Nelly Mayulu

Cancer cachexia is the main

problem in Ca patients.
1/3 cases caused by anorexia
50 80 % reducing BW
40% oncology patients develop
malnutrition during treatment
(Marnie Dobbin, 2001 )
CachexiaKankeradalahmasalah
utamapadapasienCa.
1/3kasusdisebabkanolehanoreksia
50-80%mengurangiBB

40%
penderitamengembangkanonkologi
kekurangangiziselamapengobatan
(DobbinMarnie,2001)
2

Knowetal(1983)measuredREEof200
malnourishedcancerpatientswasstudiedby
indirectcalorimetry
26%hadincreasedREE
41%hadnormalREE
33%haddecreaseREE
REEinsarcoma,leukemia,lymphoma,
lung,head
andnecktumors
REEinpancreatictumor
N REEincoloncancer
SignificantdecreasesinREEwereseeninpositively
respondedchemotherapy,aftertumor resected
(Warnoldetal1978;Scherstenetal1980;Albertetal
1984) Shike et al 1984; Harvey et al, 1981; Young, 1977;
Shaw et al 1988; Warnold et al, 1978 ).

kNoWetal(1983)REEdiukurdari200pasien
kankermalnutrisidipelajaridengankalorimetrilangsung
26%telahmeningkatREE
41%memilikiREEnormal
33%mengalamipenurunanREE

REEdisarkoma,leukemia,limfoma,paruparu,kepala
danlehertumor
REEdalamtumorpankreas
NREEdalamkankerusus

PenurunanyangsignifikandalamREEterlihatpadakemoterapidirespon
positif,setelahtumorresected
(Warnoldetal1978;1984Albertetal;Scherstenetal1980)
4

Mechanism of cancer cachexia :

Cytokines
interleukin6

:interleukin-1
:decreasesadiposetissueliposomal
proteinlipaseactivity

Braintryptophaneandserotoninlevelincrease
TNF-alpha(cachectin) :suppresslipoproteinlipase(prevent
fromstorage)
Gammainterferon
LMF(lipidmobilizingfactors):breakdowntriglyceridestoFA
andGlycerol

Jean Klastersky, Stephen C. Schimpff, Hans-Jorg Senn : Supportive

Care in Cancer , Marcel Dekker Inc, 1999.
7

Mekanismecachexiakanker:
Sitokin:interleukin-1
interleukin6:berkurangjaringanadiposaliposomal
proteinlipasekegiatan
Otaktryptophanedanmeningkatkantingkatserotonin
TNF-alpha(cachectin):menekanenzimlipaselipoprotein(mencegah
daripenyimpanan)
Gammainterferon
LMF(lipidfaktormemobilisasi):pemecahantrigliseridamenjadiFAdanG
liserol

Related Factors To Cancer Cachexia :

Oralintake(anorexia,nausea,vomiting,
tasteless)
Localeffects(obstruction,dysphagia,malabsorption(
blindloopsyndromemicrobacterialovergrowthor
exocrineinsufficiency)
Alterationofmetabolism(CHO,AA,Fat)
Cytokines(TNF-,IL-1,IL-6,INF-producedbyhost
TerkaitFaktorUntukcachexiaKanker:
tissueortumor)
Oralasupan(anoreksia,mual,muntah,
Sideeffectsoftreatments:
hambar)
Lokalefek(obstruksi,disfagia,malabsorbsi(
Postoperative
sindromloopbutapertumbuhan
Chemotherapyinduced berlebihmikrobakteriatau
insufisiensieksokrin)
Radiationinduced
Perubahanmetabolisme(CHO,AA,Lemak)
Psychosocial
Sitokin(TNF-,IL-1,IL-6,INF-dihasilkanolehtuan

Cancer cachexia is un-related

to severity and Ca staging.
CachexiaKankeradalahunberkaitandengankeparahandanpementasanCa.

rumah
jaringanatautumor)
Efeksampingdariperlakuan:
Pascaoperasi
Kemoterapiinduksi
Radiasiinduksi
Psikososial

Supportive nutritional goals :

Supportingadequatenutritionalstatus
Bodycomposition
Mendukung gizi tujuan:
Performancestatus Mendukungstatusgiziyangmemadai
Komposisitubuh
Immunefunction
StatusKinerja
Fungsikekebalan
Qualityoflife
Kualitashidup
Theuseofnutritionaltherapyinthecancer
patientsistailoredtocomplementtheprimary
treatment.
Penggunaanterapinutrisipadapasienkankeradalah
disesuaikanuntukmelengkapipengobatanprimer.

