Neoplastic Disease 1

Neoplastic Disease
Dr. Nahla Al-Bayyari

Cancer
•Disorder of cell growth and regulation; cells
know no limits for replication and produce
cells that have no purpose
•2nd leading cause of mortality

•Lung and bronchus number one
•African American men highest rate
•1/3 can be attributed to diet, physical
activity, 1/3 more to smoking

Cancer
•Carcinogenesis - Etiology
•Exposure to carcinogens: chemicals,
physical agents, radiation, microorganisms,
viral or bacterial agents
•Damage to gene
•Transformation of normal cells to cancer

cells

Cancer
• Carcinogenesis - Etiology
• Genes may be affected by antioxidants, soy,
protein, fat, kcal, alcohol
• Nutritional genomics – study of genetic

variations that cause different phenotypic
responses to diet
• Nutrigenomics: studies the effect of nutrients on health through
altering genome, proteome, metabolome and the resulting changes in
physiology.
• Nutrigenetics: studies the effect of genetic variations on the interaction
between diet and health with implications to susceptible subgroups.

Cancer
• Biomarkers - indicators used to identify
nutrition exposures; potential for
establishing cause-effect relationship
between diet and cancer

Cancer
• Epidemiological Research:
•Strong inverse relationship between
cancer and fruit and vegetable intake;
cancer risk and whole grains, fiber, type of
fat, and physical activity; cancer risk and
alcohol; obesity and BMI; food
preparation methods such as smoking,
salting, pickling, high temp. cooking of
meats
Cancer
• Cancer Screening and Prevention
• Primary prevention
• Smoking cessation
• Secondary prevention
• Screening: breast, cervical, colorectal, and
prostate cancers
• Chemoprevention
Cancer chemoprevention refers to the use of agents
for the inhibition, delay, or reversal of carcinogenesis
before invasion. In the present review, agents
examined in the context of cancer chemoprevention
are classified in four major categories—hormonal,
medications, diet-related agents, and vaccines.

Cancer
• American Cancer Society (ACS) prevention and
early detection guidelines published every 5 yrs.
• See Table 24.1
• See Table 24.2 – Major warning signs of cancer

Cancer- Pathophysiology
• Cells that reproduce - copy DNA and then split into
2 new cells, constantly regenerating
• i.e. liver, bone marrow, skin, GI tract
• Cycling cells - divide continuously: GI
• Non-dividing cells – divide before they differentiate
and not again such as myocytes, adipocytes, skin cells and
neurons, are in the non-dividing state, i.e. terminally-differentiated.
• Resting cells – remain dormant; certain conditions
may stimulate their growth such as T and B
lymphatic cells and some neural cells.

• Genetic control for cellular division and growth
• Oncogenes
An oncogene is a gene that has the potential to cause cancer. In tumor cells, they
are often mutated and/or expressed at high levels. Most normal cells will undergo
a programmed form of rapid cell death (apoptosis) when critical functions are
altered and malfunctioning.
• Tumor suppressor genes

• A tumor suppressor gene, or antioncogene, is a gene that protects a cell from one step
on the path to cancer. When this gene mutates to cause a loss or reduction in its function,
the cell can progress to cancer, usually in combination with other genetic changes.
• May also be based on telomeres

A telomere is a region of repetitive nucleotide sequences at each end of a
chromosome, which protects the end of the chromosome from
deterioration or from fusion with neighboring chromosomes.

• Telomeres and cancer. As a cell begins to become cancerous, it

divides more often, and its telomeres become very short. If
its telomeres get too short, the cell may die. Often times, these cells
escape death by making more telomerase enzyme, which prevents
the telomeres from getting even shorter.
• Cancer cells reproduce at an uncontrolled rate, become
autonomous from normal signals, and may secrete their own
growth factor
• An enzyme (Telomerase) is secreted leading to loss of cell’s internal
clock
• Physical characteristics of cell are altered

•Initiation - exposure
•Promotion – factors such as hormones
•Progression - an activation of carcinogen as
well as a failure of natural immunity;
conducive conditions for neoplasm to form
•See Figure 24.4

• Metastasis – the spread of cancer cells to distant
sites
• Lymphatic system
• Circulatory system
• Nearby body cavities
• Malignant – cancerous
• Benign – non cancerous

