An 80-year-old man has had a several-year history of low-grade B-cell non-Hodgkin lymphoma with a presacral mass and systemic light chain amyloidosis involving the heart, the gastrointestinal tract, and probably his kidneys. His chief complaints have been loss of appetite and nausea. The patient also has a longstanding history of monoclonal gammopathy with an IgM level rising to 1400 mg/dL. In response to bortezomib and dexamethasone, his IgM paraprotein almost normalized and his light chains were reduced by half. The patient was not able to tolerate any further bortezomib treatment because of side effects of nausea and diarrhea, resulting in dehydration and prerenal kidney failure. His nausea improved with low-dose prednisone. Despite his poor appetite, the patient’s weight has remained stable over 2 years. However, he has had intermittent edema and persistent pleural effusions.
Nutritional support for the older cancer patient varies at different points during the course of a malignancy ( Table 20-1 ). At the earliest stage, nutritional support (e.g., supplementation with vitamin D) may be used to attempt to prevent cancer. A recent meta-analysis of cohort and case-control studies on the effects of vitamin D supplementation and blood-circulating 25-hydroxy vitamin D levels suggests a protective effective effect on the risk of developing breast cancer. However, these observational data findings await confirmation in clinical trains and this approach is too preliminary to be recommended.
| Stage | Nutritional Support | Evidence |
|---|---|---|
| Primary prevention |
|
|
| Early after detection |
|
|
| Tumor progression/treatment side effects |
| Anecdotal |
| Cancer-related anorexia/cachexia |
|
|
| Prevention of recurrence |
|
|
| Advanced cancer |
|
|
The second stage is at the time of diagnosis. If a tumor has been detected by screening, older cancer patients may have no symptoms; the main concern is whether they have any nutritional deficiencies that would interfere with primary treatment of the malignancy. In contrast, weight loss may be a presenting symptom for many malignancies, especially colorectal cancer and lymphomas.
During the course of cancer treatment, weight loss and nutritional complications may be the result of tumor progression causing anorexia, structural or functional disturbances of dentition or the gastrointestinal tract, depression that commonly accompanies cancer, or due to side effects of treatment (e.g., mucositis).
The cancer-related anorexia/cachexia syndrome is a hypercatabolic state (increased resting energy expenditure) with high levels of tumor-activated or host-produced immune responses (e.g., proinflammatory cytokines) to the tumor. Clinical manifestations include loss of appetite and weight, especially lean body mass; tissue wasting; metabolic alterations; fatigue; and reduced functional status.
Nutritional supplementation may be needed to allow the patient to continue to receive treatment or to maintain functional status. Sometimes older cancer patients may become so sick that they cannot tolerate oral feeding and more aggressive enteral or parenteral nutritional support may be considered. An emerging concept is the use of nutritional therapy (e.g., dietary modifications to reduce energy from fat and increased intake of vegetables, fruits, and fiber) to prevent recurrence of malignancies, especially breast cancer.
Finally, there is a stage of advanced cancer when nutritional support may be palliative (e.g., feeding the patient for comfort or pleasure in spite of risks of aspiration).
The knowledge base for nutritional support of the older cancer patient is limited, in part because of the difficulty in studying this population. The sickest, most malnourished patients are often excluded from clinical trials of nutritional support. Even when eligible for clinical trials, sick older cancer patients may be reluctant to participate. Moreover, the published trials on nutritional support focus on older populations or cancer populations rather than older patients who have cancer. Hence, much of what can be gathered from the literature are extrapolations from studies conducted on one population or the other. Most of the clinical trials have focused on survival and cancer recurrence rather than functional status or quality of life. Many more published studies have relied on retrospective analysis of patients who did or did not receive a treatment. Because these patients were not randomly assigned to treatment, no conclusions can be reached about the effectiveness of these interventions; these studies are not considered in this chapter.
The approach to nutritional support of the older cancer patient is further complicated by general approaches and some tumor-specific approaches. In particular, the role of nutritional support has been the focus of considerable research on head and neck and gastrointestinal malignancies. The findings of these studies may or may not be applicable to older persons with other malignancies.
In this chapter, approaches to nutritional assessment and monitoring, general approaches to nutritional support, pharmacologic appetite stimulants, and nutritional support of the patient with advanced cancer will be described, concluding with a summary of recommended care.
