CANCER Melanie Crane, Melanie Dueck, Victoria Gerhardt, Amy Hanson,& Heidi Smith CANCER A general term referring to any malignant neoplasm ~100 disorders caused by ~300 different growths 3 progressive phases Initiation Promotion progression 1/3 of cancer deaths in US attributed to nutrition and lifestyle behaviors (poor diet, physical inactivity, overweight and obesity, alcohol use) ETIOLOGY Hyperplasia: increase in the number of cells within a tissue, leading to an increase in the size of that tissue or organ Metaplasia: dividing cells differentiate into types of cells not usually found in the area Dysplasia: an abnormality in the differentiation of proliferating cells, resulting in an abnormal degree of variation in size, shape, and appearance and arrangements of the cells PROTOONCOGENES/ONCOGENES Protooncogenes: cellular genes whose functions are to encourage and promote the normal growth and division of cells Oncogenes: cells that have mutated forms of genes have a high probability of progressing to malignancy ETIOLOGY: NEOPLASIA Neoplasia: “New growth.” Abnormal mass of proliferating cells that used to be normal cells Characteristics of Neoplasia: Autonomous Grow at an independent rate from the needs and homeostatic controls of the host Progressive growth No benefit to host; often harmful MALIGNANT NEOPLASMS CHARACTERISTICS Unencapsulated Invade surrounding tissue Hard to separate Metastasis: spread of malignant neoplasms CANCER: GENETICS Debatable if there is any relation to heredity Even though all cancer is genetic, just a small portion-perhaps 5 or 10 percent--is inherited. Information on evidence-based methods of delivering cancer genetic risk assessment services is scarce Cancer risk assessment can help reduce psychological stress STATISTICS One third of cancer deaths can be attributed to diet and physical activity habits. Another third of deaths from cancer are caused by exposure to tobacco products. Almost one in two men and women— approximately 41 percent of the population—will be diagnosed with cancer during their lifetime. DEVELOPMENT Carcinogen is physical, chemical, or viral agent that induces cancer. Can modify progression at any stage Cancer development mimics pattern of environment GENETICS AND CANCER PREVENTION Gene damage Cell growth and maturation Acquired through lifetime Current research in diet/genetic interactions Those with gene damage should be particularly careful of diet, physical activity and alcohol or tobacco use. DIET Fruits and Vegetables Antioxidants and phytochemicals Weight maintenance Whole grains Support weight maintenance Fiber Limit high fat foods Meat and dairy More omega-3 <20% energy from fat Soy Part of healthy plant-based diet Supplements can be harmful Difficult to isolate specific chemicals Long latency period Interactions FOOD PREPARATION AND PRESERVATION High-heat Grilling, broiling, barbecuing, smoking Some risk with processed meats N-nitrosocompounds Smoke,salted, pickled foods Nitrates Tobacco smoke Vitamin C from fruits and vegetables can slow conversion Acrylamide ANTIOXIDANTS AND FREE RADICALS Molecules that can block detrimental effects of activated oxygen molecules Include vitamins, minerals and other bioactive substances. Results are mixed with supplements American Cancer Society recommends antioxidants from food sources rather than supplements Fruits and Vegetables Whole grains TOBACCO Tobacco use is the most preventable cause of death from cancer. Leads to cancers of lung, larynx, mouth, esophagus, bladder, kidney, throat, stomach, pancreas, or cervix. Smokeless tobacco lead to mouth cancer. Nitrites ALCOHOL If used, should be limited to 2 a day for men and 1 for women. Stronger affect on tissues exposed to the alcohol. Malnutrition Inhibits folate absorption in women. PHYSICAL ACTIVITY Physical activity can help control your weight and reduce body fat. Decrease circulating estrogens, androgens, insulin, and insulin-like factor associated with cell and tumor