C-reactive protein, symptoms and activity of daily living in patients with advanced cancer receiving palliative care

Prognostic risk stratification using C-reactive protein, albumin, and associated inflammatory biomarkers in patients with advanced cancer in palliative care

PURPOSE

To evaluate the prognostic value of C-reactive protein (CRP), albumin, CRP/albumin ratio (CAR), and modified Glasgow Prognostic Score (mGPS) at different thresholds in patients with advanced cancer in palliative care.

METHODS

Prospective cohort study with patients evaluated at a palliative care unit in Brazil between July 2016 and March 2020. We included patients ≥ 20 years old, both sexes, able to provide the necessary information or accompanied by someone able to do so, and Karnofsky Performance Status ≥ 30 %. The exclusion criteria were the absence of laboratory data and previous diagnosis of autoimmune and infectious diseases. The thresholds analyzed were: CRP < 5 vs. 5-10 vs. > 10 mg/L, albumin < 2.4 vs. 2.4-2.9 vs. 3.0-3.5 vs. > 3.5 g/dL; CAR <1.2 vs. 1.2-2.0 vs. > 2.0, and mGPS equal to 0 vs. 1 vs. 2. Kaplan-Meier curves and Cox regression models (with hazard ratios [HR] and 95% confidence interval [CI]) were used to evaluate prognostic value, and the concordance statistic (C-statistic) was used to evaluate the predictive accuracy of these thresholds to predict death within 90 days.

RESULTS

A total of 1,877 patients were included. Median overall survival was 51 (19;124) days and decreased in line with the deterioration of the inflammatory biomarkers. According to the Cox regression models, HR increased as the thresholds worsened (CRP: 1.74 [95% CI, 1.50-2.02] to 2.30 [95% CI, 2.00-2.64]; albumin: 1.77 [95% CI, 1.52-2.07] to 2.60 [95% CI, 2.15-3.14]; CAR: 1.47 [95% CI, 1.21-1.77] to 2.35 [95% CI, 2.05-2.69]; mGPS: 1.78 [95% CI, 1.40-2.23] to 1.89 [95% CI, 1.65-2.15]). All the inflammatory biomarkers evaluated showed discriminatory accuracy for predicting death (C-statistic >0.70), with CAR as the best parameter (C-statistic: 0.80).

CONCLUSION

Our results suggest that CRP, albumin, CAR, and mGPS can be used as clinically meaningful biomarkers to stratify patients with advanced cancer in palliative care according to the severity of these indicators.

Thiamine deficiency as a cause of anorexia in terminally ill cancer patients: A case of possible gastrointestinal beriberi

OBJECTIVES

Anorexia in cancer patients has a variety of causes and impairs patients' quality of life. However, there have been few reports of thiamine deficiency (TD) playing a role in anorexia during palliative care. The objective of this report was to describe such a case.

METHODS

An 82-year-old woman with advanced cervical cancer was admitted for palliative care because of progressive disease. One month after admission, she developed myoclonus on the left side, difficulty speaking, slurred speech, and drooping of the left corner of the mouth, with no consciousness disturbance. She also developed nausea and complained of decreased dietary intake for more than 2 weeks.

RESULTS

The patient's thiamine level, which had been measured 2 weeks earlier, was 27 ng/ml, which was below the normal range, and 100 mg of thiamine was administered intravenously. After 2 hours, the patient's neurological findings resolved, and her dietary intake improved from 30% to 40% of meals to 90% to 100%. Subsequently, the patient did not experience similar symptoms, and her clinical course was stable. Based on the patient's clinical course, gastrointestinal beriberi was diagnosed.

SIGNIFICANCE OF RESULTS

This case shows that TD may cause anorexia. Many patients who receive palliative care have decreased dietary intake. Consequently, such patients may present with gastrointestinal beriberi, as in the present case. Appropriate diagnosis and treatment may contribute to increasing such patients' quality of life. It may be necessary to differentiate TD from other conditions as a cause of anorexia in patients receiving palliative care.

Association between ICW/TBW ratio and cancer prognosis: Subanalysis of a population-based retrospective multicenter study

BACKGROUND & AIMS

Disease burden is known to alter cellular integrity and water balance. Therefore, the intracellular water/total body water (ICW/TBW) ratio is used as an adjunctive indicator to predict disease severity and prognosis. The ICW/TBW ratio of patients with cancer, who typically present with low muscle mass, poor nutritional status, and high inflammatory response, reportedly differs from that of the healthy population. Herein, we aimed to evaluate the effect of the ICW/TBW ratio on the prognosis of different subgroups of patients with cancer.

METHODS

This multicenter cohort study included 2787 patients with malignancies between June 2014 and December 2018. The association between covariates and overall survival (OS) was assessed using restricted cubic spline models. The multivariate Cox regression model included variables demonstrating a statistical significance in the univariate Cox regression analysis (P < 0.05) without multicollinearity. The generated nomogram used the C-index and calibration curves to validate the predictive accuracy of the scoring system.

RESULTS

The optimal cut-off value for the ICW/TBW ratio was 0.61. The ICW/TBW ratio was an independent prognostic factor (hazard ratio [HR]: 0.621; 95 % confidence interval [CI]: 0.537-0.719, P < 0.001). Moreover, the ICW/TBW ratio had a greater impact on the prognosis of patients receiving chemoradiotherapy than on those receiving chemotherapy alone (chemoradiotherapy: HR = 0.495, P = 0.005 vs. chemotherapy: HR = 0.646, P < 0.001). Multivariate Cox regression analysis showed that sex, age, tumor stage, body mass index, neutrophil-to-lymphocyte ratio (NLR), and ICW/TBW ratio were associated with OS. Subsequently, a nomogram was developed incorporating these variables and yielded a C-index of 0.743.

CONCLUSIONS

The ICW/TBW ratio was associated with muscle mass, nutritional status, and inflammation. A low ICW/TBW ratio is an independent risk factor for poor prognosis in patients with cancer, especially when they are female, have advanced cancer stage, have sarcopenia, and are receiving radiotherapy.

Cachexia is associated with depression, anxiety and quality of life in cancer patients

OBJECTIVES

This study aimed to compare depression, anxiety and quality of life (QoL) between cachexia and non-cachexia patients, and explore the relationship between cachexia and depression, anxiety and QoL in patients with cancer.

