Cancer Cachexia and Anorexia

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The most common problems are cancer cachexia and anorexia, particularly when the tumor is already in a progressive stage. In a large study, DeWrys and co-workers reported that more than 50% of patients suffered from weight loss (21). About 15 % lost more than 10 % of their weight during the course of the disease.

Cancer cachexia interferes with the patient's physical and emotional well-being. Patients not only have to cope with their life-threatening disease, they also change in appearance due to severe loss of weight. This leads to a significant increase in morbidity, mortality, and prolonged hospitali-zation, thus representing a major cost factor (67).

Signs of cancer cachexia are anemia, anorexia, lack of energy, and increasing weight loss. The latter is caused by a decrease in body fat and muscle mass (56-58). There is no clear correlation between the extent of malnutrition, the tumor's size,

Table 8.6 Dietary recommendations for the prevention of cancer (20)

Life style

• Eat mostly plant foods derived from various types of fruits, vegetables, and legumes, while avoiding processed starchy foods

• Avoid obesity and underweight; any increase in weight during adulthood should not exceed 5 kg

• Exercise for a minimum of one hour per day, with intense physical activity for a minimum of one hour per week

• Eat five or more servings of fruits and vegetables per day (approximately 400-500 g per day)

• Eat more than seven servings of grain products, legumes, potatoes, or other plant food per day (approxi-mately 600-800 g per day); avoid highly processed foods

• Avoid alcohol; a maximum of two alcoholic beverages per day for men, and one per day for women

• Limit the consumption of meat to an average of 80 g per day; prefer fish, poultry, or game

• Limit the consumption of fatty foods; avoid fat of animal origin, prefer vegetable oils

• Avoid heavily salted foods and those preserved by salt

Handling

• Do not eat moldy or spoiled food

• Store food in fridge or freezer, or use another suitable form of preservation (boiling, pickling)

• Do not eat burnt food; limit your consumption of barbecued, pickled, and smoked meat

Nutritional supplements, such as vitamin tablets, are usually not required for cancer prevention; uncontrolled intake of high doses may be harmful under certain circumstances expansion, or degree of differentiation, and the duration of the disease. Hence, it is hard to predict in the individual case whether cancer cachexia will develop (109).

Cancer cachexia is a multifactorial process that is still poorly understood (59). It is a combination of exogenous and endogenous starvation, but substrate metabolism in a cancer patient differs considerably from that of a hungry person because adaptive processes fail to take place (56-58, 62, 63). It seems as if the contributing factors depend on both the tumor itself and the metabolic response of the cancer patient. Cytokines are currently discussed as major mediators of cancer cachexia—in addition to hormones, such as corti-costeroids, glucagon, or somatotrophic hormone. Above all, TNF-a, which is also called cachectin, seems to play an important role (108).

Metabolism in a cachectic cancer patient is characterized by increased protein turnover and degradation of muscles proteins, associated with reduced protein synthesis in peripheral muscles. Simultaneously, there is a loss of body fat caused by the high rates of lipolysis and fat oxidation—and not even glucose intake can interrupt this.

Glucose metabolism in a cancer patient is characterized by increased glucose turnover as well as increased gluconeogenesis from amino acids and lactate, with simultaneous reduction of glucose oxidation and elevated lactate production (56-58, 62, 63). Metabolic abnormalities are one of the reasons why it is so difficult to overcome malnutrition and to achieve a build-up of body mass (91). Hence, the best results with nutrition therapy can be expected when the measures are initiated as soon as possible to prevent the onset of cancer cachexia (52, 53).

It has been discussed repeatedly whether or not high caloric feeding will benefit the cancer patient or, rather, promote tumor growth. Such considerations were based on results from animal experiments, but similar findings have not been confirmed in humans. Since tumors take essential nutrients away from the rest of the body—irrespective of food intake and nutritional state of the patient—nutrition therapy benefits first the patient and not the tumor; in particular, it improves the patient's defense mechanisms. In the case of chemotherapy and radiotherapy, stimulation of tumor growth would be even advantageous because it increases the blood supply and the rate of mitosis (44).

