The disease of cancer and its treatments often alter patients' ability to meet nutritional needs and to continue their Lifestyle family Fitness Center. Therefore, administering radiation treatments, or any other cancer therapy, requires that we work with patients in order to help them feel as well as possible during treatment and to take advantage of the body's own natural mechanisms to fight the disease. The information presented below is directed to family members as well as to patients. Furthermore, it is important that those who are involved in the day-to-day care of a cancer patient understand the reasons why modifying the diet is so important.
Appetite and radiation therapy
The physical and emotional stress created by cancer treatments lowers the body's natural defenses. In addition, the cancer cells compete with the normal cells for survival, further lowering these defenses. The body's ability to handle this stress is known as immunocompetence.
Proper nutrition will enable your body to better handle the stress brought on by surgery, chemotherapy, or radiation. In practical terms, a good diet helps you feel better throughout the treatment. There is no question that adequate intake of vitamins and minerals, particularly zinc, has an effect on the immune system's response to cancer. Laboratory research with animals has demonstrated this, and much experimental work is currently being done on humans to establish the importance of nutrition in cancer therapy.
Loss of appetite is a symptom of cancer itself, although we are not sure why. We do know that there is a central regulatory system for hunger and satiety. (The exact way this system is activated in the brain is still unknown.) It is known that cancer produces chemicals and alters metabolic functions, so as to interfere with the body's system for regulating appetite. This creates a vicious cycle. The patient has little appetite, but nutrition is essential to help combat the cancer and the effects of treatment.
The common side effects of radiation (particularly for that given to the abdomen and pelvis) are nausea, diarrhea, and loss of appetite. Furthermore, some patients undergoing radiation therapy (or any cancer treatment, for that matter) become anxious and depressed, which can also cause their appetite to diminish. As you can see, loss of appetite is a constant risk for a number of reasons. Cancer patients must be diligent about getting the proper nourishment. The degree to which you'll experience loss of appetite depends on which area of your body is being treated, the size of the treatment field, and the overall treatment dose. For example, a patient receiving radiation to the mouth will often experience drying of the mouth and loss of taste, but will not be nauseated. Patients receiving radiation to the chest may complain of discomfort when the food passes through the esophagus. A patient whose abdominal region is receiving radiation will complain more about nausea than loss of taste or dry mouth. When radiation is given in the pelvic area, diarrhea, cramping, and bladder symptoms are more troublesome than nausea. These symptoms result in diminished appetite. Most people are able to continue eating food by mouth during radiation therapy. Otherwise intravenous feeding, called hyperalimentation, is required. High-calorie solutions are administered through a tube inserted in a vein. This form of feeding may be needed for a period of several weeks, during which the patient is hospitalized. The patient is carefully monitored for signs of blood clots or infection that can result from irritation to the vein.
Adjusting to dietary changes
Altering the diet is an essential part of the overall treatment plan for a patient undergoing radiation therapy. For example, commercially available artificial saliva to combat dryness in the mouth allows food to be swallowed and pass through the esophagus more smoothly. While the food may still taste bland, the act of eating will become less of a chore, and the patient will feel better physically and emotionally.
It's crucial that cancer patients and their families adjust to new eating patterns. This usually means breaking away from the adage that three square meals are best. In fact, a patient undergoing radiation therapy is much better off eating "like a bird." Birds eat small amounts of food all through their waking hours and get exactly what they need. My patients feel much better if they don't schedule regular meals, but instead eat when they feel like it. Six to eight small meals a day, or some variation on constant nibbling, seems to work best.
Sometimes well-intentioned family members and friends urge their loved one to eat. In fact, they may literally try to force food on the person, only causing further worry and strain. The whole subject of nutrition for a cancer patient must be treated rationally, because emotions tend to get in the way and family members overreact.
The "food is love" connection is often so strong that I've seen patients literally berated for not accepting the copious amount of food being prepared. Family members may feel quite helpless, and fixing elaborate meals is the one tangible thing they can do to help the person's physical recovery. But exhortations such as "You have to eat to get your strength back" are rarely compelling to a person who has no appetite.
Mike Simmons, a 22-year-old man with Hodgkin's disease, a cancer of the lymph nodes, was receiving radiation treatments to the chest and abdomen. By his third week of treatment he was still somewhat nauseated in spite of the medication he was taking to counteract it. Mike's mother had already seen him lose considerable weight as a result of his disease, and she was understandably concerned when he didn't care to eat.
