Acta Oncologica

ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: https://www.tandfonline.com/loi/ionc20

Weight loss, appetite loss and food intake in

cancer patients with cancer cachexia: Three peas
in a pod? – analysis from a multicenter cross
sectional study

Tora S. Solheim, David Blum, Peter M. Fayers, Marianne J. Hjermstad, Guro

B. Stene, Florian Strasser & Stein Kaasa

To cite this article: Tora S. Solheim, David Blum, Peter M. Fayers, Marianne J. Hjermstad, Guro
B. Stene, Florian Strasser & Stein Kaasa (2014) Weight loss, appetite loss and food intake in
cancer patients with cancer cachexia: Three peas in a pod? – analysis from a multicenter cross
sectional study, Acta Oncologica, 53:4, 539-546, DOI: 10.3109/0284186X.2013.823239

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Acta Oncologica, 2014; 53: 539–546

ORIGINAL ARTICLE

Weight loss, appetite loss and food intake in cancer patients with
cancer cachexia: Three peas in a pod? – analysis from a multicenter
cross sectional study

TORA S. SOLHEIM1,2,3, DAVID BLUM1,3, PETER M. FAYERS1,4, MARIANNE J. HJERMSTAD3,5,

GURO B. STENE6, FLORIAN STRASSER7* & STEIN KAASA1,2,3*
1Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science
and Technology (NTNU), Trondheim, Norway, 2Department of Oncology, St. Olavs University Hospital, Trondheim,
Norway,3European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular
Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway, 4Institute of
Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK, 5Regional Centre for Excellence in
Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway, 6Department of Neuroscience,
Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway, and 7Oncological
Palliative Medicine, Division of Oncology, Department of Internal Medicine and Palliative Care Center,
Cantonal Hospital, St. Gallen, Switzerland

Abstract
Background. How to assess cachexia is a barrier both in research and in clinical practice. This study examines the need for
assessing both reduced food intake and loss of appetite, to see if these variables can be used interchangeably. A secondary
aim is to assess the variance explained by food intake, appetite and weight loss by using tumor-related factors, symptoms
and biological markers as explanatory variables. Material and methods. One thousand and seventy patients with incurable
cancer were registered in an observational, cross sectional multicenter study. A total of 885 patients that had complete data
on food intake (PG-SGA), appetite (EORTC QLQ-C30) and weight loss were included in the present analysis. The asso-
ciation between reduced food intake and appetite loss was assessed using Spearman’s correlation. To find the explained
variance of the three symptoms a multivariate analysis was performed. Results. The mean age was 62 years with a mean
survival of 247 days and a mean Karnofsky performance status of 72. Thirteen percent of the patients who reported eating
less than normal had good appetite and 25% who had unchanged or increased food intake had reduced appetite. Correla-
tion between appetite loss and food intake was 0.50. Explained variance for the regression models was 44% for appetite
loss, 27% for food intake and only 13% for weight loss. Conclusion. Both appetite loss and food intake should be assessed
in cachectic patients since conscious control of eating may sometimes overcome appetite loss. The low explained variance
for weight loss is probably caused by the need for more knowledge about metabolism and inflammation, and is consistent
with the cancer cachexia definition that claims that in cachexia weight loss is not caused by reduced food intake alone. The
questions concerning appetite loss from EORTC-QLQ C30 and food intake from PG-SGA seem practical and informative
when dealing with advanced cancer patients.

Patients with advanced, incurable cancer frequently
experience involuntary weight loss. Weight loss in
cancer is usually a consequence of either reduced
nutritional intake or uptake of nutrients, or of cancer
cachexia. Reduced nutritional intake or uptake is
defined as starvation, and will normally respond well
to nutritional treatment. Cancer cachexia is caused
by a combination of decreased nutritional intake and
altered metabolism, and is defined as ongoing loss of
skeletal muscle mass that cannot be reversed by con-
ventional nutritional support [1]. It is characterized
by progressive functional impairment [1] and con-
tributes to more than 20% of cancer deaths [2].
Since around 50% of patients with malignant disease
cannot be cured and more than 80% of advanced
cancer patients experience cachexia [2], the toll

* These authors contributed equally to this article.

