Lung cancer and pulmonary nodules Resident’s seminar 02/01/2006 Elsa B. Valsdottir.
Seminar 2 Cancer
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Transcript of Seminar 2 Cancer
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Management on Oncology PatientsSiti Farrah Zaidah Bt Mohd Yazid (P60332)
Yusmaeliza bt Istihat (P60324)
ND6073
Medical Aspect In Nutrition
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Outline Presentation
1. Introduction
2. Pathophysiology & risk factor of cancer
3. Treatment option4. Dietary management
5. Complementary and alternative medicine(CAM)
6. Conclusion
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Introduction The National Cancer Registry (NCR) reports that cancer was the third leading cause
of death in PENINSULAR MALAYSIA 2006
10 Principle Cause of Deaths in Ministry of Health, Malaysia (MOH) Hospitals, 2006
Source: MALAYSIAN CANCER STATISTICS- DATA AND FIGURE,PENINSULAR MALAYSIA.2006. National Cancer Registry. Ministry of Health Malaysia
Diseases Percentage (%)
Septicaemia 16.87
Heart Diseases & Diseases of Pulmonary Circulation 15.7
Malignant Neoplasms 10.59
Cerebrovascular Diseases 8.49
Pneumonia 5.81
Accidents 5.59
Diseases of the Digestive System 4.47
Certain Conditions Originating in The Perinatal Period 4.2
Nephritis, Nephrotic Syndrrome & Nephrosis 3.83
Ill-define conditions 3.03
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Prevalence & statistics
21,773 cases diagnosed & registered with theNational Cancer Registry
National Cancer Registry Peninsular Malaysia,2006
54.2%females
(11 799 cases)
45.8%males (9 974
cases)
21,773
cases
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Ten most frequent cancers,
Peninsular Malaysia, 2006
16.5
13.2
9.4
4.9
4.5
4.1
3.6
3.6
3.4
3.2
0 5 10 15 20
BREAST
COLORECTAL
LUNG
CERVIX UTERI
NASOPHARYNX
THYROID GLAND
LIVER
STOMACH
PRSOTATE GLAND
LYMPHOMA
National Cancer Registry Peninsular Malaysia,2006
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Cancer Incidence per 100,000 population (CR) by sex in
Peninsular Malaysia 2006
16.2%colorectal
14.5%Lung
7.5% NPC
7.4%Prostate
gland
5.7% Liver
29.9% breast
10.6% Colorectal
9.1% Cervix uteri
5.8% Ovary
5.7%Thryriod
gland
Males Female
National Cancer Registry Peninsular Malaysia,2006
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Pathophysiology & Risk Factors Cancer describes a group of more than 150 disease processes
characterized by uncontrolled growth and spread of cells.Cancer is not a singular, specific disease but a group ofvariable tissue responses that result in uncontrolled cellgrowth
(McCance & Roberts, 1998; Fraumeni, 1982).
Malignant cells may also metastasize to other areas of thebody through the cardiovascular or lymphatic systems. Thisuncontrolled growth and spread of cancer cells can eventuallyinterfere with one or more of a person's vital organs orfunctions and possibly lead to death. The primary sites ofcancer metastasis are the bone, the lymph nodes, the liver,the lungs, and the brain
(McCance & Roberts, 1998).
Source: The National Center on Physical Activity and Disability, www.ncpad.org
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Pathophysiology & Risk Factors
Benign neoplasms or tumor cells are made up of the same cell type as theoriginal parent cell, but have abnormal growth rates. Benign cells do notmetastasize or invade surrounding tissue. Benign cells can, however, pose asignificant problem in the body when they grow too large and compress vitalorgans or organ systems. The following will describe both malignant andbenign tissue changes that occur in the body from abnormal growth and
differentiation(McCance & Roberts, 1998).
Factors that affect tumor growth and development include the status of anindividual's immune system, the rate the tumor cells are growing, thenumber of tumor cells actively spreading, and the rate that the normal
tissues are being destroyed by the tumor. Several factors affect normalimmune function, including stress, malnutrition, advancing age, and chronicdiseases. Cancer itself appears to suppress the immune system both earlyand late in the disease process
(McCance & Roberts, 1998).
