Unfavorable impact of cancer cachexia on activity of daily living and need for inpatient care in elderly patients with advanced non-small-cell lung cancer in Japan: a prospective longitudinal observational study

The emerging roles of necroptosis in skeletal muscle health and disease

Necroptosis is a regulated form of cell death with implications in various physiological and pathological processes in multiple tissues. However, the relevant findings from post-mitotic tissues, such as skeletal muscle, are scarce. This review summarizes the potential contributions of necroptosis to skeletal muscle health and diseases. It first discusses the physiological roles of necroptosis in muscle regeneration and development. It then summarizes the contributions of necroptosis to the pathogenesis of multiple muscle diseases, including muscular dystrophies, inflammatory myopathies, cachexia, and neuromuscular disorders. Lastly, it unravels the gaps in our understanding and therapeutic challenges of inhibiting necroptosis as a potential intervention for muscle diseases. Specifically, the findings from the transgenic animal models and the use of pharmacological inhibitors of necroptosis are discussed with relevance to improving the structure and/or function of skeletal muscle in various diseases. Recent developments from experimental animal models and clinical data are presented to discuss the roles of necroptosis in skeletal muscle health and diseases.

Relationship between Survival Days, Cancer Cachexia, and Activities of Daily Living in Palliative Cancer Patients Undergoing Rehabilitation

Objectives

Cancer cachexia has many effects on physical function and causes a decline in activities of daily living (ADL). Therefore, rehabilitation programs should be structured according to the degree of cancer cachexia. Currently, the evaluation of cancer cachexia is mainly based on body mass. However, there is no report on the use of the modified Glasgow Prognostic Score (mGPS) to evaluate the degree of cancer cachexia and survival prognosis in palliative cancer patients for whom rehabilitation has been prescribed. This study used mGPS to examine the prevalence of cancer cachexia in palliative cancer patients undergoing rehabilitation and the impacts of cancer cachexia, ADL, and complications on survival.

Methods

The participants included 135 palliative cancer patients who were admitted to the hospital and underwent rehabilitation between 2020 and 2022. Cancer cachexia classification by mGPS was conducted, and logistic regression analysis was used to examine factors affecting the survival of palliative cancer patients undergoing rehabilitation.

Results

The patients were grouped as follows: 6 (4.4%) normal, 13 (9.6%) undernourished, 12 (9.0%) pre-cachexia, and 104 (77.0%) refractory cachexia. Logistic regression analysis showed that the mGPS and BI affected survival.

Conclusions

In a cohort of palliative cancer patients undergoing rehabilitation, 86% had cachexia. mGPS and BI were associated with survival outcomes. Combination of mGPS classification with ADL assessment may provide meaningful prognostic information in these patients.

Molecular mechanisms of cancer cachexia. Role of exercise training

Cancer-associated cachexia represents a multifactorial syndrome mainly characterized by muscle mass loss, which causes both a decrease in quality of life and anti-cancer therapy failure, among other consequences. The definition and diagnostic criteria of cachexia have changed and improved over time, including three different stages (pre-cachexia, cachexia, and refractory cachexia) and objective diagnostic markers. This metabolic wasting syndrome is characterized by a negative protein balance, and anti-cancer drugs like chemotherapy or immunotherapy exacerbate it through relatively unknown mechanisms. Due to its complexity, cachexia management involves a multidisciplinary strategy including not only nutritional and pharmacological interventions. Physical exercise has been proposed as a strategy to counteract the effects of cachexia on skeletal muscle, as it influences the mechanisms involved in the disease such as protein turnover, inflammation, oxidative stress, and mitochondrial dysfunction. This review will summarize the experimental and clinical evidence of the impact of physical exercise on cancer-associated cachexia.

Low-dose orthotopic cancer implantation permits measurement of longitudinal functional changes associated with cachexia

Progressive functional decline is a key element of cancer-associated cachexia. Major barriers to translating preclinical therapies into the clinic include lack of cancer models that accurately mimic functional decline, which develops over time, and use of nonspecific measures, like grip strength, as surrogates for physical function. In this study, we aimed to extend the survival and longevity of a cancer model, to investigate cachexia-related function at the basic science level. Survival extension studies were performed by testing multiple cell lines, dilutions, and vehicle-types in orthotopic implantation of K-rasLSL.G12D/+; Trp53R172H/+; Pdx-1-Cre (KPC)-derived cells. One hundred twenty-eight animals in this new model were assessed for cachexia syndrome phenotype using a battery of anatomical, biochemical, and behavioral techniques. We extended the survival of the KPC orthotopic model to 8-9 wk postimplantation using a relatively low 100-cell dose of DT10022 KPC cells (P < 0.001). In this low-dose orthotopic (LO) model, progressive muscle wasting was detected in parallel to systemic inflammation; skeletal muscle atrophy at the fiber level was detected as early as 3 wk postimplantation compared with controls (P < 0.001). Gait speed in LO animals declined as early as 2 wk postimplantation, whereas grip strength change was a late event. Principal component and regression analyses revealed distinct cachectic and noncachectic animal populations, which we leveraged to show that the gait speed decline was specific to cachexia (P < 0.01), whereas grip strength decline was not (P = 0.19). Gait speed represents an accurate surrogate for cachexia-related physical function as opposed to grip strength.NEW & NOTEWORTHY Previous studies of cancer-induced cachexia have been confounded by the relatively rapid death of animal subjects. Using a lower dose of cancer cells in combination with a battery of behavioral, structural, histological, and biochemical techniques, we show that gait speed is actually the best indicator of functional decline due to cachexia. Future studies are required to define the underlying physiological basis of these findings.

Effect of polypharmacy on the outcomes of older patients with advanced non-small-cell lung cancer treated with PD-1/PD-L1 inhibitors: A retrospective cohort study

INTRODUCTION

The effect of polypharmacy on older patients with cancer is unclear. This study aimed to explore the effect of polypharmacy on the outcomes of treatment in older patients with advanced non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors.

MATERIALS AND METHODS

We retrospectively reviewed the records of older patients (aged ≥65 years) with advanced NSCLC who received PD-1/PD-L1 inhibitors with or without platinum-based chemotherapy as first-line treatment from March 2016 to December 2020. Patients with driver oncogenes or Eastern Cooperative Oncology Group performance status (PS) ≥2 were excluded. Polypharmacy was defined as receiving five or more oral or inhaled medications at baseline. We compared the progression-free survival (PFS), overall survival (OS), and mean cumulative length of hospital stays between the polypharmacy and non-polypharmacy groups.

RESULTS

A total of 122 patients, with a median age of 72 years (range, 65-89 years), were included in the analysis. Of the patients, 34 (27.8%) had a PS of 0 and 68 (55.7%) had a PD-L1 tumor proportion score (TPS) of ≥50%. The median number of oral or inhaled medications was 4 (range, 0-12), and 60 (49.1%) patients were taking ≥5 medications (polypharmacy). Age and Charlson Comorbidity Index score were significantly higher in the polypharmacy group (P = 0.01 and P < 0.001, respectively). Compared with the non-polypharmacy group, the polypharmacy group had a similar median PFS (6.7 vs. 8.5 months, P = 0.94) and a shorter median OS (17.3 vs. 26.0 months, P = 0.04). In the polypharmacy group, the adjusted hazard ratio for OS (adjusted for age, PS, and PD-L1 TPS) was 1.65 (95% confidence interval, 1.04-2.86, P = 0.03). Patients in the polypharmacy group had longer hospital stays (46.3 ± 7.5 vs. 27.7 ± 4.1 days/person, P < 0.05) and more emergency hospitalizations (1.6 ± 0.3 vs. 0.8 ± 0.1 times/person, P < 0.05) during the first year.

DISCUSSION

Polypharmacy was associated with shorter survival time and longer hospitalization in older patients with advanced NSCLC receiving first-line immunotherapy with or without chemotherapy.