Samuel Chan, George L.Blackburn, 1999

10

Nutritional therapy decisionsmustbebasedonthe

patientsnutritional status, type and location of tumorand
thespecific medical interventionsusedintreatment.
Appropriatenutritiontherapymayattenuatetheadverse
effectsofthetumoranditstreatmentthusincreasing
tolerancetotreatmentanddecreasingmorbid-mortality.
Duringchemoradiationtherapytheindicationofenteral
nutritionthroughafeedingtubeswasmorefrequentthen
oralfeedinginagroupofheadandneckcarcinoma
patients(Mekhail,2001)
Juan Kehr S : Enteral Nutrition in Cancer Patients
11

Terapinutrisikeputusanharus
didasarkanpadastatuspasienjenis,gizidanlokasitumor
danintervensimediskhususyangdigunakandalampengobatan.
Terapinutrisiyangtepatmungkinmenipiskandampakdaritumordan
perawatannyasehinggameningkatkantoleransiterhadappengobatandan
penurunanmorbid-kematian.
Selamaterapikemoradiasiindikasigizienteralmelaluitabungmakanlebih
seringthenmakanlisandalamkelompokpasienkankerkepaladanleher(
Mekhail,2001)

12

Nutrition therapycanbeeffectiveinreversing
malnutritionbutnot in combating cancer.
Thatmeanthatnutritiontherapyshouldbeindicated
preferentially when an antitimor therapy is being
successfully used.
Itisunlikelythatnutritionaltherapywillbeofany
benefitinwell-nourished or minimally
malnourishedcancerpatients.
Nutritionaltherapyshould notbeindicatedin
patientswhohaveterminal cancerandnotrealistic
anticancertreatmentoptions(Torellietal,1999)

13

TerapiGizidapatefektifdalammembalikkanmalnutrisitetapitidakdalam
memerangikanker.
Ituberartibahwa
terapinutrisiharusditunjukkanpreferentiallyketikasebuahterapiantitimor
sedangberhasildigunakan.
Halinitidakmungkinbahwaterapinutrisiakanmenjadimanfaat
apapunpadapasienkankerbergizibaikatauminimalkuranggizi.
TerapiGizitidakbolehdiindikasikanpadapasienyangmenderita
kankerterminaldantidakrealistispilihanpengobatanantikanker(Torelliet
al,1999)

14

Nutritionaltherapyisuselessandnot
prolong survivalifthetumorcannot be
controlled
"Terapinutrisitidakbergunadantidakmemperpanjang
kelangsunganhidupjikatumortidakdapatdikendalikan"

Propernutritionisbelievedtobeessential
tothewell-beingofallpatients,regardless
of the underlying disease
"Propergizidiyakinipentinguntukkesejahteraanse
muapasien,terlepasdaripenyakityangmendasari"

15

16

Prognostic Nutritional Index ( PNI ), Mortality

and Morbidity in Surgical and Cancer patients :
PNI >40%, Administration of TPN, mortality
and morbidity
PNI <40%, Administration of TPN, mortality
and morbidity
PrognostikgiziIndex
(PNI),MortalitasdanMorbiditaspadapasienBedahdanKanker:
PNI>40%,AdministrasiTPN,mortalitasdanmorbiditas
PNI<40%,AdministrasiTPN,mortalitasdanmorbiditas

