Cachexia in Cancer

Aka: Cachexia in Cancer, Anorexia in Cancer, Wasting Syndrome in Cancer, Anorexia-Cachexia Syndrome, Cachexia in Terminally Ill Patients, Cancer Related Cachexia, Cancer Cachexia, Palliative Management of Cachexia

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II. Pathophysiology

  1. Multifactorial
  2. Results in wasting of body fat and Muscle
  3. Cytokine elevations related to Wasting Syndromes
    1. Interferon
    2. Tumor Necrosis Factors

III. Risk Factors

  1. Systemic inflammation
  2. High tumor burden
  3. Lack of response to cancer treatment
  4. Decreased oral intake
  5. Inactivity
  6. Advanced cancers
    1. Pancreatic Cancer
    2. Gastric Cancer
    3. Lung Cancer
    4. Liver cancer

IV. Symptoms

  1. No appetite (Anorexia)
  2. Unintentional Weight Loss (Cachexia)
  3. Fatigue (see Fatigue in Cancer)
  4. Generalized weakness

V. Signs

  1. Decreased BMI
  2. Involuntary Weight Loss (e.g. >5% in 6 months)
  3. Skeletal Muscle loss and weakness (e.g. grip strength)
  4. Adipose tissue loss
  5. Functional Impairment

VI. Differential Diagnosis

  1. See Unintentional Weight Loss
  2. Chronic organ failure
  3. Serious chronic infection
  4. AIDS
  5. Hypothyroidism
  6. Adrenal Insufficiency

VII. Evaluation: Identify and treat reversible causes

  1. Chronic Pain
  2. Pancreatic exocrine enzyme insufficiency
  3. Endocrine disorders
    1. Hypothyroidism
    2. Adrenal Insufficiency
  4. Diminished gastrointestinal motility
    1. Constipation
    2. Reflux Esophagitis
    3. Gastroparesis
  5. Mouth condition
    1. Dry Mouth (Xerostomia)
    2. Dental or jaw related issues
    3. Chemotherapy related Oral Mucositis
    4. Infection
      1. Oral Candidiasis
      2. Oral Herpes Simplex infection

VIII. Management: Nutrition

  1. Background
    1. Wasting is not reversed by improved nutrition
    2. Aggressive alimentation may increase discomfort
  2. Management
    1. Small Frequent Meals
    2. Consider high Protein, calorie dense foods
      1. Nuts and Nut Butters
      2. Eggs
      3. Full-fat Greek Yogurt, Whole Milk, Whole Cottage Cheese
      4. Beef, Salmon, dark meat chicken
    3. Avoid blended, pulverized foods
    4. Avoid Parenteral nutrition and Feeding Tubes
    5. Patient eats what they want
      1. Avoid dietary restriction (diabetics eat ice cream)
      2. Avoid foods with unpleasant odor
    6. Educate families that wasting is not inadequate care
    7. Families can offer care in alternative ways
      1. Moisten patient's lips or mouth with sponge
      2. Offer massage
      3. Read or play soft music for patient

IX. Management: Medications

  1. General
    1. Discontinue medication if no benefit in 2-6 weeks
  2. Main options
    1. Megestrol acetate (Megace) 200 mg PO q6-8 hours
    2. Dexamethasone (Decadron) 2 to 20 mg PO qAM
    3. Dronabinol (Marinol) 2.5 mg PO bid to tid
    4. Medroxyprogesterone acetate
  3. Experimental: Androgens
    1. Oxandrolone (Oxandrin)
    2. Nandrolone (Durabolin)
  4. Other options
    1. Macrolide Antibiotics
    2. Cyproheptadine
    3. Hydrazine sulfate
    4. Cannabinoids
    5. Low dose Olanzapine (Zyprexa)

X. Management: Non-Cancer Comorbid Condition Specific Measures and Precautions

  1. Cardiac disease (e.g. CHF, CAD, Transplant Rejection)
    1. Decreased gastrointestinal perfusion may result in early satiety
    2. Favor small, frequent meals
  2. Lung Disease (e.g. COPD, ILD) with Pleuritic Pain
    1. Increased work of breathing is associated with increased caloric expenditure and decreased appetite
  3. Renal disease (e.g. Chronic Kidney Disease, Acute Renal Failure)
    1. Associated with Dysgeusia and early satiety
    2. Manage Electrolyte derangements and Uremia
  4. Liver disease (e.g. end-stage Cirrhosis) and Ascites
    1. Prokinetics (e.g. Metoclopramide) for Ascites-associated Gastroparesis
    2. Paracentesis

XI. Prevention

  1. Anticipatory guidance regarding Nutritional Support
  2. Early treatment of conditions that impair oral intake (e.g. mucositis)
  3. Regular Physical Activity including Resistance Training

XII. References

  1. Eary (2026) Am Fam Physician 114(4): 393-411 [PubMed]
  2. MacDonald (2003) J Am Coll Surg 197:143-57 [PubMed]
  3. McCann (1994) JAMA 272:1263-6 [PubMed]
  4. McGregor (2025) Am Fam Physician 112(5): 493-503 [PubMed]
  5. Nelson (2000) Semin Oncol 27:64-8 [PubMed]
  6. Ross (2001) Am Fam Physician 64(5):807-14 [PubMed]

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