Cancer cachexia

[Real-world study in oncological outpatients of an oral supplement enriched with ω-3 fatty acids - effect on quality of life and nutritional parameters]

Introduction

Background: cancer patients are a group at high nutritional risk. Oral nutritional supplementation (ONS) can improve nutritional status. Objective: the objective of our study was to evaluate the effectiveness on nutritional parameters and quality of life of a ω3-enriched ONS in oncology outpatients in a real-world study. Material and methods: a total of 35 outpatient cancer patients who received 2 ONS per day were recruited. Chemistry, anthropometric, impedance measurement, nutritional survey, malnutrition universal screening tool (MUST) test, and EQ5D quality of life test were all used before and after 3 months of intervention. Results: mean age was 65.4 ± 10.7 years (18 females/17 males). Mean completion of the group was 81.7 ± 7.2 %. During the intervention, total protein (1.5 ± 0.2 g/dL; p = 0.01), albumin (0.9 ± 0.1 mg/dL; p = 0.04), and transferrin (53.9 ± 21.1 mg/dL; p = 0.02) levels increased. At the beginning of the study, 100 % of the patients were in the high nutritional risk category according to MUST. After the intervention, 34.3 % (n = 12) were in the low nutritional risk category, 51.4 % (n = 18) in the moderate nutritional risk category, and only 14.3 % (n = 5) in the category of high nutritional risk; previously, 100 % of patients had high nutritional risk (p = 0.02). The total score in the quality of life test increased significantly (0.51 ± 0.06 vs 0.84 ± 0.03 points; p = 0.01), with improvement in 5 dimensions. Conclusions: the use of a ω3-enriched ONS in a real-world study with cancer outpatients showed a beneficial effect on nutritional parameters and quality of life.

N-3 fatty acid EPA supplementation in cancer patients receiving abdominal radiotherapy - A randomised controlled trial

BACKGROUND & AIMS

Malnutrition occurs frequently in patients with cancer during and after radiotherapy to the gastrointestinal (GI) and pelvic area and can lead to negative outcomes. N-3 fatty acids from fish, especially eicosapentaenoic acid (EPA) may possess anticachectic properties. The aim of this study was to investigate the effect of two nutritional interventions; dietary counselling and a daily oral nutritional supplement (ONS) containing 33.8 g of protein and 2.2 g EPA and 1.1 g docosahexaenoic acid (DHA) or standard care, including dietary counselling and protein supplementation when needed.

METHODS

Outpatients commencing radiotherapy to the GI area were randomized to receive dietary counselling and daily supplementation over a 5-7-week period or standard care. Outcome parameters were measured at baseline (onset of radiotherapy), week 5, and 12 weeks after commencing radiotherapy, with one additional measurement of body weight at week 2. Quality of life (QoL) was measured using the EORTC QLQ-C30 questionnaire. Radiotherapy-related side effects were assessed using a questionnaire developed specifically for this study. Data from a historical control group collected in a previous observational study were included in this study to compare incidence of weight loss.

RESULTS

In total, 30 patients were recruited to this study and 26 patients were enrolled and randomised. The rate of withdrawals was 7.7% at week 2, 15.4% at week 5, and 19.2% at week 12. In total, 22 patients completed the intervention. All the patients in the ONS-group and 85% in the control group experienced weight-loss. Using the intention to treat principle, there were no significant differences between groups in any of the outcomes. All patients experienced side effects. Five out of 11 patients consumed more than 75% of prescribed dose of the fish oil enriched oral nutritional supplement. Post hoc analysis showed that at week 2 the weight changed in high-compliant patients was +1.7% (1.0-2.6) compared with -0.7% (-2.8 to -0.1) in low compliant patients (p < 0,01). The results indicated a dose-response relationship, as correlation analysis recovered a significant positive correlation between weight change and compliance to the fish oil enriched nutritional supplement at both week 2 and 5 (p < 0.05 and p < 0.01, respectively), but not at week 12, indicating a dose-response relationship during radiotherapy but not after. The proportion of patients experiencing weight loss throughout the study period was higher in this study (84.2%) than in the historical control group (73%) (p<0.05%).

CONCLUSION

This study showed no effect from dietary counselling and intended protein/fish-oil supplementation on weight loss, quality of life, and nutritional intake, micronutrient status in plasma or radiotherapy-related side effects compared to the control group. However, the compliance to the fish oil enriched oral nutritional supplement was low. Post hoc analysis of dose-response relations indicate a positive correlation between the compliance and the ability to reduce weight loss in cancer patients during radiotherapy treatment. TRIAL REGISTRATION CLINICALTRIALS.

GOV IDENTIFIER

NCT04687124.

Prognostic factors, symptoms and consequences of dehydration and dyselectrolytemia in patients with terminal stomach cancer

BACKGROUND

Dyselectrolytaemia and dehydration are common symptoms in people with terminal stomach cancer.

AIMS

To determine factors related to dyselectrolytemia and dehydration in patients with terminal stomach cancer.

METHODS

An analysis of 134 patients with terminal stomach cancer admitted to the palliative care unit was conducted, through an audit of the patients' medical records. The average age of women was 63.1 years and that of men was 64.9 years.

FINDINGS

Dehydrated patients were more likely to: have dyselectrolytaemia; have a higher PS scale score; be taking opioids as an analgesic; have a high sodium concentration; experience dyspnoea, constipation, nausea and vomiting during hospitalisation; and require glucocorticoids administration both during and before hospitalisation. Patients with dyselectrolytaemia were more likely to: be admitted to the palliative care unit from the emergency department; experience cachexia and dehydration during hospitalisation and constipation at discharge; have a lower albumin level; and have a higher glucose level. Patients with dyselectrolytaemia also had a shorter duration of treatment and a 2.48 greater chance for death compared with those who did not have it.

