Cancer Cachexia
Summary of Key Points
• Loss of appetite and weight loss are common in patients with advanced, incurable cancer and are associated with a poor prognosis.
• Although patients with advanced, incurable cancer who have the “cachexia syndrome” may appear malnourished, nutritional support with either enteral or parenteral nutrition rarely provides a positive impact on clinical outcomes.
• For palliative purposes, corticosteroids and progestational agents improve appetite in patients with incurable cancer who are experiencing a loss of appetite and weight loss.
• A variety of agents that target muscle, including antimyostatin therapy, are currently being tested in clinical trials to begin to determine their role in treating cancer cachexia syndrome.
1. Which of the following clinical characteristics in a patient with incurable cancer has been associated with a poor prognosis?
2. True or false: Nutritional support in the form of parenteral or enteral nutrition has been demonstrated to improve survival in patients with advanced, incurable cancer, but for cost reasons, it is used sparingly.
3. Which agents have been demonstrated in randomized, controlled trials to improve appetite in patients with advanced, incurable cancer?
1. Answer: C. A robust amount of literature that includes prospectively gathered data from thousands of patients with cancer shows that both loss of weight and appetite predict a poor prognosis in patients with advanced cancer. Although this prognostic effect is quite powerful, to date, we have not found an intervention—apart from effective antineoplastic treatment—to reverse all aspects of this cancer cachexia syndrome.
2. Answer: B. Several metaanalyses, including a recent one from Baldwin and colleagues, indicate that nutrition support does not improve survival rates. As a result of multiple controlled trials, the American College of Physicians issued a position paper in 1989 to say that parenteral nutrition should not be routinely prescribed to patients with advanced cancer who are receiving chemotherapy. Although small case series suggest that highly select subgroups of patients with incurable cancer might benefit from parenteral nutrition, to date it is not clear how to identify such subgroups, and these patients are the exception, not the rule.
3. Answer: C. Both corticosteroids and progestational agents improve appetite in patients with advanced cancer. Importantly, they do not improve survival, and therefore they do not reverse all aspects of the cancer cachexia syndrome. The adverse effect profiles of these two classes of agents should be carefully considered before prescribing them to patients with cancer for their orexigenic effects. If long-term myopathy from corticosteroids is a concern, a progestational agent should be prescribed for that patient. If a patient has had a deep venous thrombosis in the past, a progestational agent should not be prescribed for palliating loss of appetite.
