TABLE OF CONTENTS

• Overview
• Effects of the Tumor
• Effect of Cancer Therapies
• Surgery
• Chemotherapy
• Radiation therapy
• Immunotherapy
• Psychosocial Effects
• Nutritional Assessment
• General Management Guidelines
• Enteral/Parenteral Support
• Important

Overview

Inability to maintain nutritional status is a particularly common problem forpersons with cancer. The disease process and its treatment can lead to severeprotein-calorie malnutrition, which is the single most common paraneoplasticsyndrome or secondary diagnosis in the cancer patient. It is a major cause ofmorbidity and mortality. Protein-calorie malnutrition exists when the intakeof macronutrients is inadequate to meet metabolic requirements. Progressivewasting, weakness, debilitation, compromised immune function, potential therapyintolerance, and ultimately death may result.

Anorexia, the loss of appetite or desire to eat, is the most common symptom inpeople with cancer that may occur early in the disease process or later as thetumor grows and metastasizes. 1 Anorexia is present in 15% to 25% of allcancer patients at the time of diagnosis and is almost universal in patientswith widely metastatic disease. 2 3 Anorexia is the most common cause ofdecreased nutrient intake triggering malnutrition and progressive inanition(progressive deterioration with muscle wasting and body compositional change)in malignancy.

Cachexia is a clinical wasting syndrome evidenced by weakness and a marked andprogressive loss of body weight, fat, and muscle. 4 Anorexia and cachexiafrequently occur together, but cachexia may occur in individuals who areingesting adequate calories and protein but experience malabsorption ofnutrients. It has been estimated that one half of all people with cancerexperience cachexia, two thirds while in a terminal phase of the disease. 5 In addition, investigators have found no association between cachexia and tumorsize, type, or extent. 6 It has been observed that cancer cachexia differsfrom simple starvation. 7 Individuals adapt to starvation by decreasing theirbasal metabolic rate, whereas in cancer patients, the basal metabolic rate isnot adaptive and may be increased, decreased, or normal. 8 Although the exactmechanisms causing cancer cachexia are unknown, several theories regarding itspathogenesis point to a complex mix of tumor, host, and treatment variables,which make this syndrome difficult to study.

The prognostic impact of weight loss and malnutrition has been documented sincethe 1930s 9 in benign disease and later in malignant disease. 10 11 12 13 It hasbeen estimated that up to 20% of people with cancer may die of the effects ofcancer-included or treatment-related inanition. Additionally, the impact ofmalnutrition on health care costs is substantial. 14 15

References:

1. Donoghue M, Nunnally C, Yasko JM: Nutritional Aspects of Cancer Care. Reston, VA: Reston Publishing Company, Inc., 1982.
2. Langstein HN, Norton JA: Mechanisms of cancer cachexia. Hematol Oncol Clin North Am 5 (1): 103-23, 1991.
3. Tisdale MJ: Cancer cachexia. Anticancer Drugs 4 (2): 115-25, 1993.
4. Theologides A: Cancer cachexia. Curr Concepts Nutr 6:75-94, 1977.
5. Lindsey AM, Piper BF, Stotts NA: The phenomenon of cancer cachexia: a review. Oncol Nurs Forum 9 (2): 38-42, 1982 Spring.
6. Smith SA: Theories and intervention of nutritional deficit in neoplastic disease. Oncol Nurs Forum 9 (2): 43-6, 1982 Spring.
7. Lindsey AM: Cancer cachexia: effects of the disease and its treatment. Semin Oncol Nurs 2 (1): 19-29, 1986.
8. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.
9. Studley HO: Percentage of weight loss: a basic indicator of surgical risk in patients with chronic peptic ulcer. JAMA 106(6): 458-460, 1936.
10. Blackburn GL, Bistrian BR, Maini BS, et al.: Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr 1 (1): 11-22, 1977.
11. Tubiana M, Attié E, Flamant R, et al.: Prognostic factors in 454 cases of Hodgkin's disease. Cancer Res 31 (11): 1801-10, 1971.
12. Dewys WD, Begg C, Lavin PT, et al.: Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 69 (4): 491-7, 1980.
13. DeWys WD, Begg C, Band P, et al.: The impact of malnutrition on treatment results in breast cancer. Cancer Treat Rep 65 Suppl 5:87-91, 1981.
14. Robinson G, Goldstein M, Levine GM: Impact of nutritional status on DRG length of stay. JPEN J Parenter Enteral Nutr 11 (1): 49-51, 1987 Jan-Feb.
15. Reilly JJ, Hull SF, Albert N, et al.: Economic impact of malnutrition: a model system for hospitalized patients. JPEN J Parenter Enteral Nutr 12 (4): 371-6, 1988 Jul-Aug.

