Purpose of This PDQ Summary
Overview
Tumor-Induced Effects on Nutritional Status
Nutrition Implications of Cancer Therapies

Surgery         Head and neck cancers         Gastrointestinal cancers         Additional complications and side effects from surgical oncology Chemotherapy Radiation Therapy Immunotherapy Hemopoietic and Peripheral Blood Stem Cell Transplantation

Nutrition Therapy

Nutrition Screening and Assessment Goals of Nutrition Therapy Methods of Nutrition Care         Oral nourishment         Enteral nutrition         Parenteral nutrition Nutritional Suggestions for Symptom Management         Anorexia         Taste alterations         Xerostomia         Mucositis/stomatitis         Nausea         Diarrhea         Neutropenia         Hot flashes         Hydration and dehydration         Constipation

Other Nutrition Issues

Living With Advanced Cancer Drug-Nutrient Interactions Guidelines for Healthy Eating         The Food Guide Pyramid         Cancer prevention guidelines Survivorship and Prevention of Second Cancers         Lung cancer         Prostate cancer         Breast cancer         Colon cancer         Esophageal and gastric cancer

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Purpose of This PDQ Summary

This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals about nutrition before, during, and after cancer treatment. This summary is reviewed regularly and updated as necessary by the PDQ Supportive Care Editorial Board ¹.

Information about the following is included in this summary:

• Cachexia.
• Effects of cancer therapies.
• Symptom management.

This summary is intended as a resource to inform and assist clinicians and other health professionals who care for cancer patients during and after cancer treatment. It does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.

This summary is also available in a patient version ², which is written in less technical language, and in Spanish ³.

Overview

Nutrition plays major (but not always fully understood) roles in many aspects of cancer development and treatment.[1] Malnutrition is a common problem in cancer patients that has been recognized as an important component of adverse outcomes, including increased morbidity and mortality and decreased quality of life. Weight loss has been identified as an indicator of poor prognosis in cancer patients.[2] It has been shown that at the time of diagnosis, 80% of patients with upper gastrointestinal cancer and 60% of patients with lung cancer have already experienced a significant weight loss,[3] generally defined as at least a 10% loss of body weight in 6 months' time.[4] Good nutrition practices can help cancer patients maintain weight and the body's nutrition stores, offering relief from nutrition impact symptoms and improving quality of life.[5] Poor nutrition practices, which can lead to undernutrition, can contribute to the incidence and severity of treatment side effects and increase the risk of infection, thereby reducing chances for survival.[6] Nutrition impact symptoms are those symptoms that impede oral intake. They include, but are not limited to, anorexia, nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, dysphagia, alterations in taste and smell, and pain.[7] Early recognition and detection of risk for malnutrition through nutrition screening followed by comprehensive assessments is increasingly recognized as imperative in the development of standards of quality of care in oncology practices.[2] Undesirable weight gain may be an effect of chemotherapy treatment for early-stage cancers, possibly resulting from decreases in resting metabolism.[8] Consequently, the eating practices of individuals diagnosed with cancer should be assessed throughout the continuum of care to reflect the changing goals of nutritional therapy.

Nutritional status is often jeopardized by the natural progression of neoplastic disease. (Refer to the Tumor-Induced Effects on Nutritional Status ⁴ section.) Alterations in nutritional status begin at diagnosis, when psychosocial issues may also adversely affect dietary intake, and proceed through treatment and recovery. Protein-calorie malnutrition (PCM) is the most common secondary diagnosis in individuals diagnosed with cancer, stemming from the inadequate intake of carbohydrate, protein, and fat to meet metabolic requirements and/or the reduced absorption of macronutrients. PCM in cancer results from multiple factors most often associated with anorexia, cachexia, and the early satiety sensation frequently experienced by individuals with cancer. These factors range from altered tastes to a physical inability to ingest or digest food, leading to reduced nutrient intake. Cancer-induced abnormalities in the metabolism of the major nutrients also increase the incidence of PCM. Such abnormalities may include glucose intolerance and insulin resistance, increased lipolysis, and increased whole-body protein turnover. If left untreated, PCM can lead to progressive wasting, weakness, and debilitation as protein synthesis is reduced and lean body mass is lost, possibly leading to death.[9]

Anorexia, the loss of appetite or desire to eat, is typically present in 15% to 25% of all cancer patients at diagnosis and may also occur as a side effect of treatments. Anorexia is an almost universal side effect in individuals with widely metastatic disease [10,11] because of physiologic alterations in metabolism during carcinogenesis. (Refer to the Tumor-induced Effects on Nutritional Status ⁴ section.) Anorexia can be exacerbated by chemotherapy and radiation therapy side effects such as taste and smell changes, nausea, and vomiting. Surgical procedures, including esophagectomy and gastrectomy, may produce early satiety, a premature feeling of fullness.[4] Depression, loss of personal interests or hope, and anxious thoughts may be enough to bring about anorexia and result in PCM.[3] Other systemic or local effects of cancer or its treatment that may affect nutritional status include hypermetabolism, sepsis, malabsorption, and obstructions.[9]

Anorexia can hasten the course of cachexia,[3] a progressive wasting syndrome evidenced by weakness and a marked and progressive loss of body weight, fat, and muscle. Cachexia is estimated to be the immediate cause of death in 20% to 40% of cancer patients; it can develop in individuals who appear to be eating adequate calories and protein but are malabsorbing nutrients because of the disease. Particularly at risk are patients with diseases of the gastrointestinal tract.

The etiology of cancer cachexia is not entirely understood. Cachexia can manifest in individuals with metastatic cancer as well as in individuals with localized disease. Cachexia does not appear to be the result of tumor size, type, or extent. Several theories suggest that cachexia is caused by a complex mix of variables, including tumor-produced factors and metabolic abnormalities.[11] The basal metabolic rate in cachectic individuals is not adaptive, that is, it may be increased, decreased, or normal.[12] Some individuals do respond to nutrition therapy, but most will not see a complete reversal of the syndrome, even with aggressive therapy.[6] Thus, the most prudent and advantageous approach to cachexia is the prevention of its initiation through nutrition monitoring and nutrition intervention.[13]

Reference citations in some PDQ Supportive Care information summaries may include links to external Web sites that are operated by individuals or organizations for the purpose of marketing or advocating the use of specific treatments or products. These reference citations are included for informational purposes only. Their inclusion should not be viewed as an endorsement of the content of the Web sites or of any treatment or product by the PDQ Supportive Care Editorial Board or the National Cancer Institute (NCI).

References

1. Reeves GK, Pirie K, Beral V, et al.: Cancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. BMJ 335 (7630): 1134, 2007.  [PUBMED Abstract]
   
   
2. McMahon K, Decker G, Ottery FD: Integrating proactive nutritional assessment in clinical practices to prevent complications and cost. Semin Oncol 25 (2 Suppl 6): 20-7, 1998.  [PUBMED Abstract]
   
   
3. Bruera E: ABC of palliative care. Anorexia, cachexia, and nutrition. BMJ 315 (7117): 1219-22, 1997.  [PUBMED Abstract]
   
   
4. Rivadeneira DE, Evoy D, Fahey TJ 3rd, et al.: Nutritional support of the cancer patient. CA Cancer J Clin 48 (2): 69-80, 1998 Mar-Apr.  [PUBMED Abstract]
   
   
5. American Cancer Society.: Nutrition for the Person with Cancer: A Guide for Patients and Families. Atlanta, Ga: American Cancer Society, Inc., 2000. 
   
   
6. Vigano A, Watanabe S, Bruera E: Anorexia and cachexia in advanced cancer patients. Cancer Surv 21: 99-115, 1994.  [PUBMED Abstract]
   
   
7. Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues 17 (2): 15-7, 2002. 
   
   
8. Harvie MN, Campbell IT, Baildam A, et al.: Energy balance in early breast cancer patients receiving adjuvant chemotherapy. Breast Cancer Res Treat 83 (3): 201-10, 2004.  [PUBMED Abstract]
   
   
9. Shils ME: Nutrition and diet in cancer management. In: Shils ME, Olson JA, Shike M, et al., eds.: Modern Nutrition in Health and Disease. 9th ed. Baltimore, Md: Williams & Wilkins, 1999, pp 1317-47. 
   
