BMJ Clinical Review: Clinical Oncology

by Babita Joyti, Micahel Karvelis

Overview

This volume covers a range topics in the management and treatment of cancer. Subjects dealt with include; identifying brain tumours in children and young adults, prostate cancer screening and the management, the changing epidemiology of lung cancer with a focus on screening using low dose computed tomography, the control of clinically localized disease, the management of women at high risk of breast cancer, head and neck cancer with reference to epidemiology, presentation, prevention, treatment and prognostic factors, malignant and premalignant lesions of the penis, melanoma and advances in radiotherapy.

Product Details

ISBN-13:	9781472739322
Publisher:	Bpp Learning Media Ltd (Medical)
Publication date:	08/30/2015
Series:	BMJ Clinical Review Series
Pages:	180
Product dimensions:	6.00(w) x 1.25(h) x 9.00(d)

Read an Excerpt

BMJ Clinical Review Clinical Oncology

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By Babita Jyoti, Eleftheria Kleidi

BPP Learning Media Ltd

Copyright © 2015 BPP Learning Media Ltd
All rights reserved.
ISBN: 978-1-4727-3932-2

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CHAPTER 1

Investigation and management of unintentional weight loss in older adults

Jenna McMinn foundation year 2, medicine, Claire Steel specialist trainee year 6 in medicine for the elderly, Adam Bowman consultant physician

Unintentional weight loss occurs in 15-20% of older adults (those over 65) and is associated with increased morbidity and mortality. Clinical and epidemiological studies have reported even higher prevalence in certain populations, with as many as 27% of community dwelling elderly people and 50-60% of nursing home residents being affected.

Weight loss may be the presenting problem or an incidental finding during a consultation for other reasons. There are no published guidelines on how to investigate and manage patients with unintentional weight loss, and responses range from doing nothing (if it is viewed as a normal part of the ageing process) to extensive blind investigation because of the fear that it represents underlying cancer. Observational studies have shown that in as many as 25% of cases no identifiable cause is found, despite extensive investigation. It is not clear how far clinicians should go to investigate older patients with unintentional weight loss in the absence of an obvious medical cause.

We review the available evidence (mainly epidemiological and observational studies) and outline a structured approach to investigation and management of the older patient with unintentional weight loss.

When is unintentional weight loss clinically important?

Age related physiological changes occur in elderly people and contribute to the so called "anorexia of ageing." These include a reduction in lean body mass, bone mass, and basal metabolic rate; reduced sense of taste and smell; and altered gastric signals leading to early satiation. However, observational studies of healthy older adults report this normal age related weight loss to be only 0.1-0.2 kg a year, and most elderly patients maintain weight over a reasonably long period of 5-10 years. Substantial weight loss should not be dismissed as natural age related change and should be investigated.

Although no universally accepted definition of clinically important weight loss exists, most observational studies define it as a 5% or more reduction in body weight over 6-12 months. To take into account the variability of baseline weight, weight loss is best expressed as a percentage rather than an absolute value; a loss of 2-3 kg is less important in a 90 kg patient than in a frail elderly patient who is underweight already.

Reported mortality within 1-2.5 years of clinically important weight loss ranges from 9% to 38%, and those particularly at risk include frail elderly people, those with low baseline body weight, and elderly patients recently admitted to hospital.

Substantial weight loss has been shown to be associated with an increased risk of in-hospital and disease related complications, increased disability and dependency, higher rates of admission to residential home or nursing home, and poorer quality of life. At the extreme, cachexia (the disproportional loss of skeletal muscle rather than body fat, which leads to skeletal and cardiac muscle wasting, loss of visceral protein, and alterations in physiological functions including impaired immunity and a systemic inflammatory response) contributes to adverse outcomes through increased rates of infection, poor wound healing, pressure sores, reduced response to medical treatment, and increased risk of mortality.

Weight loss in elderly people significantly increases the rate of hip bone loss and the risk of hip fracture. In a prospective cohort study of 6785 elderly women, weight loss — both intentional and unintentional — of 5% or more from baseline weight (regardless of whether baseline weight was low or normal) almost doubled the risk of subsequent hip fracture (odds ratio 1.8, 95% confidence interval 1.43 to 2.24) compared with those with stable or increasing weight.

