THI KHC MINH

PH GIO S TIN S DC S

i hc Y Dc TP. HCM
Vit Nam

DINH DNG TRONG

PHNG NGA V IU TR SUY MN
BNH NHN UNG TH
PGS. TS. DS. THI KHC MINH
thaikhacminh@gmail.com

i hc Y Dc Thnh Ph H Ch Minh
Thnh Ph H Ch Minh 19/5/2016

Cach cho n tt nht

i hc Y Dc
Thnh ph H Ch Minh

ng ming

ng thng qua da day

ng thng qua rut (Enteral

duodenal/jejunal)

ng thng vi lng nho va tim truyn

Tim truyn toan phn

Tng quan

T st cn n suy mon do ung th

Dinh dng y hc chuyn bit cho

bnh nhn ung th

Tng kt

Tng quan

T st cn n suy mon do ung th

Dinh dng y hc chuyn bit cho

bnh nhn ung th

Tng kt

St cn thng ph bin:
30-80% bnh nhn ung th

Bozzetti 2008 and 2001; Bosaeus 2001

Laviano A, Meguid MM. Nutrition 1996;12:358-71

Suy mn do ung th
30-80% bnh nhn ung th c st cn
- Bnh l ung th (loi, giai on)
- iu tr
- Tui
- Kh nng nhy cm ca c nhn
- Cng c nh gi
@20% bnh nhn ung th cht do suy mn (suy
dinh dng v mt c).
@50% bnh nhn mi chn on ung th c tnh
trng bing n.
Nutrition; 12: 358-371, 1996

St cn bnh nhn ung th

Ung th
Gim lng thc n
Tm l cng thng
au n
Bing n
Ri lon v gic
Kh nut
Bun nn v i ma
Chng bng v to bn
Tiu chy v ri lon hp thu

Carbohydrate:
- Tng glucose
- Khng Insulin
Caro MM, Laviano A, Pichard, Clin Nutr 2007

Thay i chuyn ha

Cytokin tin vim,

neuropeptides,
Hormon
Tng nng lng
Chuyn ha c bn

Cht bo:
- Tng phn hy cht bo
- Mt cn bng gia to
v phn hy lipid
- Tng oxy ha lipid
- Tng lipid huyt

Protein:
- Tng CRP
- Gim Protein c bp
- Cn bng Nit m

Caro MM, Laviano A, Pichard, Clin Nutr 2007

St cn nng: gim thi gian sng cn

Ann Oncol. 2011, 22(4):835-41.

St cn dn n kt qu iu tr km
bnh nhn ung th ng tiu ha
51%
cn nng

QoL score (0-100)

Chng sng ming 1-4
Thi gian iu tr

n=1555,
(tui 18-84 )

t l phn ng
Thi gian sng

Andreyev, Eur J Cancer 1998

n nh
76
39 %
150 ngy
cao hn
11.9 thng

49%
b st cn
59
52 %
120 ngy

p<0.0001
p<0.0001
p<0.0001

thp hn
7.6 thng

p=0.006
p<0.0001

St cn l yu t tin lng c lp cho

s sng ca bnh nhn K phi khng t
bo nho NSCLC

Bnh nhn K phi

khng t bo nh c
st cn thng
khng hon tt 3
t ha tr

D liu c ly bnh nhn giai oan III/IV NSCLC

Cn nng n nh trong ha tr gp
phn ko di s sng

D liu c ly bnh nhn giai oan III/IV

Ha tr liu tiu chun v cc tr liu ung th

khc lm tng tnh trng st cn do ung th

Carmustine
Carboplatin
Cisplatin
5-Fluoruracil
Doxorubicin
Paclitaxel

Sorafinib
Everolimus

Radiation
Surgery

Gim cn khi bt u iu tr ung th lin quan vi gim t l p ng v

tng c tnh ca thuc v l mt tiu ch quan trng trong theo di tc
dng ph ca tr liu.
US Dept Health and Human services NIH, NCI: CTCAE v4.0

Tc dng ph thng gp iu tr ung th

iu tr

St cn

Mt mi

Bun
nn

Vim
nim
mc
ming

Thay i
khu v

To bn

T l %

50% 90%

70% 100%

30% 90%

40% 100%

35% 70%

40% 50%

Ha tr

Xa Tr

Phu
thut

Liu

php
min dch
= iu tr c tc dng ph thng gp

Suy mon ung th (Cancer Cachexia)

Suy mn ung th c nh ngha l mt hi
chng c trng bi s mt lin tc khi c
xng (c hay khng c km mt khi m) m
n s khng c hi phc hon ton bi h tr
dinh dng thng thng, din tin n suy
chc nng.
V mt bnh hc: cn bng nng lng v
m m do phi hp ca 2 yu t l
- Gim cung cp lng thc n (n gim); v
- Chuyn ha bt thng.
Fearon K et al. Lancet Oncol 2011; 12:489-495

Cn pht hin sm du hiu st cn!

