The Cancer Nutrition Network for
Texans presents:
Creating Cancer Care Teams:
A workshop for Cancer Patients
and their Family Caregivers
The CNNT is funded by the University of Texas Medical Branch and the Texas Cancer Council Contract # 08-94
Information for Patients
Your Survivorship Journey
Objectives
Patient and Caregiver will:
• Name the common cancer therapies
• Explain the importance of nutrition
during your survivorship journey
• Identify several symptom management
techniques
• Describe the importance of exercise
and physical activity
The diagnosis of cancer.
• You’re not alone – 84,530 Texans are
diagnosed each year with cancer.
• It’s not a death sentence – 9.5 million people
in the US are cancer survivors.
• Strong emotions are normal – help, helps.
• Be informed – understand your diagnosis, your
treatment, ask questions.
Common Cancer Therapies
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Surgery
Radiation
Chemotherapy
Immunotherapy
Complementary and
alternative therapy
• These can be used as
single mechanisms.
• Commonly these are
used in combinations.
• Often additional therapy,
adjuvant, is also possible
– e.g., tamoxifen for early
stage breast cancer.
• All produce side-effects!
Managing Side Effects
That Impair Nutrition
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Nausea
Vomiting
Diarrhea
Constipation
Mouth Sores
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Swallowing
Early Satiety
Loss of Appetite
Change in tastes
Sensitivity to smells
Nutrition and Cancer
• Nutrition (key nutrients)
– Vitamins, minerals, protein, calories,
carbohydrates, fat and water
• Treatment causes symptoms that may
interfere with nutrition
• Treatment also may affect other senses
that interfere with nutrition
Nutrition Advice during
Treatment
The diet is an important
part of cancer treatment.
Eating the right kinds of
foods before, during, and
after treatment can help
the patient feel better and
stay stronger. To ensure
proper nutrition, a person
has to eat and drink
enough of the foods that
contain key nutrients
(vitamins, minerals,
protein, carbohydrates, fat,
and water).
Treatment Symptoms
For many patients, some side effects of
cancer and cancer treatments make it
difficult to eat well. Symptoms that
interfere with eating include nausea,
vomiting, diarrhea, constipation, mouth
sores, trouble with swallowing and pain.
Appetite, taste, smell, and the ability to eat
enough food or absorb the nutrients from
food may be affected.
Important Nutrition Fact
Malnutrition (lack of key nutrients) can
result, causing the patient to be weak,
tired, and unable to resist infections or
withstand cancer therapies. Eating too
little protein and calories is the most
common nutrition problem facing many
cancer patients. Protein and calories are
important for healing, fighting infection,
and providing energy.
Special Concerns
Hydration
Although a good rule of thumb is to drink 8 glasses of water per day,
proper hydration helps flush toxins. You should drink 1/2 ounce of water
for each pound of your body weight. For example, if you weigh 150
pounds, you should drink 75 ounces or about nine 8 ounce glasses a day.
Supplement drinks and bars
Supplements - are intended as “occasional” substitutes and should be
selected carefully:
• Bars should be well-balanced with equal portions of carbs, proteins, and
sugars
• Bars should provide 3 to 5 grams fiber
• Bar fortified but does not oversupply Recommended Daily Allowance of
vitamins & minerals (~35%)
• Bar supplies no more than 150 calories per serving
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Vitamin and mineral supplements
Herbal preparations – biologically active
Myths and realities – symptoms
Habits – junk foods, alcohol and smoking
Comorbidity
Herbal Preparations
• Be cautious as they can interfere with
treatment and/or produce side-effects
• Method of preparation can determine
effectiveness
• Not regulated by FDA, so need to be careful
with selection
• Recommend taking bottles in to family
physician/oncologist
• Avoid during protected period
• Antioxidants – can repair the cellular oxidative
damage to cancer cells caused by treatments
such as radiotherapy and chemotherapy
Managing Side Effects
That Impair Physical Function
Lymphedema
• Swelling due to localized fluid build up
• Caused by damage or removal of the lymphatic tree
– Most notably in breast cancer due to nodal dissection
• Lymphatic system
– Often referred to as the body's "second" circulatory
system
– Collects and filters the interstitial fluids
• May develop months or even years after therapy has
concluded
• Lower-limb lymphedema have been associated with the use
of Tamoxifen
Lymphedema:
Symptoms & Complications
• Heavy, swollen limb or localized fluid accumulation
– Stagnant, protein-rich fluid causes tissue channels to
increase in size & number - reducing the availability of
oxygen
• Discoloration of the skin overlying the lymphedema
– Impaired wound healing due to lack of oxygen/nutients
– Bacterial growth can result in infections: cellulitis,
lymphangitis, lymphadenitis, and in severe cases, skin
ulcers
• Eventually deformity (elephantiasis)
– Infections common and recurrent, in addition to their
inherent danger, further damage the lymphatic system
and set up a vicious circle
Lymphedema:
Staging & Grading
Stage 0 (latent): Transport capacity is
still sufficient for the amount of
lymph being removed. No
lymphedema.
