role of nutrition in radiotherapy
TRANSCRIPT
ROLE OF NUTRITION IN RADIOTHERAPY
ByDr. Ayush Garg, PG JR II
Moderator: Dr. Pavan Kumar
Malnutrition In Cancer Patients
• Reduction of food intake is a common manifestation of cancer, presenting in 15-40% of patients and up to 80% of those with advanced malignancy
• More than 80% of all patients suffers from: Anorexia, Nausea, and Emesis
• 85% of patients with pancreatic or stomach cancer had lost weight at the time of diagnosis, and in 30% the loss was severe.
• Autopsies have shown that malnutrition is one of the most common causes of death, accounting for 10–20%
Incidence Of Malnutrition In Different Tumor SitesTumor Site % Malnutrition
General Cancer Patients 60%
Oesophagus 79%
Breast 9%
Gastric 83%
Lung (small cell) 50%
Head and Neck 72%
(Adapted from Freeman 2004)
Frequency/severity of weight loss associated with cancer
Nutrition Problems During Radiotherapy
Dept. Digestive Diseases and Clinical Nutrition
Anor
exia
Naus
ea
Tast
e lo
ss
Food
ave
rsio
n
Muc
ositi
s
Wt-l
oss
Redu
ced
food
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
7460
82 8265
88 93
2640
18 1835
12 7
Present Absent
Nutrition Problems During Chemotherapy
Dept. Digestive Diseases and Clinical Nutrition
Anor
exia
Naus
ea
Tast
e lo
ss
Food
ave
rsio
n
Muc
ositi
s
Wt-l
oss
Redu
ced
food
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
70 7482
74
55
72 70
30 2618
26
45
28 30
Present Absent
Prevention of Malnutrition through Nutrition
Malnutrition with progressive tumor growth
Malnutrition as a risk factor for anticancer therapy
Surgery, Radiotherapy, Chemotherapy
Malnutrition as consequence/ complication of therapies
Mucositis, infections
Malnutrition in advanced incurable cancer
Terminal care
Nutritional Issues Throughout The Course Of Cancer Illness
Causes Of Anorexia In Cancer Patients
• Pain, • Nausea, vomiting• Abnormal taste, • Abnormal smell,
• Loss appetite, • Depression, • Weakness, • GI disturbance/ Obstruction
Cancer Cachexia
• Debilitating and life-threatening condition, characterized by negative protein and energy balance
• Present in 50% of cancer patients, more prevalent in GI and Lung Cancer
• Characterized by:• Progressive weight loss• Anorexia• Asthenia• Metabolic alterations• Depletion in lipid stores• Severe loss of skeletal muscle protein
Cancer Cachexia Starvation
Body weight
Lean body mass
Body fat
Total energy expenditure
Resting energy expenditure
Protein degradation
Cancer CachexiaVs
Simple Starvation
Cancer Cachexia Causes And Effects
Acute PhaseResponse ( CRP)
Appetitedepression
Cachexia with weight loss, inflammation, fat depletion, muscle wasting, Poor clinical outcomes
Body’s Immune response to tumor
Cytokine production elicits localand systemic inflammatory response Proteolysis- inducing
Factor (PIF)
Food Intake Loss of Lean Body Mass
Alteration in Macronutrient
Metabolism
RestingMetabolic
Rate
Release of tumor factors
Consequences of Malnutrition• Impaired immunological function
• lymphocyte count and function ↓,
• macrophage / B- ,T-, and NK cell function ↓,
• chemotaxis / migration of neutrophils ↓
• Increased complications
• Chemotherapy/Radiotherapyinduced toxicity ↑
REF: Concise Manual of Hematology and Oncology; D.P.Berger, M.Engelhardt, H.Henb, R.Mertelsmann; Springer-Verlag Berlin Heidelberg 2008
Duration Of
Hospital Stay ↑
Costs ↑
Quality Of Life
↓
Mortality ↑
Chemotherapy
• Chemotherapy can result in the following nutritional problems:
nausea, anorexia, vomiting, diarrhoea, constipation, taste changes, mucositis, internal ulceration, malabsorption
• Multiple combinations of cytotoxic drugs can increase side effects
• Normal and malignant cells can be damaged• Intake often decreases with each cycle of
chemotherapy and food aversions occur in up to 74% of patients
Radiotherapy
• Nutritional problems may arise depending on:– Area exposed– Duration and total radiation dose• Radiotherapy can result in:– burning sensation to the throat, loss of appetite, taste
alterations, sore mouth, dry mouth, damage or loss of teeth, abdominal cramping, nausea, fatigue, malabsorption or diarrhoea
• More than 10% of patients lose over 10% of their usual weight when radiotherapy continues for a period of 6-8 weeks
Emotional and social effects
• Loss of employment - loss of role in life, loss of income• Anxiety - about diagnosis, about treatment, possible
recurrence• Body Image - weight loss, loss of hair• Fear - about the future, about dying, about their family• Depression• All of these can have an impact on nutrition even before
treatment begins.
