September 2009 Issue
Nutrition Management During Chemotherapy
By Karen Wagner, MS, RD, LDN, and Jaimie Bornstein, MPH, RD,
CDN
Today’s Dietitian
Vol. 11 No. 9 P. 50
Suggested CDR Learning Codes: 5150, 5440; Level 1
The past 50 years have seen significant advancements in the war on cancer, including improvements in the identification of risk factors, the refinement of diagnostic techniques, and the development of lifesaving cancer treatments. Together, these have aided in the development of effective cancer prevention and early intervention strategies.
However, cancer (all types combined) remains the second-leading cause of death in the United States, taking an estimated 565,650 lives in 2008—one of every four deaths.1 Last year in the United States, an estimated 745,180 men and 692,000 women received a cancer diagnosis.
While cancer risk is largely based on genetic markers and lifestyle, the concept of preventing or influencing cancer growth has been researched since the early 1900s.2,3 While this research has yielded numerous new cancer treatments that can extend lives, a person’s nutritional status plays an important role in maintaining the effectiveness of these treatments.3 The original principles of nutrition care for people diagnosed with cancer were developed in 1979.4
According to a 2006 study in A Cancer Journal for Clinicians, 65% of Americans with cancer now live more than five years after their disease is diagnosed. This is partially due to a new focus on a patient’s role in improving their own condition beyond medical treatment.
Given cancer’s toll on the national and global population and the potential for nutritional management to positively impact treatment outcomes, it is important to review the nutritional studies, discuss the applicable practices from this research, and develop appropriate dietary strategies to help patients optimize the effectiveness of their treatment.
It is clear from the research that nutritional needs change during cancer treatment and recovery. These changes are particularly evident during treatment with cytotoxic chemotherapy agents, the most common type. Typically, these agents negatively impact digestion, absorption, and the body’s use of food.5
This article focuses on the important role that nutrition, with an emphasis on protein, can play in making chemotherapy more effective.
What Is Cancer?
Cancer is not just one disease but a group of diseases that disrupt
normal cell growth.2 There are more than 100 different kinds of cancer.
Cancer types can be grouped into five main categories: carcinoma (cancers
of the major organs and the majority of human cancers); sarcoma (cancers
of the bone, muscle, fat, blood vessels, or other connective tissues);
leukemia (cancers of the blood cells); lymphoma and myeloma (cancers
of the immune system); and central nervous system cancer (brain and
spinal cord cancers).2
The human body is made up of many types of cells that grow and divide to keep the body healthy. When cells die (either from age or damage), new cells replace them on an “as-needed” basis.2 Cancerous cells have mutated, which causes them to rapidly multiply. These cancerous cells can travel through the blood and lymph system and, in many cases, form tumors.
The key to successful outcomes is early diagnosis and treatment.4 Treatment modalities include surgery, radiation, and chemotherapy. In this discussion, we’ll focus on the nutritional implications of chemotherapy.
Unlike localized treatments such as surgery and radiation, which treat the affected area directly, chemotherapy is a systemic treatment that affects the whole body.4 It involves the use of cytotoxic drugs that kill the cancer cells, but they also affect other rapidly dividing cell types, including those that protect the mouth and digestive tract and those involved with hair growth.4,6 There are currently more than 90 different drugs approved for use as chemotherapy agents in the United States. Treatments are usually given intravenously but also can be given by injection, pill, or, in some cases, oral liquid.4
Side effects are related to a specific agent, dosage, duration of treatment, accompanying drugs, and individual response. They vary from person to person depending on the length and type of treatment, dosage, and nutritional intake. In general, appetite loss is one of the most common side effects associated with chemotherapy treatment. This may extend beyond the period of treatment and result in changes such as unintentional weight loss, decreased muscle mass, and difficulties with eating or digestion.5 Significant weight loss is associated with poor clinical outcomes in cancer patients.4
The severity of side effects is often compounded by poor nutrition practices, which may increase the risk of infection and decrease survival. However, good nutrition practices can considerably help cancer patients maintain weight and nutrition stores while improving quality of life.4
One of the most severe nutritional side effects of cancer and its treatment is cancer cachexia, a syndrome of progressive weight loss, anorexia, weakness, and anemia.4 It can develop in individuals who appear to be eating adequate calories and protein but are unable to absorb or utilize nutrients properly because of advanced disease or treatment effects. Cachexia is estimated to be the immediate cause of death in 20% to 40% of cancer patients.4 Nausea and vomiting are also common, and controlling these symptoms greatly improves patient comfort levels and helps them achieve better oral nutrient intake.4
Frequently, cancer patients complain of a decreased ability to eat
as the day progresses, with mornings being the best time for eating.
