Association between hypogonadism, symptom burden, and survival in male patients with advanced cancer

The relationship between hematologic malignancies on male hypogonadism: a scoping review

INTRODUCTION

The associated symptoms of hypogonadism have been reported in patients with various types of cancer. However, the prevalence and significance of hypogonadism among certain hematologic malignancies have not been completely summarized in recent literature.

OBJECTIVE

In this review we aimed to examine the current literature on hypogonadism in patients with hematologic malignancies, with emphasis on leukemias, lymphomas, and multiple myeloma (MM).

METHODS

This review included relevant studies published before July 2023 that were retrieved through a search of PubMed using the keywords "hematologic cancer," "hematologic malignancy," blood cancer," "leukemia," "lymphoma," "hypogonadism," "multiple myeloma," and "testosterone."

RESULTS

The search yielded 214 studies, of which 21 met the inclusion criteria. Commonly reported findings were that patients who had received hematopoietic stem cell therapy for acute lymphoblastic leukemia and acute myelogenous leukemia as children had laboratory-confirmed hypogonadism as adults. However, the impact of these diseases on hypogonadal symptoms was variable in these studies.Studies reporting on lymphoma and hypogonadism had mixed results, with some studies finding that the degree of cytotoxic chemotherapy was associated with hypogonadism, while others showed no correlation. Regardless, multiple studies found that hypogonadism secondary to lymphoma treatment and symptoms of hypogonadism had no apparent association.The most comprehensive assessment of the frequency of hypogonadism in an MM cohort found that 74% of 561 MM patients were classified as hypogonadal compared to 33% of patients in a control population. Testosterone supplementation was found to lower interleukin-6 levels, which could potentially help manage some of the adverse effects of MM, including decreased bone mineral density.

CONCLUSION

There is a relationship between hematologic malignancies and hypogonadism, which is likely multifactorial. In this review we established that the most plausible factors are related to the secondary effects of gonadotoxic treatments and/or systemic inflammatory responses to the diseases.

Cancer cachexia: Focus on cachexia factors and inter-organ communication

ABSTRACT

Cancer cachexia is a multi-organ syndrome and closely related to changes in signal communication between organs, which is mediated by cancer cachexia factors. Cancer cachexia factors, being the general name of inflammatory factors, circulating proteins, metabolites, and microRNA secreted by tumor or host cells, play a role in secretory or other organs and mediate complex signal communication between organs during cancer cachexia. Cancer cachexia factors are also a potential target for the diagnosis and treatment. The pathogenesis of cachexia is unclear and no clear effective treatment is available. Thus, the treatment of cancer cachexia from the perspective of the tumor ecosystem rather than from the perspective of a single molecule and a single organ is urgently needed. From the point of signal communication between organs mediated by cancer cachexia factors, finding a deeper understanding of the pathogenesis, diagnosis, and treatment of cancer cachexia is of great significance to improve the level of diagnosis and treatment. This review begins with cancer cachexia factors released during the interaction between tumor and host cells, and provides a comprehensive summary of the pathogenesis, diagnosis, and treatment for cancer cachexia, along with a particular sight on multi-organ signal communication mediated by cancer cachexia factors. This summary aims to deepen medical community's understanding of cancer cachexia and may conduce to the discovery of new diagnostic and therapeutic targets for cancer cachexia.

Acupuncture techniques and acupoints used in individuals under chemotherapy or radiotherapy treatment of cancer: A systematic review

AIMS AND OBJECTIVES

To describe the main acupuncture techniques and parameters that have been used in the most varied symptoms of different types of cancer.

BACKGROUND

Clinical evidence about the potential effectiveness of acupuncture and related therapies to control signs and symptoms associated with cancer or its treatment has been in several studies. Currently, there is already evidence of the use of acupuncture for the treatment of nausea and vomiting, fatigue, dry mouth, anxiety, depression, insomnia and pain. However, many studies lack firm rights or reproducible guidelines for treatment.

DESIGN

This study performs a systematic review of clinical trials related to the topic, based on the PRISMA protocol. Thus, a search was carried out in the Scopus, Pubmed and Web of Science databases, covering studies since January 2007.

METHODS

Structured and organised according to PICO standards, using keywords ("cancer" OR "malignant tumour" OR "chemotherapy" OR "radiotherapy") AND ("acupuncture" OR "electroacupuncture") AND ("pain" OR "nausea" OR "vomit" OR "fatigue" OR "xerostomia" OR "insomnia" OR "depression" OR "neuropathy").

RESULTS

After the selection and evaluation phase, 23 studies were included and analysed.

CONCLUSION

Based on this analysis, it is concluded that acupuncture is safe and there is evidence of the reduction of gastrointestinal symptoms, chemotherapy-induced peripheral neuropathy, pain, dry mouth, fatigue, insomnia, and improvement of cognitive capacity.

RELEVANCE TO CLINICAL PRACTICE

Acupuncture treatments could act by minimising the side effects of conventional treatments and reducing symptoms induced by tumours.

NO PATIENT OR PUBLIC CONTRIBUTION

The patients had no direct involvement with the study in question.

The effect of sarcopenia and sarcopenic obesity on survival in gastric cancer

BACKGROUND

Sarcopenic obesity arises from increased muscle catabolism triggered by inflammation and inactivity. Its significance lies in its role in contributing to morbidity and mortality in gastric cancer. This study aims to explore the potential correlation between sarcopenia, sarcopenic obesity, and gastric cancer, as well as their effect on survival.

