Clinical significance of weight loss in cancer patients: rationale for the use of anabolic agents in the treatment of cancer-related cachexia

Nutritional Prognosis of Patients Submitted to Radiotherapy and Its Implications in Treatment

Oncological patients show intense catabolic activity, as well as a susceptibility to higher nutritional risk and clinical complications. Thus, tools are used for monitoring prognosis. Our objective was to analyze the nutrition prognosis of patients who underwent radiotherapy, correlating it with outcomes and complications. We performed a retrospective transversal study based on secondary data from hospital records of patients who started radiotherapy between July 2022 and July 2023. We established Prognostic Scores through a combination of Prognostic Nutritional Index (PNI) and a Subjective Global Assessment (SGA), assessed at the beginning and end of treatment. Score 3 patients, with PNI ≤ 45.56 and an SGA outcome of malnutrition, initially presented a higher occurrence of odynophagia, later also being indicative of reduced diet volume, treatment interruption, and dysphagia. SGA alone showed sensitivity to altered diet volume, dysphagia, and xerostomia in the second assessment. Besides this, PNI ≤ 45.56 also indicated the use of alternative feeding routes, treatment interruption, and hospital discharge with more complications. We conclude that the scores could be used to indicate complications; however, further studies on combined biomarkers are necessary.

Measurement of body composition by DXA, BIA, Leg-to-leg BIA and near-infrared spectroscopy in breast cancer patients - comparison of the four methods

BACKGROUND & AIMS

Body composition plays a crucial role in therapy adherence and the prognosis of cancer patients. The aim of this work was to compare four measurement methods for determining body composition regarding their validity, reliability and practicability in order to be able to draft a practical recommendation as to which method is most suitable as a standard measurement method in oncology.

METHODS

Fat mass (FM) and fat-free mass (FFM) was estimated for 100 breast cancer patients with ages of 18-70 years during a defined 20-week inpatient and outpatient rehabilitation process after primary therapy or follow-up rehabilitation. The four methods used were dual energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), leg-to-leg BIA and near-infrared spectroscopy (NIRS). At baseline (t0) and after 20 weeks (t20) the agreement between the four body composition analysis methods was quantified by pairwise method comparisons using Bland-Altman bias and limits of agreement estimates, t-tests and Lin's concordance correlation coefficients (CCCs).

RESULTS

CCCs and Bland-Altman plots indicated that DXA and BIA, DXA and NIRS as well as BIA and NIRS showed an excellent agreement concerning FM estimation at both time points (CCC>0.9). In contrast, no methods agreed with a CCC higher than 0.9 with respect to FFM estimation. However, most estimates were also significantly different between two methods, except for BIA and NIRS which yielded comparable FFM and FM estimates at both time points, albeit with large 95% limits of agreement intervals. The agreement between DXA and BIA was best in the lowest BMI tertile and worsened as BMI increased. Significant differences were also found for FFM changes measured with DXA versus BIA (mean difference -0.4 kg, p = 0.0049), DXA versus to Leg-to-leg BIA (-0.6 kg, p = 0.00073) and for FM changes measured with DXA versus Leg-to-leg BIA (0.5 kg, p = 0.0011).

CONCLUSIONS

For accurate and valid body composition estimates, Leg-to-leg BIA cannot be recommended due to its significant underestimation of FM or significant overestimation of FFM, respectively. BIA and NIRS results showed good agreement with the gold standard DXA. Therefore both measurement methods appear to be very well suitable to assess body composition of oncological patients and should be used more frequently on a routine basis to monitor the body composition of breast cancer patients.

Targeting cancer cachexia: Molecular mechanisms and clinical study

Cancer cachexia is a complex systemic catabolism syndrome characterized by muscle wasting. It affects multiple distant organs and their crosstalk with cancer constitute cancer cachexia environment. During the occurrence and progression of cancer cachexia, interactions of aberrant organs with cancer cells or other organs in a cancer cachexia environment initiate a cascade of stress reactions and destroy multiple organs including the liver, heart, pancreas, intestine, brain, bone, and spleen in metabolism, neural, and immune homeostasis. The role of involved organs turned from inhibiting tumor growth into promoting cancer cachexia in cancer progression. In this review, we depicted the complicated relationship of cancer cachexia with the metabolism, neural, and immune homeostasis imbalance in multiple organs in a cancer cachexia environment and summarized the treatment progress in recent years. And we discussed the molecular mechanism and clinical study of cancer cachexia from the perspective of multiple organs metabolic, neurological, and immunological abnormalities. Updated understanding of cancer cachexia might facilitate the exploration of biomarkers and novel therapeutic targets of cancer cachexia.

