New cancer cachexia staging system for use in clinical practice

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Functional Liver Imaging Score Derived from Gadoxetic Acid-enhanced MRI Predicts Cachexia and Prognosis in Hepatocellular Carcinoma Patients

OBJECTIVE

Cachexia occurs in approximately half of hepatocellular carcinoma (HCC) patients as the disease progresses and is correlated with a poor prognosis. Therefore, early identification of HCC patients at risk of developing cachexia and their prognosis is crucial. This study investigated the functional liver imaging score (FLIS) derived from gadoxetic acid-enhanced magnetic resonance imaging (MRI) to identify cachexia in HCC patients and their prognosis.

METHODS

Pretreatment clinical and MRI data from 339 HCC patients who underwent gadoxetic acid-enhanced MRI scans were retrospectively collected. Patient weights were recorded for 6 months following the MRI scan to diagnose cachexia. The FLIS was calculated as the sum of the enhancement quality score, the excretion quality score, and the portal vein sign quality score. A Cox proportional hazards model was used to determine the significant factors affecting overall survival (OS). Multivariable logistic regression was then conducted to identify variables predicting cachexia in HCC patients, which were subsequently used to predict OS.

RESULTS

Cox regression analysis revealed a significant association between cachexia and worse OS. Both FLIS (0-4 vs. 5-6 points) (OR, 9.20; 95% CI: 4.68-18.10; P<0.001) and α-fetoprotein >100 ng/mL (OR, 4.08; 95% CI: 2.13-7.83; P<0.001) emerged as significant predictors of cachexia in patients with HCC. Furthermore, FLIS (0-4 vs. 5-6 points) (HR, 1.73; 95% CI: 1.19-2.51; P=0.004) was significantly associated with OS. Patients in the FLIS 0-4 points group had shorter OS than those in the FLIS 5-6 points group [20 months (95% CI, 14.7-25.3) vs. 43 months (95% CI, 27.7-58.3); P=0.001].

CONCLUSION

Cachexia was associated with worse OS. The functional liver imaging score emerged as a significant predictor of cachexia in HCC patients and their prognosis.

Prevalence of and Survival with Cachexia among Patients with Cancer: A Systematic Review and Meta-Analysis

Cachexia is associated with lower overall survival (OS) in patients with cancer; however, the relationship between the two is reported to differ according to the definitive criteria for diagnosing cachexia. We aimed to investigate 1) the difference in the prevalence of cachexia in patients with cancer and 2) the association between cachexia and OS, depending on the definitive criteria for diagnosing cachexia in patients with cancer. We searched PubMed and Web of Science from their inception until July 31, 2023, to identify eligible studies. We conducted a systematic review of the prevalence of cachexia in patients with cancer and performed a meta-analysis to investigate its relationship with OS. A total of 125 articles comprising 137,960 patients were included in the systematic review, and 26 articles consisting of 11,118 patients underwent meta-analysis. The overall prevalence of cachexia in patients with cancer was 33.0% (95% confidence interval [CI]: 32.8, 33.3); however, it varied according to the definitive criteria for diagnosing cachexia (13.9%-56.5%). According to the Fearon 2011 criteria, the prevalence of cachexia was associated with a high hazard ratio (HR) for OS compared with that of noncachexia [HR: 1.58 (95% CI: 1.45, 1.73)]; according to the other criteria, the HR was 2.78 (95% CI: 1.88, 4.11), indicating significant subgroup differences (P = 0.006). The dose-response curve indicated that the HR for OS plateaued at a cachexia prevalence range of 40%-50% (l-shaped relationship). The prevalence of cachexia in patients with cancer may vary depending on the definitive criteria used to diagnose cachexia. The HR for OS was higher for low cachexia prevalence. The definitive criteria should be carefully considered when assessing cachexia in patients with cancer. This trial was registered at the PROSPERO as CRD42023435474.

Association of the muscle mass phenotype as assessed by a grading system with the quality of life of patients with incurable cancer in palliative care

BACKGROUND

Loss of muscle mass (MM) is common in advanced stages of cancer, with an impact on worsening quality of life (QoL). In the current study the relationship of a previously proposed simple grade system to assess MM phenotypes with QoL was investigated to strengthen its clinical significance.

AIM

To verify whether the MM phenotypes, which were evaluated by using a grading system, are associated with the quality of life (QoL) of patients with incurable cancer.

METHODS

Secondary data from a cohort of patients with incurable cancer in palliative care were analyzed. The grade system considers measurements of the muscle area arm and handgrip strength. Based on these measurements, patients are classified as probably non-sarcopenic (NSarc), probably sarcopenic (PSarc), and sarcopenic (Sarc). The outcome measure was QoL domains assessed by the EORTC QoL Questionnaire Core-15. Logistic regression models were used to verify the association of the domains of QoL with the MM phenotypes.

