressings from the grocer's refrigerator case
Raw or non-heat treated honey
Raw grain products (e.g., raw oats) not baked or cooked
Unrefrigerated cream-filled pastry products (not shelf-stable)
Unroasted nuts or nuts in the shell
All miso products
Uncooked brewers yeast
Untested and unboiled well water
Sun tea or yerba mate tea
All herbal and dietary supplements (without physician approval)

Summary
Stem cells may be transplanted from an HLA-matched donor, preferably a sibling, parent or child,
or from the patients own cells that have been treated with ablative drugs to rid them of cancerous cells.
HCT from bone marrow or from peripheral blood can be a life-saving procedure, but has serious and
life-threatening side effects and possible long-term complications. Nonmyeloablative transplants offer
specific patients good results with fewer and/or milder side effects than traditional transplants using
high-dose chemotherapy and radiation therapy. Nonetheless, caring for patients receiving HCT can be
a challenge for dietetic professionals.

Resources
The Leukemia and Lymphoma Society, Inc.
www.leukemia.org
The National Cancer Institutes Physician Data Query (PDQ)
www.cancer.gov/cancerinfo/pdq/treatment

Case Study
HH is a 32-year-old female with acute lymphocytic leukemia. She achieved remission after
induction chemotherapy and then relapsed. The second course of treatment included high-dose
marrow ablative chemotherapy followed by allogeneic stem cell rescue. HH required hospitalization
after receiving her chemotherapy secondary to severe neutropenia.

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Side effects from the high-dose marrow ablative chemotherapy included myelosuppression, severe
nausea and vomiting, anorexia, mucositis, esophagitis and xerostomia. Calorie counts revealed that HH
was only taking about 150 kcal/day and, therefore, total parenteral nutrition (TPN) was initiated one
week after initiation of conditioning chemotherapy regimen. HH preferred not to see food, so she did
not receive the Diet for Immunosuppressed Patients typically given to patients who are neutropenic.
After about three weeks she wanted to try to eat again so a mechanical soft/low microbial diet was
started (her mouth and throat were still a little tender), and continuous calorie counts were recorded.
About six weeks post-transplant, her oral intake met about 50% of her needs and TPN was cut in half.
One week later TPN was stopped (she was meeting 70% of her needs orally). She was meeting about
75% of her needs orally when discharged a week later.
Her weight never appreciably decreased during hospitalization (it initially increased due to
hydration accompanying chemotherapy). As she was weaned from TPN and resumed normal hydration
by mouth, her weight decreased about 5 lbs (4% of her usual weight).
Her two-week follow-up appointment revealed that her oral intake was increasing gradually, and
she was consuming more protein than she had been previously. Her weight had decreased another
2 lbs. She was interested in liquid nutritional supplements, so she was provided with several samples, as
well as tips to boost calories and protein in the foods she was able to eat.
At her next follow-up two weeks later, she had nearly resumed her normal intake, and her weight
had stabilized. She wanted to regain strength and tone more than the weight she had lost during
treatment. A consultation for strength training with the physical therapist was ordered, and HH
continued her current diet.

References
1. National Marrow Donor Program. National Marrow Donor Program Web site. www.marrow.org. Accessed
July 19, 2012.
2. Stem cell transplantation. Leukemia and Lymphoma Society Web site.
www.lls.org/#/diseaseinformation/managingyourcancer/treatmentnextsteps/typesoftreatment/stemcelltrans
plantation/. Accessed July 19, 2012.
3. Physician Data Query (PDQ) Cancer Information Summaries: Adult Treatment. National Cancer Institute
Web site. www.cancer.gov/cancerinfo/pdq/treatment. Accessed July 19, 2012.
4. Johansson E, Sollen Hansson A, Nilsson AS, Engervall P. Vascular access devices used during harvest of
peripheral blood stem cells: high complication rate in patients with a long-term dialysis central venous
catheter. Bone Marrow Transplant. 1999;24(7):793-797.
5. Ke X, Yang Y, Zhao X, Wang L. Autologous peripheral blood stem cell transplantation in the patients with
hematologic malignancies and solid tumors. Chin Med J. 2001;114(2):196-199.
6. Gopal R, Ha CS, Tucker SL, et al. Comparison of two total body irradiation fractionation regimens with
respect to acute and late pulmonary toxicity. Cancer. 2001;92(7):1949-1958.
7. Gutierrez-Delgado F, Maloney DG, Press OW, et al. Autologous stem cell transplantation for non-Hodgkins
lymphoma: comparison of radiation-based and chemotherapy-only preparative regimens. Bone Marrow
Transplant. 2001;28(5):455-461.
8. Bhatia V, Porter DL. Novel approaches to allogeneic stem cell therapy. Expert Opin Biol Ther. 2001;1(1):3-
15.
9. Feinstein L, Sandmaier B, Maloney D, et al. Nonmyeloablative hematopoietic cell transplantation.
Replacing high-dose cytotoxic therapy by the graft-versus-tumor effect. Ann N Y Acad Sci. 2001;938:328-
337; discussion 337-339.
10. Mossad SB, Avery RK, Longworth DL, et al. Infectious complications within the first year after

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Hematopoietic Cell Transplantation Overview and Nutritional Care

nonmyeloablative allogeneic peripheral blood stem cell transplantation. Bone Marrow Transplant.
2001;28(5):491-495.
11. Khoury H, Adkins D, Brown R, et al. Low incidence of transplantation-related acute complications in
patients with chronic myeloid leukemia undergoing allogeneic stem cell transplantation with a low-dose
(550 cGy) total body irradiation conditioning regimen. Biol Blood Marrow Transplant. 2001;7(6):352-258.
12. McSweeney PA, Niederwieser D, Shizuru JA, et al. Hematopoietic cell transplantation in older patients with
hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood.
2001;97(11):3390-3400.
13. Stronach K, Dohan MC. Survivors guide to bone marrow transplantation. In: Rosenbaum EH, Rosenbaum I.
Everyones Guide to Cancer Supportive Care: A Comprehensive Handbook for Patients and Their Families.
Kansas City, MO: Andrews McMeel Publishing; 2005:51-80.
14. August D, Huhmann MB. A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer
treatment and in hematopoietic cell transplantation. JPEN J Parenteral Enteral Nutr. 2009;33(5):472-500.
15. Charuhas PM. Medical nutrition therapy in hematopoietic cell transplantation. In: Elliott L, Molseed LL,
McCallum PD, Grant B. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic
Association; 2006:126-137.
16. Robien K. Hematological malignancies. In: Marian M, Roberts S. Clinical Nutrition for Oncology Patients.
Sudbury, MA: Jones & Bartlett; 2010:297-319.
17. Seattle Cancer Care Alliance. Hematopoietic Stem Cell Transplantation Nutrition Care Criteria. 2nd ed.
Seattle, WA: Seattle Cancer Care Alliance; 2002.
18. American Dietetic Association. Oncology Evidence-based Nutrition Practice Guideline. Chicago, IL:
American Dietetic Association; 2007.
19. Herget-Rosenthal S, Uppenkamp M, Beelen D, Kohl D, Kribben A. Renal complications of high-dose
chemotherapy and peripheral blood stem cell transplantation. Nephron. 2000;84(2):136-141.
20. Jules-Elysee K, Stover DE, Yahalom J, White DA, Gulati SC. Pulmonary complications in lymphoma patients
treated with high-dose therapy autologous bone marrow transplantation. Am Rev Respir Dis. 1992;146(2):
485-491.
21. Koc S, Hagglund H, Ireton RC, et al. Successful treatment of severe hemorrhagic cystitis with cystectomy
following matched donor allogeneic hematopoietic cell transplantation. Bone Marrow Transplant.
2000;26(8):899-901.
22. Nieto Y, Cagnoni PJ, Bearman SI, et al. Cardiac toxicity following high-dose cyclophosphamide, cisplatin,
and BCNU (STAMP-I) for breast cancer. Biol Blood Marrow Transplant. 2000;6(2A):198-203.
23. NosariA, Oreste P, Cairoli R, et al. Invasive aspergillosis in haematological malignancies: clinical findings
and management for intensive chemotherapy completion. Am J Hematol. 2001;68(4):231-236.
24. Diet guidelines for immunosuppressed patients. Seattle Cancer Care Alliance Web site.
http://www.seattlecca.org/client/documents/practical-emotional-support%5CHSC-Diet-
Immunosuppressed-Patients-032508.pdf. Accessed July 19, 2012.
25. Takahata M, Hashino S, Izumiyama K, et al. Cyclosporin A-induced encephalopathy after allogeneic bone
marrow transplantation with prevention of graft-versus-host disease by tacrolimus. Bone Marrow
Transplant. 2001;28(7):713-715.
26. Trisolini R, Stanzani M, Agli L, et al. Delayed non-infectious lung disease in allogeneic bone marrow
transplant recipients. Sarcoidosis Vasc Diffuse Lung Dis. 2001;18(1):75-84.
27. Stewart BL, Storer B, Storek J, et al. Duration of immunosuppressive treatment for chronic graft-versus-host
disease. Blood. 2004;104:3501-3506.

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28. Nash RA, Antin JH, Karanes C, et al. Phase 3 study comparing methotrexate and tacrolimus with
methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow
transplantation from unrelated donors. Blood. 2000;96(6):2062-2068.
29. Mollee P, Morton AJ, Irving I, et al. Combination therapy with tacrolimus and anti-thymocyte globulin for
the treatment of steroid-resistant acute graft-versus-host disease developing during cyclosporine
prophylaxis. Br J Haematol. 2001;113(1):217-223.
30. Stern JM, Chesnut CH III, Bruemmer B, et al. Bone density loss during treatment of chronic GVHD. Bone
Marrow Transplant. 1996;17(3):395-400.
31. Hill GR, Ferrara JL. The primacy of the gastrointestinal tract as a target organ of acute graft-versus-host
disease: rationale for the use of cytokine shields in allogeneic bone marrow transplantation. Blood.
2000;95(9):2754-2759.
32. Lenssen P, Sherry ME, Cheney CL, et al. Prevalence of nutrition-related problems among long-term
survivors of allogeneic marrow transplantation. J Am Diet Assoc. 1990;90(6):835-842.
33. Zitella L, Holmes B, OLeary C. PEP card: prevention of infection. In: Eaton LH, Tipton JM, eds. Putting
Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society;
2009:267-283.

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Chapter Eight
Surviving Cancer: Nutritional Care

This chapter will focus on patients who are recovering from cancer treatment and those who are living
after recovery.

For supplemental information to this chapter, please review the following appendices:
Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms

T
he American Cancer Society (ACS) defines a cancer survivor as anyone who has been diagnosed
with cancer, from the time of diagnosis through the rest of life.1 This includes individuals just
diagnosed and receiving cancer treatment, those recovering from treatment, those post-recovery
and disease-free, and those with advanced disease. As discussed in Chapter One, more than 12 million
Americans are cancer survivors, and the survival rate for living more than five years after cancer
diagnosis is now 67%.2 Cancer survivors represent one of the largest groups of people living with a
chronic illness in the United States. The ACS describes cancer survivorship in the terms of four distinct
phases: treatment, recovery from treatment, living after recovery and living with advanced cancer.3

What Is a Survivorship Care Plan?


The Institute of Medicine (IOM) Report, From Cancer Patient to Cancer Survivor: Lost in
Transition recommends that every cancer survivor and his or her primary healthcare provider receive a
written comprehensive care summary and follow-up plan once cancer treatment is completed.4 The
National Coalition for Cancer Survivorship, the Lance Armstrong Foundation, the American Society of
Clinical Oncology and the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition
and Dietetics support the use of a survivorship care plan for identifying and addressing post-treatment
needs, and for ultimately improving health and quality of life.
At a minimum, elements of a survivorship care plan should include:
The likely course of recovery from treatment toxicities, as well as the need for ongoing
health maintenance/adjuvant therapy.
Information on possible signs of late and long-term effects of treatment and symptoms
of such effects.
Information on possible signs of recurrence and second primary cancers.
Specific recommendations for healthy behaviors (e.g., diet, exercise, healthy weight,
osteoporosis prevention and smoking cessation).
Referrals to specific follow-up care providers, support groups and/or the primary
healthcare provider.

The Academy of Nutrition and Dietetics Oncology Toolkit outlines survivorship care plan
templates for dietetic professionals working with survivors of breast, colorectal, esophageal, gastric,

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Surviving Cancer: Nutritional Care

head and neck, hematologic malignancy, and prostate cancers.5 Each template provides a framework to
document survivors medical nutrition therapy care summary, dietary supplement use, integrative
therapy use, and nutrition and lifestyle goals.

Recovery from Treatment


After cancer treatment has been completed, the next phase of cancer survival is recovery. The
symptoms and side effects of treatment that affect nutrition and physical well-being begin to diminish
and resolve.3 Generally, most acute effects of treatment diminish within a few weeks after completing
cancer therapy, while chronic effects may persist, and late effects may occur several weeks, months or
even years after treatment.
During treatment, some cancer survivors experience loss of weight and lean body mass (muscle),
while others gain weight and adipose tissue. Examples of lingering effects of cancer treatment that affect
nutritional status and physical well-being include:
Continued anorexia and poor nutrition intake
Continued taste and smell alterations
Continued myelosuppression and anemia
Persistent fatigue
Peripheral neuropathy (numbness and tingling of fingers and/or toes) that limits the
ability to be physically active

The primary nutrition goals for recovery are to achieve/maintain a healthy body weight; replenish
lean body mass; improve strength and functional ability; stabilize and correct problems, such as anemia
or impaired organ functioning; and most important, proactively manage treatment-related side effects.3
Many cancer survivors who are unable to consume adequate nutrition intake because of continuing
side effects will require ongoing nutrition care and guidance (see Chapters Four and Eleven for more
information).

Nutrition Counseling
The emphasis of nutrition counseling should focus on strategies for not only preventing cancer
recurrence (secondary prevention), but guidance for preventing second primary cancers and other
chronic diseases, as well as managing continuing and/or late effects of treatment.3
Convincing evidence exists that cancer survivors are at greater risk for developing secondary
cancers, as well as chronic diseases such as cardiovascular disease, diabetes and osteoporosis.6-8 It is
prudent to assist cancer survivors with making informed decisions regarding nutrition and lifestyle
changes that include obtaining and maintaining an appropriate body weight, eating a healthful diet and
engaging in regular physical activity.

Body W eight Implications

Evidence supports that overweight and obesity are risk factors for developing cancer at specific
sites (e.g., postmenopausal breast, prostate, colorectal, esophagus, liver, pancreas, leukemia and
lymphoma), thus many individuals are overweight or obese at the time of diagnosis.9 There is
increasing evidence that being overweight or obese increases the risk of cancer recurrence and reduces
the likelihood of survival after cancer diagnosis.10,11

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Body Mass Index (BMI) and Health Risk12


Risk Weight Classification BMI Range (kg/m2)
Underweight < 19
Minimal Normal Weight 1924
Low to Moderate Overweight 2530
High Obesity, Class I 3034
Very High Obesity, Class II 3539
Extremely High Extreme Obesity, Class III +40

Plant-based Diet

It is likely that the synergistic effect of the nutrients and phytochemicals in a low-fat, plant-based
diet provide protection from disease. It is prudent to advise survivors to get nutrients and
phytochemicals from a variety of vegetables, fruits and grains, if possible, rather than from dietary
supplements.3,13 A plant-based diet is generally low in fat, particularly saturated fat. Such a diet may
provide protection against breast, colorectal and prostate cancers, although evidence is not
conclusive.14,15 Nonetheless, a low-fat, plant-based diet helps prevent cardiovascular disease and
obesity.

Dietary Supplement Use

Whether to feel better, to treat a symptom or even if it is medically directed to correct a


micronutrient deficiency (e.g., iron supplementation for iron deficiency anemia), evidence suggests that
between 25% and 80% of all cancer survivors use dietary supplements.3,16,17
Cancer survivors benefit from a multiple vitamin and mineral supplement that contains no more
than 100% of the Daily Value, as cancer treatment makes it difficult to consume a nutritionally
adequate diet.3,18 Use of a multiple vitamin and mineral supplement can help ensure that micronutrient
needs are met.

Physical Activity
Health guidelines developed for preventing chronic diseases are especially important for cancer
survivors. Guidelines established by the ACS and Dietary Goals for Americans serve as the basis for
healthy food choices and physical activity for all Americans, including long-term cancer survivors. The
2008 Physical Activity Guidelines for Americans issued by the U.S. Department of Health and Human
Services includes the following information for survivors after cancer diagnosis:19
Increased physical activity is linked with improved quality of life and increased fitness.
While the current public health guidelines of 30 to 60 minutes of moderate-intensity
aerobic exercise five times per week have not been studied systematically in cancer
survivors, there is no reason to believe that following these guidelines would not also
benefit survivors.
Results also indicated that the particular physical, physiological and psychosocial effects of
cancer and its treatment are positively affected by cardiovascular exercise, resistance
training and flexibility training.

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How Cancer Treatment Affects Physical Activity19


Treatment Physical Changes
Surgery
Lung Decreased pulmonary function
Breast Altered lymphatic drainage and lymphedema
Radiation Therapy
Mediastinum Decreased cardiac and pulmonary function
Chemotherapy
Anthracyclines Decreased cardiac function
Taxanes Peripheral neuropathy
Other Treatments
Biotherapy Increased fat mass, myalgia and hypertension
Hormone Therapy Increased body weight, BMI and fat mass
Steroid Therapy Decreased muscle, bone loss, increased body weight, BMI and fat mass

Lifestyle Guidelines

The ACS has published Nutrition and Physical Activity During and After Cancer Treatment: An
American Cancer Society Guide for Informed Choices. This guide is based on scientific evidence and best
clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer.3
The guidelines include recommendations on nutrition and physical activity for cancer prevention,
as well as promote overall health, quality of life and longevity, with the goal of reducing the risk for
developing cancer recurrence, secondary cancers and chronic diseases.

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Nutrition in Cancer Treatment

ACS Nutrition and Physical Activity Guidelines


for Cancer Prevention20
Achieve and maintain a healthy weight throughout life.
Be as lean as possible throughout life without being underweight.
Avoid excessive weight gain at all ages. For those who are currently overweight or
obese, losing even a small amount of weight has health benefits.
Engage in regular physical activity and limit consumption of high-calorie foods and
beverages as key strategies for maintaining a healthy weight.
Adopt a physically active lifestyle.
Adults should engage in at least 150 minutes of moderate-intensity activity or 75
minutes of vigorous-intensity activity each week, or an equivalent combination,
preferably spread throughout the week.
Children and adolescents should engage in at least one hour of moderate-to-vigorous-
intensity activity each day, with vigorous-intensity activity occurring at least three days a
week.
- Limit sedentary behavior such as sitting, lying down, watching television or other
forms of screen-based entertainment.
- Doing some physical activity above usual activities, no matter what ones level of
activity, can have many health benefits.
Consume a healthy diet, with an emphasis on plant foods.
Choose foods and beverages in amounts that help achieve and maintain a healthy
weight.
Eat at least 2.5 cups of vegetables and fruits each day.
Choose whole grains instead of refined grain products.
Limit consumption of processed and red meats.
If you drink alcoholic beverages, limit consumption.
Drink no more than one drink per day for women or two drinks per day for men.

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Surviving Cancer: Nutritional Care

The American Institute of Cancer Research has also issued recommendations on ways to attempt
to prevent cancer.

American Institute of Cancer Researchs


Simple Steps to Prevent Cancer21
Lifestyle Choices Implications
Body Fatness Be as lean as possible within the normal range of body
weight.
Physical Activity Be physically active as part of everyday life.
Foods and Drinks that Promote Limit consumption of energy-dense foods. Avoid
Weight Gain sugary drinks.
Plant Foods Eat mostly foods of plant origin.
Animal Foods Limit intake of red meat and avoid processed meat.
Alcoholic Beverages Limit alcoholic beverages.
Preservation, Processing, Limit consumption of salt. Avoid moldy cereals (grains)
Preparation and pulses (legumes).
Dietary Supplements Aim to meet nutritional needs through diet alone.
Breastfeeding Mothers to breast feed, children to be breastfed.

Chronic/Late Effects of Treatment


Most side effects from cancer treatment are temporary and resolve after treatment completion, but
some side effects may persist and become chronic. Late effects are toxicities caused by cancer treatment
that appear weeks, months and even years later. Toxicities can be mild, severe or life-threatening.22
Acute effects of treatment most frequently occur in rapidly proliferating cells such as the bone
marrow and mucosa cells that line the GI tract, while late effects manifest in slowly proliferating cells
such as the heart and lung.22 Chronic or late effects may be exacerbated by the length of cancer
treatment(s), specific drug(s), total amount of drug(s) administered over time, amount of radiation
therapy delivered and specific treatment area(s), and the survivors age.23
After the completion of treatment, care must include both surveillance for cancer recurrence, as well
as monitoring for chronic and/or late effects of cancer and its treatment.3,24 Follow-up visit intervals
may vary, but it is recommended that follow-up monitoring should occur at least once a year for life.

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Nutrition in Cancer Treatment

Chronic/Late Effects of Cancer Treatment


System/Organ Treatment Effects of Treatment
Cardiovascular Total body irradiation Arrhythmias or cardiomyopathy,
Radiation therapy to the resulting in congestive heart failure
mediastinum or a mantle field
Chemotherapy agents (e.g.,
anthracyclines, high-dose
cyclophosphamide)
Constitutional Chemotherapy agents: high Chronic fatigue and anorexia
doses for extended periods of resulting in malnutrition and
time wasting
Radiation therapy: especially
bony metastases
Esophagus Esophageal surgery Permanent esophageal stenosis
Radiation therapy to the and stricture, resulting in
esophagus and/or gastric- dysphagia, odynophagia, and
esophageal junction
malnutrition
Gastrointestinal Surgery and/or resection of the Chronic radiation enteritis,
GI tract resulting in malabsorption,
Pelvic or abdominal radiation diarrhea, malnutrition and wasting
therapy
Oral Cavity Head and neck surgery Permanent xerostomia, resulting in
Radiation therapy to the head difficulty chewing and swallowing,
and neck taste alterations and increased risk
of dental caries
Respiratory Pulmonary surgery Pulmonary fibrosis or pneumonitis,
Radiation therapy to the resulting in dyspnea and
mediastinum or a mantle field decreased pulmonary function
Chemotherapy agents (e.g.,
bleomycin [Blenoxane], busulfan
[Myleran], vinca alkaloids,
alkylating agents)
Second Primary Chemotherapy agents: high Caused by damage from radiation
Cancers doses for extended periods of therapy and/or chemotherapy to
time the bodys cellular DNA
Total body irradiation

Summary
It is important for healthcare professionals and cancer survivors to understand the goals of
nutrition therapy during recovery and throughout long-term survival. Important nutrition and physical
activity-related issues for long-term cancer survivors include avoiding obesity, increasing physical

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activity, making healthful food choices, increasing fruit and vegetable intake, appropriate use of dietary
supplements and limiting alcoholic beverage use. Dietetic professionals need to help survivors navigate
through the scientific and lay literature, weighing potential benefit to potential harm, thereby enabling
them to make informed decisions to achieve recovery and survivorship goals, as well as help prevent a
recurrence or a second primary cancer diagnosis.25

References
1. Glossary. American Cancer Society Web site. www.cancer.org. Accessed July 19, 2012.
2. American Cancer Society. Cancer Facts and Figures, 2012. Atlanta, GA: The American Cancer Society;
2012.
3. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an
American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
4. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition.
Washington, DC: The National Academies Press; 2005.
5. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition
Practice Guideline. Academy of Nutrition and Dietetics: Chicago, IL; 2010.
6. Oeffinger KC, Buchanan GR, Eshelman DA, et al. Cardiovascular risk factors in young adult survivors of
childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2001;23(7):424-430.
7. de Vos FY, Nuver J, Willemse PH, et al. Long-term survivors of ovarian malignancies after cisplatin-based
chemotherapy: cardiovascular risk factors and signs of vascular damage. Eur J Cancer. 2004;40(50:696-700.
8. Eyre HJ, Kahn R, Robertson RM, ACS/ADA/AHA Collaborative Writing Committee. Preventing cancer,
cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American
Diabetes Association, and the American Heart Association. CA Cancer J Clin. 2004;54(4):190-207.
9. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a
prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625-1638.
10. Rock CL, Demark-Wahnefried W. Nutrition and survival after the diagnosis of breast cancer: a review of the
evidence. J Clin Oncol. 2002;20(15):3302-3316.
11. Amling CL. The association between obesity and the progression of prostate and renal cell carcinoma. Urol
Oncol. 2004;22(6):478-484.
12. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the
evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S.
13. Eichholzer M. Nutrition and cancer. Ther Umsch. 2000;57(3):146-151.
14. Saxe GA, Hebert JR, Carmody JF, et al. Can diet in conjunction with stress reduction affect the rate of
increase in prostate specific antigen after biochemical recurrence of prostate cancer? J Urol.
2001;166(6):2202-2207.
15. Hensrud DD, Heimburger DC. Diet, nutrients, and gastrointestinal cancer. Gastroenterol Clin North Am.
1998;27(2):325-346.
16. Rock CL, Neuman VA, Neuhouser ML, Major J, Barnett MJ. Antioxidant use in cancer survivors and the
general public. J Nutr. 2004;134(11):3194S-3195S.
17. McDavid K, Breslow RA, Radimer K. Vitamin/mineral supplementation among cancer survivors: 1987 and
1992 Health Interview Surveys. Nutr Cancer. 2001;41(1-2):29-32.
18. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA.
2002;287(23):3127-3129.
19. Physical Activity Guidelines Advisory Committee report, 2008. To the Secretary of Health and Human
Services. Part A: executive summary. Nutr Rev. 2009;67(2):114-20.

