Drs. Jatoi and Loprinzi provide a comprehensive but succinct overview of the management of cancer-associated anorexia and weight loss. These clinician researchers, who have added much to our understanding of this problem, present a balanced and reasonable approach to the management of these common paraneoplastic syndromes.
Benefit of Nutritional Support Limited
Almost 3 decades ago, it was hoped that enteral and parenteral support for the cancer patient would improve the longevity of and response to therapies. Unfortunately, controlled trials have shown that improved nutritional support does not make a suboptimal cancer therapy better.[1-4] In their review, the authors have described the limited circumstances under which optimal artificial parenteral nutrition will improve objectively measured outcomes. All occurring in the setting of possible complete control of malignancies, these circumstances include nutritional supplementation for perioperative support, accompanying therapeutic stem cell rescue after high-dose chemotherapy, and during aggressive primary radiation of localized head and neck cancer.
‘If Only They Would Eat’
The authors correctly stress the importance of reviewing the goals of nutritional or orexigenic therapy with the patient and family. An especially pertinent aspect of nutritional support pertains to the patient with advanced incurable malignancy. Near the end of life, when a patient and family acknowledge the presence of anorexia and weight loss, one should determine who is actually bothered by these problems. Often, the family or caregiver—not the patients—experience the psychological discomfort.
The offering of food has cultural, religious, and supportive significance. The false assumption that these patients would improve or live longer "if only they would eat" can become a significant point of conflict between patients and caregivers. Early patient satiety, bloating, and dyspnea can occur when food is "forced" on the patient by well-intentioned caregivers.[5] Studies of individuals near the end of life indicate that they usually do not have a sense of starvation and dehydration, even if oral or parenteral intake is curtailed.[6]
Moreover, survival in this population is not enhanced by artificial hydration or nutrition. Death results from the underlying malignancy, not from nutritional deficits.[5,7,8] The primary reason to institute use of an orexigenic agent, then, should be the patient’s desire to improve oral intake. If a trial of these medications does not improve quality of life, they can be discontinued. A similar trial of hydration could be considered for patients believed to be symptomatic from decreased fluid intake.
‘May Help, Won’t Hurt’
The authors review the use of agents that have proven to be most beneficial in the treatment of anorexia—ie, progestational medications and dexamethasone(Drug information on dexamethasone). Numerous complementary therapies and nostrums have also been purported to be beneficial with no associated toxicities. These modalities should be evaluated systematically. Agents such as the amygdalin relative Laetrile, hydrazine sulfate, or vitamin C have demonstrated no value.[9-11] A dictum of "may help, won’t hurt" cannot be assumed for these over-the-counter or unregulated medications.
Clinical trials of circulating substrates thought to be implicated in anorexia or weight loss are needed. It is hoped that ongoing and future trials assessing eicosapentaenoic acid (EPA), thalidomide(Drug information on thalidomide) (Thalomid), adenosine(Drug information on adenosine) triphosphate (ATP), nonsteroidal anti-inflammatory drugs (NSAIDs), and others will benefit patients who are adversely affected by cancer-associated anorexia and weight loss.
A 52-year-old man presented with an erythematous lesion in the axilla of unknown duration. Surgical excision was performed. What is your diagnosis?
