Cancer-associated malnutrition, cachexia and sarcopenia: the skeleton in the hospital closet 40 years later

Hepatic alterations during the development and progression of cancer cachexia

Cancer-associated bodyweight loss (cachexia) is a hallmark of many cancers and is associated with decreased quality of life and increased mortality. Hepatic function can dramatically influence whole-body energy expenditure and may therefore significantly influence whole-body health during cancer progression. The purpose of this study was to examine alterations in markers of hepatic metabolism and physiology during cachexia progression. Male C57BL/6J mice were injected with 1 × 10⁶ Lewis Lung Carcinoma cells dissolved in 100 μL PBS and cancer was allowed to develop for 1, 2, 3, or 4 weeks. Control animals were injected with an equal volume of phosphate-buffered saline. Livers were analyzed for measures of metabolism, collagen deposition, protein turnover, and mitochondrial quality. Animals at 4 weeks had ∼30% larger livers compared with all other groups. Cancer progression was associated with altered regulators of fat metabolism. Additionally, longer duration of cancer development was associated with ∼3-fold increased regulators of collagen deposition as well as phenotypic collagen content, suggesting increased liver fibrosis. Mitochondrial quality control regulators appeared to be altered before any phenotypic alterations to collagen deposition. While induction of Akt was noted, downstream markers of protein synthesis were not altered. In conclusions, cancer cachexia progression is associated with hepatic pathologies, specifically liver fibrosis. Alterations to mitochondrial quality control mechanisms appear to precede this fibrotic phenotype, potentially suggesting mitochondrial mechanisms for the development of hepatic pathologies during the development and progression of cancer cachexia. Novelty Cachexia progression results in liver collagen deposition and fibrosis. Alterations in mitochondrial quality control may precede liver pathologies during cachexia.

Nutritional, immunological and antioxidant defense status of outpatients diagnosed with colorectal cancer - a case-control study of the little-studied population

This cross-sectional study was conducted to investigate nutritional and immunological status of colorectal cancer (CRC) patients in a little-studied population from developing country, Pakistan. Data on 81 CRC patients and 37 healthy controls (HCs) were collected on nutritional status, nutrient intake, percent body fat (%BF), selected immunological parameters, phytochemical index (PI), healthy eating index (HEI), and prognostic nutrition index (PNI). Blood samples were used for immunological and antiradical defense potential (expressed as 50% hemolysis time; HT₅₀). Results show 40/81 (49.4%) patients reported weight loss in past 3-6 mo, Significant differences were found in HEI values between patients vs. HCs, and between patients in low vs. high PNI groups (P, for all trends <0.05). Patients in the higher PNI group were heavier, had higher % BF, higher energy intake, and higher PI score as compared to patients in the low PNI group (P < 0.05). Low PNI was positively associated with non-significantly lower CD4:CD8 ratios, higher B-cells and NK cells (P, for all trends >0.05), but with significantly higher hs-CRP levels, and lower HT₅₀ values (P, for all trends <0.001). In conclusion, CRC patients in a little-studied population have compromised nutritional and immunological health with lower HEI and PNI scores.

The Impact of the Disease Trend on the Macro and Micro-Nutrients Intake in Patients with Gastric Cancer

Background: Disease-related malnutrition, as a major cause of morbidity and mortality in cancer patients, is very common in patients with gastric cancer (GC). Malnutrition in cancer patients was reported to have important adverse effects, including a decreased response and tolerance to treatment, a decrease of performance, shorter survival, and lower quality of life. The treatment approaches involving chemotherapy is known to develop various acute and chronic symptoms that restrict eating and, thereby, exert a profound impact on nutritional status.Method: In this study, 82 patients with GC with an average age of 48.33 ± 10.74 were enrolled. Patients were followed up for 6 months without any nutritional intervention and/or education. A 168 item semi-quantities food frequency questioner was completed by a trained nutritionist at the beginning of the study and six months after the start of chemotherapy.Results: Intake of vitamin A (T₀:585.52 ± 203.34 vs. T₆:529.48 ± 138.91, t = 2.96), Thiamin (T₀:2.09 ± 0.76 vs. T₆:1.80 ± 0.72, t = 2.81), vitamin B6 (T₀:2.03 ± 0.53 vs. T₆:2.29 ± 0.73, t = 2.56), and vitamin B12 (T₀:5.79 ± 3.96 vs. T₆:4.48 ± 2.20, t = 2.43) significantly decreased after 6 months of receiving chemotherapy. On the other intake of beef (T0:17.79 ± 25.48 vs. T6:12.58 ± 16.66, t = 2.06), low-fat milk (T0:52.57 ± 69.80 vs. T6:29.18 ± 45.89, t = 2.95), cream (T0:2.42 ± 4.16 vs. T6:1.06 ± 1.68, t = 2.88), and raw vegetable (T0:6.54 ± 9.55 vs. T6:3.85 ± 5.23, t = 2.54) significantly decreased.Conclusion: Nutritional deterioration is an important part of the pathogenesis of cancer and its treatment that can occur at any point in the timeline of cancer diagnosis, treatment or support. Therefore nutritional counseling and supportive services are needed for cancer patients, especially when their disease is diagnosed.

Epidemiology of weight loss, malnutrition and sarcopenia: A transatlantic view

Malnutrition is a common comorbidity in patients with cancer, with determinants linked to the patients, the tumor, and the treatment. Cancer malnutrition, also called cachexia, represents the chronic form of disease-related malnutrition with chronic inflammation, and strongly impairs the prognosis. Reduced muscle mass, otherwise called sarcopenia in these patients, is a feature of malnutrition and thus of cancer cachexia that may appear before weight loss, and has a strong negative effect on prognosis, as well. The reported global prevalence of loss of muscle mass is 39%, whereas the prevalence of malnutrition in important cohorts varies from 25% to 70%. This is mostly due to the very different screening and diagnostic tools used throughout the world. The recent Global Leadership Initiative on Malnutrition has become a consensus alternative to standardize how malnutrition may be diagnosed based on etiologic and phenotypic criteria available everywhere, from rich to poor countries. This will lead to an easier diagnosis of cancer malnutrition that itself will help us speak the same language worldwide.

Assessing cachexia in older patients: Different definitions - But which one is the most practical for clinical routine?

OBJECTIVE

Patients with chronic inflammatory diseases and malignant tumors have an increased risk of cachexia. No consistent definition exists to rapidly identify cachexia in older patients with and without cancer.

METHODS

One-hundred patients (53% male) aged 70 +  years were included in the study by a university hospital. In addition to the detection of malnutrition and determination of body composition by bioelectrical impedance analysis, cachexia was assessed according to the well-established definitions of Evans (weight loss ≥ 5% within the last 12 months plus additional clinical parameters), Fearon (weight loss > 5% in 6 months) and Bozzetti (weight loss ≥ 10% of habitual weight). After a follow-up of 3.5 years, the mortality rate was recorded.

RESULTS

Thirty-three patients had a malignant tumor disease. The patients with a non-malignant underlying disease did not differ in their mental state, physical condition and state of health compared to patients with cancer. A higher percentage of patients with underlying malignancy had cachexia. There were significant differences in the body composition between the patients with or without cachexia. Cachectic patients exhibited a significantly lower skeletal muscle mass and fat mass. The risk of death was increased in cachectic patients of all three cachexia definitions.

