Cancer

Cancer: refers to uncontrolled growth of abnormal cells which may occur in various body
sites, therefore not a single disease.
Cancerogenesis or carcinogenesis: the process of cancer cell development, which consists
of initiation, promotion and metastasis.
Carcinogen :a substance which causes cancer
Oncology: the science of tumors
Tumor: growth of tissue characterized by uncontrolled cell proliferation. A tumor may
be benign or malignant; localized or invasive.

Three Progressive Phases of Carcinogenesis

1. Initiation – the initial stage of tumorigenesis, involving transformation of cellular
DNA. Initiation involves a transformation of the cell produced by the interaction of
chemicals, radiation, or viruses with cellular DNA. The transformation occurs rapidly,
but the resultant cell remains dormant for a variable period until it is activated by a
promoting agent.

2. Promotion – initiated cells are activated by a promoting agent to multiply and escape
the mechanisms set in a place to protect the body from the growth and spread of such
cells; Neoplasm or new and abnormal tissue with no useful function is established.

3. Tumor progression – the phase in which tumor cells aggregate, grow autonomously,
leading eventually to a fully malignant neoplasm or a tumor with the capacity for
tissue invasion and metastasis.

Metastasis – growth of malignant tissue that spreads to surrounding tissues or organs.

Tumors and Cancer Classification

Benign Tumor: It is confined to the area where it originated; it is not cancer, i.e. it does
not spread to other parts of the body. Its growth is usually slow. It can usually be
removed, and in most cases, they do not come back.

Malignant: Tumor grows either rapidly or slowly. They can invade and damage nearby
tissues and organs and can break away from a malignant tumor and enter the bloodstream
and lympathic system (the process is called metastasis). This is how cancer spreads from
the original (primary) cancer site to form new (secondary) tumors in other organs.

Carcinomas - arise from the lining membranes of internal organs and the glandular
organs.
Sarcomas - develop in muscles, bones, cartilages and connective tissues.
Gliomas - Cancer originating in the network of supporting connective tissues in the
brain and central nervous system. This is a rapidly pigmented tumor.
Lymphomas - the lymph nodes and other tissues of the lymphatic system give rise to
cancerous growths.
Malignant Melanoma - A tumor arising from the skin and may appear on the skin or
other body tissues; composed of melanin, the dark pigment of skin; aggravated by
excessive exposure to sunlight.

Causes of Cancer Cell Development

1. Mutation - changes in a cell’s genes; virus
2. Chemical carcinogens - cigarette smoking, environmental contaminants (pesticides,
industrial chemicals)
3. Radiation – x-ray, radioactive materials, sunlight)
4. Stress Factors
5. Dietary Factors

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 Tests recommended to detect early and prevent development are:
1. A yearly Pap smear and pelvic exam for those who are sexually active or 18 years
or older (endometrium, cervix).
2. A monthly breast self-exam (BSE) starting at age 20 (breast).
3. A mammogram every year or two between the ages of 40 and 49 and every year
starting at age 50 (breast) plus clinical breast exam (CBE).
4. A digital rectal exam (DRE) every year after age 50 (rectum, prostate).
5. A prostate-specific antigen (PSA) blood test every year starting at age 50.
6. A fecal occult blood test (FOBT) for hidden blood once a year after 50 (colon and
rectum).
7. A sigmoidoscopy every three to five years after age-50 (colon and rectum).
8. A dental check up at least once a month

Dietary Risk Factors Sites That May Be Affected

Total energy Breast (especially among post-menopausal
(independent of fat intake) women)
Total Fat Breast, colon, prostrate, pancreas, ovary
Animal fat, saturated fat Breast, prostrate, ovary
Polyunsaturated fat (linoleic acid) Breast, colon, pancreas
Cholesterol Colon
Fried Foods (due to mutagens formed at Breast, colon, prostrate, endometrium, ovary
high frying temperature)
Protein, especially animal protein Prostrate
Meat Pancreas
Alcohol Colon, esophagus, larynx, liver, oral cavity
(mouth and throat)
Salt, salt-picked foods Stomach
Nitrate-cured meat Stomach
Charcoal-broiled/smoked fatty foods Stomach
Charcoal-broiled/smoked fatty foods/ Liver
Moldy food (due to aflatoxin content)

