Nutrition in Cancer, AIDS, and Other Special Problems

The nutritional status of patients with cancer, human immunodeficiency virus (HIV), and acquired immunodeficiency syndrome (AIDS) is challenged by manifestations not only of the disease but also by the ramifications of treatment.

http://evolve.elsevier.com/Grodner/foundations/ Nutrition Concepts Online

Role in Wellness

Wasting and malnutrition, because of the effect of the disease itself or the secondary consequences of treatment, characterize the disorders of this chapter. Consequently, the nutritional status of patients with cancer, human immunodeficiency virus (HIV), and acquired immunodeficiency syndrome (AIDS) is challenged by manifestations not only of the disease but also by the ramifications of treatment. Nutrition therapy focuses on reducing these effects and supporting the nutritional status of patients through the potentially debilitating side effects of treatment. Because these disorders are chronic, nursing care often continues after the patient leaves the hospital setting and returns home. The role of home care and hospice nurses is crucial for providing continued medical care, but also important are the nutritional support and food consumption strategies as patients recover and become acclimated to their conditions. The goal of maintaining good nutritional status is to improve survival rates, reduce treatment side effects, and increase the quality of life.

Consider the effects of these disorders through the health dimensions. The physical health dimension challenge is to halt or minimize malnutrition often associated with symptoms or treatments. Intellectual health dimension is a factor because these disorders are marked by either their chronic or potentially life-threatening outcomes. For a person to maintain optimal nutrient intake while also dealing with serious illness requires the intellectual capability to comprehend the different aspects of treatment and rehabilitation. Facing death from AIDS or cancer stresses our emotional health ability to cope; nurses need to be sensitive to the emotional burden patients and families are experiencing. Social health may be compromised because prejudice against (and fear of) clients with HIV/AIDS and cancer affects the potential for individuals to continue their social and work relations as they did in the past. Dealing with societal and emotional issues may warrant counseling support for clients and their families. Spirituality and faith can provide personal insight for gathering strength to heal. (See Personal Perspectives Behind the Cancer Headlines.)

Cancer

Cancer cells differ from normal cells in several ways. These characteristics may involve any or all of the following: (1) uncontrolled cellular reproduction occurs, in which cells become independent of normal growth signals; (2) cells contain abnormal nucleus and cytoplasm; and (3) the mitosis rate generally increases. The nucleus of the cells may be an abnormal shape and have clearly abnormal chromosomes. This process that results in abnormal cell production is called carcinogenesis.¹

The abnormalities in cell replication occur in several stages: initiation, promotion, and progression. Initiation of the process results in a mutation of deoxyribonucleic acid (DNA). Though exact causes are not clear for all malignancies, physical and chemical agents or exposure to microorganisms may initially cause the mutation. The second phase is where the replication of the mutated cell is promoted and abnormal cell growth results. Factors that have been identified in some malignancies include estrogen, testosterone, nitrates, cigarette smoke, and alcohol. The third stage is the progression of the abnormal cells outside the original location of the cell.

The rate of tumor growth is dependent on characteristics of both the host and tumor. Host factors may include age, sex, nutritional status, the presence of other diseases, hormone production, and immune function. Tumor factors could include where the tumor is located and its access to adequate blood supply.¹

Cancer remains a leading cause of mortality in the United States; in 2008, there were an estimated 1.44 million new cases. Cancer is the second leading cause of death, with more than 550,000 deaths each year. Most diagnoses of cancer occur in older individuals, with almost two thirds in people older than age 65. The most common types of cancer include lung, prostate, breast, and colorectal (Box 22-1).² Scientists estimate that 50% to 75% of all cancer deaths can be linked to human behaviors and lifestyle factors.

BOX 22-1

Estimated New Cancer Cases by Sex, United States, 2008

MEN	WOMEN
Prostate	Breast
Lung and bronchus	Lung and bronchus
Colorectal	Colorectal
Urinary bladder	Uterine corpus
	Non-Hodgkin’s lymphoma

From American Cancer Society: Cancer facts and figures 2008, Atlanta, 2008, American Cancer Society.

