Evaluation of nutritional status in advanced metastatic cancer

Malnutrition in hospitalized cancer patients: A single-center, cross-sectional study in Southern Vietnam

Objectives

Malnutrition in cancer patients reduces response to chemotherapy, increases the hospitalization costs, hospital infections, and deaths. The aim of this study was to determine the prevalence, level of malnutrition, and its related factors in cancer patients at a local hospital in Southern Vietnam.

Methods

A descriptive cross-sectional study was performed on all 118 cancer patients who were undergoing inpatient treatment at Long An General Hospital, Vietnam from May to September 2020. Data were collected from patients by face-to-face interviewing using a subjective global assessment (SGA) and from medical records. Malnutrition is divided into three groups: SGA-A (normal), SGA-B (mild/moderate/suspected malnutrition), SGA-C (severe malnutrition). Multivariable logistic regression is used to identify factors related to malnutrition with statistical significance p < 0.05.

Results

Out of 118 participants, 72 (61.0%) were males and 84 (71.2%) aged ⩾60 years. The prevalence of malnutrition in cancer patients was 84.7% (100/118), in which 33% (39/118) were severe (SGA-C) and 51.7% (61/118) were mild-moderate (SGA-B). Pancreatic and lung cancers are the most malnourished. The results of multivariate logistic regression analysis showed that the factors related to malnutrition in cancer patients were gastrointestinal symptoms lasting 2 weeks (odds ratio: 6.10, 95% confidence interval: 1.12-33.35), patients with decreased motor function (odds ratio: 13.73, 95% confidence interval: 2.56-73.86), blood albumin <35 g/l (odds ratio: 6.42, 95% confidence interval: 1.54-26.82), and blood lymphocyte ⩽ 1700 cells/mm³ (odds ratio: 5.36, 95% confidence interval: 1.31-21.97).

Conclusions

There was a high proportion of malnutrition in cancer patients. Therefore, it is necessary to strengthen nutrition counseling and intervention for these patients, especially those that have prolonged gastrointestinal symptoms, reduced motor function, and low blood albumin or low blood lymphocytes.

Association between Nutritional Status and Treatment Response and Survival in Patients Treated with Immunotherapy for Lung Cancer: A Retrospective French Study

Simple Summary

It is estimated that 73% of advanced non-small cell lung cancers (NSCLC) will become malnourished and develop cachexia which is considered as an independent prognostic factor. Therefore, this study aimed to investigate the association between nutritional assessments and (i) immunotherapy efficacy, (ii) tolerance, and (iii) survival in patients with an advanced NSCLC stage of lung cancer treated with immunotherapy. In total, 67% of the 120 patients analysed were not malnourished, 20% presented with moderate malnutrition, and 13% presented with severe malnutrition. There was no significant link between the nutritional status and the toxicity of immunotherapy. However, severe malnutrition was significantly associated with treatment efficacy and with a lower survival rate. Malnutrition appears to have a negative impact in the case of immunotherapy, in contrast to a high body mass index, which seems to be protective. In addition to confirming the benefits of early and appropriate nutritional management, research must also focus on catabolism and the uncontrolled inflammatory mechanisms.

Abstract

Malnutrition is associated with a greater risk of morbidity and mortality and lower tolerance to chemotherapy. Our purpose was to study the association between nutritional status and the efficiency and tolerance of immunotherapy in non-small cell lung cancer (NSCLC). Nutritional and oncological data were reported at 2 months (M2) and 4 months (M4) after the initiation of immunotherapy (M0). The influence of nutritional status at M0 was estimated with the efficacy and toxicity of immunotherapy at M2 to M4. In total, 127 patients were included in the study, and nutritional status was estimated at M0 for 120 patients: 67% were not malnourished, 20% presented with moderate malnutrition, and 13% presented with severe malnutrition. There was no significant link between the nutritional status at M0 and the toxicity of immunotherapy at M2 and M4. However, severe malnutrition was significantly associated with treatment efficacy at M2 (p = 0.04) and with a lower survival rate with an HR (Hazard Ratio) = 2.32–95% C.I: 1.13–4.75 (p = 0.02). Furthermore, a monthly decrease of 1% of the weight had an HR = 1.17–95% C.I: 1.13–1.21 (p = 0.0001). Severe malnutrition and weight loss are independent factors associated with lower survival. Studies integrating the systemic detection of sarcopenia with a closer nutritional follow-up could highlight an improvement in survival.

Cannabinoid interventions for improving cachexia outcomes in cancer: a systematic review and meta-analysis

Cancer-associated cachexia (CAC) is a wasting syndrome characterized by involuntary weight loss and anorexia. Clear definition and diagnostic criteria for CAC are lacking, which makes it difficult to estimate its prevalence, to interpret research and to compare studies. There is no standard treatment to manage CAC, but previous studies support the use of cannabinoids for cachexia in other chronic diseases including HIV and multiple sclerosis. However, only a few randomized controlled trials (RCTs) and one meta-analysis of this intervention in cancer populations are available. Non-randomized studies of interventions (NRSIs) are often excluded from reviews due to variable methodology and potential for biases. This review aimed to consider NRSIs alongside RCTs to provide a complete summary of the available evidence that clinical decision makers could use in future investigations. Literature searches were conducted using three databases for relevant RCTs or NRSIs according to Cochrane methodology. Abstract and full texts of retrieved manuscripts were selected and retrieved by two investigators based on the PRISMA-A guidelines, and risk of bias and quality of evidence assessments were performed. Outcome data on weight, appetite, quality of life, performance status, adverse effects, and mortality were combined by narrative synthesis and meta-analysis where possible. Ten studies were included, four of which were RCTs and six NRSIs matching the eligibility criteria. Very low-quality evidence from meta-analysis suggested no significant benefits of cannabinoids for appetite compared with control (standardized mean difference: -0.02; 95% confidence interval: -0.51, 0.46; P = 0.93). Patient-reported observations from NRSIs suggested improvements in appetite. Another meta-analysis of moderate quality evidence showed that cannabinoids were significantly less efficient than active or inactive control on quality of life (standardized mean difference: -0.25; 95% confidence interval: -0.43, -0.07; P = 0.007). The effectiveness of cannabinoids alone to improve outcomes of CAC remains unclear. Low-quality evidence from both RCTs and NRSIs shows no significant benefits of cannabinoids for weight gain, appetite stimulation, and better quality of life, three important outcomes of cachexia. Higher quality research integrating cannabinoids into multi-modal therapies may offer better opportunities for developing CAC-specific treatments. This review also highlights that findings from non-randomized studies of interventions (NRSIs) can provide evidence of the effects of an intervention and advocate for the feasibility of larger RCTs.

