An update: cancer-associated anorexia as a treatment target

Effect of cyproheptadine on weight gain in malnourished children: a randomized, controlled trial

Background: Cyproheptadine has been used therapeutically as an appetite stimulant in various chronic illnesses. However, no clinical data are available on the therapeutic effect of cyproheptadine in malnourished children without underlying pathological conditions. Objective: Investigate the short-term effect of cyproheptadine on weight gain in malnourished children who appear otherwise normal on physical examination. Methods: Seventy malnourished children who were otherwise normal on physical examination were recruited to participate in a randomized, double-blind, placebo-controlled trial. Thirty-seven children were randomized to a treatment regimen of cyproheptadine (0.1 mg/kg/dose, three times/day for eight weeks), and 33 children were randomized to receive placebo over a period of eight weeks. Subjects were evaluated at a baseline visit and at four visits at two-week intervals. Parameters assessed included baseline demographics, anthropometrics (weight, height, skin-fold thickness, waist and hip circumferences, and fat composition by bioelectric impedance analysis), adverse events, and pill counts. Data were analyzed by Student’s t-test and Chi-square test; a p- value < 0.05 was considered significant. Results: No significant differences were observed in baseline demographic characteristics and anthropometric parameters between the groups. The cyproheptadine-treated group showed a significantly greater weight gain over the baseline compared with the control group. The absolute weight gain was significantly higher in the cyproheptadine-treated group than in the control group at the end of study. No significant difference was observed in the change in the body fat percentage between the groups. No serious adverse events were reported. Adverse events included mild sedation, nausea, diarrhea, abdominal pain, and headache. No significant differences in the frequency of adverse events were observed between the groups. Conclusions: Cyproheptadine treatment was well tolerated and resulted in significant weight gain in malnourished children, without increasing the body fat percentage.

Cyproheptadine significantly improves the overall and progression-free survival of sorafenib-treated advanced HCC patients

Objective

Sorafenib is a recommended treatment for advanced hepatocellular carcinoma. The study is to evaluate the efficacy of sorafenib plus cyproheptadine compared with sorafenib alone in patients with advanced hepatocellular carcinoma.

Methods

A retrospective cohort study reviewed all consecutive advanced hepatocellular carcinoma cases with Child-Pugh Class A disease starting sorafenib treatment at our hospital from August 2012 to March 2013. They were followed up until 31 December 2013. A total of 52 patients were enrolled: 32 patients in the combination (sorafenib–cyproheptadine) group and 20 patients in the control (sorafenib alone) group. The response to treatment, overall survival and progression-free survival were compared.

Results

The median overall survival was 11.0 months (95% confidence interval: 6.8–15.1 months) in the combination group compared with 4.8 months (95% confidence interval: 3.1–6.6 months) in the control group (crude hazard ratio = 0.45, 95% confidence interval: 0.22–0.82). The median progression-free survival time was 7.5 months (95% confidence interval: 5.1–10.0 months) in the combination group compared with 1.7 months (95% confidence interval: 1.4–2.1 months) in the control group (crude hazard ratio = 0.43, 95% confidence interval: 0.22–0.86). Kaplan–Meier survival analysis revealed that both overall survival and progression-free survival in the combination group were significantly longer than that in the control group. The multivariate model found patients in the combination group were 76% less likely to die (adjusted hazard ratio = 0.24, 95% confidence interval: 0.10–0.58) and 82% less likely to have progression (adjusted hazard ratio = 0.18, 95% confidence interval: 0.08–0.44) during the 17 months of follow-up.

Conclusion

Cyproheptadine may significantly improve survival outcomes of sorafenib-treated advanced hepatocellular carcinoma patients.

Megestrol acetate for treatment of anorexia-cachexia syndrome

BACKGROUND

This is an updated version of a previously published review in The Cochrane Library (2005, Issue 2) on 'Megestrol acetate for the treatment of anorexia-cachexia syndrome'. Megestrol acetate (MA) is currently used to improve appetite and to increase weight in cancer-associated anorexia. In 1993, MA was approved by the US Food and Drug Administration for the treatment of anorexia, cachexia or unexplained weight loss in patients with AIDS. The mechanism by which MA increases appetite is unknown and its effectiveness for anorexia and cachexia in neoplastic and AIDS (acquired immunodeficiency syndrome) patients is under investigation.

OBJECTIVES

To evaluate the efficacy, effectiveness and safety of MA in palliating anorexia-cachexia syndrome in patients with cancer, AIDS and other underlying pathologies.

