MNT 1-Unit 4

thrush/Candida

(Candida albicans infection) An infection in which the fungus Candida albicans accumulates in the mouth. An infection in which the fungus Candida albicans accumulates in the mouth-can happen with altered taste and smell

IV-Normal Saline

(NS): 0.9% NaCl in H2O a) 154 mEq/L NaCl = ~2 tsp. NaCl/L

Create nutrition interventions for each of the ACS, AICR/WCRF recommendations for cancer prevention.

****

Anti-diarrheal drugs

1. Decrease muscle tone and peristalsis of GI tract by stimulating opioid receptors 2. Loperamide (Imodium AD®) 3. Atropine and diphenoxylate (Lomotil®) 4. Tincture of opium

radiation

1. Dependent on sensitivity of rapidly dividing cells to X-ray or gamma radiation 2. Disadvantage: causes some damage to normal tissues and cells covering and surrounding the cancer in the area treated (the irradiation field) 3. Generally delivered daily for 5-8 weeks 4. Brachytherapy: radiation directly inside tumor via needle or "seeds" (usu. prostate) 5. Nutrition considerations a) Preexisting malnutrition leads to poorer treatment outcomes b) PO intake related to quality of life c) Most important for patients receiving head and neck or abdominal/pelvic radiation 4 d) Head and neck (1) Frequent preexisting malnutrition (2) Weight loss tends to occur during radiation, esp. d/t xerostomia, mucositis, and dysphagia (3) PEG often placed prophylactically (4) Side effects generally begin ~2 weeks into radiation therapy e) Radiation enteritis (1) Gynecological, abdominal, rectal, prostate cancers (2) Acute radiation enteritis develops due to damage to dividing cells in small intestine (a) Diarrhea, maybe bloody (b) Loss of gut barrier function with possible infection (c) Generally resolves ~2 weeks after finishing radiation (3) Chronic radiation enteritis develops due to damage to vascular endothelial and connective tissue cells, with chronic ischemia (a) May develop 6 months-30 years after radiation (b) May lead to obstruction, fistulas, colitis

surgery

1. Entirely excise tumor alone 2. Excise tumor plus draining lymph nodes ("block dissection") 3. Debulking: removal of tumor tissue to relieve symptoms (generally not curative)

Describe requirements for energy, protein, fat, and micronutrients in HIV/AIDS.

1. Kcal needs a) Based on degree of altered metabolism, nutrient deficiencies, severity of disease, comorbidities, and opportunistic infections 2. Protein needs a) No evidence for increased needs 3. Fat a) HHD; omega-3 may help lower TG 4. Micronutrients a) General healthy diet; supplementation as needed if inadequate

Understand why patients undergoing surgery are at high risk for nutrition problems

1. Preexisting malnutrition 2. Nutrition problems caused by neoadjuvant therapy 3. Nutrition problems caused by surgery 4. Side effects 5. Increased needs for healing 6. Forced NPO or low intake 7. Hospitalization 8. Nutrition problems caused by adjuvant therapy

Name 5 antiemetic medications.

1. Prochlorperazine (Compazine®), also works as anti-psychotic a) Increases need for riboflavin b) Oral or parenteral 2. Promethazine (Phenergan®) a) Increases need for riboflavin b) Oral, parenteral, transdermal gel, rectal suppository 3. Ondansetron (Zofran®), granisetron (Kytril®) a) Oral disintegrating tablets, parenteral 4. Metoclopramide (Reglan®) a) Speeds gastric emptying b) Oral, parenteral 5. Dexamethasone (Decadron®) a) Corticosteroid 6. Recommend scheduling doses (instead of PRN) to control nausea (at least at first) 7. Use IV or non-oral routes first 8. Seek out breakthrough medication when needed (different class of drug)

Name 4 validated nutrition screening tools.

1. Should be done at diagnosis and regularly throughout treatment and recovery 2. Multiple tools available a) Patient Generated Subjective Global Assessment (PG-SGA) b) Malnutrition Screening Tool (MST) c) Malnutrition Screening Tool for Cancer Patients (MSTC) for inpatients d) Malnutrition Universal Screening Tool (MUST)

chemotherapy

1. Systemic or regional delivery of cytotoxic drugs that work in various ways (targeting different parts of rapidly dividing cell cycle, inhibiting proteins found in cancer cells, inhibiting angiogenesis...) 2. Often delivered in combination, esp. since cancer cells mutate quickly/develop resistance 3. May be given daily over long periods of time, once per week, in lengthy infusion, in short infusion... 4. Common infusion device: "port," surgically placed central venous access 5. Nutrition considerations a) Address malnutrition (associated with shorter survival, more toxicity) (1) May not lose weight d/t reduction in physical activity and REE with LBM loss b) Prepare patient for side effects of chemotherapy drug(s) (1) Chemotherapy-induced nausea and vomiting (2) Chemotherapy-related diarrhea (3) Chemotherapy-related constipation (4) Mucositis

Explain cancer staging using the Tumor Node Metastasis and general staging models.

1. Tumor Node Metastases (TNM) staging system a) Tumor (T) describes the primary tumor (1) TX: Main tumor cannot be measured. (2) T0: Main tumor cannot be found. (3) T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has grown into nearby tissues. T's may be further divided to provide more detail, such as T3a and T3b. b) Node (N) describes if cancer has spread into nearby lymph nodes (1) NX: Cancer in nearby lymph nodes cannot be measured. (2) N0: There is no cancer in nearby lymph nodes. (3) N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more lymph nodes that contain cancer. c) Distant metastasis (M) (1) MX: Metastasis cannot be measured. (2) M0: Cancer has not spread to other parts of the body. (3) M1: Cancer has spread to other parts of the body. d) Cutoff values slightly different for each type of cancer 2. Generally grouped into 5 stages: a) Stage 0: Abnormal cells are present but have not spread to nearby tissue. Also called carcinoma in situ, or CIS. CIS is not cancer, but it may become cancer. b) Stage I, Stage II, and Stage III: Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues. c) Stage IV: The cancer has spread to distant parts of the body. 3. Other definitions to know: a) In situ—Abnormal cells are present but have not spread to nearby tissue. b) Localized—Cancer is limited to the place where it started, with no sign that it has spread. c) Regional—Cancer has spread to nearby lymph nodes, tissues, or organs. d) Distant—Cancer has spread to distant parts of the body. e) Unknown—There is not enough information to figure out the stage.

Describe the process of a hematopoietic cell transplant.

