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Management of Anorexia-Cachexia in Late-Stage Lung Cancer Patients

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Management of Anorexia-Cachexia in Late-Stage Lung Cancer Patients Symptom Management Series Management of Anorexia-Cachexia in Late-Stage Lung Cancer Patients Catherine Del Ferraro, MSN, Ed, BSN, PHN, RN, CCRP ƒ Marcia Grant, DNSc, RN, FAAN ƒ Marianna Koczywas, MD ƒ Laura A. Dorr-Uyemura, RD Nutritional deficiencies are experienced by most adults KEY WORDS with advanced lung cancer during the course of their anorexia, cachexia, cachexia-anorexia syndrome disease and treatment. Well-nourished individuals tolerate cancer treatment with less morbidity, mortality, n 2012, it is estimated there will be about 226,000 and increased response to treatment as compared Y with those who are malnourished. Novel anticancer new cases of lung cancer (non small cell lung can- therapies cause many deficits that impact nutritional Icer [NSCLC] and small cell lung cancer [SCLC] com- and functional status during the treatment process. bined), and more than 160,000 estimated related deaths Nutritional deficits include weight loss, malnutrition, will occur in the United States.1 About 20% of the deaths and anorexia-cachexia. Anorexia-cachexia is complex, will be caused by the effects of cancer-related anorexia- not well understood and seen in many solid tumors cachexia syndrome.2 Cancer anorexia-cachexia is a wast- in late-stage disease. Assessing adequate nutrition is ing syndrome that occurs in 80% of patients with incurable one of the most challenging problems for nurses, solid tumors.3 This syndrome is common in specific cancer their patients, and patient’s families. The purpose types: gastric, 85%; pancreatic, 83%; nonYsmall cell lung, of this review was to define and describe cancer 61%; small cell lung, 57%; prostate, 57%; and colon, anorexia-cachexia in late-stage lung cancer, through 54%.4 It involves extreme weight loss and malnutrition. Ac- case presentation, and to describe palliative strategies for prevention, assessment, and management in the cording to the data, 60% of patients with lung cancer have palliative care setting. Early assessment for nutritional already experienced a significant weight loss at diagno- 3,5 imbalances must be done regularly with reevaluation for sis. In addition, cancer itself may be complicated with intervention effectiveness and should continue metabolic disorders.6 For example, paraneoplastic syn- throughout the illness trajectory. Management of dromes (PNPs) are rare metabolic disorders that are the re- adverse effects of cancer and cancer-related treatment sult of remote clinical effects of cancer.7 They are not due is critical to improving quality of life. Palliative care to the physical effects of the cancerous tumors but are and hospice nurses play a critical role in early caused by substances produced by the tumors acting on assessment, education, and prevention to support tissues in the body.7 nutritional needs for patients and their families. Nutritional screening and assessment are recommended at initial diagnosis, before cancer treatment begins, and should continue throughout care.5 Agreement exists among clinicians that cachexia related to cancer occurs in most pa- Catherine Del Ferraro, MSN, Ed, BSN, PHN, RN, CCRP, is Senior Re- tients with advanced lung cancer, and cancer anorexia, the search Specialist, Department of Population Sciences, Division of Nurs- loss of appetite, is a common symptom of cachexia.5 Assess- ing Research and Education, City of Hope, Duarte, CA. ing adequate nutrition is one of the most challenging prob- Marcia Grant, DNSc, RN, FAAN, is Director and Professor, Depart- ment of Population Sciences, Division of Nursing Research and Educa- lems for nurses and the interdisciplinary palliative care tion, City of Hope, Duarte, CA. team. The purpose of this review was to describe cancer- Marianna Koczywas, MD, is Clinical Professor, Medical Oncology and related anorexia-cachexia in late-stage lung cancer, through Therapeutics Research, City of Hope, Duarte, CA. a case presentation, and describe current and evolving strat- Laura A. Dorr-Uyemura, RD, is Director, Clinical Nutrition Services, egies for prevention, assessment, and management. Man- City of Hope, Duarte, CA. agement strategies presented apply to other cancers and Address correspondence to Catherine Del Ferraro, MSN, Ed, BSN, PHN, RN, CCRP, Division of Nursing Research and Education, City of Hope, noncancer illnesses in which effective treatment manage- 1500 E Duarte Rd, Population Science Bldg #173, Room 169, Duarte, CA ment for anorexia-cachexia is required. 