Nutrition for Patients during Radiotherapy in Nasopharyngeal

Cancer

Ririn H

Dharmais Cancer Hospital

2010

11.3

15.5

7.9

11.5

0

5

10

15

20

Cancer: An Epidemy Potency

Disease

Cancer is a leading cause of death worldwide: it

accounted for 7.4 millions death ( 13% deaths) in

2004

Death from cancer worldwide are projected to

continue rising 12 million deaths in 2030

WHO.Cancer Fact Sheet.2007.www.who.int

WHO Online Q&A.2008.www.who.intWHO Projection

2007 2030

Incidence

Mortality

“45% Increase in cancer

deaths from 2007 to

2030”- WHO

million

Top 10 Most Diagnosed Cancer in

Dharmais Hospital, 2007

Type of Cancer Frequency Percentage

(%)

Breast

Cervical

Colorectal

Lung

Nasopharyng

Liver

Limphoma

Leukemia

Thyroid

Ovarium

437/1348

254/1348

121/1348

113/1348

104/1348

76/1348

62/1348

62/1348

62/1348

57/1348

32.4

18.8

9.0

8.4

7.7

5.6

4.6

4.6

4.6

4.2

Data Internal RS Dharmais

Nutritional Problem

Among Cancer Patients

Weight loss and malnutrition are one of most common features observed in cancer patients

Cancer associated malnutrition 40-80%

IndonesiaSurvey in Dharmais Hospital, 2008

30.9% has malnutrition

42.9% reported weight loss in 6 mo.

Nutritional Problem

Among Cancer Patients

Especially occur in patients with

head and neck cancerincluding nasoparyngeal cancer

Upper gastrointestinal cancer

Pancreas Cancer

Chemoradiotherapy

Severe malnutrition in Cancer Cachexia Cancer

Incidence of Weight Loss

in Several Types of Cancer

Laviano A et al. Nature Clin Prac Oncol 2006;2:158-64

Malnutrition vs Cachexia

Cancer

Cancer cachexia Malnutrition (Undernutrition)

Malnutrition a state of nutrition in which a

imbalance of energy, protein, and other nutrients

causes measurable adverse effects on

tissue/body form (body shape, size and

composition) and function, and clinical outcome

Muscaritoli M et al. Clin Nutr 2010;29:154–9

Cachexia Cancer

Definition of cachexia:1

Complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with/without loss of fat mass

Definition of Cachexia Cancer:2

Multi organ syndrome charactrized by:

Weight loss (at least 5%)

during the previous 3-6 mo.

Muscle and adipose wasting

Inflammation

often associated with ANOREXIA, include

the abnormalities of metabolism

1.Evans WJ dkk. Clin Nutr 2008;27:793-9

2. Argiles JM dkk. Cancer Management Res 2010;2:27-38

Etiology of Cachexia

Cancer

Remain unclear

Multifactorial:1

Tumor Factors

1. Mechanical Obstructivefood intake

2. Tumor metabolite product: lipid

mobilizing factor/LMF dan proteolysis-

inducing factor/PIF metabolism and

energy expenditure

Fietkau R. Cancer & Nutrition: Prevention and treatment. Switzerland: Nestle Ltd. 2000. 225-35

Etiology of Cachexia

Cancer

Patient Factors :

Psychological

Non psychological Anorexia, smoking,

alcohol, poor oral higiene

Cancer treatment Factors: surgery,

Chemotherapy, and radiotherapy

Nutritional Consequences Of

Cancer Therapy

Mechanism:

a. Directly interfere with metabolism

b. Indirectly affect nutrient intake (nausea,

vomiting, diarrhea, changes in taste

sensation, anorexia & food aversions)

Side Effect of

Radiotherapy

Early effect the most common, can be

anticipated and limited duration.

Severity of side effect depends on: type of

irradiation, body region, volume of irradiation

and combination with other therapy

(chemotheray).

