Cancer

CANCER

A cancer patient’s nutritional status and well-being are greatly impacted by the type of cancer and the treatment methods (Table 1.1). In turn, nutritional status and overall health affect the patient’s ability to tolerate treatment and achieve the desired clinical outcome. To optimize clinical outcomes, patients who are diagnosed with cancer should receive early nutrition intervention with a complete nutritional assessment and a plan of care (1). When patients with colorectal cancer who are undergoing pelvic radiation receive individualized nutrition counseling, they experience improvements in energy and protein intake, nutritional status, and quality of life and reductions in symptoms of anorexia, nausea, vomiting, and diarrhea (1) (Grade II). Similar findings are seen in patients who are receiving chemotherapy for esophageal cancer, head and neck cancer, lung cancer, or acute leukemia (1). Patients who receive a pretreatment nutrition evaluation and weekly visits during chemoradiation and chemotherapy experience reduced weight loss, improved energy and protein intake, and improved quality of life; these patients may also have fewer unplanned hospitalizations, shorter hospital stays, and improved tolerance to treatments for a variety of cancers (1) (Grade III).

The American Dietetic Association has published evidence-based guidelines that address the nutrition interventions that are used in the management of specific types of cancers including:

breast cancer
colorectal cancer
esophageal cancer
head and neck cancer
lung cancer
pancreatic cancer

Because the evidence is limited (Grade III or IV) for many of the current recommendations, a comprehensive overview is not presented; rather, a summary is provided in the following paragraphs. The clinician, however, can refer to this resource for guidance when determining if specific therapeutic nutrition interventions should be initiated or discontinued (1). Parenteral nutrition support is generally not recommended for patients with the types of cancer listed above because of the risks of metabolic and infectious complications and the limited evidence that parenteral nutrition affects the length of hospital stay or patient survival (1) (Grade III). Enteral nutrition may be used to increase the energy and protein intake and maintain the weight of esophageal cancer patients undergoing chemoradiation therapy (1) (Grade III). In addition, the use of enteral nutrition to increase the energy and protein intake of outpatients who are undergoing intensive radiation therapy for stage III or IV head and neck cancer maintains nutritional status and improves tolerance to therapy (1) (Grade II). Medical food supplements that are used to improve the energy and protein intake of patients who are undergoing radiation therapy for head and neck cancer are associated with fewer treatment interruptions and reduced mucosal damage and may minimize weight loss (1) (Grade II).

Vitamin and mineral supplements, special foods, and alternative health products such as herbal products are commonly used by patients diagnosed with cancer. The following discussion is based on the Oncology Evidence-Based Nutrition Practice Guideline from the American Dietetic Association (1). Limited evidence supports the use of topical honey for the treatment of mouth sores in persons who are receiving radiation for head and neck cancer (1) (Grade III). The limited evidence shows that the topical use of honey has been associated with a decreased incidence of severe mucositis as well as weight gain and fewer treatment interruptions (1) (Grade III). Oral arginine supplements, which are used in an attempt to improve the clinical response, are not recommended prior to neoadjuvant chemotherapy for breast cancer (1) (Grade III). In addition, arginine-enhanced medical food supplements or enteral nutrition is not recommended for head and neck cancer patients, because data have demonstrated no improvements in nutrition-related outcomes or treatment complications (1) (Grade II).

Vitamin E (in the form of 670 to 1,000 mg of alpha tocopherol) has not been shown to promote tolerance or reduce the late effects of radiation in patients with breast cancer; rather, vitamin E may have adverse effects such as nutrient-nutrient interactions, drug-nutrient interactions (eg, anticoagulant and anti-hypertensive medications or herbal supplements), and disease-related complications (1) (Grade III). Vitamin E oral supplements are not recommended for persons with head and neck cancer who are receiving radiation therapy, because these supplements increase the risk of developing a second primary cancer and decrease the survival rate (1) (Grade III). Doses of antioxidants (eg, vitamin C, vitamin E, beta-carotene, and selenium) that

are greater than the tolerable upper intake level, which are used in an attempt to improve treatment outcomes, are not recommended for patients who are receiving chemotherapy for advanced non-small cell lung cancer. Multiple, high-dose oral antioxidants do not significantly influence the treatment response, survival rate, survival time, or toxicity in this patient population (1) (Grade III). Supplements of omega-3 fatty acids, which are used in an attempt to improve weight gain, are not recommended for pancreatic cancer patients due to limited data and the potential for drug-nutrient interactions (1) (Grade III). Refer to Table 1.2 for suggested nutrition interventions and approaches to common problems experienced by cancer patients as a result of the disease or adjunctive treatments.