   
10. Langstein HN, Norton JA: Mechanisms of cancer cachexia. Hematol Oncol Clin North Am 5 (1): 103-23, 1991.  [PUBMED Abstract]
    
    
11. Tisdale MJ: Cancer cachexia. Anticancer Drugs 4 (2): 115-25, 1993.  [PUBMED Abstract]
    
    
12. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.  [PUBMED Abstract]
    
    
13. Zeman FJ: Nutrition and cancer. In: Zeman FJ: Clinical Nutrition and Dietetics. 2nd ed. New York, NY: Macmillan Pub . Co, 1991, pp 571-98. 
    
    

Tumor-Induced Effects on Nutritional Status

Nutritional status can be compromised in direct response to tumor-induced alterations in metabolism. Also known as cachexia, this condition is one of advanced protein-calorie malnutrition and is characterized by involuntary weight loss, muscle wasting, and decreased quality of life.[1,2] Tumor-induced weight loss occurs frequently in patients with solid tumors of the lung, pancreas, and upper gastrointestinal tract and less often in patients with breast cancer or lower gastrointestinal cancer. Although anorexia may also be present, the energy deficit alone does not explain the pathogenesis of cachexia. Several factors have been proposed.[3] Mediators including cytokines, neuropeptides, neurotransmitters, and tumor-derived factors are postulated to contribute to this syndrome.[4] Products of host tissues, such as tumor necrosis factor-α, interleukin-1, interleukin-6, interferon-γ, and leukemia inhibitor factor, as well as tumor products that have a direct catabolic effect on host tissues, such as lipid-mobilizing factor and proteolysis-inducing factor, have all been identified as mediators of this complex syndrome.[3] Altered metabolism of fats, proteins, and carbohydrates is evident in cancer patients with cachexia. Tumors may induce impaired glucose uptake and glucose oxidation, leading to an increased glucose–fatty acid cycle.[5] Weight loss can occur from a decrease in energy intake, an increase in energy expenditure, or a combination of the two. Although anorexia is a common symptom of cancer patients, studies have shown that increased caloric intake either by the oral route or by supplementation with total parenteral nutrition has failed to counteract the wasting process. This supports the theory that the increased metabolic rate is the direct response by the tumor and the immune system to disrupt the pathways that regulate the homeostatic loop of body-weight regulation.[4]

Current studies suggest that the basal metabolic rate serves as a possible prognostic indicator of survival. As cancer progresses, the basal metabolic rate declines and cachexia occurs, reducing long-term survival.[6] Although alterations in overall basal metabolic rates have not been observed by some,[7] increased basal metabolic rates have been reported in pediatric,[8] breast,[9] lung,[8] malnourished,[10] and other [11] cancer patient populations; however, the discrepancy may be related to the stage of cancer progression.[12] Nutritional support therapies aimed at preserving lean muscle mass and subcutaneous adipose stores despite this altered metabolic rate may ultimately improve patients' quality of life and impact overall survival.

Although an individual’s nutritional status may be compromised initially by the diagnosis of cancer, thorough nutritional screening procedures and the timely implementation of nutritional therapies may markedly improve the patient’s outcome. Symptoms and side effects may sometimes be managed by a combination of dietary and pharmacologic interventions.

Several approaches to the treatment of cancer cachexia have been reported, and a variety of agents have been studied for their effects on appetite and weight. The decision to use pharmacological treatment to improve a patient’s appetite should be based on the patient’s desires, current medical condition, and life expectancy. The table below lists several medications that have been proposed to treat the symptoms of cancer cachexia.[13]

Weight loss associated with cancer and its treatment may be secondary to a host of symptoms and side effects. Early intervention using appropriate nutrition and pharmacologic symptom-management strategies can keep weight loss at bay. The drug categories typically used to manage these symptoms and side effects include the following:[24]

• Prokinetic agents (e.g., metoclopramide hydrochloride).



• Antiemetic agents (e.g., phenothiazines, butyrophenones, substituted benzamides, serotonin antagonists, benzodiazepines, corticosteroids, anticholinergics, and cannabinoids).



• Antidiarrheal agents (e.g., bulk-forming agents, antimotility agents, and codeine derivatives).



• Pancreatic enzymes.



• Laxatives (e.g., stool softeners, stimulants, bulk-forming agents, hyperosmotic laxatives, and saline laxatives).



• Agents for oral care (e.g., saliva stimulants, cleansing agents, antifungal agents, topical anesthetics, mouthwashes, and healing/coating agents).



• Pain medications (e.g., nonopioid analgesics, nonsteroidal anti-inflammatory drugs, and opioids).

(Refer to the Nutrition Screening and Assessment ⁶ section and the Nutritional Suggestions for Symptom Management ⁷ section.)

References

1. Tisdale MJ: Biology of cachexia. J Natl Cancer Inst 89 (23): 1763-73, 1997.  [PUBMED Abstract]
   
   
2. Strasser F, Bruera ED: Update on anorexia and cachexia. Hematol Oncol Clin North Am 16 (3): 589-617, 2002.  [PUBMED Abstract]
   
   
3. Tisdale MJ: Pathogenesis of cancer cachexia. J Support Oncol 1 (3): 159-68, 2003 Sep-Oct.  [PUBMED Abstract]
   
   
4. Ramos EJ, Suzuki S, Marks D, et al.: Cancer anorexia-cachexia syndrome: cytokines and neuropeptides. Curr Opin Clin Nutr Metab Care 7 (4): 427-34, 2004.  [PUBMED Abstract]
   
   
5. Gambardella A, Tortoriello R, Tagliamonte MR, et al.: Metabolic changes in elderly cancer patients after glucose ingestion. The role of tumor necrosis factor-alpha. Cancer 79 (1): 177-84, 1997.  [PUBMED Abstract]
   
   
6. Jatoi A, Daly BD, Hughes V, et al.: The prognostic effect of increased resting energy expenditure prior to treatment for lung cancer. Lung Cancer 23 (2): 153-8, 1999.  [PUBMED Abstract]
   
   
7. Ottery FD: Cancer cachexia: prevention, early diagnosis, and management. Cancer Pract 2 (2): 123-31, 1994 Mar-Apr.  [PUBMED Abstract]
   
   
8. den Broeder E, Oeseburg B, Lippens RJ, et al.: Basal metabolic rate in children with a solid tumour. Eur J Clin Nutr 55 (8): 673-81, 2001.  [PUBMED Abstract]
   
   
9. Kutynec CL, McCargar L, Barr SI, et al.: Energy balance in women with breast cancer during adjuvant treatment. J Am Diet Assoc 99 (10): 1222-7, 1999.  [PUBMED Abstract]
   
   
10. Gambardella A, Tortoriello R, Pesce L, et al.: Intralipid infusion combined with propranolol administration has favorable metabolic effects in elderly malnourished cancer patients. Metabolism 48 (3): 291-7, 1999.  [PUBMED Abstract]
    
    
11. Bosaeus I, Daneryd P, Svanberg E, et al.: Dietary intake and resting energy expenditure in relation to weight loss in unselected cancer patients. Int J Cancer 93 (3): 380-3, 2001.  [PUBMED Abstract]
    
    
12. Pi-Sunyer FX: Overnutrition and undernutrition as modifiers of metabolic processes in disease states. Am J Clin Nutr 72 (2 Suppl): 533S-7S, 2000.  [PUBMED Abstract]
    
    
13. Murphy S, Von Roenn JH: Pharmacological management of anorexia and cachexia. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 127-33. 
    
