Nutritional requirements in long term conditions - Cancer

1

• Nutritional requirements in long term conditions
  - Cancer
• Rachael Donnelly Rachel Barrett
• Highly Specialist Oncology Dietitians
• Guys St Thomas NHS Foundation Trust
• PEN Group Summer Meeting August 1st 2006

2
Aims

1. Promote further understanding of cancer cachexia
   cancer as along term condition
2. Review current evidence base for nutritional
   requirements the provision of nutritional
   support for cancer patients
3. Acknowledge the practicalities of providing such
   requirements through an interactive case study

3
What is Cancer?

• the disordered uncontrolled growth of cells
  within a specific organ / tissue type . they
  often produce secondary growths / metastasis
  this is the central most threatening feature of
  malignant disorders.
• cancer is a collection of diseases with the
  common feature of uncontrolled growth there are
  several causes, but lifestyle factors are a
  major influence several cellular changes are
  required to generate cancer . invasion
  metastasis distinguish cancers from benign
  growths .. cancers are not always lethal
• (Brennan, 2004)

4
Cancer UK Facts Figures

• 1 in 3 will get cancer at some stage of their
  lives
• 250,000 diagnosed with cancer per annum
• (Equivalent to 684 diagnoses daily)
• In the UK 154 460 people died from cancer in 2001
• (www.cancerresearchuk.org)

5
Considerations in managing a cancer patient

• Site of cancer
• Type
• Stage of cancer
• Multi-modality treatment i.e. chemotherapy,
  radiotherapy, surgery biological therapies
• Side effects of treatment disease
• Co-morbidities
• Age of patient
• Social circumstances i.e. alcohol / drug
  nicotine dependency
• Cachexia syndrome

6
Theories of Nutrition Cachexia
7
Cancer Cachexia - What it is not?

• Due to starvation
• Due to malnutrition
• Due to competition by the tumour
• Restricted to cancer
• Reversed by nutritional support
• (Regnard, 2004)

8
Cancer Cachexia - Definitions

• Derives from the Greek kakos meaning bad
  hexis meaning condition
• (Shaw, 2000)
• A physical fading of wholeness
• Syndrome of decreased appetite, weight loss,
  metabolic alterations inflammatory state

9
Cancer Cachexia - What it is?

• An extreme on the continuum of weight loss in
  cancer
• Seen in cancer, cardiac disease chronic
  infection but not neurological disease
• Due to a systemic inflammatory response
• Mediated through cytokines other factors such
  as proteolysis inducing factor (PIF) lipid
  mobilising factor (LMF)
• (Regnard, 2004)

10
Cancer Cachexia - Features

• Some or all of the following features are
  exhibited in varying degrees
• Hypophagia / anorexia
• Early satiety
• Anaemia
• Weight loss with depletion alteration of body
  compartments
• Oedema
• Asthenia (weakness)
• (Freeman Donnelly, 2004)

11
Cancer Cachexia - Prevalence

• Occurs in 70 of patients during the terminal
  course of disease
• Weight loss gt 10 pre illness weight occurs in up
  to 45 of hospitalised cancer patients
• Cancer of the Upper GI lung have the highest
  prevalence of weight loss
• Lung cancer patients with 30 weight loss show
  75 depletion of skeletal muscle
• Breast cancer, sarcomas NHL show the least
  weight loss
• (Payne-James et al., 2001)

12
Cancer Cachexia - Aetiology

• Understanding is limited based upon the
  knowledge of abnormalities in nutrition behaviour
  metabolic patterns
• Appears as a classic case of malnutrition
• 3 theories have been suggested
• Metabolic competition
• Malnutrition
• Alterations of metabolic pathways
• (Payne-James et al., 2001)

13
Cancer Cachexia - Metabolic Competition

• Neo-plastic cells compete with host tissues for
  protein, functioning as a nitrogen trap
• In experiments where tumour is a high of animal
  weight this theory holds, but in human tumours
  even patients with a very small tumour can have
  severe cachexia
• (Morrison, 1976)

14
Cancer Cachexia Malnutrition (1)

• Upper aerodigestive disease is an obvious cause
  of malnutrition
• Regardless of tumour location, anorexia is the
  most common cause of hypophagia usually
  consists of a loss of appetite /or feelings of
  early satiety
• Hypophagia has been related to the presence of
  dysgeusia
• Diminished ability to perceive sweet flavours
  leads to anorexia
• (Payne-James et al., 2001)

