cancer by: mandy herlin, reilly doney, and molly roemer
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CancerBy: 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 Prostateo Lung
● Womeno Breasto Lung
Cancer Types
Cancer Types
Etiology & Risk FactorsCancer
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
o PAH, Polycyclic aromatic hydrocarbons o NOC, N-nitroso compounds o BP-A, Bisphenol A
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 cancersare thought to be related toan inherited gene changeaffecting 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 Noo 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
PreventionCancer
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 Breast, colon, endometrium, prostate, and
pancreatic cancerso Also reduces risk of other diseases (diabetes,
osteoporosis, hypertension)● 150 minutes moderate activity/75 minutes
vigorous activityo More exercise may be even more protective -
reduces obesity
3. Consume a Healthy Diet
● Eat to achieve a healthy weighto Emphasize plant foodso Limit processed and red meatso At least 2.5 cups fruits and vegetables each dayo 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 Alcohol metabolism product acetaldehyde can damage DNA.
o Alcohol consumption can raise blood estrogen, increasing risk of breast cancer.
DiagnosisCancer
Diagnosis of Cancer
Early Diagnosis● ‘CAUTION’
o Change in bowel or bladder habitso A sore that does not healo Unusual bleeding or dischargeo Thickening or lump in breast or elsewhereo Indigestion or difficulty in swallowing or chewingo Obvious change in a wart or moleo Nagging cough or hoarseness
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 DNAo 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 scano 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 originateo “-oma” = benign tumoro “-carcinoma” = malignant epithelial tumoro “-sarcoma” = malignant connective tissueo lymphoma = cancer in lymphatic tissueo leukemia = cancer in blood cells
Nomenclature Examples:
● Adenoma● Adenocarcinoma● Chondroma● Chondrosarcoma
PathophysiologyCancer
Pathophysiology Terms
● Protooncogenes = normal cells, cause cell growtho 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 uncheckedo Ex: Rbo Ex: p53 (most common gene mutated in cancer)
Pathophysiology Terms
● Carcinogen = something that can cause cancero Physicalo Chemical o Virus
● 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
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)
Carcinogenesis - Tumors
Cancer Types
Cancer Types
Carcinogenesis - Promotion
● Mutated cells multiply● Mechanisms that the body has to keep this
from happening are silencedo 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 bodyo Neoplasm turns malignant
● Angiogenesis = New blood vessel growtho 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 occurringo Pesticides produced in plantso Mycotoxins from moldo Fat in red meat
Carcinogen enhancers
● Nitrates = processed in red meato 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
ScreeningCancer
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 Clinical breast exam every 3 years for women in 20s
and 30so After a woman turns 40, yearly mammograms are
recommended● Colon Cancer = after age 50
o Flexible sigmoidoscopy every 5 years, oro Colonoscopy every 10 years, oro 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 Women should begin screening at age 21o Ages 21-30 = Pap test every 3 yearso Ages 30-65 = Pap test + HPV test every 5 yearso 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)
● Computer image of a cross-section slice of the body.
● Shows bone, organ, and tissue more clearly than an x-ray
http://www.aboutcancer.com/CT_lung_cancer_nejm.jpg
Magnetic Resonance Imaging (MRI)
● Magnetic image of a cross-section slice of the body.
http://www.k-state.edu/parasitology/upton-tumor-2f-(3-23-2006).jpg
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)
● Show body’s chemistry
● Cancer may absorb more or less of the radionuclide tracer than normal tissue
http://miamicancer.com/images/uploads/petscan.jpg
Uptake of tracer in the lymph nodes involved with lymphoma in the groin, both axilla, and neck (red areas)
Ultrasound
● Produces images from sonograms (sound waves)
● Shows soft tissues well
http://www.petcancercenter.org/sitebuilder/images/bladder-tumor-301x197.jpg
TreatmentCancer
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 machineor from implant
Treatment
Internal RadiationImplants inserted under anesthesiaDoctor uses X-ray or MRI for positioningVary from minutes to days to being permanent
External Beam RadiationPhoton beamsA 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
Stomatitis
Xerostomia
Mucositis
Treatment
● Mucositiso Sucking on ice chips right before and right after
chemo treatmento Mouthwash with lidocaine o Acetaminopheno Take good care of your moutho Avoid acidic or spicy foods (irritants)
Treatment
● Xerostomiao Saliva substituteso Salivary stimulants
Treatment
● Stomatitiso Club sodao Alcohol-free mouthwasheso benzydamine hydrochlorideo Pharmacy mouthwash mixes
“Magic mixes antifungals, antibacterials, steroids, and local
anesthetics
Treatment
SurgeryCurativeDebulkingPalliative
-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)
● Autologouso Patient’s own stem cells
● Syngeneico stem cells from identical twin
● Allogenico stem cells from relative or unrelated donoro 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 transplanto 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 careTreatment: immunosuppressants, steroids, inflammatory cytokine inhibitors (cyclosporine, tacrolimus, prednisone, etanercept)
Graft-Versus-Host Disease (GVHD)
Signs/Symptoms:Skin- maculopapular rashLiver- jaundice, abnormal liver function testsGI- 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 subsides2nd 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 stomach4th Phase- Dietary restrictions are progressively reduced, as tolerated5th 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 TherapyCancer
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 benefitso Positive physical changes, overall well-being,
increased pain tolerance, decreased stress
Nutrition AssessmentCancer
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 TherapyCancer
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 StudyAcute 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 quicklyo 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 1.4Altered 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 Societyo www.cancer.org
● Eating Hints Before, During, and After Cancer Treatmento http://www.cancer.gov/publications/patient-education
/eatinghints.pdf
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