Table 8.7 Various ways of alleviating treatment-induced eating problems (109)

Loss of appetite

Nausea/ vomiting

Problems with chewing/

swallowing

Dry mouth

Diarrhea

Constipation

Eat several small

Avoid strong-

Eat cold foods to

Prefer water-

Drink plenty of

Drink plenty of

meals (also at

smelling food

alleviate pain

containing foods

fluids (2.5-3 L)

fluids

night)

Eat and drink

Avoid crumbly

(fruits, soups,

Avoid fatty and

Prefer foods rich

Avoid strong-

slowly

food or soak it

dairy products)

bloating meals

in fiber

smelling food

Chew thoroughly

Soft, mild foods

Drink often and

Eat fruits rich in

Make sure to

Drink only

Eat many small

are best suited

take many small

pectin (apples,

drink lots of

between meals

meals

(creamy soups,

sips

bananas, carrots)

fluids when

Prepare food in an

Avoid fatty and

yogurt)

Peppermint tea

Eat rice or oat

eating isolated

appetizing way

sweet foods

Butter or cream

and lemon tea

gruel, or drink

fiber (bran, flax

(including mashed

Eat dry foods

in the food

stimulate the

black tea (let

seeds)

food)

(toast, crackers,

makes

flow of saliva

stand for 5 min)

Physical exercise

Drink appetizing

biscuits),

swallowing easier

Eat sour candies

Eat foods rich in

Gentle massage

beverages

especially in the

Avoid bitter and

or citrus fruits

potassium

of the abdomen

Eat what you like,

morning when

sour foods

between meals

(bananas)

not just what is

getting up

Pass foods

Drink sour milk

healthy

Make sure your

through a sieve

rather than fresh

upper body is

Avoid

milk

upright when

carbonated

Use soy milk in

eating

beverages

case of lactose

Clean your teeth

intolerance

or drink

Avoid alcohol,

peppermint tea

coffee, and

after each meal

carbonated

Replenish any

beverages

loss of fluid and

electrolytes

Table 8.8 Nutritional consultation for cancer patients

• Record the actual symptoms (loss of appetite, pain, intolerance)

• Develop a menu ("favorite diet," considering aversions and preferences)

• Pay attention to food preparation (size of the meal, appearance, consistency)

• Monitor nutritional parameters (amount of food taken in, nutritional condition)

• Involve and educate caretakers (family, friends, family doctor, nurses)

Nutritional care of cancer patients plays an essential role in the therapeutic concept because the nutritional state of a patient can be improved by adequate supply of nutrients. Cancer patients depend on nutritional advice because they are especially susceptible to self-proclaimed healers or to impressive, but unfortunately often health-threatening cancer diets (77).

The main goal of nutrition therapy for cancer patients is to maintain or achieve an adequate nutritional state. This strengthens the immune system, improves the physical and emotional state, increases the patient's tolerance to treatment, and enhances the quality of life. Early nutritional intervention might also prolong life expectancy—a goal that has not been achieved so far (56, 64, 66, 70, 71).

Table 8.7 shows how treatment-induced eating problems may be alleviated.

The diet should be adjusted to the situation and fine-tuned to the individual needs of the patient. A "favorite diet" may contribute to improving the quality of life, independently of whether or not it represents "healthy" food. There is no use in providing a balanced, healthy diet when the patient cannot eat it because of pain or loss of appetite, or does not like or tolerate it.

When giving advice to patients, it is important to take a detailed nutritional history and to determine any individual intolerance as well as the nutritional state. If sufficient nutrients cannot be taken in with an oral diet, supplementation with vitamins, minerals, and trace elements is needed (23). Possible ways of nutrition support include special drink mixes and additional enteral or parenteral feeding.

Proper education of patient, relatives, and nursing staff often makes it possible to discharge the patient earlier. This is of major importance for the patient's quality of life, and it saves costs. An interdisciplinary nutritional team would be ideal, and outpatients should have access to it. Timely and adequate nutrition therapy does avoid follow-up costs arising from treatment of malnutrition, and it improves the quality of life for severely sick patients.

Physicians, dietitians, hospital administration, nursing staff, and politicians should collaborate to ensure financial and personal conditions for a high-quality nutrition therapy of cancer patients (Table 8.8) (77).

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