Cancer cachexia: developing multimodal therapy for a multidimensional problem

The Global Leadership Initiative on Malnutrition (GLIM) inflammation criteria to predict survival in patients with advanced cancer: A prospective cohort study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria provides a framework for assessing cachexia in cancer patients. However, the role of systemic inflammation in this framework needs further exploration.

METHODS

This study analyzed a cohort of 388 advanced cancer patients from 18 oncological care settings. C-reactive protein (CRP), the modified Glasgow Prognostic Score (mGPS) and Neutrophil-to-Lymphocyte Ratio (NLR) were used to assess systemic inflammation. Associations between these inflammatory markers and Weight Loss (WL), Body Mass Index (BMI), Skeletal Muscle Index (SMI), and survival outcomes (OS) were evaluated using Chi-square and Kaplan-Meier survival analyses.

RESULTS

CRP was significantly associated with ECOG-PS (p < 0.01), and WL (p < 0.05). mGPS was significantly associated with ECOG-PS (p < 0.001), WL (p < 0.001), and BMI (p < 0.05). NLR was significantly associated with ECOG-PS (p < 0.05), WL (p < 0.001), and BMI (p < 0.05). CRP (p < 0.001), mGPS (p < 0.001), NLR (p < 0.001), WL (p < 0.001), and SMI (p < 0.05) were significantly associated with OS, but not BMI (p = 0.23). Combining CRP, mGPS, NLR, with WL, BMI, and SMI significantly improved OS prediction. WL was significantly associated with OS in patients with NLR<3 (p < 0.05) but not in CRP≤10 mg/L or mGPS = 0. SMI was significantly associated with OS in patients with mGPS = 0 (p < 0.05).

CONCLUSION

Systemic inflammation, as assessed by CRP, mGPS and NLR, significantly improves the relationship between phenotypic criteria and OS. These findings support the GLIM framework's inclusion of systemic inflammation as a critical factor. Given its strong predictive value, systemic inflammation should be prioritized in routine clinical assessments of cancer patients, with mGPS having greater prognostic value within the GLIM framework.

Multicomponent Interventions for Adults With Cancer Cachexia: A Systematic Review

BACKGROUND

Cancer cachexia has substantial impacts on people's quality of life. There is no current gold standard treatment, but the complex pathophysiology of cachexia suggests that a multitargeted and individualised treatment approach is needed. We aimed to evaluate the extent to which multicomponent interventions have targeted the key features of cachexia and been tailored to individuals, and differential effects on quality of life.

METHODS

We conducted a systematic review of multicomponent interventions for adults with cancer cachexia. We searched four databases, two clinical trial registers and MedRxiv on 20 June 2024. Intervention components were classified by intervention category (nutritional, exercise/physical activity, pharmacological and psychosocial), cachexia feature(s) targeted (reduced energy intake, altered metabolism, involuntary weight loss and decline in physical function) and level of tailoring. Within-arm standardised mean changes in quality of life over time, as well as standardised mean differences between study arms, were calculated.

RESULTS

Sixty-two multicomponent interventions were included, of which two combined components from all four intervention categories, and nine targeted all four key features of cachexia. Eighteen multicomponent interventions were fully tailored and 30 were partly tailored to individuals. Within-arm standardised mean changes in quality of life were calculated for thirteen studies; all had a high risk of bias or raised concerns. In eleven studies, quality of life scores improved following the intervention, whereas in two studies they declined. Standardised mean differences between study arms were calculated for four studies; in three, the intervention arm showed a greater improvement in quality of life scores than the usual care arm. Amongst these data, there was no indication that the number of cachexia features targeted, or the extent of tailoring, was associated with a greater improvement in quality of life scores; however, the heterogeneity prevented us from concluding on our hypothesis.

CONCLUSIONS

This review mapped out in detail the combinations of intervention categories used, the key features of cachexia targeted, and the extent of tailoring across multicomponent interventions for adults with cancer cachexia. Only a small proportion of the multicomponent interventions targeted all four key features of cachexia, but most were either partly or fully tailored to individuals. Despite sixty-two multicomponent interventions being investigated, only four studies compared these to usual care and reported quality of life outcomes. High risk of bias, low sample sizes and variable outcome data remain challenges to the interpretability of results in this field.

Immunonutrition to improve the quality of life of upper gastrointestinal cancer patients undergoing neoadjuvant treatment prior to surgery (NEOIMMUNE): double-blind randomized controlled multicenter clinical trial

BACKGROUND

Malnutrition is common with esophagogastric cancers and is associated with negative outcomes. We aimed to evaluate if immunonutrition during neoadjuvant treatment improves patient's health-related quality of life (HRQOL) and reduces postoperative morbidity and toxicities during neoadjuvant treatment.

METHODS

A multicenter double-blind randomized controlled trial (RCT) was undertaken. Included patients had untreated nonmetastatic esophagogastric tumor, aged 18 ≥ years with a life expectancy of >3 months. The study was powered for 80% power to detect a clinically relevant difference in EORTC-QLQC30 with standard deviation of 15 between groups. Primary end point was the quality of life as measured by the global health status at 30 days after surgery. An intention-to-treat analysis was employed.

RESULTS

The study was terminated at the interim analysis stage. About 300 patients were randomized: 149 to the IMPACT group and 151 to the control-formula group. Patient groups were well-balanced in terms of age, sex, body mass index, WHO performance status, and clinical tumor stage. Analysis of the primary end point for the study of global health status at 30-day postoperatively failed to show any significant differences between the groups (55.4 ± 18.6 [IMPACT] vs. 55.9 ± 19.8 [control]; P = 0.345). No significant differences between the groups were detected in the majority of domains from EORTC QLQC30 and OG25 tools after neoadjuvant therapy and 30 days postoperatively. Finally, no significant differences were seen between groups in neoadjuvant therapy or postoperative complications, or tumor response.

CONCLUSION

The results of this multicenter double-blind RCT fail to demonstrate any HRQOL benefits to the utilization of immunonutrition during neoadjuvant therapy in patients with esophagogastric cancer.

Nutritional interventions in randomised clinical trials for people with incurable solid cancer: A systematic review

BACKGROUND & AIMS

Malnutrition is highly prevalent in those with cancer and more so in those with incurable cancer. In incurable cancer, it is widely agreed that optimal nutritional care has the potential to positively impact patient and caregiver distress and oncological outcomes. The aim of this systematic review was to describe the diversity and frequency of nutritional interventions, whether given in isolation or as part of a multimodal intervention in those with incurable cancer, in randomised controlled trials. The secondary aims were to describe adherence and their efficacy.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following databases were searched electronically: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Central Register of Controlled Trials (CENTRAL) with the time frame from January 2000 to 7th September 2023. Eligible studies included adult patients (≥18 years) diagnosed with incurable solid cancer with a sample size ≥40. Studies were to be primary research and delivered for at least 14 days to allow for efficacy. They were to include a nutritional intervention encompassing at least one of the following: dietary counselling, oral nutritional supplements (ONS), enteral tube feeding and/or parenteral nutrition (PN), given in isolation or as part of a multi-modal intervention. Studies were excluded if the population contained patients who had completed curative treatment or are being treated with curative intent, haematological cancers, or if they examined the effects of micronutrients, proteins, amino acids or fatty acids given in isolation. The quality of the included studies was assessed using the Cochrane risk of bias tool for randomised trials (RoB2). A balloon plot was produced to present the results in addition to a table with a narrative summary of the primary outcomes.

RESULTS

A total of 7968 studies were identified, of which 18 met the eligibility criteria. This included 2720 study participants. The included studies comprised: multimodal interventions (n = 7), dietary counselling (n = 2), nutritional supplementation with or without dietary counselling (n = 7) and PN (n = 2). Primary outcomes included quality of life (QoL), body composition and nutritional status. For QoL, this was reported in 15 studies, 4 studies showed a significant improvement. Body composition was evaluated in 15 studies, 5 of which showed a significant improvement in body weight and two in fat-free mass (FFM). Nutritional status was reported in 6 studies with one showing a significant difference in Patient-Generated Subjective Global Assessment (PG-SGA) score. The risk of bias was deemed 'low' in 6 studies, with 'some concerns' in 10 studies and a 'high risk' in 2 studies. There was heterogeneity between the studies.

CONCLUSION

This systematic review has highlighted some positive findings in regard to QoL, body weight and nutritional intake. Optimum nutritional intervention was not identified. Future studies should evaluate the effectiveness of earlier nutritional interventions at the point of diagnosis, including regular reviews and the impact this has on nutritional outcomes, QoL and overall survival (OS).

