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Anorexia-Cachexia Syndrome

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Background

Anorexia-cachexia syndrome is defined as progressive weight loss associated with malignancy and is characterized by anorexia, skeletal muscle wasting, and reduced adipose tissue.1,2 Although the exact mechanism of this syndrome remains poorly understood, the pathogenesis is thought to be multifactorial, with cytokines and tumor-related factors playing an important role.3Approximately 80% of patients with advanced cancer may experience this syndrome, and it may account for up to 20% of deaths.4

Patients receiving chemotherapy for CRC may experience sensations of unpleasant taste (dysgeusia), loss of taste (ageusia) or decreased taste sensation (hypogeusia). Dysgeusia the most commonly reported change5 may be due to diffusion of drug into the oral cavity. Alteration in taste is one of the most common symptoms associated with cancer and chemotherapy treatments. Berteretche, et al reported that 62% of patients complained of taste disorders associated with chemotherapy treatments.6 The resulting alterations in taste can vary, but the most common complaints include a metallic taste, enhanced taste of bitter flavors, and a reduced taste of sweet flavors.7 Simple dietary changes as well as the addition of certain spices and flavorings can make food taste better and less offensive. Table 1 suggests techniques for managing taste change in patients with cancer.

Little is known about the chronic effects of chemotherapy on taste although the literature suggests that dysgeusia is reversible, with taste sensation returning to normal in the ensuing months.5 Taste dysfunction seems to occur with equal frequency between oral and intravenous chemotherapy.

One of the most widely quoted publications describes the prognosis of pretreatment weight loss. In 1980, Dewys and colleagues found that weight loss of greater than 5% over baseline prior to therapy was predictive of early mortality. A higher frequency of weight loss was found in patients with solid tumors, such as GI malignancies, compared with those with hematologic malignancies.8

Potential etiologic factors in the development of anorexia-cachexia syndrome include1-9:

  • Alteration in taste or smell
  • Alteration in gastrointestinal function
    • Early satiety
    • Mucositis
    • Diarrhea
    • Obstruction
    • Nausea/vomiting
  • Psychological abnormalities
    • Depression
    • Grief
    • Anxiety
    • Pain
  • Antineoplastic therapy
    • Radiation therapy
    • Chemotherapy
    • Surgery

Risk factor assessment and nutritional screening are essential for early identification of patients at risk. A complete history should be obtained, including preillness and current diet habits, medications, functional status, income level, social and psychological factors, cognitive function, and possible side effects of treatment.

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Assessment Tools

Three tools that may be used to screen for malnutrition include1:

  • Body mass index (BMI)
  • Serum albumin level
  • Percentage of weight loss

A useful screening tool in the oncology patient is the Subjective Global Assessment (SGA) of Nutritional Status download pdf of SGA tool . This tool estimates the nutritional status based on history (weight, current dietary intake, GI symptoms, functional status and physical demands) and physical examination (muscle features, fat, and fluid status). The results determine if the patient is well nourished, has moderate or suspected malnutrition or severe malnutrition. 10,11

Current pharmacologic and nonpharmacologic treatment is directed toward reversing the syndrome and improving quality of life. Although many of these agents have been used in the treatment of anorexia-cachexia, benefits are usually of short-term duration, with no influence on lean body mass or survival.12 Table 2 lists strategies for managing weight loss in patients with cancer.

It has been suggested that chemotherapy may play a role in the management of cancer related anorexia/cachexia syndrome. Some clinical trials have demonstrated that based on tumor response, patients may experience improvement in appetite. Additionally, it has been reported in some studies that the administration of chemotherapy may suggest a trend in improvement in asthenia thus providing a palliative benefit to patients with metastatic disease who have this syndrome.13


Pharmacologic measures include3:

  • Appetite stimulants: megesterol acetate and medroxyprogesterone
  • Corticosteroids: dexamethasone or prednisone
  • Tetrahydrocannabinol: dronabinol
  • Anabolic agents: oxandrolone
  • Dietary supplements14
    • Omega-3 fatty acids promote weight stability
    • Leucine, an amino acid, blocks protein synthesis
    • Arginine strengthens the immune system

Nonpharmacologic measures include:

  • Physical exercise
  • Relaxation exercises

Table 1. Strategies for Management of Taste Alterations

  • Eat small, frequent meals and healthy snacks
  • Use plastic utensils if food tastes metallic
  • Substitute poultry, fish, eggs, cheese, beans, and other protein sources for red meats
  • Season foods with tart flavors, such as lemon wedges, citrus fruits, vinegar, and marinades to overpower bad or off tastes (if patient does not have mucositis)
  • Suck on sugar-free lemon candy, gum, or mints to eliminate metallic or bitter taste
  • Add spices such as onions, garlic, basil, and sauces to foods
  • Practice regular mouth care before eating to remove bad taste and refresh the mouth
  • Eat foods cold or at room temperature to decrease food flavor and odor

