Many cancer patients experience cachexia. In collaboration with an interdisciplinary team including dietitians, oncology nurses are well positioned to implement proactive, multimodality interventions that improve clinical outcomes and quality of life for these patients.
Cancer cachexia, a common condition occurring in 50% to 75% of patients with cancer,[1,2] may lead to delayed, missed, or decreased treatments. It is a wasting syndrome involving loss of muscle and fat caused directly by tumor factors and/or indirectly by an abnormal response to tumor. Cancer cachexia most commonly occurs in gastric (85% of patients), pancreatic (83%), non–small-cell lung (61%), small-cell lung (57%), prostate (57%), and colon (54%) cancers. Notably, in 2011 an international group of experts on cancer cachexia reported that they had developed a consensus on the definition and classification of cancer cachexia. Fearon et al said they agreed that the “diagnostic criterion for cachexia was weight loss greater than 5%, or weight loss greater than 2% in individuals already showing depletion according to current body weight and height (body-mass index [BMI] < 20 kg/m2) or skeletal muscle mass (sarcopenia).” The experts agreed that cachexia can develop progressively, from precachexia, to cachexia, to refractory cachexia. Severity of cachexia, they said, can be classified based on the degree to which energy stores and body protein are depleted (BMI) in combination with the degree of ongoing weight loss. They noted that patient assessment for classification and treatment of cancer cachexia should include the domains of anorexia or reduced food intake, catabolic drive, muscle mass and strength, and functional and psychosocial impairment. The authors concluded that validation of this framework for defining and classifying cancer cachexia, “should aid clinical trial design, development of practice guidelines, and, eventually, routine clinical management” of this syndrome.
The patient, “Mr. L,” is a 53-year-old Caucasian male undergoing treatment for stage IV pancreatic cancer. In 2008, Mr. L presented for a workup due to a 20-pound weight loss and abdominal discomfort. He said that initially, he had presumed that the weight loss was caused by stress. Mr. L, a lawyer, was separated from his wife and in the process of filing for divorce and custody of his two 11-year-old children. His past medical history was unremarkable, with only a note about childhood asthma. The initial clinical impression was that the patient had either lymphoma or carcinoma. Further testing, including a CT scan of the chest, abdomen, and pelvis confirmed the diagnosis of pancreatic cancer with liver metastases.
To address Mr. L's weight loss and abdominal discomfort, a low-dose treatment of pancreases was prescribed which contains 8,000 USP units of lipase (pancrelipase, Creon). He was directed to take two tablets with meals. His initial chemotherapy treatment was a regimen of gemcitabine(Drug information on gemcitabine) (Gemzar) and erlotinib (Tarceva), which was administered from November 2008 through January 2009. Upon progression of disease, this regimen was changed to gemcitabine, docetaxel, and capecitabine(Drug information on capecitabine) (Xeloda), which he received from January 2009 through June 2010. At that time, further progression was revealed and his regimen was changed again, to FOLFIRINOX (5-fluorouracil [5-FU], leucovorin, irinotecan(Drug information on irinotecan), and oxaliplatin(Drug information on oxaliplatin) [Eloxatin]). Mr. L is continuing to receive this regimen and has stable disease, though he completed his 18th cycle with reduced doses of irinotecan and oxaliplatin, because of cytopenias.
On initial presentation, Mr. L weighed 217 pounds and his height was 70.75 inches, translating to a body mass index (BMI) of 29.7. (Individuals are considered within a normal weight range if their BMI, or body fat estimate based on height/weight is 18.5 to 24.5.) By this standard he would be classified as being overweight; his usual body weight was 235 pounds, however, so he had experienced an 8% weight loss in 1 month. Patients who have a 5% or greater weight loss in 1 month are considered at nutritional risk. In addition, Mr. L. presented with a disease that puts him at high risk for cancer-related cachexia. His weight of 217 pounds ± 2 pounds remained stable at presentation up until June 2010.