NUTRITION IN THE ETIOLOGY OF CANCER

Natural occurring dietary carcinogens are:
a. naturals pesticides produce by plants for protection against fungi, insects, or animal
b. mycotoxins that are secondary metabolites produced by molds in foods (e.g.,
aflatoxins, fumosins, or ochratoxin A).
c. Food preparation and preservation are also major sources of dietary carcinogens.

Diet contains both inhibitors and enhancers of carcinogenesis Examples:

- Dietary carcinogen inhibitors include: antioxidant (vitamin C, vitamin E,
selenium, and caroteniods) and phytochemicals (e.g., anthrocyanins, lycopene,
indoles, sulforaphanes).
- Dietary enhancers of carcinogenesis may be the fat in red meat or the polylcyclic
aromatic hydrocarbons that form with the grilling of meat at high heat.

1. Energy Intake, Body Weight, Obesity, and Physical Activity

- Regular physical activity helps to control body weight.
- Excess body weight increases the amount of circulating estrogens, insulin, and
insulin like-growth factors, all of which are associated with cell and tumor growth

2. Fat
- amount and type of fat in the diet

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 - diets high in fat also tend to be high in calories and contribute to obesity
- Obesity is associated with increased risk of cancers at several sites: colon and
rectum, esophagus, gallbladder, breast among postmenopausal women, pancreas, and
kidney.
- Dietary fat intake is correlated with the intake of other nutrients and dietary
component; it is difficult to distinguish between the effect of dietary fat and protein,
total calories and fiber.
- Eating more omega-3 fat in relation to omega-6 fat may reduce risk of
premenopausal breast cancer.

3. Protein
- In general, tumor development is suppressed by the diet that contains levels of protein
below that requirement for optimal growth.
- It is enhanced by protein levels two to three times the amount that is required.

4. Soy and Phytoestrogens

- Soy is a plant-based protein, and it contains phytoestrogens (e.g., weak plants-based
estrogens and compounds such as isoflavones and lignin).
- A soy-containing diet may be protective against breast cancer, especially if soy diet
consumed before reaching adulthood.
- The use of soy remains controversial for individuals already diagnosed with cancer.
- Commercially prepared soy supplements powders and foods made from soy protein
isolates (energy bar, cereals, soy beverages, and phytoestrogen supplements) generally
containing isoflavones as much higher concentrations than traditional whole soy foods
such as edemame, tofu, and miso.

5. Carbohydrates: Fiber, Sugars, and Gycemic Index

- A high consumption of simple sugar on a regular diet basis can increase blood glucose
and triglyceride levels and rise levels of insulin and other hormones that may stimulates
cancer cell growth.
- Consumption of high-glycemic index foods also increased risk of cancer, including
ovary, endometrium, breast, colorectal, pancreas, and lung.
- It is prudent to limit processed and refined sugar intake emphasize whole grains or
complex carbohydrate as a part of healthy diet for decreasing cancer risk.

6. Fruits and Vegetables

- Anticarcinogenic agents are found in fruits and vegetables, including antioxidants
(vitamin C and E, selenium) and phytochemicals, non-nutritive compounds in plants.
- Phytochemicals include carotenoids, flavonoids, plant sterols, allium compounds,
indoles, phenols, and terpenes.

7. Nutritive Sweeteners
- The food and drug administration (FDA) has approved five nutritive sweeteners
(ascesulfame-K, aspartame, neotame, saccharin, ans sucralose)for use in the food
supply and regulates them as food additives. They appear to be safe when
used in moderation.

8. Alcohol
- The malnutrition associated with alcoholism is also likely to be important in the
increase risk for certain cancers in the alcoholic individual.

