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Bowers M, Higginson IJ, Maddocks M. Patient and carer experiences of cancer cachexia and its management. Curr Opin Support Palliat Care 2024:01263393-990000000-00081. [PMID: 38980806 DOI: 10.1097/spc.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
PURPOSE OF REVIEW To explore the contributions of recent qualitative literature in progressing understanding of the experiences of cancer cachexia, and its management, from the perspectives of patients and unpaid/family carers. RECENT FINDINGS Challenges with conducting everyday activities, maintaining independence, and continuing usual roles within the family are sources of distress. Patients and carers value individualization, flexibility, and carer involvement in physical activity/exercise interventions. In psychosocial/educational interventions that were positively perceived, the opportunity to talk about cachexia was appreciated, leading to improved health literacy, awareness about nutrition, and relationships with food. However, the general patient and carer experience around clinical acknowledgement and management of cachexia remains poor. SUMMARY Eating-related distress and conflicts, lack of understanding about cachexia, and the visibility of weight loss remain recurring themes amongst literature on experiences of cancer cachexia. Studies exploring preferences for, and experiences of, interventions have primarily focused on physical activity or exercise. Psychosocial/educational and physical activity/exercise interventions are valued and perceived to alleviate some of the key quality of life issues amongst patients with cancer cachexia and their unpaid/family carers.
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Affiliation(s)
- Megan Bowers
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Park MA, Whelan CJ, Ahmed S, Boeringer T, Brown J, Crowder SL, Gage K, Gregg C, Jeong DK, Jim HSL, Judge AR, Mason TM, Parker N, Pillai S, Qayyum A, Rajasekhara S, Rasool G, Tinsley SM, Schabath MB, Stewart P, West J, McDonald P, Permuth JB. Defining and Addressing Research Priorities in Cancer Cachexia through Transdisciplinary Collaboration. Cancers (Basel) 2024; 16:2364. [PMID: 39001427 PMCID: PMC11240731 DOI: 10.3390/cancers16132364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
For many patients, the cancer continuum includes a syndrome known as cancer-associated cachexia (CAC), which encompasses the unintended loss of body weight and muscle mass, and is often associated with fat loss, decreased appetite, lower tolerance and poorer response to treatment, poor quality of life, and reduced survival. Unfortunately, there are no effective therapeutic interventions to completely reverse cancer cachexia and no FDA-approved pharmacologic agents; hence, new approaches are urgently needed. In May of 2022, researchers and clinicians from Moffitt Cancer Center held an inaugural retreat on CAC that aimed to review the state of the science, identify knowledge gaps and research priorities, and foster transdisciplinary collaborative research projects. This review summarizes research priorities that emerged from the retreat, examples of ongoing collaborations, and opportunities to move science forward. The highest priorities identified include the need to (1) evaluate patient-reported outcome (PRO) measures obtained in clinical practice and assess their use in improving CAC-related outcomes; (2) identify biomarkers (imaging, molecular, and/or behavioral) and novel analytic approaches to accurately predict the early onset of CAC and its progression; and (3) develop and test interventions (pharmacologic, nutritional, exercise-based, and through mathematical modeling) to prevent CAC progression and improve associated symptoms and outcomes.
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Affiliation(s)
- Margaret A. Park
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Christopher J. Whelan
- Department of Metabolism and Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Sabeen Ahmed
- Department of Machine Learning, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.A.); (G.R.)
| | - Tabitha Boeringer
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (T.B.); (S.P.)
| | - Joel Brown
- Department of Cancer Biology and Evolution, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.B.); (J.W.)