1. Used for leukemia, lymphoma, multiple myeloma 2. Process a) Patient goes into specialized unit in hospital (sterile) b) Receives high-dose chemotherapy +/- total body irradiation to kill all hematopoietic cells (including cancer cells) c) Receives infusion of isolate hematopoietic stem cells (1) From self: autologous (preferred, may be done outpatient) (2) From "matched" donor: allogenic (3) From identical twin: syngeneic d) Must make new immune system 3. Acute side effects (2 days-4 weeks post-transplant): nausea, vomiting, anorexia, dysgeusia, stomatitis, oral and esophageal mucositis, fatigue, diarrhea a) May require PN b) Remain immunosuppressed/neutropenic as immune system rebuilds 4. May develop graft-versus-host disease as allogenic transplanted cells attack body, esp. GI tract a) May need PN and slow reintroduction of foods

mutation

1st step of cancer progression diagram!

hyperplasia

2nd step of cancer progression excessive growth but no invasion

metaplasia

3rd step of cancer progression —cells not normally found in tissue, no invasion a) Ex: Barrett's esophagus, GERD May stay there, may progress

dysplasia

4th step of cancer progression —cells are not normally structured but still no invasion a) Ex: Colon polyp

Name 3 food-drug interactions in HIV/AIDS.

5. Food-drug interactions a) Avoid St. John's wort, garlic supplements, milk thistle (all interfere with ART meds)

angiogenesis

7th step of cancer progression Tumors > 2mm need blood supply for nutrients b) "Recruit" wound healing pathways to obtain vascular supply c) Potential for cancer drugs (1) Ex: Vascular Endothelial Growth Factor (VEGF) (2) Vitamin D-anti-angiogenesis factor

metastasis

8th step of cancer progression a) Movement of cancer to other sites b) Why do they colonize specific organs? How do they survive there? proximity, not always c) Usually via bloodstream, lymph nodes secondary d) Metastasis via lymph nodes-will remove surrounding lymph nodes, just in case of spreading

pancreaticoduodenectomy

A Whipple procedure is a complex operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct. The Whipple procedure is used to treat tumors and other disorders of the pancreas, intestine and bile duct

anastomosis

A procedure to connect healthy sections of tubular structures in the body after the diseased portion has been surgically removed

Understand common physical and social/emotional issues for cancer survivors

A. Always consider late or chronic effects of treatment 1. Fatigue 2. Pain 3. Increased infection risk 4. Lymphedema (swelling in arms and legs) 5. Memory loss or trouble concentrating 6. Neuropathy 7. Low bone mass 8. Secondary cancers 9. Anemia B. But also emotional and social issues 1. Going back to work after a long time away 2. Dealing with financial concerns 3. Rebuilding relationships with friends and family 4. Establishing a new "normal" and returning to day-to-day life 5. Feeling uncertain about the future 6. Concerns with fears of cancer returning

Explain the medical therapy for HIV/AIDS.

A. CD4 count used to measure immune system function B. Antiretroviral therapy 1. Drug combinations that either kill virus or suppress replication 2. Lifelong treatment to reduce risk of progression to AIDS 3. Come with side effects that must be managed 4. Lack of adherence leads to drug resistance

Name 4 goals of medical nutrition therapy in HIV/AIDS.

A. Goals: 1. Help maintain lean body mass 2. Reduce the severity of HIV-related symptoms 3. Improve quality of life 4. Enhance adherence and effectiveness of ART

HIV-associated lipodystrophy syndrome.

A. HIV-associated lipodystrophy syndrome (HALS) 1. Changes in body shape due to HIV 2. Lipoatrophy in face 3. Cervicodorsal lipodystrophy 4. No nutrition-related intervention beyond general healthy diet, physical activity, perhaps high fiber intake

Name goals of nutrition in palliative care

A. Nutrition intervention 1. Goals: a) Manage nutrition-related symptoms like pain, weakness, loss of appetite, early satiety, constipation, weakness, dry mouth, dyspnea b) Maintain strength and energy to enhance quality of life, independence and ability to perform ADLs 2. Nutrition "as tolerated or as desired" 3. Emphasize pleasurable aspects of eating, regardless of quantity, nutrient or energy content (liberalize diet) 4. Nutrition support as directed by consultation with patient, family, advanced directive

Identify a patient who may have cancer cachexia and list metabolic changes associated with cachexia

A. Pathophysiology 1. No agreed-upon definition a) Characterized by some combination of progressive weight loss, anorexia, generalized wasting and weakness, immunosuppression, altered basal metabolic rate, abnormalities in fluid and energy metabolism (1) Resting energy expenditure increases b) Fearon definition: "a multifactorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment" c) Negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism 2. Metabolic changes may include: a) Increased lipolysis with production of glycerol and free fatty acids b) Increased hepatic glucose production c) Whole-body protein turnover (greater than healthy and non-weight-losing cancer patients) d) Increased energy expenditure (lactate from tumor requiring Cori cycle) e) Alterations in type of fat (brown vs. white) f) Insulin resistance g) Decreased insulin-like growth factor 1 h) Appetite changes d/t alterations in neuropeptide Y, ghrelin, leptin metabolism 3. May be d/t tumor hormones: a) Lipid-mobilizing factor b) Proteolysis-inducing factor c) Tumor necrosis factor (TNF)-alpha or cachectin d) TNF-B e) Interleukin-1, IL-6 f) Interferon-alpha, interferon-gamma

in situ

Abnormal cells are present but have not spread to nearby tissue Stage 0: Abnormal cells are present but have not spread to nearby tissue. Also called carcinoma in situ, or CIS. CIS is not cancer, but it may become cancer.

List and explain all the diet and physical activity recommendations for cancer prevention from the American Cancer Society and American Institute for Cancer Research/World Cancer Research Fund.

Add tables in!!!!

Explain current research on the relationship between cancer development and intake of soy foods, coffee and tea, salt, and dairy.

Additional Foods a) Soy (1) Controversial d/t phytoestrogens (2) Agonist for estrogen receptor? Antagonist? (3) Whole soy foods, esp. consumed early in life, seem to be protective against breast cancer (4) Avoid soy supplements, esp. high-dose isoflavones b) Coffee and tea (1) Contain potentially protective antioxidants (2) Coffee: associated with reduced risk liver, mouth, endometrial, skin cancers (3) Tea: associated with reduced risk bladder cancers (4) Mate: associated with increased risk mouth, esophagus cancers c) Salt/food processing with salt (1) Increased risk stomach cancer d) Dairy (1) "Strong" evidence for 13% decrease in risk of colorectal cancer for each additional 400g daily (2) May be r/t calcium, but also lactic acid-producing bacteria, casein and lactose in milk that increase calcium bioavailability, lactoferrin, vitamin D (from fortified dairy products), and butyrate (3) "Limited suggestive" evidence of small effect in prostate cancer (6% increase for every additional 400g daily) (4) "Limited suggestive" decreased risk for premenopausal breast cancer

hematopoietic

An immature cell that can develop into all types of blood cells, including white blood cells, red blood cells, and platelets leukemia, lymphoma, and myeloma Hematopoietic cancers: blood-forming tissues (1) Leukemia, lymphoma

Bulking Agents

Anti-constipation a) Fiber to retain water and promote peristalsis b) Psyllium (Metamucil)

