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N116BL NAME: Karina Almanza ID: 999730656

20 points Due: Sunday 3/5/2017 by 11:59 pm Online submission only

Mini Case-Study: Cancer

Mrs. S is a postmenopausal woman who has been recently diagnosed with Stage III breast
cancer. Her treatment course includes a course of concurrent radiation treatment and
chemotherapy, then surgical resection with a mastectomy and lymph node dissection.

Mrs. S. is to begin a 10 day course of radiation treatment and is also to receive chemotherapy
treatment with 5-Fluorouracil (5-FU). The intent is to use 2 courses of these treatments to
decrease the size and growth of the tumor prior to surgical resection.

You are the outpatient dietitian consulted for advice on nutritional management of this patient.
You counseled the patient at the beginning of the treatment course and now you are seeing her
again on day 10, at the end of the first treatment course. She is complaining of diarrhea that is
painful, frequent (>6 episodes/day) and is also experiencing some soreness in her mouth and
throat on swallowing.

1. Regarding the drug 5-FU: what is the drug class and how does it work? (2 pts)
a. Drug class:
Antineoplastic, Antimetabolite
Brand name: Adrucil
Chemotherapy

Citation: FMI p. 51
b. Mechanism of action
As a thymidylate synthase inhibitor, 5-FU interferes with the synthesis of pyrimidine
thymidine furthermore, inhibiting the process of DNA replication. Typically, thymidylate
synthase allows for the methylation of deoxyuridine monophosphate (abbreviated dUMP
for short), to convert into thymidine monophosphate (abbreviated dTMP). In terms of 5-
FU administration, there will be interruption of this conversion of dUMP to dTMP,
conclusively interfering with cancerous cell proliferation.

Citation: http://www.nature.com/nrc/journal/v3/n5/full/nrc1074.html

2. Why might Mrs. S be experiencing GI problems? (2 pts)


a. What are the symptoms associated with 5-FU?:
As seen in most chemotherapy drugs, 5-FU is associated with the following symptoms:
moderate to severe nausea and vomiting, diarrhea, stomatitis, esophagitis, taste alterations
including bitter/ sour taste, anorexia, weight loss, weakness, alopecia possibly resulting in hair
loss, mood disorders, bone marrow suppression, weakness, rash, fatigue, dermatitis, ataxia,
dyspepsia, diarrhea. In some patient there are also decreased differences in WBC, albumin and
platelets count depending on dosage, making some patients more susceptible to anemia. The
symptoms in bold are specific to oral and GI sypmtoms.

Citation: Width & Reinhard: The Clinical Dietitians Essential Pocket Guide p. 147
FMI p.151

b. Why are the symptoms predominately GI related?:


N116BL NAME: Karina Almanza ID: 999730656
20 points Due: Sunday 3/5/2017 by 11:59 pm Online submission only
The chemotherapy and radiation treatment itself is associated with altering cellular and nuclear
material, making continuously proliferating cells, such as parietal cells along the GI tract, which
are more susceptible to damage.
Citation: NUT 116BL: Cancer Into: Slide 7

3. List at least 4 nutrition recommendations you would give her. (4 pts)


1. Managing diarrhea: avoid fatty foods, foods that cause gas, alcohol, caffeine and
use low lactose dairy products
a. Encourage adequate fluids for hydration
2. Provide adequate calories and protein to maintain weight, preserve lean body
mass throughout treatment and support regeneration of healthy tissue.
3. Encourage nutrient intake in a form that is practical and tolerable for Mrs. S
4. Increasing kcal and protein intake: eat small frequent meals, keeping snacks
handy.
5. BRAT or DAT diet
6. Encourage intake cold foods

Citation: Width & Reinhard: The Clinical Dietitians Essential Pocket Guide p. 147
NUT 116BL: Cancer Intro: Slide 22

Mrs. S begins her second chemotherapy course and on day 6 the lab tests indicate severe
neutropenia.

4. What is neutropenia and what health risks does it pose? (3 pts)


a. Neutropenia:
- Neutropenia is diagnosed through lab tests and detecting an unusually low of
absolute neutrophil count (ANC), which are white blood cells created by bone
marrow. Neutrophils play a critical role in the immune system that attack
bacteria and other organisms that invade the body. Having a low amount of
white blood cells in the body can make an individual more susceptible to
infection and prolong the process of healing.
Citation: NUT 116B Lecture Oncology, Slide 21-22

b. What is the general health risk with neutropenia:


- The general health risk with neutropenia decreased functionality of immune
system. As a patient with neutropenia, you are more prone to infections
including ulcers, collections of pus, rashes, fever and wounds that take a long
time to heal.
Citation: NUT 116B Lecture Cancer Treatment, Slide 21-22

c. Are there any risks related to foods or are there key messages that you should
give to Mrs. S?:
- Risks related to foods for patients with neutropenia include undercooked fresh
fruits and vegetables, some animal products including unpasteurized milk, soft
cheeses made with raw milk, luncheon meats and deli-type salads, raw/
undercooked eggs, meat, poultry, fish, shellfish and the juices of all of the
above. All of these make the body more susceptible to infections.
N116BL NAME: Karina Almanza ID: 999730656
20 points Due: Sunday 3/5/2017 by 11:59 pm Online submission only
- Key messages to give to Mrs. S would include support of food intake that she
finds tolerable while eliminating foods that would make Mrs. S more
susceptible to food borne illnesses.

