Nutrition and oncology: medical aspects. Case history. What is cancer? Head, Palliative Care RPAH/Sydney Cancer Centre May 2008

Size: px

Start display at page:

Download "Nutrition and oncology: medical aspects. Case history. What is cancer? Head, Palliative Care RPAH/Sydney Cancer Centre May 2008"

Lynette Jacobs
5 years ago
Views:

1 utrition and oncology: medical aspects? Clin Assoc Prof. Paul Glare, FRACP Head, Palliative Care RPAH/Sydney Cancer Centre May 2008 Case history What is cancer? 24M PH IDU, HCV 1/08: bowel obstruction: colon cancer surgery (hemicolectomy, spelnectomy, distal pancreatectomy) 3/08: another obstruction: recurrent colon cancer, with liver, bone secondaries defunctioning ileostomy High output from stoma Ongoing &V pain In hospital x 6 weeks; TP 4/08: discharged plan for chemo 5/08 follow-up in clinic Common sites and incidence How it spreads 1

Diagnosis: staging Diagnosing cancer (0.

Localized, big ± spread to lymph glands III.

cancer Lab tests Anemia a+, Ca++ LFT s, albumin

prostate ß HCG: GCT CEA: bowel CA-125: ovary

Lung Breast prostate Colorectal Ovary melanoma

bone, liver, brain, lungs Bone, liver Liver,

lungs, skin Chemo side effects Class Alkylating

Cyclophoshamide, chlorambucil; Melphalan;

GI Side effects Old ones not bad Cisplatin, carbo:

Antibiotics Mitotic Inhibitors Methotrexate, 5FU,

2 Diagnosis: staging Diagnosing cancer (0. Pre-malignant) I. Localized, small II. Localized, big ± spread to lymph glands III. Localized, very big ± spread to more glands IV. Spread to other tissues e.g. liver, bone, lung, brain Laboratory tests Stage IV cancer Lab tests Anemia a+, Ca++ LFT s, albumin LDH CRP Cytokines: IL6 Tumour markers PSA: prostate ß HCG: GCT CEA: bowel CA-125: ovary CA19-9: upper GI Genetics: tissue, blood Cancer Lung Breast prostate Colorectal Ovary melanoma Sites of spread bone, liver, brain, lungs, skin bone, liver, brain, lungs Bone, liver Liver, bones, lungs Peritoneum, bones Liver, bone, brain, lungs, skin Chemo side effects Class Alkylating agents itrosureas Examples Busulfan, Cyclophoshamide, chlorambucil; Melphalan; cisplatin, carboplatin; DTIC BCU, CCU, Lomustine GI Side effects Old ones not bad Cisplatin, carbo: very &V, diarrhoea Antimetabolites Antitumor Antibiotics Mitotic Inhibitors Methotrexate, 5FU, capecitabine Bleomycin, Doxorubicin, Idarubicin; mitoxantrone,gemcitabine Docetaxel, paclitaxel, Etoposide and Vinorelbine Mucositis, diarrhoea Moderate &V (neuorapthy) 2

ew treatments Monoclonal antibodies + drug/toxin/isotope Herceptin

therapy Other issues Combined chemotherapy: often worse Combined modality

cf GI &V can often be controlled with ondansetron etc Ondansetron is

short term, reversible problems o role in anorexia-cachexia syndrome Many

loss in cancer patients Traditional view: starvation Pro-inflammatory

3 ew treatments Monoclonal antibodies + drug/toxin/isotope Herceptin Biological modifiers Angiogenesis inhibitors Immunotherapy Vaccines Gene therapy Other issues Combined chemotherapy: often worse Combined modality e.g. chemort for oesophagus/lung Biological modifiers: rashes, neuropathy cf GI &V can often be controlled with ondansetron etc Ondansetron is constipating Pain killers, adjuvant agents are constipating TP: only for short term, reversible problems o role in anorexia-cachexia syndrome Many causes for anorexia/wt.loss in cancer patients Traditional view: starvation Pro-inflammatory cytokines the main culprit Inter-relation of pro-inflammatory cytokines in tumor, stromal & liver cells Slaviero, Lancet Oncol 2003;4:

4 Cachexia: zeroing in on myosin Chamberlain EJM 2004;351: utrition Cytokine Detected % mean min max IL-2 5 (6%) IL-6 54 (68%) IL-8 79 (100%) IL-1β 4 (5%) LT-α 7 (9%) IL-12 p70 17 (22%) VEGF 69 (87%) inite 4

5 utrition and survival days r 2 =-0.241,p=0.018 r 2 = , p= Malignant cachexia: management Anti cancer treatment Treatment options STREGTHE MUSCLES AS WELL AS FEEDIG THEM 5

