MNT for Cancer Prevention, Treatment, and Recovery

cancer

abnormal and uncontrolled cell division and reproduction that can spread throughout the body

etiology of cancer

related to genetic, environmental, medical, and lifestyle factors

cancer prevention

• physically active lifestyle

• healthy body weight

• healthy diet

• limit alcohol

• no tobacco

stages of carcinogenic process

• carcinogen metabolism

• cellular and host defense

• cell differentiation

• tumor growth

how many cancer deaths are attributed to diet, nutrition, and lifestyle behaviors?

one-third

epidemiological studies look at relationships of…

diet, population groups, and cancer

the term “cancer survivor” can refer to those that are…

cancer free, living with evidence of disease, or undergoing cancer treatment

dietary carcinogens

naturally occurring and added in food preparation and preservation

inhibitors of carcinogenesis

antioxidants, phytochemicals

phytochemicals

any of various biologically active compounds found in plants

• protect cells from damage caused by environmental toxins and the body’s metabolic processes

lycopene color

red

lycopene sources

tomatoes and tomato products, papaya, pink grapefruit, watermelon

lycopene potential benefits

protect against prostate cancer

examples of phytochemicals

• lycopene

• anthocyanins

• polyphenols

• alpha and beta-carotene

• lutein

• zeaxanthin

• sulforaphanes

• indoles

• allyl sulfides

anthocyanins, polyphenols color

red and purple

anthocyanins, polyphenols sources

berries, grapes, red wine, plums, purple cabbage, peanuts

anthocyanins, polyphenols potential benefits

prevent cancer formation, decrease inflammation and provide antioxidant support

alpha- and beta-carotene color

orange

alpha- and beta-carotene sources

carrots, mangos, pumpkin, sweet potato

alpha- and beta-carotene potential benefits

protect against oral, esophageal, pharynx, larynx, and lung cancers; improve immune response

lutein, zeaxanthin color

yellow and green

lutein, zeaxanthin sources

kale, spinach, collard, dandelion, mustard and turnip greens, asparagus, cooked winter sausage

lutein, zeaxanthin potential benefits

protect DNA from damage

sulforaphanes, indoles color

green

sulforaphanes, indoles sources

arugula, Bok choy, cabbage, broccoli, Brussels sprouts, cauliflower, watercress

sulforaphanes, indoles potential benefits

change DNA methylation that directly and indirectly regulates cancer progression

allyl sulfides color

white and green

allyl sulfides sources

leeks, onions, garlic, chives

allyl sulfides potential benefits

protect against stomach and colorectal cancer

what is considered a “drink”?

• 12 ounces of 5% beer

• 8 ounces of 7% malt liquor

• 5 ounces of 12% wine

• 1.5 ounces of 40% distilled spirits or liquor

recommendations for alcohol

• 1 drink/day for women

• 2 drinks/day for men

alcohol increases risk for what types of cancer?

oral cavity, pharynx, larynx, esophagus, colon, stomach, rectum, pancreas, gallbladder, liver, and breast cancers

obesity, age, and metabolic syndrome increase…

insulin-like growth factor 1 (IGF-1)

positive associations between overweight and cancers of the…

endometrium, kidney, gallbladder, esophagus, and more

fat recommendations

limit processed and red meats

sugar and nonnutritive sweeteners recommendations

<10% of total kcal from added sugar

protein recommendations

decrease animal protein

smoked, grilled, preserved, and processed foods

• increase cancer risk from nitrates that turn to nitrites

• more charred from an open flame → more risk

organic and genetically modified foods

no benefit with organic; no risk with GMOs

bisphenol A (BPA) recommendations

minimize exposurec

cancer chemoprevention

phenols, vegetables, fruits, soy, herbs

antioxidants and bioactive substances

focus on dietary sources rather than supplements

vitamin D

may prevent or decrease risk

coffee and tea provide…

phenols and antioxidants

fruits and vegetables provide…

antioxidants and phytochemicals

soy and phytoestrogens

no adverse effect if taken with cancer

vegetarian/vegan diets

protective

physical acitivity

increased physical activity decrease cancer risk

warning signs

“CAUTION” and unexplained weight loos

CAUTION

Change in bowel or bladder habits

A sore throat that does not heal

Unusual bleeding or discharge

Thickening or lump in breast or elsewhere

Ingestion or difficulty in swallowing or chewing

Obvious change in wart or mole

Nagging cough or hoarseness

staging of cancer

I, II, III, IV

staging system used

Tumor-Node-Metastasis (TNM) staging system

Stage 0

abnormal cells are present but have not spread to nearby tissue

• also called carcinoma in situ, or CIS.

