An Interdisciplinary Approach to Manage Cancer Cachexia

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

Impact of sarcopenia on the prognosis and treatment of lung cancer: an umbrella review

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality worldwide. Sarcopenia, defined as the loss of muscle mass and function, is known to cause adverse health outcomes. The purpose of this umbrella review was to integrate published systematic reviews and meta-analyses exploring sarcopenia and lung cancer to provide comprehensive knowledge on their relationship.

METHODS

Eligible studies were searched from scientific databases until June 28, 2022. Critical appraisal was performed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2. The impact of sarcopenia on the pathophysiology, prevalence, and prognosis of lung cancer is summarized at the level of systematic reviews or meta-analyses.

RESULTS

Fourteen reviews and meta-analyses were conducted. The methodological quality was high for one review, low for nine, and critically low for four. The most common standard for diagnosing sarcopenia in the lung cancer population is computed tomography (CT) to measure the skeletal muscle index at the third lumbar vertebra (L3). Sarcopenia was highly prevalent among patients with lung cancer, with a pooled prevalence ranging from 42.8% to 45.0%. The association between sarcopenia and increased postoperative complications and decreased disease control rates with immune checkpoint inhibitors has been demonstrated. Mortality was significantly higher in sarcopenic patients than in non-sarcopenic patients with lung cancer, regardless of the stage of disease or type of treatment.

CONCLUSIONS

Sarcopenia is a poor prognostic factor for lung cancer. Future studies are necessary to clarify the pathophysiology of sarcopenia and develop effective interventions for sarcopenia in patients with lung cancer.

Multidisciplinary approaches to cancer cachexia: current service models and future perspectives

INTRODUCTION

Cancer cachexia remains a complex unmet need in oncology, despite its high prevalence and high impact. Patients with cachexia experience numerous complications, including reduced tolerance and effectiveness of anti-cancer therapy, reduced mobility, and reduced functional status, leading to decreased quality of life and survival.

AREAS COVERED

As the field moves toward greater consensus of definitions and measurements, we highlight tools currently available for identification and staging of cachexia, and the barriers that people with cancer face in timely identification and management of cachexia. Multidisciplinary cachexia service models have emerged to address practice gaps and needs identified by patients and clinicians. Person-centred approaches to cachexia care demonstrate promising improvements in patient outcomes, but controlled trials of service models are lacking.

EXPERT OPINION

While significant advances have been made in the understanding of cachexia, future trials of clinical service models require standardisation of definitions and outcome measures, with more robust controlled studies to establish the efficacy of proposed best practice. We remain excited with the potential benefit of these innovative models and continue to advocate for implementation of dedicated multidisciplinary cachexia teams to ensure patients and their families receive the right support, in the right place, at the right time.

