Nutritional Considerations in Lung Cancer Rehabilitation

Introduction

It has been estimated that about 235,760 people (119,100 men and 116.660 women) will be diagnosed with lung cancer in the United States in 2021. ^, 1 in 15 men and 1 in 17 women will be diagnosed with lung cancer in their lifetime with smokers having an increased risk compared to nonsmokers. ^, 541, 000 people in the United States have at some point in their lives been diagnosed with lung cancer. According to the American Cancer Society, about 113,880 deaths (69,410 men and 62,470 women) will occur from lung cancer in 2021. Each year more people die of lung cancer than of breast, colon, and prostate combined. There has been a steady decline in lung cancer diagnoses and lung cancer deaths by 50% for men and 1/3 for women ^, mostly from people quitting smoking and from advances in early detection and treatment. Whereas smoking is responsible for 80% of lung cancer–related deaths, 20% of lung cancer deaths occur in people whom have never smoked. Family history as well as genetic factors may also have a role in development of lung cancer. ^, Lung cancer primarily occurs in people over the age of 65, with average age at diagnosis being about 70. Approximately 30%–40% of lung cancers are diagnosed in people over the age of 70. ^, The 5-year survival rate for nonsmall cell lung cancer (NSCLC) is 63% for localized disease, 35% for regional disease, and 7% for distant disease. The 5-year survival rate for small cell lung cancer (SCLC) is 27% for localized disease, 16% for regional disease, and 3% for distant disease.

Since lung cancer occurs primarily in older adults, frailty in this population can be common. Frailty has been characterized as a decline in functioning across multiple physiological systems. When compared to nonfrail patients, frail and prefrail patients have a higher risk of overall mortality and therapeutic toxicity. It has been reported that more than half of older patients with cancer are frail at the time of cancer diagnosis, which in turn can increase the risk of inability to tolerate chemotherapy treatments, lead to postoperative complications and increased mortality. ^, Frailty can be associated with an increased risk of falls, disability and early mortality, postoperative complications, prolonged hospital length of stay, and substantially increased costs. It is important for clinicians to assess lung cancer patients before, during, and after the start of lung cancer treatments for key indicators of frailty such as weight loss, fatigue, weakness, and slow gait speed. Frail lung cancer patients may have significant other comorbidities such as coronary artery disease, heart failure, COPD, diabetes, and peripheral vascular disease that can affect ability to tolerate cancer treatments. Sarcopenia can also be present along with frailty and can be associated with increased risk of falls, disability, and prolonged hospitalizations and complications postsurgery and increased mortality. The presence of sarcopenia can also reduce the benefits of immunotherapy.

Nutrition and exercise are the cornerstones of mitigating frailty and sarcopenia in lung cancer patients. Prehabilitation is the time period between cancer diagnosis and start of cancer treatment. This is a unique opportunity to identify any preexisting physical impairments that could be exacerbated by cancer treatment such as impaired balance due to an underlying peripheral neuropathy and introduce rehabilitative interventions to minimize their impact. In addition, exercise, nutritional interventions, and psychosocial support can be initiated to improve the general physical and mental status of the individual. A generalized exercise program often includes a walking component as well as strength training of major muscle groups of the upper and lower extremities. For example, a 2 -week home-based prehabilitation program that included aerobic and resistance exercises, respiratory training, nutritional counseling with whey protein supplementation, and psychological support achieved greater 6 min walking distance and peri-operative functional capacity in patients undergoing video-assisted thorascopic surgery lobectomy for lung cancer when compared to control group. Prehabilitation is a safe intervention without any significant side effects reported for lung cancer patients. It can increase exercise capacity and significantly improve pulmonary function.

Malnutrition is common in lung cancer patients. In one study, 51.1% of patients were undernourished, 23.9% were at risk for malnutrition, and only 25% showed a normal nutrition. Those that were well nourished evaluated their quality of life as better and those that were malnourished reported a decreased quality of life. In this chapter, the focus is on the nutritional challenges and interventions in lung cancer patients. At end of this chapter, a case study is provided to illustrate the important role of nutritional interventions in the care of a lung cancer patient.

Estimating Nutritional Needs for Lung Cancer Patients

Providing adequate calories is essential to maintain weight and/or prevent weight loss associated with lung cancer treatment or disease. During an initial nutritional assessment, energy and protein needs for lung cancer patients are assessed. Nutritional needs are recalculated, as needed, in all follow-up assessments. Energy needs for patients with lung cancer can be estimated using the following parameters:

15 kcal/kg actual body weight for obese patients
20–25 kcal/kg actual body weight
25–30 kcal/kg actual body weight for nonambulatory or sedentary adults
30–35 kcal/kg actual body weight for patients that are losing weight and/or malnourished
35 kcal/kg actual body weight and above for hypermetabolic or severely stressed patients, or for those with malabsorption. Avoid calorie provision above 35 kcal/kg prior to start of cancer treatment.