METHODS

A total of 528 patients from cancer centres of four hospitals were enrolled in this cross-sectional study. All patients were divided into cachexia and non-cachexia according to international consensus definition of cachexia. Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Quality of Life Questionnaire-Cancer 30 (QLQ-C30) were used to evaluate depression, anxiety and QoL.

RESULTS

285 patients (53.98%) were classified as cachexia. The prevalence of depression, anxiety, severe depression and severe anxiety in cachexia was 30.2%, 18.6%, 6.7% and 8.4%, respectively, which were significantly higher than in non-cachexia (all p<0.01). Patients with cachexia obviously acquired poorer physical function (PF), role function (RF), cognitive function (CF), emotional function (EF), social function (SF) and overall QoL than non-cachexia patients (all p<0.01). Cachexia was positively associated with depression (unstandardised coefficient (B)=2.123, p<0.001) and anxiety (B=1.123, p=0.024), and had a negative relationship with PF, CF, EF, SF and overall QoL (all B<0, all p<0.05).

CONCLUSIONS

Cachexia was associated with greater depression and anxiety and poorer QoL in patients with cancer, which emphasised the importance of timely identification and management of cachexia to improve the psychological problems and QoL among patients with cancer.

The application of the Glasgow prognostic score to predict the survival in patients with metastatic pancreatic carcinoma

Objectives:

Thither is a more pressing effort to think about chemotherapy (CTx) in second-line and beyond in patients with metastatic pancreatic cancer (mPC). The current work aimed to evaluate the value of the Glasgow prognostic score (GPS) and modified Glasgow prognostic score (mGPS) to predict the survival in patients receiving second-line CTx protocol.

Material and Methods:

We retrospectively reviewed the patients’ medical files with mPC who received second-line CTx protocol between September 2013 and December 2017. The GPS/mGPS graded from 0 to 2 based on C-reactive protein and serum albumin.

Results:

One hundred and sixty-nine patients with mPC were eligible. Survival of patients with Score 0 (GPS/mGPS) was better than that of Score 1 (GPS/mGPS) or Score 2 (GPS/mGPS), which was statistically significant (P < 0.001). Of 78 patients who died, only 16 patients belonged to Score 0 (GPS/mGPS), compared to 30 patients belonged to Score 1 (GPS/mGPS) and 32 patients belonged to Score 2 (GPS/mGPS). Univariate analysis showed that high GPS/mGPS (P < 0.000) as well as poor Eastern Cooperative Oncology Group Performance Status (P < 0.000) and metastasis either to the liver (P < 0.01) or lung (P < 0.04) were linked with worse prognosis. A statistically significant association was detected between the two scores. Cohen’s Kappa coefficient (k) was 0.9, SD = 0.03; 95% CI (0.787–0.922; P < 0.001).

Conclusion:

Our data suggested that GPS/mGPS is an easy and applicable index that may be used in daily practice and may help in the prognostic stratification of mPC patients to avert overtreatment in frail patients and raise the best supportive treatment concept.

Simple prognostic markers for optimal treatment of patients with unresectable pancreatic cancer

Most patients with pancreatic cancer are ineligible for curative resection at diagnosis, resulting in poor prognosis. This study aimed to evaluate the prognostic factors in patients with unresectable pancreatic cancer.We retrospectively collected clinical data from 196 patients with unresectable pancreatic cancer who received palliative chemotherapy (N = 153) or palliative care alone (N = 43) from January 2011 to December 2013. Patients' background data and overall survival were analyzed using the Cox proportional hazard regression model.In patients receiving palliative chemotherapy (gemcitabine-based regimen, 88.2%) and palliative care alone, the median (range) ages were 68 (43-91) and 78 (53-90) years, and metastatic diseases were present in 80% (N = 123) and 86% (N = 37), respectively. Multivariate analysis in the palliative chemotherapy patients showed that liver metastasis (hazard ratio [HR] 2.25, 95% confidence interval [CI] 1.58-3.20, P < .001), neutrophil-to-lymphocyte ratio (>4.5 vs ≤4.5; HR 3.45, 95% CI 2.22-5.36, P < .001), and cancer antigen 19-9 (CA19-9) (≥900 vs <900 U/mL; HR 1.45, 95% CI 1.02-2.05, P = .036) were independent prognostic factors. In those receiving palliative care alone, lung (HR 3.27, 95% Cl 1.46-7.35, p = 0.004) and peritoneum (HR 2.50, 95% CI 1.20-5.18, P = .014) metastases and the C-reactive protein-to-albumin ratio (≥1.3 vs <1.3; HR 3.33, 95% Cl 1.51-7.35, P = .003) were independent prognostic factors. Furthermore, patients with multiple factors had worse prognosis in both groups. Median survival time of palliative chemotherapy patients with risk factors 0, 1, 2, and 3 were 13.1 (95% CI 8.0-16.9), 9.4 (95% CI 7.9-10.1), 6.6 (95% CI 4.9-7.8), and 2.5 (95% CI 1.7-4.0) months, respectively. Similarly, median survival time was 5.7 (95% CI 1.3 -8.0), 2.1 (95% CI 1.5-3.9), and 1.3 (95% CI 0.6-1.7) months, respectively, for palliative care alone patients with risk factor 0, 1, and 2 to 3.Prognostic markers for pancreatic cancer were neutrophil-to-lymphocyte ratio, liver metastasis, and CA19-9 in patients undergoing palliative chemotherapy and C-reactive protein-to-albumin ratio and lung/peritoneum metastases in patients undergoing palliative care alone. These simple markers should be considered when explaining the prognosis and therapeutic options to patients.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

Purpose

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

Methods

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”).

Results

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

Conclusions

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06613-y.

Care needs level in long-term care insurance system and family caregivers' self-perceived time-dependent burden in patients with home palliative care for cancer: a cross-sectional study

PURPOSE

Although home care improves patients' quality of life (QOL), several studies have suggested that home care lowers the QOL of family caregivers and decreases their mortality. To alleviate the deleterious impact of home care on caregivers, the major burdens on caregivers and the clinical characteristics of the caregivers vulnerable to the major burden needs to be clarified.

METHOD

A survey questionnaire was distributed to 710 family caregivers of patients with cancer in Japan, and 342 valid responses were obtained (valid response rate: 48.2%). The Burden Index of Caregivers was used to identify the major burden on caregivers. To assess the associations of the patients' care needs level and other clinically relevant factors with the major burden, a multivariable-adjusted logistic regression model was used.

