PALLIATIVE CARE IN BREAST CANCER
Cancer palliative care is the integration of cancer care with improvements in various aspects that are painful and distressing for patients and their families and affect their quality of life, and includes all care given towards the end of life. Thanks to palliative care in the physical, psychological and spiritual problems of cancer patients 90%relief can be achieved.
TREATMENT IN BREAST CANCER
Breast cancer treatment can be divided into 4:
one-pure non-invasive carcinoma (lobular carcinoma in situ-LCIS and ductal carcinoma in situ-DCIS) [stage 0];
2-operable, loco-regional invasive carcinoma (clinical stage 1, stage 2 and some stage 3A tumors);
3-In-operable locoregional invasive carcinoma clinical stage 3B, stage 3C and some stage 3A tumors;
4-Metastatic or recurrent carcinoma (stage 4)
Breast cancer treatment; surgery, radiation therapy of local disease (RT) or using both; systemic disease includes treatment with cytotoxic chemotherapy, endocrine therapy, biologic therapy, or combinations thereof. The need for and selection of various local or systemic treatments depends on a number of prognastic and predictive factors. These include tumor histology, clinical and pathological features of the primary tumor, axillary node status, hormone receptor content of the tumor, HER2/ neu level, presence or absence of detectable metastatic disease, patient’s comorbid diseases, age, and menopausal status. Breast cancer also occurs in men, and male patients with breast cancer are treated similarly to postmenopausal women.
Nutrition plays a very important role in both the development and treatment of cancer. Malnutrition, which means malnutrition, is a common condition in cancer patients. The severity of malnutrition varies depending on the type, location and stage of the cancer.
In epidemiological studies, approximately half of the newly diagnosed patients, 75% Weight loss and loss of appetite were found in more than . Incidence of weight loss in aggressive lymphomas, colon, prostate and lung cancers 50% is . The highest incidence and most severe weight loss occur in pancreatic and gastric cancer (about 85%) . Weight loss before treatment in all tumors shortens survival. Cachexia has the lowest mortality rate in cancer patients. 20% Due to all these high rates, the nutritional status of cancer patients should be evaluated at the time of diagnosis and nutritional interventions should be initiated early before the general condition deteriorates too much. The precautions to be taken and the treatments to be applied should be carried out in parallel with the primary treatment of the patient, and the nutritional status should be re-evaluated at each visit.
ANOREXIA AND Cachexia
Anorexia is defined as anorexia associated with chronic disease in cancer patients and is associated with weight loss. Anorexia and weight loss are often accompanied by early satiety and taste disturbances. The syndrome, which consists of decreased appetite, weight loss, metabolic disorders and an inflammatory condition, is called cancer cachexia or cancer anorexia-cachexia syndrome. Cancer cachexia is different from severe starvation. It cannot be corrected by food intake alone, and there are also losses in muscle mass in addition to losses in fat mass. In severe fasting, loss of fat mass rather than muscle is predominant. Cancer cachexia is associated with decreased physical function, decreased tolerance to anticancer therapy, decreased quality of life, and decreased survival.
Cancer cachexia syndrome can be divided into two groups as primary and secondary cachexia according to its cause.
Primary cachexia occurs with tumor-induced metabolic changes. Cancer itself produces substances that damage normal tissue structure. Tumor-derived proteolysis triggering factor (proteolysis inducing factor; PIF)By increasing protein catabolism, muscle mass destruction, lipid mobilizing factor (lipid mobilizing factor; LMF) It causes loss of fat mass by increasing lipolysis in adipose tissue. These tumor products accelerate catabolism, slowing anabolism, which leads to tissue loss. As a result of these metabolic disorders;
- insulin resistance,
- Decreased body fat rate with increased lipolysis and normal or increased lipid oxidation,
- Increased protein turnover with loss of muscle mass
- There is an increase in acute phase proteins.
In addition, cancer triggers a systemic inflammatory response. This inflammatory response leads to increased metabolic rate and the release of biochemical products. interleukin (PROVINCE)-1, IL-6 and tumor necrosis factor (TNF) Cytokines such as -α are secreted by immune mechanisms against tumors, which suppress appetite and cause early satiety. These barriers; nausea, vomiting, localized pain in mouth ulcers, taste and smell disorders caused by chemotherapy, diarrhea and constipation, exhaustion and mechanical obstruction due to tumoral mass.
