Reproductive Cancers

Heather Hendrikson, RD, CSP, LD INTRODUCTION

Cancers of the female reproductive system include ovarian, endometrial, cervical, uterine sarcoma, vaginal, and vulvar types. Uterine cancer is the most common female reproductive cancer (RC) in the United States.1 Ovarian cancer is the second most common gynecologic cancer and the leading cause of death from reproductive malignancies.1-3 Table 9.1 presents the projected new cases and deaths from RC in 2008 in the United States.

The largest body of evidence in nutrition therapy and RC relates to patients with ovarian cancer, especially advanced stages that can lead to bowel obstruction. Most RC, including ovarian, endometrial, cervical, uterine, and vaginal types, can lead to abdominal bowel obstruction and fluid accumulation as a result of tumor advancement. The management of bowel obstruction is usually similar regardless of the underlying type of gynecologic cancer.

Table 9.1 Estimated New Reproductive Cancer Cases and Deaths in the United States, 2008

Type of Reproductive Cancer

New Cases

Deaths

Uterus

40,100

7,470

Ovary

21,650

15,520

Cervix

11,070

3,870

Vulva

3,460

870

Vagina

2,210

760

Source: American Cancer Society, Cancer Facts and Figures 2008.

Prevention

Ovarian Cancer

One of the risk factors for ovarian cancer is age: Approximately half of these cancers are diagnosed in women who are older than 63 years of age. Obesity appears to increase the risk of ovarian cancer, and the rate of death is 50% higher in obese women. Other risk factors include estrogen replacement therapy or hormone replacement therapy; a family history of ovarian, breast, or colorectal cancer; and a personal history of breast cancer.1

Limited evidence suggests that a diet characterized by non-starchy vegetables, moderate alcohol consumption, and low fat, when followed for at least four years, lowers the risk for ovarian cancer. Birth control pills used for greater than five years, bearing children, and lactation protect against ovarian cancer, as do late menarche, early menopause, and tubal ligation or hysterectomy. More compelling evidence shows the factors leading to, or the consequences of, greater adult-attained height are a probable cause of ovarian cancer. Adult-attained height is a marker for genetic, environmental, hormonal, and nutritional factors affecting growth during the period from preconception to completion of linear growth. Adult height increases as populations become less vulnerable to undernutrition, infestations, and infections, and as food supplies become more secure and abundant. This trend has now slowed or even stopped in most high-income countries.1-5

Ovarian cancer has no signs and symptoms during its early stages. As a consequence, the disease is usually in an advanced stage when diagnosed. Noticeable signs and symptoms may include swelling of the stomach, pelvic pressure or stomach pain, trouble eating or feeling full quickly, and having to urinate often or with increased sense of urgency. It is important to see a doctor if these symptoms persist for greater than two weeks. Regular women’s health exams, which include a pelvic exam and a Pap smear, are used as a screening device.1

Endometrial Cancer

It is unknown what causes endometrial cancers. Nevertheless, most are hormone-driven, and an imbalance toward increased estrogen production increases the risk for endometrial cancer. Risk factors include total number of menstrual cycles, history of not being able to become pregnant or having never given birth, estrogen replacement therapy, treatment with tamoxifen (a hormonal drug used for breast cancer treatment and risk reduction), and a history of other ovarian diseases. Convincing data suggest that obesity—and especially fat accumulation in the abdominal region—is a risk factor for endometrial cancer. Although most women’s estrogen is made in the ovaries, fat tissue can change some other hormones into estrogens. A diet high in animal fat, often leading to obesity, and diabetes, which is more common in overweight individuals, are also risk factors. Other factors that may play a role in the development of endometrial cancer include smoking; a family history, especially of certain types of colon, breast, or ovarian cancer; and previous pelvic radiation therapy.1

Physical activity, bearing children, birth control pills, and early menopause are probably protective against the development of endometrial cancer. Limited evidence suggests non-starchy vegetables protect against endometrial cancer, whereas red meat and the factors that result in greater adult-attained height, or its consequences, can lead to cancer of the endometrium.1-3

Possible signs and symptoms of endometrial cancer include unusual bleeding, spotting, or discharge. Pelvic pain, a pelvic mass, and weight loss are symptoms of more advanced endometrial cancer.1

Cervical Cancer

No strong evidence is available linking any aspect of food, nutrition, or physical activity to the risk of cervical cancer.2, 3 The most important risk factor for cancer of the cervix is infection with human papillomavirus (HPV).1

The most common symptom of cervical cancer is abnormal vaginal bleeding, but early cervical pre-cancers or cancers often have no signs or symptoms. Therefore, two preventive measures, which can sometimes even prevent precancers, are important for women: avoiding HPV infection and receiving regular Pap tests.

