Nutrition Screening and Assessment
Goals of Nutrition Therapy
Methods of Nutrition Care
        Enteral Nutrition
        Parenteral Nutrition

Nutrition Screening and Assessment

Finding and treating nutrition problems early may improve the patient's prognosis (chance of recovery).

Early nutrition screening and assessment can identify problems that affect the success of anticancer therapy. Patients who are underweight or malnourished may not respond well to cancer treatments. Malnutrition may be caused by the cancer or made worse as the cancer progresses. Finding and treating nutrition problems early may help the patient gain or maintain weight, improve the patient's response to therapy, and reduce complications of treatment.

Screening and assessment are done before beginning anticancer therapy, and assessment continues throughout treatment.

Because the ability to tolerate treatment is better for the well-nourished patient, screening and assessment are done before beginning anticancer therapy. Appropriate nutrition management is begun early, and nutritional status is checked often during treatment.

Screening is used to identify patients who may be at nutritional risk. Assessment determines the complete nutritional status of the patient and identifies if nutrition therapy is needed. The patient or caregiver may be asked for the following information:

• Weight changes over the past 6 months.



• Changes in the amount and type of food eaten compared to what is usual for the patient.



• Problems that have affected eating, such as nausea, vomiting, diarrhea, constipation, dry mouth, changes in taste and smell, mouth sores, pain, or loss of appetite.



• Ability to walk and perform the activities of daily living.

A physical exam is part of the assessment. The physical exam will check the body for general health and signs of disease, such as lumps or growths. The physician will look for loss of weight, fat and muscle, and fluid buildup in the body.

Ongoing assessment is completed by a healthcare team with expertise in nutritional management.

A nutrition support team will monitor the patient's nutritional status during cancer treatment and recovery. The team may include the following specialists:

• Physician.



• Nurse.



• Registered dietitian.



• Social worker.



• Psychologist.

The goals of nutrition therapy for cancer patients in active treatment and recovery are designed to restore nutrient shortages, maintain nutritional health, and prevent complications.

The goals of nutrition therapy for patients in active treatment and recovery are to do the following:

• Prevent or correct malnutrition.



• Prevent wasting of muscle, bone, blood, organs, and other lean body mass.



• Help the patient tolerate treatment.



• Reduce nutrition-related side effects and complications.



• Maintain strength and energy.



• Protect ability to fight infection.



• Help recovery and healing.



• Maintain or improve quality of life.

A patient whose religion forbids eating certain foods may consider speaking with a religious leader about waiving the restriction during cancer treatment and recovery.

Good nutrition continues to be important for patients who are in remission or whose cancer has been cured.

The goals of nutrition therapy for patients who have advanced cancer are designed to improve the quality of life.

The goals of nutrition therapy for patients who have advanced cancer are to do the following:

• Reduce side effects.



• Reduce risk of infection.



• Maintain strength and energy.



• Improve quality of life.

Nutrition support provides nutrition to patients who cannot eat normally.

Eating by mouth is the preferred method and should be used whenever possible, but some patients may not be able to take any or enough food by mouth due to complications from cancer or cancer treatment. This may include patients with cancer of the head, neck, esophagus, or stomach. A patient may be fed using enteral nutrition (through a tube inserted into the stomach or intestine) or parenteral nutrition infused into the bloodstream directly). The nutrients are delivered in formulas, liquids that contain water, protein, fats, carbohydrates, vitamins, and/or minerals. The content of the formula depends on the needs of the patient and the method of feeding.

Nutritional support can improve a patient's quality of life during cancer, but there are risks and disadvantages that should be considered before making the decision to use it. The effect of nutritional support on tumor growth is not known. Also, each form of nutrition therapy has its own benefits and disadvantages. For example, enteral nutrition keeps the stomach and intestines working normally and has fewer complications than parenteral nutrition; nutrients are used more easily by the body in enteral feeding. These and other issues should be discussed with the patient's health care providers so that an informed decision can be made. (See the Advanced Cancer section below ¹ for more information on deciding whether to use nutritional support.)