Adapted from National Cancer Institute (2007)15 and Rehwaldt et al (2006)16

Table 2. Strategies for Managing Weight Loss in Patients With Cancer

  • Increase calories and protein by encouraging consumption of foods packed with macronutrients, vitamins, and minerals
  • Consider using meal replacements either with or between meals
  • Limit beverages at meals to avoid early satiety; however, to avoid dehydration, ensure that adequate fluids are being consumed between meals
  • Serve foods at room temperature and encourage good oral hygiene
  • Schedule meals as you would medicine, encouraging small, frequent meals throughout the day
  • Consider the need for an appetite stimulant
  • Be proactive! Preventing weight loss is more effective than promoting weight gain

Adapted from Palombine (2006) 14

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Clinical Practice Guidelines

Oncology Nursing Society
http://cancersymptoms.org/anorexia/index.shtml

National Comprehensive Cancer Network (NCCN) http://www.nccn.org/professionals/physician_gls/PDF/palliative.pdf

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References

  1. Koutkia P, Apovian C, Blackburn G. Nutrition support. In Berger AM, Portenoy RK, Weissman DE, eds. Principles & Practice of Palliative Care & Supportive Oncology. Philadelphia: Lippincott Williams & Wilkins. 2002: 933-955.
  2. Tait N. Anorexia-cachexia syndrome. In Yarbro CH, Frogge MH, Goodman M, eds. Cancer Symptom Management. Sudbury, Mass: Jones & Bartlett Publishers. 1999: 183-194.
  3. Inui A. Cancer anorexia-cachexia syndrome: current issues in research and management. CA Cancer J Clin. 2002;52:72-91
  4. Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer. 2002;2:862-871.
  5. Prommer E. Taste alerations in cancer.  ASCO 2003 Annual Meeting, Abstract 3093. Available Here Accessed October 31, 2006.
  6. Berteretche MV, Dalix AM, d’Ornano AM, et al. Decreased taste sensitivity in cancer patients under chemotherapy. Support Care Cancer. 2004;12:571-576.
  7. Comeau TB, Epstein JB, Migas C: Taste and smell dysfunction in patients receiving chemotherapy: a review of current knowledge. Support Care Cancer. 2001;9:575-580.
  8. Dewys WD, Begg C, Lavin PT, et al. Prognostic effect of weight loss prior tochemotherapy in cancer patients.Eastern Cooperative Oncology Group. Am J Med. 1980;69:491-497
  9. Rosenzweig M. Anorexia/cachexia. In Camp-Sorrel D, Hakins RA, eds. Clinical Manual for the Oncology Advanced Practice Nurse. Pittsburgh: Oncology Nursing Press. 2002: 399-403
  10. Ottery FD. Supportive nutrition to prevent cachexia and improve quality of life. Semin Oncol. 1995;23(suppl 3):90-111
  11. Detsky AS, McLaughlin JR, Baker JP, et al. J Parenter Enteral Nutr. 1987;11:8-13.
  12. Gordon JN, Green SR, Goggin PM. Cancer cachexia. Q J Med. 2005;98:779-788
  13. Jatoi MD. Pharmacologic therapy for the cancer anorexia/weight loss syndrome: a data-driven, practical approach. Support Oncol. 2006;4:499-502
  14. Palombine J. Cancer-related weight loss. Clin J Oncol Nurs. 2006;10:831-832
  15. National Cancer Institute. Nutrition in cancer care. 2007. Available from: http://www.nci.nih.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/page4#Section_127. Accessed October 24, 2007.
  16. Rehwaldt M, Purl S, Tariman J, et al. A study of taste change strategies in patients receiving chemotherapy. ONS Annual Congress 2006. Abstract 256. Available at http://onsopcontent.ons.org/meetings/2006abstracts/CongressAbs/abstract256.shtml. Accessed October 20, 2007.

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Key Definitions

asthenia—lack or loss of strength

body mass index (BMI)—a measure of body fat that is the ratio of the weight of the body in kilograms to the square of its height in meters

cytokines—any of a class of immunoregulatory proteins (as interleukin, tumor necrosis factor, and interferon) that are secreted by cells especially of the immune system

etiologic—causing or contributing to the cause of a disease or condition

frequency—the number of individuals in a single class when objects are classified according to variations in a set of one or more specified attributes; the number of repetitions of a periodic process in a unit of time

protein synthesis—a process where information is taken from DNA to act as a blueprint for creating a particular protein that is in demand by the body

satiety—the quality or state of being fed to or beyond capacity; a sense of feeling full

syndrome—a group of signs and symptoms that occur together and characterize a particular abnormality

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