The provision of adequate protein is essential for building and repairing cells and to reduce negative nitrogen balance. Protein needs for lung cancer patients are 1.2–1.5 gm/kg/day.

The parameter that is used to calculate energy and protein needs is also dependent on the dietitian's judgment and discretion based on patient's best interest and outcomes.

Dietary Interventions for Lung Cancer Patient and Survivors

During the emotional stress of dealing with lung cancer at any stage, patients derive increased quality of life and a sense of control over their lives as the result of receiving supportive advice on diet and lifestyle. Therefore, the use of nutrition intervention can help lung cancer patients maintain body weight and nutrition stores, offering relief from symptoms and improving their quality of life. Whether the goal of lung cancer treatment is cure or palliation, early detection of nutritional problems and prompt intervention is essential.

A general healthful diet is recommended for cancer patients and survivors. It consists of foods low in fat, cholesterol, and sodium and high in fiber. The general healthful diet includes protein sources other than red meat, low-fat or fat-free dairy products, whole grains, and at least five servings per day of fresh fruits and vegetables.

Small, frequent meals, and snacks versus three large daily meals should be considered for those having a hard time with their oral intake. If there is any chewing or swallowing difficulties present, a texture-modified diet is considered to ease chewing or swallowing and maximize intake.

The general healthful diet can be used to achieve and maintain a healthy weight. Addition of medical food supplements or the initiation of enteral or parenteral nutrition (PN) may be considered if oral intake is not adequate to meet estimated needs for preventing undesired weight loss and or loss of muscle mass.

Diet Composition

In the general healthful diet, carbohydrate is equal to 45%–65% of energy, protein is equal to 10%–20% of energy, total fat is equal to 20%–35% of energy, and fiber is equal to 25–30 g per day.

Some cancer patients tolerate liquids better than solids. To help meet estimated energy needs, patients should consider intake of high calorie foods such as whole milk and whole milk products, regular salad dressings, regular mayonnaise, honey, nectar, jam, granola, dried fruits, eggs, egg nog, nuts, nut butters, seeds, seed butters, wheat germ, coconut milk, gravy. Most importantly, patients should eat/drink what they desire, what they find appetizing, and what they are able to tolerate to optimize oral intake. In order to increase calorie and protein intake, oral nutritional supplements may be used.

Intake of vitamins and minerals should not exceed the Dietary Reference Intake (DRI), which is based on age and gender. Higher intake does not provide added benefit and instead may be harmful.

Diet and Inflammation

Lung cancer is associated with chronic inflammation, particularly chronic pulmonary inflammation or persistent lung inflammation such as chronic airway inflammatory conditions. Certain foods can cause inflammation, such as refined carbohydrates (white bread and pastries), margarine, shortening, lard, French fries, other fried foods, sugar, high-fructose corn syrup, soda, other sugar-sweetened beverages, red meat (burgers, steaks), and processed meat (hot dogs, sausage).

The Mediterranean diet may become the preferred diet for reducing chronic inflammation since it has demonstrated antiinflammatory effects when compared with North American and Northern European diets. The Mediterranean diet has a high ratio of monounsaturated (MUFA) to saturated (SFA) fats and omega-3 to omega-6 polyunsaturated fatty acids (PUFAs) plus includes fruits, vegetables, legumes, and grains.

Fat is needed in our body in order for it to function. However, not all fats are produced by our body. Omega-3 polyunsaturated fatty acid is an essential fat that our body cannot create on its own but instead needs to obtain it from the foods we consume. It may help prevent cancer. Before omega-3 supplements are taken, a healthcare provider should be consulted for any possible interaction with current medications.

Omega-3 fatty acids can be found in plant oils, nuts and seeds, such as flaxseed and flaxseed oil, chia seeds, walnuts, canola oil, soybean oil, hemp seeds, navy beans, edamame, kidney beans, herring fish, fish oil, mackerel, salmon, rainbow trout, halibut, cod liver oil, canned tuna, rockfish, shrimp, and catfish. Certain foods, like some eggs, milk, or soy beverages, may have omega-3 added to it. The product food label will indicate if it has been fortified with omega-3.

Nutrition is an important part of cancer treatment and recovery. Eating a healthy diet can promote health and reduce the risk of developing another cancer. The diet should include many types of plant-based foods. Fruits, vegetables, grains, beans, and other plants contain natural health-promoting substances called phytochemicals, which are plant-based chemicals. Some phytochemicals may protect cells from damage that could lead to cancer.

