Management on Oncology Patients

Siti Farrah Zaidah Bt Mohd Yazid (P60332) Yusmaeliza bt Istihat (P60324) ND6073 Medical Aspect In Nutrition

Outline Presentation
1. 2. 3. 4. 5. 6. Introduction Pathophysiology & risk factor of cancer Treatment option Dietary management Complementary and alternative medicine(CAM) Conclusion

Introduction
The National Cancer Registry (NCR) reports that cancer was the third leading cause of death in PENINSULAR MALAYSIA 2006 10 Principle Cause of Deaths in Ministry of Health, Malaysia (MOH) Hospitals, 2006
Diseases Septicaemia Heart Diseases & Diseases of Pulmonary Circulation Malignant Neoplasms Percentage (%) 16.87 15.7 10.59

Cerebrovascular Diseases
Pneumonia Accidents Diseases of the Digestive System

8.49
5.81 5.59 4.47

Certain Conditions Originating in The Perinatal Period

Nephritis, Nephrotic Syndrrome & Nephrosis Ill-define conditions

4.2
3.83 3.03

Source: MALAYSIAN CANCER STATISTICS- DATA AND FIGURE,PENINSULAR MALAYSIA.2006. National Cancer Registry. Ministry of Health Malaysia

Prevalence & statistics

21,773 cases diagnosed & registered with the National Cancer Registry
54.2%
females (11 799 cases)

21,773 cases
45.8%
males (9 974 cases)

National Cancer Registry Peninsular Malaysia,2006

Ten most frequent cancers, Peninsular Malaysia, 2006

LYMPHOMA PRSOTATE GLAND STOMACH LIVER THYROID GLAND NASOPHARYNX CERVIX UTERI LUNG COLORECTAL BREAST 0 5 10 15 3.2

3.4
3.6 3.6 4.1 4.5 4.9 9.4 13.2 16.5 20

National Cancer Registry Peninsular Malaysia,2006

Cancer Incidence per 100,000 population (CR) by sex in Peninsular Malaysia 2006
29.9% breast

5.7% Liver

16.2% colorectal

10.6% Colorectal

9.1% Cervix uteri

7.4% Prostate gland 7.5% NPC

14.5% Lung

5.8% Ovary

5.7% Thryriod gland

Males

Female

National Cancer Registry Peninsular Malaysia,2006

Pathophysiology & Risk Factors

Cancer describes a group of more than 150 disease processes characterized by uncontrolled growth and spread of cells. Cancer is not a singular, specific disease but a group of variable tissue responses that result in uncontrolled cell growth (McCance & Roberts, 1998; Fraumeni, 1982).

Malignant cells may also metastasize to other areas of the body through the cardiovascular or lymphatic systems. This uncontrolled growth and spread of cancer cells can eventually interfere with one or more of a person's vital organs or functions and possibly lead to death. The primary sites of cancer metastasis are the bone, the lymph nodes, the liver, the lungs, and the brain (McCance & Roberts, 1998).
Source: The National Center on Physical Activity and Disability, www.ncpad.org

Pathophysiology & Risk Factors

Benign neoplasms or tumor cells are made up of the same cell type as the original parent cell, but have abnormal growth rates. Benign cells do not metastasize or invade surrounding tissue. Benign cells can, however, pose a significant problem in the body when they grow too large and compress vital organs or organ systems. The following will describe both malignant and benign tissue changes that occur in the body from abnormal growth and differentiation (McCance & Roberts, 1998). Factors that affect tumor growth and development include the status of an individual's immune system, the rate the tumor cells are growing, the number of tumor cells actively spreading, and the rate that the normal tissues are being destroyed by the tumor. Several factors affect normal immune function, including stress, malnutrition, advancing age, and chronic diseases. Cancer itself appears to suppress the immune system both early and late in the disease process (McCance & Roberts, 1998).
Source: The National Center on Physical Activity and Disability, www.ncpad.org

Pathophysiology & Risk Factors

Uncontrolled cell growth is a characteristic of cancer. Cellular growth rates are regulated by proteins produced by the genetic material in cells. Genetic material can be altered or mutated by environmental factors, errors in genetic replication or repair processes, or by tumor viruses. Altered or mutated genes are called oncogenes, and it is these oncogenes that allow uncontrolled growth in cells (McCance & Roberts, 1998).

Source: The National Center on Physical Activity and Disability, www.ncpad.org

Cancer- related cachexia

Characterized by equal loss of fat & muscle, adipose tissue & increased energy expenditure.
cancer

Tumor product

Endocrine alteration

Systemic inflammatory response (cytokines)

Metabolic abnormalities

lipolysis

Protein loss

anorexia

cachexia

The Clinical Guide to Oncology Nutrition 2nd edition.2006.ADA

Prevalence of Malnutrition
80% malnutrition
(National Cancer Institute US, 2007)
60% of Head & neck & GI patients lose weight upon beginning treatment 40% develop mucositis during chemotherapy & 100% during chemoradiation

20-40% died due to malnutrition

GOALS in cancer patients

Prevent & treat under nutrition Reduce adverse effects of anti tumor therapies Enhancing anti-tumor treatment effects

Improving quality of life

Nutritional goals

Source:ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology.2006

Nutrition Treatment Goals

Phase 1: Getting Through Treatment (Primary Goals)
Prevent or correct nutritional deficiencies Minimize short-term and long-term treatment side effects Improve tolerance to treatment Enhance quality of life during treatment Help achieve and maintain optimal body weight Educate family members about special nutrition needs Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!
Source: National Cancer Institute US, www.cancer.gov

Nutrition Treatment Goals

Phase 2: Cancer Fighting Nutrition For Life (Secondary Goals)
Maintain healthy weight Incorporate healthy nutrition habits for long-term health Maximize cancer preventive potential of the diet (minimize recurrence risk) Evaluate the risks and benefits of nutrition-related CAM (supplements, vitamins, minerals, herbs); consider medication interaction issues!

Source: National Cancer Institute US, www.cancer.gov

Treatment for Cancer

Local therapy Systemic treatment Supportive care Nonconventional therapy.

Surgery.

Chemotherapy.

Radiation therapy

Hormonal therapy

Monoclonal antibodies

Radioactive material

Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov

Chemotherapy
The main treatment available is systemic chemotherapy Systemic chemotherapy disseminate malignant disease Progress in chemotherapy resulted in cure for several tumors Require multiple cycles Cytotoxic agent involved in the treatment, categorized to phase nonspecific and phase specific
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov

Chemotherapeutic Agent
Alkylating agents Antimetabolites Antitumor antibiotic Plant alkaloids Other agents Hormonal agent Immunotherapy
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov

Side Effect of Chemotherapy

Short Term: Long Term:

Nausea Vomiting Myelosuppression / Infection Alopecia Mucositis Fatigue Heart failure

Heart failure Premature menopause Bone loss Cognitive impairment Neuropathy Weight gain Sexual dysfunction Fatigue

Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov

Dealing with treatment side effect

Drink more fluids during chemotherapy, intravenous hydration may also help. Chemotherapy-induced menopause, which may result in a rapid and significant decline in bone density consider adjuvant use of bisphosphonates Increase cardiovascular fitness - exercise improved cardiorespiratory fitness, physical functioning, and fatigue.
Source: British Journal of Pharmacology and Chemotherapy, www.ncbi.nlm.nih.gov

Chemotherapy: CPG Guidelines on Management of Breast Cancer

Management of locally advanced breast cancer: Neo-adjuvant chemotherapy

Locally advanced breast cancer is invasive breast cancer that has one or more of the following features: large (typically bigger than 5 cm) spread to several spread to several lymph nodes in the lymph nodes in the axilla or other areas axilla such as the near the breast skin, muscle or ribs

However, there are no signs that the cancer has spread beyond the breast region or to other parts of the body.
Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia. 2011

Chemotherapy: CPG Guidelines on Management of Breast Cancer

A study showed that neo-adjuvant chemotherapy can be given to downsize the tumour in an attempt for BCS or enable subsequent surgery for initially inoperable breast cancer. In addition to improving both operability and rates of BCS, neoadjuvant chemotherapy also provides a valuable window to assess disease response to treatment and perform correlative tissue analyses.(level I)
Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia. 2011

Chemotherapy: CPG Guidelines on Management of Breast Cancer

RECOMMENDATION
Neo-adjuvant chemotherapy or In locally advanced breast pre-operative systemic therapy cancer that is inoperable, neocan be offered to patients with adjuvant chemotherapy operable locally advanced should be given to downsize breast cancer who are not the tumour to enable suitable candidates for BCS at subsequent surgery. (Grade A) presentation. (Grade A)

Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia.2011

Radiation Therapy

Radiation therapy can affect cancer cells and healthy cells in the treatment area. It kill cancer cells and healthy cells. The amount of damage depends on the following: The part of the body that is treated. The total dose of radiation and how it is given

Nutrition impact associated w Radiation therapy

Site of radiation therapy Central nervous systems (brain & spinal cord) Acute effects nausea, vomiting Elevated blood glc due to steroid administration fatigue loss of appetite xerostomia Sore mouth, throat dysphagia, odynophagia mucositis alterations in taste & smell fatigue loss of appetide Late effects headache, letharge

Head & neck area (tongue, larynx, pharynx, oropharynx, nasopharynx, tonsils, salivary glands

Mucosa atrophy, dryness, ulceration salivary glandsxerostomia, fibrosis Trismus Alteration in taste & smell

The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association.

Nutrition impact associated w Radiation therapy

Site of radiation therapy Thorax (esophagus, lung also breast if treatment field involves esophagus Acute effects dysphagia, odynophagia heartburn fatigue loss of appetite Late effects esophageal-fibrosis, stenosis, necrosis cardac- angina on effort, pericarditis, cardiac enlargement pumonary-dry cough, fibrosis, pneumonia diarhea, malabsorption, maldigested chronic colitis @ enteritis intestinal-stricture, ulceration, obstruction perforation, fistula urinary-hematuria, cystitis

Abdomen & pelvis (gastrointestinal system, reproductive organs, prostate, colon, rectum, testicles

nausea, vomiting Changes in bowel functiondiarrhea, cramping, bloating, gas changes in urinary functionincreased frequency, burning sensation with urination acute colitis @ enteritis lactose intolerance fatigue Loss of appetite

The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association.

Evidence Based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy. 2008. Dietitians Association Of Australia. Journal of the Dietitians Association of Australia, including the Journal of the New Zealand Dietetic Association

NHMRC grades of recommendation (2005)

Level A Level B Level C Level D Body of evidence can be trusted to guide practice Body of evidence can be trusted to guide practice in most situations Body of evidence provides some support for recommendation(s) but care should be taken in its application Body of evidence is weak and recommendation(s) must be applied with caution

Recommendation
Grade

Nutrition screening All patients receiving RT to the gastrointestinal tract (GIT), head and neck area should be referred to the dietitian (and/or nutrition support)

Nutrition assessment nutrition assessment tools (e.g. scored Patient Generated-Subjective Global Assessment (PG-SGA) or Subjective Global Assessment (SGA) should be used to assess the nutritional status of patients receiving radiation therapy Dietary counseling and/or supplements are effective methods of nutrition intervention, and frequent (at least fortnightly) dietitian contact improves outcomes in patients receiving radiation therapy. Regular nutrition intervention (dietary counseling and/or supplements) improves energy and protein intake and nutritional status during radiation therapy.

Recommendation
Grade Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) feeding are B effective in achieving higher protein & energy intakes and weight maintenance in head and neck cancer patients undergoing RT compared with oral intake alone Aim for energy and protein intakes of at least 125 kJ/kg/day and 1.2 g protein/kg/day C in patients receiving RT. Patients should have their weight and food/energy intake monitored regularly to determine whether their energy requirements are being met. Aim to minimise weight loss and maintain quality of life and symptom management in patients receiving radiation therapy C

 Use intensive dietary advice and oral nutritional supplements to increase dietary intake and to prevent therapy-associated weight loss and interruption of radiation therapy. (grade A )
ESPEN Guidelines on Enteral Nutrition:Non-surgical oncology.2006

All patients receiving radiation therapy to the head and neck area should be referred to the dietitian for nutrition support (Grade A)
Clinical Oncology Society of Australia (COSA),2011

Nutrients Requirement

Estimating Energy Intake by using Equation

Harris Benedict Equation
Validation studies :original studies conducted on healthy volunteers. Note that for obese individuals (BMI>29.9), formula may overestimate REE 5% to 15% actual weight is used

Mifflin-St Jeor
Validation studies: equation developed from a sample of obese & nonobese healthy individuals. Some research has indicated that this equation may provide a more accurate estimation of REE that the HBE in both obese & nonobese individual, therefore this equation deserves consideration

