David Casalduero Cidón Asunción Cuenca Sánchez
Systemic anti-cancer therapy (SACT) is a type of cancer treatment that acts on cancer cells and stops their proliferation (Blows, 2005). This essay will look at nutrition, which has a major influence on the SACT patient experience. I will discuss malnutrition, which is related to a greater or lesser degree to several types of cancer treatments. I will also discuss the effects of SACT on nutritional status, the patients’ nutritional status assessment and the nurse’s role in it, how to treat this major impact of SACT and also how this problem can affect the patients’ quality of life.
Firstly I will describe the cell cycle and how SACT impacts upon it. The cell cycle is a procedure which includes mitosis (cell division) and interphase, the step between divisions (Blows, 2005). This cycle involves five stages (Figure 1).
According to Tadman (2007) cytotoxic drugs are more active on dynamically dividing cells; there are two basic types, cell cycle nonspecific that work in any phase of the cell cycle and cell cycle specific that work on specific phases of the cell cycle. Also, Gabriel (2007) proposes that it is significant to know the processes that happen in the cell cycle and in what way these drugs work on the cycle to use specific treatments against cancer.
The relationship between nutrition and cancer is twofold: on one hand, an inadequate diet may increase the chances of certain cancers and on the other hand the cancer itself and its treatments can lead to cases of malnutrition, which happens to 40-80% of the Cancer patients during the course of the disease (García-Luna et al., 2006)
Soeters et al. (2009) define malnutrition as a chronic or acute nutrition state, in which a mixture of variable levels of undernutrition and overnutrition without or with inflammatory action have led to a body composition and reduced function.
According to Nicolini et al. (2013) malnutrition, cachexia and anorexia are common among cancer patients, and more apparent with the spread and growth of the tumour. However, the processes by which they are supported frequently arise in the early stages of cancer (Nicolini et al., 2013). Advanced cancer patients commonly suffer weight loss. Between 30 and 80% of cancer patients have low weight; approximately 15% have experienced up to 10% in weight loss (Tisdale, 2009). The prevalence of malnutrition is also high, ranging between 40-80%, being higher in hospitalized patients (Isenring et al., 2006). It is estimated that about 20% of patients die because of malnutrition problems as opposed to the disease itself (Wu et al., 2009).
According to Garcia-Luna et al. (2006), anorexia and cancer cachexia are the principal causes of malnutrition related to this disease. Anorexia, according to Argiles et al. (2010) is defined as the inhibition of the eating desire, which onevitably leads to a reduced food intake. It is multifactorial in origin and may be secondary to depression, pain, constipation, intestinal obstruction, hypothalamic disorders, pro- inflammatory cytokines, side effects of treatments such as opioids, radiotherapy and chemotherapy and decrease in sharpness of taste and smell perception, which can contribute to a reduced food intake (Sanchez-Lara et al., 2001).
According to Tuca et al. (2013) cachexia is a metabolic syndrome related to a primary disease, recognised by muscle loss, with or without loss of body fat mass.
The central issue in this clinical picture is weight reduction, which is frequently related with anorexia, inflammation, increased muscle protein catabolism and insulin resistance. In cases of cancer cachexia, Fearon (2011) proposes the following diagnostic criteria:
- Weight loss of no less than 5% during the last 6 months; or
- BMI less than 20 kg/m2 and more than 2% of weight loss; or
- Appendicular skeletal muscle mass loss accompanied by sarcopenia, determined by CT scan or DEXA (bone densitometry) or BIA (bioelectrical impedance analysis) evaluation.
The cachexia prevalence varies from 40% at cancer diagnosis to 70–80% in progressive stages (Sarhill et al., 2003). The prevalence by primary tumours: 83– 85% in gastric and pancreatic cancer, 54–60% in colon, prostate and lung, 32–48% in sarcomas, leukaemia, breast and lymphomas. With colon, pancreatic stomach, breast and prostate cancer patients, chances of survival with cachexia are considerably smaller than in others (Argilés et al., 2006).
Effects of Chemotherapy on nutritional status
The onset of symptoms and their intensity depend on factors such as drug type, treatment regimen, dose, duration and concomitant therapies. While individual susceptibility of each patient influences the previous clinical and nutritional status (Garcia-Luna et al., 2006). The most toxic chemotherapeutic agents are cytostatic which, acting systemically on rapidly proliferating cells affect not only the tumour cells, also non- neoplastic cells such as bone marrow, digestive tract, hair follicle, among others (Van Cutsem, 2005). According to Nicolini et al. (2013) factors that may affect the nutritional status of the patient are numerous, including:
- Taste and smell alterations causing: decrease in savoury flavour perception, increase in sweet flavour perception and frequent occurrence of metallic taste.
- Constipation, increased by analgesic and antiemetic treatment.
- Nausea and vomiting leading to reduced food intake.
- Oropharyngeal and oesophageal mucositis causing lower intake.
- Acute enteritis causing diarrhoea and malabsorption.
- Alkylating agents such as 5FU or cisplatin can cause malabsorption by inducing direct metabolic and mucosal alteration.
The most common side effects of chemotherapy are nausea and vomiting, occurring in more than 70 % of patients, causing decreased oral intake, electrolyte imbalances, general weakness and weight loss (Shoemarker et al., 2011). Mucositis can cause severe pain and prevent or hinder oral intake (Nicolini et al., 2013). Chemotherapy- induced body composition changes have also been proven to exist (Garcia-Luna et al., 2006).
The nutritional status assessment should involve all health professionals, the nursing role being particularly important (Mantovani et al., 2010).