CONCLUSIONS

Knowledge of the adverse factors connected with dehydration and dyselectrolytaemia will allow health professionals to avoid dangerous clinical symptoms and prolong the life of those with terminal stomach cancer, as they might be able to foresee the occurrence of these conditions based on the medication the patient has been taking and symptoms they have been experiencing. Nurses will have a greater understanding of the importance of fluid therapy to resolve ionic disturbances and the need to address dehydration and dyselectrolytemia as a means to prolong and improve quality of life.

Cachexia in Cancer Patients: Systematic Literature Review

Introduction Cachexia in cancer patients, especially in advanced stage, is recently known as an emerging problem. Cachexia occurs in about half of all patients with neoplastic disease. The diagnosis of cachexia needs comprehensive evaluation of body weight and body composition for several months. Cachexia will give negative impacts such as increased mortality, chemotoxicity, and decreased quality of life. Here, we review the current evidence describing the definition, stages, mechanisms, diagnosis and treatment of cachexia in cancer patients.

Methods We identified 75 studies and/or review articles evaluating cachexia and weight loss in cancer patients by searching PubMed and EMBASE databases.

Results Cachexia is reported across all stages and types of cancers. The most recent definition of cachexia is reported in a 2011 paper by International Consensus. The mechanism of cachexia in cancer is complex and involved many factors which elaborate together to produce cachexia. The diagnostic evaluation and cut-off measurement of cachexia, especially in cancer varied across studies. The loss of weight that happens during chemotherapy will make a poor prognosis. Cachexia can worsen chemotherapy toxicity. Combination of dietary modification and exercise with supplementation of medication that control appetite and inflammation are important in the management of cachexia in cancer patients.

Conclusion Patients with cancer are the population at risk for developing cachexia before and after chemotherapy. Cachexia diagnosis needs evaluation of body weight and body composition. Nonpharmacological treatments, such as dietary modification and physical exercise, are the best strategy to reduce cachexia in cancer patients.

Sarcopenia in Ovarian Cancer Patients, Oncologic Outcomes Revealing the Importance of Clinical Nutrition: Review of Literature

INTRODUCTION

Ovarian cancer is the leading cause of death among gynecological malignancies. Its usual clinical manifestation is at advanced stages, with nutritional impairment, weight loss, and a consequent decline in skeletal muscle mass and strength (defined as sarcopenia). The relationship between sarcopenia and decreased survival was demonstrated not only in ovarian cancer but also in other cancer types, such as hepatocellular, pancreatic, lung, colon, cervical, metastatic breast, and renal cancer. The aim of this study is to review the current evidence regarding the relationship between sarcopenia and the surgical and oncological outcomes in ovarian cancer patients.

METHODS

The systematic search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) statement. The terms "SARCOPENIA" AND "OVARIAN CANCER" were systematically used to search PubMed and Scopus databases. Original reports in English language were identified, with the purpose to include all relevant papers regarding the role of sarcopenia and indicators of skeletal muscle quality assessment in gynecological ovarian cancer.

RESULTS

A total of 9 studies were considered eligible for the present review. The strength of recommendation was moderate and the level of evidence was low in all selected articles. No prospective studies were conducted and most of the papers were case-control series comparing ovarian cancer sarcopenic population vs. non sarcopenic population.

CONCLUSIONS

Sarcopenia appears to have an important role in oncological outcomes of ovarian cancer patients. However, sarcopenia occurrence during disease history and mechanisms underlying the possible impairment in prognosis should be better investigated. Prospective trials are awaited in order to obtain a better insight in this topic.

Alterations in body composition in Indian patients with non-small cell lung cancer

Background:

Alterations in body composition are common in cancer and may affect outcomes differentially based on geographical and ethnic factors. However, data in lung cancer are sparse and conflicting.

Methods:

We compared the body composition of Indian lung cancer patients with healthy subjects using a retrospective review of all newly diagnosed patients with nonsmall cell lung cancer. Age- and sex-matched healthy controls were recruited prospectively. Basal metabolic rate (BMR), total body water (TBW), fat mass, and fat-free mass (FFM) were calculated by bioelectric impedance method.

Results:

A total of 256 patients (83.6% males) and 210 controls (81.4% males) were studied. The mean (standard deviation) age of patients was 54.5 (9.0) years, median smoking index was 598.2 (range, 0–2500), and median Karnofsky performance scale (KPS) was 80 (range, 40–100). Majority (54.7%) had Stage IV disease. All components of body composition, i.e., BMR, TBW, fat mass, and FFM, were significantly lower (P < 0.01) in patients as compared to controls. Body mass index, fat mass, FFM, and TBW were lower in older subjects with poorer KPS. The presence of metastasis or symptom duration did not affect body composition.

Conclusion:

These results indicate that Indian patients with lung cancer have altered body composition which declines with increasing age and worsening performance status.

Novel use of bioelectric impedence technique to detect alterations in body composition in advanced small cell lung cancer

BACKGROUND

Malnutrition is frequent in lung cancer and is measured using various tools, including the novel bioelectric impedance technique for measuring body composition. However, the validation of this technique for assessing body composition in advanced small cell lung cancer (SCLC) is untested.

METHODS

Forty-one treatment naïve patients (all males) and an equal number of age- and sex-matched controls were evaluated by anthropometric measurements of skinfold thicknesses and body composition parameters such as body fat%, fat mass, fat-free mass (FFM), and total body water (TBW).

RESULTS

The mean (SD) age of the patient group was 55.7 (7.5) years, median pack-years was 20 (range, 0-80), and mean (SD) duration of symptoms was 152.6 (153.7) days. Median Karnofsky Performance Scale was 70 (range, 50-90). Majority of our patients (68.3%) were Stage IV followed by Stage III (31.7%). The percentage of patients with low, normal, and high body mass index (BMI) was 31.7%, 61%, and 7.3%, respectively. All components of body composition, i.e., body fat%, FFM, and TBW were significantly lower in patients compared to controls. However, the body composition in patients and controls with normal BMI was similar. The phenomenon of sarcopenia as a cause of cancer cachexia may explain these findings, whereas the combination of loss of body fat and lean body mass may lead to weight loss and reduced BMI.

