NonHodgkins Lymphoma LAUREN BOUTWELL MS RD LDN MING

Non-Hodgkin’s Lymphoma LAUREN BOUTWELL MS, RD, LDN MING CHEUNG MS, RD, LDN

Agenda • • Lymphoma Overview - L Nutritional Changes due to Lymphoma - M Treatment Options - L Case Study - M Nutrition Therapy General - L Nutrition Therapy Case Study - M Questions Conclusion - M

Objectives ▪Understand basic information about cancer and lymphoma ▪Learn about the different treatments for cancer ▪Understand the nutritional impact of cancer and cancer treatment ▪Understand the RD’s role in treatment ▪Understand the nutritional needs of cancer patients

Lymphoma o. Cancer of the lymph cells (lymphatic system), which is the body’s disease fighting network o. Systemic o. The lymphatic system includes blood, spleen, thymus gland, and bone marrow o. Lymphocytes act abnormally by either dividing faster than normal or living longer than usual

Types of Lymphoma ▪There are several types of lymphomas, classified by origin ▪Two main groups: ◦ Hodgkin’s lymphoma is characterized by the presence of Reed-Sternberg cells 2 ◦ Non-Hodgkin’s lymphoma is classified by the absence of Reed-Sternberg cells 3 ▪Non-Hodgkin’s lymphoma more common ◦ Tumor develops from lymphocytes 3 ◦ The most common sub-type of non-Hodgkin’s lymphoma is diffuse large B-cell lymphoma 3 ▪Classification of the type of lymphoma is important because it can affect treatment and prognosis

Symptoms of Lymphoma Common symptoms include: ▪ Swollen lymph nodes in the neck, armpits or groin ▪ Abdominal pain or swelling ▪ Chest pain, coughing or trouble breathing ▪ Fatigue ▪ Fever ▪ Night sweats ▪ Weight loss (usually unexplained weight loss and as much as 10% or more of their body weight) ▪ Loss of appetite

Lymphoma Staging Stage Definition (N = Non-Hodgkins, H = Hodgkins) 0 • Cancer is confined to site of origin, no spread I • Lymphoma in only 1 lymph node area or lymphoid organ • Or lymphoma found in only 1 area of a single organ outside the lymph system II • Lymphoma in 2+ groups of lymph nodes on the same side of diaphragm • Lymphoma extends from a single group of lymph node(s) into nearby organ III • The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm • The cancer may also have spread into an area or organ next to the lymph nodes, into the spleen, or both IV • The lymphoma has spread outside lymph system into organ not next to involved node • The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin lining of the lungs).

Nutritional Changes Due to Lymphoma

General §Fevers §Fatigue §Anorexia §Anemia §Changes in taste §Cancer cachexia §Biological Alterations

Cancer Cachexia Characterized by: § Involuntary weight loss § Tissue wasting § Inability to perform daily activities § Metabolic alterations §AA are not spared as in simple starvation §Muscle wasting: § increased protein breakdown (hypercatabolism) § decreased protein synthesis § Occurrence of both results in intense muscular atrophy §Changes in taste and smell perception plays an important role in the severity

Biological Changes in Malignancy ▪Carbohydrate abnormalities §Alterations in lipid metabolism 5 ▪ Insulin resistance § Increased lipid metabolism ▪ Increased glucose synthesis § Decreased lipogenesis ▪ Gluconeogenesis § Decreased activity of lipoprotein lipase (LPL) ▪ Increased Cori cycle activity ▪ Decreased glucose tolerance and turnover § Lipid-mobilizing factor (LMF) produced by tumor or host tissue

Lymphoma Treatment Options

Chemotherapy o. Systemic treatment o. Powerful chemicals to kill fast-growing/rapidly dividing cells o. Chemotherapeutic agents travels throughout the body to reach cancer cells o. Cannot differentiate between normal reproducing cells and cancer cells o. Interrupts cell DNA, RNA or protein synthesis of the cell cycle o. Different chemo agents interrupt cell proliferation at different stages o Combination therapy is common - enhance the effectiveness & minimize overall toxicity o. Normal cells are damaged as well as the cancer cells

Radiation Therapy § Localized treatment used to shrink tumors, kill cancer cells and prevent their growth § X-rays, gamma rays, and charged particles most common types § External-beam radiation therapy - delivered by a machine § Brachytherapy - radioactive material placed near cancer cells § Systemic radiation therapy - radioactive substances (i. e. radioactive iodine) travel in blood § Often used in conjunction with otherapies

