Therapeutic Nutrition In the Oncology Population

1. Therapeutic Nutrition In the Oncology Population Suzanne Dixon, MPH, MS, RD Oncology Nutrition Specialist & Epidemiologist Cancer Nutrition Info, LLC www.cancernutritioninfo.com

5. Cachexia vs. Anorexia Anorexia: �Lack of Appetite� & �Involuntary Decline in Food Intake� Anorexia is EFFECT rather than CAUSE of Cachexia Cachexia is term to describe the disordered metabolism of diseases including (but not limited to): Cancer HIV/AIDS Sepsis Other chronic infections Other Inflammatory Conditions

6. Cytokines Responsible for Metabolic Alterations

7. Disordered Metabolism

9. Treatment Nutrition Goals Phase 1: Getting Through Treatment (Primary Goals) Prevent or correct nutritional deficiencies Minimize short-term and long-term treatment side effects Improve tolerance to treatment Enhance quality of life during treatment Help achieve and maintain optimal body weight Educate family members about special nutrition needs Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!

10. Treatment Nutrition Goals Phase 2: Cancer Fighting Nutrition For Life (Secondary Goals) Maintain healthy weight Incorporate healthy nutrition habits for long-term health Maximize cancer preventive potential of the diet (minimize recurrence risk) Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!

11. Addressing Primary Clinical Nutrition Intervention Goals

12. Screening Vs. Assessment SCREENING To detect possibility of nutrition risk Provide information to determine if follow-up is required All oncology patients in all settings require screening Screen must be simple & self-administered Screen determines whether patient is referred to specialist (RD) If screening detects need for more intensive assessment & intervention, arrange for this immediately If referral unnecessary, document screen & re-screen at follow-up ASSESSMENT More intensive & thorough Includes intervention, follow-up, intervention, follow-up, etc.

13. The Who & How of Screening Generally, nursing staff performs screen: In-home & Outpatient May simply provide & collect form to/from patient & return it to the office for screening score & further intervention planning Different clinics & home care companies use different methods for patient referral Forms handed to dietitian prior to scoring Forms scored & referrals made by nursing/medical staff Referral must be made if patient is classified at risk Dietitian may keep & store screening forms, but it will need to be in permanent medical record Best Tool: Patient-Generated Subjective Global Assessment (PG-SGA)

14. Screening Tool Fundamentals SCREENING TOOL PG-SGA = Patient Generated Subjective Global Assessment Despite the name, PG-SGA is a good screening tool PG-SGA is validated for use in oncology populations Easy to administer & score ITEMS ON A NUTRITION SCREEN Weight History & Percent Weight Change Food Intake: Has It Changed? Symptoms Functional Status Disease & stage Metabolic demand Physical exam

15. PG-SGA Scoring & Optimal Intervention PG-SGA Score Guides Nutrition Intervention Not At Risk: Additive Score = 0 to 1 No intervention required at this time; continue to screen at follow up visits Stage A/Low Risk: Additive Score = 2 to 3 Well nourished, but may still be at risk; intervention includes education by dietitian or nurse, with pharmacologic nurse or physician triage as indicated by symptom survey Stage B/Moderately Malnourished: Additive Score = 4 to 8 Moderately malnourished, requires dietitian intervention working in conjunction with nurse, physician, and medical care team as indicated by the symptom check-off for pharmacologic management Stage C/Severely Malnourished: Additive Score = 9 or greater Critical need for symptom mgmt and other nutrition intervention. Requires interdisciplinary team discussion to address all aspects affecting nutritional status and discussion of non-oral nutrition options including enteral or parenteral nutrition as dictated by gut function

16. From Screening To Assessment AFTER SCREEN INDICATES RISK, FULL ASSESSMENT: Weight History & Percent Weight Change; Consider IBW Appearance, behavior, mental health Age & Gender Functional status (Karnofsky Score, ECOG Score, etc.) GI, oral cavity, head & neck region, cancer type & location Intake: Diet History & 24-Hour Recall FFQ generally NOT appropriate in the clinical setting Diet records are impractical Biochemical parameters: Albumin, Prealbumin, Transferrin, Hematocrit, Hemoglobin, RBP, glucose, CRP, Serum Creatinine Medications & Planned Treatment Psychosocial?? Financial??

