51
|
Yoon SL, Kim JA, Kelly DL, Lyon D, George TJ. Predicting unintentional weight loss in patients with gastrointestinal cancer. J Cachexia Sarcopenia Muscle 2019; 10:526-535. [PMID: 30834673 PMCID: PMC6596456 DOI: 10.1002/jcsm.12398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 11/21/2018] [Accepted: 01/01/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Unintentional weight loss is a major problem for patients with gastrointestinal (GI) cancers because it affects treatment, survival outcomes, and quality of life. To date, little is known about the trajectory of weight loss and the relationship between baseline body mass index (BMI), location of the cancer, and outcomes. The aims of this study were to investigate patterns of weight loss over time in patients with GI cancer according to BMI groups (low, normal, and high) and location of cancer. METHODS We examined de-identified electronic medical record data of 801 adults (>21 years) with GI cancer using ICD-9 codes (150-159). Descriptive statistics and linear mixed models were used to examine unintentional weight loss over time by BMI group (low, normal, and high) and to determine the effect of primary cancer site and patient characteristics on weight loss. RESULTS The mean age of patients was 66.5 ± 11.9 years (21-95 years), with 58% male and 86% White. Mean weight loss over 3 years was 21.39 kg. At the first observation point, 7.8% were in the low BMI group, 30.1% were in the normal, and 62% were in the high group. At the end of observation, a majority of deaths (35.5%) occurred in the low BMI group (BMI < 20 kg/m2 ). Significant weight loss was observed in patients with gastric (t = -5.11, P < 0.001), oesophageal (t = -4.18, P < 0.001), and pancreatic (35.8%, t = -3.58, P < 0.001) cancers. Predictors of weight change were gender (F = 64.93, P < 0.001), cancer stage (F = 7.28, P < 0.001), and site by days (F = 8.24, P < 0.001). Weight loss rates were similar among the three BMI groups, but patterns were different based on primary cancer type as a function of days within each group. CONCLUSIONS Weight loss in patients with GI cancers has implications for survival. Patients with upper GI cancers experienced more weight loss and decreased survival rates compared with patients with lower GI cancers. Patients with a combination of upper GI cancer (oesophagogastric or pancreatic) and low baseline BMI had the fewest survival days and worst patient outcomes. Early intervention for weight management plays a critical role for improving the health outcomes and fatality rates of these patients.
Collapse
Affiliation(s)
- Saunjoo L Yoon
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Jung A Kim
- School of Nursing, Hanyang University, Seoul, South Korea
| | - Debra Lynch Kelly
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Debra Lyon
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Thomas J George
- College of Medicine, Division of Hematology and Oncology, University of Florida, Gainesville, FL, USA
| |
Collapse
|
52
|
Layer P, Kashirskaya N, Gubergrits N. Contribution of pancreatic enzyme replacement therapy to survival and quality of life in patients with pancreatic exocrine insufficiency. World J Gastroenterol 2019; 25:2430-2441. [PMID: 31171887 PMCID: PMC6543241 DOI: 10.3748/wjg.v25.i20.2430] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/02/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
The objective of this study was to analyze the current evidence for the use of pancreatic enzyme replacement therapy (PERT) in affecting survival and quality of life in patients with pancreatic exocrine insufficiency (PEI). Systematic searches of the literature were performed using the PubMed database. Articles were selected for inclusion if they reported findings from trials assessing the effects of PERT on quality of life, survival, malabsorption, growth parameters (such as height, body weight and body mass index), or gastrointestinal symptoms (such as abdominal pain, stool consistency and flatulence). PERT improved PEI-related malabsorption and weight maintenance in patients with cystic fibrosis, chronic pancreatitis, pancreatic cancer, and post-surgical states. In patients with chronic pancreatitis, PERT improved PEI-related symptoms and quality of life measures. Several small retrospective studies have also suggested that PERT may have a positive impact on survival, but long-term studies assessing this effect were not identified. PERT is effective for treating malnutrition and supporting weight maintenance, and it is associated with improved quality of life and possibly with enhanced survival in patients with PEI. However, there is evidence that not all patients with PEI receive adequate PERT. Future work should aim to assess the long-term effects of PERT on the survival of patients with PEI.
Collapse
Affiliation(s)
- Peter Layer
- Department of Internal Medicine, Israelitic Hospital, Hamburg 22297, Germany
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis group), Federal State Budgetary Institution “Research Centre for Medical Genetics”, Moscow 115522, Russia
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman 83001, Ukraine
| |
Collapse
|
53
|
Hendifar AE, Petzel MQB, Zimmers TA, Denlinger CS, Matrisian LM, Picozzi VJ, Rahib L. Pancreas Cancer-Associated Weight Loss. Oncologist 2019; 24:691-701. [PMID: 30591550 PMCID: PMC6516128 DOI: 10.1634/theoncologist.2018-0266] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/18/2018] [Indexed: 12/17/2022] Open
Abstract
Unintentional weight loss in patients with pancreatic cancer is highly prevalent and contributes to low therapeutic tolerance, reduced quality of life, and overall mortality. Weight loss in pancreatic cancer can be due to anorexia, malabsorption, and/or cachexia. Proper supportive care can stabilize or reverse weight loss in patients and improve outcomes. We review the literature on supportive care relevant to pancreatic cancer patients, and offer evidence-based recommendations that include expert nutritional assessment, counseling, supportive measures to ensure adequate caloric intake, pancreatic enzyme supplementation, nutritional supplement replacement, orexigenic agents, and exercise. Pancreatic Cancer Action Network-supported initiatives will spearhead the dissemination and adoption of these best supportive care practices. IMPLICATIONS FOR PRACTICE: Weight loss in pancreatic cancer patients is endemic, as 85% of pancreatic cancer patients meet the classic definition of cancer cachexia. Despite its significant prevalence and associated morbidity, there is no established approach to this disease entity. It is believed that this is due to an important knowledge gap in understanding the underlying biology and lack of optimal treatment approaches. This article reviews the literature regarding pancreas cancer-associated weight loss and establishes a new framework from which to view this complex clinical problem. An improved approach and understanding will help educate clinicians, improve clinical care, and provide more clarity for future clinical investigation.
Collapse
Affiliation(s)
| | | | - Teresa A Zimmers
- Indiana University, Simon Cancer Center, Indianapolis, Indiana, USA
| | | | - Lynn M Matrisian
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
| | | | - Lola Rahib
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
| |
Collapse
|
54
|
Landers A, Brown H, Strother M. The effectiveness of pancreatic enzyme replacement therapy for malabsorption in advanced pancreatic cancer, a pilot study. Palliat Care 2019; 12:1178224218825270. [PMID: 30799929 PMCID: PMC6378466 DOI: 10.1177/1178224218825270] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022] Open
Abstract
Advanced adenocarcinoma of the pancreas has a globally poor prognosis. One of the characteristic features of pancreatic cancer (PC) is pancreatic exocrine insufficiency (PEI). This leads to a malabsorption syndrome and subsequent digestive symptoms. Given the high prevalence of PEI and malabsorption in PC, empiric use of pancreatic enzyme replacement therapy (PERT) is recommended. The aim of this pilot study was to determine the potential efficacy of PERT in improving symptoms and quality of life in those with metastatic PC. The study recruited patients with advanced PC referred to a specialist palliative care service. Following an initial assessment, patients were commenced on pancrealipase 25,000IU (Creon) and reassessed after 1 week and 3 weeks post-initiation of supplementation. These assessments included demographics, malabsorption symptom checklist, and completion of two validated quality-of-life questionnaires, the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-PAN26. PERT was associated with statistically significant improvement of symptoms in both the general (QLQ-C30) and pancreatic cancer specific tool (PAN26). Within 1 week of PERT initiation, there was a reduction in diarrhoea scores (26 vs. 8, p<0.005), pancreatic and hepatic pain (47 vs. 33 and 24 vs. 11, respectively, p<0.05). After 3 weeks, there were significant improvements in pancreatic pain and bloating/gas symptoms (47 vs. 26 and 46 vs. 26, respectively, p< 0.005). PERT appears to have the potential to improve symptoms of malabsorption in patients with metastatic PC.
Collapse
Affiliation(s)
- Amanda Landers
- Department of Medicine, University of Otago, Christchurch New Zealand
| | - Helen Brown
- Nurse Maude Hospice Palliative Care Service, Nurse Maude Association, Christchurch, New Zealand
| | | |
Collapse
|
55
|
Park JS, Kim HM, Jeung HC, Kang SA. Association between early nutritional risk and overall survival in patients with advanced pancreatic cancer: A single-center retrospective study. Clin Nutr ESPEN 2019; 30:94-99. [PMID: 30904235 DOI: 10.1016/j.clnesp.2019.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/14/2018] [Accepted: 01/31/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS We investigated the predictors of overall survival (OS) among Korean patients with advanced pancreatic cancer (PC) according to their baseline nutritional status. METHODS We retrospectively reviewed the data of 412 inpatients with PC between January 2007 and February 2015 at the Department of Oncology of the Gangnam Severance Hospital, Korea. Data on demographic and clinical parameters were collected from electronic medical records, and OS was estimated using the Kaplan-Meier method. Stepwise Cox regression analysis was used to determine the factors associated with survival. Patients with a Nutritional Risk Screening (NRS) 2002 score <3 were classified as "no-risk; " those with a score of 3 were classified as "moderate-risk; " and those with a score of ≥4 were classified as "high-risk." RESULTS Following nutritional screening at baseline, 194 patients (47.1%, mean age 61.8 ± 9.9 years) were classified as the "no risk" group; 81 patients (19.7%, mean age 65.4 ± 10.8 years), as the "moderate risk" group; and 137 patients (33.3%, mean age 67.8 ± 12.0 years), as the "high risk" group. Predictors of survival were NRS 2002 score (hazard ratio [HR] = 1.238; 95% confidence interval [CI] = 1.143-1.341), percentage of lymphocytes (HR = 0.973; 95% CI = 0.962-0.984), C-reactive protein level (HR = 1.003; 95% CI = 1.001-1.006), carcinoembryonic antigen level (HR = 1.000; 95% CI = 1.000-1.000), and carbohydrate antigen 19-9 level (HR = 1.000; 95% CI = 1.000-1.000). Kaplan-Meier survival analysis showed significant differences in the median OS among the NRS 2002 groups: "no risk" group: 12.3 ± 0.4 months (95% CI: 11.47-13.13 months); "moderate risk" group: 6.5 ± 0.9 months (95% CI: 4.78-8.17 months); and "high risk" group: 5.5 ± 0.6 months (95% CI: 4.31-6.69 months). CONCLUSIONS A good baseline nutritional status was associated with OS among Korean patients with advanced PC. An improvement in the nutritional status of patients with advanced PC through baseline nutritional interventions is therefore necessary to prolong OS.
