Defining the role of dietary intake in determining weight change in patients with cancer cachexia

Early impairment of food intake in patients newly diagnosed with cancer

Background

Patients with gastrointestinal or lung cancer often suffer from a loss of appetite (anorexia), resulting in reduced food intake (hypophagia) and body weight loss. This study evaluated the prevalence of anorexia, hypophagia, pre-cachexia and cachexia in patients with cancer at time of diagnosis.

Patients and methods

Patients with newly diagnosed gastrointestinal or lung cancers were included. Body mass index (BMI) and weight loss over the prior 6 months were recorded. Patients were assessed for (pre-)cachexia and for anorexia using the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) and a specific anorexia questionnaire (AQ). Energy and protein intake were calculated through food diaries. Patients were considered hypophagic if intake was ≤70% of guideline-recommended levels.

Results

Overall, 102 patients [53 male; median age: 67 (range, 21-88) years] were enrolled. Mean BMI (± standard deviation) was 23.1 ± 3.4 kg/m²; average percentage of weight loss was 10.1 ± 7.8%. At diagnosis, 68% (69/102) of patients had cachexia, and 11% (11/102) pre-cachexia. Prevalence of anorexia was 57% (58/102) and 75% (76/102) according to FAACT and AQ, respectively. Forty-eight percent (49/102) of patients had hypophagia. Patients with anorexia had lower daily energy (p = 0.002) and protein intake (p = 0.0257), and greater percentage of weight loss (p = 0.0005). In patients with hypophagia, negative correlations were observed between percentage of weight loss and total daily calorie (r = -0.40; p = 0.01) and protein intake (r = -0.340; p = 0.018).

Conclusion

Anorexia, inadequate nutritional intake and cachexia are highly prevalent in patients with gastrointestinal or lung cancer at diagnosis. Negative protein and energy balance may play an important role in the pathogenesis of cachexia. Early multimodal strategies to improve food intake are urgently needed.

Home Artificial Nutrition and Energy Balance in Cancer Patients: Nutritional and Clinical Outcomes

Malnutrition is one of the main factors determining cachexia syndrome, which negatively impacts the quality of life and survival. In cancer patients, artificial nutrition is considered as an appropriate therapy when the impossibility of an adequate oral intake worsened nutritional and clinical conditions. This study aims to verify, in a home palliative care setting for cancer patients, if home artificial nutrition (HAN) supplies a patient’s energy requirement, improving nutritional and performance status. A nutritional service team performed counseling at a patient’s home and assessed nutritional status (body mass index, weight loss in the past 6 months), resting energy expenditure (REE), and oral food intake; Karnofsky Performance Status (KPS); cachexia degree; and survival. From 1990 to 2021, 1063 patients started HAN. Among these patients, 101 suspended artificial nutrition for oral refeeding. Among the 962 patients continuing HAN until death, 226 patients (23.5%) survived 6 weeks or less. HAN allowed to achieve a positive energy balance in 736 patients who survived more than 6 weeks, improving body weight and KPS when evaluated after 1 month of HAN. Advanced cancer and cachexia degree at the entry of the study negatively affected the positive impact of HAN.

“I want to get myself as fit as I can and not die just yet” – Perceptions of exercise in people with advanced cancer and cachexia: a qualitative study

Cachexia is a prevalent muscle wasting syndrome among people with advanced cancer that profoundly impacts patient quality of life (QoL) and physical function. Exercise can improve QoL, physical function, and overall health in people with cancer and may be an important addition to treatment approaches for cancer cachexia. Greater understanding of patients’ perception of exercise can help elucidate the feasibility of implementing exercise interventions for cancer cachexia and facilitate the design of patient-centered interventions. We aimed to describe the perception of exercise in patients with advanced cancer and cachexia, and capture exercise motivators, barriers, and preferences, to inform the feasibility of exercise interventions. Individual interviews (n = 20) with patients with locally advanced or metastatic cancer with cachexia were conducted and analyzed using reflexive thematic analysis. Main themes from interviews were: 1) Life is disrupted by cancer and cachexia; 2) Exercise offers hope; 3) Exercise barriers are multifaceted; and 4) Exercise access and support are important. Participants reported that their cancer and cachexia had intensely altered their lives, including ability to exercise. Exercise was perceived as important and participants described a hope for exercise to improve their health and wellbeing. Yet, several complex exercise barriers, such as burdensome cancer symptoms and the overwhelming impact of the COVID-19 pandemic, hindered exercise participation and prevented participants from fully realizing the perceived benefits of exercise. Factors believed to improve exercise engagement and overcome exercise barriers included increased exercise support (e.g., professional supervision) and accessibility (e.g., convenient locations). Patient-reported exercise barriers and preferences can inform the design of exercise interventions, particularly within future research studies aiming to establish exercise feasibility and efficacy in people with advanced cancer and cachexia.