Assessment of nutritional status of oncology patients at hospital admission: A Portuguese real-world study

Background

Nutritional status in patients with cancer has a determining role in the evolution of the disease and tolerance to treatments. Severity of undernutrition impacts morbidity and mortality in cancer patients and can limit patient response to the optimal therapies if nutritional issues are not appropriately addressed and managed. Despite the importance of malnutrition for the clinical evolution of oncology patients, there is not yet a universally accepted standard method for evaluating malnutrition in such patients. The aim of this study was to stratify the nutritional status of inpatients at an Oncology Department.

Methods

This is an observational study with 561 cancer patients, assessed at admission to a Medical Oncology Department from November 2016 to February 2020. All patients were considered eligible. Non-compliant and/or comatose patients were excluded. Nutritional status was assessed using the PG-SGA, BMI classified with the WHO criteria, and calculation of the percentage of weight loss in the previous 3-6 months.

Results

A total of 561 patients (303 F: 258 M; mean age 65 ± 13 years) were included. One-third of the patients, n=191/561 (34%), lost 6% of their weight in the month prior to admission and 297/561 (53%) patients lost 10.2% of weight in the previous 6 months. Mean BMI was 24.1 ± 5.8 kg/m2; N = 280/561 (50%) patients had regular BMI according to the WHO criteria. N = 331/561 (59%) patients reported eating less in the month prior to admission. N = 303/561 (54%) had moderate/severe deficits of muscle and adipose compartments. The PG-SGA identified 499/561 (89%) patients as moderately/severely malnourished, of which 466/561 (83%) patients scored ≥9 points, meeting criteria for a critical need for nutritional support. Fifteen percent of patients scored >4 points, indicating a need for directed therapy for symptom control and only 1% scored <2 points (maintenance nutritional counseling).

Conclusion

In this oncological setting, a higher proportion of patients were nutritionally-at-risk or with moderate/severe malnutrition. The large majority of patients in this study presented with a critical need for nutritional intervention. These findings highlight the need for an integrated assessment of nutritional status at patient referral. This will allow early and timely nutrition care, which is recommended to prevent or reverse further deterioration of the condition and to optimize treatment administration.

Severe Dementia Predicts Weight Loss by the Time of Death

Background: Body mass index (BMI) in midlife is associated with dementia. However, the association between BMI and late-life obesity is controversial. Few studies have investigated the association between BMI and cognitive performance near the time of death using data from autopsy examination. We aimed to investigate the association between BMI and dementia in deceased individuals who underwent a full-body autopsy examination.

Methods: Weight and height were measured before the autopsy exam. Cognitive function before death was investigated using the Clinical Dementia Rating (CDR) scale. The cross-sectional association between BMI and dementia was investigated using linear regression models adjusted for sociodemographic and clinical variables.

Results: We included 1,090 individuals (mean age 69.5 ± 13.5 years old, 46% women). Most participants (56%) had a normal BMI (18.5–24.9 kg/m²), and the prevalence of dementia was 16%. Twenty-four percent of the sample had cancer, including 76 cases diagnosed only by the autopsy examination. Moderate and severe dementia were associated with lower BMI compared with participants with normal cognition in fully adjusted models (moderate: β = −1.92, 95% CI = −3.77 to −0.06, p = 0.042; severe: β = −2.91, 95% CI = −3.97 to −1.86, p < 0.001).

Conclusion: BMI was associated with moderate and severe dementia in late life, but we did not find associations of BMI with less advanced dementia stages.

Cancer cachexia and its pathophysiology: links with sarcopenia, anorexia and asthenia

Cancer cachexia is a multifactorial syndrome characterized by a progressive loss of skeletal muscle mass, along with adipose tissue wasting, systemic inflammation and other metabolic abnormalities leading to functional impairment. Cancer cachexia has long been recognized as a direct cause of complications in cancer patients, reducing quality of life and worsening disease outcomes. Some related conditions, like sarcopenia (age-related muscle wasting), anorexia (appetite loss) and asthenia (reduced muscular strength and fatigue), share some key features with cancer cachexia, such as weakness and systemic inflammation. Understanding the interplay and the differences between these conditions is critical to advance basic and translational research in this field, improving the accuracy of diagnosis and contributing to finally achieve effective therapies for affected patients.

Does perioperative oxandrolone improve nutritional status in patients with cachexia related to head and neck carcinoma?

Background

Cancer cachexia affects up to over 50% of advanced head and neck cancer (HNC) patients. To date, the potential utility of anabolic steroids in perioperative cachectic HNC patients has not been determined.

Methods

Retrospective review of pre- and post-oxandrolone administration prealbumin levels in 18 perioperative HNC patients between October 2007 and October 2014 at a tertiary academic medical center.

