The Cancer Cachexia Syndrome

Effects of a combined exercise and dietary intervention on body composition, physical functioning and fatigue in patients with ovarian cancer: results of the PADOVA trial

BACKGROUND

Guidelines recommend to include exercise and dietary advice in standard care for patients with cancer, based on evidence primarily derived from patients with breast cancer. Its applicability to patients with ovarian cancer is uncertain due to differences in patient characteristics and treatments. The PADOVA trial examined the effectiveness of a combined exercise and dietary intervention on fat-free mass (FFM), physical functioning, and fatigue.

METHODS

In total, 81 patients with ovarian cancer were randomised to the exercise and dietary intervention (n = 40) or control (n = 41) group. Measurements were performed before chemotherapy, after chemotherapy, and 12 weeks later. FFM was assessed by bioelectrical impedance analysis, and physical functioning and fatigue were assessed using questionnaires. Intervention effects were assessed on an intention-to-treat basis using linear mixed models.

RESULTS

FFM and physical functioning increased, and fatigue decreased significantly over time in both groups. No significant difference between the groups were found for FFM (β = -0.5 kg; 95% CI = -3.2; 2.1), physical functioning (β = 1.4; 95% CI = -5.4; 8.3) and fatigue (β = 0.7; 95% CI = -1.5; 2.8).

CONCLUSIONS

During treatment, both groups improved in FFM, physical functioning, and fatigue. The intervention group, however, did not demonstrate additional benefits compared to the control group. This highlights the need for caution when extrapolating findings from different cancer populations to patients with ovarian cancer.

Randomised controlled trial testing the feasibility of an exercise and nutrition intervention for patients with ovarian cancer during and after first-line chemotherapy (BENITA-study)

OBJECTIVES

Advanced ovarian cancer is a severe disease with major side effects caused by peritoneal carcinomatosis, ascites and gastrointestinal involvement as well as exhaustive treatment like debulking surgery and combination chemotherapy. Two most frequently reported side effects are muscle wasting and malnutrition, leading to frailty, decreased health-related quality of life (HRQoL) and cancer-related fatigue (CRF). As muscle wasting and malnutrition often commence during first-line chemotherapy and develop progressively into a refractory state, an early intervention is warranted. This pilot study aimed to evaluate the safety and acceptance of a combined exercise and nutrition intervention during and after first-line chemotherapy.

DESIGN

The pilot study was conducted as a monocentric 1:1 randomised controlled trial (RCT) with an intervention group (IG) and a control group (CG). Participants were divided by chance into IG or CG. Information on group allocation was conveyed to the study coordinator responsible for making an appointment with the patients for the baseline assessment as well as the physiotherapist and nutritionist responsible for the intervention and outcome assessment in both groups.

PARTICIPANTS

Eligibility criteria included women ≥18 years of age, diagnosed with ovarian cancer, tubal cancer or peritoneal cancer and primary or interval debulking, scheduled but not started adjuvant or neoadjuvant chemotherapy and sufficient German-language skills.

INTERVENTION

The IG received a 12-month exercise and nutrition programme, the CG continued to follow usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were recruitment rate, adherence to intervention, completion rate and adverse events. In addition, in-person assessments (eg, HRQoL, CRF, muscle quality and function and dietary intake and quality) were conducted at baseline (T0, before chemotherapy), week 9 (T1, mid-chemotherapy), week 19 (T2, after completion of chemotherapy) and after 12 months of intervention (T3).

RESULTS

Of 60 eligible patients, 15 patients signed informed consent (recruitment rate=25.0%) and were randomised into IG (n=8) and CG (n=7). Eleven participants completed the study (completion rate, 73.3%), one patient dropped out due to loss of interest, one due to poor health, one was lost to follow-up and one patient died.

CONCLUSION

The BENITA (Bewegungs- und Ernährungsintervention bei Ovarialkrebs) study demonstrated the safety and acceptance of an exercise and nutrition intervention integrated into first-line therapy and follow-up care of ovarian cancer. A large multicentre RCT is planned to investigate the effectiveness of the intervention on HRQoL, CRF and survival and to establish means of implementation into oncology guidelines and clinic routine.

TRIAL REGISTRATION NUMBER

DRKS00013231.

Randomized Phase II Study of Gemcitabine Monotherapy vs. Gemcitabine with an EPA-Enriched Oral Supplement in Advanced Pancreatic Cancer

BACKGROUND

Pancreatic cancer is often associated with cachexia. It had been reported that eicosapentaenoic acid (EPA) improve cachexia. This study aimed to evaluate the efficacy and safety of gemcitabine with an EPA-enriched oral supplement in patients with advanced pancreatic cancer.

