DEFINITION

• Cancer disorder of cell growth & regulation

uncontrolled division of abnormal cells
 EPIDEMOLOGY

• Major cause of mortality in united states

• Second to CVD
• Mostly cases seen in older individuals
• Two third of all the cases were in those over age 65
• lung and bronchus is the number one killer in both men and women
• 2nd killer prostate cancer in male
breast cancer in female
• 3rd colorectal cancer
 ETIOLOGY

Carcinogenesis is a multistep process in which normal cells are transformed into

cancer cells
Due to exposure to:
• chemicals
• physical agents
• radiations
• infectious microorganisms
• genetics & nutritional factors
• Though only a small percentage of cancers are actually considered
hereditary, all cancers involve genetics to a certain degree.
Mechanism of Defect in gene
Due to:
• exposure to viral, bacterial agents, chemicals
• nutritional components (antioxidants, soy protein, fat, calories, alcohol,
phytochemicals)
Unbalanced diet (1/3rd of 500000 cancer deaths are due to diet and activity )
Physical inactivity
Cigarette smoking lung cancer
UV-rays skin cancer
Red meat consumption (increases cancer risk, especially for colorectal, bladder,
prostate, breast, gastric, oral, and pancreatic cancers)
BIOMARKERS
• Biomarkers are distinctive biological or biologically derived indicators (such as a
biochemical metabolite in the body) that may be used
• use to identify nutrient exposure
• help to improve precision of epidemiologic studies
• Uses as a measure of internal dose (to indicate the nutrient available to tissues after
absorption and metabolism
• measure of dietary change