Citation: NTP Ch 13 p. 739 and 333

Two years later, Mrs. S. is diagnosed with recurrence of her cancer and with metastatic lesions.
She and the MD have agreed to continued aggressive treatment of her cancer using a variety of
therapies. She is currently in a six month break from therapies, waiting for the next cycle. She
recently presented at her doctors office with c/o weight loss, feeling tired, and no appetite. She
reports taking a few bites and getting full. She states that meats & coffee no longer taste good to
her. Her fatigue is beginning to limit her usual daily activities. These symptoms have increased
over the past 3 months. She feels like she may have lost a little weight over the past year, but it
has been really evident to her the past 3-4 months.

The following information is available:


Age: 60 Ht: 54 Wt: 126 lb. UBW: 145 lb. Wt 3 months ago: 140 lb
Hgb: 11.0 g/dl Hct: 31% MCV:115fL Ferritin 90 ng/ml TIBC 255 g/dl Alb: 3.1 g/dl

5. Calculate IBW, %UBW and % change in BW over the past 3 months. Indicate the level of
nutritional risk this change in BW represents. (show calculations) (3 pts)

a. IBW = (100 lbs + (4 inches)(6 lbs)) = 120 lbs or 54.55 kg

b. %UBW = (126 lbs / 145 lbs)*100 = 86.90%

c. % change = ((145-126)/145)*100 = 10.00%

d. Level of risk: Severe ( >7.5% UBW in the 3 mo span); wt loss of 10%

MNT PG p. 2

6. Interpret the biochemical data, and comment on the overall status of the patient,
considering her symptoms and weight changes. (3 pts)
a. Biochemical data interpretation:
Hgb: 11.0 g/dl (Normal: 12-16 g/dL)
- Slightly below normal range
Hct: 31% (Normal: 34-45%)
- Below normal range
MCV:115fL (Normal: 80-100 fL)
- Above normal range
Ferritin: 90 ng/ml (Normal: 12-150 ng/mL)
- Within normal limits
TIBC: 255 g/dl (Normal: 240-450 ug/dL)
- Within normal limits
Alb: 3.1 g/dl (Normal: 3.5-5.0 g/dL)
- Below normal range
N116BL NAME: Karina Almanza ID: 999730656
20 points Due: Sunday 3/5/2017 by 11:59 pm Online submission only
Hemoglobin and hematocrit mare possibly low due to the chemotherapy
medication, while targeting quick turn-over cells and interfere with
erythropoiesis. The hematological and albumin data indicate that Mrs. S might
be anemic as a result of cancer acting as a chronic disease due to the
hypermetabolic and catabolic nature of the chemotherapy and radiation
therapy on the human body and general malnutrition of energy and protein.

MNT PG p 10- 17

b. Overall patient nutritional status interpretation:


- After evaluating Mrs. Ss biochemical data and taking into consideration her
weight loss and symptoms, her biochemical data suggests that she might have
anemia, while observing her red blood cells in a state of macrocytic anemia.
- Mrs. Ss lab values demonstrate depleted values of hemoglobin, hematocrit,
and elevated mean corpuscular volume all of which enforce anemia. Despite
these values being out of range, ferritin and total iron binding capacity are
both within normal limits, lessening the possibility of B12 deficiency, iron
deficiency or folate deficiency. And ultimately increasing the possibility of
this anemia being correlated with the cancer acting as a chronic disease,
malnutrition and inflammation.
- As a response to the radiation and chemotherapy, blood cells and GI cells have
an increased turnover rate, and as a result, are more likely to be a target for
destruction during the therapy. This furthermore encourages malnutrition, lack
of energy and protein intake and a catabolic response to supply glucose to
vital organs and cell proliferation. Mrs. S has symptoms that do not encourage
nutrient absorption such a vomiting and diarrhea, despite the effort to feed her.

Citation: NUT 116BL, Cancer Intro, Slide 27


NUT 116B, Oncology, Slide 12

7. What is your priority nutritional goal for this patient? How would you determine the
appropriate energy and protein needs for Mrs. S? (Indicate why you would use either
her UBW, IBW or CBW; and show your calculations with the equations you would use
for energy and protein) (3 pts)

a. Priority MNT Goal:


- Support body composition by preventing decline and further weight loss d/t
malnutrition.
- This can be done by helping him find forms of food that she enjoys eating and
can eat without experiencing too much pain; including but not short of
introducing cold foods, shakes or nutritional supplementation, soft foods and
small, frequent meals.

Citation: NUT 116BL- Cancer Intro: Slide 2


NUT 116BL Discussion Session Friday, 3/3/2017
b. Energy:
- Determined considering her CBW- the current recommendations are not being
met or unable to be met because of GI problems and general malnutrition. The
purpose of using her CBW when calculating her energy needs would be to
N116BL NAME: Karina Almanza ID: 999730656
20 points Due: Sunday 3/5/2017 by 11:59 pm Online submission only
better attend Mrs. S in her current state. Using the current body weight will
limit the chances of overfeeding Mrs. S and will limit the nutrients that are
supplemented to the cancerous cells for proliferation.

- (30-35 kcal/kg)(57.27 kg)=1,718.1 to 2,004.45 kcal/ D


Citation: NUT 116BL Discussion Session Friday, 3/3/2017
MNT PG p. 98

c. Protein: (Determined considering her UBW)

- (1.5-2.0 g/kg)(57.27 kg) = 85.91 g/ D to 114.54 g/ D


- When calculating Mrs. Ss protein needs, CBW is used because there is a
desire to supply the needs of the patient currently to see if results would be
successful.

Citation: NUT 116BL Lecture 7, Cancer Intro: Slide 29 Estimating Patient


Needs