Cachexia and Sarcopenia in Older Adults with Cancer: A Comprehensive Review

Exercise Medicine in the Management of Pancreatic Cancer: A Systematic Review

ABSTRACT

The aim of this study was to examine the health-related effects of exercise in patients with pancreatic cancer (PanCa) through a systematic review of current evidence. Studies were obtained through searching PubMed, Web of Science, PsycINFO, Embase, CINAHL Plus, and Cochrane Library databases with additional hand searches. All intervention-based studies were included if it involved (1) adult patients with PanCa, (2) exercise training, and (3) findings in quality of life, cancer-related fatigue, psychological distress, and physical function. The review protocol was registered in PROSPERO: CRD42020154684. Seven trials described in 9 publications were included consisting of 201 patients with early-stage and advanced PanCa. Participants were required to perform supervised and/or home-based, low- to moderate-intensity resistance and/or aerobic exercise for 12 to 35 weeks or duration of neoadjuvant therapy. There were no exercise-related adverse events with a reported retention rate of 71% to 90% and exercise attendance of 64% to 96%. The programs were consistently associated with improvements in cancer-related fatigue, psychological distress, and physical function, with mixed effects on quality of life. Exercise training seems to be safe and feasible and may have a beneficial effect on various physical and psychological outcomes in patients with PanCa. Further work with rigorous study designs is required to consolidate and advance current findings.

Sarcopenia, Malnutrition, and Cachexia: Adapting Definitions and Terminology of Nutritional Disorders in Older People with Cancer

The recent publication of the revised Consensus on definition and diagnosis of sarcopenia (EWGSOP2) and the Global Leadership Initiative on Malnutrition (GLIM) criteria changed the approach to research on sarcopenia and malnutrition. Whilst sarcopenia is a nutrition-related disease, malnutrition and cachexia are nutritional disorders sharing the common feature of low fat-free mass. However, they have differential characteristics and etiologies, as well as specific therapeutic approaches. Applying the current definitions in clinical practice is still a challenge for health professionals and the potential for misdiagnosis is high. This is of special concern in the subgroup of older people with cancer, in which sarcopenia, malnutrition, and cancer cachexia are highly prevalent and can overlap or occur separately. The purpose of this review is to provide an updated overview of the latest research and consensus definitions of sarcopenia, malnutrition, and cachexia and to discuss their implications for clinical practice in older patients with cancer. The overall aim is to improve the quality of nutritional care in light of the latest findings.

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer: a protocol for a randomised controlled trial (GEPOC trial)

BACKGROUND

The incidence of colorectal cancer (CRC) increases with age. Older patients are a heterogeneous group ranging from fit to frail with various comorbidities. Frail older patients with CRC are at increased risk of negative outcomes and functional decline after cancer surgery compared to younger and fit older patients. Maintenance of independence after treatment is rarely investigated in clinical trials despite older patients value it as high as survival. Comprehensive geriatric assessment (CGA) is an evaluation of an older persons' medical, psychosocial, and functional capabilities to develop an overall plan for treatment and follow-up. The beneficial effect of CGA is well documented in the fields of medicine and orthopaedic surgery, but evidence is lacking in cancer surgery. We aim to investigate the effect of CGA on physical performance in older frail patients undergoing surgery for CRC.

METHODS

GEPOC is a single centre randomised controlled trial including older patients (≥65 years) undergoing surgical resection for primary CRC. Frail patients (≤14/17 points using the G8 screening tool) will be randomised 1:1 to geriatric intervention and exercise (n = 50) or standard of care along (n = 50) with their standard surgical procedure. Intervention includes preoperative CGA, perioperative geriatric in-ward review and postoperative follow-up. All patients in the intervention group will participate in a pre- and postoperative resistance exercise programme (twice/week, 2 + 12 weeks). Primary endpoint is change in 30-s chair stand test. Assessment of primary endpoint will be performed by physiotherapists blinded to patient allocation. Secondary endpoints: changes in health related quality of life, physical strength and capacity (handgrip strength, gait speed and 6 min walking test), patient perceived quality of recovery, complications to surgery, body composition (Dual-energy X-ray absorptiometry and bioelectric impedance), serum biomarkers, readmission, length of stay and survival.

DISCUSSION

This ongoing trial will provide valuable knowledge on whether preoperative CGA and postoperative geriatric follow-up and intervention including an exercise program can counteract physical decline and improve quality of life in frail CRC patients undergoing surgery.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov NCT03719573 (October 2018).

Associations of Skeletal Muscle With Symptom Burden and Clinical Outcomes in Hospitalized Patients With Advanced Cancer

BACKGROUND

Low muscle mass (quantity) is common in patients with advanced cancer, but little is known about muscle radiodensity (quality). We sought to describe the associations of muscle mass and radiodensity with symptom burden, healthcare use, and survival in hospitalized patients with advanced cancer.