Osmotic Laxative

Anti-constipation a) Hyperosmotic compounds pull water into colon lumen b) Magnesium hydroxide (AKA milk of magnesia) c) Sorbitol d) Lactulose e) Polyethylene glycol (Miralax)

Stimulant laxatives

Anti-constipation a) Increase peristalsis and bowel motility b) Bisacodyl (Dulcolax laxative) c) Senna (Senokot)

Stool softeners

Anti-constipation a) Increase water content of stools to make bowel movements easier to pass b) Docusate sodium (Colace, Dulcolax)

Megesterol acetate (Megace, Megace ES)

Appetite Stimulant Megace works best when eaten with high-fat meal; Megace ES does not have meal requirement Side effect may be edema

Mirtazapine (Remeron)

Appetite Stimulant a) Antidepressant, increased appetite as side effect b) Side effects: drowsiness, dry mouth, constipation

Dronabinol (Marinol)

Appetite Stimulant a) Marijuana derivative b) Side effects: N/V, abdominal pain, diarrhea, euphoria, confusion

Oxandrolone (Oxandrin)

Appetite Stimulant a) Synthetic testosterone derivative b) May cause hormonal changes

distant spread

Cancer has spread to distant parts of the body.

regional spread

Cancer has spread to nearby lymph nodes, tissues, or organs.

localized

Cancer is limited to the place where it started, with no sign that it has spread.

Define the steps of cancer progression from a single cell to metastatic cancer.

Cancer progression 1. Mutation(s) 2. Hyperplasia—excessive growth but no invasion 3. Metaplasia—cells not normally found in tissue, no invasion 4. Dysplasia—cells are not normally structured but still no invasion 5. Malignancy—invasion into tissues a) Angiogenesis b) Metastasis

Describe the multiple ways genes may mutate to create cancer cells and explain how this process develops in relationship to types of foods.

Cancer progression 1. Mutation(s) 2. Hyperplasia—excessive growth but no invasion 3. Metaplasia—cells not normally found in tissue, no invasion 4. Dysplasia—cells are not normally structured but still no invasion 5. Malignancy—invasion into tissues a) Angiogenesis b) Metastasis Mutations 1. Not so simple! Single mutations usually die: a) Cell-mediated apoptosis b) Immune system 2. Cancer requires multiple steps a) Deactivation of tumor suppressor genes b) Avoidance of apoptosis c) Avoidance of senescence d) Uncontrolled growth (1) Invasion into new tissues (2) Angiogenesis (3) Metastasis Cancer is caused by multiple issues! a) Cancer viruses (1) Insert DNA that causes uncontrolled growth (a) "Oncogene" (2) Ex: human papillomavirus (HPV) b) Oncogenes present in human DNA (1) Proto-oncogenes may cause cancer via: (a) Mutagens/carcinogens (b) Tumor viruses (c) Translocation of genes onto inappropriate chromosomes (d) Structural changes in proteins like growth factors c) Familial cancer syndromes (1) Inherited likelihood of developing cancer (2) Example: BRCA1 & BRCA2 (a) Play role in genome maintenance and recovery from injury (b) Mutations in these genes cause 50% of familial breast cancer Known carcinogens (1) Smoking (2) Nitrites in lunch meat (3) Polycyclic aromatic hydrocarbons in grilled meat (4) Acrylamide in fried starch (5) Pretty much anything can be carcinogen if overconsume... (6) Balancing Act: Red Wine (a) Cons (i) Increases cell turnover (ii) Increased estrogen levels (higher risk breast cancer) (iii) Acetaldehyde is mutagen (b) Pros (i) Resveratrol (potent antioxidant) (7) Cancer development affected by carcinogen exposure but also failure of immune system (a) Balanced diet with antioxidants & immune support critical (i) Inhibit carcinogens (ii) Reduce inflammation (increased cell turnover) (iii) Prevent or fix mutations (iv) Identify diseased cells and kill before they spread e) Rapid cell turnover (1) May be caused by damage to cells (a) Examples: Inflammation, alcohol, GERD (2) Can lead to increased mutations, esp. in cells exposed to damage

Describe the medical diagnostic process for cancer.

Diagnosis done by combination of: 1. Evaluation of patient history 2. Physical exam (palpation) 3. Laboratory tests 4. May include tumor markers a) Examples: (1) Prostate cancer: prostate-specific antigen (PSA) (2) Colon cancer: Carcinoembryonic antigen (CEA) (3) Pancreaticobiliary cancers: CA 19-9 5. Imaging a) CT, MRI, US b) Positron emission tomography (PET): radioactive tracer taken up in areas with high metabolic rate 6. Biopsy 7. Once diagnosed, referred to as "cancer survivor"

Explain the purpose of the Enhanced Recovery After Surgery guidelines and how dietitians can be a part oftheir implementation

Enhanced Recovery After Surgery (ERAS) Society a) Sets recommendations for quicker recovery, quicker discharge, recovery at home 3 Results: Gillis et. al b) Nutrition can play huge part in this! c) Example: Esophagectomy guidelines published Dec 2018 (1) 39 recommendations for standard of care to minimize postop complications, LOS (2) Include recommendations for nutrition, timing of surgery, type of surgery, fluid management, pain control, anesthesia, patient counseling (3) Nutrition-specific: (a) Routine nutrition assessment and intervention preoperatively (b) Pharmaconutrition not recommended at this time (omega-3, arginine, nucleotides) (c) Multidisciplinary tumor board (d) Prehabilitation may be beneficial (e) Routine placement and early use of enteric feeding tubes (f) Tight fluid balance (g) Inclusion in multidisciplinary postoperative standardized care pathway (h) Preoperative counseling with patient and family (i) Postoperative glycemic control

Describe general nutrition implications for patients who have undergone surgery for cancers of the esophagus,

Esophageal cancer a) May require partial or total esophagectomy b) Feeding jejunostomy is routine c) Side effects may include reflux, dumping syndrome, dysmotility, gastroparesis, early satiety, vomiting, fluid and electrolyte imbalances d) Low-fat diet with small frequent meals and avoiding large amounts of fluid at one time

Describe general nutrition implications for patients who have undergone surgery for cancers of the stomach,

Gastric cancer a) May include partial, subtotal or total gastrectomy b) Jejunal feeding tube recommended c) Side effects: dumping syndrome (limit simple carbohydrates and fluids at meals), malabsorption (iron, folic acid, vitamin B12), slow gastric emptying if vagal nerve cut

Name the 3 possible goals of cancer treatment.

Goals may include: 1. Cure a) Complete response to treatment 2. Control a) Extends life when cure is not possible 3. Palliation a) Relieve pain, manage symptoms, lessen isolation, anxiety and fear, maintain independence as long as possible b) Hospice: palliative care, generally for those with <6 months expected life 4. All types of treatment may be used for these goals!

impaction

Hardened stool that's stuck in the rectum or lower colon due to chronic constipation. Fecal impaction often occurs in people who've been constipated for a long time.-happens with constipation

Explain special considerations for a patient with head and neck cancer undergoing radiation therapy, and signs and symptoms of acute and chronic radiation enteritis.

