NUTRIENTS AND CANCER

AGUS PRASTOWO
 MASALAH NUTRISI
PADA PASIEN KANKER
• Malnutrisi 
ketidakseimbangan /
ketidakcukupan nutrisi
ATAU gangguan
memproses makanan.
• Penurunan berat badan
yang tidak disadari 5%
atau lebih dalam 6 bulan
, terutama bila disertai
dengan penurunan masa
otot kahexia kanker
Modified from: J.arends,et al. Clinical Nutr.2017;36(5):1187-96; ; Argile ́s
European Journal of Oncology Nursing 2005; 9, S39–S50
Rombeau, WB saunders, 1990; M. Argile ́s European Journal of Oncology
Nursing (2005)9, S39–S50
 Epidemiologi Malnutrisi pada Kanker
Penurunan berat badan dan malnutrisi merupakan hal
yang sering terjadi dan indikator prognosis buruk
• Insiden : 30 – 80%
– 15% malnutrisi berat
– 97.6% membutuhkan intervensi nutrisi.
• Pasien rawat jalan sulit makan dengan jumlah cukup
• Bahkan sedikit penurunan berat badan berhubungan
dengan stres psikologis dan pe↓ QOL

Anorexia, jika tidak diterapi, dapat

berkembang menjadi cancer cachexia

Choudry, HA; et al.The Jopurnal of Nutrition.2006.314S-8S

NS, Tchekmedyian,NS; et al.Oncology. 1002;49(2).3-7
Clinical Nutrition 2005; 24(5): 801-14
MENGAPA PASIEN KANKER MENGALAMI
MALNUTRISI?
• Hilang napsu makan
(Anoreksia): sel kanker,
sumbatan jalan makan,
terapi kanker, dampak
psikologis.
• Perubahan Metabolisme
tubuh: meningkatnya
pengeluaran energi pada
saat istirahatsampai
50% > vs pasien non
kanker
• Gangguan penyerapan
nutrien: sel kanker, ES
terapi.
“Anorexia (loss of appetite) is a common symptom
in cancer patient and may occur early or later in
the disease” – National Cancer Institute.2009
 KEMOTERAPI
BERDAMPAK PADA STATUS NUTRISI
No Obat
1 Cyc lo p h o s p h a m id e
2 Ca r b o p la tin
3 Cis p la tin
4 Oxa lip la tin
5 Me th o tr e xa te
6 Ca p e c ita b in e
7 5-FU
8 Ge m c ita b in e
9 Ble o m yc in
10 Do xo /Ep i-r u b ic in
11 Do c e ta xe l
12 P a c lita xe l
13 Vin c r is tin e
14 Ir in o te c a n
Efek Samping
De p r e s i s u m s u m tu la n g ,
s is titis h e m o r a g ik
De p r e s i s u m s u m tu la n g ,
m u a l m u n ta h
Ne fr o to ks ik, m u a l m u n ta h ,
n e u r o p a ti p e r ife r , o to to ks ik, d e p r e s i s u m s u m
tu la n g
De p r e s i s u m s u m tu la n g , d ia r e ,
m u a l m u n ta h , n e u r o p a ti
Mu ko s itis , u ls e r a s i s a lu r a n
c e r n a , d e p r e s i s u m s u m tu la n g
Dia r e , s to m a titis , h a n d fo o t
s yn d r o m e
S to m a titis , u lku s s a lu r a n c e r n a , d e p r e s i
s u m s u m tu la n g , d ia r e
De p r e s i s u m s u m tu la n g , m u a l
m u n ta h , r u a m ku lit, flu like s yn d r o m e
P n e u m o n itis , fib r o s is p u lm o n e r , d e m a m
De p r e s i s u m s u m tu la n g ,
ka r d io to ks ik
De p r e s i s u m s u m tu la n g ,
r e te n s i c a ir a n , r e a ks i h ip e r s e n s itif
De p r e s i s u m s u m tu la n g ,
n e u r o p a ti p e r ife r
Ne u r o p a ti p e r ife r , ile u s , n ye r i
a bdome n
De p r e s i s u m s u m tu la n g , d ia r e ,
m u a l m u n ta h
 “Penuruna
n berat
badan
progresif
merupakan
hal yang
sering
terjadi
pada
pasien
kanker”
Inui A.Cancer
Research.1999;59.4
Anorexia at point of cancer diagnosis : up to 493-501 -