Stage 1 (spontaneously reversible):
Tissue is still at the "pitting" stage.
Usually upon waking in the morning,
the limb or affected area is normal or
almost normal in size.
Stage 2 (spontaneously irreversible):
The tissue now has a spongy
consistency and is "non pitting".
Fibrosis - hardening of the limbs and
increasing size begin to persist.
Stage 3 (lymphostatic elephantiasis):
At this stage, the swelling is
irreversible and usually the limb(s) or
affected area is very large. The tissue
is hard (fibrotic) and unresponsive.
Grade 1 (mild edema): Lymphedema is in
distal parts of the affected area. The
difference in circumference is less than 4
centimeters – no other tissue changes are
present.
Grade 2 (moderate edema): Lymphedema
involves whole area. Difference in
circumference is more than 4 but less
than 6 centimeters. Tissue changes, such
as pitting, are apparent.
Grade 3 (severe edema): Lymphedema is
present in one limb. The difference in
circumference is greater than 6
centimeters. Significant skin alterations.
Grade 4 (gigantic edema): Also known as
elephantiasis where affected extremities
are huge due to almost complete
blockage of the lymph channels.
Lymphedema:
Keys to Comfort
Manage your risks:
• Adequate diet - protein rich
• Proper weight
– Within normal BMI range
• Be physically active
• Manage other conditions
– diabetes, hypertension,
kidney or heart disease, or
phlebitis (inflammation of
the veins)
• Drugs – generally not helpful
and may harm
– Avoid antibiotics, diuretics &
anticoagulants
Manage your treatments:
• Physical Manipulation
– Support the arm or leg in a
raised position.
– Manual lymphatic drainage
(a specialized form of very
light massage that helps to
move fluid from the end of
the limb to the body).
– Wear compression
garments that are customfitted and apply controlled
pressure around the
affected limb.
– TENS for pain
Neuropathy
• Usually short for peripheral neuropathy
• Mainly affects the feet and legs
• Common in cancer
– Direct result of the cancer on peripheral
nerves (e.g., compression by a tumor),
– Side effect of many chemotherapy drugs
– Electrical energy damage of radiation
• Results in tingling, numbness, or pain
Neuropathy Treatment
• Prevention – vigilance, avoidance, assistive
devices
• Drugs – alone or in combinations
– opioid analgesics such as morphine, codeine,
heroin, oxycodone or methadone
– tricyclic antidepressants such as amitriptyline
(Elavil®)
– anticonvulsants such as gabapentin (Neurontin®),
pregabalin (Lyrica®), or carbamazepine
(Tegretol®) and oxcarbazepine (Trileptal®),
Myths and Realities
• Habits – lifestyle affects prevention, treatment, and
survivorship
•Balanced diet will maximize treatment, minimize
symptoms, and increase survivorship
•Smoking – Don’t do it
•Alcohol – Intake should be moderate if not avoided.
Advice should be tailored to cancer type, stage,
treatment, risk factors and comorbidities.