MATERIALS AND METHODS

This retrospective study included 162 patients aged ≥ 18 years who were diagnosed with stomach cancer. Patient age, gender, diagnostic laboratory results, and cancer characteristics were documented. Sarcopenia was assessed using the skeletal muscle index (SMI) (cm2/m2), calculated by measuring muscle mass area from a cross-sectional image at the L3 vertebra level of computed tomography (CT).

RESULTS

Among the 162 patients, 52.5% exhibited sarcopenia (with cut-off limits of 52.4 cm2/m2 for males and 38.5 cm2/m2 for females), and 4.9% showed sarcopenic obesity. Average skeletal muscle area (SMA) was 146.8 cm2; SMI was 50.6 cm2/m2 in men and 96.9 cm2 and 40.6 cm2/m2 in women, respectively. Sarcopenia significantly reduced mean survival (p = 0.033). There was no association between sarcopenic obesity and mortality (p > 0.05), but mortality was higher in sarcopenic obesity patients (p = 0.041). Patient weight acted as a protective factor against mortality, supporting the obesity paradox. Tumor characteristics, metabolic parameters, and concurrent comorbidities did not significantly impact sarcopenia or mortality.

CONCLUSION

Sarcopenia is more prevalent in the elderly population and is linked to increased mortality in gastric cancer patients. Paradoxically, higher body mass index (BMI) was associated with improved survival. Computed tomography offers a practical and reliable method for measuring muscle mass and distinguishing these distinctions.

TRIAL REGISTRATION

This study was approved by Istanbul Training and Research Hospital Clinical Research Ethics Committee of the University of Health Sciences (29.05.2020/2383).

Retrospective study of testosterone deficiency and symptom burden in patients with pancreatic cancer

Background

Pancreatic cancer patients have poor quality of life. Testosterone deficiency is associated with constitutional symptoms and sexual dysfunction which may contribute to poor quality of life. We investigated the prevalence of screening for and presence of testosterone deficiency in male pancreatic cancer patients.

Methods

To determine the frequency of screening for testosterone deficiency in pancreatic cancer patients, our institution's electronic medical record system was queried for male patients diagnosed with a pancreatic mass between 2006 and 2020 and an available testosterone level. In a separate analysis, total testosterone was measured in serum samples from a cohort of 89 male pancreatic ductal adenocarcinoma (PDAC) patients. Low serum testosterone was defined as <300 ng/dL.

Results

One thousand five hundred and sixty-six male patients were identified with a pancreatic mass, and 35 (2.2%) also had a testosterone level. In our analysis cohort, 44 of 89 patients (49.4%) were found to have low serum testosterone. Symptoms consistent with testosterone deficiency were documented for 70% of these patients, with fatigue being the most common. Testosterone level had no significant association with progression-free survival (PFS) (P=0.66) or overall survival (OS) (P=0.95).

Conclusions

Testosterone deficiency is common but rarely assessed in male patients with pancreatic cancer. Further studies are warranted to explore the possibility of testosterone supplementation to improve quality of life in this patient population.

Perioperative substitution testosterone therapy in patients with advanced head and neck squamous cell carcinoma

Testosterone replacement therapy is becoming more and more popular in men as "anti-aging medicine". Testosterone has beneficial effects on body mass and muscle gain, and much research has examined testosterone in palliative cancer therapy for oncology patients. In addition to direct effects on weight gain, testosterone improves mood and self-confidence, strength, libido, muscle mass, bone density, and cognitive functions and reduces the risk of cardiovascular disease. Lower testosterone levels are found in 65% of male patients with progressive tumors compared to only 6% of men in the general population. We hypothesize that perioperative substitution testosterone therapy (PSTT) together with a balanced diet, may be more effective than balanced diet alone in the overall treatment outcome of patients with head and neck squamous cell carcinomas. Therefore, PSTT in combination with a balanced diet should be considered as an additional tool for head and neck carcinoma treatment.

Survival Outcomes Associated With the Size of Opioid Prescriptions in the Management of Chronic Pain Related to Advanced Nasopharyngeal Carcinoma

OBJECTIVE

Patients with advanced nasopharyngeal carcinoma (ANC) often experience chronic pain. Opioids are generally recommended to treat tumor-related pain, but increased opioid use may lead to detrimental aftereffects, particularly with respect to tumor progression, resulting in reduced quality of life and increased risk of death. Our objective was to investigate whether the high size of opioid prescriptions is associated with poor overall survival (OS) in patients with ANC.

METHODS

A consecutive cohort of patients with newly diagnosed ANC who underwent high or low opioid prescription size treatment during 2012-2019 was retrospectively identified from our medical institutions. Survival was estimated with the Kaplan-Meier method with a log-rank test. Multivariate binary logistic regression was used to assess the association between opioid use and OS, adjusting for age, sex, body mass index (BMI), Eastern Collaborative Oncology Group performance status (ECOG PS), and ANC histology. The criterion to distinguish between the high opioid prescription size group [HD] and the low opioid prescription size group [LD] was 5 mg of oral morphine equivalents (OME) per 24 hours.