55%
-- Sutton, M; et al.Lancet Oncol.2003;4.149-57 --
DAMPAK MALNUTRISI
PADA PASIEN KANKER
• Kualitas hidup • Risiko
• Status komplikasi
fungsional • Risiko infeksi
• Respons terapi • Lama
• Harapan hidup perawatan
Pilihan Terapi Kanker

• Operasi • Terapi biologi

• Radioterapi • Terapi target
• Kemoterapi • Terapi kombinasi
• Terapi Hormonal • Terapi paliatif

Tujuan terapi umumnya memperpanjang

usia harapan hidup / paliatif

↑ kualitas hidup

American Cancer Society.What Are the Goals

of Treatment with Chemotherpay?
Prognostic Effect of Weight Loss Prior to Chemotherapy in
Cancer Patients. Eastern Cooperative Oncology Group
Dewys WD, Begg C, Lavin PT, Band PR, Bennett JM, Bertino JR, et al.Am J Med.1980;69(4):491-7

ra t b a da n
a ng a n be nan
“ K e h il p e nu ru
e n g a n
e rka it an d v iv a l”
b s ur
median
 PERAN NUTRISI
PADA PASIEN KANKER
• Mencegah dan memperbaiki defisiensi nutrisi
• Membantu pasien mentoleransi terapi
• Meminimalkan efek samping dan komplikasi terkait
nutrisi.
• Membantu mempertahankan berat badan dan kondisi fit
• Mencegah kerusakan jaringan dan membantu
pembentukan jaringan
• Melawan infeksi

Memaksimalkan kualitas hidup

dan prognosis
Being well-nourished has been
linked to a better prognosis -
National Cancer Institute.2009
 McGill Cancer Nutrition-Rehabilitation Program

Tujuan manajemen diit

1. Penanganan pasien dengan gangguan pengecapan,

malnutrisi, penurunan BB, kelelahan dan penurunan
fungsi organ
2. Perbaikan nutrisi  research biomolekular dan nutrisi
3. Edukasi
 Tujuan lain
● Peningkatan kualitas hidup pasien
● Kelangsungan terapi dan kemandirian pasien.
● Penurunan beban phisical, psikis dan family.
● Penurunan efek samping terapi
 TUJUAN KHUSUS
● MEMAKSIMALKAN FUNGSI FISIK, AKITIVITAS YANG AMAN
● MENGOPTIMALKAN ASUPAN MAKAN  SUMBER ENERGI
YANG ADEQUATE HARIAN.
● MENJAMIN KEBERHASILAN MANAJEMEN DIIT 
KELANGSUNGAN HIDUP
● MEMBANTU STRATEGI UNTUK KEBERHASILAN PROGRAM
REHAB
BERAPA KEBUTUHAN NUTRISI PASIEN
KANKER?
Sobotka L. Basics in clinical nutrition, 3rd ed. Prague; Galen; 2004. Chapter 8-14;
p.392-405.
Bozzetti F, et al. ESPEN guidelines on parenteral nutrition: Non-surgical oncology. Clin
Nutr.2009;28:445-54.