The Role of Nurse in the Multidisciplinary Management of Cancer Cachexia

Cancer cachexia is a complex syndrome for which multidisciplinary management through collaboration has the potential to improve patient outcomes and efficiency of care, through the integration of nursing into practice. These authors conducted a literature review of PubMed, EBSCO, OVID, and ProQuest for publications on the roles and responsibilities of nurses who are working in multidisciplinary teams for the management of cancer cachexia. We limited our search parameters for the literature review such that: (1) the included papers were published in the English language from January 2000 to February 2021 and (2) the included papers featured an adult patient population. Based on this review, cancer cachexia can be characterized as an involuntary loss of body weight that is combined with a dysregulation in the control of energy homeostasis and protein loss, which leads to poor clinical outcomes in patients. Cancer cachexia has been recognized as having multidimensional etiologies that are related to the nutritional and metabolic systems, as well as other physical and physiological systems, and to symptoms that manifest concurrently to the cachexia. While the clinical identification and taxonomic classification of cancer cachexia are usually associated with an observable degree of weight loss and muscular atrophy in a patient, clinical evidence of inflammation and related symptoms should be considered (in addition to the weight loss and muscular atrophy) in the diagnosis and evaluation of cancer cachexia, as will be argued in this paper. Early diagnosis, appropriate clinical assessment, and evaluation of cancer cachexia are crucial to predicting the onset of the condition and managing its symptoms when it occurs. Various tools have been developed for the clinical evaluation and diagnosis of cancer cachexia which reflect the multitudinous manifestations of the condition. Due to the diversity of its manifestations, multimodal therapy has gained popularity for the management of cancer cachexia. Multimodal therapy includes combined pharmacologic intervention, nutrition supplements, nutritional consultation, physical exercise, and symptom control. As these authors will demonstrate in this paper, this mode of multidisciplinary team management is increasingly supported by scientific evidence and as such, can be seen as essential for high-quality cancer cachexia management. Nursing plays an important role in the multidisciplinary care team model for cancer cachexia management, as nurses are well situated to perform screening, referral, coordination, nutritional consultation, physical exercise consultation, direct nutritional nursing, psychosocial support, symptom control, and hospice care. However, an increased focus on education, skills training, and tool development (as well as adoption of tools) on the part of nurses and other multidisciplinary team members is required to meet the goal of efficient care and improved outcomes for patients with cancer cachexia. These authors demonstrate that increasing roles and responsibilities for nurses in the management of cancer cachexia is a valuable area to explore in the literature and to implement in clinical practice. Our review aims to summarize the etiology and epidemiology, mechanisms-of-action, and multitudinous manifestations of cancer cachexia, the therapies that are used in cancer cachexia care and the management approaches by which this care is organized. Finally, these authors emphasize nurses' responsibilities in this mode of cancer cachexia multidisciplinary team management, which represents a fruitful benefit both in the research literature and in clinical settings.

Barriers to Comprehensive Multidisciplinary Head and Neck Care in a Community Oncology Practice

Complex, coordinated, and collaborative care of patients with head and neck cancer can be challenging yet amazingly rewarding and successful. The high symptom burden across multiple functional domains in patients with head and neck cancer, even in early stages of disease, mandates a multidisciplinary team approach that harnesses the combined contributions of physicians and ancillary providers to drive greater patient-centered care, addressing factors that heavily influence morbidity, mortality, and quality of life. Well-organized community-based multidisciplinary teams fulfill this unmet need and benefit patients with conveniently located comprehensive services that are typically found in large academic centers. Equivalent, if not superior, outcomes can be achieved in a unified community-based multidisciplinary team with shared patient-centered and outcomes-based goals. However, implementing true multidisciplinary team care in today's complex health care environment is fraught with challenges and pitfalls. So how have some community-based practices managed to create safe and efficient programs with successful outcomes? The purpose of this review is to discuss barriers to reaching this success and emphasize practical solutions to such challenges.

Development and progression of cancer cachexia: Perspectives from bench to bedside

Cancer cachexia (CC) is a devastating syndrome characterized by weight loss, reduced fat mass and muscle mass that affects approximately 80% of cancer patients and is responsible for 22%–30% of cancer-associated deaths. Understanding underlying mechanisms for the development of CC are crucial to advance therapies to treat CC and improve cancer outcomes. CC is a multi-organ syndrome that results in extensive skeletal muscle and adipose tissue wasting; however, CC can impair other organs such as the liver, heart, brain, and bone as well. A considerable amount of CC research focuses on changes that occur within the muscle, but cancer-related impairments in other organ systems are understudied. Furthermore, metabolic changes in organ systems other than muscle may contribute to CC. Therefore, the purpose of this review is to address degenerative mechanisms which occur during CC from a whole-body perspective. Outlining the information known about metabolic changes that occur in response to cancer is necessary to develop and enhance therapies to treat CC. As much of the current evidences in CC are from pre-clinical models we should note the majority of the data reviewed here are from pre-clinical models.

The animal cachexia score (ACASCO)

BACKGROUND

None of the published studies involving cancer cachexia experimental models have included a measure of the severity of the syndrome like the scoring system previously developed for human subjects. The aim of the present investigation was to define and validate a cachexia score usable in both rat and mouse tumor models.

METHODS

In order to achieve this goal, we included in the study one rat model (Yoshida AH-130ascites hepatoma) and two mouse models (Lewis lung carcinoma and Colon26 carcinoma). The Animal cachexia score (ACASCO) includes five components: (a) body and muscle weight loss, (b) inflammation and metabolic disturbances, (c) physical performance, (d) anorexia, and (e) quality of life measured using discomfort symptoms and behavioral tests.

