Maximizing Nutrition in Oncology Patients - PowerPoint Presentation

Maximizing Nutrition in Oncology Patients Laura Kerns, MPH, RD, CSO, LDN Board Certified Specialist in Oncology Nutrition

Malnutrition and cachexiaMalabsorption XRT and feeding tubes Opioid induced constipationOther common concernsScreening and consults Food pantryCancer kitchen Outline 2

50% of cancer patients have some nutritional deficit prior to being diagnosed 85% of patients experience malnutrition and weight loss at some point during cancer treatmentLung, esophagus, head and neck, colon, rectum, liver, and pancreas are at highest risk 20% of cancer deaths may be attributed to cancer-induced cachexia Malnutrition in oncology 3 Halpurn-Silveira D, et al. Support Care Cancer. 2010;18:617-625. Laviano A, et al. Nutrition . 1996;12:358-371. Tisdale MJ. Nat Rev Cancer . 2002;2:862-871

Progressive loss of lean body massDecreased adipose tissue and skeletal muscle mass Cannot be reversed through nutrition intervention alone Observed in 30-80% of cancer patients Causes death in up to 20% of these cases Cachexia 4

Patients don’t feel wellAnxious about treatment Patients morbidly obese weight loss overlooked Metabolic dysfunction (cachexia) No true solutionChemotherapy dosing is based on overall body weight or BSA, not lean tissueSarcopenic obesityIncreased toxicity= increased risk for malnutrition “Part of the cancer experience” 5

Treatment interruptionGrade III and IV complications Infections Hospital readmissionsReduced response to treatment Early mortality Consequences 6

Insufficient food intake compared with nutrition requirementsWeight loss over time Loss of muscle mass Loss of fat massFluid accumulationDiminished functional status as measured by hand grip strengthClinical manifestations of malnutrition 7 White et al., JAND 2012;112:730-738.

What lowers albumin? Inflammation Renal dysfunctionHepatitis, HCC, or other liver problems CHF and other cardiac problems Inflammatory bowel disease (IBD)Certain cancers themselves (e.g. sarcomas) Side effects from medications Infections Poor nutritional status A malnourished patient can have a normal albumin level and a healthy patient can have a low serum albumin e.g. anorexia Why not albumin? 8

Insufficient energy intake Weight loss Loss of muscle massLoss of subcutaneous fatLocalized or generalized fluid accumulation that may mask weight lossDiminished functional status as measured by handgrip strength At least two of these characteristics should be identified for malnutrition ASPEN Criteria 9

Daily supplementation with fish oil (EPA+DHA) 2000mg (2g) EPA and 250mg DHA EPA down regulates the production of pro-inflammatory cytokines such as IL-6, IL-1 and TNF Supplementation may also improve response to treatment (studies in NSCLC) Early evidence has not been consistent Newer studies have shown promise Better adherence in clinical trials Supplements taste better now-not fishyFish oil is more popular Earlier interventionsCaution with Warfarin Fish Oil for Cachexia 10 Genes Nutr . 2008 Apr; 3(1): 25–28 . Curr Probl Cancer. 2011 Mar-Apr; 35(2): 58–90. Murphy et al. (2011) Nutritional intervention with fish oil provides a benefit over standard of care for weight and skeletal muscle mass in patients with nonsmall cell lung cancer receiving chemotherapy. Cancer, 117: 1775–1782.

Small, frequent, calorically dense meals Nutritional supplements Social interaction with meals Benefits: Significant increase in energy intake Weight gain Increased appetite Improved quality of life Nutrition interventions 11 Baldwin C, Spiro A, Ahern R, Emery PW. Oral nutritional interventions in malnourished patients with cancer: a systematic review and meta-analysis. J Natl Cancer Inst. 2012;104:371–385.

Anamorelin HCl Once-daily (100mg dose)Orally active ghrelin receptor agonist Published findings in The Lancet Oncology (Feb. 2016)I mprovement in lean body mass, total body mass and hand grip strength Determined benefits did not outweigh risk (due to poor study design and data reporting) Oxandrolone ( Oxandrin)Anabolic steroid Well-tolerated at low doses (10mg BID) Increased body mass and improved ECOG scores Pharmacological interventions 12 Trends Mol Med. 2013 May; 19(5): 292–301 Curr Probl Cancer. 2011 Mar-Apr; 35(2): 58–90.

