Cancer cachexia: developing multimodal therapy for a multidimensional problem

Myostatin is a novel tumoral factor that induces cancer cachexia

Humoral and tumoral factors collectively promote cancer-induced skeletal muscle wasting by increasing protein degradation. Although several humoral proteins, namely TNFα (tumour necrosis factor α) and IL (interleukin)-6, have been shown to induce skeletal muscle wasting, there is a lack of information regarding the tumoral factors that contribute to the atrophy of muscle during cancer cachexia. Therefore, in the present study, we have characterized the secretome of C26 colon cancer cells to identify the tumoral factors involved in cancer-induced skeletal muscle wasting. In the present study, we show that myostatin, a procachectic TGFβ (transforming growth factor β) superfamily member, is abundantly secreted by C26 cells. Consistent with myostatin signalling during cachexia, treating differentiated C2C12 myotubes with C26 CM (conditioned medium) resulted in myotubular atrophy due to the up-regulation of muscle-specific E3 ligases, atrogin-1 and MuRF1 (muscle RING-finger protein 1), and enhanced activity of the ubiquitin–proteasome pathway. Furthermore, the C26 CM also activated ActRIIB (activin receptor type II B)/Smad and NF-κB (nuclear factor κB) signalling, and reduced the activity of the IGF-I (insulin-like growth factor 1)/PI3K (phosphoinositide 3-kinase)/Akt pathway, three salient molecular features of myostatin action in skeletal muscles. Antagonists to myostatin prevented C26 CM-induced wasting in muscle cell cultures, further confirming that tumoral myostatin may be a key contributor in the pathogenesis of cancer cachexia. Finally, we show that treatment with C26 CM induced the autophagy–lysosome pathway and reduced the number of mitochondria in myotubes. These two previously unreported observations were recapitulated in skeletal muscles collected from C26 tumour-bearing mice.

The systemic inflammation-based Glasgow Prognostic Score: a decade of experience in patients with cancer

Since the initial work, a decade ago that the combination of C-reactive protein and albumin, the Glasgow Prognostic Score (GPS), had independent prognostic value in patients with cancer, there have been more than 60 studies (>30,000 patients) that have examined and validated the use of the GPS or the modified GPS (mGPS) in a variety of cancer scenarios. The present review provides a concise overview of these studies and comments on the current and future clinical utility of this simple objective systemic inflammation-based score. The GPS/mGPS had independent prognostic value in (a) unselected cohorts (4 studies, >19,400 patients) (b) operable disease (28 studies, >8,000 patients) (c) chemo/radiotherapy (11 studies, >1500 patients) (d) inoperable disease (11 studies, >2,000 patients). Association studies (15 studies, >2,000 patients) pointed to an increased GPS/mGPS being associated with increased weight and muscle loss, poor performance status, increased comorbidity, increased pro-inflammatory and angiogenic cytokines and complications on treatment. These studies have originated from 13 different countries, in particular the UK and Japan. A chronic systemic inflammatory response, as evidenced by the GPS/mGPS, is clearly implicated in the prognosis of patients with cancer in a variety of clinical scenarios. The GPS/mGPS is the most extensively validated of the systemic inflammation-based prognostic scores and therefore may be used in the routine clinical assessment of patients with cancer. It not only identifies patients at risk but also provides a well defined therapeutic target for future clinical trials. It remains to be determined whether the GPS has prognostic value in other disease states.

Is there a genetic cause of appetite loss?-an explorative study in 1,853 cancer patients

BACKGROUND

Appetite loss has a major impact on cancer patients. It is exceedingly prevalent, is a prognostic indicator and is associated with inferior quality of life. Cachexia is a multi-factorial syndrome defined by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism. Not all cancer patients that experience weight loss have appetite loss, and the pathophysiology between cachexia and appetite loss may thus be different. Knowledge of pathophysiology of appetite loss in cancer patients is still limited. The primary object of this study was to explore the association with 93 predefined candidate single-nucleotide polymorphisms (SNPs) and appetite loss in cancer patients to possibly generate new theories of the pathophysiology of the condition.

METHODS

A total of 1,853 cancer patients were phenotyped according to appetite loss and then genotyped.

RESULTS

After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and appetite loss. The ten most significant SNPs in the co-dominant model had observed odds ratios varying from 0.72 to 1.28.

CONCLUSIONS

This large exploratory study could not find any associations with loss of appetite and 93 SNPs with a potential to be involved in appetite loss in cancer patients. This does not however rule out genes putative role in the development of the symptom, but the observed odds ratios are close to one which makes it unlikely that any of the individual SNPs explored in the present study have great importance.

Cancer cachexia: mediators, signaling, and metabolic pathways

Cancer cachexia is characterized by a significant reduction in body weight resulting predominantly from loss of adipose tissue and skeletal muscle. Cachexia causes reduced cancer treatment tolerance and reduced quality and length of life, and remains an unmet medical need. Therapeutic progress has been impeded, in part, by the marked heterogeneity of mediators, signaling, and metabolic pathways both within and between model systems and the clinical syndrome. Recent progress in understanding conserved, molecular mechanisms of skeletal muscle atrophy/hypertrophy has provided a downstream platform for circumventing the variations and redundancy in upstream mediators and may ultimately translate into new targeted therapies.

The 2011 ESPEN Arvid Wretlind lecture: cancer cachexia: the potential impact of translational research on patient-focused outcomes

Cancer cachexia is a multifactorial syndrome characterised by loss of skeletal muscle that cannot be fully reversed by conventional nutritional support. Uncertainty continues as to its precise mediators and mechanisms. The pathophysiology is characterised by a variable combination of reduced food intake and abnormal metabolism. Recent evidence has suggested that there may be a genetic component to cachexia with emphasis on genes linked to systemic inflammation. Loss of skeletal muscle mass and function is a major contributor to the excess frailty, disability and increased mortality in cancer cachexia. Whilst muscle mass per se has been considered a key outcome measure in treating cachexia, it might be more rationale to choose a patient-centred outcome such as physical activity. Beyond good medical management, it is important that trials establish basic management for all patients (nutrition, exercise and anti-inflammatory treatment). Specific therapies for cachexia should focus on the key issues of reduced food intake and abnormal metabolism. Whilst combination regimens to treat these issues continue to be explored, there is also interest in biological therapies that target conserved molecular mechanisms of muscle growth/atrophy. The combination of approaches promises a new era for the management of cachexia in the context of supportive oncology.

