Living Well with Cancer Presentation (Webinar)

Living Well with CancerLiving Well with CancerThe POWER of NUTRITIONThe POWER of NUTRITION

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The POWER of NUTRITIONThe POWER of NUTRITION

Caring for Your Patients gJoanne B. Dragun, M.D. FACRO

Director of Oncology at 21st Century Oncology Jacksonville FloridaJacksonville, Florida

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• This program is supported by Abbott Nutrition, Abbott Nutrition Health Institute.

• No financial relationships to disclose.

• This program meets the criteria for continuing education credit.

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Objectivesj

• Review the incidence and prevalence of malnutrition and lean body mass and associated causes in patients with cancer.

• Illustrate how a decline in nutritional status and muscle can affect cancer patient’s ability to tolerate and complete treatmentpatient’s ability to tolerate and complete treatment.

• Recognize the importance of early nutrition intervention in cancer patients to preserve muscle and strength.preserve muscle and strength.

• Discuss steps to improve nutritional status and quality of life of cancer patients.

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New Cases 1,596,670 in 2011

12 Million Cancer Survivors

New Cases 1 i 21,596,670 in 2011

12 Million Cancer Survivors1 in 2 men

1 in 3 women

5Siegel R. et al Ca Journal for Clinicians 2011;61

*Estimates are rounded to the nearest 10 and exclude basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.

6Siegel R. et al Ca Journal for Clinicians 2011;61

Outpatient-Home

• Neupogen, procrit, neulasta, neumega, colony stimulating factors

• This creates a problem for those of us in the field – how can we care for people in all environmentspeople in all environments

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Case StudyCase Study“Alice”: Pancreatic Cancer

• 65 y.o. female previously morbidly obese, lost 80 lbs.

• Abdominal pain, nausea, vomiting, jaundice

• 85% risk of cachexia*85% risk of cachexia• Losing 14.2% of body wt. at

diagnosis progressing to 24.5% i t d thprior to death

8*Tisdale MJ. Physiol Rev 2009;89:381-410 8

Mass on Ct Head of Pancreas

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Objective #1j

Review the incidence and prevalence of malnutrition andprevalence of malnutrition and

lean body mass and associated i ti t ithcauses in patients with cancer.

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CACHEXIA: An involuntary weight lossCACHEXIA: An involuntary weight loss involving fat and muscle due to shifts in metabolism caused by tumor byproducts and cytokines.

Loss of 5-10% body weight in 6 mo is defining y g gpoint (5% in 1 mo)

11Del Fabbro E, et al. J Palliat Med 2006;9:409-421

Progressive Malnutrition

CachexiaCachexia

25% 50% Continues25%Prior to

diagnosis

50% At

diagnosis

Continues during

treatmentg g

Decline occurs prior to diagnosis or therapy

12Halpern-Silveira D et al. Support Care Cancer 2010;18:617-625

Cancer Related Cachexia i N t St tiis Not Starvation

Involves inflammation, hypermetabolism, neurohormonal changes and production of proteolytic and lipolytic factors. Leading to:

• Weakness• Fatigue• Pain• Pain• Electrolyte imbalances• Arrhythmias• Infections

13J D Maltzman. Abramson Cancer Center 2004.

• Over 130,000 hospital admissions with cachexia as diagnostic code 2007 (799.4)P t i 50% f ti t• Present in 50% of cancer patients

• NCI: responsible for 20% of deaths in cancer patients

14www.hcup-us.ahrq.gov/nisovirview.jsp

Tumor Specific: Cachexia

Solid tumor of Lung

Pancreas

GI tract

Less often in breast or lower GI

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or lower GI Tisdale MJ. J Support Oncol 2003;1(3):159-168

Causes of Cancer CachexiaCauses of Cancer Cachexia

Anorexia

Cachexia

MetabolismTumor F t

Cachexia

Metabolism Factors

16Chance WT, et al. Peptides 1996;17:797-801

Metabolism Affected

Carbohydrate: poor vascularization (hypoxia) anaerobic metabolism of glucose for energy

Li id ti t h i t fLipids: cancer patients have increase turnover of glycerol and fatty acids

17Holroyde CP et al. Cancer Res 1975;35:3710-3714

Protein CatabolismProtein Catabolism

Lean body mass loss common in cachexia and may reduce survival.y

This loss results in decreased physical performanceperformance

18Wing SS, Goldberg AL. A J Physiology 1993;264:E668-676

Tumor Factors/Cachexia

Cytokines: y

TNF alpha tumor necrosis factor

IL-1 interleukin-1IL-1 interleukin-1

IL-6 interleukin-6

IFN i t fIFNy interferon yammy

LIF leukemia inhibitory factor

19J Natl Canc Inst 1997;89(23):1763-1773

20Guttridge, DC, Acharyya S. Clin Cancer Res 2007;13:1356

21Lecker SH. CJASN 2009;1:564-570

Signs and Symptoms

G % ( )• Greater than 10% (total body weight) weight loss

• Skeletal muscle atrophy• Profound loss of appetite• Loss of taste

D d i t• Depressed immune system• Impaired response to chemo• Delay in treatmentsDelay in treatments• Metabolic disturbances

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Objective # 2

Illustrate how a decline in nutritional status and muscle can affect cancer status a d usc e ca a ect ca ce

patient’s ability to tolerate and complete treatmentcomplete treatment.

