PATHOPHYSIOLOGY OF CACHEXIA,NUTRTIONAL MANAGEMENT

1. Nutrition in cancer
patient
DR.BRIJESH
MAHESHWARI

2. Goals for cancer treatment
Cancer treatment goals depend on the patient’s status,
but quality of life is important in all stages of cancer
Cure Control Comfort
QOL QOL

3. Frequency/severity of weight loss
associated with cancer
80
60
40
20
0
0%–5% 5%–10% >10%
Weight loss in previous 6 months
Colon Prostate
Lung
small cell
Lung non-
small cell Pancreas
Non-
measurable
gastric
Measurable
gastric
14%
14%
28%
10%
20%
14%
21%
15%
28%
26%
32%
30%
29%
38%
%
Patients
with
weight
loss
26%
18%
23% 18%
29%
21% 20%
DeWys et al.
Am J Med 1980;69:491.

4. Malnutrition in cancer patients
 It is a condition that results from eating a diet in which
nutrients are either not enough or are too much such that the
diet causes health problems. It may involve calories, protein,
carbohydrates, vitamins or minerals.
 Reduction of food intake is a common manifestation of
cancer, presenting in 15-40% of patients and up to 80% of
those with advanced malignancy
 More than 80% of all patients suffers from: Anorexia, Nausea,
and Emesis
 Autopsies have shown that malnutrition is one of the most
common causes of death, accounting for 10–20%

5. Waitzberg DL, et al.
Nutrition 2001;17:573-80
*p < 0.01
With cancer Without cancer
794 patients 43.6%
23.3%
Severe Moderate

7. Malnutrition
 It is a state of nutrition in
which a deficiency or excess
of energy, protein and other
nutrients causes measurable
adverse effects on
tissue/body form and
function, and clinical
outcome.

8. Malnutrition in cancer due to therapy
 Some cancer patients are well - nourished
before diagnosis and treatment and become
malnourished during therapy
Kern, JPEN 1988;2:286
Ollenschager, Recent Results Cancer Res 1998; 121:249

9. Prognostic impact of malnutrition

10. Cachexia and malnutritiion

11. Cachexia is a complex syndrome that involves
weight loss, loss of muscle and adipose
tissue, anorexia, and weakness
Key clinical features of cachexia
 Weight loss (> 10%)
 Systemic inflammation (C-reactive protein > 10 mg/L)
 Reduced food intake (< 1500 kcal/day)
Tan and Fearon. 2008. Curr Opin Clin Nutr Metab Care 11: 400-407.
Fearon et al. 2006. Am J Clin Nutr 83: 1345-1350.
Cancer cachexia defined

12. Cachexia diagnosis
EvansWJ et al, Clin Nutr 2008;27:793-9

13. Cancer cachexia
versus simple starvation
Cancer cachexia Starvation
Body weight
Lean body mass
Body fat
Total energy expenditure
Resting energy expenditure
Protein degradation
Adapted from Kotler DP. 2000. Ann Intern Med133:622-634.

14. CT Scan of adipose tissue mass
OBESE
BMI: 46
Body Fat: 47%
CACHEXIA
BMI: 16
Body Fat: 12.5%

15. Stages of Cancer Cachexia

16. Cancer cachexia: causes and effects
Acute Phase
Response
( CRP)
Appetite
depression
Cachexia with weight loss, inflammation, fat depletion, muscle wasting,
Poor clinical outcomes
Body’s Immune response to tumor
Cytokine production elicits local
and systemic inflammatory response
 Proteolysis- inducing
Factor (PIF)
 Food Intake
Loss of
Lean Body Mass
Alteration in
Macronutrient
Metabolism
 Resting
Metabolic
Rate
Release of tumor factors
Cabal-Manzano, et al. 2001. Br J Cancer 84: 1599-1601.
Argiles and Lopez-Soriano. 1998. Med Hypothesis 51: 411-415.
Todorov, et al. 1996. Cancer Research 56: 1256-1261.

17. Nutritional status at the beginning
of chemotherapy
• 64.7% Stomach and esophageal cancer patients are
malnourished
• 5.8% obese patients
• 48.4% Colorectal cancer patients are malnourished
• 3.2% obese patients
• 58.0% Breast cancer patients are overweight or obese
• 9% malnourished

18. The impact of cancer-induced weight
loss
 In 1555 patients with cancer of the digestive
tract
 Those who presented with loss of weight before
chemotherapy had decreased survival time
 Those who stopped losing weight had better
survival rates
Andreyev et al.
Eur J Cancer 1998;34:503-9.