Activation of thermogenesis in brown adipose tissue and dysregulated lipid metabolism associated with cancer cachexia in mice

Cancer cachexia/anorexia is a complex syndrome that involves profound metabolic imbalances and is directly implicated as a cause of death in at least 20% to 30% of all cancers. Brown adipose tissue (BAT) plays a key role in thermogenesis and energy balance and potentially contributes to the physiologic perturbations associated with cachexia. In this study, we investigated the impact of cachexia-inducing colorectal tumor on BAT in mice. We found that brown adipocytes were smaller and exhibited profound delipidation in cachectic tumor-bearing mice. Diurnal expression profiling of key regulators of lipid accumulation and fatty acid β-oxidation and their corresponding target genes revealed dramatic molecular changes indicative of active BAT. Increased Ucp1, Pbe, and Cpt1α expression at specific points coincided with higher BAT temperatures during the dark cycle, suggestive of a temporal stimulation of thermogenesis in cachexia. These changes persisted when cachectic mice were acclimatized to 28°C confirming inappropriate stimulation of BAT despite thermoneutrality. Evidence of inflammatory signaling also was observed in the BAT as an energetically wasteful and maladaptive response to anorexia during the development of cachexia.

Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results

BACKGROUND & AIMS

Different nutrition assessment tools and definitions are proposed for cancer-associated malnutrition and wasting (cachexia). We studied the associations between these assessments and overall survival in stage IV colorectal carcinoma patients.

METHODS

Anthropometric measures, energy intake, biochemical variables, nutritional risk screening, assessment of malnutrition, cachexia and body composition from computed tomography images were analysed, in 77 patients from Norway and Canada. Results were dichotomized into presence or absence of nutritional risk, malnutrition, cachexia and sarcopenia (low muscle mass) and associated with survival.

RESULTS

Overall, 22% up to 55% of the patients had cachexia according to different cachexia criteria: 34% were malnourished, 42% were at nutritional risk, and 39% were sarcopenic. Forty-four percent of the patients did not meet criteria for any of these conditions. Patients with cachexia defined by Cancer Cachexia Study Group (CCSG) had shorter survival in an unadjusted analysis, [Hazard ratio (HR) = 2.43; 95% confidence interval (CI) 1.32-4.47; P = 0.005]. After adjusting for nation, age and gender, cachexia (HR = 2.26; CI 1.18-4.32; P = 0.014) and malnutrition (HR = 1.83; CI 1.06-3.13; P = 0.029) remained significant predictors of survival.

CONCLUSIONS

Nutritional depletion in up to 55% of the patients was found. The lack of concordance between the results obtained by different assessment criteria was obvious. CCSG's cachexia score was the best prognostic factor for overall survival.

Physical activity monitoring: a responsive and meaningful patient-centered outcome for surgery, chemotherapy, or radiotherapy?

CONTEXT

In surgical and clinical oncology, there is a growing need for patient-centered outcomes that are responsive, meaningful, and fit for purpose.

OBJECTIVES

The aim of this study was to validate physical activity (PA) monitoring as a responsive outcome measure at different stages of disease and treatment, by verifying correlations between PA, performance score, and quality of life (QoL).

METHODS

Daily life PA of 162 cancer patients, monitored by a device that records time sitting/lying, time standing, time walking, number of steps taken, and walking cadence, was compared with 20 healthy volunteers. In a subgroup of patients, functional status and QoL were assessed using the World Health Organization/Eastern Cooperative Oncology Group and the Karnofsky Performance Status scores and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) questionnaire.

RESULTS

The PA of patients with resectable gastrointestinal cancer did not differ significantly from controls. In contrast, patients with advanced cancer took 45% fewer steps and spent an extra 2.8 hours/day lying/sitting (P=0.001). Patients undergoing neoadjuvant chemotherapy and surgery (5-6 weeks after operation) experienced a similar reduction in PA. There were significant correlations between PA and the physical and role domains as well as fatigue subscale of the EORTC QLQ-C30 scale.

CONCLUSION

Objective PA scores correlate significantly with disease stage, functional status, and QoL of patients with cancer. Therefore, activity monitoring can make meaningful objective estimates of patient function in response to cancer and its treatment and may provide surrogate outcomes of QoL.

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.

Terminology in cancer cachexia: importance and status

PURPOSE OF REVIEW

This article reviews the current status of the definition of cancer cachexia, and comments on future initiatives to refine it and to use it as a foundation for a cancer cachexia classification system.

RECENT FINDINGS

There has been a plethora of work by expert panels defining cachexia. Stemming from this work, an expert panel has published a definition of cancer cachexia and a three level staging system: precachexia, cachexia, and refractory cachexia. Colleagues in the cancer pain field have put forward a sophisticated pain classification system. Work to develop a similar classification system for cachexia is now commencing. Aside from improved communication, these efforts may also enable the oncology community to better appreciate the importance of cancer cachexia and to participate in interdisciplinary treatment programmes to combat cachexia.

SUMMARY

The quest to determine the pathophysiology of cancer cachexia and to use this knowledge to identify patient subsets will further research. Equally important, the fruits of this endeavour will lead to a higher priority for addressing cachexia with consequent development of a multimodal approach to management.

Thalidomide for managing cancer cachexia

BACKGROUND

Cancer cachexia is a multidimensional syndrome characterised by wasting, loss of weight, loss of appetite, metabolic alterations, fatigue and reduced performance status. A significant number of patients with advanced cancer develop cachexia before death. There is no identified optimum treatment for cancer cachexia. While the exact mechanism of the action of thalidomide is unclear, it is known to have immunomodulatory and anti-inflammatory properties, which are thought to help reduce the weight loss associated with cachexia. Preliminary studies of thalidomide have demonstrated encouraging results.

OBJECTIVES

This review aimed to (1) evaluate the effectiveness of thalidomide, and (2) identify and assess adverse effects from thalidomide for cancer cachexia.

SEARCH METHODS

Electronic searches were undertaken in CENTRAL, MEDLINE, EMBASE, Web of Science and CINAHL (from inception to April 2011). Reference lists from reviewed articles, trial registers, relevant conference documents and thalidomide manufacturers identified additional literature.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs) and non-RCTs. Participants were adults diagnosed with advanced or incurable cancer and weight loss or a clinical diagnosis of cachexia who were administered thalidomide.

