Gastrointestinal (GI) upset is a common source of discomfort for patients with cancer and can have a large effect on overall quality of life if not tended to appropriately. GI upset can be related to dysfunction of the GI tract because of the cancer or as a result of treatment. Different types of GI upset include loss of appetite, nausea, pain, constipation, diarrhea, and acid reflux. If these issues are not addressed, serious complications may ensue, such as dehydration and malnutrition.

Treatment and Prevention of GI Upset:

Working with the multidisciplinary care team to create an individualized plan that delineates how to prevent and treat GI upset can be essential to minimizing discomfort and optimizing overall quality of life. Open communication can facilitate many useful methods of treatment, including appropriate medication. There are a number of medications that can help reduce GI upset including medications to prevent symptoms and medications that address symptoms as they are happening. On-going communication with the multidisciplinary care team can ensure that proper medications and dosages are being prescribed.

Working with a registered dietitian can also be immensely helpful in reducing GI distress. The role of a registered dietitian includes helping patients become or stay adequately nourished and hydrated by working closely with the patient to set individualized goals and create treatment plans that are tailored to the patient’s specific needs. These plans are based on the best available research. As a safety precaution, it should be noted that anyone can call themselves a nutritionist, however a master’s degree, over 1,000 hours of supervised training, and passing a board examination are just a few of the current requirements to become a registered dietitian. These standards guarantee that the person providing nutrition recommendations has been thoroughly trained and committed to staying up to date with the best available research in order to provide safe and effective care. This is especially important for patients with cancer who are at risk for malnutrition and dehydration.

When it comes to nutrition while undergoing cancer treatment, restricting intake and avoiding food that is typically categorized as unhealthy, can be particularly harmful. This is because tolerated foods are often very limited, and getting enough calories is better than being in a deficit. Choosing calorie-dense foods that the patient can tolerate is often very helpful for ensuring adequate nourishment.

Many patients with cancer experience loss of appetite. When this happens, it can be very important to prevent the stomach from becoming empty. This is because an empty stomach can produce hypersecretion of acid within the stomach that can not only cause nausea and make nausea worse but can also cause pain from heartburn and stomachache. Starting the day with food in the stomach can be incredibly helpful as it sets the tone for the rest of the day and can help ease symptoms and prevent them from getting worse. Figuring out which foods the person is able to tolerate more easily is also important for increasing intake. This can look very different from person to person, though there are some foods which tend to be more soothing and some which tend to trigger GI upset more frequently. For patients who struggle with symptoms from a fuller stomach, it can be very helpful to eat and drink smaller more frequent amounts throughout the day. It can also be helpful to eat and drink separately.

Emotional distress can also add to or cause GI upset so working with the multidisciplinary care team to find other methods to cope with emotions such as meditation, yoga, and therapy can also aid in alleviating GI upset.

Movement is another factor that can play a large role in reducing GI discomfort. Activity facilitates movement of the bowels and can greatly improve anxiety which can make GI upset worse.

Staying Hydrated

Staying hydrated is one of the most important considerations for patients who have lost their appetite or have difficulty with adequate intake for any reason. This is because dehydration can lead to dangerous complications including kidney failure. Finding ways to increase fluid intake while minimizing nausea is often key to staying hydrated for patients with cancer. Things like popsicles and shakes can offer nutrition and flavor while also offering water content. It is important to pay attention to how frequently urination is occurring and to notify the doctor if infrequent urination is noticed. This is because infrequent urination can be a symptom of dehydration and other problems.

Healthcare providers can create plans with patients to make sure they are getting enough water throughout the day. This can look like a schedule to drink water or additional fluids provided intravenously. Intravenous fluid can often be administered with treatment, which is a great option for patients having difficulty consuming enough fluid during the day. The average person who does not have diarrhea needs close to 2L of fluid per day. Breaking this down into portioned amounts throughout the day can make consuming recommended amounts a lot less overwhelming and triggering for those who have difficulty drinking a lot at one time.

When to See the Doctor

When patients present with GI upset that is so severe it is causing dehydration or high risk for dehydration, it is important to make sure the correct cause is determined. While many cancer treatments can cause GI upset, assuming the treatment is the cause can lead to other problems being overlooked. It can also lead to symptoms persisting unnecessarily when the issue could have been treated. It is important to work with the gastroenterologist and the oncologist to determine the cause, as each field offers a unique perspective and training that can be helpful in diagnosing.

