TIPS FOR PATIENTS

Nutrition is an important part of cancer treatment. Eating the right kinds of foods before, during, and after treatment can help a patient feel better and stay stronger.¹

Lung cancer patient nutrition needs

Good nutrition when living with cancer is important. Some of the symptoms associated with lung cancer and its treatment may affect a person’s appetite or ability to eat. Talk to a physician, a dietitian or other healthcare professional who should be able to help. Here we provide some advice and tips.

- Each person's nutritional needs during lung cancer are different. They are based on a patient’s lung cancer treatment plan, his/her current height and weight, and any other illnesses he/she may have such as diabetes or heart disease.²

- Although there is no prescribed diet for lung cancer patients,² a balanced diet of protein, carbohydrates, fat, fiber, water, vitamins, and mineral is essential for patients coping with cancer treatments and the road to recovery.^2,3

- Among patients with advanced non-small cell lung cancer, 61% have been found to be malnourished.⁴ In addition, a patient’s nutritional status can deteriorate during the course of cancer treatment, and healing also requires nutrients, extra calories, and additional protein.⁴ Therefore, it is important to get essential nutrients the body needs.

Nutrition tips for lung cancer patients

Listed below are some tips on how a person with lung cancer can get all of his/her nutrients:²

- Avoid low-calorie or non-nutritious foods and drinks

- Eat whenever patients feel hungry

- Supplement with high-calorie drinks if necessary

- Try liquid or pureed meals if patients have trouble in swallowing

- Eat several small meals throughout the day

- Avoid foods if they cause constipation or diarrhea

- Avoid food that is very hot or very cold

- Mint and ginger teas can help soothe gut

- Do not take dietary supplements without consulting with a doctor

- Eat sitting up. Do not lie down after eating

- Eat bland foods if a patient’s stomach is upset or mouth hurts

- Eat high fiber foods to help relieve constipation

- Talk to a doctor! 

_{1. Nutrition for the person with cancer during treatment. American Cancer Society. Available at:  https://www.cancer.org/treatment/survivorship-during-and-after-treatment/staying-active/nutrition/nutrition-during-treatment.html. Accessed 7 Feb 2017.}

_{2. Nutrition for lung cancer. American Lung Association. Available at: http://www.lung.org. Accessed 7 Feb 2017.}

_{3. Benefits of good nutrition during cancer treatment. American Cancer Society. Last Revised: July 15, 2015. Available at: https://www.cancer.org/treatment/survivorship-during-and-after-treatment/staying-active/nutrition/nutrition-during-treatment/benefits.html. Accessed 7 Feb 2017.}

_{4. Rhone M Levin. Nutrition in the patient with lung cancer. Caring Ambassadors Program 2016.}

Discharged from the hospital after lung cancer surgery, patients may experience pains, shortness of breath, and bruising, itchiness, soreness or numbness at the incision sites.⁵ A healthy lifestyle should be maintained for a speedy recovery. Patients should avoid smoking, alcohol, chemical fumes, environmental pollution and exposure to upper respiratory infections, such as colds and flu.⁶ 

- Incision care: Surgery incisions should be kept clean and dry.  Patients may use warm water and mild soap to gently clean incision sites.⁷ Pat them dry with a soft towel. Do not apply lotion, powder, or ointments until the scabs have fallen off (approximately 3-4 weeks).⁷ Immediately seek medical assistance if patients suspect an infected incision. Signs of an infected incision include:⁷

• Increased drainage, swelling or oozing from incision
• Opening of the incision line
• Redness and/or warmth around the incision
• Fever

- Pain management: Take pain medications as instructed by the doctor if needed. Don't wait until the pain gets bad before taking them.⁵ It is very important to call the doctor if pain or discomfort gets worse, or there are signs of complications.

- Physical activity: After surgery, patients should take things slowly and take as much rest as needed. For 6 to 8 weeks after surgery, avoid any activity that might put stress on the healing incisions, such as heavy-lifting or yardwork.⁵ Instead patients should slowly increase physical activity to avoid over exertion. For example, it is recommended to start walking to improve circulation, lung capacity, and strength.⁵ 

- Breathing exercise: After lung surgery, patients may notice shortness of breath with activity. It is recommended that patients practice deep breathing to help strengthen pulmonary muscles and expand the breathing capacity of the lungs.⁶ Patients may ask their doctor to demonstrate proper deep breathing exercises. In addition, a small device known as incentive spirometer can be used to exercise lungs and measure inspiratory volume.⁸ Consult a doctor if patients experience any of the below:⁶

• Trouble breathing
• Pain with breathing
• Chest pains
• Coughs
• Green, yellow, or blood-tinted phlegm
• Fever