Cancer-associated muscle weakness - From triggers to molecular mechanisms

Skeletal muscle weakness is a debilitating consequence of many malignancies. Muscle weakness has a negative impact on both patient wellbeing and outcome in a range of cancer types and can be the result of loss of muscle mass (i.e. muscle atrophy, cachexia) and occur independently of muscle atrophy or cachexia. There are multiple cancer specific triggers that can initiate the progression of muscle weakness, including the malignancy itself and the tumour environment, as well as chemotherapy, radiotherapy and malnutrition. This can induce weakness via different routes: 1) impaired intrinsic capacity (i.e., contractile dysfunction and intramuscular impairments in excitation-contraction coupling or crossbridge cycling), 2) neuromuscular disconnection and/or 3) muscle atrophy. The mechanisms that underlie these pathways are a complex interplay of inflammation, autophagy, disrupted protein synthesis/degradation, and mitochondrial dysfunction. The current lack of therapies to treat cancer-associated muscle weakness highlight the critical need for novel interventions (both pharmacological and non-pharmacological) and mechanistic insight. Moreover, most research in the field has placed emphasis on directly improving muscle mass to improve muscle strength. However, accumulating evidence suggests that loss of muscle function precedes atrophy. This review primarily focuses on cancer-associated muscle weakness, independent of cachexia, and provides a solid background on the underlying mechanisms, methodology, current interventions, gaps in knowledge, and limitations of research in the field. Moreover, we have performed a mini-systematic review of recent research into the mechanisms behind muscle weakness in specific cancer types, along with the main pathways implicated.

Nutritional care pathways in cancer patients with malignant bowel obstruction: A retrospective multi-centre study

INTRODUCTION

Variation in access to parenteral nutrition (PN) in patients with intestinal failure secondary to malignant bowel obstruction (MBO) exists due to differing practice, beliefs and resource access. We aimed to examine differences in nutritional care pathways and outcomes, by referral to nutrition team for PN in patients with MBO.

METHODS

This is a retrospective cohort study of MBO adults admitted to eight UK hospitals within a year and 1 year follow-up. Demographic, nutritional and medical data were analysed by comparing patients referred (R) or not referred (NR) for PN. Differences between groups were tested by Kruskal-Wallis, Chi-Squared tests and multi-level regression and survival using Cox regression.

RESULTS

232 patients with 347 MBO admissions [median 66yr, (IQR: 55-74yrs), 67 % female], 79/232 patients were referred for PN (R group). Underlying primary malignancies of gynaecological and gastrointestinal origin predominated (71 %) and 78 % with metastases. Those in the NR group were found to be older, weigh more on admission, and more likely to be treated conservatively compared to those in the R group. For 123 (35 %) admissions, patients were referred to a nutrition team, and for 204 (59 %) admissions, patients were reviewed by a dietician. Multi-disciplinary team discussion and dietetic contact were more likely to occur in the R group-123/347 admissions (R vs NR group: 27 % vs. 7 %, P = 0.001; 95 % vs 39 %, P < 0.0001). Median admission weight loss was 8 % (IQR: 0 to 14). 43/123 R group admissions received inpatient PN only, with 32 patients discharged or already established on home parenteral nutrition. Overall survival was 150 days (126-232) with no difference between R/NR groups.

CONCLUSION

In this multi-centre study evaluating nutritional care management of patients with malignant bowel obstruction, only 1 in 3 admissions resulted in a referral to the nutrition team for PN, and just over half were reviewed by a dietician. Further prospective research is required to evaluate possible consequences of these differential care pathways on clinical outcomes and quality of life.

Exercise-based interventions for cancer cachexia: A systematic review of randomised and non-randomised controlled trials

Objective

Cachexia is a multifactorial syndrome characterised by involuntary weight loss and functional limitation. There is a strong theoretical rationale for the use of exercise in the management of cachexia, and evidence of benefit from exercise in general cancer patients. However, clinical studies of exercise interventions in cancer cachexia are limited. We aimed to synthesise current evidence on the delivery, acceptability, safety and outcomes of exercise interventions for adults with cancer cachexia.

Methods

We conducted a systematic review. Four databases were searched up to February 2023 for randomised (RCTs) and non-randomised (NRCTs) controlled studies. Eligibility and quality were independently assessed by two authors. Data on intervention components and structure, participant flow and adherence were tabulated. Clinical outcome data on body stature and composition, muscle strength, functional performance, and health-related quality of life were synthesised using effect direction plots.

Results

Twelve studies (9 RCTs, 3 NRCTs) involving a total of 898 patients (study range 20-374) as part of a multicomponent approach. Median programme completion was 75% (range 43%-100%) and adherence was generally high. Five adverse events were considered possibly related to an intervention, including muscle or joint pain, breathlessness on exertion. Overall, 12/16 (75%) outcomes demonstrated a positive direction of effect on body stature and composition, 8/10 (80%) on muscle strength, 14/22 (64%) on functional performance, and 3/8 (38%) on health-related quality of life. Multicomponent interventions showed more consistent effects on body stature, and resistance training interventions on muscle strength.

Conclusions

Exercise interventions appear to be safe and acceptable to people with cancer cachexia. Positive effects from exercise are more consistently observed for body stature or composition and muscle strength outcomes, than in functional capacity and health-related quality of life. The synergistic effects of exercise with other cachexia interventions, including drugs, should be examined in future robust studies.

Diagnosis and outcomes of cachexia in Asia: Working Consensus Report from the Asian Working Group for Cachexia

Chronic diseases often lead to metabolic disorders, causing anabolic resistance and increased energy consumption, which result in cachexia. Cachexia, in turn, can lead to major clinical consequences such as impaired quality of life, shortened life expectancy, and increased healthcare expenditure. Existing international diagnostic criteria for cachexia employ thresholds derived from Western populations, which may not apply to Asians due to differing body compositions. To address this issue, the Asian Working Group for Cachexia (AWGC) was initiated. The AWGC comprises experts in cachexia research and clinical practice from various Asian countries and aims to develop a consensus on diagnostic criteria and significant clinical outcomes for cachexia in Asia. The AWGC, composed of experts in cachexia research and clinical practice from several Asian countries, undertook three-round Delphi surveys and five meetings to reach a consensus. Discussions were held on etiological diseases, essential diagnostic items for cachexia, including subjective and objective symptoms and biomarkers, and significant clinical outcomes. The consensus highlighted the importance of multiple diagnostic factors for cachexia, including chronic diseases, either or both weight loss or low body mass index, and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>5 mg/L [0.5 mg/dL]). The AWGC proposed a significant weight change of 2% or more over a 3-6 month period and suggested a tentative cut-off value of 21 kg/m2 for low body mass index in diagnosing cachexia. Critical clinical outcomes were determined to be mortality, quality of life as assessed by tools such as EQ-5D or the Functional Assessment of Anorexia/Cachexia Therapy, and functional status as measured by the Clinical Frailty Scale or Barthel Index, with significant emphasis on patient-reported outcomes. The AWGC consensus offers a comprehensive definition and user-friendly diagnostic criteria for cachexia, tailored specifically for Asian populations. This consensus is set to stimulate future research and enhance the multidisciplinary approach to managing cachexia. With plans to develop further guidelines for the optimal treatment, prevention, and care of cachexia in Asians, the AWGC criteria are expected to drive research across chronic co-morbidities and cancer in Asia, leading to future refinement of diagnostic criteria.

Pembrolizumab as first-line treatment for advanced NSCLC in older adults: A phase II clinical trial evaluating geriatric and quality-of-life outcomes

OBJECTIVES

Since specific data on immunotherapy in older adults with advanced non-small cell lung cancer (aNSCLC) are scarce, we designed this study to determine the overall survival (OS) at one year of first-line pembrolizumab in patients older than 70 years with aNSCLC expressing PD-L1. Secondary objectives included progression-free survival, disease-specific survival, response rate, tolerability, quality of life (QoL) changes, and geriatric assessments.

MATERIALS AND METHODS

A single-arm, open-label, phase II clinical trial was carried out by the Spanish Lung Cancer Group between February 2018 and November 2019 at ten active sites in Spain. We included patients 70 years old and older with histological or cytological documented stage IIIB or IV aNSCLC and PD-L1 expression ≥ 1%. Each subject received 200 mg of intravenous pembrolizumab every three weeks for a maximum of two years.

RESULTS

83 patients were recruited for the study and 74 were finally analysed. Most were male (N = 64, 86.5%) and former smokers (N = 51, 68.9%). 24 patients (32.4%) completed at least one year of treatment, 62 (83.7%) discontinued treatment, and 30 (40.5%) experienced disease progression. The median follow-up of our cohort was 18.0 months [range: 0.1-47.7] and 46 patients (62.2%) died during the period of study. The estimated OS at one year was 61.7% (95% CI: 49.6-71.8%) and the median OS of our cohort was 19.2 months (95% CI: 11.3-25.5). QoL tended to improve throughout the study, although the differences were not statistically significant. The main geriatric scores remained stable, except for a worsening in nutritional status (P = 0.004) and an improvement in frailty (P = 0.028).

