Esophageal Cancer Treated with Surgery and Radiation Kimberly

Esophageal Cancer Treated with Surgery and Radiation Kimberly Morris Stevie Arroyo

Esophageal Cancer that forms in tissues lining the esophagus, two main types: Squamous cell carcinoma cancer that begins in flat cells lining the esophagus Adenocarcinoma - cancer that begins in cells that make and release mucus and other fluids

Incidence/Prevalence Incidence: 4. 6 per 100, 000 men and women diagnosed per year (2001 -2005) Prevalence : Estimated new cases in 2008: New cases: 16, 470 (12, 970 men and 3, 500 women) Deaths: 14, 280 (http: //seer. cancer. gov/statfacts/html/esoph. html)

Signs/symptoms Dysphagia (difficulty swallowing ) Unintentional weight loss Pain in the throat , mid-chest area Hoarseness, hiccups vomiting of blood Diagnosis Barium swallow → Endoscopy Biopsy

The following stages are used for diagnosis of esophageal cancer:

Risk Factors Age 65 or older Being male Smoking Heavy drinking Diet Obesity Acid reflux Abnormal cells in the esophagus

Treatment When esophageal cancer is found very early, there is a better chance of recovery. At later stages, esophageal cancer can be treated but rarely can be cured. Esophageal cancer is generally treated with surgery to remove the cancer Treatment often includes minimizes discomfort caused by GERD and dysphagia. (www. cancer. gov)

Treatment Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling. (Nguyen N. , et. al. , 2005) Treatment varies depending on severity but dietary modification is a key component

Treatment In 2002 the ADA established a national dysphagia diet with four different levels of treatment: NDD Level 1: Pureed - homogenous, very cohesive, pudding-like, requiring very little chewing ability. NDD Level 2: Mechanical Altered - cohesive, moist, semisolid foods, requiring some chewing. NDD Level 3: Advanced - soft foods that require more chewing ability. Regular - all foods allowed.

Treatment Nutritional factors are believed to aggravate acidic reflux either by delaying gastric emptying or diminishing pressure of the LES (Holtmann G. 2007) Decrease gastric discomfort by eating smaller meals with fluid in between Avoid foods and activities that cause discomfort and irritation (smoking, alcohol, spicy and acidic foods)

Treatment Surgery is usually paired with radiation therapy for optimal results. Results for radiotherapy studies showed a 13% absolute improvement in survival at two years (Gebski V, et. al. 2007) Typical side effects or radiation therapy include: Trouble swallowing heartburn fatigue loss of appetite

Treatment - MNT Radiation Try to eat something at least 60 minutes before treatment. Bring snacks or nutrition supplements with you on the ride to and from treatment Eat small frequent meals with fluids Be sure to drink plenty of water and other liquids Ask friends and family members to help by shopping for groceries and preparing meals.

Nick Seyer Age: 58 Sex: Male Occupation: Contractor Ethnic Background: Caucasian

Assessment - Medical History Drugs: TUMS, Alka-Seltzer, Pepcid consistently for past year Noted 30 Ib weight loss in last several months Patient is a smoker and regular drinker Family History: Mother had liver cancer, passed at age 58

Assessment - Medical History Chief complaints: Significant heartburn for previous year Patient has recurrent cough at night Unable to eat due to heartburn pain, has difficulty swallowing foods with texture Onset of disease: Dysphasia x 3 -4 months, odynophagia x 5 -6 months

Assessment - Medications/Drug Interactions Tums- treats upset stomach, vomiting heartburn, and indigestion Side effects: Constipation and gas Drug interactions: may decrease absorption of drugs like tetracycline antibiotics and biphosphates. Do not use if you have stomach/intestinal blockage, hypocalcaemia (www. Web. MD. com)

Assessment - Medications/Drug Interactions Alka-Seltzer- Used to treat indigestion and low calcium in blood Side effects: taste problems, incomplete or infrequent bowel movements. Drug interactions: phosphate supplements/antacid use can cause less absorption of phosphates, low phosphate levels in body (www. Web. MD. com)

