Nutrition in Head & Neck Cancer

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3. Mrs. Anjali Nair
Chief Dietician
Tata Memorial Hospital
She is recepient of many awards including one from Smt Lilavati Munshi
Foundation for a project on Diet in Cancer Tube Feeding Formulation.She
has been part of research team of Food Technology Department of BARC for
developing Goods for Foods for Immuno-compromised patients and other
target groups-using radiation technology.
She has also been involved in various publications in the area of Nutrition
and Cancer and has shared her experience on practical approaches in
Nutrition and Cancer in various conferences and seminars at National and
International levels .Mrs. Nair is also involved in guiding post graduate and
research students in dessertations and has been playing a lead role in
carrying out nutrition related educational activities for Oncology &
Enterostomal Nurses along with Nutrition students.As a part of her
responsibilities at Tata Memorial Hospital , she is running many nutritional
counselling programmes for Communities-Breast/Uterine group,Head and
Neck Cancer,General Medicine and Palliative Care Patients.

4. NUTRITION IN HEAD AND NECK CANCER
Mrs. Anjali B. Nair
Chief Dietician
Tata Cancer Hospital

5. Annually, over 3,00,000 new cases of oral cancer are diagnosed all over
the world where the majority are diagnosed in the advanced stages III or
IV. Such data make the oral cancer an important public health matter
which is responsible for 3% to 10% of cancer mortality worldwide.

6. Head and neck cancer refers to a group
of biologically similar cancers
originating from the upper aero
digestive tract including lip, oral cavity,
nasal cavity, paramucosal sinuses,
pharynx, larynx, oropharynx and
Hypopharynx

7. Cancer of lip Cancer of tongue
Cancer of hard palate
Cancer of bucal mucosa
Cancer of mandible

8. An “At Risk” Population
 Alcohol use/abuse
 Tobacco use
 Up to 40% of newly diagnosed head and
neck cancer patients are malnourished.
 Malnutrition has significant impact on
morbidity, mortality and quality of life for
cancer patients
 Physicians often do not address this issue

9. Presenting Complaints
Change in voice
Change in facial appearance
Non healing ulcers
Ill-fitting dentures, loosening teeth
Lesions

10. Causes of Malnutrition
 Diminished nutrient intake
 Increased nutrient demand not matched by intake
 Tumor-induced derangements
Diminished Nutrient Intake
 Alcohol & Tobacco
 Poor dentition
 Partial or complete obstruction of aerodigestive tract
 Post-surgical functional and anatomic impairments of
chewing and swallowing
 mucositis, dysgeusia, xerostomia
 Chemotherapy-induced nausea, vomiting

11. Increased Nutrient Losses
 Vomiting
 Diarrhea
Increased Nutrient Demand
 Acute metabolic stresses caused by surgery, RT,
chemotherapy
 Duration and intensity of stresses depend on intensity and
duration of treatment as well as complications
 Tumor-induced Metabolic Abnormalities
 Abnormal metabolism of carbohydrates, lipids, and protein
 Abnormal levels of neurotransmitters leading to anorexia
 Increased basal metabolic rate
 Cytokines appear to mediate these abnormalities
 Tumor necrosis factor, IL-1, IL-6

12. Impact of Malnutrition
 Immunocompetence
Decreased cell-mediated immunity
Depressed T-cell proliferation, NKC cytotoxicity,
macrophage cytotoxicity
 Inability to tolerate antineoplastic treatments
Toxicities more severe—treatment delays, higher
costs
 Postoperative complications
Wound infection, healing—quality of life, cost

13. SWALLOWING PROBLEMS IN HEAD AND NECK CANCER.
HNCA Reduced pre-treatment swallowing function.
Reduced post-treatment swallowing function.
Surgery Chemotherapy Radiation
MALNUTRITION
Swallowing problems Worse swallowing function
&
Dysphagia Aspiration IMPAIRED
Less variety of food consistency QUALITY OF
Xerostomia Mucositis
LIFE.
Nasal regurgitation. Less nutrition through oral route

14. Treatment related complication
Surgery
Negative nitrogen balance
Inability to chew
Agluttion (inability to Chemotherapy
swallow) Nausea
Dysphagia Vomiting
Communication impairment Diarrhea
Aspiration Cheilosis
Glossitis
Radiotherapy
Pharyngitis
Mucositis Esophagitis
Xerostomia ( dry mouth) anorexia
Odynophagia ( pain in swallowing)
Dysguesia ( loss of taste)
Dental caries associated with xerostomia
Table 7.3 - Nutritional management of cancer patient

15. Clinical Manifestations of Cancer
Pain
Nutritional implication-
 Cancer Cachexia  Disturbances in water and
electrolyte metabolism.
 Anorexia
 Progressive impairment of
vital functions.
 Weight loss and
depletion
 Abnormal taste- Hypogeusia
, dysguesia
 Alteration in body
compartments
 Dysphagia

16. Macronutrient
metabolism

17. Carbohydrates
 gluconeogenesis from Acetic acid , lactate
and glycerol.
 glucose disappearance and recycling.
 Glucose intolerance
 Insulin resistance

18. Altered lipid metabolism
 Increased Lipolysis
 Increased Glycerol and fatty acid turnover.
 Lipid oxidation non – inhibited by glucose.
 Decreased lipoprotein lipase activity.
 Increase in serum lipids and fatty acids.