Appetite in Palliative Cancer Patients and Its Association with Albumin, CRP and Quality of Life in Men and Women—Cross-Sectional Data from the Palliative D-Study

Albumin is an important biochemical marker in palliative cancer care, used for assessment of nutritional status, disease severity and prognosis. Our primary aim was to investigate sex differences in the association between appetite and albumin levels in palliative cancer patients. We also aimed to study associations between appetite and C-reactive protein (CRP), Quality of Life (QoL), pain and fatigue. In the Palliative D-cohort, consisting of 266 men and 264 women, we found a correlation between appetite and albumin; low appetite, measured with the Edmonton Symptom Assessment System, correlated significantly with low albumin in men: (r = −0.33, p < 0.001), but not in women (r = −0.03, p = 0.65). In a regression analysis adjusted for confounding factors, results were similar. Lower appetite was correlated with higher CRP in men (r = 0.27, p < 0.001), but not in women (r = 0.12, p = 0.05). Appetite was correlated with QoL, fatigue and pain in both men and women; those with a low appetite had a low QoL and high fatigue- and pain-scores (p < 0.001). In conclusion, our results indicated possible sex differences in the associations between appetite and albumin, and between appetite and CRP, in palliative care patients. Understanding these associations could provide additional value for clinical practice.

Effects of Perioperative Oral Nutrition Supplementation in Malaysian Patients Undergoing Elective Surgery for Breast and Colorectal Cancers-A Randomised Controlled Trial

This study aimed to investigate the effectiveness of preoperative and an extended 90-days postoperative use of ONS among patients undergoing elective surgery for breast and colorectal cancers. Ninety-one patients were randomised into (i) Group SS received ONS up to 14 days preoperatively and postoperatively up to discharge, (ii) Group SS-E received ONS up to 14 days preoperatively, postoperatively up to discharge and for an extended 90-days after discharge and (iii) Group DS received ONS postoperatively up to discharge. Preoperatively, SS had significantly higher body weight (66.1 ± 15.3 kg vs. 62.5 ± 12.0 kg, p = 0.010) and BMI (26.8 ± 6.8 kg/m2 vs. 26.1 ± 6.7 kg/m2, p = 0.022) than DS when adjusted for baseline values. Postoperatively, SS-E had significantly higher handgrip strength (26 ± 9 kgF vs. 24 ± 6 kgF, p = 0.044) than DS at 90-days post-discharge after adjusted for preoperative values. At 90-days post-discharge, the proportions of patients in SS with albumin < 35 g/d, CAR ≥ 0.1, mPINI ≥ 0.4, mGPS score 1 or 2 were significantly reduced while in SS-E, the reduction in proportions of patients with high hsCRP and mPINI ≥ 0.4 was significant compared to upon discharge. Preoperative ONS had modest benefits in attenuating weight loss whilst postoperative supplementation up to 90-days post-discharge improved handgrip strength and inflammatory prognostic markers.

Effect of chocolate on older patients with cancer in palliative care: a randomised controlled study

Background

Older advanced stage cancer patients, with changes in nutritional status, represent an important demand for palliative care. The aim was to determine the effects of 4 weeks of chocolate consumption on the nutritional status of older cancer patients in palliative care.

Methods

Older cancer patients in palliative care with ambulatory (n = 46) monitoring were randomized to control (CG, n = 15), intervention with 55% cocoa chocolate (IG1, n = 16) and intervention with white chocolate (IG2, n = 15) groups and evaluated before and after 4 weeks for nutritional status (primary outcome), evaluated by the Mini Nutritional Assessment tool (MNA). Food consumption, anthropometry, body composition, laboratory parameters and quality of life (QL) with the European Organization for the Research and Treatment of Cancer instrument were also evaluated.

Results

IG1 progressed with increased screening (estimated difference [95% CI]: − 1.3 [− 2.2;-0.4], p < 0.01), and nutritional (estimated difference [95% CI]: − 1.3 [− 2.5;-0.1], p = 0.04) scores on the MNA, with no change in anthropometry and body composition. Regarding antioxidant capacity, reduced glutathione levels increased (estimated difference [95% CI]: − 0.8 [− 1.6;-0.02], p = 0.04) and malondealdehyde levels decreased in IG2 (estimated difference [95% CI]:+ 4.9 [+ 0.7;+ 9.1], p = 0.02). Regarding QL, functionality improved in IG1, with higher score in the functional domain (estimated difference [95% CI]:-7.0 [− 13.3;-0.7], p = 0.03).