DATA COLLECTION AND ANALYSIS

All titles and abstracts retrieved by electronic searching were downloaded to a reference management database. Duplicates were removed and the remaining citations were read by two review authors and checked for eligibility. Studies that were deemed ineligible for inclusion had clear reasons for exclusion documented. Data were extracted independently by two review authors for all eligible studies. While a meta-analysis was planned for this review, this was not possible due to the small number of studies included and high heterogeneity among them. Thus a narrative synthesis of the findings is presented.

MAIN RESULTS

The literature search revealed a dearth of large, well conducted trials in this area. This has hindered the review authors' ability to make an informed decision about thalidomide for the management of cancer cachexia. At present, there is insufficient evidence to refute or support the use of thalidomide for the management of cachexia in advanced cancer patients.

AUTHORS' CONCLUSIONS

The review authors cannot confirm or refute previous literature on the use of thalidomide for patients with advanced cancer who have cachexia and there is inadequate evidence to recommend it for clinical practice. Additional, well conducted, large RCTs are needed to test thalidomide both singularly and in combination with other treatment modalities to ascertain its true benefit, if any, for this population. Furthermore, one study (out of the three reviewed) highlighted that thalidomide was poorly tolerated and its use needs to be explored further in light of the frailty of this population.

Randomized phase III clinical trial of a combined treatment with carnitine + celecoxib ± megestrol acetate for patients with cancer-related anorexia/cachexia syndrome

BACKGROUND & AIMS

A phase III, randomized non-inferiority study was carried out to compare a two-drug combination (including nutraceuticals, i.e. antioxidants) with carnitine + celecoxib ± megestrol acetate for the treatment of cancer-related anorexia/cachexia syndrome (CACS): the primary endpoints were increase of lean body mass (LBM) and improvement of total daily physical activity. Secondary endpoint was: increase of physical performance tested by grip strength and 6-min walk test.

METHODS

Sixty eligible patients were randomly assigned to: arm 1, L-carnitine 4 g/day + Celecoxib 300 mg/day or arm 2, L-carnitine 4 g/day + celecoxib 300 mg/day + megestrol acetate 320 mg/day, all orally. All patients received as basic treatment polyphenols 300 mg/day, lipoic acid 300 mg/day, carbocysteine 2.7 g/day, Vitamin E, A, C. Treatment duration was 4 months. Planned sample size was 60 patients.

RESULTS

The results did not show a significant difference between tre atment arms in both primary and secondary endpoints. Analysis of changes from baseline showed that LBM (by dual-energy X-ray absorptiometry and by L3 computed tomography) increased significantly in both arms as well as physical performance assessed by 6MWT. Toxicity was quite negligible and comparable between arms.

CONCLUSIONS

The results of the present study showed a non-inferiority of arm 1 (two-drug combination) vs arm 2 (two-drug combination + megestrol acetate). Therefore, this simple, feasible, effective, safe, low cost with favorable cost-benefit profile, two-drug approach could be suggested in the clinical practice to implement CACS treatment.

Suppression of skeletal muscle turnover in cancer cachexia: evidence from the transcriptome in sequential human muscle biopsies

PURPOSE

The mechanisms underlying muscle wasting in patients with cancer remain poorly understood, and consequently there remains an unmet clinical need for new biomarkers and treatment strategies.

EXPERIMENTAL DESIGN

Microarrays were used to examine the transcriptome in single biopsies from healthy controls (n = 6) and in paired biopsies [pre-resection baseline (weight-loss 7%) and 8 month post-resection follow-up (disease-free/weight-stable for previous 2 months)] from quadriceps muscle of patients with upper gastrointestinal cancer (UGIC; n = 12).

RESULTS

Before surgery, 1,868 genes were regulated compared with follow-up (false discovery rate, 6%). Ontology analysis showed that regulated genes belonged to both anabolic and catabolic biologic processes with overwhelming downregulation in baseline samples. No literature-derived genes from preclinical cancer cachexia models showed higher expression in baseline muscle. Comparison with healthy control muscle (n = 6) revealed that despite differences in the transcriptome at baseline (941 genes regulated), the muscle of patients at follow-up was similar to control muscle (2 genes regulated). Physical activity (step count per day) did not differ between the baseline and follow-up periods (P = 0.9), indicating that gene expression differences reflected the removal of the cancer rather than altered physical activity levels. Comparative gene expression analysis using exercise training signatures supported this interpretation.

CONCLUSIONS

Metabolic and protein turnover-related pathways are suppressed in weight-losing patients with UGIC whereas removal of the cancer appears to facilitate a return to a healthy state, independent of changes in the level of physical activity.

Improving muscle mass and function in cachexia: non-drug approaches

PURPOSE OF REVIEW

Therapeutic exercise may help maintain or slow down the rate of decline in muscle mass and physical function that occurs with cachexia. This review considers recent evidence in relation to patients with cachexia as regards the rationale for the use of exercise, the challenges in its clinical application and future developments.

RECENT FINDINGS

Exercise may attenuate the effects of cachexia by modulating muscle metabolism, insulin sensitivity and levels of inflammation. Studies targeting cachectic patients have demonstrated that even in advanced disease peripheral muscle has the capacity to respond to exercise training. Nonetheless, there are challenges in implementing the use of exercise, particularly once cachexia is established in which tolerance to even low levels of exercise is poor. Strategies to make exercise a more accessible therapy are required and could include offering exercise earlier on in the course of the disease, at lower intensities and in various forms, including more novel approaches.

SUMMARY

The use of therapeutic exercise has a sound rationale, even in patients with advanced disease and cachexia. Because of practical issues with its application, further study is required to examine if benefits achieved in small studies can be translated to a wider clinical population.

Exploring physical activity level in patients with thoracic cancer: implications for use as an outcome measure

PURPOSE

Cachexia is common in patients with thoracic cancer impairing physical function and quality of life. New approaches which target muscle tissue are emerging and activity monitors could provide an objective assessment of their effect on physical function. We have collated data from three studies involving the use of one such monitor in order to benchmark aspects of physical activity for patients with thoracic cancer, explore how these relate to physician-rated performance status, and consider the implications for future studies.

METHODS

Patients with thoracic cancer and an Eastern Cooperative Oncology Group Performance Status (ECOG PS) of 0-2 wore an ActivPAL™ monitor for 1 week. The mean time spent each day in a range of activities, e.g. standing or stepping, or their frequency, e.g. number of sit-to-stand transitions, steps taken, were calculated and compared according to ECOG PS.

