PALLIATIVE CARE IN BREAST CANCER

PALLIATIVE CARE IN BREAST CANCER

Cancer palliative care is the integration of cancer care with improvements in various issues that are painful and distressing for patients and their families and affect their quality of life, and encompasses the entirety of care given to the end of life. Thanks to palliative care, 90% relief can be achieved in the physical, mental and spiritual problems of cancer patients.

TREATMENT OF BREAST CANCER

Breast cancer treatment can be divided into 4:

1-Pure non-invasive carcinoma (lobular carcinoma in situ-LCIS and ductal carcinoma in situ-DCIS) [stage 0];

2-operable, locally-regional invasive carcinoma (clinical stage 1, stage 2 and some stage 3A tumors);

3-In-operable local-regional invasive carcinoma clinical stage 3B, stage 3C, and some stage 3A tumors;

4-Metastatic or recurrent carcinoma(Stage 4)

Breast cancer treatment; local disease using surgery, radiation therapy (RT), or both; systemic disease includes treatment with cytotoxic chemotherapy, endocrine therapy, biological 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, comorbid diseases, age, and menopausal status of the patient. Breast cancer also occurs in men, and male patients with breast cancer are treated like postmenopausal women.

NUTRITIONAL THERAPY

Nutrition has an invaluable role in both the development and treatment of cancer. Malnutrition, which means macular nutrition, 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, weight loss and loss of appetite were found in approximately half of newly diagnosed patients and in more than 75% of advanced cancer patients. The incidence of weight loss in aggressive lymphomas, colon, prostate and lung cancers is 50%. The highest incidence and most significant weight loss occur in pancreatic and gastric cancer (approximately 85%). Weight loss before treatment in all tumors shortens survival. It has been suggested that cachexia is responsible for at least 20% of deaths in cancer patients. Because of 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 measures 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 a chronic disease-related anorexia 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 hunger. It cannot be corrected with food intake alone, and besides the loss in fat mass, the loss in muscle mass is also a matter of speech. In severe hunger, loss of fat mass is more prominent than muscle. 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 issues that damage normal tissue structure. Tumor-derived proteolysis triggering factor (PIF) causes muscle mass destruction by increasing protein catabolism, and lipid mobilizing factor (LMF) causes fat mass loss by increasing lipolysis in adipose tissue. These tumor artifacts 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 artifacts. Cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-α are secreted by immune systems against tumors, which suppress appetite and cause early satiety. occurs. These roughnesses; nausea, vomiting, localized pain in mouth ulcers, taste and smell disorders caused by chemotherapy, diarrhea and constipation, fatigue and mechanical obstruction due to tumoral mass.

DIAGNOSIS AND CLASSIFICATION OF CANCER Cachexia

In cancer-induced cachexia, in addition to weight loss, anorexia, asthenia and anemia, changes in carbohydrate (CHO), fat and protein metabolism, atrophy or hypertrophy in skeletal muscle and internal organs are observed. . Catabolic factors, especially taste, odor and gastrointestinal system (GIS) disorders, nutritional deficiencies and anabolic deficiencies, antineoplastic drugs and cytokines have valuable effects on the development of cachexia. Cancer cachexia is a progressive loss of skeletal muscle mass (with or without fat mass loss) that causes progressive functional impairment and is not fully reversible on a standard nutritional basis. Criteria for the diagnosis of cancer cachexia have been established. Weight loss, body mass index (BMI) and muscle mass loss are considered here. These determined criteria are listed below:

• Weight loss of > 5% or
• BMI < 20 kg/m2 and > 2% weight loss in the last six months without malnutrition, or
• Extremity skeletal muscle index (< 7.26 kg/m2 in men; < 5.45 kg/m2 in women) and > 2% weight loss consistent with muscle mass loss.