CONCLUSION

Our results indicate that body composition is markedly altered in Indian patients with advanced SCLC. The impact of these parameters on clinically relevant outcomes needs further evaluation.

Malnutrition Identified by the Nutritional Risk Index and Poor Prognosis in Advanced Epithelial Ovarian Carcinoma

Ovarian cancer is a chronic disease with a risk of malnutrition. Nutritional Risk Index (NRI) has been reported as a simple and accurate tool to assess the nutritional status. We sought to explore the prevalence of malnutrition and its association with survival in ovarian cancer. A retrospective study was conducted in 213 advanced ovarian cancer patients. NRI was calculated before and at the end of treatment using patients' body weight and serum albumin level. Overall survival (OS) and progression-free survival (PFS) were estimated by Kaplan-Meier method, and associations were assessed using a Cox proportional hazards analysis adjusted for known prognostic variables. Moderate to severely malnourished patients had lower 5-yr OS (45.3%) compared to normal to mild group (64.0%), respectively (P = 0.024). Adjusted for covariates, the relative risk of death was 5.8 times higher in moderate/severely malnourished group identified at the last course of chemotherapy (HR = 5.896, 95% CI = 2.723-12.764, P < 0.001). Similarly, this cohort had shorter PFS compared with normal to mild risk group (median 15 vs. 28 months, P = 0.011). Malnutrition is prevalent among ovarian cancer patients and is found to be a significant predictor for mortality.

Modeling the energetic cost of cancer as a result of altered energy metabolism: implications for cachexia

Background

Cachexia affects most patients with incurable cancer. We hypothesize that in metastatic cancer the mass of the tumor as well as its level of anaerobic energy metabolism play a critical role in describing its energetic cost, which results in elevated resting energy expenditure and glucose utilization, leading to cachexia. Prior models of cancer cachexia may have underestimated the specific energetic cost of cancer as they have not taken the range of tumor mass and anaerobic energy metabolism fully into account.

Methods

We therefore modelled the energetic cost of cancer as a function of the percentage of energy the cancer produces anaerobically, based on resting energy expenditure, glucose turnover, glucose recycling, and oxygen consumption in cancer patients found in previous studies.

Results

Data from two clinical studies where tumor burden was estimated and resting energy expenditure or oxygen consumption were measured lead to a broad range of estimates of tumor cost from 190 to 470 kcal/kg tumor/day. These values will vary based of the percentage of energy the cancer produces anaerobically (from 0 to 100 %), which in and of itself can alter the cost over a 2 to 3-fold range. In addition to the tumor cost/kg and the degree of anaerobic metabolism, the impact on a given individual patient will depend on tumor burden, which can exceed 1 kg in advanced metastatic disease. Considering these dimensions of tumor cost we are able to produce a 2-dimensional map of potential values, with an overall range of 100–1400 kcal/day.

Conclusions

Quantifying the energetic cost of cancer may benefit an understanding of the tumor’s causation of cachexia. Our estimates of the range of tumor cost include values that are higher than prior estimates and suggest that in metastatic disease the tumor cost could be expected to eclipse attempts to stabilize energy balance through nutrition support or by drug therapies. Tumor mass and the percentage of anaerobic metabolism in the tumor contribute to the cost of the tumor on the body and potentially lead directly to negative energy balance and increased muscle wasting.

Electronic supplementary material

The online version of this article (doi:10.1186/s12976-015-0015-0) contains supplementary material, which is available to authorized users.

NF-κBp65 and Expression of Its Pro-Inflammatory Target Genes Are Upregulated in the Subcutaneous Adipose Tissue of Cachectic Cancer Patients

Cancer cachexia, of which the most notable symptom is severe and rapid weight loss, is present in the majority of patients with advanced cancer. Inflammatory mediators play an important role in the development of cachexia, envisaged as a chronic inflammatory syndrome. The white adipose tissue (WAT) is one of the first compartments affected in cancer cachexia and suffers a high rate of lipolysis. It secretes several cytokines capable of directly regulating intermediate metabolism. A common pathway in the regulation of the expression of pro-inflammatory cytokines in WAT is the activation of the nuclear transcription factor kappa-B (NF-κB). We have examined the gene expression of the subunits NF-κBp65 and NF-κBp50, as well as NF-κBp65 and NF-κBp50 binding, the gene expression of pro-inflammatory mediators under NF-κB control (IL-1β, IL-6, INF-γ, TNF-α, MCP-1), and its inhibitory protein, nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor, alpha (IκB-α). The observational study involved 35 patients (control group, n = 12 and cancer group, n = 23, further divided into cachectic and non-cachectic). NF-κBp65 and its target genes expression (TNF-α, IL-1β, MCP-1 and IκB-α) were significantly higher in cachectic cancer patients. Moreover, NF-κBp65 gene expression correlated positively with the expression of its target genes. The results strongly suggest that the NF-κB pathway plays a role in the promotion of WAT inflammation during cachexia.

Improved body weight and performance status and reduced serum PGE2 levels after nutritional intervention with a specific medical food in newly diagnosed patients with esophageal cancer or adenocarcinoma of the gastro-esophageal junction

BACKGROUND

The majority of cancer patients loses weight and becomes malnourished during the course of their disease. Metabolic alterations and reduced immune competence lead to wasting and an increased risk of infectious complications. In the present study, the effect of a nutritionally complete medical food, which is high in protein and leucine and enriched with fish oil and specific oligosaccharides, was investigated on immune function, nutritional status, and inflammation in patients with esophageal cancer and compared with routine care.