Patients with certain conditions are most appropriate for treatment with nutrition support.

Nutrition support may be helpful for patients who have one or more of the following characteristics:

• Low body weight.



• Inability to absorb nutrients.



• Holes or draining abscesses in the esophagus or stomach.



• Inability to eat or drink by mouth for more than 5 days.



• Moderate or high nutritional risk.



• Ability, along with the caregiver, to handle tube feedings at home.

Enteral nutrition is also called tube feeding.

Enteral nutrition is food (in liquid form) given to the patient through a tube that is inserted into the stomach or the small intestine. The following types of tube feeding may be used:

• A tube inserted through the nose and throat down into the stomach or small intestine. This kind of tube is usually used for short-term use.



• A tube inserted into the stomach or small intestine through a stoma (an opening made on the outside of the abdomen). This kind of tube is usually chosen for long-term use or for patients who cannot tolerate a tube in the nose and throat.

If the tube is placed in the stomach, food may be given through the tube continuously or in batches several times a day. If the tube is placed in the small intestine, the food is delivered continuously. Different formulas are available. Some provide complete nutrition and others provide certain nutrients. Formulas that meet the patient's specific needs are selected. Formulas are available for patients who have other health conditions, such as diabetes.

Enteral nutrition is sometimes used when the patient is able to eat small amounts by mouth but cannot obtain enough food that way. The patient may continue to eat or drink as able, and the tube feeding provides the balance of calories and nutrients that are needed.

Enteral nutrition may be appropriate for patients whose gastrointestinal tract is still working.

Enteral nutrition continues to use the stomach and/or intestines to digest food. Enteral nutrition may be used for patients who have cancer of the head, neck, or digestive system and whose treatment with chemotherapy and radiation therapy causes side effects that limit eating or drinking.

Enteral nutrition is not appropriate for the following patients:

• Patients whose stomach and intestines are not working or have been removed.



• Patients who have a blockage in the bowel.



• Patients who have severe nausea, vomiting, and/or diarrhea.



• Patients whose platelet count is low. Platelets are blood cells that help prevent bleeding by causing blood clots to form.



• Patients who have low levels of all blood cells (white blood cells, red blood cells, and platelets).

Enteral nutrition may continue after a patient leaves the hospital.

If enteral nutrition is to be part of the patient's care after leaving the hospital, the patient and caregiver will be trained in use of the tube and pump, and in care of the patient. The home must be clean and the patient must be monitored often by the nutrition support team.

Parenteral nutrition provides the patient with nutrients delivered into the blood stream.

Parenteral nutrition is used when the patient cannot take food by mouth or by enteral feeding. Parenteral feeding bypasses the normal digestive system. Nutrients are delivered to the patient directly into the blood, through a catheter (thin tube) inserted into a vein. Patients with the following problems may benefit from parenteral nutrition:

• Stomach and intestines that are not working or have been removed.



• Severe nausea, diarrhea, or vomiting.



• Severe sores in the mouth or esophagus.



• A fistula (hole) in the stomach or esophagus.



• Loss of body weight and muscle with enteral nutrition.

The catheter may be placed into a vein in the chest or in the arm.

A central venous catheter is placed beneath the skin and into a large vein in the upper chest. Placement of a central venous catheter is done by a surgeon.

A peripheral venous catheter is placed into a vein in the arm. Placement of a peripheral venous catheter is done by trained medical staff. This site may be used for short-term parenteral feeding.

The patient is checked often for infection or bleeding at the site (place) where the catheter enters the body.

Some drugs should not be given with parenteral formulas.

Many drugs and other substances do not mix safely with the formulas used for parenteral feeding. A pharmacist or doctor should be consulted before adding anything to the formula or using the catheter for another substance.

Trained medical staff should manage the use of parenteral nutrition.

The techniques and formulas involved in parenteral nutrition support are precise and require management by trained medical staff or a nutrition support team. Some of the serious complications that may occur with parenteral feeding include the following:

• Placement of the tip of the catheter into the wrong place.