RESULTS

Using the ACASCO values, three cut-off values were estimated by applying hierarchical cluster analysis. Four groups were originally described, one exactly below the observed mean, a second exactly over the mean, and two other groups adjusted to every cue (inferior and superior). The three cut-off values were estimated through maximization of the classification function. This was accomplished by using a similarity matrix based on the metric properties of the variables and assuming multinormal distribution. The results show that the four groups were: no cachexia, mild cachexia, moderate cachexia and advanced cachexia.

CONCLUSIONS

The results obtained allow us to conclude that the score could be very useful as an endpoint in pre-clinical studies involving therapeutic strategies for cancer cachexia. The potential usefulness of ACASCO relates to the primary endpoint in pre-clinical cancer cachexia drug evaluations.

Modified Sijunzi decoction can alleviate cisplatin-induced toxicity and prolong the survival time of cachectic mice by recovering muscle atrophy

ETHNOPHARMACOLOGICAL RELEVANCE

Sijunzi decoction is a well-known traditional Chinese medicine (TCM) commonly used for invigorating vital energy and for the enhancement of immunity. Modified Sijunzi decoctions have been extensively used to treat cachexia and improve the quality of life of cancer patients undergoing chemotherapy.

AIM OF THE STUDY

This study was aimed to provide comprehensive evidence for the anti-cachectic effect of a modified Sijunzi decoction (Zhen-Qi; ZQ-SJZ) and characterize its anti-cachectic mechanism, especially in cisplatin-induced muscle atrophy.

MATERIALS AND METHODS

We employed a Lewis lung carcinoma (LLC)-induced cancer cachectic mouse model to demonstrate the anti-cachectic effect of ZQ-SJZ. Moreover, we provided an in vitro C2C12 myotube formation model to investigate the effect of ZQ-SJZ in hampering cisplatin-induced muscle atrophy.

RESULTS

The administration of ZQ-SJZ can recover tumor- and/or cisplatin-induced body weight loss, intestinal mucosal damage, as well as forelimb grip strength and myofiber size. The administration of ZQ-SJZ also significantly prolonged the survival of LLC-induced cachectic mice under cisplatin treatment. Mechanistically, ZQ-SJZ increased the levels of myogenic proteins, such as myosin heavy chain (MyHC) and myogenin, and decreased the atrophy-related protein, atrogin-1, in cisplatin-treated C2C12 myotubes in vitro. In addition, cisplatin-induced mitochondria dysfunction could be hampered by the co-administration of ZQ-SJZ, by which it recovered the cisplatin-mediated decrease in PGC-1α and PKM1 levels.

CONCLUSIONS

The administration of ZQ-SJZ can recover tumor- and/or cisplatin-induced cachectic conditions and significantly prolong the survival of LLC-induced cachectic mice under cisplatin treatment. The profound effect of ZQ-SJZ in hampering tumor- and/or cisplatin-induced cachexia may be due to its modulation of the mitochondrial function and subsequent myogenesis. Taken together, these results demonstrated the anti-cachectic mechanism of ZQ-SJZ and its potential use as a palliative strategy to improve the efficacy of chemotherapy.

Improving communication within the interdisciplinary team monitoring young women with onco-gynecological pathology in Romania

Background

The quality of medical care, as well as the application of effective treatments in the management of patients with gynecologic neoplasm, is of great importance. Finding new and efficient ways of communication between the doctors involved in the multidisciplinary team for the management of the disease, from the diagnosis to the reintegration into society, would help improve the quality of comprehensive patient care.

Objective

The objective of the study was to assess the collaboration of family physicians with specialists treating patients suffering from gynecologic cancer, in order to improve the relationship between them via electronic communication.

Study design

We conducted a descriptive, transversal study on 353 family physicians and 37 specialist doctors from Romania, between January and June 2015. For statistical data analysis, R for Data Analysis and Graphics version 3.2.1 was used.

Results

Most of the family physicians and specialist doctors believed that they provided the best care that they could, but consider that a multidisciplinary approach using online communication methods, in which doctors collaborate among each other, is needed.

