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Home , Anorexia (symptom), Cachexia

Symptom Management Series Management of - in Late-Stage Lung 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 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 , , 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 , 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 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, Services, egies for prevention, assessment, and management. Man- City of Hope, Duarte, CA. agement strategies presented apply to other 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

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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 (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 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 . 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 related to impaired gastrointestinal func- by the medical oncologist to stimulate appetite (megestrol tion.6 Therefore, because they are so closely related, de- acetate), control pain ( with acetaminophen), finitions of cancer-related anorexia and cachexia have

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been combined and referred to as the ‘‘anorexia- cachexia syndrome.’’6,10 Anorexia is the loss of appetite or desire to eat.11,12 In acute events, anorexia usually resolves with resolution of the illness, and any weight lost may be replaced with nu- tritional supplements or increased intake.3,5 In lung can- cer patients, anorexia may not be recognized and lead to insufficient caloric intake and protein-calorie malnutri- tion. Weight loss seen in this phenomenon usually involves loss of fat, rather than muscle tissue.3 FIGURE 2. European Palliative Care Research criteria for refractory 6,16 The characteristics of anorexia are common among cachexia. many patients with serious illnesses such as lung cancer, acquired immune deficiency syndrome, and other chronic symptom control with appetite stimulation and treatment .3,5 Anorexia is the most common cause of malnu- of nausea or eating-related distress of patients and fam- trition in lung cancer patients and is a symptom that is as- ilies.6 The diagnostic criteria include variable degrees of sociated with cachexia.5 cachexia, cancer disease both procatabolic and not re- Agreement exists that cachexia is a complex syn- sponsive anticancer treatment, low performance score, drome and not well understood.3,6,8 Cachexia has been and less than 3 months’ expected survival.6 recognized as a frequent problem in lung cancer patients Lung cancer itself may be complicated by the PNPs of and represents an unmet need.6 Cachexia is a multifac- cachexia, which are often associated with anorexia.17 torial syndrome and may or may not be associated with Metabolic PNPs such as hypercalcemia or anorexia, along with significant weight loss, loss of mus- may also cause anorexia or symptoms such as fatigue cle tissue as well as adipose tissue, and generalized weak- that contribute to anorexia.9 Overall, PNPs are rare, ness.6,13 It is often complicated by other food intake and only 10% to 20% of the patients with cancer expe- problems such as impaired integrity and function of the rience metabolic disorders of PNPs over the course of gastrointestinal tract from mouth to anus and poorly con- their illness.18 Paraneoplastic syndromes occur more fre- trolled physical and psychosocial symptoms including pain, quently in patients with lung cancer, particularly in SCLC, shortness of breath, , or severe fatigue.3,6,13,14 occurring in 3% to 5% of patients.18 Paraneoplastic syn- The European Palliative Care Research Collaboration dromes are the result of substances (hormones, growth (EPCRC) is currently developing classification systems factors, cytokines, and antibodies) abnormally secreted for pain, depression, and cachexia in patients with ad- by the primary tumor and its metastases.19 These sub- vanced cancer.6,15 This process has been comprehensive stances affect the endocrine, neurologic, hematologic, involving expert and public consultations and literature and musculoskeletal systems of the body.18 The most reviews.6,15 The cachexia guideline expert group identi- common and