Anorexia and cachexia is common among patients with advanced cancer.
Originally published in
, Summer 2003.
When Dahlia Cox began chemotherapy as part of her treatment for colon cancer in July 2002, she lost 12 pounds in three weeks. “I couldn’t keep food down,” says the 80-year-old retired kindergarten teacher from Decatur, Georgia.
What Cox experienced was anorexia, loss of the desire to eat or lack of hunger, which is only one aspect of a complex syndrome called cachexia or cancer “wasting”—the loss of weight common among patients with advanced cancer. In fact, according to the American Cancer Society, up to 40 percent of cancer patients report unexplained weight loss at first diagnosis; 80 percent experience weight loss in cancer’s advanced stages.
Understanding the source of cachexia is important, says Daniel W. Nixon, MD, president of the Institute for Cancer Prevention in New York City, who has studied the issue for more than 25 years.
“The first thing that a doctor and patient must determine is whether it is primary or secondary,” says Nixon. “Primary means the tumor is the direct cause by impacting the body’s ability to maintain weight for some reason. Secondary cachexia is related to treatment, and it can often be impacted more effectively than primary.”
Primary cachexia can cause early satiety—getting full too fast and/or cancer-related changes in the bowel that inhibit nutrient absorption or weight loss from unknown tumor host mechanisms. Secondary cachexia is associated with treatment that may include surgery issues, nausea, vomiting, and food aversions brought on by chemotherapy and radiation as well as obstructional cancers of the oropharynx and esophagus, in which consuming food in general is a challenge.
Those with gastric, pancreatic, small-cell and non-small cell lung cancer are especially at risk for cachexia because the tumor itself can set off a domino effect of hormonal and inflammatory changes that throw the body into a hypermetabolic state—one in which calories burn at a much higher rate than normal.
“Tumor-induced cachexia is like pushing on the gas pedal of a car stuck in the mud,” says registered dietitian Rebecca Wright, RD, Tulsa, Oklahoma. “You can eat and eat, but lose weight. We call it ‘hitting the wall.’ ”
Dr. Nixon says such weight loss is hard to manage and no data show conventional nutrition will have an impact.
“Cancer is a growing group of cells that needs food,” Nixon says. “It’s like a parasite, growing as the body shrinks. What we are trying to do is figure out the mechanism that allows the tumor to do that and block it.”
What makes tumor-induced cancer cachexia particularly problematic is that the body will preferentially cannibalize protein in the form of lean body mass, which includes the large muscles of the arms and legs as well as organ tissue in the heart and diaphragm. As a result, breathing can become more difficult and the heart can become stressed, says Wright. Cachexic muscle loss can also heighten fatigue and affect long-term prognosis.
One of the best ways to conquer cachexia is to stick to your treatment plan. “We know the chemotherapy, for example, is working when a patient starts gaining weight,” says Herman Kattlove, MD, a medical oncologist in Los Angeles and medical editor for the American Cancer Society. However, for some cachexic patients, such as those with advanced breast cancer, weight gain during treatment may worsen prognosis.
“Women need to gain what is called functional weight,” says Nixon. “Water weight and fat weight are not good and could be detrimental.”
Overall, to combat secondary cachexia, “It’s important to consolidate calories by consuming as many nutrient-dense calories as you can,” says Kim Dalzell, PhD, RD, director of Holistic Nutrition Counseling Services, Cancer Resource Center, Gurnee, Illinois, and author of Challenge Cancer and Win! Step-By-Step Nutrition Action Plans For Your Specific Cancer.
But how do you do that when you don’t feel like eating, fill up too fast, or otherwise have trouble consuming enough calories? Here are some timely weight-maintenance tips to chew on.
Rev your appetite: To stimulate appetite and promote weight gain, your doctor may prescribe steroids or a synthetic progestin (female hormone) such as Megace (megestrol) or Marinol (dronabinol), which contains a synthetic version of the active ingredient in marijuana. Take them as prescribed. “They don’t work for everyone,” says Kattlove.
