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Protein and energy requirements for cancer patients

The optimal amount of protein in people with cancer has not been determined, but recommendations often range between 1.2 to 1.5 grams per kilogram of body weight per day, according to nutrition and cancer guidelines established by The European Society for Parenteral and Enteral Nutrition (ESPEN), published in the February 2017 issue of Clinical Nutrition Guidelines for eating high protein foods during cancer treatment Each individual's calorie and protein requirements will vary. For a rough estimate of calorie needs, plan on consuming 25 to 35 calories for each kilogram of weight (1 kilogram equals 2.2 pounds). The current recommended daily allowance for protein is 45 to 60 grams per day Calorie and protein guidelines during cancer treatment Each individual's calorie and protein needs will vary depending on a number of factors, such as age, gender, body weight, and activity level. The current recommended daily allowance for protein for most adults is 46 to 56 grams per day. People with cancer may need more As a basis for assessing energy metabolism and requirements in cancer patients, selected aspects of whole-body energy metabolism are considered, with particular reference to basal energy metabolism and factors that affect it. The importance of protein metabolism in relation to wholebody energy metabolism is emphasized the majority of cancer patients typically have similar protein and calorie needs as healthy individuals. A. Yes B. No Individuals with Cancer May Need More Healthy individuals Cancer Patients Calories: 25 to 30 kcal/kg 25 to 35 kcal/kg* Protein: 0.8 to 1.0 g/kg 1.5 to 2.5 g/kg *For maintenance; for gain/repletion, up to 40 kcal/kg

Protein Requirements for Cancer Patients on Vimeo

institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients e with the exception of end of life care e energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral. People with cancer often need more protein than usual. After surgery, chemotherapy, or radiation therapy, extra protein is usually needed to heal tissues and help fight infection. Good sources of protein include fish, poultry, lean red meat, eggs, low-fat dairy products, nuts and nut butters, dried beans, peas and lentils, and soy foods

Protein Energy - Protein Energ

  1. get enough protein, it might break down muscle for the fuel it needs. This makes it take longer to recover from illness and can lower resistance to infection. People with cancer often need more protein than usual. After surgery, chemotherapy, or radiation therapy, extra protein is usually needed to heal tissues and help fight infection
  2. Energy and substrate requirements 3) We recommend that the total energy expenditure (TEE) of cancer patients, if not measured individually, be assumed to be similar to healthy subjects and generally ranging between 25 and 30 kcal/kg/day
  3. Estimating energy, protein & fluid requirements . for adult clinical conditions . Wherever possible energy requirements of individuals should be measured , using indirect calorimetry or other objective measures. Where measuring energy expenditure is not possible, prediction equations can be used however, there is a lack of strong and
  4. Generally, your diet provides enough protein; however, while undergoing surgery or treatment for cancer, your protein needs may increase. It is important to be aware of the food sources of protein and to include these foods at every meal and snack
Energy Intake - Weight Loss - Click to Cure Cancer

Patients' recommendations are 1-1.5 g/kg/d. When calculating how much protein you need if you are a patient, substitute 0.8 grams with 1-1.5 grams. In a 200 pound patient, the minimum requirement would then increase to 90 grams of protein per day. I recommend increasing protein intake to meet these requirements on the day of diagnosis Protein requirements are generally 1.5 g/kg.7 Water, in the amount of 30 mL/kg, is sufficient, but more may be needed if patients have diarrhea or chest tube drainage or if they're thirsty. RDs should ensure patients are receiving adequate water intake and the goal amount of EN formula • Eat high energy and high protein foods most of the time. Limit low fat, calorie reduced or diet foods. See page 3 for list of high protein and energy foods. • Drink liquids that give you energy through the day such as milk, smooothies, commercial nutritional supplement drinks or juice. See pages 7-8 for suggestions When you have cancer, your energy (calorie) and protein needs can be higher due to the cancer or cancer treatments. Treatment side effects can reduce your appetite, make you eat less and have direct effects on your muscle. This can result in weight loss and your body may start to break down its own protein supplies for energy

