Elsevier

Surgical Oncology

Volume 8, Issue 3, November 1999, Pages 133-141
Surgical Oncology

Cancer cachexia

https://doi.org/10.1016/S0960-7404(99)00045-6Get rights and content

Abstract

Cachexia is a common cause of morbidity and mortality in patients with advanced cancer. It is characterised by numerous metabolic abnormalities including inefficient substrate utilisation, alterations in the balance of energy intake and expenditure and the acute-phase protein response. These changes seem to be driven by pro-inflammatory cytokines, alterations of the neuro-endocrine axis and tumour-derived catabolic factors. This results in the loss of both fat and lean tissue. Trials of conventional nutritional supplements in patients with cancer cachexia have failed to show any benefit in terms of weight gain or quality of life and this may be because the ongoing metabolic abnormalities prevent the efficient use of additional calories supplied. A variety of pharmacological agents have been studied in an attempt to normalise these metabolic changes with only limited success. However, it is possible that the combination of an agent to normalise the metabolic milieu along with the provision of additional nutritional support may have the potential to reverse cachexia in advanced cancer.

Introduction

There is increasing recognition that the nutritional state of patients with surgical disease has important implications for their outcome. This is particularly true in patients with malignant disease who frequently suffer marked and progressive weight loss. This review attempts to examine the nature and causes of weight loss in cancer patients and the options for management.

Weight loss in cancer is common, being seen in the majority of patients with gastric, pancreatic, lung, prostate and colon cancer [1], [2]. In contrast haemotological malignancies and breast cancer are seldom associated with substantial weight loss. Weight loss in cancer patients is associated with shortened survival [1], [3] and poor quality of life [4]. Such patients also have impairment of physical function [5] and a greater risk of postoperative complications [6]. Weight loss may itself be a cause of mortality in a small but significant proportion of cancer patients [7], [8].

The pattern of weight loss seen in cancer patients is different to that seen in patients losing weight from simple starvation and forms part of the syndrome of cachexia. In addition to weight loss, cachexia in cancer is characterised by anorexia, changes in taste perception, early satiety and weakness [9]. Starvation primarily produces losses of fat but also muscle and visceral protein while cancer patients may lose 75% of muscle protein and 80% of fat with relative preservation of visceral protein [10], [11]. Thus, different mechanisms appear to be at work in cancer patients compared with those suffering from starvation.

Section snippets

Energy intake

Nutritional intake has been shown to be substantially reduced in weight-losing cancer patients [12], [13]. A reduction in food intake is certainly a major cause of weight loss in the majority of patients although it can be difficult to measure precisely. Cancer patients may frequently suffer from physical obstruction of the gastrointestinal tract, pain, depression, constipation, debility, malabsorption or the effects of treatment such as opiates, radiotherapy or chemotherapy which may all

Treatment of cancer cachexia — nutritional approaches

The best way to treat cancer cachexia is to cure the cancer. Unfortunately, this remains an infrequent achievement among adults with solid tumours. The next obvious option is to increase nutritional intake by enteral or parenteral means.

Two substantial randomised trials have examined the effect of enteral feeding in patients with advanced cancer undergoing chemotherapy [80], [81]. Both studies included patients with a variety of cancer types who were randomised to receive nutritional

Cancer cachexia the future

While progress has been made in understanding many of the physiological processes surrounding cachexia in cancer it remains a significant cause of morbidity and mortality in malignant disease. The metabolic alterations that occur in these patients would appear to prevent the effective use of additional calories supplied. A number of pharmacological agents have shown promise in normalising some of these metabolic changes and it may be that in the future a combination of one of these agents with

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