17

18

Reduced Glucose Disposal

Insulinresistence,notovercomewith
administrationofsupraphysilogicalinsulinconcentration.
Tumormediated(Yoshikawaetal,1994),othertumorderivedfactorsorhormones.
Majorprobleminglucosedisposalisthenon-oxidative
glucosedisposalorsynthesisofglycogen(Tayek,1995)
Reducedtriiodothyronineconcentration(Tayeketal,
1997)
Increase glucose-disposal rates were documented
in patients with head and neck cancer, suggesting
that the tumor acted as a glucose drain.
Insulin resistance in tumor bearing hosts is not
related to the type of tumor.
19

MengurangiPembuanganGlukosa
Resistensiinsulin,tidakdiatasidengan
administrasikonsentrasiinsulinsupraphysilogical.
Tumormediated(Yoshikawaetal,1994),tumorlainberasalfaktor-faktoratauhormon.
MasalahutamadiTPAglukosaadalahnon-oksidatif
glukosadilepaskanatausintesisglikogen(Tayek,1995)
Mengurangitriiodothyroninekonsentrasi(Tayeketal,
1997)

Meningkatkanpembuanganglukosa-tingkatdidokumentasikanpada
pasiendengankankerkepaladanleher,
menunjukkanbahwatumorbertindaksebagaisaluranglukosa.
Resistensi
insulinpadahostdukungtumortidakterkaitdenganjenistumor.

20

Hepatic Glucose Metabolism :

Tayek1992,75%cancerpatientstudiesreportedthereiselevationinthe
rateofhepaticglucoseproduction.
Gluconeogenesis/coriscycleincrease
Theoutputofglucosefromtheliverisquitecomplex,respondingtothe
interplayofnumerousendocrine,paracrine,andcellularfactors
producedbythetumorandthehost.
Unlikethediabeticpatientswithelevatedbloodglucoseconcentration,the
cancerpatientswithelevatedglucoseproductionratefrequentlyhas
normalbloodglucoseconcentration.

Admiminstation of CHO in cancer patients

wasted products lactic acid ( cori cycle)
acidosis

21

HatiMetabolismeGlukosa:
Tayek1992,studikanker75%pasienmelaporkanadaelevasidalamtingkatproduksi
glukosahati.
Glukoneogenesis/siklusCori'smeningkatkan
Outputdariglukosadarihatiyangcukupkompleks,menanggapiberbagaiinteraksien
dokrin,parakrin,danfaktorseluleryangdihasilkanolehtumordantuanrumah.
Tidaksepertipasien
diabetesdengankadarglukosadarahtinggi,pasienkankerdengan
tingkatproduksiglukosatinggiseringmemilikikadarglukosadarahnormal.

AdmiminstationdariCHOpadapasienkanker
terbuangprodukasamlaktat(Corisiklus)asidosis

22

Protein metabolism :
Cancerisfrequentlyassociatedwithmusclewastingandmalnutrition.
Theetiologyismultifactorial
Turnoverhasbeenelevated,reflectsmultiplesitesofproteinmetabolism(the
mostimportancearetheskeletalmuscle,liverandGImucosa).
KoeaandShaw,1992isrelatedtotumorbulk.
Proteincatabolismincreaseviatheeffectofcytokine(IL-1,6,TNF)

Tumoractsasaglutaminetrap
(Blaauw et al, 1997)

23

Proteinmetabolisme:
Kankerseringdikaitkandenganmembuangototdanmalnutrisi.
Etiologiadalahmultifaktorial
Perputarantelahditinggikan,mencerminkanbeberapasitusmetabolismeprotein(yang
terpentingadalahotothati,rangkadanmukosaGI).
KoeadanShaw,1992berkaitandengantumormassal.
Meningkatkankatabolismeproteinmelaluipengaruhsitokin(IL-1,6,TNF)

Tumorbertindaksebagai"perangkapglutamin"
(Blaauwetal,1997)

24

Protein synthesis
Cancer
Non-cancer

Protein breakdown

21%50%
33% 59%

Protein turnover
15%

External AA supply for synthesis body protein :

Cancer
39%
Non-Cancer
51%
Synthesis protein in cancer < non-cancer
EksternalAApasokanuntuksintesisproteintubuh:
Kanker39%
Non-Kanker51%
Sintesisproteinpadakanker<non-kanker

25

N : external AA for protein synthesis

In proteolysis : endogenous supply AA for protein
synthesis.
N:eksternalAAuntuksintesisprotein
Dalamproteolisis:AApasokanendogenuntuksintesisprotein.

