Updates in Cancer Cachexia: Clinical Management and Pharmacologic Interventions

Despite a better understanding of the mechanisms causing cancer cachexia (CC) and development of promising pharmacologic and supportive care interventions, CC persists as an underdiagnosed and undertreated condition. CC contributes to fatigue, poor quality of life, functional impairment, increases treatment related toxicity, and reduces survival. The core elements of CC such as weight loss and poor appetite should be identified early. Currently, addressing contributing conditions (hypothyroidism, hypogonadism, and adrenal insufficiency), managing nutrition impact symptoms leading to decreased oral intake (nausea, constipation, dysgeusia, stomatitis, mucositis, pain, fatigue, depressed mood, or anxiety), and the addition of pharmacologic agents when appropriate (progesterone analog, corticosteroids, and olanzapine) is recommended. In Japan, the clinical practice has changed based on the availability of Anamorelin, a ghrelin receptor agonist that improved lean body mass, weight, and appetite-related quality of life (QoL) compared to a placebo, in phase III trials. Other promising therapeutic agents currently in trials include Espindolol, a non-selective β blocker and a monoclonal antibody to GDF-15. In the future, a single therapeutic agent or perhaps multiple medications targeting the various mechanisms of CC may prove to be an effective strategy. Ideally, these medications should be incorporated into a multimodal interdisciplinary approach that includes exercise and nutrition.

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.

What do patients and oncologists think about the evaluation and management of cancer-related anorexia-cachexia? The Quasar_SEOM study

INTRODUCTION

Cancer patients often suffer from malnutrition and early detection and raising awareness of nutritional issues is crucial in this population.

METHODS

The Spanish Oncology Society (SEOM) conducted the Quasar_SEOM study to investigate the current impact of the Anorexia-Cachexia Syndrome (ACS). The study employed questionnaires and the Delphi method to gather input from both cancer patients and oncologists on key issues related to early detection and treatment of ACS. A total of 134 patients and 34 medical oncologists were surveyed about their experiences with ACS. The Delphi methodology was used to evaluate oncologists' perspectives of ACS management, ultimately leading to a consensus on the most critical issues.

RESULTS

Despite widespread acknowledgement of malnutrition in cancer as a significant issue by 94% of oncologists, the study revealed deficiencies in knowledge and protocol implementation. A mere 65% of physicians reported being trained to identify and treat these patients, with 53% failing to address ACS in a timely manner, 30% not monitoring weight, and 59% not adhering to any clinical guidelines. The lack of experience was identified as the primary hindrance to the use of orexigens in 18% of cases. Furthermore, patients reported concerns and a perception of inadequate attention to malnutrition-related issues from their physicians.

CONCLUSION

The results of this study point to a gap in the care of this syndrome and a need to improve education and follow-up of cancer patients with anorexia-cachexia.

The role of the nurse in meeting the educational needs for self-care in cachectic cancer patients and their family caregivers: A scoping review

Objective

To give an overview of what is known about the nurse contribution to education in self-care by people with cancer cachexia and their family caregivers. Nurse-led patient education can help patients and their family caregivers to manage cancer symptoms, cancer treatments, and treatment side effects.

Methods

This scoping review explored the extent to which nurse-led education has become part of the multimodal management of cancer cachexia. It is based on a systematic search of Medline, Embase, CINAHL, APA PsycINFO, and the Cochrane Library. Search limits were English language, date ranges from January 2015 to March 2023, and adults 18 years and older.

Results

A total of 6370 titles were screened, 127 papers and conference abstracts were selected for full-text examination, and 9 publications were included in the review. The analysis found the nurses within the multidisciplinary cancer cachexia care team, like other healthcare professionals, do not have a shared understanding of cancer cachexia and its management. For nurses to be confident and competent in the provision of nurse-led cachexia education, they themselves need evidence-based education in cachexia care and how to tailor education according to cachexia stage, symptoms, emotional response, and social circumstance.

Conclusions

Nurses with the knowledge and confidence to provide cancer cachexia education for their patients can potentially play an important role in the management of cancer cachexia and mitigation of cachexia-related problems.

