Lab Values

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

• BUN: treatment with certain chemotherapy drugs may cause kidney damage, resulting in elevated levels of BUN
• Creatinine: treatment with certain chemotherapy drugs may cause kidney damage, resulting in elevated levels of creatinine
• Sodium: vomiting and/or diarrhea can alter sodium levels
• Potassium: vomiting and/or diarrhea can alter potassium levels
• Phosphate: vomiting and/or diarrhea can alter phosphate levels
• Magnesium: vomiting and/or diarrhea can alter phosphate levels

What laboratory values would classify a patient as neutropenic?

Neutropenia refers to a significant reduction in neutrophils, an important white blood cell involved in the immune system response. In adults, a patient classifies as neutropenic if their absolute neutrophil count (ANC) is <1,500 per microliter of blood (<500 is considered severe). The diagnostic criteria for children varies with age.

Medical/Surgical Treatment

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

• Anorexia – appetite stimulants; encourage small, frequent meals; encourage high energy, high protein foods
• Early Satiety– small, frequent meals that are nutrient dense; beverages between meals; avoid raw vegetables and other high fiber foods; pro-kinetic drugs
• Nausea and vomiting– anti-emetic drugs; avoid noxious odors, e.g. cooking with opened windows, using a microwave oven, avoid frying, avoid perfumes; small, low-fat meals; bland foods and foods served cool or at room temperature; sip fruit juices, sports drinks, or flat soda throughout the day to prevent dehydration and obtain calories
• Dysgeusia– avoid metal utensils; meats are often not tolerated; incorporate high protein foods in diet, including peanut butter, cottage cheese, poultry and soy meat substitutes; use sugar-free lemon drops, gum, or mints; flavor foods with spices and seasonings, such as onion, garlic, chili powder, basil, oregano, rosemary, tarragon, barbecue sauce, mustard, ketchup, or mint
• Mucositis– narcotic analgesics; soft, non-fibrous, non-acidic foods; hot foods should be avoided as they can burn the tender, fragile mucosa; non-acidic juices such as nectars may be helpful; water to keep hydration
• Dysphagia– SLP swallow test; dysphagia diet; placement of feeding tube in advance
• Diarrhea– drink small amount of fluid frequently throughout the day; avoid large amount of simple carbs, e.g. fruit juices; oral rehydration fluids are recommended, e.g. Gatorade, Pedialyte; anti-diarrheal medications; soluble fibers may be useful; eating small meals and snacks often throughout the day; may need to avoid lactose, sorbital containing gums

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.

In an autologous bone marrow transplant, the recipient is also the donor – treatment through receipt of one’s own bone marrow. In an allogenic bone marrow transplant, the recipient and the donor have a different genetic composition – treatment trough receipt of bone marrow from a donor with a different genetic composition. Allogenic bone marrow transplants put a patient at risk for Graft Versus Host Disease (GVHD).

Nutritional implications of GVHD include abdominal pain, diarrhea, vomiting, nausea, mouth sores, heart burn, and loss of appetite. To manage these symptoms, patients should eat small, frequent meals of easy-to digest foods.

Drug Therapy

Discuss the use of the following classifications of drugs with cancer patients. Include effect of the drug on PO intake and nutrient absorption and utilization.  

Drug Classification	Use with Cancer Patients	Effect on PO Intake	Effect on Nutrient Absorption & Utilization
Antineoplastics	Treats cancer – prevents or halts the development of a tumor by inhibiting cell growth	Decreased PO intake due to ⇒ mouth sores, nausea, vomiting, loss of appetite, diarrhea, and/or constipation	Damage to GI tract cells can occur, resulting in impaired nutrient absorption Reduction in folic acid utilization
Antiemetics	Helps with nausea and vomiting symptoms caused by other drugs	The reduction in nausea and vomiting can help increase PO intake – the patient no longer feels sick while eating, and the fear of getting sick may also be alleviated	N/A
Appetite Stimulants	Stimulates appetite – can help patients maintain adequate calorie and nutrient intake from food sources	May cause nausea and indigestion	Take suspension with high fat meal since it may increase blood levels. Food is not needed with tablet or concentrated suspension. Take with food to reduce GI distress.
Pancreatic Enzyme Supplementation	Assists in macronutrient digestion – needed when the pancreas can no longer produce enough enzymes to break down food	N/A	Increased absorption of nutrients from food when taken with fat-containing meals or snacks Increased absorption of nutrients from food leads to increased utilization

Nutritional Management

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

Dysgeusia:

• If experiencing a metallic taste in their mouth:
  • Avoid metal utensils and use plastic instead
  • Pour nutritional supplements into a glass to drink instead of drinking from the metal container
• Meats are often not tolerated
• Encourage patient to incorporate high protein foods in the diet, including peanut butter, cottage cheese, poultry and soy meat substitutes, to ensure adequate protein intake
• If patient has aguesia, encourage them to flavor foods with spices and seasonings, such as onion, garlic, chili powder, basil, oregano, rosemary, tarragon, barbecue sauce, mustard, ketchup, or mint
• Use sugar-free lemon drops, gum, or mints
• If sensitive to sweet foods (they taste too sweet), provide alternative, non-sweet, nutritional supplement options

Oral and esophageal mucositis:

• Topical therapies used to for treatment may cause taste changes
• Encourage consumption of only soft, non-fibrous, non-acidic foods
• Avoid hot foods – they can burn the already damaged mucosa, worsening symptoms
• Adequate consumption of water to prevent dehydration – non-acidic juices can be helpful
• High-calorie, high-protein milkshakes or nutritional supplements if needed

Nausea:

• Determining the cause will help with treatment – e.g., chemotherapy, cooking odors, medication, delayed gastric emptying, etc.
• If caused by cooking odors, nausea can be reduced by cooking with opened windows, using a microwave oven, avoiding frying, taking a walk when meals are being cooked
• If caused by delayed gastric emptying (patient showing signs and symptoms of early satiety) – recommend small, frequent meals
• Nausea caused by chemotherapy:
  • Recommend eating only small, low-fat meals – advise this for morning of first treatment to help prevent nausea
  • Avoid fried, greasy, and favorite foods in the days following treatment – want to avoid favorite foods because vomiting is likely, and don’t want to develop an aversion to any favorites
  • If indicated, recommend a clear liquid diet for the first few days after treatment
  • Consumption of electrolyte-fortified beverages (e.g. Gatorade), nutritional fruit beverages, and non-acidic fruit drinks can help provide calories and maintain hydration
  • Take anti-emetic drugs at least 30-45 minutes before eating to ensure adequate intake and maximal control of nausea – important to take even if they are not feeling nauseated, especially important while actively receiving treatment
  • Sticking to bland foods and foods served cool or at room temperature can help prevent and reduce nausea

Diarrhea:

• Drink small amount of fluid frequently throughout the day
• Avoid large amount of simple carbs, e.g. fruit juices
• Oral rehydration fluids are recommended, e.g. Gatorade, Pedialyte
• Increase intake of foods high in soluble fibers may be useful – but a lot of the time these patients have a poor appetite and have a difficult time increasing their food intake in general
• Eating small meals and snacks often throughout the day
• May need to avoid lactose, sorbitol containing gums

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

An entero-cutaneous fistula is an abnormal tube-like passage, or connection, that forms between the intestinal tract or stomach and the skin. This can lead to malabsorption, syndromes of bacterial overgrowth, and diarrhea. In addition, fistulas can become infected and cause the formation of an abscess. Enteral or parenteral nutrition may be needed. If the fistula is near the center of the body, a feeding tube needs to be placed. If the fistula is not near the center of the body, the patient may be able to feed by mouth or through a gastric tube. Regardless of the method of nutrition support, the goal is to provide adequate protein and calories to promote healing, and plenty of electrolytes.

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

Nutrition support can be provided to a patient with a gastrointestinal obstruction by placing a feeding tube. Whether a percutaneous endoscopic gastrostomy (PEG) tube or a percutaneous endoscopic jejunostomy (PEJ) tube is used depends on the location of the obstruction. If the mouth and esophagus are the source of the issue, then a PEG tube, which goes directly into the stomach, bypassing the mouth and esophagus, is placed. If the stomach is the source of the issue, then a PEJ, which bypasses the stomach and feeds directly into the first section of the small intestine, is placed.

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 parental nutrition is appropriate for an oncology patient when they are unable to meet their nutritional needs by an oral diet or enteral nutrition. This may be due to a malfunctioning GI tract, a malabsorptive condition, a mechanical obstruction, severe bleeding, severe diarrhea, severe vomiting, a GI fistula that is difficult to bypass with an enteral tube, and/or inflammatory bowel processes. The use of central parenteral nutrition is contraindicated if the patient’s GI tract is functioning normally. Other contraindications include sepsis, poor prognosis (not generally recommended if life expectancy is less than 40-60 days), and/or severe organ dysfunction.

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

The primary goal of palliative care is to improve quality of life for the patient and their family and to provide comfort for the patient. This is done by providing a noncurative treatment which reduces symptoms such as pain. The goal of nutrition care is to alleviate symptoms, not reverse deficits. Nutrition is used to enhance the remainder of the patient’s life by reducing food-related discomfort and increasing the enjoyment of food.