Nutrition factors are considered one of the important environmental and lifestyle factors in the etiology and prevention of cancer.³ Nutrition and dietary factors may interact within the process of carcinogenesis in all three stages: initiation, promotion, and progression. Furthermore, nutritional factors may assist in blocking those three stages. For example, antioxidants in the diet may protect the cell from DNA mutation³ (see the Health Debate box, Fact or Fantasy? Food as Pharmaceuticals?). It is important to remember that no one food causes cancer and no one food can prevent it. The National Cancer Institute encourages cancer prevention by encouraging the following guidelines:

• Not smoking cigarettes or using other tobacco products

• Not drinking too much alcohol

• Eating five or more daily servings of fruits and vegetables

• Eating a low-fat diet

• Maintaining or reaching a healthy weight

• Being physically active

• Protecting skin from sunlight

Health Debate

Fact or Fantasy? Food as Pharmaceuticals?

They are touted as being able to prevent cancer, heart disease, and depression. Some say they can even boost our immune system. There is some opinion that they can even slow down the aging process. They are the foods our mothers tried to make us eat when we were kids. They are fruits and vegetables. What a surprise!

Over the past 20 years, epidemiologic researchers have consistently found that people who eat greater amounts of fruits and vegetables have lower rates of cancer. Fruits and vegetables contain hundreds of compounds such an antioxidants (beta carotene and vitamins C and E), folic acid, fiber, and at least a dozen groups of chemicals called phytochemicals (specific chemicals found in plants, primarily in fruits and vegetables) that are not strictly nutrients. Some families of plants have more than others, but none of the phytochemicals are found in animal foods. Following is a list of known phytochemicals, their action in the body, and common food sources.

Most health professionals believe that the whole plant is probably more important than the sum of its nutrients and chemical components. More benefits (some we don’t even know yet) are derived from nutrients and phytochemicals by eating foods rather than swallowing supplements. Clients may question why they shouldn’t just take specialized supplements of phytochemicals if we know their actions. What do you think? How will you explain your view to clients? Was Mom right? Should we all eat our vegetables?

Data from Webb D: Whole grains boast phytochemicals to fight disease, Environ Nutr 24:1, 2001; Phytochemical Information Center, Produce for Better Health Foundation, Eat your colors, get your phytochemicals, 2009. Accessed April 8, 2010, from www.pbhfoundation.org/pulse/research/pic/ and www.pbhfoundation.org/pulse/research/pic/phytolist/.

Nutrition and the Diagnosis of Cancer

With more than 100 variations and as the second leading cause of death, cancer affects many individuals in the United States. The physiologic response to malignancy is different for each specific tumor type, but there are general nutrition risk factors that may apply to many cancer patients. Physical impairment because of the location of the tumor or the extent of tumor involvement, metabolic changes, and the use of antineoplastic therapy all place the patient with cancer at increased risk of developing malnutrition or the wasting syndrome of cancer: cachexia. Cancer cachexia is a complex syndrome that results in severe wasting of lean body mass and weight loss. Much research has attempted to establish an understanding of this syndrome. Cytokines are proteins that, in small amounts, assist in the communication between cells of the immune system. It is hypothesized that these cytokines, such as lipid mobilizing factor, interleukins, interferons, and proteolysis inducing factor, drive the altered metabolic response in cachexia. Weight loss, anorexia, hypermetabolism, wasting of skeletal muscle mass, and increased levels of lipid breakdown are the result. Cachexia affects almost 50% of all cancer patients and is present even at the beginning stages of tumor development before actual weight loss is observed. Aggressively approaching nutrition support as a major component of medical care can assist with minimizing the nutritional complications of cancer.⁴

Personal Perspectives

Behind the Cancer Headlines

News about the latest cancer therapies is often in the headlines. Information about cancer and potential therapies is readily available on the Internet. What are not as easily accessible are the experiences of individuals whose lives are touched by cancer. Following is a compilation of comments from individuals of varying ages in my life or people whom I’ve met.

Michele Grodner

Montclair, NJ

• My mother was in the late stages of a malignant brain tumor, but my brother just couldn’t bear the thought of putting “his mother” in a nursing home. Instead, he had her stay with him and his family, setting up a bed in their family room. Within a few days, when she could no longer control her bowels, he found himself sponge bathing his seventy-five-year-old mother who hardly knew where she was. He then understood that he could no longer care for her.