Individual Differences in Chemosensory Perception Amongst Cancer Patients Undergoing Chemotherapy: A Narrative Review

Chemotherapy is an aggressive form of treatment for cancer and its toxicity directly affects the eating behavior of many patients, usually by adversely affecting their sense of smell and/or taste. These sensory alterations often lead to serious nutritional deficiencies that can jeopardize the patient's recovery, and even continue to affect their lives once treatment has terminated. Importantly, however, not all patients suffer from such alterations to their chemical senses; and those who do, do not necessarily describe the side effects in quite the same way, nor suffer from them with equal intensity. The origin of these individual differences between cancer patients undergoing chemotherapy treatment has not, as yet, been studied in detail. This review is therefore designed to encourage future research that can help to address the perceptual/sensory problems (and the consequent malnutrition) identified amongst this group of patients in a more customized/personalized manner. In particular, by providing an overview of the possible causes of these large individual differences that have been reported in the literature. For this reason, in addition to the narrative bibliographic review, several possible strategies that could help to improve the chemosensory perception of food are proposed.

Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population

Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.

The Clinical Value of Nutritional Care before and during Active Cancer Treatment

Malnutrition and muscle wasting are frequently reported in cancer patients, either linked to the tumor itself or caused by oncologic therapies. Understanding the value of nutritional care during cancer treatment remains crucial. In fact, cancer-associated sarcopenia plays a key role in determining higher rates of morbidity, mortality, treatment-induced toxicities, prolonged hospitalizations and reduced adherence to anticancer treatment, worsening quality of life and survival. Planning baseline screening to intercept nutritional troubles earlier, organizing timely reassessments, and providing adequate counselling and dietary support, healthcare professional may positively interfere with this process and improve patients' overall outcomes during the whole disease course. Several screening tools have been proposed for this purpose. Nutritional Risk Screening (NRS), Mini Nutritional Assessment (MNA), Patient Generated Subjective Global Assessment (PG-SGA) are the most common studied. Interestingly, second-level tools including skeletal muscle index (SMI) and bioelectric impedance analysis (BIA) provide a more precise assessment of body composition, even if they are more complex. However, nutritional assessment is not currently used in clinical practice and procedures must be standardized in order to improve the efficacy of standard chemotherapy, targeted agents or even checkpoint inhibitors that is potentially linked with the patients' nutritional status. In the present review, we will discuss about malnutrition and the importance of an early nutritional assessment during chemotherapy and treatment with novel checkpoint inhibitors, in order to prevent treatment-induced toxicities and to improve survival outcomes.

Should Loss of Appetite Be Palliated in Patients with Advanced Cancer?

Loss of appetite is common among patients with advanced cancer. However, it remains controversial how, when, and if to palliate this symptom. Here, we provide an update on recent as well as past literature to address the question of whether loss of appetite should be palliated in patients with advanced cancer. In our opinion—and as discussed here—we believe that this symptom should be palliated, although perhaps not always with pharmacologic interventions.

Olfaction and Changes in Body Composition in a Large Cohort of Older U.S. Adults

BACKGROUND

Poor sense of smell in older adults may lead to weight loss, which may further contribute to various adverse health outcomes. However, empirical prospective evidence is lacking. We aimed to longitudinally assess whether poor olfaction is associated with changes in body composition among older adults.

METHODS

A total of 2,390 participants from the Health ABC Study had their olfaction assessed using the Brief Smell Identification Test in 1999-2000. Based on the test score, olfaction was defined as poor (0-8), moderate (9-10), or good (11-12). Total body mass, lean mass, and fat mass were measured by dual-energy X-ray absorptiometry annually or biennially from 1999 to 2007.

RESULTS

At baseline, compared to participants with good olfaction, those with poor olfaction weighed on average 1.67 kg less (95% CI: -2.92, -0.42) in total mass, 0.53 kg less (95% CI: -1.08, 0.02) in lean mass, and 1.14 kg less (95% CI: -1.96, -0.31) in fat mass. In longitudinal analyses, compared to participants with good olfaction, those with poor olfaction had a greater annual decline in both total mass (-234 g, 95% CI: -442, -26) and lean mass (-139 g, 95% CI: -236, -43). They also tended to have a greater annual loss of fat mass (-113 g, 95% CI: -285, 59), but the difference was not statistically significant.

CONCLUSIONS

Our results indicate poor olfaction is associated with lower body weight and greater weight loss in older adults. It is imperative for future studies to investigate potential underlying mechanisms and associated adverse health consequences.

Revisiting the clinical usefulness of C-reactive protein in the set of cancer cachexia

Cancer cachexia is a highly complex multifactorial disorder that is often misdiagnosed, leading to suboptimal health outcomes. Indeed, cachexia is a concern in cancer, typifying lower response to treatment and risk of death. Thus, efforts have been made to better understand the molecular basis of this syndrome, envisioning to improve its diagnosis and management.

C-reactive protein (CRP) has been reported to be consistently increased in the circulation of patients with body wasting associated to chronic diseases. However, the role of CRP in the pathogenesis of cachexia remains elusive. Several hypotheses have been advanced but most of experimental findings support an indirect effect on the activation of muscle proteolysis, mostly through its interplay with pro-inflammatory cytokines. Herein, we overview the contribution of CRP to body wasting and its putative biomarker value for the diagnosis and follow-up of the therapeutic management of cachexia.

An individualized food-based nutrition intervention reduces visceral and total body fat while preserving skeletal muscle mass in breast cancer patients under antineoplastic treatment

BACKGROUND & AIMS

Breast cancer patients (BCP) during treatment often experience an increase in body weight and fat mass, and a decrease in muscle mass known as sarcopenic obesity, affecting their prognosis and quality of life. We aimed to evaluate the effect of a 6-month individualized food-based nutrition intervention program in nonmetastatic BCP body composition during treatment.

METHODS

This is a pre-post study in recently diagnosed women with invasive ductal/lobular breast carcinoma (clinical stage I-III). The individualized nutrition intervention was based on the dynamic macronutrient meal equivalent menu method (MEM). Dietary plans were developed according to WCRF/AICR guidelines, BCP total energy expenditure, 1.2-1.5 g/kgBW/d of protein intake, 5-9 servings/day of fruits and vegetables, and a caloric restriction (500-1000 kcal/d) when applicable (BMI ≥ 25 kg/m²). Follow-up was every 2-weeks and a different diet menu was provided in each session during 6 months. Baseline and final measurements included the assessment of anthropometry, body composition, and physical activity.

RESULTS

Twenty-two participants completed the study and at diagnosis 68% were overweighed or obese. After the 6-month nutrition intervention program, BCP lost 3.1 kg (p < 0.01) of body weight, 2.7 kg (p < 0.01) of fat-mass, 400 g (p < 0.01) of abdominal fat, 118 g (p < 0.05) of visceral fat, 1.2 kg/m² of body mass index and 1.1 kg/m² of fat mass index (p < 0.01). During the period, no changes were observed in bone mineral density (p = 0.3), fat-free mass (p = 0.1) and appendicular skeletal muscle mass (p = 0.2). Menopausal status in BCP did not modify the effect of the nutrition intervention.

