Nutrition Screening and Assessment
Goals of Nutrition Therapy
Methods of Nutrition Care
        Oral nourishment
        Enteral nutrition
        Parenteral nutrition
Nutritional Suggestions for Symptom Management
        Anorexia
        Alterations of taste and smell
        Xerostomia
        Mucositis/stomatitis
        Nausea
        Diarrhea
        Neutropenia
        Hot flashes
        Hydration and dehydration
        Constipation

Nutrition Screening and Assessment

Nutrition in cancer care embodies prevention of disease, treatment, cure, or supportive palliation. Caution should be exercised when considering alternative or unproven nutritional therapies during all phases of cancer treatment and supportive palliation, as these diets may prove harmful. Patient nutritional status plays an integral role in determining not only risk of developing cancer but also risk of therapy-related toxicity and medical outcomes. Whether the goal of cancer treatment is cure or palliation, early detection of nutritional problems and prompt intervention are essential.

The original principles of nutrition care for people diagnosed with cancer were developed in 1979 [1] and are still very relevant today. Proactive nutritional care can prevent or reduce the complications typically associated with the treatment of cancer.[1]

Many nutritional problems stem from local effects of the tumor. Tumors in the gastrointestinal tract, for example, can cause obstruction, nausea, vomiting, impaired digestion, and/or malabsorption. In addition to the effects of the tumor, marked alterations in normal metabolism of carbohydrates, protein, and/or fats can occur.[2]

The nutritional prognostic indicators most recognized as being predictive of poor outcome include weight loss, wasting, and malnutrition. In addition, significant weight loss at the time of diagnosis has been associated with decreased survival and reduced response to surgery, radiation therapy, and/or chemotherapy.[3]

Malnutrition and accompanying weight loss can be part of an individual’s presentation or can be caused or aggravated by treatments for the disease. Identification of nutrition problems and treatment of nutrition-related symptoms have been shown to stabilize or reverse weight loss in 50% to 88% of oncology patients.[4]

Screening and nutrition assessment should be interdisciplinary; the healthcare team (e.g., physicians, nurses, registered dietitians, social workers, psychologists) should all be involved in nutritional management throughout the continuum of cancer care.[5]

A number of screening and assessment tools are currently available for use in nutritional assessment. Examples of these tools include the Prognostic Nutrition Index,[6,7] delayed hypersensitivity skin testing, institution-specific guidelines, and anthropometrics. Each of these tools can help identify persons at nutritional risk; unfortunately, the values obtained using such tools can be altered by the hydration status and the immune compromise frequently found in individuals diagnosed with cancer. In addition, each of these objective measures can carry a cost in terms of laboratory or practitioner time. One author has provided a useful overview of assessment procedures for advanced cancer patients.[8]

Another example of a screening and assessment procedure is the Patient-Generated Subjective Global Assessment (PG-SGA). Based on earlier work on a protocol called Subjective Global Assessment (SGA),[9] the PG-SGA is an easy-to-use and inexpensive approach in identifying individuals at nutritional risk and in triaging for subsequent medical nutritional therapy in a variety of clinical settings.[10,11] The individual and/or caretaker complete sections on weight history, food intake, symptoms, and function. A member of the healthcare team evaluates weight loss, disease, and metabolic stress and performs a nutrition-related physical examination. A score is generated from the information collected. The need for nutrition intervention is determined according to the score.

Bioelectrical impedance analysis (BIA) is also used to assess nutritional status, as determined by body composition.[12] The BIA measures electrical resistance on the basis of lean body mass and body fat composition. Single BIA measures show body cell mass, extracellular tissue, and fat as a percent of ideal, whereas sequential measurements can be used to show body composition changes over time. Because of cost and accessibility, BIA is currently in limited use and often unavailable in most ambulatory settings.

Taste and smell defects are common in cancer patients and may affect nutritional status. The relative importance of chemosensory changes to the etiology of malnutrition was assessed in 66 patients with advanced cancer. Some degree of chemosensory abnormality was reported by 86% of patients; approximately one-half of patients reported interference with enjoying favorite foods. Poor appetite, nausea, early satiety, and chemosensory abnormalities presented concurrently. These findings were significantly related to decreased energy intake. Further research is required to design nutritional interventions for these chemosensory problems.[13]

Because nutritional status can quickly become compromised from illness and decreased dietary intake, and because nutritional well-being plays an important role in treatment and recovery from cancer, early screening and intervention as well as close monitoring and evaluation throughout all phases of cancer treatment and recovery are imperative in the pursuit of health for the individual with cancer.

Optimal nutritional status is an important goal in the management of individuals diagnosed with cancer. Although nutrition therapy recommendations may vary throughout the continuum of care, maintenance of adequate intake is important. Therefore, a waiver from most dietary restrictions observed during religious holidays is granted for those undergoing active treatment. Individuals with cancer are encouraged to speak to their religious leaders regarding this matter before a holiday.