Cancer - Diagnosis
• Biochemical – detect biomarkers for example
• ALK gene rearrangements and overexpression: Non-small
cell lung cancer and anaplastic large cell lymphoma
• Alpha-fetoprotein (AFP): Liver cancer and germ cell tumors
• Beta-2-microglobulin (B2M): Multiple myeloma, chronic
lymphocytic leukemia, and some lymphomas
• Beta-human chorionic gonadotropin (Beta-hCG):
Choriocarcinoma and germ cell tumors
• BRCA1 and BRCA2 gene mutations: Ovarian cancer
• Thyroglobulin: Thyroid cancer
Prostate-specific antigen (PSA): Prostate cancer

Cancer-Diagnosis
• Tumor imaging techniques - MRI, CT, ultrasound, PET,

mammogram, bone scans, etc.
A positron emission tomography (PET) scan is an imaging test that uses a
special dye that has radioactive tracers. These tracers are injected into a vein
in your arm. Your organs and tissues then absorb the tracer.
• Invasive techniques - biopsy, cytologic aspiration, laparoscopy

Fine needle aspiration cytology (FNAC) entails using a narrow gauge (25-22G)
needle to collect a sample of a lesion for microscopic examination. It allows a
minimally invasive, rapid diagnosis of tissue but does not preserve its
histological architecture. In some cases this limits the ability to make a
definitive diagnosis.

Cancer - Diagnosis
• Tumor classified according to “stage”
• Tumor Node Metastases Staging System (TNM) – see Box 24.1
In the TNM system:
• The T refers to the size and extent of the main tumor. The main tumor is usually
called the primary tumor.
• The N refers to the number of nearby lymph nodes that have cancer.
• The M refers to whether the cancer has metastasized. This means that the
cancer has spread from the primary tumor to other parts of the body.
• Tumors named according to tissue where they arise - “-oma”

• Carcinomas – epithelial tissue
• Sarcomas – connective tissue
• Lymphomas - lymphatic system
• Gliomas – glial cells of CNS
• Leukemias – bone marrow

Cancer - Diagnosis
Stage 0 Abnormal cells are present but have

not spread to nearby tissue. Also
called carcinoma in situ, or CIS. CIS is
not cancer, but it may become cancer.
Stage I, Stage II, and Stage III Cancer is present. The higher the
number, the larger the cancer tumor
and the more it has spread into
nearby tissues.
Stage IV The cancer has spread to distant parts

of the body.

Clinical Manifestations
• Over 100 different disease types
• Each is unique in characteristics
• Common signs and symptoms:
• Pain, infection, anemia, fatigue, malnutrition, cachexia

Treatment
•Treatment will be determined by location of
tumor, size, health of pt. etc.
•Surgery
•Chemotherapy
•Radiation
•Other Therapies
•Bone marrow transplant
•Biological therapies

Surgery
• Primary
• Adjuvant: is given in addition to the primary or initial therapy to maximize its

effectiveness. The surgeries and complex treatment regimens used in cancer
therapy have led the term to be used mainly to describe adjuvant cancer
treatments. An example of such adjuvant therapy is the additional
treatment usually given after surgery where all detectable disease has been
removed, but where there remains a statistical risk of relapse due to the
presence of undetected disease.
For example, radiotherapy or systemic therapy is commonly given as adjuvant
treatment after surgery for breast cancer. Systemic therapy consists
of chemotherapy, immunotherapy or biological response modifiers or hormone
therapy
• Combination
• Salvage: Treatment that is given after the cancer has not responded to other
treatments.

Surgery
• Palliative: is designed to relieve symptoms, and improve your quality
of life. It can be used at any stage of an illness if there are troubling
symptoms, such as pain or sickness. It can also be used to reduce or
control the side effects of cancer treatments.
• Second look procedures: sometimes performed to determine if

a cancer patient has responded successfully to a particular
treatment. Examples of cancers that are assessed during second-look
surgery are ovarian cancer and colorectal cancer. In many cases,
before a round of chemotherapy and/or radiation therapy
is performed.

