Appetite Loss in Patients with Advanced Cancer Treated at an Acute Palliative Care Unit

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Critique

This was a secondary analysis of collected symptoms scores during hospitalization in an acute Palliative Care unit.  This was a subset of patients (167/451 admissions).  The primary purpose was to study the change of appetite during hospitalization.  Assessments were made with the Edmonton Symptom Assessment Scale at admission and at the time of discharge.  Missing data was pair wise deletion if assessment did not occur at discharge but during hospitalization a last observation carried forward which was used.  This is an inadequate method of measuring missing data.  The last observation carried forward has a bias.¹

Of the 167 patient is 62% had anorexia which was associated with nausea fatigue depression anxiety dyspnea.  63% had improvement of appetite with hydration and characteristically lived alone.

This appears to be a select group in a retrospective study.  Most patients were likely admitted with reduced appetite and likely by family members since family members are more likely to be concerned about anorexia then patients.

The timeframe of assessment from the first assessment of the second has not been well characterized.

Appetite is associated with early satiety dysgeusia hypoglycemia diurnal variations in appetite smell changes constipation nausea and bloating.  Only a few of the symptoms were assessed.

The authors do discuss in a sentence or 2 the association of appetite and thirst.  I think this is an important part of this paper.  75% of fluid intake during the day occurs in the peri prandial period of time.  There is a close association between hunger and thirst both derived from mesocolon big neurons which have dopamine receptors.^2,3

On page 8 lying 198 the authors state that if anorexia is present “early recognition of appetite loss” would encourage “prevention” does not make sense.  If anorexia is already present then it can not be prevented.

There are multiple interventions occurring during hospitalizations on a Palliative Care unit so improvement of symptoms due to one therapy is difficult to prove.  Association are not causation.

Corticosteroids accelerate muscle loss and sarcopenia and accept in the those with a short term survival steroids should not be used due to their transient benefit.

Hydration improved anorexia but the distribution of hydration may separate those with cachexia and short-term survival versus those who are simply dehydrated.  Paradoxically an increase in phase angle during hydration reflects cachexia and reduced cellular membrane function and shortened survival.⁴

1.           Davis MP. Missing Data and the Last Observation Carried Forward. J Pain Symptom Manage. 2024;67(6):e921-e922.

2.           McKiernan F, Houchins JA, Mattes RD. Relationships between human thirst, hunger, drinking, and feeding. Physiol Behav. 2008;94(5):700-708.

3.           Tan B, Nobauer T, Browne CJ, Nestler EJ, Vaziri A, Friedman JM. Dynamic processing of hunger and thirst by common mesolimbic neural ensembles. Proc Natl Acad Sci U S A. 2022;119(43):e2211688119.

4.           Davis MP, Yavuzsen T, Khoshknabi D, et al. Bioelectrical impedance phase angle changes during hydration and prognosis in advanced cancer. Am J Hosp Palliat Care. 2009;26(3):180-187.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the possibility to read and review your interesting manuscript on appetite loss. The topic is very important as many palliative patients suffer from appetite loss.

I have the following comments that need to be addressed in a revised manuscript:

1)        The reasons for inclusion of patients must be included in the manuscript. It is not enough to recommend to read another paper.

2)        I miss a in depth discussion of the contribution of social, existential or psychological factors

The description of methods, results and discussion are appropriate. 

I recommend acceptance after minor revision. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf