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Slide 1 - Nutrition in Head and Neck Cancer Karen L. Stierman, M.D. Francis B. Quinn, M.D. December 09, 1998
Slide 2 - Introduction Malnutrition is present in 20% of patients with head and neck cancer Malnutrition is associated with decreased cell-mediated immunity and increased postoperative sepsis Early recognition and correction of malnutrition could result in decreased morbidity and mortality
Slide 3 - Definition and Classification Malnutrition is weight loss greater than 10% of ideal body weight associated with loss of muscle Marasmus - total caloric intake decreased, serum protein level is normal Kwashiorkor - protein caloric intake decreased
Slide 4 - Mechanisms of Malnutrition Reduced dietary intake alcohol, local tumor effects, XRT mucositis, poor dentition Anorexia learned aversion, sensory deficits Cancer cachexia Cori(lactate) vs. Krebs(CO2 and H2O) Amino acids sacrificed to make glucose
Slide 5 - Mechanisms of Malnutrition(cont’d) Specific nutrient deficiencies Decreased vitamin A or B-carotene is associated with cancer of the head and neck Decreased selenium is associated with cancer of the esophagus
Slide 6 - Assessing Nutrition History - diet, weight loss Physical Exam - loss of subQ fat, muscle wasting, edema, anthropometrics Subjective global assessment(SGA) Labs - albumin, transferrin, prealbumin, retinol binding protein, total lymphocyte count Antigen skin testing
Slide 7 - Nutritional Requirements Energy required = Basal + additional secondary to illness Basal - 25 to 45 kcal/kg/day Major trauma/surgery with complications may require up to 50% more energy Calorie:nitrogen ratio 120 - 180:1 in severely stressed patients
Slide 8 - Response to surgery Phase I - Catabolic phase lasting 3-7 days Phase II - Protein consumption and production are equal Phase III - Anabolic phase of protein and total calories Phase IV - Restoration of lipid stores
Slide 9 - Amino acids / Micronutrients Arginine - positive effect on immune function and collagen synthesis Animal studies show increased lysine and decreased arginine in tumor bearing vs. control rats Phosphate replacement is important because it is important in energy metabolism Selenium, trace metals
Slide 10 - Lipids Fat - 9 kcal/g Providing fat may help preserve protein Lipid composition of tumor cell membranes is sensitive to change in diet Consider n-3 PUFA in cancer patients May help to make more sensitive to chemotx. and hyperthermia
Slide 11 - Delivering Nutrition Oral Enteral NJ, PEG vs G-tube, G-J, J-tube Parenteral hyperalimentation PPN vs TPN
Slide 12 - Nutritional Formulas Total calories, protein Volume restriction Osmolality Cost Taste Composition
Slide 13 - Studies on the effect of nutritional replacement Preop TPN for 1 week decreased postop morbidity and mortality by 21 to 31 % in G.surg patients In chemotx and xrt patients, no change was seen Need more prospective, randomized trials
Slide 14 - Enteral vs. Parenteral Nutrition Enteral is safer, more convenient, and less expensive Enteral prevents mucosal atrophy, decreases the body’s stress response, and preserves normal flora TPN - ? effect on tumor growth
Slide 15 - Conclusions Head and neck cancer patients are frequently malnourished Perioperative nutritional support may be associated with decreased morbidity, mortality and cost Further studies needed