• Many factors can affect the use of nutritional biomarkers to validate nutrient intake, including
physiology, absorption, nutrient interactions in the body, cooking methods, and tissue and renal
saturation levels.
• Fruits and vegetables give cancer preventive effect against mouth,
pharynx, esophagus, stomach, colon, rectum, larynx, lung, ovary
(vegetables only), bladder (fruits only), and kidney
• whole grains, fiber, vitamin D, and physical activity shows inverse
relation with cancer risk
• Intakes of total fat/certain types of fat (e.g., saturated fat) and
alcohol; obesity (as measured by a high body mass index [BMI]) and
certain food preparation methods such as smoking, salting, and
pickling foods, and high-temperature cooking of meats shows direct
relation with cancer severity
• BMI > 40 deaths rate 52% in men and 62% in women
• cancer of the esophagus, colon, rectum, liver, gallbladder, pancreas,
and kidney most likely occur in individuals BMI>40
• Overweight and obesity accounts for 14% deaths in men and 20% in
women
• Individuals having metabolic syndromes are more likely to have
cancer especially prostate colecteral and breast cancer.
Pathophysiology
• Basic principles of normal cell growth
• All cells reproduce during the embryonic phase, but only some cells continue to
reproduce after the first few months following birth.
• Cells that reproduce, (liver, bone marrow, skin, and gastrointestinal tract)
• copy their DNA exactly
• split into two new daughter cells
• these types of cells to constantly regenerate.
• Cells that reproduce do so at an innate rate (rate at which they are genetically
programmed to reproduce)
• This rate may be decreased or increased depending on genetic factors.
• In general, the cells of the bone marrow and the gastrointestinal tract have the fastest
rates of replication
Cell type
• Cells are classified as
• cycling cells
• nondividing cells
• resting cells
• Cycling cells divide continuously; the epithelial cells that line the
gastrointestinal tract are an example.
• Nondividing cells divide before they differentiate (specialize), and
then they do not divide again.
• Resting cells remain dormant initially, but certain conditions can
stimulate their replication and growth.
Control of division
• Genetic controls for cellular division and growth include two basic sets of genes called
• oncogenes
• tumor-suppressor genes
• Oncogenes stimulate growth
• suppressor genes, suppress cellular growth
• cellular growth is also controlled by a counting system based on telomeres.
• Telomeres are end pieces of chromosomes that become shorter after each cell division. When the
telomere shortens to a specific length, the cell will stop dividing.
• Normal cellular reproduction is controlled by a combination of factors:
• genetic controls,
• hormones,
• growth substances secreted by distant cells;
• local growth factors;
• chemical cues from neighboring cells
• Cancer Cell Growth
• Unlike a normal cell, whose growth is closely regulated, a cancer cell
reproduces at an uncontrolled rate.
• The cancer cell becomes autonomous from the normal growth signals
and genetic control, and may even secrete its own growth factor.
• In a cancer cell, an enzyme is secreted that destroys the telomere,
• The process of cell differentiation may change, and a specific cell type
may take on other traits.
• The physical characteristics of the cancer cell are altered:
• the nucleus and cytoplasm may be enlarged,
• the mitosis rate is usually higher
• there may be derangements in the chromosome sequence
• The change from a normal cell to a cancer cell theoretically
• involves several steps. These include
• initiation,
• promotion
• progression
• It is difficult in some situations to distinguish between initiation and
promotion, but in general, initiation occurs as a result of exposure to
an initiating agent, such as tobacco.
• An initiating agent predisposes the cell to genetic mutation.
• Factors that promote the cell’s movement through the carcinogenic
changes include some hormones such as estrogen or testosterone.
• These promoters require an activation of the carcinogen as well as a
failure of natural immunity and cellular repair mechanisms.
• Tumor growth rate is dependent on characteristics of the host such as
age, sex, overall health, nutritional status, and immune function.
• Cancer cells may grow locally at the original (primary) site of cell
transformation or spread to distant sites.
• This distant spread is called metastasis.
• Specific cancer types have typical routes for metastasis that include
the lymphatic system, circulatory system, or nearby body cavities.
• For example, breast cancer typically metastasizes to brain and lung
tissue through both the circulatory and lymphatic systems.
Nutrition Intervention
• Nausea and Vomiting
• Causes of nausea and vomiting in cancer patients include
• chemotherapy,
• radiation,
• analgesics,
• odors (including food odors, perfumes),
• and delayed gastric emptying.
• Nausea and vomiting associated with chemotherapy can be classified as acute, delayed, or anticipatory.
• Acute nausea and vomiting occur within 24 hours of administration of chemotherapy.
• Delayed nausea and vomiting usually begin 24 hours after the chemotherapy has been administered
and may last up to a week.
• Anticipatory nausea and vomiting most commonly occurs before the initiation of chemotherapy, but
may also occur during or after the initiation of chemotherapy.
• Nausea and vomiting related to Radiation Therapy are dependent on
the field being irradiated.
• Almost 100% of patients undergoing total body irradiation (TBI)
during bone marrow transplantation experience emesis, while
radiation of the cranium only is considered low risk (about 10% to
30% of patients experience emesis).
• Upper- and mid-abdominal RT can also result in nausea and vomiting
starting one to two hours after treatment and persisting for several
hours.
• Patients who are experiencing nausea and vomiting due to certain
odors are encouraged to take precautions in avoiding such odors.
• A common cause of nausea and vomiting is the use of narcotic
analgesics (morphine, codeine, fentanyl), which are prescribed for
many cancer patients for chronic pain.
• Other medications known to cause nausea and vomiting include
