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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