Oncology Lecture 8 Fall 2024 PDF

10/28/24 Oncology L EC T U R E 8 C L I N I C A L N U T R I T I O N A S S ES S M E N T A N D I N T E RV E N T I O N FA L L 2 0 2 4 1 1...

10/28/24 Oncology L EC T U R E 8 C L I N I C A L N U T R I T I O N A S S ES S M E N T A N D I N T E RV E N T I O N FA L L 2 0 2 4 1 1 Cancer vAbnormal growth of cells which tend to proliferate in an uncontrolled way and, in some cases, to metastasize o Characterized by uncontrolled growth o Group of different/distinctive diseases o May involve any tissue of the body vMost cancers are named for the type of cell or organ in which they start o If a cancer spreads (metastasizes), the new tumor bears the same name as the original (primary) tumor vMolecular basis of cancer o Self-sufficiency in growth signals o Insensitivity to inhibitory growth signals o Evasion of apoptosis o Limitless replication potential o Sustained angiogenesis o Invasion and metastasis 2 2 1  10/28/24 Cancer v Risk factors o Age o Family History § BRCA1 and BRCA2 –breast cancer o Reproductive Factors § Age at menarche, menopause –gynecological cancers o Physical and ethnic characteristics o Residential or occupational characteristics § Asbestos workers –lung cancer o Tobacco use –lung, head and neck, esophagus, bladder o Exposure to sunlight o Exposure to carcinogens o Certain viruses (HPV) –cervical; bacteria (H pylori) –gastric o Nutrition and physical activity o Obesity 3 3 4 4 2  10/28/24 5 5 6 6 3  10/28/24 7 7 8 8 4  10/28/24 9 9 Cancer vThree basic stages o Initiation § Transformation of cells from interaction of chemicals, radiation, or viruses with cellular DNA § Transformation occurs rapidly, but cells can remain dormant for variable period until they are activated by promoting agent § After initial cellular damage has occurred, transformation from normal cells to detectable cancer can take years or even decades o Promotion § Initiated cells are activated by a promoting agent to multiply and form a discrete tumor o Progression § Tumor cells aggregate, grow and form tumors that lead to a malignant phenotype with capacity for tissue invasion and metastasis 10 10 5  10/28/24 Malignant Progression of Cancer Genetic Alteration Genetic Genetic Environmental Exposure Alteration Alteration Normal Tissue Premalignant Lesions Primary Tumor Metastasis Normal Cell Premalignant Cell Malignant Cell without Malignant Cell with Metastatic Ability Metastatic Ability v Malignant tumors have the ability to invade adjacent tissues and spread to distant sites in the body 11 11 Classification of Neoplasms Behavior/Clinical Characteristics Benign Malignant Gross Appearance Well circumscribed Diffuse Rate of Growth Slow Rapid Mode of Growth Expansion Invasion Metastases Absent Common Effect on Host Usually insignificant Significant Prognosis Very Good [Brain] Fair Treatment Conservative Radical 12 12 6  10/28/24 Classification of Neoplasms Histogenic Classification Benign Malignant /Nomenclature Epithelium – Glandular Adenoma Adenocarcinoma Example: Liver Hepatic adenoma Adenocarcinoma of liver Epithelium – Surface Papilloma Squamous Cell Carcinoma Example: Skin Squamous papilloma Squamous cell carcinoma (SCC) of the skin Mesenchymal Tissue of origin +oma Tissue of origin +sarcoma Example: Fat Lipoma Liposarcoma 13 13 Cancer v Staging o Based on size of primary lesion, extent of spread to regional lymph nodes and presence or absence of other metastases § TNM system § T = extent of tumor § N = nodal involvement § M = metastases o Not all cancers are staged using the TNM system o Staging varies based on cancer type o Assignment of Stage (I – IV) § Stage 0 = abnormal cells present (carcinoma in situ; may become cancer) § Stage I-III = higher the stage, larger the tumor & spread to nearby tissues § Stage IV = spread to distant parts of the body https://www.cancer.org/treatment/understanding-your-diagnosis/staging.html 14 14 7  10/28/24 Cancer Cancer Treatment Diagnosis Completed Continuum Cancer Cancer Cancer Prevention Treatment Survivorship Clinical Nutrition Assessment and Interventions o Improve or Maintain adequate nutritional status o Minimize adverse effects (toxicity of treatment) o Improve quality of life o Prevent recurrence o Improve overall survival 15 15 American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention v Obesity association: achieve and maintain healthy body weight throughout life; avoid excess weight gain v Eat a variety of healthful foods, with an emphasis on plant sources o Eat five or more servings of vegetables and fruit each day o Choose whole grains in preference to processed (refined) grains and sugars o Limit consumption of red meats, especially high-fat and processed meats o Choose foods that help maintain a healthful weight o If alcohol consumed, in moderation o Prepare and store food safely v Adopt a physically active lifestyle o Engage in at least moderate activity for >30 minutes on 5 or more days o >45 minutes of moderate to vigorous activity on 5 or more days per week may further enhance reductions in the risk of breast and colon cancer 16 16 8  10/28/24 Nutrition Assessment in Cancer v Screening and Assessment o Early o Validated (SGA commonly utilized) o History of weight loss, ↓ intake, ↓ appetite o Baseline nutritional status v What type of cancer? v Where? What part of the anatomy is affected? v What type(s) of treatment? v What are the potential side effects/consequences of treatment? 17 17 Malnutrition and Cancer v Etiology-based diagnosis: chronic disease-related malnutrition v Cancer is a heterogeneous disease; some pathologies exert more inflammatory effect than others as well impediments to oral intake v Malnutrition of cancer is due to mechanisms related to: § tumor § host response to the tumor (including inflammation) § anticancer therapies: surgery, radiation, chemotherapy § pain, fear, anxiety, depression v Prevalence in cancer ranges from 8-84%: o Variation: § tumor site (head and neck, GI, lung) § disease stage (all advanced cases no matter tumor site) § treatment (effect influenced by treatment site) 18 18 9  10/28/24 Diminished Food Intake Symptom Factors Affecting Diminished Nutrient Intake Anorexia May be present early in the course of the disease Systemic response of the disease process Result of therapy Fear, anxiety or depression Early satiety Delayed gastric emptying Decreased gastric transit time Inability to eat GI discomfort Food avoidance to prevent or alleviate symptoms N/V Lack of availability or effective dosing Diarrhea Cramping/bloating General discomfort Acquired food aversions From negative food experiences during or after therapy 19 19 Cancer Treatment v Treatment modalities o Surgery o Chemotherapy o Radiation o Immunotherapy o Transplant 20 20 10  10/28/24 Treatment v Chemotherapy o Use of chemical agents (medications) to treat cancer § Over 100 chemotherapy drugs; oral or IV delivery § Used alone or in combination with other drugs or treatments o Used to eradicate cancer, control its size and spread, alleviate symptoms o Can also be given as adjuvant or neoadjuvant therapy § Adjuvant: after surgery for cancer cells that were missed § Neoadjuvant: to shrink tumor; more easily treated with radiation or surgery o Systemic treatment, affects whole body o Affects both normal and malignant cells § Kills cells with rapid turnover § Bone marrow, hair follicles, GI mucosa o Severity of side effects depends on agent used, dosage, duration, number or cycles, accompanying drugs, individual response, current health status 21 21 Treatment v Chemotherapy o Common symptoms § Anemia § Fatigue § Nausea, vomiting § Diarrhea § Loss of appetite § Mucositis § Changes in taste and smell § Xerostomia § Dysphagia § Constipation § Neutropenia, immunosuppression § Alopecia 22 22 11  10/28/24 Treatment v Radiation therapy o Delivered with electromagnetic rays, destroys cancer cells § Commonly applied to cancerous tumor o Treatment intent § Curative, adjuvant, therapeutic, or palliative § Depends on tumor type, location, stage, general health of patient o Commonly administered along with surgery and/or chemotherapy § Can be given prior to surgery, post-operatively, or intra-operatively § Chemotherapy may be administered prior to (neoadjuvant), during (concomitant), or following RT (maintenance) o Adverse affects § Side effects of RT usually limited to specific site being irradiated § When RT used alone, typically occur ~week 2-3 of treatment and resolve within 2-4 weeks after RT has been completed § Late effects can happen weeks, months, or even years after treatment 23 23 Nutrition Related Effects of Radiation Therapy Central nervous system Acute Effects: nausea, vomiting, fatigue, loss of appetite, (brain and spinal cord) hyperglycemia (associated with corticosteroids) Late Effects: headache, lethargy Head and neck Acute Effects: xerostomia, mucositis, sore mouth/throat, thick (tongue, larynx, pharynx, saliva/oral secretions, dysphagia, odynophagia, alterations