Various types of methods for the nutritional status assessment are used today (Table 1), which can be divided into objective and subjective methods (Barbosa-Silva, 2008).
The nutritional assessment of cancer patients should be done at an early stage as well as various stages throughout the entire process of cancer care in order to adapt to the changing needs of nutrition therapy (Barbosa-Silva, 2008). In this sense, the interdisciplinary cancer care team should establish, a programme of care that addresses the patient’s nutritional needs, including objectives in the nutritional field and the activities to be developed to achieve it (Shaw et al., 2015).
From this perspective oncology nursing professionals play a vital role as the nutritional well- being of cancer patients is a basic (and fundamental) element of their health. The threat if malnutrition therefore, has led to several methods in the nurses’ assessment of the patients’ nutritional needs. Such needs are evaluated systematically and continuously and form part of the daily practice of the healthcare professional (Mantovani et al., 2010). Some of this models used by nurses include the MST (Malnutrition Screening Tool) (Kubrak et al., 2007) and PG-SGA (Patient-Generated Subjective Global Assessment of nutritional status), they are useful tools in the cachexia and nutritional risk diagnosis. According to Tuca et al. (2013) The MST (Figure 3) is a short and simple assessment tool. The MST is less specific and has similar sensitivity than PG-SGA (Figures 4 and 5). An MST mark less than 2 identifies a risk of malnutrition and, if needed, the assessment can be accompanied with a wider nutritional valuation like the PG-SGA.
Effects of malnutrition on the effectiveness of cancer treatment
Malnutrition is also associated with a reduced response and lower tolerance to radiotherapy and chemotherapy (Garcia-Luna et al., 2006). Tumour cells kinetic slow down causing reduced sensibility to chemotherapy (Nicolini et al., 2013). Moreover, malnutrition prevents adequate tolerance to treatments, increasing its toxicity. A decrease in circulating proteins prevents proper ligation of these drugs altering their half-lives and pharmacokinetic characteristics (Capuano et al., 2009). Furthermore oxidative metabolism and reductions in glomerular filtration rate can lead to increased toxicity (Garcia-Luna et al., 2006). Thus, there is a complementarity between nutritional treatment and cancer treatments; an improved nutritional status allows for higher tolerance to chemotherapy treatments (Capuano et al., 2010).
Malnutrition and quality of life in cancer patient
Malnutrition has clear adverse effects on quality of life. The reduction in muscle mass leads to muscle weakness as well as fatigue (Lis et al., 2006).
Psychologically, it can intensify or lead to symptoms of depression (Lis et al., 2006). This poor state of health will inevitably demand a significant amount of professional medical attention, therefore increasing dependence on healthcare / healthcare professionals (assuming an increase in economic spending) and decreasing independence and quality of life (Marin et al., 2007).
Multiple studies have evaluated the effects malnutrition on cancer patients’ quality of life. Isenring et al. (2004) evaluated the effect produced by an early and intensive nutritional intervention in patients with of digestive areas, head and neck cancer when receiving treatment. They demonstrated with statistical significance a clear improvement in quality of life parameters compared to the control group. The results obtained, in accordance with multiple recent evidences have an interest forecast for the quality of life.
On the other hand, Lundholm et al. (2004) evaluated the nutritional intervention within a support program in patients with advanced malignancies. Thus, they randomized to a group of patients being treated with cyclooxygenase inhibitors and recombinant human erythropoietin against the same treatment but in combination with intensive nutritional intervention. The results in terms of overall survival and quality of life measured in relation to functional status clearly supported the group with nutritional intervention.
Davidson et al. (2004) demonstrated that weight stabilization in patients with pancreatic carcinoma was enough to get improve the quality of life as well as increase medium-term survival.
These results support an early and intensive nutritional intervention program as an adjunct therapy to specific treatments.
Malnutrition treatment is founded by three issues: nutritional support, oncological treatment and pharmacological treatment (Tuca et al., 2013).
According to Mantovani et al. (2010) nutritional support includes nutritional supplements, dietary advice and an enteral diet. It is recommended that the food be chosen in accordance with patient’s predilections and their ability to swallow, fractioned ingestion, carefully presented meals and avoiding strong aromas. Nutritional supplements increase proteins and calorie intake (Nicolini et al., 2013). A whole enteral diet can be given by PEG or NG tube in patients with dysphagia or swallowing problems. An enteral diet and nutritional supplements work if the cause of malnutrition is reduced nutrient intake.
I have discussed one major influence on the SACT patient experience, nutrition. The premature diagnosis and a detailed evaluation of nutritional state play a significant role in supporting patients with progressive cancer. It can be said that despite the different and various indicators of nutritional status assessment available, there is not yet a «Gold Standard» for nutritional status diagnosis of patients with cancer; it should be performed according to the condition of each patient, selecting in each case the method or methods that are best suited to the individual’s situation. In terms of treatment, several clinical trials have shown that short initial and appropriate nutritional support improves the vitality and the feeling of weakness tends to disappear, which helps to improve the sense of well-being of the patient. However, the beneficial effects on the quality of life of nutritional support will depend on the patient baseline state, the location and type of cancer and how advanced their disease.
Figure 1. Overview of cell division (Gabriel, 2007).
Figure 2. Physiopathology of cancer cachexia (Tuca et al., 2013)
Figure 3. Malnutrition screening tool (Tappenden et al., 2013).
Figures 4 and 5. PG-SGA scale (Fairview Health Services).
Table 1. Nutritional status assessment methods (Barbosa-Silva, 2008).
Figures-SACT and nutrition.pdf
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