Improving muscle mass and function in cachexia: non-drug approaches. Curr Opin Support Palliat Care. 2011;5:361-364. [PMID: 21934503 DOI: 10.1097/spc.0b013e32834bdde3]

Muscle wasting in cancer cachexia: Mechanisms and the role of exercise

Cancer cachexia (CC) is a multifactorial disease marked by a severe and progressive loss of lean muscle mass and characterized further by inflammation and a negative energy/protein balance, ultimately leading to muscle atrophy and loss of muscle tissue. As a result, patients experiencing cachexia have reduced muscle function and thus less independence and a lower quality of life. CC progresses through stages of increasing severity: pre-cachexia, cachexia and refractory cachexia. Two proposed underlying mechanisms that drive cancer-induced muscle wasting are the autophagy-lysosome and ubiquitin-proteasome systems. An increase in autophagic flux and proteolytic activity leads to atrophy of both cardiac and skeletal muscle, ultimately mediated by tumour or immune-secreted inflammatory cytokines. These pathways occur at a basal level to maintain cellular homeostasis; therefore, it is the overactivation of the pathways that leads to muscle atrophy. Recent evidence demonstrates the ability of aerobic and resistance training to restore these pathways to their basal levels. The mechanism is not yet understood, and more research is needed to determine exactly how exercise influences each pathway. However, exercise has great promise as a therapeutic strategy for CC because of the evidence for it preserving muscle mass and function, and attenuating protein degradative pathways. The extent to which exercise affects the ubiquitin-proteasome and autophagy-lysosome systems is determined by the frequency, intensity and duration of the exercise protocol. As such, an ideal exercise prescription is lacking for individuals with CC.

Sarcopenia is an Independent Prognostic Factor in Patients With Pancreatic Cancer - a Meta-analysis

RATIONALE AND OBJECTIVES

Sarcopenia is defined as skeletal muscle loss and can be assessed by cross-sectional imaging. Our aim was to establish the effect of sarcopenia on relevant outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) in curative and palliative settings based on a large patient sample.

MATERIALS AND METHODS

MEDLINE library, EMBASE and SCOPUS databases were screened for the associations between sarcopenia and mortality in patients with PDAC up to March 2022. The primary endpoint of the systematic review was the hazard ratio of Sarcopenia on survival. 22 studies were included into the present analysis.

RESULTS

The included 22 studies comprised 3958 patients. The prevalence of sarcopenia was 38.7%. Sarcopenia was associated with a higher prevalence in the palliative setting (OR 53.23, CI 39.00-67.45, p<0.001) compared to the curative setting (OR 36.73, CI 27.81-45.65, p<0.001). Sarcopenia was associated with worse OS in the univariable (HR 1.79, CI 1.41-2.28, p<0.001) and multivariable analysis (HR 1.62, CI 1.27-2.07, p<0.001) in the curative setting. For the palliative setting the pooled hazards ratio showed that sarcopenia was associated with overall survival (HR 1.56, CI 1.21-2.02, p<0.001) as well as in multivariable analysis (HR 1.77, CI 1.39-2.26, p<0.001). Sarcopenia was not associated with a higher rate of post-operative complications in univariable analysis (OR 1.10, CI 0.70-1.72, p = 0.69).

CONCLUSION

Sarcopenia occurs in 38.7% of patients with pancreatic cancer, significantly more in the palliative setting. Sarcopenia is associated with overall survival in both settings. The assessment of sarcopenia is therefore relevant for personalized oncology. Sarcopenia is not associated with postoperative complications.

Wheel running improves fasting-induced AMPK signaling in skeletal muscle from tumor-bearing mice

Disruptions to muscle protein turnover and metabolic regulation contribute to muscle wasting during the progression of cancer cachexia. The initiation of cachexia is also associated with decreased physical activity. While chronic muscle AMPK activation occurs during cachexia progression in ApcMin/+ (MIN) mice, a preclinical cachexia model, the understanding of muscle AMPK's role during cachexia initiation is incomplete. Therefore, we examined if voluntary wheel exercise could improve skeletal muscle AMPK signaling in pre-cachectic MIN mice. Next, we examined muscle AMPK's role in aberrant catabolic signaling in response to a 12-h fast in mice initiating cachexia. Male C57BL/6 (B6: N = 26) and MIN (N = 29) mice were subjected to ad libitum feeding, 12-h fast, or 4 wks. of wheel access and then a 12-h fast during the initiation of cachexia. Male tamoxifen-inducible skeletal muscle AMPKα1 α2 (KO) knockout mice crossed with ApcMin/+ and floxed controls were examined (WT: N = 8, KO: N = 8, MIN: N = 10, MIN KO: N = 6). Male mice underwent a 12-h fast and the gastrocnemius muscle was analyzed. MIN gastrocnemius mass was reduced compared to B6 mice. A 12-h fast induced MIN muscle AMPKT172 , FOXOS413 , and ULK-1S555 phosphorylation compared to B6. Wheel running attenuated these inductions. A 12-h fast induced MIN muscle MuRF-1 protein expression compared to B6 and was suppressed by wheel running. Additionally, fasting induced muscle autophagy signaling and disrupted mitochondrial quality protein expression in the MIN, which was prevented in the MIN KO. We provide evidence that increased skeletal muscle AMPK sensitivity to a 12-h fast is an adverse event in pre-cachectic MIN mice, and exercise can improve this regulation.

