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Nutritional requirements in long term conditions - Cancer Rachael Donnelly & Rachel Barrett Highly Specialist Oncology Dietitians

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Nutritional requirements in long term conditions - Cancer Rachael Donnelly & Rachel Barrett Highly Specialist Oncology Dietitians Guy’s & St Thomas’ NHS Foundation Trust PEN Group Summer Meeting August 1st 2006. Promote further understanding of cancer cachexia & cancer as along term condition

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Nutritional requirements in long term conditions - Cancer

Rachael Donnelly & Rachel Barrett

Highly Specialist Oncology Dietitians

Guy’s & St Thomas’ NHS Foundation Trust

PEN Group Summer Meeting August 1st 2006

Promote further understanding of cancer cachexia & cancer as along term condition

Review current evidence base for nutritional requirements & the provision of nutritional support for cancer patients

Acknowledge the practicalities of providing such requirements through an interactive case study

what is cancer
‘… the disordered & uncontrolled growth of cells within a specific organ / tissue type …. they often produce secondary growths / metastasis … this is the central & most threatening feature of malignant disorders….’

‘… cancer is a collection of diseases with the common feature of uncontrolled growth … there are several causes, but ‘lifestyle’ factors are a major influence … several cellular changes are required to generate cancer …. invasion & metastasis distinguish cancers from benign growths ….. cancers are not always lethal…’

(Brennan, 2004)

What is Cancer?
cancer uk facts figures
1 in 3 will get cancer at some stage of their lives

250,000 diagnosed with cancer per annum

(Equivalent to 684 diagnoses daily)

In the UK 154 460 people died from cancer in 2001


Cancer – UK Facts & Figures
considerations in managing a cancer patient
Site of cancer


Stage of cancer

Multi-modality treatment i.e. chemotherapy, radiotherapy, surgery & biological therapies

Side effects of treatment & disease


Age of patient

Social circumstances i.e. alcohol / drug & nicotine dependency

Cachexia syndrome

Considerations in managing a cancer patient
cancer cachexia what it is not
Due to starvation

Due to malnutrition

Due to competition by the tumour

Restricted to cancer

Reversed by nutritional support

(Regnard, 2004)

Cancer Cachexia - What it is not?
cancer cachexia definitions
Derives from the Greek ‘kakos’ meaning bad & ‘hexis’ meaning condition

(Shaw, 2000)

A physical fading of wholeness

Syndrome of decreased appetite, weight loss, metabolic alterations & inflammatory state

Cancer Cachexia - Definitions
cancer cachexia what it is
An extreme on the continuum of weight loss in cancer

Seen in cancer, cardiac disease & chronic infection but not neurological disease

Due to a systemic inflammatory response

Mediated through cytokines & other factors such as proteolysis inducing factor (PIF) & lipid mobilising factor (LMF)

(Regnard, 2004)

Cancer Cachexia - What it is?
cancer cachexia features
Some or all of the following features are exhibited in varying degrees:

Hypophagia / anorexia

Early satiety


Weight loss with depletion & alteration of body compartments


Asthenia (weakness)

(Freeman & Donnelly, 2004)

Cancer Cachexia - Features
cancer cachexia prevalence
Occurs in ~ 70% of patients during the terminal course of disease

Weight loss > 10% pre illness weight occurs in up to 45% of hospitalised cancer patients

Cancer of the Upper GI & lung have the highest prevalence of weight loss

Lung cancer patients with 30% weight loss show 75% depletion of skeletal muscle

Breast cancer, sarcomas & NHL show the least weight loss

(Payne-James et al., 2001)

Cancer Cachexia - Prevalence
cancer cachexia aetiology
Understanding is limited & based upon the knowledge of abnormalities in nutrition behaviour & metabolic patterns

Appears as a classic case of malnutrition

3 theories have been suggested:

Metabolic competition


Alterations of metabolic pathways

(Payne-James et al., 2001)

Cancer Cachexia - Aetiology
cancer cachexia metabolic competition
Neo-plastic cells compete with host tissues for protein, functioning as a ‘nitrogen trap’

