Nutrition in Cancer

1. CANCER
Presented By:
Supta Sarkar
HHM-2013-10
Dept. of Foods & Nutrition

2. SEE INSIDE…
• Introduction: Cancer
• Some cancers related to the digestive system
• The side effects of cancer treatment and the nutrition therapy
• General systemic reactions in cancer
• Cancer and nutrients
• Nutritional care in cancer
• Conclusion

3. CANCER
‘WHEN GOOD CELLS GO BAD’
 Cancer refers to uncontrolled cell
growth.
 Cancer can also refers to malignant
neoplasm or tumours.
 Tumours can be benign or malignant.
 Malignant tumor have the potentiality
of metastasis.
 Mutation causes cancer: Inherited or
acquired.

4. CANCER SCENARIO
WORLDWIDE:
WHO, 2012 REPORT:
• Cancer is the second most common disease worldwide.
• 8.2 million people worldwide died from cancer in 2012.
(WHO, 2012).
• About 30% of cancer deaths are due to the five leading
behavioral and dietary risks: high body mass index, low
fruit and vegetable intake, lack of physical activity,
tobacco use, alcohol use.
• 30% of cancers could be prevented (WHO, 2012)

5. INDIA
• According to 1991 Indian census data, about
6,09,000 cancer cases had been observed.
• But the number of cancer cases in India has
drastically increased in the last decade to reach
8,06, 000.
• Cases registered by 2010: 9,79,786.
• Total cases in 2012: 10,15,000 population (WHO,
2012).

6. HOW GOOD CELLS GO BAD?
Carcinogenesis
• Different types of cells have different life spans,
depending on their location and function.
• New cells are produced by the process of cell
division, mitosis.
• 2 types of genes that causes cell growth and
division: Proto-oncogenes & Tumor suppressor
genes.

7. • Proto-oncogenes: Genes which promote cell growth
and reproduction.
• Tumor suppressor genes: Genes which inhibit cell
division, repair DNA function and tell cells when to
die(Apopstosis).
• In order for a normal cell to transform into a cancer
cell, these genes must be altered.
• Typically, changes in many genes are required to
transform a normal cell into a cancer cell.
• According to research findings from the Cancer
Genome Project, most cancer cells possess 60 or
more mutations.

10. Fig.: Seven proteins that regulate cell growth

11. Classification
of cancer
Type Origin Example
Carcinoma Endoderm or
ectoderm
Epithelial lining of
gut (e.g.,
adenocarcinoma of
colon) or bronchus
(e.g., squamous)
cell or small cell
carcinoma of
bronchus
Sarcoma Mesoderm Osteosarcoma,
Fibrosarcoma
Leukaemia White blood
cell
Acute lymphoblastic
leukaemia
Lymphoma Monocyte,
macrophage
Hodgkin’s disease

12. SOME CANCERS RELATED TO THE HUMAN DIGESTIVE
SYSTEM

13. The Digestive System
Consists of mouth,
pharynx(throat),
esophagus, stomach,
intestines, rectum and
anus.

14. • The digestive tract breaks down food, absorbs
nutrients and eliminates feces.
• The entire alimentary canal is lined with
epithelial cells.
• When the replacement of these fast-growing
cells is halted as a result of chemotherapy or
radiation , painful side effects such as moth
sores, sore throat and stomach upset can result.

15. • Damage to epithelium of the small intestine causes more
than just discomfort.
• It can result in electrolyte loss through diarrhoea or
malnutrition from malabsorption.
• The main function of the epithelium of the small intestine is to
absorb nutrients with the help of villi and microvilli which
produce the digestive enzymes.

16. • When cancer treatments injure the cells of the
villi, some nutrients can no longer be digested or
absorbed. This can result into malnutrition.
• Since the digestive system is open to the
environment and its toxins it is a common site for
cancer development.
“Every time you eat or drink, you are either feeding disease or fighting
it”

17. Oropharyngeal Cancer
 Oropharynx is a middle part
of the throat which includes
the base of the tongue, the
tonsils, the soft palate, and
the walls of the pharynx.
 Oropharyngeal cancers can be divided into two types:
1. HPV-positive cancers, which are related
to Human Papilloma Virus infection
2. HPV-negative cancers, which are usually
linked to alcohol or tobacco use.

18. Risk factors
• Smoking and chewing
tobacco
• Heavy alcohol use
• Chewing betel quid
• Mucosal infection HPV
• P53 mutation
• Asbestos exposure
• A diet low in fruits and
vegetables
• Pickled or salted foods
• Poor nutrition
A very high rates of
nasopharyngeal carcinoma have
been linked to the consumption of
salted fish (International Agency
for Research on Cancer; 1993)
Sanchez et al., (2003) reported
the beneficial effect of high intake
of vegetables and fruits on the
risk of developing cancers of the
oral cavity and oropharynx in
Spain, particularly among current
smokers and heavy alcohol
drinkers.