Prognostic role of sarcopenia in metastatic colorectal cancer patients during first-line chemotherapy: A retrospective study

BACKGROUND

Sarcopenia is a condition characterized by decreased skeletal muscle mass due to physiological ageing or to a concomitant disease such as neoplasia. In cancer patients, a low lean body mass is suggested to be a negative prognostic factor for survival and for the development of dose-limiting chemotherapy toxicities irrespective of disease stage.

AIM

To evaluate the prognostic role of sarcopenia in patients with metastatic colorectal cancer (mCRC) undergoing first-line chemotherapy.

METHODS

Our retrospective analysis included 56 mCRC patients who received first-line chemotherapy from 2014 to 2017 at the Medical Oncology Unit of our hospital. Computerized scans were performed before starting chemotherapy and at the first disease reassessment. Sarcopenia was assessed using the skeletal mass index = muscle area in cm²/(height in m²) calculated at the L3 vertebra. Overall survival and objective response rate were evaluated. Toxicities were analyzed during the first four cycles of therapy and graded according to Common Terminology Criteria for Adverse Events version 4.0. A loss of skeletal muscle mass ≥ 5% was considered indicative of deterioration in muscle condition.

RESULTS

Median age was 67 years and 35.7% of patients were ≥ 70 years old. Fourteen patients (25%) were sarcopenic at baseline computed tomography (CT) scan (7/33 men; 7/23 women); 5/14 sarcopenic patients were ≥ 70 years old. Median follow-up was 26.8 mo (3.8-66.8 mo) and median overall survival was 27.2 mo (95%CI: 23.3-37.3). Sarcopenia was not correlated to overall survival (P = 0.362), to higher toxicities reported during the first 4 cycles of chemotherapy (P = 1.0) or to response to treatment (P = 0.221). At the first disease reassessment, a skeletal muscle loss (SML) ≥ 5% was found in 17 patients (30.3%) 3 of whom were already sarcopenic at baseline CT scan, while 7 patients became sarcopenic. SML was not correlated to overall survival (P = 0.961). No statistically significant correlation was found between baseline sarcopenia and age (P = 1.0), body mass index (P = 0.728), stage at diagnosis (P = 0.355) or neutrophil/lymphocyte ratio (P = 0.751).

CONCLUSION

Neither baseline sarcopenia nor SML affected survival. In addition, baseline sarcopenia was not related to worse treatment toxicity. However, these results must be interpreted with caution due to the limited sample size.

Exercise for cancer cachexia in adults

BACKGROUND

Cancer cachexia is a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass, with or without a loss of fat mass, leading to progressive functional impairment. Physical exercise may attenuate cancer cachexia and its impact on patient function. This is the first update of an original Cochrane Review published in Issue 11, 2014, which found no studies to include.

OBJECTIVES

To determine the effectiveness, acceptability and safety of exercise, compared with usual care, no treatment or active control, for cancer cachexia in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and eight other databases to March 2020. We searched for ongoing studies in trial registries, checked reference lists and contacted experts to seek relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials in adults with cancer cachexia, that compared a programme of exercise alone or in combination with another intervention, with usual care, no treatment or an active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for relevance and extracted data on study design, participants, interventions and outcomes from potentially relevant articles. We used standard methodological procedures expected by Cochrane. Our primary outcome was lean body mass and secondary outcomes were adherence to exercise programme, adverse events, muscle strength and endurance, exercise capacity, fatigue and health-related quality of life. We assessed the certainty of evidence using GRADE and included two Summary of findings tables.

MAIN RESULTS

We included four new studies in this update which overall randomised 178 adults with a mean age of 58 (standard deviation (SD) 8.2) years. Study sample size ranged from 20 to 60 participants and in three studies the proportion of men ranged from 52% to 82% (the fourth study was only available in abstract form). Three studies were from Europe: one in the UK and Norway; one in Belgium and one in Germany. The remaining study was in Canada. The types of primary cancer were head and neck (two studies), lung and pancreas (one study), and mixed (one study). We found two comparisons: exercise alone (strength-based exercise) compared to usual care (one study; 20 participants); and exercise (strength-based exercise/endurance exercise) as a component of a multimodal intervention (pharmacological, nutritional or educational (or a combination) interventions) compared with usual care (three studies, 158 participants). Studies had unclear and high risk of bias for most domains. Exercise plus usual care compared with usual care We found one study (20 participants). There was no clear evidence of a difference for lean body mass (8 weeks: MD 6.40 kg, 95% CI -2.30 to 15.10; very low-certainty evidence). For our secondary outcomes, all participants adhered to the exercise programme and no participant reported any adverse event during the study. There were no data for muscle strength and endurance, or maximal and submaximal exercise capacity. There was no clear evidence of a difference for either fatigue (4 to 20 scale, lower score was better) (8 weeks: MD -0.10, 95% CI -4.00 to 3.80; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score was better) (8 weeks: MD 4.90, 95% CI -15.10 to 24.90; very low-certainty evidence). Multimodal intervention (exercise plus other interventions) plus usual care compared with usual care We found three studies but outcome data were only available for two studies. There was no clear evidence of a difference for lean body mass (6 weeks: MD 7.89 kg, 95% CI -9.57 to 25.35; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -2.00, 95% CI -8.00 to 4.00; one study, 60 participants; very low-certainty evidence). For our secondary outcomes, there were no data reported on adherence to the exercise programme, endurance, or maximal exercise capacity. In one study (44 participants) there was no clear evidence of a difference for adverse events (patient episode report) (6 weeks: risk ratio (RR) 1.18, 95% CI 0.67 to 2.07; very low-certainty evidence). Another study assessed adverse events but reported no data and the third study did not assess this outcome. There was no clear evidence of a difference in muscle strength (6 weeks: MD 3.80 kg, 95% CI -2.87 to 10.47; 1 study, 44 participants; very low-certainty evidence; 12 weeks MD -5.00 kg, 95% CI -14.00 to 4.00; 1 study, 60 participants; very low-certainty evidence), submaximal exercise capacity (6 weeks: MD -16.10 m walked, 95% CI -76.53 to 44.33; 1 study, 44 participants; very low-certainty evidence; 12 weeks: MD -62.60 m walked, 95% CI -145.87 to 20.67; 1 study, 60 participants; very low-certainty evidence), fatigue (0 to 10 scale, lower score better) (6 weeks: MD 0.12, 95% CI -1.00 to 1.24; 1 study, 44 participants; very low-certainty evidence) or health-related quality of life (0 to 104 scale, higher score better) (12 weeks: MD -2.20, 95% CI -13.99 to 9.59; 1 study, 60 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The previous review identified no studies. For this update, our conclusions have changed with the inclusion of four studies. However, we are uncertain of the effectiveness, acceptability and safety of exercise for adults with cancer cachexia. Further high-quality randomised controlled trials are still required to test exercise alone or as part of a multimodal intervention to improve people's well-being throughout all phases of cancer care. We assessed the certainty of the body of evidence as very low, downgraded due to serious study limitations, imprecision and indirectness. We have very little confidence in the results and the true effect is likely to be substantially different from these. The findings of at least three more studies (one awaiting classification and two ongoing) are expected in the next review update.