Conclusions

The consumption of chocolate with a greater cocoa content may contribute to the improvement of the nutritional status and functionality among older cancer patients in palliative care. The consumption of white chocolate was associated with improved oxidative stress.

Trial registration

A randomized clinical trial (ClinicalTrials.gov NCT04367493).

Diet Changes and Underlying Motives in Cancer Patients

With rising cancer incidence rates and numbers of long-term cancer survivors, diet increasingly comes into view of patients as well as healthcare providers. The aim was to analyze cancer patients' concepts of nutrition, changes in diet and reasons for these changes. This study is a cross-sectional single-center study. Data was collected 12/2017 - 01/2019 using a questionnaire. The study was set at an outpatient department at a German university hospital. 102 patients (male n = 47, female n = 54; age 34 to 86 years [mean = 62.3]) with cancer were included in the study. Statistical calculation was performed with Mann-Whitney-U-Test and Wilcoxon-signed-rank. p < 0.05 was considered significant. Patients were more concerned with diet after their diagnosis than before (p < 0.01). Seventy-one (70%) patients reported that they changed their diet or planned to do so. Some changes included an increased intake of vegetables or fruits. Patients who changed their diet more often were convinced that there was a positive influence of diet on the course of cancer (p < 0.05). Diet is an important topic for many cancer patients. Some patients seem to have a lack of information regarding the effect of diet on health. Physicians and dietitians should provide more education on healthy and safe diets for cancer patients.

Diagnostic criteria for cancer cachexia: reduced food intake and inflammation predict weight loss and survival in an international, multi-cohort analysis

BACKGROUND

Cancer-associated weight loss (WL) associates with increased mortality. International consensus suggests that WL is driven by a variable combination of reduced food intake and/or altered metabolism, the latter often represented by the inflammatory biomarker C-reactive protein (CRP). We aggregated data from Canadian and European research studies to evaluate the associations of reduced food intake and CRP with cancer-associated WL (primary endpoint) and overall survival (OS, secondary endpoint).

METHODS

The data set included a total of 12,253 patients at risk for cancer-associated WL. Patient-reported WL history (% in 6 months) and food intake (normal, moderately, or severely reduced) were measured in all patients; CRP (mg/L) and OS were measured in N = 4960 and N = 9952 patients, respectively. All measures were from a baseline assessment. Clinical variables potentially associated with WL and overall survival (OS) including age, sex, cancer diagnosis, disease stage, and performance status were evaluated using multinomial logistic regression MLR and Cox proportional hazards models, respectively.

RESULTS

Patients had a mean weight change of -7.3% (±7.1), which was categorized as: ±2.4% (stable weight; 30.4%), 2.5-5.9% (19.7%), 6.0-10.0% (23.2%), 11.0-14.9% (12.0%), ≥15.0% (14.6%). Normal food intake, moderately, and severely reduced food intake occurred in 37.9%, 42.8%, and 19.4%, respectively. In MLR, severe WL (≥15%) (vs. stable weight) was more likely (P < 0.0001) if food intake was moderately [OR 6.28, 95% confidence interval (CI 5.28-7.47)] or severely reduced [OR 18.98 (95% CI 15.30-23.56)]. In subset analysis, adjusted for food intake, CRP was independently associated (P < 0.0001) with ≥15% WL [CRP 10-100 mg/L: OR 2.00, (95% CI 1.58-2.53)] and [CRP > 100 mg/L: OR 2.30 (95% CI 1.62-3.26)]. Diagnosis, stage, and performance status, but not age or sex, were significantly associated with WL. Median OS was 9.9 months (95% CI 9.5-10.3), with median follow-up of 39.7 months (95% CI 38.8-40.6). Moderately and severely reduced food intake and CRP independently predicted OS (P < 0.0001).

CONCLUSIONS

Modelling WL as the dependent variable is an approach that can help to identify clinical features and biomarkers associated with WL. Here, we identify criterion values for food intake impairment and CRP that may improve the diagnosis and classification of cancer-associated cachexia.

Quality of Life and Symptom Burden Improve in Patients Attending a Multidisciplinary Clinical Service for Cancer Cachexia: A Retrospective Observational Review

BACKGROUND

Cancer cachexia negatively affects quality of life (QoL) and increases symptom burden. A multimodal treatment approach may optimize cachexia outcomes, including QoL. We evaluated QoL and symptoms over time among patients attending a multidisciplinary clinical service for cancer cachexia.

