Download Cancer - Molly Roemer

Cancer
By: Mandy Herlin, Reilly Doney, and Molly
Roemer
Cancer Terms
● Abnormal division and reproduction of cells
within the body
● Carcinogenesis: development and spread of
cancerous cells
● Oncology: the study of cancer
Cancer Facts & Statistics
● 2nd most common cause of death
● 1 in every 4 deaths in the United States
● 14.5 million Americans with a history of
cancer were alive on January 1st, 2014
● 1,658,370 new cases of cancer are expected
for 2015
● $88.7 billion in 2011 in the US
Cancer Types
● Most common types:
● Men
o
o
Prostate
Lung
● Women
o
o
Breast
Lung
Cancer Types
Cancer Types
Etiology & Risk
Factors
Cancer
Etiology & Risk Factors
Who Determines What Is Cancer-Causing?
● International Agency for Research On
Cancer (IARC), part of WHO
● National Toxicology Program (NTP), formed
from NIH, CDC, and FDA
● Environmental Protection Agency (EPA)
● National Cancer Institute
Etiology & Risk Factors
External Factors:
● Tobacco/ cigarette smoking
● Radiation/ UV rays
● Limited fruit and vegetable consumption
● Chemicals
PAH, Polycyclic aromatic hydrocarbons
o NOC, N-nitroso compounds
o BP-A, Bisphenol A
o
Etiology & Risk Factors
External Factors Continued:
● Viruses
● Physical inactivity
● Excess energy
● Alcohol consumption
● Other
Etiology & Risk Factors
Internal Factors:
● Age
● Gender
● Family History/ Genetics
o
Only 5%-10% of all cancers
are thought to be related to
an inherited gene change
affecting cancer risk
Etiology & Risk Factors
2012 American Cancer Society Guidelines:
● Will eating less fat reduce cancer risk?
o
No compelling evidence in humans
● Can GMOs cause cancer?
○
○
No current evidence, approved GMOs on the market
include carrot varieties, corn, tomatoes, and soy
Monitored by EPA, FDA, and USDA
Etiology & Risk Factors
2012 ACS Guidelines Continued:
● Can folic acid contribute to cancer?
o
Folic acid supplements may increase prostate and
colorectal and possible breast cancer risk
● Do irradiated foods cause cancer?
○
No evidence that they are harmful
Etiology & Risk Factors
2012 ACS Guidelines Continued:
● How does cooking meat affect cancer risk?
o
Frying, broiling, or grilling meats at very high
temperatures creates chemicals (polycyclic aromatic
hydrocarbons or heterocyclic aromatic amines) that
might increase cancer risk
● Do nonnutritive sweeteners and sugar cause
cancer?
o
No evidence at levels consumed in human diets
Etiology & Risk Factors
2012 ACS Guidelines Continued:
● Do pesticides cause cancer?
o
No evidence that low amounts found on foods
increase risk, but wash F/V before eating
● Does sugar increase cancer risk?
o
o
No
Promotes obesity, which is a risk factor
Etiology & Risk Factors
2012 ACS Guidelines Continued:
● Does high salt in food increase cancer risk?
o
Little evidence to suggest it affects cancer risk
● Do trans fats increase cancer risk?
o
Relationship with cancer not determined
Prevention
Cancer
Preventable Cancer Risk Factors
● ⅓ of cancer deaths each year are attributed
to preventable factors
● Weight control
● Dietary choices
● Physical activity
ACS Guidelines
● Published every 5 years
by a panel of cancer
experts
● Guidelines also follow
American Heart
Association and
American Diabetes
Association
ACS Disclaimer
“No diet or lifestyle pattern
can guarantee full protection
against any disease; the
potential health benefit
represents a decreased
likelihood that the disease
will occur, not a guarantee of
total protection.”
American Cancer Society
“Behaviors such as avoiding exposure to
tobacco products, maintaining a healthy
weight, staying physically active throughout
life, and consuming a healthy diet can
substantially reduce one’s lifetime risk of
developing, or dying from, cancer.”
1. Achieve and maintain a healthy body weight
● Clear obesity associations with:
o
Breast, colon, endometrium, kidney, esophagus, and
pancreas cancers
● High abdominal fat increases risk of:
o
Colon, pancreas, endometrial, and breast cancer
2. Adopt a physically active lifestyle
● Reduces the risk of:
o
o
Breast, colon, endometrium, prostate, and
pancreatic cancers
Also reduces risk of other diseases (diabetes,
osteoporosis, hypertension)
● 150 minutes moderate activity/75 minutes
vigorous activity
o
More exercise may be even more protective reduces obesity
3. Consume a Healthy Diet
● Eat to achieve a healthy weight
o
o
o
o
Emphasize plant foods
Limit processed and red meats
At least 2.5 cups fruits and vegetables each day
Eat whole grains over refined grains
Why does obesity promote cancer?