Role of myofiber-specific FoxP1 in pancreatic cancer-induced muscle wasting

Cancer cachexia affects up to 80% of patients with cancer and results in reduced quality of life and survival. We previously demonstrated that the transcriptional repressor Forkhead box P1 (FoxP1) is upregulated in the skeletal muscle of cachectic mice and people with cancer, and when overexpressed in skeletal muscle, it is sufficient to induce pathological features characteristic of cachexia. However, the role of myofiber-derived FoxP1 in both normal muscle physiology and cancer-induced muscle wasting remains largely unexplored. To address this gap, we generated a conditional mouse line with myofiber-specific ablation of FoxP1 (FoxP1SkmKO) and found that in cancer-free mice, deletion of FoxP1 in skeletal myofibers resulted in increased myofiber size in both males and females, with a significant increase in muscle mass in males. In response to murine KPC pancreatic tumor burden, we found that myofiber-derived FoxP1 mediates cancer-induced muscle wasting and diaphragm muscle weakness in male but not female mice. In summary, our findings identify myofiber-specific FoxP1 as a negative regulator of skeletal muscle with sex-specific differences in the context of cancer.NEW & NOTEWORTHY Here we identify myofiber-derived FoxP1 as a negative regulator of skeletal muscle with sex-specific effects in cancer. Under cancer-free conditions, FoxP1 knockout increased myofiber size in male and female mice. However, in response to pancreatic cancer, FoxP1 myofiber-specific deletion attenuated muscle wasting and weakness in males but not females. This highlights the need to consider sexual dimorphism in cancer-induced muscle pathologies and provides evidence suggesting that targeting FoxP1 could help mitigate these effects in males.

Effects of Antioxidant Amino Acids on Cancer Sarcopenia

Cancer sarcopenia is highly prevalent in patients with advanced cancer, which is closely related to the disease prognosis. Overcoming cancer sarcopenia is important for cancer treatment. Cystine and theanine (CT), antioxidant amino acids, have been applied to the nutritional intervention of various diseases but their effects remain unclear on cancer sarcopenia. We attempt to examine the effect of CT on cancer sarcopenia. Both mouse and in vitro cachexia models showed that CT reduced oxidative stress, inhibited autophagy and apoptosis, improved oxidative phosphorylation and the suppression of high mobility group box-1 production, and improved sarcopenia and muscle maturity. When treated with 5-fluorouracil in a mouse cachexia model, tumor weight decreased but oxidative stress increased and muscle weight and muscle maturity were suppressed regardless of diet. However, in the CT group, oxidative stress was reduced and the exacerbation of sarcopenia by 5-fluorouracil was suppressed. Thus, in cancer cachexia, oxidative stress plays a major role in skeletal muscle damage, and CT, which has an anti-oxidative stress effect, has a strong protective effect on skeletal muscle. In the future, it will be important to conduct clinical studies on nutritional intervention for cancer sarcopenia using CT.

Early administration of anamorelin improves cancer cachexia in gastrointestinal cancer patients: an observational study

To report the efficacy of anamorelin in patients with colorectal and gastric cancer with cachexia and in those receiving systemic chemotherapy. We retrospectively collected real-world data from patients diagnosed with colorectal and gastric cancers experiencing cachexia who were treated with anamorelin. We evaluated the efficacy of treatment by measuring the improvements in appetite and body weight (BW) gain. Between June 2021 and October 2022, 43 cancer patients with cachexia-23 with gastric cancer and 20 with colorectal cancer-were treated with anamorelin. Median observation period was 7.3 months. The participants were 25 males with median age of 71 years and median BMI of 19.7. The ECOG PS distribution was 4, 33, 6 for grades 0, 1, and 2, respectively. Seven patients received supportive care only, while 36 received anamorelin with chemotherapy. Thirty-four had received chemotherapy previously (≤ 2 regimens) and nine had received ≥ 3 regimens. Median anamorelin treatment duration was 2.8 months; overall survival was 7.3 months. After 3 weeks, 24 experienced appetite improvement and 21 gained weight; after 12 weeks, 20 experienced appetite improvement and 15 gained weight. Multivariate analysis showed that anamorelin treatment before second-line chemotherapy and colorectal cancer correlated with appetite improvement and weight gain at 3 weeks. In the univariate analysis, anamorelin treatment before second-line chemotherapy correlated with weight gain at 12 weeks and with improved overall survival in patients with weight gain at 12 weeks. Early anamorelin treatment contributes to appetite improvement and BW gain in colorectal and gastric cancers with cachexia.

Sarcopenia Is a Prognostic Factor of Adverse Effects and Mortality in Patients With Tumour: A Systematic Review and Meta-Analysis

BACKGROUND

The relationship between sarcopenia and the prognosis of patients with tumours who received radio- and/or chemotherapy still needs to be determined. In this study, we aim to investigate the relationship between sarcopenia and adverse effects and mortality in patients with tumours that received radio- and/or chemotherapy, stratified by study design, tumour category, the method sarcopenia assessed, treatment options, study location and among other factors.

METHODS

PubMed, Web of Science and Embase were searched from inception to 15 August 2024, without language restrictions and with a manual search of references for additional articles retrieval. Cohort studies of ≥ 100 patients with tumours that evaluated the association between sarcopenia or muscle mass and the adverse effects or overall survival induced by radio- and/or chemotherapy were included.

RESULTS

Thirty-nine studies were included, involving 8966 patients with tumours, including 3383 patients with sarcopenia. The pooled prevalence of sarcopenia in patients with tumours was 0.42 (95% CI 0.36-0.48, p < 0.001) overall. The prevalence of sarcopenia is higher in Oceania patients 0.60 (95% CI 0.28-0.89, p < 0.001), those with reproductive tumour 0.57 (95% CI 0.30-0.83, p < 0.001), and sarcopenia assessed by the lumbar-skeletal muscle index 0.46 (95% CI 0.39-0.53, p < 0.001) than in other subgroups, but not show significant differences in sex. Sarcopenia was associated with an increased risk of adverse effects in patients who received radio- and/or chemotherapy, with a relative risk (RR) of 1.44 (95% CI 1.21-1.71, p < 0.001). Retrospective studies (RR = 1.49; 95% CI 1.24-1.79; p < 0.001), sarcopenia assessed by other methods (RR = 2.98; 95% CI 1.52-5.87; p < 0.001), and patients in Europe (RR = 1.92; 95% CI 1.15-3.22; p = 0.013), received chemoradiotherapy (RR = 1.47; 95% CI 1.23-1.76; p < 0.001), and with head and neck tumours (RR = 1.54; 95% CI 1.17-2.01; p = 0.010) had higher relative risk than other subgroups. Sarcopenia was also associated with reduced overall survival in patients with tumours, with a pooled hazard ratio (HR) of 1.66 (95% CI 1.40-1.96, p < 0.001). Prospective studies (HR = 1.72; 95% CI 0.97-3.07; p = 0.065), sarcopenia assessed by the cervical-skeletal muscle index (HR = 2.66; 95% CI 1.73-4.09; p < 0.001), and patients in Asia (HR = 1.91; 95% CI 1.50-2.42; p < 0.001), received chemoradiotherapy (HR = 1.85; 95% CI 1.46-2.45; p < 0.001) and with head and neck tumours (HR = 2.35; 95% CI 1.88-2.95; p < 0.001) had higher HR than other subgroups.

CONCLUSIONS

Sarcopenia was associated with a higher risk of adverse effects and mortality in patients with tumours received radio- and/or chemotherapy.

Molecular mechanisms of cancer cachexia. Role of exercise training

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

Targeted nutritional intervention attenuates experimental lung cancer cachexia

BACKGROUND

Cachexia, a syndrome with high prevalence in non-small cell lung cancer patients, impairs quality of life and reduces tolerance and responsiveness to cancer therapy resulting in decreased survival. Optimal nutritional care is pivotal in the treatment of cachexia and a recommended cornerstone of multimodal therapy. Here, we investigated the therapeutic effect of an intervention diet consisting of a specific combination of high protein, leucine, fish oil, vitamin D, galacto-oligosaccharides, and fructo-oligosaccharides on the development and progression of cachexia in an orthotopic lung cancer mouse model.

METHODS

Eleven-week-old male 129S2/Sv mice were orthotopically implanted with 344P lung epithelial tumour cells or vehicle (control). Seven days post-implantation tumour-bearing (TB) mice were allocated to either intervention- or isocaloric control diet. Cachexia was defined as 5 days of consecutive body weight loss, after which mice were euthanized for tissue analyses.

RESULTS

TB mice developed cachexia accompanied by significant loss of skeletal muscle mass and epididymal fat mass compared with sham operated mice. The cachectic endpoint was significantly delayed (46.0 ± 15.2 vs. 34.7 ± 11.4 days), and the amount (-1.57 ± 0.62 vs. -2.13 ± 0.57 g) and progression (-0.26 ± 0.14 vs. -0.39 ± 0.11 g/day) of body weight loss were significantly reduced by the intervention compared with control diet. Moreover, systemic inflammation (pentraxin-2 plasma levels) and alterations in molecular markers for proteolysis and protein synthesis, indicative of muscle atrophy signalling in TB-mice, were suppressed in skeletal muscle by the intervention diet.