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Nutrition in Cancer Treatment

20. Kushi LH, Doyle C, McCullough M, Rock CL, et al. American Cancer Society Guidelines on nutrition and
physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical
activity. CA Cancer J Clin. 2012;62(1):30-67.
21. World Cancer Research Fund (WCRF)/American Institute for Cancer Research (ACIR). Food, nutrition,
physical activity and the prevention of cancer: a global perspective. Washington, DC: WCRF/ACIR; 2007.
22. Ronk B. Organ toxicities and late effects: risks of treatment. In: Gates RA, Fink RM. Oncology Nursing
Secrets. 2nd ed. Philadelphia, PA: Hanley & Belfus, Inc.; 2001:385-390.
23. Boice JD. Second malignancies after chemotherapy. In: Perry MC, ed. The Chemotherapy Source Book. 3rd
edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-24.
24. Polovich M, White JM, Kelleher LO. Chemotherapy and Biotherapy Guidelines and Recommendations. 2nd
ed. Pittsburgh PA: Oncology Nursing Society; 2005.
25. Harpham WS. Alternative therapies for curing cancer: what do patients want? What do patients need? CA
Cancer J Clin. 2001;51(2):131-136.

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Surviving Cancer: Nutritional Care

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Nutrition in Cancer Treatment

Chapter Nine:
Advanced Cancer and Palliative Care
This chapter discusses palliative and hospice care for patients with advanced cancer and the
importance of creating and implementing a survivorship plan for these patients.

For supplemental information to this chapter, please review the following appendices:
Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms

D espite improvements in cancer diagnosis and treatment, a cure is not always possible. As
described by the American Cancer Societys Survivorship Advisory Committee, one of the
phases of survivorship in the cancer continuum is living with advanced cancer or a cancer that
cannot be cured.1
Palliative care can be defined as the active, complete care of a patient when curative measures are
no longer considered an option by either the healthcare team or the patient.2 Another definition
describes palliative care as treatment that is designed to ease symptoms of disease rather than
attempting to cure it.3 The term palliative care is often used interchangeably, though improperly so,
with hospice. Hospice can be a component of palliative care, but palliative care is not necessarily
hospice. Hospice care focuses on relieving symptoms and supporting those with a life expectancy of
only months, and it encompasses all of the principles of palliative care.4
Palliative treatment and care, while usually provided to individuals with advanced cancer, can be
given to people receiving curative cancer treatment or in the phase of long-term survival after anti-
cancer treatment.
Quality of life and patient- and family-centered care are important aspects of care for people living
with advanced cancer. Improved knowledge and application of the principles of palliative care will help
healthcare professionals enhance the lives of their patients.5,6 The objectives of palliative care are to
relieve physical symptoms; alleviate isolation, anxiety and fear associated with advanced disease; and
maintain independence as long and as comfortably as possible.1,7

Palliative Care and Hospice Delivery Systems


Palliative care services can be provided to individuals through a variety of healthcare delivery
systems. Institution-based palliative care programs may offer inpatient consultation services, inpatient
primary care (which may or may not include a specialized palliative care nursing unit), and a range of
outpatient services.
Hospice programs may provide free-standing residential care facilities, hospice/home care and
inpatient respite care. Typically, persons must have a life expectancy of six months or fewer to enroll in
hospice care.
As an outpatient, a patient might receive homecare services, such as enteral feedings, durable
medical equipment and nursing visits. This type of arrangement, sometimes called bridge services,
may be appropriate for those not yet ready for hospice or in cases where the hospice concept conflicts

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with patients or their families philosophy (e.g., belief that hospice means giving up hope for survival).
Some palliative care outpatients do not require hospice or bridge services and return to the clinic for
regular follow-up and continuity of care.8,9
Specific guidelines regarding Medical Nutrition Therapy (MNT) and management of nutrition
impact symptoms are provided in Chapter Eleven and Appendices 3 through 11. It is important for
dietetic professionals to be aware of the common symptoms and complications associated with
advanced cancer, as well as their impact on nutritional status.1 Dietetic professionals should assess
nutritional status, identify specific nutritional needs and nutrition impact symptoms, and implement an
individualized nutrition care plan.10 Komurcu and colleagues make an interesting comment, that by
simply defining the relationship of the symptoms to the disease (we) can defuse fear and encourage a
sense of control in patients and their families.7

Prevalent Symptoms
Walsh and associates published a review of the symptoms of 1,000 patients upon their initial
referral to palliative care service.11 The 10 most common symptoms identified were pain, easy fatigue,
weakness, anorexia, lack of energy, dry mouth, constipation, early satiety, dyspnea and greater than 10%
loss of weight.
Researchers have found the most common gastrointestinal (GI) symptoms of individuals with
advanced cancer are anorexia, constipation, early satiety, xerostomia, nausea, taste changes, vomiting,
bloating and weight loss. In general, nutrition symptoms tend to worsen with disease progression;
however, many of these symptoms are manageable, further illustrating the need for greater education of
healthcare professionals.

Nutrition-Related Symptoms in Advanced Cancer8,12,13


Symptom Advanced Cancer Advanced Metastatic Palliative Care
(N=1,000) Cancer (N=352) (N=200)
Anorexia 66% 81% 59%
Bloating 18% 43% 50%
Constipation 52% 59% 39%
Diarrhea 8% 24% 10%
Early Satiety 51% 69% 49%
Nausea 36% 49% 26%
Taste Changes 28% 16% 32%
Vomiting 23% 38% 11%
Weight loss 50% 85% 54%
Xerostomia 57% 69% 67%

Paraneoplastic Syndromes
Advanced cancer often leads to a variety of complications often described as paraneoplastic
syndromes, some of which can have serious nutritional implications. Paraneoplastic syndromes are
caused by substances secreted by the cancer, such as hormones and cytokines, which cause metabolic,
nerve or muscular disorders.14,15 Common paraneoplastic syndromes with medical and nutritional
implications include cancer cachexia syndrome, hypercalcemia, hypoglycemia, syndrome of
inappropriate secretion of antidiuretic hormone (SIADH), and Lambert-Eaton syndrome.

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Nutrition in Cancer Treatment

Cancer Cachexia Syndrome

The etiology of cachexia is multifactorial, although tumor production of hormones and cytokines is
a factor. While there is no known treatment to reverse these effects, pharmacologic management and
nutritional counseling have been shown to help improve patient outcomes and quality of life.16,17

Hypercalcemia

Hypercalcemia of paraneoplastic disease and bony metastases is associated with metastatic breast
cancer and multiple myeloma, followed by cancers of the lung cancer, head and neck, and renal cell
cancer.18-20 Humoral hypercalcemia can manifest from non-metastatic tumor cells that induce
parathyroid hormone-like peptides. Hypercalcemia-associated bony metastases are caused by the
osteolytic activity of tumor cells releasing calcium into the extracellular fluid.
Although restriction of dietary calcium is not a treatment for hypercalcemia, it is important to
advise patients to avoid taking large amounts of exogenous calcium (e.g., dietary supplements, antacids
or calcium-fortified foods and beverages). Hypercalcemia is treated with the infusion of IV fluids and
the use of bisphosphonates and other antihypercalcemic agents.21

Hypoglycemia

Hypoglycemia is most common in patients with insulin-secreting islet cell tumors, as well as
mesenchymal tumors, such as fibrosarcomas, leiomyomas, rhabdomyosarcomas, liposarcomas and
mesotheliomas.18 Acute episodes of hypoglycemia can be treated with IV dextrose, while mild cases of
ongoing hypoglycemia may respond to frequent, small feedings that emphasize protein, complex
carbohydrates and fat at each feeding. Severe cases may benefit from the use of corticosteroids and/or
glucagons (although these may cause vomiting).

SIADH

SIADH is most often associated with small-cell lung cancer. Hyponatremia is the most common
symptom of SIADH, which is treated with diuretics, IV saline with potassium, and/or fluid restriction
(usually 500 to 1000 cc/day).18

Lambert-Eaton Syndrome

Lambert-Eaton syndrome, a neurological disorder similar to myasthenia gravis, is most often


associated with small-cell lung cancer. These patients can have problems with xerostomia and
dysphagia, which can be managed with nutritional intervention (see Chapter Eleven for more
information).18,22

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Symptoms and Complications


Additional symptoms and complications commonly seen in advanced cancer include:

Bowel Obstructions and Ileus

Bowel obstructions and ileus are associated with pancreatic and gynecological cancers, abdominal
carcinomatosis, enlarged retroperitoneal nodes and pelvic masses. They are also a result of pelvic and/or
abdominal radiation therapy and after surgical interventions to the GI tract.23-25
Patients with advanced cancer and bowel obstruction can be managed with medications, IV fluids
and decompression.26 If the bowel obstruction or ileus can be resolved, patients should be transitioned
from IV fluids to a clear liquid diet and then if tolerated, be instructed on a low-fiber diet.
Parenteral nutrition is in most instances inappropriate, although it may be used for some who are
medically and emotionally stable and have a reasonable life expectancy (e.g., to improve quality of life,
to assist in a patients desire to live to witness an important life event).27,28

Steroid-induced Hyperglycemia

Patients with advanced cancer are often prescribed corticosteroids to manage disease-related
symptoms. A common side effect of steroid use is hyperglycemia, which is usually managed successfully
with a no added sugar/no concentrated sweets diet and/or antihyperglycemic agents. Often patients
are eating so poorly that diet is an insignificant contribution to blood glucose levels and, therefore, diet
should be as liberal as possible to maximize quality of life.

Venous Thromboembolic Complications

A variety of disease-related factors can lead to the development of deep vein thrombosis (DVT) or
pulmonary embolism (PE) in people with advanced cancer. Some individuals may be treated with
intermittent pneumatic compression, compression stockings or vena cava filters, although
pharmacological management with anticoagulants is common. Dosing of anticoagulants is based on the
patients blood clotting time, which reflects his or her average vitamin K intake. Patients should be
advised to consume a consistent amount of vitamin K-containing foods, rather than totally restrict
vitamin K-rich foods from their diets.25

Spinal Cord Compression

Spinal cord compression is considered an oncological emergency and is usually, but not exclusively,
due to extradural metastases occurring in the vertebral column.24 Treatment of cord compression is vital
to prevent complete compression, resulting in paralysis and loss of bowel and bladder function/control.
Cord compression is usually treated with radiation therapy, bisphosphonates and/or corticosteroids.
Nutritional issues concerning spinal cord compression include constipation secondary to opiates
used for pain management, dehydration and poor dietary intake secondary to those wanting to avoid
embarrassment of urinary or fecal incontinence due to the associated loss of bladder and bowel control,
and physical inactivity. A multi-disciplinary healthcare team effort can help alleviate constipation and
manage bowel and bladder function to help preserve the patients dignity and quality of life.

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Nutrition Support in Advanced Cancer


Nutrition support (e.g., enteral or parenteral nutrition) for patients with advanced disease can be a
difficult and controversial issue.29 The American Society of Parenteral and Enteral Nutrition
(A.S.P.E.N.) states in its evidence-based clinical guidelines for nutrition support during cancer
treatment that the palliative use of nutrition support therapy in terminally ill patients is rarely
indicated.30 The A.S.P.E.N. guidelines advise that decisions should be made on a case-by-case basis and
include consideration of the patients and familys wishes, potential risks and benefits, and the patients
estimated survival. In some instances, nutrition support does have a place in the treatment of the
advanced cancer patient. Enteral nutrition is appropriate in patients with mechanical barriers to
achieving adequate oral intake wherein quality of life would suffer and death would be caused by
malnutrition, rather than the underlying disease (i.e., head and neck cancer).31
Rationale for implementing parenteral nutrition, however, is less clear. Mercadante and others
suggest that parenteral nutrition may be appropriate in cases where oral or enteral nutrition was not
possible due to mechanical obstruction or malabsorption.31,32 However, Torelli and colleagues found
that parenteral nutrition neither influenced the ultimate outcome nor improved quality of life and,
therefore, conclude that there is little validity to administering parenteral nutrition to terminally ill
cancer patients.33 The authors admit, however, that there may be subjective rationale to justify the use
of parenteral nutrition, such as compassionate, religious, ethical or emotional reasons.
Parenteral nutrition may be appropriate for use in select patients who are medically and
emotionally stable and have a reasonable life expectancy.27 Consideration of cost, burden on family
members and potential complications must be weighed against any potential benefit derived from
nutrition support, whether it is enteral or parenteral.29,34,35
Decisions regarding the provision of nutrition support and hydration may be guided by a variety of
sources, including the 2008 Position Statement of the Academy of Nutrition and Dietetics: Ethical and
Legal Issues in Nutrition, Hydration, and Feeding. The Academys position paper states:36

Each patient is unique, and the plan of care should be constantly reassessed for each individual.
For the patient to accept, and perhaps enjoy, oral intake, previous dietary restrictions should be
minimized or eliminated, depending on the physical consequences. Registered dietitians should
work with the team to coordinate administration of pain medication to maximize enjoyment of
food. Amelioration of symptoms such as nausea, vomiting, insomnia, and anxiety is an important
objective. The actual or illusory source of strength, nurturing, comfort, and caring provided by
food should be encouraged as well as family interaction and socialization.

The Academy position paper recommends the following four considerations be taken regarding
decisions about feeding:
Patient preference guides the decision-making process.
When the patients preference is not known, a substitute decision maker is guided by
the best interests of the patient.
Informed and shared decision-making is the best ethical practice.
All stakeholders are encouraged to collaborate in the decision-making process.

As Death Becomes Imminent


Dietetic professionals should remain involved in patient care throughout the course of the disease
to serve as a resource to patients, family and the healthcare team for information regarding nutritional

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care of people with advanced and terminal disease. They should assist patients and the healthcare team
in making informed decisions regarding nutrition support, educate patients and families regarding
medical nutrition therapy interventions, and provide ongoing support throughout the course of the
disease, especially for symptom control.
As death becomes imminent, dietetic professionals should remain available and supportive to the
patient and family members, providing appropriate suggestions to maximize the comfort of the patient.

Working with Terminally Ill Patients and Families


Supportive guidance to family
Let him give you the cues as to when and what hes able to eat or drink.
Nature is our best guide, as the bodys needs change.
She may be more comfortable taking sips of cool liquids rather than meals.
Too much food or liquid can make her more uncomfortable, make her lungs more wet
and make breathing more difficult.
I know you feel helpless and like youre not doing anything, but know that you are
doing what is best for her at this time. Your presence and your caring are what is
important. You are doing a wonderful job, and she is so lucky to have you.
Foods that might provide comfort
Cream soups (pureed, with uniform consistency to avoid aspiration)
Fruit-based shakes and smoothies (very small quantities, may be made with ginger ale or
lemon-lime soda to make them lighter and more refreshing)
Mashed or baked potatoes
Cream of wheat/oatmeal
Yogurt
Gelatin
Ice cream/sherbet/ices
Liquids that might provide comfort*
Clear juices and nectars
Kool-Aid (sometimes patients prefer this diluted)
Dilute Gatorade or Powerade
Lemonade or limeade
Cranberry juice
Ginger ale or lemon-lime soda (can be mixed with juices or Kool-Aid)
Popsicles
Fruit ice
Water with lemon, lime or orange slices (remove slices to prevent aspiration, unless
patient is drinking through a straw)
*
Note: Patients who would never drink these items ordinarily may find them very soothing at this time.

It is important to note that as death approaches, most people stop taking solid food, and may even
take very little liquid.34 Provision of artificial hydration is controversial and should be taken on a case-
by-case basis, similar to nutrition support.13,37 It is thought that dehydration at this point in the life
cycle is not uncomfortable, but rather creates a kind of euphoric state.38 In fact, excess fluids may
increase secretions, making breathing more difficult and disturbing to both the patient and family
members.

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Summary
Palliative care is aggressive symptom management, including nutritional care. Patients with
advanced cancer and their families and caregivers are faced with a wide range of nutrition-related
problems, which may worsen with disease progression. It is important for dietetic professionals to be
aware of potential disease symptoms and complications and their nutritional implications, and to work
with the healthcare team to ensure optimum symptom management and quality of life. Nutritional
counseling is needed throughout the course of disease to provide education and support to individuals
and their families, as well as to help guide and navigate all stakeholders involved toward appropriate
informed choices regarding nutritional care and nutrition support.

Case Study
NS was a 43-year-old female with advanced breast cancer, admitted to an inpatient hospice care
facility. She had undergone a radical mastectomy followed by chemotherapy and hormone therapy and
was presumed to be disease-free for six years when she was diagnosed with a recurrence of the disease.
By this time, the disease had metastasized to her lung and bones. Her chief complaints were cough,
shortness of breath, pain from the bone metastases, and constipation related to opioid use and physical
inactivity.
Nutrition assessment revealed the patient to be within normal limits of her ideal and usual body
weights, although she had lost 6 lbs in the previous month. Her physician had prescribed
oxycodone/acetaminophen for pain while in the hospital one month before, but had not prescribed a
prophylactic bowel regimen. Upon admission to hospice, NS had not had a bowel movement in five
days.
Her care plan included an enema to relieve her constipation initially, followed by a daily
prophylactic bowel regimen (stool softener three times daily and milk of magnesia at bedtime if no
bowel movement during the day). The registered dietitian provided her with nutrition suggestions to
help promote good bowel function (i.e., hot prune juice as a natural bowel stimulant). Additionally, the
registered dietitian suggested she try soft, moist foods or liquids, which are easier to consume for
people having difficulty with shortness of breath.
Three months later, NS was reaching the end stages of her disease and eating very little. Her
teenage daughter wanted a tube feeding placed to help her to get stronger. NS did not want to receive
tube feedings, but couldnt discuss the matter with her daughter without breaking down into tears. The
registered dietitian, nurse, social worker and attending physician held a family meeting. The patients
wishes were reiterated to the family and alternative means of providing comfort and support were
provided (i.e., cool, refreshing beverages). The family was able to discuss ways that they could help ease
NS through her final days and seemed comforted by their new understanding of the disease process.

References
1. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an
American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
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Grant D, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic
Association; 2006:201-207.
3. Markovitch H, ed. Blacks Medical Dictionary. 41st ed. Lanham, MD: Scarecrow Press; 2006:185-186.
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2005;103(4):863-868.
29. Sharp JW, Roncagli T. Home parenteral nutrition in advanced cancer. Cancer Pract. 1993;1(2):119-124.
30. August D, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of
Directors. A.S.P.E.N. clinical guidelines: Nutrition support therapy during adult anticancer treatment and in
hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472-499.
31. Bachmann P, Marti-Massoud C, Blanc-Vincent MP, et al. Standards, options and recommendations:
nutritional support in palliative or terminal care of adult patients with progressive cancer. Bull Cancer.
2001;88(10):985-1006.
32. Mercadante S. Parenteral nutrition at home in advanced cancer patients. J Pain Symptom Manage.
1995;10(6):476-480.
33. Torelli GF, Campos AC, Meguid MM. Use of TPN in terminally ill cancer patients. Nutrition. 1999;15(9):665-
667.
34. Dunlop RJ, Ellershaw JE, Baines MJ, Sykes N, Saunders CM. On withholding nutrition and hydration in the
terminally ill: has palliative medicine gone too far? A reply. J Med Ethics. 1995;21(3):141-143.
35. Pironi L, Ruggeri E, Tanneberger S, et al. Home artificial nutrition in advanced cancer. J R Soc Med.
1997;90(11):597-603.
36. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J
Am Diet Assoc. 2008;108(5):873-882.
37. Torsheim AK, Falkmer U, Kaasa S. Hydration of patients with advanced canceris subcutaneous infusion a
good solution? Tidsskr Nor Laegeforen. 1999;119(19):2815-2817.
38. Bennett JA. Dehydration: hazards and benefits. Geriatr Nurs. 2000;21(2):84-88.

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Advanced Care and Palliative Care

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Nutrition in Cancer Treatment

Chapter Ten:
Nutrition Support Therapy
This chapter will review three types of nutrition support therapy in the oncology care setting (oral intake,
enteral nutrition and parenteral nutrition), and will provide a review of the various considerations that
need to be addressed before implementing nutrition support in the oncology setting.

For supplemental information to this chapter, please review the following appendices:
Appendix 14 Complications of Enteral Feeding

R egardless of which route of nutrition support therapy is used when caring for people with
cancer, nutrition goals should be specific and achievable to provide optimal nutrition and
compliance. Nutritional care involving the patient and his or her caregivers and family should
be initiated early in the course of treatment and should continue in conjunction with follow-up
nutrition assessment and care. Being proactive and using evidence-based guidelines will help dietetic
professionals maximize safety and clinical benefits of nutrition support while minimizing potential
complications.1

Nutrition Support Therapy


The Academy of Nutrition and Dietetics Evidence Analysis Library includes evidence-based
guidelines on oncology and nutrition. These guidelines recommend medical nutrition therapy with
individualized nutrition assessment, diagnosis, intervention and counseling as an integral component of
a cancer patients treatment and care.2 According to Wong and colleagues at Memorial Sloan-Kettering
Cancer Center, the goals of nutrition support therapy are to minimize body cell mass depletion, prevent
nutrient deficiencies, support or improve immune function, and to facilitate tissue repair and would
healing.3
Nutrition support therapy for use in people with cancer remains a topic of controversy. There is
concern that while enteral and parenteral nutrition support provides needed energy, protein and
micronutrients it may also stimulate cancer growth and metastases, as observed in cell culture and
animal studies. Some believe nutrition support therapy is not appropriate for all people with cancer,
such as those with advanced cancer or those who are terminally ill. To help guide appropriate use, the
A.S.P.E.N. clinical guidelines provide evidence-based nutrition support therapy during adult cancer
treatment and in hematopoietic cell transplant (HCT).4

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Nutrition Support Therapy

Nutrition Support Therapy During Adult Cancer Treatment and HCT4


Guideline Recommendations
1. Patients with cancer are nutritionally at risk and should undergo nutrition screening
to identify those who require formal nutrition assessment with development of a
nutrition care plan.
2. Nutrition support therapy (NST) should not be used routinely in patients
undergoing major cancer operations.
3. Perioperative NST may be beneficial in moderately or severely malnourished
patients if administered for seven to 14 days preoperatively, but the potential
benefits of NST must be weighed against potential risks of NST itself and of
delaying the operation.
4. NST should not be used routinely as an adjunct to chemotherapy.
5. NST should not be used routinely in patients undergoing head and neck,
abdominal, or pelvic irradiation.
6. NST is appropriate in patients receiving active cancer treatment who are
malnourished and who are anticipated to be unable to ingest and/or absorb
adequate nutrients for a prolonged period of time.
7. The use of NST in patients with terminal cancer is rarely indicated.
8. Omega-3 fatty acid supplementation may help stabilize weight in cancer patients
on oral diets experiencing progressive, unintentional weight loss.
9. Patients should not use therapeutic diets (alone) to treat cancer.
10. Immune-enhancing enteral formulas containing mixtures of arginine, nucleic acids
and essential fatty acid may be beneficial in malnourished patients undergoing
major cancer operations.
11. All patients undergoing HCT with myeloablative conditioning regimens are at
nutrition risk and should undergo nutrition screening to identify those who require
formal nutrition assessment with the development of a nutrition care plan.
12. NST is appropriate in those undergoing HCT who are malnourished and who are
anticipated to be unable to ingest and/or absorb adequate nutrients for a
prolonged period of time. When parenteral nutrition is used, it should be
discontinued as soon as toxicities have resolved after stem cell engraftment.
13. Enteral nutrition should be used in patients with a functioning gastrointestinal tract
in whom oral intake is inadequate to meet nutrition requirements.
14. Pharmacological doses of parenteral glutamine may benefit patients undergoing
HCT.
15. Patients should receive dietary counseling regarding foods that may pose infectious
risks, as well as safe food handling during the period of neutropenia.
16. NST is appropriate for patients undergoing HCT who develop moderate-to-severe
graft-versus-host disease accompanied by poor oral intake and/or significant
malabsorption.

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Oral Intake
Oral intake includes diet, nutritional supplements, and vitamin and mineral supplements. When
combined with nutrition counseling and appropriate pharmacological agents, it can be a cost-effective
means of maintaining or improving nutriture.5,6 Because of lower cost and minimal risks associated
with oral nutrition, it is the preferred means of nutrition support (see Chapter Five for more
information).

Nutritional Supplements

Nutritional supplements can be ready-to-use or meal replacement varieties; in liquid, pudding,


bars, powdered mixes, and high-protein clear liquid drinks; or modular additives that can be used in
other supplements or added to food. In addition, there are a number of fortified soups, gelatins and hot
cereal mixes on the market. Although commercially prepared formulas have been available for many
years, companies regularly change formulations to improve the nutrition and palatability of their
products. Its a good idea to keep samples for patients to try, as well as the members of the healthcare
team, to ensure truthful recommendations to others. Commonly used commercial liquid nutrition
supplement products in the oncology setting include Ensure, Boost, Resource and Orgain (USDA
certified organic).
Although modular supplements (e.g., protein powders, lipids, carbohydrates and fiber) are not
always stocked at the grocery store, pharmacy or discount store, they can be a helpful way to add extra
nutrients to an oral diet. Modulars, when added to foods, can boost calories and/or protein without
significantly altering the flavor or volume. Several modular supplements can also be used to tailor
commercially prepared enteral feeding formulas to meet the precise needs of those whose nutritional
plans require more fine tuning.