Effects of the Tumor

Many nutritional problems in the person with cancer stem from a local tumoreffect. 1 Enlarging tumors in the gastrointestinal tract, for example, cancause obstruction, nausea and vomiting, impaired digestion, delayed transit,and malabsorption. Ovarian and genitourinary cancers may be associated withascites leading to early satiety, progressive protein malnutrition (especiallywith fluid loss at surgery or paracentesis), and fluid and electrolyteimbalances. Pain related to tumor bulk or location may be associated withsevere anorexia and decreased oral intake. Central nervous system tumors thatcause confusion or somnolence may affect nutritional status because lack ofattention may lead to decreased intake.

In addition to local tumor effects (from either the tumor itself or thepatient's response to the tumor), nutritional problems can also stem frommetabolic alterations. 2 Marked alteration in normal metabolism ofcarbohydrate, protein, and lipid can occur. Tumor cells may derive significantenergy from metabolism of glucose to lactate (Cori cycle) rather than from morecomplete oxidation of carbon dioxide and water (Krebs cycle). 3 Additionally,conversion of lactate to glucose for gluconeogenesis by the liver consumes sixATP molecules per lactate-glucose cycle, producing energy-inefficient cycling. Tumor cells have an increased requirement for glucose as an energy source,either through altered enzymatic activity or due to relative hypoxia induced bypoor tumor vascularization. Differences in the contribution of Cori cycleactivity have been seen in patients who lose weight and in those with stableweight. 2 Inhibition of phosphoenolpyruvate carboxykinase by hydrazinesulfate may decrease excess Cori cycle activity and improve glucose tolerancein cancer patients, but weight loss may not be reversed. 2 Altered proteinmetabolism in patients with cancer may stem from increased uptake of aminoacids by the tumor cells compared with that of normal cells, decreased proteinsynthesis, increased protein degradation, and protein loss through fistulas orby gastrointestinal losses. In addition, decreased intake secondary toanorexia, when need is increased or normal, is often the basis of negativenitrogen balance. Altered lipid metabolism can occur as a result ofmobilization and the use of fatty acids as an additional energy source when theglucose supply of the body is exhausted by the tumor. 4 A decrease in fatmobilization has also been observed. 5 6

Mediators of primary cachexia (i.e., cachexia without a mechanical or functionetiology) can include substances with hormone-like characteristics or productsof host tissues that influence metabolism indirectly. The latter include anumber of cytokines such as tumor necrosis factor (TNF-alpha), interleukin-6,and gamma-interferon. Additionally, lipid mobilizing factors have also beenimplicated. 2 Lack of enteral stimulation may increase levels of circulatingcytokines.

In addition to alterations in carbohydrate, protein, and lipid metabolism,cancer cells produce peptides, oligonucleotides, and other metabolites that maybe responsible for the genesis of anorexia and cachexia. 2 For example,tumor-produced substances may alter a person's sense of taste, leading to anaversion to meat and a decreased taste sensation. Tumors may cause anorexiathrough a peripheral effect on neuroendocrine cells or neuroreceptors andthrough a direct effect on hypothalamic and other central nervous systempeptidergic and responder cells. Early satiety or a sense of fullness is afrequent symptom in anorectic cancer patients, suggesting the importance ofinhibitory signals from the gastrointestinal tract in limiting their foodintake. Tumors can also produce hormone substances, similar to those seen inparaneoplastic syndromes, which can alter nutrient intake, absorption, andmetabolism. 7

References:

1. Szeluga DJ, Groenwald SL, Sullivan DK: Nutritional disturbances. In: Groenwald SL, Frogge MH, Goodman M, et al.: Cancer Nursing: Principles and Practice. Boston: Jones and Bartlett Publishers, 2nd Edition, 1990, pp 495-519.
2. Tisdale MJ: Cancer cachexia. Anticancer Drugs 4 (2): 115-25, 1993.
3. DeWys WD: Nutritional care of the cancer patient. JAMA 244 (4): 374-6, 1980.
4. Goodlad GA, Clark CM: Protein metabolism in the tumour-bearing host. Acta Chir Scand Suppl 498:137-40, 1980.
5. Axelrod L, Costa G: The contribution of fat loss to weight loss in cancer. Nutrition and Cancer 2(1): 81-83, 1980.
6. Waterhouse C: Oxidation and metabolic interconversion in malignant cachexia. Cancer Treat Rep 65 Suppl 5:61-6, 1981.
7. Smith SA: Theories and intervention of nutritional deficit in neoplastic disease. Oncol Nurs Forum 9 (2): 43-6, 1982 Spring.