Tin suy
mn

Suy mn

Suy mn nng

Bnh
thng

T
vong
St cn <5%
Bing n
Thay i
chuyn ha
(ch s vim)

Tin suy mn
l du hiu
ban u!

St cn > 5%
BMI<20 v st
>2% hay
HC. Suy mn v
st >2%
Thng n ung
km/ vim ton
thn

Mc suy mn a dng
Bnh ung th: d ha v
khng p ng vi iu tr
ung th
im ch s th cht thp
Tin lng sng cn <3
thng

Cn pht hin sm tin

suy mn v suy mn

Fearon KCH. Eur J Cancer, 2008 &

Fearon et al, Lancet Oncol 2011

Suy mon ung th (Cancer Cachexia)

3/5 tiu chun

Tiu chun bt buc

St cn 5%/ ti a
12 thng
(Hoc BMI<20kg/m2)

sc c (Bn tay)
Mt mi
Bing n
Ch s khi khng m
thp
Bt thng sinh ha:
-

Tng ch s vim (CRP, IL-6)

Thiu mu (Hb<12g/dL)
ALbumin/mu thp
(<3,2g/dL)

Dinh dng cho bnh nhn ung th

Can thip dinh dng

Sm trong tin suy mn v suy mn

iu tr ng ch (a m thc):

iu tr ung th c hiu (phu thut, ha, x tr)

iu tr phi hp nh gim au, nn
iu tr dinh dng:

Ci thin cung cp dinh dng bnh nhn

iu ha p ng chuyn ha lin quan vim (dng cht c bit
v thuc)
Vn ng c th (exercise i khng- Resistance exercise)

Dinh dng cho bnh nhn ung th

ESPEN Guideline 2006- 2009; ASPEN Guideline 2009

B sung DD ng ming
Chn PP dinh
DD qua ng thng
dng thch hp DD tnh mch (PN)

dinh dng

Cng thc iu
ha chuyn ha

NL: 25-30kcal/ kg/ngy

m: 1,2-1,5g/ kg/ ngy
(max 2g)
50% NL khng t m
Acid bo omega 3
Thuc (khng vim, ni
tit t)

Chn phng php dinh dng

ESPEN Guideline 2006- 2009; ASPEN Guideline 2009

C ch nh can thip DD

T vn DD:
B sung DD qua
ng ming
(sip feeding)

Dinh dng qua

ng thng
(Tube feeding)

Dinh dng qua

tnh mch
(Parenteral
nutrition)

Chn phng php dinh dng

ESPEN Guideline 2006- 2009; ASPEN Guideline 2009

Trong x hay ha x tr: T vn dinh dng tch

cc v b sung dinh dng qua ng ming

tng khu phn n v phng nga st cn do iu

tr v ngn nga gin on iu tr (Grade A)
t sonde nui n nu ung th u, mt c, thc
qun gy tc nghn hoc nu c th tin lng
c vim nim mc khu tr (Grade C)

Chn phng php dinh dng

ESPEN Guideline 2006- 2009; ASPEN Guideline 2009

Dinh dng tnh mch

Bn SDD hay i ko di >1 tun v khng th dng DD
qua sonde (Grade C)
Bn vim nim mc hay vim rut x tr nng (Grade C)
B sung DDTM khi tin lng kh nng n ung hay DD
qua sonde <60% nng lng tiu hao/ hn 10 ngy
(Grade C)
DDTM chu phu cho bn SDD khi DD qua tiu ha khng
th thc hin (nh u gy tc nghn ng TH) (Grade A)
Khng dng DDTM:
DD qua ng ming/ sonde nhu cu dinh dng (A)
Tnh trng DD tt trong chu phu (A)
Thng qui trong ha, x tr hay kt hp (A)

Tng quan

T st cn n suy mon do ung th

Dinh dng y hc chuyn bit cho

bnh nhn ung th

Tng kt

Chng ta cho bnh nhn n nh th no??

