Cancer
Single Nucleotide Polymorphisms(SNPs)may alter nutritional needs
(e.g. variant in the VDR-vit D receptor gene) -SNPs comprise ~ 10% of the human genome
Can diet alter colon cancer progression
- Additional data on dietary fiber is needed -Intakes of up to 1200 mg calcium in the form of low-fat dairy foods improved markers of cell proliferation and differentiation - The protective effect of a genetic polymorphism in the MTHFR gene is destroyed by one or more alcoholic beverages per day.
Why is there a proliferation of abnormal cells?
- Colon cancer is initiated by an accumulation of gene alterations in the crypt stem cells located at the base of the villi - The altered genes are normally involved in the processes of cell division, differentiation, or apoptosis - The result is the proliferation of transformed cells (cells that have genetic mutations)
What hypotheses have been put forth to suggest the cause of mutations in colon stem cells?
- High serum insulin levels - Meat intake which is associated with fat intake and intake of heterocyclic aromatic amines (HAAs) - Increases in abdominal fat have been associated with colon cancer Processed meats
Nutrition and Neutropenia Precautions
- Safe food handling •Special handling of utensils, cutting boards, and countertops •Thorough hand washing •Store food at appropriate safe temperatures. - Avoid foods that pose infection risk. •Raw meats •Spoiled/moldy foods •Special handling of raw meat, eggs, poultry
MNT Screening and Assessment
-Assess GI function -Estimate or measure energy levels -Cancer-related posttraumatic stress syndrome -Spiritual and psychological well-being -Nutrition-focused physical examination
MNT-Nutrition Care Process
-Assessment -Diagnosis -Intervention -Monitoring and Evaluation
Two Types of Hematopoietic Cell Transplants (HCT)
-Autologous of cells or tissues) obtained from the same individual. -Allogeneic
General Guidelines for Safe Use of Herbal Therapies
-Buy products that list plant components and their quantities -Use products manufactured by companies with good quality control -Use low, conservative doses; may be best to avoid daily doses -Avoid use in pregnancy and childhood If cancer, do not use
Graft-versus-Host Disease
-Donated cells react against host. Gastroenteritis, abdominal pain, vomiting, secretory diarrhea, organ involvement wMNT: •Phase 1: PN until diarrhea resolves •Phase 2: Isotonic, oral liquids •Phase 3: Reintroduce solids, low lactose, low fat, and low acid foods. •Phase 4: Progressively reintroduce food •Phase 5: Regular diet
Beginning about 30 years ago a few studies demonstrated that nutrition intervention can influence patient outcomes in cancer patients
-Fewer infections and wound complications and decreased length of patient stay were shown in surgically-treated GI cancer pts given an enteral formula enriched with arginine, omega-3 fatty acids, and RNA (Daly et al, 1992) -Bone marrow transplant patients given TPN supplemented with glutamine had fewer infections and shorter hospital stays (Ziegler et al, 1992)
MNT Goals for Cancer
-Improve treatment tolerance -Reduce need for interruptions of treatment -Decrease unintentional weight and LBM loss -Increase quality of life -Improve overall survival
Alchohol
-Increased risk of oral cavity, pharynx, larynx, esophagus, colon, stomach, rectum, pancreas, gallbladder, liver, and breast cancers -Negatively affects health outcomes for cancer survivors. •Increased risk for cancer recurrence -Alcohol and tobacco increased risk.
