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Pandey S, Bradley L, Del Fabbro E. Updates in Cancer Cachexia: Clinical Management and Pharmacologic Interventions. Cancers (Basel) 2024; 16:1696. [PMID: 38730648 PMCID: PMC11083841 DOI: 10.3390/cancers16091696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Despite a better understanding of the mechanisms causing cancer cachexia (CC) and development of promising pharmacologic and supportive care interventions, CC persists as an underdiagnosed and undertreated condition. CC contributes to fatigue, poor quality of life, functional impairment, increases treatment related toxicity, and reduces survival. The core elements of CC such as weight loss and poor appetite should be identified early. Currently, addressing contributing conditions (hypothyroidism, hypogonadism, and adrenal insufficiency), managing nutrition impact symptoms leading to decreased oral intake (nausea, constipation, dysgeusia, stomatitis, mucositis, pain, fatigue, depressed mood, or anxiety), and the addition of pharmacologic agents when appropriate (progesterone analog, corticosteroids, and olanzapine) is recommended. In Japan, the clinical practice has changed based on the availability of Anamorelin, a ghrelin receptor agonist that improved lean body mass, weight, and appetite-related quality of life (QoL) compared to a placebo, in phase III trials. Other promising therapeutic agents currently in trials include Espindolol, a non-selective β blocker and a monoclonal antibody to GDF-15. In the future, a single therapeutic agent or perhaps multiple medications targeting the various mechanisms of CC may prove to be an effective strategy. Ideally, these medications should be incorporated into a multimodal interdisciplinary approach that includes exercise and nutrition.
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Affiliation(s)
- Sudeep Pandey
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.P.); (L.B.)
| | - Lauren Bradley
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.P.); (L.B.)
| | - Egidio Del Fabbro
- Department of Medicine, Division of Palliative Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Nelson KA, Walsh TD, Sheehan FG, O'Donovan PB, Falk GW. Assessment of Upper Gastrointestinal Motility in the Cancer–Associated Dyspepsia Syndrome. J Palliat Care 2019. [DOI: 10.1177/082585979300900105] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cancer patients experience many gastrointestinal symptoms which may lead to weight loss. Assessment of gastrointestinal motility may contribute to our understanding of these symptoms and suggest rational therapeutic approaches to the anorexia-cachexia syndrome. We have evaluated a simple, inexpensive, well-tolerated test of upper gastrointestinal motility in patients with advanced cancer. One-centimetre portions of radiopaque nasogastric tubing were ingested with food. Six hours later, a flat-plate abdominal x-ray was obtained to determine the marker placement. Patients were evaluated for gastrointestinal symptoms. Those with more symptoms, particularly early satiety, had a greater incidence of reduced upper gastrointestinal motility.
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Affiliation(s)
- Kristine A. Nelson
- Palliative Care Program, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - T. Declan Walsh
- Palliative Care Program, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Finbarr G. Sheehan
- Palliative Care Program, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Peter B. O'Donovan
- Department of Diagnostic Radiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gary W. Falk
- Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Nelson KA, Walsh TD. Metoclopramide in Anorexia Caused by Cancer-Associated Dyspepsia Syndrome (CADS). J Palliat Care 2019. [DOI: 10.1177/082585979300900203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anorexia is a common problem in advanced cancer, part of the cancer anorexia-cachexia syndrome. Although the etiology is multifactorial, symptoms suggestive of gastroparesis are often present in patients with cancer anorexia. We have successfully used metoclopramide, a prokinetic agent, to stimulate appetite in advanced cancer and relieve other dyspeptic symptoms associated with anorexia.
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Affiliation(s)
| | - Kristine A. Nelson
- Palliative Care Program, Department of
Hematology/Oncoiogy, Cleveland Clinic Cancer Center, Cleveland, Ohio, USA
| | - T. Declan Walsh
- Palliative Care Program, Department of
Hematology/Oncoiogy, Cleveland Clinic Cancer Center, Cleveland, Ohio, USA
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Wilson J, Plourde JY, Marshall D, Yoshida S, Chow W, Harsanyi Z, Pearen S, Darke A. Long-Term Safety and Clinical Effectiveness of Controlled-Release Metoclopramide in Cancer-Associated Dyspepsia Syndrome: A Multicentre Evaluation. J Palliat Care 2019. [DOI: 10.1177/082585970201800203] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with cancer frequently report gastrointestinal symptoms such as anorexia, early satiety, nausea, vomiting, and bloating. A reduction of the severity of some of these symptoms would benefit the patient by enhancing quality of life and improving their treatment. Forty-eight patients (25 female and 23 male; mean age 63 ±11 years) with a minimum two-week history of cancer-associated gastrointestinal symptoms were assigned to a single, open-label treatment group and received controlled-release metoclopramide 20 mg–80 mg q12h for a maximum period of 12 weeks (mean 46 ±35 days). There was a 40%-60% decrease in the severity of nausea over the first two weeks of treatment, and an approximate 50% reduction in severity of vomiting over the first four weeks of treatment. Appetite and bloating also improved, although smaller and less consistent changes were observed. Patient ratings of overall clinical effectiveness with respect to relief from symptoms and tolerability of side effects indicated that controlled-release metoclopramide was highly and moderately effective in 36% and 30% of the patients, respectively. Controlled-release metoclopramide is a useful treatment for the management of gastrointestinal symptoms associated with the cancer-associated dyspepsia syndrome including nausea, vomiting, loss of appetite, and bloating.
