Bone Health

The National Comprehensive Cancer Network recommends a daily intake of 1200 mg calcium (diet + supplements) and 800-1000 IU vitamin D for all adults over 50 years who are undergoing therapies associated with bone loss.

Breast Cancer

Women undergoing treatment for breast cancer lose bone mineral density at a rate 2-3 times higher than disease free women.

Endocrine therapies such as aromatase inhibitors, surgical treatments (oophorectomy) and certain chemotherapy meds (anthracyclines, alkylating agents, and antimicrotubule agents) can lead to hypogonadism - one of the most common causes of secondary osteoporosis.

Estrogen identified as a key etiologic factor in the development of osteoporosis.  It acts on bone tissue via estrogen receptors on skeletal muscle.  Since estrogen inhibits osteoclasts, estrogen deficiency contributes to increased osteoclastic bone resorption with subsequent loss of bone mineral density and an increased risk of fracture.

Tamoxifen (selective estrogen receptor modulator or SERM) demonstrates both estrogenic and antiestrogenic effects.

• In postmenopausal women, tamoxifen acts as estrogen agonist on bone and serum lipids, resulting in lower cholesterol levels and bone density improvement.
• It is an estrogen antagonist in breast tissue of postmenopausal women which inhibits tumor growth.
• In premenopausal women, tamoxifen acts as an antagonist in both breast and bone tissue, resulting in tumor reduction as well as bone loss.

Aromatase inhibitors inhibit the conversion of androgens to estrone, the dominant circulating estrogen post menopause.  Induces hypogonadism.  In trial, a decrease in bone mineral density was observed at lumbar spine and hip of postmenopausal women treated with anastrazole.  Despite decreasing serum estrogen levels, there is no report change in calcium absorption with aromatase inhibitor therapy.

Calcium supplementation may potentially increase cardiovascular risk by increasing total cholesterol or by increasing oxidative stress.  Caution use in dyslipidemic postmenopausal women and limit use in premenopausal women.  Reminder that some breast cancer therapies already increase cardiovascular risk in survivors.

Goal:  meet RDA needs with diet sources and limit supplements to those who cannot meet needs with diet alone.  Encourage other bone health strategies such as weight bearing and resistance exercise.

Prostate Cancer

Men with prostate cancer undergoing androgen deprivation therapy (ADT) lose bone mineral density at a considerably higher rate than disease-free men.

Endocrine therapies such as gonadotropin releasing hormone agonists, surgical treatments (bilateral orchiectomy) and certain chemotherapy meds (anthracyclines, alkylating agents, and antimicrotubule agents) can lead to hypogonadism - one of the most common causes of secondary osteoporosis.

The American Society of Clinical Oncology (ASCO) recommends total daily intake of at least 600 IU vitamin D and </= 1200 mg calcium from dietary sources for men with prostate cancer.
However, change to 1000-1500 mg elemental calcium and 400-800 IU vitamin D daily for men with prostate cancer receiving hormone therapy.

Circulating estrogen levels in men are extremely low, but estrogen is produced by the aromatization of testosterone to estradiol.  Surgical or chemical ADT used for treatment locally advanced or metastatic prostate cancer significantly reduces plasma androgen levels, leading to severe hypogonadism.  Reduction in testosterone levels decreases the  amount of circulating estrogen as well, thus contributing to the loss of bone mineral density and increased fracture risk.
Men undergoing ADT may lose bone mineral density at femoral neck and lumbar spine.

Higher calcium intake has been identified as a potential risk factor for prostate cancer.  A significantly higher risk in advanced and fatal cancer with dietary calcium intake of >/= 2000 mg.  Even modest intake of calcium may increase risk, particularly among smaller men (BMI < 23)
Supplemental calcium can increase serum ionized calcium levels which  may increase risk through stimulation of the calcium sensing receptor and calcium dependent voltage gated channels expressed by prostate cancer cells.  May promote growth of prostate cancer cells.

Goal:  obtain sufficient calcium through dietary sources and limit supplements to those who just cannot meet needs through diet alone.  Also promote other bone health activities such as resistance and weight bearing exercise.  Test vitamin D and correct deficiencies as needed.

Esophagitis

Esophagitis is an inflammation of the esophagus.  Described as painful, irritated throat or as a "lump" in the throat.Accompanying symptoms include: indigestion, esophageal reflux, belching, feeling of fullness and early satiety.