METHODS

This open-label phase II study consisted of patients (pts) who were randomly categorized into the EPA group (1,000 mg/m² gemcitabine was administered on day 1, 8, and 15, every 4 weeks while an EPA-enriched oral supplement (prosure®, EPA 1.056 mg per pack) was taken daily at the maximum of two packs or the gemcitabine monotherapy group with an allocation ratio of 2:1. The primary endpoint was the evaluation of the 1-year survival estimating 10% addition.

RESULTS

Randomized 68 pts were examined (EPA: 45, gemcitabine: 23). The 1-year survival probability of the EPA group was 35% while the gemcitabine group was 19%. The median survival times were 8.2 and 9.7 mo, respectively. The hazard ratio for EPA group was 0.79 [95% CI 0.46-1.37]; (P = 0.40). The toxicities were mild and insignificant in both groups. More beneficial effects of EPA in survival were observed in men, pancreatic body-tail and low C-reactive protein patients.

CONCLUSION

An EPA-enriched oral supplement may be effective in advanced pancreatic cancer.

Nutrition in Cancer Patients

Background: Despite being recognised that nutritional intervention is essential, nutritional support is not widely accessible to all patients. Given the incidence of nutritional risk and nutrition wasting, and because cachexia management remains a challenge in clinical practice, a multidisciplinary approach with targeted nutrition is vital to improve the quality of care in oncology. Methods: A literature search in PubMed and Cochrane Library was performed from inception until 26 March. The search consisted of terms on: cancer, nutrition, nutritional therapy, malnutrition, cachexia, sarcopenia, survival, nutrients and guidelines. Key words were linked using “OR” as a Boolean function and the results of the four components were combined by utilizing the “AND” Boolean function. Guidelines, clinical trials and observational studies written in English, were selected. Seminal papers were referenced in this article as appropriate. Relevant articles are discussed in this article. Results: Recent literature supports integration of nutrition screening/assessment in cancer care. Body composition assessment is suggested to be determinant for interventions, treatments and outcomes. Nutritional intervention is mandatory as adjuvant to any treatment, as it improves nutrition parameters, body composition, symptoms, quality of life and ultimately survival. Nutrition counselling is the first choice, with/without oral nutritional supplements (ONS). Criteria for escalating nutrition measures include: (1) 50% of intake vs. requirements for more than 1–2 weeks; (2) if it is anticipated that undernourished patients will not eat and/or absorb nutrients for a long period; (3) if the tumour itself impairs oral intake. N-3 fatty acids are promising nutrients, yet clinically they lack trials with homogeneous populations to clarify the identified clinical benefits. Insufficient protein intake is a key feature in cancer; recent guidelines suggest a higher range of protein because of the likely beneficial effects for treatment tolerance and efficacy. Amino acids for counteracting muscle wasting need further research. Vitamins/minerals are recommended in doses close to the recommended dietary allowances and avoid higher doses. Vitamin D deficiency might be relevant in cancer and has been suggested to be needed to optimise protein supplements effectiveness. Conclusions: A proactive assessment of the clinical alterations that occur in cancer is essential for selecting the adequate nutritional intervention with the best possible impact on nutritional status, body composition, treatment efficacy and ultimately reducing complications and improving survival and quality of life.

Serum Interleukin-6 Levels Correlate with Malnutrition and Survival in Patients with Advanced Non-Small Cell Lung Cancer

Aim

To investigate the level of interleukin-6 in advanced non-small cell lung cancer and to analyze the relationship with malnutrition and survival.

Methods and study design

Seventy-one newly diagnosed advanced non-small cell lung cancer patients were enrolled in this prospective study. Malnutrition was defined by using subjective global assessment. Performance status was assessed by the Karnofsky scale. Serum levels of albumin, transferrin, C-reactive protein, lymphocytes/mm3, lactate dehydrogenase and growth hormone were determined before treatment. The patients were followed, and the factors affecting survival were analyzed.

Results

The mean follow-up after diagnosis was 180 days. IL-6 levels increased in 48 (68%) of 71 patients. According to the subjective global assessment, 28 (39%) patients were well nourished and 43 (61%) were malnourished. Of the 43 malnourished patients, 29 (41%) were moderately malnourished or suspected of being malnourished and 14 (20%) were severely malnourished. The IL-6 level was related to impaired performance status (P = 0.0001), severe malnutrition (P = 0.004), increased C-reactive protein (P = 0.013), higher growth hormone (P = 0.025) and transferrin (P = 0.03) levels. On univariate analysis, impaired performance status, moderate and severe malnutrition, decreased serum albumin and transferrin, a raised IL-6 and lactate dehydrogenase levels were the significant prognostic factors for survival. Multivariate analysis indicated that a raised IL-6, severe malnutrition and a low serum level of albumin were independent prognostic factors for survival in patients with advanced non-small cell lung cancer.