Types of Supplements
Protein Powders Non-fat dry milk
Egg white powder
Soy powder
Whey powder (Beneprotein)
Carbohydrate Modulars Polycose
Benecalorie
Lipids Modulars Microlipid
MCT Oil
Fiber Products Benefiber
Metamucil
Citrucel

Enteral Nutrition Support


It is important that all avenues of oral nutrition support and symptom management be aggressively
pursued as a primary means of managing the effects of cancer and its treatment. However, when oral
nutrition is not possible or is inadequate because of mechanical obstruction or nutrition impact
symptoms such as dysphagia, anorexia, early satiety or pain, enteral nutrition (EN) is a viable option to
help maintain or replete nutrition status.7,8 Although more expensive than oral nutrition, EN support is

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less expensive than parenteral nutrition and has far fewer potential complications.
Potential complications of EN can be mechanical, metabolic or GI in nature. Complications
include tube displacement/migration, tube occlusion, high residuals/volume intolerance, aspiration,
gastric retention, gastric reflux, nausea, vomiting, cramping, distension, bloating, hypermotility, diarrhea
and constipation.
EN may be administered via nasogastric, nasoenteric or enterostomy tube. Generally speaking,
nasogastric and nasoenteric tubes are used for short-term feeding, whereas the less visible enterostomy
variations are more common for long-term feeding.8

Nasogastric/Nasoenteric

Nasogastric (NG) and nasoenteric tubes vary in length, French size, material, weighted tips, and
opacity. While the distal tip of a NG tube is placed into the stomach (may be done at the bedside),
nasoenteric tubes are advanced beyond the pyloric sphincter into the duodenum or further into the
jejunum. This may require the use of endoscopy, fluoroscopy or prokinetic pharmacological agents.
Nasoenteric tubes are intended for use in patients who are at greater risk for aspiration.
Smaller French sizes are used more frequently in children or for adults requiring NG tube
placement for feeding during head and neck radiation therapy to decrease the possible pharyngeal
irritation; however, the smaller the French size (diameter), the greater risk of obstruction due to the
administration of medications through the tube or more viscous enteral formulas.

French Sizes of Feeding Tube Catheters9


Common External French Diameter (OD)
Size Mm
10 3.3
12 4.0
14 4.7
16 5.3

Enteric Feeding

Enterostomies include gastrostomy and jejunostomy tubes and may be placed surgically or
laparoscopically under a general anesthetic (percutaneous endoscopic gastrostomy [PEG]), or
endoscopically or radiologically under lighter anesthesia (percutaneous endoscopic jejunostomy
[PEJ]).10 A jejunal extension tube (JET) may be placed through a PEG tube to allow for simultaneous
gastric decompression and jejunal feeding when warranted.
The further the distal end of the tube is placed into the intestinal tract, the greater the potential risk
of diarrhea/dumping. Therefore, nasojejunal, jejunostomy, PEJ and JET-PEG feedings need to be
administered continuously via a pump. Feedings can be cycled overnight, as tolerated, to allow more
freedom during the day. Gastric feedings may be administered as continuous or cycled feedings via
pump, or more commonly intermittent gravity drip or bolus feedings. Duodenal feedings pose
moderate potential for dumping, and feedings should be administered as tolerated by the individual.

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Enteral Formulas

There is quite an array of commercially prepared formulas for EN support. Most patients will
tolerate standard formulas without problems. For those with volume intolerance, the concentrated
formulas are good alternatives. It is important to note that concentrated formulas will require greater
free water between feedings by mouth or via tube to ensure adequate hydration, unless the person is
fluid restricted.
To determine the amount of free water required by a patient, take the percentage of free water/L of
formula multiplied by the volume the individual receives. Subtract this number from the estimated daily
fluid requirement. Individuals with constipation or diarrhea secondary to their cancer therapy may
benefit from a fiber-containing formula, with adequate free water to ensure hydration.

Free Water Requirements for Enteral Feedings


Sample Calculation

Formula X has 840 cc H2O/L, or 84% (0.84)


Patient requires 1800 cc Formula X/day
Patient requires 2200 cc fluid/day
____________________________________
0.84 X 1800 cc Formula X = 1512 cc free water in 1800 cc Formula X

2200 cc fluid required/day


1512 cc free water from Formula X
____________________________________
688 cc additional free water/day

As indicated in the A.S.P.E.N. guideline recommendations, specialty formulas should be used on an


individual basis, as supported by evidence-based practice.4 Immune-enhanced formulas have been
shown to decrease infectious complications and length of hospital stay in surgical patients.11-13
However, the subject groups were fairly heterogeneous, and studies varied in length and time of
administration of immune-enhancing formulas. The composition of these formulas are varied (e.g.,
various combinations of arginine, glutamine, nucleic acids and essential fatty acids) and the nutritional
status of the evaluated subjects varied as well.
Similar to the immune-enhanced formulas are omega-3 fatty acid-containing formulas designed
specifically for cancer patients with solid tumors. Animal and human studies have shown that these
formulas can be an effective modulator of cancer cachexia.14-16 The amount of omega-3 fatty acids used
to achieve weight stabilization or improvement varied from 2 g/day to 27 g/day, with the enteral
product containing 1 g per 240 cc can. The only product with this formulation is no longer sold in the
United States due to poor sales, as the price was more than $6 per can. Great Britain still sells this type
of product.
Although research is not definitive as to the effects of omega-3 fatty acid-containing formulas on
platelets, caution is advised for patients with thrombocytopenia, as supplemental omega-3 fatty acids
will thin the blood. Clearly, more research is needed regarding the amount of EPA and tumor types that
might benefit from supplementation, as well as its indications/contraindications for individuals with
decreased platelets.

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Nutrition Support Therapy

Research is needed to further pinpoint population groups that may derive the greatest benefit from
omega-3 fatty acid-containing formulas. Other needed areas of study include trials evaluating the
influence of inflammatory response markers, as well as attenuation of weight loss, with the inclusion of
omega-3 fatty acids. Inflammatory response markers may become part of the guidelines used to
determine the appropriate use of these new formulas.

Parenteral Nutrition Support


The use of PN support in the oncology care setting should be determined by the patients disease
and functional status, GI function, level of stress and degree of malnutrition.17,18 The benefit of PN
should then be evaluated with regard to cost and potential adverse consequences. There are specific
areas where PN support is appropriate and necessary, and it should be an adjuvant therapy to
conventional cancer treatments.

Indications for PN in People With Cancer4,19


Nonfunctional GI tract
Bowel rest (whether caused by the cancer or as a consequence
of treatment)
Severe diarrhea
Severe malabsorption
Radiation enteritis
Short bowel syndrome
Intractable nausea and or vomiting
Bowel obstruction
Ileus
Severe pancreatitis
Enterocutaneous fistula
Graft-versus-host-disease of the gut

PN may be administered via a peripheral vein (peripheral parenteral nutrition [PPN]) or central
venous catheter (total parenteral nutrition [TPN]).

Peripheral PN

Basic PN solutions contain 3% to 15% amino acids and 5% to 70% dextrose. These basic formulas
are used as the basis for all PPN and TPN. Essential fatty acid requirements can be met by providing at
least 3% of the total calories as lipid.20 Lipids may be part of the daily admixture or lipid emulsions of
10% to 30% can be added to the PN regimen once, twice or three times/week. Vitamins, trace
elements, electrolytes and medications (e.g., famotidine [Pepcid]) can be added to the solution daily.
Risks associated with PPN include phlebitis, sepsis and catheter infiltration. PPN should be limited
to short-term use (no more than 14 days) because of the risk of phlebitis and limited venous access.
Osmolarity of PPN solutions is limited to 600 mOsm/L to 900 mOsm/L, which limits the dextrose to
no greater than 10%, and amino acids to 2.5% to 5%.21 Therefore, nutritional requirements cannot be
met with PPN. Lipid added to PPN solutions decreases the risk for phlebitis and can contribute
additional non-protein calories.

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Nutrition in Cancer Treatment

TPN

TPN solutions are much less limited than PPN in the nutrients that they provide and the duration
of nutrition support. From the base solution, TPN can be formulated to meet the calorie, protein and
individual nutrient needs of a patient. Delivery can be done continuously, or in some cases, can be
cycled on and off to give patients greater mobility.
Many patients with cancer already have central venous lines for treatment; therefore, the risks
associated with central line placement are not increased. Risks associated with TPN fall into three
categories: mechanical/technical, infectious and metabolic:
Mechanical/technical complications have to do with placement, occlusion and breakage of
catheters and thrombosis.
Infectious complications arise from endogenous skin flora, contamination of the catheter
hub, seeding of the device from a distant site and contamination of the solution.22
Metabolic complications can be serious and life-threatening. Adequate monitoring and
appropriate interpretation of laboratory values can prevent metabolic complications such
as hyper- or hypoglycemia; hypophosphatemia; hypomagnesemia; and other nutrients,
fluid and electrolyte imbalances.

NST Safety and Ethical Considerations


NST of critically ill and/or severely malnourished patients can result in serious complications.
Refeeding syndrome can result in intracellular shifts of potassium, magnesium, phosphorus and
calcium.23 Further metabolic complications of overfeeding include azotemia, fat-overload syndrome,
hepatic steatosis, hypercapnia, hyperglycemia, hyperglycemic hyperosmolar nonketotic syndrome
(HHNS), hypertonic dehydration, hypertriglyceridemia and metabolic acidosis.24 Continuous
monitoring and re-evaluation of patients requirements and response to NST are essential.
Oral nutrition is the preferred means of nutrition support and requires the development of
individualized nutrition care plans and proactive symptom management, as well as supportive care (e.g.,
pharmacologic agents and liquid supplements and meal replacements), to achieve adequate oral intake
and maintenance of nutritional status. EN and PN support is appropriate in specific instances,
particularly in severely malnourished individuals. Decisions regarding implementation of NST are best
made on an individual basis using a multidisciplinary approach that includes the patients and their
caregivers and families.25 Additionally, dietetics professionals should be familiar with the position
statement of the Academy of Nutrition and Dietetics regarding ethical and legal issues in nutrition,
hydration and feeding.25

Summary
NST may be accomplished via oral, enteral or parenteral means. EN is not without risk or added
healthcare costs, but is preferred over PN in most cases. EN support may be appropriate in the
malnourished perioperative patient or when the patient is unable to take adequate oral nutrition for
more than seven to 10 days because of nutrition impact symptoms such as esophagitis, mucositis,
obstruction of the upper GI tract (that does not preclude intestinal feeding), or dysphagia.
PN may be useful in patients who are unable to take adequate oral or enteral nutrition for more

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Nutrition Support Therapy

than seven to 10 days due to mechanical obstruction, radiation enteritis and/or treatment-related
nutrition impact symptoms. Decisions regarding the implementation of nutrition support should be
made on an individual basis in a multidisciplinary team setting.

References
1. Charney P, Malone A, eds. ADA Pocket Guide to Enteral Nutrition. Chicago, IL: American Dietetic
Association; 2006.
2. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition
Practice Guideline. Chicago, IL: Academy of Nutrition and Dietetics: 2010.
3. Wong PW, Enriquez A, Barrera R. Nutritional support in critically ill patients with cancer. Crit Care Clin.
2001;17(3):743-767.
4. August D, Huhmann MB, American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of
Directors. A.S.P.E.N. clinical guidelines: Nutrition support therapy during adult anticancer treatment and in
hematopoietic cell transplantation. JPEN J Parenter Enteral Nutr. 2009;33(5):472-499.
5. Tchekmedyian NS. Pharmacoeconomics of nutritional support in cancer. Semin Oncol. 1998;25(2 Suppl
6):62-69.
6. Pille S, Bohmer D. Options for artificial nutrition of cancer patients. Strahlenther Onkol. 1998;174(Suppl
3):52-55.
7. Waldfahrer F, Iro H. Basic principles and concepts of enteral nutrition of ENT patients. HNO.
2002;50(3):201-208.
8. Robinson C. Enteral nutrition in adult oncology. In: Elliott L, Molseed LL, McCallum PD, eds. The Clinical
Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:138-155.
9. Nestle Nutrition. 2012 HealthCare Products Booklet. http://www.nestle-nutrition.com/Products. Accessed
July 21, 2012.
10. Given MF, Lyon SM, Lee MJ. The role of the interventional radiologist in enteral alimentation. Eur Radiol.
2004;14(1):38-47.
11. Gentilini O, Braga M, Gianotti L. Rational base and clinical results of immunonutrition. Minerva Anestesiol.
2000;66(5):362-366.
12. Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical
patients: a prospective randomized study. Arch Surg. 2002;137(2):174-180.
13. Wu GH, Zhang YW, Wu ZH. Modulation of postoperative immune and inflammatory response by immune-
enhancing enteral diet in gastrointestinal cancer patients. World J Gastroenterol. 2001;7(3):357-362.
14. Whitehouse AS, Smith HJ, Drake JL, Tisdale MJ. Mechanism of attenuation of skeletal muscle protein
catabolism in cancer cachexia by eicosapentaenoic acid. Cancer Res. 2001;61(9):3604-3609.
15. Wigmore SJ, Barber MD, Ross JA, et al. Effect of oral eicosapentaenoic acid on weight loss in patients with
pancreatic cancer. Nutr Cancer. 2000;36(2):177-184.
16. Von Meyenfeldt, Ferguson M, Voss A, et al. Weight gain is associated with improved quality of life in
patients with cancer cachexia consuming an energy and protein dense, high N-3 fatty acid oral supplement.
Proc Am Soc Clin. Oncol 21: 2002 (abstr 1536).
17. Charney P, Malone A, eds. ADA Pocket Guide to Parenteral Nutrition. Chicago, IL: American Dietetic
Association; 2007.
18. De Chicco RS, Steiger E. Parenteral nutrition in medical or surgical oncology. In: Elliott LL, Molseed L,
McCallum PD. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic
Association; 2006:156-164.

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19. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral
and enteral nutrition in adults and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1Suppl):S1A-
138SA.
20. Frankenfield D. Energy and macrosubstrate requirements. In: Gottschlich MM, ed. The Science and Practice
of Nutrition Support: A Case-based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:31-52.
21. Mirtallo JM. Introduction to parental nutrition. In: Gottschlich MM, ed. The Science and Practice of
Nutrition Support: A Case-Based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:217.
22. Krzywda EA, Andris DA, Edmiston CE, et al. Parenteral access devices. In: Gottschlich MM, ed. The Science
and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque IA: Kendall-Hunt; 2001:230.
23. Hurst JD, Gallagher AL. Energy, macronutrient, micronutrient, and fluid requirements. In: Elliott L, Molseed
LL, McCallum PD, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic
Association; 2006:54-71.
24. Klein CJ, Stanek GS, Wiles CE 3rd. Overfeeding macronutrients to critically ill adults: metabolic
complications. J Am Diet Assoc. 1998;98(7):795-806.
25. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J
Am Diet Assoc. 2008;108(5):873-882.

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Nutrition in Cancer Treatment

Chapter Eleven:
Management of Cancer-related
Nutrition Impact Symptoms
This chapter will review nutrition impact symptoms common to people with cancer, including etiologies of
nutrition impact symptoms, medical nutrition therapy (MNT) and symptom management, and
pharmacological agents used in symptom management.

For supplemental information to this chapter, please review the following appendices:
Appendix 5 Medical Nutrition Therapy for Cancer-related Nutrition Impact Symptoms
Appendix 6 Pharmacological Agents for the Management of Chemotherapy-induced Nausea and
Vomiting
Appendix 7 Pharmacological Agents for the Management of Anorexia and Cachexia
Appendix 8 Pharmacological Agents for the Management of Constipation
Appendix 9 Pharmacological Agents for the Management of Diarrhea
Appendix 10 Pharmacological Agents for the Management of Oral Mucositis and Esophagitis
Appendix 11 Pharmacological Agents for the Management of Pain

C ancer, cancer treatment and recovery from treatment can significantly impact nutritional needs
and can affect digestion, absorption, and metabolism. Symptoms that affect nutritional status
include nausea and vomiting, changes in taste and smell, bowel changes, dysphagia, anorexia,
pain and fatigue.

Nutrition Impact Symptoms


People diagnosed with cancer may experience a myriad of symptoms that have an impact on their
nutritional status. These nutrition impact symptoms impede or impact nutrition intake.1
Aggressive management of nutrition impact symptoms is essential to good patient care.2
Identification of nutrition impact symptoms and their etiologies allow for optimum management with
medical nutrition therapy (MNT) and appropriate pharmacological agents.
It is important to remember that cancer does not present with one basic symptom profile.
Symptoms vary from person to person, and depending upon the type of cancer, disease stage, treatment
regimens, comorbid diseases, current health and functional status, and age. Each patient should receive
individualized care, with respect to symptom identification and management. It is true, however, that
there are commonalities in symptoms and management techniques. Experience shows that by listening
to patients and working together, nutrition professionals can manage and overcome patients nutrition-
related problems and concerns.

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Management of Cancer-related Nutrition Impact Symptoms

Alterations: Taste and Smell


Alterations in taste, or dysgeusia, and alterations in smell can occur secondary to chemotherapy,
xerostomia, infection or psychological conditioning.
Taste alterations secondary to chemotherapy are usually reversible, but may take several months to
resolve. Changes occurring with radiation therapy, however, can sometimes be permanent.
People undergoing head and neck radiation therapy usually experience more difficulty with
depression or complete loss of taste sensation for sweet, sour, bitter and salty tastes. In contrast, those
undergoing chemotherapy are more likely to complain of intolerance to meats (especially red meat),
and increased bitter or sweet sensations, as well as strange tastes, such as metallic or gamey tastes,
even between meals. They may also experience a heightened sense of smell that results in sensitivity to
food preparation odors and aversions to nonfood items such as perfumes and soaps.
Nutrition interventions that decrease the aroma of food, such as serving food cold instead of hot,
may be helpful. Patients should be encouraged to practice good oral hygiene including regular brushing,
gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution will also help
to keep the oral cavity clean, moist, and better tasting.
Zinc supplementation (220 mg zinc sulfate twice a day) has been used in cases of depressed taste
acuity with some success; however, it is thought that this may only be helpful in patients whose zinc
nutriture is suboptimal. Excessive and prolonged use of zinc supplementation may cause
immunosuppression and diarrhea, as well as decreased copper and iron absorption.3

Anorexia
Anorexia is defined as the involuntary loss of appetite or the desire to eat, with subsequent
reduction of food intake.4.5 It is most likely caused by physiological (e.g., pain, cytokines and fatigue)
and psychological (e.g., depression and anxiety) changes caused by the cancer itself or its treatment.6
Anorexia is common among cancer survivors and nearly universal among those with advanced disease.
In addition, anorexia may be secondary to other symptoms and side effects of treatment, or may be a
unique and unrelated symptom. Nutrition-related factors contributing to anorexia can include
alterations in taste and smell, alterations in gastrointestinal (GI) function and metabolic abnormalities.
Alleviation of anorexia is best achieved by treating all potential causes, such as pain,
nausea/vomiting, constipation, diarrhea, taste changes and early satiety. If symptoms are treated
satisfactorily and anorexia remains, a variety of pharmacological agents can stimulate appetite.
MNT management strategies include a thorough nutrition assessment and physical examination to
identify risk for malnutrition and factors related to poor food intake. Patients should be encouraged to
increase their intake of nutrient-dense foods, as well as consume small, frequent meals and snacks. In
addition, the Oncology Nursing Societys Putting Evidence into Practice (PEP) statement on anorexia
states that individualized dietary counseling is likely to be effective to improve nutritional intake and
quality of life.4

Cancer Cachexia Syndrome and Weight Loss


The etiology of cachexia and weight loss observed in cancer survivors is not entirely understood,
although experts agree it is most likely multifactorial.7,8 Metabolic alterations and inadequate intake
secondary to nutrition-related problems contribute to these symptoms of cancer and its treatment.9
Other factors include anorexia, nausea, vomiting, fatigue, taste and smell alterations, pain, early satiety,
constipation, mucositis, diarrhea, xerostomia and malabsorption.10,11
Alleviation of weight loss is best achieved by proactive nutrition assessment, diagnosis, intervention

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Nutrition in Cancer Treatment

and monitoring, as well as by identifying and treating its potential causes. There are several
pharmacological agents, as well as liquid nutrition supplements, available to help patients increase their
appetite and caloric intake to replenish lean body mass and to arrest weight loss.

Constipation
Constipation is defined as difficult defecation or infrequent defecation (fewer than three stools per
week) associated with the passing of hard or dry fecal matter.4 Constipation is common among cancer
survivors and can result from dehydration or mechanical changes from cancer.12 In addition, many
instances of constipation are secondary to medications, such as opioids. Inadequate intake of fiber and
fluid, as well as decreased physical activity, can be contributing factors. Severe constipation can lead to
fecal impaction and obstruction.
Constipation should be managed prophylactically, and patients should be encouraged to increase
fiber and fluid intake, and increase physical activity as able. These recommendations are supported by
the Oncology Nursing Societys PEP expert opinion on constipation that states that individualized
bowel management programs for people experiencing constipation should include fluids, dietary fiber,
activity and increased mobility as well as medications to offset constipating side effects of other
medications.4

Diarrhea
Diarrhea is a common side effect of cancer treatment.13 Diarrhea is defined as the frequent passage
of unformed, watery bowel movements. It can further be described as an increase (from usual) in
number and/or liquidity of stools and may be accompanied by abdominal cramping.4 An exact number
of stools does not define diarrhea; rather, patients diarrhea symptoms should be individually assessed
and compared with their normal bowel habits.14 The consequences of diarrhea can be severe and
include dehydration and electrolyte imbalances. Nutrition interventions can be very effective in
managing diarrhea.
The etiology of diarrhea can be secondary to excess blood or mucus in the GI tract; malabsorption
dysmotility; osmosis of water into the GI tract to dilute a concentrated substance; increased secretion of
electrolytes and fluid (likely the mechanism of chemotherapy-induced diarrhea); or combinations
thereof. Chemotherapy can cause diarrhea. Graft-versus-host disease of the gut following allogeneic
stem cell transplantation can cause severe diarrhea. Damage to the GI tract from radiation therapy can
cause radiation enteritis (acute or chronic).
People with advanced cancer may also experience diarrhea, although constipation is more prevalent
among this population. Diarrhea is common among those with cancer diagnoses involving the GI tract
such as cancers of the pancreas, gallbladder, colon, rectum, anus or neuroendrocrine cancer, such as
carcinoid tumors. Surgeries or procedures that can contribute to diarrhea include celiac plexus block
(often done to relieve pain associated with pancreatic cancer), cholecystectomy, esophagogastrectomy,
gastrectomy, pancreaticoduodenectomy (Whipple procedure), intestinal resection and vagotomy.15
Radiation therapy involving the abdomen or pelvis or total body irradiation is also a common cause of
diarrhea.
Medications, like antibiotics, can contribute to diarrhea, as can intestinal bacterial overgrowth, diet,
psychological stress and fecal impaction.
In addition to pharmacological agents, probiotic supplements and water soluble fiber
supplementation (e.g., Citrucel, Benefiber), can reduce the incidence and severity of radiation-induced
diarrhea.4 Anecdotal reports of glutamine used during radiation therapy are far more favorable than the

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current literature suggests. The effectiveness of glutamine supplementation during chemotherapy may
be dependent on the cytotoxic agent(s) used, as well as the timing of the glutamine dosing. Further
documentation in the literature is needed in both chemotherapy and radiation therapy. Currently, the
recommended dosage is 30 g glutamine/day in two or three doses. Glutamine works best in a powdered
form, which is relatively unstable. Each dose should be mixed in water, juice or other soft-moist food
and taken immediately.

Dysphagia
Dysphagia, or difficulty swallowing, is often vaguely defined. Pain with swallowing is often
classified as dysphagia, while the technical term is odynophagia. Dysphagia refers to an aberration in
one or more phases of the swallow, not simply painful swallowing. Logemann describes swallowing in
four phases: preparatory, oral, pharyngeal and esophageal:16
In the preparatory phase, food/drink (the bolus) enters the mouth and the lips, the
jaws close and saliva is produced. This action is entirely voluntary.
The oral phase is voluntary and involves further preparation of the bolus by chewing
and mixing with saliva. The tongue propels the bolus to the back of the throat, or the
pharynx.
The pharyngeal phase of the swallow is involuntary and is triggered as the bolus
passes the faucial pillars at the back of the mouth. The muscles of the pharynx contract,
the nasopharynx is closed, the epiglottis closes, the larynx is raised and vocal cords
come together, providing protection of the nasal passages and airway.
The esophageal phase of the swallow is also an involuntary action. The upper
esophageal sphincter relaxes, and peristalsis moves the bolus into the stomach.

Each phase can be affected by cancer and its treatment. Patients who are post-surgical resection for
a variety of oral cancers or those with xerostomia, oral candidiasis, mucositis, poor dentition and
history of stroke; and those who are elderly, weak and debilitated, have a history of stroke or have
advanced cancer may not be able to properly prepare a bolus of food for the pharyngeal phase of the
swallow.
The esophageal phase of the swallow is most affected by strictures and esophagitis. Patients with
esophageal cancer and those who have had esophageal resection are at greater risk for these types of
problems. The elderly may also have increased esophageal transit time, which can cause further
difficulties.

