Essentials
NCPD Article

Cancer Cachexia

Amanda French

cachexia, malnutrition, sarcopenia, anorexia, nutrition impact symptoms
CJON 2024, 28(1), 95-100. DOI: 10.1188/24.CJON.95-100

Cancer cachexia is characterized by metabolic dysregulation, inflammation, and reduced food intake, and it results in loss of skeletal muscle. Although cachexia is pervasive in patients with advanced cancer, comprehensive cachexia care is inadequate because of a lack of screening and awareness of the impact cachexia has on oncology care, including anticancer treatments, functional status, and psychosocial distress. Oncology nurses at all levels of practice need to screen for cachexia, educate patients about cachexia, monitor symptoms, facilitate interprofessional interventions, and provide psychosocial support to improve treatment outcomes and quality of life for patients with cachexia.

AT A GLANCE

  • Cancer cachexia remains an underappreciated problem in oncology care, contributing to a significant number of cancer-related deaths.
  • Interprofessional interventions are required to manage cachexia effectively, including nutritional counseling, physical therapy, palliative care, psychosocial interventions, and pharmacologic management.
  • Oncology nurses can screen, educate, monitor, and provide psychosocial support to patients and their caregivers throughout the continuum of cachexia care.

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    Cachexia is a complex, progressive syndrome, characterized by metabolic dysregulation, inflammation, and reduced food intake that results in skeletal muscle loss. It affects nearly every patient with advanced cancer. The prevalence of cancer cachexia is as high as 87% in pancreatic and gastric cancers; 61% in colon, lung, and prostate cancers and non-Hodgkin lymphoma; and 40% in breast cancer, sarcoma, leukemia, and Hodgkin lymphoma. In addition, cachexia accounts for 20% of all cancer-related deaths (Ni & Zhang, 2020). Patients who are malnourished face an increased risk of postoperative complications, greater treatment-related toxicity, decreased response to antineoplastic therapies, increased mortality, poor quality of life, increased length of hospital stay, and higher associated healthcare costs (Álvaro Sanz et al., 2019). Weight loss of as little as 2.4% may predict survival independently of cancer diagnosis, site, stage, or performance score (Ryan & Sullivan, 2021). Cachexia also contributes to psychosocial distress in patients and caregivers (Boyle, 2021).

    Despite its significant impact on cancer care, involuntary weight loss is often overlooked and rarely managed effectively. With evidence-based nutritional interventions and holistic management, cachexia can be mitigated to some degree. Integrated palliative, supportive, and nutritional care conducted by an interprofessional team is needed to address physical symptoms and psychosocial distress (Amano, Baracos, & Hopkinson, 2019). 

    Pathophysiology

    Cachexia develops as a sequela of advanced cancer and is characterized by systemic inflammation, negative protein–energy balance, and involuntary loss of lean body mass. Decreased skeletal muscle is the most obvious sign of cachexia and is followed by a decline in adipose tissue and cardiac muscle. This leads to functional decline, decreased efficacy of anticancer treatment, and increased mortality (Ni & Zhang, 2020). Cachexia develops progressively through various stages; severity can be classified according to the degree of depletion of energy stores and muscle loss, as well as ongoing weight loss (see Table 1).

    “TABLE1”

    The pathophysiology of malnutrition and cachexia is multifactorial, including metabolic changes in the disease process and the effect of nutrition impact symptoms (NISs) on oral intake (Ryan & Sullivan, 2021). The metabolic changes induced by tumor–host interaction and NISs resulting from anticancer therapy can be further broken down into primary and secondary cachexia, respectively. 

    Primary cachexia stems from tumor–host interaction and occurs because of abnormal metabolism. Proinflammatory cytokines are thought to induce cachexia and have many deleterious effects, including a shortage of muscle amino acids, hypothalamic appetite decrease, and induction of insulin resistance in the liver, which leads to abnormal glucose and fat metabolism. These changes result in a negative energy balance (indicated by a decline in skeletal muscle) and lead to weight loss, decreased physical functioning, and worsening symptoms such as anorexia, fatigue, pain, and depression (Zhao et al., 2021).

    Secondary cachexia occurs because of symptoms induced by the tumor or anticancer therapies. Symptoms include anorexia, mucositis, dysphagia, pain, dysgeusia, xerostomia, nausea, diarrhea, constipation, malabsorption, early satiety, and depression. These symptoms contribute to decreased oral intake and subsequent weight loss (Ryan & Sullivan, 2021; Zhao et al., 2021).