Efficiency utilization of external i.v AA for protein synthesis :

Cancer
39%
EfisiensipemanfaatanAAiveksternaluntuksi
ntesisprotein:
Non-Cancer
51%
Kanker39%
Non-Kanker51%

Malnourishedcancerandnon-cancerpatients,utililizedonly
endogenoussupplyAA
Kankermalnutrisidanpasiennonkanker,dikompensasisuplaihanyaAAendogen
26

Lipid metabolism :
Increasemobilizationoffat,duetoincrease
sensitivityoflipase.
However,whenweightlossiscontrolledfor,
thereisnoincreaseintherateoflipolysisin
cancerpatients(KleinandWolfe,1990)
Metabolismelipid:
Meningkatkanmobilisasilemak,karenameningkatkansensitivitaslipase.
Namun,ketikapenurunanberatbadanuntukdikendalikan,tidak
adapeningkatantingkatlipolisispadapasienkanker(KleindanWolfe,1990)
27

Acute Phase Response :

Isprimitiveresponseofthebody,whichisabasic
defensiveresponseofthebodyagainstinjury.
Unfortunately,thisresponsedoesnotoccurfor
mosttumorsbutitseenwhenthemalignancy
presentwithinfectionasinlungcancerorinother
moreaggressivemalignancyasinleukemia.
AkutFaseTanggap:
Apakahresponprimitifdaritubuh,yangmerupakanrespondefensifdasartubuh
terhadapcedera.
Sayangnya,responsinitidakterjadiuntuktumoryang
palingtapiterlihatketikahadirkeganasandenganinfeksisepertikankerparu-paru
ataupadakeganasanlebihagresiflainnyasepertipadaleukemia.
28

The responses are :

serum iron and zinc levels,
increase serum copper and ceruloplamin levels,
alteration in amino acid distribution and metabolism,
gluconeogenesis.
change in cytokine level, several classical hormone levels.
C-reactive protein promotes phagocytosis, modulates the
cellular immune response, inhibits the migration of white
blood cells into the tissue.
-1-antichymotrypsin which minimizes tissue damage due to
phagocytosis and reduced intravascular coagulation.
-2-macroglobulin, which forms complexes with proteases
and removes them from circulation, maintain antibody
production and promotes granulopoiesis and other acute
phase proteins.

29

Responadalah:
serumbesidansengtingkat,
meningkatkanserumtembagadanceruloplamintingkat,
perubahandalamdistribusidanmetabolismeasamamino,
glukoneogenesis.
perubahankadarsitokin,beberapatingkathormonklasik.
ProteinC-reaktifmempromosikanfagositosis,memodulasi
responimunseluler,menghambatmigrasiputih
sel-seldarahkejaringan.
-1-antichymotrypsinyangdapatmeminimalkankerusakanjaringankarena
fagositosisdankoagulasiintravaskularberkurang.
-2-macroglobulin,yangmembentukkompleksdenganprotease
danmenghapusmerekadariperedaran,mempertahankanantibodi
produksidanmempromosikangranulordanakut
faseprotein.

30

Albumin synthesis :
( Normal : 150 mg/kg/day. )
Stimulated by amino acid administration.
Skillman et al ( 1976), albumin synthesis is more stimulated
after 300 kcal of amino acid administration ( 240 mg/kg/day).
Further stimulated by 1 gm/kg/day with a total of 700 kcal/day.
Tayek et al 1986, albumin synthesis increase from 100 to 190
mg/kg/day with increased administration of leucine, isoleucine
and valine.
So diet rich in tryptophane, BCAA may stimulate albumin
synthesis.
1 gm drop in serum albumin levels translate into a 33% increase
in mortality.
Patients with 1.8 g/dl, had mortality rate 65%