19. Symptoms
• Ulcers that do not heal
• Persistent discomfort or pain in the mouth
• White or red patches in the mouth or throat
• Difficulty in swallowing
• Speech problems
• A lump in the neck
• Weight loss
• Bad breath (halitosis)
• A lump or thickening on the lip
• A lump in the mouth or throat
• Unusual bleeding or numbness in the mouth
• Loose teeth for no apparent reason
• Difficulty moving the jaw

20. Treatment
 There are three main treatment options :
Surgery, radiation therapy and chemotherapy.
 Surgery:
• Primary tumor surgery,
• Glossectomy (partial or total removal of the tongue),
• Mandibulectomy (partial or total removal of the jaw bone),
• Maxillectomy (partial or total removal of the hard palate i.e the bony
roof of the mouth),
• Neck dissection (to remove some or all of the lymph nodes),
• Laryngectomy (partial or total removal of the larynx or voice box
which is critical to swallowing),
• Tracheostomy (a hole in the neck when cancer is blocking the throat)

21. DIET THERAPY:
• If the swallowing problem is temporary, a
nasogastric (NG) tube (inserted through the
nose, down the esophagus, and into the
stomach).
• If cancer is inhibiting the ability to swallow, a
feeding device called a gastrostomy tube is
placed through the skin and muscle of the
abdomen directly into the stomach.
• Tubes placed into the stomach may also be
temporary methods for maintaining nutrition
until the person can safely and adequately
swallow by mouth.
***

22. EsophagEAL Cancer
• It is the cancer arising from the esophagus—the
foodpipe that runs between the throat and the stomach.
• Symptoms often include trouble swallowing and weight
loss. Other symptoms may include pain with swallowing,
a hoarse voice, enlarged lymph nodes (glands) around
the clavicle (collarbone), a dry cough, and
possibly coughing up or vomiting blood.

23. • The two main sub-types: squamous-cell carcinoma,
and adenocarcinoma.
• Squamous-cell carcinoma arises from the skin cells that line
the esophagus.
• Adenocarcinoma arises from glandular cells present in the
lower third of the esophagus.
• The most common causes of the squamous-cell type are:
tobacco, alcohol, very hot drinks, rich and spicy foods and a
poor diet.
• The most common causes of the adenocarcinoma type are
smoking tobacco, obesity, and acid reflux.
• Pickled vegetable foods have shown to elevate the risks
for oesophageal and gastric cancer (International Agency
for Research on Cancer; 1993)

24. Treatment:
Surgery: Esophagectomy
1. Transhiatal Esophagectomy
 In this method, the surgeon makes incisions in the neck
and abdomen.
 Most of the esophagus is removed through these incisions.
 Typically the surgeon attaches the stomach to the
remaining esophagus in the neck. Sometimes, a segment of
the colon is used to connect the esophagus to the stomach.

25. 2. Ivor-Lewis Esophagectomy
 In this method, the surgeon makes one incision in the
abdomen and one in the chest along the ribs.
 The lower half of the esophagus is removed through
the abdominal incision, and the stomach is attached to
the upper esophagus in the chest.

26. 3. Total Esophagectomy
 In this method the entire
esophagus is removed when
there are large tumors in the
middle of the esophagus.

27. Post surgery nutritional problem:
 Dumping syndrome
 Diarrhoea
 Indigestion & colic
 Feeling or being sick
***

28. Stomach Cancer
• Stomach cancer or gastric cancer, is
when cancer develops from the lining
of the stomach.
• The most common cause is infection by the bacteria Helicobacter
pylori.
• Other common causes include eating smoked foods, salt and salt-rich
foods, red meat, processed meat, pickled vegetables, and smoking.
• A fondness for salty tastes, especially salted foods such as pickled
vegetable and dried & salted fishes has a significantly positive
association with stomach cancer (Tajima,K & Tominaga,S. 1985)

29. Symptoms
In the early stages of stomach
cancer:
• Indigestion and stomach
discomfort
• A bloated feeling after eating
• Mild nausea
• Loss of appetite
• Heartburn
• Upper abdominal pain
In more advanced stages of
stomach cancer:
• Discomfort in the upper or
middle part of the abdomen.
• Blood in the stool (which
appears as black, tarry stools).
• Vomiting or vomiting blood.
• Weight loss.
• Pain or bloating in the stomach
after eating.
• Weakness or fatigue associated
with mild anemia (a deficiency in
red blood cells).

30. TREATMENT
 Surgery, chemotherapy, radiation,
biological therapy.
 SURGERY:
1. Endoscopic mucosal
resection (EMR):
 Treatment for early gastric cancer
(tumor only involves the mucosa)
 In this procedure, the tumor,
together with the inner lining of
stomach (mucosa), is removed
from the wall of the stomach.
 The advantage is that it is a much
smaller operation than removing
the stomach

31.  If cancer is at the lower end of the
stomach that connects with the
duodenum only part of your
stomach removed. This is called a
partial gastrectomy.
 The position of the tumour in the
stomach will affect how much of
the stomach is removed.
 After the operation the patient
have a much smaller stomach but
the valve (cardiac sphincter)
between the oesophagus and
stomach will still be there.

32.  If the cancer is in the middle
of the stomach the whole
stomach need to be
removed. This operation is
called a total gastrectomy.
 After the operation the
oesophagus is joined directly
to the small bowel.

33. 4. Gastric bypass
(gastrojejunostomy):
• Tumors in the lower part of the stomach may grow large
enough to block food from leaving the stomach.
• Thus bypass the lower part of the stomach is done.
• This is done by linking part of the small intestine (called
the jejunum) to the upper part of the stomach, which
allows food to leave the stomach through the new
connection.