This may be attributable to sluggish digestion and gastric emptying,
decreased production of digestive secretions, gastrointestinal mucosal
atrophy, and/or gastric muscle atrophy resulting from chemotherapy
treatment.7 Frequent, small feedings may help mitigate this problem.7
Chart 1 offers some helpful strategies to help patients maintain nutritional
status when experiencing reduced appetite and other side effects of
treatment.4
Side Effects Related to Blood
In addition to side effects altering nutrient intake, there are several
that increase the body’s need for nutrients and negatively affect
patient quality of life and prognosis. In particular, the side effects
of chemotherapy combined with decreased nutrient intake can contribute
to specific blood conditions, including neutropenia (decreased white
blood cell count), thrombocytopenia (decreased number of platelets),
and anemia (low red blood cell count).4,6
Patients with neutropenia are at increased risk for infection because white blood cells are responsible for fighting off infections. Patients experiencing neutropenia should be reminded to avoid consuming food past its expiration date, handle food using good hygiene practices, cook food thoroughly, and avoid contact with people who have bacterial or viral infections.4
In cases of severely reduced platelet or red blood cell count, therapy
discontinuation is required until these counts have returned to within
acceptable ranges.6
Overall, the hematological side effects of chemotherapy can be mitigated
with adequate protein and fluid intake. Increased protein intake supplies
the body with essential amino acids (the raw materials needed to construct
new cells and platelets that the body cannot make on its own) to rebuild
red cells and platelets and bolster immunity by speeding white blood
cell count recovery.4
Nutrition Intervention
Nutritional status plays an important role in helping determine the
risk of therapy-related toxicity and likely medical outcomes. Research
shows that nutrition support and intervention are relevant to all
aspects of cancer treatment—from disease prevention and treatment
to cure or supportive palliation.4
In addition, a healthy diet can help prevent or control comorbidities such as heart disease, diabetes, and hypertension and may help prevent the formation and growth of additional tumors.4 Nutritional needs assessment should occur at the time of diagnosis, anticipate nutritional needs, and continue throughout the course of treatment.7
While specific nutrition recommendations vary from patient to patient, the general goals of therapy are as follows:
• prevent or reverse nutrition deficiencies;
• preserve lean body mass;
• help patients better tolerate treatments;
• minimize nutrition-related side effects and complications;
• maintain strength and energy;
• decrease infection risk by protecting the immune system;
• aid in recovery and healing; and
• maximize quality of life.4
When patients are diagnosed with cancer, they may begin to actively search for information about their condition and for advice to increase their chance of survival. Because there is a large amount of conflicting information concerning which foods to eat and which supplements to take, meeting with an RD or a physician to determine a plan for nutrition, including meal planning, is important.
Nutrition Intake
Typically, nutritional recommendations for cancer patients are designed
to help build strength and withstand the effects of cancer and its
treatment.8 Uncontrolled or excessive weight loss can negatively affect
quality of life, delay or prevent treatment completion, prolong healing,
and increase the risk of complications. The focus for patients with
uncontrolled weight loss should be on achieving a positive energy
balance by increasing caloric intake and reducing total energy expenditure,
thus allowing them to increase their weight.5 Oral nutrition is preferred
and should be used whenever possible.4 Fat, protein, and carbohydrates
all contribute necessary calories to help maintain nutritional status.4
These American Cancer Society guidelines for cancer prevention should be followed during and after cancer treatment (when possible):
• Consume a healthy diet, with an emphasis on plant sources.
• Choose foods and beverages in amounts that help achieve and maintain a healthy weight.
• Eat five or more servings of a variety of vegetables and fruits each day.
• Choose whole grains in preference to processed [refined] grains.