Conclusions

Finding a simple, efficient and modern means of communication is essential in order to increase the efficiency of medical care overall.

ROMANA 3: a phase 3 safety extension study of anamorelin in advanced non-small-cell lung cancer (NSCLC) patients with cachexia

Background

Cancer anorexia–cachexia is a debilitating condition frequently observed in NSCLC patients, characterized by decreased body weight, reduced food intake, and impaired quality of life. Anamorelin, a novel selective ghrelin receptor agonist, has anabolic and appetite-enhancing activities.

Patients and methods

ROMANA 3 was a safety extension study of two phase 3, double-blind studies that assessed safety and efficacy of anamorelin in advanced NSCLC patients with cachexia. Patients with preserved Eastern Cooperative Oncology Group ≤2 after completing 12 weeks (w) on the ROMANA 1 or ROMANA 2 trials (0–12 weeks) could enroll in ROMANA 3 and continue to receive anamorelin 100 mg or placebo once daily for an additional 12w (12–24 weeks). The primary endpoint of ROMANA 3 was anamorelin safety/tolerability (12–24 weeks). Secondary endpoints included changes in body weight, handgrip strength (HGS), and symptom burden (0–24 weeks).

Results

Of the 703 patients who completed ROMANA 1 and ROMANA 2, 513 patients entered ROMANA 3 (anamorelin, N = 345, mean age 62.0 years; placebo, N = 168; mean age 62.2 years). During ROMANA 3, anamorelin and placebo groups had similar incidences of treatment–emergent adverse events (TEAEs; 52.2% versus 55.7%), grade ≥3 TEAEs (22.4% versus 21.6%), and serious TEAEs (12.8% versus 12.6%). There were 36 (10.5%) and 23 (13.8%) deaths in the anamorelin and placebo groups, respectively; none were drug-related. Improvements in body weight and anorexia–cachexia symptoms observed in the original trials were consistently maintained over 12–24 weeks. Anamorelin, versus placebo, significantly increased body weight from baseline of original trials at all time points (P < 0.0001) and improved anorexia–cachexia symptoms at weeks 3, 6, 9, 12, and 16 (P < 0.05). No significant improvement in HGS was seen in either group.

Conclusion

During the 12–24 weeks ROMANA 3 trial, anamorelin continued to be well tolerated. Over the entire 0–24w treatment period, body weight and symptom burden were improved with anamorelin.

Clinical trial registration numbers

ROMANA 1 (NCT01387269), ROMANA 2 (NCT01387282), and ROMANA 3 (NCT01395914).

Clinical Framework for Quality Improvement of Cancer Cachexia

The objective of this article is to introduce the Clinical Framework for Quality Improvement of Cancer Cachexia (Cachexia Care Framework) as a tool to demonstrate the relevance of integrating the clinical components of cancer cachexia and the organizational strategies of a cancer institution on the quality of patient care and delivery of services throughout the cancer cachexia continuum. The data sources included peer-reviewed literature relevant to cancer cachexia and quality cancer care, and the authors’ expertise. The Cachexia Care Framework results from a combination of the international consensus definition of cancer cachexia, the Institute of Medicine report Ensuring Quality Cancer Care, and the authors’ experience with a cancer cachexia clinic. This framework is proposed as a guidance for oncology nurses and other healthcare providers to improve the quality of care of cancer cachexia patients. Specifically, the framework can be used by oncology nurses involved in the care of patients diagnosed with cancer cachexia either in direct patient care, administration, research, or education. Nurses can use the framework in clinical practice to identify specific assessments and interventions based on the cachexia stage of the patient; in nursing administration, the framework offers a wide view of potential errors that can happen and the opportunity to prevent them; in nursing research, the framework illustrates the several factors and processes that can impact patient outcomes; and in nursing education, the framework outlines the elements necessary to develop and implement a continuum education curriculum to educate the workforce of oncology nurses, and in the academic setting, an interprofessional curriculum to educate nurses and many other healthcare disciplines.