best understood of the PNPs are of the en- fied cancer cachexia as a continuum of three stages of docrine system.20 Endocrine PNPs seen in patients with clinical relevance: precachexia, cachexia, and refractory lung cancer include humoral hypercalcemia of malig- cachexia.6 It was noted that not all patients would move nancy, ectopic adrenocorticotropic hormone syndrome through the entire spectrum.6 The stages of cachexia are (also known as Cushing syndrome), and syndrome of in- defined on the basis of the patient’s characteristics and appropriate antidiuretic hormone.20 circumstances.6,15 Diagnostic criteria for end-stage ca- Basic etiologies of the anorexia-cachexia syndrome are chexia have been defined by the EPCRC (Figure 2).6,16 (1) decreased food intake, (2) metabolic abnormalities, In 2010, the cachexia guideline development group pub- (3) the actions of proinflammatory cytokines, (4) systemic lished European Clinical Guidelines on the management , (5) neurohormonal dysregulation, (6) tu- of cachexia in advanced cancer patients with a focus on mor by-products, and (7) the catabolic state.21 Some of refractory cachexia.6 these mechanisms have a mutually reinforcing aspect; Refractory cachexia is characterized by a low perfor- for example, anorexia leads to fatigue, fatigue increases mance status and life expectancy of less than 3 months.6 anorexia, anorexia increases fatigue, and so forth.9 Refractory cachexia represents a stage where reversal of weight loss seems no longer possible because of very ASSESSMENT OF ANOREXIA-CACHEXIA advanced or rapidly progressive cancer unresponsive to anticancer therapy.6 In this stage, the burden and risks Perhaps, the most important element of assessment in- of artificial nutritional support likely outweigh any po- volves patient and family goals of care.3,5,6,9,22 Nutri- tential benefit, and therapeutic interventions focus on al- tional screening and assessment are done before lung leviating the suffering associated with cachexia, such as cancer treatment begins.5 Specific recommendations

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include completing a nutritional screening and assessment within 48 hours of admission or diagnosis of lung cancer, before initiation of cancer therapy, change in therapy, or a weight change of 2% to 5%.6,22,23 A nutritional screening profile is the process of assessing characteristics (early sa- tiety, weight loss, , fatigue, impaired immune function, , and poor performance status) of malnutrition and risk factors that will predispose a patient to nutritional deficiencies.17 Predisposing risk fac- tors include: weight loss 5% or less in 1 month, 10% or less in 6 months, inadequate oral intake for 7 days or less, serum albumin 3.5 g/dL, recent surgery, severe , recent radiation therapy or aggressive , per- sistent distress lasting more than 2 weeks, pain, nausea, , dysphagia, diarrhea, mucositis, depression, an- orexia, diminished self-care or lack of caregiver, demen- tia, poverty, and (alcohol and/or dugs).17,22 Currently, there are no clearly accepted diagnostic criteria for identifying the specific cause of anorexia-cachexia seen in lung cancer, but anorexia from some etiologies is treatable, and assessment of the possible presence of causes as mentioned above is vital to quality palliative care.6,9 Early recognition of the etiologies followed by comprehensive assessments is recognized as imperative 5,6,22 FIGURE 3. Management of anorexia/cachexia by life in the development of assessment guidelines. Other expectancy.3,9,12,26 areas of assessment include laboratory values, anthropo- metric measures (BMI), and tools to assess functioning and performance and prognosis such as the KPS, and Member authors regarding their views of currently ac- the use of multidimensional standardized instruments, cepted approaches to treatment.26,27 These guidelines such as the FAACT tool (Figure 2).6,8,9 are defined as categories to evidence and are based on lower-level evidence where uniform NCCN consensus agrees that the strategies are appropriate.27 These guide- MANAGEMENT OF 26,27 ANOREXIA-CACHEXIA lines apply to all cancer diagnoses. The guidelines are divided for patients whose life expectancy is years The