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NUTRITION FOR THE PATIENT WITH CANCER

Christy McFadden MS, RDN, CSO

Christy McFadden MS, RDN, CSO

Currently MNT Supervisor

Registered Dietitian at Spectrum Health for 12 years

Certified in Oncology Nutrition in 2008

MS Human Nutrition at Michigan State University 2005

BS Lyman Briggs Biology at Michigan State University 1998

Spectrum Health consists of a 600 bed Medical Center based in Grand Rapids, Michigan along with a 200 bed children’s hospital and 11 regional hospitals across West Michigan.

NO CONFLICT OF INTEREST Disclosure

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Objectives

• Identify the types of cancer that are associated with the highest risks for malnutrition in patients.

• Describe the nutrition-related side effects of surgery, chemotherapy and radiation therapy experienced by cancer patients.

• Develop a care plan for a patient with nutrition-related side effects from surgery, chemotherapy and radiation therapy.

• Determine when enteral nutrition is appropriate for patients with cancer.

SCREENING FOR MALNUTRITION IN THE CANCER PATIENT

Malnutrition

• 30-85% cancer patients experience malnutrition

• 15-20% malnutrition prior to diagnosis

• Intervention with high risk patients should be early & aggressive

• Involuntary weight loss is not unavoidable!

– MNT intervention has been shown to stabilize or reverse weight loss in 50-88% of patients

Abbott Nutrition. Sauer & A. Coble Voss. Improving outcomes with nutrition in patients with cancer. May 2012.

Abbott Nutrition. Daly, et al. The 7th Vital Sign: the role of nutrition in oncology nursing. Nursing Currents. Abbott. June 2012.

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Cancer-Related Malnutrition

Reduced Tolerance or Response to Treatment

Increased Risk of Postoperative Complications

Increased Infection Rate

Increased Cost Reduced

Performance Status

Social Burden

Decreased Quality of Life

(QOL)

Marin-Caro et al. Clin Nutr.2007;26:289-301

• Screening for malnutrition involves all members of the clinical team

– Nurses screening; meals consumed; referral to RD

– Dietitian assessment; intervention; document malnutrition

– Provider documentation of malnutrition for reimbursement

• Alliance to Advance Patient Nutrition call to action includes Academy of Medical-Surgical Nurses (AMSN), Academy of Nutrition and Dietetics (AND), and American Society of Parenteral and Enteral Nutrition (ASPEN)

Malnutrition

Tappenden K.A., B. Quatrara, et al. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to

Address Adult Hospital Malnutrition. JPEN. 2013.37(4):482-497.

Cancer Treatment

• Localized vs. Systemic

• Surgery

• Radiation Therapy

• Chemotherapy

• Others

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SURGERY Cancer Treatment

Cancer Treatment

Surgery

• Primary treatment for many cancers

• Fatigue, high kcal, pro diet for wound healing

• Enteral Nutrition – elemental or immune enhancing formulas as needed

• Meet with RD before surgery, inpatient, after surgery; sometimes long-term complications

Whipple Surgery

• Malnutrition Risk – Delayed gastric emptying- early satiety,

gastroparesis

– Weight loss

– Malabsorption

– Intestinal cramping

– Diarrhea

– Nausea

– High blood glucose

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Whipple Surgery

• Pancreatic enzymes to prevent malabsorption – 25% patients have malabsorption

– 30,000-40,000 units lipase with each meal

– Signs of malabsorption • Weight loss

• Cramping after meals

• Loose and frequent stools

• Floating or greasy/fatty stools (steatorrhea)

• Foul smelling gas or stools

• Large amounts of gas

Gastrectomy & Esophagectomy

• Gastric cancer; esophageal cancer; cancer at the GE Junction

• Dysphagia & weight loss common before diagnosis

• Digestive problems sometimes not discovered until months after surgery

• Dumping Syndrome

Dumping Syndrome

Early

• 15-60min postprandial

• Rapid emptying of hyperosmolar contents into small bowel: cramps, n/v/d

• Vasomotor sx: fatigue, tachycardia, faintness, flushing, hunger, difficulty concentrating

Late

• 1-3hr postprandial

• Reactive hypoglycemia – rapid absorption of glucose resulting in hyperinsulinemia