Conclusions

IL-6 secretion may play a role in the pathophysiology of malnutrition in advanced lung cancer. Results show a relation between elevated IL-6 serum levels and malnutrition, poor performance status, acute phase response and shorter survival in patients affected by advanced non-small cell lung cancer.

Chemotherapy-Related Toxicity, Nutritional Status and Quality of Life in Precachectic Oncologic Patients with, or without, High Protein Nutritional Support. A Prospective, Randomized Study

Background: Cancer disease is usually associated with impaired nutritional status, which is one of the factors contributing to deterioration of the results of surgery, chemotherapy or radiotherapy. Objectives: The aim of the study was to determine whether nutritional support with high protein (ONS) in adult oncologic patients in the first step of cancer cachexia—asymptomatic precachexia, has an influence on the toxicity of systemic therapy. However, secondary endpoints were established: to determine whether high protein ONS influences the nutritional status, the quality of life, and the performance status. Materials and Methods: A total of 114 persons aged 40–84 years old with colorectal cancer were examined. Based on the randomization, 47 patients were qualified to the interventional group (ONS group) and 48 to Control group. To evaluate the nutritional status NRS-2002 (Nutritional Risk Screening), SGA (Subjective Global Assessment), SCRINIO (SCReenIng the Nutritional status In Oncology) Working Group classification, VAS (Visual Analog Scale) for appetite was used. FAACT (Functional Assessment of Anorexia/Cachexia Therapy) questionnaire was used for assessment of the quality of life. The health status of patients was evaluated based on the Karnofsky Performance Scale. Anthropometric measurements were done. Results: Severe complications of chemotherapy, which caused the end of treatment, a slight complication of the gastrointestinal tract such as diarrhea grade 2 according to ECOG (Eastern Cooperative Oncology Group) score regardless of the studied group, were observed. There were no statistical differences in the number and severity of the observed complications, i.e., neutropenia, leucopenia, thrombocytopenia, anemia, abdominal pain, nausea and vomiting, and diarrhea. During the follow-up the significant changes of SGA, VAS, albumin and prealbumin were observed between groups. In the ONS group an improvement in nutritional status was noticed (increased appetite VAS, p = 0.05; increased points in SGA, p = 0.015, and increased levels of albumin and prealbumin, p = 0.05). In Control group nutritional status was stable during observation. The performance status and quality of life were stable in both groups. No statistical differences between groups (ONS vs. Control) in the numbers for disqualification, resignation, delay in treatment, or dose reduction were observed. Conclusions: Results of the study did not indicate that nutritional support in precachectic oncologic patients influenced the toxicity of systemic therapy. High protein nutritional support improved nutritional status assessed by SGA, VAS for appetite, albumin, and prealbumin. The performance status and quality of life were stable throughout the observation and were not changed under the supplementation.

Evaluation of Weight Change During Carboplatin Therapy in Dogs With Appendicular Osteosarcoma

Background

The prevalence of cancer cachexia in veterinary medicine has not been studied widely, and as of yet, no definitive diagnostic criteria effectively assess this syndrome in veterinary patients.

Objectives

(1) To determine the patterns of weight change in dogs with appendicular osteosarcoma treated with amputation and single‐agent carboplatin during the course of adjuvant chemotherapy; and (2) to determine whether postoperative weight change is a negative prognostic indicator for survival time in dogs with osteosarcoma.

Animals

Eighty‐eight dogs diagnosed with appendicular osteosarcoma. Animals were accrued from 3 veterinary teaching hospitals.

Methods

Retrospective, multi‐institutional study. Dogs diagnosed with appendicular osteosarcoma and treated with limb amputation followed by a minimum of 4 doses of single‐agent carboplatin were included. Data analyzed in each patient included signalment, tumor site, preoperative serum alkaline phosphatase activity (ALP), and body weight (kg) at each carboplatin treatment.

Results

A slight increase in weight occurred over the course of chemotherapy, but this change was not statistically significant. Weight change did not have a significant effect on survival. Institution, patient sex, and serum ALP activity did not have a significant effect on survival.

Conclusions and Clinical Importance

Weight change was not a prognostic factor in these dogs, and weight loss alone may not be a suitable method of determining cancer cachexia in dogs with appendicular osteosarcoma.

