Accepted Manuscript Nutrition, Metabolism, And Integrative Approaches In Cancer Victor Sierpina , MD, Lyuba Levine , MD, Juliet McKee , MD, Christina Campbell , RD, PA, Sungmi Lian , MD, Moshe Frenkel , MD PII:
S0749-2081(14)00091-6
DOI:
10.1016/j.soncn.2014.11.005
Reference:
YSONU 50675
To appear in:
Seminars in Oncology Nursing
Please cite this article as: Sierpina V, Levine L, McKee J, Campbell C, Lian S, Frenkel M, Nutrition, Metabolism, And Integrative Approaches In Cancer, Seminars in Oncology Nursing (2015), doi: 10.1016/ j.soncn.2014.11.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT NUTRITION, METABOLISM, AND INTEGRATIVE APPROACHES IN CANCER
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Sierpina Victor1, Levine Lyuba2, McKee Juliet3, Campbell Christina4, Lian Sungmi5, Frenkel Moshe6
AUTHORS:
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2. Lyuba Levine, MD Associate Professor EV Hannigan Distinguished Chair Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of Texas Medical Branch Galveston, TX 77555-0587 (832) 505-1910 [email protected]
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1. Victor S. Sierpina, MD WD and Laura Nell Nicholson Family Professor of Integrative Medicine Professor, Family Medicine University of Texas Distinguished Teaching Professor 301 University University of Texas Medical Branch Galveston, TX 77555-1123 409-772-3126 [email protected] [Corresponding author]
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3. Julie McKee, MD Associate Professor of Family Medicine UTMB Distinguished Teaching Professor Department of Family Medicine 301 University University of Texas Medical Branch Galveston, TX 77555-1123 409-772-3126 [email protected] 4. Christina Campbell, RD, PA 361-728-5816 [email protected] 1
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6. Moshe Frenkel MD Clinical Associate Professor University of Texas Medical Branch Director of Integrative Oncology Service Institute of Oncology Meir Medical Center Kfar Saba, Israel [email protected]
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5. Sungmi Lian, MD Hospitalist Harrison Medical Center Bremerton, WA 98310(907)223-3690 [email protected]
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ACCEPTED MANUSCRIPT ABSTRACT:
Objectives: To review emerging issues about metabolic changes occurring in cancer survivors during and as a result of therapy, the role of nutrition, weight control, stress management, nutritional supplements and other
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complementary diet therapies, methods of mitigating side effects of treatment affecting dietary intake, and to suggest future research directions.
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Data Sources: Literature review and professional clinical experience with oncology patients.
Conclusion: Enhancing cancer survivorship requires knowledge and application of nutritional science and
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integrative healthcare approaches
Implications for Nursing Practice: Reliable, personalized, team-generated nutritional advice must be provided to cancer patients and cancer survivors to reduce risk of recurrence, optimize energy balance, and improve quality of life.
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complementary cancer therapies
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Key Words: Nutrition, energy balance, dietary supplements, mind-body therapies, integrative oncology,
The role of nutrition in cancer has always been controversial. Do certain foods prevent cancer, cause it,
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or help prevent recurrence? Of course, unexplained weight loss always raises the specter of cancer or recurrence. What is less recognized is that obesity, both before and as a result of cancer treatment, is a significant risk for cancer and its recurrence. In this context, metabolic changes affecting the way the body handles insulin, energy, and fat metabolism are emerging concerns for cancer patients. Therapeutic challenges include fatigue, anorexia, dysgeusia, mucositis, and other afflictions limiting nutritional intake.
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ACCEPTED MANUSCRIPT The clinical team may struggle to develop dietary and exercise strategies for cancer patients and survivors to optimize their caloric intake and absorption to maintain weight, or in some cases to reduce it. Stress raises cortisol levels, affects our dietary habits, changes our hormonal milieu, and reduces immunity. Managing stress through mind body practices is another interdisciplinary intervention to manage the risk profile in cancer care.
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Complementary therapies and nutritional supplements offer additional layers of patient-centered interventions that embrace the potent impact of nutrition and diet in cancer therapy and survivorship.
In this review, we synopsize the key issues related to these topics, linking them to evidence-based
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practices and future research directions. This will support nurses and other clinicians as they offer counsel to cancer patients and survivors related to optimizing their nutritional status, survivorship chances, and overall
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well-being.
Americans are more likely to survive after a cancer diagnosis today than ever before. About 14.5 Million Americans are alive after being told they have cancer and 2 out of 3 of these will be alive for 5 years or longer after cancer diagnosis. It is estimated that 1,665,540 US citizens will be diagnosed with cancer in 2014 and,
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because many of these diagnoses occur in those who are 65 and older, there will be a rapid increase in the number of new cases diagnosed due to a large proportion of an aging population. (1)
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Cancer arises when control of cell death is lost. Some cancers are due to inherited genetic mutations but only a small percentage of these are responsible for new or recurrent cancer. In the majority of cases, interaction
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between cancer cells and their environment is responsible for cancer progression. Most of these factors that change tumor microenvironment are related to lifestyle. A significant number of cancers are preventable; the greatest example being cancers related to tobacco use. Other factors that have been associated with higher incidence of cancer are lack of physical activity, obesity, non-participation in prevention programs, and overexposure to ultraviolet light. Cancer survivors are at greater risk for developing other diseases and secondary cancers. It has been documented that cancer patients die at a higher rate than people in the general population from non-cancer 4
ACCEPTED MANUSCRIPT causes. Those with a consistent primary care provider who tends to these non-cancer problems experience longer and better quality of life in general. The decrease in functional status and increase in disability that result from cancer and its treatment are of significant concern. Cancer survivors have an almost 2-fold increase in having at least one functional limitation. [2,3]
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The presence of comorbidities, in addition to cancer history, is associated with impaired functional status. The presence of another comorbid condition increases the chance of dying from non-cancer-related causes.
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ENERGY BALANCE, METABOLISM, INSULIN RESISTANCE IN CANCER
In the western world, there has been a marked increase in obesity during the past several decades. Obesity
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has been associated with higher risk in developing cancer of the esophagus, breast (especially postmenopausal), endometrium, colon and rectum, kidneys, pancreas, thyroid, gall bladder and possibly other cancers. Obesity and weight gain have been established as negative prognostic risk factors in cancer patients because body fat is an important source of growth hormones. The relationship between obesity and incidence of cancer is a consistent association found in multiple epidemiologic studies. The fact that cancer incidence is
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lower after bariatric surgery further supports this association. Since many cancer survivors, especially those with breast, endometrial and colon cancers, are at increased
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risk for weight gain, decreasing body fat is becoming a priority in this population. Obesity, inactivity and poor dietary quality are linked to decreased overall survival. Based on a large US prevention study, obesity is linked
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to 20% of all cancer deaths in women and 14% cancer deaths in men [2] Obesity is defined as presence of highly disproportionate and unhealthy amount of body adipose tissue. One of the measures of obesity is Body Mass Index (BMI). Normal BMI is 18.5 to 24.9; a BMI of 25 to 29.9 is considered overweight. Those with a BMI of 30 and more are considered obese. Diet, physical activity and overall weight are considered as energy balance factors. When energy consumption exceeds energy expended, energy will get stored.
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ACCEPTED MANUSCRIPT Multiple studies have shown an association between obesity and development of postmenopausal breast cancer. The relationship is even stronger in women who were never treated with hormone replacement therapy. [2, 4] The relationship between obesity and increased incidence in post-menopausal breast cancer is most likely
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due to increased level of estrogens in post-menopausal women since the amount of hormones produced by ovaries dramatically declines and adipose tissue becomes a most important source of circulating estrogens. Data from the pooled analysis of nine prospective studies, the Endogenous Hormones and Breast Cancer
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Collaborative Group (EHBCCG)[5], and the European Prospective Investigation into Cancer and Nutrition (EPIC) study[6], demonstrated that postmenopausal breast cancer risk is increased in women with higher levels
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of circulating sex steroids. The association of BMI with postmenopausal breast cancer risk was almost entirely attributed to elevated levels of estradiol with increased BMI. This phenomenon is due to the fact that adipose cells have aromatase, an enzyme that converts precursor androgens into estrogens. The more adipose tissue women have, the higher is the level of circulating hormones.
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Obesity is associated with up to 30-fold increase risk of endometrial cancer regardless of menopausal status. In the case of endometrial cancer, increased level of circulating estradiol not only increases endometrial call proliferation and inhibits apoptosis, but also stimulates local synthesis of insulin-like growth factor (IGF-I).
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Circulating insulin levels and increased concentration of IGF hormones is associated with increased BMI[7, 8].
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IGF-I activates various intracellular pathways that are linked to inflammation and have mitogenic, antiapoptotic and pro-angiogenic effect [7]. Meta-analyses support the relationship between total IGF-I and risks for colorectal, prostate, endometrial, pre-menopausal breast and to a lesser extend post-menopausal breast cancers [9, 10].
Obesity is associated with a chronic inflammatory state characterized by abnormal cytokine production. As a result, there is an increase in synthesis of pro-inflammatory reactants such as C-reactive protein and activation of macrophages. Activated macrophages produce many pro-inflammatory factors. Subclinical, low6
ACCEPTED MANUSCRIPT grade chronic inflammatory state is important in development of insulin resistance, type 2 diabetes and several other chronic conditions. Adipokines are considered to be key mediators linking obesity and chronic inflammation. Adiponectin, the most abundant adipokine, is secreted mainly from visceral adipose cells and is an important insulin-sensitizing
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agent.
