The management of anorexia by patients with advanced cancer: a critical review of the literature

Taste loss in cancer patients: clinicians' perceptions of educational materials and diagnostic tools

PURPOSE

Cancer therapy is essential and lifesaving; however, it can have short- and long-term consequences on patients' health. Up to 87% of cancer patients report changes in taste function, yet patients report a lack of support from clinicians regarding their experience with taste loss during and following treatment. Thus, the objective of this study was to assess clinicians' knowledge and experience with managing patients with taste loss and identify potential gaps in the availability of educational materials and diagnostic tools.

METHOD

In an online survey, sixty-seven participants who identify as clinicians and practice in the United States and work with cancer patients that complain of taste problems answered questions on their knowledge and experience supporting cancer patients experiencing changes in taste function and provided their opinion on access to educational materials.

RESULTS

The current study reports gaps in participants' knowledge of taste and taste disorder terminology, with 15.4% correctly defining both taste and flavor and roughly half were familiar with specific taste disorder classifications. Over half of the participants reported not having access to adequate information to help their patients manage taste alterations. Only two-thirds of participants reported routinely asking patients if they are experiencing changes in taste function.

CONCLUSION

Clinicians' responses emphasized the need to improve access to educational materials regarding taste changes and increase the availability of information regarding management strategies. Addressing these inequities in education and improving the standard of care is the first step in improving the care for cancer patients suffering from altered taste function.

The role of saliva in taste dysfunction among cancer patients: Mechanisms and potential treatment

Two of the highest prevalent symptoms reported by cancer patients are taste dysfunction (17.6-93%) and dry mouth/xerostomia (40.4-93%). While it has been hypothesized that reduced saliva may impair taste function, few studies investigate the co-occurrence of taste and dry mouth symptoms in cancer patients. This review provides a summary of the physiological relationship between saliva and taste, focusing on taste transduction mechanism, regulation of the taste sensitivity, and protection of taste receptor cells, including the impact of cancer treatments and malignancy on saliva function, salivary components, and the mechanisms in which it can negatively impact the taste function. Here, the authors present a scoping review of the recent literature reporting on the association between taste dysfunction and dry mouth in cancer patients, including reports of non-pharmaceutical liposomal agents or drugs taken to improve dry mouth symptoms that also assess taste dysfunction. Considering the complexities of cancer and cancer treatment, understanding the physiological relationship between saliva and taste function may provide important insight into identifying treatments for alleviating taste dysfunction and dry mouth symptoms. There are substantial research gaps given the limited studies assessing the co-occurrence of taste loss and dry mouth and inconsistencies in the assessment of these symptoms. Clinical studies examining taste dysfunction will provide a foundational groundwork that will help understand the relationship between taste and saliva. Considering the increased rates in survivorship and the significant negative impact of taste dysfunction on quality of life, more research is needed to reduce the suffering of cancer patients.

Nutritional, immunological and antioxidant defense status of outpatients diagnosed with colorectal cancer - a case-control study of the little-studied population

This cross-sectional study was conducted to investigate nutritional and immunological status of colorectal cancer (CRC) patients in a little-studied population from developing country, Pakistan. Data on 81 CRC patients and 37 healthy controls (HCs) were collected on nutritional status, nutrient intake, percent body fat (%BF), selected immunological parameters, phytochemical index (PI), healthy eating index (HEI), and prognostic nutrition index (PNI). Blood samples were used for immunological and antiradical defense potential (expressed as 50% hemolysis time; HT₅₀). Results show 40/81 (49.4%) patients reported weight loss in past 3-6 mo, Significant differences were found in HEI values between patients vs. HCs, and between patients in low vs. high PNI groups (P, for all trends <0.05). Patients in the higher PNI group were heavier, had higher % BF, higher energy intake, and higher PI score as compared to patients in the low PNI group (P < 0.05). Low PNI was positively associated with non-significantly lower CD4:CD8 ratios, higher B-cells and NK cells (P, for all trends >0.05), but with significantly higher hs-CRP levels, and lower HT₅₀ values (P, for all trends <0.001). In conclusion, CRC patients in a little-studied population have compromised nutritional and immunological health with lower HEI and PNI scores.

Cancer Appetite and Symptom Questionnaire (CASQ) for Brazilian Patients: Cross-Cultural Adaptation and Validation Study

BACKGROUND

Appetite and symptoms, conditions generally reported by the patients with cancer, are somewhat challenging for professionals to measure directly in clinical routine (latent conditions). Therefore, specific instruments are required for this purpose. This study aimed to perform a cultural adaptation of the Cancer Appetite and Symptom Questionnaire (CASQ), into Portuguese and evaluate its psychometric properties on a sample of Brazilian cancer patients.

METHODS

This is a validation study with Brazilian cancer patients. The face, content, and construct (factorial and convergent) validities of the Cancer Appetite and Symptom Questionnaire, the study tool, were estimated. Further, a confirmatory factor analysis (CFA) was conducted. The ratio of chi-square and degrees of freedom (χ2/df), comparative fit index (CFI), goodness of fit index (GFI) and root mean square error of approximation (RMSEA) were used for fit model assessment. In addition, the reliability of the instrument was estimated using the composite reliability (CR) and Cronbach's alpha coefficient (α), and the invariance of the model in independent samples was estimated by a multigroup analysis (Δχ2).

RESULTS

Participants included 1,140 cancer patients with a mean age of 53.95 (SD = 13.25) years; 61.3% were women. After the CFA of the original CASQ structure, 2 items with inadequate factor weights were removed. Four correlations between errors were included to provide adequate fit to the sample (χ2/df = 8.532, CFI = .94, GFI = .95, and RMSEA = .08). The model exhibited a low convergent validity (AVE = .32). The reliability was adequate (CR = .82 α = .82). The refined model showed strong invariance in two independent samples (Δχ2: λ: p = .855; i: p = .824; Res: p = .390). A weak stability was obtained between patients undergoing chemotherapy and radiotherapy (Δχ2: λ: p = .155; i: p < .001; Res: p < .001), and between patients undergoing chemotherapy combined with radiotherapy and palliative care (Δχ2: λ: p = .058; i: p < .001; Res: p < .001).

CONCLUSION

The Portuguese version of the CASQ had good face and construct validity and reliability. However, the CASQ still presented invariance in independent samples of Brazilian patients with cancer. However, the tool has low convergent validity and weak invariance in samples with different treatments.

Meanings of eating deficiencies for people admitted to palliative home care

Objective:

Food and eating are embedded in people's everyday social lives: at home with family members and as part of social interactions. For people with progressive life-limiting conditions, however, eating is often obstructed. The objective of the present study was to explore the meanings of living with eating deficiencies at the end of life among people admitted to specialist palliative home care.

Method:

This qualitative inductive study employed an interpretive descriptive approach. A dozen persons, with various diagnoses and eating deficiencies, admitted to two specialist palliative home care units, participated. Data were collected through individual repeated interviews. Data collection and analysis were guided by the interpretive description method.

Results:

The results reveal that eating deficiencies among people with progressive life-limiting conditions are existentially loaded markers of impending death. Finding ways to overcome declined food intake and hampered eating enabled our participants to feel able to influence their own well-being and remain hopeful. The results also showed that the eating deficiencies influenced participants' relationships and social interactions in ways that hampered their possibilities of sharing valuable moments together with friends and family members during the final period of life.

Significance of Results:

Efforts to minimize the distress that people experience in relation to the challenges they face with eating deficiencies are important for well-being at the end of life. Person-centered approaches to acknowledge and support individuals' own ways of experiencing and dealing with their eating deficiencies are recommended that include a multidimensional perspective on food and eating.

Psychosocial impact of cancer cachexia

BACKGROUND

Cancer cachexia has impact on patients and their family members. Patients experience loss of weight often accompanied by anorexia and other debilitating symptoms that have clinical impact and impact everyday life. The importance of understanding this impact lies in (1) the alleviation of cachexia-related suffering and (2) its implications for treating cachexia.

REVIEW

Two decades of exploratory investigation of the manifestations, meaning and management of cancer cachexia reveal emotional and social impacts for both patients and their carers. Patients can describe change in appearance and loss of physical strength often accompanied by change in eating habits (amount, type and pattern of food intake). The psychosocial effects can include loss of independence, sense of failure, sense of helplessness, conflict with family members over food, social isolation and thoughts of death. They are effects that can distress. Conversely, weight loss, especially early in its course and for those who are obese, can be perceived as beneficial, which inhibits self-management of diet and physical activity.

CONCLUSION

Models of the psychosocial effects of cancer cachexia have been developed, leading to, as yet unproven, propositions of how negative patient and family impacts can be addressed. This literature overlooks the potential importance of psychosocial intervention to emerging multimodal treatments for the multicausal syndrome. Psychosocial intervention in cachexia should be tested for potential to help people affected by cancer cachexia feel better but also for potential to make people better by aiding uptake and compliance with multimodal therapy.