RESULTS

Data from 84 patients (54 male; mean (SD) age, 66 (9) years) were collated. Each day, patients spent a mean (SD) of 4.3 (2.0) h upright, completed 45 (17) sit-to-stand transitions and took 4,246 (2,983) steps. There was wide variation in each activity examined. All but the number of sit-to-stand transitions differed significantly between ECOG PS categories.

CONCLUSIONS

These data provide a detailed insight into how physical activity levels decline across the range of ECOG PS categories studied. The wide variation in physical activity within each ECOG PS category suggests that this scale may lack sufficient sensitivity to evaluate new cachexia treatments. Our data help to inform future work in this area.

Mini Nutritional Assessment (MNA) and biochemical markers of cachexia in metastatic lung cancer patients: interrelations and associations with prognosis

PURPOSE

Lung cancer patients frequently present with weight loss in the context of the cachexia syndrome. Despite its high clinical significance, definite diagnostic criteria of cachexia are lacking. Nutritional screening questionnaires, like the Mini Nutritional Assessment (MNA), have been proposed for the timely diagnosis of the syndrome. The aim of this study was to evaluate the correlation of MNA with laboratory markers of inflammation/cachexia in patients with metastatic lung cancer. The prognostic value of the measured parameters was also examined.

PATIENTS AND METHODS

Patients with metastatic lung cancer referred for systemic therapy were eligible. Baseline clinical characteristics were recorded and nutritional status was assessed using MNA. Blood samples were also collected and the following parameters were measured: hemoglobin (Hb), albumin (Alb), C-reactive protein (CRP), ghrelin, adiponectin, leptin and insulin growth factor I (IGF-I).

RESULTS

Totally, 115 patients (101 males) [median age 66 years (range 32-86)] were evaluated. According to MNA score, 27 (23.5%) patients were well nourished, 59 (51.3%) were at nutritional risk and 29 (25.2%) were already malnourished at diagnosis. MNA correlated with the following parameters: Hb (p=0.001), albumin (p<0.001), CRP (p=0.002), adiponectin (p=0.037) and leptin (p=0.008). After a median follow up of 38.2 months, multivariate analysis revealed that age (p=0.008), number of metastatic sites (p<0.001), MNA (p=0.044) and leptin (p=0.004) independently correlated with overall survival.

CONCLUSIONS

Based on the MNA, the majority of patients were either malnourished or at nutritional risk. MNA correlated with laboratory parameters related to inflammation/cachexia and was independently associated with survival.

A randomised feasibility study of EPA and Cox-2 inhibitor (Celebrex) versus EPA, Cox-2 inhibitor (Celebrex), resistance training followed by ingestion of essential amino acids high in leucine in NSCLC cachectic patients--ACCeRT study

Background

Cancer cachexia is a syndrome of progressive weight loss. Non-small cell lung cancer patients experience a high incidence of cachexia of 61%. Research into methods to combat cancer cachexia in various tumour sites has recently progressed to the combination of agents.

The combination of the anti-cachectic agent Eicosapentaenoic acid (EPA) and the cyclo-oxygenase-2 (COX-2) inhibitor celecoxib has been tested in a small study with some benefit. The use of progressive resistance training (PRT) followed by the oral ingestion of essential amino acids (EAA), have shown to be anabolic on skeletal muscle and acceptable in older adults and other cancer groups.

The aim of this feasibility study is to evaluate whether a multi-targeted approach encompassing a resistance training and nutritional supplementation element is acceptable for lung cancer patients experiencing cancer cachexia.

Methods/Design

Auckland's Cancer Cachexia evaluating Resistance Training (ACCeRT) is an open label, prospective, randomised controlled feasibility study with two parallel arms. All patients will be treated with EPA and the COX-2 inhibitor celecoxib on an outpatient basis at the study site. In the experimental group patients will participate in PRT twice a week, followed by the ingestion of essential amino acids high in leucine. A total of 21 patients are planned to be enrolled. Patients will be randomised using 1:2 ratio with 7 patients enrolled into the control arm, and 14 patients into the treatment arm. The primary endpoint is the acceptability of the above multi-targeted approach, determined by an acceptability questionnaire.

Discussion

To our knowledge ACCeRT offers for the first time the opportunity to investigate the effect of stimulating the anabolic skeletal muscle pathway with the use of PRT along with EAA alongside the combination of EPA and celecoxib in this population.

Trial registration

Netherlands Trial Register (NTR): ACTRN12611000870954

Cachexia and sarcopenia: emerging syndromes of importance in dogs and cats

Cachexia is the loss of lean body mass (LBM) that affects a large proportion of dogs and cats with congestive heart failure (CHF), chronic kidney disease (CKD), cancer, and a variety of other chronic diseases. Sarcopenia, the loss of LBM that occurs with aging, is a related syndrome, although sarcopenia occurs in the absence of disease. As many of the diseases associated with muscle loss are more common in aging, cachexia and sarcopenia often are concurrent problems. Both cachexia and sarcopenia have important clinical implications because they are associated with increased morbidity and mortality. The pathophysiology of these 2 syndromes is complex and multifactorial, but recent studies have provided new information that has helped to clarify mechanisms and identify potential new targets for treatment. Newly identified mechanisms and pathways that mediate cachexia appear to act by increasing energy requirements, decreasing energy intake, impairing nutrient absorption, and causing metabolic alterations. Whereas cachexia and sarcopenia are important areas of research for drug development in people, they are only beginning to be recognized in veterinary medicine. Greater awareness and earlier diagnosis will help provide practical approaches to managing body weight and lean tissue in dogs and cats, as well as more directed targets for treatment.

Inhibition of FoxO transcriptional activity prevents muscle fiber atrophy during cachexia and induces hypertrophy

Cachexia is characterized by inexorable muscle wasting that significantly affects patient prognosis and increases mortality. Therefore, understanding the molecular basis of this muscle wasting is of significant importance. Recent work showed that components of the forkhead box O (FoxO) pathway are increased in skeletal muscle during cachexia. In the current study, we tested the physiological significance of FoxO activation in the progression of muscle atrophy associated with cachexia. FoxO-DNA binding dependent transcription was blocked in the muscles of mice through injection of a dominant negative (DN) FoxO expression plasmid prior to inoculation with Lewis lung carcinoma cells or the induction of sepsis. Expression of DN FoxO inhibited the increased mRNA levels of atrogin-1, MuRF1, cathepsin L, and/or Bnip3 and inhibited muscle fiber atrophy during cancer cachexia and sepsis. Interestingly, during control conditions, expression of DN FoxO decreased myostatin expression, increased MyoD expression and satellite cell proliferation, and induced fiber hypertrophy, which required de novo protein synthesis. Collectively, these data show that FoxO-DNA binding-dependent transcription is necessary for normal muscle fiber atrophy during cancer cachexia and sepsis, and further suggest that basal levels of FoxO play an important role during normal conditions to depress satellite cell activation and limit muscle growth.