General Principles
• Maintain energy balance
(functionality)
• Prevent excessive weight
changes (loss)
• Plan ahead is important
(nutritionist/dietician)
• What is your current
nutritional status? (differs
from prevention)
• Normal dietary consumption
is the best means for
acquiring adequate nutrition!
Exercise and
Physical Activity
• Studies show that
physical activity helps:
Exercise as frequently as possible
and it will enhance physical and
functional well-being as well as
improve your overall quality of life.
– Energy Balance
– Appetite - expenditure of
calories help increase
appetite
– Muscle Mass –
sometimes affected
adversely by treatments
– Vitality & emotional
balance
– Symptom Management
Exercise and
Physical Activity
Individualize your physical activity to your personal
preferences and condition.
• Assess your condition – begin at lower intensity and progress at
slower pace if undergoing active therapy
• Pay careful attention to balance to reduce injuries - Exercise
in the presence of a caregiver or exercise professional (helpful if they
have special training or certification) (Tip: Request a Physical Therapy
referral)
• Take into consideration other issues such as arthritis or
peripheral neuropathies
• If you exercised prior to diagnosis you should maintain as
much activity as possible.
• Always inform physician about your exercise program
ACS Recommendations for
Increasing Physical Activity
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Use stairs instead of elevator
If you can, walk or bike instead of drive
Exercise with your family, friends, and coworkers.
Plan active vacations instead of driving trips
Take an exercise break to stretch or take a quick walk.
Use a stationary bicycle while watching TV
Plan your exercise routine to gradually increase days per
week and minutes per session.
Warnings and Cautions
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Survivors:
– with severe anemia should delay exercise, other than activities of daily living,
until the anemia is improved: minimum of 10 micro-deciliters
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with compromised immune function should avoid public gyms and other public places until their
white blood cell counts return to safe levels. Survivors who have completed a bone marrow
transplant are usually advised to avoid exposure to public places with risk for microbial
contamination, such as gyms, for 1 year after transplantation.
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suffering from severe fatigue (physical rather than emotional) - from their therapy may not feel up
to an exercise program, so they may be encouraged to do 10 minutes of stretching exercises daily.
A good guideline for determining fatigue is shortness of breath after common daily activities (test –
if after walking 10 feet, patient has shortness of breath- they have severe fatigue)
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undergoing radiation should avoid chlorine exposure to irradiated skin (eg, swimming pools).
Patients with inflammatory responses or lesions – bad sunburn, puffiness, cracked skin should
also avoid chlorine and other skin irritants.
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with indwelling catheters should avoid water or other microbial exposures that may result in
infections as well as resistance training of muscles in the area of the catheter to avoid dislodgment.
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with significant peripheral neuropathies may have a reduced ability to perform exercises that use
the affected limbs because of weakness or loss of balance. They may do better with a stationary
reclining bicycle. For example: patients will know if they are experiencing peripheral neuropathy (if
it’s numb, hurts, and they experience loss of control)
Tips for Energy Conservation
It may seem odd to be
encouraged to exercise
in one sentence, and
encouraged to conserve
your energy in the next.
The idea is to achieve
an appropriate energy
balance.
Tips for Energy Conservation
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Sit to bathe and dry off (wear a robe)
Install grab rails in shower
Organize to avoid rushing
Stop working before becoming tired
Use easy to prepare foods/prepare
double and freeze extra
• Delegate chores when possible
Complementary and
Alternative Medicine
Remember: Dietary supplements can be marketed without proof
of safety or effectiveness, likewise anyone can publish on
internet. Be sure to research complementary and alternative
medicine thoroughly, as well as being careful to research
information providers well.
• Reputable information sites:
– http://cam.utmb.edu/default.asp
– www.nccam.nih.gov
– www.mdanderson.org/departments/CIMER
• Caution – Health food stores - beware of advice from
employees. They may mean well, but not qualified to act as a
physician and will not understand the degree/components of the
individualized treatment (or the combination of co-morbidities)
For more information please visit us as:
www.utmb.edu/nsights