CONCLUSION

Our results support treating older adults with aNSCLC expressing PD-L1 with pembrolizumab in monotherapy. The stability of most geriatric scores and the positive trend on the patients' QoL should be highlighted, although our results did not reach statistical significance.

Priority of the basic and instrumental activities of daily living in older patients with cancer prescribed rehabilitation: a cross-sectional survey

BACKGROUND

There is no information on whether vulnerable older patients with cancer consider basic activities of daily living (BADL) and instrumental activities of daily living (IADL) important outcomes. Our survey aimed to investigate the priority of BADL and IADL in outcomes among vulnerable older patients with cancer.

METHODS

This was a single-center survey in a Japanese cancer center. Eligible patients were ≥ 65 years of age and were prescribed in-hospital rehabilitation while under cancer treatment. Using original self-administered ranking questionnaires, patients were asked to rank outcomes and subdomain of BADL and IADL. High-priority domains were defined as the highest, second-highest, and third-highest priority domains in individuals.

RESULTS

A total of 169 patients were analyzed. The mean age was 74.0 years (standard deviation, 5.1 years) and the number of males was 107 (63%). The order of ranking of high-priority outcomes was BADL and IADL (n = 155), cognitive function (n = 91), mental function (n = 82), nutrition (n = 61), social function (n = 51), comorbidity (n = 39), and life span (n = 28). The top three high-priority independence subdomains of BADL and IADL were toilet use (n = 140), feeding (n = 134), and mobility (n = 69) among the BADL and shopping (n = 93), food preparation (n = 88), and ability to handle finances (n = 85) among the IADL.

CONCLUSIONS

BADL and IADL can be considered the most important health outcomes in clinical trials and in practice among older patients with cancer and physical vulnerabilities.

Impact of cancer cachexia on respiratory muscle function and the therapeutic potential of exercise

Cancer cachexia is defined as a multi-factorial syndrome characterised by an ongoing loss of skeletal muscle mass and progressive functional impairment, estimated to affect 50-80% of patients and responsible for 20% of cancer deaths. Elevations in the morbidity and mortality rates of cachectic cancer patients has been linked to respiratory failure due to atrophy and dysfunction of the ventilatory muscles. Despite this, there is a distinct scarcity of research investigating the structural and functional condition of the respiratory musculature in cancer, with the majority of studies exclusively focusing on limb muscle. Treatment strategies are largely ineffective in mitigating the cachectic state. It is now widely accepted that an efficacious intervention will likely combine elements of pharmacology, nutrition and exercise. However, of these approaches, exercise has received comparatively little attention. Therefore, it is unlikely to be implemented optimally, whether in isolation or combination. In consideration of these limitations, the current review describes the mechanistic basis of cancer cachexia and subsequently explores the available respiratory- and exercise-focused literature within this context. The molecular basis of cachexia is thoroughly reviewed. The pivotal role of inflammatory mediators is described. Unravelling the mechanisms of exercise-induced support of muscle via antioxidant and anti-inflammatory effects in addition to promoting efficient energy metabolism via increased mitochondrial biogenesis, mitochondrial function and muscle glucose uptake provide avenues for interventional studies. Currently available pre-clinical mouse models including novel transgenic animals provide a platform for the development of multi-modal therapeutic strategies to protect respiratory muscles in people with cancer.

Attenuation of Muscle Damage, Structural Abnormalities, and Physical Activity in Respiratory and Limb Muscles following Treatment with Rucaparib in Lung Cancer Cachexia Mice

Simple Summary

Muscle wasting and cachexia are common in patients with cancer. Several mechanisms underlie muscle physiological and structural alterations in cancer-induced cachexia. Poly (ADPribose) polymerases (PARPs) are involved in muscle metabolism and in cancer. Selective inhibitors of PARP activity improve muscle function and structure. This study sought to investigate whether rucaparib (PARP inhibitor) may attenuate muscle damage in a mouse model of lung-cancer-induced cachexia. Rucaparib was administered to cancer-cachectic mice. Physiological and biological parameters were determined in the respiratory and limb muscles of the animals. In cancer cachexia mice compared to non-cachexia controls, body weight and body weight gain, muscle weight, limb strength, physical activity, and muscle fiber size significantly declined, while levels of PARP activity, plasma troponin I, muscle damage, and proteolytic and autophagy markers increased. Treatment with rucaparib elicited a significant improvement in body weight gain, tumor size and weight, physical activity, muscle damage, troponin I, and proteolytic and autophagy levels.

Abstract

Overactivation of poly (ADPribose) polymerases (PARPs) is involved in cancer-induced cachexia. We hypothesized that the PARP inhibitor rucaparib may improve muscle mass and reduce damage in cancer cachexia mice. In mouse diaphragm and gastrocnemius (LP07 lung adenocarcinoma) treated with PARP inhibitor (rucaparib,150 mg/kg body weight/24 h for 20 days) and in non-tumor control animals, body, muscle, and tumor weights; tumor area; limb muscle strength; physical activity; muscle structural abnormalities, damage, and phenotype; PARP activity; and proteolytic and autophagy markers were quantified. In cancer cachexia mice compared to non-cachexia controls, body weight and body weight gain, muscle weight, limb strength, physical activity, and muscle fiber size significantly declined, while levels of PARP activity, plasma troponin I, muscle damage, and proteolytic and autophagy markers increased. Treatment with the PARP inhibitor rucaparib elicited a significant improvement in body weight gain, tumor size and weight, physical activity, muscle damage, troponin I, and proteolytic and autophagy levels. PARP pharmacological inhibition did not exert any significant improvements in muscle weight, fiber size, or limb muscle strength. Treatment with rucaparib, however, improved muscle damage and structural abnormalities and physical activity in cancer cachexia mice. These findings suggest that rucaparib exerts its beneficial effects on cancer cachexia performance through the restoration of muscle structure.

Effect of Rehabilitation Nutrition Care Process on Physical Function in Lung Cancer Cachexia: A Case Report

OBJECTIVES

Patients with cancer cachexia have poor adherence to treatment, which affects their prognosis. Currently, there are many studies on the effects of rehabilitation on cancer cachexia, but there is a lack of evidence on the effects of nutrition therapy alone or in combination with rehabilitation and nutrition therapy. This article describes a case in which rehabilitation nutrition care process was effective in a patient with lung cancer who developed cancer cachexia.

METHODS

A 68-year-old woman was hospitalized for treatment of lung adenocarcinoma. The patient had moderate malnutrition, sarcopenia, and cachexia at the time of admission, so the authors intervened according to rehabilitation nutrition care process. The physiotherapist mainly prescribed resistance training and aerobic exercise, 40-60 minutes a day, 5-6 days a week. And the dietitian provided oral nutritional supplements (100 kcal, branched-chain amino acid: 3.0 g) in addition to hospital food and adjusted the patient's energy intake to 26.96-33.05 kcal/kg/day and protein intake to 1.07-1.14 g/kg/day.

OUTCOMES

Comparing the initial evaluation with the discharge, nutritional status, such as body mass index and skeletal muscle mass, and physical functions, such as maximum grip strength, gait speed, and functional independence measure (motor items), were improved.

CONCLUSIONS

Rehabilitation nutrition care process-based interventions may improve nutritional status and physical functions more than exercise therapy alone in patients with lung cancer cachexia.

Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer

PURPOSE

To investigate if early exercise can help prevent skeletal muscle loss and improve the clinical outcomes of esophageal cancer patients receiving preoperative neoadjuvant chemotherapy (NAC).

METHODS

This was a single-center, retrospective observational cohort study of 110 patients with advanced esophageal cancer. We analyzed the effect of early exercise on the risk of skeletal muscle loss (defined as > 2.98%) during NAC and the subsequent clinical outcomes. Patients in the early exercise group (n = 71) started exercise therapy 8 days earlier than those the late exercise group (n = 39).

RESULTS

The median age of the patients was 65.4 years, the mean BMI was 21.1 kg/m², and 92 (84%) of the 110 patients were men. Skeletal muscle loss occurred in 34% and 67% of the early and late exercise groups, respectively (p < 0.001). There was a lower risk of surgical site infection in the early exercise group (1% vs 16%, p = 0.021). Multivariate analysis revealed that early exercise reduced the risk of skeletal muscle loss (OR = 0.25, 95% CI 0.09-0.65, p = 0.006).

