Unit-8 Cancer

UNIT 8 NUTRTTION, DIET
Structure
8.1 Introduction
8.2 Cancer
8.2.1 Development of Cancer
8.2.2 Characteristics of Cancer
8.2.3 Identification of Cancer Cells
8.3 Etiological Risk Factors in Cancer

8.3.1 Genetic Factors
8.3.2 Environmental Factors
8.3.3 C;~rcinogenic:Dietary Factors
8.3.4 Carcinogenic: Nan-dietary Faclors
8.3.5 Stress Factors
8.4 Metabolic Alterations and the Resultant Nutritional Problems/Clinical

Manifestations Associated with Cnncer
8.4.1 Metabolic Alterations during Csncer
8.4.2 Clinical Manifestations and Niltritional Problcms Associated with Cancer
8.5 Nutritional Requirements of Cancer Patients -General Guidelines

8.6 Dietary Management of Cancer Patients and Feeding Problems Related to
Cancer Therapy
8.6.1 Surgery
8.6.2 Radiation Thcrapy
8.6.3 Chernoth'erapy
8.7 Cancer Prevei~tion
8.7.1 Guidelines ~ O Cancer
I Prevention
8.7.2 Research Filldings Related to Cancer Prcveution
8.7.3 Role of Antioxidants in Cancer Prcvenlion
8.8 Let Us Suin Up

8.9 Glossary
8.10 ~nswersto Check Your Progress Exercises
In this unit, we will discuss the common forms of cancer, how they develop, relevant
etiological factors, pathological/metabolic changes and other complications related to
cancer. We will also discuss the type of nutrition and diet counseling given to the
patients with cancer. In the case of cancer patients there will be a lot of feeding
problems related to cancer treatment. So, we are going to learn more about how to
handle these patients. We should remember that each patient will be different and the
dietary modifications should be based on individual needs, likes and dislikes, treatment
and so on. We should have real patience in handling patients with cancer,
Objectives
After studying this unit, you will be able to:
elaborate on how cancer develops,
enumerate the etiological (risk) factors in the development of cancer,
describe the metabolic changes, clinical manifestations and complications in cancer,
Clinical Therapeutic e classify the different types of cancer depending upon the site of development,
Nutrition
e discuss the different modes of treatment,
e manage the cancer patients in relation to the diet therapy and feeding problems,
and
e explain the preventive measures.
8.2 CANCER
The word 'cancer' comes from the Latin for crab. It refers 90 any malignant growth
or tumor caused by abnormal and uncontrolled cell division.
Body cells, we know, are the basic units of life - each of us has trillions of them. Our
cells help us to carry out all functions of life - from the beating of the heart to the
throwing of a football. Cancers are new growths of cells in our bodies. Through
expression of these properties, it can cause destruction of major organs, and in some
cases, life threatening disturbances in body function. Let us see why it happens.
Every cell in the body has the potential to form a new growth. Indeed, this is not a
problem just of humans, but, in fact, all living organisms (plants and animals) are
susceptible to cancer, simply because all living organisms are made up of cells. Cells,
are dynamic - they are constantly in the process of making decisions about what
they want to do next. The decision to grow is one such major decision. Cells grow by
dividing in half, such that one cell will become two, and two become four (these new
cells are called daughtcr cells). Normally, there are very strict rules as to when a cell
can grow or not. These rules are set down by a variety of factors, including all cells
around it, various hormones in the body and various external factors to which the cell
may respond. One example is growth of bones from infancy to early adulthood.
The cell basically is set loose to divide without its normal control. These genetic
events are not inherited through the gametes. There are changes in the somatic cells
(other than sperm cells and ova).When this happens, the cell continues to divide,
eventually forming a new irowth that is what we know as a tumor or neoplasia. This
growth is detectable only when this division reaches the point where the number of
daughter cells is 1,000,000,000 (one billion).
When a cell is set loose from normal control, it becomes what is known as transformed.
Basically, the cell no longer looks like its neighbours in terms of its shape, size, and its
internal components. This transformed property is conferred upon all of tlie daughter
cells. That is, all subsequent cells that arise from that initially transformed cell will
also look dserent and grow in an uncontrolled manner. This is the transmissible
nature of cancer - once one cell becomes cancerous, all cells that arise from this
abnormal cell also take on this characteristic.
There are different forms of cancer with different characteristics, requiring different
types of treatment. The causes (etiological factors) are also found to be different. So
to make it simpler, cancer is a tumor or new growth which has a high growth factor.
The new growth may be benign or malignant. A malignant growth can kill a patient
if left untreated. A malignant tumor can invade the surrounding tissue and release
cells that can be carried to other parts of the body and set up metastasis (growth of
malignant tissue that spreads to the surrounding tissues). A benign growth is non-
malignant.
Let us learn about development and characteristics of cancer next.
8.2.1 Development of Cancer

Are you interested in knowing how cancer develops? Well here it is. The cancer
development is a process involving initiation, promotion and progression as
highlighited in Figure 8.1. The first step is initiation when the exposure to a carcinogen
allows the carcinogen to enter the cell. This carcinogen then alters the cellular DNA Nutrition, Diet and
Cnncer
(de-oxyribo nucleic acid). The second step is prornotiort when there is enhancement
of cancer development and the cell begins to multiply uncontrolled. The third step is
known as progression when a tumor formation takes place. It may spread to other
tissues or organs. Thus the cells released and carried to other parts of the body are
called as metastasis.
1 e Exposure to carcinogen I e Cancer development (e Formation of tumor I

I e Entry into the cell I on increase Ie Malignancy increases 1
Ie Alters cellular DNA I Uncnnlrolled multiplication I and other tissues and ]
of cells organs are invaded
called metastasis
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Figure 8.1: Steps in develop~nentof cancer
We should remember that cancer developmelit is a process and not a single event.
The initiating event may be either chemical or physical. The chemical event may
occur when a carcinogen intrudes into the cell and alters the genetic material. The
physical event may occur when radiation bombards thc cell and alters the genetic
material. What ever is the reasoll, the proleill making machinery of the cell
changes so that the DNA produces an odd structural protein. Then the cells begin to
multiply out of control forming a tumor. In this context, let us get to know what are
carcinogens.
What do you understand by carciitogert?
Carcinogen is an agent or a process, which significantly triggers lhe cell to grow in an

uncontrolled manner producing rnaligilant neoplasm (new growth) in a tissue. Therc
are three main groups of carcinogens. They are ionizing radiiition, virus and chemicals/
non- nutritive substances.We will get to know about them in greater details later in
sectioll 8.3, but now let us understand the characteristics of cancer.
8.2.2 Characteristics of Cancer

The important characteristics of cancer are excessive cellular multiplication,
invasiveness and autonomy. The active process of invasion is known as nzerastasis.
Metastasis requires specific surface receptors, enzymes, protein synthesis and use of
energy. The process of inv.asion is described briefly below:
Metastatic cell penetrates the extra cellular matrix that surrounds the tumor and
travels through the tissue until it reaches a blood vessel or a lyrnpl~aticvessel wall. It
dissolves a portion of the wall and then propels itself through the circulating blood. At
distant site, the tumor cell again re-attaches to blood vessel wall and repeats the
process until it settles down and begins to form a ncw tumor. Tumor cells gain growth
autonomy by either activation of growth p omoting antigens or loss of growth inhibitory
cancer suppressor genes. The cancer suppressor genes are called antioncogenes.
You may be little confused about the usage of the terms tumor and cancer. Let us be
clear about what is tumor and what is cancer? Tumor is a swelling or growl11 because
of an abnormal growth of tissue. Tumors can either be benign or malignant. The
benign tumor remains highly localized. On the other hand, the malignant tumor known
as cancer is characterized by invasiveness and can form distant colonies elsewhere
in the body. Cancer cells are very irregular in shape and their arrangement in tumor
tissue is very unruly. Cancer is painless if it does not compress the adjacent organs.
Later, it causes pain by invading or pressing the adjacent vital organs.
Clinical Thernpeutic Another aspect of malignancy is the ability of tumor cells to elude the immune system.
Nutrition
These cells may cover up antigens that would otherwise mark them for destruction or
they may rid themselves of the cell surface molecules that lymphocytes use to recognize
foreign cells. The immune system is largely ineffective.
8.2.3 Identification of Cancer Cells

Cancer cells can be distinguished from normal cells by examining them under a
microscope. In a specific tissue cancer cells are usually recognized by the
characteristics of rapidly growing cells, a high nuclear to cytoplasm ratio, prominent
nucleoli, many mitoses and relatively little specialized structure. The presence of
invading cells in an otherwise normal tissue section is the most diagnostic indication of
malignancy. Malignant tumors can be classified as:
Carcitzornas: tliese tumors arise from the epithelial lining (the squamous cells)
e.g. skin, tongue, breast, stomach, large intestine (the latter three arise from t11e
glandular tissues).
e Sarcomas: these arise from the connective tissue e.g. bone, cartilage and fat.
Melatiol~za: arise from pigmented layers of skin e.g. pigmented moles.
e Gliomas: these arise from the central nervous system e.g. brain and spinal cord.
e Reticulo -endothelial tumors: these involve the lymphatic system.
m Adeno~na: the growth arises from a gland e.g. thyroid gland.
Unlike carcinogens, which initiate cancer, some dietary components promote cancers.
That is, once the initiating step has taken place, these components may accelerate
tumor development. Studies suggest that dietary fats eaten in excess may promote
cancer development. Specially, linoleic acid, the omega-6 fatty acid of vegetable oil,
has been implicated in enhancing cancer development in rats. In contrast, omega-3
fatty acids appear to delay cancer development. We shall learn about this and other
factors contributing to cancer next. ,
ETIQLOGIC'IALRISK FACTORS IN CANCER