Whether patients are undergoing active therapy, recovering from cancer therapy, or in remission and striving to avoid cancer recurrence, the benefit of optimal caloric and nutrient intake is well documented.[14-16]

The goals of nutrition therapy are to accomplish the following:

• Prevent or reverse nutrient deficiencies.
• Preserve lean body mass.
• Help patients better tolerate treatments.
• Minimize nutrition-related side effects and complications.
• Maintain strength and energy.
• Protect immune function, decreasing the risk of infection.
• Aid in recovery and healing.
• Maximize quality of life.

Patients with advanced cancer can receive nutritional support even when nutrition therapy can do little for weight gain.[17,18] Such support may help accomplish the following:

• Lessen side effects.
• Reduce risk of infection (if given enterally).
• Reduce asthenia.
• Improve well-being.

In individuals with advanced cancer, the goal of nutrition therapy should not be weight gain or reversal of malnutrition, but rather comfort and symptom relief.[19]

Nutrition continues to play an integral role for individuals whose cancer has been cured or who are in remission.[20] A healthy diet helps prevent or control comorbidities such as heart disease, diabetes, and hypertension. Following a healthful nutrition program might help prevent another malignancy from developing.

As outlined above, individuals diagnosed with cancer are at risk for malnutrition resulting from the disease itself; from anticancer therapy such as surgery, radiation, or pharmacologic therapy; and/or from anorexia due to emotional turmoil. The following sections highlight the benefits, contraindications, methods of administration, and home care issues for all forms of nutrition support—oral, enteral, and parenteral.

The preferred method of nutrition support is via the oral route, with the use of dietary modifications to reduce the symptoms associated with cancer treatments. Enteral nutrition is indicated when the gastrointestinal (GI) tract is functional but oral intake is insufficient to meet nutritional requirements. Common situations in which enteral nutrition may be needed include malignancies of the head and neck regions, esophagus, and stomach. When the GI tract is dysfunctional, total parenteral nutrition (TPN) or enteral nutrition may be indicated; however, the widespread use of TPN is controversial because little evidence of improved survival has been demonstrated in patients with advanced cancer.[21] Parenteral nutrition has been shown to be beneficial in only a small group of patients—specifically, postoperative patients who are being aggressively treated and who have demonstrated a positive response rate. One study [22] reported that patients with GI cancer benefited from perioperative support with TPN, with one-third fewer complications and decreased mortality.

Optimal nutrition can improve the clinical course, outcome, and quality of life of patients undergoing treatment for cancer.[23] Virtually every cancer patient could benefit from consultation with a registered dietitian or physician to formulate a plan for nutrition and to begin meal planning. Oral nutrition, or eating by mouth, is the preferred method of feeding and should be used whenever possible. Appetite stimulants may be used to enhance the enjoyment of foods and to facilitate weight gain in the presence of significant anorexia.[24]

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

At-risk individuals who may benefit from nutritional support might have one or more of the following characteristics:[26]

• Low body weight, as defined by less than 80% of ideal weight or recentlyexperienced unintentional weight loss of more than 10% of usual weight.
• Malabsorption of nutrients due to disease, short bowel syndrome, or anticancer therapy.
• Fistulas or draining abscesses.
• Inability to eat or drink for more than 5 days.
• Moderate or high nutritional risk status as determined by screening or an assessment tool.
• The ability to demonstrate competencies for discharge planning on nutritional support (both individual and caregiver).

Although the many benefits of achieving good nutritional status via nutritional support can clearly be detailed, the disadvantages or questionable benefits of nutritional support must also be considered. The debate regarding the effect of nutritional support on tumor growth has not been settled;[27] though quality of life is usually improved with better nutritional status, the actual impact of nutritional support on longevity has yet to be definitively determined.[27]

Once the degree of malnutrition has been assessed, the decision to offer nutritional support and which form of support to utilize must be determined by the healthcare professional and other parties involved. Enteral and parenteral nutritional support offers viable options to reduce the risk of debilitating malnutrition and interruptions in anticancer therapy that may influence outcome. Each form of nutritional support has advantages and disadvantages. It is critical to thoroughly evaluate the diagnosis, prognosis, degree of malnutrition, function of the gut, and ease of delivery before embarking on the plan of nutritional support. Caution must also be exercised to avoid refeeding syndrome, the metabolic complication that is caused by rapid repletion of potassium, phosphorous, and magnesium in a severely malnourished or cachectic patient.[26]

The following sections highlight the benefits, contraindications, methods of administration, formulas, and home care issues for both enteral and parenteral nutrition.

The benefits of enteral nutrition, or tube feeding, are that it continues to use the gut, has fewer complications such as infection and organ malfunction, is often easier to administer, and is cheaper than parenteral nutrition.[26-29] In addition, nutrients are metabolized and utilized more efficiently by the body.