METHODS

Adults with cancer who attended the clinical service three times between 2017 and 2020 were included. Quality of life and symptoms were assessed using the European Organization for Research and Treatment of Cancer Quality of life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL) and the Functional Assessment Anorexia/Cachexia Therapy (FAACT) questionnaires. Physical function was assessed using the 30s sit-to-stand test and handgrip strength.

RESULTS

Overall, 162 patients (age = 67.2 ± 12.0 years) were included. Mean six-month weight loss at baseline was 10.4% ± 9.4%. Mean body weight was stable between clinic visits (P = 0.904) and no change in sit-to-stand repetitions (P = 0.133) or handgrip strength (P = 0.734) occurred over time. Improvements in EORTC QLQ-C15-PAL overall QoL (Δ10.7 ± 2.5, P < 0.001), physical function (Δ8.0 ± 2.4, P = 0.003) and emotional function (Δ11.4 ± 2.9, P < 0.001) occurred by the second visit. EORTC QLQ-C15-PAL fatigue (Δ13.8 ± 2.9, P < 0.001), pain (Δ10.3 ± 3.3, P = 0.007), nausea/vomiting (Δ16.1 ± 3.0, P < 0.001) and appetite symptoms (Δ25.9 ± 3.8, P < 0.001) also improved by the second visit. FAACT total score (Δ14.6 ± 2.7, P < 0.001), anorexia-cachexia symptoms (Δ6.6 ± 1.1, P< 0.001), and physical (Δ3.7 ± 0.70, P < 0.001), emotional (Δ1.9 ± 0.60, P = 0.005) and functional wellbeing (Δ2.7 ± 0.71, P = 0.001) improved by the second visit. All improvements in EORTC QLQ-C15-PAL and FAACT outcomes were maintained at the third visit.

CONCLUSION

Significant improvements in QoL and symptoms were associated with attending a cancer cachexia clinical service. Our findings support using multidisciplinary, multimodal cancer cachexia treatment approaches to improve patient wellbeing.

Clinical nutrition as part of the treatment pathway of pancreatic cancer patients: an expert consensus

Purpose

Malnutrition is a common problem among pancreatic cancer (PC) patients that negatively impacts on their quality of life (QoL) and clinical outcomes. The main objective of this consensus is to address the role of Medical Nutrition Therapy (MNT) into the comprehensive therapeutic management of PC patients.

Methods

A Spanish multidisciplinary group of specialists from the areas of Medical Oncology; Radiation Oncology; Endocrinology and Nutrition; and General Surgery agreed to assess the role of MNT as part of the best therapeutic management of PC patients.

Results

The panel established different recommendations focused on nutritional screening and nutritional screening tools, MNT strategies according to PC status, and MNT in palliative treatment.

Conclusions

There is an unmet need to integrate nutritional therapy as a crucial part of the multimodal care process in PC patients. Health authorities, health care professionals, cancer patients, and their families should be aware of the relevance of nutritional status and MNT on clinical outcomes and QoL of PC patients.

A multimodal approach to cancer-related cachexia: from theory to practice

Introduction: Cachexia represents a relevant issue in oncological care, which is still lacking effective therapies. Although the incidence of cancer cachexia varies across cancer types, it is responsible for approximately a quarter of cancer-related deaths. The pathophysiology of this syndrome is multifactorial, including weight loss, muscle atrophy and impairment of the pro-/anti-inflammatory balance.Areas covered: Diagnostic criteria and optimal endpoints for cachexia-dedicated trials are still debated, slowing the identification of interventions counteracting cachexia sequaele. The multifaceted features of this syndrome support the rationale for personalized therapy. A multimodal approach is likely to offer the best option to address key cachexia-related issues. Pharmacologic agents, physical exercise, nutritional and psycho-social interventions may have a synergistic effect, and improve quality of life.Expert opinion: A personalized multimodal intervention could be the best strategy to effectively manage cancer cachexia. To offer such a comprehensive approach, a specialized staff, including health professionals with different expertise, is necessary. Each specialist plays a specific role inside the multimodal intervention, with the aim of delivering the best cancer care and access to the most effective therapeutic options for each patient.