Cancer risks are climbing due to increasingly sedentary lifestyles and diets that are
high in fat and sugar but low in fruits, vegetables, legumes and whole grains. In
developing nations, the risk is mounting due to rapid growth of the urban poor who
move from rural areas into vast cities. That migration results in a loss of traditional
agriculture and dietary habits, plus an increased use of processed foods and drinks has
long been known. Obesity is yet another major part of the growing cancer threat.
People are being constantly exposed to many risk factors. First of all we have to
remember that etiological or risk factors will be different for different types of cancer.
In general, the basic cause of cancers is the loss of control over normal reproduction
of cells. There are several factors contributing to this loss of cell control. They are
genetic factors, environmental factors, dietary factors, carcinogens, radiation, oncogenic
viruses, and others including stress factors. Let us learn more about these etiological
risk factors in cancer.
8.3.1 Genetic Factors

Some cancers are programmed by genes to develop. Gene mutatiolis result from one
or more regulatory genes in the cell nucleus. It might be an inherited one but
environmental factors also contribute to its expression. Person with a family history of
cancer have a greater risk of developing cancers than a person without such a genetic
pre-disposing factor.
Nutrition, Diet and I
8.3.2 Environmental Factors Cancer i f :
Among environmental factors, smoking, water and air pollution and sun light exposure
are known to cause cancer.
8.3.3 Carcinogenic: Dietary Factors

Dietary constituents can also be carcinogenic. But to what extent diet is one of the
contributing factors to cancer development is not known. The incidence of cancers,
especially stomach cancers is high in parts of the world where people eat a lot of
heavily smoked, pickled or salt-cured foods that produce carcinogenic nitrosamines.
Alcohol has also been associated with a high incidence of some cancers, especially
cancers of the mouth and throat. Beverages such as beer and scotch may contain
damaging nitrosamines, as well as, alcohol. Other beverages such as wine and brandy
may contain the carcinogen uretlzane, which is produced during fermentation.
Nitrosamines have been implicatcd in the etiology of cancer. Nitrosamines are a broad
class of compounds formed from the nitrosation of substituted amides, ureas and
guanidines. Nitrosamides are direct acting carciilogens meaning that the activation is
non-enzymatic occurring by spoiltslneous hydrolysis.
A number of laboratory and epicleilliological studies have shown the correlation between
dietary factor and etiology of specific cancers. Severe calorie restriction in animals
has shown to inhibit the growth of most types of tumors. But calorie restriction is not
a means to prevent tunlor formation. There is a lot of epidemiological evidence to
show that there is an association between the high intake of calories by humans and
increased risk for endometrial and gall bladder cancer.
Some epidemiological studies suggest that risk for cancer increased with high protein
intakes. For instance, cancers of breast and colon occur with greater frequency in the
industrialized nations. Some researchers have suggested a possible association between
high intakes of total protein or aninlal protein and the risk of these specific cancers.
Both the type and amount of fat are believed to influence tumor formation in animals.
A high fat intake in humans has been linked to increased risk for breast and colon
cancers. The possible mechanism that has bee11 given is a high fat intake increased
intestinal anaerobic bacteria and biliary steroid secretion. These anaerobic bacteria
are capable of synthesizing estrogens. The estrogens are believed to be potential
carcinogens in mammary tissues. In addition, bile acids are degraded by intestinal
bactcria to the secondary bile acids such as deoxycholate and lithocholate. These may
act as carcinogcns in the colon. A ~ o t h e rlhcory is that trans-fatty acids are more
carcinogenic than cis fatty acids.
Next, let us learn about the non-dietary carcinogenic factors.
8.3.4 Carcinogenic: Non-dietary Factors

A large number of agents cause genetic damage and induce neoplastic transformation
of cells, l 3 e y fall into the following categories.
1. Oncogenic viruses
2. Chemical carcinogens
3. Radiant energy
Let us review these factors.

1. Oncoge~zicViruses : Certain viruses that interfere with the functions of the
regulatory genes have been identified. These vimses are called o~icogenicviruses.
Several studies indicate that these viruses are the second most important
Clinical Therapeutic risk factor. A large number of DNA and RNA viruses have been proved to be
Nutrition
oncogenic in animals. Let us learn about these viruses.
DNA viruses : The three DNA viruses found to cause human cancers are EBV,
HBV and HPV. What are these? Let us find out.
e Epsteitl-Barr virus (EBV):EBV belongs to herpes family. It causes,Burkitt's
lymplloma. It is a tumor of B-lymphocytes. EBV virus alone cannot cause
the tumor. In patients with immune disregulation, EBV causes sustained
beta cclls proliferation. EBV is found to be closely associated with
nasopharyngeal carcinoma.
e Hepatitis B Virus (HBV): Hepatitis B virus infection is found to be closely
associated with formation of liver cancer.
e Human Papilloma Virus (HPV): HPV gives rise to multiple warts, which
are benign squamous papillomas. Some of the warts undergo malignant
transformation. Squamous cell carcinoma of cervix has been found to be
associated with HPV.
XNA Viruses: All oilcogenic RNA viruses are retroviruses. They are of 2 types.
They are acute transforming retroviruses and slow transforming retroviruses.
Acute transforming viruses include type C viruses and cause rapid induction of
tumors in animals. Tliey contain viral oncogenes (virus). The slow transforming
retroviruses do not contain V-oncs and are replication competent and cause
trailsformation of the cells slowly.
Clzemical Carcinogens: Chemicals have been shown to be carcinogenic. Some
are naturally occurring components of plants and microbial organisms. Some are
synthetic products created by industry. Chemical carcinogens can be classified
into two general categories based on the ability of compounds to bind to DNA.
Compounds that bind to DNA are genotoxic, whereas compounds that are
carcinogenic, but have no evidence of DNA binding are termed epigelzetic.
Some of the major chemical carcinogens are alkylating agents, acylating agents,
and aromatic amines. Aflatoxin B,, Betel nuts, nitrosamines and amides, vinyl
chloride, nickel, cl~roiniuminsecticide and fungicide are also some of the chemical
carcinogens.Tobacco, smoking, drug abuse are also known to cause cancers.
3. Radiant Energy : Radiant energy whether in the form of the ultraviolet rays of
sunlight or as ionizing electromagnetic and particulate radiation can transform all
cell types in vitro and induce neoplasm in vivo in both human and experimental
animals.
e Ultraviolet rays: There is ample evidence from epidemiological studies
that ultra violet rays derived from the sun induce an increased incidence of
squamous cell carcinoma, basal cell carcinoma and melanocarcinoma of
the skin.
e Ionizing Radiatio~z: Electromagnetic (X-rays, gamma rays) and particulate
(a - particles, P - particles, protons, neutrons) radiations are all carcinogenic.
Even therapeutic radiation has been documented to be carcinogenic.
Next, let us study about stress as an etiological factor for cancer.
. 8.3.5 Stress Factors
Emotions playing a part in malignancy are not a new idea. But these relationships are
extremely difficult lo measure. The interesting fact is more observations are being
made of relationships between cancer and measurable factors of stress. Clinicians
and researchers have reported that psychic trauma, seems to carry strong correlations
with cancer. Two important physiological causes are assured for this correlation. One
is damage to the thymus gland and the immune system. Second js the neuroendocrine
effects mediated through the hypothalamus, pituitary and adrenal cortex. Specific
studies need to be carried out in this area to confinn the association between stress
factors and cancer.
We sum up our discussion on risk factors by highlighting the factors that cause cancer Nutrition, Diet and
Cancer
and others that reduce the risk of cancer. Table 8.1 presents this summary.
Table 8.1: Dietary of non-dietary factors in some cancer: Factors that
prevent risk of cancers
S. No. Qpe of Cancer Dietary Factors Non-dietary Factors Rislr Factors
1. Mouth and Alcohol Smoking and tobacco Lack of
pharynx Vegetables and
fmits (vilamin C)
2. Nasophary nx Salted fish Tobacco smoking and

v~rusinfection -
3. Larynx Alcohol Tobacco smoking Lack of
Vegetables and
fruit (vitamin C
and P-carotene)
_ _ C I _ _ I _ _ l _ l _ _ _ _
4. Oesophagus Alcohol, very 1101 Tobacco slnoki~lg Lack ol'

drinks, nitroso~nes Vcgel:thles and
fruit (vitamin
C and p-carotcne)
5. Stomach Grillcd mcats and Bacterial ini'cclion Lack oP
nitrosoilles H. Py1or.i Vegctablcs and
fruits (vitamin
C :md B-cnrotenc)
green tea, garlic,
sclcniu~n
6. Pancreas High energy intake, Tobacco smoking Lack of
cholesterol, meat, Vegctahles. and
smoked meal and fluits (vitamin
fish C fibre)
7. Gall Bladder High energy and -
fat intake
8. Liver Alcohol, aflatoxins, Viruses: hepatitis B Lack of
iron and C Vcget:tblcs
(Sclenium)
9 Colon and rectum Red meat, alcohol Genetic, smoking, hick 01
high fa1 and sugar, ulcerative colitis Vegetable kind
eggs and iron Fruits (vitnmin C,
p-carotene, fiber)
10. Lung
asbestos, nickel and Vegetables and
and cholesterol fiuits (fibre and
vitamin C)
vitanlin E,selenium
11. Breast Excess energy, Late inenopausc Lack of
alcohol, saturated and pregnancy Vegctiables and
fat. fruits, fibre,
vitamin C and
carotene
12. Ovary Total fat, cggs and - Lack of
saturated fat Vegetable and
fruits (vitamin
C and carotene)
13. Prostrate Total fat, saturated - Lack of
animal fat Vegetable and
fruits (vitamin
C and p-carotene)
14. Kidney Excess energy, Smoking or drug Lack of
meat and dairy abuse Vegetables
products
The important points to remember about cancer are highighted in box.
Clinical Thcrnpeutic
Nutrition Box 1 Points to Remember
Several dietary and non-dietary factors (including genetics) can increase the risk
in the causation of cancer. Some important etiological factors being:
1. Many cancers are related to poor eating habits like lack of fruits and
vegetables in the diet which provide vitamin C, carotene and fibre.
2. Excess fats (saturated vegetable and animal fat) are linked to higher and
long-term risk for cancers. w
3. People who drink more than 2 to 3 glasses of beer or wine or whisky in a

