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Importance of nutrition alongside chemotherapy

Life is not a matter of holding good cards, but of playing a poor hand well.

Before the start of chemotherapy, patients must be taken into confidence about the nature of treatment and its sideeffects. This encourages better understanding of this form of therapy and helps patients and caregivers cope better with the side-effects.

Combating the Side Effects of Chemotherapy

I am reminded of an incident involving a friend who received treatment for breast cancer. Her surgery had been uneventful. She went for the first round of chemotherapy with a sense of optimism, not knowing what to expect. There had been no discussion about how taxotere, carboplatin and herceptin (TCH) medication would work on the body, what the sideeffects were or how to combat them. She was fine till the third day after treatment, when fatigue surfaced along with a profound nausea. Being absolutely unprepared, she handled it poorly. She took to bed, unable to consume much food or water. She developed day and night reversal, depression and dehydration. This led to a high-grade fever and urinary tract infection and required hospitalization.

Proper Counselling

Proper counselling of the patient and caregiver prior to chemotherapy, with an emphasis on proper hydration and diet to overcome the expected problems could have avoided the complications my friend had faced. Chemotherapy is toxic. A little help and guidance before treatment helps patients successfully navigate these difficulties, reducing complications and improving compliance. This experience had left her defeated. She wanted to stop treatment. Her oncologist suggested administration of only two drugs: carboplatin and herceptin (CH), eliminating taxotere, the most effective and potent drug, to reduce her toxicity. Her daughter and caregiver was greatly distressed, wanting more clarity on the further line of treatment.

There is no question that three drugs are better than two. They would have ensured maximum effect of treatment for her disease. The difficult period had been day three to six post the first round of chemotherapy. She needed a plan to keep herself well hydrated, and nourished with multiple small meals and plenty of fluids, including green tea, coconut water and soups for round two of chemotherapy. As the patient was an artist, she was advised to paint to occupy her time, along with listening to music or getting involved in any activity that interested her and could act as a diversion. With this advice, both physical and mental, she fared better during the second cycle of treatment and went on to complete all the cycles of chemotherapy.

The Body's Reaction to Chemotherapy

The traditional chemotherapeutic agents are cytotoxic. They act by killing cells that multiply rapidly-a characteristic of most malignant tumours. However, some normal cells in the body fall into this category too, particularly those of the gastro-intestinal system, bone marrow and hair follicles. This pool of normal rapidly dividing cells have to meet the body's demands during normal wear and tear, and they are also affected by the chemotherapeutic drugs.

Chemotherapy is stressful for the body. When highly potent and toxic drugs are injected directly into the bloodstream to suppress tumour growth, innocent bystander cells also take a hit. Maintaining a strong immune system reduces the risk of infection and improves the ability of the body to destroy surviving cancer cells. The food we eat must provide for all the body's demands during the the illness. treatment and during the repair of the tissues. This is diet-centric part of the therapy for cancer.

Importance of Good Nutrition

It is fundamental to recognize the importance of good nutrition during cancer therapy. The sum and substan of the diet is not only to provide nourishment--adequa intake of calories and other nutrients that the patient mi require for the physical demands of the illness and the rigours of treatment--but also to maintain a steady weight to facilitate chemotherapy (since the dose of the drugi calculated according to the surface area or the weight of the patient and to include foods with known anti-cancer effects.

Combating Gastro-Intestinal Side Effects

The most common side-effects of chemotherapy are nausea, vomiting, anorexia, abdominal cramps, change in bowell habits, change in taste and smell, dental and gum problems and soreness of mouth depending on the type, dose, frequency and duration of treatment. These side-effects are not universal. When severe, they may lead to dehydration and malnutrition, especially when sustained over long periods of time. However, most of the symptoms last for three to four days after therapy, after which food is better tolerated.

The discharge summary given at the time of the completion of chemotherapy comes in handy. It often gives tips to overcoming common symptoms, remedies for vomiting and advice on bowel care. Generally, the side-effects are similar for subsequent cycles, although the severity may vary. Mostly, these are short-lived and require little treatment.

1 teaspoon of baking soda,1 teaspoon of common salt in 1 litre of water. Mix well and keep the rinse at room temperature.

Some general precautions at home can reduce common side-effects. Kitchen or food smells that may trigger anorexia and nausea should be avoided. Eating multiple small meals keeps symptoms in check and ensures proper calorie intake. A change in taste can be achieved Baking soda rinse: by frequent mouth washes with a baking soda rinse. Rinsing the mouth before and after each meal helps improve the taste. Drinking plenty of water and adding a slice of lime for variation in taste ensures adequate hydration.