CONCLUSION

For clinical daily routine, the assessments by a weight loss according to Fearon and Bozzetti are suggested to be practicable methods to detect cachexia in older patients with and without cancer.

The Influence of Omega-3 Fatty Acids on Skeletal Muscle Protein Turnover in Health, Disuse, and Disease

Ingestion of omega-3 fatty acids is known to exert favorable health effects on a number of biological processes such as improved immune profile, enhanced cognition, and optimized neuromuscular function. Recently, data have emerged demonstrating a positive influence of omega-3 fatty acid intake on skeletal muscle. For instance, there are reports of clinically-relevant gains in muscle size and strength in healthy older persons with omega-3 fatty acid intake as well as evidence that omega-3 fatty acid ingestion alleviates the loss of muscle mass and prevents decrements in mitochondrial respiration during periods of muscle-disuse. Cancer cachexia that is characterized by a rapid involuntary loss of lean mass may also be attenuated by omega-3 fatty acid provision. The primary means by which omega-3 fatty acids positively impact skeletal muscle mass is via incorporation of eicosapentaenoic acid (EPA; 20:5n−3) and docosahexaenoic acid (DHA; 22:6n−3) into membrane phospholipids of the sarcolemma and intracellular organelles. Enrichment of EPA and DHA in these membrane phospholipids is linked to enhanced rates of muscle protein synthesis, decreased expression of factors that regulate muscle protein breakdown, and improved mitochondrial respiration kinetics. However, exactly how incorporation of EPA and DHA into phospholipid membranes alters these processes remains unknown. In this review, we discuss the interaction between omega-3 fatty acid ingestion and skeletal muscle protein turnover in response to nutrient provision in younger and older adults. Additionally, we examine the role of omega-3 fatty acid supplementation in protecting muscle loss during muscle-disuse and in cancer cachexia, and critically evaluate the molecular mechanisms that underpin the phenotypic changes observed in skeletal muscle with omega-3 fatty acid intake.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice

PURPOSE

Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities.

METHODS

This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted.

RESULTS

Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89).

CONCLUSIONS

Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

Systemic immune-inflammation index predicts prognosis of bladder cancer patients after radical cystectomy

Background

The systemic immune-inflammation index (SII) has been used as a prognostic marker for several cancer types, but there is no in-depth study in bladder cancer. This study evaluated the potential utility of the SII as a prognostic factor in patients with bladder cancer after radical cystectomy.

Methods

A retrospective analysis of 209 patients with bladder cancer who had undergone radical cystectomy and were randomized into primary (N=139) and validation (N=70) cohorts was conducted. The overall survival (OS) was calculated using the Kaplan-Meier survival curves. The prognostic value of the SII in primary and validation cohorts were analyzed by using the Cox regression model. A SII-based nomogram for bladder cancer was produced in R software.

Results

A high SII (>507) was associated with poor prognosis in bladder cancer patients. Univariate and multivariate analyses revealed that the SII was an independent predictor for OS. The SII emerged as an independent prognostic factor that provided more accurate prognostic prediction than neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and C-reactive protein/albumin ratio (CAR), in the primary and validation cohorts. The nomogram had better accuracy and discrimination than tumor, lymph node, metastasis (TNM) classification. The concordance index values of nomogram were 0.82 for the primary cohort and 0.784 for the validation cohort.

Conclusions

The SII can serve as an independent predictor of OS in patients who have undergone radical cystectomy for bladder cancer, and was found to be a better predictor of prognosis than NLR, PLR, and CAR. The nomogram is a reliable model for predicting postoperative OS of patients after radical cystectomy.

Role and impact of multimodal prehabilitation for gynecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) program

Patients undergoing major surgery are predisposed to a decrease in functional capacity as a response to surgical stress that can delay post-operative recovery. A prehabilitation program consists of patient preparation strategies before surgery, and include pre-operative measures to improve functional capacity and enhance post-operative recovery. Multimodal prehabilitation may include exercise, nutritional counseling, psychological support, and optimization of underlying medical conditions, as well as cessation of unfavorable health behaviors such as smoking and drinking. Currently, there are no standardized guidelines for prehabilitation, and the existent studies are heterogeneous; however, multimodal approaches are likely to have a greater impact on functional outcomes than single management programs. We have reviewed the literature on prehabilitation in general, and in gynecologic surgery in particular, to identify tools to establish an optimal prehabilitation program within an Enhanced Recovery After Surgery (ERAS) protocol for gynecologic oncology patients. We suggest a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support. The analysis of the prehabilitation program implementation in an ERAS protocol should undergo further research in order to test the efficacy on surgical outcome and recovery after surgery.

The Relationship Between Nutritional Status, Performance Status, and Survival Among Pancreatic Cancer Patients

Aim: The purpose of this study was to identify the nutritional and performance status of Pancreatic Cancer (PanCa) patients and to determine the relationship between these parameters and their survival time.Material and Methods: Ninety-six PanCa patients [59.6% F, 61.4% M; mean age: 60.7 (min:28, max:80) years] were followed up for 6-24 months. The Patient Generated Subjective Global Assessment (PG-SGA) and Eastern Comparative Oncology Group (ECOG) scale were performed. Anthropometric measurements [height, weight, mid-upper arm circumference (MUAC), calf circumference (CC) and triceps skin fold thickness (TSF)], hand grip strength (HGS) were recorded. Survival analyses were conducted using Kaplan-Meier curves.Results: Malnutrition was observed in 85.5% (n = 82) and 54.2% of all patients had poor performance status. A positive correlation was observed between malnutrition and ECOG scale of the patients (P < .01). Antropometric measurements for women and men, respectively, were 34.4 ± 3.03-34.6 ± 3.43 cm for CC; 26.9 ± 3.47-26.05 ± 3.37 cm for MUAC; 20.5 ± 6.3-13.02 ± 7.7 mm for TSF; - 31.02 ± 7.64-20.13 ± 6.04 kg for HGS. Survival time of patients with SGA-A and B was 38.0 ± 6.6 months and of those with SGA-C was 12.0 ± 3.1 months (P = .000).Conclusion: Malnutrition negatively affected both performance status and survival time among PanCa patients.

Factors associated with muscle function in patients with hematologic malignancies undergoing chemotherapy

PURPOSE

Muscle dysfunction such as loss of muscle mass and decreased muscle strength is often observed in patients with hematologic malignancies. However, specific factors associated with muscle function have not been identified. The purpose of this study was to identify significant factors affecting muscle function in patients with hematologic malignancies.

METHODS

This was a cross-sectional, observational study. Eighty-eight inpatients with hematologic malignancies undergoing chemotherapy were recruited. Participants were evaluated for muscle thickness and isometric knee extensor strength as indicators of muscle function, physical activity, physical symptoms, psychological distress, and self-efficacy at the start date of rehabilitation. Multiple regression analysis with muscle function as the dependent variable and clinical information and other evaluation items as explanatory variables was performed.