Assessment - Medications/Drug Interactions Pepcid- helps relieve heartburn and acid indigestion Side effects- persistent nausea, vomiting, stomach and abdominal pains Drug interactions- Aspirin/NSAIDS can cause stomach irritation/ulcers. Do not take similar acid blockers at the same time. Consult doctor of other medication uses (www. Web. MD. com)

Assessment – Anthropometrics Ht: 75” BMI: 24. 7 Wt: 198 UBW: 230 IBW: 196 %IBW: 101% normal %UBW: 86% mildly depleted energy stores

Assessment – Physical Exam Temperature: 98. 3° F Blood Pressure: 132/92 mm Hg Heart Rate: 88 bpm Resting Rate: 13 bpm Nose/throat: dry mucus membranes

Assessment - Lab Values NORMAL Albumin 3. 1 L 3. 5 -5 Total Protein 5. 7 L 6 -8 Pre-albumin 15 L 16 -35 WBC 5. 2 4. 8 -11. 8 RBC 4. 2 L 4. 5 -6. 2 (men) HGB 13. 5 L 14 -17 (men) HCT 38 L 40 -54 (men)

Assessment – Medical Diagnosis Doctor required patient to undergo chest x-ray, endoscopy, biopsy, and CT scan Doctor diagnosed patient with stage IIB adenocarcinoma of the esophagus Patient underwent a trans-hiatal esophagectomy and received pre and postoperative external beam radiation therapy During surgery patient was given a jejunal tube feed and prescribed Isosource HN 1. 5 kcal at 75 ml/hr x 24 hrs

Assessment – Nutrition Needs Energy needs: BEE 66. 5 + (13. 8 x 198/2. 2) + (5 x (75 x 2. 54)) – (6. 8 x 58) = 1866. 6 x 1. 2 (bed rest) x 1. 2 (surgery) = 2687. 9 kcal/d Kcals from Isosource HN 1. 5 75 x 24= 1800 ml/d 1. 5 kcal x 1800 ml/d= 2700 kcal Protein needs: 198 lb / 2. 2 kg/lb = 90 kg x 1. 0 g/kg/d = 90 g/d

Assessment – Nutrition History USUAL DIETARY INTAKE AM Used to eat eggs, bacon and toast every morning but has not eaten this for at least a month. Recently has had just coffee and cereal LUNCH Previously ate cold packed lunch; sandwich, cold meat or other leftovers, fruit, cookies, and tea DINNER All meats, pasta or rice, 2 -3 vegetables, 1 -2 beers SNACKS Ice cream, popcorn, or homemade dessert

Assessment – Nutrition History 24 HOUR RECALL AM 1 packet of instant oatmeal; sips of coffee LUNCH 6 oz. tomato soup with 2 -4 crackers DINNER Macaroni and cheese – homemade ½ cup SNACKS 1 scoop of chocolate ice cream

Diagnosis – PES Statement Inadequate oral food/beverage intake (NI- 2. 1) related to patients pre-surgical esophageal discomfort, and current tube feed placement as evidence by depleted protein stores and reported weight loss of 30 pounds over several months

Intervention – Goals Short term Ensure patient is tolerating advancement to soft diet prior to discharge Education patient on diet changes he can make to minimize discomfort of eating Long term Goal for patient is to maintain healthy body weight through proper nutrition

Intervention – Diet Order Recommendations After clearance by physician and speech pathologist; Discontinue enteral or parenteral nutrition (ND-2) If patient tolerates jejunal tube feeding (5 -7 days post-surgery) start on clear liquid diet and advance diet as tolerated : mechanical soft to soft. (Mackenzie, et. al. , 2005)

Intervention – Diet Order Recommendations Fruits Soft, canned or fresh fruit with pits and skin removed. Applesauce, bananas, peaches, melons (no seeds). Fruit juices. Avoid crisp or stringy fruits such as green apples and rhubarb. Vegetables Soft, cooked vegetables with seeds and skin removed Vegetable juice Avoid raw, tough, or stringy vegetables http: //www. bmc. org/thoraciconcology/pdf/esophogealsurgery. pdf

