The Royal Marsden

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Living with and beyond cancer

Clare Shaw PhD RD

Consultant Dietitian

Lung Cancer Colorectal Cancer Breast Cancer

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The Royal Marsden Nutritional issues after cancer treatment 4

Nutritional issues in cancer

– What are the nutritional issues after cancer treatment?

– Nutritional status and issues after treatment?

– Can nutrition influence prognosis?

– Late effects of cancer treatment

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Nutritional status

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What happens to body weight after cancer treatment?

Weight loss

Upper GI cancer patients

Stem cell or Bone marrow transplantation

Head and neck

Gynae-oncology

Weight stable

Breast, prostate, colo-rectal

Weight increase

Breast cancer

Prostate cancer

Cachexia ‘the synergistic combination

of a variable decrease in appetite and weight and

an increase in the catabolism of fat and lean

body mass’

European Clinical Guidelines on cancer

cachexia in advanced cancer patients

Sarcopenia No internationally agreed

definition of this phenomenon: ‘the presence of both low

muscle mass + low muscle function (strength or

performance)’

European Working Group on Sarcopenia in Older People 2010

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Sarco-penia

• Myopenia

• Myosteatosis

Flesh- poverty

Sarcopenia- Dietary treatment

Protein Directly linked to muscle

synthesis. Total amount could be debated:

Martone AM et al 2012:

>1g protein per kg body weight

Paddon-Jones and Ramussen

25-30g per meal

Aleman- Mateo H et al 2014 210g ricotta cheese (23g

protein)

Leucine- stimulates muscle synthesis

> Whey based enteral feeding, especially for patients who are

less mobile

Omega 3 Inconclusive evidence. Literature is limited to

the cachectic patient. Fearon et al 2003 Gullett et al 2012

Vitamin D Role in maintaining muscle mass and

strength- limited research in cancer patients Beaudart C et al (2014)

Recognise and initiate treatment of Vitamin D

But this alone is inadequate without:

ACTIVITY!

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Link between weight loss and symptoms

Diarrhoea consistent problem 12 months after upper GI surgery

Martin et al, 2007: Iestra et al, 2002;

Scarpa et al, 2013 J Gastrointest Surg: 17

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Can nutrition affect prognosis after cancer?

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The Royal Marsden Nutritional issues after cancer treatment 12

Diet following cancer treatment

– Few studies on diet in cancer survivors

– Good diet for health

– Reduce risk of other diseases eg. diabetes, heart disease

– Can it influence whether

the cancer returns?

The Royal Marsden Diet for breast cancer survivors 13 13

World Cancer Research Fund UK Recommendations

1. Be as lean as possible without becoming underweight

2. Be physically active for at least 30 minutes every day

3. Avoid sugary drinks and limit the consumption of high calorie foods

4. Eat more of a variety of vegetables, fruits, whole grains and pulses

5. Limit intake of red meat and avoid processed meat

6. Limit alcoholic drinks to 2 a day for men and 1 a day for women

7. Limit consumption of salty foods

8. Do not use nutritional supplements to protect against cancer

9. After treatment, cancer survivors should follow the recommendations for cancer prevention

The Royal Marsden Diet for breast cancer survivors 14

www.wcrf.org/sites/default/files/Breast-Cancer-Survivors-2014-Report.pdf

The Royal Marsden Diet for breast cancer survivors 15

www.wcrf.org/sites/default/files/Breast-Cancer-Survivors-2014-Report.pdf

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Nutrition in GI late effects

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Gastrointestinal symptoms patients present with in clinic

Change in bowel habit

Diarrhoea

Steatorrhoea

Increased frequency of

defaecation

Urgency of defaecation

Faecal incontinence

Nocturnal defaecation

Tenesmus

Mucus discharge

Excessive flatulence

Constipation

Pain (abdominal, rectal, anal,

perineal)

Sexual activity curtailed by

bowels

Nausea

Vomiting

Weight loss

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Changes in food intake – what happens after pelvic radiotherapy

Abayomi et al, 2009 Journal of Human Nutrition and Dietetics, 22; 310-316

¼ ate less fruit

1/5 ate less vegetables

1/6 ate less fat

¼ ate less fibre

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How do patients try to cope with gastrointestinal

symptoms?

Modify their diet

Avoid certain foods or food groups

Miss meals or modify the size of meals

Eat plain food or stick to tried & tested foods

Rarely go out

‘I have tried many tablets and teas, changing my diet and nothing seems to work’

Abayomi et al 2005; Abayomi et al 2009; Dunberger et al 2011; Gami et al 2003; Gillespie at al 2007; Sekhon, 2000

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General management strategies

– GI symptoms may or may not be related to the cancer treatment

– Many patients have more than one cause for symptoms

– Symptoms are unreliable at predicting the underlying cause

– Inappropriate treatment has a significant potential for causing harm

– Most patients need appropriate investigation before treatment

Andreyev et al, 2011 Gut

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Dietary intervention:

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diagnosis

Dietary intervention References

Bile acid malabsorption Low fat diet Bosaeus et al 1979; Bye et al 1992; Danielsson et al 1991

Pancreatic insufficiency Dietary manipulation & enzyme replacement therapy

Ferrone et al 2007; Keller & Layer 2005; Smith 2008

Free fatty acid malabsorption

Low fat diet Nightingale 2003; Nightingale & Woodward 2006

Coeliac Disease Gluten free diet NICE 2009

Bloating, wind, abdo pain, altered bowel habit *

Low FODMAPs* Gibson & Shepherd 2010; Rangnekar & Chey 2009; Staudacher et al 2011.

IBS type symptoms* Consult IBS algorithm e.g. reduction in high fibre

foods*

NICE 2008; Abayomi et al 2005; Abayomi et al 2009; Sekhon 200; Gami et al 2003.

* Only consider if no alternative diagnosis has been made

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Management of side effects and consequences of treatment

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Decrease in symptom ratings

p value

Urgency to open bowels <0.01

Bloating & distension <0.01

Lack of control <0.01

Frequency of opening bowels <0.01

Flatulence & wind <0.05

Abdominal pain <0.05

Greasy/ pale stool <0.05

Abdominal gurgling <0.05

Watson et al, Clinical Medicine 2014

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Other nutritional considerations

– Bone health

– Anaemia

– Body weight

– Micro nutrients eg. Fat soluble vitamins especially vitamin D, Trace elements

– Late symptoms that require immediate / urgent medical attention and possible nutritional support

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Summary

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Living with and beyond cancer

– Poor nutritional status, may be linked to symptoms

– Physical issues eg. Bone health, anaemia

– Psychological distress

– Impaired quality of life

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Acknowledgements

Lorraine Watson, Macmillan Dietitian in Pelvic Radiation Disease

Linda Wedlake, Research Dietitian

Eva Grace, Research Dietitian

Dr J Andreyev, Consultant Gastroenterologist in Pelvic Radiation Disease