Head and neck (1) Frequent preexisting malnutrition (2) Weight loss tends to occur during radiation, esp. d/t xerostomia, mucositis, and dysphagia (3) PEG often placed prophylactically (4) Side effects generally begin ~2 weeks into radiation therapy e) Radiation enteritis (1) Gynecological, abdominal, rectal, prostate cancers (2) Acute radiation enteritis develops due to damage to dividing cells in small intestine (a) Diarrhea, maybe bloody (b) Loss of gut barrier function with possible infection (c) Generally resolves ~2 weeks after finishing radiation (3) Chronic radiation enteritis develops due to damage to vascular endothelial and connective tissue cells, with chronic ischemia (a) May develop 6 months-30 years after radiation (b) May lead to obstruction, fistulas, colitis

hormone therapy

Hormone therapy 1. Removing hormones by providing antagonists may control cancer a) Ex: tamoxifen for breast cancer (anti-estrogen)

Define immunonutrition and describe the recommended treatment protocol

Immunonutrition may be indicated a) ONS with fish oil, arginine, antioxidants, nucleotides b) Given TID 5 days before surgery and 5 days after

immunotherapy

Immunotherapy or biotherapy 1. "Teach" immune system to attack cancer cells

"progression"

In medicine, the course of a disease, such as cancer, as it becomes worse or spreads in the body. can be seen in ttreatment response

Describe the 4 stages of HIV/AIDS

Infection with human immunodeficiency virus (HIV) from body fluids 1. Invades CD4+ cells (type of lymphocyte) which eventually die off, causing acquired immune deficiency syndrome (AIDS) B. 4 stages of disease 1. Initial acute infection a) Vague symptoms (fever, malaise, myalgia, sore throat, swollen lymph glands) 2-4 weeks after infection 2. Clinical latency/asymptomatic HIV infection a) May last for years as virus replicates slowly 3. Symptomatic HIV infection a) CD4+ cell counts drop below 500 cells/mm3, begin s/s fevers, chronic diarrhea, unexplained weight loss, recurrent infections 4. AIDS a) CD4+ counts less than 200 cells/mm3 or exhibiting one or more well-defined, life- threatening clinical conditions b) High risk opportunistic infections and AIDS-defining clinical conditions C. AIDS-defining conditions 1. Include infections, cancers, wasting syndrome

Describe general nutrition implications for patients who have undergone surgery for cancers of the intestines.

Intestinal cancers a) Partial or total resections of small or large intestine b) Side effects depend on amount, area removed c) May include malabsorption of nutrients (vitamin B12 for terminal ileum), fluid and electrolyte loss, oxalates causing kidney stones, lactose intolerance d) Need to know what has been removed and if possible how much remains

Explain the "balancing act" of carcinogen exposure in foods.

Known carcinogens (1) Smoking (2) Nitrites in lunch meat (3) Polycyclic aromatic hydrocarbons in grilled meat (4) Acrylamide in fried starch (5) Pretty much anything can be carcinogen if overconsume... (6) Balancing Act: Red Wine (a) Cons (i) Increases cell turnover (ii) Increased estrogen levels (higher risk breast cancer) (iii) Acetaldehyde is mutagen (b) Pros (i) Resveratrol (potent antioxidant) (7) Cancer development affected by carcinogen exposure but also failure of immune system (a) Balanced diet with antioxidants & immune support critical (i) Inhibit carcinogens (ii) Reduce inflammation (increased cell turnover) (iii) Prevent or fix mutations (iv) Identify diseased cells and kill before they spread

Name 5 types of medications that may be used to help treat cancer cachexia

Medical Treatment 1. Appetite stimulants like megestrol acetate 2. Corticosteroids like dexamethasone 3. Anti-cytokine factors like thalidomide 4. Anabolic agents like oxandralone/Oxandrin 5. Ghrelin, maybe - short half-life and parenteral administration 6. Dronabinol/Marinol does not seem to help; medical marijuana needs more study at least—smoking increases potential for pulmonary injury, aspergillus infection

Define 4 types of chemotherapy-induced nausea and vomiting and understand the general recommendations on CINV control.

Medical treatment of Chemotherapy-Induced Nausea and Vomiting (CINV) 1. Treatment recommendations based on four types of CINV: a) Acute: Onset of emesis within a few minutes to several hours after chemotherapy is administered and usually peaking in the first 4-6 hours b) Delayed: Onset of emesis more than 24 hours after chemotherapy is administered c) Anticipatory: Onset of emesis prior to chemotherapy administration as a conditioned response in patients who have experienced emesis during a previous cycle of chemotherapy d) Breakthrough/refractory: Emesis despite prophylactic/breakthrough medications 2. Chemotherapy classified as: a) High emetic risk: ≥90% or more of patients experience emesis b) Moderate emetic risk: 30% to 90% of patients experience emesis c) Low emetic risk: 10% to 30% of patients experience emesis d) Minimal emetic risk: < 10% of patients experience emesis 3. Best management of acute or delayed CINV is prevention 4. Patients should be protected before receiving chemotherapy and for the full period of risk (up to 4 days) afterward. 5. General recommendations for prevention: a) Prevention of acute emesis should start before chemotherapy and continue for the first 24 hours b) Choice of antiemetic agent should be based on the emetic risk of the chemotherapy regimen c) Prevention of delayed emesis is a continuation of prophylactic treatment for 2 to 4 days following completion of chemotherapy d) Because breakthrough/refractory emesis is difficult to reverse, prevention using routine around-the-clock administration of antiemetics is preferred over as-needed (PRN) dosing e) Prevention is also key to the management of anticipatory emesis f) Relaxation/systematic desensitization, hypnosis with guided imagery, and music therapy are behavioral interventions that may be considered for anticipatory emesis; acupuncture/acupressure are additional options g) Consider using lorazepam as an adjuvant to the antiemetic regimen to decrease anxiety in patients at risk for anticipatory emesis h) Consider using an H2 blocker or a proton pump inhibitor to prevent dyspepsia i) Consider other potential causes of emesis in cancer patients (eg, bowel obstruction)

Identify sites of radiation with the highest likelihood of nutrition-related complications.

Most important for patients receiving head and neck or abdominal/pelvic radiation

Promethazine (Phenergan®)

Nausea and vomiting a) Increases need for riboflavin b) Oral, parenteral, transdermal gel, rectal suppository

Ondansetron (Zofran®), granisetron (Kytril®)

Nausea and vomiting a) Oral disintegrating tablets, parenteral

Metoclopramide (Reglan®)

Nausea and vomiting a) Speeds gastric emptying b) Oral, parenteral

Prochlorperazine (Compazine®)

Nausea and vomiting also works as anti-psychotic a) Increases need for riboflavin b) Oral or parenteral

Assess the nutrition status of a patient with cancer.