Surgery
• Diagnoses requiring surgery
• Head and neck
• Esophageal
• Gastric
• Intestinal
• pancreatic
• Significant and long-term nutritional side effects

Surgery
• Head and Neck
• Difficulty chewing and swallowing
• Dysgeusia: distortion of the sense of taste.
• Xerostomia: Dryness of mouth
• Alterations in smell
• Difficulty speaking
• Malnutrition
• Radical neck dissection(RND) – causes severe nutritional
deficits: a fat free diet or potentially total parenteral nutrition is
successful in most patients.
• Placement of feeding tube at time of surgery is prudent

Surgery
• Esophageal
• Risk factors
• Smoking, alcohol abuse
• Barrett’s esophagus: occurs due to chronic inflammation. The
principal cause of the chronic inflammation is gastroesophageal
reflux disease, GERD (UK: GORD). In this disease, acidic stomach, bile,
and small intestine and pancreatic contents cause damage to the cells of
the lower esophagus.
• Diet low in fruits and vegetables
• Many develop cachexia
• Placement of feeding tube slow recovery of oral
intake

Surgery
• Gastric
• Repeated infection with H. pylori
• Increases risk for
• Vitamin B12 deficiency – d/t lack of intrinsic
factor
• Decreased calcium and iron absorption - d/t
reduced HCl
• Dumping syndrome
• Delayed gastric emptying, early satiety, nausea,
vomiting
Surgery
• Intestinal
• Significant effects on digestion, absorption of
nutrients
• Malabsorption and steatorrhea
• Colorectal cancer risk factors
• Family hx, lack of physical activity, obesity,
smoking, hx of IBD
• Ulcerative colitis (UC) is a disease of mucosal inflammation limited to the
colon, often characterized by bloody diarrhea, tenesmus and abdominal
pain. UC was the first subtype of inflammatory bowel disease (IBD) to be
characterized as a distinct entity.
• Treated with colostomy or ileostomy

• Electrolyte (K) and fluid loss (dehydration)

Surgery
• Pancreatic
• Weight loss and anorexia
• Pancreatic exocrine insufficiency
• Malabsorption and steatorrhea
• Hyperglycemia
• Delayed gastric emptying
• Placement of feeding tube common

Chemotherapy
• Medications that interrupt different stages of cell
cycle replication, most lethal to cells under
continual replication
• Combination chemotherapy
• Decreases drug resistance, synergistic effects, decreases
overall toxicity
• Adjuvant and neoadjuvant (the main treatment)
• See side effects – Table 24.3

Chemotherapy
• Neoadjuvant chemotherapy refers to medicines that are
administered before surgery for the treatment of cancer. The doctors
may recommend neoadjuvant chemotherapy due to the size of the
tumor, since the drugs may shrink the tumor and give you more
surgical options.
• Adjuvant (meaning “in addition to”) chemotherapy refers to
medicines administered after surgery for the treatment of cancer.
Adjuvant chemotherapy is designed to prevent recurrence of the
disease, particularly distant recurrence. The doctors may recommend
chemotherapy if your cancer is invasive, has unfavorable prognostic
factors, is a certain size, or has spread to nearby lymph nodes. It also
may be recommended if you are relatively young at the time of
diagnosis.

Most Common Side Effects of
Chemotherapy
• Fatigue • Nerve and muscle problems
• Hair loss such as numbness, tingling, and
• Easy bruising and bleeding pain
• Infection • Skin and nail changes such as dry
• Anemia (low red blood cell skin and color change
counts) • Urine and bladder changes and
• Nausea and vomiting kidney problems
• Appetite changes • Weight changes
• Constipation • Chemo brain, which can affect
• Diarrhea concentration and focus
• Mouth, tongue, and throat • Mood changes
problems such as sores and pain • Changes in libido and sexual
with swallowing function
• • Fertility problems
Chemotherapy
• Common side effects due to toxicity to rapidly
dividing cells:
• Neutropenia: is an abnormally low level of neutrophils.
• Thrombocytopenia: is a condition characterized by abnormally low
levels of thrombocytes, also known as platelets, in the blood. A normal
human platelet count ranges from 150,000 to 450,000 platelets per
microliter of blood.
• Anemia
• Diarrhea
• Mucositis: is the painful inflammation and ulceration of the mucous
membranes lining the digestive tract, usually as an adverse effect of
chemotherapy and radiotherapy treatment for cancer.
• Alopecia: hair loss

• Cardiotoxicity, neurotoxicity, nephrotoxicity
Radiation
• Alteration in cellular and nuclear material (DNA)
from electromagnetic rays and charged particles;
continuously proliferating cells most susceptible
• Toxicity of RT is localized to region being irradiated
• Internally or externally

Radiation
• Brachytherapy – placement of radioactive sources
within existing body cavity in close proximity to the
tumor or within tumor

