nutrition and cancer prevention · 2016 over 1.6 million new cases expected to be continue to rise...

Oncology Nutrition

More breaks

prevention/tx/case studies

Less handouts

Use links

More time

Request day with us

Case Studies… will have a few

2016 over 1.6 million new cases Expected to be continue to rise

Most Common: Breast, lung, prostate, colon/rectal, bladder, melanoma, lymphoma, thyroid, renal, leukemia, endometrial, pancreatic

Survivors: 14.5 million in 2014 Expected to rise to 19 million by 2024

The Numbers

Cost of cancer care 2010 in US: 125 billion- expected to be 158 billion by 2020

1/3 of all cancers related to smoking

1/3 of all cancers related to obesity, overweight, inactivity and/or poor nutrition

Cancer Stats….

Carcinogenesis: when normal cells transform into cancer cells

Role of Nutrition in Cancer

Cancer Prevention

Treatment Symptom

Management

Survivorship

Prevention/Survivorship

What do you think is the risk factor that oncology dietitians focus on the most in relation to cancer prevention/survivorship?

Treatment

What 3 treatment related side effects do you think we spend the most time counseling on?

What cancers diagnosis do you guess we spend the most time on?

What is the most common “myth” we are currently educating patients on in relation to diet and cancer?

What do you think are some of the most common supplements patients are self prescribing during treatment and survivorship?

Achieve and maintain a healthy

weight.

Engage in regular physical activity.

Eat a healthy diet, with an emphasis

on plant foods.

ACS Guidelines on Nutrition and Physical Activity for cancer Survivors

Prevention/Survivorship

What do you think is the risk factor that oncology dietitians focus on the most in relation to cancer prevention/survivorship?

As of 2014….

70% of US adults overweight

36.5% obese

1994 only 56% overweight or obese

https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet

OBESITY











Problem with Obesity

Increased Estrogen

Inflammation

Increased serum glucose

Decreased insulin resistance

BMI 18.5-24.9 (higher if older)

100# for 5 feet plus 5# per inch…. PLUS or minus 10%

Keep in mind YOUR weight history

Any amount of weight loss no matter how small is beneficial

Achieve and maintain a “healthy

weight”

Evidence indicating that body fatness is a cause of postmenopausal breast cancer is convincing

Adult weight gain and abdominal fatness are probable causes of postmenopausal breast cancer

Obesity has been associated with decreased survival from breast cancer in both pre/post menopausal women

Obesity and Breast Cancer… always use EVIDENCE

Esophageal Cancer

Obese are 2x as likely and extreme obese 4x

Endometrial Cancer

Obese and overweight are 2-4 times more likely

Gastric Cancer

Obese are twice as likely to get cancer in the cardia

Liver Cancer

Obese are twice as likely- especially for men

Pancreatic Cancer

Overweight or obese 1.5 times more likely

Gallbladder, thryroid, ovarian and multilple myeloma

Obesity is linked to…

Serum glucose control

Does improved BG reduce risk of disease and/or recurrence?

Recent Mayo Clinic Study showed ovarian cancer patients on Metformin longer survival

Prostate pt who received RT only may have less recurrence

? Reduce risk of breast, lung and colorectal cancer

ALWAYS REMEMBER

All variables are almost impossible to control for….

Is obesity the cause of my cancer????

Smoking

Dietary contents

Genetics

DM or other diseases

Environmental exposure………..

Achieve and maintain a

healthy weight.


Eat a healthy diet, with an emphasis on plant foods.


Avoid inactivity and return to normal daily activities as soon as possible following diagnosis.

Aim to exercise at least 150 minutes per week.

Include strength training exercises at least 2 days per week.

Be Physically Active

Why Exercise??

Now linked with decreased risk of 13 cancers- overall 7% decrease

Risk regardless of BMI or smoking

People who exercise do have healthier lifestyles

Helps with fatigue

https://www.nccn.org/patients/resources/life_with_cancer/exercise.aspx

Esophageal Liver

Lung Kidney

Gastric Myeloid leukemia

Myeloma Colon

Head and neck Rectal

Bladder Breast

endometrial

Exercise/obesity

Achieve and maintain a

healthy weight.


