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One third of cancers are linked to diet, developing over a long period of time. Tumor cells can get energy from
metabolism of glucose to lactate in the Cori cycle rather than from complete oxidation to carbon dioxide and water (Krebs
cycle). Antioxidants protect against free radical damage. Chromosomal damage is directly related to cancer and cell

I. Definition
1. Cancer
*abnormal division and reproduction of cells that can spread throughout the body, crowding out normal cells
and tissues
*A common term for a group of diseases characterized by uncontrolled growth and spread of abnormal
cells. The cancerous cells reproduce without control, crowding out the healthy cells and using up nutrients
needed by these cells

2. Tumor masses of unknown cause that apparently arose by unrestrained growth of the individuals own

3. Carcinogen an agent (physical, chemical or viral) that induces cancer in human and animals

4. Adenoma benign growth that may or may not transform to cancer

5. Carcinoma a form of cancer involving epithelial tissue and coverings of internal and external surfaces.
Lungs, colon, breast, stomach, uterus, skin, and tongue cancers are included in this group which comprise
80-90% of all cancers

6. Antioxidants molecules, such as some vitamins, that block action of activated oxygen molecules (free
radicals) that can damage cells

7. Phytochemicals nonnutritive compounds in plants thought to influence the process of tumorigenesis

8. Cancer cachexia syndrome a syndrome that frequently accompanies many types of cancer;
characterized by anorexia, inadequate intake of food, malnutrition, accelerated metabolism and wasting,
and general ill health

II. Stages of carcinogenesis
1. Initiation normal cells are transformed into tumor cells by the interaction of chemical, radiation, or viruses
with cellular DNA; the resultant cell remain dormant for a variable period until activated by a promoting
2. Promotion the initiated cells multiply to form a discrete tumor
3. Progression this process leads to a fully malignant phenotype with the capacity for tissue invasion and

III. Classification of Tumor
1. Benign circumscribed, usually well-encapsulated, and affect the host either by pressure, atrophy, or
2. Malignant invades surrounding tissues and release cells that are carried to other parts of the body to set
up secondary growth or metastasis
3. Intermediate locally invasive but does not metastasize

IV. Classification of Cancer Based of Tissue/Cells from which they Develop
1. Adenomas arise from glandular tissues
2. Carcinomas arise from epithelial tissues
3. Gliomas arise from glial cells of the central nervous system
4. Leukemias arise from the blood-forming cells of the bone marrow
5. Lymphomas arise from lymph tissue
6. Melanomas arise from pigmented skin cells
7. Sarcomas arise from muscle, bone, or connective tissue

V. Etiology
1. Genetic
*all cancers have a genetic component, with some having a genetically inherited component
2. Immune factors
*a healthy immune system recognizes foreign cells and destroys them; an ineffective immune system may
not recognize tumor cells as foreign thus allowing tumor growth
*the incidence of cancer increases with age since aging affect immune function
*the risk of cancer is increased by some medications (immunosuppresants) which supperess the immune
system and viral infections (HIV infections)
3. Environmental factors
Causes of cancer: radiation and sunlight, water and air pollution, smoking
*initiators factors that initiate cancer development; they cause mutations that give rise to cancer, such as
radiation and carcinogens
*promoters factors that favor the development of cancers once they have begun
*antipromoters factors that oppose the development of cancers

VI. Nutrition in the Etiology of Cancer
1. Energy balance and exercise
-physical inactivity, high energy intake, and large body mass are associated with an increased risk
of developing colon cancer in men and women while regular exercise reduces the risk of breast
and colon cancer
-increased physical activity has been shown to be inversely related to an increased risk of breast
2. Fat
-a high fat intake of both total fat and saturated or animal fat has been related to an increased risk
of breast, colon, lung and prostate cancers
3. Protein
-increased meat intake has been associated with an increased risk of colon cancer and with
advanced prostate cancer
4. Fiber
-fiber-rich diets are associated with a protective effect in colon cancer
5. Fruits and vegetables
-increased intake of fruits and vegetables is associated with a lower risk of cancers of the oral
cavity, esophagus, stomach, colon, rectum, or bladder
-epidemiologic studies report that individuals with a low consumption of raw and fresh vegetables,
leafy green vegetables, cruciferous vegetables (broccoli and cabbage), lettuce, carrots, and raw
and fresh fruits eventually develop cancer
-fruits and vegetables are low in energy and are good sources of fiber, vitamins, minerals, and
biologically active substances; they contain anticarcinogenic agents (antioxidants) such as vitamins
C and E, selenium, and phytochemicals (i.e., carotenoids, indoles, phenols, terpenes)

