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

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

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

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

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

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, Dewys WD, et al. Am J Med, Loprinzi CL, et al. JCO, 1994.

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

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, Todorov P, et al. Cancer Research, Zigman JM, et al. Endocrinology, Balkwill F, et al. Lancet, 2001.

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

… 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

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)

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

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, Von Roenn JH, et al Moertel CG, et al. Cancer, 1974.

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, Jatoi A, et al. ASCO, Fearon KCH, et al. Gut, McMillan DC, et al. Br J Ca, 1999.

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