Good nutrition is important for people with cancer.

Nutrition is a process in which food is taken in and used by the body for growth, to keep the body healthy, and to replace tissue. Good nutrition is important for good health. A healthy diet includes foods and liquids that have important nutrients (vitamins, minerals, proteins, carbohydrates, fats, and water) the body needs.

Nutrition goals are set for each person with cancer.

Nutrition goals during cancer therapy are based on a person’s cancer type, cancer stage, and other medical conditions. Eating the right amount of protein and calories is important for healing, fighting infection, and having enough energy.

A registered dietitian is an important part of the healthcare team.

A registered dietitian (or nutritionist) is a part of the team of health professionals that help with cancer treatment and recovery. A dietitian will work with you, your family, and the rest of the medical team to manage your diet during and after cancer treatment.

Cancer and cancer treatments may cause side effects that affect nutrition.

Nutrition problems are likely when tumors involve the head, neck, esophagus, stomach, intestines, pancreas, or liver.

For many people, the effects of cancer treatments make it hard to eat well. Cancer treatments that affect nutrition include:

Cancer and cancer treatments may cause malnutrition.

Cancer and cancer treatments may affect taste, smell, appetite, and the ability to eat enough food or absorb the nutrients from food. This can cause malnutrition, which is a condition caused by a lack of key nutrients.

Malnutrition can cause a person to be weak, tired, and unable to fight infection or finish cancer treatment. As a result, malnutrition can decrease the person’s quality of life and become life-threatening. Malnutrition may get worse if the cancer grows or spreads.

Anorexia and cachexia are common causes of malnutrition in people with cancer.

Anorexia is the loss of appetite or desire to eat. It is a common symptom and the most common cause of malnutrition in people with cancer. Anorexia may occur early in the disease or later, if the cancer grows or spreads. Some people already have anorexia when they are diagnosed with cancer. Most people who have advanced cancer will have anorexia.

Cachexia is a condition marked by weakness, weight loss, and fat and muscle loss. It is common in people with tumors that affect eating and digestion. It can occur in people with cancer who are eating well, but are not storing fat and muscle because of tumor growth.

Some tumors change the way the body uses certain nutrients. The body’s use of protein, carbohydrates, and fat may change when tumors are in the stomach, intestines, or head and neck. A person may seem to be eating enough, but the body may not be able to absorb all the nutrients from the food.

People with cancer may have cachexia and anorexia at the same time (CAS), causing weight loss and decreased lean body mass. Treating high-risk patients to prevent this condition, rather than treating those already diagnosed with CAS, may lead to better outcomes. Olanzapine, a drug used to treat certain mental disorders, has side effects including increased appetite and weight gain. It is being studied in the treatment of CAS with mixed success. More clinical trials are needed to develop the best possible therapies for CAS.

Chemotherapy and Hormone Therapy

Radiation Therapy

Surgery

Immunotherapy

Stem Cell Transplant

The healthcare team may ask questions about diet and weight history.

Screening is used to look for health problems that affect the risk of poor nutrition. This can help find out if you are likely to become malnourished, and if nutrition therapy is needed.

The healthcare team may ask questions about the following:

A physical exam is done. Your doctor will check for signs of weight, fat, and muscle loss, and for fluid buildup in your body.

Counseling and diet changes are made to improve the person’s nutrition.

A registered dietitian can counsel you and your family on ways to improve your nutrition. The registered dietitian gives care based on your nutritional and dietary needs during cancer treatment and recovery. Changes to the diet are made to help decrease symptoms from cancer or cancer treatment. These changes may be in the types and amount of food, how often you eat, and how food is eaten (for example, at a certain temperature or taken with a straw).

In addition to the dietitian, the healthcare team may include the following:

The goal of nutrition therapy for people who have advanced cancer depends on the overall plan of care.

The goal of nutrition therapy in people with advanced cancer is to provide the best possible quality of life and control symptoms that cause distress.

People with advanced cancer may be treated with anticancer therapy and palliative care, palliative care alone, or may be in hospice care. Nutrition goals will be different for each person. Some types of treatment may be stopped.

As the focus of care goes from cancer treatment to hospice or end-of-life care, nutrition therapy may become less aggressive to keep the person as comfortable as possible. For more information, see the Nutrition Needs at End of Life section.

Anorexia

The following may help people with cancer who have anorexia (loss of appetite or desire to eat):

If these diet changes do not help with the anorexia, tube feedings may be needed.

Medicines may be given to increase appetite. For more information, see the Medicines to Treat Loss of Appetite and Weight Loss section.

Nausea

The following may help people with cancer control nausea:

Vomiting

The following may help people with cancer control vomiting:

Dry Mouth

The following may help people with cancer who have dry mouth:

Mouth Sores

The following can help people with cancer who have mouth sores:

Taste Changes

The following may help people with cancer who have taste changes:

Sore Throat and Trouble Swallowing

The following may help people with cancer who have a sore throat or trouble swallowing:

Lactose Intolerance

The following may help people with cancer who have symptoms of lactose intolerance:

Weight Gain

The following may help people with cancer prevent weight gain:

Nutrition support helps people who cannot eat or digest food normally.

It is best to take in food by mouth whenever possible. Some people may not be able to take in enough food by mouth because of problems from cancer or cancer treatment.

Nutrition support can be given in different ways.

In addition to counseling by a dietitian and changes to the diet, nutrition therapy includes nutritional supplement drinks and enteral and parenteral nutrition support. Nutritional supplement drinks help people with cancer get the nutrients they need. They provide energy, protein, fat, carbohydrates, fiber, vitamins, and minerals. They are not meant to be the person’s only source of nutrition.

A person who is not able to take in the right amount of calories and nutrients by mouth may be fed using the following:

Nutrition support can improve a person’s quality of life during cancer treatment, but may cause problems that should be considered before making the decision to use it. The patient, family, and healthcare team should discuss the harms and benefits of each type of nutrition support. For more information on the use of nutrition support at the end of life, see the Nutrition Needs at End of Life section.

Enteral Nutrition

Parenteral Nutrition

The catheter may be placed into a vein in the chest or in the arm.

A central venous access catheter is placed beneath the skin and into a large vein in the upper chest. The catheter is put in place by a surgeon. This type of catheter is used for long-term parenteral feeding.

Enlarge

A peripheral venous catheter is placed into a vein in the arm. A peripheral venous catheter is put in place by trained medical staff. This type of catheter is usually used for short-term parenteral feeding for patients who do not have a central venous access catheter.

Enlarge

The patient is checked often for infection or bleeding at the place where the catheter enters the body.

Medicine may be given with nutrition therapy to treat loss of appetite and weight loss.

It is important that cancer symptoms and side effects that affect eating and cause weight loss are treated early. Both nutrition therapy and medicine can help lessen the effects that cancer and its treatment have on weight loss.

Different types of medicine may be used to treat loss of appetite and weight loss.

Medicines that improve appetite and cause weight gain, such as prednisone and megestrol, may be used to treat loss of appetite and weight loss. Studies have shown that the effects of these medicines may not last long, or there may be no effects. Treatment with a combination of medicines may work better than treatment with one medicine but may have more side effects.

Nutrition needs change at end of life.

For people at the end of life, the goals of nutrition therapy are focused on relieving symptoms rather than getting enough nutrients.

Common symptoms that can occur at the end of life include the following:

People who have problems swallowing may find it easier to swallow thick liquids than thin liquids.

People with cancer often do not feel much hunger at all and may want very little food. Sips of water, ice chips, and mouth care can decrease thirst in the last few days of life. Good communication with the healthcare team is important to understand the patient’s changes in nutrition needs.

People with cancer and their families decide how much nutrition and fluids will be given at the end of life.

People with cancer and their caregivers have the right to make informed decisions. The person’s religious and cultural preferences may affect their decisions. The healthcare team may work with the person’s religious and cultural leaders when making decisions. The healthcare team and a registered dietitian can explain the benefits and risks of using nutrition support for people at the end of life. In most cases, there are more harms than benefits if the person is not expected to live longer than a month.

Possible benefits of nutrition support for people expected to live longer than a month include the following:

The risks of nutrition support at the end of life include the following:

Some people with cancer try special diets to improve their prognosis.

People with cancer may try special diets to make their treatment work better, prevent side effects from treatment, or to treat the cancer itself. However, for most of these special diets, there is no evidence that shows they work.

Vegetarian or vegan diet

It is not known if following a vegetarian or vegan diet can help side effects from cancer treatment or the person’s prognosis. If the person already follows a vegetarian or vegan diet, there is no evidence that shows they should switch to a different diet.

A study in patients with non-muscle-invasive bladder cancer showed some benefits from eating a diet rich in ITC, a phytochemical found in raw cruciferous vegetables. Patients who ate large amounts of cruciferous vegetables were less likely to have two or more recurrences of their disease and a lower risk of their disease becoming muscle-invasive cancer. More research on the benefits of phytochemicals is needed.

Macrobiotic diet

A macrobiotic diet is a high-carbohydrate, low-fat, plant-based diet. No studies have shown that this diet will help people with cancer.

Ketogenic diet

A ketogenic diet limits carbohydrates and increases fat intake. The purpose of the diet is to decrease the amount of glucose (sugar) the tumor cells can use to grow and reproduce. It is a hard diet to follow because exact amounts of fats, carbohydrates, and proteins are needed.

Several clinical trials are recruiting people with glioblastoma to study whether a ketogenic diet affects glioblastoma tumor activity. People with glioblastoma who want to start a ketogenic diet should talk to their doctor and work with a registered dietitian. However, it is not yet known how the diet will affect the tumor or its symptoms.

Similarly, a study comparing the ketogenic diet to a high-fiber, low fat diet in women with ovarian cancer or endometrial cancer found that the ketogenic diet was safe and acceptable. There is not enough evidence to know how the ketogenic diet will affect ovarian or endometrial tumors or their symptoms.

Some people with cancer may take dietary supplements.

A dietary supplement is a product that is added to the diet. It is usually taken by mouth, and usually has one or more dietary ingredients. People with cancer may take dietary supplements to improve their symptoms or treat their cancer.

Vitamin C

Vitamin C is a nutrient that the body needs in small amounts to function and stay healthy. It helps fight infection, heal wounds, and keep tissues healthy. Vitamin C is found in fruits and vegetables. It can also be taken as a dietary supplement. For information about the use of intravenous vitamin C as treatment for people with cancer, see Intravenous Vitamin C.

Probiotics

Probiotics are live microorganisms used as dietary supplements to help with digestion and normal bowel function. They may also help keep the gastrointestinal tract healthy.

Studies have shown that taking probiotics during radiation therapy and chemotherapy can help prevent diarrhea caused by those treatments. People with cancer who are receiving radiation therapy to the abdomen or chemotherapy that is known to cause diarrhea may be helped by probiotics. Similarly, studies are looking at potential benefits of taking probiotics for people with cancer who are receiving immunotherapy.

Melatonin

Melatonin is a hormone made by the pineal gland (tiny organ near the center of the brain). Melatonin helps control the body’s sleep cycle. It can also be made in a laboratory and taken as a dietary supplement.