Source: The National Center on Physical Activity and Disability, www.ncpad.org
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Pathophysiology & Risk Factors
Uncontrolled cell growth is a characteristic ofcancer. Cellular growth rates are regulated byproteins produced by the genetic material incells. Genetic material can be altered or
mutated by environmental factors, errors ingenetic replication or repair processes, or bytumor viruses. Altered or mutated genes arecalled oncogenes, and it is these oncogenes
that allow uncontrolled growth in cells(McCance & Roberts, 1998).
Source: The National Center on Physical Activity and Disability, www.ncpad.org
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Cancer- related cachexia
Characterized by equal loss of fat & muscle, adipose tissue & increased
energy expenditure.
The Clinical Guide to Oncology Nutrition 2nd edition.2006.ADA
cancer
Tumor product Endocrine alteration Systemic inflammatoryresponse (cytokines)
Metabolic abnormalities
lipolysis Protein loss anorexia
cachexia
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Prevalence of Malnutrition
(National Cancer Institute US, 2007)
80%malnutrition
20-40% dieddue to
malnutrition
60%of Head & neck & GI patients lose weight upon beginningtreatment
40% develop mucositis during chemotherapy &
100% during chemoradiation
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GOALS in cancer patients
Nutritionalgoals
Reduceadverse effectsof anti tumor
therapies
Prevent &treat under
nutrition
Enhancinganti-tumortreatment
effects
Improvingquality of life
Source:ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology.2006
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Nutrition Treatment Goals
Phase 1: Getting Through Treatment
(Primary Goals)
Prevent or correct nutritional deficiencies
Minimize short-term and long-term treatment side effects
Improve tolerance to treatment
Enhance quality of life during treatment
Help achieve and maintain optimal body weight
Educate family members about special nutrition needs
Evaluate the risks and benefits of nutrition-related CAM(supplements, vitamins, minerals, herbs); consider medicationinteraction issues!
Source: National Cancer Institute US, www.cancer.gov
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Phase 2: Cancer Fighting Nutrition For Life
(Secondary Goals)
Maintain healthy weight Incorporate healthy nutrition habits for long-term health
Maximize cancer preventive potential of the diet (minimize
recurrence risk)
Evaluate the risks and benefits of nutrition-related CAM(supplements, vitamins, minerals, herbs); consider medication
interaction issues!
Nutrition Treatment Goals
Source: National Cancer Institute US, www.cancer.gov
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Treatment for Cancer
Local therapy
Surgery.
Radiationtherapy
Systemictreatment
Chemotherapy.
Hormonaltherapy
Monoclonal
antibodies
Radioactivematerial
Supportive careNon-
conventionaltherapy.
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov
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Chemotherapy
The main treatment available is systemicchemotherapy
Systemic chemotherapy disseminate malignant
disease Progress in chemotherapy resulted in cure for
several tumors
Require multiple cycles
Cytotoxic agent involved in the treatment,categorized to phase nonspecific and phase specific
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov
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Chemotherapeutic Agent
Alkylating agents
Antimetabolites
Antitumor antibiotic Plant alkaloids
Other agents
Hormonal agent Immunotherapy
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov
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Side Effect of Chemotherapy
Short Term:
Nausea
Vomiting
Myelosuppression /Infection
Alopecia
Mucositis
Fatigue Heart failure
Long Term:
Heart failure
Premature menopause
Bone loss
Cognitive impairment
Neuropathy
Weight gain
Sexual dysfunction
Fatigue
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov
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Dealing with treatment side effect
Drink more fluids during chemotherapy,
intravenous hydration may also help.
Chemotherapy-induced menopause, which
may result in a rapid and significant decline inbone density consider adjuvant use of
bisphosphonates
Increase cardiovascular fitness - exerciseimproved cardiorespiratory fitness, physical
functioning, and fatigue.
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov
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Management of locally advanced breast cancer:Neo-adjuvant chemotherapy
However, there are no signs that the cancer has spread beyond thebreast region or to other parts of the body.
Chemotherapy: CPG Guidelines on
Management of Breast Cancer
Locally advanced breast cancer is invasive breast cancer thathas one or more of the following features:
large (typicallybigger than 5 cm)
spread to severallymph nodes in theaxilla or other areas
near the breast
spread to severallymph nodes in the
axilla such as theskin, muscle or ribs
Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia. 2011
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Chemotherapy: CPG Guidelines on
Management of Breast Cancer
A study showed that neo-adjuvant chemotherapy
can be given to downsize the tumour in an
attempt for BCS or enable subsequent surgery forinitially inoperable breast cancer. In addition to
improving both operability and rates of BCS, neo-
adjuvant chemotherapy also provides a valuablewindow to assess disease response to treatment
and perform correlative tissue analyses.(level I)
Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia. 2011
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Chemotherapy: CPG Guidelines on
Management of Breast Cancer
RECOMMENDATION
Neo-adjuvant chemotherapy orpre-operative systemic therapycan be offered to patients with
operable locally advancedbreast cancer who are not
suitable candidates for BCS atpresentation. (Grade A)
In locally advanced breastcancer that is inoperable, neo-
adjuvant chemotherapyshould be given to downsize
the tumour to enablesubsequent surgery. (Grade A)
Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia.2011
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Radiation Therapy
Radiation therapy can affect cancer cells and
healthy cells in the treatment area. It kill
cancer cells and healthy cells. The amount of
damage depends on the following:
The part of the body that is treated.
The total dose of radiation and how it is given
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Nutrition impact associated w Radiation therapy
Site of radiation therapy Acute effects Late effects
Central nervous systems
(brain & spinal cord)
nausea, vomiting
Elevated blood glc due to
steroid administration
fatigue loss of appetite
headache, letharge
Head & neck area
(tongue, larynx, pharynx,
oropharynx, nasopharynx,
tonsils, salivary glands
xerostomia
Sore mouth, throat
dysphagia, odynophagia
mucositis
alterations in taste &
smell
fatigue
loss of appetide
Mucosaatrophy,
dryness, ulceration
salivary glands-
xerostomia, fibrosis
Trismus
Alteration in taste & smell
The clinical Guide to Oncology Nutrition 2nd
Edition.2006. American Dietetic Association.
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Nutrition impact associated w Radiation therapy
Site of radiation therapy Acute effects Late effects
Thorax (esophagus, lung
also breast if treatment
field involves esophagus
dysphagia, odynophagia
heartburn
fatigue
loss of appetite
esophageal-fibrosis, stenosis,
necrosis
cardac- angina on effort,
pericarditis, cardiac
enlargement
pumonary-dry cough,
fibrosis, pneumonia
Abdomen & pelvis
(gastrointestinal system,
reproductive organs,
prostate, colon, rectum,
testicles
nausea, vomiting
Changes in bowel function-
diarrhea, cramping, bloating, gas
changes in urinary function-
increased frequency, burning
sensation with urination acute colitis @ enteritis
lactose intolerance
fatigue
Loss of appetite
diarhea, malabsorption,
maldigested
chronic colitis @ enteritis
intestinal-stricture,
ulceration, obstruction
perforation, fistula urinary-hematuria, cystitis
The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association.
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Evidence Based Practice Guidelines for theNutritional Management of Patients
Receiving Radiation Therapy. 2008.