Mechanisms of cancer cachexia
-Loss of skeletal muscle may result from the presence of proinflammatory cytokines: tumor necrosis factor (TNF), interleukin-1 (IL-1), interleukin-6 (IL-6), and interferon gamma (IFN-g)
Nutrition Diagnosis
-May be related to intake, GI status, or access to food -Check out the eNCPT: https://www.ncpro.org/
MNT for neutropenic patients
-Neutropenia is defined as an absolute neutrophil count of < 2000/mm 3 -Neutropenic patients are at increased risk for life-threatening infections - See NCM Nutrition Care->Client Ed-> Organ Transplant -> Low Microbial or Client Ed -> Food Safety
Complementary and Integrative MNT
-Open, honest, nonjudgmental discussion. -Clinicians need to know and discuss the benefits and risks of alternative therapies for cancer. -Supplements showing promise: Omega-3 fatty acids, vitamin D, curcumin, selenium, medicinal mushrooms -Potential adverse effects of garlic and vitamin E on bleeding risk -Adverse interactions with chemotherapy: Garlic, green tea, mistletoe, Chinese herbs, St John's wort, ginger -Some therapies are toxic.
MNT and Cancer Cachexia
-Progressive weight loss, anorexia, generalized wasting and weakness, immunosuppression, altered BMR, abnormalities in energy metabolism - Results in loss of lean body mass and fat mass Mediated via cytokines
Graft-versus-host disease
-Reaction of donor stem cells against host cells -Affected organs: GI tract, skin, liver -Can occur within the first 100 days and as early as 7 days post-transplant -Severe GI GVHD may be accompanied by profuse diarrhea with bleeding -Severe skin GVHD may be accompanied by severe fluid loss -First-line treatment are corticosteroids -MNT: when able to take oral diet -> low lactose, low fat, low fiber
Nutrition Diagnosis
-See NCM Nutrition Care ->Oncology-> Nutrition Diagnosis -Example: "Inadequate energy intake related to mucositis as evidenced by patient report of pain with eating and 5 lb weight loss over 2 weeks."
Alterations in Macronutrient Metabolism
-Tumors demand glucose, exhibit anaerobic metabolism, and produce lactate. •Protein breaks down to meet glucose demand. •Glucose intolerance and insulin resistance - Patients often need increase in energy and protein (see previous slide).
What happens when incorrect proteins are coded?
-altered metabolism -altered cell division -altered organ function -disease
Cancer cachexia:
-anorexia -depleted lean tissue mass regardless of nutrient intake -hypoalbuminemia -increased rate of lipolysis - Edema, anemia
wSimple starvation:
-decreased liver mass -decreased hepatic protein synthesis -preferential utilization of fat as an energy source
Alchohol accounts for
3.5% of cancer-related deaths •1. 5 drinks per day (women) - 3 drinks (men) drinks per day increases risk •AICR advises no alcohol
DNA and RNA are comprised of strands of
4 nucleic acids
Which is the best describe cancer?
A assortiment of disease that result of uncontrolled growth and spread of abnormal cell
Venooclusive Disease
A complication of HCT that can result in hepatic failure
Oncogene:
A gene that plays a normal role in the cell as a proto-oncogene that then is altered by mutation which contributes to the growth of a tumor.
Prostaglandins
A group of naturally occurring, chemically related, long chain fatty acids. They are highly reactive substances that can stimulate contraction of smooth muscle, lower blood pressure, and effect the action of certain hormone
Nutrition-focused physical findings:
Age greater than 65 years Loss of muscle mass Loss of subcutaneous fat Presence of pressure ulcers or wounds Nutrition impact symptoms including but not limited to: Nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, alterations in taste and smell and anxiety Changes in appetite Vital signs Functional indicators (i.e., Karnofsky score, grip strength) Localized or generalized fluid accumulation. Client history: Patient/Family/Client Medical/Health history: Nutrition impact symptoms including but not limited to: Dysphagia, depression and pain fatigue Medical treatment or therapy Other diseases, conditions and illnesses including cancer cachexia.
wChemotherapy •
Anemia, fatigue, nausea, vomiting, loss of appetite, mucositis, changes in taste and smell, xerostomia, dysphagia, diarrhea, constipation
Complementary base pairing (
C-G, A-T, or A-U)
Initiation -
DNA damage by virus, chemicals, radiation, etc.