31

Albuminsintesis:
(Normal:150mg/kg/hari.)
Dirangsangolehadministrasiasamamino.
Skillmanetal(1976),sintesisalbuminlebih
terangsangsetelah300kkaladministrasiasamamino(240mg/kg/hari).
Selanjutnyadirangsangoleh1gm/kg/haridengantotal700harikkal/.
Tayeketal1986,sintesisalbuminmeningkat100190mg/kg/haridenganadministrasipeningkatanleusin,isoleusindanvalin.
Jadidietkayatryptophane,BCAAdapatmerangsangsintesisalbumin.
1gmpenurunankadaralbuminserumditerjemahkankedalampeningkatan33%dalam
kefanaan.
Pasiendengan1,8g/dl,memilikitingkatkematian65%

32

Nutritional adjunctive treatment strategies :

Insulin : protein sparing , reduced hepatic glucose production,
GH
: in cancer patients improve N balance and not
associated with abnormalities in glucose metabolism.
Improve wound healing by increasing protein
synthesis without increasing protein oxidation.
Anabolic steroid and testosterone :
Nitrogen balance has been shown to be improved in some of
the clinical trials but not all.
Albumin administration :
Accounts for 78% of the normal oncotic pressure.

33

Gizistrategipengobatanadjunctive:
Insulin:hematprotein,menurunkanproduksiglukosahati,
\
GH:pada
pasienkankermeningkatkankeseimbanganNdantidakterkaitdengankelainandalamm
etabolismeglukosa.
Meningkatkanpenyembuhanlukadenganmeningkatkansintesisproteintanpa
meningkatkanoksidasiprotein.
Anabolicsteroiddantestosteron:
Nitrogenkeseimbangantelahditunjukkanuntuk
ditingkatkandalambeberapaujiklinistetapitidaksemua.
Albuminadministrasi:
Menyumbang78%daritekananoncoticnormal.

34

AICR ( American Institute for Cancer

Research ), recommended for cancer
survivors
low in fat, high in fruits , vegetables and
whole grain product and has adequate levels
of the major macronutrients as well as
various vitamins and minerals necessary to
maintain good health.

Forcancerpatientsundergoingspecific
treatment,othernutritionalregimenmaybe
consideredbasedontreatmentstatusand
diseasestage. AICR(AmericanInstituteforCancerResearch),direkomendasikanuntukpenderitakanke

rendahlemak,tinggidalambuahbuahan,sayurandanprodukgandumdanmemilikitingkatmemadaimacronutrientsbesar
sertaberbagaivitamindanmineralyangdiperlukanuntukmenjagakesehatanyangbaik.
Untukpasienkankermenjalanipengobatankhusus,rejimengizilainnya
dapatdipertimbangkanberdasarkanstatuspengobatandanstadiumpenyakit.

Helen A. Norman, Ritva R. Butrum, Elaine Feldman et al : The Role

of Dietary Supplements during Cancer Therapy

35

The recommendation for cancer patients is to

take moderate doses of supplements because
evidence from human clinical studies that
confirm their safety and benefits is limited, use
of dietary supplements during cancer
treatment remain controversial
Rekomendasibagipasienkankeradalah

untukmengambildosismoderatsuplemenkarenabuktidaristudiklinis
pada
manusiayangmengkonfirmasikeselamatanmerekadanmanfaatterbatas,p
enggunaansuplemendietselamapengobatankankertetapkontroversial
supplements
together

Multiple antioxidants
with a low fat , high fiber diet and lifestyle
modifications, including physical exercise may
markedly improve the efficacy of standard and
experimental cancer therapy.

Beberapaantioksidansuplemenbersamadengandietrendah
lemak,serattinggidanmodifikasigayahidup,termasuklatihanfisiksecara
nyatadapatmeningkatkanefektifitasterapikankerstandardaneksperimental.

