Download The effect of chemotherapy on nutritional status of breast cancer

The effect of chemotherapy on
nutritional status
of breast cancer patients
Submitted in partial fulfillment of the requirements for master’s
degree in the Department of Community Health Sciences at the College of
Applied Medical Sciences King Saud University
By
Aysha. M. Alharbi
25/1/1429
I
TABLE OF CONTENT
1:Introduction
1
1-2:Rational
1-3:Objective
2:Literature review
2-1:Side effects of chemotherapy
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5
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2-2:Nutritional status
2-3:Malnutrition
2-4:Weight & chemotherapy
2-5:Hematology & chemotherapy
3:Study design & Methodology
3-1:Study design
3-2:Study area
3-3:Patients
3-4:Methods
3-4-1:Dietary intake assessment
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3-4-2:Anthropometrics measurements
3-4-3:Sample collection and laboratory measurements
3-5:Statistical analysis
4:Results
4-1:The patients Demographic-socioeconomic characteristics
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4-2:The patient’s medical history
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4-3:The patients dietary history
4-4:24 hour food recall
4-5:Weight and general characteristics
4-6:Body mass indexes
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4-7:Biochemical measures
35
5:Discussion & conclusion
37
6:Recommendations
42
7:Reference
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II
TABLE OF CONTENT
8:Appendix
8-1:Demographic data
8-2:Socioeconomic background
8-3:Dietary history
8-4:Dietary assessment
8-4-1:24-hour recall
8-4-2:Food frequency questionnaire
8-5:Anthropometric measurements
8-6:Biochemical measurements
8-7:The five steps of a breast self-examination
9:Arabic summary
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III
List of Table
Table1: The patients' demographic-socioeconomic characteristics
25
Table2: The patients' medical history
26
Table3: The patients' dietary history
27
Table4 a: Food frequency questionnaire
29
Table4 b: Food frequency questionnaire
29
Table5a: Weight and general characteristics
32
Table5b: Weight and general characteristics
33
Table6: Classification of overweight and obesity by BMI
34
Table7: Grading system for anemia
35
Table8: patients characteristics
36
Table9: t-test for variable between baseline and 3 weeks after
chemotherapy
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IV
Abbreviations
AC
Doxorubicin, cyclophosphamide
Alb
Albumin
BCG
Bromocresol green
BMI
Body mass index
CDU
Chemotherapy day unit
CMF
Cyclophosphamide, methotrexate, 5-fluorouracil
FAC
5-fluorouracil, doxorubicin, cyclophosphamide
FFQ
Food frequency questionnaire
Hb
Hemoglobin
MCV
Mean corpuscular volume
NCI
National cancer institute
RDA
Recommended daily allowances
REE
Resting energy expenditure
SD
Standard deviations
SPSS
Statistical package for social sciences
WNL
Within normal limits
V
Summary
Breast cancer is the most common cancer in women. Most studies
address the effects of chemotherapy on increasing the survival. Few studies
have focused on the effects of chemotherapy on nutritional status.
Knowledge of changes in nutritional status due to cancer or due to its
therapy will not only help in better management of nutritional problems, but
will also enable better clinical outcome. The nutritional status of breast
cancer patient receiving chemotherapy in the Kingdom of Saudi Arabia is
not known. The present investigation was designed to study the nutritional
status of breast cancer patients receiving chemotherapy, and to evaluate the
effect of chemotherapy on weight, energy, albumin, and hemoglobin.
A prospective study was carried out at the Riyadh Khorj Armed Forces
Hospital. A total of 30 females diagnosed with breast cancer, aged 30 - 55
years who received chemotherapy for the first time were included in the
study. Patients who had received chemotherapy before and patients with
diabetes were excluded.
Each patient was interviewed using questionnaire. The questionnaire
includes information on medical history, socioeconomic history, and dietary
history. Anthropometric measurements height, weight, and body mass index
(BMI) was recorded before and after the start of chemotherapy.
VI
A blood sample was drawn before the start of chemotherapy and 3 weeks
after the start of chemotherapy. It was used to estimate hemoglobin (Hb),
mean corpuscular volume (MCV), and albumin (Alb). A 24-hour recall was
obtained before the start of chemotherapy and 3 weeks after the start of
chemotherapy. Each patient was asked to complete food frequency
questionnaire.
The present study has shown from (24 hour food recall) that energy intake
before chemotherapy was 1445.96 kcal, and 3weeks after chemotherapy
became 1445.73 kcal. Protein intake before chemotherapy was 45.86 g
compared with 45.83g 3weeks after chemotherapy. All patients energy
intake, protein intake were lower from RDA before and after chemotherapy
The prevalence of weight loss was high among patients after the first cycle
of chemotherapy. This study found that 50% of patients suffered from
weight loss, which shows the impact of treatment on weight. Also 43.3%
patients gained weight between the start of treatment and 3 weeks follow up.
These changes in weight were not statistically significant on application of ttest.
BMI decrease after the first cycle of chemotherapy but was not statistically
significant on application of t-test. The percentage of anemia (Hb
12 g/dl)
in women before chemotherapy was 43.33%. After 3 weeks 60% of these
VII
women became anemic. Patients had normal MCV level 79.17 g/l before
chemotherapy while 3 weeks after chemotherapy MCV level was 79.80 g/l.
A non significant (P<0.23) decrease in MCV was observed in patients after
chemotherapy but still it was within the normal range. Patients showed a
decrease in albumin level but within the normal level. These changes in
biochemical indices were found to be statistically significant on application
of t-test.
This investigation has indicated that patients experienced weight change,
and decrease in biochemical measurements, therefore, these patients are at
risk of malnutrition and they need nutritional assessment to prevent or
minimize the effect of chemotherapy on their nutritional status.
1
Introduction
Cancer represents a major global public health problem. Annually it
accounts for 7.1 million deaths Worldwide (WHO. 2003). It has been
predicted that, by 2020, 15 million new cancer cases will be added every
year (WHO. 2003). In Europe each year there are 2.9 million new cancer
cases and 1.7 million deaths (Boyle and Ferlay. 2005). In the United States
a total of 1,444,920 new cancer cases and 559,650 deaths from cancer were
predicted to occur in 2007 (Jemal et al. 2007). In the Kingdom of Saudi
Arabia, cancer accounts for about 5.5% of total mortality (Department of
statistics KSA. 2006).
Breast cancer is the most common female cancer. It is the leading
cause of death among females (Shibuya et al. 2002). Breast cancer is the
most frequent tumor among Saudi women, accounting 19.8% of female
cancers (Ravichandran et al. 2005).
Screening for breast cancer is carried out by mammography. It is the
early detection method with proven efficacy (Day and Warren. 2000). The
Self examination of a breast involved five steps (Appendix VI).
Treatment of breast cancer includes surgery, chemotherapy, hormone
therapy, and radiotherapy (National institutes 2001, Lake and Hudis. 2004).
The establish risk factors of breast cancer include age, the number and
timing of reproductive events, lactation, exposure to radiation, alcohol
2
consumption and family history of breast cancer (Mctiernan. 2003, Santen
et al. 2007).
Diet has a significant effect on cancer incidence (Rodler and Zajkas.
2002). The incidence of breast cancer is much higher among women in
industrialized countries than among women in countries with more
traditional lifestyles (Jasienska et al. 2001). In fact, food consumption
patterns could provide major insights into cancer risk and prevention
despite the fact that their significance is not fully appreciated (Grandics.
2003). Moreover, It has been hypothesized that dietary factors may reduce
risk for secondary cancer events and increase survival in breast cancer
patients. Many women attempt to modify their diets and improve
nutritional status following diagnosis (Rock. 2003), therefore, Maunsell et
al. (2002) assessed dietary changes in the year after diagnosis among 250
women with newly diagnosed breast cancer. They found that there is 77%
decrease in meat intake and 72% increase in fruit and vegetable intake.
There are many factors that may affect a cancer patient's nutritional
status. These factors include dietary intake, treatment related side effects
(anorexia, nausea, vomiting), and the presence of cytokine mediated
metabolic changes (Van Cutsem and Arends. 2005). Cachexia occurs in
about half of all cancer patients and is associated with decrease survival
time. Cancer cachexia involves the loss of weight, mainly in skeletal
3
muscle and adipose tissue that is not caused simply by anorexia. The
syndrome of cachexia includes anemia and immunosuppression along with
a number of biochemical changes indicating systemic effects of the cancer.
It is a major factor of morbidity and mortality in cancer (Rubin. 2003).
Several side effects (nausea, vomiting, hair loss, loss or gain of body
weight) are associated with chemotherapy of breast cancer which may
adversely affect their nutritional status (Bergh et al. 2001). Chemotherapy
can change nutritional needs and alter the survivor’s food intake, digestion,
and absorption. The need for food intake may be increased during cancer
treatment (Brown et al. 2003).
Women with breast cancer now have more treatment options and a
better chance of long-term survival than ever before because of continuing
research into new treatment methods. Chemotherapy has been shown to
improve substantially the long-term disease-free and overall survival in
both premenopausal and postmenopausal women up to the age of 70 years.
Chemotherapy has a range of acute and late side effects (such as weight
gain, weight loss, nausea and vomiting) that has the potential to
substantially affect patients’ quality of life (National Institutes.2001).
Nutritional need changes for most persons during the phases of cancer
treatment. Cancer survivors are often highly motivated to seek information
about food choices, physical activity, dietary supplement use, and
4
complementary nutritional therapies to improve their treatment outcomes,
quality of life, and survival. For these long-term cancer survivors, an
appropriate weight, a healthful diet, and a physically active lifestyle aimed
at preventing cancers and other chronic diseases become a priority (Brown
et al. 2003).
Therefore, this study is designed to assess the nutritional status of
breast cancer patients receiving chemotherapy, and to evaluate the effect of
chemotherapy on weight, energy intake, albumin, and hemoglobin.
