2021 Spring HNSC4240 Clinical Nutrition I

Case study 3 Neoplastic disease (total: 100 points)

Due 5/17/2021

Instruction: Read the following case and complete the questions. Please type your
answers. The assignment must be turned in on time. One point will be deducted for
each day that the case study is late.

Please read the case below carefully then answer the questions.
Client Name: Scott Seyer
DOB: 12/3
Age: 62
Sex: male
Education: High school
Occupation: Retired
Marital status: Married
Household members: Wife, two sons
Weight: 123 lb
Height: 6’2”
Ethnicity: Non-Hispanic white

Patient summary:
Patient is a 62-year-old male with a history of lung cancer. He was first diagnosed
with limited small cell lung cancer 1 year ago. He initially received radiation therapy
and has been followed for the previous year. He now presents with a new tumor on his
left upper lobe, multiple mediastinal lymph nodes, and a left supraclavicular node.
Complaint of shortness of breath, fatigue and lack of appetite. Chemotherapy is now
planned.
Family History: Mother- breast cancer; Father- MI
Tobacco use: quit 1 year ago- smoked 1 PPD for >40 years
Food Allergies: NKFA

Physical exam:
Vitals: Temp 98.1 F, BP 118/80 mmHg, HR 80 bpm, RR 16 bpm
Extremities: Muscle weakness
Abdomen: Bowel sounds positive, soft; nontender, nondistended
Skin: warm and dry

Nutrition history:
Patient stated that his appetite was fine before the diagnosis. He was an active
smoker but that never affected his appetite. When he was put on the radiation therapy,
he couldn’t swallow anything and had to be put on tube feed for a few months. Now
he gradually got his swallowing ability back but he was too tired to eat anything. He
didn’t feel hungry either. Patient doesn’t have much knowledge about nutrition. He
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said he just ate whatever he felt like eating.
Usual dietary intake:
AM- coffee, juice or fruit (patient said he’s not a morning person)
Lunch- rice (softly cooked), pasta, or mashed potatoes, some cheese on top
Dinner- Vegetable soup, steamed vegetables, some meat (maybe 1 oz)
Drinks coke throughout the day (usually 3 12-oz cans).

Laboratory values:

Normal Patient’s value Units

Blood work
Sodium 136-145 138 mEq/L
Potassium 3.5-5 4.0 mEq/L
Calcium 9-11 10.3 mg/dL
Albumin 3.5-5 3.5 g/dL
WBC 4.8-11.8 4.5 L x103/mm3
RBC 4.5-6.2 2.8 L x103/mm3
Neutrophil 50-70 48.3 L %
Lymphocyte 15-45 33.1 %

ANSWER THE FOLLOWING QUESTIONS

1. Do an information search, find out the characteristics, treatments and prognosis of

small cell lung cancer (10 pts).

Small-cell lung cancer is a malignant “neuroendocrine tumor characterized by

early metastatic spread and responsiveness to initial treatment” (Kalemkerian et al.,
2017), involving, in most cases, only small cells. It is the second most common cancer
in both genders and the leading cause of cancer-related death in the USA, accounting
for 13% of all new diagnosis of lung cancer worldwide. More than 90% of cases are
seen in elders with current or past heavy smoking history and pulmonary,
cardiovascular or metabolic comorbidities. Thus, the risk of developing SCLC
increases with intensity and duration of smoking. (van Meerbeeck et al., 2011). At
molecular level, SCLC is associated with mutations in the genes FHIT (tumor
suppressor gene), MAD1L1 (encodes MAD1 checkpoint protein), RB1 (tumor
suppressor gene) and TP53 (proapoptotic activity). Onset of symptoms is rapid and
includes cough, dyspnea, hemoptysis, paraneoplastic syndromes and complications
due to intrathoracic spread to chest wall, vena cava or esophagus, with preferential
metastatic sites being the brain, liver, adrenal glands, bone and bone marrow. The
prognosis is poor, with median survival period of 2-4 months if no treatment is given,
and up to 25% 5-year cancer-free survival in patients at limited-stage disease and 2%
in patients at extensive-stage disease, after treatment. Prognostic factors include
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performance status, sex (higher in men) and routine laboratory tests (abnormal serum
lactate dehydrogenase). Since surgical resection is no longer performed due to low
(less than 5%) 5-year survival rate in patients; treatment is a combination
chemotherapy, with anti-cancer drugs etoposide and cisplatin, and chest radiotherapy
(Jakman et al., 2005).