RESULTS

A total of 770 patients were included, median age of 62 years and 56.6% females. The PSarc group had significantly worse scores in the QoL domains when compared to the NSarc group (physical p = 0.001, emotional p = 0.018, fatigue p < 0.001, nausea p = 0.017, insomnia p = 0.001, appetite loss p = 0.002, and global health p = 0.043). Adjusted logistic regression analysis showed an increased risk of worse QoL in the PSarc and Sarc, when compared to NSarc, respectively (odds ratio [OR], 95% confidence interval [CI]): physical (OR: 2.54, CI: 1.78-3.62 and OR: 7.18, CI: 4.24-12.17), emotional (OR: 1.61, CI: 1.15-2.24 and OR: 1.49, CI: 1.01-2.20), fatigue (OR: 1.89, CI: 1.35-2.64 and OR: 1.83, CI: 1.23-2.71), insomnia (OR: 2.01, CI: 1.43-2.83 and OR: 3.11, CI: 2.04-4.75), while appetite loss domain was associated with the PSarc (OR: 1.40, CI: 1.02-1.96), together with global health in the Sarc group (OR: 1.56, CI: 1.06-2.29).

CONCLUSION

The severity of the MM phenotype was associated with a worse QoL domains. Our results highlight the importance of MM preserving to affecting QoL status. The grading system can be useful for predicting the QoL in those patients, and its usefulness can potentially impact clinical and therapeutic decision-making.

Factors associated with variability in skeletal muscle radiodensity in patients with metastatic cancer

OBJECTIVES

This study aimed to explore factors associated with skeletal muscle radiodensity (SMD) variability in patients with metastatic cancer.

METHODS

This study included 393 patients (median age 61 y, 70% women) who had computed tomography (CT) scans within 30 days of inclusion in the study. SMD was evaluated from CT by averaging the Hounsfield unit value of the total muscle area. Skeletal muscle index (SMI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and total adipose tissue index (TATI) were also assessed by CT. Additionally, age, sex, race/skin color, disease characteristics, comorbidities, inflammatory markers, handgrip strength (HGS), and body mass index (BMI) were recorded and evaluated in the linear regression analysis to identify factors associated with SMD variability.

RESULTS

Multivariate explanatory models having SMD as an independent variable were performed and included BMI (model 1, r2 = 0.699), TATI (model 2, r2 = 0.712) or VATI and SATI (model 3, r2 = 0.706) in addition to age, race/skin color, tumor site, kidney disease, serum albumin, HGS, and SMI as dependent variables. For all models, lower SMD was associated with higher age, BMI, and adiposity measurements, kidney disease, White race/skin color, and lower serum albumin, HGS, and SMI. The primary tumor site also contributed to changes in SMD in all models, specifically those located in the gastrointestinal tract, gynecologic, and bone and connective tissue.

CONCLUSION

In this group of patients with metastatic cancer, lower SMD was associated with older age, White race/skin color, and an overall worse clinical condition.

Proposal of a nutrition screening algorithm for patients with incurable cancer receiving palliative care: Data from a prospective cohort

OBJECTIVE

To propose and evaluate the clinical utility of a new nutrition screening algorithm, NutriPal, to detect the degree of nutritional risk in patients with incurable cancer receiving palliative care.

METHODS

It is a prospective cohort conducted in an oncology palliative care unit. The NutriPal algorithm was used in a three-step process: (i) administration of the Patient-Generated Subjective Global Assessment short form; (ii) calculation of the Glasgow Prognostic Score; and (iii) application of the algorithm to classify patients into four degrees of nutritional risk. The higher the degrees of NutriPal, the worse the nutritional risk, comparing nutritional measures, laboratory data, and overall survival (OS).

RESULTS

The study included 451 patients that were classified using the NutriPal. They were allocated to the degrees: 1 (31.26%), 2 (27.49%), 3 (21.73%), and 4 (19.71%). Statistically significant differences were found in most of the nutritional and laboratory parameters and in OS with each increment in the NutriPal degrees, and OS was reduced (log-rank <0.001). In addition, NutriPal was able to predict a 120-day mortality: there was a significantly higher risk of death in the patients classified as degrees 4 (hazard ratio [HR], 3.03; 95% confidence interval [95% CI], 2.18-4.19), 3 (HR, 2.01; 95% CI, 1.46-2.78), and 2 (HR, 1.42; 95% CI; 1.04-1.95) than in those classified as degree 1. It also showed good predictive accuracy (concordance statistic, 0.76).

CONCLUSION

The NutriPal is associated to nutritional and laboratory parameters and can predict survival. It could therefore be incorporated into clinical practice for patients with incurable cancer receiving palliative care.