CONCLUSIONS

The individualized food-based nutrition intervention program empowered BCP to make informed healthy food choices within their personal preferences, socioeconomic and cultural background. With this type of intervention, nonmetastatic BCP reduced body weight, fat-mass, fat mass index, visceral and abdominal fat, while preserving skeletal muscle mass, during antineoplastic treatment. ClinicalTrials.govNCT03625635.

Assessment of malnutrition by unintentional weight loss and its implications on oncologic outcomes in patient with locally advanced cervical cancer receiving primary chemoradiation

OBJECTIVES

To determine the prevalence, risk factors for, and clinical implications of unintentional weight loss on oncologic outcomes in locally advanced cervical cancer (LACC) treated with concurrent chemotherapy and contemporary radiation techniques.

METHODS

This a single-institution, retrospective cohort study of patients with LACC who received definitive chemoradiation (CRT) from 2010 to 2015. Clinicopathologic factors were abstracted by chart review and characterized using descriptive statistics. Factors associated with severe weight loss (≥10% from baseline) were determined by Chi-square test. Time-to-event analysis was performed using the Kaplan Meier method and regression was performed using the Cox Proportional hazards model.

RESULTS

One hundred and eight patients comprised the cohort. The majority of patients were White, obese, and had squamous histology. Almost 80% of patients experienced at least some weight loss, with 14% of patients experiencing severe weight loss. Patients with FIGO 2009 stage 3 or 4 disease had a 3.4-fold increased risk of severe weight loss compared to those with earlier stage disease. Patients who had severe weight loss had a higher risk for death (HR = 2.37, 95% confidence interval [CI] 1.77, 7.37, p = 0.036) and a trend toward high risk for recurrence (HR = 1.43, 95% CI 0.46, 3.32, p = 0.107) compared to patients without severe weight loss.

CONCLUSION

Unintentional weight loss is a common symptom of patients with LACC receiving CRT that affects oncologic outcomes, yet it remains under-recognized. Increased awareness of weight loss and malnutrition may encourage interventions to improve this potentially modifiable risk factor for worse prognosis and quality of life.

Cancer cachexia has many symptoms but only one cause: anoxia

During nearly 100 years of research on cancer cachexia (CC), science has been reciting the same mantra: it is a multifactorial syndrome. The aim of this paper is to show that the symptoms are many, but they have a single cause: anoxia. CC is a complex and devastating condition that affects a high proportion of advanced cancer patients. Unfortunately, it cannot be reversed by traditional nutritional support and it generally reduces survival time. It is characterized by significant weight loss, mainly from fat deposits and skeletal muscles. The occurrence of cachexia in cancer patients is usually a late phenomenon. The conundrum is why do similar patients with similar tumors, develop cachexia and others do not? Even if cachexia is mainly a metabolic dysfunction, there are other issues involved such as the activation of inflammatory responses and crosstalk between different cell types.  The exact mechanism leading to a wasting syndrome is not known, however there are some factors that are surely involved, such as anorexia with lower calorie intake, increased glycolytic flux, gluconeogenesis, increased lipolysis and severe tumor hypoxia. Based on this incomplete knowledge we put together a scheme explaining the molecular mechanisms behind cancer cachexia, and surprisingly, there is one cause that explains all of its characteristics: anoxia.  With this different view of CC we propose a treatment based on the physiopathology that leads from anoxia to the symptoms of CC.  The fundamentals of this hypothesis are based on the idea that CC is the result of anoxia causing intracellular lactic acidosis. This is a dangerous situation for cell survival which can be solved by activating energy consuming gluconeogenesis. The process is conducted by the hypoxia inducible factor-1α. This hypothesis was built by putting together pieces of evidence produced by authors working on related topics.

The Effects of Dosage-Controlled Cannabis Capsules on Cancer-Related Cachexia and Anorexia Syndrome in Advanced Cancer Patients: Pilot Study

Background: Cancer-related cachexia and anorexia syndrome (CACS) is a common phenomenon in cancer patients. Cannabis has been suggested to stimulate appetite but research on this issue has yielded mixed results. The current study aimed to evaluate the effect of dosage-controlled cannabis capsules on CACS in advanced cancer patients. Methods: The cannabis capsules used in this study contained two fractions of oil-based compounds. The planned treatment was 2 × 10 mg per 24 hours for six months of tetrahydrocannabinol (THC) 9.5 mg and cannabidiol (CBD) 0.5 mg. If patients suffered from side effects, dosage was reduced to 5 mg × 2 per day (THC 4.75 mg, CBD 0.25 mg). Participants were weighed on every physician visit. The primary objective of the study was a weight gain of ≥10% from baseline. Results: Of 24 patients who signed the consent form, 17 started the cannabis capsules treatment, but only 11 received the capsules for more than two weeks. Three of six patients who completed the study period met the primary end-point. The remaining three patients had stable weights. In quality of life quaternaries, patients reported less appetite loss after the cannabis treatment (p=0.05). Tumor necrosis factor-α (TNF-α) levels decreased after the cannabis treatment but without statistical significance. According to patients’ self-reports, improvement in appetite and mood as well as a reduction in pain and fatigue was demonstrated. Conclusions: Despite various limitations, this preliminary study demonstrated a weight increase of ≥10% in 3/17 (17.6%) patients with doses of 5mgx1 or 5mgx2 capsules daily, without significant side effects. The results justify a larger study with dosage-controlled cannabis capsules in CACS.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Impact of taste and smell training on taste disorders during chemotherapy - TASTE trial

PURPOSE

Two-thirds of cancer patients report taste disorders during and after chemotherapy. Taste disorders impact on nutritional status which is highly relevant for treatment efficacy and overall prognosis. Improvement of taste disorder is of particular importance for cancer patients' outcomes, thus the TASTE trial was conducted to improve taste disorders with a taste and smell training.

METHODS

In this trial, patients undergoing chemotherapy were screened for taste disorders. Subsequently, patients were allocated based on the detection of taste disorders (≤8 taste strips points) to an intervention group with a taste and smell training at baseline and week 3-5 or were only followed up, if no taste disorder was detected (≥9 taste strips points) (non-intervention group). At baseline, all patients received a nutritional counseling. The primary endpoint was the minimal clinically relevant improvement of taste strips score by 2 taste strips points in at least 50% of the patients with taste disorders.

RESULTS

The trial included 62 patients (48 women [77%], 14 male [23%], age 54.5±11.6 years) who had gastrointestinal (n=29), breast (n=31), or lung cancer (n=2). Taste disorders were more frequent in gastrointestinal than in breast cancer patients. Out of 62 patients screened, 30 patients showed taste disorders. The primary endpoint was met with 92% (n=23 of 25) of the patients completing the intervention. In the intervention group, the patients' taste significantly improved from baseline (median taste strips: 7.0 points) to week 12 (median taste strips: 10.0 points) (P≤0.001). Patients of the non-intervention group who completed the reassessment (n=27 of 32) experienced no change in taste perception in the 3-month follow-up (P=0.897).