Several small studies have shown that taking a melatonin supplement with chemotherapy and/or radiation therapy for treatment of solid tumors may be helpful. It may help reduce side effects of treatment. Melatonin does not appear to have side effects.

Oral glutamine

Oral glutamine is an amino acid that is being studied for the treatment of diarrhea and mucositis (inflammation of the lining of the digestive system, often seen as mouth sores) caused by chemotherapy or radiation therapy. Oral glutamine may help prevent mucositis or make it less severe.

People with cancer who are receiving radiation therapy to the abdomen may benefit from oral glutamine. Oral glutamine may reduce the severity of diarrhea. This can help people continue with their treatment plan.

National Cancer Institute

For information from the National Cancer Institute (NCI) about nutrition and cancer treatment, see Side Effects.

Organizations

For general nutrition information and other resources, see the following:

Books

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about nutrition before, during, and after cancer treatment. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Nutrition in Cancer Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/appetite-loss/nutrition-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389440]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 3,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.

Hot flashes and night sweats are common in cancer patients and survivors.

A hot flash is a sudden warm feeling over your face, neck, and chest that may cause you to sweat and your face to turn red. Sweating is your body’s way of lowering body temperature by causing heat loss through your skin. Hot flashes combined with sweats that happen while sleeping are often called night sweats or hot flushes. Hot flashes and night sweats are common in patients receiving cancer treatment. Some people continue to have hot flashes and night sweats after cancer treatment.

In women and men, hot flashes and night sweats may be caused by surgery, radiation therapy, and taking certain medications.

Hot flashes and night sweats may be controlled with estrogen replacement therapy.

Hot flashes and night sweats during natural or treatment-related menopause can be controlled with estrogen replacement therapy. However, many women are not able to take estrogen replacement (for example, women who have or had breast cancer) and may need to take a drug that does not have estrogen in it. Hormone replacement therapy that combines estrogen with progestin may increase the risk of breast cancer or breast cancer recurrence.

Treatment of hot flashes in men who have been treated for prostate cancer may include estrogens, progestin, antidepressants, and anticonvulsants.

Other drugs may be useful in some patients.

Studies of non-estrogen drugs to treat hot flashes in women with a history of breast cancer have reported that many of them do not work as well as estrogen replacement or have side effects. Megestrol and medroxyprogesterone (drugs like progesterone), certain antidepressants, anticonvulsants, and clonidine (a drug used to treat high blood pressure) are non-estrogen drugs used to control hot flashes.

Side effects from drug therapy for hot flashes and night sweats may develop.

Side effects of non-hormonal drug therapy may include the following:

Side effects from drug therapy may vary from person to person, so treatment and dose will be specific to your needs. If one medicine does not improve your symptoms, switching to another medicine may help.

Treatments that help patients cope with stress and anxiety may help manage hot flashes.

Treatments that change how you deal with stress, anxiety, and negative feelings may help you manage hot flashes. These strategies include cognitive behavioral therapy and relaxation and breathing exercises. They help you gain a sense of control and develop coping skills to manage your symptoms.

Hypnosis has also been used as a treatment for hot flashes. It is a trance-like state that allows you to be more aware, focused, relaxed, and open to suggestion. Under hypnosis, you can concentrate more clearly on a specific thought or feeling without becoming distracted. A therapist helps you to deeply relax and focus on cooling thoughts. This may lower stress levels, balance body temperature, and calm the heart rate and breathing rate.

Cognitive behavioral therapy, relaxation and breathing exercises, or hypnosis may help hot flashes and related problems when used together with drug therapy.

Comfort measures may help relieve hot flashes and night sweats.

Comfort measures may be used to treat hot flashes and night sweats related to cancer treatment. Since body temperature goes up before a hot flash, doing the following may control body temperature and help control symptoms:

Herbs and dietary supplements should be used with caution.

It is important that your health care providers know about all of the dietary supplements, such as soy, and herbs you are taking with your medicines.

Studies of vitamin E for the relief of hot flashes show that it is only slightly better than a placebo (pill or procedure that has no effect). Most studies of soy and black cohosh show they are no better than a placebo in reducing hot flashes. Soy is rich in estrogen-like substances, but how it affects cells in the body is unknown. Studies of ground flaxseed and magnesium oxide to treat hot flashes have shown mixed results.

Claims are made about several other plant-based and natural products as remedies for hot flashes. These include dong quai, milk thistle, red clover, licorice root extract, and chaste tree berry. Since little is known about how these products work or whether they affect the risk of breast cancer, you should talk with your doctor before using them.

Acupuncture has been studied in the treatment of hot flashes.

Pilot studies of acupuncture and randomized clinical trials that compare true acupuncture and sham (placebo) treatment have been done in patients with hot flashes and results are mixed. A review of many studies combined showed that acupuncture had slight or no effects in breast cancer patients with hot flashes. In contrast, a randomized clinical trial that was not included in the review showed that breast cancer patients who were given acupuncture had fewer hot flashes. Another randomized clinical trial showed that breast cancer survivors who were given electroacupuncture had a reduction in hot flash symptoms. (See the Vasomotor symptoms section in the PDQ health professional summary on Acupuncture for more information.)

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of hot flashes and night sweats. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Hot Flashes and Night Sweats. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/hot-flashes-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389162]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 3,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.

Hormone Replacement Therapy

Estrogen replacement effectively controls hot flashes associated with biological or treatment-associated postmenopausal states in women. The proposed mechanism of action of estrogen replacement therapy is that it ameliorates hot flashes by raising the core body temperature sweating threshold;[1][Level of evidence: I] however, many women have relative or absolute contraindications to estrogen replacement. Physicians and breast cancer survivors often think there is an increased risk of breast cancer recurrence or de novo breast malignancy with hormone replacement therapies and defer hormonal management of postmenopausal symptoms. Methodologically strong data evaluating the risk of breast cancer associated with hormone replacement therapy in healthy women have been minimal, despite strong basic science considerations suggesting the possibility of such a risk.[2]

In May 2002, the Women’s Health Initiative, a large, randomized, placebo-controlled trial of the risks and benefits of estrogen plus progestin in healthy postmenopausal women, was stopped prematurely at a mean follow-up of 5.2 years (±1.3) because of the detection of a 1.26-fold increased risk of breast cancer (95% confidence interval [CI], 1.00–1.59) in women receiving hormone replacement therapy. Tumors among women in the hormone replacement therapy group were slightly larger and more advanced than tumors among women in the placebo group, with a substantial and statistically significant rise in the percentage of abnormal mammograms at first annual screening; such a rise might hinder breast cancer diagnosis and account for the later stage at diagnosis.[3,4][Level of evidence: I] These results are supported by a population-based case-control study suggesting a 1.7-fold increased risk of breast cancer (95% CI, 1.3–2.2) in women using combined hormone replacement therapy. The risk of invasive lobular carcinoma was increased 2.7-fold (95% CI, 1.7–4.3), the risk of invasive ductal carcinoma was increased 1.5-fold (95% CI, 1.1–2.0), and the risk of estrogen receptor–positive/progesterone receptor–positive breast cancer was increased 2.0-fold (95% CI, 1.5–2.7). The increased risk was highest for invasive lobular tumors and in women who used hormone replacement therapy for longer periods. The risk was not increased with unopposed estrogen therapy.[5]

The very limited data available do not indicate an increased risk of breast cancer recurrence with single-agent estrogen use in patients with a history of breast cancer.[6,7] A series of double-blind, placebo-controlled trials suggested that low-dose megestrol acetate is a promising agent for hot flash management in this population.[8][Level of evidence: I];[9][Level of evidence: II] Limited data suggest that brief cycles of intramuscular depot medroxyprogesterone acetate also play a role in the management of hot flashes.[10][Level of evidence: I] The risk associated with progestin use is unknown.[2]

Examples of hormone-based pharmacological treatments for vasomotor symptoms are summarized in Table 1.

Other Pharmacological Interventions

Numerous nonestrogenic, pharmacological treatment interventions for hot flash management in women with a history of breast cancer and in some men who have undergone androgen deprivation therapy have been evaluated. Options with reported efficacy include the following: [15–17][Level of evidence: I]

Inferior efficacy, lack of large definitive studies, and potential side effects limit the use of many of these agents.

Agents that have been found to be helpful in large, randomized, placebo-controlled clinical trials include the following: [15–17]

Agents that confer a 55% to 60% reduction in hot flashes are venlafaxine extended release, [18] paroxetine controlled release [19,20][Level of evidence: I] or immediate release, [21] gabapentin, [22–25][Level of evidence: I][26][Level of evidence: II] and pregabalin.[27][Level of evidence: I] Other effective agents resulting in a reduction in hot flashes of approximately 50% include citalopram [28][Level of evidence: I] and fluoxetine.[29][Level of evidence: I] Clonidine, transdermal [30] or oral, [31][Level of evidence: I] can reduce hot flashes by approximately 40%.

One study compared the efficacy and patient preference of venlafaxine, 75 mg once daily, to gabapentin, 300 mg 3 times per day, for the reduction of hot flashes. Sixty-six women with histories of breast cancer were randomly assigned in an open-label fashion to receive venlafaxine or gabapentin for 4 weeks; after a 2-week washout period, they received the opposite treatment for an additional 4 weeks. Both treatments reduced hot flash scores (severity multiplied by frequency) by approximately 66%. However, significantly more women preferred venlafaxine to gabapentin (68% vs. 32%, respectively).[22]

A study using citalopram to evaluate hot flashes examined how much of a reduction in hot flashes was needed to have a positive impact on activities of daily living and general health-related quality of life.[32] The authors reported that hot flashes had to be reduced at least 46% for women to report significant improvements in the degree of bother they experienced in daily activities.

In a randomized study of paroxetine versus placebo in postmenopausal survivors of gynecological cancer, paroxetine significantly reduced the severity and frequency of hot flashes and nighttime awakening attributed to vasomotor symptoms, with improvement in sleep duration.[20][Level of evidence: I]

Agents that have been evaluated in phase II trials but have not shown efficacy include bupropion,[33] aprepitant,[34] and desipramine.[35][Level of evidence: II] Interestingly, these agents do not primarily modulate serotonin. In addition, randomized clinical trials with sertraline have not provided convincing evidence of its efficacy in hot flash management.[36–38][Level of evidence: I]

Examples of nonhormonal pharmacological treatments for vasomotor symptoms are summarized in Table 2.

If nighttime hot flashes or night sweats are a particular problem without causing much bother during daytime, strategies to simultaneously improve sleep and hot flashes are in order. Limited data exist related to effective treatments that can target both symptoms. One pilot trial evaluated mirtazapine (a tetracyclic antidepressant that mainly affects serotonin) for hot flashes because it is often prescribed for sleep difficulties. Twenty-two women were titrated up to 30 mg per day of mirtazapine at bedtime over a 3-week period; then they could choose 15 mg or 30 mg at bedtime daily for the fourth week. Hot flashes were reduced by approximately 53% in this nonrandomized trial, and women were statistically significantly satisfied with their hot flash control.[44] However, only 16 of the 22 women stayed on the agent for the entire study period because of excessive grogginess. Although this agent could be further studied in a larger randomized trial, it would be particularly important to evaluate the risk/benefit ratio.