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Affiliation(s)
| | | | | | - Sam Yoshida
- Windsor Regional Cancer Centre, Windsor, Ontario
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Barajas Galindo DE, Vidal-Casariego A, Calleja-Fernández A, Hernández-Moreno A, Pintor de la Maza B, Pedraza-Lorenzo M, Rodríguez-García MA, Ávila-Turcios DM, Alejo-Ramos M, Villar-Taibo R, Urioste-Fondo A, Cano-Rodríguez I, Ballesteros-Pomar MD. Appetite disorders in cancer patients: Impact on nutritional status and quality of life. Appetite 2017; 114:23-27. [DOI: 10.1016/j.appet.2017.03.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/08/2023]
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Del Fabbro E. Current and future care of patients with the cancer anorexia-cachexia syndrome. Am Soc Clin Oncol Educ Book 2015:e229-e237. [PMID: 25993178 DOI: 10.14694/edbook_am.2015.35.e229] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Many important advances have occurred in the field of cancer cachexia over the past decade, including progress in understanding the mechanisms of the cancer anorexia-cachexia syndrome (CACS) and the development of promising pharmacologic and supportive care interventions. However, no approved agents for cancer cachexia currently exist, emphasizing the unmet need for an effective pharmacologic therapy. This article reviews the key elements of CACS assessment in daily practice, the contribution of nutritional impact symptoms (NIS), the evidence for current pharmacologic options, and promising anticachexia agents in perclinical and clinical trials. It also proposes a model for multimodality therapy and highlights issues pertinent to CACS in patients with pancreatic, gastric, and esophageal cancer.
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Affiliation(s)
- Egidio Del Fabbro
- From the Palliative Care Program, Virginia Commonwealth University, Richmond, VA
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Vaidya GN, Lutchmansingh D, Paul M, John S. Gastroparesis as the initial presentation of pulmonary adenocarcinoma. BMJ Case Rep 2014; 2014:bcr-2014-207228. [PMID: 25498111 DOI: 10.1136/bcr-2014-207228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Malignancy-associated gastroparesis is an under-reported entity and its diagnosis as a cause of cachexia or gastrointestinal symptoms is often missed in clinical practice. This case report highlights an unusual association of pulmonary adenocarcinoma with gastroparesis at presentation. Malignancy-associated gastroparesis should be added to the differential diagnosis in patients presenting with delayed gastric emptying of unknown aetiology and should prompt further radiological investigations. Early detection and treatment of underlying gastroparesis in patients with cancer is necessary to improve the quality of life and to avoid premature clinical deterioration due to intolerance to oral treatment.
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Affiliation(s)
| | - Denyse Lutchmansingh
- Department of Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Manju Paul
- Department of Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Savio John
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
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8
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Diagnostic and therapeutic approach to pancreatic cancer-associated gastroparesis: literature review and our experience. Dig Dis Sci 2009; 54:401-5. [PMID: 18618259 DOI: 10.1007/s10620-008-0354-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 06/03/2008] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease. OBJECTIVE To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience. METHODS A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998-2005. RESULTS Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression. CONCLUSIONS We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.
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Bozzetti F, Mariani L. Defining and classifying cancer cachexia: a proposal by the SCRINIO Working Group. JPEN J Parenter Enteral Nutr 2008; 33:361-7. [PMID: 19109514 DOI: 10.1177/0148607108325076] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although cancer cachexia is widely diffuse in the cancer patient population, there is no objective definition and classification of this syndrome. The purpose of this study is to propose a simple and quick classification that relies on the severity of the body weight loss and presence/absence of symptoms that are associated with cancer cachexia. METHODS The authors used a database of an ongoing multicenter prospective investigation on the screening of the nutrition risk of 1307 cancer outpatients from different (mainly Italian) university or scientific institutes or hospitals. The database included demographic, oncologic, clinical, and nutrition data. The patients were divided into 4 classes based on combinations of body weight loss (< 10%, precachexia; > or = 10%, cachexia) and the presence/absence of at least 1 symptom of anorexia, fatigue, or early satiation. The authors verified statistically whether these 4 classes were associated with the distribution of main clinical, nutrition, and oncologic variables, after adjustment for treatment status, by using the Cochrane-Mantel-Hanszel test for count data and ANOVA for continuous data. RESULTS Moving from "asymptomatic precachexia" (class 1) to "symptomatic cachexia" (class 4), there were statistically significant trends (P < .0001) in the percentage of gastrointestinal vs nongastrointestinal tumors, severity of cancer stage, percentage of weight loss, number of symptoms per patient, Eastern Cooperative Oncology Group (ECOG) performance status, and nutritional risk score. CONCLUSIONS The statistical analysis has validated the classification by identifying stages with different severity of cachexia. This classification could be adopted within a comprehensive oncologic approach to the weight-losing patients, until more specific diagnostic techniques are available in clinical practice.