Collapse
Affiliation(s)
- Joung Soon Park
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyung-Mi Kim
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hei-Cheul Jeung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Soon Ah Kang
- Department of Converting Technology, Graduated of Venture, Hoseo University, Seoul, Republic of Korea.
| |
Collapse
|
56
|
Wong HCY, Lam KY, Chong CCN, Chan AWH, Chan SL. Impact of Weight Loss During Chemotherapy in Chinese Patients with Unresectable Pancreatic Cancer. Nutr Cancer 2019; 71:954-970. [PMID: 31058551 DOI: 10.1080/01635581.2019.1595047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background: Weight loss is frequently observed in pancreatic cancer patients. We aimed to study the prognostic impacts of weight loss early during chemotherapy. Methods: A total of 72 patients of Chinese ethnicity with unresectable pancreatic cancer who underwent chemotherapy were reviewed. Critical weight loss (CWL) was defined as weight loss ≥ 5% within one month after treatment. The prognostic impact of weight loss and CWL were analyzed. Results: 47 patients (65.3%) had weight loss after one month of treatment, with 14 (19.4%) suffering from CWL. Baseline characteristics were similar between patients with and without CWL. The median OS and Time-to-treatment-failure (TTF) of patients with CWL were shorter than those without CWL (OS: 4.8 months [CWL] versus [vs.] OS 7.1 months [No CWL]; TTF 1.6 months [CWL] vs. 3.2 months [No CWL]; both P < 0.01). CWL was an independent adverse prognosticator for OS (Hazard Ratio [HR] = 2.50; P = 0.01) and TTF (HR = 2.71; P < 0.01). Other independent prognosticators for OS were serum albumin <35 mg/dl and CA19-9 ≥ 1000 IU/ml, while CWL was the only independent prognosticator for TTF (HR 2.71 [95% CI 1.33-5.52]; P < 0.01). Conclusions: Development of CWL in early course of chemotherapy was associated with worse prognosis in Chinese patients with unresectable pancreatic cancers.
Collapse
Affiliation(s)
- Henry C Y Wong
- a Department of Oncology , Princess Margaret Hospital , Hong Kong
| | - Kwan Y Lam
- b Department of Clinical Oncology , Sir YK Pao Center for Cancer, Prince of Wales Hospital , Hong Kong
| | - Charing C N Chong
- c Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery , The Chinese University of Hong Kong , Hong Kong
| | - Anthony W H Chan
- d Department of Anatomical and Cellular Pathology , Prince of Wales Hospital, The Chinese University of Hong Kong , Hong Kong
- e State Key Laboratory in Oncology in South China , The Chinese University of Hong Kong , Hong Kong
| | - Stephen L Chan
- b Department of Clinical Oncology , Sir YK Pao Center for Cancer, Prince of Wales Hospital , Hong Kong
- e State Key Laboratory in Oncology in South China , The Chinese University of Hong Kong , Hong Kong
- f Institute of Digestive Disease , The Chinese University of Hong Kong , Hong Kong
| |
Collapse
|
57
|
Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
Collapse
Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| |
Collapse
|
58
|
Britto FA, Cortade F, Belloum Y, Blaquière M, Gallot YS, Docquier A, Pagano AF, Jublanc E, Bendridi N, Koechlin-Ramonatxo C, Chabi B, Francaux M, Casas F, Freyssenet D, Rieusset J, Giorgetti-Peraldi S, Carnac G, Ollendorff V, Favier FB. Glucocorticoid-dependent REDD1 expression reduces muscle metabolism to enable adaptation under energetic stress. BMC Biol 2018; 16:65. [PMID: 29895328 PMCID: PMC5998563 DOI: 10.1186/s12915-018-0525-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 05/04/2018] [Indexed: 12/14/2022] Open
Abstract
Background Skeletal muscle atrophy is a common feature of numerous chronic pathologies and is correlated with patient mortality. The REDD1 protein is currently recognized as a negative regulator of muscle mass through inhibition of the Akt/mTORC1 signaling pathway. REDD1 expression is notably induced following glucocorticoid secretion, which is a component of energy stress responses. Results Unexpectedly, we show here that REDD1 instead limits muscle loss during energetic stresses such as hypoxia and fasting by reducing glycogen depletion and AMPK activation. Indeed, we demonstrate that REDD1 is required to decrease O2 and ATP consumption in skeletal muscle via reduction of the extent of mitochondrial-associated endoplasmic reticulum membranes (MAMs), a central hub connecting energy production by mitochondria and anabolic processes. In fact, REDD1 inhibits ATP-demanding processes such as glycogen storage and protein synthesis through disruption of the Akt/Hexokinase II and PRAS40/mTORC1 signaling pathways in MAMs. Our results uncover a new REDD1-dependent mechanism coupling mitochondrial respiration and anabolic processes during hypoxia, fasting, and exercise. Conclusions Therefore, REDD1 is a crucial negative regulator of energy expenditure that is necessary for muscle adaptation during energetic stresses. This present study could shed new light on the role of REDD1 in several pathologies associated with energetic metabolism alteration, such as cancer, diabetes, and Parkinson’s disease. Electronic supplementary material The online version of this article (10.1186/s12915-018-0525-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | | | | | - Marine Blaquière
- PHYMEDEXP, Univ. Montpellier, INSERM, CNRS, CHRU of Montpellier, Montpellier, France
| | | | | | | | | | - Nadia Bendridi
- INSERM UMR-1060, CarMeN Laboratory, Lyon 1 University, INRA U1397, Oullins, France
| | | | | | - Marc Francaux
- Institute of Neuroscience, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | | | | | - Jennifer Rieusset
- INSERM UMR-1060, CarMeN Laboratory, Lyon 1 University, INRA U1397, Oullins, France
| | | | - Gilles Carnac
- PHYMEDEXP, Univ. Montpellier, INSERM, CNRS, CHRU of Montpellier, Montpellier, France
| | | | | |
Collapse
|
59
|
Domínguez-Muñoz JE, Nieto-Garcia L, López-Díaz J, Lariño-Noia J, Abdulkader I, Iglesias-Garcia J. Impact of the treatment of pancreatic exocrine insufficiency on survival of patients with unresectable pancreatic cancer: a retrospective analysis. BMC Cancer 2018; 18:534. [PMID: 29728096 PMCID: PMC5935964 DOI: 10.1186/s12885-018-4439-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 04/26/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Malnutrition and weight loss are commonly observed in patients with pancreatic cancer and contribute to poor survival. Pancreatic exocrine insufficiency (PEI), which can be caused by ductal obstruction by a tumor, causes maldigestion and malabsorption of nutrients, thus contributing to malnutrition in these patients. In this study, we evaluated the effects of pancreatic enzyme replacement therapy (PERT) on survival in patients with unresectable pancreatic cancer. METHODS A retrospective analysis was conducted on a database of patients with unresectable, pathologically confirmed pancreatic cancer. All patients were evaluated for palliative chemotherapy and received the optimal palliative care. Patients were divided into two groups: Group 1 received standard therapy; Group 2 underwent additional evaluation of the pancreatic function and therapy with PERT, if needed. Survival (median and 95% confidence interval [CI]) was analyzed using Kaplan-Meier and Cox regression; groups were compared using the log-rank test. RESULTS Overall, 160 patients with unresectable pancreatic cancer were included in the analysis (mean age: 70.5 years [range 28-100]; gender: 57.5% male; tumor stage: 78.7% Stage IV). Eighty-six patients (53.75%) were in Group 1 and 74 (46.25%) were in Group 2. Age, gender, tumor size, location and stage, weight loss, and serum CA 19-9 were similar between groups. Ninety-three (58.1%) patients received palliative chemotherapy; 46.5% in Group 1 and 71.6% in Group 2 (P < 0.001). Forty-nine (66.2%) patients in Group 2 and none in Group 1 received PERT. Survival in Group 2 (189 days, 95% CI 167.0-211.0 days) was significantly longer than in Group 1 (95.0 days, 95% CI 75.4-114.6 days) (HR 2.117, 95% CI 1.493-3.002; P < 0.001). Chemotherapy and PERT were significantly and independently associated with longer survival in a model controlled by age and tumor stage. In patients with significant weight loss at diagnosis (> 10% bodyweight within 6 months), PERT was associated with longer survival (HR 2.52, 95% CI 1.55-4.11; P < 0.001). CONCLUSIONS In patients with unresectable pancreatic cancer, PERT in patients with PEI was associated with longer survival compared with those not receiving PERT, especially in those experiencing significant weight loss. This finding should guide future prospective clinical trials of similar interventions.