RESULTS

The time-dependent burden was identified as a major burden. An adjusted model showed a nonlinear association between the care needs level and the time-dependent burden, in which the caregivers of the patients who required moderate care needs level had the highest time-dependent burden [adjusted odds ratio of none, mild, moderate, and severe care needs levels: 0.50 (95% confidence interval 0.07-2.12), 1.08 (0.43-2.57), 1.87 (1.01-3.52), and 1.00 (reference), respectively]. Additionally, older patients and younger caregivers were significantly associated with a time-dependent burden.

CONCLUSION

The time-dependent burden was highest in caregivers at the moderate care needs level and younger caregivers. An imbalance between the demand and supply of care services may be improved by considering the clinical characteristics of both patients and caregivers.

Revisiting Cancer Cachexia: Pathogenesis, Diagnosis, and Current Treatment Approaches

The objective of this article is to group together various management strategies and to highlight the recent treatment modifications that attempt to target the multimodal etiological factors involved in cancer cachexia. The contemporary role of nursing fraternity in psychosocial and nutritional assessment of cancer patients is briefly discussed. Cachexia is a syndrome of metabolic disturbance, characterized by the inflammation and loss of muscle with or without loss of adipose tissue. In cancer cachexia, a multifaceted condition, patients suffer from loss of body weight that leads to a negative impact on the quality of life and survival of the patients. The main cancers associated with cachexia are that of pancreas, stomach, lung, esophagus, liver, and that of bowel. The changes include increased proteolysis, lipolysis, insulin resistance, high energy expenditure, and reduced intake of food, all leading to impaired response to different treatments. There is no standardized treatment for cancer cachexia that can stabilize or reverse this complex metabolic disorder at present. The mainstay of cancer cachexia therapy remains to be sufficient nutritional supplements with on-going efforts to explore the drugs that target heightened catabolic processes and complex inflammation. There is a need to develop a multimodal treatment approach combining pharmacology, exercise program, and nutritional support to target anorexia and the severe metabolic changes encountered in cancer cachexia.

Phosphorylation of Dynamin-Related Protein 1 (DRP1) Regulates Mitochondrial Dynamics and Skeletal Muscle Wasting in Cancer Cachexia

Background

Cancer-associated cachexia (CAC) is a syndrome characterized by skeletal muscle atrophy, and the underlying mechanisms are still unclear. Recent research studies have shed light on a noteworthy link between mitochondrial dynamics and muscle physiology. In the present study, we investigate the role of dynamin-related protein 1 (DRP1), a pivotal factor of mitochondrial dynamics, in myotube atrophy during cancer-associated cachexia.

Methods

Seventy-six surgical patients, including gastrointestinal tumor and benign disease, were enrolled in the study and divided to three groups: control, non-cachexia, and cancer-associated cachexia. Demographic data were collected. Their rectus abdominis samples were acquired intraoperatively. Muscle fiber size, markers of ubiquitin proteasome system (UPS), mitochondrial ultrastructure, and markers of mitochondrial function and dynamics were assayed. A cachexia model in vitro was established via coculturing a C2C12 myotube with media from C26 colon cancer cells. A specific DRP1 inhibitor, Mdivi-1, and a lentivirus of DRP1 knockdown/overexpression were used to regulate the expression of DRP1. Muscle diameter, mitochondrial morphology, mass, reactive oxygen species (ROS), membrane potential, and markers of UPS, mitochondrial function, and dynamics were determined.

Results

Patients of cachexia suffered from a conspicuous worsened nutrition status and muscle loss compared to patients of other groups. Severe mitochondrial swelling and enlarged area were observed, and partial alterations in mitochondrial function were found in muscle. Analysis of mitochondrial dynamics indicated an upregulation of phosphorylated DRP1 at the ser616 site. In vitro, cancer media resulted in the atrophy of myotube. This was accompanied with a prominent unbalance of mitochondrial dynamics, as well as enhanced mitochondrial ROS and decreased mitochondrial function and membrane potential. However, certain concentrations of Mdivi-1 and DRP1 knockdown rebalanced the mitochondrial dynamics, mitigating this negative phenotype caused by cachexia. Moreover, overexpression of DRP1 aggravated these phenomena.

Conclusion

In clinical patients, cachexia induces abnormal mitochondrial changes and possible fission activation for the atrophied muscle. Our cachexia model in vitro further demonstrates that unbalanced mitochondrial dynamics contributes to this atrophy and mitochondrial impairment, and rebuilding the balance by regulating of DRP1 could ameliorate these alterations.

C-Reactive Protein and Its Relationship with Pain in Patients with Advanced Cancer Cachexia: Secondary Cross-Sectional Analysis of a Multicenter Prospective Cohort Study

Background: Limited information is available on the relationship between C-reactive protein (CRP) levels and pain in advanced cancer.

Objectives: To investigate the relationship between serum levels of CRP and subtypes of pain.

Design: A secondary cross-sectional analysis of a prospective cohort study.

Setting/Subjects: Patients with advanced cancer admitted to 23 palliative care units in Japan.

Measurements: Patients rated the severity of pain on the numerical rating scale (NRS) and physicians evaluated pain on the integrated palliative care outcome scale (IPOS). Physicians assessed neuropathic pain and breakthrough pain based on their presence or absence. Patients were divided into four groups according to CRP levels. Comparisons were performed using the Kruskal–Wallis test or chi-squared test. To evaluate the relationship between CRP and subtypes of pain, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in logistic models were calculated.

Results: We divided 1513 patients into four groups: low CRP (n = 234), moderate CRP (n = 513), high CRP (n = 352), and very high CRP (n = 414). Spearman's correlation coefficient between CRP and pain NRS and that between CRP and pain IPOS were 0.15 (p < 0.001) and 0.16 (p < 0.001), respectively. In the models of pain NRS and pain IPOS, significantly higher adjusted ORs than in the low CRP group were observed in the very high CRP group (1.81 [95% CI 1.14–2.88], p = 0.01; 1.74 [95% CI 1.18–2.57], p = 0.005, respectively). Relationships were not observed between CRP, neuropathic pain, and breakthrough pain.

Conclusions: The results indicated direct relationships between CRP, pain NRS, and pain IPOS.