34. FIG.: GASTRIC BYPASS

35. Post surgery nutritional problem
• Dumping syndrome
• Feeling full after eating and drinking
• Weight loss and malnutrition
• Poor appetite
• Indigestion and/or reflux (this can be continuous)
• Diarrhoea
• Bilious vomiting.
• Calcium malabsorption
• Anaemia caused by iron and vitamin B12 deficiency
• Narrowing of the join between the gullet and the small bowel after
surgery (anastomosis), which can make it difficult to swallow food.

36. DIET THERAPY
 If only part of the stomach is removed very small frequent
meals should be given at first.
 As the stomach will gradually stretch larger amount can be
given at a time.
 Patient may need to be given vitamin B12 supplementation for
the rest of the life to prevent anaemia and nerve problems.
 For a while before or after stomach surgery the patient may
need to have only liquid food.

37. NUTRITION THERAPY
Enteral Nutrition:
• Some people with stomach cancer are not
able to eat or drink enough to get enough
nutrition.
• A minor operation can be done to place a
feeding tube through the skin of the
abdomen and into the distal part of the
stomach (known as a G tube) or into the
small intestine (known as a J tube). Liquid
nutrition can then be put directly into the
tube.

38.  For some patients, the most appropriate option for receiving
nutrition may be through an IV (i.e., parenteral nutrition).
 To receive this alternative form of nutrition therapy, a thin plastic
tube called a catheter is first inserted into a large vein in the arm or
chest.
 The catheter can remain for as long as one need to receive
parenteral nutrition.
 For stomach cancer patients, the catheter allows to receive a liquid
mixture of vitamins, minerals, protein, carbohydrates and fats.
 Each patient's optimal mixture may differ according to the body’s
nutritional status.

39. Small intestine Cancer
 It is relatively rare compared to other gastrointestinal
malignancies such as gastric cancer (stomach cancer)
and colorectal cancer.
 Small intestine cancer can be subdivided into duodenal
cancer (the first part of the small intestine) and cancer of
the jejunum and ileum (the later two parts of the small
intestine).
 Duodenal cancer has more in common with stomach
cancer, while cancer of the jejunum and ileum have more
in common with colorectal cancer.

40. RISK FACTORS FOR SMALL INTESTINE
CANCER INCLUDE:
• Crohn's disease
• Celiac disease
• Radiation exposure
• Hereditary
gastrointestinal cancer
• Males are 25% more likely to
develop the disease

41. TREATMENT
SURGERY is often the only treatment.
Resection:
 Usually this surgery is done through a cut made in the
abdomen.
 This operation removes the piece of intestine that has the
tumor and some of the normal tissue on either side of the
tumor.
 After surgery, it can take a few days before the patient can eat
and drink normally.
 Removing a small piece of intestine usually doesn’t cause
long-term problems with eating or bowel movements.

42. PANCREATICODUODENECTOMY
(WHIPPLE PROCEDURE)
 This operation is used to treat cancers
of the duodenum, although it is more
often used to treat pancreatic cancer.
 It removes the duodenum, part of the
pancreas, nearby lymph nodes and part
of the stomach.
 The gallbladder and part of the common
bile duct are removed and the remaining
bile duct is attached to the small
intestine so that bile from the liver can
continue to enter the small intestine.

43. Palliative surgery
• If the cancer cannot be completely removed because it has spread too
far in the abdomen, the surgeon may do an operation to help improve
some of the symptoms that the cancer is causing. This is known
as palliative surgery.
• Often, these operations are done to relieve a blocked intestine, to
decrease pain, nausea, and vomiting, and allow the patient to eat
normally for some time.
• If possible, the surgeon will remove enough of the tumor and nearby
intestine to allow digested food to pass through.
• In very advanced situations, a fairly rigid tube (called a stent) is passed
through the blocked area and left in place so digested food can pass.
• If this can’t be done, a tube may be placed in the stomach to drain it and
decrease problems with nausea and vomiting.

44. Colorectal Cancer
Malignancy of the colon, rectum and anus.
The colon is the most common site for tumors in
gastrointestinal tract.
It is one of the leading cancer worldwide.

45. Risk Factors for COLON CANCER:
• Diet, obesity, smoking, and not enough physical activity.
• Dietary factors that increase the risk include red and processed meat, as well
as alcohol.
• Low folate and high alcohol intake is associated with changes in promoter
hypermethylation of DNA in CRC (Engeland,M.V., 2003).
• Another risk factor is inflammatory bowel disease, which includes
Crohn's disease and ulcerative colitis.
• Some of the inherited conditions that can cause
colorectal cancer include: familial adenomatous
polyposis and hereditary non-polyposis colon
cancer.

46. TREATMENT:
If the left side of the colon is removed, the
operation is called a left hemi colectomy.

47. If the middle part of the bowel is
removed (the transverse colon) it is
called a transverse colectomy.

48. If the right side of the colon is removed, it
is called a right hemi colectomy.

49. If the sigmoid colon is removed it is
called a sigmoid colectomy.

50. POST SURGERY NUTRITIONAL
PROBLEM:
• Diarrhoea
• Constipation
• Feeling bloated or passing a lot of wind
• Having a sore bottom.

51. The side effects of cancer treatment and the nutrition
therapy

52. Nausea and vomiting
• Vomiting is stimulated by
sensory receptors in the
stomach including stretch
receptors and chemoreceptors.
• The emetic center in the brain
responds to these signals by
causing a wave of reverse
peristalsis.
• Chemotherapy causes nausea by
acting both on the brain and
stomach.