CONCLUSIONS

Together, these data demonstrate the potential of this multinutrient intervention, targeting multiple components of cachexia, as integral part of lung cancer management.

Myofiber-specific FoxP1 knockout protects against pancreatic cancer-induced muscle wasting in male but not female mice

Cancer cachexia affects up to 80% of cancer patients and results in reduced quality of life and survival. We previously demonstrated that the transcriptional repressor Forkhead box P1 (FoxP1) is upregulated in skeletal muscle of cachectic mice and people with cancer, and when overexpressed in skeletal muscle is sufficient to induce pathological features characteristic of cachexia. However, the role of myofiber-derived FoxP1 in both normal muscle physiology and cancer-induced muscle wasting remains largely unexplored. To address this gap, we generated a conditional mouse line with myofiber-specific ablation of FoxP1 (FoxP1SkmKO) and found that in cancer-free mice, deletion of FoxP1 in skeletal myofibers resulted in increased myofiber size in both males and females, with a significant increase in muscle mass in males. In response to murine KPC pancreatic tumor burden, we found that myofiber-derived FoxP1 is required for cancer-induced muscle wasting and diaphragm muscle weakness in male mice. In summary, our findings identify myofiber-specific FoxP1 as a negative regulator of skeletal muscle with sex-specific differences in the context of cancer.

Role of the intestinal microbiota in contributing to weight disorders and associated comorbidities

SUMMARYThe gut microbiota is a major factor contributing to the regulation of energy homeostasis and has been linked to both excessive body weight and accumulation of fat mass (i.e., overweight, obesity) or body weight loss, weakness, muscle atrophy, and fat depletion (i.e., cachexia). These syndromes are characterized by multiple metabolic dysfunctions including abnormal regulation of food reward and intake, energy storage, and low-grade inflammation. Given the increasing worldwide prevalence of obesity, cachexia, and associated metabolic disorders, novel therapeutic strategies are needed. Among the different mechanisms explaining how the gut microbiota is capable of influencing host metabolism and energy balance, numerous studies have investigated the complex interactions existing between nutrition, gut microbes, and their metabolites. In this review, we discuss how gut microbes and different microbiota-derived metabolites regulate host metabolism. We describe the role of the gut barrier function in the onset of inflammation in this context. We explore the importance of the gut-to-brain axis in the regulation of energy homeostasis and glucose metabolism but also the key role played by the liver. Finally, we present specific key examples of how using targeted approaches such as prebiotics and probiotics might affect specific metabolites, their signaling pathways, and their interactions with the host and reflect on the challenges to move from bench to bedside.

Jianpi Decoction Combined with Medroxyprogesterone Acetate Alleviates Cancer Cachexia and Prevents Muscle Atrophy by Directly Inhibiting E3 Ubiquitin Ligase

OBJECTIVE

To provide comprehensive evidence for the anti-cancer cachexia effect of Jianpi Decoction (JP) and to explore its mechanism of anti-cancer cachexia.

METHODS

A mouse model of colon cancer (CT26)-induced cancer cachexia (CC) was used to investigate the anti-CC effect of JP combined with medroxyprogesterone acetate (MPA). Thirty-six mice were equally divided into 6 groups: normal control, CC, MPA (100 mg•kg-1•d-1), MPA + low-dose (20 mg•kg-1•d-1) JP (L-JP), MPA + medium-dose (30 mg•kg-1•d-1) JP (M-JP), and MPA + high-dose (40 mg•kg-1•d-1) JP (H-JP) groups. After successful modeling, the mice were administered by gavage for 11 d. The body weight and tumor volume were measured and recorded every 2 d starting on the 8th day after implantation. The liver, heart, spleen, lung, kidney, tumor and gastrocnemius muscle of mice were collected and weighed. The pathological changes of the tumor was observed, and the cross-sectional area of the gastrocnemius muscle was calculated. The protein expressions of STAT3 and E3 ubiquitinase in the gastrocnemius muscle were measured by Western blot. In addition, an in vitro C2C12 myotube formation model was established to investigate the role of JP in hindering dexamethasone-induced muscle atrophy. In vitro experiments were divided into control, model, and JP serum groups. After 2-d administration, microscopic photographs were taken and myotube diameters were calculated. Western blot was performed to measure the protein expressions of STAT3 and E3 ubiquitinase.

RESULTS

JP combined with MPA restored tumor-induced weight loss (P<0.05, vs. CC) and muscle fiber size (P<0.01, vs. CC). Mechanistically, JP reduced the expression of atrophy-related proteins MuRF1 and MAFbx in tumor-induced muscle atrophy in vivo (P<0.05, vs. CC). In addition, JP reduced the expression of atrophy-related proteins MuRF1 and MAFbx and p-STAT3 phosphorylation (P<0.05 or P<0.01 vs. model group) in C2C12 myotubes treated with dexamethasone in vitro.

CONCLUSIONS

Administration of JP combined with MPA restores tumor-induced cachexia conditions. In addition, the profound effect of JP combined with MPA on tumor-induced cachexia may be due to its inhibition of muscle proteolysis (E3 ubiquitinase system).

Longitudinal Muscle Biopsies Reveal Inter- and Intra-Subject Variability in Cancer Cachexia: Paving the Way for Biopsy-Guided Tailored Treatment

In the rapidly evolving landscape of cancer cachexia research, the development and refinement of diagnostic and predictive biomarkers constitute an ongoing challenge. This study aims to introduce longitudinal muscle biopsies as a potential framework for disease monitoring and treatment. The initial feasibility and safety assessment was performed for healthy mice and rats that received two consecutive muscle biopsies. The assessment was performed by utilizing three different tools. Subsequently, the protocol was also applied in leiomyosarcoma tumor-bearing rats. Longitudinal muscle biopsies proved to be a safe and feasible technique, especially in rat models. The application of this protocol to tumor-bearing rats further affirmed its tolerability and feasibility, while microscopic evaluation of the biopsies demonstrated varying levels of muscle atrophy with or without leukocyte infiltration. In this tumor model, sequential muscle biopsies confirmed the variability of the cancer cachexia evolution among subjects and at different time-points. Despite the abundance of promising cancer cachexia data during the past decade, the full potential of muscle biopsies is not being leveraged. Sequential muscle biopsies throughout the disease course represent a feasible and safe tool that can be utilized to guide precision treatment and monitor the response in cancer cachexia research.

The barriers to interprofessional care for cancer cachexia among Japanese healthcare providers: A nationwide survey

BACKGROUND

Cancer cachexia is a severe complication of advanced malignancy, with few therapeutic options. To promote interprofessional care for cancer cachexia, healthcare providers' needs should be addressed in detail. This pre-planned subgroup analysis of the Global Educational Needs Evaluation: a systemic interprofessional study in cancer cachexia (GENESIS-CC) survey aimed to identify barriers to interprofessional care of cancer cachexia in Japan.

METHODS

A nationwide survey was electronically conducted for healthcare providers in oncological or general healthcare facilities from January to March 2021 in Japan. The Japanese Regional Advisory Board developed a barrier scoring system with 33 from the 58 original survey items to quantify six domains of barriers: (1) lack of confidence, (2) lack of knowledge, (3) barriers in personal practice, (4) barriers in perception, (5) barriers in team practice and (6) barriers in education. The largest possible barrier score was set at 100 points. We compared the scores by profession.

RESULTS

A total of 1227 valid responses were obtained from 302 (24.6%) physicians, 252 (20.5%) pharmacists, 236 (19.2%) nurses, 218 (17.8%) dietitians, 193 (15.7%) rehabilitation therapists and 26 (2.0%) other professionals. Overall, 460 (37.5%) were not very or at all confident about cancer cachexia care, 791 (84.1%) agreed or strongly agreed that care was influenced by reimbursement availability and 774 (81.9%) did not have cancer cachexia as a mandatory curriculum. The largest mean barrier score (± standard deviation) was 63.7 ± 31.3 for education, followed by 55.6 ± 21.8 for team practice, 43.7 ± 32.5 for knowledge, 42.8 ± 17.7 for perception and 36.5 ± 16.7 for personal practice. There were statistically significant interprofessional differences in all domains (P < 0.05), especially for pharmacists and nurses with the highest or second highest scores in most domains.

CONCLUSIONS

There is a need to improve the educational system and team practices of cancer cachexia for most Japanese healthcare providers, especially pharmacists and nurses. Our study suggests the need to reform the mandatory educational curriculum and reimbursement system on cancer cachexia to promote interprofessional care for cancer cachexia in Japan.

