Cachexia Anorexia Syndrome

Evidence Summary

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. [1] 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. [2] The goals of nutritional support are both physical and psychosocial. [3] 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. [4]

The cachexia anorexia syndrome is a complex metabolic syndrome of involuntary weight loss associated with cancer and some other palliative conditions including chronic heart failure and end-stage renal failure. A consensus definition of cachexia related to either cancer or chronic disease has been proposed: weight loss with or without fat loss, and at least three of the following additional criteria for diagnosis:

  • decreased muscle strength
  • reduced muscle mass
  • fatigue
  • anorexia 
  • biochemical alterations [anaemia, inflammation, and low albumin]. [4]

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. [5]

 

 

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Review Collection

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). [4] Nutritional assessment tools that include markers of inflammation have been investigated. [6] 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. [7] Appetite is a subjective symptom. Often cachexia is poorly managed by health care professionals due to a lack of knowledge about screening and interventions and a lack of available resources, such as referral pathways. [2,8,9] There are validated assessment tools used in research and practice such as the Patient Generated Subjective Global Assessment, which has been recommended for patients with cancer cachexia, [10] but expert consensus does not make a recommendation about which specific tool to use. [11] Loss of appetite is a common symptom included in a number of severity assessment scales developed in a palliative care context, such as the Symptom Severity Scale [2], which is part of the PCOC dataset, [11] but further validation is required for these tools.

The detailed neurophysiology of appetite / anorexia is not well understood in humans. It may be different from the mechanism of cachexia / weight loss. [12] Genetic polymorphisms are being studied and show promise in the identification of susceptibility biomarkers. [13]

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. [4,14] Raised CRP is well-established as a marker in cachexia. [5]

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]

Cachexia has an impact on performance state. [5] 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. [14]

Cachexia may also be a prognostic factor in non-malignant conditions. [16]

There is little strong evidence to support the provision of nutritional advice for weight-losing patients. [3] 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.

Practice Implications

  • Appetite is a subjective symptom. Simple assessment tools are available, such as the Patient Generated Subjective Global Assessment. [2,11]
  • The goals of nutritional support are both physical and psychosocial. [3]
  • Often cachexia is poorly managed by health care professionals due to a lack of knowledge about screening and interventions and a lack of available resources, such as referral pathways. [8,9,11]
  • 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, and support for the resident and families may be required as they deal with this change. [15]
  1. 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.
  2. Aoun SM, Monterosso L, Kristjanson LJ, McConigley R. Measuring symptom distress in palliative care: psychometric properties of the Symptom Assessment Scale (SAS). 2011 Mar;14(3):315-21. doi: 10.1089/jpm.2010.0412. Epub 2011 Jan 21.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Bressan V, Bagnasco A, Aleo G, Catania G, Zanini MP, Timmins F. The life experience of nutrition impact symptoms during treatment for head and neck cancer patients: a systematic review and meta-synthesis. 2017 May;25(5):1699-1712. doi: 10.1007/s00520-017-3618-7. Epub 2017 Feb 15.
  9. Cooper C, Burden ST, Cheng H, Molassiotis A. Understanding and managing cancer-related weight loss and anorexia: insights from a systematic review of qualitative research. J Cachexia Sarcopenia Muscle. 2015 Mar;6(1):99-111. doi: 10.1002/jcsm.12010. Epub 2015 Mar 31.
  10. 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.
  11. Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr. 2017 Feb;36(1):11-48. doi: 10.1016/j.clnu.2016.07.015. Epub 2016 Aug 6.
  12. 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.
  13. 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.
  14. Dahele M, Fearon KC. Research methodology: cancer cachexia syndrome. Palliat Med. 2004 Jul;18(5):409-17.
  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.
  16. 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.

 

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Last updated 08 November 2019