Ireton-Jones
Validation studies: equation developed from a sample of hospitalized patients including criticality ill patients & patients with burn. Recent research has reported that this equation underestimates energy requirements

Energy Estimation based on Body Weight

Useful as initial estimation of energy req. and should be adjusted as individual nutritional status & activity level changes Still lack evidence based validation.
Condition present Cancer, nutritional repletion, weight gain Cancer ,nonambulatory, inactive Cancer, hypermetabolic, stressed Sepsis Stem cell transplant Energy needs (kcal/kg) 30 35 25 30 35 25 30 30 -35

Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association

Protein
Most patients found to be negative nitrogen balance, worsen as the malignancy progresses Table: Estimating daily protein needs in adult Cancer Patients
Medical condition Normal maintenance Nonstressed cancer patients Estimation protein Needs (g/kg) 0.8 -1.0 1.0 1.2

Hypercatabolism
Severe stree Requiring nutrition support Stem cell transplant

1.2 1.6
1.5 -2.5 1.6 2.0 1.5 2.0

Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association

ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology

Clinical Nutrition (2006) 25, 245-259

ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology

Clinical Nutrition (2009) 1-10

Subjects

ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology

ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology Total daily energy expenditure in cancer patients may be assumed to be similar to healthy subjects, or Ambulant patients : 25-30 kcal/kg/d Bedridden patients : 20-25 kcal/kg/d (Grade c)

General TEE can be made for non-obese Indication patients using the actual body weight: Ambulant patients : 30-35 kcal/kg/d Bedridden patients : 20-25 kcal/kg/d Start nutrition therapy if undernutrition already exists or if it is anticipated that the pt will be unable to eat for > 7 days (Grade C) Start EN if inadequate food intake (< 60% of ER) for > 10 days is expected. Amount to give = ER actual intake (Grade C)

Supplemental PN is recommended in patients if inadequate food and enteral intake (<60% of estimated EE) is anticipated for more than 10 days (Grade C)

In wt losing pts cause by insufficient PN is recommended in patients with nutritional intake give EN to improve severe mucositis or severe radiation or maintain nutritional status (Grade B) enteritis (Grade C) PN is not recommended if oral/enteral nutrient intake is adequate (Grade A)

Subjects

ESPEN Guidelines on Enteral Nutrition:Non-surgical oncology

Perioperative

Pts with severe nutritional risk benefit from10-14 days nutritional support prior to major surgery even if the surgery has to be delayed (Grade A) Give intensive dietary advice + oral nutritional supp : dietary intake prevent therapy-assoc. wt loss prevent interruption of RT (Grade A)

ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology Perioperative PN is recommended in malnourished candidates for artificial nutrition, when EN is not possible (Grade A) Perioperative PN should not be used in the well-nourished (Grade A) The routine use of PN during chemotherapy, radiotherapy or combined therapy is not recommended (Grade A)

Pts on RT / Radio chemotharpy

During Routine EN not considered usefulchemotherapy has no effect on tumour response to chemo or on chemo-assoc. unwanted effects (Grade C)

If patients are malnourished or facing a period longer than one week of starvation and EN is not feasible, PN is recommended (Grade C)

Subjects

ESPEN Guidelines on Enteral Nutrition:Non-surgical oncology

ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology In intestinal failure, long-term PN should be offered, if enteral nutrition is insufficient, expected survival due to tumor progression is longer than 23 months), it is expected that PN can stabilize or improve performance status and quality of life the patient desires this mode of nutritional support There is probable benefit in supporting incurable cancer patients with weight loss and reduced nutrient intake with supplemental PN (Grade B)

In incurable give EN to mconsents + dying pts phase has not started (Grade C) inimize wt loss if pt Close to end of life , most pts require minimal amounts of food and water to reduce thirst & hunger (Grade B) Small amount of fluid may help to avoid dehydration induced confusion (Grade B) IV drip in hosp or at home may be helpful and provide route for drugs administration (Grade C)

Subjects

ESPEN Guidelines on Enteral Nutrition:Nonsurgical oncology

Use standard formulae (Grade C) Use preoperative enteral nutrition preferably with immune modulating substrates (arginine, o3 fatty acids, nucleotides) for 57 d in all patients undergoing major abdominal surgery independent of their nutritional status (Grade A) In cachectic patients steroids or progestins are recommended in order to enhance appetite, modulate metabolic derangements, and prevent impairment of quality of life. (Grade A)

ESPEN Guidelines on Parenteral Nutrition: Nonsurgical oncology

Enteral formula

Immunonutrient
Does supplementation with w-3 fatty acids & glutamine have beneficial effect in cancer pts?