Nutrition and Dietary Intervention in Cancer: Gaps, Challenges, and Future Perspectives

The term "cancer" refers to the state in which cells in the body develop mutations and lose control over their replication. Malignant cancerous cells invade in various other tissue sites of the body. Chemotherapy, radiation, and surgery are the first-line modalities for the majority of solid cancers. These treatments work by mitigating the DNA damage of cancerous cells, but they can also cause harm to healthy cells. These side effects might be immediate or delayed, and they can cause a high rate of morbidity and mortality. Dietary interventions have a profound impact on whole-body metabolism, including immunometabolism and oncometabolism which have been shown to reduce cancer growth, progression, and metastasis in many different solid tumor models with promising outcomes in early phase clinical studies. Dietary interventions can improve oncologic or quality-of-life outcomes for patients that are undergoing chemotherapy or radiotherapy. In this chapter, we will focus on the impact of nutritional deficiencies, several dietary interventions and their proposed mechanisms which are used as a novel therapy in controlling and managing cancers.

The association of body composition and outcomes following autologous hematopoietic stem cell transplantation in patients with non-Hodgkin lymphoma

Recently there has been a growing interest in evaluating body composition as a marker for prognosis in cancer patients. The association of body composition parameters and outcomes has not been deeply investigated in patients with autologous hematopoietic stem cell transplantation (HSCT) recipients with non-Hodgkin lymphoma (NHL). We conducted a retrospective cohort study of 264 NHL patients who received autologous HSCT. PreHSCT abdominal CT scans at the levels of L3 were assessed for body composition measures. We evaluated sarcopenia, myosteatosis, high visceral adipose tissue (VAT) and high visceral adipose tissue density (VATD). Using multivariable Cox proportional regression, we analyzed the association of clinical and transplant-related characteristics with overall survival (OS), relapse-free survival (RFS), and non-relapse mortality (NRM). In a multivariate regression model, patients with higher VATD had worse OS (HR 1.78; 95% confidence intervals CI 1.08-2.95, p = 0.02) and worse NRM (HR 2.31 95% CI 1.08-4.95, p = 0.02) than with lower VATD. Patients with lower levels of VAT also had worse RFS (HR 1.49 95% CI 1.03-2.15, p = 0.03). Sarcopenia and myosteatosis were not associated with outcomes. High pre-transplant VATD was associated with lower OS and higher NRM, and low pre-transplant VAT was associated with worse RFS in patients with NHL undergoing autologous HSCT.

Cachexia is associated with depression, anxiety and quality of life in cancer patients

OBJECTIVES

This study aimed to compare depression, anxiety and quality of life (QoL) between cachexia and non-cachexia patients, and explore the relationship between cachexia and depression, anxiety and QoL in patients with cancer.

METHODS

A total of 528 patients from cancer centres of four hospitals were enrolled in this cross-sectional study. All patients were divided into cachexia and non-cachexia according to international consensus definition of cachexia. Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Quality of Life Questionnaire-Cancer 30 (QLQ-C30) were used to evaluate depression, anxiety and QoL.

RESULTS

285 patients (53.98%) were classified as cachexia. The prevalence of depression, anxiety, severe depression and severe anxiety in cachexia was 30.2%, 18.6%, 6.7% and 8.4%, respectively, which were significantly higher than in non-cachexia (all p<0.01). Patients with cachexia obviously acquired poorer physical function (PF), role function (RF), cognitive function (CF), emotional function (EF), social function (SF) and overall QoL than non-cachexia patients (all p<0.01). Cachexia was positively associated with depression (unstandardised coefficient (B)=2.123, p<0.001) and anxiety (B=1.123, p=0.024), and had a negative relationship with PF, CF, EF, SF and overall QoL (all B<0, all p<0.05).

CONCLUSIONS

Cachexia was associated with greater depression and anxiety and poorer QoL in patients with cancer, which emphasised the importance of timely identification and management of cachexia to improve the psychological problems and QoL among patients with cancer.

The effect of anamorelin (ONO-7643) on cachexia in cancer patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cachexia is associated with increased morbidity and mortality rates in patients with cancer. This meta-analysis aims to explore the effect of anamorelin on cancer cachexia markers.

METHODS

We searched MEDLINE/PubMed, SCOPUS, and WOS from their inception until 5 June 2022. A systematic search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We included trials investigating the effect of anamorelin on body weight, lean body mass, fat mass, insulin-like growth factor 1 (IGF-1), handgrip, quality of life insulin-like growth factor-binding protein 3 (IGFBP-3), and in patients with cancer. A random-effects model was run to pooled results.

RESULTS

Five articles providing 1331 participants were analyzed in this study. Pooled analysis revealed a significant increase in body weight (weighted mean difference (WMD): 1.56 kg, 95% confidence interval (CI): 1.20, 1.92; I2= 0%), lean body mass (WMD: 1.36 kg, 95% CI: 0.85, 1.86; I2= 53.1%), fat mass (WMD: 1.02 kg, 95% CI: 0.51, 1.53; I2= 60.7%), IGF-1 (WMD: 51.16 ng/mL, 95% CI: 41.42, 60.90, I2= 0%), and IGFBP-3 (WMD: 0.43 μg/mL, 95% CI: 0.17, 0.68, I2= 98.6%). Results showed no significant increase in appetite when analysis run on all studies without considering different doses 0.29 (95% CI: -0.30, 0.89, I2= 73.8%), however, there was a significant increase in appetite without heterogeneity and inconsistency 0.59 (95% CI: 0.32, 0.86; I2= 0%) in the 100 mg/day group compared to anamorelin non-user.

CONCLUSIONS

Patients with cancer who receive anamorelin as a treatment for cachexia showed a significant increase in body weight, lean body mass, fat mass, IGF-1, and IGFBP-3.

Effects of Moderate Exercise Training on Cancer-Induced Muscle Wasting

BACKGROUND

Muscle wasting is a common phenomenon in oncology and seems to be attenuated by exercise training. The aim of this study is to determine the degree of aggressiveness of cancer-induced muscle wasting in two different phenotypic muscles. It will also determine whether exercise training can attenuate this muscle dysfunction.

METHODS

Fifty Sprague Dawley rats were randomly assigned to four experimental groups: two breast cancer model groups (sedentary and exercise) and two control groups (sedentary and exercise). Breast cancer was induced by 1-methyl-1-nitrosoureia (MNU). After 35 weeks of endurance training, animals were sacrificed, and gastrocnemius and soleus muscles harvested for morphometric analysis.

RESULTS

In sedentary tumor-bearing animals, a significant reduction in cross-sectional area was found in both muscles (p < 0.05). Interstitial fibrosis was significantly higher in the gastrocnemius muscle of the sedentary tumor-bearing animals (p < 0.05), but not in the soleus muscle. In the gastrocnemius of sedentary tumor-bearing animals, a shift from large to small fibers was observed. This cancer-related muscle dysfunction was prevented by long-term exercise training.

CONCLUSIONS

In sedentary animals with tumors, the gastrocnemius muscle showed a very pronounced reduction in cross-sectional area and a marked degree of interstitial fibrosis. There was no difference in collagen deposition between tumor groups, and the soleus muscle showed a less pronounced but significant reduction in cross-sectional area. These contrasting results confirm that cancer-induced muscle wasting can affect specific types of fibers and specific muscles, namely fast glycolytic muscles, and that exercise training can be used to improve it.

Longitudinal characterisation of cachexia in patients undergoing surgical resection for cancer

PURPOSE OF REVIEW

The complexity of the cancer cachexia phenotype has undoubtedly hindered researchers' understanding of this devastating syndrome. The presence and magnitude of host-tumour interactions are rarely considered during clinical decision-making within the current staging paradigm. Furthermore, treatment options for those patients who are identified as suffering from cancer cachexia remain extremely limited.

RECENT FINDINGS

Previous attempts to characterise cachexia have largely focussed on individual surrogate disease markers, often studied across a limited timeframe. While the adverse prognostic value of clinical and biochemical features is evident, the relationships between these are less clear. Investigation of patients with earlier-stage disease could allow researchers to identify markers of cachexia that precede the refractory stage of the wasting process. Appreciation of the cachectic phenotype within 'curative' populations may aid our understanding of the syndrome's genesis and provide potential routes for prevention, rather than treatment.

SUMMARY

Holistic, longitudinal characterisation of cancer cachexia, across all at-risk and affected populations, is of vital importance for future research in the field. This paper presents the protocol for an observational study aiming to create a robust and holistic characterisation of surgical patients with, or at risk of, cancer cachexia.

Top Ten Tips Palliative Care Clinicians Should Know About Cachexia

Cachexia is a multifactorial syndrome that is common in cancer and chronic disease. It is often underdiagnosed and therefore goes untreated or undertreated. Cachexia causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a group of clinicians and researchers across cancer care, nutrition, and exercise offers tips about assessment, classification, and management of cachexia, with attention to its stage. The required multimodal management of cachexia mirrors well the interprofessional collaboration that is the mainstay of interdisciplinary palliative care and attention to screening, diagnosis, and management of cachexia is critical to maximize patients' quality of life.

