Oncology : Head and Neck Cancer

“Oropharyngeal Squamous Cell Carcinoma” A Case Study and Literature Review By: Dietetic Intern Cameron Segura

Objectives Review current literature on nutrition care in Head and

Neck Cancer. Background Pathophysiology “Oropharayngeal Squamous Cell Carcinoma”

Diagnosis Treatment Nutritional Care Case Study Comparison Literature Review on Cancer Research Quiz

Head and Neck Cancer Background

What is it ? Cancer that affects certain regions in the body.

H & N can affect a single region or entire area of oral cavity. 3-5% of all Cancers in the U.S 55,070 people (40,220 men & 14,850

women) 12,000 Deaths will occur (8,600 men

3,400 women) Oropharyngeal (oral & pharyngeal)

Oropharyngeal Cancers

6th most common cancer in the world 90% of all Head & Neck Cancers Low survival rates in advanced stages > 5 years 60% Prognosis worsens as the depth of the

tumor increases

Oropharyngeal Cancer

Oropharyngeal cancer forms in the tissues of the oropharynx.

Back of the mouth, including soft palate, base of the tongue, & tonsils.

Oropharyngeal Cancer Background

Oral Cavity & Oropharynx composed of several cells. Different cancers can form in

different cell locations. Cancers that form in the oral

cavity and oropharynx. 1. Benign or non-cancerous growths 2. Pre-cancerous conditions 3. Squamous Cell carcinoma

Squamous Cell Carcinoma

Anatomy and physiology• Begins in the squamous cells

• Thin flat cells that form the outer layer of the skin, hollow

organs of the body, and lining of the respiratory tract

• Cancer is formed from the reserved cells

• Carcinoma in Situ

Oropharyngeal Squamous Cell Carcinoma

Risk Factors Tobacco/Alcohol use

Poor oral hygiene

Human papillomavirus infections (HPV)

Obesity

Mate’ tea

Poor diet/low fruits & vegetables/preserved & processed foods

Occupational exposure

Radiation exposure

Epstein-Barr Virus infection

Ancestry

Alcohol and tobacco

Tobacco/ETOH75%

HPV,other risk factors

25%

Main risk factors in developing Squamous Cell Carcinoma

Main Risks continued

Combined ETOH and tobacco synergistic

50 or more grams a day 2x risk

Mechanism

7 % people in the US have HPV (1% have oropharyngeal cancer)

ETOH Mechanism

ETOH AcetalaldhydeCarcinogen,

damages DNA, protein synthesis

ETOH Mechanism #2

ETOH ROS & estrogen blood levels

Damages DNA, lipids, protein

synthesis/ impairs body’s ability to

break down nutrients

HPV Mechanism

HPV Cancer

HPV invades skin cells

DNA from HPV enters skin

cells

HPV causes infected skin cells

to multiply and form warts

Virus sheds setting it free to

infect normal tissues

Diagnosis Signs & symptoms Physical

Examination Diagnostic tests Imaging Lab tests/lab

markers

Signs & Symptoms Red or White patch's in the

mouth Lump, bump, or mass Persistent sore throat Swelling Hoarseness Foul mouth odor Unexplained weight loss Ear and jaw pain Painful, difficulty chewing,

swallowing, moving jaws

Physical Examination

Inspection of head and neck area using a light and mirror

Dr. detects for present lumps in neck, gums, cheeks.

Physical Examination

Imaging Endoscopy (thin lighted flexible

tube) - Laryngoscope- Esophagoscope- Nasopharyngoscope

Biopsy (removal of a small amount of tissue for examination

MRI Pet Scan X-rays/barium swallow CT scan

Imaging

Lab Values

Complete blood count Tumor marker tests CRP ZINC Calcium BUN Cr Neutrophils/Lymphocytes/Macrophages

Cancer Diagnosis Staging

American Joint Committee (AJCC) designated staging to define oropharayngeal cancer.

TNM staging classification Stage grouping

TNM Staging Classification

T: size of the primary tumor, and which; if any tissues of the oral cavity or oropharynx it has spread to.

N: extent of spread to nearby (regional lymph nodes).

M: Indicates if the cancer has metastized to other organs/tissues of the body.

Stage Grouping Once T,N,M categories established Stages:

O

I

III IV

II

VI

Example (T1, No, Mo) Stage 1 : The tumor is 2 cm (3/4”) across or

smaller (T1) and has not grown into nearby structures, lymph nodes (N0), or distant sites (M0).

Stage IVA: can be 1 or 2

1) T4a, N0, or N1, M0: The tumor is growing into nearby structures (T4a). Size can vary (small-large). The tumor has either not spread to the lymph nodes (N0) or has spread to one lymph node on the same side of the head or neck, which is not larger than 3 cm (N1). The cancer hasn’t spread to distant sites (m0).