Dietitians Association Of Australia. Journalof the Dietitians Association of Australia,
including the Journal of the New Zealand
Dietetic Association
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NHMRC grades of recommendation (2005)
Level A Body of evidence can be trusted to guide practice
Level B Body of evidence can be trusted to guide practice in most situations
Level C Body of evidence provides some support for recommendation(s) but care
should be taken in its application
Level D Body of evidence is weak and recommendation(s) must be applied withcaution
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RecommendationGrade
Nutrition screeningAll patients receiving RT to the gastrointestinal tract (GIT), head and neck
area should be referred to the dietitian (and/or nutrition support)
B
Nutrition assessment
nutrition assessment tools (e.g. scored Patient Generated-Subjective GlobalAssessment (PG-SGA) or Subjective Global Assessment (SGA) should be
used to assess the nutritional status of patients receiving radiation therapy
B
Dietary counseling and/or supplements are effective methods of nutrition
intervention, and frequent (at least fortnightly) dietitian contact improvesoutcomes in patients receiving radiation therapy.
Regular nutrition intervention (dietary counseling and/or supplements)
improves energy and protein intake and nutritional status during radiation
therapy.
A
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Grade
Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) feeding areeffective in achieving higher protein & energy intakes and weight maintenance in head
and neck cancer patients undergoing RT compared with oral intake alone
B
Aim for energy and protein intakes of at least 125 kJ/kg/day and 1.2 g protein/kg/day
in patients receiving RT. Patients should have their weight and food/energy intakemonitored regularly to determine whether their energy requirements are being met.
C
Aim to minimise weight loss and maintain quality of life and symptom management in
patients receiving radiation therapy
C
Recommendation
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Use intensive dietary advice and oral nutritional
supplements to increase dietary intake and to prevent
therapy-associated weight loss and interruption of
radiation therapy. (grade A )ESPEN Guidelines on Enteral Nutrition:Non-surgical oncology.2006
All patients receiving radiation therapy to the head and
neck area should be referred to the dietitian for
nutrition support (Grade A)Clinical Oncology Society of Australia (COSA),2011
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Nutrients Requirement
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Estimating Energy Intake by using Equation
Harris Benedict Equation Validation studies :original studies conducted on healthy volunteers. Note that
for obese individuals (BMI>29.9), formula may overestimate REE 5% to 15%
actual weight is used
Mifflin-St Jeor Validation studies: equation developed from a sample of obese & nonobese
healthy individuals. Some research has indicated that this equation may
provide a more accurate estimation of REE that the HBE in both obese &
nonobese individual, therefore this equation deserves consideration
Ireton-Jones Validation studies: equation developed from a sample of hospitalized patients
including criticality ill patients & patients with burn. Recent research has
reported that this equation underestimates energy requirements
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Energy Estimation based on Body Weight
Useful as initial estimation of energy req. and
should be adjusted as individual nutritional
status & activity level changes
Still lack evidence based validation.Condition present Energy needs (kcal/kg)
Cancer, nutritional repletion, weight gain 30 35
Cancer ,nonambulatory, inactive 25 30
Cancer, hypermetabolic, stressed 35
Sepsis 25 30
Stem cell transplant 30 -35
Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association
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Protein
Most patients found to be negative nitrogen balance, worsen
as the malignancy progresses
Table: Estimating daily protein needs in adult Cancer Patients
Medical condition Estimation protein Needs (g/kg)Normal maintenance 0.8 -1.0
Nonstressed cancer patients 1.0 1.2
Hypercatabolism 1.2 1.6
Severe stree 1.5 -2.5
Requiring nutrition support 1.6 2.0
Stem cell transplant 1.5 2.0
Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association
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ESPEN Guidelines on Enteral Nutrition:Non-surgical oncologyClinical Nutrition (2006) 25, 245-259
ESPEN Guidelines on Parenteral Nutrition
Non-surgical oncologyClinical Nutrition (2009) 1-10
Subjects ESPEN Guidelines on Enteral Nutrition: ESPEN Guidelines on Parenteral
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Subjects ESPEN Guidelines on EnteralNutrition:
Non-surgical oncology
ESPEN Guidelines on Parenteral
Nutrition: Non-surgical oncology
General
Indication
TEE can be made for non-obese
patients using the actual body weight:
Ambulant patients : 30-35 kcal/kg/d
Bedridden patients : 20-25 kcal/kg/d
Start nutrition therapy if undernutrition
already exists or if it is anticipated that
the pt will be unable to eat for > 7 days
(Grade C)
Total daily energy expenditure in cancer
patients may be assumed to be similar to
healthy subjects, or
Ambulant patients : 25-30 kcal/kg/d
Bedridden patients : 20-25 kcal/kg/d
(Grade c)
Start EN if inadequate food intake
(< 60% of ER) for > 10 days is expected.
