Anorexia in Dying Cancer Patients

Summary

Anorexia is very common in dying cancer patients. The patients usually do not feel hungry or thirsty.  They do not need much food or water for survival.  Treatable causes should be identified and treated.  Laboratory investigation is unhelpful.  Diet manipulation, high nutrition supplement and drug management are of limited use.   Patient and carer education and support are more important.  Mild dehydration has some beneficial effects.  Subcutaneous fluid infusion can correct dehydration if necessary but cannot relieve thirst.  Nasogastric tube feeding and parenteral nutrition are inappropriate.

Introduction

Anorexia is very common in malignancy.   Approximately two thirds of cancer patients develop significant weight loss.  The proportion varies with the site of the primary tumour, varying from about one third in breast cancer to more than 80% in gastric and pancreatic cancer.  Anorexia and cachexia are so closely linked that the term cachexia-anorexia syndrome has been used.  Patients themselves rarely complain of it.   It worries relatives and friends more than the patient.

Causes

Table 1 shows the most common causes of anorexia.  Most commonly, it is the direct result of cancer and is considered as part of the paraneoplastic syndrome.  It has been suggested that cancer cells produce a number of cytokine mediators which cause widespread metabolic disturbances.¹  The most likely one is tumour necrosis factor.  Hepatic gluconeogenesis is increased and the ability of skeletal muscle to process glucose into glycogen is impaired.  These result in loss of adipose tissue with outstanding features of cachexia and weakness from reduction of skeletal muscle bulk.

Table 1: Most common causes of anorexia

Assessment

Anorexia of sudden onset may be caused by treatable causes such as pain, nausea, constipation or oral thrush.  Anorexia of para-neoplastic syndrome has a more gradual onset.  The severity can be assessed by comparing the current situation with the previous appetite.  Ask for the amount of food consumed, any particular favourite or aversion, any particular time of the day that anorexia is worst and the feelings that put him off food, such as pain, nausea and distension.  Screen through the symptoms of possible causes.

Examination should include an attempt to find the possible causes of anorexia and to look for the effects of anorexia such as dehydration, glossy tongue in iron deficiency, angular stomatitis in vitamin riboflavin deficiency.

Anorexia worries the carers more than the patient. For them, taking food implies survival.  Cessation of food can create a state of great anxiety that death seems to be imminent.  Giving of food and drink demonstrates caring. They may feel guilty for failing to provide nutrition and fear that their loved one will die experiencing hunger and thirst.   So it is important to assess the attitude of the patient and family in order to be able to correct their misconception and to give support.

Laboratory investigation

In palliative medicine, laboratory investigations should be kept to a minimum.  They are reserved for some situations where the results are essential for decision making.  Simple and non-invasive ones are done first.  Full blood count can be done for patients with symptoms and signs of anaemia.  Check the ferritin for those with microcytic hypochromic anaemia and B12 level for those with macrocytosis.  If the patient is dehydrated or there is excessive vomiting or diarrhoea, the urea and electrolyte should be checked and corrected if necessary.

Hypoalbuminaemia is quite common in cachexic patients or patients with liver involvement.  It can cause oedema.  However, albumin infusion is rarely indicated.

Management

General Measures

The goals of nutritional care are to support nutritional status, body composition, functional status, and quality of life.²  Reversible factors such as nausea, pain, constipation and depression should be identified.  Try to improve sleep and comfort of the patient.  They should be advised to do some exercise and transfusion can be considered for severe anaemia.

The family and carers’ effort should be praised.  Their frustration and helplessness should be acknowledged.  They also need support, education and reassurance.  Guilt feelings, if any, should be addressed.

Eating is an important social process. Loneliness is a cause of anorexia. Family interaction and socialisation at meal time should be encouraged since meal times often are one of the few social functions available to patient and carers.  The ability of the patient to select preferred foods gives control and independence which palliative care patients greatly need.  Effort, however, should be made to address any guilt that the patients may have in giving extra burden to the carers for preparing unusual food or in being unable to finish the food that was particularly prepared for them.

Due to a loss of weight and of muscle mass, the patient may develop a poor self-esteem.  Reassurance may be required to assist the patient to feel attractive.  Selecting appropriate clothes and cosmetics and focusing on personality attributes beyond the physical may provide some comfort.