2) T1-T4, N2, M0: The tumor is any size and may or may not grow into nearby structures (T1-T4a). It has not spread to distant sites (M0). It has spread to one of the following:

- One lymph node on the same side of the head and neck that is between 3-6 cm across (N2a).

- One lymph node on the opposite side of the head and neck that is no larger than 6 cm across (N2b).

- 2 or more lymph nodes, all of which are no more than 6 cm across. The lymph nodes can be on any side of the neck (N2c).

Treatment Treatment Factors 1. The stage of cancer2. The number of lymph nodes with

cancer 3. Whether the patient has HPV

infection of the oropharynx 4. Whether the patient has a history of

smoking for more than ten years.

Treatment Team

Treatments Surgery Chemotherapy Radiation Therapy CAM Therapy (Gerson) New treatments $$$

Surgery Surgery ( life threatening cases )

- removal of tumor- may also receive chemo and radiation - Adjuvant therapy (secondary treatment)

Chemotherapy Treatment that uses drugs to

stop the growth of cancer cells, either by killing the cells via apoptosis, or by stopping the cells from dividing .

Mouth or injected into vein or muscle.

Systemic chemotherapy (distant)

Regional therapy (local)

FDA Approved Drugs Methodtrexate Fluorouracil Bleomycin Cetuixmab (1.9 Billion) Cisplatin Docetaxel Efudex Erbitux Erbitux Flurouracil Folex PFS Methotrexate-AQ Platinol Platinol-AQ Docetaxel

Radiation Therapy High energy X-rays to kill cancer cells &

keep them from growing. Two Types1. External radiation therapy: uses a

machine outside the body to send radiation toward the cancer.

2. Internal radiation therapy: uses a radioactive substance sealed in needles, seeds, wires, or catheters placed directly into or near cancer.

CAM Complimentary medicine: used together with

conventional medicine & shown to be effective.

Alternative medicine: used in placed of conventional medicine, also shown to benefits.

4/10 diagnosed with cancer used CAM

Meta analysis study showed > 50% of all cancer patients worldwide use CAM

CAM Prayer and spiritual practice Relaxation: yoga, meditation,

religious acts . Nutritional supplements and

vitamins (40%)

CAM

Gerson Therapy Dr Max Gerson American Physician Developed Gerson therapy in

1930’s Dietary therapy claimed to

cure cancer Fresh organic juice, coffee

enemas 15-20lbs of organically grown

fruits and vegetables daily. One glass every hour, 13X/day Supplementation Detox

Gerson Therapy Journal of Clinical Oncology: head to head test of Gerson vs

chemotherapy agent gencitabine. 55 patients pancreatic cancer 23 elected chemotherapy, 32 elected enzyme treatment (raw

foods). Study stopped early due to excessive deaths in Gerson patients Conclusion: those who chose gencitabine-based chemotherapy

survived more than three times as long (14 months) and had better quality of life.

Dozen study’s published & reviewed by the Lancet Journal concluded “ there is little scientific evidence to support Gerson therapy use, and may be completely useless, expensive and dangerous”.

Nutritional Care Estimates indicate 50% of head and neck cancer

patients present malnutrition at time of diagnosis. Cancer and its therapies place great stress on

patients nutritional status. Increase risk

- severe depletion of lean muscle- weight loss - body composition- morbidity/mortality- ineffective treatment/ treatment toxicity- malnourishment

Severe Side Effects = Malnutrition

Severe Side Effects Dysphagia -87% of patients, 49% 3 months, 22% 6 months Anoreixa - >50% Decreased oral intake >50 % Odynophagia (painful swallowing) Mucositis - 76% of patients experience Esophagitis Xerostomia (dry mouth) Taste changes Dental carries Fatigue

Nutrition Therapy Maintains body weight,

strength, body tissues, and fights infection.

Patients who are well nourished have a better prognosis and quality of life.

risk of cancer cacheixa and anorexia.

risk of treatment related toxicities

Nutrition Therapy Goals 1. To achieve and/or maintain optimal

nutrition status and body weight.2. To maximize benefits of therapy/reduce

symptoms secondary to therapy. 3. To prevent or reverse a compromise in

visceral protein status. 4. To prevent or reverse

immunosuppressant 5. To improve quality of life.

Nutrition Therapy Management of side effects • small frequent meals• liquids/supplements between meals• pleasant meal time atmosphere• adding etc kcal’s w/ fats • offering the patient their favorite foods• avoid strong odors • soft moist foods (mechanical soft, pureed)• thickened liquids • use plastic flatware & glass cups/plates

Nutrition Support H & N cancer patients maintain

functional gut. Enteral Feeding vs. Parenteral Enteral feeding

- reduced weight loss- hospitalizations- dehydration- malnutrition- treatment interruptions - improvements in anthropometrics & lab values.

10% H/N cancer patients require permanent EN (dysphagai 4)

Nutrition Support Methods

- severe malnutrition : 15-20kcals/kg to avoid refeeding syndrome.