17. Symptoms Affecting Nutrition Status Diarrhea Sore Mouth Dry Mouth Altered Taste/Smell Constipation Lack of Appetite Fullness/Early Fullness Fluid status (ascites, edema) Dumping Syndrome Nausea/Vomiting Other Pain

18. Nutrition Can Help Manage Symptoms KEY: START EARLY Specific Diet Modifications Will Help Minimize Nutrition-Related Side Effects Each Side Effect Has Numerous Approaches for Mgmt Nutrients/Food will PROFOUNDLY Affect The Body Written Materials Alone May Not Be Sufficient

20. When Is Initiation of Enteral Nutrition Indicated? Actual or anticipated inability to meet 50% of needs for 7 or more days Contributes to Quality/Length of life in meaningful way Can improve tolerance to treatment and/or ultimate outcome Patient wants it A functioning gut (to some degree) is present Is not contraindicated Obstruction? Gastroparesis? May be able to by-pass with a J-tube Is there hypomotility of the small intestine as well? Nausea/Vomiting? Often can get around this if using a J-tube

21. Beginning Enteral Feeding Use HBE to determine Calorie Needs Males: BEE = 66.5+(13.7xW{kg})+(5.0xH{cm})-(6.8xA{yrs}) Females: BEE = 655+(9.6xW{kg})+(1.9xH{cm})-(4.7xA{yrs}) (Quick & Easy: 35-50 kcal/kg for hypermetabolic patients) Protein Needs 1.3 to 1.5 grams/kg body weight (IBW or Adjusted IBW) Adjusted IBW = (Actual BW - IBW) x (0.25 to 0.4) + IBW IBW: Males = 106 lbs + 6 lbs/inch + 10%; Females = 100 lbs + 5 lbs/inch + 10% Fluid Needs 1500 mL for first 20 kg of body weight + 20 mL per kg for each kg over 20 kg

22. Basic Points For Enteral Feeding SELECT FORMULA CONSIDERING: Osmolality (280 to 350 mOsm ideal for J-feeds); Albumin?? Calories per cc Malabsorption (Specialty Formulas, MCT oil) Account for free water & supplement liberally as needed ROUTE OF ADMINISTRATION Will G-Tube Be Tolerated? Is J-Tube Necessary? (can bypass nausea & high obstructions) Begin slowly; always, Always, ALWAYS use pump with J-Tubes Gravity Feed/Bolus Bolus feeding: 250 - 300 mL over 15 minutes, followed by 25-60 mL water; at least 3 hours b/w each bolus feeding

23. Trouble Shooting for Enteral Feeding Problems

24. Addressing Secondary Clinical Nutrition Intervention Goals

25. Healing 101: No Judging Why judge? It should be clear why a client is doing a specific approach! Don�t take it personally! Compliment client on initiative - Do NOT indicate disdain Don�t forget the power of �self-help�

26. Healing 102: Everyone is Unique The story of the medical student and loss of compassion Use science but be compassionate Don�t betray your own principles but DO be flexible Never say never!

27. Healing 103: Nocebo Effect What about YOUR expectations? Your power is greater than you believe or know Don�t betray your own principles but DO be honest & compassionate Never say never!

28. First Do No Harm Discouragement of a harmless or potentially beneficial intervention may constitute harm (must consider all aspects including psychological, emotional, socioeconomic, etc) Nutrients & Food Have The Ability To PROFOUNDLY Affect Our Bodies, On Many Levels For the Client, �Food & Nutrition Are POWER, And YOU Control That Power By Choices!�

29. Think About This If you think you don�t need to think about this, you�re missing the boat A Few Nutrients of Interest: Capsaicin Coenzyme Q-10 Eicosapentaenoic Acid (EPA) (Omega-3s) Glutamine Ginger Milk Thistle Probiotics Zinc

35. �Best Bet� Complementary Cancer Therapies Eicosapentaenoic Acid (EPA) (Omega-3s) Essential fatty acid with potential roles in inflammation, immunity, cachexia May help decrease cachexia May improve chemotherapy effectiveness/enhance immune function Downside: May have anticoagulant activity so use with caution if platelets low or on coagulation therapy Generally well tolerated (up to 0.3 g EPA+DHA/kg body weight/day), but diarrhea possible Dose: Minimum dose of 2.2 mg EPA per day (best to avoid coagulation complications) Two new products on the market Prosure & Resource Support

36. What Is Glutamine? Neutral, gluconeogenic nonessential amino acid Stored primarily in skeletal muscle (75%) and liver (25%) Nitrogen carrier between tissues Primary energy source for rapidly proliferating cells (e.g. intestinal epithelium, activated lymphocytes, & fibroblasts) May be conditionally essential; depleted in stress states (e.g. surgery, sepsis, & cancer) Appears to be synthesized in muscle tissue in substantial amounts Plasma concentrations are quite high, second only to alanine Needed for renal acid-base balance

37. Why Glutamine For Oncology? Neuropathy Arthralgias Myalgias Diarrhea Enteritis & GI Mucosal Damage Stomatitis Muscle Mass Preservation??

38. Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action Role in circulating nerve growth factor levels increased peripheral neuropathy concurrent with declining serum nerve growth factor concentrations animal models: glutamine up-regulates nerve growth factor mRNA ongoing studies are examining nerve growth factor concentrations in banked serum

39. Glutamine For Neuropathy:Physiology & Possible Mechanisms of Action Role in pain perception in the cerebral cortex glutamine is a precursor amino acid for excitatory neurotransmitters such as glutamate and GABA glutamine into astrocytes and converted to glutamate (glutamine synthetase), then released into synapse some glutamate in neurotransmitter capacity, but some used for neuronal energy requirements hypothesized that high systemic glutamine concentrations may down-regulate conversion of glutamine to glutamate

40. Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action Role in metabolic stress states Glutamine freely released from skeletal muscles in states of metabolic distress Advanced malignant disease results in muscle glutamine depletion and weight loss Stress hormones induce decreased muscle glutamine concentrations, even in healthy adults Intracellular glutamine concentrations ? more than 50% under metabolic stress Glutamine is known to preserve glutathione concentrations; glutathione is needed for intracellular redox status

41. Glutamine For Arthralgias/Myalgias:Physiology & Possible Mechanisms of Action Role in metabolic stress states Previous research suggests that during periods of metabolic stress, approximately 15 to 35 grams of supplemental glutamine may be needed to preserve muscle glutamine concentrations, provide fuel for cells with rapid turnover, and improve overall nitrogen balance. Glutamine is vital as energy for rapidly proliferating cells, it may be extracted from muscles and supplied to other cells at the expense of muscle and connective tissue integrity Altered redox status and resultant oxidative damage may also play a role in pain syndromes

42. Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action Role in provision of energy, nutrients, cellular building blocks to enterocytes Well-documented that glutamine is preferred fuel for GI tract Three potential mechanisms through which glutamine appears to exert positive effects on GI tissue: Primary cellular fuel of enterocytes Precursor for nucleotides needed for cell regeneration Source of glutathione, an endogenous anti-oxidant system

43. Glutamine For Diarrhea/Enteritis:Physiology & Possible Mechanisms of Action Cell, Animal, & Human Studies Demonstrate: Glutamine is documented as preferential fuel for enterocytes, esp. during stress Controls glycogen synthesis in enterocytes Decreases protein degradation in enterocytes Demonstrated to enhance gut cell mass Demonstrated to increase height of mucosal villi Demonstrated to increase numbers of mucosal villi Decreases bacterial translocation under stress

44. Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action Role in weight loss for HIV/AIDS Loss of body cell mass (BCM) correlates with length of survival in this, and other, populations Hypothesized that glutamine, which is conditionally essential, may be rate-limiting for repletion of BCM Muscles synthesize glutamine & release into circulation

45. Glutamine For Muscle Mass Maintenance:Physiology & Possible Mechanisms of Action Role in weight loss for HIV/AIDS Tissues that consume glutamine extract as needed from circulation During stress and inflammation, consumption of glutamine exceeds ability of skeletal muscle to supply this amino acid Blood & muscle glutamine concentrations decrease and muscle breaks down to satisfy needs

46. Glutamine For Muscle Mass Maintenance:Research Evidence Study Shabert et al. 1999 40 grams glutamine/day in divided doses 26 patients total Double-blind, placebo controlled (glycine as control) Over 3 months: glutamine group gained 2.2 kg vs. 0.3 in control (1.8 kg BCM vs. 0.4 kg BCM) Given common etiology between wasting seen in HIV/AIDS and wasting seen in cancer cachexia, it may be possible to enhance lean body mass retention throughout cancer treatment with glutamine

47. �Best Bet� Complementary Cancer Therapies Glutamine Amino Acid May help with diarrhea/GI symptoms & sore mouth/throat May help decrease mucositis (5-FU) May help decrease radiation enteritis May help With Aching Muscles/Nerves (Taxol) Downside: No major side effects, some minor side effects Do not take if you have poor kidney and/or liver function Dose: 10 grams glutamine powder, three times per day, dissolved in liquid (research has been done with Cambridge Nutraceuticals-Baxter Pharmaceuticals & Glutasolve by Novartis)

