Nutritional requirements in long term conditions - Cancer Rachael Donnelly & Rachel Barrett Highly Specialist Oncolo

1. Nutritional requirements in long term conditions - Cancer Rachael Donnelly & Rachel Barrett Highly Specialist Oncology Dietitians Guy’s & St Thomas’ NHS Foundation Trust PEN Group Summer Meeting August 1st 2006

2. Promote further understanding of cancer cachexia & cancer as along term condition Review current evidence base for nutritional requirements & the provision of nutritional support for cancer patients Acknowledge the practicalities of providing such requirements through an interactive case study Aims

3. ‘… the disordered & uncontrolled growth of cells within a specific organ / tissue type …. they often produce secondary growths / metastasis … this is the central & most threatening feature of malignant disorders….’ ‘… cancer is a collection of diseases with the common feature of uncontrolled growth … there are several causes, but ‘lifestyle’ factors are a major influence … several cellular changes are required to generate cancer …. invasion & metastasis distinguish cancers from benign growths ….. cancers are not always lethal…’ (Brennan, 2004) What is Cancer?

4. 1 in 3 will get cancer at some stage of their lives 250,000 diagnosed with cancer per annum (Equivalent to 684 diagnoses daily) In the UK 154 460 people died from cancer in 2001 (www.cancerresearchuk.org) Cancer – UK Facts & Figures

5. Site of cancer Type Stage of cancer Multi-modality treatment i.e. chemotherapy, radiotherapy, surgery & biological therapies Side effects of treatment & disease Co-morbidities Age of patient Social circumstances i.e. alcohol / drug & nicotine dependency Cachexia syndrome Considerations in managing a cancer patient

6. Theories of Nutrition & Cachexia

7. Due to starvation Due to malnutrition Due to competition by the tumour Restricted to cancer Reversed by nutritional support (Regnard, 2004) Cancer Cachexia - What it is not?

8. Derives from the Greek ‘kakos’ meaning bad & ‘hexis’ meaning condition (Shaw, 2000) A physical fading of wholeness Syndrome of decreased appetite, weight loss, metabolic alterations & inflammatory state Cancer Cachexia - Definitions

9. An extreme on the continuum of weight loss in cancer Seen in cancer, cardiac disease & chronic infection but not neurological disease Due to a systemic inflammatory response Mediated through cytokines & other factors such as proteolysis inducing factor (PIF) & lipid mobilising factor (LMF) (Regnard, 2004) Cancer Cachexia - What it is?

10. Some or all of the following features are exhibited in varying degrees: Hypophagia / anorexia Early satiety Anaemia Weight loss with depletion & alteration of body compartments Oedema Asthenia (weakness) (Freeman & Donnelly, 2004) Cancer Cachexia - Features

11. Occurs in ~ 70% of patients during the terminal course of disease Weight loss > 10% pre illness weight occurs in up to 45% of hospitalised cancer patients Cancer of the Upper GI & lung have the highest prevalence of weight loss Lung cancer patients with 30% weight loss show 75% depletion of skeletal muscle Breast cancer, sarcomas & NHL show the least weight loss (Payne-James et al., 2001) Cancer Cachexia - Prevalence

12. Understanding is limited & based upon the knowledge of abnormalities in nutrition behaviour & metabolic patterns Appears as a classic case of malnutrition 3 theories have been suggested: Metabolic competition Malnutrition Alterations of metabolic pathways (Payne-James et al., 2001) Cancer Cachexia - Aetiology

13. Neo-plastic cells compete with host tissues for protein, functioning as a ‘nitrogen trap’ In experiments where tumour is a high % of animal weight this theory holds, but in human tumours – even patients with a very small tumour can have severe cachexia (Morrison, 1976) Cancer Cachexia - Metabolic Competition

14. Upper aerodigestive disease is an obvious cause of malnutrition Regardless of tumour location, anorexia is the most common cause of hypophagia & usually consists of a loss of appetite &/or feelings of early satiety Hypophagia has been related to the presence of dysgeusia Diminished ability to perceive sweet flavours leads to anorexia (Payne-James et al., 2001) Cancer Cachexia – Malnutrition (1)