• Limit consumption of processed and red meats.5
Carbohydrates, Fluid, and Fats
Generally, 45% to 65% of energy intake should come from carbohydrates,
and carbohydrate choice is very important. The foods selected should
be rich in essential nutrients, phytochemicals, and fiber (whole grains,
vegetables, legumes, fruit).5
However, patients having difficulty tolerating whole foods may need some modifications. Patients with nausea, vomiting, diarrhea, or partial bowel obstructions may feel better consuming less fiber. An emphasis on refined carbohydrates may be more appropriate during these times to ensure adequate caloric and carbohydrate intake. Homemade shakes or nutritional drinks can be very useful to patients and caretakers alike during these times.
In addition, carbohydrate-rich shakes and drinks can be excellent sources of protein and can help keep the patient properly hydrated. Hydration is critically important for health maintenance, and side effects such as diarrhea or episodes of nausea and vomiting may alter hydration status and electrolyte balance.4,8 In general, patients should consume about 64 oz of fluid per day, with more or less needed at certain times depending on a patient’s treatment course.7
Recommendations for fat intake during chemotherapy may vary from patient to patient as well. In general, a low-fat diet is recommended for overall health.5 Additionally, side effects such as nausea and diarrhea can make fats less tolerable.8 However, fats can contribute needed calories to patients with weight loss who are able to tolerate them.8
Vitamins and Minerals
Patients with cancer usually wonder whether they should take vitamins,
minerals, or other nutritional supplements, such as antioxidants,
to prevent or modify toxicities experienced during treatment. The
role of these supplements in cancer therapy seems to be conflicting
and remains a controversial issue.
Some studies have noted that antioxidants, such as vitamins A, C, and E and the mineral selenium, could inadvertently repair cancer cells that have been intentionally damaged by chemotherapy.8 This subject is still open to debate, as some antioxidants, such as melatonin, may protect the body from the effects of chemotherapy.9 In general, evidence suggests that during and after cancer treatment, patients, especially vegetarians, may benefit from regular use of a vitamin/mineral supplement containing no more than 100% of Daily Values to prevent specific nutrient deficiencies.5
However, many vitamin supplements contain higher levels of antioxidants (eg, vitamins C and E) than those recommended for optimal health. Dietitians can play an important role in helping patients evaluate any supplements they may be taking.
Protein
While the benefit of vitamin or mineral supplementation during treatment
remains debatable, there is little doubt concerning patients’ need
for protein. Proteins contain essential amino acids and are a key
part of nutrition management plans during chemotherapy. Protein is
necessary to help the body repair cells and make new ones. Dietary
proteins are necessary for the synthesis of tissue protein and other
metabolic functions. Proteins perform a major structural role not
only in all body tissue but also in the formation of enzymes, hormones,
and various fluids.7
Normally, an intake of at least 10% of energy from protein is recommended. However, cancer patients should consume at least 0.8 g/kg of body weight, regardless of the total caloric intake consumed.5 In addition to these protein requirements, if a patient does not get the right amount of nutrients, he or she will risk having protein-calorie malnutrition.4
According to the National Cancer Institute, protein-calorie malnutrition is a common secondary diagnosis in individuals with cancer due to inadequate intake of carbohydrate, protein, and fat to meet metabolic requirements or reduced absorption of macronutrients.4 Protein-calorie malnutrition results from multiple factors that can include cachexia, anorexia, nausea, and early satiety. The metabolism of major nutrients is affected and can increase the incidence of protein-calorie malnutrition. Progressive wasting, weakness, and debilitation of protein synthesis ensue; loss of too much lean body mass can lead to death.4
Milk Protein
Cow milk protein has excellent nutritional value. It contains two
major protein fractions: casein (80%) and whey (20%). Both casein
and whey provide protein, essential nutrients, vitamins, and minerals
and can be part of a normal healthy diet.10
Caseins are phosphate-containing proteins that occur as micelles (small droplets suspended in liquid) in the native form.10 In the gut’s acidic environment, caseins precipitate out to form clumps or clots that delay absorption of amino acids contained within the casein proteins.10
Whey is the liquid remaining after milk has been curdled and strained to remove the caseins. Whey proteins are rapidly evacuated from the stomach, and the body easily absorbs its amino acids. These differences in amino acid delivery are responsible for varying effects on the whole body protein metabolism in humans ingesting either casein or whey protein.10
Several studies have looked at the relationship between whey protein
and cancer. Hakkak et al observed rats that were fed diets with soy,
whey, or casein (control) as the sole protein source to determine
the protective effects of these proteins against chemically induced
mammary tumors.11 Diets rich in soy reduced the incidence of chemically
induced mammary tumors by approximately 20%, while diets rich in whey
were at least twice as effective as soy at reducing both tumor incidence
and multiplicity. Whey-fed rats had lower mammary tumor incidence
than casein-fed rats.11 More research is needed in this emerging area
of nutritional support during chemotherapy.