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Davis MP, Walsh D, Lagman R, Yavuzsen T. Early satiety in cancer patients: a common and important but underrecognized symptom. Support Care Cancer 2006; 14:693-8. [PMID: 16773306 DOI: 10.1007/s00520-005-0015-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The severity of anorexia correlates with the presence of early satiety. The sense of fullness limits nutritional intake. The symptom is poorly understood because most assessment questionnaires do not include early satiety. METHODS Patients rarely volunteer early satiety. Central and peripheral mechanisms may be involved in the genesis of early satiety. These would include central sensory specific satiety, food aversions, diurnal changes in intake, gastric motility and accommodation and as gastrointestinal hormones. CONCLUSIONS Prokinetic medications, such as metoclopramide are used to treat early satiety. However, other medications which influence gastric accommodation such as clonidine, sumatriptan, or sildenafil, or diminish enteric afferent output such as kappa opioid receptor agonists, may favorably influence early satiety and should be subject to future research. Translational research is needed to understand the relationship of early satiety to gastric motility and accommodation.
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Affiliation(s)
- Mellar P Davis
- The Harry R Horvitz Center For Palliative Medicine, The Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
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12
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Suzuki S, Goncalves CG, Meguid MM. Catabolic outcome from non-gastrointestinal malignancy-related malabsorption leading to malnutrition and weight loss. Curr Opin Clin Nutr Metab Care 2005; 8:419-27. [PMID: 15930968 DOI: 10.1097/01.mco.0000172583.25009.ab] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Malnutrition of cancer patients is a significant cause of mortality and morbidity. RECENT FINDINGS The contributory factors in cancers anatomically involving the gastrointestinal tract are self-evident. However, how non-gastrointestinal malignancies affect gastrointestinal structure and function is not clear. The aim of this paper is to review the relationship between non-gastrointestinal malignancies and malabsorption, which leads to malnutrition, weight loss and increased mortality. In non-gastrointestinal cancer patients, intestinal morphological atrophy occurs, whereas in the jejunum absorption is impaired. Cytokines including IL-1 and TNF-alpha primarily induce delayed gastric emptying and also act directly on intestinal mucosa to induce malabsorption. These cytokines also directly act on several gastrointestinal hormones including cholecystokinin, neuropeptides including corticotropin-releasing factor, and via the vagus to decrease gastrointestinal motility. SUMMARY The combination of small intestine atrophy and delayed gastrointestinal motility are some of the reasons for malabsorption in cancer patients with non-gastrointestinal malignancies that contribute to the catabolic process.
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Affiliation(s)
- Sususmu Suzuki
- Surgical Metabolism and Nutrition Laboratory, Department of Surgery, University Hospital, Upstate Medical University, Syracuse, New York 13210, USA
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13
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Bruera E, Moyano JR, Sala R, Rico MA, Bosnjak S, Bertolino M, Willey J, Strasser F, Palmer JL. Dexamethasone in addition to metoclopramide for chronic nausea in patients with advanced cancer: a randomized controlled trial. J Pain Symptom Manage 2004; 28:381-8. [PMID: 15471656 DOI: 10.1016/j.jpainsymman.2004.01.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2004] [Indexed: 11/17/2022]
Abstract
Chronic nausea occurs in most patients with advanced cancer. This study was done to assess the antiemetic effects of dexamethasone in patients with chronic nausea refractory to metoclopramide. Secondary outcomes included appetite, fatigue, and pain. Fifty-one patients who had nausea (> or = 3/10 on a 0-10 scale) for > or = 2 weeks despite 48 hours of oral metoclopramide therapy (40-60 mg/day) were enrolled. Patients received 20 mg/day dexamethasone (DM) orally (n = 25) or placebo (n = 26) for severe nausea in addition to metoclopramide (60 mg/day orally). At baseline the mean nausea intensity ratings in the DM and placebo groups were 8.0 and 7.4. At Day 8 they were 2.1 and 2.0, respectively. At Day 3 and Day 8, the mean difference in nausea intensity for the DM and placebo groups was 4.5 and 2.9 (P = 0.16) and 5.9 and 5.7 (P = 0.85), respectively. Improvement in appetite and fatigue were observed on Day 3 and Day 8 in both groups as compared with the baseline. Pain, vomiting, well-being, and quality of life remained unchanged in both groups at both times. We conclude that DM was not superior to placebo in the management of chronic nausea in our patients with advanced cancer.