RESULTS

Lymphocyte count, the geriatric nutritional risk index, and physical activity were significant factors associated with muscle thickness, while physical activity and self-efficacy were significant factors associated with isometric knee extensor strength.

CONCLUSIONS

Nutritional status, physical activity, and self-efficacy were significant factors associated with muscle function in patients with hematologic malignancies. Rehabilitation intervention focusing on improving physical activity and nutritional status should be considered necessary for enhancing muscle function in patients with hematologic malignancies.

The validity of three malnutrition screening markers among older patients with cancer

Background

Malnutrition is common in older adults with cancer and is associated with adverse clinical outcomes. We assessed and compared the validity of three tools commonly used to screen for malnutrition: The Mini Nutritional Assessment (MNA), weight loss and body mass index (BMI).

Methods

In this retrospective study, we reviewed patients over age 65 with a diagnosis of cancer who were treated at the MD Anderson Cancer Center between 1 January 2013 and 31 March 2017. All patients in this study were evaluated by a trained geriatrician as part of a comprehensive geriatric assessment (CGA). Malnutrition was diagnosed by both CGA and clinical examination. The sensitivity, specificity and Cohen’s κ of each tool was also compared with the clinical diagnosis.

Results

A total of 454 older patients with cancer who had malnutrition information available were included in the analyses. The median age was 78%, and 42% (n=190) were clinically diagnosed with malnutrition at baseline. When the MNA was performed, 105 out of 352 patients (30%) were malnourished, and 122 (35%) at risk of malnutrition. Weight loss >3 kg was seen in 183 out of 359 (51%) patients, and BMI <20 kg/m2 was found in 30 of the 454 (7%) patients. MNA had the highest validity (area under curve (AUC)=0.83) and reliability (κ=0.67), weight loss had moderate validity (AUC=0.73) and reliability (κ=0.46), while BMI had the lowest validity (AUC=0.55) and reliability (κ=0.55).

Conclusions

For clinical practice, MNA should be incorporated for standard assessment/screening for these older patients with cancer.

Unintentional weight loss, its associated burden, and perceived weight status in people with cancer

Purpose

Unintentional weight loss (UWL) is a prevalent problem in people with cancer and is associated with poorer psychosocial outcomes. A gap exists in understanding whether and how perceived and/or weight status impacts experiences of UWL. Thus, we sought to examine subjective experiences of UWL in people with cancer, and whether perceived and/or actual weight status impacts these experiences.

Methods

Participants were recruited through Cancer Support Community’s Cancer Experience Registry® and related networks. Participants completed an online survey that included the FAACT Anorexia-Cachexia subscale, and 19 items that captured six themes related to “beliefs and concerns” (positive beliefs, psychosocial impact, physical impact, cancer outcomes, self-esteem, relationships with others). Perceived weight status (PWS) was assessed using a single item. Body mass index (BMI) was calculated using self-reported weight and height measurements.

Results

Of 326 respondents, 114 reported experiencing UWL. Over one-third misperceived their weight, with 29% perceiving weight status as below their BMI status. UWL in those with perceived weight status of overweight/obese was associated with positive beliefs. However, being underweight by BMI or perceiving oneself as underweight were both associated with greater concerns about weight loss. Perceived weight status of underweight compared to normal or overweight/obese weight status was associated with poorer psychosocial well-being, personal control, self-esteem, and relationships with others.

Conclusion

In people with cancer, perceived weight status, rather than BMI, had greater impact on negative “beliefs and concerns” about UWL. Findings suggest assessment of both perceived and actual BMI to address the impact of UWL on psychosocial wellbeing.

The metabolic syndrome and its components are differentially associated with chronic diseases in a high-risk population of 350 000 adults: A cross-sectional study

AIMS

We compared strengths of associations conferred by the metabolic syndrome (MetS) and its components across four chronic disease categories (cancer, cardiovascular diseases [CVDs], chronic kidney disease [CKD], and chronic obstructive pulmonary disease [COPD]) in a community-dwelling high-risk population.

METHODS

This is a cross-sectional analysis of Israeli adults insured in a single health maintenance organization during 2010 to 2013 and having greater than or equal to two MetS components (hypertension, dysglycemia, low high-density lipoprotein level, high plasma triglyceride level, and obesity). Data regarding MetS components, chronic disease prevalence, and sociodemographic variables were retrieved from electronic health records and disease registries.

RESULTS

Among 347 244 eligible members, 54.2% had MetS. MetS was negatively associated with cancer, (prevalence ratio [PR] = 0.86; 95% confidence interval, 0.79-0.93) and positively associated with CKD (PR = 1.07, [1.01-1.13]). Some MetS components conferred different associations across the chronic diseases: a high triglyceride level was positively associated with cancer (PR = 1.15, 1.12-1.18) and CKD (PR = 1.37, 1.32-1.41) but negatively associated with CVD (PR = 0.88, 0.86-0.90) and COPD (PR = 0.93, 0.88-0.98). In the presence of MetS, those with dysglycemia had higher cancer prevalence than those with normoglycemia (PR-interaction MetS*dysglycemia on cancer = 1.14, 1.06-1.22). Likewise, in the presence of MetS, men were more likely than women to present with CVD (PR-interaction MetS*sex on CVD = 1.12, [1.05-1.20]).

CONCLUSIONS

Prevalences of the MetS and MetS components distribute unequally across four chronic diseases. MetS including dysglycemia may warrant screening for cancer, and MetS in males may indicate the presence of CVD. Longitudinal studies may reveal if MetS is associated with different risks or merely indicates better prognosis once having a chronic illness.

Dietary patterns and their relationships to sarcopenia in Portuguese patients with gastrointestinal cancer: An exploratory study

OBJECTIVES

The purpose of this exploratory study was to identify the main dietary patterns of a Portuguese population of patients with gastrointestinal cancer and to analyze their association with sarcopenia.

METHODS

This was a prospective study with a consecutive sample of 100 patients with gastrointestinal cancer enrolled at diagnosis. Dietary intake was assessed with a semiquantitative Food Frequency Questionnaire, and dietary patterns were obtained with principal component analysis. Nutritional assessment was done using the Patient-Generated Subjective Global Assessment, and body composition was evaluated with anthropometric measures and computed tomography image processing obtained at the third lumbar vertebrae. Sex and body mass index specific cutoffs were used to define sarcopenia.

RESULTS

Four major patterns were identified: high-fat dairy products, fried snacks, and processed meat diet; legumes, vegetables, and fruit diet; fat and fish diet; and alcohol, cereal, and animal protein diet. On simple logistic regression, the occurrence of sarcopenia in participants in the second tertile (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.10-0.83; P = 0.02) and third tertile (OR 0.24; 95% CI 0.08-0.69; P = 0.01) of adherence to the high-fat and fish diet was reduced compared with the first tertile. On multiple logistic regression, the second tertile (OR 0.38, 95% CI 0.11-1.19; P = 0.10) of the fat and fish dietary pattern maintained a trend toward a reduction of the odds of sarcopenia compared with the first tertile, independently of calorie intake, age, disease location, and stage.

CONCLUSIONS

The fat and fish dietary pattern was associated with lower odds of sarcopenia in this population of patients with gastrointestinal cancer.