Weight loss, appetite loss and food intake in cancer patients with cancer cachexia: three peas in a pod? - analysis from a multicenter cross sectional study

BACKGROUND

How to assess cachexia is a barrier both in research and in clinical practice. This study examines the need for assessing both reduced food intake and loss of appetite, to see if these variables can be used interchangeably. A secondary aim is to assess the variance explained by food intake, appetite and weight loss by using tumor-related factors, symptoms and biological markers as explanatory variables.

MATERIAL AND METHODS

One thousand and seventy patients with incurable cancer were registered in an observational, cross sectional multicenter study. A total of 885 patients that had complete data on food intake (PG-SGA), appetite (EORTC QLQ-C30) and weight loss were included in the present analysis. The association between reduced food intake and appetite loss was assessed using Spearman's correlation. To find the explained variance of the three symptoms a multivariate analysis was performed.

RESULTS

The mean age was 62 years with a mean survival of 247 days and a mean Karnofsky performance status of 72. Thirteen percent of the patients who reported eating less than normal had good appetite and 25% who had unchanged or increased food intake had reduced appetite. Correlation between appetite loss and food intake was 0.50. Explained variance for the regression models was 44% for appetite loss, 27% for food intake and only 13% for weight loss.

CONCLUSION

Both appetite loss and food intake should be assessed in cachectic patients since conscious control of eating may sometimes overcome appetite loss. The low explained variance for weight loss is probably caused by the need for more knowledge about metabolism and inflammation, and is consistent with the cancer cachexia definition that claims that in cachexia weight loss is not caused by reduced food intake alone. The questions concerning appetite loss from EORTC-QLQ C30 and food intake from PG-SGA seem practical and informative when dealing with advanced cancer patients.

Psychosocial consequences of cancer cachexia: the development of an item bank

CONTEXT

Cancer cachexia syndrome (CCS) is often accompanied by psychosocial consequences (PSC). To alleviate PSC, a systematic assessment method is required. Currently, few assessment tools are available (e.g., Functional Assessment of Anorexia/Cachexia Therapy). There is no systematic assessment tool that captures the PSC of CCS.

OBJECTIVES

To develop a pilot item bank to assess the PSC of CCS.

METHODS

A total of 132 questions, generated from patient answers in a previous study, were reduced to 121 items by content analysis and evaluation by multidisciplinary experts (doctor, nutritionists, and nurses). In our two-step, cross-sectional study, patients, judged by staff to have PSC of CCS, were included, and the questions were randomly allocated to the patients. Questions were evaluated for understandability and triggering emotions, and patients were asked to provide a response using a four-point Likert scale. Subsequently, problematic questions were revised, reformulated, and retested.

RESULTS

A total of 20 patients with a variety of tumor types participated. Of the 121 questions, 31 had to be reformulated after Step 1 and were retested in Step 2, after which seven were again evaluated as not being perfectly comprehensible. In Step 1, 22 questions were found to trigger emotions, but no item required remodeling. Item performance using the Likert scale revealed no consistent floor or ceiling effects. Our final pilot question bank comprised 117 questions.

CONCLUSION

The final item bank contains questions that are understood and accepted by the patients. This item bank now needs to be developed into a measurement tool that groups items into domains and can be used in future research studies.

Psychosocial effects of cancer cachexia: a systematic literature search and qualitative analysis

CONTEXT

Cancer cachexia is debilitating and affects most patients with advanced cancer. Because treatment options are poor, the psychosocial effects of cancer cachexia always should be assessed and psychosocial support provided.

OBJECTIVES

To review the existing evidence of psychosocial effects of cancer cachexia with the aim of identifying factors that might be modified to improve outcomes.

METHODS

We carried out a systematic literature search in MEDLINE and Embase. The search string included key words for the topics "advanced cancer," "cancer cachexia," and "psychosocial effects." Publications were selected by two reviewers. The search was complemented by a hand search.

