CSO 2022 Study

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intervention for altered taste and smell

-use of marinades, seasonings, spices -serve/eat foods cold/room temp -use sugar free lemon drops or mints to improve mouth taste -choose foods that appeal to pt -veg sources of pro instead of meat will help with metallic taste

Biological Therapies Treatment and Nutrition Implications

-Drugs to stimulate immune responses against cancer cells -Anorexia, GI symptoms, fatigue, flu-like symptoms

Nutrition intervention

-calorie & protein needs -weight management -weight gain -types of foods/beverages to decrease nutrition related side effects -nutrition education

Maximum daily tolerance of AA w/ TPN?

2.5 g/kg

Maximum daily tolerance of Lipids w/ TPN?

2.5 g/kg/day or 60% of total kcal

Phosphorus lab value

2.5-4.5 mg/dL

What percentage of pharmaceutical products are derived from plants?

40%

Fluorouracil

5-FU Antimetabolite IV, Topical Colorectal, breast, Ovarian, Pancreatic, GI, H&N, Hepatoma Ocular tox, cardiac tox, Hnd&Ft snydrome Mucositis, nausea, occasional vomiting diarrhea, taste changes **ice chips to mouth 10-15mins pre/post bolus Cell Cycle-specific chemo agent:Antimetabolite-interferes with DNA synthesis by acting as false metabolities; incorporated into the DNA strand or block essential enzymes 5-FU Used to treat breast cancer, esophageal cancer, gastric, colorectal, liver, gallbladder, anal cancer, head/neck cancer, pancreatic cancer. Myelosuppression, N/V/D, mucositis, hand-foot syndrome, ocular toxicity, cardiotoxicity, photosensitivity, alopecia, anorexia, blistering, metallic taste. *taken with leucovorin to increase anti-cancer effects which increase side effects *suck on ice chips pre/post iv bolus to reduce mucositis *Vit. B6 may help with hand/foot syndrome

These two chemo drugs are very likely to cause mouth sores

5-FU and MTX

Chemotherapy likely to cause diarrhea

5-FU, MTX, cytarabine, capecitabine/Xeloda, and irinotecan/Camptosar

FOLFIRI

5-FU, leucovorin, irinotecan/Camptosar

Calcium lab value

8.5-10.5 mg/dL. 4.5-5.5 mEq/L

Mycophenolate mofetil GVHD treatment/prevention

Acts in B and T cells to inhibit inosine monophosphate (IMP) dehydrogenase-->decreased GMP in de novo purine synth-->decreased DNA synth in B and T cells-->decreased prolif of B and T cells Use = immunosuppressant in transplant pts, also for autoimmune disorders CellCept, Myfortic S/E: N/D/C abd pain Interaction w CALCIUM, MAGNESIUM, IRON Take on an empty stomach

What is Capecitabine mechanism of action?

Acts in S phase inhibits enzyme production for DNA synthesis --> leading to strand breakdown/early termination

Ursodiol GVHD treatment/prevention

Actigall, URSO Forte (GALLSTONE DISSOLUTION AGENT) Rapid wt loss increases risk of gallstones reduces cholesterol absorption and can dissolve cholesterol gallstones S/E: N/V/D, dyspepsia

The acidic environment of the stomach along with the production of intrinsic factor assists in the release of ___ from food and facilitates its absorption in the terminal ileum.

B12

Astragalus

Boosts immune system Limits cold and flu symptoms Immunomodulating effects May help reduce some adverse reactions induced by chemo May not be appropriate for all

The presence of undigested food in the colon can have detrimental effects locally and systemically. Bacteria can ferment undigested carbohydrates and produce _____, which can cause metabolic acidosis.

D-lactic acid

Hormone changes in cancer cachexia

Increased cortisol Decreased insulin Decreased insulin resistance Decreased testosterone

Potential outcomes of nutrition interventions during initial treatment does not include:

Less fatigue (does include ability to adhere to scheduled tx, fewer infectious complications, and delay/prevent disease progression).

long term effects of childhood cancer

compromised bone health, eating behaviors, slow/stunted growth, vitamin d deficiency

Nestle Health Science suggests limiting MCT oil to _____mL/day

Nestle Health Science suggests limiting MCT oil to 100 mL/day (~6.5 TBSP) =760 kcals

Tasigna

Nilotinib Avoid grapefruit juice Contains lactose - recommend lactase enzyme diarrhea in lactose intolerance. take on EMPTY stomach ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox

Pentostatin

Nipent (Antimetabolite)

Methchlorethamine

Nitrogen Mustard Gas (alkylating agent)

The Church of Jesus Christ of Latter -Day Saints (Mormons)

No alcohol, coffee or tea

What is not allowed on the Essiac and Flor-Essence diet?

No dietary restrictions.

CAM-DHEA

Promoted as anticancer agent May not be appropriate for people with prostate, breast, ovarian CA b/c of androgenic effect

DHEA

Promoted as anticancer agent May not be appropriate for people with prostate, breast, ovarian CA b/c of androgenic effect

CAM-Enzymes

Promoted as anticancer agent No proven effectiveness

Enzymes

Promoted as anticancer agent No proven effectiveness

CAM-Shark cartilage

Promoted as anticancer agent, may contain possible contaminants

Shark cartilage

Promoted as anticancer agent, may contain possible contaminants

Phosphorus interactions

Some medications can cause phosphorus levels to drop, including some antacids and diuretics (water pills). Symptoms of phosphorus deficiency include loss of appetite, anxiety, bone pain, fragile bones, stiff joints, fatigue, irregular breathing, irritability, numbness, weakness, and weight change. In children, decreased growth and poor bone and tooth development may occur. Alcohol: Alcohol may leach phosphorus from the bones and cause low levels in the body. Antacids: Antacids containing aluminum, calcium, or magnesium (such as Mylanta, Amphojel, Maalox, Riopan, and Alternagel) can bind phosphate in the gut and prevent the body from absorbing it. Using these antacids long term can cause low phosphate levels (hypophosphatemia). Anticonvulsants: Some anticonvulsants (including phenobarbital and carbamazepine, or Tegretol) may lower phosphorus levels and increase levels of alkaline phosphatase, an enzyme that helps remove phosphate from the body. Bile acid sequestrants: These drugs lower cholesterol. They can decrease the oral absorption of phosphates from the diet or from supplements. Oral phosphate supplements should be taken at least 1 hour before or 4 hours after these drugs. Bile acid sequestrants include: Cholestyramine (Questran) Colestipol (Colestid) Corticosteroids: Corticosteroids, including prednisone or methylprednisolone (Medrol), may increase phosphorus levels in the urine. Insulin: High doses of insulin may lower blood levels of phosphorus in people with diabetic ketoacidosis, a condition caused by severe insulin insufficiency. Potassium supplements or potassium-sparing diuretics: Using phosphorus supplements along with potassium supplements or potassium-sparing diuretics may result in too much potassium in the blood (hyperkalemia). Hyperkalemia can be a serious problem, resulting in life threatening heart rhythm abnormalities (arrhythmias). Potassium-sparing diuretics include: Spironolactone (Aldactone) Triamterene (Dyrenium) ACE inhibitors (blood pressure medication): Angiotensin converting enzyme (ACE) inhibitors, used to treat high blood pressure, may lower phosphorus levels. These include: Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Zestril, Prinivil) Quinapril (Accupril) Ramipril (Altace) Other drugs: Other drugs may lower phosphorus levels. They include cyclosporine (used to suppress the immune system), cardiac glycosides (digoxin or Lanoxin), heparins (blood thinning drugs), and nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or Advil). Salt substitutes contain high levels of potassium and may lower phosphorus levels if used long term.

Nexavar

Sorafenib John SOR NEXt to the grapefruit sun on his hands and feet empty stomach with full glass of water Avoid grapefruit, St John's WORT, phenobarbital, dexamethasone, ketoconazole, erythromycin ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox NEXAVAR is a prescription medicine used to treat: a type of liver cancer called hepatocellular carcinoma (HCC) that cannot be removed by surgery a type of kidney cancer called renal cell carcinoma (RCC) a type of thyroid cancer called differentiated thyroid carcinoma (DTC) that can no longer be treated with radioactive iodine and is progressing

Karnofsky Performance Status Scale

100 no functional complaints<-----> 0Dead 100-80 : independent 70-50: unable to work outside home, living assistance, indep personal care 40-10: unable to self care, hospice care, dz progression and prognosis poor 0: dead

reducing cancer risk from tobacco & alcohol

100% preventable

Calcium DRIs for Women with Breast Cancer

1000 mg/day (19-50) 1200 mg/day (51+)

Hyperlipasemia

12-70 U/L

After a total or partial colon surgery, the remaining colon undergoes gradual structural and functional adaptation to increase fluid and nutrient absorption. This may take _____

2+ years

Megavitamin therapy

alternative therapy use of large doses of 1 or more vit, antioxidants, coenzyme Q10, pangamic acid

Undigested proteins ferment in the colon and can increase ___ levels.

ammonia

carcinogen

an agent (physical, chemical, or viral) that induces CA

Arimidex

anastrozole increased risk of osteoporosis- take D and Ca Hot flashes, arthralgia, N/V, asthenia, thrombus, elevated cholesterol, fever/malaise, joint ache/pain, bone loss- increase Vit. D/Calc to prevent

antitumor antibiotics

anthracyclines: non anthra: daunrubicin bleomycin /blenoxane doxorubicin (Adriamycin) dactinomycin doxorubicin liposomal (doxil) mitomycin epirubicin (ellence) idarubicin

Achlorhydria may allow for ______, which can cause pain when eating and lead to suboptimal intake.

bacterial and fungal overgrowth.

Massive bowel resection frequently leads to ____, increasing the risk of ____ and ____

bacterial overgrowth bacterial translocation and systemic infection and sepsis

Gastric acid in the small bowel stimulates release of ____ to neutralize the acid, thereby protecting the function of pancreatic enzymes and bile acid.

bicarbonate

Potential for B12 deficiency with surgery for this type

bile duct, colorectal, gallbladder, gastric, hepatic, pancreas, small intestine, loss of > 20 cm of ileum Rec: if serum B 12 <300 pg/mL 1000 mcg/d for 4 wks w 500 mcg/da for maintenance IM for severe short bowel

Hyperuricemia

2.4-6 mg/dL (female) > 3.4-7 mg/dL (male) > allopurinol may be given w leukemia or lymphoma to prevent complications of chemo and tumor lysis syndrome

______ are recommended for the immediate postoperative period in severely malnourished patients and in those in whom prolonged inadequate oral intake is expected.

jejunal feedings

The ___ is the second section and comprises about 40% of the small bowel.

jejunum

medical oncology

diagnosing and treatment of cancer using antineoplastic therapies which encompass several classifications of agents including chemotherapy and hormonal therapy, biotherapy and molecular therapies.

gut GVH

diarrhea leading to protein losing watery stool, they are given fluid resuscitation

The loss of portions of the jejunum can result in inappropriate secretion of ______ and accelerate ____

digestive enzymes; gastric emptying

denervation (vagus nerve) can reduce the ability to ____, which may result in ____

experience satiety; overeating and potentially food regurgitation Adopting small frequent meals limits intake at any one time and may help to prevent overeating episodes.

Protein restriction is not recommended in a patient with liver disease unless _____. When protein intake should be limited, ___ is recommended.

experiencing mental status change; 0.8 g/kg/day

CAM-Iscador

extract from european mistletoe, contains cytotoxins, should not be used as a home remedy or beverage

Iscador

extract from european mistletoe, contains cytotoxins, should not be used as a home remedy or beverage

social QOL

family/friends financial

effects of insulinomas

fasting hypoglycemia

Hypersensitivity Infusion Reaction

fever, chills, pruritis, rash.

What are topoisomerase inhibitors?

interfere with action of topoisomerase enzymes (I, II) which manipulates the structure of DNA needed for replication (prevents repairs of DNA strands)

IL-2

interleukin-2 (cytokines) Flu-like, N/V/D/A/F, anemia, leukopenia, RENAL TOX, CARDIO TOX, capillary leak syndrome, myelo, hypotension GI issues

chemo regional

intrathecal, intra-arterial, intracavitary, intravessicular

chemo causing diarrhea (severe)

irenotecan (hi dose)

this chemo drug mayc cause cholinergic diarrhea and atropine is used to treat

irinotecan / camptosar

There is significant correlation between preoperative malnutrition and _____ along with postoperative _____/_____

longer length of stay morbidity/mortality

Generic Imodium

loperamide every 6 hours 4 mg once then 2 mg after each BM 2-4 mg 4 x/day max 16 mg/d

Calcineurin inhibitors - GVHD treatment/prevention

lCyclosporine Tacrolimus (Prograf)- Immunosuppressant, calcineurin inhibitor S/E: N/V, hypo- Mg/Phos, hyper- K, renal Ins food/drug interactions: NO grapefruit, bergamot, bitter orange, pomegranate

Surgery Small Bowel

lactose intolerance bile acid depletion diarrhea fluid and lyte imbalances vitamin and mineral malabsorption (vit B12, A,D,E, K, calcium, iron and Zn)

surgery w/ SB

lactose intolerance, bile acid depletion, D, fluid & lyte imbalance, Vit b12, A, D, E, K, Ca, iron, Zn malabsorption

decreased QOL

lead to increased morbidity

luminal A tumors

less aggressive than HER-2-positive and basal-like subtypes

Femara

letrozole may ^ cholesterol

indication for cytarabine (ara-c)

leukemia, lymphoma

Orexigenic (Anabolic agents)

limited published reports or inferior to listed orexigenics: fluoxymesterone decanoate oxandralone Nandrolone

the ____ is one of the largest organs in the body and is located in the upper right quadrant of the abdomen.

liver

Exocrine functions of the pancreas include

production of bicarb and pancreatic enzymes.

Megestrol acetate

progestational agent, appetite stimulant, dose -dependent

autologous marrow transplantation

transfer of marrow from the pt's OWN tissue (from hematopietic stem cells)

antologous marrow transplantation

transfer of marrow from the pt's own tissue (from hematopietic stem cells)

Bone marrow transplant

treatment for certain hematologic malignant dz: leukemia, lymphoma, solid tumors - starts w/ cytotoxic chemo, w/ or w/o total-body irradiation to suppress immunological reactivity, followed by IV infusion of bone marrow or peripheral stem cells

Dysmotility of the remaining esophagus and gastric dysmotility occurs secondary to resection of the ____

vagus nerve

green tea (ECCG) makes this chemo drug less active

velcade

Xeloda: n/v liklihood

very low.

Velban

vinblastine. VIN BLASTed VEL after CONSTIPATION meds IV SFX: SEVERE C!!!!!/M, myelo, HTN stomatitis, alopecia, jaw pain, metallic taste, taste change *Avoid St. John's Wort and grapefruit juice. Dexamethasone *Stool softeners to prevent constipation St. John's Wort may DECREASE the drug activity of Vinblastine (Velban) & Vincristine (Oncovin) by INDUCING Cytochrome P450 3A4 (CYP3A4). Cell cycle-specific chemotherapy agent: Vinca Alkaloid- Bind to protein tubulin, disrupt mitotic spindle formation, and prevent cell division in the mitosis phase

this chemo drug is part of CHOP and can cause neurotoxicity to bowel - prevent with stool softeners and a stimulant laxative

vincristine / Oncovin

Bacterial overgrowth in the terminal ileum following ileocecal valve resection and reduce _____ and result in the need for supplementation

vit B12

Nutrient deficiency after gastrectomy

vit B12, iron, Ca, fat soluble vitamins, folic 2/2 vit B12 def

CAM TUL's

vitamin A: 2800, 3000 mcg vitamin C: 1800, 2000 mg Vitamin E: 800, 1000 IU Selenium: 400, 400 mcg Zinc: 34, 40 mg 14-18, 19>70

Foods that increase bleeding risk

vitamin E Omega 3 Fatty acids

Located just past the gastro-esophageal junction, where the esophagus connects to the stomach, the ______ relaxes to allow food boluses to enter the stomach.

lower esophageal sphincter (LES)

subtypes of the estrogen receptor-+ve (ER-positive) tumors

luminal A and luminal B

indication for etoposide (VP-16)

lung, all, nhl, testicular

indication for ifosfamide

lung, nhl, testicular, sarcoma

indication for vincristine/oncovin

lymphoma, sarcoma, breast, lung

enteral support benefits

maintains GI function lower prevalence of infectious complications and infectious morbidity (pneumonia, central line infections etc) less expensive than TPN/PPN

Paraneoplastic syndrome

medical condition caused by tumor secretions (hormones, cytokines, TNF, Interleukin-1), may cause hypercalcermia, hypoglycemia, SIADH

CAM Head and Neck Cancer

medical food supplements and radiation Honey and radiation antioxidant vitamin E supplement postoperative use of arginine preoperative use of arginine surgery and EPA enhanced medical food supplement

Appetite stimulant

megestrerol acetate dronabinol corticosteriods

Indication for DTIC

melanoma, sarcoma

Metabolic agents & cytokine blockers

melatonin Pentoxifyline Hydrazine sulfate Eicospentaenoic acid (EPA)

6-MP purinethol

mercaptopurine. Pure milk needs a cap Cell cycle-specific chemotherapy agent: Antimetabolite- Interfere with DNA synthesis by acting as false metabolites; incorporated into the DNA strand or block essential enzymes Oral - take on an empty stomach w NO DAIRY SFX: N/V/D/M, myelo, HEPATIC TOX, hyperuricemia, pancreatitis Intrxn: avoid dairy around time of taking drug

enteral support complications

metabolic aberrations/ refeeding GI intolerance mechanical issues/clogs drug nutrient interactions microbial contamination

The central role of the liver in nutrient metabolism increases the risk of _____ after liver surgery

metabolic derangement

Major surgery is linked with deterioration in nutritional status that can lead to changes in _____, ____ and ____.

metabolism, tissue function, and body composition

this chemo drug requires strict mouth care and to avoid taking multivites with folic acid

methotrexate

antimetabolites (S) phase

methotrexate gemcitabine/Gemzar capecitabine (xeloda) cytarabine fludarabine fluourcil (5fu) mercaptopurine (6mp) pemetrexed (alimta) thioguanine (tg)

Gastric acid is important to digestion as well as ____

microbial control in the stomach.

Most surgical procedures have nutritional consequences that can range from ____ to ____.

mild postoperative nausea to permanent alteration sin GI function

chemo causing hypercalcemia

mitomycin megace (hormonal) tamoxifen (hormonal)

antioxidants

molecules (ie. vitamins) that blcok action of activated oxygen molecules (free radicals) that can demage cells

Acute nausea and vomiting

occurs during the first 24-hours after chemotherapy.

nausea and vomiting-acute

occurs during the first 24-hours after chemotherapy.

nausea and vomiting- delayed

occurs more than 24 hours after chemotherapy. Usually 1-6 days immediately. Patients at highest risk for delayed N&V include those receiving cyclophosphamide, cisplatin /Platinol, doxorubicin and ifosfamide.

Delayed nausea and vomiting:

occurs more than 24 hours after chemotherapy. Patients at highest risk for delayed N&V include those receiving cyclophosphamide, cisplatin, doxorubicin and ifosfamide.

Anticipatory nausea and vomiting

occurs prior to the beginning of a new cycle of chemotherapy. This occurs after the patient has experienced N&V from an earlier chemotherapy treatment.

nausea and vomiting - anticipatory

occurs prior to the beginning of a new cycle of chemotherapy. This occurs after the patient has experienced N&V from an earlier chemotherapy treatment.

Removal of the lower esophageal sphincter (LES) during surgery contributes to _____

postoperative reflux.

Cancer can by classified by:

presence of metastases, differentiation of cells, extent of spread to local lymph nodes, and nuclear grade of tumor.

With colon surgery, perioperative provision of _____ may decrease postoperative complications

probiotics

avoid foods high in tyramine with this chemo drug because it inhigits monoamine oxidase and also avoid alcohol

procarbazine

external beam radiation

procedure by which a beam of high-energy radiation is applied externally directly to the tumor to minimize damage to other tissues from outside the body *** most common**

photodynamic therapy (PDT)

procedure in which cells selectively treated with an agent called a photosensitizer are exposed to light to produce a reaction that destroys the cells a technique used to treat damaged and precancerous skin, as well as various types of cancer Use of light sensitive molecules or photosensitizer, which when activated by light, form oxygen radicals, resulting in cell death - porfimer sodium (Photofrin) mostly used photosensitizer photosensitivity continues for another 30-90 days

inhibitors of carcinogens from diet

-antioxidants -phytochemicals

cancer development & risk factors

abnormal cell proliferation caused by a serious of mutations or altered gene expressions that regulate cell division # of causes: 1. env carcinogens (tobacco smoke, asbestos, processed meats, UV radiation) 2. inherited genetic traits 3. viruses any of these factors can promote the initiation of this abnormal cell growth -can interfere with growth restraint and prevent apoptosis -new emerging research looking at mitochondrial dysfunction & promoting tumor genesis

steatosis complication for PN

abnormal condition of fat (increased fat at the cellular level often affecting the liver); characterized by accumulations of fat within the liver that usually does not cause liver damage - ^AST/ALT w/in 1st 2 wks of PN-> monitor LFTs, may normalize after 2 wks - overfeeding-> limit total energy intake and carbohydrates

anosmia

absence of the sense of smell

pain meds step 1 - analgesics for mild pain (WHO)

acetiminophen (various formulations with additives like caffeine, migraine meds) capsaicin (N,V,weight changes) NSAIDS (dyspepsia, N,V, other GI issues varying by med) The individual's response is used to determine effective dose for NSAIDS. When pain relief is not achieved with maximum NSAID , try other step 1 meds before stopping NSAIDS. Can skip this step if priginal pain is mod to severe -take with fluids to prevent constipation -take with food to prevent GI upset

Guidelines for reducing cancer risk

achieve & maintain healthy body weight physically active healthy diet that emphasizes plant sources limit consumption of foods that may increase cancer risk (moldy grains are implicated aphlatoxin which is a mold that inc risk for liver cancer) limit consumption of alcoholic beverages aim to meet nutritional needs through the diet avoid tobacco

______ refers to a decrease or cessation of the production of gastric acid.

achlorhydria

Removal of the LES can promote ____ and occurs in as many as 58% of patients who undergo esophagectomy.

acid reflux into the esophagus

Cancer patients should be encouraged to actively participate in what?

actively participate in their care and to communicate with their health care providers.

Surgery to the GI tract can be associated with long and short-term complications, the most common of which is ______.

altered transit time. Transit may be to slow, to fast, or in wrong direction

Ensure adequate hydration with this type of chemo to prevent hemorrhagic cystitis

cyclophosphamide

chemo causing CNS toxicity

cytarabine fludarabine *neurotoxic ifosfamide prednisone (hormonal tx) decadron (hormonal tx)

ARA-C

cytarabine Cytosar-U IV, SC, IT, IM SE: myelo, N/V/M/A, acute pancreatitis, NEURO TOX, HEPATIC TOX, PULM TOX other: conjunctivitis, keratitis **mucositis will occur 7-10days after treatment Cell Cycle-specific chemo agent:Antimetabolite-interferes with DNA synthesis by acting as false metabolities; incorporated into the DNA strand or block essential enzymes

effects of glucagonomas

erythema and diabetes

Esophagitis

esophageal inflammation

The _____ functions as a conduit for food as it travels from the mouth to the stomach.

esophagus

Hemochromatosis

excess iron deposits throughout the body Common in hepatochromatosis and treatments (Gemcitabine) - avoid high iron foods like shellfish - avoid iron sups + Vit C - avoid alcohol (stresses liver) - reduce but not entirely avoid consumption of red meat (and organ meats) - increase fruit/veg, whole grains/legumes **non-heme does not contribute to iron overload (aka plant based) The extra iron builds up in several organs, especially the liver. Hemochromatosis can be treated with therapeutic phlebotomy (routine removal of blood, similar to blood donation), iron-chelation therapy, and avoiding supplements that contain iron. Symptoms of iron overload disorder include: Elevated iron levels found in blood tests that you have for other reasons Extreme tiredness (fatigue) High blood sugar levels Skin that looks bronze or grey Stiff joints or joint pain, especially in the knuckles

CAM Ma Huang (ephedra sinica)

increases toxicity with beta blockers, MAOIs, caffeine, St Johns Wort

Patients with severe postoperative liver dysfunction may develop ____

hepatic encephalopthy

Cancer antigen 19-9 (CA 19-9)

hepatobiliary or pancreatic cancer tumor marker for pancreatic, gall bladder, and gastric cancers can be elevated in endometrial cancer

ER-negative tumors

human epidermal growth factor 2 (HER-2) and basal-like subtype

mucositis/esophagitis

inflammation of mouth or esophagus usually described as painful, irritated throat or feeling of lump in throat

Crizotinib (Xalkori)

inhibits mutant ALK protein to block stimulation of ALK+ NSCLC Protein-Targeted Agents: Tyrosine kinase inhibitors: inhibit several receptor tyrosine kinases, which are involved in tumor growth, angiogenesis, and metastasis.

neuroendrocrine tumors

insulinomas, gastrinomas, glucagonomas, VIPomas

allogeneic transplant

receive cells from another matched person

autogolous

receive own cells

autogolous transplant

receive own cells

effects of gastrinomas

recurrent ulcers, diarrhea, gastroesophageal reflux

Erthema

redness of the skin

Small bowel resection reduces _____, which can alter transit time and contribute to malabsorption and malnutrition

reduce absorptive surfaces

Raloxifene

reduce the risk of invasive breast CA in postmenopausal women with osteoporosis and in postmenopausal women at high risk

Omega 3 benefits

reduce toxicity of irinotecan and paclitaxel enhance Adriamycin, cisplatin, vincristine VICAP Pancreatic cancer

Hypogeusia

reduced ability to taste

D-lactic acid production is managed with ____, ___ and ___

refined carb restriction (lactose, fructose, alcohol sugars), antibiotics, and probiotics

removal of the LES during surgery contributes to

reflux

saw palmetto

relief of urinary symptoms in benigh prostate hyperplasia, not proven in prostate CA Rare HA, mild abd pain, N/Dizziness, antiestrogen

Orexigenic (antidepressants)

remeron-- data lacking zyprexa--data lacking further study recommended for both

bone marrow transplant goal

replace malignant cells with normal healthy cells in the hematopoetic system

B12

requires acid in stomach and intrinsic factor to release b12 from food and absorb in terminal ileum. deficiency can develop as early as 1 year after total gastrectomy

hemoptysis

spitting up blood (from lungs or bronchial)

When nutrition support is required, _____ formula is acceptable for patients with chronic liver disease.

standard enteral

Gastrointestinal Stromal Tumor (GIST)

start in special cells found in the wall of the GI tract, called the interstitial cells of Cajal (ICCs), or in very early cells that can develop into ICCs. ICCs are part of the autonomic nervous system, the part of the nervous system that regulates body processes. The autonomic nervous system sends signals to the GI tract telling it to digest food. ICCs are sometimes called the "pacemakers" of the GI tract because they send signals to the muscles in the digestive system, telling them to contract to move food and liquid through the GI tract. Not all GISTs are cancerous.

Strictures often require ____ or ____ to allow for oral intake.

stent placement or dilation Esophageal Stent Diet Recs - liquids, moist, soft, easy to chew w/in 24 hrs - adequate chewing - Small bites / food bolus - sit upright during and following meals (30 - 60 mins) - fluids w oral food intake - sips of carbonated beverages if food does not pass through stent

chemo biotherapies-cytokines Nonspecific IMMUNOTHERAPIES interleukin-2 (IL-2)/ Aldesleukin -stimulates growth and activity of immune cells (lymphocytes) to kill cancer cells (metastatic melanoma, renal) interferon-a 2b / Intron A- interferes with cancer cells ability to divide; indirectly modifies the body's immune response to the cancer cells; inhibits viral replication, modulates tumor cell growth

stimulate broad based immune response as opposed to generating a targeted response to specific tumor antigen side effects: - Flu like, N/V/D/A/F, myelo, CARDIO TOX, RENAL TOX flu like symptoms fatigue, anorexia GI issues renal toxicity cardiotoxicity

The ____ is a fist sized reservoir that stores food until it is sufficiently digested and therefore physiologically ready for entry into the small intestine.

stomach

Gastritis

stomach inflammation

Zanosar

streptozocin. ZAN is NAUSEOUS with STREP, check is BS IV - SFX: N/V, RENAL TOX - Considerations: hypoglycemia glucose metabolism in some patients causing hypoglycemia

Approximately 30% of patients experience ____ after esophagectomy

strictures

myelosuppression

suppression of bone marrow cell production

carcinoma treatment

surgery; chemotherapy; radiation --radiation can damage other structures and is therefore the last choice (typically) 1st line Cyclophosamide

Bacteria in the colon serve a host of functions including ____, _____, ____

synthesis of vit K short-chain fatty acid production defense against pathogenic microorganisms

chemo

systemic therapy, not limited to malignant tissue, cells w/ rapid turnover are most affected (bone marrow, hair follicles, mucosa of GI tract) Side effect- myelosuppression, Fatigue, N/V, loss of appetite, mucositis, changes in taste & smell, xerostomia, dysphagia, changes in BM

mitotic inhibitors

taxane: paclitaxel (taxol), docetaxel (taxotere), abraxne epothilones: ixempra vinca alkaloids: vinblastine, vincristine, vinorelbine estramustine: emcyt nerve damage potential

Partial and total resection of the colon have, at a minimum, a _____

temporary impact on fluid and electrolyte balance.

While _____ can help to compensate for loss of digestive insufficiencies, there is NO substitute for ____

the antimicrobial function of gastric acid.

cancers from infectious agents could be prevented by:

-behavior changes -vaccination -antibiotics

regular screening can detect cancer in

-breast -colon -rectum -cervix -prostate -oral cavity -skin

most common cancers in U.S. women

-breast -lung -colorectal -uterine -thyroid

5 most common cancers in women

-breast -lung -colorectal -uterine -thyroid

nutrition focused physical assessment

-loss of fat mass -muscle wasting -presence of edema/ascites -overall appearance

Leukemia - Acute Myeloid (AML)

"Acute" means that the leukemia can progress quickly, and if not treated, would probably be fatal in a few months. AML is a cancer that starts in cells that would normally develop into different types of blood cells. Most cases of AML develop from cells that would turn into white blood cells (other than lymphocytes), but some cases of AML develop in other types of blood-forming cells. AML starts in the bone marrow (the soft inner part of the bones, where new blood cells are made), but in most cases it quickly moves into the blood.

Delaney Clause of Food, Drug, and Cosmetic Act

(1959) prohibits the FDA from approving the use of any food additive found to cause cancer in animals or humans

Tumor necrosis factor

(cachectin, interluckin-1, interleukin-6, interferon-y); a hormone-like protein that releases fat from fat stores, reduces the concentration of enzymes required for the production and storage of fat & induces a stage of anorexia

SIADH

(syndrome of inappropriate antidiuretic hormone secretion) Increased blood volumes leads to decreased NA levels and hypo-osmolality. Results from inappropriate continued secretion or action of the hormone (ADH) despite normal or increased plasma volume which results in impaired water excretion. Treat with fluid restriction, meds, and treatment of cause.

Mucositis Management:

* Avoid carbonated beverages, caffeine, alcohol and tobacco * Avoid rough or coarse foods: raw fruits & vegetables, pretzels, popcorn, chips, crackers & nuts * Avoid spicy or acidic foods: tomatoes, oranges, grapefruit, lemon, chili, tacos, pickles, vinegar * Supplement diet with health shakes and milkshakes * Trial soft, moistened foods or pureed foods * Serve foods cold or at room temperature * Gargle regularly with a solution made of 1 quart of plain water, ½ tsp. table salt, ½ tsp. baking soda * Drink water and other fluids frequently throughout the day. Chew sugarless gum or suck on sugarless hard candy to moisten the mouth. Use artificial saliva frequently * Suck on ice chips or Popsicles * Avoid mouthwash that contains alcohol * Over the counter anesthetics such as Xylocaine, Anbesol or Orajel may soothe the pain * Gelclair provides pain relief by adhering to the mucosal surface of the mouth & soothing oral lesions. It forms a protective barrier in the mouth. Available by prescription only * Caphosol lubricates & cleanses the mouth similar to human saliva * Palifermin (Kepivance) speeds the healing of mucositis and stops sores from forming in the lining of the mouth and throat. It is used in patients that received high-dose chemotherapy followed by HSCT.

suggestions for Mucositis Management:

The primary goals of nutritional management of chyle leaks are to: 1. Decrease production of chyle fluid 2. Replace fluid and electrolytes; and 3. Maintain or replete nutritional status and prevent malnutrition. Describe the possible Nutritional Mgmt of Chyle Leaks:

* Fat free diet (FF); * FF diet with medium chain triglycerides * Specialized enteral feeding (fat free, MCT based or very low fat); or total parenteral nutrition (TPN). **************Adequate protein intake*************** • Chyle contains significant amounts of protein (22-60 g/L). Recommendations should account for such losses • 2%-4% of total calories from EFA required to avoid essential fatty acid deficiency (EFAD).

CAM counseling suggestions

*Communicate openly, honestly, nonjudgementally to improve pt care and limit or prevent potential problems. *Refer pts to accurate, up to date resources on CAM *Document all conversations with pt and recommendations made *Discuss all concerns about CAM with multidisciplinary colleagues involved with pt care.

Nutrition Tips for Managing Nausea & Vomiting:

*Eat small, frequent meals and snacks *Eat toast, crackers, dry cereal, bread sticks, pretzels *Try yogurt, sherbet, rice, noodles, baked chicken *Serve foods cold or at room temperature *Avoid hot, spicy foods *Avoid fatty, greasy and fried foods- potato chips, french fries, fried meat and sausage *Avoid sweet, fatty foods such as candy, cookies or cake *Avoid caffeine and alcohol *Suck on hard candies, peppermints or lemon drops *Slowly drink or sip liquids throughout the day including sports drinks, ginger ale, apple juice and flat pop *Try Ensure® Enlive!

suggestions for Managing Nausea & Vomiting:

Nutrition may modify carcinogenic process at what stage?

*any stage* 1. can promote DNA repair (antioxidants and folate can help DNA repair) 2. gene expression or cell differentiation (spices like cumin, veggies like broccoli/cauliflower and ability to cause apoptosis in a cell that needs to die/has some genetic mutation and also be inhibiting angiogenesis) 3. ketogenic diets (modified Atkin's) along with a monoclonal antibody and its ability to stop the growth of glioblastoma multiforme

Levetiracetam (Keppra)

*class*: anticonvulsants *Indication* Seizures /antiepileptic *Action*: Decreases severity and incidence of seizures S/E: D, fatigue, anorexia -May cause suicidal thoughts, dizziness, weakness - May alter RBC, WBC, and liver function - May cause somnolence - Should be infused over 15 minutes

antiemetics: phenothiazines (Dopamine agonists) perphenazine/trilafon *prochlorperazine/compazine promethazine.phenergan thiethylperazine/torecan

*compazine is most effective agent in class, sustained released option should not be crushed side effects: EPS sedation hypotension

One third of all cancer deaths attributed to what?