High BMI is associated with decreased levels of circulating adiponectin. This is one of the possible mechanisms of increased insulin resistance in obese individuals, especially in those with larger proportion of
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visceral adipose tissue. Low circulating levels of adiponectin have been associated with increased incidence of
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malignant transformation including endometrial, breast, prostate and colorectal cancers Obesity has a complex, multi-system physiology and its association with cancer is multifactorial. The mechanisms discussed above associating cancer and obesity are currently supported by multiple studies. Undoubtedly, there are additional mechanisms linking obesity to cancer and there is evidence that physical
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activity might influence cancer development and progression. NUTRITION AND DIET IN CANCER
Improving health while being treated for cancer or as a cancer survivor is a difficult challenge due to many
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factors, secondary disabilities, effects of treatment, and altered metabolism. Meeting nutritional needs and achieving ideal activity levels are important aspects to the recovery process. As cancer survivors prepare for the
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successful completion of therapy and start to pursue self-care strategies, informed lifestyle choices are necessary to improve their long-term outcomes. Diet, exercise, and weight management can help prevent recurrence, additional primary cancers, and other chronic diseases. When researching diet options, cancer survivors may encounter ambiguity or feel overwhelmed by the plethora of misinformation. They are often advised on which foods to eat, which to avoid, how to exercise, and which supplements to take, not always well founded [11]. 7
ACCEPTED MANUSCRIPT Cancer causes profound metabolic and physiological changes that can affect the requirements for macro- and micro-nutrients. Chemotherapy, targeted and precision agents, radiation treatments, and surgery can significantly affect nutritional needs, modify regular eating habits, and interfere with the ability to digest, absorb, and utilize food [12]. It is imperative that a nutritional assessment be started as soon as possible after
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diagnosis and focus on both current nutritional status and anticipated nutrition-related symptoms [13]. This can be done by any member of the healthcare team with a background, training, and interest in nutrition. Certainly, this can be a nurse, nurse practitioner, dietician, or physician, and often is aided by strategic questionnaires and
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diet diaries. Essentials in the diet history should include quantity and quality of the different food groups with particular attention to appropriate calories, sources of carbohydrates (low vs high glycemic), proteins, and types
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of fats. Daily meal patterns, frequency of fast food use, shopping and home cooking habits are all essential snapshots of patient dietary assessment. A 24-hour recall gives a fairly reliable sample that likely reflects a patient’s usual habits.
After cancer treatment, weight change should be managed with a combination of diet, physical activity, and
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behavioral strategies. Protein, carbohydrate, and fat all contribute energy to the diet, and each of these components is available from a wide variety of foods. Because cancer survivors are at increased risk for other chronic diseases, the recommended amounts and types of fat, protein, and carbohydrate to reduce the risk of
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body weight [14, 15].
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cardiovascular disease are also applicable to cancer survivors, particularly if they are above their recommended
Adequate protein intake is essential during cancer treatment, recovery, long-term survival, and living with advanced disease. The best choices to meet protein needs are foods that are low in saturated fat such as: fish, lean meat, skinless poultry, eggs, low-fat dairy products, nuts, seeds, and legumes [12]. Vegetables, fruits, whole grains, and legumes form the core of a diet that decreases the risk of cancer and heart disease. Plant foods that are not highly processed provide a broad range of nutrients and phytochemicals that may act protectively by influencing DNA repair, inflammation, cell proliferation, and cancer progression. 8
ACCEPTED MANUSCRIPT Many epidemiological studies correlate greater consumption of vegetables and fruits with a lower risk of lung, oral, esophageal, stomach, and colon cancers [14]. Cancer survivors should be encouraged to consume at least 2-3 cups of vegetables and 1.5-2 cups of fruits each day because of their health benefits. Whole grains are rich in a variety of compounds that have important biologic activities, including hormonal and antioxidant effects
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and are thought to reduce the risk and progression of cancer as well as cardiovascular disease [16]. Foods that are rich in omega-3 fatty acids such as salmon, flaxseeds, and walnuts are associated with a lower risk of cardiovascular diseases and a lower overall mortality rate and should be encouraged in the diet [17]
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The strongest evidence from observational studies regarding diet relates to the overall dietary patterns of cancer survivors. Among those with stage III colorectal cancer, a more Western dietary pattern, characterized
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by a high intake of meat, fat, refined grains, and desserts, has been linked with more than double the overall mortality and a nearly threefold increase in cancer recurrence or death [18].
MIND BODY APPROACHES TO STRESS MANAGEMENT IN CANCER Stress is unavoidable for patients with cancer. This is a serious diagnosis and patients, their families, and
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friends are required to make very difficult decisions from often conflicting sources of information. This feeling of confusion may compound the shock, fear, and sadness they feel during this difficult time. It is well known that emotional distress and particularly prolonged emotional distress negatively affects immune function. [19,
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20] In a pilot study, Albuquerque et al showed that breast cancer patients with better quality of life scores,
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including lower perceived stress scores, had higher natural killer cell activity against tumor targets. [21] In a randomized controlled trial, Cohen et al showed that just two sessions in a stress management course improved pre-surgical mood-disturbance as well as serological immune function after surgery in patients undergoing radical prostatectomy for prostate cancer. [22] Breathing therapy is simple to master. Short, shallow chest breathing can increase feelings of anxiety and panic. Long, deep abdominal or diaphragmatic breathing can help to stabilize the autonomic nervous system,
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ACCEPTED MANUSCRIPT increase heart rate variability, improve onset and maintenance of sleep, and improve immune function. [23] See Table 1 for a simple deep breathing exercise. Guided Imagery is another highly effective, yet simple to administer, mind body therapy that has shown benefit for cancer patients. [23, 24] Eremin and colleagues found in a randomized control study that women
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diagnosed with locally advanced breast cancer, and undergoing multimodality therapy, who participated in relaxation training with guided imagery had beneficially altered immune responses when compared to controls. This benefit was found to last for the entire 37 weeks of the trial. [25]
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Biofeedback is a technique that uses physiological monitors to show patients their bodies’ responses to
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thoughts and emotions. This allows patients to see tangible evidence that they can use the mind to affect change in the body. [24] Hypnosis can be used to create a relaxed state of focused attention that has been shown to be beneficial for the control of side effects of cancer therapies. [ 26] Holland et al found that progressive muscle relaxation (PMR) was as effective as alprazolam in reducing cancer-related anxiety although PMR took slightly longer than the drug to produce this effect. [27]
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The evidence for the benefit of mind-body techniques to decrease anxiety, depression, pain, and other adverse symptoms in cancer patients is overwhelming. [28-30] These therapies have shown a clear pattern of increasing
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quality of life. The techniques are low risk and low cost and they should be the standard of care for all cancer patients. See Table 2 for helpful resources for mind body therapies.
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COMPLEMENTARY MODALITIES IN CANCER Nutritional supplements
Nutritional supplements are one of the easiest and most accessible complementary modalities that patients affected by cancer use. Nutritional supplements are vitamins, minerals, botanicals, amino acids, and certain other substances. There is extensive use of nutritional supplements among patients affected by cancer with an estimated 20%-90% of patients using these products. [31-36]
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ACCEPTED MANUSCRIPT Unfortunately, the current knowledge on the effectiveness of these nutritional supplements in cancer care is limited, and only a few benefits have been proven in clinical trials. The 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Report – Food, Nutrition and Physical Activity and the Prevention of Cancer: A Global Perspective- is a comprehensive and well researched document that
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gives a framework of nutrition in cancer care for prevention as well as during survivorship. [37] The conclusion of this report is that the evidence from both observational studies and clinical trials suggests nutritional supplements are unlikely to improve prognosis or overall survival after the diagnosis of cancer. A more recent
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report from the U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamins and single or paired nutrient
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supplements, except β-carotene and vitamin E for which the findings are negative for the prevention of cancer.[38]
While scientific and evidence-based thinking is fundamental to contemporary medical practice, failure to recognize that patients often do not reason in this way, interferes with physicians’ and nurses’ abilities to
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address the unspoken needs of the patient with cancer. Psychological, social, and spiritual dimensions of care may be ignored if the physician and nurse cannot adapt to the individual needs of the patient or provide care without sensitivity. [39]
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Patients may take nutritional supplements to reduce side effects and organ toxicity, to protect and stimulate
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immunity, or to prevent further cancers or recurrences. Patients often do not report their use of supplements to their providers. [40, 41] As a result, there is a gap in communication between providers and their patients. In order to be open to the patient’s perspective, and sensitive to his or her need for autonomy and empowerment, physicians, nurses, and nutritionists may need to shift their own perspectives. Perhaps the optimal approach is to discuss both the facts and the uncertainty with the patient, in order to reach a mutually informed decision. Today’s informed patients truly value providers who appreciate them as equal participants in making their own
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ACCEPTED MANUSCRIPT health care choices. At a very minimum, reconciling the medication list to include any current supplements puts all team members on the same page to assess risk, benefit, safety, and interaction issues. In order to reach a mutually informed decision about the use of these supplements, the Clinical Practice Committee of the Society of Integrative Oncology undertook the challenge of providing basic information to
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health care providers. They identified that health care providers need basic information related to nutritional supplements that are known to be safe and have indications for clinical efficacy. The Committee surveyed clinicians with extensive experience in consulting cancer patients about nutritional supplement use in leading
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cancer centers. [42] A list of leading supplements that have the best suggestions of benefit was constructed by leading researchers and clinicians who have experience in utilizing these nutritional supplements. This list
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includes curcumin, glutamine, vitamin D, maitake Mushrooms, fish oil, green tea, milk thistle, Astragalus, melatonin, and probiotics. The list also includes basic information on each supplement such as evidence on effectiveness and clinical trials, adverse effects, and interactions with medications if known, and possible dosage. The information was constructed to provide an up to date base of knowledge, so physicians and other
benefits and risks.