Nutritional Consequences:

Radiotherapy

Head and Neck

Xerostomia

Stomatitis

Esophagitis

Dysosmia

Caries Dentis

Outcomes Associated with

Cancer-induced Weight Loss

↓ Quality of Life

↓ Functional Status

↓ Response to therapy

Change in body image

↑ Hospital Length of Stay

Unscheduled

hospitalization

↑ Complications /

Infections

↓ Survival

“Progressive wasting is common and one of the most important factors leading to early death in cancer patients”- Inui, Akio.Cancer Research.1999;59.4493-501 -

The Importance

Nutritional Support

All cancer patients especially who are

high risk to get nutritional problems

Early

Screening & Assessment

Nutritional

Support

Nasopharyngeal

Cancer

Chemo-radiotherapy

Nutritional Screening and

Assessment

Modality:

History

Physical Examination

Laboratory data

SCREENING

ASSESSMENT

Nutritional Assessment

Aim: identify patients at risk for complication and create options aimed at decreasing morbidity and mortality

Body Composisition anthropometri

Biochemical data

Clinical Assessmenttools: SGA

(Subjective Global Assessment)

PG-SGA (Patient-Generated Subjective Global Assessment)

Subjective Global

Assessment

Recommended by ESPEN for the assessment of

nutritional status

Subjective Global

Assessment

To help maintain body weight and strength

To prevent body tissue from breaking down & rebuild it

To fight infection

To prevent or reverse nutrient deficiencies

Help patients better tolerate treatments.

To minimize nutrition-related side effects and

complications.

What Is The Role Of Nutrition Therapy

For Cancer Patients ?

Maximize Quality of Life

Being well-nourished has been linked to a better prognosis - National Cancer Institute.2009

NUTRITION

REQUIREMENT IN

CANCER PATIENT

Tailored to the patients status

and treatment modalitites

Nutrition Requirement in Cancer

Patients

Calorie requirement :

The Harris-Benedict equation

Estimates : severely stressed; have malabsorption :

35 kkal/kg

Protein requirement :

Cancer patient negative nitrogen balance

Daily protein requirement :

non stress cancer patients : 1 – 1.2 g/kg

hypercatabolic : 1.2 – 1.6 g/kg

severely stress : 1.5 – 2.5 g/kg

hematopoietic stem cell transplant pt : 1.5 – 2 g/kg

Grant, B.Krause’s, Nutrition & Diet Therapy 2007

Nutrition Requirement in Cancer

Patients

Fat requirement :

30% of total energy content

Sobotka Basic in Clinical Nutrition.2007

Micronutrient requirement and Specific

Nutrition :

Difficulty in eating / anorexia

Need vitamin, mineral & specific

nutrition supplementation

Specific Nutrients for

Cancer Patients

Nutrition Elements that Have Impacts

for Cancer

a.Omega 3 Fatty Acid

b.BCAA

c.Antioxidant: SE, Vit C, Vit E

Omega 3 :

COX-2 in tumors proliferation &

differentiation of cancer cells and angiogenesis

nuclear factor-B activation and bcl-2

expression apoptosis of cancer cells

production of inflammatory and chemotatic derivatives

cancer-induced cachexia

Journal of the National Cancer Institute.1993;85(21).1743-7

Nutrition in Clinical Practice 2005;20:394–9

Specific Nutrients for Cancer

Patients

“The available evidences indicate that increasing the amount of omega 3 will be beneficial to cancer survival”

– The Journal of Nutrition.2002.3508S-12S -

Nutrition in Clinical

Practice 2007;22:74-88

Eicosapentaenoic Acid (EPA) : EPA : long chain PUFA

Decrease weight loss, promote weight gain, and increase survival in cancer cachexia patients

May activate caspase-3 apoptosis

May inhibit COX-2 reducing inflammatory process

In cancer cachexia patients, EPA significantly reduce the serum concentration of CRP (marker of inflammation)

(11.0 +/- 4.8 mg/l before, compared with 0.8 +/- 0.8 mg/l after 4

weeks of EPA, P < 0.05)

Specific Nutrition for Cancer

Patients

National Cancer Institute.Eicosapentaenoic Acid.www.cancer.gov

SJ, Wigmore; et al.Clin Sci.1997;92(2).215-21

I, Bayram; et al.Pediatr Blood Cancer.2009;52(5).571-4

Ryan, Aoife; et al.Annals of Surgery.2009;249(3).355-63

BCAAValin, Isoleucine, Leucine

Essential amino acid needed for normal cellular function

Improve morbidity and QOL

Improve immune system

Improve nitrogen balance and protein synthesis

appetite caloric intake

• Decreament of anorexia : n=25 cancer pt

BCAA vs placebo : 55% vs 16%; p<0,05

Choudry, HA; et a.The Journal of Nutrition.2006;136.314S-318SCalder, Philip.American Society for Nutrition.2006;136.288S-293SCangiano, C; et al.Journal of the National Cancer Institute.1996;88(8).550-1