15. Reduced threshold for bitter flavours linked to an aversion to meat Dysosmia is also related to an aversion to food Malnutrition leads to secondary changes in the GI tract which may be responsible for the feeling of fullness, delayed emptying, defective digestion & the poor absorption of nutrients However, malnutrition alone is not thought to be the main cause of cachexia (Payne-James et al., 2001) Cancer Cachexia – Malnutrition (2)

16. Metabolic Alterations in Starvation V. Cancer Cachexia – CHO Metabolism Adapted from Rivadeneira et al.,1998

17. Metabolic Alterations in Starvation V Cancer Cachexia – Fat Metabolism Adapted from Rivadeneira et al.,1998

18. Metabolic Alterations in Starvation V Cancer Cachexia – Protein Metabolism Adapted from Rivadeneira et al., 1998

19. Produced by host in response to tumour Cytokines regulate many of the nutritional & metabolic disturbances in the cancer patient leading to: Decreased appetite Increase in BMR Increased glucose uptake Increased mobilisation of fat & protein stores Increased muscle protein release (Tisdale, 2004) Cancer Cachexia - Cytokines

21. Nutritional Requirements in Cancer

22. Cancer itself does not have a consistent effect on resting energy expenditure (REE) Oncological treatment may influence energy expenditure (Arends et al., 2006) Energy Expenditure

23. In cancer patients, REE can be: Unchanged Increased Decreased Many cancer patients are mildly hypermetabolic with an excess energy expenditure of between 138-289 kcals per day (Hyltander et al., 1991) If not compensated by ↑ energy intake results in loss of 1.1 - 2.3kg muscle mass & 0.5 – 1.0kg body fat / month (Bozzetti F et al.,1980) The challenge is identifying which patients Resting Energy Expenditure

24. When working out the energy requirements for a patient with cancer, would you add a stress factor?

25. Assume energy requirements are normal unless data available to say otherwise (Arends et al., 2006) It is not appropriate to add calories for weight gain when calculating requirements for cancer patients Energy Requirements (1)

26. For non obese cancer patients total energy expenditure is approx: 30-35kcal/kgBW/d in ambulant patients 20-25kcal/kgBW/d in bedridden patients Assumptions are less accurate for underweight individuals (TEE per kg is higher in this group) (Arends et al., 2006) Published reference calculations are more accurate for underweight cancer patients (Harris & Benedict 1919, Schofield 1985) Energy Requirements (2)

27. Optimal nitrogen supply for cancer patients can not be determined at present (Nitenberg et al., 2002) Protein requirements are calculated as per published reference calculations (0.17-0.2g Nitrogen per kg) (Elia, 1990) Protein Requirements

28. Vitamins & Minerals – lack of evidence surrounding requirements in oncological disease Base requirements on UK RNI’s (PEN Group, 2004) For EN recommendations are based on RDA’s (ASPEN, 2002) Vitamin and Mineral Requirements (1)

29. Markers of oxidative stress are increased & levels of anti-oxidants are decreased in cancer patients (Mantovani et al., 2003) Inclusion of increased doses of anti-oxidant vitamins could be considered but at present lack data to demonstrate clinical benefit (Arends et al., 2006) In reality, not routinely measuring vitamin & mineral status in such patients Vitamin and Mineral Requirements (2)

30. Aims of Nutritional Support

31. ‘An improvement in survival due to nutritional interventions has not yet been shown’ (Arends et al., 2006)

32. ‘Unintentional weight loss of ≥ 10% within the previous 6/12 signifies substantial nutritional deficit & is a good prognostic indicator of outcome’ (DeWys et al., 1980)

33. Improve the subjective quality of life (QoL) Enhance anti-tumour treatment effects Reduce the adverse effects of anti-tumour therapies Prevent & treat undernutrition (Arends et al., 2006) Cancer - Aims of Nutritional Support (NS) (1)