53. MNT
• Avoid eating 2hrs before or
after a treatment.
• Eat small, frequent meals.
• Do not drink large amount of liquid with your meal. Too much food or
liquid can expand the stomach activating the stretch receptors &
stimulating the emetic center.
• Do not lie down immediately after meal.
• Avoid greasy or high fat foods. As it remain in the stomach longer
increasing the chance to vomit.
• Avoid foods with strong odors or flavors as it causes ‘nausea
flashback’.
• Eat food that are easy to digest.
• Avoid raw or high fibrous foods.
• It is recommended to use ginger as a complementary therapy in the
management of Chemotherapy Induced Nausea and Vomiting.
(Muthiaet al , 2013)

54. Dry mouth & difficult swallowing
• It causes difficulty chewing.
• Some chemotherapy drugs contain
bleomycin & dactinomycin that
cause a temporary dryness of the
mouth.
• Radiation may damage the salivary
glands.
• Surgery that removes salivary gland
will reduce secretion.

55. MNT
• Tart taste will stimulate salivary flow. Lemon juice about
15mins before mealtime.
• Small sips of water. This makes food easier to swallow.
• Add pickle, extra sauce or gravies.
• Suck on ice cubes.
• Dry mouth can be a breeding ground for bacteria so
maintain good oral health.

56. Taste alteration
• Stimulation of the taste bud result in taste
sensation.
• Since the taste buds are formed from the taste-dividing
epithelial tissue which are particularly
sensitive to cancer therapies.

57. MNT
• Avoid eating favorite foods before chemotherapy. The
changes in taste may cause an unpleasant association with
the food.
• Depending on tolerance use the amount of salt and sugar.
• Use herb spices to increase the flavor.
• Foods that are cold at room temp may be more palatable
than hotter one.
• Zinc supplement may increase taste sensitivity.

58. Anorexia
 Toxic effects of therapy: Side effects of treatment such as
nausea, sore mouth, stomach cramps. And taste changes can all
decrease the desire to eat.
 Localized effects of the tumor: Tumors in the gastrointestinal tract
that cause blockages can decrease appetite. Some tumors
produce chemicals that affect the endocrine system, resulting in
early satiety.
 Early satiety may kill the appetite, making proper nutrition difficult
to achieve.
 Surgery: Surgical removal of any part of the gastrointestinal tract
can decrease the ability & desire to eat.

59. MNT
• Appetite is usually best first thing in the morning, so plan the largest meal of the
day at breakfast.
• Six small meals a day instead of three large meals.
• Provide to whenever hungry. Do not wait for meal time.
• Keep cooking odours to a minimum.
• Give the most nutrient dense food first.
• Avoid drinking liquid with the meal.
• Liquid meals are more appealing than solids like smoothies.
• Avoid raw vegetables.
• High calorie, high protein beverages.
• Light exercise may stimulate appetite.

60.  Mucositis begins with the tissues feeling dry and looking red.
 The mouth and throat are sore.
 This is followed by swelling, ulcerations and bleeding.
CAUSES OF MUCOSITIS:
 Chemotherapy: Treatment prevents the division of the rapidly
dividing mucous membrane cells of the tongue, cheek, lips, gums,
and palate as well as the floor of the mouth and esophagus. When
the top layers of the cells are shed, they are not replaced. This
causes inflammation.
 Radiotherapy may also damage the mucous membranes of the
mouth and throat.

61. MNT:
• Give soft non-irritating foods such as nonfat yoghurt, oatmeal,
pureed vegetables and mashed potatoes & yams.
• Serve food lukewarm or cold.
• Avoid acidic, tart or spicy foods.
• Avoid dry rough foods as toast.
• If sores are confined to the tongue provide a straw to bypass
them.
• Use more of Vit. C & E on diet.

62. Constipation
• Treatment side effects: sore mouth, nausea,
vomiting and lack of appetite. These greatly
reduce the consumption of fibrous foods
causing constipation.
• Medication: For example the opioid painkillers
can reduce peristalsis.
• Decreased activity: cancer treatment often
leaves a patient feeling tired and drained.
• Stress
• Loss of nerve function in the colonic muscle:
Radiation and surgery can sometimes result in
a temporary or permanent loss of muscle tone
due to nerve damage.

63. MNT
• Increasing dietary fiber.
• Increasing amount of water.
• Nuts and seeds as they will give not only fiber
but also healthy fats which will increase the
calorie.
• Natural laxative foods as prune and prune
juice, apple and pear juice.
• Drinking hot or warm liquid before a meal
stimulates gastrointestinal tract movement.

64. DIARRHEA
 Chemotherapy or radiation sometimes has
a toxic effect on the lining of the small
intestine.
 Some drugs can injure the villi & microvilli
preventing the absorption of some
nutrients decreasing the amount of
enzymes produced for digestion.
 In large intestine some drugs increase the
rate of peristalsis and the transit time
through the colon, resulting in less time for
the water to be reabsorbed.
 Some temporary intolerance to milk sugar
because of the temporary absence of
lactase.

65. MNT
• Hot food stimulate muscle movement and may cause
diarrhea. Try cold food at room temperature.
• Avoid raw foods.
• Avoid milk or other dairy products.
• Give food that are easily digestible or absorbed.