Specific disease and condition-related indications for use consist of a diagnosis of a cancer of the alimentary canal (in particular, head and neck, esophageal, gastric, or pancreatic cancers) and severe complications/side effects from chemotherapy and/or radiation that are seriously jeopardizing the treatment plan of an individual already suffering from malnutrition.[26]

Contraindications for enteral nutritional support include a malfunctioning gastrointestinal tract, malabsorptive conditions, mechanical obstructions, severe bleeding, severe diarrhea, intractable vomiting, gastrointestinal fistulas in locations difficult to bypass with an enteral tube, inflammatory bowel processes such as prolonged ileus and severe enterocolitis, and/or an overall health prognosis not consistent with aggressive nutrition therapy.[26] Thrombocytopenia and general pancytopenic conditions following anticancer treatments may also prevent placement of an enteral tube.

Prospective Assessment

Several effective methods for the delivery of enteral nutritional support or tube feedings exist. An approximation of how long nutritional support will be needed is critical, however, to determine the most appropriate delivery route. Nasogastric, nasoduodenal, or nasojejunal methods are best for short-term support (<2 weeks).[29] The endpoint of delivery—the stomach, the duodenum, or jejunum—is determined by the risk of aspiration, with nasojejunal feeds recommended for individuals with aspiration risk. If the person with cancer is at very high risk for aspiration, enteral nutritional support may be contraindicated and parenteral nutrition should be considered. Also, immune-compromised individuals with mucositis, esophagitis, and/or herpetic, fungal, or candidiasis lesions in the mouth or throat may not be able to tolerate the presence of a nasogastrointestinal tube.

Tubes are constructed from silicone or polyurethane and can vary in length from 30 to 43 inches, with the shorter tubes used for nasogastric feedings. The diameters range from 5F to 16F catheters. Tubes may have weighted tips to help passage through the gut.

Percutaneous endoscopic gastrostomy tubes (PEGs) and percutaneous endoscopic jejunostomy tubes (PEJs) are generally used for long-term enteral feedings (>2 weeks).[29] The placement further down in the gastrointestinal tract has a number of advantages: the diameter of the tube is larger (15F-24F catheters), which allows easier and faster passage of formulas and medications; the risk for aspiration is lower because of the decreased chance of migration of the tube up into the esophagus; the risk for sinusitis or nasoesophageal erosion is lower; and this route is more convenient and aesthetically pleasing to the individual because of the ability to conceal the tube.[29] People anticipating long-term support may also consider a skin-level button gastrostomy or jejunostomy.

Assessment of need and ease of delivery are best done early. If the malnourished individual requires surgery for an unrelated event, a PEG or PEJ may be placed at that time to avoid an additional procedure.

Infusion Methods and Formulas

Enteral nutrition or tube feedings can be delivered at various rates. When possible, the bolus method is preferable because it mimics normal feeding, requires less time and equipment, and offers greater flexibility to the patient.[29] The following is a summary of infusion possibilities:[29]

Continuous or cyclic drip feeding

• Caloric/nutrient and free-water requirements need to be determined first to plan rate and time recommendations.



• Enteral feeding pumps provide reliable, constant infusion rates and decrease the risk of gastric retention.



• Assuming that no compounding factors are present, feeding into the stomach (25–30 cc/hr) can start at a higher rate than feeding into the jejunum (10 cc/hr); rates can be increased, with tolerance, every 4 to 6 hours until the rate reaches that needed to deliver the required caloric/nutrient needs.



• Continuous feeds can be cycled to run at night to allow greater flexibility and comfort. If it is physically possible, these nocturnal feeds can allow daytime oral or bolus feedings to meet nutritional goals and provide a more normal lifestyle.

Bolus and intermittent feeding

• Caloric/nutrient and free-water requirements need to be determined to plan the feeding schedule.



• Bolus feedings can be offered several times (3–6 times) each day; as much as 250 to 500 cc can be given over 10 to 15 minutes.



• Bolus feeding should be used ONLY when the endpoint of the tube is in the stomach; it should NEVER be used when feedings are delivered into the duodenum or jejunum. This precaution protects against gastric distention and dumping.



• A gravity drip from a bag or syringe with a slow push can be used to administer the formula.



• Diarrhea is a common side effect of this infusion method but can be controlled with a change in formula, additions to the formula, and a change in the amount of formula given over a finite period of time.

After the infusion method has been determined, a formula needs to be selected. There are many formulas on the market, ranging from elemental preparations of predigested nutrients to more complete and complex formulas that mimic oral nutrition intake. Specialized formulas are available for specific health conditions such as diabetes mellitus and compromised renal function. Modular formulas that are not nutritionally complete but add specific nutrients such as protein, fat, and carbohydrate are also available. These preparations can be added to an existing formula to provide additional benefit.