2. Calculate the calorie and protein requirements for this patient (10 pts).

Calculation
Height 6’ 2” = 74” = 188 cm
TBW 123 ÷ 2.2 = 55.9 kg
BMI 55.9 ÷ (1.88)2 = 15.8 (underweight)
Calorie 55.9 x 30 = 1956.5 kcal
Protein 55.9 x 1.0 = 55.9 g (normal albumin, stress factor 1.2)

3. Point out major nutrition concerns based on the patient’s medical and nutrition
history and dietary recall, barriers for the patient to address these nutrition concerns,
and potential consequences if these concerns are not addressed (15 pts).

The patient is very underweight and shows signs of cancer cachexia and anorexia.
The dietary recall assessment shows that patient does not eat enough calories, eats
very little protein and drinks excessive empty calories that provides no micronutrients
for energy metabolism. It is important to address the necessity of a high calorie diet
with high protein intake, prioritizing high quality animal sources, to prevent further
lean body mass loss and aid in treatment. This involuntary weight loss, shown in his
low BMI, and the lack of energy are characteristics of cachexia, which, if not
addressed through dietary changes, leads to excessive muscle waste, inability to
sustain metabolic processes and, eventually, death. Since the fatigue affects the
patient’s ability to eat, he should consider soft and easy to swallow foods, such as
protein shakes using calorie dense foods like nut butters and full-fat yogurt, in place
of sugary drinks. Fish and eggs are high-quality protein sources that are easier to
chew than red meat and poultry, and could be used in preparations such as soup and
porridge, along with starchy vegetables and grains. He could also prepare his mashed
potato using milk, another way to consume more high biological protein,
micronutrients and calories.

4. The patient is going to be put on chemotherapy. Suppose you will need to discuss
with him about the nutrition impact symptoms that can occur due to chemotherapy,
identify two symptoms and provide recommendations to address those symptoms (15
pts).

When on chemotherapy, patient might develop anorexia, due to lack of appetite

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and fatigue, and mucositis, due to inflammation of GI lining. To ensure an adequate
diet and avoid malnutrition, patient should consider a high energy and high protein
diet to meet metabolic needs and prevent muscle loss. To treat anorexia, adopting
small and frequent meals would help patients in getting enough calories while easing
digestion and avoiding excessive nausea, another symptom he might have from the
chemotherapy. In addition, patient could consider appetite stimulants to increase his
appetite and shakes with adequate protein and fat composition, which are easier to
ingest and digest. To help with the mucositis pain, patient should avoid hard and
acidic foods, foods high in fiber, and foods served in hot temperature, as this can burn
the mucosa and further complicate the pain. Patient would benefit from increased
hydration and opting for water and nectars, rather than juice, and use of narcotic
analgesics to manage the pain.

5. Design a high protein high energy shake that provides at least 300 kcal and 15 g
protein per cup; includes only natural food, without the use of protein supplements.
Include the nutrition facts of your recipe (15 pts).

Ingredients:
(Yield: ~1 cup)

½ c 1% Milk 51.2 kcal 4.1 g

½ Banana 52.5 kcal 0.6 g
2 tbsp Peanut Butter 187.8 7.8 g
(natural, unsalted) kcal
2 tbsp Oats 38.4 kcal 1.3 g
4 tbsp Greek Yogurt 36.1 kcal 6.2 g

6. There are a lot of fad diets that claim to prevent or treat cancer, such as the Gerson
therapy, Budwig diet, Macrobiotic diet, Alkaline diet, Juicing, and Raw diet. Choose
one of these diets, describe the main points of the diets, discuss potential risks and
benefits, identify at least one peer-reviewed scientific article (citation must be

