Medical Nutrition Therapy

For Cancer 1
New Cancer Cases Diagnosed
in Malaysia (2007-2011)
• New cases =103,507
• Caused 13.56% death (2015)
• 3rd most common cause of
death

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The Most Common Cancer In Malaysia

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Gender Differences in Sites of Cancer
 Introduction
Cancer
•Abnormal cell division
and reproduction that can
spread throughout the
body
•Three stages of
carcinogenesis:
i) Initiation (initial stage)
ii)Promotion (initiated cells
are activated)
iii)Progression, i.e
metastasis
 Nutrition & carcinogenesis
Carcinogen
•Physical, chemical or viral agents that
induces cancer
•Diet contain both:
I. Inhibitor – antioxidant (vitamin C,
vitamin A and the carotenoids, vitamin
E, selenium, zinc) & phytochemicals
II. Enhancer of carcinogenesis -
saturated fat in red meat, alcohol,
smoked, grilled & preserved foods.
 Nutrition & carcinogenesis
 Fat

Red meat, dietary fat and milk intake should be minimised as they
appear to increase the risk of prostate cancer. Fruit and vegetables and
polyphenols may be preventive in prostate cancer, but further studies are
needed to draw more solid conclusions and to clarify their role in
patients with an established diagnosis of prostate cancer. Selenium and
vitamin supplements cannot be advocated for the prevention of prostate
cancer and indeed higher doses may be associated with a worse
prognosis. There is no specific evidence regarding benefits of probiotics
or prebiotics in prostate cancer.
Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
 Nutrition & carcinogenesis

↑ circulating levels
of insulin-like growth
factor-1 (IGF-1)

IGF-1
•Secretion ↑ when insulin level ↑
•Stimulate the growth of cancer cells.
 MNT for
Cancer Prevention
 Chemoprevention
• Defined as the use of drugs, vitamins, or other
agents to reduce the risk of, or delay the
development or recurrence of cancer (NIH, NCI, 2015).
• Coffee and Tea: contains various antioxidant and
phenolic compounds - have anticancer properties.
• Fruits and Vegetables: contains anticarcinogenic
agents - antioxidants such as vitamins C and E,
selenium, and phytochemicals.
• Soy and Phytoestrogens: contains phytoestrogens
and isoflavones - modest amounts of soy protect
against breast cancer (ACS, 2012)
Cancer Prevention Recommendations
 MNT for
Cancer Treatment
Nutritional Issues in Cancer Care
Depletion of nutrient stores, anorexia, weight loss and poor nutritional
status are found in many individuals at the time of diagnosis (Goldman
et al. 2006).

Malnutrition in cancer patients can have a significant adverse effect impact on

clinical, cost and patient centred outcomes such as complications (infections),
treatment response, treatment interuptions, unplanned admission, length of
stay and quality of life (Schattner & Shike 2006; COSA 2011).

The prevalence of malnutrition in cancer patients ranges from 8-84%

depending on tumour site, stage and treatment (Maarten von
Meyenfeldt 2005, Brown et al. 2008).

Considering the implications of malnutrition, it is important to initiate early

intervention to help prevent or reverse malnutrition and to improve prognosis
of cancer patients.

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 Obstacles to Adequate Nutrition
1. Tumor-Induced Effects on Nutrition Status
• Tumor-induced pathophysiological changes alter
the macronutrient metabolic pathways leading to
increased protein catabolism, muscle protein
degradation and elevated lipid oxidation.
• The type or stage of cancer may affect energy
metabolism
2. Treatment-Induced Effects on Nutrition Status
• Side effects of cancer treatments vary among
patients, depending on the type, length, and
dose of treatments and the type of cancer being
treated.
 Cancer Treatment and
Nutritional Implications
 Chemotherapy
– Anemia, fatigue, nausea, vomiting,
loss of appetite, mucositis,
changes in taste and small,
xerostomia, dysphagia, diarrhea,
constipation
 Immunotherapy
– Fatigue, chills, fever, flu-like
symptoms, decreased food intake
 Radiation therapy
– Fatigue, loss of appetite, skin
changes, and site-specific effects
Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
Cancer Treatment and Nutritional Implications–cont’d
 Hematopoietic stem cell transplantation
– Nausea, vomiting, anorexia, dysgeusia, stomatitis, oral
and esophageal mucositis, fatigue, and diarrhea
– Dietary precautions with neutropenia
– Graft versus host disease (GVHD): immunologic
reaction of allogeneic donor cells (graft) reacting
against the pt (host) tissue
– Sinusoidal obstructive syndrome (SOS): occlusion of
small hepatic venules caused by hepatotoxins &
radiation therapy/ chemo
 Surgery
– Fatigue, pain, loss of appetite
Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
 Basic principles of nutrition
in cancer patients
1. Malnutrition (protein-calorie malnutrition)
2. Significant weight loss
3. Anorexia
4. Cachexia
• Progressive wasting syndrome evidenced by
weakness and a marked and progressive loss
of body weight, fat, and muscle
5. Sarcopenia (severe muscle depletion)
 Cancer Cachexia
 Progressive wt loss
 Anorexia
 Generalized wasting and weakness
 Immunosuppression
 Altered BMR
 Abnormalities in fluid and energy
metabolism
 Mediated via cytokines, including
TNF- and TNF-, cachectin, IL-1,
IL-6, and IFN-