Glutamine, an amino acid, is a key energy source for the gut and has been shown to help maintain gut health and integrity and to protect the gut from damage from radiation and chemotherapy.[29,30] The use of supplemental glutamine in tube feedings in addition to L-arginine and omega-3 fatty acids is gaining popularity. These potentially beneficial nutrients are now available in formulas and as oral supplements. More research needs to be done, however, to thoroughly evaluate the benefits and possible disadvantages.

When a formula is being chosen, the institution nutrition formulary for available preparations, modular formulas, and additions such as glutamine or fiber should be considered. Consideration should also be given to the patient’s medical condition, gastrointestinal function, and financial resources.

Transition to Home

A significant number of patients using enteral nutritional support in the hospital are discharged to home while still on therapy. This can be done successfully and requires that the following conditions are met:[29]

• The patient and/or caregiver is given enough time for education and is proficient in the use of the tubes, site care, and the use of the pump.



• The patient is discharged to a safe and clean environment.



• Regular medical follow-up is arranged to ensure appropriate function of the feeding tube and optimization of the nutrition plan.

Parenteral nutrition may be indicated in select individuals who are unable to use the oral or enteral route (i.e., those who have a nonfunctioning gut), such as those with obstruction, intractable nausea and/or vomiting, short-bowel syndrome, or ileus. Additional inclusive conditions common in the cancer population are severe diarrhea/malabsorption, severe mucositis or esophagitis, high-output gastrointestinal fistulas that cannot be bypassed by enteral intubation, and/or severe preoperative malnutrition.[27,29]

Contraindications for use of parenteral nutrition are a functioning gut, a need for nutritional support for a duration less than 5 days, an inability to obtain intravenous (IV) access, and poor prognosis not warranting aggressive nutritional support.[27,29] Additional conditions that should cause hesitation are the following: patient or caregiver does not want parenteral nutrition, patient is hemodynamically unstable or has profound metabolic and/or electrolyte disturbances, and/or patient is anuric without dialysis.[27,29]

Prospective Assessment

If parenteral nutrition is determined to be beneficial, the two venous access sites are central and peripheral. Cancer patients usually have central IV catheters to accommodate multiple IV therapies. If this is not the case, a peripheral catheter can be placed, although care must be taken to avoid overuse of the peripheral accesses with nutritional support and anticancer therapies. Numerous peripheral infusions and venesections can result in vessel sclerosis. The following discussion highlights both types of access:[27,29]

Central venous catheters

• May utilize single-, double-, or triple-lumen catheters for delivery of medication, blood and blood products, and parenteral nutrition without interruption.



• Placement of lines should be done by an experienced surgical team to minimize risk of pneumothorax, hemothorax, hematuria, aneurysms, venous or nerve damage, and microbial contamination. Evaluation of catheter tip location and site care is critically important.



• Short-term support can be provided via Cordis or Swan Ganz catheters; long-term support can be provided via Hickman or Broviac catheters.

Peripheral venous catheters

• A short canula is placed in the arm (either the percutaneous subclavian vein in adults or the arteriovenous fistulas are used as access sites).



• Catheters must be located in peripheral vessels with high blood flow to facilitate rapid dilution of the formula; access may be alternated to avoid thrombophlebitis.



• Peripherally inserted central catheters (PICC lines) are used for long-term support; the tip of the catheter must be placed in a central vein such as the superior or inferior vena cava to decrease risk of infection and thrombosis.

Solutions

Parenteral nutrition formulas are tailored to individual clinical status and nutritional needs. The formulas contain a combination of amino acids, dextrose, lipids, vitamins, minerals and trace elements, fluids, electrolytes, and, possibly, additives such as insulin, heparin, and antacids.

Solutions running through peripherally placed lines must be altered by reducing the percentage of calories from carbohydrates (hypertonic) and increasing the percentage from lipids (isotonic). Peripheral solutions with a final dextrose concentration lower than 10% and an osmolarity lower than 900 mOsm/kg are generally well tolerated.[27] The mandatory alteration in macronutrients can present problems with delivery of recommended calories/nutrients.

Central infusions are not limited by osmolarity because they use a large vein; this feature makes central venous access a good choice for severely stressed, hypermetabolic individuals and/or individuals requiring a fluids restriction.[27]

Many drugs and compounds are not compatible with parenteral solutions and should not be added to the solutions or even run through parenteral solution-designated lines to avoid the chance of interaction or precipitation. Pharmacists should be consulted in the preparation of parenteral nutrition solutions and before any additional medications or compounds are added.

Complications

Incompatibility with drugs is just one of a number of possible complications associated with parenteral nutrition administration. Complications can be categorized as mechanical (vein thrombosis, pneumothorax, and catheter tip misplacement) or metabolic (hyperglycemia/hypoglycemia, hypokalemia, and elevated liver function tests).[27] Because of the precision that is required to order, administer, and maintain this type of support, trained and experienced medical personnel should be involved. Many facilities have dedicated nutritional support multidisciplinary teams.