Additional Sources of Protein
In addition to milk and milk products, other foods of animal origin,
such as meat, poultry, fish, and eggs, are good protein sources. Plant
products that are richest in protein are legumes such as soybeans,
peanuts, peas, beans, and lentils. Cereals contain very limited amounts
of protein but can contribute to protein requirements when consumed
in large amounts.7
Anxiety and the side effects of chemotherapy may limit the patient’s desire to eat a meal, start cooking, or shop for food.8 However, protein intake is essential, especially during treatment. There are many drinks, powders, and puddings on the market that can be a beneficial source of calories and protein when eating and preparing meals become difficult. Many of these products contain extra vitamins and minerals in an effort to supply adequate nutritional intake.8 Examples of some food sources of protein, with grams per unit in parentheses, are peanut butter (4 per T); cashews (5 per oz); red beans (6 per oz); beef, cheese, poultry, and fish (all 7 per oz); eggs (7 each); milk (8 per cup); soybeans (10 per oz); and yogurt (11 per cup).
Ready-to-drink formulations are often preferred for cancer patients. (Chart 2 includes ready-to-drink nutritional supplements.)
Such beverages can be especially useful for cancer patients with fatigue because they require no preparation, mixing, or blending. Most of the commercial meal replacement drinks contain little or no lactose, which can cause bloating, cramping, and diarrhea in some people.
The drinks shown in the chart contain no lactose. They also require no refrigeration until opened, so patients can drink them anywhere and anytime they feel thirsty or hungry. While flavor varieties are limited, all are excellent sources of calories with significant amounts of protein and are suitable snacks or meal supplements.8 Isopure Plus, Enlive!, and Breeze are all made with whey protein isolate; however, Isopure Plus is the only one to use ion-exchange whey protein isolate. The ion-exchange process allows for the removal of remaining impurities by extracting electrically charged protein molecules from a solution of concentrated whey proteins. The resulting whey protein isolate contains a higher percentage of protein with less remaining lactose, fat, and ash than can be obtained through microfiltration processes.
Unlike the thick and milky vanilla, chocolate, and strawberry milkshake formulations, Isopure Plus, Enlive!, and Breeze are clear and fruit flavored, making them more suitable for patients restricted to a clear liquid diet and those with gastrointestinal complications that preclude the use of products with a milky consistency. Patients also may find these products more palatable and easier to remain compliant with nutrition recommendations, especially during bouts of chemotherapy-induced nausea. However, given the common digestive challenges and limited abilities to absorb nutrients, protein density becomes an important issue. Isopure Plus has 15 g of protein, higher than the other products listed.
Conclusion
Nutrition intervention during chemotherapy and other cancer treatments
can contribute to the success of treatment and to improving a patient’s
overall quality of life. The best way to meet nutritional needs is
through a balanced meal plan that is sufficient in calories and protein.
For a person with cancer who is dependent on others for survival,
focusing on diet as one of the tools for recovery can provide some
sense of control and self-empowerment. An appropriate diet can lead
to a stronger state of mind and body for those battling cancer.
However, during chemotherapy, patients face multiple challenges from treatment side effects. There are many strategies to help relieve these symptoms and give patients a solid nutritional foundation to aid in their recovery. Ready-to-drink, protein-based drinks can play an important role for patients who are unable to eat because of treatment-related side effects.
Made possible by an unrestricted educational grant from Isopure Plus LLC.
— Karen Wagner, MS, RD, LDN, is a clinical dietitian specialist at the Abramson Cancer Center at the University of Pennsylvania. Her work currently focuses on gynecologic oncology patients. Prior to specializing in oncology, she worked with a wide variety of patients in hospitals and clinics and has taught numerous classes on nutrition and cooking.
— Jaimie Bornstein, MPH, RD, CDN, is president and founder of Bornstein Consulting, a nutrition counseling and health education private practice based in Dix Hills, N.Y.