15
Cancer Cachexia Malnutrition (2)

• Reduced threshold for bitter flavours linked to
  an aversion to meat
• Dysosmia is also related to an aversion to food
• Malnutrition leads to secondary changes in the GI
  tract which may be responsible for the feeling of
  fullness, delayed emptying, defective digestion
  the poor absorption of nutrients
• However, malnutrition alone is not thought to be
  the main cause of cachexia
• (Payne-James et al., 2001)

16
Metabolic Alterations in Starvation V. Cancer
Cachexia CHO Metabolism
Metabolic Alteration Starvation Cancer Cachexia
Glucose tolerance Insulin sensitivity Glucose turnover Serum glucose level Serum insulin level Hepatic gluconeogenesis Serum lactate level Cori cycle activity Decreased Decreased Decreased Decreased Decreased Increased Unchanged Unchanged Decreased Decreased Increased Unchanged Unchanged Increased Increased Increased
Adapted from Rivadeneira et al.,1998
17
Metabolic Alterations in Starvation V Cancer
Cachexia Fat Metabolism
Metabolic Alteration Starvation Cancer Cachexia
Lipolysis Lipoprotein lipase activity Serum triglyceride level Increased Unchanged Unchanged Increased Decreased Increased
Adapted from Rivadeneira et al.,1998
18
Metabolic Alterations in Starvation V Cancer
Cachexia Protein Metabolism
Metabolic Alteration Starvation Cancer Cachexia
Protein turnover Skeletal muscle catabolism Nitrogen balance Urinary nitrogen excretion Decreased Decreased Negative Decreased Increased Increased Negative Unchanged
Adapted from Rivadeneira et al., 1998
19
Cancer Cachexia - Cytokines

• Produced by host in response to tumour
• Cytokines regulate many of the nutritional
  metabolic disturbances in the cancer patient
  leading to
• Decreased appetite
• Increase in BMR
• Increased glucose uptake
• Increased mobilisation of fat protein stores
• Increased muscle protein release
• (Tisdale, 2004)

20
(No Transcript)
21
Nutritional Requirements in Cancer
22
Energy Expenditure

• Cancer itself does not have a consistent effect
  on resting energy expenditure (REE)
• Oncological treatment may influence energy
  expenditure
• (Arends et al., 2006)

23
Resting Energy Expenditure

• In cancer patients, REE can be
• Unchanged
• Increased
• Decreased
• Many cancer patients are mildly hypermetabolic
  with an excess energy expenditure of between
  138-289 kcals per day
• (Hyltander et al., 1991)
• If not compensated by ? energy intake results in
  loss of 1.1 - 2.3kg muscle mass 0.5 1.0kg
  body fat / month
• (Bozzetti F et al.,1980)
• The challenge is identifying which patients

24
When working out the energy requirements for a
patient with cancer, would you add a stress
factor?
25
Energy Requirements (1)

• Assume energy requirements are normal unless data
  available to say otherwise
• (Arends et al., 2006)
• It is not appropriate to add calories for weight
  gain when calculating requirements for cancer
  patients

26
Energy Requirements (2)

• For non obese cancer patients total energy
  expenditure is approx
• 30-35kcal/kgBW/d in ambulant patients
• 20-25kcal/kgBW/d in bedridden patients
• Assumptions are less accurate for underweight
  individuals (TEE per kg is higher in this group)
• (Arends et al., 2006)
• Published reference calculations are more
  accurate for underweight cancer patients
• (Harris Benedict 1919, Schofield 1985)

27
Protein Requirements

• Optimal nitrogen supply for cancer patients can
  not be determined at present
• (Nitenberg et al., 2002)
• Protein requirements are calculated as per
  published reference calculations (0.17-0.2g
  Nitrogen per kg)
• (Elia, 1990)

28
Vitamin and Mineral Requirements (1)

• Vitamins Minerals lack of evidence
  surrounding requirements in oncological disease
• Base requirements on UK RNIs
• (PEN Group, 2004)
• For EN recommendations are based on RDAs
• (ASPEN, 2002)