Can thip bng dinh dng theo cch thng
thng t c hiu qu gii hn
Cc sn phm dinh dng ng ung
tiu chun
Cho n qua ng thng
Dinh dng tim truyn ton phn
Can thip bng dinh dng theo cch thng
thng khng gii quyt c c ch tim n
ca gim cn trong ung th

Chng ta cho bnh nhn n nh th no??

Can thip bng dinh dng theo cch thng

thng khng gii quyt c c ch tim n
ca gim cn trong ung th

Tng cung cp dinh dng n thun

KHNG c hiu qu
105 bnh nhn ung th phi t bo nho, bung trng hoc ung th v.
Tng calo ln 1,5-1,7 ln REE.

tng dung np ng k, nhng tng cn khng ng k

2

c t vn

Change in Weight (kg)

1.5

i chng

1
0.5
0

0.5
1

Time (months)

1.5
2

Tng lng nng lng np vo khng b tr c

nhng thay i chuyn ha dn ti suy mn.

70% c thay i v giac (TA) trong ha tr & cc

triu chng khng gim sau ha tr nhiu thng
Ung th phi
Ung th tuyn ty
Ung th ai trc trang
Tui: 65 nm; Nam

54%
19%
26%
57%

Nghin cu gia ngay 0 v 30 ca CT

Thay i v gic theo thi gian

N=197
Zabernigg et al, Taste alterations in in Cancer
Patients receiving Chemotherapy,
The Oncologist CME program 2010

Lin quan gia thay i v gic v cht lng

cuc sng (QoL)
Thay i v gic lin quan ng k vi:
- Mt cm gic thm n
- Mt mi
- Bun nn/ Oi ma
- Chc nng nhn thc

Zabernigg et al, 2010

Thach thc trong vic n ung

Thay i v giac thng gp nhng bnh nhn ung th do
bnh tt va / hoc iu tr
68 % bnh nhn ha tr liu c thay i v gic1:
- Mi v thc n ging ba cacton hoc giy nham
- Qua mn
- Qua ngot
- Qua chua
- Qua cay ng
- V kim loai
T l c v kim loai dao ng 9,7- 78% ty loai ung th, phng
phap ha tr, v giai oan iu tr 2
Carbohydrat: trehalose
1

Wickham et al, 1999

et al, Cancer Treat Rev 2014

2 Ijpma

i hc Y Dc
Thnh ph H Ch Minh

Ngi bnh
ung th

Khi ung
th

p ng min dch i vi khi ung th:

sn xut cytokine vim nh IL-1, IL-6,
TNF-, INF gama
cm gic
thm n
n ung

p ng protein
pha cp (CRP)
REE (tiu hao NL
lc ngh)

Cc yu t d ha
c hiu u (PIF, LMF)

Phn hy c, m
Bt thng chuyn
ha ng, m,
bo

Hi chng suy mn ung th

i hc Y Dc
Thnh ph H Ch Minh

Ung th
ng ha >>> D ha

Khng b
i ngi
bnh ung
th!

Ngi bnh:
D ha >>> ng ha

Cancer cachexia

i hc Y Dc
Thnh ph H Ch Minh

Ngi bnh
ung th

Khi ung
th

EPA

EPA
p ng min dch i vi khi ung th:
sn xut cytokine vim nh IL-1, IL-6,
TNF-, INF gama
cm gic
thm n
n ung

p ng protein
pha cp (CRP)
REE (tiu hao NL
lc ngh)

Cc yu t d ha
c hiu u (PIF, LMF)

Phn hy c, m
Bt thng chuyn
ha ng, m,
bo

Hi chng suy mn ung th

B sung EPA (-3) bo c th gip n nh cn bnh nhn

ung th c ch n ung tng cng, st cn khng ch .

Liu EPA cho bnh nhn ung th

< 2 g EPA/ngy: KHNG HIU QU
2 g EPA/ngy : LIU TI U
6 g EPA/ngy : KHNG HIU QU HN 2g

Khuyn co ca hi dinh dng lm sng Hoa K

(ASPEN):
Liu 2g/ngy EPA l thch hp gip n nh th
trng bnh nhn, y li st cn dn n suy mn

B sung EPA: ci thin cn nng v hot ng

c th bnh nhn ung th thc qun

Thay i cn nng
* p < 0.05
Change in ECOG score (% of patients)