Physical exercise for cancer patients with advanced disease: a randomized controlled trial

BACKGROUND

Physical exercise can improve cancer patients' functioning and reduce their symptom levels. A randomized, controlled trial was launched to test the hypothesis that physical exercise reduces fatigue and improves physical performance in cancer patients with advanced and incurable disease.

METHODS

Cancer patients (n = 231) with a life expectancy ≤2 years were randomized to a physical exercise group (PEG, n = 121) or a control usual care group (UCG, n = 110). The PEG exercised under supervision 60 minutes twice a week for 8 weeks. Assessments were performed before and after the intervention. The primary outcome was physical fatigue (PF) measured by the Fatigue Questionnaire. Physical performance was a secondary outcome measured by the Shuttle Walk Test (SWT) and hand grip strength (HGS) test. Analyses were performed after multiple imputations for missing data. The trial is registered with ClinicalTrials.gov (identifier, NCT00397774).

FINDINGS

Thirty-six percent of the PEG were lost to follow-up compared with 23% of the UCG, primarily as a result of disease progression. Seventy-eight PEG and 85 UCG patients completed the intervention. Analyses showed no significant between-group effects in PF. However, clinically and statistically significant between-group effects were found for the SWT and HGS test.

INTERPRETATION

Fatigue was not reduced but physical performance (SWT and HGS test) was significantly improved after 8 weeks of physical exercise. Physical exercise might therefore be a suitable approach for maintaining physical capacity in cancer patients with incurable and advanced disease.

Is there a genetic cause for cancer cachexia? - a clinical validation study in 1797 patients

BACKGROUND

Cachexia has major impact on cancer patients' morbidity and mortality. Future development of cachexia treatment needs methods for early identification of patients at risk. The aim of the study was to validate nine single-nucleotide polymorphisms (SNPs) previously associated with cachexia, and to explore 182 other candidate SNPs with the potential to be involved in the pathophysiology.

METHOD

A total of 1797 cancer patients, classified as either having severe cachexia, mild cachexia or no cachexia, were genotyped.

RESULTS

After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and the cachexia groups. However, consistent with prior reports, two SNPs from the acylpeptide hydrolase (APEH) gene showed suggestive statistical significance (P=0.02; OR, 0.78).

CONCLUSION

This study failed to detect any significant association between any of the SNPs analysed and cachexia; although two SNPs from the APEH gene had a trend towards significance. The APEH gene encodes the enzyme APEH, postulated to be important in the endpoint of the ubiquitin system and thus the breakdown of proteins into free amino acids. In cachexia, there is an extensive breakdown of muscle proteins and an increase in the production of acute phase proteins in the liver.

Antibody-directed myostatin inhibition enhances muscle mass and function in tumor-bearing mice

Cancer cachexia describes the progressive skeletal muscle wasting and weakness in many cancer patients and accounts for >20% of cancer-related deaths. We tested the hypothesis that antibody-directed myostatin inhibition would attenuate the atrophy and loss of function in muscles of tumor-bearing mice. Twelve-week-old C57BL/6 mice received a subcutaneous injection of saline (control) or Lewis lung carcinoma (LLC) tumor cells. One week later, mice received either once weekly injections of saline (control, n = 12; LLC, n = 9) or a mouse chimera of anti-human myostatin antibody (PF-354, 10 mg·kg−1·wk−1, LLC+PF-354, n = 11) for 5 wk. Injection of LLC cells reduced muscle mass and maximum force of tibialis anterior (TA) muscles by 8–10% ( P < 0.05), but the muscle atrophy and weakness were prevented with PF-354 treatment ( P > 0.05). Maximum specific (normalized) force of diaphragm muscle strips was reduced with LLC injection ( P < 0.05) but was not improved with PF-354 treatment ( P > 0.05). PF-354 enhanced activity of oxidative enzymes in TA and diaphragm muscles of tumor-bearing mice by 118% and 89%, respectively ( P < 0.05). Compared with controls, apoptosis that was not of myofibrillar or satellite cell origin was 140% higher in TA muscle cross sections from saline-treated LLC tumor-bearing mice ( P < 0.05) but was not different in PF-354-treated tumor-bearing mice ( P > 0.05). Antibody-directed myostatin inhibition attenuated the skeletal muscle atrophy and loss of muscle force-producing capacity in a murine model of cancer cachexia, in part by reducing apoptosis. The improvements in limb muscle mass and function highlight the therapeutic potential of antibody-directed myostatin inhibition for cancer cachexia.

Treatment of cachexia in oncology

Cachexia is a complex metabolic syndrome associated with many chronic or end-stage diseases, especially cancer, and is characterized by loss of muscle with or without loss of fat mass. The management of cachexia is a complex challenge that should address the different causes underlying this clinical event with an integrated or multimodal treatment approach targeting the different factors involved in its pathophysiology. The purpose of this article was to review the current medical treatment of cancer-related cachexia, in particular focusing on combination therapy and ongoing research. Among the treatments proposed in the literature for cancer-related cachexia, some proved to be ineffective, namely, cyproheptadine, hydrazine, metoclopramide, and pentoxifylline. Among effective treatments, progestagens are currently considered the best available treatment option for cancer-related cachexia, and they are the only drugs approved in Europe. Drugs with a strong rationale that have failed or have not shown univocal results in clinical trials so far include eicosapentaenoic acid, cannabinoids, bortezomib, and anti-TNF-alpha MoAb. Several emerging drugs have shown promising results but are still under clinical investigation (thalidomide, selective cox-2 inhibitors, ghrelin mimetics, insulin, oxandrolone, and olanzapine). To date, despite several years of coordinated efforts in basic and clinical research, practice guidelines for the prevention and treatment of cancer-related muscle wasting are lacking, mainly because of the multifactorial pathogenesis of the syndrome. From all the data presented, one can speculate that one single therapy may not be completely successful in the treatment of cachexia. From this point of view, treatments involving different combinations are more likely to be successful.

