Perspectives of Health Care Professionals on Multimodal Interventions for Cancer Cachexia

Healthcare professionals' knowledge of and compliance with the ASCO/ESMO/GLIM guidelines for the diagnosis and management of cancer cachexia (CC): the ASSIST-CC baseline findings in Uganda

Background

More than 50% of people with advanced cancer suffer from cancer-related cachexia (CC) - a major contributor to morbidity and mortality. Despite the lack of local guidelines on CC diagnosis and management in Uganda, the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO) and the Global Leadership Initiative on Malnutrition (GLIM) developed guidelines on CC screening and management. However, the level of knowledge on CC and compliance with the available guidelines among Ugandan oncology health professionals is unknown. This study aimed to assess the level of awareness and knowledge of CC diagnosis and management and compliance with the ASCO/ESMO/GLIM guidelines on CC among healthcare professionals (HCPs) involved in the care of cancer patients.

Methods

In this phase one, a self-administered structured questionnaire developed using the ASCO/ESMO and GLIM guidelines on diagnosis and management of CC was used to assess the level of awareness, and knowledge of 200 health professionals from three hospital settings on CC, and compliance with the ASCO/ESMO/GLIM guidelines on CC related core communication, barriers to communication, clinician training in communication, discussing goals of care, treatment options and meeting the needs of the underserved populations. The data were entered into Research Electronic Data Capture software analysed using STATA version 18.0 software.

Results

The overall objectively correct knowledge score of CC diagnosis criteria was 67.5% (n = 135), yet there was a much lower level of awareness about ASCO/ESMO/GLIM guidelines on CC at 30% (n = 60) and only 21% (n = 42) of the HCPs have ever assessed Quality of life of CC patients. The compliance with ASCO/ESMO/GLIM guidelines on nutritional interventions for patients with CC varied across the variables markedly, ranging from 25.1% (n = 50) to 81% (n = 162) for the specific ASCO/ESMO/GLIM guidelines' recommendations. Whereas compliance with the guidelines on discussing goals of care, prognosis, treatment options and end-of-life care scored the highest in most variables, most HCPs exhibited low compliance with the discussion about patients' end-of-life preferences early in the course of incurable illness (49.8%, n = 99). There were statistically significant differences between the mean scores of only two variables among the three hospitals in compliance with ASCO/ESMO/GLIM guidelines on the provision.

Conclusion

This study indicated that the overall objectively correct knowledge of CC diagnosis criteria was inadequate, with a much lower level of awareness about the ASCO/ESMO/GLIM guidelines on CC and a handful of the HCPs have ever assessed the quality of life of CC patients. Quality improvement interventions on CC diagnosis and management should prioritize improving the level of knowledge on CC, diagnostic criteria and patient-clinician communication, including discussion about patients' end-of-life care using standardised tools such as ASCO/ESMO or GLIM guidelines on CC using a multidisciplinary team approach.

Factors associated with multimodal care practices for cancer cachexia among registered dietitians

PURPOSE

This study aimed to determine factors associated with multimodal care practices for cancer cachexia among registered dietitians (RDs) working in cancer care.

METHODS

A secondary analysis was performed using RDs' data. Data on knowledge, skills, and confidence in multimodal care were obtained. Nine items regarding multimodal care practices were evaluated. Subjects were divided into two groups based on their answers associated with the nine items. Comparisons were obtained using the Mann-Whitney U test or chi-squared test. Multiple regression analysis was performed to identify the critical factors involved in practicing multimodal care by determining the variables with significant differences between the two groups.

RESULTS

Two hundred thirty-two RDs were included in this study. Significant differences were observed in their primary area of practice (p = 0.023), the number of clinical guidelines used (p < 0.001), the number of items used in cancer cachexia assessment (p = 0.002), the number of symptoms used in cancer cachexia assessment (p = 0.039), training for cancer cachexia (p < 0.001), knowledge of cancer cachexia (p < 0.001), and confidence in cancer cachexia management (p < 0.001). The number of symptoms used in cancer cachexia assessment (B = 0.42, p = 0.019), knowledge of cancer cachexia (B = 6.60, p < 0.001), and confidence in cancer cachexia management (B = 4.31, p = 0.010) were identified as critical factors according to the multiple regression analysis.

