Cancer and Appetite
April 5, 2009 2:44 PM   Subscribe

My father died from lung cancer a couple of years ago. But did he actually starve to death? And if so, why?

I've been thinking about the actual physiology associated with my father's death and I'm come to appreciate that I'd like to understand a bit more. Briefly, in his late 70s, my father developed lung cancer, did some chemo and radiation, had some bad side-effects, decided to stop treatment other than palative care, and died about a year after the initial diagnosis.

During that year he steadily lost weight. During his last months he also had repeated problems with dehydration requiring brief visits to a hospital for an IV. I remember sitting with him and he would take just tiny, tiny sips of water. A meal would often consist of a can of nutritional drink, like Ensure, sipped from a straw and often unfinished.

I didn't understand then, and I don't understand now, why the simple act of drinking a glass of water was so hard, almost the hardest thing in the world it seemed. Nor do I understand why he had virtually no appetite. Near the end, his doctor even prescribed steroids to encourage weight gain.

I've looked around on the net a bit and all I've seen are coping strategies ("Try eating small meals more often") and pseudo-religious hokum ("The body is getting ready to transition"). As an engineer, with a modest amount of biology under my belt, I'd like to know what was really going on from a physiological point of view. If you can share some insight, I'd very much appreciate it.
posted by LastOfHisKind to Health & Fitness (10 answers total) 4 users marked this as a favorite
Did his cancer progress to his esophagus? A lot of this sounds like my dad who died of esophageal & stomach cancer. He literally had tumors blocking the passage of food and liquid down his esophagus. The chemo & radiation also did a number on his ability to keep food down and/or absorb nutrients. I really don't know much about the physiological process, but this was the first thing that came to mind.
posted by katemcd at 2:55 PM on April 5, 2009

The doctor at my dad's nursing home said most people in his condition die from pneumonia because instead of swallowing the liquids they trickle down into the lungs.
posted by torquemaniac at 3:02 PM on April 5, 2009

Both chemotherapy and radiotherapy can be incredibly hard on the gut, with mucositis being a reasonably common side effect (where the lining of the gastrointestinal tract becomes inflamed and ulcerated). it could be that eating was just too incredibly painful for him that he couldn't do it.

This is just one side effect of treatment, chemotherapy is harsh. Knowing exactly what he was taking might make it easier to figure out the mechanism, but overall 'loss of appetite' isn't surprising.

Cancer itself also consumes a lot of energy, with high glucose uptake being a trademark of many solid tumours (e.g. use of radioactive glucose as a marker for PET scanning to image lung cancer). An old name for cancer is 'the hungry disease' for that reason, the body really can just waste away while the cancer takes over.

I'm sorry you lost your father in this way.
posted by shelleycat at 3:02 PM on April 5, 2009

Response by poster: I'm sorry I don't have more information. His original treatment consisted (at least) of chemotherapy but I don't think it helped much and he had such a severe reaction that he couldn't take any more. Basically he developed sores all over his skin, including inside of his mouth. They did eventually go away after he stopped chemotherapy. He went through radiation treatments during his palative care phase to modest success in retarding tumor growth.

I suppose I should mention that I'm not looking to find fault with any of his treatment. I was just hoping to get a little insight as to what might have been happening.
posted by LastOfHisKind at 3:15 PM on April 5, 2009

My Grandad eventually died of Emphysema (not lung cancer but it might be worth mentioning all the same?). Apparently when just sitting in your chair and breathing takes focus, it is really hard to eat/drink and breathe at the same time. I'd never thought of it like that, but I could see his point.
posted by mu~ha~ha~ha~har at 3:23 PM on April 5, 2009

Sorry for your loss. According to the Merck Manual, loss of appetite is very common towards the end and may even relieve suffering:
Loss of Appetite: Loss of appetite (anorexia) eventually occurs in most people who are dying. Many conditions that cause poor food and liquid intake can be relieved, including inflammation of the stomach lining, constipation, toothache, a yeast infection in the mouth, pain, and nausea. Some people benefit from appetite stimulants such as corticosteroids taken by mouth

People who are close to dying should not have to force themselves to eat, but they may especially enjoy eating small amounts of favorite home-cooked dishes.

If death is not expected to occur within hours or days, artificial nutrition or hydration—given by vein (intravenously) or via a nasogastric tube—may also be tried for a limited time to see whether the person's comfort, mental clarity, or energy improves. Improvement often does not happen; thus many people opt not to continue. The dying person and family members should have an explicit agreement with the doctor about what they are trying to accomplish with these measures and when the artificial nutrition and hydration should be stopped if they are not helping.

