Nutritional support in multimodal therapy for cancer cachexia

Review Article



Malnutrition has since long been known to be associated with adverse outcomes in cancer patients. The wasting in cancer cachexia involves loss of muscle and fat and reflects a catabolic metabolism induced by an abnormal host response to tumour presence and/or tumour factors. Patients with cancer cachexia frequently develop a chronic negative energy and protein balance driven by a combination of reduced food intake and metabolic change. Thus, alterations in both energy intake and components of energy expenditure may contribute to progressive weight loss. Increased resting energy expenditure related to the systemic inflammatory response is common and a sustained hypermetabolism over a long period of disease progression can make a large contribution to negative energy balance and wasting if not compensated for by an increase in energy intake. Hypermetabolism and diminished energy intake due to anorexia may thus constitute a vicious circle in the development of cancer cachexia.


Though nutritional support alone can improve energy intake to a variable extent and for a variable period of time, it will not address the underlying catabolic metabolism and is thus likely to be of limited efficacy if attempts to attenuate the tumour-induced catabolic response are not carried out at the same time. Concomitant drug treatments for cancer cachexia may slow down the wasting process by reducing anorexia, attenuating the systemic inflammation, the skeletal muscle catabolism or stimulating the muscle protein anabolism.

Thus, improved management of cancer cachexia may require a multimodal approach by a multi-disciplinary team and is best commenced earlier rather than later. Early start of therapy also facilitates the use of oral nutritional supplementation, which is preferable to parenteral nutrition in the majority of cases. Once a patient is severely wasted it may be neither practical nor ethical to intervene with anything else than supportive care.


An improvement in the condition of all patients with cachexia may not be possible, however, the goal must be to stabilise cachexia and prevent or delay further decline. There is currently no single or combined treatment strategy which is successful in all patients. However, strategies to counteract both hypermetabolism and reduced dietary intake have been demonstrated to be of importance for the survival, function and quality of life of cancer patients and should be further explored in interventional studies.


