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://dpgstorage.s3.amazonaws.com/ondpg/documents/9ccdd1ca724c7eee/Medicat
ion_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-andyou/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_201006-14_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
without
alteration in eating
habits
Oral intake
decreased without
significant weight
loss,
dehydration or
malnutrition
Inadequate oral
caloric or fluid
intake; tube feeding,
TPN, or
hospitalization
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
5
minutes) in 24
hrs
3 - 5 episodes
(separated by
5
minutes) in 24
hrs
>=6 episodes
(separated by
5
minutes) in 24
hrs; tube
feeding,
TPN or
hospitalization
indicated
LifeDeath
threatening
consequences;
urgent
intervention
indicated
Nausea/ Vomiting
• Causes
• Frequency
• Recommended for Practice
– Medications
– https://www.ons.org/practice-resources/pep/chemotherapyinduced-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
Asymptomati
c or mild
symptoms;
intervention
not
indicated
Moderate
pain; not
interfering
with oral
intake;
modified diet
indicated
Severe pain;
interfering
with oral
intake
LifeDeath
threatening
consequences
urgent
intervention
indicated
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
intermittent
symptoms;
occasional use
of
stool
softeners,
laxatives,
dietary
modification,
or enema
Persistent
symptoms
with
regular use of
laxatives or
enemas;
limiting
instrumental
ADL
Obstipation
with manual
evacuation
indicated;
limiting
self care ADL
Lifethreatening
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 day
over baseline;
mild increase in
ostomy output
compared to
baseline
Increase of 4 6 stools per
day
over baseline;
moderate
increase in
ostomy
output
compared to
baseline
Increase of >=7 stools
per day
over baseline;
incontinence;
hospitalization
indicated; severe
increase in ostomy
output
compared to baseline;
limiting
self care ADL
Lifethreatening
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
• Diet
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Asymptomatic;
clinical or
diagnostic
observations
only;
intervention
not indicated
Symptomatic;
altered
eating/swallow
ing; oral
supplements
indicated
Severely altered
eating/swallowi
ng; tube
feeding,
TPN or
hospitalization
indicated
Lifethreatening
consequence;
urgent
operative
intervention
indicated
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 lowbacterial 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
not
indicated
Moderate
symptoms;
medical
intervention
indicated
Severe
symptoms;
surgical
intervention
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 eat
regular diet
Symptomatic
and altered
eating/swallow
ing
Severely
altered
eating/swallow
ing; tube
feeding
or TPN or
hospitalization
indicated
Lifethreatening
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-11-19-13Summary.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)
•
•
•
•
•
•
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
–
•
•
Know when too complex for private practice
Equipment exchange
www.aicr.org
www.ons.org