Cancer And Cachexia

What is Cachexia?
“..THE SHOULDER, CLAVICLES,
CHEST AND THIGHS MELT AWAY.
THIS ILLNESS IS FATAL..”

-Hippocrates (460-370 BC)-

 Cachexia

• By Hippocrates
• Cacos  bad
• Hexus  condition
• Cachexia  bad
condition : decrease
body weight and loss of
fat – muscles very fast
 Background :
• The number of cancer is increasing.
• Cancer in Indonesia is usually diagnosed in advanced
stage, and most of them have experienced
malnutrition : weight loss (Cachexia)
• The doctor’s knowledge of the existence nutritional
disorder is still low. Nutrition support is still not
optimal. The result of therapy have not been
statisfactory.
Case 1: Lung Cancer

• 59 th year old man come

with lung cancer stage 4
(suprarenal)
• He came with chief
complaint :
– The body weight went down
10kgs for 6 month.
– Lost of appetite.
– Cough for 1 year, but in 2
month it was getting more
severe.
• He was a heavy smoker
and worked in a factory.
• He went to works by
motorcycle for almost 1
hour.
 Figure 1

Cell Metabolism 2012 16, 153-166DOI: (10.1016/j.cmet.2012.06.011)

Copyright © 2012 Elsevier Inc. Terms and Conditions
Browning of white adipose tissue in
cachexia
 The Impact of Cachexia on Patients

• Decline the quality of life

• Decrease self confidence (being very thin)
• Increase side effects of chemotherapy
• Decrease therapeutic response
• Decrease survival
 Staging Cancer Cachexia

Blum B, et al.: European Palliative Care Research Collaborative. Evolving classification

systems for CC: ready for clinical practice? Support Care Cancer 2010, 18(3):273–279.
Case 1 : Tongue Cancer
• A 42-year-old woman, a housewife, diagnosed with
tongue cancer Stage IIIB. She did not respond with the
chemotherapy, then radiotherapy was given to this
patient.
• Patient came a week after radiotherapy with complaints
of difficulty swallowing  dry mouth & stomatitis,
impaired swallowing, and no appetite. Patient become
weak.
• Body weight decreased by 4 kgs in 2 months.
• Height : 150 cm, Weight : 40 kgs (before : 44 kgs),
• Weight loss by >5%, BMI = 18,1 (below normal limit)
 Laboratory Findings
• Hb : 10,2
• WBC : 9.700
• Plt : 415.000
• Alb : 3,0
• Na: 130
• K : 3,1
• Ca: 9,2
• CRP : 10
Question 1:
• What is the nutritional status of this patient?
• Has Cachexia occured in this patient?
 Staging Cancer Cachexia

Blum B, et al.: European Palliative Care Research Collaborative. Evolving classification

systems for CC: ready for clinical practice? Support Care Cancer 2010, 18(3):273–279.
Answer : Cachexia

• Because :
1. Weight loss by >5% (6 months).
2. BMI <20%
3. Anamnesis  Cannot swallow and appetite
decreases
Question
• Why does this patient become Cachexia?
 Incidence of weight loss in some cancers

Laviano A et al. Nature Clin Prac Oncol 2006;2:158-64

 NUTRITIONAL CONSEQUENCES  RADIOTHERAPY
REGION EARLY EFFECTS LATE EFFECTS
Head & neck Odynophagia Ulceration
Xerostomia Xerostomia
Mucositis Dental caries
Anorexia Osteoradionecrosis
Dysosmia Trismus
Thorax Dysphagia Fibrosis, stenosis
Fistula
Abdomen & pelvis Anorexia Ulceration
Nausea, vomiting Malabsoption
Diarrhea Diarrhea
Acute enteritis / colitis Chronic enteritis / colitis
Multimodal supportive care

Awareness
(diagnostic
acumen)
Optimal
Multidisciplinary
oncological
team work
management

Nutritional
Support
Early intervention
(e.g. high
protein ONS)
Multimodal
therapy

Treat
Exercise
secondary factors

Anti-inflammatory Anabolic/
therapy (e.g. anti-catabolic
NSAID, EPA) therapy

Fearon KCH EJC 2008

Benefits of Enteral Feeding

• Preservation and maintenance of

intestinal organ function
• More cost-effective and safer When the
compared with PN Gut Works,
USE IT !!!