Exercise Training as Therapeutic Approach in Cancer Cachexia: A Review of Potential Anti-inflammatory Effect on Muscle Wasting

Cachexia is a multifactorial inflammatory syndrome with high prevalence in cancer patients. It is characterized by a metabolic chaos culminating in drastic reduction in body weight, mainly due to skeletal muscle and fat depletion. Currently, there is not a standard intervention for cachexia, but it is believed that a dynamic approach should be applied early in the course of the disease to maintain or slow the loss of physical function. The present review sought to explain the different clinical and experimental applications of different models of exercise and their contribution to a better prognosis of the disease. Here the advances in knowledge about the application of physical training in experimental models are elucidated, tests that contribute substantially to elucidate the cellular and biochemical mechanisms of exercise in different ways, as well as clinical trials that present not only the impacts of exercise in front cachexia but also the challenges of its application in clinical practice.

Impact of Preoperative Skeletal Muscle Quality Measurement on Long-Term Survival After Curative Gastrectomy for Locally Advanced Gastric Cancer

BACKGROUND

Skeletal muscle quality is a prognostic factor in various cancers. However, similar studies on curatively resected gastric cancer are lacking. We evaluated skeletal muscle quality using intramuscular adipose tissue content (IMAC) to clarify its impact on survival in patients with locally advanced gastric cancer.

METHODS

We reviewed 370 patients who underwent curative resection for stage II/III gastric cancer. IMAC was calculated using preoperative computed tomography images. IMAC cutoff values were determined for each sex and were set at the 75th percentile. The patients were classified into normal and high IMAC groups according to the cutoff values. Clinicopathological factors and survival outcomes were compared between the two groups. Multivariate Cox regression analysis was used to identify independent prognostic factors for overall survival (OS) and cancer-specific survival (CSS).

RESULTS

In all, 277 patients were classified into the normal IMAC group and 93 were classified into the high IMAC group. The patients in the high IMAC group were older, more obese, and had more comorbidities and poor Eastern Cooperative Oncology Group performance status than those in the normal IMAC group. Although no significant differences were observed in the pathological findings between the two groups, a high IMAC was significantly associated with poor OS and CSS. Multivariate analysis identified high IMAC as an independent prognostic factor for both OS and CSS (p = 0.046 and p = 0.035, respectively).

CONCLUSIONS

High IMAC was significantly associated with poor survival, suggesting that skeletal muscle quality has oncological implications in patients with locally advanced gastric cancer.

Sarcopenic Obesity Is Associated with Severe Postoperative Complications in Gastric Cancer Patients Undergoing Gastrectomy: a Prospective Study

OBJECTIVE

This study aimed to determine the risk of severe postoperative complications (SPCs) in patients with gastric cancer and to construct a nomogram based on independently related factors to identify high-risk patients.

METHODS

We conducted a prospective study of 636 consecutive patients with gastric cancer who underwent radical gastrectomy. Degrees of sarcopenia and obesity were calculated before surgery. Factors contributing to SPCs were determined using univariate and multivariate analysis. A nomogram consisting of the independent risk factors was constructed to quantify the individual risk of SPCs.

RESULTS

Logistic analysis revealed that sarcopenic obesity, age, open surgery, and combined resection were independent prognostic factors for SPCs. Sarcopenic obese patients have the highest risk in all patients (sarcopenic obesity vs normal, OR = 6.575 p = 0.001; sarcopenic obesity vs obesity, OR = 5.833 p = 0.001; sarcopenic obesity vs sarcopenia, OR = 2.571 p = 0.032), while obese patients share the similar rate of SPCs with normal people (obesity vs normal, OR = 1.056 p = 0.723). The nomogram we constructed was able to quantify the risk of SPCs reliably (c-index, 0.737).