CONCLUSIONS

Our results suggest that early exercise reduces the risk of both skeletal muscle loss during NAC and subsequent surgical site infection in patients with esophageal cancer.

The Effect of Cannabis-Based Medicine in the Treatment of Cachexia: A Systematic Review and Meta-Analysis

Background: Cachexia is a prevalent condition associated with underlying chronic disease. Wasting of skeletal muscle and adipose tissue loss in cachectic patients is associated with higher rates of disability, reduced quality of life (QoL), and worse prognosis. There is a large unmet need to develop strategies to treat cachexia as there are currently no standardized guidelines in the management of cachexia. Activation of endogenous cannabinoid receptors, through exogenous cannabinoids, has demonstrated potential in increasing appetite, reducing catabolism, and has shown anti-inflammatory properties. Since no single pharmacological agent is currently recommended for use in cachexia, the potential of cannabinoids as an appetite stimulant warrants further research and assessment of current evidence. Objective: This review aims to evaluate the evidence for the efficacy of cannabis-based medicinal products, against placebo and other active treatments, in anorexia-cachexia syndrome in improving appetite, weight, and QoL. Methods: A literature search of the Medline, EMBASE, CENTRAL, and the Web of Science Core Collection, for articles published up to February 2020, was conducted. All randomized controlled trials comparing the use of cannabis-based medicine versus placebo/active treatments for patients with cachexia were screened. The quality of evidence in included studies was assessed using the GRADE framework and any risk of bias was judged using the Cochrane risk of bias tool. Results: A total of five studies, encompassing 934 participants, were found to be eligible. The pooled group effect size for change in appetite was -1.79 (95% confidence interval: -3.77 to 0.19) favoring the control group (p=0.08). Additionally, no significant difference for weight change or change in QoL for cannabinoids versus placebo/other treatment was observed. The quality of evidence for all five studies was assessed to be low. Conclusion: There is a lack of high-quality evidence to recommend the use of cannabinoids in the treatment of cachexia. Given the limited available pharmacological options for cachexia and the potential for cannabinoids to increase appetite and alter the immune system, further research is needed before clinical recommendations on the pharmacological management of cachexia can be made.

Machine learning model for predicting excessive muscle loss during neoadjuvant chemoradiotherapy in oesophageal cancer

BACKGROUND

Excessive skeletal muscle loss during neoadjuvant concurrent chemoradiotherapy (NACRT) is significantly related to survival outcomes of oesophageal cancer. However, the conventional method for measuring skeletal muscle mass requires computed tomography (CT) images, and the calculation process is labour-intensive. In this study, we built machine-learning models to predict excessive skeletal muscle loss, using only body mass index data and blood laboratory test results.

METHODS

We randomly split the data of 232 male patients treated with NACRT for oesophageal cancer into the training (70%) and test (30%) sets for 1000 iterations. The naive random over sampling method was applied to each training set to adjust for class imbalance, and we used seven different machine-learning algorithms to predict excessive skeletal muscle loss. We used five input variables, namely, relative change percentage in body mass index, albumin, prognostic nutritional index, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio over 50 days. According to our previous study results, which used the maximal χ² method, 10.0% decrease of skeletal muscle index over 50 days was determined as the cut-off value to define the excessive skeletal muscle loss.

RESULTS

The five input variables were significantly different between the excessive and the non-excessive muscle loss group (all P < 0.001). None of the clinicopathologic variables differed significantly between the two groups. The ensemble model of logistic regression and support vector classifier showed the highest area under the curve value among all the other models [area under the curve = 0.808, 95% confidence interval (CI): 0.708-0.894]. The sensitivity and specificity of the ensemble model were 73.7% (95% CI: 52.6%-89.5%) and 74.5% (95% CI: 62.7%-86.3%), respectively.

CONCLUSIONS

Machine learning model using the ensemble of logistic regression and support vector classifier most effectively predicted the excessive muscle loss following NACRT in patients with oesophageal cancer. This model can easily screen the patients with excessive muscle loss who need an active intervention or timely care following NACRT.

Quality of Life and Symptom Burden Improve in Patients Attending a Multidisciplinary Clinical Service for Cancer Cachexia: A Retrospective Observational Review

BACKGROUND

Cancer cachexia negatively affects quality of life (QoL) and increases symptom burden. A multimodal treatment approach may optimize cachexia outcomes, including QoL. We evaluated QoL and symptoms over time among patients attending a multidisciplinary clinical service for cancer cachexia.

METHODS

Adults with cancer who attended the clinical service three times between 2017 and 2020 were included. Quality of life and symptoms were assessed using the European Organization for Research and Treatment of Cancer Quality of life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL) and the Functional Assessment Anorexia/Cachexia Therapy (FAACT) questionnaires. Physical function was assessed using the 30s sit-to-stand test and handgrip strength.

RESULTS

Overall, 162 patients (age = 67.2 ± 12.0 years) were included. Mean six-month weight loss at baseline was 10.4% ± 9.4%. Mean body weight was stable between clinic visits (P = 0.904) and no change in sit-to-stand repetitions (P = 0.133) or handgrip strength (P = 0.734) occurred over time. Improvements in EORTC QLQ-C15-PAL overall QoL (Δ10.7 ± 2.5, P < 0.001), physical function (Δ8.0 ± 2.4, P = 0.003) and emotional function (Δ11.4 ± 2.9, P < 0.001) occurred by the second visit. EORTC QLQ-C15-PAL fatigue (Δ13.8 ± 2.9, P < 0.001), pain (Δ10.3 ± 3.3, P = 0.007), nausea/vomiting (Δ16.1 ± 3.0, P < 0.001) and appetite symptoms (Δ25.9 ± 3.8, P < 0.001) also improved by the second visit. FAACT total score (Δ14.6 ± 2.7, P < 0.001), anorexia-cachexia symptoms (Δ6.6 ± 1.1, P< 0.001), and physical (Δ3.7 ± 0.70, P < 0.001), emotional (Δ1.9 ± 0.60, P = 0.005) and functional wellbeing (Δ2.7 ± 0.71, P = 0.001) improved by the second visit. All improvements in EORTC QLQ-C15-PAL and FAACT outcomes were maintained at the third visit.

CONCLUSION

Significant improvements in QoL and symptoms were associated with attending a cancer cachexia clinical service. Our findings support using multidisciplinary, multimodal cancer cachexia treatment approaches to improve patient wellbeing.

Evaluation of nutritional status in non-small-cell lung cancer: screening, assessment and correlation with treatment outcome

Background

Nutritional derangements are common hallmarks of non-small-cell lung cancer (NSCLC). Nevertheless, their early detection is overlooked in clinical routine. This study aimed to evaluate nutritional status and its correlation with outcome in NSCLC patients.

Methods

Data regarding NSCLC patients undergoing nutritional evaluation were prospectively collected (May 2016–October 2018). Nutritional risk was assessed by Nutritional Risk Screening 2002 (NRS-2002). Bilateral psoas major muscles were measured at L3 vertebrae level with routine staging-computed tomography and changes were evaluated using Wilcoxon signed-rank test. Clinico-pathological and nutritional data were correlated to progression-free/overall survival (PFS/OS) and response rate (ORR) using a Cox and logistic regression model. Kaplan–Meier curves were compared with log-rank test.

Results

Thirty-eight patients were included. The majority (65.8%) of them were at nutritional risk (NRS-2002 ≥3). At multivariate analysis for patients with advanced disease, age (HR 2.44, p=0.05), performance status (HR 2.48, p=0.043) and NRS-2002 (HR 1.74, p=0.001) were significant independent predictors for PFS and weight loss (HR 1.07, p=0.008) for OS. Patients with baseline NRS-2002 <3 had significantly longer 1-year PFS (85.7% vs 19.4%, p=0.02) and higher ORR (66.7% vs 21.4%) than those with NRS-2002 ≥3. An explorative evaluation demonstrated that NRS-2002 score significantly decreased after nutritional intervention (p=0.001) for 3 months.

Conclusion

Baseline nutritional risk represents a prognostic factor in NSCLC. Nutritional counselling should be applied as a fundamental tool to improve nutritional risk in a short period, ameliorating patients’ outcome.