● Excess weight stimulates release of
estrogen and insulin, which stimulate cancer
growth
● Excess weight releases VEGF
o
This causes more blood vessels to develop, which
supplies cancer with energy and enables tumor to
grow.
4. Limit Alcohol Consumption
● Men: no more than 2 drinks/day
● Women: no more than 1 drink/day
● Why?
o
o
Alcohol metabolism product acetaldehyde can
damage DNA.
Alcohol consumption can raise blood estrogen,
increasing risk of breast cancer.
Diagnosis
Cancer
Diagnosis of Cancer
Early Diagnosis
● ‘CAUTION’
Change in bowel or bladder habits
o A sore that does not heal
o Unusual bleeding or discharge
o Thickening or lump in breast or elsewhere
o Indigestion or difficulty in swallowing or chewing
o Obvious change in a wart or mole
o Nagging cough or hoarseness
o
Diagnosis of Cancer
Other signs & symptoms:
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Anorexia
Fatigue
Weight loss
Fever
Sweating
Anemia
Pain
Enlarged lymph nodes or organs
Diagnosis of Cancer
●
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Medical history
Physical examination
Laboratory tests
Imaging procedures
Biopsy
Genetic testing
Diagnosis of Cancer
Laboratory Tests:
● Blood, urine, and other bodily fluids
o
look for tumor markers
 AFP, CA, and others
● Oxidative damage to membrane, proteins,
and DNA
o
biomarkers to estimate damage after exposure
Diagnosis of Cancer
Imaging
● CT scan
o
radio waves, good overall picture
● MRI scan
o
radio waves and magnet, good for organs and soft
tissue
● PET scan
o
radioactive glucose
Staging of Cancer
● Describes the degree of spread
● Strong predictor of survival
● Helps determine course of treatment
Staging of Cancer
Stages I, II, III, and IV
● Stage I: confined to organ or origin
● Stage II: locally invasive
● Stage III: regional structures
● Stage IV: distant sites
Staging of Cancer
Tumor-Node-Metastasis staging system
(TNM)
● T = size of tumor
● N = whether is has spread to lymph nodes
● M = metastasis
Staging of Cancer
Tumor Nomenclature
● Named based on where they originate
o
o
o
o
o
“-oma” = benign tumor
“-carcinoma” = malignant epithelial tumor
“-sarcoma” = malignant connective tissue
lymphoma = cancer in lymphatic tissue
leukemia = cancer in blood cells
Nomenclature Examples:
●
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Adenoma
Adenocarcinoma
Chondroma
Chondrosarcoma
Pathophysiology
Cancer
Pathophysiology Terms
● Protooncogenes = normal cells, cause cell growth
Can mutate to become oncogenes, which promote
cancer
Oncogenes = Cause uncontrolled tumor growth
o Ex: Ras gene promotes growth
Tumor suppressor genes = Turn off cell growth;
keep cells from growing unchecked
o Ex: Rb
o Ex: p53 (most common gene mutated in cancer)
o
●
●
Pathophysiology Terms
● Carcinogen = something that can cause
cancer
Physical
o Chemical
o Virus
o
● Carcinogenesis = the process of a
carcinogen promoting cancer
Carcinogenesis - Initiation
A normal cell is transformed into a tumor.
● Tumor = neoplasm, new growth
● Cell mutates several times before it
becomes cancerous
● Can be benign or malignant
Carcinogenesis - Tumors
Benign
Malignant
Grows slowly
Grows fast
Well-defined capsule
Not encapsulated
Not invasive
Invasive
Well differentiated – resemble original cell
Anaplasia = poor cell differentiation
– look very different from original cell
Low mitotic index
High mitotic index
Does not metastasize – stays in 1 area
Can spread distantly (metastasis)
Cancer Types
Cancer Types
Carcinogenesis - Promotion
● Mutated cells multiply
● Mechanisms that the body has to keep this
from happening are silenced
o
Rb and p53 silenced, cancer cells grow uncontrolled
Carcinogenesis - Progression
● Tumor cells grow into a malignant neoplasm
● Metastasis = Cancer moves from original
site to somewhere else in the body
o
Neoplasm turns malignant
● Angiogenesis = New blood vessel growth
o
Tumor needs its own blood supply to grow
Nutrition and Carcinogenesis
● Gene expression can be promoted or altered
by nutrients, making nutrition an important
factor in cancer
● The effect of diet especially important in
early stages of cancer (initiation and
promotion phases)
Carcinogen enhancers
● Some naturally occurring
o
o
o
Pesticides produced in plants
Mycotoxins from mold
Fat in red meat
Carcinogen enhancers
● Nitrates = processed in red meat
o
Converted into nitrites, form N-nitroso compounds
(NOCs) which are mutagenic and carcinogenic
● Polycyclic aromatic hydrocarbons (PAH) =
o
When cooking over open flame or very high
temperature, PAH can form
Carcinogen inhibitors
● Antioxidant (Vitamins A, C, E, selenium,
zinc)
● Phytochemicals
Screening
Cancer
Cancer Screening
● The earlier cancer is found, the more likely
recovery is.
