neoplastic disease packet€¦ · web viewgeneral cancer information, treatment, prevention...

document.doc Due: August 31, 2012

ONCOLOGY CLINICAL PACKET Name: Birgit Humpert

The following are some Online Resources for your general information. These are not specific to this packet. You may find these resources helpful during your clinical as well as your community rotations:

General oncology information:

www.cancer.gov/

General cancer information, treatment, prevention genetics, causes, screening

pages on Omega-e, garlic, red wine, tea, anti-oxidant trials

www.caring4cancer.com

General cancer information with a great resource on nutrition

Cancer prevention:

www.aicr.org/site/PageServer?pagename=dc_home_guides

10 recommendations from American Institute for Cancer Research 2007

Complementary and alternative therapies:

http://nccam.nih.gov/ (National Center for Complementary and Alternative Medicine)

www.mdanderson.org/topics/complementary/

www.mskcc.org/mskcc/html/11570.cfm

Also recommend: ADA Evidence Analysis Library for research related to the following:

Breast Cancer

Colorectal Cancer

Esophageal Cancer

Head and Neck Cancer

Hematological Cancer

Lung Cancer

Pancreatic Cancer

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http://www.mskcc.org/mskcc/html/11570.cfm

http://www.mdanderson.org/topics/complementary/

http://nccam.nih.gov/

http://www.aicr.org/site/PageServer?pagename=dc_home_guides

http://www.caring4cancer.com/

http://www.cancer.gov/


PLEASE ANSWER ALL QUESTIONS IN YOUR OWN WORDS. LIST THE APPLICABLE REFERENCES AT THE END OF EACH SECTION.

A.) DEFINITIONS

Provide the meaning of the word.

1. Carcinogen – Agent that causes cancer.

2. Angiogenesis – Growth of new blood vessels in the body.

3. Cytokines – Class of proteins that hasve a regulatory function in the immune system, for example interleukin, interferon, tumor necrosis factor.

4. Metastasis – Cancer spreads from the primary site to other areas of the body

5. Carcinoma – Cancer that starts in epithelial tissue.

6. Adenocarcinoma – Cancer that starts in glandular tissue, a subcategory of epithelial tissue.

7. Stomatitis – Inflammation of the mouth.

8. Palliative – Type of care that is focused on reducing symptoms, not curing the disease.

9. Lymphoma – Cancer of lymph tissue.

10. Blastoma – Cancer that starts in embryonic cells.

11. Glioblastoma – Cancer that starts in glia cells in the brain.

12. Neuroblastoma – Cancer that starts in nerve tissue.

13. Sarcoma – Cancer that starts in mesodermal tissue like bone, cartilage, striated muscle, connective tissue.

14. Osteosarcoma – Cancer that starts in bone tissue.

15. Myosarcoma – Cancer that starts in muscular tissue.

16. Alopecia – Loss of hair.

17. Paracentesis – Medical procedure in which fluid is removed from a body cavity.

18. Squamous cell carcinoma – Cancer that starts in squamous cells, cells that look like fish scales in the skin and the lining of organs and body cavitis.

19. Nutrigenomics – Study of the interaction between food and other bioactive substances and gene expression.

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B.) NEOPLASTIC DISEASES AND CONDITIONS

1. Define and describe each stage of carcinogenesis:

a. Initiation:

First step in the development of cancer. An initiating agent/carcinogen like tobacco, radiation, sunlight, or chemical substances causes mutations in the genetic material of a cell. These mutations can also happen spontaneously or after chronic irritation.

b. Promotion:

Once a cell has undergone changes in the DNA, exposure to promoters can further facilitate abnormal cell growth. Promoters can be factors in the environment or hormones. Before promotion can occur initiation and failure of normal cell repair must have happened, without initiation those substances don't cause cancer.

c. Progression:

The abnormal cells form a tumor. Further changes happen until eventually the tumor becomes malignant and releases cells into neighboring tissue, the lymphatic system, or the bloodstream.

References for this section:

Development and Spread of Cancer. (2008) The Merck Manual Home Health Handbood for Patients and Caregivers. Available from http://www.merckmanuals.com/home/cancer/overview_of_cancer/development_and_spread_of_cancer.html

2. For each of the following nutrition-related factors, discuss the proposed theories of how these promote or inhibit carcinogenesis:

a. Alcohol: Alcohol can raise the risk for cancer in different ways and may act differently

in different organs. It can lead to irritation of the tissue in the upper gastrointestinal tract.

Constant irritation and the subsequent repair processes can initiate cancerous changes.

Alcohol is metabolized to acetaldehyde, acetaldehyde is toxic and has caused cancer in

lab animals. Congeners, traces of other chemical substances in alcoholic beverages, may

also play a role in the development of cancer. Alcohol is especially harmful if consumed

together with tobacco because it is a solvent of harmful chemicals in tobacco smoke. This

increases the risk for cancer of the mouth and throat. Alcohol consumption can lead to

low intake of folate and decrease absorption of folate. A low folate level has been

associated with cancer. Alcohol can also raise estrogen levels, high estrogen levels raise

the risk for breast cancer. And alcohol intake can also lead to obesity which is also a risk

factor for cancer.

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b. Artificial Sweeteners: Different artificial sweeteners have been linked to cancer,

especially after studies in the 70s and 80s. Saccharin was associated with bladder cancer

in lab animals, but the underlying mechanisms do not apply to humans. Aspartame was

associated with lymphoma and leukemia in lab animals, but these data were inconsistent

could not be supported by epidemiological studies. Cyclamate was linked to a risk for

bladder cancer, it was banned in the US in 1969. It is no longer concidered a carcinogen.