Mrs. Simmons thought the best thing she could do for her son was to fill the kitchen with his favorite food - steak and potatoes, pancakes, and hearty sandwiches. She was distressed and disappointed when her son simply refused to eat these foods.
Mike developed symptoms common to many cancer patients. First of all, he developed an aversion to meat. It is well documented that cancer patients often experience a change in their taste buds that causes them to find meat proteins unappealing. Secondly, the aroma of food triggered nausea. Food aromas, particularly when trapped in steam beneath cooking pots and chafing dishes, can be particularly troublesome. Even before the patient has touched a morsel of food, the aroma alone can cause nausea. Mike was also upset when faced with large amounts of food.
For many cancer patients, the idea of sitting at the table three times a day is nothing less than an "assignment." They begin to become anxious when large amounts of food are placed in front of them, and this is made worse when the food aromas are mixed. Mike was able to gain some weight when he began using a blender to make many cold drinks.
I encouraged him to make these drinks whenever he felt like it, not on any exact time schedule.
These drinks consisted of many nutritious substances such as vegetables, fruits, and juices. Shakes made from low-fat ice cream are a good source of calories for those who can tolerate dairy products. Mike also ate cold soups and nibbled on small amounts of cold cooked vegetables and fruit. When he felt better, he gradually added foods until he was again eating normally. Many patients will feel like eating a small plate of food, supplemented with liquid drinks. Nearly all pharmacies carry commercial liquid nutritional preparations (Sustical, Ensure, Carnation, Vivonex) designed for patients who, for whatever reason, have difficulty with solid food.
One of my patients, a 75-year-old woman with cancer of the esophagus, had become disgusted with a liquid diet. I advised her to try eating commercially available pureed baby foods instead. They are tasty and provide adequate nutrition. This patient eventually put on some weight and was able to improve the quality of her life. Patients can also mash their own home-cooked foods. If their sense of taste has been altered or diminished they may wish to season food more heavily than usual.
For the most part, people receiving radiation therapy feel better if they eat vegetable rather than animal protein. Excellent sources of vegetable protein include cooked dried beans and legumes, peas, corn, and soy products. Most natural food stores and many supermarkets carry a product called textured vegetable protein, which is spun soybean fiber. Generally, this soy product is mixed with other foods and is considered a substitute for animal protein. Some cancer patients do tolerate fish protein as well as poultry, as long as the skin (fat) is removed. Again, each individual serving need not be large. Many small amounts throughout the day are best.
Pasta, rice, and potatoes are excellent sources of calories, although fatty or spicy sauces should be avoided. Some pasta is fortified with protein, making it even more valuable in the diet. Fresh vegetables should be cooked rather than eaten raw. Raw foods tend to create too much bulk in the diet and aggravate the irritation of the small and large bowels already created by the radiation therapy.
I also urge patients not to use beverages containing caffeine (an intestinal stimulant) -- coffee, tea, hot chocolate, soft drinks, and so on. Herbal teas and decaffeinated coffee, tea, and soft drinks (regular or diet) should be substituted.
Most radiation therapy patients can use alcohol in moderation, one drink of wine or beer a day. Exceptions include those with a preexisting problem with alcohol or other medical reasons (i.e., acute bladder, prostate, and throat problems) it should be avoided. Beer provides extra calories, and a glass of wine in the evening may actually relax a person for restful sleep.
I recommend that you take multiple vitamin and mineral supplements, particularly the group of nutrients known as the B-complex vitamins, and vitamins C and E. These vitamins assist the body's own defenses in fighting the cancer and the stress of radiation and other therapies. Liquid vitamin supplements are available for patients receiving treatment to the neck or chest, which may make swallowing capsules difficult.
Special considerations
During radiation therapy some patients experience nausea and occasional vomiting, but this side effect is usually not severe and can be easily controlled with medications. The nausea usually begins after the first or second week of treatment. When you alter your diet, the dosage of antinausea medication can often be decreased. But it generally isn't effective to simply treat the nausea and then expect the patient to eat normally, meaning three full meals a day. A combination of dietary changes and medication works best. In some cases, antinausea medication can be taken in suppository form.