Protective Effects of Omega-3 Fatty Acids in Cancer-Related Complications

Omega-3 polyunsaturated fatty acids (PUFAs) are considered immunonutrients and are commonly used in the nutritional therapy of cancer patients due to their ample biological effects. Omega-3 PUFAs play essential roles in cell signaling and in the cell structure and fluidity of membranes. They participate in the resolution of inflammation and have anti-inflammatory and antinociceptive effects. Additionally, they can act as agonists of G protein-coupled receptors, namely, GPR40/FFA1 and GPR120/FFA4. Cancer patients undergo complications, such as anorexia-cachexia syndrome, pain, depression, and paraneoplastic syndromes. Interestingly, the 2017 European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for cancer patients only discuss the use of omega-3 PUFAs for cancer-cachexia treatment, leaving aside other cancer-related complications that could potentially be managed by omega-3 PUFA supplementation. This critical review aimed to discuss the effects and the possible underlying mechanisms of omega-3 PUFA supplementation in cancer-related complications. Data compilation in this critical review indicates that further investigation is still required to assess the factual benefits of omega-3 PUFA supplementation in cancer-associated illnesses. Nevertheless, preclinical evidence reveals that omega-3 PUFAs and their metabolites might modulate pivotal pathways underlying complications secondary to cancer, indicating that this is a promising field of knowledge to be explored.

The IMPACT study: early loss of skeletal muscle mass in advanced pancreatic cancer patients

BACKGROUND

Pancreatic cancer (PC) patients have multiple risk factors for sarcopenia and loss of skeletal muscle mass (LSMM), which may cause greater treatment toxicities, reduced response to cancer therapy, prolonged hospitalization, impaired quality of life, and worse prognosis.

METHODS

This is a retrospective study on advanced PC patients treated at the Department of Oncology of Udine, Italy, from January 2012 to November 2017. Among 162 patients who received chemotherapy, 94 consecutive patients with an available computed tomography (CT) scan were retrospectively analyzed. The primary objective of our study was to explore if an early LSMM ≥ 10% (measured at first radiological evaluation and compared with baseline) and/or baseline sarcopenia may impact prognosis. Baseline sarcopenia was defined according to Prado's criteria. Skeletal muscle area was measured as cross-sectional areas (cm² ) using CT scan data through the Picture archiving and communication system (PACS) image system.

RESULTS

In the whole cohort, 48% of patients were ≤70 years old, and 50% had metastatic disease. At baseline, 73% of patients had sarcopenia, and 16% presented a visceral fat area ≥ 44 cm² /m² . Overall, 21% experienced an early LSMM ≥ 10%. Approximately 33% of sarcopenic patients at baseline and ~35% of patients with early LSMM ≥ 10% had a body mass index > 25 kg/m² . Of note, 71% of patients were evaluated by a nutritionist, and 56% received a dietary supplementation (oral and/or parenteral). After a median follow-up of 30.44 months, median overall survival (OS) was 11.28 months, whereas median progression-free survival (PFS) was 5.72 months. By multivariate analysis, early LSMM ≥ 10% was significantly associated with worse OS [hazard ratio (HR): 2.16; 95% confidence interval (CI) 1.23-3.78; P = 0.007] and PFS (HR: 2.31; 95% CI 1.30-4.09; P = 0.004). Moreover, an exploratory analysis showed that inflammatory indexes, such as neutrophil-lymphocyte ratio variation, impact early LSMM ≥ 10% (odds ratio 1.31, 95% CI 1.06-1.61, P = 0.010).

CONCLUSIONS

Early LSMM ≥ 10% has a negative prognostic role in advanced PC patients. Further prospective investigations are needed to confirm these preliminary data.

Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective study

BACKGROUND

Chemotherapy is an effective treatment with good clinical response in patients with cancer. However, it can cause exacerbated toxicities in patients and consequently change the course of treatment. Some factors may interfere with this toxicity such as body composition, especially in gastrointestinal cancer. The aim of this study was to evaluate the effects of body composition, nutritional status, and functional capacity scale in predicting the occurrence of toxicities in gastrointestinal cancer patients during chemotherapy treatment.

METHODS

This is a prospective study with gastrointestinal cancer patients at the beginning of chemotherapy treatment. Sarcopenia and muscle attenuation were assessed using the skeletal muscle index from computerized tomography by measuring cross-sectional areas of the L3 tissue (cm² /m² ). Cachexia was graded according to involuntary weight loss associated with sarcopenia. Nutritional status was assessed by using anthropometric evaluation and Patient-Generated Subjective Global Assessment. Functional capacity was evaluated by handgrip strength and Eastern Cooperative Oncology Group (ECOG) Performance Status scale. Haematological gastrointestinal and dose-limiting toxicities (DLTs) were defined according to National Cancer Institute Common Toxicity Criteria. The associations among sarcopenia, cachexia, nutritional status, and functional capacity with DLT were assessed by univariate and multivariate Cox regression model.

RESULTS

A total of 60 patients were evaluated (55% male, 60.9 ± 14.0 years) and followed up for a mean of 55 days. Most patients had normal weight (44.2%) and good ECOG Performance Status (≤1) at baseline (78%). During the chemotherapy period, the most prevalent toxicities were diarrhoea, nausea, and anorexia, but the presence of DLT was similar between cycles (P > 0.05). Cachexia was associated with a higher toxicity manifested by diarrhoea (P = 0.02), nausea (P = 0.02), and anorexia (P < 0.01 and P = 0.03 at Cycles 1 and 2, respectively). Sarcopenic and cachetic individuals experienced more toxicities and DLT during chemotherapy. The only factors associated with DLT in the multivariate Cox regression analyses including the presence of metastasis and the chemotherapy protocol were cachexia and the ECOG scale (P < 0.001 for both).

CONCLUSIONS

Cachexia and ECOG score may identify patients with an increased risk for developing severe toxicity events during chemotherapy treatment for gastrointestinal cancer.

Body composition and nutritional status in malignant pleural mesothelioma: implications for activity levels and quality of life

BACKGROUND/OBJECTIVES

Malignant pleural mesothelioma (MPM) is an incurable cancer and optimizing daily physical activity and quality of life are key goals of patient management. Little is known about the prevalence of pre-sarcopenia and malnutrition in MPM or their associations with patient outcomes. This study aimed to determine the prevalence of pre-sarcopenia and malnutrition in MPM and investigate if activity levels and quality of life differed according to body composition and nutritional status.

SUBJECTS/METHODS

Patients with a diagnosis of MPM were recruited. Pre-sarcopenia was defined as low appendicular skeletal muscle mass (≤ 7.26 kg/m² for men and ≤ 5.45 kg/m² for women), measured by dual energy X-ray absorptiometry. Malnutrition was defined as a rating of B or C on the Patient-Generated Subjective Global Assessment. Outcome measures included objective activity levels (Actigraph GT3X) and health-related quality of life (HRQoL; Functional Assessment of Cancer Therapy General).