Nutrition assessment includes: 1. Appetite and oral intake 2. Assessment of symptoms (ex: nausea, vomiting, diarrhea) likely d/t their treatment and cancer type 3. Weight status and history 4. Comorbidities 5. Labs 6. Nutrition-focused physical examination a) Amount of LBM

Create a nutrition intervention appropriate for cancer cachexia

Nutrition intervention 1. Increased need for energy and protein, esp. to build LBM a) May look to sports nutrition for ideas 2. EPA/DHA may be helpful to increase appetite, cause weight gain or slow weight loss, improve quality of life a) Doses range in studies 600 mg to 3.6 g/day b) Most recommend 2 grams daily 3. Melatonin needs additional investigation 4. Best results so far in intervention trial where participants received megesterol acetate or medroxyprogesterone + EPA-rich ONS + L-carnitine + thalidomide a) Increase in LBM, decrease in REE, improved fatigue, improved appetite, reduced IL-6, reduced inflammation, improved QOL b) Just one study, though

Create a nutrition prescription appropriate for a patient with cancer, including energy, macronutrient, fluid, and micronutrient needs.

Nutrition prescription 1. Energy needs a) Indirect calorimetry preferred b) Needs to be tailored to individual c) Some cancers tend to lose weight, others tend to gain 2. Protein needs a) Must consider degree of malnutrition, extent of disease, degree of stress, ability to metabolize and use protein b) 1.5 to 2 g/kg/day 3. Carbohydrates a) No change from normal b) Restricting carbohydrates or sugars does not "starve" tumor 4. Fats a) No change from normal 5. Fluid a) Ensure adequate hydration and electrolyte balance, and prevent dehydration and hypovolemia, watch for nephrotoxic effects of anticancer treatments b) Altered fluid balance common, requires close monitoring c) General guideline for estimating fluid needs for all adults without renal concerns is 20 to 40 ml/kg, or 1 ml fluid per 1 kcal of estimated calorie needs 6. Micronutrients a) High-dose supplements common, controversial but generally discouraged b) Assess and treat preexisting deficiencies c) Recommend supplement with 100% DRI

interleukin

One of a group of related proteins made by leukocytes (white blood cells) and other cells in the body. Interleukins regulate immune responses.

Describe general nutrition implications for patients who have undergone surgery for cancers of the pancreas,

Pancreatic cancer a) Pancreaticoduodenectomy (Whipple) or distal pancreatectomy are only curative treatments (1) Pancreaticoduodenectomy (a) Removes: (i) Head of pancreas (ii) Gallbladder (iii) Common bile duct (iv) Duodenum (v) Proximal jejunum (vi) Lymph nodes (b) Most common now: pylorus- preserving PD (c) Standard procedure removed antrum, pylorus = higher risk dumping syndrome (2) Distal Pancreatectomy (a) Removes: (i) Body/tail of pancreas (ii) Spleen (iii) Lymph nodes b) Side effects: delayed gastric emptying, early satiety, glucose intolerance/Type 3c diabetes, bile acid insufficiency, diarrhea, fat malabsorption c) Pancreatic enzyme replacement, lower-fat meals and snacks, avoid simple carbohydrates

diarrhea

Pathophysiology 1. Abnormal increase in stool liquidity and frequency that may be accompanied by abdominal cramping 2. Cancer-related diarrhea can be seen in: a) Patients with carcinoid tumors, carcinoid syndrome, gastrointestinal tumors, and hormone-producing tumors b) Patients undergoing high-dose chemotherapy c) Patients receiving radiation therapy to abdominal and pelvic areas 3. Incidence of diarrhea during chemotherapy can range from 50%-90% 4. May be a dose-limiting toxicity Medical treatment 1. Address underlying issue 2. Treat fluid and electrolyte deficiencies a) Esp. potassium, sodium b) Oral rehydration solutions or IV fluids 3. Medications a) Antibiotics for infections (1) Probiotics still inadequate evidence b) Enzymes (pancreatic) for malabsorption c) Decrease muscle tone and peristalsis of GI tract by stimulating opioid receptors (1) Examples: (a) Loperamide (Imodium AD®) (b) Atropine and diphenoxylate (Lomotil®) (c) Tincture of opium Nutrition intervention 1. Assess potential food causes a) Alcohol b) Milk/dairy (lactose intolerance) c) Caffeine (coffee, tea, chocolate) d) High-fiber foods e) High fat foods f) Sorbitol (candy, chewing gum) g) Hot/spicy foods h) Gas-forming foods (cruciferous vegetables, beans, carbonation) 2. Fluids and electrolytes first a) Sip throughout the day 3. Clear liquid diets not indicated a) Sugar load may increase diarrhea 4. Little evidence for low fiber or low residue diets but often used a) Allowed: starches, progress to low fat meats, fruits and vegetables, fat b) Avoid lactose, insoluble fiber, sugar alcohols, excess fructose and sucrose, caffeine, alcohol 5. Restrictive diets (BRAT, bananas rice applesauce toast) tend to be nutrient poor and inadequate evidence 6. Soluble fiber may help thicken stool a) Pectin in banana flakes, guar and other gums as supplement