Dibutuhkan nutrisi spesifik:

Tinggi kalori, protein, BCAA, asam lemak
omega-3
 ASAM AMINO RANTAI
CABANG (BCAA)

• Memperbaiki kualitas hidup

• Memperbaiki daya tahan tubuh
• Meningkatkan pembentukan
protein
• Meningkatkan nafsu makan
• Makanan sumber: susu, telur,
daging
Cangiano C, et al. J Natl Cancer Inst.1996;88(8):550-2
Choudry HA, et al. J Nutr.2006;136:314S-318S
Calder PC. J Nutr.2006;136:288S-293S
 ASAM LEMAK OMEGA 3

(DHA and EPA)

• Anti-peradangan
• Terhadap sel kanker
– Meningkatkan kematian sel kanker
• Kualitas hidup pasien
– Memperbaiki malnutrisi dan
meningkatkan angka harapan hidup
pasien
– Dari penelitian  mengurangi rasa
nyeri yang disebabkan karena efek
Hardman WE, et al. J Nutr. 2002;132:3508S–3512S
Jatoi A. Nutr Clin Pract.2005;20(4):394-9
samping obat kemoterapi
Rose DP, et al. J Natl Cancer Inst.1993;85(21):1743-47
Siddiqui RA et al. Nutr Clin Pract.2007;22(1):74-88
Alvano CM et al. J Clin Oncol.2012;30:1280-7
 MIKRONUTRIEN: VITAMIN &
MINERAL
Tidak kalah penting
Kebutuhan meningkat jika pasien sulit makan
Nutrisi Peran
Selenium Antioksidan
Meningkatkan kematian sel kanker
Zinc Membantu meningkatkan harapan hidup
Vitamin C, E Antioksidan
Membantu mengembalikan berat badan
Vitamin B kompleks Diperlukan dalam berbagai proses
metabolik
“…Protein rich supplements containing n-3 PUFA and
high levels of antioxidant vitamins can reverse
severe weight loss…”
Grimble RF. Gut 2003;52:1391-2
 Intervensi Nutrisi bagi Pasien
Kanker : KONTRA

Tidak perlu nutrisi Beberapa nutrisi khusus

khusus untuk pasien bermanfaat bagi pasien
kanker kanker terutama dalam
mencapai kualitas hidup
Tidak perlu formulasi Pasien kanker mudah
khusus untuk pasien merasa ‘kenyang’  perlu
kanker energy-dense
intervensi nutrisi juga Hingga kini tidak terbukti.
akan ”menyuburkan” Guideline ESPEN
pertumbuhan sel merekomendasikan agar
kanker keputusan klinisi
memberikan intervensi
nutrisi tidak dipengaruhi
oleh anggapan tersebut
 GANGGUAN MAKAN
• ANXIETY
• FATIGUE
• ENERGY CONSERVATION
• ENERGY RESTORATION
 CANCER DAN ANXIETY

● SEMUA PASIEN DENGAN CANCER MENGALMI KECEMASAN

● MENURUNKAN ASUPAN MAKAN PASIEN
● MENURUNKAN SEMANGAT HIDUP
● MENURUNKAN AKTIVITAS
 PENGURANGAN KECEMASAN
● MINUMAN HANGAT SEPERTI SUSU. JAHE, MINUMAN
REMPAH
● RELAKSASI SEPERTI MENDENGARKAN MUSIC, MEMBACA
BUKU
● TIDUR DENGAN WAKTU BIASA
• EXERCISE
 CANCER DAN FATIGUE ?
● In general population:
23-30% of women.
13-20% of men.
● Most people complain of fatigue for several weeks after
surgery.
● Most people with cancer, and those having treatments
such as chemotherapy and radiotherapy (75-96% describe
cancer fatigue).
 MANAJEMEN FATIGUE
● Rest
● Activity
● Nutrition
● Energy Conservation
● Energy Restoration
GIZI DAN PENGURANGAN FATIGUE
● MINUMAN RINGAN PADA PAGI HARI.
● MAKAN MAKANAN SEHAT SESUAI SELERA
● KARBOHIDRAT SEBAGAI SUMBER ENERGI UTAMA
● PORSI KECIL MAKANAN DINGIN .
 Energy Conservation
● SELEKSI AKTIVTAS.
● PERENCANAAN AKTIVITAS DAN ISTIRAHAT DENGAN BAIK
● MAKAN BERSAMA KELUARGA
● MENCEGAH KEKURANGAN ENERGY.
● SESEKALI AKTIVITAS SAMBIL DUDUK
 Energy Restoration

● LAKUKAN AKTIVITAS YANG MENYENANGKAN.