RESULTS

Sixty-one people participated (79% male, median age 69 [IQR 62-74] years and median BMI 25.8 [IQR 24.3-28.4] kg/m²). Fifty-four percent were pre-sarcopenic and 38% were malnourished. Percent of time spent in light activity/day was lower in participants with pre-sarcopenia compared with non-sarcopenic participants (median 25.4 [IQR 19.8-32.1]% vs. 32.3 [27.1-35.6]%; p = 0.008). Participants with malnutrition had poorer HRQoL than well-nourished participants (mean 69.0 (16.3) vs. 84.4 (13.3); p < 0.001).

CONCLUSION

Participants with MPM had high rates of pre-sarcopenia and malnutrition. Pre-sarcopenia was associated with poorer activity levels, whilst malnutrition was associated with poorer quality of life. Interventions that aim to address reduced muscle mass and weight loss, should be tested in MPM to assess their impact on patient outcomes.

Cancer- and Chemotherapy-Induced Musculoskeletal Degradation

Mobility in advanced cancer patients is a major health care concern and is often lost in advanced metastatic cancers. Erosion of mobility is a major component in determining quality of life but also starts a process of loss of muscle and bone mass that further devastates patients. In addition, treatment options become limited in these advanced cancer patients. Loss of bone and muscle occurs concomitantly. Advanced cancers that are metastatic to bone often lead to bone loss (osteolytic lesions) but may also lead to abnormal deposition of new bone (osteoblastic lesions). However, in both cases there is a disruption to normal bone remodeling and radiologic evidence of bone loss. Many antitumor therapies can also lead to loss of bone in cancer survivors. Bone loss releases cytokines (TGFβ) stored in the mineralized matrix that can act on skeletal muscle and lead to weakness. Likewise, loss of skeletal muscle mass leads to reduced bone mass and quality via mechanical and endocrine signals. Collectively these interactions are termed bone-muscle cross-talk, which has garnered much attention recently as a prime target for musculoskeletal health. Pharmacological approaches as well as nutrition and exercise can improve muscle and bone but have fallen short in the context of advanced cancers and cachexia. This review highlights our current knowledge of these interventions and discusses the difficulties in treating severe musculoskeletal deficits with the emphasis on improving not only bone mass and muscle size but also functional outcomes. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Fit for Cancer Treatment: a prospective feasibility study of primary care initiated prehabilitation for patients with suspected cancer

Background

Risk profile assessment and corrective interventions using optimisation of health status and prehabilitation represent an important strategy in the management of patients with a suspected cancer diagnosis.

Aim

To determine the feasibility of pre-treatment optimisation and prehabilitation commenced at index primary care consultation, to improve patients’ preparation for treatment by maximising the time available.

Design & setting

Between January 2015 and May 2016, 195 patients presenting to 12 GP practices were deemed eligible to enter the study, of which 189 (96.9%, median age 60 [21–91] years and 65 months; 124 female) were recruited and consented to the prehabilitation bundle.

Method

All patients were simultaneously referred to secondary care using urgent suspected cancer (USC) pathways. The primary outcome measures were definitive diagnosis and treatment plan.

Results

Fifteen patients (7.9%) were diagnosed with cancer (three breast, three colon, two lung, two skin [one melanoma, one sarcoma], one tonsil, one vocal cord, one pancreas, one prostate, one ependymoma) and 62 were diagnosed with other significant medical conditions (47 gastrointestinal, 13 sepsis, two respiratory) requiring secondary care assessment and treatment. Of the 15 patients with cancer, 11 (73.3%) underwent potentially curative treatment, and four (26.7%) palliative treatment. Of the total study cohort, 84 (44%) required a form of optimisation in primary care, and patients with cancer were more likely to require optimisation than others (n = 10 [63%] versus n = 74 [43%], χ² 9.384, P = 0.002).

Conclusion

One in 12 primary care USC patients had cancer (5.6% receiving potentially curative treatment), one in three had other systemic health issues, and overall two in five benefited from healthcare intervention. Primary care optimisation was feasible and associated with important allied health benefits.

A Vegetable and Fish Dietary Pattern Is Positively Associated with Skeletal Muscle Mass in Korean Men

Isolating the effects of a single nutrient or food in relation to health outcomes including increased skeletal muscle mass is a challenging task because dietary constituents are highly correlated and synergistic. Hence, diet pattern analysis may be used to investigate the role of certain diets in health outcomes. The present study investigated the dietary patterns and their relationship to skeletal muscle mass in Korean adults. Data were extracted from the 2008–2011 Korea National Health and Nutrition Examination Surveys. To explore the dietary patterns of the study subjects, factor analysis was performed using data obtained from a 24-hour recall. The skeletal muscle index according to dietary pattern scores was then investigated to estimate the changes in skeletal muscle mass. Three patterns were initially identified from the factor analysis. Of these vegetables and fish (VF) pattern was the primary factor with high reliability and was a common factor in sex-separated analyses. The VF pattern scores were positively associated with increased skeletal muscle mass in both men and women. Further analysis according to quartile levels of VF pattern scores showed a positive association between skeletal muscle mass and VF pattern in men but not in women. These results suggest that dietary patterns focused on vegetables and seafoods may contribute to increased skeletal muscle mass in Korean men but that sex difference should be considered in nutrition care for skeletal muscle health.

Nutritional Interventions for Treating Cancer-Related Fatigue: A Qualitative Review

Cancer-related fatigue (CRF) is a debilitating syndrome that persists for many cancer survivors for years after treatment. Symptoms include early and persistent fatigue, functional decline, depression, and cognitive difficulties. Inflammation, assessed using pro-inflammatory biomarkers, is increased in cancer survivors with fatigue and treatments for fatigue are often aimed at reducing inflammation. Additionally, cancer and its treatment lead to nutritional complications, changes in body composition, and nutritional deficiencies that potentially weaken the cancer survivor and impact CRF. We conducted a qualitative review of clinical trials that assessed nutritional interventions for preventing and treating CRF. Further studies were examined that used nutritional interventions to address inflammation and fatigue, due to the dearth of nutrition research directly related to CRF. Dietary intake prior to, during, and after cancer treatment appears to affect fatigue levels. Increased protein intake may help preserve lean mass and body composition. Dietary patterns that reduce inflammation, such as the Mediterranean diet and other plant-based diets, appear tolerable to cancer survivors and may reduce fatigue. Supplementation with ginseng, ginger, or probiotics may improve cancer survivors' energy levels. Nutritional interventions, alone or in combination with other interventions should be considered as therapy for fatigue in cancer survivors.

Preoperative low skeletal muscle mass as a risk factor for pharyngocutaneous fistula and decreased overall survival in patients undergoing total laryngectomy

Background

Low skeletal muscle mass (SMM) is associated with postoperative complications, prolonged hospital stay, and short overall survival (OS) in surgical oncology. We aimed to investigate this association in patients undergoing total laryngectomy (TL).

Methods

A retrospective study was performed of patients undergoing TL. SMM was measured using CT or MRI scans at the level of the third cervical vertebra (C3).

Results

In all, 235 patients were included. Low SMM was observed in 109 patients (46.4%). Patients with low SMM had more pharyngocutaneous fistulas (PCFs) than patients with normal SMM (34.9% vs 20.6%; P = .02) and prolonged hospital stay (median, 17 vs 14 days; P < .001). In multivariate analysis, low SMM (hazards ratio, 1.849; 95% confidence interval, 1.202‐2.843) and high N stage were significant prognosticators of decreased OS.

