Kimberly MorrisStevie Arroyo

Esophageal Cancer

Cancer that forms in tissues lining the esophagus, two main types: Squamous cell carcinoma - cancer

that begins in flat cells lining the esophagus

Adenocarcinoma - cancer that begins in cells that make and release mucus and other fluids

Incidence/Prevalence

Incidence: 4.6 per 100,000 men and women diagnosed per year (2001-2005)

Prevalence : Estimated new cases in 2008: New cases: 16,470 (12,970 men and 3,500

women)Deaths: 14,280

(http://seer.cancer.gov/statfacts/html/esoph.html)

Signs/symptoms

Dysphagia (difficulty swallowing )Unintentional weight lossPain in the throat , mid-chest areaHoarseness, hiccups vomiting of blood

Barium swallow →EndoscopyBiopsy

Diagnosis

The following stages are used for diagnosis of esophageal cancer:

Risk FactorsAge 65 or olderBeing maleSmokingHeavy drinkingDietObesityAcid refluxAbnormal cells in the esophagus

TreatmentWhen esophageal cancer is found very early,

there is a better chance of recovery.

At later stages, esophageal cancer can be treated but rarely can be cured.

Esophageal cancer is generally treated with surgery to remove the cancer

Treatment often includes minimizes discomfort caused by GERD and dysphagia.

(www.cancer.gov)

Treatment Patients with moderate-to-severe dysphagia

require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling. (Nguyen N., et. al., 2005)

Treatment varies depending on severity but dietary modification is a key component

Treatment In 2002 the ADA established a national dysphagia

diet with four different levels of treatment:

NDD Level 1: Pureed - homogenous, very cohesive, pudding-like, requiring very little chewing ability.

NDD Level 2: Mechanical Altered - cohesive, moist, semisolid foods, requiring some chewing.

NDD Level 3: Advanced - soft foods that require more chewing ability.

Regular - all foods allowed.

TreatmentNutritional factors are believed to aggravate

acidic reflux either by delaying gastric emptying or diminishing pressure of the LES (Holtmann G. 2007)

Decrease gastric discomfort by eating smaller meals with fluid in between

Avoid foods and activities that cause discomfort and irritation (smoking, alcohol, spicy and acidic foods)

TreatmentSurgery is usually paired with radiation therapy

for optimal results.

Results for radiotherapy studies showed a 13% absolute improvement in survival at two years (Gebski V, et. al. 2007)

Typical side effects or radiation therapy include: Trouble swallowingheartburnfatigueloss of appetite

Treatment - MNT Radiation Try to eat something at least 60 minutes before

treatment.

Bring snacks or nutrition supplements with you on the ride to and from treatment

Eat small frequent meals with fluids

Be sure to drink plenty of water and other liquids

Ask friends and family members to help by shopping for groceries and preparing meals.

Nick Seyer

Age: 58

Sex: Male

Occupation: Contractor

Ethnic Background: Caucasian

Assessment - Medical History

Drugs: TUMS, Alka-Seltzer, Pepcid consistently for past year

Noted 30Ib weight loss in last several months

Patient is a smoker and regular drinker

Family History: Mother had liver cancer, passed at age 58

Assessment - Medical HistoryChief complaints:

Significant heartburn for previous year

Patient has recurrent cough at night

Unable to eat due to heartburn pain, has difficulty swallowing foods with texture

Onset of disease: Dysphasia x 3-4 months, odynophagia x 5-6 months

Assessment - Medications/Drug InteractionsTums- treats upset stomach, vomiting heartburn,

and indigestion Side effects: Constipation and gasDrug interactions: may decrease absorption of drugs like tetracycline antibiotics and biphosphates.

Do not use if you have stomach/intestinal blockage, hypocalcaemia

(www.WebMD.com)

Assessment - Medications/Drug Interactions

Alka-Seltzer- Used to treat indigestion and low calcium in bloodSide effects: taste problems, incomplete or infrequent bowel movements.Drug interactions: phosphate supplements/antacid use can cause less absorption of phosphates, low phosphate levels in body

(www.WebMD.com)

Assessment - Medications/Drug Interactions

Pepcid- helps relieve heartburn and acid indigestionSide effects- persistent nausea, vomiting, stomach and abdominal painsDrug interactions- Aspirin/NSAIDS can cause stomach irritation/ulcers.