Cancer Diet: Calorie and Protein Requirements for Cancer

Eating the right amount of protein and calories is important for healing, fighting infection, and having enough energy. Anorexia and cachexia are common causes of malnutrition in cancer patients. Anorexia is the loss of appetite or desire to eat. It is a common symptom in patients with cancer The nutrition status of patients with cancer can vary at presentation and through the continuum of cancer care. Many patients experience unintentional weight loss leading to a diagnosis of cancer.[1,2] Studies have reported malnutrition in 30% to 85% of patients with cancer.[3,4] Because there has previously been no universal definition of malnutrition, reports of malnutrition occurrence vary. So someone who weighs 150 lbs should have 54.6 grams of protein each day. Depending on your lifestyle, you may need more protein. Athletes, body builders, pregnant women, cancer patients and those preparing for surgery typically need more. Talk to your health care provider or dietitian about your protein needs • GRVs should not be used as part of the routine care to monitor ICU patients receiving EN (Section D2). PN: - Supplemental PN should be considered after 7-10 days if unable to meet >60% of energy and protein requirements by enteral route alone (Section G3). • Exclusive PN should be withheld over first 7 days following ICU admission

PPT - Medical Nutrition Therapy: Burn Patients PowerPoint

Sometimes cancer or cancer treatment can affect your appetite. Though you might not feel like eating, it's important to do what you can to maintain your calorie, protein and fluid intake during cancer treatment. Use this information to help plan meals and snacks that will be more appealing and provide the nutrition you need to get better The weight and muscle loss may play a significant role in your fatigue and weakness. According to the European Society for Clinical Nutrition and Metabolism clinical guidelines for cancer patients published in the September 2017 issue of Clinical Nutrition, cancer patients require 0.45 grams to 0.68 grams of protein per pound of body weight Foods with More Energy and Better Healing for Cancer Patients work better if you're well-nourished and are getting enough calories and protein, according to the American Cancer Society

Colorectal Cancer Diet & Nutrition. From understanding the benefits of a soft food diet, to establishing regular eating habits, nutrition can play an important part in your journey w hen you are faced with a colorectal cancer diagnosis. Eating a well-balanced diet before, during, and after cancer treatment can help you feel better, maintain your strength, and speed your recovery High-energy (>1.22 kcal/mL) and high-protein (>20% protein-derived energy) ONS allow the optimization of the caloric and protein supplies within a reduced volume, and special formulas could be advantageous in selected patients, such as semi-elemental products in malabsorption conditions

The most recent practice guidelines recommend a protein intake of 1 to 1.5 g/kg per day, but patients may require as much as 2 g/kg per day. 4 Chronically ill older patients have slightly higher needs and those with renal insufficiency have slightly lower ones. 9 Many factors affect patient-specific protein needs, including treatment modalities. Head and neck cancer (HNC) patients often face multiple nutritional challenges before, during, and after treatment due to the close proximity of the cancer to organs that are vital for normal eating function. Common treatment-related side effects, such as dysphagia, odynophagia, dysgeusia, xerostomi

In fact, protein-calorie malnutrition, which is caused by the body's inability to take in sufficient amounts of carbohydrates, proteins and fat, is the most common secondary diagnosis in cancer patients. Malnutrition may be caused by the disease itself, such as when a tumor in the gastrointestinal tract blocks the digestive process, hampering. Protein: 1.2-1.5 g/kg if receiving dialysis; 0.8-1 g/kg if not receiving dialysis. Fluid: urine output + 500 ml, depending on patient condition. Breastfeeding. Calories: First 6 months = EER + 500 - 170 (milk energy output - weight loss) Second 6 months = EER + 400 - 0 (milk energy output - weight loss) Burns. Calories: indirect. The fraction of cancer patients with a high-risk screening result who receive nutritional therapy to improve energy and protein intake should exceed [e.g. 80] %. (5) The fraction of cancer patients receiving nutritional therapy who are being reassessed after an interval of [e.g. 1-4] weeks should exceed [e.g. 80] %

High Protein Foods in Your Cancer Diet Stanford Health Car

The most recent practice guidelines recommend a protein intake of 1 to 1.5 g/kg per day, but patients may require as much as 2 g/kg per day. 4 Chronically ill older patients have slightly higher needs and those with renal insufficiency have slightly lower ones. 9 Many factors affect patient-specific protein needs, including treatment modalities. A significant percentage of patients who received exclusive oral feeding did not cover a minimum acceptable quantity of their protein-energy requirements. Our results point-out that poor food intakes can affect QoL by themselves