5
Rational:
Knowledge of changes in nutritional status due to cancer or due to its
therapy will not only help in better management of nutritional problems,
but will also enable better clinical outcome.
The nutritional status of breast cancer patient receiving chemotherapy in
the Kingdom of Saudi Arabia is un-known. Therefore, the present
investigation was designed to study the nutritional status of breast cancer
patients receiving chemotherapy, and to evaluate the effect of
chemotherapy on weight, energy intake, albumin, and hemoglobin.
Objective:
The objectives of this study were:
- To evaluate the nutritional status of breast cancer patients
receiving chemotherapy.
- To evaluate the effect of chemotherapy on weight, energy intake,
albumin, and hemoglobin.
6
Literature review
2-1: Side effects of chemotherapy
The use of adjuvant chemotherapy for early breast cancer patients can
significantly improves the overall survival. However, this type of therapy is
associated with several side-effects. The critical issue is whether the
survival benefits counterbalances the side-effects (Bergh et al. 2001).
Chemotherapy of breast cancer patient can have many adverse affects,
most of which resolve after treatment is completed. The most serious, even
life threatening, are secondary leukemia and cardiac dysfunction (Harold
and Eric. 2000, Ng and Green. 2007). Women receiving adjuvant
chemotherapy for breast cancer have substantial problems that lead to
fatigue, menopausal symptoms and cognitive changes (Downie et al. 2006).
Some of the acute side effects of chemotherapy are nausea, vomiting,
mucositis, taste and smell changes, and hair loss occurs in varying degrees
with the different chemotherapy regimens (Young and Mathias. 2004,
Bergkvist and Wengström. 2006, Stringer et al. 2007, Yun and Kim. 2007).
Also women with breast cancer may be at increased risk of osteoporosis
because of loss of bone mineral density owing to premature ovarian failure
from chemotherapy (Swenson et al. 2005), other changes due to
chemotherapy such as loss of body weight, loss of muscle mass, weight
7
gain, eating and digestive difficulties are usually temporary but can
sometimes persist (Brown et al. 2003).
On the other hand the gastrointestinal tract often suffers greatly from
cancer treatments, causing taste change and other symptoms (including dry
mouth, decreased appetite, nausea, and vomiting) (Williams et al. 2006).
These symptoms often result in poor nutritional intake. Gastrointestinal
tract cells are often affected because cytotoxic chemotherapy works by
killing rapidly proliferating cells. In addition to the previous chemotherapy
side effect breast cancer patients may suffer from tumor lysis syndrome.
Chemotherapy may result in the massive release of potassium, phosphate,
uric acid, and other breakdown products of dying tumor cells into the
blood. Tumor lysis syndrome develops within hours to a few days after the
beginning of the treatment (Casciato. 2004).
2-2: Nutritional status
Nutritional status is vital to patients' overall clinical management. Food
intake and appetite alterations have been identified as some of the main
causes of malnutrition. The acceptance of foods is influenced by emotional
and psychological factors in addition to those associated with the treatment
and the disease itself (Garofolo and Lopez. 2002). Metabolic disturbance is
another problem among cancer patients, and this is often represented by
catabolic status. It has been shown that the weight loss that occur in
8
cachexia lead to reductions in lean body tissue (Fanelli et al. 1996, Laviano
et al. 1996).
Cancer
treatment
itself,
and
particularly
chemotherapy
and
radiotherapy seem to be an important nutritional risk factor. The treatment
is associated with several side effects (nausea, vomiting, oral mucositis,
constipation, and food aversion) which play an important role in decreased
food intake, nutrient loss, energy expenditure alterations and weight loss,
particularly lean body mass (Andrassy and Chwals. 1998). These
conditions predispose patients towards malnutrition, especially when there
are frequent periods of chemotherapy treatment (Angus and Burakoff.
2003, Garofolo et al. 2005).
Nutritional screening and assessment play an important role in the
early
recognition
of
cancer-associated
malnutrition
(Holmes
and
Molassiotis. 2005).
Nutritional screening is the process of discovering characteristics or
risk factors known to be associated with dietary problems. Its main purpose
is to identify individuals who are at risk. As opposed to the more timeconsuming and detailed process of nutritional assessment, screening should
be a simple procedure aimed at identifying the nutritional status in an
expedient manner. Nutritional assessment is a comprehensive process of
identifying individuals and populations at risk and planning, implementing,
9
and evaluating a course of action .The evaluation of nutritional status is a
complex matter and for it to be of clinical importance the ideal method
should be able to predict whether an individual would have increased
morbidity and mortality rates in the absence of nutritional support.
Moreover, disease and nutrition interact in such a way that the disease may
cause secondary malnutrition or that malnutrition may adversely influence
the underlying disease. In fact, patient outcomes are multifactor (Slaviero
et al. 2003).
An assessment of patients’ nutritional status is usually based on the
evaluation of laboratory test results, anthropometric measurements, clinical
history, and physical examination. In general, laboratory parameters reflect
the net result of the synthesis, distribution, and loss or excretion (Davies.
2005). Therefore, to assess the nutritional status of breast cancer patients,
anthropometric measurements were used. One nutrition-related variable is
BMI. Normal BMI at the time of breast cancer diagnosis has been
associated with optimal survival, and extremes of BMI have been
associated with less favorable survival. Goodwin et al. (2003) believed that
a similar association may also be present for diet and breast cancer
outcomes. There may be optimal ranges of dietary intake that are
associated with the best outcomes, and extremes may be associated with
worse outcomes. It has been suggested that diets that minimize extremes in
10
nutrient intake and a lifestyle that results in a normal BMI may be
associated with the best breast cancer outcomes (Goodwin et al. 2003).
Dietary counseling has been shown to be effective in the management
of nutritional problems in the early stages of nutritional decline (Ravasco et
al. 2005). In fact nutrition therapy can help cancer patients get the nutrients
to maintain body weight and performance status, prevent body tissue from
breaking down and rebuild tissues (Tian et al. 2007). Therefore, assessment
and planning for survivors should begin while treatment is being planned
and should focus on current nutritional status and anticipated nutritional
problems related to treatment (Brown et al. 2003). It has been suggested
that maintaining energy balance or preventing weight loss during cancer
treatment, is the most important nutritional goal for survivors especially
those who are already undernourished (Brown et al. 2003). On the other
hand patients who are unable to meet their nutritional needs, oral
nutritional supplements can improve dietary intake.
Oral supplementation is the simplest, most natural and least invasive
method of increasing nutrient intake (Ravasco et al. 2003), on the other
hand enteral tube feeding is indicated in patients who are unable to meet
their nutritional needs orally. In patients with cancer enteral tube feeding
has been shown to be preferable to parenteral feeding for several reasons,
11
including a lower incidence of overall and infectious complications, and to
reduce length of hospital stay (Bozzetti et al. 2001).
2-3: Malnutrition
Malnutrition is a state produced by insufficient or excessive intake of
protein-energy, vitamin and mineral deficiency, excessive intake of
inappropriate substances such as alcohol. Malnutrition increases the
duration of hospitalization as well as hospital expenses. In contrast to wellnourished and normal weight patients, the malnourished ones are more
likely to stay longer in hospital due to further complications (Juretiae et al.
2004).
Cancer-associated malnutrition can result from local effects of a tumor,
the host response to the tumor and anticancer therapies. Although cancer
patients often have reduced food intake (due to systemic effects of the
disease, local tumor effects, psychological effects or adverse effects of
treatment), alterations in nutrient metabolism and resting energy
expenditure (REE) may also contribute to nutritional status (Van Cutsem
and Arends. 2005).
The consequences of malnutrition include impairment of immune
functions, performance status, muscle function, quality of life, and
responses to chemotherapy are decreased (Van Cutsem and Arends. 2005).
12
Cancer-related malnutrition is associated with significant healthcarerelated costs. Nutritional support is required to improve prognosis, and
reduces the consequences of cancer-associated nutritional decline (Van
Cutsem and Arends. 2005). Estimated prevalence rates of malnutrition vary
according to tumor site, disease stage and the type of treatment used
(Meyenfeldt. 2005).
2-4: Weight & chemotherapy
Weight gain has been associated with adjuvant chemotherapy but not
with tamoxifen therapy. In a systematic review of the relation between
obesity at diagnosis and breast cancer outcomes, twenty six out of thirty
four studies showed a statistically significant association between obesity
and breast cancer recurrence, whereas eight studies found no such
associations (Grunfeld et al. 2005). Women with breast cancer who are
overweight or gain weight after diagnosis are found to be at greater risk for
breast cancer recurrence and death compared with lighter women
(Chlebowski et al. 2002).
A number of reasons for the weight gain associated with adjuvant
chemotherapy for breast cancer have been proposed, including the type of
chemotherapy/length of treatment, fatigue, decreased level of physical
activity, increase in energy intake, decrease in REE, and development of
amenorrhea/menopause. However, there is conflicting evidence on the
13
impact of these factors. Overall, the mechanisms for this weight gain are
not well understood, making effective intervention difficult (Campbell et
al. 2007).
A significant increase in weight occur in 50–96% of all early stage
breast cancer patients during treatment with chemotherapy, with the
median gain in weight ranging from 2.5– 6.2 kg over treatment and followup periods up to 1 year. Chemotherapy has been found to be a strong
clinical predictor of weight gain in women with early stage breast cancer
that is independent of age at diagnosis, nodal status, BMI at diagnosis, and
reported caloric intake (Wahnefried et al. 2001).
The degree of weight gain in response to chemotherapy appears to be
dependent on the chemotherapeutic agents used. Women treated with
cyclophosphamide, methotrexate, 5-fluorouracil (CMF) are reported to
have significant gain in both body weight and fat mass during treatment
(Lankester et al. 2002), other studies (Kutynec et al. 1999, Wahnefried et
al. 2001) using doxorubicin and cyclophosphamide (AC)- AC includes
doxorubicin one of a group of drugs called anthracyclines- find no weight
gain during chemotherapy.