Conclusion

Low SMM is associated with PCF and prolonged hospital stay in patients undergoing TL. Low SMM is an independent prognostic factor for shorter OS.

A window beneath the skin: how computed tomography assessment of body composition can assist in the identification of hidden wasting conditions in oncology that profoundly impact outcomes

Advancements in image-based technologies and body composition research over the past decade has led to increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation (MA), as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities can be highly prevalent in patients with cancer (ranging between 10 and 90 %), depending on the cohort under investigation and diagnostic criteria used. Importantly, both low muscle mass and low MA have been associated with poorer tolerance to chemotherapy, increased risk of post-operative infectious and non-infectious complications, increased length of hospital stay and poorer survival in patients with cancer. Studies have shown that systemic antineoplastic treatment can exacerbate losses in muscle mass and MA, with reported loss of skeletal muscle between 3 and 5 % per 100 d, which are increased exponentially with progressive disease and proximity to death. At present, no effective medical intervention to improve muscle mass and MA exists. Most research to date has focused on treating muscle depletion as part of the cachexia syndrome using nutritional, exercise and pharmacological interventions; however, these single-agent therapies have not provided promising results. Rehabilitation care to modify body composition, either increasing muscle mass and/or MA should be conducted, and its respective impact on oncology outcomes explored. Although the optimal timing and treatment strategy for preventing or delaying the development of muscle abnormalities are yet to be determined, multimodal interventions initiated early in the disease trajectory appear to hold the most promise.

SEOM clinical guidelines on nutrition in cancer patients (2018)

Nutritional deficiency is a common medical problem that affects 15-40% of cancer patients. It negatively impacts their quality of life and can compromise treatment completion. Oncological therapies, such as surgery, radiation therapy, and drug therapies are improving survival rates. However, all these treatments can play a role in the development of malnutrition and/or metabolic alterations in cancer patients, induced by the tumor or by its treatment. Nutritional assessment of cancer patients is necessary at the time of diagnosis and throughout treatment, so as to detect nutritional deficiencies. The Patient-Generated Subjective Global Assessment method is the most widely used tool that also evaluates nutritional requirements. In this guideline, we will review the indications of nutritional interventions as well as artificial nutrition in general and according to the type of treatment (radiotherapy, surgery, or systemic therapy), or palliative care. Likewise, pharmacological agents and pharmaconutrients will be reviewed in addition to the role of regular physical activity.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score is a Novel Significant Prognostic Factor for Patients with Metastatic Prostate Cancer Undergoing Cytoreductive Radical Prostatectomy

Objective: The hemoglobin, albumin, lymphocyte, and platelet (HALP) score has been shown to be an important prognostic marker in some tumor types. The aim of this study was to evaluate the prognostic impact of the preoperative HALP score, with the intent to develop a new prognostic index for patients with metastatic prostate cancer (mPCA) after cytoreductive radical prostatectomy (cRP).

Methods: We retrospectively analyzed the data from 82 patients with mPCA after cRP in our institution. Of these patients, 70 patients were diagnosed with oligometastatic prostate cancer (oPCA). The main outcome measure was prostate-specific antigen (PSA) progression-free survival (PFS), which was assessed using Kaplan-Meier curves with log-rank statistics. In addition, univariate and multivariate Cox regression analyses were performed to determine the prognostic factors associated with PSA-PFS. The prediction accuracy was evaluated by assessing the area under the receiver operating characteristic (AUC) curve.

Results: The median follow-up time for all patients was 17.47 months (range: 11.73-24.38 months). Based on the Kaplan-Meier curve analysis, it was noticed that a low preoperative HALP value (<32.4) was significantly associated with a decreased PSA-PFS in both the mPCA and oPCA subgroups (P < 0.001, P = 0.002, respectively). In addition, multivariate analysis predicted that a low HALP score was a common independent prognostic factor of an overall shorter PSA-PFS (HR: 0.352; range: 0.154-0.804; P = 0.013). However, among the different subgroups, a low HALP score (HR: 0.275; range: 0.116-0.653; P = 0.003) was confirmed to be an independent predictor of a shorter PSA-PFS in patients from the oPCA subgroup. Furthermore, the effective combination of the pathologic Gleason score (PGS) and the HALP score (HALPG) as a new index was found to be an independent risk factor. Also, the AUC of the HALPG score for PSA-PFS was observed to be higher than other conventional clinical indices.

Conclusion: Overall, our results confirmed the HALP score as an independent prognostic factor for PSA-PFS in patients with mPCA or oPCA after cRP. Moreover, the new index, HALPG, also appeared to be an independent prognostic factor and was better than the HALP score. Importantly, it is evident that this new prognostic index has the ability to accurately identify patients at low, intermediate, and high risk of recurrence, thus easily allowing informed treatment decisions to be made.

The Circadian Rhythm of Breakthrough Pain Episodes in Terminally-ill Cancer Patients

Opioid therapy must be adjusted to the rhythm of a cancer patient’s pain to ensure adequate symptom control at the end of life (EOL). However, to-date no study has explored the rhythm of breakthrough pain (BTP) episodes in terminally-ill cancer patients. This prospective longitudinal study was aimed at verifying the existence of a circadian rhythm of BTP episodes in terminally-ill cancer patients. Consecutive adult cancer patients at their EOL treated with long-acting major opioids to control background pain (Numeric Rating Scale ≤ 3/10) were recruited from two Italian palliative care services. Using a personal diary, patients recorded the frequency and onset of BTP episodes and the analgesic rescue therapy taken for each episode over a 7-day period. Rhythms identified in BTP episodes were validated by Cosinor analysis. Overall, 101 patients were enrolled; nine died during the study period. A total of 665 BTP episodes were recorded (average of 7.2 episodes, mean square error 0.8) per patient, with 80.6% of episodes recorded between 8:00 a.m. and 12:00 a.m. At Cosinor analysis, a circadian rhythm of BTP episodes was observed, with a Midline Estimating Statistics of the Rhythm (MESOR) of 1.5, a double amplitude of 1.8, and an acrophase at 12:30 p.m. (p < 0.001). Oral morphine was the most frequent analgesic rescue therapy employed. In terminally-ill cancer patients, BTP episodes follow a circadian rhythm; thus, tailoring the timing of opioid administration to this rhythm may prevent such episodes. This circadian rhythm of BTP episodes in terminally-ill cancer patients should be confirmed in larger samples.

Clinical, dietary and demographic characteristics interfering on quality of life of cancer patients

OBJECTIVE

To estimate the dietary intake of cancer patients and its relation with clinical and demographic characteristics, and to assess the contribution of dietary intake, appetite/symptoms and clinical and demographic characteristics to their quality of life.

METHODS

The consumption of energy and macronutrients of patients was estimated. The relation between dietary intake and clinical and demographic characteristics was evaluated by analysis of variance. The intake of energy and macronutrient of the patients was compared to the nutritional recommendations using 95% confidence interval. The Cancer Appetite and Symptom Questionnaire (CASQ) and the European Organization for Research and Treatment of Cancer (EORTC QLQ C-30) were used to assess appetite/symptoms and quality of life, respectively. The psychometric properties of the instruments were estimated. A structural equation model was prepared.

