The Cancer Nutrition Network for Texans presents:

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The Cancer Nutrition Network for Texans presents
Creating Cancer Care Teams A workshop for
Cancer Patients and their Family Caregivers
The CNNT is funded by the University of Texas
Medical Branch and the Texas Cancer Council
Contract 08-94
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Information for Patients

• Your Survivorship Journey

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Objectives

• Patient and Caregiver will
• Name the common cancer therapies
• Explain the importance of nutrition during your
  survivorship journey
• Identify several symptom management techniques
• Describe the importance of exercise and physical
  activity

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The diagnosis of cancer.

• Youre not alone 84,530 Texans are diagnosed
  each year with cancer.
• Its not a death sentence 9.5 million people in
  the US are cancer survivors.
• Strong emotions are normal help, helps.
• Be informed understand your diagnosis, your
  treatment, ask questions.

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Common Cancer Therapies

• Surgery
• Radiation
• Chemotherapy
• Immunotherapy
• Complementary and alternative therapy

• These can be used as single mechanisms.
• Commonly these are used in combinations.
• Often additional therapy, adjuvant, is also
  possible e.g., tamoxifen for early stage breast
  cancer.
• All produce side-effects!

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Managing Side EffectsThat Impair Nutrition

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Mouth Sores

• Swallowing
• Early Satiety
• Loss of Appetite
• Change in tastes
• Sensitivity to smells

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Nutrition and Cancer

• Nutrition (key nutrients)
• Vitamins, minerals, protein, calories,
  carbohydrates, fat and water
• Treatment causes symptoms that may interfere with
  nutrition
• Treatment also may affect other senses that
  interfere with nutrition

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Nutrition Advice during Treatment

• The diet is an important part of cancer
  treatment. Eating the right kinds of foods
  before, during, and after treatment can help the
  patient feel better and stay stronger. To ensure
  proper nutrition, a person has to eat and drink
  enough of the foods that contain key nutrients
  (vitamins, minerals, protein, carbohydrates, fat,
  and water).

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Treatment Symptoms

• For many patients, some side effects of cancer
  and cancer treatments make it difficult to eat
  well. Symptoms that interfere with eating include
  nausea, vomiting, diarrhea, constipation, mouth
  sores, trouble with swallowing and pain.
  Appetite, taste, smell, and the ability to eat
  enough food or absorb the nutrients from food may
  be affected.

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Important Nutrition Fact

• Malnutrition (lack of key nutrients) can result,
  causing the patient to be weak, tired, and unable
  to resist infections or withstand cancer
  therapies. Eating too little protein and calories
  is the most common nutrition problem facing many
  cancer patients. Protein and calories are
  important for healing, fighting infection, and
  providing energy.

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Special Concerns

• Hydration
• Although a good rule of thumb is to drink 8
  glasses of water per day, proper hydration helps
  flush toxins. You should drink 1/2 ounce of water
  for each pound of your body weight. For example,
  if you weigh 150 pounds, you should drink 75
  ounces or about nine 8 ounce glasses a day.
• Supplement drinks and bars
• Supplements - are intended as occasional
  substitutes and should be selected carefully
•  Bars should be well-balanced with equal
  portions of carbs, proteins, and sugars
•  Bars should provide 3 to 5 grams fiber
•  Bar fortified but does not oversupply
  Recommended Daily Allowance of vitamins
  minerals (35)
•  Bar supplies no more than 150 calories per
  serving
• Vitamin and mineral supplements
• Herbal preparations biologically active
• Myths and realities symptoms
• Habits junk foods, alcohol and smoking
• Comorbidity

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Herbal Preparations

• Be cautious as they can interfere with treatment
  and/or produce side-effects
• Method of preparation can determine effectiveness
• Not regulated by FDA, so need to be careful
  with selection
• Recommend taking bottles in to family
  physician/oncologist
• Avoid during protected period
• Antioxidants can repair the cellular
  oxidative damage to cancer cells caused by
  treatments such as radiotherapy and chemotherapy

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Managing Side EffectsThat Impair Physical
Function
Lymphedema
Neuropathy
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Lymphedema

• Swelling due to localized fluid build up
• Caused by damage or removal of the lymphatic tree
• Most notably in breast cancer due to nodal
  dissection
• Lymphatic system
• Often referred to as the body's "second"
  circulatory system
• Collects and filters the interstitial fluids
• May develop months or even years after therapy
  has concluded
• Lower-limb lymphedema have been associated with
  the use of Tamoxifen

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LymphedemaSymptoms Complications

• Heavy, swollen limb or localized fluid
  accumulation
• Stagnant, protein-rich fluid causes tissue
  channels to increase in size number - reducing
  the availability of oxygen
• Discoloration of the skin overlying the
  lymphedema
• Impaired wound healing due to lack of
  oxygen/nutients
• Bacterial growth can result in infections
  cellulitis, lymphangitis, lymphadenitis, and in
  severe cases, skin ulcers
• Eventually deformity (elephantiasis)
• Infections common and recurrent, in addition to
  their inherent danger, further damage the
  lymphatic system and set up a vicious circle

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LymphedemaStaging Grading

• Stage 0 (latent) Transport capacity is still
  sufficient for the amount of lymph being removed.
  No lymphedema.
• Stage 1 (spontaneously reversible) Tissue is
  still at the "pitting" stage. Usually upon waking
  in the morning, the limb or affected area is
  normal or almost normal in size.
• Stage 2 (spontaneously irreversible) The tissue
  now has a spongy consistency and is "non
  pitting". Fibrosis - hardening of the limbs and
  increasing size begin to persist.
• Stage 3 (lymphostatic elephantiasis) At this
  stage, the swelling is irreversible and usually
  the limb(s) or affected area is very large. The
  tissue is hard (fibrotic) and unresponsive.

• Grade 1 (mild edema) Lymphedema is in distal
  parts of the affected area. The difference in
  circumference is less than 4 centimeters no
  other tissue changes are present.
• Grade 2 (moderate edema) Lymphedema involves
  whole area. Difference in circumference is more
  than 4 but less than 6 centimeters. Tissue
  changes, such as pitting, are apparent.
• Grade 3 (severe edema) Lymphedema is present in
  one limb. The difference in circumference is
  greater than 6 centimeters. Significant skin
  alterations.
• Grade 4 (gigantic edema) Also known as
  elephantiasis where affected extremities are
  huge due to almost complete blockage of the lymph
  channels.

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LymphedemaKeys to Comfort

• Manage your risks
• Adequate diet - protein rich
• Proper weight
• Within normal BMI range
• Be physically active
• Manage other conditions
• diabetes, hypertension, kidney or heart disease,
  or phlebitis (inflammation of the veins)
• Drugs generally not helpful and may harm
• Avoid antibiotics, diuretics anticoagulants

• Manage your treatments
• Physical Manipulation
• Support the arm or leg in a raised position.
• Manual lymphatic drainage (a specialized form of
  very light massage that helps to move fluid from
  the end of the limb to the body).
• Wear compression garments that are custom-fitted
  and apply controlled pressure around the affected
  limb.
• TENS for pain

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Neuropathy

• Usually short for peripheral neuropathy
• Mainly affects the feet and legs
• Common in cancer
• Direct result of the cancer on peripheral nerves
  (e.g., compression by a tumor),
• Side effect of many chemotherapy drugs
• Electrical energy damage of radiation
• Results in tingling, numbness, or pain

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Neuropathy Treatment

• Prevention vigilance, avoidance, assistive
  devices
• Drugs alone or in combinations
• opioid analgesics such as morphine, codeine,
  heroin, oxycodone or methadone
• tricyclic antidepressants such as amitriptyline
  (Elavil)
• anticonvulsants such as gabapentin (Neurontin),
  pregabalin (Lyrica), or carbamazepine
  (Tegretol) and oxcarbazepine (Trileptal),

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Myths and Realities

• Habits lifestyle affects prevention, treatment,
  and survivorship
• Balanced diet will maximize treatment, minimize
  symptoms, and increase survivorship
• Smoking Dont do it
• Alcohol Intake should be moderate if not
  avoided. Advice should be tailored to cancer
  type, stage, treatment, risk factors and
  comorbidities.