    
14. Deutsch J, Kolhouse JF: Assessment of gastrointestinal function and response to megesterol acetate in subjects with gastrointestinal cancers and weight loss. Support Care Cancer 12 (7): 503-10, 2004.  [PUBMED Abstract]
    
    
15. Mattox TW: Treatment of unintentional weight loss in patients with cancer. Nutr Clin Pract 20 (4): 400-10, 2005.  [PUBMED Abstract]
    
    
16. Jatoi A, Yamashita J, Sloan JA, et al.: Does megestrol acetate down-regulate interleukin-6 in patients with cancer-associated anorexia and weight loss? A North Central Cancer Treatment Group investigation. Support Care Cancer 10 (1): 71-5, 2002.  [PUBMED Abstract]
    
    
17. Ulutin HC, Arpaci F, Pak Y: Megestrol acetate for cachexia and anorexia in advanced non-small cell lung cancer: a randomized study comparing two different doses. Tumori 88 (4): 277-80, 2002 Jul-Aug.  [PUBMED Abstract]
    
    
18. Jatoi A, Windschitl HE, Loprinzi CL, et al.: Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group study. J Clin Oncol 20 (2): 567-73, 2002.  [PUBMED Abstract]
    
    
19. Strasser F, Luftner D, Possinger K, et al.: Comparison of orally administered cannabis extract and delta-9-tetrahydrocannabinol in treating patients with cancer-related anorexia-cachexia syndrome: a multicenter, phase III, randomized, double-blind, placebo-controlled clinical trial from the Cannabis-In-Cachexia-Study-Group. J Clin Oncol 24 (21): 3394-400, 2006.  [PUBMED Abstract]
    
    
20. Kardinal CG, Loprinzi CL, Schaid DJ, et al.: A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer 65 (12): 2657-62, 1990.  [PUBMED Abstract]
    
    
21. Gordon JN, Trebble TM, Ellis RD, et al.: Thalidomide in the treatment of cancer cachexia: a randomised placebo controlled trial. Gut 54 (4): 540-5, 2005.  [PUBMED Abstract]
    
    
22. Jatoi A: Fish oil, lean tissue, and cancer: is there a role for eicosapentaenoic acid in treating the cancer anorexia/weight loss syndrome? Crit Rev Oncol Hematol 55 (1): 37-43, 2005.  [PUBMED Abstract]
    
    
23. Fearon KC, Barber MD, Moses AG, et al.: Double-blind, placebo-controlled, randomized study of eicosapentaenoic acid diester in patients with cancer cachexia. J Clin Oncol 24 (21): 3401-7, 2006.  [PUBMED Abstract]
    
    
24. Kennedy LD: Common supportive drug therapies used with oncology patients. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 168-81. 
    
    

Nutrition Implications of Cancer Therapies

The nutritional status of patients diagnosed with cancer entering the treatment process varies. Not everyone begins therapy with anorexia, weight loss, and other symptoms of nutritional problems. For patients who have such symptoms, however, anticancer therapies can complicate the treatment and expected recovery. Many individuals also present with preexisting comorbid diseases and illnesses that further complicate their treatment. Surgery, chemotherapy, and radiation can have a direct (or mechanical) and/or an indirect (or metabolic) negative effect on nutritional status. The success of the anticancer therapy will be influenced by a patient’s ability to tolerate therapy, which will, in turn, be affected by nutritional status preceding treatment. The treating clinician should assess baseline nutritional status (see the Nutrition Screening and Assessment ⁶ section) and be aware of the possible implications of the various therapies. Patients receiving aggressive cancer therapies typically need aggressive nutrition management.

Surgery is often the primary treatment modality for cancer. Approximately 60% of individuals diagnosed with cancer will have some type of cancer-related surgery.[1] Malnourished surgical patients are at increased risk for postoperative morbidity and mortality. Steps should be taken to attempt to correct nutritional macronutrient and micronutrient deficiencies before surgery if time permits.[2] This involves identification and assessment of the problem, with the possible use of oral liquid nutritional supplements, enteral or parenteral nutritional support, and/or use of pharmacologic therapies to stimulate the appetite (see the Tumor-Induced Effects on Nutritional Status ⁴ section).[2]

Depending on the procedure, surgery can cause mechanical or physiologic barriers to adequate nutrition, such as a short gut that results in malabsorption after bowel resection.[2] In addition to these mechanical barriers, surgery frequently imposes an immediate metabolic response that increases the energy needs and changes the nutrient requirements necessary for wound healing and recovery at a time when baseline needs and requirements are often not being met.

The following sections highlight various surgical issues for specific cancers. Nutritional complications are usually most notable and severe with cancerous growths and anticancer therapy involving the alimentary canal.

Alcohol abuse is a major risk factor for cancer in the head and neck region and can itself lead to malnutrition.[3] Cancer occurring in this region coupled with curative or palliative surgery can alter a patient’s ability to speak, chew, salivate, swallow, smell, taste, and/or see.[2] Treatment for head and neck cancer can have a profound negative effect on nutritional status.

Nutrition assessment is advised at the initial visit. Clinicians should anticipate additional complicating factors such as the side effects of combined modality therapy (chemotherapy and radiation therapy),[4] as well as the increased nutritional requirements for withstanding these therapies. Because head and neck cancer patients are often malnourished at diagnosis and will undergo therapies that may directly affect their ability to eat, many of these individuals have enteral feeding tubes placed prophylactically before undergoing surgery.[2]

Surgery may take a tremendous toll on the body, but it has reduced mortality and morbidity from gastrointestinal cancers.[2] Anticancer therapy for aerodigestive cancers (e.g., esophageal, gastric, pancreatic, liver, gallbladder, bile duct, and small and large intestine) can result in gastric paresis, alterations in digestion, malabsorption of nutrients, hyperglycemia, elevated lipid levels, hepatic encephalopathy, fluid and electrolyte imbalance, anastomotic and chyle leaks, dumping syndrome, and vitamin and mineral deficiencies.[2] The use of enteral nutritional support is common in the treatment of gastrointestinal cancers. The feeding tube may be placed in the stomach (gastrostomy) or down into the jejunum (jejunostomy).[2,5]

Many individuals experience fatigue, pain, and loss of appetite and are unable to consume their regular diet as the result of surgery.[2] Prompt nutritional therapy can help relieve or reduce these problems. Avoiding carbonated or known gas-producing foods will help, as will altering the fiber content in the diet to encourage bowel regularity. A well-balanced diet that contains the recommended amounts of essential nutrients and calories will help promote good wound healing. Finally, proper nutrition and adequate rest may help prevent or treat fatigue.

In 2000, more than 90 different chemotherapy agents were approved for use. These agents are divided into several functional categories. Chemotherapy agents can be used in combination or as single agents, depending on the disease type and health condition of the individual.[6]

Unlike surgery and radiation therapy, cancer chemotherapy is a systemic treatment (not a localized treatment) that affects the whole body (not just a specific part).[7] Consequently, there are potentially more side effects with chemotherapy than with surgery and radiation therapy. The most commonly experienced nutrition-related side effects are anorexia, taste changes, early satiety, nausea, vomiting, mucositis/esophagitis, diarrhea, and constipation (see the Nutritional Suggestions for Symptom Management ⁷ section). Because side effects of chemotherapy, as well as the cancer itself, can greatly affect nutritional status, healthcare providers need to anticipate possible problems and educate the patient about them [7] in an effort to prevent malnutrition and weight loss (see the Nutrition Screening and Assessment ⁶ section). Malnutrition and weight loss can affect a patient’s ability to regain health and acceptable blood counts between chemotherapy cycles; this can directly affect the patient's ability to stay on treatment schedules, which is important in achieving a successful outcome.

Nutritional support or high-calorie/high-protein liquid supplements may be used in an effort to maintain adequate calorie and nutrient intake. Special formulas are available for people with secondary medical conditions such as hyperglycemia or compromised renal function.

Nutritional support during radiation therapy is vital. The effect of radiation therapy on healthy tissue in the treatment field can produce changes in normal physiologic function that may ultimately diminish a patient’s nutritional status by interfering with ingestion, digestion, or absorption of nutrients. Medications such as pilocarpine (Salagen) may be useful in treating the xerostomia (dry mouth) that accompanies radiation therapy. This medicine may reduce the need for artificial saliva agents or other oral comfort agents such as hard candy or sugarless gum.