To overcome parosmia (altered smell), serve freshly cooked food at room temperature. Once the food cools, food smells reduce, making it easier to consume. Souring agents in the food like lime, lemon or vinegar improve flavour and reduce food smell. However, these additions may be troublesome when there are mouth ulcers. Black salt can be used as a substitute. Lemon rice, curd rice, fish curries, and mango dal all work well.68 Eating frequent small meals, and drinking ginger tea, green tea or buttermilk between meals provides much-needed fluids for hydration and the removal of toxic waste from the body.

Mouth, Gum and Dental Side Effects

Dental and gum problems may occur during chemotherapy. It is prudent to get a dental check-up and attend to all dental work before the start of chemotherapy. A sore mouth following treatment with chemotherapy or radiotherapy is the consequence of the treatment on the rapidly dividing cells of the mucous membrane of the mouth. Subsequent secondary infection occurs because of low immunity. The ulceration makes eating and swallowing difficult and often lasts for a few days.

  • Management of mouthsores requires frequent mouth rinsing with the baking powder rinse, keeping mouth and teeth clean, using dental floss or Water Pik to clean between teeth, brushing teeth using a soft brush, and avoiding dentures if they cause discomfort.
  • Application of vitamin E gently with a swab on the sore (puncture a 400 IU capsule of vitamin E and apply) promotes healing.
  • Maintain good nutrition with a soft diet high in proteins.
  • Avoid spicy food, and alcohol-containing mouthwashes, very hot or cold drinks, and citrus fruits for as long as the soreness remains.
 Side Effects on the Bone Marrow

The bone marrow contains precursor cells to all three elements of the blood-red blood cells, white blood cells and platelets. The precursor cells are all part of the normal pool of rapidly multiplying cells of the body, and are therefore targeted by chemotherapy. The effects can be anaemia, due to destruction of the red blood cells, resulting in insufficient oxygenation of the tissues; reduction in the white blood cells which predisposes the patient to infections; and spontaneous bleeding from the mucosa of the mouth and/or nose, due to the suppression of the platelets. When the reduction of any of these three elements is severe enough, it may delay further treatment and necessitate transfusions to correct the deficiency that has arisen.

An anecdotal report verbally communicated to me by a treating oncologist makes for interesting reading. he treating a patient for cancer with multiple metastases, who required repeated platelet transfusions with each cycle of chemotherapy. Astonishingly, when the patient came in for his fourth cycle of treatment, the platelet count, which should have fallen significantly as on previous occasions, was reasonable and he did not require transfusion. When questioned, the suggested 'gilov these for three continued taking throughout there vine-also called Gaduchi-which wed, the patient revealed that his local doctor had giloy' capsules to improve his count. He had taken three weeks, resulting in this improvement. He wued taking giloy, not requiring any further transfusions out the remainder of his chemotherapy. Giloy is a also called Tinospora cordifolia, Indian Tinospora, or shi-which is widely used in Ayurveda, considered to immunity modulator and increases platelet counts. If the oncologist is agreeable, it may be tried.

 Effect on Skin and Hair Follicles

Hair loss or alopecia is a temporary phenomenon. It may be accompanied by dry skin and brittle nails. The cells of the hair follicles are rapidly dividing and are therefore destroyed by chemotherapy. Hair loss can be severe. It requires no treatment. Eventually, a month or two after stoppage of treatment, the hair begins to sprout again and most of it grows back over a period of time.

Miscellaneous Effects: Cancer Fatigue

Fatigue may be a consequence of the cancer treatment, be it chemotherapy or radiation. It is unpredictable, yet it is one of the most distressing side-effects. It is often worse immediately after the treatment, persisting for a few days before reducing slowly in time for the next cycle. The level of fatigue may increase as treatment continues. Many factors compound the fatigue: low levels of red blood cells, sleeping problems, loss of appetite resulting in poor nutrition and lack of exercise.

I am reminded of my friend Anil, who had developed progressive Stage IV colon cancer. His oncologist had suggested a trial of three cycles of chemotherapy, including a drug that blocked new blood vessel formation. I visited nim on the tenth day of his first cycle. He had severe fatigue, barely managing to sit up for two minutes to sip water. His voice was faint. He was struggling to eat. He was most comfortable lying in a foetal position.