Table 1.1 Cancer Treatments With Potential to Negatively Affect Nutritional Status

Treatment	Nutrition-Related Adverse Effects
Chemotherapy Corticosteroids (eg, cortisone, hydrocortisone, methylprednisolone, prednisone, prednisolone, triamcinolone)	Abdominal distention, anorexia, increased appetite, diarrhea, ulcerative esophagitis, gastrointestinal bleeding, hypocalcemia, hyperglycemia or hypoglycemia, hypokalemia, hypertension, muscle-mass loss, nausea, osteoporosis, pancreatitis, sodium and fluid retention, vomiting, weight gain
Hormones/analogs (eg, androgens, estrogens, progestins)	Anorexia, anemia, increased appetite, diarrhea, edema, fluid retention, glossitis, nausea, vomiting, weight gain
Immunotherapies (eg, B-cell growth factor, interferon, interleukin)	Anorexia, diarrhea, edema, nausea, vomiting, stomatitis, taste perversion, weight loss
General chemotherapeutic agents (eg, alkylating agents, antibiotics, antimetabolites, mitotic inhibitors, radiopharmaceuticals, other cytotoxic agents)	Abdominal discomfort, anorexia, diarrhea, oral and gastrointestinal ulceration, nausea, stomatitis, vomiting (Premedication with antiemetics will sometimes relieve or decrease severity of symptoms.)
Radiation therapy Head, neck, chest	Dysgeusia, dysosmia, dysphagia, esophagus, fibrosis, fistula, hemorrhage, odynophagia, stomatitis, stricture, trismus, xerostomia, tooth decay, tooth loss (Tooth decay and loss can be prevented by an aggressive program of dental hygiene.)
Abdomen, pelvis	Bowel damage, diarrhea, fistulization, malabsorption, nausea, obstruction, stenosis, vomiting
Surgery Radical head/neck	Altered appearance, chewing or swallowing difficulty, chronic aspiration, dysgeusia, dysphagia, impaired speech, odynophagia, voice loss
Esophagectomy	Diarrhea, early satiety, gastric stasis, hypochlorhydria, regurgitation, steatorrhea
Gastrectomy	Abdominal bloating and cramping, achlorhydria with lack of intrinsic factor, diarrhea, dumping syndrome, early satiety, hypoglycemia, mineral deficiencies, fat malabsorption, fat-soluble vitamin deficiency
Intestinal resectiona	Vitamin B12 deficiency, dehydration, diarrhea, fluid or electrolyte imbalance, hyperoxaluria, malabsorption, mineral depletion, renal stone formation, steatorrhea

aProblems that develop are determined by the nature and extent of resection; nutritional intervention must be highly individualized.
Source: Barrocas A. Cancer. In: White J, ed. The Role of Nutrition in Chronic Disease Outcome. Washington, DC: Nutrition Screening Initiative; 1997.
Reprinted by permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging, and funded in part by a grant from Ross Products division, Abbott Laboratories.

