Nutritional Challenges for Cancer Patients

Written by Harriet Smith, BSc (Hons), RD

Nutrition advice for cancer patients is highly individualised and may alter during the course of a patient’s cancer journey.

Many aspects of cancer can affect an individual’s nutritional status due to the disease itself and the effects of associated treatments on dietary intake, nutritional requirements, nutrient losses and absorption of nutrients (1).

To coincide with World Cancer Day, this article explores some common nutritional challenges for cancer patients.

Weight Loss and Malnutrition:

About 40% of cancer patients have significant protein energy malnutrition. In some particular cancers, for example, head and neck cancers, rates can be as high as 80% (2).

The aetiology of malnutrition is multifactorial, and may be related to increased nutritional requirements, precipitated by surgery, infection and/or catabolism. It may also be related to increased losses, which may be drug-induced or associated with fistulae or bleeding.  Malabsorption of nutrients and reduced dietary intake are also potential factors (1, 3).

Complications of malnutrition are well-documented and include increased postoperative recovery times, increased risk of infections, and longer hospital admissions (4). Additionally, being malnourished during chemoradiation therapy is associated with more treatment complications than normal, and diminished overall survival (5).

Cancer Cachexia:

Cancer cachexia, also known as wasting syndrome, is a complex metabolic condition characterised by loss of skeletal muscle. Its prevalence ranges from 50-80% in advanced cancer (6) and it adversely affects a patient’s ability to fight infection and withstand cancer treatments (7).

Its aetiology is multifactorial, involving a complex interaction of tumour and host factors. It is characterised by loss of body weight, anorexia, asthenia (lack of energy), and anaemia (6).

Cachexia cannot be reversed by normal nutrition support alone, and recent research has focused on the potential role of appetite stimulants, such as the hormone megestrol acetate as a means of increasing appetite and weight. However, a Cochrane review concluded that it did not result in meaningful functional outcomes or improvements in quality of life (8).

Pain:

It’s estimated that more than half of cancer patients receiving anti-cancer treatment, and two thirds of patients with advanced and metastatic cancer, experience pain (9). Whilst cancer-specific studies are required, chronic non-malignant pain is associated with self-reported appetite impairment in older adults (10).

Recent interventional studies have shown promising effects of vitamin D supplementation on cancer pain levels, but only in patients with suboptimal levels of vitamin D prior to starting supplementation (11).

Nausea and Vomiting:

Despite advances in the medical treatment of emesis, up to half of cancer patients will experience nausea or vomiting during their treatments (12)

A small study of 143 breast cancer patients found that several characteristics increased a person’s risk of developing these symptoms. These included being young (less than 40 years old), nausea expectation, and not eating prior to treatment (13) .

Early Satiety:

Early satiety is an important but unrecognised symptom in cancer patients. The severity of anorexia is known to correlate with the presence of early satiety, both of which may impair nutritional intake (14).

This symptom is poorly understood, since many patient-validated questionnaires do not measure self-reported satiety. However, prokinetics have been shown to be effective in improving chronic nausea and early satiety in cancer cachexia patients (15).

Psychological Distress:

A large meta-analysis conducted in 2010 estimated that up to one-third of acute cancer patients will experience a mental health disorder (16). Of these, depression has been most widely studied, however epidemiological studies have shown associations between cancer and increased rates of major depressive and anxiety disorders (17, 18).

There appears to be a link between malnutrition and psychological distress in patients with specific cancers, such as advanced head and neck cancer 19. What’s more, quality of life in cancer patients is largely influenced by factors such as nutritional status (20).

Side Effects from Cancer Treatments:

All cancer patients should be encouraged to eat well during the course of their treatments. However, side effects relating to anti-cancer treatments must be taken in to account when offering nutrition advice.

Surgery:

Any form of surgical procedure causes the body physiological stress, but the extent of this depends on the severity of the surgery. Energy demands are thought to rise by 10% following even minor surgery and up to 60-70% in major trauma (21,22).

Surgical removal of a cancerous tumour has numerous nutritional implications, including periods of nil by mouth, a delay in resuming normal feeding, and significant metabolic costs resulting from surgery.  Side effects impacting food intake, such as dumping syndrome or intestinal failure, are also possible risks associated with surgical intervention (1).

In addition, some patients undergoing surgery may already be in a malnourished state and are therefore at increased risk of nutritional depletion and re-feeding syndrome (1).

All of the factors above need to be accounted for when planning a patient’s nutritional care. Both pre- and post-operative nutrition support may be indicated, with the goal of restoring and maintaining good nutritional status throughout the patient’s cancer journey.

Chemotherapy:

Chemotherapy stops cancer cells from reproducing, which prevents them from growing and spreading in the body. However, the side effects of chemotherapy medications can have a detrimental impact on rapidly dividing tissues such as the lining of the gut (1).

Chemotherapy can change the taste receptors in the mouth, which may alter the way certain foods taste. This can reduce enjoyment of food, and lead to an inadequate nutrient intake, with a high impact on nutritional status and quality of life (23).

Small patient surveys have reported that avoiding strong-smelling foods and eating blander foods (which can include neutral flavour sip feeds) can help to combat this symptom.  Eating small, frequent meals and drinking more water with meals can also help (24).

Oral mucositis (a sore and inflamed gut or mouth), is one of the most debilitating complications of chemotherapy and radiotherapy treatments. However, there is very limited evidence of the efficacy of treatment regimens, and it is predominantly managed with medications such as pain analgesia, anti-inflammatory drugs and antimicrobials. If food intake is affected, a modified diet, (for example a soft diet) may be necessary (25, 26).

Radiotherapy:

Radiotherapy is usually given with curative intent but can also be used in the palliative setting for symptom control.

General side effects of radiotherapy include anorexia, nausea, fatigue, and reduced mood, often relating to physical symptoms. The site which the radiation is directed towards will determine the extent and severity of symptoms (1).

For example, radiation to the head and neck can affect a person’s ability to eat or swallow, potentially leading to radiation-induced dysphagia, whereas radiation to a person’s pelvic region may result in abdominal cramps and diarrhoea (27,28).

Patients undergoing radiotherapy should have regular nutritional screenings so that potential problems with eating and swallowing can be identified at an early stage.

Conclusion:

Nutrition is an important aspect of cancer care and appropriate nutrition advice and/or artificial nutrition should be implemented from diagnosis onwards (1).

Managing the cancer patient requires a multidisciplinary team approach, with the dietitian working closely alongside allied healthcare professionals.

Nutrition advice will be highly individualised but the overarching principles of dietetic input remain the same. These are to ensure nutrition and hydration needs are met, to restore nutrition inadequacies, to minimise nutrition consequences, and to implement nutrition support measures where required.

References:

1. Shaw, C. (2014) ‘Cancer’, in Joan Gandy (ed.) Manual of Dietetic Practice. Chichester: John Wiley & Sons, Ltd, pp. 805-858.
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3. Ryan, A. M. et al. (2016) Cancer-associated malnutrition, cachexia and sarcopenia: The skeleton in the hospital closet 40 years later. Proceedings of the Nutrition Society
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