• Blood clots.



• A collapsed lung.



• A high or low sugar level in the blood.



• A low potassium level in the blood.



• Elevated liver enzymes.

Parenteral nutrition support may continue after a patient leaves the hospital.

If parenteral nutrition is to be part of the patient's care after leaving the hospital, the patient and caregiver will be trained in the procedures and in care of the patient. The home must be clean and the patient must be monitored often by the nutrition support team.

Experienced medical staff should manage the patient's removal from parenteral nutrition support.

Going off parenteral nutrition support needs to be done gradually and under medical supervision. The parenteral feedings are reduced by small amounts over time as the patient is changed to enteral or oral feeding.

Glossary Terms

The area of the body that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.

An enclosed collection of pus in tissues, organs, or confined spaces in the body. An abscess is a sign of infection and is usually swollen and inflamed.

A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.

The long, tube-shaped organ in the abdomen that completes the process of digestion. The bowel has two parts, the small bowel and the large bowel. Also called the intestine.

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

A sugar molecule. Carbohydrates can be small and simple (for example, glucose) or they can be large and complex (for example, polysaccharides such as starch, chitin or cellulose).

A flexible tube used to deliver fluids into or withdraw fluids from the body.

The individual unit that makes up the tissues of the body. All living things are made up of one or more cells.

A tube surgically placed into a blood vessel for the purpose of giving intravenous fluid and drugs. It also can be used to obtain blood samples. This device avoids the need for separate needle insertions for each infusion or blood test. Examples of these devices include Hickman catheters, which require clamps to make sure the valve is closed, and Groshong catheters, which have a valve that opens as fluid is withdrawn or infused and remains closed when not in use.

Treatment with drugs that kill cancer cells.

In medicine, a medical problem that occurs during a disease, or after a procedure or treatment. The complication may be caused by the disease, procedure, or treatment or may be unrelated to them.

A condition in which stool becomes hard, dry, and difficult to pass, and bowel movements don’t happen very often. Other symptoms may include painful bowel movements, and feeling bloated, uncomfortable, and sluggish.

To heal or restore health; a treatment to restore health.

A disease in which the body does not properly control the amount of sugar in the blood. As a result, the level of sugar in the blood is too high. This disease occurs when the body does not produce enough insulin or does not use it properly.

Frequent and watery bowel movements.

A health professional with special training in nutrition who can help with dietary choices. Also called a nutritionist.

The organs that take in food and turn it into products that the body can use to stay healthy. Waste products the body cannot use leave the body through bowel movements. The digestive system includes the salivary glands, mouth, esophagus, stomach, liver, pancreas, gallbladder, small and large intestines, and rectum.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

A form of nutrition that is delivered into the digestive system as a liquid. Drinking nutrition beverages or formulas and tubefeeding are forms of enteral nutrition. People who are unable to meet their needs with food and beverages alone, and who do not have vomiting or uncontrollable diarrhea may be given tubefeedings. Tubefeeding can be used to add to what a person is able to eat or can be the only source of nutrition. A small feeding tube may be placed through the nose into the stomach or the small intestine, or it may be surgically placed into the stomach or the intestinal tract through an opening made on the outside of the abdomen, depending on how long it will be used.

A protein that speeds up chemical reactions in the body.

The muscular tube through which food passes from the throat to the stomach.

An abnormal opening or passage between two organs or between an organ and the surface of the body. Fistulas may be caused by injury, infection, or inflammation, or may be created during surgery.

Liquid.

Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.

A method of putting fluids, including drugs, into the bloodstream. Also called intravenous infusion.

The long, tube-shaped organ in the abdomen that completes the process of digestion. The intestine has two parts, the small intestine and the large intestine. Also called the bowel.

A large organ located in the upper abdomen. The liver cleanses the blood and aids in digestion by secreting bile.

One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.

A disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food.

A nutrient required to maintain health.

A feeling of sickness or discomfort in the stomach that may come with an urge to vomit. Nausea is a side effect of some types of cancer therapy.