The artificial sweeteners that are currently allowed by the FDA are not considered to be

carcinogens.

c. Nitrates, Nitrites, Nitrosamines: Nitrate is mostly found in leafy green vegetables and it

can be converted to nitrite by bacteria in the mouth and GI tract. Sodium nitrite is also

used in processed meat products to prevent botulism. Nitrosamines can form in the

stomach when nitrite reacts with amino acids to form nitrosamines. Nitrosamines are

potential carcinogens. The formation of nitrosamines can also occur in food itself that

contain nitrites, especially under the influence of high heat. Vitamin C and erythorbate

suppresses the formation of nitrosamines and are often added to cured meat. The link

between nitrates, nitrites and nitrosamines and cancer is still debated. In recent years

nitrates and nitrites from natural sources are studied for their blood pressure-lowering

effect.

d. High-heat cooking methods: Cooking of meat over high heat (grilling over an open

flame, smoking of meat, but also panfrying with high temperatures) can lead to the

development of heterocyclic amines and polycyclic aromatic hydrocarbons. These

substances are metabolized in the body and the resulting substances can cause mutations

and therefor increase the risk for cancer. This has been shown in animal studies, but it is

also linked to colorectal, pancreatic, and prostate cancer in epidemiological studies.

e. Calorie restriction: Calorie restriction can have a protective effect against cancer because

it reduces levels of growth factors, inflammatory cytokines and prostaglandines, and

oxidative stress. It also reduces the level of insulin, anabolic hormones and increases

immunological processes and DNA repair.

f. Obesity: Although the link between obesity and certain types of cancer (esophageal,

colorectal, breast, endometrium, kidneys ) is clear, the mechanisms are still investigated.

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Several factors may play a role in the development of cancer in obese people. A constant

state of hyperinsulinemia and insulin resistance in obese patients leads to increased levels

of insulin-growth factor-1 (IGF-1). An increase in IGF-1 leads to an increase in

bioavailable androgens and estrogens. These hormones can promote the development of

cancer. In addition to the mechanism that involves IGF-1 fat tissue itself produces

estrogen. Fat tissue also produces adipokines (for example leptin), a type of hormone that

influences cell growth. Adipose tissue also influences some tumor growth regulators, and

obesity often leads to oxidativ stress and a state of inflammation.

g. Folate/folic acid- Low levels of folate have been linked to increased cancer risk,

especially for colorectal cancer. Folate is important for DNA synthesis and repair. Folate

is though to play a role in gene expression. But folate could also be harmful if there are

already precancerous or cancerous changes in the body because it is used by healthy

tissue as well as by cancerous tissue.

h. Dietary fat: A high intake of dietary fat can contribute to obesity. But dietary fat could

also influence cancer risk independently from the calorie intake. This has been especially

studied for breast cancer because in countries with lower fat intake the rate of breast

cancer was found to be lower. A high fat diet could increase the level of hormones like

estrogen or change gene expression. A high intake of polyunsaturated fat could also lead

to more oxidativ damage.

i. Low protein diets: Low protein diets can potentially lower cancer risk the same way a

low calorie diet can. They lead to a reduction in plasma growth factors and hormones.

j. Fiber: Fiber is though to have a protective effect on colorectal cancer, some studies show

this correlation, others do not. Fiber might be able to dilute and absorb possible

carcinogens and cancer promoting substances in the colon. For example bile acid is a

tumor promoting agent that can be bound by fiber. But it also binds important nutrients

and leads to fermentation. Fermentation can lower the pH which is associated with an

increase in cancerous processes. Since fiber comes from different sources (grains,

vegetables, fruits) and has different properties it is difficult to find a consistent

connection.


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Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &

Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

Insel, P. (2011) Nutrition (4th ed.) Sudbury MA: Jones and Bartlett

Alcohol Use and Cancer (2012). American Cancer Society. Learn about Cancer. Available from http://www.cancer.org/Cancer/CancerCauses/DietandPhysicalActivity/alcohol-use-and-cancer

Obesity and Cancer Risk (2012) National Cancer Institute Fact Sheet. Available from http://www.cancer.gov/cancertopics/factsheet/Risk/obesity

Calle, E.E., Thun, M.J. (2004) Obesity and Cancer. Oncogene (2004) 23, 6365–6378. Available from http://www.prefer.pitt.edu/calle.pdf

Artificial Sweeteners and Cancer (2009). National Cancer Institute Fact Sheet. Available from http://www.cancer.gov/cancertopics/factsheet/Risk/artificial-sweeteners

Scanlan, R.A. (2000) Nitrosamines and Cancer. Linus Pauling Institute. Available from http://lpi.oregonstate.edu/f-w00/nitrosamine.html

Saucier Choate, M. (2011). Good or Bad? Nitrates and Nitrites in Food. The CO-OP Food Stores. Available from http://www.coopfoodstore.coop/content/good-or-bad-nitrates-and-nitrites-food

Chemicals in Meat Cooked at High Temperatures and Cancer Risk (2010). National Cancer Institute Fact Sheet. Available from http://www.cancer.gov/cancertopics/factsheet/Risk/cooked-meats

Longo, V.D., Fontana, L. (2010). Calorie Restriction and Cancer Prevention: Metabolic and Molecular Mechanisms. Trends Pharmacol Sci. 2010 February; 31(2): 89–98. doi: 10.1016/j.tips.2009.11.004. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829867/

Folic Acid (2011) American Cancer Society. Herbs, Vitamins, and Minerals. Available fromhttp://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/folic-acid

Dietary Fat and the Risk of Breast Cancer (2001). Breast Cancer and Environmental Risk Factors. Cornell University. Available from http://envirocancer.cornell.edu/factsheet/diet/fs27.fat.cfm

Fontana, L., Klein, S., Holloszy, J. (2006) Long-term Low-protein, Low-calorie Diet and Endurance Exercise Modulate Metabolic Factors Associated with Cancer Risk. Am J Clin Nutr December 2006 vol. 84 no. 6 1456-1462. Available from http://www.ajcn.org/content/84/6/1456.abstract

Jacobs, L.R. Dietary Fiber and Cancer (1987) Journal of Nutrition. Available from http://jn.nutrition.org/content/117/7/1319.full.pdf

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For each of the following treatments/interventions:

a. Describe the mechanism of action or treatment goal

b. Discuss the effect of treatment on disease

c. Discuss the effect of treatment on healthy tissue

3.