Eat a healthy diet, with an emphasis on plant foods.


Choose foods and drinks in amounts that help you get to and maintain a healthy weight.

Limit how much processed meat and red meat you eat.

Eat at least 2½ cups of vegetables and fruits each day.

Choose whole grains instead of refined grain products.

Eat a healthy diet with emphasis on plant foods

• Anti-initiation: • Alter carcinogen metabolism

• Enhance carcinogen detoxification

• Scavenge reactive oxygen species

• Enhance Immunity

• Weight management

Targets for Cancer Prevention Strategies

Targets for Cancer Prevention Strategies

Anti-promotion/progression strategies Scavenge reactive oxygen

species Decrease inflammation Suppress proliferation Enhance immunity Discourage angiogenesis

Weight management

Scavange free radicals: alpha-tocopherol, carotenoids, selenium, polyphenols (tea)

Alter Oncogene/Supressor Gene Expression: Retinoids, isoflavones, folate, calorie restriction

Decrease inflammation: Vitamin E compounds, reservatrol, caloric restriction, EPA

Induce Differentiation: Retinoids, calcium Suppress Proliferation: Selenium, isoflavones, cal restr. Encourage Apoptosis (cell death) Retinoids, genistein, caloric

restriction Discourage Angiogenesis (growth of new blood vessels):

Genistein, caloric restriction Block invasion/metastasis: Vitamin E compounds

Examples of Agents which may alter Promotion/Progression Events

Bottom Line is Color and Variety

Inflammation: A Double Edged Sword

Good

Removes damaged tissue

Kills pathogens

Bad

Tissue damage

Scarring

Cancer

Inflammatory Disease Cancer

Ulcerative colitis colorectal

Pancreatitis pancreatic

Gastritis stomach

Cystitis bladder

Chronic skin irritation skin

Asthma lung

Nutrition and Cancer Prevention: A Biological Perspective, K.W. Hance and C.J. Rogers, NIH, 2006

Inflammation is a Risk Factor

Plant Based including herbs Herbs: green tea, tumeric, ginger

etc Omega- 3 FA fats Limit processed foods including

meats

Anti-Inflammatory Diet

promote cellular differentiation decrease cancer cell growth stimulate cell death reduce angiogenesis (tumor blood vessel

growth) ? Reason breast, colon and prostate cancer

often more aggressive and have a higher occurrence in darker skinned persons

No studies to support high doses- two ongoing with over 20,000 participants

Vitamin D …. Thought to be preventative

Presently

600 IU under 51

600 IU 51-70

800 IU those over 70

?Likely to go to 1000

? Need lifetime consumption (like soy?)

RDA- increased for children

Vitamin D content of foods

• Herring 3oz 1380 IU

• Salmon 3oz 530 IU

• Lt tuna 3oz 200 IU

• Shrimp 3oz 130 IU

• Egg yolk 25 IU

• Mushrooms (1/2c) 25 IU

• Milk 8 oz 100 IU • cow./rice/soy

Lower Risk of Cancer: Vegetarians 12% lower overall rate of cancer (British Journal of

Cancer, 2009).

Study linked plant-based diet to 20% lower breast cancer risk.

Lower Oxidative Stress & Inflammation

Longevity:- linked to longer lifespan

Weigh Less: BMI of fish eaters, vegetarians, and vegans is lower than meat eaters. Lots of fiber to fill you up

Many foods are high in volume and low in calorie

Reduced Risk of Heart Disease & Diabetes

Plant based diet Health Benefits

Other “hot” topics

Soy and Breast cancer

Organic vs non

AICR/WCRF’s latest continuous update report on breast

cancer (2010) said the evidence is suggestive, but too inconsistent to conclude that soy reduces risk of breast cancer

Currently no scientific evidence available to support use of isoflavone supplements by breast cancer survivors

If you are currently eating soy foods: no more than three servings per day is considered safe

Choose whole soy foods, such as tofu, soymilk, and edamame 1 cup soymilk, ½ cup cooked soybeans, 1oz soy nuts

The occasional soy protein bar or snack food is fine, but as with all plant foods, less processed is better.

