ROLE OF NUTRITION IN RADIOTHERAPY

ByDr. Ayush Garg, PG JR II

Moderator: Dr. Pavan Kumar

Malnutrition In Cancer Patients

• Reduction of food intake is a common manifestation of cancer, presenting in 15-40% of patients and up to 80% of those with advanced malignancy

• More than 80% of all patients suffers from: Anorexia, Nausea, and Emesis

• 85% of patients with pancreatic or stomach cancer had lost weight at the time of diagnosis, and in 30% the loss was severe.

• Autopsies have shown that malnutrition is one of the most common causes of death, accounting for 10–20%

Incidence Of Malnutrition In Different Tumor SitesTumor Site % Malnutrition

General Cancer Patients 60%

Oesophagus 79%

Breast 9%

Gastric 83%

Lung (small cell) 50%

Head and Neck 72%

(Adapted from Freeman 2004)

Frequency/severity of weight loss associated with cancer

Nutrition Problems During Radiotherapy

Dept. Digestive Diseases and Clinical Nutrition

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82 8265

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18 1835

12 7

Present Absent

Nutrition Problems During Chemotherapy

Dept. Digestive Diseases and Clinical Nutrition

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70 7482

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72 70

30 2618

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Present Absent

Prevention of Malnutrition through Nutrition

Malnutrition with progressive tumor growth

Malnutrition as a risk factor for anticancer therapy

Surgery, Radiotherapy, Chemotherapy

Malnutrition as consequence/ complication of therapies

Mucositis, infections

Malnutrition in advanced incurable cancer

Terminal care

Nutritional Issues Throughout The Course Of Cancer Illness

Causes Of Anorexia In Cancer Patients

• Pain, • Nausea, vomiting• Abnormal taste, • Abnormal smell,

• Loss appetite, • Depression, • Weakness, • GI disturbance/ Obstruction

Cancer Cachexia

• Debilitating and life-threatening condition, characterized by negative protein and energy balance

• Present in 50% of cancer patients, more prevalent in GI and Lung Cancer

• Characterized by:• Progressive weight loss• Anorexia• Asthenia• Metabolic alterations• Depletion in lipid stores• Severe loss of skeletal muscle protein

Cancer Cachexia Starvation

Body weight

Lean body mass

Body fat

Total energy expenditure

Resting energy expenditure

Protein degradation

Cancer CachexiaVs

Simple Starvation

Cancer Cachexia Causes And Effects

Acute PhaseResponse ( CRP)

Appetitedepression

Cachexia with weight loss, inflammation, fat depletion, muscle wasting, Poor clinical outcomes

Body’s Immune response to tumor

Cytokine production elicits localand systemic inflammatory response Proteolysis- inducing

Factor (PIF)

Food Intake Loss of Lean Body Mass

Alteration in Macronutrient

Metabolism

RestingMetabolic

Rate

Release of tumor factors

Consequences of Malnutrition• Impaired immunological function

• lymphocyte count and function ↓,

• macrophage / B- ,T-, and NK cell function ↓,

• chemotaxis / migration of neutrophils ↓

• Increased complications

• Chemotherapy/Radiotherapyinduced toxicity ↑

REF: Concise Manual of Hematology and Oncology; D.P.Berger, M.Engelhardt, H.Henb, R.Mertelsmann; Springer-Verlag Berlin Heidelberg 2008

Duration Of

Hospital Stay ↑

Costs ↑

Quality Of Life

↓

Mortality ↑

Chemotherapy

• Chemotherapy can result in the following nutritional problems:

nausea, anorexia, vomiting, diarrhoea, constipation, taste changes, mucositis, internal ulceration, malabsorption

• Multiple combinations of cytotoxic drugs can increase side effects

• Normal and malignant cells can be damaged• Intake often decreases with each cycle of

chemotherapy and food aversions occur in up to 74% of patients

Radiotherapy

• Nutritional problems may arise depending on:– Area exposed– Duration and total radiation dose• Radiotherapy can result in:– burning sensation to the throat, loss of appetite, taste

alterations, sore mouth, dry mouth, damage or loss of teeth, abdominal cramping, nausea, fatigue, malabsorption or diarrhoea

• More than 10% of patients lose over 10% of their usual weight when radiotherapy continues for a period of 6-8 weeks

Emotional and social effects

• Loss of employment - loss of role in life, loss of income• Anxiety - about diagnosis, about treatment, possible

recurrence• Body Image - weight loss, loss of hair• Fear - about the future, about dying, about their family• Depression• All of these can have an impact on nutrition even before

treatment begins.

