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“Bare Necessities”… Nutrition Management of the

Oncology Resident in LTC Liz LeFevre, MHS, RD, LD

Thursday July 14th, 2016

Objectives

• Be able to identify common side effects of cancer treatment and way to manage them

• Be aware of recommendations specific for cancer survivors

• Know of resources available specific for oncology

Nutritional Needs of Cancer Patients in Long Term Care• Support healing in treatment

• Adequate calories, protein, fluid

• Manage eating difficulties

• Maintain weight

• Support healthy choices in recovery

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Cancer and Nutrition Treatment Overview

• Nutritional status of patients with cancer varies when treatment begins

• Those who enter treatment with nutritional problems may have complicated treatments and recovery

• Cancer treatment may have direct (mechanical) or indirect (metabolic) effects on nutritional status.

• Success of treatment influenced by ability to tolerate therapy

National Cancer Institute (NCI), 2013: http://www.cancer.gov

Cancer Treatment Basics

Cancer isn’t one disease

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Cancer Treatment: Surgery

• Surgery – primary modality, local treatment• Most patients will have some kind of surgery• May be preceded or followed by other

modalities (chemo, radiation)

• Malnutrition increases risk for post-operative complications

• Mechanical and physiologic barriers (i.e. short gut syndrome); increase metabolic needs for healing

Cancer Treatment: Radiation

• Radiation - local treatment• Normal tissue in the treatment area can be affected• Also given in combination with chemotherapy

esophagitis, dysphagia, or reflux

diarrhea, nausea, vomiting, enteritis,

malabsorption

40-60% experience swallowing difficulties

Bruner, Haas, & Gosselin-Acomb, 2005

Cancer Treatment: Chemotherapy• Chemotherapy – systemic treatment, administered

multiple routes • Pharmacologic action on cell reproduction/cell cycle

• Narrow therapeutic index

• Dose reduction or delay may have negative impact on survival

Polovich, Whitford, & Olsen, 2009

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Nutrition related side effects of chemotherapy• Diarrhea

• Fatigue

• Taste changes

• Weight loss

• Nausea/Vomiting

• Constipation

• Oral mucositis

• Anorexia

Leser et al., 2013

Cancer Treatment: Biotherapy• Biotherapy (targeted therapies) – target either the

tumor cell itself or intracellular processes• MoAbs (monoclonal antibodies): Predominantly IV

• Nibs (small molecule inhibitors): • Predominantly PO

• Increase risk of food-drug/drug-drug interactions

• Complex dosing schedules

Polovich et al., 2009

• Decreases rates of infection, speeds healing (shorten or prevents hospitalizations)

• Increases tolerance to oncology treatment

• Increases response to oncology treatment

• Decreases complications and protect QOL

Alexandre 2003, Capuano 2008, Eriksson 1998, Bauer 2005, Correia 2007

What Does Good Nutrition Do?

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Nutrition Outcomes Data: EAL

Nutrition Outcomes Data: EAL

Nutrition Outcomes Data: EAL

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Involuntary Weight Loss: Definitions and Implications

• Involuntary weight loss (IWL):– Unintentional, undesirable weight loss that is generally

multifactorial in etiology and catabolic in nature– Losses of weight and lean tissue are associated with adverse

outcomes– Sarcopenic obesity: worse outcomes in obese weight loss

• Anabolic Competence:– The state that optimally supports anabolism, i.e., protein

synthesis and lean body mass, as well as global aspects of organ function, immunocompetence, functionality and quality of survivorship

Anabolism

Catabolism

Involuntary Weight Loss (IWL) Frequency by Site

Weight loss in previous 6 months

DeWys WD, et al: Am J Med 1980;69:491-497.

Lean Tissues: Functional Issues

• Smooth Muscle– Delayed gastric

emptying– Delayed intestinal

transit– Loss of cardiovascular

responsiveness and stability

• Other Components– Visceral protein– Antibodies– Growth factors– Altered enzymes

• Skeletal Muscle– Fatigue– Activity– Bed rest– Risk DVT, PE– Decubitus risk– Ability to cough– Ability to clear

pulmonary secretions

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The Goals of Nutrition Intervention

• Protect QOL

Palliation of symptoms:• Pharmaceuticals (RN, MD, RPh)

• Behavior Modification in Treatment (RD, RN)

• Lifestyle Changes (RD, RN)

• Use of evidence based “Medical Nutrition Therapy” or MNT (RD)

• Protect treatment plan

Lean Body Mass and Cancer Treatment

• Sarcopenia in cancer patients:• poor functional status• shorter time to tumor progression

• shorter survival• higher incidence of dose-limiting toxicity

• may impact metabolism of cytotoxic agents

Prado, Maia, Ormsbee, Sawyer, & Baracos, 2013

Lean Body Mass and Cancer Treatment

• Sarcopenia observed in cancer patients with any BMI; variety of body compositions

• Sarcopenia has been identified in cohorts of cancer patients• Advanced breast cancer - 25% (Prado et al.)