SKELETAL MUSCLE SENSITIVITY TO WASTING INDUCED BY UROTHELIAL CARCINOMA

BACKGROUND

Skeletal muscle wasting is a common phenotypic feature of several types of cancer, and it is associated with functional impairment, respiratory complications, and fatigue. However, equivocal evidence remains regarding the impact of cancer-induced muscle wasting on the different fiber types.

AIM

The aim of this study was to investigate the impact of urothelial carcinoma induced in mice on the histomorphometric features and collagen deposition in different skeletal muscles.

MATERIALS AND METHODS

Thirteen ICR (CD1) male mice were randomly assigned into two groups: exposed to 0.05% N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) in drinking water for 12 weeks, plus 8 weeks of tap water (BBN, n = 8) or with access to tap water for 20 weeks (CONT, n = 5). Tibialis anterior, soleus, and diaphragm muscles were collected from all animals. For cross-sectional area and myonuclear domain analysis, muscle sections were stained with hematoxylin and eosin, and for collagen deposition assessment, muscle sections were stained with picrosirius red.

RESULTS

All animals from the BBN group developed urothelial preneoplastic and neoplastic lesions, and the tibialis anterior from these animals presented a reduced cross-sectional area (p < 0.001), with a decreased proportion of fibers with a higher cross-sectional area, increased collagen deposition (p = 0.017), and higher myonuclear domain (p = 0.031). BBN mice also showed a higher myonuclear domain in the diaphragm (p = 0.015).

CONCLUSION

Urothelial carcinoma induced muscle wasting of the tibialis anterior, expressed by a decreased cross-sectional area, higher infiltration of fibrotic tissue, and increased myonuclear domain, which also increased in the diaphragm, suggesting that fast glycolytic muscle fibers are more susceptible to be affected by cancer development.

Combined with prognostic nutritional index and IgM for predicting the clinical outcomes of gastric cancer patients who received surgery

Objective

Although the survival rate of patients who undergo surgery for gastric cancer has greatly improved, still many patients have a poor prognosis. This retrospective study aimed to investigate the predictive ability of the PNI-IgM score, a combined prognostic nutritional index (PNI), and immunoglobulin M (IgM), on the prognosis of patients undergoing surgery for gastric cancer.

Methods

340 patients with gastric cancer who underwent surgery from January 2016 to December 2017 were selected. The PNI-IgM score ranged from 1 to 3: score of 1, low PNI (< 48.45) and low IgM (< 0.87); score of 2, low PNI and high IgM, or high PNI and low IgM; score of 3, high PNI and high IgM. We compared the differences in disease-free survival (DFS) and overall survival (OS) among the three groups, while univariate and multivariate analyses calculated prognostic factors for DFS and OS. In addition, the nomograms were constructed based on the results of multivariate analysis to estimate the 1-, 3- and 5-year survival probability.

Results

There were 67 cases in the PNI-IgM score 1 group, 160 cases in the PNI-IgM score 2 group, and 113 cases in the PNI-IgM score 3 group. The median survival times of DFS in the PNI-IgM score group 1, the PNI-IgM score group 2, and the PNI-IgM score group 3 were 62.20 months, not reached, and not reached, and 67.57 months vs. not reached vs. not reached in three groups for OS. Patients in the PNI-IgM score group 1 had a lower DFS than the PNI-IgM score group 2 (HR = 0.648, 95% CI: 0.418-1.006, P = 0.053) and the PNI-IgM score group 3 (HR = 0.337, 95% CI: 0.194-0.585, P < 0.001). In stratified analysis, PNI-IgM score 1 had a worse prognosis in the age < 60 years group and CA724 < 2.11 U/m group.

Conclusion

PNI-IgM score is a novel combination of nutritional and immunological markers that can be used as a sensitive biological marker for patients with gastric cancer who undergo surgery. The lower the PNI-IgM score, the worse the prognosis.

Prognostic effect of cachexia in patients with non-small cell lung cancer receiving immune checkpoint inhibitors

BACKGROUND

The presence of cachexia in cancer patients negatively affects the quality of life and survival. However, the impact of cachexia on immunotherapy, such as PD-1/L1 inhibitors, is not fully understood. Therefore, we examined whether cancer cachexia affects the prognosis of patients with non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors.

METHODS

We retrospectively screened patients with pathologically confirmed advanced or recurrent NSCLC who were treated with PD-1/PD-L1 monotherapy at Kurume University Hospital. We defined cancer cachexia as weight loss of at least 5% during the past 6 months or any degree of weight loss more than 2% and BMI <20.

RESULTS

Among 182 patients, 74 had cancer cachexia. The presence of cachexia was significantly associated with females, poor performance status (PS), never-smokers, and driver mutations. Multivariate analysis revealed that poor PS and being a smoker were associated with the presence of cachexia. Patients with cancer cachexia had significantly shorter progression-free survival (PFS) and overall survival (OS). In the multivariate analysis, PS and sex were significantly correlated with PFS, whereas PS and cachexia were significantly correlated with OS. Subanalysis revealed that patients in the PS0/without cachexia group had longer PFS and OS than those in the cachexia or PS1-3 group.

CONCLUSIONS

In NSCLC patients, cachexia was associated with a worse prognosis, irrespective of tumor PD-L1 expression, indicating that cachexia is a predictive factor for NSCLC patients receiving immune checkpoint inhibitors.

Overcoming barriers to timely recognition and treatment of cancer cachexia: Sharing Progress in Cancer Care Task Force Position Paper and Call to Action

Cachexia is a life-threatening disorder affecting an estimated 50-80% of cancer patients. The loss of skeletal muscle mass in patients with cachexia is associated with an increased risk of anticancer treatment toxicity, surgical complications and reduced response. Despite international guidelines, the identification and management of cancer cachexia remains a significant unmet need owing in part to the lack of routine screening for malnutrition and suboptimal integration of nutrition and metabolic care into clinical oncology practice. In June 2020, Sharing Progress in Cancer Care (SPCC) convened a multidisciplinary task force of medical experts and patient advocates to examine the barriers preventing the timely recognition of cancer cachexia, and provide practical recommendations to improve clinical care. This position paper summarises the key points and highlights available resources to support the integration of structured nutrition care pathways.

Prognostic Impact of Nutritional Status on Overall Survival and Health-Related Quality of Life in Men with Advanced Prostate Cancer

PURPOSE

Prognostic role of nutritional status (NS) in patients with metastatic castrate-resistant prostate cancer (mCRPC) is unknown. We hypothesized that patients' NS at the presentation of mCRPC is prognostic for health-related quality of life (HRQoL) and overall survival (OS).

METHODS

We conducted a prospective observational study in mCRPC patients. At enrollment, we allocated each patient into one of four NS categories: (i) well-nourished (WN), (ii) nutritional risk without sarcopenia/cachexia (NR), (iii) sarcopenia, or (iv) cachexia. We sought the prognostic role of the NS for OS and HRQoL by regression models.

RESULTS

141 patients were included into our study. When compared to WN patients, those with NR and cachexia had a higher chance of worse HRQoL (OR 3.45; 95% CI [1.28 to 9.09], and OR 4.17; 95% CI [1.28 to 12.5], respectively), as well as shorter OS (HR 2.04; 95% CI [1.19 to 3.39] and HR 2.9; 95% CI [1.56 to 5.41], respectively). However, when accounting for possible confounding factors, we could not prove the significant importance of NS for chosen outcomes.

CONCLUSIONS

Suboptimal NS might be an unfavorable prognostic factor for HRQoL and OS. Further interventional studies focusing on therapy or prevention are warranted.

Sarcopenia as a risk factor of progression-free survival in patients with metastases: a systematic review and meta-analysis

BACKGROUND

Metastasis of cancer causes more than 90% of cancer deaths and is severely damaging to human health. In recent years, several studies have linked sarcopenia to shorter survival in patients with metastatic cancer. Several predictive models exist to predict mortality in patients with metastatic cancer, but have reported limited accuracy.

METHODS

We systematically searched Medline, EMBASE, and the Cochrane Library for articles published on or before October 14, 2022. Pooled Hazard Ratio (HR) estimates with 95% confidence intervals (CIs) were calculated using a random effects model. The primary outcome was an increased risk of death or tumor progression in patients with metastatic cancer, which is expressed as progression-free survival (PFS). In addition, we performed subgroup analyses and leave-one-out sensitivity analyses to explore the main sources of heterogeneity and the stability of the results.

RESULTS

Sixteen retrospective cohort studies with 1,675 patients were included in the 888 papers screened. The results showed that sarcopenia was associated with lower progression-free survival (HR = 1.56, 95% CI = 1.19-2.03, I2 = 76.3%, P < 0.001). This result was further confirmed by trim-and-fill procedures and leave-one-out sensitivity analysis.

