Cachexia (wasting syndrome) in cancer patients: What to know

Losing weight when you’re not trying to can be frustrating. But it may also be cause for concern.

Cachexia, sometimes called wasting syndrome, is a syndrome characterized by unintentional weight loss and a significant loss of muscle. It could be a sign of cancer or a side effect of cancer treatment. Or, it could be caused by other health conditions. The sooner cachexia in cancer patients is diagnosed and treated, the better their chance to maintain or gain weight and improve their physical function and quality of life.

Here, I’ll explain more about cachexia, including who it affects, how it’s treated and why early intervention is important.

What is cachexia?

Cachexia is more than just unintentional weight loss. It also includes severe skeletal muscle wasting, which is the progressive breakdown of your muscle tissue that controls movement and strength. As cachexia progresses, it causes your body to become extremely weak and decline in function.

What health conditions cause cachexia?

Cachexia can be caused by several health conditions, including:

• Cancer
• Congestive heart failure
• Chronic kidney disease
• Infectious diseases, such as AIDS

What causes cancer cachexia?

The term “cancer cachexia” refers to cachexia that is associated with cancer. It is typically characterized by unintentional weight loss as well as a significant loss of muscle and fat.

Cancer patients often take in fewer calories, either due to treatment side effects or the disease itself. For example, radiation to the head and neck can cause mucositis, which makes swallowing food painful. Chemotherapy can often cause nausea or appetite changes. Depression and anxiety can also play a part because when you have emotional and psychological distress, the gut tends to shut down. And sometimes when you’re fatigued, you just don’t feel like eating.

In addition, cancer increases your metabolism because your body requires more energy to fight off cancer. So, your body’s need for more energy when you’re taking in fewer nutrients can lead to a loss of weight, muscle and fat.

Cachexia is fairly common in cancer patients, most often in those with advanced-stage disease. Patients who are cachectic tend to have worse treatment outcomes.

In a survey of cancer patients in UT MD Anderson’s Supportive Care Clinic, about 50% to 60% were classified as cachectic. For patients with pancreatic cancer, colorectal cancer and lung cancer, that number is close to 80%. We tend to see varying degrees of cachexia, depending on the underlying cancer type.

For example, sarcopenia, the gradual loss of strength and muscle mass without fat loss, is seen more often in patients with breast cancer and prostate cancer.

What are the stages of cachexia?

Clinicians classify cachexia into three stages.

Pre-cachexia

In this stage, you have unintentional weight loss that is less than 5% of your body weight. Your symptoms may include a loss of appetite and metabolic changes like inflammation.

It’s best to catch cachexia in this stage before it progresses. It may be easier to intervene and prevent weight loss.

Cachexia

In this stage, you have either lost:

• More than 5% of your body weight over the past 6 to 12 months, or
• More than 2% of your body weight with a Body Mass Index (BMI) less than 20

Symptoms include loss of muscle, strength and appetite.

Refractory cachexia

This is the most severe stage of cachexia, with a loss of more than 15% of your body weight. At this stage, skeletal muscle wasting is severe and often irreversible, particularly in patients whose cancers are no longer responding to treatment.

Symptoms include extreme loss of weight and muscle mass, as well as functional decline.   

How is cachexia diagnosed?

Diagnosing cachexia is important, specifically in its earliest stage, when treatment is most effective.

That’s why it’s so important for clinicians to document patients’ weight, changes in weight and body composition.

When someone is diagnosed with cancer, these things are documented regularly. With cancer patients, I recommend monitoring their weight at least every three months. In the research setting, clinicians are studying the use of body composition assessment tools to calculate muscle mass. There is research that shows these assessments are better predictors of survival.

At UT MD Anderson, we’ve also started initiatives to document malnutrition risk, which is broader than just cachexia. Malnutrition risk describes a person who may be getting enough nutrients but doesn’t get enough of certain vitamins or essential minerals. This can also play a part in overall health.

How is cachexia treated?

At UT MD Anderson, we focus on treating and managing the symptoms of cachexia. Treatment usually includes a combination of the following:

• Medication: Doctors can prescribe medicine to help with appetite stimulation and weight gain.
• Healthy diet: Everybody should aim for a healthy diet that includes plenty of fruits, vegetables, whole grains and protein. It’s crucial for cancer patients to get enough protein because protein helps build muscle mass. If you’re a UT MD Anderson patient, ask for a referral to one of our dietitians, who can share tips to help you get more protein during treatment.
• Exercise: Exercise – particularly resistance-based activity – can help slow muscle wasting and preserve skeletal muscle mass during treatment. Try activities like strength training using resistance bands, water aerobics or tai chi. Aim for 30 minutes of light exercise per day, three times a week. If 30 minutes is too difficult, break it down into three 10-minute sessions. Any exercise done regularly can be beneficial. It also helps with other cancer treatment side effects like fatigue and neuropathy.
• Supportive care: Our Supportive Care Center can offer physical and emotional support to patients and caregivers. If you’re a patient at UT MD Anderson, ask your care team for a referral.

What is the prognosis of someone with cachexia?

Early intervention is key when it comes to cachexia. If your cancer treatment is working to control the cancer, we will work with you to start increasing your weight and muscle mass. Our goal is for you to at least maintain your weight and function.

Once cachexia reaches the refractory stage, it usually signals that you are very sick. If you are not responding to treatment, we can provide psychosocial support and counseling to you and your caregiver.

What research is being done to help treat cancer cachexia?

New research shows promise for some patients with refractory cachexia. A Phase 2 clinical trial studied the efficacy of the monoclonal antibody ponsegromab in patients with advanced cancer, cachexia and elevated levels of GDF15, a protein that helps regulate food intake, body weight and stress responses.

Results showed that patients who received ponsegromab had improvements in their weight, appetite and physical activity. A Phase 3 clinical trial is currently underway to study the efficacy of ponsegromab in patients who have cachexia and metastatic pancreatic cancer.

The vagus nerve sends signals between the brain and gut, and it helps regulate appetite. At UT MD Anderson, gastrointestinal medical oncologist Xiling Shen, Ph.D., and colleagues conducted research that suggests that targeting the vagus nerve with a non-invasive device could delay the onset of cachexia or prevent it altogether.  

What else should patients and caregivers know about cachexia?

The timeframes associated with cachexia stages don’t always tell the whole story. What happens a lot, unfortunately, is that people are diagnosed with cancer two years or so after unintentionally losing weight. We see this the most with colorectal cancer and pancreatic cancer, where people have unintentional weight loss two years before they are diagnosed. Unintentional weight loss should always be a red flag that something may be going on in your body. So, see your doctor if you experience this. This may allow them to catch a potentially serious health condition sooner.

Caring for a cachectic loved one can be distressing. It’s natural to want to feed and provide nourishment to your loved one with cancer, and you may become frustrated when the patient doesn’t want to – or simply cannot – eat.

If your loved one has cachexia, I encourage you to reach out to their care team. They can help provide support to you both.

Rony Dev, D.O., is an internal medicine and palliative care specialist at UT MD Anderson.

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