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Mrs. Anjali Nair Chief Dietician Tata Memorial Hospital

She is recepient of many awards including one from Smt Lilavati Munshi Foundation for a project on Diet in Cancer Tube Feeding Formulation.She has been part of research team of Food Technology Department of BARC for developing Goods for Foods for Immuno-compromised patients and other target groups-using radiation technology. She has also been involved in various publications in the area of Nutrition and Cancer and has shared her experience on practical approaches in Nutrition and Cancer in various conferences and seminars at National and International levels .Mrs. Nair is also involved in guiding post graduate and research students in dessertations and has been playing a lead role in carrying out nutrition related educational activities for Oncology & Enterostomal Nurses along with Nutrition students.As a part of her responsibilities at Tata Memorial Hospital , she is running many nutritional counselling programmes for Communities-Breast/Uterine group,Head and Neck Cancer,General Medicine and Palliative Care Patients.

NUTRITION IN HEAD AND NECK CANCER

Mrs. Anjali B. Nair Chief Dietician Tata Cancer Hospital

Annually, over 3,00,000 new cases of oral cancer are diagnosed all over the world where the majority are diagnosed in the advanced stages III or IV. Such data make the oral cancer an important public health matter which is responsible for 3% to 10% of cancer mortality worldwide.

Head and neck cancer refers to a group of biologically similar cancers originating from the upper aero digestive tract including lip, oral cavity, nasal cavity, paramucosal sinuses, pharynx, larynx, oropharynx and Hypopharynx

Cancer of lip

Cancer of tongue Cancer of hard palate

Cancer of bucal mucosa

Cancer of mandible

An At Risk Population
Alcohol use/abuse Tobacco use Up to 40% of newly diagnosed head and neck cancer patients are malnourished. Malnutrition has significant impact on morbidity, mortality and quality of life for cancer patients Physicians often do not address this issue

Presenting Complaints
Change in voice Change in facial appearance Non healing ulcers Ill-fitting dentures, loosening teeth Lesions

Causes of Malnutrition
Diminished nutrient intake Increased nutrient demand not matched by intake Tumor-induced derangements

Diminished Nutrient Intake

Alcohol & Tobacco Poor dentition Partial or complete obstruction of aerodigestive tract Post-surgical functional and anatomic impairments of chewing and swallowing mucositis, dysgeusia, xerostomia Chemotherapy-induced nausea, vomiting

Increased Nutrient Losses

Vomiting Diarrhea

Increased Nutrient Demand Acute metabolic stresses caused by surgery, RT, chemotherapy Duration and intensity of stresses depend on intensity and duration of treatment as well as complications Tumor-induced Metabolic Abnormalities Abnormal metabolism of carbohydrates, lipids, and protein Abnormal levels of neurotransmitters leading to anorexia Increased basal metabolic rate Cytokines appear to mediate these abnormalities Tumor necrosis factor, IL-1, IL-6

Impact of Malnutrition
Immunocompetence Decreased cell-mediated immunity Depressed T-cell proliferation, NKC cytotoxicity, macrophage cytotoxicity

Inability to tolerate antineoplastic treatments Toxicities more severetreatment delays, higher costs
Postoperative complications Wound infection, healingquality of life, cost

SWALLOWING PROBLEMS IN HEAD AND NECK CANCER.

HNCA

Reduced pre-treatment swallowing function.

Reduced post-treatment swallowing function.

Surgery

Chemotherapy

Radiation

Swallowing problems
Dysphagia Aspiration

Worse swallowing function

Less variety of food consistency Less nutrition through oral route

MALNUTRITION

&
IMPAIRED QUALITY OF LIFE.

Xerostomia Mucositis Nasal regurgitation.

Treatment related complication Surgery

Negative nitrogen balance Inability to chew Agluttion (inability to swallow) Dysphagia Communication impairment Aspiration
Radiotherapy

Chemotherapy

Mucositis Xerostomia ( dry mouth) Odynophagia ( pain in swallowing) Dysguesia ( loss of taste) Dental caries associated with xerostomia

Nausea Vomiting Diarrhea Cheilosis Glossitis Pharyngitis Esophagitis anorexia

Table 7.3 - Nutritional management of cancer patient

Clinical Manifestations of Cancer Pain Nutritional implication Cancer Cachexia Anorexia Weight loss and depletion Alteration in body compartments Disturbances in water and electrolyte metabolism.