Women with breast cancer receiving adjuvant chemotherapy show no
significant changes in weight during the first year of their treatment. They
do, however, appear to undergo unfavorable changes in body composition
14
(Freedman et al. 2004). In a small pilot study of 10 premenopausal breast
cancer patients receiving chemotherapy, a six months program focused on
strength training included aerobic exercise and guidance toward a low-fat,
high-vegetable and high-fruit diet resulted in significant changes in total
body weight and percent body fat compared with controls who experienced
weight gains (Rock and Wahnefried. 2002(a)).
Between 50% and 90% of cancer patients lose weight, and about 40%
lose more than 10% of their total body weight. Weight loss greater than
10% is associated with an increased risk of morbidity and mortality, and in
cancer patients weight loss is a negative prognostic factor (Thorese et al.
2002).
2-5: Hematology & chemotherapy
Cancer patient may suffer from protein breakdown which can reduced
body protein stores. This catabolic state may occur as a consequence of the
malignant disease itself, chemotherapy or complications of the therapy, e.g.
infections and organ failure (Garofolo et al. 2005). Altered nutritional and
inflammatory status correlates with increased risk of severe hematological
toxicity following chemotherapy (Alexandre et al. 2003). Protein loss may
be an important cause of the hypoalbuminemia. More than 80% of cancer
patients have a reduction serum albumin concentration (Dreizen et al.
1990).
15
Many patients with breast cancer suffer from anemia, as a consequence
of the disease itself or its treatment. Anemia has a negative impact on
treatment outcome and on overall survival, is a common complication in
patients with cancer (Caro et al. 2001). A retrospective data from 249
women treated for breast cancer, showed that anemia during adjuvant
chemotherapy is a negative prognostic indicator for survival of patients
with breast cancer (Boehm et al. 2007).
Anemia in patients with cancer is an independent prognostic factor for
survival, and associated with shorter survival (Leyland-Jones et al. 2005).
Anemia is a potential contributor to the functional impairment that often
occurs during and after chemotherapy. Many patients experience mild to
moderate degrees of anemia that are not considered serious enough to
warrant transfusion therapy, but anemia may adversely affect functional
capacity (Gabrilove et al. 2001).
A variety of factors are known to be involved in anemia development,
some of these factors relate to the tumor itself (blood loss, bone marrow
infiltration or nutritional deficiencies) or to chemotherapy treatment. The
most commonly used chemotherapy regimens in the adjuvant setting,
5-fluorouracil, doxorubicin, cyclophosphamide (FAC) - Doxorubicin is an
anthracycline- and CMF, and they have induced similar rates of anemia
16
about 43–47% of patients. Moreover, severe anemia has been observed in
11% of patients treated with FAC (Leonard et al. 2005).
Approximately 50% of cancer patient develop anemia. It is generally
defined as hemoglobin level <12 g/dl .The severity of anemia depends on
many factors including the nutritional status of the patient, the type of
cancer , the stage and extent of tumor burden (especially bone marrow
involvement), and bleeding. Cancer-related anemia can be associated with
debilitating symptoms and can have a profound effect on health (Kirshner
et al. 2004). There are four prediction tools for identification of patients
with breast cancer who are most likely to develop severe anemia during
chemotherapy: precycle Hb concentration, cycle of chemotherapy, age
(≥65 years), platelet count, and type of chemotherapy (Spivak. 2005).
Kailajarvi et al. (2000(a)) investigated the effect of chemotherapy
drugs on serum hormones, proteins, lipids and common biochemical test in
postmenopausal women with breast cancer, and found that serum albumin
decreased slightly after chemotherapy.
Dranitsaris et al. (2005), examined 331 patients receiving adjuvant
chemotherapy for breast cancer, and they found that 3% patients were
anemic at the start of the study, compared with 25% at the final cycle of
chemotherapy, and the result of Tchekmedyian study (2002), revealed that
37% patient were anemic (Hb < 12 g/ dl) prior to chemotherapy, and an
17
additional 41% became anemic during chemotherapy. In a retrospective
study performed on 104 patients treated for breast cancer, Hurria et al.
(2005) found that hemoglobin level decrease from cycle 1 to cycle 2.
Alexandre et al. (2003) investigated the influence of malnutrition and
inflammation on acute haematological toxicity. They found that patients
had lower hemoglobin, and serum-albumin levels. Also hematological tests
of seven women with breast cancer during chemotherapy, showed a slight,
non-significant and transient decrease in hemoglobin and in albumin
(Kallajavi et al.2001).
In retrospective survey Engl et al. (2005) studied hemoglobin level of
129 patients during chemotherapy. They found hemoglobin prior to
primary surgery was 13.8 g/dl, pre-chemotherapy hemoglobin 12.8 g/dl,
and hemoglobin during chemotherapy was 11.0 g/dl. The hemoglobin level
decrease during chemotherapy.
Gianni et al. (2008) found that among the 2,215 breast cancer patients
treated with adjuvant chemotherapy in two randomized trials, anemia was
recorded in 11% during adjuvant chemotherapy. Grade 2 and 3 anemia
occurred in 1% of patients, respectively. Moderate or severe anemia is rare
among patients treated with AC followed by CMF. Low baseline
hemoglobin and white blood cells are associated with a higher risk of
anemia.
18
Tas at el. (2002) investigated the incidence and severity of
chemotherapy-induced anemia caused by chemotherapy regimens used in
the treatment of malignancies in 552 adults. They found that before
chemotherapy, 44% of patients with breast cancer had anemia. After
chemotherapy 60 % were anemic. Severe anemia was observed in less than
1% of patients. No difference was found in the incidence of anemia
between the FAC and CMF regimens used in the adjuvant setting.
Denison et al. (2003) studied the incidence of anemia in 247 breast
cancer patients receiving chemotherapy and found that 28.7% of patients
were anemic. 42% of patients with a hemoglobin level of > or = 12 g/dl at
baseline developed anemia during adjuvant chemotherapy. The total
incidence of anemia in patients with primary breast cancer who underwent
surgery followed by adjuvant multi-agent chemotherapy was 58.7%. They
also reported that 20.2%, 19.2% and 19.2% patients showed a decrease in
hemoglobin levels by 1 g/dl, 1-2 g/dl and > 2 g/dl, respectively. Only
18.6% of the patients who were found to be anemic received anemia
treatment.
Ushering et al. (2004) monitored the nutritional status of cancer
patients receiving different treatment, by follow-up assessments of the
effect of type and duration of treatment on patient’s nutritional status. They
found that the different treatments used for treating cancer tend to affect
19
adversely the nutritional status of the patients. A progressive decrease in
weight of patients was observed as chemotherapy progressed, which was
reflected in the body mass index. Hemoglobin concentrations declined
substantially with radiotherapy and chemotherapy. Moderately low values
of serum albumin were observed in both males (67%) and females (50%).
20
Study design & Methodology
Study design:
This is a prospective study.
Study area:
The study was conducted at the chemotherapy day unit (CDU) Riyadh
Armed Forces Hospital. The CDU start at seven’ clock in the morning and
breast cancer patients received chemotherapy three days in the week
Monday, Tuesday, and Wednesday. The researcher review patients files
every day and choose patients who met the inclusion criteria to interview
them.
Patients:
A total of 30 female patients between 30 and 55 years of age newly
diagnosed with breast cancer, scheduled for chemotherapy in Riyadh
Armed Forces Hospital were included in the study.
Patients who had received chemotherapy before the study, and patients
with diabetes were excluded.
Methods:
Each patient was interviewed before chemotherapy, and follow-up
assessments were performed on the third week after initiation of treatment
before the second chemotherapy cycle.
21
All patients in this study received one cycle of chemotherapy, and the
chemotherapy reagent patients received was 5-fluorouracil, doxorubicin,
cyclophosphamide (FAC). The time between cycles was three weeks.
Patients were interviewed in the day of the first cycle before treatment start
and all anthropometrics measurement, dietary intake assessment, and blood
sample were collected in the day of the first cycle. The researcher collected
all information and parameters except the blood sample were collected by
one of CDU nurses.
The patients were interviewed using questionnaire that was developed after
a comprehensive review of literature in this field. It was written in Arabic
and consists of the following part:
- Demographic-socioeconomic data contained information about age,
number of children, number of full term pregnancies, breast feeding,
education, family income (Appendix I).
- Medical history includes data such as type of chemotherapy, vitamins
and other supplementation, complaints, and diseases (Appendix I).
- Dietary history data includes information about number of meals per
day, main meal, fast food, snacks (Appendix I).
The nutritional status of patients were assessed before and after
chemotherapy through anthropometric (Height, weight, and BMI), dietary
(24-hour recall, Food frequency questionnaire (FFQ)), and biochemical
(Hb, MCV, and Alb) methods.
22
Dietary intake assessment:
-A 24 hour food recall method was used to collect information on
nutrients intake. The patients were asked to recall the types and
approximate amount of food consumed over the previous 24 hour
(Appendix II).
- FFQ includes the most commonly eaten foods. The FFQ was used to
investigate the most frequent consumed food items (weekly and daily)
(Appendix III).
Anthropometrics measurement:
Three variables (body weight, height, BMI) were collected for the
anthropometrics measurement of the patients.
-Body weight was obtained by using beam balance scale (Seca
mode708 scale). Weight was taken to the nearest 0.l kg.
-Height was obtained by using stadiometer. Reading was reported to
the nearest 0.5 cm, in duplicate and measure was taken bare footed. The
patients were without head cover and their feet were to gather against the
measuring board and head were kept right.
- Body mass index was calculated by using equation.
BMI = [weight (kg)/ height (m²)] (Appendix IV).
