Nutritional care of surgical oncology patients

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S e m i n a r s in Oncology Nursing, Vol 16, No 2 (May), 2000: pp 128-134

OBJECTIVES: To review nutritio~ml management of surgical oncology patients, particularly patients with head and neck cancer and gastrointestinal malignancies.

DATA SOURCES: Professional journal articles, published research findings, and book chapters related to the nutri= tional management of surgical oncology patients.

CONCLUSIONS: Meeting the nutritional needs of oncology patients is chaUenging. A multidiseiplinary approach to the nutritional management of the surgical oncology patient is essential to ensure comprehensive care and assistance in the recovery process.

IMPLICATIONS FOR NURSING PRACTICE: Nurses need to have an understanding of the impact of both the disease process and surgical intervention on the nutritional needs of oncology patients to improve the quality of care and quality of life for these special populations.

From The Cancer Institute of New Jersey, New Brunswick. NJ. Marlene McGuire, RN, MA,C8, ANP:The Cancer Institute of New Jersey, New Brunswick, NJ. Address reprint requests to Marlene M¢'Guire, RN, MA, CS, ANP, The Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ 08901.

NUTRITIONAL CARE OF SURGICAL ONCOLOGY PATIENTS MARLENEMcGUIRE

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ENERALIZED symptoms of anorexia, fatigue, malaise, and weight loss may be present for months before a diagnosis of cancer. The severity and type of symptoms vary, depending on tumor location, stage of disease, and the patient's previous physical health status. Thus, patients are often malnourished at the time of diagnosis and malnutrition can cause adverse effects leading to metabolic and physiologic changes in individuals. Treatment modalities such as surgery, radiation, and chemotherapy can add further insult to the patient's already compromised nutritional state. Surgery, the primary treatment for many types of cancers, can be quite extensive, removing portions of the alimentary tract, soft tissue, muscle, or bone and resulting in substantial anatomic and physiologic changes. Nurses must be knowledgeable of these anatomic changes and understand their impact on physiologic function in order to implement effective nursing interventions and patient and family education. This article reviews nutritional issues within the context of the surgical oncology population with special emphasis on patients with head and neck cancer and gastrointestinal malignancies. BACKGROUND

Cop)right ©2000 by W.B. Samplers Company 0749-2081/00/1602.0003510.00/0 doi :l O.1053/on.2000.5551

alnutrition in cancer patients is common, with reports of

clinically detectable malnutrition ranging from 40% to 80%.1,2 M Cancer caehexia is most often associated with cancers of the stomach, colon, lung, prostate, and pancreas, with the highest

NUTRITIONAL MANAGEMENT IN SURGICAL ONCOLOGY

incidence of cachexia in patients with cancers of the pancreas and stomach. Cancers of nonviseeral organs, such as sarcomas and breast cancer, have the lowest incidence. 2 Furthermore, the degree of malnutrition has been inversely correlated with duration of survival and response to t r e a t m e n t ) Malnourished surgical patients are at increased risk for postoperative morbidity and mortality compared with well-nourished patients undergoing similar surgeries) Several methods exist to assist in proaetively combating malnutrition in the surgical population. Patients can be given oral nutritional supplementation, enteral feedings, total parenteral nutrition, and pharmacologic compounds to improve their nutritional intake. The m e t h o d of nutritional support required is dependent on patient factors, disease state, cost, and applicable clinical practice guidelines. Parenteral nutrition is the most efficacious means of nutritional support when an individual is unable to eat, digest, or absorb nutrients to prevent simple starvation. The use of parenteral nutrition in the surgical population has been studied in a variety of settings. Muller et al 5 provided evidence of the beneficial effects of parenteral nutrition on morbidity and survival when used during the preoperative and postoperative periods. Brennan ~' reviewed the literature on nutrition support in cancer and found that there was no benefit in terms of decreased complications or i m p r o v e m e n t in survival in patients receiving parenteral nutrition who were undergoing treatment for cancer. Sako et al 7 studied preoperative total parenteral nutrition versus enteral tube feedings in surgical head and neck cancer patients. In this series, investigators were unable to demonstrate any advantage of total parenteral nutrition (TPN) compared with enteral feedings in terms of i m m u n e parameters, wound healing, complications, or survival. Similarly, a randomized trial of TPN versus enteral nutrition in patients who had major pancreatic surgery failed to demonstrate any measurable benefit. Moreover, a higher complication rate was d o c u m e n t e d in the group who received TPN. s These investigators suggested that the lack of enteral feedings might predispose patients to bacterial transloeation and promote the contamination and infection of fluid collections after surgery, s While nutrition support has been greatly e n h a n c e d by the advent of parenteral nutrition in some populations, complications are associated with the use of this