CONCLUSIONS

This study suggests that sarcopenia may be a risk factor for reduced progression-free survival in patients with metastatic cancer. Further studies are still needed to explain the reason for this high heterogeneity in outcome.

TRIAL REGISTRATION

CRD42022325910.

Development and validation of the modified index of fragility in head and neck cancer surgery

BACKGROUND

This study aims to develop and validate, a clinically useful modified index of fragility (mIFG) to identify patients at risk of fragility and to predict postoperative adverse events.

METHOD

An observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database, from 2006 to 2018. All patients undergoing nonemergency head and neck cancer surgery were included. A seven-item index (mIFG) was developed using variables associated with frailty, cachexia, and sarcopenia, drawn from the literature (weight loss, low body mass index, dyspnea, diabetes, serum albumin, hematocrit, and creatinine). Multivariable logistic regression was used to model the association between mIFG, postoperative adverse events and death. A validation cohort was then used to ascertain the diagnostic accuracy of the mIFG.

RESULTS

A total of 23,438 cases were included (16,407 in the derivation group and 7031 in the validation group). There was a total of 4273 postoperative major adverse events (AE) and deaths, 1023 postoperative pulmonary complications and 1721 wound complications. Using the derivation cohort, the 7-item mIFG was independently associated with death, major AEs, pulmonary and wound complications, when controlling for significant covariates. The mIFG predicted death and major adverse events using the validation cohort with an accuracy of 0.70 (95% CI: 0.63-0.76) and 0.64 (95% CI: 0.63-0.66), respectively. The mIFG outperformed the modified Frailty index.

CONCLUSION

The modified index of fragility is a reliable and easily accessible tool to predict risk of postoperative adverse events and death in patients undergoing head and neck cancer surgery.

Effect of combined therapies including nutrition and physical exercise in advanced cancer patients: A pooled analysis

Background and aims

Although many cancer patients suffer from malnutrition or cancer cachexia, there is no standard of care so far due to limited intervention trials. Pooled data from two combined trials were analyzed regarding nutritional status and survival time.

Materials and methods

Data from two trials with advanced cancer patients were included. In both trials, patients in the intervention group received at least three times nutritional counseling and supervised training sessions. Patients in the control group continued being treated according to usual care. Nutritional status was measured using BMI, body composition and handgrip strength. Survival time was analyzed using the Cox proportional hazard model with the period between the beginning of the trial and death as underlying time scale.

Results

68 men (61.8%) and 42 women (38.2%) were randomized either to the intervention (n = 56) or the control (n = 54) group. The inter-group difference for changes in BMI and body composition was not statistically significant after 3 months. Handgrip strength improved significantly from 34.4 ± 10.2 kg to 36.3 ± 9.9 kg at 3 months in the intervention compared to 33.9 ± 9.2 kg to 34.9 ± 9.1 kg in the control group (p = 0.006). The analysis of survival time showed no inter-group difference for all patients. A detailed analysis for different diagnoses showed that in patients with lung cancer, the covariates "CRP value," "days from first diagnosis to randomization" as well as "gender" were significantly associated with survival time. Patients with higher CRP value had a shorter survival time and female patients had a shorter survival time than male patients in our analysis. In addition, patients with pancreatic cancer randomized to the control group had a 20% shorter survival time than those in the intervention group (p = 0.048).

Conclusion

The pooled analysis showed a significant improvement of handgrip strength in advanced cancer patients through the implementation of a combined therapy. Handgrip strength is of prognostic significance in hospitalized patients due to its association with mortality and morbidity. However, no improvements in further tests were detected. There is great need for further investigations examining the effect of nutritional and exercise therapy on survival time with focus on different cancer diagnoses.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and cancer cachexia]

Introduction

Diabetes is a frequent comorbidity in cancer patients, since they share common risk factors. In cancer, the concurrence of cachexia represents a poor prognostic factor, which is aggravated by poor nutritional status. Clinically, cancer cachexia manifests as a significant reduction in body weight, accompanied by changes in body composition and alterations in the balance of the biological system, and causes progressive dysfunction. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with cancer cachexia.

Effect of omega-3 supplementation on the nutritional status of patients with pancreatic cancer: A protocol for systematic review of clinical trials

BACKGROUND

Globally, pancreatic cancer is the seventh most common cause of cancer-related death in both sexes, accounting for 466,003 deaths and 495,773 new cases in 2020. The purpose of this study was to synthesize and evaluate evidence on the effects of omega-3 supplementation on the nutritional status of patients with pancreatic cancer.

METHODS

This systematic review protocol will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Five databases will be searched: MEDLINE/PubMed, CENTRAL Cochrane, EMBASE, Web of Science, and SCOPUS, with no restrictions on the publication date nor language. The internal validity and risk of bias of randomized controlled trials will be assessed using the revised Cochrane Risk-Of-Bias tool for randomized trials (RoB 2), whereas the risk of bias in non-randomized studies of interventions will be evaluated using the ROBINS-I. The heterogeneity among the studies will be assessed using the I2 statistic. Based on the results of this test, we will verify whether the meta-analysis would be feasible. If feasibility would be confirmed, a random-effect model analysis will be performed. For data analysis, the calculation of the pooled effect estimates will have a 95% confidence interval, while the alpha will be set to 0.05 using the R statistical software version 4.0.4. All methodological steps of this review will be performed independently by two reviewers and will be conducted and managed in the EPPI-Reviewer Software™.

RESULTS

This review may be of particular interest to researchers and clinicians, given the low survival and overall burden of patients with pancreatic cancer. Furthermore, the results of this systematic review may contribute to the development of new nutritional interventions in these patients.

CONCLUSION

To the best of our knowledge, this will be the first study to critically assess the scientific evidence and estimate the effect of omega-3 supplementation on the nutritional status of patients with pancreatic cancer. The review will perform a rigorous approach, adhering to the PRISMA Statement 2020 using a comprehensive and systematic search strategy in five databases and additional sources with no time period nor language restrictions.

Pentraxin 3 is an adipose tissue-related serum marker for pancreatic cancer cachexia predicting subsequent muscle mass and visceral fat loss

Cancer cachexia, a paraneoplastic syndrome characterized by ongoing skeletal muscle mass loss, is accompanied by adipose tissue loss and strongly affects chemotherapy endurance. Our aim was to detect a serum marker reflecting pancreatic cancer cachexia and predicting subsequent loss of muscle mass and adipose tissue, focusing on adipose tissue-secreted proteins. Murine-derived pancreatic cancer cells were orthotopically injected into the mouse pancreatic tail. After 3 weeks, RNA sequencing of perigonadal fat and orthotopic tumors was carried out. We analyzed stocked sera and clinical data of metastatic pancreatic cancer patients who received chemotherapy. Perigonadal fat weight/body weight decreased in mice with orthotopic tumors compared to those without tumors. By RNA sequencing and real-time PCR validation, pentraxin 3 (PTX3) was identified as a secreted protein-encoded gene whose expression was significantly higher in the perigonadal fat of mice with orthotopic tumors than in that of mice without orthotopic tumors and was least expressed in orthotopic tumors. Serum PTX3 levels correlated with PTX3 mRNA levels in perigonadal fat and were higher in mice with orthotopic tumors than in those without tumors. In 84 patients diagnosed with metastatic pancreatic cancer, patients with high serum PTX3 levels showed a greater visceral fat loss/month and skeletal muscle mass index (SMI) decrease/month than those with low serum PTX3 levels. High serum PTX3 was an independent risk factor for visceral fat loss, decreased SMI, and poor prognosis. High serum PTX3 in pancreatic cancer patients predicts visceral fat and muscle mass loss and major clinical outcomes of cancer cachexia.