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Treatments affect Nutrition

• Surgery• Surgery

• Chemotherapy

• Radiation therapy

• Immunotherapy

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Pancreatic Pre-Surgical

Abd i l di t ti• Abdominal distention• Abdominal pain• Anemia• Back pain• Nausea• New onset diabetes• Fatigue• Jaundice• Depressionp

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Surgery

Patients undergo biopsy then definitive surgery resulting g p y g y gin long recovery periods.

Use of narcotics, ileus, pain, deconditioning, nausea,Use of narcotics, ileus, pain, deconditioning, nausea, quick discharge into home environment all contribute to poor post-op nutrition. This is most critical for a patient

h t ith d bilit tiwho presents with debilitation

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27Gouma DJ et al. Eur J Surg Oncol 1999;25:113-123

Chemotherapy: EmesisHigh Risk (90%):

• Carboplatin

• Cytoxan

• Carmustine

• Dacarbazine• Cytoxan

• Daunorubicin

• Adriamycin

• Dacarbazine

• Dactinomycin

• Adriamycin

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Chemotherapy: Emesis

Moderate risk (30-90%):

• Carboplatin

• Cytoxan

• Epirubicin

• Oxaliplatin• Cytoxan

• Daunorubicin

• Adriamycin

• Oxaliplatin

• Ifosfamide

• Camptosar• Adriamycin

Most lung cancer patients are treated with Taxol Carboplatin

• Camptosar

Taxol, Carboplatin

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Chemotherapy: EmesisLow to minimal risk (<10-30%):

• Mitoxantrone

• Taxol

• Herceptin

• Navelbine

• Etoposide

• Alimta

• Taxotere

• Mitomycin

• Avastin

• Rituxan

• Methotrexate

• Fluorouracily

• Topotecan

• Gem ar

Rituxan

• Velbane

• M l

Fluorouracil

• Velcade

E bit• Gemzar

Most pancreatic cancer is treated with 5FU, gemzar

• Myleran• Erbitux

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Radiation Therapy

• Patients receive radiation treatments• Patients receive radiation treatments daily for several weeks

• Effects are cumulativeEffects are cumulative• Related to the area treated• Acute and long term effectscute a d o g te e ects• Increased insult when combined with

chemotherapy

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Radiation TherapyRadiation Therapy

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Lung CancerLung Cancer

• Presentation may include cough, hemoptysis, SOB, DOE, weight loss, occasionally esophageal compression y p g pand pain

• Second leading cause of cancer

• Leading cause of cancer death in men and women

34CA Cancer Journal 2011;61(4)

Case Studyy“Fred”: 65 y.o. Smoker

• Non-small cell lung cancer

20% i ht l• > 20% weight loss

In non small cell lung cancer, increased acute phase response (APR) in protein synthesis shifts from albumin to CRP– increasing IL-6*

35*Falconer JS et al. Ann Surg 1994;219:325-331. 35

Objective # 3

Recognize the importance of early nutrition intervention in cancer patients to preserve p p

muscle and strength.

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Benefits of Nutrition Supportpp

• Improve alertnessImprove alertness

• Improve ability to comply with therapy

M d• May decrease nausea

• Decrease hopelessness and feeling of abandonment

• Enhance self care post surgery

• Improve lean body mass, resting energy expenditure, decrease inflammatory cytokines

38Nutrition in Cancer Care, Advanced Cancer PDQ National Cancer Institute

Screen and Assess the Patient

Seek reversible causes –first step in management

Objective Tools:DetermineDetermine

Malnutrition Screening Tool (MST)

Patient Generated Subjective Global Assessment j(PG-SGA)

39BauerJ,Capra S, Ferguson M. E JCN 2002;56(8):779-785.

N t iti S i I iti ti R t f N t iti S i I T d C i W hi t DC N t iti S i i iti ti 1991

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Nutrition Screening Initiative. Report of Nutrition Screening I: Toward a Common view. Washington, DC: Nutrition Screening initiative; 1991. http://www.jblearning.com/samples/0763730629/Frank_Appendix10D.pdf Ferguson M, et al Nutrition. 1999;15(6):458-464.

Subjective Global Assessment

• Nourished: absence of weight loss f th 5% f l i ht iof more than 5% of usual weight in

last 30 days

• At risk for malnutrition: weight• At risk for malnutrition: weight loss of 5-10% last 30 days

• Malnourished: more than 10% weight loss last 30 days

41National Cancer Institute, Nutrition in Cancer Care (PDQ) 8/19/11. Detsky AS et al. JPEN 1987:11:8-13.

