Dietary patterns in patients with advanced cancer: implications for anorexia-cachexia therapy

Prediction of skeletal muscle and fat mass in patients with advanced cancer using a metabolomic approach

Urine and plasma metabolites originate from endogenous metabolic pathways in different organs and exogenous sources (diet). Urine and plasma were obtained from advanced cancer patients and investigated to determine if variations in lean and fat mass, dietary intake, and energy metabolism relate to variation in metabolite profiles. Patients (n = 55) recorded their diets for 3 d and after an overnight fast they were evaluated by DXA and indirect calorimetry. Metabolites were measured by NMR and direct injection MS. Three algorithms were used [partial least squares discriminant-analysis, support vector machines (SVM), and least absolute shrinkage and selection operator] to relate patients' plasma/urine metabolic profile with their dietary/physiological assessments. Leave-one-out cross-validation and permutation testing were conducted to determine statistical validity. None of the algorithms, using 63 urine metabolites, could learn to predict variations in individual's resting energy expenditure, respiratory quotient, or their intake of total energy, fat, sugar, or carbohydrate. Urine metabolites predicted appendicular lean tissue (skeletal muscle) with excellent cross-validation accuracy (98% using SVM). Total lean tissue correlated highly with appendicular muscle (Pearson r = 0.98; P < 0.0001) and gave similar cross-validation accuracies. Fat mass was effectively predicted using the 63 urine metabolites or the 143 plasma metabolites, exclusively. In conclusion, in this population, lean and fat mass variation could be effectively predicted using urinary metabolites, suggesting a potential role for metabolomics in body composition research. Furthermore, variation in lean and fat mass potentially confounds metabolomic studies attempting to characterize diet or disease conditions. Future studies should account or correct for such variation.

A qualitative analysis of the nutritional requirements of palliative care patients

BACKGROUND

The National Health Servive (NHS) Quality Improvement Scotland developed nutritional Clinical Standards to address the problem of malnutrition in hospitals. NHS palliative care units are obliged to incorporate these standards into nutritional aspects of care. The nutritional needs of this patient population are under-researched. The present study aimed to explore patients' views of nutrition, to begin to understand their concerns and to determine whether such standards meet the needs of patients in the palliative care setting.

METHODS

A qualitative study was conducted in 2009 in an NHS Palliative Care Unit. Six inpatients were involved in one-to-one interviews, which were audiotaped and transcribed verbatim. The transcripts were subject to qualitative data analysis in accordance with a previous framework.

RESULTS

A recurring theme that emerged was that of change and uncertainty. Four main areas subject to change were: disease state, symptoms, oral dietary intake and weight. Each change could exert control over, or be controlled by, the patient. When patients were eventually unable to exert control, they accepted the change, either willingly or enforced, thereby unintentionally setting their own targets.

CONCLUSIONS

The present study enables a deeper understanding of the concerns that palliative care patients have regarding their oral dietary intake and weight. Their 'malnutrition' not only refers to physical malnutrition alone, but also incorporates psychological and social 'malnutrition'. When applying standards or protocols regarding nutritional care, these wider issues must be taken into account to meet patients' nutritional needs.

Cancer cachexia: mechanisms and clinical implications

Cachexia is a multifactorial process of skeletal muscle and adipose tissue atrophy resulting in progressive weight loss. It is associated with poor quality of life, poor physical function, and poor prognosis in cancer patients. It involves multiple pathways: procachectic and proinflammatory signals from tumour cells, systemic inflammation in the host, and widespread metabolic changes (increased resting energy expenditure and alterations in metabolism of protein, fat, and carbohydrate). Whether it is primarily driven by the tumour or as a result of the host response to the tumour has yet to be fully elucidated. Cachexia is compounded by anorexia and the relationship between these two entities has not been clarified fully. Inconsistencies in the definition of cachexia have limited the epidemiological characterisation of the condition and there has been slow progress in identifying therapeutic agents and trialling them in the clinical setting. Understanding the complex interplay of tumour and host factors will uncover new therapeutic targets.