To account for the reduction in skeletal muscle, it is necessary to define reference costs (by gender) and standardize body composition measurements. The widely accepted rule is that absolute muscularity should be below the 5th percentile. This is evaluated as follows:

• Mid upper arm muscle area by anthropometry (male < 32 cm2; female < 18 cm2),
• Extremity skeletal muscle index determined by dual power X-ray absorptiometry ( male < 7.26 kg/m2; female < 5.45 kg/m2),
• Lumbal skeletal muscle index determined by computed tomography (male < 55 cm2/m2; female < 39 cm2/m2),
• All non-adipose BMI calculated by bioelectrical impedance (male < 14.6 kg/m2; female < 11.4 kg/m2).
• Direct measurement of muscle mass is recommended in cases of fluid retention, large tumor mass or obesity.

Cancer cachexia has three clinically determined stages: precachexia, cachexia, and refractory cachexia. In the precachexia stage, there are early clinical and metabolic signs (eg, anorexia and impaired glucose tolerance). Involuntary weight loss (≤ 5%) present at this stage can be prevented. 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. The cachexia stage is patients who have lost more than 5% of their stable body mass in the last six months or whose BMI is less than 20 kg/m2 and who have an ongoing weight loss of more than 2%. Decreased food intake and systemic inflammation are common in these patients, but they have not entered the refractory stage now. In the refractory cachexia stage, clinically refractory cachexia occurs as a result of advanced cancer or with the presence of rapidly progressive disease that does not respond to anticancer therapy. This phase is characterized by the presence of factors that enable active catabolism or effective management of weight loss. Refractory cachexia is characterized by poor performance status and a life expectancy of less than three months. Nutritional support can be beneficial. Symptom control can be achieved as a result of interventions with some drugs.

ASSESSMENT OF NUTRITIONAL STATUS

Determining the nutritional status of cancer patients is the first step to follow-up patients at high risk for malnutrition. The aim of the evaluation is to quickly distinguish patients at risk and to provide them with comprehensive and appropriate nutritional supplementation. To screen a patient’s nutritional status quickly and actively, objective and subjective data must be quickly reviewed. Length, weight, weight changes, diagnosis, stage of disease, and presence of comorbid conditions are objective data for screening nutritional status.

NUTRITIONAL BASIS

Nutritional supplementation in cancer patients should start at the time of diagnosis and should be included in the treatment plan at all disease stages. With nutritional supplementation, cancer-related symptoms can be controlled, postoperative complications and infection rates can be reduced, and hospital stay duration can be reduced, an increase in treatment tolerance and an increase in immune response can be achieved. 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, in patients without severe malnutrition, first of all, symptoms should be controlled, and factors related to cancer treatment should be prevented and treated. Correction of symptoms such as pain, nausea, vomiting, diarrhea, constipation, mucositis, difficulty in swallowing, early satiety, dry mouth and taste disorder, 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 studies, but this is not an information that has been shown to be clinically beneficial. Nutritional supplement may be provided enterally or parenterally, with oral nutritional offerings. Enteral nutrition can also be divided into oral nutrition based and tube feeding.

NUTRITIONAL SUGGESTIONS

The patient’s nutrition 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. Information can be obtained by asking the patient whether the food intake is 50% or less than the period before the onset of the disease. Oral intake can be increased with appropriate nutritional offers to patients with reduced food intake. First of all, the intake of fruit and vegetable-laden diets 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. Along with healthy diet proposals, regular physical activity should also be recommended.

Nutrition offers vary according to patient and disease characteristics. In patients suffering from nausea and vomiting, it is recommended to take food in small portions as tolerated at frequent intervals. Foods that do not smell should be eaten and care should be taken to ensure that the surroundings are 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-producing 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. For 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 too high, high-strength and high-protein formulas may be preferred.

ORAL NUTRITIONAL SUPPLEMENT

Oral nutritional supplement is effective in patients who cannot take enough nutrients orally despite dietary offers. It is an easy, non-invasive and natural way to increase patients’ food intake. With this procedure, an increase in appetite, weight gain, reduction in gastrointestinal complications and an increase in performance status can be achieved. These beneficial effects have been reported to be more evident in patients with BMI < 20 kg/m2.