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Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care & Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston 77030, USA
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14
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Abstract
Declining physical, emotional, and social function as a result of anorexia and cachexia are considerable contributors to discomfort for cancer patients and their families, and they impair the patient's ability to express optimal physical and psychosocial potential as long as possible. This decline no longer has to be accepted as an indispensable sequel to advanced cancer, just as pain is no longer considered to be unavoidable. A routine screening for anorexia and cachexia and associated symptoms is necessary, as is a careful, comprehensive assessment, because the condition is not always obvious. Decisions about anorexia and cachexia treatment are guided by prioritizing the different, concurrent physical, psychosocial, and existential problems and by considering the natural course of the cancer and the effects of antineoplastic therapies. Reversible causes for anorexia and cachexia need to be identified and treated, if appropriate. Nutritional interventions are often indicated; patients with a predominant starvation component and without inflammation may profit the most. New pharmacologic therapies for primary anorexia and cachexia syndrome are expected to enter clinical practice soon; however, until then, treatment with corticosteroids, progestins, or prokinetics may be indicated for some patients. To understand a multicausal syndrome, multimodal and interdisciplinary therapy is required. Specialist palliative care services can be helpful to provide, hand-in-hand with the disease specialists [172], assessment and management of psychophysical symptoms and sociospiritual needs of patients during the course of the illness and at the end of life [173]. Research efforts aim to better characterize subgroups of patients suffering from secondary causes of anorexia and cachexia and to elucidate the mechanisms involved in the primary anorexia and cachexia syndrome. Increasingly individualized treatments are expected with combination treatments that involve different mechanisms including nutrition.
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Affiliation(s)
- Florian Strasser
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA
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15
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Abstract
Cancer-related anorexia/cachexia (CAC) is a complex phenomenon in which metabolic abnormalities, proinflammatory cytokines produced by the host immune system, circulating tumour-derived catabolic factors, decreased food intake, and probably additional unknown factors, all play different roles. This review examines the mechanisms of CAC and its management. All the potential modalities of intervention from nutritional to pharmacological approaches are included with a clear distinction between unproven, investigational and well established treatments. Among the latter, the progestogens are currently considered the most effective and safest drugs for the management of CAC. Agents currently under investigation for CAC include thalidomide, pentoxifylline and melatonin, which most probably act on cytokine release, and clenbuterol, which acts on muscle mass and to antagonise protein wasting. Our personal experience with the synthetic progestogens megestrol and medroxyprogesterone supports their use as first-line agents. In addition, our work on the potential role of antioxidant agents in counteracting the oxidative stress, which appears to be involved in CAC, shows them to be promising agents when used in combination chemotherapy regimens either alone or with other 'biologics'. There is an ongoing need for quality of life questionnaires which specifically address the most significant symptoms present in patients with CAC.
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Affiliation(s)
- G Mantovani
- Department of Medical Oncology, University of Cagliari, Italy.
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Lee HR, Lennon VA, Camilleri M, Prather CM. Paraneoplastic gastrointestinal motor dysfunction: clinical and laboratory characteristics. Am J Gastroenterol 2001; 96:373-9. [PMID: 11232678 DOI: 10.1111/j.1572-0241.2001.03454.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to describe the clinical, manometric, and serological characteristics of 12 patients with paraneoplastic GI motor dysfunction and to assess the contributory role of diagnostic tests. METHODS Twelve patients diagnosed with malignant tumors and GI motor dysfunction were identified at the Mayo Clinic from 1985 to 1996. RESULTS Cancers identified were: nine small cell lung carcinoma (SCLC), one anaplastic lung adenocarcinoma, one retroperitoneal lymphoma, and one ovarian papillary serous adenocarcinoma. GI symptoms preceded the tumor diagnosis in all cases of SCLC (mean, -8.7 months, range, -1 to -24 months, n = 9). The diagnosis of a malignant tumor preceded the onset of GI symptoms in the three patients with other neoplasms (6, 12, and 24 months). Five of the nine patients found to have SCLC had no evidence of tumor on initial chest x-ray. One or more paraneoplastic autoantibodies were found in 10 of the 11 patients tested by autoimmune serology. Type 1 antineuronal nuclear antibody (ANNA-1 or anti-Hu) was detected in eight of the nine patients with SCLC (one patient was not tested). The patient with ovarian carcinoma had type 1 Purkinje cell cytoplasmic antibody (PCA-1 or anti-Yo). N-type calcium channel antibodies were found in one patient with SCLC, one with a retroperitoneal B cell lymphoma, and one with ovarian carcinoma. Gastric emptying was delayed in 89% (eight of nine tested) and 80% (four of five tested) had esophageal dysmotility. Autonomic reflex tests were abnormal in the seven patients tested. CONCLUSIONS The diagnosis of paraneoplastic GI motor dysfunction requires a high index of clinical suspicion. A panel of serological tests for paraneoplastic autoantibodies, scintigraphic gastric emptying, and esophageal manometry are useful as first-line screening tests. Seropositivity for ANNA-1, PCA-1, or N-type calcium channel-binding antibodies should prompt further evaluation for an underlying malignancy even when routine imaging studies are negative.