“Marinol definitely gave me the munchies,” says Nathan Ehrlich, a 6-foot, 19-year-old sophomore at Brandeis University in Boston, who got down to 130 pounds after receiving a bone marrow transplant in 2000 to treat his leukemia. Ehrlich adds that he was unaware of how much his body would be affected, and while being treated for acute myeloid leukemia, he preferred to eat cold foods like ice cream, popsicles, and salads because the chemotherapy dulled his taste buds and dried out his mouth.
Pack on protein: Because cancer cachexia can preferentially metabolize stored protein (muscle), you’ll generally need to consume 20% more daily protein than normal—or 1.2 grams of protein per kilogram of your body weight—to retain lean body mass, says Julia Hemingray, a registered dietitian at Food and Friends, an organization that delivers specially prepared meals at no charge to cancer patients in Washington, D.C.
Of course, whole food sources of protein, such as lean red meat, fish, and skinless chicken are excellent options. But you may not be able to eat enough of them to meet your quota, in which case, it’s a good idea to “spike” your foods with whey-based protein powder. Mix protein powder into soups and stews, oatmeal, fruit juice, and smoothies.
Don’t be a fat phobic: Omega-3 fatty acids, a “healthy” type of fat found in cold-water fish such as salmon and fish-oil supplements, are thought to help minimize the cascade of hormonal and inflammatory events in the body that drive hypermetabolic cachexia. And although more investigation is needed, recent studies indicate that omega-3 fatty acids may reverse cancer cachexia.
Take antinausea drugs preventively: If your doctor prescribes an antinausea drug such as Zofran (ondansetron), Kytril (granisetron), or Anzemet (dolasteron), take it before you feel nauseous (before you’ve had a chemotherapy treatment). “It’s easier to prevent nausea than to treat it,” says Wright. Another anti-nausea drug, Emend (aprepitant) was recently approved by the FDA and has been shown to be helpful in minimizing delayed chemotherapy-induced nausea.
Divide and conquer: Instead of structuring your day around breakfast, lunch, and dinner, which can seem like too much to tackle, think of your day as a running buffet and eat a couple of bites here and there, says Carolyn Katzin, a certified nutrition specialist at the Center for Health and Healing, St. Vincent’s Medical Center, Los Angeles, California, and author of The Cancer Nutrition Center Handbook.
“And if you aren’t hungry at dinnertime, make breakfast or lunch your main meal,” she says, adding that heating food in the microwave will prevent odor-induced nausea. “Microwaved food tends to give off less aroma than food that’s cooked or baked.” Another option she recommends is eating cold foods instead. And sip smoothies and other beverages through a straw with a lidded cup.
Eat your water: Instead of simply drinking water throughout the day and with meals, sip vegetable soup or low-sodium vegetable or fruit juice instead. All are nutrient-dense calorie sources that can help maintain cellular health and help you stay hydrated.
Fiber up: Besides a cornucopia of nutrients, whole grains like oatmeal and fruits and vegetables are a good source of fiber. “Fiber is especially important for cancer patients because it can help control the diarrhea or constipation they may be experiencing from chemotherapy, which can interfere with nutrient absorption,” says Hemingray.
Don’t wait to weight train: Even though you may be fatigued, it’s important to resistance train to maintain and rebuild lean tissue. Do what you can. “Besides sticking to an anticachectic diet, we have patients do bicep curls with 2- to 3-pound hand or wrist weights for 30 to 90 seconds several times throughout the day,” says Keith Block, MD, an integrative oncologist and editor of Integrative Cancer Therapies. “You might also try strapping on ankle weights and, while sitting on the edge of your bed, extend your knees slowly, one at a time. Isometric exercises and resistance bands can also be helpful for preventing cachexic muscle loss. In general, “the adage, ‘If you don’t use it, you lose it,’ holds true,” Block says.
Nixon says research continues as to the causes and control of cachexia, including how to starve the tumor and not the body.
Editor’s note: Dahlia Cox passed away April 8, 2003. CURE is proud to honor her memory.
“And I wasn’t hungry, so I didn’t want to eat.” Alarmed by her weight loss, Cox’s physicians stressed the importance of trying to maintain her standard 124 pounds throughout her six months of treatment. Since then, Cox has been steadily gaining. Her secret: “I realized that I just couldn’t say, ‘Oh, I’m not hungry today,’ and give up. I had to work at eating.”