Radiation

a.

Radiation therapy uses electromagnetic rays or charged particles from radioactive sources to destroy the DNA in cancer cells. The goal is to reach as many of the cancer cells without to much negative effect on surrounding tissue. It can be used alone or in combination with chemotherapy and/or surgery. Radiation can be delivered from the outside of the body through a beam or by placing radioactive material in a body cavity or inside the tumor itself (brachytherapy). Traditional radiation therapy is usually administered daily for a couple of weeks on an outpatient basis. It is used for cancer of the head and neck, cervical cancer, testicular cancer and Hodgkin's lymphoma.

b.

Radiation therapy destroys the DNA in cells and cells that proliferate fast, like cancer cells are most vulnerable to this treatment. Radiation therapy can used to cure cancer, either alone or in combination with other therapies. It can be used prophylactic to avoid spreading of a tumor or reduce the risk of reoccurance. It can be used before surgery to shrink a tumor. Radiation can also be part of palliative care, it can shrink tumors to manage pain or other symptoms.

c.

Although patients may feel fatigued from the treatment toxicity of radiation therapy is mostly limited to the treated area. If head or neck are radiated it comes to toxic side effects like mucositis, dysgeusia, xerostoma due to destruction of salivary glands, dysphagia, and esophagitis. These side effects can have an impact on hydration and nutrition status of the patient. Radiation to the abdomen or pelvis can result in nausea, vomiting, diarrhea, frequent urination, or dysuria. A severe side effect is radiation enteritis; it can occur years after radiation treatment. It leads to injury to the intestinal tract with fistulas and strictures and can result in severe malabsorption and malnutrition. If the eye was part of the treatment field late complications like cataracts and retinal damage may occure. It can also lead to poor healing of tissue for example poor healing after dental procedures. Other late complications are hypothyroidism, pneumonitis, pericarditis, hepatitis, sterility, and others.

4 Chemotherapy

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.a.

In chemotherapy medications are given either orally or per IV infusion that disrupt normal cell replication. Since cancer cells replicate very fast they are vulnerable to these drugs. Different classes of chemotherapy drugs exist and they all have slightly different mechanisms of action and side effects. Often drugs with different mechanisms are combined into a multi-drug regiment. This increases the effect on tumor cells while at the same time decreases side effects and the probability of drug resistance. Chemotherapy can be combined with either radiation therapy, surgery, or both. It can be given before surgery to shrink a tumor or after surgery to destroy remaining cancer cells. Chemotherapy is often given in cycles.

b.

By interrupting the replication of tumor cells chemotherapy is given to either destroy enough tumor cells to cure cancer or to support other treatments like surgery and radiation.

c.

Since antineoplastic agents target all cells that divide frequently, chemotherapy effects cancer cells but also other fast dividing cells in the body like epithelial cells in the GI tract, hair follicle cells, and cells of the bone marrow (white and red blood cells and platelets). Side effects include therefor hair loss, suppression of bone marrow with neutropenia, thrombocytopenia, and anemia, nausea, vomiting, diarrhea, and mucositis.

5.

Immunotherapy

a.

Immunotherapy uses the patients own immune system to fight cancer. There are many different types of immunotherapy today.

- Interferons and interleukins are cytokines that are produced by the body. If they are given as a cancer treatment they can modify the biological response against foreign antigens. They are not only used to fight cancer but also to provide palliative care.

- Monoclonal antibodies are a man-made version of antibodies that can attack specific parts of cancer cells. They are sometimes used in combination with chemotherapy to increase the destruction of cancer cells.

- Cancer vaccines are substances that can initiate an immune response to fight cancer.

- Colony-stimulating factors (CSFs) can increase cell production in the bone marrow and therefor reduce the effect of chemotherapy on the bone marrow.

b.

Immunotherapy can be used to control or stop the growth of tumors, it can make cancer cells more recognizable for the immune system, it can enhance the effect of other

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treatment and the immune system itself.

c.

Immunotherapy can lead to fatigue, flu-like symptoms with fever, nausea, vomiting, anorexia, and rash.

6.

Surgery

a.

Surgery is the mechanical removal of a tumor. It can be primary, that means that surgery is the only treatment a patient receives. It can be adjuvant, that means that surgery is used in combination chemotherapy and/or radiation. Sometimes those treatments are used first to shrink the tumor enough so that surgery is possible. It can be a salvage therapy, that means that an extensive surgery is done to treat a local reoccurance. Or surgery can be palliative to treat symptoms from the cancer or from the treatment.

b.

Surgery can cure cancer if the tumor is small enough to be cut out and has not produced metastases yet. It is important to make sure the tumor is removed completely and that the surgery does not damage too much neighboring tissue. It is sometimes necessary to also remove lymph nodes and other surrounding tissue. Sometimes surgery can not remove the tumor completely but only part of it. The remaining cancer cells are then more sensitive to other treatments.

c.

The effect on the remaining healthy tissue depends on the location of the primary tumor. If a tumor in the head or neck was treated with surgery this can lead to alteration in the nose, mouth, and neck. Those could be xerostomia, dysgeusia, dysphagia, different sense of smell or taste or loss of smell and taste. These side effects can lead or contribute to malnutrition. Surgical removal of gastric cancer can lead to early satiety, nausea, vomiting, dumping syndrome, vitamin B12 deficiency, iron deficiency, and calcium deficiency. Surgical removal of cancer in the intestinal tract can make colostomy and ileostomy necessary. This can lead to steatorrhea, malabsorption, and dehydration.

7.

Marrow transplant

a.