Nutritional support Cachexia Anorexia Body composition Energy balance 


  1. 1.
    Baracos VE (2006) Cancer-associated cachexia and underlying biological mechanisms. Annu Rev Nutr 26:435–461PubMedCrossRefGoogle Scholar
  2. 2.
    Dewys WD, Begg C, Lavin PT et al (1980) Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 69(4):491–497Google Scholar
  3. 3.
    Fearon KC, Voss AC, Hustead DS (2006) Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis. Am J Clin Nutr 83:1345–1350PubMedGoogle Scholar
  4. 4.
    Liedman B, Andersson H, Bosaeus I, Hugosson I, Lundell L (1997) Changes in body composition after gastrectomy: results of a controlled, prospective clinical trial. World J Surg 21:416–421PubMedCrossRefGoogle Scholar
  5. 5.
    Skipworth RJ, Fearon KC (2007) The scientific rationale for optimizing nutritional support in cancer. Eur J Gastroenterol Hepatol 19:371–377PubMedCrossRefGoogle Scholar
  6. 6.
    Tisdale MJ (1999) Wasting in cancer. J Nutr 129(1S Suppl):243S–246SPubMedGoogle Scholar
  7. 7.
    Kyle UG, Bosaeus I, De Lorenzo AD et al (2004) Bioelectrical impedance analysis—part II: utilization in clinical practice. Clin Nutr 23(6):1430–1453PubMedCrossRefGoogle Scholar
  8. 8.
    Baracos VE (2002) Hypercatabolism and hypermetabolism in wasting states. Curr Opin Clin Nutr Metab Care 5(3):237–239PubMedCrossRefGoogle Scholar
  9. 9.
    Parkinson SA, Lewis J, Morris R, Allbright A, Plant H, Slevin ML (1987) Oral protein and energy supplements in cancer patients. Hum Nutr Appl Nutr 41(4):233–243PubMedGoogle Scholar
  10. 10.
    Levine JA, Morgan MY (1998) Preservation of macronutrient preferences in cancer anorexia. Br J Cancer 78:579–581PubMedGoogle Scholar
  11. 11.
    Staal-van den Brekel AJ, Schols AM, ten Velde GP, Buurman WA, Wouters EF (1994) Analysis of the energy balance in lung cancer patients. Cancer Res 54(24):6430–6433PubMedGoogle Scholar
  12. 12.
    Wigmore SJ, Plester CE, Ross JA, Fearon KC (1997) Contribution of anorexia and hypermetabolism to weight loss in anicteric patients with pancreatic cancer. Br J Surg 84(2):196–197PubMedCrossRefGoogle Scholar
  13. 13.
    Cohn SH, Gartenhaus W, Vartsky D et al (1981) Body composition and dietary intake in neoplastic disease. Am J Clin Nutr 34:1997–2004PubMedGoogle Scholar
  14. 14.
    Simons JP, Schols AM, Hoefnagels JM, Westerterp KR, ten Velde GP, Wouters EF (1998) Effects of medroxyprogesterone acetate on food intake, body composition, and resting energy expenditure in patients with advanced, nonhormone-sensitive cancer: a randomized, placebo-controlled trial. Cancer 82(3):553–560PubMedCrossRefGoogle Scholar
  15. 15.
    Bosaeus I, Daneryd P, Svanberg E, Lundholm K (2001) Dietary intake and resting energy expenditure in relation to weight loss in unselected cancer patients. Int J Cancer 93:380–383PubMedCrossRefGoogle Scholar
  16. 16.
    Bosaeus I, Daneryd P, Lundholm K (2002) Dietary intake, resting energy expenditure, weight loss and survival in cancer patients. J Nutr 132:3465S–3466SPubMedGoogle Scholar
  17. 17.
    Warnold I, Lundholm K, Scherstén T (1978) Energy balance and body composition in cancer patients. Cancer Res 38:1801–1807PubMedGoogle Scholar
  18. 18.
    Bozzetti F, Pagnoni AM, Del Vecchio M (1980) Excessive caloric expenditure as a cause of malnutrition in patients with cancer. Surg Gynecol Obstet 150(2):229–234PubMedGoogle Scholar
  19. 19.
    Hyltander A, Drott C, Körner U, Sandström R, Lundholm K (1991) Elevated energy expenditure in cancer patients with solid tumours. Eur J Cancer 27(1):9–15PubMedCrossRefGoogle Scholar
  20. 20.
    Dempsey DT, Feurer ID, Knox LS, Crosby LO, Buzby GP, Mullen JL (1984) Energy expenditure in malnourished gastrointestinal cancer patients. Cancer 53(6):1265–1273PubMedCrossRefGoogle Scholar
  21. 21.
    Knox LS, Crosby LO, Feurer ID, Buzby GP, Miller CL, Mullen JL (1983) Energy expenditure in malnourished cancer patients. Ann Surg 197(2):152–162PubMedCrossRefGoogle Scholar
  22. 22.
    Barber MD, Ross JA, Fearon KC (1999) Cancer cachexia. Surg Oncol 8(3):133–141PubMedCrossRefGoogle Scholar
  23. 23.
    Tisdale MJ (2002) Cachexia in cancer patients. Nat Rev Cancer 2(11):862–871PubMedCrossRefGoogle Scholar
  24. 24.
    Zylicz Z, Schwantje O, Wagener DJ, Folgering HT (1990) Metabolic response to enteral food in different phases of cancer cachexia in rats. Oncology 47(1):87–91PubMedGoogle Scholar
  25. 25.
    Jatoi A, Daly BD, Hughes V, Dallal GE, Roubenoff R (1999) The prognostic effect of increased resting energy expenditure prior to treatment for lung cancer. Lung Cancer 23(2):153–158PubMedCrossRefGoogle Scholar
  26. 26.
    Jatoi A, Hillman S, Stella PJ et al (2003) Daily activities: exploring their spectrum and prognostic impact in older, chemotherapy-treated lung cancer patients. Support Care Cancer 11(7):460–464PubMedCrossRefGoogle Scholar
  27. 27.
    Gibney E, Elia M, Jebb SA, Murgatroyd P, Jennings G (1997) Total energy expenditure in patients with small-cell lung cancer: results of a validated study using the bicarbonate–urea method. Metabolism 46(12):1412–1417PubMedCrossRefGoogle Scholar
  28. 28.
    Moses AW, Slater C, Preston T, Barber MD, Fearon KC (2004) Reduced total energy expenditure and physical activity in cachectic patients with pancreatic cancer can be modulated by an energy and protein dense oral supplement enriched with n−3 fatty acids. Br J Cancer 90(5):996–1002PubMedCrossRefGoogle Scholar
  29. 29.
    American College of Physicians (1989) Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110(9):734–736Google Scholar
  30. 30.
    Lundholm K, Daneryd P, Körner U, Hyltander A, Bosaeus I (2004) Evidence that long-term COX-treatment improves energy homeostasis and body composition in cancer patients with progressive cachexia. Int J Oncol 24(3):505–512PubMedGoogle Scholar
  31. 31.
    Lundholm K, Gelin J, Hyltander A et al (1994) Anti-inflammatory treatment may prolong survival in undernourished patients with metastatic solid tumors. Cancer Res 54(21):5602–5606PubMedGoogle Scholar
  32. 32.
    Lundholm K, Körner U, Gunnebo L et al (2007) Insulin treatment in cancer cachexia: effects on survival, metabolism, and physical functioning. Clin Cancer Res 13(9):2699–2706PubMedCrossRefGoogle Scholar
  33. 33.
    Lundholm K, Daneryd P, Bosaeus I, Körner U, Lindholm E (2004) Palliative nutritional intervention in addition to cyclooxygenase and erythropoietin treatment for patients with malignant disease: effects on survival, metabolism, and function. Cancer 100(9):1967–1977PubMedCrossRefGoogle Scholar
  34. 34.
    Shang E, Weiss C, Post S, Kaehler G (2006) The influence of early supplementation of parenteral nutrition on quality of life and body composition in patients with advanced cancer. J Parenter Enteral Nutr 30:222–230CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  1. 1.Department of Clinical NutritionSahlgrenska University HospitalGöteborgSweden

Personalised recommendations