Nutritional Challenges in Lymphoma

Gayle Black

Senior Specialist Dietitian

Royal Marsden Hospital

Aims of the Session To consider the varied impacts a diagnosis

of Lymphoma can have on nutrition To consider how and why nutrition is an

important part of the patient journey To compare and contrast the role nutrition

played for two specific individuals

Nutrition at Diagnosis The lymphomas are a highly complex group of

diseases and nutritional implications at diagnosis are very much related to the individual diagnosis

The presence of B symptoms often leads to significant weight loss prior to diagnosis

Weight loss is present in approximately 50 % of all patients presenting with a gastric lymphoma (Balfe et al, 2008).

Oropharyngeal lymphomas may be related to swallowing difficulties at diagnosis

Nutritional Implications during Induction and Intensification Treatment

The exact side effects of treatments varies between individuals and treatment regimens

The diverse nature of Lymphoma leads to a wide variety of different nutrition related implications

Combination therapy can lead to more intensive side effects

Anxiety and prolonged stays in hospital can both adversely effect nutritional status

Not all patients undergoing treatment for lymphoma will have altered nutritional intake

Nutrition Related Side Effects Commonly Seen

Mucositis Xerostomia Nausea Vomiting Fatigue Anorexia Abdominal Cramps

Diarrhoea Constipation Hyperglycaemia Increased Appetite Fluid Retention Taste Changes Heart Burn

Why is Nutrition Important during treatment for Lymphoma?

The provision of food and fluids is a basic care (BMA, 1999)

Malnutrition can have a significant impact on survival and performance status

Up to 20% of all patients treated for cancer are deemed to die from the effects of malnutrition (Mercadante, 1998)

Malnutrition may decrease tolerance to treatment and increase incidence of dose limiting side effects

Wound healing is reduced in malnutrition

Eating as a Social Experience Expression of love and caring Expression of individuality To reward or punish A focus for communal activities As a control issue As a coping strategy As a treatment Weight loss is an outward symbol of poor health

Case Study 1 – The Physical Challenges of Diet and Lymphoma 58 yr old Male Presented in May 2008 with a year long history of

fatigue, poor appetite and weight loss On admission is very weak, dehydrated and

confused with a performance status of 3 Following investigations is diagnosed with Stage

IVB Diffuse Large B Cell Lymphoma

Nutritional Status on Admission Presented with a history of accelerated

unintentional weight loss over approximately a two month period

Weight on admission = 63 Kg with moderate ascites (est. 6 kg)

BMI on admission = 17.5kg/m² % wt loss on admission = 18 %

During Admission Initially nasogastric tube insertion attempted but

unsuccessful due to tube curling in the oesophagus

Following referral to the Dietitian routine of small regular snacks supplemented with Scandishake bd and Calogen 30ml tds successfully implemented

Performance status quickly improves and discharge home is planned

But then…. Patient starts to become increasingly

unwell BNO and abdomen becomes very

distended with absent bowel sounds Refusing all food and fluid due to abdo pain Paralytic ileus diagnosed secondary to

Vincristine

Management Plan Conservative management NBM with NGT for drainage PICC line inserted for TPN Over the next few weeks patient continues

to go in and out of obstruction with the reintroduction of oral diet attempted on several occasions

Weaning off PN and Moving Forward Diet eventually reintroduced although

patient has now been in hospital for 2 months

Reports sore mouth and taste changes secondary to oral Candida

Complaining of taste fatigue with hospital food and supplements

Early satiety secondary to ascites

Nutritional Status on Discharge Weight = 62 Kg (without ascites) BMI = 19 Kg/m2

Oral intake providing approximately 800 kcal/day and 40g protein from meals and snacks

Additional intake from oral nutritional supplements to support weight gain

Where are we now? Following discharge from hospital he struggled to

cope at home and family relations suffered as a result

Spent several months being cared for in a nursing home

However he has now completed a course of single agent Rituximab and is on long term follow up

His weight is stable at 67 Kg (BMI = 21 Kg/m2) and the recurrent ascites has stopped

He’s back in his own home although so far has been unable to return to work

Case Study 2 – The Psychological Challenges of Diet and Lymphoma

21 yr old Male Lives at home with his parents and younger

sister Treated in childhood for both Lymphocyte

predominant Hodgkin's Disease and B-NHL

Autologous transplant in 1999

Recent Medical History Hodgkins Disease relapsed 2008 aged 20 Presented with a history of unexplained

weight loss and lethargy Relapse confirmed following endoscopy

and chemotherapy commenced shortly afterwards

Reduced Intensity Allograft July 2009

Nutritional Status on Discharge Post Transplant

Weight on day of discharge = 55 Kg BMI on discharge = 17 Kg/m2

Managing small amounts of meals and snacks, slowly increasing portion sizes

Supplementing diet with Fortijuce bd

Challenges at Home Weight falling at each review Refusing all nutritional supplements Food choices becoming more and more

limited Mother confides that he is becoming

socially isolated and withdrawn Spending large periods of time comparing

his appearance to others

Nutritional Status at Readmission Weight = 45 Kg BMI = 14 Kg/m2

% Weight loss = 18 % Medical investigations all unable to identify cause

for weight loss, referred to gastroenterologist Agreed to referral for counselling, CLIC sergeant

social worker and young people’s activity coordinator

PEG tube inserted

Five Weeks Later Discharged from hospital Weight = 50.4 kg BMI = 16 Kg/m2

Tolerating overnight feeds very well and independent with all aspects of PEG care

Eating small meals and supplementing with extra snacks

Where are we now? PEG removed 3 weeks ago Eating a full and varied diet Weight maintained at 61 Kg with a BMI of

19 Kg/m2

Recently spent a week in Cornwall with friends from college

Looking for part time work

Summary Eating difficulties for our patients can be due to a

wide variety of factors and can change with time The consequences of a reduced nutritional intake

can impact all aspects of our patients lives and should not be underestimated

The link between nutritional status and performance status is key

Each individual we meet will have very different needs, importance of not making assumptions