Cancer cachexia: effects of the disease and its treatment

Assessment of Patient-Specific Human Leukocyte Antigen Genomic Loss at Relapse After Antithymocyte Globulin-Based T-Cell-Replete Haploidentical Hematopoietic Stem Cell Transplant

IMPORTANCE

Patient-specific human leukocyte antigen (HLA) genomic loss (HLA loss) is one of the reputed mechanisms of leukemia immune escape and relapse after haploidentical hematopoietic stem cell transplant (HSCT). However, clinical characteristics and prognosis of this distinct relapse type in the setting of haploidentical HSCT based on antithymocyte globulin (ATG) T-cell-replete conditioning are still unknown, especially for patients with lymphoid leukemia.

OBJECTIVE

To identify the incidence of and patient characteristics associated with HLA loss at hematologic cancer relapse after ATG-based haploidentical HSCT and to assess overall survival after HLA loss at relapse.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective and multicenter case series study used data from medical records to identify patients who experienced relapse of hematologic cancer after receipt of ATG-based haploidentical HSCT. The study included 788 consecutive patients aged 8 to 70 years with lymphoid or myeloid leukemia who received ATG T-cell-replete haploidentical HSCT at the Zhejiang Cooperative Group for Blood and Marrow Transplantation between May 1, 2012, and May 31, 2021.

EXPOSURES

Relapse after ATG-based haploidentical HSCT.

MAIN OUTCOMES AND MEASURES

Incidence, risk factors, and postrelapse overall survival among patients with HLA loss at hematologic cancer relapse after receipt of haploidentical HSCT. Logistic regression analysis was used to identify characteristics associated with the likelihood of HLA loss, and Kaplan-Meier and Cox regression analyses were performed to evaluate postrelapse survival.

RESULTS

A total of 788 patients who received haploidentical HSCT for hematologic cancer were identified, 180 of whom experienced relapse after HSCT. Of those, 106 evaluable patients (median age, 30.9 years [range, 8.3-64.6 years]; 54 female [50.9%] and 52 male [49.1%]) were screened for HLA loss, which was detected in 54 patients (50.9%). Patients with HLA loss experienced relapse later than those without HLA loss (lymphoid group: median, 323 days [range, 98-2056 days] vs 151 days [range, 57-2544 days]; P = .01; myeloid group: median, 321 days [range, 55-1574 days] vs 223 days [range, 68-546 days]; P = .03). Among patients with lymphoid leukemia, those with minimal residual disease positivity before hematologic relapse (odds ratio [OR], 28.47; 95% CI, 1.99-407.98; P = .01), those with chronic graft-vs-host disease (OR, 27.68; 95% CI, 1.40-546.88; P = .03), and those with more than 180 days between HSCT and relapse (OR, 6.91; 95% CI, 1.32-36.22; P = .02) were more likely to lose unshared HLA at relapse, whereas male patients (OR, 0.03; 95% CI, 0.003-0.32; P = .04) were more likely to preserve their HLA genome at relapse. Patients with myeloid leukemia had different factors associated with HLA loss, including underweight status (OR, 0.10; 95% CI, 0.02-0.60; P = .01) and acute graft-vs-host disease (OR, 4.84; 95% CI, 1.14-20.53; P = .03). The receipt of preemptive donor lymphocyte infusion among patients with minimal residual disease recurrence did not postpone hematologic cancer relapse in those with HLA loss (median, 322 days [range, 204-1030 days]) compared with no receipt of donor lymphocyte infusion (median, 340 days [range, 215 days to not available]; P > .99).

CONCLUSIONS AND RELEVANCE

In this study, HLA loss at leukemia relapse occurred frequently after receipt of ATG-based haploidentical HSCT. The identification of risk factors associated with HLA loss would help to prompt screening, avoid potentially harmful infusions of donor T cells, and develop alternative therapeutic strategies.

