This document discusses nutrition support in cancer patients. It begins by reviewing cancer mortality statistics and trends in the US. It then describes common nutritional alterations in cancer patients, such as early satiety, dysphagia, nausea/vomiting, taste changes, and cachexia. The document outlines nutritional assessments for cancer patients, including screening tools, physical exams, laboratory tests, and quality of life assessments. It provides criteria for nutritional intervention and goals of therapy. The document discusses nutritional management strategies for issues like mucositis, diarrhea, and neutropenia. It addresses special considerations for enteral and parenteral nutrition in cancer patients. Finally, it lists some online resources for patient and caregiver education.

1. Nutrition Support In Cancer

2. Incidence and Prevalence of Cancer No. of deaths % of all deaths Rank Cause of Death 1. Heart Diseases 696,947 28.5 2.Cancer 557,271 22.8 3. Cerebrovascular diseases 162,672 6.7 4. Chronic lower respiratory diseases 124,816 5.1 5. Accidents (Unintentional injuries) 106,742 4.4 6. Diabetes mellitus 73,249 3.0 7. Influenza and pneumonia 65,681 2.7 8. Alzheimer disease 58,866 2.4 9. Nephritis 40,974 1.7 10. Septicemia 33,865 1.4 US Mortality, 2002 Source: US Mortality Public Use Data Tape 2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2004. www.cancer.com (cancer statistics)

3. Rate Per 100,000 1950 2002 HeartDiseases CerebrovascularDiseases Pneumonia/Influenza Cancer * Age-adjusted to 2000 US standard population. Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised. 2002 Mortality Data: US Mortality Public Use Data Tape, 2002, NCHS, Centers for Disease Control and Prevention, 2004. www.cancer.com (cancer statistics 2005) Change in the US Death Rates* by Cause, 1950 & 2002

4. Nutritional Alterations in Cancer* Early Satiety Dysphagia Nausea Vomiting Chemo-therapy Mucositis TNF Food Intake Taste/smell Alteration Catabolism AA FA Anorexia Weight Loss GI Malabsorption Radiation Therapy Glucose MalnutritionCachexia *A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005

5. Cancer Cachexia

6. Cytokines modulate gastric motility and emptying either directly or via brain TNF suppresses lipoprotein lipase activity TNF play a role in cancer cachexia, weight loss was reversed with TNF neutralizing antibodies in mice.3 IL-1 associated with anorexia by blocking neuropeptide Y (NPY) induced feeding. IL-1 & TNF increases corticotropin hormone which decreases food intake Hormonal & Cytokine Alterations 3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154

7. Metabolic Alterations 1.Metabolic responses to tumour disease and progression: tumour–host interactionClinical Nutrition, Volume 19, Issue 6, December 2000, Pages 459-465

8. Micronutrient Deficiencies3 Reduced Levels of Vit A in Colorectal & Esophageal Cancer and pretreatment pediatric leukemia & Lymphoma Vit E, Vit C, Beta Carotene in lung, gastric, pancreatic, oral & thyroid cancer Vit D (and Calcium) in Colon Cancer Metabolic Alterations 3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154

9. Electrolyte Disturbances3 Tumor Lysis Syndrome Hyperkalemia, Hyperphosphatemia & Hypocalcemia Drug Induced Hyponatremia – cyclophosphamide & Vincristine Hypocalcemia, Hypomagnesemia and hypophosphatemia – platinum containing therapy Metabolic Alterations

10. Nutritional Assessment Screening Early assessment of nutritional risk and serial reassessments through out cancer patient’s course. Patient-Generated Subjective Global Assessment (PG-SGA) Outcome based assessment tool developed specifically for cancer patients Easily Applicable Capture Short term changes in nutritional status.

11. Physical Examination Body weight >45% of hospitalized adult cancer patients (>10%) weight loss3 Weight loss correlates with complications and mortality Body weight must be evaluated against normal or usual weight and not a reference standard Nutritional Assessment 3. A.S.P.E.N Nutrition Support Practice Manual 2nd Edition 2005 Page 153-154

12. Physical Examination Evaluation for Edema Ascites Muscle wasting Temporal wasting (Hallmark of Cachexia) Functional Assessment Assessment of muscle function (Grip Strength) Nutritional Assessment

13. Biochemical and laboratory tests Viceral Proteins Use to evaluate nutritional status but reliability is questionable Predictive of morbidity and mortality Pre-Albumin Provides better Identification of nutritional status and its recovery during NS Nutritional Assessment

14. Biochemical and laboratory tests Low Albumin and Prealbumin Poor nutrition status Infection Overhydration Decreased synthesis due to Cytotoxics agents Nutritional Assessment

15. Quality Of Life (QOL) Patient’s willingness to eat Depressed Psychological State Poor Attitude Financial constraints Ability to eat Weakness and fatigue Nutrition counseling for symptom management improves nutrient intake and QOL Nutritional Assessment

16. Nutrotional Considerations for Chemo, Radiation and immuno therapy Nausea, Vomiting, Diarrhea, Constipation Mucositis Neutropenia Change in taste Loss of appetite Dry mouth Fatigue Criteria for Interventions & Goals Of Therapy

17. Criteria for Intervention4 (Adults) Preoperative tube-feeding or PN provided for 7-14 days may benefits moderately and severely malnourished cancer patients. Specialized nutrition support is indicated in selected patients who are receiving cancer treatment and who are either severely malnourished or unable to consume and/or absorb an adequate oral diet for an extended period of time. Criteria for Interventions & Goals Of Therapy 4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.

18. Goals of therapy Maintenance of Nutritional status or Reversal of PCM Calories to prevent/minimize catabolism without overfeeding In general 25-35 Kcals/kg is a reasonable estimate Protein 1.2-1.5gm/kg (varies with degree of catabolism) Criteria for Interventions & Goals Of Therapy 4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.

19. Decreased morbidity, improved survival, and improved QOL NS may improve QOL Use of HPN also improved QOL Some nutrients like glutamine, arginine and essential fatty acids and nucleic acids have been evaluated for their specific beneficial biologic effects on the tumor and the host. Criteria for Interventions & Goals Of Therapy 4. A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(1 suppl):83SA.

20. Criteria For Intervention (Pediatrics) 3 Relapse rate is high in malnourished patients in ALL and solid tumors. Tolerance to drug therapy is lower in malnourished patients as compared to well nourished patients. Criteria for Interventions & Goals Of Therapy

21. Indication for NS (American Academy of pediatrics)5 NS must be provided to patients to support normal growth who cannot meet requirements via oral intake. Weight loss > 5% of preillness body weight Weight < 90% of ideal body weight Weight for height < 10th percentile Criteria for Interventions & Goals Of Therapy 5. Mauer AM, Burgess JB, Donaldson SS, et al. Special nutritional needs of children with malignancies: a review. J ParenterEnteralNutr. 1990;14(3):315–324.

22. Indication for NS (American Academy of pediatrics) Serum Albumin < 3.2mg/dL Triceps skinfold < 5th percentile for age and sex Oral Intake < 70% of that needed for growth for more than 5 days in well nourished patient. Expected GI dysfunction > 5 days in well nourished patients Criteria for Interventions & Goals Of Therapy

23. Goals5 Body weight > IBW Arm Fat Area > 10th percentile for age and sex Serum Albumin > 3.2mg/dL Vitamin and mineral deficiency should be prevented Decreased morbidity Improved survival Improved QOL Criteria for Interventions & Goals Of Therapy 5. Mauer AM, Burgess JB, Donaldson SS, et al. Special nutritional needs of children with malignancies: a review. J ParenterEnteralNutr. 1990;14(3):315–324.

24. Pharmacological Nausea & Vomiting Serotonin receptor antagonists (e.g. Granisteron, Ondasteron) Phenothiazines (e.g., promethazine) Antihistamine (e.g. Diphenhydramine) Benzodiazepines (e.g. Lorazepam) Steroids (e.g. Dexamethasone) Nutritional Management

25. Pharmacological Prevention and Rx of Mucositis Salt and soda rinse Chlorhexidine rinse Mouthwash (diphenhydramine +antacid+Lidocain) Nutritional Management

26. Pharmacological Bowel Medications Stool Softeners (docusate) Bulk Laxatives (Psyllium, Methylcellulose) Lubricants (Mineral Oil) Osmotic Agents (Glycerin, Lactulose) Stimulants (Bisacodyl) Antidiarrheal (loperamide, Kaolin/Pectin) Nutritional Management

27. Nutritional Nausea and Vomiting Small & Frequent Meals Eat slowly Cold and non-odorous food Light, starchy & low fat food Avoid Very sweet or spicy food Rest & sit up after eating Nutritional Management