Characterization of chemosensory alterations in advanced cancer reveals specific chemosensory phenotypes impacting dietary intake and quality of life

CONTEXT

Taste and smell (chemosensory) alterations are common and distressing among advanced cancer patients, but their specific nature is poorly described and seldom linked to dietary intake. Details of altered chemosensory perception may help to explain food intake behaviors.

OBJECTIVES

Our goal was to characterize chemosensory alterations and their relationship with dietary intake and quality of life (QOL).

METHODS

Adult advanced cancer patients (n=192) completed a chemosensory self-assessment questionnaire to characterize changes in their sense of smell and four basic tastes (sweet, sour, salty, and bitter) since the onset of cancer, three-day food record, and QOL questionnaire.

RESULTS

Patients experienced either no alteration in any basic tastes and sense of smell sensations (26% of patients) or one of three altered chemosensory phenotypes: 1) stronger sensations overall (42%), 2) weaker sensations overall (18%), or 3) mixed (some sensations stronger and others weaker, 14%). For individual sensations (sweet, sour, salty, bitter, and smell), stronger sensation was twice more prevalent than weaker sensation (P=0.035). Patients reporting chemosensory alteration consumed 20%-25% fewer calories per day (P=0.0018), experienced greater weight loss (P=0.0036), and had poorer QOL scores (P=0.0176) compared with patients with no alterations, but results did not vary by chemosensory phenotype. Chemosensory alterations were not related to tumor type (P=0.884), gender (P=0.286), or nausea (P=0.278).

CONCLUSION

Chemosensory alterations predict dietary intake and QOL; the identification of chemosensory phenotypes provides a rationale to adjust the properties of foods and dietary recommendations in function of the specific nature of these changes.

Contribution of anorexia to tissue wasting in cachexia

PURPOSE OF REVIEW

Anorexia is a severe debilitating symptom characterizing the clinical course of several chronic diseases. It negatively impacts on patient outcome by contributing to weight loss, lean body mass catabolism and adipose tissue wasting. Although disease-associated anorexia may stand alone as a clinically relevant symptom, it is now considered as a component of the cachexia syndrome. The present review discusses experimental and clinical data indicating that the pathogenic mechanisms of anorexia may also suggest a neural control of tissue wasting in cachexia.

RECENT FINDINGS

Consistent data show that selective melanocortin receptor antagonism modulates food intake and reduces wasting in experimental models of chronic disease. Consequently, ghrelin administration, whose prophagic effects are related to melanocortin antagonism, has been tested both in animal studies and human trials, with promising effects, although restoration of lean body mass has been not achieved. More interest is driven by the use of small molecules selectively antagonising hypothalamic melanocortin receptors.

SUMMARY

The 'brain-muscle axis' coordinated by the hypothalamus seems to mediate the onset of not only anorexia but also tissue wasting in cachexia, by centrally influencing energy homeostasis and the balance between anabolism and catabolism.

Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer

BACKGROUND

The concept of cancer-related anorexia/cachexia is evolving as its mechanisms are better understood. To support consensus processes towards an updated definition and classification system, we systematically reviewed the literature for items and domains associated with involuntary weight loss in cancer.

METHODS

Two search strings (cachexia, cancer) explored five databases from 1976 to 2007. Citations, abstracts and papers were included if they were original work, in English/German language, and explored an item to distinguish advanced cancer patients with variable degrees of involuntary weight loss. The items were grouped into the 5 domains proposed by formal expert meetings.

RESULTS

Of 14,344 citations, 1275 abstracts and 585 papers reviewed, 71 papers were included (6325 patients; 40-50% gastrointestinal, 10-20% lung cancer). No single domain or item could consistently distinguish cancer patients with or without weight loss or having various degrees of weight loss. Anorexia and decreased nutritional intake were unexpectedly weakly related with weight loss. Explanations for this could be the imprecise measurement methods for nutritional intake, symptom interactions, and the importance of systemic inflammation as a catabolic drive. Data on muscle mass and strength is scarce and the impact of cachexia on physical and psychosocial function has not been widely assessed.

