managing side effects of cancer treatment shayne robinson rd cso cdn ny presbyterian cornell medical...
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Managing Side Effects of Cancer Treatment
Shayne Robinson RD CSO CDN
NY Presbyterian Cornell Medical Center Ambulatory Care Network
December 5, 2014
Objectives
• Ability to name side effects of common cancer treatments, including chemotherapy, radiation therapy and combined modality treatment
• Ability to name causes of side effects and implement nutrition intervention for managing side effects of disease and treatment
• Ability to identify resources for both patient and RD to manage side effects
Types of Treatment
• Surgery• Chemotherapy• Radiation Therapy • Combined Modality Treatments
Surgery
• Period of NPO/Clear/IV fluids • Inability to swallow• Constipation• Removal of parts of GI tract• Increased metabolic requirements
Chemotherapy• Route
– IV– Oral– Injection
• Side effects– Changes in taste, food aversions, sensitivity to odors– Mouth sores– Nausea, vomiting– Diarrhea, constipation – Decreased appetite, anorexia– Low blood counts, neutropenic diet
• Look up drugs/regimens– X% get grade X mucositis– Protocols include drugs given in combination
• Resources– Complete Resource Kit for Oncology Nutrition - Medication Guide ,
http://dpg-storage.s3.amazonaws.com/ondpg/documents/9ccdd1ca724c7eee/Medication_Guide_(1).pdf
– Lexicomp
Chemotherapy Support
• IV fluid• Anti nausea medication• H 2 Blockers• Steroids• Benadryl
Radiation Therapy
• Mechanism of Action• Side effects dependent on the dose and site
radiated• Side effects• Late Side effects
http://www.cancer.gov/cancertopics/coping/radiation-therapy-and-you/radiationttherapy.pdf, accessed August 11, 2014
Combined Modality Treatment
• Both chemotherapy and radiation therapy at the same time • Chemo acts as a radiation sensitizer• Side effects are frequently worse• Require diligent MNT follow up• Most challenging patients
– Head and neck– Lung– Esophagus– Pancreatic– Colorectal
Common Nutrition Related Side Effects Of Treatment
• Causes• Nutrition Intervention
Profession Guidelines
• ASCO-evidence based, address supportive care (and treatment)– ONS• PEP (Putting Evidence into Practice)
• NCCN-consensus based guidelines address supportive care (and treatment)
• MASCC– Evidence Based-supportive care only
Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0
• The NCI CTCAE is a descriptive terminology which can be utilized for reporting adverse events
• A grading scale is provided for each term– Severity – Grades 1-5
Reference: http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf
Chemotherapy-Induced Nausea and Vomiting (CINV)
• Classification – anticipatory – acute – delayed – breakthrough – refractory
• Chemotherapeutic regimens can be classified as having high, moderate, low, or minimal risk of emetogenicity.
• Incidence and timing of CINV vary according to patient factors and chemotherapeutic agents.
• Incidence has been reported in as high as 70%–80% of patients. • Incidence of nausea > vomiting• antiemetic medications tend to be less effective in controlling nausea
Nausea
• Definition: A disorder characterized by a queasy sensation and/or the urge to vomit.
Grade 1 Grade 2 Grade 3
Loss of appetite withoutalteration in eating habits
Oral intake decreased withoutsignificant weight loss,dehydration or malnutrition
Inadequate oral caloric or fluidintake; tube feeding, TPN, orhospitalization indicated
Vomiting
• Definition: A disorder characterized by the reflexive act of ejecting the contents of the stomach through the mouth.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
1 - 2 episodes (separated by 5minutes) in 24 hrs
3 - 5 episodes (separated by 5minutes) in 24 hrs
>=6 episodes (separated by 5minutes) in 24 hrs; tube feeding,TPN or hospitalization indicated
Life-threatening consequences;urgent intervention indicated
Death
Nausea/ Vomiting
• Causes• Frequency• Recommended for Practice
– Medications– https://
www.ons.org/practice-resources/pep/chemotherapy-induced-nausea-and-vomiting
• Likely to be effective– Hypnosis for Anticipatory CINV– Managing Patient Expectations– Progressive Muscle Relaxation and Guided Imagery– Medication
• Non medication-accupuncture, fresh air, exercise • Diet interventions
Oral Mucositis
• Definition- A disorder characterized by inflammation of the oral mucosal
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Asymptomatic or mildsymptoms; intervention notindicated
Moderate pain; not interferingwith oral intake; modified dietindicated
Severe pain; interfering with oralintake
Life-threatening consequencesurgent intervention indicated
Death
Oral Mucositis
• Causes• Mouth rinses/ mouth care– Baking soda/salt
• Diet• Nutrition support
Dodd, M.J., Dibble, S.L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S.M., et al. (2000). Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 90(1), 39–47.
