1. Nutritional Challenges in Lymphoma Gayle Black Senior Specialist Dietitian Royal Marsden Hospital

2. Aims of the Session To consider the varied impacts a diagnosis of Lymphoma can have on nutrition To consider how and why nutrition is an important part of the patient journey To compare and contrast the role nutrition played for two specific individuals

3. Nutrition at Diagnosis The lymphomas are a highly complex group of diseases and nutritional implications at diagnosis are very much related to the individual diagnosis The presence of B symptoms often leads to significant weight loss prior to diagnosis Weight loss is present in approximately 50 % of all patients presenting with a gastric lymphoma (Balfe et al, 2008). Oropharyngeal lymphomas may be related to swallowing difficulties at diagnosis

4. Nutritional Implications during Induction and Intensification Treatment The exact side effects of treatments varies between individuals and treatment regimens The diverse nature of Lymphoma leads to a wide variety of different nutrition related implications Combination therapy can lead to more intensive side effects Anxiety and prolonged stays in hospital can both adversely effect nutritional status Not all patients undergoing treatment for lymphoma will have altered nutritional intake

5. Nutrition Related Side Effects Commonly Seen Mucositis Xerostomia Nausea Vomiting Fatigue Anorexia Abdominal Cramps Diarrhoea Constipation Hyperglycaemia Increased Appetite Fluid Retention Taste Changes Heart Burn

6. Why is Nutrition Important during treatment for Lymphoma? The provision of food and fluids is a basic care (BMA, 1999) Malnutrition can have a significant impact on survival and performance status Up to 20% of all patients treated for cancer are deemed to die from the effects of malnutrition (Mercadante, 1998) Malnutrition may decrease tolerance to treatment and increase incidence of dose limiting side effects Wound healing is reduced in malnutrition

7. Eating as a Social Experience Expression of love and caring Expression of individuality To reward or punish A focus for communal activities As a control issue As a coping strategy As a treatment Weight loss is an outward symbol of poor health

8. Case Study 1 – The Physical Challenges of Diet and Lymphoma 58 yr old Male Presented in May 2008 with a year long history of fatigue, poor appetite and weight loss On admission is very weak, dehydrated and confused with a performance status of 3 Following investigations is diagnosed with Stage IVB Diffuse Large B Cell Lymphoma

9. Nutritional Status on Admission Presented with a history of accelerated unintentional weight loss over approximately a two month period Weight on admission = 63 Kg with moderate ascites (est. 6 kg) BMI on admission = 17.5kg/m² % wt loss on admission = 18 %

10. During Admission Initially nasogastric tube insertion attempted but unsuccessful due to tube curling in the oesophagus Following referral to the Dietitian routine of small regular snacks supplemented with Scandishake bd and Calogen 30ml tds successfully implemented Performance status quickly improves and discharge home is planned

11. But then…. Patient starts to become increasingly unwell BNO and abdomen becomes very distended with absent bowel sounds Refusing all food and fluid due to abdo pain Paralytic ileus diagnosed secondary to Vincristine

12. Management Plan Conservative management NBM with NGT for drainage PICC line inserted for TPN Over the next few weeks patient continues to go in and out of obstruction with the reintroduction of oral diet attempted on several occasions

13. Weaning off PN and Moving Forward Diet eventually reintroduced although patient has now been in hospital for 2 months Reports sore mouth and taste changes secondary to oral Candida Complaining of taste fatigue with hospital food and supplements Early satiety secondary to ascites

14. Nutritional Status on Discharge Weight = 62 Kg (without ascites) BMI = 19 Kg/m 2 Oral intake providing approximately 800 kcal/day and 40g protein from meals and snacks Additional intake from oral nutritional supplements to support weight gain

15. Where are we now? Following discharge from hospital he struggled to cope at home and family relations suffered as a result Spent several months being cared for in a nursing home However he has now completed a course of single agent Rituximab and is on long term follow up His weight is stable at 67 Kg (BMI = 21 Kg/m 2 ) and the recurrent ascites has stopped He’s back in his own home although so far has been unable to return to work

16. Case Study 2 – The Psychological Challenges of Diet and Lymphoma 21 yr old Male Lives at home with his parents and younger sister Treated in childhood for both Lymphocyte predominant Hodgkin's Disease and B- NHL Autologous transplant in 1999

17. Recent Medical History Hodgkins Disease relapsed 2008 aged 20 Presented with a history of unexplained weight loss and lethargy Relapse confirmed following endoscopy and chemotherapy commenced shortly afterwards Reduced Intensity Allograft July 2009

18. Nutritional Status on Discharge Post Transplant Weight on day of discharge = 55 Kg BMI on discharge = 17 Kg/m 2 Managing small amounts of meals and snacks, slowly increasing portion sizes Supplementing diet with Fortijuce bd

19. Challenges at Home Weight falling at each review Refusing all nutritional supplements Food choices becoming more and more limited Mother confides that he is becoming socially isolated and withdrawn Spending large periods of time comparing his appearance to others

20. Nutritional Status at Readmission Weight = 45 Kg BMI = 14 Kg/m 2 % Weight loss = 18 % Medical investigations all unable to identify cause for weight loss, referred to gastroenterologist Agreed to referral for counselling, CLIC sergeant social worker and young people’s activity coordinator PEG tube inserted

21. Five Weeks Later Discharged from hospital Weight = 50.4 kg BMI = 16 Kg/m 2 Tolerating overnight feeds very well and independent with all aspects of PEG care Eating small meals and supplementing with extra snacks

22. Where are we now? PEG removed 3 weeks ago Eating a full and varied diet Weight maintained at 61 Kg with a BMI of 19 Kg/m 2 Recently spent a week in Cornwall with friends from college Looking for part time work

23. Summary Eating difficulties for our patients can be due to a wide variety of factors and can change with time The consequences of a reduced nutritional intake can impact all aspects of our patients lives and should not be underestimated The link between nutritional status and performance status is key Each individual we meet will have very different needs, importance of not making assumptions