NEVER in one place have more pioneers in the field of nutrition and cancer management converged to share their expertise and experience. In March of 2003, The University of Medicine and Dentistry of New Jersey, School of Health Related Professions, hosted the conference entitled Nutrition Management of Cancer: Past, Present, and Future Trends in Scotch Plains, NJ. Invited speakers included such icons in the field as Drs Maurice Shils, James Cimino, David August, Abby Bloch, and Julie O'Sullivan Maillet and Ms Kathryn Hamilton. The overriding goal of the conference was to provide participants with the history of nutrition management in cancer disease and prevention, as the basis for current practices and future trends. Presentations consisted of traditional and innovative approaches for nutrition and cancer prevention and treatment, integrative and alternative medicine, as well as palliative care. The following summary provides a brief overview of the conference initiatives.
Maurice Shils, MD, probably best known for his position as Director of Clinical Nutrition at the prestigious Memorial Sloan Kettering Cancer Center and current Editor for the renowned textbook Modern Nutrition in Health and Disease, set the pace of the conference by his opening comments concerning cancer and nutrition in the 20th century. He navigated participants through a 100-year journey chronicling advances in nutrition science from the first discoveries of vitamins and minerals in the early 1900s to the challenges with estimation of energy requirements during World War II to the role of nutrition in cancer therapy and management in present day.
According to Shils, cancer promotes more nutritional problems than any other disease. By the 1970s and 1980s, the relationship between weight loss, decreased performance, and increased morbidity and mortality was clearly identified. Although parenteral nutrition has existed for hundreds of years, Shils noted that there was an increased demand for intravenous feeding during the postwar period. The problems with hypertonic glucose infusions given peripherally created the development of improved medical procedures such as peripherally and percutaneously inserted catheters into the superior vena cava, thereby enhancing the availability of intravenous access for parenteral nutrition for long-term use. Additional advancements in parenteral nutrition administration included the creation of a sterile, stable lipid emulsion and commercially prepared multivitamin solutions. In 1978, the American Medical Association's Nutritional Advisory Group, along with the Food and Drug Administration, developed specialized recommendations for both adult and pediatric patients on parenteral nutrition.
With the development of percutaneous endoscopic gastrostomy, patients with head and neck cancers who experienced severe dysphagia and/or obstruction were able to benefit from supplementation without the risks of parenteral nutrition. Shils also emphasized that the advent of specialized nutrition support (SNS) available in the homes of patients with cancer not only increased the longevity among this population but greatly improved the quality of life since they no longer are confined to a hospital to receive such treatment.
The role of conditionally essential amino acids, glutamine and arginine, has gained interest in the last 20 years. Although research on glutamine and arginine is ever increasing, Shils summarized that currently not enough information is available concerning the safety in long-term supplemented use of these nutraceuticals.
David August, MD, PhD, presently the Chief of the Division of Surgical Oncology at Robert Wood Johnson Medical School and Cancer Institute of New Jersey, and current President of the American Society of Parenteral and Enteral Nutrition, echoed these sentiments about nutraceuticals in SNS. His presentation also closely examined the etiologies and the attributable causes for cancer. The impact of obesity and elevated body mass index was emphasized as a strong association with cancer incidence and mortality. The audience was noted with concern with the growing obesity rate in the United States in the past decade. Additionally, he identified the systemic effects of the disease and emphasized that malnutrition was one of the main reasons patients succumb to the disease. The best method for treating the cancer cachexia often experienced is by treating the underlying cancer. Interestingly, survival rates double when the patient does not experience weight loss.
August reviewed the clinical evidence regarding patient outcomes among those that received SNS. The findings are frustrating to nutrition professionals. There are no clear differences in outcome among cancer patients who received SNS and those who did not. Health care professionals can make the greatest impact when the focus is on prevention, not just disease. He raised key points concerning preventative health and discussed future research interests in terms of informatics, genomics, and nutraceuticals. Of the more promising areas of interest in current chemoprevention research is green tea.
