1. Cancer anorexia and its impact on the survival journey Palliative Care Rounds October 30, 2003 Michelle Kralt, RN MN michelle.kralt@cancercare.mb.ca

2. The World Heath Organization explains that Palliative care: The World Heath Organization explains that Palliative care: “…provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of care and offers a support system to help patients live as actively as possible until death”

3. The goal of palliative care is achievement of the best quality of life for patients and families. The goal of palliative care is achievement of the best quality of life for patients and families.

4. Session objectives 1. Examine pathophysiologic changes associated with cancer-related anorexia 1. Examine pathophysiologic changes associated with cancer-related anorexia 2. Discuss interventions for cancer-related anorexia 2. Discuss interventions for cancer-related anorexia 3. Appreciate the impact anorexia has on quality of life in people with cancer. 3. Appreciate the impact anorexia has on quality of life in people with cancer.

5. What is anorexia? “orexis” – Greek for “appetite”; “A” – “without” = anorexia; meaning to be without appetite “orexis” – Greek for “appetite”; “A” – “without” = anorexia; meaning to be without appetite Appetite is psychological, dependent on memory and associations, as compared with hunger, which is physiologically aroused by the body’s need for food. Appetite is psychological, dependent on memory and associations, as compared with hunger, which is physiologically aroused by the body’s need for food. One can feel hungry and have anorexia simultaneously One can feel hungry and have anorexia simultaneously

6. Cachexia is derived from the the Greek “kakos” meaning “bad” and “hexis” meaning “condition” is derived from the the Greek “kakos” meaning “bad” and “hexis” meaning “condition” Is a debilitating state of involuntary loss of adipose tissue and skeletal muscle mass. Is a debilitating state of involuntary loss of adipose tissue and skeletal muscle mass. Is usually diagnosed when pts have weight loss more than 5% of preillness weight in previous 2 to 6 months. Is usually diagnosed when pts have weight loss more than 5% of preillness weight in previous 2 to 6 months.

7. Different types of Anorexia 1. Anorexia nervosa: refusal to eat, most commonly occurs in pubescent girls in developed countries. 1. Anorexia nervosa: refusal to eat, most commonly occurs in pubescent girls in developed countries.

8. 2. a form of starvation related to malnutrition caused by impaired intake due to pain, GI obstruction, n/v, altered GI motility, medication s/e, depression/stress, swallowing difficulties, thyroid irregularities, constipation, poor sleep, severe fatigue 2. a form of starvation related to malnutrition caused by impaired intake due to pain, GI obstruction, n/v, altered GI motility, medication s/e, depression/stress, swallowing difficulties, thyroid irregularities, constipation, poor sleep, severe fatigue

9. Cancer-related anorexia 3. primary anorexia is the absence of appetite despite obvious nutritional needs 3. primary anorexia is the absence of appetite despite obvious nutritional needs It is directly caused by the cancer It is directly caused by the cancer It is most commonly seen in individuals with lung, pancreatic, and gastric cancers It is most commonly seen in individuals with lung, pancreatic, and gastric cancers Anorexia is not dependent on a large tumor burden Anorexia is not dependent on a large tumor burden May also occur with infections, renal failure, AIDS, CHF, IBD,COPD May also occur with infections, renal failure, AIDS, CHF, IBD,COPD

10. Significance of anorexia Anorexia has been reported in 6% of early diagnosis to 85% of advanced cancer patients (Watanabe & Bruera, 1996, Starsseer & Bruera, 2002). Anorexia effects both the patient and carer; for the carer, it can seem like the pt is “giving up.” Anorexia may often be the first presenting sign of cancer 50% of the time (Damsky Dell, 2002)

11. Continued… Anorexia is associated with asthenia, fatigue and weakness Anorexia is associated with asthenia, fatigue and weakness Change in body image Change in body image Cognitive impairment Cognitive impairment

12. Clinical significance of weight loss Weight loss of >5% of pre illness state significantly increase symptom distress and functional status in patients. (Sarna et al, 1994). Weight loss of >5% of pre illness state significantly increase symptom distress and functional status in patients. (Sarna et al, 1994). People with significant weight loss have a severely impaired tolerance to both radiation treatment and chemotherapy (Stepp & Pakiz, 2001 ) People with significant weight loss have a severely impaired tolerance to both radiation treatment and chemotherapy (Stepp & Pakiz, 2001 ) A BMI of <18.5 severely reduces physical work capacity, significantly impairing a person’s quality of life A BMI of <18.5 severely reduces physical work capacity, significantly impairing a person’s quality of life

