Nutritional Aspects of Cancer Care

Helen Webster Oncology Dietitian NHS Tayside

Aims

• • • • • • • • • • • •

Malnutrition Causes MUST Management Cancer Cachexia Management EPA supplements Alternative diets/supplements Case studies Conclusion Questions References

What is Malnutrition?

“

A state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse affects on tissue/body form, function and clinical outcome” DOH, 2002 • 1 in 4 adults admitted to hospital or care homes at risk of Malnutrition. Bapen 2007 • Estimated up to 80% of advanced ca pts have malnutrition.

Poole & Froggatt, 2002

Causes of malnutrition?

Four main causes:

• • • •

Decreased dietary intake Increased requirements Increased losses of nutrients Impaired nutrient digestion / absorption.

Causes of decreased intake

• Reduced appetite due to cachexia / depression / anxiety • Symptoms of illness – N&V, sore mouth, abdo distension, diarrhoea.

• Treatment side effects • Tumour / ascites pressing on GI Tract reducing volume available and causing early satiety • Taste changes • Constipation

Causes of decreased intake

• Social isolation, significant life change, mental illness • Repeatedly NBM for investigations / biopsies • Difficulty with eating / chewing e.g. ill fitting dentures, poor oral hygiene / dysphagia • Difficulty with self feeding

Causes of Increased Requirements

• Cachexia • SOB e.g. lung ca, PE, • Infection • Wound healing • Post op pts • Fractures

Loss of nutrients

• Vomiting • Diarrhoea • Renal losses • Haemorrhage • Wound • Fistula

Impaired digestion / absorption

• Lack of digestive enzymes e.g. ca pancreas, pancreatitis, CF • Loss of surface area for absorption e.g. pts with resections, coeliac disease • Radiation enteritis

Impact:

• Weight loss • Vitamin Deficiency • Impaired immune function • Delayed wound healing • Higher risk of pressure sores • Muscle wasting and weakness – impairing respiratory function, cardiac function, mobility

Impact Cont…

• Increased risk of post op complications.

• Apathy and depression – vicious circle.

• Lethargy, tiredness, weakness.

• Est. 20% people with cancer die from effects of malnutrition rather than cancer itself.

Management of Malnutrition

• Early intervention improves outcome.

• Ward can screen with MUST, start fortified diets, food charts, weight checks, provide assistance.

• Clinics – weight, height, BMI, weight history, recent food intake, consider planned treatments.

• Refer to dietitian using MUST score > 2, anything less should be managed at ward level.

Management of malnutrition

• Treat side effects restricting intake • Treat depression if present • Mouth care – be proactive!

• Modify diet • Consider supplements • Consider artificial nutrition if appropriate

Nutritional Supplements

• Ensure plus – 330 kcal, 13 g protein.

• Ensure plus juce – • Enshake – 330 kcal, 10 g protein.

600 kcal, 15 g protein.

• Calogen 405 kcal in 3 x 30 ml doses.

• Procal liquid – doses.

300 kcal, 6 g protein in 3 x 30 ml • Procal powder – 100 kcal, 2 g protein.

• Want to try some?

• Which do you prefer?

• Others available.

Enteral Feeding

• Various routes: NG, NJ, PEG, RIG, PEJ, Surg Jej.

• Used to meet full / part nutritional requirements.

• Various feeds.

• Emergency feeding regimen for out of hours.

Refeeding Syndrome

• • •

Refeeding syndrome complications in – “severe fluid and electrolyte shifts and related metabolic malnourished pts undergoing refeeding.” During starvation the body adapts to save energy.

On refeeding: increased insulin release leads to uptake of glucose, Phos and K+ into cells.

Refeeding Continued…

• Magnesium is used as a co-factor for cellular pump activity • Reactivation of the Na/K+membrane pump leads to more K+ moving into cells • Reduced phosphate causes increased magnesium excretion (urine) • Stimulation of protein synthesis leads to increased demand for phos, K+ and glucose by the cells • Increased thiamine use – cofactor in CHO metabolism

Parenteral Nutrition

• Intravenous nutrition • If the gut works – USE IT!

