NUTR 74600 Nutrition and Disease- Oncology Case Study PDF

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NUTR 74600 Nutrition and Disease Case Study: Oncology Fall Semester 2020 Directions: Using the accompanying case material (PPT slides posted to Bb/assignments tab), provide typed answers to the following questions with citations and references where required. Nutrition Assessment: Med Hx/PE 01. Provide a description of diffuse large B-cell lymphoma indicating the cell type involved, typical age of onset, and common presenting signs and symptoms. Note: Use the American Medical Association (AMA) citation/reference style (see PPT slides posted to Bb/course documents tab-professional development file) to cite source material in answer and provide reference(s) at end of case study write-up. (3 pts) Diffuse large B-cell lymphoma is an aggressive type of non-Hodgkin lymphoma that affects B-lymphocytes, a type of white blood cell1. The disease occurs when the body makes large, abnormal B-lymphocytes, resulting in the buildup of these cells within the lymph nodes or other organs 2. B-lymphocytes function as a part of the adaptive immune system by identifying surface antigens of bacteria and viruses and forming pathogen specific antibodies, which bind to the invading cell and mark it for destruction by other immune cells 2. Although diffuse large Bcell lymphoma can occur at any age, it most commonly affects people over the age of 50 and the average age of diagnosis is 60-65 years. It is more common in men than women. The most common presenting signs and symptoms are painless, enlarged lumps in the neck, armpit or groin due to enlarged lymph nodes that can grow rapidly, fever, fatigue, night sweats, and involuntary weight loss 1. Symptoms are also dependent on the location of the lymphoma; abdominal pain and diarrhea may occur if there are enlarged lymph nodes within the abdominal cavity, shortness of breath and cough may occur if there are enlarged lymph nodes within the chest 2. 02. Provide a description of CHOP, a combination of chemotherapeutic agents, by identifying each medication (note: hydroxydaunorubicin represents “H” in this acronym although frequently referred to a doxorubicin and oncovin represents “O” or vincristine); and then classify the “C”, “H”, and “O” according to drug classes as defined in Nelms and Sucher, Table 23.5. Note: Use AMA system to cite your source material in answer and provide reference(s) at the end. (2 pts) Treatment for diffuse large B-cell lymphoma usually consists of chemotherapy regimen of 4 drugs (cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone) and the monoclonal antibody rituxan 3. This chemotherapy regimen is given in cycles 3 weeks apart and may not be suitable in individuals with heart complications because hydroxydaunorubicin may damage the heart 3. For stage I or II DLBCL (1-2 lymph node groups on the same side of the diaphragm), CHOP is given for 3-6 cycles and is typically done before radiation therapy 3. In stages III or IV, 6 cycles of CHOP are given as a first line treatment, followed by intrathecal chemotherapy or IV methotrexate, if necessary 3. Cyclophosphamide is in a class of medications called alkylating agents. This medication is an

antineoplastic agent that slows/stops the production of cancer cells within the body. It works by directly attacking DNA by cross linking guanine bases, which prevents the uncoiling and separation of DNA strands so cells cannot replicate or divide, resulting in cell death 4. Patients taking this medication may have increased fluid needs. Side effects include nausea, vomiting, abdominal pain, and diarrhea4. Hydroxydaunorubicin (doxorubicin) is in a class of medications called anthracyclines/antitumor antibiotics. This antineoplastic antibiotic functions by intercalating within DNA base pairs, which causes the breakage of DNA strands and blocks topoisomerase II 5 . Common side effects include hair loss, nausea, vomiting, and mouth sores 6. Oncovin (vincristine) is in a class of medications called vinca alkaloids. It is an antineoplastic agent that inhibits metaphase during mitosis by interacting with tubulin7. Individuals taking oncovin should not consume grapefruit because it may increase serum concentrations of the medication, and they should not take St. John’s Wort, which may reduce serum levels of the medication 7. Common side effects include blurred vision, constipation, numbness/tingling in fingers and toes, and joint pain 8 Prednisone is in a class of medications called corticosteroids. It is used as an anti-inflammatory, antinausea and antiemetic medication. It can be used to stimulate appetite in cancer patients. It works by preventing white blood cells from traveling to the site of swelling, which decreases inflammation and swelling 9. Patients taking this medication may have increased blood glucose levels, may require increased levels of potassium, phosphate, calcium, vitamin A, C, and D, and may require increased protein consumption10. Nutrition Assessment: Biochemical Assessment 03. Provide an interpretation for both the reported serum albumin level and the leukocyte (WBC) count by comparing to normal values and noting why the change from normal. (1 pt) Normal albumin levels range between 3.4-5.4 g/dL 11. The patient’s albumin levels were noted to be 3.0 g/dL, which are lower than normal. Inflammation, hydration status, and disease states can affect albumin levels. Cancer is associated with high levels of physiological stress, which results in the production and release of proinflammatory cytokines that increase the amount of inflammation within the body. This results in the liver producing higher levels of acute phase proteins such as CRP and decreasing the synthesis of albumin 12. The production of cytokines, such as IL-6, from cancer cells can also affect albumin production 12. In addition, the patient’s poor protein intake may also be contributing to low albumin levels. Normal WBC within the blood is 4,000 - 11,000 WBCs per microliter of blood 13. The patient’s WBC levels were 2100 cells/mm3, which is lower than normal. Cancer and chemotherapy can contribute to low WBC levels due to the decreased production of healthy WBCs within the bone marrow 14.