Management:

• Easy to swallow semisolid or soft-food diet
• Avoid spicy, acidic, hard, rough-textured foods
• Avoid raw foods or foods that contain skin or seeds
• Cool or room temperature foods better tolerated (soothing)
• Concentrate while eating, chewing, swallowing and breathing
• Allow up to 1-2 minutes between bites.
• Modify dishes to be more tender, dice meats and vegetables, add foods to cream soups, soft-cooked noodles or rice, add creamy smooth sauces.
• Frozen-juice pops with non-acidic juices, nectars, sport drinks, liquid nutrition supplements, soft drinks
• Smoothies with fruits such as melon, banana, peaches or kiwi.  For extra protein, add yogurt, frozen yogurt, milk, ice cream or silken tofu.
• Increasing protein in any recipe: use dried powdered milk, powdered egg whites, protein powder.
• Use heavy cream or coconut milk to increase calories
• Add cornstarch, instant mashed potato flakes, baby cereals, gelatin or commercial thickeners to thicken food.
• Use baby food as a sauce or as an ingredient within a recipe
• For sore throat: mix 3/4 teaspoon salt and 1 teaspoon baking soda dissolve in 1 quart water.  Gargle the solution as needed
• MMW, sprays, lozenges that help soothe

Lung Cancer

Complementary Therapies and Integrative Oncology in Lung Cancer
ACCP Evidence-Based Clinical Practice Guidelines
June 2007 - American College of chest Physicians (chestjournal.org)

NCHS, of 31000 adults surveyed, 75% used some form of CAM
CAM users typically younger, more educated and more affluent

Complementary therapies - used as adjuncts to mainstream care, supportive measures that help control symptoms, enhance well-being, and contribute to overall patient care.

Alternative Therapies - unproved or disproved, promoted for use instead of mainstream treatment.  Especially problematic as it can delay treatment and diminish the possibility of remission and cure.

Mind-body modalities are strongly recommended to reduce anxiety, mood disturbance, chronic pain. (meditation, guided imagery, relaxation techniques, yoga)

Massage therapy (by qualified practitioners - deep or intense pressure should be avoided near cancer lesions or anatomic distortions such as surgery sites; light/gentle massage only in those with bleeding tendencies.)  Reduces tension, pain, improves circulation, encourages relaxation.  May help anxiety, fatigue.  Reflexology (foot massage)
Use of aromatic oils in massage - mixed results.

Acupuncture strongly recommended as a complementary approach to pain control.  Also for nausea and vomiting associated with chemotherapy.  No support for acupuncture in treating nicotine addiction, dyspnea, or fatigue - but for tobacco cessation, could trial if all other measures fail. Could also trial for fatigue, mixed results.  Possibly could be used for chemotherapy induced neuropathy (early positive results) and xerostomia.

Acupressure wristbands render continuous stimulation of PC6 point and may reduce N/V on day of chemo; no significant difference for delayed N/V.  Do not use electrostimulation wristbands.

Manipulation of bioenergy fields not recommended.  Also not recommended - use of bioelectromagnetic-based therapy (use of electromagnetic fields)

Diet:  A specific diet (ie: macrobiotic, alkaline) is not supported by clinical studies.  But lifestyle changes toward a healthy diet is encouraged.

Dietary supplements:

• B12 and folic acid required for pemetrexed treatment
• Supplementation of beta-carotene may increase risk of lung cancer in those who currently smoke or who have recently quit smoking.
• High dose antioxidants or complex botanical agents can interact/interfere with treatment.
• Some botanicals have antiplatelet activity - may interact with corticosteroids and CNS depressant drugs, may produce GI effects, hepatotoxicity and nephrotoxicity, can produce additive effects when used with opiods.
• Quality control in supplements an additional issue.
• Feverfew, garlic, ginger, ginkgo should be avoided by those taking blood-thinning medications.
• Red clover, Dong Quai, licorice (phytoestrogen components) should not be used by patients taking tamoifen or aromatase inhibitors.
• St John Wort - metabolized by P450 CYP3A4; has been shown to make irinotecan less effective.
• 
  

Von Hippel-Lindau Syndrome

Gene VHL
Kidney cancer
Multiple non-cancerous tumors such as pheochromocytoma

Multiple Endocrine Neoplasia

Type 1 - Wermer Syndrome
Gene MEN1
pancreatic endocrine tumors.
Also (usually) benign parathyroid and pituitary gland tumors

Type 2
Gene RET
Medullary thyroid cancer
Also benign adrenal gland tumor

Retinoblastoma

Gene: RB1

eye cancer, pinealoma (cancer of pineal gland), osteosarcoma, melanoma, soft tissue sarcoma

Familial Adenomatous Polyposis

Gene: APC
increased risk of colorectal cancer as well as non-malignant colon polyps.  Also cancer of small intestine, brain, stomach, bone and skin

Cowden Syndrome

PTEN hamartoma tumor syndrome

Increased risk of breast, thyroid, endometrial

Thyroid Cancer

Most rapidly increasing cancer in US.
Two of three cases are in patients less than 55

Increased late effects in patients diagnosed before age 40 - hypertension (more than twice the risk of general population), heart disease, osteoporosis (7.5 times as likely).  Five times as likely to develop swelling around the heart in 10 years after diagnosis.

Excellent prognosis and survival rate, especially in those diagnosed at younger age.