28. Nutritional Mucositis Choose blend, cold soft drinks Moisten dry foods Cut food into small pieces or puree Use straw with fluids Coordinate eating with analgesic use Nutritional Management

29. Nutritional Constipation Obtain Adequate Fluid intake Increase insoluble fiber consumption Drink hot beverages prior to the usual time of bowel movements Incorporate physical activity as permitted by medical team Nutritional Management

30. Nutritional Diarrhea Extra Fluid and K rich food sources Increase soluble fiber and decrease insoluble fiber Avoid Lactose & Sugar Alcohols Low fat food Consume food and beverages at room temperature Nutritional Management

31. Nutritional Neutropenia Food containing less bacterial load Wash fruits and vegetables well Avoid unpasteurized products Follow safe handling, storage and cooking procedures for meat, fish, poultry and eggs Nutritional Management

32. Nutritional Taste Changes Choose flavorful foods as tolerated Loss of appetite Small frequent meals Save beverages for the end of meal High calorie and Protein-nutrient dense foods Nutritional Management

33. Special Aspects of enteral nutrition Aggressive EN should be considered in patients who are unable to attain oral intake Small bowel resection and mucosal injury pateint may benefit from EN Aim is to meet requirements of Macronutrients Micronutrients Fluid needs with acceptable GI tolrance Nutritional Management

34. Special Aspects of enteral nutrition Monitoring Aspiration risk and GI tolerance Pre-existing Rx related Nausea, vomiting may be exacerbated during EN Postoperatively ileus may preclude tolerance Mechanically Ventilated patients may have poor perfusion Nutritional Management

35. Special Aspects of enteral nutrition Nasoenteric feeding tube may be contraindicated in sever thrombocytopenia Significant mucositis Recent extensive neck resection Immune-suppressed patient should be educated for careful tube feeding technique Nutritional Management

36. Special Aspects of enteral nutrition3 Safety of fish oil has not been well studies in children In case of diarrhea and mal-absorption Use low osmolar nutrient supplements that contain MCT, hydrolized carbohydrates and proteins. Increase prealbumin by 1mg/dL per day Nutritional Management

37. Special Aspects of PN PN is recommended in patients who need aggressive NS when Tube feeding is unsuccessful GI Tract is not appropriate(e.g. Obstruction, High output Fistula) In Cachectic patients, the goal may be to minimize wasting rather than to nutritionally replete patient. Nutritional Management

38. Special Aspects of PN Pediatrics Adequate calories to support growth along NCHS Growth charts Catch Up growth-if patient has PCM Prealbumin Level-1mg/dL per day increase Replacement of minerals and electrolytes (Zn in diarrohea) Nutritional Management

39. Minimization of Metabolic disturbances Glucose < 180mg/dL Triglycerides < 300mg/dL Avoidance of Refeeding Syndrome Repleting Mineral and electrolyte level prior to start PN Initiating PN slowly in case of severe malnutrition Nutritional Management

40. Monitoring Catheter Complication Hemothorax Infection at site of infection Hematoma Sepsis Rate of infection varies on the nutrition status of patient6 Nutritional Management 6. A clinical trial of hyperalimentation in children with metastatic malignancies J. Van Eys, E. M. Copeland, A. Cangir, G. Taylor, B. Teitell-Cohen, P. Carter, C. OrtizMedical and Pediatric Oncology Volume 8, Issue 1 , Pages63 - 73

41. Monitoring

42. Metabolic complication Hyperglycemia Hypophosphatemia Electrolyte disturbances Increased liver function test & bilirubin Nutritional Management

43. Drug Nutrient Interaction Neutropenic diet Educate patient & care giver about feeding methods Nutrition side effects commonly experienced with cancer therapy and how to minimize it. Patient & Caregiver Education Internet Resources

44. American Cancer society www.cancer.org American Institute of cancer research www.aicr.org Cancer centers www.cancerlinksusa.com Cancer research and prevention foundation www.preventioncancer.org Diet guidelines for immunosuppressed patients www.fhcrc.org/clinical/ltfu/ National Cancer Institute www.cancer.gov Oncolinkhttp://www.oncolink.upenn.edu/ Oncology dietetic Practice group www.oncologynutrition.org Patient & Caregiver Education Internet Resources