CONCLUSIONS

Current data support a modular concept of cancer cachexia with a variable combination of reduced nutritional intake and catabolic/hyper-metabolic changes. The heterogeneity in the literature revealed by this review underlines the importance of an agreed definition and classification of cancer cachexia.

[Bioethics and nutrition in adult patients with cancer in palliative care]

Cancer constitutes a major group of chronic diseases and is the second leading cause of death in the developed countries. Palliative care proposes to offer comprehensive support to control symptoms and improve quality of life for patients and their families. Nutrition is an important tool in palliative care, helping patients with their physical, psychological, and social issues and promoting comfort and quality of life. However, in the context of palliative care, nutritional support rarely achieves its role of fully recovering and assuring nutritional status. At this point, the nutritionist must consider the individual patient's needs, preferences, and eating habits, which are essential both for controlling symptoms and assuring satisfaction and comfort. The impossibility of conventionally applying established management and the development of a new perception of the patient often raise dilemmas for professional nutritionists.

A viscerally driven cachexia syndrome in patients with advanced colorectal cancer: contributions of organ and tumor mass to whole-body energy demands

BACKGROUND

Cancer cachexia-associated weight loss is poorly understood; energetically demanding tissues (eg, organ and tumor mass) and resting energy expenditure (REE) are reported to increase with advanced cancer.

OBJECTIVE

The objective was to quantify the potential contribution of increasing masses of energetically demanding tissues to REE with colorectal cancer cachexia progression.

DESIGN

A longitudinal computed tomography (CT) image review was performed to quantify organ size (liver, including metastases, and spleen) and peripheral tissues (skeletal muscle and adipose tissue) during colorectal cancer cachexia progression (n = 34). Body composition was prospectively evaluated by CT and dual-energy X-ray absorptiometry, and REE was determined by indirect calorimetry in advanced colorectal cancer patients (n = 18).

RESULTS

Eleven months from death, the liver (2.3 +/- 0.7 kg) and spleen (0.32 +/- 0.2 kg) were larger than reference values. One month from death, liver weight increased to 3.0 +/- 1.5 kg (P = 0.010), spleen showed a trend to increase (P = 0.077), and concurrent losses of muscle (4.2 kg) and fat (3.5 kg) (P < 0.05) were observed. The estimated percentage of fat-free mass (FFM) occupied by the liver increased from 4.5% to 7.0% (P < 0.001). The most rapid loss of peripheral tissues and liver and metastases gain occurred within 3 mo of death. A positive linear relation existed between liver mass and measured whole-body REE (r(2) = 0.35, P = 0.010); because liver accounted for a larger percentage of FFM, measured REE . kg FFM(-1) . d(-1) increased (r(2) = 0.35, P = 0.010).

CONCLUSIONS

Increases in mass and in the proportion of high metabolic rate tissues, including liver and tumor, represented a cumulative incremental REE of approximately 17,700 kcal during the last 3 mo of life and may contribute substantially to cachexia-associated weight loss.

Food products as vehicles for n-3 fatty acid supplementation

PURPOSE

An n-3 polyunsaturated fatty acid (PUFA) supplement was incorporated into three food products previously determined to be preferred by cancer patients, and overall acceptability of these foods was evaluated.

METHODS

Preliminary testing was performed; an internal panel determined initial acceptability of foods with the supplement added. Taste panel evaluations were held at the Cross Cancer Institute in Edmonton, Alberta. Each participant completed a questionnaire rating aroma, flavour, and overall acceptance on a seven-point hedonic scale (1 = dislike extremely, 7 = like extremely), as well as ability to consume each food daily.

RESULTS

Foods were well-liked by patients and non-patients. Mean +/- standard deviation acceptance scores for the three foods were pasta sauce 5.9 +/- 0.94 (n=90), oatmeal 6.1 +/- 0.88 (n=79), and smoothie 5.9 +/- 1.12 (n=126). Overall, 94% of patients and non-patients gave tomato pasta sauce, oatmeal, and the smoothie an acceptance score of at least 5.