Endometrial Cancer

Endometrial cancer survivors need careful monitoring for heart disease.
Due to shared risk factors from obesity and cancer treatment - esp blood clots, pulmonary heart disease, low blood pressure, irregular heartbeat.

Even after 5-10 years, elevated risk persists (Huntsman Cancer Institute, Utah).

Cardiovascular disease is the leading cause of death among survivors of endometrial cancer in the US.

Most common late effects: high blood pressure and cardiac disease.

Lymphedema

Breast Cancer Related Lymphedema (BCRL) affects ~20% of survivors.

Characterized by abnormal accumulation of lymphatic fluid, presenting as swelling of the arm, shoulder, hand, breast and/or trunk on the same side as breast cancer treatment.

Risk factors:

• Those who have undergone radiation or surgical dissection of the lymph nodes
• Have high BMI at diagnosis
• Experienced cellulitis after surgery

Kyprolis (Carfilzomib)

For relapsed Multiple Myeloma

Most common side effects affecting nutrition:

• SOB
• Headaches/confusion
• Low RBC
• Low WBC
• Fatigue
• Decreased potassium levels

Serious side effects:

• Heart problems
• Kidney problems
• Tumor Lysis Syndrome
• Lung Damage, Pulmonary Hypertension, other Lung Complications
• High blood pressure
• Blood clots

Kisqali (Ribociclib)

A new option for postmenopausal women with HR+ (ER+ and/or PR+) HER2- metastatic breast cancer in combination with hormone therapy.

Most common side effects affecting nutrition:

• Nausea/Vomiting
• Fatigue
• Diarrhea/Constipation

Serious side effects:

• QT prolongation (abnormal heartbeat)
• Hepatobiliary toxicity (loss of appetite, fatigue)
• Neutropenia (low WBC, increased risk of infection)
• 
  

Li-Fraumeni Syndrome

Mutation in TP53 - a gene that normally acts to suppress tumors.
Less common than BRCA, but can cause early onset of cancers such as brain tumors and soft tissue sarcoma.

BRCA

1 in 400 to 800 men and women in the general populations carry BRCA1 or BRCA2 mutations.
Risk is higher in men and women of Ashkenazi Jewish descent (1 in 40 chance)

BRCA1 - breast, ovarian, melanoma, colon

PARP inhibitors - poly ADP ribose polymerace - block an enzyme used by cancer cells to repair damage to their DNA.  Shows promise in patients with inherited BRCA mutations and BRCA abnormalities.

• Lynparza (olaparib)
• 
  

Lynch Syndrome

A hereditary disorder caused by a genetic mutation that predisposes a person to several cancers, including colon, stomach, pancreas, kidneys, brain, uterus and skin.

One out of every 279 people has it.
Lynch syndrome accounts for 2-4% of colon cancer cases in US and 2-5% endometrial cancers in women.
If a person tests positive for Lynch syndrome, their children have a 50% chance of inheriting the mutation

• MLH1
• MSH2
• MLH1 and MSH2 face a lifetime risk of developing colon cancer between 52-82% (compared with 4.8 for general population)
• MSH6 - women have 25-60% lifetime risk of developing endometrial cancer
• PMS2
• EOCAM

All genes involved in the process of DNA repair.

Chemotherapy Induced Peripheral Neuropathy

May occur in 70-95% of patients.
MD Anderson study: Neurofeedback may reduce CIPN in cancer survivors.
Neurofeedback operates by targeting the areas of the brain that contribute to the physical and emotional aspects of chronic pain.  Teaches patients to understand pain signals differently.

Ibrance (Palbocicilib)

Oral therapy for women with hormone-receptor Positive (ER+ and/or PR+) HER2- Metastatic Breast Cancer.

When used in combination with a hormone therapy, may delay disease progression.

• Letrozole
• Fulvestrant

Common Side Effects that affect nutrition:

• Fatigue
• SOB
• Low RBC/Low Platelets (contributes to fatigue)
• Other less common: nausea, sore mouth, diarrhea/constipation, loss of appetite

Serious Side Effects:

• Neutropenia (low white blood cell counts)
• Blood clots

Opdivo (Nivolumab)

Immunotherapy for adults with advanced NSCLC previously treated with platinum-based chemotherapy. (Bristol-Myers Squibb)

Most common side effects that interfere with nutrition:

• Fatigue
• Pain in muscles/joints
• Diarrhea or Constipation
• nausea
• Decreased appetite

Serious Side effects may include:

• Colitis - signs and symptoms may include diarrhea or more bowel movements than usual, blood in stools and severe abdominal pain or tenderness.
• Hepatitis - severe N/V, dark urine, feeling less hungry than usual
• Hormone gland problems - may contribute to weight loss or weight gain, extreme fatigue, forgetfulness, excessive thirst
• Kidney Problems - decrease in urine, loss of appetite
• Skin problems - mouth ulcers

IV over 60 minutes every two weeks