Managing Side Effects of Cancer Treatment

Shayne Robinson RD CSO CDN

NY Presbyterian Cornell Medical Center Ambulatory Care Network

December 5, 2014

Objectives

• Ability to name side effects of common cancer treatments, including chemotherapy, radiation therapy and combined modality treatment

• Ability to name causes of side effects and implement nutrition intervention for managing side effects of disease and treatment

• Ability to identify resources for both patient and RD to manage side effects

Types of Treatment

• Surgery• Chemotherapy• Radiation Therapy • Combined Modality Treatments

Surgery

• Period of NPO/Clear/IV fluids • Inability to swallow• Constipation• Removal of parts of GI tract• Increased metabolic requirements

Chemotherapy• Route

– IV– Oral– Injection

• Side effects– Changes in taste, food aversions, sensitivity to odors– Mouth sores– Nausea, vomiting– Diarrhea, constipation – Decreased appetite, anorexia– Low blood counts, neutropenic diet

• Look up drugs/regimens– X% get grade X mucositis– Protocols include drugs given in combination

• Resources– Complete Resource Kit for Oncology Nutrition - Medication Guide ,

http://dpg-storage.s3.amazonaws.com/ondpg/documents/9ccdd1ca724c7eee/Medication_Guide_(1).pdf

– Lexicomp

Chemotherapy Support

• IV fluid• Anti nausea medication• H 2 Blockers• Steroids• Benadryl

Radiation Therapy

• Mechanism of Action• Side effects dependent on the dose and site

radiated• Side effects• Late Side effects

http://www.cancer.gov/cancertopics/coping/radiation-therapy-and-you/radiationttherapy.pdf, accessed August 11, 2014

Combined Modality Treatment

• Both chemotherapy and radiation therapy at the same time • Chemo acts as a radiation sensitizer• Side effects are frequently worse• Require diligent MNT follow up• Most challenging patients

– Head and neck– Lung– Esophagus– Pancreatic– Colorectal

Common Nutrition Related Side Effects Of Treatment

• Causes• Nutrition Intervention

Profession Guidelines

• ASCO-evidence based, address supportive care (and treatment)– ONS• PEP (Putting Evidence into Practice)

• NCCN-consensus based guidelines address supportive care (and treatment)

• MASCC– Evidence Based-supportive care only

Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0

• The NCI CTCAE is a descriptive terminology which can be utilized for reporting adverse events

• A grading scale is provided for each term– Severity – Grades 1-5

Reference: http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf

Chemotherapy-Induced Nausea and Vomiting (CINV)

• Classification – anticipatory – acute – delayed – breakthrough – refractory

• Chemotherapeutic regimens can be classified as having high, moderate, low, or minimal risk of emetogenicity.

• Incidence and timing of CINV vary according to patient factors and chemotherapeutic agents.

• Incidence has been reported in as high as 70%–80% of patients. • Incidence of nausea > vomiting• antiemetic medications tend to be less effective in controlling nausea

Nausea

• Definition: A disorder characterized by a queasy sensation and/or the urge to vomit.

Grade 1 Grade 2 Grade 3

Loss of appetite withoutalteration in eating habits

Oral intake decreased withoutsignificant weight loss,dehydration or malnutrition

Inadequate oral caloric or fluidintake; tube feeding, TPN, orhospitalization indicated

Vomiting

• Definition: A disorder characterized by the reflexive act of ejecting the contents of the stomach through the mouth.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

1 - 2 episodes (separated by 5minutes) in 24 hrs

3 - 5 episodes (separated by 5minutes) in 24 hrs

>=6 episodes (separated by 5minutes) in 24 hrs; tube feeding,TPN or hospitalization indicated

Life-threatening consequences;urgent intervention indicated

Death

Nausea/ Vomiting

• Causes• Frequency• Recommended for Practice

– Medications– https://

www.ons.org/practice-resources/pep/chemotherapy-induced-nausea-and-vomiting

• Likely to be effective– Hypnosis for Anticipatory CINV– Managing Patient Expectations– Progressive Muscle Relaxation and Guided Imagery– Medication

• Non medication-accupuncture, fresh air, exercise • Diet interventions

Oral Mucositis

• Definition- A disorder characterized by inflammation of the oral mucosal

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Asymptomatic or mildsymptoms; intervention notindicated

Moderate pain; not interferingwith oral intake; modified dietindicated

Severe pain; interfering with oralintake

Life-threatening consequencesurgent intervention indicated

Death

Oral Mucositis

• Causes• Mouth rinses/ mouth care– Baking soda/salt

• Diet• Nutrition support

Dodd, M.J., Dibble, S.L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S.M., et al. (2000). Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 90(1), 39–47.