The side effects of radiation therapy depend on the area irradiated, total dose, fractionation, duration, and volume irradiated. Most side effects are acute, begin around the second or third week of treatment, and diminish 2 or 3 weeks after radiation therapy is completed. Some side effects can be chronic and continue or occur after treatment has been completed.[8]

Individuals receiving radiation therapy to any part of the gastrointestinal tract are more susceptible to nutrition-related side effects.[9] Patients most at risk for developing nutrition-related side effects are those whose cancers involve the aerodigestive tract, including the head and neck, lungs, esophagus, cervix, uterus, colon, rectum, and pancreas. Patients who are receiving radiation therapy to the head and neck region may present to radiation therapy with preexisting malnutrition secondary to an inability to ingest foods because of the disease itself or because of surgery to treat the disease. Many of these patients have a history of high alcohol intake, which also places them at a higher nutritional risk. These individuals are generally at the greatest risk for developing significant nutrition problems and severe weight loss.[10] In a placebo-controlled, double-blind randomized study of 57 patients receiving radiation therapy for head/neck and lung cancer, megestrol acetate (MA) was administered at a dose of 800 mg per day. Patients who received MA demonstrated significant advantages in weight maintenance and some aspects of quality of life.[11]

Nutrition intervention is based on symptom management. Patients who maintain good nutrition are more likely to tolerate the side effects of treatment. Adequate calories and protein can help maintain patient strength and prevent body tissues from further catabolism. Individuals who do not consume adequate calories and protein use stored nutrients as an energy source, which leads to protein wasting and further weight loss.

Some of the more common nutrition-related side effects caused by irradiation to the head and neck include taste alterations or aversions, odynophagia (pain produced by swallowing), xerostomia, thick saliva, mucositis, dysphagia, and stricture of the upper esophagus.[4] Thoracic irradiation may be associated with esophagitis, dysphagia, or esophageal reflux. Diarrhea, nausea, vomiting, enteritis, and malabsorption of nutrients are possible side effects of pelvic or abdominal radiation.[12] (See the Nutritional Suggestions for Symptom Management ⁷ section.) A prospective, randomized study of patients with colorectal cancer receiving radiation therapy demonstrated that concurrent individualized dietary counseling can improve patients' nutritional intake, status, and quality of life. These improvements, in turn, may reduce radiation-induced morbidity.[13]

Suggestions for appropriate dietary modifications based on nutrition-related symptoms are widely available for patient and healthcare professional use. For a full listing of dietary suggestions see the Tumor-Induced Effects on Nutritional Status ⁴ section. A list of appropriate references is also included below.

Many patients who are undergoing radiation therapy will benefit from nutritional supplements between meals.[14] Aggressive nutritional support is indicated when oral intake alone fails to maintain an individual’s weight. Tube feedings are used more frequently than parenteral nutrition, primarily to preserve gastrointestinal function. Tube feedings are usually well tolerated, pose less risk to the patient than parenteral feedings, and are more cost effective. Numerous studies demonstrate the benefit of enteral feedings initiated at the onset of treatment, specifically treatment to head and neck regions, before significant weight loss has occurred.[15-17]

Many nutrition-related side effects result from radiation therapy. Quality of life and nutritional intake can be improved by managing these side effects through appropriate medical nutritional therapy and dietary modifications.

Monoclonal antibodies, which are used to block cancer-cell receptors for growth-stimulating factors, may cause a cascade of symptoms; however, the symptoms most likely to impact nutritional status are fever, nausea, vomiting, and diarrhea.[1] Interferon (a nonspecific immunotherapy) has had the noted nutrition-related side effects of anorexia, nausea, vomiting, and fatigue.[1] Interleukin-2, approved by the U.S. Food and Drug Administration for the single-agent treatment of metastatic renal cell cancer, can also cause symptoms such as fatigue, nausea, vomiting, and diarrhea.[1,18] Response to interleukin-2 treatment varies; some patients gain weight, and some require nutritional support.[18] However, most patients taking interleukin gain weight. Finally, granulocyte-macrophage colony-stimulating factor, a very common therapy used to increase the production of white blood cells, may also cause fever, nausea, vomiting, and diarrhea.[1]

If ignored, these symptoms can cause gradual or drastic weight loss (depending on the severity of the symptoms), which may lead to malnutrition. Malnutrition can complicate the expected healing and recovery process (see the Nutritional Suggestions for Symptom Management ⁷ section).

Hemopoietic and stem cell transplant patients have special nutritional requirements.[19] Before their transplant, patients receive high-dose chemotherapy and may also be treated with total-body irradiation (TBI).[20] These treatments, in addition to medications used during transplantation, frequently result in nutritional side effects, which may affect patients' ability to consume an adequate diet. The goal of nutritional support should be the maintenance of nutritional status and protein stores. In addition, transplant patients are at very high risk for neutropenia, an abnormally small number of neutrophils in the blood, that makes them susceptible to multiple infections.[21,22]

To reduce the risk of infections related to stem cell transplantation, most healthcare setting guidelines recommend only cooked and processed foods and restrict raw vegetables and fresh fruits that could cause a food-related infection. Specific dietary restrictions and their duration depend on the type of transplant and the cancer site. In addition to specific dietary restrictions, food safety guidelines should be reviewed and stressed with all transplant patients.

The chemotherapy regimen and complications associated with the transplant may result in numerous problems that adversely affect nutritional intake and status.[23] During the transplant process, patients may experience nutrition-related side effects such as taste changes, oral dryness, thick saliva, mouth and throat sores, nausea and vomiting, diarrhea, constipation, lack of appetite/weight loss, and weight gain. Often during the first few weeks posttransplant, patients are fed intravenously to ensure that they receive sufficient calories, protein, vitamins, minerals, and fluids.[24]

Many patients experience mouth and throat sores 2 to 4 weeks after transplantation. Mucositis is the general term that refers to the erythema, swelling, and ulceration of the intraoral soft-tissue structures and the oral and esophageal mucosa in response to the cytotoxic effect of radiation therapy and high-dose chemotherapy. Mouth and throat sores can make eating and swallowing difficult. TBI may also cause dryness of the mouth, temporarily alter the taste of food, and/or cause thick saliva to form in the mouth and throat. Nausea and vomiting are common problems experienced by transplant patients. Nausea and vomiting may be caused by TBI, chemotherapy, and some medications. TBI, chemotherapy, infection, depression, and fatigue can cause a decrease in appetite and weight loss. Lack of appetite may continue to be a problem long after discharge from the hospital. Patients may also experience gastrointestinal problems such as diarrhea and constipation that could be caused by TBI, chemotherapy, gastrointestinal graft-versus-host disease, infection, and some medications.[25,26]

References

1. American Cancer Society Web Site. Atlanta, Ga: American Cancer Society, 2008. Available online. ⁸ Last accessed March 14, 2008. 
   
   
2. McGuire M: Nutritional care of surgical oncology patients. Semin Oncol Nurs 16 (2): 128-34, 2000.  [PUBMED Abstract]
   
   
3. Allison G, Dixon D, Eldridge B, et al.: Nutrition implications of surgical oncology. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 79-89. 
   
   
4. Laurell G, Kraepelien T, Mavroidis P, et al.: Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer 97 (7): 1693-700, 2003.  [PUBMED Abstract]
   
   
5. Persson CR, Johansson BB, Sjöden PO, et al.: A randomized study of nutritional support in patients with colorectal and gastric cancer. Nutr Cancer 42 (1): 48-58, 2002.  [PUBMED Abstract]
   
   
6. Eldridge B: Chemotherapy and nutrition implications. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 61-9. 
   
   
7. Fishman M, Mrozek-Orlowski M, eds.: Cancer Chemotherapy Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh, Pa: Oncology Nursing Press, 1999. 
   