RESULTS

In this study, 772 cancer patients (63.1% women) participated. There was a significant relation between dietary intake and work activity, economic class, specialty field of cancer, type of treatment and nutritional status. Patients' energy and macronutrients intake was below recommended values. Both CASQ and EORTC QLQ C-30 were refined to fit the data. In the structural model, impaired appetite, more symptoms, presence of metastasis, being female and of higher economic classes were characteristics that significantly contributed to interfering in patients' quality of life.

CONCLUSION

The dietary intake of oncology patients did not reach the recommended values. Different characteristics impacted on quality of life of patients and should be considered in clinical and epidemiological protocols.

Health-related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: a German cohort study

Background

The group of colorectal cancer (CRC) survivors continues to grow worldwide. Understanding health-related quality of life (HRQOL) determinants and consequences of HRQOL impairments in long-term CRC survivors may help to individualize survivorship care plans. We aimed to i) examine the HRQOL status of CRC long-term survivors, ii) identify cross-sectional sociodemographic and clinical correlates of HRQOL, and iii) investigate the prospective association of HRQOL after CRC diagnosis with all-cause mortality.

Methods

We assessed HRQOL within a Northern German cohort of 1294 CRC survivors at a median of 6 years after CRC diagnosis using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Cross-sectional correlates of different HRQOL dimensions were analyzed using multivariable-adjusted logistic regression models with HRQOL as a binary variable. With multivariable-adjusted Cox proportional hazards regression models, hazard ratios (HR) of all-cause mortality were estimated per 10-point-increments of an HRQOL summary score, a global quality of life scale, and HRQOL functioning and symptom domains.

Results

The median HRQOL summary score was 87 (interquartile range: 75–94). Sex, age, education, tumor location, metastases, other cancers, type of therapy, and current stoma were identified as correlates of different HRQOL scales. After a median follow-up time of 7 years after HRQOL assessment, 175 participants had died. Nearly all HRQOL domains, except for cognitive functioning and diarrhea, were significantly associated with all-cause mortality. A 10-point-increment in the summary score decreased the risk of death by 24% (HR: 0.76; 95% CI: 0.70–0.82).

Conclusions

HRQOL in CRC survivors appeared to be relatively high in the long term. Various clinical and sociodemographic factors were cross-sectionally associated with HRQOL in long-term CRC survivors. Lower HRQOL was associated with increased all-cause mortality. Individualized healthcare programs for CRC survivors (including psychosocial screening and interventions) are needed to detect decreased HRQOL and to further improve long-term HRQOL and survival.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5075-1) contains supplementary material, which is available to authorized users.

A Novel Mobile Phone App (OncoFood) to Record and Optimize the Dietary Behavior of Oncologic Patients: Pilot Study

BACKGROUND

Catabolism and tumor-specific therapy lead to reduced nutrient intake and weight loss in cancer patients. Maintaining a specific individualized diet can be challenging for the patient as the nutritional counseling options are limited. Monitoring of nutrient intake and frequent feedback are, however, vital for successful nutritional therapy because they support the patient's compliance and realization of dietary therapeutic goals.

OBJECTIVE

This study aimed at investigating the feasibility and applicability of a novel mobile phone app to assess and evaluate dietary behaviors in oncologic patients.

METHODS

To determine dietary habits and food preferences in oncologic patients, initially 1400 nutritional records were evaluated and analyzed. The results provided the basis for creating a nutritional mobile phone app. Key requirements for the app included simple handling, recording the daily intake, and a comparison of nutrient targets and current status. In total, 39 cancer patients were recruited for the study; 15 patients dropped out prior to the study. All patients received a nutritional anamnesis, nutritional analysis, and nutritional counseling. Individual energy and nutrient aims were defined. The intervention group (n=12) additionally used the app. Weight and body composition of each group were evaluated after 4 weeks.

RESULTS

The app group gained significantly more weight (P=.045; mean weight 1.03 kg vs -1.46 kg). Also, skeletal muscle mass showed a significant increase in the app group (P=.009; mean skeletal muscle mass 0.58 kg vs -0.61 kg) compared with the control group. There was no significant difference between groups relating to the daily protein intake (P=.06). Additionally, there was a decrease in macronutrient intake during the study period in the control group.

CONCLUSIONS

Our study indicates that patients who track their daily dietary habits using a mobile phone app are more likely to reach their nutritional goals than the control patients. Further large-scale studies are needed to confirm these initial findings and test the applicability on a broader basis.

Screening for low muscularity in colorectal cancer patients: a valid, clinic-friendly approach that predicts mortality

BACKGROUND

Low skeletal muscle quantified using computed tomography (CT) scans is associated with morbidity and mortality among cancer patients. However, existing methods to assess skeletal muscle from CT are time-consuming, expensive, and require training. Clinic-friendly tools to screen for low skeletal muscle in cancer patients are urgently needed.

METHODS

We included 807 scans from non-metastatic colorectal cancer patients. With the digital ruler available in most radiological software, we implemented an abbreviated method to assess skeletal muscle area at the third lumbar vertebra (L3), which consisted of assessing the height and width of the psoas and paraspinal muscles and computing their combined 'linear area' in centimetres squared (cm2 ). A subset of CT scans was assessed twice by two analysts to compute intra-rater and inter-rater reliability. We derived cut-points for 'low' linear area using optimal stratification and then calculated the sensitivity and specificity of these cut-points relative to standard methods (total L3 cross-sectional area assessed with Slice-O-Matic research software). We further evaluated the association of low linear area with death from any cause after colorectal cancer diagnosis in Cox proportional hazards models adjusting for demographics, smoking, body mass index category, and tumour characteristics.

RESULTS

The linear area was highly correlated with total cross-sectional area assessed using standard methods [r = 0.92; 95% confidence interval (CI): 0.91, 0.93] overall and within subgroups defined by age, sex, and body mass index group. Intra-rater and inter-rater reliability were equally high (both intra-class correlations = 0.98). Cut-points for low linear area were sensitive (0.75; 95% CI: 0.70, 0.80) and specific (0.77; 95% CI: 0.73, 0.80) for identifying low skeletal muscle relative to the standard of total L3 cross-sectional area. The hazard ratio and 95% CI for death associated with a low linear area were hazard ratio = 1.66; 95% CI: 1.22, 2.25.

CONCLUSIONS

Clinic-friendly methods that assess linear area from CT scans are an accurate screening tool to identify low skeletal muscle among non-metastatic colorectal cancer patients. These linear measures are associated with mortality after colorectal cancer, suggesting they could be clinically useful both to improve prognostication and to provide a practical screening tool to identify cancer patients who require nutrition or exercise intervention.