Bone marrow transplant is one type of stem cell transplant. Stem cells are immature cells in the body. Immature hematopoietic stem cells are found in the bone marrow. They develop into mature blood cells and leave the bone marrow. Stem cell transplants are used on hematologic cancers like leukemia, lymphoma, and myeloma, but also in some non-hematologic cancer. The bone marrow is either destroyed by the cancer itself or by chemotherapy or radiation. Stem cells can come either from the bone marrow, peripheral

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blood, or from cord blood. It can come either from the patient itself, a twin, or from a healthy compatible donor. Stem cells are harvested from the iliac crest or from peripheral blood of the patient or donor. The patient is then treated with chemotherapy/radiation to suppress the immune system so that the new stem cells can engraft and to destroy cancer cells. After this preparation the stem cells are infused.

b.

The treatment can provide the patient with stem cells that function normally and provide the body with healthy blood cells. The cancer cells are destroyed by the chemotherapy or radiation.

c.

The high-dose chemotherapy that is given in preparation of the transplantation can lead to side effects like nausea, vomiting, diarrhea, fever, infection, and neutropenia.

The success of bone marrow transplants is determined by how well the patients body tolerates the new stem cells. This is usually not a problem if it is a autologous transplantation. But with foreign stem cells it comes often to rejections and acute graft-versus-host disease. It leads to fever, rash, hepatitis, nausea, vomiting, and pain. The graft-versus-host reaction can become chronic and is deadly in 20 -40 % of transplant patients. Chronic graft-versus-host disease results in skin rashes, damages to the GI tract (dry mouth, ulcers in the mouth, malabsorption, delayed gastric emptying, severe diarrhea) and the liver. Anorexia, malnutrition and weight loss may occur. This is enhanced by the use of immunosuppressing medications, like corticosteroids. The patients have increased energy and protein needs. And they also have to deal with many nutrition-related consequences of their medications..

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &Pathophysiology (2nd ed.). Belmont, CA: Wadsworth Modalities of Cancer Therapy (2009) The Merck Manual for Health Care Professionals. Available from http://www.merckmanuals.com/professional/hematology_and_oncology/principles_of_cancer_therapy/modalities_of_cancer_therapy.html#v978812 Immunotherapy (2012). American Cancer Society Treatment types. Available from http://www.cancer.org/Treatment/TreatmentsandSideEffects/TreatmentTypes/Immunotherapy/index Hematopoietic Stem Cell Transplantation (2008). The Merck Manual for Health Care Professionals. Available from http://www.merckmanuals.com/professional/immunology_allergic_disorders/transplantation/hematopoietic_stem_cell_transplantation.html

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For each of the following symptoms of treatments and/or cancer:

a.

Describe the condition.

b.

List the typical causes of the condition relative to cancer and/or treatment induced

c.

Discuss the common nutritional concerns associated with the symptom (if any).

d.

List common medical interventions and describe how each intervention works.

e.

List common dietary interventions and describe how the diet works.

8.

Nausea

a.

n/a

b.

- Chemotherapy can lead to nausea, which can be acute (within 14 hours of chemotherapy), delayed, or anticipatory. Different chemotherapy drugs have different potential to lead to nausea.

- Radiation therapy can lead to nausea, especially radiation of the abdomen and total body radiation in preparation for stem cell transplantation.

- Other medications like narcotic analgesics or antibiotics can lead to nausea.

- Delayed gastric emptying (as a result of gastrectomy) can also lead to nausea. The patient may also be sensitive to certain smells and tastes that can trigger nausea.

c.

Nausea can influence the patients ability to prepare and consume food. It can lead to food aversions if nausea is associated with food that was eaten or nutritional beverages that are consumed. That can lead to limitations that can make it hard to consume enough energy and eat a balanced diet.

d.

Antiemetic drugs can be administered. There are different classes of antiemetic drugs, the most important one for chemotherapy induced nausea and vomiting are 5-HT3 receptor antogonists that block binding of serotonin to the receptor on the vagus nerve. They are often administered together with chemotherapy drugs. Other antiemetic drugs are dopamine receptor antagonists, corticosteroids, cannabinoids, and benzodiazepines. Corticosteroids are only used for short times because of their side effects like immunosuppression. Medical marijuana also works against nausea but is illegal in the US

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although some states allow its use.

e.

Several measurements can be taken to avoid nausea or make it less severe:

The patient should eat small frequent meals of foods that are well tolerated.

If smells are problematic the patient should avoid them as much as possible (have other people cook for them, tell friends and family to avoid perfumes and other problematic odors.)

The patient should avoid heavy meals before chemotherapy is administered.

If nausea is expected the patient should not consume favorite foods after chemotherapy to avoid food aversions.

Clear liquids, electrolyte-fortified beverages, and other nutritional beverages can help if the patient is unable to eat. They provide hydration, electrolytes, and some energy.

Ginger and peppermint oil can help with symptoms of nausea.

9.

Vomiting

a.

n/a

b.

see Nausea

c.

Vomiting can lead to dehydration, electrolyte imbalances, malnutrition, and weight loss. It can lead to food aversions if nausea is associated with food that was eaten or nutritional beverages that are consumed. Food aversions can make it harder to take in enough energy and nutrients and can contribute to malnutrition.

d.

see Nausea

e.

see Nausea

10.

Diarrhea

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a.

n/a

b.

- Diarrhea can be caused by colon cancer, lymphomas, pancreatic cancer, and hormone-producing tumors.

- Diarrhea can be the result of chemotherapy, radiation therapy to the abdominal area or total body radiation.

- Diarrhea can be the result of bowl resection.

- Diarrhea can be the result of stress and anxiety.

- Cancer patients are often more susceptible to infections, that can cause diarrhea. Antibiotics that are used may also be the cause.

c.

The primary concern in diarrhea is dehydration and electrolyte imbalances. If diarrhea is persistent weight loss is possible and malnutrition is also a concern.

d.