29
Vitamin and Mineral Requirements (2)

• Markers of oxidative stress are increased
  levels of anti-oxidants are decreased in cancer
  patients
• (Mantovani et al., 2003)
• Inclusion of increased doses of anti-oxidant
  vitamins could be considered but at present lack
  data to demonstrate clinical benefit
• (Arends et al., 2006)
• In reality, not routinely measuring vitamin
  mineral status in such patients

30
Aims of Nutritional Support
31
An improvement in survival due to nutritional
interventions has not yet been shown
(Arends et al., 2006)
32
Unintentional weight loss of 10 within the
previous 6/12 signifies substantial nutritional
deficit is a good prognostic indicator of
outcome (DeWys et al., 1980)
33
Cancer - Aims of Nutritional Support (NS) (1)

• Improve the subjective quality of life (QoL)
• Enhance anti-tumour treatment effects
• Reduce the adverse effects of anti-tumour
  therapies
• Prevent treat undernutrition
• (Arends et al., 2006)

34
Cancer - Aims of Nutritional Support (2)

• the principle aim of nutritional intervention
  with cancer patients will be to maintain physical
  strength optimise nutritional status within the
  confines of the disease
• (van Bokhorst de van der Schueren et al., 1999)
• nutritional intervention should be tailored to
  meet the needs of the patient realistic for the
  patient to achieve
• (Mick et al., 1991)

35
Aims of Nutritional Support (3)

• Optimum nutrition improves therapeutic modalities
  the clinical course outcome in cancer
  patients
• (Rivadeneira et al., 1998)
• Numerous studies strongly suggest substantial
  weight loss gt10 leads to adverse consequences
• Reduced response to chemotherapy radiotherapy
• Increased morbidity
• Poor quality of life (QoL)
• Increased mortality rate
• (Van Bokhorst de van der Scheren et al., 1997)

36
When should Nutritional Support be started?

• If undernutrition is already present
• If inadequate food intake is anticipated for more
  than 7 days
• It should substitute the difference between
  actual intake calculated requirements
• Inadequate nutrition throughout treatment course
  leads to increased morbidity mortality,
  reduced tolerance to treatment
• (Arends et al., 2006)

37
Can Nutritional Support improve Nutritional
Status in Cancer?

• Yes, in patients whose weight loss is due to
  insufficient nutritional intake secondary to
  obstruction e.g. upper GI, head neck
• In cachexic patients it is virtually impossible
  to achieve whole body protein anabolism
• Goals of NS are therefore different
• (Arends et al., 2006)

38
Does Nutrition Support Feed the Tumour?

• There is no reliable data to support the effect
  of nutrition on tumour growth
• Feeding the tumour should have no influence on
  the decision to feed a cancer patient
• (Arends et al., 2006)

39
Nutrition Support Throughout the Cancer Patients
Journey
40
Nutritional Support Pre / Peri - Operative

• Patients with severe undernutrition benefit from
  NS 10-14 days prior to major surgery, even if
  surgery has to be delayed
• (Meyenfeldt von., 1992)
• All patients undergoing major abdominal surgery,
  NS (with immune-modulating substrates) is
  recommended for 5-7 days independent of
  nutritional status
• (Braga et al. 1999)

41
Nutritional Support Chemotherapy

• Currently, there is no strong evidence for
  routine NS during CT as it has no effect on
  tumour response to CT, nor on CT related
  associated unwanted side effects
• Symptom control is vital prior to any NS i.e.
  adequate anti-emetic control of nausea vomiting
• Timely NS is necessary in many patients
  undergoing chemotherapy
• (Arends et al., 2006)

42
Nutritional Support RT / Chemo-RT

• Intensive dietary counselling or NS prevents
  therapy associated weight loss interruption of
  RT when compared to normal food
• Routine NS is not indicated in abdominal RT
• Nor is there any suggestion that routine NS is
  beneficial during RT to any other part of part of
  the body other than the head neck oesophageal
• (Arends et al., 2006)

43
Interactive Case Study

44
Case Study (Background)

• Male- Mr D
• 52 yrs
• Diagnosis- T4N3M0 SCC Left Floor of Mouth (FOM)
• PMH- CABG x 3 99 Hypertension

• Social History
• Lives alone above a pub
• Alcohol intake approx. 63 units/week
• Smokes 50g tobacco/week
• Security Guard