SEARCH METHODS

We sought studies through an extensive search of electronic databases, journals, reference lists, contact with investigators and other search strategies outlined in the methods. The most recent search for this update was carried out in May 2012.

SELECTION CRITERIA

Studies were included in the review if they assessed MA compared to placebo or other drug treatments in randomised controlled trials of patients with a clinical diagnosis of anorexia-cachexia syndrome related to cancer, AIDS or any other underlying pathology.

DATA COLLECTION AND ANALYSIS

Two independent review authors conducted data extraction and evaluated methodological quality. We performed quantitative analyses using appetite and quality of life as a dichotomous variable, and analysed weight gain as continuous and dichotomous variables.

MAIN RESULTS

We included 35 trials in this update, the same number but not the same trials as in the previous version of the review. The trials comprised 3963 patients for effectiveness and 3180 for safety. Sixteen trials compared MA at different doses with placebo, seven trials compared different doses of MA with other drug treatments and 10 trials compared different doses of MA. Meta-analysis showed a benefit of MA compared with placebo, particularly with regard to appetite improvement and weight gain in cancer, AIDS and other underlying conditions, and lack of benefit in the same patients when MA was compared to other drugs. There was insufficient information to define the optimal dose of MA, but higher doses were more related to weight improvement than lower doses. Quality of life improvement in patients was seen only when comparing MA versus placebo but not other drugs in both subcategories: cancer and AIDS. Oedema, thromboembolic phenomena and deaths were more frequent in the patients treated with MA. More than 40 side effects were studied.

AUTHORS' CONCLUSIONS

This review shows that MA improves appetite and is associated with slight weight gain in cancer, AIDS and in patients with other underlying pathology. Despite the fact that these patients are receiving palliative care they should be informed of the risks involved in taking MA.

Can nutritional status influence the quality of life of cancer patients?

Objective This study aimedto evaluate the influence of nutritional status on the quality of life of a cohort of cancer patients submitted to chemotherapy. Methods Patients receiving chemotherapy for the first time in a University Hospital in Pelotas (RS), Brazil, were evaluated prospectively. Their nutritional risk was determined by the Patient-Generated Subjective Global Assessment scores and their quality of life by the World Health Organization's quality of life questionnaire, administered at the beginning and end of the study. Results One hundred and forty-three patients were studied, 76.2% being females. The prevalence of malnutrition at baseline was 14.0%. The present study found that malnourished patients had a poor quality of life. The nutritional risk of 41.6% of the patients increased after chemotherapy. A significant association was found between the presence of symptoms and increased nutritional risk (p<0.001). Additionally, there was a significant negative correlation between physical domain and nutritional risk scores, showing that quality of life increases as nutritional risk decreases. Conclusion Nutritional risk is inversely associated with quality of life in cancer patients after chemotherapy. Early nutritional interventions could minimize the side effects of treatment with a positive impact on quality of life.

Results of a pilot study of the effects of celecoxib on cancer cachexia in patients with cancer of the head, neck, and gastrointestinal tract

BACKGROUND

Animal models suggest that cyclooxygenase-2 (COX-2) inhibitors may be beneficial in suppressing cancer cachexia. We investigated the effect of short-course celecoxib on body composition, inflammation, and quality of life (QOL) in patients with cancer cachexia in a phase II clinical pilot trial.

METHODS

Eleven cachectic patients with head and neck or gastrointestinal cancer were randomly assigned to receive placebo or celecoxib for 21 days while awaiting the initiation of cancer therapy. Body composition, resting energy expenditure, QOL, physical function, and inflammatory markers were measured on days 1 and 21.

RESULTS

Patients receiving celecoxib experienced statistically significant increases in weight and body mass index (BMI), while patients receiving placebo experienced weight loss and a decline in BMI. Patients receiving celecoxib also had increases in QOL scores.

CONCLUSIONS

Cachectic patients receiving celecoxib gained weight, experienced increased BMI, and demonstrated improved QOL scores. Compliance was good and no adverse events were seen.

The energetics of wasting diseases

PURPOSE OF REVIEW

Unintentional weight loss or wasting continues to be a nutritional problem in the treatment of HIV/AIDS, cancer and many other diseases. Although wasting is a general sign of energy imbalance, the relative contribution of increased energy demands and decreased energy intake remains incompletely understood.

RECENT FINDINGS

Until the development of the method using doubly labeled water for measuring total energy expenditure, it was difficult to obtain unbiased estimates of total energy expenditure, particularly in clinical populations. Although costly, this technique provides greater insight in the energy requirements of clinical populations and the relative contributions of energy expenditure, energy intake and disease to wasting diseases. Although data are available in only a small portion of wasting diseases, the data suggest that even in the presence of increased demands for resting metabolic rate, total energy expenditure is often reduced because of decreased physical activity.