Simple nutritional intervention in patients with advanced cancers of the gastrointestinal tract, non-small cell lung cancers or mesothelioma and weight loss receiving chemotherapy: a randomised controlled trial

BACKGROUND

Weight loss in patients with cancer is common and associated with a poorer survival and quality of life. Benefits from nutritional interventions are unclear. The present study assessed the effect of dietary advice and/or oral nutritional supplements on survival, nutritional endpoints and quality of life in patients with weight loss receiving palliative chemotherapy for gastrointestinal and non-small cell lung cancers or mesothelioma.

METHODS

Participants were randomly assigned to receive no intervention, dietary advice, a nutritional supplement or dietary advice plus supplement before the start of chemotherapy. Patients were followed for 1 year. Survival, nutritional status and quality of life were assessed.

RESULTS

In total, 256 men and 102 women (median age, 66 years; range 24-88 years) with gastrointestinal (n = 277) and lung (n = 81) cancers were recruited. Median (range) follow-up was 6 (0-49) months. One-year survival was 38.6% (95% confidence interval 33.3-43.9). No differences in survival, weight or quality of life between groups were seen. Patients surviving beyond 26 weeks experienced significant weight gain from baseline to 12 weeks, although this was independent of nutritional intervention.

CONCLUSIONS

Simple nutritional interventions did not improve clinical or nutritional outcomes or quality of life. Weight gain predicted a longer survival but occurred independently of nutritional intervention.

[Undernutrition and quality of life in non small cell lung cancer patients]

Cancer is related to a deterioration of nutritional status and quality of life (QoL), but the extent of these conditions in patients with Non Small Cell Lung Cancer (NSCLC) has not been studied. The aim of the present study was to assess the association between QoL and undernutrition in NSCLC patients. Nutritional status was evaluated with Patient Generated - Subjective Global Assessment and QoL using the European Organization for Research and Treatment of Cancer Quality of Life - C30 and also with the specific module for lung cancer patients. A consecutive sample of fifty six patients diagnosed with NSCLC was evaluated. A high proportion of patients is undernourished (35.7%), 1.8% in early stages vs 33.9% in advanced stages of disease. Undernutrition is related to measured dimensions of QoL: lack of appetite (rho=0.70), fatigue (rho=0.54), nausea and vomiting (rho=0.52) and constipation (rho=0.56). Undernourished patients have worse global health status, physical, emotional, social and role functioning. Patients with NSCLC have high frequency of undernutrition in advanced stages of disease. Undernourished patients present more symptoms, a worse global health status/QoL, physical, role, emotional and social functioning than patients without undernutrition. Undernutrition is associated with worse QoL, specifically in the parameters: appetite loss, nausea and vomiting, constipation and fatigue.

Cancer cachexia: traditional therapies and novel molecular mechanism-based approaches to treatment

The complex syndrome of cancer cachexia (CC) that occurs in 50% to 80% cancer patients has been identified as an independent predictor of shorter survival and increased risk of treatment failure and toxicity, contributing to the mortality and morbidity in this population. CC is a pathological state including a symptom cluster of loss of muscle (skeletal and visceral) and fat, manifested in the cardinal feature of emaciation, weakness affecting functional status, impaired immune system, and metabolic dysfunction. The most prominent feature of CC is its non-responsiveness to traditional treatment approaches; randomized clinical trials with appetite stimulants, 5-HT3 antagonists, nutrient supplementation, and Cox-2 inhibitors all have failed to demonstrate success in reversing the metabolic abnormalities seen in CC. Interventions based on a clear understanding of the mechanism of CC, using validated markers relevant to the underlying metabolic abnormalities implicated in CC are much needed. Although the etiopathogenesis of CC is poorly understood, studies have proposed that NFkB is upregulated in CC, modulating immune and inflammatory responses induce the cellular breakdown of muscle, resulting in sarcopenia. Several recent laboratory studies have shown that n-3 fatty acid may attenuate protein degradation, potentially by preventing NFkB accumulation in the nucleus, preventing the degradation of muscle proteins. However, clinical trials to date have produced mixed results potentially attributed to timing of interventions (end stage) and utilizing outcome markers such as weight which is confounded by hydration, cytotoxic therapies, and serum cytokines. We propose that selective targeting of proteasome activity with a standardized dose of omega-3-acid ethyl esters, administered to cancer patients diagnosed with early stage CC, in addition to a standard intervention with nutritionally adequate diet and appetite stimulants, will alter metabolic abnormalities by downregulating NFkB, preventing the breakdown of myofibrillar proteins and resulting in increasing serum protein markers, lean body mass, and functional status.

Extrahepatic cancer suppresses nuclear receptor-regulated drug metabolism

PURPOSE

To determine the mechanisms by which tumors situated in extrahepatic sites can cause profound changes in hepatic drug clearance, contributing to altered drug response and chemotherapy resistance.

EXPERIMENTAL DESIGN

We studied in wild-type or transgenic CYP3A4 reporter mice implanted with the murine Engelbreth-Holm-Swarm sarcoma changes in nuclear receptor and hepatic transcription factor expression and/or function, particularly related to CYP3A gene regulation.

RESULTS

Repression of hepatic CYP3A induction was dramatic and associated with reduced levels of C/EBPβ isoforms, impaired pregnane X receptor, and constitutive androstane receptor function. Unexpectedly, extrahepatic tumors strongly reduced nuclear accumulation of retinoid X receptor alpha (RXRα) in hepatocytes, providing a potential explanation for impaired function of nuclear receptors that rely on RXRα dimerization. Profiling revealed 38 nuclear receptors were expressed in liver with 14 showing between 1.5- and four-fold reduction in expression in livers of tumor-bearing animals, including Car, Trβ, Lxrβ, Pparα, Errα/β, Reverbα/β, and Shp. Altered Pparα and γ induction of target genes provided additional evidence of perturbed hepatic metabolic control elicited by extrahepatic tumors.

CONCLUSIONS

Extrahepatic malignancy can affect hepatic drug metabolism by nuclear receptor relocalization and decreased receptor expression and function. These findings could aid the design of intervention strategies to normalize drug clearance and metabolic pathways in cancer patients at risk of chemotherapy-induced toxicity or cancer cachexia.