• Metastatic renal cell - 54.5% overall and 40% among overweight/obese (Antoun et al.)

• Pancreatic cancer - 60% with 16.2% sarcopenic-obese (Tan et al.)

As cited in Prado et al., 2013

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Lean Body Mass and Cancer Treatment• Impact of sarcopenia on chemotherapy dosing and

toxicity• Indicator of overall health status

• Higher incidence of dose-limiting toxicity (causing dose reduction, treatment delay or termination)

• Dose based on weight

• 30 Stage II and III colon cancer patients receiving 5-FU/leucovorin who experienced dose limiting toxicities• Patients with low lean mass = 93%

• Higher lean mass = 52%

As cited in Prado et al., 2013; Prado et al., 2007

Identify Malnutrition

Overall incidence of malnutrition in the oncology population is between 30-85%

Patients with late-stage disease are more likely to present with and develop malnutrition than patients with early stage disease

Mild or moderate nutritional deficits may be reversible with nutrition intervention

Severe nutritional deficits are generally not reversible, goal is to stabilize and replete when possible

Lammersfield, 2003, Van Cutsem

.

Cachexia

• Profound destructive process characterized by skeletal muscle wasting and harmful abnormalities in fat, CHO, and protein metabolism in spite of adequate caloric and nutrient intake.

• Involuntary weight loss, tissue wasting (particularly lean body mass and adipose tissue), inability to perform daily activities, and metabolic alterations.

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• Occurs in approximately 2/3 of patients

• Is inversely correlated with length of survival and implies a poor prognosis.

• Degree of malnutrition is not explained by level of energy intake.

• Anorexia and weight loss are often the first symptoms of illness.

• Loss of muscle and fat occurs before decline in intake of food.

Cachexia

Dewys et.al, Am J Med. 1980

Estimating Needs for Healing

Calorie Needs Protein Needs

• 23-25 cal/kg

(breast, prostate)

• 27-29 cal/kg

• 30-35 + cal/kg

(head and neck)

1.0-1.3 g protein/kg

(breast, prostate)

1.2-1.5 g protein/kg

1.3-1.8 g protein/kg

(head and neck, GI cocombinant tx)

• *Adjusted weight for obesity

AND Clinical Diet Manual, COSA

Nutrition Impact Symptoms• Fatigue, significant

• Constipation

• Poor appetite

• Xerostomia

• Nausea and / or emesis

• Gas / bloating

• Reflux / indigestion

• Early Satiety

• 41%

• 33%

• 31%

• 27%

• 26%

• 23%

• 21% (28% Breast)

• 21%

Cancer Nutrition Research Consortium, 2012

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Nutrition Impact Symptoms• Diarrhea

• SOB

• Smells bothersome

• Mucositis

• Dysphagia, swallowing

• Pain, severe

• Decreased smell

• Dysphagia, chewing

• 20% (35% GI)

• 17% (28% Lung)

• 48%

• 12%

• 9%

• 7%

• 6%

• 3%

Cancer Nutrition Research Consortium, 2012

Oral Nutritional Supplement“Multi-nutrient, semi-solid

or powder products that provide macronutrients and micronutrients with the aim of increasing oral nutritional intake”

• Usual content: • 1.5 kcal/ml to 2.4

kcal/ml

• ~300 kcal per serving

• ~10-20 grams or protein per serving

Stratton & Elia, Proc Nutr Soc

2010;69:477-87

Oral Nutritional Supplement• Improved nutrition outcomes with use of oral

nutritional supplements

• Success may be related to:• Implementation of more structured eating

and drinking, which results in increased number of meals/snacks

• Liquid nutrition generally well tolerated during times of illness

Stratton, et. al, 2010

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Foods Preferred by Oncology Patients

• 69% Some fruits and vegetables

• 62% Soups

• 61% Poultry

• 55% Pasta

• 53% Fish

• 46% Meat

• 44% Dairy

• 41% Sweets

• 35% Oral Nutritional Supplements

• 35% High fiber foods

• 29% Crunchy foods

• 26% Salty foods

• 26% Asian dishes

• 22% Spicy foods/ Mexican

• 14% Bland food (except first week after chemo)

Cancer Nutrition Research Consortium,

2012

Nausea/Vomiting

• Prevention and Treatment of Chemotherapy Induced Nausea/Vomiting (CINV)• Prevention is primary goal