Nomegestrol acetate ameliorated adipose atrophy in a rat model of cisplatin‑induced cachexia

Cachexia, a complex disorder that results in depletion of adipose tissue and skeletal muscle, is driven by anorexia, metabolic abnormalities and inflammation. There are limited therapeutic options for this syndrome. Previous evidence has demonstrated that increasing adipose tissue may improve quality of life and survival outcomes in cachexia. Cisplatin, as a chemotherapy drug, also causes cachexia during antitumor therapy due to its adverse effects. To establish a rat model of cachexia, the animals were intraperitoneally treated with cisplatin at doses of 1, 2 and 3 mg/kg, and the rats that responded to cisplatin at the optimal dose were used to test the effect of nomegestrol acetate (NOMAc). Rats that were assessed to be sensitive to cisplatin were randomly grouped and intragastrically administered vehicle, 5 or 10 mg/kg megestrol acetate (MA) or 2.5, 5 or 10 mg/kg NOMAc. The body weights and food consumption of the rats were assessed. Serum IL-6 and TNF-α levels were assessed using ELISA. The protein expression levels of adipose triglyceride lipase (ATGL), hormone-sensitive lipase (HSL), peroxisome proliferator activated receptor γ (PPARγ), fatty acid synthase (FASN) and sterol regulatory element-binding protein-1 (SREBP-1) from inguinal white adipose tissue (iWAT) and epididymal white adipose tissue (eWAT) were evaluated using western blotting. The optimal way to establish a chemotherapy-induced rat model of cachexia demonstrated in the present study was to intraperitoneally administer the rats with 2 mg/kg cisplatin for 3 consecutive days. NOMAc (2.5, 5 mg/kg) and MA (10 mg/kg) were able to significantly ameliorate the loss of body weight in the cisplatin-induced cachectic rats. NOMAc significantly reduced the serum levels of TNF-α at 10 mg/kg. Morphologically, iWAT atrophy, with a remarkable reduction in adipocyte volume, was observed in the cisplatin-induced cachectic rats, but the effects were reversed by administering 5, 10 mg/kg NOMAc or 10 mg/kg MA. Furthermore, 2.5 mg/kg NOMAc markedly reduced the protein expression levels of the lipolysis genes HSL and ATGL, and 5 mg/kg NOMAc markedly enhanced the protein expression levels of adipogenesis genes, including FASN, SREBP-1 and PPARγ in iWAT but not in eWAT. NOMAc was demonstrated to improve cachexia at lower doses compared with MA. Overall, NOMAc is likely to be a promising candidate drug for ameliorating cancer cachexia induced by cisplatin.

Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change

In this study, we aimed to develop a theoretical framework for a multimodal, integrative, exercise, anti-inflammatory and dietary counselling (MMIEAD) intervention for patients with renal cachexia with reference to how this addresses the underlying causal pathways for renal cachexia, the outcomes anticipated, and how these will be evaluated. We used a Theory of Change (ToC) approach to guide six steps. Step 1 included inputs from a workshop to obtain key stakeholder views on the potential development of a multimodal intervention for renal cachexia. Step 2 included the findings of a mixed-methods study with Health Care Practitioners (HCPs) caring for individuals with End Stage Kidney Disease (ESKD) and cachexia. Step 3 included the results from our systematic literature review on multimodal interventions for cachexia management. In step 4, we used the body of our research team's cachexia research and wider relevant research to gather evidence on the specific components of the multimodal intervention with reference to how this addresses the underlying causal pathways for renal cachexia. In steps 5 and 6 we developed and refined the ToC map in consultation with the core research team and key stakeholders which illustrates how the intervention components of MMIEAD interact to achieve the intended long-term outcomes and anticipated impact. The results of this study provide a theoretical framework for the forthcoming MMIEAD intervention for those with renal cachexia and in subsequent phases will be used to determine whether this intervention is effective. To the best of our knowledge no other multimodal intervention trials for cachexia management have reported a ToC. Therefore, this research may provide a useful framework and contribute to the ongoing development of interventions for cachexia management.

Adherence to Mediterranean Diet and Nutritional Status in Women with Breast Cancer: What Is Their Impact on Disease Progression and Recurrence-Free Patients' Survival?

Introduction: Nutritional status impacts the survival of patients with cancer. There are few studies that investigate the role of nutritional status on breast cancer survival in women with breast cancer, and even fewer regarding the impact of adhering to the Mediterranean diet (MD). The present study aims to assess the nutritional status, MD adherence, physical activity levels and health-related quality of life (HRQOL) in women diagnosed with breast cancer and evaluate these parameters regarding recurrence-free survival. Methods: A total of 114 women, aged 35-87 years old, diagnosed with breast cancer in Larissa, Greece, participated in the study. Tumor histopathology was reported, and anthropometric indices were measured by a trained nurse, while questionnaires regarding nutritional status (via mini nutritional assessment), HRQOL via EORTC QLQ-C30, physical activity levels via IPAQ and Mediterranean diet adherence via MedDietScore were administered. The participants were followed-up for a maximum time interval of 42 months or until recurrence occurred. Results: A total of 74% of patients were overweight or obese, while 4% of women were undernourished, and 28% were at risk of malnutrition. After 42 months of follow-up, 22 patients (19.3%) had relapsed. The median time to recurrence was 38 months (IQR: 33-40 months) and ranged between 23 to 42 months. Higher levels of MD adherence were significantly associated with lower body mass index (BMI) values, earlier disease stage, smaller tumor size, absence of lymph node metastases and better physical activity levels (p < 0.05). Normal nutritional status was significantly associated with higher BMI values and better health-related quality of life (p ≤ 0.05). In univariate analysis, patients with higher levels of MD adherence and well-nourished patients had significantly longer recurrence-free survival (p < 0.05). In multivariate analysis, MD adherence and nutritional status were independently associated with recurrence-free patients' survival after adjustment for several confounding factors (p < 0.05). Conclusions: The impact of MD on time to recurrence is still under investigation, and future interventional studies need to focus on the role of adhering to the MD before and after therapy in survival and breast cancer progression. Furthermore, the present study also highlights the importance of an adequate nutritional status on disease progression, and the need for nutritional assessment, education and intervention in women with breast cancer.

Cancer Cachexia: Signaling and Transcriptional Regulation of Muscle Catabolic Genes

Simple Summary

An uncontrollable loss in the skeletal muscle of cancer patients which leads to a significant reduction in body weight is clinically referred to as cancer cachexia (CC). While factors derived from the tumor environment which trigger various signaling pathways have been identified, not much progress has been made clinically to effectively prevent muscle loss. Deeper insights into the transcriptional and epigenetic regulation of muscle catabolic genes may shed light on key regulators which can be targeted to develop new therapeutic avenues.

Abstract

Cancer cachexia (CC) is a multifactorial syndrome characterized by a significant reduction in body weight that is predominantly caused by the loss of skeletal muscle and adipose tissue. Although the ill effects of cachexia are well known, the condition has been largely overlooked, in part due to its complex etiology, heterogeneity in mediators, and the involvement of diverse signaling pathways. For a long time, inflammatory factors have been the focus when developing therapeutics for the treatment of CC. Despite promising pre-clinical results, they have not yet advanced to the clinic. Developing new therapies requires a comprehensive understanding of how deregulated signaling leads to catabolic gene expression that underlies muscle wasting. Here, we review CC-associated signaling pathways and the transcriptional cascade triggered by inflammatory cytokines. Further, we highlight epigenetic factors involved in the transcription of catabolic genes in muscle wasting. We conclude with reflections on the directions that might pave the way for new therapeutic approaches to treat CC.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

The Molecular Basis and Therapeutic Potential of Leukemia Inhibitory Factor in Cancer Cachexia

Simple Summary

The mechanism of cancer cachexia is linked to a variety of factors, and inflammatory factors are thought to play a key role. We summarize the main roles of LIF in the development of cancer cachexia, including promoting fat loss, inducing skeletal muscle atrophy and causing anorexia nervosa. The main aim of this review is to increase the understanding of the effects of LIF in cachexia and to provide new insights into the treatment of cancer cachexia.

Abstract

Cachexia is a chronic metabolic syndrome that is characterized by sustained weight and muscle mass loss and anorexia. Cachexia can be secondary to a variety of diseases and affects the prognosis of patients significantly. The increase in inflammatory cytokines in plasma is deeply related to the occurrence of cachexia. As a member of the IL-6 cytokine family, leukemia inhibitory factor (LIF) exerts multiple biological functions. LIF is over-expressed in the cancer cells and stromal cells of various tumors, promoting the malignant development of tumors via the autocrine and paracrine systems. Intriguingly, increasing studies have confirmed that LIF contributes to the progression of cachexia, especially in patients with metastatic tumors. This review combines all of the evidence to summarize the mechanism of LIF-induced cachexia from the following four aspects: (i) LIF and cancer-associated cachexia, (ii) LIF and alterations of adipose tissue in cachexia, (iii) LIF and anorexia nervosa in cachexia, and (iv) LIF and muscle atrophy in cachexia. Considering the complex mechanisms in cachexia, we also focus on the interactions between LIF and other key cytokines in cachexia and existing therapeutics targeting LIF.

The Effect of Exercise and Nutritional Interventions on Body Composition in Patients with Advanced or Metastatic Cancer: A Systematic Review

Advanced and metastatic cancers significantly alter body composition, leading to decreased lean mass and variable effects on fat mass. These effects on body composition are associated with significant physical dysfunction and poor prognosis in patients with cancer. Whilst exercise and nutritional interventions are likely to be of benefit in counteracting these effects, relatively little is known about using such interventions in patients with advanced or metastatic cancer. Therefore, in this systematic review we examine the effect of exercise and combined exercise and nutritional interventions on lean mass and fat mass among patients diagnosed with advanced or metastatic cancer. Following PRISMA guidelines, we identified 20 articles from PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PEDro, SPORTDiscus, and REHABDATA. Overall, advanced or metastatic cancer populations comprising of mixed cancer types were most commonly examined (n = 8) with exercise or combined exercise and nutritional interventions being well-tolerated with few adverse effects. Both intervention approaches may preserve lean mass, while only combined interventions may lead to alterations in fat mass. However, further exercise and nutritional studies are needed to definitively understand their effects on body composition. As exercise and nutrition-related research continues in this understudied population, the knowledge gained will help guide supportive clinical treatments.

