Case Study #33 Esophageal Cancer Lynne Roller and Teresa Schwendler

What is cancer? Cancer is a class of diseases characterized by uncontrolled cell division and the ability of these cells to invade other tissues-either by direct growth to adjacent tissue(invasion) or by migration of cells to distant sites(metastasis)

Esophageal Cancer Esophageal cancer is cancer of the esophagus. It has a 16% 5 year survival rate, there is not much research on long term effects.

Esophageal Cancer Form 1: Adenocarcinoma (AC) Form 2: Squamous cell carcinoma(SCC) Adenocarcinoma is a cancer is the most common type of esophageal cancer and it consists of cancerous tumors that are found in the lower part of the esophagus, near the stomach. Squamous cell carcinoma is when the cancer lines the upper part of the esophagus

Etiology For Esophageal Cancer Smoking Alcohol abuse Obesity Having bile reflux Eating few fruits and vegetables Having gastro-esophageal reflux disease Being male and between the ages of 45-70 Alcohol and cigarettes seem to have a synergistic effect on carcogenosis

Cancer Identification Procedures Cytologic test Physical test Biochemical test In addition to the risk factors listed there are a few test that can be done to identify if the patient has cancer Cytological Test- Biochemical- analysis of blood, urine, serum and other bodily fluids Tumor markers are also used- they can identify the type of cancer more specifically (Tumor Node Metatases Staging System) can also be used to classify the origin, spread of the cancer

Description of Patient Nick Seyer, 58 y.o. male contractor Diagnosed with Stage IIB adenocarcinoma of the esophagus. Experiencing Dysphagia and Odynophagia Smokes 2ppd; wife also smokes Alcohol use: 1-2 drinks 1-2 x/week

Mr. Sayer’s History Weight: 198lbs. BMI: 24.9 %UBW: 87% Height: 6’3” Weight: 198lbs. BMI: 24.9 %UBW: 87% Recent weight loss of 30lbs over the past few months 14% weight loss = severe weight loss Energy Requirements to maintain weight: 1796kcal/day Energy Requirements to gain weight: 2700kcal/day Protein Requirements: 135g/day Fluid Requirements to maintain weight: 1796mL/day Fluid Requirements to gain weight: 2700mL/day

Mr. Seyer’s Disease measures Chemistry Normal Value Mr. Seyer’s Value Reason for Abnormality Nutritional Implications Total Protein 6-8 5.7 Inadequate Protein intake Increase protein intake Albumin 3.5-5 3.1/3.0 Inadequate protein intake, dehydration Increase protein intake, rehydrate Prealbumin 16-35 15/12 Inadequate protein intake RBC 4.5-6.2 4.2/4.3 Malabsorption/side effect of cancer Increase iron, B12, folate Hemoglobin 14-17 13.5/13.9 Low RBC due to cancer Hematocrit 40-54 38 Decreased RBC Mean cell Hgb 26-32 32.4/32.3 Low RBC Increase iron, B12

Mr. Sayer’s Diagnosis Inadequate Protein intake Inadequate energy intake Difficulty swallowing Severe weight loss- Cachexia

Current Treatment Medical External Beam Radiation Therapy Surgery- surgical resection of tumor- transhiatal esophagectomy Nutrition Enteral Nutrition-Isosource HN Increased calories and protein intake

Esophogectomy Medical Treatment when a surgeon removes a portion of the esophagus -removed consists of lymph nodes near and around the tumor and the site containing the tumor. -moving the stomach up to meet the esophagus - Or colon is used to replace the part of the esophagus -usually after this surgery=tube feeding

Isosource HN Enteral Formula kcal/mL: 1.2 Caloric Distribution (% of kcal) Protein: 18% Carbohydrate: 53% Fat: 29%  Protein Source: soy protein isolate NPC:N Ratio: 115:1 MCT:LCT Ratio: 20:80  n6:n3 Ratio: 2.7:1 Osmolality (mOsm/kg water): 490 Water 82% High in Omega fatty acids which have been proven to help with weight gain in cancer patients who are suffering form extreme weight loss Kcals are 1.2 kcals/ mL It is also a high protein formula to help him reach the high protein needs that he has because of his condition