● AKTIVITAS LUAR RUMAH YANG MENARIK SEPERTI
BERKEBUN, JOGING DLL
● MENDENGARKAN MUSIK, AROMA TERAPI, PIJAT BUGAR
● REKREASI DENGAN KELUARGA.
 PENANGANAN SELAMA TERAPI
• JAGA ASUPAN MAKAN TETAP ADEQUATE
MAKANAN PADAT GIZI
• MINIMALKAN EFEK SAMPING
• BERUSAHA MENINGKATKAN KUALITAS
HIDUP
 Weight Loss
• 40% of patients experience anorexia and weight
loss prior to diagnosis
▫ 80% of upper GI cancer patients and 60% of lung
cancer patients have already experienced significant
weight loss at time of diagnosis

• 40-80% of patients are expected to experience

malnutrition during treatment
▫ As little as a 6% weight loss predicts a reduced
response to treatment, reduced survival, and a
reduced quality of life
Prevalence of Malnutrition

Stratton et al, eds. Disease-Related Malnutrition: An Evidence-Based Approach to

Treatment. CABI Publishing; Wallingford:2003.
 Prevalence of Treatment-Related Side
Effects
Weight Nausea/ Oral Taste
Treatment Loss Fatigue Vomiting Mucositis Alterations Constipation
Overall % of 70%– 30%– 35%– 40%–
50%–90% 40%–100%
patients 100% 90% 70% 50%

Chemotherapy      
Radiation     
Surgery   
Immunotherapy   
 Nutrition Intervention

Konseling gizi dapat meningkatkan asupan kalori dan

meningkatkan outcome

Ravasco et al. Head and Neck 27:659-668, 2005.

Ravasco et al. J Clin Oncol 23:1431-1438, 2005.
Nutrition Intervention
konseling gizi dapat meningkatkan asupan protein dan
meningkatkan outcome

Ravasco et al. Head and Neck 27:659-668, 2005.

Ravasco et al. J Clin Oncol 23:1431-1438, 2005.
 Nausea and Vomiting
• Jahe
• Hindari makanan favorit
• Hindari menyimpan makanan berbau
menyengat
• Makanan lembut dan kering
• Porsi kecil
• Sumber kalori dalam bentuk minuman
 PENURUNAN CITA RASA
• PORSI KECIL SERING
• PILIH MAKMIN KAYA KALORI
• PILIH MINUMAN BERKALORI
• PILIH MAKMIN KAYA VITAMIN SEPERTI BUAH
SEGAR
• Gunakan susu yang mengandung BCAA
 KELELAHAN
• Aktivitas ringan
• Menyiapkan makanan dingin setiap saat
• Pendampingan teman dan keluarga
MAKANAN DINGIN
 MULUT TENGGOROKAN TERASA
PANAS KERING
• Banyak minum
• Hindari pencuci mulut berbahan alkohol
• Bersihkan mulut dengan air/garam/baking soda
• MAKANAN BERAIR DAN LEMBUT

▫ SMOOTHY BUAH
▫ SUP CREAM DINGIN
▫ SEREAL
▫ PUREE KENTANG/KENTANG PANGGANG
▫ ORAK-ARIK TELUR
▫ PUDING SUSU
▫ ES CREAM
▫ Hindari makanan panas, pedas dan asam
 Perubahan indera pengecap
• Cuci mulut sebelum makan
• Gunkan wadah makanan yang kedap bau
(plastic utensils)  tupper ware
• Coba kunyah permen
• Bisa dengan herbal seperti jahe, laos, daun
salam, sereh
• Peka asin gunakan gula add sweetener
• Peka manis gunakan asin add salt
 Diare
• Segera minum
• Porsi kecil
• Hindari makanan gorengan, pedas dan manis
• Hindari kopi dan alkhohol
• Hindari makanan berbahan sorbitol, xylitol dan mannitol
• Batasi makanan bergas
▫ Kol dkk
▫ Kacang goreng/panggang
▫ Minuman berkarbon
• Makan makanan sumber pectin, FOS
▫ Pisang, tepung sagu, tepung tapioka, tepung irut
 Konstipasi
• Makan dianatara waktu makan
• Minum atau makanan hangat
▫ Jus hangat buah dan sayur
▫ Rendah caffein
▫ Coklat panas
▫ Air hangat ditambah dengan lemon atau madu
• Minum minimal 8 gelas
▫ Air
▫ jus
▫ Makanan cair beku
• Tambahkan serat makanan sayur dan buah
Cancer Prevention

