Editor’s note: One of a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.
Among the many treatments and supportive interventions for cancer, nurses and patients must not overlook a foundation of health—good nutrition. A proper diet during cancer treatment and beyond is essential for patients to feel better, have the strength needed to fight the disease, and maintain wellness.
However, as many as half of people newly diagnosed with cancer and up to 80% of those with advanced disease experience anorexia (Nelson, 2000). Cancers of the aerodigestive tract are most commonly associated with anorexia (Dewys et al., 1980), and patients receiving multimodality therapies also are high risk because treatments for cancer can produce difficulties with ingestion, digestion, and nutrient absorption (Huhmann & Cunningham, 2005).
Nurses in all settings are likely to encounter patients struggling with the symptom and need evidence-based treatment options to offer their patients.
Effects of anorexia
Anorexia is a complex problem that can be caused by a person’s inability to taste or smell food; an early sense of feeling full; or metabolic, endocrine, neuronal, or physiologic changes (Tisdale, 2001). An involuntary loss of appetite is almost always accompanied by a decrease in oral intake, frequently leading to malnutrition.
Malnutrition resulting from anorexia can cause weight loss and weakness, increase treatment toxicity, lead to muscle wasting, exacerbate other symptoms such as fatigue, and decrease quality of life. Furthermore, malnutrition is associated with reduced response to treatment and poor survival (Dewys et al., 1980).
To promote nursing practice that is based on evidence, the Oncology Nursing Society (ONS) launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice (Gobel & Tipton, 2009). Interventions recommended for practice were those for which effectiveness was demonstrated by strong evidence from rigorous studies, meta-analysis, or systematic reviews, and for which any expectation of harm was small compared to benefits (Eaton & Tipton, 2009).
The PEP team that studied anorexia found two treatments that are recommended for practice—corticosteroids and progestins. It also found evidence that individualized dietary counseling and liquid oral supplements are likely to be effective (Adams, Cunningham, & Belansky, 2009).
A systematic review of six randomized, placebo-controlled studies showed that oral dexamethasone, oral methylprednisolone and predisolone, and IV methylprednisolone and dexamethasone have short-lived benefits on anorexia and stimulate appetite, although they do not have a significant effect on weight gain.
Corticosteroids should be used only for short periods because of their significant toxicities with long-term use, such as increased anxiety, immunosuppression, hyperglycemia, muscle weakness and wasting, fat redistribution, decreases in bone density, fluid retention, easy bruising, and skin fragility (Yavuzsen et al., 2005).
The most effective type, dose, and route are not established. The studies reviewed used IV or oral methylpredisolone 32-125 mg per day; oral dexamethasone 0.75, 1.5, or 8 mg per day; and predisolone 10 mg per day.
Progestins, synthetic analogs of progesterone, have been used to treat hormone-dependent cancers and have effects on appetite and weight. The ONS PEP team found strong evidence from systematic reviews that medroxyprogesterone and megestrol acetate improved appetite, caloric intake, body weight, and sensation of well-being in patients with cancer-related anorexia.
With the two progestins recommended for practice, nurses and patients must be aware of the possibility of thrombotic events, breakthrough vaginal bleeding, peripheral edema, hyperglycemia, hypertension, Cushing syndrome, alopecia, and adrenal suppression or insufficiency or inefficiency.
Although optimal dosage is not determined, the studies that examined megestrol acetate used 160-1,600 mg per day. Because side effects appear to be dose-related, nurses should start with low doses and titrate upward.
The ONS PEP team also found that individualized dietary counseling and liquid oral supplements are likely to be effective in increasing nutritional intake, body weight, and quality of life.
Call for action
Nurses in all settings can help patients be at their best during cancer treatment and beyond by assessing appetite and nutritional intake, then intervening in cases of anorexia with counseling, appropriate referrals, and evidence-based treatments. Use the “Anorexia Rapid Resource” below as a quick reference.
Because the available evidence on anorexia is limited, nurses also have an opportunity to improve treatment and patient care with research on the side effect.
Anorexia Rapid Resource
How should nurses screen for and assess anorexia (based on information from Adams et al., 2009)?
A comprehensive evaluation of a patient’s nutritional status includes the following.
- Detailed dietary history
- Physical examination
- Anthropometric measurements (e.g., height, weight, body mass index)
- Laboratory data
The Oncology Nursing Society Putting Evidence Into Practice anorexia authors recommend the following tools to measure anorexia.
- Patient-Generated Subjective Global Assessment (Gosselin et al., 2008)
- Mini Nutritional Assessment (Nestle Nutrition Institute, 2006)
- Malnutrition Screening Tool (Isenring et al., 2006)
What interventions are effective in managing anorexia in people with cancer?
Recommended for practice: corticosteroids, progestins
Likely to be effective: dietary counseling
Effectiveness not established: cyproheptadine, eicosapentaenoic acid, erythropoietin, ghrelin,metoclopramide, oral branched-chain amino acids, pentoxifylline, thalidomide
Effectiveness unlikely: cannabinoids, hydrazine sulfate, melatonin
Note. For more information about the ONS PEP program, including results for all 16 nursing-sensitive patient outcomes studied, visit www.ons.org/Research/PEP or refer to the new ONS book Putting Evidence Into Practice: Improving Oncology Patient Outcomes (Eaton and Tipton, 2009).
Keightley Amen is a staff editor on the Publishing Team at the Oncology Nursing Society.
Adams, L.A., Cunningham, R.S., & Belansky, H. (2009). Anorexia. In L.H. Eaton J.M. & Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 25-36). Pittsburgh, PA: Oncology Nursing Society.
Dewys, W.D., Begg, C., Lavin, P.T., Band, P.R., Bennett, J.M., Bertino, J.R., et al. (1980). Prognostic effect of weight loss prior to chemotherapy in cancer patients. American Journal of Medicine, 69(4), 491-497.
Eaton, L.H. & Tipton, J.M. (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Gobel, B.H., Tipton, J. M. (2009). PEP up your practice. In L.H. Eaton J.M. & Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 1 – 8). Pittsburgh, PA: Oncology Nursing Society.
Gosselin, T.K., Gilliard, L., & Tinnen, R. (2008).Assessing the need for a dietitian in radiation oncology.Clinical Journal of Oncology Nursing, 12(5), 781-787.
Huhmann, M.B., & Cunningham, R.S. (2005). Importance of nutritional screening in treatment of cancer-related weight loss. Lancet Oncology, 6(5), 334-343.
Isenring, E., Cross, G., Daniels, L., Kellett, E., & Koczwara, B. (2006). Validity of the Malnutrition Screening Tool as an effective predictor of nutritional risk in oncology outpatients receiving chemotherapy. Supportive Care in Cancer, 14(11), 1152-1156.
Nelson, K.A. (2000).The cancer anorexia-cachexia syndrome. Seminars in Oncology, 27(1), 64-68.
Nestle Nutrition Institute. (2006). Mini Nutritional Assessment MNA®. Retrieved May 23, 2009, from http://www.mna-elderly.com/forms/MNA_english.pdf
Tisdale, M.J. (2001).Cancer anorexia and cachexia. Nutrition, 17(5), 438-442.
Yavuzsen, T., Davis, M.P., Walsh, D., LeGrand, S., & lagman, R. (2005). Systematic review of the treatment of cancer-associated anorexia and weight loss. Journal of Clinical Oncology 23(33), 8500-8511.