*diet, nutrition, and lifestyle behaviors * -Poor diet -Physical inactivity -Overweight and obesity -Alcohol use -Tobacco use *Nutrition is adversely affected by cancer itself & treatment* -pancreatic cancer = enzyme deficiencies bc of loss of enzymes from the pancreas. produces abd discomfort, diarrhea, steatorrhea, malabsorption -lung cancer = risk of cachexia, inc metabolite rate -head/neck/esophageal cancers = dysphasia & cachexia

parenteral support contraindications

*functional GI tract *inability to obtain IV access *if therapy required for less than 5 days in patients without *severe stress or malnutrition *patients with poor prognosis or short life expectancy not actively being treated for underlying disease

parenteral support indications

*non functioning GI *need for bowel rest whether caused by the underlying disease or as a consequence of antineoplastic therapy *severe diarrhea, malabsorption *severe intractable N/V *radiation enteritis *refractory short bowel *bowel obstruction *Ileus *severe pancreatitis *GI fistula unless able to feed distal to fistula or fistula is low output *GVHD of the gut

N/V Interventions

- ASSESS History of N/V - Assess and document each episode of N/V (red streaked, mucous, coffee grounds, undigested food,) color, amount - Eliminate unpleasant odors, strong cooking odors- use fans/windows - Ask Dr. about medications that may be causing patient's nausea - Antiemetics as ordered - NPO or smaller frequent meals - avoid liquids with meals oral hygiene - elevate head of bed during and after meals - Bland, starchy, clear liquids, discourage hot and spicy food food at room temp or chilled - avoid high fat foods, greasy, high seasoned

ovarian cancer risk factors

- Age: after menopause - Early menarche/ late menopause - Ht/Wt - Infertility drugs - Genetic mutations: BRCA1, BRCA2, RAD51C - Family history of ovarian or breast cancer - Obesity Factors that decrease risk: - giving birth, oral contraceptives for more that 5 years, breast feeding, tubal ligation - increased hip circumference- post menopausal, bilateral salpingo-oophorectomy

Essiac and Flor-Essence

- Claim is to strengthen immune system, improve QOL, shrink tumor and legthen life - Tea may be prepared with spring or non-fluoridated water and kept refrigerated. - One ounce is consumed 1-3 times daily - Drink on empty stomach, 2 hours before or after meals, for 1-2 years; comsuing up to 12 ounces daily may be recommended - No dietary restrictions - no clinical trials - Essiac tea has laxative effect but may cause nausea, vomiting, diarrhea, constipation, headaches - limited evidence that is is effective

Budwig Diet

- Emphasizes natural, unrefined foods - Sweeteners allowed - raw non pasteurized honey, dates, figs, berry, fruit jices, and stevia - Whole grains NOT allowed - Flaxseed oil + cottage cheese (QUARK FOCC) consumed twice daily - Avoids hydrogenated oils, trans fats, animal fat, pork, seafood, dairy (other than cottage cheese), soy and corn - Combined with breathing exercises and enemas if tolerated - No clinical trials - Encourages use of essiac tea and allows one glass of red wine and some champagne No supplements rec

Gonzalez Regimen

- Metabolic therapy - includes dietary modifications, supplements and detoxification routines such as coffee enemas - diet patterns individualized - range from vegan to plans including red meat several times per day - organic foods preferred - includes organ extracts and digestive enzymes - from 130-175 capsules taken daily - large doses of vitamin and mineral supplements, animal glandular products - trials show QOL and survival time greater in patients NOT on this regimenL - NOT approved by FDA for cancer treatment

Livingston-Wheeler

- Metabolic treatment - combines vegetarian diet supplemented with vitamins, minerals, and digestive enzymes with antibiotic treatment - individualized vaccine derived from patients own blood/urine - NO poultry, meat, eggs, milk. - no evidence for safety/efficacy - may be deficient in protein, D, B12, calcium, iron - This is no longer in operation

intervention for diarrhea 3 or more stools/day (compared to normal) or increased in liquidity of BMs CTCAE 1- ^ less than 4 over baseline; mild ^ w ostomy 2- 4-6; mod ostomy ^; limiting ADLs 3-7or more; hospitilzation; sever ^ w ostomy; limiting self-care ADLs 4- Life threatening; urgent intervention 5- Death

- SFMs, hydration, Low fat/insoluble fiber/lactose -Increase soluble fiber (pectin, applesauce, bananas, oatmeal, potatoes, rice) -avoid: gas producing foods (cruciferous veg, legumes) carbonation, straws, gum, caffeine, alcohol, high spices foods, sorbitol/sugar alcohols Potential outcomes- dehydration, electrolyte imbalances, wt loss, fatigue, nutrient insuf/def, malnutrition, skin irritation Assess etiology- osmotic, malabsorptive, secretory, infection or exudative, dysmotility-associated, chemo induced, biotherapy induced, radiation enteritis, GI mucositis, gut GVHD, pancreatic insufficiency, lactose intolerant, fat malabsorption Eval BM patterns/changes Frequency Evaluate treatments or meds, altering gastric emptying/GI function - irinotecan /Camptosar, VP-16 (etoposide), radiation therapy to pelvis, antibiotics, pro-kinetic agents, stool softeners, laxatives, alcohol, caffeine, alcohol sugars, lactose, high insoluble fiber diet Food and fluid intake- hx, food records, food frequency questionnaire Education: electrolytes, fluids, oral rehydration salts (ORS), lactase enzyme products

Metabolic Bone Disease (MBD) Complications for PN

- Vit D def-> Oral vit D repletion w ergocalciferol or cholecalciferol if able; encourage wt bearing exercise, reduction in caffeine and alcohol and smoking avoidance; consider endocrinology referral for pharmacological management - inadequate Ca dosing or excessive urinary Ca losses-> provide 1 to 15 mEq of calcium gluconate in PN; avoid excessive protein in PN; provide 20 to 40 mmol of phosphorus in PN; maintain adequate mag and cu intake - chronic metabolic acidosis-> increase acetate to chloride ratio in PN Aluminum toxicity-> minimize aluminum contamination

Gerson therapy

- a natural treatment that activates body's ability to heal itself - vegetarian diet, raw juices, coffee enemas, and natural supplements - 15-20 pounds of organically grown fruits and veggies each day, most of which are juiced - 1 c of juice each hour, 13 times per day - Avoids fats and many complete protein sources - No randomized trials - ACS urges cancer pt's to avoid this therapy - risk for malnutrition, dehydration, colitis - supplement w/B12 and potassium as well as pancreatic enzymes and thyroid hormone S/E: Malnutrition, dehydration, Colitis

cancers from infectious agents could be prevented by what?

-behavior changes -vaccination -antibiotics (HPB, HBV, HCV, HIV, H pylori)

Nutrition recs for Enterocutaneous Fistulas

- fluids and electrolytes - adjust macros and micros for wound healing - Consider PN - Consider EN distal to fistula if able High output - high does acid suppressive therapy w PPI (IV) over oral. If hypo mag substitute histamine H2 receptor - antidiarrheal: loperamide/Imodium- up to 32 gm/d; add codeine if diarrhea persists (15-30 mg orally 3-4 x/day)- but used less commonly due to sedation and nausea

some medications affecting nutrition therapy

-antiemetics (help reduce N/V) -steroids (can cause hyperglycemia in non-diabetics -antibiotics -anti-hyperglycemics

veno-occlusive disease (VOD)

- transplant related complication - a symptomatic occlusion of the small hepatic venules caused by hepatotoxins & XRT; may resolve after removal of the offending agent or may progress to portal HTN & liver failure - 1-3 wks post transplant -hepatomegaly, ascites, jaundice, hepatic failure, encephalopathy & multi-organ failure

decreased skeletal muscle involved with:

-ADLs/fall risk -Hours in bed -Skin/wound healing

Cervical Cancer Treatment

-Electrosurgical excision -Laser -Cryosurgery -Radiation and chemo for late stages 1st Line - Mitomycin C - Cisplatin - Methotrexate - Carboplatin 2nd Line - Cyclophosphamide - Lomustine - Vincristine - Doxorubicin -Conization (remove part of cervix) -Hysterectomy 1st detect with pap smear! -surgery/radiation used together -stage O (pre invasive) is treated with laser, CKC, LEEP -stage I-IV treatment based on health, age, extent/co-morbidities -brachytherapy (internal radiation) -recurrent is treated with chemo or pelvic exeneration (take out all the remaining organs internally-bladder,ureter,rectum, etc. and leave with colostomy and urostomy->body image issues)

cervical cancer risk factors

-Human papilloma virus (HPV) infection - utero exposure to diethylstilbestrol - immunosuppression fro medication or HIV factors that decrease - HPV vaccine

Pancreatic exocrine insufficiency

-Insufficient pancreatic enzyme production Lipase, amylase, trypsin, or chymotrypsin -Causes: -Pancreatitis -Pancreatic carcinoma -Pancreatic resection -Cystic fibrosis -Fat maldigestion is the main problem, so the patient will exhibit fatty stools and weight loss S/S: abd bloating cramping after meals Excessive gas Indigestion Stool Changes: - fatty or oil - frequent - floating - light colored or yellow - loose Foul-smelling gas or stools unexplained weight loss

side effects of chemotherapy

-N/V -anorexia -mucositis -esophagitis -fatigue -constipation -diarrea -changes in digestion/ absorption

side effects of BMT

-N/V -taste alterations -thick saliva/ mucous -anorexia -oral/ esophageal mucositis -diarrhea -GVHD

side effects of radiation therapy

-N/V (brain/ spinal) -mucositis, dysphagia, odyonphagia, xerostomia, loss of taste and smell (head and neck) -anorexia, N/V, diarrhea, gas/bloating, malabsorption, ulcers, strictures/fistulas, obstruction (abdominal/ pelvic areas)

ASPEN recs for EN

-No benefit from routine use -peri-op = mod/severe MN use for 7-14 d prior *weigh risk of delaying surgery to do so*

Colon Cancer Treatment

-Surgery (removal, colostomy) -Chemotherapy 1st Line - Capecitabine / Xeloda - Mitomycin - 5-FU 2nd Line - Leucovorin - Prednisolone -Biological agents -Radiation Prevention-screening at age 50 If there's extracolonic involvement (Lymph Nodes or Mets) the treatment is FOLFOX (5-Fu + Leucovorin + Oxaliplatin/Eloxatin) or FOLFIRI. Recently added to improve remission is Bevacizumab, a VEGF Inhibitor. If there's no extracolonic involvement a simple resection is curative.

nutrition assessment: clinical data

-anthropometric data: baseline Ht/Wt, arm anthropometry- somatic muscle protein and adipose reserves, hand grip strength- marker of nutritional status, growth charts -lab values- baseline values: electrolytes, glucose, renal, liver, lipids, ferritin, 25-hydroxyvitamin D -medical history -medications affecting nutrition therapy (antiemetics, steroids, antibiotics, antihyperglycemics) -cancer treatment -physical activity- typical exercise patterns

inhibitors of carcinogenesis

-antioxidants -phytochemicals

Complementary and Alternative Medicine (CAM)

-can be considered part of a patient's treatment -acupuncture, yoga, massage therapy -dietary interventions: not evidence based therapies. if they're going to go through chemo/radiation don't do the dietary interventions because they can be unsafe -there are risks associated with dietary herbs and supplements. they shouldn't take anything unless prescribed by a physician for a deficiency

referring syndrome

-caused by initial overfeeding of severe malnutrition -intracellular shifts of K+, Mg++, and phos (low serum levels_ -GI , respiratory, cardiac and renal dysfunction may occur 2/2 electrolyte imbalance

re-feeding syndrome

-caused by initial overfeeding of severe malnutrition -intracellular shifts of K+, mg and phos (low serum levels) -GI, respiratory, cardiac and renal dysfunction may occur 2/2 elyte imbalance

regular screening by healthcare profession can reduce risk of what cancers?

-cervix, colon, rectum

intervention for diarrhea

-clear liquids -food gentle on stomach -identify problem foods- as indicated follow low fat, low fiber, low lactose, etc. -avoid gas producing foods, caffeine and alcohol

intervention for n/v

-cold/room temp foods -limit exposure to food emails by avoiding cooking areas -avoid greasy/high fat goods -dry foods-crackers, toast etc -consume liquids b/w means

remember

-cultural or religious preferences -socioeconomic status -family/friend support

treatment goals

-curative: rid body of cancer -palliative: --cure is not an option --can prolong quality of life --can reduce symptoms

palliative treatment goal

-cure is not an option -can prolong quality of life -can reduce symptoms

radiation therapy

-damages DNA cells so that they can no longer divide and grow -normal tissues damaged as well, but recovers faster -radiation therefore given in smaller/more frequent doses

fluid requirements depend on what factors?

-dehydration -anorexia -excessive diarrhea or vomiting -fever/ sweating -edema/ ascites -type of treatment

fluid requirements vary based upon

-dehydration -anorexia -excessive diarrhea or vomiting -fevers/sweating -edema/ascites -type of treatment

body fatness is the cause of the following cancers ~20%

-esophagus -colorectal -endometrial -likely gallbladder -pancreas -breast -kidney

convincing evidence that body fatness is a cause of what cancers?

-esophagus -colorectal -endometrial -likely gallbladder -pancreas -post-menopausal breast cancer -kidney **decreased fruit and veg, high red meat, little physical activity

enhancers of carcinogens from diet

-excessive intake -red (< 18oz per week)and processed meats (as little as possible if any) -foods processed with salt/ sodium

enhancers of carcinogenesis

-excessive intake -red and processed meats -foods processed with salt/sodium

intervention sore mouth and throat

-foods low in acidity -foods less spicy -foods w added moisture (sauce/gravy) -softer foods -serve goods cold/room temp -avoid carbonated bev -avoid alcohol

intervention for sore mouth and throat

-foods lower in acidity -foods that are less spicy -foods with added moisture (sauce/ gravy) -softer foods -serve foods cold or room temp -avoid carbonated beverages -avoid alcohol

physical QOL

-functional status -treatment related side effects

decreased smooth muscle involved with

-gastric emptying -digestion -cardiovascular stability

kcal requirements

-guide only and each should asses on individual basis -vary greatly based on body composition, presence of malnutrition, disease stage

cancers with high nutrition risk

-head & neck -esophageal -gastric -colon/rectal *all involve GI and therefore can negatively impact nutritional status

nutrition goals for hospice

-improve QOF -preserve dignity, provide comfort and pain relief -bereavment and counseling services for families

malnutrition diagnosis

-inadequate nutritional intake -weight loss -fat loss -muscle wasting -fluid accumulation -decreased grip strength -must have 2/6

cancer prevention & plant based foods

-include whole grain foods -variety of fruits and vegetables (5 svgs each day) -goal 20-30 g of fiber each day (adults)

curative nutrition goals

-increase response/ tolerance to treatment -decrease nutrition impact symptoms -increase QOF

alterations in carb metabolism

-increased gluconeogenesis -increased glucose utilization -insulin resistance

alterations in cho metabolism

-increased gluconeogenesis -increased glucose utilization -insulin resistance

alterations in lipid metabolism

-increased lipolysis -decreased lipogenesis -free fatty acid hyperlipidemia

alterations in protein metabolism

-increased protein catabolism -decreased muscle protein synthesis

mucositis/ esophagitis

-inflammation of the mouth or esophagus usually described as painful, irritated throat or feeling of lump in throat

non-modifiable risk factors

-inherited mutations -hormones -immune conditions

negative outcomes of involuntary weight loss

-loss of lean mass can effect treatment tolerance / dosage -sarcopenic weight loss in obese patients can lead to worse outcomes -muscle wasting can be difficult to assess/often overlooked in obese patients -increase complication rates -increased hospitalizations -decrease response to treatment -predictor of EGOG performance status -decreased QOL

protein goals

-maintain positive nitrogen balance -maintain lean body mass

protein requirement goals

-maintain positive nitrogen balance -maintain lean body mass (weakness, fatigue, poor wound healing)

Palliative nutrition goals

-make pt as comfortable as possible -decrease nutrition related impact symptoms -increase QOF -respect wishes of pt and family

surgical intervention

-mechanical/physical alteration of the body -nutrition related side effects depend on type of surgery

cancer diagnosis

-medical history -physical exam -tumor markers -cytology studies -tumor biopsy -imaging studies -staging

cancer diagnosis is determined by what?

-medical history -physical exam -tumor markers -cytology studies -tumor biopsy -imaging studies -staging

causes of cancer

-modifiable risk factors -non-modifiable risk factors

interventions for dysphagia

-modified consistency foods and liquids -consider speech and language pathology consult (SLP) -enteral TF (continuous vs bolus) (supplemental or complete)

cancer cachexia

-multifactorial syndrome characterized by ongoing skeletal muscle mass (w or w/o loss of fat mass) that cannot be fully reversed by conventional nutrition support and leads to progressive functional impairment -key feature of malnutrition in the adult cancer pt is that it may or may not be associated w/cancer cachexia -up to 80% of advanced cancer patients may be diagnosed with cancer cachexia

chemotherapy risks

-n/v -anorexia -mucositis -esophagitis -fatigue -constipation -diarrhea -changes in digestion/absorption

nutrition risks with radiation: side effects

-n/v (brain/spinal) -musocitis, dysphagia, odyonphagia (painful swallowing), xerostomia( dry mouth) loss of taste and small (head & neck) -anorexia, n/v, diarrhea, gas/bloating, malabsorption, ulcers, strictures/fistulas, obstruction (ab/pelvic areas)

high fat diets

-no more than 30% of total calorie intake from fat -limit sat fat & cholesterol (high fat meat sources) -choose lower fat options (lean meat, skim milk)

emerging areas of research

-omega 3 fatty acids -soy -flax seed -green tea

psychological QOL

-perception of disease state -depression

Nutrition Goals

-prevent malnutrition -prevent nutrient deficiences -weight management if necessary

goals

-prevent malnutrition -prevent nutrient deficiencies -weight management if necessary

5 most common cancers in men

-prostate -lung -colorectal -bladder -melanoma

most common cancers in U.S. men

-prostate -lung -colorectal -bladder -melanoma

intervention for N/V

-serve cold/ room temp foods -limit exposure to food smells by avoiding cooking areas -avoid greasy/ high fat foods -dry foods-crackers, toast, etc. -consume liquids between meals **if can't tolerate regular water, usually carbonated water helps

intervention for dry mouth

-sip water -sweet or tart foods produce saliva -hard candy/gum -add gravy, sauces, salad dressings to moisten

intervention for poor appetite, anorexia, early satiety

-smaller more frequent meals -use of high kcal/high protein foods -eat by the clock rather than waiting for hunger -eat in pleasant surroundings/avoid stress -oral nutrition supplements -engage in light activity to stimulate appetite

Intervention for poor appetite, anorexia, early satiety

-smaller/ more frequent meals -use of high kcal/ high protein foods -eat by the clock rather than waiting for hunger -eat in pleasant surroundings/ avoid stress -oral nutrition supplements -engage in light activity to stimulate appetite

modifiable risk factors

-tobacco & heavy ETOH -chemicals -radiation -infectious organisms -body (fatness/overweight/obesity)

modifiable risk factors

-tobacco and heavy ETOH (alcohol) -chemicals (arsenic, esthebestis) -radiation -infectious organisms (HIV, Hepatitis, HPV, etc.) -body fatness/ overweight/ obesity

chemo - bio (biological) therapies

-treatment to boost or restore the ability of the immune system to fight cancer, infection and other diseases by inducing, enhancing or suppressing an individuals own immune response. -aka "immunotherapy" -uses the body's immune system directly or indirectly to fight the disease -agents are classified according to their innate or adaptive effects on the immune system and whether they specifically target the tumor antigen -monoclonal antibodies -protein targeted therapies -angiogenesis inhibitors -cytokines -cancer vaccine therapies -radiopharmaceuticals

chemotherapy

-use of chemical agents or medications to treat cancer -systemic therapy which affects whole body

chemo - hormonal agents

-used in treatment of hormonal-sensitive cancers -stops or reduces body's ability to produce hormones -interferes with /blocks hormone receptors -substitutes chemically similar agents for the active hormones that cannot be used by the tumor -includes: -selective estrogen receptor modulators (tamoxifen citrate, toremifene citrate, raloxifene) BREAST -aromatase inhibitors (anastrozole, letrozole, exemestane) BREAST -progesterones (megace) BREAST, ENDOMETRIAL, RENAL CELL & AS AN APPETITE STIMULANT -antiandrogens (bicalutamide, flutamide) PROSTATE -lutenizing hormone releasing hormone (LHRH) agonists (leuprolide acetate, goserelin) PROSTATE

nutrition assessment: nutrition hx/patient interview

-weight change -adequacy of intake -presence of symptoms limiting intake -functioning capacity -metabolic demands of disease -current treatment -social/economic issues -education level -readiness to learn Before Hematopoietic Cell Transplantation: Oral/GI- dysgeusia/hypogeusia, xerostomia, dysphagia/odynophagia, dental health, oral aversions, mucositis/esophagitis, heartburn/GERD, N/V, early satiety, anorexia, alter bowel habits Current diet- including special diets; Food allergies/intolerances Supplements- dosage Integrative medicine therapies Current or past nutrition support Medical hx: past oral / Gi sx, comorbidities, pain status/narcotic use

chemo causing hepatoxiticy

...asparaginase busulfan carboplatin carmustine cytarabine docetaxel/Taxotere etoposide 5FU idarubicin mercaptopurine methotrexate mitomycin mitoxantrone paclitaxel/taxol procarbazine temozolamide thioguanine vinblastine vincristine flutamide (hormonal tx) bortezomib/ velcade (molecular tx) gefitinib/iressa (molecular tx) imatinib/gleevec (molecular tx) trastuzumab/ herceptin (molecular tx)

ECOG Reference Status

0 Fully Active <------------------> Dead able to carry on pre dz activities w/ no restrictions

A patient has intermittent nausea & vomiting and is interested in taking ginger. You recommend:

0.5 - 1.0 g ginger/day supplementation with antiemetic medicine, cautioning evidence is limited.

Patients with ileostomies are instructed to consume ____

1 L more fluid than their output.

Lymphoma Drugs

1 line Vinblastine Cyclophosphamide 2nd line Bleomycin / Blenoxane Doxorubicin Cytanabine Vincristine

Following stomach surgery, B12 deficiency can develop as early as ____. Replacement can be provided via ___, __ and __

1 year; oral, EN, and PN

Nutrition plays an important role throughout the continuum of cancer care in what 3 ways?

1) helping to reduce cancer risk 2) caring for patients undergoing cancer treatment 3) promoting healthy lifestyles for cancer survivors talk about prevention diet in even in patients who have cancer because patients who already have cancer are at risk at developing other new primary or recurrent cancers. esp important for them to follow a prevention diet.

Calculate fluid needs for children

1-10 kg: 100 ml/kg 10-20 kg: 1000 ml + 50ml/kg for each kg >10kg >20kg: 1500 ml + 20 ml/kg for each Kg >20 kg

pediatrics-Calculate fluid needs for children

1-10 kg: 100 ml/kg 10-20 kg: 1000 ml + 50ml/kg for each kg >10kg >20kg: 1500 ml + 20 ml/kg for each Kg >20 kg

Na and K std replacement/day?

1-2 mEq/kgq

List some risk factors for anticipatory nausea and vomiting

1. Age younger than 50 years. 2. N&V after the last chemotherapy session. 3. Post-treatment nausea OR vomiting described as moderate, severe, or intolerable. 4. Susceptibility to motion sickness. 5. Female gender. 6. High-state anxiety 7. Patient expectations of chemotherapy-related nausea before beginning treatment. 8. Emetogenic potential of various chemotherapeutic agents. Patients receiving drugs with a moderate to severe potential for post-treatment N&V are more likely to develop ANV. 9. History of morning sickness during pregnancy.

viruses associated with increased cancer risk (3)

1. EBV = inc risk of Burkitt lymphoma 2. HepB = inc risk of liver & pancreatic cancers 3. HPV = inc risk of oral & cervical cancers

Suggested High Risk Nutrition Screening Criteria for use in Cancer Centers with one or more FT RDNs. List 5 criteria based on cancer site or stage:

1. Esophageal Ca 2. Gastric Cancer 3. Lung Cancer 4. Colorectal Ca 5. Any stage III or IV cancer Reference: Page 23 in the pocket guide to the NCP and Cancer ??? why isn't H&N on this list ?!

For the Nutrition Diagnosis of adult malnutrition in the context of chronic illness, a patient must have 2 of these 6 characteristics.

1. Intake <75% of estimated energy needs for >30 days 2. >/= 5% weight loss in 1 month 3. Loss of muscle mass 4. Loss of body fat 5. Fluid accumulation 6. Diminished functional status as measure by hand grip strength

List the FOUR valid & reliable Nutrition Screening Tools for adult patients with cancer. All FOUR may be used in the INPATIENT setting. Which TWO should be used in the ambulatory/outpatient setting

1. Malnutrition Universal Screening Tool (MUST) 2. Malnutrition Screening Tool for Cancer patients (MSTC) 3. Malnutrition Screening Tool (MST) ** outpatient 4. Scored Patient-Generated Subjective Global Assessment (PG-SGA) ** outpatient

Targeted therapy works by targeting specific genes or proteins to help stop cancer from growing and spreading. These genes and proteins are found in cancer cells or in cells related to cancer growth, like blood vessel cells. There are 2 main types of targeted therapy:

1. Monoclonal antibodies 2. Small-molecule drugs Examples: cetuximab (Erbitux) and panitumumab (Vectibix), trastuzumab (Herceptin),

Hematopoietic stem cell transplantation side effects

1. Replaces blood-forming stem cells depleted by high dose chemo/radiation 2. Graft vs disease effect 3. Nausea, vomiting, anorexia, dysgeusia, severe stomatitis, fatigue, diarrhea, xerostomia 4. *Nutrition precautions with neutropenia* (their counts are not going to come back as fast because they had chemotherapy) -Graft vs Host disease -TPN vs EN? --> do not consume any unpasteurized liquids (raw milk, unpasteurized juices, need to drink from an approved water source)

Anti-Emetic Drugs

1. Serotonin 5-HT3 (zofran, dolasetron, granisetron, palonsetron) 2. Dexamethasone (corticosteroid) 3. Aprepitant (NK1 receptor antagonist) Rezonic (casopitant) or Emend (aprepitant)

Suggested High Risk Nutrition Screening Criteria for use in Cancer Centers with one or more FT RDNs. Criteria based on h/o medical conditions or diseases- List 10 high risk medical conditions or diseases:

1. Short Bowel Syndrome 2. PCM 3. Renal failure 4. IBD or Celiac 5. HIV 6. Bariatric Surgery 7. Open wounds or pressure ulcers 8. Psychiatric Disorders 9. DM 10. Enteral/Parenteral support 11. Cancer Recurrence

Suggested High Risk Nutrition Screening Criteria for use in Cancer Centers with one or more FT RDNs. List 10 criteria based on nutrition impact symptoms:

1. Unable to maintain usual food intake 2. No appetite 3. dysphagia resulting in NPO > 2 days 4. Any of these: N/V/C/D 5. Problems with TPN 6. Stomatitis or Odynophagia 7. GI obstruction 8. Consumption of only liquids 9. Depression 10. Muscle wasting

case study

1. What lifestyle/nutrition factors may likely contribute to JT's cancer diagnosis? HPV+ History of smoking and alcohol use High animal fat intake Frequent consumption of grilled meat Inadequate consumption of fruits and vegetables 2. What factors alert the RD that JT will be at high nutrition risk as he proceeds through treatment? High incidence of cancer cachexia in head and neck carcinomas Patient has unintentional weight loss of ~ 10% of his UBW at time of diagnosis Inadequate nutrient intake puts him at risk for micronutrient deficiency Multimodality treatment JT was able to complete his multimodality treatment with minimal weight loss, has now had his peg tube removed and port de-accessed. Recent testing revealed no evidence of disease. JT is now experimenting with tasting new fruits and vegetables in an effort to increase intake as recommended by the ACS, has greatly reduced his alcohol intake from before treatment, and takes a multivitamin daily.

Suggested High Risk Nutrition Screening Criteria for use in Cancer Centers with one or more FT RDNs. List 4 criteria based on cancer treatment:

1. XRT to the GI tract or affecting the GI tract (such as esophagitis from lung radiation). 2. Concurrent chemo/xrt 3. All new cancer patients prescribed chemotherapy, biotherapy (monoclonal antibodies, growth factors, and vaccines) or targeted therapy 4. Resumption of chemo or biotherapy after cessation for > 6 months

4 types of bone marrow transplants

1. autogolous 2. allogeneic 3. haplo identical 4. cord blood

Severe Malnutrition Criteria for Social/ Environmental 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake - < or = 50% for > or = 1 month 2. % weight loss -1 month: >5% -3 months: > 7.5% -6 months: > 10% -1 year: >20% 3. body fat loss: severe 4. muscle loss: severe 5. fluid accumulation: severe 6. grip strength: reduced

Moderate Malnutrition Criteria for Social/ Environmental 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake: -< 75% for > or = 3 months 2. % weight loss -1 month: >5% -3months: >7.5% -6 months: >10% -1 year: > 20% 3. body fat loss: milk 4. muscle loss: mild 5. fluid accumulation: mild 6. grip strength: n/a

Moderate Malnutrition Criteria for Chronic Illness 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake: < 75% for > or = 1 month 2. % weight loss: -1 month: 5% -3 months: 7.5% -6 months: 10% -1 year: 20% 3. body fat loss: mild 4. muscle loss:mild 5. fluid accumulation: mild 6. grip strength : n/a

Severe malnutrition criteria for acute illness 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake: < or = 50% for > or = 5 days 2. % weight loss: -1 week: >2% -1 month: >5% -3 months: > 7.5% 3. body fat loss: moderate 4. muscle loss:moderate 5. fluid accumulation:moderate- severe 6. grip strength: reduced

Severe Malnutrition Criteria for Severe Malnutrition 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake: < or = 75% for > or = 1 month 2. % weight loss -1 month: >5% -3 months: >7.5% -6 months: >10% -1 year: > 20% 3. body fat loss: severe 4. muscle loss: severe 5. fluid accumulation: severe 6. grip strength: reduced

Moderate malnutrition criteria for acute illness 1. energy intake 2. % weight loss 3. body fat loss 4. muscle loss 5. fluid accumulation 6. grip strength

1. energy intake: <75% for > 7 days 2. % weight loss: -1 week: 1-2% -1 month: 5% 3 months: 7.5% 3. body fat loss: mild 4. muscle loss: mild 5. fluid accumulation: mild 6. grip strength : n/a

goals of nutrition oncology therapy (2)

1. goal: get patients as early on as possible, work with them to get nutrition intact to prevent uncontrolled or intractable N/V/D. any symptom or treatment that can cause cachexia scenario to start ramping up. 2. if its more the process of the disease, then that goal nutritional is to support those increased nutritional needs as much as possible until we can get the tx under control

For adequate GI absorption you need how many cm of both jejunum and ileum? also need what valve?

100 cm jej 150 cm ileo ileoceceal valce

6 criteria used to diagnosis malnutrition and need how many to diagnose malnutrition?

1. inadeq nutritional intake 2. weight loss 3. fat loss 4. muscle wasting 5. fluid accumulation 6. decreased grip strength -need 2 of the above to diagnose malnutrition

3 stages of cancer

1. initiation 2. promotion (genetic mutations or changes that induce cell division) 3. proliferation that can become mets and spread to other tissues and other parts of body

Magnesium lab value

1.5-2.5 mEq/L

According to ACS and AICR how many cancer deaths are related to obesity/overweight, physical inactivity and poor nutrition?

1/3

Research has suggested that enteral tube feeding provided for _____ days prior to surgery can reduce morbidity and mortality in malnourished surgical patients by _____ and ____.

10 days preserving bowel mucosa and modulating the immune response.

Sodium lab value

136-145 mEq/L

How many kcal/kg if refeeding risk?

15 kcal/kg

What is one of the components of the Gerson Therapy Diet?

15-20 pounds of organically grown fruits/vegetables daily that is juiced.

Triple Negative Breast Cancer

15-20% of breast cancer; mainly caused by BRCA1 gene. Most common among young and African American women. Hormone therapy is generally ineffective, but chemo is available. Poorer prognosis than other cancers.

Calcium Recommendations for Gastric Cancer Surgery

1500 mg/day When supplement needed, divide doses into <500 mg/dose, use calcium citrate, and separate iron rich foods.

List the Topoisomerase inhibitors

1: Ironotecan, Topotecan 2: Amsacrine, Etoposide, etoposide phosphate, teniposide

Hepatic Compromise and Nut Recs

25-40 kcal/kg dry wt or 15 if refeeding risk 1-1.5 g/kg protein Avoid Glutamine supplementation d/t metabolism to glutamate and ammonia Thiamine 1-2 mg /d MVI w min if poor po Low selenium levels are linked to hepatocellular carcinoma osteoporosis risk- Vit D3 2000 IU and 1200-1500 mg calcium Dextrose IV fluids due to low glycogen reserves 6 SFMs w carbohydrate rich snack at bedtime oral supplements as needed Hand grip test best predicts malnutrition and related complication in pts w cirrhosis Ascites: 2-3 gm Na SFMS liquid protein sources to replace protein loses

cancer is the ___ most common cause of death after ___

2nd. heart disease.

chronic disease lasts how long?

3 months or longer

Mouth sores occur this many days after chemo

3-10

Potassium lab values

3.5-5.3 mEq/L

number of patients who experience strictures after esophagectomy

30%

Short bowel syndrome is defined as having less that ____% of normal intestinal length

30% 75 cm in children 200 cm in adults

smoking is related to ___% of all cancer deaths and ___% of lung cancer

30%, 80%

5-FU

5-fluorouracil Antimetabolite IV, topical *suck on ice chips pre/post iv bolus to reduce mucositis SE: myelo, N/V/D/M/A OCULAR TOX, CARDIAC TOX, hand-foot syndrome, photosensitivity, alopecia, metallic taste. *Vit. B6 may help with hand/foot syndrome Leucovorin - given with fluorouracil (5-FU) causing fluorouracil to be more SEVERE *taken with leucovorin to increase anti-cancer effects which increase side effects

digestive pancreatic enzymes doses

500 - 100 lipase per g of fat do not exceed 4000 g fat or 2500 per kg or 10000 per kg / day 20000 to 75000 lipase per meal 5000-50000 lipase per snack 500 lipase per kg for meal, increase as tolerated 250 lipase per kg for snacks, increase as tolerated

What chemotherapies are Pyrimidine Antagonists?

5FU Foxuridine Cytarabine Capecitabine / Xeloda Gemcitabine /Gemzar

Most patients resume oral intake within _____ days postoperatively, though early postoperative feedings (_____ hours) can stimulate the return of normal bowel function.

6-9 24 hours

Mercaptopurine

6-MP (PO) Myelosuppression, N/V/D, mucositis, hepatic toxicity, hyperuricemia. *Avoid dairy containing products around dose. ALL, AML, CML, NHL

What chemotherapies are Purine antagonists?

6-Mercaptopurine 6-Thioguanine

Vit. D DRIs for Women with Breast Cancer

600 IU/day (19-70) 800 IU/day (71+)

What is the 5 year survival rate for all cancers?

67%

Maximum daily tolerance of Dextrose w/ TPN?

7 grams/kg/day OR 5 mg/kg/min

ASPEN guidelines suggest that nutrition support is indicated only in individuals anticipated to require nutrition support for _______. Unless _____

7-10 days UNLESS THE PATIENT IS MALNOURISHED

Mouth sores take this long to regenerate healthy cells

7-14

Renal EN products provide ____ to ___ % of kcal from protein?

7-18% of kcal from pro

Once meeting ____% of needs can EN/PN be d/c?

75%

Chloride lab value

97-107 mEq/L

Short bowel syndrome

<150 cm of small intestine left

surgery Short bowel syndrome

<150 cm of small intestine left

Triglycerides

<150 mg/dL

Calcium Correction

= Ca + [(4.0-albumin) x 0.8] if albumin is low

A patient with newly diagnosed pancreatic cancer completes the Scored Patient-Generated Subjective Global Assessment (PG-SGA©) with information regarding weight, food intake, symptoms and activities/functional status. The additive score is 10. What does this score mean? A. No intervention is required at this time. B. Requires intervention by RD with RN or MD C. Indicates a critical need for improved symptom management &/or nutrient intervention options

>/= 9 Indicates a critical need for improved symptom management &/or nutrient intervention options

Nitrosoureas (carmustine, lomustine, semustine, streptozocin)

Act similarly to alkylating agents and also inhibit enzymatic changes necessary for DNA repair.

anemia

A condition in which the blood is deficient in red blood cells, which may lead to low red blood count-> in hemoglobin, or in total volume. treatment: - epoetin alfa / procrit - Darbepoetin / Aranesp - Iron supplement - MVI - high protein diet - RBC transfusion

Psoralen and Ultraviolet irradiation GVHD treatment/prevention

A photosensitizing chemical administered orally or topically to increase the skin's reaction to light for a therapeutic effect. sensitizes the skin to ultraviolet light therapy; damages cellular DNA; decreases cell division; a compound that absorbs ultraviolet radiation, and is used to treat skin problems such as psoriasis, eczema, or alopecia S/E: Nausea, hepatoxicity

A cancer patient is fully active and able to carry on all pre-disease activities without restrictions. Which Eastern Cooperative Oncology Group (ECOG) grade is appropriate? A. Grade 0 B. Grade 1 C. Grade 2 D. Grade 3

A. Grade 0 is fully active and able to carry on all pre-disease activities without restrictions. (KS 90-100)

Esophageal Cancer Risk Factors

ABCDEFGH Achalasia/alcohol Barrett's esophagus Corosive esophagitis/cigarettes Diverticula Esophageal webs (plummer vinson) Familial/gender/race Gerd Hot dogs (nitrosamines) Obesity Smoking HPV Yerba mate

Paclitaxel Protein Bound

Abraxane

Mechanism of action Metamucil/Psyllium/Benefiber

Absorbs water from intestine, the bulk then stimulates peristalsis

What is acrylamide, and is it linked with an increased risk of cancer?

