cancer definition and risk factors plus the role of diet in prevention and treatment

cancer and mnt

1. Cancer and dietary management 1 Faisal Al- shormany . MD.PhD.SCOPE Fellow Associate Professor, Faculty of Medicine ,Sana’a University

2. Objective s 2 At the end of the presentation, participants will be able to : Know about the cancer and its progression . Know the epidemiological fact in global regional and national context . Learn the risk factor of cancer and its symptoms . Know how to cancer can be prevented and its dietary management .

3. Epidemiology- global, national scenario Classification. Risk factors Pathophysiology’ Sign and symptoms The Association of Cancer, Therapies, and Malnutrition . Practical Points in Nutritional Management of Cancer Patients . Resourc e s for E v idence - b a sed Practice in Nutrition for Cancer . Topics

4. What Is Cancer? Cancer is a large group of diseases ( over 200 ) characterized by uncontrolled growth and spread of abnormal cells. 4 American Cancer Society, Cancer Facts and Figures 2005

5. Cancer ??? Division – uncontrolled cell division . Growth – formation of a lump (tumour) or large numbers of abnormal white cells in the blood . Mutation – changes to how the cell is viewed by the immune system . Spread – ability to move within the body and survive in another part . 5

6. Key facts 6 Cancer is a leading cause of death worldwide, accounting for 8.8 million deaths in 2015. The most common causes of cancer death are consists of: Lung (1.69 million deaths) Liver (788 000 deaths) Colorectal (774 000 deaths) Stomach (754 000 deaths) Breast (571 000 deaths) ( WHO )

7. Classification of cancer Type Tissue or cell of origin example carcinoma Endoderm or ectoderm Epithelial lining of gout (e.g. adenocarcinoma of colon) or brocnchus (e.g. squamous cell) or small cell carcinoma of bronchus sarcoma mesoderm Osteosarcoma, fibrosarcoma leukemia White blood cell Acute lymphoblastic leukaemia Lymphoma Monocyte, macrophage Hodgkin’s disease Adenomas Tumours that come from glandular tissue thyroid, the pituitary gland the adrenal gland. They are often benign. 10

8. Risk factors Heredity (genetic defects) Environmental factors Ionising radiation- X- ray, gamma ray, radioactive substances . Chemical substances- cause mutation. Benzene and asbestos, tobacco . Dietary factors- may cause cancer by direct carcinogens or carcionogens may be produced by cooking . Diseases (e.g. o besity and infectious diseases). 11

9. Environmental risk factor contd… 9 Estrogens - breast and endometrial cancer. Viruses - hepatitis- B virus in human primary liver cancer, human papilloma virus and epstein barr virus are considered oncogenic. Stress - influence the integrity of the immune system and nutritional status . Age - developing colorectal cancer increase with age .

10. How diet can affect cancer

11. Before understanding the impact of nutrition on cancer, it is first important to understand the biochemical and physiological determinants of the disease . People are continuously exposed exogenously to varying amounts of chemicals that have been shown to have carcinogenic or mutagenic properties. Cancers are as a result of the interaction of genetics, epigenetics and environment al factors. Cancer is a chronic disease .

12. Initiation-dietary carcinogens A flatoxins (found in mouldy food) H eterocyclic amines (meat cooked at very high temperatures) N-nitroso compounds (in some spoiled foods, protein foods, cured meat ) . P olycyclic aromatic hydrocarbons (PAH) (products found in cooked foods, smoked foods) . T hese chemicals can start a cancer process by creating cancer cells (World Cancer Research Fund 1997; NRC 1982)

13. Diet-red meat Heavy consumption of red meat is a risk factor for several cancers, especially those of the gastrointestinal tract, but also for colorectal, prostate, bladder, breast, gastric, pancreatic and oral cancers . The hetrocyclic amines produced during the cooking of meat are carcinognic. Charcoal cooking and/or smoke curing of meat produces harmful carbon compounds which have a strong cancerous effect. Anand P et al, Cancer is a preventable disease that requires major lifestyle changes. 2008