A health professional trained to care for people who are ill or disabled.

A chemical compound (such as protein, fat, carbohydrate, vitamin, or mineral) contained in foods. These compounds are used by the body to function and grow.

The taking in and use of food and other nourishing material by the body. Nutrition is a 3-part process. First, food or drink is consumed. Second, the body breaks down the food or drink into nutrients. Third, the nutrients travel through the bloodstream to different parts of the body where they are used as "fuel" and for many other purposes. To give the body proper nutrition, a person has to eat and drink enough of the foods that contain key nutrients.

By or having to do with the mouth.

A part of the body that performs a specific function. For example, the heart is an organ.

A form of nutrition that is delivered into a vein. Parenteral nutrition does not use the digestive system. It may be given to people who are unable to absorb nutrients through the intestinal tract because of vomiting that won't stop, severe diarrhea, or intestinal disease. It may also be given to those undergoing high-dose chemotherapy or radiation and bone marrow transplantation. It is possible to give all of the protein, calories, vitamins and minerals a person needs using parenteral nutrition. Also called hyperalimentation, total parenteral nutrition, and TPN.

An exam of the body to check for general signs of disease.

Medical doctor.

A type of blood cell that helps prevent bleeding by causing blood clots to form. Also called a thrombocyte.

A metallic element that is important in body functions such as regulation of blood pressure and of water content in cells, transmission of nerve impulses, digestion, muscle contraction, and heartbeat.

In medicine, the course of a disease, such as cancer, as it becomes worse or spreads in the body.

A molecule made up of amino acids that are needed for the body to function properly. Proteins are the basis of body structures such as skin and hair and of substances such as enzymes, cytokines, and antibodies.

A specialist who can talk with patients and their families about emotional and personal matters, and can help them make decisions.

A device that is used to give a controlled amount of a liquid at a specific rate. For example, pumps are used to give drugs (such as chemotherapy or pain medicine) or nutrients.

The overall enjoyment of life. Many clinical trials assess the effects of cancer and its treatment on the quality of life. These studies measure aspects of an individual’s sense of well-being and ability to carry out various activities.

The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called radiotherapy and irradiation.

RBC. A cell that carries oxygen to all parts of the body. Also called RBC and erythrocyte.

A decrease in or disappearance of signs and symptoms of cancer. In partial remission, some, but not all, signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body.

In medicine, an improvement related to treatment.

Checking for disease when there are no symptoms. Since screening may find diseases at an early stage, there may be a better chance of curing the disease. Examples of cancer screening tests are the mammogram (breast), colonoscopy (colon), Pap smear (cervix), and PSA blood level and digital rectal exam (prostate). Screening can also include checking for a person’s risk of developing an inherited disease by doing a genetic test.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

The part of the digestive tract that is located between the stomach and the large intestine.

A professional trained to talk with people and their families about emotional or physical needs, and to find them support services.

A surgically created opening from an area inside the body to the outside.

An organ that is part of the digestive system. The stomach helps digest food by mixing it with digestive juices and churning it into a thin liquid.

A doctor who removes or repairs a part of the body by operating on the patient.

Treatment.

A type of enteral nutrition (nutrition that is delivered into the digestive system in a liquid form). For tubefeeding, a small tube may be placed through the nose into the stomach or the small intestine. Sometimes it is surgically placed into the stomach or the intestinal tract through an opening made on the outside of the abdomen, depending on how long it will be used. People who are unable to meet their needs with food and beverages alone, and who do not have vomiting or uncontrollable diarrhea may be given tubefeedings. Tubefeeding can be used to add to what a person is able to eat or can be the only source of nutrition.

A key nutrient that the body needs in small amounts to grow and stay strong. Examples are vitamins A, C, and E.

To eject some or all of the contents of the stomach through the mouth.

Refers to a blood cell that does not contain hemoglobin. White blood cells include lymphocytes, neutrophils, eosinophils, macrophages, and mast cells. These cells are made by bone marrow and help the body fight infections and other diseases. Also called WBC.