Cachexia Anorexia Syndrome

The cachexia anorexia syndrome is a complex metabolic syndrome of involuntary weight loss associated with cancer and some other palliative conditions a consensus definition of cachexia related to either cancer or chronic disease has been proposed, namely: weight loss with or without fat loss, and additional criteria (three required for diagnosis)

  • decreased muscle strength,
  • reduced muscle mass, 
  • fatigue,
  • anorexia, or
  • biochemical alterations [anemia, inflammation, and low albumin]. [1]

A systematic review of the literature on cachexia suggests that there are a range of pathways involved and that the interactions between weight loss, nutritional intake and anorexia are not straightforward or predictable. [2]

Assessment and management of cachexia should identify and treat according to the stage (pre-cachexia, cachexia, refractory cachexia),and seek to treat potentially reversible factors (secondary nutritional impact symptoms - S-NIS). [1] Nutritional assessment tools that include markers of inflammation have been investigated. [3] Their role in clinical practice may be to identify patients earlier in the palliative trajectory, and be incorporated into clinical practice guidelines about management of the syndrome. [4]

What is known

The detailed neurophysiology of appetite / anorexia is not well understood in humans. It may be different from the mechanism of cachexia / weight loss. [5] Genetic polymorphisms are being studied and show promise in the identification of susceptibility biomarkers. [6]

The metabolic profile of cancer cachexia is not the same as that of starvation, which is defined as secondary cachexia. Cancer cachexia involves inflammation, hypermetabolism, neuro-hormonal changes, and the production of proteolytic and lipolytic factors. [1,7] Raised CRP is well-establised as a marker in cachexia. [2]

Appetite loss occurs in over half of all palliative care patients, and weight loss becomes more common in the last weeks and months of life. [8]
Loss of weight and loss of appetite do not always occur together. Some patients have cachexia despite maintaining a relatively normal appetite and nutritional intake. [1]

Cachexia has an impact on performance state. [2] Loss of weight and appetite due to cancer progression have prognostic relevance for symptom burden, performance state, survival, and the ability to tolerate palliative chemotherapy. [7] 

Cachexia may also be a prognostic factor in non-malignant conditions. [9]

There is little strong evidence to support the provision of nutritional advice for weight-losing patients. [10] Two approaches have been identified, the first involving strategies to maximise intake, and the second focusing on allowing the patient to ‘eat what they like’.  Further evidence is needed to understand whether and at what stage specific subgroups may benefit from more intensive nutritional support. 

What it means in practice

  • Appetite is a subjective symptom. Simple assessment tools are available, such as the Symptom Assessment Scale, which is part of the PCOC dataset.
  • A simple and valid nutrition assessment tool used in research and practice is the Patient Generated Subjective Global Assessment, which has been recommended for patients with cancer cachexia. [11] 
  • Eating and food have great social, cultural and psychological significance for patients and their families, and issues relating to nutritional support are often socially and ethically complex. [12-14] The goals of nutritional support are both physical and psychosocial. [10]
  • If an underlying malignancy can be effectively treated, this may reverse the cachexia anorexia syndrome.
  • In patients who have advanced dementia, loss of appetite and decreasing oral intake may be a marker of the transition to end-stage disease, although contributing factors should be sought and addressed as appropriate. Families of patients with end-stage dementia may require increased support as they deal with this change. [15]

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Review Collection
  1. 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.
  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. 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.
  4. Mirhosseini N, Fainsinger RL, Baracos V. Parenteral nutrition in advanced cancer: indications and clinical practice guidelines. J Palliat Med. 2005 Oct;8(5):914-8.
  5. Davis MP, Dreicer R, Walsh D, Lagman R, LeGrand SB. Appetite and cancer-associated anorexia: a review. J Clin Oncol. 2004 Apr 15;22(8):1510-7.
  6. 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.
  7. Dahele M, Fearon KC. Research methodology: cancer cachexia syndrome. Palliat Med. 2004 Jul;18(5):409-17.
  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. Coventry PA, Grande GE, Richards DA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non-malignant life-threatening disease: a systematic review. Age Ageing. 2005 May;34(3):218-27.
  10. Hopkinson JB, Okamoto I, Addington-Hall JM. What to eat when off treatment and living with involuntary weight loss and cancer: a systematic search and  narrative review. Support Care Cancer. 2011 Jan;19(1):1-17. Epub 2010 Aug 6.
  11. Bauer JD, Ash S, Davidson WL, Hill JM, Brown T, Isenring EA, et al. Evidence based practice guidelines for the nutritional management of cancer cachexia. Nutr Diet. 2006 Sep;63(Suppl 2):S3-32.
  12. Hughes N, Neal RD. Adults with terminal illness: a literature review of their needs and wishes for food. J Adv Nurs. 2000 Nov;32(5):1101-7.
  13. Shragge JE, Wismer WV, Olson KL, Baracos VE. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliat Med. 2006 Sep;20(6):623-9.
  14. Bryon E, Gastmans C, de Casterlé BD. Decision-making about artificial feeding in end-of-life care: literature review. J Adv Nurs. 2008 Jul;63(1):2-14. Epub 2008 Jul 1.
  15. Australian Palliative Residential Aged Care (APRAC) project team. Guidelines for a palliative approach in residential aged care: enhanced version. Canberra; National Health and Medical Research Council (NHMRC) and National Palliative Care Program: May 2006.

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Last updated 17 January 2017