Sample collection and laboratory measurements:
Blood samples (10 ml) were collected from the patients before and
23
three weeks after the start of treatment. All laboratory measurements were
carried out in the hospital.
- Hb and MCV were estimated in the blood samples using coulter
automated method (Packman coulter company- USA).
- Alb was estimated by using bromocresol green dye (BCG) (Roche
hitachi system -USA) (Appendix V).
For the purpose of this study we defined anemia in breast cancer
patient receiving chemotherapy according to NCI (Groopman et al. 1999)
a patient with Hb <12g/l will be consider to be anemic.
Statistical analysis:
Statistical analysis was performed using the Statistical Package for
Social Sciences (SPSS version 15).
For descriptive purposes means and standard deviations (± SD) were
reported. Changes in the outcome variable between baseline and the end of
3
weeks
of
chemotherapy
were
determined
using
t-test.
24
Results
Patients’ demographic-socioeconomic characteristics
The information from the questionnaire showed that a total of 30 breast
cancer women receiving chemotherapy met the study criteria. Table 1
shows that 76.7 % of the patients have medium physical activity, 93.3% of
them were married, 36.7% of the study subjects were university graduates,
and 63.3% of them were housewife. The highest percentage (40%) of
women had less than 5000 SR monthly income.
Patients’ medical history
Patients’ medical history showed that 26.7% of patients used
supplementation. Most of the patients (56.7%) were disease free, and didn’t
have any complaints. Table 2 shows that 6.7% of patients were anemic
before the treatment. 20% complain the lack of appetite, and 13.3% had
nausea and vomiting.
Patients’ dietary history
The results from the dietary survey showed that 53.3% of women had
mentioned that they have three meals per day, and their main meal was
lunch. 50% of them eat fast food, and 73.3% of women eat between meals
(Table 3).
25
Table 1: The patients Demographic-socioeconomic characteristics.
Physical activity
Low
Medium
High
Breast feeding
Yes
No children
Marital status
Married
Divorce
Widow
Education level
Illiterate
Can read and write
Primary
Secondary
High
University
Employment status
Employed
Unemployed
Income
Less than 5000 SR
5000 SR-7000 SR
8000SR -10'000 SR
More than 10'000 SR
n
%
6
23
1
20.00
76.67
3.33
19
4
63.33
13.33
28
1
1
93.33
3.33
3.33
5
2
6
3
3
11
16.67
6.67
20.00
10.00
10.00
36.67
11
19
36.67
63.33
12
5
8
5
40.00
16.67
26.67
16.67
26
Table 2: The patients medical history.
Type of chemotherapy
Multi agent
Vitamins & supplements
Yes
Disease
High blood pressure
Heart disease
GI disorders
Anemia
Ulcers
Complaints
Lack of appetite
Nausea &Vomiting
Indigestion
Constipation
n
%
30
100
8
26.67
5
4
1
2
1
16.67
13.33
3.33
6.67
3.33
6
4
1
2
20.00
13.33
3.33
6.67
27
Table 3: The patients dietary history .
Shopping for food
Weekly
Monthly
Preparing food
The patient
Patient daughter
Maid
Meals per day
One meal
Two meals
Three meals
More than 3
Main meal
Breakfast
Lunch
Dinner
Skip main meal
Yes
Fast food
Yes
Eat between meals
Yes
Snacks
One
Two
Three
n
%
15
15
50.00
50.00
24
3
3
80.00
10.00
10.00
1
11
16
2
3.33
36.67
53.33
6.67
2
27
1
6.67
90.00
3.33
2
6.67
15
50.00
22
73.33
10
10
2
33.33
33.33
6.67
28
24 hour food recall
The results from the 24 hour food recall showed that the mean energy
intake before chemotherapy was 1445.9 kcal, and 3weeks after
chemotherapy became 1445.7 kcal. This is non-significant (p=0.636)
change in energy intake before and 3 weeks after chemotherapy. The REE
before chemotherapy was 1602kal/kg/d, and 3weeks after chemotherapy
became 1599 kal/kg/d. The t-test shows no significant (p=0.812) change in
REE.
The protein intake before chemotherapy was 45.86g compared with
45.83g 3 weeks after chemotherapy. The t-test shows no significant
(p=0.573) change in protein intake before and 3 weeks after chemotherapy.
Carbohydrate intake before chemotherapy was 150.6g, and 3 weeks after
chemotherapy became 150.5g, and fat intake before chemotherapy was
36.3g compared to 36.4g after chemotherapy. No significant change in
carbohydrate intake and fat intake before and 3 weeks after chemotherapy.
29
Food frequency questionnaire
Table 4 a: Food frequency questionnaire
Food groub
Starch
Meat
Fat
Milk
Fruit
Vegetable
1-3 times a week
n
%
11
36.37
9
30.00
22
73.33
7
23.33
10
33.33
7
23.33
4-6 times a week
n
%
10
33.33
15
50.00
6
20.00
14
46.67
4
13.33
6
20.00
>6 times a week
n
%
9
30.00
6
20.00
2
6.67
3
10.00
11
36.37
13
43.33
4-6 times a day
n
%
7
23.33
3
10.00
4
13.33
5
16.67
4
13.33
4
13.33
>6 times a day
n
%
3
10.00
0
00.00
0
00.00
1
3.33
0
00.00
0
00.00
Table 4 b: Food frequency questionnaire
Food groub
Starch
Meat
Fat
Milk
Fruit
Vegetable
1-3 times a day
n
%
17
56.67
12
40
26
86.67
16
53.33
18
60.00
17
56.67
30
Weight and general characteristics
Table 5a, and 5b show that the percentage of women who had gain
weight was 43.3%, and women who had lost weight were 50%.
It has been observed that 20% of women, who had weight loss suffered
from high blood pressure, and 13.3% complained of lack of appetite, while
15.4% of those with weight gain suffered from high blood pressure, 15.3%
suffered from heart disease, and 30.8% complained of lack of appetite
(Table 5a).
Higher weight loss prevalence (46.7%) was found among women who had
2-5 times full term pregnancies, and the prevalence of weight gain (30.8%)
was observed in those who had 2-9 times full term pregnancies. The
highest percentage (26.7%) of women who had weight loss had 6 children
or more, while those with weight gain had 4-6 children.
Table 5a shows that (33.3%) of women who had weight lost were
illiterate and 33.3% were university graduates.
Approximately 46.2% of women who had weight gain were university
graduates, 73.3% of women who had weight loss were unemployed, and
53.9% of women who had weight gain were employed.
Higher weight loss prevalence (46.7%) and weight gain (38.5%) was found
among women who had a family income less than 5000 SR.
The results of the dietary survey showed that 66.7% of women who
had weight loss mentioned that they had three meals per day, and their
31
main meal was lunch, while 40% of them eat fast food. The highest
percentage of weight loss (46.7%) was found among women who were
taking two snacks per day. About 46.1% of those who gained weight had
three meals per day, and their main meal was lunch, while 61.5 % of them
eat fast food. The highest percentage of weight gain (38.5%) was found
among women who were taking one snack per day (Table 5b).
In the present study prevalence of weight gain was 43.3% (69.3 vs
70.46kg) patients weight gain was between (0.1-7.4 kg), and 69.2% of the
total women who gain weight aged between 40-50 years. On the other hand
women who had weight loss were 50% (72.8 vs 71.6 kg), patients loss
between (0.1-7 kg), and 46.7% of the total women who had weight loss
aged between 40-50 years. The t-test shows no significant change in weight
before and 3 weeks after chemotherapy.
32
Table 5a : Weight and general characteristics
Loss weight
Variable
n
%
Gain weight
%
n
Age
30 - < 40
40 - < 50
≥ 50
Vitamins and supplements intake
Yes
Presence of disease
High blood pressure
Heart disease
GI disorders
Anemia
Ulcers
Presence of complaints
Lack of appetite
Nausea &Vomiting
Indigestion
Constipation
No.of pregnancies
2-5
6-9
10 - 13
> 13
No.of children
Non
1-3
4-6
>6
Education level
Illiterate
Can read and write
Primary
Secondary
High
University
Employment status
Employed
Unemployed
3
7
5
20.00
46.67
33.33
2
9
2
15.38
69.23
15.38
4
26.67
4
30.77
3
1
0
1
1
20.00
6.67
0
6.67
6.67
2
2
1
0
0
15.38
15.38
7.69
0
0
2
1
0
1
13.33
6.67
0
6.67
4
2
1
1
30.77
15.38
7.69
7.69
7
6
0
1
46.67
40.00
0
6.67
4
4
2
1
30.77
30.77
15.38
7.69
1
5
5
4
6.67
33.33
33.33
26.67
2
3
5
3
15.38
23.08
38.46
23.08
5
1
1
2
1
5
33.33
6.67
6.67
13.33
6.67
33.33
0
1
4
1
1
6
0
7.69
30.77
7.69
7.69
46.15
4
11
26.67
73.33
7
6
53.85
46.15
33
Table 5b : Weight and general characteristics
Loss weight
Variable
n
%
Income
7
46.67
Less than 5000 SR
3
20.00
5000 SR - 7000SR
5
33.33
8000SR - 10'000 SR
0
0
More than 10'000 SR
Shopping for food
66.67
Weekly
10
33.33
Monthly
5
Preparing food
66.67
She (the patient)
10
20
Patient daughter
3
13.33
Maid
2
Meals per day
6.67
One meal
1
26.67
Two meals
4
66.67
Three meals
10
0
More than 3
0
Main meal
0
Breakfast
0
93.33
Lunch
14
Dinner
1
6.67
Skipping main meal
0
Yes
0
Fast food
40.00
Yes
6
Snacks per day
Non
20.00
3
33.33
One
5
46.67
Two
7
0
Three
0
Gain weight
%
n
5
1
3
4
38.46
7.69
23.08
30.77
5
8
38.46
61.53
12
0
1
92.31
0
7.69
0
5
6
2
0
38.46
46.15
15.38
2
11
0
15.38
84.61
0
2
15.38
8
61.53
3
5
3
2
23.08
38.46
23.08
15.38
34
Body mass indexes (BMI)
Table 6 shows that before chemotherapy (30%) women consider to be
normal, 16.7% overweight, 43.3% obese, and (10%) extreme obesity. After
treatment 23.3% women consider normal, 26.7% women overweight, 40%
women obese, and 10% have extreme obesity.
Table 6:Classification of overweight and obesity by BMI
Body mass index
Severity
Underweight
Normal
Overweight
Obesity
Extreme obesity
Source: Chlebowski et al. 2002
before
BMI (kg/m2)
<18.5
18.5-24.9
25.0-29.9
30.0-39.9
≥40
n
0
9
5
13
3
30
%
0
30.00
16.67
43.33
10.00
100
after
n
0
7
8
12
3
30
%
0
23.33
26.67
40.00
10.00
100
35
Biochemical parameters
Patients had normal albumin level 41.96 g/l before chemotherapy
while 3 weeks after chemotherapy albumin level was 40.7 g/l. A significant
(P<0.01) decrease in albumin was observed in patients after chemotherapy
but still it is within the normal range (Alb reference 36-51g/l).
Patients had normal MCV level 79.17 fl before chemotherapy while 3
weeks after chemotherapy MCV level was 79.80 fl. A non significant
(P<0.23) change in MCV was observed in patients after chemotherapy but
within the normal level.
According to National Cancer Institute (NCI) grading system (Groopman et
al. 1999) for anemia (Table 7), before chemotherapy 3.3% patient had
grade 4 anemia, 3.3% patient had grade 2, 36.7% patients had grade 1, and
56.7%
patient had normal hemoglobin level. Three weeks after
chemotherapy 53.3% patients became grade 1, 6.7% patients had grade 2,
and only 40 % patient with normal hemoglobin level. The t-test shows
significant change in hemoglobin before chemotherapy and 3 weeks after
chemotherapy (p 0.035).
Table 7:Grading system for anemia
Severity
Grade 0 (WNL)
Grade 1 (mild)
Grade 2 (moderate)
Grade 3 (severe)
Grade 4 (life threatening)
before
Hb
≥11.0 g/dL
9.5–10.9 g/dL
8.0–9.4 g/dL
6.5–7.9 g/dl
<6.5 g/dL
N
17
11
1
0
1
30
%
56.67
36.67
3.33
0
3.33
100
after
N
12
16
2
0
0
30
Hb: hemoglobin, WNL: within normal limits.WNL hemoglobin values are 12.0–16.0 g/dl for women.
Source: Groopmanet al. 1999
%
40.00
53.33
6.67
0
0
100
36
Table 8: Patients characteristics
n
Mean
Std.Deviation
Age
30
43.43
6.88
Number of children
26
5.08
2.63
Number of full term pregnancies
26
6.54
3.64
Family size
30
7.47
4.74
Table 9: t-test for variable between baseline and 3 weeks after chemotherapy
Mean
SD
t
P
Weight
0.0933
2.07
0.247
0.807
BMI
0.0226
0.83
0.149
0.883
Hb
0.4667
1.16
2.2
0.035
- 0.633
2.85
- 1.22
0.233
MCV
Alb
1.233
2.46
2.747
0.018
Energy intake
0.233
2.67
0.478
0.636
Protein intake
0.033
0.31
0.571
0.573
Fat intake
-0.033
0.18
-1.00
0.325
0.067
0.45
0.812
0.423
Carbohydrate intake
BMI:body mass index, Hb:hemoglobin,MCV:Mean corpuscular volume Alb:Albumin.(P 0.05)
37
Discussion & Conclusion
In the present study the 24 hour food recall shows that energy intake
before chemotherapy was 1445.96 kcal, and 3weeks after chemotherapy
became 1445.73 kcal. All patients energy intake was lower than
recommended daily allowances (RDA) which is (1900-2200kcal). The REE
before chemotherapy was 1602kal/kg/d, and 3weeks after chemotherapy
became 1599 kal/kg/d. Our finding was different from Harvie et al. (2005).
Harvie study shows that there was significant increase in energy intake
among breast cancer patients over a course of chemotherapy. The
difference in energy intake may be due to difference in the socioeconomic
(low income) status.
Also protein intake before chemotherapy was 45.86 g compared with
45.83g 3weeks after chemotherapy, and the recommended protein intake
daily allowances for females in the same age of the study patients is 50g.
So all patients protein intake was lower than RDA before, and after
chemotherapy. However, energy and protein intake was not statistically
significant in this study.
Weight changes are valuable indicators of nutritional risk. Assessment
of changes in body weight over time can be a more informative indicator of
nutritional decline (Davies. 2005). Up to 60% of women diagnosed with
breast cancer experience an increase in body weight associated with
38
chemotherapy (Holmes and Kroenke. 2004), and there is evidence that
heavier women and women who gain weight after diagnosis have an
increased risk of disease recurrence and death compared to normal weight
women (Chlebowski et al. 2002). Women with a high BMI have double the
risk of 5-year recurrence and a 60% increased risk of death over 10 years in
comparison to normal weight women (Saxton et al. 2006).
In the present study prevalence of weight gain was 43.3% (69.3kg vs
70.46 kg). Patients gained weight was between 0.1-7.4 kg. Although this
trend was not statistically significant. In this study it has been found that
69.2% of the total women who gain weight aged between 40-50 years.
Lankester et al. (2002) also reported that 64% women treated with
chemotherapy gained weight. However, Campbell et al. (2007) studied 10
women undergoing adjuvant chemotherapy for breast cancer, and found
that seven women gained weight. Weight change ranged from -2.9 to + 6.8
kg there was no significant weight change across treatment, and three
women lost weight over the course of treatment. In Ingram and Brown
(2004) study, women did not experience marked weight gain during
therapy. Although in this study it has been found that 50% of the women
lost weight and 46.7% of them were between 40-50 years of age, but most
studies found that an overall trends toward weight gain.
39
The prevalence of weight loss was high among patients after the
first cycle of chemotherapy. In this study it has been found that 50% of
patients suffered from weight lost. The prevalence of weight gain between
the start of treatment and 3 weeks follow up was 43.3%. These changes in
weight were not statistically significant.
Body mass index is positively associated with patients suffering from
colon, kidney, esophagus, and breast cancer (Reeves et al. 2007).
In the present study BMI before chemotherapy and 3 weeks after
chemotherapy was (29.94 vs 29.92 ;P = 0.9) this changes in BMI was not
statistically significant on application of t-test. This result is in contrast to
the finding of Campbell et al. (2007), who found increase in BMI after
chemotherapy.
Biochemical and hematological parameters are subject to homeostatic
mechanisms and may be altered by underlying disease and/or treatment.
The most common biochemical measurements used to assess nutritional
status are blood parameters such as serum albumin and hemoglobin
(Davies. 2005).
In this study patients had albumin level within normal range before and 3
weeks after chemotherapy (41.9g/l vs 40.7 g/l) respectively. This finding is
in agreement with the finding of Usharani et al. (2004). A significant
40
decrease in albumin before chemotherapy and 3 weeks after chemotherapy
( p=0.018) was observed.
Anemia is the most common hematological abnormality in cancer patients;
unfortunately, it is often un-recognized and un-treated. The pathogenesis of
anemia in cancer is complex and most of the time multifactorial involving
factors related to the tumor itself or its therapy (Abdel-Razeq. 2004).
The hemoglobin level before chemotherapy was 12g/dl and after
chemotherapy was decrease to 11.5 g/dl. 43.3% of women were anemic
(Hb
12 g/dl) before chemotherapy. After 3 weeks 60% of these women
became anemic. This is similar to the finding of Usharani et al (2004) and
Engl et al. (2005). Only two patients mentioned that they were anemic and
were taking supplementation that means anemia wasn’t recognized in other
patient that can affect their nutritional status. The t-test shows a significant
change
in
hemoglobin
before
chemotherapy and
3
weeks
after
chemotherapy (p 0.035). Kallajavi et al. (2000(b)), investigated the effect
of chemotherapy on various laboratory tests, and found that hemoglobin
decreased transiently at 5-8 weeks but remained within the reference limits,
and albumin did not change.
Nutritional screening should be applied to all patients suffering from
cancer. Screening should be undertaken immediately following admission
to ensure that any nutritional decline due to therapy or disease progression
41
is identified as early as possible and can be dealt with. There is increasing
evidence that malnutrition has an adverse impact on morbidity and
mortality.
This investigation has found that breast cancer patients receiving
chemotherapy experiences weight change, and decrees in biochemical
parameters. Therefore, these patients are at risk of malnutrition if they
didn't have any help to prevent or to minimize the effect of chemotherapy
on their nutritional status, moreover, there is much remains to be studied
bout the nutritional status of breast cancer patient receiving chemotherapy
in the Kingdom of Saudi Arabia.
42
Recommendations
Based on the findings of this study, the following recommendations should
be considered:
™ All breast cancer patients receiving chemotherapy should have
nutritional assessment with the start of the treatment, and should
focus on current nutritional status and anticipated nutritional
problems related to treatment
™ During active cancer treatment patient should maintain adequate
energy intake to prevent weight loss.
™ Clinicians can advise their overweight or obese patients to increase
physical activity, and follow a healthy diet.
™ Future research is needed to evaluate the nutritional status of breast
cancer patient receiving chemotherapy to prevent nutritional
deficiency, and to improve quality of life.