M anagement of Dysphagia

It is extremely important for people with dysphagia to be evaluated by a speech pathologist and, if
needed, receive treatment from the speech pathologist. These professionals can provide valuable
diagnostic information, as well as techniques for airway protection and recommendations for
appropriate diet consistency that can prevent the need for enteral nutrition; they also determine when it
is not safe to eat or drink due to risk of aspiration. The dietitian and speech pathologist work together
as a team to coordinate the plan of care and patient education, and they should reinforce each others
care guidelines whenever possible.
There are no medications that can treat dysphagia; however, there are numerous medications that
are effective in treating problems such as xerostomia, odynophagia, oral candidiasis and mucositis that
contribute to difficult or painful swallowing.

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Early Satiety
Although early satiety is a common symptom of cancer and its treatment, it is often lumped
together with anorexia in its identification and treatment.17 Patients often describe feelings of fullness
along with loss of appetite. It is often associated with reduced upper GI motility and can be effectively
managed with MNT and pharmacological agents such as metoclopramide (Reglan).
Studies have shown that gastric emptying of solids occurs more quickly alone than when liquids are
present; therefore, patients should be encouraged to take sips of liquids between meals, throughout the
day.18 This recommendation can maximize the intake of energy- and protein-containing foods at meals
and snacks rather than "filling up" on lower calorie-containing fluids (e.g., water and juice) at
meal/snack time. It is a careful balance of intake of calorie/protein-containing foods and adequate
hydration. If fluids are encouraged at meal time the concern is the desired/needed protein and energy
intake will not be met: Patients will drink a big glass of juice and then have no room for other foods;
thus the recommendation for foods at meal time and fluids between.

Metoclopramide for Management of Early Satiety10,19-21


Action GI stimulant
Indication Early satiety
Dosage 10 mg 30 minutes before each meal and at bedtime
Side effects Restlessness, drowsiness, fatigue, lassitude, extrapyramidal effects,
nausea, diarrhea
Comments It takes about 2 weeks for desired effect; drug is often prescribed for
appetite and patients expect improvement in appetite immediately. It is
important to instruct patient on action of the drug and to take it exactly as
ordered for at least two weeks to adequately evaluate efficacy.

Early satiety can also occur secondary to constipation. Many cancer survivors require a
prophylactic bowel regimen program to maintain regular bowel movements and decrease constipation-
related symptoms, such as GI gas and bloating.

Fatigue
Fatigue is the most frequently reported and long-lasting side effect experienced by people with
cancer.22 Cancer-related fatigue can be defined as distressing or persistent tiredness, as well as a
subjective sense of physical, emotional and/or cognitive tiredness related to cancer or cancer treatment
that interferes with usual functioning.4 Fatigue is commonly manifest as weakness, tiredness, dizziness,
decreased motivation or interest, feelings of sadness, depression, frustration, irritability and decreased
cognitive abilities.
Nutrition-related symptoms of fatigue include anorexia, poor nutrition intake, cancer cachexia,
weight loss and anemia.23 Collaborative management includes energy conservation, stress management,
rest and relaxation, and nutrition consultation to ensure that patients consume adequate dietary intake
and hydration.5,24

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Lactose Intolerance
Lactose intolerance is a form of malabsorption, caused by inadequate production of lactase, the
enzyme needed to metabolize lactose to glucose and galactose for absorption. People with lactose
intolerance experience rumbling gas and/or diarrhea after consuming dairy products.
Symptoms vary depending on the amount of lactose present in the food or beverage. Individual
tolerance varies considerably, but most lactose-intolerant people can tolerate up to 12 oz/day, in
divided portions, without symptoms. Lactose intolerance approaches 100% in Native Americans and
people of Asian descent; it is also common among African Americans and Latinos, affecting nearly 80%
of their population. Lactose intolerance is present in about 15% of people of northern European
descent.25
The prevalence of lactose intolerance as it relates to cancer and its treatment is not well
documented. Some healthcare professionals believe that radiation therapy and chemotherapy can cause
lactose intolerance, while others believe that such treatments can exacerbate symptoms in previously
subclinical cases. Others believe that cancer patients may consume more dairy products (in the form of
cream sauces, milk shakes, casseroles and puddings) than they normally do and experience symptoms
related to an underlying lactose intolerance.
Lactase enzymes are sold over the counter under a variety of brand names, as well as generics or
store brands. Additionally, lactose-free dairy products (e.g., milk and cottage cheese) that have been
pretreated with lactase enzymes are available in most grocery stores in several different fat contents.
Enzymes come in chewable tablets or caplets and range in strength from 3000 to 9000 FCC lactase
units/tablet or caplet. Instructions to patients should include:
Begin with one 3000 FCC lactase unit tablet or caplet with a serving of dairy and increase
dosage until symptoms are relieved. Patients will learn how many caplets are needed for various
foods such as milk, ice cream and cheese.
Some people may find the lactase enzyme products ineffective and should then try lactose-free
products or dairy alternatives such as almond, rice or soy milk products.

Malabsorption
Patients with malabsorption may experience gas; abdominal pain; and frequent watery, frothy,
floating, greasy stools that may be malodorous. This is common among pancreatic cancer patients and
can occur in patients with GI cancers, particularly after surgical resection.15 Malabsorption is a result of
inadequate pancreatic enzymes lipase, protease and amylase.
However, rather than restrict intake in patients who may already have nutrition problems, it is best
to treat malabsorption with supplemental pancreatic enzymes. A number of pancreatic enzyme
preparations that contain lipase, protease and amylase are available by prescription. These preparations
come in capsules, tablets and powders, and are available in a variety of strengths. Potential side effects
from pancreatic enzymes include nausea, abdominal cramps and diarrhea.

Mucositis and Esophagitis


Mucositis is defined as inflammation and potentially ulcerative processes of the mucous
membranes of the body of individuals receiving chemotherapy and radiation therapy.4 Mucositis can
cause pain, which can be severe. Similarly, esophagitis is the inflammation of the esophageal mucosa.
Both are common side effects from chemotherapy and radiation therapy. Chemotherapy-induced
mucositis usually appears within three to 10 days following chemotherapy, and starts with burning,
followed by ulceration of the mucosa. Mucositis or esophagitis secondary to radiation therapy usually

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develops about two weeks into treatment. Its severity depends on the amount of radiation delivered
and the patients use of alcohol and tobacco, which exacerbate the situation.
Treatment interruptions or dose reductions in therapy may be needed because of severe mucositis
or esophagitis; therefore, aggressive supportive care management is warranted. A number of
pharmaceutical agents can be used in the supportive care plan. Additionally, glutamine has been
investigated in the prevention and treatment of mucositis secondary to chemo- and radiotherapy.26-29
Results have been favorable, although more research is necessary to determine dosage and delivery for
maximum benefit. Currently, the recommended dosage is 30 g glutamine/day in two or three doses.
Patients should be encouraged to practice good oral hygiene with regular brushing with an extra-
soft tooth brush, gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda
solution (e.g., 1 tsp salt, 1 tsp baking soda mixed into four cups of water, daily) can help to keep the
oral cavity clean, moist and better tasting.

Myelosuppression
Myelosuppression refers to the suppression of bone marrow activity by the modalities of cancer
treatment and is the most common dose-limiting toxicity of chemotherapy.5 The result of
myelosuppression can be a reduction in the number of platelets, red blood cells and white blood cells.30

Thrombocytopenia

Thrombocytopenia is a decrease in the number of platelets. Symptoms include petechiae (small tiny
red dots on the skin), excessive bleeding, enlarged liver and/or spleen, blood in the stool and prolonged
menstruation. MNT management strategies should encourage patients to consume adequate protein-
containing foods for megakaryocyte (a cell in the bone marrow necessary to produce platelets)
production and to avoid dry, scratchy foods that could be irritating to the mucosa of the oral cavity
and gut.31

Anemia

Anemia is a decrease in the number of red blood cells and/or a reduced iron content of the red
blood cells. Symptoms vary depending upon the degree of anemia and include fatigue, weakness, pallor
and shortness of breath. Patients with prolonged poor nutritional intake should be encouraged to
improve overall energy and protein intake because available iron stores can be greatly diminished due
to negative nitrogen stores, weight loss and chemotherapy-related toxicities.32 Management of anemia
should include oral iron supplementation only for those with confirmed iron deficiency.
Tolerance to iron supplementation is most often not an "acute" problem or concern for people with
cancer. "Nu-iron," an elemental iron that is an iron polysaccharide and has good GI tolerance, is
routinely recommended for people not tolerating ferrous sulfate or ferrous gluconate. It is available
over the counter. Liquid iron is often very difficult to tolerate, thus for people with treatment- or
cancer-related decreased appetite, nausea or early satiety, it is not prescribed. For patients with
profoundly low iron stores, IV iron should be administered.

Neutropenia

Neutropenia is a decrease in the number of white blood cells, specifically neutrophils. Patients
with cancer who undergo hematopoietic cell transplantation, intensive chemotherapy, and/or radiation

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Management of Cancer-related Nutrition Impact Symptoms

therapy are at significant risk for infection and neutropenia. When patients are immunosuppressed,
neutropenic precautions should be used to minimize exposure to foreign bacteria to decrease the risk of
infection and foodborne illness.33
Strategies to reduce risk of infection include hematopoietic growth factors, prophylactic treatment
of infection, strict hand washing, and the restriction of foods and beverages that are potentially high in
bacteria that could introduce foodborne pathogenic organisms into the GI tract.
Neutropenic precautions are commonly instituted when the absolute neutrophil count (ANC)
drops below 1500 mm3, although standard guidelines vary greatly among institutions. Considerations
for instituting a neutropenic or low-bacteria diet include the severity and duration of neutropenia, other
nutrition-related nutrition impact symptoms, the patients nutritional status and prescribed cancer
treatment.

Nausea and Vomiting


Nausea can be described as an unpleasant subjective experience or a feeling that arises in the
stomach and/or the back of the throat that may or may not be accompanied by vomiting or retching.4
Nausea can occur with other related symptoms such as tachycardia, perspiration, lightheadedness,
dizziness, pallor, excess salivation and weakness.5
Nausea is one of the more common symptoms experienced among cancer patients. As many as
50% of patients receiving chemotherapy experience some degree of nausea and vomiting.
Chemotherapy-induced nausea and vomiting (CINV) is classified as follows:
Acute: Occurs 24 hours or fewer after chemotherapy
Delayed: Occurs one to six days after chemotherapy
Anticipatory: Occurs within one week before the actual administration of chemotherapy
Nausea and vomiting are controlled by the central nervous system. Nausea is mediated by the
autonomic nervous system, and vomiting is a result of the stimulation of any number of CNS pathways,
including a chemoreceptor trigger zone; the cerebral cortex and limbic system response to sensory
stimulation, psychological distress and pain; vestibular-labyrinthine apparatus of the inner ear (in
response to motion); and peripheral stimuli from visceral organs and vasculature as a result of
exogenous chemicals and endogenous substances that accumulate during inflammation, ischemia and
irritation.5
Nausea and vomiting may also be secondary to hypercalcemia; volume depletion; water
intoxication; tumor invasion of the GI tract, liver or CNS; constipation; medications, such as opioids;
infection/septicemia; uremia; delayed gastric emptying; or anxiety.5
Acute nausea and vomiting is presumed to be a result of peripheral stimuli from visceral organs and
vasculature, along with stimulation of the chemoreceptor trigger zone. In addition to chemotherapy,
radiotherapy to the GI tract, liver and brain are associated with nausea and vomiting.
Chronic nausea and vomiting, not related the administration of chemotherapy, is observed in
patients with advanced cancer, and its etiology is most likely due to in part to GI, cranial, metabolic,
drug-induced, and chemo/radiation therapy-induced mechanisms.

Treatment of Nausea and Vomiting


Nausea and vomiting, as with all nutrition impact symptoms, should be managed according to its
etiologies. The risk for developing CINV is related to specific chemotherapy agent(s) being
administered, the dose prescribed and other patient factors.34 The onset and the duration of CINV can
be highly variable.35

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To effectively control CINV, oncologists determine the emetogenic level of the chemotherapy agent
prescribed and then select the appropriate antiemetic.

Emetogenic Potential of Chemotherapy Agents35,36


Level/Likelihood of Emesis (Vomiting) Individuals Experiencing Emesis (Vomiting)
5 (very high) > 90%
4 (high) 60% to 90%
3 (moderate) 30% to 60%
2 (low) 10% to 30%
1 (very low) < 10%

M NT for Nausea and Vomiting

Until vomiting is under control, patients should be cautioned against taking in solid foods, as this
may perpetuate symptoms. Vomiting can lead to dehydration, if not managed proactively. Therefore,
patients should contact their physician if nausea and vomiting persists and if they are unable to keep
down liquids. Encourage patients to sip on water and clear, calorie-containing liquids such as fruit
juices, sports drinks, gelatin and flat soft drinks to ensure adequate hydration.

Pharmacological M anagement of Nausea and Vomiting

Anticipatory nausea and vomiting (ANV) is often difficult to control with pharmacological agents.
A variety of behavioral interventions such as guided imagery, hypnosis and systematic desensitization
may be helpful with its management. ANV has been reported in up to 25% of patients as a result of
classic conditioning from stimuli associated with chemotherapy.30 Risk factors that may increase the
likelihood of ANV include being younger than 50 years, being female, having high levels of anxiety
before and during chemotherapy administration, and having susceptibility to motion sickness.5 A
referral to a mental health professional is often recommended in the management of ANV.
Acute and delayed nausea and vomiting related to cancer treatment, as well as chronic nausea and
vomiting, can be treated with several different pharmacological agents. Combination antiemetic
regimens are commonly prescribed for nausea and vomiting management. Generally, a combination
regimen includes a dopamine antagonist and other agents that have no dopamine-blocking action.5
The National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines
that guide oncologists in the effective management of cancer-related nausea and vomiting using various
single and multiple antiemetic agent schemas.37

Oral Infections and Candidiasis


Oral candidiasis is a fungal infection (the organism is Candida albicans) of the mouth,
characterized by red mucosa with white cheesy patches. It can cause decreased taste acuity,
unpleasant mouth taste and mouth pain. It is more common in:
Immunocompromised patients and those on antibiotic therapy, which destroys normal
oral flora and allows for overgrowth of fungus.

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Management of Cancer-related Nutrition Impact Symptoms

Patients undergoing radiation therapy to the oral cavity.


Patients treated with corticosteroids.

Fungal infections can spread to the esophagus, causing odynophagia and/or dysphagia.
Oral candidiasis can be managed by both MNT and pharmacological agents. Maintaining
optimum nutriture and immune status, as well as aggressive oral hygiene, helps to prevent fungal
infections. Patients should be encouraged to practice good oral hygiene including regular brushing,
gentle flossing and keeping lips moist. Regular rinsing with a saline/baking soda solution (e.g., 1 tsp salt,
1 tsp baking soda mixed into four cups of water, daily) will also help to keep the oral cavity clean,
moist, and better tasting. There are a number of antifungal agents available for use in the oncology
population.

Management of Oral Candidiasis4,10,19


Drug Dosage Side Effects
Nystatin Oral suspension: 400,000- 600,000 Units qid (half Nausea, vomiting,
(Mycostatin) of dose in each side of mouth, retaining in the diarrhea
mouth as long as possible before swallowing)
Troches (lozenges): Dissolve one to two tablets in
mouth four to five times/day for up to 14 days
Clotrimazole 10 mg oral troches: Dissolve slowly in the mouth Nausea, vomiting,
(Lotrimin) five times/day for 14 days (tid for prophylaxis) abnormal liver
function tests
Fluconazole Oral candidiasis: 200 mg PO or IV on the first day, Headache, nausea,
(Diflucan) followed by 100 mg qd, for at least two weeks vomiting, diarrhea,
Esophageal candidiasis: 200 mg PO or IV the first abdominal pain
day, followed by 100 mg qd for at least three
weeks (up to 400 mg/d may be used in severe
cases)
Amphotericin B 1 ml (100 mg) oral suspension qid (swish and hold None noted
(Fungizone, for minute, then spit), for two weeks
Amphocin)
Ketoconazole 200 mg PO qd, up to 400 mg/d in severe cases, Nausea, vomiting
(Nizoral) for three to six weeks

Pain
Pain is one of the most common symptoms of advanced cancer. One does not often associate pain
as a nutrition impact symptom unless it is pain associated with eating, digestion or elimination.
However, poorly controlled pain can have a profound impact on nutrition intake and nutrition status.
Severe pain can cause anorexia, and nausea and vomiting. Poorly controlled pain can lead to a
decreased oral intake, followed by loss of appetite, weight loss, fatigue and dehydration.

Xerostomia and Thick Saliva


Xerostomia, or dry mouth, is a common nutrition impact symptom and may be acute or chronic. It
is characterized by abnormal dryness of the mouth that can be mild to severe.
Scanty, thick, ropey saliva and xerostomia can result from certain chemotherapy agents,
medications, dehydration, oral infections and surgery of the head and neck. In addition, radiation

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Nutrition in Cancer Treatment

therapy to the head and neck area can cause the salivary glands to atrophy and become fibrotic.
Patients with xerostomia often experience dental and gum disease, difficulty with eating and/or talking,
taste alterations, sleep disturbances due to dryness of the oral cavity and difficulty wearing dentures.
All these related symptoms can further impact nutritional status and patients ability to eat. Patients
should be encouraged to practice good oral hygiene including regular brushing, gentle flossing and
keeping lips moist. Regular rinsing with a saline/baking soda solution (e.g., 1 tsp salt, 1 tsp baking soda
mixed into four cups of water, daily) will also help keep the oral cavity clean and moist. Patients should
be advised to have a thorough dental examination and cleaning before undergoing cancer treatment.
Pharmaceutical products can stimulate saliva production; artificial saliva products and mouth
moisturizers (e.g., Biotene, Salivart and Oasis) are also available. There are no negative side effects,
although some patients choose not to use them as a matter of personal preference.
Prescription saliva stimulants, or sialagogues, stimulate production of saliva. Pilocarpine (Salagen)
is the only U.S. FDA-approved drug for use as a saliva stimulant. It is given in 5 mg tablets three times
daily; some patients may require 10 mg doses, three times a day. The most common side effect of
pilocarpine is excessive sweating. In doses exceeding 5 mg, the following side effects may occur: nausea,
chills, rhinorrhea, vasodilation, watery eyes, bladder pressure, dizziness, headache, diarrhea and
dyspepsia. Saliva production usually increases within 30 minutes of ingesting pilocarpine and continual
use maximizes the effect.

Summary
Nutrition impact symptoms are common in oncology practice. MNT interventions as well as
pharmacological agents are helpful in managing nutrition impact symptoms. Proactive and aggressive
symptom management is the first line of treatment in oncology nutrition. Multidisciplinary care
provides the best means of symptom management, using the full complement of tools available.

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Management of Cancer-related Nutrition Impact Symptoms

Resources for Nutrition Impact Symptoms


The Academy of Nutrition and Dietetics (AND) Evidence Analysis Library publishes and
updates the Oncology Evidence-Based Nutrition Practice Guidelines.38 This professional
reference provides dietetic practitioners with current evidence-based recommendations
for managing symptoms and minimizing weight changes, as well as suggestions for
maintaining optimal nutrition status before, during and after cancer treatment. Another
evidence-based professional resource is the ANDs evidence-based Oncology Toolkit.38
The Toolkit details the benefit of MNT and nutrition counseling provided by dietetic
professionals and contains MNT summary recommendations for various cancer sites,
progress note documentation and outcome monitoring forms, and professional and
patient resource lists.38
The Oncology Nursing Societys Putting Evidence into Practice: Improving Oncology
Patient Outcomes is another valuable professional resource for providing cancer care
based on the best available evidence to affect the best possible patient outcomes.4 Cancer
and nutrition-related topics and recommendations included in this resource include
anorexia, constipation, diarrhea, fatigue, mucositis, nausea and vomiting, and the
prevention of infection.
Dietetic professionals should also refer to the Academy of Nutrition and Dietetics
Revised Standards of Practice and Standards of Professional Performance for Registered
Dietitians (Generalist, Specialty, and Advanced) in Oncology Nutrition Care when caring
for and working directly with individuals at risk for or diagnosed with malignant or pre-
malignant conditions in a variety of healthcare settings.39
Free patient education pamphlets are available from the following organizations:
National Cancer Institute: 800-4-CANCER
Eating Hints: For Cancer Patients Before, During and After Treatment
Chemotherapy and You: A Guide to Self-Help During Cancer Treatment
Radiation Therapy and You: A Guide to Self-Help During Cancer Treatment
Home Care for Cancer Patients
Facing Forward: Life After Treatment Series
American Cancer Society: 800-ACS-2345
Nutrition for the Person with Cancer
Living Smart: The American Cancer Societys Guide to Eating Healthy & Being Active
Understanding Chemotherapy: A Guide for Patients and Families
Understanding Radiation Therapy: A Guide for Patients and Families
Caring for the Patient at Home: A Guide for Patients and Families
Nutrition and Cancer Treatment Resources for Consumers and Healthcare Professionals
Academy of Nutrition and Dietetics: 800-877-1600
Management of Nutrition Impact Symptoms in Cancer & Educational Handouts.
Eldridge B, Hamilton KK. 2004.
The Clinical Guide to Oncology Nutrition. 2nd edition. Elliott L, Molseed LL,
McCallum PD, Grant B, eds. 2006.
American Cancer Society: 800-ACS-2345
American Cancer Societys Complete Guide to Complementary and Alternative
Cancer Methods. American Cancer Society. 2010.
American Cancer Society's Complete Guide to Nutrition for Cancer Survivors:
Eating Well, Staying Well During and After Cancer.
Bloch AS, Grant BL, Hamilton KK, Thomson CA, eds. 2011.

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Nutrition in Cancer Treatment

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with high-dose paclitaxel and melphalan for autologous bone marrow transplantation. Ann Pharmacother.
2000;34(3):300-303.
30. Camp-Sorrell D. Chemotherapy: toxicity management. In: Yarbo CH, Frogge MH, Goodman M, Groenwald
SL, eds. Cancer Nursing: Principles and Practice. 5th ed. Sudbury, MA: Jones & Bartlett; 2000:444-486.
31. Gobel B. Bleeding disorders. In: Yarbo CH, Frogge MH, Goodman M, Groenwald SL, eds. Cancer Nursing:
Principles and Practice. 5th ed. Sudbury, MA: Jones & Bartlett; 2000:709-736.
32. Loney J, Chernecky C. Anemia. Oncol Nurs Forum. 2000;27(6):951-964.
33. Seattle Cancer Care Alliance. Hematopoietic Stem Cell Transplantation Nutrition Care Criteria. 2nd ed.
Seattle, WA: Seattle Cancer Care Alliance; 2002.
34. Ettinger DS. Preventing chemotherapy-induced nausea and vomiting: an update and review of emesis.
Semin Oncol. 1995;22(4 Suppl 10):6-18.
35. Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for classifying the acute emetogenicity of cancer
chemotherapy. J Clin Oncol. 1997;15(1):103-109.
36. Hesketh PJ. Potential role of NK1 receptor antagonists in chemotherapy-induced nausea and vomiting.
Support Care Cancer. 2001;9(5):350-354.
37. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Antiemesis.
www.nccn.org. NCCN Web site. Accessed July 21, 2012.
38. Academy of Nutrition and Dietetics. Oncology Toolkit: Academy Oncology Evidence-based Nutrition
Practice Guideline. Chicago, IL: Academy of Nutrition and Dietetics; 2010.
39. Robien K, Bechard L, Elliott L, et al. American Dietetic Association: revised standards of practice and
standards of professional performance for registered dietitians (generalist, specialty, and advanced) in
oncology nutrition care. J Am Die Assoc. 2010;110:310-317, e1-23.

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Appendix 1: The Gastrointestinal Diet 1 and


Gastrointestinal Diet 2
The Gastrointestinal Diet 1 (GI 1 diet) and Gastrointestinal Diet 2 (GI 2 diet) are designed to
reduce GI discomfort (such as abdominal pain, nausea, vomiting and diarrhea) after eating. The diets
are based on the following guidelines:

Low fat: Fats are hard to digest and can increase diarrhea.
Low fiber: Certain fibers (insoluble fibers, such as those in whole wheat products) can
increase diarrhea or gas; however, the fibers allowed in the GI 2 diet contain soluble fiber
such as apples and pears that help to form stools.
Low lactose: Dairy products contain a sugar called lactose that may be hard to digest
during GI illness. Signs of poor digestion are bloating, gas, abdominal cramping and
diarrhea. Lactose-free milk is available as a substitute for regular milk. Oral lactase enzyme
tablets can be taken with other dairy products.
Low acid and irritants: Foods that are high in acid or spicy can irritate the mouth,
stomach or GI tract.

Starting the GI 1 or GI 2 Diet

The following are recommended when starting the GI diets:


Carbohydrate-rich and protein-rich foods are easier for the body to digest than high-fat
foods. Limit fatty foods to three servings each day at first.
Limit meal size. Smaller, more frequent meals are easier to digest.
Try one new food at a time. Wait at least three hours before trying another new food.
If your GI symptoms (abdominal pain, nausea, vomiting or diarrhea) increase, do not eat
the most recently introduced food again. Notify the dietitian, nurse or physician about the
symptoms.

Progressing on the GI 1 and GI 2 Diets

The GI 1 diet does not provide all of the nutrients a person needs to remain healthy, as it is a
modified BRAT diet. If it is to be followed for longer than one week, other nutrition support should be
considered. The GI 1 diet should be used to reintroduce easily digested foods and to assess a patients
tolerance to these foods. The patient should start with the foods listed in the Foods to Try First table.
Once the patient has tolerated the GI 1 beverages, cereals, starches and fruits for a few days, the foods
in the If Tolerated, Try These Foods table should be tried, and tolerance of the items assessed. When
the GI 1 diet has been tolerated without worsening GI symptoms, the patient may progress to the GI 2
diet. The GI 2 diet offers a greater variety of foods. It can provide adequate nutrition and so may be
continued for a long period of time.
Each person is different. What may be best for one patient may not be best for another. The rate of
progression from the GI 1 diet to the GI 2 diet and then to a general diet varies among people. The
decision to advance the diets is based on each patients GI symptoms, and patients should work with a
dietitian while progressing on the GI diets to help ensure that nutritional needs are met.