Amount to give = ER actual intake
(Grade C)
Supplemental PN is recommended in
patients ifinadequate food and enteral
intake (
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,
Subjects ESPEN Guidelines on Enteral
Nutrition:Non-surgical oncology
ESPEN Guidelines on Parenteral
Nutrition: Non-surgical oncology
Perioperative Pts with severe nutritional risk
benefit from10-14 days nutritional
support prior to major surgery evenif the surgery has to be delayed
(Grade A)
Perioperative PN is recommended in
malnourished candidates for artificial
nutrition, when EN is not possible(Grade A)
Perioperative PN should not be used
in the well-nourished (Grade A)
Pts on RT /
Radio
chemotharpy
Give intensive dietary advice + oral
nutritional supp :
dietary intake
prevent therapy-assoc. wt loss
prevent interruption of RT
(Grade A)
The routine use of PN during
chemotherapy, radiotherapy or
combined therapy is not
recommended (Grade A)
During
chemotherapy
Routine EN not considered useful-
has no effect on tumour response tochemo or on chemo-assoc.
unwanted effects (Grade C)
If patients are malnourished or facing
a period longer than one week ofstarvation and EN is not feasible, PN
is recommended (Grade C)
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Subjects ESPEN Guidelines on Enteral
Nutrition:Non-surgical oncology
ESPEN Guidelines on Parenteral Nutrition:
Non-surgical oncology
In incurable
pts
give EN to mconsents + dying
phase has not started (Grade C)
inimize wt loss if pt
In intestinal failure, long-term PN should
be offered, if
enteral nutrition is insufficient,
expected survival due to tumor
progression is longer than 23 months),
it is expected that PN can stabilize or
improve performance status and quality
of life
the patient desires this mode of
nutritional support
There is probable benefit in supporting
incurable cancer patients with weight loss
and reduced nutrient intake withsupplemental PN
(Grade B)
Close to end of life , most pts
require minimal amounts of food
and water to reduce thirst &hunger (Grade B)
Small amount of fluid may help to
avoid dehydration induced
confusion (Grade B)
IV drip in hosp or at home may be
helpful and provide route for
drugs administration (Grade C)
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Subjects ESPEN Guidelines on Enteral Nutrition:Non-surgical oncology
ESPEN Guidelines on
ParenteralNutrition: Non-
surgical oncology
Enteral
formula
Use standard formulae (Grade C)
Use preoperative enteral nutrition preferably
with immune modulating substrates (arginine, o-
3 fatty acids, nucleotides) for 57 d in all patients
undergoing major abdominal surgery
independent of their nutritional status(Grade A)
In cachectic patients steroids or progestins are
recommended in order to enhance appetite,
modulate metabolic derangements, and prevent
impairment of quality of life.
(Grade A)
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Immunonutrient
Does supplementation with
w-3 fatty acids & glutamine have beneficial
effect in cancer pts?
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Immunonutrient
RCTs shown :
Evidence is contradictory/controversial
At present, not possible to reach any firm conclusion
with regard to improving nutritional status/ physical
function
( Grade C )
ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology 2006
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Best Bet Complementary Cancer Therapies
Eicosapentaenoic Acid (EPA) (Omega-3s)
Essential fatty acid with potential roles in inflammation, immunity,cachexia
May help decrease cachexia
May improve chemotherapy effectiveness/enhance immune function
Downside:
May have anticoagulant activity so use with caution if platelets low oron coagulation therapy
Generally well tolerated (up to 0.3 g EPA+DHA/kg body weight/day),but diarrhea possible
Dose:
Minimum 2.2 mg EPA /day (best to avoid coagulation complications)
Two new products on the market Prosure & Resource Support
N t iti l l t i h d ith 3 f tt id
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0
0.05
0.1
0.15
0.2
0.25
0.3
Control EPA SupplementTreatment Group
MeanChan
geinPAL
80
82
84
86
88
90
92
94
96
Baseline 3 Weeks 7 Weeks
KPSMeanScore
Mean Change in Physical Activity Level
Following 8 Weeks of Oral Supplementation
Karnofsky Performance Status Following
Supplementation with EPA-Enriched Supplement
Source: Moses, et al, 2001 examined a subset of alarge randomized trial conducted in pancreatic cancerpatients and compared the intake of nutritionalsupplements with and without EPA (1.1g 2.2g/day)and the effects on total energy expenditure andphysical activity level.
