Oncology  
            Nutrition 
            Connection
            A publication of the ON DPG                                                                                                       Volume 23, Number 1, 2015
            ON DPG Website                                                                                                                                   ISSN 1545-9896
            www.oncologynutrition.org
              Table of Contents                                      Message from the Chair
              •  Message from the Chair                              I hope everyone is enjoying the beginning of 
                page 1                                               summer and looking forward to some summer 
                                                                     fun. I know I am looking forward to beginning  
              •  Case Study: Adult Gastric                           the new year with ON DPG. As I’m diving into my 
                Cancer Patient—Surgery and                           DPG-related activities, I want to give a special 
                Chemoradiation Therapy                               thanks to the many hard-working people who 
                page 2                                               have shared their time and expertise with the  
              •  Pediatric Oncology Nutrition                        ON DPG Executive Committee (EC).
                Corner: Low Microbial Diet  
                in the Oncology Population                           More than two dozen dedicated individuals                 In addition to the Benchmarking Project, 
                page 10                                              are working hard to ensure that the many                  we’ve planned some great sessions for you  
                                                                     benefits of being an ON DPG member are                    at FNCE, taking place October 3-6, 2015  
              •  Congratulations to Your                             provided for you. From our quarterly                      in Nashville, TN. We have our breakfast 
                New ON DPG Executive                                 newsletter to our bi-weekly eBlasts, electronic           reception for members and our Spotlight 
                Committee Members                                    mailing list (EML), recently updated website,             Session: “Marijuana: Is It Medicine Yet for 
                page 12                                              professional alliances, FREE webinars with                Cancer Symptom Management?” on Sunday 
                                                                     CPEs, and more, we have these volunteers to               October 4th. You do not want to miss these 
              •  CPE Articles: Soy and                               thank. When you see what we have in store                 cutting-edge topics. We are also looking 
                Breast Cancer                                        for ON DPG this year, you’ll know why we                  forward to an incredible Symposium in  
                page 13                                              truly appreciate these talented RDNs.                     the spring of 2016 in Glendale, AZ.  
              •  An Innovative Student Project:                      One of our biggest and most exciting projects             These are just a few of the highlights, so be 
                Impact of Diet on the Risk of                        is the collaboration of the ON DPG with the               sure to check out our eBlasts, the website,  
                Developing Stomach Cancer                            Institute of Medicine on a workshop to address            the EML, and future newsletters for more 
                page 18                                              access to nutritional care in cancer centers. This        information on upcoming ON DPG events, 
                                                                     is something our Executive Committee feels                activities, and new resources. We are here for 
                                                                     very passionately about and they are                      our members, and offer our sincerest thank 
                                                                     committed to making this workshop happen                  you for your continued support and interest!
                                                                     this year. Our hope is that every patient will 
                                                                     have access to a dietitian when they enter a              Warmly,
                                                                     cancer center. They deserve this expertise in             Tricia Cox, MS, RD, CSO, LD, CNSC
                                                                     care and we want to see that happen. 
           2  ❙  Oncology Nutrition Connection  ❙  Volume 23, Number 1, 2015
              Oncology Nutrition                                    CASE STUDY of Adult Gastric Cancer 
              Connection                                            Patient status/post Surgery and  
              A publication of Oncology Nutrition (ON), a           Receiving Chemoradiation Therapy
              dietetic practice group of the Academy of             By Nichole Giller, RD, CSO, LD
              Nutrition and Dietetics. ISSN 1545-9896.
              Visit the ON DPG website at  
              www.oncologynutrition.org                             Background                                               Incidence and Survival:
              Editor:                                               Medical Diagnosis:                                       The National Cancer Institute (NCI) 
              Suzanne Dixon, MPH, MS, RDN                                                                                    predicted 22,220 new cases of gastric 
              sdixon@umich.edu                                      Gastric carcinoma is a type of gastric cancer            cancer and 10,990 deaths from gastric 
              Associate Editors:                                    that grows within the stomach wall as                    cancer in the United States (U.S.) in 2014 (4).