The negative impact of being underweight and weight loss on survival of children with acute lymphoblastic leukemia

Body mass index and change in body mass index during treatment may influence treatment outcome of pediatric patients with acute lymphoblastic leukemia. However, previous studies in pediatric acute lymphoblastic leukemia reported contradictory results. We prospectively collected data on body composition from a cohort of newly diagnosed Dutch pediatric patients with acute lymphoblastic leukemia (n=762, age 2-17 years). Patients were treated from 1997-2004 and the median follow-up was 9 years (range, 0-10). Body mass index at diagnosis was expressed as age- and gender-matched standard deviation scores and on the basis of these scores the patients were categorized as being underweight, of normal weight or overweight. Multivariate analyses showed that patients who were underweight (8%) had a higher risk of relapse [hazard ratio: 1.88, 95% confidence interval (1.13-3.13)], but similar overall survival and event-free survival as patients who had a normal weight or who were overweight. Patients with loss of body mass index during the first 32 weeks of treatment had a similar risk of relapse and event-free survival, but decreased overall survival [hazard ratio: 2.10, 95% confidence interval (1.14-3.87)] compared to patients without a loss of body mass index. In addition, dual X-ray absorptiometry scans were performed in a nested, single-center cohort. Data from these scans revealed that a loss of body mass consisted mainly of a loss of lean body mass, while there was a gain in the percentage of fat. In conclusion, being underweight at diagnosis is a risk factor for relapse, and a decrease in body mass index early during treatment is associated with decreased survival. In addition, loss of body mass during treatment seems to consist mainly of a loss of lean body mass. This study was approved by the Medical Ethical Committee in 1996 (trial number NTR460/SNWLK-ALL-9).

Assessment and monitoring of nutritional status in patients with advanced cancer: part 1

Using a qualitative approach, this study set out to explore nurses' management of patients with advanced cancer, weight loss and eating-associated problems. Extreme weight loss is commonly seen in patients with incurable solid tumour cancer and, to date, it has proved difficult to manage successfully. Currently, little is known about how nurses (often directly involved in the delivery of palliative care) assess weight loss and nutritional status in everyday practice in order to provide appropriate support. In this study, 14 semi-structured interviews were conducted with nurses from both hospital and community settings. The findings revealed that many nurses did not routinely provide early identification and assessment of nutritional status including weight loss, nor did they continue to monitor the patient's progress or deterioration. Many nurses were reluctant to initiate conversations with cancer patients about weight loss, but instead waited for patients and relatives to raise their concerns. As a result, it is likely that informal assessment may have resulted in the reactive style of nutritional management seen. However, nurses interviewed received limited training, but were keen to learn more about nutritional assessment and management.

Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia

BACKGROUND

Cancer cachexia is a distressing weight loss syndrome commonly seen in advanced cancer patients. It is associated with reduced quality of life and shorter survival time. Eicosapentaenoic acid (EPA) is a long chain polyunsaturated fatty acid found naturally in some fish which has been used to decrease weight loss, promote weight gain and increase survival times in patients affected with cancer cachexia.

OBJECTIVES

To evaluate the effectiveness and safety of EPA in relieving symptoms associated with the cachexia syndrome in patients with advanced cancer.

SEARCH STRATEGY

Studies were sought through an extensive search of a range of electronic databases. Hand searching was conducted on selected journals and reference lists as well as contact made with investigators, manufacturers and experts. The most recent electronic search was conducted in February 2005.

SELECTION CRITERIA

Studies were included in the review if they assessed oral EPA compared with placebo or control in randomised controlled trials of patients with advanced cancer and either a clinical diagnosis of cachexia or self-reported weight loss of 5% or more.

DATA COLLECTION AND ANALYSIS

Both methodological quality evaluation of potential trials and data extraction were conducted by two independent review authors.

MAIN RESULTS

Five trials (involving 587 patients) met the inclusion criteria. Three trials compared EPA at different doses with placebo with two outcomes, nutritional status and adverse events comparable across two of the three included trials. In addition, two trials compared different doses of EPA with an active matched control. It was possible to compare the outcomes of weight, quality of life and adverse events across these two trials. There were insufficient data to define the optimal dose of EPA.

