Overview
Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [1]
The palliative conditions in which cachexia anorexia occurs 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:
- Pain
- Nausea
- 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
- Mouth problems – mucositis, oral thrush
- Malabsorption
- Constipation
- Dyspnoea
- Dysphagia
- Medication effects.
Problems related to appetite that are covered in this section are:
Key messages
- Whilst clinical research on cachexia and anorexia has mostly focused on weight gain, this may not result in meaningful changes for patients [2]
- There is evidence to support the use of either progestogens (megestrol acetate or medroxyprogesterone acetate) [3] or corticosteroids [4] as appetite stimulants in advanced cancer
- A Cochrane systematic review of studies of the role of eicosapentaenoic acid (EPA) as a supplement in cancer cachexia did not show any benefit. [5]
Active research areas / controversies
- 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 treatments to reverse the inflammatory drive associated with the syndrome. Specialised multidisciplinary clinics within the oncology / palliative care setting are a model of care which is being explored
- 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 associated with functional status. Other relevant outcomes such as quality of life, performance state and activity levels are now being studied in addition to changes in weight [2]
- '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 [6]
- 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 [7]
- A number of Cochrane systematic reviews are in progress for this topic. Topics include a systematic review of medically assisted nutrition for palliative care patients, and a review of the role of nutritional screening.
References
- Vigano A, Dorgan M, Buckingham J, Bruera E, Suarez-Almazor ME. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliative Medicine. 2000 Sep;14(5):363-74.
- Dahele M, Fearon, KC.Research methodology: cancer cachexia syndrome. Palliative Medicine. 2004 Jul;18(5):409-417.
- Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexia-cachexia syndrome. Cochrane Database of Systematic Reviews. 2005 Apr 18;(2):CD004310.
- Yavuzsen T, Davis MP, Walsh D, Le Grand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. Journal of Clinical Oncology. 2005 Nov 20;23(33):8500-11.
- 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 of Systematic Reviews. 2007 Jan 24;(1):CD004597.
- Davis MP, Walsh D, Lagman R, Yavuszen T. Early satiety in cancer patients: a common and important but underrecognized symptom. Supportive Care in Cancer, 2006 Jul;14(7):693-8.
- 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. Supportive Care in Cancer, 2003 Jan;11(1):60-2.
This page was created on 6 May 2008 and is due for review in May 2010
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