Image from the AICR.org

 Diet and Cancer Risk
• 1/3 of cancer deaths are related to dietary
factors or physical inactivity
• Approximately 50% of all cancers could be
prevented with the adoption of a healthy
lifestyle
– Reduction in alcohol consumption
– Healthy body weight
– Physical activity
– Plant-based diet
 Strength of Evidence of Associations Between Nutrition-Related
Factors and Cancer

Hypothesis Lung Rectum and Breast Prostate Head and Neck Endometrial
Colon
Diet rich in Probable Probable Possible Possible Probable Possible
plant-based
foods decrease
risk
Moderate Lacking Convincing Convincing Weak Weak Probable
Physical Activity
decreases risk

Obesity Lacking Convincing Convincing Convincing Probable Convincing

increases risk

Alcohol Lacking Possible Probable Lacking Convincing Weak

increases risk

The clinical guide to oncology nutrition/Oncology Nutrition Dietetic Practice Group; Elliot et al. 2nd edition
 Cancer Risk and Body Weight
• Maintaining a healthy body weight
throughout life may be the most important
lifestyle factor to reduce cancer risk.
• When BMI >40
– 52% higher risk for all cancers in men
– 62% higher risk for all cancers in women
 Waist Circumference
• Waist circumference is a measure of
abdominal fatness including both
subcutaneous and the metabolically active
visceral fat stores
• The AICR recommends waist circumference to
be no more than 37” in men and 31.5” in
women
 Foods and Drinks that Regulate
Weight
• Low Energy-Density
▫ Vegetables, fruits, legumes, whole grains, broth
based soups
▫ High water content and high fiber

• High Energy-Density
▫ Oils, fats, chips, crackers, cookies
▫ High fat and added sugars
 ANTIOKSIDAN
http://www.pcrm.org/shop/cancerproject/nutrition-
rainbow-poster
 Red and Processed Meats
• Limit consumption of red meat (beef, pork, lamb)
▫ < 18 oz per week
▫ Risk of colorectal cancer increases by 17% for every
100g of red meat consumed daily
• Avoid consumption of processed meats
▫ Meat that is preserved by smoking, curing, salting, or
addition of chemical preservatives
▫ Risk of colorectal cancer increases by 18% for every
50g of processed meat consumed daily
 Alcohol
• Ethanol in alcoholic beverages is classified as a
carcinogen
• Acetaldehyde (metabolized form of ethanol) is
classified as a carcinogen
• Alcohol metabolism damages DNA
• Alcohol causes tissue damage, inflammation,
interactions with folate, and interference with
estrogen pathways
 Sodium
• Limit consumption of salt and processed foods
with added salt
• Aim for < 2,400 mg sodium daily
• Use herbs and spices to enhance flavors and
reduce the need for salt
 PASCA TERAPI
• After a patient’s symptoms have improved
and they are able to tolerate most foods,
nutrition therapy shifts toward health
promotion and cancer prevention.
• The recommendations for survivors are the
same as cancer prevention.
 LANJ...
• Overweight/obesity increases risk of disease
recurrence or developing new primaries