• Mainly vasomotor sx

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Dumping Syndrome

• Diet to Prevent Dumping Syndrome

– Eat six small meals throughout the day; soft foods

– Protein at each meal

– Limit concentrated sugars

– Drink fluids 30-60 minutes before or after meals & snacks

– Choose high fiber foods

– Eat slowly

Other Surgeries

• Small bowel – various type and metastatic lesions; malabsorption, weight loss, obstruction requiring TPN

• Colorectal – ileostomies, avoid obstruction

• Head and neck – common complications are tumor burdens, social factors, such as alcohol abuse, that may lead to weight loss, malnutrition (high incidence)

CHEMOTHERAPY Cancer Treatment

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• Mouth – Taste changes, appetite – Xerostomia – Mucositis

• GI – Nausea, early satiety – Bowel changes – Mucositis all along GI

tract

• Bone density – Osteopenia,

osteoporosis

• Other – Electrolyte imbalance,

mineral depletion – Anemia – Lipid abnormalities

Nutrition Related Side Effects

Taste Change

• FASS = Fat, Acid, Salty, Sweet

– Olive oil, nut oils

– Citrus (lemon/lime)

– Salt

– Maple syrup, sweets

• Slow cooking

– Broth

– Soups

– Stews

• Medications

• Associated problems

– Eating, tasting, swallowing

– Speaking

– Cavities

– Indigestion

• Offer foods that are moist or wet

• Artificial saliva

Xerostomia

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• Small frequent meals and snacks

– Well-cooked and cold foods

– Avoid odors

• Ginger

• Peppermint

• Sea Bands ®

Nausea & Vomiting

• Encourage liquids

– Not too much juice!

– Strong black decaf tea

• Encourage soluble fiber

• Lactose intolerance – Yogurt, kefir for probiotics

• Congee: effective to reduce diarrhea and to sooth GI tract

• Banana flakes

Diarrhea

• Root cause – medication?

• Soluble fiber

• Fluids

– Small amounts throughout day

• Prune juice, apple juice

• Physical activity

• Stool softner/laxative; psyllium fibers

Constipation

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• Mucositis

– Routine mouth care

– Rinse with mild saline solution

– Drink liquids through a straw

– Suck on ice chips before a meal and during chemo

– Try L-glutamine 10 gm TID

Mucositis

Make Every Bite Count!

• Encourage whole foods • Calorie rich supplements for shake and

smoothie base • Greek yogurt adds protein and probiotics • Nut butters, power bites • Avocadoes • Beverages with electrolytes for hydration

• Ketogenic diet

– GBM, brain tumors

• Vegan diet

• Trends

– Juicing

– Kale

• Others?

75%

20%

5%

Ketogenic diet

Fat

Protein

Carbs

Special Diets

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Supplements

• Nutrients are best when obtained from food

• Antioxidants may interfere with treatment

• Helpful versus harmful

– Not absorbed or incorrect labels

– Supplements are not regulated

– Independent testing

– Consumerlab.com

– USP or NSF symbol

Supplements

• Pharma brands may have highest quality

• Price irrelevant

• Combinations of multiple supplements can be most dangerous

• Long term safety unknown – avoid when healthy?

RADIATION THERAPY Cancer Treatment

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Radiation Therapy

Most common associated with malnutrition risk

• Head and neck cancers

• Lung and esophageal cancers (surg/RT/chemo)

• Abdominal cancers (pancreas, gastric, liver, others)

• Pelvic RT (cervical, uterine, prostate, rectal cancers)

• Meet with RD weekly; weight; address issues

RT to Head & Neck Regions

• Includes RT to oropharyngeal, nasopharyngeal, oral cavity, tongue, tonsil, lymph nodes, larynx, etc.

• Typically 6500-7000 cGy over about 6 weeks (M->F)

• Often given with radio-sensitizing chemotherapy, such as Cisplatinum

• Most severe nutrition-related side effects

• May require enteral nutrition; tube may be placed prophylactically

• Psychosocial issues

RT to Head & Neck Regions

• RD meet weekly or twice per week with patient

– High calorie, high protein diet initially

– Modify diet according to side effects

• Soft foods, liquids, depend on nutrition supplements, such as Ensure®, Boost®

• EN; continue to encourage patient to swallow as able

– Salt/soda rinses; pain medicine; mucositis meds

– Nutrition is medicine

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RT to Head & Neck Regions

• Most side effects develop between 2-3 weeks of RT; may worsen as continues • Dysphagia, odynophagia, mucositis, dysguesia,

xerostomia, thick phlegm, anorexia, EN; psychosocial issues

• 5-10% weight loss high risk; EN recommended within this time; patient often resistant

