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Pranithi Hongsprabhas MD.

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massage (except deep tissue or forceful) for anxiety or pain ... SFA, and addition of soy in the diet of well nourished men with prostate cancer. ... – PowerPoint PPT presentation

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Title: Pranithi Hongsprabhas MD.


1
Pranithi Hongsprabhas MD.
  • Nutrition in Cancer

2
Weight Loss in Cancer Patients
  • 50 of CA pt lose wt
  • 70 of terminal stage CA pt
  • Wt loss is prognostic significant

Kondrup AJCN 2002, De Wys et al. Am J Med 1980,
Andreyev et al. Eur J Cancer 1998
3
Frequency/Severity of Weight Loss Associated with
Cancer
DeWys et al. Am J Med 198069491
4
Cancer Cachexia Myth
  • Anorexia-cachexia syndrome is due to the host
    lack of appetite and or starvation
  • Anorexia-cachexia happens because of tumor
    consumes the host nutrients

5
Progression of Cancer-induced Weight Loss
Normal
6
Cancer Cachexia
  • Syndrome of combined physiologic, metabolic and
    psychological factors
  • Manifestations
  • anorexia
  • progressive involuntary wt loss, wasting, tissue
    depletion
  • Fatigue, poor performance
  • Anemia
  • More advance disease higher risk of wt loss

7
Metabolic Response to Starvation

8
Cancer Cachexia Anorexia Syndrome (CACS)
Abdominal pain
Malabsorption
Depression
Cachexia
Taste alteration
Constipation
Radio/chemotherapy, surgery side effects
Intestinal obstruction
Derangement of Metabolism
  • Increased
  • Lipolysis/lipid metabolism
  • Proteolysis
  • REE
  • Decreased
  • Lipogenesis
  • LPL activity
  • Protein synthesis

Lipolysis
TNF-?, IFN-?
increase of leptin altered orexegenic and
anorexegenic signals LIF, TGF-ß
9
Does cancer influence energy expenditure?
  • Cancer itself does not have consistent effect on
    REE
  • Increased ¼ had 10 higher than predicted
  • Unchanged
  • Decreased ¼ had 10 lower than predicted

10
Carbohydrate Metabolism
  • 1925 Cori Cori demonstrate decreased glucose
    level
  • High anaerobic glycolysis
  • Glucose to lactate
  • Increased lactate level
  • Lactate
  • Oxidized 15
  • Regenerate to glucose 85

11
CHO Metabolism
  • Gluconeogenesis increased
  • Lactate, glycerol, alanine
  • Cannot be suppressed by glucose supplement
  • Decreased glucose tolerance insulin resistance

12
Lipid Metabolism
  • Depletion of fat store
  • The proportion of wt loss fat loss
  • Associated with hypertriglyceridemia

13
Mechanism
  • Increased lipolysis
  • Increased FFA and glycerol turnover
  • Normal or increased lipid oxidation
  • Decreased lipid clearance
  • Decreased lipoprotein lipase (LPL) activity

14
Protein Metabolism
  • Increased protein metabolism
  • Whole body protein turnover unchanged
  • Muscle tissue largest pool
  • Muscle protein loss, muscle wasting
  • Decreased protein synthesis

15
Liver Protein
  • Increased hepatic protein synthesis
  • Acute phase protein proportional to tumor growth

Intestinal Protein
  • Decreased intestinal wt
  • Net protein breakdown
  • Decrease mucosal barrier intestinal permeability

16
Protein turnover
17
Cancer induced weight loss vs. other types of
weight loss
Adapt from Kolter DP, Ann Int Med 2000133622
18
Does nutritional status influence the clinical
course and the prognosis?
  • Reduce QOL
  • Lower activity level
  • Increase treatment related adverse reactions
  • Reduce tumor response to treatment
  • Reduce survival

19
What are specific nutritional goals in cancer
patients?
  • Prevent and treating undernutrition
  • Enhancing anti-tumor treatment effects
  • Reducing adverse effects of anti-tumor Rx
  • Improve QOL

20
Energy requirement
  • If REE cannot be measured, use rule of thumb
  • Ambulant pt 30-35 kcal/kg/d
  • Bedridden pt 20-25 kcal/kg/d
  • Oncological Rx may modulate EE

21
Do cancer patients require a distinct nutrient
composition?
  • Standard formula are recommended for EN of cancer
    pt
  • Protein 1 g/kg/d (minimum)
  • 1.2-2 g/kg/d
  • Supplement with electrolyte, vitamins and trace
    element acording to RDA

22
When should EN be started?
  • If undernutrition already exists
  • If it is anticipated that Pt will be unable to
    eat for 7 d
  • If an inadequate food intake (
    10 d

23
Can EN maintain or improve nutritional status in
cancer patients?
  • Yes In wt lost patients from insufficient
    intake
  • Gain more wt, lost less wt1
  • improve or maintain nutritional status2
  • maintain QOL

1. Systematic review of ONS, counceling Baldwin
et al, 2004 2. Cancer cachexia and GI cancer
Bozzetti F1989 and Lindh A 1986. 3. GI and H
neck cancer. Isenring EA, 2004
24
Can EN maintain or improve nutritional status in
cancer patients?
  • In the presence of inflammation
  • Extremely difficult to achieve anabolism
  • Without effective antitumor Rx ?
    impossible to reverse process
  • At least to maintain wt or minimize wt loss
  • Additional intervention pharmacological effort
    recommended to modulate inflammatory response