Rehydration and correction of any electrolyte balances through IV fluids is done in severe cases. Antidiarrheal medications are either absorbents, anticholinergics bismuth compounds, or aminosalycylates. Medications that modify the intestinal flora may also be prescribed.

e.

Dehydration needs to be addressed first, oral rehydration solutions can be used to ensure adequate fluid and electrolyte intake. BRAT diet (bananas, rice, applesauce, toast) is usually well tolerated. Transition from there to a normal diet as tolerated. Intolerances, for example lactose intolerance, can lead to diarrhea, and in those cases lactose needs to be avoided. Beverages with high sugar content should be avoided, as well as sugar alcohols, caffeine, alcohol, and gass-producing foods. To thicken the stool resistant starches and soluble fiber can be used. Probiotics and prebiotics are useful to restore the normal gut flora, help the immune system in the intestines, and can reduce harmful bacteria.

11.

Constipation

a.

n/a

b.

Constipation can be a symptom of cancer itself, for example colon cancer or brain tumors.

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Constipation can also be a side effect of medication used in cancer treatment, for example chemotherapy drugs, pain medication, antacids, diuretics.

- Constipation can be diet related. Patients might not take in as much fiber or drink not enough fluid because they are anorexic, have food aversions, or feel nauseous.

- Patients might not get enough exercise and this can also lead to constipation.

- The treatment might interrupt their normal bowel routine (lack of privacy, being bed-bound, needing assistance to go to the bathroom, being away from home).

c.

Constipation does not have a significant impact on nutritional status. It might increase anorexia and can contribute to insufficient intake of calories.

d.

Medical intervention can include enemas/suppositories or medications. Medications can be bulking agents, stool softeners, osmotic medications, or stimulants.

e.

Patients should consume adequate amounts of fiber (Adequate Intake is 24 g per day for women and 38 g per day for men) together with adequate fluid and exercise (if possible). If fiber intake is low it should be increased gradually to avoid discomfort. Fiber should be consumed in form of fruits, vegetables, whole grains, nuts, and seeds. If that is not possible fiber supplements can be used. Patients should be encouraged to have good bowel habits and not ignore the need to go to the bathroom.

12.

Dumping syndrome

a.

A large amount of food from with high osmolality leaves the stomach and enters the small intestines.

b.

Dumping syndrome can occur after surgery for gastric cancer.

c.

Due to the rapid transport through the intestines it can come to maldigestion and malabsorption followed by weight loss. Steatorrhea can be present and fat-soluble vitamins are not adequately absorbed.

d.

Medical interventions might involve medications that can slow down how fast food moves through the stomach, for example acarbose and octreotide. Surgery to reconstruct parts of the stomach might be performed.

e.

After gastric surgery the patient should transition to solid food slowly. Initially all simple sugars should be avoided. If clear liquids are given those need to be free of simple sugars,

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including lactose. Later meals should be small and frequent. Liquids should be consumed in between meals. To delay gastric emptying fiber (psyllium, guar gum, pectin) can be added to the diet. The patient should be encouraged to chew well and lay down after eating. A multivitamin should be given, and special consideration need to be given to vitamin B12 (depending on the gastric surgery vitamin B12 shots may be necessary). Enteral nutrition is a possibility if everything else fails.

13.

Lactose intolerance

a.

Lactose intolerance is the inability to digest the disaccharide lactose, due to insufficient levels of the enzyme lactase in the small intestines. Patients experience abdominal pain, diarrhea, gas, and bloating.

b.

Lactose intolerance can be a side effect of chemotherapy, but it does not occur in all patients.

c.

Symptoms of lactose intolerance like diarrhea can contribute to malnutrition and weight loss in cancer patients.

d.

There is usually no medical intervention.

e.

Patients should avoid milk and dairy. Small amounts of lactose might be tolerated on an individual basis. Cheese and yogurt are often better tolerated because of lower lactose levels. Patients can use enzyme supplements before meal. If patient avoid milk and dairy other calcium-rich foods should be consumed.

14.

Gastroparesis

a.

Delayed gastric emptying that leads to a feeling of fullness, nausea, vomiting, anorexia, and dysphagia.

b.

Gastroparesis can be caused by tumors in the esophagus, stomach, pancreas, and biliary tract. It can also be due to chemotherapy treatment or radiation.

c.

The symptoms of gastroparesis can contribute to inadequate food intake in cancer patient and this can lead to malnutrition and weight loss. Since drugs need to be able to leave the stomach to be absorbed intravenous drugs are used. Electrical pacing is another possible medical intervention. It works similar to a pacemaker for the heart. If other methods fail

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surgery is sometimes performed to widen the opening between the stomach and the duodenum.

d.

Different classes of drugs are used to treat gastroparesis. Drugs to increase motility can be prescribed, for example metoclopramide (Reglan), domperidone. Medications to treat nausea and vomiting can be used to treat symptoms of gastroparesis. To treat abdominal pain ibuprofen and other painkillers are used, as well as other medications.

e.

Small frequent meals, reduced fat, reduced fiber, soft/liquid foods can help with the symptoms of gastroparesis. Tube feeding might be considered with malnutrition. The patient should be upright during eating and increase motility by walking after meals. If energy needs can not be met orally enteral feeding might be necessary.

15.

Stenosis

a.

Stenosis is the abnormal narrowing of a part of the colon. This can lead to blockage of the colon with distention, abdominal pain, and decreased ability to move stool.

b.

Intestinal stenosis in the large intestines can be caused by tumors.

c.

Intestinal stenosis can lead to malnutrition.

d.

Obstructions in the bowel by tumors are treated with surgery. If surgery is not possible a stent can be placed to open up the stenosis.

e.

Depending on the extend of the stenosis parenteral nutrition might be necessary.

16.

Stomatitis

a.

Inflammation of the mouth with swelling, redness, pain, and ulcers.

b.