DIAGNOSIS OF CANCER Cachexia and CLASSIFICATION
In cancer-induced cachexia, excessive weight loss, anorexia, asthenia, and anemia, in addition to carbohydrate (CHO) , changes in fat and protein metabolism, atrophy or hypertrophy of skeletal muscle and internal organs are observed. Taste, odor and gastrointestinal tract (GIS) Diseases, nutritional deficiencies and anabolic deficiencies, antineoplastic drugs and catabolic factors, especially cytokines, have important effects on the development of cachexia. Cancer cachexia is a progressive loss of skeletal muscle mass that causes progressive functional impairment and cannot be fully reversed with standard nutritional support. (with or without fat mass loss) is . Criteria for the diagnosis of cancer cachexia have been established. Here, weight loss, body mass index (BMI) and muscle mass loss. These determined criteria are listed below:
- In the last six months without malnutrition > 5%weight loss or
- BMI < 20 kg/m2ve > %2having weight loss or
- Extremity skeletal muscle index compatible with loss of muscle mass (< 7.26 kg/m2 for men; < 5.45 kg/m2 for women)and > %2having weight loss.
Reference values for assessing reduction in skeletal muscle (by gender) It is necessary to define and standardize body composition measurements. The generally accepted rule is that absolute muscularity is below the 5th percentile. This is evaluated as follows:
- Mid-upper arm muscle area with anthropometry (male < 32 cm2; female < 18 cm2),
- Extremity skeletal muscle index determined by dual energy X-ray absorptiometry (male < 7.26 kg/m2; female < 5.45 kg/m2),
- Lumbar skeletal muscle index determined by computed tomography (male < 55 cm2/m2; female < 39 cm2/m2),
- All BMIs other than adipose tissue calculated by bioelectrical impedance (male < 14.6 kg/m2; female < 11.4 kg/m2).
- In cases such as fluid retention, large tumor mass or obesity, direct muscle mass measurement is recommended.
Cancer cachexia has three clinically determined stages: precachexia, cachexia, and refractory cachexia. There are early clinical and metabolic signs in the precachexia stage. (eg anorexia and impaired glucose tolerance) . Involuntary weight loss at this stage (≤ 5%) can be avoided. risk of progression; It varies according to factors such as cancer type and stage, presence of systemic inflammation, decreased food intake and unresponsiveness to antitumor therapy. Cachexia stage of stable body mass in the last six months 5%Persistent weight loss with a weight loss of more than or with a BMI of less than 20 kg/m2 %2 patients with more than . Decreased food intake and systemic inflammation are common in these patients, but they have not yet entered the refractory stage. In the refractory cachexia stage, clinically refractory cachexia occurs as a result of advanced cancer or by the presence of rapidly progressive disease unresponsive to anticancer therapy. This stage is characterized by the presence of factors that allow active catabolism or the active management of weight loss. Refractory cachexia is characterized by poor performance status and a life expectancy of less than three months. Nutritional support may be beneficial. Symptom control can be achieved as a result of interventions with some drugs.
EVALUATION OF NUTRITIONAL STATUS
Determining the nutritional status of cancer patients is the first step to follow-up patients at high risk for malnutrition. The goal of evaluation is to quickly distinguish patients at risk and provide them with comprehensive and appropriate nutritional support. To quickly and effectively screen a patient’s nutritional status, objective and subjective data must be quickly reviewed. Height, weight, weight changes, diagnosis, stage of the disease, and presence of comorbid conditions are the objective data for screening nutritional status.
Nutritional support in cancer patients should begin at the time of diagnosis and should be included in the treatment plan at all disease stages. Cancer-related symptoms can be controlled, postoperative complications and infection rates can be reduced, hospital stay time can be reduced, treatment tolerance and immune response increase can be achieved with nutritional support. With all these results, an increase in the patient’s quality of life can be detected.