Phytochemicals are antioxidants, which also include vitamin C, vitamin E, and carotenoids. Antioxidants help inhibit cell damage that may play a role in the development of cancer and therefore may aid in cancer prevention.

Since fruits and vegetables contain antioxidants, their consumption may decrease the risk of some types of cancer. Eating a variety of foods rich in antioxidants each day may help cancer survivors in decreasing their risk for second cancers, which are new, different cancers and not the previously diagnosed cancer.

Supplements that contain antioxidants have not been proven to decrease the risk of cancer. Therefore, it is recommended to consume foods instead of supplements containing antioxidants. Supplements may have antioxidants in amounts greater than the indicated DRI.

Taking large doses of antioxidant supplements during chemotherapy or radiation is not recommended by some oncologists because it is believed that the antioxidants may restore the cancer cells damaged during these treatments, making chemotherapy and radiation less potent. To others, the belief that antioxidants repair the damage caused to cancer cells by cancer treatments is only speculation. Instead, they feel like there may be a net benefit in aiding to protect normal cells during cancer treatments.

Currently, there is no science-based guidance whether antioxidant supplements are beneficial or damaging during chemotherapy or radiation treatment. Due to lack of evidence, cancer patients receiving these treatments should avoid supplements unless there is an actual nutrient deficiency indicated by test results, and they should also abstain from supplements that provide greater than 100% of the Daily Value.

Cancer patients should focus on food versus supplements to optimize their nutrition. Meats at some meals should be replaced with legumes (dried beans and peas) weekly. At least five servings of fruits and vegetables, including citrus fruits, dark-green and deep-yellow vegetables, should be consumed daily. High-fiber foods, such as legumes, whole grain breads, and cereals, should be included daily. High-fat foods, particularly those from animal sources, should be limited. Lower-fat milk and dairy products should be considered. Lower-fat cooking methods, such as baking or broiling, should be used. Intake of salt-cured, smoked, and pickled foods should be reduced.

A lung cancer survivor should eat a plant-based diet high in fruits, vegetables, and whole grains. On a daily basis, survivors should consume at least 2.5 cups of fruits and vegetables. They should limit red and processed meats, and avoid cooking these and other high-fat protein sources at high temperatures. Survivors should limit high-fat foods and foods with added sugar. Supplements should only be taken by survivors if they have a nutrient deficiency.

Counseling Strategies

Effective nutrition counseling strategies for cancer patients include setting attainable goals, reducing sugar intake, increasing intake of foods rich in antioxidants, and empowering patients. The clinician should not overwhelm the patient with too much information all at once. Change is a process that takes time and each patient changes at their own pace.

Nutrition goals for cancer patients should follow the SMART criteria (specific, measurable, attainable, realistic, and timely). Goals should be created and agreed to by both patient and practitioner. Collaboration should take place in brainstorming ways to attain all goals and within what timeframe, which should lead to patients being more likely to actually change and reach their goals.

Sugar intake is associated with cancer since glucose is the main source of energy for cancer cells, also known as the Warburg effect. Cancer patients may benefit from a low-sugar diet, primarily added sugars, since it hinders the reproduction of cancer cells. Fruits and vegetables with low glycemic load should be considered over those with a high glycemic load, since it can lead to an increase risk of cancer. A high glycemic load and carbohydrate intake are linked to greater recurrence and mortality for chemotherapy patients.

Intake of antioxidants in foods such as fruits and vegetables has the opposite effect of sugar intake. Individuals who consume the highest amount of vegetables, especially cruciferous vegetables, such as broccoli, cauliflower, cabbage, kale, Brussels sprouts, among others, have a decreased risk of cancer development and recurrence, particularly for lung cancers. Intake of nonstarchy vegetables should be higher than starchy vegetables. Darker-colored vegetables also have a greater nutritional impact.

Empowering cancer patients can be achieved by using a style of counseling known as Motivational Interviewing, where clinicians try to get patients to develop intrinsic motivation to change their own behavior. Motivational Interviewing is defined as a collaborative, goal-oriented style of communication with particular attention to the language of change. Motivational Interviewing is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the patient's own reasons for change within an atmosphere of acceptance and compassion. Through this strategy, patients are given the opportunity to examine their mixed feelings and contradictory ideas, which results in the patient ultimately coming to the conclusion that their habits need to change. Listening and in letting the patient come to their own decision about what they need to do with her health is most beneficial. A sense of hope and optimism is linked with improved patient outcomes, including conditions as diverse as cancer recurrence, weight loss, depression reduction, blood pressure reduction, and more. In conclusion, clinicians should balance communicating the effect that lifestyle has on health, without overwhelming patients and contributing to more pressure and fear, since a few steps in the right direction is far better than a sense of overwhelm, paralysis, and inaction.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here