METHODS

In this exploratory double-blind study, 64 newly diagnosed esophageal cancer patients were randomized. All patients received dietary counselling and dietary advice. In the Active group, all patients received the specific medical food for 4 weeks before the start of anticancer therapy. In the routine care control arm, patients with <5% weight loss received a non-caloric placebo product, and patients with weight loss ≥5% received an iso-caloric control product to secure blinding of the study. The required study parameters of body weight and performance status were recorded at baseline and after 4 weeks of nutritional intervention, and patients were asked to complete quality of life questionnaires. In addition, blood samples were taken for the measurement of several immune, nutritional, and safety-parameters.

RESULTS

No effect of the specific nutritional intervention could be detected on ex vivo stimulations of blood mononuclear cells. By contrast, body weight was significantly increased (P < 0.05) and ECOG performance status was improved after intervention with the specific medical food (P < 0.05). In addition, serum Prostaglandin E2 (PGE2) levels were significantly decreased in the specific medical food group and increased in the control group (P = 0.002).

CONCLUSIONS

Nutritional intervention with the specific medical food significantly increased body weight and improved performance status compared with routine care in newly diagnosed esophageal cancer patients. This effect was accompanied by significantly reduced serum PGE2 levels.

The role of dietary nutrition in stomach cancer

Stomach cancer mortality still represents a significant proportion of all cancer deaths. The majority of patients with advanced cancer experience cancer anorexia-cachexia syndrome with weight loss, reduced appetite, fatigue, and weakness. Neoplastic cachexia is a very common clinical manifestation of upper gastrointestinal (GI) tract cancer and is generally assumed to be secondary to the mechanical effects of the tumor on the upper digestive tract. The main reasons are obstruction to swallowing, early satiety, nausea and vomiting. Another reason for weight loss is the co-existence of systemic inflammation. Nutritional treatment in the group of patients with gastric cancer is still used too rarely and the knowledge about it is still very limited. Nutritional support should be given for patients both in the pre- and postoperative period. Nutrition should also be used in palliative treatment in patients with unresectable stomach cancer. The main principles of nutritional support and its influence are presented in this publication.

Cancer cachexia pathophysiology and translational aspect of herbal medicine

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. In particular, tumor necrosis factor-alpha, interleukin-1, interleukin-6 and interferon-gamma have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a depression in protein synthesis, an increase in protein degradation or a combination of both. Cancer patients suffer from the reduction in physical function, tolerance to anti-cancer therapy and survival, while many effective chemotherapeutic agents for cancer are burdened by toxicities that can reduce patient's quality of life or hinder their effective use. Herbal medicines have been widely used to help improve such conditions. Recent studies have shown that herbal medicines such as rikkunshito enhance ghrelin signaling and consequently improve nausea, appetite loss and cachexia associated with cancer or cancer chemotherapy, which worsens the quality of life and life expectancy of the patients. The multicomponent herbal medicines capable of targeting multiple sites could be useful for future drug discovery. Mechanistic studies and identification of active compounds could lead to new discoveries in biological and biomedical sciences.

Cancer cachexia--pathophysiology and management

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Cachexia can have a profound impact on quality of life, symptom burden, and a patient's sense of dignity. It is a very serious complication, as weight loss during cancer treatment is associated with more chemotherapy-related side effects, fewer completed cycles of chemotherapy, and decreased survival rates. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y (NPY) signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a protein synthesis inhibition, an increase in protein degradation, or a combination of both. The best treatment of the cachectic syndrome is a multifactorial approach. Many drugs including appetite stimulants, thalidomide, cytokine inhibitors, steroids, nonsteroidal anti-inflammatory drugs, branched-chain amino acids, eicosapentaenoic acid, and antiserotoninergic drugs have been proposed and used in clinical trials, while others are still under investigation using experimental animals. There is a growing awareness of the positive impact of supportive care measures and development of promising novel pharmaceutical agents for cachexia. While there has been great progress in understanding the underlying biological mechanisms of cachexia, health care providers must also recognize the psychosocial and biomedical impact cachexia can have.

Erlotinib Plus Parenteral Nutrition

This case study details the poor performance status of a patient with non-small cell lung cancer and cancer anorexia–cachexia syndrome got through the hardest days of high tumor burden and malnutrition, by using a combined therapy of lung cancer-targeted therapy drug and parenteral nutrition. The related literatures were reviewed.

Noninvasive Nutritional Management of Ovarian Cancer Patients: Beyond Intestinal Obstruction

Objective

Malnutrition, suffered by more than 50% of patients with ovarian cancer during the course of their disease, significantly compromises the effectiveness of treatment, causes distress, and increases morbidity and mortality. This review outlines the nutritional challenges faced by women with ovarian cancer and evaluates the evidence base for current practice and possible opportunities for intervention in clinical settings.

Methods

PubMed and MetaLib databases were searched for literature on nutrition and cancer/ovarian cancer using terms and truncations covering cancer, cachexia, mouse models, malnutrition, and nutrition intervention. MEDLINE and Cochrane databases were separately searched for interventional studies and clinical and randomized controlled trials published in English (UK/United States) that involved oral nutrition and/or supplementation/intervention in ovarian cancer patients.

Results

Malnutrition continues to be a significant challenge in ovarian cancer management despite significant improvement in treatment pathways and understanding of metabolic pathways and the role of inflammation. There is little evidence of studies designed to evaluate the impact of additional oral nutrients in this population. Seven studies found compared “early” versus “traditional” postoperative oral feeding after major gynecological/oncological surgery, and 1 study evaluated the impact of nutritional status on survival. The 7 studies found evidence of safety, tolerability, reduction in length of hospitalization, and rapid recovery after early feeding. There is no evidence of benefit of additional oral nutrients in this population.

Conclusions

Current guidelines and protocols of nutritional management of ovarian cancer seem to be based on expert opinion. There is need for extensive collaborative evidence for nutritional management decisions made in the treatment of patients. Prospective cohort studies could help evaluate the impact of changes in nutritional status on health/nutritional outcomes, disease recurrence, quality of life, and survival. These would form a basis for well-designed, targeted, randomized controlled trials with specific and controlled nutrients/counseling aimed at preventing rather than treating nutritional complications.