_{5. A patient's guide to lung surgery - Recovering at home after a thoracotomy. Cardiothoracic Surgery, University of Southern California Keck School of Medicine. Available at: http://www.cts.usc.edu/lpg-thoracotomy-homerecovery.html. Accessed 7 Feb 2017.}

_{6. Lobectomy. Johns Hopkins Medicine Health Library. Available at: https://www.hopkinsmedicine.org. Accessed 7 Feb 2017.}  

_{7. Taking care of your incisions after lung surgery - Lung surgery patient guide. Cardiothoracic Surgery, University of Southern California Keck School of Medicine. Available at: http://www.cts.usc.edu/lpg-takingcareofincisionsafterlungsurgery.html. Accessed 7 Feb 2017.}  

_{8. After lung surgery: Breathing and coughing exercises. Cardiothoracic Surgery, University of Southern California Keck School of Medicine. Available at: http://www.cts.usc.edu.}

Radiation therapy or radiotherapy is a common treatment for lung cancer. The treatment is painless. However, there are some side effects which are associated with radiation therapy, and they are different for each person. Some people have many side effects; others have hardly any.⁹

- The side effects of radiation therapy for lung cancer usually come on slowly. They may last for a few weeks after treatment has ended. Once the treatment is over, the side effects will gradually get better.¹⁰ A small number of people have long term side effects, which develop up to 2 years after treatment has finished.¹⁰

- Some of common side effects include:^10,11

• Fatigue (tiredness) 
• Skin reaction
• Sore throat and trouble swallowing
• Cough
• Chest pain
• Nausea and vomiting

- Fatigue: This treatment-related fatigue might feel like an overall lack of energy and might persist for many weeks or even months.¹² Below are a few tips to help combat fatigue:

• Listen to the body, rest as much as possible, and do not do too much.¹³
• Get plenty of sleep, trying to sleep at least 8 hours each night.⁹ 
• Most people feel better when they get some exercise each day. Go for a 15- to 30-minute walk or do stretches. Talk with a doctor or healthcare professional about how much exercise a person can do while having radiation therapy.⁹
• Ask for and accept help at home or in the workplace.¹²

- Skin reaction: Most people develop a skin reaction in the area being treated, ranging from mild redness to blistering and peeling.^11,13 The reaction begins a few weeks after the beginning of a radiation therapy course, and will usually resolves within a few weeks of finishing therapy.⁹ Below are a few advice for taking care of skin reaction:¹²

• The area should be washed gently with simple non-perfumed soap, and patted dry with a soft clean towel. Perfumed soaps might make the reaction worse.
• Use lukewarm water to wash with. Do not scrub at the area.
• Do not scratch the area. Avoid exposure to extreme temperatures, such as ice packs and hot water bottles
• Do not swim in chlorinated water during radiotherapy.

- Sore throat and trouble swallowing: This may happen if the area being treated is close to the throat or oesophagus. Symptoms usually occur 2 to 3 weeks into therapy and subside a few weeks after completing treatments.⁹ Below are a few tips to help manage the problem:¹²

• Take soft diet until treatment is over.
• Avoid very hot or very cold drinks, salty and spicy foods.
• Avoid alcohol and tobacco. 

- Cough: Patients can develop a cough which maybe dry and tickly or even with blood.¹³ It may be relieved with sipping a drink or taking cough medicine. The cough should pass when the treatment is over. However, if cough persists and the sputum changes colour, becomes thicker or patients have a fever, please consult a doctor. It may be a sign of infection.¹³ 

- Chest pain: Patients may develop chest pain, often within a few weeks of starting the treatment.¹² It should go away by itself but remember to tell doctors just in case the chest pain is caused by something else.

- Nausea and vomiting: Radiation therapy can cause nausea, vomiting, or both. These symptoms may occur 30 minutes to many hours after a radiation therapy session ends.⁹ The best way to keep from vomiting is to prevent nausea. One way to do this is by having bland, easy-to-digest foods and drinks that do not upset the stomach. Besides, try to relax (such as reading a book or listening to music) before each radiation therapy treatment may help a patient feel less nausea.⁹

_{9. Radiation therapy and you. National Cancer Institute, US Department of Health and Human Services. NIH Publication No. 12-7157. Printed May 2012.}

_{10. Lung cancer radiotherapy side effects. Cancer Research UK. Available at: http://www.cancerresearchuk.org. Accessed 7 Feb 2017.}

_{11. Radiation therapy for non-small cell lung cancer. American Cancer Society. Last revised: May 16, 2016.}

_{12. Radiotherapy treatment for lung cancer - A guide for patients. National Cancer Control Programme, Health Service Executive. Dublin, Ireland.}

_{13. Panakis N. Radiotherapy to the lung: information for patients. Oxford University Hospitals NHS Trust. April 2015.}

Chemotherapy or chemo is designed to kill fast-growing cancer cells.¹⁴ But it can also affect healthy cells and cause side effects. Some common side effects from chemo are fatigue, nausea and vomiting, diarrhea or constipation, loss of appetite, skin rashes, mouth sores, hair loss, and infections.¹⁴

Every person does not get every side effect, and some people get only few.¹⁴ Most side effects will go away after chemo is over but sometimes it can take months or even years for them to subside.¹⁴ However, there are ways for patients to manage these side effects.

