Michelle Srour

2016 Spring HNSC4240 Clinical Nutrition I

Case study 3: Neoplastic disease
Due 5/18/2016

1. Her2 is a growth promoting hormone. Tumors with increased levels of HER2 are
referred to as Her2-positive. Cancers that are Her2 positive have too many copies of
the Her2 gene resulting in greater than normal amounts of the Her2 protein. These
cancers tend to grow and spread more aggressively than other breast cancers. All
newly diagnosed invasive breast cancers should be tested for Her2+ because Her2+
cancers are much more likely to benefit from targeted therapy. Her2+ cancer can be
treated with Trastuzumab, which acts as a Her2 antibody. The drug binds to the Her2
receptors on breast cancer cells blocking them from growth signals, which can either
slow or prevent growth of breast cancer.
An important step in evaluating a breast cancer is to test the cancer removed
during the biopsy to see if it has estrogen and progesterone receptors. The receptors
are proteins in certain cells that can attach to substances such as hormones that
circulate the blood. ER+ cancers indicate breast cancers that have estrogen receptors,
while PR+ cancers indicate breast cancers with progesterone receptors. The receptors
often fuel the growth of cancer cells. Breast cancers that are hormone receptor-
positive can be treated with hormone therapy drugs that lower estrogen levels or block
their receptors. Hormone therapy is a form of systemic therapy, meaning it reaches
cancer cells anywhere in the body and not just in the breast. Drugs such as; Tamoxifen
stops estrogen from binding to the cancer cells and telling them to grow and divide.
While tamoxifen acts like an anti-estrogen in breast cells, they act like an estrogen in
other tissues, like the uterus and the bones.

2. Staging of cancers describes the extent or severity of a persons cancer. Knowing

the stage of the disease helps the doctor plan treatment and estimates the persons
prognosis. The TNM staging system is based on the size or extent of the primary
tumor, whether cancer cells have spread to nearby lymph nodes and whether
metastasis (spread of the cancer to other parts of the body) has occurred.
Invasive Ductal Carcinoma indicates that the cancer began growing in the duct (a
tube like structure connected by one another in the breasts to produce milk) and has
invaded fatty tissue of the breast outside of the duct. Carcinoma means that the tumors
have been derived from epithelial cells. Stage IIB indicates that the cancer has spread
beyond the organ in which its first developed, the duct, to nearby lymph nodes and or
tissues or organs adjacent to the location of the primary tumor. This stage is divided
into groups: Stage 2A and Stage 2B. The difference is determined by the size of
the tumor and whether the breast cancer has spread to the lymph nodes. Stage B
indicates that the tumor is between the 2 and 5 centimeters and has spread to less than
four axillary lymph nodes or that the tumor is larger than five centimeters, but has not
spread to any axillary lymph nodes.

3. Mrs. Smith has a BMI of 29.2. Given that she is overweight yet, on chemotherapy
she cannot limit her calories therefore, her caloric requirement is between 1,670 and
1989 calories a day. In addition due to many nutritional manifestations of cancer
treatments (such as, cancer cachexia, anorexia, nausea and vomiting etc.) protein
1
requirement for cancer patients is increased to prevent muscle wasting. Therefore, it is
important for Jennifer to meet her protein needs of 1-1.5g/kg per day thus her protein
requirement must be between 80 and 119 grams of protein a day while on
chemotherapy. After all treatments are completed Mrs. Smiths caloric and protein
may return to normal. However given that her current BMI is of 29.2 she should limit
her calorie intake and increase her physical activity to promote weight loss to get her
in the normal BMI range. Her caloric intake should be limited to 1,590 calories (low
end and 1,980 calories (high end). In addition, her body is no longer under treatment
or metabolic stress therefore her protein intake should be about 64 grams per day.
It is important for breast cancer survivors to maintain normal weight. In addition
cancer survivors should eat a variety of fruits and vegetables Based on Jennifers
dietary recall she did consume fruits and vegetables throughout the day, although she
may want to swap the cheese and crackers after dinner for an additional fruit, since
her diet already seemed slightly high in fat. In addition, it is important for cancer
survivors to limit their consumption of red meat. Although a filet minion is a lean
steak and there are no exact guidelines on the amount or frequency of red meat
consumption that may cause cancer, 8 ounces is a large amount of red meat and
Jennifer should limit her consumption to be safe. Moreover, if consumed at all, cancer
patients should limit alcoholic to one a day. If Mrs. Smith continues to consume a diet
high in red meat and alcohol she may be at risk of bringing back the cancer.

