Introduction: Why Should We Care About the Cancer Anorexia/Weight Loss Syndrome?

In a recent study, Wolfe and others interviewed 103 parents of children who had died from cancer.[1] Approximately 80% of these children suffered anorexia, or loss of appetite. Over 35% of parents identified anorexia as a cause of distress for their child when a physician failed to recognize it. Wolfe and others concluded,"greater attention to symptom control....might ease...suffering." In adults, the syndrome of cancer anorexia/weight loss is no less pervasive, and no less distressing. Anorexia is one of the most deleterious symptoms, surpassed only by pain and fatigue.[2] The majority of adults with advanced cancer suffer from it toward the end of life. Among all cancer patients-regardless of age or cancer type-"greater attention to [the anorexia/weight loss syndrome]...might ease...suffering."

In the fall of 2002, a group of health-care providers, patient advocates, and medical researchers convened in Burlington, Vermont, coming together to discuss diagnostics, therapeutics, and future research directions relevant to the cancer anorexia/weight loss syndrome. Why this syndrome? First, it is pervasive, present in more than 65% of advanced cancer patients.[ 2] Yet, unlike other maladies such as pain and fatigue, this syndrome has been understudied.

Second, its presence is associated not only with diminished quality of life but also shortened survival. Dewys and others studied 3,047 cancer patients and concluded that weight loss predicted an early demise within this cohort independent of other prognosticators.[ 3] Providing similar data on anorexia from 1,115 cancer patients, Loprinzi and others found this symptom carried this same negative prognostic impact: patients with anorexia died sooner.[4] Thus, identifying and treating the cancer anorexia/weight loss syndrome might not only "ease suffering," but might also help patients live longer-a rationale that fortifies the argument to diagnose, treat, and further study it.

Finally, beyond statistics and prognosis, the cancer anorexia/weight loss syndrome is associated with suffering. Cohn and others observed that wasting of lean tissue, such as muscle, is a hallmark of this syndrome in patients with advanced cancer.[5] What are the implications of this observation? Dewys and others concluded that weight-losing cancer patients carried a worse performance score.[3] Similarly, Finkelstein found that weight loss of more than 5% of premorbid weight was associated with profound debility.[ 6] Such findings suggest that weight loss unravels the cancer patient's clinical course, heralding inanition, incapacity, and, ultimately, early death.

At the Vermont gathering, called the "Nutrition in Oncology Supportive Care Workshop," a group of authorities on the cancer anorexia/weight loss syndrome gathered to address timely challenges faced by cancer patients, their family members, and their health-care providers. The abstracts that follow in this special supplement to ONCOLOGY summarize the perspectives and approaches of these experts:

• Costantino Benedetti discusses pain management, drawing parallels between pain and the cancer anorexia/weight loss syndrome. Dr. Benedetti's lecture suggested that the impressive clinical and scientific accomplishments observed in pain management can also be realized in the management of the cancer anorexia/weight loss syndrome.

• Neil MacDonald places nutritional issues within the larger context of cancer therapy as a whole. As stated in the title of his persuasive article, "Nutrition as an Integral Component of Supportive Care," Dr. MacDonald reviews data to support his proposal that the cancer anorexia/weight loss syndrome should be evaluated and reevaluated throughout the cancer patient's clinical course as an essential part of the patient's care plan.

• Anne Coble Voss and Kathleen Thrush discuss novel nutritional approaches aimed at potentially preventing and treating specific aspects of the cancer anorexia/weight loss syndrome. This excellent review summarizes the rationale behind studying such agents as eicosapentaenoic acid.

• Maree Ferguson provides a valuable and pragmatic synopsis of the diagnosis of malnutrition in cancer patients, showcasing the subjective global assessment, a previously validated and potentially useful tool.

• How relevant was this workshop to the people who matter most, that is, cancer patients and their families? Kim Goodman, Julie Fleshman, and others discuss personal experiences they faced after family members had been diagnosed with pancreatic cancer. Their compelling insight underscores the importance of acquiring a knowledge base to help cope with cancer. Organizations such as the Pancreatic Cancer Action Network's Patient and Liaison Services (PALS), introduced here, offer invaluable resources for patients and their families as they confront cancer issues.

• Abby Bloch provides an insightful overview of practical, pertinent nutrition questions that have not yet been answered for cancer patients. This overview also provides relevant advice on how and when to provide enteral nutrition support for cancer patients.

• Mary Layman-Goldstein recounts a gripping, hands-on encounter with a patient who suffered from cervical cancer. This presentation highlights a cancer patient's daily nutritional challenges, many of which might have gone easily unrecognized by members of the health-care team had they not remained vigilant throughout this patient's clinical course.

Finally, in this supplement, the publication of the Guidelines for the Nutritional Algorithm for Comprehensive Cancer Care (NACCC) represents a culmination of shared ideas and experiences from all workshop participants. The hope is that these Guidelines, in conjunction with the insight from this group of experts, will steer clinical and research efforts toward the mitigation of the cancer anorexia/weight loss syndrome and toward a decline in overall cancer morbidity and mortality.

References:

1.

Wolfe J, Grier HE, Klar N, et al: Symptoms and suffering at the endof life in children with cancer. N Engl J Med 342:326-333, 2000.

2.

Walsh D, Donnelly S, Rybicki L: The symptoms of advancedcancer: Relationship to age, gender, and performance status in 1000patients. Support Care Cancer 8:175-179, 2000.

3.

Dewys WD, Begg C, Lavin PT, et al: Prognostic effect of weight lossprior to chemotherapy in cancer patients. Eastern Cooperative OncologyGroup. Am J Med 69:491-497, 1980.

4.

Loprinzi CL, Laurie JA, Wieand HS, et al: Prospective evaluation ofprognostic variables from patient-completed questionnaires. North CentralCancer Treatment Group. J Clin Oncol 12:601-607, 1994.

5.

Cohn SH, Gartenhaus W, Sawitsky A, et al: Compartmental bodycomposition of cancer patients by measurement of total body nitrogen,potassium, and water. Metabolism 30:222-229, 1981.

6.

Finkelstein DM, Cassileth BR, Bonomi PD, et al: A pilot study of theFunctional Living Index-Cancer (FLIC) Scale for the assessment ofquality of life for metastatic lung cancer patients. An Eastern CooperativeOncology Group study. Am J Clin Oncol 11:630-633, 1988.