Other Options § Surgery § Biological Therapy § Bone Marrow Transplant

Case Study: Lymphoma

Patient Introduction ▪Denise Mitchell (DM) ▪ DOB: 2/18 ▪ 21 yowf ▪ College student ▪ Religion: Methodist ▪Adm for evaluation of viral illness ▪ Experienced night sweats, fevers, and weight loss ▪CXR indicates a possible mass

Physical Exam ▪General appearance: thin, pale, appears tired ▪Vitals ▪ T: 100. 5°F, RR: 18 bpm, B/P: 95/70 mm Hg, HR: 85 bpm ▪HEENT: ▪ Head: Normocephalic ▪ Eyes: EOMI; wears glasses for myopia; fundi grossly normal bilaterally ▪ Ears: Tympanic membranes normal ▪ Nose: Dry mucous membranes without lesion ▪ Throat: Slightly dry mucous membranes without exudates or lesions; abnormal lymph nodes

Physical Exam cont. ▪Extremities: Normal muscular tone with normal ROM, nontender ▪Skin: warm and dry without lesions ▪Chest/lungs: Respirations are shallow; dullness present to percussion ▪WNL: Genitalia, Heart, Neurological tests, Abdomen, Peripheral vasculature ▪CC/HPI: “I don’t seem to have ever gotten over the flu that I had several weeks ago. I still have a fever sometimes, and the cough won’t go away. ”

Patient History §NKA §Previous Hospitalization: Tonsillectomy – age 5 §Medication: § Dimetapp, OTC (2 tsp, occ) § Tylenol, OTC (400 mg, occ) §Cold in past two weeks §Non-smoker §FH: (non-contributory)

Anthropometrics ▪Ht: 5’ 6” ▪Wt: 120 lbs ▪UBW: 130 lbs ▪%UBW: 92. 31% ▪BMI: 19. 34 – normal range ▪% unintentional wt loss: 7. 69% over the last 2 -3 months, significant loss

Nutritional Hx §General § Appetite decreased § No N/V, constipation, or diarrhea § Food allergies/intolerances/aversions: NKA § Previous nutrition therapy: None § Vitamin/mineral intake: None § Food purchase/prep: Self, parents, college cafeteria §Usual dietary intake § AM: Cold cereal, toast or doughnut, skim milk, juice § Lunch: (in college cafeteria) sandwich or salad, frozen yogurt, chips or pretzels, soda § PM: Meat (eats only chicken and fish), 1 -2 vegetables including a salad, iced tea, or skim milk § Snack: Popcorn, occasionally pizza, soda, juice, iced tea

24 -Hour Recall

Diagnosis and Treatment Plan ▪Dx: ▪ Chest CT, MRI, and bone marrow and lymph node biopsy ▪ Stage II diffuse large B-cell lymphoma w/ mediastinal disease and positive lymph node involvement ▪ Bone marrow and other organs show no indication of disease §Tx plan: § Chemotherapy – cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) § Prednisone administered orally on first 5 days of each 21 -day cycle § Other chemotherapeutic meds given intravenously on first day of cycle § Radiotherapy planned to begin 3 wks after third cycle of CHOP • Discharged for outpatient therapy on hospital day 5

What Symptoms is Denise Experiencing? §Night sweats §Fevers §Loss of appetite §Unexplained weight loss §Coughing §Fatigue/lack of energy §Abnormal lymph nodes

CHOP & What To Expect Cyclophosphamide Doxorubicin N/V, diarrhea, fatigue, loss of appetite, sores in mouth or on lips, dry mouth and sore throat N/V; loss of appetite; sore in mouth or on lips; dry mouth; sores or ulcerations in the throat, esophagus, or colon (Hydroxydaunomycin) Vincristine (Oncovin) Prednisone N/V, diarrhea, constipation, fatigue, loss of appetite, mouth sores Increased appetite, upset stomach, weight gain, loss of calcium from bones, dry mouth and sore throat

Nutritionally Related Labs Lab Measure Normal Range MD Albumin 3. 5 – 5 3. 3 L Total Protein 6– 8 5. 5 L WBC 4. 8 – 11. 8 12. 0 H HGB 12 – 15 (women) 11 L HCT 37 – 47 (women) 31 L MCV 80 – 96 70 L Retic 0. 8 – 2. 8 2. 9 H Ferritin 20 – 120 (women) 19 L