43
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‫‪55‬‬
‫‪Appendix I‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫رﻗﻢ اﻟﻤﻠﻒ‬
‫ﺗﺎرﻳﺦ ﺑﺪاﻳﺔ اﻟﻌﻼج‬
‫‪56‬‬
‫)‪Appendix I( continue‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫‪(1‬اﻟﺒﻴﺎﻧﺎت اﻟﺼﺤﻴﺔ‬
‫اﻟﻌﻤﺮ‬
‫ﻧﻮع اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‬
‫اآﺜﺮ ﻣﻦ ﻋﻘﺎر‬
‫ﻋﻘﺎر ﻣﻔﺮد‬
‫ﻧﻌﻢ‬
‫هﻞ ﺗﺘﻨﺎوﻟﻴﻦ ادوﻳﺔ ﻣﻘﻮﻳﻪ ) اﻟﻔﻴﺘﺎﻣﻴﻨﺎت او أي ادوﻳﺔ ﻣﻘﻮﻳﺔ (؟‬
‫ﻻ‬
‫هﻞ اﻧﺖ ﻣﺼﺎﺑﻪ ﺑﺎي ﻣﻦ اﻻﻣﺮاض اﻟﺘﺎﻟﻴﺔ ‪:‬‬
‫اﻣﺮاض اﻟﻘﻠﺐ‬
‫اﻣﺮاض اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬
‫اﻣﺮاض اﻟﺮﺋﺘﻴﻦ‬
‫ﺿﻐﻂ اﻟﺪم‬
‫اﻣﺮاض اﻟﻜﺒﺪ‬
‫اﻣﺮاض اﻟﻜﻠﻰ‬
‫ﻗﺮﺣﺔ اﻟﻤﻌﺪﻩ‬
‫ﻏﻴﺮ ذﻟﻚ ‪-----------------------------------------‬‬
‫هﻞ ﺗﻌﺎﻧﻴﻦ ﻣﻦ أي ﻣﻦ اﻻﻋﺮاض اﻟﺘﺎﻟﻴﺔ ‪:‬‬
‫ﻓﻘﺪان اﻟﺸﻬﻴﺔ‬
‫ﺻﻌﻮﺑﺎت ﻓﻲ اﻟﻤﻀﻎ او اﻟﺒﻠﻊ‬
‫اﺿﻄﺮاﺑﺎت اﻟﻬﻀﻢ‬
‫اﺳﻬﺎل‬
‫ﻏﺜﻴﺎن ‪ ،‬ﻗﻲء‬
‫اﻣﺴﺎك‬
‫ﻏﻴﺮ ذﻟﻚ‪--------------------------‬‬
‫اﻟﻨﺸﺎط اﻟﺠﺴﻤﻠﻨﻲ‬
‫ﻣﻨﺨﻔﺾ‬
‫ﻣﺘﻮﺳﻂ‬
‫ﻋﺎﻟﻲ‬
‫‪57‬‬
‫)‪Appendix I(continue‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫اذا آﺎن ﻟﺪﻳﻚ اﻃﻔﺎل اﺟﻴﺒﻲ ﻋﻦ اﻻﺗﻲ ‪:‬‬
‫ﻋﺪد اﻻﻃﻔﺎل‬
‫ﻋﺪد ﻣﺮات اﻟﺤﻤﻞ‬
‫هﻞ ﺗﺮﺿﻌﻴﻦ اﻃﻔﺎﻟﻚ رﺿﺎﻋﺔ ﻃﺒﻴﻌﻴﺔ ؟‬
‫ﻻ‬
‫ﻧﻌﻢ‬
‫‪(2‬اﻟﺒﻴﻠﻨﺎت اﻻﺟﺘﻤﺎﻋﻴﺔ واﻻﻗﺘﺼﺎدﻳﺔ ‪:‬‬
‫ﻋﺪد اﻓﺮاد اﻻﺳﺮة‬
‫اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋﻴﺔ‬
‫ﻋﺰﺑﺎء‬
‫ﻣﺘﺰوﺟﺔ‬
‫ﻣﻄﻠﻘﺔ‬
‫ارﻣﻠﺔ‬
‫اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ‬
‫اﻣﻴﺔ‬
‫ﺗﻘﺮا وﺗﻜﺘﺐ‬
‫اﺑﺘﺪاﺋﻲ‬
‫ﻣﺘﻮﺳﻂ‬
‫ﺛﺎﻧﻮي‬
‫ﺟﺎﻣﻌﻲ ﻓﺎآﺜﺮ‬
‫ﻣﻮﻇﻔﻪ‬
‫اﻟﺤﺎﻟﺔ اﻟﻮﻇﻴﻔﻴﺔ‬
‫رﺑﺔ ﻣﻨﺰل‬
‫دﺧﻞ اﻻﺳﺮة اﻟﺸﻬﺮي‬
‫اﻗﻞ ﻣﻦ ‪٥٠٠٠‬رﻳﺎل‬
‫‪10000-8000‬رﻳﺎل‬
‫‪7000-5000‬رﻳﺎل‬
‫اآﺜﺮ ﻣﻦ ‪١٠٠٠٠‬رﻳﺎل‬
‫‪58‬‬
‫)‪Appendix I( continue‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫ﻣﻊ ﻣﻦ ﺗﻌﻴﺸﻴﻦ ؟ ‪--------------------------------------‬‬
‫آﻢ ﻣﺮة ﺗﺸﺘﺮﻳﻦ اﺣﺘﻴﺎﺟﺎت اﻟﻤﻨﺰل اﻟﻐﺬاﺋﻴﺔ ؟ ‪-------------------------------------------‬‬
‫ﻣﻦ ﻳﻘﻮم ﺑﺎﻋﺪاد اﻟﻄﻌﺎم ﻟﻚ ؟‪--------------------------------------------------‬‬
‫‪(3‬اﻟﺒﻴﺎﻧﺎت اﻟﻐﺬاﺋﻴﺔ‬
‫آﻢ ﻋﺪد اﻟﻮﺟﺒﺎت اﻟﻐﺬاﺋﻴﺔ اﻟﺘﻲ ﺗﺘﻨﺎوﻟﻴﻨﻬﺎ ﺧﻼل اﻟﻴﻮم ؟‬
‫وﺟﺒﺔ‬
‫وﺟﺒﻴﻦ‬
‫ﺛﻼث وﺟﺒﺎت‬
‫اآﺜﺮ ﻣﻦ ﺛﻼث وﺟﺒﺎت‬
‫ﻣﺎهﻲ اﻟﻮﺟﺒﺔ اﻟﺮﺋﻴﺴﻴﺔ ﺧﻼل اﻟﻴﻮم ؟‬
‫ﻓﻄﻮر‬
‫ﻏﺪاء‬
‫هﻞ اﻧﺖ ﻣﻌﺘﺎدة ﻋﻠﻰ ﻋﺪم ﺗﺘﻨﺎول اﻟﻮﺟﺒﺔ اﻟﺮﺋﻴﺴﻴﺔ؟‬
‫هﻞ ﺗﺘﻨﺎوﻟﻴﻦ اﻟﻮﺟﺒﺎت اﻟﺴﺮﻳﻌﺔ؟‬
‫ﻧﻌﻢ‬
‫ﻋﺸﺎء‬
‫ﻻ‬
‫ﻧﻌﻢ‬
‫ﻻ‬
‫اذا آﺎﻧﺖ اﻻﺟﺎﺑﺔ ﺑﻨﻌﻢ ﻓﻤﺎ هﻲ اﻟﻮﺟﺒﺔ اﻟﺘﻲ ﺗﻔﻀﻠﻴﻨﻬﺎ؟‪-----------------------------------‬‬
‫هﻞ اﻧﺖ ﻣﻌﺘﺎدة ﻋﻠﻰ ﺗﺘﻨﺎوﻟﻴﻦ أي ﻧﻮع ﻣﻦ اﻟﻄﻌﺎم ﺑﻴﻦ اﻟﻮﺟﺒﺎت؟‬
‫آﻢ ﻋﺪد اﻟﻤﺮات اﻟﺘﻲ ﺗﺘﻨﺎوﻟﻴﻦ ﻓﻴﻬﺎ اﻟﻄﻌﺎم ﺑﻴﻦ اﻟﻮﺟﺒﺎت ؟‬
‫ﻣﺮة‬
‫ﻣﺮﺗﻴﻦ‬
‫ﺛﻼث ﻣﺮات‬
‫اآﺜﺮ ﻣﻦ ﺛﻼث ﻣﺮات‬
‫ﻧﻌﻢ‬
‫ﻻ‬
‫‪59‬‬
‫‪Appendix II‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫اﻟﻮﺟﺒﺎت اﻟﻐﺬاﺋﻴﺔ ﻟﻠﻴﻮم اﻟﺴﺎﺑﻖ‬
‫اﻟﻄﺎﻗﺔ‬
‫اﻟﺪهﻦ‬
‫اﻟﻮﺟﺒﺔ‬
‫اﻟﻔﻄﻮر‬
‫وﺟﺒﺔ ﺧﻔﻴﻔﺔ‬
‫اﻟﻐﺪاء‬
‫وﺟﺒﺔ ﺧﻔﻴﻔﺔ‬
‫اﻟﻌﺸﺎء‬
‫وﺟﺒﺔ ﺧﻔﻴﻔﺔ‬
‫ﺑﺮوﺗﻴﻦ‬
‫ﻧﻮع اﻟﻄﻌﺎم‬
‫ﻧﺸﺎء‬
‫اﻟﻜﻤﻴﺔ‬
‫‪60‬‬
‫‪Appendix III‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫ﻧﻮع اﻟﻄﻌﺎم‬
‫ﺧﺒﺰ‬
‫ﺑﺴﻜﻮت‬
‫رز‬
‫آﻮرن ﻓﻠﻴﻜﺲ‬
‫ﻣﻜﺮوﻧﺔ‬
‫ﻟﺤﻢ ﺟﻤﻞ‬
‫ﻟﺤﻢ ﻏﻨﻢ‬
‫ﻟﺤﻢ ﺑﻘﺮ‬
‫آﺒﺪ‬
‫دﺟﺎج‬
‫ﺳﻤﻚ‬
‫ﺟﻤﺒﺮي‬
‫ﺑﻴﺾ‬
‫ﺳﺠﻖ‬
‫زﻳﺖ ﻧﺒﺎﺗﻲ‬
‫زﻳﺖ زﻳﺘﻮن‬
‫ﺳﻤﻦ‬
‫ﻣﺎﻳﻮﻧﻴﺰ‬
‫ﻣﺎرﺟﻴﻦ‬
‫زﺑﺪة‬
‫ﺣﻠﻴﺐ آﺎﻣﻞ اﻟﺪﺳﻢ‬
‫ﺣﻠﻴﺐ ﻗﻠﻴﻞ اﻟﺪﺳﻢ‬
‫ﺣﻠﻴﺐ ﻣﻨﺰوع‬
‫ﻟﺒﻦ آﺎﻣﻞ اﻟﺪﺳﻢ‬
‫ﻟﺒﻦ ﻗﻠﻴﻞ اﻟﺪﺳﻢ‬
‫ﻟﺒﻦ ﻣﻨﺰوع‬
‫زﺑﺎدي‬
‫ﺟﺒﻨﺔ‬
‫ﻟﺒﻨﺔ‬
‫ﺗﻔﺎح‬
‫ﻣﻮز‬
‫ﺷﻤﺎم‬
‫ﻓﻲ اﻻﺳﺒﻮع‬
‫اﺑﺪا‬
‫ﻣﺮﻩ‬
‫‪٣-٢‬‬
‫ﻓﻲ اﻟﻴﻮم‬
‫‪٦-٤‬‬
‫ﻣﺮة‬
‫‪٢‬‬
‫‪٣‬‬
‫‪<٣‬‬
‫‪61‬‬
‫)‪Appendix III (continue‬‬
‫اﻟﺮﻗﻢ اﻟﺘﺴﻠﺴﻠﻲ‬
‫ﻧﻮع اﻟﻄﻌﺎم‬
‫ﺑﺮﺗﻘﺎل‬
‫ﺑﻄﻴﺦ‬
‫ﺗﻤﺮ‬
‫ﺟﺰر‬
‫ﺑﻄﺎﻃﺲ‬
‫ﻃﻤﺎﻃﻢ‬
‫ﺧﻴﺎر‬
‫ﻣﻠﻔﻮف‬
‫ﺑﺎﻣﻴﺔ‬
‫ﺑﺎذﻧﺠﺎن‬
‫ﺳﻠﻄﺔ‬
‫ﻣﺮﺑﻰ‬
‫ﻋﺴﻞ‬
‫ﻣﻜﺴﺮات‬