Explanation is needed that anorexia is a natural part of the malignant or dying process and that forcing the patient to eat does not help to prolong their life.  It is important to reassure them that the patient does not feel hungry or thirsty.   People can survive for months without food as long as hydration is maintained.  They need little nutrition and fluid because of little activity. Actually nutrition is used in the growth of the cancer.  The patient’s body adjusts to the lack of food and fluid.   A daily intake of  30-45 grams of glucose (1 cup of cooked rice or noodle) meets the brain energy requirements, suppresses ketosis and reduces protein catabolism. 

Hydration

Fat catabolism can produce about 400mls of water per day and the oedema fluid can be a source of fluid.  In a situation of minimal energy expenditure, reduced urea synthesis requires reduced urine production. Because of this and reduced perception of thirst, the patient may require little additional amount of water.  Two hundred mls to 1 litre of fluid per day is enough. 

Carers should be told that dry mouth is common in the terminal phase and it is not equivalent to thirst.  It is more important to provide mouth care.   Mild dehydration can be beneficial.  Less sputum and saliva production and less pulmonary oedema cause less breathlessness and terminal rattling.   Less GI tract secretion causes less vomiting and diarrhoea.  Less urine production causes less urinary incontinence.  Less cerebral oedema may produce transient paradoxical improvement in cerebral function.  There can also be less ascites and oedema. 

Diet manipulation

The patient should be advised to take food during the good appetite periods which is usually early morning.  Small attractive meals appealing to the patient can be provided every 1-2 hours.  Meat aversion may be minimised by reliance on other protein sources such as cold meat, sausage, milk, egg, cheese, beans, bean curd and chicken.  Addition of butter, gravy, cream or other moisturizing agents may improve taste perception for drier foods.  Fruit flavours are often acceptable.  Tomato, pineapple and other juice can be used in cooking.  Lemon or other flavouring can be added over food.   Place pieces of fruit such as mango or apple on top of food.  Switch from one food to another while eating may heighten taste appreciation.

Odour that adversely affect appetite in smell-sensitive patients can be eliminated by turning on kitchen ventilation fan during cooking, covering pan, using microwave and avoiding frying.  Introduction of new food ideas close to therapy should be avoided to prevent conditioned aversion.  Alcohol provides calories, analgesia and stimulate appetite.  Drinking alcohol in moderation, in patient’s favourite form, is a social event.  However, it may be disagreeable for patients with sore mouth or lymphoma.

High Nutrition Supplements

High nutrition supplements does not have much advantage over carefully home prepared foods.³  Apart from being expensive, monotonous and unpalatable, they may suppress patient’s appetite.  They should be treated as an additional source of nutrition rather than as replacement of enjoyable food.  They are suitable for patients who cannot prepare food, who can take in only small volume of high calorie high protein food or is on tube-feeding.

High calorie supplement in the form of glucose polymer is rarely used.  More commonly used ones are the complete nutrition supplement such as Sustagen or Ensure powder or liquid.  High fat supplement in the form of MCT oil (medium chain triglyceride) is suitable for patients with pancreatic insufficiency for reducing steatorrhoea.  It can be mixed with other fluid or food or being eaten slowly.

Useful Drugs

Megestrol acetate has been proven to improve appetite.⁴  To be effective, It has to be started with a high dose of 800mg/day and decreased in a stepwise fashion.⁵  It increases body fat, but does not increase lean body mass or survival.  As a result it improve body image and quality of life.  However, it is very expensive.

Multivitamin and minerals are used mainly for correcting deficiencies resulting from anorexia.  They do not stimulate appetite, but can prevent or treat problems resulting from anorexia such as glossitis, stomatitis, taste alteration, wound breakdown, reduced resistance to infection, anaemia and increased lethargy.  Megadose vitamin supplementation is not recommended.

Cyproheptadine (Periactin) 4mg three times a day has mild appetite stimulating effect only and it is quite sedative.

Dexamethasone 4-8mg twice a day or prednisolone 30mg/day orally after food increase well-being, euphoria, strength and appetite.⁶ The later dosage has to be given before 4 p.m. to avoid insomnia. However, the benefit is not maintained for more than a few weeks.  It increases urinary protein loss and negative nitrogen balance.   It may cause gastric irritation and predispose the patient to oral thrush and to skin fragility, risking pressure sore.  It has to be discontinued after 5 days if not effective unless it is used for other beneficial effects such as for anti-inflammation, tumour shrinkage, somatic or neuropathic pain.  Dexamethasone is preferred because it has less mineralocorticoid effect.