https://www.youtube.com/watch?v=sqWTt4k3PAI

Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
 BMI nutritional status by diagnoses.*Others included multiple myeloma, sarcoma, leukemia,
thymoma, meningioma, plasmocytoma, melanoma, cancer of the bladder, kidney, or pancreas, or
occult primary tumor metastases.

Mariana Ramos Chaves et al. The Oncologist 2010;15:523-530

©2010 by AlphaMed Press

 PG-SGA nutritional status (A, B, or C) by diagnoses.*Others included multiple myeloma,
sarcoma, leukemia, thymoma, meningioma, plasmocytoma, melanoma, cancer of the bladder,
kidney, or pancreas, or occult primary tumor metastases.

Mariana Ramos Chaves et al. The Oncologist 2010;15:523-530

©2010 by AlphaMed Press

Objectives of Nutrition Management
i)For individual who is at pre-cancer treatment
or pre-surgery
• To maintain or prevent declining (or further
decline) in nutritional status and improve overall
nutritional status and its associated outcomes in
adults at risk of or with malnutrition
ii)For individual who is ongoing radiotherapy
or/and systemic therapy
• To minimise a further decline in nutritional
status, maintain quality of life (QoL) and
For adequate symptom management.

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Nutrition Screening
and NCP Flowchart

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 MST

SGA &
PGSGA

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Adapted from: The American Society for Parenteral and Enteral Nutrition (ASPEN) 2011
Nutrition Screening

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 Evidence Statement of Nutrition Screening
Evidence Statement Grade References
MST is an effective and validated B DAA, 2006
screening tool for identifying risk of COSA, 2011
malnutrition in cancer patients
Malnutrition screening should be B COSA, 2011
undertaken in all patients at diagnosis to
identify those at nutritional risk and
should be repeated at intervals through
each stage of treatment (e.g. surgery,
radiotherapy / chemotherapy and post
treatment). If identified at high risk, do
refer to the dietitian for early intervention.
All HNC patients receiving radiation A
therapy should be referred to dietitian for COSA, 2011
nutrition support intervention

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 Malnutrition Screening Tool (MST)
1. Have you lost weight recently without trying?

If no (0)
If unsure( 2)
If yes, how much weight (kg) have you lost?
0.5–5.0 ( 1)
>5.0–10.0 (2)
>10.0–15.0 (3)
>15.0 (4)
2. Have you been eating poorly because of a decreased appetite?

No ( 0)
Yes (1)
If score 0 or 1 not at risk of
malnutrition
≥ 2 at risk of malnutrition
Ferguson M, Bauer J, Banks M, Capra S. 1999. Development
of a valid and reliable malnutrition screening tool for adult
acute hospital patients. Nutrition. 15: 458–464. 18
Nutrition Assessment

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Nutrition Assessment Criteria
(i) Tools/ Instruments
- The Scored Patient Generated–Subjective Global Assessment
(PG-SGA) - gold standard (Leuenberger et al., 2010)
- Subjective Global Assessment (SGA)

(ii) Assessment Parameters

- Medical history
- Anthropometric data
- Biochemical assessment
- Clinical assessment
- Dietary Information
- Functional status and QoL