Nutrition in the care of patients with cancer cachexia

Cancer cachexia, a progressive wasting syndrome experienced by approximately 80% of patients, is characterized by loss of adipose tissue and lean body mass. This complex metabolic process reflects both reduced nutrient availability and increased nutritional demand. Though cachexia is most commonly associated with particular tumours, no patient or tumour are excluded. This article provides an overview of cachexia and its pathophysiology and the factors contributing to its development before considering its impact on individuals. Emphasis is placed on the nutritional aspects of its management.

Cachexia, malnutrition, the refeeding syndrome, and lessons from Goldilocks

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death.

L-Carnitine induces recovery of liver lipid metabolism in cancer cachexia

Cancer cachexia causes metabolic alterations with a marked effect on hepatic lipid metabolism. L-Carnitine modulates lipid metabolism and its supplementation has been proposed as a therapeutic strategy in many diseases. In the present study, the effects of L-carnitine supplementation on gene expression and on liver lipid metabolism-related proteins was investigated in cachectic tumour-bearing rats. Wistar rats were assigned to receive 1 g/kg of L-carnitine or saline. After 14 days, supplemented and control animals were assigned to a control (N), control supplemented with L-carnitine (CN), tumour-bearing Walker 256 carcinosarcoma (TB) and tumour-bearing supplemented with L-carnitine (CTB) group. The mRNA expression of carnitine palmitoyltransferase I and II (CPT I and II), microsomal triglyceride transfer protein (MTP), liver fatty acid-binding protein (L-FABP), fatty acid translocase (FAT/CD36), peroxisome proliferator-activated receptor-alpha (PPAR-alpha) and organic cation transporter 2 (OCTN2) was assessed, and the maximal activity of CPT I and II in the liver measured, along with plasma and liver triacylglycerol content. The gene expression of MTP, and CPT I catalytic activity were reduced in TB, who also showed increased liver (150%) and plasma (3.3-fold) triacylglycerol content. L-Carnitine supplementation was able to restore these parameters back to control values (p<0.05). These data show that L-carnitine preserves hepatic lipid metabolism in tumour-bearing animals, suggesting its supplementation to be of potential interest in cachexia.

l-carnitine and cancer cachexia: Clinical and experimental aspects

Cancer cachexia is a multifaceted syndrome characterized, among many symptoms, by extensive muscle wasting. Chronic systemic inflammation, partly triggered and sustained by cytokines, as well as increased oxidative stress contributes to the pathogenesis of this complex metabolic disorder. l-carnitine plays a central role in the metabolism of fatty acids and shows important antioxidant and anti-inflammatory properties. Systemic carnitine depletion has been described in several diseases, and it is characterized by fatigue, muscle weakness, and decreased tolerance to metabolic stress. In cachectic cancer patients, low serum carnitine levels have been reported, and this change has been suggested to play an important contributory role in the development of cachexia. Based on these data, carnitine supplementation has been tested in preliminary studies concerning human cachexia, resulting in improved fatigue and quality of life. We present here a review of clinical and experimental evidence regarding the use of carnitine supplementation in the management of cancer cachexia.

The autophagic tumor stroma model of cancer or "battery-operated tumor growth": A simple solution to the autophagy paradox

The role of autophagy in tumorigenesis is controversial. Both autophagy inhibitors (chloroquine) and autophagy promoters (rapamycin) block tumorigenesis by unknown mechanism(s). This is called the "Autophagy Paradox". We have recently reported a simple solution to this paradox. We demonstrated that epithelial cancer cells use oxidative stress to induce autophagy in the tumor microenvironment. As a consequence, the autophagic tumor stroma generates recycled nutrients that can then be used as chemical building blocks by anabolic epithelial cancer cells. This model results in a net energy transfer from the tumor stroma to epithelial cancer cells (an energy imbalance), thereby promoting tumor growth. This net energy transfer is both unilateral and vectorial, from the tumor stroma to the epithelial cancer cells, representing a true host-parasite relationship. We have termed this new paradigm "The Autophagic Tumor Stroma Model of Cancer Cell Metabolism" or "Battery-Operated Tumor Growth". In this sense, autophagy in the tumor stroma serves as a "battery" to fuel tumor growth, progression and metastasis, independently of angiogenesis. Using this model, the systemic induction of autophagy will prevent epithelial cancer cells from using recycled nutrients, while the systemic inhibiton of autophagy will prevent stromal cells from producing recycled nutrients-both effectively "starving" cancer cells. We discuss the idea that tumor cells could become resistant to the systemic induction of autophagy, by the upregulation of natural endogenous autophagy inhibitors in cancer cells. Alternatively, tumor cells could also become resistant to the systemic induction of autophagy, by the genetic silencing/deletion of pro-autophagic molecules, such as Beclin1. If autophagy resistance develops in cancer cells, then the systemic inhibition of autophagy would provide a therapeutic solution to this type of drug resistance, as it would still target autophagy in the tumor stroma. As such, an anti-cancer therapy that combines the alternating use of both autophagy promoters and autophagy inhibitors would be expected to prevent the onset of drug resistance. We also discuss why anti-angiogenic therapy has been found to promote tumor recurrence, progression and metastasis. More specifically, anti-angiogenic therapy would induce autophagy in the tumor stroma via the induction of stromal hypoxia, thereby converting a non-aggressive tumor type to a "lethal" aggressive tumor phenotype. Thus, uncoupling the metabolic parasitic relationship between cancer cells and an autophagic tumor stroma may hold great promise for anti-cancer therapy. Finally, we believe that autophagy in the tumor stroma is the local microscopic counterpart of systemic wasting (cancer-associated cachexia), which is associated with advanced and metastatic cancers. Cachexia in cancer patients is not due to decreased energy intake, but instead involves an increased basal metabolic rate and increased energy expenditures, resulting in a negative energy balance. Importantly, when tumors were surgically excised, this increased metabolic rate returned to normal levels. This view of cachexia, resulting in energy transfer to the tumor, is consistent with our hypothesis. So, cancer-associated cachexia may start locally as stromal autophagy, and then spread systemically. As such, stromal autophagy may be the requisite precursor of systemic cancer-associated cachexia.

Understanding the "lethal" drivers of tumor-stroma co-evolution: emerging role(s) for hypoxia, oxidative stress and autophagy/mitophagy in the tumor micro-environment

We have recently proposed a new model for understanding how tumors evolve. To achieve successful "Tumor-Stroma Co-Evolution", cancer cells induce oxidative stress in adjacent fibroblasts and possibly other stromal cells. Oxidative stress in the tumor stroma mimics the effects of hypoxia, under aerobic conditions, resulting in an excess production of reactive oxygen species (ROS). Excess stromal production of ROS drives the onset of an anti-oxidant defense in adjacent cancer cells, protecting them from apoptosis. Moreover, excess stromal ROS production has a "Bystander-Effect", leading to DNA damage and aneuploidy in adjacent cancer cells, both hallmarks of genomic instability. Finally, ROS-driven oxidative stress induces autophagy and mitophagy in the tumor micro-environment, leading to the stromal over-production of recycled nutrients (including energy-rich metabolites, such as ketones and L-lactate). These recycled nutrients or chemical building blocks then help drive mitochondrial biogenesis in cancer cells, thereby promoting the anabolic growth of cancer cells (via an energy imbalance). We also show that ketones and lactate help "fuel" tumor growth and cancer cell metastasis and can act as chemo-attractants for cancer cells. We have termed this new paradigm for accelerating tumor-stroma co-evolution, "The Autophagic Tumor Stroma Model of Cancer Cell Metabolism". Heterotypic signaling in cancer-associated fibroblasts activates the transcription factors HIF1alpha and NFκB, potentiating the onset of hypoxic and inflammatory response(s), which further upregulates the autophagic program in the stromal compartment. Via stromal autophagy, this hypoxic/inflammatory response may provide a new escape mechanism for cancer cells during anti-angiogenic therapy, further exacerbating tumor recurrence and metastasis.

Outcome following splenectomy in cats

No studies have yet examined whether there are prognostic factors for survival for cats undergoing splenectomies. The medical records of 19 cats that had complete splenectomy were reviewed for information on preoperative, intraoperative, and postoperative factors. The most common presenting signs were a palpable abdominal mass in 58% and anorexia in 47% of the cats. Mast cell tumors were the most common reason for splenectomy and were found in 10/19 cats (53%); followed by hemangiosarcoma in 4/19 (21%); and lymphoma in 2/19 (11%). The Kaplan-Meier median survival time (MST) was 197 days, with a range from 2 days to 1959 days. Three cats were noted to have preoperative weight loss, and this was the only factor that had prognostic significance for survival following surgery. For cats with weight loss the MST was 3 days, for cats with no weight loss noted the MST was 293 days (P=0.008).

Attenuation of proteolysis and muscle wasting by curcumin c3 complex in MAC16 colon tumour-bearing mice

Muscle wasting or cachexia is caused by accelerated muscle protein breakdown via the ubiquitin-proteasome complex. We investigated the effect of curcumin c3 complex (curcumin c3) on attenuation of muscle proteolysis using in vitro and in vivo models. Our in vitro data indicate that curcumin c3 as low as 0.50 microg/ml was very effective in significantly inhibiting (30 %; P < 0.05) tyrosine release from human skeletal muscle cells, which reached a maximum level of inhibition of 60 % (P < 0.05) at 2.5 microg/ml. Curcumin c3 at 2.5 microg/ml also inhibited chymotrypsin-like 20S proteasome activity in these cells by 25 % (P < 0.05). For in vivo studies, we induced progressive muscle wasting in mice by implanting the MAC16 colon tumour. The in vivo data indicate that low doses of curcumin c3 (100 mg/kg body weight) was able to prevent weight loss in mice bearing MAC16 tumours whereas higher doses of curcumin c3 (250 mg/kg body weight) resulted in approximately 25 % (P < 0.05) weight gain as compared with the placebo-treated animals. Additionally, the effect of curcumin c3 on preventing and/or reversing cachexia was also evident by gains in the weight of the gastrocnemius muscle (30-58 %; P < 0.05) and with the increased size of the muscle fibres (30-65 %; P < 0.05). Furthermore, curcumin inhibited proteasome complex activity and variably reduced expression of muscle-specific ubiquitin ligases: atrogin-1/muscle atrophy F-box (MAFbx) and muscle RING finger 1 (MURF-1). In conclusion, oral curcumin c3 results in the prevention and reversal of weight loss. The data imply that curcumin c3 may be an effective adjuvant therapy against cachexia.

Inflammation and mitochondrial fatty acid beta-oxidation link obesity to early tumor promotion

Obesity is associated with increased risk for developing pancreatic cancer, and it is suggested that insulin resistance provides the missing link. Here we demonstrate that under the context of genetic susceptibility, a high fat diet (HFD) predisposes mice with oncogenic K-ras activation to accelerated pancreatic intraepithelial neoplasm (PanIN) development. Tumor promotion is closely associated with increased inflammation and abrogation of TNFR1 signaling significantly blocks this process underlining a central role for TNFalpha in obesity-mediated enhancement of PanIN lesions. Interestingly, however, despite increased TNFalpha levels, mice remain insulin sensitive. We show that, while aggravating tumor promotion, a HFD exerts dramatic changes in energy metabolism through enhancement of pancreatic exocrine insufficiency, metabolic rates, and expression of genes involved in mitochondrial fatty acid (FA) beta-oxidation that collectively contribute to improved glucose tolerance in these mice. While on one hand these findings provide significant evidence that obesity is linked to tumor promotion in the pancreas, on the other it suggests alterations in inflammatory responses and bioenergetic pathways as the potential underlying cause.