Radiation
• Side effects:
• Delayed wound healing
• Fatigue, mucositis,
• dysgeusia (also known as parageusia, is a distortion of the sense of
taste. Dysgeusia is also often associated with ageusia, which is the
complete lack of taste, and hypogeusia, which is a decrease in taste
sensitivity),
• xerostomia, dysphagia,
• Odynophagia (painful swallowing), severe esophagitis,
dehydration (head and neck)

Radiation Side Effects
• Radiation enteritis, fistulas (is an abnormal connection or
passageway that connects two organs or vessels that do not usually
connect), strictures (narrowing of a tubular structure as the
esophagus),
chronic malabsorption, severe diarrhea
(abdominal, pelvic)
• TPN may be warranted to prevent weight loss

and correct electrolytes

Other therapies
• Bone marrow transplant (BMT)
• Peripheral blood stem cells – hematopoietic stem
cell transplantation (HSCT)
• Obtained from donor, genetically identical twin,
self
• Stem cells are harvested, and then pt. goes
through conditioning regimen

Other therapies
• GVHD – graft vs. host disease: is a condition that might
occur after an allogeneic transplant. In GvHD, the donated bone
marrow or peripheral blood stem cells view the recipient's body as
foreign, and the donated cells/bone marrow attack the body.
• Nausea, vomiting, mucositis, pancytopenia (deficiency

of all three cellular components of the blood (red cells, white cells,
and platelets)), fever, infections
• If oral intake inadequate parenteral nutrition
support initiated
• Long-term complications systemic

Other therapies
• GVHD – graft vs. host disease
• Nutrition-related side effects of treatment
• Hyperglycemia, nitrogen catabolism,
hypertension, sodium retention, diabetes,
osteoporosis, weight gain, muscle wasting, poor
wound healing, Cushing’s syndrome
• A primary adrenal gland disease. In some people, the cause of Cushing
syndrome is excess cortisol secretion that doesn't depend on stimulation
from ACTH and is associated with disorders of the adrenal glands. The most
common of these disorders is a noncancerous tumor of the adrenal cortex,
called an adrenal adenoma.

Other therapies
• Biological Therapies
• Immunotherapy or biological response modifiers
– use body’s own immune system to eradicate
cancer cells
• Synthesized interferons, interleukins, cytokines
• Side effects: bone pain, fatigue, fever, anorexia,
rashes, flu-like symptoms
• Gene therapy in clinical trials

Nutrition Therapy
•Prevent malnutrition
•Screening and assessment important
•Be aware of cancer diagnoses and
treatments most likely to cause
malnutrition

Nutrition Implications
• Cachexia –
• Metabolic alterations
• Tumor induces hypermetabolic catabolic state
through chemical mediators
• Tumor specific “cachectic factors”
• Weight loss, anorexia, muscle wasting, fatigue,
early satiety
• Standard therapy – nutrition support

• Abnormalities in CHO, lipid, protein metabolism
• Normal physiologic conservation seen in

starvation does not occur
• CHO – insulin resistance, increased glucose

synthesis, gluconeogenesis, increased Cori cycle
activity, decreased glucose tolerance and
turnover

• Abnormalities in CHO, lipid, protein metabolism
• Protein - amino acids not spared, depletion of

lean body mass, increased protein catabolism, or
decreased protein synthesis
• Lipid – increased lipid metabolism, decreased

lipogenesis, decreased LPL, presence of lipid-
mobilizing factor (LMF)

• Cancer treatment
• Nausea, vomiting
• Early satiety
• Dysgeusia
• Diarrhea
• Mucositis
• Xerostomia
• Constipation
• Weight loss
• Anemia

Nutrition Interventions
• Nutrition Assessment
• Subjective global assessment (SGA)
• Anthropometrics including height, weight,
detailed weight hx, fluid retention, body
composition
• Biochemical including serum hepatic proteins
(albumin, prealbumin, transferrin), CRP, DHC
(Dehydrocholesterol)
• Clinical signs and symptoms

•Nutrition Assessment
•Detailed diet hx and current intake
•Foods tolerated,
• special diets,
•use of complementary alternative
medicines (CAM),
• supplements,
•liquid nutritional supplement
preferences
• Determining Nutrient Requirements
• Individualized
• Kcal to maintain weight and prevent loss
• Protein to prevent negative nitrogen balance and
meet synthesis needs; needs may be greater
with severe diarrhea or malabsorption
• Fluid needs - 30-35 mL/kg
• Multivitamin mineral supplement < 150% DRI

• Nausea & Vomiting
• Avoid noxious odors
• Review medication list for potential causes
• Small, frequent meals
• Pro-kinetics: A gastroprokinetic agent, gastrokinetic, or
prokinetic, is a type of drug which enhances gastrointestinal
motility by increasing the frequency of contractions in the
small intestine or making them stronger, but without
disrupting their rhythm.
• CAM – acupressure (press by hands), acupuncture
(insertion of fine needle), hypnosis (smell that trigger anxiety),
guided imagery. All are used to trigger the
acupoint or the energy points in the body.