Acrylamide is a chemical used in industrial processing. It is also found in some foods and in tobacco smoke. Acrylamide in food is formed as a by-product when the amino acid asparagine reacts with certain sugars when they are heated to high temperatures. The major sources of acrylamide in our diets are French fries, potato chips, crackers, bread, cookies, breakfast cereals, canned black olives, prune juice, and coffee. Acrylamide is classified by the International Agency for Research on Cancer (IARC) as a "probable carcinogen," based mainly on experiments in animals. However, a large number of studies in humans have found no strong evidence that dietary acrylamide is linked with an increased risk of any type of cancer.

alkylating agent

Act directly by attacking DNA causing breaks in and cross-linking DNA strands bendamustine /Treanda busulfan carboplatin (paraplatin) carmustine (bcnu) chlorambucil (leukeran) cisplatin (platinol) cyclophosphamide (ctx or Cytoxan) dacarbazine (dtic) ifosfomide (ifex) mechlorethamine melphalan oxaliplatin (eloxatin) temoxolomide (temodar) thiotepa

Nausea Medications

Acute: - ondansetron/ Zofran - dolasetron / Anzemet - granisetron / Kytril - palonosetron / Aloxi - tropisetron / Navoban Delayed: - prochlorperazine / Compazine - promethazine / Phenergan - fosaprepitant / Emend - netupitant and palonsetron / Akynzeo - rolapitant / Varubi Benzamides - metoclopramide / reglan Cannabinoids - dronadinol / Marinol -liquefied dronadinol / Syndros - nabilone / Cesamet Benzodiazapines: - lorazepam / Ativan - diazepam / Valium Corticosteroids: - dexamethasone / Decadron - prednisone

Sucralfate (Carafate)

Adheres to injured gastric ulcers upon contact with gastric acids; protective action for up to 6 hour, has no systemic effects. Used for gastric and duodenal ulcers and GERD. Administer on an empty stomach at least one hour before meals and do not administer within 30 minutes of antacids.

Kadcyla

Ado-trastuzumab emtansine. Targeted Therapy: Monoclonal Antibody-ERBB2 IV SFX: N/C, CARDIO TOX (increased risk when given with anthracycline), PULM TOX, HEPATIC TOX thrombocytopenia, peripheral neuropathy, myelosuppression, skin rash/problems osteonecrosis, hypocalcemia

Tyramine Containing Foods

Alcohol Brewer's yeast Fava Beans raspberries figs dried fruits avocado bananas miso soup soy sauce sauerkraut aged cheese aged meats caffeine

Melphalan

Alkeran. MEl stomach doesn't feel good, all nausea med before small meals IV; Oral - take on empty stomach- *pre-medicate with anti-emetic one hour before. N/V/D/M, myelo, hypersensitivity reaction to infusion Encourage small, frequent meals.

Carboplatin/Paraplatin

Alkylating Agent SFX: n/v, renal toxicity Ovarian

Oxaliplatin/Eloxatin

Alkylating Agent SFX: n/v/d, sensitivity to cold, Taste changes

Carboplatin

Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA IV Paraplatin HYPO MAG, myelosuppression, N/V, RENAL TOX, OCULAR/OTO TOX, hypersensitivity reaction, taste changes, alopecia, rash, reproductive issues, mouth sores, peripheral neuropathy, **N/V occurs within first 24hrs of treatment

Busulfan My BUs Bus

Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA Myleran oral Busulfex IV IV, PO- take on an empty stomach, AVOID ASPIRIN Myelosuppression, N/V/D/M, HEPATIC TOX, PULM TOX, HYPER GLYCEMIA, anxiety, adrenal insufficiency, insomnia, dizziness, alopecia, seizures

This type of chemotherapy is highly emetogenic

Alkylating agents

Treanda, Busulfan, Carboplatin, Cisplatin, Cyclophosphamide are all what type of chemo

Alkylating agents

LHRH Hormone Therapy These synthetic proteins, signal the pituitary gland to stop producing luteinizing hormone, which results in the suppression of testosterone to manage the growth and spread of prostate cancer. Lu Lu Gross Zol

Also known as gonadontropin releasing hormone analogues. Leuprolide Acetate( Lupron) Goserelin (Zoladex) Used to treat prostate and ovarian cancers.

CAM-Gerson therapy

Alt therapy cleansing & detoxifying program, raw fruit & veg, juice therapy & fresh calf's liver solution daily

Gerson therapy

Alt therapy cleansing & detoxifying program, raw fruit & veg, juice therapy & fresh calf's liver solution daily

CAM-Metabolic therapy

Alternative therapy- claims that toxins accumulate in body causing CA, claim that if toxins are removed, the body can heal itself. Steps: detox, strengthening of the immune system, use of special modalites to attack CA (colonic cleansing with coffee, wheat grass, etc), special diets, vitamins/minerals

Metabolic therapy

Oral Mucositis and Esophagitis Pharmacotherapy

Amino acids: - L-glutamine Topical anesthetics: - gels, rinses with lidocaine, codeine, morphine Analgesia: - opiods, anti- inflammatory agents Topical anti-inflammatory agents: - gels containing dexamethasone Mucosal barriers and protectants: - zinc gluconate and taurine / Gel-X - adherent gel / Gelclair Salt baking soda rinse

The Alkaline Diet promoted by the Acid Alkaline Association claims that ______ is toxic to the body and increases cancer risk.

An acidic environment.

Guideline for Antiemetic Use:

An antiemetic regimen administered before chemotherapy is recommended to prevent acute nausea and vomiting. This three-drug combination is recommended by ASCO (American Society of Clinical Oncology) for highly emetogenic chemotherapy medications: 1. Serotonin 5-HT3 receptor antagonist (Ondansetron, dolasetron, granisetron, palonosetron) 2. Dexamethasone (corticosteroid) 3. Aprepitant (NK1 receptor antagonist)

antiemetics, guideline for use:

An antiemetic regimen administered before chemotherapy is recommended to prevent acute nausea and vomiting. This three-drug combination is recommended by ASCO (American Society of Clinical Oncology) for highly emetogenic chemotherapy medications: 1. Serotonin 5-HT3 receptor antagonist (Ondansetron, dolasetron, granisetron, palonosetron) 2. Dexamethasone / Decadron (corticosteroid) 3. Aprepitant (NK1 receptor antagonist)

Aromatase Inhibitor

Anastrozole (Arimidex) Letrozole (Femara) Exemestone (Aromasin) *Avoid St. John's Wort Used to treat breast cancer. Hot flashes, arthralgia, N/V, asthenia, thrombus, elevated cholesterol, fever/malaise, joint ache/pain, bone loss- increase Vit. D/Calc to prevent

The following are the ONLY criteria validated as indicators of nutritional status. SELECT TWO: A. Unintentional Weight Change B. Decreased appetite/intake C. Alterations in chewing/swallowing D. GI distress E. Low albumin/prealbumin F. BMI <18

Answer: A & B Reference: Page 19 in the pocket guide to the NCP and Cancer

Which of the following chemotherapy agents should indicate the restriction of tyramine-containing food and beverages because of its MAO inhibitor-like (monoamine oxidase) action that can cause severe hypertensive events? A. Procarbazine (Mutulane) B. Streptozocin (Zanosar) C. Mitomycin (Mutamycin) D. Darcarbazine (DTIC)

Answer: A. Procarbazine (Mutulane) Examples of foods that contain high amounts of tyramine include aged cheese, soy sauce, aged meats, pickled fish, tofu (soy curd), sauerkraut, and tap beer. Wine, yogurt, ripe cheeses and bananas should also be avoided. REMEMBER: Consuming foods high in tyramine while taking procarbazine can raise your blood pressure. Patients should also avoid alcoholic beverages while taking procarbazine.

Generally, the Macrobiotic diet does NOT include A. Dairy, eggs, poultry, red meat B. Artificial flavors, processed foods or chemical additives C. Mango, pineapple and papaya D. Both A & B E. Answers A, B & C

Answer: E

Which drug is prescribed as an antidote to methotrexate?

Answer: Leucovorin Leucovorin is a reduced folic acid. Leucovorin is given to lessen the side effects of methotrexate Leucovorin is used in combination with other chemotherapy drugs to either enhance effectiveness, or as a "chemoprotectant."

TRUE or FALSE All adult patients should be screened for malnutrition risk on entry into oncology services & rescreening should be repeated routinely throughout treatment

Answer: TRUE Rating: Consensus, Imperative

When is a cancer patient most susceptible to increased risk for infection, anemia and/or bleeding?

Answer: When the patient has low blood counts- Myelosuppression Nadir: Meaning low point, Nadir is the point in time between chemotherapy cycles in which you experience low blood counts.

Women should not take this OTC medicine within 2 hours of taking Tamoxifen

Antacids- Avoid antacids within 2 hours of taking Tamoxifen

What are some groups of antitumor antibiotics?

Anthracyclines Chromomycins Misc

Omega 3

Anti-inflammatory effect. Conventional Food: Fatty fish (mackerel, trout, herring, tuna, salmon, sardines) Functional Food: eggs fortified with omega 3 fats

Anticipatory nausea and vomiting (ANV)

Anticipatory nausea and vomiting (ANV), also is widely believed to be a learned response to chemotherapy that 25% of patients develop by the 4th treatment cycle

Lacosamide (Vimpat)

Anticonvulsant Brain tumors S/E: N

Valproate (Depakote)

Anticonvulsant Brain tumors S/E: diarrhea, change in appetite, wt gain/loss, constipation

Lamotrigine (Lamictal)

Antiepileptic brain tumors S/E: Nausea, dyspepsia, constipation

Methotrexate

Antimetabolite - SFX: N (severe), mucositis (severe), oral/GI ulcerations, renal toxicity - Intrxn: avoid folic acid and its derivatives, avoid alcohol (may increase hepatotoxicity) MTX Used to treat breast cancer, esophageal cancer, head/neck cancer. Myelosuppression, N/V/D, mucositis, oral/GI ulcers, renal toxicity, hepatic toxicity, photosensitivity. *Avoid supplements containing folic acid *Avoid alcohol due to hepatic toxicity

Cytarabine/ARA-C

Antimetabolite SFX: n/v, mucositis, anorexia, acute pancreatitis

Beta Carotene

Antioxidant Conventional Food: Carrots, oranges, red/yellow foods Functional Food: Beta carotene rich juice

Coenzyme-Q10

Antioxidant made in body. May reduce renal and cardio toxicity of doxorubicin. May interfere with chemo or warfarin. May cause nausea, vomiting, or diarrhea.

Teas

Antioxidant, enhances immune system, anti platelet effect

Theanine

Antioxidant; Increases benefits/decreases toxicity of doxorubicin and idarubicin. Found in Tea.

Milk Thistle

Antioxidant; May decrease side effects of cisplatin. Potential for allergic reactions.

Lycopene

Antioxidant; blocks activity of free radicals. Conventional Food: tomatoes/products, red, yellow, and orange fruits and vegetables Functional Food: added to ready to eat cereal

Common anti-nausea medications:

Aprepitant (Emend®) Dolasetron (Anzemet®) Granisetron (Kytril®) Ondansetron (Zofran®) Palonosetron (Aloxi®) Proclorperazine (Compazine®) Promethazine (Anergan®), (Phenergan®) Netupitant-Palonosetron (Akyzeo®) Rolapitant (Varubi®) Lorazepam (Ativan®) Metoclopramide (Reglan®) Dexamethasone (Decadron®) Famotidine (Pepcid®) Ranitidine (Zantac®)

Nelarabine

Arranon (Antimetabolite)

terminal ileum resection

As little as 15cm & result in bile salt losses & affect Vit B12 absorption, steatorrhea Calcium carbonate should be administered orally to minimize oxalate absorption Diet should be low in fat, osmolality, lactose, oxalate

surgery terminal ileum resection

As little as 15cm & result in bile salt losses & affect Vit B12 absorption, steatorrhea Calcium carbonate should be administered orally to minimize oxalate absorptionv1500 mg/d if >100 cm of ileum is resected Keep Vit D >30 mg/dL Diet should be low in fat, osmolality, lactose, oxalate Bile acid malabsorption? w perianal burning. Rec bile acid sequestrants like colesevelam Probiotics to limit SIBO risk

Can soy‐based foods reduce cancer risk?

As with other beans or legumes, soy and foods derived from soy are excellent sources of protein, so they provide a healthier alternative to meat. Soy contains several bioactive food components, including isoflavones, which have a similar structure to estrogens and can bind to estrogen receptors on cells. The effects of this binding can vary, depending on conditions, the specific body tissue, and the amount consumed. There is some evidence from human and lab studies that consuming traditional soy foods such as tofu may lower the risk of breast and prostate cancer, but overall the evidence is too limited to draw firm conclusions. Many of the studies that have found such links looked at Asian populations with high lifelong consumption of soy foods, and their relevance to soy consumption at lower levels and for shorter durations in Western populations remains uncertain. There are no data to support the use of supplements containing soy phytochemicals or soy protein powders used in some food products for reducing cancer risk. In fact, a recent study found increased risk for estrogen receptor (ER)-negative breast cancer (an aggressive type) among users of soy supplements. Therefore, while soy from food sources appears to be safe and may even have beneficial health effects, soy supplements should be used with caution, if at all.

Intervention for Oral Mucositis and Esophagitis

Assess etiology: hematopoietic stem cell transplantation, chemo-biotherapy, radiation, GVHD of GI tract Evaluate for oral infections, oral care-soft toothbrushes Avoid alcohol and tobacco Lip balm Assess intake Interventions: -Cryotherapy w fluorouracil bolus and melphalan chemo - low acidic - avoid strong spices and seasonings - moist soft foods - cool or room temperatures - smoothes - limit carbonated beverages - avoid alcohol mouthwashes

Diarrhea from irinotecan /Camptosar is treated this way. Early.

Atropine.

Macrobiotic diet

Avoid animal products including dairy, eggs, coffee, sugar, poultry, and processed foods. No "nightshade vegetables" including potato, peppers and eggplant Diet may be deficient in protein, iron, zinc, vitamin B12 and calcium 50-60% from whole grains, 25-30% from veg, remaining from beans, seaweed, soups

cultural-Macrobiotic diet

Oxaliplatin (Eloxatin and Transplatine) - chemo

Avoid cold foods & drinks - may trigger acute neuropathy

chemo interactions Oxaliplatin (Eloxatin and Transplatin)

Avoid cold foods & drinks - may trigger acute neuropathy

Exemestane/Aromasin

Avoid grapefruit juice

Avoid holding EN for gastric residual volumes of <__________ mL in the absence of other signs of intolerance

Avoid holding EN for gastric residual volumes of <500mL in the absence of other signs of intolerance

Low Iodine Diet

Avoid: Egg yolks iodized salt seafood dairy red dye #3/erythrosine dough conditioners foods with significant amount of these foods

Vidaza

Azacitidine. Aza and Vida are friends oK Cell Cycle-specific chemo agent:Antimetabolite-interferes with DNA synthesis by acting as false metabolities; incorporated into the DNA strand or block essential enzymes SC IV SFX: N/V/D/C/F, hypokalemia, RENAL TOX, myelo decreased Vit K levels

constipation meds

BISACODYL- stimulant laxative (interaction w/ Calcium supplements) caution with cardiac, renal disease, HTN, rectal bleed. Avoid if pregnant. DOCUSATE/COLACE- stool softener. **Drug interaction with irenotecan. can cause throat irritation, GI cramping POLYETHYLENE GLYCOL/MIRALAX-Osmotic laxative. Caution with cardiac, renal disease, HTN, stomach pain, N/V, bowel obstruction, rectal bleed, pregnancy or nursing. can cause, abdominal cramps, frequent BMs, bloating, gas **Drug interaction with irenotecan, compazine, decadron, lasix and more.... MOM- caution with cardiac/renal disease, stomach pain, N/V, rectal bleed, pregnancy. side effects: bloating, cramping, gas, increased thirst, diarrhea, nausea ** drug interactions with aminoglycosides and quinolone antibiotics, bisphosphonates, Calcium channel blockers, muscle relaxants, k- sparing diuretics, penacillamine, digoxin, nitrofurantoin. Bisphosphpnates must be taken 2 hours separately. SENNA-stimulant laxative. avoid if pregnant or nursing, dehydrated, have intestinal blockage, crohns disease, ulcerative colitis, appendicitis, gastritis, anal prolapse, hemmorhoids. Caution with cardiac/renal disease, HTN, nausea, vomiting, rectal bleed, monitor electrolytes. side effects: belching, cramping, faintness, urine discoloration diarrhea, nausea. **Drug interaction with irenotecan, compazine, decadron, digoxin, warfarin, diuretics and more...

lung cancer treatment

Based on tumor type Small cell carcinoma - Chemotherapy 1st Line - Cyclophosphamide - Vincristine - Doxorubicin 2nd Line -Carboplatin -Methotrexate Non-small cell carcinoma - Surgery - Chemotherapy - Radiation, if surgery not feasible Stage __&__ are treated with resection Stage ___ have poor outcomes with resection alone - often need surg, chemo, and radiation Stage __ resection after chemo/radiation may be cured Stage ___ treated with chemo or sx based as palliative therapy

Micronutrient Eval of Pancreatic Ca Survivors

Baseline eval w/in 2 years of sx f/u every 5 years Labs: CBC, -B12, Methylmalonic acid: def- 1000 mcg cyanocobalamin by IM monthly -folate, ferritin, Total iron binding, iron def: 150 to 200 mcg orally daily or every other day in 2-3 divided doses -Copper def- 3-8 mg elemental copper orally daily until levels normalize -Zinc def: 50-60 mg elemental orally 1-2 x daily x 3 months -selenium def: 100 mcg orally daily until levels normalize -Retinol binding protein (Vit A) def- 30000 IU retinol palmitate orally x 4 wks - serum retinol, -a-Tocopherol (Vit E) def: 400 IU orally daily x 2 wks -25-hydroxyvitamin D def: 50000 IU cholecalciferol or ergocalciferol weekly x 8 wks then 1500-2000 IU daily or 50000 wkly -hemoglobin A1C, Mg every year ax sx F/U annual , abnormal q 3 months

Cancer prevention/survivorship

Be as lean as possible within normal range of body weight. Be physically active. Limit consumption of energy -dense foods and avoid sugary drinks. Eat mostly foods of plant origin. Limit intake of red meat and avoid processed meat. Limit alcoholic drinks. Limit consumption of salt. Avoid moldy grains or legumes (third world problem) Aim to meet nutritional needs through diet alone. Mothers should breastfeed. Cancer survivors should follow same recommendations.

Ovary Cancer S/E and Interventions

Bone- Ca, Vit D, wt bearing exercises Irregular BMs- Alter fiber as needed, Fluids, balance electrolytes

Treanda

Bendamustine (alkylating agent) Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA IV Treandra Myelosuppression, mild N/V, fatigue, infusion reaction, tumor lysis syndrome.

Avastin

Bevacizumab. BECAUSE AVA cant have TEA No GREEN Tea N/V/D/C/M/A/F, poor app, Myelo HTN, Thrombus, proteinuria, hemorrhage, GI/bowel perf., hypothyroidism, dry mouth, taste changes, neuropathy, flu like, pain, abd pain, upper respiratory infection, low white cell count medication that helps prevent tumors from creating their own blood supply (humanized monoclonal antibody - VEGF inhibitor- recognizes and binds to VEGF, stopping it from acivating the VEGR -vascular endothelial growth factor- receptor. This action helps to arrest endothelial cell proliferation and angiogenesis)

Targretin

Bexarotene. Benny at target getting A grapefruit With food - Intrxn: Grapefruit juice may increase concentration and toxicity; limit vit A <1500 IU/day to avoid additive toxicity - SFX: elevated blood lipids

Antiandrogen Therapy

Bicalutamide (Casodex) Flutamide (Eulexin) Weight gain, hot flashes/fatigue, decreased libido, bone pain, elevated BG, N/C/D

Gastroduodenostomy

Billroth I; surgical reconstruction procedure by which a new connection between the stomach and the first portion of the small intestine (duodenum) is created. Commonly used in stomach cancer.

Gastrojejunostomy

Billroth II; surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum.

What is the mechanism of action for Antitumor antibiotics?

Bind with DNA thereby inhibiting DNA/RNA synthesis There are 12 total

What are antitumor antibiotics?

Bind with DNA therefore inhibiting DNA/RNA synthesis They are cell cycle specific natural products derived from soil fungus Streptomyces

Biotherapy is a treatment to ...

Biotherapy is a treatment to boost or restore the ability of the immune system to fight cancer, infections, and other diseases. It is also used to lessen certain side effects that may be caused by some cancer treatments. Biological therapy helps your immune system fight cancer where chemotherapy attacks the cancer cells directly.

Combination therapy--Gemcitabine/Gemzar & Cisplatin

Bladder cancer Gemcitabine/Gemzar is low emetogenic. Side effects: mucositis/esophagitis, diarrhea, renal effects Cisplatin / Platinol highly emetic, side effects include anorexia, diarrhea, severe RENAL effects

Bleomycin

Blenoxane(antitumor ABX) IV, SC, IM HD, NHL, SCC, Testicular, Penile Pulm, Renal tox HyperPigment, Nail Thickening/banding Mucositis NO GREEN TEA SFX: n/v, decr app, mouth sores, renal toxicity, hyperpigmentation

chemo - Minimal emetogenic: BBBFVVV

Bleomycin / Blenoxane Busulfan Fludarabine Vinblastine Vincristine Vinorelbine Bevacizumab

Minimal emetogenic:

Bleomycin /Blenoxane Busulfan Fludarabine Vinblastine Vincristine Vinorelbine Bevacizumab

Prostate Cancer S/E and Interventions

Bone- Adequate Ca and Vit D, wt bearing exercises Enteritis/Chr Diarrhea- increase fluids, balance electrolytes, decrease fat, alter fiber, limit dairy

Breast Cancer S/E and Interventions

Bone- Adequate Ca and Vit D, wt bearing exercises Wt Gain/Met syndrome- adjust macros/fiber, promote healthy wt, good glu, circulating glucose and lipids, PA Cardiovascular- plant based diet, weight control

Uterine corpus cancer S/E and Interventions

Bone- Ca, Vit D, wt bearing exercises

Velcade

Bortezomib (Antineoplastic agent; Proteasome inhibitor) Green zombies and Valerie's juice No GREEN TEA or GRAPEFRUIT N/V/D/C/F poor app, Hand food/rash, CARDIO TOX, Peripheral NEUROPATHY, low platelets, anemia TX: multiple myeloma, mantle cell lymphoma reacts with EGCG (polyphenol found in green tea extract). that compound directly interfere with the MOA of bortezomib and decreases the effectiveness of that medication

NO Green Tea

BrAVE Bleomycin Avastin Velcade Erbitux

Care Giver Recs

Brain Tumor- Realistic goals, take breaks, back up person, take what anyone offers for help and resources Serve pt easy to eat foods Note book of schedule and meals/snacks/fluids/meds etc... Pill organizer

What are alkylating agents?

Breaks the DNA Helix, therefore interfering with DNA replication Cell Cycle nonspecific There are 15 Alkylating Agents

Typical Indication for Xeloda

Breast, colon

What are the most common types of cancer for women in the U.S?

Breast, lung, colorectal, uterine, and thyroid

High Liklihood of N/V

Busulfan, Carboplatin, Carmustine, Cisplatin, DTIC, Dactinomycin, Nitrogen mustard, procarbazine,

Busulfan

Busulfex (IV) Myerlan (PO) Myelosuppression, N/V/D, mucositis, hepatic toxicity, anxiety, adrenal insufficiency, pulmonary toxicity, insomnia, dizziness, alopecia. CML, HCT prep

Busulfan (IV)

Busulfex(AlkAgnt)IV CML, HCT Prep Busulfan Lung Hepatotoxicty N/V/D- mild anorexia, mucositis

A cancer patient is unable to provide self-care. His disease is progressing rapidly and prognosis is poor. Which number likely represents his Karnofsky Performance Status? A. 100 B. 70 C. 40 D. 0

C. 40 Disabled; requires special care & assistance. ************************************************** 0 - DEAD 100 - no evidence of disease

You are the RD assigned the inpatient oncology unit. You have been consulted to assess numerous patients. Which patient would be your first priority? A. Newly diagnosed stage II breast cancer patient with poor p.o. intake B. Prostate cancer patient s/p prostatectomy on a full liquid diet C. Head & neck cancer patient admitted after 2 weeks of radiation treatment D. Endometrial cancer patient admitted from the nursing home with diarrhea

C. Head & neck cancer patient admitted after 2 weeks of radiation treatment

Indication for Busulfan/Myleran

CML. HCT prep

Nutrients Absorbed in the Duodenum

Calcium Phosphorus Magnesium Iron Copper Selenium Thiamin Riboflavin Niacin Biotin Folate Vit. A, D, E, K

Nutrient absorption in the GI tract. DUODENUM

Calcium, magnesium, iron, fat-soluble vitamins A and D, glucose phosphorus, copper, selenium, many B vitamins, are all absorbed in the duodenum.

Cancer antigen important in the diagnosis of gynecologic cancer?

Cancer Antigen 125 (Ca 125)- Test that measures the amount of this protein in the blood. (Ovarian cancer cells) ovarian cancer test

An active area of research to decrease cancer morbidity, mortality and health care cost.

Cancer Screening

Oral Candidiasis (Thrush)

Candida yeast infection of the oral mucosa Oral hygiene, rinses replace and sanitize tooth brushes Soft, low acidic, avoid carbonation Consume active-culture yogurt several times a day Pharmacotherapy Polyene antifungal: - nystatin / Mycostatin Azole antifungal: - fluconazole / Diflucan Germicidal mouthwash: - chlorhexidine gluconate / Peridex Probiotics Cleansing rinse- salt and baking soda

Generic name of Xeloda

Capecitabine

Xeloda

Capecitabine (pyrimidine analog, antimetabolite s phase) take after meal. PAn oral prodrug that is converted to 5-FU in the body, DPD deficiency increases toxicity. 2c9 inhibitor. nterferes with DNA synthesis by acting as false metabolities; incorporated into the DNA strand or block essential enzymes PO **take with water and food Colon, Metastatic Breast N/V/D/M/F, GI mobility disorder, Increased Bili, Hand-foot Syndrome (take B6), myelosuppression - Considerations: B6 (50-100 mg 2-3 times/d) to help w Hand food syndrome Monitor if on Warfarin

CapeOx (or XelOx)

Capecitabine/Xeloda and oxaliplatin/ Eloxatin

PN- acute care monitoring

Capillary glucose- Every 6 hours until at goal then as needed to maintain glu to 140-180 mg/dL BMP, phos, mg- Daily until pt at goal then 1 or 2 x/wk Complete blood count (CBC w differential)- baseline then 1-2 x/wk LFTs- baseline then weekly TRIG- baseline if at risk for hypertriglyceridemia then as needed Iron/Vit D- Not routine Zinc/Cu/Selenium/manganese- not routine weight- daily Total fluid I/O- Daily until stable then as needed

PN- long term monitoring

Capillary glucose- Not routine, as needed BMP, phos, mg- weekly then decrease if stable Complete blood count (CBC w differential)- monthly then decrease if stable LFTs- monthly then decrease if stable TRIG- Not routine, as needed Iron/Vit D- baseline then every 3 to 6 months Zinc/Cu/Selenium/manganese- baseline then every 3 to 6 months weight- daily Total fluid I/O- as needed

chemo-Antibiotics

Cytotoxic chemo - doxorubicin, mitomycin, bleomycin /Blenoxane Myelosuppression, anorexia, N/V/D, mucositis, fatigue,

High emetogenic potential (incidence 60-90%)

Carmustine Cyclophosphamide Procarbazine Etoposide: high dose Semsutine Lormustine Dactinomycin Plicamycin Methotrexate: high dose Cytarabine Epirubicin Idarubicin Oxaliplatin /Eloxatin

BCNU

Carmustine Be seeing you SFX: N/V, myelo, HEPATIC TOX, RENAL TOX, PULM TOX Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA IV N/V-- within 2-4hrs of infusion, lasting 4-6hrs Gliadel wafer

Doxorubicin liposomal/Doxil

Cell cycle-specific chemotherapy agent: Anthracycline antitumor antibiotics- inhibit cell division by binding to DNA and interfering with RNA synthesis IV SFX: n/v/d, mucositis, hyperpigmentation, myelosuppression, cardiotoxicity, hang-foot syndrome, alopecia, red-orange urine, infusion reaction

Hydroxyurea

Cell cycle-specific chemotherapy agent: Antimetabolite- Interfere with DNA synthesis by acting as false metabolites; incorporated into the DNA strand or block essential enzymes Hydrea PO CML, H&N, Melanoma, Refractory ovarian Renal tox, hyperuricemia, hepa tox, myelosuppression, darkening and/or thickening of the nails N/V/D/M (less than 30%) *strict mouth care

Thioguanine/6-TG

Cell cycle-specific chemotherapy agent: Antimetabolite- Interfere with DNA synthesis by acting as false metabolites; incorporated into the DNA strand or block essential enzymes Oral SFX: n/v, mucositis, D, myelosupression, hepatic toxicity, renal toxicity, rash

Paclitaxel (protein-bound)

Cell cycle-specific chemotherapy agent: Taxane- active in the mitosis phase of the cell cycle; antimicrotubule agents, which lead to inhibition of mitosis and cell division IV Abraxane Used to treat breast cancer. Myelosuppression, N/V/D, mucositis, arthralgia, myalgia, peripheral neuropathy, alopecia, swelling of feet and ankles, eye problems

Antimitotic agents

Cytotoxic chemo - vincristine, vinorelbine, paclitaxel/Taxol, docetaxel/taxotere Myelosuppression, anorexia, N/V/D, mucositis, fatigue, peripheral neuropathy

Docetaxel

Cell cycle-specific chemotherapy agent: Taxane- active in the mitosis phase of the cell cycle; antimicrotubule agents, which lead to inhibition of mitosis and cell division IV Taxotere Used to treat breast cancer, esophageal cancer, gastric cancer, head/neck cancer, pancreatic cancer. Myelosuppression, mucositis, N/V/D/C, neurotoxicity, fluid retention, skin/nail changes, hypersensitivity, elevated BILI/alkaline phosphate, alopecia, peripheral neuropathy

Vinorelbine

Cell cycle-specific chemotherapy agent: Vinca Alkaloid- Bind to protein tubulin, disrupt mitotic spindle formation, and prevent cell division in the mitosis phase IV Navelbine Used to treat breast cancer, NSCLC, ovarian cancer. Myelosuppression, N/V/C, stomatitis, anorexia, elevated liver enzymes, neurotoxicity, pulmonary toxicity, osteopenia, osteoporosis, alopecia *stool softeners to help with constipation

Bleomycin/Blenoxane

Cell cycle-specific drug: Antitumor ABX- inhibit cell division by binding to DNA and interfering with RNA synthesis IV, SC, IM SFX: n/v, decr app, mouth sores, renal toxicity, hyperpigmentation, pulmonary toxicity, skin/nail changes, hypersensitivity infusion reaction

Endocrine cells

Cells that excrete insulin and glucagon directly into the blood.

Erbitux

Cetuximab (Antineoplastic agent, monoclonal antibody, EGFR Inhibitor) Targeted Therapy: Monoclonal Antibody- EGFR (Epidermal Growth Factor Receptor- involved in cancer cell proliferation, blocking apoptosis, mobilizing cells to promote metastasis, and angiogenesis) IV SFX: N/V/D/C/A/F low Mg, PULM TOX, infusion/skin rash, pruritus Considerations: *Monitor serum MAG and CA levels closely Used to treat esophageal cancer, colorectal, gallbladder, head/neck cancer.

The following dietary supplements have been banned from the US for being unsafe except:

Chaparral, comfrey, and ephedra have been banned. Pennyroyal has not.

Antineoplastic agents

Chemical agents (cytotoxics, immuniologic preparations, hormones) or meds used to prevent the development, maturation or spread of neoplastic cells

CAM Lung Cancer

Chemotherapy and antioxidant supplements

chemo-Antimitotic agents

Cytotoxic chemo - vincristine, vinorelbine, paclitaxel/taxol, docetaxel /taxotere Myelosuppression, anorexia, N/V/D, mucositis, fatigue, peripheral neuropathy

Some of the possible nutrition problems r/t surgery affecting the small bowel:

Chyle leak lactose intolerance Bile acid depletion Diarrhea Fluid & electrolyte imbalance Vit/Mineral malabsorption. Vitamins A, D, E, K; B12, calcium, zinc & iron

Platinol

Cisplatin Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA IV - SFX: N/V(severe and delayed)/D, metallic taste, SIADH, RENAL TOX -(10-20days delayed), SIADH, OTO TOX, low Mg/Ca/Phos Myelo, Peripheral NEUROPATHY, - Considerations: hydration to prevent nephrotoxicity; monitor renal fxn and lytes (Mg, Ca, Na, K) hold if Cr >1.3 **N/V may last up to 1 week, can be delayed up to 6days **Aggressive hydration prior for kidney preservation *Rigorous hydration needed for renal toxicity. Monitor electrolytes, renal fxn and Mg Milk Thistle- may help reduce side effects Curcumin- may increase benefits and decrease neurotoxicity Green tea Fish oil Selenium Mannitol (prevent AKI)

Highly emetogenic:

Cisplatin Mechlorethamine Cyclophosphamide >1500mg/m2 Carmustine Dacarbazine

High Risk of Emesis Chemo

Cisplatin Mechlorthamine Cyclophosphamide Carmustine Dacarbazine

chemo - Highly emetogenic: CCCMD

Cisplatin /Platinol Cyclophosphamide >1500mg/m2 Carmustine Mechlorethamine Dacarbazine

Chemotherapy regimens that commonly cause delayed N/V

Cisplatin, Carboplatin, Cyclphosphamide

What chemotherapies are adenosine deaminase inhibitors?

Cladribine Fludarabine Nelarabine Pentostatin

Clorfarabine

Clolar (Antimetabolite)

Clofarabine

Clolar (Antimetabolite) IV Refractory/Relapsed ALL (1-21yo) Hepatobiliary toxicity, renal toxicity, TLS, SIRS Nausea, Vomiting, Diarrhea *pediatric

Which dietary supplements should be recommended when a patient is prescribed Zoledronic acid for stage IV breast cancer with bone metastasis?

Co-administer oral calcium 500 mg and a multiple vitamin containing 400 IU Vit D daily. Reference: https://www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/Zometa.pdf

Xeloda is used in these types of cancer

Colon, Rectal, Breast, Stomach, Pancreatic, Esophageal

Diabetes is linked to what cancers?

Colorectal Pancreatic Breast Bladder Liver Endometrial ***metformin -possible benefits as a cancer therapy*** Also Ovarian - high glycemic index diets are linked to increased risk of above digestive and hormonal cancers

ER+/PR-, ER-/PR+, ER-/PR-

Combo of estrogen and progesterone receptor status; Approximately 10% are ER+/PR-; 5% are ER-/PR+; 20% are ER-/PR-. Breast cancer with combined positive and negative receptor status do not respond well to hormone treatments but chemo is available.

Phytoestrogen

Compounds, produced by plants, with an ability to bind to estrogen receptor sites in the body, and subsequently elicit an estrogen-like effect. Soy Red Clover Flaxseed Dong Quai

azotemia (uremia)

Condition of increased amounts of nitrogenous waste products in the blood; urea in the blood (a toxic condition resulting from disease of the kidney in which waste products are in the blood that are normally excreted by the kidney) Excessive protein-> reduce amino acid dose Dehydration-> ensure adequate fluid in PN or provide additional IV fluids if needed Inadequate energy from nonprotein sources-> provide adequate nonprotein energy in PN level:

Delayed n/v

Consider dopamine antagonists: Phenothiazines: Prochlorperazine/Compazine Promethazine/Phenergan Benzamides: Metoclopramide/Reglan Cannabinoids: Marinol Nabilone/Cesamet Benzodiazapines: Lorazepam/Ativan Diazepam/Valium Corticosteroids: Decadron/dexamethasone Prednisone

Acute n/v

Consider serotonin antagonists: Ondansetron/Zofran Dolasetron/Anzemet Granisetron/Kytril Palonosetron/Aloxi

Pancreatic Enzyme Replacements

Creon Pancreaze Pertzye Ultresa Viokace Zenpep

Which of the following would not likely interfere with warfarin or cause a concern with bleeding?

Cucurmin

The following supplement can inhibit COX-2, an enzyme that can increase inflammation:

Curcumin

Cytoxan

Cyclophosphamide IV, PO, IP Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA SFX: N/V (severe w ≥1,500 mg/m2) usually beginning 6-10 hours after therapy, SIADH, CARDIO TOX, BLADDER TOX, Low blood counts, Poor appetite, myelo, alopecia, neuropathy The following are less common side effects: Diarrhea, Mouth sores Considerations: advise 2-3 L fluid/day, empty bladder every 2-3 hours to prevent hemorrhagic cystitis Monitor for Vit D Def *Increases effect of anti-coagulants Mesna/Mesnex (bladder protectant) given to reduces the incidence of hemorrhagic cystitis with Cyclophosphamide (Cytoxan) by interacting with urotoxic metabolites; given at same time as Cytoxan

Interferon-a

Cytokines Flu-like, N/V/D/A/F, anemia, leukopenia, RENAL TOX, CARDIO TOX, capillary leak syndrome

Total parenteral nutrition is most appropriate for which of these hospitalized patients? A. An elderly male with c/o esophagitis s/p 20 fractions radiation to the LT lung B. A patient with stage III head and neck ca on weekly Erbitux with radiation x 2 weeks C. A patient with stage IV pancreatic cancer with malabsorption receiving hospice care D. A gastric cancer patient with h/o moderate PCM in the context of chronic illness admitted to the hospital for dehydration related to intractable nausea and vomiting x 5 days

D. A gastric cancer patient with h/o moderate PCM in the context of chronic illness admitted to the hospital for dehydration related to intractable nausea and vomiting x 5 days

Evidence Based Oncology Nutrition Practice Guidelines- MNT in Colorectal Cancer: RDNs should provide WEEKLY MNT that includes an individualized nutrition prescription and counseling for patients with colorectal cancer on pelvic radiation. Individualized counseling may improve: A. Calorie and protein intake B. Nutritional Status C. Quality of Life D. All of the above And reduce symptoms of anorexia, N/V/D

D. All of the above RATING: FAIR, IMPERATIVE

Evidence Based Oncology Nutrition Practice Guidelines-MNT and Radiation Therapy in H&N Cancer. MNT has been shown to improve: A. Calorie and protein intake B. Maintain anthropometric measurements C. Improve Quality of Life D. All of the above

D. All of the above RATING: STRONG, IMPERATIVE

Which medication is used to reduce the severe dry mouth caused by radiation treatment for head and neck cancer? A. Xerostomia B. Cisplatin C. Oxaliplatin/Eloxatin D. Amifostine

D. Amifostine Protective for toxic effects of radiation therapy and some chemo meds

End in taxel

D/M, sensory neuropathy

St. John's Wort may ______________________ the drug activity of Vinblastine (Velban) & Vincristine (Oncovin)

DECREASE St. John's Wort may DECREASE the drug activity of Vinblastine (Velban) & Vincristine (Oncovin) by INDUCING Cytochrome P450 3A4 (CYP3A4). CYP3A4 is an important enzyme in the body, mainly found in the liver and in the intestine. It oxidizes xenobiotics, such as toxins or drugs, so that they can be removed from the body.

Dacarbozine

DTIC (IV) Myelosuppression, N/V, flu like symptoms, CNS toxicity, photosensitivity. HD, melanoma, sarcomas

If the pyloric valve (located at the base of the stomach) was removed or manipulated during surgery, the patient is at risk for _______________________________

DUMPING SYNDROME If the pyloric valve (located at the base of the stomach) was removed or manipulated during surgery, the patient is at risk for DUMPING SYNDROME

Meds that cause diarrhea

Dacarbazine Dactinomycin Docetaxel 5-FU Irinotecan/ Camptosar Paclitaxel/ Taxol Topoisomerase Inhibitors Topotecan

DTIC

Dacarbazine IV N/V/A, CNS TOX, photosensitivity, Increased LFTs, myelo, flu like Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA

Decitabine

Dacogen Antimetabolite IV MDS Hyperglycemia, peripheral edema N, constipation, diarrhea- some mouth sores

What chemotherapies are chromomycins?

Dactinomycin Plicamycin

Actinomycin D

Dactinomycin. DAC ACTs hungover with all the symptoms and renal Antitumor Antibx IV N/V/D/A/M, RENAL TOX, HEPATIC TOX, myelo, alopecia **N/V occurs within hours/day; mucositis within weeks Cell cycle-specific drug: Antitumor ABX- inhibit cell division by binding to DNA and interfering with RNA synthesis

Daunorubicin citrate liposomal

DaunoXome (antitumor antibiotic)

Daunomycin

Daunorubicin DAUN pees uric orange it made his heart stop Antitumor Antibiotic IV N/V/D/A/M, Myelo, hyperuricemia, CARDIO TOX, alopecia, red-orange urine, hyperpigmentation **N/V usually mild, within 1-2hrs of treatment. May turn urine red. Cell cycle-specific chemotherapy agent: Anthracycline antitumor antibiotics- inhibit cell division by binding to DNA and interfering with RNA synthesis

Prevention of chemo-induced vomiting

Decadron and Zofran with a neurokinin-1 receptor antagonist like Rezonic (casopitant) or Emend (aprepitant) Reglan

Hypokalemia Corrections for EN

Decrease nutrition delivery to 25% of goal (refeeding syndrome process); replace K Excessive GI loss/Diuretics/dialysis/ insulin therapy-> replace K IV if levels under 3; replace K via EN if hypokalemia mild Inadequate intake-> evaluate need to change the formula

Achlorhydria

Decrease or cessation of the production of gastric acid. No substitute. May lead to bacterial or fungal overgrowth which can lead to pain when eating and suboptimal food intake.

What might antioxidant supplementation do for cancer patients/survivors?

Decrease risk of some cancers, increase risk of some cancers, and could decrease side effects of cancer tx.

Kidney Cancer S/E and Interventions

Decreased creatinine clearance/ Renal failure- MNT for altered kidney fxn HTN- sodium intake, wt control, PA, adq K/Ca

CAM Yohimbe

Decreased effect of antidepressants, antihypertensives, hypoglycemic agents, St Johns Wort.

Cytarabine liposomal

DepoCyt (Antimetabolite)

Drug used to reduce the undesired side effects of doxorubicin (cumulative does over 300 mg/m2). "Chemo protectant agent" or "extravasation antidote" Used to reduce the incidence and severity of heart problems associated with the chemotherapy agent doxorubicin in women being treated for metastatic breast cancer. It is only used for women who have received a high cumulative dose of doxorubicin and who would benefit from continued therapy. It is not recommended for women who are just starting doxorubicin. Can be used to treat tissue damage caused by some drugs if they leak from the vein while they are being given

Dexrazoxane / Zinecard

FACTS: Dextrose is the primary energy substrate in TPN and provides ___________ kcals/gram. Amino acids provide ____________ kcals/gm IV fat emulsions (IVFE) provide ____________kcals/gm. New TPN patients start on a 24 hr infusion and once tolerance is established & metabolic derangements corrected, cyclic PN can be considered.

Dextrose is the primary energy substrate in TPN and provides 3.4kcals/gram. Amino acids provide 4kcals/gm IV fat emulsions (IVFE) provide 10-11 kcals/gm.

Hypertriglyceridemia complication for PN

Dextrose overfeeding- appropriate carb dosing Rapid infusion rate of IV lipid- limit IV lipid infusion rate to less than 0.11 g/kg, limit daily IV dos to less than 30% of total energy intake or 1 g/kg, reduce dose of or discontinue IV lipid if TRIG 400 mg/dL or more

Side effects of Xeloda

Diarrhea, nausea, vomiting, mouth sores

Revlimid

Lenalidomide. REVrand LENA N/V/C, fever, HTN, Thromboembolic, proteinuria, hemorrhage, GI/bowel perforation, Hypothyroid

diarrhea meds

Diphenoxylate atropine/LOMOTIL: avoid: colitis, ecoli, dehydration, lyte imbalances, renal or hepatic failure, lactation. caution with : pregnancy, chronic lung disease, ulcerative colitis, liver disease, history of ETOH abuse. TAKE WITH FOOD. sfx: anorexia, thirst, sore or swollen gums, cramps, bloating, dyspepsia, blurred vision, confusion, depression, drowsiness, numbness of extremities, Headache, pancreatitis (rare).CNVX *MAOI 1-2 tablets orally 3-4 x/day. Max 8 tablets/day loperamide/IMODIUM- avoid: colitis, fever, blood or mucous in stool. Caution: hepatic failure, lactation. sfx: abdominal cramps, bloating, drowsiness, fatigue, rash. CNVX. *SJW octreotide/SANDOSTATIN- caution: DM, pregnancy or lactation, cardiac, gallbladder, liver or renal disease, *latex allergy, INJECT BETWEEN LOWFAT MEALS TO DECREASE GI EFFECTS. Monitor glucose, [thyroid function, lytes, vit B12 (if used long term)]. sfx: abdominal pain, biliary sludge, bloating, heartburn, steatorrhea, edema, fatigue, fever, flushing, gallbladder problems, gas, hair loss, bradycardia , hypothyroidism, goiter, hyperglycemia, fatigue, joint pain, nosebleed, CDN. **DRUG INTERACTIONS: beta blockers, Ca channel blockers, cyclopsporine, insulin and oral DM meds, quinidine. TINCTURE OF OPIUM- avoid ETOH, CNS depressants, pain meds, antidepressants, cough or cold medicines, allergy medicines. Caution : elderly, diarrhea caused by poisoning, head injury, increased brain pressure, brain disease, GI bleed, hypothyroidism, surgery, liver or renal disease, ETOH or drug abuse, lung disease, PBH, pregnancy or lactation. Special dropper to measure, do not change dose or stop suddenly. Monitor : lytes, fluids. sfx: drowsiness, itching, CNVX DRUG INTERACTIONS: sedating meds: antihistamines, chloral hydrate, CNS depressants, glutethimide, methocarbomol, tricyclic antidepressants, cimetidine. *SJW 0.3-1 mL orally 4x/day. Max 6 mL/d

Doxorubicin liposomal

Doxil Anthracycline

Doxorubin Liposomal

Doxil Antitumor Antibiotic IV AIDS Karposi Sarcoma, Ovarian, Hepatocellular, MM, Sarcoma Cardiotox, Radiation recall, hand foot N/V/D; Mucositis

What chemotherapies are Anthracyclines?

Doxorubicin Daunorubicin Epirubicin Mitoxantrone Idarubicin

Moderate emetogenic potential (30-60%)

Doxorubicin Mitoxantrone 5-FU Mitomycin-C Carboplatin Daunorubicin L-asparaginase Toptecan Ifosfamide Irinotecan /Camptosar Epirubicin Idarubicin

Overhydration Corrections for EN

Excess fluid intake -> decrease free water, change to lower free water formula Refeeding syndrome-> fluids, daily weight

Adriamycin

Doxorubicin. Doxorubicin is an anti-cancer ("antineoplastic" or "cytotoxic") chemotherapy drug. Doxorubicin is classified as an "anthracycline antibiotic." Doxorubicin is a vesicant. A vesicant is a chemical that causes extensive tissue damage and blistering if it escapes from the vein. IV SFX: N/V/D/M/A hyperpigmentation, pain, low blood count (nadir 10-14 days), hair loss, dark nail beds, tumor lysis syndrome (monitor kidney fx)-usually occurs w/in 24-48 hrs of therapy, Cardio tox, Hnd&Ft Snydrome, Red/Orange urine *n/v either at treatment or within 2wks s/p treatment Myelosuppression, cardio toxicity, hand-foot syndrome, hyperpigmentation, ocular toxicity, alopecia, red-orange urine. *Do not exceed a lifetime cumulative dose of 550 mg/m2 (450 mg/m2 if you have had prior chest XRT or simultaneous cyclophosphamide treatment) Antioxidant; Increases benefits/decreases toxicity of doxorubicin and idarubicin. Theanine found in Tea. OMEGA 3/COENZYME Q 10/THEANINE - may reduce toxicity Black Cohosh may interfere with Tamoxifen and can also increase toxicity of doxorubicin and docetaxel/Taxotere Cell cycle-specific chemotherapy agent: Anthracycline antitumor antibiotics- inhibit cell division by binding to DNA and interfering with RNA synthesis Dexrazoxane / Zinecard used to reduce the undesired side effects of doxorubicin (cumulative does over 300 mg/m2). "Chemo protectant agent" or "extravasation antidote" Used to reduce the incidence and severity of heart problems associated with the chemotherapy agent doxorubicin in women being treated for metastatic breast cancer. It is only used for women who have received a high cumulative dose of doxorubicin and who would benefit from continued therapy. It is not recommended for women who are just starting doxorubicin. Can be used to treat tissue damage caused by some drugs if they leak from the vein while they are being given

Mechanism of action: Milk of Magnesia and Magnesium Citrate (Saline Laxatives)

Draws water into intestine, stimulates peristalsis

radiation- radiopharmaceutical therapy (unsealed)

Drugs that contain radioisotopes for the systemic treatment of cancer.

Xerostomia Interventions

Dry Mouth -SFMs - alternate bites and liquids - moist - sip liquids all day - Swish club soda and carbonated water - humidifier - good oral hygiene - suck on hard candy, frozen grapes or melon balls - avoid alcohol mouthwashes - avoid alcohol and tobacco

List some of the possible nutrition impact symptoms r/t gastrectomy

Dumping Syndrome- limit concentrated sweets, test lactose, avoid fried/greasy-test small amounts of fat, protein rich, liquids 30 mins before or after meals, SFMs, eat slow/chew Dehydration Early Satiety/epigastric pain/Vomiting- SFMs, liquids consumed separately Gastroparesis Fat malabsorption- monitor 72 hr fecal fat tex and fecal elastase concentration. Consider SIBO. If no improvement-> pancreatic enzymes Malabsorption of Vit B12 (1000 mcg IM monthly, or 1000-2000 mcg/d orally), Vit D- monitor, calcium (1500 mg/d), iron (200 mg ferous sulfate TID), Folate (5 mg of folate D to replete def) Diarrhea- may improve, diet mod, avoid instigating foods, fiver sup, add antidiarrheal agents and cholestyramine Bile reflux/gastritis- cholestyramine, ursodeoxycholic acid, sucralfate, antacids, promotility agents, histamine receptor blockers, proton pump inhibitors, anticholinergics, sx (roux-en

When should iron supplementation be avoided?

During and after HCT

What are potential deficiencies w/ TPN use?

EFA Fe Selenium Zinc w/ excessive GI losses Mg Ca Vit D carnitine Choline

As the peritonitis and ileus resolve, ____ may be initiated until oral diet is tolerated.

Orexigenic (antinflammatory)

EPA (omega 3 fish oils)- mixed results MELATONIN- mixed results PENTOXIFYLLINE-mixed results THALIDOMIDE- waiting for results from large study (causes constipation, daytime somnolence, peripheral neuropathy, rash)

F&N interactions Methotrexate

ETOH=> hepatoxicity

Chemo that damages GI Tract

Methotrexate Melphalan Irinotecan /Camptosar Fluorouracil

Candidates for PROPHYLACTIC FEEDING TUBE with a DIAGNOSIS OF H&N CANCER:

Elderly patients H&N flap reconstruction Cancer of BOT Weight Loss before cancer treatment Smoking >20 cigarettes daily Stage III or IV cancer Reference: Page 22 in the pocket guide to the NCP and Cancer

Leukemia Cancer Treatment

Elevated WBC count, cells multiply or disfunction, can be acute or chronic Chemo 1st Line - Daunorubicin - Cyclophosphamide 2nd Line - Cytarabine - Methotrexate

Asparaginase

Elspar IV, SC, IM ALL Pancreatitis, Hepatoxicity Hi Glu, Renal Toxicity N/V, Anorexia, Cramps

Rouex-en-Y

End of Duodenum is connected to esophagus after stomach is removed, while the other end is reconnected to the small bowel forming a Y connection.

Endometrial (Uterine) Cancer

Endometrial cancer is a cancer that starts in the endometrium, the inner lining of the uterus (womb). Risk Factors: Hormonal conditions, diet/exercise, family hx, medical hx- metabolic Factors to decrease risk: diet and exercise, coffee, veg, fruit, mediterranean diet, PA

Bladder Cancer Treatment

Endoscopic resection for superficial carcinoma Intravesical BCG or laser therapy for superficial recurrence Simple or radical cystectomy for invasive disease Chemo for metastatic disease Surgical Removal Radiation therapy can be used in combination with cystectomy or as primary therapy when the cancer is inoperable or the pt refuses surgery -*chemo can be delivered directly into the bladder by a urethral catheter* 1st line - Methotrexate - Vinblastine - Doxorubicin 2nd line - Cisplatin - 5 FU - Pacilitaxil -provide urine flow -if tumor has to be removed, urinary diversion will be used

Nutrition Requirements for Hematopoietic Cell transplantation

Energy: 0-6. BMR x 1.6-1.8 7-14 BMR x 1.4-1.6 15-18 BMR x 1.5-1.6 Adults BMR 1.3 to 1.5 or 25 to 30 kcal/kg Increase during immediate post transplant d/t metabolic stress Protein: 0-12 m 3.0 1-6 2.5 7-10 2.4 11-14 2.0 15-18 1.8 Adult 1.5 if obese 2-2.5 g/kg IBW Carbohydrate: 50-60% total. Decrease w DM or hyperglycemia, lower PN dextrose concentration FAT: Min- 6-8% max - 40% Increase when providing lower PN dextrose concentrations Decrease if hyperlipidemia Fluids: 1-10 kg-> 100 ml/kg/day 11-20 ->1000ml + 50 ml/kg over 10 kg /day >20 kg-> 1500 ml + 20 ml /kg over 20 kg /day Increase during fever, excessive GI loss, hypermetabolism, high output renal failure, nephrotoxic meds decrease with compromised organs, iatrogenic fluid overload Vitamins / Minerals Discontinue extra Vitamin C during presence of elevated serum ferritin (>1000 mcg/L) to decrease oxidative damage from release of free iron Increase calcium during corticosteroid therapy or w osteoporosis. Increase zinc w large-volume diarrhea (1 mg per 100 mL of stool output) Eliminate copper and manganese from PN in presence of hepatic dysfunction ng corticosteroid therapy or w osteoporosis. Increase zinc w large-volume diarrhea (1 mg per 100 mL of stool output) Eliminate copper and manganese from PN in presence of hepatic dysfunction IRON SUPPLEMENTATION IS CONTRAINDICATED Acute complications - GI toxicities from chemo - Acute GVHD - SOS - Infection Long term complications - chronic GVHD 80100 days post transplant) - osteoporosis (Ca/Vit D, wt bearing exercise, Biphosphanate therapy) - growth and dev issues- peds - endocrine complications- metabolic syndrome, HLD, - PEDS- DM, HTN, obesity - Iron overload- due to large amounts of transfusions, avoid iron containing supplements

Hyperglycemia Corrections for EN and PN

Enteral : Insulin resistance/DM-> carb control or fiber containing formula Metabolic stress or sepsis, steroids-> use/adjust insulin or oral hypoglycemic agents Parenteral: Excessive Carbohydrate-> limit dose to 4-5 mg/kg/min or 20 to 25 kcal/kg until glu stabilizes Inadequate insulin dosing/ impaired glucose tolerance-> adding regular insulin to PN formulation

Ellence

Epirubicin. ELLEN had a EPIc HT Attack when she peed red Antitumor ABX IV SFX: N/V/D/M , CARDIO TOX, myelo Red/Orange urine, skin rash, alopecia, premature menopause/amenorrhea. **n/v within 1 week of treatment; Diarrhea within 2 wk Cell cycle-specific chemotherapy agent: Anthracycline antitumor antibiotics- inhibit cell division by binding to DNA and interfering with RNA synthesis

TKI

Erlotinib (Tarceva) *Used to treat pancreatic cancer with Gemcitabine/Gemzar. Avoid St. John's Wort, grapefruit juice. Gefitinib (Iressa) * Imatinib (Gleevac) *Avoid St. John's Wort, grapefruit juice Sorafonib (Nexavar)*Used to treat liver cancer Sunitinib (Sutent) Lapatinib (Tykerb)-Diarrhea may be severe; liver toxicity may be severe. *Used to treat breast cancer. Avoid grapefruit juice. Skin rash, hand-foot syndrome, cardio toxicity, N/V/D, decreased appetite. *fluid retention in Gleevac

Tarceva

Erlotinib. Tara Love Erni not John Juice Protein-Targeted Agents: Tyrosine kinase inhibitors: inhibit several reeptor tyrosine kinases, which are involved in tumor growth, angiogenesis, and metastasis. - Intrxn: grapefruit juice, St Johns WORT - SFX: N/V/D/A/F, decr. app, SOB, cough, rash, CARDIO TOX ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox

Asparaginase Erwinia chrysanthemi

Erwinaze IM ALL (used when pt has sensitivity to E.coli derived Elspar)

Lung Cancer S/E and Interventions

Esophageal pain- alter food/bev consistency, oral sups, alter food temp, avoid alcohol, spicy, acidic or other irritants monitor wt and nutrition status Resp failure- monitor and correct fluid balance, decrease carbs Before tx: screen for malnutrition, assessment During: re screen for malnutrition, prevent wt loss (under 5%), assess muscle and strength After: screen for malnutrition, monitor nutrition status, measure muscle and strength

Glutamine

Essential for GI health and wound healing. May lessen: mucositis, stomatitis, esophagitis, and diarrhea. May decrease efficacy of Lactulose and seizure meds.

ER+

Estrogen positive; 2/3 of breast cancer are ER+. Estrogen stimulates growth of breast cancer. Respond to SERMs such as tamoxifen. Aromatase Inhibitors stop estrogen in post-menopausal women-not used before. LHRHs such as Lupron Depot and Zoladex shut down ovaries to prevent estrogen production.

Vepesid

Etoposide Etopophos is an anti-cancer ("antineoplastic" or "cytotoxic") chemotherapy drug. Etopophos is classified as a "plant alkaloid" and "topoisomerase II inhibitor." epiodophyllo toxin - damages cell prior to mitosis late S and G2 phases. Oral, IV Epipodophyllotoxins SFX: N/V/D/M/A metallic taste changes during infusion, low WBC, low platelets, low blood count (nadir 7-14 days), hair loss, menopause, loss of fertility hypersensitivity reaction, alopecia, orthstatic HTN

What chemotherapies are podophyllotoxins?

Etoposide Tenisopide

Interventions for Fatigue

Evaluate etiology: anemia, hydration MVI w min Check for wt loss and sarcopenia Intake Interventions: - SFMs - Oral supplements - snacks at bedside - Large meal when appetite is the best - easy to chew- energy preservation - easy to prepare meals, snacks, foods - Save energy - Continue ADL - monitor weight / loss - physical therapy for strengthening - Avoid excessive daytime sleep Pharmacotherapy: Blood transfusions Erythropoietin - epoetin alfa / Epogen, Procrit

Malabsorption Intervention

Evaluate: bowel patterns/changes w sx, onc dx and tx - stool freq, volume, color, consistency - Exocrine panreatic insuf/ fat malabsorption - fecal elastase level- pancreatic enzyme production - Some PERT require PPI - lactose intolerance - assess intake Intervention: Bloating /gas- avoid swallowing air/no straw, no carbonated bevs, chewing gum, eat slowly, chew thoroughly w mouth closed Bloading/crapming/gas w milk- low lactose diet w pills gas from veg- avoid cruciferous vegs, beans and legumes, take enzyme supps w a-galactosidase and invertase (beano) Pharmacotherapy: - simethicone / Gas-X - lasctase enzyme / Lactaid - a-galactosidase / Beano Probiotics (gas/diarrhea): - Saccharomyces boulardii - Lactobacillus rhamnosus GG

Afinitor

Everolimus No grape juice for John in the EVER AFter Avoid grapefruit juice or St Johns wort N/v/d, decr app skin rash/skin problems cardiotoxicity (QT prolngation, sudden death...) GI issues decreased appetite MUS- N/V/D, poor app, rash, HTN, CARDIO TOX, Hand foot Protein-Targeted Agents: Mammalian target of rapamycin (mTOR) inhibitors: block angiogenesis by preventing the release of vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), thus blocking tumor cell proliferation and causing cell death

Hypoglycemia Corrections for PN

Excessive insulin dosing-> reduce subcutaneous insulin or PN insulin Abrupt discontinuation of PN-> taper down over 1 to 2 hours prior to discontinuation

Vitamin / mineral PN complications

Excessive or Inadequate dose - reduce frequency of fat-soluble vit to 2x/wk in pt with renal failure to avoid vitamin A toxicity - empiric removal of manganese and copper during cholestasis - periodic IV iron or blood transfusion for iron-dep pts - oral Vit D supp if tolerated

Inulin

Exhibits prebiotic activity which can enhance intestinal health. Conventional Food: onions, shallots, jerusalem shallots. Functional Food: used as fat replacement; added to beverages and jellies.

Deferasiox

Exjade oral IRON chelator If not fully dissolved, can cause diarrhea. Contains lactose and may cause diarrhea in lactose intolerant.

radiation- EBRT/teletherapy

External Beam Radiation Therapy can both curative and palliative side effects depend on part of body being treated dividing doses into multiple fractions helps to minimize damage to healthy tissue. measured in units called centigray (cGy) possible EARLY/ACUTE side effects (site dependent): diarrhea fatigue hair loss mouth changes nausea, vomiting sexuality/fertility changes skin changes throat changes urinary bladder changes miscellaneous( headaches, breast tenderness, cough, dyspnea, thickened saliva, jaw stiffness) possible LATE effects (site dependent): headaches cognitive impairment damage to osteoblasts angina esophogeas stenosis, fibrosis, necrosis diarrhea, colitis, malabsorption. stricture, ulceration, obstruction, perforation, fistula) trismus, permanent taste alterations, xerostomia, dyspnea, cough, pigmentation changes, hematuria, cystitis, secondary malignancies

electrolyte derangement for PN

Extrarenal losses from: ostomies, decompressing Gtube, peritoneal, biliary, pancreatic or pleural drains, N/V, renal losses from chemo regimens or Syndrome of inappropriate antidiuretic hormone (SIADH)-> replace renal or extrarenal fluid and electrolytes; w SIADH restrict fluids and consider increasing NA concentration in PN Metabolic alkalosis/acidosis-> adjust chloride to acetate ratio in PN Refeeding syndrome-> limit dextrose when initiating PN; replete electrolytes separately from PN

palliative care

FOCUS of nutrition care is to relieve and manage symptoms and adverse side effects AIM of nutrition care is to maintain patients strength and energy to: -enhance QOL -foster independence -promote ability to perform activities of daily living (ADLs) Nutrition should be provided as tolerated, along with emotional support, respect and awareness of the individual patients needs and wishes. The pleasurable aspects of eating should be emphasized, with less concern for the quantity or nutrient content of foods consumed.

FOLFOX

FOL (Folinic acid; leucovorin) F (5-fluoracil) Oxaplatin

Floxuridine

FUDR Antimetabolite IV, Intraaterial Adenocarcinoma of GI, Gallbladder, Bile duct Hnd&ft snydrome, increased LFTs Mouthsores, diarrhea; N/V, anorexia, gastritis

Metallic Taste

FVCE FU Vinblastine Cisplatin Etoposide Plant based proteins, sweet

A false-negative screening test result may cause anxiety and is usually followed by more invasive tests and procedures (T/F).

False

Most cancers are caused by genetic factors (T/F).

False

Fulvestrant

Faslodex Estrogen receptor antagonist. Used to treat breast cancer. C/D, N/V- mild, sore throat.

What is an antimetabolite?

Incorporates into DNA chain acting as a metabolite, thereby inhibiting DNA repair Are Cell Cycle Specific There are 18 total with several different mechanisms of action

Lignans have shown to reduce risk for breast cancer. The following food is an excellent source:

Flaxseed

What functional food contains lignans with phytoestrogen that is associated with reduced breast cancer risk?

Flaxseed

Possible causes of hyponatremia?

Fluid overload ---> restrict FW Sodium Losses in GI ----> supp Na SIADH ---> restrict FW, diuresis

Once carcinogenesis is initiated, which of the following provides substrates for DNA synthesis and accelerates cancer cell proliferation?

Folate

Supplementation of this nutrient is suspected to increase rates of colorectal cancer:

Folate

folate deficiency

Folate deficiency is confirmed with low serum folate, low erythrocyte folate, and elevated plasma homocysteine

What nutrients can support DNA repair?

Folate, Slenium, Allyl sulfur compounds

Pralatrexate

Folotyn (Antimetabolite)

S/E: Weight gain, hot flashes, fatigue, decrease libido, impotence, bone pain

Hormonal Agents utilized in hormone sensitive cancers, to reduce level of hormones in the body or blocks the tumors ability to utilize endogenous hormones): Antiangrogens Bicalutamide / Casodex Flutamide / Eulexin Apalutamide / Erleada Darolutamide / Nubeqa Enzalutamide / Xtandi Nilutamide / Nilandron / Anandron

Why are foods irradiated, and can these foods increase cancer risk?

Food irradiation (applying ionizing radiation to food) is a technology that improves the safety and extends the shelf life of foods by reducing or eliminating germs and insects. Like pasteurizing milk and canning fruits and vegetables, irradiation can make food safer. Irradiation does not make foods radioactive, affect nutritional quality, or noticeably change the taste, texture, or appearance of food. In fact, changes made by irradiation are so minimal that it is not easy to tell if a food has been irradiated. The US Food and Drug Administration (FDA) has evaluated the safety of irradiated food for more than 30 years and has found the process to be safe. The World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and the US Department of Agriculture (USDA) have also endorsed the safety of irradiated food. There is currently no evidence that irradiation of foods causes cancer or has harmful human health effects.

F&N interactions Temozolomide

Food may decrease drug rate and absorption

For Cancer Prevention: The American Institute for Cancer Research (AICR) recommends that Americans stay physically active for at least ______minutes every day

For Cancer Prevention: The American Institute for Cancer Research (AICR) recommends that Americans are physically active for at least 30 minutes every day. Limit sedentary behavior like watching TV.

Sinusoidal Obstructive Syndrome

Formerly called veno-occlusive disease; common side effect of cell transplant. Toxic injury to sinusoidal (liver) and ventral epithelium. Symptoms: weight gain, ascites, right upper quadrant tenderness and painful hepatomegaly (enlarged liver), high bilirubin, and renal dysfunction. MNT: concentration of PN fluids as well as med volumes, and reduction in oral and IV sodium to minimize fluid retention. Monitor triglycerides if BILI elevated >10 ml/dL. If BILI remains elevated, remove biliary excreted copper and manganese from PN.

Curcumin

Found in turmeric, may inhibit cancer cell growth. Works better with black pepper. May increase Cisplatin benefit and reduce neurotoxicity.

Can periods of limiting food intake to juices remove toxins and help protect against cancer?

Fruit and vegetable juices can be a convenient way to get some healthy food components from vegetables and fruits. In moderation, they can be a worthwhile part of healthful dietary patterns. However, juices contain less fiber, lower levels of some other healthy nutrients, and more naturally occurring sugar than the whole fruits and vegetables they are made from, so they are not the best way to get nutrients from plant-based foods. There is no scientific evidence to support claims that consuming only juices for one or more days, known as juice cleansing or juice detoxification, reduces cancer risk or provides other health benefits. This kind of diet is promoted as a way to remove "toxins" from the body, but this claim is not supported by scientific evidence. Toxins that enter our body through foods and beverages are constantly removed by the kidneys and liver, regardless of whether a person is consuming liquid or solid foods. Although vegetable juicing may be one way to increase nutrient intake, a diet limited to juice may also be lacking in some important nutrients, and in select cases it may contain dangerous levels of some substances that can cause kidney damage and other health problems.

Consequences of malnutrition for patients with cancer include: A. Reduced response and tolerance to the prescribed cancer treatment B. Impaired wound healing & immune response C. Reduced muscle strength and quality of life D. Increased Fatigue E. A & B are correct F. C & D are correct G. All of the above

G. All of the above

gvhd phase 1 GI symptoms

GI cramping >500 mL/d diarrhea low alb reduced transit time SBO or diminished bowel sounds N/V Diet: NPO PN

In addition to killing cancer cells chemotherapy agents may also damage cells in what other areas of the body?

GI tract, bone marrow, hair follicles, and reproductive system

stool color chart

GREEN rapid transit, contains bile ( dietary causes: green leafy vegs, green food colorings, iron supplements) CLAY OR LIGHT COLORED: lack of bile in stool, possible bile duct obstruction (other possible causes: large doses of bismuth subsalicylate or other antidiarrheals) BLACK: blood in stool (possible dietary causes: iron supplements, bismuth subsalicylate, black licorice) BRIGHT RED: bleeding in rectum (possible dietary causes: beets, red food colorings)

Orexigenics (growth Hormone)

GREHLIN-limited studies

If a cancer patient needs surgery r/t cancer of the gallbladder &/or bile duct he may experience these nutrition problems:

Gastroparesis Hyperglycemia Fluid & electrolyte imbalance Fat malabsorption Malabsorption of Vitamins A, D, E, K; MAGNESIUM, calcium, zinc & iron

Possible nutrition problems r/t surgery affecting the pancreas:

Gastroparesis Hyperglycemia Fluid & electrolyte imbalance Fat malabsorption Malabsorption of Vitamins A, D, E, K; Vit B12, calcium, zinc & iron

Iressa

Gefitinib Protein-Targeted Agents: Tyrosine kinase inhibitors: inhibit several reeptor tyrosine kinases, which are involved in tumor growth, angiogenesis, and metastasis. Take with water N/V/D decr app, Hand foot syndrome drug toxicity with barbiturates refractory NSCLC

Gemcitabine /Gemzar and albumin-bound paclitaxel /Abrazane

GEM-E

Gemcitabine/Gemzar and Erlotinib/ Taxceva

Gemcitabine/Gemzar and capecitabine/Xeloda

GemCis

Gemcitabine/Gemzar and cisplatin/Platinol

What are genetically modified crops, and are they safe?

Genetically modified (also known as bio-engineered) crops are made by adding genes from other plants or organisms to increase a plant's resistance to insect pests, slow spoilage, or improve transportability, ﬂavor, nutrient composition, or other desired qualities. Certain foods made from genetically modified crops have been approved for sale in the US since the mid-1990s, and more than 70% of all highly processed foods in US supermarkets—including pizza, potato chips, cookies, ice cream, salad dressing, corn syrup, and baking powder—contain ingredients from bio-engineered soybeans, corn, or canola plants. Growing public concern about the potential harmful effects of genetically modified foods, in part, led to federal legislation in 2016 requiring uniform labeling of foods containing genetically engineered ingredients. In theory, these added genes might create substances that could cause reactions in sensitized or allergic people, or result in high levels of compounds that could cause other health effects. However, at this time there is no evidence that foods now on the market that contain genetically engineered ingredients or the substances found in them are harmful to human health, or that they would either increase or decrease cancer risk. The World Health Organization, the American Medical Association, the National Academy of Sciences, and the American Association for the Advancement of Science have all taken the stance that current evidence suggests that foods containing genetically engineered ingredients are safe.

_____________ may block estrogen receptors; with early exposure possibly decreasing breast cancer risk.

Genistein

A number of studies suggest that _________, which is essential for gastrointestinal health and wound healing, may lessen the degree of mucositis, stomatitis, esophagitis, and diarrhea resulting from some cancer therapies.

Glutamine

Does eating a gluten-free diet help reduce cancer risk?

Gluten is a protein in wheat, rye, and barley. In most people, it causes no ill effects. For people with celiac disease, gluten triggers an immune response that damages the lining of the small intestine and could increase the risk of cancer. Some people experience gluten sensitivity without overt celiac disease. In these people, gluten may contribute to inflammation in the intestines, which might in turn increase the risk of gastrointestinal cancers. However, this possible link is not well-proven. There is very little evidence linking gluten intake to risk of gastrointestinal cancers in the general population. The bottom line: For people without celiac disease, there is no evidence that consuming a gluten-free diet is linked with a lower cancer risk, and many studies suggest that consuming whole grains, including those containing gluten, probably reduces the risk of colon cancer.

CAM-Flaxseed

Possible anticancer effect. Estrogenic, GI upset with ingestion of large amounts

What are these, and do they impact cancer risk?