              Robin Brannon, MS, RD, CSO                            individual scattered cells, rather than 
              robin.brannon@gmail.com                               forming a single mass or tumor (1). It is 
              Jodie Greear, MS, RD, LDN                             invasive, consistent with cancers that grow              The survival rate of gastric cancer depends 
              jodie.greear@gmail.com                                into normal, healthy tissues.                            on the specific type, stage, and presence of 
              Maureen Leser, MS, RD, CSO, LD                                                                                 metastasis. When diagnosed at stage 1, 
              mgoreleser@gmail.com                                  The patient, FG, was diagnosed with a                    gastric cancer is associated with a 70% cure 
              Jocelyne O’Brien, MPH, RDN, CSO, LDN                  poorly differentiated gastric cancer with                rate; that rate falls to 4% when diagnosed at 
              jocelynenasser@yahoo.com                              histopathologic grade 3 and stage IIIC (2).              stage IV (5). The majority of patients have 
              Oncology Nutrition Connection (ONC) ISSN              The TNM cancer staging system is based on                either regional or distant metastasis when 
              1545-9896, is the official newsletter of the                                                                   diagnosed, which is associated with an 
              Oncology Nutrition Dietetic Practice Group            the size and/or extent (reach) of the primary            overall five-year survival rate of 29% (6). 
              (ON DPG), a practice group of the Academy             tumor (T), whether cancer cells have spread 
              of Nutrition and Dietetics, and is published          to nearby (regional) lymph nodes (N), and 
              quarterly. All issues of ONC are distributed to                                                                Usual medical treatment:
              members in electronic format only.                    whether metastasis (M), or the spread of the             Surgery with concurrent chemoradiation is 
              Articles published in ONC highlight specific          cancer to other parts of the body, has                   commonly used to treat those patients 
              diseases or areas of practice in oncology             occurred (3). The specifics of FG’s stage 2              diagnosed at advanced stages of gastric 
              nutrition. Viewpoints and statements in each          diagnosis include: 
              newsletter do not necessarily reflect the                •  T4a – The tumor (T) has grown through              cancer.
              policies and/or positions of the Academy of 
              Nutrition and Dietetics or ON DPG.                        the stomach wall into the serosa, but the            Usual nutrition needs for patients 
              Oncology Nutrition Connection is indexed in the           cancer has not grown into any of the                 diagnosed with gastric cancer (7):
              Cumulative Index to Nursing and Allied Health             nearby organs or structures.                         Energy: 30-40 kcals/kg (for stable patients 
              Literature. For inquiries regarding copyright,           •  N3b – The cancer has spread to 16 or 
              single-issue sales and past issues, contact the                                                                who are malnourished / in need of 
              editor. Individuals interested in submitting a             more nearby lymph nodes (N).                        nutritional repletion)
              manuscript to ONC should contact the editor              •  M0 – There is no distant metastasis (M); 
              or check the ON website for author guidelines.             (i.e., the cancer has not spread to distant 
              Individuals who are ineligible for membership                                                                  Protein: 1.2-1.5 g/kg (assuming normal renal 
              in the Academy of Nutrition and Dietetics can              organs or sites, such as the liver, lungs,          and hepatic function)
              order yearly subscriptions to ONC for $35.00               or brain).                                             •  With concurrent kidney disease:  
              (domestic fee) and $40.00 (International fee),           •  Stage IIIC - The cancer has grown 
              payable to the Academy of Nutrition and                                                                            0.5-0.6 g/kg (unstressed), 1.0 g/kg  
              Dietetics/ON DPG. Institutions can subscribe               completely through all the layers of the                (with stress and hemodialysis)
              to ONC for $50.00 (domestic yearly fee) and                stomach wall into the serosa, but it has               •  With concurrent encephalopathy: 
              $65.00 (International yearly fee). ON DPG                  not grown into nearby organs or tissues 
              members have access to archived back                                                                               0.6-0.8 g/kg (with end stage liver 
              issues in pdf format. Non-members can order                (T4a). It has spread to 7 or more nearby                disease), 1.0-1.2 g/kg (with cirrhosis)
              printed copies of back issues (contact editor              lymph nodes (N3), but it has not spread             Fluids: 1ml/kcal 
              for availability) at a cost of $10.00 each if              to distant sites (M0). 
              mailed domestically and $20.00 each if 
              mailed internationally. Send requests for                                                                      An Anti-dumping diet is often needed while 
              subscriptions or back issues to the editor. All                                                                recovering from gastric surgery to prevent 
              ON DPG member mailing address changes 
              and email address changes should be sent to                                                                    or alleviate symptoms of dumping 
              the Academy using the address change card                                                                      syndrome. 
              in the Journal of the Academy of Nutrition 
              and Dietetics or at eatright.org in the 
              members-only section.