Effects of an oral nutritional supplement containing eicosapentaenoic acid on nutritional and clinical outcomes in patients with advanced non-small cell lung cancer: randomised trial

BACKGROUND

Nutritional interventions have shown increased energy intake but not improvement in health-related quality of life (HRQL) or prognosis in non small cell lung cancer (NSCLC) patients. Eicosapentaenoic acid has been proposed to have anti-inflammatory, anticachectic and antitumoural effects.

OBJECTIVE

To compare the effect of an oral EPA enriched supplement with an isocaloric diet on nutritional, clinical and inflammatory parameters and HRQL in advanced NSCLC patients.

DESIGN

Patients with advanced NSCLC were randomized to receive diet plus oral nutritional supplement containing EPA (ONS-EPA) or only isocaloric diet (C). All patients received paclitaxel and cisplatin/carboplatin treatment. Weight, body composition, dietary intake, inflammatory parameters and HRQL were assessed at baseline and after the first and second cycles of chemotherapy. Response to chemotherapy and survival were evaluated.

RESULTS

Ninety two patients were analysed (46 ONS-EPA,46 C). ONS-EPA group had significantly greater energy (p < 0.001) and protein (p < 0.001) intake compared with control. Compared with baseline, patients receiving the ONS-EPA gained 1.6 ± 5 kg of lean body mass (LBM) compared with a loss of -2.0 ± 6 kg in the control (p = 0.01). Fatigue, loss of appetite and neuropathy decreased in the ONS-EPA group (p ≤ 0.05). There was no difference in response rate or overall survival between groups.

CONCLUSION

Patients with NSCLC receiving ONS-EPA significantly improves energy and protein intake, body composition. and decreased fatigue, loss of appetite and neuropathy. Registered with ClinicalTrials.gov (NCT01048970).

Connexin- and pannexin-based channels in normal skeletal muscles and their possible role in muscle atrophy

Precursor cells of skeletal muscles express connexins 39, 43 and 45 and pannexin1. In these cells, most connexins form two types of membrane channels, gap junction channels and hemichannels, whereas pannexin1 forms only hemichannels. All these channels are low-resistance pathways permeable to ions and small molecules that coordinate developmental events. During late stages of skeletal muscle differentiation, myofibers become innervated and stop expressing connexins but still express pannexin1 hemichannels that are potential pathways for the ATP release required for potentiation of the contraction response. Adult injured muscles undergo regeneration, and connexins are reexpressed and form membrane channels. In vivo, connexin reexpression occurs in undifferentiated cells that form new myofibers, favoring the healing process of injured muscle. However, differentiated myofibers maintained in culture for 48 h or treated with proinflammatory cytokines for less than 3 h also reexpress connexins and only form functional hemichannels at the cell surface. We propose that opening of these hemichannels contributes to drastic changes in electrochemical gradients, including reduction of membrane potential, increases in intracellular free Ca(2+) concentration and release of diverse metabolites (e.g., NAD(+) and ATP) to the extracellular milieu, contributing to multiple metabolic and physiologic alterations that characterize muscles undergoing atrophy in several acquired and genetic human diseases. Consequently, inhibition of connexin hemichannels expressed by injured or denervated skeletal muscles might reduce or prevent deleterious changes triggered by conditions that promote muscle atrophy.

Inflammation in cancer cachexia: to resolve or not to resolve (is that the question?)

BACKGROUND & AIMS

Cachexia is associated with poor prognosis and shortened survival in cancer patients. Growing evidence points out to the importance of chronic systemic inflammation in the aetiology of this syndrome. In the recent past, chronic inflammation was considered to result from overexpression and release of pro-inflammatory factors. However, this conception is now the focus of debate, since the importance of a crescent number of pro-resolving agents in the dissolution of inflammation is now recognised--leading to the hypothesis that chronic inflammation occurs rather due to failure in the resolution process. We intend to put forward the possibility that this may also be occurring in cancer cachexia.

METHODS

Recent reviews on inflammation and cachexia, and on the factors involved in the resolution of inflammation are discussed.

RESULTS

The available information suggests that indeed, inflammation resolution failure may be present in cachexia and therefore we speculate on possible mechanisms.

CONCLUSIONS

We emphasise the importance of studying resolution-related mechanisms in cancer cachexia and propose the opening of a new venue for cachexia treatment.

Understanding weight loss in patients with colorectal cancer: a human response to illness

PURPOSE/OBJECTIVES

To provide a comprehensive overview of weight loss in patients with colorectal cancer (CRC) within the context of the Human Response to Illness (HRTI) model.

DATA SOURCES

Research from 1990-2008 and classic research from the 1980s were included. PubMed, CINAHL(R), and Google Scholar were searched for the terms cancer, CRC, weight loss, and cancer cachexia.

