Recommendations Summary

ONC: Nutrition Assessment for the Stages of Cancer Cachexia in Adult Oncology Patients 2013

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  • Recommendation(s)

    ONC: Nutrition Assessment for the Stages of Cancer Cachexia in Adult Oncology Patients

    As part of the nutrition assessment, in patients with lung, pancreatic or head and neck and gastrointestinal (GI) cancers or those who are at high risk for weight loss or have experienced unintended weight loss, the registered dietitian nutritionist (RDN) should assess for nutrition impact symptoms, markers of inflammation [e.g., elevated C-reactive protein (CRP)] and other signs of wasting,  which may indicate pre-cachexia or cancer cachexia.

    The presence of cachexia does not always indicate end of life or need for hospice. Therefore, the identification of cachexia leading to intervention can positively impact clinical outcomes. 

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Failure to assess for the stages of cancer cachexia may lead to lack of nutrition intervention and increased risk of mortality.

    • Conditions of Application

      • This recommendation applies to patients with lung, pancreatic or head and neck and GI cancers or those who are at high risk for weight loss or have experienced unintended weight loss
      • For some individuals, unintended weight loss may be irreversible due to underlying medical conditions
      • If necessary data are not available, the RDN should use professional judgment to request or obtain addition data, such as markers of inflammation (CRP).

    • Potential Costs Associated with Application

      • Although medical nutrition therapy (MNT) costs and reimbursement vary, MNT is essential for improved outcomes
      • Accessibility and costs of additional laboratory testing should be considered.

    • Recommendation Narrative

      The metabolic response to cancer is heterogeneous, so it is important to intervene and manipulate the factors that are behavior-related, to address the direct causes of decreased intake (obstruction, dysphagia) and address the secondary causes (depression, fatigue, pain, gastrointestinal function) because “symptom management alone can improve survival in patients with advanced cancer (Fearon, 2011).”

      In cancer-specific pre-cachexia, early clinical and metabolic signs such as loss of appetite and impaired glucose tolerance can precede substantial involuntary weight loss (i.e., up to 5%). The risk of progression is variable and depends on cancer type, stage, presence of systemic inflammation, low food intake and lack of response to anti-cancer therapy (Fearon et al, 2011).

      Definitions of Cachexia

      There are several stages of cancer cachexia: Pre-cachexia, cachexia and refractory cachexia.

      Cancer cachexia: A multi-factorial syndrome characterized by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. The pathophysiology is characterised by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism (Fearon et al, 2011).

      Pre-cachexia (in general): Defined by the presence of all of the following criteria:

      • Underlying chronic disease
      • Unintended weight loss of up to 5% usual body weight during the last six months
      • Chronic or recurrent systemic inflammatory response
      • Anorexia or anorexia-related symptoms (Muscaritoli et al, 2010).

      Pre-cachexia (in cancer): Characterized by early clinical and metabolic signs such as loss of appetite and impaired glucose tolerance; can precede substantial involuntary weight loss (i.e., up to 5%). The risk of progression is variable and depends on cancer type, stage, presence of systemic inflammation, low food intake and lack of response to anti-cancer therapy (Fearon et al, 2011).

      Refractory cachexia: May be a result of very advanced cancer (pre-terminal) or the presence of rapidly progressive cancer unresponsive to anti-cancer therapy. This stage is associated with active catabolism or the presence of factors that make active management of weight loss no longer possible or appropriate. Refractory cachexia is characterized by a low performance score (e.g., WHO grade 3 or 4) and a life expectancy of less than three months (Fearon et al, 2011).

      • Nutrition impact symptoms that impede intake, digestion or absorption (such as anorexia, nausea, vomiting, diarrhea, constipation, stomatitis, mucositis, dysphagia, alterations in taste and smell, pain, depression and anxiety) can be caused by the cancer itself or the oncology treatment. (American Cancer Society, 2000; Kubrak et al, 2010; Wojtaszek et al, 2002)
      • Request a CRP lab value if one is not available in order to assess for presence of inflammation. The presence of inflammation supports a diagnosis of pre-cachexia. If CRP is elevated*, it may be indicative of the presence of inflammation and this value determines the severity of any weight loss (Jensen et al, 2012; White et al, 2012). The metabolic response to cancer is heterogeneous, so it is important to intervene and manipulate the factors that are behavior-related, to address the direct causes of decreased intake (obstruction, dysphagia) and address the secondary causes (depression, fatigue, pain, gastrointestinal function) because “symptom management alone can improve survival in patients with advanced cancer (Fearon 2011).”
        • *Past interpretation of >10mg/L CRP has been used to indicate inflammation. However, further research will elucidate more specific markers for use.
      • Wasting in cancer cachexia may be assessed through the following:
        • Loss of subcutaneous fat (e.g., orbital, triceps, fat overlying the ribs) (White et al, 2012; Tan et al, 2009; Fearon et al, 2011) 
          • As 50% of patients with advanced cancer have frank sarcopenia (Fearon, 2011) and the shortest survival times are among obese patients with sarcopenia (Tan et al, 2009), reducing weight at the possible expense of lean muscle mass in obese cancer patients should not be a priority.
        • Muscle loss [e.g., wasting of the temples (temporalis muscle); clavicles (pectoralis and deltoids); shoulders (deltoids); interosseous muscles]; scapula [latissimus dorsi, trapezious, deltoids; thigh (quadriceps) and calf (gastrocnemius)] [White et al, 2012; Prado et al, 2009 (Clin Cancer Res.)]  
          • Patients with loss of muscle mass experience greater treatment toxicity and shorter survival
          • Low muscle mass is a common and independent predictor of immobility and mortality (Prado et al, 2008), is a particularly adverse prognostic indicator in obese patients and is associated with greater toxicities of chemotherapy, leading to treatment interruptions including dose reductions, treatment delays and treatment termination [Fearon et al, 2013; Prado et al, 2009 (Clin Cancer Res.), Prado et al, 2009 (Curr Opin Support Palliat Care.), Prado et al, 2011; Antoun et al, 2010; Fearon, 2011].
          • Body weight has been used as an outcome in clinical trials in cancer-induced weight loss and only recently has research begun to focus on LBM as a primary outcome. Existing computerized tomography (CT) images used to diagnose and monitor disease progression are readily available and provide an opportunistic means for body composition analysis. Although this type of analysis is relatively new, its use will be common in the near future and offers the RDN the ability to demonstrate value. Other methods of measuring muscle mass are bioelectrical impedence analysis (BIA), dual-energy X-ray absorptiometry (DXA) and anthropometry. Patients with loss of muscle mass experience greater treatment toxicity and shorter survival. [Prado et al, 2009 (Curr Opin Support Palliat Care.); Cruz-Jentoft et al, 2010].