Source: Barber MD, et al, 1999. Prospective study in20 patients with pancreatic cancer experiencingongoing weight loss. Patients consumed average 1.9cans/day of a nutritional supplement containing 1.1gEPA/can along with normal intake for 7 weeks.
Nutritional supplements enriched with omega-3 fatty acids
(EPA/DHA) have been shown to improve QOL and performancestatus
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0
50
100
150
200
250
300
With EPA Supplement Without EPA Supplement
Treatment Group
LifeExpec
tancy(days)
Source: Voss AC, et al, 2003. Voss, et al, examined survival rates in pancreatic cancer patients from2 different studies. In one study patients received an omega-3 fatty acid nutritional supplementcontaining 1.1g EPA/can and in the other a supplement containing no omega-3.
Impact of EPA Supplement on Survival
Nutritional supplements enriched with omega-3 fatty acids(EPA/DHA) have been shown to increase life expectancy
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What Is Glutamine?
Neutral, gluconeogenic nonessential amino acid
Stored primarily in skeletal muscle (75%) and liver (25%)
Nitrogen carrier between tissues
Primary energy source for rapidly proliferating cells (e.g.intestinal epithelium, activated lymphocytes, & fibroblasts)
Maybe conditionally essential; depleted in stress states (e.g.
surgery, sepsis, & cancer)
Appears to be synthesized in muscle tissue in substantialamounts
Plasma concentrations are quite high, second only to alanine
Needed for renal acid-base balance
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Why Glutamine For Oncology?
Neuropathy
Arthralgias
Myalgias
Diarrhea
Enteritis & GI Mucosal Damage
Stomatitis
Muscle Mass Preservation??
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Best Bet Complementary Cancer Therapies
Glutamine
Amino Acid May help with diarrhea/GI symptoms & sore mouth/throat
May help decrease mucositis (5-FU)
May help decrease radiation enteritis
May help With Aching Muscles/Nerves (Taxol)
Downside:
No major side effects, some minor side effects
Do not take if you have poor kidney and/or liver function
Dose:
10 grams glutamine powder, three times per day, dissolved inliquid (research has been done with Cambridge Nutraceuticals-Baxter Pharmaceuticals & Glutasolve by Novartis)
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Cancer and Exercise
The cancers that are reported to occur less frequently inactive people are cancers of the colon, breast, prostate, andpossibly the lung, digestive system, thyroid, bladder andthe hematopoietic system (Lichtenstein, et al. 2000;Sternfeld, et al., 1992; Frisch, et al., 1985).
aerobic exercise has been shown to provide benefitsspecifically to people undergoing treatment for cancer.These benefits include improved physical function andrelief from fatigue, nausea, and depression (Pinto &Maruyama, 1999).
exercise enables people who survive cancer with a meansto recover their physical functions and return to a healthyand active lifestyle (Augustine & Gerber, 2000,Friendenreich & Courneya, 1996).
The National Center on Physical Activity and Disability, www.ncpad.org
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Evidence-Based Clinical PracticeGuidelines for Integrative
Oncology: ComplementaryTherapies and Botanicals
Gary E. Deng et al. 2009. Journal of the Society for Integrative Oncology, Vol 7, No 3 (Summer).: pp 85120
h i f d iti it t th
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emphasizes awareness of and sensitivity to themental emotional, and spiritual needs of apatient, combining the best of evidence-based,complementary therapies and mainstream care
in a multidisciplinary approach to evaluate andtreat the whole person.