Cyproheptadine Hydrochloride ( Periactin) Histamine and serotonin antagonistMostly observational studies Corticosteroids Short-term responseUse with advanced cancer only Indirectly improves appetite Euphorigenic and anti-inflammatory effectsContinued… 13

Needs prior auth Documentation Why marinol over other options (megace, etc)Indication (anorexia vs nausea/vomiting) Sign a PA form and do progress noteWe’ll take care of the rest! Marinol 14

Malabsorption Maximizing nutrition for oncology patients with 15

Can be a direct effect of cancer Pancreatic cancer Gastrinomas Can be an indirect effect from cancer treatment Gastrectomy Colectomy Intractable diarrhea from chemotherapy or radiation therapy Causes of Malabsorption 16

Soluble Draws in water and slows down digestion Oatmeal, nuts, beans, apples, barley, seeds, lentils, peas, and some fruits and vegetablesAlso found in psyllium, a common fiber supplement (Metamucil) Can be good for diarrhea Insoluble Adds bulk to stool Helps food pass more quickly through the GI tract (decreases gut transit time)Examples: whole grains, vegetables, berries, flaxseed Good for constipation Fiber 17

Indicated with exocrine pancreatic insufficiency Steatorrhea is the most common symptomNot always present, especially when patients are using opioid pain medications Other signsBloatingPostprandial stomach pain Excessive gas Trial of pancreatic enzymes Generally safe S tarting point: 25,000-50,000 lipase units with meals ½ the prescribed dose with snacks Better to start high than too low Max dose is 2,500 lipase units/kg body weight per meal Pancreatic Enzymes 18

Supposed to repair the gut mucosal barrier Reduce diarrhea Maintain weight Lessen dehydration $60 for 12 pack Enterade 19

Radiation therapy in Head and neck cancers Maximizing nutrition for oncology patients receiving 20

Drink plenty of fluids Eat small, frequent meals Add sauces to moisten foods Thicken liquids if needed Enteral nutritionSpeech therapy consultDysphagia 21

Prophylactic G tube Placement 22

Process 23

Presentations LSU Annual QI Forum (2017)World Conference Interventional Oncology (2017)Oncology Nutrition Biannual Conference (2018)Best practice 24

Newer for adults UMC one of only hospitals in region Improved quality of life Safer for some patients Difficult first placement if obese Low-profile (mic-key) 25

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Opioid induced constipation Maximizing nutrition for oncology patients with 27

Abdominal pain Gas and bloating Feeling full Vomiting Appetite loss/food aversion Nutrition Impact 28

Fluids Water, prune juice, decaf teas, etc. Hot beverages Exercise Probiotics Culturelle (studied with diarrhea from 5FU) Philips Colon Health Caution with HIV if CD4 counts are low Increase insoluble fiber intake Remember:Adds bulk to stoolHelps food pass more quickly through the GI tract (decreases gut transit time) Examples: whole grains, vegetables, berries, flaxseed Good for constipation OTC supplement: Nopalina Nutrition intervention 29

Pharmacological intervention Dosage Schedule Drug Brand Names Dose Daily Senna ‐docusate 8.5‐ 50mg per tablet Senokot -S 2 tablets orally 2 times per day (Hold for loose stool) PRN 1 st Line Magnesium hydroxide Milk of Magnesia 30mL orally 2 times per day Polyethylene glycol Mira Lax 17grams dissolved in 8 ounces of fluid 1-3x daily Bisacodyl Dulcolax 10mg orally once a day PRN – 2nd Line Magnesium citrate 150 to 300 mL (1.745 g/30 mL solution) mL orally once daily 30 Table adapted form AGA technical review on constipation: Gastroenterology 2000;119(6):pp1766‐78

Other common concerns Maximizing nutrition for oncology patients with 31

Soft, bland dietHigh calorie liquids Use a straw Temperatures Some like cold, some like warm/hot Avoid mouthwashes with alcohol Avoid spicy or highly seasoned foods Avoid rough, dry, or acidic foods Baking soda/salt water rinses Peroxyl, Mugard, others Mucositis 32

