MEDICAL NUTRITION THERAPY

for CANCER

Nutrition Department
Medical Faculty of North Sumatera University
WHAT IS CANCER?

An abnormal division and reproduction of

cells that can spread throughout the body
DIAGNOSIS
- Medical history
- Physical examination
- Evaluation for tumor markers (e.g. AFP(Alpha-
Fetoprotein),, CA-125 , CEA(Carcinoembryonic
antigen) , PSA(Prostate-Specific Antigen)
- Cytology studies and tumor biopsy (e.g. fluid, sputum,
urine tissue)
- Imaging studies (e.g. X-rays, CT, MRI, PET scan/
Positron Emission Tomography)
- Staging (radiographic, pathologic, surgical or staging for
tumor size/T, nodes/N and metastasis/M)
TREATMENT

Conventional modalities :
• Chemotherapy
• Immunotherapy
• Radiation therapy
• Surgical used alone or in combination

Solid tumors and hematologic malignant diseases (leukemias,

lymphomas and multiple myelomas)  hemopoietic cell
transplantation
Nutrition in The Etiology of Cancer
Diet and nutrition  causes, consequences and
treatments of cancer

Nutrition may modify the carcinogenic process

• Carcinogen metabolism (physical, chemical or
viral agent)
• Cellular and host defense
• Cell differentiation
• Tumor growth
Nutrition is affected by:
- The cancer
- The treatment
- The current health
- The nutritional status

US; 1/3 the cancer deaths per 1 year can be attributed to

nutrition and lifestyle behaviors such as:
- Poor diet
- Physical activity
- Overweight and obesity
- Alcohol use
Diet contains inhibitors and enchancers of
carcinogenesis

Dietary carcinogenesis inhibitors such as:

- Antioxidants (vit. C, vit. E, selenium, carotenoids)
- Phytochemicals (anthrocyanins, lycopene, indoles,
sulforaphanes)

Dietary carcinogenesis enchancers such as:

- The fat in the red meat
- Polycyclic aromatic hydrocarbon that form with the grilling
of meat at high heat
ENERGY INTAKE, BODY WEIGHT, OBESITY AND PHYSICAL
ACTIVITY

• Obesity increases the risk for developing and dying from cancer,
heart disease, diabetes (Eyre et al, 2004)

• Body weight, BMI, relative body weight  cancers of breast,

endometrium, kidney, colon and prostate
▫ Breast cancer has a positive association with weight gain in
postmenopausal women (Abu-Abid et al, 2002; Biachini et al, 2002
▫ A study that followed 4.5 million male veterans found that obesity was
associated with higher risks of cancers in men (specifically cancers of the
lower esophagus, stomach, small intestine, colon, rectum, gallbladder,
ampulla of Vater, breast, prostate, bladder, thyroid, connective tissue,
melanoma, multiple myeloma and two types of leukimia (Samanic et al,
2004)
• The Cancer Prevention Study II showed that BMI was
associated with higher death rates from 11 types of
cancer in men and 12 types of cancer in women

• Physical activity controls body weight

▫ Excess body weight increases the amount of circulating
estrogens, androgens, insulin, and insulin like growth
factors  associated with cell and tumor growth (NCHS,
2001)
▫ Physical inactivity, high energy intake and large body mass
 increased risk of developing colon cancer in men and
women (Kushner, 2002)
FAT

• Diets high in fat also tend to high in calories  obesity  increased

risk of cancers (colon, rectum, esophagus, gallbladder, breast among
postmenopausal women, endometrium, pancreas and kidney

• The type of fat such as that in read meats and dairy products that is
associated with an increased risk of prostate, breast and lung cancer

• Eating Omega 3 fat > omega 6 fat reduce risk of premenopausal breast
cancer.

• Breast cancer recurrance reduce by eating low fat (less than 20% energy
from fat)
PROTEIN

• Low protein (below of the requirement for

optimal growth) supprese the development of
tumor
• High protein (2-3 x) enchance the tumor
development
• Red meat (beef, pork, lamb) intake  increased
risk of colon and prostate cancer
SOY AND PHYTOESTROGENS
• A soy containing diet may reduce the risk of breast
cancer, especially if it’s consumed before

CARBOHYDRATES: FIBERS, SUGARS,

GLYCEMIC INDEX
• High fiber food intake could prevent the cancer of colon,
rectum, breast and ovaries.
• A high consumption of simple sugars  increases blood
glucose and triglycerids levels and raise levels of insulin
and other hormones  stimulate cancer cell growth
• Consumption of high glycemic index foods 
increased risk of cancers (ovary, encometrium, breast,
colorectal, lung)
FRUITS AND VEGETABLES
• Increased consumption of fruits and vegetables  lower risk
of cancer
• It’s recommended to eat 5-9 servings per day

