Cancer Nutritionist

Oncology Case Studies

2011-10-22T16:55:00.000-07:00

Oncology Case Studies
Case #1: Sharon R. is a 42-year-old mother of four, recently diagnosed with breast cancer. She is scheduled to have a lumpectomy and node dissection in seven days. After surgery, she is scheduled to begin chemotherapy followed by radiation therapy. She is 5’4” tall and weighs 190 pounds. Her usual body weight is 210 pounds. She states she is under a lot of stress since her diagnosis.
1. What recommendations do you have to prepare Sharon for surgery?

Answer: Monitor weight for change. Ask if she knows why she lost 20lbs from UBW. Is she eating less due to the stress? Recommendations should be based on her response. Emphasize adequate calorie & protein intake for healing after surgery.

2. What recommendations do you have to prepare Sharon for chemotherapy and associated side effects? List some dietary alterations that Sharon may follow if she is experiencing the following: weight loss, nausea, vomiting, and taste changes.

Answer: Advise Sharon to inform her physician if the N/V isn’t well controlled with medications. If weight loss occurs it’s important to figure out the underlying etiology, i.e., early satiety, N/V, poor appetite and address that particular nutrition impact symptom. Small, frequent meals would be appropriate for early satiety, poor appetite and nausea. Monitor weight and if >1% weight loss in one week initiate oral supplements prn. If taste changes occur would provide a handout with these strategies: Use a marinade for red meats to mask any metallic taste or switch to other sources of protein such as poultry, fish & dairy. Use plastic utensils instead of stainless steel. Rinse mouth frequently with a baking soda solution. Suck on lemon drops or try sugar free gum.

3. Sharon states, “I am glad to go through chemotherapy because I will probably lose weight and I need to anyway.” What recommendations do you have for Sharon regarding her desire to lose weight?

Answer: Maintain UBW until treatment is completed. Explain that this is necessary due to the possible nutrition impact symptoms she may experience during her treatment. Rapid weight loss could result in clinical malnutrition that could delay treatment or alter the outcome of therapies. Once treatment is completed she may want to consider altering her diet and lifestyle for weight loss and to prevent cancer recurrence.

4. Sharon also inquires about vitamins and herbal supplements at her nutrition consultation with you. She tells you a family friend told her to start taking Essiac tea, IP-6, coenzyme Q10 and selenium immediately? What recommendations do you have for Sharon regarding these supplements with her upcoming surgery and therapies?

Answer: The AICR does not recommend taking supplements for cancer prevention or for cancer survivors. These recommendations are based on a review of thousands of studies from hundreds of experts around the world- The Second Expert Report. Explain that supplements aren’t regulated the same as prescribed medications. Supplements are regulated as food items. Some supplements may interfere with the chemotherapy due to antioxidant activity. Others may increase the risk for bleeding and are contraindicated with an upcoming surgery. Specifically, there haven’t been any human studies completed with IP-6. If desired, Sharon can eat cereal, grains, legumes & meat to increase her oral intake of IP-6. There are some promising studies regarding selenium in cancer patients, but at the present time it’s recommended to eat a healthy diet to obtain our micronutrients. Selenium can be found in seafood, meat & fortified grains.

Readings Read pages 105-109 in the Handbook of Integrative Oncology Nursing Evidence-Based Practice www.cancer.gov/cancertopics/factsheet/therapy/tamoxifen http://www.cancer.gov/cancertopics/pdq/supportivecare/fever/HealthProfessional/page2 Go to the Memorial Sloan-Kettering website and search “About herbs, botanicals and other supplements” at: http://www.mskcc.org/mskcc/html/11570.cfm http://www.nlm.nih.gov/medlineplus/ency/article/000300.htm http://www.ncbi.nlm.nih.gov/pubmed/1618054 http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/Patient/page7

Oncology Nutrition Experts

2011-10-20T11:43:00.000-07:00

1. Make sure you are acquainted with all areas of oncology:

Medical Oncology

Radiation Oncology

Surgical Oncology

Complementary and Alternative Medicine

2. Get acquainted with the American Institute for Cancer Research, www.aicr.org. Be familiar with the Second Expert Report at www.dietandcancerreport.org

3. Learn about current guidelines for Estrogen Receptor Positive Breast Cancer and soy foods versus isoflavones.

4. Go to www.mskcc.org and look for the section "About herbs, botanicals and other supplements". Read about over the counter products that may interfere with radiation and chemotherapy treatments.

5. E-mail any questions to: sbidini@hotmail.com

Free online self study guide for the CSO exam

2008-11-16T06:48:00.000-08:00

My blog is designed to help oncology dietitians prepare for the CSO exam.