best way to treat anorexia-cachexia seen in lung to months, months to weeks, and weeks to days (dying cancer is obviously to cure lung cancer; this will normal- patient).26 ize the metabolic abnormalities induced by the tumor When life expectancy is years to months, the NCCN and/or tumor host interactions.6,21,24 If cure cannot be guidelines recommendations include assessments, med- achieved, the next option would be to increase nutri- ications, and nonpharmacologic approaches. These are tional intake by dietary counseling and education and as follows: evaluate rate and severity of weight loss26; oral nutritional supplements.5,6 Early intervention to try treat readily reversible causes of anorexia, for example, to prevent malnutrition is easier than trying to reverse early satiety (eg, metoclopramide 10 mg before meals) it after it occurs.25 Therefore, management is multimodal and symptoms that interfere with intake such as dysgeu- with the focus of stabilizing weight, improving comfort, sia, xerostomia, oral-pharyngeal candidiasis, mucositis, lowering the risk of infection, keeping up strength and nausea and/or vomiting, dyspnea, depression, constipa- energy, minimizing distress, and improving quality of life tion, and pain26; review and/or modify medications that (QOL).5,9 As previously stated, management and recom- interfere with intake26; evaluate for endocrine abnormal- mendations for anorexia-cachexia seen in lung cancer ities such as hypogonadism, thyroid dysfunction, and met- apply to other advanced cancers and illnesses. abolic abnormalities (hypercalcemia and hyponatremia)7,26; The National Comprehensive Cancer Network (NCCN) consider appetite , for example, progestational has published Guidelines for Supportive and Palliative agents (eg, 160-180 mg BID), corticoste- Care Symptom Management for anorexia-cachexia roids (eg, decadron 4 mg/d or prednisone 10-20 mg/d), and (Figure 3).26,27 The NCCN guidelines are a statement of ( 5-20 mg/d)9,12,26; consider an ex- evidence and consensus of the Palliative Care Panel ercise program9,12; assess social and economic factors9,26;

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consider a nutritional consultation9,26; consider nutrition atic and gastric cancer, but also lung, esophageal, colo- support, enteral and parental feeding (as appropriate)26; rectal, and head and neck cancer.5,27 The distress and and reassess the effectiveness of intervention and con- disruption in daily activities caused by anorexia-cachexia tinue to treat and monitor symptoms and QOL to deter- leave patients frail and weak, and their emaciated appear- mine whether status warrants change in strategies with ance is devastating for patients and their families.5,6,27,28 ongoing assessments.26 If the patient shows weight stabi- Quality of life encompasses four dimensions of well- lization or gain, improvement in symptoms that inter- being: physical, psychological, social, and spiritual.5,6,27,28 fere with intake, improved energy level, and resolution of In some ways, the dimensions are distinct; however, there metabolic/endocrine abnormalities, continue to treat and is tremendous overlap. The impact of anorexia-cachexia monitor symptoms and QOL to determine whether status on QOL, seen in late-stage lung cancer is illustrated warrants change in management.26 If unacceptable symp- in Figure 4, adapted from the City of Hope Quality of Life toms continue, intensify palliative care interventions, pro- Model.28 Whether physical, psychological, social, or spiri- vide dietary consultation, and consider a clinical trial for tual, a deficit that is identified in one domain impacts all anorexia-cachexia.26 other domains of QOL.27,28 The symptoms caused by When life expectancy is months to weeks or weeks to anorexia-cachexia that impact physical well-being include days, the NCCN guidelines are as follows: assess impor- weight loss, decrease in muscle mass and body in fat, fa- tance of symptoms of anorexia and cachexia to patient tigue weakness, and .5,6,17,27,28 Anorexia- and family, and if important consider short course of cor- cachexia impacts psychological well-being with symptoms ticosteroids26; focus on patient goals and preferences9,26; that include