66. SOME GENERAL SYSTEMIC REACTIONS IN CANCER

67. ABNORMALITIES IN METABOLISM
 Cancer cells reprogram their metabolic pathways to meet their abnormal
demands for proliferation and survival (Tennant et al, 2010).
 It has long been recognized that cancer cells need a higher rate of
metabolism to support their accelerated proliferation rate (Cairns et al, 2011).
 Cancer cells take up and utilize much more glucose for glycolysis compared
to normal cells, even in the normoxic condition (Warberg, 1956).
 Abnormalities in glucose metabolism.
 Cancer patients cannot produce glucose efficiently from carbohydrates.
 Gluconeogenesis increases.
 Straining the supply of body proteins.
 Many patients develop insulin resistance.
 Increased insulin resistance

68.  There is increased lipolysis, free fatty acids and glycerol
turnover and decreased lipogenesis and hyperlipidemia.
 The rates of whole body catabolic rate exceeds that of
synthetic rate.
 Fat oxidation rates are higher.
 Depletion of body protein occurs.
 Albumin is depleted.
 Branched chain amino acid infusion can decrease protein
catabolism.
 These metabolic abnormalities may be the cause for the
failure to gain lean body mass or maintain healthy body
weight inspite of receiving adequate energy and nutrients.

69. ANOREXIA
 Often accompanied by
depression or discomfort from
normal eating.
 Contributes to limited nutrient
intake
 Causes imbalance of
decreased intake & increased
demand.
 Creates a negative nitrogen
balance & thus wasting.
 Can lead to cancer cachexia
 Occurs in 80% of cancer
patients.
A study by Cangiano,1996 suggests that:
 Brain tryptophan and serotonin
concentrations seem to play a pivotal
role in the regulation of eating behavior.
 Increased brain serotonin activity is
indeed associated with a reduction of
food intake.
 Reducing brain tryptophan availability
represents a possible mechanism to
restore brain serotonin activity to normal.
 There is evidence that the oral
administration of neutral amino acids
competing with tryptophan for brain entry
results in a significant improvement of
cancer anorexia.

70. WASTING
 Progressive weight loss is a common feature of many types of cancer and is
responsible not only for a poor quality of life and poor response to
chemotherapy, but also a shorter survival time than is found in patients with
comparable tumors without weight loss (Tisdale,1999).
 The combined effects of a poor appetite, accelerated and abnormal
metabolism and diversion of nutrients for tumor growth results in a lower
supply of energy and nutrients at instances when demands are high.
 Various factors have been investigated as mediators of tissue wasting in
cachexia. These include cytokines such as tumor necrosis factor-α (TNF-α),
interleukin-6 (IL-6), interferon-γ (IFN-γ) and leukemia inhibitory factor (LIF), as
well as tumor-derived factors such as lipid mobilizing factor (LMF) and protein
mobilizing factor (PMF), which can directly mobilize fatty acids and amino
acids from adipose tissue and skeletal muscle respectively (Tisdale,1999).

71. MALABSORPTION
• Can occur due to blind loop syndrome.
• Bacterial overgrowth may result in steatorrhoea &
Vit.B12 deficiency.
• Malignancy involving pancreas or bile duct may limit
the function of digestive enzymes or bile salts.
• Surgery involving partial or total organ of digestive
system may lead to malabsorption.
• Chemotherapy or radiotherapy causing damage to the
epithelial lining of the digestive system.

72. FLUID-ELECTROLYTE IMBALANCES
• Vomiting and diarrhoea not only bring loss of water and
electrolyte but also water soluble vitamins
• Villous adenoma and adenocarcinomas of the colon can
contribute to severe electrolyte imbalance.

73. ANAEMIA
• May be compounded by a number of factors: anorexia with less
intake of nutrients necessary for haemoglobin synthesis, iron,
protein, folic acid, vit.B12, and C.
• Malabsorption of the nutrients.
• Increased hemolysis
• Bleeding of ulcerated lesions
• Presence of fistulas.

74. HYPERCALCEMIA
• It is one of the most common metabolic
complication of cancer.
• Approximately 20-40% of patients with breast, squamous, bladder &
renal carcinoma develop hypercalcemia at some point in their disease.
• The three main sites of regulation of calcium and phosphorus
metabolism, as at present understood, are the intestine which is the
portal of entry, the bones which are the storehouse and the kidneys
which provide the excretory channel.
• Hypercalcemia, which is not uncommon in cancer patients, is usually
associated with osteolytic secondaries in bone. In such cases it is
usually due to erosion of bone by actively growing tumour cells and the
mechanism is clear(Watson, 1963).

75. OSTEOMALACIA
• Certain tumours reduce plasma calcitriol
concentration in conjuction with
hypophosphatemia, thereby inducing an
oncogenic osteomalacia.
• Gastrointestinal malabsorption of calcium and
phosphate has been observed.

76. Cancer and nutrients

77. Carbohydrate & cancer
 One of the purposes of nutrition therapy for cancer is to deny the
growing tumor glucose while providing enough to feed the brain and to
form red blood cells.
 This can be done in a crude way by keeping the blood sugar levels
even.
 One way is to eat foods that have low glycemic index.
 Another way can be by low carb diet. A low carb diet is usually one that
gets 40 percent of its calories from carbohydrate.
 Positive caloric balance and the resulting accumulation of body fat
during adult life also increase the risk of important human cancers. The
best-established relationships are with cancers of the endometrium and
gall bladder (Austin et al, 1991).

