When Dr. E. Donnall Thomas first interviewed Saundra Aker to be the nutritionist on his bone-marrow transplant team, he remembers, "The entire program was so new we were not even sure just what a 'nutritionist' would do." Nevertheless, Thomas, who founded the center's pioneering transplant program, hired Aker on the spot.
Thirty-five years later, Aker, now the manager of nutrition and patient food services at the Seattle Cancer Care Alliance, has more than demonstrated the importance of the nutrition program to the success of Fred Hutchinson's transplant program.
Over the course of her career, Aker has developed innovative patient-nutrition practices and standardized them to assure that nutrition would not serve as a variable in transplant protocols. She led her own team's research into nitrogen balance, nutrient requirement and exercise to understand and address the dramatic loss of muscle mass they observed in patients. She and her staff have shared their knowledge in dozens of professional publications, including the award-winning patient publication, the "Guide to Good Nutrition During Cancer Treatment."
From her development of a la carte food service to the now standard "immunosuppressed-patient diet, which is safe for patients whose immune systems have been compromised by radiation and chemotherapy, Aker's program serves as a model for institutions worldwide.
In her current role, Aker has expanded that program to include general and radiation oncology.
"Saundra has been a leader in research into the special needs of marrow-transplant patients, and she continues to provide her expertise to the center," Thomas said.
Innovative food sterilization
Thomas asked for two things when Aker took up her post in 1969: sterile food for transplant patients in Laminar Air Flow (LAF) rooms, where the environment is kept germ-free by controlling the air movement, and nutrient intakes (calorie counts) on every patient.
The latter was a more familiar request for Aker. She and her team calculated, at first by hand and later by computer, the protein, fat, carbohydrates and calories patients ingested. These daily data grew into extensive nutritional records that proved invaluable to Thomas and other researchers.
Aker's response to Thomas' request for sterile food required much more innovation. Early transplant patients endured treatment without the benefits of drugs to combat severe side effects like mucositis (inflammation of the mouth), nausea and vomiting. Aker explained that "patients didn't, wouldn't, couldn't eat" often for months after treatment. Their caloric intakes would drop to starvation levels of 150 to 400 calories per day.
At the time, Aker could serve canned foods, which were already sterile, and anything that survived the autoclave, a machine that uses steam and pressure to sterilize medical and lab equipment. These "pressure cooker" conditions rendered foods, such as bread and pastries, unpalatable and unappetizing.
In 1973, Thomas mentioned to Aker that the University of Washington fisheries department was using a cobalt-60 irradiation source to irradiate food. At high enough dosages, irradiation sterilizes foods without altering taste, texture and appearance the way autoclaving can. Aker worked with UW and the astronaut-feeding program at NASA to make irradiation a practical complement to her other sterilization options. Eventually, she and Thomas applied for and received approval from the U.S. Food and Drug Administration to irradiate food for their LAF-isolated patients — the first time anyone in the country had been approved to irradiate food for general human consumption.
Better sterilization techniques meant Aker could offer patients a fairly extensive menu — from irradiated toast with autoclaved jam to an irradiated turkey sandwich with a pickle on the side. But Aker recognized that even with sterile, nutritious, appetizing selections, a traditional hospital food service was far from ideal for patients whose appetites and nutritional needs changed rapidly. In 1975, Aker developed a la carte food service so patients "could order food 18 hours a day, and even during the night, nurses could prepare food for them." The innovative cooks, who prepared meals in LAF hoods using aseptic techniques, specialized in adapting recipes to "exactly the way mother cooked them."
Akers' philosophy was "if staff wouldn't eat it neither would a patient. We did a lot of taste-testing in those years."
A personal approach
The nutrition team's approach was touchingly personal and sensitive. Aker explains how "mothers would come into the kitchen and wait, and cooks would fix the food according to the mother's specifications. And then she'd go back and tell her child that she had prepared the pancakes or whatever."
For patients who were too ill to eat orally, Aker investigated new protein hydrolysate solutions, the precursors to the amino acids used in modern parenteral (IV) nutrition. Total parenteral nutrition (TPN) was a godsend for their patients. The catch was fitting the TPN in amongst all the other fluids patients received as part of their treatment. In 1971, Dr. Robert Hickman created his famous single lumen catheter, which helped, but the access demand was still too great. Within two weeks of treatment, Aker documented that less than half of the TPN ordered was being infused. "So Dr. Hickman developed the double-lumen catheter so we could infuse the required TPN volumes," she said.
In the mid 1980s, as the center passed the 2,000th transplant milestone, Aker had to adapt to the demands of cost containment. She focused on improving outpatient services so patients could be discharged from the hospital sooner while still receiving the nutritional support they needed.
More recently, attention has focused increasingly on patient wellness and complementary medicine. Aker and her team have led the way in publishing guidelines for cancer patients' use of nutritional supplements and herbal and botanical products. Counseling regarding use of whole and nutritious foods during the healing process is an integral part of the nutrition team's practice.
Throughout her career, Aker said, "the major objective of the transplant team was to do everything in our power to support our patients and to maintain their quality of life." She believes the secret to the center's incredible progress was its environment and dedicated staff.
"The unique team effort that was created in those early years is key to the present-day Hutchinson culture," she said. "The atmosphere was that of research, development, creativity and dedication to excellence. And we ran with it." She also said with satisfaction, "that general philosophy is now an integral part of the Alliance."
With the growth of the Alliance, Aker no longer provides direct patient care, something she admits she misses. Patients, however, continue to benefit from Aker's inspiring dedication and innovation. The program she has built attracts and trains the best dietitians and students, who go on to improve care for patients at the Alliance and around the world.
"Saundra goes beyond what the usual nutritionist does at other institutions," said Dr. Marc Stewart, Alliance medical director. "She has a passion for the principles of nutrition and that's what it takes to aspire to the level that she's achieved. That passion is what has made the program a great one."
Looking back, Aker said, "Few of us recognized in those early years the potential hugeness of this amazing program."