Cachexia is a multifactorial metabolic syndrome that presents clinically as an involuntary loss of lean body mass, including progressive reduction of skeletal muscle and adipose tissues.1,2 Associated symptoms include functional impairment, fatigue, higher treatment-related toxicities, and lower quality of life. While common across many disease states, cancer cachexia has been associated with poor responses to chemotherapy, as well as decreased survival. Thus, the development of comprehensive guidelines for cancer cachexia is important for the standardization of therapy across various clinical care settings.1,2

The American Society of Clinical Oncology (ASCO) published clinical guidelines on the management of cachexia for adults with advanced cancer in the Journal of Clinical Oncology. Cochair of the guideline panel, Eric J. Roeland, MD, of Massachusetts General Hospital Cancer in Boston, and his coauthors, developed the evidence-based recommendations to advise frontline primary care practitioners who treat adult patients with advanced cancer and cachexia.

“Primary care practitioners may be the most accessible to patients with [cachexia] symptoms, and should be aware that we can address nutritional impact symptoms, such as pain, nausea, and depression, which [all] contribute to the syndrome,” guideline coauthor, Egidio Del Fabbro, MD, of the department of internal medicine at Virginia Commonwealth University in Richmond, told Hematology Advisor.

The panel established recommendations based on 3 different categories (Tables 1-3) of interventions used to treat cancer cachexia, including:


Continue Reading

  1. Nutritional interventions
  2. Pharmacologic interventions
  3. Other interventions
Table 1. Selected Recommendations by the ASCO Guideline Panel on the Management of Cancer Cachexia in Adults With Advanced Cancer: Nutritional Interventions2
Intervention (strength of recommendation)BenefitsHarms
Dietary counseling (moderate in favor)ModerateLow
Parenteral or enteral nutrition (routine use) (moderate against)LowModerate to high
Omega-3 fatty acids (no recommendation)LowLow
Vitamins, minerals, and other dietary supplements (no recommendation)LowLow
Table 2. Selected Recommendations by the ASCO Guideline Panel on the Management of Cancer Cachexia in Adults With Advanced Cancer: Pharmacologic Interventions2
Intervention (strength of recommendation)BenefitsHarms
Progesterone analogs (moderate in favor)ModerateModerate
Corticosteroids (moderate in favor)ModerateModerate
Anamorelin (no recommendation)ModerateLow
Olanzapine (no recommendation)ModerateLow
Androgens (no recommendation)ModerateLow
Thalidomide (no recommendation)LowLow
NSAIDs (no recommendation)LowLow
Cyproheptadine (no recommendation)NoneLow
Cannabinoids (weak against)NoneLow
Melatonin (weak against)NoneLow
TNF inhibitors (moderate against)NoneModerate
Hydrazine sulfate (strong against)NoneModerate
Abbreviations: NSAIDs = nonsteroidal anti-inflammatory drugs; TNF = tumor necrosis factor.
Table 3. Selected Recommendations by the ASCO Guideline Panel on the Management of Cancer Cachexia in Adults With Advanced Cancer: Other Interventions2
Intervention (strength of recommendation)BenefitsHarms
Exercise (no recommendation)UnknownUnknown

To read the detailed recommendations containing qualifying remarks, readers should refer to the full publication in the Journal of Clinical Oncology.

The panel acknowledged that without stronger evidence, no specific pharmacological therapy is currently considered the standard of care. As a result, clinicians may elect to forgo pharmacologic intervention in favor of other treatment strategies.

“Primary practitioners should be aware that [nonpharmacological] strategies are effective to attenuate weight loss,” Dr Del Fabbro said. “Currently, a major barrier is the absence of an FDA approved drug [for the condition]. Once approved, primary practitioners may be more aware of cachexia, and their important role in the use of a multimodal strategy that includes [nonpharmacological] measures.”

Other Clinical Recommendations

Winston Tan, MD, of the department of internal medicine at the Mayo Clinic in Jacksonville, Florida, and fellow coauthor on the guidelines, told Hematology Advisor, “A nutritional consult is essential for patients with cachexia secondary to cancer. It is important to identify the correctable factors, such as medications, organ obstruction, [and] psychogenic factors.”

“Progestational agents and corticosteroids are the best studied agents and we strongly recommend against parenteral nutrition. There is a window of opportunity to look for medications that would work for this condition, and we need to develop [better] novel agents.”

Another guideline coauthor, Eduardo Bruera, MD, of the department of palliative, rehabilitation and integrative Medicine at the University of Texas MD Anderson Cancer Center in Houston, told Hematology Advisor, “The first step is to be vigilant and always ask about recent weight loss. Many patients who appear overweight have already lost considerable body mass and are cachectic.”

“Dietary recommendations should focus on high energy and protein intake, and, occasionally, pharmacological interventions, including corticosteroids or progestational agents, may be needed,” he explained.

Effective management of cancer cachexia can be challenging for busy clinicians. Ultimately, improving survival and patient quality of life remain key goals of therapy.

References

  1. Aoyagi T, Terracina KP, Raza A, Matsubara H, Takabe K. Cancer cachexia, mechanism and treatment. World J Gastrointest Oncol. 2015;7(4):17‐29.
  2. Roeland EJ, Bohlke K, Baracos VE, et al. Management of cancer cachexia: ASCO guideline [published online May 20, 2020]. J Clin Oncol. doi:10.1200/JCO.20.00611

This article originally appeared on Hematology Advisor