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Impact of appetite-related symptoms on the patient life

Although under recognized by medical providers and professional organizations, the cancer anorexia-cachexia syndrome (CACS) has a profound impact on many patients and their families. CACS affects multiple dimensions of health related quality of life, including physical, psychological, and social functioning1. Decreased independence and impaired productivity at home and work are often accompanied by a perception of being a burden to others, and an altered sense of self. The visible effects of weight loss and deterioration in patients’ appearance have been described by Chochinov as one of the factors associated with a ‘fractured sense of dignity’2. These changes in physical strength, appearance, and body image may influence relationships, and even inhibit intimacy between patients and their partners. For patients and their families, mealtimes may also become a source of frustration and conflict. Since patients often complain of early satiety, taste alterations, or no desire  for foods they once enjoyed, family members may have the false impression their loved one is not ‘trying’ and may pressure the patient to eat3.

Multidisciplinary interventions can improve symptoms and quality of life in CACS

These adverse effects of the CACS on quality of life are self-evident to most health practitioners managing patients with cancer. Unfortunately, because of a lack of effective pharmacological therapies, practitioners may have the perception that CACS is an intractable, untreatable condition. As a result of this misconception, patients may not receive effective, relatively inexpensive medication for symptoms that impact appetite, such as pain, depression, early satiety, chronic nausea and constipation. A study of patients with advanced cancer referred to a cachexia clinic at a comprehensive cancer center, showed at least one third were able to gain weight after receiving treatment for their nutritional impact symptoms4. In addition to medications for symptom management, all patients received dietary counseling and exercise recommendations. Although a formal assessment tool for quality of life was not used, symptom scores  for appetite improved significantly and almost half the patients were treated for nausea , depression or constipation.
In clinical trials, quality of life assessment scales have been used as outcomes for patients with CACS, and have shown encouraging results. Randomized trials of patients with gastrointestinal cancers and head and neck cancers found individualized nutritional counseling improved calorie intake and quality of life compared to nutritional supplements alone.5,6 Another retrospective study of patients referred to a specialized clinic for CACS, showed that subjective improvements in physical function associated with weight gain correlated with improved quality of life7.

A false choice between better quality of life and longer survival?

For over a decade, evidence has supported the role of nutrition in improving quality of life and decreasing the risk of recurrence for survivors with cancer. In contrast, patients with advanced cancer have traditionally  been presented with a choice of  prolonging survival with cancer–specific treatment or electing ‘comfort care’, where the focus is solely on symptom management.  However, growing evidence suggests that a simultaneous integrated model of care is most effective, where concurrent supportive care or palliative care aimed at improving symptoms and quality of life, is provided alongside anticancer treatment. The study by Temel and colleagues found that palliative care provided concurrently with chemotherapy to newly diagnosed lung cancer patients, improved quality of life, depression and also survival8. Since that landmark study, additional research has demonstrated that quality of life scores and even individual symptoms are important indicators for survival. Systematic reviews have found that appetite scores individually or in combination predict survival9 and provide important prognostic information in addition to existing characteristics such as age, sex and metastases10. Symptoms such as poor appetite, depression, fatigue, insomnia, nausea, and pain are universal across cancer types and potentially could be measured by a single instrument. As yet, no  intervention  directed against a single symptom e.g. appetite has demonstrated improved survival, however, a multimodal intervention in patients with CACS  improved survival compared to a control group11.

In conclusion, poor appetite and other symptoms related to the CACS affect multiple dimensions of quality of life, impacting patients and their families. In future, a multidisciplinary approach that includes management of nutritional impact symptoms, dietary counseling, and exercise in combination with an effective pharmacological agent, is likely to be the best strategy for improving CACS and quality of life in our patients.

Egidio Del Fabbro

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