in taste and oropharynx, nasopharynx, smell, fatigue, loss of appetite tonsils, salivary glands) Late Effects: mucosal atrophy/dryness, salivary glands (xerostomia, fibrosis), trismus, osteoradionecrosis, alterations in taste and smell Thorax Acute Effects: esophagitis, dysphagia, odynophagia, heartburn, (esophagus, lung, breast) fatigue, loss of appetite Late Effects: esophageal (fibrosis, stenosis, stricture, ulceration), cardiac (angina on effort, pericarditis, cardiac enlargement), pulmonary (dry cough, fibrosis, pneumonitis) Abdomen and pelvis Acute Effects: nausea, vomiting, changes in bowel function (diarrhea, (stomach, ovaries, uterus, cramping, bloating, gas), changes in urinary function (increased colon, rectum) frequency, burning sensation with urination), acute colitis or enteritis, fatigue, loss of appetite Late Effects: diarrhea, malabsorption, maldigestion, chronic colitis or enteritis, intestinal (stricture, ulceration, obstruction, perforation, fistula), urinary (hematuria, cystitis) *Late effects >90 days after treatment 24 24 12  10/28/24 Immunotherapy (Biotherapy) v Works in two ways: o Active immunotherapies stimulate your body's own immune system to fight disease; stimulate immune response à destroys cancer cells o Passive immunotherapies use immune system components (i.e. antibodies) that are made in the lab v Stimulate an immune response that destroys cancer cells § Mimicking function of B cells § Triggering cell apoptosis § Inhibiting signals that prevent immune cells from attacking the body’s own tissues (including cancer cells) § Targeting proteins that are necessary for tumor growth or binding to cell surface growth factor receptors, preventing targeted receptors from sending their normal growth-promoting signals v Adverse Outcomes o Fatigue, chills, fever, flu-like symptoms, impact on food intake 25 25 Hematopoietic Stem Cell Transplant (HSCT) v Previously referred to as bone marrow transplant v Used primary in treatment of hematologic and lymphoid cancers § Chronic and acute leukemia § Lymphoma § Hodgkin’s disease § Multiple myeloma § Myelodysplastic syndromes v Stem cells come from bone marrow, peripheral blood or umbilical cord v Can be obtained from 3 sources 1. Autologus: self, individual who will be undergoing HSCT 2. Allogeneic: donor, related or unrelated 3. Syngeneic: genetically identical, twin 26 26 13  10/28/24 Hematopoietic Stem Cell Transplant (HSCT) v Stem cells harvested, surgically (bone marrow) or apheresis v Preoperative treatment (conditioning regimen) o High-dose chemotherapy and/or total body irradiation (TBI) § To provide sufficient immunosuppression to prevent rejection § To eradicate malignant cells v Stem cells are infused once conditioning treatment complete v Toxicities associated with chemotherapy and TBI, from graft rejection (GVHD), infectious complications due to immunosuppression v Energy and protein requirements § 30-35 kcal/kg § 1.5g protein/kg -first 1-3 months after transplant 27 27 Stomatitis: inflammation of the mouth Mucositis: inflammation in the mucous lining of the upper GI Esophagitis: inflammation of the esophagus Nutritional Implications v HSCT can significantly alter nutritional status o Goal: for patient to be well nourished before transplant v HSCT nutritional treatment: o Typically 1st few weeks are EN or PN § TPN often used as GI tract is usually compromised o PO diet § Bland and soft solids, bland liquids § NO strong flavored, acidic or spicy foods o Toxicities of immunosuppression can last 2-4 weeks and cause: § Nausea, vomiting, anorexia, dysgeusia, stomatitis, oral and esophageal mucositis, fatigue, and diarrhea § Side effects seem to be worse in allogeneic § Dietary precautions with neutropenia, food safety 28 28 14  10/28/24 Graft Versus Host Disease (GVHD) v Major complication after allogeneic transplants o Functional immune cells in the transplanted marrow recognize the recipient as "foreign" and mount an immunologic attack o Characterized by selective damage to the liver, skin, mucosa, and GI tract o Acute GI GVHD: secretory diarrhea, abdominal pain, nausea/vomiting § Medical Tx: immunosuppressive medications, IV corticosteroids o Chronic GVHD can develop up to 3 months after transplant § Can affect skin, oral mucosa (ulcerations, stomatitis, xerostomia), GI tract (anorexia, reflux symptoms, diarrhea), can à weight changes v MNT, acute GI GVHD: o Total bowel rest until the diarrhea is reduced o When PO diet begins, use