Intervention – Diet Order Recommendations Meat & Alternatives Minced or ground meat Soups prepared with soft foods Cooked eggs, omelets Soft cheeses Tofu Avoid overcooked or dry and stringy meats. Dairy & Misc. Yogurt Ice cream Pudding Whole milk Nutrition Supplements such as ensure or carnation instant breakfast http: //www. bmc. org/thoraciconcology/pdf/esophogealsurgery. pdf

Intervention – Education Nutrition education including textured modified, high protein/energy diet and/or managing nausea/vomiting and fluid intake (Odelli C, et. al. , 2005) Education should include: Use of Protein supplements, high-energy foods, and a soft dysphasia diet Sit upright, chew slowly, and eat more than 3 hours before bedtime

Intervention – Education cont. 6 to 8 small frequent meals each day Avoid foods that cause discomfort for example very hot or cold beverages and spicy foods Avoid alcohol and smoking Educate wife on cooking techniques and food selection

Monitoring and Evaluation While patient is still in the hospital monitor weight and food intakes Check labs every 3 days, ordered by physician Once patient is discharged provide handouts and resources on nutrition Patient may need additional nutrition counseling in the future; if he is having trouble eating he should ask to be referred to a RD

References “Cancer of the Esophagus Risk Factors. ” National Cancer Institute. 01 Apr. 2009 <http: //www. cancer. gov/cancertopics/wyntk/esophagus /page 5 >. “ Diagnosis of Esophageal Cancer. ” National Cancer Institute. 01 Apr 2009 < http: //www. cancer. gov/cancertopics/wyntk/esophagus/ page 7>. “Drugs & Medication- Alka-Seltzer Antacid Oral. ” Web. MD. 2005 -2009. 01 Apr 2009 < http: //www. webmd. com/drugs/drug-13879 -Alka Seltzer+Antacid+Oral. aspx? drugid=13879&drugname=Alka. Seltzer+Antacid+Oral>. “Drugs & Medication- Pepcid AC Oral. Web. MD. 2005 -2009. 01 Apr 2009 < http: //www. webmd. com/drugs/mono-250 -FAMOTIDINE+10+MG++ORAL. aspx? drugid=16241&drugname=Pepcid+AC+Oral>. “Drugs & Medication- Tums Oral. ” Web. MD. 2005 -2009. 01 Apr 2009 <http: //www. webmd. com/drugs/mono-2123 -CALCIUM+CARBONATE +ANTACID+-+ORAL. aspx? drugid=9574&drugname=Tums+Oral

References “Esophageal Cancer. ” Mayo Clinic Online. 11 May 2007. 01 Apr. 2009 < http: //www. mayoclinic. com/print/esophageal-cancer/DS 00500 /METHOD=print&DSECTION=all>. “SEER Stat Fact Sheet- Cancer of the Esophagus. ” National Cancer Institute. 01 Apr. 2009 <http: //seer. cancer. gov/statfacts/html/esoph. html>. Shaleen, Nicholas and David Ransohoff. “Gastroesophageal Reflux, Baretts Esophagus, and Esophageal Cancer. “ Journal of the American Medical Association. 2002; 287: 1972 -1981 “Radiation Therapy. ” American Cancer Society. 13 Apr. 2009 http: //www. cancer. org/docroot/MBC/content/MBC_6_2 X_When_You_Have_Radi ation_Therapy. asp? sitearea=MBC Holtmann, G. GERD: How to Have a Better Day. Journal of Clinical Gastroenterology. July 2007; 41: 204 -208.

References Odelli C, Burgess D, Bateman L, Hughes A, Ackland S, Gillies J, Collins CE. Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in esophageal cancer. Journal of Clinical Oncology. 2005; 17: 639 -645. Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J; Australasian Gastro-Intestinal Trials Group. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in esophageal carcinoma: a meta-analysis. Lancet Oncol. 2007 Mar; 8(3): 226 -34 Nguyen N. , Moltz F. , Vos C. , Smith P. , Karlsson H. , Dutta U. , Midyett S. , Barloon A. , Sallah J. , Sabah F. Impact of dysphagia on quality of life after treatment of head-and-neck cancer. International Journal of Radiation Oncology, Biology, Physics; Mar 2005, Vol. 61 Issue 3, p 772 -778, 7 p