Collapse
Affiliation(s)
- Juan Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Laura Nieto-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Javier López-Díaz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Jose Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Ihab Abdulkader
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Department of Pathology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| |
Collapse
|
60
|
Trestini I, Carbognin L, Sperduti I, Bonaiuto C, Auriemma A, Melisi D, Salvatore L, Bria E, Tortora G. Prognostic impact of early nutritional support in patients affected by locally advanced and metastatic pancreatic ductal adenocarcinoma undergoing chemotherapy. Eur J Clin Nutr 2018; 72:772-779. [DOI: 10.1038/s41430-018-0155-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 01/31/2018] [Accepted: 03/04/2018] [Indexed: 02/07/2023]
|
61
|
Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma. Eur J Cancer 2018; 92:20-32. [PMID: 29413686 DOI: 10.1016/j.ejca.2017.12.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/13/2017] [Accepted: 12/20/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Quality of life (QOL) is impaired in pancreatic cancer patients. Our aim was to investigate the determinants and prognostic value of QOL after diagnosis in a hospital-based cohort of racially/ethnically diverse patients with pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS QOL was prospectively assessed using the Short Form-12 in 2478 PDAC patients. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were categorised into tertiles based on their distribution. Ordered logistic regression was adopted to compare the risk of having lower PCS and MCS by patient sociodemographic and clinical characteristics. The association of PCS and MCS with mortality was assessed by Cox regression. RESULTS Compared with non-Hispanic whites, Hispanics were at significantly higher risk of having lower PCS (odds ratio [95% CI], 1.69 [1.26-2.26]; P < 0.001) and lower MCS (1.66 [1.24-2.23]; P < 0.001). Patients diagnosed with stage III (1.80 [1.10-2.94]; P = 0.02) and stage IV (2.32 [1.50-3.59]; P < 0.001) PDAC were more likely to have lower PCS than stage I patients. Other determinants of QOL included sex, age, drinking, smoking, education level, comorbidities and time since diagnosis. The low tertile of PCS (hazard ratio [95% CI], 1.94 [1.72-2.18]; P < 0.001) and MCS (1.42 [1.26-1.59]; P < 0.001) were each related to poor prognosis. Similar results were found for non-Hispanic whites as compared with African-Americans/Hispanics/others. CONCLUSION QOL after diagnosis is a significant prognostic indicator for patients with PDAC. Multiple factors determine QOL, suggesting possible means of intervention to improve QOL and outcomes of PDAC patients.
Collapse
|
62
|
Hendifar AE, Chang JI, Huang BZ, Tuli R, Wu BU. Cachexia, and not obesity, prior to pancreatic cancer diagnosis worsens survival and is negated by chemotherapy. J Gastrointest Oncol 2018; 9:17-23. [PMID: 29564167 DOI: 10.21037/jgo.2017.11.10] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Although advanced pancreatic ductal adenocarcinoma (PDAC) is characterized by progressive weight loss and nutritional deterioration, the effect of cancer cachexia and body mass index (BMI) at diagnosis on survival remains unclear. Methods We retrospectively evaluated a prospectively collected internal cancer registry of PDAC cases from 2006-2014 at the Kaiser Permanente Medical Center. Cancer cachexia was defined as weight loss greater than 5% over the 6 months prior to diagnosis. Multivariate cox proportional hazards regression was used to assess the influence of cachexia on survival. To evaluate effect measure modification of this relationship, we performed additional analyses stratified by race, BMI class, stage, receipt of surgery and receipt of chemotherapy. We tested for heterogeneity by fitting models with an interaction term for cachexia and the modifying variable. Results Of the 977 patients, 611 (63%) were identified with cachexia. Cachexia in PDAC patients was prevalent across all stages of disease and BMI classes. Patients with cachexia had lower survival (median 4.3 months, IQR 1.7-10.0) compared to those without cachexia (median 5.2 months, IQR 2.0-10.6), log-rank P=0.03. In this analysis BMI at diagnosis was not associated with survival. In the multivariate Cox regression, cachexia was independently associated with decreased overall survival (HR 1.24, CI: 1.06-1.45, P=0.01). However, the effect of cachexia on survival outcomes was modified by receipt of chemotherapy. Cachectic patients who did not receive chemotherapy had a 40% increase in risk of death compared to non-cachectic patients (HR 1.40, CI: 1.12-1.75), while those receiving chemotherapy were unaffected by cachexia (HR 1.04, CI: 0.82-1.32, Pinteraction=0.01). Conclusions In the largest cohort of pancreatic cancer patients examined to date, cachexia and not obesity is independently associated with worse survival in PDA and its effect is negated by systemic chemotherapy.
Collapse
Affiliation(s)
- Andrew E Hendifar
- Hematology and Oncology, Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jonathan I Chang
- Department of Internal Medicine, Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| | - Brian Z Huang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Richard Tuli
- Division of Biomedical Sciences, Department of Radiation Oncology, Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bechien U Wu
- Center for Pancreatic Care, Division of Gastroenterology, Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
63
|
Lewis AR, Pihlak R, McNamara MG. The importance of quality-of-life management in patients with advanced pancreatic ductal adenocarcinoma. Curr Probl Cancer 2018; 42:26-39. [PMID: 29631711 DOI: 10.1016/j.currproblcancer.2018.01.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 12/15/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) carries a poor prognosis, and as such, a focus on quality of life is vital. This review will discuss various aspects of quality of life in patients with PDAC and their treatment. Pancreatic exocrine and endocrine insufficiency may result in issues related to nutrition, and pain and fatigue are other common symptoms, and may be managed with pharmaceutical or nonpharmaceutical methods. It has also been reported that low mood is a particular problem for patients with PDAC compared to patients with other cancers; however, the data supporting this is inconsistent. Data regarding improvements in quality of life in patients with PDAC receiving chemotherapy is also reviewed, which in some cases suggests a benefit to chemotherapy, particularly in the presence of a radiological response. Furthermore, the importance of early palliative care is discussed and the benefits reported including improved quality of life and mood, reduced aggressive interventions at the end of life and improved survival. Areas for future development may include increased use of quality of life as a trial outcome and the use of patient-reported outcomes to improve symptomatic care of patients, and particularly in those receiving active systemic treatment.
Collapse
Affiliation(s)
- Alexandra R Lewis
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Rille Pihlak
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK.
| |
Collapse
|
64
|
Dunne RF, Mustian KM, Garcia JM, Dale W, Hayward R, Roussel B, Buschmann MM, Caan BJ, Cole CL, Fleming FJ, Chakkalakal JV, Linehan DC, Hezel AF, Mohile SG. Research priorities in cancer cachexia: The University of Rochester Cancer Center NCI Community Oncology Research Program Research Base Symposium on Cancer Cachexia and Sarcopenia. Curr Opin Support Palliat Care 2017; 11:278-286. [PMID: 28957880 PMCID: PMC5658778 DOI: 10.1097/spc.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Cancer cachexia remains understudied and there are no standard treatments available despite the publication of an international consensus definition and the completion of several large phase III intervention trials in the past 6 years. In September 2015, The University of Rochester Cancer Center NCORP Research Base led a Symposium on Cancer Cachexia and Sarcopenia with goals of reviewing the state of the science, identifying knowledge gaps, and formulating research priorities in cancer cachexia through active discussion and consensus. RECENT FINDINGS Research priorities that emerged from the discussion included the implementation of morphometrics into clinical decision making, establishing specific diagnostic criteria for the stages of cachexia, expanding patient selection in intervention trials, identifying clinically meaningful trial endpoints, and the investigation of exercise as an intervention for cancer cachexia. SUMMARY Standardizing how we define and measure cancer cachexia, targeting its complex biologic mechanisms, enrolling patients early in their disease course, and evaluating exercise, either alone or in combination, were proposed as initiatives that may ultimately result in the improved design of cancer cachexia therapeutic trials.
Collapse
Affiliation(s)
- Richard F Dunne
- aWilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York bDepartment of Medicine, University of Washington School of Medicine, Seattle, Washington cDepartment of Supportive Care Medicine, City of Hope, Duarte dSchool of Sport and Exercise Science, University of Northern Colorado, Greeley, Colorado eDepartment of Medicine, Brown University, Providence, Rhode Island fDepartment of Medicine, The University of Chicago, Chicago, Ilinois gKaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
65
|
Roberts KJ, Schrem H, Hodson J, Angelico R, Dasari BVM, Coldham CA, Marudanayagam R, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF. Pancreas exocrine replacement therapy is associated with increased survival following pancreatoduodenectomy for periampullary malignancy. HPB (Oxford) 2017; 19:859-867. [PMID: 28711377 DOI: 10.1016/j.hpb.2017.05.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 05/10/2017] [Accepted: 05/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although many patients undergoing pancreatoduodenectomy (PD) for cancer have pancreatic exocrine insufficiency, pancreatic enzyme replacement therapy (PERT) is not routinely used, and effects upon post-operative survival are unclear. METHODS This review of patients undergoing PD for periampullary malignancy sought to test for an association between PERT and overall survival, with post-hoc subgroup analysis performed after stratifying patients by the year of surgery, pancreatic duct width and tumour type. RESULTS Some 202/469 (43.1%) patients received PERT. After accounting for pathological variables and chemotherapy, PERT use was found to be independently associated with improved survival on multivariable analysis [HR 0.72 (95% CI: 0.52-0.99), p = 0.044] and on propensity matched analysis (p = 0.009). The effect of PERT upon improved survival was predominantly observed amongst patients with a dilated pancreatic duct (≥3 mm). DISCUSSION PERT use was independently associated with improved survival following PD for cancer. The validity of this observation is supported by an effect largely confined to those patients with a dilated pancreatic duct. The nutritional status of patients undergoing PD for cancer needs further investigation and the effects of PERT require verification in further clinical studies.