METHODS

We prospectively enrolled hospitalized patients with advanced cancer from September 2014 through May 2016. Upon admission, patients reported their physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used CT scans performed per routine care within 45 days before enrollment to evaluate muscle mass and radiodensity. We used regression models to examine associations of muscle mass and radiodensity with patients' symptom burden, healthcare use (hospital length of stay and readmissions), and survival.

RESULTS

Of 1,121 patients enrolled, 677 had evaluable muscle data on CT (mean age, 62.86 ± 12.95 years; 51.1% female). Older age and female sex were associated with lower muscle mass (age: B, -0.16; P<.001; female: B, -6.89; P<.001) and radiodensity (age: B, -0.33; P<.001; female: B, -1.66; P=.014), and higher BMI was associated with higher muscle mass (B, 0.58; P<.001) and lower radiodensity (B, -0.61; P<.001). Higher muscle mass was significantly associated with improved survival (hazard ratio, 0.97; P<.001). Notably, higher muscle radiodensity was significantly associated with lower ESAS-Physical (B, -0.17; P=.016), ESAS-Total (B, -0.29; P=.002), PHQ-4-Depression (B, -0.03; P=.006), and PHQ-4-Anxiety (B, -0.03; P=.008) symptoms, as well as decreased hospital length of stay (B, -0.07; P=.005), risk of readmission or death in 90 days (odds ratio, 0.97; P<.001), and improved survival (hazard ratio, 0.97; P<.001).

CONCLUSIONS

Although muscle mass (quantity) only correlated with survival, we found that muscle radiodensity (quality) was associated with patients' symptoms, healthcare use, and survival. These findings underscore the added importance of assessing muscle quality when seeking to address adverse muscle changes in oncology.

Development of Sarcopenia in Patients With Bladder Cancer: A Systematic Review

OBJECTIVE

Sarcopenia is known to influence cancer-related complications and overall survival. However, the effect of cancer treatment on the development or progression of sarcopenia is relatively unknown. The primary aim of this systematic review was to determine the prevalence and development of sarcopenia among people with bladder cancer.

DATA SOURCES

A systematic search was performed in PubMed, Web of Science, and EMBASE. Studies with ≥2 assessments of sarcopenia were eligible for inclusion. Five retrospective cohorts were included with a total of 438 participants. The baseline prevalence of sarcopenia across studies varied from 25% to 69% and post-treatment prevalence from 50% to 81%. The average loss of muscle mass was 2.2% to 10% during a time course of 3 to 12 months.

CONCLUSION

The prevalence of sarcopenia markedly increased during cancer treatment in patients with bladder cancer. Further research into the effect of different treatment regimens on the development of sarcopenia, and how these changes might affect functional capacity and survival is needed.

IMPLICATIONS FOR NURSING PRACTICE

The development of sarcopenia is important to understand because of its negative affect on quality of life, complications, and mortality. Further, understanding how sarcopenia develops during treatment could potentially strengthen nurses' future care plans for patients with bladder cancer.

Harnessing Muscle-Liver Crosstalk to Treat Nonalcoholic Steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) has reached epidemic proportions, affecting an estimated one-quarter of the world's adult population. Multiple organ systems have been implicated in the pathophysiology of NAFLD; however, the role of skeletal muscle has until recently been largely overlooked. A growing body of evidence places skeletal muscle-via its impact on insulin resistance and systemic inflammation-and the muscle-liver axis at the center of the NAFLD pathogenic cascade. Population-based studies suggest that sarcopenia is an effect-modifier across the NAFLD spectrum in that it is tightly linked to an increased risk of non-alcoholic fatty liver, non-alcoholic steatohepatitis (NASH), and advanced liver fibrosis, all independent of obesity and insulin resistance. Longitudinal studies suggest that increases in skeletal muscle mass over time may both reduce the incidence of NAFLD and improve preexisting NAFLD. Adverse muscle composition, comprising both low muscle volume and high muscle fat infiltration (myosteatosis), is highly prevalent in patients with NAFLD. The risk of functional disability conferred by low muscle volume in NAFLD is further exacerbated by the presence of myosteatosis, which is twice as common in NAFLD as in other chronic liver diseases. Crosstalk between muscle and liver is influenced by several factors, including obesity, physical inactivity, ectopic fat deposition, oxidative stress, and proinflammatory mediators. In this perspective review, we discuss key pathophysiological processes driving sarcopenia in NAFLD: anabolic resistance, insulin resistance, metabolic inflexibility and systemic inflammation. Interventions that modify muscle quantity (mass), muscle quality (fat), and physical function by simultaneously engaging multiple targets and pathways implicated in muscle-liver crosstalk may be required to address the multifactorial pathogenesis of NAFLD/NASH and provide effective and durable therapies.

