Cancer cachexia Richard Berman Cachexia quiz 1 What

Cancer cachexia Richard Berman

Cachexia quiz

1. What is the definition of cancer cachexia? • A multifactorial syndrome • Characterised by: • • Ongoing loss of skeletal muscle With or without loss of fat mass Not reversible by conventional nutritional support alone Leading to progressive functional impairment

2. List the effects / consequences of CC Weight loss Reduced physical function Increased symptom burden Treatment delays Treatment toxicity Increased healthcare costs Increased mortality / reduced survival

3. How might cancer cachexia be classified / staged? • Precachexia • Early clinical and metabolic signs • (eg anorexia and impaired glucose tolerance) • Cachexia • Substantial involuntary weight loss (<5% weight loss of stable body weight over the past 6 months) • Risk of progression varies (cancer type, stage, level of systemic inflammation) • Refractory cachexia • • • Very advanced disease Or rapidly progressive despite SACT Associated with active catabolism Active management of wt loss no longer possible or appropriate (burden would outweigh benefit) WHO PS 3 -4 / prognosis <3 months

4. How might cancer cachexia be assessed? • Anorexia or reduced food intake • Reduced central drive to eat • Chemosensory disturbances • GI dysmotility (early satiety / nausea / constipation) • Catabolic drivers • Hypercatabolism due to tumour metabolism • Systemic inflammation (? CRP) • Rate of disease progression / response to SACT • Muscle mass and strength • Upper limb hand-grip dynamometry • Functional and psychological effects • Assessment of physical function (EORTC QLQ-C 30) • KP score

5. How might cancer cachexia be treated? (for each, describe how they work) • NSAIDs • Cancer patients with cachexia often have increased inflammation • Attenuation of the pro-inflammatory response is key component • COX inhibition – COX converts arachnoid acid to PGs inflammation and pain • Omega-3 fatty acids • EPA – found in fish oils • EPA is a competitive substrate with AA for the COX pathway • This leads to the conversion of LESS inflammatory lipid modulators than those derived from AA • EPA also has an ability to maintain muscle mass

• Dietary intervention • Address anorexia (loss of appetite) • Conflicting evidence for nutritional interventions • Dietary counselling • Exercise • • Strength training anabolic effect (increased muscle mass) Exercise can reduce fatigue and improve health-related QOL Recommended pre, during and after cancer treatment There is evidence to suggest exercise can reduce CRP

6. Which types of cancer treatments can directly impact on muscle bulk? • Chemotherapy • Targeted therapy • Important to focus on strategies to reduce adverse effects of cancer therapies alongside treatment

7. When should cancer cachexia treatment start? • Early! • Some evidence that cancer-related outcomes or toxicity are improved with early intervention • Treatment with EPA, NSAIDs, nutrition and exercise, given alongside cancer therapy can improve outcomes

8. How would you go about improving cachexia management in your own centre? • Work with dietetics… • Think of an initiative! • “Food versus cancer”; “The Big Eat”; “Ca. Ke-xia”; “Creamo-therapy” • Get the evidence (audit / outcomes) • Link to important trust / hospice objectives • Patient experience / stories • Publish the data!

Food for thought Preservation Stage the host