- Fatigue from chemo: It can range from mild tiredness to feeling completely wiped out. It is different from feeling tired after a long day and does not get better with rest or sleep. Things that may help with fatigue are:¹⁵

• Get plenty of rest, and allow time during the day for rest periods.
• Eat a well-balanced diet, and drink plenty of liquids.
• Limit activities; do only the things that are most important.
• Get up slowly to help prevent dizziness after sitting or lying down.
• Get help by asking family, friends, and neighbors when needed.

- Nausea and vomiting: These may start during treatment and last a few hours. Sometimes, severe nausea and vomiting can last for a few days. Be sure to tell a doctor or nurse if nausea has become intolerant, or if patients have been vomiting for more than a day. Things that may help with nausea and vomiting are:¹⁵

• Avoid big meals. Eat frequent, small meals throughout the day.
• Drink liquids at least an hour before or after mealtime instead of with meals.
• Eat and drink slowly. Chew food well for better digestion.
• Stay away from sweet, fried, or fatty foods.
• Rest in a chair after eating, but do not lie flat for at least 2 hours after a meal.
• Breathe deeply and slowly when you feel nauseated.

- Mouth sores: Chemotherapy may cause mouth sores, increase of bacteria in mouth, and chances of mouth infections.¹⁶ Things that may help with mouth sores are:^15,16

• Brush teeth with a soft bristled brush 2-3 times a day, and use a toothpaste with fluoride.
• Rinse mouth 4 times a day with a salt and baking soda solution (mix one half teaspoon of salt and one half teaspoon of baking soda in 8 ounces or 240 mL of water).
• Do not use mouth wash which contain alcohol. Please consult a doctor for the most appropriate mouth wash.
• Foods high in salt, vinegar which can aggravate sores should be avoided.  Soft foods, such as papaya, fish, egg and tofu, are good options if patients are having difficulty in eating. 

- Hair loss from chemo: Some chemo drugs can cause hair to become brittle. The degree of hair loss depends on the medication used, dosage and length of treatment. Hair loss may continue throughout treatment and up to a few weeks after chemo ends.¹⁴ Things that may help with hair loss are:^14,15,17

• Before treatment, patients may consider cut hair short or shave head, and should take care to avoid bleaching, colouring, and perming hair.
• During treatment, continue gentle hair care throughout chemo treatment. Wash hair only as often as necessary, use mild shampoos and soft-bristle hair brushes, and low heat if a hair dryer is used. Don’t use brush rollers to set hair.
• After hair loss, protect scalp by using a sunscreen, hat, scarf, or wig when going outside. Use a satin pillowcase which creates less friction than cotton when sleeping on it.
• Although hair loss may be stressful, patients should maintain a relaxed attitude to avoid additional stress Try to talk to a doctor, nurse, family member, close friend, or someone who has had hair loss caused by cancer treatment if needed, and remember that hair will grow back after treatment ends.

- Infections: Chemotherapy may reduce white blood cell (WBC) count over an extended period, weakening the patient’s immune system. During this period, patient may be more susceptible to illnesses or infections. Things that may help prevent infections are:^15,16

• Safe eating and drinking by avoiding raw foods, or anything that may be undercooked or spoiled.
• Wash hands often during the day, especially before meals and after the use of toilet. 
• Clean rectal area very well but gently after each bowel movement.
• Keep house clean. Stay away from crowds, and stay away from people who have diseases, such as colds, flu, measles, or chicken pox.
• Do not get any immunization shots (vaccines) without first checking with a cancer doctor.
• Be careful with pets and animals. Do not play rough with cats. Scratches and bites can get infected. Stay away from puppies, kittens, and other very young animals.
• Consult a doctor if patients suffer from any of the following symptoms:
• Fever over 38°C
• Chills
• Prolonged diarrhea
• Prolonged vomiting
• Burning feeling when urinating
• Severe cough or shortness of breath
• Bleeding or unexplained bruising
• Rash or signs of a possible allergic reaction, such as swelling, severe itching or wheezing

_{14. Chemotherapy and you. National Cancer Institute, US Department of Health and Human Services. NIH Publication No. 11-7156. Printed June 2011.}

_{15. A guide to chemotherapy. American Cancer Society. Last revised: June 2015. Available at:  https://old.cancer.org/acs/groups/cid/documents/webcontent/003025-pdf.pdf. Accessed 7 Feb 2017.}