Diarrhea can also be a problem for some patients. To control it, I recommend limiting the amount of fat in the diet. We've found over the years that fat is poorly absorbed by patients and delays the emptying of the stomach. Therefore, many frozen dinners and packaged foods should be eliminated from the diet because they tend to be high in fat content. Radiation therapy may also cause some gastrointestinal enzyme (lactase) deficiencies resulting in intolerance to lactose, the sugar in milk. When lactose is no longer properly digested, water is attracted to the intestine, ultimately causing intestinal irritability that results in watery diarrhea.
Under normal conditions, the cells in the intestinal tract lining slough off very rapidly. Radiation therapy only aggravates this process. The turnover of the cell lining may be so great that small ulcers occur and an inflammation of the intestine, called enteritis, takes place. This condition also leads to lactose intolerance, which means that some patients can't ingest milk and other dairy products without risk of irritation and diarrhea. Because lactose is used as a sweetener in many prepared foods and as a filler in many drugs, it's important to become a careful label reader. Lactose intolerance varies so much from individual to individual that trial and error is the only way to tell if dairy products can be comfortably eaten.
Diet and medication work
Together Diet and medication work together to relieve the side effects of radiation therapy. It's possible to reduce your need for medication with a proper diet. On the other hand, to refuse the safe medications we now have available and to try to control side effects with diet alone generally isn't satisfactory. Be sure to discuss your diet with your radiation oncologist who is familiar with the specific details of your case.
Most important, don't allow food to become a source of anxiety or conflict. Those involved with the patient's care should not take control of the person's diet, particularly the amount of food eaten or the timing of the meals. The reading list in the back of this book provides sources of information about dietary adjustments and cancer. You can also ask to be referred to a hospital dietitian who has experience advising cancer patients and their families about these issues.
We can loosely define lifestyle as the kinds of activities a person undergoing radiation therapy will feel like doing, balanced by the amount of rest he or she will need. As mentioned earlier, patients receiving radiation therapy will often experience an overall sense of fatigue. Neither patients nor those around them should become alarmed. Although we aren't sure why this dragged-out feeling occurs, we know that it isn't related to the severity of the cancer. It does not mean that the disease is getting worse.
Getting the rest you need naturally
Getting adequate rest is a priority during radiation therapy. When fatigue appears a week or two into treatment, I generally advise listening to what your body tells you, and resting. This does not mean actually sleeping. When possible, it is better to move about during the day, perhaps even taking a walk if it isn't inadvisable for other medical reasons. For some patients, a short daytime nap is beneficial.
You will probably notice that sleep doesn't relieve the kind of fatigue the radiation therapy induced. (The exception is, of course, when the brain is being treated. In that case, sleepiness is natural and a nap is usually refreshing.) If you give in to the fatigue and sleep during the day, you may have trouble sleeping at night. This sleep pattern will then make you out of step with the rest of the family and the outside world. It sets up a situation that causes strain on your family and friends, who want to be available to help out. However, if they are carrying on their normal activities during the day and trying to stay up with an ill person during the night, it can prove to be too much for them.
The night hours are often dreaded by cancer patients -- after all, we are all more vulnerable to our emotions at night. If a person is already anxious and somewhat depressed, these feelings will be amplified when the house is quiet and others are sleeping. Suffering from physical symptoms combined with the fear of pain can turn the night into a very bleak time. A patient's problems become a loved one's problems too, and the next day might be even more difficult. When a person has trouble falling asleep or staying asleep, altering the time of the evening doses of medication can help. I recommend taking the medication approximately an hour before going to bed for the night.
You will get the maximum benefit from the medication, allowing you to fall asleep while you are comfortable. This is true if the medication is for pain, nausea, diarrhea, or bladder irritation. The goal should always be to have a restful night. Home remedies that are recommended for people suffering from insomnia are worth trying. These include a warm bath before retiring, a glass of wine, a cup of herbal tea or a glass of warm milk (if milk is tolerated well), listening to a relaxation tape or soothing music, and so on.
It is very important that sleep disturbances be dealt with, because studies have shown that sleep disorders are detrimental to the body's ability to fight disease and infection. Sleeping pills are sometimes useful, and they are best prescribed by your family doctor, who is familiar with your overall physical condition. If you have any questions about sleep problems, by all means discuss them with your primary-care physician.
Physical activities
By using a combination of diet and medication, most patients undergoing radiation therapy should be able to remain alert during the day and enjoy mild physical activity. However, as with diet, well-intentioned relatives and friends may actually try to push the ill person too far. Patients are the best judges of just how much activity they can tolerate. There is nothing to be gained from "working through" the disease with excessive exercise.