9. Cancer and Tea

- Regular consumption of caffeinated coffee or caffeinated tea or caffeine intake
was not associated with the incidence of colon or rectal cancer in either cohort.
- Another study found that the regular drinking of green tea and other sources of
polyphenols may reduce the risk of stomach cancer.
- Some studies have shown that the consumption of very hot drinks has been associated

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 with an increase of esophageal cancer.

10. Methods of Food Preparation and Preservation

- Both methods of food preparation and preservation are major sources of dietary
carcinogens.
- A possible increased cancer risk posed by the formation of the dietary carcinogens
(polycyclic aromatic, hydrocarbons and heterocyclic amines) when high-heat cooking
methods such as grilling, broiling, barbecuing, and smoking of meats are used.
- Sodium and potassium nitrates are used in the processes of salting, pickling and curing
foods; they give hot dogs and luncheon meats their pink color.
- Nitrates are reduced to nitrites to produce nitrosamines and nitrosamides.
- Diets high w/ vit C & phytochemicals can retard the conversion of nitrites to
nitrosmaines.
- Nitrosamines are also present in tobacco and tobacco smoke.

Acrylamide – a carcinogen in carbohydrate rich foods such as potatoes and baked goods
that has been cooked at high temperatures. It is a by-product that is formed during frying,
roasting and baking.

American Institute of Cancer Research Guidelines for Cancer Prevention

1. Choose a diet rich in variety of plants-based foods.
2. Eat plenty o vegetables and fruits
3. Maintain a healthy weight and be physically active
4. Drink alcohol only in moderation, if at all
5. Select foods low in fat and salt
6. Prepare and store food safety.
7. Do not use tobacco in any form.

The Food and Nutrition Research Institute has specified five nutritional guidelines for the
prevention of cancer among Filipinos. These guidelines suggest ways in which the
present average diet of the country could be improved to reduce or delay development of
cancer:
1. Increase consumption of green leafy & yellow vegetables, fruit & unrefined
cereals.
2. Eat fat and fatty foods in moderation.
3. Limit consumption of smoked, charcoal-boiled, salt-cured and salt-pickled foods.
4. Avoid moldy foods.
5. Drink alcoholic beverages in moderation and stop smoking.

NUTRITION MANAGEMENT OF CANCER PATIENTS

Goals of nutritional care are:
1. To prevent or reverse nutrient deficiencies
2. To preserve lean body mass
3. To minimize nutrition related side effects and
4. to maximize the quality of life.

Nutrition Screening and Risk Assessment

Nutrition status is evaluated by:
• taking a careful review of the individual’s appetite and oral intake,
• nutrition impact symptoms (e.g., nausea, vomiting, and diarrhea),
• weight loss,
• co-morbidities,
• laboratory studies

Nutritional Assessment: provides baseline information used in the care plan, which
includes monitoring, evaluation and education; provides vital information to fully
evaluate the individual’s nutrition status and degree of risk.

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 1. Anthropometric data: body measurements and calculations of body
composition
- Unexplained weight loss is one of the seven danger signals of cancer.
- Cancer patients develop ascites, as well as accumulation of fluids in other body
cavities.
- Assessment of subcutaneous fat stores, muscle mass, and fluid status
2. Biochemical data: laboratory tests and interpretation of results (serum proteins
and serum transferring)
3. physical examination and clinical observations
4. complete dietary analyses
5. socioeconomic history

Indications:
• measures of malnutrition uses three parameters: weight loss of 10 percent or more
body weight; serum albumin < 3.4 gms/dl; serum transferrin <190 mg per deciliter.
• The presence of any two of those findings indicates a need for nutritional support.

Body Weight
• Weight loss during cancer therapy is often more likely caused by the loss of
muscle (lean body mass) rather than fat stores.
• Even if individuals are overweight, the maintenance of lean body mass should be
encouraged throughout treatment and recovery.

Effects of Cancer with Nutritional Implications

A. Anorexia, which may be due to altered taste, fatigue, early satiety, eating difficulties,
pain, food aversions and malabsorption.
B. Cachexia (severe tissue wasting / a state of malnutrition and wasting) – the patient
becomes hypercatabolic.