6. Alcohol
-epidemiologic studies show that alcohol has a causal role in carcinogenesis (especially in cancers
of the mouth, pharynx, larynx, esophagus, lung, colon, rectum, liver, and breast)

7. Coffee and Tea
-regular consumption of coffee or tea has no significant relationship with the risk of cancer

8. Artificial Sweeteners
-cyclamate and saccharin consumption has been investigated in relation to bladder cancer

9. Nitrates, nitrites, and nitrosamines
-nitrosamines are potent carcinogens
-nitrate can be reduced to nitrite which can in turn interact with dietary substrates such as amides
and amines to produce nitrosamides and nitrosamines
-diets high in fruits and vegetables which contain vitamin C and phytochemicals can retard the
conversion of nitrites to nitrosamines
-sodium and potassium nitrates are used in salting, pickling and curing foods
-nitrosamines are present in tobacco or tobacco smoke
-dome epidemiologic studies have shown the link between high intakes of processed meat and
increased risk of cancers of the colon, rectum and stomach

10. Method of Food Preparation
-high-heat cooking methods such as grilling, broiling, barbecuing, and smoking of meats form
polycyclic aromatic hydrocarbons and heterocyclic aromatic amines which are toxic substances;
these substances are formed during combustion of carbon fuel and pyrolysis of protein

VII. Nutritional effects of Cancer
1. Cancer Cachexia
-characterized by weight loss, anorexia, generalized wasting, immunosuppression, altered basal
metabolic rate, and abnormalities in fluid and energy metabolism

2. Energy metabolism
-an increase in energy expenditure and reduction in energy intake result in a negative energy
balance and subsequent weight loss

3. Substrate metabolism
-tumor growth alters carbohydrate, protein, and lipid metabolism since tumors have a constant
demand for glucose
-protein breakdown and lipolysis occur at increases rates to maintain high rates of glucose
-changes in protein metabolism occur to provide adequate amino acids for tumor growth; loss of
skeletal muscle protein, visceral organ atrophy, hypoalbuminemia also take place
-changes in lipid metabolism occur: free fatty acids are mobilized from adipose tissues and total
body fat is depleted

4. Other metabolic abnormalities
-fluid and electrolyte imbalances among those with advance cancer; hypercalcemia in bone-
metastasizing tumors of the breast, lung, and pancreas; severe diarrhea can result from tumors
that secrete serotonin, calcitonin, or gastrin; enzyme systems and certain endocrine functions can
be altered; impairment of immunologic functions

5. Sensory changes
-alterations in tastes and smell which contribute to anorexia; heightened sense of smell that results
in sensitivity to food preparation odors; elevated recognition of threshold for sweet, sour, and salty;
lowered threshold for bitter, associated with meat aversion