Some alterations in protein metabolism for cancer patients could look like increased muscle wasting, increased liver protein synthesis, negative nitrogen balance or other issues. Protein requirements are increased, up to doubling, after a cancer diagnosis and during treatment (protein-energy malnutrition) At least one of the following criteria must be met: • BMI 16.0 -16.9 • Weight loss of 16-25% of UBW within <6 months Mild malnutrition (protein-energy malnutrition) At least one of the following criteria must be met: • BMI 17 -18.4 • Weight loss of 5-15% of UBW within <6 month Other cancers can increase your body's need for energy, weaken your muscles, cause damage to certain organs (such as liver, kidney, heart or lungs) or alter your body's hormones, all of which may contribute to fatigue. Cancer treatment. Chemotherapy, radiation therapy, surgery, bone marrow transplantation and immunotherapy may all cause fatigue Fatigue is a common side effect of chemotherapy. Eggs may fight tiredness due to their generous supply of protein and fats — nearly 6 grams of protein and 4 grams of fat in a single medium-sized.

Utilizing foods from the dairy group is an efficient way to create high protein diets for chemo patients. In addition, meat, nuts, and legumes are sources of high protein that chemo patients might want to consider for their diet enhancement Strict dieting is not recommended during cancer treatment. Losing weight can lower your energy level and decrease your body's ability to fight infection. Eat small, frequent meals throughout the day. Eating frequent small meals will ensure your body is getting enough calories, protein, and nutrients to tolerate treatment PrOTein inTaKe After a patient is working toward improvements in overall caloric intake, then education can shift toward the second priority: protein intake. Ensuring the patient meets protein requirements is essential to conserving lean body mass. Protein requirements are recommended to be 1.0 to 1.5 g/kg dry body weight (Table 1).2,

High-energy protein formulas and liquid supplements are offered to increase energy density in pediatric patients, but with less success and poor tolerance because of taste and smell perception. A balanced diet with sufficient proteins and high energy levels is required to prevent an extreme overload of carbohydrate and fat consumption, as seen. 2.2. Protein Requirements for Elderly Adults. Experts in the field of protein and aging recommend a protein intake between 1.2 and 2.0 g/kg/day or higher for elderly adults [3,8,15].The RDA of 0.8 g/kg/day is well below these recommendations and reflects a value at the lowest end of the AMDR Dietary Protein and Energy Requirements in ESRD Patients Joel D. Kopple, MD c The published reports of dietary protein and energy intake and protein and energy requirements for maintenance hemodialysis (MHD) patients and chronic peritoneal dialysis (CPD) patients are reviewed. Evidence indicates tha Evidence shows that patients with wounds as well as cancer need a higher amount of both calories and protein than individuals not undergoing wound healing and/or is not a cancer patient. Some high calorie and protein formulas include Osmolite 1.5, Jevity 1.5, and TwoCal HN. I chose all three of these formulas because woul Recommendation: Based on expert consensus, we suggest the provision of protein at 1.5-2.0 g/kg/d and energy intake appropriate to the patient's energy requirements based on results of nutrition assessment. More protein may be required (up to 2.5 g/kg/d) in patients with enteroatmospheric fistula and high fistula output

Nutrition and Cancer: High-Protein Foods - Health

Patients who suffer from overnutrition consume excess energy, and patients who suffer from undernutrition consume too few nutrients, including energy and protein 8. The 'body composition' term refers to anthropometric changes in total body and lean mass 1 , whereas 'function', which most commonly refers to physical function, also. nutritional therapy for the hospitalized patient who is unable to eat adequately. • Enteral tube feedings may also be administered at home. • IPAA may increase protein balance in malnourished PD patients who have low protein intakes. • A single 2-L exchange of 1.1% amino acid dialysate for 5-6 hours provides a net uptake of about 17-18. In healthy adults, protein is used to repair tissue, maintain a healthy immune system, and provide energy. Cancer patients often need twice as much protein on a daily basis because of the physical stress that they are under. By this, I do not mean that that a cancer patient needs to eat a 15-ounce steak The exact amount needed differs from patient to patient. We typically recommend .04-.05 ounces of protein per 2.2 pounds of body weight every day for a healthy person who's not very active. The source of protein is just as important as the amount. Avoid red meat and processed meats like hot dogs

Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or ≤ 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day. To capture use of hypocaloric PN dosing. Goal: 90%. Recommendation: Target blood glucose range of 140 - 180 mg\dL for the general ICU population Adult oncology patients should be screened using a malnutrition screening tool validated in the setting (inpatient or ambulatory/outpatient) in which the tool is intended for use. Research indicates that the following tools are valid and reliable for identifying malnutrition risk in oncology patients. The following have been shown to be valid and reliable for identifying malnutrition risk in. Age: Incidence increases with age; 90% of cases occur in patients over age 50.. Race: In the US, Black people have higher rates of colorectal cancer and a 20% higher mortality, compared with white people.. Family history: 25% of patients have a positive family history.There is a several-fold increased risk if one or more first-degree relatives have colon cancer Patient and carer information & resources. Good nutrition is important at all times of your life, but it is especially important in the context of cancer. Following a healthy, well balanced diet as part of a healthy lifestyle can help prevent a cancer diagnosis. If you have a cancer diagnosis, then the nutrition needs of your body are increased. In HIV patients, food parcels with nutritional supplements were sent home, and the conclusion was that the family benefitted from the food parcels, and the supplements were used for the individual patient. Advice on how to enrich food items with protein and energy must be given as well to ensure adequate nutrient intake at home

In discussing that protein-energy malnutrition is highly prevalent among peritoneal dialysis patients, Chung et al noted that although nutritional status assessments had improved over the decade from 1997 to 2007, no definitive single test was available to assess nutritional status. [] Instead, they proposed that several different markers of nutrition must be used to understand nutritional status for energy. Due to the increased stress from COVID-19, you need more calories than your normal diet. • Try to eat 75‒100 grams of protein per day which is 10‒14 ounces of a protein source. Good protein sources are: peanut or nut butters, milk, eggs, yogurt, cheese, meat/fish/poultry, protein shakes Protein requirements in the range of 1.2 to 2.0 g/kg have been recommended for critically ill patients with a body mass index < 30 by the American Society for Enteral and Parenteral Nutrition, and intakes in the range of 1.2 to 1.5 g/kg have been found helpful for promoting the healing of pressure ulcers An additional method for determining energy requirements is a general calculation using body weight. Providing the critically ill patient with 25 to 30 kcal/kg per day has been recommended. 12-14. Patients with ARDS have increased protein requirements because of the rapid protein turnover known to occur in hypermetabolic states ·What are the main objectives in nutrition intervention for cancer patients? The main objectives are to prevent or treat nutrition problems, including preventing bone or muscle loss due to the cancer treatment. Also to keep up the same strength and energy as be-fore the cancer treatment.· What are Mr. Palmer's protein and energy requirements? What are his fluid requirements

Energy Metabolism and Requirements in the Cancer Patient

American Institute for Cancer Research www.aicr.org 800-843-8114 Has information on diet and cancer prevention research and education as well as recipes. Cook For Your Life www.cookforyourlife.org Many recipe ideas for patients with cancer. Recipes can be filtered by diet type or treatment side effect Energy Lipid Protein Amino acids summary In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy.

PPT - Non-Hodgkin’s Lymphoma PowerPoint Presentation - IDFortisip Compact Protein - Nutricia Cancer CareNutrition for the immune compromised patient

• Energy Energy needs of TB patients are increased because of the disease itself. The current recommendations for TB patients are based on the nutrient and energy requirements for hyper catabolic and undernourished patients. (Approximately 35 - 40 kCal per kilogram of ideal body weight) In steady-state conditions, protein oxidation equals protein intake, and under such conditions, exogenous protein serves as an energy supply. However, in Europe, it is generally assumed that in critically ill patients, the structural or biosynthetic function of amino acids outweighs their function as a metabolic fuel Whey protein improves immune function and fights infections. Animals fed whey protein concentrate consistently showed dramatic enhancement of both the humoral and cellular immune response to a variety of immune challenges, such as salmonella, streptococcus pneumonia 9 and extreme cancer-causing chemicals There is no consensus as to the amount of protein necessary following injury; however, studies suggest that protein intakes as high as 1.5 to 3 g protein/kg/day are necessary to prevent muscle loss in periods of negative energy balance. 3 Age of the athlete (older adults may have higher protein requirements due to decreased ability to. In the past it has been suggested (most commonly in the context of parenteral nutrition) that a patient's energy requirements should be provided as 'non-protein calories', in order to spare the protein for healing and anabolism. However, predictive equations estimate the consumption rate of all energy, not just non-protein energy

