Overcoming Cancer Cachexia

As I have been advising patients for thirty years now, and as you read in my blog from last week, most cancer patients don’t die from cancer, they die from the complications associated with the disease and its treatment.  Knowing this empowers you to take the steps needed to prevent these complications from arising in the first place.  Here I will focus on one of the most common of all cancer-related complications: the wasting syndrome known as cancer cachexia.  According to the National Cancer Institute, cachexia is estimated to be the immediate cause of death in 20% to 40% of cancer patients.  In addition, about eight out of every ten patients with advanced cancer will suffer from this potentially deadly syndrome.

Cachexia can peel away both one’s visible muscle (somatic muscle) and one’s invisible muscle, (the visceral proteins in your gut and elsewhere, responsible in great part for your immune functioning).  A wasting syndrome can also drive down body fat, impairing energy stores, advance anemia and promote feelings of fatigue and depression.  Overall, it is common for patients with cachexia to experience an underlying state of fecklessness.  And because your muscles, particularly your visceral muscle, serve as a reservoir for certain immune-enhancing nutrients, the loss of muscle leads to a weakening of your immune system, making you more prone to life-threatening infections such as pneumonia.  To further complicate matters, many patients suffer from anorexia (a moderate to severe aversion to food) at the same time that they have cachexia.

For decades, oncologists and dietitians alike believed that cachexia was mainly due to the tumor’s ability to siphon away the body’s energy reserves, starting with glucose and fat reserves, then moving on to the proteins that comprise muscle tissue.  This simplistic belief seemed to justify an aggressive dietary approach based on loading up the patient with calorie-rich foods.  Indeed, even today, recommendations coming out of several major cancer organizations encourage patients to eat whatever they want of the typical American diet; that is, more saturated fats, refined flours and sugars.  And in fact, many of the high calorie replacement drinks, particularly those ubiquitous canned beasts lining hospital pharmacy units, are loaded with sugar, sugar, more sugar and fat!  And almost universally, the wrong fat!  However, we now know that cachexia is not a matter of simply getting enough calories, from fats, carbs or protein.  Rather, the disorder is a metabolic dysfunction driven by a chronic, low-grade pro-inflammatory condition with the unrelenting and consequent breakdown of muscle and other lean tissues.  While a pro-inflammatory diet has traumatic consequences for all of us, consuming a pro-inflammatory diet high in red meat, dairy products and refined sugars, for the patient with early signs of cachexia, such choices can be devastating.  These foods, if you can call them such, can fuel this muscle-wasting process and promote the very disease you are trying to fight! 

Combating cachexia

What I know from my care of hundreds of cachectic patients over the years, you either curb the underlying inflammatory problem, or you will fail at countering what can rapidly become a life-threatening wasting syndrome.  In other words, the condition will worsen.  From a perspective of evidence, numerous studies have linked the nutrients abundant in meats, dairy products, and refined carbohydrate foods with inflammation and with an increased risk of cancer cachexia.  Among the major offenders are the “bad fats” such omega 6, saturated, and trans fats, as well as “bad carbs” such as refined flour products.  Therefore, I always encourage patients to immediately reduce or eliminate saturated fats, whether from milk, cheese, butter, red meat, pork, coconut, or poultry.  In addition, eliminate unnatural fat, called trans fat, found abundantly in margarine, hydrogenated oils, as well as many baked goods and convenience foods.  And finally, strive for an optimal dietary balance of polyunsaturated fats (PUFAs) known as omega-6’s, omega-3’s and omega-9’s.  For most Americans, omega-6 fats (found in certain vegetable oils including corn oil, safflower and sunflower oil) need to be radically reduced, while omega-3 and omega-9 fats, commonly found in walnuts, flax, cold water fish, fish oil supplements, as well as the monosaturated fats found in olive oil and avocado, need to be increased.

