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 caregivernot the
patientsexperience 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. 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.
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 anorexiaie, progestational medications and
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 (Thalomid),
adenosine triphosphate (ATP), nonsteroidal anti-inflammatory drugs (NSAIDs), and
others will benefit patients who are adversely affected by cancer-associated
anorexia and weight loss.
1. Nixon DW, Moffitt S, Lawson DH, et al: Total parenteral
nutrition as an adjunct to chemotherapy of metastatic colorectal cancer. Cancer
Treat Rep 65(suppl 5):121-128, 1981.
2. Valdivieso M, Bodey GP, Benjamin RS, et al: Role of
intravenous hyperalimentation as an adjunct to intensive chemotherapy for
small-cell bronchogenic carcinoma. Cancer Treat Rep 65(suppl 5):145-150, 1981.
3. Klein S, Simes J, Blackburn G: Total parenteral nutrition and
cancer clinical trials. Cancer 58:1378-1386, 1986.
4. McGeer AJ, Detsky AS, O’Rourke KO: Parenteral nutrition in
cancer patients undergoing chemotherapy: A meta-analysis. Nutrition 6:233-240,
5. Andrews M, Bell E, Smith SA, et al: Dehydration in terminally
ill patients: Is it appropriate palliative care? Postgrad Med 1:201-206, 1993.
6. Vullo-Navich K, Smith S, Andrews M, et al: Comfort and
incidence of abnormal serum sodium, BUN, creatinine, and osmolality in
dehydration of terminal illness. Am J Hosp Palliat Care 15(2):77-84, 1998.
7. Burge FI: Dehydration symptoms of palliative care cancer
patients. J Pain Symptom Manage 8(7):454-464, 1993.
8. McCann RM, Hall WJ, Groth-Juncker A: Comfort care for
terminally ill patients; the appropriate use of nutritional hydration. JAMA
9. Moertel CG, Fleming TR, Rubin J, et al: A clinical trial of
amygdalin (Laetrile) in the treatment of human cancer. N Engl J Med
10. Creagan ET, Moertel CG, O’Fallon JR, et al: Failure of
high-dose vitamin C (ascorbic acid) therapy to benefit patients with advanced
cancer. A controlled trial. N Engl J Med 301(13):687-690, 1979.
11. Loprinzi CL, Kurros SA, O’Fallon JR, et al: Randomized
placebo-controlled evaluation of hydrazine sulfate in patients with advanced
colorectal cancer. J Clin Oncol 12(6):1121-1125, 1994.