Enteral or parenteral nutrition
Despite the demonstrated efficacy of corticosteroids and progestational agents in patients with cancer anorexia and cachexia, these drugs do not have a major long-term impact on the vast majority of such patients. Consequently, other treatment approaches, such as enteral or parenteral nutritional methods, have been studied extensively. Several randomized trials failed to demonstrate that these nutritional approaches improve either quantity or quality of life. As a result, experts generally agree that the routine use of parenteral or enteral nutrition cannot be justified in patients with advanced cancer anorexia and cachexia.
There are, however, relatively rare circumstances in which parenteral nutrition may play a role in patients with advanced cancer. Such circumstances have been documented by case reports and small case series and have included patients with GI insufficiency due to surgery, radiation therapy, or abdominal carcinomatosis (without impending failure of other organs). The decision to initiate parenteral nutrition under these circumstances typically requires a multidisciplinary approach with extensive discussions between healthcare providers and family members.
Given the positive impact of corticosteroids and progestational agents on cancer anorexia and cachexia and the fact that many patients with advanced cancer die with, and/or of, inanition, the potential prophylactic use of these agents was evaluated. A double-blind trial was conducted in which patients with newly diagnosed, extensive-stage small-cell lung cancer were randomized to receive megestrol(Drug information on megestrol) or placebo along with standard chemoradiation therapy. This trial was unable to demonstrate any beneficial effect of megestrol on treatment response, quality of life, or survival.
Thus, patients should not be treated prophylactically for cancer anorexia and cachexia outside a clinical trial. Rather, such treatment should be reserved for patients in whom anorexia and cachexia are patient-determined, symptomatic clinical problems.
NUTRITION AS IT RELATES TO END-OF-LIFE CARE
Anorexia and cachexia are major problems for many oncology patients as they approach the final stage of life. Family members are generally more distressed than the patients if/when appetite stimulants do not provide relief. Questions commonly arise about giving enteral or parenteral nutrition or “forcing” patients to consume more calories in the belief that they would feel better, get stronger, and live longer. A small measure of appropriate education, noting that the intake of more calories does not appear to have a clinical benefit, provides substantial relief. It is worthwhile to note that patients randomized to receive total parenteral nutrition or appetite stimulants (such as megestrol) do not live any longer than do control patients and that “force-feeding” is not in the patients’ best interests.