Medroxyprogesterone (Provera) 200mg twice daily has been shown to be effective.⁶ Pentoxifylline decreases tumour necrosis factor activity, but clinical trials have not yet confirmed its clinical use.  Dronabinol (Cannibis derivative) which has antiemetic, euphoriant and orexigenic has also been recommended for use in palliative care patients.

Nasogastric Tube Feeding

Tube feeding is suitable only for patients who will recover such as those who are undergoing chemotherapy or radiotherapy with temporary malfunction of the GI tract, or obstruction of the upper GI tract.  It is inappropriate in the terminal phase.  It is very uncomfortable for the patient.  The tube inhibits social contact with family and can cause erosion of the nose, oesophagus and stomach.  It may also cause gastric dilatation and aspiration.  Tubal administration of nutritional supplements often produces diarrhoea.  Very often, the family asks for that just for something to be done.  However, it may appropriately be used sometimes for suction to reduce distension.

Total Parenteral Nutrition (TPN)

The family of the patient usually requests the patient to be admitted into hospital for total parenteral nutrition, or at least for an IV drip for fluid replacement.  Apart from discomfort, it has been shown that TPN is associated with net harm.⁷  The major complications are pneumothorax, subclavian and axillary vein thrombosis, phlebitis and catheter-related septicaemia.  The drip also becomes a barrier between the patient and the carer.  Attention to the patient is replaced by attention to the drip.

Subcutaneous Fluid Infusion (Hypodermoclysis)

Dehydrated patients who cannot tolerate adequate oral intake can have slow subcutaneous fluid infusion.  An intravenous cannula can be inserted in abdominal wall, chest or thigh.  One litre of normal saline can be given overnight or 500ml in one hour 1 - 3 times daily.  Five percent Dextrose can provide a small energy supply, but this may cause discomfort.  Pulmonary oedema is unlikely.  It can reduce confusion but correction of dehydration may not correct symptom of thirst.  Potassium chloride 40mmol/L can be added to the infusion. Because acidic or alkaline solutions are irritating, they cannot be given subcutaneously to correct acidosis or alkalosis in protracted diarrhoea or vomiting.

References: 

1.                  Bruera E, Higginson I (Eds.), Cachexia-Anorexia in Cancer Patients, Oxford University Press: New York, 1996. 

2.                  Ottery FD, Supportive nutrition to prevent cachexia and improve quality of life, Seminars in Oncology, 1995; 22(2), suppl 3:98-111. 

3.         Lipman T, Clinical trials of nutritional support in cancer: parenteral and enteral therapy. Haematology Oncology Clinics of North America,  1991; 5:91-102. 

4.         Lai Y, Fang F, Yeh C, Management of anorexic patients in radiotherapy: a prospective randomised comparison of megestrol and prednisone.  Journal of Symptom Management, 1994; 9(4):265-8. 

5.         Giasosa A, Frascio F, Sukkar South, Constantini M, Baracco G, Capelli M, Changes of nutritional and psychological status after megestrol acetate treatment of cancer cachexia.   Rivista Italiana Di Nutrizione Parenterale Ed Enterale, 1997; 15(1):20-23. 

6.         Simons J, Schols A, Hoefnagels J, Westerterp K, ten-Velde G, Wouters E, Effects of medroxyprogesterone acetate on food intake, body composition, and resting energy expenditure in patients with advanced, nonhormone-sensitive cancer: a randomised placebo-controlled trial.  Cancer, 1998; 82(3):553-60. 

7.         American College of Physicians, Parenteral nutrition in patients receiving cancer chemotherapy.  American College of Physicians position paper.  Ann Intern Med, 1989; 110:734-6. 

Key Messages

1.      Little food and water are needed for inactive dying patients.

2.      Total parenteral nutrition and nasogastric tube feeding are usually not appropriate.

3.      Dehydration is sometimes beneficial to the patient and can be corrected, if necessary, ith subcutaneous fluid infusion.

4.      Drug treatment is of limited use.

5.      Explanation to and support of patient and family are of utmost important.