Key issues in oncology Nutrition.2012

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Key Issues in Oncology Nutrition:

Key Issues in Oncology Nutrition Atta-ur-Rehman Khan, Ph.D, RD,. Clinical Dietitian King Khalid National Guard Hospital, Jeddah

Objectives:

Objectives 1. Type of cancers and Nutrition risk. 2.Nutritional co-morbidities in cancer 3.Goals of Nutritional support 4.Type of Nutritional support 5.Nutritional support and treatment outcomes 6.Summary

Systemic effects of cancer:

Systemic effects of cancer Altered Metabolism Anorexia Electrolyte Imbalance

Localized effects of Cancer & Tx:

Localized effects of Cancer & Tx Typhlitis Ileus or Bowel Obstruction Malabsorption syndrome: Such as pancreatic insufficiency that can lead to weakness, weight loss, Growth failure and ultimately Malnutrition

Malnutrition:

Malnutrition Malnutrition at diagnosis in children with cancer :06-50% Malnutrition in children during therapy can occur in 08-32%.

Malnutrition:

Malnutrition Predisposes to: Increased morbidity Decrease immune functions Poorer treatment outcomes Diminished quality of life

Therefore early detection,prevention and treatment of nutrition related problems are very important:

Therefore early detection,prevention and treatment of nutrition related problems are very important

High nutritional risk cancer Diagnosis:

High nutritional risk cancer Diagnosis Acute Lymphocytic Leukemia (HR categories and relapsed) Wilm’ tumor (stage III and IV,unfavorable histopathology and relapsed) Neuroblastomas (stage III and IV) Metastatic Solid Tumors Non Hodgkin’s lymphoma (stage III and IV and relapsed) Acute and Chronic Mylogenous Leukemia (newly diagnosed and relapsed) Medulloblastoma and other brain tumors ABMT : Autologous Bone Marrow Transplantation.

Low nutritional risk cancer Diagnosis:

Low nutritional risk cancer Diagnosis Acute Lymphocytic Leukemia with good prognosis Non-metastatic Solid Tumors Advanced diseases in remission during maintenance treatment

Cancer and Weight Loss :

Cancer and Weight Loss • Weight loss is often an early symptom • Up to 80%of cancer patients will lose weight • 20% of cancer patients die from effects of malnutrition rather than from malignancy Kondrup, AJCN 2002 De Wys et al: Am J Med 1980. Andreyevet al: Eur J Cancer 1998

Nutritional Co-morbidities in CA patients :

Nutritional Co-morbidities in CA patients Progressive depletion of vital host tissues resulting emaciation and wasting Cancer Cachexia Altered Metabolism Impaired food and nutrient intake Malabsorption Fluid and electrolyte disturbances

Cancer Cachexia :

Cancer Cachexia Prevails in 80 % cancer patient Incidence in stage IV : 40% 3000 Adult patients with advanced cancer 54 % Weight loss. In presence of weight loss, prognosis is poorer and survival shorter. Ss Donaldson. Am J Dis Child 1981;135:1107 Dewys WD.Am.J Med 1980;69:491

Etiology of cancer Cachexia :

Etiology of cancer Cachexia Basal metabolic rate increases with decreased caloric intake BMR and REE inversely related to energy intake Hansell Dt. Ann Surg 1986; 203: 240 Peacock JL. Surg Fourm 1986;37:11 Stallings VA. Pediatr Res 1986;20:288A

Effects of CA on food and nutrient intake :

Effects of CA on food and nutrient intake Oropharynx and GI tract (  intake / absorption) Soft tissue sarcoma (  access to food ) CNS tumors (  appetite, food intake ) Carinoid tumors (  absorption, metabolism ) Paraneoplastic syndromes ( Multiple effects )

Psychological Considerations:

Psychological Considerations Depression and anxiety can contribute to malnutrition and must be evaluated by the oncology and behavioral medicine staff members. Illness, Tx and its psychosocial effects on the family may affect a patient’s behavior and lead to depression related anorexia

Malnutrition Screening Codes:

Malnutrition Screening Codes Weight Loss Impending treatment Oral Intake Serum Albumin (indicator of visceral protein status)

Malnutrition Screening Codes-Weight Loss:

Malnutrition Screening Codes-Weight Loss <5% Low Risk 5-10% in children or 1% in infants Moderate Risk >10% High Risk

Malnutrition Screening Codes-Impending Treatment:

Malnutrition Screening Codes-Impending Treatment GI tract surgeries Radiation therapy to GI tract or CNS Bone marrow transplant GI problems including but not limited to typhlitis,ileus, mucositis (>grade3 based on National Cancer Institute(NCI) common toxicity criteria Radiation enteritis and dumping syndrome

Malnutrition Screening Codes- Oral Intake :

Malnutrition Screening Codes- Oral Intake Oral intake less 50% of assessed needs for >3days Moderate Risk

Malabsorption secondary to :

Malabsorption secondary to Deficiency/ inactivation of pancreatic enzyme Deficiency/ inactivation of bile salts Small bowel fistula Blind loop syndrome ( bacterial overgrowth ) Small bowel hypoplasia induced by malnutrition