25
Therapeutic challenges
  • Cancer induced weight loss
  • Metabolic abnormalities
  • Other types of weight loss (caloric deprivation)
  • Mechanical causes
  • Treatment related causes
  • Pcycholocical issues

No weight gain, even when added energy and
protein provided
Provision of energy and protein can promote
weight gain
Ottery FD Cancer Practice 19942123
26
Can metabolic modulators increase nutritional
intake
  • Steroids (short term)
  • Improve appetite
  • Nausea
  • Pain
  • Mechanisim ? TNF-?, IL-1
  • ADR PUD, osteoporosis

27
Can metabolic modulators increase nutritional
intake
  • Progesterone
  • Improve appetite
  • Wt gain
  • QOL
  • Megestorol acetate, Medroxy- progesteone acetate
  • ADR fluid retention, thromboembolism

28
Can metabolic modulators increase nutritional
intake
  • ? 3 fatty acid
  • ? 3 fatty acid less active pro-inflammatory
    midiators
  • Improve appetite and body weight
  • Antagonized Lipid mobilizing factors,
    proteolysis inducing factors

29
(No Transcript)
30
Does supplementation with ?-3 fatty acid have
beneficial effect in cancer patients?
  • RCT contradictory/controversial
  • Evidence level C
  • RCT
  • improve survival/Non significant effect on wt
  • Did not improve wt or appetite
  • Non RCT improve survival, side effect of CTX
  • Recent RCT high dose EPA wt stabilization, wt
    gain
  • Unlikely to prolong survival in advance cancer
  • The result of further trials are awaited

31
Special situation
  • Perioperative EN
  • Radiotherapy
  • Chemotherapy
  • Transplantation
  • Advance stage/ incurable

32
Perioperative
  • Severe nutritional risk benefit from SNS 10-14 d
    prior to major surgery even if surgery has to be
    delayed (A)
  • All CA pt undergoing major abdominal surgery,
    preop EN preferably with immune modulating
    substreates 5-7 d independent of nutritional
    status (A)

ESPEN guidelines on EN Clin Nutr 2006
33
Radiotherapy
  • -ve effect of XRT on oral feeding
  • early SNS may lead to complete course of Rx ?
    reduce morbidity in Rx of head neck cancer
  • PN failed to improve survival, infectious
    complication and noninfectious complication in
    abd XRT
  • EN reduce wt loss, digestive intolerance to abd
    and pelvic XRT

Critical Reviews in OncologyHematology 34 (2000)
137168
34
Is there indication for EN during radiotherapy
(XRT)or combined radiotherapy(cXRT)?
  • Yes, use intensive counceling and ONS to increase
    intake (A)
  • to prevent Rx associated wt loss
  • To prevent interuption of XRT
  • in GI, head and neck area
  • If obstructive HN or esophageal CA interferes
    with swallowing tube feeding is preferred
  • TF is preferred if local mucositis is expected
    (c)
  • Routine EN is not indicated during XRT of other
    body regions (c)

ESPEN guidelines on EN Clin Nutr 2006
35
Is there indication for EN during chemotherapy?
  • No
  • Routine EN during CTX has no effect on tumor
    response nor CTX associated unwanted effects (b)

ESPEN guidelines on EN Clin Nutr 2006
36
Bone Marrow Transplantation
  • Nutritional consequences of BMT
  • NV, mucositis, diarrhea
  • Venooclusive disease (VOD)
  • Graft vs. host dis (GVHD)
  • Metabolic abnormalities
  • Increased protein metabolism
  • Hyperglycemia
  • Hypertriglyceridemia
  • Electrolyte abnormalities
  • TPN indicated

37
Is there an indication for EN in advanced stages
of incurable cancer patients?
  • EN should be provided in order to minimize wt
    loss, as long as pt consents and the dying phase
    has not started (c)
  • When EOL is very close, most pt require only
    minimal of food and water to reduce thirst and
    hunger (b)

ESPEN guidelines on EN Clin Nutr 2006
38
Risk of EN
  • Does EN feed the tumor?
  • No reliable data
  • Theoretical considerations should
  • No influence of the decision to feed a cancer
    patient

39
Complementary and alternative mdicine (CAM)
  • Current evidence CAM is more effective in
    relieving cancer-related symptoms in slowing
    disease progression.
  • acupuncture for CTx related NV or for pain
  • massage (except deep tissue or forceful) for
    anxiety or pain
  • moderate exercise to minimize fatigue
  • psychological and mind-body techniques
  • reduction of animal and SFA, and addition of soy
    in the diet of well nourished men with prostate
    cancer.

40
An CAM Rx should be discouraged if
  • Delays conventional Rx
  • No scientific prove
  • Provided by unlicensed practitioner
  • Require injection of substances not approved by
    FDA

41
Conclusion
  • Complete improvement of nutritional state is not
    attained in short time
  • Cancer Rx should not be postponed until
    nutritional rehabilitation achieved
  • Nutritional Rx should be incorporated in to the
    overall Rx as early as possible
  • Effort to improve nutritional and metabolic
    status may ? morbidity and mortality in pts who
    need surgery, XRx, XR-CTx
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