Pharmacological or genetic inhibition of iNOS prevents cachexia-mediated muscle wasting and its associated metabolism defects

Cachexia syndrome develops in patients with diseases such as cancer and sepsis and is characterized by progressive muscle wasting. While iNOS is one of the main effectors of cachexia, its mechanism of action and whether it could be targeted for therapy remains unexplored. Here, we show that iNOS knockout mice and mice treated with the clinically tested iNOS inhibitor GW274150 are protected against muscle wasting in models of both septic and cancer cachexia. We demonstrate that iNOS triggers muscle wasting by disrupting mitochondrial content, morphology, and energy production processes such as the TCA cycle and acylcarnitine transport. Notably, iNOS inhibits oxidative phosphorylation through impairment of complexes II and IV of the electron transport chain and reduces ATP production, leading to energetic stress, activation of AMPK, suppression of mTOR, and, ultimately, muscle atrophy. Importantly, all these effects were reversed by GW274150. Therefore, our data establish how iNOS induces muscle wasting under cachectic conditions and provide a proof of principle for the repurposing of iNOS inhibitors, such as GW274150 for the treatment of cachexia.

Impact of Physical Inactivity on the Risk of Disability and Hospitalization in Older Patients with Advanced Lung Cancer

Purpose

This prospective observational study aimed to explore the influence of physical inactivity during initial chemotherapy on the risk of disability and hospitalization in later life among older patients with advanced non-small-cell lung cancer (NSCLC).

Patients and Methods

Patients aged 70 or above who were scheduled to receive first-line chemotherapy for newly diagnosed advanced NSCLC were recruited for the study. An electronic pedometer was used to measure daily steps; based on the change rate (cutoff: −12.5%) from pretreatment to 12 ± 4 weeks after enrolment, patients were classified as active or inactive. The Barthel Index estimated activities of daily living. We compared disability-free survival time, mean cumulative functions of hospital stays, and medical costs, between the active and inactive groups.

Results

Among the 29 patients enrolled, 21 were evaluable. Compared with active patients (n = 11), inactive patients (n = 10) showed shorter disability-free survival (6.4 vs 19.9 months, p < 0.05) and tended to have longer hospital stays (23.7 vs 6.3 days/person) and higher inpatient care cost (¥1.6 vs ¥0.3 million/person [US$16,000 vs US$3000/person]) during the first year.

Conclusion

Physical inactivity during initial chemotherapy may be a risk factor for developing disability and requiring hospitalization in later life for older patients with advanced NSCLC. Our findings may indicate the need for lifestyle interventions with multidisciplinary teams, which include physicians, nurses, and physiotherapists, for older patients with advanced lung cancer during an active cancer treatment. A large-sample-sized study is needed to validate our findings.

Characteristics Associated With Functional Changes During Systemic Cancer Treatments: A Systematic Review Focused on Older Adults

BACKGROUND

Maintaining functional status is important to older adults with cancer, but data are limited on how systemic treatments affect functional status. We systematically reviewed changes in functional status during systemic cancer treatments and identified characteristics associated with functional decline and improvement.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Register of Controlled Trials for articles examining characteristics associated with functional changes in older adults during systemic cancer treatment published in English between database inception and January 11, 2019 (PROSPERO CRD42019123125). Findings were summarized with descriptive statistics. Study characteristics between older adult-specific and non-older adult-specific studies were compared using the Fisher exact test.

RESULTS

We screened 15,244 titles/abstracts and 519 full texts. The final analysis included 44 studies, which enrolled >8,400 patients; 39% of studies focused on older adults (1 study enrolled adults aged ≥60 years, 10 enrolled adults aged ≥65 years, and 6 enrolled adults aged ≥70 years). Almost all studies (98%) used patient-reported outcomes to measure functional status; only 20% used physical performance tests. Reporting of functional change was heterogeneous, with 48% reporting change scores. Older adult-specific studies were more likely to analyze functional change dichotomously (29% vs 4%; P=.008). Functional decline ranged widely, from 6% to 90%. The most common patient characteristics associated with functional decline were older age (n=7 studies), worse performance status (n=4), progressive disease status (n=4), pain (n=4), anemia (n=4), and worse nutritional status (n=4). Twelve studies examined functional improvement and identified 11 unique associated characteristics.

CONCLUSIONS

Functional decline is increasingly recognized as an important outcome in older adults with cancer, but definitions and analyses are heterogeneous, leading to a wide range of prevalence. To identify patients at highest risk of functional decline during systemic cancer treatments, trials need to routinely analyze functional outcomes and measure characteristics associated with decline (eg, nutrition).

Exercise for cancer cachexia in adults

BACKGROUND

Cancer cachexia is a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass, with or without a loss of fat mass, leading to progressive functional impairment. Physical exercise may attenuate cancer cachexia and its impact on patient function. This is the first update of an original Cochrane Review published in Issue 11, 2014, which found no studies to include.

OBJECTIVES

To determine the effectiveness, acceptability and safety of exercise, compared with usual care, no treatment or active control, for cancer cachexia in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to March 2020. We searched for ongoing studies in trial registries, checked reference lists and contacted experts to seek relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials in adults with cancer cachexia, that compared a programme of exercise alone or in combination with another intervention, with usual care, no treatment or an active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for relevance and extracted data on study design, participants, interventions and outcomes from potentially relevant articles. We used standard methodological procedures expected by Cochrane. Our primary outcome was lean body mass and secondary outcomes were adherence to exercise programme, adverse events, muscle strength and endurance, exercise capacity, fatigue and health-related quality of life. We assessed the certainty of evidence using GRADE and included two Summary of findings tables.

MAIN RESULTS

We included four new studies in this update which overall randomised 178 adults with a mean age of 58 (standard deviation (SD) 8.2) years. Study sample size ranged from 20 to 60 participants and in three studies the proportion of men ranged from 52% to 82% (the fourth study was only available in abstract form). Three studies were from Europe: one in the UK and Norway; one in Belgium and one in Germany. The remaining study was in Canada. The types of primary cancer were head and neck (two studies), lung and pancreas (one study), and mixed (one study). We found two comparisons: exercise alone (strength-based exercise) compared to usual care (one study; 20 participants); and exercise (strength-based exercise/endurance exercise) as a component of a multimodal intervention (pharmacological, nutritional or educational (or a combination) interventions) compared with usual care (three studies, 158 participants). Studies had unclear and high risk of bias for most domains. Exercise plus usual care compared with usual care We found one study (20 participants). There was no clear evidence of a difference for lean body mass (8 weeks: MD 6.40 kg, 95% CI -2.30 to 15.10; very low-certainty evidence). For our secondary outcomes, all participants adhered to the exercise programme and no participant reported any adverse event during the study. There were no data for muscle strength and endurance, or maximal and submaximal exercise capacity. There was no clear evidence of a difference for either fatigue (4 to 20 scale, lower score was better) (8 weeks: MD -0.10, 95% CI -4.00 to 3.80; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score was better) (8 weeks: MD 4.90, 95% CI -15.10 to 24.90; very low-certainty evidence). Multimodal intervention (exercise plus other interventions) plus usual care compared with usual care We found three studies but outcome data were only available for two studies. There was no clear evidence of a difference for lean body mass (6 weeks: MD 7.89 kg, 95% CI -9.57 to 25.35; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -2.00, 95% CI -8.00 to 4.00; one study, 60 participants; very low-certainty evidence). For our secondary outcomes, there were no data reported on adherence to the exercise programme, endurance, or maximal exercise capacity. In one study (44 participants) there was no clear evidence of a difference for adverse events (patient episode report) (6 weeks: risk ratio (RR) 1.18, 95% CI 0.67 to 2.07; very low-certainty evidence). Another study assessed adverse events but reported no data and the third study did not assess this outcome. There was no clear evidence of a difference in muscle strength (6 weeks: MD 3.80 kg, 95% CI -2.87 to 10.47; 1 study, 44 participants; very low-certainty evidence; 12 weeks MD -5.00 kg, 95% CI -14.00 to 4.00; 1 study, 60 participants; very low-certainty evidence), submaximal exercise capacity (6 weeks: MD -16.10 m walked, 95% CI -76.53 to 44.33; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -62.60 m walked, 95% CI -145.87 to 20.67; 1 study, 60 participants; very low-certainty evidence), fatigue (0 to 10 scale, lower score better) (6 weeks: MD 0.12, 95% CI -1.00 to 1.24; 1 study, 44 participants; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score better) (12 weeks: MD -2.20, 95% CI -13.99 to 9.59; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The previous review identified no studies. For this update, our conclusions have changed with the inclusion of four studies. However, we are uncertain of the effectiveness, acceptability and safety of exercise for adults with cancer cachexia. Further high-quality randomised controlled trials are still required to test exercise alone or as part of a multimodal intervention to improve people's well-being throughout all phases of cancer care. We assessed the certainty of the body of evidence as very low, downgraded due to serious study limitations, imprecision and indirectness. We have very little confidence in the results and the true effect is likely to be substantially different from these. The findings of at least three more studies (one awaiting classification and two ongoing) are expected in the next review update.