Oncology nutrition website as a resource….

https://www.oncologynutrition.org/erfc/hot-topics/soy-and-breast-cancer/

Soy: Beneficial Or Harmful??

There is a lack of evidence to support Organic foods are less likely to

cause cancer than conventionally grown foods there are no studies on humans to show that organic foods can

prevent cancer

Pesticides and Herbicides: At this time there is no evidence that residues of pesticides and

herbicides at the low doses found in foods increase the risk of cancer. Overwhelming scientific evidence supports the overall health benefits

and cancer-protective effects of eating vegetables and fruits despite the possibility of low levels of these chemicals

Several studies have looked at the nutrient content of organic versus conventionally grown fruits or vegetables some studies suggest a higher nutrient content, others suggest no

difference. More studies are needed

BUT NO EVIDENCE ORGANIC IS HARMFUL

36

Should I go Organic?

Prevention Questions??

OBJECTIVES

Quick Cancer Overview

Assessing Nutritional Needs

Management of Symptoms

Treatment

Oncology – branch of medicine that deals with cancer

Hematology- branch of medicine that deals with diseases and blood disorders

Grouped together : Hem-Onc

Oncology vs. Hematology

TNM Classification (most common especially for solid tumors)

Tumor

Size and extent of tumor

Lymph Nodes

Extent of spread or local lymph nodes

Metastasis (spread to other parts of body)

Presence of metastatic disease

Cancer Staging To determine appropriate treatment plan

Grade Definition

Primary Tumor

TX Primary tumor cannot be evaluated

T0 No evidence of primary tumor

Tis Carcinoma in situ (CIS): Abnormal cells present. No spread to neighboring tissues **

T1-T4 Tumor not palpable or visible by imaging

Lymph Nodes

NX Regional lymph nodes cannot be evaluated

N0 No regional lymph nodes involvement

N1-N3 Involvement of regional lymph nodes

TNM

All patients should be screened for nutrition risk in both inpatient and outpatient settings.

Done primarily by nursing

Poor appetite Weight loss Diarrhea/constipation Nausea/vomiting Nutrition support initiation or changes Head and neck cancer patients Patient requesting education

Nutrition Screening of Patients

Treatment





Loss of appetite/weight loss

Disease State

Treatment side effects

Diarrhea/constipation

Dysphagia

Frequent Consults

Cancer

Tumor Products Endocrine Alterations

Metabolic Abnormalities

Lipolysis

Protein Loss

Cachexia

Anorexia

Systemic Inflammatory

Response (Cytokines)

Cachexia: Multifactoral syndrome characterized by an ongoing loss of

skeletal muscle (with or without fat loss) that CANNOT be reversed with conventional nutrition

New definition: “complex metabolic syndrome associated with an underlying illness and characterized by muscle loss with or without loss of fat mass” (Evans et al. Am J Clin Nutr Feb 2010)

Cachexia

Treatment





Occurs in approximately half of cancer patients

Lung, colorectal, pancreatic, and head and neck cancers

Seen less frequently in early stage hormonal cancers such as breast, prostate, ovarian, and uterine.

Prevalence as high as 86% at end stages of life

cancer cachesi: impact, mechanisms and emerging treatments.

J Cachesia Sarcopenia Muscle (2013) 4:95-109

Cancer Cachexia

Multifactorial:

Increase Cytokines A small protein released by cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells.

Anorexia/early satiety

Severe fat loss by enhancing lypolysis

Release of cortisol and catecholamines from adrenal gland leading to an increase in resting metabolic rate

Possible Mechanisms of Cancer Cachexia

Cachexia vs Starvation

Morely et al. Cachexia: pathophysiology and clinical relevance

Am J Clin Nutr 2006

Cachexia

Low serum albumin

Inflammation (↑CRP)

