Jane is a 64-year-old woman married to John for 26 years and who has a daughter, Sara, from a previous marriage. Jane enjoys caring for her granddaughters aged 1 and 5 on weekdays while Sara works. Jane had been attending her general practitioner (GP) with non-specific abdominal symptoms, which were treated as irritable bowel syndrome until she developed abdominal ascites, which led to further investigation and a diagnosis of advanced ovarian cancer. Along with her irritable bowel-type symptoms, Jane complained of a loss of appetite, fatigue and a metallic food taste, which led to a reduction in nutritional intake and unplanned weight loss of >10% over the last 6 months adjusting for the presence of ascites. Prior to this illness, Jane reported that her diet and her lifestyle had always been very healthy. Her weight and body mass index (adjusted for fluid) are 63 kg and 23 kg/m2, respectively.
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1. What might be the contributors to Jane’s loss of appetite?
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Correct answer:
There are many factors that may be responsible for Jane’s loss of appetite. Physical causes may include bowel discomfort when eating, a sensation of fullness due to ascites, reduced gut motility, metabolic derangements caused by the tumour and taste changes leading to food aversion. Physiological stress and fatigue relating to her diagnosis could reduce her desire to eat and affect her ability to shop and prepare meals.
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2. What is the clinical significance of the unintentional weight loss Jane has experienced?
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Significant unintentional weight loss and lack of appetite are suggestive of a diagnosis of cancer cachexia. It is likely that Jane has lost skeletal muscle mass and fat mass as a result of her insufficient oral intake, nutrient malabsorption and metabolic derangement. This unintentional weight loss is itself a recognised independent predictor of morbidity and earlier mortality in advanced cancer.
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3. What advice might you give Jane to reduce the impact of her loss of appetite on her dietary intake?
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Advice should be given on ways to modify her diet and meal plan to cope with fatigue and appetite loss whilst optimising her macronutrient and micronutrient intake to prevent further weight loss. She should be encouraged to eat small amounts of nutritious food often and to choose higher-calorie snacks and drinks rather than diet or low-fat options. It might also be helpful to enlist family support for shopping and meal preparation. It would also be beneficial to encourage her to remain as physically active as possible to maintain muscle mass and function.
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4. What advice might you give her to reduce the impact of taste changes leading to food aversion?
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Sauces, pickles or marinades are useful in disguising the metallic taste experienced by many cancer patients when eating meats. In addition, some patients find benefit from using non-metallic cutlery. Good oral hygiene is key, and it is best to avoid foods which requiring a lot of chewing prior to swallowing as the metallic tastes will linger longer in the mouth. Fruit or herbal tea may be better tolerated than tea or coffee. Taste changes can alter over time, so it is advisable to retest tastes for foods to prevent unnecessary dietary exclusions.
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5. Jane is going to start a course of platinum-based chemotherapy treatment. How is this likely to impact on her nutritional status?
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Correct answer:
Platinum-based chemotherapy drugs are known to be challenging in terms of side effects. The most severe side effects include neurotoxicity, nephrotoxicity, nausea and vomiting, which all can impact on food intake. The chemotherapy is also likely to exacerbate her existing symptoms. Optimising macronutrient and micronutrient intake to prevent further weight loss with small frequent meals will help attenuate the impact of such symptoms.