RESULTS

The cohort consisted of 244 consecutive patients (HD: n = 120, median age = 66 years [range, 40-81 years]; LD: n = 124, median age = 65 years [40-82 years]. Patients who underwent treatment with a high opioid prescription size had a worse median OS than those who underwent treatment with a low opioid prescription size (5.1 vs 6.6 months), and the high opioid prescription size was associated with a remarkable 48% higher risk of death than the low opioid prescription size (HR 1.48, 95% CI 1.11-1.98; P = .005). The cumulative dose of opioids greater than or equal to 500 mg of OME was associated with a higher risk of death, adjusted for age, sex, BMI, ECOG PS, and ANC histology.

CONCLUSIONS

In patients with newly diagnosed ANC experiencing palliative care, a high opioid prescription size may be associated with shorter OS than a low opioid prescription size.

Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency

A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.

Managing Nutrition Impact Symptoms in Cancer Cachexia: A Case Series and Mini Review

Malnutrition is common in cancer patients and can occur throughout a patient’s disease course. The contributors to the clinical syndrome of cancer cachexia are often multifactorial, and produced by the cancer and associated pro-inflammatory response. Since cancer cachexia is a multifactorial syndrome, a multimodal therapeutic approach is ideal. A key component of therapy is identifying and managing symptom barriers to adequate oral intake, known as nutritional impact symptoms (NIS). NIS are associated with reduced intake and weight loss in patients with advanced cancer, and aggregate NIS are a predictor of survival in patients with Head and Neck Cancer and in patients undergoing surgery for esophageal cancer. Currently, there are no guidelines regarding the specific management of NIS in oncology patients. Experience from specialist centers suggest relatively simple assessments and inexpensive interventions are available for the diagnosis and treatment of NIS. We present three patient cases from a cachexia clinic, where NIS management decreased symptom burden and improved clinical outcomes such as weight and physical performance.

Combination of body mass index and albumin predicts the survival in metastatic castration-resistant prostate cancer patients treated with abiraterone: A post hoc analysis of two randomized trials

Background

Low body mass index (BMI) and low serum albumin levels are suggested indicators of malnutrition and are associated with poor outcomes in cancer patients. Decreasing androgen can alter lipid metabolism, so the prognostic value of BMI may change in metastatic castration‐resistant prostate cancer (mCRPC) patients receiving abiraterone. We aimed to delineate the prognostic value of BMI, serum albumin, and BMI and serum albumin (ALB) combined.

Materials and methods

A post hoc analysis was performed on data from two randomized clinical trials evaluating the efficacy of abiraterone in chemotherapy‐pretreated and ‐naïve mCRPC patients. Survival analysis was conducted using Kaplan–Meier and Cox proportional hazard methods.

Results

A total of 2,205 mCRPC patients were included in this study. Low ALB independently predicted the OS in both cohorts (HR, 1.54; 95%CI, 1.34–1.78 and HR, 1.40; 95%CI, 1.21–1.64, respectively), while low BMI independently predicted the OS only in the post‐chemotherapy cohort (HR, 1.30; 95%CI, 1.12–1.50) but not in the pre‐chemotherapy cohort (HR, 1.19; 95%CI, 0.98–1.43). By combining BMI (<25 kg/m² or ≥30 kg/m²) and ALB (<4 g/dl or >4 g/dl), the four groups were characterized and their HRs were 1, 0.60 (95%CI, 0.47–0.76, p < 0.001), 0.75 (95%CI,0.61–0.92 p = 0.006), and 0.49 (95%CI, 0.41–0.60, p < 0.001) in post‐chemotherapy patients and 1, 0.64 (95%CI, 0.46–0.89, p = 0.008), 0.75 (95%CI,0.58–0.98 p = 0.034), and 0.55 (95%CI, 0.42–0.72, p < 0.001) in chemotherapy‐naïve patients, respectively.

Conclusions

Our results demonstrate that the combination of BMI and ALB better characterizes the risk groups irrespective of previous chemotherapy. Patients with high BMI but low ALB have higher risk of death than patients with low BMI but high ALB.

Neural Mechanisms of Cancer Cachexia

Simple Summary

Cancer cachexia is a devastating wasting syndrome that occurs in many illnesses, with signs and symptoms including anorexia, weight loss, cognitive impairment and fatigue. The brain is capable of exerting overarching homeostatic control of whole-body metabolism and is increasingly being recognized as an important mediator of cancer cachexia. Given the increased recognition and discovery of neural mechanisms of cancer cachexia, we sought to provide an in-depth review and update of mechanisms by which the brain initiates and propagates cancer cachexia programs. Furthermore, recent work has identified new molecular mediators of cachexia that exert their effects through their direct interaction with the brain. Therefore, this review will summarize neural mechanisms of cachexia and discuss recently identified neural mediators of cancer cachexia.

Abstract

Nearly half of cancer patients suffer from cachexia, a metabolic syndrome characterized by progressive atrophy of fat and lean body mass. This state of excess catabolism decreases quality of life, ability to tolerate treatment and eventual survival, yet no effective therapies exist. Although the central nervous system (CNS) orchestrates several manifestations of cachexia, the precise mechanisms of neural dysfunction during cachexia are still being unveiled. Herein, we summarize the cellular and molecular mechanisms of CNS dysfunction during cancer cachexia with a focus on inflammatory, autonomic and neuroendocrine processes and end with a discussion of recently identified CNS mediators of cachexia, including GDF15, LCN2 and INSL3.

Low Testosterone in Male Cancer Patients and Survivors

INTRODUCTION

Hypogonadism (HG) is prevalent among patients with ongoing advanced cancer and cancer survivors. The etiology of HG in these patients is multifactorial and can be examined from cancer-related and cancer-treatment perspectives. There is evidence that HG contributes to increased morbidity in male cancer patients. Testosterone replacement therapy (TRT) for cancer survivors and advanced cancer patients is not well studied outside of prostate cancer. Here, we evaluate and summarize the current literature on HG in male cancer patients, including the role of TRT in nonprostate cancer patients.

OBJECTIVE

To summarize and present the literature for the background, etiology, clinical consequences, and treatment for HG in male cancer patients and survivors.

METHODS

A literature review was performed in MEDLINE between 1980 and 2020 using the terms hypogonadism, advanced cancer, testosterone replacement therapy, quality of life, and cancer survivors. Studies including only prostate cancer patients were excluded.

RESULTS

The main outcome measure was to complete a review of peer-reviewed literature. HG is not only prevalent among male cancer patients and survivors but also clinically reduces quality of life and increases morbidity. The etiology of HG in male cancer patients and survivors is multifactorial. There are few studies examining the benefit of TRT in these patient populations. The results of randomized controlled trials show potential benefit for TRT in hypogonadal male cancer survivors and those with advanced cancer.

CONCLUSION

HG affects many male cancer patients and survivors because of a multifactorial etiology. HG in these patients contributes to increased morbidity and reduced quality of life. Treatment of HG in male cancer patients is not well studied, and further studies are needed to elucidate the role of TRT. Xu P, Choi E, White K, et al. Low Testosterone in Male Cancer Patients and Survivors. Sex Med 2021;9:133-142.

Blood concentrations of vitamins B1, B6, B12, C and D and folate in palliative care patients: Results of a cross-sectional study

Objective

The main purpose of palliative care is symptom relief. Frequently, the symptoms of patients requiring palliative care are the same as common symptoms of vitamin deficiency (e.g. pain, weakness, fatigue, depression). The study aim was to investigate whether patients in palliative care are vitamin deficient.

Method

This was a monocentre cross-sectional study. Patients attending the palliative care unit of a general hospital in Germany from October 2015 to April 2016 were examined for vitamin blood concentrations and symptoms. Data were analysed using univariate analysis and bivariate correlations.

Results

Data were available from 31 patients. Vitamin D3 deficiency (<62.5 nmol/L) affected 93.5% of patients, vitamin B6 deficiency (<4.1 ng/mL) 48.4%, vitamin C deficiency (<4.5 mg/L) 45.2%, vitamin B1 deficiency (<35 µg/L) 25.8% and vitamin B12 deficiency (<193 pg/mL) 12.9%. There was a significant negative correlation between vitamin B1 ranges and pain (r = −0.384) and depression (r = −0.439) symptoms.

Conclusion

All patients showed a deficiency in at least one of the measured vitamins; 68% had concurrent deficiencies in >1 vitamin. A follow-up study using validated questionnaires and a larger sample is needed to investigate the effects of targeted vitamin supplementation on quality of life and symptom burden.

Scalp hair cortisol and testosterone levels in patients with sarcoidosis

Background

Patients with sarcoidosis often experience fatigue and psychological distress, but little is known about the etiology of these conditions. While serum and saliva steroid hormones are used to monitor acute steroid levels, scalp hair analysis is a relatively new method enabling measurement of long-term steroid levels, including hair cortisol reflecting chronic stress. We investigated whether scalp hair cortisol and testosterone levels differ between sarcoidosis patients both with and without fatigue and general population controls. Additionally, we studied if these hormones could serve as objective biomarkers for psychological distress in patients with sarcoidosis.

Methods

We measured hair steroid levels using liquid chromatography–tandem mass spectrometry in glucocorticoid naïve sarcoidosis patients. Patients completed the Perceived Stress Scale, Fatigue Assessment Scale, Hospital Anxiety and Depression Scale and Short Form 36 (SF-36). Hair steroid levels from 293 participants of the population-based Lifelines cohort study served as controls.

Results

Thirty-two patients (14 males) were included. Hair cortisol, but not testosterone, concentrations were significantly higher in patients with sarcoidosis than in general population controls (mean 6.6 versus 2.7 pg/mg, p<0.001). No differences were found in hair cortisol and testosterone levels between fatigued and non-fatigued patients with sarcoidosis. Hair cortisol of sarcoidosis patients correlated significantly with anxiety (r = 0.47, p = 0.01), depression (r = 0.46, p = 0.01), and SF-36 mental domain (r = -0.38, p = 0.03), but not with fatigue.

Conclusions

Patients with sarcoidosis have chronically higher levels of the stress hormone cortisol than the normal population, while testosterone levels in hair did not differ. Hair cortisol levels were positively related to subjective measures of psychological distress, but not to fatigue. Our study shows that hair cortisol is a promising non-invasive biomarker for psychological distress in patients with sarcoidosis.

Trial registration

ClinicalTrials.gov: NCT03108547. Registered 31 March 2017, retrospectively registered.

Pancreas Cancer-Associated Weight Loss

Unintentional weight loss in patients with pancreatic cancer is highly prevalent and contributes to low therapeutic tolerance, reduced quality of life, and overall mortality. Weight loss in pancreatic cancer can be due to anorexia, malabsorption, and/or cachexia. Proper supportive care can stabilize or reverse weight loss in patients and improve outcomes. We review the literature on supportive care relevant to pancreatic cancer patients, and offer evidence-based recommendations that include expert nutritional assessment, counseling, supportive measures to ensure adequate caloric intake, pancreatic enzyme supplementation, nutritional supplement replacement, orexigenic agents, and exercise. Pancreatic Cancer Action Network-supported initiatives will spearhead the dissemination and adoption of these best supportive care practices. IMPLICATIONS FOR PRACTICE: Weight loss in pancreatic cancer patients is endemic, as 85% of pancreatic cancer patients meet the classic definition of cancer cachexia. Despite its significant prevalence and associated morbidity, there is no established approach to this disease entity. It is believed that this is due to an important knowledge gap in understanding the underlying biology and lack of optimal treatment approaches. This article reviews the literature regarding pancreas cancer-associated weight loss and establishes a new framework from which to view this complex clinical problem. An improved approach and understanding will help educate clinicians, improve clinical care, and provide more clarity for future clinical investigation.

Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution

Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.

[Andrology in oncological diseases]

In dermato-oncological treatment there are many gonadotoxic interventions. Alkylating and hormonally active substances as well as gonadal irradiation, in particular, are known to have a fertilization-limiting effect in men. Since 2017 certified skin cancer centers in Germany therefore have the task to implement counselling on preservation of fertility. This is supported by the S2k guidelines on preservation of fertility in oncological treatment. Because recommendation of the various interventions from the dermato-oncological guidelines are dependent on the stage, the authors advocate at least the question "Is the desire to have children of interest to you?" when patients reach the appropriate stage. Fertility protection of men via cryopreservation of ejaculates or testicular tissue is then a simple and safe option. The procedure is standardized and usually available. In addition, the possibility of cryopreservation of testicular tissue from prepubertal male children and infants is now available via the new Androprotect project. If signs of hypogonadism occur during therapy, a treatment can be considered by weighing up the effects of testosterone but in this case it is important to take the anabolic and immunomodulating effects into account.

Lower Circulating Androgens Are Associated with Overall Cancer Risk and Prostate Cancer Risk in Men Aged 25-84 Years from the Busselton Health Study

Androgens, notably testosterone (T), have been implicated in development of several common cancers and prostate cancer; however, precise mechanisms remain unclear. This study assessed prospective associations of serum T, dihydrotestosterone (DHT) and estradiol (E2) with overall cancer (excluding skin cancer), prostate, colorectal and lung cancer risk in 1574 community-dwelling men aged 25-84 years. Sex hormones were assayed using mass spectrometry and men were followed for 20 years with outcomes ascertained using data linkage. Over 20 years, there were 289, 116, 48 and 22 men who developed any cancer, prostate cancer, colorectal cancer and lung cancer, respectively. Androgens in the lowest quartile were associated with an increased overall cancer risk (HR = 1.36, 95% CI 1.05-1.76, p = 0.020 for T; and HR = 1.30, 95% CI 1.00-1.69, p = 0.049 for DHT comparing the lowest vs other quartiles). T in the lowest quartile was associated with an increased risk of prostate cancer (HR = 1.53, 95% CI 1.02-2.29, p = 0.038 comparing the lowest vs other quartiles). The association between androgens and overall cancer risk remained similar after excluding prostate cancer outcomes; however, results were not significant. There were no associations of T, DHT or E2 with colorectal or lung cancer risk; however, LH in the highest quartile was associated with an increased risk of lung cancer (HR = 4.55, 95% CI 1.70-12.19, p = 0.003 for the highest vs other quartiles). Whether T is a biomarker of poor health in men with any cancer or prostate cancer requires further confirmation as does the nature and mechanism of the association of a high LH with future lung cancer.

A Combination of Testosterone and White Blood Cell Count as a Predictive Factor of Overall Survival in Localized Prostate Cancer

BACKGROUND

It has been shown that neutrophil count or an elevated neutrophil-to-lymphocyte ratio (NLR) as well as testosterone levels are separately associated with increased mortality in patients with localized prostate cancer.

OBJECTIVE

We tested a combination of testosterone levels and white blood cell (WBC) counts to predict overall survival (OS) in a prospective cohort of patients treated with radiotherapy for localized prostate cancer.

PATIENTS AND METHODS

The 381 patients included in this study were prospectively enrolled in phase 2 or 3 studies. Multivariate Cox proportional hazards models were used to analyze the influence of WBC count and testosterone level on biochemical recurrence and OS. Cutoff levels of ≤10.4 nmol/L (300 ng/dL) for testosterone and a median value of 6.2 (×10⁹/L) for WBC count were used.

RESULTS

The median follow-up for biochemical recurrence and OS were 72 and 78 months, respectively. A WBC count of ≥6.2 alone was not associated with OS (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.30-1.46). When combined with a testosterone level of >10.3 nmol/L, a WBC count of ≥6.2 was associated with increased mortality (HR 2.96; 95% CI 1.45-6.06) when compared with a WBC count of <6.2 (p-interaction = 0.01). The HR for biochemical recurrence for patients with a testosterone level >10.3 nmol/L combined with a lymphocyte level above or equal to the median was nearly identical to the HR of a testosterone level >10.3 nmol/L with a WBC above or equal to the median. There was no association between testosterone level and the NLR.