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Affiliation(s)
- H R Lee
- Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
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Langer CJ, Hoffman JP, Ottery FD. Clinical significance of weight loss in cancer patients: rationale for the use of anabolic agents in the treatment of cancer-related cachexia. Nutrition 2001; 17:S1-20. [PMID: 11428126 DOI: 10.1016/s0899-9007(01)80001-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- C J Langer
- Fox Chase Cancer Center, Philadelphia, Pa., USA
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18
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Westman G, Bergman B, Albertsson M, Kadar L, Gustavsson G, Thaning L, Andersson M, Straumits A, Jeppson B, Lindén CJ, Ewers SB, Andersson H, Mercke C, Hafström L, Birck O, Orgum P. Megestrol acetate in advanced, progressive, hormone-insensitive cancer. Effects on the quality of life: a placebo-controlled, randomised, multicentre trial. Eur J Cancer 1999; 35:586-95. [PMID: 10492632 DOI: 10.1016/s0959-8049(98)00398-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A randomised double-blind placebo-controlled multicentre trial was performed to investigate the effects of megestrol acetate (MA) on the quality of life (QoL), appetite, weight and survival of patients with advanced, incurable, hormone-insensitive cancer. QoL was assessed at the start of treatment and at 4, 8 and 12 weeks, using the EORTC-QLQ-C30 instrument. 255 patients were randomised to 320 mg of MA daily or placebo for 12 weeks. 244 patients were assessable at baseline, 190 at 4 weeks (placebo 94; MA 96), 150 at 8 weeks (placebo 69; MA 81) and 112 at 12 weeks (placebo 55; MA 57). A beneficial effect of MA on appetite loss was observed at week 4 (P < 0.0001) and possibly at week 8 (P = 0.058). Further weight loss during treatment was significant only in the placebo group. In the first 8 weeks, changes in mean global QoL were small and similar in both groups. By 12 weeks the decrease in mean global QoL was more pronounced in the MA group (P = 0.028), which was related to a deterioration in physical function, while psychosocial function was not affected. Survival was not affected by MA, and side-effects were mild. The results show that MA has a beneficial effect on appetite and that it may retard weight loss with no adverse impact on survival and with mild toxicity. However, MA does not appear to improve global QoL as measured by the EORTC QLQ-C30.
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Affiliation(s)
- G Westman
- Department of General Oncology, Orebro Medical Center Hospital, Sweden.
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Abstract
A 36-yr-old woman with metastatic mucinous cystadenocarcinoma of the pancreas underwent neurolytic celiac plexus block with 100% ethanol and 0.5% bupivacaine for intractable back pain. Several hours after the procedure she developed severe nausea and vomiting, which persisted for days despite cessation of opioid analgesics, and administration of intravenous metoclopramide and ondansetron. Both esophagogastroduodenoscopy and barium examination of the stomach and small intestine showed excess gastric fluid but no evidence of mechanical obstruction. A radionuclide study revealed delayed gastric emptying of solids. Treatment with oral cisapride 10 mg p.o. q.i.d. resulted in considerable symptomatic improvement. We document the first reported case of gastroparesis after celiac plexus block and discuss possible etiological mechanisms.
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Affiliation(s)
- S Iftikhar
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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20
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Godden D, Devereux G. Nutritional Factors in Respiratory Disease. J R Coll Physicians Edinb 1998. [DOI: 10.1177/147827159802800212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- D.J. Godden
- Thoracic Medicine Unit, Aberdeen Royal Infirmary
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Gough DB, Heys SD, Eremin O. II--Cancer cachexia: treatments strategies. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:286-92. [PMID: 8654614 DOI: 10.1016/s0748-7983(96)80020-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- D B Gough
- Department of Surgery, University of Aberdeen Medical School, UK
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Abstract
The objective of this article was to investigate the relationship between nutrition and cancer, as it relates to the initiation, promotion, and treatment of tumor growth. English-language studies published in the last 25 years were retrieved using MEDLINE, bibliographies, and consultation with experts. MEDLINE search terms included "cancer", "malnutrition," and "nutritional support." In vitro and in vivo controlled studies addressing the impact of nutritional factors on cancer prevention and treatment were selected. Approximately 30% of cancers in the Western countries are diet-related. The presence of malignancy affects patients' nutritional status negatively, leading to increased morbidity and mortality. Standard nutritional support (both enteral and parenteral) is not always effective in significantly improving outcome in malnourished cancer patients, due to characteristic changes in host metabolism. Preliminary studies suggest that newer nutritional-pharmacologic agents may be beneficial in counteracting the derangement of host metabolism, and consequently in ameliorating cancer patients' nutritional status and outcome of malnourishment. This review suggests that dietary manipulations and nutritional-pharmacologic therapy might be highly effective adjuncts in controlling the symptoms of patients with neoplastic disease.
