Medical Nutrition Therapy for Cancer Prevention, Treatment and Recovery

(Chapter 40)
Cancer
-disease of the bodys cells.
-its development involves damage to the DNA of cells.

Neoplasm when damaged cells escapte the mechanisms in place to protect the organism from the growth and spread
of such cells.
Metastasis- growth of a malignant neioplasm usually destroys surrounding tissue and may eventually spread to distant
tissues and organs.
Tumors- classification is based on their site of origin.
-Common adult tumors involve epithelial linings and are rare in children.
-Leukemias and lymphomas are tumors of the immune system which occur in both children and adults.

Carcinogenesis
-multistage process that proceeds on a continuum described in three progressive phases:
(1) Initiation- transformation of the cell produced by the interaction of chemicals, radiation or viruses with
cellular DNA.
(2) Promotion- activated transformed cell by a promoting agent. Initiated cells multiply to form a discrete
tumor.
(3) Tumor progression
Nutrition in the Etiology of Cancer
-1/3 of the cancer deaths can be attributed to nutrition
-millions of cases of human cancers could be prevented worldwide by changes in eating, weight control, physical activity
and tobacco usage.
-In Japan, mortality from breast and colon cancer is low, and mortality from stomach cancer is high.
-Diets contain both inhibitors and enhancers of carcinogenesis. Many cancers have a long latency period, in which case
the diet at the time of initiation or promotion-not at the time of diagnosis-may be important.
Energy Balance and Exercise
-In animal studies, chronic restriction of food inhibits the growth of most experimentally induced cancers and the
occurrence of many spontaneous cancers. The degree of effect depends mainly on the extent and timing of caloric restriction
and the tumor type. Underfeeding is most effective when maintained during all phases, if limited to one phase, caloric
restriction during the progression phase is more effective in inhibiting tumor growth.
-In breast cancer, a positive association with weight gain is seen in postmenopausal women and increased risk for
disease occurs with relative body leanness in premenopausal women.
-Physical inactivity, high energy intake and large body mass are associated with an increased risk of developing colon
cancer in men and women. The metaanalysis of colon cancer and physical activity levels found a 50% reduction in colon cancer
incidence among those with the highest level of activity.
Fat
-Diets high in fat tend to be high in calories and contribute to obesity, which in turn is associated with increased risk
of cancers at several sites, including the colon and rectum, esophagus, gall bladder, breast, endometrium, pancreas and kidney.
-Dietary fat intake is correlated with intake of other nutrients and dietary components, it is difficult to distinguish
between the effects of dietary fats and protein, total calories and fiber.
Protein
Most diets high in protein are also high in meat and fat and low in fiber. The effect of protein on experimental
carcinogenesis depends on the tissue of origin and type of tumor as well as on the type of protein and the caloric adequacy of
the diet.
-Increased meat intake has been found to be associated with an increased risk of colon cancer.
Fiber
-possible protective role of fiber in preventing cancer of colon, rectum, breast and ovaries.

Fruits and Vegetables

-increased consumption has shown to be associated with a lower risk of cancers of the oral cavity, esophagus, stomach,
colon, rectum and bladder.
Generally they are low in energy and are good sources of fiber, vitamins, minerals and biologically active substances.
-To most effectively reduce cancer risk, the best advice at present is to consume these substance through food
sources rather than supplements.
Chemoprevention
-seeks to reverse carcinogenesis in the premalignant phase.
Alcohol
tobacco.
studies.