4. To prevent the cancer from recurring Mrs. Smith should follow the AICRS
guidelines for cancer survivors or guidelines for cancer survivors from other cancer
associations. Jennifer should try to be as lean as possible without becoming
underweight and given that she is looking to keep the weight off, Mrs. Smith can try
increasing her exercise intensity and decreasing her caloric intake while consuming
nutrient dense foods. The cancer guidelines to prevent the cancer from recurring is
very similar to general USDA guidelines to maintain a healthy weight and prevent
metabolic diseases. Jennifer should avoid sugary drinks and limit her consumption of
energy dense foods (especially since she has a history of T2D and has current high
blood glucose). In addition, she should eat a variety of fruits, vegetables, whole grains
and legumes. She should limit her consumption of red meat, processed meats and
processed foods and salty foods. A more straightforward guideline for Mrs. Smith is
to make sure her plate has about 1/3 animal proteins and about 2/3 plant foods.
Moreover, Jennifer should not smoke nor chew tobacco to prevent recurring cancer.
Given that Mrs. Smith had a BMI of 32 prior to the chemo and radiation therapy,
I would recommend Jennifer to lose some weight and create healthier eating habits to
prevent her from returning to original weight. Given that Jennifer has a genetic
predisposition of developing cancer and she was obese can be the reason why Mrs.
Smith developed breast cancer. IGF or insulin growth factor has growth promoting
effects and prevents apoptosis. When someone is obese their insulin levels are most
likely to be increased (especially since she has a history of T2D). The increased
insulin increases IGF, freeing it from being bound to proteins. The IGF can then
attach to an IGF receptor on cells or cancer cells and thus promote its growth and
survival. Therefore it is significantly important for Jennifer to reach a healthy weight
and develop healthy lifestyle behaviors. In doing so, she can follow the AICRS
guidelines she may enable her to develop a healthier lifestyle. In addition, she should
see a dietician to make sure she is consuming a healthy diet and on track in reaching a
healthier weight. Jennifer mentioned she would like to increase her daily physical
2
activity. Perhaps she can increase her mileage walk with her dog by half a mile every
other week. As she becomes more physically fit she can increase her speed and
intensity and begin jogging. Jennifer can even join a gym and attend exercise classes
to make the physical activity more social and fun! She can chose from an array of
classes such as spin, Zumba, aerobics and body conditioning.