Nutritional Assessment and Monitoring
Weight and Body Mass Index
Weighing the patient is easy and provides a general indication of whether the patient is getting adequate nutritional intake. Weight loss and low body mass index (BMI) have been associated with adverse outcomes in older persons. In a 4-year cohort study, the annual incidence of involuntary weight loss (defined as loss of more than 4% of body weight) among community-dwelling veterans was 13.1%. Over a 2-year follow-up period, involuntary weight losers had an increased risk of mortality (RR = 2.4, 95% CI = 1.3 to 4.4) that was 28% among weight losers and 11% among those who did not lose weight. Voluntary weight losers had a 36% mortality rate during this time. Weight loss also has prognostic value among cancer patients independent of disease stage, tumor histology, and patient performance status. Among community-dwelling old persons, body mass index (BMI) demonstrates a “U” shaped relation with functional impairment, with increased risk among those at the lowest and highest BMIs.
In older persons, involuntary weight loss may be the presenting symptom of cancer. A case series of 306 patients with unexplained weight loss who were followed for at least 1 year reported that 38% had cancer; it also reported on blood tests (complete blood count, erythrocyte sedimentation rate, and biochemical profile) that were useful, particularly in excluding patients who had cancer. If none of these were abnormal, the likelihood ratio for a diagnosis of cancer was 0.2 (95% confidence interval 0.1-0.4).
Nevertheless, the interpretation of weight as a nutritional indicator is complicated. Weight may remain stable or even increase among those who are progressively malnourished, because of other factors contributing to weight such as edema, ascites, and pleural effusions.
Depression Screening
Depression in cancer patients is a cause of anorexia and weight loss that may respond to antidepressant treatment or psychotherapy. A simple screen such as the Patient Health Questionnaire-9 (PHQ-9) (or its shorter version, the PHQ-2 ) can be used to detect depressive symptoms.
Biochemical Measures
Serum albumin is the best-studied serum protein and has prognostic value for subsequent mortality and morbidity in community-dwelling older persons. Because serum albumin does not fall quickly (half-life 18-21 days) in protein deprivation, it may be quite a useful indicator for chronic moderate to severe undernutrition. In contrast, proteins with shorter half-lives such as prealbumin (half-life 2-3 days) and transferrin (half-life 8-9 days) may respond to nutritional interventions more quickly and may be better for monitoring treatment.
Other Measures
Anthropometric measures such as midarm muscle circumference and skin-fold thickness tend to be less reliable in older persons. Lymphocyte count, which is low (<1500 cells/mm ) in protein-energy malnutrition, is also sometimes used as a measure but may not have independent prognostic value beyond albumin.
Weight and Body Mass Index
Weighing the patient is easy and provides a general indication of whether the patient is getting adequate nutritional intake. Weight loss and low body mass index (BMI) have been associated with adverse outcomes in older persons. In a 4-year cohort study, the annual incidence of involuntary weight loss (defined as loss of more than 4% of body weight) among community-dwelling veterans was 13.1%. Over a 2-year follow-up period, involuntary weight losers had an increased risk of mortality (RR = 2.4, 95% CI = 1.3 to 4.4) that was 28% among weight losers and 11% among those who did not lose weight. Voluntary weight losers had a 36% mortality rate during this time. Weight loss also has prognostic value among cancer patients independent of disease stage, tumor histology, and patient performance status. Among community-dwelling old persons, body mass index (BMI) demonstrates a “U” shaped relation with functional impairment, with increased risk among those at the lowest and highest BMIs.
In older persons, involuntary weight loss may be the presenting symptom of cancer. A case series of 306 patients with unexplained weight loss who were followed for at least 1 year reported that 38% had cancer; it also reported on blood tests (complete blood count, erythrocyte sedimentation rate, and biochemical profile) that were useful, particularly in excluding patients who had cancer. If none of these were abnormal, the likelihood ratio for a diagnosis of cancer was 0.2 (95% confidence interval 0.1-0.4).
Nevertheless, the interpretation of weight as a nutritional indicator is complicated. Weight may remain stable or even increase among those who are progressively malnourished, because of other factors contributing to weight such as edema, ascites, and pleural effusions.
Biochemical Measures
Serum albumin is the best-studied serum protein and has prognostic value for subsequent mortality and morbidity in community-dwelling older persons. Because serum albumin does not fall quickly (half-life 18-21 days) in protein deprivation, it may be quite a useful indicator for chronic moderate to severe undernutrition. In contrast, proteins with shorter half-lives such as prealbumin (half-life 2-3 days) and transferrin (half-life 8-9 days) may respond to nutritional interventions more quickly and may be better for monitoring treatment.
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