_{16. After chemotherapy - discharge. MedilinePlus. National Institutes of Health, US National Library of Medicine. Jan 2017.}

_{17. Chemotherapy and hair loss: How to make the best of it. Mayo Clinic, April 05, 2016. Available at: http://www.mayoclinic.org/tests-procedures/chemotherapy/in-depth/hair-loss/art-20046920. Accessed 7 Feb 2017.}

Targeted therapy is a type of cancer treatment that uses drugs or other substances to more precisely identify and attack cancer cells, usually while doing little damage to normal cells.¹⁸

Different targeted therapies cause different side effects. Common side effects of all EGFR inhibitors include skin problems, diarrhea, mouth sores, and loss of appetite.¹⁹ However, most side effect would slowly subside as the treatment ends.

- Care for skin problems: Patients may develop an acne-like rash on the face and chest, which in some cases can lead to skin infections.¹⁹ Other skin changes may include dry skin, itchiness, nail changes, and hand-foot syndrome.²⁰ Below are some advice that may help minimize skin problems:²⁰

• Use very mild soaps, body washes, and shampoos that do not contain alcohol, perfume, or dye.
• Bathe with cool or lukewarm (instead of hot) water.
• Moisturize skin at least twice a day with a thick emollient cream that has no alcohol, perfumes, or dyes.
• Wear loose, soft clothing.
• Stay out of the sun as much as possible. When going outside during the day, wear a hat and clothes with long sleeves.
• Use a broad-spectrum sunscreen with SPF of at least 30 and zinc oxide or titanium dioxide at least 1 hour before going out.
• Do not use acne medicines. They do not work, and may make skin dry and rashes worse.
• Try gel shoe inserts if the soles of feet are tender.
• Wear shoes that fit well and are not too tight.  
• Tell doctors immediately if any rashes or skin changes are noticed. Left untreated, rashes can get worse and lead to infections.

- Care for nails: During and after targeted therapy treatment, patients may find their finger nails and toenails have darkened and become brittle, and may also experience painful swelling and redness around their nails.^20,21 Things that may help with nail changes:^20,21

• Take extra care when cutting nails. Cut them evenly and keep them short.
• In the case of pain or redness, patients may soak fingers or toes in a mixture of white vinegar and water in equal amount
• To avoid infections, patients should maintain hygiene by gently washing hands and feet with mild soaps regularly.
• It is recommended that patients should wear soft shoes to avoid further aggravating their toenails.

- Diarrhea management: Targeted therapy could cause mild to serious diarrhea in patients. Serious diarrhea could result in dehydration and loss of electrolytes.   Patients should ensure to drink plenty of water, and avoid eating dairy products, oily foods, and foods high in fibre.²² 

- Care for month sores: If patients have mouth sores after targeted therapy treatment, eat soft, non-spicy foods. Besides, good oral care is important. Be sure to brush teeth, and see a dentist before and during treatment if needed.²¹ See Mouth Sores under Post-chemotherapy care section for more information.

- Loss of appetite: Loss of appetite is a common side effect of targeted therapy. It can begin with the refusal of the favourite foods and may also involve the loss of weight. Below are some useful advice for managing it:²³

• Eat only the amount of food a patient desires.
• Take small meals throughout the day, not necessarily to eat three regular meals each day.
• Eat with friends and/or with the family or with the radio or television on.
• Eat foods high in calories, easy to eat, such as porridge, puddings, yogurt, etc.
• Drink between meals instead of during the meal.

See Nutrition Tips for Lung Cancer Patients under Nutrition-related information section for more information.

_{18. Targeted cancer therapy. American Cancer Society. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/targeted-therapy.html. Accessed 7 Feb 2017.}

_{19. Targeted therapy drugs for non-small cell lung cancer. American Cancer Society. Last revised: May 16, 2016. Available at: https://www.cancer.org/cancer/non-small-cell-lung-cancer/treating/targeted-therapies.html. Accessed 7 Feb 2017.}

_{20. Side Effects of Targeted Cancer Therapy Drugs. American Cancer Society. Last Revised: June 6, 2016. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/targeted-therapy/side-effects.html. Accessed 7 Feb 2017.}

_{21. Caring for your skin, hair and nails when on targeted therapies. Multinational Association of Supportive Care In Cancer. Available at: http://www.mascc.org/assets/documents/skin_toxicity_egfri_patientbrochure.pdf. Accessed 7 Feb 2017.}

_{22. Fight against lung cancer. The Hong Kong Anti-Cancer Society, 2015. ISBN 978-988-15283-0-8, page 35.}  

_{23. Loss of appetite. Lung Cancer Alliance. Available at: http://www.lungcanceralliance.org/what-if-i-am-diagnosed/side-effect-management/loss-of-appetite.html. Accessed 7 Feb 2017.}