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Another cause of cachexia
Vol. 4.No. 2 June 1989
Letters
Journal
of Pain and Symptom Management
57
Letters
Another Cause of Cachex~ To the Editor: I think it is appropriate to comment on the article of Bruera and MacDonald concerning nutrition in cancer patients (j Pain Symptom Manage 1988;3: 133- 140). I find it disconcerting that the authors give no attention to the role of pain with respect to the inanition and cachexia that cancer patients develop. Certainly, the influence of the pain itself, and clearly the effect on appetite of analgesic agents that suffering patients take, produce major effects on the metabolic system and on food consumption. In the days when cordotomies were being done regularly, and pain relief could be effected without metabolic depression by drugs or adjuvant treatments, it was a common experience to see relief of pain be accompanied by sudden weight gain and the feeling of wellness that such pain relief can afford. Weight gains of as much as 40 lb in a month have been seen. You have written an article for those of us who deal with pain regularly, and not to address the pain issue is to be decried. I wonder why the reviewers did not point this out to the authors for their consideration. Hubert L. Rosomoff, MD Professor and Chairman, Department of Neurological Surgery University of Miami School of Medicine Miami, Florida
Lb-. Bruma Replies To the Editor: Dr. Rosomoff makes an interesting comment about the association between pain and malnutrition. As Dr. Rosomoff himself recognizes, the association between pain, narcotic analge0 U.S. Cancer Pain Relief Committee, 1989 Published by Elsevier, New York, New York
sits, adjuvant agents and cachexia is an extremely complex one. Perhaps it is for this reason that our review and others have not found good research papers addressing this interaction. In three randomized, controlled blind trials conducted by our group, improved pain control was not associated with increased food intake.le3 While it is true that our patients were treated with drugs and not with neurosurgical procedures, it is also true that neurosurgical procedures are only indicated in a minority of cancer patients. Dr. Rosomoff makes reference to significant weight gain in a short period of time after cordotomy. Although our experience with this technique is very limited, we have not made similar observations, and a recent compehensive review on percutaneous cordotomy does not make any reference to weight gain as a consequence of the procedure.4 Cachexia and pain are frequently present in the same population. This association needs to be explored in prospective clinical trials. However, at the present time, knowledge is very limited, and we preferred not to address it in a review on malnutrition. Eduardo Bruera, MD Clinical Director, Palliative Care Unit Edmonton General Hospital Edmonton, Alberta, Canada References 1. Bruera E, Brenneis C, Chadwick S, et al. Methylphenidate associated with narcotics for the treatment of cancer pain. Cancer Treat Rep 1987;71:127-132. 2. Bruera E, Carraro S, Rota E. Double blind evaluation of the effects of mazindol on pain, depression, anxiety, appetite and activity in terminal cancer patients. Cancer Treat Rep 1986;70:751-756. 3. Bruera E, Rota E, Cedar0 L. Action of oral methylprednisolone in terminal cancer patinets: a prospective randomized double blind study. Cancer Treat Rep 1985;69:751-755.
Letters
Journal
of Pain and Symptom Management
57
Letters
Another Cause of Cachex~ To the Editor: I think it is appropriate to comment on the article of Bruera and MacDonald concerning nutrition in cancer patients (j Pain Symptom Manage 1988;3: 133- 140). I find it disconcerting that the authors give no attention to the role of pain with respect to the inanition and cachexia that cancer patients develop. Certainly, the influence of the pain itself, and clearly the effect on appetite of analgesic agents that suffering patients take, produce major effects on the metabolic system and on food consumption. In the days when cordotomies were being done regularly, and pain relief could be effected without metabolic depression by drugs or adjuvant treatments, it was a common experience to see relief of pain be accompanied by sudden weight gain and the feeling of wellness that such pain relief can afford. Weight gains of as much as 40 lb in a month have been seen. You have written an article for those of us who deal with pain regularly, and not to address the pain issue is to be decried. I wonder why the reviewers did not point this out to the authors for their consideration. Hubert L. Rosomoff, MD Professor and Chairman, Department of Neurological Surgery University of Miami School of Medicine Miami, Florida
Lb-. Bruma Replies To the Editor: Dr. Rosomoff makes an interesting comment about the association between pain and malnutrition. As Dr. Rosomoff himself recognizes, the association between pain, narcotic analge0 U.S. Cancer Pain Relief Committee, 1989 Published by Elsevier, New York, New York
sits, adjuvant agents and cachexia is an extremely complex one. Perhaps it is for this reason that our review and others have not found good research papers addressing this interaction. In three randomized, controlled blind trials conducted by our group, improved pain control was not associated with increased food intake.le3 While it is true that our patients were treated with drugs and not with neurosurgical procedures, it is also true that neurosurgical procedures are only indicated in a minority of cancer patients. Dr. Rosomoff makes reference to significant weight gain in a short period of time after cordotomy. Although our experience with this technique is very limited, we have not made similar observations, and a recent compehensive review on percutaneous cordotomy does not make any reference to weight gain as a consequence of the procedure.4 Cachexia and pain are frequently present in the same population. This association needs to be explored in prospective clinical trials. However, at the present time, knowledge is very limited, and we preferred not to address it in a review on malnutrition. Eduardo Bruera, MD Clinical Director, Palliative Care Unit Edmonton General Hospital Edmonton, Alberta, Canada References 1. Bruera E, Brenneis C, Chadwick S, et al. Methylphenidate associated with narcotics for the treatment of cancer pain. Cancer Treat Rep 1987;71:127-132. 2. Bruera E, Carraro S, Rota E. Double blind evaluation of the effects of mazindol on pain, depression, anxiety, appetite and activity in terminal cancer patients. Cancer Treat Rep 1986;70:751-756. 3. Bruera E, Rota E, Cedar0 L. Action of oral methylprednisolone in terminal cancer patinets: a prospective randomized double blind study. Cancer Treat Rep 1985;69:751-755.