Effect of COVID-19 on Lungs: Focusing on Prospective Malignant Phenotypes

Currently, the healthcare management systems are shattered throughout the world, even in the developed nations due to the COVID-19 viral outbreak. A substantial number of patients infected with SARS-CoV2 develop acute respiratory distress syndrome (ARDS) and need advanced healthcare facilities, including invasive mechanical ventilation. Intracellular infiltration of the SARS-CoV2 virus particles into the epithelial cells in lungs are facilitated by the spike glycoprotein (S Protein) on the outer side of the virus envelope, a membrane protein ACE2 (angiotensin-converting enzyme 2) and two proteases (TMPRSS2 and Furin) in the host cell. This virus has unprecedented effects on the immune system and induces a sudden upregulation of the levels of different pro-inflammatory cytokines. This can be a cause for the onset of pulmonary fibrosis in the lungs. Existence of a high concentration of inflammatory cytokines and viral load can also lead to numerous pathophysiological conditions. Although it is well established that cancer patients are among the high-risk population due to COVID-19-associated mortality, it is still unknown whether survivors of COVID-19-infected subjects are at high-risk population for developing cancer and whether any biologic and clinical features exist in post-COVID-19 individuals that might be related to carcinogenesis.

The Acute Effects of 5 Fluorouracil on Skeletal Muscle Resident and Infiltrating Immune Cells in Mice

5 fluorouracil (5FU) has been a first-choice chemotherapy drug for several cancer types (e.g., colon, breast, head, and neck); however, its efficacy is diminished by patient acquired resistance and pervasive side effects. Leukopenia is a hallmark of 5FU; however, the impact of 5FU-induced leukopenia on healthy tissue is only becoming unearthed. Recently, skeletal muscle has been shown to be impacted by 5FU in clinical and preclinical settings and weakness and fatigue remain among the most consistent complaints in cancer patients undergoing chemotherapy. Monocytes, or more specifically macrophages, are the predominate immune cell in skeletal muscle which regulate turnover and homeostasis through removal of damaged or old materials as well as coordinate skeletal muscle repair and remodeling. Whether 5FU-induced leukopenia extends beyond circulation to impact resident and infiltrating skeletal muscle immune cells has not been examined. The purpose of the study was to examine the acute effects of 5FU on resident and infiltrating skeletal muscle monocytes and inflammatory mediators. Male C57BL/6 mice were given a physiologically translatable dose (35 mg/kg) of 5FU, or PBS, i.p. once daily for 5 days to recapitulate 1 dosing cycle. Our results demonstrate that 5FU reduced circulating leukocytes, erythrocytes, and thrombocytes while inducing significant body weight loss (>5%). Flow cytometry analysis of the skeletal muscle indicated a reduction in total CD45+ immune cells with a corresponding decrease in total CD45+CD11b+ monocytes. There was a strong relationship between circulating leukocytes and skeletal muscle CD45+ immune cells. Skeletal muscle Ly6cHigh activated monocytes and M1-like macrophages were reduced with 5FU treatment while total M2-like CD206+CD11c- macrophages were unchanged. Interestingly, 5FU reduced bone marrow CD45+ immune cells and CD45+CD11b+ monocytes. Our results demonstrate that 5FU induced body weight loss and decreased skeletal muscle CD45+ immune cells in association with a reduction in infiltrating Ly6cHigh monocytes. Interestingly, the loss of skeletal muscle immune cells occurred with bone marrow cell cycle arrest. Together our results highlight that skeletal muscle is sensitive to 5FU's off-target effects which disrupts both circulating and skeletal muscle immune cells.

Older adults with cancer and their caregivers - current landscape and future directions for clinical care

Despite substantial improvements in the outcomes of patients with cancer over the past two decades, older adults (aged ≥65 years) with cancer are a rapidly increasing population and continue to have worse outcomes than their younger counterparts. Managing cancer in this population can be challenging because of competing health and ageing-related conditions that can influence treatment decision-making and affect outcomes. Geriatric screening tools and comprehensive geriatric assessment can help to identify patients who are most at risk of poor outcomes from cancer treatment and to better allocate treatment for these patients. The use of evidence-based management strategies to optimize geriatric conditions can improve communication and satisfaction between physicians, patients and caregivers as well as clinical outcomes in this population. Clinical trials are currently underway to further determine the effect of geriatric assessment combined with management interventions on cancer outcomes as well as the predictive value of geriatric assessment in the context of treatment with contemporary systemic therapies such as immunotherapies and targeted therapies. In this Review, we summarize the unique challenges of treating older adults with cancer and describe the current guidelines as well as investigational studies underway to improve the outcomes of these patients.

Associations of baseline patient-reported outcomes with treatment outcomes in advanced gastrointestinal cancer

BACKGROUND

Patient-reported outcomes (PROs) assessing quality of life (QOL) and symptom burden correlate with clinical outcomes in patients with cancer. However, to the authors' knowledge, data regarding associations between PROs and treatment response are lacking.

