1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3b Symptoms – Anorexia / cachexia Module 3b Symptoms – Anorexia / cachexia EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Anorexia / cachexia... Cachexia – wasting syndrome l  Lean tissue l  Performance status l Altered resting energy expenditure l  Appetite Cachexia – wasting syndrome l  Lean tissue l  Performance status l Altered resting energy expenditure l  Appetite

4. ... Anorexia / cachexia CachexiaStarvation Lean tissue  - Fat mass   Impact of feeding- + + CachexiaStarvation Lean tissue  - Fat mass   Impact of feeding- + +

5. Anorexia / cachexia Epidemiology l Incidence varies with site l Incidence increases with stage Epidemiology l Incidence varies with site l Incidence increases with stage

6. Anorexia / cachexia Impact ≥ 5% weight loss and poor prognosis ≥ 5% weight loss and poor prognosis l Trend toward lower chemotherapy response rates l Anorexia and poor prognosis l  QOL, function l Affects caregivers Impact ≥ 5% weight loss and poor prognosis ≥ 5% weight loss and poor prognosis l Trend toward lower chemotherapy response rates l Anorexia and poor prognosis l  QOL, function l Affects caregivers MacDonald N, et al. J Am Coll Surg, 2003. Dewys WD, et al. Am J Med, 1980. Loprinzi CL, et al. JCO, 1994.

7. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

8. Pathophysiology l Chronic inflammation l Metabolic changes l Lipolytic / proteolytic substances l Hormonal changes l Role of neurotransmitters l Cytokine impact on hypothalamus l Chronic inflammation l Metabolic changes l Lipolytic / proteolytic substances l Hormonal changes l Role of neurotransmitters l Cytokine impact on hypothalamus Todorov P, et al. Nature, 1996. Todorov P, et al. Cancer Research, 1998. Zigman JM, et al. Endocrinology, 2003. Balkwill F, et al. Lancet, 2001.

9. Assessment l Appetite / weight loss history l Identify reversible causes l Physical signs of wasting l Biochemical markers l Radiographic studies as indicated l Appetite / weight loss history l Identify reversible causes l Physical signs of wasting l Biochemical markers l Radiographic studies as indicated

10. … Assessment Reversible causes of weight loss l Psychological factors l Mucositis l Nausea / vomiting l Constipation l Early satiety l Psychological factors l Mucositis l Nausea / vomiting l Constipation l Early satiety l Malabsorption l Pain l Endocrine l Comorbid conditions l Social / economic l Malabsorption l Pain l Endocrine l Comorbid conditions l Social / economic

11. Management... l Treat comorbid conditions l Educate, support l Favorite foods / nutritional supplements / counseling l Treat reversible causes (eg, early satiety, mucositis) l Treat comorbid conditions l Educate, support l Favorite foods / nutritional supplements / counseling l Treat reversible causes (eg, early satiety, mucositis)

12. Anorexia / cachexia what does not work l Feeding (enteral or parenteral) ACP. Ann Int Med, 1989. Ovesen. J Clin Oncol, 1993.

13. Management of anorexia l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens Loprinzi CL, et al. JCO, 1999. Von Roenn JH, et al. 2003. Moertel CG, et al. Cancer, 1974.

14. Management of cachexia l Investigational Anabolic steroids Omega-3-fatty acids Amino acids NSAIDsMulti-vitaminsExercise l Investigational Anabolic steroids Omega-3-fatty acids Amino acids NSAIDsMulti-vitaminsExercise Von Roenn JH, et al. ASCO, 2003. Jatoi A, et al. ASCO, 2003. Fearon KCH, et al. Gut, 2003. McMillan DC, et al. Br J Ca, 1999.

15. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience