1 Cancer Treatment Centers of America Treating the Whole Patient Presented by: Jill Schuman, RD, CNSC, CSP, LCN Date: Spring 2012
2 What is Cancer Two types of tumors Liquid tumor Leukemia Lymphoma Aplastic anemia Myeloma Solid tumor Organs
3 What is Cancer Oncology The study of tumors Carcinoma Cancers that originate in the epithelial tissue Melanoma Malignant tumors beneath the skin Sarcoma Malignancies of the connective tissues
4 Up to 40% of cancer patients die from malnutrition and not the cancer itself. Malnutrition correlates to poor outcomes A well nourished patients has Improved QOL Better tolerance to treatment Fewer treatment interruptions 2011 Rising Tide 4
5 4 Steps in the Nutrition Care Process 1. Nutrition Assessment (risk vs no risk) 2. Nutrition Diagnosis (identify nutrition barriers) 3. Nutrition Intervention (develop plan to manage barriers) 4. Monitoring and evaluation (assess and reassess success of intervention) 2011 Rising Tide 5
6 Nutrition Impact of cancer diagnosis Weight loss Weight gain Anorexia cachexia Nausea Vomiting Diarrhea Constipation Taste changes Dry mouth Painful eating Early satiety Difficulty swallowing
7 Metabolism and Cancer Some tumors are hypermetabolic, some are hypometabolic and some no not alter metabolism Cancer cachexia Adipose and muscle stores are depleted during starvation that often occurs with decreased intake during cancer treatment Cachexia is associated with a much more significant loss of lean muscle
8 Metabolism and Cancer Cancer-associated weight loss and cachexia in multifactorial Likely that the etiology is specific to tumor type Can be affected by additional factors such as hormones, cytokines and other catabolic factors
9 Types of Cancer Treatment Radiation Destroys cells that are rapidly reproducing Can also affect healthy cells within the radiation field Can have radiation treatment alone or in combo with chemo and surgery Goal can be cure or palliation Generally given over 4 6 weeks Side effects depend on site of radiation
10 Types of Cancer Treatment Radiation Site CNS Nausea and vomiting Head and Neck Mucositis, stomatitis, dysphagia, odynophagia, xerostomia, loss of taste, dysguesia, altered or decrease sense of smell, weight loss Chest/Thorax Dysphagia, odynophagia, esophagitis, dyspepsia, weight loss Abdomen/Pelvis Anorexia, nausea, vomiting, diarrhea, flatulence, bloating, enteritis, weight loss
11 Types of Cancer Treatment Chemotherapy Treating with chemicals or drugs Often called cytotoxic or anti-neoplastic Can be for a cure, to control rate of growth or for palliation of symptoms
12 Types of Cancer Treatment Surgery Nutrition is important in the pre-, peri- and postoperative course of cancer patients Optimum nutrition can decrease rates of mortality and morbidity (length of stay and wound healing for example)
13 Nutrition Goals The primary nutrition goals for recovery are the achieve and maintain a healthy body weight, strength and functional ability, optimize body composition and visceral protein stores, correct issues such as impaired organ function or anemia and manage chronic treatment side effect
14 How do we do this? Cancer Treatment Centers of America Here are CTCA Easter, we use the PEC Model to insure that our patients are provided with wellrounded care that looks at the needs of the WHOL patient in order to provide them with optimal care. PEC stands for Patient Empowered Care
15 PEC Model - Every patient comes to us for a 3 day evaluation Day 1 the patient comes to our clinic and stays in one room while s/he gets to meet all the PEC team members individually including RN, MD, RD, ND and nurse navigator From here, patients are scheduled for any further tests that the MD needs to comprise a treatment plan over the next 2 days Day 3 the team meets together to discuss each patient in the morning meeting and then each practitioner meets with the patient, again, to provide them with the information from their specialty 2011 Rising Tide 15
16 Wellness Wheel 2011 Rising Tide 16
17 The RD s role at CTCA Each RD works with one specific oncologist and PEC team That RD sees the patients on their first and third day of their evaluation That RD also follows the patients during their return visits as often as needed or, at a minimum of once a month
18 The RD s role at CTCA The RD will assess each patient s changing needs and side effects throughout their treatment course and provide nutrition counseling to help manage symptoms and also to supplement their treatment when appropriate Vitamin D Fish Oil Others.