METHODS

The authors prospectively approached consecutive patients with advanced gastrointestinal cancer who were initiating a new treatment. Prior to treatment, patients reported their QOL (Functional Assessment of Cancer Therapy-General [FACT-G], 4 subscales: Functional, Physical, Emotional, Social; higher scores indicate better QOL) and symptom burden (Edmonton Symptom Assessment System [ESAS], Patient Health Questionnaire-4 [PHQ-4]; higher scores represent greater symptoms). Regression models were used to examine associations of baseline PROs with treatment response (clinical benefit or progressive disease [PD] at time of first scan), healthcare utilization, and survival.

RESULTS

From May 2019 to April 2020, a total of 112 patients with advanced gastrointestinal cancer were enrolled. For treatment response, 64.3% had CB and 35.7% had PD. Higher baseline ESAS-Physical (odds ratio, 1.04; P = .027) and lower FACT-G Functional (odds ratio, 0.92; P = .038) scores were associated with PD. Higher ESAS-Physical (hazard ratio [HR], 1.03; P = .044) and lower FACT-G Total (HR, 0.96; P = .005), FACT-G Physical (HR, 0.89; P < .001), and FACT-G Functional (HR, 0.87; P < .001) scores were associated with a greater hospitalization risk. Lower FACT-G Total (HR, 0.96; P = .009) and FACT-G Emotional (HR, 0.86; P = .012) scores as well as higher ESAS-Total (HR, 1.03; P = .014) and ESAS-Physical (HR, 1.04; P = .032) scores were associated with worse survival.

CONCLUSIONS

Baseline PROs are associated with treatment response in patients with advanced gastrointestinal cancer, namely physical symptoms and functional QOL, in addition to health care use and survival. The findings of the current study support the association between PROs and important clinical outcomes, including the novel finding of treatment response.

Effects of protein supplementation on muscle wasting disorders: A brief update of the evidence

OBJECTIVE

To examine the effects of protein supplementation on muscle mass, strength and function in individuals at risk of muscle wasting disorders.

METHODS

A narrative overview of the literature based on a PubMed search.

RESULTS

Increasing protein intake beyond the recommended dietary intake may prevent or attenuate muscle loss in people at risk of muscle wasting disorders; however, there is inconsistent evidence for any benefits on muscle strength or physical function. This is likely due to the significant heterogeneity and bias regarding baseline demographics, basal protein/energy intakes and protein supplement type, dose, timing and compliance.

CONCLUSION

Protein supplementation attenuates muscle loss in some populations at increased risk of muscle wasting, but there is no consistent evidence to support benefits on muscle strength or physical function. Further randomised controlled trials are needed that focus on whether there is an optimal type, dose and timing of protein intake, and potential interaction with other nutrients.

Association between temporal muscle thickness and clinical outcomes in patients with newly diagnosed glioblastoma

PURPOSE

Temporal muscle thickness (TMT) has been suggested as a novel biomarker that can represent sarcopenia in head and neck malignancies. This study investigated the association of TMT with clinical outcomes in patients with newly diagnosed glioblastoma (GBM).

METHODS

Using electronic medical records, all GBM patients between 2008 and 2018 at Seoul St. Mary's Hospital were reviewed. Total 177 patients met our eligibility criteria.

RESULTS

The thinner group who had TMT less than the median showed shorter overall survival (OS) and progression-free survival (PFS) than the thicker group who had TMT more than median (OS; 11.0 versus 18.0 months, p < 0.001, and PFS; 6.0 versus 11.0 months, p < 0.001). In the multivariate analysis, the thinner group had negative associations with OS and PFS (OS; HR 2.63 (1.34-2.63), p < 0.001, and PFS; HR 2.21 (1.34-2.50), p = 0.002). We also performed propensity score matching between the thinner and thicker groups to minimize the potential bias. The thinner group showed shorter OS and PFS (OS; 13.5 versus 19.0 months, p = 0.006, and PFS; 6.5 versus 9.0 months, p = 0.028) and had negative associations with OS and PFS than the thicker group (OS; HR 1.90 (1.19-3.03), p = 0.008, and PFS; HR 1.70 (1.07-2.70), p = 0.026) in matched patients.

CONCLUSION

Our findings suggest that TMT can be a useful prognostic biomarker for clinical outcomes in GBM patients. Further preclinical and clinical studies could help elucidate this association of sarcopenia with clinical outcomes in GBM patients.

The Impact of Immune Cells on the Skeletal Muscle Microenvironment During Cancer Cachexia

Progressive weight loss combined with skeletal muscle atrophy, termed cachexia, is a common comorbidity associated with cancer that results in adverse consequences for the patient related to decreased chemotherapy responsiveness and increased mortality. Cachexia's complexity has provided a barrier for developing successful therapies to prevent or treat the condition, since a large number of systemic disruptions that can regulate muscle mass are often present. Furthermore, considerable effort has focused on investigating how tumor derived factors and inflammatory mediators directly signal skeletal muscle to disrupt protein turnover regulation. Currently, there is developing appreciation for understanding how cancer alters skeletal muscle's complex microenvironment and the tightly regulated interactions between multiple cell types. Skeletal muscle microenvironment interactions have established functions in muscle response to regeneration from injury, growth, aging, overload-induced hypertrophy, and exercise. This review explores the growing body of evidence for immune cell modulation of the skeletal muscle microenvironment during cancer-induced muscle wasting. Emphasis is placed on the regulatory network that integrates physiological responses between immune cells with other muscle cell types including satellite cells, fibroblast cells, and endothelial cells to regulate myofiber size and plasticity. The overall goal of this review is to provide an understanding of how different cell types that constitute the muscle microenvironment and their signaling mediators contribute to cancer and chemotherapy-induced muscle wasting.