Effect of Cancer Therapies

Cancer therapies and their side effects can also greatly contribute toprogressive nutritional deterioration. The therapy may have a direct effect,such as protein and fat malabsorption after a gastrectomy or pancreatectomy, orindirect effects, such as increases in metabolic demands caused by infection ora neutropenic febrile reaction (there is an increased caloric need ofapproximately 10% to 13% per degree above 37 degrees Celsius). Nutritionalproblems can be induced by each general type of antineoplastic therapy. 1 2 The nutritional literature has defined severe malnutrition in two ways:functionally (increased risk of morbidity and/or mortality) and by degree ofweight loss (greater than 2% per week, 5% per month, 7.5% per 3 months, and 10%per 6 months). 3 In the cooperative group format, nutrition toxicity does notgenerally take into account baseline deficit and includes degrees of weightloss that are much greater than the above criteria. Grading (withoutconsideration of time course) is as follows: grade 0 = less than 5.0% loss,grade 1 = 5.0%-9.9%, grade 2 = 10.0%-19.9%, grade 3 = greater than 20.0%. Grade 4 (life-threatening) is not specifically defined. Attention to weightloss at an earlier time point is required to successfully prevent deteriorationof weight, body composition, and performance status.

Surgery

Head and neck surgery may directly cause difficulty in chewing and swallowingor may be associated with substantial psychosocial stresses related to thedegree of surgical resection. Esophageal surgery may cause gastric stasis andfat malabsorption secondary to vagal sectioning. Fat and proteinmalabsorption, dumping syndrome with reactive hypoglycemia, and early satietymay occur following gastric surgery. Pancreatic surgery may also cause proteinand fat malabsorption, as well as vitamin and mineral deficiencies, anddiabetes mellitus. Small bowel and colon surgery may cause protein and fatmalabsorption, vitamin and mineral deficiencies, diarrhea, and excessive fluidand electrolyte losses. Surgery involving the urinary tract can lead toacid-base imbalances and electrolyte abnormalities. Additionally,complications of surgery with nutritional implications may include infection,fistulae (internal or enterocutaneous), and short-bowel syndrome. Patients mayactively decrease their oral intake after a diverting or end colostomy todecrease the ostomy output. This should be addressed in any patient with amarked decrease in oral intake after such surgery.

Chemotherapy

Chemotherapy can cause anorexia, nausea and/or vomiting, diarrhea orconstipation, stomatitis/mucositis, taste alterations or aversions, andinfectious complications. Symptoms that have an impact on nutrition and thatlast longer than 2 weeks are especially significant. The frequency andseverity of these side effects depend on the class of drug, the dose, the drugcombination, and whether the chemotherapy is part of a combined modalityprogram. Nutritional status may be strongly affected with prolonged treatmentof febrile neutropenia where metabolic needs may increase 25% with atemperature of 39 degrees Celsius.

Radiation therapy

Radiation therapy is associated with both acute and late sequelae that affectnutritional status. Irradiation of the head and neck area can induce or beassociated with anorexia, taste alterations or aversions, dry mouth, mucositis,gingivitis, dysphagia, trismus, dental caries, and abscess formation. Thoracicirradiation may be associated with esophagitis (radiation-induced esophagealmucositis, candidiasis, or viral infections), dysphagia, esophageal reflux, andnausea and vomiting. Diarrhea, nausea and vomiting, enteritis, proctitis, orfistula formation are possible side effects caused by abdominal or pelvicirradiation. Use of a pelvic sling, tissue expander in the pelvis, or othermethods for removing the small bowel from a pelvic irradiation field may beincluded as part of surgery to decrease these complications. Radiation therapymay also be associated with fatigue, which may result in decreased appetite andmotivation to eat. Late sequelae include strictures, chronic radiationenteritis, malabsorption, or gastrointestinal obstruction.

Immunotherapy

Immunotherapy (e.g., biologic response modifiers) may be associated with fever,fatigue, and weakness, which can lead to decreased appetite and increased needfor protein and calories. Again, febrile reactions are associated with anapproximate 10% increase in metabolic requirements per degree above 37 degreesCelsius.