VIII. Side effects of treatment and common problems of cancer
1. Loss of teeth makes the patients mouth more sensitive to cold, heat, and sweets. Food should be served
at room temperature.
2. Xerostomia, dry mouth from atrophy of mucous membranes, causes difficulty in eating and swallowing Use
saliva substitutes, lip balm. sugarless gum and candies, gravies and sauces. Increase fluid and use
softened, moist foods (custard, stews, and soups). Sip beverages with each bite of food. Cut food into small
pieces. Ice chips and popsicles also can help. Pureed or baby foods often are useful.
3. For the patient with poor dentition and caries, avoid sweets and use sodium fluoride three times daily.
Mouth care should be provided several times daily.
4. Thick saliva can produce more caries. Use less bread, milk, gelatin, and oily foods. Blenderized food such
as fruits and vegetables.
5. Sore mouth and throat (stomatitis, mucositis, or esophagitis) result from local bleeding and lesions. Paon
and inflammation are common. Modify the texture and consistency of the foods as needed. Use a bland
diet with fewer spices and seasonings in the food. Have the patient rinse mouth with water and NaHCO3.
Avoid acidic juices, salty foods or soups, and grainy breads and cereals. Grind meats, Use the mechanical
soft diet as needed. Offer fluids frequently and by straw cold or tepid. Popsicles and cold liquid foods
may help. Smaller meals are useful. Have the patient swish lidocaine in his mouth before meals; some
changes in taste or enjoyment of foods may result.
6. Mouth blindness (dysgeusia) is defines as disinterest and aversion to foods. Emphasize the arome and
colors of foods. Provide a variety of foods and use garnishes. Acidic foods may help stimulate the patients
ability to taste foods. Use highly flavored foods and sauces. Try milk shakes that are coffee and mint
flavored. Fresh vegetables, special breads, highly flavored snacks, olives, and pickles may be well received
by the patient. Add sauces to meats.
7. Anorexia may be caused by mental depression, medications, GI distress, altered sensory experiences, or
tumors. The condition leads to cachexia. Anorexia cachexia syndrome (ACS) is caused by numerous
factors; altered glucose metabolism may be one of them. Use small frequent feedings and supplements.
Teach ways to increase calories and protein. Fortify foods when possible. Relieve symptoms before meals
whenever possible.
8. Weight loss can be treated by adding fats to foods, dry milk to mashed potatoes and shakes, and extra
sugar to coffee and cereals. Use small, frequent feedings and the patients favorite foods. Use 40 to 50
kcal/kg for repletion. Add cream sauces, extra meat or cheeses in casseroles and gravies.
9. To treat diarrhea, alter fiber in the diet. Beware of lactose intolerance secondary to disease process or
drug/radiation therapies. Decrease fatty foods; increase fluids and potassium. Use cold or room
temperature foods. Evaluate all medications carefully.
10. Constipation requires fiber and fluids to be added to the diet. Milk may also be beneficial if tolerated. Fruits,
vegetables, and bran may help
11. Aversion to tastes.

IX. Nutritional Effects of Cancer Therapy
1. Chemotherapy
a. Mucositis, cheilosis, glossitis, stomatitis, esophagitis inhibits food intake
b. Nausea and vomiting
c. Taste abnormalities
d. Anorexia and oligophagy (eating a few foods)
e. Diarrhea or constipation or a dynamic ileus (malabsorption for GI toxicity)
f. Corticosteroids cause tissue breakdown, excessive losses of urinary protein, K, and Ca
g. Altered digestion and absorption and metabolism of protein, energy, and vitamins
h. Depressed immune function
2. Radiation therapy
a. Head and neck sore throat, mucositis; xerostomia; severe dental and gum destruction; altered
taste and smell; anorexia and weight loss are major problems
b. Thorax esophagitis with dysphagia; esophageal stricture with obstruction
c. Abdomen and pelvis acute gastritis or enteritis; nausea; vomiting; diarrhea and anorexia; severe
GI damage; malabsorption of disaccharides, fats and electrolytes
d. Depressed immune function

3. Surgery
a. Head and neck impaired digestion; temporary or permanent dependence on tube feeding;
b. Esophagus partial or total ablation of the esophagus
c. Gastrectomy decreased stomach capacity; early satiety; reduced gastric secretion; impaired
absorption of Vitamin B12, and iron; steatorrhea and diarrhea; dumping syndrome
d. Pancreatic resection altered insulin secretion; malabsorption
e. Colectomy (partial or total) fluid and electrolyte losses; bile salt losses; decreased vitamin B12

4. Immunotherapy monoclonal antibodies with lymphoma; GI cancer and neuroblastoma; alpha-interferon
hairy cell leukemia; interleukin-2 (IL-2) with melanoma and renal cell carcinoma; cytokine with neutropina

