Effect of fish oil on appetite and other symptoms in patients with advanced cancer and anorexia/cachexia: a double-blind, placebo-controlled study

Therapy Insight: cancer anorexia–cachexia syndrome—when all you can eat is yourself

Tumor growth is associated with profound metabolic and neurochemical alterations, which can lead to the onset of anorexia-cachexia syndrome. Anorexia is defined as the loss of the desire to eat, while cachexia results from progressive wasting of skeletal muscle mass--and to a lesser extent adipose tissue--occurring even before weight loss becomes apparent. Cancer anorexia-cachexia syndrome is highly prevalent among cancer patients, has a large impact on morbidity and mortality, and impinges on patient quality of life. However, its clinical relevance is frequently overlooked, and treatments are usually only attempted during advanced stages of the disease. The pathogenic mechanisms of cachexia and anorexia are multifactorial, but cytokines and tumor-derived factors have a significant role, thereby representing a suitable therapeutic target. Energy expenditure in anorexia is frequently increased while energy intake is decreased, which further exacerbates the progressive deterioration of nutritional status. The optimal therapeutic approach to anorectic-cachectic cancer patients should be based on both changes in dietary habits, achieved via nutritional counseling; and drug therapy, aimed at interfering with cytokine expression or activity. Our improved understanding of the influence a tumor has on the host's metabolism is advancing new therapeutic approaches, which are likely to result in better preservation of nutritional status if started concurrently with specific antineoplastic treatment.

Investigating the utility of serum cytokine measurements in a multi-institutional cancer anorexia/weight loss trial

BACKGROUND

Interleukin-1 beta (IL-1beta), tumor necrosis factor alpha (TNFalpha), and interleukin-6 (IL-6) have been implicated in the cancer anorexia/weight loss syndrome. However, previous smaller studies have yielded conflicting results as to whether circulating, serum concentrations of these cytokines are in fact elevated. As the translational component of a large multi-institutional trial, this study assessed the clinical value of serum concentrations of these cytokines in patients with this syndrome.

METHODS

Patients with incurable cancer with anorexia and/or weight loss were eligible. All underwent weekly weight measurements and appetite assessment for the first month and then monthly assessments thereafter. Serum was obtained at baseline and at 1 month, and all three cytokines were measured with the Immunolite assay.

RESULTS

A total of 118 patients participated. At baseline, 99%, 54%, and 47% of patients' samples had undetectable IL-1beta, TNFalpha, and IL-6, respectively. Similar results were obtained at 1 month. No correlations were observed between serum cytokine concentrations and changes in weight or appetite. Baseline serum IL-6 predicted a diminished survival but only after adjustment for age and cancer site.

CONCLUSION

Serum concentrations of IL-1beta, TNFalpha, and IL-6, as measured in this study, provide data of limited clinical value for patients with the cancer anorexia/weight loss syndrome.

Fish oil supplementation in the treatment of cachexia in pancreatic cancer patients

Patients with pancreatic cancer often experience a loss of weight and appetite, known as the anorexia-cachexia syndrome, which is associated with decreased quality of life and reduced survival. Research into the biological mechanisms of cachexia has demonstrated that an array of inflammatory mediators and tumor-derived factors cause appetite suppression, skeletal muscle proteolysis, and lipolysis,producing an overall hypercatabolic state that contributes to loss of fat and lean body mass. Omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been shown to modulate levels of proinflammatory cytokines, hepatic acute phase proteins, eicosanoids, and tumor-derived factors in animal models of cancer and may reverse some aspects of the process of cachexia. Results of clinical trials of n-3 PUFAs in the form of fish oils have been mixed, but should encourage further investigation into dietary fish oil supplementation, including the most effective route of administration and the proper dosage to promote optimal weight maintenance and to limit side effects. Concerns about standardization and quality control should also be considered. With the current available evidence, a recommendation for the use of omega 3 polyunsaturated fatty acids in pancreatic cancer cachexia is premature.

Nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy--a pilot study

GOALS OF THE WORK

The aim of this study was to examine the effect of nutrition intervention on outcomes of dietary intake, body composition, nutritional status, functional capacity and quality of life in patients with cancer cachexia receiving chemotherapy.