Walking is probably the best overall exercise, and I encourage my patients to walk as much as they believe they can. Again, you, as the recovering person, are the best judge. Walking also gets you out of the house and into the fresh air. In addition, the exercise may stimulate the appetite, and increased food intake can lead to greater feelings of well-being.
Many employed persons continue working, usually keeping up with their normal schedules. I've found that most people want to work if they can because it keeps them out in the world and allows less time to dwell on the illness or feel sorry for themselves. Maintaining a normal lifestyle also provides a boost in self-esteem and overall mental attitude, which in turn may strengthen the immune system.
Patients are able to work because most side effects of radiation treatment are not debilitating, although they may be annoying and require medication and adjustments in diet. Of course, if the disease itself is severe, patients may need to alter their work schedules.
I believe it is crucial for cancer patients to participate in social activities as much as possible. The disease itself may make them feel severely isolated, and cutting off all regular interaction with friends and family only makes this feeling worse. For some people, the interaction with people in self-help and support groups may be integrated into a normal, if somewhat modified, lifestyle. Moreover, those who have always been religious should stay in touch not only with friends from their church or synagogue, but with their spiritual counselor. This is the time to call on all one's support systems.
Hobbies and creative activities, such as art and music, may bring pleasure and joy. Studies have shown that these kinds of activities may stimulate areas of the brain to secrete chemicals beneficial to the healing process. Basically, the goal is for you to feel as much a part of normal life as possible. While it's pointless to deny the fatigue, depression, pain, or physical side effects of treatment, it's not necessary to unduly restrict all activity.
Sexuality
Although few people admit it, the fear that cancer is contagious still lurks. Nowhere does this fear have greater impact than in sexual relationships. All too often, the sex act is viewed as a possible vehicle for transmitting the disease. Women will ask if their husbands' prostate cancer could infect them through sexual intercourse. Husbands will worry that their wives' uterine cancer could infect them in the same way. If you have had these fears, you are by no means alone. However, there is no evidence to date that cancer is in any way contagious. In other words, it can't be sexually transmitted.
As with exercise and diet, patients are the best judges of how much sexual activity they feel like engaging in. Some cancer patients will be bedridden and nearly disabled, and therefore sexual activity will not be appealing or even possible. On the other hand, some people will feel relatively well, at least some of the time. They may desire this kind of intimacy and consider it part of living as fully as they can. Remember, however, that sexual intimacy need not involve intercourse. Touching, hugging, and so forth, are also part of intimacy.
We know that self-image has an enormous impact on sexuality. The cancer patient is no different, and self-image can be quite fragile. Those around him or her must be sensitive to this. Loss of a breast, loss of hair, and other visible damage to the body can cause anxiety, not to mention the fear that these changes will mar sexual attractiveness. These fears are understandable, but they are often blown out of proportion. In many cases, support groups or individual counseling can help.
Anna Gomez, a 45-year-old woman, underwent partial mastectomy for cancer and was seeing me for postoperative radiation therapy. She was concerned about the cosmetic appearance of her breast, since a considerable amount of tissue had been removed. She was quite concerned that her husband would no longer find her sexually attractive. She told me her husband tried to reassure her, but that she thought he was just placating her. After finding a local breast-cancer support group through the American Cancer Society, she was able to regain her own self-esteem and resolve the sexual issue in her marriage. By the end of treatment, her body image was remarkably improved.
Seeking help for appearance issues
Even with improved surgical techniques and radiation technology, many patients must cope with changes in their bodies. Nowadays, there are many resources available to help cancer patients adjust to these physical changes. Support groups and the American Cancer Society can help you. For example, breast-cancer support groups offer advice about the emotional adjustment to losing a breast, the pros and cons of reconstructive surgery, specially designed clothing, and so on.
Both men and women have to make practical adjustments to such treatment side effects as hair loss, and your local chapter of the American Cancer Society can help you locate centers that specialize in advising cancer patients about appearance and cosmetic issues. While these are never easy issues, seeking help can make them easier to cope with.
Making adjustments
It is difficult to do more than generalize about lifestyle during radiation treatment and recovery from cancer. There is simply too much individual variation among patients. And how a person feels has much to do with age, other medical conditions, and the severity of the disease.
When you have questions or concerns about your diet and other activities, ask your team of physicians and their staff to help you find the advice you need. Remember that you are in charge, and when you approach these issues with as positive an attitude as possible, you will feel better physically and emotionally.
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