Cancer anorexia and its impact on the survival journey

1. Cancer anorexia and its impact on the survival journey Palliative Care Rounds October 30, 2003 Michelle Kralt, RN MN michelle.kralt@cancercare.mb.ca

2. The World Heath Organization explains that Palliative care: “…provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of care and offers a support system to help patients live as actively as possible until death”

3. The goal of palliative care is achievement of the best quality of life for patients and families.

4. Session objectives • 1. Examine pathophysiologic changes associated with cancer-related anorexia • 2. Discuss interventions for cancer-related anorexia • 3. Appreciate the impact anorexia has on quality of life in people with cancer.

5. What is anorexia? • “orexis” – Greek for “appetite”; “A” – “without” = anorexia; meaning to be without appetite • Appetite is psychological, dependent on memory and associations, as compared with hunger, which is physiologically aroused by the body’s need for food. • One can feel hungry and have anorexia simultaneously

6. Cachexia • is derived from the the Greek “kakos” meaning “bad” and “hexis” meaning “condition” • Is a debilitating state of involuntary loss of adipose tissue and skeletal muscle mass. • Is usually diagnosed when pts have weight loss more than 5% of preillness weight in previous 2 to 6 months.

7. Different types of Anorexia • 1. Anorexia nervosa: refusal to eat, most commonly occurs in pubescent girls in developed countries.

8. 2. a form of starvation related to malnutrition caused by impaired intake due to pain, GI obstruction, n/v, altered GI motility, medication s/e, depression/stress, swallowing difficulties, thyroid irregularities, constipation, poor sleep, severe fatigue

9. Cancer-related anorexia • 3. primary anorexia is the absence of appetite despite obvious nutritional needs • It is directly caused by the cancer • It is most commonly seen in individuals with lung, pancreatic, and gastric cancers • Anorexia is not dependent on a large tumor burden • May also occur with infections, renal failure, AIDS, CHF, IBD,COPD

10. Significance of anorexia • Anorexia has been reported in 6% of early diagnosis to 85% of advanced cancer patients (Watanabe & Bruera, 1996, Starsseer & Bruera, 2002). • Anorexia effects both the patient and carer; for the carer, it can seem like the pt is “giving up.” • Anorexia may often be the first presenting sign of cancer 50% of the time(Damsky Dell, 2002)

11. Continued… • Anorexia is associated with asthenia, fatigue and weakness • Change in body image • Cognitive impairment

12. Clinical significance of weight loss • Weight loss of >5% of pre illness state significantly increase symptom distress and functional status in patients. (Sarna et al, 1994). • People with significant weight loss have a severely impaired tolerance to both radiation treatment and chemotherapy (Stepp & Pakiz, 2001) • A BMI of <18.5 severely reduces physical work capacity, significantly impairing a person’s quality of life

13. Clinical significance of weight loss • Malnutrition leads to 1) gastrointestinal impairment, 2) respiratory problems, 3) cardiac problems and 4) decreased immune function. • Anorexia and malnutrition lead to deterioration in psychologic function which manifests as apathy, lassitude, lack of self help motivation, depression and anxiety Meguid & Laviano, 2001

14. Anorexia Anxiety Weakness Depression Fatigue

15. Pt’s with significant weight loss experience 40-60% increase in frequency of complications in response to surgical/medical treatments • They have higher hospital admissions • They have a twofold to threefold higher death rate than their well nourished counterparts. (Meguid & Laviano, 2001) • Median survival was significantly shorter in pts with weight loss • Chemotherapy responses are lower in pts with weight loss (Dewys, et al , 1980).

16. Anorexia-cachexia syndrome • Anorexia and cachexia are associated and often experienced together; however it is possible that one can experience anorexia or cachexia independently of the other. • Protracted anorexia will eventually lead to cachexia (Morris, 1999) • ACS is one of the most common causes of death in cancer

17. Physiology of appetite • Appetite is the desire to eat and is influenced by cultural, sensory, and physiological consequences on choices and intakes of foods

18. Decreased plasma glucose Net Effect: Plasma fatty acids and glucose Glucose receptors in the hypothalamus Spinal Cord Liver Adipose Tissue Muscle Sympathetic Neurons Adrenal medualla

19. Pathophysiology of primary anorexia (& cachexia)

20. Yesterday’s theory • Cancer steals nutrients from body • metabolism increases to meet demand • toxins secreted that depress appetite