ALCOHOL
• Alcohol consumption increased cancer risk
• Recommendation
▫ Men 2 drinks per day, women 1 drink per day and adequate
folate intake
COFFEE AND TEA
• Regular consumption of green tea and other sources of polyphenols may reduce
the risk of stomach cancer
• No significant relationship between coffe or tea and the risk of cancer

METHODS OF FOOD PREPARATION AND PRESEAVATION

• High heat cooking  form the dietary carcinogen  increased cancer risk.
• Dietary carcinogens :
Grilling, boiling, barbecuing, smoking of meats  polycyclic aromatic
hydrocarbons and heterocyclic amines
Smoked, salted, pickled foods  N-nitrosocompounds (NOCs)
• Recommendation
▫ Eat fewer foods containing NOCs
▫ Healthier cooking for meats such as boiling, poaching, steaming, stewing, braising,
baking, macrowaving, roasting
American Institute for Cancer Research Guidelines
for Cancer Prevention
1. Choose a diet rich in variety of plant-based foods
2. Eat plenty of vegetables and fruits
3. Maintain a healthy weight and be physically active
4. Drink alcohol only in moderation
5. Select foods low in fat and salt
6. Prepare and store food safety

always remember ..... Do not used tobacco in any form

Nutritional Implications of Cancer
• The adverse nutritional effects of cancer can be severe and be
compounded by the effects of the treatment regiments and the
psychological impact of cancer
• Small amounts of weight loss (< 5% of BW) before treatment are
associated with of poor prognosis

CANCER CACHEXIA
• Characterized by progressive weight loss, anorexia, generalized wasting
and weakness, immunosupression, altered BMR, abnormalities in fluid
and energy metabolism

ENERGY METABOLISM
• Chronic starvation REE (Resting Energy Expenditure) is reduced as
the body adapts to conserve energy and preserve body tissue
• Hospitalized cancer patients were reported to be hypometabolic,
normometabolic, hypermetabolic
PROTEIN, FAT AND CARBOHYDRATE METABOLISM
• Tumor exert a consistent demand for glucose.
• Neoplastic cells  high rate of anaerobic metabolism and yeild lactate
(the end of product)  requires an increased rate of host gluconeogenesis
• Protein breakdown and lipolysis increase to mantain high rates of glucose
synthesis
• Alterations in protein metabolism  providing adequate amino acids for
tumor growth  loss of skeletal mucle protein

NUTRITION, TUMOR GROWTH AND TREATMENT OUTCOME

• Dietary intake and nutrition support show benefit in preserving lean body
mass, toxicity to therapy, quality of life >>, but also support benefit to
malignancy
OTHER METABOLIC ABNORMALITIES

• Hyperclacmia (individuals with bone metastases) caused by the

osteolytic activity of tumor cells releasing calcium into the extracellular
fluid
Symptomps: nausea, weakness, fatigue, lethargy, confusion
Medical management: rehydrations, use of biphosphonates and
other antihypercalcemic agents

• Critical imbalances in fluid and electrolyte status (individuals that

promote excessive diarrhea or vomitting)
Caused by partial bowel obstructions, endocrine secreting tumors
(serotonin, calcitonin, gastrin), chemotherapy agents, antibiotics

• The mass of tumor may anatomically alter the normal physiology of

specific organ systems
LOST OF APPETITE AND SENSORY ORGANS

• Alterations in taste and smell  anorexia

• A heightened sense of smell  sensitivity to food
preparations odors and nonfood items (soaps or perfumes)
• Dietary interventios;
▫ Decrease the aroma of foods such as serving foods cols instead
of hot
Nutrition Care

GOALS
• To prevent or reverse nutritient deficiencies
• To preserve lean body mass
• To minimeze nutrition-related side effects
• To maximize the quality of life
NUTRITION SCREENING AND RISK ASSESMENT

• Should be interdisciplinary and instituted at the time of diagnosis

and reevaluated and monitored throughout treatment and recovery

• Nutrition status:
▫ Individual’s appetite and oral intake
▫ Nutrition impact symptomps; nausea, vomitting, diarrhea
▫ Weight loss
▫ Comorbidities
▫ Laboratory studies
▫ Physical examination (subcutaneus fat stores, muscle mass, fluid
status )
BODY WEIGHT

• Inviduals who are able to maintain the body weight and

nutrient stores  much better to tolerate treatment
impact symptomps and recover more quickly

• Weight loss during cancer caused by the loss of muscle

(lean body mass) rather than fat stores

• KeepBMI 18.5-25 for the best health.

