Appetite Problems

Key messages

  • A focus on weight gain on its' own may not result in meaningful clinical changes for palliative care patients. [1] Cancer cachexia is now viewed as a modular concept, with variable interaction between appetite, nutritional intake, catabolic processes, muscle and fat loss. [2]
  • There is evidence to support the use of either progestogens (megestrol acetate or medroxyprogesterone acetate) [3] or corticosteroids [4,5] as appetite stimulants in advanced cancer, but less evidence to suggest that they are associated with any improvement in quality of life.
  • 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. [6,7,8] Non-steroidal anti-inflammatory drugs are also being studied, but the evidence is not conclusive at this stage. [9,10]
  • Guidelines for managing anorexia and cachexia in advanced cancer patients are available. [11]

Overview

Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [12,13]

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
  • Dysgeusia - changed sense of taste and smell
  • Malabsorption
  • Dyspnoea
  • Medication effects.
Issues related to appetite that are covered in this section are Cachexia Anorexia SyndromeAppetite Stimulants and 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, and developing a decision tool [14] Specific Quality of Life assessment tools are needed for cancer cachexia. [15]
  • Interactions between the various domains associated with cancer cachexia are complex and unpredictable. The relationship between catabolic state, anorexia and nutritional intake, is extremely variable. The data support a modular concept of cancer cachexia. [2]
  • 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, [16] and treatments to reverse the inflammatory drive associated with the syndrome. [17] 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. [14]
  • 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. [18]
  • '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. [19]
  • Dysgeusia (abnormalities of the sense of taste) have been found to be common during cancer treatment (56 - 76% estimated prevalence). It is often associated with other oral symptoms, and with a worse quality of life. Treatments that have been studied include prophylaxis with zinc and amifostine, which have been shown to be of small benefit. Dietary and educational counselling may be of some assistance. [20]
  • 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. [17,21] Genetic polymorphisms are being investigated in the search for susceptibility biomarkers. [22]
 

PubMed Searches

Appetite Problems
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Review Collection
  1. Dahele M, Fearon KC. Research methodology: cancer cachexia syndrome. Palliat Med. 2004 Jul;18(5):409-17.
  2. Blum D, Omlin A, Baracos VE, Solheim TS, Tan BH, Stone P, et al. Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. 2011 Oct;80(1):114-44. Epub 2011 Jan 8.
  3. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310.
  4. 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.
  5. Miller S, McNutt L, McCann MA, McCorry N. Use of corticosteroids for anorexia in palliative medicine: a systematic review. J Palliat Med. 2014 Apr;17(4):482-5.
  6. 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.
  7. 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. Epub 2008 Dec 2.
  8. Ries A, Trottenberg P, Elsner F, Stiel S, Haugen D, Kaasa S, et al. A systematic review on the role of fish oil for the treatment of cachexia in advanced cancer: an EPCRC cachexia guidelines project. Palliat Med. 2012 Jun;26(4):294-304. Epub 2011 Aug 24.
  9. Solheim TS, Fearon KC, Blum D, Kaasa S. Non-steroidal anti-inflammatory treatment in cancer cachexia: a systematic literature review. Acta Oncol. 2013 Jan;52(1):6-17. Epub 2012 Oct 1.
  10. Reid J, Hughes CM, Murray LJ, Parsons C, Cantwell MM. Non-steroidal anti-inflammatory drugs for the treatment of cancer cachexia: a systematic review. Palliat Med. 2013;27(4):295-303. Epub 2012 Mar 26.
  11. 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.
  12. 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.
  13. 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.
  14. Blum D, Omlin A, Fearon K, Baracos V, Radbruch L, Kaasa S, et al. Evolving classification systems for cancer cachexia: ready for clinical practice? Support Care Cancer. 2010 Mar;18(3):273-9.
  15. Wheelwright S, Darlington AS, Hopkinson JB, Fitzsimmons D, White A, Johnson CD. A systematic review of health-related quality of life instruments in patients with cancer cachexia. Support Care Cancer. 2013 Sep;21(9):2625-36. Epub 2013 Jun 25.
  16. 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.
  17. 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.
  18. 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.
  19. Davis MP, Walsh D, Lagman R, Yavuzsen T. Early satiety in cancer patients: a common and important but underrecognized symptom. Support Care Cancer, 2006 Jul;14(7):693-8. Epub 2006 Apr 20.
  20. Hovan AJ, Williams PM, Stevenson-Moore P, Wahlin YB, Ohrn KE, Elting LS, et al. A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer 2010;18(8):1081-7. Epub 2010 May 22.
  21. 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. Epub 2002 Aug 21.
  22. Tan BH, Ross JA, Kaasa S. Skorpen F, Fearon KCH, European Palliative Care Research Collaborative. Identification of possible genetic polymorphisms involved in cancer cachexia: a systematic review. J Genet. 2011 Apr;90(1):165-77.

Last updated 17 January 2017