CONCLUSIONS

Sarcopenic obesity, together with age, open surgery, and combined resection are independent predictors of SPCs. Obesity will significantly increase the risk of SPCs in sarcopenic patient with gastric cancer, but it will not bring higher risk to normal patients. Our nomogram is a simple and practical instrument to identify patients at high risk of surgical complications.

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

Inflammatory signalling regulates eccentric contraction-induced protein synthesis in cachectic skeletal muscle

BACKGROUND

Skeletal muscle responds to eccentric contractions (ECC) with an anabolic response that involves the induction of protein synthesis through the mechanistic target of rapamycin complex 1. While we have reported that repeated ECC bouts after cachexia initiation attenuated muscle mass loss and inflammatory signalling, cachectic muscle's capacity to induce protein synthesis in response to ECC has not been determined. Therefore, we examined cachectic muscle's ability to induce mechano-sensitive pathways and protein synthesis in response to an anabolic stimulus involving ECC and determined the role of muscle signal transducer and activator of transcription 3 (STAT3)/nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) signalling on ECC-induced anabolic signalling.

METHODS

Mechano-sensitive pathways and anabolic signalling were examined immediately post or 3 h after a single ECC bout in cachectic male Apc^Min/+ mice (n = 17; 16 ± 1% body weight loss). Muscle STAT3/NFκB regulation of basal and ECC-induced anabolic signalling was also examined in an additional cohort of Apc^Min/+ mice (n = 10; 16 ± 1% body weight loss) that received pyrrolidine dithiocarbamate 24 h prior to a single ECC bout. In all experiments, the left tibialis anterior performed ECC while the right tibialis anterior served as intra-animal control. Data were analysed by Student's t-test or two-way repeated measures analysis of variance with Student-Newman-Keuls post-hoc when appropriate. The accepted level of significance was set at P < 0.05 for all analysis.

RESULTS

Apc^Min/+ mice exhibited a cachectic muscle signature demonstrated by perturbed proteostasis (Ribosomal Protein S6 (RPS6), P70S6K, Atrogin-1, and Muscle RING-finger protein-1 (MuRF1)), metabolic (adenosine monophosphate-activated protein kinase, Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), and Cytochrome c oxidase subunit IV (COXIV)), and inflammatory (STAT3, NFκB, extracellular signal-regulated kinases 1 and 2, and P38) signalling pathway regulation. Nonetheless, mechano-sensitive signalling pathways (P38, extracellular signal-regulated kinases 1 and 2, and Protein kinase B (AKT)) were activated immediately post-ECC irrespective of cachexia. While cachexia did not attenuate ECC-induced P70S6K activation, the protein synthesis induction remained suppressed compared with healthy controls. However, muscle STAT3/NFκB inhibition increased basal and ECC-induced protein synthesis in cachectic Apc^Min/+ mice.

CONCLUSIONS

These studies demonstrate that mechano-sensitive signalling is maintained in cachectic skeletal muscle, but chronic STAT3/NFκB signalling serves to attenuate basal and ECC-induced protein synthesis.

Impact of physical exercise in cancer survivors during and after antineoplastic treatments

Cancer patients experience symptoms and adverse effects of treatments that may last even after the end of treatments. Exercise is a safe, non-pharmacological and cost-effective therapy that can provide several health benefits in cancer patient and survivors, reducing cancer symptoms and cancer treatment side effects. The purpose of this review is to describe how the physical exercise is capable to reduce cancer symptoms and cancer treatment side effects. We realized a pragmatic classification of symptoms, dividing them into physical, psychological and psycho-physical aspects. For each symptom we discuss causes, therapies, we analyse the effects of physical exercise and we summarize the most effective type of exercise to reduce the symptoms. This review also points out what are the difficulties that patients and survivors face during the practice of physical activity and provides some solutions to overcome these barriers. Related to each specific cancer, it emerges that type, frequency and intensity of physical exercise could be prescribed and supervised as a therapeutic program, like it occurs for the type, dose and duration of a drug treatment.

A Novel Preoperative Skeletal Muscle Measure as a Predictor of Postoperative Complications, Long-Term Survival and Tumor Recurrence for Patients with Gastric Cancer After Radical Gastrectomy

BACKGROUND

Increasing numbers of studies have shown that skeletal muscle measures are closely associated with tumors. This study explored the relationship between skeletal muscle measures and short- and long-term outcomes after radical gastrectomy (RG) for gastric cancer (GC).

METHODS

The study analyzed 221 GC patients who underwent RG between December 2009 and December 2010. The total psoas area (TPA) and psoas density [Hounsfield unit average calculation (HUAC)] were measured. The total psoas gauge (TPG) was created by multiplying TPA × HUAC. Low TPA, low HUAC, and low TPG were defined in the categorical analyses as the lowest quartile. Logistic regression modeling, the Kaplan-Meier method, and three-step multivariate analysis were used.

RESULTS

The median follow-up period was 64 months. Compared with low TPA and low HUAC, only low TPG was an independent risk factor for postoperative complications. The univariate analysis showed that low TPA, low HUAC, and low TPG were predictors of overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CCS) after surgery. The result of the three-step multivariate analysis demonstrated that low TPG was an independent risk factor for OS, RFS, and CCS. Moreover, the prognostic value of TPG was superior to that of TPA and HUAC. The patients with low TPG experienced significantly more postoperative liver recurrence than the patients with high TPG (p = 0.011).

CONCLUSION

Compared with preoperative skeletal muscle quantity (TPA) and quality (HUAC), TPG can more accurately predict complications and prognosis after RG. In addition, TPG may be an indicator for the early detection of liver recurrence after RG.