A
1.75
1.50
Body weight change (kg)

im s nh gi hot ng
Performance score

1.25
1.00
0.75
0.50
0.25
0.00
Activ e

Control

100

Active
Control

80

* p < 0.05
60

40

20

0
Improved

Stable

Worsened

J Cachexia Sarcopenia Muscle. 2015 , 6(1):32-44

Tng cng kt qu ha tr bng FEC 75

cho bnh nhn ung th v di cn
Time to progression

Overall survival

Nghin cu mc p ng v an ton:
1,8 gr DHA l khng c tc dng ph v ci thin kt qu ca ha tr liu khi
dng liu cao kt hp
Kt hp vi DHA liu cao (n=12) cho thy t l p ng iu tr v kh
nng sng st cao hn so vi nhm kt hp DHA liu thp (n=13)
Bougnoux et al., Br J Cancer 2009

i hc Y Dc
Thnh ph H Ch Minh

Suy mn do ung th v 3

Gut. 2003 52(10):1479-86.

i hc Y Dc
Thnh ph H Ch Minh

Eur J Clin Nutr. 2012, 66(3):399-404

i hc Y Dc
Thnh ph H Ch Minh

Can thip dinh dng bnh nhn ung th suy dinh

dng: tng quan h thng v nghin cu gp

Khng lm gim nguy c t vong

Oral nutritional interventions and

mortality meta-analysis.

J Natl Cancer Inst. 2012;104(5):371-85

i hc Y Dc
Thnh ph H Ch Minh

Can thip dinh dng bnh nhn ung th suy dinh

dng: tng quan h thng v nghin cu gp

Ci thin

cht lng
sng cn

Oral nutritional
intervention and global
quality of life
metaanalysis

J Natl Cancer Inst. 2012;104(5):371-85

i hc Y Dc
Thnh ph H Ch Minh

Can thip dinh dng bnh nhn ung th suy dinh

dng: tng quan h thng v nghin cu gp

Gip bnh

nhn tng
cn

Oral nutritional
interventions and
weight gain metaanalysis.

J Natl Cancer Inst. 2012;104(5):371-85

i hc Y Dc
Thnh ph H Ch Minh

T st cn n suy mon do ung th

FortiCare cung cp hm lng cao protein v du c
(n -3 EPA)

n -3 EPA gip gim suy mn, gim vim v h

tr chc nng min dch
Nng lng v protein p ng nhu cu gia
tng bnh nhn ung th
Hng v thch hp, khi lng nh (gip tng s
tun th)

Nghin cu ti Vit Nam

Nghin cu ng dng lm sng, ngu nhin c nhm chng
trn 60 bnh nhn
St cn trung bnh 3,3 kg/thng trc khi vo nghin cu
Bnh nhn ung th i trc trng c suy dinh dng, suy mn theo
bng nh gi SGA tnh trng C (cn nng, chn n, teo c):
St > 5% cn nng trong 6 thng qua,
Teo c t u hoc c denta,
Mt lp m di da c tam u hoc vng xng sn di
ti im gia vng nc
+ Tiu chun loi:
Khng st cn trn hoc bng 3,3 Kg/thng hoc khng c du hiu suy mon
Suy cc chc nng gan, thn, bnh ni tit chuyn ha. Thiu 1 phn c th ( ct
tay, chn ) .
a im:

Khoa ngoi C Bnh vin K.

Trung tm dinh dng lm sng Bnh vin Bch Mai
Khoa ung bu v chm sc gim nh , BV HY H ni
Thi gian: thng 12/2012 6/2015

Nghin cu ti Vit Nam

iu tr phc EPA (2g/ngy) gip bnh nhn
ung th i trc trng chng gim cn v suy mn:
tng trng lng trung bnh ca mi bnh nhn ln
3 kg sau 8 tun iu tr.
iu tr EPA gip bnh nhn ung th i trc trng tng
protein ca c th, ngn nga s ging ha protein ca
c th: Bnh nhn c tng chu vi vng cnh tay; tng
nng Albumin trong mu sau iu tr (40,4 so vi trc
can thip l 29,0 g/l).
Can thip dinh dng b sung EPA gp phn ci thin
cht lng sng cho BN UTTT: 100% BN c cm gic
ngon ming, bnh nhn tng trung bnh 3 kg , tng kch
thc chu vi vng cnh tay, ci thin Albumin mu.

