Download ppt - Management of cancer cachexia. Cancer cachexia Anorexia, chronic nausea, asthenia, psychological stress. Poor survival and decreased tolerance to both

Management of cancer cachexia

Cancer cachexia Anorexia, chronic nausea, asthenia,

psychological stress. Poor survival and decreased tolerance

to both radiotherapy and chemotherapy. No evidence : nutritional or

pharmacological intervention improve survival.

Exception : GI obstruction from malignancy.

Lancet Oncolo 2000;1:138-47

Goals Ideal : reverse syndrome

completely eliminate tumor mass impossible

Reasonable : Improving general comfort. Relieving of symptoms : anorexia,

nausea, asthenia. Improve level of functioning.


Management approach Nutrition Pharmacological intervention Psychological and behavioral therapy


Nutrition Nutritional counseling improve the daily

caloric intake. Maximize oral intake by allowing the patient

flexibility in type, quantity and timing if meals. Disease progresses decrease nutritional

support. Adequate mouth care and small amount of ice

chips or sips of cold beverages may be adequate

In dehydration : use hypodermoclysis


ESPEN guideline 2006

Hypodermoclysis• A family member can do hypodermoclysis at home after one lesson from the doctor• Using hypodermoclysis, a family member can give the sick person about 90 ounces of fluid a day by giving 45 ounces of fluid in two different places . American Family Physician Nov

1,2001

Pharmacological interventions Main purpose :

Anorexia Chronic nausea

Not affect psychological distress from a negative body image : no weight gain.


Pharmacological interventions Proven

efficacy Corticosteroi

d Progesterone Metocloprami

de

No proven efficacy Cyproheptadine Hydrazine sulphate Thalidomide Melatonin B2-agonist Anabolic steroid GH Cannabinoid NSAIDs Eicosapentanoic acid(EPA) Branched chain amino acid


CA Cancer J Clin 2002;52:72-91

Corticosteroid Mechanism

Inhibition of synthesis and/or release of proinflammatory cytokines (TNF-α,IL-1), anorexigenic mediators(leptin, CRF, serotonin)

Enhance NPY levels in hypothalamus.

X

X


Corticosteroid Improving appetite, food intake,

sensation of well-being, performance status.

No significant weight gain. Dose : 20-40 mg of prednisolone Risk : peptic ulcer, etc.


Progesterone Mechanism

Stimulate NPY in the hypothalamus

Modulation of Ca channel in VMH(satiety center)

Inhibition of proinflammatory cytokines

X

X


Progesterone Improve appetite, caloric intake, sensation

of well-being. Significant weight gain (mostly fat) . Dose : megestrol acetate 160-1600 mg ,

optimum dose : 800 mg Response can be seen in 1 week. Risk : thromboembolism, breakthrough

bleeding, peripheral edema, hyperglycemia, hypertension, Cushing syndrome, alopecia, adrenal insufficiency.


Metoclopramide Mechanism

Antidopaminergic drug

Central antiemetic Gastroprokinetic :

improve gastric emptying

X

X


Metoclopramide Improve in appetite, food intake. Dose : 10 mg before meals and

bedtime. Risk : minimal


Cyproheptadine Mechanism

Antiserotoninergic RCT

mild increase appetite, food intake.

No weight gain. Risk : sedation

X


Hydrazine sulphate Mechanism

Inhibit gluconeogenesis

Pilot study improve appetite and

nutritional status. No weight gain.

Substantial side effects and deterioration of QOL scales

X


Thalidomide Mechanism

Inhibit production of TNF-α

Pilot study Improve appetitie,

well-being, nausea, insomnia

X


Melatonin Mechanism

Decrease circulating concentration of TNF-α

Preliminary studies Weight loss > 10%

fewer than best supportive care

X


Beta-adrenoreceptor agonist Clenbuterol

Mechanism Decrease protein

catabolism. Positive effect on

muscle mass in tumor-bearing rats.

Risk : nervousness, tachycardia, tremor, headache.

X


Anabolic steroid Mechanism

Decrease protein catabolism

RCT Less effective than

dexamethasone/megestrol acetate in appetite and nutritional variables.

X


Growth hormone Mechanism

Stimulate muscle protein synthesis.

No trial in cancer cachexia. X


Cannabinoid Mechanism

Stimulate appetite No trial in cancer

cachexia. Risk :

somnolence, confusion, perceptual disturbance.

X


NSAIDs Mechanism

Inhibit the production of cytokine

Stimulate appetite Preliminary

studies : Ibuprofen Weight gain Decrease

production of CRP

X

X


EPA(Eicosapentanoic acid) Omega 3 fatty acid

Mechanism Inhibition of

lipolysis and muscle protein degradation

Eicosapentanoic acid decrease production of IL-6

RCT : controversy in efficacy

X

X X


Psychological and behavioral therapy Multidisciplinary approach

Oncologist Nurses Dieticians Patient and family

Secondary depression. Relaxation, hypnosis, group

psychotherapy.


Thank you