• CIS is not cancer, but may become cancer

Stage I

Stage II

Stage III

cancer is present

• the higher the number, the larger the cancer tumor and the more it has spread into nearby tissues

Stage IV

the cancer has spread to distant parts of the body

classification

• solid vs liquid (hematologic)

• tissue of origin, growth properties, and invasion of other tissues

• malignant or benign

common types of cancer in children

neuroblastoma, osteosarcoma

common types of cancer in adults

epithelial tissue: skin, digestive, urinary, respiratory, reproductive

cancer treatment therapy

• chemotherapy

• biotherapy/immunotherapy

• hormonal therapy

• radiation therapy

• surgery

• hematopoietic cell transplantation

cancer treatment therapy goals

cure, control, or palliative

MNT goals for cancer

• improve treatment tolerance—side effect management

• reduce need for interruptions of treatment through individualized nutrition therapy

• decrease unintentional weight and LBM loss

• increase quality of life

• improve overall survival

energy requirements

• support healthy weight

• standardized equations, indirect calorimetry if available/indicated

• calculate using actual body weight

protein requirements

• consider degree of malnutrition, extent of disease, degree of stress, ability to metabolize and use protein

• 1.2-2 g/kg/day or more

• calculate using actual body weight

cancer, nutritional repletion, weight gain energy and protein needs

• energy

  • 30-35 kcal/kg/day

• protein

  • 1.0-1.5 g/kg/day

cancer, inactive, nonstressed energy and protein needs

• energy

  • 25-30 kcal/kg/day

• protein

  • 0.8-1.0 g/kg/day

cancer, hypermetabolic, stressed energy and protein needs

• energy

  • 35 kcal/kg/day

• protein

  • 1.5-2.5 g/kg/day

hematopoietic cell transplant energy and protein needs

• energy

  • 30-35 kcal/kg/day

• protein

  • 1.5 g/kg/day

sepsis energy and protein needs

• energy

  • 25-30 kcal/kg/day

• protein

  • 1.5-2.0 g/kg/day

fluid requirements

• ensure adequate hydration and electrolyte balance, and prevent dehydration and hypovolemia, watch for nephrotoxic effects of anticancer treatments

• altered fluid balance common, requires close monitoring

• general guideline for estimating fluid needs for all adults without renal concerns

  • 20-40 ml/kg

  • 1 ml fluid per 1 kcal of estimated calorie needs

  • body surface area method

alterations in macronutrient metabolism

• tumors demand glucose, exhibit anaerobic metabolism, and produce lactate

  • protein and fat break down to meet glucose demand

  • glucose intolerance and insulin resistance

• patients need increase in energy and protein

MNT and cancer cachexia

• progressive weight loss, anorexia, generalized wasting and weakness, immunosuppression, altered BMR, abnormalities in fluid and energy metabolism

• results in loss of LBM and fat mass

• mediated via cytokines, including tumor necrosis factor (TNF-a and TNF-b), interleukin-1, interleukin-6, and interferon-alpha (increased in inflammatory response)

MNT and pharmacotherapy of cardiac cachexia

• anorexia treatment and counseling, diet modification, and medications

• medications

  • antihistamines, corticosteroids, pregestational agents, prokinetic agents, antidepressants

  • cannabis

  • cannabinoids

fluid and electrolyte imbalance

• diarrhea, vomiting, malabsorption

• provide hydration and replace electrolytes

hypercalcemia with bone metastases

• provide hydration and antihypercalcemic agents

• dietary calcium does not affect serum calcium levels in this condition

complementary and integrative MNT

• open, honest, nonjudgmental discussion

• clinicians need to know and discuss the benefits and risks of alternative therapies for cancer

• supplements showing promise: Omega-3 fatty acids, vitamin D, curcumin, selenium, medicinal mushrooms

• potential adverse effects of garlic and vitamin E on bleeding risk

• adverse interactions with chemotherapy: garlic, green tea extracts, some Chinese herbs, mistletoe, some Chinese herbs, St. John’s wort, and ginger