day, increase their chances of getting cancer of mouth, throat, voice box,
neck and liver.
4. Tobacco is the most common agent of cancer - smoking, snuffing or
chewing tobacco is harmful.
5. Some cancers such as colon cancer and breast cancer seem to run in
families (genetic origin).
6. Certain viruses, carcinogens and radiation may increase the risk of some
cancer.
7. Certain chemicals may increase cancer risk.
8. Almost all cases of skin cancer are caused by exccss sun exposure.
Increased intake of vegetables and fruits can reduce the risk of cancers.
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Check Your Progress Exercise 1
1. Define the following terms:
a) Carcinogen: ..................... .
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b) Tumor: .............................................................................................
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.'...............,....................................,......*.............*......................,.....,....
c) Metastasis: ............................................................................................
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d) Oncogenic virus: ...................... .

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e)
.
Antioncogenes: ............................ .... ...............................................
,
~..................~.............,,~,,,,,.,.,.......,..,.*..,....,..,..,...,,..
....................I...........
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2. What is cancer? Briefly discuss the steps involved in cancer development.
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3. How can cancer cells be distinguished from normal cells?
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4. Enumerate the risk factors associated with the etiology of cancer. Briefly
discuss dietary factors known to cause cancer.
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5. Match the following:

A B
a) Carcinoma i) Burkilt's lymphoma
b) RNAVirus ii) Melanocarcinonla
c) Epstein-Barr Virus iii) V oncs
d) Hepatitis B Virus iv) Epithelial lining
e) Ultraviolet rays v) Liver Cancer
8.4 METABOLIC AXTIERATIONSAND THE

RESULTANT NUTRITIONAL PROBLEMS/
CLINICAL IFESTATIONSASSOCIATED
WITH CANCER
Several research studies have shown that malignant growth (cancer) is responsible
for numerous metabolic abnormalities which are associated with changes in body
composition and nutritional status of the patient. These changes cxi be observed in
the form of several clinical complications which are commonly grouped under the
broad term of Cancer Cachexia. Let us then discuss in detail about these metabolic
changes.
8.4.1 Metabolic Alterations during Cancer
As we have studied earlier, patients with advanced cancer experience profound
anorexia, early satiety, changes in the structure/function of organs/glands/body parts,
several nutritional deficiencies and weight loss. Although the cause for these symptoms
is not clear but they have definitely been found to be associated with the metabolic
status of the patient. There are alterations in the energy expenditure, carbohydrate,
protein and fat metabolism, acid -base balance, enzyme activities, and endocrine
functions. Generally, there is an increased metabolic rate. For example, it may be 10
percent greater than the normal level. But, there are variations among patients with
gastrointestinal cancers. Some patients may be hyper metabolic, whereas patients
with colon and rectal cancer do not show any difference. Therefore, it is evident that
there can be variations among patients. Let us now discuss these metabolic changes
in detail.
Clinical Therapeutic Cancer patients have been shown to have glucose intolerance. This is due to an
Nutrition
increased insulii~resistance and also reduced insulin secretion. There are also many
reports to show that there is an increased rate of endogellous glucose production ill
cancer patients. This increased production combined with other carbohydrate changes
is associated with weight loss. An increased rate of Cori cycling has been reported to
occur in cancer patients.
What d o you meaan by Cori Cycling?
You may remember reading about the cori cycle in the Nutritional Biochemisty Course
(MFN-002) in Unit 6. If you are not able to recollect, let us help you recapitulate. In
this cycle, glucose released by peripheral tissues is metabolized to lactate, which is
then resyilthesized to glucose in the liver. This process is energy consuming because
6 ATP are required for sy~~thesizing only 2 ATP. Therefore, if tlle tumor cells release
more lactate, more energy will be wasted on the resynthesis of glucose. So, it is
understood that the Cori Cycling could be one of the significant factors in the
development of weight loss.
We should always remember that one of the important and significant concerns in
cancer patients is weight loss.
Next, we shall discuss about the abnormalities caused in lipid and protein metabolism.
Many research reports have stated that the major portion of weight loss in cancer
patients is mainly due to body fat depletion. These include: increased lipolytic (break
down of fats) rates caused by decreased food intake, stin~ulationof lipolysis due to the
stress response to illness and release of lipolytic factors produced by the tumor itself.
Loss of body fat occurs when both lipolysis and fatty acid oxidation are increased.
Elevated levels of lipid aie not significant in cancer patients, but may occur in association
with certain tumors. The rate of fat oxidation is found to be greater than the rate of
carbohydrate oxidation in cancer patients who had lost weight significantly.
With regard to protein metabolism the following changes are observed.
1. The rates 0.1whole body turnover increase.
2. Catabolic (breakdown) rates of muscle protein increase with advancing stages
of disease leading to weight loss.
3. Decreased plasma branched - chain amino acids.
4. Skeletal muscle mass is reduced.
5. Albumin is the principal secretory protein of the liver. Its depletion is common
in cancer and results in hypoalbuminemia.
6. Negative nitrogen balance occurs inspite of sufficient intake.
Severe metabolic changes can cause progressiveweight loss, protein energy malnutrition
anaemia and other abnormalities in protein, fat and carbohydrate metabolism. This
syndro~neis known as cancer cachexia. Apart from these metabolic changes tliere
are other changes, which are believed to be endogenous host responses. Fluid and
electrolyte imbalances are seen in advanced cancer patients. Severe vomitting/
diarrohoea and changes affected in the enzyme system could elicit many symptoms.
Immunologic functions of the host may be affected leading to progressive malnutrition.
These are attributed to the release of mediators derived from cells of the immune
system, These mediators are called cytokines.
What are Cytokines?
Cytokines are polypeptides, which influence the proliferation, differentiation,
metabolism and activation of cells. There are three areas in cancer that have special
relations to these regulatory polypetides. One relates to the inhibiting cylokines wit11
activated oncogenes, loss of tumor suppressor genes, emergence of drug resistance,
and loss of intimate cell to cell contact. Secondly, the role of these regulators in tumor
growth and in the development of various cancer metabolic abnormalities. Thirdly, Nutrition, Diet and
Cnncer
the use of certain citokines in anti tumor therapy.
Many cancer patients have diminished taste and appetite. Factor affecting taste and
smell are quite con~plicated.There are few studies, which indicate that there is no
abnormality in taste perception. Though these variations are existing in the research
findings, we should not disregard the loss of taste and appetite in cancer patients.
These are also contributory factors for weight loss in them.
Hypercalcemia is one of the most common metabolic complications. The common
symptoms are nausea, muscle weakness, excess urine, elevated blood pressure,
anorexia, lethargy, confusion and stupor progressing to coma. On the other hand,
certain type of tumors reduces calicitrol concentration in conjunction with
hypophosphatemia, thereby inducing an oncogenic osteomalacia. Muscle weakness
of varying degree and back pain have been the frequent complaint.
Having studied about the metabolic aberrations next, let us review the clinical
manifestations and nutritional problems associated with cancer.
8.4.2 Clinical Manifestations and Nutritional Problems
Associated with Cancer
In the previous section we learnt that cancer results in several changes in the metabolism
of carbohydrates, protein, fat, fluids and several micronulrients. Changes in nletabolism
along with altered stri~ctural/functionalcapacity get elicited in the form of cancer
cachexia, increased morbidity and mortality. Major clinical signs and symptoms which
are associated with the nutritional status of cancer patient includes:
1. Anorexia with progressive weight loss and undernutrition.
2. Taste changes causing depressed or altered food intake.
3. Alterations in protein, carbohydrate and fat metabolism.
4. Increased energy expenditure despite weight loss.
5. Impaired food intake and mal~lutritionsecondary to mechanical bowel obstruction
at any level, intestinal dysmotility induced by various cancerous tumors,
6. Malabsorption associated with deficiency or inactivation of pancreatic enzymes,
bile salts, failure of food to mix with digcstive enzymes; fistulous bypass of small
bowel, infiltration of small bowel wall or lymphatics and mesentery by malignant
cells. Blind loop syndrome ( blockage 01small intestine resulting in stasis of the
movement of food or digestive secretions) occilrring with depressed gastric
secretion or partial upper small bowel obstruction leading to bacterial overgrowth;
malnutrition induced villous hypoplasia.
7. Protein losing enteropathy.
8. Metabolic abnormalities induced by tumor.
9. Anaemia of chronic blood loss and bone marrow suppression.
10. Electrolyte and fluid problems with persistent vomiting associated with intestinal
obstruction or intracranial tumors, intestinal fluid losses through fistulas or
diarrhoea.
1. Enlist the metabolic abnormalities associated with the cancer.
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Clinical Therapeutic
Nutrition 2. What changes are obse~vedin protein n~etabolismin cancer patients?
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3. What are cytokines?
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4. Enumerate any five ~lutritionalproblems and clinical maiiifestatioi~sassociated
with cancer.
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v
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In om discussion so far we have focussed on the metabolic abcrratiolis clinical
manifestations and nutritional problems linked with cancer. Now we shall study the
nutritio~lalrequirements of cancer patients.
8.5 NUTRITIONAL REQUImMENTS OF