Practical multimodal care for cancer cachexia

PURPOSE OF REVIEW

Cancer cachexia is common and reduces function, treatment tolerability and quality of life. Given its multifaceted pathophysiology a multimodal approach to cachexia management is advocated for, but can be difficult to realise in practice. We use a case-based approach to highlight practical approaches to the multimodal management of cachexia for patients across the cancer trajectory.

RECENT FINDINGS

Four cases with lung cancer spanning surgical resection, radical chemoradiotherapy, palliative chemotherapy and no anticancer treatment are presented. We propose multimodal care approaches that incorporate nutritional support, exercise, and anti-inflammatory agents, on a background of personalized oncology care and family-centred education. Collectively, the cases reveal that multimodal care is part of everyone's remit, often focuses on supported self-management, and demands buy-in from the patient and their family. Once operationalized, multimodal care approaches can be tested pragmatically, including alongside emerging pharmacological cachexia treatments.

SUMMARY

We demonstrate that multimodal care for cancer cachexia can be achieved using simple treatments and without a dedicated team of specialists. The sharing of advice between health professionals can help build collective confidence and expertise, moving towards a position in which every team member feels they can contribute towards multimodal care.

A Novel Prognostic Scoring System Based on Preoperative Sarcopenia Predicts the Long-Term Outcome for Patients After R0 Resection for Gastric Cancer: Experiences of a High-Volume Center

BACKGROUND

The relationship between sarcopenia and prognosis of gastric cancer (GC) is unclear. This study aimed to develop a prognostic scoring system combining sarcopenia with preoperative clinical parameters for patients with GC to predict 3-year overall survival (OS) and 3-year recurrence-free survival (RFS).

METHODS

In this study, 924 patients with GC who underwent radical gastrectomy were retrospectively analyzed. The data were divided into a training set and a validation set. Sarcopenia was diagnosed by the cutoff value of the skeletal muscle index (SMI) obtained by X-tile software. The study used COX regression to identify preoperative risk factors associated with 3-year OS and RFS.

RESULTS

In the training set, 103 patients (14.8%) were sarcopenic based on the cutoff value of the SMI (32.5 cm2/m2 for men and 28.6 cm2/m2 for women). Multivariate analysis showed the following preoperative risk factors for the training set: sarcopenia and preoperative T (cT) and N (cN) stages. A prognostic scoring system was developed based on these findings. The 3-year OS rates were 89% for the low-risk patients, 77.9% for the intermediate-risk patients, and 54.8% for the high-risk patients (P < 0.001), and the 3-year RFS rates were respectively 86.9, 75.3 and 49.3% (P < 0.001). The area under the receiver operating characteristic curves were 0.708 for the 3-year OS rates and 0.713 for the 3-year RFS rates. The observed and predicted incidence rates for 3-year OS and RFS in the validation set did not differ significantly.

CONCLUSIONS

The prognostic scoring system combining sarcopenia with the cT and cN system can accurately predict 3-year OS and RFS rates after radical gastrectomy for GC.

Body Composition as a Predictor of Toxicity in Patients Receiving Anthracycline and Taxane-Based Chemotherapy for Early-Stage Breast Cancer

Purpose: Poor body composition metrics (BCM) are associated with inferior cancer outcomes; however, in early breast cancer (EBC), there is a paucity of evidence regarding the impact of BCM on toxicities. This study investigates associations between BCM and treatment-related toxicity in patients with EBC receiving anthracyclines and taxane-based chemotherapy.Experimental Design: Pretreatment computerized tomographic (CT) images were evaluated for skeletal muscle area (SMA), skeletal muscle density (SMD), and fat tissue at the third lumbar vertebrae. Skeletal muscle index (SMI = SMA/height²) and skeletal muscle gauge (SMG = SMI × SMD) were also calculated. Relative risks (RR) are reported for associations between body composition measures and toxicity outcomes, after adjustment for age and body surface area (BSA).Results: BCM were calculated for 151 patients with EBC (median age, 49 years; range, 23-75 years). Fifty patients (33%) developed grade 3/4 toxicity, which was significantly higher in those with low SMI (RR, 1.29; P = 0.002), low SMG (RR, 1.09; P = 0.01), and low lean body mass (RR, 1.48; P = 0.002). Receiver operating characteristic analysis showed the SMG measure to be the best predictor of grade 3/4 toxicity. Dividing SMG into tertiles showed toxicity rates of 46% and 22% for lowest versus highest tertile, respectively (P = 0.005). After adjusting for age and BSA, low SMG (<1,475 units) was significantly associated with hematologic (RR, 2.12; P = 0.02), gastrointestinal grade 3/4 toxicities (RR, 6.49; P = 0.02), and hospitalizations (RR, 1.91; P = 0.05).Conclusions: Poor BCMs are significantly associated with increased treatment-related toxicities. Further studies are needed to investigate how these metrics can be used to more precisely dose chemotherapy to reduce treatment-related toxicity while maintaining efficacy. Clin Cancer Res; 23(14); 3537-43. ©2017 AACR.

Skeletal Muscle Measures as Predictors of Toxicity, Hospitalization, and Survival in Patients with Metastatic Breast Cancer Receiving Taxane-Based Chemotherapy

PURPOSE

Severe skeletal muscle (SM) loss (sarcopenia) is associated with poor cancer outcomes, including reduced survival and increased toxicity. This study investigates SM measures in metastatic breast cancer (MBC) patients receiving first-line taxane-based chemotherapy and evaluates associations with treatment toxicity and other outcomes.