Learn from my mistakes!

I studied for months before taking the September 2008 CSO exam. I felt confident that I would ace the exam!

I memorized a lot of information from the Candidate Handbook. I created flashcards from the Oncology Nutrition Test Specifications & spent countless hours preparing for the big day.

I assumed that my years of experience and months of studying would result in total confidence on exam day. I have worked as an inpatient oncology dietitian at a large 500-bed hospital since 2004 and transitioned to the outpatient cancer center position in August 2008.

Much to my surprise the CSO exam was challenging. I left the testing site sick to my stomach. I thought that there was a good chance I would need to take the CSO exam again in March.

When I returned to work my supervisors, co-workers and a medical oncologist asked me if I passed. I honestly said, "I don't know. The exam was very difficult." I felt embarrassed for 6 weeks and waited on pins and needles to discover that I passed!

73 RD's took the September CSO exam & only 15 RD's had a higher score than me.

I guess this information proves that I had prepared well for the CSO exam. I can't imagine how the other RD's felt.

I created this blog as a self study guide for oncology dietitians.

Keep watching this blog and my website at http://www.cancernutritionist.com/ for new developments!

My website will be fully functional in early 2009.

Good luck!

Sharlene Bidini, RD, CSO

sbidini@hotmail.com

2008-11-15T13:47:00.000-08:00

Specialized knowledge in cultural food practices increases the RD’s competence.

Pork is not permitted on a Halal or Kosher diet.

This information is required for the CSO exam!

The dietary restrictions for the following will be reviewed:
1. Muslim: Halal
2. Jewish: Kosher
3. Macrobiotic diet
4. Seventh-Day Adventist
5. Mormon (The Church of Jesus Christ of Latter –Day Saints)

Halal diet- forbidden foods:
Rare meat
Alcoholic beverages , or any intoxicant
Pork and its by-products such as bacon and lard

Kosher diet- forbidden foods:
Mixing meat with milk
Pork
Shellfish
Bloody meat

Macrobiotic Diet:
Avoid animal products including dairy, eggs, coffee, sugar, poultry, and processed foods.
No "nightshade vegetables" including potato, peppers and eggplant
Diet may be deficient in protein, iron, zinc, vitamin B12 and calcium

Seventh-Day Adventist:
Lacto-ovo vegetarian diet
Avoid: beef, lamb, pork, chicken, seafood, coffee, tea and alcohol
Diet may be deficient in protein, iron, zinc, vitamin B12 and calcium

The Church of Jesus Christ of Latter –Day Saints (Mormons)
No alcohol, coffee or tea

Nausea and vomiting related to cancer treatment

2008-11-01T08:35:00.000-07:00

The guidelines for managing nausea & vomiting are different for anticipatory, acute, or delayed nausea & vomiting.

Anticipatory nausea and vomiting: occurs prior to the beginning of a new cycle of chemotherapy. This occurs after the patient has experienced N&V from an earlier chemotherapy treatment.

Acute nausea and vomiting: occurs during the first 24-hours after chemotherapy.

Delayed nausea and vomiting: occurs more than 24 hours after chemotherapy. Patients at highest risk for delayed N&V include those receiving cyclophosphamide, cisplatin, doxorubicin and ifosfamide.
(National Cancer Institute, http://www.cancer.gov/)

Chemotherapy agents are categorized according to their potential to induce nausea & vomiting.
High risk >90%
Moderate risk 30-90%
Low risk 10-30%
Minimal risk <10%

Single IV Agents
Highly emetogenic:
Cisplatin
Mechlorethamine
Cyclophosphamide >1500mg/m2
Carmustine
Dacarbazine

Moderate emetogenic:
Oxaliplatin
Cytarabine >1gm/m2
Carboplatin
Ifosfamide
Cyclophosphamide <1500mg/m2
Doxorubicin

Daunorubicin

Epirubicin

Idarubicin

Irinotecan

Low emetogenic:
Paclitaxel
Docetaxel
Topotecan
Etoposide
Methotrexate
Mitomycin
Gemcitabine
Cytarabine

Minimal emetogenic:
Bleomycin
Busulfan
Fludarabine
Vinblastine
Vincristine
Vinorelbine
Bevacizumab

Guideline for Antiemetic Use:
An antiemetic regimen administered before chemotherapy is recommended to prevent acute nausea and vomiting. This three-drug combination is recommended by ASCO (American Society of Clinical Oncology) for highly emetogenic chemotherapy medications:
1. Serotonin 5-HT3 receptor antagonist (Ondansetron, dolasetron, granisetron, palonosetron)
2. Dexamethasone (corticosteroid)
3. Aprepitant (NK1 receptor antagonist)
(©MASCC 2007, Multinational Association of Supportive Care in Cancer)