PATIENTS AND METHODS

Patients received weekly counselling by a dietitian and were advised to consume a protein- and energy-dense oral nutritional supplement with eicosapentaenoic acid for 8 weeks. The medical oncologist determined the chemotherapy protocol. Eight patients enrolled and seven completed the study.

MAIN RESULTS

There were significant improvements in total protein intake (median change 0.3 g/kg per day, range -0.1 to 0.8 g/kg per day), total energy intake (median change 36 kJ/kg per day, range -2 to 82 kJ/kg per day), total fibre intake (median change 6.3 g/day, range -3.4 to 20.1 g/day), nutritional status (patient-generated subjective global assessment score, median change 9, range -5 to 17), Karnofsky performance status (median change 10, range 0-30) and quality of life (median change 16.7, range 0-33.3). There were clinically significant improvements in weight (median change 2.3 kg; range -2.7 to 4.5 kg) and lean body mass (median change 4.4 kg, range -4.4 to 4.7 kg), although these were not statistically significant. Change in nutritional status was significantly associated with change in quality of life, change in Karnofsky performance status and change in lean body mass.

CONCLUSIONS

Nutrition intervention together with chemotherapy improved outcomes in patients with pancreatic and non-small-cell lung cancer over 8 weeks. Supplement intake does not inhibit meal intake.

Outcome research in palliative care: could it represent a new dimension of clinical research or clinical practice?

Outcome research is a new dimension of clinical research, and all fields of clinical medicine are involved in this kind of analysis. Overall survival and quality of life are the main outcomes identified in clinical oncology. The former must be the main outcome whenever possible; the latter has to be the main outcome when an improvement of overall survival cannot be expected. It follows that quality of life is the main outcome of palliative care, in which the patient instead of the disease represents the target of the clinical approach. In our critical paper, we review the meaning of clinical outcomes in palliative care, classifying the outcomes as main and surrogate outcomes, and the results of the trials as indexes of activity and efficacy of a treatment. We also review the main randomized clinical trials on the treatment of cancer cachexia, trying to define the role of the treatments in cachexia-related symptom control and quality of life improvement. Strictly related to outcome analysis is the dimension of pharmacoeconomic evaluation. The models of the different designs of pharmacoeconomic analysis are revisited in an attempt to conjugate the pharmacoeconomic evaluation with the particular dimension of palliative care.

Dietary flaxseed protects against ventricular fibrillation induced by ischemia-reperfusion in normal and hypercholesterolemic Rabbits

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), the (n-3) PUFA found in fish oils, exert antiarrhythmic effects during ischemia. Flaxseed is the richest plant source of another (n-3) PUFA, alpha-linolenic acid (ALA), yet its effects remain largely unknown. Our objective was to determine whether a flaxseed-rich diet is antiarrhythmic in normal and hypercholesterolemic rabbits. Male New Zealand White (NZW) rabbits (n = 14-16) were fed as follows: regular diet (REG group); diet containing 10% flaxseed (FLX group); 0.5% cholesterol (CHL group); or 0.5% cholesterol + 10% flaxseed (CHL/FLX group) for up to 16 wk. Plasma cholesterol was significantly elevated in the CHL and CHL/FLX groups. Plasma triglycerides were unchanged. ALA levels increased significantly in plasma and hearts of the FLX and CHL/FLX groups. After the feeding period, rabbit hearts were isolated and subjected to global ischemia (30 min) and reperfusion (45 min). Ventricular fibrillation (VF) occurred during ischemia in 33% of REG but in none of FLX hearts, and 28% of CHL but only 6% of CHL/FLX hearts. VF incidence during reperfusion was 28% and 26% in REG and FLX hearts, respectively. The incidence significantly increased to 64% in CHL hearts, and was significantly attenuated (18%) in CHL/FLX hearts. CHL markedly prolonged the QT interval, whereas FLX significantly shortened the QT interval and reduced arrhythmias in the FLX and CHL/FLX hearts. In vitro application of (n-3) PUFA shortened the action potential duration, an effect consistent with the QT data. This study demonstrates that dietary flaxseed exerts antiarrhythmic effects during ischemia-reperfusion in rabbit hearts, possibly through shortening of the action potential.