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Alternative nutritional practices
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healthcare providers would be aware of the supplements, and able to discuss realistic expectations and potential
Another aspect of nutrition that is commonly raised by patients is the utilization of “alternative” cancer diets.
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Examples are the Macrobiotic diet, Gerson diet, raw food diet and others. [43, 44] Most of these “alternative” diets used by cancer patients follow low-fat, plant-based patterns. However, these diets are potentially problematic for cancer patients in certain situations and generally lack the quantity of food intake necessary for optimal diet therapy.
The macrobiotic diet is an adaptation of the traditional Japanese diet. It is comprised of 50% to 70% whole grains, 20% to 25% vegetables, 5% to 10% beans and sea vegetables, and 5% vegetable soups. Nuts, seeds, fruits, and fish are consumed occasionally, but red meat, dairy, and sugar are avoided. Macrobiotic counselors 12
ACCEPTED MANUSCRIPT adapt the diet according to personal conditions, season, climate, and other factors. There have been no randomized clinical studies published in the available medical literature to show the macrobiotic diet can be used to prevent or cure cancer. On the basis of current evidence and its similarity to dietary recommendations for chronic disease prevention, the macrobiotic diet may add a reduced cancer risk. However, at present, the
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empirical scientific basis for or against recommendations for use of macrobiotics for cancer therapy is limited. Difficulties can arise for patients with cachexia due to the low caloric density of this diet. [44,45] Gerson therapy requires following a strict low-salt, low-fat, vegetarian diet and drinking juice from about
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twenty pounds of fresh fruits and vegetables each day. Fasting and coffee enemas are included in the protocol, which can be very rigorous and sometimes difficult to follow. There have been no well-controlled studies
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published in the available medical literature that show the Gerson therapy is effective in treating cancer. Monitoring for adequate protein intake in patients with cachexia is necessary, and the intake of fruit juice may compromise electrolyte balance and blood-sugar control.
Raw Foods Diet, developed by Ann Wigmore, is a diet based on only raw foods, fermented vegetables,
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sprouted grains, and juices such as wheatgrass juice. Inadequate protein and n-3 fatty acid intakes have been raised as potential problems with long-term use of this diet. There is some data that suggests improvement in
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quality of life for the use of wheatgrass juice in patients undergoing active chemotherapy. [46] NUTRITIONAL RESOURCES AND SYMPTOM REDUCTION PROTOCOLS IN CANCER CARE
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One of the challenges in cancer nutrition is making food palatable. Sometimes, the best thing is a good cookbook with practical, evidence-based experience, and recipes to support health and nutrition. In our Integrative Oncology consultations, a favorite resource is Rebecca Katz’s The Cancer Fighting Kitchen.47 Savory, health promoting foods provident nutrient-rich meals to support cancer patients through treatment and in the survivorship stage. This well written book is a toolbox that takes the patient and the care provider through the full spectrum of eating and nutritional problems that can occur during cancer. For example, the first chapter reviews some pre-chemotherapy and post-chemotherapy food protocols and provides a useful list of spices and 13
ACCEPTED MANUSCRIPT seasonings to help overcome problems with taste buds. It also describes the cancer-fighting benefits of many foods and spices, e.g., turmeric, an array of vegetables, fruits, and teas, and protein sources. A long chapter on nourishing soups and broths offers superb recipes that are easy to prepare, eat, and digest. Similarly, chapters on healthy vegetables, protein-building foods, snacks, tonics and elixirs, and other yummy and sweet foods make
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the process of eating wonderful again, and health promoting. Smaller more frequent meals in wide variety seem to be the optimum combination.
Another excellent resource is Dr. Keith Block’s Life Over Cancer48. This book offers three excellent
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chapters covering diet: The Anti-Cancer Diet, The Life Over Cancer Core Diet Plan, and Individualizing Your Diet. Dr. Block began his cancer-fighting career utilizing the macrobiotic diet back in the 1970’s and has
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expanded it to a full service holistic and integrative cancer program in Chicago, The Block Cancer Center. The diet chapters in this book offer some key principles emphasizing the power of diet in cancer: Emphasize low fat foods and healthy fats such as omega-3 fatty acids
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Avoid refined carbohydrates and eat whole grains, fruits, and vegetables instead
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Reduce intake of animal protein and dairy but emphasize fish, egg white, whey protein
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Get micronutrients and phytochemicals from a rainbow of plant foods plus carefully selected dietary
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supplements such as vitamins, minerals, prebiotics, probiotics, mushroom extracts Maintain albumin level over 3.0g/dL, preferably over 3.6g/dL
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At times for cancer patients, true nutritional rescue is needed. There are a number of approaches to cancer cachexia, weight loss, and malnutrition due to side effects of treatment, catabolic state, and other factors. Dr. Block’s book covers this well with a nutritional rescue program, healthy smoothies, and other practical approaches48.
Symptom Management Protocols Cancer therapy can reduce a patient’s ability to take in food by its effects on the gastrointestinal tract. There are a significant number of conventional as well as evidence-based complementary and integrative approaches to 14
ACCEPTED MANUSCRIPT managing the side effects of cancer that largely impact the ability of patient during cancer therapy to maintain adequate nutrition. There are specific and common problems such as anorexia, dysgeusia, mucositis, dry mouth, nausea and vomiting. See Tables 3, 4, 5, 6, 7. Each of these conditions limits the ability of cancer patient to sustain and assimilate adequate caloric intake and if left untreated, contribute to cancer-related
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cachexia, delay in healing, immune suppression, risk of cancer progression or recurrence, and general degradation on quality of life measures.
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FUTURE RESEARCH DIRECTIONS
The spectrum of nutritional issues in cancer is truly expansive. The role of and proper mix of nutrients in
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cancer prevention and in cancer survivorship is still evolving. Studies have been inconclusive about this area though what has generally evolved is that a plant-based, low glycemic diet is likely to be the most useful. This may not be appropriate or acceptable to all patients and getting adequate protein from purely plant sources while achievable, is a cultural and culinary challenge for many patients.
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One of the most exciting and promising areas here is the evolving big data sets that are increasingly used to characterize individuals genomically. Foods, exercise, and other lifestyle factors have epigenetic impacts that can raise or lower cancer risk. As with pharmacogenomics, nutrigenomics offer increasingly personalized
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choices for nutritional selections. Emerging studies on the human microbiome are also revealing the importance of our inner ecosystem on immunity and good health in general, not just the gastrointestinal tract.
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Working in health care teams with nutritionists, motivational specialists, mind-body therapists, coaches, and trainers can all facilitate sensible lifestyle choices among our patients with cancer, for those who are trying to prevent cancer, or those seeking to maintain remission in the survivorship stage. Nutrition plays an essential and complex role in all of these settings.
TABLE 1: Deep Breathing Exercise 1. Lie in a comfortable position with your knees bent. 2. Place one hand on your chest and one hand on your abdomen.
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ACCEPTED MANUSCRIPT 3. Inhale deeply and slowly into your abdomen. You should notice that your chest moves only a little and only with your abdomen. Practice this for 5-10 minutes two times a day. TABLE 2: Helpful Resources for Mind-Body Therapies A. Books The Relaxation and Stress Reduction Workbook by Davis, Eshelman and McKay (2000) Fighting Cancer from Within by Martin LR (2003) Timeless Healing by Benson (1996) Prayer is Good Medicine: How to Reap the Healing Benefits of Prayer by Dossey (1997) Kitchen Table Wisdom: Stories that Heal by Remen (1997) Spontaneous Healing: How to Discover and Enhance your Body’s Natural Ability to Maintain and Heal Itself by Weil (1996) B. Websites:
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1. 2. 3. 4. 5. 6.
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1. Commonweal: Week-long retreats for cancer patients and their support people. www.commonweal.org/program/commonweal-cancer-help-program/ 2. Health Journeys: MP3’s and CDs of guided imagery for stress reduction, fighting cancer, chemotherapy, fatigue, successful surgery and many more. www.healthjourneys.com 3. Mindful Living Programs: Online mindfulness-based stress reduction programs. www.mindfullivingprograms.com 4. Dr. Weil: Videos and explanations for three highly effective breathing exercises. http://www.drweil.com/drw/u/ART00521/three-breathing-exercises.html
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TABLE 3 Evidence-based recommendations for Anorexia [49, 50, 51, 52] Recommend eating small, frequent meals or snacks (try something every two hours) Avoid drinking during meals. Advise to start eating earlier in the morning. If they return to bed, elevate head of bed or prop up with pillows to avoid reflux Recommend selecting foods that are calorie and protein-rich such as cream soups, puddings, custards, cheese, casseroles, milk, milk shakes and liquids nutritional supplements like Boost ®or Ensure® Emphasize avoiding low-calorie filler foods Make sure constipation, pain or nausea do not interfere with food consumption Advise to separate solids and liquids (drinking just enough to get food down); drinking liquids "between" meals and snacks Fish oil supplements. Recommend high quality, molecular distilled fish oil at 2g per day. Glutamine—15-30 g/daily as a modulator of protein turnover and for enhancing net protein synthesis Medications: Megestrol acetate (160-1600mg/day)* Dexamethasone, methylprednisolone, and prednisolone for short-term treatment TABLE 4 Evidence-based recommendations for Dysgeusia [49,50,53] If mucosa is intact, add seasoning such as lemon pepper, chili, BBQ, pickles; add spices like oregano, rosemary, thyme.