              ©2015. Oncology Nutrition Dietetic Practice 
              Group. All rights reserved. 
                                                                                                         Oncology Nutrition Connection  ❙  Volume 23, Number 1, 2015  ❙  3
           Case Study                                                Table 1. Common Side Effects and Nutrition Impact Symptoms (NIS) of 
           Introduction:                                             Planned Treatment (8)
           38 y/o female (FG) with history of invasive, 
           poorly differentiated diffuse gastric carcinoma           Medication/Treatment           Nutrition Impact Symptoms / Side Effects
           (found in the lesser curve of the antrum of               Epirubicin                     Nausea, vomiting, diarrhea, mucositis, myelosuppression
           stomach), stage T4aN3bM0 (stage IIIC) was                 Oxaliplatin                     Nausea, vomiting, diarrhea, myelosuppression, hepatic 
           admitted for chemoradiation treatment. FG                                                toxicity, neurotoxicity, myelosuppression
           is s/p laparoscopic subtotal gastrectomy                  Fluorouracil (5-FU)             Nausea, vomiting, diarrhea, myelosuppression, neurotoxicity
           (Roux-en-Y surgery 9/10/2013), with liver                 Radiation to Stomach           Diarrhea, malabsorption, enteritis, fatigue, nausea &  
           wedge biopsy (negative) and scheduled for                 and Abdomen                     vomiting, skin changes (e.g., erythema), urinary & bladder 
           three sets of post-operative outpatient                                                  changes (e.g., cystitis)
           chemotherapy (three cycles per set) and 
           one set of post-operative radiation. 
                                                                     Table 2. Common Nutrition Interventions for Nutrition Impact 
           Baseline Demographics:                                    Symptoms (NIS) Associated with Treatment (9–11)
              •  Age: 38 y/o
              •  Gender: Female                                      Nutrition Impact Symptom  Recommended Nutrition Interventions
              •  Language: English speaking                          Nausea                          Eat 5-6 small meals/day; limit exposure to food odors; 
              •  Korean descent                                                                     consider eating cool, light foods with little odor; avoid 
                                                                                                    greasy & high fat foods; rest with head elevated for 30 
              •  Nonsmoker with no history of alcohol or                                            minutes after eating; take anti-nausea medications as 
               drug use                                                                             directed; consider use of evidence-based complementary 
              •  Employment: worked as a high school                                                therapies, such as standardized ginger dietary supplements 
               social worker prior to her diagnosis and                                             and referral for acupuncture, if available
               treatment                                             Vomiting                        Eat 5-6 small meals/day; limit exposure to food odors; 
                                                                                                    consider eating cool, light foods with little odor; avoid 
              •   Adopted                                                                           greasy & high fat foods; rest with head elevated for 30 
              •  Married with 2 children (10 y/o and 8 y/o)                                         minutes after eating; take anti-nausea medications as 
              •  Many friends and family involved in care                                           directed; consider use of evidence-based complementary 
                                                                                                    therapies such as standardized ginger dietary supplements
           Baseline Nutrition Assessment:                            Diarrhea                        Identify problem foods or eating habits via detailed diet  
                                                                                                    & symptom history; encourage low fat, low fiber, low 
              •  Height: 62 inches                                                                  insoluble and/or low lactose diet; avoid gas producing 
              •  Weight: usual adult weight 148 lbs;                                                foods and alcohol; encourage small, frequent meals; 
               pre-operative weight (9/5/2013) 145 lbs;                                             consider bulking agents, pectin, and foods high in soluble 
                                                                                                    fiber; avoid sorbitol and other sugar-alcohol containing 
               post-op weight (and weight at start of                                               products; consider multivitamin and mineral supplements
               first chemotherapy treatment) 128 lbs.                Mucositis                       Use “Magic Mouthwash” as needed; use a soft toothbrush; 
              •  Body Mass Index (BMI) for pre-op                                                   practice good oral hygiene; use a baking soda + salt 