Transition to Home

Cancer is one of the most common diagnoses among home parenteral nutrition recipients. The following criteria should be used when assessing the appropriateness of discharge to home on parenteral feeds. The individual must meet the following conditions:[27]

• Be medically and emotionally stable.



• Have a relatively long life expectancy (>6 months).



• Be educated and able to perform the requisite tasks to maintain a sterile access site in a safe and clean environment.



• Have a long-term access in place and be stable on the formula before being discharged.



• Have a medical follow-up and support system in place for questions and complications.

Tapering off parenteral nutritional support requires coordination between the medical staff and the patient. Because parenteral support is given continuously, the taper involves a gradual reduction in rate and time. Parenteral nutritional support cannot be abruptly discontinued.

When transitioning to enteral feeds, parenteral support can be decreased to 50% when enteral feeds reach 33% to 50% of the goal rate; it can be discontinued when enteral feeds reach 75% of goal and are tolerated.[27]

When transitioning to oral nutrition, parenteral solutions can be decreased to 50% when the patient is tolerating a full liquid diet or beyond and can be discontinued once solid foods are tolerated in addition to the consumption of adequate fluids.[27]

Both enteral and parenteral nutritional support can be safe and effectively used to help reverse the effects of malnutrition in individuals with cancer. However, nutritional support, particularly parenteral support, is still controversial when used as routine adjuvant therapy to anticancer therapies or when there is an absence of efficacious cancer treatment.[31] Every measure should be employed to sustain an individual and improve his or her condition through oral intake before consideration is given to nutritional support.

Side effects of cancer treatments vary from patient to patient, depending on the type, length, and dose of treatments as well as the type of cancer being treated. This section offers practical suggestions for managing the common symptoms affecting nutrition intake.

Recommendations during treatment may focus on eating foods that are high in energy, protein, and micronutrients to help maintain nutritional status. This may be especially true for individuals with early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, or diarrhea. Under most of these circumstances, eating frequently and including high-energy and high-protein snacks may help overall intake.[25]

Loss of appetite or poor appetite is one of the most common problems that occurs with cancer and its treatment.[32] The cause of anorexia may be multifactorial. Treatment modality, the cancer itself, and psychosocial factors may all play a role in appetite.[32] Eating frequent meals and snacks that are easy to prepare may be helpful. Liquid supplements may improve total energy intake and body function [33] and may work well when eating solids is difficult. Other liquids that contain energy may also help, such as juices, soups, milk, shakes, and fruit smoothies. Eating in a calm, comfortable environment and exercising regularly may also improve appetite.[32]

Suggestions for appetite improvement include the following:[34-36]

• Plan a daily menu in advance.
• Eat small, frequent, high-calorie meals (every 2 hours).
• Arrange for help in preparing meals.
• Add extra protein and calories to food.
• Prepare and store small portions of favorite foods.
• Consume one third of daily protein and calorie requirements at breakfast.
• Snack between meals.
• Seek foods that appeal to the sense of smell.
• Be creative with desserts.
• Experiment with different foods.
• Perform frequent mouth care to relieve symptoms and decrease aftertastes.

What types of foods are usually recommended?

• Cheese and crackers.
• Muffins.
• Puddings.
• Nutritional supplements.
• Milkshakes.
• Yogurt.
• Ice cream.
• Powdered milk added to foods such as pudding, milkshakes, or any recipe using milk.
• Finger foods (handy for snacking) such as deviled eggs, cream cheese or peanut butter on crackers or celery, or deviled ham on crackers. (For information about the peanut product recall, see the National Cancer Institute (NCI) fact sheet on Peanut Product Recall and Cancer Patients.)
• Chocolate.

See the NCI Web site Eating Hints for Cancer Patients: Before, During, and After Treatment for recipes such as Lactose-Free Double Chocolate Pudding, Banana Milkshake, and Fruit and Cream. For a free copy of this booklet, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

Alterations in taste can be related to unknown effects of cancer, radiation treatment, dental problems, mucositis and infection (thrush), or medications. Cancer patients undergoing chemotherapy frequently report changes in their sense of taste, specifically a bitter taste sensation during administration of the cytotoxic drugs.[37] One study measured the taste thresholds among cancer patients under chemotherapy compared with controls.[38] In this study, 62% of patients complained of taste disorders associated with the chemotherapy medications. Taste dysfunction can result in food avoidance, inducing weight loss and anorexia, all of which can have significant consequences on patients' quality of life. Simply changing the types of foods eaten as well as adding additional spices or flavorings to foods may help. Citrus may be tolerated well if no mouth sores or mucositis is present. Rinsing the mouth before eating may help improve the taste of food.[32]

While undergoing cancer therapy, patients may experience taste changes or develop sudden dislikes for certain foods. Their sense of taste may return partially or completely, but it may be a year after therapy ends before their sense of taste is normal again. A randomized clinical trial found that zinc sulfate during treatment may be helpful in expediting the return of taste after head and neck irradiation.[39]

Suggestions for helping cancer patients manage taste changes include the following:

• Eat small, frequent meals and healthy snacks.