Factors Affecting the Assessment of Cancer Cachexia by Nurses Caring for Patients with Advanced Cancer Undergoing Chemotherapy: A Cross-Sectional Survey

Objective

This study aimed to identify the awareness, knowledge, and assessment of cancer cachexia among nurses who cared for patients with advanced cancer undergoing chemotherapy. In addition, we identified the factors that affected their assessments.

Methods

A cross-sectional survey was conducted among nurses who cared for patients with advanced cancer undergoing chemotherapy at designated cancer care hospitals and regional cancer care cooperation hospitals between June and September 2020. We applied Bandura's triadic reciprocal causation as the research framework. The questionnaire consisted of questions on awareness, knowledge, and assessment of cancer cachexia. Single and multiple regression analyses were conducted on the relationship between each variable and the number of assessment items.

Results

Questionnaires were sent to 1026 nurses, 403 of whom responded (response rate: 39.3%). Among these, 299 responses were valid, being a 74.1% valid response rate. The average age was 39.74 ​± ​9.65 years and the mean work experience as a nurse was 16.50 ​± ​9.14 years. In respect of the awareness of cancer cachexia, 93.3% of the participants answered “assessment of cancer cachexia was needed,” and 75.2% answered “a nurse's role includes assessing for cancer cachexia.” Only 15.4% responded positively regarding “confidence in the assessment of cancer cachexia.” Regarding knowledge of cancer cachexia, the percentage of correct answers to questions about the definition of cachexia and diagnostic criteria ranged from 45.5% to 53.8%. With regard to cancer cachexia assessments, the participants assessed “weight loss or rate of weight loss (56.9%),” “symptoms affecting nutritional status (54.2%),” and “anorexia (46.2%).” Factors affecting the assessment of cancer cachexia were higher knowledge scores on cancer cachexia (P ​= ​0.039), routine assessment of cancer cachexia (P ​< ​0.001), experiences of participating in in-hospital training on cancer cachexia (P ​= ​0.027), and collaborating with physical/occupational therapists in the nutritional management of patients (P ​= ​0.025).

Conclusions

Nurses held the view that their role required them to assess for cancer cachexia, but they did not feel confident in doing so. In addition, they lacked knowledge of reversible “cancer cachexia;” hence, the assessments were not routinely completed. Education on these topics and the development and standardization of tools to assess or collaborate with other professions are required.

Assessment of Cancer-Associated Cachexia - How to Approach Physical Function Evaluation

PURPOSE OF REVIEW

Cachexia is a devastating syndrome that impacts a majority of cancer patients. Early assessment of cachexia is critical to implementing cachexia treatments. Our aim was to summarize the existing cachexia assessment tools for their utility in both symptom and function evaluation.

RECENT FINDINGS

Several tools now exist that provide a symptom-based approach for evaluating weight change, appetite, and nutrition impact symptoms in cancer patients with cachexia. However, current instruments used to assess physical function changes related to cachexia are limited in depth and breadth. Instead, we recommend a tiered approach to cachexia-related functional assessment that involves evaluation of activities of daily living, general mobility, and exercise tolerance in a prioritized sequence. Current tools for cancer-associated cachexia assessment are adept at symptom evaluation. New approaches to physical function evaluation are needed that efficiently and broadly evaluate the diverse functional needs of cachexia patients.

Barriers in Nursing Practice in Cancer Cachexia: A Scoping Review

This scoping review aims to identify the barriers in practice and clinical trials for oncology nurses in cancer cachexia. We used the framework proposed by Arksey and O'Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Studies written in English and published between 2008 and 2021 were retrieved from five databases: MEDLINE, Cochrane Library, CINAHL, PsycINFO, and EMBASE. A total of 1075 studies were identified, and 34 full-text studies were assessed for eligibility by three researchers. Seventeen studies met the inclusion criteria. This review revealed several barriers to nursing practice and clinical trials in cancer cachexia. First, health-care professionals, including nurses, faced individual barriers (insufficient understanding and skills for diagnosis and management) and environmental barriers (lack of standardized screening tools or treatment options, difficulties in collaboration with other professions, and limited human resources) in practice. Second, studies on nurse-led interventions for cancer cachexia were relatively few and different in objectives, making it challenging to integrate the outcomes. Finally, there were no established educational programs for nurses that explicitly focused on cancer cachexia. This scoping review revealed individual and environmental barriers in nursing practice. In addition, there have relatively few clinical trials involving oncology nurses in cancer cachexia. Continuing education for nurses should cover cancer cachexia to improve the quality of oncology care in the future. It is also necessary to standardize practical assessment tools that are easy to assess daily and lead to interventions and develop nurse-led multidisciplinary care.