5-HT3 antagonists are most effective in the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), especially that caused by highly emetogenic drugs such as cisplatin; when used for this purpose, they may be given alone or, more frequently, with glucocorticoid, usually dexamethasone. They are usually given intravenously, shortly before administration of the chemotherapeutic agent. The concomitant administration of a NK1 receptor antagonist, such as aprepitant, increases the efficacy of 5-HT3 antagonists in preventing both acute and delayed CINV.
The 5-HT3 antagonists are also indicated in the prevention and treatment of radiation-induced nausea and vomiting (RINV) and post-op nausea and vomiting (PONV).
From Wikipedia, the free encyclopedia

Suggestions for managing delayed nausea & vomiting:

The combination of dexamethasone and aprepitant

Suggestions for managing anticipatory nausea & vomiting:

Physchological techniques and/or the use of benzodiazepines such as lorzepam (Ativan®)

Nutrition Tips for Managing Nausea & Vomiting:
*Eat small, frequent meals and snacks
*Eat toast, crackers, dry cereal, bread sticks, pretzels
*Try yogurt, sherbet, rice, noodles, baked chicken
*Serve foods cold or at room temperature
*Avoid hot, spicy foods
*Avoid fatty, greasy and fried foods- potato chips, french fries, fried meat and sausage
*Avoid sweet, fatty foods such as candy, cookies or cake
*Avoid caffeine and alcohol
*Suck on hard candies, peppermints or lemon drops
*Slowly drink or sip liquids throughout the day including sports drinks, ginger ale, apple juice and flat pop
*Try Ensure® Enlive! (apple or mixed berry) supplement or Nestle Nutritional juice beverage

Nutrition interventions for stomatitis/mucositis

2008-10-28T07:08:00.000-07:00

Stomatitis: Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, throat, and roof or floor of the mouth.

Mucositis is the painful inflammation & ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiation treatment for cancer.

Wikipedia, the free encyclopedia

Not everyone undergoing cancer treatment develops mouth sores.
Approximately 400,000 cancer patients develop mouth sores every year in the United States.
Sores are likely to appear within 10 days of starting some cancer treatments.
The ulcers and pain usually disappear within 3 weeks after treatment is completed.
(©CANCERcare 2005, www.cancercare.org)

Some forms of chemotherapy cause damage to the gastrointestinal mucosa, including Methotrexate, Melphalan, Irinotecan & 5-fluorouracil (5-FU).

Radiation to the head and neck or to the pelvis or abdomen causes mucositis in greater than 50% of the patients.

Mucositis can affect the entire alimentary track from the mouth to the rectum.

Stomatitis: mouth inflammation

Esophagitis: esophageal inflammation

Gastritis: stomach inflammation

Enteritis: Intestinal inflammation, especially the small intestine

Mucositis is a common side effect of high-dose chemotherapy or total body irradiation (TBI) given prior to hematopoietic stem cell transplantation (HSCT). An estimated 75-85% of HSCT recipients experience mucositis, of which stomatitis is the most common and debilitating side effect.

Mucositis Management:
* Avoid carbonated beverages, caffeine, alcohol and tobacco
* Avoid rough or coarse foods: raw fruits & vegetables, pretzels, popcorn, chips, crackers & nuts
* Avoid spicy or acidic foods: tomatoes, oranges, grapefruit, lemon, chili, tacos, pickles, vinegar
* Supplement diet with health shakes and milkshakes
* Trial soft, moistened foods or pureed foods
* Serve foods cold or at room temperature
* Gargle regularly with a solution made of 1 quart of plain water, ½ tsp. table salt, ½ tsp. baking soda
* Drink water and other fluids frequently throughout the day. Chew sugarless gum or suck on sugarless hard candy to moisten the mouth. Use artificial saliva frequently
* Suck on ice chips or Popsicles
* Avoid mouthwash that contains alcohol
* Over the counter anesthetics such as Xylocaine, Anbesol or Orajel may soothe the pain
* Gelclair provides pain relief by adhering to the mucosal surface of the mouth & soothing oral lesions. It forms a protective barrier in the mouth. Available by prescription only
* Caphosol lubricates & cleanses the mouth similar to human saliva
* Palifermin (Kepivance) speeds the healing of mucositis and stops sores from forming in the lining of the mouth and throat. It is used in patients that received high-dose chemotherapy followed by HSCT.