34. ‘…the principle aim of nutritional intervention with cancer patients will be to maintain physical strength & optimise nutritional status within the confines of the disease…’ (van Bokhorst de van der Schueren et al., 1999) ‘…nutritional intervention should be tailored to meet the needs of the patient & realistic for the patient to achieve…’ (Mick et al., 1991) Cancer - Aims of Nutritional Support (2)

35. Optimum nutrition improves therapeutic modalities & the clinical course & outcome in cancer patients (Rivadeneira et al., 1998) Numerous studies strongly suggest substantial weight loss >10% leads to adverse consequences: Reduced response to chemotherapy & radiotherapy Increased morbidity Poor quality of life (QoL) Increased mortality rate (Van Bokhorst de van der Scheren et al., 1997) Aims of Nutritional Support (3)

36. If undernutrition is already present If inadequate food intake is anticipated for more than 7 days It should substitute the difference between actual intake & calculated requirements Inadequate nutrition throughout treatment course leads to increased morbidity & mortality, & reduced tolerance to treatment (Arends et al., 2006) When should Nutritional Support be started?

37. Yes, in patients whose weight loss is due to insufficient nutritional intake secondary to obstruction e.g. upper GI, head & neck In cachexic patients it is virtually impossible to achieve whole body protein anabolism Goals of NS are therefore different (Arends et al., 2006) Can Nutritional Support improve Nutritional Status in Cancer?

38. There is no reliable data to support the effect of nutrition on tumour growth ‘Feeding the tumour’ should have no influence on the decision to feed a cancer patient (Arends et al., 2006) Does Nutrition Support Feed the Tumour?

39. Nutrition Support Throughout the Cancer Patient’s Journey

40. Patient’s with severe undernutrition benefit from NS 10-14 days prior to major surgery, even if surgery has to be delayed (Meyenfeldt von., 1992) All patients undergoing major abdominal surgery, NS (with immune-modulating substrates) is recommended for 5-7 days independent of nutritional status (Braga et al. 1999) Nutritional Support – Pre / Peri - Operative

41. Currently, there is no strong evidence for routine NS during CT as it has no effect on tumour response to CT, nor on CT related associated unwanted side effects Symptom control is vital prior to any NS i.e. adequate anti-emetic control of nausea & vomiting Timely NS is necessary in many patients undergoing chemotherapy (Arends et al., 2006) Nutritional Support – Chemotherapy

42. Intensive dietary counselling or NS prevents therapy associated weight loss & interruption of RT when compared to normal food Routine NS is not indicated in abdominal RT Nor is there any suggestion that routine NS is beneficial during RT to any other part of part of the body other than the head & neck & oesophageal (Arends et al., 2006) Nutritional Support – RT / Chemo-RT

43. Interactive Case Study

44. Male- Mr D 52 yrs Diagnosis- T4N3M0 SCC Left Floor of Mouth (FOM) PMH- CABG x 3 ’99 & Hypertension Social History Lives alone above a pub Alcohol intake approx. 63 units/week Smokes 50g tobacco/week Security Guard Case Study (Background)

46. Weight on referral- 55kg 17/05/05 Usual weight- 55-60kg Ideal weight- 56-69kg BMI- 19.7kg/m2 No recent weight loss Grip strength 28.5kg (<69% of normal) Diet History 4 strong black coffee’s each with 2 sugars 1 meal daily, early evening, takeaway Cornish pasty & chips Approx. 5 pints strong lager +/- 2-3 double vodkas per night Initial Nutritional Assessment

47. 23/05/05 resection of FOM with DCIA flap Hemi-glossectomy Left radical neck dissection Right neck dissection Dental clearance Nil by mouth & tracheostomy in situ 13/06/05 debridement of DCIA flap 15/06/05 PEC major flap after failure of DCIA flap 04/08/05 post surgery 6/52 radiotherapy Oncological Treatment

49. When calculating Mr D’s energy requirements post operatively what stress factor would you use?

50. Requirements calculated using 10% stress factor (SF) & 20% activity factor (AF) – approx. 2000kcal, 60-70g Protein Fed 2000ml Nutrison Multi fibre (2000kcal, 80g Protein) Weight increased 61.2kg- oedematous, 5 days later 55.3kg What actually happened