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Serving the food hot so as to stimulate the olfactory senses too. Sucking on lemon drops, mints or chew gum to rid a bad taste in the mouth Recommend liquid nutritional supplements and to vary the flavors to avoid taste fatigue. Try Chef Rebecca Katz’s strategies using FASS…Fats, Acid, Salt and Sweet. Cookbook entitled One Bite at a Time: Nourishing Recipes for Cancer Survivors and their Friends. Good mouth care, e.g., rinse mouth frequently with baking soda and salt swish and spit solution, and brush teeth with very soft/soft toothbrush Brushing teeth and tongue before eating. Using good plastic utensils if food tastes metallic. Trial of zinc (45mg) three times daily for one month
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TABLE 5 Evidence-based recommendations for Mucositis [49, 50, 51, 54, 55] Emphasize eating soft, moist, easy-to-chew foods Advise consumption of nutrient-dense liquids/nutrient supplements Recommend using a straw to drink room temperature or cool beverages Avoid acidic and spicy foods; Avoid dry, rough/course foods; Avoid alcohol. Check for ulcerations and other problems in the mouth. Encourage self inspection by the patient Have patient get a soft toothbrush and use gentle toothpaste Recommend baking soda and salt. (1 tsp baking soda and 1 tsp of salt added to 17-18 ounce bottle of water. Swish and spit and repeat at least every two hours. Avoid alcohol-containing mouthwash Glutamine 15-30 g daily Zinc l-carnosine (8 mg zinc and 29 mg l-carnosine taken 3 times daily) Lemon/glycerin swabs Medications: Caphasol® Neutrasal® “Pink, Magic or Miracle Mouthwash” compounded solution that usually contains Benadryl, viscous lidocaine and Mylanta; some preparations contain Nystatin.
TABLE 6 Evidence-based recommendations for Dry Mouth [50, 51] Advise to drink/swallow small amounts of food at one time Recommend eating soft moist foods and adding extra gravies and sauces Avoid dry rough foods; take care with breads and crackers
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Advise trying sweet/tart foods Suck on hard candies Recommend spring water to help swallow foods; carrying a bottle at all times; sipping on liquids, sucking on ice chips throughout the day Avoid caffeine-containing beverages, alcohol and tobacco Encourage good mouth care: rinsing mouth frequently with baking soda and salt swish and spit solution, and brushing teeth with very soft/soft toothbrush Avoid alcohol-containing mouthwash Advise drinking through a straw Utilize a cool mist humidifier in the living areas and bedroom; make sure to use bottled water and clean regularly Trial of Biotene® products (mouthwash, gum, toothpaste) Artificial saliva Zinc l-carnosine (8 mg zinc and 29 mg l-carnosine taken 3 times daily)
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TABLE 7 Evidence-based recommendations for Nausea and Vomiting [49,56,57, 58] Advise small frequent meals and snacks; avoid skipping meals as an empty stomach can contribute to nausea. Recommend putting foods by the bedside so to snack before rising. Advise to eat and drink lower fat foods and beverages Recommend eating and drinking foods and beverages that are room temperature or cool. Avoid spicy foods and caffeine Avoid foods that have strong smells Advise not eating 1-2 hours before chemotherapy or radiation treatment Acupressure bands may be helpful for mild nausea or instruct patient on use of acupressure with their fingers at MH6 point on inner wrist Advise wearing loose clothing and keep rooms well ventilated Dried ginger 500 mg two times daily two days before, the day of, and two days after chemotherapy may be helpful Relaxation, hypnosis, acupuncture, music therapy, guided imagery, progressive muscle relaxation (for anticipatory nausea) are also effective Medications:
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5-HT3 receptor agonists (palonosetron, granisetron, ondansetron, dolasetron, tropisetron) NK1 receptor antagonist (aprepitant) Corticosteroid (dexamethasone) Benzodiazepine (lorazepam) Metoclopramide ± diphenhydramine Phenothiazine (prochlorperazine) Butyrophenones (haloperidol) Cannabinoids Olanzapine Promethazine
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Accessed October 26, 2014. [2]Calle EE, Rodriguez C, Walker-Thurmond K, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348:1625–1638; [3] Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: A systematic review and meta-analysis of prospective observational studies. Lancet. 2008;371:569–578
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[4] Thompson CL, Owusu C, Nock NL, Li L, Berger NA. Race, age, and obesity disparities in adult physical activity levels in breast cancer patients and controls.; Front Public Health. 2014 Sep 19;2:150. doi: 10.3389/fpubh.2014.00150. eCollection 2014.
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[5] Capasso I, Esposito E, de Laurentiis M, et al. Metabolic syndrome-breast cancer link varies by intrinsic molecular subtype. Diabetol Metab Syndr. 2014 Sep 26;6(1):105. doi: 10.1186/1758-5996-6-105. eCollection 2014. [6] Key TJ., Appleby PN., Reeves GK, et al., Body mass index, serum sex hormones, and breast cancer risk in postmenopausal women J Natl Cancer Inst 2003; 95:1218-1226
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[7] Kaaks R, Randali S, Key TJ, et al., Postmenopausal serum androgens, oestrogens and breast cancer risk: the European prospective investigation into cancer and nutrition. Endocr. Relat Cancer 2005;12:1071-1082 [8] Pisani P Hyper-insulinaemia and cancer, meta-analyses of epidemiological studies. Arch Physiol Biochem 2008; 114(1):63-70 [9] Giovannucci E. Insulin and colon cancer. Cancer Causes Control 1995; 6(2):164-179.
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[10] Renehan AG, Harvie M, Howell A. Insulin-like growth factor ( IGF)-I, IGF binding protein- 3, and breast cancer risk: eight ears on. Endocrin Relat Cancer 2006; 13(2):273-278
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[11] Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 2012;62: 242–274. [12] Schattner M, Shike M. Nutrition support of the patient with cancer. In: Shils ME, Shike M, Ross AC, Cabellero B, Cousins RJ, eds. Modern Nutrition in Health and Disease. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 1290-1313. [13] McMahon K, Brown JK. Nutritional screening and assessment. Semin Oncol Nurs. 2000; 16: 106-112. [14] World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR; 2007. [15] Kushi LH, Doyle C, McCullough M, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2012; 62: 30-67. 19
ACCEPTED MANUSCRIPT [16] Slavin J. Why whole grains are protective: biological mechanisms. Proc Nutr Soc. 2003;62:129-134. [17] US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2010. [18] Meyerhardt JA, Niedzwiecki D, Hollis D, et al. Association of dietary patterns with cancer recurrence and survival in patients with stage III colon cancer. JAMA. 2007;298(7):754-764.
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[19] Jaremka LM, Glaser, R, Malarkey WB, Keicolt-Glaser JK “Marital Distress Prospectively Predicts Poorer cellular immune function.” Psychoneuroendocrinology.2013; 38(11):2713-2719 . [20] Gruber, BL, Hersh SP, Hall NR, et al. Immunological responses of breast cancer patients to behavioral interventions. Biofeedback and Self Regul 1993;18(1) : 1-22.
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[21] Albuquerque K, Tell D, Lobo P, Millbrandt L, Mathews H and Janusek L “Impact of Partial versus whole breast radiation therapy on fatigue, perceived stress, quality of life and natural killer cell activity in women with breast cancer. BMC Cancer, 2012, 12:251-262. [22] Cohen L, Parker P, Vence L et al. “Presurgical Stress Management improves postoperative immune function in men with prostate cancer undergoing radical prostatectomy” Psychosomatic Med 2011;73(3): 218-225
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[23] Rakel, D Integrative Medicine. 2012, Philadelphia, PA : Elsevier Saunders 3rd edition,. [24] Rossman, M, Shrock, D. “Mind Body Medicine in Integrative Cancer Care” Weil A, Abrams, Integrative Oncology, Oxford University Press, 2009,pp 244-257. [25] Eremin O, Walker MB, Simpson E, et al. Immuno-modulatory effects of relaxation training and guided imagery in women with locally advanced breast cancer undergoing multimodality therapy: A randomized controlled trial. Breast 2009;18(1):17-25.
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[26] Montgomery GH, Bovberg D, Schnur J, et al. “A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients.” J Natl Cancer Inst. 2007;99:1304-1312. [27] Holland JC, Morrow GR, Schmale A, et al “A randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms.” J Clin Oncol. 1991;9(6):1004-1011.
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[28] Barsevick AM, Sweeney, C, Haney E, Chang EA . Systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer.” Oncol Nurs Forum, 2002;29(1): 7384.