References:

1. Clark J, McGee R, Preston R: Nursing management of responses to the cancer experience: nutrition. In: Clark J, McGee R, eds.: Core Curriculum for Oncology Nursing. Philadelphia: W.B. Saunders, 1992, pp 93-106.
2. Kokal WA: The impact of antitumor therapy on nutrition. Cancer 55 (1 Suppl): 273-8, 1985.
3. Blackburn GL, Bistrian BR, Maini BS, et al.: Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr 1 (1): 11-22, 1977.

Psychosocial Effects

Dining is a major focus of social activity. Anorexia and food aversionscontribute to social isolation when people cannot participate in communalactivities associated with eating. Multiple psychological and social factorscan affect a person's desire and willingness to eat. The stress of coping withthe cancer diagnosis and its treatment can have a major role. Depression,anxiety, anger, and fear are common emotions experienced by persons with cancerand can contribute to anorexia. A sense of loss of control or helplessness mayalso have a role in nutritional intake. Refusing to eat despite strongrecommendations or pleading by family members, friends, or health professionalsmay be one way in which a patient (who may feel no option to refuseantineoplastic therapy) feels able to exercise some control in life. Learnedfood aversions may also contribute to decreased oral intake, nausea, and/orvomiting. 1 Individuals who have experienced unpleasant symptoms after eatinga specific food may begin to avoid this food or food group.

Factors such as living alone, inability to cook or prepare meals, or even towalk to the kitchen as a result of physical limitations can contribute toeating disorders. A thorough evaluation of the home situation by a socialworker or visiting nurse may identify easily correctable factors thatcontribute to poor eating habits.

Establishing the cancer diagnosis and initiating treatment often require thepatient to spend large amounts of time away from normal routines, includingmeals. Cultural food preferences may not be accessible in treatment settingsor may not be well tolerated because of treatment side effects. A person whoenjoys hot, spicy food and has esophagitis may dislike the taste of bland foodand eat very little. Taste alterations can psychologically affect a person'sappetite and desire for food.

Unfortunately, lack of adequate nutritional intake leads to progressivenutritional deterioration, representing to the patient and family, progressionof the cancer process. The wasting is a constant reminder to the patient,family, and health care team of the cancer diagnosis and expected poorprognosis. This can significantly influence quality of life, socialinteraction, and outlook. Additionally, with progressive wasting, and itsassociated fatigue, the person generally decreases social interaction. Becauseof the role food and eating have in society, this can serve as a significantisolation factor for a person with cancer.

Studies have reported a positive impact of exercise (e.g., walking or mildaerobic) on the sense of well-being, nausea and vomiting, and nutritionalintake. 2 Patients forced to rely on artificial feeding methods (includingforced oral feeding as well as enteral or parenteral feeding) can experiencedepression, body image changes, and stress related to problems with feedingtubes and equipment. 3 Problems related to nutrition have been identified bycancer patients as the most important factor in affecting their sense ofwell-being, more important than sexuality and continued employment. 4

References:

1. Bernstein IL: Physiological and psychological mechanisms of cancer anorexia. Cancer Res 42(2, Suppl): 715s-720s, 1982.
2. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.
3. Padilla GV, Grant MM: Psychosocial aspects of artificial feeding. Cancer 55 (1 Suppl): 301-4, 1985.
4. Padilla GV, Presant C, Grant MM, et al.: Quality of life index for patients with cancer. Res Nurs Health 6 (3): 117-26, 1983.

Nutritional Assessment

The history and physical examination are the most important components ofassessment of nutritional status. This should include weight history (current,usual, and ideal); assessment of oral intake changes (type and duration);symptoms impacting on nutrition (including anorexia, nausea and vomiting,diarrhea, constipation, stomatitis/mucositis, dry mouth, taste/olfactoryabnormalities, and pain); medications that may affect intake or metabolicrequirements; other medical conditions that may affect nutritional intake ornutrition intervention options; and performance status evaluation. The personwith cancer should be asked about changes in intake compared with what isnormal for them and the duration of the change if present. Physicalexamination entails a general assessment of physical condition, includingevidence of weight loss, loss of subcutaneous fat, muscle wasting, presence ofsacral or tibial edema, or ascites. Standardized staging criteria for degreeof nutritional deficit or risk have been developed and validated. 1 2 Knownas the Subjective Global Assessment (SGA) of nutritional status, thisevaluation tool has been validated in a number of patient populations includingsurgical, human immunodeficiency virus (HIV), and acquired immunodeficiencysyndrome (AIDS) populations. 2 3 With appropriate training, the method issensitive, specific, and has little interobserver variability. A modificationspecifically developed for oncology patients is currently being piloted.

