Case Study: Cancer

Mrs. S has been recently diagnosed with Stage III breast cancer. Her treatment course
includes a course of concurrent radiation treatment and chemotherapy, then surgical
resection with a mastectomy and lymph node dissection.
Mrs. S. is to begin a 10 day course of radiation treatment and is also to receive
chemotherapy treatment with 5-Fluorouracil (5-FU). The intent is to use 2 courses of
these treatments to decrease the size and growth of the tumor prior to surgical resection.
You are the outpatient dietitian consulted for advice on nutritional management of this
patient. You counseled the patient at the beginning of the treatment course and now you
are seeing her again on day 10, at the end of the first treatment course. She is
complaining of diarrhea that is painful, frequent (>6 episodes/day), and is also
experiencing some soreness in her mouth and throat on swallowing.
1. What is the drug 5-FU and how does it work? (2 pts)
-5-Fluorouracil is an antineoplastic medication, meaning it is meant to fight
certain types of cancer, and in Mrs. S case, specifically breast cancer. This
chemotherapy agent is also an antimetabolite, which means that it interferes with
certain metabolites that are needed for normal metabolism, and particularly with
RNA and DNA synthesis. This interference with metabolites overall interferes
with cell growth and division, leading to cell death. This may be helpful in killing
cancer cells, but may also kill other rapid-replicating cells that are not cancerous.
*(FMI Book and NTP Book pg. 695).
2. Why might Mrs. S be experiencing GI problems? (2 pts)
-Mrs. S might be experiencing GI problems because most cells in the GI tract are
rapid-replicating cells, and are affected by the chemotherapy drug 5-FU that is
being administered to her. The 5-FU interferes with metabolites, which means
that cancer cells and also replication of healthy, normal cells is being interfered
with and the cells are being killed. The treatment she is receiving is targeting
many cells in her body, including many GI tract cells, and contributing to these GI
problems she is experiencing.
3. List at least 4 nutrition recommendations you would give her. (4 pts)
-Recommend electrolyte fortified beverages to promote hydration and prevent
dehydration.
-Recommend consuming cold and bland foods and avoiding hot, acidic foods that
may irritate her mouth and GI tract further.
-Recommend eating small frequent meals that are nutrient dense.
-Recommend soft, low-residue foods that may be easier for her to swallow and
tolerate.
*(Pocket Resource Guide).

Mrs. S begins her second chemotherapy course and on day 6 is admitted to the hospital
with severe neutropenia.
4. What is neutropenia and what health risk does it pose? (2 pts)
-Neutropenia is a low concentration of neutrophils. Neutrophils are white blood
cells that help the body fight infection. With a low concentration of WBC during
neutropenia, it decreases the ability of Mrs. S to fight infections and certain
diseases, since she is now immunocompromised. She is also more prone to
contracting infections.
5. What hospital diet would be most appropriate for her at this time? (2 pts)
-A neutropenic, low-microbial diet would be most appropriate for her at this time.
This includes foods that are cooked, canned, and generally does not include fresh
fruits or vegetables. Microbial exposure to fresh fruits and vegetables may
compromise her immune system and exacerbate her overall condition. Food
safety is very important as well, in order to prevent any microbial infections.
Mrs. S. subsequently completes her radiation and chemotherapy, has successful surgery
and does well for nearly two years.
6. She asks you whether it is OK for her to eat soy foods (tofu, soy milk, edamame).
What do you recommend? (2 pts)
-I would let Mrs. S know that it is okay to consume soy foods, but she should do
so in moderation. Soy products are high in certain phytochemicals, particularly
isoflavones. Many phytochemicals have been shown to be beneficial in overall
health, but there is some controversy as well, since isoflavones have a similar
structure to estrogen found in our bodies. Both estrogen and isoflavones activate
estrogen receptor cells, so soy may lead to over-activation of these estrogen
receptor cells at high amounts, and may cause problems in people who are
estrogen receptor positive. This tends to be the case in people with breast cancer,
since high amounts of estrogen receptors have been present in breast cancer
tumors. It is risky for Mrs. S to consume soy, but 1-2 servings should be safe. I
would definitely explain all of this to Mrs. S and allow her to make an informed
decision on her own. I will add that she should definitely avoid soy and isoflavone
supplements, since these high intakes may be harmful, and we wouldnt want to
promote the growth of any cancer cells from returning. (AJCN Soy Article).
Mrs. S. recently presented at her doctors office with c/o weight loss, feeling tired, and no
appetite. She reports taking a few bites and getting full. She states that meats & coffee no
longer taste good to her. Her fatigue is beginning to limit her usual daily activities. These
symptoms have increased over the past 3 months. She feels like she may have lost a little
weight over the past year, but it has been really evident to her the past 3-4 months.
The following information is available:
Age: 60 Ht: 54 Wt: 126 lb. UBW: 145 lb. Wt 3 months ago: 140 lb
Hgb: 11.0 g/dl Hct: 31% MCV:115fL Ferritin 90 ng/ml TIBC 255 g/dl Alb: 3.1 g/dl