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Sylvia L. Crowder
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.L.C.); (H.S.L.J.); (N.P.); (S.M.T.)
| | - Kenneth Gage
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.G.); (D.K.J.); (A.Q.)
| | - Christopher Gregg
- School of Medicine, University of Utah, Salt Lake City, UT 84113, USA;
| | - Daniel K. Jeong
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.G.); (D.K.J.); (A.Q.)
| | - Heather S. L. Jim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.L.C.); (H.S.L.J.); (N.P.); (S.M.T.)
| | - Andrew R. Judge
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA;
| | - Tina M. Mason
- Department of Nursing Research, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Nathan Parker
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.L.C.); (H.S.L.J.); (N.P.); (S.M.T.)
| | - Smitha Pillai
- Department of Drug Discovery, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (T.B.); (S.P.)
| | - Aliya Qayyum
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.G.); (D.K.J.); (A.Q.)
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Ghulam Rasool
- Department of Machine Learning, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.A.); (G.R.)
| | - Sara M. Tinsley
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (S.L.C.); (H.S.L.J.); (N.P.); (S.M.T.)
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Matthew B. Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Paul Stewart
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
| | - Jeffrey West
- Department of Cancer Biology and Evolution, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.B.); (J.W.)
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Patricia McDonald
- Department of Metabolism and Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
- Lexicon Pharmaceuticals, Inc., Woodlands, TX 77381, USA
| | - Jennifer B. Permuth
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA;
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Bertocchi E, Frigo F, Buonaccorso L, Venturelli F, Bassi MC, Tanzi S. Cancer cachexia: A scoping review on non-pharmacological interventions. Asia Pac J Oncol Nurs 2024; 11:100438. [PMID: 38774537 PMCID: PMC11107192 DOI: 10.1016/j.apjon.2024.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/05/2024] [Indexed: 05/24/2024] Open
Abstract
Objective Cancer cachexia occurs in 30%-80% of patients, increasing morbidity and mortality and impacting the health-related quality of life also for caregivers. Pharmacological interventions have been studied but have shown inconsistent effects on patients' lives in terms of relative outcomes and poor adherence to pharmacological treatment. We provide an overview of the evidence on non-pharmacological interventions for cancer cachexia. Methods We conducted a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping review (PRISMA-ScR). On September 21, 2022, plus an update on January 10, 2024, we searched MEDLINE, Embase, CINAHL, Cochrane, PsycINFO, and Scopus for 2012-2024. We excluded pharmacological interventions defined as "any substance, inorganic or organic, natural or synthetic, that can produce functional modifications, through a chemical, physicochemical or physical action." Results The search retrieved 9308 articles, of which 17 were eligible. Non-pharmacological interventions included nutritional counseling, complementary therapies (acupuncture), rehabilitation, and psychoeducational/psychosocial support. The data showed small and heterogeneous samples and different disease localization and stages. Thirty-nine percent were multimodal interventions and aimed at patients, not families. The common primary outcomes were body weight and composition, biomarkers, quality of life, psychological suffering, and muscular strength. Only three studies focus on the patient-caregiver dyad. Conclusions Interventions on cancer cachexia should be multimodal and multiprofessional, proposed early, and aimed at quality of life outcomes. The caregiver's involvement is essential. Nurses can play an active role in managing cancer cachexia. More well-designed studies are needed to understand the efficacy and contents of non-pharmacological interventions. Systematic review registration The review protocol has been registered in the OSF registry (DOI: 10.17605/OSF.IO/H4A29).
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Affiliation(s)
| | - Francesco Frigo
- Gastroenterology Unit, Città della Salute e della Scienza di Torino, Turin, Italy; University of Turin, Torino, Italy
| | | | | | | | - Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
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Ispoglou T, McCullough D, Windle A, Nair S, Cox N, White H, Burke D, Kanatas A, Prokopidis K. Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways. Clin Nutr 2024; 43:552-566. [PMID: 38237369 DOI: 10.1016/j.clnu.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.