-increased effect on those tissues directly exposed to it during its consumption and tends to act synergistically with
-alcohol, especially beer consumptions, has been associated with an increased risk for colorectal cancer in a number of

Coffee and Tea

-regular consumption of coffee or tea has no significant relationship with the risk of cancer.
-consumption of very hot drinks has been associated with an increased risk of esophageal cancer.
Artificial Sweeteners
-cyclamate was banned as a food additive based on the results of a study that demonstrated a significant increase in
bladder tumors.
Nitrates, Nitrites and Nitrosamines
-Nitrate can be readily reduced to nitrite, which in turn can interact with dietary substrates, such as amines and
amides to produce N-nitroso compounds, or nitrosamines and nitrosamides. This conversion, known as N-nitrosation, has been
demonstrated to occur in saliva, as well as in the stomach, colon and bladder.
-Nitrates are present in a variety of foods, but the main dietary sources are vegetables and drinking water. Sodium and
potassium nitrates are used in the process of salting, pickling and curing foods: they also give hot dogs and luncheon meat their
pink color. Nitrosaminees are present in tobacco and tobacco smoke.
Method of Food Preparation
-Formation of polycyclic aromatic hydrocarbons and hetryocyclic amines when high-heat cooking methods such as
grilling, broiling, barbecueing and smoking of meats are used can possibly increase cancer risk.
Dietary Recommendations for Cancer Prevention
1) Eating a variety of healthful foods, with an emphasis on plant sources
2) Adopting a physically active lifestyle.
3) Achieving and maintaining a healthy body weight throughout life
4) Limiting consumption of alcoholic beverages.
Nutritional Implications of Cancer
-results is often a profound depletion of nutrient stores. Significant weight loss and poor nutritional status were
documented in more than 50% of patients at the time of diagnosis.
Cancer Cachexia
-progressive weight loss, anorexia, generalized wasting, immunosuppression, altered basal metabolic rate and
abnormalities in fluid and energy metabolism.
Cytokines- thought to play a role in cancer cachexia include tumor necrosis factor, interleukin-1, interleukin-6 and
gamma interferon. These cytokines have overlapping physiologic activities, which makes it likely that no single substance is the
sole cause of cancer cachexia.
-A pool of anticytokin antibodies or toher cytokine inhibitors might be considered as a potential intervention for the
treatment of cachectic patients. Administration of thalidomide, an inhibitor of tumor necrosis factor alpha, has resulted in
weight gain in patients with HIV.
Pharmaceutical Management of Anorexia-Cachexia Syndrome

-use of appetite stimulants, metabolic agents and cytokine blockers, prokinetic agents and anabolic agents.
Energy Metabolism
-in chronic starvation, the metabolic rate is reduces as the body adapts toconserve anergy and preserve body tissue.
However, in comparison with control groups, cancer patients have been reported to have reduced, normal, or increased energy
expenditure. The difference in findings is a result of the stages of illness and of nutritional status among subjects.
Substrate Metabolism
-Energy metabolism is intimately related to carbohydrate, protein, and lipid metabolism , all of which are altered by
tumor growth. Tumors exert a consistent demand for glucose, Neoplastic cells eshibit a characteristically high rate of
anaerobic metabolism and yield lactate as th end product. This expanded lactic acid pool requires an increased rate of host
gluconeogenesis via Cori cycle activity. Both protein breakdown and lipolysis take place at increasing rates to maintain high rates
of glucose synthesis. A relative state of insulin resitance, characterized by excess fatty acid oxidation and decreased ptake
and use of glucose, especially in muscle may develop.
-Most notable is the loss of muscle protein. Abnormalities of protein metabolism include inappropriate elevations in
whole-body protein turnover and increases in skeletal muscle protein synthesis, catabolism and liver protein synthesis. These
changes occur in the presence of reduced nitrogen intake, thus suggesting inability to adapt to diminished protein intake by
reducing protein turnover.
Other metabolic activities
-Fluid and electrolyte imbalance are seen in patients with advance cancer. Hypercalcemia may be seen in bonemetastasizing tumors of the breast, lung and pancreas as well as in nonmetatastatic tumors that induce parathyroid hormonelike peptides.
-Severe imbalances in fluid and electrolye status may be present in patients with cancers that promote excessive
diarrhea or vomiting. Severe diarrhea can result from tumors that secret serotonin, calcitonin or gastrin. Persistent vomiting is
associated with intestinal obstruction or intracranial tumors.
Sensory changes
Patients may also experience a heightened sense of smell that results in sensitivity to food preparation of odors and
aversions to nonfood items such as soaps or perfumes. Dietary intervention that decrease the aroma of food, such as serving
goods cold instead of hot, may be helpful.
Goals of Nutritional Care:
The goals are to prevent or reverse nutrient deficiencies, to preserve lean body mass, to minimize nutrition-related
side effects, and to maximize the quality of life. Symptoms with a nutritional impact include nausea and vomiting, changes in
taste and smell, bowel changes, dysphagia, anorexia, pain and fatigue.
Common Nutrition Impact Symptoms of Cancer Therapies
Chemotherapy
Is the use of chemical agents or medications to treat cancer. Whereas surgery and radiation therapy are used to
treat localized tumors, chemotherapy is a systemic therapy that affects the whole body. Cells of the body with a
rapid turnover such as bone marrow, hair follicles, and the mucosa of the alimentary tract are typically the most
affected.
The reality is that despite the supportive care, many patients still experience significant side effects, especially in
dose-intensive chemotherapy regimens, and neutropenia and myelosuppression are the primary limiting factors of
their administration.
Taste abnormalities lead to anorexia and oligophagy (eating few foods). Diarrhea, constipation, or adynamic ileus
may occur. Symptoms of gastrointestinal toxicity are usually not long-lasting; however, some multiagent
chemotherapy regimens have sever and prolonged gastro-intestinal effects.
Radiation Therapy
Radiation therapy can be delivered externally into the body from a linear accelerator or a cobalt unit or internally
by placing a radioactive source (implant) directly inside the body or next to the tumor to deliver a highly localized
dose.
Radiation therapy to the abdomen may produce acute gastritis or enteritis accompanied by nausea, vomiting,
diarrhea and anorexia.

