A Fighting Chance
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At Cancer Treatment Centers of America, nutritional support helps strengthen patients for the most important battle of their lives.
SUMMARY
Several CTCA studies conducted in the last few years indicated that well-nourished patients in the studies lived longer on average than malnourished patients. Paying close attention to every patient’s nutritional needs is an important part of the integrative approach to treatment at CTCA. Every patient who arrives at a CTCA hospital meets with a licensed, registered dietician with 72 hours. Because nutrition is so important, CTCA clinicians stay well-versed in the newest, validated research and publish and present our results so others can benefit.
When Francis Zielinski arrived at Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center (Midwestern) in Zion, Illinois, he didn't appear to have a fighting chance. He had lost 36 pounds in six weeks. He was weak, malnourished and confined to a wheelchair. Fran, as his wife and friends call him, was in no shape to battle cancer.
Fran's normal weight was 142, but when he arrived at CTCA, he weighed only 106 pounds. This 54 year old truck driver from Lakeland, Florida, was dying, but not from his Stage IV colorectal cancer. Fran was dying from malnutrition – a common and very serious side effect of his and others' cancers and their treatments. According to the National Cancer Institute , about 80 percent of all cancer patients are malnourished and 20 to 40 percent of patients die not from the cancer itself, but from complications associated with malnutrition.
"Mr. Zielinski's cancer had obstructed his bowel, which prevented him from eating. He could not keep food down," said Pankaj Vashi, M.D., a gastroenterologist and national director of nutrition/metabolic support at CTCA. "We needed to get him built up, nutritionally, before we could even consider chemotherapy or surgery to treat his cancer."
Just a few days after Fran arrived at Midwestern, Dr. Vashi started him on liquid nutrition that was delivered intravenously. "We provided him with the proteins, fat, carbohydrates, micronutrients and trace elements he needed," says Dr. Vashi. "Since he was unable to eat on his own, nutrition therapy provided him with the essential nutrients that sustain life without eating or drinking anything."
According to the National Cancer Institute (NCI), finding and treating nutrition problems as early in treatment as possible can help improve a patient’s chance of recovery. Patients who are underweight or malnourished may not be strong enough for surgery or respond well to cancer treatments. Finding and treating nutrition problems promptly may help the patient gain or maintain weight, improve the patient's response to therapy, and reduce complications of treatment.
Nutrition therapy benefited Fran. Once he was receiving the protein and nutrients he needed, he began to put on some of the weight he had lost. After about six weeks, he was strong enough to walk on his own. Soon after that he started chemotherapy and, when he was healthy enough, his tumor was surgically removed.
Good Nutrition Is Central to the Fight Against Cancer at Cancer Treatment Centers of America
Pankaj G. Vashi, M.D.
Pankaj G. Vashi, M.D., is the national director of gastroenterology and nutrition metabolic support at Cancer Treatment Centers of America (CTCA). He is passionate about helping patients fight cancer by making sure they are as nutritionally fit as possible. “The majority of cancer patients are malnourished, which is absolutely unnecessary,” says Dr. Vashi. “The better nourished the patient is the better they can withstand treatment.”
Nutritional intervention alone cannot save a patient whose cancer is not responding to treatment, but reversing malnutrition can significantly enhance treatment and improve the patient’s quality of life. “We are making a positive difference in patients’ lives every day,” he says. “No matter where patients enter our hospital system they are assured of the quality nutritional care they expect and deserve.”
Fran Zielinski is not the only Cancer Treatment Centers of America (CTCA) patient who has benefited from nutritional therapy. Paying close attention to every patient's nutritional needs is an important part of the integrative approach to cancer treatment at CTCA. By carefully matching conventional and complementary treatments to the individual, CTCA treats the whole person and not just the tumor.
"Nutrition is an important part of our care model," says Dr. Vashi, a board certified gastroenterologist, chief of CTCA department of surgery, and the national clinical director of gastroenterology and nutrition metabolic support for CTCA. "Our philosophy is that we should not let patients reach the stage of malnutrition. It is not necessary. Malnourished patients cannot withstand their treatment, they don't heal well, and, most important, they have little chance of overcoming their cancer. We are proactive. We anticipate the natural progression of certain cancers and we intervene early."