Oral Care: Exploring Education, Attitudes, and Behaviors Among Nurses Caring for Patients With Breast Cancer

BACKGROUND

Patients treated for breast cancer often experience severe oral complications, such as mucositis, xerostomia, and infections, which can result in dose reductions and treatment delays, affecting treatment outcomes.
.

OBJECTIVES

The purpose of this article is to explore oncology nurses' perceptions of their educational experiences, professional attitudes, and behavior related to providing oral healthcare education to patients with breast cancer.
.

METHODS

The Oncology Nursing Society sent an email to 5,000 nursing team members who cared for patients with breast cancer, requesting participation in a web-based survey; 194 responses were received, with 164 meeting study eligibility.
.

FINDINGS

More oral health-related education was received during clinical experiences than during formal or continuing education. Although patient-driven oral care and diagnostic efforts were frequent, actual behavior was less frequent. No major barriers to providing oral care were indicated. Increased oral health-related education and behavior correlated with the reported importance of increased oral health education for nurses.

Increased hypoxia-inducible factor-1α in striated muscle of tumor-bearing mice

Cancer cachexia is a progressive wasting disease resulting in significant effects on the quality of life and high mortality. Most studies on cancer cachexia have focused on skeletal muscle; however, the heart is now recognized as a major site of cachexia-related effects. To elucidate possible mechanisms, a proteomic study was performed on the left ventricles of colon-26 (C26) adenocarcinoma tumor-bearing mice. The results revealed several changes in proteins involved in metabolism. An integrated pathway analysis of the results revealed a common mediator in hypoxia-inducible factor-1α (HIF-1α). Work by other laboratories has shown that extensive metabolic restructuring in the C26 mouse model causes changes in gene expression that may be affected directly by HIF-1α, such as glucose metabolic genes. M-mode echocardiography showed progressive decline in heart function by day 19, exhibited by significantly decreased ejection fraction and fractional shortening, along with posterior wall thickness. Using Western blot analysis, we confirmed that HIF-1α is significantly upregulated in the heart, whereas there were no changes in its regulatory proteins, prolyl hydroxylase domain-containing protein 2 (PHD2) and von Hippel-Lindau protein (VHL). PHD2 requires both oxygen and iron as cofactors for the hydroxylation of HIF-1α, marking it for ubiquination via VHL and subsequent destruction by the proteasome complex. We examined venous blood gas values in the tumor-bearing mice and found significantly lower oxygen concentration compared with control animals in the third week after tumor inoculation. We also examined select skeletal muscles to determine whether they are similarly affected. In the diaphragm, extensor digitorum longus, and soleus, we found significantly increased HIF-1α in tumor-bearing mice, indicating a hypoxic response, not only in the heart, but also in skeletal muscle. These results indicate that HIF-1α may contribute, in part, to the metabolic changes that occur during cancer cachexia.NEW & NOTEWORTHY We used proteomics and metadata analysis software to identify contributors to metabolic changes in striated muscle during cancer cachexia. We found increased expression of hypoxia-inducible factor-1α in the heart and skeletal muscle, suggesting a potential target for the therapeutic treatment of cancer cachexia.

Validation of the CAchexia SCOre (CASCO). Staging Cancer Patients: The Use of miniCASCO as a Simplified Tool

The CAchexia SCOre (CASCO) was described as a tool for the staging of cachectic cancer patients. The aim of this study is to show the metric properties of CASCO in order to classify cachectic cancer patients into three different groups, which are associated with a numerical scoring. The final aim was to clinically validate CASCO for its use in the classification of cachectic cancer patients in clinical practice. We carried out a case -control study that enrolled prospectively 186 cancer patients and 95 age-matched controls. The score includes five components: (1) body weight loss and composition, (2) inflammation/metabolic disturbances/immunosuppression, (3) physical performance, (4) anorexia, and (5) quality of life. The present study provides clinical validation for the use of the score. In order to show the metric properties of CASCO, three different groups of cachectic cancer patients were established according to the results obtained with the statistical approach used: mild cachexia (15 ≤ × ≤ 28), moderate cachexia (29 ≤ × ≤ 46), and severe cachexia (47 ≤ × ≤ 100). In addition, a simplified version of CASCO, MiniCASCO (MCASCO), was also presented and it contributes as a valid and easy-to-use tool for cachexia staging. Significant statistically correlations were found between CASCO and other validated indexes such as Eastern Cooperative Oncology Group (ECOG) and the subjective diagnosis of cachexia by specialized oncologists. A very significant estimated correlation between CASCO and MCASCO was found that suggests that MCASCO might constitute an easy and valid tool for the staging of the cachectic cancer patients. CASCO and MCASCO provide a new tool for the quantitative staging of cachectic cancer patients with a clear advantage over previous classifications.