135
Appendices

Foods to Try First


Beverages (1 cup) Tea, weak decaffeinated or brewed herbal, except peppermint
Gatorade
Rice milk
Lactaid 100% lactose-free milk
Apple juice (half-strength)
Kool-Aid or Tang (half-strength)
Cranberry drinks (half-strength)
Hot Cereals ( cup), all made Cream of Rice
with water Cream of Wheat
Farina
Grits
Malt-o-Meal
Cold Cereals ( cup) Puffed rice
Rice Krispies
Cheerios
Other: _________
Starches (allowed with 1 tsp White bread, plain bagel or English muffin (1 slice)
margarine) Pasta: macaroni, egg noodles or plain spaghetti ( cup)
Potato (no skin), baked or mashed ( medium or cup)
Rice, white ( cup)
Saltine crackers (2)
Pretzels (1 oz)
White dinner roll (1)
Fruits ( cup) Applesauce, plain
Banana ()
Peaches, canned in juice or light syrup
Pears, canned in juice or light syrup
Other Lifesavers
Lemon drops
Broth, beef or chicken (1 cup)
Popsicle
Miscellaneous Sugar: 1 packet or 1 tsp
Salt: as desired

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Nutrition in Cancer Treatment

If Tolerated, Try These Foods


Protein Sources Well-cooked chicken or turkey breast (no skin), baked, broiled or boiled
(allowed with 1 tsp ( breast or 3 oz)
margarine or Ham, lean (3 oz)
mayonnaise) Egg, well cooked only (1)
Fish, baked or poached (3 oz)
Tuna, water packed ( cup)
Resource fruit beverage ( cup)
Pediasure ( cup)
Ensure, Boost High Protein ( cup)
Other: _________
Other Chicken rice or chicken noodle soup (1 cup)
Sandwiches made with low-fat mayonnaise on white bread: egg salad,
tuna salad, chicken, turkey or lean ham ( sandwich)
Vanilla wafers or graham crackers (2)
Animal crackers (4)
Angel food cake
Carrots, well cooked ( cup)
Green beans, well cooked ( cup)
Sweet potatoes (peeled and mashed) ( cup)

Reference
Introduction to Gastrointestinal Diets. Seattle Cancer Care Alliance Web site.
http://www.seattlecca.org/introduction-to-gastrointestinal-diets.cfm. Accessed July 21, 2012.

137
Appendices

138
Nutrition in Cancer Treatment

Appendix 2: General Oncology Diet


Guidelines Safe Food Diet
Diet Guidelines for General Oncology Patients with Low W hite Blood Counts
(Absolute Neutrophil Count Less Than 1,000)

People with decreased immune function due to chemotherapy or radiation, or those receiving
therapy that affects the mouth, esophagus, stomach, intestines, colon or rectum are at increased risk for
developing a food-related infection. Following these guidelines will help them protect themselves from
infection by preparing food and drinks properly and by avoiding specific foods that are more likely to
contain infection-causing organisms.

Milk and Dairy Products


Eat or drink only pasteurized milk, yogurt, cheese or other dairy products (pasteurized, grade-A
milk and milk products).
Avoid soft mold-ripened and blue-veined cheese, including brie, camembert, Roquefort, stilton,
gorgonzola and blue cheese.
Avoid Mexican-style cheeses, such as queso blanco fresco, as they are frequently made from
unpasteurized milk and are associated with a higher rate of foodborne illness.
Eggs
Cook eggs until the yolk and white are solid, not runny.
Do not eat foods that may contain raw eggs, such as hollandaise sauce, raw cookie dough,
homemade mayonnaise, and Caesar salad dressing. If these foods are prepared at home, use a
pasteurized egg product instead of eggs in the shell. (Pasteurized eggs can be found in the dairy
case in the grocery store; Egg Beaters is one example.)
Meat, Poultry, Fish and Tofu
Use a food thermometer to ensure meat and poultry reach the proper temperature when cooked.
Red meat and ground beef should reach a minimum internal temperature of 160 degrees F.
Ground poultry should reach an internal temperature of 165 degrees F, and whole poultry should
reach an internal temperature of 180 degrees F. Casseroles should be cooked to an internal
temperature of 165 degrees F. Do not eat meat, poultry and fish that are spoiled, raw or
undercooked.
Do not eat raw or lightly cooked fish, shellfish, lox, sushi or sashimi.
It is recommended to heat until steaming all hot dogs and ready-to-eat luncheon meats, colds
cuts and other deli-style meats before eating.
Cut tofu into 1-inch cubes or smaller, and boil for five minutes in water or broth before eating or
using in recipes. (Note: This process is not necessary if using aseptically packaged, shelf-stable
tofu, such as Mori-Nu silken tofu).
Fruits and Vegetables
Raw fruits and vegetables and fresh herbs are safe to eat if they are washed carefully under cold
running water. Special produce sprays are not necessary. Do NOT use soap to wash produce, as
soap can cause diarrhea if not thoroughly rinsed off the food.
Avoid fresh salsas and salad dressings found in the refrigerated section of the grocery store.

139
Appendices

Choose shelf-stable salsas and salad dressings instead. (Shelf-stable refers to unopened canned,
bottled or packaged food products that can be stored at room temperature before opening; the
container may require refrigeration after opening.)
Do not eat any raw vegetable sprouts, such as alfalfa, radish, broccoli, mung bean or other
sprouts.
Bread, Grain and Cereal Products
Avoid bulk bin sources of cereals, grains or other foods.
Desserts and sweets
Avoid unrefrigerated, cream-filled pastry products. (Shelf-stable items, such as Twinkies or
Ding Dongs, are allowed.)
Do not consume raw honey or honeycomb. Select commercial, grade-A, heat-treated honey.
Water
Drinking water from a home faucet is considered safe if the water is from a city water supply or a
municipal well serving highly populated areas.
Do not consume well water from a private or small community well unless it is tested at least
yearly and contains no coliforms. It is recommended to use distilled or bottled water if using a
water service other than city water service.
At home, safe water can be made by bringing tap water to a rolling boil for one minute. After
boiling, the water should be stored in a clean, covered container in the refrigerator. Discard
water not used within 72 hours.
Do not drink water straight from lakes, rivers, streams or springs.
Beverages
Do not drink unpasteurized fruit or vegetable juices.
Do not drink sun tea. Make tea with boiling water, using commercially packaged tea bags.
Dining Out
Eat early to avoid crowds.
Ask that food be prepared fresh in fast-food establishments. (It may help to order the product
prepared slightly differently from standard offerings, such as without pickles.)
Ask if fruit juices are pasteurized.
Avoid raw fruits and vegetables when dining out; save these items for home, where you can wash
them thoroughly and prepare them safely.
Do not eat salsa or other condiments that are unrefrigerated and used by multiple people at a
restaurant.
Ask for single-serving condiment packages. Do not use public self-serve condiment containers.
Avoid salad bars, delicatessens, buffets, smorgasbords, potlucks and sidewalk vendors. These are
high-risk food sources due to potential improper food storage or holding temperature and poor
hygiene by food handlers.
Check the general condition of the restaurant. Are the plates, glasses and utensils clean? Are the
restrooms clean and stocked with soap and paper towels? How clean the restaurant looks may
tell the amount of care taken while preparing the food.

Reference
General Oncology Diet Guidelines. Seattle Cancer Care Alliance Web site. http://www.seattlecca.org/general-
oncology-diet-guidelines.cfm. Accessed July 21, 2012.

140
Appendices

Appendix 3: Nestls Mini Nutritional Assessment

141
Nutrition in Cancer Treatment

Appendix 4: Scored Patient-Generated Subjective


Global Assessment (PG-SGA)

142
Appendices

143
Nutrition in Cancer Treatment

Appendix 5: Medical Nutrition Therapy


for Nutrition Impact Symptoms

Symptom Tips for Symptom Management Potential


Secondary
Problems
Nausea Try small, frequent feedings Vomiting
Try dry, starchy and/or salty foods (pretzels, saltines, Anorexia
rice, noodles and dry cereals) Weight loss
Avoid large amounts of liquids on an empty stomach Dehydration
Sip on liquids between meals Electrolyte imbalances
Avoid sweet, rich, greasy and/or spicy foods
Avoid strong odors
Try room temperature, cool or cold foods
Try light exercise and cleansing breaths of fresh air
Try sips of ginger ale, ginger tea or candied dried
ginger
Avoid lying down for about an hour after eating
Avoid favorite foods when nauseated to decrease
potential aversions
Capitalize on the times when feeling best
Take anti-nausea medication as directed
Vomiting If nausea precedes vomiting, try nausea management Anorexia
tips Weight loss
Once vomiting subsides, sip on fluids Dehydration
Breathe deeply and slowly and get fresh air Electrolyte imbalances
Take anti-nausea medication as directed
Anorexia Eat nutrient-dense meals and snacks Weight loss
Add protein and calories to favorite foods using extra Cachexia
butter, margarine, olive oil, cheese and protein Dehydration
powder (whey, soy or non-fat dry milk) Electrolyte imbalances
Drink nutrient-dense beverages between meals to
avoid feeling too full with meals
Try a small amount of wine, beer or aperitif to
stimulate the appetite, if approved by physician
Take meals and snacks in pleasant atmosphere
Keep nutrient-dense snacks close at hand and snack
frequently
Try light exercise to stimulate appetite
Capitalize on the times when feeling best (breakfast is
often the best meal of the day)
If prescribed, take appetite stimulant as directed
Weight Determine cause of weight loss, if possible, and treat Electrolyte imbalances
Loss/Cachexia appropriately Impaired organ
Eat small, frequent, nutrient-dense meals and snacks function
Add protein and calories to favorite foods using extra Immunosuppression

144
Appendices

Symptom Tips for Symptom Management Potential


Secondary
Problems
butter, margarine, olive oil, cheese and protein
powder (whey, soy or non-fat dry milk)
Try a small amount of wine, beer or aperitif to
stimulate the appetite, if approved by the physician
Take meals and snacks in pleasant atmosphere
Keep nutrient-dense snacks close at hand and snack
frequently
Capitalize on the times when feeling best (breakfast is
often the best meal of the day)
If prescribed, take appetite stimulant as directed
Early satiety Eat small, frequent, nutrient-dense meals and snacks Anorexia
Add protein and calories to favorite foods using extra Weight loss
butter, margarine, olive oil, cheese and protein Cachexia
powder (whey, soy or non-fat dry milk) Electrolyte imbalances
Take nutrient-dense liquids between meals to avoid Bloating
feeling too full with meals Nausea
Try a nutrient-dense liquid diet, which may be more
quickly digested and absorbed than solid food
Avoid fried, greasy or rich foods that take longer to
digest
Avoid gassy foods and carbonated beverages that can
cause bloating
Keep nutrient-dense snacks close at hand and snack
frequently
Capitalize on the times when feeling best (breakfast is
often the best meal of the day)
Try light exercise to help stimulate digestion
Consider a medication to help stimulate gastric
emptying
Constipation Eat at regular intervals throughout the day Nausea
Increase fluid intake to eight to 10 cups/day Bloating
Avoid caffeine-containing beverages that can decrease Anorexia
intestinal hydration and cause stools to be harder Weight loss
Increase dietary fiber, if able to take adequate fluids
Try hot beverages as a bowel stimulant
Try prune juice as a bowel stimulant
Try hot prune juice for a double whammy effect
Try to increase physical activity, as able
Try to establish a schedule for having bowel
movements
Initiate and follow a daily bowel regimen (stool
softeners, stimulant or osmotic laxatives, medicinal
fiber and polyethylene glycol)
Diarrhea Add soluble fiber to diet at regular intervals Dehydration
throughout day Electrolyte imbalances
Limit/avoid insoluble fiber Malabsorption

145
Nutrition in Cancer Treatment

Symptom Tips for Symptom Management Potential


Secondary
Problems
Eat foods containing probiotics (yogurt, kefir) or try a Anorexia
probiotic supplement Weight loss
Eat small, frequent meals and snacks throughout the
day
Avoid greasy, fried, spicy or very rich foods
Avoid alcoholic beverages
Avoid caffeine-containing beverages
If lactose intolerant, avoid dairy products or use a
lactase enzyme product
Avoid excessive amounts of sweetened beverages
(fruit drinks, soft drinks, sports drinks and sweet teas)
and juices that might contribute to osmotic diarrhea
Avoid foods, gum and candy that contains sugar
alcohols (sorbitol, mannitol and xylitol)
Increase fluid intake throughout the day
Increase consumption of high-potassium foods if
diarrhea is severe (peeled potatoes, pulp-free orange
juice and bananas)
Increase consumption of high-sodium foods if diarrhea
is severe (commercially prepared broths and soups)
Increase sources of pectin/soluble fiber (peeled apples
and potatoes, applesauce, bananas, cooked carrots,
white rice, corn or rice cereals)
Take anti-diarrheal medication as prescribed
Malabsorption Eat several small, frequent meals throughout the day Nutrient deficiencies
Avoid fluids and foods that promote diarrhea (intake Steatorrhea
and output should be monitored, along with the
Weight loss
number, color and consistency of stools to determine
which foods are problematic)
Increase fluid intake throughout the day
Consider use of pancreatic enzymes
Lactose Try lactase enzyme supplement, to help lessen Avoidance of dairy
Intolerance symptoms products without diet
Try dairy products treated with lactase enzyme instruction or dietary
Limit/avoid dairy products supplementation could
Substitute milk with soy, almond or rice milk; or non- lead to calcium and
dairy beverage vitamin D deficiencies
Increase consumption of non-dairy high calcium foods
Xerostomia Try tart foods to stimulate saliva Difficulty chewing and
Sip on liquids or suck on ice chips throughout the day swallowing
(aim for eight to 10 cups fluid/day) Decreased intake of
Try sipping non-sweetened liquids throughout the day food
Rinse mouth frequently throughout the day with a
saline baking soda solution (1 tsp salt and 1 tsp baking
soda in four cups of water)
Avoid caffeine-containing beverages

146
Appendices

Symptom Tips for Symptom Management Potential


Secondary
Problems
Avoid alcohol-containing mouthwashes
Avoid alcoholic beverages and tobacco products
Try soft and/or moist foods with extra sauce, dressing,
gravy
Try sucking on sugar-free lemon drops, frozen grapes,
popsicles
Try using a cool mist humidifier when napping or
sleeping
Taste Try different protein sources such as poultry, fish, Anorexia
Changes eggs, dairy products, beans or soy foods if red meat is Decreased intake of
unappealing food
Try marinades and spices to mask strange tastes Weight loss
Use plastic utensils rather than metal to help alleviate
or lessen taste
Try to eat foods at room temperature or chilled
Add lemon, lime, vinegar or salt to foods that seem
too sweet
Try adding lemon, lime, instant decaffeinated coffee
powder, or mint to milkshakes or commercially
prepared supplements that taste too sweet
Rinse mouth frequently throughout the day with a
saline baking soda solution (1 tsp salt and 1 tsp baking
soda in four cups of water)
Try sipping pleasant-tasting beverages, sucking
popsicles or hard candy, or eating sherbet or sorbet to
mask bad taste between meals
Try fresh or frozen foods rather than canned
Dysphagia Try soft, moist or pureed foods/uniform consistency is Decreased intake
best, as opposed to chunky soups and stews Weight loss
Eat smaller, more frequent meals and snacks
Avoid breads, cakes, cookies and crackers; or soak in
milk, juice, gravy or sauce before eating
If indicated, follow instructions regarding diet
consistency and swallowing techniques provided by
the speech pathologist
If directed by a speech pathologist: try ice,
sherbet/sorbet, or popsicles before a meal to
stimulate swallow reflex
If directed by a speech pathologist, use commercially
prepared food thickeners, tapioca, flour, instant
mashed potatoes, infant rice cereal and/or cornstarch
to thicken liquids
Consider using a mucosal protectant and/or topical
anesthetic
Mucositis Try soft, moist foods with extra sauce, dressings and Decreased intake
gravies (Use caution when eating acidic ingredients Weight loss

147
Nutrition in Cancer Treatment

Symptom Tips for Symptom Management Potential


Secondary
Problems
like tomatoes, citrus or vinegar)
Use a straw to direct fluid away from painful parts of
mouth
Avoid alcoholic beverages, citrus, caffeine, tomatoes
and vinegar
Avoid dry, coarse or rough foods
Avoid spicy foods, pepper or hot peppers
Try foods at room temperature or chilled
Try sucking popsicles or ice chips to numb the mouth
Rinse the mouth frequently throughout the day with
saline baking soda solution (1 tsp salt and 1 tsp baking
soda in four cups of water)
Avoid alcohol-containing mouthwashes
Use a soft toothbrush that is replaced regularly
Consider using a topical anesthetic
Esophagitis Try soft, moist foods with extra sauce, dressings and Decreased intake
gravies (Use caution when eating acidic ingredients Weight loss
like tomatoes, citrus or vinegar)
Avoid alcohol, citrus, caffeine, tomatoes and vinegar
Avoid dry, coarse or rough foods
Avoid spicy foods, pepper and hot peppers
Try foods at room temperature or chilled
Try sucking popsicles or ice chips to numb the mouth
Rinse the mouth and gargle frequently throughout the
day with baking soda solution (1 tsp salt and 1 tsp
baking soda in 4 cups of water)
Avoid alcohol-containing mouthwashes
Consider using a mucosal protectant and/or topical
anesthetic
Thick Oral If gagging on oral secretions triggers vomiting: Decreased intake
Secretions Increase fluid intake to help thin secretions and Nausea
hydrate oral cavity Vomiting
Rinse and gargle frequently throughout the day Weight loss
with a saline baking soda solution (1 tsp salt and 1 tsp
baking soda in four cups of water) to clean oropharynx
and temporarily remove thick, ropey secretions
Try pineapple or papaya to help thin oral and
pharyngeal secretions
Avoid alcohol-containing mouthwashes
Limit caffeine-containing beverages
Try using a cool mist humidifier while napping or
sleeping
Consider using a guaifenesin-containing medication to
help thin secretions
Oral Try soft, moist foods with extra sauce, dressings and Taste changes
Candidiasis gravies (Use caution when eating acidic ingredients Sore mouth

148
Appendices

Symptom Tips for Symptom Management Potential


Secondary
Problems
like tomatoes, citrus or vinegar) Decreased intake
Use a straw to direct fluid away from the painful parts Weight loss
of the mouth Can spread to the
Avoid alcoholic beverages, citrus, caffeine, tomatoes, pharynx and
vinegar esophagus, causing
Avoid dry, coarse or rough foods sore throat and
Avoid spicy foods, pepper or hot peppers dysphagia
Try foods at room temperature or chilled
Try sucking popsicles or ice chips to numb the mouth
Rinse the mouth and gargle frequently throughout the
day with a saline baking soda solution (1 tsp salt and 1
tsp baking soda in four cups of water)
Avoid alcohol-containing mouthwashes
Use a soft toothbrush that is changed regularly
Use anti-fungal medication as directed
Pain Try small frequent feedings Anorexia
(not specific Avoid taking pain medications on an empty stomach Nausea
to alimentary Try soft foods at room temperature or chilled Vomiting
tract) Try deep cleansing breaths of fresh air Sedation
Increase intake of hydrating liquids throughout the day Weight loss
Initiate and follow a daily bowel regimen, including a
stool softener and laxative
Take pain medications as ordered (to avoid catching
up with the pain)

References
Eating Hints: Before, During, and After Cancer Treatment. National Cancer Institute Web site.
http://www.cancer.gov/cancertopics/coping/eatinghints/page2. Accessed July 21, 2012.
Eaton LH, Tipton JM, eds. Putting Evidence into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA:
Oncology Nursing Society; 2009.
Eldridge B, Hamilton K. Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago,
IL: American Dietetic Association; 2004.
Elliott L, Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd edition. Chicago,
IL: American Dietetic Association; 2006.
Grant BL, Bloch AS, Hamilton KK, Thomson CA. American Cancer Society Complete Guide to Nutrition for Cancer
Survivors: Eating Well, Staying Well During and After Cancer. Atlanta, GA: American Cancer Society; 2010.

149
Nutrition in Cancer Treatment: Continuum of Care

Appendix 6: Pharmacological Agents for the


Management of Chemotherapy-Induced Nausea
and Vomiting
Classificati Medicatio Route Indication Side Effects Site of
on n Action
Ondansetro Oral, Prevention of Headache, fever, CTZ
n (Zofran) injection nausea and diarrhea, PGSEC
vomiting associated constipation,
with single-day hypotension,
highly emetogenic transient elevation
Serotonin chemotherapy of liver
receptor function
antagonist Granisetron Oral, Prevention of Headache, CTZ
(5HT3) (Kytril) injection, nausea and asthenia, diarrhea, PGSEC
transdermal vomiting during constipation,
chemotherapy at fever, somnolence
initial and repeated
cycles
Dolasetron Oral, Prevention of CINV Headache, CTZ
(Anzemet) injection diarrhea, PGSEC
dizziness, fatigue,
abnormal liver
function
Palonosetro Oral, Prevention of acute Headache, CTZ
n (Aloxi) injection CINV w/initial and constipation, PGSEC
repeated cycles of pruritis, elevated
moderately and liver enzymes
highly emetogenic
chemotherapy;
prevention of
delayed CINV
NK-1 Aprepitant Oral Prevention of acute Constipation, CTZ
receptor (Emend) and delayed CINV in hiccups, loss of
antagonist combination appetite, diarrhea,
w/other antiemetics fatigue, hair loss
Corticoster Dexamethas Oral, Prevention of CINV insomnia, Unknown
oid one injection caused by euphoria,
(Decadron) moderately headache,
emetogenic anxiety, acne,
chemotherapy; hyperglycemia,
prevention of weight gain,
delayed CINV peptic ulcer,
osteoporosis
Metoclopra Oral, Prevention of CINV Sedation, CTZ
mide injection caused by extrapyramidal
(Reglan) moderately symptoms,
emetogenic dystonia,
Dopamine chemotherapy; dizziness,
antagonist prevention of orthostasis
Appendices

Classificati Medicatio Route Indication Side Effects Site of


on n Action
delayed CINV
Prochlorper Oral, Prevention of CINV Sedation, CTZ
azine injection, caused by extrapyramidal
(Compazine) rectal moderately symptoms,
emetogenic dystonia,
chemotherapy; dizziness,
prevention of orthostasis
delayed CINV
Haloperidol Oral, Prevention of acute Sedation, CTZ
(Haldol) injection, or delayed CINV extrapyramidal
rectal symptoms,
dystonia,
dizziness,
orthostasis
Dronabinol Oral Prevention of CINV Sedation, CNS
Cannabanoi (Marinol) caused by euphoria,
d moderately dysphoria, dry
emetogenic mouth, orthostasis
chemotherapy
Alprazolam Oral, Prevention of Sedation, physical CNS
(Xanax) injection anticipatory nausea dependence
and vomiting; used
Benzodiaze in combination
pine w/other antiemetics
as needed for acute
or delayed CINV
Lorazepam Oral, Prevention of Sedation, CNS
(Ativan) injection anticipatory nausea dependence
and vomiting; used
in combination
w/other antiemetics
as needed for acute
or delayed CINV
CINV = chemotherapy-induced nausea and vomiting; CNS = central nervous system; CTZ = chemoreceptor trigger zone;
PGSEC = peripheral gastrointestinal stimulation to emetic center.

References
Chu E, DeVita VT Jr. Physicians Cancer Chemotherapy Drug Manual 2011. Sudbury, MA: Jones & Bartlett;
2011.
Friend PJ, Johnston MP, Tipton JM, et al. ONS PEP resource: chemotherapy-induced nausea and vomiting. In:
Eaton LH, Tipton JM, eds. Putting Evidence into Practice: Improving Oncology Patient Outcomes.
Pittsburgh, PA: Oncology Nursing Society; 2009:71-83.
Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for
Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009.
Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: Elliott L,
Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL:
American Dietetics Association; 2006:165-179.
Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones & Bartlett; 2011.