Fluid and electrolyte disturbances secondary to :

Fluid and electrolyte disturbances secondary to Persistent vomiting Diarrhea, fistula Intestinal secretary abnormalities with hormone-secreting tumors Miscellaneous organ dysfunction with nutritional implications Gastrinomas ( gastric ulcers ) Brain tumor

Goals of Nutrition Support :

Goals of Nutrition Support O ptimal nutritional status and body weight Benefits of therapies Reduce symptoms Prevent or reverse protein status Prevent or reverse immunosuppression Improve or maintain quality of life Prevention/ correction of nutritional and metabolic derangement

Factors to be considered before nutritional intervention :

Factors to be considered before nutritional intervention Primary organ site and metastases Clinical symptoms Type and frequency of therapy Potential side effects of therapy Effect of malignancy or disease on food and nutrient ingestion, tolerance and utilization

Methods of Nutrition Support :

Methods of Nutrition Support Oral Nutrition Support (ON) Enteral Nutrition Support (EN) Parenteral Nutrition Support (PN)

Oral Nutrition Support :

Oral Nutrition Support ON Simplest, cost effective, safe oral feeding with in-depth Counseling Supplementation: Modular formulas Complete formulas Elemental formulas

Enteral Nutrition Support:

When the gut works, use it Enteral Nutrition Support

Enteral Nutrition Support :

Enteral Nutrition Support Unable to take adequate nutrition orally NG- Feeding G/PEGT Feeding JT-Feeding Complete formulae with compromised GIT Elemental Low Osmolality Low residue

Oncology - Colorectal cancer :

28 Oncology - Colorectal cancer Dietitians should provide weekly Medical Nutrition Therapy (MNT) that includes an individualized nutrition prescription and counseling for patients with colorectal cancer undergoing pelvic radiation. Individualized counseling with a focus on the consumption of regular foods may improve calorie and protein intake, nutrition status, quality of life (QOL) and reduce symptoms of anorexia, nausea, vomiting and diarrhea. Fair Imperative Radiation and MNT

Medical Food Supplements and Radiation:

Medical Food Supplements and Radiation Dietitians should consider use of medical food supplements (MFS) to improve protein and calorie intake for patients with head and neck cancer undergoing radiation therapy. Use of MFS may be associated with fewer treatment interruptions, a reduction of mucosal damage, and may minimize weight loss. Fair Imperative © 2008 ADA Evidence Analysis Library ® 29 ONC – Head and neck cancer

Medical Nutrition Therapy (MNT) and radiation therapy:

Medical Nutrition Therapy (MNT) and radiation therapy Medical Nutrition Therapy (MNT) that consists of nutrition assessment, intensive intervention, and ongoing monitoring and evaluation by an RD should be provided for patients with head/neck cancer being considered for radiation therapy. MNT has been shown to improve calorie and protein intake, maintain anthropometric measurements and improve quality of life (QOL). Strong Imperative © 2008 ADA Evidence Analysis Library ® 30 ONC – Head and neck cancer

Medical Nutrition Therapy (MNT) and pre-treatment evaluation:

Medical Nutrition Therapy (MNT) and pre-treatment evaluation The Dietitian should provide MNT consisting of a pre-treatment evaluation and weekly visits during radiation treatment for head and neck cancer to improve outcomes. Strong Imperative © 2008 ADA Evidence Analysis Library ® 31 ONC – Head and neck cancer

Radiation and use of EN:

Radiation and use of EN Use enteral nutrition (EN) to increase calorie and protein intake for outpatients with stage III or IV head and neck cancer undergoing intensive radiation treatment. Maintenance of nutritional status by EN during radiation therapy may improve tolerance of therapy to promote better outcomes. Strong Imperative © 2008 ADA Evidence Analysis Library ® 32 ONC – Head and neck cancer

PowerPoint Presentation:

Robinson et al, JPEN 1987. Nutritional Status Days Benefits of Enteral Nutrition Support Reduces Length Of Stay

Benefits of Enteral Nutrition Support Less Costly, Less complication:

0 5 10 15 20 25 30 35 Septic morbidity ENT PNT Percent of Patients Kudsk et al, Ann Surg 1992. Pneumonia (p<.02) Intra-Abdominal Abscess (p<.04) Line Sepsis (p<.05) Benefits of Enteral Nutrition Support Less Costly, Less complication

Parenteral Nutrition Support :

Parenteral Nutrition Support PN includes Dextrose, Amino Acid and Lipid emulsion Peripheral (Low Energy) Central (High Energy)

Parenteral Nutrition Support :

Parenteral Nutrition Support Benefits of PN are questionable Short term (<7days) of PN is not recommended Outcome parameters takes time (28days) to improve PN slows the transition to ON in pediatric cancers

Summary:

Summary 1. Patients with cancer are at nutritional risk 2. SNS should be a an integral part in malnutrition or Hypophagia 3. Nutrition influences QOL in cancer patients 4. SNS in terminally ill cancer has to be limited to specific cases

THANKS:

THANKS

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