19. Nutritional screening vs assessment
 Patient Gererated Subjective Global
Assessment (PG - SGA)
 Malnutrition ScreeningTool (MST)
 Nutritional Risk Screening (NRS
2002)
 Univ. Nottingham Hospital
 MUST (BAPEN)
 Glasgow prognostic score
RISK

20. Ideal nutritional assesment tool
 Sensitive enough to idnetify alterations in early
stage
 Specific enough to be modified only due to
nutritional imbalances
 A nutrition intervention would correct its
alteration
 Correction of its levels would result in a better
outcome
Seres D et al, Clin Pract 2006;21:529-32

21. Components of SGA
Makhija S, Baker J. Nutr Clin Pract 2008;23:405-409

22. SGA questionnaire
Detsky AS, et al. JPEN J Parenteral Enterall Nutr 1987;11:8-13
Montaya JE et al. Singapore Med J 2010;51:860-4

23. Effect of RadiationTherapy
on Malnutrition
 Nutritional problems may arise depending on:
– Area exposed
– Duration and total radiation dose
 Radiotherapy can result in:
– burning sensation to the throat, loss of appetite, taste alterations, sore
mouth, dry mouth, damage or loss of teeth, abdominal cramping,
nausea, fatigue, malabsorption or diarrhoea
 More than 10% of patients lose over 10% of their usual weight when
radiotherapy continues for a period of 6-8 weeks
 Eg- RT with or without Concurrent Chemo to Head & Neck Region,
GIT and Pelvic Tumors.

24. Effect of Surgery on Malnutrition
 Resection and bypass of segments of GI
tract
 Postoperative complications such as
fistulas, strictures

25. Effects of Chemotherapy
on Malnutrition
 Chemotherapy can result in the following nutritional problems:
nausea, anorexia, vomiting, diarrhoea, constipation, taste changes, mucositis,
internal ulceration, malabsorption
 Multiple combinations of cytotoxic drugs can increase side effects
 Normal and malignant cells can be damaged
 Intake often decreases with each cycle of chemotherapy and food aversions
occur in up to 74% of patients
 Eg- Cisplatin, 5FU, Methotrexate, Carboplatin, Paclitaxel and Docetaxel

26. Weight loss of 5% in cancer patients
results in
• Increased toxicity of chemotherapy
• Decreased response to therapy
• Increased morbidity and mortality
• Increased unplanned hospitalizations
• Increased length of hospital stay
• Decreased quality of life
• Decreased functional status
.
Van Cutsem E, et al. EurJ Oncol Nurs. 2005;9 suppl 2:S51

27. Causes Of Anorexia In
Cancer Patients
• Pain,
• Nausea, vomiting
• Abnormal taste,
• Abnormal smell,
• Loss appetite,
• Depression,
• Weakness,
• GI disturbance/Obstruction

28. Objectives of Nutrition
Therapy
o Maintenance / improvement of nutritional status
o Maintenance / improvement of subjective quality of life
o Increase in treatment efficacy
o Reduction of treatment related side effects and complications
o Preserve lean body mass
o Maintain strength and energy
o Protect immune function, decreasing the risk of infection
o Aid in recovery and healing
o Improvement of prognosis, prevention of treatment breaks or delays

29. Efficacy of nutritional support in
cancer, contd
 Better quality of life
 Better physical performance and function
 Better body image, maintenance of weight
 Family satisfaction
 Avoiding death due to electrolyte
imbalances (eg, Na, K, Ca, Mg, P) and
micronutrient (vitamins, trace element)
deficiencies

30. Current Strategies
forWeight Stabilization
 Pharmacologic agents
 Nutrition counseling
 Oral supplementation
 Tube feeding
 Parenteral nutrition – central vein or
peripheral vein

32. Nutrition intervention
Parenteral nutrition
Oral supplementation
Enteral nutrition
Oral diet

33. Oral diet
 “If the gut works use it”
 Alone when 80% of nutritional
requirements are reached
 Modulated oral diet
 Respect individual preferences
 Oral supplements

34. Oral supplements
 Hypercaloric and hyperproteic
 Omega-3 (EPA)
 Glutamine
 Soluble fiber – prebiotics
 Probiotics
 Other nutrients (arginine, BCAA)
 Micronutrients

35. Enteral Feeding
 Enteral nutrition is also called tube feeding.
 Enteral nutrition is giving the patient nutrients in liquid form
through a tube that is placed into the stomach or small
intestine. The following types of feeding tubes may be used:
 A nasogastric tube
 A gastrostomy tube
 Enteral nutrition is sometimes used when the patient is able
to eat small amounts by mouth, but cannot eat enough for
health. Nutrients given through a tube feeding add
the calories and nutrients needed for health

36. Indications for Parenteral
Nutrition in Oncology
 Individual need depending on:
 Nutritional status
 Co-morbidities (concomitant diseases)
 Type of anti-neoplastic treatment
 Patient’s performance status
 Parenteral nutrition is indicated when:
 Oral / enteral nutrition < 500 Kcal/d expected for at least 5 days
 Oral / enteral nutrition < 60% of the calculated nutritional needs
expected for at least 10 days

37. Conclusion
 Malnutrition is a problem among cancer
patients
 It impacts on outcome
 Medical awareness is low
 Not the case with patients
 Interventions should be considered
 Oral supplements are important
 EPA should be considered

38. Our food should be our medicine,
Our medicine should be our food.

56. Thank you