Peritoneal Cancer Diet Recommendations: A Comprehensive Guide

Peritoneal cancer, also known as peritoneal carcinoma, is a rare malignancy that develops in the peritoneum, the epithelial cell-lined tissue that lines the abdominal wall. While less common than other cancers, understanding its characteristics and treatment is crucial for effective management. This article provides a comprehensive overview of peritoneal cancer, its treatment, and specific dietary recommendations to support patients throughout their journey.

Understanding Peritoneal Cancer

The peritoneum is a delicate membrane that supports abdominal organs and produces a watery fluid. Peritoneal cancer can be primary, originating in the peritoneum itself, or secondary, resulting from the spread (metastasis) of cancer cells from other sites, such as the ovaries, fallopian tubes, colon, rectum, stomach, or bladder.

Symptoms and Diagnosis

In its early stages, peritoneal cancer often presents with nonspecific symptoms, making early diagnosis challenging. As the disease progresses, symptoms may include:

• A palpable abdominal mass
• Fluid accumulation in the abdomen (ascites)
• Bleeding abnormalities
• Difficulty swallowing
• Shortness of breath

Due to these nonspecific symptoms, peritoneal cancer is often diagnosed at an advanced stage. Diagnosis typically involves a thorough medical history review, physical examination, lab work, and imaging tests like CT scans. In some cases, a laparoscopy is performed to obtain tissue samples for biopsy. Genetic testing is also recommended to identify potential genetic mutations that may increase the risk of developing the disease and to determine the best maintenance strategy.

Treatment Approaches

Peritoneal cancer treatment mirrors that of ovarian and fallopian tube cancers, typically involving a combination of surgery and chemotherapy.

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• Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): CRS involves the maximum removal of visible tumor implants within the abdomen, often including resection of involved organs. The peritoneal cancer index (PCI) score is used to assess the extent of the disease throughout the peritoneal cavity. Completeness of cytoreduction (CC) score is a reliable prognosticator. HIPEC involves delivering heated chemotherapy directly into the abdominal cavity after CRS. This approach targets both visible masses and microscopic residual disease. The heated chemotherapy solution, typically at 41-43 degrees Celsius, achieves a higher concentration and more uniform drug distribution. Hyperthermia enhances chemotherapy's effects, increasing intracellular drug accumulation, reducing DNA repair, decreasing drug detoxification, reducing cell proliferation, enhancing apoptosis, and improving tissue penetration.
• Chemotherapy: Chemotherapy drugs, such as carboplatin (a platinum-based agent), are commonly used as a first-line treatment. If the cancer returns within six months of platinum-based chemotherapy, it is considered platinum-resistant; if it returns after six months, it is considered platinum-sensitive.
• Early Postoperative Intraperitoneal Chemotherapy (EPIC): EPIC involves delivering chemotherapy via an intraperitoneal catheter for several days post-surgery before adhesions develop. However, it is associated with increased morbidity, and its benefits depend on the tumor origin and specific pharmaceutical agent used.
• Maintenance Therapy: Maintenance therapy is an option for some patients to lower the chances of recurrence. Genetic testing can identify biomarkers to guide the selection of the best maintenance strategy.

The Critical Role of Nutrition in Peritoneal Cancer Care

Cancer patients are at high risk for malnutrition due to the disease itself and its treatment. Malnutrition can lead to a range of adverse health outcomes, including increased treatment toxicities, diminished quality of life, and increased mortality. Therefore, proactive nutritional interventions are crucial to prevent or attenuate malnutrition risk.

Nutritional Status and Outcomes

Studies have demonstrated a strong link between nutritional status and clinical outcomes in patients undergoing CRS with HIPEC:

• Length of Stay (LOS): Malnourished patients have significantly longer hospital stays compared to well-nourished patients.
• Survival: Well-nourished patients have significantly longer survival rates compared to malnourished patients.
• Postoperative Infections: Malnourished patients are more likely to experience postoperative infections.

Nutrition Screening and Assessment

It is essential to assess baseline nutrition status and be aware of potential implications of various therapies. Patients receiving aggressive cancer therapies typically require aggressive nutrition management.

Key components of nutrition assessment include:

• Subjective Global Assessment (SGA): A tool used to evaluate nutritional status based on patient history, physical examination, and subjective assessments.
• Body Mass Index (BMI): While BMI alone is not a sufficient marker, it can be a helpful indicator when combined with other assessments.
• Skeletal Muscle Mass: Depletion of skeletal muscle mass (sarcopenia) is associated with increased risk of severe postoperative complications.
• Weight Loss Evaluation: Significant weight loss over time is a critical indicator of malnutrition.

Nutritional Needs Calculation

Calculating nutritional needs can be challenging in cancer patients due to changes in resting energy expenditure, body composition, systemic inflammation, tumor calorie demand, and brown adipose tissue activation. General recommendations include:

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• Calories: 25-30 kcal/kg/day, but this may underestimate needs after CRS with HIPEC.
• Protein: At least 1.2-2.0 g protein/kg/day. Monitoring urinary urea nitrogen can help estimate protein needs.

Nutrition Support Strategies

Nutrition support is frequently required for patients after CRS and HIPEC due to prolonged ileus (intestinal obstruction) and other gastrointestinal complications.