anxiety, depression, worry, and fear.5,6,17,27,28 provide family with alternative way of caring for the pa- Physical and psychological distress may also impact social tient26; provide emotional support and treat for depres- well-being for patients and family caregivers.27,28 Often, sion (eg, 7.5-30 mg HS), if appropriate26; family caregivers continue to try to help the patient by re- provide education and support to patient and family re- minding and pleading with the patient to eat, as eating/ garding emotional aspects of withdrawal of nutritional feeding has great cultural meanings.5,6,17,27,28 The patient’s support26; recognize that discontinuation of nutrition is inabilitytoeatcanleadtoirritabilityandbecomeasource a value-laden issue and consider consultation with a of tension, leading to family conflict and social isola- bioethicist or spiritual counselor9; educate the patient tion.5,6,17,27,28 Food we eat is derived from our cultural her- and family of the natural history of end-stage disease in- itage, and in some cultures, eating provides a way of cluding the following points: absence of hunger and thirst socialization.5,6,17,27,28 Increasing weight loss may lead to is normal in the dying patient, nutritional support may not alteration in body image.5,6,17,27,28 Spiritual well-being is be metabolized in patients with advanced disease,26 risks impacted by helplessness, hopelessness, and uncertainty associated with artificial nutrition (eg, fluid overload, in- fection,andhasteneddeath),26 intravenous hydration may increase excretion of drug metabolites providing benefits to the patient,26 symptoms like dry mouth should be treated with local measures (eg, mouth care and small amounts of liquids),26 withholding or withdrawal of enteral or paren- teral nutrition is ethically permissible in this setting, and therefore it will not cause exacerbation of symptoms and may improve some symptoms26; and reassess the effective- ness of intervention. If acceptable, continue to monitor, treat, and reassess.26 If unacceptable, intensify palliative care efforts and involve specialized palliative services or hospice.26 These guidelines provide current accepted prac- tical approaches to the treatment and care.3,9,12,26,28 The goal in palliative care is to minimize distress of symptoms and improve QOL.5,6

IMPACTS ON QUALITY OF LIFE Quality of life is influenced by nutritional status.17,27 The anorexia-cachexia syndrome is the most common syn- drome experienced by people with advanced stages of FIGURE 4. Anorexia-cachexia impacts the dimensions of quality of disease and seen in a subset of cancers, led by pancre- life.28 Adapted from the City of Hope Quality of Life Model.28

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and may cause one to reflect on meaning of his/her life 7. Tyson LB. Paraneoplastic syndromes. In: Houlihan NG, ed. and imminence of death.27,28 Site-Specific Cancer Series Lung Cancer.Pittsburg,PA: Pennsylvania Oncology Nursing Society; 2004:57-72. 8. Kravits KG, Grant M. Malnutrition and cachexia. In: Chernecky CC, Murphy-Ende K, eds. AcuteCareOncologyNursing.2nded.St NURSING IMPLICATIONS Louis, MO: Saunders Elsevier; 2009:406-418. 9. Wholihan D, Kemp C. Anorexia and cachexia. In: Ferrll BR, Palliative care is an approach that improves the QOL of Coyle N, eds. Oxford Textbook of Palliative Nursing. 2nd ed. patients and their families facing the problems associated New York: Oxford University Press; 2010:211-219. with advanced illnesses such as lung cancer, through the 10. Strasser F. Eating-related disorders in patients with advanced cancer. Support Care Cancer. 2003;11(1):11-20. prevention and relief of suffering by means of early iden- 11. Benson LM, Cawley KA. Principles of symptom management: an- tification and impeccable assessment. Palliative care nurses orexia. In: Newton S, Hickey M, Marrs J, eds. Mosby’s Oncology play a crucial role in ensuring that nutritional screening and Nursing Advisor A Comprehensive Guide to Clinical Practice. assessments are conducted for all patients with lung can- St Louis, MO: Mosby Elsevier; 2009. 12. Becze E. Put evidence into practice to prevent and manage cer, regardless of where the patient is in the disease trajec- anorexia. ONS Connect. 