Module IV.

Nutritional Management in Cancer

 Overview and etiology of cancer
 Modes of therapy,
 Nutritional management
 Diet to prevent cancer

WHAT IS CANCER?

Cancer is an uncontrolled growth of abnormal cells anywhere in a body. These abnormal cells
are termed cancer cells, malignant cells, or tumor cells. These cells can infiltrate normal body
tissues. Many cancers and the abnormal cells that compose the cancer tissue are further
identified by the name of the tissue that the abnormal cells originated from (for
example, breast cancer, lung cancer, colorectal cancer). When damaged or unrepaired cells do
not die and become cancer cells and show uncontrolled division and growth -- a mass of
cancer cells develop. Frequently, cancer cells can break away from this original mass of cells,
travel through the blood and lymph systems, and lodge in other organs where they can again
repeat the uncontrolled growth cycle. This process of cancer cells leaving an area and
growing in another body area is termed metastatic spread or metastasis. For example, if breast
cancer cells spread to a bone, it means that the individual has metastatic breast cancer to
bone.
What are the risk factors and causes of cancer?
Anything that may cause a normal body cell to develop abnormally, potentially can cause
cancer. Some cancer causes remain unknown while other cancers have environmental or
lifestyle triggers or may develop from more than one known cause. Some may be
developmentally influenced by a person's genetic makeup. Many patients develop cancer
due to a combination of these factors.

RISK FACTORS & CAUSES OF CANCER:

1. Heredity
Several specific cancers have been linked to human genes and are as follows: breast,
ovarian, colorectal, prostate, skin and melanoma. The higher the amount or level of
cancer-causing materials a person is exposed to, the higher the chance the person will
develop cancer. In addition, the people with genetic links to cancer may not develop it for
similar reasons (lack of enough stimulus to make the genes function). In addition, some
people may have a heightened immune response that controls or eliminates cells that are
or potentially may become cancer cells.
2. Ionizing radiation
Uranium, ultraviolet rays from sunlight, radiation from alpha, beta, gamma, and X-ray-
emitting sources can predispose to cancer by rupturing DNA strands, thus causing
mutations.
3. Chemical substances
Chemical substances that can cause mutations are called carcinogens. Example of
carcinogens are - benzene, asbestos, nickel, cadmium, vinyl chloride, benzidine, N-
nitrosamines, tobacco or cigarette smoke (contains at least 66 known potential
carcinogenic chemicals and toxins).
4. Dietary factors – Meat, energy balance, fat, protein, alcohol, nitrates
MEAT:
• Meat intake has been associated with risk of digestive tract cancers.
• Intake of red meat and white meat is known to increase the risk of colon cancer.
• High intake of fish sauce may be a risk factor for gastric cancer.
ENERGY BALANCE
• The relationship between body weight, body mass index, or relative body weight and
site-specific cancer has been found to be positively associated with the cancers of the
breast, endometrium, gall bladder, and kidney.
• Physical inactivity, high energy intake, and large body mass are associated with
increased risk of developing colon cancer in both men and women.
FAT:
• A high intake of saturated fat increases the risk of prostate cancer.
PROTEIN:
• Increased meat intake has been found to be associated with an increased risk of colon
cancer and with advanced prostate cancer.
ALCOHOL:
• Alcohol has a causal role in carcinogenesis, especially for cancers of the mouth,
pharynx, and esophagus.
• Alcohol has an increased effect on those tissues that directly get exposed to it during
its consumption and tends to act cooperatively with tobacco.
• Beer consumption has been associated with an increased risk for colorectal cancer.
NITRATES:
• Nitrates are present in a variety of foods, and the main dietary sources are vegetables
and drinking water.
• Sodium and potassium nitrates are used in the processes of salting, pickling and
curing foods.
• Nitrosamines are present in tobacco and tobacco smoke.
• Nitrosamines related to nitrates and nitrates are potent carcinogens.
• When Nitrates are taken into the body by drinking water and through other dietary
sources, nitrate and nitrite can react with amines and amides to form N-nitroso
compounds (NOC), which are known to cause cancer in animals and may cause
cancer in humans.
• Nitric oxide can cause irreparable damage to several basic cancer control genes.
 5. Estrogens
Estrogens have been given for the relief of post-menopausal symptoms and for the
prevention of osteoporosis. Estrogens may play a role in the production of breast and
endometrial cancer. The prevailing view of estrogen's role in breast cancer is that it acts as
a catalyst for cancer growth because it stimulates the division and proliferation of breast
tissue, a process that carries the risk for cancer-causing mutations.
6. Viruses
Viruses may act as cofactors in the development of some malignant diseases. There may
be a possible role of hepatitis B virus in human primary liver cancer. Human
papillomavirus and the Epstein Barr virus are considered oncogenic.
7. Stress
Stress may cause damage to the thymus gland, and the immune system and hormonal
effects mediated through the hypothalamus, pituitary and adrenal cortex. This may
provide the neurologic currency that converts anxiety to malignancy.
8. Age
The risk of developing colorectal cancer increases with age. The incidence is 6 times
higher among persons aged 65 years and older than in comparison to persons aged 40-64
years. Increasing risk of cancer with age reflects the accumulation of critical genetic
mutations .