What can cause unintentional weight loss in older adults?

Although involuntary weight loss in younger adults often has a medical cause, in older patients causes are more diverse, with psychiatric and socioeconomic factors playing an important part.

Prospective and retrospective studies from Germany, Belgium, Israel, the United States, and Spain have looked at patients who were investigated for involuntary weight loss to determine the common causes and their relative frequency (table 1). The studies varied considerably in terms of country, age of patients (most were not confined to the elderly), length of follow-up, and the type of patients recruited. However, cancer, non-malignant gastrointestinal disease, and psychiatric problems (particularly dementia and depression) were consistently among the most common causes of unintentional weight loss).

Several aids have been devised to enable doctors to consider the many possible causes of unintentional weight loss in older patients. These include the "9 Ds of weight loss in the elderly" and "meals on wheels" mnemonics (box 1). Our approach is to group the possible causes of weight loss into organic (malignant and non-malignant), psychosocial, and unknown causes.

Organic causes

Organic causes of weight loss include cancer, non-malignant medical disorders, and side effects of drugs (table 2).

Psychosocial

Published observational studies (summarised in table 1) report that psychiatric problems, particularly dementia and depression, are the main cause of unexplained weight loss in 10-20% of elderly patients. This figure rises to 58% in nursing home residents.

Cognitive impairment

Patients with cognitive impairment who are agitated or have a tendency to "wander" can expend substantial energy. Others may forget that they have to eat or become suspicious and paranoid about food. Self feeding skills are lost with the progression of Alzheimer's disease and dysphagia may develop.

Depression

Depression can lead to weight loss because of loss of appetite or reduced motivation to buy and prepare food. Depression is more commonly associated with weight loss in elderly people than in younger adults, and it was associated with increased mortality in a systematic review of elderly patients (>65 years) living in the community (estimated odds ratio for mortality with depression of 1.73, 1.53 to 1.95).

Reported rates of depression in the community vary dramatically according to a systematic review of 34 community based studies of the prevalence of depression in later life (>55 years), but they can be as high as 35%, depending on the criteria used to define depression. Even higher prevalences have been reported in institutionalised elderly patients

Socioeconomic factors

Poverty or social isolation may contribute to weight loss in elderly people through inadequate food intake and malnutrition. Physical or cognitive impairment may prevent elderly people from shopping for themselves and may reduce the availability of preferred foods. Inability to cook or feed themselves may further contribute to insufficient food intake because they may rely on family members or carers, who may visit at erratic times.

Unknown

The cause of weight loss remained unknown in 16-28% of patients in published prospective and retrospective observational studies, despite extensive investigation over periods ranging from six months to three years. This may be because elderly patients often have multiple comorbidities rather than one serious illness, are on multiple drugs, and may have psychological or social problems. Each individual factor might not be sufficient to cause substantial weight loss, but the cumulative effect of all the factors might result in clinically important weight loss.

All studies that have assessed prognosis in elderly patients with unintentional weight loss have found that patients who fall into this category of "unknown cause" have a much better prognosis than those diagnosed with cancer, and no worse than that of patients diagnosed with non-malignant causes. Cancers diagnosed in the setting of involuntary weight loss usually have a poor prognosis because they are often advanced by the time weight loss becomes apparent.

How is unintentional weight loss in older adults investigated?

We present our approach to investigation, which is based on an extensive literature review (fig 1. We know of no clinical guidelines or standardised system for investigating this common and complex problem.

Initial evaluation of the patient involves a detailed history, clinical examination, and baseline investigations. The findings should be used to guide further investigation.

History

Try to establish the exact amount of weight loss over a specified time. Questions about appetite may help elucidate whether the weight loss is caused by inadequate energy intake or has occurred despite an adequate intake. A corroborative history from relatives or carers may help in patients with cognitive impairment.

Previous and current medical history may identify conditions that could have led to weight loss (see table 2) and drugs that may contribute via their side effects.