AICR recommended , should not take more

than the amount obtained in a reliable daily
vitamin and mineral pill at the level
comparable with RDAs. AICRdianjurkan,tidakbolehmengambillebihdarijumlahyang
diperolehdalamvitaminsehariharihandaldanpilmineralditingkatsebandingdenganRDAs.
36

New Formula Enteral Supplements :

Clinicalstudiessuggestimpactonsecondaryendpointrelatedto
cancer development and spread(Antietal,1994;Baggaet
al,1997).
Inaddition,certainn-3 FAmayinfluencecytokineresponse
potentiallyassociatedwithcachexiaandimmunologicfunction
(Erickson,1998;Tisdaleetal,1994;MoldawerandCopeland,
1997).
Glutamine foritspotentialinfluenceonmucosalandimmune
function(Turowskietal,1994;Bozzettietal,1997;Collinetal
1997;Fordetal1997;Gardneretal1997;Muscritolietal,1997;
SkubitzandAnderson1996.
Arginine, nucleic acid,n-3FAformtheirimmuneenhancing
potential(Kemenetal,1995;Moraisetal,1995;Senkaletal,1995;
VanBurenandRudolph,1997).
Daly and colleagues , 1995

37

FormulaBaruSuplemenEnteral:
Studiklinismenunjukkandampakpadatitikakhirsekunderyang
berkaitandenganperkembangan
kankerdanmenyebar(Antietal,1994;Baggaetal,1997).
Selainitu,beberapan-3FAdapatmempengaruhiresponsitokinpotensialberkaitan
dengancachexiadanfungsiimunologi(Erickson,
1998;Tisdaleetal,1994;MoldawerdanCopeland,1997).
Glutaminuntukpengaruhpotensialpadamukosadanfungsikekebalan
tubuh(Turowskiet
al,1994;Bozzettietal,1997;Collinetal1997;Fordetal1997;Gardneretal1997;
Muscritolietal,1997;SkubitzdanAnderson1996.
Arginin,asamnukleat,bentukn-3FApotensimeningkatkankekebalan
tubuhmereka(Kemenetal,1995;Moraisetal,1995;Senkaletal,
1995;VanBurendanRudolph,1997).

38

PUVA :
n-3cansignificantlyretardthegrowthoftumors,
n-6potentiallycanincreasetumordevelopment
PUVA:
n-3secarasignifikandapatmenghambatpertumbuhantumor,n6
berpotensidapatmeningkatkanperkembangantumor

Vit D-3 :
Suppressthegrowthoftumorsofdifferentorgans,including
breastcancercells,colon
Highdosecanleadtohypercalcemiaanddeath.
SynthesisofanalogsofD-3arepotentinhibitorsofcancer
cellgrowth,haveantiproliferativeandprodifferentiation
effectsagainstscancercellswithouthypercalcemia.
SynergiceffectvitD-3,withretinoids,anti-estrogens,and
conventionalchemotherapydrugs.
Helen A. Norman, Ritva R. Butrum, Elaine Feldman et al : The Role of
Dietary Supplements during Cancer Therapy
39

VitD-3:
Menekanpertumbuhantumororganyangberbeda,termasukselselkankerpayudara,ususbesar
Dosistinggidapatmenyebabkanhypercalcemiadankematian.
SintesisanalogD-3adalahinhibitorampuhpertumbuhansel
kanker,memilikiefekantiproliferatifdanprodifferentiationagainstsselselkankertanpahypercalcemia.
EfeksinergisvitD-denganretinoid,3,antiestrogen,danobatkemoterapikonvensional.

40

Daly et al ( 1995)randomized60malnourishedcancer
patientstoreceiveenteralnutritionviajejunostomy
beginningonthefirstpostoperativeday.
Enteralfeedingpatientswerefurtherrandomizedto
receivestandarddietoranenteralformulasupplemented
withimmuno-enhancing nutrients.Infection
complicationoccurredin43%ofthepatientsreceivingthe
standarddietandinonly10%ofthepatientsofthe
supplementedgroups.thelengthhospitalstaywas
reducedfrom222.9daysto160.9daysinthe
supplementeddietgroup.