The path from oral nutrition to home parenteral nutrition: a qualitative interview study of the experiences of advanced cancer patients and their families

BACKGROUND AND AIM

Little is known about the perspectives that patients with advanced cancer and their family members have concerning nutritional problems and nutritional support. The aim of this study was to investigate their experiences of the nutritional situation prior to introduction of home parenteral nutrition (HPN) in order to understand factors contributing to the decision to accept HPN.

METHODS

Semi-structured interviews were conducted with 13 patients with advanced cancer who had received HPN and 11 family members. The constant comparative method was used for data analysis.

RESULTS

Patients and family members described the nutritional situation prior to HPN as a source of worry and often desperation. Patients reported wanting and trying to eat, but being unable to do so. Family members experienced powerlessness and frustration, as they could not enable the patient to eat. A lack of attention to nutritional problems by the hospital staff was described. The offer of HPN came when patients and family no longer felt able to solve the nutritional problems within the family.

CONCLUSION

The desperate and chaotic nutritional situation in the family led to willingness to accept HPN. Because of the severity of the problems, HPN was viewed as a positive alternative.

Should CA-125 Response Criteria Be Preferred to Response Evaluation Criteria in Solid Tumors (RECIST) for Prognostication During Second-Line Chemotherapy of Ovarian Carcinoma?

Purpose

The aim of the study was to compare the prognostic value of a response by the Gynecologic Cancer Intergroup (GCIG) Cancer Antigen (CA) -125 response criteria and the Response Evaluation Criteria in Solid Tumors (RECIST) on survival in patients with ovarian carcinoma receiving second-line chemotherapy.

Patients and Methods

From a single-institution registry of 527 consecutive patients with primary ovarian carcinoma, 131 records satisfied the inclusion criteria: ovarian carcinoma of International Federation of Gynecology and Obstetrics stage IC to IV, first-line chemotherapy with paclitaxel and a platinum compound, refractory or recurrent disease, and second-line chemotherapy consisting of topotecan or paclitaxel plus carboplatin. Univariate and multivariate analyses of survival were performed using the landmark method.

Results

In patients with measurable disease by RECIST and with assessable disease by the CA-125 criteria (n = 68), the CA-125 criteria were 2.6 times better than the RECIST at disclosing survival. In a multivariate Cox analysis with inclusion of nine potential prognostic parameters, CA-125 response (responders v nonresponders; hazard ratio, 0.21; P < .001) and number of relapse sites (solitary v multiple; hazard ratio, 0.47; P = .020) were identified as contributory prognostic factors for survival, whereas the parameters of RECIST (responders v nonresponders), as well as the remaining variables, had nonsignificant prognostic impact.

Conclusion

The GCIG CA-125 response criteria are a better prognostic tool than RECIST in second-line treatment with topotecan or paclitaxel plus carboplatin in patients with ovarian carcinoma.

A pilot study on safety and pharmacokinetics of infliximab for the cancer anorexia/weight loss syndrome in non-small-cell lung cancer patients

BACKGROUND

Weight loss predicts a poor prognosis for patients with non-small-cell lung cancer. Tumor necrosis factor alpha (TNFalpha) is a mediator of this weight loss, yet no studies have tested infliximab, an IgG monoclonal antibody that blocks the binding of TNFalpha to its p55 and p75 receptors, for this indication. The safety and pharmacokinetics of infliximab in combination with docetaxel, a commonly used chemotherapy agent for non-small-cell lung cancer, were explored in this pilot study.

METHODS/RESULTS

Four patients with metastatic non-small-cell lung cancer were treated initially with infliximab 5 mg/kg per day intravenously once a week on weeks 1, 3 and 5, and docetaxel 36 mg/m2 per day intravenously once a week on weeks 1, 2, 3, 4, 5 and 6 of an 8-week treatment cycle. Therapy was well tolerated with no grade 4 or 5 adverse events. Maximal serum concentrations of infliximab at 1, 3 and 5 weeks were (mean+/-SD) 108+/-11, 135+/-19, and 139+/-6 microg/ml, respectively, and appeared similar to historical concentrations from non-cancer patients not receiving concomitant chemotherapy (144+/-68 microg/ml). One patient manifested weight stability. One patient manifested a partial tumor response, one stable disease, and two disease progression. Median survival within the cohort was 203 days (range 111 to 324 days).