RESULTS

Nineteen studies were included. The available information revealed mechanisms leading to, various presentations of, and coping strategies for psychosocial effects of cancer cachexia in both patients and their carers. Not all those affected manage the effects of the condition constructively. A number of clinically important adverse reactions have been identified. The main causes for negative psychosocial effects are a lack of knowledge of the irreversible nature of cancer cachexia and unsuccessful attempts to increase body weight with altered patterns of nutritional intake. Depending on patients' and their carers' coping resources, psychosocial effects may escalate or decrease. Early identification of psychosocial effects creates the potential for psychosocial interventions that improve the quality of life of those affected. Our analysis engendered a broader conceptualization of the psychosocial effects of cancer cachexia, leading to a number of suggestions for psychosocial interventions with the potential for providing relief.

CONCLUSION

The concept of psychosocial effects in cancer cachexia has the potential to sensitize health care professionals to cachexia-related problems and inform their clinical management of the condition.

Is there a genetic cause of appetite loss?-an explorative study in 1,853 cancer patients

BACKGROUND

Appetite loss has a major impact on cancer patients. It is exceedingly prevalent, is a prognostic indicator and is associated with inferior quality of life. Cachexia is a multi-factorial syndrome defined by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism. Not all cancer patients that experience weight loss have appetite loss, and the pathophysiology between cachexia and appetite loss may thus be different. Knowledge of pathophysiology of appetite loss in cancer patients is still limited. The primary object of this study was to explore the association with 93 predefined candidate single-nucleotide polymorphisms (SNPs) and appetite loss in cancer patients to possibly generate new theories of the pathophysiology of the condition.

METHODS

A total of 1,853 cancer patients were phenotyped according to appetite loss and then genotyped.

RESULTS

After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and appetite loss. The ten most significant SNPs in the co-dominant model had observed odds ratios varying from 0.72 to 1.28.

CONCLUSIONS

This large exploratory study could not find any associations with loss of appetite and 93 SNPs with a potential to be involved in appetite loss in cancer patients. This does not however rule out genes putative role in the development of the symptom, but the observed odds ratios are close to one which makes it unlikely that any of the individual SNPs explored in the present study have great importance.

A qualitative analysis of the nutritional requirements of palliative care patients

BACKGROUND

The National Health Servive (NHS) Quality Improvement Scotland developed nutritional Clinical Standards to address the problem of malnutrition in hospitals. NHS palliative care units are obliged to incorporate these standards into nutritional aspects of care. The nutritional needs of this patient population are under-researched. The present study aimed to explore patients' views of nutrition, to begin to understand their concerns and to determine whether such standards meet the needs of patients in the palliative care setting.

METHODS

A qualitative study was conducted in 2009 in an NHS Palliative Care Unit. Six inpatients were involved in one-to-one interviews, which were audiotaped and transcribed verbatim. The transcripts were subject to qualitative data analysis in accordance with a previous framework.

RESULTS

A recurring theme that emerged was that of change and uncertainty. Four main areas subject to change were: disease state, symptoms, oral dietary intake and weight. Each change could exert control over, or be controlled by, the patient. When patients were eventually unable to exert control, they accepted the change, either willingly or enforced, thereby unintentionally setting their own targets.

CONCLUSIONS

The present study enables a deeper understanding of the concerns that palliative care patients have regarding their oral dietary intake and weight. Their 'malnutrition' not only refers to physical malnutrition alone, but also incorporates psychological and social 'malnutrition'. When applying standards or protocols regarding nutritional care, these wider issues must be taken into account to meet patients' nutritional needs.

The emotional aspects of cancer anorexia

PURPOSE OF REVIEW

To discuss the psychosocial support of people affected by cancer anorexia, drawing on recent publications.

RECENT FINDINGS

Recent studies describe the problem of distress in response to cancer anorexia. There are propositions of appropriate support and calls for the development of psychosocial interventions to relieve cachexia-related distress. Preliminary work is now testing these ideas.

SUMMARY

Psychosocial support for cancer anorexia is a new and promising field of study. The prevention or alleviation of the anorexia of cachexia would relieve much eating-related suffering experienced by patients and their families. However, whilst the scientific community works to achieve this goal there is another task to be addressed: to help people with cancer anorexia to adapt and live with the symptom. Despite accounts over many years of the distress caused by poor appetite, little attention has been paid to the potential for psychosocial support to aid self-management of the symptom. Emergent thinking is that psychosocial support for cancer anorexia can have benefit for both patients and their family members.

