Nutrition Screening and Assessment in Breast and Gynecological Cancers
Facing a cancer diagnosis is always detrimental. Many cancer patients have to deal with the physiological burden that cancer treatments may cause. Optimal nutrition during cancer treatment is essential in order to meet the increased nutritional demands needed to support healing and recovery. By achieving optimal nutrition, we assure that our patients are more prepared to tolerate a full treatment with fewer complications and better quality of life.
Nutritional screening is the first step in determining nutritional problems. The purpose of nutrition screening and assessment is the early identification of malnutrition. As many as 40% of cancer patients experience anorexia prior to diagnosis, and 40%–80% will experience malnutrition during their treatment. The Academy of Nutrition and Dietetics defines nutrition screening as the process of identifying characteristics known to be associated with nutrition problems, with a goal of identifying individuals who are malnourished or at nutritional risk and are in need of intervention and/or counseling from a registered dietitian nutritionist (RDN). Patients at nutritional risk should undergo a more detailed nutritional assessment to identify and quantify those nutritional problems.
Malnutrition is an independent risk factor that adversely affects a patient’s clinical outcomes, quality of life, body function, and autonomy. The early identification of patients at risk of malnutrition or who are malnourished is extremely important in order to start nutritional interventions in a timely manner. Ovarian cancer patients have the highest rate of disease-related malnutrition among all gynecological (GYN) cancers. Malnutrition among ovarian cancer patients is an important predictor of mortality. In advanced ovarian cancer the involvement of the intraabdominal area is common. These patients present with multiple symptoms (dyspepsia, nausea, lack of appetite, fatigue, abdominal pain) that lead to inadequate caloric intake and impaired nutritional status.
The use of a validated malnutrition screening tool (MST) has been associated with better nutritional care and outcome. It is essential to have sensitive and appropriate screening parameters to make the best use of the RDN. At Miami Cancer Institute the clinical nutrition team is utilizing the MST to identify patients at nutritional risk. The MST is a validated evidence-based tool used in inpatient and ambulatory/outpatient care settings with adult patients who have cancer. It was selected for use based on its simplicity. It is a three-question tool with both high sensitivity and specificity. The presence of unintentional weight loss, amount of weight loss, and decreased appetite is used to identify malnutrition risk. The answers to the questions are electronically computed and referred to as the RDN for action.
The RDN then follows the Nutrition Care Process (NCP) model established by the Academy of Nutrition and Dietetics in 2003. The NCP is a systematic method that the RDN uses to provide nutritional care. The NCP is a road map that consists of four separate yet interconnected steps: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention, and Nutrition Monitoring and Evaluation. Each step of NCP model is important to complete before advancing to the next step.
The NCP model is dynamic and multidirectional allowing the RDN to revisit previous steps of the NCP to reassess, update nutrition diagnosis, adapt interventions, and modify goals. The NCP is evolving to become the international standard for the delivery of nutritional care. Nutritional assessment and evidenced-based nutrition interventions by the oncology RDN allow cancer patients to achieve optimal nutrition during cancer treatment in order to have a better tolerance of treatment.
Estimating Energy Needs for Cancer Patients
Energy metabolism can vary significantly among cancer patients. When determining energy needs, best practice indicates that estimates should be individualized and based on clinical judgment. RDNs in clinical practice may quickly calculate energy needs from formulas that suggest that a certain number of kilocalories are required per kilogram of body weight. These methods are useful as initial estimates and need to be adjusted based on an individual’s nutritional status and activity level. Factors to consider when assessing calorie requirements include age, physical activity level, cancer treatment modality with anticipated side effects, and current nutritional status (e.g., involuntary weight loss).
In patients who are at a desirable body weight range (BMI 18.5–24.9 kg/m 2 ), the goal is to maintain weight during and after treatment. Most breast cancer patients may be either overweight or obese at the time of diagnosis, and many of them gain weight during treatment. However, some GYN cancer patients (e.g., ovarian) may present with unintentional weight loss and their energy needs may be higher. In patients who are underweight (BMI<18.5 kg/m 2 ), calorie needs range between 30 and 35 cal/kg. For weight maintenance an acceptable caloric range is between 25 and 30 cal/kg of body weight. For overweight (BMI≥25 kg/m 2 ) and obese (BMI≥30 kg/m 2 ) breast/GYN cancer patients, an acceptable caloric level is around 20–25 cal/kg.