CONCLUSIONS

The above combination appears safe, and docetaxel does not appear to increase serum concentrations of infliximab. A larger study testing the role of this combination for weight loss in non-small-cell lung cancer patients is ongoing and utilizes the doses described above.

Phase II study of high-dose fish oil capsules for patients with cancer-related cachexia

BACKGROUND

The authors undertook a multiinstitutional Phase II cooperative group study to examine the potential of oral fish oil fatty acid supplements administered at high doses to slow weight loss and to improve quality of life in patients with malignancy-related cachexia.

METHODS

Patients with advanced malignancy and weight loss > or = 2% of body weight in the preceding month took concentrated, high-dose omega-3 fatty acid capsules (7.5 g eicosapentaenoic acid plus docosahexaenoic acid for a 70 kg individual) that were supplied by the National Institutes of Health.

RESULTS

Forty-three patients with moderate or severe malnutrition were enrolled. The median time receiving treatment was 1.2 months. For the 36 patients who took at least 1 capsule and did not have edema, there was a weight change ranging from -6.2 kg to +3.5 kg and an overall median weight loss of 0.8 kg. Twenty-four patients had weight stabilization (a gain of < or = 5% or a loss of < 5%), 6 patients gained > 5% of their body weight, and 6 patients lost > or = 5% of their body weight. There was marked variability in the tolerability of the capsules, and many patients had gastrointestinal side effects. There was a correlation between time receiving treatment and weight gain for the 22 patients who were able to tolerate the capsules for at least 1 month. Quality-of-life scores were superior for patients who gained weight.

CONCLUSIONS

A majority of patients did not gain weight, and in that sense, the results of the study were unfavorable. However, a small but definite subset of patients had weight stabilization or weight gain. This suggests that omega-3 fatty acids have potential utility at the study doses, which were more than twice the doses used in published Phase III studies.

An eicosapentaenoic acid supplement versus megestrol acetate versus both for patients with cancer-associated wasting: a North Central Cancer Treatment Group and National Cancer Institute of Canada collaborative effort

PURPOSE

Studies suggest eicosapentaenoic acid (EPA), an omega-3 fatty acid, augments weight, appetite, and survival in cancer-associated wasting. This study determined whether an EPA supplement-administered alone or with megestrol acetate (MA)-was more effective than MA.

PATIENTS AND METHODS

Four hundred twenty-one assessable patients with cancer-associated wasting were randomly assigned to an EPA supplement 1.09 g administered bid plus placebo; MA liquid suspension 600 mg/d plus an isocaloric, isonitrogenous supplement administered twice a day; or both. Eligible patients reported a 5-lb, 2-month weight loss and/or intake of less than 20 calories/kg/d.

RESULTS

A smaller percentage taking the EPA supplement gained >or= 10% of baseline weight compared with those taking MA: 6% v 18%, respectively (P =.004). Combination therapy resulted in weight gain of >or= 10% in 11% of patients (P =.17 across all arms). The percentage of patients with appetite improvement (North Central Cancer Treatment Group Questionnaire) was not statistically different: 63%, 69%, and 66%, in EPA-, MA-, and combination-treated arms, respectively (P =.69). In contrast, 4-week Functional Assessment of Anorexia/Cachexia Therapy scores suggested MA-containing arms experienced superior appetite stimulation compared with the EPA arm, with scores of 40, 55, and 55 in EPA-, MA-, and combination-treated arms, respectively (P =.004). Survival was not significantly different among arms. Global quality of life was not significantly different among groups. With the exception of increased impotence in MA-treated patients, toxicity was comparable.

CONCLUSION

This EPA supplement, either alone or in combination with MA, does not improve weight or appetite better than MA alone.