● Screening tests can be performed by a
physician or a specialist
ACS Screening Recommendations
● Breast Cancer
o
o
Clinical breast exam every 3 years for women in 20s
and 30s
After a woman turns 40, yearly mammograms are
recommended
● Colon Cancer = after age 50
o
o
o
Flexible sigmoidoscopy every 5 years, or
Colonoscopy every 10 years, or
CT colonography every 5 years
ACS Screening Recommendations
● Lung cancer
o
Screening not recommended unless one is at risk of
lung cancer (due to smoking)
● Cervical cancer
o
o
o
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Women should begin screening at age 21
Ages 21-30 = Pap test every 3 years
Ages 30-65 = Pap test + HPV test every 5 years
After age 65 = screening unnecessary if no
precancer has ever been found
Screening: Mammogram
● Look for possibility of breast cancer
● X-ray of breast
● Only 2-4 mammograms of every 1,000 lead
to a breast cancer diagnosis
Screening: Image tests
● Image tests used
for diagnosis, to
see how cancer’s
progressed, and
to follow up if
cancer returns
after treatment
http://educationcareerarticles.com/wp-content/uploads/2013/01/CAT-Scan-Technologist.jpg
Computer Tomography Scan (CT)
http://www.aboutcancer.com/C
T_lung_cancer_nejm.jpg
● Computer image
of a cross-section
slice of the body.
● Shows bone,
organ, and tissue
more clearly than
an x-ray
Magnetic Resonance Imaging (MRI)
● Magnetic image
of a cross-section
slice of the body.
http://www.kstate.edu/parasitology/upton-
Radiographs (x-rays)
● Show shadow-like
images
● Not as clear as
other scans, but
faster and less
expensive
http://www.spacedaily.com/images/lung-cancer-x-ray-bg.jpg
Nuclear scans (PET scan)
Uptake of tracer in the lymph nodes
involved with lymphoma in the groin, both
axilla, and neck (red areas)
● Show body’s
chemistry
● Cancer may absorb
more or less of the
radionuclide tracer
than normal tissue
http://miamicancer.com/images/
uploads/petscan.jpg
Ultrasound
● Produces images
from sonograms
(sound waves)
● Shows soft
tissues well
http://www.petcancercenter.org/sitebuilder/imag
es/bladder-tumor-301x197.jpg
Treatment
Cancer
Treatment
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Diagnose the cancer
Stage the cancer
Treatment options and centers
Feel comfortable with health care team and
facility
Treatment
Chemotherapy: the use of chemical agents or
medications to treat cancer; use cytotoxic
agents; systemic therapy
-Can be given by mouth, IV, directly into
abdomen through catheter, directly into
bladder, injected into CNS
Treatment
Chemo Side Effects That Affect Nutrition:
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Myelosuppression
Anorexia
Nausea, Vomiting
Peripheral Neuropathy
Fatigue
Renal Toxicity
Diarrhea
Mucositis
Treatment
Radiation Therapy- uses high-energy particles
or waves to destroy or damage cancer cells;
most common treatment; used to treat localized
tumors
-Delivery externally from machine
or from implant
Treatment
Internal Radiation
Implants inserted under anesthesia
Doctor uses X-ray or MRI for positioning
Vary from minutes to days to being permanent
External Beam Radiation
Photon beams
A lot like getting and X-ray, but for longer
Can treat large areas of the body or multiple sites
Treatment
Total-Body Irradiation- used specifically for
hematopoietic cell transplantation to get rid of
malignant cells, ablate bone marrow, suppress
immune system and make room for new cells
-Fever, nausea, vomiting, headache, mucositis,
parotitis, xerostomia, diarrhea, anorexia,
fatigue, weight loss
Treatment
Xerostomia
Stomatitis
Mucositis
Treatment
● Mucositis
Sucking on ice chips right before and right after
chemo treatment
o Mouthwash with lidocaine
o Acetaminophen
o Take good care of your mouth
o Avoid acidic or spicy foods (irritants)
o
Treatment
● Xerostomia
o
o
Saliva substitutes
Salivary stimulants
Treatment
● Stomatitis
o
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o
Club soda
Alcohol-free mouthwashes
benzydamine hydrochloride
Pharmacy mouthwash mixes
 “Magic mixes
 antifungals, antibacterials, steroids, and local
