Many patients with advanced cancer undergo a wasting syndrome associated with cancer anorexia/cachexia and asthenia. In defining these terms a bit further, anorexia is associated with a marked loss of appetite and/or an aversion to food. Cachexia is a wasting syndrome associated with loss of body mass, including lean body mass, associated with a disease. In a study that looked at symptoms in cancer patients being entered on a palliative care service, anorexia/cachexia and asthenia were more common problems than were pain or dyspnea. Patients who exhibit such symptoms generally have a short survival, respond poorly to cytotoxic agents, and suffer from increased toxicity from these agents.
In addition, cancer anorexia/cachexia often is associated with weakness, fatigue, and a poor quality of life. This problem not only affects the patient but also frequently has an impact on family members, as the patient is no longer able to participate fully in eating as a social activity.
Cancer cachexia is not difficult to identify. In NCCTG research trials involving more than 2,500 patients, simple criteria for anorexia/cachexia have been used:
• a 5-lb weight loss in the preceding 2 months and/or an estimated daily caloric intake of < 20 calories/kg
• a desire by the patient to increase his or her appetite and gain weight
• the physician’s opinion that weight gain would be beneficial for the patient.
Recently, other investigators have attempted to provide more detailed or comprehensive definitions of cachexia. These definitions are important in stimulating further discussion of this entity and its pathophysiology.
Nutritional counseling, as provided by written materials, dietitians, physicians, and nurses, has been recommended, although its value has not been well demonstrated. Recommendations typically include eating frequent, small meals (as opposed to large meals), consuming larger quantities of food in the morning than in the evening, and avoiding spicy foods.
Patients may do better if they are not exposed to the aroma of cooking. Although the benefits of such nutritional counseling are clearly limited, it does appear reasonable to provide.
Recent trials have led to further interest in studying dietary counseling. Ravasco and others observed improvements in treatment-related side effects and quality of life among colorectal cancer patients who had received dietary counseling as part of a randomized controlled trial. Similar findings from this same group were observed among head and neck cancer patients. These findings require confirmation.
Corticosteroids were the first agents to undergo placebo-controlled, double-blind evaluation for possible use in cancer cachexia. The first such trial, conducted in the 1970s by Moertel and colleagues at the Mayo Clinic, demonstrated that corticosteroids can stimulate appetite in patients with advanced, incurable cancer. Several subsequent placebo-controlled trials, using various steroid preparations and doses, have confirmed these results.
Dexamethasone (3 to 8 mg/d) is a reasonable option for clinical use. Known detriments to corticosteroid use include the well known toxicities associated with chronic administration, including myopathy, peptic ulcer disease, infection, and adrenal suppression. Many patients with advanced cancer anorexia and cachexia, however, do not survive long enough to suffer from these toxicities.
Several placebo-controlled, double-blind clinical trials have demonstrated that progestational agents, such as megestrol(Drug information on megestrol) and medroxyprogesterone(Drug information on medroxyprogesterone), can lead to appetite stimulation and weight gain in patients with anorexia and cachexia. These trials also demonstrated that the effect of these drugs is seen in a matter of days and that they are effective antiemetics.