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modality. Patient selection for this approach should be made only after careful consideration. PERIOPERATIVE NUTRITIONAL ASSESSMENT omprehensive nutritional planning for the surgical ontology patient begins with a careful assessment during the preoperative phase. For most surgical ontology patients, consultation with a dietician is essential. Comprehensive assessm e n t of surgical patients' nutritional status comprises several key components. A thorough health history and physical examination focuses on weight changes, dietary patterns, and assessment of associated symptomatology. Anthropometric measurements are assessed, including body weight, height, skinfold measurements, and circumference. 9 Normal parameters for age are taken into consideration when calculating a n t h r o p o m e t r i c indices. 1° A serum biochemical profile should be completed, including serum albumin level. Each of these parameters is then reviewed to create an overall analysis of the patient's nutritional status. Appropriate interventions are initiated during the preoperative phase and continued into the postoperative period.

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SPECIAl, NUTRITIONAL ISSUES IN THE TREATMENT OF HEAD AND NECK CANCERS 'ead and neck cancers are associated with .lifestyle issues, with tobacco being the prime risk factor. Although head and neck cancers account for a small percentage of all diagnosed cancers (5%), they are often most devastating due to their location and impact on functional status.11,12 The head and neck area is complex and is responsible for speech, mastication, deglutition, and respiration. Some of the more severe cases of malnutrition in cancer patients are seen in this population, particularly those with large intraoral, oropharyngeal, and hypopharyngeal tumors. Tumor location can effect physiologic function, causing signs and symptoms such as difficulty in swallowing or dysphagia, painful swallowing (odynophagia), ulcerative lesions in the oral cavity, trismus (inability to open the jaw), and possible aspiration. T r e a t m e n t modalities for head and neck cancers include surgery, radiation, c h e m o t h e r a p y , and combined multimodality approaches that can further h a m p e r a patient's

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MARLENE McGUIRE

nutritional status. Furthermore, many of these patients have histories of both tobacco and alcohol abuse, with poor dietary habits. Surgical resections for head and neck cancers can be extensive, removing large portions of soft tissue and or bone, which alter both appearance and ability to eat. The impact of surgery on the ability to swallow and chew will depend on tumor location, extent of resection, and need for reconstruction. Nutritional intervention may need to be performed before surgery in patients in whom significant weight loss has occurred. A nasogastric feeding can be placed under endoscopic guidance to start patients on enteral tube feedings. After surgery, most complex resections require the patient to have nothing by mouth (NPO) for several days, usually requiring a nasogastric tube to be placed during the surgery to provide nutritional support. Enteral feedings are then given either by gravity or by pump. If long-term dysphagia from either the surgical resection or the effects of postoperative radiation are anticipated, a percutaneous gastrectomy tube is placed_ Ensuring that the appropriate food consistencies and referrals to the rehabilitation team are made is essential to improving the quality of life of these patients. Table 1 provides additional information on food consistency that can be helpful for patients experiencing difficulty with swallowing. 13

s, !iow ng :DiSOrder

.......

:

Chin u p : : : : Chin: down : goal:swallow : ::i: : :: ...... Reduced poste-;: Chin :down r~or n'~ot~onof :

:;: ....

