NEW YORK CITY—Patients with pancreatic cancer who undergo surgery, chemotherapy, or radiation can experience a number of nutritional and digestive problems such as weight loss and pancreatic insufficiency, which can be effectively managed with medical nutrition therapy. So said Jeannine B. Mills, MS, RD, LD, an Oncology Dietitian at the Norris Cotton Cancer Center at Dartmouth Hitchcock Medical Center, during a presentation here at the Pancreatic Cancer Symposium.
“Patients with pancreatic cancer tend to share the same complaints,” said Ms. Mills. In addition to weight loss, patients may have to contend with a number of overlapping digestive conditions, including pancreatic insufficiency, poor appetite, early satiety, diarrhea, constipation, nausea, lactose intolerance, and symptoms specific to having undergone Whipple surgery.
Because the pancreas is the digestive system's main enzyme-producing organ, such gastrointestinal symptoms can occur in these patients, explained Nessa Coyle, NP, PhD, FAAN, a nurse practitioner in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center, who spoke at a separate session at the symposium.
Additionally, some symptoms may be due to the cancer itself or disease therapy. For example, loss of appetite, feeling full quickly, and weight loss may all be associated with the cancer, its treatment, or a combination of the two.
Nutrition symptom management can be used to address challenges unique to pancreatic cancer patients, Ms. Mills explained. Early nutrition therapy may help avoid or reverse the catabolic effects of the disease, while controlling treatment-related side effects and improving quality of life. Additionally, researchers are evaluating potential new nutritional therapies.
More than 90% of patients with pancreatic cancer experience weight loss, Ms. Mills said, adding that maintaining weight is therefore the most important goal.
Patients need healthy fats such as olive oil, nuts, seeds, salmon, and avocado in their diet, and fats help to provide twice the amount of calories per gram than carbohydrates or proteins, she explained.
Proteins are also needed and help to support body mass. “Cottage cheese, yogurt, and soybeans are a great source of calories and protein,” she said.
Pancreatic insufficiency occurs in about 25% of patients who have undergone Whipple surgery, Ms. Mills noted. Symptoms, however, can occur at all stages of disease—at diagnosis, during treatment, and following surgery.
Patients can experience a 10% reduction in pancreatic enzymes and may therefore have problems with fat and micronutrient malabsorption. Symptoms of pancreatic insufficiency include gas, bloating, indigestion, cramping, abdominal pain, and loose, frequent, floating, or very foul-smelling stools. Diarrhea may be masked by narcotics or pain relievers, which can cause constipation.
Pancreatic enzyme therapy may help to relieve some of the patient's symptoms. Prescriptions are available through physicians or nurses, and some over-the-counter options are available, although they are not regulated by the Food and Drug Administration, Ms. Mills noted.
“So many of them are different in activity and potency. Consequently, patients taking enzymes such as pancreatin and Viokase may have different responses. All pharmaceutical manufacturers of pancreatic enzymes will have to comply with FDA standards by 2008.
Patients taking enzymes should be dosed based on the amount of fat they take in, Ms. Mills said. Data indicate that 4,000 units of lipase per 5 to 7 grams of fat are recommended. Patients should generally take two or three lipase tablets before a meal, and one before a snack, she added.
Taking digestive enzymes throughout a meal is optimal. “Line your enzymes alongside a plate,” Ms. Mills said. On average patients take 35,000 units of lipase per meal.
Excessive doses can result in nausea, abdominal cramps, or diarrhea, though, she warned. But more often patients may complain of constipation. Patients should not take antacids such as calcium carbonate or magnesium hydroxide with lipase because they will counteract the enzyme's effectiveness. Proton pump inhibitors and H2 blockers increase the activity of pancreatic enzymes.
If diarrhea is a problem, patients may want to consider 1 tsp of soluble fiber in 2 ounces of water after meals to help bulk the stool, she said. Tincture of opium can help to slow intestinal transit, and Imodium or Lomotil can help with diarrhea.
Poor Appetite, Dysgeusia
Poor appetite and impaired taste are also concerns. Small frequent meals that are high in protein and calories, experimenting with different nutrient rich foods, and keeping small snacks nearby are strategies that may help patients get enough nutrients, Dr. Coyle said.
Patients may also need to learn how to manage impaired taste. Foods can often taste too salty, sweet, bitter, or bland. Good oral care and rinsing the mouth before eating can help combat the condition.
Some of Ms. Mills' patients have found that using fresh herbs or squeezing lemon on foods can improve taste, she said. In addition, cool foods and foods at room temperature may also be more appealing to patients than hot foods.
Appetite stimulants such as Megace, Marinol, or low-dose steroids are another option for these individuals. Health care professionals also need to assess whether lack of appetite is due to pain or depression, she added.
“Early satiety happens so often in our patients that they can't manage to eat what they used to eat,” Ms. Mills said. Eating small servings more often, even if this consists of a single cracker and a slice of cheese, may help.