↑ Protein catabolism

Low or normal food

intake

↑ REE

↑oxidation stress

Resistant to ↑ dialysis

and nutrition support

Starvation

Normal or ↓ serum

albumin

No inflammation

↓ Protein catabolism

Low food intake

Normal REE

Minimal ↑ oxidative

stress

Reversed by adequate

dialysis and nutrition

support

^ Kcal intake: increases weight through water retention and replenish fat stores

Steroids: ? Negative impact on muscle retention- may effect BG

Nutrition Counseling: May increase caloric intake but not ^weight, QOL, or survival

However does help caregiver QOL,

TPN: little observed benefit

EPA- may be of benefit due to reduction of inflammation

Cachexia Treatments

Radiotherapy

Chemotherapy

Immunotherapy

Surgical

Modes of Treatment

C

h

e

m

o

t

h

e

r

a

p

y

R a d i a t i o n T h e r a p y

Dysphagia Difficulty swallowing

Odynophagia Painful swallowing in mouth or esophagus

Xerostomia Dry mouth

Mucositis Painful inflammation and ulceration of the mucous

membranes lining the digestive tract

Stomatitis Inflammation of mouth and lips (w/ or w/out oral

ulceration)

Commonly used terms

Nutrition Related Treatment Toxicities

Chemotherapy

Nausea

Lack of Appetite

Mouth Sores

Taste Changes

Diarrhea

Constipation

Neuropathy

Neutropenia

Toxicities are less with immunotherapies such as monoclonal antibodies and immune checkpoint inhibitors

Radiation

Diarrhea

Dry Mouth

Dysphagia

Nausea:

Acute: within the first few hours of receiving chemo

Delayed: develops over the next few days following chemo

Anticipatory: symptoms appear before chemo is administered; often triggered by sights, sounds, and smells.

Chemotherapy /Immunotherapy Side

Effects All are graded on level of 0-5 (see RN assessment)

Each drugs classified in accordance to it’s emetic potential. This determines the anti-emetic regime the patient is given.

Level 5 very high (>90%)

Level 4 high (60-90%)

Level 3 moderate (30-60%)

Level 2 (low (10-30%)

Level 1 (very low (<10%)

Nausea

Seretonin (5HT3) antagonists: stop serotonin from signaling the brain

to feel nausea. Can be given p.o or I.V.Most given day of chemo before treatment with highly emetogenic regimens

Zofran (Ondansetron)

Anzemet (Dolasetron)

Kytril (granisetron)

Corticostreroids: used to help prevent delayed N/V- approved for moderately emetic regimens

Decadron (dexamethasone)

Nk-1 antagonist:Blocks the action of substance P which triggers nausea in the brain. Good for acute and delayed nausea in combination with other antiemetics

Emend (Aprepitant)

Classification of antiemetic drugs

Dopamine antagonists: long used medications for nausea and vomiting with many chemotherapy drugs. Reglan (metoclopramide) for mod. emetogenic drugs may cause

diarrhea in large amounts Compazine (prochlorperazine) for mod, emetogenic drugs- not used

in pediatrics as it is highly sedating Haloperidol for prevention of acute or delayed nausea

Benzodiazepines: help relieve anxiety Ativan Valium

Cannabinoids: Prevention of anticipatory nausea and vomitting Marinol (Dronabinol)- caution with elderly

Antiemetics drugs continued

Lack of Appetite Poor Appetite from Toolkit- Eating hints booklet Supplements

Boost, ensure, CIB, etc. Thoughts on this??

Mouth Sores/ Mucositis Salt water rinses

Altered Taste Plastic utensils Salty, sweet, sour, bitter

Chemo Side Effects

Often well tolerated

Many are beneficial if lactose intolerance

Many patients find them too sweet

Many are high in CHO

Some patients c/o increased mucus

Let’s try some!

Medical Nutrition Supplements

• Diarrhea: especially with Xeloda & Irrinotecan • Increase fluids and soluble fiber intake • Some suggest banana flakes • Reduce insoluble fiber intake- increase soluble fiber/ rice congee, brat

diet.

• Constipation • Increase insoluble fiber • Increase fluid intake • Increase activity • ? Need for laxatives • Smooth Moves Tea

Chemo Side Effects

Neuropathy

? Benefit from glutamine- 15 gm BID

? Benefit IV Mg and Ca?