7. Calculate IBW, %UBW and % change in BW over the past 3 months. Indicate the
level of nutritional risk this change in BW represents. (show calculations) (2 pts)
-IBW: (100+ 5*4): 120lbs/2.2kg: 54.5kg
-%UBW: 126/145: 0.8689*100: 86.9%: 87%
*(PR Guide).
-% change in BW: 140-126/140: 0.1*100: 10%
-This change in BW indicates severe weight loss, and represents a high
nutritional risk. It is possible that Mrs. S cancer is back, and this severe weight
loss may be due to cancer cachexia and perhaps anorexia due to poor appetite.
8. Interpret the biochemical data, and comment on the overall status of the patient,
considering her symptoms and weight changes. (2 pts)
-Hgb and Hct are low, indicating anemia. Ferritin and TIBC are normal, so we
know that the anemia is not due to iron deficiency. The MCV is slightly above
normal, but nothing too concerning. Albumin is also slightly below normal. Mrs.
S could definitely be experiencing anemia of chronic disease, due to all of the
complications her body is undergoing with her cancer journey. She is showing
signs of fatigue and appetite change, which may explain her severe wt. loss and
signs of cancer cachexia. Her low albumin levels may be attributed to her
increased metabolic rate and cancer state, but arent severely low. Her cancer
might be back, so further tests may be necessary to make sure. *(PR Guide).
9. How would you determine the appropriate energy and protein needs for Mrs. S?
(Indicate why you would use either her UBW, IBW or CBW; and show your
calculations with the equations you would use for energy and protein) (2 pts)
-Although the Mifflin St. Jeor equation is typically not used in critically ill
patients, it may be appropriate to use it in this case, because it allows us to use
Mrs. S specific characteristics such as age, weight, and height to help determine
her appropriate energy needs.
- Energy needs: (10 x wt. [kg]) + (6.25 x ht. [cm]) (5 x age) 161
=(10 x 57.27) + (6.25 x 162.56) (5 x 60) 161
=572.7 + 1016 300 161=1127.7kcal
=1127.7 x (1.2-1.4AF)=1353.24-1578.78 x 1.1 IF= 1488.56-1736.65
=1489-1737 kcal
-For protein needs, a range of 1.2-1.5g/kg/d of protein may be appropriate for
Mrs. S, since she is a cancer patient who isnt under too much stress, but there is
still a lot going on in her body.
-Protein needs: 126lbs/2.2kg: 57.3kg* (1.2-1.5g PRO): 68.7-85.9g
=69-86g PRO
-CBW would be most appropriate to use in this case, since our primary goal is to
maintain Mrs. S current weight, and prevent any further weight loss which would
worsen her condition. We wouldnt want to use UBW or IBW, since increased
calorie recommendations might overwhelm her and lead to further weight loss in
the long run. *(PR Guide).