Alleviating gas and bloating can reduce feelings of satiety. Taking Beano before meals can aid with relief by breaking down complex carbohydrates. Gas-X after a meal can relieve additional gas and bloating, she said.
Drinking liquids between meals rather than while eating can help patients not feel as full. Avoiding higher fat or fried foods, which tend to be filling after eating only a small portion, is another important consideration.
To help relieve diarrhea related to treatment for pancreatic cancer, Ms. Mills emphasizes adequate fluid intake, which helps to combat potassium and sodium imbalances. The patient should drink a cup of water for each loose stool. “I prefer Pedialyte instead of Gatorade, which I flavor with Crystal Light,” she said.
Diarrhea may be associated with a lack of pancreatic enzymes and difficulty digesting fats, Dr. Coyle explained. It can also be associated with chemotherapy, radiation, antibiotics, infection, or constipation.
Management will depend on the cause. Patients will need to replace fluid loss, and pancreatic-enzyme replacement may be indicated. Avoiding fatty foods may also be necessary.
Constipation can be caused by decreased activity, decreased food and fluid intake, pain, fatigue, and narcotics, Ms. Mills said. A bowel protocol may be warranted, which may include increasing the intake of warm liquids and fiber and limiting gas-forming foods, carbonated beverages, straws, and chewing gum.
Constipation may add to feelings of nausea, bloating, fullness, lack of appetite, and abdominal pain. Stool softeners, bowel stimulants, and osmotic laxatives may also be a part of therapy.
Another common digestive problem is nausea. Nausea and vomiting can be relieved with anti-nausea medications and by eliminating offending odors; avoiding foods that are overly sweet, greasy, fried or spicy; and cooling foods to room temperature, Ms. Mills said. Patients should also be reminded to maintain good oral care.
“Cold fruit seems to make patients feel better when they are feeling nauseated,” she said, adding that watermelon, cantaloupe, and grapes are popular choices.
Lactose intolerance can become a problem after radiation therapy or surgery. This may be temporary, and the patient may be able to tolerate low-lactose foods such as aged cheese and yogurt. Providing the patients with lactase enzymes taken before a high-dairy meal is often recommended, Ms. Mills said.
Patient may need to limit or avoid dairy foods, Dr. Coyle agreed.
Nutritional Therapy Specific to Whipple Surgery
After Whipple surgery, patients may experience dumping, delayed gastric emptying, poor appetite, or glucose intolerance.
“Eating after surgery is going to be a little different,” Ms. Mills explained. “The stomach is smaller, the duodenum is removed, and the remaining pancreas and stomach are both reconnected to the small intestine.” Transit time may be affected, she added.
Because of these changes, preoperative nutrition is important. Well-nourished patients will be less compromised, less likely to develop an infection, and able to better tolerate surgery.
Following Whipple surgery, patients may or may not have a jejunostomy feeding tube. If patients have a tube, feeding will generally be cycled to night time, said Ms. Mills. An oral diet will start with clear liquids and advance to regular food. Initially, patients need to eat smaller meals and avoid greasy and fried foods, and raw fruits and vegetables.
Three months out from surgery, nutritionists will continue to work with patients to decrease the intake of greasy and fatty foods and replace these with foods containing good fats. Patients also need to eat five to nine servings of fruit and vegetables a day.
People are often not able to achieve normal fat-absorption after Whipple, Ms. Mills noted. However, the goals are to eliminate diarrhea, restore adequate nutrition, prevent weight loss, and decrease symptoms.
Patients will also need to take enzymes to aid digestion, as well as a proton pump inhibitor or H2 blocker. Additionally, exercising or increasing activity to at least 30 minutes a day most days and weight training as advised by the individual's surgeon are important to recovery, she said.
Impact on Cancer Development
While nutritionists can offer patients with pancreatic cancer a number of strategies to manage gastrointestinal symptoms, researchers continue to develop an understanding of how the compounds found in foods can affect disease.
For example, noted Jeannine B. Mills, MS, RD, LD, of the Norris Cotton Cancer Center at Dartmouth Hitchcock Medical Center, the literature indicates that omega-3 fatty acids, which contain eicosapentanoic and docosohexanoic acids, may create an anti-inflammatory response, inhibiting cancer cell growth and enhancing apoptosis.
In addition, on the basis of promising pilot study data, the National Center for Complementary and Alternative Medicine and the National Cancer Institute are funding a clinical trial comparing gemcitabine-containing chemotherapy with an alternative cancer treatment consisting of proteolytic-enzyme therapy with nutritional support (the Gonzalez regimen) to treat patients with advanced pancreatic cancer.
Study results should be available in the next two to three years, Ms. Mills said.
Other trials include a Phase II study of curcumin in advanced pancreatic cancer and an evaluation of ghrelin levels, a newly discovered stomach hormone that may cause weight loss in pancreatic cancer patients.
Phytochemicals in fruits and vegetable may also help to deter cancer, although more research is needed, she said. “We're in the infancy of understanding how nutrition impacts cancer. But I feel strongly that it's an important relationship.”