Nghin cu ti Vit Nam

Phc iu tr EPA cho bnh nhn ung

th i trc trng
Liu lng: iu tr lin tc
Protein trung bnh 1,5 1,7g/kg/ngy
Nng lng trung bnh 35 Kcal/kg/ngy
EPA 2g/ngy
Kin ngh: EPA nn c a vo trong iu tr
nhng BN st cn do UTTT v d phng suy
mn v chm sc gim nh trong UTTT giai
on mun

Hiu qu ca iu tr bng EPA trong

dinh dng bng ng ung ph thuc
vo s tun th ca bnh nhn. Bn
cnh vic chn n, vic tun th iu tr
ca bnh nhn vi dng dinh dng cao
nng lng, cao protein v b sung EPA
b gii hn bi v thng xuyn gp phi
mi v kh chu (ca du c). V vy, vic
cn thit l ci thin thin tnh ngon
ming, d chu ca dng dinh dng b
sung EPA ci thin s tun th ca
bnh nhn vi iu tr v mang li hiu
qu tr liu.

i hc Y Dc
Thnh ph H Ch Minh

Thc n m khng
c n th khng
bao gi l dinh
dng!
Prof Jeya Henri

CC CCH CUNG CP
> 2 GRAM EPA/NGY
n lng ln m c
C trch, c ng, c thu, c mi,

Vin du c

Dng sa kt hp gia dinh

dng vi lng v a lng

i hc Y Dc
Thnh ph H Ch Minh

i hc Y Dc
Thnh ph H Ch Minh

FORTICARE: CCH TIN LI CUNG CP DINH

DNG QUAN TRNG CHO BNH NHN UNG TH
Dinh dng chuyn bit cho bnh nhn ung th:
Dinh dng iu tr
Nng lng cao
Hm lng protein cao
H dinh dng hon chnh
Ch s GI thp
Th tch nho
nht thp
B sung nhiu EPA
Hng v tuyt vi

ap ng nhu cu bnh nhn mt cach

thun tin
Nhu cu c th

S tin li

Nng lng cao

Giu protein
Protein cht lng cao
Cht dinh dng vi m
Cht x
Vi cht
EPA (200 g c trch

Khi lng nho

Dinh dng hon chnh
Cn bng
nht thp
Hng v ph hp

2 con c trch/ ngy

2.2 gr EPA/ngy
trong FortiCare

i hc Y Dc
Thnh ph H Ch Minh

Ch nh:

Bnh nhn ung th, suy mn do ung th

Bnh nhn suy dinh dng, n km, chn n
i tng cn nhu cu dinh dng cao
Bnh nhn cn tng cn chun b phu thut;
Bn nhn hu phu, k c ph n c thai, sinh con
S dng c cho bnh ai tho ng, tng ng
huyt. Bnh nhn tiu ng cn chia nho ba n.

Liu dng: ty theo nhu cu bnh nhn

B sung dinh dng: 1-3 chai/ngy.
Bnh nhn ung th: ti thiu 3 chai/ngy
Chng ch nh: Tr em di 3 tui, d ng thnh phn

H TR DINH DNG VI
EPA PH HP CHO BNH
NHN UNG TH

i hc Y Dc
Thnh ph H Ch Minh

Tai sao:
ci thin kt qu ca iu tr ung th v nng
cao cht lng cuc sng cho bnh nhn.

Khi no:
Kim sot tnh trng dinh dng ca mi ln chn on ung th
v la chn can thip tt c cc giai on ung th.

Nh th no:
H tr dinh dng chuyn su vi cc cht dinh dng ph hp
v iu ha chuyn ha mt cch nhanh chng tin li v ngon
ming (kch thch v gic).

Th so snh gi tr

(BS. Lm c Hong
Bnh vin Ung bu TPHCM)

=
+

+
=

Tng quan

T st cn n suy mon do ung th

Dinh dng y hc chuyn bit cho

bnh nhn ung th

Tng kt

Tng kt: Dinh dng cho

bnh nhn ung th

Cn pht hin sm du hiu st cn, suy mn do ung th tt

c cc giai on.

Suy mn ung th nh hng n kt qu iu tr (p ng km

iu tr), tng gii hn liu c, liu lng iu tr t hn, gin
on iu tr

Dinh dng thng thng khng gii quyt c c ch tim n

gy suy mn trong ung th

Dinh dng giu nng lng, giu m v b sung EPA liu

2g/ngy.

Mi v v s tun th iu tr dinh dng b sung

Tng ng huyt l ph bin cc bnh nhn ung th v cn
s dng mt sn phm ph hp vi Gl thp

i hc Y Dc
Thnh ph H Ch Minh

Hy thuc l thc phm

v thc phm l thuc ca con ngi.

Hippocrates of Cos, Greece

460-377 B.C.

i hc Y Dc
Thnh ph H Ch Minh

CM N S CH LNG
NGHE CA QU V!