Glycemic index is a measure of the increase in the blood level of glucose (a type of sugar) after eating a specific carbohydrate-rich food, compared with eating a standard amount of glucose. Foods with a high glycemic index release glucose quickly and lead to a rapid rise in blood glucose. Foods with a low glycemic index release glucose into the blood more slowly, with a lower overall peak in blood glucose over time. In general, high glycemic index foods are highly refined, processed grain products with added sugars and low fiber content, as well as some starchy vegetables. The glycemic index can be considered a measure of carbohydrate-rich food quality. Beyond glycemic index, glycemic load captures both the quality and quantity of carbohydrates consumed. The glycemic load gives a truer picture of how blood glucose is elevated in relation to intake of a specific food item. A lot of research has looked at the potential impact of the glycemic load of a diet and cancer risk. Most recent reports have found that eating a dietary pattern high in glycemic load is linked with a higher risk of endometrial cancer. More research is needed to determine the impact on other types of cancer.

List 3 possible causes of hyponatremia on EN

H20 retention/fluid overload Sodium Losses (GI) SIADH

BMT Energy need for adult receiving HSCT

HB equation, adjusted Wt for >25% of IBW - Initial period - 1.5 x BMR - Maintenance - 1.3 x BMR

Energy need for adult receiving HSCT

HB equation, adjusted Wt for >25% of IBW - Initial period - 1.5 x BMR - Maintenance - 1.3 x BMR

Most common use of EN in what cancers?

HN Gastric Esophageal Pancreatic

examples of infectious agents that can be prevented

HPV, HBV, HCV, HIV, H. pylori

Orexigenics (metabolic inhibitors)

HYDRAZINE SULFATE-no efficacy, not FDA approved

Eribulin

Halaven IV Breast Neurotox, Peripheral Neurop, QTc prolongation, alopecia Fatigue, nausea; constipation

Short Bowel Syndrome

Having less than 30% of intestinal length. Results in insufficient absorptive surface, which increases risk of maldigestion and malabsorption and nutritional deficiencies.

Hyperphosphatemia Corrections for EN

Having too much phosphorus in the body is actually more common and more worrisome than having too little. Too much phosphorus is generally caused by kidney disease or by consuming too much dietary phosphorus and not enough dietary calcium. Several studies suggest that higher intakes of phosphorus are associated with an increased risk of cardiovascular disease. As the amount of phosphorus you eat rises, so does the need for calcium. The delicate balance between calcium and phosphorus is necessary for proper bone density and prevention of osteoporosis. Too much phosphate can be toxic. It can cause diarrhea and calcification (hardening) of organs and soft tissue, and can interfere with the body's ability to use iron, calcium, magnesium, and zinc. Kidney insuf/failure/Tumor lysis syndrome-> consider change to lower phos formula; rec phos binders Phos containing antacids-> rec potential change in meds

Glutamine supplementation has shown to reduce stomatitis, mucositis, and esophagitis secondary to chemotherapy. It can be safely recommended for the following populations:

Head & neck patients

Food and Lifestyle recs for pts with Breast Cancer

Healthy lifestyle Low fat diet Fruit / Veg intake Carotenoid intake- 3 x wk food- not supplements Fiber0 30 g Flaxseed 1 to 3 TBSP / day Omega 3 2 / wk Soy- 2 /day 10-40 mg soy isoflavones/day Low fat dairy 2-3 /day Red meat limit Green tea- 5 cups a day Fasting- 13 hrs /night Weight- healthy Calcium- 1200 mg via food Vit D supp if def Alcohol limi 2-4 /wk Activity 30 min 6 days/wk

F&N Medication Interactions Counseling suggestions

Helping pts understand restrictions can : improve compliance prevent hospitalization affect outcomes provide comfort Provide the pt with brief, simple explanation of the reason for restriction/ control. Review foods to restrict or avoid and discuss alternate choices. Note the amount of tyramine allowed with various medications that require a tyramine reduced diet. Provide appropriate handout or guide.

Altretamine

Hexalen (Alk Agent) Via PO Ovarian Ca Neurotoxicity, Periph.Neuropthy N/V, Diarrhea take w/meals, @bedtime abd cramps

Herbs/supplements that cause diarrhea

High dose Vit. C Magnesium Potassium Aloe Bromelain Buckhorn Cascara Cat's Claw Creatine Teas Eucalyptus Oil Fish Oil Flaxseed Garlic Guggulipid Lecithin Milk Thistle Rhubarb Rose Hips Sarsaparilla Senna

Stenotactic Radio-surgery

High dose radiation is delivered to a precise area via a gamma knife **common with brain tumors**

Calcium requirements during steroid therapy or osteoporosis

High incidence of osteoporosis with HCT 7-12 months-600 mg/day 1-3 yo-1000 mg/day 4-8 yo- 1200 mg/day >9 yo-1500 mg/day

Chemotherapy agents are categorized according to their potential to induce nausea & vomiting.

High risk >90% Moderate risk 30-90% Low risk 10-30% Minimal risk <10%

Angiogenesis Inhibitor

Hinder the formation of new blood vessels in primary tumors thus preventing their growth, invasion, and spread.

Hodgkin Disease

Hodgkin disease is a type of lymphoma (Hodgkin lymphoma), a cancer that starts in cells called lymphocytes. Lymphocytes are part of the body's immune system. There are 2 kinds of lymphomas: Hodgkin disease & Non-Hodgkin lymphoma

non-steroidal anti-estrogen agents compete with estrogen for binding to estrogen receptors tore my Fare No Taxes Relax Eva Fulvestrant

Hormonal Agents (utilized in hormone sensitive cancers, to reduce level of hormones in the body or blocks the tumors ability to utilize endogenous hormones): Anti estrogen Tamoxifen Citrate / Novaldex Toremifene citrate / Fareston Raloxifene / Evista

S/E: hot flashes, sweating, N, menstrual irregularities, vaginal dryness, mood changes, decrease libido, fatigue Fluid retention and peripheral edema Increased risk of endometrial changes and cancer Thromboembolic complications Skin changes, rash, joint aches and pains, weight gain

Hormonal Agents utilized in hormone sensitive cancers, to reduce level of hormones in the body or blocks the tumors ability to utilize endogenous hormones): Anti estrogen Tamoxifen Citrate / Novaldex Toremifene citrate / Fareston Raloxifene / Evista

Bind to androgen receptors and block the effects of testosterone in androgen-sensitive prostate cancer cells calcu -dex flute in ewww Lead Plates Be Darling Enz-X

Non-steroidal and/or steroidal inhibitors of aromatase block the production of estrogen by inhibiting the conversion of adrenal androgens to estrogens. Ana and Ari Let Mara do it Exempt masons

Hormonal Agents utilized in hormone sensitive cancers, to reduce level of hormones in the body or blocks the tumors ability to utilize endogenous hormones): Aromatase Inhibitors: prevents the final step in the conversion of androgens to estrogens in peripheral tissues Anastrozole / Arimidex Letrozole / Femara Exemestane / Aromasin

S/E: Hot flashes, Arthralgias (joint pain), N/V, Asthenia (weakness) Thromboembolic complications Skin changes, rash Weight gain

S/E: weight gain/fluid retention, thromboembolic events, N/V Menstrual bleeding, hot flashes, sweating, mood changes, Hyperglycemia

Hormonal Agents utilized in hormone sensitive cancers, to reduce level of hormones in the body or blocks the tumors ability to utilize endogenous hormones): Progestins Medroxyprogesterone acetate /Depa- Prevera Megestrol acetate / megace

Suppress the release of luteinizing hormone from the pituitary gland and subsequently decrease estrogen levels. Additional mechanisms include binding to progesterone, glucocorticoid and androgen receptors, resulting in decreased number of estrogen receptors and decreased estrogen and progesterone levels peripherally in target tissues.

Antiestrogens

Hormonal chemo - N, bone pain, fluid retention, hot flashes, hypercalcemia

Progestins

Hormonal chemo - megesterol acetate Increased appetite, wt gain, fluid retention, hypercalcemia

Glucocorticoids

Hormonal chemo - predenisone, dexamethasone Na & fluid retention, GI upset, glucose intolerance, K wasting, osteoporosis

Antiandrogens

Hormonal chemo- flutamide N/D, hot falshes

Gonadotropin-releasing hormone analog

Hormonal chemo- leuprolide N, bone pain

The following are factors that influence the risk for carcinogenesis:

Hormone and immune system, infection, environmental factors

HER2+

Human Epidermal Growth Factor Receptor 2; approximately 20% of breast cancer puts. These breast cancers contain large amounts of protein (HER2) that promotes cancer growth. Fast growing and aggressive. Monoclonal antibodies such as perception are used to treat.

Topotecan

Hycamtin Used to treat esophageal cancer, ovarian cancer. Anorexia, N/V/D, mucositis, myelosuppression.

WHAT changes in electrolytes and metabolites are expected in tumor lysis syndrome ?

Hyperkalemia Hyperphosphatemia LOW calcium (hypocalcemia), High uric acid (hyperuricemia), and higher than normal levels of blood urea nitrogen (BUN) and other nitrogen-containing compounds (azotemia)

Non-sealed radioactive therapy

IV injection or oral of radioactive source Iodine 131 taken orally for thyroid cancer

If Gastric Residual Volume (GRV) is >/= _________ mL , HOLD EN and perform a physical assessment, evaluate glycemic control, consider a promotility agent (metoclopramide or erythromycin) and consider narcotic alternatives

If Gastric Residual Volume (GRV) is >/= 500 mL , HOLD EN

Ifex

Ifosfamide (give with mesna+hydration) IV Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA SFX: N/V/A, SIADH, myelo, BLADDER TOX, neurotoxicity, alopecia Pre-medicate for N w/serotonin antagonist and dex Mesna /mesdex Protective to the bladder against Ifosfamide *Sulfonade and fluids for urological protections

Gleevec

Imatinib Ima geeve you no juice John! Avoid grapefruit juice and St Johns WORT ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox *fluid retention/hepatoxicity in Gleevac

Interferon alfa

Immunologic-biologic response modifiers Myelosuppression, anorexia, N/V, flulike symptoms

*chemo-Monoclonal antibodies

Immunologic-biologic response modifiers Rituximab, trastuzumab Myelosuppression, anorexia, N/V, fever, chills, rash

Monclonal antibodies

Immunologic-biologic response modifiers Rituximab, trastuzumab Myelosuppression, anorexia, N/V, fever, chills, rash

Epoetin alpha

Immunologic-hematopoietic erthropoietin, EPO fever, iron supplementation may be necessary

*chemo-Epoetin alpha

Immunologic-hematopoietic erthropoietin, EPO. Used to increase production of RBCs in the treatment of fatigue, anemia. fever, iron supplementation may be necessary

Filgastrim

Immunologic-hematopoietic granulocytic colony-stimulating factor, G-CSF Fever, bone pain, flulike symptoms

chemo-Filgastrim

Immunologic-hematopoietic granulocytic colony-stimulating factor, G-CSF, stimulates production of WBC's. Fever, bone pain, flulike symptoms

*chemo-Sargramostin

Immunologic-hematopoietic granulocytic macrophage-stimulating factor, GM-CSF Fever, bone pain, flulike symptoms

Sargramostin

Immunologic-hematopoietic granulocytic macrophage-stimulating factor, GM-CSF Fever, bone pain, flulike symptoms

Azathioprine

Imuran S/E: N/V/D/A, mucosal ulceration, esophagitis, steatorrhea

In order for a patient to receive TF he needs ______cm jejunum and ___ ___cm ileum w/ileocecal valve for adequate GI absorption of nutrients

In order for a patient to receive TF he needs 100 cm jejunum and 150 cm ileum w/ileocecal valve for adequate GI absorption of nutrients

Where are Vitamin B12 and bile salts absorbed ?

In the terminal ileum. Vitamin B12 is absorbed in the ileum and must be bound to intrinsic factor, a protein secreted in the stomach, in order to be absorbed. If intrinsic factor is missing, then Vitamin B12 is not absorbed and pernicious anemia results.

Essential fatty acid deficiency Complication for PN

Inadequate fat in PN-> provide minimum fat requirements, trial of topical skin application or oral ingestion of oils if PN fat is not tolerated

Dehydration Corrections for EN

Inadequate free water-> increase free water Fluid loses ( emesis, diarrhea, drains, dialysis, fever) -> monitor I/Os and daily weights Concentrated formula-> change formula to higher free water

List some of the possible nutrition problems r/t surgery affecting the colon &/or rectum:

Increased transit time Diarrhea Dehydration Bloating, cramping, gas Fluid & electrolyte imbalance Vit/Mineral malabsorption (B12, Na, K+, Mg, Ca)

How does sleep affect diet, physical activity, and cancer risk?

Increasing evidence suggests important interactions among sleep, diet, physical inactivity, and cancer risk: Disordered sleep has been linked with higher cancer risk, and sleep deprivation (usually defined as less than 7 hours a night) has been linked with a higher risk for obesity and overeating, as well as metabolic syndrome, which is a known risk factor for several types of cancer. Alternately, a healthy sleep pattern has been linked with better weight maintenance after weight loss. Studies have found high levels of sedentary time (time spent sitting or lying down) are linked with poor sleep quality and shorter sleep duration. Inadequate sleep has been linked with higher levels of stress hormones and inflammation, which are known mechanisms affecting cancer risk.

Capeitabine (Xeloda) PO

Indication: colon and metastatic breast SE: myelo, N/V/D/F, increased bilirubin* other: hand food syndrome

Azacitidine (Vidaza) SC, IV

Indication: myelodysplastic syndrome (MDS) SE: myelo, N/V/D, fatigue, hypokalemia*, renal toxicity*

Do anti-inflammatory diets reduce cancer risk?

Inflammation has long been recognized as the body's response to tissue injury, and its link to infections was recognized hundreds of years ago. However, the role of inflammation in causing cancer has been recognized more recently, and the relationships between diet, inflammation, and the risk of cancer (as well as heart disease and dying at an earlier age) are still an evolving area of research. A combination of lab and human studies has identified certain foods and chemicals in them that promote inflammation in certain body tissues. This is the basis of anti-inflammatory dietary patterns, which share some traits with the recommendations in this guideline, such as being high in vegetables and fruits and low in red and processed meats.

Stomatitis

Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth.

Immunomodulatory Drugs

Inhibit anti-inflammatory cytokines and exert anti-angiogenic properties. Ex: Revlimid, Thaudomide

Mechanism of Action: Lomotil/ Diphenoxylate atropine, Kaopectate, Imodium/Loperamide (antimotility agent)

Inhibits peristalsis.

Axitinib

Inlyta Interacts with St. John's Wort, Phenobarbital, grapefruit juice, ketoconazole (fungal medicine), erythromycin

Do pesticides in foods cause cancer?

Insecticides and herbicides can be toxic when used improperly in industrial, agricultural, or other workplace settings. The International Agency for Research on Cancer (IARC) classifies 3 common agricultural herbicides (glyphosate, malathion, and diazinon) as 'probable human carcinogens.' All 3 are linked with a higher risk of non-Hodgkin lymphoma. In addition, malathion is linked with a higher risk of prostate cancer, and diazinon is linked with a higher risk of lung cancer. Currently, scientific evidence supports the overall health benefits and cancer‐protective effects of eating vegetables and fruits, regardless of whether they are grown using organic or conventional practices. Washing conventionally grown produce can remove some of the pesticide residues, and is also important to minimize the risk of microbial contamination.

Cytokines / Non Specific Immunotherapies

Interleukin-2 (Aldesleukin) Interferon-a (referon, intonA) flu like symptoms, fatigue, anorexia, N/V/D, CRI, capillary leak syndrome. - Flu like, N/V/D/A/F, myelo, CARDIO TOX, RENAL TOX

Enteritis

Intestinal inflammation, especially the small intestine

What chemotherapies are Camptothecans?

Irinotecan / Camptosar Topotecan / Hycamtin

Camptosar

Irinotecan S phase topo 1 inhibitor. Acute / Early- Diarrhea treated with atropine. Ugt allele increased neutropenia. Mucositis Late Loperimide 2 caps first then one cap every two hours until diarrhea free for 12 hours. Two caplets every 4 hours at night. N/V/D/C/A D-early or late, N/V -mod risk, mouth sore, myelosuppression, hair loss, decreased appetite, fever, weight loss No St Johns WORT

Urinary/bladder Cancer S/E and Interventions

Irregular BMs- Alter fiber as needed, Fluids, balance electrolytes

Mesna (Mesnex)

Is always given ppx w/ ifosfamide & sometimes w/ cyclophosphamide to reduce risk of hemorrhagic cystitis Inactivate their metabolite (acrolein) Cytoprotective agent that reduces the incidence of hemorrhagic cystitis with Cyclophosphamide (Cytoxan) by interacting with urotoxic metabolites; given at same time as Cytoxan Protective to the bladder against Ifosfamide

Romidepsin

Istodax inhibits enzymatic activity of HDAC (which allows for accumulation of acetyl groups)

Ixabepilone

Ixempra Used to treat breast cancer. Alopecia, N/V/D, neuropathy, myelosuppression, altered taste sensation, AMS, pulmonary toxicity, coagulopathy.

A ____ is often placed at the time of esophageal surgery to allow for initiation of EN postoperatively.

J-tube

SGA developed by

Jeejeebhoy 1980's

Cabazitaxel

Jevtana (Taxane) IV Prostate Diarrhea, Nausea, Fatigue (>30%); Vomiting, Taste Changes Avoid St Johns Wort, Avoid Grapefruit/Juice

Kosher diet

Jewish dietary laws. There are three categories of Kosher food - Meat, Dairy and Parve (or Pareve). Rules: No Mixing meat with milk, Pork, Shellfish, Bloody meat Pesah (Passover) - prohibition on eating leavened bread or derivatives

cultural-Kosher diet

Jewish dietary laws/ Parve: separate utensils for food prep/eating diet tends to be high in cholesterol, sat fat, sodium, consider DASH Forbidden: pork, pork products, rabbit, shellfish, eel ALL meats must be slaughtered according to Jewish Law, blood drained prior to cooking/eating. Dairy: milk can be consumed prior to a meal or 3-6 hours after meal no leavened bread during passover fasting during yom kippur

JCAHO

Joint commission accreditation healthcare organization

Possible causes of hyperphosphatemia?

Kidney insufficiency --> consider change to low phos formula vs binders Tumor lysis syndrome --> consider change to low phos vs binders Phosphate binding antacids --> rec change in meds

Leukemia S/E and Interventions

Kidney stones- fluids Bone- Ca, Vit D, wt bearing exercises Metabolic Syndrome- Adjust needs for healthy wt, blood sugar, circulating insulin and lipids, PA Hypothyroid- healthy weight, PA

The _____ tightens after the bolus passes through to prevent stomach acid and digestive enzymes from refluxing back up and into the esophagus.

LES

Pediatric Info

LT Radiation Therapy S/E: - Dental - Cognitive impairment - Bone development/growth - learning/hearing impairments - Neuroendocrine problems Vit D <1 400 IU >1 600 IU Energy DRI (energy for normal wt)

Carcinoma Embryonic Antigen (CEA)

Lab testing for colon and rectum cancer

cultural-Seventh-Day Adventist:

Lacto-ovo vegetarian diet Avoid overeating snacking discouraged strong seasonings avoided Avoid: beef, lamb, pork, chicken, seafood, coffee, tea and alcohol Diet may be deficient in protein, iron, zinc, vitamin B12 and calcium

Seventh-Day Adventist:

Lacto-ovo vegetarian diet Avoid: beef, lamb, pork, chicken, seafood, coffee, tea and alcohol Diet may be deficient in protein, iron, zinc, vitamin B12 and calcium

Tykerb

Lapatinib Ty has a lab named john Juice, bad dog no chew Do not chew or crush, take on an empty stomach Avoid grapefruit juice, erythromycin, St Johns WORT ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox Diarrhea may be severe; liver toxicity may be severe

Aloe Vera

Laxative Effect

Immunomodulatory Angiogenesis Inhibitor

Lenalidemide (Revlimid) Thalidemide HTN, hemorrhage, GI perf., decreased thyroidism.

This drug _________________________is given in combination with fluorouracil (5-FU) causing the side effects of fluorouracil to be more _________________________

Leucovorin SEVERE

LHRH Hormone Therapy

Leuprolide Acetate( Lupron) Goserelin (Zoladex) Used to treat breast cancer. Hot flashes, fatigue, decreased libido, bone pain, gynomastia, headaches, muscle weakness.

Cladribine

Leustatin (antimetabolite) IV Hairy Cell Leukemia, AML, CLL, NHL Neurotoxicity, TLS, Nephrotoxicity N/V, Poor Appetite, Diarrhea

Anti-Dumping Diet

Limit foods high in concentrated sugars. Foods high in soluble fibers may help. Lactose-free foods are better tolerated. Avoid fried and greasy foods. Drink liquids 30 minutes before meals. Eat 5-6 small meals a day and avoid large portions. Eat slowly and chew foods into small pieces.

EN Medication Concerns Vitamin and Supplements

Liquid vitamins and minerals are often available NOT RECOMMENDED FOR USE WITH EN DEVICES - Slow Mag - K-Dur - Micro-K

Which of the following alternative diets for cancer treatment involves the use of a vaccine derived from a patient's own blood or urine?

Livingston-Wheeler

Diarrhea fron irinotecan/Camptosar is treated this way. Late

Loperimide 2 caps first then one cap every two hours until diarrhea free for 12 hours. Two caplets every 4 hours at night.

Ageusia

Loss or absence of the sense of taste

F&N interactions Procarbazine

Low Tyramine Diet when taking this medication and for 4 weeks after treatment finishes. Pt may experience headache and elevated blood pressure. ETOH may cause disulfiram reaction. Caffeine containing compounds may raise blood pressure

5-Fluoracil (5-FU)

Low emetogenic Moderate myelosuppresion Severe--mucositis/esophagitis Diarrhea, renal effects

What has selenium NOT been involved with?

Lower risk of cancer

Indication for Cisplatin

Lung, ovarian, testicular, head/neck, NHL

S/E: Hot flashes, fatigue, decreased libido, bone pain, impotence, gynecomastia, gynomastia, headaches, muscle weakne, gynecomastia, gynomastia, headaches, muscle weakness.ess.

Luteinizing Hormone-releasing hormone (LHRH) Also known as gonadontropin releasing hormone analogues. Leuprolide Acetate( Lupron) Goserelin (Zoladex)

Mitotane

Lysodren Inhibits adrenal steroid production

Orexigenic ( cannabinoids)

MARINOL-no effect on cancer cachexia, inconsistent evidence

The National Center for Complementary and Alternative Medicine at the NIH has funded a study to examine the cancer-preventive benefits of this diet.

Macrobiotic Diet

Breast Cancer Tips to Reduce Risk and Progression

Maintain healthy weight ( BMI<25) Enjoy physically active lifestyle -move more(>10,000 steps daily) -exert yourself (30-60 minutes moderate activity daily) -preserve muscle mass with strength training (>2x weekly) -Eat plenty of vegetables (BIG color and STRONG flavor best) -vegetables (4-5 servings daily) -fruits (2-3 servings daily) -Choose carbohydrates wisely -best sources are non starchy vegetables, beans/legumes, fruits, whole grains -eat more beans/legumes (>3-4 servings/week) -Limit refined carbohydrates (sugars, sweeteners, foods made with white flour) -Focus on healthy fats -choose healthy fats obtained from whole foods (including nuts, seeds, avacodos, fish) -Limit or avoid fried foods, savory snacks, fast foods -Limit or avoid salad dressings, mayonnaise -Limit or avoid red meat ( < 11 oz per week) Little if any processed or deli meat. -Select beverages carefully -Water is best bet -avoid sweetened beverages -Limit fruit juice and alcoholic beverages (1 or less daily)

Colon and Rectum Cancer S/E and Interventions

Malabsorption- Increased / modification of nutrients malabsorbed Liver/cirrhosis- follow MNT Wt Changes- balanced nutrients and achieve healthy weight, balance w PA Irregular BM- fiber, liquid, probiotics or prebiotics Enteritis/Diarrhea- fluids, electrolytes, decrease fat, alter fiber, limit dairy

Pancreas Cancer S/E and Interventions

Malabsorption- Irregular BMs- Alter fiber as needed, Fluids, balance electrolytes, pancreatic enzymes (PERT), monitor wt/nutrition/fluids Irregular BMs- Alter fiber as needed, Fluids, balance electrolytes

Black cohosh

Management of menopausal symtoms. large dose may cause dizziness, N, HA, hypotension

CAM Ginseng

May adversely affect platelets/ coagulation. May increase hypoglycemia with insulin. May interfere with psyche meds.

Genistein

May block estrogen receptors; early exposure may decrease breast cancer risk. Conventional Food: soy good, edamame, tofu, soy milk Functional Food: variety of snack foods including snack bars.

CAM St Johns Wort

May cause serotonin syndrome with antidepressants. May reduce the effect of meds for Cancer, AIDS, transplants, heart disease and birth control.

CAM Black Cohosh

May further reduce lipids or Blood Pressure when combined with prescription meds. May increase the effect of Tamoxifen.

CAM Kava Kava

May increase CNS depression with ETOH and sedatives. May cause liver damage.

CAM Garlic

May increase bleeding time with aspirin, dipyridamole and warfarin. May increase effect of hypoglycemic agents.

CAM Ginko Biloba

May increase bleeding time with aspirin, dipyridamole, and warfarin. May increase blood pressure when used with diuretics.

Melatonin

May increase response of Tamoxifen.

Gingko

May inhibit proliferation of cancer cells. May increase risk of bleeding; interfere with seizures meds.

St. John's Wort

May interfere with Imatinib and Irinotecan /Camptosar. May reduce risk of colon cancer.

Black Cohosh

May interfere with atorvastin (lipitor), azathiopurine, cyclospurine. May reduce menopause symptoms. (little evidence)

CAM Echinacea

May interfere with immunosuppressive therapy

Theanine, an amino acid found in tea, may enhance some chemotherapies, but a potential concern is:

May reduce blood pressure

Garlic

May reduce tumor growth and stimulate apoptosis. May interfere with drugs and increase risk of bleeding.

Methotrexate exerts its chemotherapeutic effect by being able to counteract and compete with ____________________ in cancer cells resulting in _____________________deficiency in the cells and causing their death.

Methotrexate exerts its chemotherapeutic effect by being able to counteract and compete with FOLIC ACID in cancer cells resulting in FOLIC ACID deficiency in the cells and causing their death.

Chemo that causes damage to the GI mucosa

Methotrexate, Melphalan, Irinotecan /Camptosar & 5-fluorouracil (5-FU).

AICR New American Plate

Meal planning guide by American Institute for Cancer Research (AICR) The New American Plate The modest 3-ounce serving of meat (fish, poultry, or red meat) pictured here fits AICR guidelines for cancer prevention. This plate also features a wider variety of foods, resulting in a diverse assortment of cancer-fighting nutrients. Two kinds of vegetables increase the proportion of plant-based foods, and a healthy serving of a tasty whole grain (brown rice, barley, kasha, bulgur, millet, and quinoa) completes the meal. AICR's New American Plate is a plant-based diet created to reflect research on reducing cancer risk. It emphasizes choosing foods with plenty of fiber, nutrients and plant compounds that may help protect against cancer; limits foods that increase the risk of cancer; and helps reach and maintain a healthy weight, which research shows can play a major role in reducing cancer risk. The New American Plate can be personalized to meet individual preferences while making healthy choices for the proportion of different foods on your plate and for the portions you eat. The goal is to have vegetables, fruits, whole grains and beans make up 2/3 (or more) of each meal, and animal protein to make up 1/3 (or less). Interpreting the data AICR's New American Plate is an inclusive approach that shows how to put into practice the recommendations to reduce cancer risk and promote overall health. All plant foods are not the same. Limited evidence suggests that high-fiber diets rich in whole grains, non-starchy vegetables, and fruits reduce the risk of a wide range of cancers. Although evidence linking individual nutrients or types of foods with lower cancer risk is limited, combined as an overall eating pattern, these choices add up to reduce cancer risk. Including relatively unprocessed plant foods — whole grains, vegetables, fruits, beans and nuts — as at least 2/3 of each meal may offer cancer protection beyond the fiber these foods provide. In laboratory studies, nutrients and compounds in these plant foods can change the expression of tumor suppressor and other genes, and influence cell signaling pathways, inflammation, and self-destruction of abnormal cells. Dairy products, poultry, fish or red meat - if included - are kept to no more than 1/3 of each meal. Red meat (beef, lamb and pork) is limited to no more than 12-18 ounces (cooked) per week because excess amounts increase risk of colorectal cancer. And on the New American Plate, red meat choices are most often unprocessed red meat. Even smaller amounts of processed meats (like bacon, sausage, salami and hot dogs) increase cancer risk, so save them for special occasions. Even though they're technically plant-based foods, choices that are highly processed and contain a lot of fat and added sugar make it harder to maintain the healthy weight that plays a strong role in reducing the risk of at least 12 forms of cancer.

FOLFIRINOX

Medication for treatment of exocrine pancreatic cancer. Includes oxaliplatin, leucovorin, irinotecan, and fluorouracil. LOIF Possible side effects include nausea, vomiting, diarrhea, constipation, stomatitis, and mucositis. With oxaliplatin treatment, the patient must avoid ice cold food and beverages. Irinotecan is associated with severe diarrhea in some patients.

Progesterone Hormone Therapy

Megace Weight gain, thrombus, N/V, menstrual symptoms, hyperglycemia

Pernicious anemia is a form of megaloblastic anemia. Megaloblastic anemia refers to an abnormally large type of red blood cell (megaloblast). Megaloblasts are produced in the bone marrow when vitamin ____________________or ___________________levels are low

Megaloblasts are produced in the bone marrow when vitamin B-12 or folic acid levels are low

Medications for Treatment of Lack of Appetite:

Megestrol acetate are forms of the progesterone hormone that can improve appetite and weight gain. Steroid medications, which can increase appetite, improve a person's sense of well-being, and help with nausea, weakness, or pain. Metoclopramide (Reglan), which helps move food out of the stomach and can prevent feeling full before eating enough food. Dronabinol (Marinol), a cannabinoid made in the laboratory, which may stimulate appetite.

When administered with tamoxifen, _________ may improve the anti-cancer response of women with metastatic breast cancer who did not respond to tamoxifen alone.

Melatonin

What is the lifetime risk of developing cancer for men and women?

Men 1:2, women 1:3

Non-Hodgkin Lymphoma S/E and Interventions

Metabolic Syndrome- Adjust needs for healthy wt, blood sugar, circulating insulin and lipids Hypothyroid- healthy weight, PA

Hyperkalemia Corrections for EN

Metabolic acidosis-> correct acidosis; recheck K Excessive K intake-> if poss correct k before initiation of feeding; reduce K intake from formula and oral diet; eliminate K from IV fluids Renal failure-> medication therapy (K binding resin, glucose, insulin)

Prokinetic drugs

Metaclopramide

What chemotherapies are folic acid antagonists?

Methotrexate

MTX

Methotrexate Antimetabolite IM, IV, IT, PO- TAKE ON empty stomach Leucovorin is a reduced folic acid. Leucovorin is given to lessen the side effects of methotrexate - SFX: N (severe), mucositis (severe), oral/GI ulcerations, RENAL TOX, HEPATIC TOX - Intrxn: avoid folic acid and its derivatives, avoid alcohol (may increase hepatotoxicity) Cell cycle-specific chemotherapy agent: Antimetabolite- Interfere with DNA synthesis by acting as false metabolites; incorporated into the DNA strand or block essential enzymes

Can using microwave ovens or other cooking methods increase cancer risk?

Microwaves are a form of non-ionizing electromagnetic radiation, and their use in cooking does not increase cancer risk. On the other hand, grilling, smoking, or pan-frying meats (including red meats as well as poultry and fish) at high temperatures can cause chemical reactions that form cancer-causing heterocyclic amines. Goals of food preservation, processing, and preparation that are relevant to individual and public health include: Removing or inactivating any harmful chemical or microbiological contaminants Avoiding addition or production of harmful substances Maintaining the amount and availability of nutrients For example, proper canning or freezing methods can help maintain the nutrient content of vegetables and fruits, which can expand consumers' access to these products. On the other hand, certain methods of preserving red meats introduce nitrates into them, which can be converted in the stomach into cancer-causing N-nitroso compounds. Contamination of foods by substances from storage containers or cookware is another concern of some consumers. Plastic containers can release substances such as phthalates (some of which are classified as possible carcinogens) or phenolic compounds such as bisphenol A (a probable carcinogen) during storage of food or during cooking in a microwave oven. Use of Teflon-coated cookware may release perfluorooctanoic acid (PFOA, a possible carcinogen) into foods. These substances have been found to have negative biological effects in some lab studies, and they may influence onset of puberty, a possible factor in the long-term risk of some cancers such as breast cancer. However, evidence of the impact of long-term exposure to these chemicals on cancer risk in human studies is lacking. Nonetheless, people who are concerned about possible harm from these exposures can choose glass or metal storage containers and cookware.

gvhd phase 2 GI symptoms- into to oral feeding/liquids

Min Gi cramping 500 mL/d diarrhea improved transit time Infrequent N/V Diet: isotonic, low residue, low lactose fluids IV: PN Symptoms of diet intolerance: increase stool volume/diarrhea increase emesis increased abd cramping

gvhd phase 3 GI symptoms- solids

Min or no Gi cramping formed stool Diet: solids- intro to low fiber, low fat, low acidity, no gastric irritants, min lactose IV: PN Symptoms of diet intolerance: increase stool volume/diarrhea increase emesis increased abd cramping

gvhd phase 4 GI symptoms- expansion of diet

Min or no Gi cramping formed stool Diet: solids- low fiber, low acidity, no gastric irritants, min lactose; if stools indicate fat malabsorption- add low fat diet IV: PN - as needed to meet needs Symptoms of diet intolerance: increase stool volume/diarrhea increase emesis increased abd cramping

gvhd phase 5 GI symptoms- Resumption of regular diet

Min or no Gi cramping normal stool normal transit time Normal alb Diet: solids- progress to regular; steatorrhea- fat restriction slowly liberalized IV: PN- discontinue when oral intake meets needs Symptoms of diet intolerance: increase stool volume/diarrhea increase emesis increased abd cramping

What chemotherapies are antitumor antibiotics but fall into the misc category?

Mitomycin Bleomycin/ Blenoxane

Mutamycin

Mitomycin-C. MITO is a MUT Cell cycle-specific drug: Antitumor ABX- inhibit cell division by binding to DNA and interfering with RNA synthesis IV SFX: N/V/D/A/F/M, SEVERE MYELO, hyperpigmentation, PULM TOX, RENAL TOX, HEPATIC TOX, alopecia, HYPERCALCIUM

EN Medication Concerns Histamine H2-receptor antagonists and proton pump inhibitor (PPIs)

Mixing and administration instructions vary by brand and product type. Refer to package inserts or product websites for the most up to date info. NOT RECOMMENDED FOR USE WITH EN DEVICES - Pantoprazole tablets - Rabeprazole tablets Alternatives for EN devices: - Dexlansoprazole capsules and disintegrating tablets - Esomeprazole capsules and packet - Lansoprazole capsule and disintegrating tablet - Omeprazole, Pantoprazole, Rabeprazole packet

Surgical Resection of Ileum

Monitor B12 levels, monitor for diarrhea-add bile sequestrants if needed, may need to supplement fat soluble vitamins, calcium, zinc, and magnesium.

Surgical Resection of Ileum MNT

Monitor B12 levels, monitor for diarrhea-add bile sequestrants if needed, may need to supplement fat soluble vitamins, calcium, zinc, and magnesium.

bone marrow toxicity (myelosuppression)

Monitor Hgb, Hct, RBC, WBC, platelets -Leukopenia (low WBC) -Neutropenia (low neutrophils) -anemia (low RBC) -Thrombocytopenia (Low platelets) -Pancytopenia (low ALL blood cells)

If refeeding syndrome is suspected in a patient receiving EN, the RD should recommend:

Monitor fluid status Decrease nutrition delivery to 25% of goal, replace phosphorus & potassium monitor labs, vitals and fluid balance

Pertuzumab/Perjeta

Monoclonal antibodies SFX: cardiotoxicity

Rituximab/Rituxan

Monoclonal antibodies SFX: n/v (mild)

Ibritumomab tiuxetan/Zevalin

Monoclonal antibodies SFX: n/v (mild), dyspnea

Halal diet

Muslim. Designating any object or an action which is permissible to use or engage in, according to Islamic law. No Rare meat, ETOH, or any intoxicant, Pork and its by-products such as bacon and lard

cultural-Halal diet

Muslim/Islamic law. Fasting common Women have decreased sun exposure 2/2 coverings forbidden: pork, pork products, gelatin, ETOH (including extracts), diet can be low in heme iron

enteral support indications

Must have a functioning gut peri-operative support may be beneficial for moderately severely malnourished pts Pt is malnourished and anticipate they will be unable to take in /absorb adequate nutrients for > 7-14 days.