19. Altered Protein metabolism
 Increased Muscle Protein catabolism
 Increased whole body protein turnover
 Increased liver protein synthesis.
 Decreased muscle protein synthesis.

20. Gastrointestinal Dysfunction
Abnormalities in the mouth and the digestive tract, either as a
result of a disease or its treatment,
May interfere with food ingestion
Changes in taste and smell .
Changes in taste and smell correlate with decreased nutrient
intake, a poor response to therapy, and tumor progression,
including metastasis .
Zinc-deficiency, alterations in brain neuro-transmitters such as
NPY, that affect taste and nutrient selection .

21. Standards of care to be followed
 Early nutrition support.
 Total calorie intake should be restricted to 1500-2000
kcals/day.
 Main substrates providing calories should be
Carbohydrates and lipids.
 Protein intake determined by severity of catabolism.
 Assessment of nutritional status based on SGA.
 Enteral nutrition should be the choice.

22.  Parenteral nutrition if needed , certain
recommendation should be followed.
 Timing of nutritional support to be studied.
 Specific diseased stated may require certain
modifications.
 Immuno-nutrition
 Preventive nutritional support with primary
treatment to be considered.

23. NUTRITIONAL CARE
 Weight loss and altered nutritional status are evident in 50%
of the patient with cancer at time of diagnosis and therefore
nutritional support can improve overall patient performance
status.
 Nutrition therapy recommendation may vary throughout the
continuum of care. Maintenance of adequate intake is
important, whether the patient on active therapy, recovering
from cancer therapy or in remission and striving to avoid
cancer re-occurrence.

24. The Goals of Nutritional Therapy
c. Prevent or reverse nutritional deficiencies
d. Preserve lean body mass
e. Help patient better tolerate treatment
f. Minimize nutrition related side effects and
complication
g. Maintain strength and energy
h. Protect immune function and decrease the rush
of infection
i. Aid in recovery and healing
j. Maximize the quality of life

25. Dietary Guidelines
 Macro nutrients:
Energy: 15-20 kcals/kg PBW/day to prevent re-feeding
syndrome
25-35 kcals/kg PBW for maintenance
39-40kcals/kg PBW/day. for weight gain:
Proteins: 1-1.5gm/kg PBW/day for maintenance
1.5-2.5gm/kg PBW/day for hyper metabolic, weight gain
patients.

26.  Micronutrients
1. Sodium: hyponatrimia due to
3. SIADH.
4. Dehydration
5. Drains
2. Zinc: common deficiency, results in:
vii. decreased NK cell lytic activity and decreased
proportion of CD4+ CD45RA+ cells in the peripheral
blood.
viii.Zinc deficiency was associated with increased tumor
size, overall stage of the cancer and increased
unplanned hospitalizations
iii. Zinc deficiency resulted in an imbalance of TH1 and
TH2 functions. AJCN (Vol. 17, No. 5, 409-418 (1998 )

27.  Water: 30-40ml/kg PBW/day
2. Prevent dehydration
3. Prevent respiratory distress due to drying of
secretions.
 Arginine: (controversial)
Shown to increases fistula and wound complications
 Glutamine:
9. Decreases the risk and severity of stomatitis
10. Helps in wound healing after surgery
11. Reduced the side effects of chemo drugs like
doxorubicin etc.
Contraindicated: shown to stimulate growth of
cancer cells.

28. Symptoms Dietary intervention
Anorexia Frequent small quantity and variation in
meals
Nutritious snacks and drinks between meals
Supplementation of high calorie and
proteins
Nausea Avoid cooking smell and food with strong
odors
Have dry meals with drinks taken
separately
Biscuits, dry toast and cold foods
Avoid very sweet and fatly foods

29. Symptom Dietary intervention
s
Difficulty Small frequent feed with soft and
in liquid diets with nutritious drinks after
swallowin food
g
(Dysphasi
a)
Altered Avoid food that worsen the unpleasant
taste taste mainly because of zinc deficiency

30. Sympto Dietary intervention
ms
Dry Eat moist foods with extra sauces,
butter or margarine and avoid liquids
Mouth and food that contain lots of sugars and
dry fruit nectar instead of juice
Mouth Eat foods that are easy to chew and
swallow with cool temperature and soft
sores fruits like bananas stewed apple and
peach, cottage cheese, mashed potatoes,
scramble eggs, cooked cereals, and milk
shakes

31. Few Considerations
 Strategies for modifying nutrient intake depend on
specific feeding problem and the extent of
depletion.
 Oral route is preferred mode of feeding but may be
resisted by patient experiencing nausea , altered
sensation and dysphagia.
 In patients with head and neck cancer the cancer
lesions in the oral cavity makes difficult to
consume food orally.

