Nutrition

Although uncontrolled pain is the principal complaint of many patients, the family's primary concern is often the patient not eating well. The causes of cancer cachexia are still poorly understood. Because patients seem to stop eating, lose weight, and eventually die, the natural assumption has been that even if physicians cannot effectively treat the cancer, they can at least treat malnutrition and thereby delay death.

The problem is that more harm than good can come from tube feedings or pushing multiple cans of supplement each day. The family may feel responsible if the patient loses weight and may feel guilty when the person dies. Unfortunately, the patient's final weeks become a struggle with the family over how much the person has eaten. One patient said, "Tell her to stop pushing that spoon into my face; I don't want any more!" This can be carried to extremes, such as inserting nasogastric tubes in patients who "do not cooperate." If they tug on the tube, their hands may be tied to the bed rails. A study of tube feedings in elderly patients revealed that, within 2 weeks, 67% of patients with nasogastric tubes had attempted self-extubation, and 43% had aspiration pneumonia. Gastric or jejunal tubes had a lower self-extu-bation rate (44%), but 56% of the patients had aspiration pneumonia, 31% had a leak or infection at the insertion site, and 50% had a clogged or kinked tube (Ciocon et al., 1988). Another comprehensive analysis found evidence of many risks and no benefits from tube feeding in patients with advanced dementia (Finucane et al., 1999). Large volumes of supplemental feeding can cause painful gastric distention, nausea, diarrhea, and copious pulmonary secretions.

There is no evidence that forced feeding of cancer or dementia patients prolongs life. Careful metabolic studies on force-fed cancer patients at the National Institutes of Health showed irreversibly increased metabolic rates from forced feeding. It was speculated that tumor growth was accelerated (Terepka and Waterhouse, 1956). Animal experiments have shown that growth rates of a variety of different cancers are nutrient dependent; the growth rate slows down with fasting or protein-free diets and speeds up with total parenteral nutrition (TPN) (Buzby et al., 1980; Stragand et al., 1979). In several trials, patients who received TPN plus chemotherapy were compared with those receiving chemotherapy alone. The TPN group died faster, especially patients with lung adenocarcinoma (Jordan et al., 1981), colorectal cancer (Nixon et al., 1981), and small-cell lung cancer (Shike et al., 1984). Pooling data on TPN and cancer through 1985, Klein and associates (1986) found that infections were more common in patients receiving TPN, and that these patients were less responsive to chemotherapy and had shortened survival. After reviewing all the clinical trials of parenteral nutrition in patients receiving cancer chemotherapy, the American College of Physicians (1989) concluded, "The evidence suggests that parenteral nutritional support was associated with net harm, and no conditions could be defined in which such treatment appeared to be of benefit. Thus, the routine use of parenteral nutrition for patients undergoing chemotherapy should be strongly discouraged."

What should be done to relieve the anorexia of advanced cancer? eTable 5-2 lists a number of treatable causes of anorexia. Uncontrolled pain blunts any person's appetite and can be alleviated. Low-level nausea, oral candidiasis, and constipation can interfere with eating and can be treated effectively. Families can be taught to relieve xerostomia (dry mouth), using a small syringe filled with water or juice, and to prepare soft foods. Corticosteroids or megestrol have been beneficial to some but can cause side effects. The most important service the family physician can provide is to allay guilt. An appropriate statement would be: "I do not believe that how much time your husband has, or how comfortable he is, depends on how much he eats."

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