Integrativeoncology
A substitute for mainstream care, not scientificallyproven, often have no scientific foundation and
have sometimes even been disproved
Alternative
therapy
Medicine that makes use ofunconventional
treatment modalities and approaches that arenonsurgical and nonpharmaceutical but thathave known efficacy and when combined withmainstream care, can enhance effectivenessand reduce adverse symptoms
Complementarytherapy
Complementary and alternative
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Complementary and alternative
medicine (CAM)
Complementary medicine means nonstandard
treatments that you use along with standard ones
(conventional treatment) for supportive care &improve QOF
Alternative medicine means treatments that you use
instead of standard ones (conventional treatment)
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Categories of Complementary Therapy
Therapeutic Approaches Characteristics
Biologically based practices Herbal remedies, vitamins, other dietary
supplements
Mind-body techniques Meditation, guided imagery, expressive arts (music
therapy, art therapy, dance therapy)
Manipulative and body-based
practices
Massage, reflexology, exercise
Energy therapies Magnetic field therapy, Reiki, Healing Touch, qi gong
Ancient medical systems Traditional Chinese medicine, ayurvedic medicine,
acupuncture
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recommendation
Mind-Body Medicine Mind-body modalities are recommended as part of a
multidisciplinary approach to reduce anxiety, mood disturbance,
chronic pain and improved QOL.
Grade: 1B
Manipulative and
Body-Based Practice
For cancer patients experiencing anxiety or pain, massage therapy
delivered by an oncology-trained massage therapist is
recommended as part of multimodality treatment.
Grade: 1C
Exercise and Physical
Activity
Regular physical activities can play many positive roles in cancer
care. Patients should be referred to a qualified exercise specialist
for guidelines on physical activity to promote basic health.
Grade: 1B
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recommendation
Energy Therapies Therapies based on a philosophy of bioenergy fields are safe and may
provide some benefit for reducing stress and enhancing QoL. There islimited evidence as to their efficacy for symptom management,
including reducing pain and fatigue.
Grade: 1B (for anxiety)
1C (for pain, fatigue and other symptom management)
Acupuncture Acupuncture is recommended as a complementary therapy whenpain is poorly controlled, when nausea and vomiting associated with
chemotherapy or surgical anesthesia are poorly controlled, or when
the side effects from other modalities are clinically significant.
Grade: 1A
Acupuncture Acupucture is recommended as a complementary therapy forradiation-induced xerostomia.
Grade: 1B
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NHMRC levels of evidence (1999)Level I Evidence obtained from a systematic review of all relevant randomised
controlled trials
Level II Evidence obtained from at least one properly designed randomised
controlled trial
Level III-1 Evidence obtained from well-designed pseudo-randomised controlled
trials (alternate allocation or some other method)
Level III-2 Evidence obtained from comparative studies with concurrent control
and allocation not randomised (cohort studies), casecontrol studies, or
interrupted time series with a control group
Level III-3 Evidence obtained from comparative studies with historical control, two
or more single arm studies, or interrupted time series without a parallel
groupLevel IV Evidence obtained from case studies, either post-test or pre- and post-
test.
d l d f
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Dietary guidelines & recommendation for cancer prevention
Organization Dietary pattern Physical activity Alcohol other
USDA,US Deptof health &
Human
Service.2005
make smart choicefrom every foods
Get most nutrition
from your calorie
Variety of fruit &
vege.