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provided) related to the diets and describe the findings from that article, then give
your own conclusion about the scientific soundness of the diet. What
recommendations would you give the patients if they want to go for these diets? Your
answer should not exceed 1 page, 12-pt font size (25 pts).
The Gerson Therapy diet aims to prevent or treat cancer by activating the body’s
ability of healing itself through removal of toxins and increase of immunity. The three
components of this therapy are diet, supplements and detoxification. The diet is plant-
based, with focus on organic produce to make raw juices (required 1 glass per hour),
and extremely low in sodium, fats and proteins. Supplementation of potassium, B3,
B12, pancreatic enzymes, Lugol’s solution and thyroid hormone is required to support
metabolic processes. The combination of diet and supplements is said to release
toxins, and consumption of coffee enemas (1 per 3 glasses og juice) is required to
widen bile’s duct and aid liver in toxin removal. The benefits of this diet include a
high vegetable consumption with minimal artificial chemical products, avoiding the
development of negative side effects on health by overconsumption of pesticides and
fungicides. This diet is also high in potassium and low in sodium, which are factors to
decrease blood pressure in individuals. However, there are some side effects from
following this trend. It is a very limited diet, with low protein and low essential fatty
acids. Because protein is required for recovery and treatment, especially if patient has
cachexia, restricting could lead to further lean mass breakdown and exacerbation of
condition of patient. Essential fatty acids are not produced by the body, therefore not
consuming these nutrients from the diet could impair the inflammation response.
There is also risk of atrophy of chewing muscles due to lack of stimulus caused by
excessive juice, which does not require mastication, and restriction of solid foods. A
study from the NCI showed that patients with pancreatic cancer, following diets
similar to the Gerson, who underwent chemotherapy, survived 3x higher than patients
taking only pancreatic enzymes, organic diet, supplementation and detoxification
(Cassileth, 2010). Patients with malignant melanoma following the Gerson therapy
also showed improvements in survival and maintained a good life quality (Molassiotis
& Peat, 2007). However, I personally believe that further studies need to be conducted
to effectively determine the successfulness of this diet, and that diets restrictive in
certain macronutrients, especially protein, are not adequate for cancer treatment.
Since patients are usually underweight and have low lean mass, an adequate protein
and fat intake would aid to maintain muscle mass and meet calorie goals for metabolic
processes. Although juices and smoothies are a great, easy to digest option, especially
if patient is feeling very tired to cook, more ingredients like liquid fats and high value
protein could be incorporated into these juices to aid individuals to consume a high
calorie diet and get essential nutrients.

7. If the patient’s disease deteriorates rapidly and he is terminally ill. Survival time
will be less than a month. The patient is in a lot of pain and couldn’t eat. Shall we
persuade him to receive enteral or parenteral nutrition? What do you need to consider?
(10 pts)
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 If patient is terminally ill and suffering from pain, he would benefit from an
enteral nutrition or, if not possible, parenteral nutrition. Although this would not
change the course of the disease, administrating tube feeding rather than oral intake
would relieve pain and ensure that nutrients are being delivered without causing pain
to the patient. In the terminally ill phase, formulas with glutamine, EPA and DHA,
fiber and arginine are beneficial to the patient and show positive effects and helps to
maintain a healthy microbiota. However, occurrence of sepsis should be considered
prior administration of arginine, as this amino acid increases the production of nitric
oxide, which increases vascular permeability and worsens condition. There is also
need for monitoring patient’s lipid panel and status of blood glucose, avoiding
hypertriglyceridemia and hyperglycemia, especially if patient receives parenteral
nutrition, and occurrence of diarrhea, electrolyte imbalance and, in terminally ill
patients, fluid overload and shortness of breath. Other factors to consider, as well, are
the psychological status of patient, as the placement of a tube feeding may cause
discomfort and alter mental status, and costly charges for these types of nutrition (Dy,
2006).

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 References

Cassileth B. (2010). Gerson regimen. Oncology (Williston Park, N.Y.), 24(2), 201.

Dy S. M. (2006). Enteral and parenteral nutrition in terminally ill cancer patients: a

review of the literature. The American journal of hospice & palliative care, 23(5),
369–377. https://doi.org/10.1177/1049909106292167

Jackman, D. M., & Johnson, B. E. (2005). Small-cell lung cancer. Lancet (London,

England), 366(9494), 1385–1396. https://doi.org/10.1016/S0140-6736(05)67569-1

Kalemkerian, G. P., & Schneider, B. J. (2017). Advances in Small Cell Lung

Cancer. Hematology/oncology clinics of North America, 31(1), 143–156.
https://doi.org/10.1016/j.hoc.2016.08.005

Molassiotis, A., & Peat, P. (2007). Surviving against all odds: analysis of 6 case
studies of patients with cancer who followed the Gerson therapy. Integrative cancer
therapies, 6(1), 80–88. https://doi.org/10.1177/1534735406298258

van Meerbeeck, J. P., Fennell, D. A., & De Ruysscher, D. K. (2011). Small-cell lung
cancer. Lancet (London, England), 378(9804), 1741–1755.
https://doi.org/10.1016/S0140-6736(11)60165-7