Cancer anorexia: clinical implications, pathogenesis, and therapeutic strategies

Anorexia and reduced food intake are important issues in the management of patients with cancer because they contribute to the development of malnutrition, increase morbidity and mortality, and impinge on quality of life. Accumulating evidence indicates that cancer anorexia is multifactorial in its pathogenesis, and most of the hypothalamic neuronal signalling pathways modulating energy intake are likely to be involved. Several factors are considered to be putative mediators of cancer anorexia, including hormones (eg, leptin), neuropeptides (eg, neuropeptide Y), cytokines (eg, interleukin 1 and 6, and tumour necrosis factor), and neurotransmitters (eg, serotonin and dopamine). These pathways are not isolated and distinct pathogenic mechanisms but are closely inter-related. However, convincing evidence suggests that cytokines have a vital role, triggering the complex neurochemical cascade which leads to the onset of cancer anorexia. Increased expression of cytokines during tumour growth prevents the hypothalamus from responding appropriately to peripheral signals, by persistently activating anorexigenic systems and inhibiting prophagic pathways. Hypothalamic monoaminergic neurotransmission may contribute to these effects. Thus, the optimum therapeutic approach to anorectic cancer patients should include changes in dietary habits, achieved via nutritional counselling, and drug therapy, aimed at interfering with cytokine expression or hypothalamic monoaminergic neurotransmission.

Megestrol acetate in pediatric oncology patients may lead to severe, symptomatic adrenal suppression

BACKGROUND

Despite the widespread use of megestrol acetate (MA) among a growing number of pediatric oncology departments, there is only one published study on the use of MA in children with malignant disease. The objectives of the current study were to examine the effect of MA in improving the nutritional status of children with malignant disease and to describe and consider the implications of MA-associated adrenal suppression that was found consistently.

METHODS

Medical records of 19 children with malignant disease who were treated with MA were reviewed. During MA therapy, clinical assessments every 4 weeks included anthropometrics, caloric intake, quality-of-life scores, and appetite scores. Serum cortisol levels, lipid profiles (including cholesterol levels) random blood glucose levels, and coagulation screening were measured at 4-6-week intervals.

RESULTS

MA use was associated with significant increases in weight, weight z score, middle-upper arm circumference, triceps skin-fold thickness, appetite, and caloric intake. MA was extremely useful in aiding the efficient tapering of nasogastric feeds. However, a significant and potentially dangerous decrease in cortisol was seen in 10 of 11 patients tested, with 1 patient who manifested clinical hypoadrenalism with hemodynamic collapse, requiring inotropic support. This is the first report of MA-associated clinical adrenal suppression in a child with malignant disease.

CONCLUSIONS

Although the results of this study support the ability of MA to improve nutritional status, its use was complicated by severe adrenal suppression in almost all patients tested, with a serious clinical adverse event occurring in one patient. Routine hydrocortisone supplementation throughout MA treatment should be considered as well as larger doses for patients with acute illness and patients who undergo surgery.

Plasma and neutrophil fatty acid composition in advanced cancer patients and response to fish oil supplementation

Metabolic demand and altered supply of essential nutrients is poorly characterised in patients with advanced cancer. A possible imbalance or deficiency of essential fatty acids is suggested by reported beneficial effects of fish oil supplementation. To assess fatty acid status (composition of plasma and neutrophil phospholipids) in advanced cancer patients before and after 14 days of supplementation (12+/-1 g day(-1)) with fish (eicosapentaenoic acid, and docosahexaenoic acid) or placebo (olive) oil. Blood was drawn from cancer patients experiencing weight loss of >5% body weight (n=23). Fatty acid composition of plasma phospholipids and the major phospholipid classes of isolated neutrophils were determined using gas liquid chromatography. At baseline, patients with advanced cancer exhibited low levels (<30% of normal values) of plasma phospholipids and constituent fatty acids and elevated 20 : 4 n-6 content in neutrophil phospholipids. High n-6/n-3 fatty acid ratios in neutrophil and plasma phospholipids were inversely related to body mass index. Fish oil supplementation raised eicosapentaenoic acid and docosahexaenoic acid content in plasma but not neutrophil phospholipids. 20 : 4 n-6 content was reduced in neutrophil PI following supplementation with fish oil. Change in body weight during the supplementation period related directly to increases in eicosapentaenoic acid in plasma. Advanced cancer patients have alterations in lipid metabolism potentially due to nutritional status and/or chemotherapy. Potential obstacles in fatty acid utilisation must be addressed in future trials aiming to improve outcomes using nutritional intervention with fish oils.