• Standardized protocol for pharmacologic management based on emetogenicpotential and assessment of patient characteristics and risk factors

• Nonpharmacologic Interventions• Acupressure, Acupuncture; Guided imagery, music therapy, progressive relaxation

• Pyschoeducational support/information

Polovich et al, 2009

Nausea/Vomiting Food Recommendations

• Assess timing of nausea and vomiting: Identify acute, delayed or anticipatory

• Review actual medication use vs. prescribed, andbowel regimen

• Assess for malignant or tx related gastroparesis

• Schedule frequent, small volume intake

• Avoid cooking odors

• Use cold plates to reduce smell and taste alteration, use straws

• Choose easy to digest foods, bland items

• Clear liquids, liquid nutrition, starchy foods

• Tart and sour food or beverages

NCI, ACS, 2013

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Oral Mucositis: Medical Interventions and Considerations

• Oral Mucositis Management and Treatment• Oral care protocols (routine oral care, diet considerations, tobacco and

alcohol cessation)

• Topical Treatments: Salt and Soda oral rinses; calcium/phosphate rinses; oral bandages; morphine rinse; Triple/Miracle/Magic Mouthwash; doxepin, tetracaine lollipops; phenol

• Stepwise approach to pain control: NSAIDS-Narcotics-transdermal fentanyl

Mucositis Food Recommendations

• Can effect entire lining the GI tract andcan occur at any point from the mouth to the anus. Often precedes onset of diarrhea.

• Use of pain medications: Assess when chewing and swallowing

• Use soups and gravies to moisten or dip dry textures

• Encourage to eat soft texture foods: Avoid scratchy and high fiber foods

• Avoid acidic foods, avoid spicy foods if uncomfortable

• Use beverages with nutritional content as drinking may be easier than eating

• Use a wide straw to direct liquids away from sores or ulcerations

NCI, ACS

Dysphagia ,Esophagitis Food Recommendations

• Patient describes “lump in the

throat after swallowing” and “food

gets stuck”, “food causes burning spasm”

• Soft foods, moisten food with gravy or sauce

• Use of a wide straw

• Instruct on adequate fluid intake

• Moderate temperatures may reduce pain

• Texturize foods to soft, puree or blended consistency

• May need nutritional beverages and soups to meet calorie/protein needs.

NCI, ACS, 2013

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Xerostomia (Dry Mouth) Food Recommendations

• Rinse before and after meals with plain water or a homemade salt solution.

• Grind, shred, or blend meats so they are soft, and then add back into main dishes.

• Moisten dry foods before eating. Alternate a bite of food with a sip of a liquid to help moisten before swallowing.

• If starchy foods, like breads and pasta, are difficult to chew and swallow, consider substituting other starchy but moist foods, like cereals, rice with gravy, mashed potatoes, or pork and beans.

• Beverages can be used in place or in addition to meals, and may be better tolerated, these can be convenience drinks or home made.

• Try tart foods or beverages, such as lemonade or cranberry juice alongside the meal. Try frozen fruit pops, fruit ices.

NCI, ACS, 2013

Anorexia, Early Satiety Food Recommendations

• Patients describe “waiting to feel hungry”, “nothing sounds good”

• Schedule or plan intake every 2-3 hours, minimum

• Educate on need to nourish vs. wait for appetite, focus on strength and energy

• Small portions are less overwhelming

• Soft and moist, easy to chew and swallow

• Rotate through foods to avoid taste fatigue

• Use beverages with nutritional content as drinking may be easier than eating

NCI, ACS, 2013

Diarrhea recommendations

• Identify foods that make symptoms worse

• Low fat, low fiber diet. Limit caffeine and alcohol

• Avoid foods that cause gas

• Bulking agents (applesauce, banana, oatmeal, potatoes, rice), pectin, soluble fiber as needed

• Avoid sorbitol or other sugar-alcohol containing products (ex. Sugarless gum/candy)

Leser et al., 2013

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Fatigue

• Soft , easy to chew foods

• Small, frequent meals

• Keep non-perishable snacks at bedside

Leser et al., 2013

Taste/smell changes

• Little or no flavor• Fruit marinades, use lemon, herbs, spices, pickles, or hot sauce

• “Off taste”• Fruit and salt well excepted

• Bitter or metallic• Use onion, garlic, chili powder

• Use plastic silverware

• Flavor water

• Fruit based marinades

• Choose eggs, tofu, dairy, beans

Leser et al., 2013

Cady, 2007; Kubrak et al,. 2010; Lammersfeld et al, 2003; Van Cutsem, 2005

Head and Neck Cancer and Nutrition • High risk for malnutrition

• 30% of patients with HNC who undergo radiotherapy will experience weight loss and associated morbidity during treatment