Results

The median pretreatment prealbumin was 88.5 mg/L. The median post-treatment prealbumin was 227 mg/L. The median interval improvement of the prealbumin level was 131.5 mg/L. The median differences between the pretreatment and post-treatment prealbumin levels were found to be statistically significant (P < .001). Subjective improvement in wound healing was also observed.

Conclusions

Perioperative administration of oxandrolone resulted in objective improvements in prealbumin levels and subjective improvements in surgical wounds. Oxandrolone administered 10 mg twice daily (BID) for 10 days may be a useful adjunct in the perioperative care of nutritionally deficient HNC patients who are at risk for or have demonstrated impaired wound healing.

Level of Evidence

3.

Anabolic competence: Assessment and integration of the multimodality interventional approach in disease-related malnutrition

Disease-related malnutrition (DRM) is a frequent clinical problem, characterized by loss of lean body mass and decreased function, including muscle function and immunocompetence. In DRM, nutritional intervention is necessary, but it has not consistently been shown to be sufficient. Other factors, for example, physical activity and hormonal or metabolic influencers of the internal milieu, are also important in the treatment of DRM. A prerequisite for successful treatment of DRM is the positive balance between anabolism and catabolism. The aim of this review was to approach DRM using this paradigm of anabolic competence, for conceptual and practical reasons. Anabolic competence is defined as "that state which optimally supports protein synthesis and lean body mass, global aspects of muscle and organ function, and immune response." Anabolic competence and interdisciplinary, multimodality interventions create a practical foundation to approach DRM in a proactive comprehensive way. Here, we describe the paradigm of anabolic competence, and its operationalization by measuring factors related to anabolic competence and suited for clinical management of patients with DRM.

Whole Body Protein Oxidation Unaffected after a Protein Restricted Diet in Healthy Young Males

Protein oxidation may play a role in the balance between anabolism and catabolism. We assessed the effect of a protein restricted diet on protein oxidation as a possible reflection of whole body protein metabolism. Sixteen healthy males (23 ± 3 years) were instructed to use a 4-day isocaloric protein restricted diet (0.25 g protein/kg body weight/day). Their habitual dietary intake was assessed by a 4-day food diary. After an overnight fast, a 30 g 13C-milk protein test drink was administered, followed by 330 min breath sample collection. Protein oxidation was measured by Isotope Ratio Mass Spectrometry. To assess actual change in protein intake from 24-h urea excretion, 24-h urine was collected. During the 4-day protein restricted diet, the urinary urea:creatinine ratio decreased by 56 ± 9%, which is comparable to a protein intake of ~0.65 g protein/kg body weight/day. After the protein restricted diet, 30.5 ± 7.3% of the 30 g 13C-milk protein was oxidized over 330 min, compared to 31.5 ± 6.4% (NS) after the subject's habitual diet (1.3 ± 0.3 g protein/kg body weight/day). A large range in the effect of the diet on protein oxidation (-43.2% vs. +44.0%) was observed. The residual standard deviation of the measurements was very small (0.601 ± 0.167). This suggests that in healthy males, protein oxidation is unaffected after a protein restricted diet. It is uncertain how important the role of fluctuations in short-term protein oxidation is within whole body protein metabolism.

Cancer cachexia: Diagnosis, assessment, and treatment

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

Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment

PURPOSE OF REVIEW

The Scored Patient-Generated Subjective Global Assessment (PG-SGA) is used internationally as the reference method for proactive risk assessment (screening), assessment, monitoring and triaging for interventions in patients with cancer. This review aims to explain the rationale behind and data supporting the PG-SGA, and to provide an overview of recent developments in the utilization of the PG-SGA and the PG-SGA Short Form.

RECENT FINDINGS

The PG-SGA was designed in the context of a paradigm known as 'anabolic competence'. Uniquely, the PG-SGA evaluates the patient's status as a dynamic rather than static process. The PG-SGA has received new attention, particularly as a screening instrument for nutritional risk or deficit, identifying treatable impediments and guiding patients and professionals in triaging for interdisciplinary interventions. The international use of the PG-SGA indicates a critical need for high-quality and linguistically validated translations of the PG-SGA.

SUMMARY

As a 4-in-1 instrument, the PG-SGA can streamline clinic work flow and improve the quality of interaction between the clinician and the patient. The availability of multiple high-quality language versions of the PG-SGA enables the inclusion of the PG-SGA in international multicenter studies, facilitating meta-analysis and benchmarking across countries.