78.  Cancer cell change the metabolism of protein so that more amino acids are
available for tumor growth.
 Causes a loss of muscle tissue.
 Most of the protein in the diet should come from plant sources as it comes
with complete numerous cancer fighting nutrients and phytochemicals.
 Decreased risk was associated with high intakes of soya proteins, total
soya products and a high proportion of soya to total protein (Lee et al,
1991) .
 The proteins from fatty fish come packaged with omega-3 fatty acids
necessary for body’s defense system. They should provide the second
highest amount of proteins in the diet.
 Skinless poultry should make the smallest contribution to the amino acid
pool.

79.  Omega-3-fatty acids protect the cell
from cancer development.
 The biological activity of both the Lipid mobilizing factor (LMF) and
Protein Mobilizing Factor (PMF) was shown to be attenuated by
eicosapentaenoic acid (EPA) (Tisdale,M.J., 1999).
 MUFA have shown neutral effect.
 There are several contradictory studies in this regard.
 In case-control studies conducted in Spain and Greece, women who
used more olive oil had reduced risks of breast cancer possibly
related to its high content of monounsaturated fat and antioxidants
(Martin Moreno et al, 1994).

80. • High intake of PUFA have shown to increase the development of
breast, uterus, prostate & colon cancer.
• Linoleic acid have shown to be a causative factor of cancer.
• Clinical studies show that this PUFA is able to stabilize the rate of
weight loss and adipose tissue and muscle mass in cachectic patients
with unresectable pancreatic cancer (Tisdale, 1999).
• Decreased risk was associated with high intakes of polyunsaturated
fatty acids (PUFA) and a high PUFA to saturated fatty acid ratio (Lee et
al, 1991).
• A diet having a low content of total fat, the polyunsaturated fatty acids
are more tumorigenic than the saturated fatty acids (Jensen and
Madsen, 1988).

81. Vitamins & minerals and cancer
 Vitamins & minerals have shown to have a protective role in cancer.
 Epidemiological studies have shown that there is an inverse
relationship between the risk of carcinogenesis and the amounts of
vitamin A and provitamin A ingested. The relationship has been
found strongest for cancer of the lungs (Jensen and Madsen, 1988).
 A diet rich in vitamin C gives a lower risk of developing cancer of the
stomach and oesophagus in particular (Bjelke,1978).

82.  Vitamin-C can inhibit the formation of carcinogenic nitroso-compounds
(Mirvish et al, 1972).
 Intake of 800 IU/day of vitamin D may be associated with enhanced survival
rates among breast cancer cases (Gardland et al,2006).
 Supplementation with selenium or vitamin E is associated with a reduction
of prostate cancer risk(Meyer et al, 2005).
 Calcium intake up to 1200mg/day seems to have a protective influence.
 Most cases of colon cancer may be prevented with regular intake of calcium
in the range of 1,800 mg per day, in a dietary context that includes 800 IU
per day (20 μg) of vitamin D3. In women, an intake of approximately 1,000
mg of calcium per 1,000 kcal of energy with 800 IU of vitamin D would be
sufficient (Gardland et al,2006).

83. Antioxidants & cancer
 Epidemiological studies strongly suggest
that high intakes of food rich in B-carotene
as well as Vit.B & C decrease risk of some
cancers.
 Vit.E help to stabilise most of the oils
derived from plant.
 The antioxidant Vit. E activity decreases
from delta to alpha tocopherol.
 It also inhibits the formation of nitrosamines
especially at low pH.

84.  Selenium, manganese, zinc, copper and iron
are components of the antioxidant enzymes.
 Glutathione peroxidase (GSH-Px) is selenium
dependent.
 Manganese superoxide dismutase, copper-zinc superoxide
dismutase (SOD) and catalase are enzyme antioxidants.
 Selenium (Se) is an essential dietary component and is regarded
as a protective agent against cancer. Se has a potential to be used
not only in cancer prevention but also in cancer treatment where in
combination with other anticancer drugs or radiation, it can
increase efficacy of cancer therapy (Brozmanova et al,2010).
 Nutritional copper deficiency may impair antioxidant status by
decreasing the activity of these enzymes.

85. Table: Beneficial effects of nutrient antioxidants
Antioxidant Beneficial effect
B-carotene Reduced risk of various cancers especially lung
cancer and also stomach, cervix, oesophageal
and throat cancer
Vitamin C Reduced risk of upper gastrointestinal tract,
cervix cancer, cardiovascular disease.
Vitamin E Significant decrease in the risk of oral and
pharyngeal cancer, cardiovascular disease
Selenium Reduced risk of oesophageal and stomach
cancer.
SOURCE: Mathur Pulkit, 1997, Natural Antioxidants in Our Diet, Nutrition, 31,4.

86. Table: Optimal plasma levels of antioxidants
Antioxidant Plasma level (micromol/litre)
Vitamin C ≥50
Vitamin E ≥30
Vitamin A ≥22
B-carotene ≥0.4
α-plus B-carotene ≥0.4-0.5
Source: Joseph Maria M. Antioxidants and cancer.
A manual of second regional workshop on planning diet for
health, Indian Dietetic Association, 1999.
Levels 25-35% below the optimal predict atleast 2-fold high
risk.