In experiments where tumour is a high % of animal weight this theory holds, but in human tumours – even patients with a very small tumour can have severe cachexia

(Morrison, 1976)

Cancer Cachexia - Metabolic Competition
cancer cachexia malnutrition 1
Upper aerodigestive disease is an obvious cause of malnutrition

Regardless of tumour location, anorexia is the most common cause of hypophagia & usually consists of a loss of appetite &/or feelings of early satiety

Hypophagia has been related to the presence of dysgeusia

Diminished ability to perceive sweet flavours leads to anorexia

(Payne-James et al., 2001)

Cancer Cachexia – Malnutrition (1)
cancer cachexia malnutrition 2
Reduced threshold for bitter flavours linked to an aversion to meat

Dysosmia is also related to an aversion to food

Malnutrition leads to secondary changes in the GI tract which may be responsible for the feeling of fullness, delayed emptying, defective digestion & the poor absorption of nutrients

However, malnutrition alone is not thought to be the main cause of cachexia

(Payne-James et al., 2001)

Cancer Cachexia – Malnutrition (2)
metabolic alterations in starvation v cancer cachexia cho metabolism
Metabolic Alterations in Starvation V. Cancer Cachexia – CHO Metabolism

Adapted from Rivadeneira et al.,1998

metabolic alterations in starvation v cancer cachexia fat metabolism
Metabolic Alterations in Starvation V Cancer Cachexia – Fat Metabolism

Adapted from Rivadeneira et al.,1998

metabolic alterations in starvation v cancer cachexia protein metabolism
Metabolic Alterations in Starvation V Cancer Cachexia – Protein Metabolism

Adapted from Rivadeneira et al., 1998

cancer cachexia cytokines
Produced by host in response to tumour

Cytokines regulate many of the nutritional & metabolic disturbances in the cancer patient leading to:

Decreased appetite

Increase in BMR

Increased glucose uptake

Increased mobilisation of fat & protein stores

Increased muscle protein release

(Tisdale, 2004)

Cancer Cachexia - Cytokines
energy expenditure
Cancer itself does not have a consistent effect on resting energy expenditure (REE)

Oncological treatment may influence energy expenditure

(Arends et al., 2006)

Energy Expenditure
resting energy expenditure
In cancer patients, REE can be:




Many cancer patients are mildly hypermetabolic with an excess energy expenditure of between 138-289 kcals per day

(Hyltander et al., 1991)

If not compensated by ↑ energy intake results in loss of 1.1 - 2.3kg muscle mass & 0.5 – 1.0kg body fat / month

(Bozzetti F et al.,1980)

The challenge is identifying which patients

Resting Energy Expenditure
energy requirements 1
Assume energy requirements are normal unless data available to say otherwise

(Arends et al., 2006)

It is not appropriate to add calories for weight gain when calculating requirements for cancer patients

Energy Requirements (1)
energy requirements 2
For non obese cancer patients total energy expenditure is approx:

30-35kcal/kgBW/d in ambulant patients

20-25kcal/kgBW/d in bedridden patients

Assumptions are less accurate for underweight individuals (TEE per kg is higher in this group)

(Arends et al., 2006)

Published reference calculations are more accurate for underweight cancer patients

(Harris & Benedict 1919, Schofield 1985)

Energy Requirements (2)
protein requirements
Optimal nitrogen supply for cancer patients can not be determined at present

(Nitenberg et al., 2002)

Protein requirements are calculated as per published reference calculations (0.17-0.2g Nitrogen per kg)

(Elia, 1990)

Protein Requirements
vitamin and mineral requirements 1
Vitamins & Minerals – lack of evidence surrounding requirements in oncological disease

Base requirements on UK RNI’s

(PEN Group, 2004)

For EN recommendations are based on RDA’s

(ASPEN, 2002)

Vitamin and Mineral Requirements (1)
vitamin and mineral requirements 2
Markers of oxidative stress are increased & levels of anti-oxidants are decreased in cancer patients