Correspondence: T. S. Solheim, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU),
PRC, Bevegelsessenteret, Olav Kyrres Gatan 13, Trondheim, 7030 Norway. Tel: 47 92049507. Fax: 47 72826028. E-mail: toralang@ntnu.no

(Received 27 March 2013 ; accepted 4 July 2013)

ISSN 0284-186X print/ISSN 1651-226X online © 2014 Informa Healthcare
DOI: 10.3109/0284186X.2013.823239
540 T. S. Solheim et al.
of this condition is severe both for society and the
individual patient.
An international cachexia consensus indicated
four domains to be assessed in cachexia: 1) catabo-
lism driven by inflammation, tumor products,
and neuro-hormonal alterations including hypo-
anabolism; 2) anorexia or reduced food intake; 3)
loss of muscle mass and a variable loss of fat mass;
and 4) reduced physical/psychosocial function, e.g.
manifesting as physical fatigue and psychosocial
distress [1]. There is a wide range of items that may
be of interest when measuring these domains, i.e.
various biomarkers, patient-reported outcomes or
several disease-related patient characteristics. The
consensus offered little guidance on which items to
use, but for the nutrition domain it was recom-
mended that patients’ own estimates of total food
intake compared to normal should be registered, as
well as probable causes for reduced intake.
Cancer cachexia was previously referred to as the
cancer cachexia-anorexia syndrome, as anorexia is
frequently encountered. There is, however, no agree-
ment about how to diagnose anorexia, and different
instruments (e.g. AQ, VAS, AC/S-12, FAACT) all
measure different aspects of the condition [3].
Anorexia can be regarded as an overarching concept
consisting of a variety of symptoms such as appetite
loss, early satiety, taste alterations [4], reduced food
intake, meat aversions and nausea/vomiting [5]. In
daily practice, appetite and anorexia are commonly
used as synonyms as both can be defined as loss of
desire to eat [3,5]. In the following this definition of
anorexia and appetite loss will be applied.
The term “appetite loss” can be perceived as an
indicator of both quality of life and cancer severity,
and is independently linked to survival [6] and
Figure 1. Factors that impact weight loss in cancer patients.
correlates significantly with physical function [7].
The pathophysiology behind primary appetite loss in
advanced cancer is probably in part caused by pro-
inflammatory cytokines and neuro-hormonal altera-
tions [8], and seems accordingly to be related to the
host reaction to tumor. Appetite loss may, however,
also be affected by secondary factors such as depres-
sion/psychosocial stress, nausea, constipation, taste
alterations or pain [6,9].
The item “food intake” is logically associated
with appetite loss or factors causing appetite loss, but
can also be influenced by a wide range of factors like
cognitive impairment [10], vomiting, stomatitis, dys-
phagia, dietary restrictions etc. [11].
The lack of knowledge and agreement about how
to assess weight loss and cachexia has been an impor-
tant barrier in the interpretation of cachexia research
and in the clinical treatment of involuntary weight
loss. It is therefore important to work towards a
common functional understanding of which items to
consider and which to bypass in the evaluation
of patients with advanced cancer and weight loss
(Figure 1).
A systematic review of items measured in clinical
studies of weight loss showed that dietary records
were sporadically reported, that many studies only
extrapolated the amount of food intake from self-
reported appetite, and that appetite loss and energy
intake were inconsistently related to weight loss [12].
There are indications that reduced food intake
and appetite loss are distinct items [13]. There is,
however, still controversy concerning the necessity to
assess both self-reported food intake and appetite as
a part of the nutritional domain in cachexia, or if
these measurements can be used interchangeably.
There is also insufficient information as to which
 Weight loss, appetite loss and food intake in cancer patients
factors are associated with food intake, appetite loss
and weight loss in advanced cancer.
Our primary aim was to examine the association
between reduced food intake and appetite loss to
confirm our hypothesis of a modest correlation. The
secondary aim was to evaluate the associations
between food intake, appetite loss and weight loss
with tumor-related factors, symptoms, survival and
CRP. The third objective was to examine whether
reduced food intake, appetite loss and weight loss
can be explained by symptom burden and treatment-
or disease-related factors.
Material and methods
Patients and study design
Between October 2008 and December 2009, 1070
patients were registered in the European Palliative
Research Collaborative – Computerized symptom
assessment study (EPCRC-CSA) [14]. This obser-
vational, cross sectional multicenter study aimed to
advance the development of a computer-based
symptom assessment and classification tool for
pain, cachexia and depression. A major research
objective was to characterize the different symp-
toms, and investigate how these should be assessed.
The choice of items was based on the work of the
EPCRC. The assessment and classification tool is
intended for use in clinic and research. Adult
patients with incurable cancer and metastatic or
advanced disease were recruited from 17 centers in
Norway, UK, Austria, Germany, Switzerland, Italy,
Canada and Australia [14].
Data collection
The entire data collection was performed using
touch-sensitive computers (HP Compaq TC4200
1200 tablet PCs). Specific details regarding methods
and instruments have been presented elsewhere [14].
One part of the registration was completed by health-
care professionals, the other by the patients. A
research nurse assisted patients if necessary. Health-
care professionals obtained and recorded informa-
tion on age, gender, height, weight, blood tests and
treatment. Cancer diagnosis including stage of dis-
ease and metastases with localization was also
recorded.
Patients’ subjective health was measured by the
European Organisation for Research and Treatment
of Cancer Core Quality of Life Questionnaire, the
EORTC QLQ-C30 version 3.0 [15]. This well-
validated and extensively used 30-item tool is spe-
cifically developed for cancer patients [16]. The items
form five functional scales, three symptom scales and
six single items. Appetite loss during the last week
541
is measured on a four-point categorical scale (not at
all – very much).
Three of four items from the Patient-Generated
Subjective Global Assessment (PG-SGA) [17] were
used to assess weight loss and food intake: patient-