DATA SYNTHESIS

Progressive, unintentional weight loss is a common issue in patients with CRC that has a devastating effect on patients' self-image, quality of life, and survival. Physiologic abnormalities, responses to the tumor, and treatments contribute to weight loss in these patients. In addition, cancer cachexia is an end-stage wasting syndrome and a major cause of morbidity and mortality in this population.

CONCLUSIONS

The HRTI model provides an appropriate framework to gain a comprehensive understanding of the physiologic, pathophysiologic, behavioral, and experiential perspectives of weight loss and cancer cachexia in patients with CRC.

IMPLICATIONS FOR NURSING

By examining weight loss in patients with CRC within the context of the four perspectives of the HRTI model, oncology and gastroenterology nurses can gain insight into optimal, evidence-based assessment and management of this patient population. In addition, current gaps in knowledge can be identified and provide guidance for future nursing research.

Quantifying the impact of standardized assessment and symptom management tools on symptoms associated with cancer-induced anorexia cachexia syndrome

The objective of this study was to quantify the impact of standardized assessment and management tools on patient symptom scores in cancer-induced anorexia cachexia syndrome (ACS) using a within-group study design. Baseline assessments included the Patient Generated Subjective Global Assessment (PG-SGA) tool and an amended Symptoms and Concerns Checklist (SCC). Symptom management strategies, written for this project, were instigated. Follow-up SCC scores were collected at 2 and 4 weeks. Forty out of 79 patients referred were recruited; 29/79 (36.7%) were too unwell or had died prior to consent. At baseline, the PG-SGA tool revealed 250 active symptoms associated with ACS. Total PG-SGA score was above 9 for all patients. Predominant interventions involved simple dietary advice and prescription of artificial saliva, mouthwash and prokinetic antiemetics. Median total SCC score improved sequentially from 11 at baseline, to 7 and 4 at first and second review, respectively (visit 1 to 2, p = 0.001; visit 1 to 3, p < 0.001; and visit 2 to 3, p = 0.02). We conclude that patients with ACS are recognised late in their disease and have a considerable burden of active symptoms. A structured approach to assessment and management has a significant impact on symptom burden.

Colorectal Cancer: Intrinsic Characteristics Modulate Cancer Energy Expenditure and the Risk of Cachexia

PURPOSE

To conduct a prospective longitudinal study in colorectal cancer (CRC) patients: 1) to evaluate resting energy expenditure (REE), weight/dietary intake changes, and response to treatment, taking into consideration cancer stage and histology; 2) to determine their potential interrelations; and 3) to quantify the relative contributions to REE of cancer/nutrition/treatment.

PATIENTS AND METHODS

101 CRC patients proposed for neoadjuvant radiotherapy (RT) were evaluated before and after RT: REE (indirect calorimetry measurements), percentage of weight loss, usual diet (diet history), current diet (24 hour recall), and treatment response.

RESULTS

REE was higher in Stages III/IV versus I/II, at the RT onset (p < 0.002) and end (p = 0.02), and in moderately/poorly/undifferentiated cancers vs well differentiated (onset, p < 0.001) and (RT end, p = 0.01); weight/intake reductions were also greater in Stages III/IV versus I/II (p < 0.01) and in moderately/poorly/undifferentiated cancers versus well differentiated (p < 0.02). According to patients' response to treatment, REE was increased in Stage III/IV (p < 0.005) and Grade 2/3 histology (p < 0.003). In nonresponders, REE increased 7.2 +/- 1.3 kcal/kg/day and decreased 2.8 +/- 0.4 kcal/kg/day in responders. REE changes were not-significantly influenced by weight/intake. Relative contributions to baseline REE were determined in 25 percent by stage, in 25 percent by histology, in 3 percent by intake and in 4 percent by weight loss. At the end of RT, higher REE was attributed in 26 percent to stage, in 27 percent to histology, in 30 percent to nontreatment response, in 9 percent to intake, and in 8 percent to weight loss.

CONCLUSIONS

In this CRC patient population, higher metabolic rates were mainly determined by the tumor burden and aggressiveness in association with response to treatment clearly disclaiming the effect of weight loss and/or dietary intake reductions.

Cancer wasting and quality of life react to early individualized nutritional counselling!