CONCLUSION

Intensified nutritional counseling with taste and smell training may improve taste perception of patients undergoing chemotherapy. A confirmatory randomized trial is planned.

Hypoalbuminemia as an Independent Risk Factor for Perioperative Complications Following Surgical Decompression of Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Malnutrition has been shown to be a risk factor for poor perioperative outcomes in multiple surgical subspecialties, but few studies have specifically investigated the effect of hypoalbuminemia in patients undergoing operative treatment of metastatic spinal tumors. The aim of this study was to assess the role of hypoalbuminemia as an independent risk factor for 30-day perioperative mortality and morbidity after surgical decompression of metastatic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.

METHODS

We identified 1498 adult patients in the ACS-NSQIP database who underwent laminectomy and excision of metastatic extradural spinal tumors. Patients were categorized into normoalbuminemic and hypoalbuminemic (ie, albumin level <3.5 g/dL) groups. Univariate and multivariate regression analyses were performed to examine the association between preoperative hypoalbuminemia and 30-day perioperative mortality and morbidity. Subgroup analysis was performed in the hypoalbuminemic group to assess the dose-dependent effect of albumin depletion.

RESULTS

Hypoalbuminemia was associated with increased risk of perioperative mortality, any complication, sepsis, intra- or postoperative transfusion, prolonged hospitalization, and non-home discharge. However, albumin depletion was also associated with decreased risk of readmission. There was an albumin level-dependent effect of increasing mortality and complication rates with worsening albumin depletion.

CONCLUSIONS

Hypoalbuminemia is an independent risk factor for perioperative mortality and morbidity following surgical decompression of metastatic spinal tumors with a dose-dependent effect on mortality and complication rates. Therefore, it is important to address malnutrition and optimize nutritional status prior to surgery.

Amikacin Pharmacokinetics in Terminal Stage of Hematological Malignancy

BACKGROUND

The influence of cancer cachexia on the pharmacokinetics of and kidney injury caused by amikacin remains unclear. This study investigated whether the pharmacokinetics of amikacin and the risk of kidney injury are altered with the progression of cancer cachexia.

METHODS

A retrospective analysis was conducted using therapeutic drug monitoring data obtained from 52 cancer patients who received amikacin intravenously for infection(s). The patients were classified into 2 groups based on the status of cachexia using a consensus definition: noncachexia group (n = 31) and cachexia group (n = 21). Differences in amikacin pharmacokinetics and occurrence of kidney injury were compared between the 2 groups. Amikacin pharmacokinetics was calculated based on a 1-compartment model using peak and trough concentrations measured clinically for therapeutic drug monitoring. In addition, intrapatient analysis was conducted based on patients who received amikacin treatments more than once during the study period to examine the alteration in amikacin pharmacokinetics with the progression of cancer cachexia.

RESULTS

Systemic clearance of amikacin [median (range)] was significantly (P < 0.05) lower in the cachexia group [37.3 (11.2-87.3) (mL/min)] than in the noncachexia group [52.0 (19.1-133.4) (mL/min)]. In contrast, volume of distribution was significantly (P < 0.05) increased in the cachexia group [0.47 (0.20-1.45) L/kg] compared with the noncachexia group [0.32 (0.21-1.00) L/kg]. There was no difference in the occurrence of kidney injuries between the 2 groups. In an intrapatient analysis of the longitudinal alteration of amikacin pharmacokinetics, an approximately 50% reduction in clearance and 30% increase in volume of distribution were observed as cancer cachexia progressed.

CONCLUSIONS

The present study suggests that progression of cancer cachexia may reduce amikacin clearance and increase the volume of distribution, but cancer cachexia does not increase amikacin-induced kidney injury.

Nutrition Impact Symptoms Are Prognostic of Quality of Life and Mortality after Surgery for Oesophageal Cancer

We aimed to clarify the influence of nutritional problems after surgery for oesophageal cancer on functional health related quality of life (HRQOL) and survival. A prospective nationwide cohort of oesophageal cancer patients operated 2001–2005 in Sweden with 6 months postoperative follow up was used. Nutritional problems were categorized as low/moderate/severe/very severe based on weight loss and nutrition impact symptoms. An ANCOVA model calculated mean score differences (MD) with 95% confidence intervals (CI) of global quality of life (QOL), social and physical function scores, stratified by preoperative body mass index (BMI) <25 and ≥25. A Cox proportional hazards model produced hazard ratios (HR) with 95% CI for overall 5-year survival. Of 358 patients, 196 (55%) had preoperative BMI ≥25. Very severe and severe nutritional problems were associated with worse HRQOL in both BMI groups. E.g. MD’s for global QOL among ‘very severe’ group was −29 (95% CI −39–−19) and −20 (95% CI −29–−11) for <25 and ≥25 BMI, respectively, compared to the ‘low’ group. Overall 5-year survival among ‘very severe’ and BMI ≥ 25 was worse; HR 4.6 (95% CI 1.4–15.6). Intense nutritional problems negatively impact postoperative HRQOL and combined with preoperative BMI ≥ 25 are associated with poorer 5-year overall survival representing a group needing greater clinical attention.

Cancer cachexia: rationale for the MENAC (Multimodal-Exercise, Nutrition and Anti-inflammatory medication for Cachexia) trial

Cancer cachexia is a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass that cannot be fully reversed by conventional nutritional support alone. Cachexia has a high prevalence in cancer and a major impact on patient physical function, morbidity and mortality. Despite the consequences of cachexia, there is no licensed treatment for cachexia and no accepted standard of care. It has been argued that the multifactorial genesis of cachexia lends itself to therapeutic targeting through a multimodal treatment. Following a successful phase II trial, a phase III randomised controlled trial of a multimodal cachexia intervention is under way. Termed the MENAC trial (Multimodal-Exercise, Nutrition and Anti-inflammatory medication for Cachexia), this intervention is based on evidence to date and consists of non-steroidal anti-inflammatory drugs and eicosapentaenoic acid to reduce inflammation, a physical exercise programme using resistance and aerobic training to increase anabolism, as well as dietary counselling and oral nutritional supplements to promote energy and protein balance. Herein we describe the development of this trial.

TRIAL REGISTRATION NUMBER

NCT02330926.

Serum C-reactive protein is an important and powerful prognostic biomarker in most adult solid tumors

INTRODUCTION

Prognostication in cancer is challenging and inaccurate. C-Reactive Protein (CRP), a cheap and sensitive marker of inflammation may help. This study investigated the relationship between CRP and prognosis in a large cohort of solid tumors with mixed cancer diagnoses and stages.