Effects of anabolic-androgens on brain reward function

Androgens are mainly prescribed to treat several diseases caused by testosterone deficiency. However, athletes try to promote muscle growth by manipulating testosterone levels or assuming androgen anabolic steroids (AAS). These substances were originally synthesized to obtain anabolic effects greater than testosterone. Although AAS are rarely prescribed compared to testosterone, their off-label utilization is very wide. Furthermore, combinations of different steroids and doses generally higher than those used in therapy are common. Symptoms of the chronic use of supra-therapeutic doses of AAS include anxiety, depression, aggression, paranoia, distractibility, confusion, amnesia. Interestingly, some studies have shown that AAS elicited electroencephalographic changes similar to those observed with amphetamine abuse. The frequency of side effects is higher among AAS abusers, with psychiatric complications such as labile mood, lack of impulse control and high violence. On the other hand, AAS addiction studies are complex because data collection is very difficult due to the subjects' reticence and can be biased by many variables, including physical exercise, that alter the reward system. Moreover, it has been reported that AAS may imbalance neurotransmitter systems involved in the reward process, leading to increased sensitivity toward opioid narcotics and central stimulants. The goal of this article is to review the literature on steroid abuse and changes to the reward system in preclinical and clinical studies.

The Malnutrition Universal Screening Tool (MUST) and a nutrition education program for high risk cancer patients: strategies to improve dietary intake in cancer patients

Four hundred and forty-four high-risk oncology patients with malnutrition participated in this study aimed at assessing the effectiveness of nutrition education on improving an oncology patient’s dietary intake. We used a nutritional risk screening to select oncology patients in need of nutritional care. Team Nutrition provides technical assistance for foodservice, nutrition education for patients and their caregivers, and support for healthy eating and physical activity to improve their diets and their lives. The average contribution of protein and total energy of each patient increased after imparting the nutritional education to them. Thus, nutritional education is an effective measure to bring about a favorable and significant change in oncology patients’ nutrient intake.

Quantitative Assay Validation for Oxandrolone in Human Plasma Using LC-MS-MS

A high-performance liquid chromatography-tandem mass spectrometry (LC-MS-MS) method for the determination of oxandrolone concentration in human plasma (0.5 mL) was developed and validated according to the 2001 FDA Bioanalytical Guidelines. Oxandrolone is an anabolic steroid used to promote weight gain for cachectic patients with severe burn injuries, HIV/AIDS, hepatitis C and other wasting syndromes. The assay procedure involved a liquid-liquid extraction of oxandrolone and methyltestosterone (the internal standard, IS) from plasma with n-butyl chloride. The organic layer was clarified by centrifugation and evaporated to dryness under a stream of air. The residue was reconstituted in a solution containing 25% methanol and 75% Milli-Q water, and injected onto a Luna C18 reversed-phase HPLC column (30 mm × 2.0 mm, 2 μm). Separation of oxandrolone and methyltestosterone was achieved with a mobile phase starting composition of 55% methanol and 45% ammonium formate buffer at a flow rate of 0.1 mL/min. The total run time was 21 min per sample. Selected reaction monitoring mode was used for quantifying oxandrolone (m/z 307 → 271) and the IS, methyltestosterone (m/z 301 → 149). To the authors' knowledge, this is the first LC-MS-MS method validated for oxandrolone quantification in human plasma. This method can be used in future pharmacokinetic studies involving oxandrolone.

Cancer cachexia update in head and neck cancer: Pathophysiology and treatment

The pathophysiology of cancer cachexia remains complex. A comprehensive literature search was performed up to April 2013 using PubMed, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and the Google search engine. In this review, we focus on the different mediators of impaired anabolism and upregulated catabolism that alter the skeletal muscle homeostasis resulting in the wasting of cancer cachexia. We present recent evidence of targeted treatment modalities from clinical trials along with their potential mechanisms of action. We also report on the most current evidence from randomized clinical trials using multimodal treatments in patients with cancer cachexia, but also the evidence from head and neck cancer-specific trials. A more complete understanding of the pathophysiology of the syndrome may lead to more effective targeted therapies and improved outcomes for patients.

Immunonutrition stimulates immune functions and antioxidant defense capacities of leukocytes in radiochemotherapy-treated head & neck and esophageal cancer patients: A double-blind randomized clinical trial

BACKGROUND

Immunonutrition has been reported to improve the immune status of perioperative cancer patients, thereby reducing complications and length of hospital stay.

AIM

This study aimed to assess whether immunonutrition enriched in arginine, EPA & DHA and nucleotides could impact the immune cells responses in head & neck and esophageal cancer patients treated by radiochemotherapy (RCT).