Nutrition Diagnosis ▪ Malnutrition ▪ Altered nutrition related laboratory values (albumin) ▪ Unintended weight loss (involuntary weight loss) ▪ Inadequate oral food/beverage intake ▪ Increased energy expenditure ▪ Inadequate energy intake ▪ Hypermetabolism (Increased nutrient needs)

Nutrition Therapy

Nutritional Goals for Lymphoma ▪Prevent or reverse poor nutrition ▪Manage symptoms ▪Maintain or improve weight and strength ▪Maximize quality of life

Dietary and Weight Changes after Treatments for Lymphoma Russell NC, et al. Nutrition and Cancer. 2007; 57(2): 168– 176 o. Retrospective/cross-sectional study o. Focused on current BMI o. Post-treatment therapy longer than other cancers o. No association b/w BMI and recurrence/death o. Challenging to detect diet and BMI associations - many complications o. Dietary counseling important - choosing foods that alleviate symptoms o. Encouraging healthy choices can lead to weight gain

Keys to Nutritional Therapy ▪Careful screening & assessment ▪Symptoms/side-effects vary with pt ▪Individualization (Plan & Recommendations) ◦ Severity of malabsorption, ◦ Increase/decrease protein synthesis ◦ Lipid metabolism changes ◦ Appetite changes ▪Some pts do not need additional calories ▪Wt gain during/after treatment associated with worse outcome & higher relapse rates

Nutrition Therapy: General Side Effects Side Effect Nutrition Therapy N/V small, low-fat meals, avoid fried/greasy foods, electrolytefortified beverages to maintain hydration Early satiety small nutrient-dense meal frequently, nutrient beverages b/w meals, avoid consumption of high-fiber foods Dehydration drink adequate fluids throughout day, consume fluidcontaining foods (i. e. soup), limit caffeine products Xerostomia artificial saliva or mouth moisturizers/lubricants, sugar-free gum, sour-flavored sugar-free hard candies

Nutrition Therapy: Chemotherapy Side Effects Side Effect Nutrition Therapy Neutropenia avoid raw vegetables, fruits, meat, fish, eggs, avoid salad bars & deli counters, consume only pasteurized dairy, drink tap/well water Anemia increase iron consumption w/ Vit C, add iron-rich foods to diet, supplementation Diarrhea drink small amounts clear fluid throughout the day, avoid high-sugar beverages, simple-sugars, alcohol, caffeine, avoid gas-producing foods, add foods with soluble fiber Mucositis eat soft, non-fibrous non-acidic foods, avoid hot foods, drink plenty of liquids, high-calorie/high-protein shakes and supplements may help

Radiation Side Effects Side Effect Nutrition Therapy Radiation enteritis -avoid dairy products, raw veggies, fried foods, nuts/seeds, caffeine, strong spices, fresh fruit -encourage consumption of cooked/broiled fish, poultry, meat, applesauce, white bread, mashed potatoes, mild veggies -ingest foods at room temp -low residue diet may be recommended Delayed wound healing increase consumption Vit A, E, C, increase zinc and iron consumption, ensure adequate fluid, protein, and fat intake Dysgeusia -avoid metal utensils, drink from glass instead of metal container ensure adequate protein intake if meat not tolerated -try highly spiced/flavorful food

Radiation Side Effects Cont. Side Effect Nutrition Therapy Dysphagia -specific food consistencies using thickening agents (depending on ability to swallow -enteral nutrition may be needed Odynophagia -avoid hot, rough, acidic, and/or spicy foods -suck on ice or consume cold beverages -try soft or pureed diet Esophagitis -sit upright when eating -eat slowly -eat small frequent meals -avoid spicy, acidic foods -avoid alcohol and tobacco

DM’s Nutritional Needs

Energy Requirement ▪Formula for patients who need to gain weight, are anabolic, or slightly hypermetabolic: ▪ 30 – 35 kcal/kg 5 ▪Her energy needs is between 1, 637 kcal and 1, 909 kcal ▪Since she has unintentional weight loss, her energy requirement to be closer to 1, 909 kcal

Protein o. DM does not appear to be very stressed o. Protein guidelines: • • Non-stressed cancer patient: 1. 0 – 1. 5 g/kg 5 Her protein needs would be between 54. 55 g and 81. 83 g o. Experiencing some unintentional weight loss o. PE indicates that she looks thin o. Her protein needs would be closer to 1. 5 g/kg to help her increase her energy intake and prevent protein losses due to cancer o. Her protein need is approximately 76 – 82 g (1. 4 g/kg and 1. 5 g/kg).

