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Mrs. Anjali NairChief Dietician Tata Memorial Hospital

She is recepient of many awards including one from Smt Lilavati Munshi Foundation for a project on Diet in Cancer Tube Feeding Formulation.She has been part of research team of Food Technology Department of BARC for developing Goods for Foods for Immuno-compromised patients and other target groups-using radiation technology.She has also been involved in various publications in the area of Nutrition and Cancer and has shared her experience on practical approaches in Nutrition and Cancer in various conferences and seminars at National and International levels .Mrs. Nair is also involved in guiding post graduate and research students in dessertations and has been playing a lead role in carrying out nutrition related educational activities for Oncology & Enterostomal Nurses along with Nutrition students.As a part of her responsibilities at Tata Memorial Hospital , she is running many nutritional counselling programmes for Communities-Breast/Uterine group,Head and Neck Cancer,General Medicine and Palliative Care Patients.

 

Mrs. Anjali B. NairChief Dietician

Tata Cancer Hospital

NUTRITION IN HEAD AND NECK CANCER

Annually, over 3,00,000 new cases of oral cancer are diagnosed all over the world where the majority are diagnosed in the advanced stages III or IV. Such data make the oral cancer an important public health matter which is responsible for 3% to 10% of cancer mortality worldwide.

Head and neck cancer refers to a group of biologically similar cancers originating from the upper aero digestive tract including lip, oral cavity, nasal cavity, paramucosal sinuses, pharynx, larynx, oropharynx and Hypopharynx

Cancer of lip Cancer of tongue

Cancer of hard palate

Cancer of bucal mucosaCancer of mandible

An “At Risk” Population

Alcohol use/abuseTobacco useUp to 40% of newly diagnosed head and

neck cancer patients are malnourished.Malnutrition has significant impact on

morbidity, mortality and quality of life for cancer patients

Physicians often do not address this issue

Presenting Complaints

Change in voiceChange in facial appearanceNon healing ulcersIll-fitting dentures, loosening teethLesions

Causes of Malnutrition 

Diminished nutrient intake Increased nutrient demand not matched by intake Tumor-induced derangements

Diminished Nutrient Intake 

Alcohol & Tobacco Poor dentition Partial or complete obstruction of aerodigestive tract Post-surgical functional and anatomic impairments of

chewing and swallowing mucositis, dysgeusia, xerostomia Chemotherapy-induced nausea, vomiting  

Increased Nutrient Losses Vomiting Diarrhea

Increased Nutrient Demand Acute metabolic stresses caused by surgery, RT,

chemotherapy Duration and intensity of stresses depend on intensity and

duration of treatment as well as complications  

Tumor-induced Metabolic Abnormalities Abnormal metabolism of carbohydrates, lipids, and protein Abnormal levels of neurotransmitters leading to anorexia Increased basal metabolic rate Cytokines appear to mediate these abnormalities Tumor necrosis factor, IL-1, IL-6

Impact of Malnutrition 

Immunocompetence Decreased cell-mediated immunity Depressed T-cell proliferation, NKC cytotoxicity,

macrophage cytotoxicity

Inability to tolerate antineoplastic treatments Toxicities more severe—treatment delays, higher

costs

Postoperative complications Wound infection, healing—quality of life, cost  

  

SWALLOWING PROBLEMS IN HEAD AND NECK CANCER.

Reduced post-treatment swallowing function.

Reduced pre-treatment swallowing function.

Surgery

Chemotherapy Radiation

Swallowing problems

Dysphagia Aspiration

Xerostomia Mucositis

Nasal regurgitation.

Worse swallowing function

Less variety of food consistency

Less nutrition through oral route

MALNUTRITION

&

IMPAIRED QUALITY OF

LIFE.

HNCA

Surgery

Negative nitrogen balanceInability to chewAgluttion (inability to swallow)DysphagiaCommunication impairmentAspiration

Radiotherapy

MucositisXerostomia ( dry mouth)Odynophagia ( pain in swallowing)Dysguesia ( loss of taste) Dental caries associated with xerostomia

Chemotherapy

NauseaVomitingDiarrheaCheilosisGlossitisPharyngitisEsophagitisanorexia

Treatment related complication

Table 7.3 - Nutritional management of cancer patient

Clinical Manifestations of CancerPainNutritional implication-

Cancer Cachexia

Anorexia

Weight loss and depletion

Alteration in body compartments

Disturbances in water and electrolyte metabolism.

Progressive impairment of vital functions.

Abnormal taste- Hypogeusia , dysguesia

Dysphagia

Macronutrient

metabolism

Carbohydrates

gluconeogenesis from Acetic acid , lactate and glycerol.

glucose disappearance and recycling.