Progressive impairment of vital functions. Abnormal taste- Hypogeusia , dysguesia

Dysphagia

Macronutrient metabolism

Carbohydrates
gluconeogenesis from Acetic acid , lactate
and glycerol. glucose disappearance and recycling. Glucose intolerance Insulin resistance

Altered lipid metabolism

Increased Lipolysis Increased Glycerol and fatty acid turnover. Lipid oxidation non inhibited by glucose. Decreased lipoprotein lipase activity. Increase in serum lipids and fatty acids.

Altered Protein metabolism

Increased Muscle Protein catabolism Increased whole body protein turnover Increased liver protein synthesis. Decreased muscle protein synthesis.

Gastrointestinal Dysfunction
Abnormalities in the mouth and the digestive tract, either as a result of a disease or its treatment,

May interfere with food ingestion

Changes in taste and smell . Changes in taste and smell correlate with decreased nutrient intake, a poor response to therapy, and tumor progression, including metastasis . Zinc-deficiency, alterations in brain neuro-transmitters such as NPY, that affect taste and nutrient selection .

Standards of care to be followed

Early nutrition support. Total calorie intake should be restricted to 1500-2000 kcals/day. Main substrates providing calories should be Carbohydrates and lipids. Protein intake determined by severity of catabolism. Assessment of nutritional status based on SGA. Enteral nutrition should be the choice.

Parenteral nutrition if needed , certain recommendation should be followed. Timing of nutritional support to be studied. Specific diseased stated may require certain modifications. Immuno-nutrition Preventive nutritional support with primary treatment to be considered.

NUTRITIONAL CARE
Weight loss and altered nutritional status are evident in 50% of the patient with cancer at time of diagnosis and therefore nutritional support can improve overall patient performance status. Nutrition therapy recommendation may vary throughout the continuum of care. Maintenance of adequate intake is important, whether the patient on active therapy, recovering from cancer therapy or in remission and striving to avoid cancer re-occurrence.

The Goals of Nutritional Therapy

a. b. c. d. Prevent or reverse nutritional deficiencies Preserve lean body mass Help patient better tolerate treatment Minimize nutrition related side effects and complication e. Maintain strength and energy f. Protect immune function and decrease the rush of infection g. Aid in recovery and healing h. Maximize the quality of life

Dietary Guidelines
Macro nutrients: Energy: 15-20 kcals/kg PBW/day to prevent re-feeding syndrome 25-35 kcals/kg PBW for maintenance 39-40kcals/kg PBW/day. for weight gain: Proteins: 1-1.5gm/kg PBW/day for maintenance 1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain patients.

 Micronutrients
1. Sodium: hyponatrimia due to 1. SIADH. 2. Dehydration 3. Drains 2. Zinc: common deficiency, results in: i. decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood. ii. Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations iii. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. AJCN (Vol. 17, No. 5, 409-418 (1998 )

 Water: 30-40ml/kg PBW/day 1. Prevent dehydration 2. Prevent respiratory distress due to drying of secretions. Arginine: (controversial) Shown to increases fistula and wound complications Glutamine: Decreases the risk and severity of stomatitis Helps in wound healing after surgery Reduced the side effects of chemo drugs like doxorubicin etc. Contraindicated: shown to stimulate growth of cancer cells. 1. 2. 3.

Symptoms Dietary intervention

Anorexia

Frequent small quantity and variation in meals Nutritious snacks and drinks between meals Supplementation of high calorie and proteins Avoid cooking smell and food with strong odors Have dry meals with drinks taken separately Biscuits, dry toast and cold foods Avoid very sweet and fatly foods

Nausea

Symptom s Difficulty in swallowin g (Dysphasi a) Altered taste

Dietary intervention Small frequent feed with soft and liquid diets with nutritious drinks after food

Avoid food that worsen the unpleasant taste mainly because of zinc deficiency

Sympto Dietary intervention ms Eat moist foods with extra sauces, Dry butter or margarine and avoid liquids Mouth and food that contain lots of sugars and
dry fruit nectar instead of juice

Mouth sores

Eat foods that are easy to chew and swallow with cool temperature and soft fruits like bananas stewed apple and peach, cottage cheese, mashed potatoes, scramble eggs, cooked cereals, and milk shakes

Few Considerations
Strategies for modifying nutrient intake depend on specific feeding problem and the extent of depletion. Oral route is preferred mode of feeding but may be resisted by patient experiencing nausea , altered sensation and dysphagia.

In patients with head and neck cancer the cancer lesions in the oral cavity makes difficult to consume food orally.