Supplementing with Poor Intake

Many patients with poor intake use supplements in hopes to improve their nutrition, however supplements in the United States are not regulated for safety and efficacy. There is no guarantee that what is on the label is what is being consumed. Supplements can also interact with medications and may be contraindicated with certain medical conditions. Serious and harmful effects have occurred from taking supplements, and the risk is increased for patients with cancer who are on a variety of medications and have multiple medical conditions. 

Using the Internet

It’s important to proceed with caution when using the internet to get information about remedies of any type. Unfortunately, there is a lot of misinformation on the internet, and even if the information is accurate, it may not be safe for each individual patient.

Nutrition and Recovery

Muscle loss is often a byproduct of weight loss. In recovery, gaining back lost muscle is very important. Muscle mass helps prevent falls, protect bones, and improve metabolism. Getting enough calories and the appropriate amount of the macronutrients (protein, fat, and carbohydrates) is important in recovery.

10 Tips for Managing GI-related Symptoms

  1. Avoid eating and drinking at the same time if a full stomach trigger symptoms.
  2. Consult with your oncologist and GI doctor if symptoms are unmanageable.
  3. Work with a registered dietitian to come up with a plan that is tailored to your needs and includes foods you can tolerate and a schedule you can maintain.
  4. Small, frequent meals can be helpful for nausea.
  5. There are a variety of medications that can help with GI distress including anti-nausea medication.
  6. Movement is important for all areas of health including emotional health.
  7. Try to eat in an environment where eating is comfortable for you.
  8. Music and meditation can be very helpful to reduce GI symptoms that are enhanced by anxiety.
  9. Consume foods that are nutrient-dense when possible.
  10. Surround yourself with people that lift up your spirits!

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Meet the Panelists:

Dara Kurtz

Dara is a cancer survivor, creator of Crazy Perfect Life, author of Crush Cancer, and founder of The Thrive Podcast with Dara Kurtz and Garth Callaghan. She speaks regularly around the country leading Crush Cancer, Thrive and Self Care Workshops.

Dr. Moshe Shike

Dr. Shike is a gastroenterologist, internist, and nutritionist with a particular interest in cancer prevention at Memorial Sloan Kettering.

What is Supportive Care?

Supportive care involves addressing symptoms, side effects, and mental health concerns to enhance comfort in all areas of life throughout the cancer journey.

Why is Supportive Care Important for Patients with Cancer?

Supportive care is often viewed as secondary to traditional cancer treatment yet is actually one of the most important aspects of care for patients with cancer. This is because it can greatly ease the burden of treatment-related discomfort and be immensely empowering. Incorporating supportive care that addresses elements core to the patient’s identity into treatment plans, provides patients with autonomy, purpose and drive that can greatly enhance overall quality of life. Supportive care should be implemented from diagnosis. While at times, life-threatening issues must take precedence, supportive care should always be considered and integrated thoughtfully into treatment plans.

Who Provides Supportive Care?

Supportive care measures should be provided by each member of the multidisciplinary care team and prioritized throughout each stage of the cancer journey. Multidisciplinary care team members include physicians, nurses, case managers, social workers, dietitians, mental health practitioners, religious leaders and anyone else who provides patient care. The nurse is often the clinician facilitating supportive care. This is because nurses typically spend a substantial amount of time with patients, and on-going assessment of needs is a large part of nursing practice. Through careful assessment, nurses identify patient needs and addresse them to promote care of the whole patient. Nurses can provide supportive care through direct delivery and by coordinating involvement of other practitioners to provide care.

Examples of Supportive Care

Supportive care is specific to the patient and can include side effect management, mental health care, easily accessible communication with providers, alternative therapies, nutrition therapy, advocacy for funding of relevant studies, peer support, exercise, meditation, pain management and managing symptoms of the cancer itself.