antibiotics, digoxin, and anticholinergic agents.
• Intervention
• The patient should be advised to eat only a small, low-fat meal the
morning of the first treatment and to avoid fried, greasy, and favorite
foods for several days following the treatment.
• A clear liquid diet for the first few days after therapy may be
indicated.
• To provide calories and maintain hydration, consumption of
electrolyte-fortified beverages, nutritional fruit beverages and non-
acidic fruit drinks (apple and grape juice, nectars) should be
encouraged.
• One important intervention is to encourage patients to take their antiemetics as instructed by
their physician.
• To encourage adequate intake and maximal control of nausea and vomiting, antiemetics
should be taken at least 30–45 minutes before a meal is consumed.
• Patients should be encouraged to take their antiemetics even if they do not feel nauseated at
the time, especially while actively receiving treatment.
• It is important for the patient with early satiety to eat small, frequent meals that are nutrient
dense.
• Beverages should also contain nutrients and should be consumed between meals rather than
with meals so as not to add to the feeling of fullness.
• Consumption of raw vegetables, such as salads, and other high-fiber foods should be avoided.
• Prokinetics, medications that increase gastric emptying, may be useful
• Mucositis
• Mucositis, also known as stomatitis, is irritation and inflammation of
the epithelial cells of the mucosal membranes lining the
gastrointestinal tract that can occur at any point in the GI tract.
• The patient with oral mucositis should have a thorough and
systematic assessment of mouth.
• Chemotherapy-induced mucositis commonly occurs five to seven
days after chemotherapy is initiated and may continue until the
patient recovers from the immunosuppression.
• Intervention
• Patients with oral mucositis may need nutrition education to provide guidelines
for eating until the mucositis resolves.
• The patient should be encouraged to eat only soft, non-fibrous, non-acidic foods.
• Hot foods should be avoided as they can burn the already tender, fragile mucosa.
• Liquids should be encouraged to prevent dehydration; non-acidic juices such as
nectars may be helpful.
• High-kcal, high-protein milkshakes or nutritional supplements may be beneficial
at this time.
• Diarrhea
• Antineoplastic agents target those cells that have the highest replication rate, they often cause diarrhea.
• When mucositis is present in the oral mucosa, it can be assumed that it may also be present in the
stomach and in the small and large intestine, resulting in diarrhea, which may at times become severe.
• Intervention
• The patient with diarrhea should be encouraged to drink small amounts of fluid frequently throughout
the day.
• Large amounts of fruit juices should be avoided as excessive fructose can exacerbate diarrhea.
• Patients should be encouraged to use the antidiarrheal medications as prescribed by their physicians.
• Instructing the patient to increase their intake of foods high in soluble fiber may help with the
treatment of diarrhea; however, often these patients have a poor appetite and may have a difficult time
increasing their intake of foods in general.
Dysgeusia
• Dysgeusia, or alterations in taste, can have a profound effect on a
patient’s ability to ingest an adequate amount of nutrition.
• Taste changes that occur include a metallic taste (usually due to the
chemotherapeutic agent), no taste sensation (aguesia), a heightening
of certain tastes (especially sweets), or aversions to foods the patient
liked to eat in the past.
• Patients who experience a metallic taste in their mouth should be
advised to avoid metal utensils and instead use plastic utensils.
• Meats are often not tolerated. To ensure an adequate protein intake,
the patient should be encouraged to incorporate other high-protein
foods into the diet, including peanut butter, cottage cheese, cheese,
poultry, and soy meat substitutes.
• Patients with dysguesia should be encouraged to use more highly
spiced and flavorful foods, such as marinated foods.
• Sweet foods often taste too sweet to individuals undergoing cancer
therapy.
• Many homemade drinks and nutritional beverages may be too sweet
for these patients.
• Xerostomia
• Xerostomia, reduced saliva production, is a common side effect of head and neck
radiation and chemotherapy.
• The severity of xerostomia is correlated with the severity of oral discomfort, dysgeusia,
dysphagia, and dysphonia.
• Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry.
• Treatment of xerostomia may include use of artificial saliva and/or mouth moisturizers.
• Mouth moisturizing lubricants come in the form of gels, lozenges, and mouthwashes.
• Chewing gum is more effective than artificial saliva for the treatment of radiation-
induced xerostomia.
• Denture wearers may not be able to chew gum for the treatment of xerostomia.
• Anorexia
• Lack of appetite, or anorexia, is a challenging problem for both patients and clinical
dietitians.
• Nutrition therapy for the treatment of anorexia is helpful for some patients,
improvement requires intensive counseling and motivation by the patient.
• Exercise may help to increase appetite, but many patients may be unable to increase
their physical activity for a variety of reasons, including profound fatigue, severe
thrombocytopenia, severe immunosuppression, and side effects from therapy, such
as nausea, vomiting, or diarrhea.
• Exercise, on the other hand, may actually relieve fatigue, prevent muscle wasting,
and improve the ability to perform activities of daily living by improving endurance
levels.
General Instructions
Eat smaller, more frequent meals.
• Maximize your intake when appetite is most normal.
• Limit fluid with meals to avoid feeling of fullness.
• Keep favorite foods readily available at all times.
• Mild exercise, as tolerated (check with physician).
• Eat meals in a pleasant environment.
• Avoid noxious odors; ventilate eating area.
• Find a liquid nutritional supplement that is appealing and drink only 2–4 ounces at a time (to
avoid a feeling of fullness); keep unopened beverage in the refrigerator.
• Try relaxation exercises before mealtimes.
• Consider pharmacologic agents/appetite stimulants.
Nutrition Support of Cancer