• Used to meet patients requirements where the gut is not working • Short and long term indications e.g. enterocutaneous fistulae, post-op ileus, severe mal absorption, short bowel syndrome, radiation enteritis etc • Requested via the nutrition team

Cancer Induced Weight loss (Cachexia)

• Weight not maintained despite normal diet • Complex combination of metabolic abnormalities.

• Particularly prevalent with solid tumours.

• Adequate nutrition has little or no effect • Early visible sign of deterioration • Associated with Anorexia and Early satiety

Aetiology of cachexia

   o     Many different factors

Cytokine involvement

Pro-inflammatory cytokines implicated in metabolic disturbances TNF, IL-1, IL-6, IL-8 and LIF Mediate acute phase protein response (APPR) Causes increased synthesis of proteins by the liver e.G. CRP Req. Amino acids from lean body tissue causing weight loss CRP elevated in 45 % of ca panc pts at diagnosis. Falconer et al. 1994

Metabolic changes causing REE

Metabolically Inefficient Recycling of glucose Glucose Production/ turnover Whole body Protein turnover APPR REE Protein catabolism PIF Lipogenesis Protein synthesis Lipoprotein lipase REE = resting energy expenditure PIF = proteolysis inducing factor APPR: Acute phase protein response

Effects of tumour on weight loss Effects of treatment / anxiety on weight loss Tumour Inflammation like response Increased metabolic rate Altered use of protein, fat and carbohydrate by the body Treatment Side effects such as: dry mouth, loss of appetite, sore mouth, nausea, taste changes, decreased food intake Anxiety Reduced food intake Cancer induced early satiety and anorexia Reversible weight loss can be stopped / reversed by adequate nutrient intake Loss of fat tissue Loss of fat and muscle tissue Combined effects lead to

overall weight loss

Management of Cachexia

•

Team approach.

• Cure the cancer – not always possible.

• Increase nutritional intake – diet and supplements to meet the deficit.

• Reduce effects of factors listed previously through cancer treatments, pharmacology, dietary interventions, involvement of other AHPs etc.

• • Improve nutritional status.

Improve quality of life.

EPA Supplements

• High fish oil content providing patient with mega-dose of eicosapentaenoic acid (EPA) • Proven to reduce inflammatory response • Reduce further weight loss • Improve quality of life • Limited evidence, small studies.

• 2 available: Prosure (any cachexic pt) and Forticare (licensed only for ca pancreas) • Not widely used as other supplements tend to be more appropriate/palatable when pts diagnosed.

• Cost implications: Ensure plus = 3 p on contract (in hospital) Forticare = £1.80

Prosure = £2.70 Wigmore et al, 1996

Alternative Diets/ Supplements

• Many different types • Vulnerable/desperate patients seeking help / advice • Not evidence based • Tend to cut out/restrict good sources of calories and protein • Tend to encourage lots of f&v >10 portions, bulky, low in kcals and protein • Some claim to cure cancers • Some promote weight loss as part of the healing process

Bristol Cancer Diet

• Well publicised.

• It recommends:  High intake of fresh veg & fruit, high in whole grains beans and pulses on a regular basis.

• It rules out: • Sugar and refined carbohydrates, dairy products, red meat, processed foods, smoked/cured foods, caffeine, alcohol, salt .

Problems With The Bristol Cancer Diet

• Cancer patients commonly have poor appetite and early satiety • Eating bulky foods such as raw veg, brown rice and pasta, lentils and pulses – not tolerated.

• People fill up on these quickly.

• Therefore unable to meet calorie and protein requirements and lose weight.

• Limited evidence.

• Where appropriate Healthy eating advice should be given by a dietitian and tailored to the individual e.g. in a weight gaining breast ca pt.

Gerson Diet

• Claims a 50% recovery rate if followed – no evidence to support those claims • Strictly based on organic fruit and veg – juiced • Therefore entirely vegan • Coffee enemas, thyroid hormones and liver extract used • Very expensive, time consuming and pts lose weight dramatically Gerson institute, 2006

Metabolic Therapy

• Claims to boost the immune system • Uses Lætrile (vit B17) a derivative of bitter almonds/apricot kernels • Also uses coffee enemas and liver extract and mega doses of vits and mins • Scientific studies showed no effect on outcome for patients • Demonstrated higher levels of cyanide from L ætrile in blood stream of those taking part

National Cancer Institute, 2006

Immuno-augmentative Therapy

• Iscador – extract of mistletoe • Said to boost immune function • Studies have shown rise in WBC • Seen to affect growth of ca cells in laboratories • Limited evidence – mechanism not fully understood.