               weight = 26.5 (overweight range); BMI                                                solution to swish and spit daily; use spoons and straws to 
               at start of first chemotherapy treatment                                             direct food around sores; avoid extreme food temperatures 
               = 23.3 (normal range)                                 Anorexia*                       Encourage small, frequent meals; use medical nutrition 
                                                                                                    beverages; use foods that are easy to prepare and serve; eat 
              •  Good appetite and intake when diagnosed                                            by the clock rather than waiting for appetite or hunger cues; 
              •  Normal diet with acceptable variety of                                             consume liquids between meals rather than with meals
               food when diagnosed                                   Fatigue                         Encourage use of easy-to-prepare meals, snacks, prepared 
              •  FG did report heartburn and abdominal                                              foods, energy dense foods, and medical nutrition 
               pain prior to surgical consult                                                       beverages; advise on use of non-perishable snacks at 
                                                                                                    bedside; eat small, frequent meals and snacks; encourage 
              •  After surgery the inpatient RDN met with                                           energy-saving lifestyle habits 
               FG once to provide post-gastrectomy                   *  Even when anorexia is not a direct side effect of treatment, it can result from other NIS (e.g., nausea). 
               diet education (anti-dumping diet) and 
               to give FG samples of high protein foods 
               and medical nutrition beverages                   oxaliplatin and 5-FU (EOF), followed by                  Cycle 1: EOF (epirubicin, oxaliplatin)  
                                                                 radiation therapy.                                       on Day 1 with continuous infusion  
           Planned Treatment                                                                                              5-FU Days 1-21
           FG was scheduled to receive three sets of             History During the First Set of                          Cycle 2: EOF was stopped secondary  
           outpatient chemotherapy treatments, with              Chemotherapy Treatments (began                           to diarrhea
           each set involving three cycles of epirubicin,        10/16/2013, one-month post-surgery):                                        (Continued on next page)
            4  ❙  Oncology Nutrition Connection  ❙  Volume 23, Number 1, 2015
               Cycle 3: 5-FU was not provided during                   knowledge, skills, experience, and expertise               provided by a dietitian seen in a previous 
               cycle 3 due to grade 3 diarrhea* as                     to complete a comprehensive dietary intake                 consultation, prior to referral to the Certified 
               well as grade 3 Palmar-Plantar                          and analysis, was not consulted until after                Specialist in Oncology Nutrition (CSO). 
               Erythrodysesthesia (PPE) (i.e., severe                  completion of the first set of chemotherapy.
               blisters and hyperkeratosis on hands                                                                               To manage micronutrient losses secondary 
               and feet), (12).                                        During the first set of treatments, FG lost                to diarrhea, FG received a saline solution 
               * Per the Common Terminology Criteria of                17 pounds, or 12% (severe) of beginning                    containing sugar, multivitamins, folate, and 
                Adverse Events version 4.0, Grade 3 diarrhea           weight, which meets criteria for malnutrition              thiamine (referred to as a “Banana Bag” in our 
                is considered severe and reflects ≥7 stools per 
                day over baseline as well as incontinence;             established by the Academy of Nutrition and                institution) three times per week during the 
                hospitalization indicated; severe increase in          Dietetics and the American Society of                      treatment break, along with the maximum 
                ostomy output compared to baseline. 
                Symptoms limit self-care of activities of              Parenteral and Enteral Nutrition (13).                     allowable doses of loperamide and lomotil 
                daily living (ADL) (12).                                                                                          (diphenoxylate and atropine). Per the 
                                                                       After the first set of treatments was                      medical oncologist, FG would need to keep 
            The M.D. requested an outpatient RDN                       completed, the physician noted in the                      weight above 100 pounds, and if unable to 
            consult for nutrition assessment during first              medical record that FG was drinking                        do so, enteral or parenteral nutrition would 
            series of chemotherapy for post-gastrectomy                “protein drinks” and consuming a liquid diet               be provided to improve nutritional intake. 