"And, when you consider that 45 percent of malnourished patients are hospitalized longer than other patients in the same clinical diagnosis group," says Dr. Vashi, "it's clear that, in addition to being life-threatening and unnecessary, malnourishment lowers the patient's quality of life. It's also expensive for the patient, the hospital and the healthcare system."
Nutrition is so important that every patient who arrives at a CTCA hospital meets with a licensed, registered dietician (R.D.) within 72 hours after their arrival, and there's no waiting. CTCA at Midwestern Regional Medical Center (Midwestern) in Zion, IL has ten R.D.s. Southwestern Regional Medical Center (Southwestern) in Tulsa, OK has six R.D.s, Eastern Regional Medical Center (Eastern) in Philadelphia, PA has seven R.D.s and Western Regional Medical Center in Phoenix, AZ the newest CTCA hospital, has three R.D.s.
CTCA registered dietitians are assigned to each patient for the duration of the patient's stay. They conduct an individualized, comprehensive nutrition assessment upon each patients' arrival and follow the patients during and after treatment. The initial nutrition assessment is comprehensive, and includes taking blood samples and a medical history, as well as determining whether the patient is eating, what foods they prefer, what supplements they are taking, whether they are having digestive or intestinal problems, and, of course, documenting of their weight.
Carolyn Lammersfeld, M.S., R.D., L.D.N., C.N.S.D., is the national director of nutrition at CTCA. "If the patient is having digestive issues, such as nausea or constipation, we develop individualized diet plans to help alleviate the problem so they feel better and their nutrition doesn't suffer," she says. "If they are unable to eat, can't keep food down or can't digest it, we work with the physicians to provide nutrition parenterally (through a vein) or enterally (through a tube)."
Keeping patients well-nourished offers a number of benefits, says Lammersfeld. Their immune systems are more effective so they are less prone to infection and they heal faster after surgery. They enjoy greater strength and increased energy, and they can better tolerate treatments like chemotherapy or radiation. "The quality of patients' lives seems to improve as their nutrition improves," she says.
Cancer Treatment Centers of America Research Underscores the Value of Nutrition
It may seem obvious that patients who respond better to treatments, heal faster and have more energy would also have a better prognosis and a better quality of life. Nonetheless, dietary and medical staff at Cancer Treatment Centers of America (CTCA) continually research the impact of nutritional therapy to test these theories, and to provide better care for their patients. Several CTCA studies conducted in the last few years indicated that well-nourished patients in the studies lived longer on average, had a higher level of function and had fewer side effects than malnourished patients.
CTCA at Midwestern Regional Medical Center (Midwestern) carried out two studies that provided statistically significant data indicating well-nourished cancer patients may live longer. The first study, published in the Journal of Supportive Care in Cancer, in May, 2009, followed 98 ovarian cancer patients over a five-year period. The second study, published in the journal, Clinical Ovarian Cancer, included 184 ovarian cancer patients who were followed for four years. To evaluate each patient's nutritional status, Midwestern researchers used a standardized questionnaire, called the Subjective Global Assessment (SGA), and monitored each patient's serum albumin levels. As the most abundant protein in the human body, low serum albumin can indicate malnutrition.
In both of these ovarian cancer studies, patients who entered the program well-nourished and maintained their good nutritional status lived longest (21.6 and 26.9 months, respectively). Patients with improved nutritional status during the three months of the study were the next longest lived (18.5 and 25.4 months), and patients who were malnourished throughout the study had the lowest survival times (3.2 and 3.7 months). Patients who progressed from malnourished to well-nourished during the course of the project had about the same median survival times as patients who were well-nourished throughout. These findings suggest that proper nutrition, as well as nutritional intervention may significantly benefit all ovarian cancer patients.
Another study, also conducted at CTCA at Midwestern, attempted to quantify the relationship between nutritional status and quality of life for colorectal cancer patients, like Fran Zielinski. The researchers chose colorectal cancer because, in stages III and IV, malnutrition is a frequent, life-threatening complication of the disease.
