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The Royal Marsden
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Living with and beyond cancer
Clare Shaw PhD RD
Consultant Dietitian
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Lung Cancer Colorectal Cancer Breast Cancer
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The Royal Marsden Nutritional issues after cancer treatment 4
Nutritional issues in cancer
– What are the nutritional issues after cancer treatment?
– Nutritional status and issues after treatment?
– Can nutrition influence prognosis?
– Late effects of cancer treatment
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The Royal Marsden
Nutritional status
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What happens to body weight after cancer treatment?
Weight loss
Upper GI cancer patients
Stem cell or Bone marrow transplantation
Head and neck
Gynae-oncology
Weight stable
Breast, prostate, colo-rectal
Weight increase
Breast cancer
Prostate cancer
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Cachexia ‘the synergistic combination
of a variable decrease in appetite and weight and
an increase in the catabolism of fat and lean
body mass’
European Clinical Guidelines on cancer
cachexia in advanced cancer patients
Sarcopenia No internationally agreed
definition of this phenomenon: ‘the presence of both low
muscle mass + low muscle function (strength or
performance)’
European Working Group on Sarcopenia in Older People 2010
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The Royal Marsden
Sarco-penia
• Myopenia
• Myosteatosis
Flesh- poverty
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Sarcopenia- Dietary treatment
Protein Directly linked to muscle
synthesis. Total amount could be debated:
Martone AM et al 2012:
>1g protein per kg body weight
Paddon-Jones and Ramussen
25-30g per meal
Aleman- Mateo H et al 2014 210g ricotta cheese (23g
protein)
Leucine- stimulates muscle synthesis
> Whey based enteral feeding, especially for patients who are
less mobile
Omega 3 Inconclusive evidence. Literature is limited to
the cachectic patient. Fearon et al 2003 Gullett et al 2012
Vitamin D Role in maintaining muscle mass and
strength- limited research in cancer patients Beaudart C et al (2014)
Recognise and initiate treatment of Vitamin D
But this alone is inadequate without:
ACTIVITY!
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Link between weight loss and symptoms
Diarrhoea consistent problem 12 months after upper GI surgery
Martin et al, 2007: Iestra et al, 2002;
Scarpa et al, 2013 J Gastrointest Surg: 17
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The Royal Marsden
Can nutrition affect prognosis after cancer?
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The Royal Marsden Nutritional issues after cancer treatment 12
Diet following cancer treatment
– Few studies on diet in cancer survivors
– Good diet for health
– Reduce risk of other diseases eg. diabetes, heart disease
– Can it influence whether
the cancer returns?
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The Royal Marsden Diet for breast cancer survivors 13 13
World Cancer Research Fund UK Recommendations
1. Be as lean as possible without becoming underweight
2. Be physically active for at least 30 minutes every day
3. Avoid sugary drinks and limit the consumption of high calorie foods
4. Eat more of a variety of vegetables, fruits, whole grains and pulses
5. Limit intake of red meat and avoid processed meat
6. Limit alcoholic drinks to 2 a day for men and 1 a day for women
7. Limit consumption of salty foods
8. Do not use nutritional supplements to protect against cancer
9. After treatment, cancer survivors should follow the recommendations for cancer prevention
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The Royal Marsden Diet for breast cancer survivors 14
www.wcrf.org/sites/default/files/Breast-Cancer-Survivors-2014-Report.pdf
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The Royal Marsden Diet for breast cancer survivors 15
www.wcrf.org/sites/default/files/Breast-Cancer-Survivors-2014-Report.pdf
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The Royal Marsden
Nutrition in GI late effects
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The Royal Marsden
Gastrointestinal symptoms patients present with in clinic
Change in bowel habit
Diarrhoea
Steatorrhoea
Increased frequency of
defaecation
Urgency of defaecation
Faecal incontinence
Nocturnal defaecation
Tenesmus
Mucus discharge
Excessive flatulence
Constipation
Pain (abdominal, rectal, anal,
perineal)
Sexual activity curtailed by
bowels
Nausea
Vomiting
Weight loss
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The Royal Marsden 18
Changes in food intake – what happens after pelvic radiotherapy
Abayomi et al, 2009 Journal of Human Nutrition and Dietetics, 22; 310-316
¼ ate less fruit
1/5 ate less vegetables
1/6 ate less fat
¼ ate less fibre
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The Royal Marsden
How do patients try to cope with gastrointestinal
symptoms?
Modify their diet
Avoid certain foods or food groups
Miss meals or modify the size of meals
Eat plain food or stick to tried & tested foods
Rarely go out
‘I have tried many tablets and teas, changing my diet and nothing seems to work’
Abayomi et al 2005; Abayomi et al 2009; Dunberger et al 2011; Gami et al 2003; Gillespie at al 2007; Sekhon, 2000
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General management strategies
– GI symptoms may or may not be related to the cancer treatment
– Many patients have more than one cause for symptoms
– Symptoms are unreliable at predicting the underlying cause
– Inappropriate treatment has a significant potential for causing harm
– Most patients need appropriate investigation before treatment
Andreyev et al, 2011 Gut
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The Royal Marsden 21
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Dietary intervention:
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The Royal Marsden 24 Symptoms/
diagnosis
Dietary intervention References
Bile acid malabsorption Low fat diet Bosaeus et al 1979; Bye et al 1992; Danielsson et al 1991
Pancreatic insufficiency Dietary manipulation & enzyme replacement therapy
Ferrone et al 2007; Keller & Layer 2005; Smith 2008
Free fatty acid malabsorption
Low fat diet Nightingale 2003; Nightingale & Woodward 2006
Coeliac Disease Gluten free diet NICE 2009
Bloating, wind, abdo pain, altered bowel habit *
Low FODMAPs* Gibson & Shepherd 2010; Rangnekar & Chey 2009; Staudacher et al 2011.
IBS type symptoms* Consult IBS algorithm e.g. reduction in high fibre
foods*
NICE 2008; Abayomi et al 2005; Abayomi et al 2009; Sekhon 200; Gami et al 2003.
* Only consider if no alternative diagnosis has been made
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Management of side effects and consequences of treatment
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Decrease in symptom ratings
p value
Urgency to open bowels <0.01
Bloating & distension <0.01
Lack of control <0.01
Frequency of opening bowels <0.01
Flatulence & wind <0.05
Abdominal pain <0.05
Greasy/ pale stool <0.05
Abdominal gurgling <0.05
Watson et al, Clinical Medicine 2014
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Other nutritional considerations
– Bone health
– Anaemia
– Body weight
– Micro nutrients eg. Fat soluble vitamins especially vitamin D, Trace elements
– Late symptoms that require immediate / urgent medical attention and possible nutritional support
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Summary
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Living with and beyond cancer
– Poor nutritional status, may be linked to symptoms
– Physical issues eg. Bone health, anaemia
– Psychological distress
– Impaired quality of life
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Acknowledgements
Lorraine Watson, Macmillan Dietitian in Pelvic Radiation Disease
Linda Wedlake, Research Dietitian
Eva Grace, Research Dietitian
Dr J Andreyev, Consultant Gastroenterologist in Pelvic Radiation Disease