Thymine in
DNA only
Nutrition Monitoring and Evaluation
Don't forget physical activity! Why? rebuild muscle, regain strength, energy, flexibility -What parameters may be appropriate for monitoring in cancer patients undergoing cancer therapy? weight change, ,food nutrition related history, biochemical data, client history, nutrition-focused physical findings
wTotal body irradiation •
Fever, nausea, vomiting, headache, mucositis, parotitis(painful swelling of your parotid glands) , xerostomia( dry mouth), diarrhea, anorexia, weight loss
Progression
Follows the initiation stage of carcinogenesis and is the tendency for tumors to become more malignant as they grow
How does cancer start?
Genetic mutations leading to abnormally expressed genes that interfere with the cell cycle
The RDN should assess the following anthropometric measurements in adult oncology patients:
Height and weight Weight change Body Mass Index (BMI).
Carcinogenesis
Initiation - DNA damage by virus, chemicals, radiation, etc. Promotion - mutated cells multiply Progression - tumors form Metastasis - tumors develop their own blood supply and spread
The presence of two or more of the following criteria or characteristics supports a nutrition diagnosis of malnutrition in the adult oncology patient (See Clinical Characteristics to Document Malnutrition). I
Insufficient energy intake Unintended weight loss Loss of subcutaneous fat Loss of muscle mass Localized or generalized fluid accumulation (that may mask weight loss) Reduced grip strength.
Cell cycle -review
M phase- divisions S phase - DNA synthesis
The following has been shown to be valid and reliable for identifying malnutrition risk in adult oncology patients in the ambulatory/outpatient setting:
MST. - Malnutrition Screening Tool (MST)
Single Nucleotide Polymorphisms(SNPs)
May lead to disease (sickle cell anemia), but may also confer resistance to disease
Composition of Genes -
Nucleic Acids •Adenine •Thymine •Cytosine •Guanine
Two types of genes that when mutated alter the cell cycle leading to cancer
Oncogenes - Tumor Suppressor Genes
Research indicates that the following tools have been shown to elicit valid and reliable data as part of a comprehensive nutrition assessment of adult oncology patients in ambulatory and acute care settings:
Patient-Generated Subjective Global Assessment (PG-SGA) Subjective Global Assessment (SGA).
wNutrition screening tools •
Patient-generated subjective global assessment -SEE BLACKBOARD •Malnutrition screening tool (MST) •Malnutrition universal screening tool (MUST)
growth factor
a polypeptide or protein produced by cell that can stimulate cell proliferation . Some have been associated with abnormal growth of transported cell
gene
a sequence of DNA that codes for polypeptides
promoter
a substance( like a fat) that can not be carcinogenic by itself, but can stimulate initiated cells to proliferate to form cancer. promotion is slow, reversible process that follows the initiation stage of carcinogenesis
wGraft-versus-host disease (GVHD) is a potential complication of
allogeneic HCT
Energy restriction inhibits c
ancer and extends life span in animals -Overweight increases the risk of cancer recurrence and decreases survival -Physical activity is inversely associated with cancer
global assessment (SGA) evaluates whether an individual is
appropriately nourished
Nucleic acids: Adenine, guanine, and cytosine are in
both DNA and RNA
_Team-oriented medical care, pain management, and emotional and spiritual support -Principle of autonomy : " all individuals have the right to make
choices to medical are they desire or to refuse such services if they become unable to make decisions.."
Phytochemicals (indoles)in broccoli have a dose dependent effect on reducing
colon cancer risk
-Palliative care is total care when
curative measures no longer pursued. -Hospice provides symptom relief and emotional support. -MNT: Manage nutrition-related symptoms, maintain strength and energy to promote quality of life; provide nutrition as tolerated. -Advance directives guide family and health care providers to adhere to patient wishes.