After taking charge of your fat consumption, one needs to look at the main source of caloric energy—carbohydrates.  It turns out that high-glycemcic foods, ones that cause a sudden rise in blood sugar (even in non-diabetics) accelerate the formation of arachadonic acid, a product of omega-6 fatty acid metabolism.  This is the main fuel supporting the inflammatory pathway and foods increasing this should be reduced or avoided.  These foods include sugar, honey, high-fructose corn syrup, concentrated sweeteners, sugary beverages, cookies, cakes, pastries; white bread, crackers, and sugar-laden or white-flour baked goods.

Omega-3 supplementation—either with fish oil or algae oil—may prove to be an excellent strategy for counteracting cancer cachexia, especially if combined with prescriptive exercise and a high antioxidant intake and anabolic hormones such as testosterone.  Even during chemotherapy, my clinical experience has shown that this nutritional and integrative approach affords our best hope for combating cancer while countering the deadly problem of cancer cachexia.

In a randomized clinical trial published in the October 2003 issue of the medical journal Gut, 200 pancreatic cancer patients received either a dietary supplement containing omega-3s or a similar supplement lacking these more therapeutic fatty acids for 8 weeks.  Initially, the overall analysis showed that both supplements were equally effective at stopping the loss of body weight and muscle tissue.  At closer scrutiny, the study showed that many of the patients were actually not taking the recommended daily amount of omega-3s and thus, the effect, though similar, was not all that clinically impressive.  However, further analysis of the data revealed that as the consumed amount of the omega-3 increased, so did weight and muscle gain, as well as patients’ quality of life.

At this writing, at least seven clinical trials have attempted to test the issue of whether fish oil or omega-3 supplementation can halt the process of cancer cachexia.  The results have been mixed, and a recent meta-analysis (examining all the research collectively) concluded that there is insufficient evidence to establish whether omega-3 supplementation is helpful.  However, I would argue that even if only two or three studies indicate a benefit, we should pay attention to those, given the supplement’s wide margin of safety and quality-of-life benefits.  And just for the record, there are many studies that have focused on non-steroidal anti-inflammatories (NSAIDs), Megastrol Acetate, and anabolic hormones such as testosterone, that have shown similar mixed reviews.  Also, the more alternative compound, Hydrazine Sulfate, has been researched and used with varying opinions as to its effectiveness.  Getting back to omega-3 supplementation: cachexia is a potentially life-threatening condition, so why would you not try a supplement that is safe to take and has at least some evidence of effectiveness?

Still, don’t forget the calories!  And for the matter, protein as well!  Patients do need the added protein and calories in order to rebuild and stop the decline.  But this must be from good anti-inflammatory whole food sources.  In Life Over Cancer, I provide several shake recipes containing optimal sources of proteins, fats and carbohydrates specifically designed to counter this syndrome.  My clinical experience suggests these, along with anti-inflammatory supplementation like fish oil, turmeric/curcumin, ginger, scutelleria and others, can make a pronounced impact on stopping and reversing this distressful disorder.  And yes, in spite of the fatigue that many patients will experience, I do prescribe gentle resistance exercise.  This is essential to maintain and rebuild fragile muscles.

Dietary recommendations

At the Block Center, we recommend a diet high in fiber, complex carbohydrates, plant-based sources of protein such as lentils, chickpeas, tofu, tempeh, veggie burgers, and wheat-gluten products such as seitan, plenty of whole grains, a wide variety of vegetables including crucifers and leafy greens, fruits and berries rich in antioxidants, and nuts, seeds and cold water fish, rich in omega-3 fatty acids.  For patients with low protein and albumin levels, egg whites and only omega-3 enhanced yolks, can be considered.  This nutritional strategy is intended to not only help curtail inflammation, but reduce free-radical damage, minimize platelet activation (which can lead to dangerous blood clotting), manage blood sugar surges, and reduce serum levels of insulin-like growth factor 1, or IGF-1 (which stimulates cell multiplication and inhibits cell death).