Obtaining a quantitative as well as qualitative dietary history can be helpfulin dietary assessment, especially as a means of demonstrating to the personwith cancer and his or her family or caregiver, that changes can be made toincrease calorie, protein, and micronutrient intake. Useful data also includespecific likes, dislikes, and intolerances of the person with cancer. Thelatter may help to determine the need for specific supplemental enzymes(lactase, other disaccharidases, or pancreatic enzymes).

Anthropometric measurements such as skin fold thickness and midarm musclecircumference are not useful in clinical situations. However, clinicalpalpation of the tricep muscle can often provide an excellent estimate ofnutrition, since extensors tend to lose muscle faster than flexors. 4 Thismethod of nutritional assessment is limited by both the technique andinterobserver variability. Laboratory evaluations that may contribute tonutritional evaluation or appropriate nutritional intervention includeassessment of visceral protein status (serum transferrin or albumin), renal andliver function, pancreatic endocrine function (glucose), serum electrolytes andminerals (calcium, magnesium, and phosphorus), and hematologic evaluation(total lymphocyte count and red cell indices). Although not routinely used,delayed cutaneous hypersensitivity testing (skin test antigens) may be helpfulto gauge systemic immune function.

Determination of nitrogen balance by 24-hour urinary urea nitrogen (UUN) ishelpful in nutritional intervention regimens, particularly in the use ofenteral or parenteral nutrition. The aim of nutritional intervention is tominimize the degree of negative nitrogen balance (i.e., excessive loss of bodyprotein not compensated by adequate nutritional intake). Nitrogen balance isdefined as nitrogen intake (in grams) minus nitrogen output (in grams) and canbe estimated from (protein intake/6.25) - (UUN+4). If nitrogen intake is lessthan output, the patient is considered to be in negative nitrogen balance, witha net loss of body protein. This contributes to progressive muscle wasting,fatigue, and immune compromise.

References:

1. Detsky AS, McLaughlin JR, Baker JP, et al.: What is subjective global assessment of nutritional status?. JPEN J Parenter Enteral Nutr 11(1): 8-13, 1987.
2. Hirsch S, de Obaldia N, Petermann M, et al.: Subjective global assessment of nutritional status: further validation. Nutrition 7 (1): 35-7; discussion 37-8, 1991 Jan-Feb.
3. Detsky AS, Baker JP, O'Rourke K, et al.: Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery. JPEN J Parenter Enteral Nutr 11 (5): 440-6, 1987 Sep-Oct.
4. Winick M , ed.: Hunger Disease: Studies by the Jewish Physicians in the Warsaw Ghetto. New York: John Wiley & Sons, 1979.

General Management Guidelines

Options for supportive nutritional care of the person with cancer aredetermined by one or more of the following:

1. Presence of a functional gastrointestinal tract
2. Type of therapy (independent of palliative or curative intent), i.e., siteand extent of surgical resection, specific type of chemotherapy, site and sizeof radiation field, use of biologic response modifiers, or multimodalitytherapy
3. Quality of life, performance status, or prognosis
4. Cost effectiveness and cost-utility determinations

It is believed that maintenance of body composition and adequate nutritionalstatus can help people with cancer feel and look better and can maintain orimprove performance status and daily functional status. It may also help themtolerate therapy. 1 The type of nutritional intervention used will depend onthe basis of the nutritional risk or deficit. Problems caused by local tumoreffects may subside when the tumor responds to therapy. Those nutritionalimpact symptoms related to side effects of therapy must be proactivelyaddressed to ensure adequate symptom control measures. (Refer to the PDQsummaries on Constipation, Impaction, and Bowel Obstruction; Pain; Nausea andVomiting; and Oral Complications for more information.)

A major cause of anorexia in patients with cancer is food odor. Patientssuffering from anorexia should not be in a room where the odors of foodpreparation can be detected. Foods with reduced odors are preferable forpatients with cancer. This explains why cancer patients will often eat best atbreakfast, since many breakfast foods have little odor.

