Case Study #33 Esophageal Cancer Lynne Roller and Teresa Schwendler What is cancer? Cancer is a class of diseases characterized by uncontrolled cell division and the ability of these cells to invade other tissues-either by direct growth to adjacent tissue(invasion) or by migration of cells to distant sites(metastasis) Esophageal Cancer Esophageal Cancer Form 1: Adenocarcinoma (AC) Form 2: Squamous cell carcinoma(SCC) Etiology For Esophageal Cancer Smoking Alcohol abuse Obesity Having bile reflux Eating few fruits and vegetables Having gastro-esophageal reflux disease Being male and between the ages of 45-70 Cancer Identification Procedures Cytologic test Physical test Biochemical test Description of Patient ● ● ● ● ● Nick Seyer, 58 y.o. male contractor Diagnosed with Stage IIB adenocarcinoma of the esophagus. Experiencing Dysphagia and Odynophagia Smokes 2ppd; wife also smokes Alcohol use: 1-2 drinks 1-2 x/week Mr. Sayer’s History • • • • • • • • • • • Height: 6’3” Weight: 198lbs. BMI: 24.9 %UBW: 87% Recent weight loss of 30lbs over the past few months 14% weight loss = severe weight loss Energy Requirements to maintain weight: 1796kcal/day Energy Requirements to gain weight: 2700kcal/day Protein Requirements: 135g/day Fluid Requirements to maintain weight: 1796mL/day Fluid Requirements to gain weight: 2700mL/day Mr. Seyer’s Disease measures Chemistry Normal Value Mr. Seyer’s Value Reason for Abnormality Nutritional Implications Total Protein 6-8 5.7 Inadequate Protein intake Increase protein intake Albumin 3.5-5 3.1/3.0 Inadequate protein intake, dehydration Increase protein intake, rehydrate Prealbumin 16-35 15/12 Inadequate protein intake Increase protein intake RBC 4.5-6.2 4.2/4.3 Malabsorption/side effect of cancer Increase iron, B12, folate Hemoglobin 14-17 13.5/13.9 Low RBC due to cancer Increase iron, B12, folate Hematocrit 40-54 38 Decreased RBC Increase iron, B12, folate Mean cell Hgb 26-32 32.4/32.3 Low RBC Increase iron, B12 Mr. Sayer’s Diagnosis Inadequate Protein intake Inadequate energy intake Difficulty swallowing Severe weight loss- Cachexia Current Treatment Medical External Beam Radiation Therapy Surgery- surgical resection of tumor- transhiatal esophagectomy Nutrition Enteral Nutrition-Isosource HN Increased calories and protein intake Esophogectomy Medical Treatment Isosource HN Enteral Formula kcal/mL: 1.2 Caloric Distribution (% of kcal) Protein: 18% Carbohydrate: 53% Fat: 29% Protein Source: soy protein isolate NPC:N Ratio: 115:1 MCT:LCT Ratio: 20:80 n6:n3 Ratio: 2.7:1 Osmolality (mOsm/kg water): 490 Water 82% Enteral Nutrition Comparison to Mr. Seyer’s Estimated Nutrition Requirements Value from I/O chart Rate of 60.24mL/hr mL/hr. Total of Enteral 1.7 L Formula for day Total Calories for 2,082 kcal day Total 90.1g Protein Currently Receiving To maintain weight (REE with PAL factor of 1.3) To gain weight (using 30kcals/kg) 75mL/hr 81 mL/hr 94 mL/hr 1.8 L 2L 2.25 L 2,160 kcals 2,335kcals 2,700 kcals 95.4g 103 g 119g Protein needed for Cancer Patient (1.5g/ kg) 135g PES Malnutrition (NI-5.2) related to insufficient enteral nutrition recommendations as evidence by weight loss of over 30 pounds in a two month period and signs of cachexia Inadequate protein energy intake (NI-5.7.3) related to metabolic abnormality due to cancerous state as evidence by Estimated protein intake higher than recommended prescribed enteral nutrition therapy. Goals Talk with other members of the nutrition care team about the current amount of enteral nutrition that Mr. Seyer is receiving . Increase Mr. Seyer’s daily protein intake, via enteral nutrition, to 135g and increasing calories to 2,700kcals Intervention Increase enteral protein intake to 135g per day. Increase total energy intake to 2700kcal/day in order to gain weight. Monitoring and Evaluation Monitor anthropometrics to track weight gain. Monitor biochemical data- track protein Subjective Global Assessment- gauges the patient’s perception of their ability to accomplish self-care. True or False? When people have surgery to remove their cancer they often also have chemotherapy before to reduce the size of the tumor and after to treat local areas of reoccurrence? When people who have cancer start eating again sometimes they have aversions to eating certain foods? Enteral nutrition is always suggested for terminally ill cancer patients? True or False? When people have surgery to remove their cancer they often also have chemotherapy before to reduce the size of the tumor and after to treat local areas of reoccurrence?(T) When people who have cancer start eating again sometimes they have aversions to eating certain foods? (T) Resources Jager-Wittenaar, H;Dijkstra PU; Vissink A. “Changes in nutritional status and dietary intake during and after head and neck cancer treatment.” http://www.ncbi.nlm.nih.gov/pubmed/20737491 Mayo Clinic (n.d.). Chemotherapy - MayoClinic.com. Retrieved May 5, 2011, from http://www.mayoclinic.com/health/chemotherapy/MY00536 Mayo Clinic (2011, May). Esophageal cancer: Treatments and drugs - MayoClinic.com, from http://www.mayoclinic.com/health/esophagealcancer/DS00500/DSECTION=treatments-and-drugs National Cancer Institute (2012, November 1). When Someone You Love Has Advanced Cancer - National Cancer Institute. Retrieved from http://www.cancer.gov/cancertopics/coping/when-someone-you-love-hasadvanced-cancer/page4 National Institutes of Health (2013). Esophageal cancer - National Library of Medicine PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001328/ Nelms, Marcia; Sucher, Kathryn; Lacey, Karen; Roth, Sara Long. Nutrition Therapy and Pathophysiology.2/e