- Adjust nutrition needs in relation to progression.

Enteral Nutrition weight loss poor wound healing activity levels

Enteral Nutrition N/V uncomfortable fullness excessive weight gain

Nutrition Support Route PEG placement most common Long term NG tube <3 weeks ND & NJ Complications:

- Infection- Site leakage- Skin breakdown

Nutrition Support Determining Needs: surgery, therapy,

stage, activity level, nutritional status. Energy needs

- 25-35 kcals/kg (40kcals/kg H & N) - 1500-2500 kcals/day adequate

Protein - 1-1.5 g/kg (normal weight) - 1.5-2.5 g/kg (malnourished

Nutrition Support

Formula - Standard polymeric formula well

tolerated - High protein - 1.5-2.0 kcals/mL preferred for

long term use. - Arginine-enhanced controversial

Nutrition Support

Bolus feeds 1-2 cans/cartons per day

Convenient Minimal cost Oncology Dietitian

Case Study: Mr. M 62 year old Christian Caucasian

Male Husband/Father to a 23 YO

daughter. Retired Air Force Hobbies: climbing 14r’s /hiking,

racquetball Very positive happy man “ God is in control of my life”

Lifestyle Non-smoker Non-drinker Diet - Enjoys his apple pie- Fruit juice - Soups/stews- Doesn’t like vegetables to much- Fast food every so often maybe

once a week

Medical History Hypertension Arthritis Depression Anxiety Squamous cell

carcinoma on the bridge of nose excised 13 years ago.

Diagnostic timeline Oct, 2014 Noticed swelling

Evaluation by primary care physician

Nov, 2014 Ultrasound of left neck

Dec, 2014 MRI of neck

Dec, 2014 Biopsies taken from left and right tongue base.

Diagnosis 1/6/15 Squamous cell carcinoma on left & right tongue

base (oropharynx region) (carcinoma in situ) P16 positive (HPV) No malignancy of other biopsies MRI scan shows no evidence of distant

metastasis. Oropharyngeal cancer: T1 N2 a MO stage IVA (tumor is 2 cm (3/4”) or smaller, the cancer has spread to

one lymph node on the same side as primary tumor, the lymph node is larger than 3 cm across but no larger than 6 cm across, no distant spread has occurred.

Treatment Plan

Chemo-radiation Salvage surgery if needed Radiation 6 weeks Cisplatin 40mg weekly during radiation. PICC line placement Side effects: infection, fatigue,

myelosupression, nausea, vomiting, renal injury, and ototoxicity.

Nutrition Therapy Plan

Peg placement 1/14

90% nutrition via tube

Outpatient

advice for oral intake

Weight Changes

January 6th Febuary 18th April 23rd May 2nd 152154156158160162164166168170

Mr. M weight trends

Dates 2015

poun

ds (l

bs)

169 lbs

165 lbs

158 lbs

163lbs

Comparison of Care Main goals provided to Mr. M Early EN administration PEG placement Bolus Feeds Adjusted TF due to weight loss Received recommendations by

oncology dietitian

Progress and Prognosis

PEG removed

90-95% nutrition via oral intake

Cancer is residing

Will continue ongoing treatment

Successful

Cancer Research 2 servings of nuts/week may protect against pancreatic cancer-British journal of cancer, 2013 Which nuts fights cancer better? Walnuts, Pecans, & peanuts- decreased human liver cancer

& colon cancer cell proliferation – British Journal of cancer, 2013 A follow up of the nurses health study involving the daughters (the growing up study)

showed that those who consumed peanut butter, nuts, lentils, corn found to have a fraction of the risk for fibrocystic breast disease (increases risk of breast cancer) Breast Cancer Research Treatment, 2013

Those eating one or more apples a day had less colon, breast, oral, larynx, kidney, & ovarian cancer. – Planta medicine review, 2008.

Curcumin found to sensitize tumor necrosis factors and up regulate death receptors of cancer cells. – Carcinogenesis journal, 2005.

Higher intake of soluble fiber, was associated with a significantly reduced risk of breast cancer, 62 % lower chance. – European journal of nutrition, 2012.

Positive association between breast cancer risk and saturated fat intake in postmenopausal women. – Journal of the National Cancer Institute, 1990.

25 men with prostate cancer awaiting prostatectomy were given 3 tablespoons of flaxseed/day 1 month before surgery, researchers found lower proliferation rates and higher rates of cancer cell death. Urology, 2004.

Meta-analysis showed that those who have the highest consumption of coffee compared with those who drink no coffee had a 50% reduction in liver cancer risk. – Gastroenterology, 2013

Compounds found in broccoli have inhibitory effects on several types of cancer cells growth, including leukemia, prostate, breast, cervical, lung and colorectal cancer, and shown to decrease metastasis. – BMC Cancer, 2010