Nutrition and physical activity professional education in gastrointestinal oncology: a national multidisciplinary survey

Objectives

Sarcopenia, present in more than 50% of digestive oncology patients, has a negative impact on clinical outcomes. Nutrition and adapted physical activity are two major interventions for the management of sarcopenia. However, young hepato-gastroenterologists, oncologists and surgeons in France have limited awareness on these topics. We aimed to evaluate the need for training programmes of physicians (residents and senior doctors) involved in digestive oncology on nutrition and adapted physical activity.

Methods

A 42-question survey was developed, by a working group of clinicians, dieticians and adapted physical activity teachers, to assess five areas related to demographics of respondents, nutrition practices, nutrition training, adapted physical activity practices and adapted physical activity training. The national survey was undertaken between April and July of 2019.

Results

230 physicians participated in the survey; 34% were hepato-gastroenterologists, 31% were oncologists, 23% were surgeons and 40% were residents. Sixty-one per cent of participants had received training in nutrition and only 21% in adapted physical activity. Ninety per cent of the physicians expressed their desire for more effective training on these two topics. Disparities in clinical practices were observed between hepato-gastroenterologists, oncologists and surgeons.

Conclusions

More initial and continuing training on nutrition and adapted physical activity is needed for French physicians in the current digestive oncology clinical practice.

Sarcopenia represents a negative prognostic factor in pancreatic cancer patients undergoing EUS celiac plexus neurolysis

Background and Objectives:

Increasing evidence suggests a prognostic role of sarcopenia in pancreatic cancer patients. The aim of this study was to assess the influence of sarcopenia on treatment outcomes after EUS-guided celiac plexus neurolysis (CPN).

Materials and Methods:

Data regarding 215 patients treated with EUS CPN between 2004 and 2019 were reviewed. Determination of body composition was conducted on contrast-enhanced CT scan, and pain response was considered as the primary outcome. Univariate and multivariate logistic regression was performed to identify the independent predictors of pain response.

Results:

Treatment was successful in 187 patients (86.9%). The median age was 62 (range 39–84) years, and most patients were male (61.8%). Of the whole study population, 139 patients (64.6%) were defined as sarcopenic, of which 116 (83.4%) responded to the treatment and 5 (3.5%) experienced a complete response. Among 76 nonsarcopenic participants, 71 (93.4%) responded to the treatment and 22 (28.9%) obtained a complete response (P = 0.03 and <0.001, respectively). The median duration of pain relief was 8 (2–10) and 15 (8–16) weeks in sarcopenic and nonsarcopenic patients, respectively (P = 0.01). The median overall survival after neurolysis was 4 months (3–5) in sarcopenic participants and 7 months (6–8) in nonsarcopenic participants (P = 0.05). Tumoral stage, interval from the diagnosis to treatment, and sarcopenia resulted as significant prognostic factors for treatment response both in univariate and multivariate regression analyses. No severe treatment-related adverse events were reported in the whole study population, with no difference between the two groups.

Conclusions:

Sarcopenia represents a predictor of poorer response to EUS CPN.

Management of diet in gastrointestinal cancer

Nutrition and gastrointestinal cancer are inextricably linked. The metabolic effects of cancer along with changes in dietary intake, the development of cancer cachexia and the presence of sarcopenia can influence changes in body composition. These have a negative impact on quality of life and tolerance to cancer treatment. Treatment for cancer presents some significant nutritional challenges as nutrition impact symptoms may develop, be exacerbated by treatment and may contribute to a worsening in nutritional status. Nutrition screening and assessment should be an integral part of holistic patient care. The provision of appropriate, evidence-based dietary advice should occur before, during and after cancer treatment. Appropriate and timely methods of nutritional support across the spectrum of gastrointestinal cancer are needed to ensure that people are adequately supported during courses of treatment that can span weeks and months. These can range from standard approaches of supplementing oral intake to complex interventions such as managing high output intestinal stomas. The gastrointestinal tract is particularly susceptible to impact from systemic anti-cancer treatments and radiotherapy. Gastrointestinal late effects of cancer treatment are now recognised to present particular challenges in terms of both medical and nutritional management. These late effects have a significant impact on the individual and their quality of life in addition to implications for the health service. Dietary intake following cancer treatment has an impact on quality of life and future research may demonstrate its influence on the risk of recurrence of gastrointestinal cancer.