The Role of Nurse in the Multidisciplinary Management of Cancer Cachexia

Cancer cachexia is a complex syndrome for which multidisciplinary management through collaboration has the potential to improve patient outcomes and efficiency of care, through the integration of nursing into practice. These authors conducted a literature review of PubMed, EBSCO, OVID, and ProQuest for publications on the roles and responsibilities of nurses who are working in multidisciplinary teams for the management of cancer cachexia. We limited our search parameters for the literature review such that: (1) the included papers were published in the English language from January 2000 to February 2021 and (2) the included papers featured an adult patient population. Based on this review, cancer cachexia can be characterized as an involuntary loss of body weight that is combined with a dysregulation in the control of energy homeostasis and protein loss, which leads to poor clinical outcomes in patients. Cancer cachexia has been recognized as having multidimensional etiologies that are related to the nutritional and metabolic systems, as well as other physical and physiological systems, and to symptoms that manifest concurrently to the cachexia. While the clinical identification and taxonomic classification of cancer cachexia are usually associated with an observable degree of weight loss and muscular atrophy in a patient, clinical evidence of inflammation and related symptoms should be considered (in addition to the weight loss and muscular atrophy) in the diagnosis and evaluation of cancer cachexia, as will be argued in this paper. Early diagnosis, appropriate clinical assessment, and evaluation of cancer cachexia are crucial to predicting the onset of the condition and managing its symptoms when it occurs. Various tools have been developed for the clinical evaluation and diagnosis of cancer cachexia which reflect the multitudinous manifestations of the condition. Due to the diversity of its manifestations, multimodal therapy has gained popularity for the management of cancer cachexia. Multimodal therapy includes combined pharmacologic intervention, nutrition supplements, nutritional consultation, physical exercise, and symptom control. As these authors will demonstrate in this paper, this mode of multidisciplinary team management is increasingly supported by scientific evidence and as such, can be seen as essential for high-quality cancer cachexia management. Nursing plays an important role in the multidisciplinary care team model for cancer cachexia management, as nurses are well situated to perform screening, referral, coordination, nutritional consultation, physical exercise consultation, direct nutritional nursing, psychosocial support, symptom control, and hospice care. However, an increased focus on education, skills training, and tool development (as well as adoption of tools) on the part of nurses and other multidisciplinary team members is required to meet the goal of efficient care and improved outcomes for patients with cancer cachexia. These authors demonstrate that increasing roles and responsibilities for nurses in the management of cancer cachexia is a valuable area to explore in the literature and to implement in clinical practice. Our review aims to summarize the etiology and epidemiology, mechanisms-of-action, and multitudinous manifestations of cancer cachexia, the therapies that are used in cancer cachexia care and the management approaches by which this care is organized. Finally, these authors emphasize nurses' responsibilities in this mode of cancer cachexia multidisciplinary team management, which represents a fruitful benefit both in the research literature and in clinical settings.

Cancer Cachexia: Identification by Clinical Assessment versus International Consensus Criteria in Patients with Metastatic Colorectal Cancer

BACKGROUND

Cancer cachexia is associated with poorer outcomes and is often diagnosed by the Fearon criteria. Oncologists clinically identify cachexia based on a patient's presentation. In this study agreement between these identification methods was evaluated and associations with outcomes were studied in patients with metastatic colorectal cancer.

METHODS

Fearon criteria comprised weight loss >5% OR weight loss >2% with either BMI <20 kg/m² or sarcopenia (determined by CT-imaging). Clinical assessment by the oncologist was based on the patient's clinical presentation. Agreement was tested with Kappa. Associations with treatment tolerance and progression free survival (PFS) were tested with logistic regressions and Cox proportional hazards, respectively.

RESULTS

Of 69 patients, 52% was identified as cachectic according to Fearon criteria and 9% according to clinical assessment. Agreement between both methods was slight (Kappa 0.049, P = 0.457). Clinically cachectic patients had a shorter PFS than clinically non-cachectic patients (HR 3.310, P = 0.016). No other differences in outcomes were found between cachectic vs. non-cachectic patients using both methods.