Immunonutrient
RCTs shown :
Evidence is contradictory/controversial At present, not possible to reach any firm conclusion with regard to improving nutritional status/ physical function ( Grade C )

ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology 2006

Best Bet Complementary Cancer Therapies Eicosapentaenoic Acid (EPA) (Omega-3s)

Essential fatty acid with potential roles in inflammation, immunity, cachexia May help decrease cachexia May improve chemotherapy effectiveness/enhance immune function

Downside:
May have anticoagulant activity so use with caution if platelets low or on coagulation therapy Generally well tolerated (up to 0.3 g EPA+DHA/kg body weight/day), but diarrhea possible Dose: Minimum 2.2 mg EPA /day (best to avoid coagulation complications) Two new products on the market Prosure & Resource Support

Nutritional supplements enriched with omega-3 fatty acids (EPA/DHA) have been shown to improve QOL and performance status
Mean Change in Physical Activity Level Following 8 Weeks of Oral Supplementation
0.3 0.25 0.2 0.15 0.1 0.05 0 Control EPA Supplement Treatment Group
KPS Mean Score

Karnofsky Performance Status Following Supplementation with EPA-Enriched Supplement

96 94 92 90 88 86 84 82 80 Baseline 3 Weeks 7 Weeks

Source: Moses, et al, 2001 examined a subset of a large randomized trial conducted in pancreatic cancer patients and compared the intake of nutritional supplements with and without EPA (1.1g 2.2g/day) and the effects on total energy expenditure and physical activity level.

Mean Change in PAL

Source: Barber MD, et al, 1999. Prospective study in 20 patients with pancreatic cancer experiencing ongoing weight loss. Patients consumed average 1.9 cans/day of a nutritional supplement containing 1.1g EPA/can along with normal intake for 7 weeks.

Nutritional supplements enriched with omega-3 fatty acids (EPA/DHA) have been shown to increase life expectancy
300
Life Expectancy (days)

Impact of EPA Supplement on Survival

250 200 150 100 50 0

With EPA Supplement Without EPA Supplement Treatment Group

Source: Voss AC, et al, 2003. Voss, et al, examined survival rates in pancreatic cancer patients from 2 different studies. In one study patients received an omega-3 fatty acid nutritional supplement containing 1.1g EPA/can and in the other a supplement containing no omega-3.

What Is Glutamine?
Neutral, gluconeogenic nonessential amino acid Stored primarily in skeletal muscle (75%) and liver (25%) Nitrogen carrier between tissues Primary energy source for rapidly proliferating cells (e.g. intestinal epithelium, activated lymphocytes, & fibroblasts) May be conditionally essential; depleted in stress states (e.g. surgery, sepsis, & cancer) Appears to be synthesized in muscle tissue in substantial amounts Plasma concentrations are quite high, second only to alanine Needed for renal acid-base balance

Why Glutamine For Oncology?

Neuropathy Arthralgias Myalgias Diarrhea Enteritis & GI Mucosal Damage Stomatitis Muscle Mass Preservation??

Glutamine For Muscle Mass Maintenance: Research Evidence

Study Shabert et al. 1999

40 grams glutamine/day in divided doses 26 patients total Double-blind, placebo controlled (glycine as control) Over 3 months: glutamine group gained 2.2 kg vs. 0.3 in control (1.8 kg BCM vs. 0.4 kg BCM)
Given common etiology between wasting seen in HIV/AIDS and wasting seen in cancer cachexia, it may be possible to enhance lean body mass retention throughout cancer treatment with glutamine

Best Bet Complementary Cancer Therapies

Glutamine Amino Acid May help with diarrhea/GI symptoms & sore mouth/throat May help decrease mucositis (5-FU) May help decrease radiation enteritis May help With Aching Muscles/Nerves (Taxol) Downside: No major side effects, some minor side effects Do not take if you have poor kidney and/or liver function Dose: 10 grams glutamine powder, three times per day, dissolved in liquid (research has been done with Cambridge NutraceuticalsBaxter Pharmaceuticals & Glutasolve by Novartis)