Constipation

• Definition-A disorder characterized by irregular and infrequent or difficult evacuation of the bowels.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Occasional or intermittentsymptoms; occasional use ofstool softeners, laxatives,dietary modification, or enema

Persistent symptoms withregular use of laxatives orenemas; limiting instrumentalADL

Obstipation with manualevacuation indicated; limitingself care ADL

Life-threatening consequence; urgent intervention indicated

Death

Constipation

• Causes• Meds• Diet vs no diet– Prunes– Laxative Paste recipes (dried fruits and bran)– Senna Tea– Breathing Stretching– Relaxation in restroom–Water/ fluids/ hot fluids

Diarrhea

• A disorder characterized by frequent and watery bowel movements.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Increase of <4 stools per dayover baseline; mild increase inostomy output compared tobaseline

Increase of 4 - 6 stools per dayover baseline; moderateincrease in ostomy outputcompared to baseline

Increase of >=7 stools per dayover baseline; incontinence;hospitalization indicated; severeincrease in ostomy outputcompared to baseline; limitingself care ADL

Life-threatening consequence;urgent intervention indicated

Death

Radiation Induced Diarrhea

• Causes• Medication• Diet restrictions– Low fiber/ low lactose– Diet for RT to the pelvis – Fluid/ electrolyte replacements

Chemotherapy Induced Diarrhea

• Can be dose limiting• Treatment– Hydration (IV vs PO)– Electrolyte replacement– Clear liquid w progression to low insoluble fiber

with a source of soluble fiber and low lactose diet

Reference:Benson, A.B., Ajani, J.A., Catalano, R.B., Engelking, C., Kornblau, S.M., Martenson, J.A., . . . Wadler, S. (2004). Recommended guidelines for the treatment of cancer treatment-induced diarrhea. Journal of Clinical Oncology, 22, 2918–2926.

Esophagitis• Definition: A disorder characterized by

inflammation of the esophageal wall.• Causes• Medication• DietGrade 1 Grade 2 Grade 3 Grade 4 Grade 5

Asymptomatic; clinical ordiagnostic observations only;intervention not indicated

Symptomatic; alteredeating/swallowing; oralsupplements indicated

Severely alteredeating/swallowing; tube feeding,TPN or hospitalization indicated

Life-threatening consequence;urgent operative interventionindicated

Death

Neutropenia/ Avoiding Infection

• Neutropenia is defined by ONS, National Comprehensive Cancer Network and the Infectious Disease Society of America as an ANC of 500 or an ANC of 1000 which is expected to continue declining.

• Diet– Food safety– Avoiding Fresh Fruits and vegetables rated “effectiveness unlikely” by

ONS Putting Evidence into Practice database– LMD-transplant

DeMille, D., Deming, P., Lupinacci, P., & Jacobs, L. (2006). The effect of the neutropenic diet in the outpatient setting: A pilot study. Oncology Nursing Forum, 33, 337–343.

Gardner, A., Mattiuzzi, G., Faderl, S., Borthakur, G., Garcia-Manero, G., Pierce, S., & Estey E. (2008). Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. Journal of Clinical Oncology, 26, 5684–5688.

Moody, K., Finlay, J., Mancuso, C., & Charlson, M. (2006). Feasibility and safety of a pilot randomized trial of infection rate: Neutropenic diet versus standard food safety guidelines. Journal of Pediatric Hematology/Oncology, 28, 126–133.

Van Tiel, F.H., Harbers, M.M., Terporten, P.H.W., van Boxtel, R.T.C., Kessels, A.G., & Voss, G.B. (2007). Normal hospital and low-bacterial diet in patients with cytopenia after intensive chemotherapy for hematologic malignancy: A study of safety. Annals of Oncology, 18, 1080–1084.

Neutropenia/ Avoiding Infection• Non Transplant

– RDN should provide dietary counseling to neutropenic patients on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution.