Glucose intolerance

Insulin resistance

Altered lipid metabolism

Increased Lipolysis

Increased Glycerol and fatty acid turnover.

Lipid oxidation non – inhibited by glucose.

Decreased lipoprotein lipase activity.

Increase in serum lipids and fatty acids.

Altered Protein metabolism

Increased Muscle Protein catabolism

Increased whole body protein turnover

Increased liver protein synthesis.

Decreased muscle protein synthesis.

  Gastrointestinal Dysfunction Abnormalities in the mouth and the digestive tract, either as a

result of a disease or its treatment,

May interfere with food ingestion

Changes in taste and smell .

Changes in taste and smell correlate with decreased nutrient intake, a poor response to therapy, and tumor progression,

including metastasis .

Zinc-deficiency, alterations in brain neuro-transmitters such as NPY, that affect taste and nutrient selection .

Standards of care to be followed

Early nutrition support.Total calorie intake should be restricted to 1500-2000

kcals/day.Main substrates providing calories should be

Carbohydrates and lipids.Protein intake determined by severity of catabolism.Assessment of nutritional status based on SGA.Enteral nutrition should be the choice.

Parenteral nutrition if needed , certain recommendation should be followed.

Timing of nutritional support to be studied.Specific diseased stated may require certain

modifications.Immuno-nutritionPreventive nutritional support with primary

treatment to be considered.

NUTRITIONAL CAREWeight loss and altered nutritional status are evident in 50%

of the patient with cancer at time of diagnosis and therefore nutritional support can improve overall patient performance status.

Nutrition therapy recommendation may vary throughout the continuum of care. Maintenance of adequate intake is important, whether the patient on active therapy, recovering from cancer therapy or in remission and striving to avoid cancer re-occurrence.

The Goals of Nutritional Therapy

a. Prevent or reverse nutritional deficiencies

b. Preserve lean body mass

c. Help patient better tolerate treatment

d. Minimize nutrition related side effects and complication

e. Maintain strength and energy

f. Protect immune function and decrease the rush of infection

g. Aid in recovery and healing

h. Maximize the quality of life

Dietary Guidelines

Macro nutrients:

Energy: 15-20 kcals/kg PBW/day to prevent re-feeding syndrome

25-35 kcals/kg PBW for maintenance

39-40kcals/kg PBW/day. for weight gain:

Proteins: 1-1.5gm/kg PBW/day for maintenance

1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain patients.

Micronutrients1. Sodium: hyponatrimia due to 1. SIADH. 2. Dehydration3. Drains2. Zinc: common deficiency, results in:i. decreased NK cell lytic activity and decreased

proportion of CD4+ CD45RA+ cells in the peripheral blood.

ii. Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations

iii. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. AJCN (Vol. 17, No. 5, 409-418 (1998 )

Water: 30-40ml/kg PBW/day1. Prevent dehydration2. Prevent respiratory distress due to drying of

secretions.

Arginine: (controversial)Shown to increases fistula and wound complications

Glutamine:1. Decreases the risk and severity of stomatitis2. Helps in wound healing after surgery3. Reduced the side effects of chemo drugs like

doxorubicin etc. Contraindicated: shown to stimulate growth of

cancer cells.

Symptoms Dietary intervention

Anorexia Frequent small quantity and variation in meals

Nutritious snacks and drinks between meals

Supplementation of high calorie and proteins

Nausea Avoid cooking smell and food with strong odors

Have dry meals with drinks taken separately

Biscuits, dry toast and cold foods

Avoid very sweet and fatly foods

Symptoms

Dietary intervention

Difficulty in swallowing (Dysphasia)

Small frequent feed with soft and liquid diets with nutritious drinks after food

Altered taste

Avoid food that worsen the unpleasant taste mainly because of zinc deficiency

Symptoms

Dietary intervention

Dry Mouth

Eat moist foods with extra sauces, butter or margarine and avoid liquids and food that contain lots of sugars and dry fruit nectar instead of juice

Mouth sores

Eat foods that are easy to chew and swallow with cool temperature and soft fruits like bananas stewed apple and peach, cottage cheese, mashed potatoes, scramble eggs, cooked cereals, and milk shakes

Strategies for modifying nutrient intake depend on specific feeding problem and the extent of depletion.

Oral route is preferred mode of feeding but may be resisted by patient experiencing nausea , altered sensation and dysphagia.

In patients with head and neck cancer the cancer lesions in the oral cavity makes difficult to consume food orally.

Few Considerations

Dysphagia due to oral lesions can be lessened with intake of soft and liquefied foods served at moderate and room temperature.