Rehabilitation in primary and metastatic brain tumours: impact of functional outcomes on survival

OBJECTIVES

Patients with brain tumours have major disabilities and guarded prognosis but may benefit from inpatient rehabilitation.The objectives were to compare functional outcomes inpatients with glioblastoma multiforme(GBM), brain metastases and other brain tumours, and to determine predictors of survival.

METHODS

Demographic, clinical,functional, and survival data were collected for 63 patients.Kaplan-Meier and Cox regression were used for survival analyses.

RESULTS

Functional Independence Measure(FIM ) scores improved from admission to discharge for patients with GBM, brain metastases and other tumours. Estimated median survival was 141 days for brain metastases, 214 days for GBM and 439 days for other tumours. Low admission dexamethasone dose and high FIM gain predicted better survival in GBM. For brain metastases, high FIM gain, low dexamethasone dose and no organ metastases were positive prognostic factors.

CONCLUSIONS

Patients with primary and metastatic brain tumours achieved functional gains after rehabilitation. High functional improvement is a significant predictor of longer survival in brain metastases and GBM. This study has implications for rehabilitation in the post-acute management of patients who have disabilities due to brain tumours.

Bioelectric impedance spectroscopy underestimates fat-free mass compared to dual energy X-ray absorptiometry in incurable cancer patients

BACKGROUND/OBJECTIVES

Weight loss is frequently seen in advanced cancer. Bioelectrical impedance spectroscopy (BIS) is a convenient method for estimating body composition. We examined in a prospective, comparative study if BIS could accurately estimate fat-free mass (FFM) in cancer patients compared to dual-energy X-ray absorptiometry (DXA).

SUBJECTS/METHODS

The study was based on 132 consecutive incurable cancer patients with solid tumours in a University hospital outpatient clinic. Comparison of FFM from DXA and BIS with standard and revised equations. Bland-Altman plots, t-tests and linear regression analysis were used to evaluate agreement and differences between methods.

RESULTS

BIS significantly underestimated mean FFM with 7.6+/-4.7 kg compared to DXA (P<0.001). Bias was significantly correlated to % weight loss (r=0.32), systemic inflammation as measured by C-reactive protein (r=0.29), malnutrition as assessed by low insulin-like growth factor-1 (r=-0.23) and inversely to the per cent body fat estimated by DXA (P=-0.61) and body mass index (BMI; r=-0.30). Revised BIS equations taking BMI into account reduced bias significantly but still with great individual variation.

CONCLUSIONS

BIS by standard equations grossly underestimates FFM compared to DXA in cancer patients. This bias is related to weight loss, malnutrition and systemic inflammation. Revised equations improved FFM estimates, but with large individual variation. Thus, BIS with standard equations is not suitable to estimate FFM in patients with cachexia, inflammation and malnutrition.

Computational modeling of cancer cachexia

PURPOSE OF REVIEW

Measurements of whole-body energy expenditure, body composition, and in-vivo metabolic fluxes are required to quantitatively understand involuntary weight loss in cancer cachexia. Such studies are rare because cancer cachexia occurs near the end of life when invasive metabolic tests may be precluded. Thus, models of cancer-associated weight loss are an important tool for helping to understand this debilitating condition.

RECENT FINDINGS

A computational model of human macronutrient metabolism was recently developed that simulates the normal metabolic adaptations to semi-starvation and re-feeding. Here, this model was used to integrate data on the metabolic changes in patients with cancer cachexia. The resulting computer simulations show how the known metabolic disturbances synergize with reduced energy intake to result in a progressive loss of body weight, fat mass, and fat-free mass. The model was also used to simulate the effects of nutritional support and investigate inhibition of lipolysis versus proteolysis as potential therapeutic approaches for cancer cachexia.

SUMMARY

Computational modeling is a new tool that can integrate clinical data on the metabolic changes in cancer cachexia and provide a conceptual framework to help understand involuntary weight loss and predict the effects of potential therapies.

Critical Evaluation of Nutrition Screening Tools Recommended for Oncology Patients

Malnutrition ranges from 20% to 80% in oncology patients. Malnutrition has been associated with reduced response to treatment, survival, and quality of life. Therefore, screening for malnutrition in patients with cancer is recommended by clinical practice groups including the Oncology Nursing Society. Nurses are in an ideal position to carry out nutrition screening. Three nutrition screening tools that have been recommended for use with oncology patients by the Oncology Nursing Society are critically evaluated. The Patient Generated-Subjective Global Assessment has demonstrated diagnostic value in oncology patients at risk of malnutrition or who are malnourished.

Nutritional treatment of cancer cachexia in rats

BACKGROUND

Terminal cancer-associated cachexia, characterized by a marked weight loss, anorexia, asthenia and anemia, is usually associated with a malnutrition status.

AIM OF THE STUDY

To investigate whether a diet formulated with a crayfish enzymatic extract, enriched in essential amino acids, omega-3 fatty acids, and astaxanthin, would be effective for the treatment of cancer-associated cachexias, by decreasing mortality and morbidity rates in cachectic rats and/or improving survival.

METHODS

Two types of diet were used: a standard diet and one formulated with crayfish enzymatic extract. Rats were divided into two groups (24 animals per group): one without tumor (T-) and the other with tumor (T+) (AH-130 Yoshida ascites hepatoma). Each group was further divided into two subgroups (12 animals per subgroup). Two subgroups (T-(standard) and T+(standard)) were fed the standard diet and the other two (T-(CFEE) and T+(CFEE)) the crayfish enzymatic extract one for four weeks, after which different tissue and plasma parameters were studied.

RESULTS

The implantation of the tumor resulted in a considerable loss of muscle and adipose tissue mass in both groups, but the loss of muscle and fat was lower in the group fed the crayfish enzymatic extract diet. There was also a concomitant increase in the plasma concentration of TNF-alpha, although the increase was smaller in the crayfish enzymatic extract-treated group.