• Grading of Malnutrition:

Body weight loss < 10% wt. loss :- Mild Malnutrition 10 – 20% wt. loss :- Moderate Malnutrition > 30% wt. loss :- Severe Malnutrition

Subjective global assessment, group C

• Using dietary history or nutrition protocols.• Starvation = daily oral energy intake < 500 kcal• Insufficient energy intake = daily oral energy intake <

60% of required intake

Diagnosis of Malnutrition in Cancer Patients

Objectives of Nutrition Therapyo Maintenance / improvement of nutritional statuso Maintenance / improvement of subjective quality of lifeo Increase in treatment efficacyo Reduction of treatment related side effects and complicationso Preserve lean body masso Maintain strength and energyo Protect immune function, decreasing the risk of infectiono Aid in recovery and healingo Improvement of prognosis, prevention of treatment breaks or

delays

Strategies in Nutrition Therapy

oAppetite StimulantsoDrugs which are capable of inhibiting the synthesis and/or release

of cytokines E.g. COX inhibitors, Non-steroidal anti-inflammatory drugs,

pentoxifylline, thalidomide, melatonin, statins, ACE inhibitorsoAgents which promote skeletal muscle anabolism e.g. Anabolic androgenic steroid

Metabolic intervention: To optimize patient’s nutritional status but minimize tumor nourishment

Substrate intervention: To modulate effects of mediators & control inflammatory response

Metabolic Intervention

• High caloric density feeding• Improve lean body mass

• Low carbohydrate content • “Starve the tumor, feed the patient”

• Suggested composition:• High energy >1.2 – 1.5 kcal /ml • High fat 45 - 50 % and low CHO • High protein 18 - 20 %

(50% - Fat, 20% - Protein, 30% - CHO)

Specific Metabolic Changes In The Tumor Host

• Tumor hosts reveal abnormalities of: • Lipid metabolism

• Increased lipolysis• Increased oxidation of fatty acids

• Carbohydrate metabolism• Increased glucose turnover • Impaired peripheral glucose disposal • Caused by insulin resistance

• Protein degradation , nitrogen depletion, muscle protein synthesis

Calculation of required Nutrition (per Kg of normal weight / ideal weight and day)

Indications for Parenteral Nutrition in Oncology

• Individual need depending on:• Nutritional status• Co-morbidities (concomitant diseases)• Type of anti-neoplastic treatment• Patient’s performance status

• Parenteral nutrition is indicated when:• Oral / enteral nutrition < 500 Kcal/d expected for at least

5 days• Oral / enteral nutrition < 60% of the calculated

nutritional needs expected for at least 10 days

ASPEN Guidelines: OncologyParenteral & Enteral nutrition 2009

• Omega 3 FA supplementation may help in• Decrease rate of weight loss• Maintain lean body mass• Improve appetite• Improve quality of life• Inhibit progress of cachexia in cancer• Inhibit Proteolysis-inducing factor• Decrease fatigue• Cytotoxic to variety of tumor cells• May reduce adverse effects of chemotherapy

Glutamine: Beneficial Effects In Cancer

• Supports immune, muscle, gut function• Enhances activity of NK lymphocytes• Improves tolerence to adjuvant treatment• Inhibits tumor growth, enhances response• Corrects host depletion, improves nitrogen retention, &

reverses impairement of intestinal integrity associated with cancer.

• Reduces 6-months mortality• Shortens hospital stay

Can Nutrition Treatment Maintain Or Improve Nutritional Status In Cancer Patients?

Nutrition therapy in oncology is required to improve prognosis and reduce the cancer-related decline in nutritional status.

In surgical oncology, it reduces the postoperative symptoms, lessens the hospital stay and improved tolerance to treatments.

In palliative care, the nutritional therapy focuses on symptoms associated with weight loss, thus improving the quality of life.

Summary• Early focused assessment - “proactive”• Clear and realistic definition of goals• Manipulation of nutrient intake• The overall nutritional goal is to optimally feed the host

and to minimise any nourishment of tumour tissue

Integrate Nutrition into the overall treatment plan

Nutritional recommendations for cancer patients

include a high fat and low carbohydrate feed

Thanks