Comparison to Mr. Seyer’s Estimated Nutrition Requirements Enteral Nutrition Comparison to Mr. Seyer’s Estimated Nutrition Requirements   Value from I/O chart Currently Receiving To maintain weight (REE with PAL factor of 1.3) To gain weight (using 30kcals/kg) Protein needed for Cancer Patient (1.5g/ kg) Rate of mL/hr. 60.24mL/hr 75mL/hr 81 mL/hr 94 mL/hr Total of Enteral Formula for day 1.7 L 1.8 L 2 L 2.25 L Total Calories for day 2,082 kcal 2,160 kcals 2,335kcals 2,700 kcals Total Protein 90.1g 95.4g 103 g 119g 135g His protein is at 135g because he has an increased protein need status do to his cancer (1.5g/g) His calories are at 30kcals/ kg because he is a cancer patient that needs to gain weight

PES Malnutrition (NI-5.2) related to insufficient enteral nutrition recommendations as evidence by weight loss of over 30 pounds in a two month period and signs of cachexia Inadequate protein energy intake (NI-5.7.3) related to metabolic abnormality due to cancerous state as evidence by Estimated protein intake higher than recommended prescribed enteral nutrition therapy.

Goals Talk with other members of the nutrition care team about the current amount of enteral nutrition that Mr. Seyer is receiving . Increase Mr. Seyer’s daily protein intake, via enteral nutrition, to 135g and increasing calories to 2,700kcals gain back the weight that he has lost get him on a solid food diet-starting with soft food with 6-8 meals a day

Intervention Increase enteral protein intake to 135g per day. Increase total energy intake to 2700kcal/day in order to gain weight.

Monitoring and Evaluation Monitor anthropometrics to track weight gain. Monitor biochemical data- track protein Subjective Global Assessment- gauges the patient’s perception of their ability to accomplish self-care.

True or False? When people have surgery to remove their cancer they often also have chemotherapy before to reduce the size of the tumor and after to treat local areas of reoccurrence? When people who have cancer start eating again sometimes they have aversions to eating certain foods? Enteral nutrition is always suggested for terminally ill cancer patients?

True or False? When people have surgery to remove their cancer they often also have chemotherapy before to reduce the size of the tumor and after to treat local areas of reoccurrence?(T) When people who have cancer start eating again sometimes they have aversions to eating certain foods? (T) True-neoadjuvant chemo is often administered before and adjuvent chemo is administered after True- dysgeusia -metallic taste in their mouth due to chemo -plastic silverware when eating -aversions to meat may occur -other foods that are high in protein such as cottage cheese, peanut butter and cheese or nutritional supplements can be encouraged.

Resources Jager-Wittenaar, H;Dijkstra PU; Vissink A. “Changes in nutritional status and dietary intake during and after head and neck cancer treatment.” http://www.ncbi.nlm.nih.gov/pubmed/20737491 Mayo Clinic (n.d.). Chemotherapy - MayoClinic.com. Retrieved May 5, 2011, from http://www.mayoclinic.com/health/chemotherapy/MY00536 Mayo Clinic (2011, May). Esophageal cancer: Treatments and drugs - MayoClinic.com, from http://www.mayoclinic.com/health/esophageal-cancer/DS00500/DSECTION=treatments-and-drugs National Cancer Institute (2012, November 1). When Someone You Love Has Advanced Cancer - National Cancer Institute. Retrieved from http://www.cancer.gov/cancertopics/coping/when-someone-you-love-has-advanced-cancer/page4 National Institutes of Health (2013). Esophageal cancer - National Library of Medicine - PubMed Health. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001328/ Nelms, Marcia; Sucher, Kathryn; Lacey, Karen; Roth, Sara Long. Nutrition Therapy and Pathophysiology.2/e