14. Diet: Fats and sugars Saturated fatty acids, trans fatty acids and refined sugars and flour present in most foods have also been associated with various cancers (1 ) Epidemiologic studies suggested a positive association between dietary fat and colon cancer. ( 2 ) Frequent consumption of sugar and high-sugar foods may increase the risk of pancreatic cancer by inducing frequent postprandial hyperglycemia, increasing insulin demand,and decreasing insulin sensitivity . (3) Anand P et al, Cancer is a preventable disease that requires major lifestyle changes. 200 Reddy, B Dietary Fat & Colon cancer. Chemistry & material science vol 27 no 10 807-813 American Journal of Clinical Nutrition Vol 84 No 5 1171-1176 Nov 06

15. © - excess fat - ↑ insulin, ↑ estroge - ns, ↑ oxidative stress, ↑ inflammation - excess protein -↑ insulin, ↑ IGF-1 . - excess calories - ↑ insulin, ↑ IGF-1, ↑ oxidative stress, ↑ inflammation - excess Omega 6 EFA- ↑ oxidative stress, ↑ inflammation DietaryTumour Promoters

16. © - insulin- promotes cancer cell proliferation and decreases apoptosis . estrogens- induces cancer cell proliferation . oxidative stress- can act as cancer initiator and promoter . inflammation- strong association between chronic inflammation and cancer (mechanisms: promoting proliferation of cancer cells formation of cancer blood vessels?-not entirely understood ). - IGF-1- potent growth factor for many cancer lines . ( Heber et al 2006 ) Metabolic Tumour Promoters

17. Food related cause to cancer Type of cancer Food items Breast cancer, premenopause Alcoholics drinks Breast cancer, postmenopause Alcoholics drinks, body fatness, sedentary living Colon, rectum cancer, kidney cancer Red meat, processed meat, barbecuing meat, high intake of fat, body fatness, abdominal fatness, sedentary living Lung Arsenic in drinking water Stomach, liver, mouth, pahrynx, larynx, oesophagus, pancreas High intake of alcohol, body fatness Prostrate Diet in high calcium Folate deficiency Cervical cancer 12

18. Food related cause to cancer Vitamins and minerals Low blood carotonoids levels cause lung cancer Low dietary vitamin C cause oro- phryangeal, stomach and esophgeal cancer Low vitamin E cause lung, cervix and colorectal cancer Selenium and zinc deficiency may also increase risk of cancer Nitrates Cause nasophryngeal, stomach and colorectal cancer aflatoxins Cause liver cancer Energy dense foods, sugar drink fast foods. Cancer in any part of the body 13

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20. Symptoms of cancer Oral cancer Ulcers, white or red patches inside the oral cavity or difficulty in swallowing Lung/throat cancer Persistent cough, chest pain, blood in sputum, shortness of breath, weight loss, loss of appetite, hoarseness Stomach cancer Indigestion, heartburn, abdominal pain, bloating of stomach, loss of appetite, tiredness, diarrhoea. Constipation Colon cancer Change in bowel habits, malena Breast cancer A lump in the breast or under arm area, change in shape size, color of breast, discharge from the nipple Cervical/uterine cancer Unusual vaginal discharge, pain in pelvic area Kidney cancer Hematuria, fevers, weight loss, pain in left loin, anemia, high BP Bladder cancer Frequent and painfulurine, Prostrate cancer Urination problem Melanoma Change in size, shape or color of a wart 16

21. Treatment-related Side Effects on Nutrition Treatment Side effects Surgery difficulty swallowing (esophagus, voice box), diarrhea (bowel, stomach, pancreatic), incomplete absorption of nutrients Chemotherapy loss of appetite, nausea, vomiting, constipation, diarrhea, mouth sores, taste changes, difficulty swallowing, lowered immunity, fatigue Radiotherapy loss of appetite, fatigue, taste changes, nausea, vomiting, diarrhea, dry mouth, difficulty swallowing, bowel obstruction, mouth sores Steroid Therapy increased appetite, weight gain, increased risk of infection, stomach irritation Stem Cell Transplant lowered immunity, sore mouth and throat, nausea, vomiting, diarrhea, fatigue, loss of appetite Hormone Therapy weight gain, increased cholesterol levels Targeted Therapies diarrhea, nausea, vomiting, constipation, taste changes, mouth sores, fever, increased risk of infection Cancer Council Victoria. 2016. https:// www.cancervic.org.au/