Patients with Xerostomia should be encouraged to have plenty of fluids(25-30ml/kgbdwt) and eat moist foods with extra gravies and butter.

Patients with chemotherapy complain of decreased ability to eat as the day progresses. Thus morning can be the best time for eating.

This is an attribute to sluggish digestion and gastric emptying as a result of GI mucosal atrophy and gastric muscle atrophy

Approach to Nutrition Support

PRETREATMENT-Nutrition screening, History( weight loss), Physical examination( BMI) , Lab studies(Serum albumin)

Malnourished

Is therapy intensive

Oral supplements

NO

Moderately or severely malnourished

Aggressive nutritional support

Is GI tract functional

Oral supp or Enteral tube feeding

Parenteral nutrition

YES NO

ROUTES OF FEEDING

SELECTION OF FORMULA

Functional capacity of gutIntubations sitePatient's metabolic statusCostConvenience considerations

COMPARISION BETWEEN PRODUCTS

RESOURCE HIGH PROTEIN (100gms)

ACTIBASE NEUTRAL

(100gms)

ENE 374kcals 338 kcals

PRO 41gms 45 gms

Na 500mg 360mg

K 800mg 546mg

Cost Rs 215 Rs 240

Case Studies

MRS RKT 43 YR/F

CA UPPER LIP --- T4 N0 M0 STAGE IV

COMPLAINED OF SWELLING IN UPPER LIP

ADMITTED TO TMH---24/5/10

DIAG: SPINDLE CELL CARCINOMA

BIOCHEMICAL NORMAL EXCEPT FOR Na

OPERATED ON 31/5/10

PT ON RT FEEDS SINCE 1/6/10

HT: 151CMS

WEIGHT: 60KGS

BMI:26KG/M2

GRADE I OBESE

ENERGY: 30X46(IBW)=1380

+STRESS FACTOR=1450KCALS

PROTEINS: 1.5 GM/KG IBW=69GMS

CHO:65%=227 GMS

FAT:22%=34 GMS

HOSPITAL DIETDAY1(1/6) DAY2(2/6) DAY3(3/6)

ENERGY 432 906 1157

PROT 7.2 27.1 48.2

FATS 9 20.7 21.6

CHO 75 128 125

Na 134 128

GIVEN 1GM SALT

143

REMARKS SEVERELY NAUSEATED

NAUSEA REDUCED WITH FEELING OF FULLNESS

INTAKE IMPROVED

PT DISCHARGED ON 4/6/10

ON RT FEEDS+ORAL LIQUIDS ON ACTIBASE NEUTRAL

WEIGHT MAINTAINED SO CONTINUED WITH SAME DIET.

MRS.SINGH 40/ F

CA LATERAL BORDER OF TONGUE—T3NOMO

SYMP: PAIN WHILE EATING FOOD

ADMITTED TO TMH 27/4/10

BIOCHEMICAL NORMAL EXCEPT FOR FLUCTUATING Na

OPERATED ON 31/5/10

RT FEEDS STARTED ON 1/6/10

HT: 161 CMS

WEIGHT:82KG

BMI:31.66KG/M2

GRADE II OBESE

ENERGY:25KCALS/KG= 1400

PROTEINS: 1.3GM/KG= 73 GMS

CHO 65%= 228GMS

FATS 15%= 23 GMS

HOSPITAL DIET

DAY1(1/6) DAY2(2/6) DAY3(3/6)

ENERGY 554 1278 1541

PROT 32.6 68 72

FATS 20 38.5 44

CHO 57 141 171

Na 134 -- 134

REMARKS ½ RT FEEDS AS NAUSEATED

COCONUT WATER=SWEETLIME JUICE SO LESS OF BLEND FEEDS TAKEN

INTAKE PROPER

LOW HB WAS BEFORE SURGERY 10GMS(25/5)

3/6: HB FURTHER REDUCED TO 9.70GMS DUE TO BLOOD LOSS DURING SURGERY

DISCHARGED ON SAME DIET WITH ADDITION OF RAGI PORRIDGE AND ½ BOILED EGG ADDED TO THE RT FEEDS

Conclusion

Head and neck cancer and disease induced dysphagia can adversely affect a patient’s ability to eat and thus its QOL.

Dysphagia has serious emotional and social consequences.The inability to participate in eating , one of the life’s most social occasion generates a lot of frustration , anxiety and depression.

Quality of life assessment is important for patients with neoplasm of head and neck.

Apart from the treatment modalities, the type of cancer carries a significant influence on the physical , functional , social , emotional and a global wellbeing of the patients.

Questions & Answers

To submit a question for Mrs.Anjali Nair,please message Akash Srivastava via the chat

Closing Remarks