Social history may elicit information on alcohol intake (which might contribute to malnutrition or vitamin deficiency) and smoking (a risk factor for cancer and other organic diseases). It is important to elucidate the patient's social circumstances. Who does he or she live with? Who buys and prepares the food? Is there any home help or help from family members?

A history that includes a review of systems may elicit additional symptoms that might direct further investigation.

In addition, screen all patients for cognitive impairment and depression using standardised assessment tools.

Some authors recommend a nutritional assessment only when no evidence of organic disease is found. We believe, however, that all elderly patients presenting with unintentional weight loss should undergo nutritional assessment by a dietitian. This is because malnutrition has a high prevalence in elderly people and might still be present even when an organic cause of the weight loss is found.

We suggest that patients seen in primary care (by general practitioners) — where facilities (and time) for assessing cognitive function, mood, and nutritional status are not always readily available — should be referred to specialists in the care of older people.

Physical examination

In patients with unintentional weight loss a full physical examination should aim to exclude major cardiovascular and respiratory illnesses, as well as abdominal masses, organomegaly, prostate enlargement, and breast masses that may indicate cancer. Palpable lymphadenopathy could indicate infection, cancer, or haematological disease. Examine the mouth to exclude any obvious dental problems, poor oral hygiene, dry mouth, or lesions that may make chewing and swallowing difficult or painful.

Baseline investigations

Baseline investigations for all patients should include bloods tests (full blood count, urea and electrolytes, liver function tests, thyroid function tests, C reactive protein, glucose, and lactate dehydrogenase), chest radiography, urinalysis, and faecal occult blood testing. The rationale behind these baseline tests is explained in box 2.

Tumour markers are not useful diagnostic tests; they should not be used as part of the initial evaluation and may be misleading. Their role is in monitoring response to treatment in patients with cancer or detecting tumour recurrence early after treatment. Abnormal findings on initial evaluation should be used to guide further investigations into the cause of the weight loss.

If the history, examination, and baseline investigations are all normal, published evidence suggests that further investigation is not warranted immediately and that three months' "watchful waiting" is advisable, rather than a blind pursuit of additional, more invasive or expensive investigations. Because organic disease is found only rarely in patients with normal results from physical examination and laboratory tests, this waiting period is unlikely to have an adverse outcome.

Although three scoring systems have been developed to help clinicians identify which patients with weight loss are likely to have a physical or malignant cause rather than a psychological or social cause, none of these has been validated in independent populations presenting with weight loss.

Should a negative baseline reassure?

The claim that a negative baseline evaluation should reassure the clinician of the lack of serious underlying disease is based on only small non-randomised studies. Most of these are also not limited to elderly patients (in the UK defined as >70 years of age). However, most authors agree that in elderly patients with clinically relevant unintentional weight loss, major organic (and especially malignant) diseases are highly unlikely when a thorough baseline evaluation is normal, and that in this setting a watchful waiting approach may be preferable to undirected and invasive testing.

There is currently no evidence that blind computed tomography scanning is helpful in investigating such patients. Disadvantages of blind computed tomography scanning include high costs (with low yield) and the likelihood of finding "incidental-omas."

Several studies have used abdominal ultrasound as part of their initial evaluation, although they did not comment on its usefulness in this role, noting only that 27% of patients with underlying cancer had hepatomegaly on examination and a similar percentage had palpable masses. Abnormal findings on examination (or abnormal liver function tests) would have prompted further investigation anyway.

Gastrointestinal disorders (malignant and non-malignant) account for about a third of all causes of unexplained weight loss in studies of adults of all ages, so some authors advocate upper gastrointestinal endoscopy in patients as a first line investigation. However, because endoscopy is invasive and not without risk (particularly for elderly patients), we think that it should be reserved for patients in whom it is indicated on the basis of history, examination, or baseline investigations (such as a history of gastrointestinal bleeding or evidence of iron deficiency anaemia).

In one study where patients with a normal baseline evaluation underwent further investigations including computed tomography and endoscopy, only one additional diagnosis was made (a patient diagnosed with lactose intolerance).