   
8. Donaldson SS: Nutritional consequences of radiotherapy. Cancer Res 37 (7 Pt 2): 2407-13, 1977.  [PUBMED Abstract]
   
   
9. Unsal D, Mentes B, Akmansu M, et al.: Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study. Am J Clin Oncol 29 (2): 183-8, 2006.  [PUBMED Abstract]
   
   
10. Chencharick JD, Mossman KL: Nutritional consequences of the radiotherapy of head and neck cancer. Cancer 51 (5): 811-5, 1983.  [PUBMED Abstract]
    
    
11. McQuellon RP, Moose DB, Russell GB, et al.: Supportive use of megestrol acetate (Megace) with head/neck and lung cancer patients receiving radiation therapy. Int J Radiat Oncol Biol Phys 52 (5): 1180-5, 2002.  [PUBMED Abstract]
    
    
12. Polisena CG: Nutrition concerns with the radiation therapy patient. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 70-8. 
    
    
13. Ravasco P, Monteiro-Grillo I, Vidal PM, et al.: Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol 23 (7): 1431-8, 2005.  [PUBMED Abstract]
    
    
14. McCarthy D, Weihofen D: The effect of nutritional supplements on food intake in patients undergoing radiotherapy. Oncol Nurs Forum 26 (5): 897-900, 1999.  [PUBMED Abstract]
    
    
15. Tyldesley S, Sheehan F, Munk P, et al.: The use of radiologically placed gastrostomy tubes in head and neck cancer patients receiving radiotherapy. Int J Radiat Oncol Biol Phys 36 (5): 1205-9, 1996.  [PUBMED Abstract]
    
    
16. Heymsfield SB, Greenwood T, Roongpisuthipong C: Dietetics and enteral nutrition: past, present, and future. J Am Diet Assoc 85 (6): 667-8, 1985.  [PUBMED Abstract]
    
    
17. Beer KT, Krause KB, Zuercher T, et al.: Early percutaneous endoscopic gastrostomy insertion maintains nutritional state in patients with aerodigestive tract cancer. Nutr Cancer 52 (1): 29-34, 2005.  [PUBMED Abstract]
    
    
18. Samlowski WE, Wiebke G, McMurry M, et al.: Effects of total parental nutrition (TPN) during high-dose interleukin-2 treatment for metastatic cancer. J Immunother 21 (1): 65-74, 1998.  [PUBMED Abstract]
    
    
19. Charuhas PM: Bone marrow transplantation. In: Skipper A, ed.: Dietitian's Handbook of Enteral and Parenteral Nutrition. 2nd ed. Gaithersburg, Md: Aspen Publishers, 1998, pp 273-94. 
    
    
20. Johns A: Overview of bone marrow and stem cell transplantation. J Intraven Nurs 21 (6): 356-60, 1998 Nov-Dec.  [PUBMED Abstract]
    
    
21. Ninin E, Milpied N, Moreau P, et al.: Longitudinal study of bacterial, viral, and fungal infections in adult recipients of bone marrow transplants. Clin Infect Dis 33 (1): 41-7, 2001.  [PUBMED Abstract]
    
    
22. Jantunen E, Ruutu P, Piilonen A, et al.: Treatment and outcome of invasive Aspergillus infections in allogeneic BMT recipients. Bone Marrow Transplant 26 (7): 759-62, 2000.  [PUBMED Abstract]
    
    
23. Roberts SR: Bone marrow and peripheral blood stem cell transplantation. In: Lysen LK, ed.: Quick Reference to Clinical Dietetics. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 162-8. 
    
    
24. Weisdorf SA, Schwarzenberg SJ: Nutritional support of bone marrow transplantation recipients. In: Forman SJ, Blume KG, Thomas ED, eds.: Bone Marrow Transplantation. Boston, Mass: Blackwell Scientific Publications, 1994, pp 327-36. 
    
    
25. Charuhas PM: Medical nutrition therapy in bone marrow transplantation. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago, Ill: The American Dietetic Association, 2000, pp 90-8. 
    
    
26. Shapiro TW, Davison DB, Rust DM, eds.: A Clinical Guide to Stem Cell and Bone Marrow Transplantation. Boston, Mass: Jones and Bartlett Publishers, 1997. 
    
    

Nutrition Therapy

Nutrition Screening and Assessment

Nutrition in cancer care embodies prevention of disease, treatment, cure, or supportive palliation. Caution should be exercised when considering alternative or unproven nutritional therapies during all phases of cancer treatment and supportive palliation, as these diets may prove harmful. Patient nutritional status plays an integral role in determining not only risk of developing cancer but also risk of therapy-related toxicity and medical outcomes. Whether the goal of cancer treatment is cure or palliation, early detection of nutritional problems and prompt intervention are essential.

The original principles of nutrition care for people diagnosed with cancer were developed in 1979 [1] and are still very relevant today. Proactive nutritional care can prevent or reduce the complications typically associated with the treatment of cancer.[1]

Many nutritional problems stem from local effects of the tumor. Tumors in the gastrointestinal tract, for example, can cause obstruction, nausea, vomiting, impaired digestion, and/or malabsorption. In addition to the effects of the tumor, marked alterations in normal metabolism of carbohydrates, protein, and/or fats can occur.[2]

The nutritional prognostic indicators most recognized as being predictive of poor outcome include weight loss, wasting, and malnutrition. In addition, significant weight loss at the time of diagnosis has been associated with decreased survival and reduced response to surgery, radiation therapy, and/or chemotherapy.[3]

Malnutrition and accompanying weight loss can be part of an individual’s presentation or can be caused or aggravated by treatments for the disease. Identification of nutrition problems and treatment of nutrition-related symptoms have been shown to stabilize or reverse weight loss in 50% to 88% of oncology patients.[4]

Screening and nutrition assessment should be interdisciplinary; the healthcare team (e.g., physicians, nurses, registered dietitians, social workers, psychologists) should all be involved in nutritional management throughout the continuum of cancer care.[5]

A number of screening and assessment tools are currently available for use in nutritional assessment. Examples of these tools include the Prognostic Nutrition Index,[6,7] delayed hypersensitivity skin testing, institution-specific guidelines, and anthropometrics. Each of these tools can help identify persons at nutritional risk; unfortunately, the values obtained using such tools can be altered by the hydration status and the immune compromise frequently found in individuals diagnosed with cancer. In addition, each of these objective measures can carry a cost in terms of laboratory or practitioner time. One author has provided a useful overview of assessment procedures for advanced cancer patients.[8]

Another example of a screening and assessment procedure is the Patient-Generated Subjective Global Assessment (PG-SGA). Based on earlier work on a protocol called Subjective Global Assessment (SGA),[9] the PG-SGA is an easy-to-use and inexpensive approach in identifying individuals at nutritional risk and in triaging for subsequent medical nutritional therapy in a variety of clinical settings.[10,11] The individual and/or caretaker complete sections on weight history, food intake, symptoms, and function. A member of the healthcare team evaluates weight loss, disease, and metabolic stress and performs a nutrition-related physical examination. A score is generated from the information collected. The need for nutrition intervention is determined according to the score.

Bioelectrical impedance analysis (BIA) is also used to assess nutritional status, as determined by body composition.[12] The BIA measures electrical resistance on the basis of lean body mass and body fat composition. Single BIA measures show body cell mass, extracellular tissue, and fat as a percent of ideal, whereas sequential measurements can be used to show body composition changes over time. Because of cost and accessibility, BIA is currently in limited use and often unavailable in most ambulatory settings.

Taste and smell defects are common in cancer patients and may affect nutritional status. The relative importance of chemosensory changes to the etiology of malnutrition was assessed in 66 patients with advanced cancer. Some degree of chemosensory abnormality was reported by 86% of patients; approximately one-half of patients reported interference with enjoying favorite foods. Poor appetite, nausea, early satiety, and chemosensory abnormalities presented concurrently. These findings were significantly related to decreased energy intake. Further research is required to design nutritional interventions for these chemosensory problems.[13]

Because nutritional status can quickly become compromised from illness and decreased dietary intake, and because nutritional well-being plays an important role in treatment and recovery from cancer, early screening and intervention as well as close monitoring and evaluation throughout all phases of cancer treatment and recovery are imperative in the pursuit of health for the individual with cancer.