151
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152
Appendices

Appendix 7: Pharmacological Agents for the


Management
of Anorexia and Cancer Cachexia
Classification Medicatio Route Indication Side Effects Action
n Name
Antidepressant Mirtazapine Oral Appetite Sedation, Stimulates
(Remeron) stimulant; weight decreased appetite
gain mental alertness
and physical
coordination,
hypotension,
edema
Cannabinoid Dronabinol Oral Appetite Sedation, Stimulates
(Marinol) capsule stimulant; weight euphoria, appetite,
gain; antiemetic nervousness, leading to
dysphoria, dry improved
mouth, body weight
orthostasis and mood
Corticosteroid Methylpred Oral, Appetite Insomnia, Stimulates
nisolone injection stimulant; euphoria, appetite
(Prednisolon antiemetic headache, fluid
e) retention,
Dexamethas osteoporosis,
one hyperglycemia
(Decadron)
Dietary beta- Oral Appetite stimulant Headache, Shown to
supplement hydroxy- and weight gain diarrhea, decrease
beta- dizziness, protein
methylbutyr fatigue, breakdown
ate abnormal liver
(HMB) function
(Juven)
Eicosapenta Oral Weight gain for Nausea, Appears to
enoic acid patients with non- steatorrhea, affect
(EPA); fish hormone-based fishy burps potential
oil solid tumors mediators of
cachexia,
anti-
inflammatory
effect
Dopamine Metoclopra Oral, Enhances gastric Sedation, Stimulates
antagonist mide injection emptying; extrapyramidal upper
hydrochlorid antiemetic symptoms, gastrointesti
e (Reglan) diarrhea, nal motility,
dizziness, dry increasing
mouth, gastric
hypotension emptying

153
Nutrition in Cancer

Classification Medicatio Route Indication Side Effects Action


n Name
Synthetic Megestrol Oral (pill Appetite stimulant Headache, fever, Appears to
progestin acetate or and weight gain diarrhea, stimulate
(Megace) liquid) constipation, appetite/wei
hypotension, ght gain in
transient cancer
elevation of liver cachexia
function directly or
indirectly by
antagonism
of tumor
necrosis
factor (TNF)

References
Adams LA, Cunningham RS. ONS PEP resource: anorexia. In: Eaton LH, Tipton JM, eds. Putting Evidence Into
Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:31-34.
Chu E, DeVita VT Jr. Physicians Cancer Chemotherapy Drug Manual 2011. Sudbury, MA: Jones & Bartlett;
2011.
Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: Elliott L,
Molseed LL, McCallum PD, Grant B, eds. The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL:
American Dietetics Association; 2006:165-179.
Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones & Bartlett; 2011.

154
Nutrition in Cancer Treatment

Appendix 8: Pharmacological Agents


for the Management of Constipation

Classification Medication Route Side Effects Mechanism
Name of Action
Medicinal fiber Psyllium Oral Diarrhea, abdominal Absorbs water from
(Metamucil, powder, cramping, constipation, intestine, bulk expansion
Citrucel) chewable bowel obstruction stimulates peristalsis
Wheat dextrin wafer,
(Benefiber) liquid
Hyperosmotic Glycerin Rectal Chronic use alters normal Local irritant with
laxatives suppository bowel function (lazy hyperosmotic action,
or enema bowel), vomiting, stimulates evacuation
dizziness, excessive
diarrhea
Lactulose (Cholac) Oral or Flatulence, abdominal Delivers osmotically active
rectal pain and distension, molecules to the intestine,
solution alterations in fluid, stimulates peristalsis
electrolyte imbalance,
diarrhea
Lubricant Mineral Oil Oral Excessive diarrhea, Lubricates intestine, water
solution; headache, vomiting; retention distends colon,
rectal chronic use alters normal stimulates peristalsis and
enema bowel function, impaired evacuation
absorption of fat soluble
vitamins, lipid
pneumonitis if reclined
Osmotic Polyethylene Oral Chronic use alters normal Osmotic agent that pulls
cathartic glycol (Miralax) powder/sol bowel function, water into the stool,
ution alterations in fluid and softens stool and causes
electrolyte balance, peristalsis and evacuation
excessive diarrhea
Saline laxatives Magnesium Oral tablet Abdominal cramping, Draws water into small
hydroxide or solution excessive diarrhea; intestine lumen,
(Milk of Magnesia) muscle weakness, stimulates peristalsis and
hypotension, chronic use evacuation
alters normal bowel
function
Magnesium Oral Abdominal cramping, Draws water into small
citrate solution excessive diarrhea; intestine lumen,
chronic use alters normal stimulates peristalsis and
bowel function evacuation
Stimulant Bisacodyl Oral Abdominal cramping, Stimulates/irritates
laxatives (Dulcolax) capsule; excessive diarrhea; smooth muscle of the
rectal chronic use alters normal intestine, increases
suppository bowel function peristalsis
Senna (Senokot) Oral Abdominal cramping, Stimulates/irritates
capsule; excessive diarrhea; smooth muscle of the
rectal chronic use alters normal intestine, increases
suppository bowel function peristalsis
Stool softener Docusate (Colace) Oral Abdominal cramping, Reduces surface tension
Nutrition in Cancer Treatment

Classification Medication Route Side Effects Mechanism


Name of Action
capsule, excessive diarrhea; of the stool, allowing for
syrup, chronic use alters normal softening
solution bowel function
Opioid receptor Methylnaltrexone Injection Flatulence, abdominal Treats opioid-induced
antagonist (Relistor) pain, nausea constipation in advanced
disease, where laxatives
have not been effective


References
Bisantz AK, Woolery MJ. Constipation. In: Eaton LH, Tipton JM. Putting Evidence Into Practice: Improving
Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:85-104.
Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: The
Clinical Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL:
American Dietetic Association; 2006:165-179.
Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones and Bartlett
Publishers; 2011.
GI and mucosal side effects. In: Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and Biotherapy
Guidelines and Recommendations for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2009:174-
182.

156
Appendices

Appendix 9: Pharmacological Agents


for the Management of Diarrhea
Classification Medication Route Side Effects Mechanism
Name of Action
Antimotility Diphenoxylate/ Oral capsule Rash, nausea, blurred Inhibits peristalsis,
agents atropine or liquid vision, vomiting, dry prolongs transit time
(Lomotil) mouth, abdominal
cramping,
constipation
Bismuth Oral chewable Transient Acts as an absorbent
subsalicylate tablet or constipation, tinnitus, and protectant,
(Kaopectate) liquid black stools and decreases stool
tongue fluidity

Loperamide Oral capsule Rash, nausea, Inhibits peristalsis,


hydrochloride or liquid vomiting, dry mouth, prolongs transit time
(Imodium) abdominal cramping,
constipation
Tincture of Oral liquid Nausea, vomiting Increases GI smooth
opium muscle tone and
(Laudanum) inhibits GI motility,
delays movement of
intestinal contents
Medicinal Psyllium Oral powder, Diarrhea, abdominal Absorbs water from
fiber (Metamucil, chewable cramping, intestine, bulk
Citrucel) wafer, liquid constipation, bowel expansion stimulates
Wheat dextrin obstruction peristalsis
(Benefiber)
Miscellaneous Octreotide Intramuscular Rash, flushing, Mimics somatostatin,
antidiarrheals acetate injection edema, fatigue, lengthens transit time
(Sandostatin) (intragluteally) headache, dizziness, of intestinal contents,
increased liver stimulates fluid and
function tests, electrolyte absorption
transient hypo- or from GI tract
hyperglycemia,
gallbladder problems
Cholestyramine Oral powder Constipation, Acts as a bile acid
(Questran, or chewable bloating, gas, sequestrant, indicated
Questran Light) bar nausea, vomiting, for individuals after
heartburn, ileal resection
steatorrhea,
indigestion, diarrhea;
may decrease
absorption of fat-
soluble vitamins: A,
D, E and K
Pancrelipase Oral capsule Constipation, nausea, Digestive enzyme,
(Creon, abdominal cramps, aids in fat, protein and
Zenpep, diarrhea carbohydrate

157
Nutrition in Cancer Treatment

Classification Medication Route Side Effects Mechanism


Name of Action
Pancreaze) absorption
GI = gastrointestinal.


References
Chu E, DeVita VT. Physicians Cancer Chemotherapy Drug Manual: 2011. Sudbury, MA: Jones & Bartlett; 2011.
Muehlbauer P, Thorpe D. Diarrhea. In: Eaton LH, Tipton JM. Putting Evidence Into Practice: Improving
Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:119-134.
Von Roenn JH. Pharmacological management of nutrition impact symptoms associated with cancer. In: The
Clinical Guide to Oncology Nutrition. 2nd ed. Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL:
American Dietetics Association; 2006:165-179.
Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones and Bartlett; 2011.

158
Nutrition in Cancer Treatment

Appendix 10: Pharmacological Agents


for the Management of Oral Mucositis and
Esophagitis
Classification Medication Route Side Effects Mechanism of
Name Action
Anti- Prednisone Oral tablets or Headache, Reduces inflammation of
inflammation (Deltasone) solution electrolyte and mucosa
agent Elixir fluid retention,
(corticosteroid) (Dexamethasone) increased
appetite, peptic
ulcer disease,
osteoporosis,
hyperglycemia
Bland rinses Glutamine Oral swish and Gritty solution Emerging evidence
swallow that may cause suggests reduction of
discomfort while severity and duration of
swishing in mouth mucositis; may help to
reduce oral pain
Saline/baking soda Oral swish, then None other than Soothes and keeps oral
rinse (four cups of spit aversion to salty mucosa clean
water + 1 tsp salt + taste of solution
1 tsp baking soda)
Cryotherapy Ice chips Oral cavity, suck on Oral discomfort Produces temporary
ice five minutes secondary to cold vasoconstriction of oral
before and 25 mucosa; reduces local
minutes after 5- drug delivery 5-
fluorourcil bolus fluorouracil
Topical Gelclair gel Oral viscous gel Oral discomfort Temporarily reduces oral
analgesic pain
coating agent
Mucosal Hydroxypropyl Oral swish and Burning, stinging, Adheres to inflamed
protectant/ cellulose film swallow tenderness, mucosa and provides a
coating agent swelling, tissue protective coating; helps
irritation reduce pain
Sucralfate Oral swish and Burning, stinging, Adheres to inflamed
suspension swallow tenderness, tissue mucosa and provides a
(Carafate) irritation protective coating; helps
reduce pain
Topical Capsaicin Oral candy Burning, stinging Temporarily reduces oral
anesthetics dissolves in mouth or pain pain

Lidocaine Oral swish, then Temporarily reduces oral


spit pain
BMX solution: Oral swish, then Temporarily reduces oral
Benadryl/Maalox/ spit pain
Viscous xylocaine
(1:1:1 ratio)
Nutrition in Cancer Treatment

References
Harris DJ, Eilers JI, Eaton LH. Mucositis. In: Eaton LH, Tipton JM. Putting Evidence into Practice: Improving
Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:193-213.
Wilkes GM, Barton-Burke M. Oncology Nursing Drug Handbook: 2010. Sudbury, MA: Jones & Bartlett; 2010.
Yarbo CH, Frogge MH, Goodman H. Cancer Symptom Management. 3rd ed. Sudbury, MA: Jones & Bartlett;
2005.

160
Appendices

Appendix 11: Pharmacological Agents


for the Management of Pain
Classification Medication Route Side Effects
Name
Opioid Codeine Oral, IV Sedation, headache, dizziness, nausea,
narcotic vomiting, constipation, paralytic ileus, dry
mouth, anorexia, hypotension
Acetaminophen Oral Sedation, headache, dizziness, nausea,
+ Codeine vomiting, constipation, paralytic ileus, dry
(Tylenol + mouth, anorexia, hypotension
Codeine)
Fentanyl Transdermal Sedation, headache, dizziness, nausea,
(Duragesic) patch vomiting, constipation, dry mouth, anorexia
Hydrocodone + Oral Sedation, headache, dizziness, nausea,
Acetaminophen vomiting, constipation, dry mouth, anorexia
(Vicodin)
Hydromorphone Oral Sedation, headache, dizziness, nausea,
(Dilaudid) vomiting, constipation, dry mouth, anorexia
Morphine Oral, oral Sedation, headache, dizziness, nausea,
sulfate (MS sustained vomiting, constipation, dry mouth, anorexia
Contin, MSIR, release,
Roxanol, intramuscular,
Oramorph) IV, epidural,
intrathecal,
suppository
Oxycodone Oral, oral Sedation, headache, dizziness, nausea,
(Percodan) sustained vomiting, constipation, dry mouth, anorexia
release
Oxycodone + Oral Sedation, headache, dizziness, nausea,
Acetaminophen vomiting, constipation, dry mouth, anorexia
(Percocet)
Nonsteroidal Choline Oral Diarrhea, nausea, GI bleed, platelet
anti- magnesium inhibition
inflammatory trisalicylate
drugs (Trilisate)
(NSAIDs) Ibuprofen Oral Headache, dizziness, somnolence, nausea,
(Advil, Nuprin) dyspepsia, GI pain, diarrhea, vomiting,
flatulence, constipation, GI bleed, platelet
inhibition
Naproxen Oral Headache, dizziness, somnolence, nausea,
(Aleve) dyspepsia, GI pain, diarrhea, vomiting,
flatulence, constipation, platelet inhibition
Salsalat Oral Headache, dizziness, somnolence, nausea,
(Disalcid) dyspepsia, GI pain, diarrhea, vomiting,
flatulence, constipation, platelet inhibition
Non-opioid Acetaminophen Oral or rectal More than 4 g/day increases hepatic toxicity,
analgesics (Tylenol) suppository do not exceed 2.5 g/day in people who
drink 2 oz of alcohol daily, nausea, vomiting
Tramadol Oral Sedation, dizziness/vertigo, headache,

161
Nutrition in Cancer Treatment

Classification Medication Route Side Effects


Name
(Ultram) hypotension, nausea, vomiting, constipation,
flatulence

References
Aiello-Laws LB, Ameringer SW. Pain. In: Eaton LH, Tipton JM. eds. Putting Evidence into Practice: Improving
Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society; 2009:215-234.
Wilkes GM, Barton-Burke M. Oncology Nursing Drug Handbook: 2010. Sudbury, MA: Jones & Bartlett; 2010.

162
Appendices

Appendix 12A: Nutritional Implications


of Chemotherapy
Chemotherapy/ Indication Myelo- Nausea/ Anorexia Mucositis Diarrhea Other
(Cancer) suppression
Cytotoxics Vomiting /
Stomatitis
Asparaginase ALL Moderate Yes Yes Weight loss,
(Elspar) fever,
hyperglycemia,
abdominal pain
Azacitidine MDS Mild to Mild Yes Yes Yes Elevated
(Vidaza) moderate creatinine,
hypokalemia,
fever
Bleomycin Head and neck, Mild Very low Yes Yes Weight loss,
(Blenoxane) NHL, HD, xerostomia,
cervical, pulmonary
testicular fibrosis
Busulfan CML, HCT Mild to High to Yes Yes Pulmonary
(Myleran) preparation Moderate very high fibrosis,
alopecia, if oral
take on empty
stomach to
decrease
nausea and
vomiting
Capecitabine Breast, met. Moderate Very low Yes Yes Yes Hand and foot
(Xeloda) colon syndrome,
fever
Carboplatin Ovarian, lung, Moderate to High Yes Ototoxicity,
(Paraplatin) testicular severe taste
alterations
Carmustine HD, NHL, CNS Moderate to High to Yes Yes Pulmonary
(BCNU) tumors severe very high toxicity

Chlorambucil CLL, HD, NHL Mild to Very low Yes Pulmonary


(Leukeran) moderate fibrosis
Cisplatin Lung, ovarian, Mild to High to Yes Yes Decreased
(Plantinol-AQ, DDP) testicular, head moderate very high serum Mg, K,
and neck, HD, Zn; taste
NHL changes,
ototoxicity,
adequate
hydration to
prevent renal
toxicity
Cyclophosphamide Breast, ovarian, Moderate to Low to Yes Yes Xerostomia,
(Cytoxan) lymphomas, severe moderate abdominal
leukemias pain,
pulmonary
fibrosis, if oral

163
Nutrition in Cancer Treatment

Chemotherapy/ Indication Myelo- Nausea/ Anorexia Mucositis Diarrhea Other


(Cancer) suppression
Cytotoxics Vomiting /
Stomatitis
encourage fluid
intake,
hematuria
Cytarabine Leukemias, Moderate to Moderate Yes Yes Yes Flu-like
(Cytosar-U, Ara-C) lymphomas severe to very high symptoms,
CNS toxicity
Dacarbazine (DTIC) Melanoma, Moderate Very high Yes Yes Yes Taste changes,
sarcomas, HD flu-like
symptoms
Dactinomycin Sarcoma, Moderate to Very high Yes Yes Yes Xerostomia,
testicular
(Actinomycin) severe taste changes,
radiation recall
Daunorubicin ALL Moderate to Moderate Yes Yes Yes Xerostomia,
hydrochloride severe to high taste changes,
(Daunomycin) cardiotoxicity
Docetaxel Breast, lung, Severe Low Yes Yes Yes Neuropathy,
(Taxotere) head and neck, risk for acute
met. ovarian allergic
reaction during
infusion
Hair loss
Doxorubicin Breast, HD, Moderate to Low to high Yes Yes Yes Xerostomia,
hydrochloride NHL, ovarian, severe alopecia, hand
(Adriamycin) lung, ALL, and foot
AML, thyroid syndrome,
cardiotoxicity
Epirubicin Breast Moderate Low to high Yes Yes Yes Alopecia,
(Ellence) cardiotoxicity
Etoposide Lung, ALL, HD, Moderate Low Yes Yes Yes Hypertension,
(Vepesid, VP-16) NHL, testicular fever
Fludarabine CLL, Moderate to Very low Yes Yes Yes Neurotoxicity
phosphate lymphomas severe
(Fludara)
Fluorouracil Colorectal, Moderate Low Yes Yes Taste
(5-FU) esophageal, alterations,
head and neck, hand and foot
stomach syndrome, ice
chips pre/post
IV bolus to
reduce
mucositis
Gemcitabine Pancreas, Mild to Low Yes Yes Fever, rash,
hydrochloride bladder, lung, moderate dyspnea,
(Gemzar) ovarian hematuria
Hydroxyurea CML, Moderate Very low Yes Yes Yes Severe anemia
(Hydrea) melanoma
Idarubicin ALL Mild to Moderate Yes Yes Cardiotoxicity,
(Idamycin PFS) moderate alopecia
Ifosfamide (Ifex) Lung, NHL, Moderate Moderate Yes Yes Yes Cystitis, CNS
testicular, toxicity, hair
sarcomas loss

164
Appendices

Chemotherapy/ Indication Myelo- Nausea/ Anorexia Mucositis Diarrhea Other


(Cancer) suppression
Cytotoxics Vomiting /
Stomatitis
Irinotecan Met. colorectal Moderate to High Yes Yes Fever,
(Camptosar) severe abdominal pain
Mechlorethamine Severe Very high Yes Yes Yes Taste changes,
(Nitrogen mustard) fever
Melphalan Myeloma, Moderate Very low Yes Yes Yes If oral take on
(Alkeran) ovarian, empty stomach
melanoma,
sarcomas
Mercaptopurine ALL, AML, Moderate Very low Yes Yes Yes Biliary stasis,
(Purinethol) CML, NHL pancreatitis,
rash
Methotrexate HD, breast, Moderate Low to high Yes Yes Yes Folic acid
sodium (Trexall) lymphomas, containing
leukemias vitamins should
be avoided,
taste changes
Mitomycin Pancreas, Severe Low Yes Yes Yes Alopecia,
(Mutamycin) stomach, lung hypercalcemia
Mitoxantrone Breast, Mild to Moderate Yes Yes Blue
(Novantrone) prostate, moderate discoloration of
lymphomas urine
Oxaliplatin Met. colorectal Mild to Moderate Yes Yes Yes Avoid exposure
(Eloxatin) moderate to cold food
and drinks for
four days after
infusion
Paclitaxel Breast, ovarian, Moderate to Low Yes Neuropathy,
(Taxol) lung, head and severe fatigue
neck
Pemetrexed Mesothelioma, Moderate to Low Yes Yes Yes To reduce
(Alimta) met. lung severe hematologic
toxicity
supplement
with folic acid
and vitamin B-
12, dysnea
Procarbazine HD, brain Moderate to High Yes Yes Yes MAO inhibitor
(Matulane) severe (low tyramine
diet indicated)
Streptozotocin Carcinoid, Moderate High Yes Hyperglycemia,
(Zanosar) pancreas proteinuria
Temozolomide Brain Moderate Moderate Yes Yes Headache,
(Temodar) fatigue

Thiotepa Bladder, brain, Moderate Very low Yes Yes Renal toxicity
(Thioplex) lymphomas
Topotecan Met. ovarian, Severe Low Yes Yes Fever
(Hycamtin) lung
Vinblastine sulfate Testicular, HD Moderate Moderate Yes Yes Jaw pain,
(Velban) peripheral

165
Nutrition in Cancer Treatment

Chemotherapy/ Indication Myelo- Nausea/ Anorexia Mucositis Diarrhea Other


(Cancer) suppression
Cytotoxics Vomiting /
Stomatitis
neuropathy,
paralytic ileus,
constipation
Vincristine sulfate Lymphomas, Mild Very low Yes Yes Peripheral
(Oncovin) sarcomas, neuropathy,
breast, lung constipation,
jaw pain,
paralytic ileus
Vinorelbine tartrate Lung, breast, Moderate to Low Yes Yes Neuropathy,
(Navelbine) ovarian, HD severe constipation
ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic lymphocytic
leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI =
gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkins disease; HER2/neu + = human epidermal growth
factor receptor 2 positive; MAO = monoamine oxidase MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-
Hodgkins lymphoma.

166
Appendices

Appendix 12B: Nutritional Implications of


Hormone Therapy
Hormone Indication Myelo- Nausea/ Anorexia Mucositis/ Diarrhea Other
(Cancer) suppression Stomatitis
Therapy Vomiting
Anastrozole ER+ breast Low Hot flashes,
(Arimidex) headaches, mood
changes

Bicalutamide Prostate Low Yes Hot flashes,


(Casodex) decreased libido,
impotence, back
pain
Exemestane ER+ advanced Low Yes Hot flashes, fatigue,
(Aromasin) breast, post- increased appetite,
menopausal increased sweating,
depression
Flutamide Met. prostate Low Yes Hypertension, hot
(Eulexin) flashes, impotence,
edema,
gynecomastia
Fulvestrant ER+ met. Low Yes Yes Yes Myalgia, flu-like
symptoms, hot
(Faslodex) breast, post-
flashes,
menopausal constipation,
edema, bone pain,
insomnia
Goserelin Prostate, Low Yes Gynecomastia, hot
(Zoladex) breast, flashes, impotence,
endometriosis bone pain,
headache

Letrozole Breast, post- Low Yes Bone pain, hot


(Femara) menopausal flashes, arthralgia,
dyspnea, fatigue,
constipation,
headache, chest
pain
Leuprolide Prostate, Low Yes Gynecomastia, hot
(Lupron) breast, flashes, impotence,
endometriosis bone pain, sodium
retention,
headache
Tamoxifen ER+ breast Low Edema, menstrual
(Nolvadex) irregularities, hot
flashes,
hypercalcemia
Toremifene Met. breast, Low Hot flashes,
(Fareston) post- sweating, vaginal
menopausal changes, edema,
dizziness

ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic

167
Nutrition in Cancer Treatment

lymphocytic leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI
= gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkins disease; HER2/neu + = human epidermal
growth factor receptor 2 positive; MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-Hodgkins lymphoma.

168
Appendices

Appendix 12C: Nutritional Implications of


Biotherapy and Antiangiogenic Agents
Biotherapies Indication Myelo- Nausea/ Anorexia Mucositis/ Diarrhea Other
(Cancer) suppression Vomiting Stomatitis
Monoclonal antibodies
Bevacizumab Met. Mild Moderate Yes Moderate Yes Hypertension,
colorectal
(Avastin) hemorrhage,
proteinuria
Bortezomib Multiple Moderate Low Moderate Yes Yes Peripheral
(Velcade) myeloma neuropathy,
hypotension,
fatigue, blurred
vision
Cetuximab Met. Mild Low Yes Yes Rash, hypotension,
(Erbitux) colorectal, fever, malaise
head and
neck (wild-
type KRAS)
Erlotinib Advanced or Moderate Yes Yes Yes Rash, abnormal
(Tarceva) met. lung liver function test,
GI bleeding,
conjunctivitis
Ibritumomab Non- Moderate Allergic reaction
Hodgkins
Tiuxetan during infusion,
lymphoma
(Zevalin) fever, chills,
headache, dyspnea
Imatinib CML Moderate Low Yes Edema, fluid
mesylate retention, GI
(Gleevec) irritation,
hepatotoxicity
Lenalidomide Multiple Moderate Yes Rash, dyspnea,
peripheral edema,
(Revlimid) myeloma,
dizziness,
MDS headache, muscle
cramps
Rituximab NHL Moderate Moderate Moderate Fever, chills, rash,
(Rituxan) (CD20+) angioedema, abd
pain, back pain,
arthralgia, dyspnea
Tositumomab I- NHL Moderate Low Yes Yes Anaphylaxis,
131 (Bexxar) (CD20+) hypothyroidism,
fever, infection,
MDS
Trastuzumab HER2/neu + Moderate Moderate Yes Yes Chills, fever, rash,
(Herceptin) met. breast vague pain
sensation,
cardiomyopathy,
headache
Panitumumab Met. Moderate Moderate Yes Yes Rash, fatigue,
(Vectibix) colorectal to high Itching,
hypomagnesemia

169
Nutrition in Cancer Treatment

Biotherapies Indication Myelo- Nausea/ Anorexia Mucositis/ Diarrhea Other


(Cancer) suppression Vomiting Stomatitis
Miscellaneous Agents
Interferon Alfa- Leukemia, Moderate to Moderate Yes Fever, chills,
high malaise, myalgia,
2B melanoma,
headache, fatigue,
(Intron A) chronic pancreatitis, renal
hepatitis toxicity
Interleukin, Renal cell, Moderate Yes Yes Yes Fever, rigors,
malaise,
Aldesleukin melanoma
hypotension,
(Proleukin, IL-2) anemia, capillary
leak syndrome,
dizziness
Hemopoietic Growth Factors
Darbepoetin Increase Mild Moderate Moderate Pain at injection
site, hypertension,
(Aranesp) red blood
myalgia
cells
Erythropoietin Increase Pain at injection
site, hypertension,
(Procrit, red blood
myalgia
Epogen) cells
Granulocyte-colony-stimulating Factors
Filgrastim Promote Bone pain, flu-like
symptoms
(Neupogen) neutrophils
Pegfilgrastim Promote Moderate Mild Mild Bone pain, flu-like
symptoms
(Neulasta) neutrophils
Romiplostim Platelet Mild Mild Mild Increase risk of
(Nplate) booster blood clots,
headache, joint
pain, myalgia,
abdominal pain,
dizziness
Antiangiogenic Agents
Bevacizumab Colorectal, Moderate Mild Mild Yes Weakness, vague
(Avastin) lung pain, hemorrhage,
hypertension,
proteinuria, CHF,
headache, GI
perforation, wound
healing
ALL = acute lymphocytic leukemia; AML = acute myeloid leukemia; CHF = congestive heart failure; CLL = chronic
lymphocytic leukemia; CML = chronic myeloid leukemia; CNS = central nervous system; ER+ = estrogen receptor positive; GI
= gastrointestinal; HCT = hematopoietic stem cell transplant; HD = Hodgkins disease; HER2/neu + = human epidermal
growth factor receptor 2 positive; MDS = myelodysplastic syndromes; Met. = metastatic; NHL = non-Hodgkins lymphoma.

