Cancer anorexia and its impact on the survival journey Palliative Care Rounds October 30, 2003...

Cancer anorexia and its Cancer anorexia and its impact on the survival impact on the survival

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Palliative Care Rounds Palliative Care Rounds October 30, 2003October 30, 2003

Michelle Kralt, RN MNMichelle Kralt, RN MNmichelle.kralt@cancercare.mb.camichelle.kralt@cancercare.mb.ca

The World Heath Organization explains that The World Heath Organization explains that Palliative care: Palliative care:

“…“…provides relief from pain and other provides relief from pain and other distressing symptoms, integrates the distressing symptoms, integrates the psychological and spiritual aspects of care and psychological and spiritual aspects of care and offers a support system to help patients live as offers a support system to help patients live as actively as possible until death”actively as possible until death”

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

Session objectivesSession objectives

1. Examine pathophysiologic changes 1. Examine pathophysiologic changes associated with cancer-related anorexiaassociated with cancer-related anorexia

2. Discuss interventions for cancer-related 2. Discuss interventions for cancer-related anorexiaanorexia

3. Appreciate the impact anorexia has on 3. Appreciate the impact anorexia has on quality of life in people with cancer.quality of life in people with cancer.

What is anorexia?What is anorexia?

““orexis” – Greek for “appetite”; “A” – orexis” – Greek for “appetite”; “A” – “without” = anorexia; meaning to be without “without” = anorexia; meaning to be without appetiteappetite

Appetite is psychological, dependent on Appetite is psychological, dependent on memory and associations, as compared with memory and associations, as compared with hungerhunger, which is physiologically aroused by , which is physiologically aroused by the body’s need for food.the body’s need for food.

One can feel hungry and have anorexia One can feel hungry and have anorexia simultaneouslysimultaneously

CachexiaCachexia

is derived from the the Greek “kakos” is derived from the the Greek “kakos” meaning “bad” and “hexis” meaning meaning “bad” and “hexis” meaning “condition”“condition”

Is a debilitating state of involuntary loss of Is a debilitating state of involuntary loss of adipose tissue and skeletal muscle mass. adipose tissue and skeletal muscle mass.

Is usually diagnosed when pts have weight Is usually diagnosed when pts have weight loss more than 5% of preillness weight in loss more than 5% of preillness weight in previous 2 to 6 months.previous 2 to 6 months.

Different types of AnorexiaDifferent types of Anorexia

1. Anorexia nervosa: refusal to eat, most 1. Anorexia nervosa: refusal to eat, most commonly occurs in pubescent girls in commonly occurs in pubescent girls in developed countries.developed countries.

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

Cancer-related anorexiaCancer-related anorexia

3. primary anorexia is the absence of appetite 3. primary anorexia is the absence of appetite despite obvious nutritional needs despite obvious nutritional needs

It is directly caused by the cancer It is directly caused by the cancer It is most commonly seen in individuals with lung, It is most commonly seen in individuals with lung,

pancreatic, and gastric cancerspancreatic, and gastric cancers Anorexia is not dependent on a large tumor burdenAnorexia is not dependent on a large tumor burden

May also occur with infections, renal failure, AIDS, CHF, May also occur with infections, renal failure, AIDS, CHF, IBD,COPDIBD,COPD

Significance of anorexiaSignificance of anorexia

Anorexia has been reported in 6% of early Anorexia has been reported in 6% of early diagnosis to 85% of advanced cancer patients diagnosis to 85% of advanced cancer patients (Watanabe & Bruera, 1996, Starsseer & Bruera, 2002). (Watanabe & Bruera, 1996, Starsseer & Bruera, 2002).

Anorexia effects both the patient and carer; for Anorexia effects both the patient and carer; for the carer, it can seem like the pt is “giving up.”the carer, it can seem like the pt is “giving up.”

Anorexia may often be the first presenting sign Anorexia may often be the first presenting sign of cancer 50% of the timeof cancer 50% of the time (Damsky Dell, 2002)(Damsky Dell, 2002)

Continued…Continued…

Anorexia is associated with asthenia, fatigue Anorexia is associated with asthenia, fatigue and weaknessand weakness

Change in body imageChange in body image Cognitive impairmentCognitive impairment

Clinical significance of weight lossClinical significance of weight loss

Weight loss of >5% of pre illness state Weight loss of >5% of pre illness state significantly increase symptom distress and significantly increase symptom distress and functional status in patients. functional status in patients. (Sarna et al, 1994).(Sarna et al, 1994).