Definition and classification of cancer cachexia: an international consensus

To develop a framework for the definition and classification of cancer cachexia a panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. Cancer cachexia was defined as a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. The agreed diagnostic criterion for cachexia was weight loss greater than 5%, or weight loss greater than 2% in individuals already showing depletion according to current bodyweight and height (body-mass index [BMI] <20 kg/m(2)) or skeletal muscle mass (sarcopenia). An agreement was made that the cachexia syndrome can develop progressively through various stages--precachexia to cachexia to refractory cachexia. Severity can be classified according to degree of depletion of energy stores and body protein (BMI) in combination with degree of ongoing weight loss. Assessment for classification and clinical management should include the following domains: anorexia or reduced food intake, catabolic drive, muscle mass and strength, functional and psychosocial impairment. Consensus exists on a framework for the definition and classification of cancer cachexia. After validation, this should aid clinical trial design, development of practice guidelines, and, eventually, routine clinical management.

Cancer pain and its relationship to systemic inflammation: an exploratory study

Pain is the commonest symptom in cancer patients, whereas inflammation is implicated in cancer development and progression. The relationship between pain and inflammation in cancer is therefore of interest; however, it is challenging to examine because multiple factors may affect these variables. This study assessed the relationship between cancer pain and systemic inflammation using a retrospective analysis of 2 clinical trial datasets of patients with cancer cachexia. Included patients had gastrointestinal, lung, or pancreatic cancer. Pain was assessed using the pain subscale of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C-30. Inflammation was assessed using C-reactive protein (CRP). A regression analysis between pain and logarithmically transformed CRP was run, and Pearson correlation coefficients were calculated. A total of 718 patients entered the trials, of whom 449 had CRP measured. Both trial populations were well matched. Pain positively correlated with CRP. The Pearson correlation coefficients were 0.126 and 0.163 for trials 1 and 2, respectively. This correlation was statistically significant at the P<.05 level. These findings support that pain is related to systemic inflammation in a cohort of cancer patients. Many factors can affect pain and inflammation in cancer, demonstrating that any relationship that exists between pain and inflammation is of interest. This is in keeping with work showing this relationship in nonmalignant pain. Studies targeting inflammation and assessing its effect on pain in cancer would be an important step in the research agenda.

Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer

BACKGROUND

The concept of cancer-related anorexia/cachexia is evolving as its mechanisms are better understood. To support consensus processes towards an updated definition and classification system, we systematically reviewed the literature for items and domains associated with involuntary weight loss in cancer.

METHODS

Two search strings (cachexia, cancer) explored five databases from 1976 to 2007. Citations, abstracts and papers were included if they were original work, in English/German language, and explored an item to distinguish advanced cancer patients with variable degrees of involuntary weight loss. The items were grouped into the 5 domains proposed by formal expert meetings.

RESULTS

Of 14,344 citations, 1275 abstracts and 585 papers reviewed, 71 papers were included (6325 patients; 40-50% gastrointestinal, 10-20% lung cancer). No single domain or item could consistently distinguish cancer patients with or without weight loss or having various degrees of weight loss. Anorexia and decreased nutritional intake were unexpectedly weakly related with weight loss. Explanations for this could be the imprecise measurement methods for nutritional intake, symptom interactions, and the importance of systemic inflammation as a catabolic drive. Data on muscle mass and strength is scarce and the impact of cachexia on physical and psychosocial function has not been widely assessed.

CONCLUSIONS

Current data support a modular concept of cancer cachexia with a variable combination of reduced nutritional intake and catabolic/hyper-metabolic changes. The heterogeneity in the literature revealed by this review underlines the importance of an agreed definition and classification of cancer cachexia.

Reversal of cancer cachexia and muscle wasting by ActRIIB antagonism leads to prolonged survival

Muscle wasting and cachexia have long been postulated to be key determinants of cancer-related death, but there has been no direct experimental evidence to substantiate this hypothesis. Here, we show that in several cancer cachexia models, pharmacological blockade of ActRIIB pathway not only prevents further muscle wasting but also completely reverses prior loss of skeletal muscle and cancer-induced cardiac atrophy. This treatment dramatically prolongs survival, even of animals in which tumor growth is not inhibited and fat loss and production of proinflammatory cytokines are not reduced. ActRIIB pathway blockade abolished the activation of the ubiquitin-proteasome system and the induction of atrophy-specific ubiquitin ligases in muscles and also markedly stimulated muscle stem cell growth. These findings establish a crucial link between activation of the ActRIIB pathway and the development of cancer cachexia. Thus ActRIIB antagonism is a promising new approach for treating cancer cachexia, whose inhibition per se prolongs survival.

Systemic zinc redistribution and dyshomeostasis in cancer cachexia

Cachexia affects up to two thirds of all cancer patients and is a significant cause of morbidity and mortality. It is a complex metabolic syndrome associated with the underlying illness and characterized by loss of skeletal muscle tissue with or without loss of fat mass. Cachexia's other prominent clinical symptoms include anorexia, systemic inflammation, pediatric growth failure, and hypogonadism. The relationship between the symptoms of cancer cachexia and the underlying illness is unclear, and there is an urgent need for a better understanding of the pathophysiology of this syndrome. Normal Zn metabolism is often disrupted in cancer patients, but the possible effects of systemic Zn dyshomeostasis in cachexia have not been investigated. We propose that the acute phase response can mediate Zn redistribution and accumulation in skeletal muscle tissue and contribute to the activation of the ubiquitin-proteasome pathway that regulates protein catabolism. This chronic redistribution deprives Zn from other tissues and organs and compromises critical physiological functions in the body. The cardinal symptoms of Zn deficiency are anorexia, systemic inflammation, growth failure in children, and hypogonadism. These symptoms also prominently characterize cancer cachexia suggesting that the role of systemic Zn dyshomeostasis in cachexia should be investigated.

Clinical priorities, barriers and solutions in end-of-life cancer care research across Europe. Report from a workshop

AIM

The PRISMA project is aiming to co-ordinate research priorities, measurement and practice in end-of-life (EOL) care in Europe. As part of PRISMA we undertook a questionnaire survey and a subsequent workshop to (1) identify clinical priorities for EOL care research in Europe and propose a future research agenda and (2) identify barriers to EOL care research, and possibilities and solutions to improve the research.