Benefits of Good Nutrition During Cancer Treatmen

Some patients struggle with certain treatment side effects like nausea and vomiting, poor appetite, and taste changes that can make it difficult to eat a healthy diet. Your doctor and a registered dietitian can work with you to adjust your diet to help you maintain a healthy body weight, manage your side effects and help you feel your best The individualized energy requirements and nutrient proportions for patients without comorbidities, and for patients with comorbidities such as obesity, type 2 diabetes, hypertension and renal dysfunction, will be calculated according to the recommendations derived from the Consensus of Nutrition in patients with cancer treated with chemo. Protein-energy wasting (PEW) in CKD patients receiving hemodialysis (HD) is a well-documented and highly discussed condition. Patients with severe PEW are at greatest risk and are in need of the. The basic energy and protein needs of healthy children are summarized in Table 1 below. Although it would seem logical to measure each patient's energy needs by means of indirect calorimetry and to deliver calories accordingly, this is impractical and of unproven value

Protein Needs During Cancer Treatment OncoLin

The Importance of Protein for Cancer Patients PearlPoint

energy levels, gain or maintain weight, heal, fight or resist infections, and recover more quickly from surgery or illness This booklet gives ideas for high energy, high protein foods Tips to help you eat better • Make every bite count by choosing foods that are high in energy and protein For example Weight gain and maintenance is often a major concern in the treatment of many cancers. Some wonder if weight gainer protein powders could be used to assist cancer patients in their efforts to gain weight. Let's take a look at what goes into a quality weight gainer protein powder to get a better understanding

The NCI recommends eating more protein when undergoing chemotherapy to give you energy and keep your muscles strong when treatment is draining. Opt for lean proteins like eggs, fish, and chicken. Many people with cancer find that red meat takes on an unpleasant metallic taste. Don't miss these other things cancer patients wish you knew The evidence is conflicting, but a recent study found that cancer patients undergoing chemotherapy who consumed a high protein drink with ginger twice a day during treatment reported significantly. Investigators at Colorado State University monitored canine cancer patients, looking at body-weight ratios, percentages of body fat and lean muscle mass, protein contents, the benefits of fatty acids and fiber, patterns in metabolic rates, eating habits, and more MedlinePlus reports some cancer patients are unable to tolerate high-fat foods. Opt for cottage cheese, low-fat milk, lean meat and yogurt to continue high-protein consumption. Add protein to your meals by adding chopped boiled eggs to salads and casseroles, drinking milk shakes with added protein powder and add extra cheese to soups and. For these patients, the cancer itself, as well as treatment, changes the ability and desire to eat. This is true for other cancer patients, since chemoradiation treatment often has side effects that impact appetite and how foods taste. It's also important to understand that cancer changes in the way the body uses food for energy

Nutrition Support for Esophageal Cancer Patients

The body uses calories and protein for fuel to support healthy organs, muscle repair, and daily activity. Your body needs more calories and proteins during most types of cancer and treatments. The extra calories and protein are used to heal tissues and fight infections during chemotherapy or radiation therapy, or after surgery Energy and nutritional requirements. Cancer patients have similar nutritional requirements to the healthy population, around 25-30 kcal/kg/day, with a balance between calorie intake and expenditure, including the degree of physical activity (strength of recommendation: strong; level of evidence: low)