• Intentional weight loss post-treatment for

overweight or obese survivors may reduce
cancer recurrence and also their risk for other
health-related conditions such as
cardiovascular disease, diabetes, and
hypertension.
Recommendation
Be as lean as possible without
becoming underweight
Be physically active for at least 30
minutes daily. Avoid sedentary
habits like watching T.V.
Avoid sugary drinks and energy
dense foods
Follow a plant based diet
Limit Consumption of Red Meat
(beef, pork, lamb) and processed
meats (ham, bacon, hot dogs, salami)
Details
Avoid weight gain and increased
waist circumference throughout
adulthood. Healthy BMI 18.5-24.9
30 min of mod. intense activity daily
and as fitness improve, 60 min of
mod or 30 min of vigorous activity
daily.
Limit added sugars, foods low in
fiber, and high in fat. Water is best
alternative.
Consume 5-7 servings of fruits and
veggies daily. Aim to fill at least 2/3
of your plate with vegetables, fruits,
whole grains and beans.
Limit intake of red meat to <18
oz/wk. Avoid processed meats.
http://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-
prevention/
Benefits
Protects against colon, pancreatic,
endometrium, and postmenopausal
breast cancer
Strengthens immune system, keeps
GI tract healthy, maintains weight
Avoids weight gain, thereby reducing
cancer risk
Protects mouth, pharynx, larynx,
esophagus and lung cancer. Contains
vit and minerals, which strengthen
immune system. Fiber increases gut
transit time to reduce risk of cancer.
Red meat is linked to colon cancer and
processed meat has been linked to
stomach cancer
Recommendation
Avoid Alcohol
Limit consumption of salty foods and
foods processed with salt
Don’t use supplements to protect
against cancer
Breastfeed
Cancer survivors should follow the
recommendations for cancer
prevention
Details
If consumed at all, limit intake to no
more than 2 drinks for men and 1
drink for women
Limit salt (sodium) intake to less than
2,400mg/day
Aim to meet nutritional needs though
diet alone
It is best for mothers to breastfeed
exclusively for up to 6 months
Once treatment has been completed
and unless otherwise advised, aim to
follow cancer prevention
recommendations for diet, physical
activity and healthy weight
http://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-
prevention/
Benefits
Alcohol increases risk of mouth,
pharynx, larynx, esophagus, liver,
breast, colorectal & stomach cancer
High salt intake damages the lining of
the stomach, potentially causing
stomach cancer.
Supplements can upset the balance
of nutrients and some have been
linked to cancers.
Breastfeeding can protect moms
from breast cancer & protect babies
from excess weight gain leading to
obesity in adulthood.
Physical activity , healthy weight, and
balanced diet, may help to prevent
cancer recurrence.
 TIPS MAKAN PADA
PASIEN KANKER
• Makan dengan porsi kecil namun sering
• Pilih makanan yang tinggi kalori & protein
(termasuk snack)
• Hindari makanan dengan kalori ’kosong’ (seperti
soda)
• Untuk menghindari mual & memperbaiki selera
makan jangan minum bersama makan, karena
menyebabkan cepat kenyang tanpa kalori yang
cukup.
• Upayakan makan setiap kali merasa selera makan
baik
• Makan meal substitute (makanan pengganti),
seperti minuman tinggi kalori tinggi protein pada
saat selera makan hilang.
 TIPS MAKAN PADA
PASIEN KANKER
• Upayakan meningkatkan selera makan dengan melakukan
latihan fisik (exercise) ringan.
• Tambahkan ekstra kalori dan protein pada makanan
dengan menambahkan susu, madu atau brown sugar
• Makan obat dengan cairan tinggi kalori dan protein
• Makan makanan dengan suhu tidak terlalu panas dan tidak
terlalu dingin.
• Hindari makanan terlalu berbumbu dengan aroma tajam.
• Kreatiflah dalam hal menyajikan makanan.
 KESIMPULAN

• Malnutrisi / gizi kurang sering dialami

pasien kanker.
• Malnutrisi pada pasien kanker dapat
menurunkan efektivitas terapi dan
kualitas hidup pasien serta
meningkatkan komplikasi.
• Pemberian nutrisi dengan jumlah,
jenis dan cara yang tepat akan
menunjang keberhasilan terapi
kanker.
Matur nuwun