Nutritional Screening and Assessment toolsAssessment tools

Screening tools start the process:Screening tools start the process:

Evaluate food intake

Weight loss documented other factors include:• Mobility indexMobility index• Psychological stress• N h l i l (d ti )• Neuropsychological (dementia)• BMI

42Vellas B, Villaris H, et al. J Nutr Health Aging 2009;10:454-465

Nutritional Interventions

• Once the patient is assessed, the p ,critical problems should be detailed and then addressed systematically

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• Detail nutritional assessment tools for accreditation

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• Detail nutritional assessment tools for accreditation

• Consider the opportunities for quality improvement initiatives involving

t itinutrition

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Goals of Nutrition InterventionGoals of Nutrition Intervention

P t t i t d fi i i• Prevent or reverse nutrient deficiencies• Preserve lean body mass

Help patient tolerate treatments• Help patient tolerate treatments• Maintain strength and energy• Decrease risk of infection• Decrease risk of infection• Aid in recovery and healing• Maximize quality of life improve well being• Maximize quality of life, improve well-being

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Design a Plan of Careg

• Include nutrition in your care plan

• Include ongoing evaluationsg g

• Keep a weight chart

• Intake recall on every visit

• Enlist help of other team membersp

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Multidisciplinary

• Nurse

• Dietitian

• Speech Therapist

• Social Worker

• Doctor

• Physical Therapist

• Psychologist

• Family!!y p

• Occupational Therapist

y

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Objective # 4Objective # 4

Discuss steps to improve nutritional status and quality of life of cancer patients.q y p

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Make Nutrition a PriorityMake Nutrition a Priority

• Develop a systematic approach for teaching

• Gather nutrition brochures

• Individualize teaching tools• Individualize teaching tools

• Provide nutritional supplements i f tiinformation

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Be Specific!!

P ti t d f ili d itt di ti d l• Patients and families need written directives and goals

• Weigh often

• Monitor fluids

• Add supplements between meals

• Give the patient some responsibilityp p y

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General Guidelines

• Eat small frequent meals (every one to two hours)• Eat small frequent meals (every one to two hours)

• Eat high protein, high calorie foods

• Avoid empty calories

• Eat when you feel well regardless of time of the dayEat when you feel well regardless of time of the day

• To increase appetite, light exercise

• Take medications with high calorie foods

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General Guidelines

• Use meal substitutes such as high calorie, high protein drinks g g pwhen you do not feel like eating.

• Add extra calories and protein to foods such as butter, dry p , ymilk powder, honey, baby foods

• Eat food at room temperaturep

• Avoid spicy foods with strong odors

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General Guidelines

• Metallic taste? Try plastic utensilseta c taste y p ast c ute s s

• Poultry, fish, eggs cheese instead of red meat

S b tit t ilk h k ddi i h f• Substitute milkshakes, puddings, ice cream, cheese for meat

• Soft, moist foods

• Blenderize

• Small bites and chew!

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Management: “Alice”Management: Alice

Pancreatic cancer requires multifaceted approachPancreatic cancer requires multifaceted approach. Frequently, patient are newly diagnosed with diabetes, but still require high calories and protein. q g p

Use nutritional supplements that are rich in protein, low in simple sugars and adequate to avoid further weight losssimple sugars and adequate to avoid further weight loss.

Manage bowel-constipation from narcotic ileus, diarrheafrom treatment nausea painfrom treatment, nausea, pain.

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M t “F d”Management: “Fred”

Inflammation of the esophagus requires dramatic change: soft foods, high calorie and protein enriched beverages, slower eating, calorie monitoring.

Frequently patients complain that water burns. Use thicken liquids, crush medications when possible. Patients cannot h l if t iti i i d t H it li ti fheal if nutrition is inadequate. Hospitalization for dehydration, malnutrition is frequent in this group.

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Positron Emission Tomography EsophagusPositron Emission Tomography Esophagus

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List 5 actions to improve your patient’sList 5 actions to improve your patient s nutrition

1. Assess the individual and issues

2. Get help from the team and include the family

3 Monitor intake weight3. Monitor intake, weight

4. Encourage small frequent meals

5. Employ supplemental feedings

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Remember, What You Do Now Counts!Remember, What You Do Now Counts!Cancer is a Chronic Disease

People are living longer.

Therapy is more complex: surgeries radiationTherapy is more complex: surgeries, radiation, chemotherapy, biologics.

Combination of treatments are lasting longer toxic andCombination of treatments are lasting longer, toxic and debilitating.

M i t iti i it l t ll b iManaging nutrition is vital to well-being.

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Keep the CARING in Cancer CareKeep the CARING in Cancer Care

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Resources

1. American Cancer Society: www.cancer.org

2. American Dietetic Assoc: www.eatright.org

3. American Institute for Cancer Research: www.aicr.org

4. National Center for Complementary and Alternative Medicine (NCCAM): www.nccam.nih.gov

5. Office of dietary supplements: ods.od.nih.gov

6. Nutrition in Cancer Care (PDQ) National Cancer Institute (1-800 4 cancer)

7. American College of Surgeons: www.facs.org/cancer

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Living Well with Cancer Presentation (Webinar)

Education

Transcript of Living Well with Cancer Presentation (Webinar)