After a discussion on the causes for his fatigue that so overwhelmed him, we deduced that it was the progression of his cancer, the effects of chemotherapy and the lack of nourishment. In addition to the antidepressant the oncologist had prescribed, it was suggested that some of his needs could be met by consuming six to eight small meals. which included foods rich in protein, vitamins and minerals. He promised to make an attempt to improve his diet after realizing that the hollow feeling in the abdomen was hunger. and not the cancer growing rapidly. Ten days later I met him again-he had decided to stop further chemotherapy and was on multiple small meals daily. He felt better for it. His voice was stronger, he could sit up, and he even walked to the table for lunch.

Other reasons for fatigue are increased energy requirement for repair and healing of damaged tissues, build-up of toxio substances from cell destruction due to the treatment, and the challenges faced by the immune system during treatment. Adequate fluid intake and exercise are ways to flush out the accumulated toxins.

Management of Cancer Fatigue

Fatigue is a side-effect that needs proper handling and management. Some of the causes are food-related and can be factored into the diet-like eating foods rich in proteins, vitamins and minerals, or protein supplements and vitamin tablets to deal with anaemia, along with extra proteins for tissue repair.

Apart from food, many other factors can help in alleviating fatigue:

  • Building a new routine created by the patient can ensure better time management. They should undertake some exercise like short walks, listen to music, read-whatever is of interest to the individual. These help patients remain focused, preventing daynight reversal, reduce stress, and promote relaxation by participating in activities that are light and meaningful. Involvement in day-to-day activities at home or work helps to keep depression at bay.
  • When fatigue is profound immediately after chemotherapy, short rest-breaks, three to four times a day, balanced with some activity, are ideal.
  • Avoid long rest-breaks or sleeping all day. Conversely, although it is important for patients to remain active, they should not be pushed excessively.
  • Daily exercise improves appetite and prevents constipation.
  • Sunning oneself helps relax the body, elevates the mood and provides the much-needed daily supply of Vitamin D.
  • Vitamins, proteins and omega-3 must be provided in the diet.
  • Vegetables that can be washed well, preferably soaked and scrubbed, should be eaten. The food preparing counter must be cleaned before and after each use.
  • Eat fruits that can be peeled, i.e. avoiding the peels of fruits like pears, peaches and apples, etc.
  • Tomatoes should be soaked in boiling water before adding to the salad.
  • Microwave meat and chicken for rapid thawing and then cook immediately.
  • Anaemia requires foods rich in iron, folic acid and B12 (see p. 98 in 'Surgery and Nutrition').
 Foods to Be Avoided

Food safety becomes a priority during treatment. Both chemotherapy and radiotherapy weaken the immune system Diarrhoea can be problematic. During treatment avoid raw vegetables like sprouts, lettuce, frozen foods, smoked fish and pate, sushi and sashimi, raw milk or cheeses made from un-pasteurized milk, uncooked eggs, non-homemade salade and sandwiches. Eat only freshly cooked food, not leftovers. reheated or frozen and thawed food.

On one occasion, I met a friend just before his first dose of chemotherapy. He had had surgery for cancer of the colon. It was lunchtime, and he was getting admitted that afternoon for chemotherapy. He was calm; it was his first cycle. I was taken aback with what he ate for lunch: a slice of thick-crust pizza that was left over from a previous meal. It had been frozen and was thawed that morning for him. There was also a salad where most of the greens were raw, along with a bowl of yogurt.

Even at the best of times, fast foods must to be avoided. But stale food, even though frozen, spells big trouble. That friend developed diarrhoea during chemotherapy. Was the diarrhoea only due to chemotherapy, or had the stale frozen pizza contributed to it? I cannot say, but I must emphasize again the need to eat freshly cooked, light food before chemotherapy.

Food Time-table for Chemotherapy

Whichever meal works well should be eaten to the fullest. Breakfast is the meal that is generally best tolerated.

7:30 a.m.: Freshly made mixed fruit juice.

8 a.m.: Sugar-free cereal with flax seeds and cinnamon upma/egg and toast with tea. Boiled or scrambled eggs, one to two whole grain toasts OR hot or cold cereal are easy to consume.

11:30 a.m.: Yogurt with 1 tablespoon of mixed nuts. Yogurt with berries also works well, and can be eaten between meals.

1:30 p.m.: Soft food-khichri cooked with vegetables, dal and rice. Chopped chicken can be added if desired.

4:30 p.m: Stewed fruits and a cup of tea. Bananas are a good snack. 6 p.m.: Soup (See p. 122-23 in Managing Palliative Care).

8 p.m.: Dinner-similar to lunch. Cup of green tea after dinner.