EXPERIMENTAL DESIGN

Using computerized tomography (CT) images taken for the evaluation of disease burden, skeletal muscle area (SMA), and density (SMD) were measured at the third lumbar vertebrae. Sarcopenia was defined as skeletal muscle index (SMI = SMA/height²) ≤ 41. Skeletal muscle gauge (SMG) was created by multiplying SMI × SMD. Fisher exact tests, t tests, the Kaplan-Meier method, and Cox regression modeling were used.

RESULTS

MBC patients (N = 40), median age 55 (range, 34-80), 58% sarcopenic, median SMG 1296 AU (SD, 522). Grade 3-4 toxicity was found in 57% of sarcopenic versus 18% of non-sarcopenic patients (P = 0.02). Toxicity-related hospitalizations were also higher in sarcopenic patients (39% vs. 0%, P = 0.005) as were any adverse events-defined as any grade 3-4 toxicities, hospitalizations, dose reductions, or dose delay-(74% vs. 35%, P = 0.02). Low SMG was associated with grade 3-4 toxicity (P = 0.04), hospitalization (P = 0.01), and time to treatment failure (for progression or toxicity; P = 0.03). Low SMG had a borderline significant association with any adverse event (P = 0.06) and overall survival (P = 0.07).

CONCLUSIONS

SM measures are associated with toxicity outcomes and survival in MBC patients receiving first-line taxane-based chemotherapy. Further studies are needed to explore how routinely obtained CT scans can be used to individualize dosing and improve treatment planning. Clin Cancer Res; 23(3); 658-65. ©2016 AACR.

Aerobic and resistance training dependent skeletal muscle plasticity in the colon-26 murine model of cancer cachexia

PURPOSE

The appropriate mode of exercise training for cancer cachexia is not well-established. Using the colon-26 (C26) mouse model of cancer cachexia, we defined and compared the skeletal muscle responses to aerobic and resistance training.

METHODS

Twelve-month old Balb/c mice were initially assigned to control, aerobic training (AT; wheel running), or resistance training (RT; ladder climbing) (n=16-17/group). After 8weeks of training, half of each group was injected with C26 tumor cells, followed by 3 additional weeks of training. Body composition and neuromuscular function was evaluated pre- and post-training. Muscles were collected post-training and analyzed for fiber cross-sectional area (CSA), Akt-mTOR signaling, and expression of insulin-like growth factor-I (IGF-I) and myogenic regulatory factors.

RESULTS

Total body mass decreased (p<0.05) in C26 (-8%), AT+C26 (-18%), and RT+C26 (-15%) but not control. Sensorimotor function declined (p<0.05) in control (-16%), C26 (-13%), and RT+C26 (-23%) but not AT+C26. Similarly, strength/body weight decreased (p<0.05) in control (-7%), C26 (-21%), and RT+C26 (-10%) but not AT+C26. Gastrocnemius mass/body weight tended to be greater in AT+C26 vs. C26 (+6%, p=0.09). Enlargement of the spleen was partially corrected in AT+C26 (-27% vs. C26, p<0.05). Fiber CSA was lower in all C26 groups vs. control (-32% to 46%, p<0.05); however, the effect size calculated from C26 and AT+C26 was large (+24%, d=1.04). Phosphorylated levels of mTOR in AT+C26 exceeded C26 (+32%, p<0.05). RT+C26 showed greater mRNA expression (p<0.05) of IGF-IEa (+79%) and myogenin (+126%) with a strong tendency for greater IGF-IEb (+127%, p=0.069) vs.

CONCLUSIONS

Aerobic or resistance training was unable to prevent tumor-induced body weight loss. However, aerobic training may have preserved function, reduced the inflammatory response of the spleen, and marginally rescued muscle mass possibly through activation of mTOR. Aerobic training may therefore have therapeutic value for patients with cancer cachexia. In contrast, resistance training induced the expression of genes associated with muscle damage and repair. This gene response may be supportive of excessive stress generated by high resistance loading in a tumor-bearing state.

Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review

BACKGROUND

Body composition plays an important role in predicting treatment outcomes in adults with cancer. Using existing computed tomographic (CT) cross-sectional imaging and readily available software, the assessment of skeletal muscle mass to evaluate sarcopenia has become simplified. We performed a systematic review and meta-analysis to quantify the prognostic value of skeletal muscle index (SMI) obtained from cross-sectional CT imaging on clinical outcomes in non-haematologic solid tumours.

METHODS

We searched PubMed and the American Society Clinical Oncology online database of meeting abstracts up to October 2015 for relevant studies. We included studies assessing the prognostic impact of pre-treatment SMI on clinical outcomes in patients with non-haematologic solid tumours. The primary outcome was overall survival (OS) and the secondary outcomes included cancer-specific survival (CSS), disease-free survival (DFS), and progression-free survival (PFS). The summary hazard ratio (HR) and 95% confidence interval (CI) were calculated.

RESULTS

A total of 7843 patients from 38 studies were included. SMI lower than the cut-off was associated with poor OS (HR = 1.44, 95% CI = 1.32-1.56, p < 0.001). The effect of SMI on OS was observed among various tumour types and across disease stages. Worse CSS was also associated with low SMI (HR = 1.93, 95% CI = 1.38-2.70, p < 0.001) as well as DFS (HR = 1.16, 95% CI = 1.00-1.30, p = 0.014), but not PFS (HR = 1.54, 95% CI = 0.90-2.64, p = 0.117).