Surgery
-

The surgical resection or removal of any part of the alimentary tract- as well as the malignant disease process I
tself-can impair digestion and absorption significantly. Surgery may be used as the only mode of cancer treatment,
or it may be combined with preoperative or postoperative adjuvant chemotherapy or radiation therapy. After
surgery, additional energy and protein are required for wound healing and recovery. Commonly experience nutrition
impact symptoms include some degree of fatigue , pain, loss of appetite, and changes in normal eating. Most side
effects are temporary and dissipate after a few days following the surgery.

Bone Marrow Transplantation

Is performed for the treatment of certain hematologic malignant diseases such as leukemia and lymphoma, and for
solid tumors. The preparative regimen includes cytotoxic chemotherapy, with or without total-body irradiation, to
suppress immunological reactivity and eradicate malignant cells. This regimen is followed by intravenous infusion of
bone marrow or peripheral stem cells from the patient (autologous) or from a histocompatible related or unrelated
donor.
Severe Oral Mucositis
Patients should be instructed on food safety practices, including the following: avoidance of foods that contain
unsafe levels of bacteria (raw meats, spoiled or moldy foods and - unpasteurized beverages); Many institutions
institutions prescribe a low-microbial or low-bacteria diet for these patients.
Graft Versus-Host Disease (GVHD
A major complication after allogeneic transplantation, in which the donor marrow cells react against the tissues of
the foreign host. Acute GVHD is usually manifested within 3 months after the transplant and may be seen as
early as 7 to 10 days postransplant.
The symptoms of acute gastrointestinal GVHD are severe. The volume of secretory diarrhea suggests mucosal
damage. In addition to immunosuppressive medications, a phased dietary regimen should be instituted. The first
phase consists of total bowel rest until the diarrhea is reduced. Nitrogen losses associated with diarrhea can be
severe and are compounded by the high-dose corticosteroids used to treat GVHD.
The second phase reintroduces oral feedings of beverages that are isomotic, low-residue, and lactose-free so as to
compensate for the loss of intestinal enzymes secondary to alterations in the intestinal villi and mucosa.
Veno-Occlusive Disease (VOD)
It is characterized by chemotherapy-induced damage to the hepatic venules. It can develop 1 to 3 weeks
postransplant.
Nutritional Care of Adults Diagnosed with Cancer
Body Weight, Energy and Protein Needs
-Patients who are able to maintain their body weight and nutrient stores may be better able to tolerate treatment
impact symptoms and recover more quickly from therapy. They also experience improved quality of lie. Thus, patients should be
advised to consume sufficient energy and protein to maintain their nutrition stores and to achieve and maintain appropriate
weight for height. Weight lost during cancer therapy is often more likely caused by the loss of muscle (lean body mass) rather
than fat stores. A widely used tool to estimate body weight for height is the body mass index (BMI).
-Patients need for protein is increased during times of illness and stress. The additional protein is required by the
body to repair and rebuild tissues affected by cancer therapy.
Guidelines for Oral Feeding During Anticancer Therapy
Chemotherapy-induces nausea and vomiting are commonly classified a anticipatory, acute, or delayed, each of which
is manifested by distinct patho-physiologic events and requires different therapeutic interventions. Currently, the
most effective agents for treating acute nausea and vomiting are the serotonin antagonists.
The timing of food presentation also deserves consideration. Patients with cancer often complain of a decreased
ability to eat as the day progresses, which means that the morning is often the best time for eating. This
phenomenon may be attributable to sluggish digestion and gastric emptying as a result of decreased production of
digestive secretions, gastrointestinal mucosal atrophy.
Fatigue is one of the most common symptoms reported by patients with cancer and is often characterized as
physical tiredness, mental slowness and lack of emotional resilience.
Enteral Nutrition