IIENTS - GENE
Cancer we know is a chronic degenerative disease characterized by cancer cachexia

which is a stage of marked body dysfunction, general ill health, malnutrition, anorexia
and anaemia. Certain other associated symptonis includes xerostomia, nausea,
vomiting cheilosis, glossitis which impair food intake. Whatever nlay be the type of
cancer, the nutritional requirements are govemcd by:
- impact of the cancer
- impact of the drugs1 treatment 011 the overall health status of the patient.
In view of the pathophysiology, signs and symptoms, as well as, the impact of various
forms of cancer on the health and nutritional status of the patient the dietary
management should aim at meeting the following objectives.
- To prevent further tissue catabolism
- To meet the increased nletabolic demands of the body
- To provide relief from the symptoms
- To prevent progression and promote recovery from cancer cachexia.
We will now discuss the nutrient requirements of cancer patients (in general ) to fulfill
the above mentioned objectives. Our discussions would begin with the calorie needs
and proceed to the requirements of various inicro and macronutrients. You will find
details on specific nutrition support required for different tumors in section 8.6. So let
us get started with individual nutrients requirements.
Energy: Remember, we read about Cori's cycle and its association with weight loss
in section 8.4 of this unit. It must be clear to you that cailder imposes increased
energy demands because of the hypermetabolic state of the diseasc process and
increased energy requirement to spare proteins for tissue Ilealing and promote weight
gain. In view of the inhibitory factors associated wit11 food intake (cancer cachexia); Nutrition, Diet and
Cancer
it may not be feasible to promote an intake beyond 2000 Kcallday. However, by the
help of appetite stimulants and / or nutrition support systems (enteral tube feeding)
malnourished patients can be inolivated to consume around 30-35 Kcallkg body weight /
day (3000-4000 Kcal/day.). Ahigh energy diet is helpful in inhibiting the side-effects
of chemotherapy and cancer cachexia.
Protein: Both the metabolic stress of c;mcer, as well as, chemotherapy result in
increased tissue catabolism. Hypoalbuininenlia and anaemia are also very common.
Tissue protein synthesis, a necessary component of healing aiid rehabilitation, requires
essential amino-acids and nitrogen. Efficient protein utilizatioli which depends upon
protein: energy ratio help lo promote tissue anabolism, prevent catabolism and help
build up body reserves. An adult patient with average nutritional status will require
80-100 grams protein per day to meet maintenance needs and ensure anabolism.
Howevel; a malnourished patient must coilsume 100-150 grnprotein per day to replenish
reserves and restore a positive nitrogen balance. Emphasis of course should be laid
on the inclusion of high biological value protein rich food sources as milk, eggs, marine
foods, and poultry. Renal and liver Cunclioil tests nlust he closely monitored tinder
such conditions.
Fat: You may wish to recapitulate From section 8.4 of' this unit that during cancer
there is enhanced mobilization of free filtty acids B o n ~adipose lissues lesulting in
subsequent depletion of total body l'at. Around 15-20% of the modified energy
requirements sl~ouldbc provided from fat as they help in making the meals calorie
dense and improve palatability. Emphasis should bc laid on the incorporation of
emulsified fats and vegetable oils particularly lhose which are rich in medium chain
triglycerides. Visible sources of aniinill fiat (pure ghee, lard etc.) iilld flesh food (red
meat) should be restricted in diet. A combination of vegetable oils (olive, coconut,
safflower etc.) cream, butter etc. can help in improvirlg taste and providing variety in
term of flavour in different meals.
Carbolzydrate: Adequate amount (60% of totzll energy ) of carl~ohydratesshould be
provided. If a very high calorie diet is being given, eniphasis may be required on the
incorporation of easy-to-digest carbohydrates (mono/disaccharides and starches) s o
as lo make the meals small in volunle and energy dense. Tllc fibre intake may need
to be curtailed if the patient is suffering from cancer of the gastrointestinal tract or
digestive disturbances. However, some patients may experience hyperglycemia. In
such situations inclusion of food particularly those which are rich in soluble fibre
(pulses and legumes) would be helpful.
Vitan~ins,Mineruls atzcl P~~~~tochemicu1s : Several vitaniins particularly those of the
B-group are essential to promote adequate metabolism of energy and protein. Vitamin
A, C and E should be provided liberally as they help in reducing the morbidity and
mortality due to cancer, (required for tihue synthesis, cell differentiation and for
maintaining cell integrity). Among the minerals, zinc and selenium are particularly
important and their intake should be slightly increased by giving supplements, The
role of phytochemicals (carotenoids,flavonoids, plant sterols, allium compounds, indols,
phenols etc.) is gaining importance over the past Few years. Incorporalion of good
amount of fresh fruits1 vegetables preferably with their edible peels, soyabean and
certain Indian condiments1 herbs such as turmeric can help in promoting the dietary
intake of phytochemicals. The role of peigallacatecl~ingallate in green tea, curcumin
in turmeric, genistein in soya and Colic acid in reducing the morbidity associated with
cancer is under investigation.
Fluids: Adequate fluid intake is imperative to replace losses due to gastroiiltestinal
disturbances, infectionlfever can also to help the kidney's dispose off the metabolic
breakdown products from the destroyed cancer cells, as well as, from the toxic drugs
used in the treatment. Certain drugs such as cyclophosphamide requires 2-3 litres
fluids to prevent cystilis. Adequate intake of fluids/l>everageshelps in providing relief
Clinical Therapeutic from xerostomia and other swallowing problems. Menu's should be planned such that
Nutrition
they include dishes rich in moisture1 water along with a beverage. Dry meals may not
be preferred by most patients.
So far we have discussed the nutrient requirements. The pattern of feeding the cancer
patient and basic guidelines are presented next.
Meal Pattern and Feeding Considerations
The meal pattern and the feeding considerations include the following::
- Meal timings play an important role in ensuring adequate food intake. Cancer
patients often complain of decreased ability to eat as the day progresses. This
might be because of delayed gastric emptying, decreased production of gastric
secretions and mucosal atrophy of the gastroilltestinal tract. Small frequent meals
with greater emphasis in the morning is recommended.
- Patients with altered taste sensations may benefit by increased use of flavourings
and seasonings particularly those which are rich in antioxidants (mint, coriander,
turmeric etc.)
- Some patients may experience meat aversions due to chemotherapy. This may
necessitate the elimination of red meats (lamb, pork, buffalo, cow etc.) which are
stronger in flavour as compared to lean meats (marine foods, chicken etc.). For
such patients alternative sources of protein shoulcl be incorporated in the diet.
- Semi-soft/ full fluid diets should be given to those who experience dysphagia, have
lesions in the mouth or oesophagus.
- High energy nutrient dense dishes (cream soups, creamed vegetables, puddings1
souffli, honey/ jam toppings on fruit, milk shake, custard, sandwitches with cheese1
egg, addition of dextrose, sugar etc. to fruit juice, milk shakes etc.) should be
served to facilitate a high energy intake.
- Although oral route is always the preferred form of feeding, it is recommended to
use alternative methods of feeding (enteral, parenteral) as a supplement/ substitutes
according to the feasibility. Soy-based or milk-based formulas are very popular
for long-term enteral feeding particularly for home-based patients. TPN solutions
comprising of glucose and a mixture of amino-acids which provide 25-35 Kcallkg
day and 1.2 to 2.0 gm protein per kg per day are also frequently ulilized to help in
maintaining a good nutritional status.
With a basic understanding on the nutrient requirements, in our subsequeilt discussions

we will learn about the various factors related to different modes of feeding and
specialized requirements most suitable for a particular type of cancerltreatment that
would be helpful in the dietary management of patients.
8.6 DIETARY MANAGEMENT OF CANCER

PATIENTS AND FEEDING PROBLEMS
]RELATED TO CANCER THERAPY
We took an overview about the general nutritional requirements of cancer patients.
However, in order to be successful in maintaining an optimum nutritional status oS the
patient it is equally important to feed the right type of diet through an appropriate
method and route by keeping in mind the details of the disease and mode of treatment.
We shall now discuss about the different types or modes of cancer treatment and the
feeding problems associated with the treatments. While reading the details mentioned
below w e must also remember that the line of treatment for the cancer patients will
depend on the site of cancer development. Currently the cancer therapy includes
three major types of interventions namely surgery, radiation therapy and chemotherapy. Nutrition, Diet and
Cnncer
Differentiation therapy and adoptive immuilotherapy are other cancer therapy
strategies. Cancer therapy often involves combined significant nutritional problems,
as well as, feeding problems which may arise not only from the malignant condition
but also from specific treatment undertaken to control the neoplastic process.
So our discussioil will now begin with a review on different cancer therapies, the
feeding problems related lo these therapies and the dietary management.
8.6.1 Surgery
Surgery is generally coilducted in the absence of metastasis i.e when a tumor is
localized. Nutrition support would vary depending on the area being operated and its
association with the digestionlabsorption of food. For instance, surgical removal of
the tumor of appendix may not call for any major demands on the nutritional support
whereas, surgical removal of a part of liverlpancreas may require specialized feeds
and feeding support techniques (enteralltotalparenteral).We shall now discuss methods
of feeding required during surgical resections of different tissues.
a) Head and Neck Tumor