growth Calorie restriction inhibits growth 30 minutes of moderate physical activity on 5 or more days of the week. BMI between 18.5 and 25 Community support OTHER RISK FACTORS Age One of most important risk factors. Most cancers occur in people over the age of 65. UV Radiation Leads to early aging in the skin and skin damage that can result in cancer. Ionizing Radiation and Chemicals Radiation Pesticides Food preparation and preservation Hormones Viruses and Bacteria HOW TO DIAGNOSE CANCER Screening PET scan Symptoms Endoscopy Tissue samples Endoscopic Ultrasound CT scan Biopsy MRI Barium Swallow MRI SCREENINGHELP OR HARM FOR BREAST CANCER? Cochrane Review 2011, Issue 1 Breast cancer screening Results: Women were diagnosed with cancer who didn’t have it 10 in 2000 screened would be diagnosed and treated despite an actual need to (30% estimated over diagnosed and treated) False positives lead to psychological distress 15% estimated mortality reduction PROGNOSIS The chance of recovery or reoccurrence predicted using statistics Effected by: location, stage and grade, type of cancer, age, health, and treatment response Survival rate- percent of people who survive with the same type and stage of cancer 5 year survival rate- those with few or no cancer symptoms 5 years after diagnosis Favorable: controllable Unfavorable: difficult to control PROGNOSIS Favorable: Carcinoma insitu Areas of occurrence: cervix, skin, mouth, esophagus, bronchus, stomach, endometrium, breast, and large intestine PROGNOSIS Unfavorable: Invasion Cellular Multiplication Mechanical Invasion Lytic enzymes Decreased Cell Adhesion Increased Motility GENERAL SIGNS AND SYMPTOMS Pain Fatigue Fever Skin Changes Unexplained weight loss Cachexia a syndrome that consists of anorexia, weight loss, altered taste, anemia, sever malnutrition causing muscle wasting, loss of adipose tissue, emaciation, and altered protein, lipid, and carbohydrate metabolism SIGNS AND SYMPTOMS OF SPECIFIC CANCERS Change in bowel and bladder Unhealing sores White spots in mouth(leukoplakia) Blood Lump Skin change Persistent cough Dysphagia STAGES OF CANCER Staging: conducting texts to determine the extent of the disease by observing the spread of the disease from its original site. T Stage (tumor size) T0- free of tumor T1- lesion <2 cm in size T2- lesion 2-5 cm T3- skin and/or chest wall invaded N Stage (lymph node) N0- no axillary nodes N1- mobile nodes N2- fixed nodes M Stage (metastases) M0- no metastases M1- Demonstrable metastases M2- suspected metastases STAGING GRADES OF CANCER How normal the cells look under microscope G0- not detectable G1- well differentiated G2- moderately differentiated G3- poorly differentiated G4- undifferentiated TYPES OF CANCER The name of a cancer is derived from where the cancer originated in the body. Carcinomas- epithelial tissue Adenocarcinomas- ducts or glands Sarcoma- connective tissue Lymphomas- lymphatic tissue Leukemias- bone marrow Myelomas- hematopoietic bone marrow PREVALENCE PREVALENCE INCIDENCE INCIDENCE CHEMOTHERAPY is a systemic treatment that uses drugs which spread throughout the entire body and destroy wherever cancer cells are located. • • • • • Discovery of chemotherapy How cancer cells are affected Balance- cancerous cells vs. tissue cells Cause of side effects Timing of the dosage ADMINISTRATION OF CHEMOTHERAPY When administering chemotherapy the dosage is usually calculated based on the individual’s body surface area. It can be given: Oral Intravenous Intraosseous Intramuscular Subcutaneous RADIATION THERAPY Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. Types of radiation used for cancer treatment: X-rays gamma rays charged particles Administration methods: External-beam radiation therapy Internal-beam radiation therapy- ACTIONS OF RADIATON THERAPY -Effects of Radiation on the cell -When and why a patient undergoes radiation SURGERY Primary and oldest treatment for many cancers. It helps determine what cancer is present and