45
(No Transcript)
46
Initial Nutritional Assessment

• Diet History
• 4 strong black coffees each with 2 sugars
• 1 meal daily, early evening, takeaway Cornish
  pasty chips
• Approx. 5 pints strong lager /- 2-3 double
  vodkas per night

• Weight on referral- 55kg 17/05/05
• Usual weight- 55-60kg
• Ideal weight- 56-69kg
• BMI- 19.7kg/m2
• No recent weight loss
• Grip strength 28.5kg
• (lt69 of normal)

47
Oncological Treatment

• 23/05/05 resection of FOM with DCIA flap
• Hemi-glossectomy
• Left radical neck dissection
• Right neck dissection
• Dental clearance
• Nil by mouth tracheostomy in situ
• 13/06/05 debridement of DCIA flap
• 15/06/05 PEC major flap after failure of DCIA
  flap
• 04/08/05 post surgery 6/52 radiotherapy

48
(No Transcript)
49
When calculating Mr Ds energy requirements post
operatively what stress factor would you use?

50
What actually happened

• Requirements calculated using 10 stress factor
  (SF) 20 activity factor (AF) approx.
  2000kcal, 60-70g Protein
• Fed 2000ml Nutrison Multi fibre (2000kcal, 80g
  Protein)
• Weight increased 61.2kg- oedematous, 5 days later
  55.3kg

51
What happened next

• Withdrawing from alcohol confused AWOL from
  ward
• Changed feed 1000ml Nutrision Energy Multi Fibre
  boluses 2 x 200ml Fortisip
• Not meeting requirements due to compliance issues
• Flap failure need for further surgery
• Remains NBM PEG placed 19/07/05
• Weight 52.1kg (2.9kg (5) weight loss in 2/12)

52
(No Transcript)
53
(No Transcript)
54
What happened next

• Commenced radiotherapy 04/08/05
• Weight 49.5kg
• Remained an inpatient
• Refusing pump feeding bolusing only

55
Mr Ds requirements were re-calculated- what SF
AF would you use?

56
What actually happened

• Energy requirements were calculated with no SF
  25 AF approx. 1800kcal, 50-60g Protein
• Feed regimen 6 x 200ml Fortisip bolused daily
  provides 1800kcal, 72g protein
• Only taking 4 x 200ml Fortisip daily- provided
  1200kcal, 48g protein
• Weight 07/09/05 47.5kg

57
Mr D was discharged home post radiotherapy, his
weight dropped to 47kg his requirements
re-calculated. What activity factor would you use?

58
What actually happened

• Energy requirements were calculated using a PAL
  factor (1.5 moderately active in a light
  occupation) not an activity factor as this
  patient was now in the community
• Feed switched to 4 x 237ml cans of Two CalHN
  bolused in an attempt to meet requirements in a
  minimum volume
• Oral diet resumed (alcohol only)

59
Would you add 400kcal for weight gain?

60
What actually happened (1)

• In this case, no, in light of compliance issues
  problems meeting baseline requirements
• Mr D has since had multiple admissions with
  acopia, continued weight loss, deterioration of
  swallow now NBM, undergone further surgery
  for wound dehiscence
• Dietetic intervention has incorporated both
  social medical aspects of care

61
(No Transcript)
62
(No Transcript)
63
What actually happened (2)

• Taken 18 months to fully heal wounds, weight gain
  has just begun in conjunction psychological
  psychiatric support re-housing
• Highlights the need for regular dietetic review
  consideration of the wider issues

64
Conclusions

• If the patient remains cachectic adding
  additional kcal for weight gain is unlikely to be
  of any clinical benefit
• Our opinion is if the tumour has been removed/
  treated/ controlled you meet nutritional
  requirements (BMR adequate AF/ PAL factor)
  weight continues to decline, consider additional
  kcal for weight gain
• BUT, this is unlikely as few patients are
  entirely disease free/ controlled ongoing
  weight loss is often a sign of disease
  progression/ recurrence

65
Summary

• Cancer is increasingly becoming a chronic / long
  term condition
• The evidence for the nutritional requirements of
  this patient group is limited are reliant on
  estimation
• Dietetic interventions need to be individualised
  as no two cancer patients journey are the same
• Regular reassessment is vital in order to
  maximise the therapeutic potential of nutritional
  support