19 The RD s role at CTCA Sometimes patients become sick enough that they need to be admitted to the hospital during treatment or for surgery related to their treatment The RD will see the patient within 72 hours of admission or within 48 hours of admission if there is a consult The RD will classify the patient as either wellnourished, moderately malnourished or severely malnourished All malnourished patients are seen every 3 days and all well-nourished patients are seen every 5 days
22 Assessing Risk Well nourished patients Are diet changes appropriate or desired? Patients could benefit from more focused oncology nutrition guidance versus symptom management Continue to follow up and monitor tolerance to treatment At risk patients Identify barriers to meeting calorie/pro needs Develop plan to manage barriers Schedule follow up appointment to determine success of intervention and need to modify plan Malnourished patients Identify barriers to meeting calorie/pro needs Evaluate trends Develop plan to manage barriers Assess appropriateness for alternative nutrition Schedule follow up appointment to determine success of intervention and need to modify plan 2011 Rising Tide 22
23 Sites of Secretion and Absorption in the GI **Digestion begins in the mouth with salivary amylase. Stomach Secretes pepsin HCL Absorbs - ETOH Duodenum approx 10 Secretes bicarbonate Enzymes Absorbs Cl, SO4 Fe, Ca, Mg, Zn Jejunum approx 7 ½ feet **intestinal brush Border enzymes Absorbs glucose, Galactose, fructose Water soluble vits (vit C, thiamin, Riboflavin, pyridoxine, folic acid) Colon Absorbs Na K Vitamin K formed by Bacterial action H2O Ileum approx 10 ½ feet Absorbs protein, Vitamins A, D, E, K Fat cholesterol bile salts vitamin B12
24 Overview Enteral nutrition can be obtained through either a gastrostomy tube (G-tube) or a jejunostomy tube (J-tube).
25 Gastrostomy Overview Enteral Access A gastrostomy can be placed radiologically, surgically, or percutaneously placed via endoscope (PEG), laparoscope, or fluoroscope. Indication Long-term enteral feeding (>6 weeks) Indicated in patients with normal gastric function including normal gag reflex and no esophageal reflux. Used when transnasal/transoral route is unavailable, ie swallowing dysfunction.
26 Jejunostomy Overview Enteral Access Can be placed surgically or percutaneously. Indication Long-term feeding Enteral access in upper GI unobtainable or contraindicated Impaired gastric motility GERD/aspiration potential Gastric dysfunction due to trauma or surgery
27 Criteria for TPN Non functioning GI tract Small bowel resection (jejunum < cm) periodic evaluation necessary to monitor bowel adaptation Refractory Inflammatory bowel disease. i.e. Crohns patients with high output fistulas, bowel obstruction or failed enteral attempts. Enterocutaneous Fistula High output fistulas that cannot be managed with enteral feeds show improvement with TPN. Reduced surgery rates. Chronic intestinal obstructions may need permanent TPN therapy.
28 Criteria for TPN Adjunctive Therapy Severe GI toxicities associated with Chemo and XRT. i.e.; esophagitis, stomatitis, n/v, diarrhea, BMT, GI bleed Diarrhea TPN presents the only alternative for diarrhea refractory to medications and aggravated by enteral feeds. i.e.; radiation enteritis Concurrent malabsorptive syndrome Concurrent severe catabolism patients with extensive burns, trauma, complicated sepsis.
29 Criteria for TPN Organ failure/other indications Pancreatitis use of TPN suppresses pancreatic secretions. Recommended if bowel rest is > 1 wk. Hepatic failure ETOH induced cirrhosis (other causes not studied); branched chain AA resulted in a more rapid recovery from encephalopathy. Perioperative Patients surgical patients where the GI tract cannot be accessed.
30 Guidelines for Diet and Cancer Prevention Choose most foods from plant sources fiber Limit your intake of high-fat foods, particularly from animal sources Nitrates, preservatives and sodium Be physically active Aim for a healthy weight Limit consumption of alcoholic beverages
31 Nutrition Needs of the Patient with Cancer As discussed previously, metabolism can be greatly altered during the course of cancer treatment Energy estimates 20 kcal/kg for initial refeeding of the malnourished patient kcal/kg for maintenance of obese patient kcal/kg for maintenance of patient at usual or ideal body weight kcal/kg for patient with recent weight loss or patient undergoing extensive treatment or with severe infection Protein estimates g/kg for patient who is well-nourished at start of treatment g/kg for patient who is post-operative or with infection 1.5 g/kg used for wound healing or depleted visceral protein stores Must remember to make adjustment for liver or kidney function 2011 Rising Tide 31
32 Lung Cancer Weight loss is common Nausea and vomiting Anorexia and cachexia Early satiety Dysphagia Shortness of breath and coughing
33 Colorectal Cancer Most associated with GI side effects Abdominal pain Change in bowel function Weight loss Nausea and vomiting Bowel obstruction Altered nutrient absorption
34 Breast Cancer Symptoms for this may be more associated with stage of the disease, metastasis or menopausal state of the patient Often see weight gain with treatment
35 Prostate Cancer Nutrition issues are often secondary to treatment Diarrhea due to radiation Constipation due to narcotics
36 Head, neck and esophageal cancer Often patients present with dysphagia, odynophagia, weight loss Often patients have surgery that leads to resection or some part of digestive tract requiring feeding tube or parenteral nutrition Other complications of therapy include mucositis, early satiety, taste changes and xerostomia
37 Pancreatic cancer Often diagnosed in later stages due to vague symptoms Weight loss, abdominal pain, nausea, vomiting and anorexia Surgical resection can cause dumping syndrome and certain vitamin deficiencies.