With Oxaliplatin (colorectal ca) pt must avoid all cold foods for 48 hours

Vitamin B- may benefit from 100mg/d >200mg/d

may increase risk of neuropathy

Chemo Side Effects

“An abnormally low level of neutrophils “

Increases risk of developing infections

CAUSES:

Chemotherapy causes bone marrow to not work well -> lowering production of neutrophils

Cancer itself affects bone marrow directly

Radiation therapy – specifically if radiating legs, pelvis, chest, or abdomen

http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets - Food Safety Education Sheets by USDA

NEUTROPENIA

http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets















Lacks evidence

Still in use in many facilities

Not used for Pediatrics Why??

Neutropenic Diet

Diarrhea: with RT to intestines, colon and prostate (recommendations for diet vary)

“Pelvic Diet”

Mouth sores/Mucositis

Magic mouth rinse

Soft, room temp foods

? Glutamine up to 10mg TID

Side Effects: Radiation

Dry Mouth Biotene

Increase fluids

Papaya juice or enzymes

Dysphagia: may take months to come off TF after RT Thicker liquids

Supplements

?Speech consult

Radiation Side Effects Con’t

Signs they are needed

Diarrhea Floating stools Abdominal pain Foul smelling stools Kahki colored stools Weight loss Dosage Start with .5 units lipase per kg

Pancreatic Enzymes

Energy metabolism varies greatly

Tumor site and type does not predict energy needs

Best to use clinical judgment and individualize estimates based on full assessment.

Harris-Benedict may overestimate

Mifflin-St Jeor may be considered

Ireton-Jones may underestimate

Kcal/kg lacks evidenced based validation: but may be used for initial estimates and adjusted based on activity

Assessment of the Adult Oncology Patient: Energy Requirements

Mifflin St. Jeor Men: REE= 10W + 6.25Ht – 5A + 5 Women: REE= 10W + 6.25Ht – 5A – 161 (wt in Kg, Ht in cm, Age in years)

Activity and injury factors Activity Factors:

Vent support 1-1.1 Bedridden 1.2 Ambulatory 1.3

Injury Factors: Mild starvation 0.85-1.0 Cancer-based on severity of illness 1.1-1.45 Cancer wt maintenance 1.15-1.3 Cancer wt gain/nutritional repletion 1.5 Vent support/catabolic 1.5 Sepsis 1.5

Caloric Requirements

Estimated Caloric Needs Based on Body WT

Condition Kcals/Kg

Cancer, nutritional repletion/wt gain 30-35

Cancer non-ambulatory 25-30

Cancer hypermetabolic/stressed 35

Sepsis 25-30

Stem Cell Transplant 30-35

Protein Needs Condition Estimated Protein

Needs (gm/kg)

Normal maintenance 0.8-1.0

Non-stressed Ca pt 1.0-1.2

Hypercatabolism 1.2-1.6

Severe stress 1.5-2.5

Requiring nutrition

support

1.6-2.0

Stem cell transplant 1.5-2.0

Normal maintenance 0.8-1.0

Non-stressed cancer pt 1.0-1.2

Hypercatabolism 1.2-1.6

Severe Stress/nutrition support 1.5-2.0

Stem cell transplant 1.5-2.0

ARF .6 (1.0 with dialysis)

Dialysis 1.0

Hemodialysis or Peritoneal Dialysis 1.2-1.5

Hepatic Failure 1.0-1.5

ESLD with Cirrhosis 1.0-1.2

Determining Protein Needs

May vary based on side effects of treatment (such as diarrhea with Xeloda, 5-FU, RT, etc)

May use RDA method 1ml fluid per kcal energy needs or BSA, or ADA : 16-30yrs active: 40mL/kg

31-55 years: 35mL/kg

56-75 years: 30mL/kg

76 years or older: 25 mL/kg

Fluid Needs

Fluid Requirements

Age Fluid requirement

(ml/kg)

16-30 40

31-55 35

56-75 30

>76 25

Or 1ml fluid per 1kcal per estimated needs

Often patients with head and neck CA receive PEG tube placement before start treatment- as well as some lung pts

Not all patients end up using PEG Mainly given for all stage 3 or 4 head and neck cancer

patients who are getting chemo with RT Many esophageal patients start to eat better as tumor

shrinks with treatment

Some esophageal and stomach CA patients receive PEJ or PEG before treatment.