22. Malnutrition in Cancer Patients At cancer diagnosis, ~50% of patients present with some nutritional issues. In certain cancers, up to 85% of patients will develop malnutrition and/or weight loss during treatment. 40% of hospitalized oncology patients were malnourished. Halpern-Silveira D, et al. Support Care Cancer. 2010. Laviano A, et al Nutrition. 1996. Hebuterne X, et al. JPEN. 2014. Illustration: https://well.blogs.nytimes.com/2015/07/27/ when-cancer-triggers-or-hides-an-eating-disorder/

23. Pathophysiology of Cancer-related Malnutrition Arends J, et al. Clin Nutr. 2017.

24. Cancer management Primary goals Support tumourcidal effects of treatment Reduce side effects of treatments Support overall wellness Secondary goals Support immunity Reduce tumour promoting factors Inhibit metastasis and tumour progression Promote appropriate apoptosis

25. Dietary management 26 Objective of nutritional therapy To meet the increased metabolic demands of the disease and prevent catabolism as much as possible . To alleviate symptoms resulting from the disease and its treatment through adaptation of food and the feeding process . Increase caloric intake Prevent weight loss

26. Route of Nutrit i on Support Ukleja A, et al. Nutr Clin Pract. 2010.

27. Management of Cancer Prevention: Measures known to reduce the risk of cancer: Avoiding smoking or exposure to tobacco smoke Avoiding occupational carcinogens (for example, asbestos) Avoiding prolonged exposure to sunlight without sunscreen protection Avoiding excessive alcohol intake Avoiding use of hormone therapy (for example- estrogen and progesterone ) for symptoms of menopause 17

28. Management of Cancer.. 29 Measures that may reduce the risk of cancer: Limiting intake of high- fat foods, particularly from animal sources (for example, high- fat meats and whole- fat dairy products) Limiting intake of processed meat Increasing intake of fruits and vegetables Increasing intake of whole- grain foods Being physically active Keeping weight below the obese level

29. Energy 30 Calorie requirements are : 20- 25kcal/kg for sedentary patient . 30- 35kcal/kg for slightly hypermetabolic, weight gain/anabolism . 40- 45kcal/kg for hypermetabolic or severly stressed patient, signi fi cant malabsorption.

30. Protein 31 Additional protein is required for regenaeration, healing and rehabilitation. 0.8- 1.0g/kg- normal maintenance level 1.5- 2.5g/kg if increased protein demands exist. E.g. protein losing enteropathy, hyper metabolism or extreme wasting .

31. Vitamins and minerals 32 Optimal intake of vitamins and minerals are recommended . A pproximately equal to RDA ; discourage the use of high-dose micronutrients in the absence of specific deficiencies. .

32. Beneficial effects of nutrient antioxidants 33 Nutrient Beneficial effect Beta carotene Reduced risk of various cancers especially lung cancer and also stomach, cervix, oesophageal Vitamin C Reduced risk of upper GI tarct, cervix cancer, cardiovascular disease. Vitamin E Significant decreases in the risk of oral and pharyngeal cancer, CVS Selenium Reduced risk of esophageal and stomach cancer

33. nd MA, MBS, BSc Tumour Anti- Promoters: estrogens; Insulin growth factors (IGF-1) inflammation downregulation of oncogenes upregulation of tumour suppressor genes © CNM; by Gosia Desmo (World Cancer Research Fund 2007 Nu ; t H M e e b d e J r o 2 G a m 6 bl ; e O BA rn (h is o h ns e ) D t i a p l C 2 N M 08; Saxe 2006) low fat; high fibre adequate protein adequate calories whole plant foods O6: O3 ratio 2:1 Physical activity

34. s t i m u l a tes immune response Phytonutrients lowers IGF-1 full of a n tio x i d a n ts promotes synthesis of detoxification enzymes lowers insulin lowers estrogens lowers oxidative damag minimizes carcinogen exposure creates powerful anti-cancer environment Low Fat Vegan Diet

35. Management of Cancer contd … 36 Screening , self examination and medical history: Some types of cancer - - such as those of the skin, breast, mouth, testicles, prostate, and rectum -- may be detected by routine self- exam or other screening measures before the symptoms become serious. Laboratory studies of blood, BM , Body fluids can detect abnormalities that may indicate cancer .

