Practical approaches to managing cancer patients with weight loss

Updates in Cancer Cachexia: Clinical Management and Pharmacologic Interventions

Despite a better understanding of the mechanisms causing cancer cachexia (CC) and development of promising pharmacologic and supportive care interventions, CC persists as an underdiagnosed and undertreated condition. CC contributes to fatigue, poor quality of life, functional impairment, increases treatment related toxicity, and reduces survival. The core elements of CC such as weight loss and poor appetite should be identified early. Currently, addressing contributing conditions (hypothyroidism, hypogonadism, and adrenal insufficiency), managing nutrition impact symptoms leading to decreased oral intake (nausea, constipation, dysgeusia, stomatitis, mucositis, pain, fatigue, depressed mood, or anxiety), and the addition of pharmacologic agents when appropriate (progesterone analog, corticosteroids, and olanzapine) is recommended. In Japan, the clinical practice has changed based on the availability of Anamorelin, a ghrelin receptor agonist that improved lean body mass, weight, and appetite-related quality of life (QoL) compared to a placebo, in phase III trials. Other promising therapeutic agents currently in trials include Espindolol, a non-selective β blocker and a monoclonal antibody to GDF-15. In the future, a single therapeutic agent or perhaps multiple medications targeting the various mechanisms of CC may prove to be an effective strategy. Ideally, these medications should be incorporated into a multimodal interdisciplinary approach that includes exercise and nutrition.

Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways

Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.

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.

Nutritional and Exercise Interventions in Cancer-Related Cachexia: An Extensive Narrative Review

One of the common traits found in cancer patients is malnutrition and cachexia, which affects between 25% to 60% of the patients, depending on the type of cancer, diagnosis, and treatment. Given the lack of current effective pharmacological solutions for low muscle mass and sarcopenia, holistic interventions are essential to patient care, as well as exercise and nutrition. Thus, the present narrative review aimed to analyze the nutritional, pharmacological, ergonutritional, and physical exercise strategies in cancer-related cachexia. The integration of multidisciplinary interventions could help to improve the final intervention in patients, improving their prognosis, quality of life, and life expectancy. To reach these aims, an extensive narrative review was conducted. The databases used were MedLine (PubMed), Cochrane (Wiley), Embase, PsychINFO, and CinAhl. Cancer-related cachexia is a complex multifactorial phenomenon in which systemic inflammation plays a key role in the development and maintenance of the symptomatology. Pharmacological interventions seem to produce a positive effect on inflammatory state and cachexia. Nutritional interventions are focused on a high-energy diet with high-density foods and the supplementation with antioxidants, while physical activity is focused on strength-based training. The implementation of multidisciplinary non-pharmacological interventions in cancer-related cachexia could be an important tool to improve traditional treatments and improve patients' quality of life.

Managing Nutrition Impact Symptoms in Cancer Cachexia: A Case Series and Mini Review

Malnutrition is common in cancer patients and can occur throughout a patient’s disease course. The contributors to the clinical syndrome of cancer cachexia are often multifactorial, and produced by the cancer and associated pro-inflammatory response. Since cancer cachexia is a multifactorial syndrome, a multimodal therapeutic approach is ideal. A key component of therapy is identifying and managing symptom barriers to adequate oral intake, known as nutritional impact symptoms (NIS). NIS are associated with reduced intake and weight loss in patients with advanced cancer, and aggregate NIS are a predictor of survival in patients with Head and Neck Cancer and in patients undergoing surgery for esophageal cancer. Currently, there are no guidelines regarding the specific management of NIS in oncology patients. Experience from specialist centers suggest relatively simple assessments and inexpensive interventions are available for the diagnosis and treatment of NIS. We present three patient cases from a cachexia clinic, where NIS management decreased symptom burden and improved clinical outcomes such as weight and physical performance.

The Psychosocial Components of Multimodal Interventions Offered to People with Cancer Cachexia: A Scoping Review

The supportive care of people with cancer cachexia is a rapidly evolving field. In the past decade, multimodal treatments have been developed and new multidisciplinary cachexia clinics have been established across the world. This scoping review examines the extent to which psychosocial support has become part of the multimodal management of cancer cachexia. The review draws on a systematic search of Medline, Embase, CINAHL, PsycINFO, and the Cochrane Library for publications about people who have cancer cachexia and receive multimodal interventions. Search limits were the English language, date range January 2013 to March 2021, and adults 18 years and older. The search found 19 papers about multimodal interventions for either cancer cachexia or its defining feature involuntary weight loss that included a psychosocial component. This review found three different ways a psychosocial component of a multimodal intervention can help patients: (1) enable adherence to multimodal therapies; (2) aid emotional adaptation and coping; and (3) treat comorbid anxiety and depression. Recognizing these three different functions of psychosocial support is important because they have different mechanisms of action. Behavioral change techniques are important for enabling adherence, education in coping methods is important to alleviate stress, and cognitive reframing for the treatment of anxiety and depression. The analysis reveals that multimodal interventions for cancer cachexia with a psychosocial component can either focus on physical health or have a more holistic focus. Holistic care is considered the best practice in cancer nursing. Thus multimodal interventions that can address not only physical health problems, but psychosocial issues are consistent with high-quality nursing care.