Treatment mostly involves combination of surgery and radiation. Chemotherapy is
also used in some cases, We will learn about these therapies in a little while from
now. But, remember radiation induces loss of taste (mouth blindness) and dry
mouth (xerostomia). Injury to teeth may also occur. Surgery ]nay include partial or
total glossectomy (partial or total surgical excision of the tongue) and mandibulectoilly
(re-section of the lower jaw). Sometimes they may do a surgery of the hard or soft
palate, or of the soft tissues of the lower face and neck. Tliese procedures add to the
difficulties in chewing and swallowing. Aspiration of food on swallowing may be
another serious problems. S o then what type of nutritional support would be required?
Read and find out.
Nutritional Support Management

Tube feeding is usually started. If tube feeding is not possible, parenteral nutrition
through peripheral vein or through the central vein can be given.
Before treatment, foods that are attractive with pleasant aroma can be given. Foods
should be of high energy value. We should try our best to increase their total food
intake. After treatment, nutritious food formulas can be administered by mouth if the
patients are able to swallow. If they find it difficult, nnsoesophageal tube feeding can
be started. For long-term maintenance of patients requiring such support, gastrostomy
tubes should be inserted. Some patients are at serious risk of aspiration of regurgitated
food (tendency to vomit). This danger is reduced by placing the tip of the tube in the
small bowel and infusing formula by slow drip. Care sho~lldbe taken to regulate the
flow rate.
Discharged patients who require long-term liquid feeding at home should be given
information about both commercial and homemade fonnulas. Whatever be the type
of feed, it should be nutritionally adequate and have sufficient bulk-forming materials
to prevent constipation.
b) Oesoplzageal Carcinoma 111/1

Management of patients with oesophageal carcinoma includes surgery, radiation and
combination chemotherapy. Radiation to the lower neck can induce oesophagitis,
fistulas and haemorrhage may also occur due to re-growth of the cancer. Chemotherapy
may induce nausea, anorexia, sore mouth, and odynophagia. All these inhibit food
intake and decrease the acceptance of tube feeding.
Surgical treatment usually involves total or distal oesophagect.omy(procedure lo remove

1
a portion of the tongue). Easy regurgitation, ra~id~satiety, decreased rate of gastric 175 1
\
Clinical Therapeutic emptying of solid food, diarrhoea and steatorrhoea are common results of this surgery.
Nutrition
Weight loss is another great problem. Preoperative parenteral feeding is indicated to
improve nutritional status. This is found to reduce postoperative complications. Oral
or tube feeding is oftenh~adequateto meet the nutritional needs in the period of radiation
and chemotherapy because of interference with the feeding programme, nausea, pain
or combination of all these. Once the oral intake by the patient is normal, the dietary
prescription should provide for frequent meals high in carbohydrate and adequate in
protein and fat. In some cases, steatorrhoea occurs with increased frequency and foul
smelling stools alongwith abdominal discomlort. For these patients partial substitutior~
of long-chain triglycerides (LCT) by medium chain triglycerides (MCT) can be tested
and may be helpful.
Postoperative stricture (narrowing of a passage due to scar tissue or tumor) may

occur and requires dilation. Oral or tube fed liquid formulas can be given to assure
adequate intake until the stricture is over come.
Carcinoma of the oesophagogastric junction creates similar problems like those
described of above. Production of gastric juice may be reduced there by resulting in
decrease of vitamin B,, absorption.
c) Gastric Cnnoer
Surgical treatmel~tis a very common mode of treatment in gastric cancer. Radiation
and/or chemotherapy are given for patients with resected but residual localized disease.
Removal of most of the residues of the stomach reduces its functions such as secretory,
diluting 'and digestive.This will definitely result in physiological and nutritional problems.
These problems may vary from mild to severe depending on tlie extent of resection,
the individual patient response, the appropriateness of the intervention and the
postoperative care.
During the post-operative period, when food is ingested some patients show various
signs and symptoms known as 'dumping syndrome'. This syndrome develops with
varying severity. Usually the signs and symptoms occur within 25 to 30 minutes following
ingestion of a meal. The gastrointestinal signs and symptoms include abdominal bloating,
cramping and diarrhoea. These symptoms are more pronounccd shortly after a meal.
Another set of symptoms that usually occurs two hours after eating is also characterized
by sweating, tachycardia (heart rate above 100 per minute) and faintness. Mental
confusion may also occur. These symptoms are related to the discharge of
catecholamine. This catecholamine discharge is mediated by hypoglycemia induced
by the insulin response to the rapid entry of the meal into the upper small bowel.
Malabsorption of fat occurs. ~e?icieienciesof iron, calcium and fat-soluble vitamins
may also occur due to malabsorption. Yle beneficial effect of somatostatin, especially
its analogue - 'Octreotide' has been reportcd in the treatment of dumping syndrome.
Some patients benefit fiom long-term use but many are unable to tolerate the drug due
to diarrhoea. Let us learn about the nutritional management of dumping syndrome
next.
The 'dumping syndrome' can be greatly minimized or prevented by adhering strictly
to an antidumping dict. In general, such a diet is high in protein, has adequate fat, is
low in total carbohydrate, particularly simple cai-bohydratedrestricted in fluids at meal
time. Small frequent meals, say six times per day should be served. Paticnt should be
discouraged to lie down immediately after the meal, instead, encourage them to be in
a reclining position for a short period of time. The use of soluble fibre such as pectin
derivative has been reported to prolong gastric emptying, to decrease dumping and to
minimize the fall in blood sugar.
If steatorrhoea (loss of fat in the stools) is significant, replacement of a portion of LCT
(long-chain triglycerides) with MCT (medium chain triglycerides) will be helpful, The
I
I
patient will be able to tolerate this better. Pancreatic extract can also be tried to rule Nutrition, Diet and
Cancer
out luminal pancreatic enzyme insufficiency. Insufficiency of pancreatic enzyme(s)
may result from rapid entry of food and fluid into the upper small bowel or from a
pancreatic secretory defect or from both.
Deficiencies of vitamins and minerals can be prevented by adequate oral administration
of iron with ascorbic acid and by supplementing both water-soluble and fat-soluble
vitamins. Monthly injections of 100 micrograms of vitamin B,, are required because
the extensive gastric resection will eventually result in vitamin B,, deficiency.
Milk is found to be poorly tolerated by these patients. They can be asked to drink milk
in small amounts frequently over the day (or to drink lactase treated milk if available)
01. to use yoghurt as tolerated. In case these approaches are of no use, the more
soluble calcium salts should be given in divided doses. At least one gram of calcium
should be given for a day.
Antiemetics (drugs to prevent nausea or vomitting) are used in treatment of
chemotherapy induced nausea and vomiting. Antiemetics become absolutely necessary
to help better adherence to therapeutic programmes and better intake of food and
fluids.
Weight loss seen in these patients is inainly due to poor food intake. In addition to this,
discomfort associated with eating may result from esophagitis secondary to bile
regurgitation, anorexia associated with depression or the side effects of drugs and/or
radiation. Hence, a careful diet history, conform an adequate basis for dietary
modifications.
If the above prescribed dietary management does not prevent the dumping syndrome
or there is no adequate food intake to maintain gain body weight, slow-drip tube
feedings of a complete formula is recommended. Because of the slow entry of food
into the upper intestine by this technique, dumping is not likcly to occur. Such feedings
may need Lo be given only during the period of chemotherapy. This will help to improve
the appetite. When patients remain seriously anorexia followiilg chemotllerapy, tube
feedings at night are helpful.
d) Pancreatic Carzcer
This is a condition often associated with abdominal pain, anorexia, nausea, vomiting
and weight loss. Ealing may aggravate pain. There may be digestive enzyme deficiency.
Malabsorption combined with anorexia contributes to progressive weight loss. Bile
insufficiency call occur if there is any obstruction in thc common bile duct. This may
reduce the intestinal absorption of vitamin K.Pancreatic carcinoma is an aggressive
disease, and by the time it is diagnosed, most patients are at a stage in which curative
treatment is not possible.
Surgical resection is the only chance of cure at present. There are numerous problems
interfering with normal food intake. Fat malabsorption, decreased glucose tolerance
and hyperglycemia are common. Under such circumstances, the nutritional
management of pailcreatic cancer patient is very important which is explained next.
When there is deficiency of exocrine pancreatic secretions, adequate amounts of
pancreatic extract are helpful. It should be administered with all meals and snacks
specially whet1 there is severe fat malabsorption syndrome. MCT are more efficiently
absorbed than the LCT in the absence of pancreatic enzymes and decreased bile
salts. Glucose oligosaccharide may also help to increase the calorie intake and
absorption among patients with pancreatic insufficiency. These are relatively short-
chain glucose polymers and can be hydrolyzed to glucose by the brush border enzyme
sucrase - x - dextrimase. This white powdery material is not sweet and may be used
in variety of ways to supplement intake.
Clinical ~ h e r a ~ e u t i c e) Other. Surgical Procedures
Nutrition
Major resection of the small bowel is not common. Resection of the ileum leads to
certain pl~ysiologicaland nutritional problems. Colectomy (partial, total and diverting)
etc. resection of the right colon with the ileocecal valve and a portion of the distal
ileum may result in watery diarrhoea. Since only a small segment of distal ileum
usually is sacrificed, vitamin B,, deficiency is not likely to occur.
In total proctocolectomy (surgical removal of the rectum together with part or all of
the colon), an ileostomy with stool collected in an external pouch is used for the
patients. Loss of water and sodium through the ileoslomy is significant during the first
10 days of postoperative period. These patients usually lose 300 to 600 ml of water, 40
to 100 mEq of sodium and 2.5 to 10 mEq of potassium daily. Patients can be managed
with increased fluids and salt administration. Various other procedures have been
designed and advocated depending on the conditionsof individual patient. Eating paltcr~v,
and dietary recon~mendationsalso depend on the patient's condition.
Sometinles a major portion of the large bowel is laken out of continuity by a diverting
procedure. As a result of this, an inflammatory process termed diversion colitis can
occur in this area. The common symptoms associated with the diversion colitis are
abdominal cramping with mucoid and blood discharge. Studies have shown that infusion
of a salt solution containing short-chain fatty acids (SCFA) into the rectal remnant
results in healing.
The discussion so far focussed on surgeiy as a therapy and the nutritional support
management after surgery for cancer patients. Next, we shall look at the radiation
therapy and its nutritional support management.
8.6.2 Radiation Therapy
Radiation therapy is one of the option for the treatment of various tumors. During the
administration of radiation patients experience acute radiation toxicity. This toxicity is
manifested as nausea, vomiting and diarrhoea. This type of toxicity will subside usually
within weeks of ending the radiation therapy (RT). Chronic, late gastrointestinal
complications occur and may cause major morbidity and mortality. After 2 to 3 weeks
of RT, abdominal cramping and watery diarrhoea may occur. Weight loss is common.
Malabsorption of water, fats, bile salts, carbohydrales, calcium, magnesium, iron and
vitamin B,, occur during RT. Several factors contribute to the malabsorption that
occurs in radiation damage. These include.
1. Decreased available absorptive surface area due to radiation damage.
2. Chronic lymphatic obstruction causingsteatorrhoea and protein loss,
3. Secondary disaccharidase deficiency
4. Bile salts malabsorption leading to choleric diarrhoea.
5. Rapid intestinal transit.
So then how to manage this condition through nutritional support. Let us find out.
For managing these patients on radiation therapy, the following measures can be under
taken:
1. Administration of broad spectrum of antibiotics for bacterial overgrowth.
2. Diet low in fat and lactose.
3. Antidiarrhoea medications and anticholinergic and antispasmodic preparations,
Diet therapy can play a major role in controlling symptoms and assuring adequate
nutrition. In addition, enteral and parentera1 nutrition can be used in severe cases.
Enters] feedings with solutions containing alnino acids or partially digested protein and
very low fat content can be given. Studies have indicated that those patients who
received only such feeding during RT show less diarrhoea and weight loss. Though
this type of feedings is useful, there are some practical difficulties. Therefore, it is
advisable to use such enteral feedings for oilly those patients who develop severe/
acute toxicity. Total parenteral feedings should be reserved only for those patients
malnourished before starting a course of RT.
Some patient may also suffer from chronic radiation enteritis (inflammation of the
i 1 1 1 i\line). Let us learn how to manage this condition.
Clzro/l/c / \ ' t i i l i ( / ~Enteritis