People with significant weight loss have a People with significant weight loss have a severely impaired tolerance to both radiation severely impaired tolerance to both radiation treatment and chemotherapy treatment and chemotherapy (Stepp & Pakiz, 2001(Stepp & Pakiz, 2001))

A BMI of <18.5 severely reduces physical A BMI of <18.5 severely reduces physical work capacity, significantly impairing a work capacity, significantly impairing a person’s quality of lifeperson’s quality of life

Clinical significance of weight loss Clinical significance of weight loss

Malnutrition leads to 1) gastrointestinal Malnutrition leads to 1) gastrointestinal impairment, 2) respiratory problems, 3) impairment, 2) respiratory problems, 3) cardiac problems and 4) decreased immune cardiac problems and 4) decreased immune function.function.

Anorexia and malnutrition lead to Anorexia and malnutrition lead to deterioration in psychologic function which deterioration in psychologic function which manifests as apathy, lassitude, lack of self help manifests as apathy, lassitude, lack of self help motivation, depression and anxietymotivation, depression and anxiety

Meguid & Laviano, 2001Meguid & Laviano, 2001

Anorexia

Weakness

Fatigue

Depression

Anxiety

Pt’s with significant weight loss experience 40-60% increase Pt’s with significant weight loss experience 40-60% increase in frequency of complications in response to in frequency of complications in response to surgical/medical treatmentssurgical/medical treatments They have higher hospital admissionsThey have higher hospital admissions They have a twofold to threefold higher death rate than They have a twofold to threefold higher death rate than

their well nourished counterparts.their well nourished counterparts.(Meguid & Laviano, 2001)(Meguid & Laviano, 2001)

Median survival was significantly shorter in pts with weight Median survival was significantly shorter in pts with weight loss loss

Chemotherapy responses are lower in pts with weight lossChemotherapy responses are lower in pts with weight loss

(Dewys, et al , 1980).(Dewys, et al , 1980).

Anorexia-cachexia syndromeAnorexia-cachexia syndrome

Anorexia and cachexia are associated and Anorexia and cachexia are associated and often experienced together; however it is often experienced together; however it is possible that one can experience anorexia or possible that one can experience anorexia or cachexia independently of the other.cachexia independently of the other.

Protracted anorexia will eventually lead to Protracted anorexia will eventually lead to cachexia (cachexia (Morris, 1999Morris, 1999))

ACS is one of the most common causes of ACS is one of the most common causes of death in cancerdeath in cancer

Physiology of appetitePhysiology of appetite

Appetite is the desire to eat and is influenced Appetite is the desire to eat and is influenced by cultural, sensory, and physiological by cultural, sensory, and physiological consequences consequences on choices and intakes of foodson choices and intakes of foods

Decreased plasma

glucose

Spinal

Cord

Glucose receptors in the hypothalamus

Sympathetic

Neurons

Net Effect:

Plasma fatty acids and glucose

Liver Muscle Adipose

Tissue

Adrenal

medualla

Pathophysiology of Pathophysiology of primary anorexia (& primary anorexia (&

cachexia)cachexia)

Yesterday’s theoryYesterday’s theory

Cancer steals nutrients from bodyCancer steals nutrients from body metabolism increases to meet demand metabolism increases to meet demand toxins secreted that depress appetitetoxins secreted that depress appetite

Dispelling the Myths of CachexiaDispelling the Myths of Cachexia

-Cachexia ≠ Anorexia-Cachexia ≠ Anorexia

-Cachexia is not caused by the tumor consuming -Cachexia is not caused by the tumor consuming the nutrientsthe nutrients

-Cachexia ≠ Starvation-Cachexia ≠ Starvation

Characteristics of Cancer Versus Starvation Cachexia

Variable Starvation CancerEnergy intake ( *)Energy Expenditure (resting)

Body fat

Skeletal muscle

Liver †atrop

hy

Increased size and metabolic

activity‡

Todays’ TheoryTodays’ Theory

Cytokines

NeurohormonalAlterations

Metabolic Abnormalities

1. Inefficient metabolic alterations1. Inefficient metabolic alterations

Energy expenditure in relation to lean body Energy expenditure in relation to lean body mass is increased.mass is increased.

Glucose turnover is present via hepatic Glucose turnover is present via hepatic gluconeogenesis and lipolysisgluconeogenesis and lipolysis

Whole body protein turnover increased, amino Whole body protein turnover increased, amino acid turnover is alteredacid turnover is altered

Increase in production of c-reactive proteinIncrease in production of c-reactive protein

Elevated amino acids Elevated amino acids levels in the plasma may levels in the plasma may decrease appetitedecrease appetite

2. Neurhormonal regulation and 2. Neurhormonal regulation and food intakefood intake

LHA = Lateral Hypothalamic Area

VMH = Ventral Medial Hypothalamic Area

Homeostasis

Hypothalamus

VMH LHASatiety

Center

Hunger

Center

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

CytokinesCytokines

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

CytokinesCytokines

TNF-TNF-αα (tumour necrosis factor alpha) (tumour necrosis factor alpha) IL-1 (Interleukin 1)IL-1 (Interleukin 1) IL-6 (Interleukin 6)IL-6 (Interleukin 6) CCK (Cholecystokinin)CCK (Cholecystokinin) CRF (Corticotropin releasing factor)CRF (Corticotropin releasing factor)