Obesity and Cancer Risk
Obesity is associated with changes in the physiology and hormonal environment of the body, and these changes can promote the development of a number of chronic diseases, including diabetes and cardiovascular disease. Obesity is also associated with an increased risk of developing some types of cancer (e.g., endometrial, colorectal, esophageal, and breast cancer among others) and with a poorer survival outcome for patients with those cancers.
At the time of diagnosis the majority of women with breast/GYN cancer are overweight or obese. Obesity is associated with a 35%–40% increased risk for breast cancer recurrence and poorer survival outcomes. This is most evidently recognized in postmenopausal women with estrogen-positive (ER+) breast cancer. This association can be attributed to the prevalence of higher estrogen levels in overweight, postmenopausal women. Conversely, in premenopausal hormone with receptor-positive breast cancer women, being overweight or obese has been associated with a lower risk. On the other hand, recent evidence shows an increased risk of triple-negative breast cancers in obese premenopausal women.
Evidence indicates that endometrial cancer, which is one the most common GYN cancers, is often associated with the metabolic syndrome (caused by obesity, diabetes, and hypertension). Furthermore, metabolic syndrome is closely associated with the incidence and poor prognosis of endometrial cancer. Recent data suggest that high insulin levels in overweight women may also play a role in this association as insulin has mitogenic and antiapoptotic activity. Some studies have shown that obese patients present with larger tumors, increased lymph node metastasis, and higher grade tumors. This finding may reflect more aggressive biology in obesity that may lead to a higher risk of recurrence.
Weight gain is commonly reported by breast/GYN cancer patients who are receiving chemotherapy, as well as by patients on tamoxifen or aromatase inhibitors. The average weight gain for patients undergoing chemotherapy is between 3 and 7 kg and for patients on endocrine therapy is between 1 and 2 kg. Unfortunately, evidence indicates that excess weight at diagnosis and weight gain during treatment are associated with an increased relapse rate and poorer survival rate. During chemotherapy, involuntary weight gain may be attributed to the use of corticosteroids as well as to the more frequent intake of food to prevent nausea. However, there is not enough evidence to confirm that the use of endocrine therapy such as tamoxifen or aromatase inhibitors can cause any significant involuntary weight gain in breast cancer patients. Indeed, in some of the studies reviewed, weight gain was also observed in those randomized to placebo as compared to the treatment group who were on tamoxifen or anastrozole.
Dietary Interventions for Overweight and Obese Cancer Patient and Survivors
Weight management plays an important role in the treatment, rehabilitation, and recovery of breast cancer. Obesity and/or weight gain during treatment may lead to poor prognosis as well as an increase of the prevalence of comorbid conditions, poor surgical outcomes, lymphedema, fatigue, functional decline, and decrease in the quality of life. Weight management interventions at all phases of cancer care are important to possibly avoid adverse effects, to improve overall health and possibly survival. Thus it is imperative for health-care professionals to encourage breast and GYN cancer survivors to achieve and maintain a healthy weight that is within the ideal range in an effort to promote overall health.
Maintaining adequate energy balance is important for preventing chronic diseases that are associated with excess body weight. Regulation of body weight encompasses a balance between energy intake and energy expenditure. As previously mentioned, many cancer patients are overweight or obese at the time of diagnosis, and thus the recommendations on how to manage these patients have been changed. In the past, any weight loss during cancer treatment was not recommended due to its association with cachexia and poor survival. The 2012 American Cancer Society (ACS) Nutrition and Physical Activity Guidelines for Cancer Survivors state that intentional weight loss during treatment may not be contraindicated for those who are overweight or obese. A controlled weight loss of up to 2 lb/week may be safe by following a healthy diet with regular physical activity as long as it does not interfere with treatment. However, it is important to identify the etiology of unintended weight loss that occurs during treatment. If weight loss is due to nutrition impact symptoms associated with treatment toxicities then the appropriate intervention is to control and minimize symptoms. Therefore weight loss recommendations for cancer patients should be individualized and based on patient’s health status, goals, and physicians and RDNs.
RDNs are challenged to implement appropriate dietary interventions for breast/GYN cancer patients, whether it is before, during, or after treatment, with the ultimate goal being the preservation of lean muscle mass while promoting gradual loss of excess body fat. Controlling the amount and rate of weight loss along with regular physical activity is a strategy that can help achieve this. Further, regular nutritional assessments and reassessments conducted by the RDN while modifying the nutrition care plan will help to continue to meet the nutritional needs of the patient.