Nutrition underpinnings; It is any nutritional element used in tube feeding or as a basis for oral nutrition and prepared for special medical indications. The products used in the basis of oral nutrition are in the form of ready-to-use liquid or reconstituted powders. They can be used as the sole source of nutrition or as a basis for oral nutrition when given in the recommended amount. Consumption of these artifacts may be difficult in patients with changes in taste and smell. The factors that determine the harmony of these patients are the taste and size of the works. Various flavors can be added to these works to facilitate consumption. Standard polymeric formulas are often sufficient in cancer patients. Standard formulas are formulas that contain macro and micronutrients, which are needed by the healthy population, to the required extent. Many standard formulas contain high molecular load protein, lipids made up of long chain triglycerides, and fiber. Non-fibre-free formulas are also available. More than one standard formula does not contain gluten or lactose. If it contains gluten or lactose, it should be clearly stated on the label. Different formulas are produced that are specific to the disease or designed for children.

ENTERAL NUTRITION

Regardless of the route of administration, “nutritional support applied for special medical purposes” is defined as enteral nutrition. It includes feeding solutions given orally and tube feeding methods made through nasogastric, nasoenteral or percutaneous tube. On the other hand, enteral nutrition, tube feeding and oral nutritional supplementation have been accepted as nutrition. With enteral nutrition, the patient’s nutritional status is improved and intestinal functions are also preserved. In addition, it has advantages compared to parenteral nutrition such as being easier, less costly and less complications of infection.

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 requirements 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 (PEG) is the preferred tube feeding method in cases of oral and esophageal mucositis, which are common in cancer patients.

Enteral nutrition, which is started earlier than parenteral nutrition in the postoperative period, provided a significant reduction in complication rates and hospital stay in patients with malnourished gastrointestinal cancer and candidates for major surgical intervention. 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, it has been reported that enriched enteral nutrition products reduce infection rates by 50% compared to standard formulas and parenteral nutrition. 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 the quality of life were similar in both clusters. Weight loss and frequency of hospital admissions in patients with oropharyngeal cancer receiving radiotherapy can be reduced by providing early nutritional support with PEG.

PARENTERAL NUTRITION

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. Since the treatments used during bone marrow transplantation cause severe mucositis, enteral nutrition is often not tolerated. Better results were obtained with formulas enriched with glutamine and omega-3 fatty acids in these patients. Although it is an effective nutrition technique, its high complication rates and cost are its main disadvantages.

Decreased weight loss, increased appetite and improved quality of life were found in advanced stage, incurable and malnourished patients, patients treated with heavy oral nutritional supplements and then switched to parenteral nutrition. 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 essential in intestinal obstructions seen in advanced gastrointestinal cancers or metastatic gynecological cancers. In such cases, parenteral nutrition should be given at home. It has been observed that in some patients with advanced cancer and who cannot be fed orally , parenteral nutrition at home provides sufficient nutritional support in the last 2-3 months of life of the patients without impairing their quality of life.

PHARMACOLOGICAL THERAPY

In many clinical studies, the activity 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.

• Studies with megestrol acetate and medroxyprogesterone acetate have shown an increase in appetite and weight gain, and an increase in life quality.
• Corticosteroids also increase appetite, reduce pain and vomiting and improve quality of life. However, due to the side effects of the drugs in this group, it is recommended to be used for a short time.

CONCLUSIONS AND Suggestions

Breast cancer is the most common type of cancer in women and is the leading cause of death in women. 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 affect the nutritional status in a terrible way. Malnutrition develops as a result of the inability to meet the macro and micro nutrient needs due to decreased food consumption. Cachexia is a syndrome seen in the vast majority of cancer patients and causes 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 effectively treat especially patients with severe malnutrition.

With appropriate nutritional basis and pharmacological treatment approaches, an increase in the quality of life and survival can be achieved in these patients.