Branched Chain Amino Acids

Branched-chain amino acids

(BCAA)

Mechanism of BCAA to appetite

Block tryptophan serotonin appetite

J. Nutr. 2006 136: 314S–8S

BCAAs IMPROVE

NITROGEN BALANCE AND PROTEIN SYNTHESIS

Specific Nutrition for Cancer

Patients

SELENIUM

Protects against oxidative tissue damage

May modulate carcinogenesis by inhibiting damaged

DNA

and by enhancing host immune response

Selenium induce cancer cell death via COX-2/PGE2

signaling pathway

Descriptive geographic studies have shown an

inverse relationship between cancer mortality and

incidence rates and selenium availability

Mark, Steven D; et al.Journal of the National Cancer Institute.2000;92(21).1753-63

Peters, Ulrike; et al.Cancer Epidemiol.2006;15.315-20

Jiang, W; et .Molecular Cancer Therapeutics.2009;1(8)

Hwang, JT; et al.Cancer Research.2006;66(20).p10057-63

VITAMIN C

Vitamin C deficiency is common in patients with advanced cancer

Vitamin C helps induce apoptosis in various human cancer cell lines : Induce G2-M arrest

augment TNF-related apoptosis

Patients with low plasma concentrations of vitamin C have a shorter survival.

Specific Nutrition for Cancer

Patients

Mayland, CR; et al.Palliative Medicine.2005;19(1).17-20

Vitamin E :

- Help recover electrophysiology and evoked

potential of neuron cell Help protect form

chemotherapy-induced neuropathy.

- Omega3 and high level of antioxidant can

reverse severe weight loss

Specific Nutrition for Cancer

Patients

Morani, AS: Bodhankar, SL.Neuroanatomy.2008;7.33-7Marcus R; Coulston.Goodman & Gilman’s The Pharmacological Basis of Therapeutics 10th ed.2001.McGraw-Hill.Pace, A; et al.J Clin Oncol.2003;21(5).924-31J of Clin Oncology 2005;23(24):5805-13. Grimble, RF.Gut.2003;52.1391-2

Zinc : Reduced serum-zinc concentrations are well

known as typical laboratory characteristics in advanced head and neck cancer.

Zinc supplementation improved survival for

patients with Stages III-IV disease.

Zinc sulfate useful for patients with

hypogeusia due to radiation/chemotherapy

Buntzel, J; et al.International Institute of Anticancer Research.2007

L Lin, etal. Int J of Rad Oncology Biol & Physics. 69 (3):S466-S466

A M Nally: http://www.nutraingredients.com

Silverman JE et al. J Oral Med 38 (1): 14-6, 1983 Jan-Mar

Specific Nutrition for Cancer

Patients

Nutrition can be delivered by:

Oral

Enteral

Parenteral

Choosing nutritional route depend on:

Gastrointestinal tract function

Ability of patient’s food intake

Route of Nutritional Support

Oral

Enteral

Parenteral

Route of Nutritional Support

Preferred modality in patients who are able to

eat

Should modified based on the physiologic and

anatomic constraints of the disease process

loss appetite, dry mouth, nausea-vomiting,

swallow difficulties, taste/smell alteration

Oral Nutrition

Frequent small meals

Increase caloric and protein density of foods,

avoid excessive fat

Avoid strong odors

Select soft, moise foods; add sauce/gravy

Limit liquids at mealtime

Provide a pleasant mealtime atmosphere

Oral Nutrition

Enteral nutrition

If oral intake is not adequate

Preferred to parenteralpreserves the gastrointestinal architecture & prevents bacterial translocation fewer complication

Type•Short term:

•nasoenteral tube•Long term:

•Gastrostomy•jejunostomy

Enteral Nutrition

Enteral Nutrition

Tube feeding:

obstruction of head or neck or esophageal

cancer interferes with swallowing

Severe local mucositis

percutaneous gastrostomy (PEG):

radiation induced oral and esophageal

mucositis

Routine enteral nutrition is not indicated during radiation

Therapy or chemotherapy as long as food intake is adequate

by oral

Enteral Nutrition

Recommendation

Enteral nutrition if an inadequate food intake (<

60% of estimated energy expenditure for > 10

days) is anticipated (C)