Days Spent at Home near the End of Life in Japanese Elderly Patients with Lung Cancer: Post hoc Analysis of A Prospective Study

Objective:

Days spent at home (DASH) near the end of life is considered an important patient-centered goal and outcome because many patients want to stay at home toward the end of life. This study aimed to estimate the individual DASH near the end of life and identify its early predictors, including muscle mass and physical function, among elderly patients with advanced non-small-cell lung cancer (NSCLC).

Methods:

We conducted a post hoc analysis of the prospective observational study (UMIN000009768) that recruited patients aged ≥ 70 years who were scheduled to undergo first-line chemotherapy because of advanced NSCLC. We measured the muscle mass by bioelectrical impedance analysis at baseline. DASH was calculated as 30 days minus the number of days spent in hospitals, palliative care facilities, or nursing homes during the last 30 days of life. We performed linear regression analyses to evaluate the predictors of DASH.

Results:

Altogether, 16 women and 28 men with a median overall survival of 15.5 months (range: 2.9–58.9) were included. The median DASH in the last 30 days of life was 8 days (range: 0–30, interquartile range: 0–23). Men had longer DASH than women by 7.3 days. Patients who had good trunk muscle mass index and hand-grip strength had significantly longer DASH than those who did not (4.7 days per kg/m² increase [P = 0.017] and 0.4 days per kg increase [P = 0.032], respectively).

Conclusions:

Most elderly patients with advanced NSCLC had a limited DASH near the end of life. The risk factors for reduced DASH were women, reduced muscle mass, and poor physical function at the time of diagnosis of advanced NSCLC. Our findings would encourage early discussions about end-of-life care for patients with advanced cancers with risk factors for short DASH at the time of diagnosis, and thus, improve the quality of end-of-life care.

Surface-directed engineering of tissue anisotropy in microphysiological models of musculoskeletal tissue

Here, we present an approach to model and adapt the mechanical regulation of morphogenesis that uses contractile cells as sculptors of engineered tissue anisotropy in vitro. Our method uses heterobifunctional cross-linkers to create mechanical boundary constraints that guide surface-directed sculpting of cell-laden extracellular matrix hydrogel constructs. Using this approach, we engineered linearly aligned tissues with structural and mechanical anisotropy. A multiscale in silico model of the sculpting process was developed to reveal that cell contractility increases as a function of principal stress polarization in anisotropic tissues. We also show that the anisotropic biophysical microenvironment of linearly aligned tissues potentiates soluble factor-mediated tenogenic and myogenic differentiation of mesenchymal stem cells. The application of our method is demonstrated by (i) skeletal muscle arrays to screen therapeutic modulators of acute oxidative injury and (ii) a 3D microphysiological model of lung cancer cachexia to study inflammatory and oxidative muscle injury induced by tumor-derived signals.

Clinical impact of walking capacity on the risk of disability and hospitalizations among elderly patients with advanced lung cancer

PURPOSE

Little is known about the impact of decreased walking capacity on clinical outcomes in elderly patients with cancer. This prospective observational study aimed to investigate the impact of walking capacity on the risk of disability and hospitalization in elderly patients with advanced lung cancer.

METHOD

This study prospectively enrolled 60 patients aged ≥ 70 years with advanced non-small-cell lung cancer (NSCLC) scheduled to receive first-line chemotherapy or radical radiotherapy between January 2013 and December 2014 (trial registration number: UMIN000009768). Patients were classified into the mobile or less mobile group based on the median incremental shuttle walking distance (ISWD) before initial treatment. Assessments included the Barthel index, disability-free survival time, mean cumulative lengths of hospital stay, and inpatient medical costs.

RESULTS

The median ISWD was 290 m (interquartile range, 245-357.5 m). The mobile group (ISWD ≥ 290 m) had a longer disability-free survival time than the less mobile group (ISWD < 290 m, 24.6 months vs. 8.4 months, p < 0.05). During the first year from study entry, the mobile group had shorter cumulative lengths of hospital stay (41.3 vs. 72.9 days/person, p < 0.05) and lower inpatient medical costs (¥1.9 vs. ¥2.9 million/person, p < 0.05) than the less mobile group.

CONCLUSION

Elderly NSCLC patients with adequate walking capacity showed lower risks of disability, shorter hospitalizations, and lower inpatient medical costs than patients with reduced walking capacity. Further prospective research is needed to validate these findings. The trial was registered with the University Hospital Medical Information Network as trial number UMIN000009768 on January 13, 2013.

TRIAL REGISTRATION

UMIN000009768.

Cancer cachexia and treatment toxicity

PURPOSE OF REVIEW

Cancer cachexia is a metabolic disturbance resulting in a loss of skeletal muscle mass that is generally not reversed through traditional nutritional interventions. We review on both the impact of nutritional status on cancer treatment side effects, as well as cancer- specific outcomes.

RECENT FINDINGS

Cancer-specific cachexia and sarcopenia are associated with increased treatment-associated toxicity, and overall worse cancer-specific outcomes across all cancer types in surgical, chemotherapeutic, and radiotherapeutic populations. Despite the fact that cancer cachexia is generally thought to be irreversible, there is some evidence that nutritional intervention can be helpful.

SUMMARY

Nutritional status is an important factor to consider in determining cancer therapy. Patients with poor nutritional status should be identified prior to the initiation of therapy and be monitored judiciously.

Prognostic Markers of Overall Survival in Cancer Patients Attending a Cachexia Support Service: An Evaluation of Clinically Assessed Physical Function, Malnutrition and Inflammatory Status

BACKGROUND

Cancer cachexia is a muscle-wasting syndrome that results in physical function impairments and decreased survival. While body weight and muscle mass loss predict survival, the prognostic significance of physical function in this population is unclear. Thus, we evaluated the association between physical function, and other routine measures, and overall survival (OS) in cancer patients attending a cachexia support service.

METHODS

Physical function was clinically-assessed using the 30 s sit-to-stand test and handgrip strength. Six-month weight loss, the Patient-Generated Subjective Global Assessment (PG-SGA) total score, C-reactive protein (CRP), albumin, and quality of life were also evaluated.

RESULTS

Records from 203 patients (age: 68.6 ± 11.6 years) were included. Handgrip strength did not predict OS. Sit-to-stand repetitions predicted OS in the single variable, but not the multivariable analysis. Multivariable results suggested higher PG-SGA total scores (HR: 1.04, 95% CI: 1.01-1.07), six-month weight loss (HR: 1.02, 95% CI: 1.004-1.04), and elevated CRP (HR: 1.004, 95% CI: 1.0004-1.01) predicted shorter OS. Higher albumin predicted longer OS (HR: 0.93, 95% CI: 0.90-0.97).

CONCLUSION

Six-month weight loss, the PG-SGA total score, CRP, and albumin independently predicted survival, while physical function did not. Functional impairments remain a hallmark of cancer cachexia and the benefit of their routine assessment warrants further exploration, especially in relation to patient quality of life.