METHODS

Electronic medical records of 4931 adults with solid tumors who attended the Taussig Cancer Institute from 2006-2012 were reviewed. Demographic and clinical characteristics were recorded. Maximum CRP (mCRP) was identified for each individual. CRP was analysed as a time-dependent, continuous and categorical variable for association with survival.

RESULTS

Two thirds of patients had a high mCRP. This was consistently associated with shorter survival, even after correction for time from diagnosis, and when analysed as a continuous or a categorical variable. When mCRP values above 10 mg/L were subcategorized, a higher mCRP was always worse. Even among those with normal values, statistically and clinically significant shorter survival was noted at mCRP levels >5 mg/L.

CONCLUSIONS

In a large representative cohort of consecutive solid tumor patients the risk of death was clinically and statistically significantly greater with a high mCRP. This was independent of other variables and regardless of statistical method from both dates of diagnosis and test. CRP appeared to be underutilized. Our results support the routine use of CRP as a universal cost-effective independent prognostic indicator in most solid tumors.

Nutritional status and interventions in hospice: physician assessment of cancer patients

BACKGROUND

Cancer cachexia is a multifactorial syndrome characterised by a progressive loss of skeletal muscle mass. It adversely influences quality of life, treatment response and survival. Early identification and multimodal interventions can potentially treat cancer cachexia. However, healthcare professionals demonstrate a lack of understanding and the ability to identify cancer cachexia early. The present study aimed to evaluate the assessment by physicians of nutritional status in cancer patients admitted to hospice.

METHODS

A retrospective medical record review was conducted on all cancer admissions to a specialist in-patient palliative care unit over a 4-month period between October 2016 and January 2017. Charts were reviewed for evidence of documented nutritional assessment by physicians. Data were collected from the referral letter, admission notes, drug kardex and discharge letter. The information extracted included: (i) patient demographics and characteristics; (ii) terms used by physicians to describe nutritional status; (iii) any record of nutritional impact symptoms (NIS) experienced by the patient; and (iv) nutritional interventions prescribed.

RESULTS

One hundred and forty admissions were evaluated. Nutritional terminology and NIS were most commonly documented on the admission notes. Only 41% of documents recorded any nutritional term used by physicians to assess nutritional status. Furthermore, 71% of documents recorded at least one NIS experienced by the patient. Fatigue was the most frequent NIS.

CONCLUSIONS

We identified an inadequate nutritional assessment of cancer patients admitted to hospice. Implementation of a nutritional symptom checklist and nutrition screening tools, along with enhanced physician education and multidisciplinary nutrition care, could improve the identification and management of cancer cachexia in the palliative care setting.

Prevalence and Implications of Abnormal Laboratory Results in Patients in the Terminal Phase of Life

BACKGROUND

Pathophysiological changes at the end of life may affect pharmacokinetics of drugs. However, caregivers typically do not extensively monitor patients' laboratory parameters at the end of life.

OBJECTIVE

Our aim was to describe laboratory parameters of hospice patients in the week before death.

METHODS

A cohort study was conducted on available laboratory results in the week before death, including clinical chemistry and hematology tests.

RESULTS

Laboratory data of 125 patients in a palliative care center were included, assessed at a median of 3 days before death. Eighty percent of patients had anemia and almost all had hypoalbuminemia (97%). Elevated levels of gamma-glutamyl transferase (gGT) were found in 75%, of alkaline phosphatase (ALP) in 60%, of aspartate aminotransferase (ASAT) in 60%, and of calcium (Ca) in 68%. Alanine aminotransferase (ALAT), bilirubin, sodium (Na), and potassium (K) were abnormal in from 8.8% to 36.0% of patients. A previous unknown poor kidney function was found in 60% of patients. Thirteen patients (22%) with a regular morphine prescription and one patient treated with a non-steroidal anti-inflammatory drug (NSAID) had severe kidney failure.

CONCLUSIONS

Abnormal laboratory results were expected due to the pathophysiological changes that occur during the last phase of life. Remarkably, however, electrolytes (Na and K) were balanced even shortly before death. Estimated glomerular filtration rate (eGFR), reflecting the kidney function, seems the most clinically relevant laboratory parameter, because it may guide drug choice and dosing.

Prevalence of low body mass index among newly diagnosed lung cancer patients in North India and its association with smoking status

There is limited data from South Asia on the prevalence of low body mass index (BMI) among newly diagnosed lung cancer patients at presentation and its association with smoking status. A retrospective analysis of a prospective cohort of newly diagnosed lung cancer patients is presented here. Patients were categorized as normal/overweight (BMI ≥ 18.50 kg/m² ; group I), mild/moderately underweight (BMI = 16.00-18.49 kg/m² ; group II) or severely underweight (BMI < 16.0 kg/m² ; group III). Smoking status was assessed using the smoking index (SI; product of number of bidis/cigarettes smoked per day with number of years smoked). Based on the SI, patients were categorized as never-smokers, light/moderate smokers [SI = 1-300] and heavy smokers [SI ≥ 301]. A low BMI was present in 155 (44.3%) patients. Compared to group I, patients in groups II and III had higher percentages of men and current/ex-smokers. On univariate logistic regression analysis (LRA), SI = 1-300 [odds ratio (OR) = 2.75; 95% confidence intervals (CI) = 1.27-5.97] and SI ≥ 301 [OR = 4.57; 95% CI = 2.20-9.49] were associated with higher odds of the presence of low BMI among non-small cell lung cancer (NSCLC) patients while female sex had lower odds [OR = 0.34; 95% CI = 0.16-0.72]. On multivariate LRA, only SI ≥ 301 [OR = 3.74; 95% CI = 1.59-8.80] had a significant association with occurrence of low BMI. Low BMI is common among newly diagnosed lung cancer patients in North India. Heavy smoking is independently associated with presence of low BMI at presentation among NSCLC patients.

The impact of preoperative elevated serum C-reactive protein on postoperative morbidity and mortality after anatomic resection for lung cancer

INTRODUCTION

The aim of this study was to determine whether preoperative elevated serum C-reactive protein (CRP) is an independent risk factor of postoperative morbidity and mortality after pulmonary resection for lung cancer.

MATERIAL AND METHODS

A retrospective analysis of prospectively collected data on 1414 consecutive patients that underwent an anatomic resection for lung cancer was performed. Patients' characteristics, operative procedures and the postoperative outcome were assessed with a standardised data entry form. Univariate and multivariate analyses were conducted to identify factors that affect morbidity and mortality.

RESULTS

Postoperative complications occurred in 35.5% of the patients. The mortality rate was 3.2%. Patients with preoperative C-reactive protein above 40mg/l showed more overall complications and a higher mortality than patients below this limit. Patients with a CRP level between 3mg/l and 40mg/l had no significant increase in morbidity and mortality compared to patients with values ​​below the detection limit (< 3mg/l).

