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
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21 Interventions Interventions -diet modifications meal replacement shakes high calorie foods additional snacks soft/bland foods cold foods -appetite stimulant -EPA -zinc supplementation -calcium supplementation -vitamin D supplementation -Iron supplementation -Enteral Nutrition -TPN 2011 Rising Tide 21
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
39 Conclusion Questions????? 2011 Rising Tide 39