• always check for drug-nutrient interactions

chemotherapy side effects

anemia, fatigue, nausea, vomiting, loss of appetite, mucositis, changes in taste and smell, xerostomia, dysphagia, diarrhea, constipation

hormone therapy side effects

hot flashes, decreased libido, bone pain

biotherapy side effects

fatigue, chills, fever, flu-like symptoms, decreased food intake

radiation therapy

fatigue, loss of appetite, skin changes, and site-specific effects

surgery nutrition impact

depends on what is resected and how extensive resection is

surgery side effects

fatigue, changes in appetite, and bowel function

nutrition-related side effects of cancer treatment

• anorexia

• N/V/D

• constipation

• sore mouth/throat

• mucositis/thrush

• fatigue

• neutropenia

• altered taste and/or smell— often metallic taste

• thickened saliva/dry mouth (xerostomia)

MNT for head and neck cancer

• chewing and swallowing troubles; dysphagia

• enteral nutrition

• oral dysphagia diet based on food and textures tolerated, chewing/swallowing training

MNT for esophageal cancer

• reflux, dumping syndrome, dysmotility, gastroparesis, early satiety, vomiting, fluid and electrolyte imbalance

• jejunostomy feeds

• low fat diet

• small frequent meals

• avoid large amounts of fluids at meals

MNT for gastric cancer

• dumping syndrome, malabsorption, gastric stasis, lactose intolerance, anemias, MBD

• jejunostomy feeds

• treat deficiencies

• antidumping

MNT for cancer of intestinal tract treated with surgery

• fluid and electrolyte imbalances, diarrhea, bile salt losses, B12 malabsorption, steatorrhea

• diet low in fat, osmolality, lactose, and oxalates

MNT for pancreatic cancer treated with surgery

• delayed gastric emptying, early satiety, glucose intolerance, bile acid deficiency, diarrhea, malabsorption

• enzyme replacement

• small frequent meals

• avoid simple CHO

hematopoietic cell transplant

• treatment for leukemia, lymphoma, multiple myeloma

• stem cells from bone marrow, peripheral blood, or umbilical cord blood

• acute toxicities: nausea, vomiting, dysgeusia, stomatitis, mucositis, fatigue, diarrhea

• delayed onset: mucositis, xerostomia

• MNT: PN

graft-versus-host disease

donated cells react against host

• gastroenteritis, abdominal pain, vomiting, secretory diarrhea, organ involvement

MNT for graft-versus-host disease

• phase 1: PN until diarrhea resolves

• phase 2: isotonic, low residue oral liquids

• phase 3: reintroduce solids, low lactose, low fat, and low acid foods

• phase 4: progressively reintroduce food

• phase 5: regular diet

nutrition and neutropenia precautions

• safe food handling

  • special handling of utensils, cutting boards, and countertops

  • thorough hand washing

  • store food at appropriate safe temperatures

• avoid foods that pose infection risk

  • raw meats

  • spoiled/moldy foods

  • special handling of raw meat, eggs, and poultry

nutrition monitoring and evaluation

• determine and quantify progress to goals

  • goals should be specific, achievable, and individualized actions

  • objective measures of progress

• evaluate outcomes and make necessary adjustments

• documentation

nutritional care of children

• greater risk of nutrition depletion due to more aggressive multimodality therapy

• families and caregivers often have an extreme preoccupation with eating and weight

• creativity in feeding

• enteral nutrition support

• individualize requirements

• requirements for growth and development

palliative care

total care when curative measures no longer pursued

hospice

provides symptom relief and emotional support

MNT for palliative care and hospice

manage nutrition-related symptoms, maintain strength and energy to promote quality of life; provide nutrition as tolerated

• advance directives guide family and healthcare providers to adhere to patient wishess

  • for nutrition, this may include limitations on EN/PN

3 phases of cancer survivorship

• active treatment and recovery

• living after recovery

• advance cancer and end of life

MNT for cancer survivors

long-term cancer survivors should focus on healthy diets and physical activity geared toward prevention of a second cancer and reducing the risk of other chronic diseases

MNT for cancer

• prevent or correct nutritional deficiencies

• minimize weight loss

• ensure optimal protein and fluids

• promote food safety

• enteral or parenteral nutrition

• manage nutritional side effects of treatment

  • diarrhea, taste changes, etc.