• Be flexible. Eat meals when hungry rather than at set mealtimes.



• Use plastic utensils if foods taste metallic.



• Try favorite foods.



• Plan to eat with family and friends.



• Have others prepare the meal.



• Try new foods when feeling best.



• Substitute poultry, fish, eggs, and cheese for red meat.



• A vegetarian or Chinese cookbook can provide useful nonmeat, high-protein recipes.



• Use sugar-free lemon drops, gum, or mints when experiencing a metallic or bitter taste in the mouth.



• Add spices and sauces to foods.



• Eat meat with something sweet, such as cranberry sauce, jelly, or applesauce.

Xerostomia (dry mouth) is most commonly caused by radiation therapy that is directed at the head and neck.[35] A number of medications may also induce xerostomia. Dry mouth may affect speech, taste sensation, ability to swallow, and use of oral prostheses. There is also an increased risk of cavities and periodontal disease because less saliva is produced to cleanse the teeth and gums.

A primary method of coping with xerostomia is to drink plenty of liquids (25–30 mL/kg per day) and eat moist foods with extra sauces, gravies, butter, or margarine.[25,36,40] In addition, hard candy, frozen desserts such as frozen grapes, chewing gum, flavored ice pops, and ice chips may be helpful.[32] Oral care is very important to help prevent infections. Irradiation to the head and neck of a patient who has permanent dry mouth symptoms may result in reduced intake of energy, iron, zinc, selenium, and other key nutrients.[41] Special efforts should be made to help tailor meals and snacks for individuals with xerostomia.

Suggestions for lessening or alleviating dry mouth include the following:[36]

• Perform oral hygiene at least 4 times per day (after each meal and before bedtime). (Refer to the Routine Oral Hygiene Care section of the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.)
• Brush and rinse dentures after each meal.
• Keep water handy at all times to moisten the mouth.
• Avoid rinses containing alcohol.
• Consume very sweet or tart foods and beverages, which may stimulate saliva.
• Drink fruit nectar instead of juice.
• Use a straw to drink liquids.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on xerostomia.)

Stomatitis, or a sore mouth, can occur when cells inside the mouth, which grow and divide rapidly, are damaged by treatment such as bone marrow transplantation, chemotherapy, and radiation therapy. These treatments may also affect rapidly dividing cells in the bone marrow, which may make patients more susceptible to infection and bleeding in their mouth. By carefully choosing foods and by taking good care of their mouths, patients can usually make eating easier.[42-44] Individuals who have mucositis, mouth sores, or tender gums should eat foods that are soft, easy to chew and swallow, and nonirritating.[32] Some conditions may require processing foods in a blender. Irritants may include acidic, spicy, salty, and coarse-textured foods. A pilot study found that oral glutamine swishes might be helpful in reducing the duration and severity of mucositis.[45] Glutamine may also reduce the duration and severity of stomatitis during cytotoxic chemotherapy.[45,46]

Suggestions for people with cancer who are experiencing stomatitis include the following:

• Eat soft foods that are easy to chew and swallow, including bananas and other soft fruits; applesauce; peach, pear, and apricot nectars; watermelon; cottage cheese; mashed potatoes; macaroni and cheese; custards; puddings; gelatin; milkshakes; scrambled eggs; oatmeal or other cooked cereals; pureed or mashed vegetables such as peas and carrots; and pureed meats.



• Avoid foods that irritate the mouth, including citrus fruits and juices such as orange, grapefruit, or tangerine; spicy or salty foods; and rough, coarse, or dry foods, including raw vegetables, granola, toast, and crackers.



• Cook foods until soft and tender.



• Cut foods into small pieces.



• Use a straw to drink liquids. Eat foods cold or at room temperature; hot and warm foods can irritate a tender mouth.



• Practice good mouth care, which is very important because of the absence of the antimicrobial effects of saliva.



• Increase the fluid content of foods by adding gravy, broth, or sauces.



• Supplement meals with high-calorie, high-protein drinks.



• Numb the mouth with ice chips or flavored ice pops.

(Refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information on mucositis.)

Nausea can affect the amount and types of food eaten during treatment. Eating before treatment is important, as well as finding foods that do not trigger nausea. Frequent triggers for nausea include spicy foods, greasy foods, or foods that have strong odors.[32] Once again, frequent eating, and slowly sipping on fluids throughout the day may help.

Additional eating suggestions include the following:[19]

• Eat dry foods such as crackers, breadsticks, or toast, throughout the day.



• Sit up or recline with a raised head for 1 hour after eating.



• Eat bland, soft, easy-to-digest foods rather than heavy meals.



• Avoid eating in a room that has cooking odors or is overly warm; keep the living space comfortable but well ventilated.



• Rinse out the mouth before and after eating.