Constipation
• Definition-A disorder characterized by irregular and infrequent or difficult evacuation of the bowels.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Occasional or intermittentsymptoms; occasional use ofstool softeners, laxatives,dietary modification, or enema
Persistent symptoms withregular use of laxatives orenemas; limiting instrumentalADL
Obstipation with manualevacuation indicated; limitingself care ADL
Life-threatening consequence; urgent intervention indicated
Death
Constipation
• Causes• Meds• Diet vs no diet– Prunes– Laxative Paste recipes (dried fruits and bran)– Senna Tea– Breathing Stretching– Relaxation in restroom–Water/ fluids/ hot fluids
Diarrhea
• A disorder characterized by frequent and watery bowel movements.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Increase of <4 stools per dayover baseline; mild increase inostomy output compared tobaseline
Increase of 4 - 6 stools per dayover baseline; moderateincrease in ostomy outputcompared to baseline
Increase of >=7 stools per dayover baseline; incontinence;hospitalization indicated; severeincrease in ostomy outputcompared to baseline; limitingself care ADL
Life-threatening consequence;urgent intervention indicated
Death
Radiation Induced Diarrhea
• Causes• Medication• Diet restrictions– Low fiber/ low lactose– Diet for RT to the pelvis – Fluid/ electrolyte replacements
Chemotherapy Induced Diarrhea
• Can be dose limiting• Treatment– Hydration (IV vs PO)– Electrolyte replacement– Clear liquid w progression to low insoluble fiber
with a source of soluble fiber and low lactose diet
Reference:Benson, A.B., Ajani, J.A., Catalano, R.B., Engelking, C., Kornblau, S.M., Martenson, J.A., . . . Wadler, S. (2004). Recommended guidelines for the treatment of cancer treatment-induced diarrhea. Journal of Clinical Oncology, 22, 2918–2926.
Esophagitis• Definition: A disorder characterized by
inflammation of the esophageal wall.• Causes• Medication• DietGrade 1 Grade 2 Grade 3 Grade 4 Grade 5
Asymptomatic; clinical ordiagnostic observations only;intervention not indicated
Symptomatic; alteredeating/swallowing; oralsupplements indicated
Severely alteredeating/swallowing; tube feeding,TPN or hospitalization indicated
Life-threatening consequence;urgent operative interventionindicated
Death
Neutropenia/ Avoiding Infection
• Neutropenia is defined by ONS, National Comprehensive Cancer Network and the Infectious Disease Society of America as an ANC of 500 or an ANC of 1000 which is expected to continue declining.
• Diet– Food safety– Avoiding Fresh Fruits and vegetables rated “effectiveness unlikely” by
ONS Putting Evidence into Practice database– LMD-transplant
DeMille, D., Deming, P., Lupinacci, P., & Jacobs, L. (2006). The effect of the neutropenic diet in the outpatient setting: A pilot study. Oncology Nursing Forum, 33, 337–343.
Gardner, A., Mattiuzzi, G., Faderl, S., Borthakur, G., Garcia-Manero, G., Pierce, S., & Estey E. (2008). Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. Journal of Clinical Oncology, 26, 5684–5688.
Moody, K., Finlay, J., Mancuso, C., & Charlson, M. (2006). Feasibility and safety of a pilot randomized trial of infection rate: Neutropenic diet versus standard food safety guidelines. Journal of Pediatric Hematology/Oncology, 28, 126–133.
Van Tiel, F.H., Harbers, M.M., Terporten, P.H.W., van Boxtel, R.T.C., Kessels, A.G., & Voss, G.B. (2007). Normal hospital and low-bacterial diet in patients with cytopenia after intensive chemotherapy for hematologic malignancy: A study of safety. Annals of Oncology, 18, 1080–1084.