Anorexigenic Neuropeptide

Neurotensin

Melanocortin

CRF

Orexigenic Neuropeptide

Glucogon

CCKLeptin

Blood Brain Barrier

NPY

AGRP

MCH Neurotensin

Melanocortin

CRF

Glucogon

CCKLeptin

NPY

AGRP

MCH

CNS Cytokinase

Cytokinase

CNTF

IL-1

CNS CytokinaseCNTFIL-1

Food Intake

Energy Expenditure

Food Intake

Energy Expenditure

Seratonin

Blood Brain Barrier

IL-6

Tryptophan

Glucocorticoids

ACTH

Anorexigenic Neuropeptide

Orexigenic Neuropeptide

IL-1IL-6

TNF-INF-

_

+

+

+

+

+

+

+

++

+

+

+

+

_

_

_

__

__

_

A B

Taste ChangesTaste Changes

Taste and smell aversions are also common with Taste and smell aversions are also common with cancer related anorexiacancer related anorexia

Possible link between high levels of serotonin and Possible link between high levels of serotonin and taste aversions taste aversions (Edelman et al, 1999)(Edelman et al, 1999)

A large tumor burden can increase the degree and A large tumor burden can increase the degree and duration of taste alterations duration of taste alterations (Sherry, 2001)(Sherry, 2001)

Etiology of taste changesEtiology of taste changes

1. Presence of malignant cells or cancer tx 1. Presence of malignant cells or cancer tx may reduce # of taste budsmay reduce # of taste buds

2. Dividing cancer cells secrete amino acid-2. Dividing cancer cells secrete amino acid-like substance, causing a bitter taste sensationlike substance, causing a bitter taste sensation

3. Cancer-induced deficiencies in zinc, copper, 3. Cancer-induced deficiencies in zinc, copper, nickel and vitamin A, which are heavy metals nickel and vitamin A, which are heavy metals involved in normal taste functioninvolved in normal taste function

Comprehensive assessment of Comprehensive assessment of anorexiaanorexia

1. detailed hx of involuntary weight loss1. detailed hx of involuntary weight loss 2. Hx of nutritional intake2. Hx of nutritional intake 3. perceived change in body image?3. perceived change in body image? 4. presence of anorexia? (Visual analog scale)4. presence of anorexia? (Visual analog scale) 5. Anxiety/depression?5. Anxiety/depression? 6. Taste or smell changes?6. Taste or smell changes? 7. Dysphagia or painful mouth problems?7. Dysphagia or painful mouth problems?

Assessment continuedAssessment continued

8. thyroid function test8. thyroid function test 9. early satiety?9. early satiety? 10. nausea and vomiting?10. nausea and vomiting? 11. constipation?11. constipation? 12. Sleep patterns12. Sleep patterns 13. Fatigue?13. Fatigue? 14. Functional status?14. Functional status? 15. pain? 15. pain?

ExperientialExperiential

Why not TPN/EN?Why not TPN/EN?

TPN/EN causes further anorexiaTPN/EN causes further anorexia Complications (ie: mechanical, metabolic and Complications (ie: mechanical, metabolic and

infection)infection) ExpensiveExpensive Does not improve survival Does not improve survival Does not cause weight gainDoes not cause weight gain How does one make the decision to How does one make the decision to

discontinue TPN – very hard for pt & familydiscontinue TPN – very hard for pt & family

Orexigenic agentsOrexigenic agents

MegaceMegace CorticosteroidsCorticosteroids DronabinolDronabinol CyproheptadineCyproheptadine ThalidomideThalidomide MelatoninMelatonin

NSAIDS/COX-2NSAIDS/COX-2 Fish oils Fish oils

(Eicosapentaenoic acid)(Eicosapentaenoic acid)

MetoclopramideMetoclopramide Ginger rootGinger root EssiacEssiac

Nursing interventionsNursing interventions

Acknowledge the losses the patient and family Acknowledge the losses the patient and family are experiencing and help them explore these are experiencing and help them explore these losses, including time to explore the losses, including time to explore the possibilities of the futurepossibilities of the future

Encourage family members to focus their Encourage family members to focus their energies on other activities that convey energies on other activities that convey nurturingnurturing

Nursing interventions continued…Nursing interventions continued…

Educate that failure to eat is not “giving up,” Educate that failure to eat is not “giving up,” and that the pt will not “starve to death”. and that the pt will not “starve to death”.

Explaining the nature of ACS as irreversible Explaining the nature of ACS as irreversible and caused by metabolic abnormalities, and and caused by metabolic abnormalities, and that eating more food will not help the pt gain that eating more food will not help the pt gain weightweight

ConclusionConclusion

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