91010 ([email protected]). The authors have no conflict of interest to disclose. This work is supported by a grant from the National Cancer Institute CASE PRESENTATION (PO1 CA 136396YPalliative Care for Quality of Life and Symptom Con- cerns in Lung Cancer; B. Ferrell, principal investigator). Mrs A.C. is a 72-year-old elderly Latina woman, who is DOI: 10.1097/NJH.0b013e31825f3470 newly diagnosed with stage IV NSCLC with metastatic Journal of Hospice & Palliative Nursing www.jhpn.com 397 Symptom Management Series disease to the brain and liver. She initially presented when undergoing preoperative workup for bladder re- construction 1 month ago. Chest x-ray and computed ax- ial tomography scan revealed a 4-cm left upper lobe lung mass. Bronchoscopy with biopsy demonstrated atypical cells highly suggestive of bronchogenic carcinoma. She underwent a left upper lobectomy with lymph node dis- section. Pathology confirmed a 4-cm poorly differen- tiated adenocarcinoma with clear margins and positive lymph nodes, consistent with adenocarcinoma. She was referred to medical oncology for evaluation and an opin- ion of further treatment and care. A comprehensive physical evaluation of the patient was done. Mrs A.C. is a thin, elderly bilingual female in no acute distress, alert, and oriented times three. She is 5¶4µ tall, weighs 115 lb, with a body mass index (BMI) of 19.7 kg/m2. Her vital signs and oxygen saturation are within normal limits, and Karnofsky Performance Scale (KPS) score is 70. Her comorbidities include osteoporosis, FIGURE 1. Functional Assessment of Anorexia/Cachexia Treatment gastroesophageal reflux disease, and urinary incontinence. (FAACT) tool (http://facit.org). She is also status-post two bladder resuspension surgeries. Her current medications are risedronate sodium (Actonel) and constipation (docusate sodium and sennosides). Non- and lansoprazole (Prevacid). Her family cancer history in- pharmacologic interventions included referrals to the dieti- cludes a brother who died at age 80 years of lung cancer, tian for nutritional counseling and education; pulmonary with a heavy smoking history. Her social history reveals rehabilitation to assess pulmonary function; physical ther- that she is divorced, self-employed, college educated, apy to increase strength, endurance, and mobility; occupa- and a lifetime nonsmoker. She has three adult children. tional therapy to address energy conservation needs for Mrs A.C. lives at her younger son’s home, and he is her self-care; palliative care medicine for pain management; caregiver. She is Catholic and attends church regularly. and radiation oncology for treatment evaluation. Before ad- A complete blood count and comprehensive meta- juvant treatment began, reevaluation of the effectiveness of bolic panel are normal. Her current complaints are mod- interventions was scheduled in 1 week. Reevaluation erate back pain, mild hoarse voice, mild hand tremors, noted a 1-lb increase in weight. Reports by the patient moderate continual urinary incontinence, mild constipa- and family included an increased appetite and resolved tion, mild dyspnea on exertion, 3-lb weight loss within pain. She continued to have mild constipation and ad- the last month, and mild fatigue. mitted to ‘‘forgetting’’ to take her stool softener. She also After discussion of diagnosis, prognosis, treatment op- stated that food was once again appetizing to eat espe- tions, and goals of care with Mrs A.C. and her family, she cially foods she was culturally accustomed to cooking agreed to initiate palliative adjuvant therapy of oral erlo- for lent. Treatment was initiated without delay. tinib and whole-brain radiation. Before initiation of treat- ment, the medical oncologist ordered a comprehensive CLINICAL CHARACTERISTICS OF nutritional screening and assessment based on Mrs A.C.’s ANOREXIA-CACHEXIA complaints and examination noted above. The palliative care nurse conducted a comprehensive nutritional screen- Cancer malnutrition has been described as a state of nu- ing and assessment, assessing subjective and objective trition in which a deficiency or excess (or imbalance) of information. The Functional Assessment of Anorexia/ energy, protein, and other nutrients causes measurable Cachexia Treatment (FAACT) tool version 4 (Figure 1) was adverse effects on tissue/body form, function, and clini- utilized to further assess concerns in Mrs A.C.’s appetite. cal outcome.8 Cancer- related anorexia and cancer-related The medical oncologist was notified, and the findings were cachexia are distinct syndromes but are often intertwined reviewed with Mrs A.C. and her son. in progressive disease.9 Cancer cachexia is unique but dif- A treatment plan was formulated with a multimodal ap- ficult to distinguish from other causes of weight or muscle proach consistent with the patient and family goals of care. loss such as malnutrition related to cancer anorexia or Appropriate pharmacologic interventions were prescribed malabsorption related to impaired gastrointestinal func- by the medical oncologist to stimulate appetite (megestrol
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