The RDN addresses different issues while treating breast/GYN cancer patients, whether they are in treatment or survivorship. First issue is to promote a healthy balanced diet for optimal nutrition and weight management. Second issue is to enhance the quality of life while undergoing cancer treatment. The RDN assists patients in managing nutrition impact symptoms while receiving radiation and chemotherapy. Third issue is to promote postsurgery recovery. The RDN provides nutritional recommendations to promote wound healing through a balance intake of macro- and micronutrients that are important to enhance the healing process. Last issue is to promote posttreatment recovery and a healthy survivorship that focuses on achieving a healthy weight with emphasis on a diet that is high on nutrients that have a protective effect on breast cancer.
Diet Composition
In breast/GYN cancer survivors, low-fat diets rich in vegetables and fruits are generally recommended. However, in metabolic syndrome patients with central obesity, diets are often aimed at reducing glucose and insulin levels. In these patients, reduction of refined carbohydrates and controlled total carbohydrate intake may be more effective. Multiple studies are being conducted on the effects of diet on breast cancer survivors. Two large studies tested whether diet modifications after breast cancer diagnosis affected their outcomes. The Women’s Intervention Nutrition Study tested low-fat diets in postmenopausal women diagnosed with early stages of breast cancer. The women in the study reduced their fat intake to 20% of their total calories, which resulted in a 24% reduction of new breast cancer events. The Women’s Healthy Eating and Living Study looked at the effects of a low-fat diet high in vegetables, fruits, and fiber and its effect on cancer outcomes on pre- and postmenopausal women. The study did not find a significant difference between the recurrences of breast cancer, but it did find a protective effect of diet and decrease in hot flashes in the subgroup studied.
A variety of dietary approaches can promote weight loss if a reduction of dietary intake is achieved. Multiple studies have looked at the macronutrient makeup and its effect on weight loss on overweight and obese individuals in a variety of populations. The ones that get the most attention are the diets that are low in carbohydrates and low in fat. Ultimately, weight loss is achieved when you create an energy deficit, and the best diet is the one that the patient will follow and incorporate into their daily life.
Counseling Strategies
Healthy diet and regular physical activity are important factors in reducing cancer recurrence risk, mortality, and lifestyle-related chronic conditions. Counseling on weight control and physical activity is not currently used in all practices of the cancer care continuum. Clinicians typically advise their patients to change their lifestyle in a more prescriptive and impersonal approach. However, this is often ineffective. Patients often seem confused or unmotivated with these messages and can bring about resistance or indifference to make changes. When a patient does not follow the recommendations of the health-care practitioner, it is perceived as a lack of motivation. However, these assumptions are false. How a practitioner talks to patients about their health can affect their motivation to change behaviors. Motivational interviewing (MI) is a way to get patients to adhere to healthy behavior changes. It elicits the patient’s own interest in making these changes. It is usually described as a “dance rather than a wrestling match.” MI is collaborative, evocative and honors the patient’s autonomy.
MI is an effective alternative approach to address behavior changes that promote a constructive patient–clinician relationship that leads to better results. This type of intervention is directed to encourage a positive health behavioral change and can help improve adherence to diet and other lifestyle modifications within a clinical setting (see Table 5.1 ). Furthermore, MI has been shown to be a highly effective counseling strategy, especially when combined with cognitive behavioral therapy (CBT). CBT is based on the assumption that all behavior is learned and that environmental and internal factors are related to one’s behavior. Some additional strategies used to promote behavior change are self-monitoring, problem-solving, goal setting, cognitive restructuring, stimulus control, stress management, and relapse prevention. These strategies make a person more aware of internal and external cues and how they respond to them. Nutrition counseling conducted by an RDN is a supportive process that is set to establish goals, individualize action plans, and promote behavior change. It uses both cognitive behavioral therapies and MI to foster positive healthy behavior changes.
| Guiding Principles | Definition |
|---|---|
| 1. Resist the righting reflex | Resist telling the patient what they are doing wrong and what they need to do to fix it |
| 2. Understand your patient’s motivation | Patient’s own reason for change is more likely to trigger change. Be interested in the concerns and motivations of the patient. Ask reasons why they want to change and how they may do it instead of telling them what to do |
| 3. Listen to your patient | Listen as much as you educate and inform the patient |
| 4. Empower your patient | Guide a patient through their own ideas on how they can make positive changes in health. The patient is more likely to make a change if they are engaged in the consultation and are able to think out loud of how and why they should make a change |
A successful weight loss program encompasses a variety of successful strategies. Frequent follow-ups and encounters with the RDN help facilitate weight loss and keep the patient motivated and engaged in weight loss program. Self-monitoring, although challenging, has been identified as a successful tool to use when facilitating weight loss. With the use of technology, there are many tools that can be used such as cell phones, applications, computers, and activity trackers. Frequent contact with the clinician and self-monitoring helps with accountability. Social support is also an important part of the process.