Collapse
Affiliation(s)
- Keith J Roberts
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom.
| | - Harald Schrem
- Dept. of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - James Hodson
- Medical Statistician, Institute of Translational Medicine, University Hospitals Birmingham, United Kingdom
| | - Roberta Angelico
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| | - Bobby V M Dasari
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| | - Chris A Coldham
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| | | | | | - Paolo Muiesan
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| | - John Isaac
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| | - Darius F Mirza
- Dept. of HPB Surgery, University Hospitals Birmingham, United Kingdom
| |
Collapse
|
66
|
Shen S, Araujo JL, Altorki NK, Sonett JR, Rodriguez A, Sungur-Stasik K, Spinelli CF, Neugut AI, Abrams JA. Variation by stage in the effects of prediagnosis weight loss on mortality in a prospective cohort of esophageal cancer patients. Dis Esophagus 2017; 30:1-7. [PMID: 28859366 PMCID: PMC6036662 DOI: 10.1093/dote/dox073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Indexed: 12/11/2022]
Abstract
Cancer cachexia is increasingly recognized as a poor prognostic marker for various tumor types. Weight loss in esophageal cancer is multifactorial, as patients with bulky tumors also have reduced ability to eat. We aimed to investigate the relationship between prediagnosis weight loss and mortality in esophageal cancer and to determine whether these associations vary with tumor stage. We conducted a prospective cohort study of esophageal cancer patients at two tertiary centers. We recorded baseline patient characteristics including medications, smoking, body mass index, and weight loss in the year prior to diagnosis, and collected data on treatment and outcomes. We used Cox regression modeling to determine the associations between percent weight loss and outcomes. The main outcome of interest was all-cause mortality; secondary endpoints were esophageal cancer-specific mortality and development of metastases. We enrolled 134 subjects, the majority of whom had adenocarcinoma (82.1%); median percent weight loss was 4.7% (IQR: 0%-10.9%). Increasing percent weight loss was not associated with all-cause mortality (ptrend = 0.36). However, there was evidence of significant interaction by tumor stage (p = 0.02). There was a strong and significant association between prediagnosis weight loss and mortality in patients with T stages 1 or 2 (adjusted HR 8.26 for highest versus lowest tertile, 95%CI 1.11-61.5, ptrend = 0.03) but not for T stages 3 or 4 (ptrend = 0.32). Body mass index one year prior to diagnosis was not associated with mortality. Prediagnosis weight loss was associated with increased all-cause mortality only in patients with early stage esophageal cancer. This suggests that tumor-related cachexia can occur early in esophageal cancer and represents a poor prognostic marker.
Collapse
Affiliation(s)
- S. Shen
- Department of Medicine, Columbia University Medical Center
| | - J. L. Araujo
- Veterans' Administration New York Harbor Healthcare System, Brooklyn, New York, USA
| | - N. K. Altorki
- Department of Thoracic Surgery, Weill Cornell Medical Center, New York
| | - J. R. Sonett
- Thoracic Surgery, Columbia University Medical Center
| | - A. Rodriguez
- Department of Medicine, Columbia University Medical Center
| | | | - C. F. Spinelli
- Department of Thoracic Surgery, Weill Cornell Medical Center, New York
| | - A. I. Neugut
- Department of Medicine, Columbia University Medical Center
| | - J. A. Abrams
- Department of Medicine, Columbia University Medical Center
| |
Collapse
|
67
|
Werner K, Küllenberg de Gaudry D, Taylor LA, Keck T, Unger C, Hopt UT, Massing U. Dietary supplementation with n-3-fatty acids in patients with pancreatic cancer and cachexia: marine phospholipids versus fish oil - a randomized controlled double-blind trial. Lipids Health Dis 2017; 16:104. [PMID: 28578704 PMCID: PMC5455128 DOI: 10.1186/s12944-017-0495-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/23/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Like many other cancer patients, most pancreatic carcinoma patients suffer from severe weight loss. As shown in numerous studies with fish oil (FO) supplementation, a minimum daily intake of 1.5 g n-3-fatty acids (n-3-FA) contributes to weight stabilization and improvement of quality of life (QoL) of cancer patients. Given n-3-FA not as triglycerides (FO), but mainly bound to marine phospholipids (MPL), weight stabilization and improvement of QoL has already been seen at much lower doses of n-3-FA (0,3 g), and MPL were much better tolerated. The objective of this double-blind randomized controlled trial was to compare low dose MPL and FO formulations, which had the same n-3-FA amount and composition, on weight and appetite stabilization, global health enhancement (QoL), and plasma FA-profiles in patients suffering from pancreatic cancer. METHODS Sixty pancreatic cancer patients were included into the study and randomized to take either FO- or MPL supplementation. Patients were treated with 0.3 g of n-3-fatty acids per day over six weeks. Since the n-3-FA content of FO is usually higher than that of MPL, FO was diluted with 40% of medium chain triglycerides (MCT) to achieve the same capsule size in both intervention groups and therefore assure blinding. Routine blood parameters, lipid profiles, body weight, and appetite were measured before and after intervention. Patient compliance was assessed through a patient diary. Quality of life and nutritional habits were assessed with validated questionnaires (EORTC-QLQ-C30, PAN26). Thirty one patients finalized the study protocol and were analyzed (per-protocol-analysis). RESULTS Intervention with low dose n-3-FAs, either as FO or MPL supplementation, resulted in similar and promising weight and appetite stabilization in pancreatic cancer patients. MPL capsules were slightly better tolerated and showed fewer side effects, when compared to FO supplementation. CONCLUSION The similar effects between both interventions were unexpected but reliable, since the MPL and FO formulations caused identical increases of n-3-FAs in plasma lipids of included patients after supplementation. The effects of FO with very low n-3-FA content might be explained by the addition of MCT. The results of this study suggest the need for further investigations of marine phospholipids for the improvement of QoL of cancer patients, optionally in combination with MCT.
Collapse
Affiliation(s)
- Kristin Werner
- Institute of Surgical Pathology, Medical Center-University of Freiburg, Freiburg, Germany. .,Institute of Pharmaceutical Science, University of Freiburg, Freiburg, Germany. .,Tumor Biology Center Freiburg, Freiburg, Germany.
| | - Daniela Küllenberg de Gaudry
- Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany.,Cochrane Deutschland, Universitätsklinikum Freiburg, Breisacher Str. 153, D - 79110, Freiburg, Germany
| | - Lenka A Taylor
- Pharmacy, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
| | - Tobias Keck
- Clinic for Surgery, Medical Center University of Lübeck, Lübeck, Germany
| | - Clemens Unger
- Cancer Center Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
| | - Ulrich T Hopt
- Department of Surgery, Medical Center-University of Freiburg, Freiburg, Germany
| | - Ulrich Massing
- Institute of Pharmaceutical Science, University of Freiburg, Freiburg, Germany.,Tumor Biology Center Freiburg, Freiburg, Germany
| |
Collapse
|
68
|
Fogelman DR, Morris J, Xiao L, Hassan M, Vadhan S, Overman M, Javle S, Shroff R, Varadhachary G, Wolff R, Vence L, Maitra A, Cleeland C, Wang XS. A predictive model of inflammatory markers and patient-reported symptoms for cachexia in newly diagnosed pancreatic cancer patients. Support Care Cancer 2017; 25:1809-1817. [PMID: 28111717 DOI: 10.1007/s00520-016-3553-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cachexia is a frequent manifestation of pancreatic cancer, can limit a patient's ability to take chemotherapy, and is associated with shortened survival. We developed a model to predict the early onset of cachexia in advanced pancreatic cancer patients. METHODS Patients with newly diagnosed, untreated metastatic or locally advanced pancreatic cancer were included. Serum cytokines were drawn prior to therapy. Patient symptoms were recorded using the M.D. Anderson Symptom Inventory (MDASI). Our primary endpoint was either 10% weight loss or death within 60 days of the start of therapy. RESULTS Twenty-seven of 89 patients met the primary endpoint (either having lost 10% of body weight or having died within 60 days of the start of treatment). In a univariate analysis, smoking, history symptoms of pain and difficulty swallowing, high levels of MK, CXCL-16, IL-6, TNF-a, and low IL-1b all correlated with this endpoint. We used recursive partition to fit a regression tree model, selecting four of 26 variables (CXCL-16, IL-1b, pain, swallowing difficulty) as important in predicting cachexia. From these, a model of two cytokines (CXCL-16 > 5.135 ng/ml and IL-1b < 0.08 ng/ml) demonstrated a better sensitivity and specificity for this outcome (0.70 and 0.86, respectively) than any individual cytokine or tumor marker. CONCLUSIONS Cachexia is frequent in pancreatic cancer; one in three patients met our endpoint of 10% weight loss or death within 60 days. Inflammatory cytokines are better than conventional tumor markers at predicting this outcome. Recursive partitioning analysis suggests that a model of CXCL-16 and IL-1B may offer a better ability than individual cytokines to predict this outcome.
Collapse
Affiliation(s)
- David R Fogelman
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA.
| | - J Morris
- Department of Biostatistics, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - L Xiao
- Department of Biostatistics, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - M Hassan
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - S Vadhan
- Department of Sarcoma Research, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - M Overman
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - S Javle
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - R Shroff
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - G Varadhachary
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - R Wolff
- Department of Gastrointestinal Medical Oncology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd Unit 426, Houston, TX, 77030, USA
| | - L Vence
- Department of Immunology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - A Maitra
- Department of Pathology, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - C Cleeland
- Department of Symptom Research, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - X S Wang
- Department of Symptom Research, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| |
Collapse
|
69
|
Ertz-Archambault N, Keim P, Von Hoff D. Microbiome and pancreatic cancer: A comprehensive topic review of literature. World J Gastroenterol 2017; 23:1899-1908. [PMID: 28348497 PMCID: PMC5352932 DOI: 10.3748/wjg.v23.i10.1899] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/06/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
AIM To review microbiome alterations associated with pancreatic cancer, its potential utility in diagnostics, risk assessment, and influence on disease outcomes.
METHODS A comprehensive literature review was conducted by all-inclusive topic review from PubMed, MEDLINE, and Web of Science. The last search was performed in October 2016.
RESULTS Diverse microbiome alterations exist among several body sites including oral, gut, and pancreatic tissue, in patients with pancreatic cancer compared to healthy populations.
CONCLUSION Pilot study successes in non-invasive screening strategies warrant further investigation for future translational application in early diagnostics and to learn modifiable risk factors relevant to disease prevention. Pre-clinical investigations exist in other tumor types that suggest microbiome manipulation provides opportunity to favorably transform cancer response to existing treatment protocols and improve survival.
Collapse
|
70
|
Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G. Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection. Nutrients 2017; 9:nu9030243. [PMID: 28272344 PMCID: PMC5372906 DOI: 10.3390/nu9030243] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/20/2017] [Accepted: 02/28/2017] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.