CONCLUSIONS

Preoperative serum C-reactive protein level is an independent and significant indicator for elevated morbidity and mortality after pulmonary resection. We propose the evaluation of CRP levels as a preoperative diagnostic modality of risk assessment in addition to standardised functional testing.

Ω-3 Fatty Acid Supplements for Cancer-Associated Weight Loss

Omega-3 fatty acids have been tested for the treatment of cancer anorexia/weight loss, a syndrome that predicts a poor prognosis among cancer patients with incurable disease. This review focuses on both the preclinical and clinical data of omega-3 fatty acids for treating this syndrome. Overall, the promise of the former does not seem to be borne out completely in the latter. This review includes a discussion of how these data might be interpreted and explained to cancer patients who are striving to cope with this syndrome.

The Relationship between Sarcopenia and Systemic Inflammatory Response for Cancer Cachexia in Small Cell Lung Cancer

BACKGROUND

The prognostic significance of sarcopenia, an important component of cancer cachexia, has been demonstrated in oncologic patients. Catabolic drivers have been suggested to be key features of cancer cachexia.

OBJECTIVE

To determine the relationship between systemic inflammatory markers and CT-determined muscle mass in patients with SCLC.

METHODS

Cross-sectional muscle areas were evaluated at the level of the third lumbar vertebra (L3) using baseline CT images in 186 SCLC patients. Sarcopenia was defined as a L3 muscle index (L3MI, muscle area at L3/height2) of < 55 cm2/m2 for men and of < 39 cm2/m2 for women. Systemic inflammatory markers investigated included serum white blood cell count (WBC), neutrophil: lymphocyte ratio (NLR), C-reactive protein (CRP), and albumin.

RESULTS

Mean L3MI was 47.9 ± 9.7 cm2/m2 for men and 41.6 ± 7.0 cm2/m2 for women. Sarcopenia was present in 128 patients (68.8%), and sarcopenic patients had significant serum lymphocyte counts and albumin levels (p = 0.002 and 0.041, respectively), and higher NLRs and CRP levels (p = 0.011 and 0.026) than non-sarcopenic patients. Multivariable analysis revealed that CRP independently predicted L3MI (β = -0.208; 95% CI, -0.415 to -0.002; p = 0.048), along with gender and BMI (p values < 0.001) and performance status (p = 0.010).

CONCLUSION

The present study confirms a significant linear relationship exists between CT-determined muscle mass and CRP in SCLC patients. This association might provide a better understanding of the mechanism of cancer cachexia.

Muscle wasting as main evidence of energy impairment in cancer cachexia: future therapeutic approaches

The present review aimed at discussing the impact, pathogenesis and therapeutic approaches of muscle wasting, which is a major clinical feature of cancer-related cachexia syndrome. The pathogenesis of muscle wasting in cancer cachexia lies in a discrepancy between anabolic and catabolic pathways mediated by chronic inflammation. Effective interventions specifically aimed at hampering muscle loss and enhancing muscle function are still lacking. Promising agents include anti-inflammatory, orexigenic and anabolic drugs, alongside with nutritional supplements that influence the STAT3 and PI3K/Akt/mTOR pathways involved in muscle wasting. Personalized physical activity combined with pharmacological and nutritional support hold promise. A greater understanding of the pathogenetic processes of cancer cachexia-related muscle wasting will enable the development of an early and effective targeted mechanism-based multimodal approach.

Liposomal treatment of xerostomia, odor, and taste abnormalities in patients with head and neck cancer

BACKGROUND

Smell and taste disorders, sicca symptoms, can be detected in patients with head and neck cancer. The purpose of this study was to assess the utility of local liposomal application in the treatment of patients with head and neck cancers.

METHODS

Ninety-eight patients with head and neck cancer were included in this study. The groups were defined as: group 1 = only surgery; group 2 = surgery + adjuvant radiochemotherapy; and group 3 = primarily radiochemotherapy. All patients had finished cancer treatment and received liposomal sprays for the nose and mouth for 2 months (LipoNasal, LipoSaliva; Optima Pharmaceutical GmbH, Germany) and suffered from taste and smell disorders. We performed tests with "Sniffin' Sticks," "Taste Strips," and a xerostomia questionnaire before and after treatment.

RESULTS

After application of liposomes, patients demonstrated a statistically significant increase in smell and taste, and reduced xerostomia.

CONCLUSION

Our results demonstrate that using nonpharmaceutical liposomal sprays improve smell, taste, and symptoms of xerostomia in patients with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1232-E1237, 2016.

Association of sarcopenia and observed physical performance with attainment of multidisciplinary team planned treatment in non-small cell lung cancer: an observational study protocol

BACKGROUND

Non-small cell lung cancer (NSCLC) frequently presents in advanced stages. A significant proportion of those with reportedly good ECOG performance status (PS) fail to receive planned multidisciplinary team (MDT) treatment, often for functional reasons, but an objective decline in physical performance is not well described. Sarcopenia, or loss of muscle mass, is an integral part of cancer cachexia. However, changes in both muscle mass and physical performance may predate clinically overt cachexia, and may be present even with normal body mass index. Physical fitness for treatment is currently subjectively assessed by means of the PS score, which may be inadequate in predicting tolerance to treatment. This study aims to evaluate whether measuring physical performance and muscle mass at baseline in NSCLC patients, in addition to PS score, is able to predict commencement and successful completion of MDT-planned treatment.

METHODS/DESIGN

This is a prospective, single-centre exploratory study of NSCLC patients attending a Rapid Access Lung Cancer clinic. Baseline data collected are (methods in brackets): physical performance (Short Physical Performance Battery), muscle mass (bioelectrical impedance ± dual energy x-ray absorptiometry), patient and physician-assessed PS (ECOG and Karnofsky), nutritional status and presence of cachexia. Longitudinal data consists of receipt and completion of MDT treatment plan. The primary outcome measure is commencement of MDT-planned treatment, and important secondary outcomes include successful completion of treatment, length of stay in surgical patients, and risk of chemotherapy- and radiotherapy-related side effects.

DISCUSSION

A more comprehensive assessment of phenotype, particularly with regards to physical performance and muscle mass, will provide additional discriminatory information of patients' fitness for treatment. If positive, this study has the potential to identify targets for early intervention in those who are at risk of deterioration. This will subsequently enable optimisation of performance of patients with NSCLC, in anticipation of systemic treatment.

Differences in food intake of tumour-bearing cachectic mice are associated with hypothalamic serotonin signalling

BACKGROUND

Anorexia is a common symptom among cancer patients and contributes to malnutrition and strongly impinges on quality of life. Cancer-induced anorexia is thought to be caused by an inability of food intake-regulating systems in the hypothalamus to respond adequately to negative energy balance during tumour growth. Here, we show that this impaired response of food-intake control is likely to be mediated by altered serotonin signalling and by failure in post-transcriptional neuropeptide Y (NPY) regulation.