reported current weight, weight change in the last
six months, and changed food intake compared to
normal on a three-point categorical scale (less than
usual – more than usual).
Since cachexia was not the primary study out-
come and it is essential not to overburden the patients,
other relevant items for cancer cachexia such as a
checklist for nutrition-impact symptoms, tests for
physical function, presence of clinically relevant
edema or registrations of tumor activity were not part
of the EPCRC-CSA assessment. The last retrospec-
tive registration of death was completed by 31
December 2010.
Statistical considerations
For all analyses, “weight loss” was defined as self-
reported weight loss the last six months expressed as
a percentage. Patients were assumed to have reduced
food intake if they rated their food intake as less than
usual compared to normal (both items from PG-
SGA). Patients were considered to have reduced
appetite if they reported a little, quite a bit or
very much appetite loss on the EORTC QLQ-C30
questionnaire.
The analytical approach in this paper consists of
three steps.
In the first step, Spearman’s correlation was cal-
culated to explore the relationship between self-
reported reduced food intake and appetite loss. The
next two analytical steps examined whether food intake,
appetite and weight loss are distinctive assessments.
In the second step, univariate analyses were per-
formed to describe associations between tumor-
related factors, symptoms and biological markers
and levels of food intake, appetite and weight loss.
The factors explored were all 15 scales from EORTC
QLQ-C30, weight loss, food intake, origin of cancer,
metastasis site, treatment and CRP. CRP was log
normally distributed and was transformed before the
regression analysis.
The impact on survival of food intake, weight loss
and appetite loss was explored using univariate log-
rank tests. Significant factors (p  0.05) were included
in a multivariate survival analysis using Cox-model
regression.
In the third step, multivariate regression analyses
were conducted to determine the portion of variance
explained by weight loss, appetite loss and reduced
food intake. All factors used in the univariate analy-
sis in step two were regarded as explanatory vari-
ables. Factors were then explored for associations
542 T. S. Solheim et al.
using a mixed forward-backwards stepwise multi- Table I. Demographic data.
variate regression analysis and included if significant Characteristics na Range %
(p  0.05). Factors were reported if the standardized
regression coefficients were larger than 0.1. The aim Female 412 46.6
Age 62 18–89
was to find the factors that best predicted appetite, BMI 24.3 10–61.9
food intake and weight loss. A multiple regression Tumor localization
analysis such as this should be regarded as exploratory, Digestive organs 249 28.1
as it will not provide a definitive set or of variables that Breast 146 16.5
contribute to the three symptoms since these will Respiratory organs 140 15.9
Male genitals 93 10.5
vary with the studied population and the strength of Urinary 50 5.6
connections between the factors evaluated. Leukemias/lymphomas 36 4.1
Skin 36 4.1
Bone/soft tissue 33 3.7
Results Head and neck 28 3.2
Other 71 8.0
Patient demographics Metastatic diseaseb
A total of 885 patients with complete data on weight Bone 325 36.7
Liver 273 30.8
loss, appetite loss and food intake were available for Lymph node 249 28.1
analysis after excluding four patients due to with- Lung 174 19.7
drawal of informed consent, 15 patients because of Brain 74 8.4
technical failure, and 166 patients with incomplete Other 218 24.6
data on food intake (n  82), appetite loss (n  37) Current oncological treatment
Chemotherapy 424 47.9
or weight loss (n  166). Radiotherapy 184 20.8
Mean age was 62 years (range 18–89) and 53.4% No cancer treatment 225 25.4
were male patients. Most patients (n  535) had Survival (days) 247 1–713
metastatic tumors originating from digestive organs, Karnofsky 72 20–100
breast or lung. At inclusion, 254 patients were not aNumber of patients or mean.
receiving active tumor treatment. The mean survival bThe patients might have several metastatic sites.
was 247 days (95% CI 233–261) and mean Karnof-
sky performance status was 72 (range 20–100). The significantly less weight loss (3.4% vs. 5.7%), describ-
charecteristics of the patients are reported in Table I. ing their appetite as better and their food intake as
closer to normal. All three symptoms were associated
Correlation between weight loss, appetite loss and with the use of anti-emetics (other than glucocorti-
change in nutritional intake coids), more nausea/vomiting and increased CRP-
values. All variables from EORTC QLQ-C30 were
Eating less than normal was reported by 13% of the associated with appetite loss. All EORTC QLQ-C30
patients who had good appetite, while 25% of the variables except insomnia, diarrhea and financial
patients who had reduced appetite ate more than situation were associated with reduced food intake
usual or unchanged (Table II). Correlation between and weight loss.
appetite loss and food intake was 0.50. The correla- The standardized βs imply that, for all three symp-
tions between weight loss and food intake, and weight toms, age, gender, tumor localization, metastatic site
loss and appetite were both 0.34. and current therapy had less impact than most vari-
ables on the EORTC QLQ-C30 scale and LogCRP
Distribution of symptoms, tumor-related factors, (Table III).
biological markers and survival In univariate analysis food intake, appetite and
Neither food intake nor appetite loss was significantly weight loss were significantly associated with reduced
associated with tumor or site of metastases in the survival (Figure 2). In the multivariate survival anal-
univariate analysis. Reduced food intake was associ- Table II. Comparison of appetite loss and food intake.
ated with higher age. Weight loss was associated with
gender (higher if male), and had a weak negative Appetite loss
correlation with tumors originating from the breast Food intake
Not at all A little Quite a bit Very much
compared to
as these patients had significantly less weight loss normal N % N % N % N %
compared to the rest of the population (2.2% vs.
5.2%). Weight loss, appetite and food intake were Less than usual 49 13 102 27 127 33 104 27
associated with the current use of chemotherapy, Unchanged 230 56 123 30 42 10 16 4
More than usual 57 62 18 20 13 14 4 4
with patients treated with chemotherapy having
 Weight loss, appetite loss and food intake in cancer patients 543
Table III. Univariate linear regression.

