Recommendations Summary

ONC: Nutrition Intervention of Adult Oncology Patients with Cancer Cachexia 2013

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Nutrition Intervention of Adult Oncology Patients with Cancer Cachexia

  In adult oncology patients who have been identified to have pre-cachexia or cancer cachexia, prompt and aggressive intervention to address nutrition impact symptoms and preserve or prevent loss of lean body mass (LBM) and weight should be initiated by the registered dietitian nutritionist (RDN). Early rather than later intervention to prevent weight loss in this population is more likely to be effective. The metabolic derangements in cancer cachexia that promote wasting can lead to loss of weight and LBM and poor outcomes.

  Rating: Consensus
  Conditional

  • Risks/Harms of Implementing This Recommendation

    There are no potential risks or harms associated with the application of this recommendation.

  • Conditions of Application

    • This recommendation applies to adult oncology patients who have pre-cachexia or cachexia.
    • Consider advance directives when planning nutrition intervention.

  • Potential Costs Associated with Application

    Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essential for improved outcomes.

  • Recommendation Narrative

    Adult oncology patients may have a cachexia syndrome in addition to malnutrition. Cachexia does not mean end of life or hospice. There are several stages of cancer cachexia: Pre-cachexia, cachexia and refractory cachexia (Fearon et al, 2011).

    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).

    Nutrition intervention of the adult oncology patient with cancer cachexia should address altered nutrition status and nutrition impact symptoms that may result in a measurable adverse effect on body composition, function, QoL or clinical outcome and may also include indicators of malnutrition (Stratton et al, 2004). 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.  

    Definitions of 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 characterized 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).

  • 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

    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.

    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. 

    Stratton RJ, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients and inpatients: Prevalence,  concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr. 2004; 92(5): 799-808.