Diet for Cancer Patients, Foods that Boost Immune System

for protein-energy malnutrition in the elderly and all situations that may cause a reduction in food intake and/or an increase in energy requirements. - Risk factors more specific to the elderly: Psycho-socio-environmental • Provide high-energy and/or high-protein foods suited to patients' preference Protein is critical to help the good cells heal in a timely manner, as well as help the body regain strength after chemotherapy, radiation, and surgery. 2 Protein is also an essential component of a healthy immune system and it is important for cancer patients to be able to continue treatment and fight off infection Cancer as well all know is one of the most dangerous and terrible diseases known to humans. This is the reason there are many medical professionals specially suggest healthy drinks for cancer patients. When it comes to searching for perfect drinks for cancer patients there are plenty of amazing choices are available Critically ill patients require adequate nutritional support to meet energy requirements both during and after intensive care unit (ICU) stay to protect against severe catabolism and prevent significant deconditioning. ICU patients often suffer from chronic critical illness causing an increase in energy expenditure, leading to proteolysis and related muscle loss

Weight fluctuations are a common problem for patients undergoing cancer therapy. Weight loss is the most frequent problem; however some cancer treatments may result in weight gain. Those undergoing treatment for cancer should try to maintain a healthy weight and avoid any losses or gains in weight. Research shows that cancer patients who retain weight and maintain a good nutritional state have. Purpose Weight loss and poor food intake have been shown to affect several outcomes in patients undergoing surgery for gastrointestinal cancer. This review aims to examine the effect of pre-, post- or perioperative nutrition interventions focused on increasing oral energy or protein intake in patients undergoing surgery for gastrointestinal cancer. Interventions using standard oral nutrition.

Lec 2 estimated energy requirement among diabetic patientsRecommended energy and protein intake in liver cirrhosis

Guidance should be given to ensure the protein intake meets the recommended daily intake for the patients' age and gender and adequate energy is consumed. Micronutrients such as potassium and phosphorous should only be restricted if blood levels are elevated This is important for cancer patients that exhibit swallowing problems or experience mouth sores from cancer treatments of the head and neck. This product delivers 8 g of protein, 230 calories and provides 25 percent of the daily recommended amounts of 18 vitamins and minerals To meet their energy demands, cancer patients must consume more calories than would normally be recommended. Snacks furnish some of this extra energy between meals. Individual protein and calorie requirements differ, so patients should discuss their personal requirements with the registered dietitians and doctors at Beaumont in patients with cancer and is a major cause of morbidity and mortality6. The incidence of malnutrition in cancer patients ranges between 40% and 80%, the prevalence ranges from 50% to 80% depending on the tumour type, tumour location, stage of disease, treatment received and the type of nutritional assessment method used7-9 Be sure to meet your daily protein needs (about 6-12 ounces per day). Several factors (ie, weight, activity level and type of injury) affect individual protein requirements, so you may want to consult a nutritionist for more information. Avoid weight loss/crash dieting before and after surgery to ensure adequate nutrients and energy for recovery

(PDF) Predictors for achieving protein and energyHigh Protein Diet Plan For Cancer Patients - Diet Plan

40 g protein/day to provide 2 000 kcal (8 000 kJ) 90 g protein (1.5 g/kg) Goal—High-energy, high-protein diet for weight maintenance during admission Plan Commence oral nutrition supplements providing 1 000 kcal (4 000 kJ) and 45 g protein Educate patient and family on importance of nutrition weight maintenance and optimal treatment outcomes Protein energy malnutrition varies greatly between healthy individuals and patients with critical illness or injury. Healthy individuals experiencing starvation adapt to this state through the use of nutritional reserves. Restricted access to nutrients results in a reduction in resting energy expenditure (REE) and urinary nitrogen excretion. Th Resting energy expenditure can be unchanged, increased, or decreased. 2 Cancer patients are mildly hypermetabolic with an excess energy expenditure of between 138 and 289 kcal/day. Total energy expenditure and protein requirements for non-obese ambulatory patients using their actual body weight can be estimated as follows toms, and dietary restrictions can lead to protein energy malnutrition and specific nutritional deficien-cies. It is estimated that up to 85% of hospitalized IBD patients have protein energy malnutrition, based on abnormal anthropometric and biochemical parameters (1,2). As Crohn's disease can occur anywhere fro negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism.1 Weight loss is prevalent in patients with cancer and can occur anytime during three distinct phases of the disease: before or at diagnosis, during the course of the disease, or after medical/radiation/surgical treatment