Steps to avoid HPV consist of delaying sex, using condoms, and being immunized with the HPV vaccine (Gardasil). The HPV vaccine, which consists of a series of three shots given over six months, is administered before sexual activity begins. The American Cancer Society (ACS) recommends the vaccine for females aged 11-12 years and as early as age 9 years in some individuals if recommended by a physician. The ACS also suggests that women aged 13-18 years receive the vaccine for “catch-up” purposes and that women aged 19-26 years speak with their physician to determine if the vaccine is indicated. The vaccine does not protect individuals from all cancer-causing types of HPV, however, so Pap tests are still needed.1

The Pap test, using either conventional or liquid-based cytology, is the most common screening form for pre-cancers. The majority of cervical cancers are found in women who have not had Pap tests at the recommended intervals. Initiation and timing of tests depend on the patient’s age and risk factors. The ACS recommends working closely with a women’s health professional to determine commencement and frequency of testing. An HPV DNA test, which includes a sampling of the cells of the cervix, can be used in conjunction with a Pap test. Administration of the HPV DNA test also depends on age and risk factors. Patients are advised to consult with their physicians to determine the necessity for this test.1

Uterine Cancer

Risk factors for uterine cancer include prior pelvic radiation therapy and race—this disease is twice as common in African Americans as in whites or Asian Americans. Hormone balance plays a large role in uterine cancer, with risks including obesity, estrogen replacement therapy, treatment with tamoxifen, infertility, diabetes, early menstruation (before age 12), and menopause after age 52.1

Most uterine sarcomas are asymptomatic and cannot be prevented. Their signs and symptoms may include unusual bleeding or discharge and pelvic pain and/or mass. There are no recommended screening tests or examinations to detect uterine sarcomas. The Pap test can occasionally find some early uterine cancers, but most cases are not detected by this test.1

Vaginal Cancer

Risk factors for vaginal cancer include age (most cases appear in women older than age 60), vaginal irritation, cervical or pre-cervical cancer, and smoking. Another risk is vaginal adenosis: Vaginal walls are normally lined with squamous cells, but in adenosis the vagina may contain one or more areas of the types of cells lining the uterus. Also, 65-80% of vaginal cancers have been found to contain HPV. Lastly, human immunodeficiency virus (HIV) infection can increase the risk of vaginal cancer because immunosuppression can increase the risk of HPV, thereby increasing the risk of cancer development.1

The exact cause of vaginal cancer is unknown. Prevention measures include avoiding HPV infection and receiving regular Pap tests to detect pre-cancers. Signs and symptoms include abnormal vaginal bleeding, often after intercourse; abnormal vaginal discharge; a mass that can be felt; and pain during intercourse. In advanced stages of the disease, painful urination, constipation, and continuous pain in the pelvis may occur.1

Vulvar Cancer

Risks of vulvar cancer include age (85% of women diagnosed are older than age 50 and 50% are older than age 70), HPV infection, smoking, HIV infection, vulvar intraepithelial neoplasia (VIN), lichen sclerosis, other genital cancers, and melanoma or atypical moles on nonvulvar skin. Regular gynecologic checkups are essential to assist in detection of this disease. Usually,

vulvar cancer is characterized by persistent itching and a growth or ulcer in the vulvar area.1

Treatment Options

Most cases of RC are treated with surgery. The surgical interventions will vary depending on disease type, stage, and presence of metastatic disease. Surgery is often followed by chemotherapy and/or radiation therapy. For nondisease-specific nutrition care during medical, radiological, and surgical oncology treatments, refer to Chapters 4 and 5. The following sections detail the treatments for each type of RC.

Ovarian Cancer

Surgery in ovarian cancer is important for staging and tumor removal. Staging assists in determining the treatment plan but often requires removing the uterus, both ovaries, and the fallopian tubes, along with the omentum (a layer of fatty tissue over the abdomen) and lymph nodes in the pelvic and abdominal areas. Also, surgery typically includes tumor removal and/or debulking, so as to eliminate as much of the tumor as possible. Chemotherapy, which can be delivered either intravenously or directly into the abdomen for advanced-stage disease, is also used as treatment for ovarian cancer.1 Chemotherapy medications commonly used to treat ovarian cancer and their nutrition-related side effects are listed in Table 9.2. Radiation therapy is not routinely used in ovarian cancer.1,6 Recurrent cancer may require hematopoietic stem cell transplantation.1

Endometrial Cancer

Surgical intervention for endometrial cancer most commonly involves a radical hysterectomy, which includes the removal of the uterus, cervix, upper part of the vagina, and other tissues next to the uterus, along with laparoscopic lymph node sampling. Radiation therapy is used and can include either brachytherapy, in which radioactive pellets are placed via the vagina, or external radiation. Hormone therapy with progesterone-like drugs is administered to slow the growth of the cancer and is more often used in cases of advanced or recurrent endometrial cancer. Chemotherapy may be given depending on the stage of disease,1 with this treatment typically being offered to women with more advanced stages of disease. The chemotherapy

Chemotherapy Agent

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Cisplatin

X

X

X

Carboplatin

X

X

X

(metallic taste)

Docetaxel

X

X

Doxorubicin

X

X

Etoposide

X

X

X

X

Gemcitabine

X

X

X

Paclitaxel

X

X

X

Topotecan

X

X

X

X

Vinorelbine

X

X

X

X

Source: www.cancer.about.com.

agents typically employed in endometrial cancer are cisplatin, carboplatin, doxorubicin, and paclitaxel.

Cervical Cancer

Several types of surgery are performed to treat cervical cancer. Some involve removing the uterus; others do not. Cryosurgery, which kills abnormal cells on the cervix by freezing them, and laser surgery, which burns cells or removes small pieces of tissue, are used in treating pre-invasive cervical cancer (stage 0) only. Conization involves the removal of a cone-shaped piece of tissue from the cervix. This surgical technique can be used to find the cancer or treat early cancers, especially in women who want to have children. Depending on staging and treatment plans, a simple hysterectomy (uterus only is removed) or radical hysterectomy including a pelvic lymph node dissection can be done.

Trachelectomy may allow young women who have an early stage of cervical cancer to be treated and still be able to have children. This procedure entails removal of the cervix and upper part of the vagina and the placement of a “purse-string” stitch to act as an artificial opening of the cervix in the uterus. Women who have undergone a trachelectomy have a 50% pregnancy rate after five years, but have a higher than normal rate of miscarriage; a caesarean section is required to deliver their children.

Pelvic exenteration, besides removing the reproductive organs mentioned previously, includes removal of the bladder, vagina, rectum, and part of the colon. This procedure is used more often in the presence of a recurrent cancer occurring after initial treatment and remission.1

Radiation therapy for cervical cancer can take the form of either external radiation or internal radiation.1 Chemotherapy is not commonly used in cervical cancer. although it may be employed in select cases.16 If chemotherapy is required, the agents used more commonly are carboplatin, cisplatin, paclitaxel, 5-fluorouracil, cyclophosphamide, and ifosfamide.

Uterine Cancer

Surgery to remove uterine cancer typically includes a radical hysterectomy, which entails the removal of the uterus, cervix, upper part of the vagina, and other tissues next to the uterus, and can include lymph node removal in the pelvis and lower abdominal back. Radiation therapy for this type of cancer may consist of either brachytherapy, in which radioactive pellets are inserted via the vagina, or external radiation therapy. Chemotherapy (doxorubicin combined with either Platinol or paclitaxel) and hormone therapy are also used in the treatment of uterine cancer, typically if surgery and radiation therapy have failed.1

Vaginal Cancer

The two main treatments for vaginal cancer are surgery and radiation therapy. Surgery generally includes laser surgery in which a high-energy beam of light vaporizes the abnormal tissues. A wide local excision or partial vaginectomy are performed rarely, but may be needed if other treatment options fail. Topical chemotherapy applied directly to the vaginal lining or intravenous chemotherapy (cisplatin, carboplatin, 5-fluorouracil, paclitaxel, etoposide, capecitabine, bleomycin, mitomycin C, vincristine or ifosfamide) may be used to treat advanced stages.1