After the nutritional status of the patient is evaluated, it is necessary to control the symptoms first, and to prevent and treat the factors related to cancer treatment in patients who do not have severe malnutrition. Correction of symptoms such as pain, nausea, vomiting, diarrhea, constipation, mucositis, dysphagia, early satiety, dry mouth and taste disturbance and treatment of depression will also provide better nutrition for the patient.
Nutrition should be supported with electrolytes, trace elements and vitamins. Because oxidative stress markers increased and antioxidant levels decreased in cancer patients. It may be recommended to increase the doses of antioxidant vitamins in enteral nutrition products, but this is not a clinically beneficial data. Nutritional support, oral nutrition recommendations, enteral nutrition or parenterally. Enteral nutrition can also be divided into oral nutrition support and tube feeding.
Nutrition of the patient should primarily be provided orally. It is usually sufficient to question the foods that the patient has taken in the last 24 hours to determine the decreased food intake. The patient’s nutritional intake compared to the period before the onset of the disease 50%or 25% Information can be obtained by asking whether it is less than . First of all, the intake of fruit and vegetable-based diet and unprocessed grain products should be encouraged. Restriction is recommended in the intake of high-saturated fat, sugary, processed grain products and red meat consumption. Regular physical activity should be recommended along with healthy dietary recommendations.
Nutrition recommendations vary according to the characteristics of the patient and the disease. In patients suffering from nausea and vomiting, it is recommended to take food in as small portions as tolerated at frequent intervals. It should be paid attention to eat foods that do not smell and that the environment is odorless. Food and beverages are consumed more easily when they are cold or at room temperature. Oral hygiene should be taken care of and oral care should be done before and after meals. In treatment-related nausea and vomiting, drug therapy should be administered before the onset of nausea. In patients with diarrhea, fluid intake should be increased, and fiber-rich food intake should be reduced. A glass of liquid should be consumed after each defecation. Oily and gas-forming foods should be avoided. In patients with constipation, fibrous food intake should be increased along with fluid intake. Physical activity should be increased. In the presence of mucositis, it is recommended to consume more liquid and semi-solid foods. Acidic and salty foods should be avoided. In those with anorexia, foods that the patient likes and high in calories are recommended. Avoiding the smell of food while cooking, avoiding liquids during meals, and elegant presentation of food on small plates may be beneficial for patients with anorexia. If the patient has a feeling of early satiety and the amount of recommended enteral nutrition products is excessive, formulas with high energy and high protein content may be preferred.
ORAL NUTRITIONAL SUPPORT
Oral nutritional support is effective in patients who cannot take enough nutrients orally despite dietary recommendations. It is a simple, non-invasive and natural method that increases the food intake of patients. With this method, an increase in appetite, weight gain, a decrease in gastrointestinal complications and an increase in performance can be achieved. These beneficial effects BMI < 20 kg/m2reported to be more pronounced in patients with
Nutritional supplement products; It is any nutrient used in tube feeding or as an oral nutritional support, prepared for special medical indications. Products used in oral nutritional support are in the form of ready-to-use liquids or reconstituted powders. When given in the recommended amount, they can be used as a sole source of nutrition or as a supplement to oral nutrition. Consumption of these products may be difficult in patients with changes in taste and smell. The factors that determine the compliance of these patients are the taste and quantity of the products. Various flavors can be added to these products to facilitate consumption. Standard polymeric formulas are usually sufficient in cancer patients. Standard formulas are formulas that contain the necessary amount of macro and micronutrients needed by the healthy population. Most standard formulas contain high molecular weight protein, lipid of long chain triglycerides, and fiber. Similar formulas without fiber are also available. Most standard formulas do not contain gluten or lactose. If it contains gluten or lactose, it should be clearly stated on the label. Different formulas are produced for the disease or designed for children.
Regardless of the route of administration, “nutritional support applied for special medical purposes” is defined as enteral nutrition. It includes orally administered nutrition solutions and tube feeding methods through nasogastric, nasoenteral or percutaneous tube. On the other hand, enteral nutrition, tube feeding and oral nutrition support were accepted as nutrition. With enteral nutrition, the nutritional status of the patient is improved and intestinal functions are preserved. In addition, it has advantages such as being easier, less costly and less infectious complications compared to parenteral nutrition.