Nutrition Assessment: Dietary Assessment

04. Provide a plausible explanation for the patient’s mouth “hurts so badly she can hardly talk.” (0.5 pt) The patient’s mouth pain, or stomatitis, is likely due to the chemotherapy. Chemotherapeutic agents such as Doxorubicin target rapidly dividing and growing cancer cells, however cells within the mouth can also be damaged because they also rapidly divide and grow, resulting in painful sores inside the mouth that are unable to heal 15. Since chemotherapeutic agents can suppress the body’s immune system, these sores are more susceptible to infection by viruses, bateria, and fungi 15. Nutrition Assessment: Anthropometric Assessment 05. Review the anthropometric data and accompanying interpretation; and then calculate body mass index and indicate classification. (0.5 pt) BMI = 49 kg ÷ (1.68 M)2 = 17.4 (i.e., underweight) 2 Nutrition Diagnoses 06. The clinical nutritionist (RDN) has identified three nutrition dx’s, i.e., swallowing difficulty, inadequate oral intake, and unintended weight loss, and has formatted three corresponding problem/etiology/signs and symptoms (PES) statements. Complete the “signs and symptoms” phrase for the two incomplete PES statements. (1 pt) Dx 1 (NC-1.1 Swallowing difficulty): Swallowing difficulty related to mucositis as evidenced by patient/family interview and physical assessment. Dx 2 (NI-2.1 Inadequate oral intake): Inadequate oral intake related to mucositis as evidenced by an oral intake of less than 15% estimated energy and protein requirements. Dx 3 (NC 3.2 Unintended weight loss): Unintended weight loss related to limited food choices and inadequate energy intake as evidenced by 22 lb weight loss over the past 6 months and current BMI of 17.4. Intervention: Planning (in-patient care plan) 07. Review the intervention (care plan) that was implemented for this patient (PPT slide #5); and then complete the following food options grid (PPT slide #6) by proposing three appropriate food items with respect to grains, fruits, and dairy that would be consistent with the care plan. (2 pts) Meat/poultry/fish/eggs - finely cut meat, poultry w/ gravy or sauce; scrambled eggs Grains - oatmeal ; pasta ; white rice ; refined soft white/wheat/rye breads Fruits - apple sauce ; mashed avocado ; fruit smoothies ; bananas Vegetables - diced vegetables, e.g., green and red/orange; m potatoes Dairy - yogurt (without granola or nuts) ; ice cream/froyo/sherbert ; cottage cheese or ricotta ; milk ; milkshakes

Intervention: Planning (out-patient goal setting) 08. Using the verb, condition, criteria template for goal setting, complete the second goal that the clinical nutritionist (RDN) and patient have discussed. Note: In practice, goals are mutually determined, so your proposed goal setting represents a possible condition and criteria that the clinical nutritionist (RDN) and patient would decide upon. (1 pt) To consume dairy products (2 servings) from, for example, yogurt, custard, pudding, milkshake (or enteral nutrition supplement) every day at breakfast, lunch or dinner, 6-7 days/week. (Note: ≈ 10 g protein/serving) Intervention: Implementation (out-patient nutrition counseling) The patient’s mother has accompanied her to the out-patient visit and she again parenthetically mentions that the patient’s aunt and uncle are willing to provide an anti-cancer diet; this time the mother mentions milk thistle. 09. The clinical nutritionist (RDN) is aware that milk thistle has purported anti-cancer effects but limited, if any, clinical (human) studies to support treatment efficacy. Run a literature search in pubmed.gov using the following keywords: lymphoma AND (milk thistle). Of the approximately four journal articles that are identified in this search, how many of the articles report studies based on human study participants and how many of the studies are based on randomized control trial (RCT) study designs? Note: Answer can be determined by reading abstracts and thus reading articles in full is not required. (1 pt) Based on the 4 research articles found on pubmed.gov using the keywords lymphoma and milk thistle, one of them was a case study involving a human patient, two of them used rat models, and the final one involved human oral squamous carcinoma cells. None of the studies were based on RCT design or used human study participants. 10. The clinical nutritionist (RDN) senses that the mother would like to further discuss this herbal option (perhaps for her own edification or for responding to the aunt and uncle). Select one of the following possible responses for the clinical nutritionist (RDN) and briefly explain why this selection may facilitate more effective nutrition counseling. (2 pts) 3 A. I would advise you to disregard herbal treatments as we provide only governmentapproved modalities. (Verbal response based on “premature” advice-giving.) B. Tell me more. You seem to be saying that you’re interested in exploring all options. (Verbal response based on continuing response.) The RDN should respond with response B because it allows the patient’s mother to elaborate on why she would like to use herbal supplements and to facilitate further conversation. The RDN can explain how there is very little research regarding milk thistle and its potential anti-cancer properties in human participants. Some sources say how milk thistle does not interfere with chemotherapy’s effectiveness, however due to the lack of research, there may be side effects that may further impair the patient’s health and cause further complications 16. The