Table 1.2 Suggested Nutrition Intervention (1,2)
Problem (Signs and Symptoms)	Nutrition Intervention
Chewing or swallowing difficulty (secondary to surgery, radiation therapy)	Modify consistency (See Full Liquid Blenderized Diet; Dysphagia Feeding Plan).
Dryness, soreness, or inflammation of oral mucosa (secondary to tumor, chemotherapy, radiation therapy)	Evaluate effect of medications. Consume fluids with meals. Avoid acidic foods. Avoid very coarse foods that do not soften in the mouth. Cut foods into small pieces. Moisten dry foods; modify diet consistency. Use oral mouth rinses. Evaluate use of glutamine (10 g orally three or four times per day) (3).
	Patients applying topical honey experienced a significant reduction in grade 3/4 mucositis with 54% either maintaining or gaining weight (1,4) (Grade III).
	Try artificial saliva products. For prevention of dental caries, between-meal candies and gum should be sugarless. Avoid hot foods to reduce the risk of burning the mouth. Cold foods may be soothing. Avoid alcohol. Lidocaine (Xylocaine) can be used to relieve pain before eating. Use a straw or spoon for consuming liquids. Saliva stimulants, such as sugarless candy or gum, may be beneficial.
Anorexia and altered taste perception (secondary to systemic effects of cancer, radiation therapy to head and neck, chemotherapeutic agents)	Determine if other problems, such as pain, fear of vomiting, medication, or constipation, could be factors. Recommend modifications in diet order as necessary. Monitor intake. Take a nutrition history to identify well-liked foods. Vigorous nutrition intervention may reverse some of the factors causing anorexia and taste abnormalities. Consider the use of pharmacotherapy (eg, progestational agents, cannabinoids, anabolic agents, prokinetic agents, antiserotonergic agents) (2). Cold foods may be more acceptable than warm foods. Chocolate and fruit-flavored supplements are well accepted. Recommend well-seasoned foods (liberal use of herbs, spices, flavorings). Patient should rinse mouth with tea, ginger ale, or salt water before and after eating. Use zinc supplementation only if there is a clinically validated deficiency (5).
Lower threshold for bitterness (meat rejection, especially beef)	Use nonmeat sources of protein: eggs, dairy products, poultry, or vegetable sources; poultry or fish may be better tolerated than red meat; fish with a strong aroma may not be accepted. Eat with plastic utensils rather than metal utensils.
Elevated threshold for sweetness	Add sugar to foods (sweet sauces, marinades).
Early satiety (secondary to malnutrition, obstruction, pain, effects of decreased secretions and peristalsis, chemotherapeutic effects on digestive tract)	Eat small, frequent meals with high-energy, nutrient-dense foods (addition of glucose polymers). Drink liquids between meals rather than with meals. Keep head elevated following a meal; avoid meals at bedtime. Low-fat foods may be better tolerated; avoid fatty, greasy foods. Light exercise is allowed if tolerated. Intake may be best at breakfast. Keep high-protein, high-energy snacks on hand for nibbling. Chew thoroughly and eat slowly.
Nausea and vomiting (associated with chemotherapy, radiation therapy to abdominal and gastric areas, partial obstruction of the gastrointestinal tract) (Note: Nausea and vomiting are usually over within 24-48 hours after chemotherapy and 24 hours after total body irradiation.)	Evaluate effects and timing of medications. Use antiemetic drugs ½ hour before meals. Take deep breaths, sip a carbonated beverage, or suck on ice chips. Try a dry diet (liquid between meals). Decrease intake of fatty foods. Avoid cooking odors. Avoid favorite foods when nauseated to prevent development of permanent dislike for such foods. Eat foods without strong odors. Cold foods are often better accepted than hot foods. Vigorous nutritional intervention may reverse atrophy due to malnutrition. Enteral route may be preferable to the parenteral route, as it supplies nutrition directly to mucosal cells. Use lactose-free supplements. Decrease fiber content.
Steatorrhea and diarrhea (secondary to thoracic esophageal resection, gastric resection, cancerous involvement of lymphatics, blind loop syndrome, obstruction of the pancreatic or bile ducts)	Decrease proportion of energy from fat. Use medium-chain or long-chain triglycerides if diarrhea related to malabsorption (2). Decrease fiber content as needed; however, bulking agents and foods high in water-soluble fiber may be helpful if diarrhea is secondary to radiation. Promote adequate fluid intake. Recommend a lactose-controlled diet, if required. Evaluate all medications (eg, magnesium-containing medications, prokinetic agents) and herbal supplements (especially milk thistle, aloe, cayenne, saw palmetto, and ginseng) that can cause diarrhea (2). Evaluate intake of foods high in sugar and sorbitol, as both may cause diarrhea if consumed in large amounts. Probiotic supplementation (yogurt with live cultures) may be appropriate if diarrhea is related to altered microflora from antibiotics (2,6). Glutamine, a powdered protein supplement, has been recommended to help control cancer treatment–related diarrhea. Not all studies have demonstrated efficacy, but it may be related to the dose (7,8). In general, a dose of 10 g three times per day has been recommended (2,7,8).
Protein-losing enteropathy (secondary to fistula, disruption of intestinal epithelium or lymphatics)	Recommend a high-protein intake. Monitor nutritional status.
Weight loss (secondary to increased basal metabolic rate, catabolism, decreased food intake, decreased absorption) Anorexia-cachexia syndrome (9)	Provide high-energy, nutrient-dense foods. Use above strategies to promote food intake. Consider use of pharmacotherapy (eg, progestational agents, cannabinoids, anabolic agents, prokinetic agents, antiserotonergic agents, branched-chain amino acids, melatonin) with anorexia-cachexia syndrome (2). Note: Energy expenditure may be increased or decreased; diseases of long duration are associated with hypermetabolism.
Constipation	Increase fiber and fluid intake; limit gas-forming foods. Light exercise is advised, if tolerated. Evaluate medications as underlying cause (eg, narcotics).
Heartburn	See Gastroesophageal Reflux Disease.

