Nutritional Guidance for Weak HER2 Breast Cancer Patients on Tube Feeding

Nutritional support for HER2-positive breast cancer patients (patients are very weak)?

Hello, Nutritionist: My mother is 63 years old and is a stage IV HER2-positive breast cancer patient with metastasis to the brain and bones.
She was diagnosed in early January and has been undergoing treatment, which includes surgery and radiation therapy for the brain.
She is receiving chemotherapy with Trastuzumab (approximately 40 mg) combined with targeted therapy, administered weekly for two weeks followed by a one-week break.
Due to her unstable condition, she has received the treatment four times so far.
Generally, she does not experience significant side effects, but she is very weak and occasionally has a scattered mental state, requiring her to remain bedridden.
Her blood cell counts have not improved; maintaining a count of 3,000 allows her to continue treatment, but sometimes when the count drops to 1,000-2,000, she receives injections to boost her white blood cells.
She has experienced urinary tract infections and severe septic shock.
Due to the tumor's effects, she also has electrolyte imbalances and diabetes insipidus (with high sodium and low potassium levels).
The diabetes insipidus is controlled with medication.
It is likely that the brain surgery and tumor have significantly impacted her mental state and cognition, and she has difficulty moving her limbs.
She has swallowing difficulties and requires a nasogastric tube for feeding.
Currently, she is receiving six feedings (two meals of Ensure, two meals of Peptamen, and two meals of blended food prepared by a nutritionist at the nursing center), spaced four hours apart, with additional water intake in between.
After feeding, she is turned and her back is tapped for 30 minutes.
One of her meals each day has poor digestion, with the nasogastric tube aspirating 50-70 ml.
We have tried supplementing with chicken essence during hydration, but it seems that the food is not digested in time, leading to some vomiting.
Other cancer patients have suggested that relying solely on formula milk is insufficient and that dairy products are harder to digest.
They recommend using bone broth for blood cell replenishment, filtered for feeding, and also boiling and straining the herb "Nikkiro" (white phoenix vegetable) for soup.
Given the complexity of my mother's condition and the abundance of information, I would like to ask the nutritionist how her current diet and nutritional support can be arranged.
The situation is very challenging, but we are still striving to move forward.
Thank you for your help!

Chen A-Hsiung, 20~29 year old female. Ask Date: 2017/03/23

Dr. Cai Xiuwen reply Nutrition

Dear Mr.
Chen,
I understand that your mother is going through a tough time during her treatment, and the family is also putting in a lot of effort to care for her.
During cancer treatment, it is common to experience a decrease in white blood cell counts, and nutritional support is crucial.
Based on your description, the current caloric intake from enteral feeding seems to be around 1500 calories.
If there continues to be a problem with low white blood cell counts, I recommend discussing with the nutritionist at your mother's treatment hospital to increase protein intake and consider supplementation with arginine and glutamine as needed.
Could you please let me know which meal tends to have the most issues with reflux? If there are concerns regarding the timing of enteral feeding or medications, it would be beneficial to consult the nutritionist about possible adjustments.
Some studies suggest that if reflux does not exceed 100cc, there is no need to delay feeding to avoid inadequate caloric intake, but clinical circumstances should still be taken into account.
There are many nutritional products and related information available on the market, but it is advisable to follow the recommendations of the nutritionist at the treating hospital based on your mother's specific condition to effectively address her nutritional needs.
The suitability of natural foods and herbal supplements should also be assessed by a clinical nutritionist according to individual physiological conditions and blood test results.
While beef bone broth is easy to digest, it is very low in calories and can be tried in small amounts between meals.
I appreciate your dedication in caring for your mother, and I hope for a positive outcome.
Wishing you peace and comfort.
This message is from Dietitian Tsai Hsiu-Wen at Nantou Hospital, Ministry of Health and Welfare.

Reply Date: 2017/03/23

More Info

Nutritional guidance for patients with advanced HER2-positive breast cancer, particularly those undergoing treatment and experiencing significant challenges, is crucial for their overall well-being and recovery. Your mother's situation is complex, given her advanced stage of cancer, recent surgeries, and ongoing treatments, including chemotherapy and targeted therapy. Here are some recommendations based on her current condition and nutritional needs.

Nutritional Goals
1. Caloric and Protein Needs: Given your mother's weakened state and the fact that she is on tube feeding, it is essential to ensure she receives adequate calories and protein. The goal should be to provide at least 1.2 to 1.5 grams of protein per kilogram of body weight per day, depending on her overall health and activity level. For a 63-year-old woman weighing around 50 kg, this translates to approximately 60-75 grams of protein daily.

2. Hydration: Maintaining hydration is critical, especially since she has experienced electrolyte imbalances and urinary issues. Ensure she receives adequate fluids between feedings, and monitor her fluid intake closely to prevent dehydration.

3. Electrolyte Balance: Given her history of electrolyte imbalances (high sodium and low potassium), it is vital to monitor her electrolyte levels regularly. Incorporating foods or supplements that are rich in potassium (like bananas or potassium-rich broths) may help, but this should be done under medical supervision.

Tube Feeding Recommendations
1. Balanced Nutritional Formula: The current feeding regimen includes two meals of Ensure and two meals of another nutritional supplement. Ensure that these formulas are high in protein and calories. If she is tolerating the current regimen, consider consulting with a clinical dietitian to explore higher-calorie formulas or adding protein supplements to her feedings.

2. Homemade Broths and Soups: As suggested, homemade bone broth can be a good addition to her diet. Bone broth is rich in nutrients and can be easier to digest. Ensure it is well-filtered to avoid any solid particles that could cause discomfort. Additionally, incorporating pureed vegetables or other nutrient-dense soups can provide variety and additional vitamins.

3. Monitoring and Adjustments: Since she experiences some difficulty with digestion, it is crucial to monitor her tolerance to the feedings. If she frequently experiences reflux or vomiting, consider adjusting the feeding rate or volume. Smaller, more frequent feedings may help improve tolerance.

4. Nutritional Supplements: If she is struggling with her current nutritional intake, consider adding supplements that are specifically designed for cancer patients, which often contain higher protein and calorie content. These can be administered through the tube as well.

Addressing Digestive Issues
1. Digestive Aids: If she is experiencing poor digestion, consider discussing with her healthcare provider the possibility of using digestive enzymes or probiotics, which may help improve her digestive health and nutrient absorption.

2. Positioning: After feeding, ensure she remains in an upright position for at least 30 minutes to help with digestion and reduce the risk of aspiration.

Psychological and Emotional Support
Lastly, it’s essential to address the psychological and emotional aspects of her condition. The stress of cancer treatment can affect appetite and overall well-being. Engaging with a nutritionist who specializes in oncology can provide tailored advice and support. Additionally, consider involving a mental health professional or support groups to help her cope with the emotional challenges of her diagnosis and treatment.

In conclusion, your mother's nutritional needs are critical to her recovery and quality of life. By focusing on adequate caloric and protein intake, ensuring hydration, and monitoring her digestive health, you can help support her during this challenging time. Regular consultations with healthcare professionals, including dietitians and doctors, will be essential in adapting her nutritional plan as her condition evolves.

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