i~~~
First of all the ~ L ~ L I . I ~ ~ O I\ >I , , I II IL I ~ 01 LJIU I ) ; I ~ I C.\110uld

I~~ be assessed. Assessment of
selected biochemical parameters, radiographic studies of the intestinal tract, and
absorption studies should be carried out. Dietary management iilcludes restrictioil of
fat, fiber, lactose and glutens. This may help in the symptomatic relief and improved
nutrition. In patients with severe radiation enteritis who are unable to maintain their
weight wit11 oral or enteral diets, TPN is absolutely essential. It helps them to gain
weight and improve overall nutrition.
Next, we shall lear~labout chemotheraphy.
8.6.3 Chemotherapy
Chemotherapy results in lot of side effects. This is because the drug effects are not
specific to cancer cclls alone. Even the host cells will be affected by chemotherapy.
The severity of these side effects depends 011 factors such as the type of drug, dosage,
duration of treatment, patient's nutritional status and individ~~alsusceptibility. Major
areas affected by side effects are alimentary tract and bonc marrow. 111soille instances,
major effects occur on renal tubules and also in hcpnric, cardiac. pulmonary and
nerve cells.
Nausea and vomiting may occur acutely and in some cases it may be delayed for 24
hours or more after receiving chemotherapy. Factors influencing emeses - 'vomiting'
include patient sensitivity, type of drug, dosage and frequency as well as route of
administration.
The nitrogen equilibrium present before chemotherapy cllanges to negative nitrogen
balance. Protein turnover, synthesis and catabolism decrease with the drug therapy
despite continuing intravenous nutrition support.
A thorough study of the more commollly used chemotl~erapeuticagents, their
mechanisms of action and potential side effects that iiffluence nutritional status should
be undertaken. Let us review the nutrilional support in chemotherapy next.

Antiemetics are used in the treatment of chemotherapy induced nausea and vomiting.
Antiemetics become absolutely necessary to promote enha~lcedadherence to
therapeutic programmes and better intake of food and fluids.
1. Which is the most important factor on which dietary management of cancer
depend up on? Also list the three types of cancer therapy.
........................................................................................................................
. . . . . . . . . . . . . . . . . . . . .
...........................................................................11........ ....................................
............................................................................................................. .........
........................................................................................................................
Nutrition 2. Discuss the nutritional support management of the following:
a) Head and Neck Tumor
b) Oesophageal Carcinoma
...................................................................................................................
...................................................................................................................
...................................................................................................................
c) Dumping Syndrome
...................................................................................................................
d) Pancreatic Carcinoma
3. Enumerate the various factors contributing to the malabsorption that occurs

in radiation damage.
........................................................................................................................
........................................................................................................................
........................................................................................................................
4. What are the side effects of chemotherapy?
8.7 CANCER PREVENTION

A continuing and urgent need is there to take all steps to prevent cancer. Cancer rates
are set to increase another 50 percent by the year 2020. Based on the current
knowledge and research evidence, certain guidelines are recommended for cancer
prevention. These are highlighted next.
8.7.1 Guidelines for Cancer Prevention

Tile guidelines for cancer prevention focus on tlie following:
1. Iilclude plant-based diet, limiting red meat in particular.
2. Limiting t d t consumption, especially saturated fat. Total fat consumption sllould
not exceed 30% of total energy intake.
0
3, Avoiding or limiting alcohol. Nutrition, Diet and
Cancer
4. Reducing intake of energy rich foods.
5. Include more of vegetables and cut down cereals.
6. Increase fiber intake to 20 to 30 grams per day.

7. Include a variety of vegetables and fruits daily in your diet.
8. Minimize consumption of salt-cured, salt-pickled and smoked foods.
9. Control body weight and prevent obesity.
And other additional recommendation is varying food choices. Instead of eating the
same type of food, try and include a variety of other foods. This will help to dilute
whatever is in one food with what is in the other foods.
Next, we shall review research finding related to specific foods and nutrients which
play an importants role in cancer prevention.
8.7.2 Research Findings Related to Cancer Prevention

In this section we shall discuss some of the research findings related to cancer
prevention. Many of the natural, cancer-fighting pl~ytochemicalsare found in citrus
fruits, cruciferous vegetables such as broccoli, brussels sprouts and cauliflower.
Alpha Lipoic Acid (ALA),a potent antioxidant, has been used in the prevention and
treatment of cancer. It is found in foods such as potatoes, carrots, yarn and red meat,
and is synthesized in the body. Astaxanthin, a fat-soluble carotenoid has been found
to have the ability to fight cancer. Flavonoid, a colour pigment is found to possess
anti-inflammatory compounds and protect against cancer. The rich food sources of
this flavonoid are garlic, carrots, brinjal, grape fruit, onions, oranges, red cabbage, tea
and tomatoes. Low blood levels of glutathione are associated with problems such as
heart disease and cancer. Foods rich in this, such as asparagus and avocado can be
included more often in our diet.
Vitamin C is another well researched water soluble vitamin, which is found to destroy
cancer-causing agents. Food sources include broccoli, brussels sprouts. Consumption
of these vegetables has been found to increase in the Indian dietary. Capsicum, lime,
orange, papaya and amla are other rich sources. Vitainill E, a fat-soluble vitamin is
another antioxidant which call be used for cancer prevention. Food sources of this
vitamin are almonds, soybeans, spinach, sunflower seeds, sweet potatoes, walnut,
wheat germ, and whole-wheat flour. Laboratory studies suggest that omega - 3 -
fatty acids found in fish, walnuts, soybean oils many help protect against cancer. -
Dietary fiber is found to exert a protective effect against colon cancer by several
mechanisms. It [nay bind wit11 some of the potential carcinogens thereby reducing the
exposure of epithelial surfaces to potential carcinogens. It ii~fluencesin decreased
formation or enhanced excretion of potential carcinogens. It influences intestinal flora
with decreased degradation of bile acids and neutral sterols and diluting potential
carcinogen in the bowel. Unrefined carbohydrates such as wllole wheat, brown rice
contain dietary fiber, which is linked to lower colon cancer risk. The impact of nuts on
the cancer is less certain. The studies link regular consumption of nuts, seeds and
beans with lower risk of prostrate cancer. Laboratory research has identified at least
five natural phytochemicals in nuts that seem to offer protection against cancer
development although 101s remain to be learned about this process.
The goal is a balanced, mostly plant-based diet with plenty of fruits, vegetables, whole
grains, beans and nuts in the prevention of cancer. Antioxidants play a very important
role in treating people with different types of cancers,
Nutrition
8.7.3 Role of Antioxidants in Cancer Prevention
What are antioxidants?To put it simply, antioxidants are important nntr4rally occurring
nutrients, (vitamins, minerals).which help to protect body from certain types of
cancers. Vitamin A, vitamin C and vitamin E are well proved antioxidants in treating
cancers such as gastrointestinal, cervical and breast cancers. Also, antioxidants
decrease the risk of cancer mortality.
How to antioxidants work? As cells function normally in the body, they produce
damaged molecules called free radicals about which you have already studied in the
Nutritional Biochemistry Course (MFN-002) in Unit 9. These frce radicals, we learnt
are highly unstable and steal components from other cellular molecules, such as fat,
protein, or DNA, thereby spreading the damage. This damage continues in a chain
reaction, and entire cells soon become damaged and die. This process is called
peroxidation. Peroxidation is useful because it helps the body destroy cells that have
outlived their usefulness and kills germs and parasites. However, peroxidation, when
left unchecked, also destroys or damages healthy cells. Antioxidants help prevent
widespread cellular destruction by willingly donating components to stabilize free
radicals. More importantly, antioxidants return to the surface of the cell to stabilize
rather than damage other cellular components.
Lycopene is a carotenoid which colours fruits and vegetables and is most abundantly
present in the prostrate gland. Studies have shown that this carotenoid reduces the
risk of various deadly cancers including cancers of the prostrate, colon and rectum.
High intake of lycopene by patients with prostrate cancer has caused a regression in
the disease and decreased the malignancy.
Fat-soluble vitamin A compounds include retinol, retinal and retinoic acid. This group
is vital for eye and retinal function, protects the niucous membrane and reduces the
risk of infection. Therefore, it is called an immune enhancer and reduces the risk of
cancer. Apart from reducing the cancer mortality, it helps in treating cancer patients
who have had surgery to remove primary tumors.
Vitamin Aand carotenoids antioxidant and immune stimulatory property have developed
synergistic cancer treatment application. Vitamin A levels decrease during
chemotherapy. Hence, additional intake of vitamin A is recommended during
chemotherapy.
Vitamin C based on research evidence plays an important role in the prevention and
treatment of cancer. Its anti cancer properties are:
e Scavenging cancer causing free radicals such as hydrogen peroxide to prevent