Leveraging a Team Mental Model to Develop a Cancer Anorexia-Cachexia Syndrome Team

This article discusses the care of a 62-year-old man with non-small-cell lung cancer and associated cancer anorexia-cachexia syndrome (CACS), and demonstrates common challenges faced by such patients and their family caregivers. The case description illustrates the fragmented approach of various disciplines to the patient's CACS care, resulting in undertreatment, delayed and burdensome visits, and patient and caregiver frustration and emotional distress. The mounting problems that arise for the patient over time exemplify the absence of a shared mental model among the various providers, patient, and caregiver for the care of CACS. Shared knowledge among providers regarding the tasks to be performed, the other clinicians' functions, and optimal processes for CACS care was limited. Each provider was responsive to individual symptoms, rather than conceptualizing the constellation of symptoms as a syndrome that warrants coordinated care among clinicians. This resulted in the patient and the family caregiver being at odds with their various providers instead of working in partnership with a shared understanding toward common goals. Team mental models have the potential to enhance development and implementation of care plans and improve patient care and satisfaction by helping clinical care teams establish team membership, identify shared tasks, and facilitate interactions. To help inform ongoing clinical practice and research, this article demonstrates how clinicians at one cancer center are leveraging a team mental model to form and support an interdisciplinary CACS team that provides coordinated patient-centered care.

Omega-3 polyunsaturated fatty acids and cancer: lessons learned from clinical trials

Over the past decades, extensive studies have addressed the therapeutic effects of omega-3 polyunsaturated fatty acids (omega-3 FAs) against different human diseases such as cardiovascular and neurodegenerative diseases, cancer, etc. A growing body of scientific research shows the pharmacokinetic information and safety of these natural occurring substances. Moreover, during recent years, a plethora of studies has demonstrated that omega-3 FAs possess therapeutic role against certain types of cancer. It is also known that omega-3 FAs can improve efficacy and tolerability of chemotherapy. Previous reports showed that suppression of nuclear factor-κB, activation of AMPK/SIRT1, modulation of cyclooxygenase (COX) activity, and up-regulation of novel anti-inflammatory lipid mediators such as protectins, maresins, and resolvins, are the main mechanisms of antineoplastic effect of omega-3 FAs. In this review, we have collected the available clinical data on the therapeutic role of omega-3 FAs against breast cancer, colorectal cancer, leukemia, gastric cancer, pancreatic cancer, esophageal cancer, prostate cancer, lung cancer, head and neck cancer, as well as cancer cachexia. We also discussed the chemistry, dietary source, and bioavailability of omega-3 FAs, and the potential molecular mechanisms of anticancer and adverse effects.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

REHABILITATION IN PALLIATIVE CARE

ABSTRACT: The objective of this study was to describe the activities and effects of functional rehabilitation in patients receiving palliative care. It is an integrative review, in which LILACS, BDENF, Coleciona SUS (Brazil) and PUBMED were used, 20 articles were selected, subsequently characterized as having designs of medium and low impact, more than half ranked with evidence levels II, III and IV and with samples not always consistent with the research designs. However, the results revealed the potential of rehabilitation to improve the functional status, quality of life and symptoms like pain and anxiety in this population, through interventions that are many times undervalued in palliative care. The conclusion is that rehabilitation is a feasible strategy to combat functional decline and improve the quality of life of patients in palliative care.

Identifying clinical and support service resources and network practices for cancer patients and survivors in southern Puerto Rico

OBJECTIVE

The objectives of this study were to identify cancer-related health care services and to explore the presence of inter-organizational interactions among clinical and support oncology services in southern Puerto Rico.