Bowel obstruction: Patients who have had radiation or surgery to the pelvic area are at risk for bowel obstruction. Symptoms of bowel obstruction include cramping abdominal pain, diarrhea, and constipation. Patients who have a partial bowel obstruction may have thin, pencil-like stools or sloughing of necrotic tissue, which may be mistaken for diarrhea. Patients should not take over-the-counter medications without their physicians’ approval (2). Patients should consume a low-residue diet and reduce their intake of bowel-stimulating foods, such as caffeine and sorbitol (2). Symptoms of complete bowel obstruction include cramping that is often accompanied by nausea and vomiting. Diarrhea may precede the complete cessation of bowel movements. The physician should be contacted immediately.

References

Oncology Evidence-Based Nutrition Practice Guideline. American Dietetic Association Evidence Analysis Library. Chicago, Ill: American Dietetic Association; 2008. Available at: http://www.adaevidencelibrary.com. Accessed January 16, 2008.
Oncology. In: Nutrition Care Manual. American Dietetic Association; 2004. Available at: nutritioncaremanual.org. Accessed August 23, 2006.
Coghlin Dickson TM, Wong RM, Offrin RS, Shizuru JA, Johnston LJ, Hu WW, Blume KG, Stockerl-Goldstein KE. Effect of oral glutamine supplementation during bone marrow transplantation. J Parenter Enteral Nutr. 2000;24:61-66.
Biswal B, Zakaria A, Ahmad N. Topical application of honey in the management of radiation mucositis: a preliminary study. Support Care Cancer. 2003;11:242-248.
Ripamonti C, Zecca E, Brunelli C, Fulfaro F, Villa S, Balzarini A, Bombardieri E, De Conno F. A randomized, controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer. 1998;82:1938-1945.
Del Piano M, Ballare M, Montino F, Orsello M, Garello E, Ferrari P, Masini C, Strozzi G, Sforza F. Clinical experience with probiotics in the elderly on total enteral nutrition. J Clin Gastroenterol. 2004;38(6 Suppl):S111-S114.
Kozelsky T, Meyers G, Sloan J, Shanahan T, Dick S, Moore R, Engeler G, Frank A, McKane T, Urias R, Pilepich M, Novotny P, Martenson J. Phase III double-blind study of glutamine versus placebo for the prevention of acute diarrhea in patients receiving pelvic radiation therapy. J Clin Oncol. 2003;21:1669-1674.
Savarese D, Savy G, Vahdat L, Wischmeyer P, Corey B. Prevention of chemotherapy and radiation toxicity with glutamine. Cancer Treat Rev. 2003;29:501-513.
Inui A. Cancer anorexia-cachexia syndrome. Current issues in research and management. CA Cancer J Clin. 2002;52:72-91.