1. Case Study #33 Esophageal Cancer Lynne Roller and Teresa Schwendler

2. 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)

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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
4.2/4.3
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

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

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

12. 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

13. 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

14. 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

15. 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.

16. 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

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

18. 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.

19. 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?

20. 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.

21. Resources
Jager-Wittenaar, H;Dijkstra PU; Vissink A. “Changes in nutritional status and dietary intake
during and after head and neck cancer treatment.”
Mayo Clinic (n.d.). Chemotherapy - MayoClinic.com. Retrieved May 5, 2011, from
Mayo Clinic (2011, May). Esophageal cancer: Treatments and drugs - MayoClinic.com, from
National Cancer Institute (2012, November 1). When Someone You Love Has Advanced Cancer - National Cancer Institute. Retrieved from
National Institutes of Health (2013). Esophageal cancer - National Library of Medicine - PubMed Health. Retrieved from
Nelms, Marcia; Sucher, Kathryn; Lacey, Karen; Roth, Sara Long. Nutrition Therapy and Pathophysiology.2/e