Beginning in June 2010, symptomatic changes occurred, with increasing complaints of abdominal discomfort, diarrhea, nausea, and poor appetite. At this time, Mr. L was found to have progressive disease. A weight decline to 210 pounds began in July 2010, and by August his weight had dropped to 198 pounds, for a 9% weight loss in 2 months. Along with treatment adjustment for disease progression, aggressive symptom management was initiated to address the diarrhea and nausea.
The previous prescription of pancreatic enzymes was increased to doses of 16,000 USP units of lipase, with two pills taken with meals and one pill taken with snacks. Commonly, people with pancreatic cancer have a pancreatic enzyme insufficiency. If weight loss is observed and the patient begins to complain of indigestion, flatulence, cramps and/or a change in stool characteristics, this condition and initiation of pancreatic enzyme replacement therapy should be considered. It is helpful to question the patient about whether stools are more frequent, loose or floating, and greasy in appearance.
Mr. L was referred to the CARE (Cancer Appetite and Rehabilitation) Clinic at our cancer center in January 2011. The CARE Clinic provides comprehensive supportive care services through an interdisciplinary team that assesses and addresses the needs of cancer patients who experience cancer-related cachexia. Team members include a physician, nurse practitioner, dietitian, physical therapist, and speech and swallowing therapist. The purpose of the clinic is to reduce the effects of cancer cachexia and to improve the nutrition, function, symptom management, and quality of life of cancer patients. An individualized plan is developed to maintain an optimal nutritional status throughout treatment and survivorship. Patients are referred to the CARE Clinic when they experience
• involuntary weight loss;
• increasing fatigue;
• difficulty with function and activities of daily living;
• difficult or painful swallowing; and/or
• speech impaired by muscle weakness.
The goals of the CARE Clinic are to
• prevent or reverse weight loss in cancer patients when possible;
• provide strategies to improve both speech and oral nutrition;
• improve cancer-related fatigue and function; and
• improve quality of life of cancer patients by managing symptoms.
At the CARE Clinic, Mr. L was assessed by the team and followed in monthly appointments. His main symptoms to be addressed were involuntary weight loss, fatigue, decreasing performance status, nausea, and depression. The nurse, registered dietitian, and physical therapist were instrumental in developing a plan of care to address each specific symptom. The registered dietitian educated Mr. L about eating strategies to reduce his nausea. (Useful nausea-management strategies to discuss with patients can be found on the National Cancer Institute's website.) He was given a nutritional supplement (Juven) that assists in the rebuilding of lean muscle mass. His symptoms subsided and his weight stabilized at 198 pounds through early January 2011. Burping, bloating, flatulence, and loose stools became more problematic. The cancer cachexia became more prominent with time, and his weight had plummeted to 184 pounds by mid January 2011 (see Table 1).
Mr. L admitted to feeling depressed and stated that he was forcing himself to eat but on some days it was just too difficult. Treatment with appetite stimulants such as megestrol acetate (Megace) and dronabinol (Marinol) has been unsuccessful. Because of his many symptoms indicating pancreatic enzyme insufficiency, the pancreatic enzymes were again dose-adjusted to 24,000 USP units of lipase (12 capsules) per day. He was prescribed mirtazapine(Drug information on mirtazapine) (Remeron) for depression, and he was advised that his appetite might increase as a side effect of this agent.
For the patient with cancer cachexia, nutrition intervention is essential, but if body weight is the only parameter utilized for outcome, the intervention may seem futile. With cancer cachexia, individuals may or may not present with appetite loss, and there is muscle and fat breakdown. In the CARE Clinic, the registered dietitian assessed the patient's baseline nutritional status, muscle mass, and calorie expenditure using specialized tools. These tools may include bioelectrical impedance analysis (BIA) and indirect calorimetry, along with a review of additional laboratory parameters that may not be regularly obtained during the patient's routine physician and chemotherapy visits.