SUMMARY

Wasting is often the result of endocrine disorders accompanying the disease process itself. This, coupled with reduced energy intake, is often the primary contributor to wasting.

Symptom distress as rated by advanced cancer patients, caregivers and physicians in the last week of life

OBJECTIVES

To study the symptom distress as rated by patients with advanced cancer during their last week of life, and to compare patients' ratings with those perceived by caregivers and physicians.

METHOD

This was a prospective study on all patients admitted to the Hospice Unit of the Caritas Medical Centre with an estimated life expectancy of two weeks or less from May 2002 to September 2002. A questionnaire with a list of 13 symptoms, including pain, dyspnoea, nausea, vomiting, dry mouth, cough, fatigue, cachexia, anorexia, constipation, diarrhoea, insomnia and haemoptysis, was administered to assess the distress. Distress was rated by a verbal rating scale consisting of five grades (grade 0 to grade 4). Patients, caregivers and physicians completed the questionnaire weekly until the patient died. Only the questionnaires completed in the last week of life were included for analysis.

RESULTS

Of 82 patients who were recruited in the study, 30 patients were able to complete the questionnaire within the last week of life. Their median age was 69 years and the gender ratio was 1:1. Lung cancer was the most common primary tumour. Fatigue, cachexia and anorexia caused distress of all grades in nearly all 30 patients and caused significant distress of grade 3 and above in two-thirds of patients. Neither the caregivers nor the physicians gave congruent distress scores for these three symptoms (kappa<0.4). Caregivers' ratings agreed well with those of patients for five symptoms (kappa>0.4, P<0.005), including dyspnoea, cough, dry mouth, constipation and insomnia. For physicians, good agreement was found for three symptoms only, including pain, dyspnoea and cough. Moreover, physicians tended to underrate the distress.

CONCLUSION

Fatigue, cachexia and anorexia were the three most distressful symptoms in the last week of life in this group of patients, but caregivers and physicians failed to rate them in agreement with patients.

Should patients with advanced, incurable cancers ever be sent home with total parenteral nutrition? A single institution's 20-year experience

BACKGROUND

Home total parenteral nutrition (TPN) can be lifesaving and life sustaining for some patients. However, in patients with advanced, incurable cancer, its role is controversial. A retrospective study was conducted to explore whether home TPN was associated with long-term survival (>or=1 year) in patients with metastatic disease and to identify predictive factors to enable its judicious use.

METHODS

The records of all adult patients with incurable cancer were identified between 1979 and 1999. Records were reviewed in depth for survival from TPN initiation to death and for a variety of demographic and clinical factors.

RESULTS

Fifty-two patients were identified. Their median age was 56 years (range, 18-83 years), and 30 (58%) were women. Malignant diagnoses included carcinoid/islet cell tumor (n=10), ovarian carcinoma (n=6), amyloidosis/multiple myeloma (n=6), colorectal carcinoma (n=5), sarcoma (n=5), pancreatic carcinoma (n=4), gastric carcinoma (n=3), lymphoma (n=2), pseudomyxoma peritonei (n=2), and other (n=9). TPN was initiated for the following reasons (indications are not mutually exclusive): alimentary tract obstruction (n=20), short bowel syndrome/malabsorption (n=16), fistula (n=11), dysmotility (n=3), nausea/emesis (n=2), anorexia (n=2), and mucositis (n=1). The median time from initiation of TPN to death was 5 months (range, 1-154 months). Sixteen patients survived >or=1 year. TPN-related complications included 18 catheter infections (1 per 2.8 catheter-years), 4 thromboses, 3 pneumothoraces, and 2 episodes of TPN-related liver disease. Tumor grade, the interval between diagnosis of metastatic disease and initiation of TPN, the presence of prominent cancer symptoms, and the administration of cancer therapy after TPN were not associated in any way with overall survival.

CONCLUSIONS

The initiation of home TPN can be associated with long-term survival in very select patients with incurable cancer, and complication rates with its use appear acceptable. However, the judicious use of home TPN in this setting requires careful clinical assessment on a patient-by-patient basis.

Nutrition in the elderly

It is now well accepted that older persons experience a physiologic anorexia, the anorexia of aging, which is caused by alterations in hedonic qualities of food, fundal compliance, and increased leptin levels. Depression is the most common pathologic cause of weight loss in older persons. Older persons fail to recognize thirst and as such have an increased risk of dehydration. Alterations in brain membrane fatty acids can lead to cognitive impairment in older persons.