METHODS

A double-blind clinical trial was carried out in 28 patients randomized into two groups, receiving either an immunomodulating enteral nutrition formula (IEN, n = 13, Impact(®), Nestlé) or an isoenergetic isonitrogenous standard enteral nutrition formula (SEN, n = 15) throughout RCT (5-7 weeks). After isolation from whole blood, immune cells metabolism and functions were assessed at the beginning (Db) and at the end (De) of RCT.

RESULTS

Immunonutrition maintained CD4(+)/CD8(+) T-lymphocyte counts ratio and CD3 membrane expression between Db and De. Polymorphonuclear cells CD62L and CD15 densities and ROS production were increased in IEN patients. Peripheral blood mononuclear cells (PBMC) production of pro-inflammatory prostaglandin-E2 was stable in IEN patients and lower than in SEN patients at De. Genes coding for immune receptors, antioxidant enzymes and NADPH oxidase subunits were overexpressed in the PBMC of IEN vs SEN patients at De.

CONCLUSION

Immunonutrition can enhance immune cell responses through the modulation of their phenotypes and functions. By modulating the gene expression of immune cells, immunonutrition could make it easier for the organism to adapt to the systemic inflammation and oxidative stress induced by RCT.

CLINICAL TRIAL REGISTRATION

This clinical trial has been registered on ClinicalTrial.gov website: NCT00333099.

Anabolic androgens affect the competitive interactions in cell migration and adhesion between normal mouse urothelial cells and urothelial carcinoma cells

The urothelium is constantly rebuilt by normal urothelial cells to regenerate damaged tissues caused by stimuli in urine. However, the urothelial carcinoma cells expand the territory by aberrant growth of tumor cells, which migrate and occupy the damaged tissues to spread outside and disrupt the normal cells and organized tissues and form a tumor. Therefore, the interaction between normal urothelial cells and urothelial carcinoma cells affect the initiation and progression of urothelial tumors if normal urothelial cells fail to migrate and adhere to the damages sites to regenerate the tissues. Here, comparing normal murine urothelial cells with murine urothelial carcinoma cells (MBT-2), we found that normal cells had less migration ability than carcinoma cells. And in our co-culture system we found that carcinoma cells had propensity migrating toward normal urothelial cells and carcinoma cells had more advantages to adhere than normal cells. To reverse this condition, we used anabolic androgen, dihyrotestosterone (DHT) to treat normal cells and found that DHT treatment increased the migration ability of normal urothelial cells toward carcinoma cells and the adhesion capacity in competition with carcinoma cells. This study provides the base of a novel therapeutic approach by using anabolic hormone-enforced normal urothelial cells to regenerate the damage urothelium and defend against the occupancy of carcinoma cells to thwart cancer development and recurrence.

Relationships among Malnutrition, Depression and Quality of Life in Patients with Gynecologic Cancer receiving Chemotherapy

PURPOSE

The purpose of this study was to identify nutritional status, and relationships among malnutrition, depression and quality of life in patients with gynecologic cancer who were receiving chemotherapy.

METHODS

For this study a descriptive cross-sectional design was used. Participants were 111 women who were enrolled and agreed to undergo a face-to-face interviews including administration of the structured questionnaires: Patient-Generated Subjective Global Assessment (PG-SGA), Beck Depression Inventory (BDI), Simplified Nutritional Appetite Questionnaire (SNAQ), and Functional Assessment of Cancer Therapy-General (FACT-G).

RESULTS

Mean body mass index was 23.3 and mean body weight was 56.5 kg. Sixty-three (57%) of the 111 patients were malnourished according to the PG-SGA. The malnourished patients showed higher levels of depression and lower quality of life compared to the non-malnourished patients. In addition, malnutrition was associated with BMI level, depression, appetite and quality of life.

CONCLUSION

The findings indicate that the prevalence of malnutrition is high and malnutrition in patients with gynecologic cancer influences depression and adversely affects the quality of life of these women. To improve the patient's quality of life, nutritional assessment and appropriate management is important to decrease malnutrition in patients with gynecologic cancer.

Validation of nutritional risk index method against patient-generated subjective global assessment in screening malnutrition in colorectal cancer patients

OBJECTIVE

To validate malnutrition screening tool of nutrition risk index (NRI) against patient-generated subjective global assessment (PG-SGA) as a gold standard tool in colorectal cancer patients before radiotherapy.

METHODS

Nutritional status of 52 volunteer colorectal cancer patients with a mean age of 54.1±16.8 years who referred to radiotherapy center were assessed by PG-SGA (gold standard method) and NRI. Serum albumin levels of patients were determined by colorimetric method. A contingency table was used to determine the sensitivity, specificity, and predictive value of the NRI in screening patients at risk of malnutrition, in comparison with the PG-SGA in patients before radiotherapy.