CONCLUSIONS

This meta-analysis demonstrates that low SMI at cancer diagnosis is associated with worse survival in patients with solid tumours. Further research into understanding and mitigating the negative effects of sarcopenia in adults with cancer is needed.

'I am actually doing something to keep well. That feels really good': Experiences of exercise within hospice care

Background: Patients with advanced cancer frequently experience functional impairment and reduced quality of life. Therapeutic exercise can provide benefit and be made accessible through the use of tailored programmes. Most studies examining exercise programmes for people with advanced cancer have used quantitative outcome measures and focussed on objective physical function, therefore offer a limited perspective on the experience of exercise participation.

Methods: This qualitative study explored patients' experiences of an exercise programme within a palliative care setting. The interviews focussed on the perceived impact on all aspects of quality of life.

Results: Nine people with advanced cancer, attending a hospice-based exercise programme, completed a one-to-one interview with a senior physiotherapist to explore the physical, emotional, and social impacts of their participation. Interviews were audiotaped, transcribed verbatim and analysed using interpretive phenomenological analysis. Patients reported an awareness of the positive physical, psychological, and social consequences of exercising. Their experiences reflected on all dimensions of quality of life, the impact of others and the sense of meaning gained through participation in exercise.

Conclusion: Our findings highlight that exercise in palliative care should not be viewed solely a physical intervention, but one that has potential to enhance many aspects of patients' quality of life.

Exercise for cancer cachexia in adults

BACKGROUND

Cancer cachexia is a multi-factorial syndrome characterised by an ongoing loss of skeletal muscle mass, with or without a loss of fat mass, which leads to progressive functional impairment. Physical exercise may attenuate the effects of cancer cachexia via several mechanisms, including the modulation of muscle metabolism, insulin sensitivity and levels of inflammation.

OBJECTIVES

The primary objective was to determine the effects of exercise, compared to usual care or no treatment, on lean body mass, the main biomarker of cachexia, in adults with cancer. Secondary objectives, subject to the availability of data, were to examine the acceptability and safety of exercise in this setting and to compare effects according to the characteristics of the exercise intervention or patient population.

SEARCH METHODS

We searched the databases CENTRAL (Issue 6, 2014) , MEDLINE (1946 to June 2014), EMBASE (1974 to June 2014), DARE and HTA (Issue 6, 2014), ISI Web of Science (1900 to June 2014), LILACS (1985 to 28 June 2014), PEDro (inception to 28 June 2014), SciVerse SCOPUS (inception to 28 June 2014), Biosis Previews PreMEDLINE (1969 to June 2014) and Open Grey (inception to 28 June 2014). We also searched for ongoing studies, checked reference lists and contacted experts to seek potentially relevant research.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults meeting the clinical criteria for cancer cachexia comparing a programme of exercise as a sole or adjunct intervention to no treatment or an active control. We imposed no language restriction.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of articles for relevance and extracted data on study design, participants, interventions and outcomes from potentially relevant articles.

MAIN RESULTS

We screened 3154 individual references, of which we removed 3138 after title screening and read 16 in full. We found no trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the safety and effectiveness of exercise for patients with cancer cachexia. Randomised controlled trials (i.e., preferably parallel-group or cluster-randomised trials) are required to test the effectiveness of exercise in this group. There are ongoing studies on the topic, so we will update this review to incorporate the findings.

Is exercise ignored in palliative cancer patients?

Exercise and rehabilitation approaches in palliative care programs for cancer patients affect patients’ symptoms, physical functioning, muscle strength, emotional wellbeing, psychological symptoms, functional capacities, quality of life, mortality and morbidity positively. Based on scientific data, palliative cancer patients should be recommended to participate in exercise programs. There is no standard approach to recipe an exercise regimen for a palliative cancer survivor. Studies for demonstrating the positive effects of exercising in palliative care patients are increasing in number day by day. At this point, increasing awareness about exercising in the entire team monitoring the patient and our efforts in this matter seems to be very important.

Immunological and hormonal effects of exercise: implications for cancer cachexia

PURPOSE OF REVIEW

There is increasing interest in the use of therapeutic exercise for cancer cachexia. Apart from the directly beneficial effects on muscle, exercise has the potential to attenuate some of the immunological and hormonal abnormalities found in cachexia. This review summarizes the findings of recent studies, which have explored such effects in patients with cancer, and discusses their relevance to patients with cancer cachexia.

RECENT FINDINGS

Our search identified 11 studies in patients with breast, colorectal, lung, and prostate cancer, predominantly with early stage disease or following primary curative treatment. Overall, exercise was associated with reduced levels of C-reactive protein (CRP), but not other markers of systemic inflammation. There was no consistent impact on levels of glucose, insulin or measures of insulin sensitivity or, in patients with prostate cancer, on levels of testosterone.

SUMMARY

There is limited scope to extrapolate these findings to patients with cancer cachexia, who are more likely to have advanced disease, higher levels of systemic inflammation, and greater degrees of metabolic dysfunction. Studies specific to this group are required to explore what, if any, changes exercise can make to levels of CRP and other immune and hormonal biomarkers, along with their potential clinical relevance.

The feasibility and acceptability of neuromuscular electrical stimulation to improve exercise performance in patients with advanced cancer: a pilot study

Background

To determine the feasibility and acceptability of lower limb neuromuscular electrical stimulation (NMES) as a home-based exercise therapy in patients with cancer who could not attend hospital-based exercise training.