Such emphasis on preventative health was a great segue into the presentation by Abby Bloch, PhD, RD, a private nutrition consultant and researcher in New York City, who provided a comprehensive review of the recently published American Cancer Society's (ACS's) Nutrition and Physical Activity Guidelines (see Table 1). By 2015, the society's goal is to decrease cancer incidence and mortality in half. These guidelines not only encourage dietary and physical activity changes to minimize cancer risk, but also emphasize the importance of community action needed to support the adoption and maintenance of healthful behaviors. Bloch established the link between dietary and exercise factors as well as presence of obesity to cancer risk. The ACS guidelines suggest moving toward a plant-based diet abundant in vegetables, fruits, and whole grains, moderate in meats and unsaturated fats, and limited in simple sugars. The guidelines also give specific information about maintaining a healthful weight and the importance of physical activity and exercise. Bloch concluded the ACS's recommendations concerning dietary supplements usage in cancer treatment and prevention by noting that limited evidence exists for inclusion into the society guidelines.
This attitude concerning dietary supplements was further expressed by Katherine Hamilton, RD, from Carol G. Simon Cancer Center at Morristown Memorial Hospital. She began her presentation by defining complementary and alternative medicine (CAM), and established why cancer sufferers and survivors may be seeking CAM treatments. She focused most of her discussion, as it related to CAM, integrative therapies, and nutrition interventions, to those most commonly used by cancer patients. Hamilton stated that CAM includes modest dietary modifications for cancer prevention like vegetarianism to more radical approaches, such as the macrobiotic diet, as well as dietary supplements. She covered in great detail the harmful effects of some herbals and the potential interactions or toxicities that may exist among vitamins, minerals, and herbal remedies. Hamilton concluded with practical approaches to CAM in cancer therapy by giving participants a plethora of information, reliable resources concerning dietary supplements, and advocating continuing education in CAM. Lastly, she addressed the importance of communication with patients on CAM treatments as the responsibility of individual practitioners and the responsibility of a team approach.
Julie O'Sullivan Maillet, PhD, RD, Associate Dean of University of Medicine and Dentistry of New Jersey, School of Health Related Professions, and President of the American Dietetic Association, investigated the role of the health care team in the treatment of the patient diagnosed with cancer, and emphasized that the team's approach should be patient-centered rather than disease-focused. Maillet enumerated what she termed as "Patch Adams Principles" that assure professionals keep the patient as the first and foremost priority and involve them in the decision-making process.
Maillet also gave a historical perspective of who's on the patient care team from the 20th century to present day. Currently, the team encompasses more than the traditional participants, such as the physician, nurse, dietitian, social worker, pharmacist; it now includes the massage therapist, pain manager, herbalist, and the spiritual healer. This clearly indicates why health care professionals must expand their skills and become more aware of unconventional modalities and treatments in order to be effective practitioners.
The role of patient-focused care could not be expressed any louder than in the presentation by James Cimino, MD, FACP, Director of Palliative Care Institute at Calvary Hospital, Bronx, NY, who challenged all participants to explore their feelings and beliefs concerning hospice and palliative care and how to incorporate it into clinical nutrition practice. He discussed the meaning of medical futility as well as the legal ramifications of palliative care. Caregivers and patients are "obliged" to act ethically, and the principles of beneficence (doing good) and nonmaleficence (do no harm) should be embraced. Cimino discussed key topics such as autonomy, informed consent, advance directives, euthanasia, and sedation therapy. His insight into end-of-life decisions assisted participants in understanding when it is inappropriate to feed, and potentially burdensome. Above all, honoring the patient's wishes in treatment decisions is of primary importance as noted in his article, "The Role of Nutrition in Hospice and Palliative Care of the Cancer Patient."
The conference concluded with an afternoon panel discussion that encouraged participants to inquire further about key topics raised earlier. The moderator, Riva Touger-Decker, PhD, RD, asked each panel member to offer a "take home message" for the participants. August recommended that all health care professionals be involved in research. Hamilton emphasized the need to evaluate dietary supplements critically before making recommendations, but to be "open-minded" about unconventional therapies. Bloch wanted professionals to familiarize themselves with the ACS guidelines (see Table 1) and help their clients in choosing one area to make changes and adopt healthful behaviors. Finally, Maillet stressed the importance of the health care team and the patient as the leader of that team.