48. Think About This Looking at a summary of some other potentially important interventions: A Few Nutrients of Interest: Capsaicin Coenzyme Q-10 Eicosapentaenoic Acid (EPA) (Omega-3s) Glutamine Ginger Milk Thistle Probiotics Zinc

50. �Best Bet� Complementary Cancer Therapies Coenzyme Q10 Antioxidant May protect heart muscle from damage during treatment with certain chemotherapy regimens (adriamycin) Downside: Appears to be safe when used in reasonable dose It acts as an antioxidant and some experts believe antioxidants are counterproductive during radiation therapy; data is mixed concerning antioxidants during radiation therapy, but overall suggests moderate use is ok Dose: 30 mg two times daily

51. �Best Bet� Complementary Cancer Therapies Ginger Food spice that also has medicinal properties Taken as tea or root may help alleviate nausea Also try 'natural' ginger ales Downside: Can act as mild anti-coagulant Use with caution if low platelets or are on anti-coagulant medications (e.g. coumadin, heparin, etc.) Dose: Chopped/dried extracts for tea, taken 2-3 times daily 940 mg once daily of powdered ginger root for nausea prevention 250 mg of powder taken 4 times daily for nausea mgmt

52. �Best Bet� Complementary Cancer Therapies Milk Thistle May help protect the liver from damaging effects of chemotherapy; may protect kidney & other organs May help the liver regenerate & recover after damage Downside: Appears very safe for use in cancer patients; not much data on use in those with liver involvement Mild nausea is a reported side effect Mild anti-coagulant; use with caution if platelets are low May reduce effectiveness of oral contraceptives Dose: 140 mg standardized to 70-80% silymarin, 3 times daily Phosphatidylcholine-bound silymarin, 100 mg 3 to 4 times daily

53. �Best Bet� Complementary Cancer Therapies Probiotics �Healthy Bacteria� in yogurt & other fermented foods May have selective immune modulating activity May decrease rates of �opportunistic� infections May decrease diarrhea, mucositis, improve nutrient absorption Downside: Not many downsides however� Dietary supplement products are poorly regulated and contamination is possible (yogurt & other fermented dairy are good options) May need to be avoided in severe immune compromise (e.g. BMT populations) Dose: Unknown

54. �Best Bet� Complementary Cancer Therapies Zinc May help restore sense of taste during radiation therapy to head/neck region May take up to 1 month for noticeable effect Downside: Short term use improves immune function, long term use may suppress immune function DO NOT USE if on cisplatin as zinc may increase toxicity Dose: 30 - 50 mg daily elemental zinc daily (~135 - 220 mg zinc sulfate, divided into three doses)

55. Use the Resources That Are Available To Evaluate CAM Herbal/Supplement Resources (websites): http://www.cancernutritioninfo.com http://www.tnp.com http://www.mcp.edu/herbal/ http://www.herbmed.org http://www.naturaldatabase.com/ http://ods.od.nih.gov (http://ods.od.nih.gov/databases/ibids.html) http://my.webmd.com/medical_information/drug_and_herb/drugs/default.htm http://www.mskcc.org/aboutherbs http://www.consumerlabs.com http://www.quackwatch.org http://vm.cfsan.fda.gov/~djw & http://www.cfsan.fda.gov/~dms/supplmnt.html http://www.ncbi.nlm.nih.gov/pubmed http://www.herbalgram.org http://www.ars-grin.gov/duke/index.html http://www.herbs.org http://dietary-supplements.info.nih.gov http://nccam.nih.gov

56. Use the Resources That Are Available To Evaluate CAM Look at the Herbal/Supplement Resources (books): Mosby�s Handbook of Herbs & Natural Supplements German Commission E Monographs The Health Professional�s Guide to Popular Dietary Supplements The Honest Herbal & Herbs of Choice Herbal Drugs and Phytopharmaceuticals The Encyclopedia of Medicinal Plants Integrative Medicine: Your Quick Reference Guide PDR for Herbal Medicines Herbal Medicinals: A Clinician�s Guide H erbal Medicines: A Guide for Healthcare Professionals The American Pharmaceutical Association Practical Guide to Natural Medicines Rational Phytotherapy: A Physican�s Guide to Herbal Medicine Many, many journals also available