Techniques in Gastrointestinal Endoscopy 2013; 15: 216–223

Enteral Feeding Decision Tree

Guenter, P., Silkroski, M. 2001. Tube Feeding Practical Guidelines and Nursing Protocols.
 Screening
• It must be fast and simple
• 3 basic questions :
– Body weight before getting cancer
– Decrease in food intake
– Current BMI
 Several Ways

1. Subjective Global Assessment (SGA) :

• The standard method for estimating the nutritional status of
cancer patients with cachexia

2. Patient Generated – Subjective Global Assessment (PG-SGA):

• Same as SGA

Level IV Bauer & Capra 2005

 Types of Nutrition Intervention
1. Low Nutrition Risk:
– Enough with counseling

2. High Nutrition Risk:

– Nutrition interventions with
oral/enteral/parenteral
• When reffering to PG SGA : high nutrition risk.
– So nutritional therapy must be given to improve
patient’s nutrition
 Nutritional Needs
• Calories :
– 30-35 kcal/kg = 30 x 54 kg = 1620 kcal
• Proteine :
– Protein : (1.5 – 2.5 g/kg) = 1.5 x 54 kg = 81 g
• Fat :
± 30% of total energy = 507 kcal
• Micronutrient : vitamin and mineral supplementation : Fish
Oil and Omega 3
• Blended food or liquid diet through NGT with composition as
above
Grant, B.Krause’s, Nutrition & Diet Therapy 2007
 Question
• What nutrition therapy should be given? And
which route?
Answer
• The nutrition must be given enterally, because :
– Can’t swallow
– Decrease of appetite
– But intestine can still work well, so we chose NGT
Questions :
• What other therapies should be given to this
patient?
 Cachexia Therapy

• Different from starvation  Cachexia is not

enough treated by nutritional therapy alone in
returning body mass  must be combined with
other modalities
 Management of Cachexia

Non Pharmacology Pharmacology

– Diet modification – Appetite stimulants
– Physical training – Anabolic agent
– Counseling and – Cytokine and
education metabolic inhibitor
– Other agents :
Megestrol acetate
1. Diet modification through NGT
2. Counseling and education
– It is important to remember the appearance of
being “bad” with “plastic trunk named NGT”.
– in certain patients need phychologist for
counseling and education about how the service
of this trunk supports their recovery.
3. Pharmacological therapy is not necessary
because through NGT
Questions :
• What is the treatment of Cachexia in this
patient?
• Is the target to reach body weight back to
normal?
Answers :
• Body weight does not increase, but does not
drop again.
• The patient feels comfortable
• Can do daily work properly (Good QoL)
• Train the family to be
able to feed themselves
through NGT (homecare
preparation)
Case 2 : Breast Cancer
• 50-year-olf woman, a convection tailor, diagnosed
with Breast cancer stage IIB since 5 years ago. She
had received surgery, chemotherapy, and radiation
therapy.
• Patient controlled regularly for the first 3 years. All
results were good. After that, the patient never
controlled again.
• Since the last 6 months, the stomach had enlarged
and low back pain. The doctor said it was metastatic
to the liver and bone VL4-5.
• After received radiotherapy + chemotherapy,
the mass of the liver is slightly reduced, but
the patient complained of coughing and both
legs could not be moved. The patients was
waiting for the schedule for radiotherapy.
• Thoracic CT results : lung metastases.
Case 3 : Mandibular Cancer
• Man, 62 years old with chief complain: lump in the
mandibula since 1 year ago. The mass has grown up but
he went to herbal medicine .
• Since 3 month before hospitalized he had cough, and
when he came to the doctor : diagnosed as Ca
Mandible stage IV (lung meth).
• He became anorexia and weak, difficult to eat because
can’t open the mouth normally. But he always tried to eat
soft food. The body weight slightly decreased (3,5 kg in 6
month).
• Height: 172 cm , weight: 70 kg (73,5 kg): 3%, BMI 23,0
• He recieved paliiative chemotherapy.
Question :
• What is the nutritional status of this patient?
Answer :

