Coping With Cancer Weight Loss
The Wasting Syndrome Known as Cachexia Causes Loss of Body Fat, Muscle
By Marian Dennis
Originally published in Forward – Winter/Spring 2021
Among the many changes that cancer and its treatment bring, perhaps none is more challenging than cachexia (pronounced “kuh-KEK-see-uh”), a wasting syndrome in which patients experience loss of body fat and muscle as a result of advanced cancer or malnourishment. One female patient who weighed 120 pounds before her illness saw her weight drop significantly, by upwards of 20 to 30 pounds, even though she was able to eat regularly.
For Rishi Jain, MD, a medical oncologist at Fox Chase Cancer Center who specializes in cancers of the gastrointestinal tract, cachexia is one of the most pressing issues for cancer patients. He is currently researching the relationships between specific cancers, nutrition, and physical activity with the goal of improving clinical outcomes by enhancing treatment effectiveness and reducing therapy-related side effects.
“Cancer cachexia is best described as a syndrome that can accompany cancer in approximately half of patients. Cachexia is the loss of appetite, weight loss, and more specifically, skeletal muscle loss, that occurs,” said Jain.
It is common in cancer in general, but even more common with advanced cancer, specifically certain types like lung or pancreatic, Jain added. “The appetite, weight, and muscle loss can lead to fatigue, weakness, and ultimately, reduced quality of life, more complication risks, hospitalizations, and even reduced survival.”
Jain said there is usually a great deal of overlap in cases of malnutrition and cachexia, so much so that the terms are often used interchangeably. In some cases, malnutrition can be reversed by meeting the body’s nutritional needs. But for most patients with cancer-related cachexia, nutritional support alone is not enough to reverse the underlying process through which skeletal muscle and fat are broken down uncontrollably.
Diagnosing Cancer Cachexia
This risk of death makes identifying early signs of cachexia paramount to its treatment. However, although there is evidence-based guidance on identifying stages of cachexia, there is no universal standard for its diagnosis and identifying it can get complicated when patients have different symptoms.
In addition to monitoring symptoms like weight loss to diagnose cancer-related cachexia, physicians may also diagnose cancer-associated muscle loss through routine diagnostic scans, said Charles Loprinzi, a medical oncologist at the Mayo Clinic who served as senior author on the American Society of Clinical Oncology (ASCO) guidelines on cancer cachexia.
We have to do a better job of helping patients and their family members understand that at some point cancer cachexia is irreversible and we have to accept it as a complication that comes with cancer.”
RISHI JAIN, MEDICAL ONCOLOGIST
“These patients have a propensity to lose muscle mass early on. They might still be a bit heavy and yet have thin muscles,” said Loprinzi. “We didn’t understand that so much in the distant past, but we understand it quite a bit more now. The one way you can see that is on CT scans.” CT scans combine X-ray images from different angles to provide more in-depth images than X-rays alone can provide.
According to the ASCO guidelines, the international consensus is that cancer cachexia is a continuum that can be categorized into three phases: pre-cachexia, cachexia, and refractory cachexia.
The guidelines describe pre-cachexia as occurring in patients who experience only minimal weight loss and have early clinical and metabolic signs that could indicate more weight loss in the future. These signs include anorexia, insulin resistance, inflammation, and hypogonadism.
The ASCO guidelines describe the onset of cachexia as weight loss that exceeds 5% over the previous six months or depletion of muscle mass and more than 2% weight loss. Refractory cachexia is characterized by poor performance status, progressive cancer, and a life expectancy of less than three months.
Not every patient will necessarily experience all stages, and risks of experiencing them vary based on different factors. In all of these stages, appetite and food consumption can play a vital role.
For cancer patients, treatments can often be accompanied by nausea or lack of appetite. For some patients, eating is no longer enjoyable. Some patients lose their sense of taste and can find that when eating, they feel like they are consuming something akin to wet paper.
Loprinzi said although there is no guarantee it will lead to increased survival or weight gain, seeing a dietitian can help patients learn about what they should and should not be eating. It can also provide helpful methods for dealing with loss of appetite.
“Cancer cachexia can be very difficult,” said Tara Mauro, a registered dietitian who works as the oncology nutrition care coordinator at Fox Chase. “As a dietitian, trying to optimize a patient’s nutrition is really important to help prevent further weight loss and maintain the muscle mass they still have. It’s difficult when a patient doesn’t have an appetite, so it can be helpful to set a schedule to remind themselves to eat. That way, it’s less of a push from the caregiver.”
Mauro said it’s imperative that patients dealing with cachexia consume more protein to help maintain muscle mass. She recommends against diets that are overly restrictive and suggests educating both patients and caregivers on preparing nutrient-dense foods that are higher in protein and calories.
“I think it’s beneficial for patients, caregivers, and medical providers to know that a dietitian is always available and is the best person to get the patient in touch with if they are struggling with eating and maintaining their weight,” said Mauro.
In some cases, patients dealing with cachexia may be even less inclined to eat when family members become involved.
A dietitian is always available and is the best person to get the patient in touch with if they are struggling with eating and maintaining their weight.”
TARA MAURO, REGISTERED DIETITIAN
“There’s a story I heard about a psychiatrist who interviewed cancer cachexia patients. She talked with a patient who had advanced cancer and the patient was in her dying weeks. The patient told the psychiatrist that when some of her family members would come to visit her, she would pretend she was asleep, because otherwise they would try to force feed her,” said Loprinzi.
“I get chills when I say that. The person has limited time, and valuable family interactions are more important at that stage of the disease process than trying to get in a few more calories,” he added. Loprinzi said he tells struggling family members that they should give a patient food if they want it, but trying to force an individual to eat may ultimately be counterproductive.
“Sometimes cachexia, particularly toward the end of life, can cause a lot of stress on patients and family members because eating is something that is very social and very important as a behavior,” said Jain. “We have to do a better job of helping patients and their family members understand that at some point cancer cachexia is irreversible and we have to accept it as a complication that comes with cancer.”
Although many cases of cachexia can make a cancer diagnosis look bleak, there is still some hope on the horizon, according to researchers.
Loprinzi said some exciting developments in clinical trials include a recent paper he published on the use of the anti-psychotic drug olanzapine for patients with advanced cancer. The research showed olanzapine to be effective in controlling nausea and vomiting in patients with advanced cancer; additionally, olanzapine appeared to significantly impact a patient’s appetite and improve their quality of life.
Jain said researchers at Fox Chase are also currently doing novel work to develop more effective approaches to cachexia. This includes clinical trials in which researchers are looking at chemotherapy in combination with an anti-cachexia medication to determine if cachexia that arises from pancreatic cancer is preventable.
“From a diet perspective, I’m also doing some trials looking at a computerized diet assessment tool to see if we can better capture what people are eating, which could better signal a person who is developing cachexia,” said Jain. “We absolutely have to put in all our effort to try to use the tools in our toolbox to manage cachexia.”
Photo by Joe Hurley