What are cancer signs and symptoms?

• Symptoms and signs of cancer depend on the type of cancer, where it is located,
and/or where the cancer cells have spread.
• For example, breast cancer may present as a lump in the breast or as nipple
discharge while metastatic breast cancer may present with symptoms of pain (if
spread to bones), extreme fatigue (lungs), or seizures (brain).
• A few patients show no signs or symptoms until the cancer is far advanced.
Seven warning signs and/or symptoms that a cancer may be present, and which should
prompt a person to seek medical attention.
1. Change in bowel or bladder habits.
2. A sore throat that does not heal.
3. Unusual bleeding or discharge (for example, nipple secretions or a "sore" that will not
heal that oozes material)
4. Thickening or lump in the breast, testicles, or elsewhere
5. Indigestion (usually chronic) or difficulty swallowing
6. Obvious change in the size, color, shape, or thickness of a wart or mole
 7. Irritating cough or hoarseness
Other signs or symptoms may include the following:
• Unexplained loss of weight or loss of appetite
• A new type of pain in the bones or other parts of the body that may be steadily
worsening, or come and go, but is unlike previous pains one has had before
• Persistent fatigue, nausea, or vomiting
• Unexplained low-grade fevers which may be either persistent or come and go
• Recurring infections which will not clear with usual treatment

THE DEVELOPMENT OF CANCER (PATHOGENESIS)

Carcinogenesis is a multistage process. The application of a cancer-producing agent
(carcinogen) does not lead to the immediate production of a tumor. There are a series of
changes after the initiation step induced by the carcinogen. The subsequent stages tumor
promotion may be produced by the carcinogen or by other substances (promoting agents),
which do not themselves "produce" tumors. Initiation, which is the primary and essential step
in the process, is very rapid, but once the initial change has taken place the initiated cells may
persist for a considerable time, perhaps the life span of the individual. The most likely site for
the primary event is in the genetic material (DNA), although there are other possibilities. The
carcinogen is thought to damage or destroy specific genes probably in the stem cell
population of the tissue involved.
The earliest events, initiation, and promotion, require exogenous exposures to carcinogenic
chemicals. Initiation is mutagenic in nature and generally results from DNA damage
produced by a metabolically activated genotoxic carcinogen. In this regard, it is an
irreversible phenomenon. In contrast, tumor promotion is epigenetic in nature and is often
reversible. Promoters induce changes in epidermal homeostasis (the epidermis undergoes
continuous self-renewal to maintain its protective function) that provide a tissue environment
favorable for the clonal expansion of initiated cells. The consequence of initiation and
promotion is the formation of single clone of initiated cells. Initiated cells remain latent until
acted upon by promoting agents. Many of these 'transformed' cells may not grow at all or
grow very slowly. It is at this stage that the influence of growth appears. Promoting agents are
not carcinogenic by themselves but they induce initiated cells to divide. Many agents will
induce cell division, but only promoters will induce tumor development, so that although cell
growth is necessary for tumor development there must also be other factors involved. The
suggestion is that promoting agents may interfere with the process of differentiation that
normally takes place when cells move from the dividing stem cell population into
functioning, and usually non-dividing, cells. Even though these growth-promoting stimuli are
acting on the cells, they may still be sensitive to the normal growth-inhibiting factors in the
body so that the final outcome depends on the balance between the factors and the extent of
the changes in the initiated cells. This explains why preneoplastic, or even apparently fully
transformed tumors, can be found but do not appear to be growing, and sometimes even
regress.

TYPES OF CANCER TREATMENT

There are many types of cancer treatment. The types of treatment that one receives will
depend on the type of cancer one has and how advanced it is. Some people with cancer will
have only one treatment. But most people have a combination of treatments, such as
surgery with chemotherapy and/or radiation therapy.

1. Surgery
Surgery is a procedure in which a surgeon removes cancer from the body.
How Surgery Is Used for Cancer?
• Surgery is used to prevent, diagnose, stage, and treat cancer. Surgery can also relieve
(palliate) discomfort or problems related to cancer.
• Sometimes, one surgery can take care of more than one of these goals. In other cases,
different operations may be needed over time.
Curative surgery:
• Curative or primary surgery is usually done when cancer is found in only one part of
the body, and it’s likely that all of the cancer can be removed.
• It is called "curative" because the purpose of the surgery is to remove all of the cancer
completely.
• In this case, surgery can be the main treatment.
• It may be used along with other treatments like chemotherapy or radiation
therapy given before or after the operation, but surgery can also be used alone.
2. Radiation Therapy
Radiation therapy is a type of cancer treatment that uses high doses of radiation to kill cancer
cells and shrink tumors.
What is radiation therapy?
• Radiation therapy uses high-energy particles or waves, such as x-rays, gamma rays,
electron beams, or protons, to destroy or damage cancer cells.
• Cells normally grow and divide to form new cells. But cancer cells grow and divide
faster than most normal cells.
• Radiation works by making small breaks in the DNA inside cells. These breaks
keep cancer cells from growing and dividing and cause them to die.
• Nearby normal cells can also be affected by radiation, but most recover and go back
to working the way they should.
• While chemotherapy and other treatments that are taken by mouth or injection usually
expose the whole body to cancer-fighting drugs, radiation therapy is usually a local
treatment.
• This means it’s usually aimed at and affects only the part of the body needing
treatment.
• Radiation treatments are planned so that they damage cancer cells with as little harm
as possible to nearby healthy cells.

3. Chemotherapy:
 • Chemotherapy is a type of cancer treatment that uses drugs to kill cancer cells.
• Chemo is considered as a systemic treatment because the drugs travels throughout the
body and can kill cancer cells that have spread (metastasized) to parts of the body far
away from the original (primary) tumor.
• This makes it different from treatments like surgery and radiation.
• Surgery removes a tumor from a part of the body where cancer has been found, and
radiation therapy is aimed at a certain area of the body to kill or damage cancer cells.
• Treatments like these are called local treatments because they affect one part of the
body.
• Chemotherapy is commonly given at regular intervals called cycles.
• A cycle may be a dose of one or more drugs on one or more days, followed by several
days or weeks without treatment.
• This gives normal cells time to recover from drug side effects.