Cancer-Mediated Muscle Cachexia: Etiology and Clinical Management

Muscle cachexia has a major detrimental impact on cancer patients, being responsible for 30% of all cancer deaths. It is characterized by a debilitating loss in muscle mass and function, which ultimately deteriorates patients' quality of life and dampens therapeutic treatment efficacy. Muscle cachexia stems from widespread alterations in whole-body metabolism as well as immunity and neuroendocrine functions and these global defects often culminate in aberrant signaling within skeletal muscle, causing muscle protein breakdown and attendant muscle atrophy. This review summarizes recent landmark discoveries that significantly enhance our understanding of the molecular etiology of cancer-driven muscle cachexia and further discuss emerging therapeutic approaches seeking to simultaneously target those newly discovered mechanisms to efficiently curb this lethal syndrome.

Laboratory prognostic score for predicting 14-day mortality in terminally ill patients with gynecologic malignancy

BACKGROUND

There are few studies developing a scoring system for short-term survival of patients with gynecologic malignancy.

METHODS

Seventy-three terminally ill patients with gynecologic malignancy who were admitted to our palliative care unit (PCU) from June 2009 to February 2018 were included. We accumulated routine blood data within 3 months before PCU discharge. Receiver-operating characteristic analysis was performed on each blood factor, and area under the curve (AUC) was calculated to determine the predictive value for 14-day survival after the blood test. Multivariable logistic regression analysis was performed to identify significant independent prognostic factors of 14-day mortality. To develop a scoring system for 14-day mortality, laboratory prognostic score for gynecologic malignancy (G-LPS) was calculated using the sum of indices of the independent prognostic factors.

RESULTS

Multivariable analysis showed that 6 of 24 indices, namely, C-reactive protein ≥ 13.3 mg/dL, total bilirubin ≥ 1.1 mg/dL, sodium < 131 mEq/L, blood urea nitrogen ≥ 28 mg/dL, white blood cell count ≥ 17.7 × 103/μL, and eosinophil level < 0.2%, were significant independent factors of 14-day survival. G-LPS was obtained from the sum of the six indices. The AUC was 0.7977 at the optimal cut-off value of G-LPS 3. G-LPS 3 predicted death within 14 days with a sensitivity of 72% and a specificity of 79%.

CONCLUSIONS

Six of the 24 laboratory indices were identified as independent prognostic factors of 14-day mortality in terminally ill patients with gynecologic malignancy. G-LPS showed acceptable ability of predicting 14-day survival.

New cancer cachexia staging system for use in clinical practice

OBJECTIVES

Previous attempts to classify cancer cachexia (CC) have demonstrated limitations regarding stages and diagnostic criteria. This study aims to develop and validate a new staging system for CC in patients with incurable cancer.

METHODS

This is an analysis of a database from a prospective cohort study of 1325 patients with advanced cancer referred for palliative care between 2016 and 2020. The cohort was randomly divided into two groups: Development (882 patients) and validation (443 patients) sets. A hierarchical cluster analysis was performed to distinguish different stages of CC in the development set. Next, the optimal cutoff points and ideal combinations of the most important factors associated with the CC groups (clusters) were ascertained. Finally, the relationship between the CC stages determined using the new system and body composition, quality of life, and overall survival was verified with the validation set.

RESULTS

The new system classified CC into three stages: Precachexia (10.8%), cachexia (57.8%), and refractory cachexia (31.4%), based on a combination of percentage weight loss in the past 6 mo (<15 or ≥15), body mass index (<21.0, 21.0-26.4, >26.4 kg/m²), and mid-upper-arm muscle area (≥38.0/≥35.5 or <38.0/<35.5 cm² in men/women, respectively). The new staging system enabled a clear classification of patients into three CC groups according to the outcomes analyzed. Outcomes of patients with refractory cachexia were significantly worse than those in the other groups.

CONCLUSIONS

This study presents a useful, valid system for CC staging in the clinical setting, and is also capable of predicting outcomes, including quality of life and overall survival.

Revisiting the clinical usefulness of C-reactive protein in the set of cancer cachexia

Cancer cachexia is a highly complex multifactorial disorder that is often misdiagnosed, leading to suboptimal health outcomes. Indeed, cachexia is a concern in cancer, typifying lower response to treatment and risk of death. Thus, efforts have been made to better understand the molecular basis of this syndrome, envisioning to improve its diagnosis and management.

C-reactive protein (CRP) has been reported to be consistently increased in the circulation of patients with body wasting associated to chronic diseases. However, the role of CRP in the pathogenesis of cachexia remains elusive. Several hypotheses have been advanced but most of experimental findings support an indirect effect on the activation of muscle proteolysis, mostly through its interplay with pro-inflammatory cytokines. Herein, we overview the contribution of CRP to body wasting and its putative biomarker value for the diagnosis and follow-up of the therapeutic management of cachexia.

Prognostic model for patients with advanced cancer using a combination of routine blood test values

PURPOSE

The purpose of this study was to develop a simple prognostic model based on objective indicators alone, i.e., routine blood test data, without using any subjective variables such as patient's symptoms and physician's prediction.

METHODS

The subjects of this retrospective study were patients at the palliative care unit of Tohoku University Hospital, Japan. Eligible patients were over 20 years old and had advanced cancer (n = 225). The model for predicting survival was developed based on Cox proportional hazards regression models for univariable and multivariable analyses of 20 items selected from routine blood test data. All the analyses were performed according to the TRIPOD statement ( https://www.tripod-statement.org/ ).

RESULTS

The univariable and multivariable regression analyses identified total bilirubin, creatinine, urea/creatinine ratio, aspartate aminotransferase, albumin, total leukocyte count, differential lymphocyte count, and platelet/lymphocyte ratio as significant risk factors for mortality. Based on the hazard ratios, the area under the curve for the new risk model was 0.87 for accuracy, 0.83 for sensitivity, and 0.74 for specificity. Diagnostic accuracy was higher than provided by the Palliative Prognostic Score and the Palliative Prognostic Index. The Kaplan-Meier analysis demonstrated a survival significance of classifying patients according to their score into low-, medium-, and high-mortality risk groups having median survival times of 67 days, 34 days, and 11 days, respectively (p < 0.001).

CONCLUSIONS

We developed a simple and accurate prognostic model for predicting the survival of patients with advanced cancer based on routine blood test values alone that may be useful for appropriate advanced care planning in a palliative care setting.