• My friend Karen fought the good fight against breast cancer. For nine years she battled but lost. When she was first diagnosed, she came to see each of us (her neighbors) to tell us in person. I felt honored. I think it was her way of making it real, of announcing it to the world. She learned everything there was to know about every kind of treatment. Several times she traveled to the Dominican Republic for controversial stem cell treatments, riding through the countryside in a rickety van with others in search of medical miracles. The cancer spread, but so did Karen’s spirit. Perhaps the miracle of Karen’s spirit was to show us how to struggle against disease while still enjoying life.

• Barbara said she didn’t want to hold her newborn grandson because she was too weak, but I think it was because she knew that her cancer had spread and she didn’t want to become too attached to the baby.

• I was more nervous about choosing a treatment for my prostate cancer than I was when I had lung cancer because I was afraid I would end up incontinent.

• My uncle’s case was complicated. What with inoperable bladder and prostate cancer, high blood pressure, anemia, and advancing Parkinson’s disease, there was a lot to consider. One day his oncologist told him that “there are no more treatments available for your cancer” and that he (the oncologist) was going on vacation for two weeks. Fortunately, my uncle, guided by my aunt, immediately found a new oncologist who prescribed a different treatment protocol. My uncle is now in remission.

Benefits of Nutritional Adequacy

Can adequate nutrition make a difference in those patients with cancer? The answer is yes. Maintenance of nutritional status may accomplish the following:4–6

• Decrease the risk of surgical complications.

• Ensure that patients are able to meet increased energy and protein requirements.

• Help to repair and rebuild normal tissues affected by antineoplastic therapy.

• Promote an increased tolerance to therapy.

• Assist in promoting an enhanced quality of life.

Nutritional Effects of Cancer Treatments

Surgery

Treatment for many malignancies (particularly, solid tumors) includes surgical resection of the tumor.¹ This route of treatment can allow for diagnosis, resecting a solid tumor, preventing metastasis of the malignancy, or reducing the size of the tumor to alleviate pain. The nutritional consequences related to surgery are dependent on the type and extent of the surgical resection. Resections of any portion of the gastrointestinal (GI) tract can cause alterations in nutrition intake and nutrient absorption.⁶ Second, energy and protein requirements may need to be increased to promote optimal wound healing postoperatively. Malabsorption does tend to be the primary nutritional problem with surgeries involving the GI tract; yet unless small bowel resection is extensive, the adaptability of the small intestine may prevent the occurrence of major clinical problems.⁶ Many cancer patients enter surgery already experiencing protein-kcal malnutrition that places them at higher risk for complications. For example, more than 60% of patients with malignancies affecting the head and neck enter surgery malnourished.⁷ Additionally, any problems associated with surgery (Table 22-1) will be further complicated if the patient receives subsequent radiation therapy and chemotherapy.

TABLE 22-1

NUTRITION SIDE EFFECTS OF CANCER SURGERY

SITE OF SURGERY	SIDE EFFECT
Head and neck	Impaired chewing and swallowing
Esophagectomy	Diarrhea, steatorrhea, esophageal stenosis
Vagotomy	Gastric stasis, diarrhea, fat malabsorption
Gastrectomy	Dumping syndrome; hypoglycemia; malabsorption; possible deficiencies of iron, calcium, vitamin B₁₂, and fat-soluble vitamins
Pancreatectomy	Type 1 diabetes mellitus, possible malabsorption of fats, protein, fat-soluble vitamins, minerals
Small bowel resection	Possible malabsorption of many nutrients; depends on extent and site of surgery
Ileostomy	Sodium and water losses, vitamin B₁₂, malabsorption_, fat malabsorption, bile salt diarrhea

Data from McCallum PD, Polisena CG, editors: The clinical guide to oncology nutrition, Chicago, 2002, American Dietetic Association.