• According to anamnesis and physical

examination :
– Weight loss < 5% in 6 months
– Anorexia
– Fatigue

 Pre Cachexia
 Staging Cancer Cachexia

Blum B, et al.: European Palliative Care Research Collaborative. Evolving classification

systems for CC: ready for clinical practice? Support Care Cancer 2010, 18(3):273–279.
Question:
• What is the patophysiology of the Cachexia?

63
Answer:
1. Tumor Factor:
H&N Cancer : high incidence of Cachexia.
Stage IV: high metabolism
2. Treatment Factor:
Chemotherapy: cispl-5 FU
3. Patient Factor:
- ( no stress)

64
Before and after 6 cycles chemotherapy
Before After
Question
• What is nutritional therapy should be given?
Answer

• We chosen Enteral ( NGT) for his feeding.

• But when he sometimes vomited because of the
chemotherapy, we add parenteral nutrition for
several days.
• We stop the NGT and back to normal food after
the mass getting smaller ( 4 th cycles ) and he
could open his mouth normally.
Question:
• What is the result of the nutrition treatment?

69
Answer :
• Physically : Body weight raised 1,5kg
• Psychologically:
– the patient feels ok : decrease cough,eat normally.
– he went home with better QoL
• Respons chemotherapy: Partial respons.
 Pathway - Proteolytic Proteosome Ubiquitin

http://www.biomol.de/infos_bostonbiochem.html?id=735&hersteller=BostonBiochem. 2012
Case 4 : Pallatum Cancer
Before and After chemotherapy, waiting for
radiotherapy
• A 46-year-old woman, a teacher, diagnosed with : Ca
Palatum stage IIIB.
• She felt anorexia, weak and loss of body weight 6 kg
in 4 month.
• The treatment was chemotherapy and then continued
with radiation .
• Height : 152cm
• Weight : 43kg (49kg-50kg) : 7%
• BMI : 19,2
Question :

• What is the nutritional status of this patient?

Answer :
• According to anamnesis and physical examination :
– Weight loss > 5% in 6 months
– Anorexia
– Fatigue
– BMI : 19,2

 Cachexia
Question:
• What is the patophysiology of the Cachexia?

77
Answer :
1. Tumor Factor:
H&N cancer high incidence of Cachexia.
2. Treatment Factor:
Chemotherapy: cispl-5 FU
3. Patient Factor:
- ( no stress)

78
Question

• What is nutritional therapy should be given?

Answer
• We chosen Enteral (NGT) for her feeding:
4x300cc.
• When she sometimes vomited because of the
chemotherapy, and we will add parenteral
nutrition, but she refused to hospitalized: we
made the food intake via NGT slower 8x 150cc
(every 3 hours). This method worked well.
• Because the next treatment was radiotherapy,
we still use the NGT to prevent the side effect,
and made sure that she will have a good /stable
nutritional status.
Question:

• What is the result of the nutrition treatment?