CONCLUSION

The RDs' knowledge and confidence in cancer cachexia management were associated with their multimodal care practices.

The barriers to interprofessional care for cancer cachexia among Japanese healthcare providers: A nationwide survey

BACKGROUND

Cancer cachexia is a severe complication of advanced malignancy, with few therapeutic options. To promote interprofessional care for cancer cachexia, healthcare providers' needs should be addressed in detail. This pre-planned subgroup analysis of the Global Educational Needs Evaluation: a systemic interprofessional study in cancer cachexia (GENESIS-CC) survey aimed to identify barriers to interprofessional care of cancer cachexia in Japan.

METHODS

A nationwide survey was electronically conducted for healthcare providers in oncological or general healthcare facilities from January to March 2021 in Japan. The Japanese Regional Advisory Board developed a barrier scoring system with 33 from the 58 original survey items to quantify six domains of barriers: (1) lack of confidence, (2) lack of knowledge, (3) barriers in personal practice, (4) barriers in perception, (5) barriers in team practice and (6) barriers in education. The largest possible barrier score was set at 100 points. We compared the scores by profession.

RESULTS

A total of 1227 valid responses were obtained from 302 (24.6%) physicians, 252 (20.5%) pharmacists, 236 (19.2%) nurses, 218 (17.8%) dietitians, 193 (15.7%) rehabilitation therapists and 26 (2.0%) other professionals. Overall, 460 (37.5%) were not very or at all confident about cancer cachexia care, 791 (84.1%) agreed or strongly agreed that care was influenced by reimbursement availability and 774 (81.9%) did not have cancer cachexia as a mandatory curriculum. The largest mean barrier score (± standard deviation) was 63.7 ± 31.3 for education, followed by 55.6 ± 21.8 for team practice, 43.7 ± 32.5 for knowledge, 42.8 ± 17.7 for perception and 36.5 ± 16.7 for personal practice. There were statistically significant interprofessional differences in all domains (P < 0.05), especially for pharmacists and nurses with the highest or second highest scores in most domains.

CONCLUSIONS

There is a need to improve the educational system and team practices of cancer cachexia for most Japanese healthcare providers, especially pharmacists and nurses. Our study suggests the need to reform the mandatory educational curriculum and reimbursement system on cancer cachexia to promote interprofessional care for cancer cachexia in Japan.

Validity of the diagnostic criteria from the Asian Working Group for Cachexia in advanced cancer

BACKGROUND

Recently, the Asian Working Group for Cachexia (AWGC) published a consensus statement on diagnostic criteria for cachexia in Asians. We aimed to validate the criteria in adult patients in Japan with advanced cancer.

METHODS

We conducted a single-institution retrospective cohort study between April 2021 and October 2022. The AWGC criteria include chronic comorbidities and either a weight loss of >2% over 3-6 months or a body mass index (BMI) of <21 kg/m2 . In addition, any of the following items were required: anorexia as a subjective symptom, decreased grip strength as an objective measurement and an elevated C-reactive protein (CRP) level as a biomarker. We used the cut-off value of grip strength of 28/18 kg for male/female individuals and CRP level of 5 mg/L.

RESULTS

Of the 449 consecutive patients, 85 of those who could not be evaluated because of end-of-life or refractory symptoms (n = 41) or missing data (n = 44) were excluded from the primary analysis. The prevalence of the AWGC-defined cachexia was 76% (n = 277), and the median survival time (MST) for all patients was 215 (95% confidence interval [CI] 145-270) days. The prevalence of the following criteria was significantly higher in patients with cachexia than in those without cachexia: a BMI of <21 kg/m2 (65% vs. 15%, P < 0.001), a weight loss of >2% in 6 months (87% vs. 14%, P < 0.001), anorexia (75% vs. 47%, P < 0.001), a grip strength of <28 kg in male individuals (63% vs. 28%, P < 0.001) and CRP level of >5 mg/L (85% vs. 56%, P < 0.001). Overall survival was significantly shorter in patients with cachexia than in those without cachexia (MST 157 days, 95% CI 108-226 days vs. MST 423 days, 95% CI 245 days to not available, P = 0.0023). The Cox proportional hazards analysis showed that best supportive care (hazard ratio [HR] 2.91, P ≤ 0.001), lung cancer (HR 1.67, P = 0.0046), an Eastern Cooperative Oncology Group Performance Status score of ≥3 (HR 1.58, P = 0.016), AWGC-defined cachexia (HR 1.56, P = 0.015), an age of ≥70 years (HR 1.53, P = 0.0070), oedema (HR 1.31, P = 0.022) and head/neck cancer (HR 0.44, P = 0.023) were found to be the significant predictors for mortality.