CONCLUSIONS

A high WBC and lymphocyte count combined with normal testosterone levels increases the overall mortality of patients treated with radiotherapy for localized prostate cancer within the first 6-7 years post-treatment. Validation in larger cohorts is necessary.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Androgen-Induced Immunosuppression

In addition to determining biological sex, sex hormones are known to influence health and disease via regulation of immune cell activities and modulation of target-organ susceptibility to immune-mediated damage. Systemic autoimmune disorders, such as systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis are more prevalent in females, while cancer shows the opposite pattern. Sex hormones have been repeatedly suggested to play a part in these biases. In this review, we will discuss how androgens and the expression of functional androgen receptor affect immune cells and how this may dampen or alter immune response(s) and affect autoimmune disease incidences and progression.

Clinical significance of androgen secretion disorders in men with a malignancy

Cancer and its treatment can lead in men to testosterone deficiency, accompanied by somatic and mental symptoms. Germ cell tumours and their treatment may disturb the pituitary-gonadal axis, hence leading to significant clinical abnormalities. In some prostate cancer patients, castration, temporary or permanent, is a desired therapeutic condition. Yet, it is burdened with various side effects of complex intensity and significance. Last but not least, patients in the terminal stage of a malignancy present with low testosterone concentrations as a part of anorexia-cachexia syndrome. Oncological management of such patients disturbs their homeostasis, androgen metabolism included, which results in numerous complications and worsens their quality of life. In the present paper, we analysed the frequency and sequelae of testosterone deficiency in some clinical scenarios, on the basis of original papers, meta-analyses and reviews available in PubMed. Androgen secretion disorders in male cancer patients depend on a cancer type, stage and methods of treatment. Number of testicular cancer survivors is increasing, and as a consequence, more patients cope with late complications, testosterone deficiency included. Hormone therapy in prostate cancer patients significantly prolongs survival, and then numerous men experience long-term adverse effects of androgen deficiency. Those, in turn, particularly the metabolic syndrome, may contribute to increased mortality. Androgen deficiency is a part of cancer anorexia-cachexia syndrome. The role of androgen deficiency in cancer patients is still under debate, and further studies are urgently needed to establish appropriate clinical guidelines.

Sex differences and sex hormones in anxiety-like behavior of aging rats

Sex differences in the prevalence of affective disorders might be attributable to different sex hormone milieu. The effects of short-term sex hormone deficiency on behavior, especially on anxiety have been studied in numerous animal experiments, mainly on young adult rats and mice. However, sex differences in aged animals and the effects of long-term hypogonadism are understudied. The aim of our study was to analyze sex differences in anxiety-like behavior in aged rats and to prove whether they can be attributed to endogenous sex hormone production in males. A battery of tests was performed to assess anxiety-like behavior in aged female, male and gonadectomized male rats castrated before puberty. In addition, the aged gonadectomized male rats were treated with a single injection of estradiol or testosterone or supplemented with estradiol for two-weeks. Female rats displayed a less anxious behavior than male rats in most of the conducted behavioral tests except the light-dark box. Long-term androgen deficiency decreased the sex difference in anxiety either partially (open field, PhenoTyper cage) or completely (elevated plus maze). Neither single injection of sex hormones, nor two-week supplementation of estradiol in gonadectomized aged male rats significantly affected their anxiety-like behavior in the elevated plus maze. In conclusion, our results confirm sex differences in anxiety in aged rats likely mediated by endogenous testosterone production in males. Whether long-term supplementation with exogenous sex hormones could affect anxiety-like behavior in elderly individuals remains to be elucidated.

Range of Effective Corticosteroid Doses for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review

This study aimed to determine the range of mean cumulative corticosteroid doses that could effectively palliate dyspnea in opioid-treated patients with terminal cancer and to investigate the demographic or biochemical factors predictive of corticosteroid responsiveness. To this end, responders and nonresponders were compared with regard to corticosteroid dose and whether they had initiated opioid use before or concomitantly with corticosteroid use. A logistic regression analysis was conducted to assess the impacts of demographic and biochemical factors on corticosteroid effectiveness. The final sample comprised 20 patients who satisfied the selection criteria. The responders accounted for 70% of the total sample (n = 14) and experienced the strongest effect with regard to dyspnea palliation at a mean cumulative dose equivalent to 64.4 mg prednisolone. However, no factors predictive of response were identified. In summary, this retrospective study identified effective corticosteroid doses for dyspnea alleviation in terminal cancer patients. Although our study sample was limited in size, the results support further prospective research.

Pain and Opioids in Cancer Care: Benefits, Risks, and Alternatives

Pain remains common in the setting of malignancy, occurring as a consequence of cancer and its treatment. Several high-quality studies confirm that more than 50% of all patients with cancer experience moderate to severe pain. The prevalence of pain in cancer survivors is estimated to be 40%, while close to two-thirds of those with advanced disease live with pain. Progress has occurred in the management of cancer pain, yet undertreatment persists. Additionally, new challenges are threatening these advances. These challenges are numerous and include educational deficits, time restraints, and limited access to all types of care. New challenges to access are occurring as a result of interventions designed to combat the prescription drug abuse epidemic, with fewer clinicians willing to prescribe opioids, pharmacies reluctant to stock the medications, and payers placing strict limits on reimbursement. A related challenge is our evolving understanding of the risks of long-term adverse effects associated with opioids. And reflective of the opioid abuse epidemic affecting the general population, the potential for misuse or abuse exists in those with cancer. Guidelines have been developed to support oncologists when prescribing the long-term use of opioids for cancer survivors. The challenges surrounding the use of opioids, and the need for safe and effective alternative analgesics, are leading to intense interest in the potential benefits of cannabis for cancer-related pain. Oncologists are faced with questions regarding the types of cannabis available, differences between routes of administration, data concerning safety and efficacy, and legal and regulatory dynamics.