‫ﺑﺮﺟﺮ ﻟﺤﻢ‬
‫ﺑﺮﺟﺮ دﺟﺎج‬
‫ﺑﻴﺘﺰا‬
‫ﺑﻄﺎﻃﺲ ﻣﻘﻠﻲ‬
‫ﻣﺮﻗﻮق‬
‫ﻣﻄﺎزﻳﺰ‬
‫ﺟﺮﻳﺶ‬
‫آﺒﺴﺔ‬
‫ﻣﻨﺪي‬
‫ﺣﻨﻴﻨﻲ‬
‫ﻗﺮﺻﺎن‬
‫ﺷﺎي‬
‫ﻗﻬﻮﻩ‬
‫ﻣﺸﺮوﺑﺎت ﻏﺎزﻳﺔ‬
‫ﻋﺼﻴﺮ ﻓﻮاآﺔ‬
‫ﻏﻴﺮ ذﻟﻚ‬
‫ﻓﻲ اﻻﺳﺒﻮع‬
‫اﺑﺪا‬
‫ﻣﺮﻩ‬
‫‪٣-٢‬‬
‫ﻓﻲ اﻟﻴﻮم‬
‫‪٦-٤‬‬
‫ﻣﺮة‬
‫‪٢‬‬
‫‪٣‬‬
‫‪<٣‬‬
62
Appendix IV
Anthropometric measurements:
0 before the start of
chemotherapy
Height
Weight
BMI
3weeks after the start of
chemotherapy
63
Appendix V
Biochemical measurements:
Laboratory test
Hb before chemotherapy
Hb after chemotherapy
MCV before chemotherapy
MCV after chemotherapy
Alb before chemotherapy
Alb after chemotherapy
Level
Reference
Units
11.5 ‫ـ‬16.5
g/dl
75 ‫ـ‬95
fl
36 ‫ـ‬51
g/L
64
Appendix VI
The five steps of a breast self-examination
Step 1: Begin by looking at your breasts in the mirror with your shoulders
straight and your arms on your hips and you should look for:
- Breasts that are their usual size, shape, and color
- Breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor's
attention:
- Dimpling, puckering, or bulging of the skin.
-
A nipple that has changed position or an inverted nipple (pushed
inward instead of sticking out) redness, soreness, rash, or swelling.
Step 2: Now, raise your arms and look for the same changes.
Step 3: While you're at the mirror, gently squeeze each nipple between
your finger and thumb and check for nipple discharge (this could be a
milky or yellow fluid or blood).
Step 4: Next, feel your breasts while lying down, using your right hand to
feel your left breast and then your left hand to feel your right breast. Use a
firm, smooth touch with the first few fingers of your hand, keeping the
fingers flat and together. Cover the entire breast from top to bottom, side to
side—from your collarbone to the top of your abdomen, and from your
armpit to your cleavage.
65
Follow a pattern to be sure that you cover the whole breast. You can begin
at the nipple, moving in larger and larger circles until you reach the outer
edge of the breast. You can also move your fingers up and down vertically,
in rows, as if you were moving a lawn. Be sure to feel all the breast tissue:
just beneath your skin with a soft touch and down deeper with a firmer
touch. Begin examining each area with a very soft touch, and then increase
pressure so that you can feel the deeper tissue, down to your ribcage.
Step 5: Finally, feel your breasts while you are standing or sitting. Many
women find that the easiest way to feel their breasts is when their skin is
wet and slippery, so they like to do this step in the shower. Cover your
entire breast, using the same hand movements described in Step 4.
(Breastcancer.2007).
‫‪66‬‬
‫اﻟﻤﻠﺨﺺ اﻟﻌﺮﺑﻲ‬
‫ﺳﺮﻃﺎن اﻟﺜﺪي هﻮ اﻟﺴﺮﻃﺎن اﻷآﺜﺮ ﺷﻴﻮﻋﺎ ﻟﺪى اﻟﻨﺴﺎء‪ .‬ﻣﻌﻈﻢ اﻟﺪراﺳﺎت ﺗﻬﺪف إﻟﻰ ﻣﻌﺮﻓﺔ ﺗﺄﺛﻴﺮ‬
‫اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻋﻠﻰ اﻟﻤﺮض واﻟﺸﻔﺎء ﻣﻨﻪ‪ .‬وﻟﻜﻦ اﻟﺪراﺳﺎت اﻟﺘﻲ ﺑﺤﺜﺖ ﻓﻲ ﺗﺄﺛﻴﺮ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‬
‫ﻋﻠﻰ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻗﻠﻴﻠﺔ ﺟﺪا‪.‬‬
‫اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻟﻤﺮﺿﻰ اﻟﺴﺮﻃﺎن ﻳﻤﻜﻦ أن ﻳﺘﺄﺛﺮ ﺑﺎﻟﻤﺮض واﻟﻌﻼج اﻟﻤﺴﺘﺨﺪم ﻟﻤﺮﺿﻰ اﻟﺴﺮﻃﺎن‪.‬‬
‫اﻟﺘﻐﺬﻳﺔ أﺛﻨﺎء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻬﻤﺔ ﻟﺼﺤﺔ اﻟﻤﺮﻳﺾ‪ .‬اﻟﻬﺪف اﻟﺮﺋﻴﺴﻲ ﻗﺒﻞ وأﺛﻨﺎء وﺑﻌﺪ اﻟﻌﻼج‬