• Suck on hard candies such as peppermints or lemon drops if the mouth has a bad taste.

(Refer to the PDQ summary on Nausea and Vomiting for further information.)

Radiation, chemotherapy, gastrointestinal surgery, or emotional distress can result in diarrhea. Avoiding hyponatremia, hypokalemia, and dehydration during episodes of diarrhea requires the intake of additional oral fluids and electrolytes. Broth, soups, sports drinks, bananas, and canned fruits may be helpful for the replenishment of electrolytes. Diarrhea may worsen with greasy foods, hot or cold liquids, or caffeine.[32] In the presence of radiation enteritis, fibrous foods—especially dried beans and cruciferous vegetables—may contribute to frequent stools.[47] Meal planning should be individualized to meet nutritional needs and tolerances. Oral glutamine may also help prevent intestinal toxicity from fluorouracil.[48]

Additional suggestions include the following:[19]

• Drink plenty of fluids through the day; room-temperature fluids may be better tolerated.



• Limit milk to 2 cups or eliminate milk and milk products until the source of the problem is determined.



• Limit gas-forming foods and beverages such as soda, cruciferous vegetables, legumes and lentils, and chewing gum.



• Limit the use of sugar-free candies or gum made with sugar alcohol (sorbitol).



• Drink at least 1 cup of liquid after each loose bowel movement. (Refer to the Impaction section of the PDQ summary on Gastrointestinal Complications for more information.)

(Refer to the PDQ summary on Gastrointestinal Complications for more information on diarrhea.)

People with cancer may have a low white blood cell count for a variety of reasons, some of which include radiation therapy, chemotherapy, or the cancer itself. Patients who have a low white blood cell count are at an increased risk for developing an infection.[49] Suggestions for helping people prevent infections related to neutropenia include the following:

• Check expiration dates on food and do not buy or use if the food is out of date.



• Do not buy or use food in cans that are swollen, dented, or damaged.



• Thaw foods in the refrigerator or microwave—never thaw foods at room temperature.



• Cook foods immediately after thawing.



• Refrigerate all leftovers within 2 hours of cooking and eat them within 24 hours.



• Keep hot foods hot and cold foods cold.



• Avoid old, moldy, or damaged fruits and vegetables.



• Avoid tofu in open bins or containers.



• Cook all meat, poultry, and fish thoroughly; avoid raw eggs or raw fish.



• Buy individually packaged foods, which are better than larger portions that result in leftovers.



• Use caution when eating out—avoid salad bars and buffets.



• Limit exposure to large groups of people and people who have infections.



• Wash hands frequently to prevent the spread of bacteria.

This list may be modified after chemotherapy or when blood count returns to normal.

Hot flashes, typically associated with postmenopausal states in women without cancer, occur in two thirds of women with a history of breast cancer and three quarters of men with locally advanced or metastatic prostate cancer. Estrogen replacement controls hot flashes in postmenopausal women but may be contraindicated in patients with hormone-responsive tumors or other medical conditions. In May 2002, the Women's Health Initiative, a large randomized placebo-controlled trial of the risks and benefits of estrogen plus progestin in healthy postmenopausal women, was stopped prematurely at a mean follow-up of 5.2 years (± 1.3) because of the detection of a 1.26-fold increased breast cancer risk (95% confidence interval, 1.00–1.59) in women receiving hormone replacement therapy. Tumors among women in the hormone replacement therapy group were slightly larger and more advanced than those in the placebo group, with a substantial and statistically significant rise in the percentage of abnormal mammograms at first annual screening; such a rise might hinder breast cancer diagnosis and account for the later stage at diagnosis.[50,51] Dietary soy phytoestrogens have been proposed for hot flash control in individuals for whom estrogen is contraindicated; however, the risk of soy phytoestrogen use on breast cancer recurrence and/or progression has not yet been clarified. Soy phytoestrogens are weak estrogens found in plant foods. In vitro models suggest that these compounds have a biphasic effect on mammary cell proliferation that is dependent on intracellular concentrations of phytoestrogens and estradiol.[52] Risk in vivo has not been clarified; however, two randomized placebo-controlled trials in breast cancer survivors show no benefit of soy over placebo in alleviating hot flashes.[53,54] (Refer to the PDQ summary on Fever, Sweats, and Hot Flashes for more information.)

Adequate hydration is critically important for health maintenance. There are several common scenarios found in cancer treatment that may lead to altered hydration status and electrolyte imbalance. Hydration status can become compromised with prolonged disease or treatment-related diarrhea and/or episodes of nausea and vomiting.[55] Acute and chronic pain can also adversely affect the appetite and hence the desire to eat and drink. Fatigue, an all-too-common complaint of people with cancer, can be one of the first signs of dehydration.[56] Once the underlying cause for altered hydration is appropriately managed, some suggestions to promote adequate hydration include the following:[32,57,58]

• Drink 8 to 12 cups of liquids a day; take a water bottle whenever leaving home. It is important to drink even if not thirsty, as the thirst sensation is not a good indicator of fluid needs.