Tumor cell anabolism and host tissue catabolism-energetic inefficiency during cancer cachexia

Cancer-associated cachexia (CC) is a pathological condition characterized by sarcopenia, adipose tissue depletion, and progressive weight loss. CC is driven by multiple factors such as anorexia, excessive catabolism, elevated energy expenditure by growing tumor mass, and inflammatory mediators released by cancer cells and surrounding tissues. In addition, endocrine system, systemic metabolism, and central nervous system (CNS) perturbations in combination with cachexia mediators elicit exponential elevation in catabolism and reduced anabolism in skeletal muscle, adipose tissue, and cardiac muscle. At the molecular level, mechanisms of CC include inflammation, reduced protein synthesis, and lipogenesis, elevated proteolysis and lipolysis along with aggravated toxicity and complications of chemotherapy. Furthermore, CC is remarkably associated with intolerance to anti-neoplastic therapy, poor prognosis, and increased mortality with no established standard therapy. In this context, we discuss the spatio-temporal changes occurring in the various stages of CC and highlight the imbalance of host metabolism. We provide how multiple factors such as proteasomal pathways, inflammatory mediators, lipid and protein catabolism, glucocorticoids, and in-depth mechanisms of interplay between inflammatory molecules and CNS can trigger and amplify the cachectic processes. Finally, we highlight current diagnostic approaches and promising therapeutic interventions for CC.

Myostatin/Activin Receptor Ligands in Muscle and the Development Status of Attenuating Drugs

Muscle wasting disease indications are among the most debilitating and often deadly noncommunicable disease states. As a comorbidity, muscle wasting is associated with different neuromuscular diseases and myopathies, cancer, heart failure, chronic pulmonary and renal diseases, peripheral neuropathies, inflammatory disorders, and, of course, musculoskeletal injuries. Current treatment strategies are relatively ineffective and can at best only limit the rate of muscle degeneration. This includes nutritional supplementation and appetite stimulants as well as immunosuppressants capable of exacerbating muscle loss. Arguably, the most promising treatments in development attempt to disrupt myostatin and activin receptor signaling because these circulating factors are potent inhibitors of muscle growth and regulators of muscle progenitor cell differentiation. Indeed, several studies demonstrated the clinical potential of "inhibiting the inhibitors," increasing muscle cell protein synthesis, decreasing degradation, enhancing mitochondrial biogenesis, and preserving muscle function. Such changes can prevent muscle wasting in various disease animal models yet many drugs targeting this pathway failed during clinical trials, some from serious treatment-related adverse events and off-target interactions. More often, however, failures resulted from the inability to improve muscle function despite preserving muscle mass. Drugs still in development include antibodies and gene therapeutics, all with different targets and thus, safety, efficacy, and proposed use profiles. Each is unique in design and, if successful, could revolutionize the treatment of both acute and chronic muscle wasting. They could also be used in combination with other developing therapeutics for related muscle pathologies or even metabolic diseases.

Association Between Systemic Inflammation and Malnutrition With Survival in Patients With Cancer Sarcopenia-A Prospective Multicenter Study

Objective

Systemic inflammation and malnutrition are correlated with cancer sarcopenia and have deleterious effects on oncological outcomes. However, the combined effect of inflammation and malnutrition in patients with cancer sarcopenia remains unclear.

Methods

We prospectively collected information on 1,204 patients diagnosed with cancer sarcopenia. the mean (SD) age was 64.5 (11.4%) years, and 705 (58.60%) of the patients were male. The patients were categorized into the high advanced lung cancer inflammation index (ALI) group (≥18.39) and the low ALI group (<18.39) according to the optimal survival cut-off curve. We selected the optimal inflammation marker using the C-index, decision curve analysis (DCA), and a prognostic receiver operating characteristic curve. Univariate and multivariate survival analyses were performed to determine the prognostic value of the optimal inflammation indicator. We also analyzed the association between inflammation and malnutrition in patients with cancer.

Results

The C-index, DCA, and prognostic area under the curve of ALI in patients with cancer sarcopenia were higher or better than those of neutrophil-lymphocyte ratio (NLR), prognostic nutritional index (PNI), systemic immune-inflammation index (SII), and platelet-lymphocyte ratio (PLR). The prognosis for patients in the low ALI group was worse than that of patients in the high ALI group [HR (95%CI) = 1.584 (1.280–1.959), P < 0.001]. When the ALI was divided into quartiles, we observed that decreased ALI scores strongly correlated with decreased overall survival (OS). Patients with both a low ALI and severe malnutrition (vs. patients with high ALI and well-nourished) had a 2.262-fold death risk (P < 0.001). Subgroup analysis showed a significant interactive association between the ALI and death risk in terms of TNM stage (P for interaction = 0.030).

Conclusions

The inflammation indicator of the ALI was better than those of the NLR, PNI, SII, and PLR in patients with cancer sarcopenia. Inflammation combined with severe malnutrition has a nearly 3-fold death risk in patients with cancer sarcopenia, suggesting that reducing systemic inflammation, strengthening nutritional intervention, and improving skeletal muscle mass are necessary.

Randomised controlled trial testing the feasibility of an exercise and nutrition intervention for patients with ovarian cancer during and after first-line chemotherapy (BENITA-study)

OBJECTIVES

Advanced ovarian cancer is a severe disease with major side effects caused by peritoneal carcinomatosis, ascites and gastrointestinal involvement as well as exhaustive treatment like debulking surgery and combination chemotherapy. Two most frequently reported side effects are muscle wasting and malnutrition, leading to frailty, decreased health-related quality of life (HRQoL) and cancer-related fatigue (CRF). As muscle wasting and malnutrition often commence during first-line chemotherapy and develop progressively into a refractory state, an early intervention is warranted. This pilot study aimed to evaluate the safety and acceptance of a combined exercise and nutrition intervention during and after first-line chemotherapy.

DESIGN

The pilot study was conducted as a monocentric 1:1 randomised controlled trial (RCT) with an intervention group (IG) and a control group (CG). Participants were divided by chance into IG or CG. Information on group allocation was conveyed to the study coordinator responsible for making an appointment with the patients for the baseline assessment as well as the physiotherapist and nutritionist responsible for the intervention and outcome assessment in both groups.

PARTICIPANTS

Eligibility criteria included women ≥18 years of age, diagnosed with ovarian cancer, tubal cancer or peritoneal cancer and primary or interval debulking, scheduled but not started adjuvant or neoadjuvant chemotherapy and sufficient German-language skills.

INTERVENTION

The IG received a 12-month exercise and nutrition programme, the CG continued to follow usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were recruitment rate, adherence to intervention, completion rate and adverse events. In addition, in-person assessments (eg, HRQoL, CRF, muscle quality and function and dietary intake and quality) were conducted at baseline (T0, before chemotherapy), week 9 (T1, mid-chemotherapy), week 19 (T2, after completion of chemotherapy) and after 12 months of intervention (T3).

RESULTS

Of 60 eligible patients, 15 patients signed informed consent (recruitment rate=25.0%) and were randomised into IG (n=8) and CG (n=7). Eleven participants completed the study (completion rate, 73.3%), one patient dropped out due to loss of interest, one due to poor health, one was lost to follow-up and one patient died.

CONCLUSION

The BENITA (Bewegungs- und Ernährungsintervention bei Ovarialkrebs) study demonstrated the safety and acceptance of an exercise and nutrition intervention integrated into first-line therapy and follow-up care of ovarian cancer. A large multicentre RCT is planned to investigate the effectiveness of the intervention on HRQoL, CRF and survival and to establish means of implementation into oncology guidelines and clinic routine.

TRIAL REGISTRATION NUMBER

DRKS00013231.

A case of squamous cell lung cancer treated with anamorelin in combination with a multidisciplinary collaborative approach for treating cancer cachexia

Anamorelin (ANA) is approved for treating cancer cachexia (CCX) in Japan. We report the case of a 69-year-old man with stage IVB squamous cell lung cancer complicated by CCX, having a 13.6% weight loss in 6 months. After chemotherapy was initiated, his weight was further reduced. Therefore, we started ANA combined with a treatment approach by a multidisciplinary collaboration, including nutritionists and physical therapists. After initiation of ANA, the body weight, appetite, psoas muscle index, and physical functions rapidly improved during chemotherapy. ANA administration combined with a multidisciplinary collaboration approach can be an effective supportive therapy against CCX during chemotherapy.