– Research has not demonstrated the effectiveness of low-microbial diets.

• Transplant– In patients undergoing bone marrow transplant, the RDN should

provide dietary counseling on safe food handling and foods which may pose infectious risks during the period of neutropenia. A neutropenic diet is not necessary, but safe food counseling is recommended as a prudent precaution.

– There is conflicting research regarding the effectiveness of neutropenic diets in the bone marrow transplant population.

Reference:https://www.ons.org/practice-resources/pep/prevention-infection

Alterations of Taste and Smell

• Causes• Types

– No taste– Metallic– Bitter– Gasoline– Sweet or salty– Texture perception

• Treatment– miracle fruit/berry– Change flavor– Enhance Flavor– Rinse– Rule out zinc deficiency

Anorexia

• Determine cause/ Treat if possible– Dx/Tx– Anxiety/Depression – Eating environment

• Small Frequent Meals• Supplements– Commercial– Home made

• Nutrient Dense Foods• Physical Activity

Anorexia

• Medications– Megace– Marinol– Remeron– Periactin– Steroid– Medical Marijuana

Fatigue

• Exercise• Medication– ritalin – steroid

• Reverse malnutrition• Ensure adequate hydration• Caffeine• Complex vs simple CHO

Dry Mouth• Causes– Tx– Medications

• Diet– Moist– Tart– Hydration– Sauces

• Mouth rinses• Papaya

Heartburn/GERD

• A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Symptoms include heartburn and acid indigestion.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Mild symptoms; intervention notindicated

Moderate symptoms; medicalintervention indicated

Severe symptoms; surgicalintervention indicated

Grade not available

Grade not available

Heartburn/GERD• Bland Diet

– Avoid mint– Chocolate– Alcohol– Caffeinated beverages and decaffinated coffee (regular tea, coffee, colas, energy drinks, other caffeinated

soft drinks)– Pepper– High-fat foods, including– Any fruits or vegetables that cause symptoms. (These will vary from person to person.)

• Medication• Lifestyles changes

– Exercise at least three or four times each week.– Wear loose-fitting clothes.– Do not smoke.– Raise the head of the bed 6 to 9 inches. – Wait 3 hours after eating before lying down.– Eat in a calm, relaxed place. Sit down while you eat.

• Apple Cider Vinegar

http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=165

Dysphagia

• A disorder characterized by difficulty in swallowing

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Symptomatic, able to eatregular diet

Symptomatic and alteredeating/swallowing

Severely alteredeating/swallowing; tube feedingor TPN or hospitalizationindicated

Life-threatening consequences;urgent intervention indicated

Death

Dysphagia

• Causes• Treatment– Speech Evaluation by SLP– Diet Modification– PEG/PEJ

• Diet– Oral– Enteral

National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association; 2002.

Access to Food

• GLWD• MOW• Oncology Social Work-AOSW

SIDE EFFECTS OF TREATMENT FORM THE PATIENT PERSPECTIVE

• About 1,200 surveys were collected and analyzed from seven medical centers from April to Dec. 2012: – Roswell Park Cancer Institute – New York University Clinical Cancer Center – Dana Farber/Brigham and Women’s Cancer Center – Sidney Kimmel Comprehensive Cancer Center at Johns

Hopkins – University of Chicago Comprehensive Cancer Center – Mayo Clinic Cancer Center – Cedars-Sinai / Samuel Oschin Comprehensive Cancer Institute

• Mixed types of cancers• Most undergoing chemotherapy (90%), some

undergoing RT (15%)http://www.cancernutritionconsortium.org/wp-content/uploads/2013/11/Overview-Deck-Cancer-Nutrition-Research-11-19-13-Summary.pdf

, accessed August 11th, 2014

Resources• Oncology Nutrition Dietetic Practice Group

– Website– Listserv– RD CSO-challenging to replace the expertise of an experienced CSO (seen it all before)

• Know when too complex for private practice

• NCM• www.cookforyourlife.com• www.meals-to-heal.com• www.glwd.org• NCI-www.cancer.gov

– Eating Hints

• Cancer.org (Asian materials)• Cancer.gov• SPONC• Oley

– Equipment exchange

• www.aicr.org• www.ons.org