Food Appetite Weight

Characterizationsa intake loss loss

Global health status/QoL 0.22* 0.37* 0.16*

Physical function 0.16* 0.32* 0.20*
Role function 0.17* 0.33* 0.17*
Emotional function 0.11* 0.27* 0.08
Cognitive function 0.08 0.24 * 0.11*
Social function 0.14* 0.24* 0.13*
Fatigue 0.24* 0.47* 0.20*
Nausea/vomiting 0.24* 0.45* 0.15*
Pain 0.18* 0.32* 0.15*
Dyspnea 0.12* 0.19* 0.06
Insomnia  0.01 0.15* 0.01
Appetite 0.47* 0.29*
Constipation 0.14* 0.23* 0.14*
Diarrhea 0.02 0.16* 0.08
Financial problems 0.04 0.11* 0.07
Log CRP 0.24* 0.26* 0.19*
Breast cancer 0.02 0.04 0.11*
Chemotherapy 0.07* 0.11* 0.12*
Anti-emetic therapy 0.12* 0.18* 0.10
Weight loss 0.26* 0.29*
Food intake 0.47* 0.26*
aOnly factors with standardized b values higher than 0.1 are
presented, and thus not most cancer origins, metastatic sites,
cancer treatments, age and gender. The standardized bs allow for
comparison of the impact of the explanatory variables on the
outcomes regardless of scales used. They indicate the highest
relevance among the examined variables.
*P-values 0.001.

ysis only weight loss (p  0.01) and appetite loss

(p  0.001) remained significantly associated with
reduced survival.

Multiple regression analysis

To determine the need for registering additional infor-
mation in future studies, a multiple regression analysis
was performed to examine how well weight loss,
appetite and food intake could be explained by other
factors (Table IV). Explained variance for the regres-
sion models (adjusted R2) was 44% for appetite loss,
27% for food intake and 13% for weight loss. Explan-
atory variables used were demographic, tumor-related
and treatments factors as well as CRP, self-reported
quality of life, nutritional intake and weight loss.
Appetite loss, LogCRP and weight loss were sig-
nificantly associated with food intake, but appetite
had the highest standardized β (0.42 compared to
0.11 and 0.13). Food intake, fatigue and nausea/
vomiting were significantly associated with appetite
loss, with similar standardized βs (0.33, 0.26 and
0.25, respectively). Physical function, appetite loss,
food intake and gender were significantly associated
with weight loss and had similar standardized βs
(0.15, 0.15, 0.16 and 0.11).
Figure 2. Survival curves.
Discussion
In this observational, cross sectional, multicenter
study, we explored whether food intake and appetite
could be used as equivalent measurements in the
assessment of cachexia in advanced cancer patients.
In the studied population the correlation between
food intake and appetite loss was r  0.50 (p  0.01),
a rather moderate association. In a substantial num-
ber of patients (25%) self-reported food intake
increased or remained unchanged in spite of some
degree of appetite loss, and 13% ate less despite
reporting good appetite. These data are consistent
with the primary hypothesis, suggesting that the two
factors, food intake and appetite loss, cannot be used
interchangeably. This means that they cannot be sub-
544 T. S. Solheim et al.
Table IV. Multiple regression analysis*.
Food intake R²  0.27
Characterizations b CI Stand. b
Food intake
Appetite loss 0.01 (0.01–0.01) 0.42
Weight loss 0.01 0.01–0.01 0.13
LogCRP 0.11 (0.17–0.03) 0.11
Fatigue
Nausea/vomiting
Physical function
Gender
*All standardized β 0.1, p  0.01.
stituted for one another or be extrapolated from each
other when looking into the complexity of weight loss
in e.g. cancer cachexia.
In order to understand how food intake, appetite
and weight loss might be interrelated, regression
analysis was performed with these items as explana-
tory variables. In this population other symptoms
showed a higher association with food intake and
appetite loss than variables related to the cancer dis-
ease and treatment in both univariate and multivari-
ate analysis.
The multivariate analysis showed that dissimilar
variables were associated with food intake, appetite
and weight loss, and that it was possible to explain
44% of the variance of appetite loss, 27% of the vari-
ance of food intake, but only 13% of the variance of
weight loss. This suggests that there might be differ-
ences as to which factors best predict appetite loss,
food intake and weight loss, and also that the present
variables are insufficient to explain these symptoms.
Therefore additional factors such as other nutritional
impact symptoms (early satiety, mouth sores, dys-
phagia, and information on metabolism) should be
assessed. A longitudinal study of newly diagnosed
head and neck cancer patients found that symptoms
such as pre-treatment anorexia, pain, dysphagia and
mouth sores were predictors of reduced dietary
intake and weight [11].
It was possible to explain more of appetite loss
and reduced food intake than weight loss in the mul-
tivariate analysis. Furthermore, the correlations of
weight loss to appetite loss and to reduced food
intake were low to moderate (both r  0.34, p  0.01).
This is probably because of a gap in the understand-
ing of metabolism and inflammation in relation to
weight loss; consistent with the cancer cachexia def-
inition that claims that cachexia/weight loss is not
caused by reduced food intake alone. CRP was asso-
ciated with weight loss in the univariate analysis, but
not in the multivariate analysis. A review of items
associated with weight loss found that albumin, CRP
and IL-6 were the inflammation markers most con-
sistently associated with weight loss [12]. Results
Appetite loss, R²  0.44 Weight loss, R²  0.13
b CI Stand. b b CI Stand. b
18.03 (21.84–14.22) 0.32 2.48 1.11–3.86 0.16
0.04 (0.07–0.02) 0.15
0.30 0.18–0.41 0.26
0.38 0.30–0.48 0.22
0.05 0.09–0.28 0.15
2.10 0.55–3.65 0.11
for other cytokines such as TNFα, IL-10, IL-8,
IL-4, IFN-γ were more inconsistent or mainly not