Stomatitis can occur as symptom of leukemia, but is most often a side effect of chemotherapy and radiation.

c Since Stomatitis is very painful it often makes eating difficult. As a result dehydration

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. and malnutrition can occur.

d.

Topical anesthetics (lidocaine) are used to numb the mouth before eating. Mouthwashes may also contain substances that provide coating like sucralfate, aluminium-magnesium antacid, or antihistamines. Sometimes local antifungal medication is needed. Analgesics can help manage pain and make food intake possible. Palifermin is a new medication that encourages new cell growth in the mucosa and is given together with chemotherapy.

e.

The patient should be encouraged to have good mouth hygiene. Very hot and very cold food, carbonated beverages, caffeine, alcohol, and other irritating food (spicy, acidic) should be avoided. Glutamine supplementation can be helpful. If stomatitis prevents adequate oral food intake enteral nutrition might be necessary.

17.

Xerostomia

a.

Dry mouth due to decreased saliva production.

b.

Xerostomia can occur

- as a result of damage to the salivary glands from radiation therapy,

- as a result of the removal of salivary glands,

- and as the result of many medications, including chemotherapy drugs.

c.

Xerostomia can lead to malnutrition because it predisposes the patient to infections in the mouth that can make eating painful. Xerostomia can also over time have an impact on teeth which might further contribute to malnutrition.

d.

The patient can use medication that increase the amount of saliva, like pilocarpine or artificial saliva.

e.

The patient should be encouraged to have good mouth hygiene to avoid further complications. They should rinse their mouth often. Tart food can help stimulate saliva production. Patients should avoid caffeine, alcohol, and tobacco. Drinking through a straw, sipping on liquids constantly, sucking on ice chips, chewing gum, and using a humidifier can help. Food should be moist and contain gravies and sauces.

18

Mucositis

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.a.

Inflammation of the mucous membrane anywhere in the digestive tract. It can lead to painful inflammation in the mouth or to a persistent burning feeling in the esophagus, stomach, or intestines. Diarrhea can occur if the lining of the intestines is effected.

b.

Since epithelial cells of the mucosa divide often they are vulnerable to the effects of chemotherapy. Mucositis is therefor often a side effect of chemotherapy. It can also be a side effect of radiation therapy.

c.

Mucositis can be very painful and can make eating difficult. As a result dehydration and malnutrition can occur.

d.

For treatment of mucositis in the mouth see stomatitis. For gastrointestinal mucositis medication against diarrhea might be prescribed.

e.

For oral mucositis see stomatitis. For gastrointestinal mucositis diet can help to manage symptoms of diarrhea.

Beverages with high sugar content should be avoided, as well as sugar alcohols, caffeine, alcohol, and gas-producing foods. To thicken the stool resistant starches and soluble fiber can be used. Insoluble fiber should be reduced to decrease the amount and frequency of stools.

19.

Dysgeusia

a.

The sensation of taste is changed or decreased. Patients may have a metallic taste when eating certain foods, taste of sweet is increased, or they taste less than they normally do.

b.

Dysgeusia is a side effect of chemotherapy or radiation.

c.

Because food does not taste good dysgeusia can contribute to anorexia, food aversions, and ultimately to malnutrition and weight loss.

d.

-

e.

If patients experience a decline in taste it can help to make food more flavorful with more herbs, spices, garnishes, appealing presentation, and variety. Hot food usually has more flavor than cold food. Acidic food can help increase taste sensation. If meat is not well tolerated due to a metallic taste other sources of protein can be used. Plastic utensils can

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also help.

20.

Dysphagia

a.

The patient has difficulty swallowing and this can lead to drooling, choking, and aspiration of food.

b.

Dysphagia is a associated with cancers of the head and neck. It can also be a side effect of radiation of these cancers and of chemotherapy.

c.

Difficulty swallowing can lead to insufficient food intake, malnutrition, and weight loss.

d.

The speech pathologist makes the diagnosis and works on swallowing. Artificial saliva can be helpful.

e.

Patient should follow the National Dysphagia Diet. Depending on the severity of the symptoms the diet is altered to exclude food that is too difficult to swallow. In NDD-3 this is hard, crunchy, or sticky food, in NDD-2 food is moist and minced or diced, and in NDD-1 the diet consists only of pureed food. Thickening agents, sauces, and gravies can help make the food more manageable. With severe dysphagia enteral feeding might be necessary.

21.

Fatigue

a.

Feeling of exhaustion, lack of energy, and tiredness.

b.

Fatigue occurs

- as a side effect of the treatment,

- because of the cancer itself,

- as result of pain,

- because of anemia,

- because of lack of sleep (due to pain, anxiety),

- as the result of depression,

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- due to low energy intake.

c.

Fatigue can make food preparation and food intake difficult. This can contribute to low energy intake, malnutrition, and weight loss.

d.

Sometimes the underlying cause can be treated, for example anemia. Depression can be treated with antidepressants.

e.

The patient should be encouraged to get enough rest, exercise as appropriate, and use available support. Food preparation and food intake should be when the patient feels most energetic. Foods that are easy to chew and eat should be readily available. Rest before meals can increase food intake.

22.

Sodium and fluid retention

a.

Excessive build up of fluid and sodium in the body. It leads to swelling, that can occur in the extremities, the abdomen, or the lungs.

b.

Sodium and fluid retention can occur as a result of some chemotherapy drugs.

Kidney, liver, or ovarian cancer can also cause fluid retention.

Low levels of protein in the blood (hypoproteinemia) due to inadequate intake and losses can lead to fluid retention.

c.

Fluid retention in the abdomen can contribute to anorexia.

d.

Diuretics can be prescribed to manage the condition.

e.

Salt restriction is the most effective to avoid fluid build up in the body.

23.

Anorexia – iron deficiency vs. anemia of chronic disease

a.

Patients are not interested in food.

b Anorexia can be caused by

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. - metabolic changes due to cancer processes. Circulation hormones, and cytokines can effect appetite.

- depression.

- chemotherapy, surgery, or radiation therapy.

- nausea and vomiting, especially if they lead to learned food aversions.

- fatigue.

- other medications, for example corticosteroids.

c.

Anorexia can contribute to malnutrition and weight loss. An increased need in the patient can not be met by increased intake of calories due to anorexia.

d.

Medications can be given to increase appetite. Megestrol acetate and corticosteriod agents are most often prescribed.

e.

To maximize food intake small, frequent meals of foods that are well tolerated should be eaten. Food should be readily available so the patient can eat when he is up to it. A pleasant atmosphere, maybe a glass wine can help to stimulate appetite. Patients should avoid high fluid intake with meals. Exercise (if tolerated) and relaxation therapy can help with appetite. To increase intake high-calorie, high-protein beverages can be consumed.

24.

Anemia

a.

A reduction in the number of normal red blood cells. This results in decreased oxygen delivery, fatigue and pale appearance. Severe anemia can lead to shortness of breath, tachycardia, and chest pain.

b.

Anemia can be caused

- by blood loss. This can happen with cancer in the gastrointestinal tract.

- by cancer of the hematopoietic system.

- by chemotherapy, because cells in the hematopoietic system are vulnerable to chemotherapy drugs.

- by radiotherapy that is aimed at bone marrow.

- by angiogenesis, the building of new blood vessels for the tumor, that increase iron needs.

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- by blood loss because of tissue destruction.

- by inadequate iron intake.

c.

Symptoms of anemia, like fatigue and weakness, can exasperate low food intake and contribute to malnutrition and weight loss.

d.

Treatment depends on the cause of the anemia. Blood transfusions may be done to raise hemoglobin levels. Medications can be given to increase production of more red blood cells, for example Epogen.

e.

Nutritional therapy has the goal to provide enough iron in the diet so the body can produce hemoglobin. If meat is not tolerated due to dysgeusia other sources of iron like poultry, seafood, fortified cereal, spinach, and others should be consumed. Iron supplementation might be necessary. But it is important to find a way to supplement iron that does not increase any gastrointestinal symptoms.

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &Pathophysiology (2nd ed.). Belmont, CA: Wadsworth Escott-Stump, S. (2011). Nutrition and Diagnostic Related Care (7th ed.). LippincottWilliams & Wilkins Diarrhea: Cancer-related Causes and how to cope. Majo clinic. Available from http://www.mayoclinic.com/health/diarrhea/CA00040 Constipation. Description and Causes. (2012) National Cancer Institute. Available from http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/Patient/page3 Dumping syndrome. Majo clinic. Available from http://www.mayoclinic.com/health/dumping-syndrome/DS00715 Malignancy-associated gastroparesis: Pathophysiology and Management. Wolter Kluver Health. Available from http://www.uptodate.com/contents/malignancy-associated-gastroparesis-pathophysiology-and-management Marks, J.W., Gastroparesis (2012) Medicine Net. Available from http://www.medicinenet.com/gastroparesis/article.htm Stomatitis (2012). The Merck Manual for Health Care Professionals. Available from http://www.merckmanuals.com/professional/dental_disorders/symptoms_of_dental_and_oral_disorders/stomatitis.html Mucositis (2011). National Health Service. Available from http://www.nhs.uk/conditions/Mucositis/Pages/Introduction.aspx

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Edema or Fluid Retention (2012). Managing side effects. Cancer.Net. Available from http://www.cancer.net/all-about-cancer/treating-cancer/managing-side-effects/edema-or-fluid-retention Anemia in People with Cancer (2010). American Cancer Society. Available from http://www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/Anemia/anemia-in-people-with-cancer

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C.) NUTRITION RELATED TOPICS

For each of the following dietary treatments:

a. Describe the diet and discuss the theory behind the treatment.

b. Explain why a cancer patient might need this diet prescription

c. Discuss current controversies (if any) about use of the diet as nutrition therapy for cancer patients.

1. Neutropenica. Definition of the neutropenic diet varies among institutions who use it. Some prohibit

fresh vegetables, fruits, and raw eggs. Other institutions also exclude fresh juice, dried fruit, nuts, anything raw (like honey, spices, herbs), deli meat, yogurt, aged cheese, undercooked meat or seafood. Sometimes food is sterilized or treated in an autoclave.

b. A neutropenic diet is prescribed to protect patients who have neutropenia (low white blood cell count) from infections. Bacteria that are ingested with food might be translocated to the blood and other parts of the body and cause infections that could be life-threatening for those patients. The timing of initiation of the diet varies among hospitals.

c. The neutropenic diet is controversial because there is not enough evidence that it has the intended protective effect. Some studies even suggest that patients on a normal diet have fewer infections than those on a neutropenic diet. A neutropenic diet can be very limiting and can increase danger of anorexia, food aversions, malnutrition, vitamin deficiencies, and alterations in the GI tract. Nutritional status of these patients could deteriorate even further putting them at an increased risk of infections.

2. Increased proteina. Protein needs of cancer patients are often increased. Nonstressed

cancer patients need between 1 and 1.5 g/kg. Patients undergoing a bone marrow transplant need 1.5 g/kg. If there is extreme wasting, protein-losing enteropathy, and hypermetabolism due to cancer cachexia needs can be as high as 2.5 g/kg. The patient can increase protein intake by choosing more protein food sources and protein with a high biological value. Nutrition support with beverages high in protein and energy can make it easier to meet the high needs in

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these often anorexic patients.b. In cancer cachexia is comes to changes in the protein metabolism.

Protein is used to provide energy and and protein synthesis is reduced, leading to loss of lean body mass. A high protein diet can try to offset these losses.

c. It is widely accepted that optimal protein intake is important for cancer patient.