RESULTS

The findings of PG-SGA and NRI showed that 52% and 45% of patients in our study were moderately or severely malnourished respectively. The NRI had a sensitivity of 66% and a specificity of 60% against PG-SGA. The positive predictive value was 64% and the negative predicative value was 62%. The agreement between NRI and PG-SGA was statistically insignificant (kappa =0.267; P>0.05).

CONCLUSIONS

The findings of present study showed that the prevalence of malnutrition was high in patients with colorectal cancer. Moreover, NRI method had low sensitivity and specificity in assessing nutritional status of patients with cancer. It seems that the combination of anthropometric, laboratory parameters and a subjective scoring system may be helpful tools in screening of malnutrition in cancer patients.

Immunonutrition improves functional capacities in head and neck and esophageal cancer patients undergoing radiochemotherapy: a randomized clinical trial

BACKGROUND & AIMS

Malnutrition is frequent in head and neck (HN) and esophageal cancer patients and aggravated by radiochemotherapy (RCT), increasing morbi-mortality and treatment toxicity. Our goal was to investigate the effect of immunonutrition consisting of an arginine, omega-3 fatty acid, nucleotides-enriched diet on nutritional status, and functional capacity in HN or esophageal cancer patients undergoing RCT.

METHODS

37 patients were randomized in a double-blind clinical trial. 5 days before and until the end of RCT (5-7 weeks), they received either an Immunomodulating Enteral Nutrition (IEN) or an isonitrogenous, isoenergetic Standard Enteral Nutrition (SEN). Anthropometrical parameters, nutritional risk index (NRI), serum albumin, plasma antioxidant capacity, and functional capacity were recorded between the beginning and the end of RCT.

RESULTS

A significant gain in total body weight (+2.1 ± 3.1 kg) was observed in IEN patients. Albuminemia and NRI were improved concomitantly in IEN malnourished patients. Plasma antioxidant capacity was improved (+100 ± 13 μM EqTrolox) in IEN patients. Functional capacity measured by WHO Performance Status and Karnofsky index was maintained in IEN patients but significantly reduced in SEN patients.

CONCLUSIONS

These preliminary data show that immunonutrition could improve the nutritional status together with functional capacity in HN and esophageal cancer patients undergoing RCT.

CLINICAL TRIAL REGISTRATION

This clinical trial promoted by the University Hospital Center of Clermont-Ferrand has been registered at ClinicalTrial.gov website under the following reference: NCT00333099.

Painful decisions for senior pets

Osteoarthritis and cancer are the inevitable consequences of aging and significantly contribute to the cause of death in cats and dogs. Managing the pain associated with these disease states is the veterinarian’s mandate. Many treatment modalities and agents are available for patient management; however, it is only with an understanding of disease neurobiology and a mechanism-based approach to problem diagnosis that the clinician can offer patients an optimal quality of life based on evidence-based best medicine. When treating pain, knowledge is still our best weapon.

Nutritional interventions for cancer-induced cachexia

Cancer-induced cachexia remains a significant cause of morbidity and mortality in cancer treatment. Cancer research and development continues at an aggressive pace and yet a degree of cancer-induced cachexia is experienced by up to 80% of advanced stage cancer patients. Unfortunately, there are no established treatment regimens for this condition. Weight loss and fatigue consistently appear in patient oncologic histories and progress notes. However, few oncologists fully understand the pathologic mechanisms causing cachexia resulting in well-meaning advice to increase caloric intake with minimal results. Our goal is to describe the pathologic basis of cancer-induced cachexia and to detail accompanying metabolic derangements. Understanding the causes of cachexia sheds light on the subsequent need for multi-modality therapy including clinical intervention with specialized nutrition support, drug therapy, lifestyle and diet changes. In addition to nutrition support modalities, practicing oncologists may prescribe medical therapies designed to increase body weight and lean body mass, including megestrol acetate, tetrahydrocannibinol, oxandrolone, and non-steroidal anti-inflammatory drugs. A variety of experimental therapies are also being investigated for cancer-induced cachexia including tumor necrosis factor-alpha inhibitors and ghrelin infusions. We review the available data to support nutrition-oriented interventions in cancer-induced cachexia, including omega-3 fatty acids, amino-acid loading/protein supplementation, parenteral and enteral nutrition support, and food-derived compounds such as curcumin, reservatrol, and pomegranate.

Body composition of children with cancer

BACKGROUND

Nutritional status, as represented by body composition, is an important consideration in the treatment of pediatric cancer patients because it is linked to poor outcomes. Little is known about how a child's body composition responds to cancer and treatment.