32.  Dysphagia due to oral lesions can be lessened with
intake of soft and liquefied foods served at moderate
and room temperature.
 Patients with Xerostomia should be encouraged to
have plenty of fluids(25-30ml/kgbdwt) and eat moist
foods with extra gravies and butter.
 Patients with chemotherapy complain of decreased
ability to eat as the day progresses. Thus morning can
be the best time for eating.
 This is an attribute to sluggish digestion and gastric
emptying as a result of GI mucosal atrophy and gastric
muscle atrophy

33. Approach to Nutrition Support
PRETREATMENT-Nutrition Moderately or severely
screening, History( weight loss), malnourished
Physical examination( BMI) ,
Lab studies(Serum albumin)
Aggressive nutritional
support
Malnourished
Is GI tract
functional
Is therapy YES NO
intensive
NO Oral supp or Parenteral
Enteral tube nutrition
Oral supplements
feeding

34. ROUTES OF FEEDING

35. SELECTION OF FORMULA
 Functional capacity of gut
 Intubations site
 Patient's metabolic status
 Cost
 Convenience considerations

36. COMPARISION BETWEEN PRODUCTS
RESOURCE HIGH PROTEIN ACTIBASE NEUTRAL
(100gms) (100gms)
ENE 374kcals 338 kcals
PRO 41gms 45 gms
Na 500mg 360mg
K 800mg 546mg
Cost Rs 215 Rs 240

37. Case Studies

38. MRS RKT 43 YR/F
CA UPPER LIP --- T4 N0 M0 STAGE IV
COMPLAINED OF SWELLING IN UPPER LIP
ADMITTED TO TMH---24/5/10
DIAG: SPINDLE CELL CARCINOMA
BIOCHEMICAL NORMAL EXCEPT FOR Na
OPERATED ON 31/5/10
PT ON RT FEEDS SINCE 1/6/10

39. HT: 151CMS
WEIGHT: 60KGS
BMI:26KG/M2
GRADE I OBESE
ENERGY: 30X46(IBW)=1380
+STRESS FACTOR=1450KCALS
PROTEINS: 1.5 GM/KG IBW=69GMS
CHO:65%=227 GMS
FAT:22%=34 GMS

40. HOSPITAL DIET
DAY1(1/6) DAY2(2/6) DAY3(3/6)
ENERGY 432 906 1157
PROT 7.2 27.1 48.2
FATS 9 20.7 21.6
CHO 75 128 125
Na 134 128 143
GIVEN 1GM
SALT
REMARKS SEVERELY NAUSEA INTAKE
NAUSEATED REDUCED IMPROVED
WITH FEELING

41. PT DISCHARGED ON 4/6/10
ON RT FEEDS+ORAL LIQUIDS ON ACTIBASE
NEUTRAL
WEIGHT MAINTAINED SO CONTINUED WITH
SAME DIET.

42. MRS.SINGH 40/ F
CA LATERAL BORDER OF TONGUE—T3NOMO
SYMP: PAIN WHILE EATING FOOD
ADMITTED TO TMH 27/4/10
BIOCHEMICAL NORMAL EXCEPT FOR FLUCTUATING Na
OPERATED ON 31/5/10
RT FEEDS STARTED ON 1/6/10

43. HT: 161 CMS
WEIGHT:82KG
BMI:31.66KG/M2
GRADE II OBESE
ENERGY:25KCALS/KG= 1400
PROTEINS: 1.3GM/KG= 73 GMS
CHO 65%= 228GMS
FATS 15%= 23 GMS

44. HOSPITAL DIET
DAY1(1/6) DAY2(2/6) DAY3(3/6)
ENERGY 554 1278 1541
PROT 32.6 68 72
FATS 20 38.5 44
CHO 57 141 171
Na 134 -- 134
REMARKS ½ RT FEEDS COCONUT INTAKE
AS WATER=SWE PROPER
NAUSEATED ETLIME JUICE
SO LESS OF

45.  LOW HB WAS BEFORE SURGERY 10GMS(25/5)
 3/6: HB FURTHER REDUCED TO 9.70GMS DUE
TO BLOOD LOSS DURING SURGERY
DISCHARGED ON SAME DIET WITH ADDITION OF
RAGI PORRIDGE AND ½ BOILED EGG ADDED TO
THE RT FEEDS

46. Conclusion
 Head and neck cancer and disease induced dysphagia can
adversely affect a patient’s ability to eat and thus its QOL.
 Dysphagia has serious emotional and social consequences.The
inability to participate in eating , one of the life’s most social
occasion generates a lot of frustration , anxiety and depression.
 Quality of life assessment is important for patients with neoplasm
of head and neck.
 Apart from the treatment modalities, the type of cancer carries a
significant influence on the physical , functional , social ,
emotional and a global wellbeing of the patients.

47. Questions & Answers
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48. Closing Remarks