Suggestions for helping people with cancer manage anorexia include thefollowing: 2 3 4

1. Eat small frequent meals (every 1-2 hours by the clock).
2. Eat food (including snacks) that is caloric- and protein-dense.
3. Avoid foods low in calories and protein and avoid empty calories (i.e.,food without protein and micronutrients, such as soda).
4. Avoid liquids with meals (unless used sparingly to improve dry mouth ordysphagia) to decrease problem of early satiety.
5. Time meals to coincide with periods during the day when the patient isfeeling best; use nutritional supplements at times of decreased appetite ordesire to eat. (Generally, patients tend to feel better and have improvedappetites early in the day with a progressive decrease in appetite as the dayprogresses.)
6. Taste-test several different commercially available nutritional supplementsor different high-calorie, high-protein drink or pudding recipes. Adding thejuice from half of a freshly-squeezed lemon can help lessen the excessivesweetness and bitter aftertaste that sometimes distresses patients with cancer,but which may not be detectable to individuals who do not have cancer.
7. Stimulate appetite with light exercise (e.g., walking), glass of wine orbeer if not contraindicated, and use of orexigenic agents (appetitestimulants).
8. Add extra calories and protein to food (e.g., butter, skim milk powder, honey, brown sugar).
9. Take medications with high-calorie fluids (e.g., commercial nutritionalsupplement) unless the medication must be taken on an empty stomach.
10. Make surroundings pleasant and varied; food presentation should beattractive (e.g., try new recipes, eat with friends, prepare food with colorand texture variation).
11. Experiment with recipes, flavorings, spices, types and consistencies offood. This is important since food preferences may change from day to day.
12. Avoid strong aromas if they are bothersome. Strategies include the use ofboiling bags, cooking outdoors on a grill, the use of kitchen fan when cooking,serving cold plates rather than hot foods (since odors come from the risingsteam), and removal of hospital food tray covers in the hallway rather than atthe patient's bedside to dissipate some of the odors. A portable fan can beused to blow away the aroma of hot foods. Food ordered from outside so thatpreparation odors are not detected will often be tolerated if consumedimmediately after arrival (e.g. pizza).

Suggestions for helping people with cancer manage taste changes include thefollowing:

1. Use plastic utensils if patient experiences metallic taste while eating.
2. Substitute poultry, fish, eggs, and cheese for red meat.
3. Marinate meats with sweet marinades or sauces.
4. Serve meats chilled rather than hot.
5. Use extra seasonings, spices, and flavorings, but avoid flavorings that are very sweet or very bitter. An elevated threshold for taste may make foodtaste bland or boring.
6. Substitute milk shakes, puddings, ice cream, cheese, and other high-proteinfoods for meats if patient experiences an aversion to meat.
7. Rinse mouth before eating.
8. Use lemon-flavored drinks to stimulate saliva and taste, but avoidartificial lemon and use sweeteners sparingly.

Suggestions for prevention of conditioned taste aversions include thefollowing:

1. Try new foods and supplements when feeling best/well, e.g., on Sundays forpatients undergoing daily radiation therapy or after the patient leaves thehospital rather than during chemotherapy infusion.
2. Eat lightly on the morning of or several hours prior to receivingchemotherapy.
3. Separate novel taste introductions from noxious stimuli.

Suggestions for lessening or alleviating either dry mouth or dysphagia includethe following:

1. Eat soft or moist foods.
2. Process foods in blender.
3. Lubricate foods with creams, gravies, or oils.
4. Avoid rough, irritating foods.
5. Avoid hot or cold foods.
6. Avoid foods that adhere to the roof of the mouth. 5
7. Take small bites and chew thoroughly. 5

Suggestions for stomatitis (refer to the PDQ summary on Oral Complicationsfor more information):

No matter what the nutritional deficit, the person with cancer should beencouraged to maintain a positive attitude toward treating the cause andassuring adequate intake of protein and calories. Calculating individualizedcalorie and protein requirements and explaining to the person with cancer(and/or family or caregiver) will allow specific and realistic goals. Theactual amount of protein and calories needed by each cancer patient will varydepending on the person's baseline and current nutritional status, particularnutritional deficits, and individual factors.