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Affiliation(s)
- A Laviano
- Department of Surgery, University Hospital, SUNY Health Science Center, Syracuse 13210, USA
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Laviano A, Renvyle T, Yang ZJ. From laboratory to bedside: new strategies in the treatment of malnutrition in cancer patients. Nutrition 1996; 12:112-22. [PMID: 8724382 DOI: 10.1016/0899-9007(96)90709-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The objective of this review is to present and discuss the current and the possible future perspectives of artificial nutrition in preventing and treating cancer cachexia. English-language studies published in the last 25 years were retrieved using MEDLINE, bibliographies and consultation with experts. MEDLINE search terms included "cancer," "malnutrition," and "nutritional support." In vivo and in vitro controlled studies were selected, and data from each study were independently abstracted by the authors. Data obtained indicate that cancer cachexia is a common manifestation of advanced malignant disease, characterized by marasmus due to impaired nutrient metabolism, weight loss, and anemia. In patients, the presence of cachexia increases morbidity and mortality, delays or impedes the delivery of the adequate treatment, reduces the efficacy of anti-neoplastic therapy, and impairs patient's quality of life. Indirect evidence indicates that cancer cachexia is mediated by circulating cytokines, produced by the host in response to the presence of the malignancy. In the past two decades, nutritional support was used to counteract the detrimental effect of cancer cachexia on the host, but with limited success. More recently, the better understanding of the mechanisms of cancer cachexia and the identification of pharmacologic effects provided by specific nutrients, has formed the rationale for a "new" mode of nutrition therapy/nutritional support, adding pharmacotherapy to adjunctive initial care.
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Affiliation(s)
- A Laviano
- Department of Surgery, University Hospital, SUNY Health Science Center, New York 13210, USA
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Affiliation(s)
- L E Harrison
- Surgical Metabolism Laboratory, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Sikora SS, Mital BR, Prasad KR, Das BK, Kaushik SP. Functional gastric impairment in carcinoma of the pancreas. Br J Surg 1995; 82:1112-3. [PMID: 7648168 DOI: 10.1002/bjs.1800820835] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- S S Sikora
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Bruera ED, MacEachern TJ, Spachynski KA, LeGatt DF, MacDonald RN, Babul N, Harsanyi Z, Darke AC. Comparison of the efficacy, safety, and pharmacokinetics of controlled release and immediate release metoclopramide for the management of chronic nausea in patients with advanced cancer. Cancer 1994; 74:3204-11. [PMID: 7982184 DOI: 10.1002/1097-0142(19941215)74:12<3204::aid-cncr2820741220>3.0.co;2-g] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The short elimination half-life of metoclopramide necessitates frequent administration for optimal relief of nausea. This study compares a newly developed controlled release preparation of metoclopramide (CRM) and immediate release metoclopramide (IRM) with respect to efficacy, safety, and pharmacokinetics in patients with chronic nausea associated with advanced cancer. METHODS Thirty-four patients with advanced cancer with nausea lasting more than 1 month and with no evidence of involvement of the gastrointestinal tract, peptic ulcer or gastritis, brain metastases, or metabolic abnormalities were randomized, in a double-blind cross-over study, to receive 40 mg of CRM every 12 hours or 20 mg of IRM every 6 hours for 3 days. Nausea, food intake, and side effects were assessed four times daily. On Day 3, sequential venous samples were taken (12 patients) to determine plasma metoclopramide concentrations. RESULTS In 29 evaluable patients, the intensity of nausea on Day 3, measured by a 0-100-mm visual analogue scale and 0-3 categoric scale was 15 +/- 17 and 0.6 +/- 0.6 after IRM, versus 8 +/- 9 (P = 0.033) and 0.4 +/- 0.5 (P = 0.055) after CRM, respectively. Visual analogue scale nausea scores recorded by time of day and by day for the 3 treatment days were significantly lower for patients who received CRM compared with those who received IRM (P = 0.047 and P = 0.043, respectively), but categoric nausea scores were not significantly different between treatments by time of day and by day across the 3 treatment days. No differences were observed in caloric intake or side effects between treatments. In a pharmacokinetic analysis, the CRM/IRM ratio for area under the curve0-12 (microgram x hours x L-1), Cmax (microgram/L), and Tmax (hours) was 100%, 98%, and 2.3 fold, respectively. CONCLUSION Controlled release metoclopramide is safe and effective in managing chronic nausea in patients with advanced cancer. Future studies should focus on characterizing this syndrome more clearly and on determining the optimal dose of metoclopramide and the effects of drug combinations that have proven to be useful in managing chemotherapy-induced emesis (i.e., metoclopramide plus corticosteroids).
