Oncology Nutrition Connection A publication of the ON DPG Volume 23, Number 2, 2016 ON DPG Website ISSN 1545-9896 www.oncologynutrition.org Table of Contents ON DPG Message from the Chair For this issue of Oncology Nutrition Connection’s Message from the • Message from the Chair: CNM DPG Supporting ON DPG Chair, we are highlighting a letter from the Chair of a different DPG, the page 1 Clinical Nutrition Management (CNM) DPG. This all began at the ON DPG Breakfast at FNCE 2014, where Elaine Trujillo, MS, RDN, Past Chair • Brief Report: Fluoride Toxicity of ON DPG and Ann Yaktine, PhD, RD, Director of the Food and in Hematopoietic Stem Cell Transplantation Nutrition Board at the Institute of Medicine (IOM), presented ON DPG’s page 2 plan to hold an IOM workshop to address Access to Nutrition Care in Outpatient Oncology. One of our active ON DPG members, Terese • Pediatric Oncology Nutrition Scollard, MBA, RD, LD, also is an active member of CNM DPG. Terese Corner: Pediatric vs. Adult Cancer: Critical Differences had the tremendous vision to see how our workshop could lay the page 3 foundation for improved access to RDs in many settings, not just in outpatient oncology. She had the foresight to invite CNM DPG to • CPE Article: Miraculin and support our workshop, and ON DPG was amazed and grateful when The Miracle Berry: An Option for Dysguesia? CNM pledged some of their hard-earned budget to support our page 7 workshop. We say “Kudos!” to CNM DPG, and are pleased to share this letter from CNM DPG with you! • Medical Cannabis Comes Out from Underground To members of CNM DPG and ON DPG, page 14 The quality of operational practices and Common concerns to both Clinical level of service integration can vary widely Nutrition Management and the Oncology among cancer programs. Cancer programs Nutrition Practice Group are improving strive for quality; however, there remain patient access to nutrition care, improving inconsistencies within and between the quality of and timing of nutrition programs related to nutritional practices intervention, support for team nutrition and access. Operational practices can care planning for patients, and negatively or positively impact patients’ improvement of access to nutritional nutritional status and outcomes. services for all cancer patients. (Continued on next page) 2 ❙ Oncology Nutrition Connection ❙ Volume 23, Number 2, 2016 National standards for cancer nutrition Every cancer patient deserves access to Oncology Nutrition services do not include quality metrics quality nutrition care provided by a with which to evaluate success or identify registered dietitian, embedded in cancer Connection improvement activities within cancer treatment programs. We must be A publication of Oncology Nutrition (ON), a nutrition programs. Reports in the advocates for our patients, and strive for dietetic practice group of the Academy of literature on practices, staffing levels, and the provision of quality nutrition care Nutrition and Dietetics. ISSN 1545-9896. training of professionals are inconclusive, within our organizations and our own Visit the ON DPG website at and therefore, challenging for program clinical practice. Attention to the basics of www.oncologynutrition.org leadership to identify the best workflows nutrition and hydration lessens suffering, Editor: or program practices. Few programs readmissions, delays in treatment, and Suzanne Dixon, MPH, MS, RDN include periodic nutrition risk screening gives hope to patients and families. For [email protected] with a validated and reliable screening tool these reasons, the CNM DPG is happy to Associate Editor: to identify patients who are struggling support this important first step of helping Jodie Greear, MS, RD, LDN [email protected] with nutrition before, during or after to finance the Nutrition and Cancer IOM treatment. Therefore, patients’ nutritional Workshop. Oncology Nutrition Connection (ONC) ISSN 1545-9896, is the official newsletter of the problems and needs may be missed or Oncology Nutrition Dietetic Practice Group inadvertently delayed until they result in We encourage our members to consider (ON DPG), a practice group of the Academy treatment dose reductions, serious side donating individually at: https://www. of Nutrition and Dietetics, and is published effects, and inability to heal and recover. oncologynutrition.org/get-involved/register- quarterly. All issues of ONC are distributed to to-become-a-member/iom-workshop/ members in electronic format only. The Oncology DPG has taken the major Articles published in ONC highlight specific step to plan for a collaborative workshop Sincerely, diseases or areas of practice in oncology with the Institute of Medicine to review the The Board of the Clinical Nutrition nutrition. Viewpoints and statements in each newsletter do not necessarily reflect the topic of nutrition care in cancer. The CNM Management Dietetic Practice Group policies and/or positions of the Academy of DPG, with a common concern for this Caroline Steele, MS, RD, CSP, IBCLC Nutrition and Dietetics or ON DPG. topic, has allocated $4,000 of member Chair, CNM DPG 2015-2016 Oncology Nutrition Connection is indexed in resources to support the IOM Workshop. the Cumulative Index to Nursing and Allied Health Literature. For inquiries regarding copyright, single-issue sales and past issues, contact the editor. Individuals interested in submitting a manuscript to ONC should Brief Report: Fluoride Toxicity in contact the editor or check the ON website for author guidelines. Individuals who are Hematopoietic Cell Transplantation ineligible for membership in the Academy of By Kerry McMillen, MS, RD, CSO Nutrition and Dietetics can order yearly subscriptions to ONC for $35.00 (domestic fee) and $40.00 (international fee), payable Many hematopoietic cell transplant (HCT) patients are treated for to the Academy of Nutrition and Dietetics/ invasive fungal infections. First line therapy for fungal pneumonia is ON DPG. Institutions can subscribe to ONC for $50.00 (domestic yearly fee) and $65.00 voriconazole, which is a fluorinated triazole compound (1). At standard (international yearly fee). ON DPG members voriconazole dosing, daily fluoride intake may be as high as 62.6 mg. The have access to archived back issues in pdf format. Non-members can order printed WHO guidelines document that fluoride intake of >6 mg/day increases copies of back issues (contact editor for risk of skeletal events, such as increased fracture risk, tingling and availability) at a cost of $10.00 each if mailed domestically and $20.00 each if mailed numbness in extremities, and joint pain (2,3). Because fluoride toxicity internationally. Send requests for symptoms include bone pain and weakness, which also are common in subscriptions or back issues to the editor. All ON DPG member mailing address changes many post-HCT patients, fluoride toxicity may be overlooked. and email address changes should be sent to the Academy using the address change card In an article by Gerber and colleagues, correlated to glomerular filtration rate in the Journal of the Academy of Nutrition contributors to fluoride-related, clinically (GFR) (1). Impaired renal function, and Dietetics or at eatright.org in the relevant skeletal disease in patients on common with immunosuppressive members-only section. voriconazole treatment include (1): medications such as tacrolimus, ©2016. Oncology Nutrition Dietetic Practice • Impaired renal function. Gerber et al. cyclosporine and sirolimus, is associated Group. All rights reserved. noted fluoride levels are inversely with higher circulating fluoride levels. Oncology Nutrition Connection ❙ Volume 23, Number 2, 2016 ❙ 3 • Prolonged intake. Patients in the Gerber study developed toxicity symptoms Pediatric Oncology Nutrition Corner: Critical between 3 and 7.5 months. Differences in Pediatric and Adult Cancers • Individual differences in By Nancy Sacks, MS, RD, LD and Chelsea Schulman, MS, RD, LDN pharmacogenetics and drug-drug interactions. • Inflammatory processes, the symptoms of Introduction which may be masked when patients are Cancer is the leading cause of death by disease among children in the on systemic corticosteroids, commonly United States (1). Leukemia, brain, and other central nervous system used for Graft vs. Host Disease treatment. (CNS) tumors account for more than half of new diagnoses of major Patients complaining of bone pain and childhood cancers. Advances in treatment for childhood cancer, along weakness on voriconazole should be with supportive care and participation in clinical trials, have improved evaluated for fluoride toxicity. If fluoride survival. The combined five-year survival rate for all childhood cancers levels are high, patients should be has improved from less than fifty percent prior to the 1970s to eighty counseled to limit dietary and other fluoride percent currently (2-4). As of 2010, an estimated 379,112 survivors of sources; choosing fluoride-free toothpaste, avoiding fluoridated water and avoiding childhood cancer were living in the United States (5). Approximately 24 eating the bones of fish such as sardines are percent of these childhood cancer survivors are living more than thirty examples of steps a patient can take to years after their diagnosis, thus contributing to the growing number of lower fluoride intake. For the majority of long-term survivors (6). patients, symptoms of fluoride toxicity resolve after discontinuing voriconazole. Current therapies for pediatric cancer Bone pain resolves rapidly