Cancer and Exercise

The cancers that are reported to occur less frequently in active people are cancers of the colon, breast, prostate, and possibly the lung, digestive system, thyroid, bladder and the hematopoietic system (Lichtenstein, et al. 2000; Sternfeld, et al., 1992; Frisch, et al., 1985). aerobic exercise has been shown to provide benefits specifically to people undergoing treatment for cancer. These benefits include improved physical function and relief from fatigue, nausea, and depression (Pinto & Maruyama, 1999). exercise enables people who survive cancer with a means to recover their physical functions and return to a healthy and active lifestyle (Augustine & Gerber, 2000, Friendenreich & Courneya, 1996).
The National Center on Physical Activity and Disability, www.ncpad.org

Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals

Gary E. Deng et al. 2009. Journal of the Society for Integrative Oncology, Vol 7, No 3 (Summer).: pp 85120

Integrative oncology

emphasizes awareness of and sensitivity to the mental emotional, and spiritual needs of a patient, combining the best of evidence-based, complementary therapies and mainstream care in a multidisciplinary approach to evaluate and treat the whole person.

Alternative therapy

A substitute for mainstream care, not scientifically proven, often have no scientific foundation and have sometimes even been disproved

Complementary therapy

Medicine that makes use of unconventional treatment modalities and approaches that are nonsurgical and nonpharmaceutical but that have known efficacy and when combined with mainstream care, can enhance effectiveness and reduce adverse symptoms

Complementary and alternative medicine (CAM)

Complementary medicine means nonstandard treatments that you use along with standard ones (conventional treatment) for supportive care & improve QOF Alternative medicine means treatments that you use instead of standard ones (conventional treatment)

Categories of Complementary Therapy

Therapeutic Approaches Biologically based practices Mind-body techniques Characteristics Herbal remedies, vitamins, other dietary supplements Meditation, guided imagery, expressive arts (music therapy, art therapy, dance therapy) Massage, reflexology, exercise Magnetic field therapy, Reiki, Healing Touch, qi gong Traditional Chinese medicine, ayurvedic medicine, acupuncture

Manipulative and body-based practices Energy therapies Ancient medical systems

recommendation Mind-Body Medicine Mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain and improved QOL. Grade: 1B

Manipulative and Body-Based Practice

For cancer patients experiencing anxiety or pain, massage therapy delivered by an oncology-trained massage therapist is recommended as part of multimodality treatment. Grade: 1C Regular physical activities can play many positive roles in cancer care. Patients should be referred to a qualified exercise specialist for guidelines on physical activity to promote basic health. Grade: 1B

Exercise and Physical Activity

recommendation

Energy Therapies

Therapies based on a philosophy of bioenergy fields are safe and may provide some benefit for reducing stress and enhancing QoL. There is limited evidence as to their efficacy for symptom management, including reducing pain and fatigue. Grade: 1B (for anxiety) 1C (for pain, fatigue and other symptom management)
Acupuncture is recommended as a complementary therapy when pain is poorly controlled, when nausea and vomiting associated with chemotherapy or surgical anesthesia are poorly controlled, or when the side effects from other modalities are clinically significant. Grade: 1A Acupucture is recommended as a complementary therapy for radiation-induced xerostomia. Grade: 1B

Acupuncture

Acupuncture

NHMRC levels of evidence (1999)

Level I Level II Level III-1 Level III-2 Evidence obtained from a systematic review of all relevant randomised controlled trials Evidence obtained from at least one properly designed randomised controlled trial Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method) Evidence obtained from comparative studies with concurrent control and allocation not randomised (cohort studies), casecontrol studies, or interrupted time series with a control group Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel group

Level III-3

Level IV

Evidence obtained from case studies, either post-test or pre- and posttest.