Symptom clusters and survival in Portuguese patients with advanced cancer

This study aimed to identify clusters of symptoms, to determine the patient characteristics associated with identified, and determine their strength of association with survival in patients with advanced cancer (ACPs). Consecutively eligible ACPs not receiving cancer‐specific treatment, and referred to a Tertiary Palliative Care Clinic, were enrolled in a prospective cohort study. At first consultation, patients rated 9 symptoms through the Edmonton Symptom Assessment System (0–10 scale) and 10 others using a Likert scale (1–5). Principal component analysis was used in an exploratory factor analysis to identify. Of 318 ACPs, 301 met eligibility criteria with a median (range) age of 69 (37–94) years. Three SCs were identified: neuro‐psycho‐metabolic (NPM) (tiredness, lack of appetite, lack of well−being, dyspnea, depression, and anxiety); gastrointestinal (nausea, vomiting, constipation, hiccups, and dry mouth) and sleep impairment (insomnia and sleep disturbance). Exploratory factor analysis accounted for 40% of variance of observed variables in all SCs. Shorter survival was observed for patients with the NPM cluster (58 vs. 23, P < 0.001), as well as for patients with two or more SCs (45 vs. 21, P = 0.005). In a multivariable model for survival at 30‐days, age (HR: 0.98; 95% CI: 0.97–0.99; P = 0.008), hospitalization at inclusion (HR: 2.27; 95% CI: 1.47–3.51; P < 0.001), poorer performance status (HR: 1.90, 95% CI: 1.24–2.89; P = 0.003), and NPM (HR: 1.64; 95% CI: 1.17–2.31; P = 0.005), were associated with worse survival. Three clinically meaningful SC in patients with advanced cancer were identifiable. The NPM cluster and the presence of two or more SCs, had prognostic value in relation to survival.

Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors.

METHODS

An ASCO-convened expert panel conducted a systematic literature search of studies investigating chronic pain management in cancer survivors. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation.

RESULTS

A total of 63 studies met eligibility criteria and compose the evidentiary basis for the recommendations. Studies tended to be heterogeneous in terms of quality, size, and populations. Primary outcomes also varied across the studies, and in most cases, were not directly comparable because of different outcomes, measurements, and instruments used at different time points. Because of a paucity of high-quality evidence, many recommendations are based on expert consensus.

RECOMMENDATIONS

Clinicians should screen for pain at each encounter. Recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain should be evaluated, treated, and monitored. Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. Systemic nonopioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. Clinicians may prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and who continue to experience distress or functional impairment. Risks of adverse effects of opioids should be assessed. Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids and should incorporate universal precautions to minimize abuse, addiction, and adverse consequences. Additional information is available at www.asco.org/chronic-pain-guideline and www.asco.org/guidelineswiki.

Acupuncture and Related Therapies for Symptom Management in Palliative Cancer Care: Systematic Review and Meta-Analysis

Available systematic reviews showed uncertainty on the effectiveness of using acupuncture and related therapies for palliative cancer care. The aim of this systematic review and meta-analysis was to summarize current best evidence on acupuncture and related therapies for palliative cancer care. Five international and 3 Chinese databases were searched. Randomized controlled trials (RCTs) comparing acupuncture and related therapies with conventional or sham treatments were considered. Primary outcomes included fatigue, paresthesia and dysesthesias, chronic pain, anorexia, insomnia, limb edema, constipation, and health-related quality of life, of which effective conventional interventions are limited. Thirteen RCTs were included. Compared with conventional interventions, meta-analysis demonstrated that acupuncture and related therapies significantly reduced pain (2 studies, n = 175, pooled weighted mean difference: -0.76, 95% confidence interval: -0.14 to -0.39) among patients with liver or gastric cancer. Combined use of acupuncture and related therapies and Chinese herbal medicine improved quality of life in patients with gastrointestinal cancer (2 studies, n = 111, pooled standard mean difference: 0.75, 95% confidence interval: 0.36-1.13). Acupressure showed significant efficacy in reducing fatigue in lung cancer patients when compared with sham acupressure. Adverse events for acupuncture and related therapies were infrequent and mild. Acupuncture and related therapies are effective in reducing pain, fatigue, and in improving quality of life when compared with conventional intervention alone among cancer patients. Limitations on current evidence body imply that they should be used as a complement, rather than an alternative, to conventional care. Effectiveness of acupuncture and related therapies for managing anorexia, reducing constipation, paresthesia and dysesthesia, insomnia, and limb edema in cancer patients is uncertain, warranting future RCTs in these areas.

Prognostication of Survival in Patients With Advanced Cancer: Predicting the Unpredictable?

BACKGROUND

Prognosis is a key driver of clinical decision-making. However, available prognostication tools have limited accuracy and variable levels of validation.

METHODS

Principles of survival prediction and literature on clinician prediction of survival, prognostic factors, and prognostic models were reviewed, with a focus on patients with advanced cancer and a survival rate of a few months or less.