Nausea and vomiting

Pathophysiology 1. Causes: numerous and nondiagnostic a) Infection, pain, pregnancy, syncope, headache, metabolic disorders, motion sickness, kidney failure, MI, drug side effects, obstruction in GI tract... 2. Can lead to esophageal tearing or rupture, electrolyte imbalance, dehydration, bleeding and hematemesis, aspiration B. Medical treatment of Chemotherapy-Induced Nausea and Vomiting (CINV) 1. Treatment recommendations based on four types of CINV: a) Acute: Onset of emesis within a few minutes to several hours after chemotherapy is administered and usually peaking in the first 4-6 hours b) Delayed: Onset of emesis more than 24 hours after chemotherapy is administered c) Anticipatory: Onset of emesis prior to chemotherapy administration as a conditioned response in patients who have experienced emesis during a previous cycle of chemotherapy d) Breakthrough/refractory: Emesis despite prophylactic/breakthrough medications 2. Chemotherapy classified as: a) High emetic risk: ≥90% or more of patients experience emesis b) Moderate emetic risk: 30% to 90% of patients experience emesis c) Low emetic risk: 10% to 30% of patients experience emesis d) Minimal emetic risk: < 10% of patients experience emesis 3. Best management of acute or delayed CINV is prevention 4. Patients should be protected before receiving chemotherapy and for the full period of risk (up to 4 days) afterward. 5. General recommendations for prevention: a) Prevention of acute emesis should start before chemotherapy and continue for the first 24 hours b) Choice of antiemetic agent should be based on the emetic risk of the chemotherapy regimen c) Prevention of delayed emesis is a continuation of prophylactic treatment for 2 to 4 days following completion of chemotherapy d) Because breakthrough/refractory emesis is difficult to reverse, prevention using routine around-the-clock administration of antiemetics is preferred over as-needed (PRN) dosing e) Prevention is also key to the management of anticipatory emesis f) Relaxation/systematic desensitization, hypnosis with guided imagery, and music therapy are behavioral interventions that may be considered for anticipatory emesis; acupuncture/acupressure are additional options g) Consider using lorazepam as an adjuvant to the antiemetic regimen to decrease anxiety in patients at risk for anticipatory emesis h) Consider using an H2 blocker or a proton pump inhibitor to prevent dyspepsia i) Consider other potential causes of emesis in cancer patients (eg, bowel obstruction) Medical treatment—Radiation-induced nausea and vomiting 1. Radiation field and risk of RINV a) High risk: Total body irradiation and total nodal irradiation b) Moderate risk: Upper abdomen, half body irradiation, upper body irradiation c) Low risk: Cranium, craniospinal, head and neck, lower thorax region, pelvis d) Minimal risk: Extremities, breast 2. Generally use combination of dexamethasone (Decadron®) and ondansetron (Zofran®) Nutrition Intervention 1. Hold intake while vomiting continues 2. "Sips and chips" - small sips of fluid and ice chips a) Start slowly, ~1 tsp. every 10 minutes, and increase gradually as tolerated 3. Sip on liquids after vomiting has stopped: water, apple juice, sports drinks, warm or cold tea, lemonade 4. Cool or room-temperature 5. When vomiting has stopped for ~ 8 hours, small bites of solids a) Avoid fatty, spicy, overly sweet, gas-producing, and fibrous foods b) Avoid odors; cold foods may have less odor or open food tray outside c) Eat in well-ventilated areas d) Ginger may help 6. Use straws if liquid has an unpleasant odor (ONS) 7. Small frequent meals when reestablishing intake 8. Sip on fluids separate from meals 9. Use antiemetics proactively 10. Monitor hydration and electrolyte balance 11. Emphasize bland, easy-to-digest foods on scheduled treatment days (chemotherapy-induced) or on "bad" days (delayed)

Xerostomia

Pathophysiology 1. Dry mouth d/t salivary gland destruction 2. Acute tends to be d/t chemotherapy 3. Chronic d/t radiation or surgery 4. May cause: a) Functional alterations, such as speech and swallowing difficulties, taste alterations, glossodynia (burning sensation of the tongue), and cheilitis (inflamed lips and tongue) b) Gagging sensation with fear of choking for the patient and difficulty or painful swallowing c) Periodontal disease d) Oral infections e) Low PO intake f) Weight loss g) Lower quality of life Medical treatment 1. Amifostine/Ethyol—drug to protect cells, given with chemotherapy 2. Pilocarpine helps increase saliva production Nutrition intervention 1. Sip liquids throughout the day 2. Try tart foods to stimulate saliva, if open sores are not present. 3. Try sugar-free lozenges, mints, candy, or gum. 4. Eat soft, moist foods with extra sauces, dressings, or gravies. 5. Try mouth moisturizers or saliva substitutes to keep the oral cavity moist 6. Maintain good oral hygiene

Mucositis

Pathophysiology 1. Inflammation including mouth and GI tract - generally referred to as mouth sores 2. May cause anorexia, dehydration, weight loss, and malnutrition because of difficulty eating and drinking 3. 1/3 patients halt treatment Medical treatment 1. Cryotherapy (ice/ice water before treatment) constricts blood vessels in mouth, reduces exposure to chemo 2. Palifermin/Kepivance - a growth hormone that targets epithelial cells lining GI tract, used in HCT and head and neck chemotherapy 3. Nystatin swish and swallow - antifungal medication 4. Magic mouthwash: no standard formula, but it usually contains at least three of these basic ingredients: a) An antihistamine or anticholinergic agent, which may help relieve pain b) A local anesthetic to reduce pain and discomfort c) An antacid that helps ensure the other ingredients adequately coat the inside of your mouth d) An antifungal to reduce fungal growth e) A corticosteroid to treat inflammation f) An antibiotic to kill bacteria around the sore 5. Lactobacillus lozenges Nutrition intervention 1. Maintain good oral hygiene a) Baseline and ongoing oral examinations b) Brushing for 2 minutes after every meal with soft toothbrush c) Dental floss to scrape sides of teeth, especially near gums d) Replace toothbrush every 2 months e) Bland rinse that does not contain alcohol (1) Biotene (2) NCI: ¾ tsp. salt and 1 tsp. baking soda in 4 c. water, rinsing 3-4 times per day 2. Adequate hydration 3. Eat soft, moist foods with extra sauces, dressings, and gravies. 4. Avoid alcohol, citrus, caffeine, tomatoes, vinegar, and hot peppers, as well as dry, coarse, or rough foods. 5. Eat foods at room temperature, cool, or chilled.

Neutropenia

Pathophysiology 1. Low number of neutrophils (WBC responsible for phagocytosis) 2. May be caused by treatment or patient-specific factors (comorbidities, etc.) Medical treatment 1. Neupogen (Neulasta®) Nutrition Intervention 1. Inadequate evidence to avoid fresh fruits/vegetables 2. Emphasize food safety: a) Hand hygiene: soap and water for 20 seconds b) Keep kitchen surfaces clean (1/3 c. household bleach mixed with 3 1/3 c. water) c) Change dishcloths/towels daily d) Separate cutting board for meats and produce e) No raw or undercooked meats or eggs f) Only pasteurized milk, yogurt, cheese, etc. g) Avoid "bulk bins" h) Use food thermometer i) Store food safely (below 40 or over 165) j) Wash all fresh fruits and vegetables before eating k) Check sell by and use by dates l) Avoid salad bars, delis, buffets, potlucks, sidewalk food vendors m) "When in doubt, throw it out" and "No oldie or moldy"

Altered taste and smell

Pathophysiology 1. Often present as: a) Not being able to smell things other people do, or noticing a reduced sense of smell. b) Noticing things smell different or certain smells are stronger c) Having a bitter or metallic taste in the mouth. d) Food tasting too salty or sweet. e) Food not having much taste. 2. May be caused by: a) Certain kinds of tumors in the head and neck area b) Radiation to the head and neck area c) Certain kinds of chemotherapy and targeted therapy d) Mouth sores or dryness due to certain treatments e) Medications used to help with side effects or other non-cancer problems Nutrition intervention 1. Oral hygiene 2. Check for thrush (Candida albicans infection) 3. Cook foods using marinades and spices to mask strange tastes. 4. Enhance the flavor of food by using the FASS technique (fat, acid, salt, and sweet) a) Examples: (1) Add a pat of butter to hot cereal (2) Add a few drops of lemon or lime juice to a smoothie (3) Sprinkle sea salt on fresh melon cubes (4) Add a drizzle of maple syrup to steamed carrots 5. For metallic taste: a) Plastic utensils b) Avoid foods that come from a can or metal container 6. Eat cooler foods rather than warm or hot foods (to dampen taste) 7. Place liquids with strong odors in a cup with a lid, and drink them through a straw 8. Zinc can be tried a) Conflicting evidence b) 50 mg of elemental zinc daily c) Limit the duration of supplementation to 60 days d) Take with meal/food if causes nausea