To devise a meaningful nutritional therapy in cancer, a greater understanding of nutritional dimensions as well as patients' expectations and disease impact is essential. We have shown that nutritional deterioration in patients with gastrointestinal and head and neck cancer was multifactorial and mainly determined by the tumour burden and location. In a larger cohort, stage and location were yet again the major determinants of patients' quality of life (QoL), despite the fact that nutritional deterioration combined with intake deficits were functionally more relevant than cancer stage. Based on this framework, the potential role of integrated oral nutritional support on outcomes was investigated. In a pilot study using individualized nutritional counselling on a heterogeneous patient population, the achieved improvement of nutritional intake was proportional to a better QoL. The role of early nutritional support was further analysed in a prospective randomized controlled trial in head and neck cancer patients stratified by stage undergoing radiotherapy. Pre-defined outcomes were: nutritional status and intake, morbidity and QoL, at the end and 3 months after radiotherapy. Nutritional interventions, only given during radiotherapy, consisted of three randomization arms: (1) individualized nutritional counselling vs. (2) ad libitum diet+high protein supplements vs. (3) ad libitum diet. Nutritional interventions 1 and 2 positively influenced outcomes during radiotherapy; however, 3 months after its completion individualized nutritional counselling was the single method capable of sustaining a significant impact on patients' outcomes. The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes in cancer patients.

Ghrelin may reduce radiation-induced mucositis and anorexia in head-neck cancer

Body weight loss is common in cancer patients, and is often associated with poor prognosis, it greatly impairs quality of life (QOL). Radiation therapy (RT) is used in head and neck cancers (HNC) either as a primary treatment or as an adjuvant therapy to surgery. Patients with HNC are most susceptible to malnutrition especially due to anorexia, which is aggravated by RT. Multiple pro-inflammatory cytokines, such as interleukin-6 (IL-6), interleukin-1beta (IL-1beta), interferon (IFN)-gamma and tumor necrosis factor-alpha(TNF-alpha), have been all associated with the development of both anorexia and oral mucositis. Radiation-induced mucositis occurs in almost all patients, who are treated for HNC, it could also cause weight loss. Ghrelin is a novel 28-amino acid peptide, which up-regulates body weight through appetite control, increase food intake, down-regulate energy expenditure and induces adiposity. Furthermore, ghrelin inhibits pro-inflammatory cytokines such as IL-1alpha, IL-1beta, TNF-alpha which may cause oral mucositis and aneroxia, which are the results of weight loss. Thus weight loss during RT is an early indicator of nutritional decline, we propose that recombinant ghrelin used prophylactically could be useful as an appetite stimulant; and preventive of mucositis because of its anti-inflammatory effect, it might help patients maintain weight over the course of curative RT of the HNC and can improve specific aspects of QOL. This issue warrants further studies.

Double-blind, placebo-controlled, randomized study of eicosapentaenoic acid diester in patients with cancer cachexia

PURPOSE

Eicosapentaenoic acid (EPA) has been proposed to have specific anticachectic effects. This trial compared EPA diethyl ester with placebo in cachectic cancer patients for effects on weight and lean body mass.

PATIENTS AND METHODS

Five hundred eighteen weight-losing patients with advanced gastrointestinal or lung cancer were studied in a multicenter, double-blind, placebo controlled trial. Patients were randomly assigned to receive a novel preparation of pure EPA at a dose of 2 g or 4 g daily or placebo (2g EPA, n = 175; 4 g EPA, n = 172; placebo, n = 171). Patients were assessed at 4 weeks and 8 weeks.

RESULTS

The groups were well balanced at baseline. Mean weight loss at baseline was 18% (n = 518). Over the 8-week treatment period, both intention-to-treat analysis and per protocol analysis revealed no statistically significant improvements in survival, weight, or other nutritional variables. There was, however, a trend in favor of EPA with analysis of the primary end point, weight, at 8 weeks showing a borderline, nonsignificant treatment effect (P = .066). Relative to placebo, mean weight increased by 1.2 kg with 2 g EPA (95% CI, 0 kg to 2.3 kg) and by 0.3 kg with 4 g EPA (-0.9 kg to 1.5 kg).

CONCLUSION

The results indicate no statistically significant benefit from single agent EPA in the treatment of cancer cachexia. Future studies should concentrate on other agents or combination regimens.

Resting energy expenditure in patients with solid tumors undergoing anticancer therapy

OBJECTIVE

Few studies have investigated the resting energy expenditure (REE) of, or determined the individual predictive accuracy of prediction equations in, cancer patients undergoing anticancer therapy. This study compared the measured REE of patients with cancer undergoing anticancer therapy with (1) healthy subjects and (2) REE estimated from commonly used prediction methods.

METHODS

Resting energy expenditure was measured in 18 cancer patients and 17 healthy subjects by using indirect calorimetry under standard conditions and was estimated from seven prediction methods. Fat-free mass (FFM) was measured by bioelectrical impedance analysis. Data were analyzed with regression modeling to adjust REE for FFM. Agreement between measured and predicted REE values was analyzed using the Bland-Altman approach.