- lipid peroxidation,
Neutralizing carcinogenic chemicals,
e Generating potent antioxidant vitamin E,

o Enhancing lymphocyte function and rapid mobilization of phagocytes,
e Potent an tiviral and antibacterial activity,
e Enhancement of immunoglobulins IgA, IgM,
e Modulation of interferon synthesis, and
e Increasing synthesis of prostaglandin.
Research studies reveal that, higher the vitamin C intake, lower the level of mortality
for all cancer patients. Vitamin C reduces the risk of gastrointestinal cancer, breast
cancer and liver cancer.
Various other studies have proved vitamin E to be effective in decreasing the risk of Nutrition, Diet and
Cancer
colon cancer, inhibiting breast tumors, reducing the severity of liver cancer and also
restoring the cellular immune function inpatients treated with radiotherapy. Mentioned
below is a list of cancer preventive nutrientslfood conpoilents and their food sources.
Foods Related to Cancer Prevention
Active ingredient Food sources
Phytochemicals Fruits, broccoli, cauliflower, etc.
Alpha Lipoic Acid (ALA) Potatoes, Spinach
Anthaxanthin & Flavonoids Fruits, vegetables, grains
Lycopene Fruits and vegetables (especially tomatoes)
Flavonoids Garlic, Carrots, Onions, Brinjal, Red cabbage,
tomatoes grapefruit, oranges, tea.
Glutathione Asparagus and avocado
Fiber Whole wheat, Brown Rice, Nuts, Fruits and
Vegetables.
Vitamin A Butter, dairy products, fish oils, carrots, egg, yolk.
Vitamin E Almonds, soybeans, spinach, sunflower seeds, sweet
potatoes, walnuts, wheat germ, whole wheat flour.
Selenium Seafoods
To sum up, low plasma levels of all major essential antioxidants (Vitamin A, C, E and
beta carotene) is associated with an increased risk of cancer mortality. Hence, the
plasma levels of these antioxidants have to be increased to reduce the risk of cancer
by providing diets rich in these antioxidants. Selenium is an essential micronutrieilt and
the best source of selenium is seafood. It is toxic in extremely high doses (2.5 to 3.0 g/
day), but normal level of 50-200 microgranls per day is safe. It is a potent antioxidant.
Selenium reduces the risk of breast cancer and inhibits colon cancer due to challges in
prostaglandin synthesis. The antioxidant property protects the body against
environmental and chemical sensitivities and their immune functions enhance the body's
antibacterial and antiviral defenses.
With a review on antioxidants and their role in cancer prevention we end our study on
nutrition, diet and cancer.
- -

1. Discuss the guidelines for cancer prevention.
......... ........................................
.......................................................................................................................
......................................................................................................................
......................................................................................................................
2. What are antioxidants? Discuss the role of antioxidants in cancer prevention.
......................................................................................................................
......................................r.......................
......................................................................................................................
.....................................................................................................................
..................
Nutrition 3. Why vitamin A is @led an immune enhancer? Why additional intake of
; 1 4:, vitjmili'A is gcommended during chemotherapy?
'
fiQ:lg{ik.t j.,/ .::, t
a .......................I......1......................................................................................
...................................................................................................................
......................................................................................................................
4. Discuss the anti-cancer properties of vitamin C.
.............................................
.........I ............................................................................................................
......................................................................................................................
5. Match the following:
i) Phytochemicals a) Carrots
ii) Flavonoid b) Sea food
iii) Glutathione c) Whole Wheat
iv) Selenium d) Brocoli
v) Dietary Fibre e) Asparagus
LET US SUM UP
In this unit, we studied about what is cancer, how it develops and how cancer cells
differ from iiormal cells. We also learnt about the characteristics and types of cancer.
Tl~enwc focused on the major etiological (risk) factors associated with causation of
cancer. These, as you would recall, include genetic factors, environmental factors,
dietary and non-dietary factors, as well as, the stress factors. After this, we nloved on
to the discussion on various metabolic abnormalilies associated with cancel; referred
to as cancer cachexia.
Finally, we looked at the nutritional problems and clinical manifestations associated
with cancer, Our last section focused on the therapies for different types of cancers
* along with their dietary management and feeding problems.
Lastly, we dealt with a few guidelines pertaining to cancer prevention, the research
findings and the role of antioxidants in preventing cancer.
Anastomosis : the intercommunication between two or more vessels

or nerves, as the cross communication between arteries
or veins.
An ti-emetics : drugs that prevent or relieve nausea and vomiting.
Anorexia : loss or deficiency of appetite for food.
Benign tumor : mass of abnormal tissue that is encapsulated and does
not infiltrate adjacent tissue.
Cancer cachexia : a stage of marked body dysfunclion, general ill health ,
malnutrition, anorexia and anaemia.
Carcinogen : any cancer producing substance/agent.
Chemotherapy : the use of certain drugs to treat a disease as distinct
from other form of treatment, such as surgery.
Nutrition, Diet and t
I !,
I
Cheilosis : inflammation and cracking of the lips.
Cancer /I'
Coma : a sleep-like state in which a person is not conscious.
Cori Cycle : the conversion of glucose to lactate in the skeletal muscle
on exertion and then lactate to glucose in the liver.
Cytokines : non-antibody proteins secreted by inflamtnatory
leukocytes and some non-leukocytic cells that act as
intercellular mediator.
Dumping syndrome : a syndrome that occurs when food moves too fast from
the stomach into the small ilitestine.
Dyshagia : difficulty in swallowing.
Enteral feeding : a way to provide food through a tube placed in the nose,
stomach, or the small intestine.
Eutopic hormones : a peptide hormone released from its usual site or from a
neoplasm of that tissue.
Fistula : an abnormal collnectioll between two organs, or
between an organ and outside of the body.
Gametes : the reproductive cells in multicellular organisms.
Glossitis : inflatnmation of the tongue.
Glossectomy : the surgical removal of all or part of the tongue.
Hypocalcemia : excessive calcium in the blood .
Ileostomy : a surgically made fistula between ileum and anterior
abdominal wall as a permanent artificial anus when
whole of large bowel has to be removed.
Interferon : a protein produced naturally by the cells of our bodies
and increases the resistance of surrounding cells to
attacks by viruses.
Malignant : mass of abnorinal tissues that is not encapsulated and
infiltrates adjacent tissue,
Melanocarcinoma : a malignant tumour or melanocytes predominantly
occurring in the skin.
Neoplasm : an abnormal growth of tissue which may be benign or
malignant.
Ody nophagia : severe pain or swallowing due to a disorder of the
oesophagus.
Oesophagitis : an inflammation of the oesophagus.
Oncogenes : genes that promote cell growth and duplication. They
may undergo changes that activate them, causing cells
to grow too quickly and form tumors.
Oncogenic osteomalacia : tumour-induced osteomalacia.
Papillomas : benign epithelial tumors that are caused by infection with
the human papilloma virus (HPV).
Parenteral feeding : a way to provide a liquid food mixture through a special
tube in the large central or peripheral vein.
Phytochemicals :any chemical or nutrient derived from a plant source
and have a beneficial effect on health or an active role
in treatment and/or prevention of diseases.
Clinicnl Therapeutic Proctocolectoiny : surgical procedure of an operation to remove the colon
Nutrition
and rectum.
Prostaglandins : a lipid molecule that is derived from fatty acids and
have a variety of strong and important physiological
effects.
Steatorrhea : a passage of pale, bulk, greasy stools due to defects of
fat absorption from gut.
Stricture : an abnormal narrowing of a duct, canal or passage, due
. to scarring or a tumor.
Stupor : a condition in which an affected individual is conscious
with some ability to move voluntarily but shows a
markedly reduced response to stimuli.
Tachycardia : an abnormally rapid beating of the heart defined as a
resting heart rate of over 100 beats per minute.
Xerostomia : marked reductio~lin secretioli of salivary glands
ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
1. a) Carcinogen: a carcinogen is any substance or agent that promotes cancer.
b) Tumor: Tumor originally means swelling and is sometimes still used with
that meaning. The term is now primarily used to denote abliorlnal growth.
Malignant tumors are called cancer.
c) Metasis: derived from greekword which means change of the state. It is
the sprcacl ol' cancer from its primary site to other places in the body (e.g,
h r a i ~ i Ii~~cs).
.
d) Oncogenic virus: They transfer their genetic material to other cells and
then remain in the body for longtime as latent infection (meaning that they
are dormant or inactive, but not dead), or as a chronic infection (meaning
that the infection occurs for a long time).
e) Antioncogens: There are generally recognized as cancer suppressing factors
or genes which prevent the multiplication and hence the growth of a tumor.
2. The term cancer refers to abnormal and uncontrolled multiplication of cells/ cell
divisions. It is essentially a consequence of genetic mulations within a cell which
result in the production and proliferation of abnormal cells. The development of
cancer is a complex multi-stage process and includes the three stages, namely
initiation, promotion and progression. For details on these stages look up sub-
section 8.2.1.
3. As compared to normal cells; carcinogenic cells have a high nuclear to cytoplasm
ratio, prominent nuclei and due to altered multiplication of several mitosis may be
seen. Malignant tumors may be seen as invading cells into normal healthy tissue.
4. The risk factors associate with the occurrence/developme~ztof cancer
include: genetic factors; environmental factors such as air, water pollution
and exposure to sunlight.; life style: smoking, bettlel tobacco chewing alcohol
sedentary and dietary factors. For a brief discussion on dietary factors look up
sub-section 8.3.3.
5, a) - iv)
b) - iii)
c) - i)
d) - v) \
e) - iii I
1 1
Check Your Progress Exercise 2 Nutrition, Diet and ,
1. Advailccd ncopl;~stic diseases are associated with progressive weight loss,

