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Key Messages

• Whilst clinical research on cachexia and anorexia has mostly focused on weight gain, on its own this may not result in meaningful changes for palliative care patients [1]
• There is evidence to support the use of either progestogens (megestrol acetate or medroxyprogesterone acetate) [2] or corticosteroids [3] as appetite stimulants in advanced cancer
• Systematic reviews of the role of dietary polyunsaturated fatty acids (eicosapentaenoic acid -EPA and docosahexanoic acid -DHA) as a supplement in cancer cachexia have not shown any benefit. [4-5]
• Guidelines for managing anorexia and cachexia in advanced cancer patients are available. [6]

Overview
Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [7-8]

The palliative conditions in which cachexia and anorexia occur most frequently are progressive malignancy, HIV/AIDS, end-stage cardiac failure, end-stage respiratory failure, chronic renal failure, chronic liver disease, and advanced dementia.

Potentially reversible contributors to appetite problems should be sought, and treated as appropriate. These may include:

• Mouth problems – mucositis, oral thrush
• Nausea
• Pain
• Dysphagia
• Constipation
• Depression
• Family, social and cultural expectations related to food, diet, and body weight
• Inappropriate presentation of food
• De-conditioning / reduced level of activity
• Changed sense of taste and smell
• Malabsorption
• Dyspnoea
• Medication effects.

Issues related to appetite that are covered in this section are:

• Cachexia anorexia syndrome
• Appetite stimulants
• Artificial nutrition.

Active research areas / controversies 

• The European Association for Palliative Care (EAPC) is refining definitions of cachexia for palliative care, reviewing the significance of secondary nutritional impact syndromes, and studying the psychosocial outcomes of cachexia and anorexia. [9] Further work aimed at developing a clinical decision tool is under way.
• With better understanding of the cachexia anorexia syndrome, future treatments are likely to be multidimensional and initiated earlier. They may include appetite stimulants, tailored nutritional support and exercise, [10] and treatments to reverse the inflammatory drive associated with the syndrome. [11] Specialised multidisciplinary clinics within the oncology / palliative care setting are a new model of care which is being explored.
• Study of the differences between specific cachexia syndromes – cancer, chronic renal failure and cardiac failure – is evolving. [9] 
• Many studies with weight gain as an outcome do not identify how weight is gained - whether as muscle, fat, or oedema. Skeletal muscle mass, rather than total weight, is most closely associated with functional status. Other relevant outcomes such as quality of life, performance state, exercise and activity levels are now being studied in addition to changes in weight. [1]
• Significant muscle wasting (sarcopenia) may occur in patients with maintained body weight due to fat; the possibility of assessing this with CT scanning is being studied, in order to identify those patients with early stages of cachexia who might benefit from earlier intervention. [12] 
• 'Early satiety' is when a person wants to eat but can only take small amounts due to a sense of fullness. It is common in cancer patients, and may be separate from other appetite problems, or it may co-exist with anorexia or nausea. Autonomic neuropathy may be a contributing factor. Early satiety is not well understood, but has been identified as an area for further research. [13]
• Inflammatory markers, including C-reactive protein and others, are being studied for potential clinical use as screening and monitoring tools in the cachexia anorexia syndrome, and as a possible intervention target. [11, 14] 

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References

1. Dahele M, Fearon KC. Research methodology: cancer cachexia syndrome. Palliat Med. 2004 Jul;18(5):409-417.
2. Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004310.
3. Yavuzsen T, Davis MP, Walsh D, Le Grand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol. 2005 Nov 20;23(33):8500-11.
4. Dewey A, Baughan C, Dean T, Higgins B, Johnson I. Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004597.
5. Mazzotta P, Jeney CM. Anorexia-cachexia syndrome: a systematic review of the role of dietary polyunsaturated Fatty acids in the management of symptoms, survival, and quality of life. J Pain Symptom Manage. 2009 Jun;37(6):1069-77.
6. Dy SM, Lorenz KA, Naeim A, Sanati H, Walling A, Asch SM. Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea. J Clin Oncol. 2008 Aug 10;26(23):3886-95.
7. Vigano A, Dorgan M, Buckingham J, Bruera E, Suarez-Almazor ME. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med. 2000 Sep;14(5):363-74. 
8. Teunissen SC, Wesker W, Kruitwagen C, de Haes HC, Voest EE, de Graeff A. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage. 2007 Jul;34(1):94-104. Epub 2007 May 23.
9. Blum D, Omlin A, Fearon K, Baracos V, Radbruch L, Kaasa S, Strasser F; European Palliative Care Research Collaborative. Evolving classification systems for cancer cachexia: ready for clinical practice? Support Care Cancer. 2010 Mar;18(3):273-9.
10. Al-Majid S, Waters H. The biological mechanisms of cancer-related skeletal muscle wasting: the role of progressive resistance exercise. Biol Res Nurs. 2008 Jul;10(1):7-20.
11. Bartosch-Härlid A, Andersson R. Cachexia in pancreatic cancer – mechanisms and potential intervention. e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism. 2009 Dec;4(6):e337-43.
12. Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009 Dec;3(4):269-75.
13. Davis MP, Walsh D, Lagman R, Yavuszen T. Early satiety in cancer patients: a common and important but underrecognized symptom. Support Care Cancer, 2006 Jul;14(7):693-8.
14. Walsh D, Mahmoud F, Barna B. Assessment of nutritional status and prognosis in advanced cancer: interleukin-6, C-reactive protein, and the prognostic and inflammatory nutritional index. Support Care Cancer. 2003 Jan;11(1):60-2.

This page was created on 6 May 2008
Last updated 13 December 2010*