An update on nutrient modulation in the management of disease-induced muscle wasting: evidence from human studies

PURPOSE OF REVIEW

Skeletal muscle has many essential roles in maintaining human health, not only being crucial for locomotion, but further as a metabolically important organ. Muscle wasting in disease (cachexia) is highly prevalent, associated with poor clinical outcomes and is not fully reversible with nutritional interventions. Understanding proteostasis in diseased states is of great importance to design novel, effective nutritional/nutraceutical strategies aimed at alleviating muscle wasting. In this review, we will provide an update on muscle kinetics in disease and the effects of nutritional interventions.

RECENT FINDINGS

Whole body and skeletal muscle kinetics are commonly shown to be imbalanced in disease, promoting overall catabolism that underlies the development of cachexia. However, recent advancements in defining the effectiveness of nutritional interventions on muscle anabolism are clouded by heterogenous patient populations and a lack of direct incorporation stable isotope techniques. Current recommendations are focused on combating malnutrition, with increased protein intake (high in EAA) demonstrating promise.

SUMMARY

Recent progress in understanding catabolic states in cachexia across disease is minimal. Further, studies investigating muscle-specific protein turnover along with nutritional interventions are scarce. As such, there is a significant requirement for strong RCT's investigating both acute and chronic nutritional interventions and their impact on skeletal muscle in individual disease states.

MicroRNAs as potential therapeutic targets for muscle wasting during cancer cachexia

PURPOSE OF REVIEW

Muscle wasting in cancer cachexia remains an unmet clinical need due to lack of effective therapies associated with the complexity of the disease. Here, we discuss microRNAs, robust regulators of the expression of multiple genes, only recently characterized in cancer cachexia in humans and their therapeutic potential for muscle wasting.

RECENT FINDINGS

Changes in microRNAs in muscle of cancer patients have been demonstrated for the first time and these are associated with dysregulated signalling networks during muscle wasting. These data, together with studies in animal models, indicate that microRNAs are attractive therapeutic candidates for maintaining muscle mass, both during and following cancer treatment ultimately improving patient outcomes.

SUMMARY

Cancer cachexia is a complex metabolic condition associated with muscle wasting. Maintenance of muscle mass in cancer patients can improve their response to therapy and prognosis. microRNAs, which can act as oncogenes or tumour suppressors, are also dysregulated in muscle of cachexia patients. Studies in animal models of muscle wasting have demonstrated that microRNAs regulate muscle mass and strength. With more microRNA-based therapeutics in clinical trials and first RNA drugs approved, microRNAs present an attractive novel therapeutic avenue for maintaining muscle homeostasis in cachexia patients to improve their prognosis.

Assessment of Sarcopenia Measures, Survival, and Disability in Older Adults Before and After Diagnosis With Cancer

IMPORTANCE

Progressive loss of muscle mass and strength, known as sarcopenia, is a well-known phenomenon of aging; however, little is known about the trajectory of sarcopenia measures before and after cancer diagnosis and its contribution to subsequent disability.

OBJECTIVE

To examine the rate of decline of sarcopenia measures (ie, appendicular lean mass [ALM], muscle strength, and physical performance) in older adults with cancer both before and after the cancer diagnosis compared with the trajectory of a population without cancer, and secondarily to assess the association of sarcopenia measures with overall survival and major disability in patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This matched cohort study included participants from the Health, Aging, and Body Composition (Health ABC) study, which included 3075 community-dwelling older adults aged 70 to 79 years recruited from a random sample of white Medicare beneficiaries and all eligible black residents in and around Pittsburgh, Pennsylvania, and Memphis, Tennessee, beginning in January 1997 and observed for 17 years until December 2013. Data were analyzed from May 2018 to February 2020.

EXPOSURES

The development of an adjudicated cancer diagnosis confirmed with pathology or cytology reports during the first 7 years of follow-up.

MAIN OUTCOMES AND MEASURES

Annual assessments of ALM, hand grip strength, and gait speed were the primary outcome measures. Linear mixed-effect models were used to compare the change in ALM, hand grip strength, and gait speed between individuals who developed cancer and those who did not, adjusted for multiple comparisons (P < .01). Multivariable Cox regression was used to examine the association of sarcopenia measures with overall survival and major disability from date of cancer diagnosis.