anorexia, gcneri~li~ed vvilsling, immunosuppresion altered basal metabolic rate
and abnorm:~liliesin the metabolism of energy, protein, fat, fluids and several
electrolytes, which is also termed as cancer cachexia.
2. Changes in protein metabolism include: notable loss of skeletal muscle protein,
visceral organatrophy and hypoalbuminemia, inappropriate elevations in whole-
body protein turnover, increase in muscle protein synthesis, catabolism and liver
protein synthesis, and negative nitrogen balance due to low protein (food) intake.
3. Cytokines are polypoeptides whicll influence the proliferation differentiation,
metabolism and activation of cells.
4. Cancer is a chronic degenerative disease which may impose varied demands on
the nutritioilal and healtli status of a patient, The most common ones being:
weight loss, dehydration and deficiency of electrolytes, anaemia, hypercalcemia
and malnutrition.
For details look up sub-section 8.4.2.
1. While the line of treatment for cancer patient depends upon the site of cancer
development, dietary management is governed by proper nutrition screening
and assessment. This includes the present nutrition / health status, requirements
in terms of quantity1 quality of nutrients and nutritional support required for
efficient and adequate management of the disease.The three types of cancer
therapy include: chemotherapy, radiatibn lherapy and surgery.
2. 1) Head and Neck tumor may cause difficulty in chewing1 swallowing,
xerostoma, alterations in taste/ smell, fibrosis of salivary glands etc. Enteral
feeding through nasojejunal, nasogastric route or gastrostomies would be
required to ensure adequale intake of calories and macro/micro-nutrients.
b) Oesophegeal carciiloina may cause esophageal fibrosis/ stenosisl necrosis,

d ysphagia, heart burn fatigue. Oral intake may not be feasible due to absence
of upper and lowcr oesophageal sphincter. Small frequent tube feeds rich
in carbohydrates and protein but moderate in fat should be preferred. The
feeding tube should open in the other part of the stomacl~/justabove the
small intestine to prevent regurgitation of the acidic gastric contents (if the
sphincters are damaged.).
c ) Dumping syndrome generally occurs post-operatively. The patient should

be given a high protein, moderate fat diet restricted in simple carbohydrates.
The fibre content of the meals should be high to prolong gastro-intestinal
transit time. Small frequent meals (6-7) should be served and the patient
should avoid drinking water/fluids with meals.
d) For pancreatic cancer, modifications may be reqdred in the quality of diet

being given to the patient. Emphasis should be laid on medium chain
triglycerides and oligosaccharides. Meals should be co-ordinated with
pancreatic enzyme supplementatioll therapy and the insulin status of the
patient.
3. Malabsorplion associated with radiation therapy can occur due to atrophy,
degeneration of the digestive and / or absorptive surfaces/ organs, obstmction(s)
in the gastrointestinal tract, secondary changes in the villi resulting in deficiency
of disaccharides and dumping syndrome
4. Chemotherapy affects both the cancer, as well as, normal cells of the body and
is frequently associated with repeated episodes of nausea and vommitting.
Alternations in taste sensations and dryness of mouth lower/ hinder food intake
Clinical Therapeutic and result in the development of cancer cachexia. Chemotherapy may affect
Nutrition
the structure and/or functional capacity of several organs such as alimentary
tract, bone marrow, renal tubules, hepatic, cardiac, pullnonary and nerve cells.
1. The guidelines for preveiltion of cilncer emphasize on including plant-based diet,
limiting red meat in particular, limiting consumption of saturated fat, total fat
consumption should not exceed 30%of total energy intake, avoiding or limiting
alcohol, reducing intake of energy rich foods, control body weight and prevent
obesity.
2. Antioxidants are substances that may protect cells from the damage caused by
unstable molecules known as free radicals. Exanlples of antioxidants include:
p carotene, lycopene, vitamin K,C,E and certain phytocheinicals.
Antioxidallts neutralize free radicals as the natural by-product of normal cell
processes. Antioxidants are often described as "mopping up" free radicals,
meaning they neutralize the electrical charge and prevent the free radical from
taking electrons from other molecules, and causing damage to the DNA and
preventing cancer.
3. Vitamin A is called an immune enhancer because it protects the cells from free
radical damage and reduces the risk of infections. Cancer and its treatment
weaken the body's immune system by affecting the blood cells that protect us
against disease and foreign organisms. As a result, the body cannot fight infection
and other diseases caused by toxin/ chemicals. Thus, vitamin A is suggested to
be taken in liberal amounts during chemotherapy.
4. The chemopreve~ltiveproperties of vitamin C!are highlighted in sub-section 8.7.3.
Read them carefully and answer on your own.
ii) - d)
ii) - e)
iv) - b)
v) - c)

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UNIT 8 NUTRTTION, DIET

8.3 Etiological Risk Factors in Cancer

8.4 Metabolic Alterations and the Resultant Nutritional Problems/Clinical

8.5 Nutritional Requirements of Cancer Patients -General Guidelines

8.8 Let Us Suin Up

8.2.1 Development of Cancer

1 e Exposure to carcinogen I e Cancer development (e Formation of tumor I

Figure 8.1: Steps in develop~nentof cancer

What do you understand by carciitogert?

Carcinogen is an agent or a process, which significantly triggers lhe cell to grow in an

8.2.2 Characteristics of Cancer

8.2.3 Identification of Cancer Cells

ETIQLOGIC'IALRISK FACTORS IN CANCER

8.3.1 Genetic Factors

8.3.3 Carcinogenic: Dietary Factors

Next, let us learn about the non-dietary carcinogenic factors.

8.3.4 Carcinogenic: Non-dietary Factors

Let us review these factors.

2. Nasophary nx Salted fish Tobacco smoking and

4. Oesophagus Alcohol, very 1101 Tobacco slnoki~lg Lack ol'

3. People who drink more than 2 to 3 glasses of beer or wine or whisky in a

d) Oncogenic virus: ...................... .

5. Match the following:

8.4 METABOLIC AXTIERATIONSAND THE

8.5 NUTRITIONAL REQUImMENTS OF

Cancer we know is a chronic degenerative disease characterized by cancer cachexia

With a basic understanding on the nutrient requirements, in our subsequeilt discussions

8.6 DIETARY MANAGEMENT OF CANCER

a) Head and Neck Tumor

Nutritional Support Management

b) Oesoplzageal Carcinoma 111/1

Surgical treatment usually involves total or distal oesophagect.omy(procedure lo remove

Postoperative stricture (narrowing of a passage due to scar tissue or tumor) may

Clzro/l/c / \ ' t i i l i ( / ~Enteritis

First of all the ~ L ~ L I . I ~ ~ O I\ >I , , I II IL I ~ 01 LJIU I ) ; I ~ I C.\110uld

Nutritional Support Management

3. Enumerate the various factors contributing to the malabsorption that occurs

8.7 CANCER PREVENTION

8.7.1 Guidelines for Cancer Prevention

6. Increase fiber intake to 20 to 30 grams per day.

8. Minimize consumption of salt-cured, salt-pickled and smoked foods.

9. Control body weight and prevent obesity.

8.7.2 Research Findings Related to Cancer Prevention

e Scavenging cancer causing free radicals such as hydrogen peroxide to prevent

Neutralizing carcinogenic chemicals,

e Generating potent antioxidant vitamin E,

e Enhancement of immunoglobulins IgA, IgM,

e Modulation of interferon synthesis, and

e Increasing synthesis of prostaglandin.

Check Your Progress Exercise 4

fiQ:lg{ik.t j.,/ .::, t

Anastomosis : the intercommunication between two or more vessels

ANSWERS TO CHECK YOUR PROGRESS

1. Advailccd ncopl;~stic diseases are associated with progressive weight loss,

b) Oesophegeal carciiloina may cause esophageal fibrosis/ stenosisl necrosis,

c ) Dumping syndrome generally occurs post-operatively. The patient should

d) For pancreatic cancer, modifications may be reqdred in the quality of diet

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