AUTHORS' CONCLUSIONS

There were insufficient data to establish whether oral EPA was better than placebo. Comparisons of EPA combined with a protein energy supplementation versus a protein energy supplementation (without EPA) in the presence of an appetite stimulant (Megestrol Acetate) provided no evidence that EPA improves symptoms associated with the cachexia syndrome often seen in patients with advanced cancer.

The Validity and Clinical Utility of Symptom Monitoring in Advanced Lung Cancer: A Literature Review

Symptom monitoring and quality-of-life (QOL) evaluation in lung cancer patients might improve care. Brief, valid, and responsive tools are available to measure symptoms and their effect on QOL. Instruments available for use in lung cancer patients can be classified into 3 categories: generic, cancer-specific, and lung cancer symptom-specific. These instruments might assist clinicians in assessing and interpreting treatment outcomes from the patient perspective. They also can assist in treatment decision making, symptom palliation, and they might even be prognostic of survival. Over the past 20 years, these brief evaluations have been used in clinical trials to evaluate patient-reported outcomes. Now, with the advent of less toxic, targeted molecular therapies such as gefitinib (Iressa) in non-small-cell lung cancer, these instruments' value in showing symptomatic improvement from tumor control or regression might be further enhanced. To date, however, such assessments are not widely implemented in routine clinical practice. To better understand benefits of such assessments, we review existing evidence surrounding the instruments' use, evaluate their success, and highlight recent developments. We hope to encourage clinicians to incorporate these evaluations in clinical practice.

A systematic review of the evidence on symptom management of cancer-related anorexia and cachexia

PURPOSE/OBJECTIVES

To evaluate and synthesize the evidence regarding cancer-related anorexia and cachexia symptom management and make recommendations for future directions.

DATA SOURCES

Cochrane Library, MEDLINE, CANCERLIT, CINAHL, Dissertation Abstracts, EBM Reviews--Best Evidence, EMBASE, and the Computer Retrieval of Information on Scientific Projects. Current overviews, clinical trials, systematic research reviews, and meta-analyses.

DATA SYNTHESIS

All studies focused on increasing food intake. Nonpharmacologic clinical trials increased caloric and protein intake but resulted in no improvement in nutritional status, weight, tumor response, survival, or quality of life. Weight, appetite, and well-being were improved with megestrol acetate, but nutritional status was not improved. Some exercise studies demonstrated improvements in nutrition-related outcomes, but these were not primary research outcomes.

CONCLUSIONS

Symptom management of anorexia and cachexia should focus on decreasing energy expenditure or minimizing factors creating a negative energy balance, as well as improving food intake. Increased measurement sensitivity also is needed.

IMPLICATIONS FOR NURSING

Improved nutritional assessment skills are needed with an emphasis on anticipated problems and current status.

Nutrition in cancer: an overview

OBJECTIVES

To provide a review of weight loss, cachexia (both primary and secondary), and weight gain in cancer patients.

DATA SOURCES

Research reports, review articles, textbooks, and personal communications.

CONCLUSIONS

Alterations in nutritional status have the potential to affect mortality, morbidity, and quality of life outcomes. The detection and treatment of malnutrition is important to success of therapy.

IMPLICATIONS FOR NURSING PRACTICE

Nursing interventions to help maintain optimal nutritional status in patients with cancer include careful assessment, identification of patients at risk, and management of problems before the initiation of therapy.

Fatigue in cancer patients: a review of the literature

This paper reviews the research literature concerning fatigue in cancer patients, evaluating the quality of the evidence, thus helping to focus the direction and methodological rigour required in future investigations. Since fatigue in this population has been attributed to several mechanisms these will be discussed. The prevalence of fatigue in cancer patients will then be documented. An overview of what is currently understood about fatigue in cancer will follow. Based on the literature, conceptual and methodological difficulties will be described. Finally, gaps in understanding will be identified. Suggestions for future research will be formulated and potential interventions to decrease feelings of fatigue explored.