The Role of Bariatric Surgery in Weight Management for Breast and Gynecological Cancers
Over one-third of the adult population in the United States is classified as obese (BMI≥30 kg/m 2 ). Evidence shows that obesity is associated with an increased risk for certain breast and GYN cancers, more specifically, postmenopausal breast and endometrial cancer. Therefore aggressive weight management seems a necessary intervention to help prevent breast and other GYN cancers and cancer recurrence.
The biggest challenge found in weight management is the maintenance of weight loss. Many patients are successful at losing weight but most gain the weight back. According to some studies, bariatric surgery is one of the few weight loss interventions where significant weight loss is maintained. In addition, a recent retrospective cohort study that examined whether bariatric surgery is associated with reduced risk of breast cancer among pre- and postmenopausal women concluded that bariatric surgery was associated with a reduced risk of breast cancer among severely obese women (BMI≥35 kg/m 2 ).
The benefit of bariatric surgery in severely obese patients needs to be evaluated on a case-by-case basis. Patients at high risk for breast and other GYN cancer recurrence and who have been unsuccessful at reaching an acceptable weight after intensive nutritional counseling may benefit from this aggressive and more permanent weight loss intervention. Nutritional counseling needs to continue after bariatric surgery to ensure success. Even after bariatric surgery, there is a risk of gaining some of the weight back if healthy eating habits are not practiced on a consistent basis.
Diet and Inflammation
The immune system is the first line of defense that our bodies have against internal and external stressors (food, chemicals, virus, bacteria, psychological stress, etc.). Inflammation is a physiological way the body uses to repair itself. In normal condition of homeostasis the body controls the inflammatory responses necessary to fight infection or improve tissue repair. However, with aging, the load of internal and external stressors turns into a silent chronic inflammatory state that is associated with increased risk of many chronic diseases such as cardiovascular diseases, dementia, arthritis, depression, and cancer. Chronic inflammation increases cancer risk and affects all cancer stages.
The way we eat can improve or worsen the state of inflammation. Nutrition has a strong power that modulates inflammation. The Western diet, characterized by high sugar intake, fried foods, and refined grains, is associated with higher levels of inflammatory biomarkers, such as C-reactive protein (CRP), tumor necrosis factor-alfa (TNF-α), and interleukin-6 (IL-6). The chronic state of hyperglycemia due to the intake of carbohydrates with high glycemic load promotes increased free radicals and proinflammatory cytokines, as well as insulin and insulin growth factor-1 (IGF-1). Moreover, high intake of food sources of linoleic acid (LA) such as corn oil, sunflower oil, or safflower oil induces the conversion to arachidonic acid (AA) that is an omega-6 fatty acid, a highly inflammatory compound; naturally occurring food sources of AA are eggs, grain-fed poultry, and meat. Intake of trans- fatty acids (TFA) derived from hydrogenated fatty acids found in baked goods is also linked to high inflammation. The standard Western diet is considered to be high in omega-6 fatty acids and TFA. Intake of TFA has been associated with increased levels of IL-6 and CRP in women with high BMI. High caloric intake has also been associated with chronic inflammation due to increased adiposity; adipose tissue releases proinflammatory cytokines, TNF-α and IL-6.
How Can We Fight Inflammation Through Food?
The constituents of an antiinflammatory diet are described in the following sections.
Phytochemicals
Phytochemicals are plant chemicals with nonnutritive characteristics that have a strong antiinflammatory function due to their powerful antioxidant and antitumor role via the modulation of signaling pathways. They are found in fruits, vegetables, legumes, nuts, seeds, herbs, and spices. They have a major role in preventing and fighting disease. The more studied phytochemicals are quercetin, polyphenols (flavonoids, catechins, resveratrol, and anthocyanins), carotenoids, and phytosterols. The best way to increase them in the diet is by eating a variety of colorful vegetables, fruits, and spices in every meal. Table 5.2 shows the more common phytochemicals and their related food source.