Vulvar Cancer

Laser surgery, in which a focused laser beam is employed to vaporize the layer of vulvar skin containing the abnormal cells, is used in the treatment of pre-invasive cancer. Excision—that is, removal of the cancer and a margin of the normal-appearing skin around it—is sometimes called a local excision; if the area removed is more extensive, the procedure is called a simple partial vulvectomy. A vulvectomy can be simple or radical. It can include inguinal node dissection and sentinel lymph node biopsy. In advanced stages, pelvic exenteration is performed; this procedure involves a vulvectomy and removal of the pelvic lymph nodes, as well as one or more of the following structures: the lower colon, rectum, bladder, uterus, cervix, and vagina.1

External-beam radiation is often used in conjunction with chemotherapy in cases of vulvar cancer. Radiation therapy can also be used to treat the groin nodes and pelvic nodes alone. Chemotherapy can be given intravenously for more invasive cancer, or it can be applied as a topical cream directly to the skin in less invasive cancers.1

Primary Surgery and Nutritional Issues

Early postoperative oral intake in patients with RC has been debated and studied for many years. In the late 1990s, clinicians realized that traditional feeding protocols, which avoided oral intake in the early postoperative period, were not based on scientific literature, but instead were passed down from surgical mentors. Traditional management included nasogastric suction, awaiting the return of bowel sounds, and the passage of flatus or bowel movement before initiating oral intake.7

While research has not identified the cause of postoperative ileus, fear of this complication has prompted many surgeons to continue with traditional postoperative management. Scientific data demonstrate that small intestinal function returns almost immediately after surgery, gastric emptying returns by the second postoperative day, and colonic function is normal in two to three days.7 Studies have concluded early postoperative oral intake results in decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery.78 These studies utilized clear liquid diets on postoperative day 1 and advanced to a regular diet once liquids were tolerated.7, 8 Patients also receiving irradiation, neurotoxic chemotherapy, or extensive abdominal surgery may need a more individualized diet; more research is currently needed in these specific areas.7

The disease stage and patient condition at time of surgery may influence which type of surgical intervention is appropriate. The use of a nutrition laboratory value, prealbumin, has also been proposed as a predictor of patient outcomes. In a study by Geisler and colleagues, prealbumin level and complications were used to establish which patients would not be good candidates for primary radical cytoreductive surgery for ovarian cancer.9 The prospective study was carried out at one institution and included patients with advanced epithelia ovarian cancer (stage III or IV). The study participants had a mean age of 59 years, had a mean BMI of 32 kg/m2, and were operated on by two staff surgeons over a two-year period. Although 114 patients met the criteria for inclusion, 6 patients were deemed too ill to undergo surgery regardless of their prealbumin levels. Ultimately, 108 patients underwent primary surgical debulking with optimal cytoreduction. Of these individuals, 88 had a prealbumin level less than 18 mg/dL and 24 had a level less than 10 mg/dL.

Following the surgeries, the investigators found that postoperative complications increased with lower prealbumin levels. Postoperative complications included estimated blood loss greater than 2,000 mL; death within 30 days; unplanned intensive care unit admission; unplanned readmission to the hospital; significant vascular, gastrointestinal, or genitourinary injury; and hospital stay greater than 14 days. All complications occurred in patients with prealbumin levels of less than 18 mg/dL, and a significantly larger number of complications occurred in patients with prealbumin levels of less than 10 mg/dL. All postoperative mortality occurred in patients with prealbumin less than 10 mg/dL.

In this study, the patients with a prealbumin level less than 10 mg/dL were given nutrition support in the form of parenteral nutrition (PN) for greater than 10 days prior to surgery. After this period of PN, only 50% of the patients had improved prealbumin levels; the other 13 patients’ prealbumin level remained less than 10 mg/dL. All 24 patients underwent surgery, and all 13 of the PN patients whose prealbumin remained less than 10 mg/dL preoperatively experienced postoperative complications.