Enteral nutrition is the route that should be preferred primarily in patients with functional gastrointestinal system. Enteral tube feeding should be started as early as possible in patients who cannot meet their daily nutritional needs orally. This can be achieved through gastric or intestinal feeding tubes. Tube feeding is mostly needed in head and neck cancers and gastrointestinal system cancers. Percutaneous endoscopic gastrostomy in cases of oral and esophageal mucositis, which is common in cancer patients. (PEG)It is the preferred tube feeding method.
Early enteral nutrition compared to parenteral nutrition in the postoperative period resulted in a significant reduction in complication rates and hospital stay in patients with malnourished gastrointestinal cancer who were candidates for major surgery. However, fewer gastrointestinal symptoms were seen in patients receiving parenteral nutrition.
In a study conducted in patients with surgically resected gastric and pancreatic cancer, standard formulas and formulas enriched with arginine, omega-3 fatty acids and nucleotides, and parenteral nutrition were compared. It has been stated that enteral nutrition is a more suitable option in terms of reducing complications and shortening the hospital stay. In addition, enriched enteral nutrition products compared to standard formulas and parenteral nutrition, infection rates. 50% reported to be reduced. Similar results were obtained in the perioperative period in patients with colorectal cancer with enriched formulas.
When standard formulas and arginine-enriched formulas were compared in patients with head and neck cancer scheduled for surgery, a decrease in the levels of inflammatory markers such as IL-6 and C-reactive protein and an increase in quality of life were observed in both groups. Weight loss and frequency of admission to hospital in patients with oropharyngeal cancer receiving radiotherapy PEGcan be reduced by providing early nutritional support.
Parenteral nutrition should only be used in situations where the gastrointestinal tract is unsuitable, such as severe malabsorption, high-output fistula, dysmotility, and abdominal pain. In addition, parenteral nutrition is often preferred in patients with solid tumors or hematological malignancies who will undergo bone marrow transplantation. Enteral nutrition is generally not tolerated because the treatments used during bone marrow transplantation cause severe mucositis. In these patients, better results were obtained with formulas enriched with glutamine and omega-3 fatty acids. Although it is an effective nutrition technique, its high complication rates and cost are its main disadvantages.
In advanced stage, incurable and malnourished patients, patients who were treated with intensive oral nutritional support and then switched to parenteral nutrition, decreased weight loss, increased appetite and improved quality of life. Parenteral nutrition may be advantageous in patients with upper gastrointestinal system cancer as well as in patients with advanced cancer. However, its use is controversial, especially in patients who cannot be cured. Parenteral nutrition becomes mandatory in intestinal obstructions seen in advanced gastrointestinal cancers or metastatic gynecological cancers. In such cases, parenteral nutrition should be done at home. It has been observed that home parenteral nutrition provides adequate nutritional support in the last 2-3 months of life of the patients without impairing their quality of life in some patients with advanced cancer and who cannot be fed orally.
In many clinical studies, the efficacy of some drugs as appetite stimulant in cancer patients has been evaluated. Two types of treatment have been determined in cancer cachexia. These are; are corticosteroids and progestins.
- In studies with megestrol acetate and medroxyprogesterone acetate, appetite and weight gain were achieved, while an increase in quality of life was observed.
- Corticosteroids also increase appetite, reduce pain and vomiting and improve quality of life. However, due to the side effects of drugs in this group, short-term use is recommended.
CONCLUSION AND RECOMMENDATIONS
Breast cancer is the most common type of cancer in women and is the leading cause of female death. If it is diagnosed early, the quality of life and survival time are not affected much by the disease. Changes in the sense of taste and smell and loss of appetite in cancer patients adversely affect the nutritional status. Malnutrition develops as a result of not meeting the macro and micro nutrient needs due to decreased food consumption. Cachexia is a syndrome seen in the vast majority of cancer patients, causing deterioration in quality of life and reduced survival. For this reason, it is important to evaluate the nutritional status of all patients diagnosed with cancer at an early stage, and to treat patients with severe malnutrition effectively.
With appropriate nutritional support and pharmacological treatment approaches, these patients can increase their quality of life and survival.