In the short term, side effects for antidepressant agents in the doses used to treat hot flashes are minimal and primarily include:

In the long term, the prevalence of decreased sexual function with the use of SSRIs at doses for treating hot flashes is not known. The anticonvulsants gabapentin and pregabalin can cause sedation, dizziness, and difficulty concentrating, while clonidine can cause dry mouth, sedation, constipation, and insomnia.[25,27,46][Level of evidence: I] Patients respond as individuals to both the efficacy and the toxicity of various medications. Therefore, careful assessment and tailored treatment chosen collaboratively by the provider and patient are needed.

Data indicate that if a medication does not help an individual, switching to another medication—whether a different antidepressant or gabapentin—may be worthwhile. In a randomized phase III trial (NCCTG-N03C5) of gabapentin alone versus gabapentin with an antidepressant in women who had inadequate control of their hot flashes with an antidepressant alone,[47][Level of evidence: I] gabapentin use resulted in an approximately 50% median reduction in hot flash frequency and score, regardless of whether the antidepressant was continued. In other words, for women who were using antidepressants exclusively for the management of hot flashes that were inadequately controlled, initiation of gabapentin with discontinuation of the antidepressant produced results equal to those obtained with combined therapy, resulting in the need for fewer medications. Similarly, in a pilot study of women receiving inadequate benefit from venlafaxine for hot flash reduction, switching to open-label citalopram, 20 mg per day, resulted in a 50% reduction in hot flash frequency and score.[48]

Drug Interactions

Many SSRIs can inhibit the cytochrome P450 enzymes involved in the metabolism of tamoxifen, which is commonly used in the treatment of breast cancer. When SSRIs are being used, drug-drug interactions are noted. Tamoxifen is metabolized by the cytochrome P450 enzyme system, specifically CYP2D6. Wild-type CYP2D6 metabolizes tamoxifen to an active metabolite, 4-hydroxy-N-desmethyl-tamoxifen, also known as endoxifen. A prospective trial evaluating the effects of the coadministration of tamoxifen and paroxetine, a CYP2D6 inhibitor, on tamoxifen metabolism, found that paroxetine coadministration resulted in decreased concentrations of endoxifen. The magnitude of decrease was greater in women with the wild-type CYP2D6 genotype than in those with a variant genotype (P = .03).[49][Level of evidence: II]

In a prospective observational study of 80 women initiating adjuvant tamoxifen therapy for newly diagnosed breast cancer, variant CYP2D6 genotypes and concomitant use of SSRI CYP2D6 inhibitors resulted in reduced endoxifen levels. Variant CYP2D6 genotypes do not produce functional CYP2D6 enzymes.[50][Level of evidence: II] Since this study was published, several researchers have evaluated the clinical implications of this finding.[51];[52–54][Level of evidence: II] One study followed more than 1,300 women for a median of 6.3 years and concluded that women who were poor metabolizers or heterozygous extensive/intermediate metabolizers (hence, less CYP2D6 activity) had higher rates of recurrence, worse event-free survival, and worse disease-free survival than did women who were extensive metabolizers.[53] Similarly, authors of a retrospective cohort study of more than 2,400 women in Ontario, Canada, who were being treated with tamoxifen and had overlapping treatment with an SSRI concluded that women who concomitantly used paroxetine and tamoxifen had an increased risk of death that was proportionate to the amount of time they used these agents together.[54][Level of evidence: II]

The clinical implications of these changes and of other CYP2D6 genotypes [55] have not yet been elucidated, but the pharmacokinetic interaction between tamoxifen and the newer antidepressants used to treat hot flashes merits further study.[56] Likewise, the risk of soy phytoestrogen use on breast cancer recurrence and/or progression has not yet been clarified. Soy phytoestrogens are weak estrogens found in plant foods. In vitro models suggest that these compounds have a biphasic effect on mammary cell proliferation that is dependent on intracellular concentrations of phytoestrogen and estradiol.[57]

Information Specific to Men

Data are scant regarding the pathophysiology and management of hot flashes in men with prostate cancer. The rate of hot flashes in men receiving androgen deprivation therapy is approximately 75%.[58] The limited data suggest that hot flashes in men are related to changes in sex hormone levels that cause instability in the hypothalamic thermoregulatory center. This is analogous to the proposed mechanism of hot flashes that occur in women. As in women with breast cancer, hot flashes impair the quality of life for men with prostate cancer who are receiving androgen deprivation therapy. The vasodilatory neuropeptide, calcitonin gene–related peptide, may be instrumental in the genesis of hot flashes.[58]

In a prespecified secondary analysis of a prostate cancer clinical trial, 93% of men receiving 12 months of androgen deprivation therapy experienced hot flashes. The hot flashes occurred at castrate levels of testosterone, and cessation of hot flashes preceded full recovery of testosterone in most men, with 99% of men reporting resolution of hot flashes.[59][Level of evidence: I]

Cognitive behavioral therapy (CBT) has been studied for the treatment of hot flashes in men undergoing androgen deprivation therapy for prostate cancer.[60][Level of evidence: I] Patients were randomly assigned to a guided self-help CBT regimen that included a booklet and CD with relaxation and breathing exercises, or to treatment as usual. At 6 weeks, those assigned to CBT experienced a statistically significant 40% reduction in hot flash/night sweat symptoms versus a 12% reduction in patients who received treatment as usual. Symptom reduction continued but was not statistically significant at 32 weeks. Adherence to CBT was good, with 88% reading all or more than half of the booklet and 79% using the relaxation CD.

With the exception of clonidine, the agents mentioned previously were effective in treating hot flashes in women have shown similar efficacy rates in men. For more information, see the Other Pharmacological Interventions section.Treatment modalities for men have included the following:[61]

One large, multisite study from France [62] randomly assigned men who were taking leuprorelin for prostate cancer to receive venlafaxine, 75 mg; cyproterone acetate (an antiandrogen), 100 mg; or medroxyprogesterone acetate, 20 mg, when they reported at least 14 hot flashes per week. All three treatments significantly reduced hot flashes, with cyproterone acetate resulting in a 100% median reduction, medroxyprogesterone resulting in a 97% reduction, and venlafaxine resulting in a 57% reduction at 8 weeks. More adverse events were reported with cyproterone acetate, including one serious adverse event (dyspnea) attributable to the drug. Venlafaxine was not associated with any serious adverse events and overall had a 20% adverse event rate. Medroxyprogesterone was the best-tolerated drug, with an adverse event rate of 12%, but with one serious event, urticaria. The most frequent side effects for all agents were gastrointestinal issues: nausea, constipation, diarrhea, and abdominal pain.[62]

On the basis of its efficacy in women, the combination of venlafaxine and soy was studied in hot flash reduction in androgen-deprived men.[63][Level of evidence: I] Patients were randomly assigned to receive venlafaxine with soy protein, venlafaxine with milk protein placebo, soy protein with placebo, or dual placebos during a 12-week period. The number and severity of hot flashes fell for all arms during the study period, but there was no significant difference between arms. The authors concluded that neither agent should be used to treat hot flashes in men, that there is a significant placebo effect in the study of hot flash treatment, and that agents demonstrating success for hot flashes in women may not be successful in men.

A small, multicenter, retrospective review evaluated the use of two doses of intramuscular medroxyprogesterone acetate (400 mg and 150 mg) as a single dose to treat and prevent hot flashes associated with luteinizing hormone-releasing hormone agonist therapy for prostate cancer.[14][Level of evidence: III] Of the 48 men studied, 91% experienced symptomatic improvement in hot flashes, and 46% experienced complete resolution of hot flashes. The trial was not powered to detect a difference between the two doses; however, the authors concluded that they would now use the 400-mg dose.

Pilot studies of the efficacy of the SSRIs paroxetine and fluvoxamine suggest that these drugs decrease the frequency and severity of hot flashes in men with prostate cancer.[64,65] As in women with hormonally sensitive tumors, there are concerns about the effects of hormone use on the outcome of prostate cancer, in addition to other well-described side effects.[58]

Cognitive and Behavioral Methods

Comprehensive nonpharmacological interventions have been developed and evaluated for their ability to reduce hot flashes, night sweats, and the related perception of burden or problems. These interventions have typically included the following:[66–69]

Behavioral interventions as a primary or adjunctive modality may also play a role in hot flash management. Core body temperature has been shown to increase before a hot flash;[70] therefore, interventions that control body temperature could improve hot flash management. Some methods of controlling body temperature include the use of the following:

Since serotonin may be involved as a central hot flash trigger, behavioral interventions such as stress management may modulate serotonin, causing a decrease in hot flashes.

Relaxation training and paced breathing were initially found to decrease hot flash intensity by as much as 40% to 50% in controlled pilot trials;[71,72] however, randomized trials with control arms using a different pace of breathing have not demonstrated significant benefit for paced-breathing interventions.[73,74]

Three large studies [67–69] of similar interventions have been completed using no treatment, usual care, or wait-list control comparison groups. While all of the studies demonstrated significant reductions in problem ratings or bother ratings related to hot flashes and night sweats, none showed actual reductions in hot flash frequency. Only one of the three studies demonstrated some significant improvements in night sweats at some data points.[68] Similar results were seen in a large trial of Internet-based CBT with and without therapist support.[75][Level of evidence: I] Cognitive behavioral interventions may be an important addition to pharmacological treatment to improve a patient’s overall experience with symptoms related to hot flashes. However, data have not supported the sole use of CBT for reducing hot flashes.

Medical hypnosis is a newer intervention for hot flashes that has been shown to be helpful. In medical hypnosis, the provider facilitates a deep relaxation and trance state in the patient and gives suggestions to the subconscious to mitigate the symptom or problem being addressed. For hot flashes, medical hypnosis uses cooling suggestions and stress reduction to prevent rises in core body temperature and to decrease sympathetic activation. On the basis of strong pilot data, a randomized controlled trial of 187 postmenopausal women used an attention-control comparison and demonstrated significantly greater reductions in hot flashes in the hypnosis group than in the control group. The hypnosis intervention was 5 weeks long. At week 6, hot flash frequency was reduced in the hypnosis group by 64%, compared with a 9% reduction in the control group. At week 12, the reduction in the hypnosis group was 75%, compared with a 17% reduction in the control group.[76] Cancer survivors were not included in this study, but previous research has not demonstrated that interventions have a differential effect on hot flashes on the basis of breast cancer history.

Future research on hot flash management may be aided by the development of psychometrically sound assessment tools such as the Hot Flash Related Daily Interference Scale, which evaluates the impact of hot flashes on a wide variety of daily activities.[77]

Integrative Approaches

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of hot flashes and night sweats. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Hot Flashes and Night Sweats are:

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website’s Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Hot Flashes and Night Sweats. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/hot-flashes-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389188]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

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Getting enough sleep is needed for both physical and mental health.