For oncology patients, use clinical judgment for formula based on needs and volume estimate.

Tube Feedings in RT

Treatment





Cancer cells like all other cells in the human body use “sugar” or glucose as fuel Tumors can and will make their own glucose for fuel

Keto diet:

Finding more patients interested in this during treatmet

Theory is based on tumor cells having altered mitochondria that are not able to utilize fatty acids and ketones for energy- thus “starving the tumor”

Few studies with very few patients-

Mixed results

Compliance issues

Does Sugar Feed cancer?

Sugar increases calorie intake without providing any of the nutrients that reduce cancer risk.

By promoting obesity, a high sugar intake may indirectly increase cancer risk.

Eating more sugar causes insulin levels to rise. Consistent high levels of insulin have been linked to increased risk for certain

cancers

White (refined) sugar is no different from brown (unrefined) sugar or honey with regard to their effects on body weight or insulin levels.

Limiting foods such as cakes, candy, cookies, and sweetened cereals, as well as sugar-sweetened drinks such as soda and sports drinks can help reduce calorie intake

ADVICE: Limit simple sugars

Supplements During Treatment

Recommendations vary per practitioner/facility

Current LVHN recommendations: no more than RDA for anti-oxidants via supplement

Treatment





St John’s Wart known to interfere with cytoxic agents

Milk thistle recently shown to reduce hepatotoxicity in children receiving chemo

Ginger shown to compliment anti-emetics in reducing nausea during chemotherapy but not blood thinners

Curcumin- depending on other meds, treatment ? DM

Theoretically, many herbs MAY alter chemo…bottom line is that we do not know NCCAM great handouts http://nccam.nih.gov

Sloan Kettering: http://www.mskcc.org/mskcc/html/58481.cfm#M

NCCAM

Popular Supplements

http://www.mskcc.org/mskcc/html/58481.cfm#M

BREAK?

57 year old male. Recently diagnosed with tongue cancer. PEG placement two days ago. To undergo 30 treatments of radiation Presently having some difficulty chewing. Taking mainly soft foods, milkshakes and water. Does NOT want to use PEG. Complains of dry mouth and taste changes

Height: 5’9” Weight 156# Weight History: recently lost 10# Lives with wife and daughter. Presently not working. Meds: Percocet, magic mouth rinse and prilosec. Stopped multivitamin. c/o mild dysphagia, constipation, fatigue and frequent dizziness

Needs Suggestions including enteral formula Labs you would look for Nutrition Diagnostic Statement

Case Study

• 56 year old female with pancreatic cancer post whipple. • Ht 5’7” Wt 124# UBW 145# Wt loss of over 20# over

past 6 months- continued at a rate of 1-2# per week last month

• Diet recall indicates bland, low protein, moderate fat, diet with CIB at all meals.

• Presently undergoing radiation • Meds: Prilosec, ativan, MVI, Vitamin C 500mg • Symptoms: c/o fullness after meals, foul smelling stools,

gas pains

Needs Suggestions Labs you would look for Nutrition Diagnostic Statement

Case Study

53 year old post-menopausal who finished chemo and radiation for breast cancer last year.

Height 5’3” Present wt 155# Wt History: In 30’s 125-130# 40’s 130-140# Gained 10 # during chemo Has gained 5# over past 6 months Daily Meds: MVI, calcium with vitamin D,2,000 IU vitamin D , Tamoxifen, black

cohosh for hot flashes Medical history: two children ages 24 and 26 NKA, menopause at 48 years of age Works as a secretary 4 days a week in a doctors office. Skips breakfast. Complaints: fatigue, constipation, sweet-tooth Calculate needs Diagnostic statement What are you recommendations

Case Study/Discussion: Survivor/Prevention

nutrition and cancer prevention · 2016 over 1.6 million new cases expected to be continue to rise...

Documents