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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: ● ● ● ● ● ● ● ● Anorexia Fatigue Weight loss Fever Sweating Anemia Pain Enlarged lymph nodes or organs Diagnosis of Cancer ● ● ● ● ● ● 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: ● ● ● ● 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 o 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 ● ● ● ● 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: ● ● ● ● ● ● ● ● 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 o o 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 ● ● ● ● ● 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 ● ● ● ● 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