57. Does Nutrition Matter for Survival?

58. Findings of Special Interest Body Weight, ER status & Risk of Death After Breast Cancer: 1997 Int J Epidemiol: 1169 early stage breast cancer cases Lower # estrogen receptors assoc w/ hazard ratio of 1.8 Highest BMI vs. lowest BMI (quartiles) assoc w/ a hazard ratio of 2.5!! Diet & Body Weight & Risk of Death After Breast Cancer: 1998 Breast Cancer Res Treat: 472 early stage breast cancer cases, diet data collected & patients followed Higher consumption of butter, margarine, lard, beer, red meat, liver, bacon increases likelihood of dying AFTER diagnosis of breast cancer HIGHER body weight (as measured by BMI) assoc w/ higher risk of death AFTER diagnosis of breast cancer

59. Findings of Special Interest Zinc Supplements For Taste Changes: 1998 Cancer: 20 head and neck cancer cases randomized to 45 mg zinc sulfate, 3 times daily or placebo Those receiving zinc supplement: less worsening sense of taste when compared to placebo Those receiving zinc recovered their sense of taste faster after treatment Saturated Fat & Risk of Death After Prostate Cancer: 1999 Eur Urol: 384 confirmed prostate cancer cases Diet data collected & patients followed Higher consumption of saturated fat increases likelihood of dying AFTER diagnosis of prostate cancer

60. Findings of Special Interest Diet & Risk of Death After Stomach Cancer Diagnosis: 2000 Nutr Cancer: 877 confirmed stomach cancer cases Diet data collected & patients followed Higher consumption of tofu & raw vegetables decreases likelihood of dying AFTER diagnosis of stomach cancer Processed Tomato Products & Prostate Cancer: 2001 JNCI: 32 men w/ prostate cancer fed 3/4 cup tomato sauce daily for 3 weeks; serum & prostate lycopene concentrations, PSA, oxidative damage assessed pre- and post-intervention Post-intervention: serum & prostate lycopene significantly increased; oxidative damage & PSA significantly decreased

61. Findings of Special Interest Fasting Insulin & Breast Cancer Recurrence Risk: 2002 Journal of Clin Onc: 512 women with early stage breast cancer (T1-T3, N0-N1, M0) w/o known diabetes followed prospectively Highest vs. Lowest quartile had twice the risk of distant recurrence & death Insulin associated w/ BMI and BMI a known risk factor AHCC� & Hepatocellular Carcinoma (HCC) 2002 J Hepatol: 222 people with confirmed HCC By self choice: assigned to surgical resection vs. surgical resection plus AHCC� and followed for a time ranging between 2 months to 10 years Intervention vs. Normal Care: 34% vs. 66% recurrence 80% vs. 53% survival

62. Findings of Special Interest Avemar� & Colorectal Cancer 2003 Br J Cancer: 176 people, Dukes A-D colorectal cancer diagnosis By self choice: assigned to regular treatment vs. regular treatment plus Avemar� and followed for 30-34 months Intervention vs. Normal Care: 3% vs. 17% recurrence 7% vs. 23% new metasases 31% vs. 64% progression 75% vs. 54% survival Lycopene & Advanced Prostate Cancer 2003 BJU Int: 54 men randomized to orchidectomy or orchidectomy + lycopene and followed for 2+ years PSA of 78% of supplemented group returned to normal vs. only 40% in orchidectomy alone group Normal bone scans in 25% of supplemented group vs only 15% of orchidectomy alone group having normal scans 2 years after intervention: 87% of supplemented group alive vs. 78% of orchidectomy alone group

63. Findings of Special Interest Diet, Insulin & Risk of Death After Breast Cancer: 2004 Cancer Epidemiol Biomarkers Prev: 603 women with breast cancer asked about diet & had blood samples collected Higher level of insulin = worse survival Higher protein & lower fat = better survival Higher intake of sweets and sugar = worse survival Breast Cancer & Health Behavior Changes 2004 Eur J Clin Nutr: 354 Finnish & Australian women diagnosed with breast cancer surveyed about experiences & choices One-third reported changing diet & exercise habits Both populations reported high need for diet & lifestyle counseling Both populations reported this need as unrecognized by physicians

64. Nutrition For Prevention of Recurrence:Fantasy or Reality? Consider the research and there is A LOT of it!! So many things are not in our control, encourage your clients to take advantage of the things that are!  Nutrition & Diet are powerful tools that one can use in the journey to regain and maintain health after a cancer diagnosis.