Sleep is an important part of physical and mental health. While we sleep, the brain and body do a number of important jobs that help us stay in good health and function at our best.

Getting the sleep we need:

Sleep has two main phases that repeat during the sleeping period.

There are two main phases of sleep, and both are needed in order to get “a good night’s sleep.” The two main phases of sleep are rapid eye movement (REM) and non-rapid eye movement (NREM):

The phases of sleep repeat during the night in a cycle of a non-REM phase followed by a REM phase. Each cycle lasts about 90 minutes and is repeated 4 to 6 times during 7 to 8 hours of sleep.

Sleep disorders affect normal sleep patterns.

Normal sleep patterns differ from person to person. The amount of sleep you need to feel rested may be less or more than others need. If sleep is interrupted or does not last long enough, the phases of sleep are not completed and the brain cannot finish all the tasks that help restore the body and mind. There are five major types of sleep disorders that affect normal sleep.

Sleep disorders keep you from having a good night’s sleep. This may make it hard for you to stay alert and involved in activities during the day. Sleep disorders can cause problems for people with cancer. You may not be able to remember treatment instructions and may have trouble making decisions. Being well-rested can improve energy and help you cope with side effects of cancer and treatment.

Sleep problems that go on for a long time may increase the risk of anxiety or depression.

Sleep disorders are common in people with cancer.

As many as half of people with cancer have problems sleeping. The sleep disorders most likely to affect people with cancer are insomnia and an abnormal sleep-wake cycle.

There are many reasons you may have trouble sleeping, including:

Tumors may cause sleep problems.

If you have a tumor, it may cause the following problems that make it hard to sleep:

Certain drugs or treatments may affect sleep.

Common cancer treatments and drugs can affect normal sleep patterns. How well you sleep may be affected by:

Long-term use of certain drugs may cause insomnia. Stopping or decreasing the use of certain drugs can also affect normal sleep. Other side effects of drugs and treatments that may affect the sleep-wake cycle include the following:

Being in the hospital may make it harder to sleep.

Getting a normal night’s sleep in the hospital is difficult. The following may affect your sleep in a hospital:

Getting sleep during a hospital stay may also be affected by anxiety and age.

Stress caused by learning the cancer diagnosis often causes sleeping problems.

Stress, anxiety, and depression are common reactions to learning you have cancer, receiving treatments, and being in the hospital. These are common causes of insomnia. For more information, see Depression.

Other health problems not related to cancer may cause a sleep disorder.

People with cancer can have sleep disorders that are caused by other health problems. Conditions such as snoring, headaches and daytime seizures increase the chance of having a sleep disorder.

An assessment is done for people with sleep disorders.

An assessment is done to find problems that may be causing the sleep disorder and how it affects your life. People with mild sleep disorders may be irritable and unable to concentrate. People with moderate sleep disorders can be depressed and anxious. These sleep disorders may make it hard for you to stay alert and involved in activities during the day. You may not be able to remember treatment instructions and may have trouble making decisions. Being well-rested can improve energy and help you cope with side effects of cancer and treatment.

People with cancer should have assessments done from time to time because sleep disorders may become more or less severe over time.

A sleep disorder assessment includes a physical exam, health history, and sleep history.

Your doctor will do a physical exam and take a medical history that includes:

You and your family can tell your doctor about your sleep history and patterns of sleep.

A polysomnogram may be used to help diagnose the sleep disorder.

A polysomnogram is a group of recordings taken during sleep that show:

This information helps the doctor find the cause of your sleeping problems.

Treating sleep disorders may include supportive care for side effects of cancer or cancer treatment.

Sleep disorders often occur along with cancer-related fatigue and may be related. Sleep disorders that are caused by side effects of the cancer or cancer treatment may be helped by relieving the symptoms of those side effects. It’s important to talk about your sleep problems with your family and the health care team so education and support can be given. Supportive care may improve your quality of life and ability to sleep.

Cognitive behavioral therapy may reduce anxiety and help you relax.

Cognitive behavioral therapy (CBT) helps reduce anxiety about getting enough sleep. You learn to change negative thoughts and beliefs about sleep into positive thoughts and images, in order to fall asleep more easily. CBT helps replace the anxiety of “I need to sleep” with the idea of “just relax.” You learn how to change sleep habits that keep you from sleeping well. If in-person CBT sessions with a health professional are not available, video CBT sessions have been shown to be helpful. CBT may include the following:

Learning good sleep habits is important.

Good sleep habits help you fall asleep more easily and stay asleep. Habits and routines that may help improve sleep include the following:

A comfortable bed and bedroom

Making your bed and bedroom more comfortable may help you sleep. Some ways to increase bedroom comfort include:

Regular bowel and bladder habits

Regular bowel and bladder habits reduce the number of times you have to get up during the night. Waking during the night to go to the bathroom may be reduced by doing the following:

Diet and exercise

The following diet and exercise habits may improve sleep:

Other habits that may improve sleep include:

Hospital routines

Getting a good night’s sleep in a hospital or other care facility can be hard to do. The good sleep habits listed above may help you. As a hospital patient, you may also:

If treatment without drugs does not help, sleep medicines may be used for a short time.

Treatment without drugs does not always work. Sometimes cognitive behavioral therapies are not available or they do not help. Also, some sleep disorders are caused by conditions that need to be treated with drugs, such as hot flashes, pain, anxiety, depression, or mood disorders. The drug used will depend on your type of sleep problem (such as trouble falling asleep or trouble staying asleep) and other medicines you’re taking. All of your other medicines and health conditions will affect which sleeping medicines are safe and will work well for you.

Some drugs that help you sleep should not be stopped suddenly. Suddenly stopping them may cause nervousness, seizures, and a change in the REM phase of sleep that increases dreaming, including nightmares. This change in REM sleep may be dangerous for people with peptic ulcers or heart conditions.

People Who Have Pain

If pain disturbs your sleep, treatment to relieve the pain will be used before sleep medicines are used. Pain drugs, other drugs being taken, and any other health conditions may affect which sleeping medicines are prescribed.

Older Patients

It’s normal for older people to have some insomnia. Changes related to age can cause lighter sleep, waking up more often during the night, and sleeping less total time. If you are an older person with cancer who is having trouble sleeping, the doctor will look for the specific causes, such as:

Treating sleeping problems without drugs is tried first. The following may help improve sleep in older people with cancer:

Medicine may be used if non-drug treatments don’t work. The doctor will look at all your medicines and health conditions before choosing a sleeping medicine. For some people, doctors will suggest a sleep disorder clinic for treatment.

People Who Have Jaw Surgery

People who have surgery on the jaw may develop sleep apnea, which is a sleep disorder that causes the person to stop breathing for 10 seconds or more during sleep. Plastic surgery to rebuild the jaw may help prevent sleep apnea.

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of sleep disorders. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Sleep Disorders. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/sleep-disorders-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389249]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 3,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.

Oral complications are common in cancer patients, especially those with head and neck cancer.

Complications are new medical problems that occur during or after a disease, procedure, or treatment and that make recovery harder. The complications may be side effects of the disease or treatment, or they may have other causes. Oral complications affect the mouth.

Cancer patients have a high risk of oral complications for a number of reasons:

This summary is about oral complications caused by chemotherapy and radiation therapy.

Preventing and controlling oral complications can help you continue cancer treatment and have a better quality of life.

Sometimes treatment doses need to be decreased or treatment stopped because of oral complications. Preventive care before cancer treatment begins and treating problems as soon as they appear may make oral complications less severe. When there are fewer complications, cancer treatment may work better and you may have a better quality of life.

Patients receiving treatments that affect the head and neck should have their care planned by a team of doctors and specialists.

To manage oral complications, the oncologist will work closely with your dentist and may refer you to other health professionals with special training. These may include the following specialists:

The goals of oral and dental care are different before, during, and after cancer treatment:

The most common oral complications from cancer treatment include the following:

These complications can lead to other problems such as dehydration and malnutrition.

Cancer treatment can cause mouth and throat problems.

Oral complications may be caused by the treatment itself (directly) or by side effects of the treatment (indirectly).

Radiation therapy can directly damage oral tissue, salivary glands, and bone. Areas treated may scar or waste away. Total-body radiation can cause permanent damage to the salivary glands. This can change the way foods taste and cause dry mouth.

Slow healing and infection are indirect complications of cancer treatment. Both chemotherapy and radiation therapy can stop cells from dividing and slow the healing process in the mouth. Chemotherapy may decrease the number of white blood cells and weaken the immune system (the organs and cells that fight infection and disease). This makes it easier to get an infection.

Complications may be acute (short-term) or chronic (long-lasting).

Acute complications are ones that occur during treatment and then go away. Chemotherapy usually causes acute complications that heal after treatment ends.

Chronic complications are ones that continue or appear months to years after treatment ends. Radiation can cause acute complications but may also cause permanent tissue damage that puts you at a lifelong risk of oral complications. The following chronic complications may continue after radiation therapy to the head or neck has ended:

Oral surgery or other dental work can cause problems in patients who have had radiation therapy to the head or neck. Make sure that your dentist knows your health history and the cancer treatments you received.

Finding and treating oral problems before cancer treatment begins can prevent oral complications or make them less severe.

Problems such as cavities, broken teeth, loose crowns or fillings, and gum disease can get worse or cause problems during cancer treatment. Bacteria live in the mouth and may cause an infection when the immune system is not working well or when white blood cell counts are low. If dental problems are treated before cancer treatments begin, there may be fewer or milder oral complications.

Prevention of oral complications includes a healthy diet, good oral care, and dental checkups.

Ways to prevent oral complications include the following:

Patients receiving high-dose chemotherapy, stem cell transplant, or radiation therapy should have an oral care plan in place before treatment begins.

The goal of the oral care plan is to find and treat oral disease that may cause complications during treatment and to continue oral care during treatment and recovery. Different oral complications may occur during the different phases of a transplant. Steps can be taken ahead of time to prevent or lessen how severe these side effects will be.

Oral care during radiation therapy will depend on the following:

It is important that patients who have head or neck cancer stop smoking.

Continuing to smoke tobacco may slow down recovery. It can also increase the risk that the head or neck cancer will recur or that a second cancer will form.

Regular Oral Care

For special oral care during high-dose chemotherapy and stem cell transplant, see the Managing Oral Complications of High-Dose Chemotherapy and/or Stem Cell Transplant section of this summary.

Oral Mucositis

Pain

Infection

Bleeding

Dry Mouth

Tooth Decay

Dry mouth and changes in the balance of bacteria in the mouth increase the risk of tooth decay (cavities). Careful oral hygiene and regular care by a dentist can help prevent cavities. See the Regular Oral Care section of this summary for more information.

Taste Changes

Fatigue

Cancer patients who are receiving high-dose chemotherapy or radiation therapy often feel fatigue (a lack of energy). This can be caused by either the cancer or its treatment. Some patients may have problems sleeping. Patients may feel too tired for regular oral care, which may further increase the risk for mouth ulcers, infection, and pain. For more information, see Cancer Fatigue.

Malnutrition

Mouth and Jaw Stiffness

Treatment for head and neck cancers may affect the ability to move the jaws, mouth, neck, and tongue. There may be problems with swallowing. Stiffness may be caused by:

Jaw stiffness may lead to serious health problems, including:

The risk of having jaw stiffness from radiation therapy increases with higher doses of radiation and with repeated radiation treatments. The stiffness usually begins around the time the radiation treatments end. It may get worse over time, stay the same, or get somewhat better on its own. Treatment should begin as soon as possible to keep the condition from getting worse or becoming permanent. Treatment may include the following

Swallowing Problems

Tissue and Bone Loss

Radiation therapy can destroy very small blood vessels within the bone. This can kill bone tissue and lead to bone fractures or infection. Radiation can also kill tissue in the mouth. Ulcers may form, grow, and cause pain, loss of feeling, or infection.

Preventive care can make tissue and bone loss less severe.

The following may help prevent and treat tissue and bone loss:

See the PDQ summary on Nutrition in Cancer Care for more information about managing mouth sores, dry mouth, and taste changes.

Patients who receive transplants have an increased risk of graft-versus-host disease.

Graft-versus-host disease (GVHD) occurs when your tissue reacts to bone marrow or stem cells that come from a donor. Symptoms of oral GVHD include the following:

It’s important to have these symptoms treated because they can lead to weight loss or malnutrition. Treatment of oral GVHD may include the following:

Oral devices need special care during high-dose chemotherapy and/or stem cell transplant.

The following can help in the care and use of dentures, braces, and other oral devices during high-dose chemotherapy or stem cell transplant:

Care of the teeth and gums is important during chemotherapy or stem cell transplant.

Talk to your medical doctor or dentist about the best way to take care of your mouth during high-dose chemotherapy and stem cell transplant. Careful brushing and flossing may help prevent infection of oral tissues. The following may help prevent infection and relieve discomfort of oral in tissues:

Medicines and ice may be used to prevent and treat mucositis from stem cell transplant.

Medicines may be given to help prevent mouth sores or help the mouth heal faster if it is damaged by chemotherapy or radiation therapy. Also, holding ice chips in the mouth during high-dose chemotherapy, may help prevent mouth sores.

Dental treatments may be put off until the patient’s immune system returns to normal.

Regular dental treatments, including cleaning and polishing, should wait until the transplant patient’s immune system returns to normal. The immune system can take 6 to 12 months to recover after high-dose chemotherapy and stem cell transplant. During this time, the risk of oral complications is high. If dental treatments are needed, antibiotics and supportive care are given.

Supportive care before oral procedures may include giving antibiotics or immunoglobulin G, adjusting steroid doses, and/or platelet transfusion.

Certain drugs used to treat cancer and other bone problems are linked to bone loss in the mouth.

Some drugs break down bone tissue in the mouth. This is called osteonecrosis of the jaw (ONJ). ONJ can also cause infection. Symptoms include pain and inflamed lesions in the mouth, where areas of damaged bone may show.

Drugs that may cause ONJ include the following:

It’s important for the health care team to know if a patient has been treated with these drugs. Cancer that has spread to the jawbone can look like ONJ. A biopsy may be needed to find out the cause of the ONJ.

ONJ is not a common condition. It occurs more often in patients who receive bisphosphonates or denosumab by injection than in patients who take them by mouth. Taking bisphosphonates, denosumab, or angiogenesis inhibitors increases the risk of ONJ. The risk of ONJ is much greater when angiogenesis inhibitors and bisphosphonates are used together.

The following may also increase the risk of ONJ:

Patients with bone metastases may decrease their risk of ONJ by getting screened and treated for dental problems before bisphosphonate or denosumab therapy is started.

Treatment of ONJ usually includes treating the infection and good dental hygiene.

Treatment of ONJ may include the following:

During treatment for ONJ, you should continue to brush and floss after meals to keep your mouth very clean. It is best to avoid tobacco use while ONJ is healing.

You and your doctor can decide whether you should stop using medicines that cause ONJ, based on the effect it would have on your general health.

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of oral complications of cancer therapies. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Oral Complications of Cancer Therapies. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/mouth-throat/oral-complications-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389169]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 3,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.

Nonpharmacological Management of Sleep Disturbances

Many people who experience insomnia have poor sleep hygiene (such as smoking and drinking excessive alcohol just before bedtime), which can exacerbate or perpetuate insomnia.[1][Level of evidence: III] A complete assessment of sleep hygiene (i.e., time in bed; napping during the day; intake of caffeine, alcohol, or foods that are heavy, spicy, or sugary; exercise; and sleep environment) and use of behavioral management strategies (i.e., fixed bedtime; restrictions on smoking, diet, and excessive alcohol 4–6 hours before bedtime; and increased exercise) may prove effective in reducing sleep disturbances.

Sleep hygiene in an inpatient setting involves modifying the sleep environment to decrease sleep disruption. Minimizing noise, dimming or turning off lights, adjusting room temperature, and consolidating patient care tasks to reduce the number of interruptions can increase the amount of uninterrupted sleep.[2][Level of evidence: IV]

Cognitive strategies include:[3]

Behavioral strategies include:

Both of these strategies seek to limit the time spent in bed that does not involve sleeping.[3–5] Several large randomized trials and meta-analyses provide the evidence base for the efficacy of cognitive behavioral therapy (CBT) for insomnia (CBT-I).[3,6,7] Most of these trials have been in populations of patients without cancer.

Components of CBT-I include the following:

Relaxation therapy can be used to achieve both behavioral and cognitive outcomes, particularly when it is combined with imagery. Educational objectives around sleep hygiene are also used to treat insomnia and include content on the following:[4]

Practice guidelines from the American Academy of Sleep Medicine clearly state that multicomponent therapy is recommended over single therapies. Because of insufficient evidence about its efficacy, sleep hygiene education is not recommended as a single-modality management approach; other reviews state that sleep hygiene by itself is not effective.[6,8] Information about sleep hygiene should be included in patient education about sleep issues.

Several trials and meta-analyses have shown CBT-I to be at least as effective as conventional pharmacological therapies in treating primary chronic insomnia but without side effects.[6,7,9–11]

A four-arm study (conducted in patients with primary chronic insomnia) that evaluated zolpidem versus CBT versus zolpidem and CBT versus placebo reported a greater effect (P = .05) on sleep-onset latency for both groups involving CBT (change of 44%) versus the group receiving zolpidem alone (change of 29%).[12] Another study, also conducted in patients with primary chronic insomnia, evaluated CBT with temazepam alone versus a combination of CBT and temazepam versus placebo and found that all active treatments were significantly better than placebo and that there was a trend for the most improvement in the combined arm of CBT and temazepam.[13] Both arms with CBT demonstrated greater reductions in time to sleep onset than the pharmacotherapy-alone arm (64% in the combined arm, 55% in the CBT arm, and 47% in the temazepam arm). A meta-analysis examining pharmacological and behavioral studies for persistent insomnia found that pharmacological and behavioral treatments did not differ in magnitude of benefit except for latency to sleep onset, in which greater reductions were found with behavioral therapy.[7]

There are limited data evaluating elements of CBT-I in cancer survivors, and most data are about women with breast cancer. However, there have been at least four randomized controlled trials of CBT-I in cancer survivors.[14–17] The intervention was typically delivered over five to eight weekly, small-group, in-person sessions. One trial included patients with cancer diagnoses other than breast cancer,[16] and results did not differ by cancer diagnosis. All studies showed improvements in numerous sleep parameters over time in the groups receiving CBT-I and demonstrated continued benefits 6 and 12 months later. Two of the four trials did not use active control arms.[14,16]

Most studies using active control arms were in breast cancer survivors. One study compared CBT-I with sleep education and hygiene in 72 women,[15] while the other study used a healthy-eating education control group.[17] In the first study, both groups significantly improved over time, with some significant differences between groups favoring CBT-I for time to fall asleep, time awake after sleep, total sleep time, and overall sleep quality. For example, the group receiving CBT-I improved by 30 minutes in time to fall asleep, compared with 11 minutes in the sleep education and hygiene group.[15]

In the second study, 219 women were randomly assigned to a behavioral therapy group consisting of stimulus control, general sleep hygiene (limiting naps, going to bed and rising at consistent times), and relaxation or to a healthy-eating education control group. The interventions were delivered by trained nurses in person, 2 days before the initiation of chemotherapy, before each chemotherapy treatment, and 30 days after the last chemotherapy treatment. The nurses worked with women assigned to behavioral therapy to individualize and reinforce the behaviors. The Pittsburgh Sleep Quality Index (PSQI) was used to measure subjective sleep quality, complemented by use of a sleep diary and wrist actigraph. Sleep quality significantly improved in the group receiving behavioral therapy, compared with the control group. These differences were also seen in data from the sleep diary and actigraph, with both showing significantly fewer awakenings in the behavioral therapy group.[18] Sleep quality was significantly better at 90 days and at 1 year in the behavioral therapy group, as measured by the PSQI but not the diary or actigraph.[17]

In some places, patients may not have access to in-person, professionally delivered CBT-I. A randomized controlled trial conducted with breast cancer survivors demonstrated that CBT-I delivered via digital media can also produce meaningful clinical improvements, although improvements are not as robust as those produced with professionally delivered CBT-I. This three-armed trial compared video-based CBT-I (VCBT-I) and professionally delivered CBT-I (PCBT-I) with a no-treatment control group in 242 breast cancer survivors. Both the VCBT-I and PCBT-I groups had significantly greater improvements in diary-measured sleep variables, compared with the control group. The patients in the PCBT-I group reported greater improvements in some sleep outcomes and in fatigue and depression levels than did the VCBT-I group.[19]

Pharmacological Management of Sleep-Wake Cycle Disturbances

When cancer survivors experience sleep-wake disturbances, cognitive behavioral intervention counseling should be the first consideration for management. For more information, see the Nonpharmacological Management of Sleep Disturbances section. Resources for education and training in CBT may not be readily available in many cancer centers; therefore, community resources need to be investigated. If CBT is not available or has not been successful, pharmacological management can be considered. In addition, when patients have comorbidities contributing to sleep-wake cycle disturbances (such as hot flashes, uncontrolled pain, anxiety, depression, or other mood disturbances),[26,27] then pharmacological management will probably be necessary. While many pharmacological agents are approved for primary insomnia and many others are used off-label to manage sleep and related symptoms, most of the approved sleep aids have not been studied in cancer populations; therefore, the risk/benefit profiles of these drugs are not delineated in this setting.

Despite the lack of evidence in cancer populations, clinicians widely use pharmacological interventions. Therefore, the following discussion of pharmacological agents and recommendations for use is based on evidence from studies conducted in patients with primary insomnia and clinical experience.[4,28,29]

Several classes of medications are used to treat sleep-wake cycle disturbances, including the following:

Drug characteristics to consider before a drug is chosen to treat an individual patient include the following:

These pharmacokinetic principles are important to match the agent to the type of sleep disturbance (e.g., problems falling asleep versus problems staying asleep). There are also safety issues to be considered, such as potentials for tolerance, abuse, dependence, withdrawal (including risk of rebound insomnia), and drug-drug and drug-disease interactions. Medications for sleep-wake cycle disturbances should be used short term and/or as needed.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

The Patient With Pain

Since enhanced pain control improves sleep, appropriate analgesics or nonpharmacological pain management should be administered before introducing sleep medications. Tricyclic antidepressants can be particularly useful for the treatment of insomnia in patients with neuropathic pain and depression. Patients on high-dose opioids for pain may be at increased risk for the development of delirium and organic mental disorders. Such patients may benefit from the use of low-dose neuroleptics as sleep agents (e.g., haloperidol 0.5–1 mg).

The Older Patient

Older patients frequently have insomnia due to age-related changes in sleep. The sleep cycle in this population is characterized by lighter sleep, more frequent awakenings, and less total sleep time. Anxiety, depression, loss of social support, and a diagnosis of cancer are contributory factors in sleep disturbances in older patients.[1]

Sleep problems in older adults are so common that nearly one-half of all hypnotic prescriptions written are for people older than 65 years. Although normal aging affects sleep, the clinician should evaluate the many factors that cause insomnia, such as:[2]

Nonpharmacological treatment of sleep disorders is the preferred initial management, with the use of medication when indicated and referral to a sleep disorder center when specialized care is necessary.[2]

Providing a regular schedule of meals, discouraging daytime naps, and encouraging physical activity may improve sleep. Hypnotic prescriptions for older patients must be adjusted for variations in metabolism, increased fat stores, and increased sensitivity. Dosages should be reduced by 30% to 50%. Problems associated with drug accumulation (especially flurazepam) must be weighed against the risks of more severe withdrawal or rebound effects associated with short-acting benzodiazepines. An alternate drug for older patients is chloral hydrate.[1]

Sleep Apnea After Mandibulectomy

Anterior mandibulectomy can result in the development of sleep apnea. All patients with head and neck tumors who have had extensive anterior oral cavity resection should be evaluated before decannulation of the tracheostomy tube. Subsequent flap and/or reconstruction of the lower jaw seems to prevent the development of sleep apnea. In contrast, facial sling suspension of the lower lip does not prevent the development of sleep apnea.[3] Assessment for symptoms and preparation for the appearance of symptoms in this population provide indications for interventions related to sleep apnea.

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of sleep disorders. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Sleep Disorders are:

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website’s Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Sleep Disorders. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/sleep-disorders-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389467]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s Email Us.

Nausea and vomiting are serious side effects of cancer therapy.

Nausea and vomiting are side effects of cancer therapy and affect most patients who have chemotherapy. Radiation therapy to the brain, gastrointestinal tract, or liver also cause nausea and vomiting.

Nausea is an unpleasant feeling in the back of the throat and/or stomach that may come and go in waves. It may occur before vomiting. Vomiting is throwing up the contents of the stomach through the mouth. Retching is the movement of the stomach and esophagus without vomiting and is also called dry heaves. Although treatments for nausea and vomiting have improved, nausea and vomiting are still serious side effects of cancer therapy because they cause the patient distress and may cause other health problems. Patients may have nausea more than vomiting.

Nausea is controlled by a part of the autonomic nervous system which controls involuntary body functions (such as breathing or digestion). Vomiting is a reflex controlled in part by a vomiting center in the brain. Vomiting can be triggered by smell, taste, anxiety, pain, motion, or changes in the body caused by inflammation, poor blood flow, or irritation to the stomach.

It is important that nausea and vomiting are controlled so that the patient can continue treatment and have a better quality of life.

It is very important to prevent and control nausea and vomiting in patients with cancer, so that they can continue treatment and perform activities of daily life. Nausea and vomiting that are not controlled can cause the following:

Different types of nausea and vomiting are caused by chemotherapy, radiation therapy, and other conditions.

Nausea and vomiting can occur before, during, or after treatment.

The types of nausea and vomiting include:

Many factors increase the risk of nausea and vomiting with chemotherapy.

Nausea and vomiting with chemotherapy are more likely if the patient:

Patients who drank large amounts of alcohol over time have a lower risk of nausea and vomiting after being treated with chemotherapy.

Radiation therapy may also cause nausea and vomiting.

The following treatment factors may affect the risk of nausea and vomiting:

The following patient factors may cause nausea and vomiting with radiation therapy if the patient:

Patients who drank large amounts of alcohol over time have a lower risk of nausea and vomiting after being treated with radiation therapy.

Other conditions may also increase the risk of nausea and vomiting in patients with advanced cancer.

Nausea and vomiting may also be caused by other conditions. In patients with advanced cancer, chronic nausea and vomiting may be caused by the following:

Anticipatory nausea and vomiting may occur after several chemotherapy treatments.

In some patients, after they have had several courses of treatment, nausea and vomiting may occur before a treatment session. This is called anticipatory nausea and vomiting. It is caused by triggers, such as odors in the therapy room. For example, a person who begins chemotherapy and smells an alcohol swab at the same time may later have nausea and vomiting at the smell of an alcohol swab. The more chemotherapy sessions a patient has, the more likely it is that anticipatory nausea and vomiting will occur.

Having three or more of the following may make anticipatory nausea and vomiting more likely:

Other factors that may make anticipatory nausea and vomiting more likely include:

The earlier that anticipatory nausea and vomiting is identified, the more effective treatment may be.

When symptoms of anticipatory nausea and vomiting are diagnosed early, treatment is more likely to work.

Psychologists and other mental health professionals with special training can often help patients with anticipatory nausea and vomiting. The following types of treatment may be used:

Antinausea drugs given for anticipatory nausea and vomiting do not seem to help.

Acute and delayed nausea and vomiting are common in patients being treated with chemotherapy.

Chemotherapy is the most common cause of nausea and vomiting that is related to cancer treatment.

How often nausea and vomiting occur and how severe they are may be affected by the following:

The following may make acute or delayed nausea and vomiting with chemotherapy more likely if the patient:

Patients who have acute nausea and vomiting with chemotherapy are more likely to have delayed nausea and vomiting as well.

Acute and delayed nausea and vomiting with chemotherapy or radiation therapy are usually treated with drugs.

Drugs may be given before each treatment, to prevent nausea and vomiting. After chemotherapy, drugs may be given to prevent delayed vomiting. Patients who are given chemotherapy several days in a row may need treatment for both acute and delayed nausea and vomiting. Some drugs last only a short time in the body and need to be given more often. Others last a long time and are given less often.

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by chemotherapy and the type of drug.

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by radiation therapy and the type of drug:

It is not known whether it is best to give antinausea medicine for the first 5 days of radiation treatment or for the full treatment course. Talk with your doctor about the treatment plan that is best for you.

Treatment without drugs is sometimes used to control nausea and vomiting.

Non-drug treatments may help relieve nausea and vomiting, and may help antinausea drugs work better. These treatments include:

Nausea and vomiting in children treated with chemotherapy is a serious problem.

Like adults, nausea in children receiving chemotherapy is more of a problem than vomiting. Children may have anticipatory, acute, and/or delayed nausea and vomiting.

Anticipatory nausea and vomiting may occur in children.

Children who have nausea and vomiting after a chemotherapy treatment may have the same symptoms before their next treatment when the child sees, smells, or hears sounds from the treatment room. This is called anticipatory nausea and vomiting.

When the child’s nausea and vomiting is well controlled during and after a chemotherapy treatment, the child may have less anxiety before the next treatment and less chance of having anticipatory symptoms.

Health professionals caring for children who have anticipatory nausea and vomiting have found that children may benefit from:

In children, acute nausea and vomiting is usually treated with drugs and other methods.

Drugs may be given before each treatment to prevent nausea and vomiting. After chemotherapy, drugs may be given to prevent delayed vomiting. Patients who are given chemotherapy several days in a row may need treatment for both acute and delayed nausea and vomiting. Some drugs last only a short time in the body and need to be given more often. Others last a long time and are given less often.

The following table shows drugs that are commonly used to prevent nausea and vomiting caused by chemotherapy and the type of drug. Different types of drugs may be given together to treat acute and delayed nausea and vomiting.

Non-drug treatments may help relieve nausea and vomiting, and may help antinausea drugs work better in children. These treatments include:

Dietary support may include:

Delayed nausea may be hard to detect in children.

Unlike in adults, delayed nausea and vomiting in children may be harder for parents and caregivers to see. A change in the child’s eating pattern may be the only sign of a problem. In addition, most chemotherapy treatments for children are scheduled over several days. This makes the timing and risk of delayed nausea unclear.

Studies on the prevention of delayed nausea and vomiting in children are limited. Children are usually treated the same way as adults, with doses of drugs that prevent nausea adjusted for age.

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of nausea and vomiting (emesis) (N&V). It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Nausea and Vomiting Related to Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/nausea/nausea-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389289]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 3,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.

Cancer, cancer treatment, or diagnostic tests may cause you pain.

Pain is one of the most common symptoms in cancer patients. Pain can be caused by cancer, cancer treatment, or a combination of factors. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, therapies such as bisphosphonates, and diagnostic procedures may cause you pain.

Younger patients are more likely to have cancer pain and pain flares than older patients. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.

This summary is about ways to control cancer pain in adults.

Pain can be managed before, during, and after tests and procedures.

Some tests and procedures are painful. It helps to start pain control before a procedure begins. Some drugs may be used to help you feel calm or fall asleep. Therapies such as imagery or relaxation can also help control pain and anxiety related to treatment. To help lower your anxiety, ask about the test before it begins so you know what to expect. Have a family member or friend stay with you during the procedure.

Different cancer treatments may cause specific types of pain.

Patients may have different types of pain from the treatments they receive, including:

Peripheral neuropathy is a type of pain that can be caused by chemotherapy.

Peripheral neuropathy is a nerve problem that can cause pain, numbness, and tingling in the hands and feet. Patients on chemotherapy may have chemotherapy-induced peripheral neuropathy (CIPN). In some patients, CIPN may continue after chemotherapy has ended.

Studies of drugs and natural products used to treat CIPN have shown mixed results. Duloxetine is a drug that has been studied to treat CIPN.

Studies of acupuncture for CIPN have been reported. For more information about these studies, see the Chemotherapy-induced peripheral neuropathy section in Acupuncture.

Cancer pain may continue after treatment ends.

Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. If you feel depressed or have anxiety, your pain may feel worse and make it harder to control. Some patients are unable to work because of the pain.

Pain control can improve your quality of life.

Pain can be controlled in most patients who have cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life during cancer treatment and after it ends.

Each patient needs a personal plan to control cancer pain.

Each person’s diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your healthcare team can work together to manage your pain. As part of your pain control plan, your healthcare provider can give you and your family members written instructions to manage your pain at home. Ask your healthcare provider who you should call if you have questions about your pain.

Your healthcare team will ask you about your pain to determine the best treatment.

