Awareness of malnutrition and cachexia in cancer patients
The urgent need for better recognition of malnutrition and cachexia in cancer patients was highlighted by the Sharing Progress in Cancer Care (SPCC) task force on Nutrition and Cachexia in Cancer Patients, held as a virtual meeting on June 22, 2020, with 13 stakeholders from organisations across Europe.
The task force looked to disseminate findings from the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in cancer patients and the related ESPEN recommendations for action against cancer-related malnutrition:
– Screening all patients with cancer for nutritional risk early in the course of care,
– Expanding measures of anorexia, body composition, and inflammatory biomarkers,
– Increasing nutritional intake, decreasing inflammation and hypermetabolic stress, and increasing physical activity.
Cachexia and malnutrition should be detected at cancer diagnosis, treated as early as possible and monitored through the patient journey.
Three distinct stages.
One of the first issues identified by the task force was the need to align definitions of cachexia. Cachexia is a subtype of malnutrition, involving either weight loss, low BMI, or low muscle mass (sarcopenia) combined with systemic inflammation.
The latest definition from the Global Leadership Initiative on Malnutrition (GLIM) defined cachexia as weight loss greater than 5% or weight loss greater than 2% in individuals already showing depletion according to body mass index less or skeletal muscle mass.
The GLIM experts also defined three distinct stages: precachexia (where the weight loss is less than 5% with anorexia and metabolic change, cachexia, and refractory cachexia.
Basic knowledge of cachexia.
Health care professionals lack basic knowledge of cachexia. The need for education was underlined by a survey of health care professionals from 14 countries. The majority of respondents were unaware of guidelines. When asked about the percentage of weight loss (from baseline) considered indicative of cancer cachexia, 46% indicated a weight loss of 10%, 35% said they would wait until weight loss was 15 to 20%, and over 10% of respondents would wait until weight loss was > 25%. A second survey involving 907 cancer patients from 10 countries revealed how few physicians actually assess nutritional issues in cancer patients.
Assessing cachexia: new approaches.
For accurate diagnosis of cachexia health care professionals need clinically applicable tools. To overcome patients with obesity experiencing ‘hidden cancer cachexia syndrome’, it was important to consider changes in muscle mass as opposed to just measuring weight or BMI.
A diagnostic approach could be cross-sectional analysis of single CT images, typically landmarked at the 3rd lumbar vertebra (L3) which has been shown to correlate with whole body mass muscle. Since body composition represents an important determinant of the likelihood of response to treatment as well as toxicity greater knowledge was felt to be of immense value. The development of automated analysis of body composition offers the potential to make the approach routine.
A method that is already widely available for early detection of the inflammatory component of cachexia is identifying the presence of alterations in inflammatory biomarkers. The modified version of the Glasgow Prognostic Score, reflecting both the acute and chronic contributions to systemic inflammation, is highly prognostic in many different categories of cancer patients.
Nevertheless, assessments can be as simple as asking the patient their weight now, and what it was a few months back.
Cachexia affects cancer treatment.
Two clinical situations where it is recognised to be especially valuable to diagnose cachexia are when cancer patients are scheduled for surgery or receiving immunotherapy treatment. The presence of cachexia represents a negative predictor of efficacy for immune therapy with check-point inhibitors. Catabolic drivers accompanying skeletal muscle loss in cachexia promote elimination pathways for pembrolizumab and other biologics. A study of pembrolizumab in melanoma and non-small cell lung cancer found patients with slower drug clearance achieved double the life expectancy.
Taken together, such research suggests that patients treated with check point inhibitors might benefit from additional treatment of their cachexia. The time has come to conduct clinical studies combining immunotherapy with anti-cachexia treatments.
The experts also pointed out the importance of improving nutritional status of cancer patients prior to surgery.
Lack of available treatments.
The dearth of phase 3 trials for nutritional treatments resulted in the recent ASCO guidelines concluding that enteral and parental nutrition should not be used routinely, and that instead patients should be offered dietary counselling.
The lack of agreed clinically relevant definition of cachexia has been a hindrance to the demonstration of clinical efficacy of drugs. Yet, a lot of observational studies show that patients feel better when their nutritional status is taken into consideration. These interventions are simple, not expensive and above all improve the patient’s quality of life.
The Sharing Progress in Cancer Care (SPCC) task force meeting resulted in the following Call-To-Action for:
– Early diagnosis of cancer patients with malnutrition/cachexia.
– Introduction of practical guidance tools to routinely identify cancer patients at risk.
– A multimodal supportive care approach becoming an integral part of treatment for malnutrition/cachexia.