5. Marrow transplant for the treatment of leukemia, lymphoma and some solid tumors

X. Nutritional Care
In general, (1) to prevent or correct nutritional deficiencies and (2) to minimize weight loss

1. Overcome the side effects of treatment. Diminish the toxicity of treatment. Coordinate the total care plan
with doctor, nurse, patient, family, etc.
2. Correct cachexia from weakness, anorexia, redistribution of host nutrients, and nutritional depletion. Control
the cancer and complications, such as anemia or multiple organ dysfunction.
3. Prevent weight loss from increased basal metabolic rate (usual increase is 15%). Some patients are
hypometabolic; others hypermetabolic by 10-30% above normal rates. Greatest losses occur from protein
stores and body fat. Early nutritional status is a good prognostic indicator.
4. Prevent further depletion of humoral and cellular immunity from malnutrition
5. Prevent infection or sepsis, further morbidity, or death from starvation or infections
6. Provide appropriate micronutrients
7. Control glucose intolerance (NIDDM is common)
8. Control GI symptoms, which are common with weigh loss greater than 10%.
9. For some, synthetic retinoids are being used to prevent recurrence after surgery. Further studies are

Dietary and Nutritional Recommendations
1. In general, intake of protein should be high (1-1.5 g/kg body weight to maintain; 1.5 to 2g/kg body weight to
replete losses). Intake of calories should be high (25 to 25 kcal/kg body weight to maintain; 30-35 kcal/kg
body weight to replete body stores). Add calories if the patient is febrile or septic. Fat should be 30 to 50%
nonprotein calories.
2. Schedule a large meal earlier in the day. If needed, schedule five to six small meals daily, tube feeding or
intravenous feeding. If the gut works, use it.
3. Use TPN with weight loss of more than 20% and with a good prognosis. PN is not likely to benefit
advanced cancer that is unresponsive to treatment. Routine TPN therapy should not be used with
chemotherapy because of the risks from sepsis.
4. Provide adequate but no excessive micronutrient supplementation; vitamin B6, pantothenic acid, folic acid,
vitamins A, E and C. Use more foods high in beta-carotene; include foods such as fruits and vegetables in
appropriate forms. Do not use excesses of iron but correct anemias when possible.
5. Nutritional treatment for specific cancers. Alter diet therapy as needed; each persons needs vary before
and after treatments and various therapies
6. For patients who are unable to discuss their wishes, force feed only if the tumor is treatable. Review each
case individually and honor the patients wishes.
7. Leucine and methionine may be needed. Increases in BCAAs have been suggested; data are not
8. After surgery or abdominal radiation; glutamine may be useful to protect from enteropathy, to lower
morbidity, to augment tumor cell kill, and to boost natural killer cell (NK) activity
9. Control simple sugar with CHO tolerance

Additional Dietary Recommendations
1. History weight changes, food preferences and eating habits, current food intake (kilocalories and protein), food
intolerances, taste abnormalities, meal distribution throughout the day, who does the cooking, whether patient eats
alone, nutritional side effects of past or current treatment
2. Appetite stimulants for patients suffering from anorexia/cachexia
3. Antiemetic drugs for nausea; to be given 30 to 60 minutes before meals
4. Multiple vitamin and mineral supplement
5. Food should be the major dietary source. If necessary, supplementation may be given (high kilocalorie, high protein
6. If oral feeding fails or impossible, consider alternative feeding methods such as tube feeding or TPN

Dietary Guidelines to Reduce Cancer Risks
1. Increase consumption of leafy green and yellow vegetables, fruits and unrefined cereals
2. Eat fat and fatty foods in moderation
3. Limit consumption of smoked, charcoal-broiled, salt-cured and salt-pickled foods
-benzopyrene is a carcinogen formed when meat is barbecued, grilled, or charcoal-broiled
4. Avoid moldy foods
-moldy cassvam yam, sweet potato, peanut, corn, rice and rice product have been found to contain high aflatoxin
5. Drink alcoholic beverages in moderation and stop smoking
-moderate alcohol consumption means an intake of not more than 2 equivalents of alcohol once or twice a week