CONCLUSIONS

We demonstrated that AWGC-defined cachexia has a significant prognostic value in advanced cancer.

Holistic multimodal care for patients with cancer cachexia and their family caregivers

Patients with cancer cachexia frequently suffer from physical symptoms and psychological symptoms of illness, which can lead to emotional distress in patients and family caregivers. Although there is no standard care to manage cancer cachexia despite its high prevalence and negative impact on quality of life in patients and family caregivers, there is accumulating evidence showing the importance of holistic multimodal care for cancer cachexia. However, there is no agreement on the essential components of holistic multimodal care. Therefore, the aims of this review are to give an overview of what is known about the holistic multimodal care and to suggest the composition of a multidisciplinary team to achieve holistic interventions. Holistic multimodal care for cancer cachexia is defined as an approach that addresses physical health through medical, pharmacological, nutritional, and rehabilitative interventions as well as psychological, emotional, and social well-being issues according to the needs of patients and family caregivers. Moreover, an ideal multidisciplinary team is proposed to achieve holistic interventions based on patient- and family-centered care. However, the development of educational programs on cancer cachexia for both clinicians and patients and family caregivers is needed. Furthermore, measurements to assess the benefits of holistic multimodal care also need to be established.

The role of the nurse in meeting the educational needs for self-care in cachectic cancer patients and their family caregivers: A scoping review

Objective

To give an overview of what is known about the nurse contribution to education in self-care by people with cancer cachexia and their family caregivers. Nurse-led patient education can help patients and their family caregivers to manage cancer symptoms, cancer treatments, and treatment side effects.

Methods

This scoping review explored the extent to which nurse-led education has become part of the multimodal management of cancer cachexia. It is based on a systematic search of Medline, Embase, CINAHL, APA PsycINFO, and the Cochrane Library. Search limits were English language, date ranges from January 2015 to March 2023, and adults 18 years and older.

Results

A total of 6370 titles were screened, 127 papers and conference abstracts were selected for full-text examination, and 9 publications were included in the review. The analysis found the nurses within the multidisciplinary cancer cachexia care team, like other healthcare professionals, do not have a shared understanding of cancer cachexia and its management. For nurses to be confident and competent in the provision of nurse-led cachexia education, they themselves need evidence-based education in cachexia care and how to tailor education according to cachexia stage, symptoms, emotional response, and social circumstance.

Conclusions

Nurses with the knowledge and confidence to provide cancer cachexia education for their patients can potentially play an important role in the management of cancer cachexia and mitigation of cachexia-related problems.

Toward a holistic understanding of cancer cachexia: Application of the human response to illness model

Cachexia is a commonly presenting multidimensional syndrome in individuals living with advanced cancer. Given its prevalence of between 50% and 80%, nurses are going to encounter individuals manifesting ongoing loss of skeletal muscle mass (with or without loss of fat mass) that can be partially but not entirely reversed by conventional nutritional support. Thus nurses require a comprehensive understanding of this complex clinical problem. Research suggests, however, that nurses receive minimal education about cachexia or its management. Limited understanding undermines the ability to confidently care for patients with cachexia and their families, thereby hampering effective practice. The human response to illness model provides nurses with an organizing framework to guide and make sense of their assessments in clinical practice when caring for patients with cancer cachexia and provides direction for appropriate intervention. This article illustrates the integration of the human response to illness model to clinical practice, thereby assisting nurses to develop a comprehensive understanding of the physiological, pathophysiological, behavioral, and experiential facets of cachexia in advanced cancer patients. Contemporary areas of further interest and research will be presented.