CONCLUSIONS

The agreement between cancer cachexia identification by clinical assessment vs. Fearon criteria was slight. Further improvement of cachexia criteria is necessary to identify cachectic patients at risk of poorer outcomes, who may benefit from targeted cachexia interventions.

Cancer Anorexia and Cachexia: Screening in an Ambulatory Infusion Service and Nutrition Consultation

BACKGROUND

Cancer anorexia-cachexia syndrome compromises physical function and nutritional and emotional well-being. Systematic screening followed by nutrition referral for appropriate interventions is rare.
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OBJECTIVES

The purpose of this study was to pilot a screening process followed by nutritional assessment and intervention when warranted for patients with lung malignancies.
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METHODS

Adult patients with lung malignancies were invited to complete the 12-item Anorexia/Cachexia Scale (A/CS-12) on the day of chemotherapy initiation in ambulatory infusion. Those who scored at a preset threshold were referred to nutrition services for a comprehensive assessment and intervention plan. Those who scored better than the threshold completed the A/CS-12 at each infusion visit for as many as 16 weeks. 
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FINDINGS

90 participants enrolled, and 46 scored in a moderate-to-severe-risk category; of those, 42 were referred to nutrition services.

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.

Leveraging a Team Mental Model to Develop a Cancer Anorexia-Cachexia Syndrome Team

This article discusses the care of a 62-year-old man with non-small-cell lung cancer and associated cancer anorexia-cachexia syndrome (CACS), and demonstrates common challenges faced by such patients and their family caregivers. The case description illustrates the fragmented approach of various disciplines to the patient's CACS care, resulting in undertreatment, delayed and burdensome visits, and patient and caregiver frustration and emotional distress. The mounting problems that arise for the patient over time exemplify the absence of a shared mental model among the various providers, patient, and caregiver for the care of CACS. Shared knowledge among providers regarding the tasks to be performed, the other clinicians' functions, and optimal processes for CACS care was limited. Each provider was responsive to individual symptoms, rather than conceptualizing the constellation of symptoms as a syndrome that warrants coordinated care among clinicians. This resulted in the patient and the family caregiver being at odds with their various providers instead of working in partnership with a shared understanding toward common goals. Team mental models have the potential to enhance development and implementation of care plans and improve patient care and satisfaction by helping clinical care teams establish team membership, identify shared tasks, and facilitate interactions. To help inform ongoing clinical practice and research, this article demonstrates how clinicians at one cancer center are leveraging a team mental model to form and support an interdisciplinary CACS team that provides coordinated patient-centered care.

Second-Line Treatment Selection in Patients With Non-Small-Cell Lung Cancer of Adenocarcinoma Histology: Findings From a European Survey of Treating Physicians

BACKGROUND

Guidelines provide treatment recommendations for advanced non-small-cell lung cancer (NSCLC), but physicians must also consider other factors. We surveyed physicians treating NSCLC to determine their therapy goals, drivers of treatment choice, current prescribing behavior, and therapy expectations.

MATERIALS AND METHODS

In 2015, an online survey was conducted of 500 pulmonologists/oncologists treating lung adenocarcinoma in Germany, France, Italy, Spain, and the United Kingdom, comprising screening and therapy decision questions.

RESULTS

On average, physicians had 14.7 years of experience and treated 79 patients/3 months with stage IIIb/IV NSCLC. In patients with Eastern Cooperative Oncology Group (ECOG) 0-1, "prolonged survival/extending life" was the main therapy goal of physicians for first- (63%) and second-line (40%) patients; improvement in quality of life (QoL) was the main goal of 14% of physicians for second-line patients. For patients with ECOG ≥2, the main goal of second-line therapy was improvement in QoL (26%) or tumor-related symptoms (23%). Most (57%) physicians strongly agreed that they preferred a second-line treatment that extends overall survival (OS) while maintaining QoL; their greatest dissatisfaction with available second-line treatment options was the inability to "stop tumor progression over the long term" (66%). Physicians expected new therapies to become available within 12 months that would provide improvements in progression-free survival (83%) or OS (69%).