CONCLUSION

This study shows that although the treatment of cachetic rats with the crayfish enzymatic extract diet did not revert the cachexia, it increased survival (57.1% vs. 25.9% in the group treated with crayfish enzymatic extract and standard diets, respectively) and meliorated the cachexia symptoms--anorexia and body mass loss (muscle and adipose tissue).

Anorexia in cancer: role of feeding-regulatory peptides

Anorexia is one of the most common symptoms in advanced cancer and is a frequent cause of discomfort for cancer patients and their families. The pathogenesis of cancer anorexia is multi-factorial and involves most of the hypothalamic neuronal signalling pathways modulating energy homeostasis. It is considered to be the result of a failure of usual appetite and satiety signals. Loss of appetite can arise from decreased taste and smell of food, as well as from dysfunctional hypothalamic signalling pathways and cytokine production. Cytokines in particular, appear to play a key role in energy balance through persistent activation of the melanocortin system and inhibition of the neuropeptide Y pathway. The imbalance between anorexigenic and orexigenic peptides leads to suppression of appetite, and increased satiety and satiation associated with marked weight loss and decline in physical performance. High levels of serotonin also appear to contribute to these effects and recent findings implicate corticotropin-releasing factor in the pathogenesis of cancer anorexia as well. Despite significant advances in our understanding of the regulation of food intake and energy expenditure, few effective therapies are available. A better appreciation of the molecular and neuronal mechanisms that control body weight homeostasis may lead to the development of new therapies for improving the survival and quality of life of these patients.

β-Hydoxy-β-methylbutyrate supplementation affects Walker 256 tumor-bearing rats in a time-dependent manner

BACKGROUND & AIMS

Cancer cachexia affects intermediary metabolism with intense and general catabolism. Walker 256 tumor is a model injected either subcutaneously (Sc) or intraperitoneally (Ip), with different metabolic features. Beta-hydroxy beta-methylbutyrate (HMbeta) is a leucine metabolite with anti-catabolic properties, the aim of this study being to investigate its effects on metabolic parameters in both tumor models.

METHODS

Controls (subcutaneous control group (ScC) and intraperitoneal control group (IpC)) and supplemented animals (subcutaneous supplemented group (ScS) and intraperitoneal supplemented group (IpS)) showed these results.

RESULTS

Protein Sc values were (47.8%) lower than Ip groups. Sc group fat content was (65.16%) higher than Ip groups. Liver glycogen value for Sc groups was (38.4%) higher than Ip groups. Muscle glycogen value for Sc groups were (2.75 times) higher than Ip groups. Corticosterone and insulin values were lower (44.53%) and higher (45.94%), respectively, in Sc when compared with Ip groups. Glucose and lactate values for ScS were the lowest (61.7% and 41.53%) compared to other groups. ScC glutamine value was the highest (40.8%) of all groups. Glutamate Sc values were (42.65%) lower than Ip groups. Sc groups showed greater survival time compared with Ip groups. ScS group showed 100% increase in survival time when compared with ScC.

CONCLUSIONS

HMbeta supplementation can increase survival time and promotes metabolic changes in cancer-bearing animals, but it seems to work in a time-dependent manner.

The influence of early supplementation of parenteral nutrition on quality of life and body composition in patients with advanced cancer

BACKGROUND

According to current evidence, most organizations, including the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), do not recommend the routine use of artificial nutrition for patients with cancer. Despite the recommendation for parenteral nutrition (PN), data for early PN supplementation (PNS) in patients with an advanced malignancy are extremely limited, especially in terms of the affects on nutrition outcomes, body composition, and quality of life (QOL), as well as effects on oncologic outcomes. The aim of the study was to evaluate the effect of PNS on body composition and the quality of life in patients with advanced malignancies.

METHODS

One hundred fifty-two consecutive patients with advanced cancer were prospectively randomized to either use of oral enteral nutrition supplement (PN-) or use of oral enteral nutrition supplement plus supplemental PN (PN+). Body weight, body mass index (BMI), and caloric intake were assessed, and hemoglobin (g/dL) and serum albumin (g/L) were measured. Body composition was assessed by body impedance analysis (BIA), and QOL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire every 6 weeks.

RESULTS

No significant differences were evident at baseline between the 2 groups for age, gender, medical diagnosis, weight, BMI, or QOL. A statistically significant difference in mean BMI was observed by week 48 for the PN+ group (PN+ = 21.9, PN-= 20.5, p = .0149), by week 6 in mean body cell mass (PN+ = 55%, PN-= 50,1%, p < .001), mean albumin (PN+ = 40.2 g/L, PN-= 36.2 g/L, p = .015), mean QOL (PN+ = 55.7, PN-= 50.9, p = .035). The cumulative survival rate was significantly greater in the PN+ group (p < .0001).

CONCLUSIONS

According to the positive effect of supplemental PN on survival, body composition, and QOL, additional controlled studies must be conducted to confirm these findings.

Anorexia–Cachexia syndrome in cancer: implications of the ubiquitin–proteasome pathway

INTRODUCTION

Malnutrition is a common problem in cancer patients. Its incidence varies according to disease stage (between 15 and 90%) and is considered a possible prognostic factor for therapeutic response and survival. It is also one of the causes contributing to the increase in morbidity and mortality in patients. Tumor cachexia is defined as a nutritional defect caused by tumor growth in the patient and presents as a significant weight loss. This weight loss is mainly caused by a degradation of skeletal muscle proteins.

CONCLUSION

The ubiquitin-proteasome system is the most important pathway of protein degradation. As a regulatory system governing protein half-life, it is involved in the regulation of the cell cycle, signal transmission, immune system response, apoptosis, and oncogenesis. Knowledge of the molecular pathways involved in the induction of cancer-associated cachexia will favor a more rational approach to its treatment as well as possible quality of life and survival benefit for the patient.

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.