13. Clinical significance of weight loss Malnutrition leads to 1) gastrointestinal impairment, 2) respiratory problems, 3) cardiac problems and 4) decreased immune function. Malnutrition leads to 1) gastrointestinal impairment, 2) respiratory problems, 3) cardiac problems and 4) decreased immune function. Anorexia and malnutrition lead to deterioration in psychologic function which manifests as apathy, lassitude, lack of self help motivation, depression and anxiety Anorexia and malnutrition lead to deterioration in psychologic function which manifests as apathy, lassitude, lack of self help motivation, depression and anxiety Meguid & Laviano, 2001

14. Anorexia Weakness Fatigue Depression Anxiety

15. Pt’s with significant weight loss experience 40-60% increase in frequency of complications in response to surgical/medical treatments Pt’s with significant weight loss experience 40-60% increase in frequency of complications in response to surgical/medical treatments They have higher hospital admissions They have higher hospital admissions They have a twofold to threefold higher death rate than their well nourished counterparts. They have a twofold to threefold higher death rate than their well nourished counterparts. (Meguid & Laviano, 2001) Median survival was significantly shorter in pts with weight loss Median survival was significantly shorter in pts with weight loss Chemotherapy responses are lower in pts with weight loss Chemotherapy responses are lower in pts with weight loss (Dewys, et al, 1980).

16. Anorexia-cachexia syndrome Anorexia and cachexia are associated and often experienced together; however it is possible that one can experience anorexia or cachexia independently of the other. Anorexia and cachexia are associated and often experienced together; however it is possible that one can experience anorexia or cachexia independently of the other. Protracted anorexia will eventually lead to cachexia ( Morris, 1999 ) Protracted anorexia will eventually lead to cachexia ( Morris, 1999 ) ACS is one of the most common causes of death in cancer ACS is one of the most common causes of death in cancer

17. Physiology of appetite Appetite is the desire to eat and is influenced by cultural, sensory, and physiological consequences on choices and intakes of foods Appetite is the desire to eat and is influenced by cultural, sensory, and physiological consequences on choices and intakes of foods

18. Decreased plasma glucose Spinal Cord Glucose receptors in the hypothalamus Sympathetic Neurons Net Effect: Plasma fatty acids and glucose Liver Muscle Adipose Tissue Adrenal medualla

19. Pathophysiology of primary anorexia (& cachexia)

20. Yesterday’s theory  Cancer steals nutrients from body  metabolism increases to meet demand  toxins secreted that depress appetite

21. Dispelling the Myths of Cachexia -Cachexia ≠ Anorexia -Cachexia is not caused by the tumor consuming the nutrients -Cachexia ≠ Starvation

22. Characteristics of Cancer Versus Starvation Cachexia Variable Starvation Cancer Energy intake ( *) Energy Expenditure (resting) Body fat Skeletal muscle Liver † atrop hy Increased size and metabolic activity ‡

23. Todays’ Theory Cytokines Neurohormonal Alterations Metabolic Abnormalities

24. 1. Inefficient metabolic alterations Energy expenditure in relation to lean body mass is increased. Energy expenditure in relation to lean body mass is increased. Glucose turnover is present via hepatic gluconeogenesis and lipolysis Glucose turnover is present via hepatic gluconeogenesis and lipolysis Whole body protein turnover increased, amino acid turnover is altered Whole body protein turnover increased, amino acid turnover is altered Increase in production of c-reactive protein Increase in production of c-reactive protein

25. Elevated amino acids levels in the plasma may decrease appetite Elevated amino acids levels in the plasma may decrease appetite

26. 2. Neurhormonal regulation and food intake LHA = Lateral Hypothalamic Area VMH = Ventral Medial Hypothalamic Area

27. Homeostasis Hypothalamus VMHLHA Satiety Center Hunger Center

28. Anorexia is associated with low dopamine and high serotonin levels in the VMH Anorexia is associated with low dopamine and high serotonin levels in the VMH

29. Cytokines Nonantibody proteins released by one cell population on contact with a specific antigen, which acts as cellular mediators in the generation of an immune response Nonantibody proteins released by one cell population on contact with a specific antigen, which acts as cellular mediators in the generation of an immune response

30. Cytokines TNF-α (tumour necrosis factor alpha) TNF-α (tumour necrosis factor alpha) IL-1 (Interleukin 1) IL-1 (Interleukin 1) IL-6 (Interleukin 6) IL-6 (Interleukin 6) CCK (Cholecystokinin) CCK (Cholecystokinin) CRF (Corticotropin releasing factor) CRF (Corticotropin releasing factor)