RESULTS

The 4 principles of survival prediction are (a) prognostication is a process instead of an event, (b) prognostic factors may evolve over the course of the disease, (c) prognostic accuracy for a given prognostic factor/ tool varies by the definition of accuracy, the patient population, and the time frame of prediction, and (d) the exact timing of death cannot be predicted with certainty. Clinician prediction of survival is the most commonly used approach to formulate prognosis. However, clinicians often overestimate survival rates with the temporal question. Other clinician prediction of survival approaches, such as surprise and probabilistic questions, have higher rates of accuracy. Established prognostic factors in the advanced cancer setting include decreased performance status, delirium, dysphagia, cancer anorexia-cachexia, dyspnea, inflammation, and malnutrition. Novel prognostic factors, such as phase angle, may improve rates of accuracy. Many prognostic models are available, including the Palliative Prognostic Score, the Palliative Prognostic Index, and the Glasgow Prognostic Score.

CONCLUSIONS

Despite the uncertainty in survival prediction, existing prognostic tools can facilitate clinical decision-making by providing approximated time frames (months, weeks, or days). Future research should focus on clarifying and comparing the rates of accuracy for existing prognostic tools, identifying and validating novel prognostic factors, and linking prognostication to decision-making.

Identifying nutritional, functional, and quality of life correlates with male hypogonadism in advanced cancer patients

With the availability of a potential treatment to reverse male hypogonadism (MH), the primary aim of this case series study was to determine independent relationships between this condition and the nutritional, functional, and quality of life characteristics of advanced cancer patients (ACP). Free testosterone levels were measured in 100 male patients with advanced lung and gastrointestinal (GI) cancer. Routine blood markers of nutrition and inflammation, self-reporting questionnaires for symptom, nutrition, and functional status along with handgrip dynamometry were assessed for all patients at bedside. Almost half of this cohort underwent further assessments (body composition, lower body strength, in depth quality of life and fatigue questionnaires) at the McGill Nutrition and Performance Laboratory (mnupal.mcgill.ca). Multiple regression analyses were performed to identify independent correlations between free testosterone and the above measures. Seventy-six percent of patients were diagnosed with MH. Using multiple linear regression, low free testosterone (31.2 pmol/L) was independently associated with lower albumin (B = –3.8 g/L; 95% confidence interval CI –6.8:–0.8), muscle strength (–11.7 lbs; –20.4: –3.0) and mass in upper limbs (–0.8 kg; –1.4: –0.1), overall performance status (Eastern Cooperative Oncology Group Performance Scale, ECOG PS 0.6; 0.1:1.1), cancer-related fatigue (Brief Fatigue Inventory, BFI 16.7; 2.0: 31.3), and overall quality of life (MQoL total score –1.42; –2.5: –0.3). Thus MH seems to be highly prevalent in ACP, and it is independently associated with important nutritional, functional, and quality of life characteristics in this patient population.

Medical Manuscript

The role of total serum testosterone in the prognosis of terminal cancer is unclear. We retrospectively investigated the total serum testosterone level in 69 male patients with terminal cancer in a palliative care unit. The association between the serum testosterone level and survival was assessed using Cox proportional hazard model. The median value of serum total testosterone was 44.5 ng/dL, far lower than previously reported in patients with advanced cancer. Multivariate analysis revealed thrombocytopenia (adjusted hazard ratio [aHR], 2.68), hypoalbuminemia (aHR, 2.02), azotemia (aHR, 2.67), and lower serum testosterone level (aHR, 2.03) were significantly negatively prognostic of survival. Lower serum testosterone level was an independent unfavorable prognostic factor for life expectancy in male patients with terminal cancer.

The implications of low testosterone on mortality in men

Testosterone levels in men slowly decline with aging and also decline more abruptly due to medical illness or medications. Prescriptions for testosterone have increased dramatically over the past decade, since a testosterone-gel formulation was approved and since numerous studies reported an association between low serum testosterone and increased mortality. However, recent observational studies of testosterone treatment have reported conflicting results with some studies reporting decreased risks for mortality while others reported increased mortality risks with testosterone treatment. This paper will summarize recent studies of low serum testosterone and mortality and testosterone treatment and mortality and what the potential implications of these studies are for the clinician.

Loss of muscle mass in the end of life in patients with advanced cancer

PURPOSE

Muscle mass depletion is associated with adverse outcomes in cancer patients. There is limited information on the impact of age, sex, tumor type, and inflammation on muscle loss in the end of life of cancer patients.

METHODS

Muscle depletion and loss of muscle in the last 2 years of life was estimated in 471 cancer patients from 779 dual-energy X-ray absorptiometry scans. A linear mixed model was used to estimate the impact of age, sex, tumor type, and inflammation.

RESULTS

Patients above median age (>71 years) had less muscle mass (-1.1 ± 0.3 kg, P < 0.001). Prevalence of muscle depletion was higher in men than women (59 vs. 28%, P < 0.001). Men lost muscle mass over time (mean, 1.4 ± 0.3 kg/year, P < 0.001) contrary to women (0.3 ± 0.4 kg/year, P = 0.5). Patients with pancreatic cancer had less muscle mass than patients with biliary tract and colorectal cancers (P < 0.02). There were no differences in muscle loss over time in patients grouped by median age or tumor type. The prevalence of elevated C-reactive protein was 61 to 70% during the study. Patients with C-reactive protein >10 mg/L had less muscle mass (0.6 ± 0.2 kg, P < 0.001) and lost muscle mass at an accelerated pace during the disease trajectory (0.7 ± 0.3 kg/year, P = 0.03).

CONCLUSIONS

Muscle loss in advanced cancer is related to age, sex, tumor type, and inflammation. The mechanism(s) behind the apparent sexual dimorphism warrants further study.