            symptom management, but patient was                        with > 1000 kcal, > 60 g protein, and > 300 ml             FG’s husband stated she had a good appetite 
            not seen until completion of the first set                 fluids per day. The physician ordered a                    and had been eating well at meal times 
            of treatments.                                             pureed diet for two weeks, because the                     during the break; however, FG was unable  
                                                                       physician felt FG would tolerate pureed                    to gain the physician-requested goal of  
            During the first set of treatments, the surgeon            foods better than solid foods, and the                     10 pounds. Contradictory to the husband’s 
            and nurse practitioner provided nutrition                  physician wanted FG to take in more than                   report, FG’s friend observed she was “just not 
            advice, with the reported goal of maximizing               liquid “protein drinks” for nutrition.                     eating or even taking in the shakes.”  
            calorie and protein intake. They recommended                                                                          FG remained on a regular diet as tolerated. 
            a minimum intake of 850 calories with                      History Between First and                                  She lost an additional 15 pounds during her 
            50 grams protein and 48 ounces of fluid per                Second Set of Treatments:                                  treatment break, confirming an inadequate 
            day. Evidence-based energy needs for a                     The treating physician scheduled a                         intake contributing to further weight loss 
            stressed cancer patient in need of nutrition               one-month break in between the first and                   and malnutrition. 
            repletion are 30-35 kcal/kg, equal to                      second sets of treatments, in order to allow 
            1740-2030 kcal for FG’s pre-chemotherapy                   FG to regain strength. The physician advised               FG’s 45 pound weight loss over four months 
            weight of 58 kg (7). The surgeon’s                         FG “to gain 10 pounds” via a regular diet. On              prompted the treating physician to consult 
            recommended intake goal of 850 kcal                        12/4/2013 the physician ordered a nutrition                the CSO/RDN, who recommended nutrition 
            represents 42-49% of FG’s estimated energy                 consult with an RDN, due to FG’s continued                 support, optimally to begin before the second 
            needs and is inadequate for maintaining                    poor oral intake and ongoing diarrhea. The                 set of treatments commenced. The CSO/RDN 
            nutrition status. FG experienced difficulty                RDN counseled FG on symptom management                     discussed enteral nutrition (J-tube), peripheral 
            eating due to mucositis, diarrhea,                         strategies for diarrhea, nausea, and vomiting;             parenteral nutrition (PPN), and Central 
            constipation, and nausea. The surgeon                      a food pattern that would prevent and/or                   Parenteral Nutrition (CPN) options with the 
            considered placing a peripherally inserted                 reduce risk of dumping syndrome events;                    physician, and CPN was recommended 
            central catheter (PICC) to allow for                       and high energy food and beverage choices                  because of the risk for radiation enteritis and 
            parenteral nutrition (PN), but FG refused                  that were likely to be well-tolerated, were                severe mucositis. FG already had single 
            and committed to increasing her intake. FG                 consistent with other dietary modifications,               mediport placed for 5-FU delivery, however, a 
            remained on a regular diet, supplemented                   and which could be used to increase her                    peripherally inserted central catheter (PICC) 
                                                 ®
            with one-half to one can Ensure  per day.                  energy and protein intake. The RDN requested               was chosen over double lumen for CPN 
                                                                       FG’s husband submit a one-week food diary                  administration, because Interventional 
            Per the medical record, FG’s daily intake                  for his wife, but the food diary was not                   Radiology noted the mediport is smaller  
            during the first set of treatments was                     submitted, nor was any further mention                     and often becomes clogged. 
            approximately 500 kcal, and less than                      of it recorded in the medical record. RDN 
            16 ounces of fluids. In addition, the                      recommended that the medical team                          Second Set of Chemotherapy/
            physician noted that FG was eating some                    consider Enteral Nutrition (EN) or Parenteral              Radiation Treatments (began 
            “healthy” foods and some “energy-dense”                    Nutrition (PN) if FG did not consume at least              1/20/2014):
            foods such as flavored corn chips, onion dip,              500 calories (an amount equal to 25-29% of                 The second set of treatments included 25 
            and regular cola. Unfortunately, the RDN,                                                                                                                          2
                                                                       estimated energy needs) and 40-50 grams                    radiation sessions and 5-FU (150 mg/m /day 
            the oncology team member with the                          protein per day, a recommendation                          x 5 days via single mediport). Because of