Oncology

Lab Values

What are some causes of abnormal glucose levels in oncology patients? What are the goals for glucose management in a patient with a poor PO intake?

Cancer cells use glucose as a primary source of fuel and have a slightly different metabolic pathway than non-cancerous cells. Cancer cells undergo anaerobic glycolysis which causes greater lactic acid buildup whereas non-cancer cells undergo aerobic metabolic pathways. The body is forced to do more work in order to eliminate the lactic acid build up. Therefore the cancer patient uses more energy and is more likely to become cachexic. Treating a patient who has poor PO intake should focus on maintaining glucose levels within a tight range in order to prevent complications of unregulated glucose levels and to decrease fatigue.

What are some causes of elevated renal labs (BUN, Cr, Na, K, P, Mg) in oncology patients?  

Chemotherapy drugs, drug interactions, an inflammatory response, dehydration.

What laboratory values would classify a patient as neutropenic?

ANC=Absolute Neutrophil Count

Severe: ANC < .5 G/l

Moderate: ANC between .5 G/l - 1 G/l

Mild: ANC between 1 G/l -1.5 G/l

Medical/Surgical Treatment

Describe radiation therapy. List the nutritional problems associated with radiation therapy and provide recommendations to alleviate these problems.

Radiation is used to kill cancer cells by changing DNA and other cellular and nuclear material. Ionizing material breaks down DNA and prevents it from continuing to proliferate thus preventing more cancerous cells from being formed. Radiation is localized treatment that can be done internally or externally. Patients undergoing radiation may experience fatigue, mucositis, dysgeusia, xerostomia, dysphagia, odynophagia, esophagitis, dehydration, enteritis, diarrhea, and malabsorption. The side effects and nutritional problems associated with radiation depend on the site of radiation and nutritional management will vary based on the problems specifically experienced by the patient. Patients should avoid favorite foods following their treatment and may possibly require a clear liquid diet following treatment. The patient's diet will have to be tailored to the problems they are experiencing at that time. In general, small and frequent meals and foods that are easy to chew, swallow, and digest should be consumed. It may be necessary to prescribe a nutritional supplement in order to ensure the patient receives the nutrition they need. Also, drugs such as antimetics and appetite stimulants may need to be prescribed.

Discuss the different types of bone marrow transplant (autologous, allogenic). Which of these puts a patient at risk for Graft Versus Host Disease (GVHD)? Describe the nutritional implications of GVHD.

Autologous transplantation is a form of bone marrow transplant in which stem cells are removed from a person before they undergo radiation or chemotherapy. Several days after the completion of radiation or chemotherapy the stem cells are replaced. In allogenic bone marrow transplantation stem cells are taken and transplanted from another individual. Individuals who undergo an allogenic bone marrow transplantation are at risk of graft versus host disease. Graft Versus Host Disease occurs as a result of graft rejection. The donor cells do not recognize the recipient's cells and as a result the donor cells attack the cells of the recipient. GVHD can lead to tissue damage in the skin, liver, and GI tract. Complications can lead to dry mouth, oral ulcerations, small intestinal GI mucosal damage, diarrhea, liver abnormalities. As a result recipients often have nutritional deficiencies, and severe weight loss. Patients suffering from GVHD will have higher protein needs based on the increased energy needs and to replace losses. 

Drug Therapy

Discuss the use of the following classifications of drugs. Include indication and contraindication for use with cancer patients, effect of the drug on nutrient absorption and utilization, effect of nutrients on drug absorption and utilization.

•Antineoplastics: Used to inhibit cancer cell growth. Used to treat lymphoma, leukemia, sarcomas, teratoma, and carcinomas. Should be avoided on if a person has an allergy to the medication or severe liver or kidney disease. Antineoplastics impair the action of folic acids and fat, calcium, cobalamin, lactose, folate, and carotene absorption.

•Antiemetics: Used to prevent nausea and vomiting in patients who have undergone chemotherapy, irradiation, operations, and in pregnant women and to treat motion sickness. Contraindications include hypotension and cardiac arrhythmia.

•Appetite Stimulants: Decreased appetite is one of the major side effects of cancer  and appetite stimulants are used to increase appetites in cancer and HIV patients with Cachexia, anorexics, and children with failure to thrive. They are contraindicated in cases in which an individual has an allergy to the medication. 

•Enzyme supplementation: In cancer enzyme supplementation is used to repair damaged cells and build new ones. Enzyme supplementation is contraindicated in patients who may be allergic to the enzymes. Enzyme supplementation with pancreatin may reduce folic acid absorption. 

Nutritional Management

Describe the nutritional management of the following problems that commonly occur in cancer patients.

•Dysgeusia: Cancer patients undergoing chemotherapy often suffer from a lack of taste. They can try several different methods of modifying how they prepare and consume food in order to improve taste. Taste problems and preferences will be unique to each individual. Work to prevent and avoid problem tastes while promoting consumption and enhancing flavors the patient enjoys. Possible alterations include: consuming foods that are cold at room temperature, adding spices to food, adding sugar to food, avoid bitter foods, eat small meals throughout the day, and use sauces or marinades.

•Oral and esophageal mucositis: Cancer patients undergoing radiation or chemotherapy may suffer from inflammation of the mucosa and resulting pain. in order to ensure adequate intake nutrient dense foods that are non-irritating should be consumed. Other suggestions for a patient with mucositis include: moistening food before consumption, consumption of small frequent meals, taking pain medications, and altering both the temperature and consistency of food.

What is an entero-cutaneous fistula?  What nutritional intervention(s) would be indicated? 

A entero-cutaneous fistula is a tube like passage between the skin and intestines. Patients with fistulas have increased protein, calorie, and fluid needs. The patient may need to be placed on enteral feeding.

Describe 2 ways of providing nutrition support to a patient with a gastrointestinal obstruction.

Modifying food intake to ensure adequate fluid and electrolyte balance and calorie intake.

When is central parenteral nutrition appropriate for an oncology patient?  When would the use of central parenteral nutrition be contraindicated in this patient population?

Central parenteral nutrition is appropriate with total gastrointestinal failure. The use of central parenteral nutrition would be contraindicated when the patient has a functioning gut, intravenous access can't be gained, there is poor prognosis and aggressive treatment is not warranted, the patient is not hemodynamically stable, and there are metabolic and electrolyte disturbances. 

What is the primary goal of palliative care?  What is the role of nutrition in palliative care of oncology patients?

Goals include relief from suffering and pain, reducing psychological problems, establishing a strong support system. The nutrition goal is to relieve isuees that may bother the patient.

 Click here to view the oncology chart review.

INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Oncology

CHARTING TYPE: Not specified 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

List specifically how you know the patient has edema and the weight is not applicable. In this case see MD note on 10/19/11

Always state why lab values are abnormal. In this case Hcb and Hct levels low secondary to chemotherapy treatment and pain management.

Always state the percentage of wt loss or gain times 1 month, times 3 months and times 6 months. 

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

In this particular case there were no changes made. I would have liked to see efforts made to decrease the patient’s weight because many deaths related to cancer are related to overweight/obesity. 

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

There was really no intervention made. The diet was maintained the same and no education could be provided because the patient was not present. I would have liked to work with the patient to better understand her dieting patterns. Unfortunately, during my time in the nursing home I observed that there is a general lack of effort put into tracking down patients to provide education. This appears to mainly be a result of lack of time. In addition tracking down patients is a particular problem at Coler-Goldwater where many of the patients are ambulatory and go out throughout the day. It would be beneficial if there was a system in which the dietitians could schedule meetings with patients.