Due to the increased risk of postoperative complications, it appears that patients with extremely poor nutrition status—in this study, characterized by a prealbumin level of less than 10 mg/dL—may be better served by neoadjuvant chemotherapy with interval cytoreductive surgery once their nutritional status improves. The researchers suggest providing nutrition support to all patients with a prealbumin level of less than 10 mg/dL prior to surgery in the form of nutrition supplements, enteral nutrition (EN), or PN.

Nutrition Management During Aggressive Therapy

Malnutrition in gynecological cancer patients is a significant problem, especially among patients who have been diagnosed with ovarian cancer.10 Laky and colleagues used the Patient-Generated Subjective Global Assessment (PG-SGA) to establish this point. The PG-SGA, which has been previously validated,11 is an easy-to-use nutrition assessment tool that allows for quick identification and prioritization of malnutrition in patients with cancer. It classifies patients into one of three categories: well nourished, moderately or suspected of being malnourished, and severely malnourished. The Laky et al. study included 145 patients with gynecologic cancer, aged 20-91 years. Using the PG-SGA, 67% of the patients with ovarian cancer were classified as moderately or suspected of being malnourished, which was higher than the rate for all other gynecologic cancers combined.10

Deterioration in the nutritional status of patients with ovarian cancer has multifactoral roots. Both the derangements in cytokine levels and the bowel obstruction associated with an enlarging tumor can lead to cachexia and malnutrition. Very few agents have proven to have true anticachectic activity in patients with advanced cancer, although research is now underway to identify medications targeted at blocking the activity of cancer-related catabolic factors.12 Patients with ovarian cancer should undergo routine nutrition screening and assessment, preferably with a validated tool such as the PG-SGA, to enable their healthcare providers to detect and treat nutritional issues.

Providing adequate nutrition by mouth is often challenging in the presence of advanced disease, gastrointestinal side effects associated with chemotherapy, or radiation enteritis symptoms. The results of a small study conducted by Dillon and associates13 could lead to more promising research in this area, however. Their study included 6 patients with stage IIIC ovarian cancer and a mean age of 47 years. The patients were either undergoing primary therapy or therapy for recurrence and were classified as cachectic based on a weight loss of more than 10% of their premorbid weight. All participants were on a 21-day chemotherapy cycle and were studied on day 20 of the cycle. Study participants were given a balanced oral amino acid supplement containing 40 g of amino acids and 166 calories. Phenylalanine concentration in the blood and muscle were analyzed both before and after consumption of the amino acid supplement. The amino acid supplement led to increased protein synthesis and a stable protein breakdown. The researchers concluded that, despite the patients’ advanced cancer, ongoing therapy, and enhanced inflammatory burden, amino acids were capable of acutely stimulating muscle protein synthesis.13 Further research, including studies focusing on important outcomes such as quality of life and survival, is required to establish the role of an amino acid supplement in this patient population.

Oral supplementation and nutrient-dense foods are key elements in managing patients with gynecologic cancer who experience weight loss and eating difficulties. Determining the individual nutrient needs of these patients is challenging and, unfortunately, not well studied. The only study in this area to date was done by Dickerson and colleagues.14 It included 61 hospitalized patients with biopsy-proven cervical or ovarian carcinoma who were followed by the Nutrition Support Service. Resting energy expenditure was measured by indirect calorimetry and compared to predicted energy expenditure as determined by the Harris-Benedict equation for females. Measured resting energy expenditure varied between 53% and 157% of predicted energy expenditure. This study demonstrated the Harris-Benedict equation for females provides an unreliable estimate of caloric expenditure in patients with cervical or ovarian cancer receiving specialized nutrition support.14 Therefore, it is important to monitor patients’ weight and nutrition status closely, provide counseling regarding food and supplement selections, and, if aggressive therapy is desired, provide nutrition support during times of hypermetabolic stress and prolonged periods of inadequate oral intake.