significant [12]. Nevertheless, CRP is today prob-
ably the most robust biomarker for cachexia [18],
although it is highly unspecific and new biomarkers
are warranted. It is also important to acknowledge
that cachexia can occur without manifest systemic
inflammation [1].
In the current study it is evident that advanced
cancer patients with appetite loss have a greater
symptom burden and reduced survival compared to
patients with weight loss alone. If assessing cachectic
patients without considering appetite loss, one would
lose an important predictor of survival, an important
aspect of quality of life as well as an important topic
for information/psychosocial intervention [19]. Infor-
mation from the present study supports the sugges-
tions that “cachexia with anorexia” should be a
sub-type of cachexia [4] or a part of a grading system
for cachexia [1,20]. While arguing for this, some
emphasize that appetite loss and loss of weight/mus-
cle have similarities in their pathophysiology as they
both might be affected by inflammation [21], while
others propose a more diverse pathophysiology [4].
The present results are based on selected vari-
ables, which represent some but not all possible items
in the four cachexia domains. Body weight was avail-
able, but no information on edema or direct mea-
sures of muscle mass was assessable, which might
reduce the value of weight loss as an indicator. In the
analyses we investigated self-reported weight and
weight loss, the correlation between self-reported
weight and caregiver reported weight was in this
study r  0.97 (numbers not shown).
For the nutritional domain there was no informa-
tion on early satiety or symptoms such as xerostomia,
stomatitis or changes in sense of smell, but the mea-
sures for appetite seem robust. For the catabolism
domain, there was no information on current cancer
disease dynamics (e.g. whether the cancer was resis-
tant to anticancer treatment and progressing) or
hypo-anabolism, but the dataset contains the impor-
tant marker CRP. Considering the functional domain,
 Weight loss, appetite loss and food intake in cancer patients
the dataset contains self-reported physical function,
but no objective measures of muscle strength. It is
not possible to evaluate whether the inclusion of
these additional variables would have changed the
present results substantially.
This was a cross sectional study and there were
no documented measurements of what the patients
used to eat or what they actually were eating at inclu-
sion. Only patients’ own estimate of food intake in
relation to normal intake was reported in accordance
with the minimal requirements described in the
international consensus [1]. This assessment of food
intake has however not been compared with precise
longitudinal measurements of nutritional intake, and
as mentioned self-reported estimates are known to
have some bias [22]. The self-reported question of
food intake has not been validated against prospec-
tively collected diet records and there is a possibility
that patients have been eating less than they report;
in this case the correlation between weight loss and
food intake might have been higher if the information
on food intake were based on precise measurements
of food intake instead of self-reported information.
This study nevertheless demonstrates that food
intake needs to be assessed in addition to appetite loss.
Even though cachexia cannot be cured with nutrition
alone [1], it is important to secure sufficient energy
and protein intake and avoid under-nutrition in patients
with curative cancer or with pre-cachexia/cachexia.
Consultations with nutritional professionals (registered
dietitian or equivalent) might be of great value [23]. In
patients with late cachexia overview on food intake is
essential to enable patient information. In this situation
nutritional advice should be given in a manner that
attempts to relieve the burden for patient and their care
givers. One example of this might be to end the
focus on calories and help increase meal enjoyment by
lowering demands and expectations.
In this population, grading of appetite loss on a
four-point scale gave a more nuanced prediction of
survival and returned higher significance levels than
the question of reduced intake. One reason for this
might be that some patients who realize they have
short expected survival might eat more in the hope
of fighting heir cancer disease. Another possibility is
that patients might claim to eat more, even though
they eat less or the same, in order to give the clinician
the supposedly “right answer”. The focus on eating