38 Summary The RD s role can cover a variety of topics and concerns when working with patients with cancer It is important to treat the whole person using a multidisciplinary team approach Medical Nutrition Therapy can have a huge impact on a patient s tolerance to and outcomes from cancer treatment 2011 Rising Tide 38
Lifestyle Changes That Make a Difference Nutrition and Physical Activity Guidelines for Cancer Survivors What s Inside Nutrition and Physical Activity During Cancer Treatment and Recovery 1 Disease-free
National Cancer Institute Facing Forward Life After Cancer Treatment U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health A Note About Cancer Survivors There are almost 14 million
High Impact Actions for Stoma Care Background: to the High Impact Actions for Stoma Care There are approximately 102,000 people with a stoma in the United Kingdom and about 21,000 new stomas are formed
Colorectal Cancer Overview The information that follows is based on the more detailed information in our document, Colorectal Cancer. What is cancer? The body is made up of trillions of living cells. Normal
THe Rich PiCtuRE Other cancers 1,100,000 Around 340,000 getting cancer for the first time Lung 72,000 Colorectal 290,000 Breast 691,000 Prostate 330,000 2.5m Living with cancer 66% aged 65+ Around 163,000
National Cancer Institute What You Need To Know About Thyroid Cancer U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Cancer Institute Services This is only one of many
A GUIDE TO YOUR HEALTH CARE AFTER HEART TRANSPLANTATION I T N S www.itns.org Supported by an educational grant from XDx, the makers of 2011 ITNS Heart Transplant Handbook A Guide for Your Health Care after
Cancer Facts & Figures 2015 CA 172,090 OR 22,410 WA 38,180 NV 13,640 AK 3,700 ID 8,080 UT 11,050 MT 5,950 WY 2,860 CO 24,540 MN 29,730 IA 17,140 AZ OK 32,440 NM 19,280 AR 9,970 15,830 HI 6,730 ND 3,840
American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention This document is a condensed version of the article describing the American Cancer Society (ACS) Nutrition and
Hemodialysis: What You Need to Know Healthy kidneys clean your blood and remove extra fluid in the form of urine. They also make hormones your body needs for some important functions. When kidney failure
Gastrointestinal problems in children with Down's syndrome by Dr Liz Marder This article was written for parents for the Down s Syndrome Association newsletter and is reproduced here with the permission
Need to know Nutrition for children with Prader Willi Syndrome A Guide for Parents and Carers By Professor Peter SW Davies, The Children s Nutrition Research Centre, The University of Queensland and Helen
National Cancer Institute What You Need To Know About Leukemia U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health How Can We Help? You may want information about cancer for yourself,
North of England Cancer Network Palliative and end of life care guidelines for cancer and non-cancer patients Third edition: 2012 NORTH OF NORTH ENGLAND OF ENGLAND CANCER NETWORK CANCER NETWORK PALLIATIVE
Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families Nutrition is an important part of cancer treatment. Eating the right kinds of foods before, during, and after treatment
Palliative and End-of-Life Care for Patients with Brain Tumors AUTHORS: Michael Cohn, MD Brook Calton, MD Susan Chang, MD Margaretta Page RN, MS Neuro-Oncology Gordon Murray Caregiver Program University
After Diagnosis: A Guide for Patients and Families Finding out you have cancer brings many changes for you and your loved ones. You probably have lots of questions: Can it be cured? What are the best treatment
THE TREATMENT OF DIARRHOEA A manual for physicians and other senior health workers World Health Organization Department of Child and Adolescent Health and Development THE TREATMENT OF DIARRHOEA A manual
EAT FOR HEALTH Infant Feeding Guidelines Information for health workers EAT FOR HEALTH Infant Feeding Guidelines Information for health workers 2012 Commonwealth of Australia 2012 Paper-based publication
Surgical outpatients Hospital admission Theatre and recovery Discharge Primary care referral Pre-operative assessment Post-operative care Management of adults with diabetes undergoing surgery and elective
Special Section: Cancer in Children & Adolescents Overview The news of a cancer diagnosis is never welcome, but may be even more unexpected and difficult when the disease is diagnosed in a child or adolescent.
A Behind the Headlines report June 2011 Supplements Who needs them? Foreword Millions of us take vitamins and dietary supplements hoping to achieve good health, ease our illnesses or defy ageing. Recent
T H E C A N A D I A N T Y P E 2 DIABETES S O U R C E B O O K 3 RD EDITION M. Sara Rosenthal, Ph.D. John Wiley & Sons Canada, Ltd. First published in Canada in 2002, 2004 by M. Sara Rosenthal, Ph.D. Copyright
National Cancer Institute Support for People With Cancer Chemotherapy and You U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health Important Phone Numbers Emergency Clinic Nurse Doctor
Your Stroke Journey A guide for people living with stroke Acknowledgements Sincere thanks to the many people who helped create this resource: To those living with stroke your willingness and openness to
INVISIBLE MINERALS PART II MULTIPLE MINERALS CAROLYN DEAN MD ND Disclaimer: The contents of this book are included for educational purposes only to provide helpful information on the subjects discussed.