References
Grant B, Byron J. Nutritional implications of chemotherapy. In: The Clinical Guide to Oncology Nutrition. 2nd ed.
Elliott L, Molseed LL, McCallum PD, Grant B, eds. Chicago, IL: American Dietetic Association; 2006:72-87.
Angiogenesis and antiangiogenic agents. In: Polovich M, Whitford JM, Olsen M, eds. Chemotherapy and
Biotherapy Guidelines: Recommendations for Practice. 3rd ed. Pittsburgh, PA: Oncology Nursing Society;
2009:34-72.
Wilkes GM, Barton-Burke M. 2010 Oncology Nursing Drug Handbook. Sudbury, MA: Jones & Bartlett; 2011.

170
Nutrition in Cancer Treatment

Appendix 13A: Nutritional Implications


of Surgical Oncology
Symptom Bile Brai Breas Colorect Esophagu Gallbladd Gastri GY
Duc n t al s er c N
t
Altered taste
Bloating X
Bowel X X
obstruction/ile
us
Chyle leak X X X
Constipation
Dehydration X X
Diarrhea X X X X X
Difficulty
chewing
Dumping X X
syndrome
Dysphagia X
Early satiety X X X X
Esophagitis
Fatigue X X X X X X X X
Fluid/electrolyt X X X X
e imbalance
Gas X X X
Gastritis X X
Gastrointestina X X X
l bleed
Hyperglycemia X
Malabsorption X X X X
Maldigestion X X X
Nausea and X X X X
vomiting
Nutrient B- B-12 B-12, A, D, B-12,
deficiencies 12, E, K, Ca, Fe, D, Fe,
A, Zn Ca
D, E,
K,
Ca,
Fe,
Zn
Odynophagia X
Steatorrhea X X X X
Urinary
changes
Weight gain X X
Weight loss X X X
Wound healing X X X X X X X X
Nutrition in Cancer Treatment

Appendix 13B: Nutritional Implications of


Surgical Oncology
Symptom Head/Ne Hepatic Lung Pancreas Prostat Small Amputati
ck e Intestin on
e
Altered taste X
Bloating
Bowel X
obstruction/ileus
Chyle leak X X X X
Constipation
Dehydration X
Diarrhea X X X
Difficulty chewing X
Dumping X
syndrome
Dysphagia X X X
Early satiety X X X
Esophagitis X
Fatigue X X X X X X X
Fluid/electrolyte X X X
imbalance
Gas
Gastritis
Gastrointestinal
bleed
Hyperglycemia X X
Malabsorption X X X
Maldigestion X X
Nausea and X
vomiting
Nutrient B-12, A, B-12, A, B-12, A,
deficiencies D, E, K, D, E, K, D, E, K,
Mg, Zn, Ca, Fe, Zn Ca, Fe,
Folic Zn
Acid
Odynophagia X
Steatorrhea X X
Urinary changes X
Weight gain
Weight loss X X X X X X X
Wound healing X X X X X X X

References
Thomas S. Nutritional implications of surgical oncology. In: Elliott L, Molseed LL, McCallum PD, Grant B, eds.
The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, IL: American Dietetic Association; 2006:94-109.
Huhmann MB, August D. Surgical oncology. In: Marian M, Roberts S, eds. Clinical Nutrition for Oncology

172
Appendices

Patients. Sudbury, MA: Jones & Bartlett; 2010:101-136.

173
Nutrition in Cancer Treatment

Appendix 14: Complications Secondary


to Enteral Feeding
Complication Possible Causes Treatment/Prevention
Tube Displacement/ Coughing, vomiting, Replace tube and confirm placement
Migration uncooperative patient
Tube Occlusion Crushed medications Thoroughly crush medications; use liquid
medications whenever possible
Incompletely dissolved Mix formulas thoroughly
formula
Failure to irrigate Flush adequately
Irrigation with Flush only with clear water (saline or plain club
inappropriate substance soda, as appropriate)
(i.e., cranberry juice,
cola)
High Residuals Decreased gastric motility head of bed 30 degrees
Prokinetic agents
Check residuals frequently
Duodenal or jejunal feedings
Aspiration Altered gastric motility or Continuous infusion; check residuals often;
gag reflex prokinetic agents
Vomiting Concentrated formula; antiemetics; decrease
feeding rate
Gastric Reflux Patient not upright or at head of bed 30 degrees
an incline
Displaced tube Monitor tube placement; distal end of tube
should be beyond ligament of Treitz
Nausea/Vomiting Formula administration Advance rate and concentration gradually;
continuous infusion; decrease rate and/or
concentration
Cramping Lactose intolerance; cold Use lactose-free formula; formula at room
formula temperature
Distention/Bloating Volume sensitivity Concentrated formula; decrease rate;
prokinetic agent
Hypermotility Antibiotic therapy Fiber-containing formula; anti-motility agents
Diarrhea Formula administration Advance rate and concentration gradually;
continuous infusion; decrease rate and/or
concentration
Overfeeding Reduce excess caloric intake
Lactose intolerance Lactose-free formula
Hypoalbuminemia Elemental diet initially; administer albumin
malnutrition
Malabsorption Pancreatic enzymes
Bacterial contamination Use clean administration technique; change
solutions frequently; hang feeding for four
hours or less

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Appendices

Complication Possible Causes Treatment/Prevention

Constipation Inadequate fluid Increase free water


Decreased gastric motility Fiber-containing formula; prune juice
(preceded and followed by adequate tube
flushing with clear water)
Inadequate bulk Fiber-containing formula
Medications Daily stool softeners; laxatives as needed
Inadequate activity Increase activity, as able

References
Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Enteral Nutrition. Chicago, IL:
American Dietetic Association; 2006.
Robinson CA. Enteral nutrition in adult oncology. In: The Clinical Guide to Oncology Nutrition. 2nd ed. Elliott
LL, Molseed LL, McCallum PD, Grant BL, eds. Chicago, IL: American Dietetic Association; 2006:138-155.

175
Nutrition in Cancer Treatment

Appendix 15: General Formulary Information


for Oral and Enteral Nutritionals
Category Caloric Protein Osmolality Characteristics Possible usage
density Density (mOsm/kg
(kcal/cc) H2O)
Standard, 1.01.25 8.810 270670 Flavored or Uncomplicated oral
Ready-to-use, g/240 unflavored; supplementation or tube
oral and/or cc some products feeding
enteral designed for
oral or enteral
use, while
others are only
for enteral use
Clear liquid 0.67 6.50 750990 Available in a For patients requiring clear
Juice drink 1.25 g/240 variety liquid diet, or preferring
cc of fruit flavors lighter, non-milky
supplements
Concentrated 1.52.0 1321.3 680870 Same as Patients with volume
g/240 standard intolerance, higher calorie
cc formulas and/or protein needs

Fiber- 1.06 4068 300650 Same as Patients requiring


containing 1.25 g/L standard regulation of bowel
Formulas function
Fructooligo- 1.01.2 35.2 450500 1.0 g FOS/240 To promote healthy
saccaride- 55.5 cc bacterial growth and
containing g/L intestinal tract health
High protein 0.951.5 4460 300610 Same as For patients requiring
g/L standard greater protein without
Formulas greater calories
Elemental/semi- 1.01.5 2194 320630 Usually Inflammatory bowel
elemental g/L unflavored, disease
but flavor Short-gut syndrome
packets may Transition from TPN to
be available enteral therapy
Non-specific
malabsorptive/maldigesti
ve states
Need for postoperative
feeding
Disease-specific 1.02.0 3075 665700 High branched- Acute or chronic renal
g/L chain amino failure; predialysis, hepatic
acids in hepatic failure
formulas
Immune- 1.01.5 5684 375630 May contain Pre- and/or perioperatively

176
Appendices

Category Caloric Protein Osmolality Characteristics Possible usage


density Density (mOsm/kg
(kcal/cc) H2O)
enhanced g/L arginine,
glutamine,
RNA, and EPA
EPA-containing 1.271.5 1621 635800 1 g EPA/240 Solid tumors, especially
g/240 cc; 480 cc/day with suspected
cc recommended hypermetabolism and/or
as an oral inflammatory process
supplement or
as part of an
enteral feeding
plan; may
contain 3 g
fiber/240 cc
EPA = eicosapentaenoic acid; FOS = fructooligosaccaride; RNA = ribonucleic acid; TPN = total parenteral nutrition.

References
Charney P, Malone A. Academy of Nutrition and Dietetics Pocket Guide to Enteral Nutrition. Chicago, IL:
American Dietetic Association; 2006.
Robinson CA. Enteral nutrition in adult oncology. In: The Clinical Guide to Oncology Nutrition. 2nd ed. Elliott
LL, Molseed LL, McCallum PD, Grant BL, eds. Chicago, IL: American Dietetic Association; 2006:138-155.

177
Appendices

Appendix 16
Glossary
Abdominal carcinomatosis: widespread dissemination of carcinoma throughout the abdomen.
Acute lymphocytic leukemia: acute onset of unrestrained growth of nongranular leukocytes, more
common in children.
Acute myelogenous leukemia (acute myeloid leukemia, acute nonlymphocytic leukemia,
granulocytic leukemia, myeloblastic leukemia, splenomedullary leukemia,
splenomyelogenous leukemia): acute onset of unrestrained growth of particular subtypes of
myelocytes, or leukocyte precursors.
Adjuvant: that which assists, hastens or increases the action of a principal ingredient.
Allogeneic transplant (allograft): stem cell transplant wherein related or unrelated donors HLA
matched cells are transplanted into the recipient.
Alveolar soft-part sarcoma: malignant tumor arising from vascular tissue; a variant of
rhabdomyosarcoma; see also sarcoma.
Anaphylactic reaction: a life-threatening allergic reaction.
Angiosarcoma: malignant tumor arising from vascular tissue; see also sarcoma.
Anorexia: loss of appetite.
Antineoplastic: preventing the development, growth or proliferation of malignant cells.
Antithymocyte globulin: a potent immunosuppressive agent.
Apheresis: a process in which blood is drawn from a donor or patient and a component (stem cells,
platelets, plasma or white blood cells) is separated out, with the remaining blood components
being returned to the body.
Aplastic anemia: a rare bone marrow disorder characterized by decreased function of the bone
marrow, which results in abnormally low levels of all the cellular elements of the blood
(pancytopenia). In some cases, the disorder may affect primarily single cell lines (i.e., red blood
cells, white cells or platelets).
Autologous transplant (autograft): a stem cell transplant where the patients own stem cells are
transplanted, after being purged of cancerous cells.
Basal cell carcinoma: skin cancer with low incidence of metastasis and is common among the
elderly; accounts for more than 90% of all skin cancer in the United States; secondary to sun
exposure.
Benign: description of a non-cancerous tumor; it is also used to describe a mild or non-life
threatening illness or medical condition.
Biotherapy (biological response modifiers, immunologicals): a broad term encompassing the use
of various agents, most of which occur naturally, to induce or enhance the patients own
immune responses to disease.
Bolus: a soft mass of chewed food; a dose of enteral formula administered fairly rapidly, as
opposed to administration via continuous or gravity drip.
Nutrition in Cancer Treatment

Glossary
Brachytherapy: radiation treatment given by placing radioactive material directly in or near a
target.
Buccal mucosa: the inner lining of the cheeks and lips.
Cancer cachexia syndrome: wasting; decreased body weight characterized by significant loss of
both adipose tissue and muscle mass.
Candidiasis: overgrowth of the Candida albicans yeast, usually found in moist, warm areas of skin
(i.e., vagina, mouth/throat); thrush (a condition characterized by patches of white inside the
mouth and/or throat); tends to develop when the normal balance of bacterial flora in the area is
upset, as with antibiotic use.
Carcinoma: a malignant tumor occurring in epithelial tissue.
Carcinomatosis: widespread dissemination of carcinoma.
Chemoprevention: the use of natural or synthetic substances to reduce the risk of developing
cancer or to reduce the risk of recurrence.
Chemotherapy: chemical/drug treatment; see also CNS prophylaxis, consolidation, induction,
intrathecal and maintenance.
Chronic lymphocytic leukemia: chronic disease with abnormal proliferation of lymphocytes.
Chronic myelocytic leukemia (chronic myelogenous leukemia, chronic granulocytic leukemia):
chronic disease of the bone marrow that causes rapid growth of the blood-forming cells
(myeloid precursors) in the bone marrow, peripheral blood, and body tissues.
Chylothorax (chyle leak, chylous leak): fluid consisting of a mixture of lymphatic fluid (lymph) and
chylomicrons that has entered the pleural cavity.
Central nervous system (CNS) prophylaxis: preventive therapy using intrathecal and/or high-dose
systemic chemotherapy to the CNS to kill leukemia cells present there or to prevent the spread
of cancer cells to the brain and spinal cord even if cancer has not been detected there.
Consolidation: high-dose chemotherapy, following induction, to attempt to kill any remaining
leukemia cells.
Cori Cycle: the metabolic cycle of reactions in which glycogen is broken down and resynthesized;
muscle glycogen blood glucose liver glycogen blood glucose muscle glycogen.
Cytokine: substance released by T-cells that has a specific effect on the interactions between cells,
on communications between cells or on the behavior of cells; cytokines include interleukins,
lymphokines and cell signal molecules, such as tumor necrosis factor and the interferons, which
trigger inflammation and respond to infections.
Cytotoxic: destructive to cells.
Deep vein thrombosis (DVT): a blood clot (thrombus) in a vein of the deep system (veins within the
muscle); DVT can lead to pulmonary embolism.
Deltoid: the muscle covering the shoulder prominence.
Dendritic cell: (branched like a tree); a special type of cell that is a key regulator of the immune
system, acting as a professional antigen-presenting cell capable of activating nave T cells and
stimulating the growth and differentiation of B cells; dendritic cells are found in the lymph

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Glossary
nodes and spleen.
Dermatofibrosarcoma protuberans: fibrohistiocytic tumor found on the skin, predominantly on the
trunk and proximal areas of extremities; see also sarcoma.
Dysgeusia: change in taste; unusual taste sensation.
Dyspepsia: vague description of abdominal discomfort, which may include heartburn, bloating,
abdominal pain, nausea, belching and indigestion.
Dysphagia: difficulty or inability to swallow.
Dyspnea: air hunger; difficult or labored breathing.
Early satiety: the feeling of being full prematurely (sooner than normal or after eating less than
usual).
Endoscopy: a flexible tube and an optical system introduced through the mouth (or rectum) to view
gastrointestinal tract; may be used to assist in placing enteral feeding tubes.
Enteral nutrition: nutrition support via the gastrointestinal tract.
Epidermoid carcinoma: cancer of the epidermis, or outer layer of skin; see also basal cell
carcinoma, squamous cell carcinoma and papillomatous carcinoma.
Epithelial tissue: the basic tissue that covers surface areas: the spaces, surfaces and the cavities of
the body; three types of epithelial tissues: covering and lining, glandular, sensory.
Epithelioid sarcoma: slow-growing malignant soft tissue tumor, usually occurring in adults;
pseudo-capsule or poorly circumscribed mass often attached to tendons, tendon sheath, or
joint capsule; predisposition for fingers, hands and forearm; most common soft tissue sarcoma
of the hand; see also sarcoma.
Erythrocytes: red blood cells.
Esophagitis: inflammation of the esophagus; may be painful; may cause odynophagia and/or
dysphagia.
Ewings sarcoma: family of tumors of the bone and soft tissue; the second most common type of
bone cancer; frequently found in the flat bones, such as the pelvis and ribs, as well as the bones
of the arms and legs; commonly spreads to bones, lungs and bone marrow; usually occurs in
those between ages 10 and 20; see also sarcoma.
Ewings sarcoma of the bone: bone cancer that forms in the middle (shaft) of large bones; most
often affects the hip bones and the bones of the upper arm and thigh; see also sarcoma.
External beam radiation: uses a machine located outside the body to aim high-energy rays at a
tumor.
Extraskeletal mesenchymal chondrosarcoma: rare soft tissue tumors that are related to
chondrosarcomas of the bone by a similar histopathology; majority are classified as myxoid
chondrosarcomas; the majority of tumors present in extremities, though various organs around
the body have reported cases; see also sarcoma.
Extraskeletal myxoid chondrosarcoma: resembles chordoma; accounts for less than 2% of all soft-
tissue sarcomas; usually affects men in fifth decade of life; frequently arises in deep soft tissues,
especially of lower extremity and frequently the foot; see also sarcoma.

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Nutrition in Cancer Treatment

Glossary
Extraskeletal osteosarcoma: a primary tumor arising in the somatic soft tissue with all of the
features of classic osteosarcoma; see also sarcoma.
Extraosseous Ewings sarcoma: Ewings sarcoma occurring in soft tissue; see also sarcoma.
Fibromatosis: infiltrative proliferation of fibroblasts and myofibroblasts; see also sarcoma.
Fibrosarcoma: spindle-celled sarcoma containing much connective tissue; see also sarcoma.
Fistula: an abnormal passageway in the body; may go from the body surface into a blind pouch or
into an internal organ, or go between two internal organs.
Flatulence: excessive gas in the stomach and intestines.
Fluoroscopy: observing the internal structure of opaque objects (as the living body) by means of
the shadow cast by the object examined upon a fluorescent screen when placed between the
screen and a source of X-rays; used chiefly for diagnostic purposes.
Fructooligosaccharides: probiotics, which are beneficial to the growth of desirable intestinal
bacterial flora.
Gardners syndrome: familial polyposis of the colon; high risk for colon cancer.
Gastrocnemius muscle: calf muscle.
Gastroparesis: paralysis of the stomach by a disease of either the stomach muscle itself or the
nerves controlling the muscle; food and secretions do not empty normally from the stomach;
may result in early satiety, bloating, nausea and vomiting.
Gluconeogenesis: formation of glucose from non-carbohydrate sources.
Glycogenesis: formation of glycogen from glucose.
Glycogenolysis: breakdown of glycogen to glucose.
Glycolysis: a multistep reaction that converts glucose to two pyruvate during which two ATP are
produced via substrate level phosphorylation; hydrolysis of glucose (catalyzed by enzymes).
Graft-versus-host disease: donated stem cells respond to and attack the patients own tissue as if it
were a foreign body.
Hemangiopericytoma: a rare tumor arising in the cells that form part of the blood vessel walls of
small capillaries; accounts for about 3% of all soft tissue sarcomas in children; can be malignant
or benign; can occur in any part of the body, but most often occurs in the lower extremities;
also occurs in adults and very rarely in infants; see also sarcoma.
Hematology: medical specialty dealing with disorders of the blood and blood-forming tissues.
HLA type: a pattern of human leukocyte antigens found in each persons cells; HLA matching helps
to ensure engraftment and acceptance of donated stem cells.
Hodgkins lymphoma: cancer of the lymphatic system characterized by painless swelling in the
lymph nodes in the neck, underarm or groin, as well as fevers, night sweats, tiredness, weight
loss or itching skin; distinguished from other types of lymphoma by the presence of one
characteristic type of cell, known as the Reed-Sternberg cell.
Hormone therapy: blocks endogenous hormones that lead to cancer proliferation.

181
Appendices

Glossary
Hospice: a concept of care designed to provide comfort and support to patients and their families
when a life-limiting illness no longer responds to cure-oriented treatments; neither prolongs life
nor hastens death.
Hypercalcemia: higher-than-normal level of calcium in the blood.
Hypermetabolic: greater energy expenditure than normal or calculated.
Hypogammaglobulinemia: a condition in which the levels of the gamma fraction of serum globulin
are abnormally low.
Hypometabolic: lower energy expenditure than normal or calculated.
Immune therapy (biologics, biological response modifiers): a broad term encompassing the use
of various agents, most of them naturally occurring, to induce or enhance the patients own
immune responses to disease.
Immunosuppression: Lowering the immune response.
Immunotherapy: a broad term encompassing the use of various agents, most of them naturally
occurring, to induce or enhance the patients own immune responses to disease.
Indirect calorimetry: the determination of metabolic rate from the measure of oxygen
consumption.
Induction: the first stage of chemotherapy for leukemia; the purpose of induction therapy is to kill
as many leukemia cells as possible and force the disease into remission.
In situ: localized.
Interosseous muscle: the muscle located between the forefinger and thumb.
Intrathecal: treatment with drugs that are injected into the fluid surrounding the brain and spinal
cord (cerebrospinal fluid).
In vitro: outside the living body and in an artificial environment.
In vivo: in the living body of a plant or animal; real life situation.
Invasive cancer: malignancy with a tendency to spread.
Krebs cycle: a complicated series of reactions involving the oxidative metabolism of pyruvate and
the production of energy; primary metabolic pathway for energy production in the body; see
also tricarboxylic acid cycle.
Lambert-Eaton syndrome: an autoimmune disease characterized by weakness and fatigue of the
proximal muscles (those near the trunk), particularly the muscles of the pelvic girdle (the pelvis
and hips) and the thighs, with relative sparing of eye and respiratory muscles; associated in 40%
of cases with cancer, most often with small cell cancer of the lung and less often with other
tumors; due to insufficient release of the neurotransmitter acetylcholine by nerve cells.
Laparoscopy: the use of a slender illuminated optical or fiber-optic instrument that is inserted
through an incision in the abdominal wall and used to examine visually the interior of the
peritoneal cavity.
Leiomyosarcoma: rare malignant tumor consisting of smooth muscle cells and small cell sarcoma
tumor; see also sarcoma.

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Nutrition in Cancer Treatment

Glossary
Leukapheresis: a process in which blood is drawn from a donor or patient and white blood cells are
separated out, the remaining blood components being returned to the body; see also
apheresis.
Leukocyte: white blood cell.
Leukocytosis: increased white blood cell count.
Li-Fraumeni syndrome: a rare, autosomal dominant cancer predisposition syndrome that is
remarkable for the wide variety of cancer types involved, the young age at onset of
malignancies and the potential of multiple primary sites of cancer during the lifetime of affected
people.
Linear accelerator: machine used to deliver radiation therapy.
Lipogenesis: the formation or deposition of body fat; the transformation of carbohydrates or
protein into body fat.
Lipolysis: breakdown of fat into glycerol and free fatty acids.
Lipoma: a fatty tumor; frequently appears in multiples, but is not malignant.
Liposarcoma: malignant fatty tumor; see also sarcoma.
Lumpectomy: excision of a breast tumor with a limited amount of associated tissue.
Lymphoma: cancer of the lymphatic system that results when a lymphocyte (a type of white blood
cell) undergoes a malignant change and begins to multiply, eventually crowding out healthy
cells and creating tumors, which enlarge the lymph nodes and other sites in the body; see also
Hodgkins lymphoma and non-Hodgkins lymphoma.
Macrophage: type of white blood cell that ingests foreign material; key player in the immune
response to foreign invaders such as infectious microorganisms.
Malignancy: describes a cancer that has the ability to invade into adjacent tissues or spread
(metastasize) into lymph nodes, body organs or distant sites.
Malignant fibrous histiocytoma: the most common malignant sarcoma of older adults; tends to
occur in the deep soft tissue of the extremities and the retroperitoneum, though it has been
described in nearly every organ of the body; see also sarcoma.
Malignant mesenchymoma: a tumor containing a combination of mesenchymal tissues; see also
sarcoma.
Malignant peripheral nerve sheath tumor: the malignant counterpart to benign soft tissue tumors
such as neurofibromas and schwannomas; this term is preferred to older designations such as
malignant schwannomas and neurofibrosarcomas; most common in deep soft tissue, usually in
close proximity of a nerve trunk; most common sites include sciatic nerve, brachial plexus, sacral
plexus; see also sarcoma.
Malignant schwannoma: tumors derived from schwann cells, which produce myelin, insulating
nerves and facilitating neural transmission; has been associated with neurofibromatosis; see also
sarcoma.
Maintenance: chemotherapy given for several years after consolidation to maintain remission.
Melanoma: a form of skin cancer that arises in melanocytes, the cells that produce pigment.