Factors Associated With Practice of Multimodal Care for Cancer Cachexia Among Physicians and Nurses Engaging in Cancer Care

PURPOSE

Multimodal care for cancer cachexia is needed. This study examined factors associated with practicing multimodal cachexia care among physicians and nurses engaging in cancer care.

METHODS

This was a preplanned secondary analysis of a survey investigating clinicians' perspectives on cancer cachexia. Data of physicians and nurses were used. Data on knowledge, skills, and confidence in multimodal cachexia care were obtained. Nine items on practicing multimodal cachexia care were evaluated. Participants were divided into two groups as practicing multimodal cachexia care (above median value for the nine items) or not. Comparisons were made using the Mann-Whitney U test or chi-square test. Multiple regression analysis was performed to identify the factors of practicing the multimodal care.

RESULTS

Total of 233 physicians and 245 nurses were included. Significant differences were observed between the groups: female sex (P = .025), palliative care versus oncology specialization (P < .001), the number of clinical guidelines used (P < .001), the number of symptoms used (P = .005), training for cancer cachexia (P = .008), knowledge on cancer cachexia (P < .001), and confidence in cancer cachexia management (P < .001). Palliative care specialization (partial regression coefficient [B] = 0.85; P < .001), the number of clinical guidelines used (B = 0.44; P < .001), knowledge on cancer cachexia (B, 0.94; P < .001), and confidence in cancer cachexia management (B = 1.59; P < .001) were statistically significant in multiple regression analysis.

CONCLUSION

Specialization in palliative care, specific knowledge, and confidence were associated with the practice of multimodal care for cancer cachexia.

Educational needs of self-care in cachectic cancer patients and caregivers

PURPOSE OF REVIEW

To give an overview of what is known about the educational component of supportive care for people with cancer cachexia and their family caregivers.

RECENT FINDINGS

The educational needs for self-care by people with cancer cachexia are largely unmet. There is potential for education to enable self-care that mitigates cachexia-related distress with benefit to quality of life and mitigates malnutrition/malnutrition risk with implications for treatment tolerance and outcomes. Theoretically informed approaches to cancer cachexia education for patients and their family members are needed if optimal methods for support of self-care are to be identified. The cancer workforce also needs education to have the confidence and knowledge to play a role in the cancer cachexia education of their patients.

SUMMARY

To address the educational needs of self-care in cachectic cancer patients and their caregivers, there is much work to do. Healthcare professionals need to know the best educational process and methods for cachexia for supporting quality of life and to facilitate improving cancer treatment outcomes including survival.

Perspectives of registered dietitians and factors associated with their personal accomplishment in the management of cancer cachexia

PURPOSE

Registered dietitians (RDs) have the potential in cancer cachexia management. We investigated RDs' knowledge on cancer cachexia and assessed the effects of factors on RDs' perception of playing an important role in cancer cachexia management.

METHODS

This is a secondary analysis of a survey examining the perspectives of health care professionals on cancer cachexia management. We sent the questionnaire to 451 RDs. RDs were divided into two groups: RDs with and without the perception. Comparisons were made using the Mann-Whitney U test or chi-square test. To examine the effects of factors on the perception, estimated crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the logistic regression model were calculated.

RESULTS

A total of 237 RDs were analyzed. Significant differences were observed in the number of cancer patients/month, the primary area of practice, the number of clinical guidelines used, the number of items used, the number of symptoms used, and training for cancer cachexia management (p values all < 0.05). After adjustments, the factors of cancer care experience ≥ 20 years (OR 8.32, 95% CI 1.22-56.70; p = 0.030), the number of patients/month ≥ 50 (OR 27.35, 95% CI 3.99-187.24; p = 0.001), using the clinical guidelines (OR 2.69, 95% CI 1.29-5.61; p = 0.008), the number of items ≥ 5 (OR 3.52, 95% CI 1.47-8.40; p = 0.005), and receiving training (OR 3.91, 95% CI 1.77-8.67; p = 0.001) significantly associated with the perception.

CONCLUSION

Specific knowledge and training as well as abundant experience were associated with the perception.