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[29] Mundy EA, DuHamel KN and Montgomery GH . “The efficacy of behavioral interventions for cancer treatment-related side effects.” Semin Clin Neuropsych 2003; 8(4): 253-275. [30] Ledesma D, Kumano H. Mindfulness-based stress reduction and cancer. A meta-analysis. Psychooncology. 2009 ; 18(6): 571-579. [31] Sandler S, Halabi S, Kaplan E, et al. Use of vitamins, minerals, and nutritional supplements by participants in a chemoprevention trial. Cancer. 2001;91:1040-1045. [32] Newman V, Rock C, Faerber S, et al. Dietary supplement use by women at risk for breast cancer recurrence. The women’s healthy eating and living study group. J Am Diet Assoc. 1998;98(3):285-292. [33] Von Gruenigen V, White L, Kirven M, et al. A comparison of complementary and alternative medicine use by gynecology and gynecologic oncology patients. Int J Gynecol Cancer. 2001;11(3):205-209. 20
ACCEPTED MANUSCRIPT [34] Paltiel O, Avitzour T, Cherny N, et al. Determinants of the use of complementary therapies by patients with cancer. J Clin Oncol. 2001;19:2439-2444. [35] Velicer CM, Ulrich CM) Vitamin and mineral supplement use among US adults after cancer diagnosis: a systematic review. J Clin Oncol 2008;26(4):665–673
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[36] Kwan ML, Weltzien E, Kushi LH, Castillo A, Slattery ML, Caan BJ. Dietary patterns and breast cancer recurrence and survival among women with early-stage breast cancer. J Clin Oncol. 2009;27(6):919-926. [37] World Cancer Research Fund/ American Institute for Cancer Research. Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective Expert Report. Washington DC: AICR, 1997 and update 2007.
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[38] Moyer VA. Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of Cardiovascular Disease and Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;160(8):558-564.
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[39] Frenkel M, Cohen L. Effective communication about the use of complementary and integrative medicine in cancer care. J Altern Complement Med. 2014;20(1):12-18. [40] Eisenberg D, Davis R, Ettner S, et al. Trends in Alternative Medicine Use in the United States, 19901997: Results of a Follow-up National Survey. JAMA. 1998;280:1569-1575. [41] Frenkel M, BenArye E, Baldwin CD, Sierpina V. Approach to communicating with patients about the use of nutritional supplements in cancer care. South Med J. 2005;98(3):289-94.
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[42] Frenkel M, Abrams D, Ladas E, et al. Integrating Dietary Supplements into Cancer Care. Integr Cancer Ther. 2013;12 369-384.
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[43] Block KI, Gyllenhaal C. Nutritional interventions in cancer. In Abrams D, Weil A. Integrative Oncology. (Weil Integrative Medicine Library) Second Edition 2014, Oxford University Press New York NY. [44] Lerman RH. The macrobiotic diet in chronic disease. Nutr Clin Pract. 2010;25(6):621-6.
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[45] Kushi LH, Cunningham JE, Hebert JR, Lerman RH, Bandera EV, Teas J. The macrobiotic diet in cancer. J Nutr. 2001 ;131(11 Suppl):3056S-64S. [46] Bar-Sela G, Tsalic M, Fried G, et al. Wheat grass juice may improve hematological toxicity related to chemotherapy in breast cancer patients: a pilot study. Nutr Cancer 2007; 58: 43–8. [47] Katz R, Edelson M. The Cancer Fighting Kitchen. Berkeley, CA: Celestial Arts, 2009. [48] Block KI. Life Over Cancer. New York: Bantam, 2009, pp.52-153. [49] National Cancer Institute. Eating Hints: Before, during and after cancer treatment. 2009. www.cancer.gov/cancertopics/coping/eatinghints/page1/AllPages Accessed November 14, 2014 [50] Grant BL, Bloch AS, Hamilton KK, Thompson CA. American Cancer Society Complete guide to nutrition for cancer survivors. Atlanta, GA:American Cancer Society, 2010 21
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[51] American Cancer Society. Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families www.cancer.org/acs/groups/cid/documents/webcontent/002903-pdf.pdf Accessed November 14, 2014 [52] Oncology Nursing Society. Anorexia. www.ons.org/practice-resources/pep/anorexia Accessed November 14, 2014
[53] Peregrin T. Improving taste sensation in patients who have undergone chemotherapy or radiation therapy. J American Dietetic Association 15 2006;106(10):1536-40
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[54] Oncology Nursing Society. Mucositis. www.ons.org/practice-resources/pep/mucositis Accessed November 14, 2014
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[55] Deng Z. Kiyuna A, Hasegawa M, Nakasone I, Hosokawa A, Suzuki M, Oral candidiasis in patients receiving radiation therapy for head and neck cancer. Otolaryngol Head Neck Surg. 2010 :143(2):242-247 [56] Legrand SB, Walsh D. Scopolamine for cancer-related nausea and vomiting. JPain Symptom Manage. 2010;40(1);136-141 [57] Roscoe JA, Bushunow P, Jean-Pierre P, et al. Acupressure bands are effective in reducing radiation therapy-related nausea. J Pain Symptom Manage. 2009;38(3):381-9
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[58] Oncology Nursing Society. Chemotherapy induced nausea and vomiting.www.ons.org/practiceresources/pep/chemotherapy-induced-nausea-and-vomiting Accessed November 14, 2001
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S0749-2081(14)00091-6
DOI:
10.1016/j.soncn.2014.11.005
Reference:
YSONU 50675
To appear in:
Seminars in Oncology Nursing
Please cite this article as: Sierpina V, Levine L, McKee J, Campbell C, Lian S, Frenkel M, Nutrition, Metabolism, And Integrative Approaches In Cancer, Seminars in Oncology Nursing (2015), doi: 10.1016/ j.soncn.2014.11.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT NUTRITION, METABOLISM, AND INTEGRATIVE APPROACHES IN CANCER
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Sierpina Victor1, Levine Lyuba2, McKee Juliet3, Campbell Christina4, Lian Sungmi5, Frenkel Moshe6
AUTHORS:
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2. Lyuba Levine, MD Associate Professor EV Hannigan Distinguished Chair Division of Gynecologic Oncology Department of Obstetrics and Gynecology University of Texas Medical Branch Galveston, TX 77555-0587 (832) 505-1910 [email protected]
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1. Victor S. Sierpina, MD WD and Laura Nell Nicholson Family Professor of Integrative Medicine Professor, Family Medicine University of Texas Distinguished Teaching Professor 301 University University of Texas Medical Branch Galveston, TX 77555-1123 409-772-3126 [email protected] [Corresponding author]
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3. Julie McKee, MD Associate Professor of Family Medicine UTMB Distinguished Teaching Professor Department of Family Medicine 301 University University of Texas Medical Branch Galveston, TX 77555-1123 409-772-3126 [email protected] 4. Christina Campbell, RD, PA 361-728-5816 [email protected] 1
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6. Moshe Frenkel MD Clinical Associate Professor University of Texas Medical Branch Director of Integrative Oncology Service Institute of Oncology Meir Medical Center Kfar Saba, Israel [email protected]
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5. Sungmi Lian, MD Hospitalist Harrison Medical Center Bremerton, WA 98310(907)223-3690 [email protected]
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ACCEPTED MANUSCRIPT ABSTRACT:
Objectives: To review emerging issues about metabolic changes occurring in cancer survivors during and as a result of therapy, the role of nutrition, weight control, stress management, nutritional supplements and other
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complementary diet therapies, methods of mitigating side effects of treatment affecting dietary intake, and to suggest future research directions.
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Data Sources: Literature review and professional clinical experience with oncology patients.
Conclusion: Enhancing cancer survivorship requires knowledge and application of nutritional science and
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integrative healthcare approaches
Implications for Nursing Practice: Reliable, personalized, team-generated nutritional advice must be provided to cancer patients and cancer survivors to reduce risk of recurrence, optimize energy balance, and improve quality of life.
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complementary cancer therapies
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Key Words: Nutrition, energy balance, dietary supplements, mind-body therapies, integrative oncology,
The role of nutrition in cancer has always been controversial. Do certain foods prevent cancer, cause it,
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or help prevent recurrence? Of course, unexplained weight loss always raises the specter of cancer or recurrence. What is less recognized is that obesity, both before and as a result of cancer treatment, is a significant risk for cancer and its recurrence. In this context, metabolic changes affecting the way the body handles insulin, energy, and fat metabolism are emerging concerns for cancer patients. Therapeutic challenges include fatigue, anorexia, dysgeusia, mucositis, and other afflictions limiting nutritional intake.
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ACCEPTED MANUSCRIPT The clinical team may struggle to develop dietary and exercise strategies for cancer patients and survivors to optimize their caloric intake and absorption to maintain weight, or in some cases to reduce it. Stress raises cortisol levels, affects our dietary habits, changes our hormonal milieu, and reduces immunity. Managing stress through mind body practices is another interdisciplinary intervention to manage the risk profile in cancer care.
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Complementary therapies and nutritional supplements offer additional layers of patient-centered interventions that embrace the potent impact of nutrition and diet in cancer therapy and survivorship.
In this review, we synopsize the key issues related to these topics, linking them to evidence-based
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practices and future research directions. This will support nurses and other clinicians as they offer counsel to cancer patients and survivors related to optimizing their nutritional status, survivorship chances, and overall
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well-being.