Dalyetal(1995)acak60pasienkankergizi
burukuntukmenerimanutrisienteralmelaluijejunostomydimulaipadaharipertama
pascaoperasi.
Enteralmakanpasientersebutkemudiansecara
acakmenerimadietstandaratauformulaenteraldilengkapidengannutrisiimmunomeningkatkan.KomplikasiInfeksiterjadipada43%daripasienyang
menerimadietstandardanhanya10%daripasienkelompokditambah.tinggalruma
hsakitpanjangberkurangdari222.9dayssampai
160,9haripadakelompokdietsuplemen.
41

If the patients is being treated :

With curative intent :
Stabilizingorimprovingthepatientsnutritionalstatusas
wellasincreasingthepotentialofafavorableresponseto
therapyandenhancingrecoveryfromanyadverseeffectof
therapy.
For palliative care :
Stabilizeperformancestatus,maintainactivitiesofdaily
living,improvethequalityoflife.
Jikapasiensedangdirawat:
Denganniatkuratif:
Menstabilkanataumeningkatkanstatuspasiengizi
sertameningkatkanpotensiresponbaikterhadap
terapidanmeningkatkanpemulihandaridampakburukdariterapi.
Untukperawatanpaliatif:
StatuskinerjaStabilkan,memeliharaaktivitashidupseharihari,meningkatkankualitashidup.

42

Nutrition support Controversies :

Tumor growth is stimulated by a number of nutrients,
limitation of the nutrients preferred by tumor can lead to
detriments in the host.

At present, the possibility of increased tumor growth

with the use of TPN should not be used as a reason not
to use TPN in patients with cancer

Maintenance of good nutritional status does not

appear to have deleterious effects on tumor growth.

43

Nutrition support Controversies

Terminal care :
A natural stage in dying occurs when the
patients ceases to eat or drink.
As death approaches, the patients refuse all
food and oral fluids, At this points : only
hydration enteral feeding.
Living with advance cancer :
Nutrition and physical activity are important
factors in establishing and maintaining a
sense of well-being and enhancing quality of
life.

44

Nutrition support Controversies

Dietary vitamin and mineral supplementation during cancer
treatment is controversial.
Folic acid and Mtx
Many cancer researchers have recommended against taking
antioxidant supplements during treatment because
antioxidants could repair cellular oxidative damage to cancer
cells caused by treatment ( radio, chemo)
Others have noted antioxidants may be a net benefit to help
protect normal cells from the collateral damage associated
with these therapy.
Antioxidants are beneficial or harmful is a critical question without a
clear scientific answer at this time.
45

Nutrition support Controversies :

GHinanimalstudiesandinvivohumantumor
studiesshowednoincreaseintumorvolume
(Wolfetal,1994;Harrisonetal,1997;Harrison
andBrenan,1995)
GlutamineimprovedNbalanceandpromote
proteinsyn
thesiswithoutstimulatingtumorgrowth.

46

Select of the dietcouldaffect primary tumoritgenesis.

Altered metastasisbyselectdietaryfatregimen.
Dietcontaining23%cornoil(12%linoleicacid),
stimulatedgrowthofimplatedtumors,alsoenhanced
theirmetastaticascomparedtoa5%cornoildiet(2,7%
linoleicacid)Rossetal,1991

Kent L. Erickson and Neil E. Hubbard : Invation and Metastasis in

Nutritional Oncology, Acadimic Press, 1999 : page : 36 -92

47

Obesity relate to breast ca and

colorectal ca, increasing evidence
indicates that being overweight
increase the risk for recurrence of
many cancers.
Safe weight loss with well balance
diet, not interfere with the treatment.

48

Food safety :
To avoid eating foods that may contain
unsafe levels of pathogenic organisms.
During chemotherapy can impair the
immune response, raw vegetables may
increase the risk for infection.
Betacarotene was associated with lower
risk of lung cancer.
Betacarotene may increase colorectal
adenoma recurrence in persons who
smoke
49

Pharmacological considerations affecting nutritional status :

Asparaginase
Chlorotrianisene
Cisplain
Corticosteroid
Diethylstilbestrol
Methotrexate
Mithramycin
Streptozocin
Tamoxifen
Taxol
Tretinoin
tests
Vincristine

