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

CANCER AND DIETARY
MANAGEMENT
1
Faisal Al-shormany. MD.PhD.SCOPE Fellow
Associate Professor,
Faculty of Medicine ,Sana’a University

OBJECTIVES
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.

• Epidemiology-global,nationalscenario
• Classification.Riskfactors
• Pathophysiology’
• Signandsymptoms
• The Association of Cancer
, Therapies, and
Malnutrition.
• Practical Points in Nutritional Management
of Cancer Patients.
• Resources for Evidence-based Practice in
Nutrition for Cancer
.
Topics

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

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

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)

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

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. obesity and infectious
diseases).
11

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.

• 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 environmental factors.
• Cancer is a chronic disease.

Initiation-dietary carcinogens
- Aflatoxins (found in mouldy food)
- Heterocyclic amines (meat cooked at very high temperatures)
-N-nitroso compounds (in some spoiled foods, protein foods,
cured meat).
-Polycyclic aromatic hydrocarbons (PAH) (products found in cooked
foods, smoked foods).
These chemicals can start a cancer process by creating cancer
cells
(World Cancer Research Fund 1997; NRC 1982)

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

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)
(1) Anand P et al, Cancer is a preventable disease that requires major lifestyle changes. 200
(2) Reddy, B Dietary Fat & Colon cancer. Chemistry & material science vol 27 no 10 807-813
(3) American Journal of Clinical Nutrition Vol 84 No 5 1171-1176 Nov 06

©
- 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

©
- 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

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

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

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
Melanom
a
Change in size, shape or color of a
wart
16

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/

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. LavianoA, 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/

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

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

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

Route of
Nutritio
n
Support
Ukleja A, et al. Nutr Clin Pract. 2010.

MANAGEMENT OF CANCER
1. 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
menopaus
e
17

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

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, significant malabsorption.

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.

VITAMINS AND MINERALS
32
 Optimal intake of vitamins and minerals are
recommended.
 Approximately equal to RDA; discourage the use
of high-dose micronutrients in the absence of
specific deficiencies.
 .

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

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 2007N
u;tHMeebdeJro2G0a0m6b
l;eOB
Arn(
hisohn
se) Dtiap
low fat; high fibre
adequate protein
adequate calories
whole plant foods
O6: O3 ratio 2:1
Physical activity

stimulates
immune
response
Phytonutrients
lowers IGF-1
full of
antioxidants
promotes synthesis of
detoxification enzymes
lowers insulin
lowers estrogens
lowers oxidative
damag
minimizes
carcinogen exposure
creates powerful
anti-cancer
environment
Low Fat Vegan Diet

CONTD…
36
2.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.

CONTD…
37
3. 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.

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 .

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

STAGES OF CANCER ( EG. BOWEL)
30
.
Stage 0: cancer cells - within the bowel lining. Little risk of
spread ( carcinoma in situ).
Stage I: cancer grown throughthe 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.

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

Let food be your medicine." - Hippocrates

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

MENU PLANNING FOR 1800KCAL
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

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

 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
37

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

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

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

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