Stages of Cancer Therapy and Nutritional Objectives

1. Curative stage is when treatment is aggressive or radical (e.g. radiotherapy,
chemotherapy and surgery) and the aim is to eliminate the disease and cure the
patient. The overall goal is the prolongation of life and survival.
- Dietary management at this point is aimed at the treatment-related side effects
of the medical/surgical therapy as well as the effects of the disease itself.

2. Palliative Stage is when cure is not the expected outcome rather the improvement
of the quality of life.
– Diet therapy at this stage is less restrictive. Major consideration is the patient’s
informed preference for the level of nutrition support acceptable to him.

3. Terminal Stage is when death appears imminent (within weeks or hours) and
management is aimed solely at comfort.
– The continuation of aggressive nutrition support at this time becomes an ethical
question. The wishes of the patient and his relatives may be followed.

Dietary Management of Cancer

1. Dietary strategies for the management of nutrition-related problems associated with
cancer & its treatment (anorexia, nausea & vomiting, altered taste perception, dry
mouth, esophagitis, malabsorption & diarrhea) should be given attention.
2. Cancer patients are usually in a hypercatabolic state. Hence nutritional support, enteral
or parenteral, is indicated.
3. Energy, Protein, Fluid, and Micronutrient Requirements:
a. Energy: energy needs are increased possibly by 20%.
b. Protein
• An individual’s need for protein is increased during times of illness and stress.

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 • Additional protein is required by the body to repair and rebuild tissues affected by
cancer therapy and to maintain a healthy immune system.
• A protein intake of 1.5 to 2 g/kg body weight allows for metabolic alterations.
c. Fluid
• The goals of fluid management are to ensure the maintenance of adequate
hydration, and electrolyte balance.
• Careful evaluation of an individual’s hydration status is critical to identify
possible causes for alterations in fluid balance such as fever, ascites, edema,
profuse vomiting and diarrhea, multiple concurrent intravenous (IV) therapies,
impaired renal function, or medications
d. Multivitamin Supplements
• the use of multivitamins and mineral supplement that provides no more than
100% of the dietary reference intakes (DRIs) is generally considered safe
e. Antioxidants during Anticancer Therapy
- Controversy over whether the use of antioxidant supplements such as vitamins A, C,
E, β-carotene, zinc, and selenium actually inhibits or enhances the antitumor effects
of radiation therapy and chemotherapy continues.

Mechanisms of action of phytochemicals and antioxidants:

a. Induce detoxification of enzymes
b. Inhibits nitrosamine formation
c. Dilutes and binds carcinogens in the digestive tract
d. Acts as antioxidants

Nutritional Support For Cancer Treatment

A. Radiotherapy – use of x-rays, radiostopes and atomic particles. The effects depend on
the area subjected to radiotherapy
1. head and neck area
• destruction of sense of taste
• reduction of salivary secretion, leading to mouth dryness
• esopahgitis

2. abdominal area
• bowel damage
• malabsorption leading to diarrhea

B. Chemotherapy – use of chemicals to check the growth of cancer cells. The

antineoplastic drugs used are alkaloids, alkylating agents, antibiotics,
antimetabolites, enzymes and hormones. The effects include:
1. Bone marrow effects – interference with the production of red cells, white cells
and platelets. Thus anemia, lowered resistance to infections
and tendency to bleeding are side effects of chemotherapy.

2. Gastrointestinal effects – include nausea and vomiting, stomatitis, anorexia, ulcers

and diarrhea.

3. Hair follicle effects – include hair loss and alopecia (baldness). These effects are
largely due the anti-vitamin property of the chemotherapeutic agents used, e.g.,
amethopterin is a folic acid antagonist. Hence, the effects of its use are basically those
of folic acid deficiency.

C. Immunotherapy
- interferon and interleukin 2
- chills, fatigue, fever, flulike symptoms and decreased food intake

D. Surgery - cancer patients about to undergo or have undergone surgery may need

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 varying levels of nutrition support depending upon their nutritional status.