• Nausea & Vomiting - Chemotherapy
• Small, low-fat meals morning of, avoid fried, greasy and
favorite foods (Bagel, hamburger, pizza…) for several
days
• Clear liquid diet
• Electrolyte-fortified beverages
• Non-acid fruit drinks
• Avoid favorite foods (to avoid subsequent low
consumption)
• Avoid “creamy” liquid nutritional drinks (same reason as
above)
• Anti-emetics 30-45 min. before meal
• Early Satiety
• Small, frequent nutrient-dense meals

• Beverages between meals and should contain
nutrients
• Avoid high-fiber and raw vegetables
• Pro-kinetics

• Mucositis (stomatitis)
• Thorough and systematic assessment of mouth
• Good oral hygiene important
• Oral glutamine: reduce duration and severity of
stomatitis
• Narcotic analgesics (Pain relief products)
• Eat soft, non-fibrous, non-acidic foods
• Avoid hot foods
• Encourage liquids; non-acidic juices
• High-kcal, high-protein shakes & supplements

• Diarrhea
• Drink small amounts of fluid frequently
throughout day
• Avoid large amounts of fruit juice
• Oral rehydration fluids and nutritional beverages
• Antidiarrheal medications
• Foods high in soluble fiber

• Dysgeusia
• Assess taste changes – metallic taste, aguesia,
heightening of certain tastes (sweets), aversions
• Avoid metal utensils, drink from glass
• Incorporate other high-protein foods if aversion
to meats exists
• Increase spices, flavors (aguesia)
• Non-sweet supplements, or juice- or yogurt-
based alternatives

• Xerostomia (dry mouth)
• Artificial saliva/ mouth moisturizers

• Gels, lozenges, mouthwashes
• Sugar-free gum, sour-flavored hard candy

• Anorexia
• Pharmacologic agents to increase appetite
• Megestrol acetate, corticosteroids
• Pharmacologic agents to treat weight loss
• Physical activity
• Oral supplements

• Nutrition Support
• Enteral vs. parenteral – if the gut works use it
• Nutrition support inappropriate for those with
terminal cancer or for pts. with poor prognosis
for whom other therapies have been exhausted
– ethical implications
• American Society for Parenteral & Enteral
Nutrition (ASPEN) practice guidelines for
nutrition support

• Nutrition Support
• Home nutrition support
• May maintain quality of life
• Lack of appetite and food intake may be
greater concern to family members, caregivers
than to pt. - gives a sense of control

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Neoplastic Disease

Dr. Nahla Al-Bayyari

•2nd leading cause of mortality

Dr. Nahla Al-Bayyari

•Transformation of normal cells to cancer

Dr. Nahla Al-Bayyari

• Nutritional genomics – study of genetic

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• See Table 24.2 – Major warning signs of cancer

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Tumor suppressor genes

• May also be based on telomeres

Dr. Nahla Al-Bayyari

• Telomeres and cancer. As a cell begins to become cancerous, it

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Tumor imaging techniques - MRI, CT, ultrasound, PET,

• Invasive techniques - biopsy, cytologic aspiration, laparoscopy

Dr. Nahla Al-Bayyari

• Tumors named according to tissue where they arise - “-oma”

Dr. Nahla Al-Bayyari

Stage 0 Abnormal cells are present but have

Stage IV The cancer has spread to distant parts

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Adjuvant: is given in addition to the primary or initial therapy to maximize its

Dr. Nahla Al-Bayyari

• Second look procedures: sometimes performed to determine if

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Treated with colostomy or ileostomy

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• See side effects – Table 24.3

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Alopecia: hair loss

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• TPN may be warranted to prevent weight loss

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Nausea, vomiting, mucositis, pancytopenia (deficiency

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

Dr. Nahla Al-Bayyari

• Normal physiologic conservation seen in