Nutrition Management in Advanced Reproductive Cancer

Intestinal obstruction is a well-recognized complication of advanced ovarian cancer. It significantly affects survival, influences quality of life,15 and occurs in approximately 45% of patients.8 Bowel obstruction may present at diagnosis or with recurrent disease following anticancer therapy.16 Malignant bowel obstruction is particularly common and is the most frequent cause of death in patients with ovarian cancer.15, 16

Hospitalization and conservative measures, which include nasogastric suction, bowel rest, and intravascular fluids, constitute the initial treatment approach for intestinal obstruction.15 If this approach fails, surgical intervention or drainage gastrostomy is considered. More than half of all patients with ovarian cancer and intestinal obstruction can benefit from a definitive surgical procedure, a therapeutic approach that is associated with a low perioperative mortality rate and a mean survival rate of 6.8 months following surgical intervention.17 The decision to offer palliative surgery must be balanced against the potential morbidity and mortality and the ability to improve the quality of life for a patient with a limited life expectancy. Data suggest that patients undergoing repeat surgery for recurrent bowel obstruction have a low likelihood of achieving successful palliation and experience significant morbidity, including enterocuta-neous fistula, wound infection, rapid development of subsequent bowel obstructions, and limited survival.18

Patients with advanced unresectable disease and/or inoperable bowel obstruction, as a result of carcinomatosis and intestinal encasement with tumor, have a worse prognosis and require palliation with drainage gastrostomy, intravenous fluid supplementation, and an oral liquid diet.151718 Gastrostomy tube placement in ovarian carcinoma is technically feasible and safe in the palliative setting.19 Additionally, it plays an important role in the treatment of women with obstructive gynecological cancer, allowing for gastric drainage and decompression without the disadvantages of nasogastric tubes.20 One 7-year retrospective review, which included 94 patients with ovarian cancer requiring drainage gastrostomy tube placement due to malignant bowel obstruction, demonstrated that gastrostomy drainage tubes, as compared to nasogastric tube drainage, allowed the majority of patients to receive end-of-life care either at home or in an inpatient hospice setting.19

Since the early 1970s, studies have supported the use of PN in gynecologic oncology patients during aggressive treatment of gastrointestinal obstruction due to the morbidities and mortalities associated with preoperative and postoperative malnutrition and overall quality of life.21 Nutrition support is used in the inpatient or home setting, often in conjunction with gastrostomy drainage tubes. However, research has yielded conflicting data on the use of PN in patients with nonoperative bowel obstruction. In the seven-year retrospective review mentioned previously, no survival benefit was found with the use of PN.19 Another study by Abu-Rustum and associates17 demonstrated a median survival of 84 days for all patients post-gastrostomy drainage tube placement. The median survival for patients with obstructive ovarian cancer who received salvage chemotherapy and PN was 89 days, compared to median survival of 71 days for patients who received salvage chemotherapy alone. The researchers concluded chemotherapy alone is ineffective in restoring bowel function in heavily pretreated patients with recurrent disease.17 A recent study by Brard and colleagues15 concluded that terminally ill ovarian cancer patients with intestinal obstruction receiving PN have a median survival benefit of 4 weeks. This survival benefit decreased when patients were treated with concurrent chemotherapy. The researchers concluded, contrary to previous research that terminally ill ovarian cancer patients should not receive PN, a subgroup of patients benefited from PN and found it life-sustaining.15

Issues of cost, quality of life, and human values need to be investigated to assess the full impact of PN in this patient population, especially given the variable outcomes described in the literature.15 The value of PN in patients with advanced- or end-stage ovarian cancer remains debatable.15, 17 Conversely, PN may be justified for selected patients9 and should be carefully considered by the medical team and the patient.

One study, which was conducted prior to the establishment of palliative care programs, suggested that care given to ovarian cancer patients at the end of life might be inadequate.22 In more recent times, the combination of gastrostomy drainage tubes, PN use, and palliative care programs has enabled many patients to meet their end-of-life wishes. In particular, home PN and gastrostomy drainage tubes often give patients freedom from the hospital setting. A study of home PN in patients with malignant bowel obstruction demonstrated a low complication rate and found PN was usually perceived by patients and care providers as beneficial. In this study, home PN was found to have palliative benefits and to facilitate compassionate home care for carefully selected patients with malignant bowel obstruction.23 Nutrition intervention and care of patients with reproductive cancers must include an individualized approach, taking into account patient and family end-of-life wishes.