Diagnosis and prevalence of cachexia in Asians: A scoping review

The aim of this scoping review was to characterize the diagnostic criteria, their cutoff values, and the prevalence of cachexia in Asians. We systematically reviewed studies involving Asian adult patients with cachexia due to cancer and chronic diseases other than cancer, such as heart and renal failure. Sources in English and Japanese published between December 2008 and April 2022, including observational, longitudinal, cross-sectional, and clinical trials, were examined. We searched six databases. Altogether, 4131 studies were screened, and 107 eligible articles were identified, of which 11 and 96 were conducted on non-cancer and cancer patients, respectively. The most common clinical indicators used for diagnosis were weight loss, body mass index (BMI), and muscle mass. The most frequently employed diagnostic criteria for cachexia in non-cancer patients were the modified/excerpt Evans criteria. Contrarily, the original Fearon's criteria were often used in patients with cancer. Additionally, cutoff values for BMI and muscle mass affected by racial anthropometric differences were investigated. The mean or median value of BMI ranges were 18.3 to 25.2 and 17.5 to 25 kg/m2 for non-cancer and cancer patients, respectively. The prevalence rates of cachexia were 3.4% to 66.2% and 6.2% to 93% in non-cancer and cancer patients, respectively. Several diagnostic criteria, such as BMI and muscle mass, have been used, which are affected by racial differences in body size. However, few studies have used cutoff values for Asians.

The Role of Exercise in Cancer-Related Sarcopenia and Sarcopenic Obesity

One of the most common adverse effects of cancer and its therapeutic strategies is sarcopenia, a condition which is characterised by excess muscle wasting and muscle strength loss due to the disrupted muscle homeostasis. Moreover, cancer-related sarcopenia may be combined with the increased deposition of fat mass, a syndrome called cancer-associated sarcopenic obesity. Both clinical conditions have significant clinical importance and can predict disease progression and survival. A growing body of evidence supports the claim that physical exercise is a safe and effective complementary therapy for oncology patients which can limit the cancer- and its treatment-related muscle catabolism and promote the maintenance of muscle mass. Moreover, even after the onset of sarcopenia, exercise interventions can counterbalance the muscle mass loss and improve the clinical appearance and quality of life of cancer patients. The aim of this narrative review was to describe the various pathophysiological mechanisms, such as protein synthesis, mitochondrial function, inflammatory response, and the hypothalamic-pituitary-adrenal axis, which are regulated by exercise and contribute to the management of sarcopenia and sarcopenic obesity. Moreover, myokines, factors produced by and released from exercising muscles, are being discussed as they appear to play an important role in mediating the beneficial effects of exercise against sarcopenia.

Cachexia staging score predicts survival in patients with cancer who receive palliative care

OBJECTIVE

The aim of this study was to validate the cachexia staging score (CSS), a multidimensional, item-based diagnostic method of cachexia severity, for patients with advanced cancer receiving palliative care.

METHODS

Eligible patients were those with cancer who received palliative care during hospitalization between May 2019 and April 2020. All data were collected retrospectively from medical records. Cachexia was graded into four levels according to the CSS. Kaplan-Meier curves were constructed with or without death as the outcome, comparing prognoses among different levels of cachexia with Bonferroni correction. Cox proportional hazards regression analysis was performed to identify factors affecting mortality.

RESULTS

The mean age of the 196 patients was 65.8 ± 14 y. Men made up 42% of the study population. Lower body mass index, increased rate of weight loss, increased strength, assistance walking, rising from a chair, climbing stairs, and falls (SARC-F) points, decline in activities of daily living, appetite loss, and abnormal blood biomarkers were significantly more common with increasing severity of cachexia, and survival was shorter (P < 0.001). The hazard ratio (HR) increased with worsening severity of cachexia according to CSS classification (precachexia: HR, 2.78; 95% confidence interval [CI], 0.62-12.46, P = 0.182; cachexia: HR, 4.77; 95% CI, 1.09-20.80; P = 0.038; and refractory cachexia: HR, 11.00; 95% CI, 2.37-51.07; P = 0.002).

CONCLUSIONS

The CSS predicted life expectancy in a population of patients receiving palliative care and had excellent prognostic discriminative power to classify patients at different stages of cachexia.

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.

Cachexia and bladder cancer: clinical impact and management

PURPOSE OF REVIEW

The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa).

RECENT FINDINGS

Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia.

SUMMARY

Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.

Contemporary Insights into Cancer Cachexia for Oncology Nurses

Cachexia is a complex, multiorgan phenomenon targeting skeletal muscle resulting from systemic metabolic imbalances. Multifocal in nature, It's ultimate outcome is significant muscle degradation and loss of adipose tissue exhibited as the "wasting syndrome" which is associated with significant functional decline. Currently, there are no approved biomarkers for screening nor therapeutic options to manage cancer cachexia. Furthermore, multiple psychosocial sequelae characterize the patient and family coping paradigm. Heightened education about the pathophysiology of cancer cachexia and awareness of intra-familial emotional distress can enhance oncology nurses' advocacy about, and attentiveness to, this common manifestation of advanced cancer.