Nutrition Screening, Reported Dietary Intake, Hospital Foods, and Malnutrition in Critical Care Patients in Malawi

In low-income countries there are few data on hospital malnutrition. Reduced food intake combined with nutrient-poor foods served in hospitals contribute to nutritional risk. This study investigated whether reported dietary intake and disease state of hospitalized adults in critical care units was related to malnutrition determined by mid-upper arm circumference (MUAC). Adult in-patients (n = 126) in tuberculosis, burn, oncology, and intensive care units in two public tertiary hospitals in Malawi were screened for nutritional status using MUAC and a question on current dietary intake. The hospital menu was reviewed; portion sizes were weighed. The prevalence of moderate and severe malnutrition was 62%. Patients with organ-related diseases and infectious diseases had the highest rates of reduced reported dietary intake, 71.4% and 57.9%, respectively; however, there was no association between reported dietary intake and MUAC. In those unable to eat, however, the rate of severe malnutrition was 50%. The menu consisted of porridge and thickened corn-based starch with fried cabbage; protein foods were provided twice weekly. There was a nutrient gap of 250 calories and 13 gm protein daily. The findings support the need for increasing dietetic/nutrition services to prevent and treat malnutrition in hospitals using simple screening tools.

Resting energy expenditure in cancer patients: Agreement between predictive equations and indirect calorimetry

BACKGROUND/OBJECTIVES

Disorders of energy metabolism is a common phenomenon in cancer patients. Changes in resting energy expenditure (REE) combined with inadequate nutrition support appear to be causes of nutritional depletion in cancer patients. In clinical practice, REE is typically calculated using predictive equations. The aim of this study was to determine the agreement between REE estimated by predictive equations and REE measured by IC in Portuguese cancer patients. Differences in measured REE between patients with different types of digestive cancers were also assessed.

SUBJECTS/METHODS

REE was measured by indirect calorimetry (IC) in 61 patients with cancer diagnosis (gastric cancer, cholangiocarcinoma, pancreatic cancer, liver cancer and colorectal cancer). Measured REE values were compared with those estimated by equations of Harris-Benedict, Schofield, Ireton-Jones, Mifflin-St.Jeor and Barcellos I and II.

RESULTS

Mean Respiratory Quotient (RQ) was 0.77 ± 0.09, which indicates high lipids utilization as substrate. No statistically significant differences between REE or RQ from patients with different cancer types were observed. All equations underestimate REE: Harris-Benedict, mean difference -648 kcal (limits of agreement +627 to -1923 kcal); MifflinSt.Jeor, mean difference -694 kcal (limits of agreement +544 to -193 kcal); Schofield, mean difference -531 kcal (limits of agreement +662 to -1723 kcal); and Ireton-Jones, mean difference -556 kcal (limits of agreement +774 to -1887 kcal). Barcellos I and II showed lower mean difference when compared to measured REE, +59 and + 52 kcal, respectively, although presenting wide limits of agreement, +1542 to -1424 kcal and +1429 to -1326, respectively.

CONCLUSIONS

Although Barcellos Equations underestimate less and enable more accurate average REE prediction in cancer patients, still present wide limits of agreement and therefore clinically important differences in REE estimation may be found at individual level. Our results support the appropriateness of measuring REE by IC to better adequate the nutrition support to cancer patients. Further research is needed to improve the current knowledge base of energy expenditure in cancer patients, and to improve the accuracy of existing predictive equations.

Factors associated with patient weight loss and prescribed diet during hospitalization

Introduction

Objective: the aim of this study was to assess weight loss, diet prescribed, and nutritional status in hospitalized patients, as well as their associated factors. Methods: weight loss during hospitalization, nutritional status, disease type, and prescribed diet were investigated in a retrospective study in 621 hospitalized patients. The chi-squared, Fisher's, Mann-Whitney, and Kruskal-Wallis tests were used for statistical analysis. To identify factors associated with weight loss a logistic regression analysis was performed. The significance level adopted for statistical tests was 5 %. Results: patients who experienced weight loss during hospitalization were associated with longer hospital stays (p < 0.0001; OR = 1.052; 95 % CI = 1.030 to 1.073), malnourishment according to the subjective global assessment (p = 0.0358; OR = 1.520; 95 % CI = 1,028 to 2,248), digestive disorders (p = 0.0081; OR = 3.177; 95 % CI = 1.351 to 7.469), and digestive neoplasms (p = 0.0407; OR = 2.410; 95 % CI = 1.038 to 5.597). Conclusion: weight loss during hospitalization was associated with neoplasms, digestive diseases, malnutrition, and length of stay.

End-of-Life Care Provided for Cancer Patients: A Metasynthesis Study

In the health care setting, and especially in cancer patients nearing the end of life, administrators, medical staff, patients, and families face challenges of a social, legal, religious, and cultural nature in the process of care. The present study aimed to perform a metasynthesis of qualitative studies conducted on providing end-of-life care for cancer patients. The present metasynthesis was conducted using Sandelowski and Barroso's method. A literature search was performed in PubMed, Scopus, Web of Science, and Embase databases, from the inception to date, and a total of 21 articles were identified as eligible for inclusion in the study. Critical Appraisal Skills Programme (CASP) criteria were used for assessing the articles, and data were analyzed by the subject review. Six themes were extracted for end-of-life care including psychological support, palliative support, educational-counseling support, spiritual support, preferential support, and supportive interactions, each comprising a number of categories. The most frequently mentioned categories were high-value care (67%) and adaptive acceptance (57%). The findings of this metasynthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The present study showed that providing high-value care and facilitating adaptive acceptance are important constituents of a holistic strategy for providing end-of-life care to cancer patients.

Management of Cancer Cachexia: ASCO Guideline

PURPOSE

To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer.

METHODS

A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment.

RECOMMENDATIONS

Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.

Management of Cancer Cachexia: ASCO Guideline

PURPOSE

To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer.

METHODS

A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment.

RECOMMENDATIONS

Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.

Older Adult Cancer Patients Under Palliative Care With a Prognosis of 30 Days or More: Clinical and Nutritional Changes

Objective: The aim of this study was to characterize nutritional status, body composition, oxidative stress, and inflammatory activity and to determine the possible associations between nutritional status and clinical variables in advanced cancer patients.Method: This was a cross-sectional study of 46 elderly cancer patients under palliative care with a prognosis of 30 days or more. Nutritional status, food intake, anthropometry, body composition (deuterium oxide method), metabolic profile, inflammation damage (C-reactive protein), oxidative damage (8-hydroxy-2'-deoxyguanosine), and symptom intensity were evaluated.Results: Among elderly cancer patients, 36.9% were malnourished or at risk of malnutrition. Systemic inflammation was detected, with a correlation between worse nutritional status and higher C-reactive protein levels (p < 0.01, r= -0.57), while lower lean mass (p < 0.01, r = 0.62) and higher fat mass percentages (p < 0.01, r = 0.62) correlated with higher levels of 8-hydroxy-2'-deoxyguanosine. Furthermore, daily energy (n = 25; 57.4%) and protein intake (n = 24; 52.2%) were lower than recommended in more than half the patients. The most prevalent symptoms were anxiety, impairment of well-being, drowsiness, tiredness, and lack of appetite.Conclusions: Despite preserved functionality, patients already had clinical and laboratory changes that, together with inadequate food intake, risk of malnutrition, systemic inflammation, and the presence of uncontrolled symptoms, alerted to the importance of an early and comprehensive palliative approach.

Defining barriers to implementation of nutritional advice in patients with cachexia

BACKGROUND

Cancer cachexia is a multidimensional wasting syndrome and a reduced dietary intake is both common and strongly correlated with degree of weight loss. Many patients with cachexia do not achieve recommended dietary intake even after nutritional counselling. Prior reports suggest this is likely due to barrier symptoms, but other potential contributory factors have not been studied in detail.

METHODS

Dietitian-assigned barriers to successful nutritional intervention were recorded at each visit in all patients attending a multidisciplinary clinic for management of cancer cachexia. The barriers were grouped into 15 categories and classified as either symptom-related or not symptom-related. In addition, symptom scores, dietary intake, and weight change were recorded.

RESULTS

Data on 94 new patients showed that 89% of patients had at least one major barrier. Four of the five most common barriers and 65% of all barriers identified were not symptom-related. Over sequential visits the specific barrier(s) in any one patient changed approximately 50% of the time. However, the presence of barriers did not render patients refractory to nutritional intervention and with intervention from the CNR-JGH team, mean dietary intake increased significantly.

CONCLUSIONS

In advanced cancer patients with cachexia, non-symptom-related barriers to nutritional intervention are more common than symptom-related. Barriers are dynamic, and repeated careful evaluation over time is required to achieve optimal impact with nutritional intervention in cancer cachexia. Members of the multidisciplinary team need appropriate expertise to address the barriers identified and achieve optimal results with nutritional intervention.