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Affiliation(s)
- E D Bruera
- Palliative Care Program, Edmonton General Hospital, Cross Cancer Institute, University of Alberta, Canada
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27
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McCarthy DO, Daun JM. The effect of diet consistency on food intake of anorectic tumor-bearing rats. Res Nurs Health 1992; 15:433-7. [PMID: 1448574 DOI: 10.1002/nur.4770150605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Delayed gastric emptying has been shown to occur in cancer patients complaining of anorexia and early satiety. Given that liquids are emptied from the stomach faster than solid food, the present study was undertaken to determine if diet consistency would affect food intake of hypophagic rats implanted with the Walker 256 carcinosarcoma. By Day 15 of tumor-growth, caloric intake of tumor-bearing animals was 20% less than controls. The caloric intake of tumor-bearing animals fed a liquid diet was not significantly different from animals fed a solid diet. Furthermore, a delay in gastric emptying was not seen in this animal model of tumor-induced anorexia.
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Affiliation(s)
- D O McCarthy
- School of Nursing, University of Wisconsin-Madison 53792-2455
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28
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Abstract
BACKGROUND The current study was undertaken to determine if changes in gastric emptying contribute to tumor-induced anorexia. METHODS Rats were implanted with the Walker 256 carcinoma, and food intake was measured daily. On days 0, 8, and 15, the rats were fasted overnight, gavage fed a bolus of liquid food, and residual gastric contents were measured 3 hours later. RESULTS Tumor growth was associated with a progressive decline in voluntary food intake. When the rats were gavage fed 2.5 or 7 ml of liquid food, the percent of gastric contents cleared in 3 hours was unchanged with tumor growth. CONCLUSIONS Changes in gastric emptying did not contribute to decreased food intake with growth of the Walker 256 in rats.
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Affiliation(s)
- D O McCarthy
- School of Nursing, University of Wisconsin-Madison 53792
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29
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Armes PJ, Plant HJ, Allbright A, Silverstone T, Slevin ML. A study to investigate the incidence of early satiety in patients with advanced cancer. Br J Cancer 1992; 65:481-4. [PMID: 1558808 PMCID: PMC1977596 DOI: 10.1038/bjc.1992.98] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- P J Armes
- Imperial Cancer Research Fund, Department of Medical Oncology, St Bartholomew's Hospital, London
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Kinsley BT, Gramm HF, Rolla AR. Diabetic gastroparesis: a review. THE JOURNAL OF DIABETIC COMPLICATIONS 1991; 5:207-17. [PMID: 1779016 DOI: 10.1016/0891-6632(91)90078-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- B T Kinsley
- Department of Medicine, New England Deaconess Hospital, Boston, Massachussetts 02215
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32
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Geoghegan J, Delaney PV, Egan TJ. Duodenal obstruction in advanced pancreatic carcinoma: how effective is gastroenterostomy in palliation? Ir J Med Sci 1990; 159:213-4. [PMID: 1704358 DOI: 10.1007/bf02937268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Gastro-enterostomy produces variable and often disappointing results in the management of duodenal obstruction due to advanced pancreatic carcinoma. In a series of 51 patients who had palliative surgery for carcinoma of the pancreas five required a gastro-enterostomy. Three of these subsequently had difficulty with gastric emptying. The problem of gastro-enterostomy failure in palliation of pancreatic carcinoma is discussed.
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Affiliation(s)
- J Geoghegan
- Department of Surgery, Limerick Regional Hospital, Dooradoyle, Republic of Ireland
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Choe AI, Ziessman HA, Fleischer DE. Tumor-associated gastroparesis with esophageal carcinoma. Use of intravenous metoclopramide during radionuclide gastric emptying studies to predict clinical response. Dig Dis Sci 1989; 34:1132-4. [PMID: 2663388 DOI: 10.1007/bf01536387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This case report describes a patient with esophageal carcinoma and tumor-associated gastroparesis. The radionuclide gastric emptying study diagnosed very delayed liquid and solid gastric emptying. Metoclopramide was administered intravenously during the study and was able to predict a good response to oral therapy.