Anorexia

Pathophysiology 1. Tumor hormones 2. Tumor location 3. Medications 4. Underlying health/weight prior to illness Medical treatment 1. Corticosteroids - dexamethasone, prednisone, methylprednisolone a) Dexamethasone usual dose: 4 mg/day b) Side effects: myopathy, Cushingoid disease, peptic ulcers c) Not for long-term use 2. Progesterone derivative - megesterol acetate/Megace or Megace ES (higher strength) a) Usual dose: 400 mg/day (Megace) or 625 mg/day (Megace ES) b) Side effects: edema, thrombosis, suppression of pituitary adrenal axis c) Better option for long-term use 3. More/better evidence needed for: a) Antidepressant - mirtazapine/Remeron b) Human growth hormone somatropin/Serostim c) Androgen - oxandraolone/Oxandrin d) Synthetic THC - dronabinol/Marinol and nabilone/Cesamet Nutrition intervention 1. Eat small, more frequent meals and snacks. 2. Increase intake of nutrient-dense foods 3. Drink liquid medical food supplements or homemade drinks and smoothies. 4. Take advantage of times when feeling good. 5. Eat meals and snacks in a pleasant atmosphere. 6. Try to be as physically active as able to stimulate the appetite. 7. Enlist the help of family and caregivers to assist with food procurement and preparation. 8. Consult with a physician for consideration of pharmacologic interventions to stimulate the appetite

Early satiety

Pathophysiology 1. Tumor location 2. Tumor type 3. Medications 4. Age Medical treatment 1. Metoclopramine/Reglan Nutrition intervention 1. Small frequent meals if able (5-6 per day) 2. High-fat meals are least satiating 3. Address hyperglycemia if appropriate 4. Capitalize on times when feeling best (breakfast often best meal) 5. Light exercise to stimulate digestion 6. Avoid gaseous foods that may increase bloating 7. Add protein/calories to favorite foods 8. Liquids leave stomach most quickly 9. Smoothies at home, supplements out (reduce taste fatigue)

Constipation

Pathophysiology-SEE IMAGE Medical treatment 1. Treat cause, if possible 2. Start with peristaltic stimulant such as senna or a stool softener 3. Titrate towards effect 4. Add osmotic laxatives such as lactulose or sorbitol every 4-6 hours until BM (but avoid long-term use d/t fluid and electrolyte imbalances) 5. Treat distal constipation with suppositories or enemas 6. After no BM for 3 days, follow the "rescue" enemas with an increase in oral laxatives 7. Distal fecal impaction on digital exam may require digital disimpaction and oil-retention enema 8. Proximal fecal impaction on X-ray may require magnesium citrate and oral lubricants (mineral oil) 9. Medications a) Bulk-forming agents (1) Cellulose, psyllium seed, bran (2) Increase mass and water content of stool; intraluminal fluid increased after gut microflora breakdown b) Lubricants (1) Liquid paraffin, mineral oil (2) Adverse effects: impaired absorption of fat-soluble vitamins, irritation of perianal area, risk of lipid pneumonia if aspiration occurs (3) Short-term use for fecal impaction c) Osmotic laxatives (1) Lactulose, sorbitol (30-70%), mannitol (2) Short-chain organic acids lower intestinal pH and stimulate peristalsis and increase stool bulk (3) Adverse effects: flatulence d) Saline laxatives (1) Magnesium hydroxide (most potent), magnesium citrate, sodium phosphate, sodium sulfate (2) Increases intestinal water secretion, directly stimulates peristalsis (3) Rapid onset throughout the gut, not only colon (4) Adverse effects: electrolyte accumulation, volume overload, severe cramping, bloating, dehydration, bowel perforation, hypocalcemia (phosphates) e) Contact laxatives (1) Docusate (a) Increases mucosal secretion and peristalsis, surfactant allows water and fat to mix with feces and stool softener (b) Patient may develop tolerance (2) Castor oil (a) Hydrolyzed by gut microflora to ricinoleic acid (b) Adverse effects: cramping, diarrhea, malabsorption f) Senna (1) Converted to active form by colonic bacteria (2) Stimulates mucosal electrolyte transport and motility, affecting mainly colon (3) Takes 12-24 hours for action (4) Pink urine can occur 7 g) Enemas and suppositories (1) Sodium phosphate or sodium citrate (2) Glycerin suppository (3) Sorbitol enema (4) Tap water enema (5) Soap suds enema (6) Saline enema (7) Bisacodyl suppositories Nutrition intervention 1. Consult with team on pharmacologic interventions 2. Assess "normal" 3. Adequate fluid intake 4. Activity as tolerated 5. Add fiber but avoid excess intake (may cause impaction) a) Rule of thumb: add 5 g/day weekly to usual intake 6. Hot liquids help stimulate bowel movement (caffeine can help) 7. Avoid gas-producing foods (beans, cruciferous vegetables, carbonation) 8. Location and timing: comfortable area, patience, regular mealtimes

Identify when a diet can begin after surgery

Postoperative Nutrition Intervention 1. Nutrition aids in healing but also reduces surgical complications like infection, anastomotic leak 2. Begin diet ASAP a) No waiting for bowel sounds, flatus, or BM! b) Avoid restrictions or slow diet progression (i.e., CL, FL) c) May consider "transitional" diet 3. Immunonutrition may be indicated a) ONS with fish oil, arginine, antioxidants, nucleotides b) Given TID 5 days before surgery and 5 days after 4. Still need RD help, even months later!