Chemotherapy

Most chemotherapy protocols include a combination of chemotherapy agents. Chemotherapy agents include alkylating, antimetabolite agents (folate antagonists), purine/pyrimidine antagonists, anthracyclines, platinum antitumor compounds, antibiotics, nitrosoureas, mitotic inhibitors, cytokines, biologic response modifiers, monoclonal antibodies, immunotherapy, hormones, and enzymes. These agents act by inhibiting one or more steps of DNA synthesis in rapidly proliferating cells that are characteristic of the malignant cell or by enhancing the host’s immune system to allow for improved response to therapy. Using a combination of medications that interrupt the cancer process in different ways allows for maximum effect with the fewest side effects. Cells of the bone marrow and those lining the GI tract tend to be susceptible to damage from chemotherapy because of their rapid turnover rate.1,4,6

The effect on these cells accounts for many of the side effects associated with chemotherapy including nausea, vomiting, diarrhea, mucositis, hair loss, and immunosuppression.6,7 The severity and manifestation of the side effects depend on the particular chemotherapy agent, dosage, duration of treatment, rates of metabolism, accompanying drugs, and individual tolerance. These symptoms can lead to malnutrition through a variety of mechanisms: anorexia; nausea; vomiting; mucositis; stomatitis; cardiac, renal, and liver injury (toxicity); and learned food aversions.^4–7 Nutritional implications of chemotherapeutic agents are summarized in Table 22-2.

TABLE 22-2

NUTRITIONAL IMPLICATIONS OF CHEMOTHERAPEUTIC AGENTS

DRUG CLASSIFICATION	SELECTED EXAMPLES	ACTIONS	NUTRITIONAL IMPLICATIONS
Alkylating agents	Cisplatin Hexamethylmelamine Dacarbazine	React with susceptible deoxyribonucleic acid (DNA) sites	Anorexia, nausea, vomiting, mucositis/stomatitis
Antibiotics	Bleomycin Doxorubicin Dactinomycin	Bind to DNA and inhibit cell division, interfere with ribonucleic acid (RNA) transcription	Anorexia, nausea, mucositis/stomatitis, diarrhea; some may cause decreased calcium and iron absorption
Antimetabolites	Methotrexate 5-Fluorodeoxyuridine 5-Fluorouracil	Inhibit a stage of DNA synthesis	Anorexia, nausea, vomiting, diarrhea, mucositis, abdominal pain, intestinal ulceration; some may cause decreased absorption of vitamin B₁₂, fat, and xylose
Hormones	Prednisone Tamoxifen Diethylstilbestrol	Alter cell metabolism to cause unfavorable tumor growth	Corticosteroids: sodium and fluid retention, hyperglycemia, gastrointestinal upset, osteoporosis (calcium losses), negative nitrogen balance Estrogens: nausea, vomiting, anorexia, hypercalcemia
Enzymes	Asparaginase	Delay DNA and RNA synthesis by inhibiting protein synthesis (deprive cells of asparagine)	Anorexia, nausea, hyperglycemia, pancreatitis, azotemia (uremia), weight loss
Plant alkaloids	Vinblastine Vincristine	Inhibit mitosis	Nausea, vomiting, constipation, diarrhea, abdominal pain
Biologic response modifiers	Interferon Interleukin	Modify host biologic response to tumor	Nausea, vomiting, anorexia, weight change (increase or decrease)

Data from McCallum PD, Polisena CG, editors: The clinical guide to oncology nutrition, Chicago, 2002, American Dietetic Association.

Radiation Therapy

Radiation therapy uses ionizing radiation to kill cells by altering the DNA of the malignant cell. This alteration interferes with the factors controlling replication. Radiation is used to treat tumors sensitive to radiation exposure or tumors that cannot be surgically resected. Radiation also can be used to reduce tumor size so that a successful surgical resection can occur. Though technology has allowed for significant specificity in using radiation therapy some normal cells within the treatment range that are also in that stage of cell replication may also be damaged. This may contribute to the physical side effects, which may include hair loss, mucositis, and vomiting and diarrhea.

Nutritional problems vary according to the region or area of the body radiated, dose, fractionation, and whether radiation is used as combination therapy with surgery or chemotherapy.4–7 Complications may develop during radiation treatment or become chronic and progress even after treatment is completed.^4–7 Primary radiation sites that result in nutrition problems include the head and neck, the abdomen and pelvis (GI tract), and the central nervous system (CNS).^4–7 Radiation at any of the three sites may cause anorexia, nausea, and vomiting. In the head and neck these common effects create problems of food ingestion, such as stomatitis, esophageal mucositis, loss of taste sensation, and changes in the production of saliva. Side effects to the abdomen and pelvis alter the GI tract (radiation enteritis), reducing digestion and absorption of nutrients because of the development of diarrhea and steatorrhea, and possibly, malabsorption, ulceration, and bowel damage or obstruction.

Bone Marrow Transplantation

Bone marrow transplantation (BMT) is used to treat certain hematologic malignancies (acute and chronic leukemia and some forms of lymphoma), as well as in adjunct therapy for solid tumors such as breast cancer.¹ Types of transplant include autologous, allogeneic, and syngenic. When using bone marrow transplant as the treatment of a solid tumor, the patient’s own bone marrow is harvested and saved before the initiation of chemotherapy or radiation therapy. The patient then receives high-dose chemotherapy and possibly total body irradiation to eradicate the cancer.^4–7 The patient’s own bone marrow is then infused as a “rescue” from the effects of both chemotherapy and radiation. For hematologic malignancies, a patient receives bone marrow from a genetically matched donor (allogeneic) or in some cases from a twin (syngenic).

The ability to maintain adequate oral intake is difficult because of the nausea, vomiting, and mucositis that is associated with such high-dose therapies. Parenteral nutrition is a standard component of transplantation protocols, but when possible, recent research indicates that maintaining some oral intake or providing enteral nutrition is important to maintaining the integrity of the small intestine.⁸

Immunosuppression, as a result of the antineoplastic regimens and BMT, places the BMT patient at high risk for infections from bacterial and fungal pathogens. Pathogens can be commonly found in the environment, including fresh fruits and vegetables that ordinarily do not present a hazard to healthy persons (Box 22-2). Therefore, a low-bacterial diet is indicated whenever the plasma neutrophil (a type of white blood cell) count is less than 1000 mm³.^6,7 Standard practice varies between institutions, but in general, food safety guidelines for patients with low immune function or who are neutropenic include avoiding undercooked meats and eggs, ensuring that raw fruits and vegetables are washed well and/or are peeled (including salads and garnishes), and following appropriate sanitation guidelines for food preparation and storage. Frequent monitoring of nutritional intake and encouragement to take in adequate nutrition are essential in the care of these patients (Box 22-3).

BOX 22-2

Common Foods

Select the Lower-Risk Options for Safety

TYPE OF FOOD	HIGHER RISK	LOWER RISK
Meat and Poultry	• Raw or undercooked meat or poultry	• Meat or poultry cooked to a safe minimum internal temperature
Tip: Use a food thermometer to check the internal temperature. See “Food Preparation Strategies” on page 40 for specific safe minimum internal temperature.
Seafood	• Any raw or undercooked fish, e.g., sushi or ceviche • Refrigerated smoked fish • Precooked seafood, such as shrimp and crab	• Smoked fish and precooked seafood heated to 165 °F • Canned fish and seafood • Seafood cooked to 145 °F
Milk	• Unpasteurized milk	• Pasteurized milk
Eggs	Foods that contain raw/undercooked eggs, such as: • Caesar salad dressings* • Homemade raw cookie dough* • Homemade eggnog*	At home: • Use pasteurized eggs/egg products when preparing recipes that call for raw or undercooked eggs When eating out: • Ask if pasteurized eggs were used
*Tip: Most pre-made foods from grocery stores, such as Caesar dressing, pre-made cookie dough, or packaged eggnog are made with pasteurized eggs.
Sprouts	• Raw sprouts (alfalfa, bean, or any other sprout)	• Cooked sprouts
Vegetables	• Unwashed fresh vegetables, including lettuce/salads	• Washed fresh vegetables, including salads
Cheese	• Soft cheeses made from unpasteurized milk, such as: – Feta – Brie – Camembert – Blue-veined cheese – Queso fresco	• Hard cheeses • Processed cheeses • Cream cheese • Mozzarella • Soft cheeses that are clearly labeled “made from pasteurized milk”
Hot Dogs and Deli meats	• Hot dogs, deli meats, and luncheon meats that have not been reheated	• Hot dogs, luncheon meats, and deli meats reheated to steaming hot or 165 °F
Tip: You need to reheat hot dogs, deli meats, and luncheon meats before eating them because the bacteria Listeria monocytogenes grows at refrigerated temperatures. This bacteria may cause severe illness, hospitalization, or even death. Reheating these foods destroys this dangerous bacteria, making these foods safe for you to eat.
Pâtés	• Unpasteurized, refrigerated pâtés or meat spreads	• Canned pâtés or meat spreads