 Dysphagia due to oral lesions can be lessened with intake of soft and liquefied foods served at moderate and room temperature. Patients with Xerostomia should be encouraged to have plenty of fluids(25-30ml/kgbdwt) and eat moist foods with extra gravies and butter.
Patients with chemotherapy complain of decreased ability to eat as the day progresses. Thus morning can be the best time for eating. This is an attribute to sluggish digestion and gastric emptying as a result of GI mucosal atrophy and gastric muscle atrophy

Approach to Nutrition Support

PRETREATMENT-Nutrition screening, History( weight loss), Physical examination( BMI) , Lab studies(Serum albumin)

Moderately or severely malnourished

Aggressive nutritional support Malnourished

Is GI tract functional Is therapy intensive NO

YES Oral supp or Enteral tube feeding

NO Parenteral nutrition

Oral supplements

ROUTES OF FEEDING

SELECTION OF FORMULA
Functional capacity of gut Intubations site Patient's metabolic status Cost Convenience considerations

COMPARISION BETWEEN PRODUCTS

RESOURCE HIGH PROTEIN (100gms) ENE 374kcals ACTIBASE NEUTRAL (100gms) 338 kcals

PRO
Na K

41gms
500mg 800mg

45 gms
360mg 546mg Rs 240

Cost Rs 215

Case Studies

MRS RKT 43 YR/F

CA UPPER LIP --- T4 N0 M0 STAGE IV
COMPLAINED OF SWELLING IN UPPER LIP ADMITTED TO TMH---24/5/10 DIAG: SPINDLE CELL CARCINOMA BIOCHEMICAL NORMAL EXCEPT FOR Na

OPERATED ON 31/5/10
PT ON RT FEEDS SINCE 1/6/10

HT: 151CMS

WEIGHT: 60KGS
BMI:26KG/M2 GRADE I OBESE ENERGY: 30X46(IBW)=1380 +STRESS FACTOR=1450KCALS

PROTEINS: 1.5 GM/KG IBW=69GMS

CHO:65%=227 GMS FAT:22%=34 GMS

HOSPITAL DIET
DAY1(1/6) ENERGY PROT FATS CHO Na 432 7.2 9 75 134 DAY2(2/6) 906 27.1 20.7 128 128 GIVEN 1GM SALT DAY3(3/6) 1157 48.2 21.6 125 143

REMARKS

SEVERELY NAUSEATED

NAUSEA INTAKE REDUCED IMPROVED WITH FEELING

PT DISCHARGED ON 4/6/10

ON RT FEEDS+ORAL LIQUIDS ON ACTIBASE NEUTRAL

WEIGHT MAINTAINED SO CONTINUED WITH SAME DIET.

MRS.SINGH 40/ F
CA LATERAL BORDER OF TONGUET3NOMO

SYMP: PAIN WHILE EATING FOOD

ADMITTED TO TMH 27/4/10 BIOCHEMICAL NORMAL EXCEPT FOR FLUCTUATING Na OPERATED ON 31/5/10 RT FEEDS STARTED ON 1/6/10

HT: 161 CMS

WEIGHT:82KG BMI:31.66KG/M2

GRADE II OBESE

ENERGY:25KCALS/KG= 1400
PROTEINS: 1.3GM/KG= 73 GMS CHO 65%= 228GMS FATS 15%= 23 GMS

HOSPITAL DIET
DAY1(1/6) DAY2(2/6) DAY3(3/6)

ENERGY
PROT FATS CHO Na

554
32.6 20 57 134

1278
68 38.5 141 --

1541
72 44 171 134

REMARKS

RT FEEDS AS NAUSEATED

COCONUT INTAKE WATER=SWE PROPER ETLIME JUICE SO LESS OF

LOW HB WAS BEFORE SURGERY 10GMS(25/5) 3/6: HB FURTHER REDUCED TO 9.70GMS DUE TO BLOOD LOSS DURING SURGERY DISCHARGED ON SAME DIET WITH ADDITION OF RAGI PORRIDGE AND BOILED EGG ADDED TO THE RT FEEDS

Conclusion
Head and neck cancer and disease induced dysphagia can adversely affect a patients ability to eat and thus its QOL.

Dysphagia has serious emotional and social consequences.The inability to participate in eating , one of the lifes most social occasion generates a lot of frustration , anxiety and depression. Quality of life assessment is important for patients with neoplasm of head and neck.
Apart from the treatment modalities, the type of cancer carries a significant influence on the physical , functional , social , emotional and a global wellbeing of the patients.

Questions & Answers To submit a question for Mrs.Anjali Nair, please message Akash Srivastava via the chat

Closing Remarks