Nutrition and the cancer patient

Question 1

10 most common cancers?

Answer 1

Prostate
Lung
Bowel
Bladder
NHL
Malignant melanoma
Kidney
Oesophagus
Leukaemia
Brain tumours
Other sites

Question 2

What are the three most common cancers in men?

Answer 2

Prostate, lung and bowel

Account for 50% of male cancers

Question 3

What are the three most common cancers in women?

Answer 3

Breast, lung and bowel

Over 50%

Question 4

Which cancer accounts for most deaths?

Answer 4

Lung

Question 5

How effective is nutritional support in lung cancer therapy?

Answer 5

Little evidence that dietary therapy in patients with lung cancer undergoing radiotherapy has an effect on patient or clinical outcomes- randomised controlled trials are needed

Question 6

Which cancer patients are at high risk of weight loss?

Answer 6

Upper GI: stomach, pancreatic (secretions affected and cytokines released by tumours causing cachexia), head and neck
Medium- Prostate, colon and lung
Low- Breast, sarcoma and favourable NHL

Question 7

What are the consequences of weight loss?

Answer 7

Reduced immunity
Impaired muscle function, weakness
Impairments to organ functions e.g. cardiac and respiratory
Reduced mobility, loos of independence
Reduced quality of life

Question 8

What does the therapeutic index dictate?

Answer 8

Ability of patient to cope with toxic treatment that they are given

Question 9

What is therapeutic index scaled to?

Answer 9

Weight, height, body surface area +/- GFR, +/- blood levels

Question 10

What does too much therapy lead to?

Answer 10

Toxicity

Question 11

What does too little therapy lead to?

Answer 11

Ineffective treatment

Question 12

What is the greatest risk factor for response to therapy?

Answer 12

Sarcopaenia

Question 13

What is sarcopaenia?

Answer 13

Loss of muscle mass

Question 14

In what way is the relationship between sarcopenia and txicity a two way process?

Answer 14

Toxicity aggravates loss of weight and muscle

Weight loss and sarcopenia enhance toxicity

Question 15

What is sarcopenia associated with?

Answer 15

More treatment delays
Dose reductions
Termination of treatment
Decreased OS in age, sex, stage and performance matched patients

Question 16

What are the 5 main causes of malnourishment in lung cancer patients?

Answer 16

Iatrogenic causes of decreased intake
Inadequate symptom control
Site of tumour- functional and physiological causes of malnutrition
Increased metabolic rate
Cancer cachexia

Question 17

What iatrogenic causes of decreased intake are there?

Answer 17

Decreased intake, increased expenditure and increased losses
Surgery- pain and fatigue, SOB
RadioTx: odynophagia (painful swallowing, fatigue, dysgeusia (altered taste) due to low saliva production all cause patient to eat less
Chemotherapy:
-Fatigue, nausea, anorexia and dysgeusia
-Vomiting and bowel changes (directing chemo at absorptive surfaces of gut will cause diarrhoea)- energy losses
- Infection will cause increase expenditure
-Mucositis

Question 18

What is the relationship between symptoms and amount of weight loss?

Answer 18

Weak significant association

Question 19

What are the common symptoms?

Answer 19

Most common to least:
No appetite
Early satiety
Pain
Taste changes
Nausea
Dry mouth
Constipation
Vomiting
Diarrhoea

Question 20

Which sites of tumours can lead to weight loss?

Answer 20

GI function/motility- changes affecting absorption of food
Obstructions of tumours in GIT- in head and neck cancer- difficult to eat
Malabsorption- cancer/mets in small intestine

Question 21

What happens to BMR in vast majority of cancers as cancer progresses?

Answer 21

It increases

Question 22

What are the two different definitions of cachexia?

Answer 22

Multifactorial syndrome that leads to ongoing loss of skeletal muscle with/without loss of fat mass. Can’t be fully reversed by conventional nutritional support and leads to progressive functional impairment

Specific metabolic response brought about by the presence of tumour, either from the tumour itself or its metabolites and stimulation of immune/acute phase response.