3 cups low fat @ fat-free/d
3 whole grain
product everyday
choose lean protein
Low in SFA & trans
fats
balance between food& PA
Regular PA & reduce
sedentary activities to
promote health,
Psychological well being
& healthy body weight.Moderate-intensity PA
30-60minutes/d
moderateamount
choose &prepare foods
with less
salt/sugar
< 2.3 g
sodium daily.
i id li & d i f i
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Dietary guidelines & recommendation for cancer prevention
Organization Dietary pattern Physical activity Alcohol other
AmericanCancer
Society.2002
variety of foods,emphasis on plant
sources
5 fruits & vege
everyday
choose whole grain
limit red meat esp. highfat & processed
physically activelifestyle
Maintain healthful
weight throughout
life
Chose foods help
maintain healthfulweight
limitconsumption
National
cancer
institute.1996
include variety of fruit &
vege in the daily diet
avoid obesity moderation
consumption
Dietary guidelines & recommendation for cancer prevention
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Dietary guidelines & recommendation for cancer prevention
Organizat
ion
Dietary pattern Physical activity Alcohol other
American
Institute
for cancer
Research
1997
choose plant-based
diet rich in vege,
fruits, pulse,
minimally processed
eat 13-30 oz @ > 5
serving vege & fruits
daily eat 20-30 oz @ >7
serving cereal,
legumes, nuts, tuber
red meat should
provide
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Conclusion
Treatment for cancer is a multidisciplinary effort.
Special attention must be given to the establishment &
upgrading of treatment facilities & the training of
specialized personnel. In doing so, many lives will be saved & countless more
patients will have chance of obtaining relief from the
distressing symptoms of cancer
Gerard C. C. L. Overview of Cancer in Malaysia.2000.Jpn J Clin Oncol.S37-S42
References
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References MALAYSIAN CANCER STATISTICS- DATA AND FIGURE,PENINSULAR MALAYSIA.2006.
National Cancer Registry. Ministry of Health Malaysia
Evidence Based Practice Guidelines for the Nutritional Management of Patients withHead and Neck Cancer. Clinical Oncology Society of Australia (COSA).2011
Bozzetti F, et al., ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology,
Clinical Nutrition (2009),doi:10.1016/j.clnu.2009.04.011
J. Arends et al.2006 European Society for Clinical Nutrition and Metabolism. All rights
reserved.doi:10.1016/j.clnu.2006.01.020
Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American
Dietetic Association.
Mary M., Susan R., Clinical Nutrition for Oncology Patients.2007. Jones and Bartlett
Publishers.
Linda et al., Evidence Based Practice Guidelines for the Nutritional Management of
Patients Receiving Radiation Therapy.2008. Journal of the Dietitians Association ofAustralia, including the Journal of the New Zealand Dietetic Association. Nutrition &
Dietetics 2008; 65 (Suppl. 1): S1S20 DOI: 10.1111/j.1747-0080.2008.00252.x
Gary et al., Evidence-Based Clinical Practice Guidelines for Integrative Oncology:
Complementary Therapies and Botanicals.2009. Journal of the Society for Integrative
Oncology, Vol 7, No 3 (Summer), : pp 85120
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References Jacqueline Drouin and Lucinda Pfalzer, Cancer Pathophysiology, NCPAD, University of
Illinois, Chicago Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health
Malaysia. November 2010.
Clinical Practice Guidelines. Management of Cervical Cancer. Ministry of HealthMalaysia. April 2003.
Clinical Practice Guidelines. Management of Cancer Pain. Ministry of Health Malaysia.July 2010.
C.Decker Baumann, K. Buhl, S. Frohmuller, A.v. Hurbey, M. Dueck and P.M. Schlag.Reduction of induced-chemotherapy-side effects by Parenteral GlutamineSupplementation in Patient with Metastatic Colorectal Cancer. European Journal ofCancer Volume 35, Issue 2, February 1999, Pages 202-207
Shabert JK, Winslow C, Lacey JM, Wilmore DM. Glutamine-anti-oxidantsupplementation increases body cell mass in AIDS patients with weight loss: Arandomized, double-blind controlled trial. Nutrition 1999;15:860-864.
The National Center on Physical Activity and Disability, www.ncpad.org
British Journal of Pharmacology and Chemotherapy
National Cancer Institute, www,cancer.gov
http://www.ncpad.org/http://www.ncpad.org/http://www.ncpad.org/http://www.ncpad.org/http://www.ncpad.org/http://www.ncpad.org/ -
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Thank You