Christine Batten DFM 484 Cast Study 31 Lymphoma Treated with Chemotherapy

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1 Christine Batten DFM 484 Cast Study 31 Lymphoma Treated with Chemotherapy 1. What type of cancer is lymphoma? Lymphoma is cancer of the lymphatic system, a blood-forming cancer. 4. Generally, patients with cancer are treated with surgery, radiation therapy, chemotherapy, biological therapy, bone marrow transplant, or a combination of therapies. Ms. Mitchell s medical plan indicates that she will have both chemotherapy and radiation therapy. Describe how each of these therapy modalities work to treat malignant cells. Surgery is a localized process of removing a tumor, aiming to prevent the spread of cancerous cells through this removal. Radiation therapy targets the specific area affected, and uses electromagnetic rays and charged particles to alter DNA. Chemotherapy treats the entire system with antineoplastic drugs. These drugs kill rapidly dividing cells, like cancer cells. Biological therapy is a process where agents (such as antibodies, interleukins, gene-therapy, and immunomodulating agents) are used to boot a patient s own immune system/response to fight the tumor. A bone marrow transplant removes the person s entire bone marrow and replaces it with bone marrow cells from a healthy bone marrow donor. These cells proliferate and build up the patient s new bone marrow supply. This is used specifically for patients with hematological cancers, such as leukemia and lymphoma. Chemotherapy and/or radiation therapy usually precedes the transplant. 5. Radiation and chemotherapy may also affect healthy tissues. a. What other cells in the body may be affected by either or both of these treatments? Typically, these treatments tend to affect other cells that divide very quickly, like epithelial cells (which line the surfaces such as the inside of organs and body cavities) as well as hair follicles, bone marrow, and lymph tissue. Chemotherapy will affect all of these cells, as the drugs used circulate the entire body. Radiation therapy will only affect these continually proliferating cells if they are in the area that the radiation therapy is given, since this treatment is localized and not systemic. b. What symptoms may the patient experience as a result of the destruction of these cells? Depending on the type of treatment, the patient may experience nausea, vomiting, hair loss, diarrhea, constipation, malabsorption, abdominal pain, mucositis (inflammation of the mucous membrane lining the digestive tract), early satiety, xerostomia (dry mouth), dysgeusia (distorted sense of taste or smell), and odynophagia (painful swallowing).

2 9. Calculate the patient s BMI and percent usual body weight. How would their interpretation differ? Which is the most appropriate to use in determining nutritional risk for this patient? Patient is 5 6, 120 lbs, UBW is kg 167cm = 1.67m 54.5kg/(1.67m) 2 = 19.5 BMI = 20 (120/130) x100 = 92.3% = %UBW BMI uses a person s current height and weight to assess one s body fat or weight. Percent UBW assess a change in body weight. Since this patient has cancer, BMI is not as relevant to her treatment plan as %UBW, since this measure assesses a change that can indicate poor nutritional status. The interpretation may differ in the her BMI is normal, indicating there is no issue, while her %UBW indicates a potential poor nutritional status. 12. Calculate the patient s protein requirements. The patient should consume more protein than a healthy individual. Her intake should be 1 to 1.5 grams of protein per kg of body weight. 1gx 54.5kg = 54.5g/kg 1.5g x 54.5kg = 81.75g/kg Her protein needs range from 54.5g/kg to 81.75g/kg per day. 13. Calculate energy requirements for Denise. Identify the formula/calculation method you used and explain the rationale for using it. What weight (UBW or current body weight) should you use to accurately calculate the patient s energy needs? Using the Harris-Benedict equation, Denise s energy requirements are as follows: REE= ( x 54.5 kg) + ( x 165 cm) ( x 21years) REE= 1,383 kcals/day 1,383 x stress factor 1.5 = kcals/day = TEE 14. How would you assess the dietary information gathered for usual nutrition intake? Usual Intake: Food Item Energy (kcals) Protein (grams) Cold cereal (1 cup) Skim milk (1/2 cup) Juice (8 oz) Sandwich, Tuna Salad (5 oz) w. mayo, 3 oz Bread Frozen yogurt (1 cup) Chips (small bag Lay s classic) 160 2

