Nutritional Challenges in Lymphoma
Gayle Black
Senior Specialist Dietitian
Royal Marsden Hospital
Aims of the Session To consider the varied impacts a diagnosis
of Lymphoma can have on nutrition To consider how and why nutrition is an
important part of the patient journey To compare and contrast the role nutrition
played for two specific individuals
Nutrition at Diagnosis The lymphomas are a highly complex group of
diseases and nutritional implications at diagnosis are very much related to the individual diagnosis
The presence of B symptoms often leads to significant weight loss prior to diagnosis
Weight loss is present in approximately 50 % of all patients presenting with a gastric lymphoma (Balfe et al, 2008).
Oropharyngeal lymphomas may be related to swallowing difficulties at diagnosis
Nutritional Implications during Induction and Intensification Treatment
The exact side effects of treatments varies between individuals and treatment regimens
The diverse nature of Lymphoma leads to a wide variety of different nutrition related implications
Combination therapy can lead to more intensive side effects
Anxiety and prolonged stays in hospital can both adversely effect nutritional status
Not all patients undergoing treatment for lymphoma will have altered nutritional intake
Nutrition Related Side Effects Commonly Seen
Mucositis Xerostomia Nausea Vomiting Fatigue Anorexia Abdominal Cramps
Diarrhoea Constipation Hyperglycaemia Increased Appetite Fluid Retention Taste Changes Heart Burn
Why is Nutrition Important during treatment for Lymphoma?
The provision of food and fluids is a basic care (BMA, 1999)
Malnutrition can have a significant impact on survival and performance status
Up to 20% of all patients treated for cancer are deemed to die from the effects of malnutrition (Mercadante, 1998)
Malnutrition may decrease tolerance to treatment and increase incidence of dose limiting side effects
Wound healing is reduced in malnutrition
Eating as a Social Experience Expression of love and caring Expression of individuality To reward or punish A focus for communal activities As a control issue As a coping strategy As a treatment Weight loss is an outward symbol of poor health
Case Study 1 – The Physical Challenges of Diet and Lymphoma 58 yr old Male Presented in May 2008 with a year long history of
fatigue, poor appetite and weight loss On admission is very weak, dehydrated and
confused with a performance status of 3 Following investigations is diagnosed with Stage
IVB Diffuse Large B Cell Lymphoma
Nutritional Status on Admission Presented with a history of accelerated
unintentional weight loss over approximately a two month period
Weight on admission = 63 Kg with moderate ascites (est. 6 kg)
BMI on admission = 17.5kg/m² % wt loss on admission = 18 %
During Admission Initially nasogastric tube insertion attempted but
unsuccessful due to tube curling in the oesophagus
Following referral to the Dietitian routine of small regular snacks supplemented with Scandishake bd and Calogen 30ml tds successfully implemented
Performance status quickly improves and discharge home is planned
But then…. Patient starts to become increasingly
unwell BNO and abdomen becomes very
distended with absent bowel sounds Refusing all food and fluid due to abdo pain Paralytic ileus diagnosed secondary to
Vincristine
Management Plan Conservative management NBM with NGT for drainage PICC line inserted for TPN Over the next few weeks patient continues
to go in and out of obstruction with the reintroduction of oral diet attempted on several occasions
Weaning off PN and Moving Forward Diet eventually reintroduced although
patient has now been in hospital for 2 months
Reports sore mouth and taste changes secondary to oral Candida
Complaining of taste fatigue with hospital food and supplements
Early satiety secondary to ascites
Nutritional Status on Discharge Weight = 62 Kg (without ascites) BMI = 19 Kg/m2
Oral intake providing approximately 800 kcal/day and 40g protein from meals and snacks
Additional intake from oral nutritional supplements to support weight gain
Where are we now? Following discharge from hospital he struggled to
cope at home and family relations suffered as a result
Spent several months being cared for in a nursing home
However he has now completed a course of single agent Rituximab and is on long term follow up
His weight is stable at 67 Kg (BMI = 21 Kg/m2) and the recurrent ascites has stopped
He’s back in his own home although so far has been unable to return to work
Case Study 2 – The Psychological Challenges of Diet and Lymphoma
21 yr old Male Lives at home with his parents and younger
sister Treated in childhood for both Lymphocyte
predominant Hodgkin's Disease and B-NHL
Autologous transplant in 1999
Recent Medical History Hodgkins Disease relapsed 2008 aged 20 Presented with a history of unexplained
weight loss and lethargy Relapse confirmed following endoscopy
and chemotherapy commenced shortly afterwards
Reduced Intensity Allograft July 2009
Nutritional Status on Discharge Post Transplant
Weight on day of discharge = 55 Kg BMI on discharge = 17 Kg/m2
Managing small amounts of meals and snacks, slowly increasing portion sizes
Supplementing diet with Fortijuce bd
Challenges at Home Weight falling at each review Refusing all nutritional supplements Food choices becoming more and more
limited Mother confides that he is becoming
socially isolated and withdrawn Spending large periods of time comparing
his appearance to others
Nutritional Status at Readmission Weight = 45 Kg BMI = 14 Kg/m2
% Weight loss = 18 % Medical investigations all unable to identify cause
for weight loss, referred to gastroenterologist Agreed to referral for counselling, CLIC sergeant
social worker and young people’s activity coordinator
PEG tube inserted
Five Weeks Later Discharged from hospital Weight = 50.4 kg BMI = 16 Kg/m2
Tolerating overnight feeds very well and independent with all aspects of PEG care
Eating small meals and supplementing with extra snacks
Where are we now? PEG removed 3 weeks ago Eating a full and varied diet Weight maintained at 61 Kg with a BMI of
19 Kg/m2
Recently spent a week in Cornwall with friends from college
Looking for part time work
Summary Eating difficulties for our patients can be due to a
wide variety of factors and can change with time The consequences of a reduced nutritional intake
can impact all aspects of our patients lives and should not be underestimated
The link between nutritional status and performance status is key
Each individual we meet will have very different needs, importance of not making assumptions