Effects of Cancer Therapy with Nutritional Implications

A. Early satiety and Anorexia
- Although they may look starved, cancer clients may take a few bites of food and
declare that they are full. They may say that they have no appetite at all. The main
source of these symptoms is the cancer itself, by a mechanism that is poorly
understood. Control of the disease improves the appetite.
- Some additional factors may interfere with appetite. The psychological stress of
dealing with cancer may produce anxiety or depression. The person may be
grappling with a body image change and may be going through the grieving process
for the loss of a body function or the potential loss of life itself.

B. Taste Alterations
- Cancer clients often have changes in taste perceptions, particularly a decreased
threshold for bitterness.
- Accordingly, they will often say that beef and pork taste bitter and metallic. Some
clients report a decreased sensation of sweet, salty, and sour tastes and desire
increased seasonings. These taste changes are due to the cancer and the various
modes of therapy.

C. Local Effects in the Mouth

- Clients who are being treated for head and neck cancers often experience mouth
ulcers, decreased and thick saliva, and swallowing difficulty. Any of these may
interfere with nutritional intake.

D. Nausea, Vomiting and Diarrhea

- This triad symptoms often accompany cancer treatment, either radiation or
chemotherapy, as well as certain types of tumors. Since the gastrointestinal tract
cells are replaced every few days, these rapidly dividing cells are more vulnerable
to the cancer treatments than are more slowly reproducing cells.
- Not all clients suffer these side effects to the same extent. Health care workers
must be careful not to program clients to be sick.

E. Altered Immune Response

- Sometimes, antineoplastic agents also suppress the client’s immune system. Clients
receiving them are at risk of overwhelming infections from organisms that would
not affect other persons.

Nutritional Interventions
A. Early Satiety
• may give nutrient dense food
• should be encouraged to eat by providing attractive prepared food
• give small servings, offered frequently
• clients with severe chronic anorexia who can tolerate oral intake may benefit from
drug therapy with medicines.

B. To Combat Bitter or Metallic Tastes

• oral hygiene before meals may freshen the mouth.
• Cooking in the microwave oven or in glass utensils may minimize the metallic
taste.
• As protein sources, eggs, fish, poultry, and dairy products may be better received
than beef or pork
• Serving meat cold or at room temperature lessens the bitter taste
• May add sauces or seasonings to the meat to improve its taste.

C. For Local Effects About the Mouth

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 • Mouth ulceration:
– foods should be soft, mild and saucy;
– cold foods are better than hot foods;
– straws may help get the liquids past mouth ulceration;
– avoid hot items, salty, spicy foods and acidic juices

• Dry Mouth:
– adequate hydration will help keep the mouth moist;
– food lubricants such as gravy, butter, margarine milk may aid in
consuming adequate diet;
– sips of water, candies, chewing gum or popsicles may stimulate saliva
production.

• Swallowing Difficulty:
– foods should be nonsticky and of even consistency;
– soft or pureed foods can be given.

D. For Nausea, Vomiting and Diarrhea

• medications may be given 6 hours before chemotherapy begins, and continued on
a regular basis to prevent becoming nauseated.
• A low fat diet is digested faster, leaving less content in the stomach to cause
nausea or be vomited.
• Eat slowly and chew thoroughly
• Patients with gastrointestinal upset
– clear liquids should be given first, after vomiting ceases, and the diet
progressed as tolerated.
• A low residue diet helps reduce intestinal stimulation

E. For altered Immune System

• Clients may placed in protective isolation to minimize their exposure to
microorganisms. As for dietary interventions, fresh fruits and vegetables may be
restricted since they cannot be disinfected adequately.

F. Total Parenteral Nutrition or Tube Feedings

• The principles of tube feedings and TPN apply to cancer patients as well as clients
generally.
• Clients should be started on appropriate feedings methods before they become
severely malnourished.
• Clients whose weights and whose serum albumin is less than 3 grams per 100
milliliters should be considered candidates for intensives nutritional support.