SWISH trial Alcohol-free dexamethasone-based mouthwash (0.5mg/5mL) Start day one of treatment 10mL 4 times per day Swish for 2 minutes then spit Avoid eating/drinking for at least one hour after Recommend rinsing AFTER meals and before bed Stomatitis (with mTOR inhibitors) 33

Increase fluid intake Soft foods Moisten foods with sauces, gravy, etc.Avoid alcohol, tobacco, caffeine Products such as Biotene and Xylimelts Sugar free hard candies Baking soda/salt water rinses Club soda+ lemon juice Xerostomia 34

Baking soda and salt water rinse Plastic utensils Marinades, herbs, spicesPlay with flavors: sweet, salty, tart, etc. Most patients can still taste sweet and sour Zinc supplements???Mixed reviews 50mg TID No longer than 6 weeksInterferes with copper absorption Dysgeusia / Ageusia 35

WATER Flavored caffeine-free beverages NUUN tablets Sports drinks Homemade rehydration solution½ teaspoon salt½ teaspoon salt substitute made from potassium chloride (found in the spice aisle at the grocery store) ½ teaspoon baking soda2 tablespoons sugar4 cups water 1 tablespoon orange juice, lemon juice, or sugar-free drink mix ( optional to add flavor ) Dehydration 36

Better hydration support NUUN sodium 359mgpotassium 101mg vitamin c 38mg riboflavin .5mg calcium 13mgmagnesium 25mg$6 for 12 tabs G2 sodium 160mg potassium 45mg $6 for 12-count 37

Patients prescribed a neutropenic diet have been shown to have poor nutritional status The neutropenic diet has continued in practice despite limited evidence from well-designed and statistically proven studiesDiets have had little or no effect on infection rates in patients with neutropeniaLarge study in 2012 revealed following a neutropenic diet did not reduce infection Reevaluating the Neutropenic Diet 38 Clin J Oncol Nurs. 2014;18(2):239-241.

Neutropenia 39 Teach patients and family members how to wash produce, hands, and surfaces often Counsel patients and family members to rewash produce labeled "prewashed" Cook foods to the proper temperatures Cook meats and seafood No raw oystersAvoiding unpasteurized dairy products and beer Avoid salad bars and buffets

Avoid high doses (>200% daily value) of vitamins or minerals unless there is a known deficiency or need Not enough data or research Supplements not FDA regulated No guarantee of purity or quality Some supplements may promote metastasis of cancer cells Avoid high dose antioxidants Quality and purity testing https://labdoor.com/rankings/fish-oil Supplements 40 Piskounova et al. (2015) Oxidative stress inhibits distant metastasis by human melanoma cells. Nature. 2015/10/14/online

Studies have shown that EGCG and other flavonoids (a type of antioxidant) actually prevent tumor cell death induced by Velcade (bortezomib)Avoid green tea, OTC vitamin C, herbal supplements, and other “antioxidants” Some findings are still controversial but overall consensus at this time is to avoid these foods/supplements Recommend Memorial Sloan Kettering Cancer Center About Herbs https :// www.mskcc.org/cancer-care/treatments/symptom-management/integrative-medicine/herbs/search A note about Velcade 41

Metastatic colorectal cancer GIST HCCSwallow tablet whole with water after a low-fat meal that contains less than 600 calories and less than 30% fat Regorafenib (Stivarga) 42

Screening and Referrals 43

Two Validated Tools Malnutrition screening tool Food insecurity screening 44

From screening tools Ambulatory referral to nutrition (NOT dietary) Select “oncology” If able, allow multiple visits (12)Referrals 45

Obesity or chronic conditions Can also send to Pam (clinic dietitian, diabetes educator) Survivorship General questions Pancreatic insufficiency Treatment related side effects Including oral chemo Other reasons for referrals 46

Food pantry 47

Only one in the state Less than 10 in the country Partnership with Second Harvest and Aramark 3 year grant through BCMAims to address food insecurity Based on community needs assessment First of its kind 48

Current Pantry 49

Refrigeration Fresh and frozen produce, eggs, meat, milk (all types) Nutritional supplements Research Support programs Future Plans 50

Cancer kitchen 51

Chance to “get out” Every other month Cancer survivors and a guest 6-8pm Simplee Gourmet Cooking store in south market district Cancer Kitchen 52

Great participation 53

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Thank you! Questions?? 56