• Enteral Nutrition (EN): Early EN has been associated with reduced postoperative ileus and decreased LOS for malnourished patients with gastrointestinal cancer. Studies suggest that EN may be superior to parenteral nutrition (PN) in terms of hospital LOS, complication rates, and nutritional status parameters.
• Parenteral Nutrition (PN): PN may be necessary when EN is not feasible or sufficient to meet nutritional needs.
• Combination of EN and PN: A combination of EN and PN may be used to meet nutritional needs, particularly in patients undergoing total or subtotal gastrectomy and CRS with HIPEC.
• Oral Nutritional Supplements: Oral nutritional supplements are recommended for all patients, especially those identified as malnourished.

Peritoneal Cancer Diet Recommendations

While research on specific dietary recommendations for peritoneal cancer is limited, a nutritious diet can significantly impact a person's overall health.

Dietary Guidelines: General Principles

A diet high in fruits, vegetables, and whole grains and low in saturated fat, sodium, and added sugar may be beneficial. The Dietary Guidelines for Americans 2020-2025 provides general information about maintaining a nutritious diet.

Key Food Groups

• Whole Grains: Consuming whole grains may help reduce cancer mortality risk. Examples include:
  • Certain types of bread
  • Oats
  • Millet
  • Quinoa
  • Barley
  • Brown rice
• Protein: Adequate protein intake is crucial for maintaining immune function, repairing tissues, and supporting recovery. Sources include:
  • Dairy products (fat-free or low-fat milk, yogurt, cheese)
  • Lean meat and poultry
  • Eggs
  • Seafood (fish)
  • Beans
  • Peas
  • Lentils
  • Nuts
  • Certain seeds (pumpkin seeds, sunflower seeds, chia seeds)
  • Soy products (fortified soy beverages)

Foods to Limit

• Added sugar
• Saturated fat
• Sodium

Additional Dietary Considerations

• Low-Fiber Diet: A low-fiber diet may be recommended to reduce the amount of undigested food passing through the body, especially if cancer treatments irritate the digestive tract or make it difficult to pass stool. Limit fiber intake to 12 grams per day and avoid foods with more than 2 grams of fiber per serving.
• Managing Treatment Side Effects:
  • Nausea: Liquid or soft foods, toast, oatmeal, and broth may be helpful.
  • Mouth Sores: Liquid or soft foods can reduce chewing.
  • Taste Changes: Chemotherapy can alter how food tastes.
  • Constipation: Increase dietary fiber and water intake.
  • Diarrhea: Limit fats and oils and consider lactose-free dairy products.
• Food Safety: Due to weakened immune systems during treatment, food safety is critical. Avoid raw or undercooked meat, poultry, seafood, and eggs. Wash fruits and vegetables thoroughly.

Specific Diets and Their Potential Role

• Ketogenic Diet: A ketogenic diet, characterized by high fat, moderate protein, and low carbohydrate content, has shown promise in some studies. It restricts glucose and generates ketone bodies as an energy source. In a mouse model of peritoneal dissemination, a ketogenic diet prolonged survival time, reduced ascites retention, and improved health status. However, it is essential to consult a healthcare professional before starting a ketogenic diet, as it may not be appropriate for all individuals.

The Importance of Meal Planning and Preparation

• Small, Frequent Meals: Eating smaller portions throughout the day can help ensure adequate nutrient intake without feeling overwhelmed.
• Snacking: Snack whenever you're hungry, even if it's not mealtime.
• Advance Meal Preparation: Preparing meals in advance and freezing them into meal-sized portions can make it easier to maintain adequate nutrition.

Addressing Specific Nutritional Challenges

• Weight Loss: Focus on nutrient-dense foods that are easy to eat. Add avocado to sandwiches and salads.
• Maintaining Muscle Mass: Consume adequate protein from sources like tofu, tempeh, spinach, beans, nuts, Greek yogurt, cheese, eggs, fish, poultry, and lean red meat.
• Altered Eating Habits:
  • Drink liquids after meals or as snacks, not before or during mealtime.
  • Eat your favorite foods any time of day.
  • Create a joyful or relaxing setting while eating.

Additional Risk Factors and Prevention

While the exact causes of peritoneal cancer are not fully understood, certain factors may influence the risk of developing the disease.

Risk Factors

• Age: Females around the ages of 56-62 may have a higher risk.
• Genetic Mutations: Mutations in genes like BRCA may increase the risk.
• Hormone Replacement Therapy: Receiving hormone replacement therapy after menopause may increase the risk of ovarian cancer, which shares similarities with peritoneal cancer.
• Other Factors: Alcohol, talc, infertility treatment, and the use of nonsteroidal anti-inflammatory drugs and aspirin have been suggested to increase the risk.

Protective Factors

• Giving Birth:
• Breastfeeding:
• Taking Oral Contraceptives:

The Role of a Registered Dietitian

A registered dietitian can assess your nutritional needs and help you develop a personalized mesothelioma nutrition plan. They’ll base a program on your needs, preferences and health status. Yes, some foods may interact with chemo drugs, which can impact their effectiveness or cause side effects. Supplements may also interfere with cancer treatments. A registered dietitian can guide you on potential interactions.

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