: hyperglycemia, hemorrhagic pancreatitis

: hypercalcemia
: hyperuricemia, hypomagnesemia
: sodium retention, potassium, calcium, magnesium
and zinc excreation, hyperglycemia.
: hypercalcemia
: folate and calcium deficiency
: hypocalcemia, hypokalemia
: sudden hypoglycemia
: hypercalcemia
: nausea, vomiting, mucositis
: hypertriglyceridemia, elevated liver function
: inappropriate antidiuretic hormone secretion,
hyponatremia, water retention, decrease serum
osmolality, increased urine osmolality.
50

Both enteral and parenteral nutritional support was

beneficial in decreasing complications in
malnourished patients when given preoperatively.
Perioperative TPN support of cancer therapy :
Muller and colleagues (1982), reported that preoperative
parenteral feeding in patients with GI carcinoma
decreased mortality and postoperative complications
including infection.
Askanazi and colleagues, 1986 showed that immediate
postoperative nutrition support shorten the length of
hospitalization.
Miguel M. Echnique : Pearls in Nutritional Support of The Cancer Patients
in ASPEN 22 nd Clinical Congress, Florida , Jan 18 21, 1998 page : 292
293

51

Reversed Cancer Cachecia / Anorexia :

Parenteral nutrition
Anabolicsteroid
Pentoxyfyline
Cyproheptadine
Hydrazinesulfate
BCAA

:inhibitTNFalpha
:aserotoninantagonist
:inhibitenzymephosphoenolpyruvatekinase.
:todecreasetryptophanetransporttothe
brainbycompetitiveinhibition.
Dronabinol
:tetrahydro-cannabinolhasbeenstudied
inAIDS,nowprospectivelyevaluate
theuseofthisdrugtotreatcancer
anorexia/cachexia.
Corticosteroid
Progestationalagents :megestrolacetate

52

TerbalikKankerCachecia/Anorexia:
Nutrisiparenteral
Anabolicsteroid
Pentoxyfyline:menghambatTNFalfa
Siproheptadin:antagonisserotonin
Hidrazinsulfat:phosphoenolpyruvatekinasemenghambatenzim.
BCAA:untukmengurangitransportasitryptophaneke
otakdenganinhibisikompetitif.
Dronabinol:tetrahidro-cannabinoltelahdipelajari
diAIDS,sekarangprospektifmengevaluasi
penggunaanobatiniuntukmengobatikanker
anoreksia/cachexia.
Kortikosteroid
Progestationalagen:asetatmegestrol

53

Kesimpulan:
CachexiaKankeradalahmasalahutamapadapasienCa.
REE:,,
Mekanismecachexiakanker:multifaktorial
CachexiaKankeradalahun-berkaitandenganpementasankeparahandanCa
Tujuangizipendukung:pendukungyangmemadainutrisi
status,komposisitubuh,statuskinerja,fungsikekebalan,
kualitashidup.
Terapinutrisikeputusanharusdidasarkanpadapasien
statusgizi,jenisdanlokasitumordanspesifik
intervensimedisyangdigunakandalampengobatan.
TerapiGizidapatefektifdalammembalikkanmalnutrisitetapitidak
dalammemerangikanker,harusditunjukkanpreferentiallybila
Terapiantitimorsedangberhasildigunakan,mungkinmanfaatapapun
padapasienkankerbergizibaikatauminimalkuranggizi,
tidakbolehditunjukkanpadakankerterminal
Giziyangtepatdiyakinipentinguntukkesejahteraansemua
pasien,terlepasdaripenyakityangmendasari
NutrisidukunganKontroversi:pertumbuhantumor,suplemen
vitamindanmineral,GH,glutamin.

54

Lanjutkan.......
Pilihdietyangdapatmempengaruhitumoritgenesisprimer.
Diubahmetastasisolehrejimenlemakpilihmakanan.
Amanberatbadandengandietyangseimbang,tidakmengganggu
pengobatan
Keamananpangan:untukmenghindarimakanmakananyangmen
gandungamantingkatorganismepatogen
Farmakologipertimbanganyangmempengaruhigizi
status
Keduadukungannutrisienteraldanparenteraladalah
menguntungkandalampenurunankomplikasikuranggizi
pasienketikadiberikansebelumoperasi.

55