Managing unexplained weight loss in elderly people

The primary principle of management is to identify and treat any underlying causes. Optimal management often requires multidisciplinary assessment (doctors, dentists, dietitians, speech therapists, physiotherapists, occupational therapists, social services). We strongly suggest reviewing drugs in an attempt to eliminate those whose side effects may contribute to weight loss.

If a psychiatric cause of weight loss, such as depression, is suspected we recommend assessment by a psychogeriatrician or psychologist. In such cases, consider treatment with an antidepressant because depression is a potentially reversible cause of weight loss.

If the initial baseline evaluation is negative, we suggest that patients are reassessed after three months to establish if any further symptoms or signs have developed and to check their weight. In the interim, because evidence to support any drug treatment is lacking, a variety of non-drug based interventions can be used (outlined in box 3).

(Continues...)

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Excerpted from BMJ Clinical Review Clinical Oncology by Babita Jyoti, Eleftheria Kleidi. Copyright © 2015 BPP Learning Media Ltd. Excerpted by permission of BPP Learning Media Ltd.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Contents

About the publisher,
About the BMJ,
About the editors,
Introduction to Clinical Oncology,
Investigation and management of unintentional weight loss in older adults Jenna McMinn, Claire Steel, Adam Bowman,
The changing epidemiology of lung cancer with a focus on screening Gerard A Silvestri, Anthony J Alberg, James Ravenel,
Screening for lung cancer using low dose computed tomography Martin C Tammemagi, Stephen Lam,
Serum tumour markers: how to order and interpret them C M Sturgeon, L C Lai, M J Duffy,
Testicular germ cell tumours Alan Horwich, David Nicol, Robert Huddart,
Identifying brain tumours in children and young adults S H Wilne, R A Dineen, R M Dommett, T P C Chu, D A Walker,
Head and neck cancer — Part 1: Epidemiology, presentation, and prevention H Mehanna, V Paleri, C M L West, C Nutting,
Head and neck cancer — Part 2: Treatment and prognostic factors H Mehanna, C M L West, C Nutting, V Paleri,
Low risk papillary thyroid cancer Juan P Brito, Ian D Hay, John C Morris,,
Oesophageal cancer Jesper Lagergren, Pernilla Lagergren,
The diagnosis and management of gastric cancer Sri G Thrumurthy, M Asif Chaudryo, Daniel Hochhauser, Kathleen Ferrier, Muntzer Mughal,
Ductal carcinoma in situ of the breast Nicola L P Barnes, Jane L Ooi, John R Yarnold, Nigel J Bundred,
Management of breast cancer — Part I Nicholas C Turner, Alison L Jones,
An update on the medical management of breast cancer Belinda Yeo, Nicholas C Turner, Alison Jones,
Management of women at high risk of breast cancer Anne C Armstrong, Gareth D Evans,
Gynaecomastia and breast cancer in men Catherine B Niewoehner, Anna E Schorer,
Pancreatic adenocarcinoma Giles Bond-Smith, Neal Banga, Toby M Hammond, Charles J Imber,
Hepatocellular carcinoma for the non-specialist T Kumagi, Y Hiasa lecturer, G M Hirsch,
Diagnosis and management of anal intraepithelial neoplasia and anal cancer J A D Simpson, J H Scholefield,
Endometrial cancer Srdjan Saso, Jayanta Chatterjee, Ektoras Georgiou, Anthony M Ditri, J Richard Smith, Sadaf Ghaem-Maghami,
Prostate cancer screening and the management of clinically localized disease Timothy J Wilt, Hashim U Ahmed,
Malignant and premalignant lesions of the penis Manit Arya, Jas Kalsi, John Kelly, Asif Muneer,
Melanoma — Part 2: management Christina Thirlwell, Paul Nathan,
Diagnosis and management of soft tissue sarcoma Shiba Sinha, Howard S Peach,
Preservation of fertility in adults and children diagnosed with cancer Roger Hart,
Cancer induced bone pain Christopher M Kane, Peter Hoskin, Michael I Bennett,
Advances in radiotherapy Saif S Ahmad, Simon Duke, Rajesh Jena, Michael V Williams, Neil G Burnet,