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Affiliation(s)
| | | | - Angela Windle
- Department of Nursing and Midwifery, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK; School of Medicine, University of Leeds, Leeds, UK
| | | | - Natalie Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen White
- School of Health, Leeds Beckett University, Leeds, UK
| | - Dermot Burke
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Konstantinos Prokopidis
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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Gautam P, Shankar A. Management of cancer cachexia towards optimizing care delivery and patient outcomes. Asia Pac J Oncol Nurs 2023; 10:100322. [PMID: 38197039 PMCID: PMC10772213 DOI: 10.1016/j.apjon.2023.100322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/17/2023] [Indexed: 01/11/2024] Open
Abstract
Cancer cachexia is a complex syndrome characterized by progressive weight loss, muscle mass depletion, and systemic inflammation, profoundly affecting the well-being and treatment outcomes of cancer patients. Effective management of cancer cachexia demands a coordinated, multifaceted approach involving various healthcare disciplines and operational strategies. Streamlining care processes is crucial to ensure timely interventions and support, reducing delays in diagnosis and treatment initiation. Multidisciplinary collaboration is pivotal in creating integrated care plans that address the multifactorial nature of cancer cachexia comprehensively. Data-driven decision-making empowers healthcare teams to identify trends, monitor treatment responses, and tailor care plans to individual needs, ultimately leading to improved patient outcomes. Standardized assessment and monitoring play a vital role in maintaining consistent, high-quality care, facilitating early interventions and treatment adjustments. Implementing patient-centered care fosters trust, enhances treatment adherence, and encourages patients to actively engage in their care journey, thereby improving their overall quality of life. This paper underscores the significance of applying operations management principles to optimize care delivery and enhance patient outcomes in the management of cancer cachexia. It provides valuable insights for healthcare institutions and professionals striving to provide comprehensive and effective care for individuals affected by this challenging condition.
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Affiliation(s)
- Prerna Gautam
- Department of Management Sciences, Indian Institute of Technology, Kanpur, Uttar Pradesh, India
| | - Abhishek Shankar
- Department of Radiation Oncology, Dr. B R Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Delhi, India
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Amano K, Hopkinson JB, Baracos VE, Mori N. Holistic multimodal care for patients with cancer cachexia and their family caregivers. Asia Pac J Oncol Nurs 2023; 10:100290. [PMID: 38197043 PMCID: PMC10772164 DOI: 10.1016/j.apjon.2023.100290] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/01/2023] [Indexed: 01/11/2024] Open
Abstract
Patients with cancer cachexia frequently suffer from physical symptoms and psychological symptoms of illness, which can lead to emotional distress in patients and family caregivers. Although there is no standard care to manage cancer cachexia despite its high prevalence and negative impact on quality of life in patients and family caregivers, there is accumulating evidence showing the importance of holistic multimodal care for cancer cachexia. However, there is no agreement on the essential components of holistic multimodal care. Therefore, the aims of this review are to give an overview of what is known about the holistic multimodal care and to suggest the composition of a multidisciplinary team to achieve holistic interventions. Holistic multimodal care for cancer cachexia is defined as an approach that addresses physical health through medical, pharmacological, nutritional, and rehabilitative interventions as well as psychological, emotional, and social well-being issues according to the needs of patients and family caregivers. Moreover, an ideal multidisciplinary team is proposed to achieve holistic interventions based on patient- and family-centered care. However, the development of educational programs on cancer cachexia for both clinicians and patients and family caregivers is needed. Furthermore, measurements to assess the benefits of holistic multimodal care also need to be established.
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Affiliation(s)
- Koji Amano
- Palliative and Supportive Care Center, Osaka University Hospital, Osaka, Japan
- Department of Psycho-Oncology and Palliative Medicine, Osaka International Cancer Institute, Osaka, Japan
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Aichi, Japan
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Jane B. Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Wales, UK
| | - Vickie E. Baracos
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Cross Cancer Institute, Alberta, Canada
| | - Naoharu Mori
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Aichi, Japan
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7
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McClement SE. Toward a holistic understanding of cancer cachexia: Application of the human response to illness model. Asia Pac J Oncol Nurs 2023; 10:100306. [PMID: 38197036 PMCID: PMC10772185 DOI: 10.1016/j.apjon.2023.100306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/30/2023] [Indexed: 01/11/2024] Open
Abstract
Cachexia is a commonly presenting multidimensional syndrome in individuals living with advanced cancer. Given its prevalence of between 50% and 80%, nurses are going to encounter individuals manifesting ongoing loss of skeletal muscle mass (with or without loss of fat mass) that can be partially but not entirely reversed by conventional nutritional support. Thus nurses require a comprehensive understanding of this complex clinical problem. Research suggests, however, that nurses receive minimal education about cachexia or its management. Limited understanding undermines the ability to confidently care for patients with cachexia and their families, thereby hampering effective practice. The human response to illness model provides nurses with an organizing framework to guide and make sense of their assessments in clinical practice when caring for patients with cancer cachexia and provides direction for appropriate intervention. This article illustrates the integration of the human response to illness model to clinical practice, thereby assisting nurses to develop a comprehensive understanding of the physiological, pathophysiological, behavioral, and experiential facets of cachexia in advanced cancer patients. Contemporary areas of further interest and research will be presented.
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Affiliation(s)
- Susan E. McClement
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
- Helen Glass Centre for Nursing, The University of Manitoba, Winnipeg, Manitoba, Canada
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Blum D, Vagnildhaug OM, Stene GB, Maddocks M, Sørensen J, Laird BJA, Prado CM, Skeidsvoll Solheim T, Arends J, Hopkinson J, Jones CA, Schlögl M. Top Ten Tips Palliative Care Clinicians Should Know About Cachexia. J Palliat Med 2023; 26:1133-1138. [PMID: 36723498 DOI: 10.1089/jpm.2022.0598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Cachexia is a multifactorial syndrome that is common in cancer and chronic disease. It is often underdiagnosed and therefore goes untreated or undertreated. Cachexia causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a group of clinicians and researchers across cancer care, nutrition, and exercise offers tips about assessment, classification, and management of cachexia, with attention to its stage. The required multimodal management of cachexia mirrors well the interprofessional collaboration that is the mainstay of interdisciplinary palliative care and attention to screening, diagnosis, and management of cachexia is critical to maximize patients' quality of life.
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Affiliation(s)
- David Blum
- Competence Center for Palliative Care, Department of Radiation Oncology, University Hospital Zurich, and University of Zurich UZH, Zurich, Switzerland
| | - Ola Magne Vagnildhaug
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology and Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Guro Birgitte Stene
- Faculty of Medicine and Health Science, Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Jonas Sørensen
- Department of Biomedical Sciences, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology, Centre for Cancer and Organ Diseases, Rigshospitalet, Denmark
| | - Barry J A Laird
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, United Kingdom
| | - Carla M Prado
- Division of Human Nutrition, Department of Agricultural, Food and Nutritional Science, University of Alberta, Alberta, Canada
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Faculty of Medicine and Health Sciences, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jann Arends
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jane Hopkinson
- School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mathias Schlögl
- Division of Geriatric Medicine, Clinic Barmelweid, Barmelweid, Switzerland
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Abstract
PURPOSE OF REVIEW To give an overview of what is known about the educational component of supportive care for people with cancer cachexia and their family caregivers. RECENT FINDINGS The educational needs for self-care by people with cancer cachexia are largely unmet. There is potential for education to enable self-care that mitigates cachexia-related distress with benefit to quality of life and mitigates malnutrition/malnutrition risk with implications for treatment tolerance and outcomes. Theoretically informed approaches to cancer cachexia education for patients and their family members are needed if optimal methods for support of self-care are to be identified. The cancer workforce also needs education to have the confidence and knowledge to play a role in the cancer cachexia education of their patients. SUMMARY To address the educational needs of self-care in cachectic cancer patients and their caregivers, there is much work to do. Healthcare professionals need to know the best educational process and methods for cachexia for supporting quality of life and to facilitate improving cancer treatment outcomes including survival.
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Buonaccorso L, Fugazzaro S, Autelitano C, Bertocchi E, Accogli MA, Denti M, Costi S, Martucci G, Braglia L, Bassi MC, Tanzi S. Psycho-Educational and Rehabilitative Intervention to Manage Cancer Cachexia (PRICC) for Advanced Patients and Their Caregivers: Lessons Learned from a Single-Arm Feasibility Trial. Cancers (Basel) 2023; 15:cancers15072063. [PMID: 37046724 PMCID: PMC10093308 DOI: 10.3390/cancers15072063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Key elements in cancer cachexia (CC) management are personalized and multimodal interventions, but it is hard for some patients to follow programs based on several components. We examined the feasibility of a bimodal intervention, including a psycho-educational component and exercises, to support patients and their caregivers in managing CC; Methods: Prospective mixed-methods pilot study explored feasibility data, changes in patient-reported outcomes, and performance outcomes over time in a convenient sample of 30 consecutive CC patients and their caregivers. Results: Twenty-four dyads consented to participate. Twenty dyads received at least two psycho-educational sessions, so the psycho-educational component was feasible for 83.3% of the sample. Six dyads participated in at least fourteen out of twenty-seven rehabilitation sessions, so the exercise program was feasible for 25.0% of the sample. Six dyads showed compliance greater than 50% for both components of the bimodal intervention. Conclusions: While we did not meet our primary feasibility endpoint and had mixed acceptability, our experience provides insight into the challenges and lessons learned in implementing a primary palliative care intervention for CC. More robust studies are needed to help clinicians understand the best exercise program for CC patients, to be included in a multimodal intervention.
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Chang VT, Sandifer C, Zhong F. GI Symptoms in Pancreatic Cancer. Clin Colorectal Cancer 2023; 22:24-33. [PMID: 36623952 DOI: 10.1016/j.clcc.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.
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Affiliation(s)
- Victor T Chang
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ.
| | | | - Fengming Zhong
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ
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Amano K, Morita T, Miura T, Mori N, Tatara R, Kessoku T, Matsuda Y, Tagami K, Otani H, Mori M, Taniyama T, Nakajima N, Nakanishi E, Kako J, Ishiki H, Matsuoka H, Satomi E, Hopkinson JB, Baracos VE, Miyashita M. Development and validation of questionnaires for eating-related distress among advanced cancer patients and families. J Cachexia Sarcopenia Muscle 2023; 14:310-325. [PMID: 36403291 PMCID: PMC9891939 DOI: 10.1002/jcsm.13133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/05/2022] [Accepted: 10/25/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Eating-related distress (ERD) is one type of psychosocial distress among advanced cancer patients and family caregivers. Its alleviation is a key issue in palliative care; however, there is no validated tool for measuring ERD. METHODS The purpose of this study was to validate tools for evaluating ERD among patients and family caregivers. The study consisted of a development and validation/retest phase. In the development phase, we made preliminary questionnaires for patients and family caregivers. After face validity and content validity, we performed an exploratory factor analysis and discussed the final adoption of items. In the validation/retest phase, we examined factor validity with an exploratory factor analysis. We calculated Pearson's correlation coefficients between the questionnaire for patients, the Functional Assessment of Anorexia/Cachexia Therapy Anorexia Cachexia Subscale (FAACT ACS) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Cachexia 24 (EORTC QLQ-CAX24) and Pearson's correlation coefficients between the questionnaire for family caregivers and the Caregiver Quality of Life Index-Cancer (CQOLC) for concurrent validity. We calculated Cronbach's alpha coefficients (Cronbach's alpha) and intraclass correlation coefficients (ICCs) for internal consistency and test-retest reliability. We performed the Mann-Whitney U test between the questionnaires and cancer cachexia based on criteria from the international consensus for known-group validity. RESULTS In the development phase, 162 pairs of patients and family caregivers were asked to participate, and 144 patients and 106 family caregivers responded. In the validation/retest phase, 333 pairs of patients and family caregivers were asked to participate, and 234 patients and 152 family caregivers responded. Overall, 183 patients and 112 family caregivers did the retest. Seven conceptual groups were extracted for the ERD among patients and family caregivers, respectively. Patient factors 1-7 correlated with FAACT ACS (r = -0.63, -0.43, -0.55, -0.40, -0.38, -0.54, -0.38, respectively) and EORTC QLQ-CAX24 (r = 0.58, 0.40, 0.60, 0.49, 0.38, 0.59, 0.42, respectively). Family factors 1-7 correlated with CQOLC (r = -0.34, -0.30, -0.37, -0.37, -0.46, -0.42, -0.40, respectively). The values of Cronbach's alpha and ICC of each factor and all factors of patients ranged from 0.84 to 0.96 and 0.67 to 0.83, respectively. Those of each factor and all factors of family caregivers ranged from 0.84 to 0.96 and 0.63 to 0.84, respectively. The cachexia group of patients had significantly higher scores than the non-cachexia group for each factor and all factors. CONCLUSIONS Newly developed tools for measuring ERD experienced by advanced cancer patients and family caregivers have been validated.
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Affiliation(s)
- Koji Amano
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan.,Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Tomofumi Miura
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Naoharu Mori
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Ryohei Tatara
- Department of Palliative Medicine, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan
| | - Takaomi Kessoku
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama, Japan.,Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Tomohiko Taniyama
- Department of Clinical Oncology and Palliative Medicine, Mitsubishi Kyoto Hospital, Nishikyo-ku, Kyoto, Japan
| | - Nobuhisa Nakajima
- Division of Community Medicine and International Medicine, University of the Ryukyus Hospital, Nakagami-gun, Okinawa, Japan
| | - Erika Nakanishi
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.,Graduate School of Public Health, St. Luke's International University, OMURA Susumu & Mieko Memorial St. Luke's Center for Clinical Academia, Chuo-ku, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Jane B Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK
| | - Vickie E Baracos
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Canada
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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13
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Amano K, Koshimoto S, Hopkinson JB, Baracos VE, Mori N, Morita T, Oyamada S, Ishiki H, Satomi E, Takeuchi T. Perspectives of Health Care Professionals on Multimodal Interventions for Cancer Cachexia. Palliat Med Rep 2022; 3:244-254. [PMID: 36636614 PMCID: PMC9811833 DOI: 10.1089/pmr.2022.0045] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 12/12/2022] Open
Abstract
Background Holistic multimodal interventions have not been established for cancer cachexia. The beliefs and perceptions of health care professionals (HCPs) based on their experiences influence the interventions. Objectives HCPs' knowledge, perceptions, and practices in cancer cachexia management were evaluated. Design/Setting/Subjects/Measurements A nationwide questionnaire survey was conducted that focused on the perspectives of HCPs on interventions in 451 designated cancer hospitals across Japan. Descriptive statistics were applied. Results Among 2255 participants, 1320 responded (58.5%), and 1188 in 258 institutes were included in the analysis. The current international definition of cancer cachexia is not commonly known and recent clinical practice guidelines have not been widely adopted. More than 50% of participants considered ≥5% weight loss in six months and ECOG PS (Eastern Cooperative Oncology Group Performance Status) 2-4 to be cancer cachexia, whereas 50% answered that there was no relationship between life expectancy and cancer cachexia. Participants tended to consider it important to initiate nutritional and exercise interventions before cancer cachexia becomes apparent. The majority of participants recognized the importance of holistic multimodal interventions, particularly for the management of physical and psychological symptoms; however, only 20% reported that they educated patients and families. Furthermore, 33% of participants considered themselves to have provided patients and families with sufficient nutritional and exercise interventions and evidence-based information. Conclusion The results reveal that HCPs are not regularly providing education and emotional support to patients and families suffering from cancer cachexia. The results also show the need for education for HCPs to enhance implementation of holistic multimodal interventions for cancer cachexia.