how far it has spread throughout the body. Offers the greatest chance of survival for cancer that has not spread. Minor surgeries are called procedures and major surgeries are called operations. There are many factors that decide what type of surgery you will receive for your situation: Location Size Type Grade Stage Age General health TYPES OF SURGERY Preventative surgery- Diagnostic surgery- Curative surgery- Palliative surgery- Reconstructive surgery- OTHER TYPES OF CANCER TREATMENT Proton therapy- Angiogenesis Inhibitors Therapy- Hyperthermia- Laser therapy- Cyrosurgery- FUTURE THERAPIES IN CANCER TREATMENT Gene Therapy- Immunotherapy- Biological therapy- ALTERNATIVE THERAPIES Relaxation therapy Lifestyle diets Herbal Medications Homeopathy High-dose vitamin therapy Energy healing Biofeedback Chiropractic medicine Massage therapy Imagery Spiritual healing Self-help groups • Commercial weight loss programs • Hypnosis • Acupuncture • Folk remedies POST TREATMENT LIFESTYLE Join a support group Meet with a social worker if emotional support is needed May not be able to do everything as easily but a return pre-treatment lifestyle is expected. Return to the doctor for follow-up care is recommended every 3-4 months Make changes to improve lifestyle: Quit smoking Eat a healthier diet Exercise Reduce stress Limit alcohol intake SIDE EFFECTS OF CANCER TX Different treatments cause a range of symptoms including: Anorexia Cachexia Nausea and vomiting Constipation Mucositis Diarrhea Xerostomia Relief of symptoms is best accomplished when therapy is directed at underlying causes DRONABINOL Primary orexigenic component of marijuana Stimulates appetite in patients with AIDS and cancer-related anorexia Side effects: dizziness, euphoria, somnolence, poor concentration Contraindications:give with caution when given with sedatives and other psychoactive meds MEGESTROL ACETATE Synthetic, orally active progestational agent used widely for Tx of metastatic breast cancer Most potent appetite stimulant Effects on appetite and weight are dose dependent (higher dose, higher benefit) Glucocorticoid effects-interferes with normal endocrine activities impotence in men adrenal insufficiency decrease glucose tolerance CORTICOSTEROIDS Appetite improvement Short lived Unknown mechanism of action, but exhibit peripheral and central effects Prolonged use may result in proximal muscle weakness Osteoporosis Delirium fluid retention adrenal suppression glucose intolerance Hyperglycemia electrolyte disturbances OXANDROLONE Synthetic, oral anabolic agent offset the protein catabolism associated with the prolonged administration of steroids. Increase in total and lean tissue weight with Tx of oxandrolone and progressive resistance exercise and good nutrition Β-HYDROXY Β-METHYLBUTYRATE AKA(JUVEN) Dietary (HMB) supplement made of combination of three nutrients-a metabolite of leucine, L-glutamine, and L-arginine Each has been shown to decrease protein breakdown Increase in lean body mass May be of benefit especially with resistance exercise program METOCLOPRAMIDE Antiemetic and prokinetic agent Early satiety as a result of delayed gastric emptying and gastroparesis May relieve cancer-related anorexia SIDE EFFECTS: NAUSEA AND VOMITING Prolonged emesis can lead to dehydration, weight loss, metabolic abnormalities, and electrolyte imbalance Most feared side effect of cancer treatment Antiemetics offer relief of symptoms Most effective when used preventatively rather than to treat existing nausea and vomiting ETIOLOGY OF NAUSEA AND VOMITING Complex neural pathways interact Final common pathway is emetic center, located in brain stem Stimulation of emetic center comes from chemoreceptor trigger zone (CTZ) located adjacent to fourth ventricle CTZ is stimulated by a variety of chemicals Emetic center also stimulated by tumors and increased intracranial pressure ANTIEMETICS Phenothiazines-block dopamine receptors in the CTZ Butyrophenones-dopamine receptor