87. Phytochemicals & cancer
1. TERPENES:
 Terpenes: Carotenoids are one subclass of terpenes that
are present in tomatoes, orange, spinach. Act as
antioxidants and inhibit tumor growth.
 Lycopene: Most effective antioxidant, two times powerful
as B-carotenes.(Research show that it reduce the risk of
prostate cancer).
 Limonoids: Detoxify carcinogens by making them more
water soluble for excretion from the body. Limitation:
Chemopreventive agent.

88. 2. PHENOLS:
 Phenols: Subclass flavonoids scavenge free radical compounds.
 Phenolic compounds: Caffeic and ferulic acids act by preventing the
formation of carcinogens from precursor compounds.
 Isoflavones: Genisteim, phytoestrogens (Soya) act as antioxidants,
carcinogen blockers and tumor suppressor. May exert a protective
effect against hormone related cancer.

89. 3. THIOLS: Sulphur containing phytonutrient. Upregulate enzymes involved
in detoxification of carcinogens and other foreign compounds.
4. LIGNANS:
 Lignan: Phytoestrogens protective against hormone-sensitive cancer.
 Phytic acid: Suppress oxidant damage. May also induce detoxification
enzymes, inhibition of nitrosamine formation, provision of substrate for
the formation of antineoplastic agents dilution binding the carcinogens
in the digestive tract, alteration of hormone metabolism and antioxidant
effects.
The plant lignan and isoflavonoid glycosides are converted by intestinal
bacteria to hormone-like compounds with weak estrogenic and antioxidative
activity; they have now been shown to influence not only sex hormone
metabolism and biological activity but also intracellular enzymes, protein
synthesis, growth factor action, malignant cell proliferation, differentiation
and angiogenesis, making them strong candidates for a role as natural
cancer protective compounds. (Herman, 1995).

90. Probiotic & Cancer
• Carcinogenic agents (aflatoxin, food dyes,
pesticides, nitrites) & cancer causing agents
in non-food (tobacco,drugs) are bioactivated
by enzyme system in gut.
• These bioactivation can lead to cancer.
• The probiotic support by inhibiting the over growth of toxic bacteria.
• By competing for attachment sites and nutrients these beneficial bacteria
inhibit the proliferation of non-beneficial organism.
• Lactobacillus & bifidobacteria also produces organic acid that reduce
intestinal pH and retard the growth of pathogenic bacteria.

91. DIETARY FIBRE & CANCER
• Dilute bile acids or binds to it thereby preventing mutation or cell proliferation.
• Fermentation of fibre results in formation of SCFAs lowering intestinal pH. This inhibits
conversion of primary bile acids to secondary bile acids which can promote mutation in
intestine.
• Fermentation of fibre produces butyrate which is antineoplastic.
• Speeding the passage of faeces through the large intestine so that carcinogens are in
contact with the intestinal wall for much shorter period.
• Bulk & water of the faeces may dilute the carcinogens to a non-toxic level.
• In populations with low average intake of dietary fibre, an approximate doubling of total fibre
intake from foods could reduce the risk of colorectal cancer by 40%. (Bingham et al, 2003).
• Fiber has been hypothesized to reduce risk of colon cancer by diluting potential carcinogens
and speeding their transit through the colon, binding carcinogenic substances, altering the
colonic flora, reducing the pH, or serving as the substrate for the generation of short-chain
fatty acids that are the preferred substrate for colonic epithelial cells. (Willett, 2000).

92. Nutritional care in cancer

93. • A cancer patient needs a high-calorie, high protein diet.
• Cancer causes a hypermetabolic state.
• Studies have shown that once lean body mass is
significantly depleted, regardless of the cause death
follows.
• Without adequate nutrients body is poorly equipped to
maintain immune defenses, support organ function,
absorb nutrients and mend damaged tissues.

94. • Energy: For an adult with good nutritional status about
2000kcal and for malnourished patient about 3000-
4000kcal can be given or 45-50kcal/kg body weight may
be recommended.
• Protein: For an adult with good nutritional status about
80-100g may be recommended or
1-1.2g/kg for those with good nutrition
1.3-2g/kg for malnourished patients
• Vitamins & Minerals: Optimal intake are recommended.
There are mounting evidence that vitamins protect
against several types of cancer.
• Fluid: Sufficient fluids need to be ingested.

95. Conclusion
 Abnormal cell growth.
 Can occur in any body tissue.
 Treatment: Chemotherapy, radiation, surgery.
 Parenteral or enteral nutrition may be necessary in the early
stages of recovery.
 Hypermetabolic state.
 Demand high energy & protein.
 Antioxidants, phytochemicals & probiotics can be preventive.
Let food be your medicine and let medicine be your
food.

96. REFERENCE
TEXT BOOKS:
1. Keane,M and Chace,D. What to eat if you have cancer. Updated Second
Edition. 2007. McGraw Hills Publisher. New York.
2. Mudambi,S.R and Rajagopal,M.V. Fundamentals of Foods, Nutrition
and Diet Therapy. Fifth Edition. 2007. New Age International Publishers.
New Delhi.
3. Srilakshmi,B. Dietetics. Fifth Edition. 2005. New Age International
Publishers. New Delhi.
4. Lodish,H., Berk,A and Zipursky,S.L. Molecular Cell Biology. 4th edition.
2000. W. H. Freeman. New York