During the last few days of life, anorexia is quite common and does not cause additional physical problems or suffering, even though the ill person's lack of eating or drinking may distress family members. Anorexia probably even helps people die more comfortably. As the heart and kidneys fail, an otherwise normal intake of liquids often causes dyspnea, because fluid accumulates in the lungs. A reduced food and liquid intake may lessen the need for suctioning because of less fluid in the throat and may reduce pain in people with cancer because of reduced swelling around tumors. Dehydration may even help the body release larger amounts of the body's natural pain-relieving chemicals (endorphins). Therefore, people who are dying should not usually be forced to eat or drink, especially if doing so requires restraints, intravenous or nasogastric tubes, or hospitalization.
posted by footnote at 3:35 PM on April 5, 2009 [7 favorites]

Well wasting away (cachexia) and loss of appetite (anorexia) are known symptoms of lung cancer, so it may just have been his illness that got him in the end. Cachexia is now thought to be caused by inflammation, the pro-inflammatory cytokines cause systemic changes to metabolism such that the body uses energy faster than it can be provided. The anorexia could be caused by a number of mechanisms which may or may not be related to the cachexia, and it's not that well understood overall.

Cachexia and anorexia are known symptoms of both the disease and the treatments your father was having, as well as for chronic inflammatory diseases like IBD, for serious illness such as cardiovascular or kidney disease, and is really common in terminally ill patients in general. The mechanisms for all these things may be the same or may be different and we just don't know what they are yet, so there really isn't an easy answer for you I'm afraid.
posted by shelleycat at 3:50 PM on April 5, 2009 [2 favorites]

I saw exactly what footnote quotes above happen to my mother, who died of breast cancer. Ensure, oral yeast infection, no appetite, dehydration, the lot. Also morphine suppresses appetite - cancer sufferers in pain get a lot of morphine if they need it.

My father was very troubled for a long time by the sorts of concerns you express. Could we have got her to eat more? If she had eaten, would she have had more time? Did she suffer from thirst? And so on. The doctors and nurses had seen this all before many times, but their reassurances were not sufficiently concrete to make him feel better.

I think part of the issue is that if we say "loss of appetite", that implies that all we need to do is forcefeed or otherwise get more calories into the dying person. We start asking "why did she lose her appetite? can we fix that?" But the "loss of appetite" is not like what you or I feel when we are off our food. They don't want to eat, eating is painful, eating is pointless.

I realise you asked for a physiological explanation, but I recognise in your question a concern that haunts my Dad and bothers me, about whether we could or should have done more to feed a dying person. It is good to let that concern go. The fact that our medical advisors can't coherently explain why this phenomenon happens doesn't take away from the fact that it DOES happen, and there isn't anything we can do about it.
posted by i_am_joe's_spleen at 4:00 PM on April 5, 2009 [1 favorite]

I think part of the issue is that if we say "loss of appetite", that implies that all we need to do is forcefeed or otherwise get more calories into the dying person.

Also when loss of appetite is coupled with cachexia (which is a given in terminal cancer) then feeding more food still doesn't help. The body's metabolism has literally changed, it is now incapable of using outside nutrients as it once did and literally uses itself up instead. The cancer is greedy, it leaves nothing left for the rest of the body while messing the body up so that it can't take care of itself.
posted by shelleycat at 4:08 PM on April 5, 2009

Shelleycat has mostly covered this, but here goes: this phenomenon is seen often in people with advanced cancer and is called cachexia. The predominant mediators, as far as it is understood, are cytokines, secreted proteins including interleukins 1 and 6 and tumor necrosis factor alpha, produced by inflamed or injured tissues and by responding elements of the immune system.

These cytokines have local effects, ramping up the function the immune system at the site of injury, but they also diffuse out into the bloodstream and have systemic effects, reprioritizing the body's function towards resolving the infection rather than taking care of homeostatic functions. Systemic sites of action include the muscle tissue, resulting in muscle wasting, and the central nervous system, causing the loss of appetite and development of fever. This is why having the flu feels so shitty: the fever, aches, and loss of appetite are caused your body's response to the infection, not the infection itself.

In short-term infections this is a good trade-off: you spend a few days with low energy and fever, but the disease is eliminated more quickly. With a persistent and severe inflammatory load, like you'd get with your father's cancer, you are essentially trapped in a condition equivalent to the peak of the nastiest flu that you've ever had. Treatments directed at controlling the immune system and stimulating appetite can be used to try to moderate the symptoms, and parenteral nutrition can help by shunting large quantities of nutritional energy past the digestive system, but the only definitive treatment is correcting the underlying problem, something that is sadly not possible with many cases of cancer.

There is a good review of the science of cachexia here which covers some additional hormonal systems which may be important in generating the syndrome.
posted by monocyte at 4:14 PM on April 5, 2009 [4 favorites]

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