Comparison of Three Nutritional Screening Tools to Predict Malnutrition Risk and Detect Distinctions Between Tools in Cancer Patients Receiving Radiochemotherapy

The aim of this study was to compare three screening tools for malnutrition in patients with head and neck cancers or central nervous system tumors (CNS) who are undergoing radiochemotherapy. The study evaluated 124 adult cancer patients. The Subjective Global Assessment (SGA), Mini-Nutritional Assessment (MNA), and Nutritional Risk Screening 2002 (NRS-2002) were chosen to assess the risk of malnutrition. The prevalence of patients at nutritional risk was 31% with SGA, 31% with MNA and 23% with NRS-2002 in all patients. The agreement between SGA and MNA was substantial (κ = 0.886, P < 0.001); the agreement between SGA and NRS-2002 was moderate (κ = 0.713, P < 0.001); and the agreement between MNA and NRS-2002 was also moderate (κ = 0.795, P < 0.001). In subgroup analysis, SGA and MNA substantially (κ = 0.973, P < 0.001), SGA and NRS-2002 moderately (κ = 0.722, P < 0.001), and MNA and NRS-2002 moderately (κ = 0.747, P < 0.001) agreed in head and neck cancer patients. In CNS tumor patients, SGA and MNA slightly (κ = 0.390, P = 0.005), SGA and NRS-2002 fairly (κ = 0.457, P =0.001), and MNA and NRS-2002 substantially (κ = 0.878, P < 0.001) agreed. The best agreement in tools was observed between SGA with MNA in all patients. Further studies in different tumor groups will enhance our understanding of current tools for malnutrition detection of radiotherapy patient.

Effects and moderators of exercise on muscle strength, muscle function and aerobic fitness in patients with cancer: a meta-analysis of individual patient data

Objective

To optimally target exercise interventions for patients with cancer, it is important to identify which patients benefit from which interventions.

Design

We conducted an individual patient data meta-analysis to investigate demographic, clinical, intervention-related and exercise-related moderators of exercise intervention effects on physical fitness in patients with cancer.

Data sources

We identified relevant studies via systematic searches in electronic databases (PubMed, Embase, PsycINFO and CINAHL).

Eligibility criteria

We analysed data from 28 randomised controlled trials investigating the effects of exercise on upper body muscle strength (UBMS) and lower body muscle strength (LBMS), lower body muscle function (LBMF) and aerobic fitness in adult patients with cancer.

Results

Exercise significantly improved UBMS (β=0.20, 95% Confidence Interval (CI) 0.14 to 0.26), LBMS (β=0.29, 95% CI 0.23 to 0.35), LBMF (β=0.16, 95% CI 0.08 to 0.24) and aerobic fitness (β=0.28, 95% CI 0.23 to 0.34), with larger effects for supervised interventions. Exercise effects on UBMS were larger during treatment, when supervised interventions included ≥3 sessions per week, when resistance exercises were included and when session duration was >60 min. Exercise effects on LBMS were larger for patients who were living alone, for supervised interventions including resistance exercise and when session duration was >60 min. Exercise effects on aerobic fitness were larger for younger patients and when supervised interventions included aerobic exercise.

Conclusion

Exercise interventions during and following cancer treatment had small effects on UBMS, LBMS, LBMF and aerobic fitness. Demographic, intervention-related and exercise-related characteristics including age, marital status, intervention timing, delivery mode and frequency and type and time of exercise sessions moderated the exercise effect on UBMS, LBMS and aerobic fitness.

Chemotherapy dosing and toxicity in a patient with muscular dystrophy

BACKGROUND

Chemotherapy dosing has traditionally been based on a body surface area (BSA) calculation despite BSA dosing being problematic in a number of conditions, such as renal failure, liver failure, obesity, and sarcopenia. This case highlights another condition in which BSA dosing is problematic.

CASE

A 57-year-old man with limb-girdle muscular dystrophy presents with stage IIA inoperable squamous cell carcinoma of the lung. He is treated with chemotherapy and radiotherapy with curative intent but develops significant chemotherapy related toxicity affecting chemotherapy scheduling and dosing. Later, his cancer progresses, and he is commenced on palliative chemotherapy resulting in further significant chemotherapy toxicity.

CONCLUSION

Sarcopenia is known to increase risk of chemotherapy toxicity. This case postulates that changes in muscle mass seen in muscular dystrophy increases risk of chemotherapy toxicity, similar to sarcopenia.

A systematic review of the use of ketogenic diets in adult patients with cancer

BACKGROUND

A growing body of evidence indicates the importance of nutrition in cancer treatment. Ketogenic diets are one strategy that has been proposed to enhance traditional anticancer therapy. This review summarises the evidence concerning the effect of oral ketogenic diets on anthropometry, metabolism, quality of life (QoL) and tumour effects, at the same time as documenting adverse events and adherence in patients with cancer.

METHODS

We searched electronic databases using medical subject headings (MeSH) and text words related to ketogenic diets and cancer. Adult patients following a ketogenic diet as a complementary therapy prior, alongside or after standard anticancer treatment for more than 7 days were included. Studies were assessed for quality using the Critical Appraisal Skills Programme tools (https://www.casp-uk.net).

RESULTS

Eleven studies were included with 102 participants (age range 34-87 years) from early-phase trials, cohort studies and case reports. Studies included participants with brain, rectal or mixed cancer sites at an early or advanced disease stage. The duration of intervention ranged from 2.4 to 134.7 weeks (0.5-31 months). Evidence was inconclusive for nutritional status and adverse events. Mixed results were observed for blood parameters, tumour effects and QoL. Adherence to diet was low (50 out of 102; 49%) and ranged from 23.5% to 100%.

CONCLUSIONS

High-quality evidence on the effect of ketogenic diets on anthropometry, metabolism, QoL and tumour effects is currently lacking in oncology patients. Heterogeneity between studies and low adherence to diet affects the current evidence. There is an obvious gap in the evidence, highlighting the need for controlled trials to fully evaluate the intervention.

Total energy intake according to the level of skeletal muscle mass in Korean adults aged 30 years and older: an analysis of the Korean National Health and Nutrition Examination Surveys (KNHANES) 2008-2011

BACKGROUND/OBJECTIVES

Since gain or loss of skeletal muscle mass is a gradual event and occurs due to a combination of lifestyle factors, assessment of dietary factors related to skeletal muscle is complicated. The aim of this study was to investigate the changes in total energy intake according to the level of skeletal muscle mass.

SUBJECTS/METHODS

A total of 8,165 subjects ≥ 30 years of age from the Korean National Health and Nutrition Examination Surveys (KNHANES) 2008-2011 were included in the analysis, and multivariate-adjusted regression analyses were performed to analyze the association of the quartiles of sarcopenia index (SI) with energy intake of the study population after adjusting for age and metabolic parameters.

RESULTS

The increase in SI quartile was in proportion to the gradual decrease in systemic lipids and the anthropometric measurement of fat accumulation (P < 0.001). Subjects in higher SI quartiles tended to consume more total energy and energy-producing nutrients than those in lower quartiles (P < 0.001). After age, body weight, alcohol consumption, and metabolic parameters were adjusted in the analysis, total energy intake gradually increased according to the increase in SI quartile, and the association between total energy intake and SI was more pronounced in men. However, the risk (odd ratio) of having a low SI was not affected by any single macronutrient intake.

CONCLUSIONS

In this study, total energy intake was positively associated with SI and relative skeletal mass in both men and women. However, no significant association or a weak association was observed between any single macronutrient intake and skeletal muscle mass. The data indicated that acquiring more energy intake within the normal range of energy consumption may help to maintain skeletal muscle mass.