METHODS

Two tumour cachectic mouse models with different food intake behaviours were used: a C26-colon adenocarcinoma model with increased food intake and a Lewis lung carcinoma model with decreased food intake. This contrast in food intake behaviour between tumour-bearing (TB) mice in response to growth of the two different tumours was used to distinguish between processes involved in cachexia and mechanisms that might be important in food intake regulation. The hypothalamus was used for transcriptomics (affymetrix chips).

RESULTS

In both models, hypothalamic expression of orexigenic NPY was significantly higher compared with controls, suggesting that this change does not directly reflect food intake status but might be linked to negative energy balance in cachexia. Expression of genes involved in serotonin signalling showed to be different between C26-TB mice and Lewis lung carcinoma-TB mice and was inversely associated with food intake. In vitro, using hypothalamic cell lines, serotonin repressed neuronal hypothalamic NPY secretion while not affecting messenger NPY expression, suggesting that serotonin signalling can interfere with NPY synthesis, transport, or secretion.

CONCLUSIONS

Altered serotonin signalling is associated with changes in food intake behaviour in cachectic TB mice. Serotonins' inhibitory effect on food intake under cancer cachectic conditions is probably via affecting the NPY system. Therefore, serotonin regulation might be a therapeutic target to prevent the development of cancer-induced eating disorders.

Impact of mesothelioma histologic subtype on outcomes in the Surveillance, Epidemiology, and End Results database

BACKGROUND

This study was conducted to determine how malignant pleural mesothelioma (MPM) histology was associated with the use of surgery and survival.

METHODS

Overall survival of patients with stage I-III epithelioid, sarcomatoid, and biphasic MPM in the Surveillance, Epidemiology, and End Results database from 2004-2010 was evaluated using multivariate Cox proportional hazards models.

RESULTS

Of 1183 patients who met inclusion criteria, histologic subtype was epithelioid in 811 patients (69%), biphasic in 148 patients (12%), and sarcomatoid in 224 patients (19%). Median survival was 14 mo in the epithelioid group, 10 mo in the biphasic group, and 4 mo in the sarcomatoid group (P < 0.01). Cancer-directed surgery was used more often in patients with epithelioid (37%, 299/811) and biphasic (44%, 65/148) histologies as compared with patients with sarcomatoid histology (26%, 58/224; P < 0.01). Among patients who underwent surgery, median survival was 19 mo in the epithelioid group, 12 mo in the biphasic group, and 4 mo in the sarcomatoid group (P < 0.01). In multivariate analysis, surgery was associated with improved survival in the epithelioid group (hazard ratio [HR] 0.72; P < 0.01) but not in biphasic (HR 0.73; P = 0.19) or sarcomatoid (HR 0.79; P = 0.18) groups.

CONCLUSIONS

Cancer-directed surgery is associated with significantly improved survival for MPM patients with epithelioid histology, but patients with sarcomatoid and biphasic histologies have poor prognoses that may not be favored by operative treatment. The specific histology should be identified before treatment, so that surgery can be offered to patients with epithelioid histology, as these patients are most likely to benefit.

Baicalin, a component of Scutellaria baicalensis, alleviates anorexia and inhibits skeletal muscle atrophy in experimental cancer cachexia

Inflammatory responses are key contributors to cancer cachexia and foster a complex cascade of biological outcomes. Baicalin is a natural compound derived from Scutellaria baicalensis that possesses anti-inflammatory properties in many diseases; therefore, the aim of this study was to verify whether baicalin could ameliorate cachexia in a CT26 adenocarcinoma-induced model. Tumour-bearing and control mice were injected with CT26 adenocarcinoma cells and phosphate-buffered saline (PBS), respectively, and baicalin was administered intraperitoneally for 15 days. During the study, food intake, body weight, major organ weight, gastrocnemius muscle weight, tibialis muscle weight, epididymal fat weight and serum cytokine levels were measured and evaluated. Additionally, the expression of two E3 ubiquitin ligases and NF-κB pathway proteins were detected by Western blot. The total food intake in tumour-bearing mice receiving baicalin from days 1-16, as well as the average food intake on days 10-16, were less than normal but were significantly higher than in vehicle-treated tumour-bearing mice. Loss of tumour-free body mass in vehicle-treated tumour-bearing mice was significantly increased compared with control mice and tumour-bearing mice receiving baicalin. Serum cytokines, including tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6), were lowered in tumour-bearing mice treated with baicalin. Gastrocnemius muscle, epididymal fat, heart and kidney weight were significantly greater in the baicalin treatment groups compared with the vehicle-treated tumour-bearing mice. In addition, the expression of two E3 ubiquitin ligases, as well as phospho-p65, was significantly downregulated, whereas the expression of IκBα was up-regulated in tumour-bearing mice treated with baicalin, as determined by Western blotting. The present study demonstrates that baicalin effectively ameliorates anorexia by inhibiting cytokine expression and prevents skeletal muscle atrophy most likely by inhibiting activation of NF-κB in an experimental cancer cachexia model, suggesting that baicalin represents a promising natural medicine for treating cancer-induced cachexia.

Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and the Malnutrition Screening Tool (MST) against the Patient-Generated Subjective Global Assessment (PG-SGA)

BACKGROUND

Oncology inpatients are at high risk of malnutrition. Identification of at risk patients by nutrition screening requires a practical and easy to use tool. In this study, we have compared a simple, novel nutrition screening tool designed for an oncology inpatient setting and the Malnutrition Screening Tool (MST) against the Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

This was an observational study to compare assessment of nutritional status by PG-SGA with nutrition screening using the Royal Marsden Nutrition Screening Tool (RMNST) and the MST. Patients were recruited from a single tertiary cancer centre.

RESULTS

One hundred and twenty-six oncology inpatients underwent a full nutritional assessment and nutrition screening. The PG-SGA tool identified 90 (71%) patients as malnourished or at risk and 36 (29%) patients as well-nourished. The RMNST had a sensitivity of 93% and a specificity of 53%, and the MST had a sensitivity of 66% and a specificity of 83 %. Predictive value (ROC AUC) of both screening tools was excellent at 0.84 and 0.83 for RMNST and MST, respectively.

CONCLUSIONS

This study identified a high prevalence of malnutrition in the population with 71% of patients being identified as malnourished or at risk of malnutrition. The RMNST had an excellent sensitivity for identifying patients who were malnourished or at risk of malnutrition in the inpatient setting although it had a poor specificity. The MST had a poorer sensitivity of 66 %. We would recommend that the RMNST is trialled in other oncology inpatient settings and also in the outpatient setting.