Collapse
Affiliation(s)
- Taylor M Gilliland
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nicole Villafane-Ferriol
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Kevin P Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Rohan M Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Hop S Tran Cao
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nader N Massarweh
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eric J Silberfein
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eugene A Choi
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Cary Hsu
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Amy L McElhany
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Omar Barakat
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - William Fisher
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - George Van Buren
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| |
Collapse
|
71
|
Schwarz S, Prokopchuk O, Esefeld K, Gröschel S, Bachmann J, Lorenzen S, Friess H, Halle M, Martignoni ME. The clinical picture of cachexia: a mosaic of different parameters (experience of 503 patients). BMC Cancer 2017; 17:130. [PMID: 28193264 PMCID: PMC5307774 DOI: 10.1186/s12885-017-3116-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/07/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Despite our growing knowledge about the pathomechanisms of cancer cachexia, a whole clinical picture of the cachectic patient is still missing. Our objective was to evaluate the clinical characteristics in cancer patients with and without cachexia to get the whole picture of a cachectic patient. METHODS Cancer patients of the University Clinic "Klinikum rechts der Isar" with gastrointestinal, gynecological, hematopoietic, lung and some other tumors were offered the possibility to take part in the treatment concept including a nutrition intervention and an individual training program according to their capability. We now report on the first 503 patients at the time of inclusion in the program between March 2011 and October 2015. We described clinical characteristics such as physical activity, quality of life, clinical dates and food intake. RESULTS Of 503 patients with cancer, 131 patients (26.0%) were identified as cachectic, 369 (73.4%) as non-cachectic. The change in cachexia were 23% reduced capacity performance (108 Watt for non-cachectic-patients and 83 Watt for cachectic patients) and 12% reduced relative performance (1.53 Watt/kg for non-cachectic and 1.34 Watt/kg for cachectic patients) in ergometry test. 75.6% of non-cachectic and 54.3% of cachectic patients still received curative treatment. CONCLUSION Cancer cachectic patients have multiple symptoms such as anemia, impaired kidney function and impaired liver function with elements of mild cholestasis, lower performance and a poorer quality of life in the EORTC questionnaire. Our study reveals biochemical and clinical specific features of cancer cachectic patients.
Collapse
Affiliation(s)
- S. Schwarz
- Department of Prevention, Rehabilitation and Sports Medicine, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - O. Prokopchuk
- Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - K. Esefeld
- Department of Prevention, Rehabilitation and Sports Medicine, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - S. Gröschel
- Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - J. Bachmann
- Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - S. Lorenzen
- Department of Hematology and Oncology, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - H. Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - M. Halle
- Department of Prevention, Rehabilitation and Sports Medicine, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - M. E. Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technical University, Munich, Germany
| |
Collapse
|
72
|
Zdenkowski N, Radvan G, Pugliese L, Charlton J, Oldmeadow C, Fraser A, Bonaventura A. Treatment of pancreatic insufficiency using pancreatic extract in patients with advanced pancreatic cancer: a pilot study (PICNIC). Support Care Cancer 2017; 25:1963-1971. [DOI: 10.1007/s00520-017-3602-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/23/2017] [Indexed: 01/05/2023]
|
73
|
Graf CE, Herrmann FR, Spoerri A, Makhlouf AM, Sørensen TI, Ho S, Karsegard VL, Genton L. Impact of body composition changes on risk of all-cause mortality in older adults. Clin Nutr 2016; 35:1499-1505. [DOI: 10.1016/j.clnu.2016.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 02/16/2016] [Accepted: 04/01/2016] [Indexed: 12/26/2022]
|
74
|
Krüger J, Meffert PJ, Vogt LJ, Gärtner S, Steveling A, Kraft M, Mayerle J, Lerch MM, Aghdassi AA. Early Parenteral Nutrition in Patients with Biliopancreatic Mass Lesions, a Prospective, Randomized Intervention Trial. PLoS One 2016; 11:e0166513. [PMID: 27861546 PMCID: PMC5115751 DOI: 10.1371/journal.pone.0166513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 10/28/2016] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Patients with biliopancreatic tumors frequently suffer from weight loss and cachexia. The in-hospital work-up to differentiate between benign and malignant biliopancreatic lesions requires repeated pre-interventional fasting periods that can aggravate this problem. We conducted a randomized intervention study to test whether routine in-hospital peripheral intravenous nutrition on fasting days (1000 ml/24 h, 700 kcal) has a beneficial effect on body weight and body composition. MATERIAL AND METHODS 168 patients were screened and 100 enrolled in the trial, all undergoing in-hospital work-up for biliopancreatic mass lesions and randomized to either intravenous nutrition or control. Primary endpoint was weight loss at time of hospital discharge; secondary endpoints were parameters determined by bioelectric impedance analysis and quality of life recorded by the EORTC questionnaire. RESULTS Within three months prior to hospital admission patients had a median self-reported loss of 4.0 kg (25*th: -10.0 kg and 75*th* percentile: 0.0kg) of body weight. On a multivariate analysis nutritional intervention increased body weight by 1.7 kg (95% CI: 0.204; 3.210, p = 0.027), particularly in patients with malignant lesions (2.7 kg (95% CI: 0.71; 4.76, p < 0.01). CONCLUSIONS In a hospital setting, patients with suspected biliopancreatic mass lesions stabilized their body weight when receiving parenteral nutrition in fasting periods even when no total parenteral nutrition was required. Analysis showed that this effect was greatest in patients with malignant tumors. Further studies will be necessary to see whether patient outcome is affected as well. TRIAL REGISTRATION ClinicalTrials.gov NCT02670265.
Collapse
Affiliation(s)
- Janine Krüger
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Peter J. Meffert
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Lena J. Vogt
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Simone Gärtner
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Antje Steveling
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | | | - Julia Mayerle
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Markus M. Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Ali A. Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
75
|
Sagar G, Sah RP, Javeed N, Dutta SK, Smyrk TC, Lau JS, Giorgadze N, Tchkonia T, Kirkland J, Chari ST, Mukhopadhyay D. Pathogenesis of pancreatic cancer exosome-induced lipolysis in adipose tissue. Gut 2016; 65:1165-74. [PMID: 26061593 PMCID: PMC5323066 DOI: 10.1136/gutjnl-2014-308350] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 04/03/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES New-onset diabetes and concomitant weight loss occurring several months before the clinical presentation of pancreatic cancer (PC) appear to be paraneoplastic phenomena caused by tumour-secreted products. Our recent findings have shown exosomal adrenomedullin (AM) is important in development of diabetes in PC. Adipose tissue lipolysis might explain early onset weight loss in PC. We hypothesise that lipolysis-inducing cargo is carried in exosomes shed by PC and is responsible for the paraneoplastic effects. Therefore, in this study we investigate if exosomes secreted by PC induce lipolysis in adipocytes and explore the role of AM in PC-exosomes as the mediator of this lipolysis. DESIGN Exosomes from patient-derived cell lines and from plasma of patients with PC and non-PC controls were isolated and characterised. Differentiated murine (3T3-L1) and human adipocytes were exposed to these exosomes to study lipolysis. Glycerol assay and western blotting were used to study lipolysis. Duolink Assay was used to study AM and adrenomedullin receptor (ADMR) interaction in adipocytes treated with exosomes. RESULTS In murine and human adipocytes, we found that both AM and PC-exosomes promoted lipolysis, which was abrogated by ADMR blockade. AM interacted with its receptor on the adipocytes, activated p38 and extracellular signal-regulated (ERK1/2) mitogen-activated protein kinases and promoted lipolysis by phosphorylating hormone-sensitive lipase. PKH67-labelled PC-exosomes were readily internalised into adipocytes and involved both caveolin and macropinocytosis as possible mechanisms for endocytosis. CONCLUSIONS PC-secreted exosomes induce lipolysis in subcutaneous adipose tissue; exosomal AM is a candidate mediator of this effect.
Collapse
Affiliation(s)
- Gunisha Sagar
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester
| | - Raghuwansh P. Sah
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester
| | - Naureen Javeed
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester
| | - Shamit K Dutta
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester
| | - Thomas C Smyrk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester
| | - Julie S Lau
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester
| | - Nino Giorgadze
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester MN, USA
| | - Tamar Tchkonia
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester MN, USA
| | - James Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester MN, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester MN, USA
| | | |
Collapse
|
76
|
Ansari D, Tingstedt B, Andersson B, Holmquist F, Sturesson C, Williamsson C, Sasor A, Borg D, Bauden M, Andersson R. Pancreatic cancer: yesterday, today and tomorrow. Future Oncol 2016; 12:1929-46. [PMID: 27246628 DOI: 10.2217/fon-2016-0010] [Citation(s) in RCA: 254] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is one of our most lethal malignancies. Despite substantial improvements in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since the 1960s. Pancreatic cancer is usually detected at an advanced stage and most treatment regimens are ineffective, contributing to the poor overall prognosis. Herein, we review the current understanding of pancreatic cancer, focusing on central aspects of disease management from radiology, surgery and pathology to oncology.
Collapse
Affiliation(s)
- Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Fredrik Holmquist
- Department of Radiology, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Christian Sturesson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Agata Sasor
- Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - David Borg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Monika Bauden
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University & Skåne University Hospital, Lund, Sweden
| |
Collapse
|
77
|
Ní Bhuachalla É, O’ Connor A, Healy J, Dwyer F, Ryan AM. Good Nutrition for Cancer Recovery - a nutritional resource for the treatment of cancer-induced weight loss. NUTR BULL 2016. [DOI: 10.1111/nbu.12204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- É. Ní Bhuachalla
- School of Food & Nutritional Sciences; University College Cork; Cork Ireland
| | - A. O’ Connor
- Department of Tourism and Hospitality; Cork Institute of Technology; Cork Ireland
| | - J. Healy
- Department of Tourism and Hospitality; Cork Institute of Technology; Cork Ireland
| | - F. Dwyer
- School of Food & Nutritional Sciences; University College Cork; Cork Ireland
| | - A. M. Ryan
- School of Food & Nutritional Sciences; University College Cork; Cork Ireland
| |
Collapse
|
78
|
Marx W, Kiss N, McCarthy AL, McKavanagh D, Isenring L. Chemotherapy-Induced Nausea and Vomiting: A Narrative Review to Inform Dietetics Practice. J Acad Nutr Diet 2016; 116:819-27. [PMID: 26686816 DOI: 10.1016/j.jand.2015.10.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 10/22/2015] [Indexed: 01/01/2023]
Abstract
Chemotherapy-induced nausea and vomiting (CINV) are common symptoms experienced by patients with cancer that influence nutrition. They exert a detrimental effect on dietary intake, risk of malnutrition, and quality of life. Whereas CINV are primarily managed with medication, nutrition and dietetics practitioners play an important role in the management of CINV-related complications such as reduced dietary intake. This review discusses the burden of nausea and vomiting that patients with cancer can experience, including the effect on quality of life, nutritional status, and treatment outcomes. Implications for dietetics practice include the need to explore the nature of reported symptoms, identify predisposing risk factors, and to consider the use of a variety of interventions that are individualized to a patient's symptoms. There are little clinical data regarding effective dietetic interventions for nausea and vomiting. In summary, this review discusses dietetics-related issues surrounding CINV, including the pathophysiology, risk factors, prevalence, and both pharmacologic and dietetic treatment options.