• The use of combination method (Tools and

Assessment Parameters) is best suggested for
nutritional assessment (Davies, 2005)
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(ii) Assessment Parameters
(ii) Assessment Parameters
(ii) Assessment Parameters
 Nutrition Prescription:
Energy Requirement
Factors to be considered to ensure that adequate energy:
•individual’s diagnosis, presence of other diseases,
•intent of treatment (e.g., curative, control, or palliation),
•anticancer therapies (e.g., surgery, chemotherapy, biotherapy, or radiation therapy)
•presence of fever or infection, and other metabolic complications such as refeeding syndrome

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Protein Requirement
Table 4: Estimating Daily Protein Needs in Cancer Patients

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 FLUID &
MACRONUTRIENT
REQUIREMENT

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 Table 5: Estimating Fluid
Needs in Cancer Patients

Age (years) Fluid Requirement, ml/kg

16-30, active 40
31-55 35
56-75 30
76 or older 25
These recommendations are just for maintenance needs. Fluid
requirement in fluid overload or dehydration patients need to
be adjusted.
Source: ADA, 2000

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Algorithm of Nutrition
Support for Cancer Patients

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Ref: ESPEN, 2006; FESEO, 2008
Nutrition Intervention
and Recommendation

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 Diet and Counseling
Recommendation Grade References

• Intensive dietary counselling and ONS are able to A ESPEN, 2006;

increase dietary intake and to prevent therapy- FESEO, 2008;
associated weight loss and interruption of radiation DAA, 2008
therapy in patients undergoing radiotherapy of
gastrointestinal or head and neck areas
• Dietitian should be part of the multidisciplinary team A DAA, 2008
and frequent dietitian contact has been shown to COSA, 2011
improve patients’ nutrition outcomes and quality of life

• At low nutritional risk patients (MST = 0-1) C Bauer, 2007;

-Recommend a well balanced diet FESEO, 2008
-Recommend healthy traditional diet according to
needs, preferences and symptomatology
-Healthy, balanced, assorted, appetizing and
adequate amount of food and nutrients

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 Diet and Counseling
Recommendation Grade References

• At moderate nutritional risk patients (MST = 2) C Bauer, 2007

- Recommend high protein-energy diet
- Try 6 smaller meals/snacks per day
- Include 3-4 servings of energy and protein
rich foods or drinks daily

- Oral nutritional supplements 2-3 servings per

day
• At high nutritional risk patients (MST = 3-5) C Bauer, 2007
- Recommend high protein high energy diet
- Recommend high protein high energy
supplements 2-3 times per day
- Consider intensive nutrition support

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 Dietary Guidelines for Immunosuppressed
Patients – Neutropenic Diet

• The use and effectiveness of neutropenic diet is

not scientifically proven.
• Neutropenic diets are not standardized.
• Further research is needed to better evaluate
the benefit of neutropenic diet (Steven, 2011).
• Food safety education and high risk foods
restriction is needed when handling
immunosuppressed patients (ADA, 2006).

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Nutrition Education
& Counselling

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Nutrition Intervention Strategies for
Patients with Cancer
Nutrition Intervention Strategies for
Patients with Cancer
Nutrition Intervention Strategies for
Patients with Cancer
Nutrition Intervention Strategies for
Patients with Cancer
Nutrition Intervention Strategies for
Patients with Cancer
Complementary and Alternative Therapies
 Whole medical systems
– Traditional Chinese Medicine, ayurvedic medicine, homeopathy,
naturopathy
 Mind-body interventions
– Mindfulness, meditation
 Biologically based therapies
– Botanicals, dietary supplements, vitamins, minerals
 Manipulative and body-based methods
– Massage, yoga, reflexology, prayer
 Energy therapies
– Veritable and measurable – sound, light, energy
– Putative such as biofields
 Islamic medical approach

Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
Elsevier items and derived items © 2008, 2004 by Saunders, an imprint of Elsevier Inc.
Physical Activity
& Cancer

53
…exercise after the diagnosis of breast cancer improves mortality,
morbidity, health related quality of life, fatigue, physical functioning,
muscle strength, and emotional wellbeing.
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 MNT for
Cancer Survivor

• Most eating-related side effects of cancer

treatments go away after treatment ends.

• Key recommendations:
 Maintain healthy weight
 Practice healthy eating & be physically
active

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