A Plea to Let Patients With Cancer “Just Eat”

Stephanie Jackson, DNP, MSN, RN, AOCNS, BMTCN

A 23-year-old woman with Hodgkin lymphoma is admitted to the inpatient oncology unit for her first cycle of adriamycin, bleomycin, vinblastine, dacarbazine (ABVD). After the nurse discusses the chemotherapy and its possible adverse events, the patient asks for a menu to order dinner. She tells the nurse that she would like to eat to avoid getting sick from the chemotherapy. The nurse brings a menu and the patient recognizes it immediately. It is the neutropenic diet.

Restricted Diets

For many years, high-dose chemotherapy has been known to eradicate cancer and improve survival rates among patients.¹ However, high-dose chemotherapy can often cause prolonged pancytopenia, which increases the patient’s risk of an opportunistic infection. Chemotherapy can also cause mucositis, which can significantly increase the risk for translocation of bacteria from the gut to the bloodstream.

One strategy that hematologists and oncologists surmised would reduce the risk of infections is to restrict the introduction of bacteria through food.¹ The low bacteria diet is nationally known and a standard practice at many comprehensive cancer centers.¹ It prohibits the intake of fresh fruits, vegetables, dairy products, and raw or undercooked meats because these foods consistently carry microorganisms such as Enterobacter, Klebsiella, and Pseudomonas on their surface, even after being washed. However, it is important to note that the neutropenic diet has never been proven effective in reducing the risk for gastrointestinal infections.

In 2017, a study was conducted to evaluate the impact of a low bacteria diet among patients with acute leukemia compared with those on a nonneutropenic diet.² The results showed that the infection rate among the patients who consumed a neutropenic diet was 29% and the rate for those who consumed raw foods was 35%. The mortality rate was synonymous between the groups. These findings suggest that restricted diets do not provide better outcomes, although one 2014 study showed that if the gut flora remains in homeostasis, it reduces bacterial infections as well as rejection of the stem cell transplant.³

One study conducted in 2019 evaluated the impact of liberalizing a traditional neutropenic diet and infection rates in the first 3 months posttransplant. A sample population of 102 pediatric and young adult patients were surveyed for more than a year. At the completion of the study, there was no statistical difference in outcomes between the 2 groups.⁴

Not only had the neutropenic diet been found ineffective at significantly reducing infection rates, it also put patients undergoing stem cell transplantation at great risk for malnutrition. The prevalence of malnutrition in these patients ranges from 20% to 80% and has a significant impact on their survival as well as their quality of life.⁵ Prevention is therefore key to assisting them with overall well-being and optimal health.

Nutritional deficiencies are an important aspect of care to consider when managing oncology patients. Pediatric patients can develop vitamin deficiencies, including of vitamin C, when their fruit and vegetable intake is restricted. It can also have a deleterious impact on their intake of fiber.⁶ As clinicians, it is important that we focus less on restricting foods and more on evaluating the impact of food consumption on the pharmacological management of patients with cancer.

In 2020, the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation assisted with the development of food safety guidelines for stem cell transplant recipients.⁷ Under these guidelines, which recommend that patients consume a diet low in microbes, patients are able to eat fresh fruits and vegetables. Fruits that have a rough surface and raw vegetable sprouts were not recommended.⁷ Items for which cooking was recommended included nuts, tofu, grains, and yeast.

Conclusion

Although dietary restrictions may continue to vary across settings, nurses must familiarize themselves with the evidence regarding adequate nutrition in this patient population. These practices continue owing to longstanding habits among clinicians and a lack of randomized trials in the stem cell transplant population.

It is important to note that the FDA does support safe handling practices that reduce contamination of the gastrointestinal tract in both the inpatient and outpatient setting. Fruits and vegetables should be adequately washed before being consumed. Raw meats should be separated from other foods, and food should be appropriately refrigerated.¹ The lids of canned foods should be washed before opening.¹

Patients undergoing stem cell transplantation should be taught about the importance of adequate nutrition before, during, and after treatment. Health care providers can make use of expert dieticians and of the FDA guidelines to educate patients.⁵ Finally, oncology centers should provide consistent resources for the health care team to increase the likelihood of compliance.

References

1. Wolfe H, Sadeghi N, Agrawal D, Johnson D, Gupta A. Things we do for no reason: neutropenic diet. J Hosp Med. 2018;13(8):573-576. doi: 10.12788/jhm.2985
2. Moody KM, Baker RA, Santizo RO, et al. A randomized trial of the effectiveness of the neutropenic diet vs food safety guidelines on infection rate in pediatric oncology patients. Pediatr Blood Cancer. 2018;65(1):10.1002/pbc.26711. doi:10.1002/pbc.26711
3. Foster, M. Reevaluating the neutropenic diet: time to change. Clin J Oncol Nurs. 2014:18(2):239-241. doi:10.1188/14.CJON.239-241
4. Taggart C, Neumann N, Alonso PB, et al. Comparing a neutropenic diet to food safety-based diet in pediatric patients undergoing hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2019;25(7):1382-1386. doi: 10.1016/j.bbmt.2019.03.017
5. Lassiter M, Schneider SM. A pilot study comparing the neutropenic diet to a non-neutropenic diet in the allogeneic hematopoietic stem cell transplantation population. Clin J Oncol Nurs. 2015:19(3):273-278. doi:10.1188/15.CJON.19-03AP
6. Maia JE, da Cruz LB, Gregianin LJ. Microbiological profile and nutritional quality of a regular diet compared to a neutropenic diet in a pediatric oncology unit. Pediatr Blood Cancer. 2018;65(3):10.1002/pbc.26828. doi:10.1002/pbc.26828
7. Moody, K. Neutropenic dietary restrictions for hematopoietic stem cell patients: time for a change. Biol Blood Marrow Transplant. 2019;25(7):e223-e225. doi10.1016/j.bbmt.2019.05.011