Collapse
|
79
|
Gärtner S, Krüger J, Aghdassi AA, Steveling A, Simon P, Lerch MM, Mayerle J. Nutrition in Pancreatic Cancer: A Review. Gastrointest Tumors 2016; 2:195-202. [PMID: 27403414 DOI: 10.1159/000442873] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 11/30/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pancreatic cancer is the fourth leading cause of cancer-related mortality in both genders. More than 80% of patients suffer from significant weight loss at diagnosis and over time develop severe cachexia. Early nutritional support is therefore essential. SUMMARY This review evaluates the different nutritional therapies, such as enteral nutrition, parenteral nutrition and special nutritional supplements, on nutritional status, quality of life and survival. KEY MESSAGE Due to the high prevalence of malnutrition and the rapid development of anorexia-cachexia-syndrome, early nutritional intervention is crucial and supported by clinical data. PRACTICAL IMPLICATIONS Enteral nutrition should be preferred over parenteral nutrition. Omega-3 fatty acids and l-carnitine are promising substances for the prevention of severe cachexia, but further randomized controlled trials are needed to establish generally accepted guidelines on nutrition in pancreatic cancer.
Collapse
Affiliation(s)
- Simone Gärtner
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Janine Krüger
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Ali A Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Antje Steveling
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Peter Simon
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
80
|
Bourgouin S, Ewald J, Mancini J, Moutardier V, Delpero JR, Le Treut YP. Predictors of Survival in Ampullary, Bile Duct and Duodenal Cancers Following Pancreaticoduodenectomy: a 10-Year Multicentre Analysis. J Gastrointest Surg 2015; 19:1247-55. [PMID: 25947547 DOI: 10.1007/s11605-015-2833-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/20/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Predictors of survival following pancreaticoduodenectomy (PD) are well described for pancreatic cancers but are less detailed in ampullary (AC), bile duct (BDC) and duodenal cancers (DC). We therefore sought to evaluate the long-term results of PD for AC, BDC and DC, and to determine for each tumour the predictive factors of survival. METHODS Medical charts of patients operated on between 2001 and 2011 were retrospectively reviewed. Univariate and multivariate analyses were performed to determine predictors of survival. RESULTS One hundred thirty-five patients were identified. Mean follow-up was 47 ± 33 months. Median survival was not reached for DC and was 66 and 24 months for AC and BDC, respectively. Two-year and five-year survival rates were 80 and 51% for DC and 69 and 51% for AC, respectively. BDC had a significantly poorer prognosis, with two-year and five-year survival rates of 51 and 34%, respectively. Predictors of survival were weight loss, N stage and International Union Against Cancer (UICC) stage for AC, T stage and resection margin status for BDC and N stage for DC. CONCLUSION AC, BDC and DC display distinctive predictors of survival related to the biological aggressiveness. Preoperative malnutrition worsens the prognosis. The effect of adapted nutritional management on the survival improvement has to be studied.
Collapse
Affiliation(s)
- Stéphane Bourgouin
- APHM La Conception, Department of Surgery and Liver Transplantation, Aix-Marseille University, 147 Boulevard Baille, Marseille, France,
| | | | | | | | | | | |
Collapse
|
81
|
Ma YJ, Yu J, Xiao J, Cao BW. The consumption of omega-3 polyunsaturated fatty acids improves clinical outcomes and prognosis in pancreatic cancer patients: a systematic evaluation. Nutr Cancer 2014; 67:112-8. [PMID: 25425246 DOI: 10.1080/01635581.2015.976315] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study was aimed to systematically evaluate results of trials examining the effects of omega-3 polyunsaturated fatty acid (n-3 PUFA) consumption on body weight, lean body mass, resting energy expenditure, and overall survival in pancreatic cancer patients. We searched Medline, Pubmed, Embase, and Cochrane databases. We selected randomized controlled trials of n-3 PUFA vs. conventional nutrition in unresectable pancreatic cancer patients. We analyzed our data using the Cochrane statistical package RevMan 5.1. Eleven trials met our inclusion criteria. There was a significant increase in body weight [weighted mean difference (WMD) = 0.62; 95% confidence interval (CI), 0.54-0.69, P < 0.00001) and lean body mass (WMD = 0.96; 95% CI, 0.86-1.06, P < 0.00001), a significant decrease in resting energy expenditure (WMD = -29.74; 95% CI, -55.89-3.59, P = 0.03), and an increase in overall survival (130-259 days vs. 63-130 days) in unresectable pancreatic cancer patients who consumed an oral nutrition supplement enriched with n-3 PUFAs compared to those who consumed conventional nutrition. This preliminary study suggests that n-3 PUFAs are safe and have a positive effect on clinical outcomes and survival in pancreatic cancer patients.
Collapse
Affiliation(s)
- Ying-Jie Ma
- a Department of Oncology, Beijing Friendship Hospital , Capital Medical University , Beijing , China
| | | | | | | |
Collapse
|
82
|
Fujiwara Y, Kobayashi T, Chayahara N, Imamura Y, Toyoda M, Kiyota N, Mukohara T, Nishiumi S, Azuma T, Yoshida M, Minami H. Metabolomics evaluation of serum markers for cachexia and their intra-day variation in patients with advanced pancreatic cancer. PLoS One 2014; 9:e113259. [PMID: 25411961 PMCID: PMC4239056 DOI: 10.1371/journal.pone.0113259] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 10/21/2014] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Cancer cachexia is a multifactorial syndrome characterized by progressive loss of weight and muscle atrophy. Using metabolomics, we investigated serum markers and their intra-day variation in advanced pancreatic cancer patients with cachexia. METHODS Patients were enrolled in two groups: those with or without cachexia. Blood samples collected at 6:30 AM, 11:30 AM, 4:30 PM, and 9:30 PM were analyzed using metabolomics, and serum levels of IL-6, TNF-α, and leptin were measured and compared between the two groups. Intra-day variation was then evaluated. RESULTS Twenty-one patients were enrolled in total. In the cachexia group (n = 9), median body weight loss rate over 6 months was greater, performance status was poorer, and anorexia was more severe than in the non-cachexia group (n = 12). Each metabolites level showed substantial intra-day variation, and some of them displayed significant differences between the two groups. Levels of paraxanthine remained markedly lower in the cohort with cachexia at all measurement points. Besides, median IL-6 and TNF-α levels appeared higher and leptin concentration appeared lower in the cachexia group, albeit without statistical significance. CONCLUSION Some metabolites and some serological marker levels were affected by cancer cachexia. Although paraxanthine levels were consistently lower in patients with cachexia, we identified that many metabolites indicated large intra- and inter-day variation and that it might be necessary to pay attention to intra-day variation in metabolomics research.
Collapse
Affiliation(s)
- Yutaka Fujiwara
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoko Chayahara
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshinori Imamura
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masanori Toyoda
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naomi Kiyota
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toru Mukohara
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
- Cancer Center, Kobe University Hospital, Kobe, Japan
| | - Shin Nishiumi
- Division of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaru Yoshida
- Division of Gastroenterology, Kobe University Graduate School of Medicine, Kobe, Japan
- Division of Metabolomics Research, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
- Cancer Center, Kobe University Hospital, Kobe, Japan
| |
Collapse
|
83
|
Sheard JM, Ash S, Mellick GD, Silburn PA, Kerr GK. Improved nutritional status is related to improved quality of life in Parkinson's disease. BMC Neurol 2014; 14:212. [PMID: 25403709 PMCID: PMC4237731 DOI: 10.1186/s12883-014-0212-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 10/27/2014] [Indexed: 01/04/2023] Open
Abstract
Background Quality of life is poorer in Parkinson’s disease than in other conditions and in the general population without Parkinson’s disease. Malnutrition also results in poorer quality of life. This study aimed at determining the relationship between quality of life and nutritional status. Methods Community-dwelling people with Parkinson’s disease >18 years old were recruited. The Patient-Generated Subjective Global Assessment (PG-SGA) assessed nutritional status. The Parkinson’s Disease Questionnaire 39 (PDQ-39) measured quality of life. Phase I was cross-sectional. The malnourished in Phase I were eligible for a nutrition intervention phase, randomised into 2 groups: standard care (SC) with provision of nutrition education materials only and intervention (INT) with individualised dietetic advice and regular weekly follow-up. Data were collected at baseline, 6 weeks, and 12 weeks. Results Phase I consisted of 120 people who completed the PDQ-39. Phase II consisted of 9 in the SC group and 10 in the INT group. In Phase I, quality of life was poorer in the malnourished, particularly for mobility and activities of daily living domains. There was a significant correlation between PG-SGA and PDQ-39 scores (Phase I, rs = 0.445, p = .000; Phase II, rs = .426, p = .002). In Phase II, no significant difference in the PDQ-39 total or sub-scores was observed between the INT and SC groups; however, there was significant improvement in the emotional well-being domain for the entire group, X2(2) = 8.84, p = .012. Conclusions Malnourished people with Parkinson’s disease had poorer quality of life than the well-nourished, and improvements in nutritional status resulted in quality of life improvements. Attention to nutritional status is an important component of quality of life and therefore the total care of people with Parkinson’s disease. Trial registration ACTRN12610000819022
Collapse
Affiliation(s)
- Jamie M Sheard
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Queensland, Australia.
| | | | | | | | | |
Collapse
|
84
|
Sachlova M, Majek O, Tucek S. Prognostic value of scores based on malnutrition or systemic inflammatory response in patients with metastatic or recurrent gastric cancer. Nutr Cancer 2014; 66:1362-70. [PMID: 25356861 DOI: 10.1080/01635581.2014.956261] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cancer patients are frequently affected by malnutrition and weight loss, which affects their prognosis, length of hospital stay, health care costs, quality of life and survival. Our aim was to assess the prognostic value of different scores based on malnutrition or systemic inflammatory response in 91 metastatic or recurrent gastric cancer patients considered for palliative chemotherapy at the Masaryk Memorial Cancer Institute. We investigated their overall survival according to the following measures: Onodera's Prognostic Nutritional Index (OPNI), Glasgow Prognostic Score (GPS), nutritional risk indicator (NRI), Cancer Cachexia Study Group (CCSG), as previously defined, and a simple preadmission weight loss. The OPNI, GPS, and CCSG provided very significant prognostic values for survival (log-rank test P value < 0.001). For example, the median survival for patients with GPS 0 was 12.3 mo [95% confidence interval (CI): 7.7-16.7], whereas the median survival for patients with GPS 2 was only 2.9 mo (95% CI: 1.9-4.8). A significantly worse survival of malnourished patients was also suggested by a multivariate model. The values of GPS, OPNI, and CCSG represent useful tools for the evaluation of patients' prognosis and should be part of a routine evaluation of patients to provide a timely nutrition support.
Collapse
Affiliation(s)
- Milana Sachlova
- a Department of Gastroenterology , Masaryk Memorial Cancer Institute , Brno , Czech Republic
| | | | | |
Collapse
|
85
|
Landers A, Muircroft W, Brown H. Pancreatic enzyme replacement therapy (PERT) for malabsorption in patients with metastatic pancreatic cancer. BMJ Support Palliat Care 2014; 6:75-9. [PMID: 25164613 DOI: 10.1136/bmjspcare-2014-000694] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 08/13/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE The diagnosis of metastatic pancreatic cancer (PC) carries a poor prognosis. PC is associated with weight loss and malabsorption in high rates secondary to pancreatic exocrine insufficiency. UK and USA guidelines exist recommending the empiric use of pancreatic enzyme replacement therapy (PERT) for quality of life in these patients. The aim of this study is to review the use of PERT in patients with metastatic PC referred to a specialist palliative care service. METHODS Retrospective observational study of patients referred to the service between January 2010 and July 2012 with a diagnosis of PC. Information about PERT use, tumour site and frequency of symptoms was collected. RESULTS 129 patients were referred, with a higher number in the eighth decade. Only 21% of this study group were prescribed PERT. Over 70% of patients had symptoms that could be attributable to malabsorption, mainly abdominal pain. Other symptoms such as bloating, wind and steatorrhoea were also common. CONCLUSIONS Guidelines recommending empiric treatment of PERT in patients with metastatic PC are not currently being utilised.
Collapse
Affiliation(s)
- Amanda Landers
- Hospice Palliative Care Service, Nurse Maude Association, Christchurch, New Zealand
| | - Wendy Muircroft
- Department of Palliative Care, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Helen Brown
- Hospice Palliative Care Service, Nurse Maude Association, Christchurch, New Zealand
| |
Collapse
|
86
|
Mueller TC, Burmeister MA, Bachmann J, Martignoni ME. Cachexia and pancreatic cancer: Are there treatment options? World J Gastroenterol 2014; 20:9361-9373. [PMID: 25071331 PMCID: PMC4110568 DOI: 10.3748/wjg.v20.i28.9361] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/14/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Cachexia is frequently described in patients with pancreatic ductal adenocarcinoma (PDAC) and is associated with reduced survival and quality of life. Unfortunately, the therapeutic options of this multi-factorial and complex syndrome are limited. This is due to the fact that, despite extensive preclinical and clinical research, the underlying pathological mechanisms leading to PDAC-associated cachexia are still not fully understood. Furthermore, there is still a lack of consensus on the definition of cachexia, which complicates the standardization of diagnosis and treatment as well as the analysis of the current literature. In order to provide an efficient therapy for cachexia, an early and reliable diagnosis and consistent monitoring is required, which can be challenging especially in obese patients. Although many substances have been tested in clinical and preclinical settings, so far none of them have been proven to have a long-term effect in ameliorating cancer-associated cachexia. However, recent studies have demonstrated that multidimensional therapeutic modalities are able to alleviate pancreatic cancer-associated cachexia and ultimately improve patients’ outcome. In this current review, we propose a stepwise and pragmatic approach to facilitate and standardize the treatment of cachexia in pancreatic cancer patients. This strategy consists of nutritional, dietary, pharmacological, physical and psychological methods.
Collapse
|
87
|
Smith LA, Jamieson NB, McKay CJ. Investigation and management of pancreatic tumours. Frontline Gastroenterol 2014; 5:144-152. [PMID: 28839761 PMCID: PMC5369717 DOI: 10.1136/flgastro-2013-100364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/23/2013] [Accepted: 09/25/2013] [Indexed: 02/04/2023] Open
Abstract
Pancreatic cancer is the 10th most commonly diagnosed cancer in the UK and the fifth most common cause of cancer death. It remains one of the most aggressive cancers with over 95% of patients affected dying of their disease. Often presenting at an advanced stage of disease progression, there is currently no simple screening test available. Therefore a high clinical suspicion and prompt appropriate investigation is required from physicians when dealing with patients with symptoms in keeping with pancreatic cancer. The gastroenterology 2010 curriculum states that trainees should learn the presentation and multidisciplinary management of patients with pancreatic tumours. In this article we discuss the typical clinical presentations of common and less common pancreatic tumours followed by the investigation, staging and management required.
Collapse
Affiliation(s)
- Lyn A Smith
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Nigel B Jamieson
- Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Colin J McKay
- Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
| |
Collapse
|
88
|
Saira Chowdhury, Orla Hynes. Nutrition in Upper Gastrointestinal Cancer. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
89
|
The Psychosocial Influences of Food Choices Made by Cancer Patients. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
90
|
Shaw C. Nutrition and Palliative Care. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
91
|
Kim SY, Wie GA, Lee WJ, Park SJ, Woo SM. Changes in dietary intake, body weight, nutritional status, and metabolic rate in a pancreatic cancer patient. Clin Nutr Res 2013; 2:154-8. [PMID: 23908983 PMCID: PMC3728466 DOI: 10.7762/cnr.2013.2.2.154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/19/2013] [Accepted: 07/02/2013] [Indexed: 11/29/2022] Open
Abstract
Pancreatic cancer patients often have a poor prognosis and suffer from nutritional problems. Malnutrition is characterized by weight loss and decreased dietary intake, and is common among pancreatic cancer patients. The objective of this report was to describe the changes in dietary intake, body weight, nutritional status, and metabolic rate on a continuum from the time of diagnosis until the end of life in a patient with pancreatic cancer. In summary, the patient's nutritional status gradually declined, accompanied by extreme weight loss and decreased dietary intake. Conversely, resting energy expenditure, measured by indirect calorimetry, increased from 24 kcal/kg/day to 35 kcal/kg/day. Nutritional management during cancer treatment is important but may be challenging in pancreatic cancer patients.
Collapse
Affiliation(s)
- So Young Kim
- Department of Clinical Nutrition, National Cancer Center, Goyang 410-769, Korea
| | | | | | | | | |
Collapse
|
92
|
Gooden HM, White KJ. Pancreatic cancer and supportive care--pancreatic exocrine insufficiency negatively impacts on quality of life. Support Care Cancer 2013; 21:1835-41. [PMID: 23397095 DOI: 10.1007/s00520-013-1729-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 01/28/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Pancreatic cancer is a fatal cancer with a median survival from diagnosis of around 5 months Speer et al. (Med J Aust 196(8):511-515, 2012). Given the short survival time for people with pancreatic cancer, effective supportive care is imperative to enable best quality of life. This article presents an unexpected finding from research into the psychosocial supportive care needs of people affected by pancreatic cancer that management of pancreatic exocrine insufficiency is an area of unmet need that severely impacts on quality of life and increases carer burden in people affected by pancreatic cancer. METHODS A qualitative inquiry framework was used to explore participants' perspectives and experience. Two groups of participants (N = 35) were recruited across Australia from people accessing the Cancer Helpline or direct referral from clinicians/nurses: patients diagnosed with pancreatic cancer (N = 12) and carers/family (N = 23) including a subgroup of bereaved participants (N = 14). Sampling continued until saturation. A thematic content analysis was conducted. RESULTS The findings revealed that the major quality of life theme was difficulty in managing gut symptoms and complex dietary issues. Issues were related to lack of information about malabsorption and managing symptoms of pancreatic exocrine insufficiency. This was compounded by a lack of routine dietary consultation: perceived reluctance of clinicians to prescribe enzyme supplements and poor understanding of dose to diet guidelines. CONCLUSION Participants expressed distress relating to the effects of pancreatic exocrine insufficiency. Pancreatic enzyme supplement therapy with clear dosage guidelines and associated dietary advice could resolve symptoms of malabsorption and markedly improve quality of life. For people affected by pancreatic cancer, this is an essential supportive care.
Collapse
Affiliation(s)
- H M Gooden
- Cancer Nursing Research Unit, Sydney Nursing School, University of Sydney, Camperdown, Australia.
| | | |
Collapse
|
93
|
A systematic review of health-related quality of life instruments in patients with cancer cachexia. Support Care Cancer 2013; 21:2625-36. [PMID: 23797577 DOI: 10.1007/s00520-013-1881-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/06/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE Assessing the health-related quality of life (HRQOL) of cancer patients with cachexia is particularly important because treatments for cachexia are currently aimed at palliation and treatment efficacy must be measured in ways other than survival. The aim of this systematic review was to evaluate HRQOL assessment in cancer patients with cachexia. METHODS Using guidance from the Centre for Reviews and Dissemination, relevant databases were searched from January 1980 to January 2012 with terms relating to cancer, cachexia and HRQOL for papers including adult cancer patients with cachexia or documented weight loss at baseline. RESULTS We found one cachexia-specific instrument, the Functional Assessment of Anorexia/Cachexia Therapy, but the tool has not been fully validated, does not cover all the relevant domains and the consensus-based standards for the selection of health status measurement instruments checklist highlighted a number of weaknesses in the methodological quality of the validation study. Sixty-seven studies assessed HRQOL in cachectic or weight-losing cancer patients. Most used generic cancer HRQOL instruments, limiting the amount of useful information they provide. A modified version of the Efficace minimum data checklist demonstrated that the quality of reporting on HRQOL tool use was inadequate in many of the studies. A negative relationship between HRQOL and weight loss was found in 23 of the 27 studies which directly examined this. CONCLUSION There is a pressing need for a well-designed HRQOL tool for use with this patient group in both clinical trials and clinical practice.
Collapse
|
94
|
Rhondali W, Chisholm GB, Daneshmand M, Allo J, Kang DH, Filbet M, Hui D, Fingeret MC, Bruera E. Association between body image dissatisfaction and weight loss among patients with advanced cancer and their caregivers: a preliminary report. J Pain Symptom Manage 2013; 45:1039-49. [PMID: 23102755 DOI: 10.1016/j.jpainsymman.2012.06.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 05/28/2012] [Accepted: 06/03/2012] [Indexed: 02/03/2023]
Abstract
CONTEXT No prospective studies have dealt with the impact of cachexia-related weight loss on patients' body image as well as the impact of patients' body image changes on the level of patient and family distress. OBJECTIVES Our aim was to examine associations between body mass index (BMI), weight loss, symptom distress, and body image for patients with advanced cancer and their caregivers. METHODS Outpatients with advanced cancer and different levels of BMI, along with their caregivers, were recruited. Patient assessments included BMI, precancer weight, Body Image Scale (BIS; 0-30), Edmonton Symptom Assessment System (ESAS), Hospital Anxiety and Depression Scale (HADS), and sexual interest and enjoyment as measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck Cancer Module 35. Caregivers were asked to assess the patient's body image, using the BIS; rate their own quality of life, using the Caregiver Quality of Life Index-Cancer; and rate their overall distress and distress regarding the patient's weight, using the Distress Thermometer (DT). RESULTS We included 81 patients and 30 caregivers. Forty-eight patients (59%) experienced weight loss of at least 10%. The mean BIS score was 11.23 (SD = 7.24). Body image dissatisfaction was correlated with weight loss (r = 0.31, P = 0.006), anxiety (HADS-A; r = 0.39, P < 0.001), depression (HADS-D; r = 0.46, P < 0.001), decreased sexual interest (r = 0.37, P = 0.001), decreased sexual enjoyment (r = 0.33, P = 0.004), ESAS score for pain (r = 0.25, P = 0.026), fatigue (r = 0.28, P = 0.014), drowsiness (r = 0.28, P = 0.014), shortness of breath (r = 0.27, P = 0.016), sleep disorders (r = 0.24, P = 0.036), and well-being (r = 0.29, P = 0.011). We found a significant association between the caregivers' evaluation of patients' body image dissatisfaction and patients' BIS score (r = 0.37, P = 0.049) and caregivers' distress regarding the patients' weight (DT; r = 0.58; P = 0.001). CONCLUSION Body image dissatisfaction was strongly associated with patients' weight loss and with psychosocial distress among patients and their caregivers. More research is necessary to better understand the association between the severity of body image dissatisfaction and the severity of other problems in patients with cancer.
Collapse
Affiliation(s)
- Wadih Rhondali
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
95
|
Yeh KY, Wang HM, Chang JWC, Huang JS, Lai CH, Lan YJ, Wu TH, Chang PH, Wang H, Wu CJ, Hsia S, Wang CH. Omega-3 fatty acid-, micronutrient-, and probiotic-enriched nutrition helps body weight stabilization in head and neck cancer cachexia. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116:41-8. [PMID: 23562359 DOI: 10.1016/j.oooo.2013.01.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/07/2013] [Accepted: 01/13/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate whether an oral nutritional supplement enriched with omega-3 fatty acids, micronutrients, and probiotics affected body weight (BW) changes, serum albumin and prealbumin levels in patients with head and neck cancer (HNC) cachexia. STUDY DESIGN Sixty-eight HNC patients were randomly assigned to receive either an Ethanwell/Ethanzyme (EE) regimen enriched with omega-3 fatty acids, micronutrients, and probiotics, or control (Isocal) for a 3-month period. Analysis of covariance was used to examine the association between BW change and variables. RESULTS Patients with body mass index (BMI) <19 and those receiving the EE regimen consumed fewer daily calories but showed significantly increased BW and maintained higher serum albumin and prealbumin levels than other patients (P<.05). Their BW changes were significantly associated with changes in serum albumin and prealbumin levels. CONCLUSIONS EE regimen improved BW as well as serum albumin and prealbumin levels in HNC patients with BMI <19.
Collapse
Affiliation(s)
- Kun-Yun Yeh
- Division of Hemato-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung & Chang Gung University, College of Medicine, Taiwan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
96
|
Isenring E, Zabel R, Bannister M, Brown T, Findlay M, Kiss N, Loeliger J, Johnstone C, Camilleri B, Davidson W, Hill J, Bauer J. Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy. Nutr Diet 2013. [DOI: 10.1111/1747-0080.12013] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Elisabeth Isenring
- School of Human Movement Studies; University of Queensland; Brisbane Queensland Australia
- Department of Nutrition and Dietetics; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Rachel Zabel
- School of Human Movement Studies; University of Queensland; Brisbane Queensland Australia
| | - Melanie Bannister
- Department of Nutrition Services; The Wesley Hospital; Brisbane Queensland Australia
| | - Teresa Brown
- School of Human Movement Studies; University of Queensland; Brisbane Queensland Australia
- Department of Nutrition and Dietetics; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Merran Findlay
- Department of Nutrition and Dietetics; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Nicole Kiss
- Department of Nutrition and Dietetics; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Jenelle Loeliger
- Department of Nutrition and Dietetics; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | | | - Belinda Camilleri
- Department of Nutrition and Dietetics; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Wendy Davidson
- Department of Nutrition and Dietetics; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Jan Hill
- Patient Safety and Quality Improvement Service, Centre for Healthcare Improvement; Queensland Health; Brisbane Queensland Australia
| | - Judy Bauer
- School of Human Movement Studies; University of Queensland; Brisbane Queensland Australia
- Department of Nutrition Services; The Wesley Hospital; Brisbane Queensland Australia
| |
Collapse
|
97
|
Nutrition chez le patient adulte atteint de cancer : besoins nutritionnels, énergétiques et protéiques, au cours de la prise en charge du cancer chez l’adulte. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
98
|
Cachexia but not obesity worsens the postoperative outcome after pancreatoduodenectomy in pancreatic cancer. Surgery 2012; 152:S81-8. [PMID: 22770957 DOI: 10.1016/j.surg.2012.05.028] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prognosis after pancreatoduodenectomy for pancreatic cancer is determined by tumor characteristics, completeness of resection, and patient's comorbidity. Our aim was to assess the effects of body mass and fat distribution on the postoperative course after pancreatoduodenectomy. METHODS Of 2,968 pancreatic resections, 408 patients with primary pancreatic adenocarcinoma who underwent pancreatoduodenectomy and of whom cross sectional images were available were identified and followed-up in a prospective database. Preoperative computed tomographic or magnetic resonance imaging scans were analyzed for abdominal wall fat, hip girdle fat, visceral fat, and abdominal depth. Peri- and postoperative parameters, including preoperative unintentional weight loss, cachexia-associated serum parameters, nonoperative and operative complications, and mortality and long-term survival were evaluated and correlated with body mass index and fat distribution. RESULTS Patients with low body mass index had a greater 90-day mortality (P = .048) and a trend toward greater complication rates and in-hospital mortality, despite a greater comorbidity in obese patients with a higher body mass index. Accordingly, patients with large amounts of abdominal wall fat had fewer intra-abdominal abscesses (P = .047), lower in-hospital (P = .019) and 90-day mortality rates (P = .007), and better long-term survival (P = .016). CONCLUSION In pancreatic cancer, underweight but not obese patients have a poor outcome after pancreatoduodenectomy. This observation emphasizes the need for pre- and perioperative therapeutic improvements in the setting of pancreatic cancer-associated cachexia.
Collapse
|
99
|
PREVOST V, GRACH MC. Nutritional support and quality of life in cancer patients undergoing palliative care. Eur J Cancer Care (Engl) 2012; 21:581-90. [DOI: 10.1111/j.1365-2354.2012.01363.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
100
|
Trajkovic-Vidakovic M, de Graeff A, Voest EE, Teunissen SCCM. Symptoms tell it all: a systematic review of the value of symptom assessment to predict survival in advanced cancer patients. Crit Rev Oncol Hematol 2012; 84:130-48. [PMID: 22465016 DOI: 10.1016/j.critrevonc.2012.02.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 02/14/2012] [Accepted: 02/29/2012] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To determine the prognostic meaning of symptoms in patients with advanced cancer. DESIGN Medline, Embase, Cochrane and Cinahl databases were systematically explored. The predicting symptoms were also evaluated in the three stages of palliative care: disease-directed palliation, symptom-oriented palliation and palliation in the terminal stage. RESULTS Out of 3167 papers, forty-four papers satisfied all criteria. Confusion, anorexia, fatigue, cachexia, weight loss, cognitive impairment, drowsiness, dyspnea, dysphagia, dry mouth and depressed mood were associated with survival in ≥ 50% of the studies evaluating these symptoms. Multivariate analysis showed confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia as independent prognostic factors in 30-56% of the studies. In the stage of disease-directed palliation anorexia, cachexia, weight loss, dysphagia and pain and in the stage of symptom-oriented palliation confusion, fatigue, cachexia, weight loss, dyspnea, dysphagia and nausea were shown to be independent predictors of survival in >30% of the studies. CONCLUSION Symptoms with independent predictive value are confusion, anorexia, fatigue, cachexia, weight loss, dyspnea and dysphagia. New insights are added by the variance between the three palliative stages.
Collapse
Affiliation(s)
- Marija Trajkovic-Vidakovic
- Department of Medical Oncology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | | | | | | |
Collapse
|