    Screening and Assessment

    Clinical practice guidelines for cancer cachexia management have been developed by the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) (Arends et al., 2021; Roeland et al., 2020). ESMO recommends routine screening with a validated tool for all patients undergoing anticancer treatment and assessment of at-risk patients at regular intervals for metabolic, nutritional, and other impairments that may endanger their nutritional status (Arends et al., 2021).

    Several tools are available to assess nutritional risk, including the Patient-Generated Subjective Global Assessment (PG-SGA©), the Malnutrition Universal Screening Tool, the Nutritional Risk Screening 2002, the Malnutrition Screening Tool, and the Short Nutritional Assessment Questionnaire (Chen et al., 2020; Pt-Global, 2014) (see Figure 1). Cavalcante Martins et al. (2019) found that the PG-SGA not only detected cancer cachexia but also was a useful prognostic tool for mortality. The patient completes part 1 of the PG-SGA, which gathers information regarding recent weight changes, NISs, food intake, and functional status. Part 2 is completed by the provider and screens for weight loss, comorbid disease, and metabolic demand. It includes a physical examination assessing muscle, fat, and fluid status. A score is calculated and stratified into the categories A, well nourished; B, moderately malnourished; and C, severely malnourished, with suggested interventions based on level of risk (Cavalcante Martins et al., 2019; Pt-Global, 2014). 

    “FIGURE1”

    Nonpharmacologic Management

    The ASCO and ESMO clinical practice guidelines recommend offering supportive nutritional advice and referral to a registered dietitian or other nutritionally trained professional, such as a nutritionist or an RN with specialty education in nutrition (Arends et al., 2021; Roeland et al., 2020). Registered dietitians are integral to the supportive care team, particularly for patients with pancreatic, gastrointestinal, and head and neck malignancies. However, there are only 869 board-certified oncology specialist dietitians in the United States as of October 2023 (Commission on Dietetic Registration, 2023). Additional oncology-specific nutrition training for dietitians, nutritionists, and nurses is needed to meet the needs of patients at risk for malnutrition and those currently experiencing cachexia, particularly in the early stages where interventions are likely most effective. 

    The role of exercise in attenuating cancer cachexia is under investigation. Although ASCO has not recommended it (Roeland et al., 2020), ESMO states that moderate physical exercise is safe in patients with cachexia, and recommends exercise guided by professional experts to maintain and improve muscle mass (Arends et al., 2021). Although there is insufficient evidence to assess exercise’s direct impact on cachexia, it is well established that exercise can help improve fatigue, aerobic fitness, functional status, and overall quality of life (Arends et al., 2021; Mislang et al., 2018). In addition, exercise may help reduce the incidence and severity of sarcopenia, a gradual and progressive loss of skeletal muscle mass leading to reduced strength (Mislang et al., 2018). Because increasing physical activity can positively affect fatigue and other symptoms that contribute to reduced quality of life, it can be incorporated into an interprofessional, holistic intervention to mitigate functional decline.

    Caregivers often experience high levels of distress when facing the impact of cachexia on a loved one. This phenomenon is known as eating-related distress. In fact, caregivers may be more troubled by symptoms such as anorexia than patients (Amano, Morita, et al., 2019). Eating-related distress includes many intersecting factors, such as the patient’s and the caregiver’s struggle to cope with cachexia, impaired food intake, relationship disturbance, and changing roles (Amano, Baracos, & Hopkinson, 2019). To alleviate this distress, the ASCO and ESMO guidelines encourage open communication among the healthcare team, the patient, and caregivers regarding the nature and evolution of cachexia (Arends et al., 2021; Roeland et al., 2020). However, the healthcare team may be uncomfortable addressing cachexia because of its complicated and often irreversible nature, poor associated prognosis, and potential for lessening the hope for recovery. Early integration of palliative care may help improve communication and provide an additional layer of support throughout the trajectory of cachexia for the patient and caregiver (Reid, 2014).

    Pharmacologic Management

    Pharmacotherapy for the management of primary cachexia is limited. Although many medications are available for treating NISs and secondary cachexia (e.g., antiemetics, analgesics), the discussion of these medications is beyond the scope of this article.