• Nutrition support is considered an aggressive form of therapy and

should be utilized only when other aggressive medical approaches
(i.e., chemotherapy, surgery, radiation) are also being used to treat the
cancer
• Nutrition support is inappropriate for most terminal cancer patients or
for patients with a poor prognosis for whom all medical anticancer
therapies have been exhausted
Guidelines
The practice guidelines for nutrition support of adults with cancer of the American Society for Parenteral and
Enteral Nutrition (ASPEN) include the following:
• Patients with cancer are nutritionally at risk and should undergo nutrition screening to identify those who require
formal nutrition assessment with development of a nutrition care plan
• Nutrition support therapy should not be used routinely in patients undergoing major cancer operations
• Perioperative nutrition support therapy may be beneficial in moderately or severely malnourished patients if
administered for 7–14 days preoperatively, but the potential benefits of nutrition support must be weighed
against the potential risks of the nutrition support therapy itself and of delaying the operation
• Nutrition support therapy should not be used routinely as an adjunct to chemotherapy
• Nutrition support therapy should not be used routinely in patients undergoing head and neck, abdominal, or
pelvic irradiation
• Nutrition support therapy is appropriate in patients receiving active anticancer treatment who are malnourished
and who are anticipated to be unable to ingest and/or absorb adequate nutrients for a prolonged period of time
• The use of nutrition support therapy in terminally ill cancer patients is rarely indicated.
• Patients should not use therapeutic diets to treat cancer
Nutritional Manifestations of Cancer
• Each disease type has its own unique characteristics; therefore,
specific signs and symptoms will correlate with the specific diagnosis.
• Yet there are common signs and symptoms that an individual may
experience.
• These signs and symptoms, such as pain, infection, anemia, fatigue,
and malnutrition, may result from the effects of the tumor on nearby
body systems.
Cachexia
• cachexia is characterized by involuntary weight loss, tissue wasting
(particularly lean body mass and adipose tissue), inability to perform
daily activities, and metabolic alterations.
• It is one of the most common causes of death among patients with
cancer, and is present in 80% at death.
• metabolic alterations in glucose, amino acid/protein, and lipid
metabolism can have an impact on the patient’s nutritional and
medical status with a subsequent impact on quality of life, morbidity,
and mortality
Pathophysiology of cachexia
• pathophysiology of cancer cachexia is not completely understood, it
seems to be attributable, at least in part,
• to metabolic alterations that lead to increased energy expenditure.
• These alterations are thought to be partially attributable to increased
levels of circulating
• C-reactive protein,
• fibrinogen,
• white blood cells
• pro-infl ammatory cytokines (e.g., IL-1, IL-6, TNF-α).
Specificity of Cachexia
• “cachectic factors” are presumably tumor-specific
• for example, lung and gastrointestinal tumors including pancreatic
cancer are well known for causing cachexia with much higher
incidence than breast and hematopoietic tumors.
• Changes in taste and smell perception, psychologic factors,
uncontrolled pain, and therapy-induced side effects also play an
important role in the severity of cachexia, but vary from one patient
to another.
Phases of Caner Cachexia
• Cancer cachexia has been described as involving three phases:
• precachexia,
• moderate cachexia
• advanced cachexia.
• Upon clinical examination of the patient, cachexia may be further
classified into symptomatic and asymptomatic cachexia.
• Standard methods of nutritional therapy, including enteral and
parenteral nutrition support, may not be effective in improving the
outcomes of cancer patients due to alterations in metabolism.
Diagnosis
• There are no standard criteria with which to diagnose cachexia.
• Diagnosis usually stems from the presenting signs and symptoms.
• These include weight loss, anorexia, muscle wasting, fatigue, and
early satiety.
Abnormalities in Carbohydrate, Protein,
and Lipid Metabolism
• The normal physiologic conservation mechanisms seen during periods of
simple starvation do not occur in the presence of cancer.
• During periods of simple starvation, free fatty acids from adipose tissue
supply energy to the liver and muscle.
• The free fatty acids are converted to ketone bodies that can then be
utilized by most tissues in the body as a source of energy.
• Ketone bodies inhibit glucose utilization and protein degradation from
lean body mass.
• Therefore, protein is not used as a primary energy source.
• Serum insulin levels decline with increasing ketone body formation.
CHO Metabolism
• The most important carbohydrate abnormalities are insulin
resistance, increased glucose synthesis, gluconeogenesis and
decreased glucose tolerance and turnover.
• changes in carbohydrate metabolism in cancer patients probably arise
as a consequence of meeting the metabolic demands of the tumor,
and may contribute to the development of the cachectic state.
Protein Metabolism
• In cancer cachexia, amino acids are not spared as they are during
simple starvation, and depletion of lean body mass occurs.
• Muscle wasting may be due to increased protein catabolism
(hypercatabolism) or decreased protein synthesis; the simultaneous
presence of both results in the most intense muscular atrophy.
• Simple anorexia alone cannot fully explain wasting of lean body mass
and increased protein breakdown observed in cancer cachexia.
Lipid Metabolism
• Alterations in lipid metabolism also occur in the presence of malignancy.
• Fat is the body’s primary fuel source.
• Abnormalities that occur in the presence of cancer include
• increased lipid metabolism,
• decreased lipogenesis
• decreased activity of lipoprotein lipase (LPL), the enzyme responsible for
triglyceride clearance from the plasma.
• Mobilization of fatty acids from adipose tissue may occur before weight loss,
suggesting the presence of a lipid-mobilizing factor (LMF) produced either
by the tumor or host tissues
MNT
• Nutrition complications of cancer therapy
• Taste abnormalities
• Loss of appetite
• Fatigue
• Decrease food intake
• Diarrhea
Carbohydrates
 purpose= to minimize cancer progression+ energy to brain cells and
rbcs
 Low glycemic index food
 Low carb diet-40_% calories from carbs
pose= to minimize cancer progression+ energy to brain cells and rbcs
 Low glycemic index food
 Low carb diet-40_% calories from carbs
Protein
• Cancer cells change its metabolism
• losses