• Side effects may continue for weeks/months after treatment

• Speech & Language Therapy (SLP) services

Mouth/Throat Side effects

Common Side Effects • Dysphagia • Odynophagia • Mucositis • Dysguesia • Xerostomia • Thick “ropey” phlegm • Anorexia

Remedies • Soft foods & liquid

supplements • Salt/soda rinse,

Biotene, MuGard, Triple Mix, liquid pain medicine

• Hard candy • Plastic utensils • Zinc supplementation • Cold foods • Megace/Marinol

RT to Head & Neck Regions

• Feeding tubes

–Formula

–Types of tubes

–Various regimens

–Emotional challenge

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RT to Chest

• Lung and esophageal cancers (surg/RT/chemo) – Lung patients often present with weight loss

– Lung patients have social issues as factors

• Esophageal – often followed by surgery

• High calorie, high protein diet

• Side effects: Esophagitis, food feels “stuck,” heartburn, anorexia

• EN

• SLP

RT to Abdomen

• Pancreas, gastric, liver, others

– Nausea and vomiting

– Bowel changes and lactose intolerance

– Anorexia

– Early satiety

• Monitor for malabsorption

• Encourage small, frequent meals, supplements

RT to Pelvis

• Cervical, uterine, prostate, rectal cancers

• Diarrhea or other changes in bowel pattern

– Low fiber, residue restricted; diarrhea management diet

– Adequate fluids

– Glutamine, probiotics

– Imodium

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Fatigue

• Fatigue

–Most common side effect; affects nearly all patients going through radiation therapy

–May affect food intake if sleeping much of the day

• Help at home (lists, convenience)

• Food as medicine

PREVENTION & SURVIVORSHIP

Cancer Prevention & Survivorship

• About 30% of all cancers may be prevented by:

–Making better food choices

–Being active

–Getting to and keeping a healthy weight

• Another 30% of cancers may be prevented by not smoking

• American Institute for Cancer Research

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Nutrition:

• Affects both sides of the

equation

• Supports gene expression

of health while treatment

addresses disease

ENTERAL NUTRITION

• Oral nutrition is preferred, but not always possible

• If the gut works, use it (EN vs. TPN)

– Stimulates bile flow

– Reduces risk of bacterial translocation

– Able to provide glutamine, FOS

– Lower risks of infection

– More cost effective

Basics of Enteral Nutrition

Ryan, Alison. (2013) Nutrition Support in the Oncology Setting. Oncology Nutrition for Clinical Practice. (pp. 123-

133). Oncology Nutrition Dietetic Practice Group Academy Nutrition and Dietetics.

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Quality of Life Factors

EN can prevent

₋ Weight loss

₋ Dehydration

₋ Hospitalizations

₋ Treatment interruptions

EN can promote

– Increased energy levels

– Participation in daily activities

The inability to eat is distressing to patients, however, most patients on EN report a positive experience

Indications for EN

• Disease specific – Head & neck

– Gastric

– Esophageal

– Pancreatic

• Treatment related – Malnourished patients who are unable to ingest or

absorb adequate nutrients for a prolonged period of time

– Treatment side effects anticipated to lead to malnutrition (H&N with RT and chemo)

Contraindications of EN

• Peritonitis(inflammation of peritoneal tissue)

• Intractable n/v/d

• Gastrointestinal bleed (GIB)

• Ileus (lack of GI propulsion/motility)

• Fistula (abnormal connection between organs/tissues)

• Poor prognosis

• TPN may be more appropriate with some of above

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• Percutaneous Endoscopic

Gastrostomy (PEG)

• Percutaneous Gastrostomy

Jejunostomy tube (PGJ)

• Percutaneous Gastrostomy

and Jejunostomy tube (PG&J)

• Jejunostomy tube (JT or PEJ)

• Nasogastric (NG)

• Nasoduodenal, nasojejunal

(ND, NJ)

Picture from : http://www.accc-cancer.org/resources/pdf/Nutrition-Optimizin-Enteral-Nutrition.pdf

Types of Tubes

• PEG percutaneous endoscopic gastrostomy

– Delivers feedings to stomach

– Feeding by syringe (bolus), pump or gravity drip

– NPO after placement (time varies – 6 hours at SH)

– Best for patients without insurance coverage – less supply cost

– Quick placement procedure by Interventional Radiology (IR) or endoscopy

Types of Tubes

• Single lumen PGJ

– Example: Shetty – one tube through stomach with feedings entering jejunum

– Feedings via pump or gravity drip (NO BOLUS!)