Facilitating Supportive Care

Open communication between members of the multidisciplinary team and the patient is essential for optimizing supportive care measures. Every patient is different, so it is of utmost importance for healthcare practitioners to use assessment tools that allow for the full scope of the patient’s needs to be addressed. Several factors can make it challenging for patients to feel comfortable expressing their concerns, making communicating in a way that is tailored to individual needs a vital component of optimizing quality of life.

Peer support can be a critical aspect of supportive care. It is important that peers are in a space where they can support the individual’s needs and that the patient can relate to the peers within the group.

Journaling can also be very helpful when it comes to allocating supportive care. This is because it can be easy to forget symptoms or other concerns that are necessary to address in between doctor’s visits. Journaling also allows for enhanced thought processing which can be very cathartic and revealing.

Rapport between patients and the care team is another important part of supportive care because “good rapport” allows patients to feel comfortable addressing concerns.

It’s recognized that supportive care is not often a high priority research focus. There is evidence that shows that supportive care can have a greater benefit to survivability than FDA-approved treatments that target cancer in certain circumstances.

Traditional Therapies & New Therapies

Both newer treatment options and older treatment options have pros and cons. Different medications are often given with certain types of chemotherapy to minimize side effects and thus provide more comfort to the patient. Open communication about side effects, concerns, and needs is important so that supportive and individualized care can be provided.

5-Fluorouracil (5-FU), Gemcitabine, Taxotere are all traditional therapies that can cause many side effects but also work well to treat a variety of cancers. Immunotherapies or checkpoint inhibitors are newer therapies and can offer few to no side effects for many patients, though are not devoid of risk. These therapies can cause the immune system to become overly activated, resulting in diarrhea, colitis, and liver damage. Steroids can be used to combat these side effects. Another category of cancer treatment is called “targeted therapies.” These therapies target a specific protein or gene to treat cancer. Peeling and dryness of the hands and mouth sores can be caused by targeted therapies. CAR-T cell therapy is another newer therapy that utilizes the patient’s own immune system to attack the cancer cells by removing the patient’s T-cells through apheresis and genetically modify them to specifically target the person’s cancer. This type of therapy is particularly useful in treating many of the blood cancers like leukemia and lymphoma. If CAR-T cell therapy causes the immune system to “over attack,” it can cause a cytokine storm which causes the body to become quite ill, requiring hospitalization.

It is important for providers to be able to differentiate between side effects from chemo and cancer symptoms so that the appropriate treatment can be provided. There are a variety of options to mitigate side effects of various cancer treatments including scalp cooling to reduce hair loss and medications to combat nausea, vomiting, diarrhea, and low blood counts.

There are also a variety of pain management options including injections, spinal taps, and pills that can help alleviate pain from treatment side effects and cancer itself.

Supportive Care Resources

https://www.cancer.org/cancer/caregivers.html

www.cancercare.org/helpinghand

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Meet the Panelists:

Leah Evert

Leah Evert is a registered dietitian, breast cancer survivor and co-founder of The Willow Foundation— a non-profit organization that funds research in alternative practices to enhance quality of life for patients with cancer. She is also a former exercise physiologist, former division one athlete and avid runner who directs a corporate health program for a large pharmaceutical company. Leah was diagnosed with stage four breast cancer in 2017 at the age of 36 and quickly learned that the cancer had spread to her liver, lymph nodes, and lung. She has received over 109 rounds of chemotherapy and 19 rounds of radiation to date. Her inspiring story depicts the essential nature of supportive care when it comes to the overall health of patients with cancer.   

Dr. Diane Reidy-Lagunes

Dr. Diane Reidy-Lagunes is a gastrointestinal oncologist at Memorial Sloan Kettering who cares for patients with a variety of gastrointestinal and endocrine cancers including cancers of the large intestine, small intestine, pancreas and adrenal cancer. She is currently involved in neuroendocrine cancer research with a focus on enhancing treatment outcomes for patients. Her experience as an oncologist provides a unique perspective on the importance of supportive care and how it can best be facilitated to optimize quality of life for patients with cancer.

Dave Norkin has far outlived his original doctor’s expectations. It will be 10 years since he was diagnosed. Dr. Diane Reidy specializes in caring for people with gastrointestinal cancers, including neuroendocrine cancer, and has been Dave’s doctor. Together they will discuss what to do after hearing “You have cancer.”