3. Increased caloriesa. Calorie needs of cancer patients are often increased due to the

metabolic changes that can occur in cancer. Non-ambulatory or sedentary adults that are not hypermetabolic need 25 -30 kcal/kg, slightly hypermetabolic patients and those who need weight gain should consume 30 - 35 kcal/kg, hypermetabolic, severely stressed patients, and patients with malnutrition need 35 kcal/kg. An increase in calories is often difficult to achieve if patients are anorexic, have nausea, vomiting or other symptoms that keep them from eating. Nutritional beverages high in energy can be helpful.

b. It is important for cancer patient to maintain a healthy weight and avoid weight loss. To offset the metabolic changes that occur in cancer an increase in calories is often necessary.

c. It is widely accepted that optimal energy intake is important for cancer patients.

References for this section: Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &Pathophysiology (2nd ed.). Belmont, CA: Wadsworth Aftandilian, C.C., Milotich, C., Sakamoto K.M., (2012) The Neutropenic Diet - Still Ageless? Cancer Network. Available from http://www.cancernetwork.com/complications/content/article/10165/2079280

Cancer Cachexia

4. Define cancer cachexia and describe its pathogenesis. Include factors related to both the

cancer and the treatment.

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Cancer cachexia is a syndrome marked by weight loss, loss of lean body mass and adipose

tissue, and severe malaise. Increased levels of C-reactive protein, fibrinogen, white blood

cells, and pro-inflammatory cytokines lead to changes in carbohydrat, protein, and fat

metabolism. Some cancers, like lung cancer and pancreatic cancer are more likely to cause

cachexia. This is due to cancer specific cachectic factors like cytokines, hormones, serotonin,

neurotransmitters and others that facilitate these metabolic changes. A major change in

carbohydrate metabolism is an increase in Cori cycle activity, insulin resistance and glucose

intolerance. Unlike with starvation the body does not conserve protein and an increase in

protein catabolism together with decreased protein synthesis leads to loss of lean body mass.

Increased liposlysis leads to loss of body fat. Cachexia can occur even without anorexia, and

weight loss with or without anorexia is used to classify cachexia into four stages. Cachexia is

the leading cause of death among cancer patients

5. Discuss the sensory changes that accompany cancer and its treatment.

Cancer patient can experience changes in taste that make food taste metallic or overly sweet.

Sense of smell can be greatly diminished or heightened. Metallic taste often occurs with the

consumption of meat and from metallic utensils, cans, and so on. These changes can happen

as a result of the cancer but are most often seen with chemotherapy or radiation therapy to

the neck and head. These taste changes can have a great impact on food choices and food

intake. Foods that were usually well liked, are not tolerated anymore and the patient has to

find other choices that he likes better. If there is loss of taste food should be made more

flavorful and aromatic to provide a better experience.

6. What are some strategies to improve nutrition status in a cachexic patient?

Cachexia patients can increase their calorie and protein intake. Well tolerated food should be

readily available so patients can eat when they are less fatigued. Increasing calorie with

sauces, gravies, additional fat and increasing protein with addition of protein powder can

increase intake. Nutritional beverages can be a convenient method to take in additional

energy and protein.


Nelms, M., Sucher, K.P., Lacey, K., Roth, S.L. (2011). Nutrition Therapy &

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Pathophysiology (2nd ed.). Belmont, CA: Wadsworth

Cancer Prevention

7. Outline the process by which free radicals are hypothesized to play a role in cancer development.

Free radicals are molecules that have an unpaired electron. They form in the body with

normal metabolic processes that involve oxidation, they are used by the immune system to

fight pathogens, but they also occure when the body is exposed to sunlight, cigarette smoke,

pollution, and other harmful substances. The free radical makes these substances very

reactive and they can damage for example the cell structures like DNA. This can lead to

mutations and ultimately cancer initiation.

8. What vitamins and minerals are parts of antioxidant systems? Outline the mechanism by which antioxidants reduce oxidative damage.

Vitamin A and beta-carotene, vitamin E, vitamin C, and selenium are part of the

antioxidative system. Some of them give up an electron to the free radical, others are part of

antioxidative enzyme systems.

Vitamin E has antioxidative properties especially in the phospholipid layer of the cell

membrane and for polyunsaturated fatty acids, and LDL cholesterol.

Vitamin C can protect DNA and other structures in the molecules in the body from free

radicals and reactive oxygen. Vitamin C can also regenerate vitamin E.

Selenium is part of the glutathione peroxidase enzyme that neutralizes free radicals in the

cell. It also spares vitamin E by limiting the oxidation of lipids. It is also part of thioredoxin

reductase which regenerates other antioxidants, possibly vitamin C.

Copper and zinc are part of superoxide dismutase and iron is part of catalase.

Vitamin A is speculated to act as an antioxidant. Caroteinoids have antioxidative properties

and some of them are also precursor of vitamin A.

9. Several phytochemicals have been correlated to a reduction in cancer rates. What are phytochemicals. Give specific examples of how phytochemicals are theorized to effect the initiation, promotion, and progression of cancer cells.

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Phytochemicals are substances in plant food that are not nutrients but have important health

protecting functions. Some caroteinoids that are not precursors for vitamin A, like lutein,

lycopene, and zeaxanthin act as antioxidants. Flavonoids are another class of phytochemicals

that have antioxidative properties. But this has mostly been shown in test tubes. The level of

circulating flavonoids might be too low to have a big impact in the body. Another example is

isothiocyanate, which has several metabolites. In animal models these substances have been

shown to inhibit different types of cancer. Epidemiological studies seem to support these

findings. The effect of isothiocyanates might be stronger in people who have a genetic

variation that makes them metabolize this substance more slowly.

References for this section: Insel, P. (2011) Nutrition (4th ed.) Sudbury MA: Jones and Bartlett Micronutrition Information Center. Linus Pauling Institute. Oregan State University. Available from http://lpi.oregonstate.edu/infocenter/

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