Tongue dysfur~ation ::: Delayed phanjn,

ryngea! toares,s Unilateral

tongue and phar/ngeal weakness, same side

The structures of the oral cavity include the lips, buccal mucosa, oral tongue, floor of the mouth, upper and lower alveolar ridge, hard palate, and retromolar trigone. 11,14 The oral cavity maintains oral competence and plays an important role in the process of eating. The salivary glands secrete saliva that assists the tongue and jaw in mixing and breaking up the food bolus_ The tongue then propels the bolus into the oropharynx to begin the swallow. During this process the palate and uvula elevate to prevent food from entering the nasal cavity. Thus, surgery in this area can result in swallowing problems, particularly resections that inhibit tongue movement and reduce the ability to chew and control food. Nutrition can be impaired if resection of the retromolar trigone region is performed, since this is the area where the swallowing reflex is located. Many patients with tumors in this area require swallowing rehabilitation after surgery. Resection of the palate can also impede the swallowing process. Reconstruction of the palate generally is

::Consistency

Thickenedli ~ ~ids : Thickened:liq~ uidsl pureesl : :: : Liquids and

:i:

damaged side::: L e a n toward : ......stronger, unaf:

foods

:

Liquids and thickened liq-

fected side

uids

Bilateral p h a r y n - Ue on side or geal weak. .... back

LiqUids, thinner foods

ness Reduced larym

geaiclosure : Reduced laryn.

geal elevation

i :Chin down, head

Purees

rotated to damaged side

.... Purees

Chin down, lie

on side or ..... back

Cricopharyngeal

Head rotated to

~uids

:

:dysfunction, : :...... either side

:;: reduced anteriot laryngeal

Cancers of the Oral Cavity

::::: Food::::

::; Posture

i

movement Repnnted with permission,43

performed with the use of maxillary obturators and intraoral skin grafts to line the defect. 14 The obturator serves as a prosthetie device mueh like an extended denture to restore the normal separation of oral and nasal cavities and prevent food from entering the nasal eavity.

Cancers of the Larynx The larynx is divided into three anatomic regions: the glottis, supraglottis, and subglottis. 11,15 The surgical treatment of laryngeal cancer varies depending on tumor location and need to treat cervical lymph nodes. Surgical resection for early glottic cancer involves a partial vertical laryngectomy or hemilaryngectomy. During this procedure half of the larynx is resected, with removal of one true and one false cord and half of the thyroid cartilage. 11 Patients have a hoarse voice after

NUTRITIONAL MANAGEMENT IN SURGICAL ONCOLOGY

surgery and usually do not experience trouble swallowing. However, difficulties with swallowing can occur if the reseetion is extended to the arytenoid. Early supraglottic cancers are treated with a supraglottie laryngeetomy (horizon tal laryngeetomy) or removal of the false vocal eords, epiglottis, and hyoid bone. u Resections for cancers of the supraglottie larynx can cause problems with aspiration due to removal of the epiglottis and result in decreased airway protection, n Patients are taught swallowing techniques such as the "supraglottic swallow," which enhanees airway protection by tightening laryngeal closure and elevating the larynx. Advanced laryngeal cancers are treated with total laryngeetomy or removal of the entire larynx, hyoid bone, true and false cords and two or three tracheal rings. 12 Surgical outcomes include a p e r m a n e n t traeheostoma (through which the patient breathes) and loss of voice or aphonia. Swallowing problems generally do not occur as the trachea and esophagus are no longer eonneeted.