Americans are more likely to survive after a cancer diagnosis today than ever before. About 14.5 Million Americans are alive after being told they have cancer and 2 out of 3 of these will be alive for 5 years or longer after cancer diagnosis. It is estimated that 1,665,540 US citizens will be diagnosed with cancer in 2014 and,
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because many of these diagnoses occur in those who are 65 and older, there will be a rapid increase in the number of new cases diagnosed due to a large proportion of an aging population. (1)
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Cancer arises when control of cell death is lost. Some cancers are due to inherited genetic mutations but only a small percentage of these are responsible for new or recurrent cancer. In the majority of cases, interaction
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between cancer cells and their environment is responsible for cancer progression. Most of these factors that change tumor microenvironment are related to lifestyle. A significant number of cancers are preventable; the greatest example being cancers related to tobacco use. Other factors that have been associated with higher incidence of cancer are lack of physical activity, obesity, non-participation in prevention programs, and overexposure to ultraviolet light. Cancer survivors are at greater risk for developing other diseases and secondary cancers. It has been documented that cancer patients die at a higher rate than people in the general population from non-cancer 4
ACCEPTED MANUSCRIPT causes. Those with a consistent primary care provider who tends to these non-cancer problems experience longer and better quality of life in general. The decrease in functional status and increase in disability that result from cancer and its treatment are of significant concern. Cancer survivors have an almost 2-fold increase in having at least one functional limitation. [2,3]
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The presence of comorbidities, in addition to cancer history, is associated with impaired functional status. The presence of another comorbid condition increases the chance of dying from non-cancer-related causes.
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ENERGY BALANCE, METABOLISM, INSULIN RESISTANCE IN CANCER
In the western world, there has been a marked increase in obesity during the past several decades. Obesity
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has been associated with higher risk in developing cancer of the esophagus, breast (especially postmenopausal), endometrium, colon and rectum, kidneys, pancreas, thyroid, gall bladder and possibly other cancers. Obesity and weight gain have been established as negative prognostic risk factors in cancer patients because body fat is an important source of growth hormones. The relationship between obesity and incidence of cancer is a consistent association found in multiple epidemiologic studies. The fact that cancer incidence is
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lower after bariatric surgery further supports this association. Since many cancer survivors, especially those with breast, endometrial and colon cancers, are at increased
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risk for weight gain, decreasing body fat is becoming a priority in this population. Obesity, inactivity and poor dietary quality are linked to decreased overall survival. Based on a large US prevention study, obesity is linked
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to 20% of all cancer deaths in women and 14% cancer deaths in men [2] Obesity is defined as presence of highly disproportionate and unhealthy amount of body adipose tissue. One of the measures of obesity is Body Mass Index (BMI). Normal BMI is 18.5 to 24.9; a BMI of 25 to 29.9 is considered overweight. Those with a BMI of 30 and more are considered obese. Diet, physical activity and overall weight are considered as energy balance factors. When energy consumption exceeds energy expended, energy will get stored.
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ACCEPTED MANUSCRIPT Multiple studies have shown an association between obesity and development of postmenopausal breast cancer. The relationship is even stronger in women who were never treated with hormone replacement therapy. [2, 4] The relationship between obesity and increased incidence in post-menopausal breast cancer is most likely
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due to increased level of estrogens in post-menopausal women since the amount of hormones produced by ovaries dramatically declines and adipose tissue becomes a most important source of circulating estrogens. Data from the pooled analysis of nine prospective studies, the Endogenous Hormones and Breast Cancer
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Collaborative Group (EHBCCG)[5], and the European Prospective Investigation into Cancer and Nutrition (EPIC) study[6], demonstrated that postmenopausal breast cancer risk is increased in women with higher levels
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of circulating sex steroids. The association of BMI with postmenopausal breast cancer risk was almost entirely attributed to elevated levels of estradiol with increased BMI. This phenomenon is due to the fact that adipose cells have aromatase, an enzyme that converts precursor androgens into estrogens. The more adipose tissue women have, the higher is the level of circulating hormones.
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Obesity is associated with up to 30-fold increase risk of endometrial cancer regardless of menopausal status. In the case of endometrial cancer, increased level of circulating estradiol not only increases endometrial call proliferation and inhibits apoptosis, but also stimulates local synthesis of insulin-like growth factor (IGF-I).
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Circulating insulin levels and increased concentration of IGF hormones is associated with increased BMI[7, 8].
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IGF-I activates various intracellular pathways that are linked to inflammation and have mitogenic, antiapoptotic and pro-angiogenic effect [7]. Meta-analyses support the relationship between total IGF-I and risks for colorectal, prostate, endometrial, pre-menopausal breast and to a lesser extend post-menopausal breast cancers [9, 10].
Obesity is associated with a chronic inflammatory state characterized by abnormal cytokine production. As a result, there is an increase in synthesis of pro-inflammatory reactants such as C-reactive protein and activation of macrophages. Activated macrophages produce many pro-inflammatory factors. Subclinical, low6
ACCEPTED MANUSCRIPT grade chronic inflammatory state is important in development of insulin resistance, type 2 diabetes and several other chronic conditions. Adipokines are considered to be key mediators linking obesity and chronic inflammation. Adiponectin, the most abundant adipokine, is secreted mainly from visceral adipose cells and is an important insulin-sensitizing
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agent.
High BMI is associated with decreased levels of circulating adiponectin. This is one of the possible mechanisms of increased insulin resistance in obese individuals, especially in those with larger proportion of
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visceral adipose tissue. Low circulating levels of adiponectin have been associated with increased incidence of
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malignant transformation including endometrial, breast, prostate and colorectal cancers Obesity has a complex, multi-system physiology and its association with cancer is multifactorial. The mechanisms discussed above associating cancer and obesity are currently supported by multiple studies. Undoubtedly, there are additional mechanisms linking obesity to cancer and there is evidence that physical
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activity might influence cancer development and progression. NUTRITION AND DIET IN CANCER
Improving health while being treated for cancer or as a cancer survivor is a difficult challenge due to many
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factors, secondary disabilities, effects of treatment, and altered metabolism. Meeting nutritional needs and achieving ideal activity levels are important aspects to the recovery process. As cancer survivors prepare for the
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successful completion of therapy and start to pursue self-care strategies, informed lifestyle choices are necessary to improve their long-term outcomes. Diet, exercise, and weight management can help prevent recurrence, additional primary cancers, and other chronic diseases. When researching diet options, cancer survivors may encounter ambiguity or feel overwhelmed by the plethora of misinformation. They are often advised on which foods to eat, which to avoid, how to exercise, and which supplements to take, not always well founded [11]. 7
ACCEPTED MANUSCRIPT Cancer causes profound metabolic and physiological changes that can affect the requirements for macro- and micro-nutrients. Chemotherapy, targeted and precision agents, radiation treatments, and surgery can significantly affect nutritional needs, modify regular eating habits, and interfere with the ability to digest, absorb, and utilize food [12]. It is imperative that a nutritional assessment be started as soon as possible after
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diagnosis and focus on both current nutritional status and anticipated nutrition-related symptoms [13]. This can be done by any member of the healthcare team with a background, training, and interest in nutrition. Certainly, this can be a nurse, nurse practitioner, dietician, or physician, and often is aided by strategic questionnaires and
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diet diaries. Essentials in the diet history should include quantity and quality of the different food groups with particular attention to appropriate calories, sources of carbohydrates (low vs high glycemic), proteins, and types
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of fats. Daily meal patterns, frequency of fast food use, shopping and home cooking habits are all essential snapshots of patient dietary assessment. A 24-hour recall gives a fairly reliable sample that likely reflects a patient’s usual habits.
After cancer treatment, weight change should be managed with a combination of diet, physical activity, and
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behavioral strategies. Protein, carbohydrate, and fat all contribute energy to the diet, and each of these components is available from a wide variety of foods. Because cancer survivors are at increased risk for other chronic diseases, the recommended amounts and types of fat, protein, and carbohydrate to reduce the risk of
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body weight [14, 15].
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cardiovascular disease are also applicable to cancer survivors, particularly if they are above their recommended
Adequate protein intake is essential during cancer treatment, recovery, long-term survival, and living with advanced disease. The best choices to meet protein needs are foods that are low in saturated fat such as: fish, lean meat, skinless poultry, eggs, low-fat dairy products, nuts, seeds, and legumes [12]. Vegetables, fruits, whole grains, and legumes form the core of a diet that decreases the risk of cancer and heart disease. Plant foods that are not highly processed provide a broad range of nutrients and phytochemicals that may act protectively by influencing DNA repair, inflammation, cell proliferation, and cancer progression. 8
ACCEPTED MANUSCRIPT Many epidemiological studies correlate greater consumption of vegetables and fruits with a lower risk of lung, oral, esophageal, stomach, and colon cancers [14]. Cancer survivors should be encouraged to consume at least 2-3 cups of vegetables and 1.5-2 cups of fruits each day because of their health benefits. Whole grains are rich in a variety of compounds that have important biologic activities, including hormonal and antioxidant effects
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and are thought to reduce the risk and progression of cancer as well as cardiovascular disease [16]. Foods that are rich in omega-3 fatty acids such as salmon, flaxseeds, and walnuts are associated with a lower risk of cardiovascular diseases and a lower overall mortality rate and should be encouraged in the diet [17]
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The strongest evidence from observational studies regarding diet relates to the overall dietary patterns of cancer survivors. Among those with stage III colorectal cancer, a more Western dietary pattern, characterized
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by a high intake of meat, fat, refined grains, and desserts, has been linked with more than double the overall mortality and a nearly threefold increase in cancer recurrence or death [18].