Mechlorethanine

Mustard Gas Myelosuppression, N/V, hyperuricemia, pain/inflammation in the injection site, alopecia.

What are subgroups of Alkylating Agents?

Mustard Gas Derivatives Alkysulfoneals Hydrazine, Triazines Nitroureas (these cross the blood brain barrio) Metal Salts

Mitomycin-C

Mutamycin Used to treat esophageal cancer, gastric, anal cancer, pancreatic cancer. Myelosuppression, N/V/D, mucositis, anorexia, pulmonary toxicity, renal toxicity, fatigue, alopecia.

What is Myelosuppression?

Myelosuppression is a condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets. It is a side effect of some cancer treatments.

Busulfuran

Myleran Aspirin containing OTC should be avoided.

Busulfan (Oral)

Myleran Oral CML, HCT Prep Myelosuppression, Pulmonary fibrosis ("Busulfan lung"), Hepatotoxicity, Adrenal insufficiency, increased risk of 2ndary cancer Nausea, Vomiting, Diarrhea (all mild), anorexia, mouth sores

surgery with brain CA

N/V

XRT to Abd & pelvis

N/V, D, cramping, bloating, gas, increases urinary frequency, burning, acute colitis or enteritis, lactose intolerance, fatigue, loss of appetite, late effect, D, malabsorption, maldigestion, chroinc colitis or enteritis, GI stricture, ulceration, obstruction, perforation, fistula, urinary hematuria, cystitis

XRT to Central nervous system (brain & spinal cord) CA

N/V, elevated BG caused by steriod, fatigue, loss of appetite, late effects (>90 days after treatment), HA, lethargy

Ending in MUS

N/V/D, poor app, rash, HTN, CARDIO TOX, Hand foot

ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox

N/V/D, poor app, rash, Hand food sy, Cardio tox

EN Medication Concerns Laxatives

NOT RECOMMENDED FOR USE WITH EN DEVICES - Methylcellulose or psyllium - cholestyramine - Bisacodyl tablets Alternative to EN devices - Docusate liquid - Senna - Polyethylene glycol 3350 - Lactulose - Bisacodyl suppositories

EN Medication Concerns for Pancreatic Enzyme Replacement Therapy (PERT)

NOT RECOMMENDED FOR USE WITH EN DEVICES Pancreatic enzyme replacement therapy capsules EN options: open capsule, mix w applesauce if oral route available. otherwise suspend the contents in water or nectar thick juice. Do not administer in an alkaline food substance- like yogurt.

EN Medication Concerns Appetite Stimulants

NOT RECOMMENDED FOR USE WITH EN DEVICES Dronabinol Alternatives for EN device: Megestrol acetate liquid, Mirtazapine tablets, Cyropheptadine tablets, Dexamethasone/decadron, Medroxyprogesterone

EN Medication Concerns Antibiotics

NOT RECOMMENDED FOR USE WITH EN DEVICES Fluoroquinolones: cirpofloxacin/levofloxacin

B-glucans

Natural polysaccharide and soluble fiber that may boost the immune system. Conventional Food: barley, oats, fruits, vegetables, seaweed. Functional Food: B-glucan enriched breakfast cereals, breads, snack bars, bran products, and milk beverages.

What are plant alkaloids? List subgroups

Naturally occuring substances that block cell division by inhibiting spindle formation during mitosis. Derived from certain types of plants; they are cell-cycle specific cytotoxic chemo agents Vinca Alkaloids Taxanes Podophyllotoxin Camptothecan Analogs

Surgery Brain

Nausea, vomiting if on corticosteroids, possible hyperglycemia

Do non-nutritive sweeteners/sugar substitutes cause cancer?

Non-nutritive sweeteners are substances used instead of sugars like sucrose, corn syrup, honey, agave nectar to sweeten foods, beverages and other products. Several non-nutritive sweeteners are now approved by the FDA, including aspartame, acesulfame potassium, saccharin, sucralose, and stevia. These sweeteners contain few or no calories, or nutrients. They may be derived from herbs and other plants, or sugar itself, and typically are many times sweeter than sugar, allowing smaller amounts to be used. Other sugar substitutes include sugar alcohols such as sorbitol, xylitol and mannitol. There is no clear evidence that these sweeteners, at the levels typically consumed in human diets, cause cancer. Questions about artificial sweeteners and cancer risk arose when early studies showed that saccharin caused bladder cancer in lab animals, but studies in humans have shown no increased cancer risk. People with a rare genetic disorder called phenylketonuria (PKU) aren't able to metabolize aspartame normally, which can result in nervous system toxicity, so they should avoid aspartame in their diets. With this exception, all these sweeteners appear to be safe when used in moderation, although larger amounts of sugar alcohols may cause bloating and abdominal discomfort in some people.

Mitoxantrone

Novantrone (antitumor antibiotic)

CAM Pancreatic Cancer

Omega 3 supplements for wt loss omega 3 supplements for anticachectic effects

Oleic Acid

Omega 9 FA; found in olive oil and avocado. May be synergistic with Perception. Not sold as supplement.

Pegaspargase

Oncaspar Enzyme modulator

Flaxseed

Possible anticancer effect. Estrogenic, GI upset with ingestion of large amounts

Soluble Fiber

Promote intestinal health. Conventional Food: oats, lentils, apples, oranges, bananas, pears, strawberries, nuts, flaxseed, beans, dried peas, blueberries. Functional Food: banana flakes, ready to eat cereal

Diarrhea Pharmacotherapy

Opioid receptor agonists: - Loperamide/Imodium AD - Diphenoxylate atropine/Lomotil Hormonal: - Octreotide / Sandostatin Opiods: - anhydrous morphine / Paregoric - Camphorated tincture of opium / Deodorized tincture of opium Anti-inflammatory/Anti-diarrheal - bismuth subsalicylate / Pepto-Bismol - attapulgite / Kaopectate Bile acid sequestrant: - cholestyramine / Questran Anti-cholinergics: - diphenhydramine / Benadryl Medicinal Fibers: - psyllium / Metamucil - psyllium or calcium polycarbophil caplets / Konsyl - methylcellulose / Citrucel Preventive for gut radiotherapy: - amifostine / Ethyol Amino acids: - L-glutamine (may reduce duration but not severity) - Enterade (a proprietary blend of amino acids) Probiotics - Saccharomyces boulardii - Lactobacillus rhamnosus GG

CAM Hematological Cancers

Oral glutamine Glutamine enhanced parenteral formulations

CAM-Oxymedicine

Promoted as an immune stimulating agent. No proven evidence

Osteosarcoma

Osteosarcoma is the most common type of cancer that develops in bone. Like osteoblasts of normal bone, the cells that form this cancer make bone matrix. But the bone matrix of an osteosarcoma is not as strong as that of normal bones.

Indication for carboplatin

Ovarian, lung, testicular

Eloxatin

Oxaliplatin Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA IV myelosuppression, N/V/D/C, peripheral neuropathy, sensitivity to cold, dysesthesia, HEPATIC TOX, NEURO TOX, allergic reaction. *Avoid all cold foods *Vit. B6 may help with hand/foot syndrome

This medication has an unusual side effect called "cold dysesthesia".

Oxaliplatin (Eloxatin)

Which chemotherapy drug is known to cause Pharyngolaryngeal dysesthesia?

Oxaliplatin (Eloxatin)

Moderate emetogenic:

Oxaliplatin /Eloxatin Cytarabine >1gm/m2 Carboplatin Ifosfamide Cyclophosphamide <1500mg/m2 Doxorubicin Daunorubicin Epirubicin Idarubicin Irinotecan /Camptosar

Moderate Risk of Emesis Chemo

Oxaliplatin/Eloxatin Cytarabine Carboplatin Ifosfamide Cyclophosphamide Doxorubicin Daurorubicin Epirubicin Idarubicin Irinotecan /Camptosar

chemo - Moderate emetogenic: CCDDEIIIO

Oxaliplatin/Eloxatin Cytarabine >1gm/m2 Carboplatin Ifosfamide Cyclophosphamide <1500mg/m2 Doxorubicin Daunorubicin Epirubicin Idarubicin Irinotecan/Camptosar

Pertzumab

Perieta Used to treat breast cancer. Infusion reaction, cardiotoxicity, fatigue, N/V/C, embryo-fetal toxicity. Target:Her2/NEU Monoclonal Antibody Targeted Therapy: Monoclonal Antibody- ERBB2 IV Perieta Used to treat breast cancer Infusion reaction, cardiotoxicity, fatigue, N/V/D/C, embryo-fetal toxicity, myelosuppression

Oxymedicine

Promoted as an immune stimulating agent. No proven evidence

orexigenic agents: *only one drug with proven (small) benefit in improving cachexia *decision to use them should be based on side effects, cost and burden of treatment. * benefits of using these with the elderly is not clear * current research is studying combined approach of drug combinations to reverse cancer cachexia *Better to intervene early and prevent cachexia and prevention of treatment related morbidities: nausea, vomiting, diarrhea, dysphagia, pain or depression is advised.

PERIACTIN- (somewhat effective with carcinoid syndrome and cachexia) sfx: constipation, diarrhea, edema, nausea, polyuria, vomiting, xerostomia DECADRON-improves appetite (short lived) and QOL but no increase in LBM. May be beneficial for pts with poor prognosis. sfx: bloating, dyspepsia, edema, esophagitis, gastritis, hyperglycemia, nausea, vomiting, delayed wound healing, immune suppression, insomnia, muscle weakness, calcium wasting, adrenal insufficiency, low zinc level, NEEDS vitamin D supplement PROVERA-wt gain 2/2 increased fat and fluid retention, increased sense of well being. sfx: constipation, cramps, diarrhea, dyspepsia, edema, hyperglycemia, nausea, vomiting, xerostomia, depression, drowsiness, headache, hot flashes, vision changes. Monitor diabetics, liver function. MEGACE: weight gain 2/2 increased fat and fluid retention , no increase in LBM. increases appetite and QOL, must take for 4-6 weeks for improvement. *Avoid with bedridden patients sfx: diarrhea, dyspepsia, edema, flatulence, hyperglycemia, nausea, vomiting, adrenal suppression, bone pain, DVT's ( esp with doses >800 mg/day) hot sweats, impotence, edema, vaginal spotting. monitor diabetics, renal function, adrenal insufficiency, testosterone (in men). METHYLPREDNISOLONE/SOLUMEDROL: improves appetite and QOL, effects may lower after 4 weeks and side effects may increase. sfx: bloating, dyspepsia, pedal edema, esophagitis, gastritis, hyperglycemia, nausea, vomiting, adrenal suppression, bone thinning, cataracts, insulin resistance, protein breakdown, fluid retention, immune suppression, insomnia, muscle weakness, poor wound healing. **SJW PREDNISOLONE: improves appetite and QOL, no weight gain. Effects may lower after 4 weeks and side effects may increase. sfx: dyspepsia, bloating, edema, esophagitis, gastritis, nausea, protein catabolism, vomiting, catotonia, delusions,hallucinations, pancreatitis, violent behavior, adrenal suppression, bone loss, increased intraoccular pressure, immune suppression, peptic ulcer, insulin resistance, vertebral compression fractures, osteoporosis. Monitor: hypernatremia, hypokalemia, fluid retention, negative nitrogen balance.

With peritonitis, ____ is preferred because of the profound ileus that usually accompanies it.

Parenteral nutrition-associated liver disease

PNLD; liver disease caused by long term PN. Serious risk in children.

What chemotherapies are taxanes?

Paclitaxel /taxel / Abraxane Docetaxel/Taxotere

Low emetogenic:

Paclitaxel/Taxol Docetaxel /taxotere Topotecan Etoposide Methotrexate Mitomycin Gemcitabine/ Gemzar Cytarabine

chemo - Low emetogenic:CDEGMMPT

Paclitaxel/Taxol Docetaxel/ taxotere Topotecan Etoposide Methotrexate Mitomycin Gemcitabine /Gemzar Cytarabine

EN Medication Concerns Pain meds

Pain patches are available but are not always appropriate for pts w rapid wt loss d/t altered drug levels in the blood. NOT RECOMMENDED FOR USE WITH EN DEVICES - Enteric-coated aspirin - Morphine sulfate extended-release tablets - Morphine sulfate sustained-release tablets - Oxycodone Alternative for EN device: - Morphine liquid - Oxycodone liquid - Acetaminophen and hydrocodone bitartrate - OTC liquid meds- ibuprofen or acetaminophen

VIPomas

Pancreatic tumor with increased secretion of vasoactive intestinal peptide, Verner-Morrison Syndrome, pancreatic cholera, or WHDA (watery diarrhea, hypokalemia, and achlorhydria). Treat with medications and fluids to manage losses. EN/PN to replace electrolytes as needed.

Glucagonomas

Pancreatic tumors that cause erythema and diabetes. Treat with carb counting plan.

Gastrinomas

Pancreatic/duodenal tumors that cause recurrent ulcers, diarrhea, and GERD. Treat with meds and anti-GERD methods.

Vectibix

Panitumumab Maggies my mum's Vet IV Monoclonal antibodies SFX: N/V/D/M/F/A, myelo, skin rash, pruritus, PULM TOX, LOW Mg Monitor Mg levels closely Targeted Therapy: Monoclonal Antibody- EGFR (Epidermal Growth Factor Receptor- involved in cancer cell proliferation, blocking apoptosis, mobilizing cells to promote metastasis, and angiogenesis)

Neulasta

Pegfilgrastim Used to prevent neutropenia

Alimta

Pemetrexed All 12 Bic pens have folic acid IV Myelosuppression, N/V/D/F, rash, anemia. - Considerations: supplement w/folic acid (350-1000 ug) and B12 (1000 ug q 3 cycles) to prevent severe anemia starting 1 wk prior to tx and throughout Cell cycle-specific chemotherapy agent: Antimetabolite- Interfere with DNA synthesis by acting as false metabolites; incorporated into the DNA strand or block essential enzymes

Chemotherapy definition + side effects

Pharmaceuticals used to dec tumor growth Inhibit tumor growth, shrink tumors prior to surgery, prevent or eradicate metastasis prior to surgery, or prevent mets in general Side effects Anemia, fatigue, nausea, vomiting, *anorexia*, mucositis, changes in taste and smell, xerostomia, dysphagia, diarrhea, constipation. *not all chemos have same side effects profiles*

Suggestions for managing anticipatory nausea & vomiting:

Physchological techniques and/or the use of benzodiazepines such as lorzepam (Ativan®)

Lignans

Phytoestrogen; associated with decreased risk of breast cancer. Conventional Food: Flaxseed, sesame seed, chickpea, oats, barley Functional Food: flaxseed added to snack bars and muffins

GI Complications and Corrections w EN Constipation

Poss causes: Inadequate fluids- > increase free water / fluid intake inadequate or excess fiber-> change formula to adjust fiber Physical inactivity-> increase PA as able Medication-> minimize narcotics, add stool softener/laxative, trial of prune juice GI obstruction/colonic dysmotility/ileus-> evaluate and address underlying cause, may needs to hold EN until cause is determined

GI Complications and Corrections w EN Diarrhea

Poss causes: Medications-> evaluate hyperosmolar meds ( sorbitol, magnesium-containing), laxatives, lactulose and others Antibiotic -> provide antidiarrheals if appropriate Infectious-> check stool for Clostridium difficile or other pathogens Bacterial contamination-> observe hanging formula- change every 24 hrs, use closed system Fiber free formula or high fiber-> change to a different fiber content Malabsorption or steatorrhea-> elemental or semielemental formula, lower fat or high MCT formula, add pancreatic enzyme replacement therapy

GI Complications and Corrections w EN N/V, abd distention, bloating

Poss causes: delayed gastric emptying, rapid infusion Correction: - continuous feeds w low fat or isotonic formula or both - prokinetic agents - postpyloric - fiber free to enhance gastric emptying - antiemetics - low rate and adv slowly - check placement w possible migration

GI Complications and Corrections w EN Aspiration / GERD

Poss causes: flat head of bed, incomplete closure of lower esophageal sphincter, large volume bolus feeds, delayed gastric motility Corrections: - elevate bed above 30 to 45 degrees - small bore - post pyloric - continuous feeds - add prokinetic agent - change to concentrated formula at lower rate - fiber free formula to enhance gastric emptying

Name 3-4 foods that can alter the CYP3A4 metabolizing enzyme- thus altering a drugs' efficacy/toxicity

Possible food & drug interactions occur with: •grapefruit and GFJ ••pomegranate •star fruit *citrus juice/ seville oranges (In the USA, Seville oranges are grown on a limited scale by small farmers)

Definitive Therapy

Prescribed treatment modality with or without additional treatment

Dry Mouth Products - prescription

Preventive therapies: *amifostine (ethyol) -reduces damage to salivary glands, injection only. *cevimeline (Evoxac)- salivary glands must be partially functional. *pilocarpine (salagen)-1 1/2 hours to work, short acting. Salivary glands must be partially functional. after the fact: aquaoral caphosol numoisyn liquid, lozenges

Matulane

Procarbazine. Tyra AND MAT play pro-bal - SFX: N/V(severe)/D/C, dry mouth - Intrxn: - avoid caffeine, alcohol - avoid TYRAMINE-rich foods while taking drug and 2 weeks after (beer, red wine, sherry, distilled spirits, brewer's yeast, fava beans, raspberries, figs, dried fruits, avocados, bananas, miso, soy sauce, sauerkraut, aged and strong cheeses, anchovies, caviar, beef and chx livers, meat extracts, sausage, bologna, pepperoni, salami)

Exocrine cells

Produce pancreatic secretions which contain bicarb and digestive enzymes (lipase, amylase, protease) that help neutralize stomach acid and digest fats, carbs, and protein.

PR+

Progesterone receptor positive; 2/3 of breast cancer are also PR+.Respond to SERMs such as tamoxifen. Aromatase Inhibitors stop estrogen in post-menopausal women-not used before. LHRHs such as Lupron Depot and Zoladex shut down ovaries to prevent estrogen production.

Surgery Lung

SOB early satiety

colony stimulating factors

Protein that stimulates the growth and proliferation of white blood cells (granulocytes). Newer medications, called colony-stimulating factors such as Filgrastim (Neupogen), pegfilgrastim (Neulasta), and sargramostim (Leukine or Prokine) help the body make more neutrophils. The exogenous administration of these medications stimulates the stem cells in the bone marrow to produce more infection-fighting white blood cells. Before these medical interventions were available, implementing a neutropenic diet was done as one precaution to help prevent life-threatening infections in patients with neutropenia.

Pylorus preserving pancreaticoduodenctomy

Pylorus preserving whipple; PPPD Head of pancreas, duodenum, gallbladder, and part of the common bile duct are removed; the stomach and pylorus are kept intact. Impact: - Pancreatic exocrine insufficiency - Delayed gastric emptying - Lactose intolerance - Diabetes

The following supplement offers anti-inflammatory effects but may decrease bioavailability of iron:

Quercetin

Evidence Based Oncology Nutrition Practice Guidelines- MNT & pretreatment evaluation in H&N Cancer: RDNs should provide MNT consisting of a PRETREATMENT evaluation and weekly visits during radiation for H&N ca to improve outcomes

RATING: STRONG, IMPERATIVE RDNs should provide MNT consisting of a pretreatment evaluation and weekly visits during radiation for H&N ca to improve outcomes

Evidence Based Oncology Nutrition Practice Guidelines: Esophageal ca patients on concurrent chemo/xrt should receive MNT consisting of a PRETREATMENT evaluation and weekly visits x 6 weeks during treatment to improve outcomes.

RATING: WEAK, IMPERATIVE

calculate catch-up growth in children

RDA in kcals/kg x IBW / actual wt in Kg

pediatrics-calculate catch-up growth in children

RDA in kcals/kg x IBW / actual wt in Kg

Criteria for the rating of evidence -based nutrition recommendations:

STRONG, FAIR, WEAK, CONSENSUS, INSUFFICIENT EVIDENCE

S/E: Myelosuppression (Bone marrow suppression also known as myelotoxicity or myelosuppression, is the decrease in production of cells responsible for providing immunity, carrying oxygen, and/or those responsible for normal blood clotting. Bone marrow suppression is a serious side effect of chemotherapy and certain drugs affecting the immune system such as azathioprine. The risk is especially high in cytotoxic chemotherapy for leukemia.): anemia, thrombocytopenia, neutropenia

Radiopharmaceuticals for Metastatic Bone Pain Samarium 153 / Quadramet (also N/V, Dizziness, pherifpheral neuropathy) Strontium 89 / Metastron (also temporary increase in bone pain, flushing) Radium 223 / Xofigo (aslo N/V/D, peripheral edema)

Possible causes of hypophosphatemia?

Refeeding Insulin therapy Phosphate binding antacids

Hypophosphatemia Corrections for EN

Refeeding syndrome-> decrease delivery to 25% of goal (refeeding process); replace phos Insulin therapy-> replace phos IV if severe; via EN if mild Phosphate-binding antacids-> rec discontinue or adjustments of Antacids containing aluminum, calcium, or magnesium (such as Mylanta, Amphojel, Maalox, Riopan, and Alternagel) can bind phosphate in the gut and prevent the body from absorbing it. Using these antacids long term can cause low phosphate levels (hypophosphatemia).

Most effective treatment for delayed N/V

Reglan (metoclopramide) and Dexamethasone / Decadron

Stivarga

Regorafenib Fat Reggie's heart is starving for liver Take in morning with meal that contains <8 g fat N/V/D/M/A, myelo, HEPATIC TOX, CARDIO TOX, HTN, proteinuria, impaired wound healing

Esophagectomy

Removal of cancerous tissue within the esophagus, nearby lymph nodes, and possibly part of the stomach. Remaining part of the esophagus is then connected to the stomach.

Distal pancreatectomy

Removes only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen may be removed as well. Impact: - Pancreatic exocrine insufficiency - Diabetes

Hematopoietic stem cell transplantation definition

Replaces blood-forming stem cells depleted by high dose chemo/radiation --> giving high dose/lethal chemotherapy. several different chemotherapies used in conjunction with each other to try to get the most cell kill. high dose chemo ablates bone marrow. if we did not provide stem cell transplantation following administration of chemo, those people would die of overwhelming infection within 60-90 days. they are not producing any bone marrow cells. used in tx of leukemia, lymphoma, multiple myeloma

Cancer prevention/survivorship counseling suggestions

Review lifestyle habits that influence cancer risk with patient. Encourage patient to follow plant based diet. Provide individualized counseling based on the assessment of pt's particular issues such as wt mgt or lack of nutrition knowledge. Review basics of good nutrition. Review guidelines for reducing risk of recurrence. Recommend reputable sources for information on cancer and nutrition.

Rituximab

Rituxan Infusion reaction, tumor lysis syndrome, skin reaction, N/V, myelosuppression. Target: CD20 Monoclonal Antibody Targeted Therapy: Monoclonal Antibody- CD20 (CD group of antigens present on the surface of all cells in different combinations, which makes them useful for classifying cells. CD 20- is found on B cells) IV Rituxan Infusion reaction, tumor lysis syndrome, skin reaction, N/V, myelosuppression

Beclomethasone Dipropionate GVHD treatment/prevention

S/E: - Dysgeusia - Oral candidiasis - xerostomia - N Beclomethasone / beclomethasone dipropionate / Qvar is a steroid medication. It is available as an inhaler, cream, pills, and nasal spray. The inhaled form is used in the long-term management of asthma. The cream may be used for dermatitis and psoriasis. The pills have been used to treat ulcerative colitis. The nasal spray is used to treat allergic rhinitis and nasal polyps.

Methotrexate GVHD treatment/prevention

S/E: N/V/D Anorexia Mucositis Renal/hepatic changes

Budesonide GVHD treatment/prevention

S/E: Xerostomia

Prednisone GVHD treatment/prevention

S/E: Dyspepsia Hyperphagia insulin resistance / hyperglycemia Edema hypokalemia, hypophosphatemia hyperlipidemia Skeletal muscle catabolism Osteoporosis growth retardation in children

Ruxolitinib GVHD treatment/prevention

S/E: weight gain abnormalities in lipid metabolism

CAM questions

Scientific evidence to support? Benefits outweigh risks? Unfounded claims? What is the cost? Is this cost prohibitive to a well rounded diet? Does it violate basic dietary recommendations regarding food variety and appropriate balance of macronutrients? Nutritionally adequate? Do they create peri-operative concerns or complications? Have they demonstrated harmful side effects?

Some MTE's don't contain what additive and can be issue with long term TPN use?

Selenium (and iron -- not compatible)

Does sugar increase cancer risk?

Several types of sugars are found in foods and beverages. These sugars vary in their chemical structures, but once they are consumed, they all have similar metabolic effects in the body. All sugars in foods and beverages add to calorie intake, which can lead to obesity, so eating a lot of sugar can indirectly increase cancer risk. There is also evidence that a dietary pattern high in added sugars affects levels of insulin and related hormones in ways that may increase the risk of certain cancers. Brown (unrefined) sugar contains the same chemical form of sugar (sucrose) as white (refined) sugar. It also contains extremely small amounts of other substances that affect its color and flavor, but they don't influence the unfavorable effects of sucrose on body weight or insulin levels. Fructose, the natural sugar in fruit and in many sugar-sweetened beverages in the form of high-fructose corn syrup, is similar to sucrose in its effects on weight and insulin levels, as is honey, which contains a mixture of fructose and glucose (another form of sugar). Lab studies have shown that metabolism of glucose (the main sugar used as an energy source in the body) is faster in cancer cells than in normal cells. This fact is often misinterpreted by people, who assume (incorrectly) that sugars in foods and beverages directly "feed" cancer cells. Nonetheless, limiting highly processed foods that contain high levels of added sugars, such as cakes, candy, cookies, and sweetened cereals, as well as sugar‐sweetened beverages such as soda, sports drinks, and energy drinks, can help reduce calorie intake, limit weight gain, and promote a healthier body weight. It can also lower insulin secretion in people with metabolic conditions such as pre-diabetes or type 2 diabetes.

Sirolimus

Similar to Tacrolimus, but inhibits *mTOR*-->decreased T cell proliferation S/E: hypertriglyceridemia

Provenge

Sipuleucel-T. Sip in my Ca Coffee cup you Pro Avoid caffeine on day of leukapheresis Drink more water days prior to tx and Consume Ca-rich breakfast prior to receiving tx infusion Own vaccine

What two allergies do you need to be mindful of when hanging IVFE?

Soy Egg

What is something not allowed on the Budwig diet?

Soy (honey, flaxseed oil, and papaya are all allowed)

Dasatinib

Sprycel da grapefruit spray for john Avoid grapefruit juice, no St Johns WORT Avoid ketoconazole and erythromycin Avoid St. John's Wort and phenobarbitals, grapefruit juice, ketoconazole, and erythromycin. Protein-Targeted Agents: Tyrosine kinase inhibitors: inhibit several receptor tyrosine kinases, which are involved in tumor growth, angiogenesis, and metastasis.

Cytokines

Stimulate broad base immune response as opposed to generating a targeted response to specific tumor antigen.

Mechanism of action: Bisacodyl/Dulcolax and Senna (Stimulant Laxatives)

Stimulates/irritates intestinal muscle, increases peristalsis

Mechanism of action: Miralax

Stool softener, osmotic agent, causes peristalsis

Streptozotocin (Zanosar®) alters __________________________ metabolism in some patients causing ________________________

Streptozotocin (Zanosar®) alters glucose metabolism in some patients causing hypoglycemia

EN Medication Concerns Sucralfate

Sucralfate may bind to protein left in the feeding tube from formula Alternatives for EN devices - An appropriate PPI or H2 blocker formulation

Sutent

Sunitinib Avoid grapefruit, St John's WORT, phenobarbital, dexamethasone, ketoconazole, erythromycin ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox

Prostate Cancer treatment

Surgery Radiation Chemotherapy - 1st line Bicalutamide Gonadotrophin -2nd line Doxorubicin Cisplatin 5-fluo Androgen-deprivation hormone therapy (block testosterone) "Watchful waiting"

gastrojejunostomy

Surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum.

Esophagogastrectomy

Surgical removal of the cancerous tissue within the esophagus, nearby lymph nodes, and the top portion of the stomach. Remaining stomach is then pulled up and connected to the remaining portion of the esophagus. Sometimes uses a small portion of the colon to reconnect. Required when cancer has advanced and spread to the upper portion of the stomach.

Esophageal Cancer Treatment

Surgical resection is ALWAYS the thing to try, chemo and radiation may be used in addition -stent placement in lesions that are non resectable, to keep esophagus open surgical resection if there are no local or distant mets; follow with chemo based on 5-FU 1st line - Doxorubicin - Vincristine 2nd line -Carmistine -Daunorubicin

Omacetaxine

Synribo inhibits protein synthesis independent of direct Bcr-Abl binding

Monoclonal Antibodies

Therapies that signal external cellular pathway targets which activate pathways inside. Disrupts cell function and causes cell apoptosis.

If TG are over what mg/dL is it rec that you hold VS d/c IVFE?

TG > 400 mg/dL

Total pancreatectomy

TP Removes the entire portion of the pancreas and sometimes the spleen. The additional structures removed are the same as the PD (duodenum, gallbladder, distal stomach, common bile duct). Reconstruction is the same except without remnant pancreas. Impact: - Pancreatic exocrine insufficiency - Dumping syndrome - Delayed gastric emptying - Lactose intolerance - Diabetes

TRUE or FALSE Reglan (metoclopramide) is a dopamine antagonist that can be used as an antiemetic agent, and/or prescribed for loss of appetite, early satiety and heartburn

TRUE

True or False A patient with a new ileostomy should avoid both soluble and insoluble fiber after surgery

TRUE Patients should avoid SOLUBLE fiber until the surgeon confirms the intestine has healed.

TRUE or FALSE Grapefruit juice (GFJ) can INCREASE a drugs' activity by INHIBITING the enzyme responsible for the drug's metabolism

TRUE Example: Concomitant use of GFJ and docetaxel /Taxotere resulted in a reduction of clearance greater than 15%

TRUE OR FALSE IV lipids are NOT contraindicated in patients with chyle leaks.

TRUE Parenteral lipids are phospholipids designed for IV infusion. They are delivered directly into the blood stream and as a result do not pass through the lymph system as chyle. Therefore, IV lipids are NOT contraindicated in patients with chyle leaks.

TRUE or FALSE The antiemetic Ondansetron (Zofran) may cause constipation or diarrhea in cancer patients

TRUE •Constipation -- in up to 9% of patients •Diarrhea -- in up to 7 % of patients

SERMS hormone therapy

Tamoxifen (Novaldex)* Used to treat breast cancer. Avoid grapefruit juice and St. John's Wort Toremifene (Fareston) Raloxifone (Evista) Menstrual symptoms, N/V/C/D, fluid retention, increased risk of endometrial cancer, thrombus, skin change/rash, joint ache/pain, weight gain.

Nolvadex

Tamoxifen. No - SFX: N/V/D/C, hot flashes, weight gain, fluid retention, peripheral edema - Intrxn: avoid antacids w/in 2 hrs of taking; black cohosh Avoid St. John's Wort and phenobarbitals, grapefruit juice, ketoconazole, and erythromycin. - Consideration: melatonin may improve effect when tamoxifen isn't working Flaxseed may enhance the efficacy Black Cohosh may interfere with Tamoxifen and can also increase toxicity of doxorubicin and docetaxel/Taxotere

Protein Targeted Therapies

Therapies the signal internal cellular pathway that targets proteins. Ex: TKIs, MTOR inhibitor, Proteasome Inhibitor.

Ketogenic Diet

Target energy metabolism, angiogenesis, and inflammation through IGF-1 signaling which reduces the availiability of glucose and glutamine. If glucose is not available, the brain shifts to using ketones for energy-which malignant brain cells cannot do. Used to slow down tumor growth and spread. Side effects: difficulty to follow, C/V, decreased energy, increased hunger.

Alemtuzumab

Targeted Therapy: Monoclonal Antibody- CD54(CD group of antigens present on the surface of all cells in different combinations, which makes them useful for classifying cells. CD52 is found on the surface of B and T lymphocytes, most monocytes, macrophages and NK cells, and certain granulocytes) IV Campath Myelosuppression, N/V

Ibritumomab Tiuxetan

Targeted Therapy: Monoclonal Antibody-CD20 ( Zevalin Possible infusion reaction, myelosuppression, asthenia, infections, N/V-mild, SOB, sinusitis. Target: CD20 -Monoclonal Antibody relapsed/refractory b cell NHL Targeted Therapy: Monoclonal Antibody- CD20 (CD group of antigens present on the surface of all cells in different combinations, which makes them useful for classifying cells. CD 20- is found on B cells) IV Zevalin Possible infusion reaction, myelosuppression, asthenia, infections, N/V-mild, SOB, sinusitis, cough, dyspnea

Pembrolizumab

Targeted Therapy: Monoclonal Antibody-PD (Programmed Death Receptor 1 and Programmed Death Receptor Ligand 1- PD-1 receptors are located on T-cells. When ligands bind to PD-1 receptors they switch off T-cells, which fight cancer. Agents that target PD-1 are referred to as Checkpoint Inhibitors) IV Keytruda S/E: Anemia, N/V/D, Hyperglycemia, Hyponatremia, hypoalbuminemia, pruritus, pulmonary symptoms, increased liver enzymes, anorexia

Nivolumab

Targeted Therapy: Monoclonal Antibody-PD-1/PD-L1 (Programmed Death Receptor 1 and Programmed Death Receptor Ligand 1- PD-1 receptors are located on T-cells. When ligands bind to PD-1 receptors they switch off T-cells, which fight cancer. Agents that target PD-1 are referred to as Checkpoint Inhibitors) IV Opdivo S/E: myelosuppression, colitis, N/V/C, hyponatremia, hypokcalemia, hypomagnesemia, pruritus, pulmonary symptoms, PNA

Ipilimumab

Targeted Therapy: Monoclonal Antibody-PD-1/PD-L1 (Programmed Death Receptor 1 and Programmed Death Receptor Ligand 1- PD-1 receptors are located on T-cells. When ligands bind to PD-1 receptors they switch off T-cells, which fight cancer. Agents that target PD-1 are referred to as Checkpoint Inhibitors) IV Yervoy S/E: Anemia, N/V/D, rash, pruritus, pulmonary symptoms

Denosumab

Targeted Therapy: Monoclonal Antibody-RANKL (Receptor Activator of Nuclear Factor Kappa-B Ligand- activates osteoclasts, leading to bone resorption) IV Prolia SFX: n/v/d, low Ca, osteonecrosis of the jaw

Temodar

Temozolamide. TemTem has a hangover N/V/C/F, myelo, headache, HEPATIC TOX, photosensitivity, rash. Oral- take on empty stomach w full glass of water/ do not crush Food may decrease drug rate and absorption CHEMO Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA

radiation- brachytherapy (sealed)

Temporary or permanent placement of radioactive material directly into tumors or next to tumors. Designed to precisely deliver radiation therapy in an individualized and targeted manner in an effort to spare normal tissue. Can be used alone or with EBRT. Radiation source placed directly into the body

mTor Inhibitor

Temsirolimus (Tonsel) Everolimus (Affinitor) *Avoid St. John's Wort, grapefruit juice. Skin rash, cardio toxicity, hand-foot syndrome, N/V/D, decreased appetite

Torisel

Temsirolimus. SIR TEM TORe his BS and CHOL chart SFX: hyperglycemia & hypercholesterolemia ends w NIB/MUS/MIB- N/V/D, poor app, rash, Hand food sy, Cardio tox

On the average, how many years does it take for cancer to develop?

Ten

Vumon / VM-26

Teniposide TEN couldnt breath when VUMONed, then BP dropped Epidodophyllotoxins SFX: Myelosuppression, N/V, hypotension, PULM TOX epiodophyllo toxin - damages cell prior to mitosis late S and G2 phases.

Thalomid

Thalidomide. an inhibitor of tumor necrosis factor- has resulted in wt gain in pts with HIV (increased appetite), may cause drowsiness S/E: N/C, dry mouth, Bowel perforation, HTN, Proteinuria, Hypothyroid arterial thromboembolic events (ATE) hemorrhage Avoid alcohol, take a bedtime,

What is arsenic? Does it cause cancer?

