Cancer Cachexia AND Nutritional Support

The answer first

Cancer cachexia is a multifactorial syndrome defined by ongoing skeletal-muscle loss (with or without fat loss) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. [1] It is common, devastating, and treatable. Roughly 50 to 80 percent of patients with advanced cancer develop clinically significant cachexia, and it is the immediate cause of death in up to one-third. [2]

A physician-level answer rests on four pillars: [2]

1. Screen every cancer patient at every visit. Validated tools include the Patient-Generated Subjective Global Assessment (PG-SGA), the Malnutrition Universal Screening Tool (MUST), and weight-loss percent. Weight loss greater than 5 percent in 6 months meets diagnostic criteria; weight loss greater than 10 percent with systemic inflammation predicts reduced survival independent of stage. [1]
2. Identify the dominant mechanism. Starvation alone responds to nutritional support; inflammatory cytokine-driven cachexia (the typical cancer phenotype) requires multimodal therapy; mechanical obstruction (dysphagia, bowel obstruction) requires procedural intervention. [2] [12]
3. Quantify body composition, not just weight. CT at the third lumbar vertebra (L3) provides a precise skeletal-muscle index and is now routinely extracted from staging scans. Sarcopenic obesity (low muscle, normal or high BMI) is easily missed without CT body composition. [9]
4. Set realistic goals and integrate with oncology. Curative-intent chemotherapy with nutritional failure: maximise intake by mouth, supplement, enteral feed, or home parenteral nutrition as needed. Palliative phase: shift goals toward comfort, symptom relief, and quality of life; medically assisted nutrition is no longer obligatory. [3]

DWE high-yield: The Fearon 2011 three-stage classification — pre-cachexia, cachexia, refractory cachexia — defines cachexia as weight loss > 5 percent in 6 months (or BMI < 20 with any degree of weight loss, or sarcopenia with any degree of weight loss), plus at least one of anorexia, fatigue, low grip strength, and abnormal biochemistry (anaemia, low albumin, low sodium, raised CRP or IL-6). The 2015 Martin classification stratifies weight-loss percentiles by BMI and stage — patients with grade 4 weight loss (greatest severity) have a hazard ratio for death exceeding 4. [1] [12]

References12Show ledgerHide ledger

1. [1]Martin L, Senesse P, Gioulbasanis I, et al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol, 2015.PMID 25422490
2. [2]Roeland EJ, Bohlke K, Baracos VE, et al. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol, 2020.PMID 32432946
3. [3]Arends J, Bachmann P, Baracos V, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr, 2017.PMID 27637832
4. [4]Temel JS, Currow DC, Fearon K, et al. Anamorelin in patients with non-small-cell lung cancer and cachexia (ROMANA 1 and ROMANA 2): results from two randomised, double-blind, phase 3 trials. Lancet Oncol, 2016.PMID 26906526
5. [5]Khatib MN, Shankar AH, Kirubakaran R, et al. Ghrelin for the management of cachexia associated with cancer. Cochrane Database Syst Rev, 2018.PMID 29489032
6. [6]Mantovani G, Macciò A, Lai P, et al. Cytokine activity in cancer-related anorexia/cachexia: role of megestrol acetate and medroxyprogesterone acetate. Semin Oncol, 1998.PMID 9625383
7. [7]Maddocks M Physical activity and exercise training in cancer patients. Clin Nutr ESPEN, 2020.PMID 33183519
8. [8]Arends J, Baracos V, Bertz H, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr, 2017.PMID 28689670
9. [9]Prado CM, Purcell SA, Laviano A Nutrition interventions to treat low muscle mass in cancer. J Cachexia Sarcopenia Muscle, 2020.PMID 31916411
10. [10]Pironi L, Boeykens K, Bozzetti F, et al. ESPEN practical guideline: Home parenteral nutrition. Clin Nutr, 2023.PMID 36796121
11. [11]Malik JS, Yennurajalingam S Prokinetics and ghrelin for the management of cancer cachexia syndrome. Ann Palliat Med, 2019.PMID 30525771
12. [12]Aoyagi T, Terracina KP, Raza A, et al. Cancer cachexia, mechanism and treatment. World J Gastrointest Oncol, 2015.PMID 25897346