36. Management of Cancer contd … 37 Diagnosis, staging and Treatment When a tumor is suspected, imaging tests such as X- rays, computed tomography (CT),magnetic resonance imaging (MRI), ultrasound, and fiber- optic endoscopy examinations help doctors determine the cancer's location and size .

37. Diagnosis… 38 To confirm the diagnosis of most cancers , a biopsy needs to be performed in which a tissue sample is removed from the suspected tumor and studied under a microscope to check for cancer cells. It helps to evaluate the staging of cancer- prognosis of the patient and to choose the appropriate treatment .

38. Staging... 39 Cancer staging is carried out on the basis of.... Size of tumor Invasion Lymph nodes Metastasis

39. STAGES OF CANCER ( EG. BOWEL) 30 . Stage : cancer cells - within the bowel lining. Little risk of spread ( carcinoma in situ ) . Stage I : cancer grown through the inner lining up to muscle wall, but no further. Stage II : cancer has grown through the outer covering of the bowel wall . Stage III : Cancer has spread to the lymph nodes . Stage IV : Cancer that has spread to other organs such as lung, liver.

40. TNM Staging T ( 1- 4 ): size or direct extent of the primary tumour N (0- 3): degree of spread to regional lymph nodes N0: tumour cells absent from regional lymph nodes N1(1 to 3 lymph nodes), N2 (4 or more ) . M (0/1): presence of metastasis M0: no distant metastasis M1: metastasis to distant organs (beyond regional lymph nodes) 41

41. Let food be your medicine." - Hippocrates

42. A 25 years old male patient has presented with a known diagnosed case of Ca.nasopharynx in TUTH dietetics OPD for diet consultation. He is 5 feet 2 inch tall and 45kg weight. What kind of diet plan will you adopt ? Patients weight = 45kg Height = 5’.2” i.e.157.8cm IBW= 51.82kg BMI = 18.21 Energy requirement= 35 * 51= 1785kcal 43

43. MENU PLANNING FOR 1800 KCAL Nutrient distribution Carbohydrate = 280gm (62%) Protein = 67.5gm(15%) Fat = 47gm(23%) Serving distribution Total serving = 23 Carbohydrate =11.5 Protein = 8 Fat = 2 Vitamins/minerals= 1.5 35

44. Food groups List Unit Protein fat Carbohydr ate CHO 1 10 20 - 180 2 1.5 - - 27 protein 3 2 18 12 - 4 3 12 15 18 5 3 18 3 39 fats 6 2 - 18 - Vitamins/mi nerals 7 1.5 7.5 1.5 19.5 36

45. Protein= 75.5gm(16%) Fats= 50gm(24%) Carbohydrate 285gm(60%) Breakfast ( 07:00-0800am) Milk 1 glass (130ml) Egg 1 pcs (50gm) Bread/biscuits 4 slice(120gm) Launch(10:11:00am) Rice 2 glass (240gm) Dal 1 cups Vegetables 1 glass Meat 4- 5pcs Milk/yoghurt 1 glass Green salad few 37

46. Mid afternoon (01:00-02:00pm) Fruits 1 medium Snacks (03:00-04:00pm) Pulses/legumes 1 glass and egg white 1 pcs Bread 1pcs and vegetables 1/2 glass Dinner (07:00-08:00pm) Bread 3 slice or rice 1 and half glass Dal 1 glass Vegetables 1 glass Yoghurt/milk 1 glass Meat 3- 4 pcs Green salad few 38

47. CONCLUSION Cancer is a disease of Division, growth and spread It has a number of causes many of them are preventable The survival of the patient is determined by the stage of the disease, the earlier the detection or the smaller the tumour the better the survival 39

48. 10 Rules to Avoid Cancer Don’t smoke Don’t smoke . Don’t smoke. Avoid exposure to other known carcinogens, including aflatoxin, asbestos and UV light. Enjoy a healthy diet, moderate in calories, salt and fat, and low in alcohol . Eat fresh fruit and vegetables several times a day. Be physically active and avoid obesity. Have vaccination against, or early detection/treatment of, cancer causing chronic infections. Have the right genes. 10. Have good luck !!!!! 40

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