oral feedings that are low residue, lactose free § As tolerated, gradually introduce solid foods that have low levels of fiber, lactose, fat and total acidity o Progressively reduce dietary restrictions as tolerance increases o Eventually progress to a normal diet 29 29 Surgical Interventions v Surgery used in cancer prevention, diagnosis, staging, treatment (both localized and metastatic disease), palliation, rehabilitation o Tongue cancer à glossectomy o Esophageal cancer à esophagectomy § Stomach used for reconstruction § Small intestine used when also gastric resection o Gastric cancer à subtotal or total gastrectomy o Colorectal cancer à colectomy (partial or total) with re-anastomosis § Colostomy (temporary or permanent) o Pancreatic cancer à whipple § Pancreatic head, duodenum, gallbladder, bile duct, gastric antrum § More recent modification preserves pylorus and gastric antrum o Palliative surgery o used to ameliorate symptoms without attempting to cure cancer o ie removal of tumor causing spinal cord compression 30 30 15  10/28/24 Nutrition Related Effects of Surgery in Cancer Treatment Oral cavity difficulty with chewing and swallowing, aspiration potential, sore mouth and throat, xerostomia, alteration in taste and smell Esophagus gastroparesis, indigestion, acid reflux, alterations in normal swallowing, dysphagia, decreased motility, anastomotic leak Lung shortness of breath, early satiety Stomach dumping syndrome, dehydration, early satiety, gastroparesis, fat malabsorption, vitamin and mineral malabsorption (B12, vit D, Ca, Fe) Gallbladder, bile duct fluid and electrolyte imbalance, gastroparesis, hyperglycemia, vitamin and mineral malabsorption (vitamins A, D, E, and K; Mg, Ca, Zn, Fe) Liver hyperglycemia, hypertriglyceridemia, fluid and electrolyte malabsorption, vitamin & mineral malabsorption (vitamins A, D, E, K, B12; Ca, Zn, Fe) Small bowel lactose intolerance, bile acid depletion, diarrhea, fluid & electrolyte imbalance, vitamin & mineral malabsorption (vits A, D, E, K, B12; Ca, Zn, Fe) Colon and rectum increased transit time, diarrhea, bloating, cramping, gas, fluid and electrolyte imbalance, vitamin & mineral malabsorption (B12, Na, K, Mg, Ca) Ovaries and uterus early satiety, bloating, cramping, gas Brain nausea, vomiting, hyperglycemia associated with corticosteroids 31 31 Complementary and Alternative Therapies v Whole medical systems o Chinese medicine, homeopathy, naturopathy v Mind-body interventions o Mindfulness, meditation v Biologically based therapies o Botanicals, dietary supplements, vitamins, minerals v Manipulative and body-based methods o Massage, yoga, reflexology v Massive megavitamin therapy v Dietary restrictions (majority not evidence based) v Do research about any supplements your patients are taking 32 32 16  10/28/24 Energy Requirements v Calorie needs vary based on: o Nutritional status o Type of cancer and stage o Type of treatment(s) o Other medical conditions v Indirect calorimetry is the gold standard to accurately determine needs v Standardized equations o Based on facility standards or available data for equation § ↑ stress factors ASPEN: Nutrition Support Core Curriculum 33 33 Energy Requirements v Consider degree of malnutrition, extent of disease, degree of stress, presence of weight loss, reason for weight loss Patient Type Estimated Energy Needs Cancer, general 25-35kcal/kg; >30kcal/kg with wt loss Non-stressed, normal weight 25-30kcal/kg Non-stressed, obese 21-25kcal/kg, no clear consensus Slightly hypermetabolic; those who need 30-35kcal/kg to gain weight; patients who are anabolic Hypermetabolic or severely stressed; >35kcal/kg patients with malabsorption Hematopoietic cell transplant 30-35kcal/kg 34 34 17  10/28/24 Protein Requirements v Consider degree of malnutrition, extent of disease, degree of stress, ability to metabolize and use protein General Non-stressed: 1-1.5 g Pro/kg Stressed: 1.5-2.5 g Pro/kg Patient Type Estimated Protein Needs Normal, maintenance 0.8-1.0g/kg Non-stressed cancer patient 1.0-1.2g/kg Nutritional repletion, weight gain 1.0-1.5g/kg Hypermetabolic, stressed cancer patient 1.5-2.5g/kg Hematopoietic stem cell transplant >1.5g/kg In Elliott L et al, editors: The clinical guide to oncology nutrition, ed 2, Chicago, 2006, American Dietetic Association. 