Pancreatic Cancer Cachexia: The Role of Nutritional Interventions

Pancreatic cancer is a cancer with one of the highest mortality rates and many pancreatic cancer patients present with cachexia at diagnosis. The definition of cancer cachexia is not consistently applied in the clinic or across studies. In general, it is “defined as a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass with or without loss of fat mass that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.” Many regard cancer cachexia as being resistant to dietary interventions. Cachexia is associated with a negative impact on survival and quality of life. In this article, we outline some of the mechanisms of pancreatic cancer cachexia and discuss nutritional interventions to support the management of pancreatic cancer cachexia. Cachexia is driven by a combination of reduced appetite leading to reduced calorie intake, increased metabolism, and systemic inflammation driven by a combination of host cytokines and tumour derived factors. The ketogenic diet showed promising results, but these are yet to be confirmed in human clinical trials over the long-term. L-carnitine supplementation showed improved quality of life and an increase in lean body mass. As a first step towards preventing and managing pancreatic cancer cachexia, nutritional support should be provided through counselling and the provision of oral nutritional supplements to prevent and minimise loss of lean body mass.

Combining optimal nutrition and exercise in a multimodal approach for patients with active cancer and risk for losing weight: Rationale and practical approach

Weight loss and functional decline is a common and detrimental consequence of cancer. The interventions that are offered to patients with weight loss and functional decline often seem haphazard and varying from center to center. The lack of stringent management is probably based both on lack of knowledge of existing treatment guidelines and the current weak level of evidence of clinical effects of different nutritional and exercise interventions. Some studies evaluated multimodal interventions with various treatment combinations, including nutrition and exercise, that report clinically significant effects on cachexia outcomes. As of today, however, there is a paucity of large randomized controlled trials that incorporate both a fully structured exercise program and a well-described nutritional intervention. Studies investigating combinations of several interventions in patients with active cancer and risk for losing weight are too few and too heterogeneous to enable firm conclusions about effect, optimal dose, or timing of interventions. However, data presented in this review suggest an overall benefit, especially if interventions are started before weight loss and loss of function become too severe. Thus, the aim of this review was to examine the evidence for combined treatments targeting weight loss in cancer patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nutrition support and clinical outcome in advanced cancer patients

Newly diagnosed cancer patients are frequently found suffering from a metastatic disease, which poses additional challenges to the delivery of effective therapies. Chemotherapy and radiotherapy are associated with side effects which reduce tolerance to treatment and likelihood of tumour response. Identifying preventable factors of reduced response to therapy would translate into better care of cancer patients. Among other factors, malnutrition, as diagnosed by non-volitional weight loss, and cachexia, as revealed by sarcopenia, are universally recognised negative prognostic factors. Less certainty exists on the role of nutrition therapy in improving cancer patients' body composition and clinical outcome. The reasons for the lack of convincing evidence are manifold, mostly related to the poor design of nutritional trials. Metastatic cancer patients should receive a quantitatively and qualitatively adequate diet, and in case of reduced tolerance of food, artificial nutrition is indicated. Most importantly, nutritional care should target the underlying mechanisms of reduced food intake/impaired anabolic response, and aim at minimising the impact of catabolic crisis, to maximise the recovery phase. The combined and early use of supplemental energies and proteins, as well as modulators of inflammatory response has been shown to improve nutritional status and may also benefit clinical outcome. When part of early palliative care, nutrition therapy improves cancer patients' quality of life and may prolong survival at a fraction of the costs of developing new drugs.

A randomized trial of adjunct testosterone for cancer-related muscle loss in men and women

BACKGROUND

Cancer cachexia negatively impacts cancer-related treatment options, quality of life, morbidity, and mortality, yet no established therapies exist. We investigated the anabolic properties of testosterone to limit the loss of body mass in late stage cancer patients undergoing standard of care cancer treatment.

METHODS

A randomized, double-blind, placebo-controlled phase II clinical trial was undertaken to assess the potential therapeutic role of adjunct testosterone to limit loss of body mass in patients with squamous cell carcinoma of the cervix or head and neck undergoing standard of care treatment including chemotherapy and chemoradiation. Patients were randomly assigned in blocks to receive weekly injections of either 100 mg testosterone enanthate or placebo for 7 weeks. The primary outcome was per cent change in lean body mass, and secondary outcomes included assessment of quality of life, tests of physical performance, muscle strength, daily activity levels, resting energy expenditure, nutritional intake, and overall survival.

RESULTS

A total of 28 patients were enrolled, 22 patients were studied to completion, and 21 patients were included in the final analysis (12 placebo, nine testosterone). Adjunct testosterone increased lean body mass by 3.2% (95% confidence interval [CI], 0-7%) whereas those receiving placebo lost 3.3% (95% CI, -7% to 1%, P = 0.015). Although testosterone patients maintained more favourable body condition, sustained daily activity levels, and showed meaningful improvements in quality of life and physical performance, overall survival was similar in both treatment groups.