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General Principles

• Maintain energy balance (functionality)
• Prevent excessive weight changes (loss)
• Plan ahead is important (nutritionist/dietician)
• What is your current nutritional status? (differs
  from prevention)
• Normal dietary consumption is the best means for
  acquiring adequate nutrition!

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Exercise and Physical Activity

• Studies show that physical activity helps
• Energy Balance
• Appetite - expenditure of calories help increase
  appetite
• Muscle Mass sometimes affected adversely by
  treatments
• Vitality emotional balance
• Symptom Management

Exercise as frequently as possible and it will
enhance physical and functional well-being as
well as improve your overall quality of life.
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Exercise and Physical Activity

• Individualize your physical activity to your
  personal preferences and condition.
• Assess your condition begin at lower intensity
  and progress at slower pace if undergoing active
  therapy
• Pay careful attention to balance to reduce
  injuries - Exercise in the presence of a
  caregiver or exercise professional (helpful if
  they have special training or certification)
  (Tip Request a Physical Therapy referral)
• Take into consideration other issues such as
  arthritis or peripheral neuropathies
• If you exercised prior to diagnosis you should
  maintain as much activity as possible.
• Always inform physician about your exercise
  program

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ACS Recommendations for Increasing Physical
Activity

• Use stairs instead of elevator
• If you can, walk or bike instead of drive
• Exercise with your family, friends, and
  coworkers.
• Plan active vacations instead of driving trips
• Take an exercise break to stretch or take a quick
  walk.
• Use a stationary bicycle while watching TV
• Plan your exercise routine to gradually increase
  days per week and minutes per session.

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Warnings and Cautions

• Survivors
• with severe anemia should delay exercise, other
  than activities of daily living,
• until the anemia is improved minimum of 10
  micro-deciliters
• with compromised immune function should avoid
  public gyms and other public places until their
  white blood cell counts return to safe levels.
  Survivors who have completed a bone marrow
  transplant are usually advised to avoid exposure
  to public places with risk for microbial
  contamination, such as gyms, for 1 year after
  transplantation.
• suffering from severe fatigue (physical rather
  than emotional) - from their therapy may not feel
  up to an exercise program, so they may be
  encouraged to do 10 minutes of stretching
  exercises daily. A good guideline for determining
  fatigue is shortness of breath after common daily
  activities (test if after walking 10 feet,
  patient has shortness of breath- they have severe
  fatigue)
• undergoing radiation should avoid chlorine
  exposure to irradiated skin (eg, swimming pools).
  Patients with inflammatory responses or lesions
  bad sunburn, puffiness, cracked skin should also
  avoid chlorine and other skin irritants.
• with indwelling catheters should avoid water or
  other microbial exposures that may result in
  infections as well as resistance training of
  muscles in the area of the catheter to avoid
  dislodgment.
• with significant peripheral neuropathies may have
  a reduced ability to perform exercises that use
  the affected limbs because of weakness or loss of
  balance. They may do better with a stationary
  reclining bicycle. For example patients will
  know if they are experiencing peripheral
  neuropathy (if its numb, hurts, and they
  experience loss of control)

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Tips for Energy Conservation

• It may seem odd to be encouraged to exercise in
  one sentence, and encouraged to conserve your
  energy in the next. The idea is to achieve an
  appropriate energy balance.

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Tips for Energy Conservation

• Sit to bathe and dry off (wear a robe)
• Install grab rails in shower
• Organize to avoid rushing
• Stop working before becoming tired
• Use easy to prepare foods/prepare double and
  freeze extra
• Delegate chores when possible

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Complementary and Alternative Medicine

• Remember Dietary supplements can be marketed
  without proof of safety or effectiveness,
  likewise anyone can publish on internet. Be sure
  to research complementary and alternative
  medicine thoroughly, as well as being careful to
  research information providers well.
• Reputable information sites
• http//cam.utmb.edu/default.asp
• www.nccam.nih.gov
• www.mdanderson.org/departments/CIMER
• Caution Health food stores - beware of advice
  from employees. They may mean well, but not
  qualified to act as a physician and will not
  understand the degree/components of the
  individualized treatment (or the combination of
  co-morbidities)
•  

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• For more information please visit us as
• www.utmb.edu/nsights