RESULTS

Of the 3075 included patients, 1491 (48.5%) were male, 1281 (41.7%) were black, and the mean (SD) age was 74.1 (2.9) years. A total of 515 patients (16.7%) developed cancer within the first 7 years of the study. The most common cancers were prostate (117 [23.2%]), colorectal (63 [12.5%]), lung (61 [12.1%]), and breast (61 [12.1%]) cancer, and 165 patients (32.0%) were diagnosed as having metastatic disease. Compared with controls without cancer, patients with a cancer diagnosis had a steeper decline in gait speed (β = -0.02; 95% CI, -0.03 to -0.01; P < .001) but not ALM (β = -0.02; 95% CI, -0.07 to 0.04; P = .49) or hand grip strength (β = -0.21; 95% CI, -0.43 to 0; P = .05) prior to cancer diagnosis. After cancer diagnosis, there was a decline in ALM (β = -0.14; 95% CI, -0.23 to -0.05; P < .001) but not hand grip strength (β = -0.02; 95% CI, -0.37 to 0.33; P = .92) or gait speed (β = 0; 95% CI, -0.01 to 0.02; P = .51). Declines in ALM after a cancer diagnosis were most striking in patients with metastases (β = -0.32; 95% CI, -0.53 to -0.10; P = .003). Slow gait speed was associated with a 44% increase in mortality (hazard ratio, 1.44; 95% CI, 1.05 to 1.98; P = .02) and a 70% increase in disability (hazard ratio, 1.70; 95% CI, 1.08 to 2.68; P = .02) but not low ALM or hand grip strength.

CONCLUSIONS AND RELEVANCE

Accelerated losses in differing sarcopenia measures exist both prior to and after a cancer diagnosis and may present opportunities for targeted interventions to improve outcomes.

1H-NMR Based Serum Metabolomics Identifies Different Profile between Sarcopenia and Cancer Cachexia in Ageing Walker 256 Tumour-Bearing Rats

Sarcopenia among the older population has been growing over the last few years. In addition, the incidence of cancers increases with age and, consequently, the development of cachexia related cancer. Therefore, the elucidation of the metabolic derangements of sarcopenia and cachexia are important to improve the survival and life quality of cancer patients. We performed the ¹H-NMR based serum metabolomics in adult (A) and ageing (S) Walker 256 tumour-bearing rats in different stages of tumour evolution, namely intermediated (Wi) and advanced (Wa). Among 52 serum metabolites that were identified, 21 were significantly increased in S and 14 and 19 decreased in the Wi and Wa groups, respectively. The most impacted pathways by this metabolic alteration were related by amino acid biosynthesis and metabolism, with an upregulation in S group and downregulation in Wi and Wa groups. Taken together, our results suggest that the increase in metabolic profile in ageing rats is associated with the higher muscle protein degradation that releases several metabolites, especially amino acids into the serum. On the other hand, we hypothesise that the majority of metabolites released by muscle catabolism are used by tumours to sustain rapid cell proliferation and tumorigenesis.

Leveraging the Potential Synergy Between Patient-Reported Outcomes and Body Composition Analysis in Patients with Cancer

In the oncology setting, data on the relationship between body composition, patient-reported outcomes, and patient outcomes are limited. This editorial outlines the available data and discusses the potential for using such information as a strategy to predict and enhance patient outcomes.

Advances in cancer cachexia: Intersection between affected organs, mediators, and pharmacological interventions

Advanced cancer patients exhibit cachexia, a condition characterized by a significant reduction in the body weight predominantly from loss of skeletal muscle and adipose tissue. Cachexia is one of the major causes of morbidity and mortality in cancer patients. Decreased food intake and multi-organ energy imbalance in cancer patients worsen the cachexia syndrome. Cachectic cancer patients have a low tolerance for chemo- and radiation therapies and also have a reduced quality of life. The presence of tumors and the current treatment options for cancer further exacerbate the cachexia condition, which remains an unmet medical need. The onset of cachexia involves crosstalk between different organs leading to muscle wasting. Recent advancements in understanding the molecular mechanisms of skeletal muscle atrophy/hypertrophy and adipose tissue wasting/browning provide a platform for the development of new targeted therapies. Therefore, a better understanding of this multifactorial disorder will help to improve the quality of life of cachectic patients. In this review, we summarize the metabolic mediators of cachexia, their molecular functions, affected organs especially with respect to muscle atrophy and adipose browning and then discuss advanced therapeutic approaches to cancer cachexia.

Exosomal circular RNA sorting mechanisms and their function in promoting or inhibiting cancer

Exosomes are nanoscale phospholipid bilayer vesicles that can be artificially engineered into vectors for the treatment of cancer. Circular RNA (circRNA), a type of non-coding RNA, has crucial regulatory functions in various aspects of cancer, such as tumorigenesis, apoptosis, proliferation, invasion, metastasis and chemo- and radiotherapeutic resistance, as well as in cancer prognosis. Notably, the exosomal transfer of circRNAs may function to both promote and inhibit cancer. Numerous studies have addressed the importance of circRNAs in cancer and non-coding RNAs (such as microRNAs and long non-coding RNAs) in exosomes. However, little research has focussed on a class of RNAs called exosomal circRNAs. The present review discusses current studies regarding exosomal circRNAs, including their biogenesis and biological functions, their abundance in exosomes and possible sorting mechanisms and their potential roles in both promoting and inhibiting cancer. It is predicted that in the next five years there will be increasing research exploring the functional mechanisms of exosomal circRNA in various diseases, in particular their roles in cancer genesis and progression.