    • Recommendation Strength Rationale

      Consensus.

    • Minority Opinions

      None.

  • Supporting Evidence

    The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

    • References
    • References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

      American Cancer Society: Nutrition for the Person with Cancer: A Guide for Patients and Families. Atlanta, Ga: American Cancer Society, Inc., 2000.

      Antoun S, Baracos VE, Birdsell L, Escudier B, Sawyer MB. Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Ann Oncol. 2010 Aug; 21 (8): 1, 594-1, 598. Epub 2010 Jan 20. PMID: 20089558.

      Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M; European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul; 39 (4): 412-423. doi: 10.1093/ageing/afq034. Epub 2010 Apr 13. PMID: 20392703.

      Fearon K, Strasser F, Anker SD, Bosaeus I, Bruera E, Fainsinger RL, Jatoi A, Loprinzi C, MacDonald N, Mantovani G, Davis M, Muscaritoli M, Ottery F, Radbruch L, Ravasco P, Walsh D, Wilcock A, Kaasa S, Baracos VE. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011 May; 12 (5): 489-495. Epub 2011 Feb 4. Review. PMID: 21296615.

      Fearon KC. Cancer cachexia and fat-muscle physiology. N Engl J Med. 2011 Aug 11; 365 (6): 565-567. doi: 10.1056/NEJMcibr1106880. No abstract available. PMID: 21830971.

      Fearon K, Arends J, Baracos V. Understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. 2013 Feb; 10 (2): 90-99. doi: 10.1038/nrclinonc.2012.209. Epub 2012 Dec 4. PMID: 23207794.

      Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter Enteral Nutr. 2012 May; 36 (3): 267-274. Epub 2012 Mar 8.

      Kubrak C, Olson K, Jha N, Jensen L, McCargar L, Seikaly H, Harris J, Scrimger R, Parliament M, Baracos VE. Nutrition impact symptoms: key determinants of reduced dietary intake, weight loss, and reduced functional capacity of patients with head and neck cancer before treatment. Head Neck. 2010 Mar; 32 (3): 290-300. doi: 10.1002/hed.21174. PMID: 19626639.

      Muscaritoli M, Anker SD, Argilés J, Aversa Z, Bauer JM, Biolo G, Boirie Y, Bosaeus I, Cederholm T, Costelli P, Fearon KC, Laviano A, Maggio M, Rossi Fanelli F, Schneider SM, Schols A, Sieber CC.Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics". Clin Nutr. 2010 Apr; 29 (2): 154-159. Epub 2010 Jan 8. PMID: 20060626.

      Prado CM, Baracos VE, McCargar LJ, Reiman T, Mourtzakis M, Tonkin K, Mackey JR, Koski S, Pituskin E, Sawyer MB. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment. Clin Cancer Res. 2009 Apr 15; 15 (8): 2, 920-2, 926. Epub 2009 Apr 7. PMID: 19351764.

      Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, Baracos VE. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008 Jul; 9 (7): 629-635. Epub 2008 Jun 6. PMID: 18539529.

      Prado CM, Birdsell LA, Baracos VE. The emerging role of computerized tomography in assessing cancer cachexia. Curr Opin Support Palliat Care. 2009 Dec; 3 (4): 269-275. Review. PMID: 19667996.

      Prado CM, Lima IS, Baracos VE, Bies RR, McCargar LJ, Reiman T, Mackey JR, Kuzma M, Damaraju VL, Sawyer MB. An exploratory study of body composition as a determinant of epirubicin pharmacokinetics and toxicity. Cancer Chemother Pharmacol. 2011 Jan; 67 (1): 93-101. Epub 2010 Mar 5. PMID: 20204364.

      Tan BH, Birdsell LA, Martin L, Baracos VE, Fearon KC. Sarcopenia in an overweight or obese patient is an adverse prognostic factor in pancreatic cancer. Clin Cancer Res. 2009 Nov 15; 15 (22): 6, 973-6, 979. Epub 2009 Nov 3. PMID: 19887488.

      White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy Malnutrition Work Group, A.S.P.E.N. Malnutrition Task Force, A.S.P.E.N. Board of Directors. J Acad Nutr Diet. 2012 May; 112 (5): 730-738. Epub 2012 Apr 25. 

      Wojtaszek CA, Kochis LM, Cunningham RS: Nutrition impact symptoms in the oncology patient. Oncology Issues. 17 (2): 15-17, 2002.