It’s important that the cause of your pain is found early and treated quickly. Your healthcare team will help you measure pain levels often, including at the following times:

To learn about your pain, the healthcare team will ask you the following questions:

Your healthcare team will also review your health history, including the following information:

The information you give your healthcare team will be used to decide how to help relieve your pain. Treatment may include drugs or non-drug therapies. In some cases, patients are referred to pain or palliative care specialists. Your healthcare team will work with you to decide whether the benefits of treatment outweigh any risks. They will also let you know how much relief to expect from your pain treatment. Your doctor will continue to ask you how well your treatment is working and make changes if needed.

A family member or caregiver may be asked to give answers for a patient who has problems with speech, language, or understanding.

Physical and neurological exams will be done to help plan pain control.

The following exams will be done:

Your healthcare team will also assess your psychological, social, and spiritual needs.

Drugs will be given based on whether your pain is mild, moderate, or severe.

Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or given in other ways, such as by infusion or injection.

Your doctor may prescribe extra doses of a drug for pain that occurs between scheduled doses of the drug. The doctor will adjust the drug dose for your needs.

A scale from 0 to 10 is used to measure how severe the pain is and decide which pain medicine to use. On this scale:

Other pain scales that use happy or sad faces may be used for those who have trouble giving their pain a number. These scales are useful for adults who have trouble with memory or thinking, and with young children.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.

Acetaminophen and NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain.

Pain relievers of this type include:

Side effects of NSAIDs include stomach, kidney, heart, and blood problems. Patients, especially older patients, who take acetaminophen or NSAIDs need to be closely watched for side effects. For more information, see Treating Cancer Pain in Older Patients.

Opioids are used to relieve moderate to severe pain.

Opioids work well to relieve moderate to severe pain. Some patients with cancer stop getting pain relief from opioids if they take them for a long time. This is called tolerance. Larger doses or a different opioid may be needed if your body stops responding to the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence).

Since 1999, the number of prescriptions written for opioids and the number of deaths caused by drug overdose in the United States have increased. Although most patients who are prescribed opioids for cancer pain use them safely, some patients may become addicted to opioids. Your doctor will monitor your opioid doses so that you are treated for pain safely.

There are several types of opioids:

The doctor will prescribe drugs and the times they should be taken to best control your pain. It is important that patients and family caregivers know how to safely use, store, and dispose of opioids.

Other drugs may be added to help treat your pain.

Other drugs may be given while you take opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:

Patients will not always respond in the same way to these drugs. Side effects are common and should be reported to your doctor.

Bisphosphonates (pamidronate, zoledronic acid, and ibandronate) are drugs that may be given when cancer has spread to the bones. They are given as an intravenous infusion and combined with other treatments to decrease pain and reduce risk of broken bones. However, bisphosphonates sometimes cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.

The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). For more information, see Oral Complications of Cancer Therapies.

Denosumab is another drug that may be used when cancer has spread to the bones. It is given as a subcutaneous injection and may help prevent and relieve pain.

Nerve blocks

A nerve block is the injection of either a local anesthetic or other drug into or around a nerve to block pain. Nerve blocks help control pain that can’t be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures.

Neurological treatments

Surgery can be done to insert a device that delivers drugs or stimulates the nerves with mild electric current.

Cordotomy

Cordotomy is a less common surgery that is used to relieve pain by cutting certain nerves in the spinal cord. This blocks pain and hot/cold feelings. This procedure may be chosen for patients who are near the end of life and have severe pain that cannot be relieved in other ways.

Palliative care

Certain patients are helped by palliative care services. Palliative care providers may also be called supportive care providers. They work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of the goals of palliative care are to:

For more information, see Planning the Transition to End-of-Life Care in Advanced Cancer.

Radiation therapy

Radiation therapy is used to relieve pain in patients with skin lesions, tumors, or cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that cause pain. Radiation therapy may help patients with bone pain move more freely and with less pain.

The following types of radiation therapy may be used:

Physical medicine and rehabilitation

Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help these patients.

Physical medicine uses physical methods, such as exercise and machines, to prevent and treat disease or injury.

Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain.

Integrative therapies

Complementary and alternative therapies combined with standard treatment may be used to treat pain. They are also called integrative therapies. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to relieve pain.

Certain factors affect cancer pain treatment in older adults.

Some problems are more likely in patients 65 years and older. For caregivers of these patients, the following should be kept in mind:

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute’s (NCI’s) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of pain. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary (“Updated”) is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become “standard.” Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI’s website. For more information, call the Cancer Information Service (CIS), NCI’s contact center, at 1-800-4-CANCER (1-800-422-6237).

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PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Cancer Pain. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: /side-effects/pain/pain-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389322]

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Malnutrition

In 2010, the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism published their proposed etiology-based definitions of malnutrition. These have been accepted by both groups and the Academy of Nutrition and Dietetics (the Academy).[7,11,13] The definitions and characteristics of malnutrition have also been accepted by the Academy’s Oncology Nutrition Evidence Analysis Library Work Group.[14]

Etiology-based definitions of malnutrition include the following:

In 2012, ASPEN and the Academy released a joint statement regarding assessment of malnutrition.[12] The statement serves as a guide for nutrition assessment, including nutrition-focused physical assessment, to determine nutrition status. The assessment takes into consideration that obesity may mask malnutrition and that weight and BMI alone are not good surrogates for nutrition status.[13] The consensus statement provides the criteria for evaluating each of the following six potential indicators of malnutrition, with the recommendation that if two or more characteristics are present, the diagnosis of malnutrition is warranted.

Significant Weight Loss

Weight loss is often used as a surrogate for malnutrition. It has been correlated with adverse outcomes, including increased incidence and severity of treatment side effects and increased risk of infection, thereby reducing chances for survival.[15] Weight loss has been used as an indicator of poor prognosis in cancer patients.[16] One limitation of using weight loss as a surrogate for malnutrition is that it does not take into account the time course of the weight loss or the type of tissue loss.[7] In addition, weight may be affected by fluid shifts and may represent changes in hydration status, edema, or ascites rather than actual changes in fat and lean body mass.

The major nutrition societies in the United States have published criteria for the evaluation of weight loss over time and classifications as moderate or severe [12] (see Table 1). It is important that changes in weight be evaluated in the context of other clinical characteristics of underhydration or overhydration.

Anorexia and Cachexia

Anorexia, the loss of appetite or desire to eat, is typically present in 15% to 25% of all patients with cancer at diagnosis and may also occur as a side effect of treatments or related to the tumor itself. In an observational study of patients in outpatient clinics, anorexia was reported by 26% of patients receiving chemotherapy.[17] Anorexia can be exacerbated by chemotherapy and radiation therapy side effects such as taste and smell changes, nausea, and vomiting. Surgical procedures, including esophagectomy and gastrectomy, may produce early satiety, a premature feeling of fullness.[18] Depression, loss of personal interests or hope, and anxious thoughts may be enough to bring about anorexia and result in malnutrition.[19] Anorexia is an almost-universal symptom in individuals with widely metastatic disease [20,21] because of physiologic alterations in metabolism during carcinogenesis.

Anorexia can hasten the course of cachexia,[19] a progressive wasting syndrome evidenced by weakness and a marked and progressive loss of body weight, fat, and muscle. It can develop in individuals who have adequate protein and calorie intake but have primary cachexia whereby tumor-related factors prevent maintenance of fat and muscle. Patients with diseases of the gastrointestinal tract are particularly at risk of developing anorexia. For more information, see the Tumor metabolism section.

Sarcopenia

Sarcopenia is the condition of severe muscle depletion.[1] The importance of lean body mass is shown in studies of sarcopenia in cancer. A meta-analysis of 38 studies found that a low skeletal muscle index at cancer diagnosis was associated with worse survival in patients with solid tumors.[8] Other studies have also reported poorer overall survival and increased chemotherapy toxicity in patients with sarcopenia.[1,2,9] Sarcopenic obesity may represent a chronic low-level inflammatory state that, as with disease-related malnutrition, often limits the effectiveness of nutrition interventions and requires successful treatment of the underlying disease or condition.[11] Sarcopenia is associated with increased toxicity of treatment and therefore treatment interruptions and dose reductions. It is reported to occur in 50% of patients with advanced cancer.[22–24]

Sarcopenic obesity is the presence of sarcopenia in individuals with a high BMI (≥25 kg/m2), often precipitated by the loss of skeletal muscle and gain of adipose tissue. Sarcopenic obesity is an independent risk factor for poor prognosis.[1,25,26]

It is important to identify and anticipate malnutrition and other nutrition impact symptoms early. (Nutrition impact symptoms are a range of side effects of cancer and cancer treatment that impede oral intake, e.g., alterations in taste and smell, mucositis, dysphagia, stomatitis, nausea, vomiting, diarrhea, constipation, malabsorption, pain, depression, and anxiety.) Nutrition intervention improves outcomes by helping a patient do the following:[4,6,16,22,27–29]

It is suggested that the treating clinician assess baseline nutrition status and be aware of the possible implications of the various therapies. Patients receiving aggressive cancer therapies typically need aggressive nutrition management. For more information, see the Nutrition Screening and Assessment section.

Tumor-Induced Effects on Nutrition Status

Tumors may have systemic or local effects that affect nutrition status, including hypermetabolism, malabsorption, dysmotility, and obstructions.[5]

Treatment-Induced Effects on Nutrition Status

Cancer treatments may cause acute and chronic effects. Nutrition intervention is based on symptom management. Patients who maintain good nutrition are more likely to tolerate the side effects of treatment. Adequate calories and protein can help maintain patient strength and prevent body tissues from further catabolism. Side effects of cancer treatments vary among patients, depending on the type, length, and dose of treatments and the type of cancer being treated (see Table 3). Cancer treatment has toxic effects on the GI tract, including the following:

Screening

Early recognition of nutrition-related issues is necessary for appropriate nutrition management of cancer patients. Nutrition screening can be performed with a validated tool before treatment begins and at regular intervals over the course of treatment.

Nutrition screening can be a simple process that may be completed by hospital staff or members of the community/ambulatory health care team, with the goal of early identification of individuals with or at risk of malnutrition.[1,5,17,18] Leading nutrition organizations—including the American Society for Parenteral and Enteral Nutrition, the European Society for Clinical Nutrition and Metabolism, and the Academy of Nutrition and Dietetics (the Academy)—recommend screening patients in both acute and ambulatory settings for risk of malnutrition.[8,17,18] The Academy’s Oncology Nutrition Dietetic Practice Group, the Oncology Nursing Society, and the Association of Community Cancer Centers recommend screening all patients with cancer in the outpatient setting.[1,5] Because of a mandate from The Joint Commission that all patients admitted to the hospital undergo nutrition screening,[19] most acute care facilities have a screening system set up,[17] although such a system may not be specific to or validated in the oncology setting.