OBJECTIVES

We aimed to compare the body composition of children undergoing treatment of cancer with that of healthy controls and to compare body composition between children with hematologic malignancies and children with solid tumors.

DESIGN

This cross-sectional study measured height, weight, body cell mass, fat-free mass, and fat mass in 48 children undergoing treatment of cancer and blood-related disorders and in age-matched healthy controls.

RESULTS

Patients with cancer had a significantly lower body cell mass index z score (body cell mass/height raised to the power of 2.5 for females and 3 for males) than did controls (P = 0.0001), and 45% of the patients with cancer were considered malnourished according to body cell mass. Subjects with cancer had a significantly higher percentage of body fat (P = 0.0001) and fat mass (P = 0.0001) than did controls; however, there was no significant difference in fat-free mass (P = 0.09). On the basis of percentage fat, 77% of subjects with cancer were considered obese. No difference in body composition was observed between cancer types.

CONCLUSIONS

This study showed that children undergoing treatment of all types of cancer have a significantly lower body cell mass and a significantly higher fat mass than do healthy controls. Nutritional support is suggested for all children undergoing treatment of cancer.

Pathogenesis of muscle wasting in cancer cachexia: targeted anabolic and anticatabolic therapies

PURPOSE OF REVIEW

Cancer-related muscle loss, or cachexia, is the cause of death for approximately 2 million people worldwide and severely reduces quality of life. The degree of cachexia is inversely correlated with survival time; however, the exact mechanisms behind cancer-induced muscle wasting remain under investigation.

RECENT FINDINGS

Cytokines such as tumor necrosis factor-alpha trigger degradatory pathways through nuclear factor-kappaB signaling that activate the ubiquitin-proteasome system and muscle proteolysis. Androgen treatment has been shown to reduce inflammatory cytokines and even stimulate anti-inflammatory cytokine production. Amino acid supplementation has been shown to induce muscle protein synthesis in ovarian cancer patients.

SUMMARY

Targeted anabolic therapies aimed at preventing or reversing cancer cachexia might involve the combined use of androgens and amino acids working concurrently to enhance muscle protein synthesis and reduce muscle protein breakdown. Additional focused clinical studies are needed to identify muscle-specific targets or biomarkers for defined therapeutic approaches to slow or prevent cancer cachexia. In this review, we summarize the pathogenesis of cancer-related muscle wasting and discuss potential interventions at reversing or preventing cancer-related muscle loss.

Bedside nutrition assessment past, present, and future: a review of the Subjective Global Assessment

Bedside nutrition assessment remains an essential skill for the practicing clinician to master as the nutrition status of our patients directly influences clinical outcomes and mortality rates. Dr Charles E. Butterworth Jr's initial report of malnutrition in hospitalized patients, the so-called "skeleton in the closet," riveted the medical community. Two other studies in the 1970s published prevalence rates of hospital malnutrition of 48% in adult medical patients and 50% in adult surgical patients. Even more disturbing, 75% of patients at risk for malnutrition on admission had worsening nutrition parameters during their hospitalization. These findings led to a search to find an integrated bedside nutrition assessment tool to identify malnutrition in hospitalized patients. Initially reported in 1982, The Subjective Global Assessment is an integrated tool that utilizes the clinical judgment of a practitioner to identify patients at risk of or with malnutrition. It is a clinically useful tool that can be applied at the bedside by the average practitioner. It is a simple, safe, and inexpensive tool allowing for widespread use by trained clinicians and remains the gold standard for new bedside assessment tools.

A biobehavioral model for the study of exercise interventions in cancer-related fatigue

Cancer-related fatigue (CRF) is a multifactorial, biobehavioral phenomenon experienced by the majority of persons with cancer. It has negative consequences on the individual's physical functioning and quality of life. An array of biological, psychobehavioral, and functional mechanisms contributes to its occurrence. A relatively large number of studies have examined the effect of physical exercise on CRF over the past few decades. Most of these studies did not specifically examine the effect of physical exercise on the biobehavioral mechanisms underlying CRF. For the most part, these studies have not been guided by a consistent theoretical model. Consequently, the mechanisms by which exercise may ameliorate CRF are not fully elucidated. A theoretical model incorporating fatigue-related biobehavioral variables that could be affected by physical exercise will allow for effective knowledge development in this area and could lead to the development and refinement of exercise protocols that specifically target these mechanisms. Thus, the purpose of this paper is to present a comprehensive theoretical model to guide future research on the effectiveness of exercise interventions in CRF. The proposed model incorporates the biological, psychobehavioral, and functional variables implicated in the induction of CRF.