antagonists. Substituted Benzamides-(like metoclopramide) block dopamine receptors in the CTZ peripherally increase esophageal sphincter tone, improve gastric emptying, and increase transit through the small bowel. Serotonin antagonist-block serotonin receptors peripherally in the upper GI or in the area postrema located in the CTZ. Prescribed for acute, chemotherapy-induced nausea and vomiting. ANTIEMETICS CONTINUED Benzodiazepines-treats anxiety related to anticipated nausea or vomiting. Corticosteroids-Drug of choice for nausea and vomiting caused by intracranial pressure and GI obstruction. Anticholinergic-used for nausea associated with motion sickness. Block acetylcholine in emetic center Side effects: urinary retention, dry eyes, constipation CONSTIPATION AND DIARRHEA TX LAXATIVES Bulk forming agent-absorbs water from intestine and holds water in stool Antimotility agent-inhibits persistalsis, prolongs transit time. Stool softener-reduces surface tension of the stool to allow softening Stimulant-stimulates GI Hyperosmotic laxative-local irritation Lubricant-lubricate intestinal mucosa and soften stool Saline laxative-retains water in intestinal lumen. MUCOSITIS Frequent complication for chemotherapy and radiation therapy Mouth care is important to prevent possible infection and/or further irritation Oral candidiasis is leading infectious cause PALIFERMIN Tx for oral mucositis Decreases incidence and duration XEROSTOMIA Xerostomia Radiation of head and neck requires saliva stimulants or artificial saliva Amifostine-protects cells against radiation Side effect of amifostine: nausea, vomiting, hypotension, allergic reaction, and venous catheter complications NUTRITION THERAPY GOALS Provide nutrients that are missing Maintain nutritional health Preserve lean body mass Decrease side effects of treatment Improve quality of life NUTRITION CARE Calories: Determined by diagnosis, presence of other diseases, intent of treatment, anticancer therapies, and presence of infection. Protein: Based on actual body weight & according to stress level. .8- 2.5 g/kg Cancer patients need: HIGH PROTIEN & HIGH CALORIES NUTRITION CARE Fluid: Ensure maintenance of hydration, tissue perfusion, and electrolyte balance. Daily requirement method: 1 ml of fluid per 1 kcal of estimated needs Micronutrients: Vitamin and mineral supplements may be used HOW TO INCREASE CALORIES Use whole milk Add cheese to dishes Stir granola in foods Beat eggs into sauces or vegetables Add hard-boiled eggs to casseroles or salads Put gravy, butter, sour cream, or other toppings on food items HOW TO INCREASE PROTEIN Melt cheese on sandwiches or add to soups Use milk instead of water in cooking Use nonfat instant dry milk Add eggs and nuts in diet Spread peanut butter on toast or pancakes Add meat and beans to casseroles, soups or salads NEUTROPENIC DIET Needed for those with ANC below 500/mm3 Avoid raw foods Avoid self serve restaurants Only drink pasteurized products Hot foods hot, cold foods cold No cross contamination Thaw/cook properly NUTRITIONAL SIDE AFFECTS LOSS OF APPETITE NAUSEA Eat small meals every 1-2 hours High protein and kcal Eat foods that smell good Always carry snacks with you Eat large meals when you feel well Drink meal replacements Small meals Avoid greasy, sweet, and spicy foods Sip fluids all day but drink less during meals Rest after meals Avoid eating in a room with strong odors or too warm TASTE/SMELL CHANGES Eat favorite foods Rinse mouth with water often Use plastic utensils Increase flavor and seasonings Make foods sweeter DRY MOUTH MUCOSITIS Drink plenty of liquids Eat moist foods with gravies or sauces Eat foods that are sweet or tart Suck on hard candy or chew gum Rinse mouth often Keep lips moist with moisturizer Bland liquids and soft solids Avoid citrus fruits, spicy or salty foods, and dry/rough food Eat foods at room temperature DIARRHEA Plenty of fluids Eat foods that contain Na and K Avoid greasy foods, caffeine, high fiber, and be careful