Do not take similar acid blockers at the same time. Consult doctor of other medication uses

(www.WebMD.com)

Assessment – Anthropometrics

Ht: 75” BMI: 24.7

Wt: 198 UBW: 230

IBW: 196 %IBW: 101% normal

%UBW: 86% mildly depleted energy

stores

Assessment – Physical Exam

Temperature: 98.3° F

Blood Pressure: 132/92 mm Hg

Heart Rate: 88 bpm

Resting Rate: 13 bpm

Nose/throat: dry mucus membranes

Assessment - Lab Values

Albumin 3.1 L 3.5-5

Total Protein 5.7 L 6-8

Pre-albumin 15 L 16-35

WBC 5.2 4.8-11.8

RBC 4.2 L 4.5-6.2 (men)

HGB 13.5 L 14-17 (men)

HCT

38 L 40-54 (men)

NORMAL

Assessment – Medical DiagnosisDoctor required patient to undergo chest x-

ray, endoscopy, biopsy, and CT scan

Doctor diagnosed patient with stage IIB adenocarcinoma of the esophagus

Patient underwent a trans-hiatal esophagectomy and received pre and postoperative external beam radiation therapy

During surgery patient was given a jejunal tube feed and prescribed Isosource HN 1.5 kcal at 75ml/hr x 24hrs

Assessment – Nutrition NeedsEnergy needs: BEE

66.5 + (13.8 x 198/2.2) + (5 x (75x2.54)) – (6.8 x 58) = 1866.6 x 1.2 (bed rest) x 1.2 (surgery)= 2687.9 kcal/d

Kcals from Isosource HN 1.575 x 24= 1800ml/d 1.5kcal x 1800ml/d= 2700 kcal

Protein needs: 198 lb / 2.2 kg/lb = 90 kg. 90 kg x 1.0 g/kg/d = 90 g/d

Assessment – Nutrition History

AM Used to eat eggs, bacon and toast every morning but has not eaten this for at least a month. Recently has had just coffee and cereal

LUNCH Previously ate cold packed lunch; sandwich, cold meat or other leftovers, fruit, cookies, and tea

DINNER All meats, pasta or rice, 2-3 vegetables, 1-2 beers

SNACKS Ice cream, popcorn, or homemade dessert

USUAL DIETARY INTAKE

Assessment – Nutrition History

AM 1 packet of instant oatmeal; sips of coffee

LUNCH 6 oz. tomato soup with 2-4 crackers

DINNER Macaroni and cheese – homemade ½ cup

SNACKS 1 scoop of chocolate ice cream

24 HOUR RECALL

Diagnosis – PES Statement

Inadequate oral food/beverage intake (NI- 2.1)

related to patients pre-surgical esophageal

discomfort, and current tube feed placement

as evidence by depleted protein stores and

reported weight loss of 30 pounds over

several months

Intervention – Goals

Short termEnsure patient is tolerating advancement to soft diet prior to dischargeEducation patient on diet changes he can make to minimize discomfort of eating

Long termGoal for patient is to maintain healthy body weight through proper nutrition

Intervention – Diet Order Recommendations

After clearance by physician and speech pathologist; Discontinue enteral or parenteral nutrition (ND-2)

If patient tolerates jejunal tube feeding (5-7 days post-surgery) start on clear liquid diet and advance diet as tolerated : mechanical soft to soft. (Mackenzie, et. al., 2005)

Intervention – Diet Order Recommendations

FruitsSoft, canned or fresh

fruit with pits and skin removed.

Applesauce, bananas, peaches, melons (no seeds).

Fruit juices. Avoid crisp or stringy

fruits such as green apples and rhubarb.

VegetablesSoft, cooked

vegetables with seeds and skin removed

Vegetable juiceAvoid raw, tough, or

stringy vegetables

http://www.bmc.org/thoraciconcology/pdf/esophogealsurgery.pdf

Intervention – Diet Order Recommendations

Meat & AlternativesMinced or ground

meatSoups prepared with

soft foodsCooked eggs, omelets Soft cheesesTofu Avoid overcooked or

dry and stringy meats.