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Affiliation(s)
- Koji Amano
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan.,Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Aichi, Japan.,Address correspondence to: Koji Amano, MD, Department of Palliative Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
| | - Saori Koshimoto
- School of Health Care Sciences, Faculty of Medicine, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Human Nutrition, Faculty of Human Nutrition. Tokyo Kasei Gakuin University, Tokyo, Japan
| | - Jane B. Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Vickie E. Baracos
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Naoharu Mori
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Aichi, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu City, Japan
| | | | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Takashi Takeuchi
- Liaison Psychiatry and Psycho-oncology Unit, Department of Psychiatry and Behavioral Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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14
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Holdoway A. Nutrition in palliative care: issues, perceptions and opportunities to improve care for patients. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S20-S27. [PMID: 36416622 DOI: 10.12968/bjon.2022.31.21.s20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Dietary advice, the provision of timely nutritional support and the alleviation of diet-related issues, should be an essential component of a holistic approach to palliative and end-of-life care, adjusted to account for the stage in the patient's journey, including prognosis. With an ageing population and increasing numbers of people living with not just one life-limiting disease but several, the dietary management of these patients is becoming more complex. This article considers the issues patients and families experience, how nurses can play a key role in identifying and alleviating nutrition- and diet-related issues in palliative care, including the use of tools to screen, assess and guide nutrition conversations and interventions. The content of the article is mostly drawn from the literature relating to palliative cancer care, knowledge derived from stakeholder engagement, clinical observations in a dietetic role in a hospice setting and qualitative research on the role of diet in palliative care as perceived by patients, carers, and health professionals.
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Affiliation(s)
- Anne Holdoway
- Consultant Dietitian, The Bath Clinic, Bath; Chair, Managing Adult Malnutrition in the Community Panel; Education Officer, British Association for Parenteral and Enteral Nutrition
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15
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Abe A, Amano K, Morita T, Miura T, Mori N, Tatara R, Kessoku T, Matsuda Y, Tagami K, Otani H, Mori M, Taniyama T, Nakajima N, Nakanishi E, Kako J, Kiuchi D, Ishiki H, Matsuoka H, Satomi E, Miyashita M. Beliefs and Perceptions About Parenteral Nutrition and Hydration by Advanced Cancer Patients. Palliat Med Rep 2022; 3:132-139. [PMID: 36059904 PMCID: PMC9438434 DOI: 10.1089/pmr.2022.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Akiko Abe
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Koji Amano
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute City, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka, Japan
| | - Tomofumi Miura
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa City, Japan
| | - Naoharu Mori
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute City, Japan
| | - Ryohei Tatara
- Department of Palliative Medicine, Osaka City General Hospital, Osaka City, Japan
| | - Takaomi Kessoku
- Department of Palliative Medicine, Yokohama City University Hospital, Yokohama City, Japan
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama City, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai City, Japan
| | - Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, Sendai City, Japan
| | - Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, St. Mary's Hospital, Kurume City, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka, Japan
| | - Tomohiko Taniyama
- Department of Clinical Oncology and Palliative Medicine, Mitsubishi Kyoto Hospital, Kyoto City, Japan
| | - Nobuhisa Nakajima
- Division of Community Medicine and International Medicine, University of the Ryukyus Hospital, Nakagami-Gun, Japan
| | - Erika Nakanishi
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai City, Japan
- Graduate School of Public Health, St. Luke's International University, OMURA Susumu and Mieko Memorial St. Luke's Center for Clinical Academia, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi City, Japan
| | - Daisuke Kiuchi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai City, Japan
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16
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Brasser M, Frühholz S, Schneeberger AR, Ruschetti GG, Schaerli R, Häner M, Studer-Luethi B. A Randomized Controlled Trial Study of a Multimodal Intervention vs. Cognitive Training to Foster Cognitive and Affective Health in Older Adults. Front Psychol 2022; 13:866613. [PMID: 35795412 PMCID: PMC9251428 DOI: 10.3389/fpsyg.2022.866613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
Research over the past few decades has shown the positive influence that cognitive, social, and physical activities have on older adults’ cognitive and affective health. Especially interventions in health-related behaviors, such as cognitive activation, physical activity, social activity, nutrition, mindfulness, and creativity, have shown to be particularly beneficial. Whereas most intervention studies apply unimodal interventions, such as cognitive training (CT), this study investigates the potential to foster cognitive and affective health factors of older adults by means of an autonomy-supportive multimodal intervention (MMI). The intervention integrates everyday life recommendations for six evidence-based areas combined with psychoeducational information. This randomized controlled trial study compares the effects of a MMI and CT on those of a waiting control group (WCG) on cognitive and affective factors, everyday life memory performance, and activity in everyday life. Three groups, including a total of 119 adults aged 65–86 years, attended a 5- or 10-week intervention. Specifically, one group completed a 10-week MMI, the second group completed 5-week of computer-based CT followed by a 5-week MMI, whereas the third group paused before completing the MMI for the last 5 weeks. All participants completed online surveys and cognitive tests at three test points. The findings showed an increase in the number and variability of activities in the everyday lives of all participants. Post hoc analysis on cognitive performance of MMI to CT indicate similar (classic memory and attention) or better (working memory) effects. Furthermore, results on far transfer variables showed interesting trends in favor of the MMI, such as increased well-being and attitude toward the aging brain. Also, the MMI group showed the biggest perceived improvements out of all groups for all self-reported personal variables (memory in everyday life and stress). The results implicate a positive trend toward MMI on cognitive and affective factors of older adults. These tendencies show the potential of a multimodal approach compared to training a specific cognitive function. Moreover, the findings suggest that information about MMI motivates participants to increase activity variability and frequency in everyday life. Finally, the results could also have implications for the primary prevention of neurocognitive deficits and degenerative diseases.
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Affiliation(s)
- Maria Brasser
- Cognitive and Affective Neuroscience Unit, University of Zürich, Zürich, Switzerland
- *Correspondence: Maria Brasser,
| | - Sascha Frühholz
- Cognitive and Affective Neuroscience Unit, University of Zürich, Zürich, Switzerland
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Andres R. Schneeberger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital, Zürich, Switzerland
| | | | - Rahel Schaerli
- Department of Psychology, University of Bern, Bern, Switzerland
| | - Michèle Häner
- Department of Psychology, University of Bern, Bern, Switzerland
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17
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Amano K, Hopkinson J, Baracos V. Psychological symptoms of illness and emotional distress in advanced cancer cachexia. Curr Opin Clin Nutr Metab Care 2022; 25:167-172. [PMID: 34966115 DOI: 10.1097/mco.0000000000000815] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Cachexia induces both physical and psychological symptoms of illness in patients with advanced cancer and may generate emotional distress in patients and families. However, physical symptoms of cachexia received the most emphasis. The aims of this review are to elucidate a link between systemic inflammation underlying cachexia and psychological symptoms and emotional distress, and to advance care strategy for management of psychological symptoms and emotional distress in patients and families. RECENT FINDINGS The main themes in the literature covered by this review are psychological symptoms in patients and emotional distress in patients and families. Studies of the underlying biology of cachexia identify the role of the central nervous system to amplify tumor-induced systemic inflammation. The brain mediates a cluster of symptoms, such as sleep disruption, anxiety, cognitive impairment, and reduction in motivated behavior (notably anorexia). These are distressing to patients as well as to families. SUMMARY There is growing recognition that holistic multimodal interventions are needed to alleviate psychological symptoms and emotional distress and to improve quality of life in patients with cancer cachexia and families. This is an approach that addresses not only physical health but also psychological, emotional, and social well being issues.
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Affiliation(s)
- Koji Amano
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute city, Aichi, Japan
| | - Jane Hopkinson
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK
| | - Vickie Baracos
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Alberta, Canada
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