Tools for Patient Assessment
BIA is easy to perform in a clinical setting, and is a useful tool to assess for lean muscle wasting in the patient with cachexia. To perform a BIA, two conductors are attached to the patient and a small electric current is passed through the body. The resistance between the conductors provides a measure of body fat, because resistance to electricity is different between fat (a poor conductor), muscle, and skeletal tissue. Thus the technique in effect “compartmentalizes” body weight by lean muscle mass, fat, and extracellular tissue. The BIA measurement is reimbursable by most major insurance providers. Indirect calorimetry will help to personalize the nutrition care plan further by providing a patient's resting metabolic rate; a few handheld or easily transportable calorimetry tools are available (eg, BodyGem).
A useful screening tool in the busy ambulatory care setting is the Mini Nutritional Assessment (MMA), a six-item checklist that determines a patient's overall nutritional status by assessing for decline in food intake and weight loss (assigning scores of 0 for weight loss > 6.6 pounds, 1 for weight loss unknown, 2 for weight loss between 2.2 and 6.6 pounds, and 3 for no weight loss) during the last 3 months, BMI (or calf circumference if BMI is not available), mobility, dementia/depression, and psychological stress. Patients with total scores of 0 to 7 are classified as malnourished, those with scores of 8 to 11 are designated as being at risk of malnutrition, and those with a screening score of 12 to 14 points are deemed to have normal nutritional status. The MMA is available here.
In addition to obtaining the routine CBC (complete blood count) and chemistry profile, it is useful to obtain prealbumin values. Prealbumin, which has a short half-life, is an indicator of a patient's nutritional status and protein intake. Within the structure of the CARE Clinic, we further assess 25-hydroxy vitamin D levels, C-reactive protein levels, and testosterone levels in men. Prealbumin may be altered when inflammation is present, and assessment of C-reactive protein may confirm this. Cachexia may be exacerbated by the presence of inflammatory cytokines secreted by the cancer cells.
The role of vitamin D in cancer and other illnesses is being heavily researched, with the recommended daily allowance in vitamin D supplements still a subject of controversy. In November 2010 the Institute of Medicine (IOM) issued the report, “Dietary Reference Intakes for Calcium and Vitamin D,” updating its 1997 guidelines. The IOM reports recommends that adults 50 years of age and younger take 600 IU/day and those aged 51 years and older take 800 IU/day, with a suggested limit of 4,000 IU/day. These intake amounts translate to a serum level of 20 ng/mL, but some experts believe that target serum levels of vitamin D should be higher, in the 30–32 ng/mL range. Symptoms of vitamin D deficiency in addition to osteoporosis may include bone pain, muscle weakness, and cognitive impairment. Not surprisingly, Mr. L's vitamin D level was found to be low (see Table 1) due to fat malabsorption, and he was give supplementation with 50,000 IU of vitamin D twice a week for 6 weeks.
Testosterone deficiencies also may manifest as depression, decreased sense of well-being, decreased lean muscle mass, and decreased libido. This was not an issue for Mr. L, as his testosterone level was normal. All of these symptoms directly affect quality of life and performance status of the patient with cancer.
Nutritional recommendations need to be individualized and based on a patient's nutritional status and goals. While dietary adjustments may be sufficient for the patient with cachexia, administration of additional nutritional supplements may be warranted.
Specialized nutritional supplements (eg, Juven and Ensure Clinical Strength) can help patients to maintain and rebuild lean body mass, supporting their recovery and rehabilitation. The specialized compound in these supplements is HMB, or beta-hydroxy-beta-methylbutyrate, which regulates protein metabolism in muscle cells.
Calorie modules in a variety of forms are available for supplemental protein, fat, or carbohydrates. Homemade smoothies can be excellent vehicles with which to deliver these nutritional supplements to patients in a taste-enhanced manner.
Nursing management of the patient with cancer cachexia includes a complete history and physical examination. The history should include the cancer diagnosis, current cancer treatment, current medications, prior cancer diagnoses, weight loss, anorexia, and any related symptoms. Symptom-assessment tools such as the Edmonton Symptom Assessment Scale can be useful in monitoring changes in symptoms when following a patient with cancer cachexia. Measurement of functional status with the Karnofsky performance status tool is also a helpful way to monitor the impact of cancer cachexia on the patient's activities of daily living. Physical examination may reveal loss of muscle mass, indicated by temporal wasting and poor muscle tone. The patient's skin may be dry with poor turgor, and the nails may be brittle. Oral examination may reveal poor dentition, lesions, and dry mouth.
The general approach toward management of cancer cachexia is based on the understanding of its multifactorial origin. Cancer cachexia originates from a combination of factors, including decreased dietary intake, anabolic endocrine deficiency, hyperexpression of catabolic elements, lack of physical activity, and presence of comorbid conditions. Unfortunately, no single agent has been found to be effective in treating cancer cachexia. Several authors have recommended implementation of a combination of modalities by an experienced interdisciplinary team.[11,13–15] Investigation of a variety of agents to treat cancer cachexia, some novel and some approved for other indications, is ongoing.[16–19] The 6th Cachexia Conference, sponsored by the Society on Sarcopenia, Cachexia and Wasting Disorders, was held in Milan in December 2011 (click here for selected abstracts of preclinical and clinical studies presented at the conference).
At the time of this writing, Mr. L was able to sustain a weight of 190 pounds. Although he would have preferred to weigh closer to 200 pounds, he was relieved to be able to maintain his weight. He reported that his episodes of diarrhea are now “rare,” and his nausea is minimal and mostly associated with chemotherapy. His appetite is fair but he is able to eat small frequent meals, incorporating high protein, calorically dense foods. He is now 3 years post-diagnosis of stage IV pancreatic cancer, and is receiving palliative chemotherapy with 5-FU, leucovorin, and reduced doses of irinotectan and oxaliplatin(Drug information on oxaliplatin), due to cytopenias. His disease and symptoms of cachexia have been stabilized with treatment, strategic eating, nutritional supplements, pancreatic enzymes, and antidepressant therapy with mirtazapine(Drug information on mirtazapine) (Remeron).
While his depression has improved, it is still evident; he has declined psychotherapy at this time. Mr. L. has maintained an ECOG performance status of 2 (ambulatory and capable of all self-care but unable to carry out work activities, up and about more than 50% of waking hours). He has stated, “I have been enjoying my time with the kids and hope to get out on my bike now that the weather is nice.” As of this writing, Mr. L is comfortably living with a chronic life-limiting disease and his symptoms are well controlled through the interdisciplinary management of his cachexia.
Oncology nurses who work directly with patients on a daily basis, including chemotherapy nurses and oncology nurse practitioners, are particularly well positioned to have a positive impact on the lives of patients with cancer cachexia. Proactive, multimodality interventions to address cancer cachexia are an integral part of cancer therapy, with the aim of improving clinical outcomes and the patient's quality of life. Working in collaboration with other members of the interdisciplinary team, including the dietitian, nurses can improve outcomes by providing multiple strategies for assessing and managing cancer-related cachexia.
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.