ENERGY

• Based on the clinical status and the avaibility of

assesment information and equipment (patient data,
laboratory values, access to metabolic chart)
• To get adequate energy (calories) consider the diagnosis,
presence of other disease, intent of treatment, anticancer
therapies, fever or infection, other metabolic
complications
• Close monitoring and follow up to ensure adequate
energy
PROTEIN
• Protein needs increase during ill and stress to repair and rebuild
tissues affcted by cancer therapy and to maintain a healthy immune
system
• Inadequate protein
▫ The body will use its lean body mass as a fuel source
• Consider the degree of malnutrition, extent the disease, degree of
stress, ability to metabolize and use protein.
• Daily protein needs
▫ RDA for adults 0.8 g/Kg
▫ Normal maintenance : 0.8 to 1 g/Kg
▫ Nonstressed cancer patient : 1 to 1.2 g/Kg
▫ Hypercatabolic cancer patient : 1.2 to 1.6 g/Kg
▫ Severely stressed cancer patient 1.5 to 2.5 g/Kg
▫ Hematopoietic stem cell transplant patient 1.5 to 2 g/Kg
FLUID
• To maintain hydration, tissue perfution, electrolyte balance.
• Daily fluid requirements
Body surface area: 1500 ml/m2 or BSA x 1500 ml
Daily requirement method
1 ml of fluid per 1 kcal of estimated needs
Holliday-Segar method
>20 Kg of BW = 1500 ml+20 ml/Kg for each Kg > 20 Kg
Age-based method:
<55 years: 30-40 ml/kg
55-65 years: 30 ml/kg
>65 years: 25 ml/kg
MICRONUTRIENTS
• For individuals who have difficulty with eating
• No more than 100 % of DRI (dietary reference intake)
• Supplementation or restriction of specific micronutrients
may be required above or below DRI levels, depend on
diagnosis and laboratory analysis (e.g. Iron supplementation
for IDA)

ANTIOXIDANTS
• Controversy whether the use of antioxdant supplements
actually inhibits or enchances the antitumor effects of
radiation and chemotherapy
Management of Nutrition Impact Systems
Symptomps with a nutrition impact: nausea, vomitting, changes in
taste and smell, bowel changes, dysphagia, anorexia, pain, fatigue

DETERMINING ROUTES OF NUTRITION THERAPY

• Nutritional goals; specific, achievable, individualized in scope to encourage
cooperation, minimize the effects of nutrition impact symptomps, maximize
the individual’s nutritional status

ORAL NUTRITION MANAGEMENT STRATEGIES

• Altered taste acuity (dysgeusia, hypogeusia, ageusia); increased used of
flavorings and seasonings
• Dysphagia secondary or mucositis; intake of foods that are soft or liquefied,
served at moderate or room temperature
• Diminished salivation; artificial saliva preparations, saliva stimulants, such
as foods with high moisture content and plenty of fluids
ENTERAL NUTRITION
• Indication: malnutrition, prolonged anorexia, mechanical
obstruction, dysphagia, odynophagia, mucositis
• Helps to preserve immune and fut barrier function, fewer
postoperative complications and shortened lenghts of stay
• Short term: nasogastric or nasojejunal feeding tubes
Long term (>3-4 weeks): gastrostomy or jejunostomy
feeding tubes.
• Enteral nutrition formula is determined by the functional
capacity of the gut, nutrition status, cost and convenience,
physical characteristics of the formula (osmolality, FOS,
protein content, energy density, nutrient content).
PERENTERAL NUTRITION
• The type of PN is determined by the clinical and nutrition
status and the type of IV access
• Via central IV access or peripheral catheter (usually lower
in osmolarity and lipid-base formulas)
• Potential complications
Fluid overloads (receive multiple IV therapies)
Hyperglicemia resulting form high concentration of
dextrose
Insulin resistence associated with illness and stress
Electrolyte imbalance
Infection
REHABILITATION AND PHYSICAL ACTIVITY

• To rebuild muscle and regain strength and energy

• Poor or inadequate nutrition  fatigue
• Physical activity and exercise managing primary fatigue,
improve immune function, reduce anxiety and depression,
improve mood and self esteem, reduce symtomps
PALLIATIVE CARE
• The active total care of an individual when
curative measures are no longer considered an
option by either the medical team or the
individual
• To provide for optimal quality of life, relieve
physical symtomps, alleviate isolation, anxiety,
fear, mantain independence as long as possible
Thank You