Methods

A single-arm prospective pilot study of NMES, applied daily to both quadriceps muscles for six weeks. Participants were recruited from patients referred to a hospital-based multi-disciplinary supportive care team specializing in treatment of patients with nutritional depletion and functional decline.

Results

Of the 15 participants who underwent baseline testing, 10 (67%) completed the study and only one (7%) withdrew because of discomfort due to NMES treatment. 7/10 (70%) of participants used NMES at least three times a week for the duration of the study. Use of NMES did not lead to significant improvements in physical performance tests.

Conclusions

NMES is a feasible and acceptable intervention for home use in patients with cancer, poor performance status and metastatic disease. However, whether NMES is an effective strategy to stabilize or improve physical performance in such patients is not proven.

Effect of physical exercise on muscle mass and strength in cancer patients during treatment--a systematic review

Cancer treatment and its side effects may cause muscle wasting. Physical exercise has the potential to increase muscle mass and strength and to improve physical function in cancer patients undergoing treatment. A systematic review was conducted to study the effect of physical exercise (aerobic, resistance or a combination of both) on muscle mass and strength in cancer patients with different type and stage of cancer disease. Electronic searches were performed up to January 11th 2012, identifying 16 randomised controlled trials for final data synthesis. The studies demonstrated that aerobic and resistance exercise improves upper and lower body muscle strength more than usual care. Few studies have assessed the effect of exercise on muscle mass. Most studies were performed in patients with early stage breast or prostate cancer. Evidence on the effect of physical exercise on muscle strength and mass in cancer patients with advanced disease is lacking. More exercise studies in patients with advanced cancer and at risk of cancer cachexia are warranted.

Have guidelines addressing physical activity been established in nonalcoholic fatty liver disease?

The purpose of this review was to highlight, in relation to the currently accepted pathophysiology of non-alcoholic fatty liver disease (NAFLD), the known exercise habits of patients with NAFLD and to detail the benefits of lifestyle modification with exercise (and/or physical activity) on parameters of metabolic syndrome. More rigorous, controlled studies of longer duration and defined histopathological end-points comparing exercise alone and other treatment are needed before better, evidence-based physical activity modification guidelines can be established, since several questions remain unanswered.

Research on cachexia, sarcopenia and skeletal muscle in cardiology

BACKGROUND

The awareness of cardiac cachexia, i.e. involuntary weight loss in patients with underlying cardiovascular disease, has increased over the last two decades.

METHODS AND RESULTS

This mini-review looks at recent research in the cardiovascular literature that is relevant to the areas of interest of the Journal of Cachexia, Sarcopenia and Muscle. It identifies significant research in the last 3 years on the obesity paradox, the causes and effects of skeletal muscle wasting, animal models of cachexia and emerging treatment ideas in cardiac cachexia.

CONCLUSIONS

Assuming a similar literature in the fields of cancer, chronic obstructive pulmonary disease, chronic renal failure and chronic liver failure, the emergence of cachexia as a vibrant area of clinical and experimental research seems assured.

Changes in activities of daily living, nutrient intake, and systemic inflammation in elderly adults receiving recuperative care

OBJECTIVES

To determine the relationships between physical function, systemic inflammation, and nutrient intake in elderly adults who are deconditioned or recovering from medical illness.

DESIGN

Prospective observational study.

SETTING

Recuperative care and rehabilitation setting of a Veterans Affairs hospital.

PARTICIPANTS

Older adults assessed to be in need of and likely to benefit from specialized inpatient care (N = 336, aged 78.9 ± 7.5, median length of stay 24 days).

MEASUREMENTS

Functional assessments and plasma analyses for albumins and inflammatory markers were performed at admission and discharge. Complete nutrient intake assessments were performed daily. Katz (independence in activities of daily living) and walking endurance (distance capability and summation of need for assistive device and human help) scores were based on direct observation and provider query. Data were analyzed using least-squares and logistic regression analyses.

RESULTS

Changes in physical function between admission and discharge were positively correlated with change in nutrient intake and inversely correlated with inflammation at admission and its change. Participants in the upper quartile of change for nutrient intake (particularly improved protein intake) were two to three times as likely to experience a clinically significant change in functional status during the hospitalization. Similarly, the odds of experiencing an improvement in physical function were two to four times as great for participants whose C-reactive protein levels declined as for those whose levels increased. These relationships remained significant after controlling for age, length of stay, and other baseline indicators of health status.

CONCLUSION

Protein intake and inflammation are significantly correlated with functional recovery for aging individuals undergoing recuperative care and rehabilitation. Future studies should investigate whether combined interventions that target these factors improve recovery during hospitalization for this population.

Muscle function in COPD: a complex interplay

The skeletal muscles play an essential role in life, providing the mechanical basis for respiration and movement. Skeletal muscle dysfunction is prevalent in all stages of chronic obstructive pulmonary disease (COPD), and significantly influences symptoms, functional capacity, health related quality of life, health resource usage and even mortality. Furthermore, in contrast to the lungs, the skeletal muscles are potentially remedial with existing therapy, namely exercise-training. This review summarizes clinical and laboratory observations of the respiratory and peripheral skeletal muscles (in particular the diaphragm and quadriceps), and current understanding of the underlying etiological processes. As further progress is made in the elucidation of the molecular mechanisms of skeletal muscle dysfunction, new pharmacological therapies are likely to emerge to treat this important extra-pulmonary manifestation of COPD.