anesthetics
Treatment
Surgery
Curative
Debulking
Palliative
-Additional protein and energy for wound
healing and recovery
Treatment
Other Methods:
● Targeted therapy
● Immunotherapy, Biotherapy
● Hyperthermia
● Stem cell transplant
● Photodynamic therapy
● Lasers
● Blood product donation and transfusion
● Hormone therapy
● Antiangiogenic agents
Treatment
Prednisone
● Medication given to increase appetite, lower blood
calcium levels in bone cancers, prevent/treat nausea
and vomiting with some chemo drugs, help prevent
allergic reactions to some drugs, help treat leukemias
lymphomas and other types of cancer
Hematopoietic Cell Transplant (HCT)
● Bone marrow transplantation to restore stem
cells that were intentionally destroyed
through chemo, radiation, or from the cancer
● Used to treat leukemia, lymphoma, and
multiple myeloma
● Stem cells come from bone marrow,
peripheral blood, or umbilical cord blood
Hematopoietic Cell Transplant (HCT)
● Autologous
o
Patient’s own stem cells
● Syngeneic
o
stem cells from identical twin
● Allogenic
o
o
stem cells from relative or unrelated donor
Most common
Hematopoietic Cell Transplant (HCT)
● Cells that are obtained from bone marrow
come from pelvic or breast bones of donor
● Procedure takes about
1 hour
● Given to cancer patient by IV
Hematopoietic Cell Transplant (HCT)
Risky procedure
● Pt. on a lot of immunosuppressant drugs that cause
acute toxicities lasting 2-4 weeks after transplant
o Nausea, vomiting, anorexia, dysgeusia,
stomatitis, oral and esophageal mucositis,
fatigue, diarrhea
● PN after treatment, may be for as long as 3 months to
rest gut
Graft-Versus-Host Disease (GVHD)
● Major complication after allogenic transplants
● Donor stem cells react against tissues of host
● Can occur within first 100 days after transplant, or as
early as 7-10 days after
● Can resolve or may be long-term
o Long-term requires careful nutrition care
Treatment: immunosuppressants, steroids, inflammatory
cytokine inhibitors (cyclosporine, tacrolimus, prednisone,
etanercept)
Graft-Versus-Host Disease (GVHD)
Signs/Symptoms:
Skin- maculopapular rash
Liver- jaundice, abnormal liver function tests
GI- gastroenteritis, abdominal pain, nausea,
vomiting, large volumes of secretory diarrhea
Graft-Versus-Host Disease (GVHD)
Nutrition Treatment:
1st Phase- total bowel rest and use of
parenteral nutrition until diarrhea subsides
2nd Phase- oral feedings of beverages that are
isosmotic, low-residue, and lactose-free
Graft-Versus-Host Disease (GVHD)
3rd Phase- Reintroduction of solids that
contain low lactose, fiber, fat, and total acidity;
nothing that irritates the stomach
4th Phase- Dietary restrictions are
progressively reduced, as tolerated
5th Phase- Resume regular diet
Sinusoidal Obstructive Syndrome (SOS)
● Another transplant-related complication
● Chemo or radiation damage to liver venules
● Can develop 1-3 weeks after transplant
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Right upper quadrant discomfort
Hepatomegaly
Fluid retention
Jaundice
Severe: hepatic liver failure leading to multiple-organ
system failure
Treatment
Palliative Care/ Supportive care
● Focusing on relieving symptoms, helping patient feel
comfortable
● Physical, emotional, spiritual, social
● Increase quality of life
● Promotes less time in ICU, less likely to be readmitted
● Studies show patients have less severe symptoms
● Families are more satisfied
● May increase survival
Alternative &
Complementary
Therapy
Cancer
Alternative/ Complementary Therapy
Types of Treatment:
● Vitamin, mineral, herb supplements
● Placebo effect
● Mind, body, spirit
● Manual healing, physical touch
● Diet and nutrition
● Pharmacological and biological
Alternative/ Complementary Therapy
Most Common:
● Meditation
o
which helps to reduce stress
● Acupuncture
o
which may help reduce pain,
● Peppermint tea
o
which can help with nausea
Alternative/ Complementary Therapy
Humor Therapy (Laugh therapy)
● Using humor to relieve stress and pain
● Promotes good quality of life and encourages relaxation