Fluid Needs § 35 m. L/kg (night sweats & diarrhea) § 35 m. L/kg x 54. 5 kg = 1, 907 m. L §Approximately 1. 9 - 2 Liters of fluids per day

DM’s Nutrition Plan Calculated Goal/Recs § 1, 900 Kcal/d § 82 gms Protein/d § 2 L fluids/d Recommendations Symptoms § Diarrhea § Early satiety § Esophagitis oconsume mild/non-acidic foods oeat small, frequent meals throughout the day oconsume nutrient-dense beverages/shakes otry to consume balanced diet, but primarily whatever is tolerated to meet needs

Supplements §No definitive data §No regulation of herbal supplements § Contaminants - harmful with depressed immune status § High doses of antioxidants can actually work against the action of chemo thereby decreasing efficacy §Individual basis

Questions and Concerns from Family §Family has been asking questions about different diets. . . § Family support is great § Encourage questions § Don’t judge!

Reputable Sources for Information o Lots of recommendations for alternative treatments for lymphoma o Not all researched based Good Sources of Information § Dana Farber’s (www. danafarber. org/nutrition) § National Cancer Institute (www. cancer. gov) § American Cancer Society (www. cancer. org) § National Institute of Health (www. nih. gov) § Massachusetts General Hospital Cancer Center (www. massgeneral. org/cancer/) § The Leukemia and Lymphoma Society (www. lls. org)

Follow-Up/Evaluation §Food journal (what, where, when, and how much; also mood and symptoms she was experiencing) §Weight measured and recorded every day (preferably at the same time everyday), assess compliance and identify any necessary modifications to plan §This may be too much while she is not feeling well and undergoing chemo §I/O, prealbumin, CRP, hospital generated calorie count if she's not feeling well enough to manage it

Nutrition Education §Proper record keeping (food journal) §Soluble fiber for diarrhea §Symptoms §Common food and drug interactions §Importance of obtaining adequate energy and nutrient intake during the treatment §List of foods and recommendations for common symptoms §Meal replacements §Mouth care §All the instructional material should be given before the symptoms occur 21. §Low microbial diet §Review safe food handling & clean technique (Dining In/Out)

Sensitivity o Understand this is a stressful time o Education is important o Be careful to not overwhelm o Be sensitive to patient needs

Questions o. Is it recommended that all cancer patients consume more calories? o. Is too much weight gain bad? o. What if the pt refuses to eat? o. What about conflicting advice?

Conclusion §Nutritional care is important in conjunction medical treatment §Good nutrition can lead to better outcome & tolerance of cancer treatment §There are metabolic changes that can occur with lymphoma §Goal is to prevent malnutrition, treat symptoms, and improve QOL §RDs can make a big difference

How is DM doing Today? ▪Chemotherapy went well ▪Complete remission ▪Feeling a lot better and gained some weight back ▪Finishing up undergraduate degree ▪Impressed and inspired by the difference RDs make in medical treatment, she plans to pursue a degree in Nutrition (MS/DPD + DI)