5. Becoming a vegetarian after completing chemotherapy may be a common concern

among many cancer patients or survivors. Many studies show that consuming a
vegetarian diet may be may be helpful in cancer prevention, given that, most
vegetarian diets limit meat products and increase plant consumption. Increased plant
consumption may be associated with a decreased risk of many chronic diseases, due
to their high quality of vitamins, minerals, antioxidants and phytochemicals.
Glucosinolates are natural components of many powerful plants such as mustard,
cabbage, and horseradish. The pungency of those plants is due to mustard oils
produced from glucosinolates when the plant material is chewed, cut, or otherwise
damaged. These natural chemicals most likely contribute to plant defense against
pests and diseases, but are also enjoyed in small amounts by humans and are believed
to contribute to the health promoting properties of cruciferous vegetables.
Glucosinolates could also stimulate phase II detoxification enzymes (Abdull Razis et
al., 2010; 2011a; 2011b; 2012c). These studies provide strong evidence that
glucosinolates have the potential to modulate enzyme systems involved both in the
bioactivation and detoxification of chemical carcinogens, and may play a role in the
chemopreventive activity of glucosinolates. Stimulating phase II detoxification may
help in cancer prevention. When toxins enter the body, they undergo a detoxification
process known as xenobiotic metabolism. By stimulating phase II of the
detoxification process, enzymes catalyze the conjugation of the reactive metabolite,
formed in phase I. This will ensure that toxins are detoxified because phase II
conjugation makes the metabolite less reactive and easier to excrete. High stimulation
of phase II detoxification may help remove cancer causing toxins thus, decreasing the
chance of cancer development.
Isoflavins -Soy isoflavones have been identified as dietary components having
an important role in reducing the incidence of breast and prostate cancers. Genistein,
the predominant isoflavones found in soy, has been shown to inhibit the
carcinogenesis in animal models. There are growing body of experimental evidence
that show the inhibition of human cancer cells by genistein through the modulation of
genes that are related to the control of cell cycle and apoptosis. Moreover, it has been
shown that genistein inhibits the activation of NF-B and Akt signaling pathways,
both of which are known to maintain a homeostatic balance between cell survival and
apoptosis. Genistein is commonly known as phytoestrogen, which targets estrogen-
and androgen-mediated signaling pathways in the processes of carcinogenesis.
Furthermore, genistein has been found to have antioxidant property, and shown to be
a potent inhibitor of angiogenesis and metastasis. Taken together, both in vivo and in
vitro studies have clearly shown that genistein, one of the major soy isoflavones, is a
promising reagent for cancer chemoprevention and/or treatment. Most vegetarian
diets are high in soy, a plant protein generally used to provide an alternative to meat
protein.
Lycopene is the most abundant carotenoid in tomatoes. Lycopersicon esculentum
L. Lycopenes known, physiological function in humans is for its strong antioxidant
activity. In fact, the molecule is able to efficiently quench single oxygen because the
presence of several conjugated double bonds and to scavenge free radicals. It has been
3
demonstrated that a single lycopene molecule can scavenge more than one ROS, due
to the presence of the long polyene chain. The antioxidant properties of lycopene have
been largely proved in cell culture at micromolar concentrations on several targets,
including nitration of protein, DNA damage by hydrogen peroxide and peroxynitrite.
In addition, lycopene has been reported to up-regulate the ARE (antioxidant response
element)-dependent transcription of antioxidant enzymes, such as superoxide
dismutase-1, catalase, epoxide hydrolase and transferrin under the control of Nrf2
transcription factor.
Current guidelines regarding a vegetarian diet to breast cancer survivors is safe
and even encouraged. The AICRS guidelines cancer prevention diet specifies to avoid
red meat products. These guidelines are even similar to a vegetarian diet such as; limit
the consumption of meat products, avoid processed meats and foods, consume a
variety of fruits, vegetables and whole grains and try to always keep your plate
consisting of 2/3 plant foods and 1/3 animal proteins. Due to the similarities of a
vegetarian diet and the AICRS guidelines along with the cancer preventive properties
found in plant foods, I would encourage Jennifer to follow a vegetarian diet.
However, I would mention to Mrs. Smith that consuming lean meat may not be
harmful to her health nor might it promote cancer. In addition, I would explain and go
through exactly what a vegetarian diet entails. I would further clarify misread labels,
and explain that just because something is marked vegan or vegetarian it does not
necessarily mean that the food is healthy. Many foods may be marked began or
vegetrain yet they may be highly processed or high in fat. Therefore, a vegetarian
diet would be encouraged along with the USDA and AICRS guidelines.

Literature cited

1. Cruciferous Vegetables: Dietary Phytochemicals for Cancer Prevention.

Abdull Razis, Ahmad Faizal; Noor, Noramaliza Mohd;
http://www.koreascience.or.kr/search/articlepdf_ocean.jsp?
url=http://ocean.kisti.re.kr/downfile/volume/apocp/POCPA9/2013/v14n3/POC
PA9_2013_v14n3_1565.pdf&admNo=POCPA9_2013_v14n3_1565

2. Soy Isoflavones and Cancer Prevention. Fazlul H. Sarkar , Yiwei Li. Cancer
Investigation .Vol. 21, Iss. 5, 2003
http://www.tandfonline.com/doi/abs/10.1081/CNV-120023773

3. Toxins 2010, 2(4), 517-551; doi:10.3390/toxins2040517. Review

Phytochemicals in Cancer Prevention and Therapy: Truth or Dare?
Maria Russo , Carmela Spagnuolo, Idolo Tedesco and Gian Luigi Russo
http://www.mdpi.com/2072-6651/2/4/517/htm

4. http://www.breastcancer.org