The protein requirement for non-weight losing individuals is approximately 0.5grams per pound of ideal body weight. For the person who has lost weight, isfebrile, or is on medications that increase protein requirements, such ascorticosteroids, it is important to aim for approximately 0.7 grams per pound. Ideal body weight (IBW) is calculated as follows:

• males: 106 pounds for height of 5 feet plus 6 pounds for each inchgreater than 5 feet (e.g., IBW for male 5'10" tall = 166 pounds +/- 10%)
• females: 100 pounds for height of 5 feet plus 5 pounds for each inchgreater than 5 feet (e.g., IBW for female 5'10" tall = 150 pounds +/- 10%)

In terms of caloric needs, the following formulas can be used:

General Guidelines of Calories Required (assuming light activity)
• Underweight adults: multiply weight in pounds by 18
• Normal weight adults: multiply weight in pounds by 16
• Overweight adults: multiply weight in pounds by 13

Additional calories and increased protein intake may be required for specificpeople and situations. An oncology nutritionist (dietitian, diet technician,nurse, or physician with specialized education or training in nutrition) canoffer guidance in determining the appropriate macronutrient (calories andprotein) and micronutrient (vitamins, electrolytes, minerals) needs and optionsfor nutritional intervention.

References:

1. Irwin MM: Enteral and parenteral nutrition support. Semin Oncol Nurs 2 (1): 44-54, 1986.
2. Szeluga DJ, Groenwald SL, Sullivan DK: Nutritional disturbances. In: Groenwald SL, Frogge MH, Goodman M, et al.: Cancer Nursing: Principles and Practice. Boston: Jones and Bartlett Publishers, 2nd Edition, 1990, pp 495-519.
3. National Cancer Institute: Eating Hints: Recipes and Tips for Better Nutrition During Cancer Treatment. Bethesda: NIH Publication, No. 91-2079, 1990.
4. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.
5. Bloch AS: Nutritional management of patients with dysphagia. Oncology (Huntington NY) 7(11, Suppl): 127-137, 1993.

Enteral/Parenteral Support

An algorithm of nutritional options is available 1 to address nutritionproactively and to prevent or treat malnutrition and its complications.

General indications for enteral nutrition (gastric and duodenal/jejunal, withsite dependent on the intake gastrointestinal impediment) include thefollowing:

1. Upper gastrointestinal impediment to adequate oral intake (dysphagia,esophageal stricture, tumor, gastroparesis, gastric outlet obstruction, etc.).
2. Combined modality therapy with chemotherapy and radiation therapy (especially with radiation therapy to the upper aerodigestive tract) with known esophageal or gastrointestinal tract toxicity that will limit adequate oral intake.
3. Anorexia and/or psychologic inability (e.g., severe depression,confusion/disorientation) to maintain adequate oral intake.
4. Contraindications/inability to take large volumes of oral nutrition,(e.g.,pain with bolus eating).

General contraindications to enteral nutrition include the following:

1. Bowel obstruction.
2. Intractable nausea and vomiting unresponsive to optimal antiemetic regimen(Refer to the PDQ summary on Nausea and Vomiting for more information.)
3. Severe short gut with intractable gastrointestinal output despite attemptswith appropriate enteral formulations and pharmacologic intervention (e.g.,somatostatin).
4. Upper gastrointestinal tract or high-output fistula (tumor-related oriatrogenic).

General indications for parenteral nutrition (complete or supplemental) includethe following:

1. Nonfunctioning gastrointestinal tract in the following contexts:
   1. Temporary problems impeding oral or enteral intake for longer than 10days, especially with baseline nutritional deficit.
   2. Obstruction or other mechanical problems expected to respond toantineoplastic therapy or surgical intervention.
   3. Multiple and/or noncorrectable obstructive/mechanical problemsassociated with an indolent cancer.

2. Severe short gut secondary to surgical resection, radiation enteritis,high gastrointestinal fistula and inability to maintain weight and bodycomposition with appropriate enteral regimen.
3. Severe and/or continuing nutritional deterioration in a person with indolent cancer or any malignancy in which malnutrition, rather thancancer is the primary problem.

General contraindications to parenteral nutrition include the following:

1. Functional gut.
2. Limited life expectancy (< 40 days).
3. Lack of adequate vascular access.
4. Lack of severe nutritional deficit such as temporary inability to eat(e.g., post surgery).