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Affiliation(s)
- A I Choe
- Department of Radiology, Georgetown University Medical Center, Washington, D.C
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Grosvenor M, Bulcavage L, Chlebowski RT. Symptoms potentially influencing weight loss in a cancer population. Correlations with primary site, nutritional status, and chemotherapy administration. Cancer 1989; 63:330-4. [PMID: 2910438 DOI: 10.1002/1097-0142(19890115)63:2<330::aid-cncr2820630221>3.0.co;2-u] [Citation(s) in RCA: 140] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A nutritional assessment including determination of symptoms potentially influencing weight loss was prospectively performed on 254 consecutive cancer patients with favorable performance scores (Eastern Cooperative Oncology Group [ECOG] level 0 to 2). Primary cancer sites included the following: non-small cell lung (n = 93), colon (n = 50), prostate (n = 23), oropharyngeal (n = 18), breast (n = 15), gastrointestinal (n = 13), and other (n = 42). Thirty-nine percent of patients had received no prior chemotherapy or radiation therapy. Common symptoms in the population were abdominal fullness (61%), taste change (46%), constipation (41%), mouth dryness (40%), nausea (39%), and vomiting (27%). Current caloric intake was surprisingly similar in 170 patients with weight loss (percent usual body weight [PUBW], less than or equal to 95%) compared with 84 without weight loss (PUBW, greater than 95%; 31.4 +/- 1.5 versus 30.5 +/- 2.1 kcal/kg/d, respectively). Symptoms identified by multivariate analysis as occurring significantly more frequently in populations with weight loss included abdominal fullness (P less than 0.001), taste change (P less than 0.002), vomiting (P less than 0.005), and mouth dryness (P less than 0.02). There was no difference in frequency of symptoms between patients with or without prior chemotherapy. These results indicate that gastrointestinal/oral symptoms potentially influencing weight loss are prevalent early in the course of cancer patients with unresectable disease, regardless of current nutritional status, caloric intake, or prior therapy experience.
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Affiliation(s)
- M Grosvenor
- UCLA School of Medicine, Department of Medicine, Harbor-UCLA Medical Center, Torrance 90509
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35
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Barkin JS, Goldberg RI, Sfakianakis GN, Levi J. Pancreatic carcinoma is associated with delayed gastric emptying. Dig Dis Sci 1986; 31:265-7. [PMID: 3004847 DOI: 10.1007/bf01318117] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fifteen patients with histologically confirmed pancreatic carcinoma, without evidence of gastroduodenal invasion or obstruction, were prospectively studied to determine the frequency of gastric emptying disorders as determined by a solid-phase gastric emptying study. Nine of these (60%) had gastric emptying curves more than two standard deviations below normal mean values. The majority of patients did not have symptoms of gastric stasis. Nausea and/or vomiting was present in 33% of patients with abnormal gastric emptying and in none of those with normal emptying. Abdominal and/or back pain was present in 8/9 with delayed gastric emptying and in 3/6 with normal emptying. Disordered gastric emptying did not correlate with tumor stage, histology, location, or hyperbilirubinemia. Delayed solid-food gastric emptying may be responsible for the nonspecific abdominal complaints that occur during the course of pancreatic carcinoma, although more frequently, gastroparesis exists on a subclinical level.
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Abstract
The previously unaddressed impact of radiotherapy and vagotomy on palliative gastroenterostomy (GE) in patients with unresectable pancreatic cancer was studied. Sixty-eight patients were retrospectively evaluated. A higher overall incidence of complications was found in the group (N = 44) undergoing irradiation as well as gastroenterostomy compared to a group undergoing gastroenterostomy alone. The increased complications were due to 16 episodes of bleeding among the irradiated patients. Rates of obstructive complications were similar for both groups (20%). Rates of bleeding were highest among patients undergoing prophylactic GE and irradiation compared to those receiving GE alone. Vagotomy in 12 patients who were irradiated did not appear to protect against bleeding. We found the irradiated prophylactic GE to provide poor palliation in patients with unresectable pancreatic cancer and recommend it not be performed if radiotherapy is to be used for attempt in local control of unresectable pancreatic cancer.
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Abstract
Metoclopramide, a dopamine antagonist, is approved in the U.S. for the treatment of various gastrointestinal disorders. Its use has been investigated in a wide variety of diseases, including those not involving the intestinal tract. Although more study is required before routine clinical use of metoclopramide can be advocated, it may be effective in the treatment of tardive dyskinesia, in decreasing the risk factors associated with anesthetic-related aspiration, and as an adjunct in the treatment of gastric bezoars. It also may be used safely in patients with Parkinson's disease. The use of metoclopramide in the treatment of neurogenic bladder, orthostatic hypotension, tumor-associated gastroparesis, nonprolactinemic amenorrhea, failure to thrive, Tourette's syndrome, anorexia nervosa, and hiccups, as well as an adjunct to migraine therapy, has been investigated, but sufficient evidence has not been accumulated to advocate the use of metoclopramide in these disorders.
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