31. Anorexigenic Neuropeptide Neurotensin Melanocortin CRF Orexigenic Neuropeptide Glucogon CCKLeptin Blood Brain Barrier NPY AGRP MCHNeurotensin Melanocortin CRF Glucogon CCKLeptin NPY AGRP MCH CNS Cytokinase Cytokinase CNTF IL-1 CNS Cytokinase CNTF IL-1 Food Intake Energy Expenditure Food Intake Energy Expenditure Seratonin Blood Brain Barrier IL-6 Tryptophan Glucocorticoids ACTH Anorexigenic Neuropeptide Orexigenic Neuropeptide IL-1 IL-6 TNF-  INF-  _ + + + + + + + ++ + + + + _ _ _ _ _ _ _ _ A B

32. Taste Changes Taste and smell aversions are also common with cancer related anorexia Taste and smell aversions are also common with cancer related anorexia Possible link between high levels of serotonin and taste aversions (Edelman et al, 1999) Possible link between high levels of serotonin and taste aversions (Edelman et al, 1999) A large tumor burden can increase the degree and duration of taste alterations (Sherry, 2001) A large tumor burden can increase the degree and duration of taste alterations (Sherry, 2001)

33. Etiology of taste changes 1. Presence of malignant cells or cancer tx may reduce # of taste buds 1. Presence of malignant cells or cancer tx may reduce # of taste buds 2. Dividing cancer cells secrete amino acid- like substance, causing a bitter taste sensation 2. Dividing cancer cells secrete amino acid- like substance, causing a bitter taste sensation 3. Cancer-induced deficiencies in zinc, copper, nickel and vitamin A, which are heavy metals involved in normal taste function 3. Cancer-induced deficiencies in zinc, copper, nickel and vitamin A, which are heavy metals involved in normal taste function

34. Comprehensive assessment of anorexia 1. detailed hx of involuntary weight loss 1. detailed hx of involuntary weight loss 2. Hx of nutritional intake 2. Hx of nutritional intake 3. perceived change in body image? 3. perceived change in body image? 4. presence of anorexia? (Visual analog scale) 4. presence of anorexia? (Visual analog scale) 5. Anxiety/depression? 5. Anxiety/depression? 6. Taste or smell changes? 6. Taste or smell changes? 7. Dysphagia or painful mouth problems? 7. Dysphagia or painful mouth problems?

35. Assessment continued 8. thyroid function test 8. thyroid function test 9. early satiety? 9. early satiety? 10. nausea and vomiting? 10. nausea and vomiting? 11. constipation? 11. constipation? 12. Sleep patterns 12. Sleep patterns 13. Fatigue? 13. Fatigue? 14. Functional status? 14. Functional status? 15. pain? 15. pain?

36. Experiential

37. Why not TPN/EN? TPN/EN causes further anorexia TPN/EN causes further anorexia Complications (ie: mechanical, metabolic and infection) Complications (ie: mechanical, metabolic and infection) Expensive Expensive Does not improve survival Does not improve survival Does not cause weight gain Does not cause weight gain How does one make the decision to discontinue TPN – very hard for pt & family How does one make the decision to discontinue TPN – very hard for pt & family

38. Orexigenic agents Megace Megace Corticosteroids Corticosteroids Dronabinol Dronabinol Cyproheptadine Cyproheptadine Thalidomide Thalidomide Melatonin Melatonin NSAIDS/COX-2 NSAIDS/COX-2 Fish oils (Eicosapentaenoic acid) Fish oils (Eicosapentaenoic acid) Metoclopramide Metoclopramide Ginger root Ginger root Essiac Essiac

39. Nursing interventions Acknowledge the losses the patient and family are experiencing and help them explore these losses, including time to explore the possibilities of the future Acknowledge the losses the patient and family are experiencing and help them explore these losses, including time to explore the possibilities of the future Encourage family members to focus their energies on other activities that convey nurturing Encourage family members to focus their energies on other activities that convey nurturing

40. Nursing interventions continued… Educate that failure to eat is not “giving up,” and that the pt will not “starve to death”. Educate that failure to eat is not “giving up,” and that the pt will not “starve to death”. Explaining the nature of ACS as irreversible and caused by metabolic abnormalities, and that eating more food will not help the pt gain weight Explaining the nature of ACS as irreversible and caused by metabolic abnormalities, and that eating more food will not help the pt gain weight

41. Conclusion By offering nutritional support and pharmacological advice, symptom control and psychological support to individuals with cancer at risk for anorexia, nurses can reduce the distress experienced even if symptoms of anorexia or cachexia do not appear. By offering nutritional support and pharmacological advice, symptom control and psychological support to individuals with cancer at risk for anorexia, nurses can reduce the distress experienced even if symptoms of anorexia or cachexia do not appear.