Potential for drug-herbal interaction Potential for interference with anticancer drugs affecting
elimination rate or amount absorbed (e.g. increased activity of cytochrome 450, a hepatic enzyme that metabolizes drugs, could result in a blood level of drug that is lower than its therapeutic level)
While the Dietary Guidelines are for general health and AICR's recommendations are specific to cancer prevention, the two are largely aligned. Both recommend eating more
fruits, vegetables, and whole grains; limiting intake of foods high in saturated fat and added sugars; and eating appropriate portion sizes to manage weight Both also recommend exclusive breastfeeding, if possible, for about six months, followed by continued breastfeeding with introduction of age-appropriate foods.
wLong-term cancer survivors should focus on
healthy diets and physical activity geared toward prevention of a second cancer and reducing the risk of other chronic diseases.
Early identification and diagnosis of malnutrition leading to intervention can positively
impact body composition, function, quality of life (QoL), treatment tolerance and clinical outcomes.
•Uracil •
in RNA only
Radiation enteritis is
inflammation of the intestines that occurs after radiation therapy.
Nutrition support does prevent/treat
malnutrition, and in this function it plays an important role
The RDN should be a member of the interdisciplinary team providing
multi-modal therapy to adult oncology patients undergoing chemotherapy or radiation treatment
MNT has been shown to be effective in improving
multiple treatment outcomes in patients undergoing chemotherapy, radiation or chemoradiotherapy in ambulatory or outpatient and inpatient oncology settings.
Promotion -
mutated cells multiply
. Research indicates parenteral GLN( glutamine) should be initiated early in the treatment course. Parenteral GLN is associated with improved
nitrogen balance and decreased morbidity. However, decreased hospital length of stay (LOS) was found only when data from allogeneic and autologous transplants were combined. Fair
patients receiving parenteral glutamine has
not established the effectiveness of L-Alanyl-L-Glutamine in treating or preventing oral mucositis.
Nutrition support in cancer has been shown to improve
nutrition indices and patient performance, but only limited evidence shows improvement in patient outcome; it increases tolerance to cancer therapy
Low muscle mass is a common and independent predictor of immobility and mortality, is a particularly adverse prognostic indicator in
obese patients and is associated with greater toxicities of chemotherapy leading to treatment interruptions including dose reductions, treatment delays and treatment termination. Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions.
wAntiangiogenic agents- inhibit formation
of blood vessels to the tumor
wChemotherapy- interferes with
phases of the cell cycle
However, AICR also recommends limiting intake of
red meats and processed meats to reduce colorectal cancer risk, a recommendation that is not featured prominently in the Dietary Guidelines. With respect to alcohol, the guidelines recommend limiting intake to no more than one drink per day for women and two for men. Based on evidence that alcohol intake increases the risk of at least six types of cancer, AICR recommends that for cancer prevention, it is best not to drink alcohol.
The biggest risk factors:
smoking, alcohol, poor diet, inactivity, overweight and obesity accounting for 1/3 cancer deaths!
Initiation
the first state of carcinogenic that involves interaction of the carcinogen with the DNA in the target cells. Replication of damaged DNA in these cells can cause a permanent lesion . Initiation is rapid and irreversible process that proceeds promotion and progression
Each group of three DNA bases (ultimately coding for three tRNA bases) specifies an amino acid
to be incorporated into a protein Example: GCA = alanine
In the Subjective Global Assessment (SGA), a weight loss of 10% in one month or 20% in 6 months is assigned a score with the greatest nutritional risk.