with milk products Small meals CONSTIPATION High fiber diet if ok with doctor 8-12 C. fluid a day Exercise regularly Drink hot liquids WEIGHT LOSS Eat when it is time Small meals Tube feeding WEIGHT GAIN Fruits and vegetables High fiber Lean meats Low-fat milk Small portions Less salt NUTRITION AFTER TREATMENT Patients should try to consume a healthy diet Return to healthy eating by: Making simple meals you like Go easy of fat and salt Eat many different foods Whole grains, fruits, and vegetables ASSESSING QUALITY OF LIFE Health-related quality of life (HRQOL) Measures perceived physical/mental health over time Effects on patients or clients of chronic illness Criteria for assessment include Symptoms of cancer Adverse effects of treatment Physical functioning Social interaction Psychological adjustment Sexual function Body image QUALITY OF LIFE IN CANCER PATIENTS Unrelieved Pain Isolation Exhausted caregivers Disturbed sleep Ability to work is Depression impaired Decreased will to Exhaustion survive Diminished appetite Increased vulnerability to infection Can’t enjoy simple pleasures (family, food, etc.,) Trips of vacations are uncomfortable IMPLICATION FOR FAMILY MEMBERS Family members or other supporting individuals for cancer patients are also effected by the disease. One study showed mental component of HRQL assessment lower in family members and suggest therapy for both. NUTRITION ASSESSMENT A Closer Look at the Case Study ASSESSMENT Age: 58 Height: 6’3” Weight: 198 lb BMI: 25= over weight Ideal Body Weight: 101% BIOCHEMICAL Albumin: 3.0 (moderate depletion) Total Protein: 5.7 (below normal) Prealbumin: 12 (moderate deficient) Transferrin: 175 (mild depletion) RBC: 4.3 HGB: 13.9 HCT: 38 ESR: 17 (high) CLINICAL Distressed, thin, pale BP: 132/92mmHg Sunken eyes Dry mucous membranes Muscle wasting but no edema Epigastic tenderness Lost 30 lb in the last month DIETARY REE: 1806kcal x 1.1-1.3= 1986-2347kcal Protein requirement based on visceral protein status is 1.2g/kg 24-HOUR RECALL Patient consumed about 28% of daily recommended calories 9% Protein, 52% CHO, 40% Fat Deficient most vitamins and minerals (ok in iron) Low in all food groups Diet affected by dysphagia EPIDEMIOLOGY-ESOPHAGEAL CANCER Rates are per 100,000 persons. DIAGNOSIS Stage IIB (T1, N1, M0) adenocarcinoma (chest x-ray, endoscopy brushings and biopsy, CT scan) What does this mean? T1: <2cm, grown in to muscus lining and/or submucosa but not outside esphoagel tissue N1: cancer has spread to 1-2 nodes near the esophagus M0: no metastais FUNCTIONAL Dysphasia- inability to swallow Odynophagia- pain when swallowing GENETICS Mother died of liver cancer at age 59 HISTORIES Smoking Tums 2-3 pill 2-3 times/day Alka-Seltzer: 2 pills 1-2 times/day Long history of heart burn Drinks alcohol TRANSHIATAL ESOPHAGECTOMY Removing Esophagus without opening the chest CASE STUDY- JEJUNOSTOMY Surgery affected ability to digest Problems are found in: Chewing, swallowing, tasting, smelling, and making saliva Enteral nutrition needed Individuals may progress to oral intake with special dietary recommendations MNT- ESOPHAGEAL CANCER Puree/soft foods Cut food into small bites Eat slowly Dumping syndrome diet SAMPLE DIET- ESOPHAGEAL CANCER Breakfast Snack 1 ½ C. Oatmeal ½ C. Puree squash Dinner 1 ½ C. Soup with noodles 1 ½ C. Applesauce Snack 1 ½ C. Cream of wheat ¾ C. Puree broccoli Lunch 1 C. Fruit milkshake 2 scrambled eggs ¼ C. Cheese 4 oz. Pureed chicken ¼ C. Gravy ½ C. Mashed potatoes Snack 1 C. Yogurt Banana CASE STUDY- TUBE FEEDING Surgery affected ability to digest Problems are found in: Chewing, swallowing, tasting, smelling, and making saliva Reliance on enteral nutrition is needed Individuals may progress to oral intake with special dietary recommendations PES STATEMENT Swallowing difficulty related to Stage IIB (T1, N1, M0) adenocarcinoma of the esophagus as evidenced by reports of odynophagia and imaging procedures.
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