Although there remains continued controversy concerning the ultimate benefit ofnutritional support, 2 it is believed that a properly nourished cancer patientis better able to tolerate both the cancer therapy and its complications. 3 4 The delivery method chosen for nutritional support should be based on theindividual's physiologic requirements, degree of nutritional debilitation,disease process, estimated duration for the need of support, and the resourcesavailable. If the gastrointestinal tract is functioning and not adverselyaffected by the cancer treatment, enteral support is the route of choice,especially when dealing with issues of system immune function. Options forplacement of enteral feeding tubes include non-surgical (via nasal route) aswell as endoscopic, radiologic, laparoscopic, and open surgical placement. Practical issues of tube options and formulations have been reviewed. 5 6

Nutritional Support, Pharmacological Approaches 7

Pharmacologic intervention to increase oral nutritional intake can range frompain management to treatment of constipation or diarrhea, the use of gastricprokinetic agents, and the use of specific orexigenic agents (appetitestimulants). 8 Megestrol acetate (at a recommended dose of 800 mg/day) hasshown success. 9 10 Corticosteroid use in situations other than terminal careis generally not indicated because of exacerbation of progressive musclewasting. Dronabinol as an appetite stimulant has been used primarily in AIDScachexia, but has been suggested for cancer patients, with a dose of 2.5 mg/dayto 5 mg/day.

Hydrazine sulfate has been studied in three multicenter, randomized, phase IIItrials sponsored by the National Cancer Institute, however no clinical benefitswere found. These trials included 600 patients diagnosed with advanced lungcancer and advanced colon cancer. 11 12 13 The end points in these studiesincluded survival, weight gain, nutritional parameters and quality of life. The results of these three studies were negative, with no benefit seen. In thetwo studies of advanced lung cancer patients, the addition of hydrazine sulfateto a standard chemotherapy regimen resulted in somewhat worse quality of life,with no effect on weight gain or loss and a suggestion of decreased time todisease progression and survival when compared with placebo. 11 12 In thetrial evaluating hydrazine sulfate in metastatic colon cancer, the survivaltime for patients receiving the hydrazine was decreased compared with patientsreceiving placebo. 13 Compared with patients receiving placebo, patientsreceiving hydrazine sulfate demonstrated a more rapid deterioration ofperformance scores and quality of life indices, and also experienced more rapidweight loss. The incidence of severe and life threatening treatment-relatedadverse effects, particularly sensory and motor neuropathies were significantlygreater among patients who received hydrazine sulfate.

References:

1. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.
2. Chlebowski RT: Critical evaluation of the role of nutritional support with chemotherapy. Cancer 55 (1 Suppl): 268-72, 1985.
3. Hays DM, Merritt RJ, White L, et al.: Effect of total parenteral nutrition on marrow recovery during induction therapy for acute nonlymphocytic leukemia in childhood. Med Pediatr Oncol 11 (2): 134-40, 1983.
4. Copeland EM, Daly JM, Dudrick SJ: Nutrition as an adjunct to cancer treatment in the adult. Cancer Res 37(7, Part 2): 2451-2456, 1977.
5. Bloch AS: Nutrition Management of the Cancer Patient. Rockville, Maryland: Aspen Publishers, 1990.
6. Rombeau JL, Caldwell MD , eds.: Clinical Nutrition: Parenteral Nutrition. Philadelphia: Saunders, 2nd ed., 1993.
7. Nelson KA, Walsh D, Sheehan FA: The cancer anorexia-cachexia syndrome. J Clin Oncol 12 (1): 213-25, 1994.
8. Bruera E: Current pharmacological management of anorexia in cancer patients. Oncology (Huntingt) 6 (1): 125-30; discussion 132, 137, 1992.
9. Parnes H, Tait N, Aisner J: The potential of megestrol acetate in the treatment of cancer cachexia. Nutrition 5 (3): 206-9, 1989 May-Jun.
10. Tchekmedyian NS, Hickman M, Siau J, et al.: Treatment of cancer anorexia with megestrol acetate: impact on quality of life. Oncology (Huntingt) 4 (5): 185-92; discussion 194, 1990.
11. Loprinzi CL, Goldberg RM, Su JQ, et al.: Placebo-controlled trial of hydrazine sulfate in patients with newly diagnosed non-small-cell lung cancer. J Clin Oncol 12 (6): 1126-9, 1994.
12. Kosty MP, Fleishman SB, Herndon JE, et al.: Cisplatin, vinblastine, and hydrazine sulfate in advanced, non-small-cell lung cancer: a randomized placebo-controlled, double-blind phase III study of the Cancer and Leukemia Group B. J Clin Oncol 12 (6): 1113-20, 1994.
13. Loprinzi CL, Kuross SA, O'Fallon JR, et al.: Randomized placebo-controlled evaluation of hydrazine sulfate in patients with advanced colorectal cancer. J Clin Oncol 12 (6): 1121-5, 1994.

Important

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

About OncoLink  Contact OncoLink  Privacy statement   Disclaimer  Link to OncoLink  Home
For assistance please visit our HELP section
© Trustees of the University of Pennsylvania