(Mantovani et al., 2003)

Inclusion of increased doses of anti-oxidant vitamins could be considered but at present lack data to demonstrate clinical benefit

(Arends et al., 2006)

In reality, not routinely measuring vitamin & mineral status in such patients

Vitamin and Mineral Requirements (2)

‘An improvement in survival due to nutritional interventions has not yet been shown’ (Arends et al., 2006)


‘Unintentional weight loss of ≥ 10% within the previous 6/12 signifies substantial nutritional deficit & is a good prognostic indicator of outcome’ (DeWys et al., 1980)

cancer aims of nutritional support ns 1
Improve the subjective quality of life (QoL)

Enhance anti-tumour treatment effects

Reduce the adverse effects of anti-tumour therapies

Prevent & treat undernutrition

(Arends et al., 2006)

Cancer - Aims of Nutritional Support (NS) (1)
cancer aims of nutritional support 2
‘…the principle aim of nutritional intervention with cancer patients will be to maintain physical strength & optimise nutritional status within the confines of the disease…’

(van Bokhorst de van der Schueren et al., 1999)

‘…nutritional intervention should be tailored to meet the needs of the patient & realistic for the patient to achieve…’

(Mick et al., 1991)

Cancer - Aims of Nutritional Support (2)
aims of nutritional support 3
Optimum nutrition improves therapeutic modalities & the clinical course & outcome in cancer patients

(Rivadeneira et al., 1998)

Numerous studies strongly suggest substantial weight loss >10% leads to adverse consequences:

Reduced response to chemotherapy & radiotherapy

Increased morbidity

Poor quality of life (QoL)

Increased mortality rate

(Van Bokhorst de van der Scheren et al., 1997)

Aims of Nutritional Support (3)
when should nutritional support be started
If undernutrition is already present

If inadequate food intake is anticipated for more than 7 days

It should substitute the difference between actual intake & calculated requirements

Inadequate nutrition throughout treatment course leads to increased morbidity & mortality, & reduced tolerance to treatment

(Arends et al., 2006)

When should Nutritional Support be started?
can nutritional support improve nutritional status in cancer
Yes, in patients whose weight loss is due to insufficient nutritional intake secondary to obstruction e.g. upper GI, head & neck

In cachexic patients it is virtually impossible to achieve whole body protein anabolism

Goals of NS are therefore different

(Arends et al., 2006)

Can Nutritional Support improve Nutritional Status in Cancer?
does nutrition support feed the tumour
There is no reliable data to support the effect of nutrition on tumour growth

‘Feeding the tumour’ should have no influence on the decision to feed a cancer patient

(Arends et al., 2006)

Does Nutrition Support Feed the Tumour?
nutritional support pre peri operative
Patient’s with severe undernutrition benefit from NS 10-14 days prior to major surgery, even if surgery has to be delayed

(Meyenfeldt von., 1992)

All patients undergoing major abdominal surgery, NS (with immune-modulating substrates) is recommended for 5-7 days independent of nutritional status

(Braga et al. 1999)

Nutritional Support – Pre / Peri - Operative
nutritional support chemotherapy
Currently, there is no strong evidence for routine NS during CT as it has no effect on tumour response to CT, nor on CT related associated unwanted side effects

Symptom control is vital prior to any NS i.e. adequate anti-emetic control of nausea & vomiting

Timely NS is necessary in many patients undergoing chemotherapy

(Arends et al., 2006)

Nutritional Support – Chemotherapy
nutritional support rt chemo rt
Intensive dietary counselling or NS prevents therapy associated weight loss & interruption of RT when compared to normal food

Routine NS is not indicated in abdominal RT

Nor is there any suggestion that routine NS is beneficial during RT to any other part of part of the body other than the head & neck & oesophageal

(Arends et al., 2006)

Nutritional Support – RT / Chemo-RT
case study background
Male- Mr D

52 yrs

Diagnosis- T4N3M0 SCC Left Floor of Mouth (FOM)