Question 23

What defines an increased inflammatory response/status?

Answer 23

Increased CRP, IL-1, IL-6, IL-10 and TNF-alpha

Question 24

What are the symptoms of cancer cachexia?

Answer 24

Reduced food intake/anorexia
Fatigue
Weight loss- muscle and fat
Weakness
Impaired immunity
Can be masked by oedema or obesity- very important in certain cancers e.g. breast, people remain overweight
Early cancer patients less likely to have cachexia than metastatic patients

Question 25

What are the key differences between starvation and cancer cachexia?

Answer 25

The key differences are in cachexia,glucose (lowered in starvation) and protein metabolism (not increased in starvation, protein is preserved) are elevated; and there is rapid weight loss (slow in starvation) due to increased energy expenditure

Question 26

Give an overview of cancer metabolism?

Answer 26

Tumour uses glucose to fuel itself- via anaerobic metabolism. Therefore no ATP is generated, instead lactate is which is delivered to liver and reprocessed into pyruvate -> glucose Increased glucose cycling causes protein to be pulled from muscle to mett tumours demand for glucose. Release of TNF causes an increased breakdown of muscle to fuel the cancer. With so much glucose used by the tumour, the body relies on fat metabolism to fuel itself This causes preferential loss of lean body tissue. Increased muscle turnover and decreased synthesis, upregulated proteolytic pathways come into play Increased lipolysis is required for liver to convert lactate into glucose which is very energy costly. This fuels the liver

Question 27

What are the stages of cancer cachexia?

Answer 27

Precachexia- weight loss is 5%. Anorexia and metabolic change Cachexia- Weight loss is >5%. or BMI<20 and weight loss >2% or sarcopenia and weight loss>2% Often reduced food intake and systemic inflammation Refractory cachexia- Variable degree Cancer disease both pro-catabolic and not responsive to anti-cancer treatment. Low performance score. <3m expected survival

Question 28

What are the goals of nutritional support in cancer?

Answer 28

Depends on what you're trying to do and where patient is in their treatment pathway and what is happening: Prevent/treat cancer therapy related malnutrition and/or weight loss Increase treatment efficacy Increase strength and quality of life

Question 29

What are quality of life scores determined by?>

Answer 29

Tumour site- 30% Weight loss- 30% Intake- 20%

Question 30

When should artificial nutritional support be given (tube or IV)?

Answer 30

Moderatly-severely malnourished patients if given 7-14 days pre-op Anticipated inability to ingest/absorb nutrients for 7-14 days in malnourished at risk patient receiving treatment

Question 31

When should you not give artificial nutrition?

Answer 31

As routine adjunct to surgery or chemo | Terminal illness- Rarely results in weight gain or altered outcome

Question 32

Between breast and lung cancer, which patients are at greater risk of wasting?

Answer 32

Lung

Question 33

What are the dietary recommendations for a cancer patient?

Answer 33

Decreased saturated fat Increased intake of fish Variety is good- maximise essential vitamins and minerals Increase carotenoid containing fruit and veg Prostate- increase soy intake Colorectal- increase fibre

Question 34

What are the physical activity recommendations for cancer patients?

Answer 34

At least 30 minutes 5 or more days/week Even modest amounts help -> dose-response relationship Exercise to improve lean body mass most useful in GI, head and neck cancers Exercise to control body weight and lose body fat most useful in breast cancer

Question 35

Give summary points for lecture?

Answer 35

Malnourishment is common in cancer patients and multifactorial Important for all team to consider early nutritional intervention Important to effectively manage symptoms Metabolic changes due to cancer can't be reversed without treating underlying cause first Nutritional support is important in- improving oral intake, help with symptoms and side effects, improve tolerance to treatments, improve rehab potential, enhancing quality of life Improved detection and treatment result in increased numbers living with and beyond cancer which changes emphasis of advice for cancer survivors Not a single disease and requires holistic approach