MIND BODY APPROACHES TO STRESS MANAGEMENT IN CANCER Stress is unavoidable for patients with cancer. This is a serious diagnosis and patients, their families, and
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friends are required to make very difficult decisions from often conflicting sources of information. This feeling of confusion may compound the shock, fear, and sadness they feel during this difficult time. It is well known that emotional distress and particularly prolonged emotional distress negatively affects immune function. [19,
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20] In a pilot study, Albuquerque et al showed that breast cancer patients with better quality of life scores,
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including lower perceived stress scores, had higher natural killer cell activity against tumor targets. [21] In a randomized controlled trial, Cohen et al showed that just two sessions in a stress management course improved pre-surgical mood-disturbance as well as serological immune function after surgery in patients undergoing radical prostatectomy for prostate cancer. [22] Breathing therapy is simple to master. Short, shallow chest breathing can increase feelings of anxiety and panic. Long, deep abdominal or diaphragmatic breathing can help to stabilize the autonomic nervous system,
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ACCEPTED MANUSCRIPT increase heart rate variability, improve onset and maintenance of sleep, and improve immune function. [23] See Table 1 for a simple deep breathing exercise. Guided Imagery is another highly effective, yet simple to administer, mind body therapy that has shown benefit for cancer patients. [23, 24] Eremin and colleagues found in a randomized control study that women
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diagnosed with locally advanced breast cancer, and undergoing multimodality therapy, who participated in relaxation training with guided imagery had beneficially altered immune responses when compared to controls. This benefit was found to last for the entire 37 weeks of the trial. [25]
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Biofeedback is a technique that uses physiological monitors to show patients their bodies’ responses to
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thoughts and emotions. This allows patients to see tangible evidence that they can use the mind to affect change in the body. [24] Hypnosis can be used to create a relaxed state of focused attention that has been shown to be beneficial for the control of side effects of cancer therapies. [ 26] Holland et al found that progressive muscle relaxation (PMR) was as effective as alprazolam in reducing cancer-related anxiety although PMR took slightly longer than the drug to produce this effect. [27]
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The evidence for the benefit of mind-body techniques to decrease anxiety, depression, pain, and other adverse symptoms in cancer patients is overwhelming. [28-30] These therapies have shown a clear pattern of increasing
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quality of life. The techniques are low risk and low cost and they should be the standard of care for all cancer patients. See Table 2 for helpful resources for mind body therapies.
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COMPLEMENTARY MODALITIES IN CANCER Nutritional supplements
Nutritional supplements are one of the easiest and most accessible complementary modalities that patients affected by cancer use. Nutritional supplements are vitamins, minerals, botanicals, amino acids, and certain other substances. There is extensive use of nutritional supplements among patients affected by cancer with an estimated 20%-90% of patients using these products. [31-36]
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ACCEPTED MANUSCRIPT Unfortunately, the current knowledge on the effectiveness of these nutritional supplements in cancer care is limited, and only a few benefits have been proven in clinical trials. The 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Report – Food, Nutrition and Physical Activity and the Prevention of Cancer: A Global Perspective- is a comprehensive and well researched document that
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gives a framework of nutrition in cancer care for prevention as well as during survivorship. [37] The conclusion of this report is that the evidence from both observational studies and clinical trials suggests nutritional supplements are unlikely to improve prognosis or overall survival after the diagnosis of cancer. A more recent
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report from the U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamins and single or paired nutrient
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supplements, except β-carotene and vitamin E for which the findings are negative for the prevention of cancer.[38]
While scientific and evidence-based thinking is fundamental to contemporary medical practice, failure to recognize that patients often do not reason in this way, interferes with physicians’ and nurses’ abilities to
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address the unspoken needs of the patient with cancer. Psychological, social, and spiritual dimensions of care may be ignored if the physician and nurse cannot adapt to the individual needs of the patient or provide care without sensitivity. [39]
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Patients may take nutritional supplements to reduce side effects and organ toxicity, to protect and stimulate
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immunity, or to prevent further cancers or recurrences. Patients often do not report their use of supplements to their providers. [40, 41] As a result, there is a gap in communication between providers and their patients. In order to be open to the patient’s perspective, and sensitive to his or her need for autonomy and empowerment, physicians, nurses, and nutritionists may need to shift their own perspectives. Perhaps the optimal approach is to discuss both the facts and the uncertainty with the patient, in order to reach a mutually informed decision. Today’s informed patients truly value providers who appreciate them as equal participants in making their own
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ACCEPTED MANUSCRIPT health care choices. At a very minimum, reconciling the medication list to include any current supplements puts all team members on the same page to assess risk, benefit, safety, and interaction issues. In order to reach a mutually informed decision about the use of these supplements, the Clinical Practice Committee of the Society of Integrative Oncology undertook the challenge of providing basic information to
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health care providers. They identified that health care providers need basic information related to nutritional supplements that are known to be safe and have indications for clinical efficacy. The Committee surveyed clinicians with extensive experience in consulting cancer patients about nutritional supplement use in leading
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cancer centers. [42] A list of leading supplements that have the best suggestions of benefit was constructed by leading researchers and clinicians who have experience in utilizing these nutritional supplements. This list
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includes curcumin, glutamine, vitamin D, maitake Mushrooms, fish oil, green tea, milk thistle, Astragalus, melatonin, and probiotics. The list also includes basic information on each supplement such as evidence on effectiveness and clinical trials, adverse effects, and interactions with medications if known, and possible dosage. The information was constructed to provide an up to date base of knowledge, so physicians and other
benefits and risks.
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Alternative nutritional practices
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healthcare providers would be aware of the supplements, and able to discuss realistic expectations and potential
Another aspect of nutrition that is commonly raised by patients is the utilization of “alternative” cancer diets.
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Examples are the Macrobiotic diet, Gerson diet, raw food diet and others. [43, 44] Most of these “alternative” diets used by cancer patients follow low-fat, plant-based patterns. However, these diets are potentially problematic for cancer patients in certain situations and generally lack the quantity of food intake necessary for optimal diet therapy.
The macrobiotic diet is an adaptation of the traditional Japanese diet. It is comprised of 50% to 70% whole grains, 20% to 25% vegetables, 5% to 10% beans and sea vegetables, and 5% vegetable soups. Nuts, seeds, fruits, and fish are consumed occasionally, but red meat, dairy, and sugar are avoided. Macrobiotic counselors 12
ACCEPTED MANUSCRIPT adapt the diet according to personal conditions, season, climate, and other factors. There have been no randomized clinical studies published in the available medical literature to show the macrobiotic diet can be used to prevent or cure cancer. On the basis of current evidence and its similarity to dietary recommendations for chronic disease prevention, the macrobiotic diet may add a reduced cancer risk. However, at present, the
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empirical scientific basis for or against recommendations for use of macrobiotics for cancer therapy is limited. Difficulties can arise for patients with cachexia due to the low caloric density of this diet. [44,45] Gerson therapy requires following a strict low-salt, low-fat, vegetarian diet and drinking juice from about
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twenty pounds of fresh fruits and vegetables each day. Fasting and coffee enemas are included in the protocol, which can be very rigorous and sometimes difficult to follow. There have been no well-controlled studies
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published in the available medical literature that show the Gerson therapy is effective in treating cancer. Monitoring for adequate protein intake in patients with cachexia is necessary, and the intake of fruit juice may compromise electrolyte balance and blood-sugar control.
Raw Foods Diet, developed by Ann Wigmore, is a diet based on only raw foods, fermented vegetables,
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sprouted grains, and juices such as wheatgrass juice. Inadequate protein and n-3 fatty acid intakes have been raised as potential problems with long-term use of this diet. There is some data that suggests improvement in
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quality of life for the use of wheatgrass juice in patients undergoing active chemotherapy. [46] NUTRITIONAL RESOURCES AND SYMPTOM REDUCTION PROTOCOLS IN CANCER CARE
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One of the challenges in cancer nutrition is making food palatable. Sometimes, the best thing is a good cookbook with practical, evidence-based experience, and recipes to support health and nutrition. In our Integrative Oncology consultations, a favorite resource is Rebecca Katz’s The Cancer Fighting Kitchen.47 Savory, health promoting foods provident nutrient-rich meals to support cancer patients through treatment and in the survivorship stage. This well written book is a toolbox that takes the patient and the care provider through the full spectrum of eating and nutritional problems that can occur during cancer. For example, the first chapter reviews some pre-chemotherapy and post-chemotherapy food protocols and provides a useful list of spices and 13
ACCEPTED MANUSCRIPT seasonings to help overcome problems with taste buds. It also describes the cancer-fighting benefits of many foods and spices, e.g., turmeric, an array of vegetables, fruits, and teas, and protein sources. A long chapter on nourishing soups and broths offers superb recipes that are easy to prepare, eat, and digest. Similarly, chapters on healthy vegetables, protein-building foods, snacks, tonics and elixirs, and other yummy and sweet foods make
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the process of eating wonderful again, and health promoting. Smaller more frequent meals in wide variety seem to be the optimum combination.