true
Metastasis -
tumors develop their own blood supply and spread
Progression -
tumors form
In order to lower risk of cancer what component of life style( other than tobacco use) can be more easily to control
types of quantities of food controls
73% of cancer patients have reported using s
upplements; 38 % use herbs; 29% use vitamins Diet histories should investigate: • Are you taking supplements? •What are you taking? •How much are you taking? Be an unbiased, sympathetic listener
Drugs for treatment of anorexia and/or cachexia:
wAppetite stimulants (Megestral acetate) wAntiemetics (Reglan, Compazine, Benadryl, Zofran) wMedical marijuana (cannabis) legal in some states to treat N, V, and anorexia
MNT Screening and Assessment
wAssess GI function wEstimate or measure energy levels wCancer-related posttraumatic stress syndrome wSpiritual and psychological well-being wNutrition-focused physical examination
Cancer Diagnosis
wComputed tomography (CT ) scan wMagnetic resonance imaging (MRI) wPositron emission tomography (PET scan) wBlood tests (CEA, PSA, etc) wBiopsies wStaging -.Look it up in Krause
Goals of Medical Therapy
wCure wControl wPalliate (comfort care)
MNT for Cancers treated with Surgery
wHead and neck cancer •Chewing and swallowing, dysphagia •MNT: Enteral nutrition; oral dysphagia diet based on food and textures tolerated, chewing/swallowing training
Cancer Prevention
wPhysically active lifestyle wHealthy body weight wHealthy diet wLimit alcohol wNo tobacco
Nutrition Management
wPrevent or correct nutritional deficiencies wMinimize weight loss wEnsure optimal protein and fluids wPromote food safety wEnteral or parenteral nutrition wManage nutritional side effects of treatment (diarrhea, vomiting, taste changes, etc.)
What are the nutrition intervention options?
wRegular or modified oral diet , accommodate food preferences wLiquid oral supplements wEnteral nutrition by tube wParenteral nutrition
Nutrients in Chemoprevention
• difficult to interpret studies associating fat intake with cancer incidence; low fat diet may help protect breast cancer survivors • • difficult to interpret studies associating fiber intake with cancer incidence • • dietary intake of carotenoids, vitamin C, and vitamin E supplements were associated with a lower lung cancer risk in Finnish nonsmokers; higher risk in smokers!
wOther tools
•Activities of daily living (ADLs) •Common toxicity criteria for adverse events •Karnofsky performance scale
wMNT
•Diarrhea: Maintain hydration status, replace electrolytes, low fat, fiber and lactose diet, BRAT diet(Bananas, Rice, Applesauce, Toast) plus oatmeal and potatoes. •Nausea/vomiting: Ginger, 5 to 6 small meals. Cool, light foods, avoid strong odors, liquids between meals, sit up after eating
Weight is positively associated with
•Mouth/larynx/pharynx/esophageal •Breast cancer (post menopausal) •Colon, rectal, gastric, liver, thyroid, multiple myeloma • endometrial cancer • ovarian cancer, renal cancer
Dietary Carcinogens
•Nitrates->nitrites->nitroso compounds (carcinogens) (burnt meat) •Polycyclic aromatic hydrocarbons (PAHs) (high temperature cooking) and heterocyclic aromatic amines • •Bisphenol A (BPA)- in plastic bottles and epoxy linings of food cans??? • •Red meat/processed meat •
MNT Caloric and protein intake to prevent weight loss during Rx
•Resting energy expenditure may be •normal (0.9-1.0 X BEE) •low (<0.9 X BEE) or •high (> 1.1 X BEE) • may be measured using indirect calorimetry •Signs of metabolic stress suggest that calorie needs are higher than normal (normal calorie needs are 1.3 X BEE, increased are 1.5 X BEE) •Protein for maintenance (0.8 - 1.0 g/kg) or repletion (1.2 - 1.5 g/kg) or severe metabolic stress ( 1.5 - 2.0 g/kg)
w3 phases of cancer survival
•active treatment and recovery •health maintenance to prevent recurrence or secondary malignancies •for some, living with advanced cancer
Nutritional Effects of Cancer
•alterations in calorie (energy) expenditures • • alterations in protein metabolism • • hypercalcemia associated with bone metastasis • • alterations in taste and smell • • relationship between weight loss and survival; a 5% weight loss may worsen prognosis significantly • •cancer cachexia