enough and healthily might also be a reason for the
moderate correlation between appetite and food
intake. Patients who know they are at risk of losing
weight may force themselves to eat despite lack of
appetite. Thus, treating loss of appetite might not
affect the intake in some patients but might affect
their feelings and joy of their meals.
The cross sectional design can only evaluate asso-
ciations, not causality. Weight loss in cachexia is known
545
to be caused not only by reduced food intake but also
by additional factors; appetite loss and weight loss
might be concurrent events caused in part by common
pathophysiology. Reduced food intake is, however,
likely to accelerate weight loss. The present study
design does not give information on consequences for
weight, quality of life variables and survival following
improved nutrition or appetite.
A problem when studying these issues is to
untangle the question of whether appetite loss and
reduced food intake are merely irreparable indicators
of patients in whom treatment soon will fail, or
whether the symptoms decrease the ability of some
patients to be treated and that modifications can lead
to improved survival or quality of life. Large prospec-
tive studies with well-defined assessments and man-
agement of both malnutrition and cachexia are
needed in order to answer this question.
Information in this paper is based on a large mul-
ticenter study with advanced cancer of heterogeneous
origin. It may contribute to the ongoing work on
assessment of cancer cachexia, which builds on the
cancer cachexia framework. Currently it is difficult
to differentiate well between starvation/malnutrition
and cachexia, partly because these conditions are
intertwined in varying degrees. Hopefully, the
future refinement of the cachexia classification sys-
tem will help discriminate somewhat between these
conditions, and thus improve treatment strategies.
The current cross-sectional study did not define
cachexia as an inclusion criterion and therefore a
mixture of patients with and without malnutrition
and cachexia, were included which provides an
opportunity to describe the comprehensive cancer
population well.
Conclusion
The intention of the present study was to contribute
to the clinical understanding of which items are nec-
essary for the assessment of a cachectic patient, and
by this to the progression of the international clas-
sification system for cachexia.
Cachexia is defined by weight loss and is char-
acterized by several domains. Both appetite loss
and food intake should be assessed in the charac-
terization of cachexia as each of these symptoms
appears to provide distinct information. One of the
reasons for this is that anorexia can sometimes be
overcome by conscious control of eating [24].
Patients who know they are sick and have a flawed
appetite regulation may force themselves to eat
without appetite.
The questions concerning appetite loss from
EORTC-QLQ C30 and food intake from PG-SGA
are practical and seem informative when assessing
advanced cancer patients.
546 T. S. Solheim et al.
Acknowledgement
The EPCRC (2006–2010) was funded by the Euro-
pean Commission’s Sixth Framework Programme
(contract no LSHC-CT-2006–037777) with the overall
aim to improve treatment of pain, depression, and
fatigue through translation research. Core scientific
group/work package leaders: Stein Kaasa (project coor-
dinator), Frank Skorpen, Marianne Jensen Hjermstad,
and Jon Håvard Loge, Norwegian University of Science
and Technology; Geoffrey Hanks, University of Bristol;
Augusto Caraceni and Franco De Conno, Fondazione
IRCCS Istituto Nazionale dei Tumori, Milan; Irene
Higginson, King’s College London; Florian Strasser,
Cantonal Hospital St. Gallen; Lukas Radbruch, RWTH
Aachen University; Kenneth Fearon, University of
Edinburgh; Hellmut Samonigg, Medical University of
Graz; Ketil Bø, Trollhetta AS, Norway; Irene Rech-
Weichselbraun, Bender MedSystems GmbH, Austria;
Odd Erik Gundersen, Verdande Technology AS,
Norway. Scientific advisory group: Neil Aaronson, The
Netherlands Cancer Institute;Vickie Baracos and Robin
L. Fainsinger, University of Alberta; Patrick C. Stone,
St. George’s University of London; Mari Lloyd-
Williams, University of Liverpool. Project management:
Stein Kaasa, Ola Dale, and Dagny F. Haugen, Norwe-
gian University of Science and Technology. There are
no financial benefits or conflicts of interest that might
bias this work.
Declaration of interest: The authors alone are
responsible for the content and writing of the paper.
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