September 22nd, 2010
08:35 AM ET
Is the inability of cancer patients to eat a concern?
Every weekday, a CNNHealth expert doctor answers a viewer question. On Wednesdays, it's Dr. Otis Brawley, chief medical officer at the American Cancer Society.
Question asked by Steve Snodgrass, Bowling Green, Kentucky
I wanted to see what your experts thought about cancer/chemotherapy patients and protein malnutrition. I have read it leads to as many as 45 to 50 percent of cancer deaths. Is the inability of cancer patients to eat of major concern to cancer health care providers? Thank you.
You ask an important question about a devastating problem.
Cachexia is a condition in which the body consumes excess energy. There is accelerated loss of fat stores and then consumption of proteins such as skeletal muscle. Cachexia is best known as a disease of cancer patients, but it is seen in patients with chronic infection, AIDS, heart failure, rheumatoid diseases and chronic obstructive pulmonary disease. Nearly half of patients with cancer that has spread to organs other the original site of disease (metastatic disease) have cachexia.
Loss of appetite or anorexia is often associated with cachexia, especially cachexia of malignancy. Contrary to what many think, this is not a disease caused by starvation. The loss in weight and body mass is driven by a metabolic disease manifested by increased energy consumption. As a result aggressive feeding and caloric replacement are not adequate treatments. Extremely aggressive efforts are to be discouraged. There are studies to suggest that forced tube feeding or intravenous feeding (known as hyperalimentation) can actually increase risk of infection and death.
Cachectic patients generally do not respond well to anti-cancer therapies. In one National Cancer Institute sponsored study, weight loss of greater than 5% from baseline was a predictor of poor outcome independent of cancer stage, type of cancer and patient performance status. Performance status is a rating of a patient's ability to walk and independently care for ones activities of daily living such as dressing oneself or hygiene.
Studies demonstrate that cachexia is the direct cause of death in a small number of cancer patients (1 to 2 percent). This is akin to the body running out of fuel or extreme malnutrition. More commonly the person has lost a great deal of immune function and becomes susceptible to infection or cachexia can lead to metabolic disorders that can cause heart rhythm disturbances. There are no good estimates as to how often this occurs.
Cancer cachexia appears to be caused by chemicals given off by the tumor or by the patient's immune system that is trying to combat the tumor. These chemicals are called cytokines. Some cytokines have also been found to cause depression which can also of course cause loss of appetite which worsens the condition. When there is effective treatment of the cancer, symptoms of cachexia decrease.
A number of agents have been studied, not as treatment of the cancer, but as a treatment of the condition known as cachexia of malignancy. These include melatonin, thalidomide, cannabinoids, and androgenic steroids. Only the corticosteroids, such as dexamethasone, and the progestational agents, such megesterol acetate, have proven of benefit in treatment of the loss of appetite. While a number of studies show corticosteroids and progestational agents cause an increase in appetite and even weight gain, these studies have not shown that they improve quality of live or survival.
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