-If the gut is functional, enteral nutrition is indicated. Enteral nutrition, rather than parenteral nutrition, helps to
reduce infectious complications such as bacterial translocation by preserving immune and gut barrier function. Nasograstric or
nasojejunal tubes are used most commonly for the short-term administration of enteral nutrition formulas.
Parenteral Nutrition
-appropriate for some patients with cancer for whom oral intake or enteral nutrition is not an option and who are
otherwise expected to survive.
Rehabilitation and Physical Activity
-Recovery from cancer treatment also requires physical activity to rebuild muscle strength.
-Fatigue and impairment of physical performance are common and often sever problems of cancer patients.
Psychological and physical factors play roles. Poor nutrition contributes to fatigue; conversely, fatigue may hinder eating and
nutritional support regimen. Appropriate exercise may be helpful in treating primary fatigue. In addition, physical activity may
improve the immune system, which is important in preventing cancer recurrence.
Individuals with advance cancer receiving palliative care.
-The goals of nutrition intervention should focus upon managing nutrition impact symptoms such as pain, weakness, loss
of appetite, early satiety, constipation, weakness, dry mouth and dyspnea.
- Cox and McCallum define palliative care as the active total care of an individual when curative measures are no longer
considered an option by either the medical team or the patient. They go on to to state that the goal of palliative care are to
provide for optimal quality of life for the individual and the family through the use of multidisciplinary team approach to
managing physiological symptoms as well as psychological, social and spiritual issues.
Complement and Alternative Therapies
Defines complementary therapies as supportive methods that are used to complement evidence-based treatment.
Patients explore alternative therapies when (1) Health promotion and disease prevention are sought (2)
conventional therapies have been exhausted (3) conventional therapies are of indeterminate effectiveness or are
commonly associated with side effects or significant risks. (4) no conventional therapy is known to relieve the
patients condition (5) The conventional approach is perceived to be emotionally or spiritually without benefit.
Metabolic therapy
-is a term used for a variety of cancer management methods, including unproven and disproved diagnostic methods and
treatments. Metabolic practitioners generally claim that diseases, including cancer, are caused by an accumulation of toxic
substances in the body. They allege that if these toxins are removed, the body can heal itself naturally. 3 Basic steps are
common to metabolic therapy: (1) detoxification (2) strengthening of the immune system (3) use of special modalities to attack
cancer.
-Nutrition and diet therapies generally are based on the you are what you eat principle.