METHODS

From January through July of 2010, a survey was completed by 54 health care organizations offering clinical, supportive, or both services to cancer patients/survivors (CPS) in southern PR. Survey data were compiled and descriptive analyses performed using the software Statistical Package for a Social Science (SPSS), version 18.0.

RESULTS

The distribution of the primary services provided by the participating organizations was the following: 26 had clinical services, 16 had support services, and 12 offered a combination of clinical and support services. Only 24 % of the surveyed organizations offered their services exclusively to patients diagnosed with cancer. In terms of referral practices, 61 % of the responses were for medical specialists, 43 % were for mental health services, and 37 % were referrals for primary care services. The most common reason for interacting (n = 27) was to provide a given patient both a referral and information.

CONCLUSION

Findings suggest gaps in both the availability of oncology services and the delivery of integrated health care. Lack of communication among clinical and support organizations (for cancer patients, specifically) could negatively impact the quality of the services that they offer. Further network analysis studies are needed to confirm these gaps. Until systemic, structural changes occur, more efforts are needed to facilitate communication and collaboration among these kinds of organization.

A mixed-methods qualitative research study to develop a complex intervention for weight loss and anorexia in advanced cancer: the Family Approach to Weight and Eating

BACKGROUND

Worldwide, most people with incurable cancer experience weight loss and anorexia. These symptoms can distress patients and their family caregivers. Interventions that take account of the relationship between patient and family caregiver may improve outcomes for both members of this dyad.

AIM

To report an example of process for the development of a complex intervention, the Family Approach to Weight and Eating.

DESIGN

A mixed-methods process informed by the Medical Research Council's guidelines for developing a complex intervention was used to develop a psychosocial intervention for patients with incurable cancer and weight loss or poor appetite and their family caregivers and then to test for its feasibility, acceptability and perceived benefit.

SETTING

South of England in 2010/2011.

PARTICIPANTS

A purposive sample of patient-family caregiver dyads under the care of a specialist community palliative care team. Patient participants had incurable cancer and were cachectic or at risk of cachexia.

RESULTS

The patient-family caregiver dyads comprised seven female and nine male patients (age range 41-84 years) and their carers. The emergent form of the Family Approach to Weight and Eating was found to aid family talk about food, feelings and reciprocity, without adverse consequences. Of the dyads, 15 reported benefits of the Family Approach to Weight and Eating. Three patient participants spoke of the approach evoking sadness and three carers of guilt.

CONCLUSION

The Family Approach to Weight and Eating should now be tested in a pilot trial and the effect on emotional health outcomes in patients and their family caregivers evaluated.

Exercise and nutrition interventions in advanced lung cancer: a systematic review

In this systematic review, we sought to evaluate the effect of physical activity or nutrition interventions (or both) in adults with advanced non-small-cell lung cancer (nsclc).

METHODS

A systematic search for relevant clinical trials was conducted in 6 electronic databases, by hand searching, and by contacting key investigators. No limits were placed on study language. Information about recruitment rates, protocol adherence, patient-reported and clinical outcome measures, and study conclusions was extracted. Methodologic quality and risk of bias in each study was assessed using validated tools.

MAIN RESULTS

Six papers detailing five studies involving 203 participants met the inclusion criteria. Two of the studies were single-cohort physical activity studies (54 participants), and three were controlled nutrition studies (149 participants). All were conducted in an outpatient setting. None of the included studies combined physical activity with nutrition interventions.

CONCLUSIONS

Our systematic review suggests that exercise and nutrition interventions are not harmful and may have beneficial effects on unintentional weight loss, physical strength, and functional performance in patients with advanced nsclc. However, the observed improvements must be interpreted with caution, because findings were not consistent across the included studies. Moreover, the included studies were small and at significant risk of bias. More research is required to ascertain the optimal physical activity and nutrition interventions in advanced inoperable nsclc. Specifically, the potential benefits of combining physical activity with nutrition counselling have yet to be adequately explored in this population.