METHODS

Thirty participants selected among the principally medical survey responders from 25 European countries attended. Twenty-six answered a preparatory pre-workshop questionnaire based on the survey results. Group work was a main part of the workshop.

RESULTS

Consensus was reached on the following priorities for EOL cancer care research in Europe: symptomatology, issues related to care of the dying, and policy and organisation of services. Methodology was regarded important in all areas, including assessment/measurement and classification. Symptom research should particularly emphasise pain, fatigue, cachexia, delirium and breathlessness. Research should move from descriptive to interventional studies. The lack of consensus on definitions and outcomes was identified as a substantial research barrier. Other barriers were related to capacity and funding, environment and culture and knowledge transfer and dissemination. These areas are interrelated and should not be addressed in isolation.

CONCLUSION

Consensus was obtained on priority areas and research nature for EOL care research in the next years, and a model for addressing barriers was developed.

Cachexia - an intrinsic factor in wound healing

Systemic diseases are intrinsic factors that alter and may impair the wound healing process. Cachexia is a manifestation of systemic, often chronic, diseases and is characterised by systemic inflammation, appetite suppression and skeletal muscle wasting. Anorexia in cachectic states is commonly associated with malnutrition. Malnutrition may cause impaired healing. Therefore, it would follow that cachexia could influence wound healing because of reduced food intake. However, the lack of response to measures to reverse cachexia, such as supported nutrition, would suggest that a direct causal link between anorexia and weight loss in cachexia is too simple a model. To date, there is no published literature that examines the role of cachexia in human wound healing specifically. This article aims to demonstrate that cachexia is an intrinsic factor in wound healing. The role of the common mediators in wound healing and in cachexia are compared - specifically inflammation, including the nitric oxide synthase pathway, collagen deposition and reepithelialisation.

An update on promising agents for the treatment of cancer cachexia

PURPOSE OF REVIEW

There are no published conclusive phase III controlled clinical trials nor general consensus about treatment approaches despite several years of coordinated efforts in basic and clinical research. Consequently, practice guidelines for the prevention and treatment of cancer-related muscle wasting are lacking. The purpose of this review is to supply an update on the promising agents and/or combined approaches for the treatment of cancer cachexia.

RECENT FINDINGS

The choice for cancer cachexia treatment in clinical practice is very limited: the only approved drugs in Europe are progestagens. Several drugs with a strong rationale have failed or have not shown univocal results in clinical trials: they include eicosapentaenoic acid, cannabinoids, bortezomib and anti-tumor necrosis factor (TNF)-alpha monoclonal antibody. Several emerging drugs have shown promising results but are still under clinical investigation [thalidomide, selective cyclooxygenase (COX)-2 inhibitors, ghrelin mimetics, oxandrolone, olanzapine]. Moreover, increasing knowledge of cachexia pathophysiology and preliminary clinical findings seem to suggest that a combined treatment approach may be the most effective option.

SUMMARY

A number of promising new agents are currently being developed but are not as yet regarded as standard of care. They include: selective COX-2 inhibitors, ghrelin mimetics, oxandrolone, selective androgen receptor modulators (ostarine), olanzapine, anti-IL-6 antibody and an innovative approach of multitargeted combined treatment. The data reported seem to suggest that the most effective treatment for cancer cachexia may be a combination regimen rather than single-agent treatments. This is in keeping with the general consensus that cancer cachexia is a multifactorial process and, hence, a potentially effective approach should be multimodal.

Treatment of cancer-related anorexia with olanzapine and megestrol acetate: a randomized trial

PURPOSE

The purpose of the study was to determine the effectiveness of megestrol acetate (MA) and olanzapine (OLN) for the treatment of cancer-related anorexia (CRA).

METHODS

Eighty adult patients with advanced gastrointestinal cancer or lung cancer (stages III and IV) with CRA (loss of appetite and greater than or equal to 5% loss of preillness stable weight) were randomized to receive daily MA or MA plus OLN for a period of 8 weeks. Patients were assessed weekly using the M.D. Anderson Symptom Inventory with specific measurement of weight, appetite, nausea, and quality of life (QOL) measures.

RESULTS

For the 37 patients receiving MA, 15 patients had a greater than or equal to 5% weight gain, 2 patients had an appetite improvement, 3 patients had an improvement in nausea, and 5 patients had an improvement in QOL at both 4 and 8 weeks. For the 39 patients receiving MA plus OLN, 33 patients had a greater than or equal to 5% weight gain, 25 patients had an appetite improvement, 21 patients had an improvement in nausea, and 23 patients had an improvement in QOL at both 4 and 8 weeks, and there was an improvement in general activity, mood, work, walking, and enjoyment at 8 weeks. There were no grade III or IV treatment-related toxicities in patients receiving MA or the combination of MA plus OLN.

CONCLUSIONS

The combination of MA and OLN appears to be an effective intervention for patients with CRA.

Cancer cachexia: medical management

BACKGROUND

Cachexia is a complex metabolic syndrome associated with many chronic or end-stage diseases, especially cancer, and is characterized by loss of muscle with or without loss of fat mass. The management of cachexia is a complex challenge that should address the different causes underlying this clinical event with an integrated or multimodal treatment approach targeting the different factors involved in its pathophysiology.

MATERIALS AND METHODS

The purpose of this article was to review the current medical treatment of cancer-related cachexia, in particular focusing on combination therapy and ongoing research.

RESULTS

Among the treatments proposed in the literature for cancer-related cachexia, some proved to be ineffective, namely, cyproheptadine, hydrazine, metoclopramide, and pentoxifylline. Among effective treatments, progestagens are currently considered the best available treatment option for cancer-related cachexia, and they are the only drugs approved in Europe. Drugs with a strong rationale that have failed or have not shown univocal results in clinical trials so far include eicosapentaenoic acid, cannabinoids, bortezomib, and anti-TNF-alpha MoAb. Several emerging drugs have shown promising results but are still under clinical investigation (thalidomide, selective cox-2 inhibitors, ghrelin mimetics, insulin, oxandrolone, and olanzapine).

CONCLUSIONS

To date, despite several years of co-ordinated efforts in basic and clinical research, practice guidelines for the prevention and treatment of cancer-related muscle wasting are lacking, mainly because of the multifactorial pathogenesis of the syndrome. From all the data presented, one can speculate that one single therapy may not be completely successful in the treatment of cachexia. From this point of view, treatments involving different combinations are more likely to be successful.