In the outpatient oncology setting, it is recommended that patients be screened initially before treatment begins and rescreened at planned intervals. Screening can most often coincide with the patient’s treatment schedule, such as weekly during radiation therapy and as frequently as every 2 to 3 weeks during chemotherapy, before surgery, and at follow-up visits after completion of treatment or surgical recovery.[1,2,5]

The following five screening tools are validated for use in oncology:[5,20–24]

Only the MST and the PG-SGA have been validated for use in both inpatient and outpatient oncology settings. Several studies have validated use of the abridged PG-SGA (abPG-SGA) or short-form PG-SGA (PG-SGAsf), each of which is simply the section of the PG-SGA completed by the patient.[25,26]

The Nutrition Risk Screening-2002 has not been validated in the oncology setting, but it has been used in several studies of oncology patients. Scores are correlated to general outcomes associated with malnutrition, such as hospital length of stay, complications, and mortality.[2,3,18,27,28]

The NUTRISCORE tool utilizes the MST as a base but has additional items, including tumor location and treatment, that help improve sensitivity (97.3% vs. 84%) and specificity (95.9% vs. 85.6%). The authors used the PG-SGA as the reference for validation in the outpatient oncology setting, also finding that it took less time to complete the NUTRISCORE than it did to complete the PG-SGA.[24] When choosing a screening method, consider who will perform the screen, how much time may be devoted to the process, and what the process will be for referring the patient for a full nutrition assessment.[1] It is also ideal to use a validated tool. The two tools validated for both inpatient and outpatient in oncology settings are presented in further detail below.

Assessment

Nutrition assessment is a comprehensive approach to evaluating and diagnosing nutrition problems and designing interventions.[17] A full nutrition assessment involves evaluation of the following six components:

The assessment of anthropometric measurements evaluates weight loss, takes into account the time frame of weight loss, and is considered in the context of physical findings such as dehydration or fluid retention. Evaluation of food- and nutrition-related history ideally involves a dietitian obtaining a diet history and comparing intake with the patient’s calculated energy needs.[2,6] The nutrition-focused physical assessment evaluates loss of muscle mass and subcutaneous fat, fluid accumulation, and potential micronutrient deficiencies. The physical examination of the following areas determines loss of subcutaneous fat or muscle:

Within the nutrition assessment, the following factors are considered in diagnosing malnutrition:[8]

In addition to the issues described above, the oncology nutrition assessment also takes into account the following:[5]

The goal of an oncology nutrition assessment is to collect the information necessary to determine current or anticipated nutrition issues and to formulate a plan with the patient, caregivers, and other members of the health care team involved with nutrition interventions. Additionally, this multidisciplinary team approach may also include metabolic, pharmacologic, and functional interventions to address and prevent the identified or anticipated nutrition issues.[1,5,30]

Goals of Nutrition Therapy

The goals of medical nutrition therapy are to do the following:[1]

Goals must be individualized for each patient on the basis of the following:

Decisions about the best approach for therapy are informed by symptom severity and function of the gastrointestinal (GI) tract. Treatment could include multiple strategies based on these factors.

Nutrition goals during and after cancer therapy are integrated with goals related to nutrition status and the presence of malnutrition.[2] Table 5 summarizes nutrition goals on the basis of nutrition status, malnutrition as defined by current guidelines,[3] and stage of cancer treatment.

A healthy diet with an emphasis on plant-based foods, regular physical activity, and achievement of a healthy weight has been recommended for all patients after cancer treatment on the basis of extensive reviews of the evidence.[4,5] Evidence-based guidelines for a healthy diet for cancer risk reduction are available online from the American Institute for Cancer Research (AICR) and the American Cancer Society (ACS).

Methods of Nutrition Therapy

Prompt and aggressive nutrition intervention is required for patients with precachexia or cancer cachexia. Intervention is more likely to be effective when started early. Interventions include an individualized approach to oral, enteral, and parenteral nutrition using evidence-based recommendations, guidelines, and program and regulatory standards.

The dietitian works with the patient, caregivers, and members of the health care team to (1) improve compliance and the effectiveness of pharmacotherapy interventions prescribed to manage cancer and cancer treatment–related symptoms; and (2) counsel patients about behavioral strategies to alleviate nutrition impact symptoms.[1]

Goals of Nutrition Therapy in Advanced Cancer

Nutrition goals for a patient with advanced cancer may depend on the overall plan of care. These patients may be receiving anticancer therapy (with or without concurrent palliative care), may be receiving palliative care alone, or may be enrolled in hospice. Regardless of the care setting, patients are screened to determine the need for nutrition intervention. The Patient-Generated Subjective Global Assessment (PG-SGA) has been validated in cancer patients and addresses body weight history, food intake, symptoms, and functional status.[9,10] When palliative care is initiated early in the disease process, nutrition goals focus on supporting active treatment and aim to improve treatment outcomes, body composition, physical function, and symptom palliation.

As the focus of care shifts from cancer-modifying therapy to hospice or end-of-life care, nutrition goals may become less aggressive, with a shift toward comfort. Continued assessment and adjustment of nutrition goals and interventions is required throughout this continuum to meet the changing needs of the patient receiving palliative or hospice care services.[9]

Nutrition Intervention in Advanced Cancer

Ethical issues may arise when patients, families, or caregivers request artificial nutrition and hydration when there is no prospect of recovering from the underlying illness or benefiting appreciably from the intervention. When there is uncertainty about whether a patient will benefit from artificial nutrition, hydration, or both, a time-limited trial with clear, measurable endpoints may be useful. The caregiving team will explain that, as with other medical therapies, artificial nutrition and hydration can be stopped if the desired nutrition effects do not occur.[11]

Randomized controlled trials of enteral or parenteral nutrition in cancer patients receiving formal palliative care are lacking.[12] On the basis of available evidence and expert consensus, clinical guidelines recommend that the use of nutrition support therapy in advanced cancer be limited to carefully selected patients.[13,14] Patients who have demonstrated a favorable response to parenteral nutrition include those with the following:[15,13,16]

If patients are to benefit from parenteral nutrition, they must be physically and emotionally capable of participating in their own care and have the following:[13]

Patients with a life expectancy shorter than 40 days may be palliated with home intravenous (IV) fluid therapy, although this practice is controversial.[13]

Nutrition Considerations for the End of Life

Patients and caregivers often consider the provision of food and fluids to be basic care. However, the use of artificial nutrition and hydration at the end of life is a complex and controversial intervention that is influenced by clinical, cultural, religious, ethical, and legal factors. Patients and families often believe these interventions will improve quality and length of life, but evidence of clear benefit is lacking.[12,17] There are also potential burdens associated with this care, including the following:

In addition, agitated or confused patients receiving artificial nutrition and hydration may need to be physically restrained to prevent them from removing a gastrostomy tube, nasogastric tube, or central IV line.[18]

Patients at the end of life who have increased difficulty with swallowing have less risk of aspiration with thick liquids than with thin liquids.[7] Thirst can often be alleviated with sips of water, ice chips, and good mouth care. In the last few days of life, the incidence of swallowing problems can be as high as 79% and include frequent coughing, anorexia, and problems with oral secretions.[19] Communication within the health care team and support of the family and caregivers is important in alleviating the distress concerning decreased food and fluid intake and in eliminating unrealistic expectations.[7]

For patients at the end of life, the goal of nutrition therapy is to alleviate symptoms rather than reverse nutrition deficits. The pleasure of tasting food and the social benefits of participating in meals with family and friends can be emphasized over increasing caloric intake.[6] A systematic review of practices and effects on cancer patients in the last week of life found no study supporting the use of artificial nutrition, and studies with artificial hydration had mixed results.[20] Studies on hydration with positive effects reported less chronic nausea and physical signs of dehydration, while studies with negative effects found more ascites and intestinal drainage. Other studies found no effect on terminal delirium, thirst, chronic nausea, or fluid overload.[20]

A well-designed randomized trial reported that hydration at 1 L/d for a week did not improve dehydration symptoms (fatigue, myoclonus, sedation, hallucinations) and provided no benefit in quality of life or survival.[21] A prospective evaluation of Japanese national guidelines for parenteral hydration at the end of life suggests little harm or benefit; however, patients expressed a high level of satisfaction and felt it was beneficial.[22] A subsequent study utilizing the Japanese guidelines reported that hydration-related symptoms (nausea, edema, dyspnea, abdominal pain/distention) were significantly improved, as were quality of life, global satisfaction, and feeling of benefit.[23]

The American Academy of Hospice and Palliative Medicine suggests that providers facilitate respectful and informed discussions about the effects of artificial nutrition and hydration near the end of life among physicians, other health care professionals, patients, and families.[11] It is incumbent on physicians and other health care providers to describe the options when the implementation, continuation, or discontinuation of artificial nutrition and hydration is being considered, and to establish goals of care with the patient and/or surrogate decision-maker. Ideally, patients will make their own decisions on the basis of a careful assessment of potential benefits and burdens, consistent with legal and ethical norms that permit patients to accept or forgo specific medical interventions.[11]

Ethical, Cultural, and Religious Issues in Medically Assisted Nutrition and Hydration in Advanced Cancer

Decisions about whether to provide artificial nutrition and hydration to patients in the late stages of life are complex and influenced by ethical, cultural, and religious issues, as well as by legal issues, clinical considerations, and patient and family preferences. The event of death itself, the manner in which it occurs, and the patient’s quality of life are significant matters that have spiritual and psychological consequences for each person involved.[24]

A number of organizations have published guidelines on the ethical considerations about whether to forgo or discontinue hydration and nutrition support, including the following:

These guidelines reflect judicial decisions that have supported the authority and liberty of the competent individual to refuse life-saving hydration and nutrition, the role of medical expertise, and respect for the dignity and values of the patient and family. For more information, see the sections on Artificial Hydration and Artificial Nutrition in Last Days of Life.

Religion and religious traditions provide a set of core beliefs about life events and an ethical foundation for clinical decision-making.[24] Although the fundamental principles of major religions provide perspectives on death and dying, decisions related to artificial nutrition and hydration remain complicated, varying even within the same major religion or faith tradition.

To provide an optimal and inclusive healing environment, all palliative team members need to be aware of their own spirituality and how it may differ from that of fellow team members and the patients and families they serve.[29,30] Clinical practice guidelines established by the National Consensus Project for Quality Palliative Care address spiritual, religious, and existential aspects of care.[31] One group of researchers [24] has provided insight into the principles and perspectives held by Roman Catholic, Jewish, Buddhist, and Islamic faith traditions. Another group [32] has provided an extensive analysis of how world religions formulate ethical decisions related to withdrawing treatment and determining when death has occurred.

Religious beliefs are often closely related to cultural views. Individuals living in the midst of a particular tradition can continue to be influenced by it, even if they have stopped believing in or practicing it.[32] In some cultures, individual autonomy is not the prevailing or predominant principle; some Asian, American Indian/Alaska Native, and Hispanic cultures favor family or community autonomy.[26] Distinguishing between majority and minority cultures is important. Patients may rely on religion and spirituality as important means to interpret and cope with illness.[33]

Religious and cultural preferences about artificial nutrition and hydration are expressions of a patient’s autonomy and, in many cases, may outweigh clinical considerations. When these values conflict with clinical judgment, practitioners may work with the patient and/or surrogate in consulting with faith leaders and the patient’s ethnic community, as well as the institutional ethics committee, to facilitate resolution.[26,27]