Dairy & Misc. Yogurt Ice cream Pudding Whole milkNutrition

Supplements such as ensure or carnation instant breakfast

http://www.bmc.org/thoraciconcology/pdf/esophogealsurgery.pdf

Intervention – Education

Nutrition education including textured modified, high protein/energy diet and/or managing nausea/vomiting and fluid intake (Odelli C, et. al., 2005)

Education should include:Use of Protein supplements, high-energy foods,

and a soft dysphasia diet

Sit upright, chew slowly, and eat more than 3 hours before bedtime

Intervention – Education cont.

6 to 8 small frequent meals each day

Avoid foods that cause discomfort for example very hot or cold beverages and spicy foods

Avoid alcohol and smoking

Educate wife on cooking techniques and food selection

Monitoring and Evaluation While patient is still in the hospital monitor

weight and food intakes

Check labs every 3 days, ordered by physician

Once patient is discharged provide handouts and resources on nutrition

Patient may need additional nutrition counseling in the future; if he is having trouble eating he should ask to be referred to a RD

References “Cancer of the Esophagus Risk Factors.” National Cancer Institute. 01

Apr. 2009 <http://www.cancer.gov/cancertopics/wyntk/esophagus/page5 >.

“ Diagnosis of Esophageal Cancer.” National Cancer Institute. 01 Apr 2009 < http://www.cancer.gov/cancertopics/wyntk/esophagus/page7>.

“Drugs & Medication- Alka-Seltzer Antacid Oral.” WebMD. 2005-2009. 01 Apr 2009 < http://www.webmd.com/drugs/drug-13879-Alka Seltzer+Antacid+Oral.aspx?drugid=13879&drugname=Alka-Seltzer+Antacid+Oral>.

“Drugs & Medication- Pepcid AC Oral. WebMD. 2005-2009. 01 Apr 2009 < http://www.webmd.com/drugs/mono-250-FAMOTIDINE+10+MG+-+ORAL.aspx?drugid=16241&drugname=Pepcid+AC+Oral>.

“Drugs & Medication- Tums Oral.” WebMD . 2005-2009. 01 Apr 2009 <http://www.webmd.com/drugs/mono-2123-CALCIUM+CARBONATE+ANTACID+-+ORAL.aspx?drugid=9574&drugname=Tums+Oral

References “Esophageal Cancer.” Mayo Clinic Online. 11 May 2007. 01 Apr. 2009

< http://www.mayoclinic.com/print/esophageal-cancer/DS00500 /METHOD=print&DSECTION=all>.

“SEER Stat Fact Sheet- Cancer of the Esophagus.” National Cancer Institute . 01 Apr. 2009 <http://seer.cancer.gov/statfacts/html/esoph.html>.

Shaleen, Nicholas and David Ransohoff. “Gastroesophageal Reflux, Baretts Esophagus, and Esophageal Cancer. “ Journal of the American Medical Association. 2002; 287: 1972-1981

“Radiation Therapy.” American Cancer Society .13 Apr. 2009 http://www.cancer.org/docroot/MBC/content/MBC_6_2X_When_You_Have_Radiation_Therapy.asp?sitearea=MBC

Holtmann, G. GERD: How to Have a Better Day. Journal of Clinical Gastroenterology. July 2007; 41: 204-208.

References Odelli C, Burgess D, Bateman L, Hughes A, Ackland S, Gillies J,

Collins CE. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in esophageal cancer. Journal of Clinical Oncology. 2005;17:639-645.

Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J; Australasian Gastro-Intestinal Trials Group.Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in esophageal carcinoma: a meta-analysis. Lancet Oncol. 2007 Mar;8(3):226-34

Nguyen N., Moltz F., Vos C., Smith P., Karlsson H., Dutta U., Midyett S., Barloon A., Sallah J., Sabah F. Impact of dysphagia on quality of life after treatment of head-and-neck cancer. International Journal of Radiation Oncology, Biology, Physics; Mar2005, Vol. 61 Issue 3, p772-778, 7p