2009;24(3):14-15. tory. It should be done early and should be tailored to the 13. Mantovani G, Madeddu C. Cancer cachexia: medical manage- goals of the patient and family. Most importantly, contin- ment. Support Care Cancer. 2010;18(1):1-9. V ued reassessment is necessary to evaluate the effectiveness 14. Perboni S, Inui A. Anorexia in cancer: role of feeding regulatory peptides. Philos Trans R Soc Lond B Biol Sci. 2006;361(1471): of the response of interventions throughout the care. Man- 1281-1289. agement strategies are multimodal; therefore, collaborating 15.BlumD,OmlinA,BaracosVE,etal.Cancercachexia:a with other specialists in the palliative care team is neces- systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. sary to minimize suffering for patients and their families. 2011;80(1):114-144. In conclusion, anorexia-cachexia is a challenging syn- 16. Blum D, Omlin A, Fearon K, et al. Evolving classification systems drome found in many cancers and other diseases. Further for cancer cachexia: ready for clinical practice? Support Care research is needed to continue testing of assessment and Cancer. 2010;18(3):273-279. 17. Wilkes GM, Smallcomb KM. Nutritional issues facing lung management approaches. Meanwhile, nursing assessment cancer individuals. In: Haas ML, ed. Contemporary Issues in and reassessment of nutritional statuscanbeusedtoimple- Lung Cancer A Nursing Perspective. 2nd ed. Sudbury, MA: ment current strategies. Collaborating between palliative Jones and Bartlett; 2010:155-193. care clinicians and researchers will allow the development 18. Tyson LB, Ginex PK. Paraneoplastic syndromes. In: Houlihan NG, Tyson LB, eds. Site-Specific Cancer Series Lung Cancer. of effective and practical guidelines, which is long overdue. 2nd ed. Pittsburgh, PA: Oncology Nursing Society (ONS) The European Palliative Research Collaborative currently is Publications; 2012:71-85. the primary source of evidence-based practice guidelines 19. Mayden KD. Paraneoplastic syndrome. In: Yarbro CH, Wujcik of cancer cachexia with the overall aim of improving the D, Gobel BH, eds. Cancer Nursing: Principles and Practice. 7th ed. Sudbury, MA: Jones and Bartlett; 2011:845-862. management of pain, depression, and cachexia with trans- 20. Armstrong TS. Paraneoplastic syndromes. In: Yarbro CH, lational research. Frogge MH, Goodman M, eds. Cancer Nursing: Principles and Practice. 6th ed. Sudbury, MA: Jones and Bartlett; 2005:808-824. 21. Inui A. Cancer anorexia-cachexia syndrome: current issues in References research and management. CA Cancer J Clin. 2002;52(2):72-91. 1. National Cancer Institute (NCI). NonYsmall cell lung cancer 22. Moreland SS. Nutrition screening and counseling in adults with treatment (PDQ). 2012; http://www.cancer.gov/cancertopics/ lung cancer: a systematic review of the evidence. Clin J Oncol pdq/treatment/non-small-cell-lung/healthprofessional/. Accessed Nurs. 2010;14(5):609-614. January 25, 2012. 23. McMahon K, Brown JK. Nutritional screening and assessment. 2. Walz DA. Cancer-related anorexia-cachexia syndrome. Clin J Semin Oncol Nurs. 2000;16(2):106-112. Oncol Nurs. 2010;14(3):283-287. 24. Bosaeus I. Nutritional support in multimodal therapy for cancer 3. Jatoi A. Pharmacologic therapy for the cancer anorexia/weight cachexia. Support Care Cancer. 2008;16(5):447-451. loss syndrome: a data-driven, practical approach. JSupport 25. Ottery FD. Cancer cachexia prevention, early diagnosis, and Oncol. 2006;4(10):499-502. management. Cancer Pract. 1994;2(2):123-130. 4. Granda-Cameron C, DeMille D, Lynch MP, et al. An inter- 26. National Comprehensive Cancer Network (NCCN) Guidelines. disciplinary approach to manage cancer cachexia. Clin J Oncol NCCN Guidelines Palliative Care. Anorexia/Cachexia 2011. Nurs. 2010;14(1):72-80. http://www.nccn.org/professionals/physician_gls/f_guidelines 5. National Cancer Institute (NCI). Nutrition in Cancer Care (PDQ). .asp. Accessed April 11, 2012. 2011; http://www.concer.gov/cancertopics/pdq/supportivecare/ 27. National Comprehensive Cancer Network (NCCN) Guidelines. nutrition/Patient/page1. Accessed January 25, 2012. NCCN Categories of Evidence and Consensus. 2012; http:// 6. 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