● Increased oxygen use, hormonal and neurotransmitter
changes, increased heart rate
● Available evidence does not support as treatment for
cancer, but laughter has benefits
o Positive physical changes, overall well-being,
increased pain tolerance, decreased stress
Nutrition
Assessment
Cancer
Nutrition Assessment
● Should continue throughout care
● Weight history, food intake, symptoms, &
functioning
● Appetite, oral intake, labs, anthropometrics,
vital signs, fat stores, muscle mass, & fluid
status
● Various tools
Nutrition Assessment
Subjective Global
Assessment (SGA)
Nutrition Assessment
Activities of Daily
Living (ADL)
Nutrition Assessment
Common
Toxicity Criteria
(CTC)
Nutrition Assessment
Karnofsky
Performance
Scale Index
(KPS)
Nutrition Assessment
● Prognostic Inflammatory and Nutritional
Index (PINI)
● Connects markers of inflammatory stress
and nutritional deprivation
Medical Nutrition
Therapy
Cancer
Medical Nutrition Therapy
Energy needs
● Focus on maintaining weight and preventing
weight loss
● Depends on type of cancer and treatment
● Can use standard equations and IC
● Guidelines for quick estimation
Medical Nutrition Therapy
Condition
Estimated Energy Needs (kcal/kg/day)
Cancer, nutritional repletion, weight gain
30-40
Cancer, normometabolic
25-30
Cancer, hypermetabolic, stressed
35
Hematopoietic cell transplant
30-35
Sepsis
25-30
Obese
21-25
Medical Nutrition Therapy
Protein
● Increased during illness and stress
● Repair and build after cancer treatment
● Immune system function
● Use actual body weight to calculate
Medical Nutrition Therapy
Condition
Estimated Protein Needs (g/kg/day)
Normal
0.8-1.0
Nonstressed cancer patient
1.0-1.2
Hypercatabolism
1.2-1.6
Severe stress
1.5-2.5
Nutrition support
1.6-2.0
Medical Nutrition Therapy
Fluid
● Prevent dehydration and hypovolemia
● Close monitoring
● 30-35 mL/kg/day for patients without renal
problems
● IV fluid an option
Medical Nutrition Therapy
Vitamins & Minerals
● Only for patients with inadequate nutrition
status
● Over 100% RDA not recommended
● High doses may lead to cancer growth
Low Microbial Diet
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HCT patients become immunocompromised
Want to avoid infections
Cooked food diet
No evidence that it reduces rate of infection
or death
Case Study
Acute Lymphoblastic Leukemia
Acute Lymphoblastic Leukemia
● Malignant immature lymphoid blasts
o
Immature B and T lymphoid cells
● Affect mainly blood and bone marrow, but
can spread to other tissues
● Acute = it progresses quickly
o
Without treatment, it’s rapidly fatal.
Case Study
Background:
● 28 year old white male
● Acute lymphoblastic leukemia (ALL)
● 10/10 HLA matched unrelated donor
transplant (MUD)
● Myeloablative cyclophosphamide
● Total body irradiation (TBI)
● Graft-versus-host disease (GVHD)
Case Study
Anthropometric:
● Weight 198 lbs, 90 kg
● Height 5’ 9’’ or 1.75 m
● BMI of admit weight: 29.3, overweight
Case Study
Medications on Admission:
● Lorazepam
● Docusate
● Oxycodone
● Senna
Case Study
Other Considerations:
● Rash on palms and trunk
● Mucositis in mouth
● Prior to diagnosis lost 50 lbs, re-gained 20
lbs in next year and maintained
● Excessive diarrhea
Case Study
Diet Recommendations:
● Energy Needs: 2700 Kcal
● Protein Needs: 1.5 g/kg, 135g/day
● Fluid Needs: 35 ml/kg/day, 3150 ml/day
Nutrition Assessment, Diagnosis,
and Intervention
Nutrition Diagnosis:
NC 1.4
Altered GI function related to cancer treatment,
including total body irradiation, and subsequent
graft versus host disease (GVHD) as evidenced
by increased diarrhea/ stool output 3X greater
than urinary output.
Sample Diet
Considerations:
● Low bacterial (neutropenic) diet
-Transplant, diarrhea
● Decreased fiber, simple sugars
● Easily digested foods
● Wash fresh foods well, be sure food is cooked to correct
temperature
● Small, frequent meals
● Electrolyte balance
Useful Resources
● American Cancer Society
o
www.cancer.org
● Eating Hints Before, During, and After
Cancer Treatment
o
http://www.cancer.gov/publications/patienteducation/eatinghints.pdf