References 1. Lymphoma facts, 2013. Mayo Clinic website. http: //www. mayoclinic. org/lymphoma/. Updated July 13, 2013. Accessed September 20, 2013. 2. Hodgkin’s Lymphoma facts, 2013. Mayo Clinic website. http: //www. mayoclinic. com/health/hodgkins-disease/DS 00186. Updated July 9, 2011. Accessed September 20, 2013. Non-Hodgkin’s Lymphoma facts, 2013. Mayo Clinic website. http: //www. mayoclinic. com/health/non-hodgkins-lymphoma/DS 00350. Updated July 26, 2013. Accessed September 20, 2013. 4. Non-Hodgkin’s Lymphoma symptoms, 2013. Mayo Clinic website. http: //www. mayoclinic. com/health/non-hodgkins-lymphoma/DS 00350/DSECTION=symptoms. Updated July 26, 2013. Accessed September 20, 2013. 5. Nelms M, Sucher KP, Lacey K, and Roth SL. Nutrition Therapy and Pathophysiology. 2 nd ed. Belmont (CA): Wadsworth, Cengage Learning; 2011. Pg 708 6. Tumor staging, 2013. National Cancer Institute website. http: //www. cancer. gov/cancertopics/factsheet/detection/staging. Updated May 03, 2013. Accessed September 20, 2013. 7. Chemotherapy facts, 2013. Mayo Clinic website. http: //www. mayoclinic. com/health/chemotherapy/MY 00536. Updated July 13, 2013. Accessed September 20, 2013. 8. Cancer treatment facts, 2013. American Cancer Society website. http: //www. cancer. org/treatmentsandsideeffects/index. Updated 2013. Accessed September 20, 2013. 9. American Cancer Society chemotherapy facts, 2013. American Cancer Society website. http: //www. cancer. org/acs/groups/cid/documents/webcontent/003025 -pdf. Updated 2013. Accessed September 20, 2013. 10. Radiation therapy facts, 2013. National Cancer Institute website. http: //www. cancer. gov/cancertopics/factsheet/Therapy/radiation. Updated June 06, 2010. Accessed September 21, 2013. 11. Biological treatment for cancer facts, 2013. American Cancer Society website. http: //www. cancer. org/cancer/waldenstrommacroglobulinemia/detailedguide/waldenstrom-macroglobulinemia-treating-biologicaltherapy-immunotherapy. Updated 2013. Accessed September 21, 2013.

References cont 12. Bone marrow transplant for cancer facts, 2013. American Cancer Society website. http: //www. cancer. org/cancer/non-hodgkinlymphoma/overviewguide/non-hodgkin-lymphoma-overview-treating-bonemarrow-stem-cell-transplant. Updated 2013. Accessed September 21, 2013. Cancer nutrition facts, 2013. National Cancer Institute website. http: //www. cancer. gov/cancertopics/pdq/supportivecare/nutrition/Patient/page 1. Updated August 15, 2013. Accessed September 21, 2013. 14. Khor SM and Mohd BB. Assessing the Resting Energy Expenditure of Cancer Patients in the Penang General Hospital. Malaysian Journal of Nutrition 17(1): 43 – 53, 2011. 15. Lab value interpretations, 2013. RN. com website. http: //www. rn. com/getpdf. php/1754. pdf. Published March 30, 2013. Accessed September 21, 2013. 16. CHOP chemotherapy facts, 2013. Lymphoma Information website. http: //www. lymphomainfo. net/therapy/chemotherapy/chop. html. Updated 2013. Accessed September 21, 2103. 17. Doxorubicin facts, 2013. American Cancer Society website. http: //www. cancer. org/treatmentsandsideeffects/guidetocancerdrugs/doxorubicin. Updated November 07, 2011. Accessed September 22, 2013. 18. Vincristine facts, 2013. American Cancer Society website. http: //www. cancer. org/treatmentsandsideeffects/guidetocancerdrugs/vincristine. Updated December 18, 2009. Accessed September 23, 2013. 19. Cyclophosphamide facts, 2013. American Cancer Society website. http: //www. cancer. org/treatmentsandsideeffects/guidetocancerdrugs/cyclophosphamide. Updated January 12, 2010. Accessed September 24, 2013. 20. Prednisone facts, 2013. American Cancer Society website. http: //www. cancer. org/treatmentsandsideeffects/guidetocancerdrugs/prednisone. Updated October 26, 2009. Accessed September 24, 2013. 21. Mogensen K. SAR HS 586: Medical Nutrition Therapy II. Boston University College of Health & Rehabilitation Sciences: Sargent College. 2013 Spring Semester. 22. Low-mircobial diet facts, 2013. Memorial Sloan-Kettering Cancer Center website. http: //www 2. mskcc. org/patient_education/_assets/downloads-english/401. pdf. Updated 2012. Accessed September 29, 2013. 23. Glutamine facts, 2013. Caring 4 Cancer website. https: //www. caring 4 cancer. com/go/cancer/nutrition/dietary-supplements/glutamine. htm. Updated April 15, 2010. Accessed September 29, 2013. 24. Russell NC, et al. Dietary and Weight Changes after Treatments for Lymphoma. Nutrition and Cancer. 2007; 57(2): 168– 176 25. The Leukemia and Lymphoma Society. Nutrition in Cancer Care. Available at: http: //www. lls. org/diseaseinformation/managingyourcancer/treatmentnextsteps/foodnutrition/neutropenicdiet/. Accessed September 29, 2013.