Optimal nutritional status is an important goal in the management of individuals diagnosed with cancer. Although nutrition therapy recommendations may vary throughout the continuum of care, maintenance of adequate intake is important. Therefore, a waiver from most dietary restrictions observed during religious holidays is granted for those undergoing active treatment. Individuals with cancer are encouraged to speak to their religious leaders regarding this matter before a holiday.

Whether patients are undergoing active therapy, recovering from cancer therapy, or in remission and striving to avoid cancer recurrence, the benefit of optimal caloric and nutrient intake is well documented.[14-16]

The goals of nutrition therapy are to accomplish the following:

• Prevent or reverse nutrient deficiencies.
• Preserve lean body mass.
• Help patients better tolerate treatments.
• Minimize nutrition-related side effects and complications.
• Maintain strength and energy.
• Protect immune function, decreasing the risk of infection.
• Aid in recovery and healing.
• Maximize quality of life.

Patients with advanced cancer can receive nutritional support even when nutrition therapy can do little for weight gain.[17,18] Such support may help accomplish the following:

• Lessen side effects.
• Reduce risk of infection (if given enterally).
• Reduce asthenia.
• Improve well-being.

In individuals with advanced cancer, the goal of nutrition therapy should not be weight gain or reversal of malnutrition, but rather comfort and symptom relief.[19]

Nutrition continues to play an integral role for individuals whose cancer has been cured or who are in remission.[20] A healthy diet helps prevent or control comorbidities such as heart disease, diabetes, and hypertension. Following a healthful nutrition program might help prevent another malignancy from developing.

As outlined above, individuals diagnosed with cancer are at risk for malnutrition resulting from the disease itself; from anticancer therapy such as surgery, radiation, or pharmacologic therapy; and/or from anorexia due to emotional turmoil. The following sections highlight the benefits, contraindications, methods of administration, and home care issues for all forms of nutrition support—oral, enteral, and parenteral.

The preferred method of nutrition support is via the oral route, with the use of dietary modifications to reduce the symptoms associated with cancer treatments. Enteral nutrition is indicated when the gastrointestinal (GI) tract is functional but oral intake is insufficient to meet nutritional requirements. Common situations in which enteral nutrition may be needed include malignancies of the head and neck regions, esophagus, and stomach. When the GI tract is dysfunctional, total parenteral nutrition (TPN) may be indicated; however, its widespread use is controversial because little evidence of improved outcomes has been demonstrated in patients with advanced cancer.[21] Parenteral nutrition has been shown to be beneficial in only a small group of patients—specifically, postoperative patients who are being aggressively treated and who have demonstrated a positive response rate. One study [22] reported that patients with GI cancer benefited from perioperative support with TPN, with one-third fewer complications and decreased mortality.

Optimal nutrition can improve the clinical course, outcome, and quality of life of patients undergoing treatment for cancer.[23] Virtually every cancer patient could benefit from consultation with a registered dietitian or physician to formulate a plan for nutrition and to begin meal planning. Oral nutrition, or eating by mouth, is the preferred method of feeding and should be used whenever possible. Appetite stimulants may be used to enhance the enjoyment of foods and to facilitate weight gain in the presence of significant anorexia.[24]

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

Enteral or parenteral nutrition can be a safe and effective way to nourish critically ill cancer patients who cannot sustain themselves with oral intake.[26]

At-risk individuals who may benefit from nutritional support might have one or more of the following characteristics:[27]

• Low body weight, as defined by less than 80% of ideal weight or recently experienced unintentional weight loss of more than 10% of usual weight.
• Malabsorption of nutrients due to disease, short bowel syndrome, or anticancer therapy.
• Fistulas or draining abscesses.
• Inability to eat or drink for more than 5 days.
• Moderate or high nutritional risk status as determined by screening or an assessment tool.
• The ability to demonstrate competencies for discharge planning on nutritional support (both individual and caregiver).

Although the many benefits of achieving good nutritional status via nutritional support can clearly be detailed, the disadvantages or questionable benefits of nutritional support must also be considered. The debate regarding the effect of nutritional support on tumor growth has not been settled;[28] though quality of life is usually improved with better nutritional status, the actual impact of nutritional support on longevity has yet to be definitively determined.[28]

Once the degree of malnutrition has been assessed, the decision to offer nutritional support and which form of support to utilize must be determined by the healthcare professional and other parties involved. Enteral and parenteral nutritional support offers viable options to reduce the risk of debilitating malnutrition and interruptions in anticancer therapy that may influence outcome. Each form of nutritional support has advantages and disadvantages. It is critical to thoroughly evaluate the diagnosis, prognosis, degree of malnutrition, function of the gut, and ease of delivery before embarking on the plan of nutritional support. Caution must also be exercised to avoid refeeding syndrome, the metabolic complication that is caused by rapid repletion of potassium, phosphorous, and magnesium in a severely malnourished or cachectic patient.[27]

The following sections highlight the benefits, contraindications, methods of administration, formulas, and home care issues for both enteral and parenteral nutrition.

The benefits of enteral nutrition, or tube feeding, are that it continues to use the gut, has fewer complications such as infection and organ malfunction, is often easier to administer, and is cheaper than parenteral nutrition.[27-30] In addition, nutrients are metabolized and utilized more efficiently by the body.

Specific disease and condition-related indications for use consist of a diagnosis of a cancer of the alimentary canal (in particular, head and neck, esophageal, gastric, or pancreatic cancers) and severe complications/side effects from chemotherapy and/or radiation that are seriously jeopardizing the treatment plan of an individual already suffering from malnutrition.[27]

Contraindications for enteral nutritional support include a malfunctioning gastrointestinal tract, malabsorptive conditions, mechanical obstructions, severe bleeding, severe diarrhea, intractable vomiting, gastrointestinal fistulas in locations difficult to bypass with an enteral tube, inflammatory bowel processes such as prolonged ileus and severe enterocolitis, and/or an overall health prognosis not consistent with aggressive nutrition therapy.[27] Thrombocytopenia and general pancytopenic conditions following anticancer treatments may also prevent placement of an enteral tube.

Prospective Assessment

Several effective methods for the delivery of enteral nutritional support or tube feedings exist. An approximation of how long nutritional support will be needed is critical, however, to determine the most appropriate delivery route. Nasogastric, nasoduodenal, or nasojejunal methods are best for short-term support (<2 weeks).[30] The endpoint of delivery—the stomach, the duodenum, or jejunum—is determined by the risk of aspiration, with nasojejunal feeds recommended for individuals with aspiration risk. If the person with cancer is at very high risk for aspiration, enteral nutritional support may be contraindicated and parenteral nutrition should be considered. Also, immune-compromised individuals with mucositis, esophagitis, and/or herpetic, fungal, or candidiasis lesions in the mouth or throat may not be able to tolerate the presence of a nasogastrointestinal tube.

Tubes are constructed from silicone or polyurethane and can vary in length from 30 to 43 inches, with the shorter tubes used for nasogastric feedings. The diameters range from 5F to 16F catheters. Tubes may have weighted tips to help passage through the gut.

Percutaneous endoscopic gastrostomy tubes (PEGs) and percutaneous endoscopic jejunostomy tubes (PEJs) are generally used for long-term enteral feedings (>2 weeks).[30] The placement further down in the gastrointestinal tract has a number of advantages: the diameter of the tube is larger (15F-24F catheters), which allows easier and faster passage of formulas and medications; the risk for aspiration is lower because of the decreased chance of migration of the tube up into the esophagus; the risk for sinusitis or nasoesophageal erosion is lower; and this route is more convenient and aesthetically pleasing to the individual because of the ability to conceal the tube.[30] People anticipating long-term support may also consider a skin-level button gastrostomy or jejunostomy.

Assessment of need and ease of delivery are best done early. If the malnourished individual requires surgery for an unrelated event, a PEG or PEJ may be placed at that time to avoid an additional procedure.

Infusion Methods and Formulas

Enteral nutrition or tube feedings can be delivered at various rates. When possible, the bolus method is preferable because it mimics normal feeding, requires less time and equipment, and offers greater flexibility to the patient.[30] The following is a summary of infusion possibilities:[30]

Continuous or cyclic drip feeding

• Caloric/nutrient and free-water requirements need to be determined first to plan rate and time recommendations.