RDN should then respond saying that the patient’s main goals are to increase her calorie intake using nutrient dense foods, however milk thistle can act as a mild laxative and cause GI upset, which can make the patient feel more uncomfortable and less likely to eat 10. Finally, the RDN can suggest including more fruits and vegetables into the patient’s diet as they are rich in vitamins, minerals, and antioxidants that can positively support her chemotherapy treatment. Response A is very dismissive and closed ended, which may be discouraging to the patient’s mother. Grading rubric: Point allocation noted after each question, 14 pts; quality of writing, 1 pt DUE: Fri, Sept 25 (Bb, submit online) References 1.

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Diffuse large B-cell lymphoma. Leukaemia Foundation. Accessed September 22, 2020. https://www.leukaemia.org.au/blood-cancer-information/types-of-bloodcancer/lymphoma/non-hodgkin-lymphoma/diffuse-large-b-cell-lymphoma/ Diffuse large B cell lymphoma | non-Hodgkin lymphoma | Cancer Research UK. Accessed September 22, 2020. https://www.cancerresearchuk.org/about-cancer/non-hodgkinlymphoma/types/diffuse-large-B-cell-lymphoma Treating B-Cell Non-Hodgkin Lymphoma. Accessed September 22, 2020. https://www.cancer.org/cancer/non-hodgkin-lymphoma/treating/b-cell-lymphoma.html Cyclophosphamide. Accessed September 22, 2020. https://go.drugbank.com/drugs/DB00531 Doxorubicin. Accessed September 22, 2020. https://go.drugbank.com/drugs/DB00997 Doxorubicin (Intravenous Route) Side Effects - Mayo Clinic. Accessed September 22, 2020. https://www.mayoclinic.org/drugs-supplements/doxorubicin-intravenous-route/sideeffects/drg-20063553?p=1 Vincristine. Accessed September 22, 2020. https://go.drugbank.com/drugs/DB00541 Vincristine (Intravenous Route) Side Effects - Mayo Clinic. Accessed September 22, 2020. https://www.mayoclinic.org/drugs-supplements/vincristine-intravenous-route/sideeffects/drg-20066703 Prednisone - Chemotherapy Drugs - Chemocare. Accessed September 22, 2020. http://chemocare.com/chemotherapy/drug-info/Prednisone.aspx Nelms M, Sucher K. Nutrition Therapy and Pathophysiology. 4th Edition. VitalSource Technologies Inc.; 2019. Accessed April 21, 2020. https://www.bookshelf.vitalsource.com/ Albumin Serum. ucsfhealth.org. Accessed September 24, 2020. https://www.ucsfhealth.org/medical-tests/003480 Nazha B, Moussaly E, Zaarour M, Weerasinghe C, Azab B. Hypoalbuminemia in colorectal cancer prognosis: Nutritional marker or inflammatory surrogate? World J Gastrointest Surg. 2015;7(12):370-377. doi:10.4240/wjgs.v7.i12.370 How to read a white blood cell count. Ada. Accessed September 24, 2020. https://ada.com/white-blood-cell-count/ Low white blood cell count and cancer: MedlinePlus Medical Encyclopedia. Accessed September 24, 2020. https://medlineplus.gov/ency/patientinstructions/000675.htm When cancer treatment causes mouth sores. Mayo Clinic. Accessed September 23, 2020. https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/mouth-sores/art-20045486 Milk Thistle Protects Cancer Patients from Chemotherapy-Associated Liver Toxicity. American Cancer Society MediaRoom. Accessed September 24, 2020. http://pressroom.cancer.org/releases?item=212...