Knowledge Difference of Tumor Nutrition Risk Among Thoracic Cancer Patients, Their Family Members, Physicians, and Nurses

To investigate the difference among patients, family members, physicians, and nurses in their ability to identify malnutrition risk in patients with thoracic cancer. The enrolled patients were evaluated by the NRS2002 nutritional risk scale. The patient-centered groups, including the patient, the primary caretaker, the physician, and the nurse, were given a questionnaire on their knowledge and understanding of nutrition therapy in cancer treatment. The incidence rate of nutritional risk in hospitalized patients with thoracic cancer was 13.8%. There were significant differences in the accuracy rate of nutritional risk assessment among the four groups (P < 0.001), in which the nurses' was 70.3%, 55.1% for the physician, 38.7% for family members, and 33.0% for patients, which was the poorest accuracy rate. No significant correlation was found between the accuracy of nutritional risk assessment and the education level and personal monthly income of each population (P > 0.05). Nearly all four groups considered it necessary to learn more about cancer nutrition therapy. For patients and their families, the main way to understand the knowledge of tumor nutrition was consultation with medical staff and information exchange between patients; for doctors, new media; and for nurses, classroom training. Nurses' assessment of nutritional risk in cancer patients achieved the highest accuracy, while the poorest accuracy originated from the patients.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Effects of conditioned media from murine lung cancer cells and human tumor cells on cultured myotubes

Factors secreted from tumors/tumor cells are hypothesized to cause skeletal muscle wasting in cancer patients. We examined whether cancer cells secrete factors to promote atrophy by evaluating the effects of conditioned media (CM) from murine lung cancer cells and primary cultures of human lung tumor cells on cultured myotubes. We evaluated murine Lewis lung carcinoma (LLC) and KRAS^G12D cells, and primary cell lines derived from tumor biopsies from patients with lung cancer (hTCM; n = 6). In all experiments, serum content was matched across treatment groups. We hypothesized that CM from murine and human tumor cells would reduce myotube myosin content, decrease mitochondrial content, and increase mitochondrial reactive oxygen species (ROS) production. Treatment of myotubes differentiated for 7 days with CM from LLC and KRAS^G12D cells did not alter any of these variables. Effects of murine tumor cell CM were observed when myotubes differentiated for 4 days were treated with tumor cell CM and compared with undiluted differentiation media. However, these effects were not apparent if tumor cell CM treatments were compared with control cell CM or dilution controls. Finally, CM from human lung tumor primary cell lines did not modify myosin content or mitochondrial content or ROS production compared with either undiluted differentiated media, control cell CM, or dilution controls. Our results do not support the hypothesis that factors released from cultured lung cancer/tumor cells promote myotube wasting or mitochondrial abnormalities, but we cannot dismiss the possibility that these cells could secrete such factors in vivo within the native tumor microenvironment.

Emerging Treatment Options For Cancer-Associated Cachexia: A Literature Review

Cachexia is a disease that has been recognized since antiquity; however, research in this area has recently increased. Promising new agents, including anamorelin hydrochloride, have been tested in large randomized controlled studies, and multidrug as well as multimodal approaches have been proposed as having the potential to improve outcomes in patients with cancer cachexia. However, standard treatment remains elusive. This review summarizes the current literature on treatment of cancer-associated cachexia, showing that there are challenges associated with conducting clinical trials in such patients. First, poor recruitment, retention, and compliance among cachectic patients cause research delays. Second, the lack of consensus regarding clinically meaningful endpoints impedes standardization of study designs and results. Further consideration is needed to identify the most suitable study design and endpoints, which can lead to the development of pharmacological and nonpharmacological interventions that improve patients’ prognosis and outcomes.

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Preoperative Cachexia predicts poor outcomes in young rather than elderly gastric cancer patients: a prospective study

Background

Cachexia affects nearly 50–80% of cancer patients, and most studies have only focused on elderly patients. We investigated preoperative cachexia in gastric cancer (GC) patients by age group and comprehensively analyzed the impact of preoperative cachexia on the prognosis of GC patients in all age groups.

Methods

In total, 575 patients were prospectively analyzed. The effect of preoperative cachexia on overall survival (OS) in all the patients and in patients with different age groups were investigated using log-rank test and Cox proportional hazards regression, respectively.

Results

In total, 35.8% (206 of 575) individuals were diagnosed with cachexia. The median survival of cachexia patients (29.2 months) was shorter than that of non-cachexia patients (35.7 months). Cachexia (HR =1.976, P<0.001), age (HR =1.811, P<0.001), readmission (HR =2.559, P<0.001), tumor size (HR =1.639, P=0.003), TNM stage (stage II: HR =2.215, P=0.017; stage III: HR =5.758, P<0.001), whole stomach cancer (HR =2.639, P<0.001), and combined operation (HR =1.598, P=0.032) were independently associated with worse OS. After grouping by age, cachexia was associated with OS in patients younger than 50 years old (HR =4.947, P=0.029), patients 51–60 years old (HR =2.232, P=0.026), and patients 61–70 years old (HR =1.806, P=0.032), but not in patients older than 71 years (HR =1.411, P=0.119). Further, cachexia only significantly affected the postoperative length of stay (P=0.015) and hospitalization costs (P=0.032) in patients younger than 50 years old.

Conclusions

Preoperative cachexia predicts poor outcome in younger GC patients, and greater attention should be paid to these patients.

Staging of nutrition disorders in non-small-cell lung cancer patients: utility of skeletal muscle mass assessment

BACKGROUND

An international consensus proposed in 2011 a definition and classification system for cachexia (CAX), mainly based on weight loss, sarcopenia [skeletal muscle mass (SMM) loss], inflammation, and anorexia. The aim of this study was to stage CAX in non-small-cell lung cancer (NSCLC) patients by using a classification based on the Fearon criteria and supported by quantifiable parameters.

METHODS

This was a cross-sectional and non-interventional multicentre study. SMM was assessed by analysing L3 computed tomography-scan images. Patients completed the anorexia/CAX subscale of the Functional Assessment of Anorexia/Cachexia Therapy, EORTC QLQ-C30 quality of life (QoL) and International Physical Activity Questionnaire (IPAQ).

RESULTS

Patients were recruited in 56 sites. The analysis population comprised 531 patients, and SMM was assessed in 312 patients. Male patients were 66.5%, with a mean (SD) age of 65.2 (10.0) years, 79.9% were PS 0-1, and the tumour stage was mainly IIIB-IV (87.3%). Overall, 38.7% of patients had CAX, 33.8% pre-CAX, and 0.9% refractory CAX. Molecular tumour profiles were significantly associated with the presence of CAX: 23.9% in EGFR, ALK, ROS1, BRAF, or HER2+ patients, 41.4% in K-RAS+, and 43.2% in patients with no molecular abnormality (P = 0.003). The more advanced the CAX stage, the poorer the scores of functional items of the QoL (P < 0.001) and International Physical Activity Questionnaire (P < 0.001). Sarcopenia was present in 66.7% of CAX and 68.5% of pre-CAX patients. Overall, 43.8% of pre-CAX patients had only sarcopenia with limited weight loss (≤2%) and no anorexia.

CONCLUSIONS

This is the first study to show the distribution of CAX in a population of NSCLC patients and an association between molecular abnormality in NSCLC and CAX. The original Fearon classification for CAX stages was supported by the associated functional QoL scores and physical activity levels, resulting in a clinically relevant system for detection of early stages of CAX.

A randomized phase II study of nutritional and exercise treatment for elderly patients with advanced non-small cell lung or pancreatic cancer: the NEXTAC-TWO study protocol

Background

Most advanced elderly cancer patients experience fatigue, anorexia, and declining physical function due to cancer cachexia, for which effective interventions have not been established. We performed a phase I study of a new nonpharmacological multimodal intervention called the nutritional and exercise treatment for advanced cancer (NEXTAC) program and reported the excellent feasibility of and compliance with this program in elderly patients with advanced cancer who were at risk for cancer cachexia. We report here the background, hypothesis, and design of the next-step multicenter, randomized phase II study to evaluate the efficacy of the program, the NEXTAC-TWO study.

Methods

Patients with chemo-naïve advanced non-small cell lung cancer or pancreatic cancer, age ≥ 70 years, performance status ≤2, with adequate organ function and without disability according to the modified Katz index will be eligible. In total, 130 participants will be recruited from 15 Japanese institutions and will be randomized into either the intervention group or a control group. Computer-generated random numbers are allocated to each participant. Stratification factors include performance status (0 to 1 vs. 2), site of primary cancer (lung vs. pancreas), stage (III vs. IV), and type of chemotherapy (cytotoxic vs. others). Interventions and assessment will be performed 4 times every 4 ± 2 weeks from the date of randomization. Interventions will consist of nutritional counseling, nutritional supplements (rich in branched-chain amino acids), and a home-based exercise program. The exercise program will include low-intensity daily muscle training and lifestyle education to promote physical activity. The primary endpoint is disability-free survival. It is defined as the period from the date of randomization to the date of developing disability or death due to any cause. This trial also plans to evaluate the improvements in nutritional status, physical condition, quality of life, activities of daily living, overall survival, and safety as secondary endpoints. Enrollment began in August 2017. The study results will demonstrate the efficacy of multimodal interventions for elderly cancer patients and their application for the maintenance of physical and nutritional conditions in patients with cancer cachexia. This work is supported by a grant-in-aid from the Japan Agency for Medical Research and Development.