The International Agency for Research on Cancer (IARC), the US National Toxicology Program (NTP), and others have classified arsenic as carcinogenic to humans. Arsenic is a naturally occurring element that can be found in rocks and soil, water, air, plants, and animals, as well as in industrial and agricultural compounds. Arsenic is found in two forms: Inorganic arsenic compounds are used in industry and in building products (such as some "pressure-treated" woods) and are found in arsenic-contaminated water. This tends to be the more toxic form of arsenic and has been linked to cancer. Organic arsenic compounds are thought to be much less toxic than the inorganic arsenic compounds and are not thought to be linked to cancer. The main sources of human exposure to arsenic are water and food. Water in some areas of the United States, especially in the Southwest, New England, and the Upper Midwest, may be higher in arsenic. Natural arsenic levels tend to be higher in drinking water that comes from ground sources, such as wells. For most people, food is the largest source of arsenic, although much of this is likely to be in the less dangerous, organic form. The highest levels of arsenic in foods are found in seafood, rice and other rice products, mushrooms, and poultry, although many other foods, including some fruit juices, can contain arsenic. Studies have found that exposure to arsenic in drinking water may cause lung, bladder, and skin cancers. Because arsenic has been linked to cancer and other unwanted health effects, several US government agencies regulate arsenic levels and exposures. While arsenic is a naturally occurring element and can't be avoided completely, there are things people can do that may lower their exposure. Those whose drinking water comes from a public source can obtain publicly-available information about the levels of certain substances in drinking water, including arsenic. People who get their water from a private source such as a well can have arsenic levels tested by a reputable laboratory. Those who live in areas with high levels of arsenic in the water may consider using alternate sources of drinking water, such as bottled water. Common household water filters do not effectively remove arsenic. Avoiding excess consumption of foods known to contain high levels of arsenic, including seafood, rice and rice products, and fruit juice can also help lower exposure, and maintaining adequate folate levels is important for the elimination of arsenic in the body.

Generally, the Macrobiotic diet is made up of these foods:

The Macrobiotic diet is made up of: •organic whole grains (50% of food intake) •locally grown, organic fruits/vegs (25% of diet) •soups made with vegetables, seaweed, beans, fermented soy (miso) (up to 25% food intake)

What are some subgroups of Antimetabolites?

The are categorized by the substance they interfere with: Folic Acid Antagonist Pyrimidine Antagonist, Purine Antagonist Adenosine Deanimase Inhibitor

Food components such as Curcumin may play a role in carcinogenesis by inducing apoptosis and by inhibiting angiogenesis. What food should be recommended to increase the intake of Curcumin?

Tumeric

What are antioxidants, and what do they have to do with cancer?

The body uses certain nutrients and other compounds to help protect against damage to tissues that is constantly occurring as a result of normal metabolism. Because this type of damage is linked with increased cancer risk, some antioxidants are thought to protect against cancer. Antioxidants in the diet include vitamin C, vitamin E, carotenoids (compounds related to vitamin A), and many other food components. Studies suggest that people who eat more vegetables and fruits, which are rich sources of antioxidants, may have a lower risk for some types of cancer. But this does not mean that the benefits of vegetables and fruits are from their antioxidant content, rather than from other food components. Most clinical trials of antioxidant supplements have not found they reduce cancer risk. In fact, some studies have found an increased risk of cancer among those taking supplements. When it comes to reducing cancer risk, the best advice is to get your antioxidants through whole food sources rather than supplements.

Suggestions for managing delayed nausea & vomiting:

The combination of dexamethasone and aprepitant

The initiation rate of bolus or gravity feedings should be _____- ______ mL for the first 1-2 feedings and increase by ______ - _____ mL every 8-12 hours or every 1-2 feedings

The initiation rate of a bolus or gravity feeding should be 60-120 mL for the first 1-2 feedings and increase by 60-120 mL every 8-12 hours or every 1-2 feedings

What does T1N0M0 mean?

Tumor is not palpable, no lymph node involvement, no distant metastasis

Promotion

The stage of tumorigenesis in which initiated cells are activated by a promoting agent to multiply and form a discrete tumor

Are foods labeled "organic" more effective in lowering cancer risk?

The term "organic" is used to designate foods grown without the addition of artificial chemicals. Under USDA regulations, animal-derived foods that are labeled as organic come from animals raised without the addition of hormones or antibiotics to the feed they eat. Plant foods that are organic come from agricultural methods that do not use most conventional pesticides or herbicides, chemical fertilizers, or sewage sludge as fertilizer. Organic foods also exclude the use of industrial solvents or food irradiation in processing, and genetically modified foods are also excluded. A main benefit of consuming organic foods is to support environmentally sustainable agricultural practices. Many consumers also believe that organic foods may provide health benefits, but there is little evidence that organic produce has higher nutrient levels than conventionally grown produce. Little research has been done on the link between organic food consumption and cancer risk, although a recent study found eating more organic produce was linked with a lower risk of non-Hodgkin lymphoma. While this finding needs to be confirmed by other studies, it is in line with the strong and consistent link between workplace pesticide exposure and this type of cancer. Washing conventionally grown produce can remove some of the pesticide residue. It's also important to wash all produce to limit the risk of health effects from microbial contamination. Because organic produce is often more expensive than similar conventionally produced items, it's important that people with limited resources recognize that meeting the recommendation for vegetable and fruit intake is a higher priority for cancer prevention and overall health than choosing organic produce.

Adjuvant Therapy

The use of additional cancer treatment given after the primary therapy. Ex: chemo after lobectomy

Neoadjuvant Therapy

The use of one or more treatment modalities given before the primary treatment.

Nutrients Absorbed in the Jejunum

Thiamin Riboflavin Niacin Pantothenate Biotin Folate Vit. B6 Vit. C Vit. A,D,E,K Calcium Phosphorus Magnesium Iron Zinc Chromium Manganese Molybdenum Lipids Monosaccharides Amino Acids Small Peptides

6-TG

Thioguanine oral SE: myelo, N/V/M/D, HEPATIC TOX, RENAL TOX, rash ST Johns WORT may decrease activity

Thiotepa

Thioplex N/V/M, myelo, RENAL TOX, rash, skin bronzing.

small cell lung cancer

This cancer often starts in the bronchi near the center of the chest. Although the cancer cells are small, they can divide quickly, form large tumors, and spread to lymph nodes and other organs throughout the body. This is important because it means that surgery is rarely an option and never the only treatment given. Treatment must include drugs to kill the widespread disease. This kind of cancer is almost always caused by smoking.

Allogenic marrow transplantation

Transfer of marrow from donor to another person who is not genetically identical

Herceptin

Trastuzumab. TASTE HER AVOCADOS IV Targeted Therapy: Monoclonal antibody used to treat HER2+ breast cancer N/V/D, Infusion reaction, cardiotoxicity, pulmonary toxicity infusion related symptoms GI issues (usually mild) cardiotoxicity (increased risk when given with anthracycline) myelosuppression pulmonary toxicity skin rash/problems osteonecrosis, hypocalcemia Avocados, olive oil increase sensitivity to drug

Bendamustine

Treanda (alkylating agent)

Biotherapy

Treatment to boost or restore the ability of the immune system to fight cancer by inducing, enhancing, or suppressing the immune system response. Also called immunotherapy.

Arsenic Trioxide Name its mechanism of action

Trisenox (misc) degrades PML/RAR alpha protein

Arsenic Trioxide

Trisenox, ATO IV APL Prolonged QT APL Diff. Syndrme Ftge, N/V, D

Aloe vera has a strong laxative effect. True or False

True

Bot hereditary and acquired factors influence the carcinogenic process (T/F).

True

In the women's Health Initiative, intervention with calcium and vitamin D did not alter risk of colorectal, breast, or overall cancer incidence. (T/F)

True

Overall, cancer incidence rates have declined since 1999 (T/F).

True

T/F: cancers caused by tobacco or ETOH are 100% preventable

True

The Macrobiotic Diet might require a patient to supplement with B12. (T/F)

True

The term carcinogenesis refers to the process by which normal cells transform into cancer cells, usually as a result to accumulating genetic damage (T/F).

True

True or False: As evidence on supplement use during treatment is often equivocal, RDs/RDNs should discuss findings regarding the use of supplements with the multidisciplinary team to jointly develop recommendations for each patient.

True

Vegetables and fortified cereals are considered functional foods. (T/F)

True

True or False The ketogenic diet limits carbohydrate intake to 5-10% of the total diet, typically between 15-50 grams daily

True The ketogenic diet limits carbohydrate intake to 5-10% of the total diet, typically between 15-50 grams daily

People about to receive chemotherapy for a cancer with a high cell turnover rate, especially lymphomas and leukemias, should receive prophylactic oral or IV allopurinol as well as adequate IV hydration to maintain high urine output (> 2.5 L/day) to prevent which condition?

Tumor lysis syndrome

Tumor lysis syndrome can lead to _____________________failure

Tumor lysis syndrome can lead to kidney failure and other sudden health problems within 24 - 48 hours of therapy

Cytokines related cancer cachexia

Tumor necrosis factors Cachectin Interleukin 1 Interleukin 6 Interferon

Insulinomas

Tumors on pancreas that cause fasting Hypoglycemia. Treat with complex carbs every 2-3 hours.

protein requirements for cancer its undergoing treatment

Underweight ( BMI <18.5) 1.5-2 g/kg wt Normal Weight ( BMI 18.5-24.9) 1.2-1.5 g/kg wt Overweight ( BMI 25-29.9) 1-1.2 gkg wt) Obese (BMI >30) ~20% of kcal

cancer pts undergoing treatment kcal requirements

Underweight ( BMI <18.5) 35-40 kcal/kg wt Normal Weight ( BMI 18.5-24.9) 30-25 kcal/kg wt Overweight ( BMI 25-29.9) 25-30 kcal/kg wt) Obese (BMI >30) Mifflin St Jeor w/ ~1.2 SF)

TPN vs EN for allogeneic stem cell transplantation patients?

Use *enteral nutrition* during allogeneic transplant to reduce grades III and IV severe gut GVHD *focus on feeding the gut* for those going through allogeneic stem cell transplants, if they have had poor PO intake less than 500 cal for 4 days after day of transplant --> risk of developing GHV inc 7% less than 500 cal for 4-9 days --> risk of developing GVH inc 17% 9 days or more of poor PO intake, risk of 36% of developing stages 3 and 4 gut GVH

Cannabinoids

Use to treat N/V Dronabinol & benzodiazepines (lorazepam & diazepam)

serotonin antagonists

Use to treat N/V Ondansetron, granisetron and dolasetron Generally ineffective in delayed N/V

Dopamine antagonists

Use to treat N/V Phenothiazines (Prochlorperazine) Benzamides (metoclopramide)

Tamoxifen and Raloxifene

Used to decrease growth of estrogen-sensitive cells by binding to estrogen receptor in ER+ breast cancer. Shown to lessen risk of breast cancer in high risk population.

Hematopoietic Growth Factors (HGFs)

Used to reduce toxicity of chemo (bone marrow toxicity and protect against infection and anemia) Stimulates the bone marrow to increase production of new cells: epoetin alfa(Epogen, Procrit)- stimulates production of red blood cells. Treats anemia oprelvekin(Neumega)- stimualtes production of platelets filgrastim(Neupogen)-stimulates WBC production

Hormone Therapy

Used to treat hormone sensitive cancers. Stops or reduces the body's ability to produce hormones. Also, substitutes chemically similar agents for the active hormones that cannot be used by the tumor. Ex: SERMS, AIs, Progesterones, Antiandrogens, LHRH.

Nutrients Absorbed in the Ileum

Vit. C Folate Vit. B12 Vit. D, K Magnesium Bile Salts/Acids

EN Medication Concerns Antiemetics

Usually given before chemo or w IV fluids. Often given before meal or tube feeds. Ondansetron ODT is absorbed in the stomach. If poss, have pt dissolve the tablet in their mouth and swallow. NOT RECOMMENDED FOR USE WITH EN DEVICES - Aprepitant / Emend is a medication used to prevent chemotherapy-induced nausea and vomiting and to prevent postoperative nausea and vomiting. It may be used together with ondansetron and dexamethasone. It is taken by mouth or administered by intravenous injection. Common side effects include tiredness, loss of appetite, diarrhea, abdominal pain, hiccups, itchiness, pneumonia, and blood pressure changes. Other severe side effects may include anaphylaxis. - Ondansetron orally disintegrating tablet (ODT) Alternative meds for EN device: IV fosaprepitant, Lorazepam liquid, Promethazine liquid, Metoclopramide liquid, Erythromycin liquid

Angiogenesis inhibitors

VEGF (bevacizumab -- avastin), Immunomodulatory drugs (lenalidomide -- revlimid; thalidomide)

Valrubicin

Valstar (antitumor antibiotic)

Do vegetarian diets reduce cancer risk?

Vegetarian diets can include many healthy features: They tend to be low in saturated fat They tend to be high in fiber, vitamins, and other bioactive food components They do not include red and processed meats Thus, vegetarian diets may be helpful for cancer risk reduction. Many studies of vegetarians indicate a lower risk of cancer overall, compared to people who also eat meat. But whether vegetarian diets confer any special health benefits over diets that include smaller amounts of animal products than are typically consumed in Western diets is less clear. Indeed, in a large British study, people who ate fish but not other meats appeared to have the same overall cancer risk as vegetarians. The available evidence supports the recommendation of a dietary pattern that is mainly foods from plant sources, with limited if any intake of red and processed meats. In addition to a modest level of risk reduction for some forms of cancer, vegetarian dietary patterns are linked with lower risks of heart disease and type 2 diabetes and are generally more affordable. People on strict vegetarian diets that omit all animal products (including milk and eggs), referred to as vegan diets, often need supplementation with vitamin B12, zinc, and iron (or foods fortified with these nutrients), especially for children and premenopausal women. They should also aim to get enough calcium, as people consuming vegan diets with relatively low calcium content have been shown to have a higher risk of bone fractures compared with people consuming vegetarian or meat‐containing diets. It's important that people on strict vegetarian diets, referred to as vegan diets that do not include animal products (including milk and eggs), talk with their doctor or a dietitian or nutritionist about supplements they may need.

Busulfan: N/V liklihood

Very high.

Azacitidine

Vidaza (Anti Metabolite) SC, IV MDS, CMML Renal Toxicity, Low K Anx/Dprsn; Confusion N,V,D,C,Fatigue

What chemotherapies are Vinca Alkaloids?

Vincristine Vinblastine Vinorelbine

Meds that cause constipation

Vincristine Vinblastine Vinorelbine Paclitadel Docetaxel /Taxotere Oxaliplatin /Eloxatin Calcium Antacids Iron Antidepressants

Oncovin

Vincristine VINne and CRIS ON the toilet w CONSTIPATION. Give Omega Oil not Johns JUice IV SFX: SEVERE C!!!!!/M, myelo, HTN poor appetite, sensory neuropathy, NEURO TOX to bowel, abd cramps, N, taste changes, SIADH, Hypersensitivity reaction, jaw pain, peripheral neuropathy *Avoid St. John's Wort and grapefruit juice. Dexamethasone *Stool softeners to prevent constipation Omega 3 may enhance St. John's Wort may DECREASE the drug activity of Vinblastine (Velban) & Vincristine (Oncovin) by INDUCING Cytochrome P450 3A4 (CYP3A4). Cell cycle-specific chemotherapy agent: Vinca Alkaloid- Bind to protein tubulin, disrupt mitotic spindle formation, and prevent cell division in the mitosis phase vinca alkaloids - binds to protein and disrupt spindle formation prevents division

Navelvine

Vinorelbine. VIN has all the NAVEL problems, BINEs cant breath or feel IV SFX: N/V/D/C/M/F/A, Myelo peripheral neuropathy, elevated liver enzymes, NEURO TOX, PULM TOX, osteopenia, osteoporosis, alopecia *stool softeners to help with constipation Cell cycle-specific chemotherapy agent: Vinca Alkaloid- Bind to protein tubulin, disrupt mitotic spindle formation, and prevent cell division in the mitosis phase

Loss of intrinsic factor as a result of proximal gastric resection may result in ____, which can lead to ___ and ____.

Vit B12 malabsorption; megaloblastic anemia and dementia

Generally additives are adequate to meet needs aside from what exception?

Vitamin D

Nutrient absorption in the GI tract. STOMACH: List 6 things that are absorbed here

WATER ALCOHOL COPPER IODIDE FLUORIDE MOLYBDENUM

Nutrients Absorbed in Stomach

Water Ethyl Alcohol Copper Iodide Fluoride Molybdenum

Nutrients Absorbed in Large Intestine

Water Vit. K Biotin Na Cl K Short Chain Fatty Acids

Hyponatremia Corrections for EN

Water retention/fluid overload-> change to lower free water formula, restrict fluids and free water Sodium losses (GI)-> supplement sodium Syndrome of inappropriate antidiuretic hormone (SIADH)-> restrict fluids/free water; induce diuresis

Pancreatic CA

When >70% is removed, insulin is required Up to 90% of pancreas can be removed before clinical symptoms of malabsorption results, may use pancreatic enzyme replacement therapy

Refeeding Syndrome

When malnourished patients are fed full energy needs and or high carb diet. It is potentially life threatening and characterized by electrolyte abnormalities, (Ex: Hypophosphatemia, hypokalemia, hypomagnesemia) and glucose and fluid shifts which can result in fluid retention, cardiac dysfunction, and respiratory failure. Once electrolytes have been restored to normal limits, start with 25% of energy needs and advance over 3-5 days to meet energy goals.

Does drinking coffee affect cancer risk?

Whether coffee lowers or raises the risk of different types of cancer has been an active area of research. Studies have suggested that drinking coffee likely lowers the risk of liver and endometrial cancers, although the link to endometrial cancer may be confounded by smoking. There is some evidence that coffee lowers the risk of cancers of the mouth, throat, and voice box, as well as basal cell skin cancer in both men and women, and possibly melanoma in women. On a related topic, some studies have suggested that consuming very hot beverages, such as coffee and/or tea, may increase the risk of esophageal cancer. Therefore, it may make sense to avoid drinking coffee and other beverages at very high temperatures. The potential ways in which coffee may lower the risk of cancer are not completely understood. Roasted coffee contains hundreds of biologically active compounds, including caffeine, flavonoids, lignans, and other polyphenols. These and other compounds have been shown to increase energy expenditure, protect against cellular damage, regulate genes involved in DNA repair, have anti-inflammatory properties and/or inhibit cancer spread (metastasis). Coffee also influences the amount of time food is in the intestines, as well as liver metabolism of carcinogens, which may also contribute to a lower risk for some digestive cancers.

Pancreaticoduodenectomy

Whipple Procedure; PD Head of pancreas, duodenum, gallbladder, distal stomach, and part of the common bile duct are removed. GI tract is reconstructed by attaching a loop of the jejunum to the liver, pancreatic remnant, and stomach. Impact: - Pancreatic exocrine insufficiency - Dumping syndrome - Delayed gastric emptying - Lactose intolerance - Diabetes

Surgery Treatment and Nutrition Implications

Whipple procedure, esophagectomy, gastrectomy, GI resection, oral reconstruction with free flap (done with head & neck cancers), site specific therapies Fatigue, pain, anorexia, site-specific effects ie: *malabsorption, acute dumping syndrome, severe dysphagia*

Radiation therapy definition & side effects

X-rays, gamma rays, various atomic particles. Treatments generate charged particles within cell to promote cell death Side effects: Fatigue, anorexia, skin changes, esophagitis, xerostomia, and diarrhea

Lutein

Xanthophyll; antimutagenic and anticarcinogenic properties. Conventional Food: dark green leafy vegs, spinach, kale, broccoli, squash, green peas, lettuce, onions, corn, pumpkin, egg yolk Functional Food: added to ready to eat cereal

XRT to head & neck

Xerostoma, sore mouth & throat, dysphagai, odynophagia, mucositis, altered tastes & smell, fatigue, loss of appetite, late effects, mucosal atrophy, dryness & ulceration, salivary glands xerostomia, fibrosis, osteoradionecrosis, trismus, altered taste & smell

Oral Cavity / Pharynx Cancer S/E and Interventions

Xerostomia- Ade intake, wet foods, oral care, alter consistency if needed, oral supplements, NS- if needed Dysphagia- Consistency if needed, oral supplements, monitor wt, SLP Tooth Decay- Consistency, oral supplements, temp/sensitivity, dentist dysgeusia-(altered taste) alter types of food

Ziv-albercept

Zaltrap Colorectal Cancer Anorexia, D, mucositis, myelosuppression.

Streptozocin

Zanosar (nitroureas)

Vemurafenib

Zelboraf Protein-Targeted Agents: MOA: Small molecular inhibitor of *BRAF oncogene+ melanoma*; BRAF inhibitors- target the mutant form of the BARF protein. Use: Metastatic melanoma

Zoledronic acid (Zometa®) is a supportive care drug in the category of bisphosphonates that can be used to decrease complications produced by metastasis to the: A. Brain B. Bone C. Liver D. Kidney

Zoledronic acid (Zometa®) is a supportive care drug in the category of bisphosphonates to decrease complications produced by metastasis to the: B. BONE

Vorinostat

Zolinza Inhibits enzymatic activity of HDAC

Zoledronic Acid

Zometa Treats MM Take oral supplement of 500 mg calcium and 400 IU of Vit. D daily

zoledronic acid

Zometa. (bone mets or pain) Considerations: Supplement with 500 mg Ca and 400 IU D3

Kaposi Sarcoma

a cancer that develops from the cells that line lymph or blood vessels. The abnormal cells of KS form purple, red, or brown blotches or tumors on the skin. These affected areas are called lesions. The skin lesions of KS may look bad, but in many cases, the lesions cause no symptoms. In other cases, the disease causes painful swelling, especially in the legs, groin area, or skin around the eyes. KS can cause serious problems (or even become life threatening) when the lesions are in the lungs, liver, or digestive tract. KS in the digestive tract, for example, can cause bleeding, while tumors in the lungs may cause difficulty breathing.

staging

a classification system known as TNM that is used to identify the "extent" of the tumor: its size, the degree of growth & spread; T - size of tumor, N- degree of spread to lymph nodes; M- presence of mets

radiation-induced enteritis

a condition of inflammation that can occur after XRT to the GI tract & that leads to diarrhea & malabsorption

Aplastic Anemia

a disorder in which the bone marrow fails to make enough blood cells. the stem cells are damaged and there are very few of them. As a result, too few blood cells are produced. In most cases of aplastic anemia, all 3 types of blood cells are low (which is called pancytopenia). Rarely, just one of the cell lines, such as red cells, white cells, or platelets, is abnormal. Aplastic anemia is not a type of cancer but may be associated with certain cancers (especially those affecting the bone marrow, such as leukemia) or cancer treatments. A small number of patients with aplastic anemia may develop leukemia.

graft-versus-host disease (GVHD)

a dz caused by the immune response of histoincompatible, immunocompetent donor cells against the tissues of an immunoincompetent host; an immuniologic reaction of allogeneic donor cells (graft) reacting against the pt (host) tissues evidenced by icterus & abnormal liver functions, severe /secretory diarrhea - may need total bowel rest --> isomotic, low residue, lactose-free diet --> solids with low lactose, fiber, fat & acideity, gastric irritants --> regular diet - usually 3 onths after transplant (but may be 7-10 days post)

Alpha-fetoprotein (AFP) Test / Screening

a fetal protein that appears in the blood of adults with certain types of cancer A blood test that measures the level of alpha-fetoprotein in the mothers' blood during pregnancy as an indicator of possible birth defects in a fetus For liver and testicular cancers

Neuroblastoma

a form of cancer that starts in certain types of very primitive nerve cells found in an embryo or fetus. This type of cancer occurs in infants and young children. It is rarely found in children older than 10 years. Neuroblastomas are cancers that start in early nerve cells of the sympathetic nervous system (sympathetic neuroblasts), so they can be found anywhere along this system.

Decreased transit time frequently occurs with removal of

a large section of the bowel, ileocecal valve resection and ileostomy.

peripheral neuropathy natural treatments following chemo

a painful condition of the nerves of the hands and feet due to damage to the peripheral nerves; also known as peripheral neuritis -glutamine -glutathione - B vitamins - Vit E -Alpha-lipoic acid **acupuncture- improves pain, nerve function, sensation and relieve peripheral neuropathy with chemo

pancytopenia

a reduction in all cellular elements of the blood

neutropenia

a reduction of WBC (neutrophils) that can be caused by chemo or XRT, results in increased susceptibility to life-threatening infections

multiple myeloma

a type of cancer formed by malignant plasma cells. Normal plasma cells are found in the bone marrow the overgrowth of plasma cells in the bone marrow can crowd out the normal blood-forming cells. This can cause anemia, can also cause the level of platelets in the blood to become low (called thrombocytopenia).

Leukemia - Chronic Lymphocytic (CLL)

a type of cancer that starts from white blood cells (called lymphocytes) in the bone marrow. It then invades the blood. Leukemia cells tend to build up in the body over time, but in many cases people don't have any symptoms for at least a few years. In time, it can also invade other parts of the body, including the lymph nodes, liver, and spleen. Compared to other types of leukemia, CLL usually grows slowly.

Leukemia - Chronic Myelomonocytic (CMML)

a type of cancer that starts in blood-forming cells of the bone marrow and invades the blood. In CMML, patients have an elevated number of monocytes in the blood, with a monocyte count of at least 1,000 (per mm3). Many patients have enlarged spleens (an organ that lies just below the left rib cage). About 15% to 30% of patients go on to develop acute myeloid leukemia.

Leukemia - Chronic Myeloid (CML)

a type of cancer that starts in the blood-forming cells of the bone marrow and invades the blood. In CML, leukemia cells tend to build up in the body over time, but in many cases people don't have any symptoms for at least a few years. In time, the cells can also invade other parts of the body, including the spleen. CML can also change into a fast-growing acute leukemia that invades almost any organ in the body.

Wilms Tumor

a type of cancer that starts in the kidneys. It is the most common type of kidney cancer in children.

Nephrotoxic medications

a. Antibiotics (ciprofloxin, rifampin, tetracycline, acyclovir, vancomycin, amphotericin, pentamidine, penicillins, cephalosporins) b. NSAIDS-ibuprophen c. ace inhibitors (antihypertensive) d. Dilantin (seizure medication) e. Cimetidine (Tagamet - GERD medication) f. Chemo (cisplatin/platinol, Streptozocin/zanosar)

Those diagnosed with peritoneal cancer or metastasis present with general GI symptoms such as :

abdominal bloating, cramping, nausea, diarrhea, constipation, anorexia

Chemo- Alkylating agents

ability to alkylate many nucleophilic functional groups. They impair cell function by forming covalent bonds with the amino, carboxyl, sulfhydryl, and phosphate groups in biologically important molecules. Example: Cytotoxic chemo - cisplatin, ifosfamide, cyclosphosphamide, busulfan Side effects: Myelosuppression, anorexia, N/V, fatigue, renal toxicities

CAM potentially harmful supplements

alfalfa androstenedione aristolochia belladonna borage butchers broom chaparral comfrey ephedra foxglove germander kava kombacha tea licorice lobelia mistletoe pau d'arco pennyroyal sassafras snakeroot skullcap St Johns Wort Wormwood Yohimbe *not a comprehensive list

administer 350-1000 mcg folic acid daily for 1 week prior to first cycle and daily for three weeks after final cycle. give b12 injection 1 week before first cycle and repeat every 9 weeks until treatment completed

alimta

Lomustine (CCNU)

alkylating agent CeeNU Nitroureas S/E: N/V, anorexia, stomatitis Avoid alcohol

urticaria

allergic reaction of the skin characterized by the eruption of pale red, elevated patches called wheals or hives

Following major abdominal surgery, the small bowel regains function ______. However, after intestinal resection, adaptation of the GI tract may take ____.

almost immediately weeks to months

Leukemia - Acute Lymphocytic (ALL) in Adults

also called acute lymphoblastic leukemia, is a cancer that starts from white blood cells called lymphocytes in the bone marrow (the soft inner part of the bones, where new blood cells are made). The term "acute" means that the leukemia can progress quickly, and if not treated, would probably be fatal in a few months. "Lymphocytic" or "lymphoblastic" means it develops from cells that were destined to become certain cells called lymphocytes or lymphoblasts. This is different from acute myeloid leukemia (AML), which develops in other blood cell types found in the bone marrow.

CAM-Megavitamin therapy

alternative therapy use of large doses of 1 or more vit, antioxidants, coenzyme Q10, pangamic acid

ASPEN guidelines for nutrition support

anticipated to require for 7-10days + unless malnourished Indications for PN: - paralytic or post op ileus - Malignant bowel obstruction - high output distal GI fistula (>200 mL/d) - Inability to tolerate EN for 7-14 days - Large volume diarrhea or high output ostomies refractory to medication management

CAM-Ginger

antiemetic, digestive aid.

Ginger

antiemetic, digestive aid.

CAM-Milk thistle

antioxidant, little evidence to support anticancer may delay the clearance of chemo by the liver

Milk thistle

antioxidant, little evidence to support anticancer may delay the clearance of chemo by the liver

Extracorporeal photopheresis GVHD treatment/prevention

apheresis and photodynamic therapy in which blood is subject to apheresis to separate buffy coat from whole blood, chemically treated with 8-methoxypsoralen, exposed to ultraviolet light, and then returned to the patient. S/E: Hypocalcemia IV fluid maybe needed for adq hydration status May not be possible w sig hypertriglyceridemia (lipemic serum blocks UV light)

CAM Breast Cancer

arginine and chemotherapy vitamin E and radiation

Benefits of enteral access in patients with malnutrition usually outweigh the risks of access-related complications. However, risks may outweigh benefits in the presence of ____, ____ or ____.

ascites, peritoneal carcinomatosis, inoperable bowel obstruction

Conditions when enteral access risks might outweigh benefits

ascites, peritoneal carcinomatosis, inoperable bowel obstruction

chemo causing renal toxicity

asparaginase capcitabine carboplatin carmustine cisplatin /platinol cytarabine fludarabine gemcitabine/Gemzar ifosfamide mercaptopurine methotrexate mitomycin procarbazine flutamide( hormonal tx) bevacizumab/ avastin (molecular tx)

chemo causing pancreatitis

asparaginase mercaptopurine

chemo goal

attain maximum therapeutic effect without extreme toxicity to normal tissue

4 types of bone marrow transplant

autogolous allogeneic haplo identical cord blood

F&N interactions Oxaloplatin (Eloxatin)

avoid cold foods and drinks for 5 days after treatment to avoid neuropathy

dry mouth products OTC * many contain sorbitol, xylitol There are significant differences in the performance of various saliva substitue=tes and more studies are needed. It is estimated that saliva substitutes provide relief for approximately 40% of patients who use them.

biotene products bioXtra moisturizing gel, mouth spray, tablets carrots or celery (oral cancer foundation) cherry or olive pit entertainers secret throat relief glandosane mouth moisturizer Halls refresh candy MedActive patient friendly oral relief spray Moistir oral spray mouth kote Numoisyn liquid, lozenges Oasis moisturizing mouthwash, spray optimoist spray oramoist time released dry mouth disc salivart oral moisturizing spray salivasure tablets stoppers dry mouth spray sugar free candies, gum thayers dry mouth spray xero lube artificial saliva spray xylimelts thyme tea

generic name for Dulcolax

bisacodyl

What supplement may interfere with Tamoxifen and can also increase toxicity of doxorubicin and docetaxel/Taxotere?

black cohosh

chemo causing pulmonary fibrosis / toxicity

bleomycin /Blenoxane (fibrosis) carmustine (toxicity) chlorambucil (fibrosis) cyclophosphamide (fibrosis) melphalen (fibrosis)

prostate-specific antigen (PSA)

blood test used to screen for prostate cancer blood test that measures the level of prostate-specific antigen in the blood

Hypercalcemia

bone-mets of breast, lung, & pancreas, dietary Ca should not be restricted.

Operative trauma can cause intestinal dysfunction, but in most patients GI function returns rapidly postoperatively and intraluminal nutrients promote ____

bowel hypertrophy and anastomotic healing

enteral support contraindications

bowel obstruction in lower GI hemodynamically unstable, requiring pressor support, MAPs<60-70 severe active GI bleed ischemic or perforated GUT high output fistula aggressive intervention not warranted extensive resection of small bowel or small bowel not functioning must have 100cm jejunum +150 cm of ileum with ileocecal valve for adequate absorption

indication for taxotere

breast, lung, h/n, met ovarian

indication for adriamycin

breast, nhl, ovarian, lung, all, aml, thyroid

Indication for cyclophosphamide

breast, ovairan, lymphoma, leukemia

Preventative measures for mouth sores (all patients)

brush 3-4x per day, floss

chemo causing nausea/vomiting (severe)

busulfan carboplatin carmustine cisplatin /Platinol hi dose cytarabine cyclophosphamied dacarbazine dactinomycin daunorubicin doxorubicin epirubicin irenotecan mechlorethamine methotrexate procarbazine

XRT

can be delivered externally or internally by placing a radioactive implant in the body next to the tumor -Affects only the tumor & surrounding tissue - Side effects usually begins in 2nd -4th weeks after XRT, can occur even years after treatment - fatigue, loss of appetite, skin changes, hair loss in the area being treated

radiation -general

Deferasiox/Exjade

can cause diarrhea in lactose intolerant patients, recommend lactase enzymes

Prompt and appropriate nutrition management can help to improve what in a cancer patient?

can help to improve patients' tolerance of treatment, minimize nutrition-related symptoms and maximize quality of life.

weight management during cancer treatment

cancer survivorship-guidelines suggest overweight/obese can pursue weight loss

Aflatoxins

carcinogens. mycotoxins produced by certain molds or fungi. in cereal grains and legumes

Surgery m ay increase the risk of malnutrition due to ____, ____ and ____, which in combination with anesthesia can cause intestinal dysfunction, impair bowel permeability, alter gut-associated lymphoid tissues and stress the immune system.

catabolism, nutrient losses, operative trauma

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

caused by the overproduction of the antidiuretic hormone ADH overproduction of the antidiuretic hormone ADH, leading to bloating, water retention, and electrolyte imbalance

Radiation to the head and neck or to the pelvis or abdomen

causes mucositis in greater than 50% of the patients.

central vs peripheral PN

central preferred for patients who are stressed, hypermetabolic or require a fluid restriction because formula can be concentrated since it is infused via a large vein. Also preferred if PN will be required for longer than 1 week or if central access is already in place. CVAD, Hickman, Broviac, Groshong, PICC, port. peripheral via peripheral catheter for less than 1 week. Requires formula that is modest in osmolarity (<10% dextrose and < 900 mOsm/kg) and periodic changing of IV sites to prevent thrombophlebitis. May be limited in dextrose and protein. *peripheral indications: -short term need -mild to moderate malnutrition -normal to mildly increased metabolic rate -no fluid restriction -no allergy to lipids -no central line in place

regular screening can prevent cancer of:

cervix, colon, rectum

ovarian cancer treatment

chemo/radiation, opt to do complete hysterectomy depending on stage •If they are advanced stage, they will only do a hysterectomy for palliative reasons to promote comfort 1st Line - Cisplatin - Carboplatin - Paclitaxel / taxol / Abraxane - Cyclophosphamide 2nd Line - Melphalah - Chlorambucil - 5-Fluro - Methotrexate - Vincristine - Doxorubicin

Surgery Oral cavity

chewing/swallowing difficulty aspiration risk sore mouth xerostomia taste and smell alterations

CAM-PC-SPECS

chinese herbs & saw palmetto, estrogenic, not proven treatment for prostate CA may elevated BP, increase estrogen levels & forms blood clots in legs & lungs

PC-SPECS

chinese herbs & saw palmetto, estrogenic, not proven treatment for prostate CA may elevated BP, increase estrogen levels & forms blood clots in legs & lungs

Leukeran

chlorambucil. Luke likes to color but not with spicy Barb Alkylating agent- interfers with DNA bases, causing breaks in DNA helix strands, thus preventing DNA replication and transcription of RNA PO Oral- TAKE ON AN EMPTY STOMACH *Risk of toxicity with barbiturates SFX: N/V, hyperuricemia, PULM TOX, skin rash, seizure- in children ** Avoid acidic, spicy, hot foods

chemo causing oto toxicity

cisplatin carboplatin

cisplatin and oxaliplatin / Eloxatin effects

cisplatin is a platinum based medication known for causing Mg deficiency, K+ wasting, metallic taste, wearing difficulties. oxaliplatin /Eloxatin causes more peripheral neuropathy & inc sensitivity to cold

indication for hydrea

cml, melanoma

indication for 5-fu

colorectal, esophageal, h/n, stomach

Nutrition related factors that influence cancer

combined exposure or multiple of these factors increase your risk of developing cancer significantly

CAM-Kelley/Gonzales regimen

consumption of 25 nutritional supplements & digestive enzymes, detoxifying treatments - coffee enemas, moderate exercise, fasting & purging

Kelley/Gonzales regimen

consumption of 25 nutritional supplements & digestive enzymes, detoxifying treatments - coffee enemas, moderate exercise, fasting & purging

why can red meat lead to cancer

contains heme iron which can lead to free radical production

chemo causing mucositis/esophagitis (severe)

dactinomycin daunorubicin doxorubicin 5FU methotrexate

chemo causing cardiotoxicity

daunorubicin doxorubicin epirubicin 5FU idarubicin bevacizumab/velcade (molecular) *--> CHF trastuzumab/herceptin (molecular tx) *-->CHF

When gastric acid secretion exceeds the amount of bicarbonate available, it _____ and ____, leading to maldigestion, which can cause malabsorption

deactivates digestive enzymes and deconjugates bile acids

hypogeusia

decreased taste acuity

Strictures following an esophagectomy are a result of ____ and ____.

decreased vascularization and late ischemia in response to a decrease in blood supply to the stomach

Patients with ileostomy are at increased risk for ____ and ____

dehydration and electrolyte abnormalities.