Fifty-eight patients participated in the two-year study. The CTCA researchers used the SGA to assess the patients' nutritional status along with another standardized questionnaire to evaluate their physical and mental functions, symptoms and overall health. Across the board, the 34 patients who were well-nourished had greater physical, emotional and cognitive abilities and suffered fewer symptoms, such as nausea, insomnia and pain, than the malnourished patients. They also reported a better quality of life.
Christopher G. Lis, M.P.H., CTCA vice president of research and development, was lead author on the abstract that described the two-year study that was presented at a recent meeting of the American Society of Clinical Oncology. According to Lis, the results suggest improving patients' nutrition may also improve their quality of life by increasing their functionality and lessening their symptoms. "We're pursuing additional, prospective studies," said Lis, "to see if other patients who progress from malnourished to well-nourished report a positive change in the quality of their lives."
In addition to studying overall nutrition and how it affects patient longevity and/or quality of life, CTCA dietitians also research nutritional supplements, such as vitamins or minerals, to better understand how and when they should be administered. One project, led by CTCA dietitian Kristen Trukova, R.D., L.D.N., C.N.S.D. tested the theory that malnourished patients would be deficient in Vitamin D. Trukova and her team were particularly interested in the Vitamin D status of patients because other research suggests this vitamin may play an important role in cancer survival.
"There's research that says Vitamin D can help prevent cancers from growing by inhibiting the development of new blood vessels that nourish the tumor," says Trukova. "Also, the immune system functions better and bone health improves if Vitamin D levels are adequate. And, chemotherapy can damage the cells that form bone, so Vitamin D may be particularly important for breast cancer patients who often enter menopause early, a time when bone growth diminishes."
In the study, which was presented in June, 2009 at a meeting of the American Society of Clinical Oncology, Trukova's team followed 737 patients diagnosed with lung, breast, colorectal, pancreatic, prostate or ovarian cancer. They used the SGA to divide the patients into three groups – well-nourished, moderately malnourished and severely malnourished – and monitored their Vitamin D levels for six months. They theorized that only malnourished patients would have low levels of Vitamin D.
The results of the study not only surprised Trukova and her CTCA colleagues, they made the medical community more aware of the importance of Vitamin D. "We found that all the patients were Vitamin D deficient," says Trukova, "regardless of their nutritional status or their cancer type. This result was important because everyone had assumed that well-nourished patients would have sufficient levels of Vitamin D, but they didn't." As a result of this important study, the medical community is now more aware that all cancer patients should be routinely screened for Vitamin D deficiency and they should all receive Vitamin D supplements as part of their care.
Trukova and her CTCA colleagues now provide Vitamin D supplements to each patient, as appropriate. "If the patient is eating well and is not deficient, we will supplement with about 2,000 units a day," she says, "but if a patient is significantly deficient, we will give them up to 50,000 units a week."
Cancer treatment Centers of America Patient Outcomes Exceed the National Average
Due to the results of these studies, Cancer Treatment Centers of America (CTCA) is now investigating whether nutrition could be one of the reasons why CTCA patient survival rates for seven different advanced-stage cancers are higher than the nation's averages represented in the National Cancer Institute's Surveillance and Epidemiology End Results (SEER) database. Patient data gathered from 2000 to 2005 show that a higher percentage of CTCA patients with certain types of cancer survived for six months, one year and 1.5 years following their diagnosis than patients with a similar diagnosis who are represented in the SEER.
For example, in one study 78.5 percent of Stage IV colon cancer patients who treated at CTCA lived to six months compared to 57.6 percent of similarly diagnosed patients represented in the SEER. One year after diagnosis, 58 percent of CTCA patients were living versus 42 percent of the patients with similar diagnosis represented in the SEER. CTCA comparison data for all seven cancers is publicly available at www.cancercenter.com/cancer-statistics.cfm.
"Would we expect someone who is poorly nourished to metabolize anti-nausea or pain medication or chemotherapy to manage their cancer? We wouldn't," says Edgar D. Staren, MD, PhD, MBA, senior vice president for clinical affairs and chief medical officer for CTCA. "At CTCA, we recognize that nutritional support optimizes treatment. It helps patients better tolerate the therapies we're providing. And because nutrition is so important, we stay well-versed in the newest, validated research; we lead knowledge growth about supplements and their effects on patients through our own research; and, we publish and present our results so others can benefit."