– Feedings immediately after placement

– Indicated for patients with gagging, n/v, aspiration risk; gastroparesis, gastric outlet obstruction, duodenal obstruction or fistula proximal to feeding tube

– Longer procedure, but same cost as PEG placement

Types of Tubes

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• Double lumen PG&J – Example: MIC – 2 tubes, one port to stomach & one

port to jejunum; G-port for decompression

– Feedings & flushes to j-port; meds & flush to g-port

– Feedings via pump or gravity drip

– Feedings immediately after placement via j-port • Nothing via g-port for 6-24 hours after placement

• Jejunostomy – Often placed in surgery

– Feedings via pump or gravity drip (NO BOLUS!)

Types of Tubes

• Size of tubes measured in French units

French # divided by 3 = mm of tube diameter

• Safety spike bags and ENFit connectors new 2015

Safety Spike set “ENPlus”

Transition tubing

EN syringe

Kangaroo feeding tube

Kangaroo Enteral Feeding Products ENFit Connections System. Covidien. 2014

Tube Tidbits

Patient Care

• Prevent muscle atrophy • Speech & language pathology

– Involved earlier the better – Swallowing exercises & therapy; detect silent

aspiration – Particularly head & neck patients, occasionally work

with esophageal

• Sanitation – Site care: soap & water; keep clean & dry; sutures

removed 10-14 days

• Mouth care

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• Polymeric

– Intact carbohydrates, proteins & triglycerides

• Standard = 1.0 – 1.2kcal/mL (moderate pro density)

• High nitrogen = 1.0 – 2.0kcal/mL (40-66g Pro/L)

– Fiber options

– Concentrated - Most often used for home EN plans

• 1.5 – 2.25kcal/mL

• Increase water flushes as needed

Types of Formulas

• Monomeric – Hydrolyzed nutrients for immediate absorption

– Appropriate for impaired digestion

– Low fat – generally MCT

• Disease specific

– Renal, hepatic, respiratory failure, glucose intolerant, stress/trauma

– Presurgical feedings for those malnourished (5-7 days)

• Modulars

– Supply a single ingredient (carb, pro, lipid)

Types of Formulas

• Oncology RDs often stock donated formula & supplies

• Oley Foundation

– National database of available formula

– Transfer between patients or organizations

– Only pay shipping costs

– Formula types depend on availability

– Supplies sometimes available

Formula Access

Oley Foundation http://www.oley.org/. Accessed April 2017.

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• Complications

– Aspiration/reflux (elevate head of bed)

– Diarrhea/constipation (likely NOT due to EN)

– Nausea/vomiting

– Refeeding syndrome (caution for oncology patients)

– Pressure necrosis, ulceration

• Prevent clogging with diligent flushing

• Tubes may need to be replaced every 6-12 months

Tube Management

• Water • Back & forth method with 60mL syringe • Small syringe for added pressure (30mL syringe) • Enzymes (Viokase) & sodium bicarbonate for

activation

– Mix together in 10mL syringe until dissolved

• NO COKE – Nothing should go into a feeding tube other than

prescribed formula, medications & water – Nothing is proven to work better than water to unclog

tubes

Unclogging Tubes

• Oncology RD in contact with patient for months after treatment

– Assess po intake; side effect improvement; weight

• Removal – MD office or IR – only takes a few minutes

Tube Removal

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• Insurance sometimes influences tube type

• Permanence = need of tube for at least 90 days “sustained in the medical record”

• 100% nutrition needs

• Rate 100mL/hour or less for pump justification

• Trial standard formula before special formula, such as a hydrolyzed formula

Medicare Guidelines

Center for Medicare and Medicaid Services. NCD for Enteral and Parenteral Nutrition Thereapy (180.2).

http://www.cms.gov/medicare-coverage-database/details/ncd-

details.aspx?NCDId=242&ncdver=1&DocID=180.2&SearchType=Advanced&bc=IAAAAAgAAAAAAA%3d%3d& . Accessed April 2017.

• Cancer treatments have a profound effect on the nutrition status of patients

• Side effects are common and similar across different types of treatments

• MNT is beneficial for most if not all and crucial to many cancer patients

• EN can help prevent and treat malnutrition in some cancer patients

Summary