Cancers of the Pharynx The pharynx is divided into the oropharynx, nasopharynx, and hypopharynx. Surgical intervention for pharyngeal cancers depend Oll tumor location, stage of disease, need for reconstruction, and patient status. Resections of advanced base of the tongue tumors may result in aspiration due to decreased airway proteetion. Swallowing techniques are taught to patients to assist in controlling the food bolus and improving laryngeal elevation and closure. Pharyngeal resections can also inhibit the swallowing process by delaying pharyngeal peristalsis. Advanced hypopharyngeal carcinomas that extend below the level of the thoracic outlet are treated with a pharyngolaryngoesophagectomy with gastric pullup. During this procedure the entire pharynx, larynx, and esophagus are removed and the stomach is mobilized and "pulled up" into the chest cavity. These patients have no difficulty in swallowing, but are at risk for postprandial dumping syndrome. Patients should be advised to eat small frequent meals and sit up straight for at least 1 hour following meals to improve digestion and prevent the food from regurgitating due to the lack of lower esophageal sphincter muscle. The complexities of nutritional support in head and neck cancers are unique. A multidiseiplinary approach with involvement of surgeons, nurses,

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speeeh pathologists, dietitians, dental oneologists, and social workers is imperative to m e e t the challenges of caring for these patients. SPECIAL NUTRITIONAL ISSUES IN THE TREATMENT OF GASTROINTESTINAL CANCERS

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atients with gastrointestinal malignancies can have profound weight loss and malnutrition. The discussion of nutritional needs in this population will be addressed by diagnosis.

Gastric Cancer Gastric eancers are associated with a high mortality rate since most patients are diagnosed with advanced disease and adjuvant therapies are not promising. The death rate from gastric c a n c e r has been declining in the United States in the last 50 years; however, the incidence worldwide remains high, with the highest incidence in Japan. Several risk factors are linked to the development of gastric cancer: ingestion of smoked, pickled, and salt-cured foods, consumption of foods high in nitrates, and diets low in vitamins A and C. ll' Patients may present with symptoms of early satiety, weight loss, fatigue, malaise, and anemia. Surgery remains the only curative treatment. Surgical resection involves removal of the entire tumor and regional lymphatics. The type of resection that is performed depends primarily on the tumor location. Surgical procedures include a partial gastreetomy, subtotal gastreetomy, Billroth I or gastroduodenostomy, and a Billroth I1 or gastrojejunostomy. A total gastrectomy is performed if the tumor is extensive or if r e c u r r e n c e has occurred at the reanastamosis site. Nutritional support is fundamental in the eare of these patients. Patients often have significant weight loss at the time of their initial diagnosis due to poor absorption and compression of the stomach creating early satiety. Total parenteral nutrition m a y be initiated before surgery in patients undergoing major resections if they have had a body weight loss of more than 20%. 1 After surgery, patients who have undergone an extensive resection of the stomach are at risk for anemia from iron, folate, and vitamin B12 deficiencies. Vitamin B12 deficiencies occur after a gastreetomy due to the loss of the parietal cells, which secrete intrinsic factor, a product that assists with absorption of vitamin B12. In addition,

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MARLENE McGUIRE

decreased gastric acid production, which is important in breaking down and absorbing iron, leads to problems with iron malabsorption. The incidence of iron deficiency anemia is highest in patients who have undergone a Billroth II procedure (approximately 45%). 17 Folate deficiencies can also develop due to poor intake and decreased absorption. Patients who develop B12 deficiencies will require life-long injections of vitamin B12 on a monthly basis. Folate and iron deficiencies can be treated with oral supplementation. Nearly half of all patients who undergo gastric resection experience postprandial dumping syndrome. Dumping syndrome occurs when there is rapid emptying of hypertonic chyme into the intestines with resultant fluid shifts and intravascular volume depletion, is These rapid fluid shifts cause the release of peptide hormones with vasomotor effects, is Patients may experience flushing, dizziness, abdominal pain and fullness, diarrhea, palpitations, nausea, and vomiting. Special dietary instructions include avoidance of concentrated sugars, a decrease in simple carbohydrate intake, and an increase in protein and complex carbohydrate intake. Patients are instructed to drink fluids between meals rather than with meals to maximize caloric intake and decrease gastric emptying time. Patients also should be instructed to sit up straight for 1 hour following meals to prevent reflux into the esophagus due to the loss of the cardiac sphincter. Octreotide, a long-acting analog of naturally occurring somatostatin, has been studied in the treatment of severe dumping syndrome, ls,19 Resuits indicate that octrcotide is able to reduce the symptoms associated with dumping syndrome. However, patient response to the drug was unfavorable because it required parenteral administration, and caused frequent diarrhea.