• Add food to the diet that contains a significant portion of fluid, such as soup, flavored ice pops, flavored ices, and gelatins.



• Limit consumption of caffeine-containing products, including colas and other caffeine-containing sodas, coffee, and tea (both hot and cold); these foods may not be as nourishing as noncaffeinated beverages.



• Drink most liquids after and/or between meals to increase overall consumption of both liquids and solids.



• Use antiemetics for relief from nausea and vomiting; antiemetic use can be very helpful and may prevent hospital admissions from dehydration. The classes of available antiemetics include anticholinergics, phenothiazines, antihistamines, butyrophenones, benzamides, and serotonin receptor antagonists. Of note, all of these antiemetics have side effects that many individuals would consider less problematic than nausea and vomiting.

Constipation is defined as fewer than three bowel movements per week.[59] It is a very common problem among individuals with cancer and may result from lack of adequate fluids or dehydration, lack of fiber in the diet, physical inactivity or immobility, anticancer therapies such as chemotherapy, and medications used in the treatment of side effects of anticancer therapy such as antiemetics and opioids.[59,60] In addition, commonly used pharmacologic agents such as minerals (calcium, iron), nonsteroidal anti-inflammatory drugs, and antihypertensives can cause constipation.[59]

An effective bowel regimen should be in place before the problem of constipation occurs. Preventive measures should be common practice, and special attention should be paid to the possibility of constipation as a side effect of certain therapies. Suggestions include the following:[57,59]

• Eat more fiber-containing foods on a regular basis. The recommended fiber intake is 25 to 35 grams per day. Fiber should be gradually added to the diet, and adequate fluids must be consumed at the same time (see list below).



• Drink 8 to 10 cups of fluid each day; beverages such as water, prune juice and warm juices, decaffeinated teas, and lemonade can be particularly helpful.



• Take walks and exercise regularly (proper footwear is important).

If prevention does not work and constipation is a problem, the application of a three-pronged approach for treatment is suggested: diet (fiber and fluids), physical activity, and over-the-counter or prescription medication. The use of biofeedback or surgery may also be considered.[61]

Suggestions are as follows:[57,59,62,61,15]

• Continue to eat high-fiber foods and drink adequate fluids. Try adding wheat bran to the diet; begin with 2 heaping tbsp each day for 3 days, then increase by 1 tbsp each day until constipation is relieved. DO NOT EXCEED 6 TBSP PER DAY.



• Maintain physical activity.



• Include over-the-counter treatments if necessary. This refers to bulk-forming products (e.g., psyllium, methylcellulose [Citrucel], psyllium hydrophilic mucilloid [Metamucil (if adequate hydration is tolerated), Fiberall], calcium polycarbophil [FiberCon, Fiber-Lax]); stimulants (e.g., bisacodyl [Dulcolax] tablets or suppositories, glycerin suppositories, and calcium salts of sennosides [Senokot]); stool softeners (e.g., docusate sodium [Colace] and docusate calcium [Surfak]); and osmotics (e.g., milk of magnesia, lactulose, and magnesium sulfate/epsom salts). Cottonseed and aerosol enemas can also help relieve the problem. Lubricants such as mineral oil would be included in this group but are NOT recommended because of the potential for binding and preventing absorption of essential nutrients.

Good sources of fiber include the following:[19,57]

• 4+ grams per ½ cup cooked serving.
  • Legumes.*
    • Kidney beans.
    • Navy beans.
    • Garbanzo beans.
    • Lima beans.
    • Split peas.
    • Pinto beans.
    • Lentils.
• 4+ grams per designated unit.
  • Corn (½ cup).
  • Pears with skin (medium piece of fruit).
  • Popcorn (3 cups popped).
• 4+ grams per 1 oz. serving.
  • Whole-grain cereals (cold).
  • Bran cereals (cold).
• 4+ grams per 1/3 cup serving, dry.
  • Oatmeal.
  • Oat bran.
  • Grits.
• 2+ grams per ½ cup cooked or 1 cup raw serving.
  • Asparagus.
  • Green beans.
  • Broccoli.*
  • Cabbage.*
  • Carrots.
  • Cauliflower.
  • Greens.
  • Onions.
  • Peas.
  • Spinach.
  • Squash.
  • Green peppers.
  • Celery.
  • Canned tomatoes.
• 2+ grams per ½ cup serving or medium piece of fruit.
  • Apples with the skin.
  • Bananas.
  • Oranges.
  • Strawberries.
  • Peaches.
  • Blueberries.
• 2 grams per slice or designated serving size.
  • Whole wheat bread.
  • Whole grain bagel.
  • Pita (½ portion).
  • Whole-grain crackers.

 [Note: *These food items may cause gas; products containing alpha-galactosidase enzyme may be helpful.]

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