Could ketogenic diet "starve" cancer? Emerging evidence

Cancer cells (CCs) predominantly use aerobic glycolysis (Warburg effect) for their metabolism. This important characteristic of CCs represents a potential metabolic pathway to be targeted in the context of tumor treatment. Being this mechanism related to nutrient oxidation, dietary manipulation has been hypothesized as an important strategy during tumor treatment. Ketogenic diet (KD) is a dietary pattern characterized by high fat intake, moderate-to-low protein consumption, and very-low-carbohydrate intake (<50 g), which in cancer setting may target CCs metabolism, potentially influencing both tumor treatment and prognosis. Several mechanisms, far beyond the originally proposed inhibition of glucose/insulin signaling, can underpin the effectiveness of KD in cancer management, ranging from oxidative stress, mitochondrial metabolism, and inflammation. The role of a qualified Nutritionist is essential to reduce and manage the short and long-term complications of this dietary therapy, which must be personalized to the individual patient for the planning of tailored KD protocol in cancer patients. In the present review, we summarize the proposed antitumor mechanisms of KD, the application of KD in cancer patients with obesity and cachexia, and the preclinical and clinical evidence on KD therapy in cancer.

Development and progression of cancer cachexia: Perspectives from bench to bedside

Cancer cachexia (CC) is a devastating syndrome characterized by weight loss, reduced fat mass and muscle mass that affects approximately 80% of cancer patients and is responsible for 22%–30% of cancer-associated deaths. Understanding underlying mechanisms for the development of CC are crucial to advance therapies to treat CC and improve cancer outcomes. CC is a multi-organ syndrome that results in extensive skeletal muscle and adipose tissue wasting; however, CC can impair other organs such as the liver, heart, brain, and bone as well. A considerable amount of CC research focuses on changes that occur within the muscle, but cancer-related impairments in other organ systems are understudied. Furthermore, metabolic changes in organ systems other than muscle may contribute to CC. Therefore, the purpose of this review is to address degenerative mechanisms which occur during CC from a whole-body perspective. Outlining the information known about metabolic changes that occur in response to cancer is necessary to develop and enhance therapies to treat CC. As much of the current evidences in CC are from pre-clinical models we should note the majority of the data reviewed here are from pre-clinical models.

Cancer cachexia: an overview of diagnostic criteria and therapeutic approaches for the accredited practicing dietitian

BACKGROUND

Cancer cachexia (CC) is a multifactorial syndrome characterised by ongoing skeletal muscle loss that leads to progressive functional impairment driven by reduced food intake and abnormal metabolism. Despite the traditional use of non-volitional weight loss as the primary marker of CC, there is no consensus on how to diagnose and manage CC.

METHODS

The aim of this narrative review was to describe and discuss diagnostic criteria and therapeutic approaches for the accredited practicing dietitian with respect to identifying and managing CC.

RESULTS

Available diagnostic criteria for cachexia include the cancer-specific (Fearon and Cachexia Score) and general criteria (Evans and Global Leadership Initiative on Malnutrition). These include phenotypic criteria [weight loss, body mass index, (objective) muscle mass assessments, quality of life] and aetiological criteria (disease burden, inflammation, energy expenditure, anorexia and inadequate food intake) and can be incorporated into the nutrition care process (NCP). This informs the nutrition diagnosis of 'chronic disease- or condition-related malnutrition (undernutrition) as related to increased nutrient needs, anorexia or diminished intake due to CC'. Optimal nutrition care and management of CC is multidisciplinary, corrects for increased energy expenditure (via immunonutrition/eicosapentaenoic acid), suboptimal protein/energy intake and poor nutrition quality of life, and includes a physical exercise intervention. Monitoring of intervention efficacy should focus on maintaining or slowing the loss of muscle mass, with weight change as an alternative gross indicator.

CONCLUSIONS

Dietitians and the NCP can play an essential role with respect to identifying and managing CC, focusing on aspects of nutrition screening, assessment and intervention.

Potential Measurement Properties of a Questionnaire for Eating-Related Distress Among Advanced Cancer Patients With Cachexia: Preliminary Findings of Reliability and Validity Analysis

BACKGROUND

There are no validated tools for measuring eating-related distress among patients with advanced cancer. The aim of the study was to investigate the potential measurement properties of a questionnaire for eating-related distress.

METHODS

This is a secondary analysis. We performed an exploratory factor analysis for factorial validity and calculated Cronbach's α for internal consistency. Patients were classified into the 2 groups categorized using the international cachexia criteria. The total scores of each factor and all items were calculated, and comparisons were performed for known-group validity. We performed statistical correlation analysis for concurrent validity, convergent validity, and discriminant validity using Pearson's product moment correlation coefficient.

RESULTS

A total of 140 patients responded. Three factors were identified. The values of Cronbach's α were 0.90, 0.89, and 0.86, respectively. Patients were classified into 2 groups: Non-cachexia/Pre-cachexia (n = 57) and Cachexia/Refractory cachexia (n = 83). Significant differences were observed in the total scores of each factor and all items: (factor 1) 7.5 vs. 11.0, p < 0.001; (factor 2) 8.0 vs. 13.0, p < 0.001; (factor 3) 5.0 vs. 10.0, p < 0.001; (all items) 20.0 vs. 35.0, p < 0.001, respectively. The total scores of each factor and all items significantly correlated with the Edmonton Symptom Assessment System-revised and the nutrition impact symptoms: 0.62 (p < 0.001) and 0.63 (p < 0.001), respectively. Scaling success rates were 100% in factor 1, 2, and 3.

CONCLUSION

The questionnaire appears to be useful. Eating-related distress in patients with advanced cancer had 3 factors.

A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes

BACKGROUND

Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis.

METHODS

A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others.

RESULTS

The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting.

CONCLUSION

There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness.

C-Reactive Protein Levels and Survival Following Cytoreductive Nephrectomy in 118 Patients with Metastatic Renal Cell Carcinoma Treated with Sunitinib: A Retrospective Study

Background

This study aimed to evaluate the factors associated with a survival benefit for patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib, with and without cytoreductive nephrectomy (CN).

Material/Methods

This retrospective clinical study included 118 patients with mRCC who were treated with CN and sunitinib (CN-sunitinib) (N=70) and with sunitinib-alone (N=48). Categorical clinicopathological variables were compared with hypothesis tests using contingency tables and a chi-squared test. Independent indicators for progression-free survival (PFS) and overall survival (OS) were analyzed with univariate and multivariate Cox regression models. The Kaplan-Meier method and log-rank test were used to evaluate patient survival.