Another excellent resource is Dr. Keith Block’s Life Over Cancer48. This book offers three excellent
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chapters covering diet: The Anti-Cancer Diet, The Life Over Cancer Core Diet Plan, and Individualizing Your Diet. Dr. Block began his cancer-fighting career utilizing the macrobiotic diet back in the 1970’s and has
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expanded it to a full service holistic and integrative cancer program in Chicago, The Block Cancer Center. The diet chapters in this book offer some key principles emphasizing the power of diet in cancer: Emphasize low fat foods and healthy fats such as omega-3 fatty acids
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Avoid refined carbohydrates and eat whole grains, fruits, and vegetables instead
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Reduce intake of animal protein and dairy but emphasize fish, egg white, whey protein
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Get micronutrients and phytochemicals from a rainbow of plant foods plus carefully selected dietary
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supplements such as vitamins, minerals, prebiotics, probiotics, mushroom extracts Maintain albumin level over 3.0g/dL, preferably over 3.6g/dL
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At times for cancer patients, true nutritional rescue is needed. There are a number of approaches to cancer cachexia, weight loss, and malnutrition due to side effects of treatment, catabolic state, and other factors. Dr. Block’s book covers this well with a nutritional rescue program, healthy smoothies, and other practical approaches48.
Symptom Management Protocols Cancer therapy can reduce a patient’s ability to take in food by its effects on the gastrointestinal tract. There are a significant number of conventional as well as evidence-based complementary and integrative approaches to 14
ACCEPTED MANUSCRIPT managing the side effects of cancer that largely impact the ability of patient during cancer therapy to maintain adequate nutrition. There are specific and common problems such as anorexia, dysgeusia, mucositis, dry mouth, nausea and vomiting. See Tables 3, 4, 5, 6, 7. Each of these conditions limits the ability of cancer patient to sustain and assimilate adequate caloric intake and if left untreated, contribute to cancer-related
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cachexia, delay in healing, immune suppression, risk of cancer progression or recurrence, and general degradation on quality of life measures.
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FUTURE RESEARCH DIRECTIONS
The spectrum of nutritional issues in cancer is truly expansive. The role of and proper mix of nutrients in
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cancer prevention and in cancer survivorship is still evolving. Studies have been inconclusive about this area though what has generally evolved is that a plant-based, low glycemic diet is likely to be the most useful. This may not be appropriate or acceptable to all patients and getting adequate protein from purely plant sources while achievable, is a cultural and culinary challenge for many patients.
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One of the most exciting and promising areas here is the evolving big data sets that are increasingly used to characterize individuals genomically. Foods, exercise, and other lifestyle factors have epigenetic impacts that can raise or lower cancer risk. As with pharmacogenomics, nutrigenomics offer increasingly personalized
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choices for nutritional selections. Emerging studies on the human microbiome are also revealing the importance of our inner ecosystem on immunity and good health in general, not just the gastrointestinal tract.
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Working in health care teams with nutritionists, motivational specialists, mind-body therapists, coaches, and trainers can all facilitate sensible lifestyle choices among our patients with cancer, for those who are trying to prevent cancer, or those seeking to maintain remission in the survivorship stage. Nutrition plays an essential and complex role in all of these settings.
TABLE 1: Deep Breathing Exercise 1. Lie in a comfortable position with your knees bent. 2. Place one hand on your chest and one hand on your abdomen.
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ACCEPTED MANUSCRIPT 3. Inhale deeply and slowly into your abdomen. You should notice that your chest moves only a little and only with your abdomen. Practice this for 5-10 minutes two times a day. TABLE 2: Helpful Resources for Mind-Body Therapies A. Books The Relaxation and Stress Reduction Workbook by Davis, Eshelman and McKay (2000) Fighting Cancer from Within by Martin LR (2003) Timeless Healing by Benson (1996) Prayer is Good Medicine: How to Reap the Healing Benefits of Prayer by Dossey (1997) Kitchen Table Wisdom: Stories that Heal by Remen (1997) Spontaneous Healing: How to Discover and Enhance your Body’s Natural Ability to Maintain and Heal Itself by Weil (1996) B. Websites:
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1. 2. 3. 4. 5. 6.
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1. Commonweal: Week-long retreats for cancer patients and their support people. www.commonweal.org/program/commonweal-cancer-help-program/ 2. Health Journeys: MP3’s and CDs of guided imagery for stress reduction, fighting cancer, chemotherapy, fatigue, successful surgery and many more. www.healthjourneys.com 3. Mindful Living Programs: Online mindfulness-based stress reduction programs. www.mindfullivingprograms.com 4. Dr. Weil: Videos and explanations for three highly effective breathing exercises. http://www.drweil.com/drw/u/ART00521/three-breathing-exercises.html
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TABLE 3 Evidence-based recommendations for Anorexia [49, 50, 51, 52] Recommend eating small, frequent meals or snacks (try something every two hours) Avoid drinking during meals. Advise to start eating earlier in the morning. If they return to bed, elevate head of bed or prop up with pillows to avoid reflux Recommend selecting foods that are calorie and protein-rich such as cream soups, puddings, custards, cheese, casseroles, milk, milk shakes and liquids nutritional supplements like Boost ®or Ensure® Emphasize avoiding low-calorie filler foods Make sure constipation, pain or nausea do not interfere with food consumption Advise to separate solids and liquids (drinking just enough to get food down); drinking liquids "between" meals and snacks Fish oil supplements. Recommend high quality, molecular distilled fish oil at 2g per day. Glutamine—15-30 g/daily as a modulator of protein turnover and for enhancing net protein synthesis Medications: Megestrol acetate (160-1600mg/day)* Dexamethasone, methylprednisolone, and prednisolone for short-term treatment TABLE 4 Evidence-based recommendations for Dysgeusia [49,50,53] If mucosa is intact, add seasoning such as lemon pepper, chili, BBQ, pickles; add spices like oregano, rosemary, thyme.
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Serving the food hot so as to stimulate the olfactory senses too. Sucking on lemon drops, mints or chew gum to rid a bad taste in the mouth Recommend liquid nutritional supplements and to vary the flavors to avoid taste fatigue. Try Chef Rebecca Katz’s strategies using FASS…Fats, Acid, Salt and Sweet. Cookbook entitled One Bite at a Time: Nourishing Recipes for Cancer Survivors and their Friends. Good mouth care, e.g., rinse mouth frequently with baking soda and salt swish and spit solution, and brush teeth with very soft/soft toothbrush Brushing teeth and tongue before eating. Using good plastic utensils if food tastes metallic. Trial of zinc (45mg) three times daily for one month
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TABLE 5 Evidence-based recommendations for Mucositis [49, 50, 51, 54, 55] Emphasize eating soft, moist, easy-to-chew foods Advise consumption of nutrient-dense liquids/nutrient supplements Recommend using a straw to drink room temperature or cool beverages Avoid acidic and spicy foods; Avoid dry, rough/course foods; Avoid alcohol. Check for ulcerations and other problems in the mouth. Encourage self inspection by the patient Have patient get a soft toothbrush and use gentle toothpaste Recommend baking soda and salt. (1 tsp baking soda and 1 tsp of salt added to 17-18 ounce bottle of water. Swish and spit and repeat at least every two hours. Avoid alcohol-containing mouthwash Glutamine 15-30 g daily Zinc l-carnosine (8 mg zinc and 29 mg l-carnosine taken 3 times daily) Lemon/glycerin swabs Medications: Caphasol® Neutrasal® “Pink, Magic or Miracle Mouthwash” compounded solution that usually contains Benadryl, viscous lidocaine and Mylanta; some preparations contain Nystatin.
TABLE 6 Evidence-based recommendations for Dry Mouth [50, 51] Advise to drink/swallow small amounts of food at one time Recommend eating soft moist foods and adding extra gravies and sauces Avoid dry rough foods; take care with breads and crackers
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Advise trying sweet/tart foods Suck on hard candies Recommend spring water to help swallow foods; carrying a bottle at all times; sipping on liquids, sucking on ice chips throughout the day Avoid caffeine-containing beverages, alcohol and tobacco Encourage good mouth care: rinsing mouth frequently with baking soda and salt swish and spit solution, and brushing teeth with very soft/soft toothbrush Avoid alcohol-containing mouthwash Advise drinking through a straw Utilize a cool mist humidifier in the living areas and bedroom; make sure to use bottled water and clean regularly Trial of Biotene® products (mouthwash, gum, toothpaste) Artificial saliva Zinc l-carnosine (8 mg zinc and 29 mg l-carnosine taken 3 times daily)
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TABLE 7 Evidence-based recommendations for Nausea and Vomiting [49,56,57, 58] Advise small frequent meals and snacks; avoid skipping meals as an empty stomach can contribute to nausea. Recommend putting foods by the bedside so to snack before rising. Advise to eat and drink lower fat foods and beverages Recommend eating and drinking foods and beverages that are room temperature or cool. Avoid spicy foods and caffeine Avoid foods that have strong smells Advise not eating 1-2 hours before chemotherapy or radiation treatment Acupressure bands may be helpful for mild nausea or instruct patient on use of acupressure with their fingers at MH6 point on inner wrist Advise wearing loose clothing and keep rooms well ventilated Dried ginger 500 mg two times daily two days before, the day of, and two days after chemotherapy may be helpful Relaxation, hypnosis, acupuncture, music therapy, guided imagery, progressive muscle relaxation (for anticipatory nausea) are also effective Medications:
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5-HT3 receptor agonists (palonosetron, granisetron, ondansetron, dolasetron, tropisetron) NK1 receptor antagonist (aprepitant) Corticosteroid (dexamethasone) Benzodiazepine (lorazepam) Metoclopramide ± diphenhydramine Phenothiazine (prochlorperazine) Butyrophenones (haloperidol) Cannabinoids Olanzapine Promethazine
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