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The EPEC-O TM Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O The EPEC-O TM Project Education in Palliative and End-of-life Care - Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

EPEC – Oncology Education in Palliative and End-of-life Care – Oncology Module 3 b: EPEC – Oncology Education in Palliative and End-of-life Care – Oncology Module 3 b: Symptoms – Anorexia / Cachexia

Anorexia / Cachexia. . . Cachexia – wasting syndrome l Decreased lean tissue l Anorexia / Cachexia. . . Cachexia – wasting syndrome l Decreased lean tissue l Diminished performance status l Altered resting energy expenditure l Diminished appetite

. . . Anorexia / Cachexia Lean tissue Fat mass Impact of feeding Starvation . . . Anorexia / Cachexia Lean tissue Fat mass Impact of feeding Starvation Decreased Sparing disproportionately Moderate Large preferential decrease No impact Positive impact

Anorexia / Cachexia Epidemiology in cancer: l Incidence varies with site l Incidence increases Anorexia / Cachexia Epidemiology in cancer: l Incidence varies with site l Incidence increases with stage

Anorexia / Cachexia Impact: l l l ≥ 5% weight loss associated with poor Anorexia / Cachexia Impact: l l l ≥ 5% weight loss associated with poor prognosis Trend toward lower chemotherapy response rates Anorexia associated with poor prognosis Diminished function and quality of life Adversely affects caregivers Mac. Donald N, et al. J Am Coll Surg. 2003. Dewys WD, et al. Am J Med. 1980. Loprinzi CL, et al. JCO. 1994.

Key points l Pathophysiology l Assessment l Management Key points l Pathophysiology l Assessment l Management

Pathophysiology l l l Chronic inflammation Metabolic changes Lipolytic / proteolytic substances Hormonal changes Pathophysiology l l l Chronic inflammation Metabolic changes Lipolytic / proteolytic substances Hormonal changes Role of neurotransmitters Cytokine impact on hypothalamus Todorov P, et al. Nature. 1996. Todorov P, et al. Cancer Research. 1998. Zigman JM, et al. Endocrinology. 2003. Balkwill F, et al. Lancet. 2001.

Assessment l Appetite / weight loss history l Reversible causes l Physical signs of Assessment l Appetite / weight loss history l Reversible causes l Physical signs of wasting l Biochemical markers l Radiographic studies as indicated

… Assessment Reversible causes of weight loss: l Psychological factors l Mucositis l Nausea … Assessment Reversible causes of weight loss: l Psychological factors l Mucositis l Nausea / vomiting l Early satiety Malabsorption l Pain l Endocrine Constipation l l Comorbid conditions Social / economic

Management. . . l Treat comorbid conditions l Educate, support l l Provide favorite Management. . . l Treat comorbid conditions l Educate, support l l Provide favorite foods / nutritional supplements / counseling Treat reversible causes (e. g. , early satiety, mucositis)

Anorexia / cachexia: what does not work l Feeding (enteral or parenteral) ACP. Ann Anorexia / cachexia: what does not work l Feeding (enteral or parenteral) ACP. Ann Int Med. 1989. Ovesen. J Clin Oncol. 1993.

Management of anorexia l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens Loprinzi Management of anorexia l Dexamethasone l Megestrol acetate l Tetrahydrocannabinol (THC) l Androgens Loprinzi CL, et al. JCO. 1999. Von. Roenn JH, et al. ASCO. 2003. Moertel CG, et al. Cancer. 1974.

Management of cachexia l Investigational Ø Anabolic steroids Ø Omega-3 -fatty acids Ø Amino Management of cachexia l Investigational Ø Anabolic steroids Ø Omega-3 -fatty acids Ø Amino acids Ø NSAIDs Ø Multivitamins Ø Exercise Von Roenn JH, et al. ASCO. 2003. Jatoi A, et al. ASCO. 2003. . Fearon KCH, et al. Gut. 2003. Mc. Millan DC, et al. Br J Ca. 1999

Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.