CONCLUSIONS

The supplement was incorporated successfully into three foods, which were highly accepted by patients with cancer. Further research should focus on incorporating the supplement into flavoured or sweet foods, as these appear most effective. Microencapsulated fish oil in food products may be used as an alternative to fish oil capsules for delivering n-3 PUFA in clinical trials.

Clustering dietary habits and the risk of breast and ovarian cancers

BACKGROUND

Limited information is available on the relationship between dietary patterns and breast and ovarian cancers.

PATIENTS AND METHODS

Cases were 2569 breast cancers and 1031 ovarian cancers hospitalized in four Italian areas from 1991 to 1999. Controls were 3413 women in hospital for acute non-neoplastic diseases. Dietary habits were investigated through a validated food-frequency questionnaire. Dietary patterns were obtained from a K-means clustering on factor scores from factor analysis. Odds ratios (ORs) for both cancers were estimated using unconditional multiple logistic regression models on clusters of patients. Floating absolute risk method was used for reporting 95% floating confidence intervals (FCIs).

RESULTS

We identified five groups of subjects. The G3 cluster, including subjects with the lowest intakes of any food group, was used as reference. The G5 cluster, including subjects mainly consuming bread and pasta, was unfavorable for both cancers (OR=1.23, 95% FCI=1.08-1.38 for breast cancer, OR=1.21, 95% FCI=1.03-1.42 for ovarian cancer). The G1 group, including subjects mainly consuming fruits and vegetables, was protective against ovarian cancer (OR=0.81, 95% FCI=0.67-0.98).

CONCLUSIONS

A diet mainly based on bread and pasta is unfavorable for breast and ovarian cancers; a diet rich in fruits and vegetables may be associated with a reduced risk of ovarian cancer.

Computational modeling of cancer cachexia

PURPOSE OF REVIEW

Measurements of whole-body energy expenditure, body composition, and in-vivo metabolic fluxes are required to quantitatively understand involuntary weight loss in cancer cachexia. Such studies are rare because cancer cachexia occurs near the end of life when invasive metabolic tests may be precluded. Thus, models of cancer-associated weight loss are an important tool for helping to understand this debilitating condition.

RECENT FINDINGS

A computational model of human macronutrient metabolism was recently developed that simulates the normal metabolic adaptations to semi-starvation and re-feeding. Here, this model was used to integrate data on the metabolic changes in patients with cancer cachexia. The resulting computer simulations show how the known metabolic disturbances synergize with reduced energy intake to result in a progressive loss of body weight, fat mass, and fat-free mass. The model was also used to simulate the effects of nutritional support and investigate inhibition of lipolysis versus proteolysis as potential therapeutic approaches for cancer cachexia.

SUMMARY

Computational modeling is a new tool that can integrate clinical data on the metabolic changes in cancer cachexia and provide a conceptual framework to help understand involuntary weight loss and predict the effects of potential therapies.

Cysteine-rich protein reverses weight loss in lung cancer patients receiving chemotherapy or radiotherapy

Oxidative stress plays a role in the tumor-cytotoxic effect of cancer chemotherapy and radiotherapy and also in certain adverse events. In view of these conflicting aspects, a double-blind trial over a 6-month period was performed to determine whether a cysteine-rich protein (IMN1207) may have a positive or negative effect on the clinical outcome if compared with casein, a widely used protein supplement low in cysteine. Sixty-six patients with stage IIIB-IV non-small cell lung cancer were randomly assigned to IMN1207 or casein. Included were patients with a previous involuntary weight loss of > or =3%, Karnofsky status > or =70, and an estimated survival of >3 months. Thirty-five lung cancer patients remained on study at 6 weeks. Overall compliance was not different between treatment arms (42-44% or 13 g/day). The patients treated with the cysteine-rich protein had a mean increase of 2.5% body weight, whereas casein-treated patients lost 2.6% (p = 0.049). Differences in secondary endpoints included an increase in survival, hand-grip force, and quality of life. Adverse events were mild or moderate. Further studies will have to show whether the positive clinical effects can be confirmed and related to specific parameters of oxidative stress in the host.