SUMMARY Limited data are available to guide nutrition management during the treatment of reproductive cancers. Research suggests that most of these patients are in a hypermetabolic state and, therefore, are at risk for becoming malnourished. Assessment and intervention tools, including aggressive initiation of oral diet postoperatively, monitoring of prealbumin levels, use of high-protein oral supplements, employing gastrostomy drainage tubes, and initiation of nutrition support as needed should be implemented to prevent and treat nutritional issues. The use of PN in the palliative care process is controversial, and the patient’s end-of-life goals must be considered when deciding whether to pursue this option.

REFERENCES

1. American Cancer Society. http://www.cancer.org.

2. Kushi LH, Byers T, Doyle C, et al; The American Cancer Society 2006 Nutrition and Physical Activity Guidelines Advisory Committee, American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2006;56(5):254-281.

3. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR; 2007.

4. Bandera EV. Nutritional factors in ovarian cancer prevention: What have we learned in the past 5 years? Nutr Cancer. 2007;59(2):142-151.

5. Schulz M, Nothlings U, Allen N, et al. No association of consumption of animal foods with risk of ovarian cancer. Cancer Epidemiol Biomarkers Prev. 2007;16(7): 1527.

6. Penn State Milton S. Hershey Medical Center College of Medicine. Health and disease information: Reproductive cancers. www.hmc.psu.edu/healthinfo/r/reprocancers .htm. Accessed October 31, 2006.

7. Keely DG, Stanhope CR. Postoperative enteral feeding: Myth or fact? Gynecol Oncol. 1997;67:233-234.

8. Schilder JM, Hurteau JA, Look KY, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol. 1197;67(3):235-240.

9. Geisler JP, Linnemeier GC, Thomas AJ, Manahan KJ. Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer. Gynecol Oncol. 2007;106 (1):128-131.

10. Laky B, Janda M, Baur J, et al. Malnutrition among gynaecological cancer patients. Eur J Clin Nutr. 2007;61(5):642-646.

11. Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56:779-785.

12. Gadducci A, Cosio S, Fanucchi A, Genazzani AR. Malnutrition and cachexia in ovarian cancer patients: Pathophysiology and management. Anticancer Res. 2001; 21(4B):2941-2947.

13. Dillon EL, Volpi E, Wolfe RR, et al. Amino acids metabolism and inflammatory burden in ovarian cancer patients undergoing intense oncological therapy. Clin Nutr. 2007;26(6):736-743.

14. Dickerson RN, White KG, Curcillo PG, et al. Resting energy expenditure of patients with gynecologic malignancies. J Am Coll Nutr. 1995;14(5):448-454.

15. Brard L, Weitzen S, Strubel-Lagan SL, et al. The effect of total parenteral nutrition on the survival of terminally ill ovarian cancer patients. Gynecol Oncol. 2006; 103:176-180.

16. Ripamonti C, Bruera E. Palliative management of malignant bowel obstruction. Intl J Gynecol Cancer. 2002;12:135-143.

17. Abu-Rustum NR, Barakat RR, Venkatraman E, Spriggs D. Chemotherapy and total parenteral nutrition for advanced ovarian cancer with bowel obstruction. Gynecol Oncol. 1197;64:493-495.

18. Pothuri B, Meyer L, Gerardi M, Barakat RR, Chi DS. Reoperation for palliation of recurrent malignant bowel obstruction in ovarian carcinoma. Gynecol Oncol. 2004; 95:193-195.

19. Pothuri B, Montenarano M, Gerardi M, et al. Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma. Gynecol Oncol. 2005;96(2):330-334.

20. Tsahalina E, Woolas RP, Carter PG, et al. Gastrostomy tubes in patients with recurrent gynaecological cancer and intestinal obstruction. BJOG: Intl J Obstetr Gynaecol. 1999;106(9):964-968.

21. Ford JH Jr, Dudan RC, Bennett JS, Averette HE. Parenteral hyperalimentation in gynecologic oncology patients. Gynecol Oncol. 1972;1:70-75.

22. Herrinton LJ, Neslund-Dudas C, Rolnick SJ, et al. Complications at the end of life in ovarian cancer. J Pain Symp Manage. 2007;34(3):237-243.

23. August DA, Thorn D, Fisher RL, Welcheck CM. Home parenteral nutrition for patients with inoperable malignant bowel obstruction. J Parenteral Enteral Nutr. 1991;15(3):323-327.

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