• High risk for functional sequelae before tx, during, and late effects

• Risk for Malnutrition is increased:• Poor baseline performance status • Patients with late-stage disease are more likely to present with

and develop malnutrition than patients with early stage disease• Aggressive radiation or combined modality treatment• Patients with nasopharyngeal, hypopharyngeal, or base of

tongue primary tumors• Feeding tube refusal or late placement

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Indications for Nutrition Support:ASPEN Guidelines for Oncology

• Tube Feedings

1. Head and neck CA dysfunction or obstruction

2. Dysphagia

3. Radiation treatment to head/neck/GI

4. Post-gastrectomy

5. GI motility disorders

6. GE junction, TAEG

• TPN

1. Bowel obstruction

2. Malabsorption (short-bowel syndrome)

3. Fistula

4. High-output ostomy

5. Some GI cancers

• Food Safety Guidelines for everyone!!!

• Low Bacteria Diet

• Autologous transplant

• Allogenic tranplant

AND, Micromedix, Seattle Cancer Care

Diet and Neutropenia: Who, What, and When?

Case Study #1-JS

• 72 year old female

• Anthropometrics• UBW-72.7 kg-BMI 27.4• Down 5 kg since dx (10% x 3

months)

• Colon Cancer-stage II• 18” resection of the colon• Chemo-Folfox

• Cold sensitivity• Diarrhea• Mouth Sores• Fatigue

• Food recall: 1 scrambled egg, pudding cup, 1 c chicken noodle soup, 4 saltine crackers, Ensure, ½ cup mashed potatoes, a few bites meat loaf

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Case study 2-MH

• 78 y.o. woman

• Locally advanced adenocarcinoma of pancreas, possible early mets to lung

• Anthropometrics• 61.8 kg • Weight loss of 3.5 kg/1 month (5%)• BMI 27.6

Nutrition Impact Symptoms: Early satiety, gassiness, burping,

fatigue, nausea Stooling: mild constipation with

enzyme, “more normal” appearance with enzyme use, light (tan) colored stool without enzyme use, increased abdominal pain if not using enzymes

• Oral intake: Vegetarian , limiting carbohydrates to avoid taking DB medication ~1000 cal, 40 g protein

Estimated needs: 1450 cal/d (27 cal/kg) 65-75 g pro/d (1.0-1.2 g/kg)

Prevention/Survivorship

Late Effects and Comobidity

• Cardiovascular disease• Cancer and Menopause Study (CAMS)

• Diabetes

• Endocrine disorders

• Osteopenia / osteoporosis

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2012 ACS Guidelines on Nutrition and Physical Activity for Cancer Prevention

• www.cancer.org

• Achieve and maintain a healthy weight throughout life

• Adopt a physically active lifestyle

• Consume a healthy diet, with an emphasis on plant foods

• Limit consumption if you drink alcoholic beverages

AICR guidelines

1.Achieve healthy weight: be as lean as possible through out life. Use of BMI is recommended with routine plotting at health care visits.

2.Engage in physical activity: Adults 150 minutes of moderate intensity or 75 minutes vigorous intensity activity each week.

3.Limit consumption of high calorie food and beverages4.Consume a healthy diet: Read food labels, to become aware of portion sizes and calories

consumed, choose vegetables, whole fruits (not juice), instead of calorie dense foods/snacks/desserts

5.Limit consumption of sugar sweetened beverages (soft drinks, sports drinks, fruit flavored drinks)

6.Limit consumption of processed meats and red meats (bacon, sausage, lunch meats, hot dogs)

7.Prepare animal foods by baking, broiling, or poaching rather than frying or charbroiling8.Include vegetables and fruits at every meal and for snacks, eat a variety9.Choose whole grain foods, limit consumption of refined carbohydrate foods, and high

sugar foods.10.Breast feed if able

AICR “New American Plate”

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• What does the American Cancer Society say?

• What impression does a PET scan leave?

Does Sugar Feed Cancer?