• High protein in cancer

• Protein source
• Plant protein ….readily available A.a+ phytochemicals.
• Fatty fish protein….omega 3-F.A( defense system)
• Skinless poultry…smallest contribution
Lipids
• weight loss
• Adipose , muscle mass (low)

• Omega 3 F.A:
• Fish oils, tuna ,flaxseed, walnut, eggs, black beans, canola oil
• Mufa:
• Nuts ,avocadoes, olive oil,fish,egg
• Pufa:
• Walnut, sunflower seeds ,flaxseeds, fish
Antioxidants
• Vit E: inhibit formation of nitrosamine
• Selenium: glutathione peroxidase is selenium dependent
• cancer prevention
• cancer treatment (in combo with medicine)
• Vitc
• Copper
Diet order
• High protein
• Moderate fat
• Low carbs
• Modified diets
• Antioxidant rich
American cancer society s’ dietary
recommendations for cancer prevention
• Eat variety of healthy foods, with emphasis on plant source.
• Adopt physically active lifestyle
• Achieve and maintain a healthy body weight
• Limit consumption of beverages
Problem Diet Foods to avoid

Nausea Clear, non acidic liquids, low fat Milk products, dried foods, deserts

Esophagitis Liquid and soft(broth base) Citrus, hot ,cold and spicy

Decrease salivation Regular diet with extra moisture Dry fruits ,crackers, bread

Taste alteration Regular diet with cold foods milk Red meat, chocolate, coffee ,tea
products

Early satiety High caloric food, smaller meals high Low fat milk, salads
frequency

constipation Regular diet with extra fiber+ fluids Beverages

Complimentary Therapies
• Macrobiotic diet
• Vegetarian diet
• Juice therapies
• Coenzyme q10
• Flaxseed
• Ginger
• Soy and soy foods
Supplements
• Vit E
• Selenium
• Copper
• Vit c
• Vit d
• Calcium….1800mg/day
Diet plan
Recommended Book
• Nutrition and diet therapy