CONCLUSION

OS is important for second-line treatments in patients with stage IIIb/IV NSCLC, although QoL improvements should not be underestimated. This survey highlights the wait faced by patients and physicians as treatments transition from clinical trials to clinical practice.

Perspectives of health care professionals on cancer cachexia: results from three global surveys

Cachexia has a high prevalence in cancer patients, leading to reduced tolerance/response to treatment and decreased quality of life. Results from three global surveys presented herein demonstrate a definite need for increased awareness and educational initiatives to improve the knowledge and understanding of cancer cachexia among physicians in order to optimize patient outcomes.

Background

Cachexia has a high prevalence in cancer patients and negatively impacts prognosis, quality of life (QOL), and tolerance/response to treatments. This study reports the results of three surveys designed to gain insights into cancer cachexia (CC) awareness, understanding, and treatment practices among health care professionals (HCPs).

Methods

Surveys were conducted globally among HCPs involved in CC management. Topics evaluated included definitions and synonyms of CC, diagnosis and treatment practices, and goals and desired improvements of CC treatment.

Results

In total, 742 HCPs from 14 different countries participated in the surveys. The majority (97%) of participants were medical oncologists or hematologists. CC was most frequently defined as weight loss (86%) and loss of appetite (46%). The terms loss of weight and decreased appetite (51% and 34%, respectively) were often provided as synonyms of CC. Almost half (46%) of the participants reported diagnosing CC and beginning treatment if a patient experienced a weight loss of 10%. However, 48% of the participants would wait until weight loss was ≥15% to diagnose CC and start treatment. HCPs also reported that 61%–77% of cancer patients do not receive any prescription medication for CC before Stage IV of disease is reached. Ability to promote weight gain was rated as the most important factor for selecting CC treatment. Key goals of treatment included ensuring that patients can cope with the cancer and treatment and have a QOL benefit. HCPs expressed desire for treatments with a more CC-specific mode of action and therapies that enhance QOL.

Conclusions

These surveys underscore the need for increased awareness among HCPs of CC and its management.

Cardiac cachexia: hic et nunc

Cardiac cachexia (CC) is the clinical entity at the end of the chronic natural course of heart failure (HF). Despite the efforts, even the most recent definition of cardiac cachexia has been challenged, more precisely, the addition of new criteria on top of obligatory weight loss. The pathophysiology of CC is complex and multifactorial. A better understanding of pathophysiological pathways in body wasting will contribute to establish potentially novel treatment strategies. The complex biochemical network related with CC and HF pathophysiology underlines that a single biomarker cannot reflect all of the features of the disease. Biomarkers that could pick up the changes in body composition before they convey into clinical manifestations of CC would be of great importance. The development of preventive and therapeutic strategies against cachexia, sarcopenia, and wasting disorders is perceived as an urgent need by healthcare professionals. The treatment of body wasting remains an unresolved challenge to this day. As CC is a multifactorial disorder, it is unlikely that any single agent will be completely effective in treating this condition. Among all investigated therapeutic strategies, aerobic exercise training in HF patients is the most proved to counteract skeletal muscle wasting and is recommended by treatment guidelines for HF.

Cardiac cachexia: hic et nunc: "hic et nunc" - here and now

Cardiac cachexia (CC) is the clinical entity at the end of chronic natural course of heart failure (HF). Despite the efforts, even the most recent definition of cardiac cachexia has been challenged, more precisely the addition of new criteria on top of obligatory weight loss. The pathophysiology of CC is complex and multifactorial. Better understanding of pathophysiological pathways in body wasting will contribute to establish potentially novel treatment strategies. The complex biochemical network related with CC and HF pathophysiology underlines that a single biomarker cannot reflect all of the features of the disease. Biomarkers that could pick-up the changes in body composition before they convey into clinical manifestations of CC would be of great importance. The development of preventive and therapeutic strategies against cachexia, sarcopenia and wasting disorders is perceived as an urgent need by healthcare professionals. The treatment of body wasting remains an unresolved challenge to this day. As CC is a multifactorial disorder, it is unlikely that any single agent will be completely effective in treating this condition. Among all investigated therapeutic strategies, aerobic exercise training in HF patients is the most proved to counteract skeletal muscle wasting and is recommended by treatment guidelines for HF.