Anorexia in cancer patients: Prevalence and impact on the nutritional status

Total Parenteral Nutrition and Tumor Growth in Malnourished Patients with Gastric Cancer

Aims and Background

Evidence that total parenteral nutrition (TPN) can stimulate tumor growth in humans is scanty and contradictory. The purpose of this study was to evaluate the impact of TPN on tumor cell proliferation in malnourished patients receiving preoperative TPN.

Methods

We evaluated variations in the S-phase cell fraction, defined as 3H-thymidine labeling index (TLI), before and after 10 days of TPN or non-administration of nutritional support in 19 malnourished patients (weight loss, ≥ 10%) with gastric cancer. TLI was determined on endoscopic biopsies at the time of diagnosis, and subsequently on the operative specimen or through intraoperative sampling.

Results

At diagnosis, a higher median TLI value was observed in the control than in the TPN group. Administration of TPN enhanced tumor cell proliferation in 50% of patients; however, at surgery there was no difference in the median TLI value of the two groups.

Conclusions

The TPN regimen seems to be associated with increased tumor cell proliferation, even though this stimulating effect was moderate and at surgery the TLIS of TPN patients and controls were not different. Although the potential stimulation probably has little consequence for patients receiving short-term preoperative nutrition, it may call for further investigation in cancer patients undergoing long-term home TPN.

Development and validation of a nutrition screening tool for hospitalized cancer patients

BACKGROUND & AIMS

Although various nutrition screening tools are used, they are not specific for the screening of malnourished cancer patients. The objective of this study was to develop a nutrition screening tool that could be used to identify cancer patients at risk for malnutrition.

METHODS

Of 3010 cancer patients admitted to the National Cancer Center of Korea between April 1 and June 2, 2008, the nutritional status of 1057 patients was assessed by the Scored Patient-Generated Subjective Global Assessment (PG-SGA). Variables used in current nutrition screening tools were analyzed to select indices for a developing malnutrition screening tool for cancer patients (MSTC). The equation for the MSTC was established using receiver operating characteristics curves. Sensitivities and specificities of the MSTC were calculated using the PG-SGA as gold standard.

RESULTS

The MSTC was calculated as follows: [MSTC = -0.116 + (1.777 × intake change) + (1.304 × Eastern Cooperative Oncology Group performance status) + (1.568 × weight loss) + (-0.187 × body mass index)]. The MSTC had a sensitivity of 94.0%, a specificity of 84.2%, and high agreement (κ = 0.70, P < 0.0001) with the PG-SGA.

CONCLUSIONS

The MSTC appears to be a valid nutrition screening tool for determining nutritional risk in hospitalized cancer patients.

An epidemiological evaluation of the prevalence of malnutrition in Spanish patients with locally advanced or metastatic cancer

OBJECTIVE

Malnutrition is frequent in cancer. The objective of this study was to determine the prevalence, in Spain, of malnutrition in cancer patients with advanced disease and to assess the therapeutic focus.

METHODS

A total of 781 patients were evaluated to determine individual nutritional status using the Scored Patient Generated-Subjective Global Assessment (Scored PG-SGA) questionnaire. Almost 60% of the patients included were receiving cancer treatment.

RESULTS

Patients with the highest weight loss were those with tumours of oesophagus (57%), stomach (50%) and larynx (47%). Serious eating problems were encountered by 68% of the patients; the principal problem being anorexia (42.2%). The median number of symptoms impeding food intake was 2. According to the Scored PG-SGA, 52% of the patients were moderately or severely malnourished and 97.6% required some form of nutritional intervention/recommendation.

CONCLUSIONS

(a) the majority of patients in the study needed nutritional intervention; (b) more than 50% had moderate or severe malnutrition; (c) the Scored PG-SGA is a useful and simple tool for evaluating nutritional status and contains additional information on nutritional recommendations; (d) nutritional evaluation of the cancer patients needs to be improved so as to offer better treatment of symptoms and to improve the patient's quality of life.

The syndrome of anorexia-cachexia

Cancer anorexia/cachexia is a major clinical problem, especially in advanced cancer patients. Its pathogenesis is quite complex. Anorexia plays a central role, but cancer cachexia is more complex than pure chronic starvation. One of the key differences is the preferential mobilization of fat and the sparing of skeletal muscle in simple starvation compared with an equal mobilization of fat and skeletal muscle in cancer patients. An increase in basal energy expenditures seems to play a contributory role in many patients. Cytokines, essentially but not exclusively tumor necrosis factor alpha, play an essential role, and the syndrome can be compared with a low-grade chronic inflammatory state. As it is in most fields in medicine, prevention is more efficacious than treatment, and, to avoid the final and dramatic stages of cancer cachexia, adequate nutritional advice and support must be provided sufficiently early. Parenteral nutrition could facilitate the administration of complete doses of chemotherapy or radiotherapy, but no significant survival benefit or decrease in treatment-induced toxicity have ever been demonstrated in prospective randomized trials. The gut should always be used if at all possible. Percutaneous endoscopic gastrostomy is used increasingly in patients who cannot eat but who have functionally intact gastrointestinal tracts, especially in patients with head and neck cancer. Eight randomized, double-blind, placebo-controlled studies have demonstrated that progestational drugs can somewhat stimulate appetite, food intake, and energy level; increase weight in many patients; and often decrease nausea and vomiting severity; however, pharmacologic treatment of cancer cachexia remains disappointing, and more trials with anticytokine drugs should be conducted.

Megestrol acetate for anorexia in patients with far-advanced cancer: a double-blind controlled clinical trial

The aim of this study was to evaluate a low-dose regimen of megestrol acetate (MA; 320 mg/day) on appetite in advanced cancer patients. Out-patients with far-advanced non-hormone responsive tumours and loss of appetite were randomised in a phase III trial, with two consecutive phases: a 14-day double-blind placebo controlled phase (phase A) and a 76-day open phase (phase B). During phase A, patients were treated with MA, two 160 mg tablets/day, or placebo. In phase B, the MA dose was titrated to clinical response in both groups. Appetite, food intake, body weight, performance status, mood and quality of life were evaluated with standardised measures; patients' global judgement about treatment efficacy was also requested. Of 42 patients entering the study, 33 (17 MA and 16 placebo) were evaluable for efficacy. The appetite score improved significantly with MA after 7 days (P = 0.0023), and this effect was still significant at 14 days (P = 0.0064). Patients judged the treatment with MA effective in 88.2% of cases (14th day), whilst placebo was considered effective by 25% (P = 0.0003). None of the other measures showed significant changes during treatment. The remarkable effect on appetite evident after 7 days, without serious side-effects, shows that MA can produce significant subjective effects at a low-dose even in patients with far-advanced disease.

The effect of caloric density of food on energy intake and body weight in tumor-bearing rats

Anorexia and weight loss are major problems for cancer patients and are associated with increased cancer morbidity and mortality. The current clinical approach is to encourage high calorie food intake. In the present study, we used an animal model of tumor-induced anorexia to evaluate the effect of feeding a high caloric diet on food and caloric intake and body weight of tumor-bearing rats. Tumor-bearing rats fed a diet containing 4.7 kcal/g reduced the amount of food they ate to equal the caloric intake of rats fed a diet containing 3.7 kcal/g. Body weight and tumor growth were not affected by the diet intervention. These data suggest that energy intake is regulated in tumor-bearing rats as it is in healthy animals, albeit at a lower level. These data have implications for further study of the effects of nutritional supplements on food intake and nutritional status of cancer patients.