Cancer care nutrition

NUtritioN iN CANCer CAre

dr mabel Blades independent Freelance dietitian and nutritionist

dr mabel Blades is a member of the BdA and NAGe, food Counts and freelance dietitians specialist Groups. As a registered dietitian she is passionate about diet and that anyone with a diagnosis of cancer gets the best nutritional advice possible.

Cancer is a major cause of death and morbidity in the uk and 29 percent of deaths were caused by it in 2011. approximately 159,000 people died in 2011 in the uk from various types of cancer (1). lung, bowel, breast and prostate cancer are the most common forms of cancer and account for over half of the causes of death.

Advice to those being treated for various types of cancer on nutrition can be of vital importance to enhancing the outcome of treatments, as well as feelings of wellbeing. Thus the role of the Registered Dietitian in undertaking such work can be important to outcomes.

Screening and treatments for various types of cancer mean that nowadays many more people diagnosed with the condition survive than did in the past.

Malnutrition is associated with cancer and indeed can be one of the symptoms that cause individuals to seek a GP appointment and to commence the pathway to the diagnosis of cancer. The complication of malnutrition in cancer can adversely affect the outcome of treatment (2). Unfortunately about 40 percent of those with cancer have been found to suffer from protein energy malnutrition (3). In those with head and neck cancers this can increase to 80 percent.

FaCtoRs Causing CanCER Lifestyle factors of diet (including obesity) have been well recognised with the development of various forms of cancer. Indeed, the World Cancer Research Fund in 2007 in their comprehensive report on the subject of ‘Food, Nutrition, Physical Activity and the Prevention of Cancer; a Global Perspective’, considered that up to 35 percent cancer cases throughout the world are preventable by dietary means (4).

The following associations of diet with a higher risk of cancer are found: • Obesity with endometrial and breast cancer. • Lack of fibre and colon cancer. • High intake of meat and meat products with colorectal cancer. • Excess alcohol with liver cancer. • High salt intake with stomach cancer. • One of the key dietary aspects associated with a lower incidence of oral, pharyngeal, laryngeal, pancreatic, lung, colorectal, breast and prostate was considered to be a lack of fruit and vegetable consumption.

Accordingly the World Cancer Research Fund made various recommendations to rectify this: • Be as lean as possible within the normal range of body weight. • Be physically active as part of everyday life. • Limit consumption of energy-dense foods and avoid sugary drinks. • Eat mostly foods of plant origin. • Limit intake of red meat and avoid processed meat. • Limit alcoholic drinks. • Limit consumption of salt and avoid mouldy cereals (grains) or pulses. • Aim to meet nutritional needs through diet alone. • Mothers to breastfeed children. • All cancer survivors to receive nutritional care from an appropriately trained professional if able to do so and, unless otherwise advised, aim to follow the recommendations for diet, healthy weight and physical activity.

For the first time, the report made a recommendation as regards to those diagnosed with cancer and the need for advice. An overview of such information in respect of these recommendations is provided by Cancer Research UK (5).

thE multidisCiPlinaRy tEam and thE RolE oF thE Rd Unfortunately, attention to nutrition may be neglected in the turmoil of treatments for the condition. There is also a lack of information on nutrition intervention studies to demonstrate the best method of support. Such interventions can include chemotherapy, radiation or surgery, as well as other medications. Chemotherapy can have various toxic side effects such as loss of appetite, nausea, vomiting and fatigue which can in turn lead to malnutrition. Consideration of nutrition and the assessment of malnutrition and the management of this is vital to the outcome of treatments and is a recommendation in NICE guidance (6). As long ago as 1992 Professor Leonard Jones proposed such a team approach in the Kings Fund report on ‘A positive Approach to Nutrition as Treatment’ (7). Registered Dietitians can be key members of such teams.

malnutRition sCREEning People suffering from cancer are at greater risk of malnutrition which can be due to factors such as: • the site of the cancer; • the tumour growing and increasing the metabolic rate, plus causing problems like vomiting, diarrhoea or reduced absorption; • anxiety and depression leading to a distorted or diminished appetite; • treatments such as surgery, chemotherapy, radiotherapy and medications which may have profound effects on the gastrointestinal tracts.

The form of malnutrition ‘Cancer Cachexia’ is associated with weight loss, reduced muscle strength, tiredness and anorexia and is seen in 50 percent of those with cancer, particularly advanced cancers. This condition is accompanied by not just a loss of body fat but also muscle tissues and a resultant weakness. The condition is complex and includes various biochemical pathways including tumour necrosis factor and it is hoped that pharmacological agents can be produced to reverse the condition (8).

Such malnutrition may well be a factor in the negatively affecting clinical decisions such as further interventions and, in particular, surgery. It can also have a detrimental effect on healing and recovery, as well as being associated with an increased risk of complications. Therefore, it is recommended to screen those suffering from cancer so that early nutritional interventions can be made. The Malnutrition Universal Screening Tool (MUST) produced by BAPEN is a well-known and useful tool for the assessment of malnutrition and is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition (under-nutrition), or who are obese.

CaRE Plans From the assessment of malnutrition, a care plan should be developed for the individual concerned. This care plan may include the use of various steps, including the use of energy dense foods, fortification of meals, recording food intake, and the use of prescribable supplements to increase calories and protein, as well as the referral to a Registered Dietitian.