RESULTS

There was no significant difference in FFM-adjusted REE between cancer patients and healthy subjects (mean difference 10%). Limits of agreement were wide for all prediction methods in estimating REE as much as 40% below and up to 30% above measured REE.

CONCLUSIONS

REE in cancer patients undergoing anticancer therapies does not appear to be as high as commonly thought. None of the prediction equations examined were acceptable for predicting REE of individual cancer patients or healthy subjects.

Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy

BACKGROUND

We aimed to determine the effect of dietary counseling or oral supplements on outcome for patients with cancer, specifically, nutritional outcome, morbidity, and quality of life (QOL), during and 3 months after radiotherapy.

METHODS

Seventy-five patients with head and neck cancer who were referred for radiotherapy (RT) were randomized to the following groups: group 1 (n = 25), patients who received dietary counseling with regular foods; group 2 (n = 25), patients who maintained usual diet plus supplements; and group 3 (n = 25), patients who maintained intake ad lib. Nutritional intake (determined by diet history) and status (determined by Ottery's Subjective Global Assessment), and QOL (determined by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire version 3.0 [EORTC QLQ-C30]) were evaluated at baseline, at the end of RT, and at 3 months.

RESULTS

Energy intake after RT increased in both groups 1 and 2 (p < or = .05). Protein intake also increased in both groups 1 and 2 (p < or = .006). Both energy and protein intake decreased significantly in group 3 (p < .01). At 3 months, group 1 maintained intakes, whereas groups 2 and 3 returned to or below baseline levels. After RT, >90% of patients experienced RT toxicity; this was not significantly different between groups, with a trend for reduced symptomatology in group 1 versus group 2/group 3 (p < .07). At 3 months, the reduction of incidence/severity of grade 1+2 anorexia, nausea/vomiting, xerostomia, and dysgeusia was different: 90% of the patients improved in group 1 versus 67% in group 2 versus 51% in group 3 (p < .0001). After RT, QOL function scores improved (p < .003) proportionally with improved nutritional intake and status in group 1/group 2 (p < .05) and worsened in group 3 (p < .05); at 3 months, patients in group 1 maintained or improved overall QOL, whereas patients in groups 2 and 3 maintained or worsened overall QOL.

CONCLUSIONS

During RT, nutritional interventions positively influenced outcomes, and counseling was of similar/higher benefit; in the medium term, only counseling exerted a significant impact on patient outcomes.

Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy

PURPOSE

To investigate the impact of dietary counseling or nutritional supplements on outcomes in cancer patients: nutritional, morbidity, and quality of life (QoL) during and 3 months after radiotherapy.

PATIENTS AND METHODS

A total of 111 colorectal cancer outpatients referred for radiotherapy, stratified by staging, were randomly assigned: group 1 (G1; n = 37), dietary counseling (regular foods); group 2 (G2; n = 37), protein supplements; and group 3 (G3; n = 37), ad libitum intake. Nutritional intake (diet history), status (Ottery's Subjective Global Assessment), and QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0) were evaluated at baseline, at the end, and 3 months after radiotherapy.

RESULTS

At radiotherapy completion, energy intake increased in G1/G2 (P < or = .04), G1 more than G2 (P = .001), and decreased in G3 (P < .01). Protein intake increased in G1/G2 (P < or = .007), G1 less than G2 (not significant), and decreased in G3 (P < .01). At 3 months, G1 maintained nutritional intake and G2/G3 returned to baseline. After radiotherapy and at 3 months, rates of anorexia, nausea, vomiting, and diarrhea were higher in G3 (P < .05). At radiotherapy completion, in G1 all QoL function scores improved proportionally to adequate intake or nutritional status (P < .05); whereas in G2 only three of six function scores improved proportionally to protein intake (P = .04), and in G3 all scores worsened (P < .05). At 3 months, G1 patients maintained/improved function, symptoms, and single-item scores (P < .02); in G2, only few function and symptom scales improved (P < .05); in G3, QoL remained as poor as after radiotherapy. In G1/G2, respectively, improvement/deterioration of QoL correlated with better or poorer intake or nutritional status (P < .003).

CONCLUSION

During radiotherapy, both interventions positively influenced outcomes; dietary counseling was of similar or higher benefit, whereas even 3 months after RT, it was the only method to sustain a significant impact on patient outcomes.