PMH- CABG x 3 ’99 & Hypertension

Social History

Lives alone above a pub

Alcohol intake approx. 63 units/week

Smokes 50g tobacco/week

Security Guard

Case Study (Background)
initial nutritional assessment
Weight on referral- 55kg 17/05/05

Usual weight- 55-60kg

Ideal weight- 56-69kg

BMI- 19.7kg/m2

No recent weight loss

Grip strength 28.5kg

(<69% of normal)

Diet History

4 strong black coffee’s each with 2 sugars

1 meal daily, early evening, takeaway Cornish pasty & chips

Approx. 5 pints strong lager +/- 2-3 double vodkas per night

Initial Nutritional Assessment
oncological treatment
23/05/05 resection of FOM with DCIA flap


Left radical neck dissection

Right neck dissection

Dental clearance

Nil by mouth & tracheostomy in situ

13/06/05 debridement of DCIA flap

15/06/05 PEC major flap after failure of DCIA flap

04/08/05 post surgery 6/52 radiotherapy

Oncological Treatment
when calculating mr d s energy requirements post operatively what stress factor would you use

When calculating Mr D’s energy requirements post operatively what stress factor would you use?

what actually happened
Requirements calculated using 10% stress factor (SF) & 20% activity factor (AF) – approx. 2000kcal, 60-70g Protein

Fed 2000ml Nutrison Multi fibre (2000kcal, 80g Protein)

Weight increased 61.2kg- oedematous, 5 days later 55.3kg

What actually happened
what happened next
Withdrawing from alcohol – confused & AWOL from ward

Changed feed 1000ml Nutrision Energy Multi Fibre & boluses 2 x 200ml Fortisip

Not meeting requirements due to compliance issues

Flap failure & need for further surgery

Remains NBM & PEG placed 19/07/05

Weight 52.1kg (2.9kg (5%) weight loss in 2/12)

What happened next
what happened next1
Commenced radiotherapy 04/08/05

Weight 49.5kg

Remained an inpatient

Refusing pump feeding – bolusing only

What happened next
what actually happened1
Energy requirements were calculated with no SF & 25% AF – approx. 1800kcal, 50-60g Protein

Feed regimen 6 x 200ml Fortisip bolused daily – provides 1800kcal, 72g protein

Only taking 4 x 200ml Fortisip daily- provided 1200kcal, 48g protein

Weight 07/09/05 47.5kg

What actually happened

Mr D was discharged home post radiotherapy, his weight dropped to 47kg & his requirements re-calculated. What activity factor would you use?

what actually happened2
Energy requirements were calculated using a PAL factor (1.5 – moderately active in a light occupation) & not an activity factor as this patient was now in the community

Feed switched to 4 x 237ml cans of Two CalHN bolused in an attempt to meet requirements in a minimum volume

Oral diet resumed (alcohol only)

What actually happened
what actually happened 1
In this case, no, in light of compliance issues & problems meeting baseline requirements

Mr D has since had multiple admissions with acopia, continued weight loss, deterioration of swallow – now NBM, & undergone further surgery for wound dehiscence

Dietetic intervention has incorporated both social & medical aspects of care

What actually happened (1)
what actually happened 2
Taken 18 months to fully heal wounds, weight gain has just begun in conjunction psychological & psychiatric support & re-housing

Highlights the need for regular dietetic review & consideration of the wider issues

What actually happened (2)
If the patient remains cachectic adding additional kcal for weight gain is unlikely to be of any clinical benefit

Our opinion is if the tumour has been removed/ treated/ controlled & you meet nutritional requirements (BMR + adequate AF/ PAL factor) & weight continues to decline, consider additional kcal for weight gain

BUT, this is unlikely as few patients are entirely disease free/ controlled & ongoing weight loss is often a sign of disease progression/ recurrence

Cancer is increasingly becoming a chronic / “long term” condition

The evidence for the nutritional requirements of this patient group is limited & are reliant on estimation

Dietetic interventions need to be individualised as no two cancer patients journey are the same

Regular reassessment is vital in order to maximise the therapeutic potential of nutritional support