Transcript Nutritional Challenges in Lymphoma

Nutritional
Challenges in
Lymphoma
Gayle Black
Senior Specialist Dietitian
Royal Marsden Hospital
Aims of the Session
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To consider the varied impacts a diagnosis
of Lymphoma can have on nutrition
To consider how and why nutrition is an
important part of the patient journey
To compare and contrast the role nutrition
played for two specific individuals
Nutrition at Diagnosis
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The lymphomas are a highly complex group of
diseases and nutritional implications at diagnosis
are very much related to the individual diagnosis
The presence of B symptoms often leads to
significant weight loss prior to diagnosis
Weight loss is present in approximately 50 % of
all patients presenting with a gastric lymphoma
(Balfe et al, 2008).
Oropharyngeal lymphomas may be related to
swallowing difficulties at diagnosis
Nutritional Implications during Induction
and Intensification Treatment
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The exact side effects of treatments varies
between individuals and treatment regimens
The diverse nature of Lymphoma leads to a wide
variety of different nutrition related implications
Combination therapy can lead to more intensive
side effects
Anxiety and prolonged stays in hospital can both
adversely effect nutritional status
Not all patients undergoing treatment for
lymphoma will have altered nutritional intake
Nutrition Related Side Effects
Commonly Seen
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Mucositis
Xerostomia
Nausea
Vomiting
Fatigue
Anorexia
Abdominal Cramps
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Diarrhoea
Constipation
Hyperglycaemia
Increased Appetite
Fluid Retention
Taste Changes
Heart Burn
Why is Nutrition Important during
treatment for Lymphoma?
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The provision of food and fluids is a basic care (BMA, 1999)
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Malnutrition can have a significant impact on survival and
performance status
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Up to 20% of all patients treated for cancer are deemed to die
from the effects of malnutrition (Mercadante, 1998)
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Malnutrition may decrease tolerance to treatment and
increase incidence of dose limiting side effects
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Wound healing is reduced in malnutrition
Eating as a Social Experience
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Expression of love and caring
Expression of individuality
To reward or punish
A focus for communal activities
As a control issue
As a coping strategy
As a treatment
Weight loss is an outward symbol of poor health
Case Study 1 – The Physical
Challenges of Diet and Lymphoma
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58 yr old Male
Presented in May 2008 with a year long history of
fatigue, poor appetite and weight loss
On admission is very weak, dehydrated and
confused with a performance status of 3
Following investigations is diagnosed with Stage
IVB Diffuse Large B Cell Lymphoma
Nutritional Status on Admission
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Presented with a history of accelerated
unintentional
weight
loss
over
approximately a two month period
Weight on admission = 63 Kg with
moderate ascites (est. 6 kg)
BMI on admission = 17.5kg/m²
% wt loss on admission = 18 %
During Admission
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Initially nasogastric tube insertion attempted but
unsuccessful due to tube curling in the
oesophagus
Following referral to the Dietitian routine of small
regular snacks supplemented with Scandishake
bd and Calogen 30ml tds successfully
implemented
Performance status quickly improves and
discharge home is planned
But then….
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Patient starts to become increasingly
unwell
BNO and abdomen becomes very
distended with absent bowel sounds
Refusing all food and fluid due to abdo pain
Paralytic ileus diagnosed secondary to
Vincristine
Management Plan
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Conservative management
NBM with NGT for drainage
PICC line inserted for TPN
Over the next few weeks patient continues
to go in and out of obstruction with the
reintroduction of oral diet attempted on
several occasions
Weaning off PN and Moving Forward
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Diet eventually reintroduced although
patient has now been in hospital for 2
months
Reports sore mouth and taste changes
secondary to oral Candida
Complaining of taste fatigue with hospital
food and supplements
Early satiety secondary to ascites
Nutritional Status on Discharge
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Weight = 62 Kg (without ascites)
BMI = 19 Kg/m2
Oral intake providing approximately 800
kcal/day and 40g protein from meals and
snacks
Additional intake from oral nutritional
supplements to support weight gain
Where are we now?
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Following discharge from hospital he struggled to
cope at home and family relations suffered as a
result
Spent several months being cared for in a nursing
home
However he has now completed a course of single
agent Rituximab and is on long term follow up
His weight is stable at 67 Kg (BMI = 21 Kg/m2) and
the recurrent ascites has stopped
He’s back in his own home although so far has
been unable to return to work
Case Study 2 – The Psychological
Challenges of Diet and Lymphoma
21 yr old Male
 Lives at home with his parents and younger
sister
 Treated in childhood for both Lymphocyte
predominant Hodgkin's Disease and BNHL
 Autologous transplant in 1999
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Recent Medical History
Hodgkins Disease relapsed 2008 aged 20
 Presented with a history of unexplained
weight loss and lethargy
 Relapse confirmed following endoscopy
and chemotherapy commenced shortly
afterwards
 Reduced Intensity Allograft July 2009
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Nutritional Status on Discharge Post
Transplant
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Weight on day of discharge = 55 Kg
BMI on discharge = 17 Kg/m2
Managing small amounts of meals and
snacks, slowly increasing portion sizes
Supplementing diet with Fortijuce bd
Challenges at Home
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Weight falling at each review
Refusing all nutritional supplements
Food choices becoming more and more
limited
Mother confides that he is becoming
socially isolated and withdrawn
Spending large periods of time comparing
his appearance to others
Nutritional Status at Readmission
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Weight = 45 Kg
BMI = 14 Kg/m2
% Weight loss = 18 %
Medical investigations all unable to identify cause
for weight loss, referred to gastroenterologist
Agreed to referral for counselling, CLIC sergeant
social worker and young people’s activity
coordinator
PEG tube inserted
Five Weeks Later
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Discharged from hospital
Weight = 50.4 kg
BMI = 16 Kg/m2
Tolerating overnight feeds very well and
independent with all aspects of PEG care
Eating small meals and supplementing with
extra snacks
Where are we now?
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PEG removed 3 weeks ago
Eating a full and varied diet
Weight maintained at 61 Kg with a BMI of
19 Kg/m2
Recently spent a week in Cornwall with
friends from college
Looking for part time work
Summary
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Eating difficulties for our patients can be due to a
wide variety of factors and can change with time
The consequences of a reduced nutritional intake
can impact all aspects of our patients lives and
should not be underestimated
The link between nutritional status and
performance status is key
Each individual we meet will have very different
needs, importance of not making assumptions