4. Immunotherapy:
• Immunotherapy is treatment that uses certain parts of a person’s immune system to
fight cancer.
This can be done in a couple of ways:
• Stimulating, or boosting, the natural defenses of our immune system so it works
harder or smarter to find and attack cancer cells.
• Making substances in a lab that are just like immune system components and using
them to help restore or improve how our immune system works to find and attack
cancer cells
5. Targeted Therapy
• Targeted therapy is a type of cancer treatment that uses drugs designed to "target"
cancer cells without affecting normal cells.
• Cancer cells typically have changes in their genes that make them different from
normal cells.
• When a cell has certain gene changes, it doesn't behave like a normal cell. For
example, gene changes in cancer cells might allow the cell to grow and divide very
quickly. These types of changes are what make it a cancer cell.
• Targeted drugs can block or turn off signals that make cancer cells grow or can signal
the cancer cells to destroy themselves.
6. Hormone Therapy
• Some cancers depend on hormones to grow. Because of this, treatments that block or
alter hormones can sometimes help slow or stop the growth of these cancers.
 • Treating cancer with hormones is called hormone therapy, hormonal
therapy, or endocrine therapy.
• Hormone therapy is mostly used to treat certain kinds of breast cancer and prostate
cancer that depend on sex hormones to grow.
• Hormone therapy is considered a systemic treatment because the hormones they target
circulate in the body. The drugs used in hormone therapy travel throughout the body
to target and find the hormones.
How hormone therapy works
Hormone therapy travels throughout the body to find and target hormones. Different types of
hormone therapy work in different ways. They can:
• Stop the body from making the hormone
• Block the hormone from attaching to cancer cells
• Alter the hormone so it doesn't work like it should
Hormone therapy can be used to:
• Treat a certain kind of cancer by stopping or slowing its growth
• Lessen symptoms related to a certain type of cancer

7. Stem Cell Transplant

• Stem cell transplants are procedures that restore blood-forming stem cells in cancer
patients who have had theirs destroyed by very high doses of chemotherapy or
radiation therapy.
• So, transplanting the healthy cells lets doctors use much higher doses of chemo to try
to kill all of the cancer cells, and the transplanted stem cells can grow into healthy,
mature blood cells that work normally and reproduce cells that are free of cancer.
8. Precision Medicine
Precision medicine helps doctors select treatments that are most likely to help patients based
on a genetic understanding of their disease.

NUTRITIONAL AND EATING PROBLEMS IN CANCER

1. Problems related to surgical treatment.
2. Problems related to radiotherapy.
3. Problems related to chemotherapy.

1. Problems related to surgical treatment:

 • Gastrointestinal surgery poses problems of normal ingestion, digestion and absorption
of food nutrients.
• Head and neck surgery or resections in the oropharyngeal area can greatly affect the
food intake.
• Long term tube feeding may be required in some cases.
• Gastrectomy may cause numerous post gastrectomy “dumping” problems requiring
frequent, small, low carbohydrate feedings.
• Vagotomy contributes to gastric stasis.
• Pancreatectomy contributes to loss of digestive enzymes, induced insulin dependent
diabetes mellitus and general weight loss.
2. Problems related to radiotherapy:
• Radiation to the oropharyngeal area produces a loss of taste sensation with increasing
anorexia, nausea and consequent decreased appetite.
• Abdominal radiation may cause intestinal damage with tissue edema and congestion,
decreased peristalsis or endarteritis in small blood vessels.
• In the intestinal wall there may be fibrosis, stenosis (narrowing), necrosis, or
ulceration.
• If this condition continues over time, it may lead to hemorrhage, obstruction, fistulas,
diarrhea or malabsorption.
• The liver is resistant to damage from radiation in adults, but children are more
vulnerable.

3. Problems related to chemotherapy:

1. The gastrointestinal symptoms caused by the effect of the toxic drugs on the rapidly
developing mucosal cells.
2. The anemia associated with bone marrow effects, and
3. The general systemic toxicity affects appetite.
• Stomatitis, nausea, diarrhea and malabsorption contribute to many food intolerances.
• Prolonged vomiting affects fluid and electrolyte balance especially in elderly persons.
• Anti-depressant drugs can cause pressor effects when used with tyramine rich foods.
 NUTRITIONAL MANAGEMENT

Objectives of nutritional therapy:

• To meet the increased metabolic demands of the disease and prevent catabolism as
much as possible, and
• To alleviate symptoms resulting from the disease and its treatment through adaptation
of food and the feeding process.
1. Energy:
• To prevent excessive weight loss and to meet increased metabolic demands, the total
energy value of the diet must be increased.
• Calorie density sufficient to counter catabolic or hyper-metabolic states and to support
necessary anabolism is necessary.
• Of this total dietary kilocalorie value, there must be sufficient carbohydrate to spare
protein for vital tissue synthesis.
• For an adult patient with good nutritional status about 2000 kcal is recommended.
• A malnourished patient may require 3000-4000 kcal depending on the degree of
malnutrition and body trauma.
2. Protein:
• Additional protein is required to provide essential amino acids and nitrogen necessary
for tissue regeneration, healing, and rehabilitation.
• An adult patient with good nutritional status will need about 80 to 100 g to meet
maintenance needs and to ensure anabolism.
• A malnourished patient will need more to replenish tissues and to ensure positive
nitrogen balance.

3. Vitamins and minerals:

• Optimal intake of vitamins and minerals atleast at recommended dietary allowance
levels and frequently augmented with supplements according to nutritional status is
indicated.
4. Fluid:
• Fluids are increased to compensate losses from gastrointestinal problems as well as
any additional loss caused by infections and fever.
• Sufficient fluid intake is necessary to help the kidneys rid the body of the breakdown
products from the destroyed cancer cells and from the drugs themselves.
• Increased fluid also helps to protect the urinary tract from irritation and inflammation.
Important points to be considered while planning diet for cancer patients:
• Oral and other enteral feeding modes are recommended as they pose fewer problems.
• Oral diets can be amplified with nutrient supplements for increased protein,
kilocalories, vitamins and minerals.
• Enteral tube feeding with several routes of entry and parenteral nutrition through
central and peripheral veins are suggested.
• Based on individual nutritional assessment, a personal food plan is developed with the
patient, incorporating desired food forms and family food patterns.
• A number of adjustments in food texture, temperature, amount, timing, taste,
appearance and form can be made to help alleviate symptoms.
• Food should be nutrient dense.
• Texture is varied as tolerated, with appeal to sensory perceptions of color, aroma, and
taste to enhance the desire to eat.
• A series of mini meals using a wide variety of food items is better tolerated than
regular large meals.
• If appetite is better in the morning, a good breakfast should be emphasized.
• Exercise before meals and maintaining surroundings that reduce stress may help in the
eating process.
• Zinc supplement may be indicated, as Zn deficiency is related to diminished taste.
• Salivary secretion is also affected by cancer therapy, so foods with a high liquid
content should be used.
• Hot, sweet, fatty or spicy foods can enhance nausea, so these foods should be avoided.
• Frequent small meals and snacks, soft in texture, bland in nature and cool to cold in
temperature are better tolerated.

ROLE OF FOOD IN CANCER PREVENTION

While no one food or food component alone can prevent cancer, research suggests that a diet
rich in vegetables, fruits, whole grains, beans, and legumes can help significantly lower our
risk for a variety of cancers. There are multiple food components and chemicals found in
certain foods that aid in preventing cancer. Phytochemicals that naturally occur in plants are
chemicals that reduce inflammation (which may increase the risk for cancer), enhance the
immune system, and have many other protective properties against cancer. Antioxidants
block chemicals, known as free radicals, that may damage cells and increase risk for cancer.
There are various antioxidants found in certain foods and beverages. Examples of dietary
antioxidants include lycopene, beta-carotene, and vitamins A, C, E, which are found in a
variety of fruits and vegetables. Catechins, which are antioxidants found in tea, have been
shown to potentially decrease risk for cancer. A high fibre diet has also been shown to
significantly decrease risk of colorectal cancer, particularly due to fiber’s ability to bind
carcinogens in the colon.
In many studies, multiple vitamins, minerals, and phytochemicals have been shown to have
anti-cancer effects, but evidence suggests that many of these compounds work together in an
overall diet to offer protection against certain cancers.
If combined in a well-balanced diet, the 5 foods listed below are at the top of the list for
prevention of various types of cancer:
• Brussel sprouts, broccoli, and other cruciferous vegetables
• Dark green leafy vegetables including spinach.
• Blueberries
• Bright, orange-coloured vegetables and fruits including sweet potatoes, carrots, and
bell peppers.
• Garlic

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