35 35 Fluid Requirements v Estimated fluid needs o Age based: § 20-55 year of age: 30-35ml/kg § 55-75 years of age: 25-30ml/kg, § >75 years of age: 20-25 mL/kg o Daily Baseline needs § 1 mL fluid/kcal of estimated needs o Holliday-Seger method § >20 kg of body weight = 1500 mL +20 mL/kg for each kg >20 kg o Take fluid losses into consideration (I/O) 36 36 18  10/28/24 Micronutrient Requirements v Micronutrients o Regular foods preferred o If intake inadequate, provide multivitamin to meet 100% DRI o Pre-existing deficiencies may require supplement o Effect on treatment --? o Use of antioxidants with chemotherapy --? o Continued research is still necessary 37 37 Calcium v Hypercalcemia o Occurs in bone metastasis o Caused by osteolytic activity of tumor cells releasing calcium into the extracellular fluid o May be fatal o Treatment: medications o Do not need to restrict intake of foods containing calcium, has little effect on the management o Calcium supplements should be avoided 38 38 19  10/28/24 Symptom Management Symptoms Nutrition Strategy Anorexia Encourage frequent energy dense meals & snacks Poor appetite Consumption of liquids between meals Early satiety Educate on ways to add protein & calories to favorite foods Oral nutrition supplements between meals Addition of calorie-dense smoothies, beverages Maximize intake when appetite is most normal Suggest eating meals in pleasant environment Avoid noxious odors, ventilate eating area Encourage activities of daily living and physical activity as able Best to have favorite foods when feeling good 39 39 Strategies to Increase Calories and Protein v Consume small frequent meals and snacks (6-8x/day) v Avoid “skim” or “low fat” foods v Keep easy to eat, high protein snacks readily available o Ex: nuts and seeds, nut butters on crackers, hard-boiled eggs, yogurt v Encourage consumption of energy-dense meals o Add butter, margarine, oils, sour cream, salad dressing, peanut butter, avocado, hummus, mayonnaise, or cheese to meals and snacks o Ex: add cream or yogurt to soups, peanut butter to oatmeal, avocado to sandwiches, dried fruit or nuts to cereal v Drink calorie dense liquids between meals o Regular milk, soy milk, oral nutrition supplements (Ensure, Boost) § Try adding milk powder to milk for “double protein” o Add peanut butter to chocolate or vanilla shake o Make a fruit smoothie with whole milk or cream o Fruit nectars or fruit shakes 40 40 20  10/28/24 Oral Nutrition Supplements v Examples of oral supplements o Boost (Nestle), Ensure (Abbott) –many different versions § Ex: Ensure, Ensure Plus, Ensure Enlive, Ensure Compact § Ex: Boost, Boost Plus, Boost Very High Calorie o Clear Liquid: Ensure Clear, Boost Breeze o Pudding: Ensure Pudding, Boost Pudding o Specialized: Glucerna (diabetes), Nepro (renal) o Modified Consistency: Magic Cup (frozen dessert), Gelatin Plus/20 o Orgain (organic), Enu (meal replacement), Compleat (blenderized) o Plant-Based: Kate Farms, OWYN (vegan) o Impact Advanced Recovery o Modulars: § Benecalorie § Beneprotein 41 41 Appetite Stimulants v Corticosteroids v Megesterol acetate (Megace) v Medroxyprogesterone acetate v Dronabinol (Marinol) v Remeron (anti-depressant) 42 42 21  10/28/24 Symptom Management Symptoms Nutrition Strategy Nausea & vomiting Encourage small frequent meals and snacks as tolerated Dry foods (crackers, toast) throughout the day Sipping on cool or room temperature clear liquids Avoidance of high-fat, greasy, spicy or overly sweet foods Avoidance of certain foods with strong odors Focus on bland, soft, easy to digest foods on treatment days Medications may be prescribed to help control nausea Ginger tea may help Fatigue Recommend small frequent meals and snacks Recommend intake of easy-to-prepare, easy-to-eat foods Advise keeping nutrient dense snacks close at hand, snack frequently Keep oral nutrition supplements and snacks at bedside Suggest eating when appetite is best 43 43 Symptom Management Symptoms Nutrition Strategy Diarrhea Encourage adequate hydration Encourage binding foods (applesauce, bananas, white rice or pasta, peanut butter, white toast, potatoes without skin) Avoidance of high-fiber foods (insoluble fiber) Avoidance of sugar alcohols (sugar free candies or gum) Evaluate for fat malabsorption, intolerance Medications may be prescribed to help control diarrhea Constipation Increasing intake of high-fiber foods Intake of at least 64 ounces of fluid each day Use of probiotic containing foods or supplements (sometimes) Encourage activities of daily living and physical activity as able Consider fiber supplements Medications may be prescribed to help with constipation 44 44 22  10/28/24 