Discussion

This is the first randomized trial to evaluate the efficacy and safety of a multimodal intervention specific for elderly patients with advanced cancer.

Trial registration

Registered at August 23, 2017. Registry number: UMIN000028801.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5762-6) contains supplementary material, which is available to authorized users.

The IMPACT study: early loss of skeletal muscle mass in advanced pancreatic cancer patients

BACKGROUND

Pancreatic cancer (PC) patients have multiple risk factors for sarcopenia and loss of skeletal muscle mass (LSMM), which may cause greater treatment toxicities, reduced response to cancer therapy, prolonged hospitalization, impaired quality of life, and worse prognosis.

METHODS

This is a retrospective study on advanced PC patients treated at the Department of Oncology of Udine, Italy, from January 2012 to November 2017. Among 162 patients who received chemotherapy, 94 consecutive patients with an available computed tomography (CT) scan were retrospectively analyzed. The primary objective of our study was to explore if an early LSMM ≥ 10% (measured at first radiological evaluation and compared with baseline) and/or baseline sarcopenia may impact prognosis. Baseline sarcopenia was defined according to Prado's criteria. Skeletal muscle area was measured as cross-sectional areas (cm² ) using CT scan data through the Picture archiving and communication system (PACS) image system.

RESULTS

In the whole cohort, 48% of patients were ≤70 years old, and 50% had metastatic disease. At baseline, 73% of patients had sarcopenia, and 16% presented a visceral fat area ≥ 44 cm² /m² . Overall, 21% experienced an early LSMM ≥ 10%. Approximately 33% of sarcopenic patients at baseline and ~35% of patients with early LSMM ≥ 10% had a body mass index > 25 kg/m² . Of note, 71% of patients were evaluated by a nutritionist, and 56% received a dietary supplementation (oral and/or parenteral). After a median follow-up of 30.44 months, median overall survival (OS) was 11.28 months, whereas median progression-free survival (PFS) was 5.72 months. By multivariate analysis, early LSMM ≥ 10% was significantly associated with worse OS [hazard ratio (HR): 2.16; 95% confidence interval (CI) 1.23-3.78; P = 0.007] and PFS (HR: 2.31; 95% CI 1.30-4.09; P = 0.004). Moreover, an exploratory analysis showed that inflammatory indexes, such as neutrophil-lymphocyte ratio variation, impact early LSMM ≥ 10% (odds ratio 1.31, 95% CI 1.06-1.61, P = 0.010).

CONCLUSIONS

Early LSMM ≥ 10% has a negative prognostic role in advanced PC patients. Further prospective investigations are needed to confirm these preliminary data.

Communicating with Adolescents and Young Adults about Cancer-Associated Weight Loss

Purpose of Review

Over the past two decades, advances have been made in understanding the pathophysiology of cancer-associated weight loss, termed “cachexia.” To date, there is no proven effective intervention to completely reverse cachexia and there are no approved drug therapies to treat it. This paper will review relevant literature in relation to communicating with adolescents and young adults about cancer-associated weight loss.

Recent Findings

Adolescents and young adults (AYAs) who have cancer are a unique group of patients due to their stage of development and maturity.

Summary

This article outlines issues specific to this patient cohort that need to be considered to better understand the impact of cachexia and explore pertinent matters when communicating with AYAs in relation to cachexia.

Feasibility of early multimodal interventions for elderly patients with advanced pancreatic and non-small-cell lung cancer

BACKGROUND

Combinations of exercise and nutritional interventions might improve the functional prognosis for cachectic cancer patients. However, high attrition and poor compliance with interventions limit their efficacy. We aimed to test the feasibility of the early induction of new multimodal interventions specific for elderly patients with advanced cancer Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) programme.

METHODS

This was a multicentre prospective single-arm study. We recruited 30 of 46 screened patients aged ≥70 years scheduled to receive first-line chemotherapy for newly diagnosed, advanced pancreatic, or non-small-cell lung cancer. Physical activity was measured using pedometers/accelerometer (Lifecorder^® , Suzuken Co., Ltd., Japan). An 8 week educational intervention comprised three exercise and three nutritional sessions. The exercise interventions combined home-based low-intensity resistance training and counselling to promote physical activity. Nutritional interventions included standard nutritional counselling and instruction on how to manage symptoms that interfere with patient's appetite and oral intake. Supplements rich in branched-chain amino acids (Inner Power^® , Otsuka Pharmaceutical Co., Ltd., Japan) were provided. The primary endpoint of the study was feasibility, which was defined as the proportion of patients attending ≥4 of six sessions. Secondary endpoints included compliance and safety.

RESULTS

The median patient age was 75 years (range, 70-84). Twelve patients (40%) were cachectic at baseline. Twenty-nine patients attended ≥4 of the six planned sessions (96.7%, 95% confidence interval, 83.3 to 99.4). One patient dropped out due to deteriorating health status. The median proportion of days of compliance with supplement consumption and exercise performance were 99% and 91%, respectively. Adverse events possibly related to the NEXTAC programme were observed in five patients and included muscle pain (Grade 1 in two patients), arthralgia (Grade 1 in one patient), dyspnoea on exertion (Grade 1 in one patient), and plantar aponeurositis (Grade 1 in one patient).

CONCLUSIONS

The early induction of multimodal interventions showed excellent compliance and safety in elderly patients with newly diagnosed pancreatic and non-small-cell lung cancer receiving concurrent chemotherapy. We are now conducting a randomized phase II study to measure the impact of these interventions on functional prognosis.

Evaluation of the True Endpoint of Clinical Trials for Cancer Cachexia

Cachexia is an old disease but a new research area that has recently been vigorously investigated. The diagnostic and staging criteria for cancer-associated cachexia have been established through an international consensus report (CR) published in 2011, which may greatly influence the designs and interventions of future clinical trials. However, no standard treatment has been established so far. This may be partially due to the lack of a widely accepted common endpoint for clinical trials. This review aimed to summarize designs and endpoints of 65 randomized controlled trials for cancer cachexia in the past 16 years and seek clinically relevant patient-centered outcomes for future clinical trials. Compared with trials before the CR, trials after the report revealed that the study populations tended to be at the earlier stage of cachexia and included patients with precachexia or those at risk for cachexia. Nonpharmacological interventions have been widely tested, and functional endpoints have increasingly been selected in combination with standard endpoints of body mass or lean body mass. Disability-free survival has recently been used as a functional endpoint in clinical trials in several research fields. It might be also a suitable patient-centered outcome responsive to multiple physical changes in cancer cachexia, and patients might find it more acceptable than other classical endpoints. More efforts would be needed to identify an optimal measurable endpoint and establish a better combination of pharmacological and nonpharmacological interventions to improve the functional prognosis for patients with cancer cachexia.

Impact of Cancer Cachexia on Hospitalization-associated Physical Inactivity in Elderly Patients with Advanced Non-small-cell Lung Cancer

Objective:

New or worsening disability can develop in elderly patients in just 1 week of hospitalization for acute illness. Elderly patients with cancer, particularly those with cancer cachexia, are vulnerable to disability. This study aimed to explore the impact of hospitalization and cachexia on physical activity (PA) in elderly patients during chemotherapy.

Methods:

We prospectively enrolled 18 patients aged ≥70 years with newly-diagnosed, advanced non-small-cell lung cancer scheduled to initiate first-line chemotherapy. PA was measured using an accelerometer (Lifecorder^®, Suzuken Co., Ltd., Japan). Mean daily steps at baseline, during hospitalization, and subsequent weeks (1^st, 2^nd, and 3^rd week after discharge) were compared.

Results:

A total of 30 hospitalizations for chemotherapy were evaluated in 18 patients with a median age of 74.5 years. The median number of baseline daily steps was 3756. Fifteen cases (50%) showed fewer daily steps during hospitalization and no recovery to baseline level during the 1^st week after discharge. Long hospitalizations (≥8 days) and the presence of cachexia were associated with persistent physical inactivity. One patient developed disability within 30 days after hospitalization.

Conclusions:

Physical inactivity was frequently seen after hospitalization for chemotherapy in elderly patients with advanced lung cancer. Longer in-hospital days and the presence of cancer cachexia caused slow recovery from physical inactivity. Individualized hospitalization planning based on careful consideration of patient age and the presence of cancer cachexia may be needed to prevent physical inactivity and disability.