Management of Anorexia-Cachexia in Late Stage Lung Cancer Patients

Nutritional deficiencies are experienced by most adults with advanced lung cancer during the course of their disease and treatment. Well-nourished individuals tolerate cancer treatment with less morbidity, mortality, and increased response to treatment as compared to those who are malnourished. Novel anti-cancer therapies cause many deficits that impact nutritional and functional status during the treatment process. Nutritional deficits include weight loss, malnutrition, and anorexia-cachexia. Anorexia-Cachexia is complex, not well understood and seen in many solid tumors in late stage disease. Assessing adequate nutrition is one of the most challenging problems for nurses, their patients and patient's families. The purpose of this review is to define and describe cancer anorexia-cachexia in late stage lung cancer, through case presentation, and to describe palliative strategies for prevention, assessment, and management in the palliative care setting. Early assessment for nutritional imbalances must be done regularly with re-evaluation for intervention effectiveness and should continue throughout the illness trajectory. Management of adverse effects of cancer and cancer-related treatment is critical to improving quality of life. Palliative care and hospice nurses play a critical role in early assessment, education and prevention to support nutritional needs for patients and their families.

A multimodal, interdisciplinary programme for the management of cachexia and fatigue

Fatigue and cachexia are common symptoms of advanced disease that have a significant impact on quality of life for palliative care clients. Management of cachexia and fatigue is often overlooked, but growing understanding of the multidimensional nature of fatigue and muscle wasting has led to interest in a model of care based on multimodal therapy that has been successfully implemented in specialized multidisciplinary hospital-based clinics in the oncology/palliative care setting. This article reports on an innovative incorporation of features of this model into a client-centred, interdisciplinary programme that aims to manage the effects of cachexia and fatigue and to improve quality of life for palliative care clients in their home setting. This Cachexia and Fatigue Management Programme (CFMP) involves the use of an anti-inflammatory agent, high protein intake, and an individually tailored resistance exercise regimen to counteract muscle wasting and fatigue. The article provides an overview of the role of multimodal therapies in the management of cachexia and fatigue before moving on to discuss the development of the CFMP, its features, and potential benefits for palliative care clients, caregivers, and health services.

The cachexia score (CASCO): a new tool for staging cachectic cancer patients

BACKGROUND: According to a recent consensus, the cachectic syndrome is defined as: "… a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass. The prominent clinical feature of cachexia is weight loss in adults (corrected for fluid retention) or growth failure in children (excluding endocrine disorders). Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently associated with cachexia." Although this definition is accompanied by diagnostic criteria, it does not consider the problem of staging. Stratification of patients is important when considering therapy. The very first stage of the wasting syndrome does not necessarily involve body weight loss-a state known as pre-cachexia. METHODS AND RESULTS: The aim of the present score was to overcome the problem of patient staging in cancer. This score considers five main different factors: body weight and lean body mass loss; anorexia; inflammatory, immunological, and metabolic disturbances; physical performance; and quality of life. The scoring scale goes from 0 to 100: mild cachexia (less than 25), moderate (more than 26 and less than 50), severe (more than 51 and less than 75), and terminal phase (more than 76 and up to 100). The score also takes into consideration the condition known as pre-cachexia. CONCLUSION: The present score will facilitate cachexia staging and will therefore allow for a more adequate therapy. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s13539-011-0027-5) contains supplementary material, which is available to authorized users.

The emotional aspects of cancer anorexia

PURPOSE OF REVIEW

To discuss the psychosocial support of people affected by cancer anorexia, drawing on recent publications.

RECENT FINDINGS

Recent studies describe the problem of distress in response to cancer anorexia. There are propositions of appropriate support and calls for the development of psychosocial interventions to relieve cachexia-related distress. Preliminary work is now testing these ideas.

SUMMARY

Psychosocial support for cancer anorexia is a new and promising field of study. The prevention or alleviation of the anorexia of cachexia would relieve much eating-related suffering experienced by patients and their families. However, whilst the scientific community works to achieve this goal there is another task to be addressed: to help people with cancer anorexia to adapt and live with the symptom. Despite accounts over many years of the distress caused by poor appetite, little attention has been paid to the potential for psychosocial support to aid self-management of the symptom. Emergent thinking is that psychosocial support for cancer anorexia can have benefit for both patients and their family members.