Novel treatments for cancer cachexia

Cancer cachexia is a debilitating and life-threatening syndrome characterised by anorexia, body weight loss, loss of adipose tissue and skeletal muscle, and accounts for > or = 20% of deaths in neoplastic patients. Cancer cachexia significantly impairs quality of life and response to antineoplastic therapies, increasing the morbidity and mortality of cancer patients. Muscle wasting is the most important phenotypic feature of cancer cachexia and the principle cause of function impairment, fatigue and respiratory complications, and is mainly related to a hyperactivation of muscle proteolytic pathways. Existing therapeutic strategies have proven to be only partially effective. In the last decade, the correction of anorexia, the inhibition of catabolic processes and the stimulation of anabolic pathways in muscle has been attempted pharmacologically, giving encouraging results in animal models and through preliminary clinical trials.

Cancer chemotherapy II: atypical hepatic injuries

Although chemotherapy generally is accompanied by regular testing for liver enzyme abnormalities, atypical reactions may occur that escape ordinary detection, because hepatocyte injury is not the primary event. The presence of fatty liver, mitochondrial changes, and even biliary abnormalities can be associated with normal or nearly normal liver enzyme levels. This article discusses unique aspects of liver damage associated with cancer chemotherapy. These unique reactions merit special attention and a special vigilance from clinicians.

Cancer cachexia: it's time for more clinical trials

Cancer cachexia (CC) is a multifactorial paraneoplastic syndrome characterized by anorexia, body weight loss, loss of adipose tissue and skeletal muscle, accounting for at least 20% of deaths in neoplastic patients. CC significantly impairs quality of life and response to anti-neoplastic therapies, increasing morbidity and mortality of cancer patients. Muscle wasting is the most important phenotypic feature of CC and the principal cause of function impairment, fatigue and respiratory complications, mainly related to a hyperactivation of muscle proteolytic pathways. Most current therapeutic strategies to counteract CC have proven to be only partially effective. In the last decade, the correction of anorexia, the inhibition of catabolic processes and the stimulation of anabolic pathways in muscle have been attempted pharmacologically with encouraging results in animal models and through preliminary clinical trials. However, data in the clinical setting are still scanty and non definitive. It is time to start prospective, randomized, controlled trials to evaluate which drugs are effective in counteracting the loss of lean of muscle mass and in improving nutritional status and quality of life in patients affected by cancer-related cachexia.

An epidemiological evaluation of the prevalence of malnutrition in Spanish patients with locally advanced or metastatic cancer

OBJECTIVE

Malnutrition is frequent in cancer. The objective of this study was to determine the prevalence, in Spain, of malnutrition in cancer patients with advanced disease and to assess the therapeutic focus.

METHODS

A total of 781 patients were evaluated to determine individual nutritional status using the Scored Patient Generated-Subjective Global Assessment (Scored PG-SGA) questionnaire. Almost 60% of the patients included were receiving cancer treatment.

RESULTS

Patients with the highest weight loss were those with tumours of oesophagus (57%), stomach (50%) and larynx (47%). Serious eating problems were encountered by 68% of the patients; the principal problem being anorexia (42.2%). The median number of symptoms impeding food intake was 2. According to the Scored PG-SGA, 52% of the patients were moderately or severely malnourished and 97.6% required some form of nutritional intervention/recommendation.

CONCLUSIONS

(a) the majority of patients in the study needed nutritional intervention; (b) more than 50% had moderate or severe malnutrition; (c) the Scored PG-SGA is a useful and simple tool for evaluating nutritional status and contains additional information on nutritional recommendations; (d) nutritional evaluation of the cancer patients needs to be improved so as to offer better treatment of symptoms and to improve the patient's quality of life.

The causes and consequences of cancer-associated malnutrition

Cancer-associated malnutrition can result from local effects of a tumour, the host response to the tumour and anticancer therapies. Although cancer patients often have reduced food intake (due to systemic effects of the disease, local tumour effects, psychological effects or adverse effects of treatment), alterations in nutrient metabolism and resting energy expenditure (REE) may also contribute to nutritional status. Several agents produced by the tumour directly, or systemically in response to the tumour, such as pro-inflammatory cytokines and hormones, have been implicated in the pathogenesis of malnutrition and cachexia. The consequences of malnutrition include impairment of immune functions, performance status, muscle function, and quality of life. In addition, responses to chemotherapy are decreased, chemotherapy-induced toxicity and complications are more frequent and severe, and survival times are shortened. Depression, fatigue and malaise also significantly impact on patient well-being. In addition, cancer-related malnutrition is associated with significant healthcare-related costs. Nutritional support, addressing the specific needs of this patient group, is required to help improve prognosis, and reduce the consequences of cancer-associated nutritional decline.