Weight loss, appetite loss and food intake in cancer patients with cancer cachexia: three peas in a pod? - analysis from a multicenter cross sectional study

BACKGROUND

How to assess cachexia is a barrier both in research and in clinical practice. This study examines the need for assessing both reduced food intake and loss of appetite, to see if these variables can be used interchangeably. A secondary aim is to assess the variance explained by food intake, appetite and weight loss by using tumor-related factors, symptoms and biological markers as explanatory variables.

MATERIAL AND METHODS

One thousand and seventy patients with incurable cancer were registered in an observational, cross sectional multicenter study. A total of 885 patients that had complete data on food intake (PG-SGA), appetite (EORTC QLQ-C30) and weight loss were included in the present analysis. The association between reduced food intake and appetite loss was assessed using Spearman's correlation. To find the explained variance of the three symptoms a multivariate analysis was performed.

RESULTS

The mean age was 62 years with a mean survival of 247 days and a mean Karnofsky performance status of 72. Thirteen percent of the patients who reported eating less than normal had good appetite and 25% who had unchanged or increased food intake had reduced appetite. Correlation between appetite loss and food intake was 0.50. Explained variance for the regression models was 44% for appetite loss, 27% for food intake and only 13% for weight loss.

CONCLUSION

Both appetite loss and food intake should be assessed in cachectic patients since conscious control of eating may sometimes overcome appetite loss. The low explained variance for weight loss is probably caused by the need for more knowledge about metabolism and inflammation, and is consistent with the cancer cachexia definition that claims that in cachexia weight loss is not caused by reduced food intake alone. The questions concerning appetite loss from EORTC-QLQ C30 and food intake from PG-SGA seem practical and informative when dealing with advanced cancer patients.

The assessment and impact of sarcopenia in lung cancer: a systematic literature review

OBJECTIVES

There is growing awareness of the relationship between sarcopenia (loss of muscle mass and function), and outcomes in cancer, making it a potential target for future therapies. In order to inform future research and practice, we undertook a systematic review of factors associated with loss of muscle mass, and the relationship between muscle function and muscle mass in lung cancer, a common condition associated with poor outcomes.

DESIGN

We conducted a computerised systematic literature search on five databases. Studies were included if they explored muscle mass as an outcome measure in patients with lung cancer, and were published in English.

SETTING

Secondary care.

PARTICIPANTS

Patients with lung cancer.

PRIMARY OUTCOME

Factors associated with loss of muscle mass and muscle function, or sarcopenia, and the clinical impact thereof in patients with lung cancer.

RESULTS

We reviewed 5726 citations, and 35 articles were selected for analysis. Sarcopenia, as defined by reduced muscle mass alone, was found to be very prevalent in patients with lung cancer, regardless of body mass index, and where present was associated with poorer functional status and overall survival. There were diverse studies exploring molecular and metabolic factors in the development of loss of muscle mass; however, the precise mechanisms that contribute to sarcopenia and cachexia remain uncertain. The effect of nutritional supplements and ATP infusions on muscle mass showed conflicting results. There are very limited data on the correlation between degree of sarcopenia and muscle function, which has a non-linear relationship in older non-cancer populations.

CONCLUSIONS

Loss of muscle mass is a significant contributor to morbidity in patients with lung cancer. Loss of muscle mass and function may predate clinically overt cachexia, underlining the importance of evaluating sarcopenia, rather than weight loss alone. Understanding this relationship and its associated factors will provide opportunities for focused intervention to improve clinical outcomes.

Cancer Prevention and Therapy: Integrating Traditional Korean Medicine Into Modern Cancer Care

In spite of billions of dollars spent on cancer research each year, overall cancer incidence and cancer survival has not changed significantly in the last half century. Instead, the recent projection from the World Health Organization suggests that global cancer incidence and death is expected to double within the next decade. This requires an "out of the box" thinking approach. While traditional medicine used for thousands of years is safe and affordable, its efficacy and mechanism of action are not fully reported. Demonstrating that traditional medicine is efficacious and how it works can provide a "bed to bench" and "bench to bed" back approach toward prevention and treatment of cancer. This current review is an attempt to describe the contributions of traditional Korean medicine (TKM) to modern medicine and, in particular, cancer treatment. TKM suggests that cancer is an outcome of an imbalance of body, mind, and spirit; thus, it requires a multimodal treatment approach that involves lifestyle modification, herbal prescription, acupuncture, moxibustion, traditional exercise, and meditation to restore the balance. Old wisdoms in combination with modern science can find a new way to deal with the "emperor of all maladies."

Hydration in advanced cancer: can bioelectrical impedance analysis improve the evidence base? A systematic review of the literature

CONTEXT

Decisions surrounding the administration of clinically assisted hydration to patients dying of cancer can be challenging because of the limited understanding of hydration in advanced cancer and a lack of evidence to guide health care professionals. Bioelectrical impedance analysis (BIA) has been used to assess hydration in various patient groupings, but evidence for its use in advanced cancer is limited.

OBJECTIVES

To critically appraise existing methods of hydration status assessment in advanced cancer and review the potential for BIA to assess hydration in advanced cancer.

METHODS

Searches were carried out in four electronic databases. A hand search of selected peer-reviewed journals and conference abstracts also was conducted. Studies reporting (de)hydration assessment (physical examination, biochemical measures, symptom assessment, and BIA) in patients with advanced cancer were included.

RESULTS

The results highlight how clinical examination and biochemical tests are standard methods of assessing hydration, but limitations exist with these methods in advanced cancer. Furthermore, there is disagreement over the evidence for some commonly associated symptoms with dehydration in cancer. Although there are limitations with using BIA alone to assess hydration in advanced cancer, analysis of BIA raw measurements through the method of bioelectrical impedance vector analysis may have a role in this population.

CONCLUSION

The benefits and burdens of providing clinically assisted hydration to patients dying of cancer are unclear. Bioelectrical impedance vector analysis shows promise as a hydration assessment tool but requires further study in advanced cancer. Innovative methodologies for research are required to add to the evidence base and ultimately improve the care for the dying.

Clinical evaluation and optimal management of cancer cachexia

Cancer anorexia-cachexia syndrome (CACS) is a complex metabolic syndrome, different from malnutrition and sarcopenia, which is very common in cancer patients. Treatment for CACS is based on nutritional support and CACS pathophysiology-modulating drugs. The most commonly used are megestrol acetate (MA) and corticosteroids. The efficacy of MA has been confirmed by multiple clinical trials and meta-analyses. Glucocorticoids are also effective but should only be used for short periods and in selected cases. Future strategies should include intensified research into potentially effective drugs (ω-3 fatty acids, thalidomide, cannabinoids, ghrelin, bortezomib, and COX-2 inhibitors), combined treatment and new drugs (anti-IL-6 monoclonal antibodies, melanocortin, β-2 antagonists, and androgen receptor-modulating analogues). We propose a review based on the literature on the pathophysiology of CACS, the diagnostic criteria and treatment, and future strategies.