97. JOURNAL
• Austin,H., Austin,J.M., Partridge,E.E. 1991. Endometrial cancer, obesity, and body fat
distribution. Journal of Cancer Research. 51:568-572.
• Bingham, A.S. Day,N.E., Luben,R., Ferrari,P., Slimani,N., Norat,T., Clavel-Chapelon,F.,
Kesse,E., Nieters,A., Boeing,H., Tjϕnneland,A., Overvad,K., Martinez,C.,
Dorronsoro,M., Gonzalez,C.A., Key,T.J., Trichopoulou,A., Naska,A., Vineis,P.,
Tumino,R., Krogh,V., Bueno-de-Mesquita,H.B.,Peeters,P.H.M., Berglund,G,B.,
Hallmans,G., Lund,E., Skeie,G., Kaaks, and Riboli,E. 2003. Dietary fibre in food and
protection against colorectal cancer in the European Prospective Investigation into
Cancer and Nutrition (EPIC): an observational study. The Lancet. 361 (9368): 1496-
1501.
• Bjelke,E. 1978. Dietary factors and the epidemiology of cancer of the stomach and
large bowel. Aktuel Ernaehrungsmed Klin Prax (Suppl). 2: 1-7
• Brozmanova,J., Mániková,D., Vlčková,V., Chovanec,M. 2010. Selenium: a double-edged
sword for defense and offence in cancer. Archives of Toxicology. 84(12): 919-
938 .
• Cairns,R.A., Harris,I.S., Mak ,T.W. 2011. Regulation of cancer cell metabolism. Nat
Rev Cancer. 11:85-95.

98. • Cangiano,C., Laviano,A., Muscaritoli,M., Meguid,M.M., Cascino,A., Fanelli,F.R. 1996.
Cancer anorexia: new pathogenic andtherapeutic insights. Journal of Nutrition. 12(1):
S48–S51
• Engeland,M.V., Weijenberg,M.P., Roemen,G.M.J.M., Brink,M., Bruïne,A.P.,
Goldbohm,R.A., Brandt,P.A.V.D., Baylin,S.B., Goeij,A.F.P.M and Herman,J.G. 2003.
Effects of Dietary Folate and Alcohol Intake on Promoter Methylation in Sporadic
Colorectal Cancer: The Netherlands Cohort Study on Diet and Cancer. Journal of
Cancer Research. 63: 3133.
• Garland,C., Frank,C., and Gorham,E.D. 2006. Calcium And Vitamin D: Their Potential
Roles In Colon And Breast Cancer Prevention, Annals Of The New York Academy Of
Sciences. 889(1).
• Herman,c., Adlercrea,t., Goldin,b.R., Gorbach,s.L.,Ha–ckerstedt,K.A.V., Watanabe,s.,
Markkanen,M.H., Kristiina,T.W. 1995. Soybean Phytoestrogen Intake And Cancer
Risk. Journal Of Nutrition. 125:757s-770s.
• International Agency for Research on Cancer. 1993: 599.

99. • Jensen,H and Madsen,J.L. 1988. Diet And Cancer. Acta Med Scand. 223: 293-304.
• Lee,H.P., Lee,J., Gourley,L., Duffy,S.W., Day,N.E and Estève,J. 1991. Dietary effects
on breast-cancer risk in Singapore. The lancet. 337(8751): 1197–1200
• Martin-Moreno,JM., Willett,W.C., Gorgojo,L.1994. Dietary fat, olive oil intake and
breast cancer risk. International Journal of Cancer. 58:774-780.
• Meyer,F., Galan,P., Douville,P., Bairati,I., Kegle,P., Bertrais,S., Estaquio,C and
Hercberg,S.2005. Antioxidant vitamin and mineral supplementation and prostate
cancer prevention in the SU.VI.MAX trial. International Journal of Cancer. 116(2)
:182–186.
• Mirvish,S.S., Wallcave,L., Eagan,M., Shubik,P. 1972. Ascorbate-nitrite Reaction:
Possible Means Of Blocking The Formation Of Carcinogenic N-nitroso Compounds.
Journal Of Science.177: 65-8.
• Muthia,R., Wahyu,W., and Dachriyanus. 2013. Effect Of Ginger Infusion On
Chemotherapy Induced Nausea And Vomiting In Breast Cancer Patients, Journal Of
Biology Agriculture And Healthcare. 3(13).

100. • Sanchez,M. J., Martínez,C., Nieto,A., Castellsague,X., Quintana,M.J., Bosch,F.X.,
Munoz,N., Herrero,R and Franceschi,S. 2003. Oral and oropharyngeal cancer in
Spain: influence of dietary patterns, European Journal of Cancer Prevention. 12(1):
49-56
• Tajima,K and Tominaga,S. 1985. Dietary habits and gastro-intestinal cancers: a
comparative case-control study of stomach and large intestinal cancers in Nagoya,
Japan. Japanese Journal of Cancer Research. 76(8):705-716.
• Tennant,d.A., Durán,r.V., Gottlieb,e. 2010. Targeting Metabolic Transformation For
Cancer Therapy. National Rev Cancer. 10:267-277.
• Tisdale,M.J. 1999. Wasting in Cancer. Journal of Nutrition. 129(1): 243S-246S.
• Warburg,O. 1956. On the origin of cancer cells. Journal of Science. 123:309-314.
• Watson,l. 1963. Hypercalcaemia And Cancer. Postgrad. Med. Journal. 39(646).
• Willett,W.C. 2000. Diet and Cancer. The Oncologist. 5(5): 393-404.
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102. OCTOBER