Multidisciplinary team Dietician Physiotherapist Psychologist urse doctor Health

factors utrition and Rehabilitation Clinic Medical Oncology Referrals MST screening

Declines Basic diet & exercise information + contact number PG-SGA re-screen 1 month

80% on Rx (2/3 chemo) Median KPS 70 (all 50+); 6MWT: 420m Median wt loss: 12%;

6 Multidisciplinary team Dietician Physiotherapist Psychologist urse doctor Health Services Innovations Grants 2007 Pilot program to evaluate weight loss & prognostic factors utrition and Rehabilitation Clinic Medical Oncology Referrals MST screening Positive MST egative MST PG-SGA 9 PG-SGA <9 MST re-screen 2 months RECRUIT! Declines Basic diet & exercise information + contact number PG-SGA re-screen 1 month Activity (10/07-3/08): 33 patients 24m, 9f; 66.5 yrs (38-83); All stage III/IV. 80% on Rx (2/3 chemo) Median KPS 70 (all 50+); 6MWT: 420m Median wt loss: 12%; median BMI 20; PG-SGA B/C: 78% CRP (n=18) >10: 78%; alb (n=24) <35: 38% Outcomes so far

Guideline Role of doctor normal Pre-cachexia Mild-mod cachexia Marked cachexia Malnutrition intake weight

palliative care) Symptoms interfering with eating ilstat, mouth care, maxolon, dexamethasone, laxatives

antagonists creatine, ATP, EPO, Anti-oxidants, ghrelin, mysotatin inhibitors, MC4 inhibitors safe for

utrition Recommendations Monitor Physiotherapy Goals - Reduce symptoms disability and handicap - Physical

7 Guideline Role of doctor normal Pre-cachexia Mild-mod cachexia Marked cachexia Malnutrition intake weight CRP Action nil CRP CRP CRP or PCS Diet, rehab Appropriateness for CRP (vs. palliative care) Symptoms interfering with eating ilstat, mouth care, maxolon, dexamethasone, laxatives Drugs (clincial trials) Thalidomide ACE inhibitors, B blockers, statins IL-6 agonists or receptor antagonists creatine, ATP, EPO, Anti-oxidants, ghrelin, mysotatin inhibitors, MC4 inhibitors safe for physiotherapy Cancer complications; Comorbidities Role of dietician utrition Screening utrition Assessment utrition Recommendations Monitor Physiotherapy Goals - Reduce symptoms disability and handicap - Physical training endurance and strengthening - Improve functional independence - Individually tailored and designed programs Gym Based Program Endurance Results 6MWT Changes 7

Results - Strength Changes Results Changes in Grip strength Results Changes in ESAS totals Treatment: needs to be early!

live and good KPS full assessment/therapy Maxolon, EPA, vitamins, Dietician, exercise program < 1 month/poor KPS Treat pain, thrush, constipation, nausea Favourite foods

in patients with poor appetite (GIT rather than pain) Opioids: dry mouth, constipation, nausea, anorexia Ordine worse than Duragesic for taste Crucial to manage these

8 Results - Strength Changes Results Changes in Grip strength Results Changes in ESAS totals Treatment: needs to be early! Clinical trials Effects modest Degree of inflammation Muscle damage Early: fibres intact Late: fibres disappear Approach to the palliative care patient If > 1 month to live and good KPS full assessment/therapy Maxolon, EPA, vitamins, Dietician, exercise program < 1 month/poor KPS Treat pain, thrush, constipation, nausea Favourite foods Orexigens: Steroids; olanzepine, cannabinoids Education of patient/family re realities of ACS Pain, analgesics and appetite Pain and anorexia are common Symptoms common in patients with poor appetite (GIT rather than pain) Opioids: dry mouth, constipation, nausea, anorexia Ordine worse than Duragesic for taste Crucial to manage these side effects Endogenous opioids elevated in anorexia nervosa/bulimia (Marrazzi, Life Sci 1997) released during an initial period of dieting and reinforce a state of starvation dependence Relevance in palliative care??? 8

9 Summary Cancer, natural history, diagnosis, treatment ew treatments GI toxicity of common chemo agents Anorexia/wt loss and cancer: causes Malnutrition, cachexia, mixed utrition, quality of life, survival in advanced cancer ew approaches: CRP 9

CANCER CACHEXIA. Negativity cancer nutrition. Do we think it s s important? Lack of past success alimentation trials counselling therapeutic failures

CANCER CACHEXIA. Negativity cancer nutrition. Do we think it s s important? Lack of past success alimentation trials counselling therapeutic failures CANCER CACHEXIA A wasting syndrome characterized by loss of muscle and fat caused by an aberrant host response to a wide variety of chronic illnesses. Anorexia usually accompanies cachexia,, and is caused