If an inadequate intake is taken orally then enteral feeding may be recommended, which may provide total or supplementary nutrition. Indeed, trials have shown that enteral feeding of patients after gastrointestinal surgery for cancer showed an improved recovery time, plus cost benefits (9).

nutRition in hosPital Those who are malnourished fare less well as regards the clinical outcome. Therefore, monitoring weight as described using the MUST and if required increasing the calories in the diet, can be invaluable in helping to prevent weight loss.

The British Dietetic Association (BDA) has produced a comprehensive resource on nutrition and diet for hospital patients called The Nutrition and Hydration Digest (10). This contains recommendations for nutritionally vulnerable patients and could include those who have experienced weight loss due to cancer.

Such recommendations include an energy target of 1,800 to 2,100 kcal per day for a 60kg

weight patient and 2,250 to 2,625kcal per day for a 75kg weight patient, plus a protein target of 1.0g per kg body weight. This is usually provided by three meals and two higher energy snacks per day, as well as possibly additional supplements. A higher calorie meal comprising of a starter, main course and pudding should thus provide 800kcal. For practical purposes, to achieve this, soups must be nourishing and provide at least 100kcal per portion and 3.0g of protein. If a snack meal is chosen such as a sandwich or salad then this should achieve the same amount of energy. The higher energy between meal snacks should provide in two snacks 300kcal and 4.0g protein.

Both chemotherapy and radiotherapy may cause mucositis due to the effects on the oral cavity, including the salivary glands and may cause a dry or sore mouth which results in difficulties in chewing and swallowing. Hospital menus are recommended to include a soft choice of food which is easy to eat for such patients.

nEutRoPEniC diEts During cancer treatments, the immune system can be compromised. During this phase, a neutropenic or ‘clean’ or ‘low microbial’ diet is used to protect the patient from infections. There is considerable variation in what is considered to be a neutropenic diet between centres in the UK and abroad (11).

Comprehensive information is provided by the BDA for both a neutropenic diet and another for profound neutropenia. Suitable diet sheets can be provided by local Registered Dietitians. Key points: • Wash hands. • Wash crockery and cutlery well at a high temperature preferably in a dishwasher - disposable cutlery and crockery can be used on occasions where this is not possible. • Make sure any food is thoroughly cooked and served while piping hot. • Avoid items like unpasteurised cheeses and blue veined cheese, uncooked meats and fish like sushi, plus smoked fish and hams, raw eggs such as in homemade mayonnaise and probiotic products.

miCRonutRiEnt dEFiCiEnCy There are reductions in micronutrient levels in those with cancer versus healthy controls (12). Some studies have looked at the supplementation of the diet with additional micronutrients with beneficial results in prostate cancer (13).

BonE hEalth Some of the hormonal therapies used in cancer treatments, forms of chemotherapy, as well as surgery on the ovaries or testes can have adverse effects on calcium metabolism due to the effect on oestrogens and testosterone (14). Therefore, supplements of vitamin D and calcium can be provided to maximise bone health.

ConClusion Registered Dietitians can have an important role in nutrition in cancer care and such improved nutrition can have numerous beneficial effects.

references 1 cancer research UK, accessed July 2014, http://publications.cancerresearchuk.org/downloads/Product/cs _ cs_MOrtALItY.pdf 2 santarpia L, contaldo F and Pasanisi F (2011). Nutritional screening and early treatment of Malnutrition in cancer Patients. J cachexia sarcopenia

Muscle. March 2011. 2(1) 27-35 3 ravasco P et al (2003). Nutritional Deterioration in cancer: the role of Disease and Diet. clinical Oncology 15 p443-450 4 world cancer research Fund (2007). Food, Nutrition, Physical Activity and the Prevention of cancer: a Global Perspective. world cancer research Fund. 5 cancer research UK. www.cancerresearchuk.org/cancer-nfo/healthyliving/diet-healthy-eating-and-cancer/diet-healthy-eating-and-cancer Accessed september 2014 6 National Institute of clinical excellence (NIce) (2004). Improving supportive and Palliative care for Adults with cancer. the Manual. London 7 Jones LJ (1992). A positive Approach to Nutrition as treatment. Kings Fund report 8 Laviano A et al (2008). Neural control of anorexia-cachexia syndrome. American Journal of Physiology endocrinology and Metabolism. 295 e1000-1008 9 Barlow r et al (2009). randomised control trial of early enteral nutrition versus conventional management in patients undergoing major resection for upper gastrointestinal cancer. NcrI conference 2009 10 British Dietetic Association, accessed Dec 2012. www.bda.uk.com/publications/NutritionHydrationDigest.pdf 11 Mank AP et al (2008). examining low bacterial dietary practice. european Journal of Oncology Nursing 12 (4) 342-348 12 McMillan Dc et al (2000). changes in micronutrient concentrations following anti-inflammatory treatment in patients with gastrointestinal cancer. Nutrition 16 (6) 425-428 13 thomas r et al (2007). can dietary intervention alter prostate cancer progression? Nutrition & Food science. 37(1) 24-36 14 Macmillan Nurses, accessed Dec 2012. Nutrition treatments and Bone Health (booklet) www.macmillan.org.uk/cancerinformation/

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