Esophageal Cancer Esophageal cancer is associated with lifestyle choices, abuse of tobacco and alcohol, and a diet high in nitrates. Barrett's esophagus is a premalignant condition that is associated with a 50% risk of developing adenocarcinoma of the esophagus. 2° At the time of initial presentation, many patients are severely malnourished due to progressive dysphagia and weight loss, and unfortunately are often found to have advanced disease. Treatment modalities for esophageal cancer include surgery, chemotherapy, radiation, and multimodality therapy. Surgery is often performed if there is no

evidence of distant metastasis or regional lymph node involvement. Tumors located in the esophagus are treated with a transhiatal esophagectomy. Distal esophageal lesions can sometimes be treated with a transabdominal approach. During a transhiatal esophagectomy a vagotomy is performed, the esophagus is removed, and the stomach is mobilized for esophageal replacement. 21 A feeding jejunostomy is placed during surgery and enteral tube feedings are begun after surgery. A cineesophagram study is done before oral intake commences to ensure that there are no anastomotic leaks, strictures, or signs of aspiration. If no problems are detected the patient is started on a liquid diet and gradually advanced to solids by the time of discharge_ Some patients may require continued enteral feedings due to poor nutritional intake_ Postsurgical patients may experience easy regurgitation, early satiety, and rapid emptying of foods with diarrhea and/or steatorrhea. 1 Such patients should be instructed to eat small frequent meals and sit up straight for 1 hour following meals. If diarrhea is severe, antidiarrheal medication is recommended. Steatorrhea can be improved by replacement of long chain fats with medium chain triglycerides.1

Pancreatic Cancer Pancreatic cancer is usually diagnosed in an advanced stage and has a poor prognosis. Although direct correlations have not been demonstrated, factors thought to influence the development of pancreatic cancer include smoking, coffee, alcohol, and a high-fat animal protein diet. 22 Surgery is the patient's only chance at a cure. Unfortunately, only 20% of all patients with pancreatic cancer are surgical candidates. 22Perioperative imaging studies with computed tomography and endoscopic ultrasound are performed to evaluate the extent of disease. Tumor location is the key factor in determining the type of surgery to be performed. Tumors located in the head of the pancreas are resected with a Whipple procedure or a pancreaticoduodenectomy. During the procedure, the head of the pancreas, distal common bile duct, gallbladder, duodenum, and distal stomach are removed. 22 The common bile duct and the remaining pancreas are anastomosed to the jejunum (choledochoj ejunostomy/pancreaticojejunostomy) proximal to where the stomach has been attached (gastrojejunostomy). The gastrojejunostomy is done so that pancreatic secretions and bile can enter the jejunum before gastric juices to