Neutropenia/ Avoiding Infection• Non Transplant
– RDN should provide dietary counseling to neutropenic patients on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution.
– Research has not demonstrated the effectiveness of low-microbial diets.
• Transplant– In patients undergoing bone marrow transplant, the RDN should
provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution.
– There is conflicting research regarding the effectiveness of neutropenic diets in the bone marrow transplant population.
Reference:https://www.ons.org/practice-resources/pep/prevention-infection
Alterations of Taste and Smell
• Causes• Types
– No taste– Metallic– Bitter– Gasoline– Sweet or salty– Texture perception
• Treatment– miracle fruit/berry– Change flavor– Enhance Flavor– Rinse– Rule out zinc deficiency
Anorexia
• Determine cause/ Treat if possible– Dx/Tx– Anxiety/Depression – Eating environment
• Small Frequent Meals• Supplements– Commercial– Home made
• Nutrient Dense Foods• Physical Activity
Anorexia
• Medications– Megace– Marinol– Remeron– Periactin– Steroid– Medical Marijuana
Fatigue
• Exercise• Medication– ritalin – steroid
• Reverse malnutrition• Ensure adequate hydration• Caffeine• Complex vs simple CHO
Dry Mouth• Causes– Tx– Medications
• Diet– Moist– Tart– Hydration– Sauces
• Mouth rinses• Papaya
Heartburn/GERD
• A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Symptoms include heartburn and acid indigestion.
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Mild symptoms; intervention notindicated
Moderate symptoms; medicalintervention indicated
Severe symptoms; surgicalintervention indicated
Grade not available
Grade not available
Heartburn/GERD• Bland Diet
– Avoid mint– Chocolate– Alcohol– Caffeinated beverages and decaffinated coffee (regular tea, coffee, colas, energy drinks, other caffeinated
soft drinks)– Pepper– High-fat foods, including– Any fruits or vegetables that cause symptoms. (These will vary from person to person.)
• Medication• Lifestyles changes
– Exercise at least three or four times each week.– Wear loose-fitting clothes.– Do not smoke.– Raise the head of the bed 6 to 9 inches. – Wait 3 hours after eating before lying down.– Eat in a calm, relaxed place. Sit down while you eat.
• Apple Cider Vinegar
http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=165
Dysphagia
• A disorder characterized by difficulty in swallowing
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Symptomatic, able to eatregular diet
Symptomatic and alteredeating/swallowing
Severely alteredeating/swallowing; tube feedingor TPN or hospitalizationindicated
Life-threatening consequences;urgent intervention indicated
Death
Dysphagia
• Causes• Treatment– Speech Evaluation by SLP– Diet Modification– PEG/PEJ
• Diet– Oral– Enteral
National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association; 2002.
Access to Food
• GLWD• MOW• Oncology Social Work-AOSW
SIDE EFFECTS OF TREATMENT FORM THE PATIENT PERSPECTIVE
• About 1,200 surveys were collected and analyzed from seven medical centers from April to Dec. 2012: – Roswell Park Cancer Institute – New York University Clinical Cancer Center – Dana Farber/Brigham and Women’s Cancer Center – Sidney Kimmel Comprehensive Cancer Center at Johns
Hopkins – University of Chicago Comprehensive Cancer Center – Mayo Clinic Cancer Center – Cedars-Sinai / Samuel Oschin Comprehensive Cancer Institute
• Mixed types of cancers• Most undergoing chemotherapy (90%), some
undergoing RT (15%)http://www.cancernutritionconsortium.org/wp-content/uploads/2013/11/Overview-Deck-Cancer-Nutrition-Research-11-19-13-Summary.pdf
, accessed August 11th, 2014
Resources• Oncology Nutrition Dietetic Practice Group
– Website– Listserv– RD CSO-challenging to replace the expertise of an experienced CSO (seen it all before)
• Know when too complex for private practice
• NCM• www.cookforyourlife.com• www.meals-to-heal.com• www.glwd.org• NCI-www.cancer.gov
– Eating Hints
• Cancer.org (Asian materials)• Cancer.gov• SPONC• Oley
– Equipment exchange
• www.aicr.org• www.ons.org