21. Dispelling the Myths of Cachexia -Cachexia ≠ Anorexia -Cachexia is not caused by the tumor consuming the nutrients -Cachexia ≠ Starvation

22. Characteristics of Cancer Versus Starvation Cachexia Variable Starvation Cancer Energy intake ( *) Energy Expenditure (resting) Body fat Skeletal muscle Liver †atrophy Increased size and metabolic activity‡

23. Todays’ Theory

24. 1. Inefficient metabolic alterations • Energy expenditure in relation to lean body mass is increased. • Glucose turnover is present via hepatic gluconeogenesis and lipolysis • Whole body protein turnover increased, amino acid turnover is altered • Increase in production of c-reactive protein

25. Elevated amino acids levels in the plasma may decrease appetite

26. 2. Neurhormonal regulation and food intake • LHA = Lateral Hypothalamic Area • VMH = Ventral Medial Hypothalamic Area

27. Hypothalamus Homeostasis VMH LHA Satiety Center Hunger Center

28. Anorexia is associated with low dopamine and high serotonin levels in the VMH

29. Cytokines • Nonantibody proteins released by one cell population on contact with a specific antigen, which acts as cellular mediators in the generation of an immune response

30. Cytokines • TNF-α (tumour necrosis factor alpha) • IL-1 (Interleukin 1) • IL-6 (Interleukin 6) • CCK (Cholecystokinin) • CRF (Corticotropin releasing factor)

31. A B Anorexigenic Neuropeptide Orexigenic Neuropeptide Anorexigenic Neuropeptide Orexigenic Neuropeptide Neurotensin MCH Neurotensin MCH _ _ CNS Cytokinase Melanocortin AGRP CNS Cytokinase Melanocortin AGRP _ CNTF _ IL-1 IL-6 TNF- INF- + _ IL-1 CRF NPY CRF NPY Tryptophan + _ + Seratonin _ _ + ACTH Food Intake Energy Expenditure Food Intake Energy Expenditure Blood Brain Barrier Blood Brain Barrier + Glucocorticoids + _ + + + IL-6 Glucogon Cytokinase Glucogon CNTF Leptin CCK Leptin CCK IL-1 + + + +

32. Taste Changes • Taste and smell aversions are also common with cancer related anorexia • Possible link between high levels of serotonin and taste aversions (Edelman et al, 1999) • A large tumor burden can increase the degree and duration of taste alterations (Sherry, 2001)

33. Etiology of taste changes • 1. Presence of malignant cells or cancer tx may reduce # of taste buds • 2. Dividing cancer cells secrete amino acid-like substance, causing a bitter taste sensation • 3. Cancer-induced deficiencies in zinc, copper, nickel and vitamin A, which are heavy metals involved in normal taste function

34. Comprehensive assessment of anorexia • 1. detailed hx of involuntary weight loss • 2. Hx of nutritional intake • 3. perceived change in body image? • 4. presence of anorexia? (Visual analog scale) • 5. Anxiety/depression? • 6. Taste or smell changes? • 7. Dysphagia or painful mouth problems?

35. Assessment continued • 8. thyroid function test • 9. early satiety? • 10. nausea and vomiting? • 11. constipation? • 12. Sleep patterns • 13. Fatigue? • 14. Functional status? • 15. pain?

36. Experiential

37. Why not TPN/EN? • TPN/EN causes further anorexia • Complications (ie: mechanical, metabolic and infection) • Expensive • Does not improve survival • Does not cause weight gain • How does one make the decision to discontinue TPN – very hard for pt & family

38. Megace Corticosteroids Dronabinol Cyproheptadine Thalidomide Melatonin NSAIDS/COX-2 Fish oils (Eicosapentaenoic acid) Metoclopramide Ginger root Essiac Orexigenic agents

39. Nursing interventions • Acknowledge the losses the patient and family are experiencing and help them explore these losses, including time to explore the possibilities of the future • Encourage family members to focus their energies on other activities that convey nurturing

40. Nursing interventions continued… • Educate that failure to eat is not “giving up,” and that the pt will not “starve to death”. • Explaining the nature of ACS as irreversible and caused by metabolic abnormalities, and that eating more food will not help the pt gain weight

41. Conclusion • By offering nutritional support and pharmacological advice, symptom control and psychological support to individuals with cancer at risk for anorexia, nurses can reduce the distress experienced even if symptoms of anorexia or cachexia do not appear.