Effects of high-intensity training on the quality of life of cancer patients and survivors: a systematic review with meta-analysis

Cancer and associated medical treatments affect patients' health-related quality of life (HRQoL) by decreasing functional dimensions of physical, social, cognitive, and emotional well-being, while increasing short and late-term symptoms. Exercise, however, is demonstrated to be a useful therapy to improve cancer patients' and survivors' HRQoL, yet the effectiveness of high-intensity training (HIT) exercise is uncertain. This systematic review and meta-analysis aimed to analyse the effects of HIT on HRQoL dimensions in cancer patients and survivors as well as evaluate the optimal prescription of HIT. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) and examined Web of Science and PubMed (Medline) databases. Data were analysed utilizing Review Manager Software. Twenty-two articles were included in the systematic review and 17 in the meta-analysis. Results showed HIT improved global quality of life, physical functioning, role functioning, social functioning, cognitive functioning, fatigue, pain, dyspnea, and insomnia, compared to an inactive control group, yet no differences were found between HIT and low to moderate-intensity exercise interventions. Particular improvements in HRQoL were observed during cancer treatment and with a training duration of more than eight weeks, a frequency of 2 days/week, and a volume of at least 120 min/week, including 15 min or more of HIT. Our findings whilst encouraging, highlight the infancy of the extant evidence base for the role of HIT in the HRQoL of cancer patients and survivors.

Chemosensory perception and food preferences in colorectal cancer patients undergoing adjuvant chemotherapy

BACKGROUND AND AIM

Cancer is one of the major public health problems, with colorectal cancer being one of the most occurring types of cancer. During treatment, patients may experience changes in their dietary intake due to side-effects of treatment, like changes in chemosensory perception, i.e. smell and taste function. This study investigated alterations in chemosensory perception and food preferences in colorectal cancer patients during and after adjuvant chemotherapy.

METHODS

Objective olfactory and gustatory function were measured by the Sniffin' Sticks and the Taste Strips test. Subjective smell and taste perception were determined with a questionnaire, while food preferences were assessed with a computer-based ranking task. To investigate changes during chemotherapy, patients undergoing adjuvant chemotherapy were measured before the start, halfway through (approximately 3 months after the start of adjuvant chemotherapy), and within one month after finishing chemotherapy (longitudinal measurements, n = 15 patients). As a comparison group, colorectal cancer patients not undergoing chemotherapy (n = 20), underwent the same measurements at similar time points. To measure changes after treatment, chemosensory perception and food preferences of patients who had undergone chemotherapy treatment were measured once, either at 6, 12 or 24 months after diagnosis (cross-sectional measurements; n = 20 for all time points). Changes during treatment were assessed using linear mixed model analyses, and changes after treatment were assessed with a one-way ANOVA or a Kruskal Wallis test.

RESULTS

Objective olfactory and gustatory function did not differ statistically significantly between any of the groups and at any time point during or after treatment (all p > 0.05). In contrast, subjective smell (F(1,84) = 8.17, p = 0.005) and taste (F(1,99) = 4.08, p = 0.046) perception were rated statistically significantly lower by patients undergoing chemotherapy than the comparison group during treatment. At 6 months after diagnosis, patients who underwent chemotherapy rated their subjective taste perception significantly lower than patients at 12 and 24 months after treatment (F(2,57) = 12.05, p = 0.002). Food preferences did not change during treatment, or thereafter (all p > 0.05). Preference for protein-rich foods was positively correlated with objective gustatory function (r = 0.36, p < 0.001), while the preference for low-energy foods showed a negative correlation with objective gustatory function (r = -0.28, p = 0.004).

CONCLUSIONS

Similar to other cancer patient populations, mainly subjective smell and taste perception are affected in colorectal cancer patients undergoing adjuvant chemotherapy. Changes in objective olfactory and gustatory function in relation to chemotherapy were not detected by the tests used in our study nor did food preferences change. However, it should be noted that subjective changes in smell and taste perception can affect subsequent flavor perception and food enjoyment, which might negatively impact eating behavior and nutritional intake.

Inter-tissue communication in cancer cachexia

Cachexia is a systemic condition that occurs during many neoplastic diseases, such as cancer. Cachexia in cancer is characterized by loss of body weight and muscle and by adipose tissue wasting and systemic inflammation. Cancer cachexia is often associated with anorexia and increased energy expenditure. Even though the cachectic condition severely affects skeletal muscle, a tissue that accounts for ~40% of total body weight, it represents a multi-organ syndrome that involves tissues and organs such as white adipose tissue, brown adipose tissue, bone, brain, liver, gut and heart. Indeed, evidence suggests that non-muscle tissues and organs, as well as tumour tissues, secrete soluble factors that act on skeletal muscle to promote wasting. In addition, muscle tissue also releases various factors that can interact with the metabolism of other tissues during cancer. In this Review, we examine the effect of non-muscle tissues and inter-tissue communication in cancer cachexia and discuss studies aimed at developing novel therapeutic strategies for the condition.