81
Answer :
• Physically : Stable body weight
• Psychologically:
– the patient felt better : although she couldn’t eat normally
– She went home with better QoL
• Respons of chemotherapy : Partial respons, with less
side effect.
Before and After chemotherapy, waiting for
radiotherapy
Tisdale MJ. J Support Oncol 2003;1:159-68
 Cori Cycle
Krebs Cycle
2 ATP/glucose + Lactate Acid
36 ATP/glucose
• Complaints :
– decrease appetite
– Decrease in body weight of 8 kgs in 6 month
– No response with treatment

• Height : 163cm,
• Weight : 50kg (previously 58kg) : 7%
• BMI : 18,27 (decrease of BMI)
• Metastases to liver, bone and lung.
Question 1 :
• What is the nutritional status of this patient?
Nutritional Status : Refractory Cachexia,
because
– Weight loss 8 kg in 6 months
- BMI < 20
- There are nausea and decrease of appetite
- Patient did not response with several modalities
of chemotherapy
- Stage IV
 Staging Cancer Cachexia

Blum B, et al.: European Palliative Care Research Collaborative. Evolving classification

systems for CC: ready for clinical practice? Support Care Cancer 2010, 18(3):273–279.
Question 2 :
• What kind of nutrition should be given to this
patient?
• First choice always oral therapy
• But, because oral intake was inadequate, it was
combined with parenteral nutrition for a few days
• Patient felt nauseous and sometimes vomit so she
couldn’t get enteral nutrition

Question :
• What are the nutritional needs of this patient?
 Nutritional Needs for Cancer Patients
• Calories :
– 30-35 kcal/kg
• Proteine :
– In cancer patients  negative nitrogen balance
– Increased protein needs : (1.5 – 2.5 g/kg)
• Fat :
± 30% of total energy
• Micronutrient : vitamin and mineral supplementation : Fish
Oil and Omega 3

Grant, B.Krause’s, Nutrition & Diet Therapy 2007

Question :
• What other therapies should be given to this
patient?
Answer :
1. Physical training
2. Counseling and Education
Patient is a breadwinner, so counseling is more
necessary here. Because, patient feels ”totally
useless” and “no money income”.
Both of these cause severe stress which can
make the patient have no desire to eat, even
though the patient is able to eat.
3. Pharmacology:
• Appetite Stimulant
Case 1: Parotid Cancer Patient in Radiation
Therapy
 Clinical Status
• A 58-year-old woman, a housewife, diagnosed with
Parotid Cancer Stage IIIB.
• Radiotherapy was planned for treatment because there
was bleeding.
• Patient came a week after radiotherapy with complaints
of difficulty swallowing  dry mouth & stomatitis,
impaired swallowing and no appetite. The patient
become weak
• Weight loss : 3.5 kg in 1 month
• Height : 155 cm,
• Weight : 54 kg (previously 57,5 kg),
• BMI = 24,4
 Laboratory Findings
• Hb: 10,2
• Leko: 10.700
• Trombo: 415.000
• Alb: 3,0
• Na: 130
• K: 3,1
• Ca: 9,2
• CRP : 12
Answer :
• Anamnesis  Can not swalow and decrease
of appetite
• Physical examination  Weight loss 3,5 kg in 1
month (<5%)
• Laboratory findings  Alb 3,0; CRP 12
• Patient status : Pra-Cachexia because of
weight loss <5% in 6 months and anorexia
 Staging Cancer Cachexia

Blum B, et al.: European Palliative Care Research Collaborative. Evolving classification

systems for CC: ready for clinical practice? Support Care Cancer 2010, 18(3):273–279.
Is this Mr. Smith Cachexia?
• A 54-year-old, man, with Gaster
cancer post surgery
• Height : 174 cm
• Weight : 88 kg
• BMI : 29,1 (above normal)
• Can’t eat as much as before
Answer : Yes
• Because the previous weight
was 122 kg
• Weight loss = 122-88 = 34 kg
in 4 months
• There is a decrease in appetite
 Conclusions
1. Cachexia is a problem that often occurs in cancer
patients, especially in advance stage  poor
prognostic factor
2. Patients must not have BMI<18,5 to be called
Cachexia (Hipocrates)
3. The etiology is multifactorial  can not be corrected
with nutritional support alone
4. Cachexia therapy must be accompanied by physical
exercise, counseling/education, and pharmacology
therapy, so the results are maximal.
Thank You 