Define "prehabilitation" and give an example prehabilitation program

Preparing for Surgery 1. Patients come in with varying degrees of malnutrition d/t cancer, treatment 2. Preparation or prehabilitation appears beneficial! 3. First cancer prehabilitation study: Gillis et al. a) Colorectal cancer resection b) 3-day food record c) Randomized to "prehab" or "rehab" (1) Prehab: Intervention 4 weeks before surgery, continue for 8 weeks (2) Rehab: Intervention after surgery for 8 weeks d) Intervention: (1) Exercise (kinesiologist): 150 min/week aerobic + strength (2) Nutrition (dietitian): protein goal 1.2 g/kg, whey supplement, symptom management, blood glucose control, weight change, overall healthy diet (3) Psychology: coping strategies for anxiety

Sedative

Propofol (Diprivan) a) Lipid-based sedative often used for patients on mechanical ventilator b) Provides 1.1 kcal/mL c) Must account for kcal in assessment d) Ex: patient needs 1800 kcal; propofol infusing @ 4.5 ml/hr (continuous infusion) (1) 4.5 ml/hr x 24 hours = 108 ml/day (2) 108 ml/day x 1.1 kcal/ml = 118.8 kcal/day (3) Remaining kcal needs = 1800 - 119 = 1681 kcal

List recommendations for nutrition in cancer survivors

Recommendations 1. AICR/WCRF: Follow cancer prevention guidelines as much as possible 2. ACS Guidelines a) Achieve and maintain a healthy weight b) Limit consumption of high-calorie foods and beverages, increase physical activity to promote and maintain weight loss c) Avoid inactivity and return to normal daily activities as soon as possible, goal 150 minutes moderate or 75 minutes vigorous aerobic activity per week d) Strength training 2 days per week e) Dietary pattern high in vegetables, fruits, whole grains, legumes, fiber; low in saturated fats and limited ETOH consumption

esophagectomy

Remove all or part of your esophagus and nearby lymph nodes through incisions in your chest, abdomen or both. Reconstruct the esophagus using the stomach or colon

BRAT diet

Restrictive diets (BRAT, bananas rice applesauce toast) tend to be nutrient poor and inadequate evidence-for diarrhea

Describe general nutrition implications for patients who have undergone surgery for cancers of the head and neck

Select Surgeries with Nutrition Implications 1. Head and neck cancer a) High risk preexisting malnutrition b) VERY high risk dysphagia c) May require PEG or gastrostomy placement—often placed prophylactically

Name the delivery device often used for chemotherapy.

Systemic or regional delivery of cytotoxic drugs that work in various ways (targeting different parts of rapidly dividing cell cycle, inhibiting proteins found in cancer cells, inhibiting angiogenesis...) 2. Often delivered in combination, esp. since cancer cells mutate quickly/develop resistance 3. May be given daily over long periods of time, once per week, in lengthy infusion, in short infusion... 4. Common infusion device: "port," surgically placed central venous access IMAGE ON NOTES!

Corticosteriods

Systemic steroids that are similar to cortisol a) Prednisone b) Methylprednisolone c) Cortisone Used to decrease activity of immune system a) Autoimmune diseases b) Respiratory diseases c) Excessive inflammation 3. Effects of long-term use: a) Increased appetite and weight gain (predominantly fat) b) Protein catabolism c) Atrophy of bone protein matrix d) Delayed wound healing e) Decreased absorption of calcium f) Increased urinary loss of calcium, potassium, zinc, vitamin C g) Sodium and fluid retention

gastrectomy

There are 4 main types of gastrectomy, depending on which part of your stomach needs to be removed: total gastrectomy - the whole stomach is removed partial gastrectomy - the lower part of the stomach is removed sleeve gastrectomy - the left side of the stomach is removed oesophagogastrectomy - the top part of the stomach and part of the oesophagus (gullet), the tube connecting your throat to your stomach, is removed

"response"

Treatment response denotes the extent to which a patient improves, irrespectively of the presence or absence of symptoms

hematopoietic cell therapy or stem cell transplant

Treatments often used in combination a) Treats leukemia, lymphoma, multiple myeloma b) High-dose chemotherapy or radiation to kill all parts of blood cells, transplant with own or other's stem cells

Describe tissues most likely to develop common cancers in childhood and in adulthood.

Types of cancer 1. Most common in adults: carcinomas a) Begin in epithelial lining b) Squamous cell carcinoma—protective epithelial cells c) Adenocarcinoma—epithelial cells that secrete "stuff" 1. Called by site, then cancer type: (1) Pancreatic adenocarcinoma (2) Renal cell carcinoma 2. Less common types: a) Osteosarcoma, liposarcoma, leiomyosarcoma, angiosarcoma, etc. b) Hematopoietic cancers: blood-forming tissues (1) Leukemia, lymphoma c) Neuroectodermal tumors: nervous system (1) Gliomas, glioblastomas, neuroblastomas, schwannomas, medulloblastomas Pediatric cancer d) Tissue type is often different; occur in rapidly growing tissues during normal childhood growth e) Childhood cancers not strongly linked to lifestyle choices or environment f) Normally respond better than adult cancers to treatment g) Long term issues from treatment are a bigger concern

dumping syndrome

a group of symptoms, such as diarrhea, nausea, and feeling light-headed or tired after a meal, that are caused by rapid gastric emptying. Rapid gastric emptying is a condition in which food moves too quickly from your stomach to your duodenum

sarcoma

a rare type of malignant (cancerous) tumor that develops in bone and connective tissue, such as fat, muscle, blood vessels, nerves and the tissue that surrounds bones and joints Less common types: a) Osteosarcoma, liposarcoma, leiomyosarcoma, angiosarcoma, etc.

Dexamethasone (Decadron®)

a) Corticosteroid

carcinoma

cancer that forms on epithelial tissues Most common in adults: carcinomas a) Begin in epithelial lining b) Squamous cell carcinoma—protective epithelial cells c) Adenocarcinoma—epithelial cells that secrete "stuff" 1. Called by site, then cancer type: (1) Pancreatic adenocarcinoma (2) Renal cell carcinoma

Energy needs and cancer

cancer, nutritional repletion, weight gain- 30-40 kcal/kg/day cancer, normometabolic- 25-30 kcal/kg/day cancer, hypermetabolic, stressed-35 kcal/kg/day hematopoiectic cell transplant- 30-35 kcal/kg/ day sepsis-25-30 kcal/kg/day obese-21-25 kcal/kg/day

"stable disease"

from treatment Cancer that is neither decreasing nor increasing in extent or severity

cryotherapy

ice/ice water before treatment, constricts blood vessels in mouth, reduces exposure to chemo-for mucositis

TNF-α

is a cytokine that has pleiotropic effects on various cell types. It has been identified as a major regulator of inflammatory responses and is known to be involved in the pathogenesis of some inflammatory and autoimmune diseases

brachytherapy

radiation directly inside tumor via needle or "seeds" (usu. prostate)

debulking

surgery removal of tumor tissue to relieve symptoms (generally not curative)

lymphedema

swelling due to build-up of lymph fluid in the body. Lymph nodes act like a drain in your sink. If the drain is clogged, the fluid cannot drain. It usually happens in the arms or legs, but can occur in other parts of the body.

apoptosis

the death of cells which occurs as a normal and controlled part of an organism's growth or development.

graft-versus-host disease

the graft reacts against the host. The graft is the marrow or stem cells from the donor. The host is the person having the transplant. GvHD happens when particular types of white blood cell (T cells) in the donated stem cells or bone marrow attack your own body cells

biopsy

the removal of living tissue from the body for diagnostic examination such as for cancer detection

distal pancreatectomy

usually done to remove benign (not cancer) or malignant (cancer) pancreatic tumors found in the body or tail of the pancreas