Meyerhardt et al. 2012; George et al. 2009; Shikany et al. 2011; Tsilidis et al. 2013

Case Study # 3-JB

• 70 y.o. male

• Hx: Colon cancer, s/p chemo/radiation 3 years

• Anthropometrics: • 90.9 kg, BMI 27.1

• Weight stable for 2 years

• Activity Level: sedentary

• Diet Recall:• Breakfast: omelet w/ cheese,

bacon

• Lunch: grilled cheese, tomato soup, cookie

• Snack: peanut butter cup

• Dinner: Meatloaf, mashed potatoes, green beans

• Desert: ice cream

Resources

www.oncologynutrition.org (ON DPG)

www.eatright.org (The Academy)

www.adaevidencelibrary.com (The Academy)

www.cdrnet.org (CDR)

www.cancer.org (ACS)

www.cancer.gov (NCI)

www.cancercare.org (CancerCare)

www.nutritioncare.org (ASPEN)

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References

Special thanks to Rhone Levin, for the use of many of her slides

• Alexandre J, Gross‐Goupil M, Falissard B, et al.Evaluation of the nutritional and inflammatory status in cancer patients for the risk assessment of severe haematologicaltoxicity following chemotherapy. Ann Oncol. 2003; 14: 36‐41.

• Bauer JD, Capra S. Nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy‐a pilot study. Support Care Cancer. 2005; 13: 270‐274.

• Brugler L, et al. J Qual Improv 1999;25-191-206.

• Bruner, D.W., Hass, M.L., & Gosselin-Acomb, T.K. (Eds.). (2005). Manual for radiation oncology nursing practice and education. Pittsburg, PA: Oncology Nursing Society.

• Cancer Nutrition Research Consortium: 2012 WHP Research, Inc.

• Capuano G, et al. Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy. Head Neck. 2008 Apr; 30(4): 503‐508.

• Correia M, et al.Serum concentrations of TNF‐alpha as a surrogate marker for malnutrition and worse quality of life in patients with gastriccancer. Clin Nutr. 2007 Dec; 26(6): 728‐735.

• Dewys WD, Begg C, Lavin PT, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980; 69(4): 491‐497.

• Eriksson KM, Cederholm T, Palmblad JE. Nutrition and acute leukemia in adults: Relation between nutritional status and infectious complications during remission induction. Cancer. 1998; 82: 1,071‐1,077.

• Kubrack C, Olson K, et al. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head and Neck. 2010 Mar;32(3):290-300.

References• Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, et.al. Definition and classification of cancer

cachexia an international consensus. Lancet Oncol. 2011 May;12(5):489-95.

• Fearon KC, Voss AC, Hustead DS. Definition of cancer cachexia: Effect of weight loss, reduced food intake and systemic inflammation on functional status and prognosis. American Society of Nutrition. 2006; 83: 1,1345-1350.

• Gariballa S. et al. Am J Med 2006;119(8):693-699.

• Griggs, J., Mangu, P.B., Anderson, H., et al. (2012). Appropriate chemotherapy dosing for obese adult patients with cancer: ASCO practice guideline. Journal of Clinical Oncology, 30 (13), 1553-1561.

• Kumar, N. Nutritional Management of Cancer Side Effects. Springer 2012.

• Lammersfeld CA, Vashi PG, Gupta D, Grutsch JF, Burrows JL, Becker JD, Lis CG. 2003 ASCO Annual Meeting: The impact of changes in nutritional status on survival in advanced colorectal cancer. Proc Am Soc Clin Oncolol 22:2003 (abstr 1251).

• MASCC/ISOO Evidence-Based Clinical Practice guidelines for mucositis secondary to cancer therapy, (2013).

• Milne A, et al.Cochrane Database Syst Rev. 2009 Apr 15(2)

• Murphy, B.(2007). Critical component of supportive care. Journal of Support Oncology, 5 (5), 228-229.

• National Cancer Institute (NCI), 2013, retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page1/AllPages#Section_17

References

• National Cancer Institute (NCI), 2013: http://www.cancer.gov

• Polovich, M., Whitford, J.M., & Olsen, M. (Eds.). (2009). Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburg, PA: Oncology Nursing Society.

• Prado, C.M., Maia, Y.L., Ornsbee, M., Sawyer, M.B., & Baracos, V.E. (2013). Assessment of nutritional status in cancer – The relationship between body composition and pharmacokinetics. Anti-Cancer Agents in Medicinal Chemistry, 13, 1197-1203.

• Smith P, et al. Healthcare Finan Management 1997;51:66-69.

• Stratton RJ,Aging Res Rev, 2005;4:422-450.

• Stratton $ Elia, Proc Nutr Soc 2010;69:477-87.

• The Academy of Nutrition and Dietetics Evidence Analysis Library: http://andevidencelibrary.com/topic.cfm?cat=2819, retrieved 1/24/14.

• Van Cutsem, E. The causes and consequences of cancer-associated malnutrition.Eur J Oncol Nurs. 2005;9 Suppl 2:S51-63

• White J, Guenter P, Jensen G, Malone,A, Schofield M. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN J Parenter Enteral Nutr. 2012 36: 275.

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