NUTRITIONAL MANAGEMENT IN SURGICAL ONCOLOGY

prevent breakdown and ulceration at the anastotootle site. 22,23 A modification of the Whipple procedure is the pylorus-preserving pancreaticoduodenectomy, which preserves the entire stomach and pylorus. The goal of this surgery is maintenance of a normal gastric reservoir and improved digestion. Tumors of the body and tail of the pancreas are rarely resectable. However, if the t u m o r is diagnosed early and is amenable to resection, a distal pancreatectomy and splenectomy can be pertbrmed. Total pancreatectomy removes the entire pancreas, requiring the patient to receive lifetime insulin. Enteral feedings via a j e j u n o s t o m y tube are given following a Whipple procedure to sustain the patient until oral intake can be tolerated. In eases of severe weight loss, or if delayed gastric emptying occurs, patients may be discharged home on enteral feedings. Following the Whipple procedure, patients may experience dumping syndrome. Fat malabsorption and deficiency of exocrine secretions of the pancreas have been reported to be as high as 27% to 50% in patients who have undergone the Whipple procedure. 1 Pancreatic enzymes are ordered before meals and at bedtime to enhance fat absorption and decrease steatorrhea. Endocrine function following pancreatic surgery needs to be earefully evaluated to monitor glucose levels and assess the need for insulin. Coloreetal Cancers Risks factors for colorectal cancers include environmental factors, genetic predisposition, and diet. Diets, especially those rich in saturated fat, have been linked to eolorectal cancer. 24,es Colon cancers include tumors arising in the large bowel, with 70% occurring on the right side. Cancers of the r e c t u m are tumors lying below the peritoneal reflection, or less than 12 cm from the anal verge. 24 T r e a t m e n t options for colon cancer include surgery, radiation, and c h e m o t h e r a p y or combined modality approaches. Surgery, however, is the mainstay of t r e a t m e n t for colon cancers. Surgery can be performed with the intent of eradicating the primary tumor and assessing nodal status, or in the setting of widely metastatic disease, as a palliative procedure to prevent ensuing obstruction. T u m o r location and extent of disease will dictate the type of procedure to be done. A right h e m i e o l e c t o m y is usually done for lesions in the ascending colon, cecal, and hepatic flexure. This procedure involves removal of the distal ileum (15 to 8 era), right colon, hepatic flexure, and transverse colon just proximal to the

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middle colic artery. 24 A transverse colectomy removes the transverse colon for t r e a t m e n t of midtransverse lesions and a left h e m i c o l e c t o m y is done for left colon cancers. During a low anterior resection, the descending colon distal to the splenic flexure, the sigmoid colon, and the upper two thirds of the r e c t u m are removed. 2s This is generally done for t r e a t m e n t of sigmoid lesions or proximal rectal lesions. Subtotal colectomy is usually performed when there are multiple lesions in the colon. During this surgery, the right, transverse, descending, and sigmoid colon are removed with an ileorectal anastomosis_ An abdominoperineal resection is done for low-lying rectal tumors, within 3 cm of the anal verge, or tumors involving the sphincter_ This involves an abdominal approach to remove the r e c t u m and m e s o r e c t u m from the level of the inferior mesenterie vessels to the levator muscles, in combination with a transperineal resection of the anus and distal rectum. 24,2s These patients will have a p e r m a n e n t colostomy post-surgery. Patients who have undergone some type of colon resection m a y experience postoperative diarrhea. This is particularly likely in surgeries involving the right colon with ileoeeeal valve and removal of a porEion of the distal ileum. These patients experience watery diarrhea in large amounts due to increased bile salts in the colon and loss of the valve, 1 affecting the patient's quality of life and nutritional status. Dietary modification with avoidance of spicy foods and eating a more bland diet may assist in controlling the diarrhea. Long-term use of antidiarrheals may be needed to help control diarrhea.

CONCLUSION eeting the nutritional needs of the surgical ontology patient presents m a n y challenges. A multidiseiplinary team approach is crucial in providing patients with c o m p r e h e n s i v e care and the best resources to meet their unique needs, Oneology nurses are an integral part of the health care team and need to have clear understanding of normal anatomy and physiology, the changes that are induced by the variety of surgical techniques available, and the physiologic and psyehosoeial impact that treatments can have on nutritional status. This knowledge is necessary to ensure that patients are properly educated and optimally managed.