Results

The median PFS and OS for the 118 patients were 8.38 and 15.48 months, respectively. There were no significant differences between the CN-sunitinib group and the sunitinib-alone group for either PFS (7.2 months vs. 11.6 months; P=0.525) or OS (16.7 months vs. 15.2 months; P=0.839). Stratification of patients based on clinicopathological characteristics showed that CN was significantly associated with reduced PFS and OS for patients with lymph node metastasis (PFS, P<0.001; OS, P<0.001) and high International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk scores (PFS, P=0.003; OS, P=0.011). However, CN was associated with a significant survival benefit for patients with low levels of serum C-reactive protein (CRP<10 mg/L) (PFS, P=0.026; OS, P=0.007).

Conclusions

Sunitinib-alone without CN improved the survival of patients with mRCC who had high IMDC risk scores or lymph node metastasis. CN and sunitinib resulted in significantly improved survival in patients with low serum CRP.

Collapse of Fluid Balance and Association with Survival in Patients with Advanced Cancer Admitted to a Palliative Care Unit: Preliminary Findings

Background: Few studies have investigated water balance as a predictor of survival in cancer patients in the last days of life. Objective: To examine the association between extracellular water (ECW), intracellular water (ICW), ratio of ECW to ICW (ECW/ICW), and survival in nonedematous and edematous patients with advanced cancer admitted to a palliative care unit. Design: A prospective observational study. Setting/Subjects: Patients with advanced cancer admitted to a palliative care unit. Measurements: Upon enrollment, bioelectrical impedance analysis was used to assess ECW, ICW, and body composition. We conducted time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses. Results: A total of 190 of 204 patients who participated in this study had ICW and ECW measures available for analysis. The median survival was 10 days (95% confidence interval [CI] 9-12) days. The median ECW, ICW, and ECW/ICW were 18.9 L, 19.1 L, and 1.0 for 72 nonedematous patients, and 21.9 L, 20.1 L, and 1.1 for 118 edematous patients, respectively. In univariate Cox regression analysis, ICW ≤20 L was associated with a shorter survival in the nonedematous patients (hazard ratio [HR] 1.92, 95% CI 1.10-3.34, p = 0.02) and a longer survival in the edematous patients (HR 0.61, 95% CI 0.41-0.90, p = 0.01). In multivariable analysis, ICW (≤20 L vs. >20 L) remained an independent prognostic factor in edematous patients (HR 0.64, 95% CI 0.43-0.95, p = 0.03). Conclusions: Greater ICW was an independent predictor of poorer survival in cancer patients with edema in the last days of life.

Coix seed oil ameliorates cancer cachexia by counteracting muscle loss and fat lipolysis

Background

Cancer cachexia is a cancer-induced multifactorial debilitating syndrome directly accounting for 20% of cancer deaths without effective therapeutic approaches. It is extremely urgent to explore effective anti-cachexia drugs to ameliorate muscle and fat loss in cachexia patients.

Methods

Lewis lung carcinoma bearing C57BL/6 mice were applied as the animal model to examine the therapeutic effect of Coix seed oil (CSO) on cancer cachexia. The food intake and body weight change were monitored every 3 days throughout the experiment. The IL-6 and TNF-α levels in serum were detected by ELISA assay. Several key proteins involved in muscle wasting and fat lipolysis were tested by Western blot to identify the potential mechanism of CSO.

Results

Administration of CSO through gavage significantly prevented body weight loss and ameliorated systemic inflammation without affecting food intake and tumor size. The weight and histological morphology of gastrocnemius muscle and epididymal adipose tissue in CSO-treated mice were also improved. In mechanism, we found that CSO decreased the expression of MuRF1 and the ratio of phospho-p65 (Ser536) to p65 in muscle tissue. Meanwhile, cancer-induced activation of HSL and AMPK was also inhibited by CSO administration.

Conclusion

Coix seed oil exerts an anti-cachexia pharmaceutical effect by counteracting muscle and adipose tissue loss most likely through regulating NF-κB-MuRF1 and AMPK-HSL pathway.

Application Effects of Whole Course High-Quality Nursing on Patients with Liver Cancer during Radiotherapy

BACKGROUND

To explore the application effects of whole course high-quality nursing on patients with liver cancer during radiotherapy.

METHODS

One hundred and five patients with liver cancer who received radiotherapy in Liaocheng People's Hospital, Liaocheng, China from March 2010 to February 2012 were selected and divided into a control group (42 cases with routine nursing) and an experimental group (63 cases with whole course high-quality nursing). The two groups of patients were observed and compared in terms of clinical data and the Activity of Daily Living (ADL) score before and after nursing (1 course of treatment/6 week). The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used to evaluate and compare the patients' anxiety and depression before and after nursing. Adverse reactions during radiotherapy and nursing satisfactory of patients were observed and compared between the two groups.

RESULTS

After nursing, the ADL score and the nursing satisfaction in the experimental group was significantly higher than that in the control group (P<0.05). The SDS and SAS scores in the 2 groups before nursing were significantly higher than those after nursing (P<0.05). The total incidence of adverse reactions in the control group was significantly higher than that in the experimental group (P<0.05).

CONCLUSION

Whole course high-quality nursing can improve the negative emotions, quality of life and nursing satisfaction, and reduce adverse reactions of patients with liver cancer during radiotherapy.

Clinical utility of the modified Glasgow Prognostic Score to classify cachexia in patients with advanced cancer in palliative care

BACKGROUND & AIMS

It is a challenge in clinical practice to identify and classify cancer cachexia. Currently, it has been extensively discussed if the presence of alterations in inflammatory biomarkers implies the presence of cachexia. This study aimed to evaluate the clinical relevance of cachexia classification through modified Glasgow Prognostic Score (mGPS) in advanced cancer patients in palliative care.

METHODS

Observational prospective cohort study conducted at a Palliative Care Unit in Brazil. Cachexia classification was performed according to mGPS (based on albumin and C-reactive protein) in four different stages: no cachexia (NCa), undernourished (Un), pre cachexia (PCa), and refractory cachexia (RCa). Logistic regression models were used to test the association between cachexia stages and clinical, nutritional and functional domains. Kaplan-Meier curve and Cox multivariate model were used to analyze overall survival (OS).

RESULTS

A total of 1166 patients were included in the study. According to the cachexia framework 37.5% were NCa, 32.3% Un, 3.9% PCa and 26.4% RCa. Significant differences were observed among cachexia stages for most of the outcome measures. This classification was able to predict mortality in 90 days [Un (HR, 1.55; 95% CI, 1.25; 1.93); PCa (HR, 2.00; 95% CI, 1.34; 2.98); RCa (HR, 2.45; 95% CI, 1.34; 2.98)].