Symptom Management Symptoms Nutrition Strategy Sore throat, esophagitis Intake of softer, moister foods with extra sauces, dressings, gravies Avoidance of dry, coarse, rough foods Avoidance of alcohol, citrus, caffeine, tomatoes, vinegar, hot pepper Experiment with food temperatures (warm, cool, icy) to find temperature that is the most soothing Meds may be prescribed to manage esophagitis or painful swallow Sore mouth, mucositis, Recommend good oral hygiene (frequent rinse, keep mouth clean) or oral thrush Intake of softer, moister foods with extra sauces, dressings, gravies Suggest eating foods at room temperature or chilled, cool Avoidance of dry, coarse, rough foods Avoid foods that irritate the mouth (citrus, spicy, salty foods) Meds may be prescribed to manage oral pain or infection 45 45 Severe Oral Mucositis 46 46 23  10/28/24 Symptom Management Symptoms Nutrition Strategy Xerostomia, dry mouth Suggest sipping on liquids throughout day to keep oral cavity moist Trying tart foods to stimulate saliva –if open sores not present Alternating bites of food with sips of liquids at meals Eating softer, moister foods with extra sauces, dressings, gravies Avoidance of alcoholic beverages or alcohol-containing mouth wash Recommend good oral hygiene (frequent rinse, keep mouth clean) Recommend using cool mist humidifier while sleeping Thickened saliva Suggest sipping on liquids throughout day to keep oral cavity moist Thinning oral secretions with club soda, seltzer water Recommend using cool mist humidifier while sleeping 47 47 Symptom Management Symptoms Nutrition Strategy Dysguesia Use more spices and flavorings Altered taste or smell Use of marinades Bitter taste Add condiments to add more flavor Metallic taste Adjust temperature of foods, some foods taste better when cool or warm, rather than at room temperature Try sour or salty foods, extreme flavors Using plastic utensils if having metallic taste Recommend good oral hygiene (frequent rinse, keep mouth clean) Rinse mouth before meals when metallic or strange taste Presentation of foods can make difference Choose poultry, fish and eggs instead of meats 48 48 24  10/28/24 Symptom Management Symptoms Nutrition Strategy Neutropenia Advise frequent hand washing; keep kitchen surfaces, utensils clean Avoidance of raw or undercooked animal products, including meat, pork, poultry, eggs, fish; pasteurized dairy only Thoroughly cook foods (heat food >140⁰) Advise thoroughly washing all fruits and vegetables before eating Avoid items that cannot be thoroughly washed Discard perishable foods left at room temperature for >2 hours No leftovers that are > 2 days Avoid any spoiled or moldy foods When in doubt about if food is spoiled, err on side of caution Caution when eating out (no salad bars, no fountain beverages, etc) Be wary of cross contamination 49 49 Nutrition Support v Enteral Nutrition o IF nutritional counseling and pharmacological interventions to enhance oral intake have failed, then EN considered o Less complications than parenteral nutrition support and has been found to preserve gut integrity o Certain cancer types have higher need, benefit from EN support § Head and neck cancer § GI malignancies o For those with uncomfortable GI fullness, can use more concentrated formulas (2 kcal/mL) to get more nutrition with less volume v Parenteral Nutrition o When aggressive nutrition support is part of the medical care plan and enteral nutrition is contraindicated 50 50 25  10/28/24 Nutrition Support v Enteral nutrition and parenteral nutrition support use in patients with advanced incurable cancer is controversial o Not indicated if survival < 3 months o Families may have a difficult time ending support o Consider § Patient or family’s wishes § Potential risks vs benefits § Estimated survival v A.S.P.E.N. o “The palliative use of nutrition support in terminally ill cancer patients is rarely indicated.” 51 51 Cancer Treatment v Survivorship o Begins at diagnosis o General prevention guidelines used in this phase § Preventing recurrence or new primary o Different issues for different cancers § Breast cancer: avoidance of weight gain o Continued follow-up for life o Diet, exercise and stress management v Palliative care o Goal is comfort and symptom management o Data does not support aggressive nutrition support § Palliative vs end of life o Minimize restrictions –focus on: § Pleasurable foods or ones with positive associations § Foods that require minimal effort 52 52 26