CONCLUSIONS

In patients with advanced cancer undergoing the early phase of standard of care therapy, adjunct testosterone improved lean body mass and was also associated with increased quality of life, and physical activity compared with placebo.

Partnering with families to promote nutrition in cancer care: feasibility and acceptability of the PIcNIC intervention

Background

Malnutrition is frequent in patients with cancer, particularly those in advanced stages of the disease. The aim of the present study was to test the feasibility of a family-centred nutritional intervention, based on the Family Systems theory and past research.

Methods

This was a single-arm trial assessing feasibility (eligibility, recruitment and retention rates); acceptability by patients, family caregivers and health professionals; intervention fidelity, and energy/protein intake (in one site only). Two sites were involved; one each in Australia (AUS) and Hong Kong (HK), with one site delivering the intervention to oncology patients receiving curative treatments in the hospital, and the other to advanced cancer patients in the home.

Results

The sample included 53 patients (23 from AUS and 30 from HK), 22 caregivers (3 from AUS and 19 from HK) and 30 health professionals (20 from AUS and 10 from HK). Recruitment was difficult in the acute inpatient oncology care setting (AUS) and feasibility criteria were not met. Sufficient recruitment took place in the home care setting with advanced cancer patients in HK. Patients, family members and health professionals found the intervention helpful and acceptable, and patients and families indicated they would take part in the future in a similar study. Energy and protein intake improved from baseline to end of intervention (mean 22 kcal/kg/day to 26 and 0.9 g/kg/day to 1.0 respectively).

Conclusion

The new intervention is feasible in a home setting when delivered to patients with advanced cancer, acceptable to patients and families, and has the potential to improve nutritional status in patients. A large randomised trial is warranted in the future.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0306-4) contains supplementary material, which is available to authorized users.

The effect of nabilone on appetite, nutritional status, and quality of life in lung cancer patients: a randomized, double-blind clinical trial

BACKGROUND

Over one half of the patients diagnosed with advanced lung cancer experience anorexia. In addition to its high incidence, cancer-induced anorexia promotes the development of the anorexia-cachexia syndrome, which is related to poor clinical outcomes. Recently, drugs derived from cannabinoids, such as Nabilone, have been recognized for their appetite improvement properties; however, clinical trials to support their use in cancer patients are necessary.

METHODS

This is a randomized, double-blind, placebo-controlled clinical trial to assess the effect of Nabilone vs. placebo on the appetite, nutritional status, and quality of life in patients diagnosed with advanced Non-small cell lung cancer (NSCLC) (NCT02802540).

RESULTS

A total of 65 patients from the outpatient clinic at the National Institute of Cancer (INCan) were assessed for eligibility and 47 were randomized to receive Nabilone (0.5 mg/2 weeks followed by 1.0 mg/6 weeks) or placebo. After 8 weeks of treatment, patients who received Nabilone increased their caloric intake (342-kcal) and had a significantly higher intake of carbohydrates (64 g) compared to patients receiving placebo (p = 0.040). Quality of life also showed significant improvements in patients in the experimental arm of the trial, particularly in role functioning (p = 0.030), emotional functioning (p = 0.018), social functioning (p = 0.036), pain (p = 0.06), and insomnia (p = 0.020). No significant change in these scales was seen in the control group.

CONCLUSION

Nabilone is an adequate and safe therapeutic option to aid in the treatment of patients diagnosed with anorexia. Larger trials are necessary in order to draw robust conclusions in regard to its efficacy in lung cancer patients.

Resistance and tolerance defenses in cancer: Lessons from infectious diseases

Infectious disease and cancer are two maladies with multiple similarities. Both types of disease induce activation of the host immune response and induce pathologies that compromise host heath and survival. In infection biology, defense against pathogens can be broken down into two distinct components called resistance and tolerance. Resistance protects the host by killing pathogens. Tolerance protects the host by alleviating the pathology caused by the infection. The conceptual framework of resistance and tolerance, concepts explored during infectious disease, is applicable to cancer, a condition for which patient survival is dependent on tumor eradication (resistance) and the mitigation of pathologies that occur during disease (tolerance). Here, we propose that integration of the concept of disease tolerance into cancer studies will result in new therapies to complement current resistance-based treatment strategies to increase the likelihood of patient survival and to improve quality of life. Furthermore, by drawing parallels between infectious disease and cancer, we propose that host interactions with microbes could provide therapeutic insight for promoting tolerance defense and focus our discussion on cachexia, a pathology resulting in significant morbidity in cancer patients.