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REFERENCES 1. Shils M: Nutrition and diet in eancer management, in Shils M, Olson J, Shike M (eds): Modern Nutrition in Health and Disease (ed 8). Philadelphia, PA, Lea & Febinger, 1994, pp 1317-1348 2. Kern K, Norton J: Cancer cachexia. J Parenter Enteral Nutr 12:286-298, 1988 3. American Society for Parenteral and Enteral Nutrition Board of Directors: Guidelines for use of parenteral and enteral nutrition in adult and pediatric patients: Nutrition support for adults with specific diseases and conditions. JPEN J Parenter Enteral Nutr 17:7a-12a, 1993 (suppl) 4. Veterans Affairs Total Parenteral Nutrition Cooperative Study Group: Perioperative total parenteral nutrition in surgical patients. N Engl J Med 325:525-532, 1991 5. Muller J, Keller H, Brenner U, et al: Indications and effects of preoperative parenteral nutrition. World J Surg 10:53-63, 1986 6. Brennan M: Total parenteral nutrition in the cancer patient. N Engl J Med 305:375-382, 1981 7. Sako K, Lore J, Kaufman S, et al: Parenteral hyperalimentation in surgical patients with head and neck cancer: A randomized study. J Surg Onco116:391-402, 1981 8. Brennan M, Pisters P, Posner P, et al: A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 220:436-444, 1994 9. Jeejeebhoy K: Clinical and functional assessment, in Shils M, Olson J, Shikc M (eds): Modern Nutrition in Health and Disease (ed 8). Philadelphia, PA, Lea & Febinger, 1994, pp 805-811 10. Heymsfield S, Tighe A, Wang Z: Nutritional assessment by anthropometric and biochemical methods, in Shils M, Olson J, Shike M (eds): Modern Nutrition in Health and Disease (ed 8). Philadelphia, PA, Lea & Febinger, 1994, pp 812-840 11. McGuire M: Current trends in management of head and neck cancer. Dev Support Cancer Care 3:30-39, 1999 12. Cyr M, Higgins T, McGuire M: Laryngeal, hypopharyngeal conditions and care, in Harris L, Huntoon M (eds): Core Curriculum for Otorhinolaryngology and Head and Neck Nursing. New Smyrna Beach, FL, Society of Otorhinolaryngology and Head-Neck Nurses Ine, 1998, pp 275-290

13. Logemann JA: Manual for Videofluorographic Study of Swallowing (ed 2). Austin, TX, Pro-Ed, 1993 14. Schantz S, Harrison L, Forastiere A: Tumors of the nasal cavity and paranasal sinuses, nasopharynx, 0ral eavity, and oropharynx, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Ontology (ed 5). Philadelphia, PA, Lippincott-Raven, 1997, pp 741-801 15. Session R, Harrison L, Forastiere A: Tumors of the larynx and hypopharynx, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Ontology (ed 5). Philadelphia, PA, Lippineott-Raven, 1997, pp 802-830 16. O'Connor K: Gastric caneer. Semin Oneol Nurs 15:2635, 1999 17. Fairbanks V: Iron in medicine and nutrition, in Shils M, Olson J, Shike M (eds): Modem Nutrition in Health and Disease (ed 8). Philadelphia, PA, Lea & Febinger, 1994, pp 185-213 18. Gray J, Debas H, Hulvihill S: Control of dumping syndrome by somatostatin analogue in patients after gastric surgery. Arch Surg 126:1231-1235, 1991 19. Geer R, Riehards W, O'Dorision T, et al: Efficacy of octreotide in treatment of severe postgastrectomy dumping syndrome. Ann Surg 212:678-687, 1990 20. Roth J, Putnam J, Rich T, et al: Cancer of the esophagus, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Ontology (ed 5). Philadelphia, PA, Lippincott-Raven, 1997, pp 980-1021 21. Quinn K, Reedy A: Esophageal cancer: Therapeutic approaehes and nursing care. Semin Oncol Nurs 15:17-25, 1999 22. Sauter P, Coleman J: Pancreatic cancer: A continuum of care. Semin Oncol Nurs 15:36-47, 1999 23. Evans D, Abbruzzese J, Rich T: Cancer of the pancreas, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Ontology (ed 5). Philadelphia, PA, Lippincott-Raven, 1997, pp 1054-1087 24. Saddler D, Ellis C: Colorectal cancer. Semin Oneol Nurs 15:58-69, 1999 25. Cohen A, Minsky B, Schilsky R: Cancer of the colon, in DeVita VT, Hellman S, Rosenberg SA (eds): Cancer Principles and Practice of Ontology (ed 5). Philadelphia, PA, LippincottRaven, 1997, pp 1144-1196