183
Appendices

Glossary
Mesenchymal tissue: cells capable of differentiating into a variety of soft tissues, such as blood,
blood vessels and the lymphatic system.
Mesothelioma: a malignant tumor of the mesothelium, the thin lining on the surface of the body
cavities and the organs contained within them; most mesotheliomas begin as one or more
nodules that progressively grow to form a solid coating of tumor surrounding the lung,
abdominal organs or heart; most commonly occurs in the chest cavity and is associated with
exposure to asbestos in up to 90% of cases.
Metastasis: the spread of cancer from an original site or location to a remote location of the body.
Common sites of cancer metastasis include the lymph nodes, liver, bone, brain and lungs.
Micronutrient: an organic compound (as a vitamin or mineral) essential in minute amounts.
Mini-transplant (nonmyeloablative transplant, mixed chimera transplant): stem cell transplant
wherein smaller doses of chemotherapeutic agents and radiation are used than in a traditional
transplant; goal is to lessen side effects and take advantage of the graft-versus-tumor effect;
used more frequently in older or frailer patients.
Modular supplement: macronutrient supplements that can be added to foods or other nutritional
supplements.
Monoclonal antibody: an antibody derived from a single cell, synthesized in large quantities for use
against a specific antigen (as a cancer cell); currently being investigated as a form of cancer
treatment.
Mucositis: an inflammation and ulceration of the lining of the mouth, throat or gastrointestinal tract
most commonly associated with chemotherapy or radiotherapy.
Multiple myeloma: a malignancy of plasma cells (a form of lymphocyte) that typically involves
multiple sites within the bone marrow; also called plasma cell myeloma.
Myeloid cells: precursors to phagocytes, which include neutrophils, eosinophils and monocytes;
group of non-lymphocyte white blood cells.
Nadir: lowest point in white cell, red cell and platelet counts following chemotherapy or radiation;
patients are often cautioned to be extra careful with exposure to infection and avoid anything
that could cause bleeding during this time.
Natural killer (NK) cells: a type of non-antigen-specific lymphocyte.
Neoplasm: a new and abnormal formation of tissue; grows at the expense of healthy tissue.
Nephropathy: abnormally functioning kidney(s).
Neurofibromatosis-1: an inherited disorder characterized by formation of neurofibromas (tumors
involving nerve tissue) in the skin, subcutaneous tissue, cranial nerves and spinal root nerves;
see also neurofibromatosis-2 and sarcoma.
Neurofibromatosis-2: von Recklinghausen neurofibromatosis; a neurocutaneous disorder similar to
neurofibromatosis-1, but associated with the presence of acoustic neuromas; see also
neurofibromatosis-1 and sarcoma.
Neuropathy: an abnormal and usually degenerative state of the nervous system or nerves.
Neutropenia: marked decrease in the number of neutrophils, white blood cells produced in the
bone marrow that ingest bacteria.

184
Nutrition in Cancer Treatment

Glossary
Non-Hodgkins lymphoma: a diverse group of cancers with the distinctions between types based
on the characteristics of the cancerous cells; groups are often classified as indolent or
aggressive; or low, intermediate and high grade; usually progress in a far less systematic and
predictable manner than Hodgkins disease.
Odynophagia: pain when swallowing.
Oncogene: a normal gene that has been transformed into a gene that promotes the growth of
cancer.
Oncology: study of cancer.
Osteoradionecrosis: death of bony tissue following radiation therapy.
Osteosarcoma: the most common malignant bone tumor in children; average age of diagnosis is 15
years; boys and girls have a similar incidence of this tumor until late adolescence, at which time
more boys are affected than girls; see also sarcoma.
Palliative care: the active total care of patients whose disease is not responsive to curative
treatment, including control of pain, symptoms and psychological, social and spiritual problems;
goal is best possible quality of life for patients and their families.
Pancytopenia: abnormally low levels of all blood constituents: platelets, white and red blood cells.
Papillomatous carcinoma: benign tumor featuring hypertrophied papillae covered by epithelium;
includes warts, condylomas and polyps.
Paraneoplastic syndrome: a group of signs and symptoms caused by a substance produced by a
tumor or in reaction to a tumor.
Parenteral nutrition: nutrients provided via peripheral or central venous access.
Perioperative: the time before, during and after surgery.
Philadelphia chromosome: chromosome abnormality found in chronic myeloid leukemia (CML).
Phlebitis: inflammation of a vein.
Primitive neuroectodermal tumors (PNET): different morphological expression of the Ewings
tumor type; in general, Ewings sarcoma arises within the bone while PNET arises within soft
tissues; also known as peripheral neuroepithelioma; see also sarcoma.
Prokinetic agent: pharmacological agent used to promote gastric motility.
Pulmonary embolism: a blood clot in the arteries of the lung.
Quadriceps: a large extensor muscle of the front of the thigh divided above into four parts that
include the rectus femoris, vastus lateralis, vastus intermedius and vastus medialis.
Radiation therapy: use of high-energy rays to damage cancer cells, stopping them from growing
and dividing; local treatment that affects cancer cells only in the treated area; see also external
beam radiation, brachytherapy and stereotaxis.
Reed-Sternberg cells: abnormal cells that are usually associated with Hodgkins lymphoma.
Reticuloendothelial system: diffuse system of phagocytic cells associated with the connective
tissue framework of the liver, spleen, lymph nodes and other serous cavities; a group of cells,
including macrophages or macrophage precursors, specialized endothelial cells lining the

185
Appendices

Glossary
sinusoids of the liver, spleen, and bone marrow, and reticular cells of lymphatic tissue
(macrophages) and of bone marrow (fibroblasts); also called the mononuclear phagocyte
system.
Reticulocyte: immature red blood cell, precursor to the erythrocyte.
Rhabdomyosarcoma: malignant, soft tissue tumor found in children; most common sites are the
structures of the head and neck, the genitourinary tract, and the arms or legs; see also sarcoma.
Sarcoma: type of cancer that starts in bone or connective tissue; see also alveolar soft-part
sarcoma, angiosarcoma, dermatofibrosarcoma protuberans, epithelioid sarcoma, extraskeletal
mesenchymal chondrosarcoma, extraskeletal myxoid chondrosarcoma, extraskeletal
osteosarcoma, Ewings sarcoma, Ewings sarcoma of the bone, fibromatosis, fibrosarcoma,
hemangiopericytoma, leiomyosarcoma, liposarcoma, malignant fibrous histiocytoma, malignant
mesenchymoma, malignant peripheral nerve sheath tumor, malignant schwannoma,
neurofibromatosis, osteosarcoma, primitive neuroectodermal tumors, rhabdomyosarcoma and
synovial sarcoma.
Scapula: shoulder blade.
Sepsis: a toxic condition resulting from the spread of bacteria or their byproducts from a focus of
infection.
Squamous cell carcinoma: found in the tissue that forms the surface of the skin, the lining of the
hollow organs of the body, and the passages of the respiratory and digestive tracts; can
metastasize; can occur secondary to exposure to sun, alcohol and tobacco.
Stem cell: a generic cell that can make exact copies of itself indefinitely; has the ability to
produce specialized cells for various tissues in the body, such as heart muscle, brain tissue and
liver tissue; embryonic stem cells are obtained from either aborted fetuses or fertilized eggs
that are left over from in vitro fertilization; adult stem cells are found in adults and children
and are not as versatile for research purposes because they are specific to certain cell types,
such as blood, intestines, skin and muscle, while embryonic stem cells are non-specific.
Stenosis: constriction or narrowing of a passage or orifice.
Stereotaxis: use of a number of precisely aimed beams of ionizing radiation, each coming from
different directions and meeting at a specific point, to deliver radiation treatment to that spot.
Stomatitis: inflammation of the mouth.
Syndrome of inappropriate secretion of antidiuretic hormone (SIADH): disorder of fluid and
electrolyte balance caused by excessive release of antidiuretic hormone.
Syngeneic transplant: stem cell transplant between identical twins.
Synovial sarcoma: soft-tissue sarcoma that usually emerges in adolescence or young adulthood;
usually arises near a joint (particularly the knee joint), and comprises cells similar to the synovial
cells that normally line a joint; see also sarcoma.
Temporalis: a large muscle in the temporal fossa (where the temple piece of eyeglasses rests).
Thrombocytes: platelets.
Thrombocytopenia: abnormally low platelet count; risk for bleeding.
Thromboembolism: blood clot blocking a blood vessel.

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Glossary
Thrombophlebitis: inflammation of a vein with formation of a thrombus (clot).
Trapezius: a large, flat, triangular superficial muscle on each side of the upper back and lower neck.
Tricarboxylic acid cycle: a complicated series of reactions involving the oxidative metabolism of
pyruvate and the production of energy; primary metabolic pathway for energy production in
the body; see also Krebs cycle.
Trismus: tonic contraction of the muscles of mastication; can occur secondary to radiation therapy.
Tuberous sclerosis: a group of two genetic disorders characterized by problems with the skin,
brain/nervous system, kidneys and a predisposition to tumors; named after a characteristic
abnormal growth in the brain in the shape of a tuber.
Tumor: a solid cancer in the form of a distinct lump or mass.
Veno-occlusive liver disease: blockage of the small- or medium-sized hepatic veins due to
nonthrombotic subendothelial edema, which may progress to fibrosis.
Werner syndrome: an autosomal recessive disorder that causes premature aging in adults,
characterized by sclerodermal skin changes, cataracts, subcutaneous calcification, muscular
atrophy, a tendency to diabetes mellitus, aged appearance of the face, baldness and a high
incidence of neoplastic disease.
Xerostomia: dry mouth.

Sources for Glossary


HONsearch section for medical professionals. http://www.hon.ch/HONsearch/Pro/index.html.
Health on the Net Foundation Web site. Accessed July 22, 2012.
MedicineNet. http://www.medicinenet.com/script/main/hp.asp. MedicineNet Web site. Accessed
July 22, 2012.
Medical Encyclopedia. http://www.nlm.nih.gov/medlineplus/encyclopedia.html. MedlinePlus Web
site. Accessed July 22, 2012.
Types of Cancer. www.nci.nih.gov/cancer_information/. National Cancer Institute Web site.
Accessed July 22, 2012.
Venes D, ed. Tabers Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: FA Davis Co.; 2009.

187
Examination

Examination
1. According to the American Cancer Society, which of the following signs and symptoms are early
warnings of cancer?
a. Change in sleeping habits
b. Voluntary loss of weight
c. Headaches
d. Muscle achiness
e. Obvious change in a wart or mole

2. Which of the following cancer diagnostic methods is a tumor marker?


a. Computed tomography (CT)
b. Magnetic resonance imaging (MRI)
c. Prostate-specific antigen (PSA)
d. Positron emission tomography (PET)
e. Prostate ultrasound (US)

3. According to 2012 statistics compiled by the American Cancer Society, the four most common
cancer diagnoses in the United States are:
a. Leukemia, liver, breast and prostate
b. Lung, breast, prostate and pancreatic
c. Lung, breast, colorectal and pancreatic
d. Lung, breast, colorectal and prostate
e. Pancreatic, liver, breast and prostate

4. The American Cancer Societys 2012 guidelines on nutrition and physical activity for cancer
prevention provide Americans with recommendations to reduce cancer risk. What nutrition strategy
can assist adults in reducing cancer risk?
a. Increase intake of omega-3 fatty acid dietary supplements
b. Increase intake of calcium-containing dietary supplements
c. Decrease carbohydrate intake
d. Achieve and maintain a healthy body weight
e. Decrease fiber intake

5. JB is a 63-year-old man with lung cancer. His cancer treatment will include chemotherapy and
radiation therapy to his mediastinum. Which of the following treatment-related nutrition impact
symptoms will JB most likely experience?
a. Diarrhea
b. Dysuria
c. Esophagitis
d. Colitis
e. Myalgia

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Nutrition in Cancer Treatment

6. CH is a 73-year-old man diagnosed with prostate cancer and will receive hormone therapy
(leuprolide [Lupron]) for treatment. Which side effect will CH most likely experience as result of his
therapy?
a. Peripheral neuropathy
b. Hot flashes
c. Nausea and vomiting
d. Mucositis
e. Anorexia

M ini-Case Study for Questions 7 and 8


Before beginning cancer therapy, a 55-year-old man with tongue cancer has been referred for nutrition
counseling. His cancer treatment will include head and neck radiation therapy and concurrent
chemotherapy. During the past three months he has lost 20 lbs due to dysphagia; his body mass index
is 22.

7. Anticipating treatment-related side effects, which of the following routes of nutrition support
therapy should be recommended by the dietitian to support this patient nutritionally?
a. Daily parenteral IV fluids
b. Total parenteral nutrition
c. Enteral nutrition using a percutaneous endoscopic gastrostomy (PEG) feeding tube
d. Plant-based, cancer-prevention diet
e. Ad-lib diet

8. Which side effect is commonly experienced by patients undergoing radiation therapy for treatment
of oral cancer?
a. Esophageal reflux
b. Xerostomia
c. Peripheral neuropathy
d. Hiccups
e. Dysuria

9. Which side effect is commonly experienced by patients after undergoing a partial gastrectomy for
treatment of stomach cancer?
a. Weight gain
b. Xerostomia
c. Steatorrhea
d. Constipation
e. Dumping syndrome

10. Which side effect is commonly experienced by patients after undergoing a surgical resection for
treatment of colorectal cancer?
a. Hyperglycemia
b. Diarrhea
c. Dysgeusia
d. Gastritis
e. Mucositis

189
Examination

M ini-Case Study for Questions 11 and 12


RH is a 33-year-old man diagnosed with acute lymphocytic leukemia. As an inpatient, he is undergoing
conditioning high-dose chemotherapy in preparation for a hematopoietic cell transplant. RH reports a
very poor appetite, and his weight has decreased 5 lbs during the last three days. He has an absolute
neutrophil count of 150.

11. Which of the following terms describes the condition a patient with an absolute neutrophil count
of 150 is experiencing?
a. Neutropenia
b. Thrombocytopenia
c. Microcytic anemia
d. Pernicious anemia
e. Cytopenia

12. Which treatment-related side effect most likely explains RH's recent weight loss?
a. Side effects from engraftment of stem cells
b. Side effects from graft-versus-host disease of the gut
c. Nausea and vomiting secondary to his high-dose conditioning chemotherapy
d. Taste alterations secondary to his high-dose conditioning chemotherapy
e. Constipation secondary to his high-dose conditioning chemotherapy

13. According to the American Institute for Cancer Researchs Simple Steps to Prevent Cancer, the
lifestyle goals for long-term cancer survival should include which recommendation?
a. Regaining weight that was lost during treatment
b. Obtaining and maintaining a healthy body weight
c. Decreasing carbohydrate intake
d. Increasing protein intake
e. Increasing intake of dietary supplements

14. According to the American Cancer Societys Nutrition and Physical Activity Guidelines for Cancer
Survivors, which of the following lifestyle strategies should be recommended for long-term cancer
survivors?
a. Consume an "all natural," organic diet and be physically active.
b. Take dietary supplements to boost and strengthen the immune system.
c. Eat a plant-based diet and be physically active.
d. Take herbal supplements to boost and strengthen the immune system.
e. Eat a high-protein, low-carbohydrate diet and be physically active.

15. Which symptoms commonly occur in people with advanced cancer?


a. Weight gain, constipation and nausea
b. Anorexia, early satiety and constipation
c. Pain, fatigue and sleep disturbances
d. Anorexia, early satiety and sleep disturbances
e. Weight loss, constipation and sleep disturbances

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Nutrition in Cancer Treatment

16. Which of the following treatment strategies are used to manage hypercalcemia observed in
patients with advanced cancer and bony metastases?
a. Fluid restriction and calcium binder agents
b. IV fluids and antihypercalcemic agents
c. IV fluids and calcium channel blockers
d. Calcium-restricted diet
e. High phosphate diet

17. Which of the following cancer diagnoses pose the greatest risk for patients developing bowel
obstruction after receiving chemotherapy and pelvic radiation therapy?
a. Colon cancer and stomach cancer
b. Pancreatic cancer and liver cancer
c. Pancreatic cancer and prostate cancer
d. Colon cancer and ovarian cancer
e. Pancreatic cancer and stomach cancer

M ini-Case Study for Questions 18 and 19


KL is a 72-year-old man with advanced prostate cancer receiving hospice care. Medical history includes
hypercholesterolemia, hypertension and adult onset diabetes mellitus. He has tried to follow a cardiac
and carbohydrate controlled diet for more than 20 years. His cancer has metastasized to several bony
areas. KL reports chronic bone pain, poor appetite, continued weight loss and constipation.

18. Which of the following diets should KL follow to manage his cancer-related symptoms?
a. Continue carbohydrate-controlled diet
b. Continue cardiac diet
c. High-fiber diet
d. Ad-lib diet
e. High-calorie, high-protein diet

19. Which of the following pharmacological agents could alleviate KLs constipation?
a. Take stool softeners daily
b. Take anti-motility agents regularly
c. Take Kaopectate daily
d. Take milk of magnesia daily
e. Take megestrol acetate (Megace) regularly

20. Which statement defines cancer cachexia?


a. A multifactorial process thought to be caused by the suppression of bone marrow activity
b. A common secondary diagnosis observed in patients diagnosed with early stage cancer and is
characterized by progressive weight loss, anorexia, and generalized wasting and weakness
c. A multi-factorial process thought to be caused by direct or indirect damage to the central nervous
system, peripheral nervous system, cranial nerves or any combination of the three
d. A common secondary diagnosis observed in patients with advanced cancer and is characterized
by progressive weight loss, anorexia, and generalized wasting and weakness
e. A multifactorial process thought to be caused by alterations in the cell cycle of both normal and
malignant cells

191
Examination

21. Which of the following nutrition screening tools is well suited for the outpatient oncology setting,
and why?
a. Weight history and albumin, because it is used for nutrition screening in most institutions
b. Patient-Generated Subjective Global Assessment (PG-SGA), because it is validated, quick,
inexpensive and provides consistent reliable identification of oncology patients at risk
c. Prognostic Nutrition Index (PNI), because it is a validated predictor of negative outcomes
related to malnutrition in surgical oncology and labs are readily available and covered by insurance
d. Mini Nutritional Assessment (MNA), because it is quick and easy, inexpensive, based on
multiple parameters and is validated in the oncology population
e. Subjective Global Assessment (SGA), because it is quick, inexpensive, validated in the oncology
population and includes an action plan

M ini-Case Study for Questions 22, 23 and 24


NC is a 45-year-old woman with an astrocytoma. She has undergone surgical resection and is currently
receiving daily dexamethasone (Decadron) and temozolomide (Temodar) chemotherapy, and
concurrent whole brain radiation therapy. She is 56, and her current weight is 138 lbs; her usual body
weight is 145 lbs.

22. Which of the following side effects will NC most likely experience as a result of her combined
modality cancer therapy?
a. Diarrhea
b. Peripheral neuropathy
c. Mucositis
d. Fatigue
e. Dyspnea

23. Which condition is NC at risk for developing while undergoing cancer therapy?
a. Acute renal failure
b. Hyperglycemia
c. Hyperlipidemia
d. Hepatic toxicity
e. Hypercalcemia

24. What is the purpose of a safe food or neutropenic diet?


a. To decrease foods that could further irritate the oral and gastric mucosa
b. To control diarrhea caused by graft-versus-host disease or conditioning chemotherapy regimen
c. To eliminate foodborne pathogens that could cause an infection in immunocompromised
patients
d. To enhance immune function in patients who are neutropenic
e. To add immune-enhancing supplements to reduce potential infectious complications

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Nutrition in Cancer Treatment

25. A patient is interested in taking vitamin and mineral supplements to boost his immune system
during cancer treatment. According to the literature cited in this course, which of the following
recommendations should be provided by the dietitian regarding vitamin and mineral supplementation
during therapy?
a. Dietary Reference Intakes provide Estimated Average Requirements (EAR) that meet nearly
100% of the nutrients required by all people at all times.
b. Health experts conclude that taking a vitamin and mineral supplement containing no more than
100% of the Daily Value (DV) is considered safe for patients during cancer treatment.
c. Health experts conclude that water-soluble vitamins are harmless at any dosage, so megadoses of
the Recommended Dietary Allowance (RDA) are not considered harmful for patients desiring greater
protection.
d. The Dietary Reference Intake Average Intake (AI) is the highest amount of a nutrient that can be
taken safely at any time.
e. Health experts conclude that the RDA meets 100% of the needs of most patients and should
never be exceeded.

M ini-Case Study for Questions 26, 27 and 28


CR is a 55-year-old patient, newly diagnosed with esophageal cancer. CRs recommended treatment
plan includes chemotherapy and gastroesophageal radiation therapy followed by an esophagectomy. He
has an almost complete obstruction of the esophagus and documented dysphagia with aspiration. He is
59, and his current weight is 138 lbs; his usual body weight is 170 lbs, and one month ago he
weighed 155 lbs.

26. Which route of nutrition support therapy is recommended for patients undergoing this treatment
regimen?
a. Percutaneous endoscopic jejunostomy
b. Peripheral parenteral nutrition
c. Nasogastric feeding tube
d. Ad-lib diet
e. Plant-based, cancer-prevention diet

27. Which side effect is most frequently experienced by patients undergoing an esophagectomy?
a. Constipation
b. Dumping syndrome
c. Peripheral neuropathy
d. Dysgeusia
e. Alopecia

28. Which side effects are most frequently experienced by patients undergoing CRs planned
chemotherapy and radiation therapy?
a. Diarrhea and malabsorption
b. Constipation and bloating
c. Esophagitis and dysphagia
d. Xerostomia and taste changes
e. Mucositis and stomatitis

193
Examination

29. In which scenario would the use of parenteral nutrition be indicated for a patient diagnosed with
cancer?
a. When a patients oral intake is inadequate and results in weight loss while undergoing
chemotherapy for her breast cancer
b. When a hospice patient with advanced cancer is unable to eat due to bowel obstruction
c. When a patient receiving head and neck radiation therapy refuses the placement of a PEG
feeding tube
d. When a patient receiving chemotherapy experiences episodes of diarrhea between cycles of
chemotherapy
e. When a patient with acute graft-versus-host disease experiences severe diarrhea after receiving
an allogeneic stem cell transplant

30. Which of the following foods should be recommended for a patient experiencing nausea after
receiving a highly emetogenic chemotherapy?
a. A large glass of warmed milk
b. A mug of hot coffee
c. A serving of pretzels
d. A serving of a favorite food
e. A dish of ice cream

31. Which of the following medications is prescribed for the management of anticipatory nausea
before the administration of chemotherapy?
a. Prochlorperazine (Compazine)
b. Aprepitant (Emend)
c. Lorazepam (Ativan)
d. Metoclopramide (Reglan)
e. 5-HT3 antagonists (e.g., ondansetron [Zofran])

32. Which of the following pharmacological agents has been shown to be effective for improving
appetite in people with cancer?
a. Megestrol acetate (Megace)
b. Polyethylene glycol (Miralax)
c. Bisacodyl (Dulcolax)
d. Amifostine (Ethyol)
e. Prochlorperazine

33. Which of the following nutrition interventions should be recommended for a patient with prostate
cancer experiencing acute radiation enteritis during pelvic irradiation?
a. Consume a high-fiber, low-fat diet
b. Consume a low-fiber, low-fat diet
c. Consume a low-fiber, high-fat diet
d. Consume a high-fiber, high-fat diet
e. Consume an ad-lib diet

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Nutrition in Cancer Treatment

34. MF is a 58-year-old woman with pancreatic cancer undergoing chemotherapy. She complains of
abdominal bloating, steatorrhea and early satiety. Which pharmacological agents could be prescribed?
a. Corticosteroids
b. Antiemetics
c. Cathartics
d. Pancreatic enzymes
e. Mucosal protectant agents

35. JT is a 16-year-old boy diagnosed with Hodgkins disease. He has undergone chemotherapy and is
now receiving radiation therapy to a para-aortic field. Which of the following side effects will JT most
likely experience as a result of his radiation therapy?
a. Headaches and hearing changes
b. Xerostomia and dysgeusia
c. Odynophagia and heartburn
d. Nausea and diarrhea
e. Oral and esophageal mucositis

36. Which of the following oral care suggestions should be recommended for management of radiation
therapy-induced oral mucositis?
a. Spraying the oral cavity with a saliva stimulant
b. Spraying the oral cavity with an artificial saliva
c. Rinsing the oral cavity with a saline/baking soda rinse throughout the day
d. Sucking on lemon drops or peppermint candy throughout the day
e. Rinsing the oral cavity with a mouthwash (e.g., Listerine) throughout the day

37. According to the American Cancer Societys 2012 guidelines for nutrition and physical activity for
cancer prevention, which of the following physical activity recommendations should be discussed to
assist adults with reducing their cancer risk?
a. Engage in at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity
activity each week
b. Engage in at least 75 minutes of moderate-intensity activity or 150 minutes of vigorous-intensity
activity each week
c. Physical activity does not affect cancer risk
d. Engage in at least one hour of vigorous-intensity activity each day, with moderate-intensity
activity occurring at least three days a week
e. Engage in at least one hour of moderate- or vigorous-intensity activity each day, with vigorous-
intensity activity occurring at least three days a week

38. A patient undergoing head-and-neck radiation therapy presents to the clinic with a reddened oral
mucosa and white cheesy patches on his tongue, soft palate and oropharynx. Which treatment-related
side effect is this patient experiencing?
a. Esophageal fibrosis
b. Neutropenia
c. Candidiasis
d. Cholelithiasis
e. Esophageal stenosis

195
Examination

39. Which of the following interventions could be recommended by the dietitian for a patient
experiencing chronic dysgeusia related to cancer treatment?
a. Magnesium supplementation
b. Zinc supplementation
c. Calcium supplementation
d. Folic acid supplementation
e. Iron supplementation

40. A patient is experiencing constipation, loss of appetite and a feeling of fullness. Which of the
following pharmacological agents could be recommended to alleviate this patients symptoms?
a. Metoclopramide
b. Prochlorperazine
c. Ondansetron
d. Bisacodyl
e. Senna (Senokot)

196