Can Bioelectrical Impedance Analysis and BMI be a Prognostic Tool in Head and Neck Cancer Patients? A Review of the Evidence

Background: Malnutrition can significantly affect disease progression and patient survival. The efficiency of weight loss and bioimpedance analysis (BIA)-derived measures in the evaluation of malnutrition, and disease progression and prognosis in patients with head and neck cancer (HNC) are an important area of research. Method: The PubMed database was thoroughly searched, using relative keywords in order to identify clinical trials that investigated the role of BIA-derived measures and weight loss on the disease progression and prognosis of patients with HNC. Twenty-seven studies met the criteria. More specifically, six studies examined the prognostic role of the tissue electrical properties in HNC patients; five examined the role of the tissue electrical properties on identifying malnutrition; four studies looked at the changes in the tissue electrical properties of HNC patients; and 12 examined the prognostic role of weight loss on survival and/or treatment outcomes. Results: Several studies have investigated the role of nutritional status tools on prognosis in HNC patients. Current studies investigating the potential of BIA-derived raw data have shown that phase angle (PA) and capacitance of the cell membrane may be considered prognostic factors of survival. Weight loss may be a prognostic factor for treatment toxicity and survival, despite some conflicting evidence. Conclusions: Further studies are recommended to clarify the role of BIA-derived measures on patients’ nutritional status and the impact of PA on clinical outcomes as well as the prognostic role of weight loss.

1H-NMR Based Serum Metabolomics Highlights Different Specific Biomarkers between Early and Advanced Hepatocellular Carcinoma Stages

The application of non-targeted serum metabolomics profiling represents a noninvasive tool to identify new clinical biomarkers and to provide early diagnostic differentiation, and insight into the pathological mechanisms underlying hepatocellular carcinoma (HCC) progression. In this study, we used proton Nuclear Magnetic Resonance (¹H-NMR) Spectroscopy and multivariate data analysis to profile the serum metabolome of 64 HCC patients, in early (n = 28) and advanced (n = 36) disease stages. We found that ¹H-NMR metabolomics profiling could discriminate early from advanced HCC patients with a cross-validated accuracy close to 100%. Orthogonal partial least squares discriminant analysis (OPLS-DA) showed significant changes in serum glucose, lactate, lipids and some amino acids, such as alanine, glutamine, 1-methylhistidine, lysine and valine levels between advanced and early HCC patients. Moreover, in early HCC patients, Kaplan-Meier analysis highlighted the serum tyrosine level as a predictor for overall survival (OS). Overall, our analysis identified a set of metabolites with possible clinical and biological implication in HCC pathophysiology.

Can We Distinguish Age-Related Frailty from Frailty Related to Diseases ? Data from the MAPT Study

BACKGROUND

No study has tried to distinguish subjects that become frail due to diseases (frailty related to diseases) or in the absence of specific medical events; in this latter case, it is possible that aging process would act as the main frailty driver (age-related frailty).

OBJECTIVES

To classify subjects according to the origin of physical frailty: age-related frailty, frailty related to diseases, frailty of uncertain origin, and to compare their clinical characteristics.

MATERIALS AND METHODS

We performed a secondary analysis of the Multidomain Alzheimer Preventive Trial (MAPT), including 195 subjects ≥70 years non-frail at baseline who became frail during a 5-year follow-up (mean age 77.8 years ± 4.7; 70% female). Physical frailty was defined as presenting ≥3 of the 5 Fried criteria: weight loss, exhaustion, weakness, slowness, low physical activity. Clinical files were independently reviewed by two different clinicians using a standardized assessment method in order to classify subjects as: "age-related frailty", "frailty related to diseases" or "frailty of uncertain origin". Inconsistencies among the two raters and cases of uncertain frailty were further assessed by two other experienced clinicians.

RESULTS

From the 195 included subjects, 82 (42%) were classified as age-related frailty, 53 (27%) as frailty related to diseases, and 60 (31%) as frailty of uncertain origin. Patients who became frail due to diseases did not differ from the others groups in terms of functional, cognitive, psychological status and age at baseline, however they presented a higher burden of comorbidity as measured by the Cumulative Illness Rating Scale (CIRS) (8.20 ± 2.69; vs 6.22 ± 2.02 frailty of uncertain origin; vs. 3.25 ± 1.65 age-related frailty). Time to incident frailty (23.4 months ± 12.1 vs. 39.2 ± 19.3 months) and time spent in a pre-frailty condition (17.1 ± 11.4 vs 26.6 ± 16.6 months) were shorter in the group of frailty related to diseases compared to age-related frailty. Orthopedic diseases (n=14, 26%) were the most common pathologies leading to frailty related to diseases, followed by cardiovascular diseases (n=9, 17%) and neurological diseases (n = 8, 15%).

CONCLUSION

People classified as age-related frailty and frailty related to diseases presented different frailty-associated indicators. Future research should target the underlying biological cascades leading to these two frailty classifications, since they could ask for distinct strategies of prevention and management.