PALLIATIVE CARE IN BREAST CANCER
Cancer palliative care is the integration of improvements into cancer care for various issues that are painful and distressing for patients and their families and affect their quality of life, and towards the end of life. It covers all the care provided. Thanks to palliative care, 90% relief can be achieved in the physical, psychological and spiritual problems of cancer patients.
TREATMENT IN 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, local-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; It includes treating systemic disease 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 prognostic 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, detectable metastatic disease or not, comorbid diseases of the patient, age and menopausal status. Breast cancer also occurs in men, and male patients with breast cancer are treated similarly to postmenopausal women.
NUTRITIONAL TREATMENT
Nutrition is very important in both the development and treatment of cancer. has a role. Malnutrition, meaning poor nutrition, is a common condition in cancer patients. The severity of malnutrition varies depending on the type, location and stage of cancer.
In epidemiological studies, weight loss occurs in approximately half of newly diagnosed patients and in more than 75% of advanced-stage cancer patients. and i Loss of appetite was detected. The incidence of weight loss in aggressive lymphomas, colon, prostate and lung cancers is 50%. The highest incidence and most severe weight loss is seen in pancreatic and stomach cancer (about 85%). In all tumors, weight loss before treatment shortens survival. It has been suggested that cachexia is responsible for at least 20% of deaths in cancer patients. Due to all these high rates, the evaluation of the nutritional status of cancer patients should begin at the time of diagnosis and nutritional interventions should be started early before the general condition deteriorates too much. Precautions to be taken and treatments to be applied should be carried out in parallel with the patient's primary treatment, and nutritional status should be re-evaluated at each visit.
ANOREXIA AND CCHEXIA
Anorexia is associated with chronic disease in cancer patients. It is defined as loss of appetite and is accompanied by weight loss. Loss of appetite and weight loss are often accompanied by early satiety and taste disturbances. The syndrome consisting 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 nutritional intake alone, and in addition to losses in fat mass, there is also loss in muscle mass. In severe starvation, losses in fat mass rather than muscle are at the forefront. Cancer cachexia is associated with decreased physical function, decreased tolerance to anticancer treatment, decreased quality of life and decreased survival.
Cancer cachexia syndrome is classified as primary and secondary cachexia depending on the cause. can be divided into two groups
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) causes muscle mass destruction by increasing protein catabolism, lipid mobilizing factor (LMF) causes fat mass by increasing lipolysis in adipose tissue. causes loss. These tumor products accelerate catabolism and slow down anabolism, leading to tissue loss. As a result of these metabolic disorders;
- Decrease in body fat rate with increased lipolysis and normal or increased lipid oxidation,
- Increased protein turnover with loss of muscle mass,
- Acute phase There is an increase in proteins.
In addition, cancer triggers a systemic inflammatory response. This inflammatory response leads to increased metabolic rate and the release of biochemical products. Cytokines such as interleukin (IL)-1, IL-6 and tumor necrosis factor (TNF)-α are secreted by immune mechanisms against the tumor, which suppress appetite and lead to early satiety. .Secondary cachexia consists of impaired food intake and feeding-related disabilities that lead to malnutrition. These obstacles; We can list these as nausea, vomiting, localized pain seen in mouth ulcers, taste and smell disorders caused by chemotherapy, diarrhea and constipation, fatigue and mechanical obstruction due to tumoral mass.
DIAGNOSIS OF CANCER CACHEXIAandCLASSIFICATION
In cancer-induced cachexia, in addition to excessive weight loss, anorexia, asthenia and anemia, carbohydrate (CHO), fat and changes in protein metabolism, atrophy or hypertrophy of skeletal muscle and internal organs are observed. Catabolic factors, especially taste, smell and gastrointestinal system (GIS) disorders, nutritional deficiencies and anabolic deficiencies, antineoplastic drugs and cytokines, have important effects on the development of cachexia. Cancer cachexia is a progressive skeletal muscle mass loss (with or without fat mass loss) that leads to progressive functional impairment and is not fully reversible with standard nutritional support. Criteria for the diagnosis of cancer cachexia have been established. Here, weight loss, body mass index (BMI) and muscle mass loss are taken into account. These determined criteria are listed below:
- Weight loss of > 5% in the last six months without malnutrition or
- BMI < 20 kg/m2 and > 2% weight loss or
- Extremity skeletal muscle index compatible with loss of muscle mass (< 7.26 kg/m2 in men; < 5.45 kg/m2 in women) and > 2% weight loss
To evaluate the reduction in skeletal muscle, it is necessary to define reference values (by gender)and standardize body composition measurements. The generally accepted rule is that absolute muscularity is below the 5th percentile. This is evaluated as follows:
- Middle upper arm muscle area by anthropometer (male < 32 cm2; female < 18 cm2),
- Dual energy Extremity skeletal muscle index determined by -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 bioelectric impedance (male < 14.6 kg/m2; female < 11.4 kg/m2).
- Direct muscle mass measurement is recommended in cases such as fluid retention, large tumor mass or obesity.
Cancer cachexia has three clinically determined There are three stages: precachexia, cachexia and refractory cachexia. In the precachexia stage, there are early clinical and metabolic signs(e.g. anorexia and impaired glucose tolerance). In this stage, unintentional weight loss (≤ 5%) can be prevented. Risk of progression; It varies depending on factors such as cancer type and stage, presence of systemic inflammation, decreased nutritional intake and unresponsiveness to antitumor treatment. Cachexia phase is defined as those who have lost more than 5% of stable body mass in the last six months or have a BMI of less than 20 kg/m2 and ongoing weight loss of more than 2% are patients. Decreased food intake and systemic inflammation are common in these patients, but they have not yet entered the refractory phase. In the refractory cachexia phase, cachexia that is clinically refractory occurs as a result of advanced stage cancer or the presence of rapidly progressive disease that is unresponsive to anticancer therapy. This phase is characterized by active catabolism or the presence of factors that actively manage 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 medications.
NUTRITION D ASSESSMENT OF THEIR CONDITION
Determining the nutritional status of cancer patients is the first step in monitoring patients at high risk for malnutrition. The goal of the assessment 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 the presence of comorbid conditions are objective data in the screening of nutritional status.
NUTRITIONAL SUPPORT
Nutritional support in cancer patients at the time of diagnosis. It should start and be included in the treatment plan at all disease stages. With nutritional support, cancer-related symptoms can be controlled, postoperative complications and infection rates can be reduced, hospital stay can be reduced, treatment tolerance and immune response can be increased. With all these results, an increase in the patient's quality of life can be detected.
After evaluating the patient's nutritional status, it is necessary to first control the symptoms and 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, difficulty swallowing, early satiety, dry mouth and taste disturbance, and treatment of depression will also ensure better nutrition of the patient.
Nutrition, electrolytes, trace elements. and vitamins. Because oxidative stress markers are increased and antioxidant levels are decreased in cancer patients. It may be recommended to increase the doses of antioxidant vitamins in enteral nutrition products, but this is not a data that has been shown to be clinically beneficial. Nutritional support can be provided enterally or parenterally with oral nutrition recommendations. Enteral nutrition can also be divided into two: oral nutritional support and tube feeding.
NUTRITIONAL RECOMMENDATIONS
The patient's nutrition should primarily be provided orally. To determine the decreased nutritional intake, the patient's last nutritional intake should be determined. It is usually sufficient to question the nutrients consumed within 24 hours. The patient is given 5% of the nutritional intake compared to the period before the disease started.
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