‫اﻟﻜﻴﻤﻴﺎﺋﻲ هﻮ إﻋﻄﺎء اﻟﻤﺮﻳﺾ اﻟﺴﻌﺮات اﻟﺤﺮارﻳﺔ اﻟﻜﺎﻓﻴﺔ ﻟﻠﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ اﻟﻮزن وﻟﻠﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ‬
‫اﻟﺒﺮوﺗﻴﻦ أﻻزم ﻻﺳﺘﻤﺮار ﺟﻬﺎز اﻟﻤﻨﺎﻋﺔ‪ .‬ﻟﺬاﻟﻚ ﻓﺈن هﺬﻩ اﻟﺪراﺳﺔ ﺗﻬﺪف إﻟﻰ ﺗﻘﻴﻴﻢ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ‬
‫ﻟﻤﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ‪ ،‬وﺗﻘﻴﻴﻢ ﺗﺄﺛﻴﺮ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻋﻠﻰ اﻟﻮزن ‪،‬‬
‫واﻟﺴﻌﺮات اﻟﺤﺮارﻳﺔ ‪،‬و اﻻﺑﻴﻮﻣﻴﻦ ‪ ،‬و اﻟﻬﻴﻤﻮﻏﻠﻮﺑﻴﻦ‪.‬‬
‫اﻟﺪراﺳﺔ أﺟﺮﻳﺖ ﻓﻲ ﻣﺴﺘﺸﻔﻰ اﻟﻘﻮات اﻟﻤﺴﻠﺤﺔ ﺑﺎﻟﺮﻳﺎض ﺷﻤﻠﺖ اﻟﺪراﺳﺔ ﻣﺎ ﻣﺠﻤﻮﻋﻪ ‪٣٠‬اﻣﺮأة ﻣﺼﺎﺑﺔ‬
‫ﺑﺴﺮﻃﺎن اﻟﺜﺪي ﻋﻤﺮهﺎ ﻣﺎ ﺑﻴﻦ ‪ ٢٥‬إﻟﻰ ‪ ٥٥‬ﺳﻨﺔ‪ ،‬واﻟﻼﺗﻲ ﻳﺘﻠﻘﻴﻦ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻠﻤﺮة اﻷوﻟﻰ‪ .‬ﺗﻢ‬
‫اﺳﺘﺒﻌﺎد اﻟﻤﺮﻳﻀﺎت اﻟﻼﺗﻲ ﺗﻠﻘﻴﻦ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻦ ﻗﺒﻞ واﻟﻤﺼﺎﺑﺎت ﺑﻤﺮﺿﻰ اﻟﺴﻜﺮي‪.‬‬
‫أﺟﺮﻳﺖ ﻣﻘﺎﺑﻠﺔ ﻟﻜﻞ ﻣﺮﻳﻀﺔ ﻗﺒﻞ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‪ ،‬وﺑﻌﺪ ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪاﻳﺘﻪ‪ .‬وﻗﺪ اﺳﺘﺨﺪام‬
‫اﺳﺘﺒﻴﺎﻧﻪ ﻓﻲ إﺟﺮاء اﻟﻤﻘﺎﺑﻠﺔ‪ ،‬اﻻﺳﺘﺒﻴﺎن ﺗﻀﻤﻦ ﻣﻌﻠﻮﻣﺎت ﻋﻦ اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ‪ ،‬واﻻﺟﺘﻤﺎﻋﻲ‪،‬‬
‫واﻻﻗﺘﺼﺎدي‪ ،‬واﻟﺘﺎرﻳﺦ اﻟﻐﺬاﺋﻲ‪.‬‬
‫ﺗﻢ ﺟﻤﻊ اﻟﺒﻴﺎﻧﺎت اﻟﺘﺎﻟﻴﺔ ﻣﻦ ﻗﺒﻞ اﻟﺒﺎﺣﺜﺔ ﻋﻦ اﻟﻤﺮﻳﻀﺎت اﻟﻼﺗﻲ ﺷﻤﻠﺘﻬﻦ اﻟﺪراﺳﺔ‪:‬‬
‫اﻟﻘﻴﺎﺳﺎت اﻟﻤﺘﺮﻳﺔ ‪ :‬اﻟﻄﻮل واﻟﻮزن وﻣﺆﺷﺮ آﺘﻠﺔ اﻟﺠﺴﻢ )اﻟﻜﺘﻠﺔ( ﺳﺠﻠﺖ ﻗﺒﻞ اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ‪ ،‬وﺑﻌﺪ‬
‫ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‪.‬‬
‫ُأﺧﺬت ﻋﻴﻨﻪ ﻣﻦ اﻟﺪم ﻗﺒﻞ اﻟﺒﺪء ﺑﺎﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‪ ،‬وﺑﻌﺪ ﺛﻼﺛﺔ أﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ‪ .‬وﻗﺪ‬
‫‪67‬‬
‫اﺳﺘﺨﺪﻣﺖ ﻟﺘﻘﺪﻳﺮ اﻟﻬﻴﻤﻮﻏﻠﻮﺑﻴﻦ ‪ ،‬واﻻﻟﺒﻴﻮﻣﻴﻦ‪ .‬أﺟﺮﻳﺖ اﻟﺘﺤﺎﻟﻴﻞ ﻓﻲ ﻣﺨﺘﺒﺮات اﻟﻤﺴﺘﺸﻔﻰ‪.‬‬
‫اﻟﻨﺘﺎﺋﺞ‪:‬‬
‫ƒ أﻇﻬﺮت اﻟﺪراﺳﺔ أن ﻣﻌﺪل ﺧﺴﺎرة اﻟﻮزن آﺎن ﻋﺎﻟﻴﺎ ﺑﻴﻦ اﻟﻤﺮﺿﻰ ﺑﻌﺪ ﺗﻠﻘﻴﻬﻢ اﻟﻌﻼج‬
‫اﻟﻜﻴﻤﻴﺎﺋﻲ وﺟﺪﻧﺎ أن ‪ ٪٥٠‬ﻣﻦ اﻟﻤﺮﺿﻰ ﻋﺎﻧﻮا ﻣﻦ ﻧﻘﺺ اﻟﻮزن وذﻟﻚ ﺑﻌﺪ أول ﺟﻠﺴﺔ ﻣﻦ‬
‫اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻤﺎ ﻳﻮﺿﺢ ﻣﺪى ﺗﺄﺛﻴﺮ اﻟﻌﻼج ﻋﻠﻰ اﻟﻮزن‪.‬‬
‫ƒ ﻣﻌﺪل زﻳﺎدة اﻟﻮزن ﻣﺎ ﺑﻴﻦ ﺑﺪاﻳﺔ اﻟﻌﻼج واﻟﺜﻼث أﺳﺎﺑﻴﻊ اﻟﺘﺎﻟﻴﺔ ﺑﻠﻐﺖ ‪ ٪٤٣٫٣٣‬وهﺬﻩ ﻧﺴﺒﺔ‬
‫ﻣﻘﺎرﺑﺔ ﻟﻤﻌﺪل ﺧﺴﺎرة اﻟﻮزن ﻟﻨﻔﺲ اﻟﻤﺠﻤﻮﻋﺔ وهﺬا ﻳﺠﻌﻠﻨﺎ ﻧﺴﺘﻨﺘﺞ أن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻪ‬
‫ﺗﺄﺛﻴﺮﻳﻦ ﻣﺘﻀﺎدﻳﻦ ﻋﻠﻰ اﻟﻮزن ﻓﻬﻮ ﻗﺪ ﻳﻮدي إﻟﻰ زﻳﺎدة أو ﻧﻘﺼﺎن ﻓﻲ اﻟﻮزن‪.‬‬
‫ƒ ‪ ٪٤٣٫٣٣‬ﻣﻦ اﻟﻤﺮﺿﻰ آﺎﻧﻮا ﻣﺼﺎﺑﻴﻦ ﺑﻔﻘﺮ اﻟﺪم ) هﻴﻤﻮﺟﻠﻮﺑﻴﻦ اﻗﻞ ﻣﻦ‪ ١٢‬ﺟﺮام( ﻗﺒﻞ‬
‫اﻟﻌﻼج وﺑﻌﺪ ‪٣‬اﺳﺎﺑﻴﻊ ﻣﻦ ﺑﺪاﻳﺔ اﻟﻌﻼج ارﺗﻔﻌﺖ اﻟﻨﺴﺒﺔ ﻟﺘﺼﺒﺢ ‪.٪٦٠‬ﻣﻦ هﺬﻩ اﻟﻨﺴﺒﺔ‬
‫ﻣﺮﻳﻀﺘﻴﻦ ﻓﻘﻂ آﺎن ﻟﺪﻳﻬﻤﺎ ﺗﺸﺨﺺ ﻣﺴﺒﻖ ﺑﻔﻘﺮ اﻟﺪم ﻗﺒﻞ اﻟﻌﻼج‪.‬‬
‫اﻟﺘﻮﺻﻴﺎت‪:‬‬
‫اﺳﺘﻨﺎدا إﻟﻰ ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ ﻧﻮﺻﻲ ﺑﻤﺎ ﻳﻠﻲ‪:‬‬
‫™ ﻳﻨﺒﻐﻲ ﺗﻘﻴﻴﻢ اﻟﺤﺎﻟﺔ اﻟﻐﺬاﺋﻴﺔ ﻟﻜﻞ ﻣﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻣﻊ‬
‫ﺑﺪاﻳﺔ اﻟﻌﻼج‪ ،‬وﻳﻨﺒﻐﻲ اﻟﺘﺮآﻴﺰ ﻋﻠﻰ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ اﻟﺤﺎﻟﻲ و ﻣﺸﺎآﻞ اﻟﺘﻐﺬﻳﺔ اﻟﻤﺘﻮﻗﻌﺔ‬
‫اﻟﻤﺘﻌﻠﻘﺔ ﺑﺎﻟﻌﻼج‪.‬‬
‫™ أﺛﻨﺎء اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻳﺠﺐ اﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﻰ آﻤﻴﺔ ﻣﺘﻮازﻧﺔ ﻣﻦ اﻟﻄﺎﻗﺔ ﻟﻤﻨﻊ ﻓﻘﺪان اﻟﻮزن‪.‬‬
‫™ ﻳﻤﻜﻦ ﻟﻸﻃﺒﺎء ﻧﺼﺢ ﻣﺮﺿﺎهﻢ ذوي اﻟﻮزن اﻟﺰاﺋﺪ واﻟﻤﺼﺎﺑﻴﻦ ﺑﺎﻟﺴﻤﻨﺔ إﻟﻰ زﻳﺎدة اﻟﻨﺸﺎط‬
‫اﻟﺒﺪﻧﻲ ‪ ،‬وإﺗﺒﺎع ﻧﻈﺎم ﻏﺬاﺋﻲ ﺻﺤﻲ‪.‬‬
‫™ ﻧﺤﺘﺎج إﻟﻰ زﻳﺎدة اﻷﺑﺤﺎث ﻟﺘﺤﺪﻳﺪ اﻟﻮﺿﻊ اﻟﻐﺬاﺋﻲ ﻟﻤﺮﺿﻰ ﺳﺮﻃﺎن اﻟﺜﺪي اﻟﺬﻳﻦ ﻳﺘﻠﻘﻮن‬
‫اﻟﻌﻼج اﻟﻜﻴﻤﻴﺎﺋﻲ ﻟﻤﻨﻊ ﻧﻘﺺ اﻟﻌﻨﺎﺻﺮ اﻟﻐﺬاﺋﻴﺔ وﺗﺤﺴﻴﻦ ﻧﻮﻋﻴﺔ اﻟﺤﻴﺎة‪.‬‬