Nursing management of nutrition in cancer and palliative care

Malnutrition is prevalent in patients with cancer. This can have deleterious effects including reduced response to treatment, diminished quality of life, increased length of hospital stay and decreased survival. It is, therefore, imperative that thorough nutritional screening is carried out by nurses on patients' admission and during their hospital stay to detect those who are malnourished or at risk of malnutrition in order to plan their nutritional care effectively. Cancer cachexia is the progressive weight loss and emaciation seen in cancer patients, particularly in advanced disease, which can have a devastating effect on the physical, psychological, social and spiritual aspects of the patient's life. Therefore, the aims of nutritional care are identified depending on the stage of the patient's illness and recommendations made for nursing, pharmacological and nutritional intervention. These include nursing comfort strategies, the use of recommended pharmacological agents and dietary interventions such as experimenting with different foods, textures, portion sizes and nutritional supplements. The use of fish oil-enhanced nutritional supplements and artificial nutritional support is also discussed. Consideration is also given to the legal and ethical aspects of providing nutrition and nutritional support.

Distinguishing starvation from cachexia

The poor response to hypercaloric feeding in ill adults may be caused by failure to distinguish cachexia from starvation (Table 1). The chief difference between starvation and cachexia is that refeeding reverses starvation but is less effective for cachexia. The ineffectiveness of refeeding in treating cachexia may explain some of the poor results from direct nutritional interventions in clinical trials. Simple starvation should respond to voluntary or involuntary hypercaloric feedings. The failure to demonstrate a more positive response may be caused by underlying cachexic states.

Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia

Loss of appetite, or anorexia, has profound implications for older persons, altering social interactions, reducing quality of life, and leading to weight loss with grave health consequences. Two conditions associated with anorexia considered in this article are the multidetermined anorexia of aging and the wasting syndrome termed cachexia induced by cancer. Nutritional interventions may have some benefit in the former, but are of limited value in the latter. Emerging studies at the molecular level relating to appetite regulation and energy balance may offer new approaches to arrest progressive weight loss in the anorexia of aging and cancer cachexia.

The systemic inflammatory response, weight loss, performance status and survival in patients with inoperable non-small cell lung cancer

The relationship between the magnitude of systemic inflammatory response and the nutritional/functional parameters in patients with inoperable non-small cell lung cancer were studied. The extent of weight loss, albumin, C-reactive protein, performance status and quality of life was measured in 106 patients with inoperable non-small cell lung cancer (stages III and IV). Survival analysis was performed using the Cox proportional hazard model. The majority of patients were male and almost 80% had elevated circulating C-reactive protein concentrations (>10 mg x l(-1)). On multivariate analysis, age (P=0.012), tumour type (0.002), weight loss (P=0.056), C-reactive protein (P=0.047), Karnofsky performance status (P=0.002) and fatigue (P=0.046) were independent predictors of survival. The patients were grouped according to the magnitude of the C-reactive protein concentrations (< or =10, 11-100 and >100 mg x l(-1)). An increase in the magnitude of the systemic inflammatory response was associated with increased weight loss (P=0.004), reduced albumin concentrations (P=0.001), reduced performance status (P=0.060), increased fatigue (P=0.011) and reduced survival (HR 1.936 95%CI 1.414-2.650, P<0.001). These results indicate that the majority of patients with inoperable non-small cell lung cancer have evidence of a systemic inflammatory response. Furthermore, an increase in the magnitude of the systemic inflammatory response resulted in greater weight loss, poorer performance status, more fatigue and poorer survival.

Cachexia in patients with advanced cancer

Cancer cachexia generally is considered to be the end stage in the progression of nutritional deterioration and wasting of malignancy (Ottery, 1995). In patients with advanced cancer, this condition is very common and decreases quality of life, as well as survival (Fearon et al., 2001; Ottery; Smith & Souba, 2001; Whitman, 2000). However, if early diagnosis and intervention can control cachexia, the potential exists to greatly improve a patient's quality of life and prolong survival. Because metabolic alterations inhibit the effective use of conventional nutritional support, anti-inflammatory agents or fish oil are possible options. Orexigenic agents may be prescribed if patients wish to improve oral intake. Steroids and progestational agents may be used to attempt to improve mood and appetite. Nutrition affects symptoms that need to be managed effectively. Nurses should work aggressively to correct factors that contribute to decreased food intake (e.g., nausea, pain) and correct factors that worsen debility (e.g., anemia). Information must be presented so that informed choices can be made and realistic eating goals set. An interdisciplinary approach that involves the nurse, physician, dietician, and possibly social worker or case manager, as well as the patient and family, is necessary to identify nutritional alterations, assess specific needs, and plan individual interventions. Whitman (2000) stated that counseling is the most effective and least expensive intervention. It may be conducted by any member of the healthcare team and should be combined with other interventions. Palliation of cachexia in patients with advanced cancer is a challenge for nurses. Hopefully, early and judicious use of these interventions may decrease the significant morbidity and mortality that result from cancer cachexia.