    Research is being conducted on medications to mitigate the effects of cachexia, including ghrelin receptor agonists, prokinetics, androgens, olanzapine, cannabinoids, nonsteroidal anti-inflammatory drugs, omega-3 fatty acids, progestins, corticosteroids, and others (see Table 2). To date, the only pharmacologic interventions endorsed by the ESMO and ASCO clinical practice guidelines are corticosteroids and megestrol, a progestin (Arends et al., 2021; Roeland et al., 2020).

    “TABLE2”

    Dexamethasone benefits appetite and cancer-related fatigue temporarily and is recommended for short-term use (in the order of a few weeks), although optimal dosing and duration have yet to be established. Dexamethasone’s mechanism of action is thought to be related to its potent anti-inflammatory properties. However, its efficacy declines after several weeks, and because of the side effects of prolonged use (loss of muscle mass, insulin resistance, risk of infection, stomatitis), extended use is not recommended (Arends et al., 2021; Roeland et al., 2020).

    Progestins such as megestrol stimulate appetite and inhibit the synthesis of proinflammatory cytokines. Although many studies have confirmed their modest impact on appetite, the significant risk of side effects, including thromboembolism, fluid retention, and adrenal insufficiency, limit their use (Arends et al., 2021). Dexamethasone and megestrol produce similar appetite results but with very different toxicities (Roeland et al., 2020). Before initiating therapy, providers should discuss risks and benefits with each patient.

    Implications for Nursing

    Oncology nurses are well positioned to intervene in all aspects of cachexia care. Acute care nurses can participate in cachexia screening and management through monitoring patients’ weight and functional status and facilitating early referral to nutrition counseling and physical therapy. In addition, nurses can monitor patients receiving supplemental nutrition (such as tube feedings and parenteral nutrition) and screen for and report adverse events. Acute care nurses can also educate patients and their families regarding the management of supplemental nutrition, feeding tubes, and new medications, as well as provide emotional support (Zhao et al., 2021).

    Similarly, community-based, telehealth, ambulatory, and homecare nurses can participate in cachexia management by ensuring accurate weights are obtained at every visit. All can screen for NISs and facilitate provider visits or referrals for additional support. Because cachexia is a chronic, progressive disease, continuity of care is essential to ensure timely management. Ambulatory and homecare nurses frequently interact with the same patient population and can detect subtle changes in functional status, eating-related behaviors, NISs, and patient and caregiver distress (Zhao et al., 2021). In addition, oncology nurses can advocate for enhanced training and education regarding cancer cachexia and how to navigate difficult conversations.

    Cachexia screening and risk assessment can be conducted during initial appointments with nurse navigators or nurse practitioners (Granda-Cameron & Lynch, 2018). Patients interact with nurse navigators and nurse practitioners frequently throughout anticancer treatment; thus, follow-up screening and assessment of interventions can be conducted during these visits, eliminating the need for additional appointments. Nurse practitioners and nurse navigators can make referrals to other team members, including dietitians, physical therapists, and palliative care providers. In centers that lack nurse navigators or nurse practitioners, providers could train clinic nurses to perform screening at regular intervals and report findings needing additional intervention (Granda-Cameron & Lynch, 2018; Zhao et al., 2021).

    Oncology nurses can fill the gap between the need for oncology-dedicated nutrition professionals and current staffing realities. As one of the first points of patient contact, oncology nurses are well positioned to build rapport and provide tailored nutritional advice (Zhao et al., 2021). Increasingly, there are continuing education opportunities about nutrition available to nurses. Opportunities include participation in journal clubs, continuing education courses, professional certifications, conferences, facility in-services, and podcasts.

    “KNOWLEDGE”

    Conclusion

    Cachexia affects most patients with advanced cancer and accounts for about 20% of cancer-related deaths (Ni & Zhang, 2020). It is a complex, progressive syndrome. Oncology nurses can ensure early screening, education, and intervention to mitigate cachexia’s effects and provide support for patients with cancer and their families. Cachexia treatment includes nonpharmacologic management strategies such as nutritional supplements, exercise, and psychosocial support. Pharmacologic interventions include use of medications to mitigate NISs, as well as emerging therapies to address the physical manifestations of cachexia.

    About the Author

    Amanda French, MSN, CRNP, AGACNP-BC®, OCN®, BMTCN®, was, at the time of writing, a graduate of the acute care nurse practitioner program in the School of Nursing at the University of Pennsylvania in Philadelphia and a traveling nurse at Aya Healthcare in Jersey City, NJ. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. French can be reached at alfrenchrn@gmail.com, with copy to CJONEditor@ons.org.

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