CONCLUSION

Cachexia stages were associated with significant differences in poor clinical outcomes and were also capable of predicting OS. This framework based on simple and objective criteria can be used as part of the routine to characterize the presence and stages of cachexia in advanced cancer patients.

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.

Predictors and trajectory of performance status in patients with advanced cancer: A secondary data analysis of the international European Palliative Care Cancer Symptom study

BACKGROUND:

Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated.

AIM:

The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer.

DESIGN:

The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC).

SETTING AND PARTICIPANTS:

This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739).

RESULTS:

The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC.

CONCLUSION:

This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated.

Augmentation of Cancer Cachexia Components With Targeted Acupuncture in Patients With Gastrointestinal Cancers: A Randomized Controlled Pilot Study

INTRODUCTION

Patients with gastrointestinal (GI) cancer-associated cachexia are at risk of high morbidity and mortality. This randomized single-blind pilot study compared the complementary use of targeted acupuncture (TA) with nontargeted acupuncture (NTA) for halting cachexia symptoms.

METHODS

GI cancer patients with cachexia undergoing chemotherapy were assigned to receive 8 weekly sessions of either TA (n = 15) or NTA (n = 15) following a specific acupuncture protocol. Bioelectrical impedance analysis and weight were measured weekly. Biological markers, including C-reactive protein, prealbumin, tumor necrosis factor-α, lactate dehydrogenase (LDH), leptin, and ghrelin blood levels were determined at specific intervals.

RESULTS

Prealbumin levels and fat-free mass were significantly higher in the NTA group at the end of the study, but remained stable in TA group. TA group had significantly lower (230 IU/L vs 288 IU/L, P = .04) LDH at the end of the study, but elevated tumor necrosis factor-α levels (13.15 pg/mL vs 9.24 pg/mL, P = .04). The absolute blood leptin and ghrelin levels decreased in the TA but remained stable in the NTA group. Both groups maintained weight, but the TA group trended toward weight gain during the last 2 weeks of the study. No adverse events related to acupuncture were reported.

CONCLUSIONS

TA using predetermined, reproducible points may provide benefits to some patients with GI cancer cachexia by normalizing metabolic dysregulation. Elevated ghrelin levels are indicative of insulin resistance, which can lead to increased muscle loss represented by increased LDH activity in the NTA group. The pilot study provided completion rate and effect size for the primary outcome measures for a larger study. A longer treatment duration may be required to further refine these findings.

The Role of Inflammation in the Pain, Fatigue, and Sleep Disturbance Symptom Cluster in Advanced Cancer

CONTEXT

Symptom researchers have proposed a model of inflammatory cytokine activity and dysregulation in cancer to explain co-occurring symptoms including pain, fatigue, and sleep disturbance.

OBJECTIVES

We tested the hypothesis that psychological stress accentuates inflammation and that stress and inflammation contribute to one's experience of the pain, fatigue, and sleep disturbance symptom cluster (symptom cluster severity, symptom cluster distress) and its impact (symptom cluster interference with daily life, quality of life).

METHODS

We used baseline data from a symptom cluster management trial. Adult participants (N = 158) receiving chemotherapy for advanced cancer reported pain, fatigue, and sleep disturbance on enrollment. Before intervention, participants completed measures of demographics, perceived stress, symptom cluster severity, symptom cluster distress, symptom cluster interference with daily life, and quality of life and provided a blood sample for four inflammatory biomarkers (interleukin-1β, interleukin-6, tumor necrosis factor-α, and C-reactive protein).

RESULTS

Stress was not directly related to any inflammatory biomarker. Stress and tumor necrosis factor-α were positively related to symptom cluster distress, although not symptom cluster severity. Tumor necrosis factor-α was indirectly related to symptom cluster interference with daily life, through its effect on symptom cluster distress. Stress was positively associated with symptom cluster interference with daily life and inversely with quality of life. Stress also had indirect effects on symptom cluster interference with daily life, through its effect on symptom cluster distress.

CONCLUSION

The proposed inflammatory model of symptoms was partially supported. Investigators should test interventions that target stress as a contributing factor in co-occurring pain, fatigue, and sleep disturbance and explore other factors that may influence inflammatory biomarker levels within the context of an advanced cancer diagnosis and treatment.

Physical Exercise: An Evaluation of a New Clinical Biomarker of Survival in Hospice Patients

PURPOSE

Survival analysis is an important issue in palliative care. However, there is a lack of quality clinical biomarkers for assessing survival, especially in bedridden patients. Recent research supports the benefit of physiotherapy in palliative care, as majority of hospice patients are able to perform physical therapy. We propose the hypothesis that the difference in activity during physical exercise can be used as a biomarker of survival in hospice care.

METHODS

We examined 536 consecutive patients who performed physical exercises in our hospice from March 2013 to July 2017. Univariate, multivariate, and Kaplan-Meier analysis were performed to explore the association between the level of physical exercise activity and survival.

RESULTS

Physical exercises were performed by almost 70% of our hospice patients. The patients who initially performed active exercises lived longer, on average, compared to patients who only managed passive exercises (15 days vs 6 days, hazard ratio 0.60, 0.49-0.74). Surprisingly, the difference in survival based on the level of physical activity remained consistent regardless of the patient performance score, emphasizing its usefulness as an independent survival biomarker in a hospice setting. This tool also gave us an option to recognize a significant proportion of bedridden patients performing active exercises (30%), previously unrecognized using standard performance scales, exhibiting longer survival compared to others with the same performance score.

CONCLUSION

Patients' level of activity during physical exercises has the potential to be a valuable new clinical biomarker in palliative care, whether used individually or combined with commonly used performance scales.

Cancer-associated cachexia

Cancer-associated cachexia is a disorder characterized by loss of body weight with specific losses of skeletal muscle and adipose tissue. Cachexia is driven by a variable combination of reduced food intake and metabolic changes, including elevated energy expenditure, excess catabolism and inflammation. Cachexia is highly associated with cancers of the pancreas, oesophagus, stomach, lung, liver and bowel; this group of malignancies is responsible for half of all cancer deaths worldwide. Cachexia involves diverse mediators derived from the cancer cells and cells within the tumour microenvironment, including inflammatory and immune cells. In addition, endocrine, metabolic and central nervous system perturbations combine with these mediators to elicit catabolic changes in skeletal and cardiac muscle and adipose tissue. At the tissue level, mechanisms include activation of inflammation, proteolysis, autophagy and lipolysis. Cachexia associates with a multitude of morbidities encompassing functional, metabolic and immune disorders as well as aggravated toxicity and complications of cancer therapy. Patients experience impaired quality of life, reduced physical, emotional and social well-being and increased use of healthcare resources. To date, no effective medical intervention completely reverses cachexia and there are no approved drug therapies. Adequate nutritional support remains a mainstay of cachexia therapy, whereas drugs that target overactivation of catabolic processes, cell injury and inflammation are currently under investigation.

Clinicopathologic and prognostic significance of C-reactive protein/albumin ratio in patients with solid tumors: an updated systemic review and meta-analysis

C-reactive protein/albumin ratio (CAR) was originally used as a novel inflammation-based prognostic score in predicting outcomes in septic patients. Recently, more and more studies have reported the prognostic value of pretreatment CAR in solid tumors. However, the results remain controversial rather than conclusive. We conducted a meta-analysis based on 24 studies with 10203 patients to explore the relationship between CAR and survival outcomes in patients with solid tumors. The correlation between CAR and clinicopathological parameters was also assessed. Hazard ratio (HR) or odds ratio (OR) with its 95% confidence interval (CI) was applied to be the effect size estimate. The overall results showed that elevated CAR was associated with shorter overall survival (OS) (including 23 studies and 10067 patients) and poorer disease-free survival (DFS) (including 6 studies and 2904 patients). Significant associations between high CAR level and poor OS were also found in the subgroup analyses of study region, cancer type, primary treatment, clinical stage, cut-off selection, sample size, and cut-off value. Moreover, subgroup analyses demonstrated that study region, primary treatment, clinical stage, sample size, and cut-off value did not alter the prognostic value of CAR for DFS. Furthermore, elevated CAR was correlated with certain phenotypes of tumor aggressiveness, such as poor histological grade, serious clinical stage, advanced tumor depth, positive lymph node metastasis, and positive distant metastasis. Together, our meta-analysis suggests that elevated level of serum CAR predicts worse survival and unfavorable clinical characteristics in cancer patients, and CAR may serve as an effective prognostic factor for solid tumors.

Skeletal muscle function during the progression of cancer cachexia in the male ApcMin/+ mouse

While cancer-induced skeletal muscle wasting has been widely investigated, the drivers of cancer-induced muscle functional decrements are only beginning to be understood. Decreased muscle function impacts cancer patient quality of life and health status, and several potential therapeutics have failed in clinical trials due to a lack of functional improvement. Furthermore, systemic inflammation and intrinsic inflammatory signaling's role in the cachectic disruption of muscle function requires further investigation. We examined skeletal muscle functional properties during cancer cachexia and determined their relationship to systemic and intrinsic cachexia indices. Male Apc^Min/+ (MIN) mice were stratified by percent body weight loss into weight stable (WS; <5% loss) or cachectic (CX; >5% loss). Age-matched C57BL/6 littermates served as controls. Tibialis anterior (TA) twitch properties, tetanic force, and fatigability were examined in situ. TA protein and mRNA expression were examined in the nonstimulated leg. CX decreased muscle mass, tetanic force (P_o), and specific tetanic force (_sP_o). Whole body and muscle fatigability were increased in WS and CX. CX had slower contraction rates, +dP/d t and -dP/d t, which were inversely associated with muscle signal transducer and activator of transcription 3 ( STAT3) and p65 activation. STAT3 and p65 activation were also inversely associated with P_o. However, STAT3 was not related to _sP_o or fatigue. Muscle suppressor of cytokine signaling 3 mRNA expression was negatively associated with TA weight, P_o, and _sP_o but not fatigue. Our study demonstrates that multiple functional deficits that occur with cancer cachexia are associated with increased muscle inflammatory signaling. Notably, muscle fatigability is increased in the MIN mouse before cachexia development. NEW & NOTEWORTHY Recent studies have identified decrements in skeletal muscle function during cachexia. We have extended these studies by directly relating decrements in muscle function to established cachexia indices. Our results demonstrate that a slow-fatigable contractile phenotype is developed during the progression of cachexia that coincides with increased muscle inflammatory signaling. Furthermore, regression analysis identified predictors of cancer-induced muscle dysfunction. Last, we report the novel finding that whole body and muscle fatigability were increased before cachexia development.

C-reactive protein, symptoms and activity of daily living in patients with advanced cancer receiving palliative care

BACKGROUND

The association between C-reactive protein (CRP) level, symptoms, and activities of daily living (ADL) in advanced cancer patients is unclear.

METHODS

Secondary data analysis of a multicenter prospective cohort study consisted of 2426 advanced cancer patients referred to palliative care settings was conducted to examine the cross-sectional relationships between CRP level, symptoms, and ADL disabilities. Laboratory data, symptoms, ADL, and manual muscle testing (MMT) results were obtained at baseline. Participants were divided into four groups: low (CRP < 1 mg/dl), moderate (1 = < CRP <5 mg/dl), high (5 = < CRP < 10 mg/dl), and very high CRP (10 mg/dl = < CRP). The proportions of eight symptoms, five ADL disabilities, and three categories of MMT according to the CRP groups were tested by chi-square tests. Multiple-adjusted odd ratios (ORs) were calculated by using ordinal logistic regression after adjustment for age, gender, site of primary cancer, metastatic disease, performance status, chemotherapy, and setting of care.

RESULTS

A total of 1702 patients were analysed. Positive rates of symptoms and ADL disabilities increased with increasing CRP level. In the very high-CRP group, rates of positivity for anorexia, fatigue, and weight loss were 89.8%, 81.0%, and 79.2%, respectively, and over 70% of patients received assistance for bathing, dressing, going to the toilet, and transfer. The grade of MMT also deteriorated with increasing CRP level. Adjusted ORs for the accumulated symptoms significantly increased with increasing CRP level in the moderate-CRP, high-CRP, and very high-CRP groups [1.6 (95% confidence interval 1.2-2.0), P < 0.001; 2.5 (1.9-3.2), P < 0.001; 3.5 (2.7-4.6), P < 0.001, respectively]. Adjusted ORs for the accumulated ADL disabilities significantly increased in the very high-CRP groups [2.1 (1.5-2.9), P < 0.001].

CONCLUSIONS

Associations between CRP level, symptoms, and ADL were observed in advanced cancer patients receiving palliative care.