Dysmotility is common following stomach resections and may manifest as ____

delayed or accelerated gastric emptying. Delayed: early satiety, heart burn, dysphagia, aspiration, pneumonia Accelerated: dumping syndrome

______ is one of the many causes of chronic GI dysmotility.

denervation

Due to the proximity of the peritoneum to the GI system, surgical resections involving the peritoneum have the potential to ______

disrupt normal GI function.

chemo causing myelosuppression (severe)

docetaxel/Taxotere mechlorethamine mitomycin thioguanine topotecan

generic name for Colace

docusate

antiemetics: benzamides (Dopamine agonists or 5HT3) metoclopramide/reglan

dopamine agonist or 5HT3 at high doses side effects: sedation fatigue diarrhea nausea also used in early satiety and anorexia

dronabinol, mirtazapine, megastrol acetate

dronabinol is an appetite stimulant to treat anorexia associated with chemotherapy, helps in 15-20% of cases, hard to get covered with insurance mirtazapine is an anxiolytic that has been known to improve appetite in 20% of cases megastrol acetate - steroid, not used in patient populations. inc risk of DVTs in older adults

Surgery with gastric CA

dumping sydrome, dehydration, early satiety, gastroparesiss, fat malabsorption, vit, mineral malabsorption (Vit b12, D, Ca, iron)

Disruption of the pyloric sphincter and gastrojejunostomy may lead to ____

dumping syndrome

Surgery Stomach

dumping syndrome dehydration early satiety gastroparesis fat malabsorption vitamin and mineral malabsorption ( B12, D, Calcium, iron)

Clinical manifestations of altered GI transit include:

dumping syndrome, heartburn, early satiety, pain, meteorism, abdominal distention, dysphagia, constipation, diarrhea

The first and shortest section of the small intestines is the ____

duodenum

resection of the vagus nerve during an esophagectomy results in

dysmotility, overeating

Surgery Larynx

dysphagia aspiration risk

In esophageal cancer, ______ is the primary preoperative symptom, which is a result of esophageal narrowing as the tumor grow.

dysphagia - assess etiology. Review swallow study results and SLP recs Evaluate SLP recs compliance Assess intake- hx, records, frequency, 24 recall Interventions: - altered texture - thickeners if SLP recs - moist foods -Avoid dry - alternate solids and liquids - eat upright - avoid distractions during meals - avoid straws - Odynophagia (painful swallow) - pain meds/lozenges - Chin tuck -Verbalization after swallowing liquids Pharmacotherapy: Topical anesthetics- lidocaine spray / Xylocaine Analgesia- opioids, pain meds Thickeners

XRT to Thorax (esophagus, lung, breast)

dysphagia, odynophagia, heartburn, fatigue, loss of appetite, late effects, esophogeal fibrosis, stenosis, neocrosis, cardiac angina, pericarditis, cardiac enlargement, pulmonary dry cough, fibrosis, PNA

higher risk for breast CA

early menarche, late menopause, not having children, having children after age 30

Surgery Gynecological

early satiety bloating, cramping, gas

surgery w/ gyneocologic CA

early satiety, bloating cramping, gas

hyperamylasemia

elevated amylase- 1-137 U/L

Adiponectin

enhances sensitivity to insulin

Neupogen

filgrastim used to treat neutropenia

Quercetin

flavonoid in apples, onions, tea, red wine, berries. inhibit the expression of CYP1A1

Fludara

fludarabine SE: myelo, N/V/D/A, NEURO TOX, taste change, rash Antimetabolite IV, PO **oral can be taken +- food. **monitor for TLS in new dx CLL

The primary digestive function of the colon is ____ and ____

fluid resorption and electrolyte absorption

cultural-The Church of Jesus Christ of Latter -Day Saints (Mormons)

forbidden: ETOH, hot drinks (coffee-tea), caffeine church encouraged limited meat consumption and to eat mostly grains some fast 1 day per month and donate food money to the poor

pain meds step 3- Adjuvant meds to increase analgesic efficacy (WHO)

frequently used with analgesics or opiods to treat the hard to manage cancer related bone or nerve pain. Examples: amitriptyline baclofen bupropion anticonvulsants skeletal muscle relaxers antidepressants bisphosphonates steroids antitussives CNS stimulants anticholinergics local anasthetics (eg lidocaine) cannabinoids

CAM-Juice therapy

fresh fruit & veg juice to cleanse & detox Inadequate energy & macro/micronutrients

Juice therapy

fresh fruit & veg juice to cleanse & detox Inadequate energy & macro/micronutrients

Surgery Pancreas

gastroparesis fluid and lyte imbalance hyperglycemia fat malabsorption vitamin and mineral malabsorption ( vitamins B12, A,D,E,K, Calcium, iron and Zn) chyle leak When >70% is removed, insulin is required Up to 90% of pancreas can be removed before clinical symptoms of malabsorption results, may use pancreatic enzyme replacement therapy

Surgery Gallbladder and Bile Duct

gastroparesis hyperglycemia fluid and lyte imbalances fat malabsorption vitamin and mineral malabsorption( B12, A,D,E,K, Mg, Zn, Calcium, iron)

Surgery Esophagus

gastroparesis indigestion, acid reflux alterations in normal swallowing, decreased motility anastomotic leak/breakdown

surgery with SB

gastroparesis, fat malab, hyperglycemia, fluid/elyte imbalance, chyle leak, vit malab b12, a, d, e, k, iron, ca, zinc

Surgery with pancreas

gastroparesis, fluid & lyte imbalance, hyperglycemia, fat malabsorption, Vit A, D, E, K, B12, Ca, Zn, iron malabsorption, chyle leak

Surgery with gallbladder & bile duct

gastroparesis, hyperglycemia, fluid & lyte, fat malabsorption, vit, min malabsorption (vit b12, A, D, E, K, Mg, Zinc, Ca iron)

surgery with esophagus CA

gastroparesis, indigestion/ acid reflux, altered swallowing decreased motility, anastomotic leak

Intraoperative placement of feeding tubes has become commonplace during major gastrointestinal procedures and can take the form of ____ or _____

gastrostomy or jejunal tube

Gemzar

gemcitabine. GEM GEM poops clay b/c of the flu Cell Cycle-specific chemo agent:Antimetabolite-interferes with DNA synthesis by acting as false metabolities; incorporated into the DNA strand or block essential enzymes IV Myelosuppression, N/V/D/M, PULM TOX, rash, flu like, mouth, fluid retention, poor appetite. *May cause clay colored stool Avoid St. John's Wort, grapefruit juice.

GTX

gemcitabine/Gemzar, docetaxel/Taxotere, capecitabine/Xeloda

parenteral monitoring

glucose, lytes, BUN, creatinine: prior to initiation, daily x 3 days then weekly if stable Mg Phos: prior to initiation, daily x 3 days, weekly if stable (refeeding!) Cc, LFTs, CBC, PT/INR: prior to initiation TGs: prior to initiation, repeat if abnormal or if receiving lipid based PN or meds.

Use of what additive is controversial with HCT?

glutamine -- may be beneficial

bone marrow transplant

goal to replace malignant cells with normal healthy cells in the hematopoietic system

oral mucositis grades

grade 1: soreness/erythema grade 2: ulceration/solid foods grade 3: liquid diet grade 4: no alimentation

Cancer

group of neoplastic disease characterized by uncontrolled growth and spread of abnormal cells which if left untreated result in death

cancer

group of neoplastic diseases characterized by uncontrolled growth & spread of abnormal cells - which if left untreated result in death

Anabolic agents

growth hormone oxandralone Nandrolone

metastasis

growth of malignant tissue that spreads to surrounding tissue or organs

haplo identical transplant

half match often parent or child

haplo identical

half match (often a parent or child)

skin GVH grades 3 and 4

have huge fluid filled bullae that represent infection risks, fatal protein, zinc, vit A & vit C needed for wound healing

In general, surgery to the ______, ____ and ____ have the greatest potential for major derangements in nutritional status.

head and neck, GI tract, abdominal vasculature

EN Medication Concerns Antidiarrheals

hydrolyzed guar gum can be used ot thicken stool and is appropriate for administering via enteral access device (EAD) when mixed with water. - NOT RECOMMENDED FOR USE WITH EN DEVICES :cholestyramine (caution w small bore tubes); alternative meds for EN: Loperamide liquid, diphenoxylate hydrochloride, and atropine sulfate

parenteral complications

hyper /hypo glycemia refeeding syndrome, lyte abnormalities venous thrombosis catheter occlusion catheter sepsis tunnel infection exit site/cuff infection bloodstream infection metabolic bone disease: osteomalacia, osteoporosis hepatic disease: hepatic stenosis, cholestasis biliary disease: biliary sludge, gallstones renal disease: decreased glomerular filtration rate, tubular dysfunction GI: gastroparesis, intestinal hypoplasia

Surgery Hepatocellular

hyperglycemia hypertriglyceridemia fluid and lyte imbalances fat malabsorption vitamin and mineral malabsorption( A,D,E,K,thiamin, folic acid, Mg, Zn)

Surgery with hepatocellular

hyperglycemia, hyper-TG, fluid & lytes imbalance, Vit/min malabsorption Vit A, D, E, K, B12, folic acid, Mg, Zinc)

preoperative liver disease may cause ___, ___, __, ___ and ___

hypoalbuminemia, hyperglucagonemia, increase energy expenditure, depleted muscle mass, and anorexia

Reduced synthesis and increased catabolism of serum hepatic protein levels may occur following liver surgery. This may lead to ____ resulting in malabsorption due to ____ and ___.

hypoalbuminemia; bowel wall edema as well as fluid retention in the extremities

Refeeding syndrome is characterized by severe electrolyte abnormalities such as...

hypophosphatemia hypokalemia hypomagnesemia Once electrolytes are restored to the normal range, EN should start with 25% of estimated energy needs and advance over 3-5 days to feeding goals

Thyroid Cancer S/E and Interventions

hypothyroid- healthy weight, PA

Idamycin

idarubicin. IDA KICKED her HT when she peed red then had some tea Antimetabolite IV SFX: /V/D/M , CARDIO TOX, myelo Red/Orange urine, alopecia, HAND FOOT SYNDROME *n/v = mild, within first 1-2 hrs *mucositis within 1st week of therapy Antioxidant; Increases benefits/decreases toxicity of doxorubicin and idarubicin. Theanine found in Tea. Cell cycle-specific chemotherapy agent: Anthracycline antitumor antibiotics- inhibit cell division by binding to DNA and interfering with RNA synthesis

Surgery w/ colorectal CA

increased transit time, D, dehydration, bloating, cramping, fluid/ lytes imbalance, Vit b12, Na, K, Mg, Ca malabsorption

radiation side effects when radiation is done near GI tract or salivary glands

if you have radiation anywhere near the GI tract you're going to have xerostomia. if it's near the salivary glands can cause dry mouth. can be permanent and end up with sore throat, esophagitis, gastritis, diarrhea if in the gut area

The final section of the small bowel is the ____, and it is almost 60% of the small bowel length.

ileum

immunosuppression complication for PN

impaired ability to provide an immune response Soy-based IV lipid emulsions-> use alternative IV lipid, limit IV lipids in critical care during first week of PN therapy Overfeeding-> avoid , particularly w dextrose

Gallbladder Complication for PN

impaired bile flow/ lack of enteric stimulation-> encourage enteral intake or trickle TF if able

cholestasis complication of PN

impaired biliary secretion; TBili >2 mg/dL - Sepsis/ileal dz/resection/small intestine bacterial overgrowth (SIBO)/malignant dz-> assess for and treat underlying contributing medical conditions - Loss of enteric stimulation/short bowel syndrome-> encourage enteral intake or trickle TF if able - Duration of PN-> cycle PN over 12 to 16 hours

dysgeusia

impaired taste

2 indicators associated with cancer cachexia?

in addition to weight loss, *loss of appetite & hypoalbuminemia* are the 2 indicators that we primarily see in patients that are then diagnosed in patients with cachexia

Trimus

inability to fully open mouth due to inflamed jaw muscles

Possible causes of hypernatremia?

inadequate FW ----> change FW to fix Excess fluid losses (diurese) ---> monitor fluid status, I/O, daily wts

Hypernatremia Corrections for EN

inadequate free water-> increase free water Excessive losses (diuresis)-> monitor fluids, I/Os, daily wts

soy & soy foods

inconsistent evidence, may not be appropriate for women with hormone -responsive CA

Excess abdominal fat

increase risk of colorectal and possible pancreatic, postmenopausal breast, endometrial CA

Elevated CYP1A1

increased risk of Lung CA

effects of VIPomas

increased secretion of vasoactive intestinal peptide -Verner-Morrison syndrome - Pancreatic cholera -WHDA (watery diarrhea, hypokalemia, achlorhydria)

Decreased albumin is associated with _____ and ____.

increased surgical mortality and morbidity, especially sepsis and healing complications

Surgery Colorectal

increased transit time diarrhea dehydration bloating, cramping and/or gas fluid and lyte imbalance vitamin and mineral malabsorption ( vitamin B12, sodium, potassium, magnesium, calcium)

Ewing's sarcoma bone

malignant round-cell tumor. It is a rare disease in which cancer cells are found in the bone or in soft tissue. The most common areas in which it occurs are the pelvis, the femur, the humerus, the ribs and clavicle.occurs most frequently in male teenagers. frequently associated with malnutrition

Ewing's sarcoma

____ postoperatively impacts the return of liver function and regeneration and may increase morbidity and mortality

malnutrition

1/5 of people diagnosed with cancer will die of what?

malnutrition (not that cancer itself)

Echinacea

managament of colds, flu, fever, resp & urinary infxn, immune stimulant contraindicated in autoimmune disease & allergies to daises, numbing of tongue

What potential toxicities are r/t to TPN?

manganese Chromium aluminum hypertriglyceridemia

chemo- Antimetabolites

masquerade as purines or pyrimidines—which become the building blocks of DNA. They prevent these substances from becoming incorporated in to DNA during the "S" phase (of the cell cycle), stopping normal development and division. They also affect RNA synthesis. Due to their efficiency, these drugs are the most widely used cytostatics. Example: Cytotoxic chemo - 5-Fluorouracil, methotrexate, fludarabine Side effect: Myelosuppression, anorexia, N/V/D, mucositis, fatigue,

malignant neoplasm

mass of CA cells that invades surrounding tissues or spreads to distant areas of body

CAM Chammomile

may increase bleeding with anticoagulants may increase sedative effect of benzos

CAM Dong Quai

may increase effects of warfarin

prognostic nutritional index

measures the risk a patient has of developing complications related to malnutrition PNI%= 158-16.6A-0.78TSF-0.2TFN-5.8DH <40:low risk 40-49.99: intermediate risk >/= 50: high risk

chelating agents

molecules that attract or bind with other molecules and are therefore useful in either preventing or promoting movement of substances from place to place Ingredients added to a product to enhance the effectiveness of the preservative trap trace amounts of metal atoms that would otherwise cause food to discolor or go rancid

chemo biotherapies-radiopharmaceuticals contain radioisotopes for the systemic treatment of cancer: radioimmunotherapy agents:monoclonal antibodies combined with radioactive substances that deliver radiation directly to cancer cells radioactive substances: radioiodine or iodine 131 for treatment of thyroid cancers radiopharmaceuticals: method of palliative radiation tx used for relief of metastatic bone pain

monoclonal antibodiy therapies that deliver radioactive molecules to specific cancer cells side effects: RIA: acute: myelosuppression, infusion related issues, mild nausea, vomiting, diarrhea, anorexia, infection, cough, throat irritation, dyspnea, generalized aches and pains late: secondary malignancy RS: acute: neck tenderness and swelling, nausea, vomiting, fatigue, salivary gland tenderness and swelling, taste changes and xerostomia. late/long term: risk of secondary malignancy RP: acute-myelosuppression, nausea, vomiting, flushing late: risk of secondary malignancy

mesothelioma

most common occupationally cause of Lung CA from Asbestos exposure

antiemetics-5-HT3 serotonin antagonists dolasetron/anzemet granisetron/kytril ondansetron/zofran

most effective in the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), esp caused by highly emetogenic drugs such as cisplatin/Platinol; when used for this purpose, they may be given alone or, more frequently, with glucocorticoid, usually dexamethasone. They are usually given intravenously, shortly before administration of the chemotherapeutic agent. The concomitant administration of a NK1 receptor antagonist, such as aprepitant, increases the efficacy of 5-HT3 antagonists in preventing both acute and delayed CINV. The 5-HT3 antagonists are also indicated in the prevention and treatment of radiation-induced nausea and vomiting (RINV) and post-op nausea and vomiting (PONV). side effects: headache, diarrhea, constipation, possible EKG changes, somnolence

5-HT3 antagonists

most effective in the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), esp caused by highly emetogenic drugs such as cisplatin; when used for this purpose, they may be given alone or, more frequently, with glucocorticoid, usually dexamethasone. They are usually given intravenously, shortly before administration of the chemotherapeutic agent. The concomitant administration of a NK1 receptor antagonist, such as aprepitant, increases the efficacy of 5-HT3 antagonists in preventing both acute and delayed CINV. The 5-HT3 antagonists are also indicated in the prevention and treatment of radiation-induced nausea and vomiting (RINV) and post-op nausea and vomiting (PONV).

Non-small cell lung cancer (NSCLC)

most lung CA type * Squamous cell carcinoma: About 25% to 30% of all lung cancers are this kind. They are linked to smoking and tend to be found in the middle of the lungs, near a bronchus. * Adenocarcinoma: This type accounts for about 40% of lung cancers. It is usually found in the outer part of the lung. * Large-cell (undifferentiated) carcinoma: About 10% to 15% of lung cancers are this type. It can start in any part of the lung. It tends to grow and spread quickly, which makes it harder to treat.

Xerostomia

mouth dryness

The small bowel, which is approximately 20 ft long, is the primary site of ____

nutrient absorption

Pulmonary products provide what special nutrition considerations?

nutrient dense (~1.5 kcal) low CHO high lipid -- EPA, GLA; Pro = 16-18%

Although dilation is successful in 99% of patients, 50% of patients need to undergo ____

multiple dilations

nutrition risk with BMT

n/v taste alterations thick saliva/mucous anorexia oral/esophageal mucositis diarrhea GVHD

Alkaline diet

need for Ca and Vit D

ANC of <1500 is

neutropenia - The National Cancer Institute defines neutropenia as an absolute neutrophil count (ANC) below 1,500/mm3 . An ANC from 500 to 1,000/mm3 is considered severe neutropenia and below 500/mm3 is life threatening.1 However, the definition of neutropenia and the criteria for using the neutropenic diet vary from institution to institution. The most common causes of neutropenia include disease of the bone marrow (eg, leukemia), viral infections such as HIV, and the use of chemotherapy and other cancer-related treatments such as bone marrow transplantation, which interfere with neutrophil production within the bone marrow.

Mechlorethamine

nitrogen mustard Alkylating agent SFX: N/V, hyperuricemia, Myelo, pain/inflammation in the injection site, alopecia.

Orexigenics (NSAIDS)

no increase in LBM sfx: GI upset/bleed

phytochemicals

nonutritive compounds in plants though to influence the process of tumorigenesis

transition from PN to EN

once pt demonstrates ability to digest, absorb and utilize enteral nutrition in adequate amounts either orally, via feeding tube or in combination. PN should be decreased once intake equals 500 kcals/day and discontinued once pt meeting 60% of estimated energy and protein goal.

gastrectomy, the surgical removal of part of all of the stomach, may affect ____

one or more sphincter (LES and/or pyloric)

pain meds step 2- opiods for moderate to severe pain (WHO)

opiods (narcotics) major supportive pain therapy for cancer pain management. Often used concurrently with analgesics. Opiods slow gastric and intestinal contractions and therefore cause constipation in 40-95% of patients treated with opiods and can occur with even ONE DOSE of morphine. If constipation is already present (no BM>3days) lactulose may be used to clean out the bowel. If experiencing nausea, cleansing enemes may be required.

For patients in whom nutrition support is initiated, support should continue until ______

oral intake is tolerated and consistently meeting 2/3-3/4 of their nutrition needs + 1000 mL fluids for 3 consecutive days

chemo systemic

oral, IV, subQ, IM, intraosseous

corticosteroids side-effects

osteoporosis, fluid retention, adrenal suppression, glucose intolerance, lyte imbalance, muscle wasting

This chemotherapy drug makes patients sensitive to cold

oxaliplatin /Eloxatin

Taxol

paclitaxel IV Cell cycle-specific chemotherapy agent: Taxane- active in the mitosis phase of the cell cycle; antimicrotubule agents, which lead to inhibition of mitosis and cell division N/V/D/C/M, myelo, HEPATIC TOX, peripheral neuropathy, hypersensitivity, changes in transaminases, elevated BILI/alkaline phosphate, arthralgia, myalgia, swelling of feet and ankles, hypersensitivity reaction, alopecia

causes of cancer cachexia

pain, depression, anxiety, hypoguesia, hyposmia, taste/food aversions, chronic n/v, gi dysfxn, metabolic shifts, iatrogenic causes

To promote earlier return of liver function, patients can undergo preoperative _____, which induces hepatic hypertrophy and can help preserve function of liver volume

portal vein embolization

daidzein

possible protect against Lung CA. an isoflavonoid phytoestrogenic compound found in soybeans, pea pods, clover, kudzu, and other legumes.

Mucositis

painful inflammation & ulceration of the mucous membranes lining the digestive tract, can affect the entire alimentary track from the mouth to the rectum. usually as an adverse effect of chemotherapy and radiation treatment for cancer. Not everyone undergoing cancer treatment develops mouth sores. ~400,000 cancer pts develop mouth sores every year in the US Sores are likely to appear within 10 days of starting some cancer treatments. The ulcers and pain usually disappear within 3 weeks after treatment is completed. Mucositis is a common side effect of high-dose chemotherapy or total body irradiation (TBI) given prior to hematopoietic stem cell transplantation (HSCT). An estimated 75-85% of HSCT recipients experience mucositis, of which stomatitis is the most common and debilitating side effect.

Odynophagia

painful swallowing

For a patient with cancer, surgery is utilized as both _____ and ___ intervention.

palliative and curative

The duodenum receives ____ and ___ that facilitate micronutrient absorption.

pancreatic and bile secretions

head and neck cancer areas

paranasal sinuses nasal cavity tongue oral cavity salivary glands pharynx nasopharynx oropharynx

The _____ is a thin membrane that lines the inside of the abdomen.

peritoneum

_____ (inflammation of the peritoneum due to intestinal perforation or as a result of surgical intervention) can cause ileus and impair gut absorption

peritonitis

Immunotherapy

promising type of treatment for certain cancers. It is sometimes called biologic therapy, biotherapy, or biological response modifier therapy. These therapies use different parts of the body's immune system to fight cancer or to lessen the side effects of some cancer treatments. Ex: interferons, interleukins, cytokines, monoclonal antibodies, or tumor necrosis factor.

What are the most common types of cancer for men in the U.S.?

prostate, lung, colorectal, urinary bladder, melanoma skin cancer

cytokines

protein mediators produced by inflammatory cells in response to exogenous stimuli, produce metabolic changes & wating

Patients have different needs and challenges with regard to their nutrition management, providing what is an essential component of their care?

providing *individualized nutritional guidance* is an essential component of their care

Data shows that feeding _____ to an anastomosis may make it more resistant to disruption or leak.

proximal

Food remains in the stomach for a significant time before emptying through the _____ into the ____.

pyloric sphincter; duodenum

The small intestine regains the ability to absorb nutrients _____ after surgery, even in the absence of peristalsis. Dysmotility can be attenuated if feeding is started ____

quickly; within 24 hours postoperatively

breast cancer treatment

radiation therapy, chemotherapy, hormone therapy, immunotherapy, lumpectomy, mastectomy, or combo; 50% of women with breast cancer experience sexual problems resulting from physical effects of therapy, lumpectomy, radical mastectomy, chemotherapy. Lumpectomy and radiation for most single lesions (standard of care) Axillary evaluation, as indicated Pre-operative and/or post-operative combination chemotherapy for large lesions or poor prognosis histology 1st Line - Tamoxifen/aromatase inhiitors for ER positive tumors - Methotrexate Herceptin for Her2Neu positive tumors 2nd line -Prednisolone -Vincristine -Paclitaxel/ taxol / Abraxane Carcinoma- 5-Fluo, Docetaxel/Taxotere, Cyclophosphamide

allogeneic

receive cells from another matched person

Preventative measures for 5FU and MTX mouth sores

rinse with saline, soda, or Peridex

borborygmus

rumbling or gurgling noise produced by the movement of gas, fluid, or both in the gastrointestinal tract

kcal requirements for bone marrow transplant

same as regular cancer patients, but with obese patients increase SF to 1.4 when using mifflin st jeor

Cancer Cachexia

seen in patients with *lung, head & neck, and end stage cancers* Abnormalities in fluid and energy metabolism -Altered BMR -Progressive, unintentional weight loss Anorexia / Generalized wasting and weakness Immunosuppression *hypoalbuminemia* Mediated via cytokines: TNFα, TNFβ, cachectin, IL-1, IL-6, interferon-α

The use of BCAA should be reserved for patients with ____

severe hepatic encephalopathy

chemo hormonal -selective estrogen receptor modulators (tamoxifen citrate, toremifene citrate, raloxifene) BREAST

side effects menstrual symptoms, hot flashes, sweating, menstrual irregularities fluid retention, edema risk of endometrial changes thromboembolic complications skin changes, rash joint pain weight gain

chemo hormonal-progesterones (megace) BREAST, ENDOMETRIAL, RENAL CELL & AS AN APPETITE STIMULANT

side effects weight gain/fluid retention thromboembolic events nausea/vomiting menstrual bleeding, hot flashes, mood changes hyperglycemia

chemo hormonal-aromatase inhibitors (anastrozole, letrozole, exemestane) BREAST

side effects: hot flashes arthralgia mild nausea/vomiting asthenia thromboembolic events high cholesterol fever joint pain

chemo hormonal-lutenizing hormone releasing hormone (LHRH) agonists (leuprolide acetate, goserelin) PROSTATE

side effects: hot flashes, fatigue decreased libido, impotence bone pain gynecomastia headache muscle weakness

antiemetics: corticosteroids (unknown mechanism of action) dexamethasone/decadron

side effects: increased appetite anxiety mood changes euphoria headache metallic taste hyperglycemia muscle weakness impaired wound healing *most effective when used with 5HT3 agonists

antiemetics: cannabinoids (unknown mechanism) dronabinol/marinol

side effects: mood changes (vivid dreams) increased appetite hypotension tachycardia well tolerated in younger patients, may be crushed. Less tolerated in older patients.

antiemetics: benzodiazepines (benzodiazepine) lorazapam/ativan diazepam/valium

side effects: sedation confusion amnesia slurred speech effective for anticipatory nausea/anxiety. Lorazepam may be placed under the tongue.

antiemetics: anticholernigics (anticholinergic) scopolamine transderm patch

side effects: urinary retention dry eyes constipation effective for nausea related to motion, useful with bowel obstructions

chemo hormonal -antiandrogens (bicalutamide, flutamide) PROSTATE

side effects: weight gan hot flashes decreased libido, impotence bone pain

antiemetics : butyrophenone (Dopamine agonists) droperidol/inapsine haloperidol/haldol

side effects: sedation EPS droperidol is more sedating

chemo biotherapies-cancer vaccine therapies unlike targeted therapies, vaccines do not act on a certain pathway in tumor cells. Stimulates individuals own immune system against abnormal and foreign cells. only one FDA approved currently: Provenge for metastatic prostate cancer

signal am individual's own immune system against tumor antigens side effects:

chemo biotherapies -protein targeted therapies: tyrosine kinase inhibitors (TKI):Inhibits multiple receptor tyrosine kinases which are involved in tumor growth, angiogenesis and metastasis : erlotinib/Tarceva, gefetinib, imatinib, sorafenib, sunitinib mTOR inhibitor: block angiogenesis by preventing release of VEGF and PDGF thus blocking cell proliferation anc causing cell death : temsirolimus, everolimus protease inhibitors: inhibit breakdown of intracellular proteins and disrupt the protosome pathway: bortezomib, velcade

signal extracellular pathway targets , disrupt cell function which causes apoptosis side effects: skin rash/skin problems cardiotoxicity (QT prolngation, sudden death...) GI issues decreased appetite

chemo biotherapies-angiogenesis inhibitors VEGF: bevacizumab/avastin (targeted therapy) : binds to VEGF, stopping the activation of the VEGF receptor arresting endothelial cell proliferation and angiogenesis immunomodulatory: lenalidomide/revlimid, thalidomide : mechanism of action not fully understood, they inhibit pro inflammatory cytokines (TNFa, IL-1B, IL-6) and exert angiogenic properties.

signal internal pathway targets, hinders formation of new blood vessels in primary tumors thus preventing their growth, invasion and spread. side effects: hypertension arterial thromboembolic events (ATE) proteinuria hemorrhage GI perforation hypothyroidism

chemo biotherapies-monoclonal antibodies target: CD20: (ibritumomab/zevalin, rituxamab/rituxan). NHL, Bcell NHL, CLL HER20/neu: ( pertuzumab/perjeta, trastuzumab/herceptin, adotrastuzumab emtansine/kadcyla. Metastatic gastric cancer, metastatic breast cancer. EGFR: (cetuximab, panitumumab)colorectal cancer, h&n cancer RANKL: (denosumab) bone mets

signals extracellular pathway targets side effects: infusion related symptoms GI issues (usually mild) cardiotoxicity (increased risk when given with anthracycline) myelosuppression pulmonary toxicity skin rash/problems osteonecrosis, hypocalcemia

myelodysplastic syndrome

some of the cells in the bone marrow are damaged and have problems making blood cells. Many of the blood cells that are formed by the bone marrow cells are defective. The body destroys these abnormal blood cells, leaving the patient with low blood counts because there aren't enough normal blood cells.

cytotoxic chemo agents

specific mechanisms of action, toxic to malignant cells and normal host cells with high replication rate include: alkylating agents, antibiotics, anyimetabolites, plant alkaloids, misc agents

radiation oncology

the diagnosis and treatment of cancer utilizing a spectrum of ionizing radiation to a localized area. Modalities include: teletherapy, brachytherapy, and radiopharmaceutical therapy - Side effects usually begins in 2nd -4th weeks after XRT, can occur even years after treatment

initiation

the initial stage of tumorigenesis, involving transformation of cellular DNA

Intensity Modulated Radiation Therapy (IMRT)

the intensity of the radiation beam can be changed during treatment to spare adjoining normal tissue and increase the dose to the tumor. high-dosage radiation delivered via a beam that changes its dosage and shape Uses digital technology and computer generated images to aim powerful radiation beams at tumors and reduce damage to nearby tissues

carcinogenesis

the origin or development of CA, a multistage, biological process that proceeds on a continuum but is often described in stages of initiation, promotion and progression

progression

the phase in which tumor cells aggregate, grow autonomously and form benign tumors that eventually lead to malignant phenotype with the capacity for tissue invasion & mets

palliation

the use of cancer treatment modalities when cure and control of disease cannot be achieved

neoadjuvant

the use of one or more treatment modalities given before the primary therapy Ex: treatment before surgery generally to reduce tumor size and volume

prophylaxis therapy

the use of radiation therapy for the relief of symptoms such as pain, bleeding, neurological compromise or airway obstruction to improve QPL or treat life threatening problems.

Acid reflux into the esophagus after an gastrectomy and removal of the LES is difficult to manage. why?

there are no drugs available to "neutralize" the irritant effects of bile in the esophagus

curative treatment goal

to rid the body of cancer

screening

tools to identify those patients who may be at nutrition risk for malnutrition -requirement of JCAHO -aggressive nutrition intervention can help improve overall nutritions status and reverse negative side effects

topoisomerase inhibitors

topotecan (1) irinotecan(1) /Camptosar etoposide (2) teniposid(2)

Factors affecting response to cancer treatment

tumor burdon/tumor load tumor growth rate drug resistance

Tamoxifen

tx for premenopausal breast CA

protein requirements for cancer pts

underweight: 1.5-2g/ kg normal weight: 1.2-1.5g/ kg overweight: 1-1.2g/ kg obese: ~20% of kcal

kcal requirements for cancer pts undergoing treatment

underweight: 35-40kcal/ kg normal weight: 30-35kcal/ kg overweight: 25-30kcal/ kg obese: mifflin st jeer with ~1.2 SF

The first and only antidote for a chemotherapy overdose appears to be a safe and effective life-saving emergency treatment. The product_____________________________________________ increased the chances of recovery from severe and rapid-onset toxicity related to a 5-fluorouracil (5-FU) infusion, or an overdose of 5-FU.

uridine triacetate (Vistogard)

Energy need for children receiving HSCT

use BMR (not RDA), use adjusted IBW for obese Initial period - 1.6-1.8 x BMR Maintenance - 1.4-1.6 x BMR

pediatrics Energy need for children receiving HSCT

use BMR (not RDA), use adjusted IBW for obese Initial period - 1.6-1.8 x BMR Maintenance - 1.4-1.6 x BMR

adjuvant

use of additional cancer treatment after the primary therapy Ex: treatments after surgery Has a microcellular tissue target

is it recommended to give vitamins to cancer patients?

we usually do not recommend that patients take multi-vitamins. we want patients to get their nutrition from foods first unless we know they have chronic deficiencies, vitamins don't protect from chronic illness

combo chemo + radiation at same time has what effect on cancer cells?

when you give the combination of chemo + radiation at the same, that has the effect of sensitizing those cells to react more strongly to that radiation treatment

Postoperatively with liver surgery, ____ may be compromised

whole-body protein synthesis

Perioperative nutrition is necessary to promote ________ and preserve ____ in patients with peritonitis

wound healing and gut function

Early initiation of EN postoperatively promotes may physiologic benefits such as

wound healing, gut function and immunity, and reduces length of hospital stay

administer this chemo drug with food and water

xeloda / capecitabine

The American Society of Clinical Oncology (ASCO) provides a summary of IV chemotherapeutic agents and their respective risk of acute and delayed emesis. •High risk: Emesis that has been documented to occur in more than 90% of patients:

•Anthracycline/cyclophosphamide combination. •Carmustine (BiCNU®) •Cisplatin (Platinol®) •Cyclophosphamide (Cytoxan) (≥1,500 mg/m2). •Dacarbazine •Dactinomycin. •Mechlorethamine (Mustargen®) •Streptozotocin (Zanosar®)

What can a cancer patient do to reduce the likelihood of experiencing cold dysesthesia while receiving treatment with Oxaliplatin/Eloxatin?

•Do not drink cold drinks or use ice cubes in drinks. •Do not put ice or ice packs on your body. •Do not take things from the freezer or refrigerator without wearing gloves. •Drink fluids warm or at room temperature. •Always drink through a straw. •Do not use ice chips if you have nausea or a sore mouth.

There are many different herbal supplements that affect CYP3A enzymes, including these 5 supplements:

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