Chart 1: Managing Nutrition in Patients With Side Effects From Cancer Treatment
Side Effect |
Recommendation |
Loss of Appetite |
|
Nausea/Vomiting
|
|
Diarrhea
|
|
Constipation |
|
Taste Alteration
|
|
Xerostomia (dry mouth) |
|
Stomatitis |
|
Chart 2: Liquid Nutritional Supplements
Nutrition Drink |
Grams of Protein |
Protein Source |
Enlive! |
9 g/8 oz |
Whey protein isolate |
Breeze |
9 g/8 oz |
Whey protein isolate |
Ensure Plus |
13 g/8 oz |
Milk protein |
Boost Plus |
14 g/8 oz |
Milk protein |
Isopure Plus |
15 g/8 oz |
Whey protein isolate |
References
1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA
Cancer J Clin. 2008;58(2):71-96.
2. National Cancer Institute. What is cancer? Available at: http://www.cancer.gov/cancertopics/what-is-cancer. Accessed February 18, 2009.
3. Brosman SA, Moyad MA. Prostate cancer — Nutrition. Medscape. Updated April 27, 2009. Available at: http://emedicine.medscape.com/article/453191-overview. Accessed February 16, 2009.
4. National Cancer Institute. Nutrition in cancer care (PDQ). Available at: http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition. Accessed February 18, 2009.
5. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323-353.
6. Zeman FJ. Nutrition and cancer. In: Clinical Nutrition and Dietetics, 2nd ed. New York: Macmillan Publishing Company: 1991.
7. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition and Diet Therapy, 9th ed. Philadelphia: W. B. Saunders Company; 1996: 805-827.
8. National Cancer Institute. Eating hints for cancer patients: Before, during, and after treatment. Available at: http://www.cancer.gov/cancertopics/eatinghints. Accessed February 18, 2009.
9. Lawenda BD, Kelly KM, Ladas EJ, et al. Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J Natl Cancer Inst. 2008;100(11):773-783.
10. Lacroix M, Bos C, Léonil J, et al. Compared with casein or total milk protein, digestion of milk soluble proteins is too rapid to sustain the anabolic postprandial amino acid requirement. Am J Clin Nutr. 2006;84:1070-1079.
11 Hakkak R, Korourian S, Shelnutt SR, et al. Diets containing whey proteins or soy protein isolate protect against 7,12-dimethylbenz(a)anthracene-induced mammary tumors in female rats. Cancer Epidemiol Biomarkers Prev. 2000;9:113-117.
Learning Objectives
After completing this continuing education exercise, the student will
be able to:
1. Identify the five major categories of cancer.
2. Explain the important role that protein plays in cancer treatment.
3. Discuss the goals of nutrition management for patients undergoing
chemotherapy.
4. Identify the chief components of milk protein and the differences
between them.
5. Explain the increased caloric intake needs of patients with cancer.
6. Discuss the impact of chemotherapy side effects on nutritional
status.
Examination
1. Cancer risk is determined in part by which of the following?
a. Diet
b. Genetics
c. Lifestyle choices
d. All of the above
2. Which of the following are general kinds of cancers?
a. Leukemia and lymphoma
b. Sarcoma
c. Carcinoma
d. All of the above
3. Significant weight loss is associated with poor clinical outcomes
in people undergoing cancer treatment.
a. True
b. False
4. The goals of nutritional care during cancer treatment include
all of the following except:
a. maintain strength and energy.
b. aid in recovery and healing.
c. cause patients to have negative side effects from their treatments.
d. maximize quality of life.
5. RDs can help people undergoing cancer treatment meet their nutritional
needs.
a. True
b. False
6. Cancer patients should receive what percentage of their calories
from carbohydrates?
a. 10% to 20%
b. 20% to 30%
c. 45% to 65%
d. 65% to 75%
7. Nausea, vomiting, and diarrhea may alter hydration status and
electrolyte balance during chemotherapy.
a. True
b. False
8. Protein is necessary in the body during chemotherapy:
a. to help repair and make new cells.
b. for the synthesis of tissue protein.
c. to help in the formation of enzymes, hormones, and fluids.
d. All of the above
9. Casein and whey are components of which of the following?
a. Fat
b. Carbohydrates
c. Milk protein
d. Vitamins
10. The role of supplements in cancer therapy seems to be conflicting
and remains a controversial issue.
a. True
b. False