Enteral nutrition should be provided to improve

or maintain nutritional status in weight losing

patients due to insufficient nutritional intake (B)

unsuitable for oral or enteral nutritional

support

Indication :

- Gastrointestinal tract can be used

ionperable cancer

- Side effect of radiotherapy: malabsorbsion, enteritis

Parenteral Nutrition

Route

- Perifer

- Central

Recommendations

Patients with expectation having inadequate oral

or enteral nutrition intake for >10 to 14 days

Severe malnutrition perioperative parenteral

nutrition

Bone marrow transplant recipients

Parenteral Nutrition

Based on patient’s

needed & condition

Possible causes : mucositis radiation and/or chemotherapy

• Mucositis cancer treatments break down the rapidly divided epithelial cells lining the GIT particularly in oral cavity, leaving the mucosal tissue open to ulceration and infection

• Oral mucositis the most common

20-40%chemotherapy alone

> 50% combination (chemo-radiotherapy)

consequences : hypovolemia, electrolyte abnormalities & malnutrition

Sore mouth / throat

Mucositis should be treated as early as possible

Adequate education on proper nutrition and oral

hygiene is essential

Management

- Give intensive mouth care to prevent bacterial infection or mouth lesions

- Eat soft, bland foods

- Try eating cold, odorless foods

- Avoid eating too hot or cold food

- Drink through a straw to bypass mouth sores

- Avoid irritating spices such as pepper, chili

- Eat high-protein foods to speed healing

Sore mouth / throat

Management (continue)

• Drink high-calorie liquid nutritional supplements to help maintain adequate calorie intake

• Avoid alcohol, tobacco irritate mucous membranes

• Begin use of tube feedings

• Puree / liquefy food in blender easier to swallow

• Avoid rough, dry or coarse foods which can scratch an irritated mouth or throat

Sore mouth / throat

Possible causes saliva production from radiation

or surgery

Xerostomia minor complication significant for

long time

Subjective sensation of dryness and is usually

associated with hypo-salivation

excessive dry mouth discomfort, taste sensation,

interferes with eating

oral intake and subsequent nutritional deficiencies

Dry mouth

• Xerostomia

Change the oral Ph conductive to dental decay

• Medical management

- Fluoride treatment

- oral hygiene

- saliva substitute

- saliva stimulant

Dry mouth

Managements

- Regular mouth care to keep mouth clean and reduce risk for oral lesion and infection

- Drink 8-12 cups of liquid a day

- In general, foods that are cold and have no odor

- Eat soft, moist foods that are cool or at room temperature

- Try eating fruit purees, soft cooked

- Use fluids other than water, such as non-acidic juice, to aid

with hydration and increase calorie intake

- Avoid caffeinated foods and beverage

- Avoid dry foods

Dry mouth

Possible causes

• tumor location

• inflammation / pain in throat or mouth due to surgery

• radiation / chemotherapy

• nerve damage from surgery or radiation

Patients with dysphagia need advice on food consistencies and teaching in swallowing techniques to prevent risk for aspiration

Swallowing difficulty

Management

• Drink 6 – 8 cups of fluid each day and thicken the

fluid to the right consistency

• coughing or chocking while eating especially with

fever should be reported

• Eat small, frequent, soft, moist meals and snacks

• Drink high-calorie liquid nutritional supplements

several times per day especially if there is disability to

eat regular foods

Swallowing difficulty

Possible causes :

• inflammation and mucous membrane changes from radiation or taste change from chemotherapy

• lack of smell because nasopharyngeal cancer

Management

• Seasoning foods with tart flavors, such as lemon, citrus fruits, to overpower bad or off tastes

• Suck on sugar-free lemon candy or mints to get rid of unpleasant taste

• Flavor foods with natural ingredients

• Rinse mouth before eating to help to clear taste buts

• Eat foods cold or room temperature to decrease food flavor and odor

Change in smell and taste

Summary

Malnutrition in cancer is common especially in head and neck cancer, including nasopharyngeal cancer

Radiotherapy cause the worsening nutritional problem sore throat, dry mouth, swallowing difficulty, change in smell and taste

Nutritional support is needed since malnutrition has bad impact to cancer outcome

Oral and enteral nutrition route is preferredthan parenteral