3 Soda (1 can Coke Classic) 90 0 Chicken (approx 4 oz roasted without skin) Boiled broccoli, (1 cup) Skim milk (1 cup) 90 9 Salad (mixed vegetables tossed without dressing, 1.5 cups) Popcorn (air-popped, white, 2 cups) Soda (1 can Coke Classic) 90 0 TOTAL 2, hour recall: Food Item Energy (kcals) Protein (grams) 1 slice dry wheat toast Plain hot tea 0 0 ½ C vanilla ice cream ¼ C fruit cocktail oz chicken, baked without skin 2 T plain mashed potatoes 30.5 ½ C Jell-O 10 1 TOTAL Based on her 24-hour diet recall, the patient has substantially decreased her caloric intake. Her calorie and protein intakes have not be adequate recently; she needs substantially more protein and calories to sustain even her basic needs, let alone her needs for her upcoming treatment and healing process. 18. What common side effects of her illness may affect her dietary intake and subsequently her nutritional status? Her most common side effect related to lymphoma is increased weight loss (cancer cachexia) due to increased energy needs from the tumor growth and cytokine activity altering metabolism. Other side effects are changes in taste and subsequent appetite, and fatigue (which can all contribute to her weight loss). These can all play a factor in her ability to either take in or use nutrients. 19. What physical symptom(s) is this patient experiencing that might affect her dietary intake? This patient is experiencing fatigue, dry mouth, dry mucous membranes, a fever, and general flulike symptoms. These symptoms can play a role in the patient s desire to eat and can also increase her body s need for energy. 20. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. Inadequate protein intake N Inadequate energy intake N1-1.4

4 Inadequate oral food/beverage intake N1-2.1 Increased nutrient needs (protein) N Which labs can be used to assess protein status? Visceral protein labs can be used to assess protein status: albumin, prealbumin, retinol-binding protein, fibronectin, transferin. Not all of these are the best measures in hospital settings. Fibronectin and prealbumen are the best, due to their short half-lives and the fact that they are not negative acute response proteins, so their levels remain more consistent with immune and inflammatory responses. a. Which labs will reflect acute changes in protein status versus chronic changes? Why? Albumin (half-life os days) and tranferrin (8-10 days) have longer half-lives and thus these lab results reflect chronic changes in protein status. Prealbumin (2-3 days), retinolbinding protein (10-12 hours), and fibronectin (15 hours) all reflect acute protein changes, due to their shorter half-life. b. Which labs are available for this patient? Considering her diagnosis, which labs would not be appropriate to use to evaluate protein status? Albumin and total protein are available labs for this patient. Albumin would not be appropriate to evaluate her protein status due to its long half-life. Also, albumin is a negative acute phase reactant protein, so its levels decrease in response to illnesses such as cancer. Total protein status may be a better measure to use. Other visceral protein labs may not be appropriate to order, such as transferring due to its levels changing with iron status. c. Determine the nutritional risk associated with this patient s lab value. Would you request additional nutrition labs? The patient s WBC count is high, MCV (mean corpuscle volume) is low, MCHC (mean corpuscular hemoglobin concentration) low, HGB is low, HCT is low, ferritin is low, and albumen and total protein is low. Since both the MCV and MCHC are low, this patient s red blood cells are microcytic, hypochromic. This means the patient is iron deficient, which is consistent with her low hemoglobin and hematocrit level, as well as low ferritin levels (though low ferritin can also stem from the body s need to fight infection). Since her protein levels are low, she may be protein deficient. I would order a prealbumen lab, as it is a better measure of protein status for ill patients due to its short half-life. 25. Select two high priority nutrition problems and complete the PES statement. 1. Inadequate energy intake related to poor appetite as evidenced by involuntary weight loss of 10 pounds, 24-hour food recall, and general appearance 2. Involuntary weight loss related to insufficient energy intake as evidenced by recent 10- pound weight loss

5 26. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 1. Inadequate energy intake related to poor appetite consistent with cancer medical diagnosis as evidenced by involuntary weight loss of 10 pounds, 24-hour food recall, and general appearance Ideal goal: No further weight loss should occur and patient should gain 10 pounds to achieve usual body weight. Intervention: Patient will incorporate kcal dense foods and nutritional drinks to increase calorie and nutrient intake. Soft foods and small frequent meals are ideal. Patient will be provided with nutrition education regarding nutrition support needed during lymphoma treatment. 2. Involuntary weight loss related to insufficient energy intake as evidenced by recent 10-pound weight loss Ideal goal: Patient will meet her calorie and protein needs. Intervention: Patient will increase energy intake to 2,075kcals per day and keep a daily food log. Smaller meals will be given frequently. Protein supplementation will be provided as needed between meals. Incorporate softer foods if swallowing is difficult.

Shyana Sadiq DFM 484: MNT Case Study 33: Esophageal Cancer Treated with Surgery and Radiation 10/14/2013

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