The deliverability, acceptability, and perceived effect of the Macmillan approach to weight loss and eating difficulties: a phase II, cluster-randomized, exploratory trial of a psychosocial intervention for weight- and eating-related distress in people with advanced cancer

CONTEXT

Up to 80% of people with cancer will develop weight loss and anorexia during the advanced stages of the disease. The Macmillan Weight and Eating Studies (2000-2009) have used the Medical Research Council complex interventions framework to develop the first psychosocial intervention for weight- and eating-related distress (WRD and ERD) in people with advanced cancer and their carers: The Macmillan Approach to Weight and Eating (MAWE).

OBJECTIVES

This article reports the findings of a Phase II trial of MAWE that investigated its deliverability, acceptability, and patient-perceived effect on WRD and ERD.

METHODS

The Phase II trial, conducted in 2006-2007, was of cluster-randomized design, with two community palliative care teams randomized to different arms. It used mixed methods to compare an intervention group (n=25), the MAWE group, which was supported by MAWE-trained clinical nurse specialists, with a group that received usual care (n=25), the control group.

RESULTS

MAWE was deliverable in clinical practice and acceptable to patients. Unplanned exposure of the MAWE group to the intervention before an initial measure of WRD and ERD proved problematic to the trial process. Despite this, quantitative and qualitative analyses indicate that MAWE does not exacerbate WRD and ERD and may help patients with advanced cancer live with the weight loss and anorexia that are the symptoms of cancer cachexia syndrome.

CONCLUSION

A follow-on randomized controlled trial of MAWE is warranted but should be of a revised design.

Perceptions of food and eating among Chinese patients with cancer: findings of an ethnographic study

This article explores the ways that participants in a Chinese cancer support group talk about food, diet, and eating. An ethnographic research design was used, including participant observation at a Chinese cancer support group over an 8-month period and key informant interviews with 7 members of the group. Food, eating, and diet were a recurrent focus of discussion at support group meetings throughout the fieldwork period. The ways in which support group participants talked about food centered on 3 distinct but interconnected themes: the prevalence of eating issues as an adverse effect of cancer and its treatment, the importance of eating ability, and questions and concerns connected with the differing and often contradictory cultural models of diet that they were exposed to. Culturally specific understandings of the relationship between food and health informed Chinese patients' experience of eating issues during cancer treatments and their ongoing concern with food and nutrition after the completion of treatment. Health professionals need to pay more attention to the meanings and attributes of food and eating beyond their physiological properties, and further research needs to be conducted with other immigrant populations with culturally distinct understandings of food.

Taste and smell changes in patients receiving cancer chemotherapy: distress, impact on daily life, and self-care strategies

Few studies have described how patients receiving chemotherapy experience taste/smell changes (TSCs). Food and meal situations have important meaning beyond nutrition, so these common symptoms may affect daily lives. This study aims to investigate distress and impact on daily life from TSCs in patients receiving cancer chemotherapy, analyze reported levels of distress and impact on daily life from TSCs with regard to sociodemographic and clinical factors, and explore patients' reports of self-care strategies and communication with staff. The 340 patients reporting TSCs on a multicenter survey (n = 518) were grouped into subsets by level of TSC-related distress and impact on daily life, which served as the basis for statistical comparison. Written comments were analyzed inductively using content analysis. Nearly one-third of participating patients reported both high levels of distress and impact on daily life (high distress and high impact on daily life [HDHI]) from TSCs. The HDHI subset reported other symptoms more often than others did (P = .01) and also more often responded to open questions about distress, impact, and self-care strategies (P = .01). Taste/smell changes were not always reported to staff, even in the HDHI subset. The specific aspects of TSCs resulting in distress and impact on daily life varied greatly, affecting both psychological and somatic aspects, with little consensus and great individual differences described in self-care strategies. The variety of distress, impact, and strategies used to alleviate TSCs clarifies the importance of situational meaning.

When advanced cancer patients won't eat: family responses

We conducted a grounded theory study examining nutritional care experiences in advanced cancer from the perspective of patients (n = 13), families (n = 23), and health care providers (n = 11) (McClement, 2001). That work generated an inductively derived model that captured important information about adult family members' perceptions and behaviour regarding the nutritional care their terminally ill adult relative received while hospitalized on an inpatient palliative care unit, and has been reported elsewhere (McClement et al, 2003). This article provides a more detailed description of one of the major sub-processes of the model regarding family member responses to declining oral intake and weight loss in a terminally ill relative-the sub-process of 'letting nature take its course: it's best not to eat.' The strategies family members use when letting nature take its course, and the consequences of these strategies for patients, family members and health care providers are reported. Implications for practice and research are provided.