Dietary guidelines & recommendation for cancer prevention

Organization USDA,US Dept of health & Human Service.2005 Dietary pattern make smart choice from every foods Get most nutrition from your calorie Variety of fruit & vege. 3 cups low fat @ fatfree/d 3 whole grain product everyday choose lean protein Low in SFA & trans fats Physical activity Alcohol other choose & prepare foods with less salt/sugar < 2.3 g sodium daily.

balance between food moderate & PA amount Regular PA & reduce sedentary activities to promote health, Psychological well being & healthy body weight. Moderate-intensity PA 30-60minutes/d

Dietary guidelines & recommendation for cancer prevention

Organization American Cancer Society.2002 Dietary pattern variety of foods, emphasis on plant sources 5 fruits & vege everyday choose whole grain limit red meat esp. high fat & processed Physical activity physically active lifestyle Maintain healthful weight throughout life Chose foods help maintain healthful weight Alcohol limit consumption other

National cancer institute.1996

include variety of fruit & avoid obesity vege in the daily diet

moderation consumption

Dietary guidelines & recommendation for cancer prevention

Organizat ion American Institute for cancer Research 1997 Dietary pattern choose plant-based diet rich in vege, fruits, pulse, minimally processed eat 13-30 oz @ > 5 serving vege & fruits daily eat 20-30 oz @ >7 serving cereal, legumes, nuts, tuber red meat should provide <10% TEI Total fat 15-30% TEI include 400g/day fruits & vege in the diet Moderate consumption of preserved meat Physical activity Alcohol other limit salt <6g/day for adult store & preserve food properly limit sugar < 10% TEI dietary supplement are unnecessary & unhelpful for reducing cancer

avoid being over Not @underweight & limit recommended weight gain during adulthood to <11 pounds If activity is low @ moderate, walk briskly daily for 1 hr & vigorously exercise for 1 hr/week

WHO. 2002

maintain desirable BMI (18.5 -24.9), avoid wt gain during adult life maintain regular PA

not recommended If consumed limit 2 unit/d

moderate consumption salt avoid foods at very hot C min alfatoxin foods

Conclusion
Treatment for cancer is a multidisciplinary effort. Special attention must be given to the establishment & upgrading of treatment facilities & the training of specialized personnel. In doing so, many lives will be saved & countless more patients will have chance of obtaining relief from the distressing symptoms of cancer
Gerard C. C. L. Overview of Cancer in Malaysia.2000.Jpn J Clin Oncol.S37-S42

References

MALAYSIAN CANCER STATISTICS- DATA AND FIGURE,PENINSULAR MALAYSIA.2006. National Cancer Registry. Ministry of Health Malaysia Evidence Based Practice Guidelines for the Nutritional Management of Patients with Head and Neck Cancer. Clinical Oncology Society of Australia (COSA).2011 Bozzetti F, et al., ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology, Clinical Nutrition (2009),doi:10.1016/j.clnu.2009.04.011 J. Arends et al.2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.doi:10.1016/j.clnu.2006.01.020 Laura et al., The clinical Guide to Oncology Nutrition 2nd Edition.2006. American Dietetic Association. Mary M., Susan R., Clinical Nutrition for Oncology Patients.2007. Jones and Bartlett Publishers. Linda et al., Evidence Based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy.2008. Journal of the Dietitians Association of Australia, including the Journal of the New Zealand Dietetic Association. Nutrition & Dietetics 2008; 65 (Suppl. 1): S1S20 DOI: 10.1111/j.1747-0080.2008.00252.x Gary et al., Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals.2009. Journal of the Society for Integrative Oncology, Vol 7, No 3 (Summer), : pp 85120

References
Jacqueline Drouin and Lucinda Pfalzer, Cancer Pathophysiology, NCPAD, University of Illinois, Chicago Clinical Practice Guidelines. Management of Breast Cancer. Ministry of Health Malaysia. November 2010. Clinical Practice Guidelines. Management of Cervical Cancer. Ministry of Health Malaysia. April 2003. Clinical Practice Guidelines. Management of Cancer Pain. Ministry of Health Malaysia. July 2010. C.Decker Baumann, K. Buhl, S. Frohmuller, A.v. Hurbey, M. Dueck and P.M. Schlag. Reduction of induced-chemotherapy-side effects by Parenteral Glutamine Supplementation in Patient with Metastatic Colorectal Cancer. European Journal of Cancer Volume 35, Issue 2, February 1999, Pages 202-207 Shabert JK, Winslow C, Lacey JM, Wilmore DM. Glutamine-anti-oxidant supplementation increases body cell mass in AIDS patients with weight loss: A randomized, double-blind controlled trial. Nutrition 1999;15:860-864. The National Center on Physical Activity and Disability, www.ncpad.org British Journal of Pharmacology and Chemotherapy National Cancer Institute, www,cancer.gov

Thank You