• Enteral feeding pumps provide reliable, constant infusion rates and decrease the risk of gastric retention.



• Assuming that no compounding factors are present, feeding into the stomach (25–30 cc/hr) can start at a higher rate than feeding into the jejunum (10 cc/hr); rates can be increased, with tolerance, every 4 to 6 hours until the rate reaches that needed to deliver the required caloric/nutrient needs.



• Continuous feeds can be cycled to run at night to allow greater flexibility and comfort. If it is physically possible, these nocturnal feeds can allow daytime oral or bolus feedings to meet nutritional goals and provide a more normal lifestyle.

Bolus and intermittent feeding

• Caloric/nutrient and free-water requirements need to be determined to plan the feeding schedule.



• Bolus feedings can be offered several times (3–6 times) each day; as much as 250 to 500 cc can be given over 10 to 15 minutes.



• Bolus feeding should be used ONLY when the endpoint of the tube is in the stomach; it should NEVER be used when feedings are delivered into the duodenum or jejunum. This precaution protects against gastric distention and dumping.



• A gravity drip from a bag or syringe with a slow push can be used to administer the formula.



• Diarrhea is a common side effect of this infusion method but can be controlled with a change in formula, additions to the formula, and a change in the amount of formula given over a finite period of time.

After the infusion method has been determined, a formula needs to be selected. There are many formulas on the market, ranging from elemental preparations of predigested nutrients to more complete and complex formulas that mimic oral nutrition intake. Specialized formulas are available for specific health conditions such as diabetes mellitus and compromised renal function. Modular formulas that are not nutritionally complete but add specific nutrients such as protein, fat, and carbohydrate are also available. These preparations can be added to an existing formula to provide additional benefit.

Glutamine, an amino acid, is a key energy source for the gut and has been shown to help maintain gut health and integrity and to protect the gut from damage from radiation and chemotherapy.[30,31] The use of supplemental glutamine in tube feedings in addition to L-arginine and omega-3 fatty acids is gaining popularity. These potentially beneficial nutrients are now available in formulas and as oral supplements. More research needs to be done, however, to thoroughly evaluate the benefits and possible disadvantages.

When a formula is being chosen, the institution nutrition formulary for available preparations, modular formulas, and additions such as glutamine or fiber should be considered. Consideration should also be given to the patient’s medical condition, gastrointestinal function, and financial resources.

Transition to Home

A significant number of patients using enteral nutritional support in the hospital are discharged to home while still on therapy. This can be done successfully and requires that the following conditions are met:[30]

• The patient and/or caregiver is given enough time for education and is proficient in the use of the tubes, site care, and the use of the pump.



• The patient is discharged to a safe and clean environment.



• Regular medical follow-up is arranged to ensure appropriate function of the feeding tube and optimization of the nutrition plan.

Parenteral nutrition may be indicated in select individuals who are unable to use the oral or enteral route (i.e., those who have a nonfunctioning gut), such as those with obstruction, intractable nausea and/or vomiting, short-bowel syndrome, or ileus. Additional inclusive conditions common in the cancer population are severe diarrhea/malabsorption, severe mucositis or esophagitis, high-output gastrointestinal fistulas that cannot be bypassed by enteral intubation, and/or severe preoperative malnutrition.[28,30]

Contraindications for use of parenteral nutrition are a functioning gut, a need for nutritional support for a duration less than 5 days, an inability to obtain intravenous (IV) access, and poor prognosis not warranting aggressive nutritional support.[28,30] Additional conditions that should cause hesitation are the following: patient or caregiver does not want parenteral nutrition, patient is hemodynamically unstable or has profound metabolic and/or electrolyte disturbances, and/or patient is anuric without dialysis.[28,30]

Prospective Assessment

If parenteral nutrition is determined to be beneficial, the two venous access sites are central and peripheral. Cancer patients usually have central IV catheters to accommodate multiple IV therapies. If this is not the case, a peripheral catheter can be placed, although care must be taken to avoid overuse of the peripheral accesses with nutritional support and anticancer therapies. Numerous peripheral infusions and venesections can result in vessel sclerosis. The following discussion highlights both types of access:[28,30]

Central venous catheters

• May utilize single-, double-, or triple-lumen catheters for delivery of medication, blood and blood products, and parenteral nutrition without interruption.



• Placement of lines should be done by an experienced surgical team to minimize risk of pneumothorax, hemothorax, hematuria, aneurysms, venous or nerve damage, and microbial contamination. Evaluation of catheter tip location and site care is critically important.



• Short-term support can be provided via Cordis or Swan Ganz catheters; long-term support can be provided via Hickman or Broviac catheters.

Peripheral venous catheters

• A short canula is placed in the arm (either the percutaneous subclavian vein in adults or the arteriovenous fistulas are used as access sites).



• Catheters must be located in peripheral vessels with high blood flow to facilitate rapid dilution of the formula; access may be alternated to avoid thrombophlebitis.



• Peripherally inserted central catheters (PICC lines) are used for long-term support; the tip of the catheter must be placed in a central vein such as the superior or inferior vena cava to decrease risk of infection and thrombosis.

Solutions

Parenteral nutrition formulas are tailored to individual clinical status and nutritional needs. The formulas contain a combination of amino acids, dextrose, lipids, vitamins, minerals and trace elements, fluids, electrolytes, and, possibly, additives such as insulin, heparin, and antacids.

Solutions running through peripherally placed lines must be altered by reducing the percentage of calories from carbohydrates (hypertonic) and increasing the percentage from lipids (isotonic). Peripheral solutions with a final dextrose concentration lower than 10% and an osmolarity lower than 900 mOsm/kg are generally well tolerated.[28] The mandatory alteration in macronutrients can present problems with delivery of recommended calories/nutrients.

Central infusions are not limited by osmolarity because they use a large vein; this feature makes central venous access a good choice for severely stressed, hypermetabolic individuals and/or individuals requiring a fluids restriction.[28]

Many drugs and compounds are not compatible with parenteral solutions and should not be added to the solutions or even run through parenteral solution-designated lines to avoid the chance of interaction or precipitation. Pharmacists should be consulted in the preparation of parenteral nutrition solutions and before any additional medications or compounds are added.

Complications

Incompatibility with drugs is just one of a number of possible complications associated with parenteral nutrition administration. Complications can be categorized as mechanical (vein thrombosis, pneumothorax, and catheter tip misplacement) or metabolic (hyperglycemia/hypoglycemia, hypokalemia, and elevated liver function tests).[28] Because of the precision that is required to order, administer, and maintain this type of support, trained and experienced medical personnel should be involved. Many facilities have dedicated nutritional support multidisciplinary teams.

Transition to Home

Cancer is one of the most common diagnoses among home parenteral nutrition recipients. The following criteria should be used when assessing the appropriateness of discharge to home on parenteral feeds. The individual must meet the following conditions:[28]

• Be medically and emotionally stable.



• Have a relatively long life expectancy (>6 months).



• Be educated and able to perform the requisite tasks to maintain a sterile access site in a safe and clean environment.



• Have a long-term access in place and be stable on the formula before being discharged.



• Have a medical follow-up and support system in place for questions and complications.

Tapering off parenteral nutritional support requires coordination between the medical staff and the patient. Because parenteral support is given continuously, the taper involves a gradual reduction in rate and time. Parenteral nutritional support cannot be abruptly discontinued.

When transitioning to enteral feeds, parenteral support can be decreased to 50% when enteral feeds reach 33% to 50% of the goal rate; it can be discontinued when enteral feeds reach 75% of goal and are tolerated.[28]

When transitioning to oral nutrition, parenteral solutions can be decreased to 50% when the patient is tolerating a full liquid diet or beyond and can be discontinued once solid foods are tolerated in addition to the consumption of adequate fluids.[28]

Both enteral and parenteral nutritional support can be safe and effectively used to help reverse the effects of malnutrition in individuals with cancer. However, nutritional support, particularly parenteral support, is still controversial when used as routine adjuvant therapy to anticancer therapies or when there is an absence of efficacious cancer treatment.[32] Every measure should be employed to sustain an individual and improve his or her condition through oral intake before consideration is given to nutritional support.

