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The Key Role of Nonpharmacologic Management of Cachexia in Persons With Advanced IllnessA Teachable Moment

Educational Objective
To describe the psychological distress that anorexia and/or cachexia leads to in patients with advanced illness and their caregivers, and how clinicians can help without using pharmacologic management.
1 Credit CME

A man in his 80s with advanced colon cancer and malignant ascites presented to the oncology clinic to discuss next steps. He reported weight loss (approximately 15 kg in 2 months), and his daughter commented on his limited appetite, weakness, and that he was “just bones.” Recent computed tomography staging scans had demonstrated progression of the cancer. On examination, temporal wasting and an indwelling peritoneal catheter were noted.

The oncologist discussed the lack of further meaningful chemotherapy or clinical trial options. The daughter requested that something be done for appetite and weight loss. The patient expressed food aversion. The oncologist prescribed a 2-week supply of megestrol acetate solution for anorexia and/or cachexia. The co-pay was $57. Three days later, the daughter called the oncologist and was distressed because her father was now weaker and bedbound. The patient enrolled in home hospice and died the next day. The daughter expressed guilt that she was unable to nourish her father during his last days.

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Article Information

Corresponding Author: Arjun Gupta, MD, Medical Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, 401 N Broadway, Baltimore, MD 21231 (guptaarjun90@gmail.com).

Published Online: April 26, 2021. doi:10.1001/jamainternmed.2021.1533

Conflict of Interest Disclosures: Dr Gupta reported support from a Young Investigator Award from the Conquer Cancer Foundation and the American Society of Clinical Oncology during the conduct of the study. No other disclosures were reported.

Additional Contributions: We thank the patient and his family for granting permission to share their story. We thank Ramy Sedhom, MD, Palliative Care, Memorial Sloan Kettering Cancer Care, for reviewing earlier versions of this manuscript. Contributors were not compensated for their work.

References
1.
Roeland  EJ , Bohlke  K , Baracos  VE ,  et al.  Management of cancer cachexia: ASCO guideline.   J Clin Oncol. 2020;38(21):2438-2453. doi:10.1200/JCO.20.00611PubMedGoogle ScholarCrossref
2.
Ruiz-García  V , López-Briz  E , Carbonell-Sanchis  R , Bort-Martí  S , Gonzálvez-Perales  JL .  Megestrol acetate for cachexia-anorexia syndrome. A systematic review.   J Cachexia Sarcopenia Muscle. 2018;9(3):444-452. doi:10.1002/jcsm.12292PubMedGoogle ScholarCrossref
3.
Fearon  K , Strasser  F , Anker  SD ,  et al.  Definition and classification of cancer cachexia: an international consensus.   Lancet Oncol. 2011;12(5):489-495. doi:10.1016/S1470-2045(10)70218-7PubMedGoogle ScholarCrossref
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Cooper  C , Burden  ST , Cheng  H , Molassiotis  A .  Understanding and managing cancer-related weight loss and anorexia: insights from a systematic review of qualitative research.   J Cachexia Sarcopenia Muscle. 2015;6(1):99-111. doi:10.1002/jcsm.12010PubMedGoogle ScholarCrossref
5.
Dy  SM , Gupta  A , Waldfogel  JM ,  et al. Interventions for breathlessness in patients with advanced cancer. Agency for Healthcare Research and Quality; 2020. Accessed March 18, 2021. https://www.pcori.org/research-results/2019/interventions-breathlessness-patients-advanced-cancer-systematic-review-update
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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