• Grading of Malnutrition:
Body weight loss < 10% wt. loss :- Mild Malnutrition 10 – 20% wt. loss :- Moderate Malnutrition > 30% wt. loss :- Severe Malnutrition
Subjective global assessment, group C
• Using dietary history or nutrition protocols.• Starvation = daily oral energy intake < 500 kcal• Insufficient energy intake = daily oral energy intake <
60% of required intake
Diagnosis of Malnutrition in Cancer Patients
Objectives of Nutrition Therapyo Maintenance / improvement of nutritional statuso Maintenance / improvement of subjective quality of lifeo Increase in treatment efficacyo Reduction of treatment related side effects and complicationso Preserve lean body masso Maintain strength and energyo Protect immune function, decreasing the risk of infectiono Aid in recovery and healingo Improvement of prognosis, prevention of treatment breaks or
delays
Strategies in Nutrition Therapy
oAppetite StimulantsoDrugs which are capable of inhibiting the synthesis and/or release
of cytokines E.g. COX inhibitors, Non-steroidal anti-inflammatory drugs,
pentoxifylline, thalidomide, melatonin, statins, ACE inhibitorsoAgents which promote skeletal muscle anabolism e.g. Anabolic androgenic steroid
Metabolic intervention: To optimize patient’s nutritional status but minimize tumor nourishment
Substrate intervention: To modulate effects of mediators & control inflammatory response
Metabolic Intervention
• High caloric density feeding• Improve lean body mass
• Low carbohydrate content • “Starve the tumor, feed the patient”
• Suggested composition:• High energy >1.2 – 1.5 kcal /ml • High fat 45 - 50 % and low CHO • High protein 18 - 20 %
(50% - Fat, 20% - Protein, 30% - CHO)
Specific Metabolic Changes In The Tumor Host
• Tumor hosts reveal abnormalities of: • Lipid metabolism
• Increased lipolysis• Increased oxidation of fatty acids
• Carbohydrate metabolism• Increased glucose turnover • Impaired peripheral glucose disposal • Caused by insulin resistance
• Protein degradation , nitrogen depletion, muscle protein synthesis
Calculation of required Nutrition (per Kg of normal weight / ideal weight and day)
Indications for Parenteral Nutrition in Oncology
• Individual need depending on:• Nutritional status• Co-morbidities (concomitant diseases)• Type of anti-neoplastic treatment• Patient’s performance status
• Parenteral nutrition is indicated when:• Oral / enteral nutrition < 500 Kcal/d expected for at least
5 days• Oral / enteral nutrition < 60% of the calculated
nutritional needs expected for at least 10 days
ASPEN Guidelines: OncologyParenteral & Enteral nutrition 2009
• Omega 3 FA supplementation may help in• Decrease rate of weight loss• Maintain lean body mass• Improve appetite• Improve quality of life• Inhibit progress of cachexia in cancer• Inhibit Proteolysis-inducing factor• Decrease fatigue• Cytotoxic to variety of tumor cells• May reduce adverse effects of chemotherapy
Glutamine: Beneficial Effects In Cancer
• Supports immune, muscle, gut function• Enhances activity of NK lymphocytes• Improves tolerence to adjuvant treatment• Inhibits tumor growth, enhances response• Corrects host depletion, improves nitrogen retention, &
reverses impairement of intestinal integrity associated with cancer.
• Reduces 6-months mortality• Shortens hospital stay
Can Nutrition Treatment Maintain Or Improve Nutritional Status In Cancer Patients?
Nutrition therapy in oncology is required to improve prognosis and reduce the cancer-related decline in nutritional status.
In surgical oncology, it reduces the postoperative symptoms, lessens the hospital stay and improved tolerance to treatments.
In palliative care, the nutritional therapy focuses on symptoms associated with weight loss, thus improving the quality of life.
Summary• Early focused assessment - “proactive”• Clear and realistic definition of goals• Manipulation of nutrient intake• The overall nutritional goal is to optimally feed the host
and to minimise any nourishment of tumour tissue
Integrate Nutrition into the overall treatment plan
Nutritional recommendations for cancer patients
include a high fat and low carbohydrate feed
Thanks