Weleda, 2006

Shark Cartilage Extract

• Claim that sharks don’t get cancer.

• Cartilage thought to prevent angiogenesis.

• One major study showed no effect.

• However phase 3 trial using Neovastat in USA underway (renal ca and NSCLCa).

• £20 for 100 capsules online.

• ? Dosage.

Cancerhelp, 2008.

Alternative Diets/supplements

• The weird and the wacky.

• Used by the very vulnerable / desperate people as well as the sensible.

• Can be avoided if given appropriate advice early on.

• Tread carefully.

• Allow the patient to make an informed choice.

• And allow the dietitian to support their choice without detriment to their health.

Case Study 1

• • • • • • •

76 yr old male.

Admitted with SOB, recurrent chest infections.

Recently found to have lung ca on CT and pleural effusion.

C/O poor appetite.

Mouth “like the Sahara desert.” Gets fatigue from SOB.

Lost approx 7 kg (1 stone) over last 4-6 weeks.

Case Study 1

• What steps can be taken to improve this pt’s nutritional intake?

• What can be done at ward level?

• What other proactive measures would help prevent a worsening of his nutritional intake?

• What other meds are likely to be used that will help his appetite anyway?

Case Study 2

• • • • •

72 yr old male pt adm to oncology unit with oesophagitis, dry, sore mouth, dysphagia and pain on eating and swallowing.

Has been receiving radiotherapy for oesophageal cancer Minimal dietary intake Unable to wear dentures Epigastric pain, particularly at night.

Case Study 2

• What has caused the oesophagitis?

• How can we reduce the pain on eating and at night?

• What sort of mouthcare might you recommend?

• What dietary steps / advice may be useful?

• What steps can the ward take?

Conclusion

•

No quick fix to nutrition support for patients.

•

Not necessarily about pt gaining weight.

•

Aiming to improve quality of life for the pt and reassure anxious relatives.

• •

Proactive approach is best.

Early referral and intervention improves outcome for the patient.

Conclusion

•

Oncology Dietitians available for patients on ward 32 east, west and day pt area

• •

MUST scoring with common sense and proactive thinking Refer other ward’s patients to local dietitians

• •

Food first approach Not just about supplements – lots of other issues we can address as a team to improve a patient’s oral intake and in turn their quality of life.

Thanks for listening

•

Any questions?

References:

• • DOH. Nutrition screening in quality of care 2002.

McWhirter J.P., Pennington C.R., Incidence & recognition of malnutrition in hospital. Br MED J 1994:308:945-948.

• Poole K, Frogatt K, weight loss in advanced cancer – a literature review. Macmillan cancer relief, 2002.

• Tisdale MJ, biology of cachexia, J Natl cancer inst 1997:23: 1763-73.

• Falconer JS, Plester CE, et al. Cytokines, the acute-phase response, and resting energy expenditure in cachexic patients with pancreatic cancer. Ann surg 1994;219(4): 325-31.

• Tisdale MJ, metabolic abnormalities in cachexia and anorexia. Nutrition 2000;6:d164-74.

• Billingsley KG, Alexander HR. The pathophysiology of cachexia in advanced cancer and AIDS. In: Bruera E and Higginson I, Cachexia – anorexia in cancer patients: NY: oxford university press, 1996. P1-22.

References

• Wigmore SJ et al. The effect of polyunsaturated fatty acids on the progress of cachexia on the progress of cachexia in patients with pancreatic cancer. Nutrition, 1996;12.

• Bristol cancer help, 2006 www.bristolcancerhelp.org.uk.

• Gerson institute, 2006 www.gerson.org.

• National cancer institute, 2006 http://www.cancer.gov/cancertopics/pdq/cam/laetrile.

• Weleda, 2006 www.iscador.com.

• Cancerhelp, 2008 http://www.cancerhelp.Org.uk/help/default.Asp?Page

=31060.