Side effects of cancer treatments vary from patient to patient, depending on the type, length, and dose of treatments as well as the type of cancer being treated. This section offers practical suggestions for managing the common symptoms affecting nutrition intake.

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

Loss of appetite or poor appetite is one of the most common problems that occurs with cancer and its treatment. Anorexia is a complex problem involving abnormalities in protein, carbohydrate, and fat metabolism.[33] The cause of anorexia may be multifactorial. Treatment modality, the cancer itself, and psychosocial factors may all play a role in appetite.[33] Eating frequent meals and snacks that are easy to prepare may be helpful. Liquid supplements may improve total energy intake and body function [34] and may work well when eating solids is difficult. Other liquids that contain energy may also help, such as juices, soups, milk, shakes, and fruit smoothies. Eating in a calm, comfortable environment and exercising regularly may also improve appetite.[33]

Suggestions for appetite improvement include the following:[35-37]

• Plan a daily menu in advance.
• Eat small, frequent, high-calorie meals (every 2 hours).
• Arrange for help in preparing meals.
• Add extra protein and calories to food.
• Prepare and store small portions of favorite foods.
• Consume one third of daily protein and calorie requirements at breakfast.
• Snack between meals.
• Seek foods that appeal to the sense of smell.
• Be creative with desserts.
• Experiment with different foods.
• Perform frequent mouth care to relieve symptoms and decrease aftertastes.

What types of foods are usually recommended?

• Cheese and crackers.
• Muffins.
• Puddings.
• Nutritional supplements.
• Milkshakes.
• Yogurt.
• Ice cream.
• Powdered milk added to foods such as pudding, milkshakes, or any recipe using milk.
• Finger foods (handy for snacking) such as deviled eggs, cream cheese or peanut butter on crackers or celery, or deviled ham on crackers.

See the NCI Web site ⁹ Eating Hints for Cancer Patients: Before, During, and After Treatment for recipes such as Lactose-Free Double Chocolate Pudding ¹⁰, Banana Milkshake ¹¹, and Fruit and Cream ¹². For a free copy of this booklet, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

Alterations in taste can be related to radiation treatment, dental problems, or medications. Cancer patients undergoing chemotherapy frequently report changes in their sense of taste, specifically a bitter taste sensation during administration of the cytotoxic drugs.[38] One study measured the taste thresholds among cancer patients under chemotherapy compared with controls.[39] In this study, 62% of patients complained of taste disorders associated with the chemotherapy medications. Taste dysfunction can result in food avoidance, inducing weight loss and anorexia, all of which can have significant consequences on patients' quality of life. Simply changing the types of foods eaten as well as adding additional spices or flavorings to foods may help. Citrus may be tolerated well if no mouth sores or mucositis is present. Rinsing the mouth before eating may help improve the taste of food.[33]

While undergoing cancer therapy, patients may experience taste changes or develop sudden dislikes for certain foods. Their sense of taste may return partially or completely, but it may be a year after therapy ends before their sense of taste is normal again. A randomized clinical trial found that zinc sulfate during treatment may be helpful in expediting the return of taste after head and neck irradiation.[40]

Suggestions for helping cancer patients manage taste changes include the following:

• Eat small, frequent meals and healthy snacks.



• Be flexible. Eat meals when hungry rather than at set mealtimes.



• Use plastic utensils if foods taste metallic.



• Try favorite foods.



• Plan to eat with family and friends.



• Have others prepare the meal.



• Try new foods when feeling best.



• Substitute poultry, fish, eggs, and cheese for red meat.



• A vegetarian or Chinese cookbook can provide useful nonmeat, high-protein recipes.



• Use sugar-free lemon drops, gum, or mints when experiencing a metallic or bitter taste in the mouth.



• Add spices and sauces to foods.



• Eat meat with something sweet, such as cranberry sauce, jelly, or applesauce.

Xerostomia (dry mouth) is most commonly caused by radiation therapy that is directed at the head and neck.[36] A number of medications may also induce xerostomia. Dry mouth may affect speech, taste sensation, ability to swallow, and use of oral prostheses. There is also an increased risk of cavities and periodontal disease because less saliva is produced to cleanse the teeth and gums.

A primary method of coping with xerostomia is to drink plenty of liquids (25–30 mL/kg per day) and eat moist foods with extra sauces, gravies, butter, or margarine.[25,37,41] In addition, hard candy, frozen desserts such as frozen grapes, chewing gum, flavored ice pops, and ice chips may be helpful.[33] Oral care is very important to help prevent infections. Irradiation to the head and neck of a patient who has permanent dry mouth symptoms may result in reduced intake of energy, iron, zinc, selenium, and other key nutrients.[42] Special efforts should be made to help tailor meals and snacks for individuals with xerostomia.

Suggestions for lessening or alleviating dry mouth include the following:[37]

• Perform oral hygiene at least 4 times per day (after each meal and before bedtime).
• Brush and rinse dentures after each meal.
• Keep water handy at all times to moisten the mouth.
• Avoid liquids and foods with high sugar content.
• Avoid rinses containing alcohol.
• Consume very sweet or tart foods and beverages, which may stimulate saliva.
• Drink fruit nectar instead of juice.
• Use a straw to drink liquids.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation ¹³ for more information on xerostomia.)

Stomatitis, or a sore mouth, can occur when cells inside the mouth, which grow and divide rapidly, are damaged by treatment such as bone marrow transplantation, chemotherapy, and radiation therapy. These treatments may also affect rapidly dividing cells in the bone marrow, which may make patients more susceptible to infection and bleeding in their mouth. By carefully choosing foods and by taking good care of their mouths, patients can usually make eating easier.[43-45] Individuals who have mucositis, mouth sores, or tender gums should eat foods that are soft, easy to chew and swallow, and nonirritating.[33] Some conditions may require processing foods in a blender. Irritants may include acidic, spicy, salty, and coarse-textured foods. A pilot study found that oral glutamine swishes might be helpful in reducing the duration and severity of mucositis.[46] Glutamine may also reduce the duration and severity of stomatitis during cytotoxic chemotherapy.[46,47]

Suggestions for people with cancer who are experiencing stomatitis include the following:

• Eat soft foods that are easy to chew and swallow, including bananas and other soft fruits; applesauce; peach, pear, and apricot nectars; watermelon; cottage cheese; mashed potatoes; macaroni and cheese; custards; puddings; gelatin; milkshakes; scrambled eggs; oatmeal or other cooked cereals; pureed or mashed vegetables such as peas and carrots; and pureed meats.



• Avoid foods that irritate the mouth, including citrus fruits and juices such as orange, grapefruit, or tangerine; spicy or salty foods; and rough, coarse, or dry foods, including raw vegetables, granola, toast, and crackers.



• Cook foods until soft and tender.



• Cut foods into small pieces.



• Use a straw to drink liquids. Eat foods cold or at room temperature; hot and warm foods can irritate a tender mouth.



• Practice good mouth care, which is very important because of the absence of the antimicrobial effects of saliva.



• Increase the fluid content of foods by adding gravy, broth, or sauces.



• Supplement meals with high-calorie, high-protein drinks.



• Numb the mouth with ice chips or flavored ice pops.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation ¹³ for more information on mucositis.)

Nausea can affect the amount and types of food eaten during treatment. Eating before treatment is important, as well as finding foods that do not trigger nausea. Frequent triggers for nausea include spicy foods, greasy foods, or foods that have strong odors.[33] Once again, frequent eating, and slowly sipping on fluids throughout the day may help.

Additional eating suggestions include the following:[19]

• Eat dry foods such as crackers, breadsticks, or toast, throughout the day.



• Sit up or recline with a raised head for 1 hour after eating.



• Eat bland, soft, easy-to-digest foods rather than heavy meals.



• Avoid eating in a room that has cooking odors or is overly warm; keep the living space comfortable but well ventilated.