Pearls of optimizing nutrition and physical performance of older adults undergoing cancer therapy.

As the global population continues to age, the prevalence of cancer is increasing, with more than half of new cancer diagnoses occurring in those aged 65years and older. As a result of improved oncological care, a greater number of older patients undergo treatment, either chemoradiotherapy or surgery or both. The older oncology patient is not part of a homogenous group; chronological age poorly describes the health status of an individual. Comprehensive geriatric assessment (CGA) identifies domains, assessed by a multidisciplinary team, that should be considered to guide appropriate oncological treatment decisions. This paper will focus on two aspects of the CGA: the assessment of nutrition and functional status of the older patient with cancer. Optimization of both diet and physical activity may help patients improve their tolerance to oncological treatments and health-related quality of life (HRQOL). Beginning with definitions of frailty, sarcopenia, cachexia, and malnutrition, this paper will suggest standardized screening, diagnostic and interventional procedures to identify and treat these conditions in the older oncology patient.

Use of routinely available clinical, nutritional, and functional criteria to classify cachexia in advanced cancer patients.

BACKGROUND: Cachexia is a highly prevalent syndrome in cancer and chronic diseases. However, due to the heterogeneous features of cancer cachexia, its identification and classification challenge clinical practitioners. OBJECTIVE: To determine the clinical relevance of a cancer cachexia classification system in advanced cancer patients. DESIGN: Beginning with the four-stage classification system proposed for cachexia [non-cachexia (NCa), pre-cachexia (PCa), cachexia (Ca) and refractory cachexia (RCa)], we assigned patients to these cachexia stages according to five classification criteria available in clinical practice: 1) biochemistry (high C-reactive protein or leukocytes, or hypoalbuminemia, or anemia), 2) food intake (normal/decreased), weight loss: 3) moderate (≤5%) or 4) significant (>5%/past six months) and 5) performance status (Eastern Cooperative Oncology Group Performance Status ≥ 3). We then determined if symptom severity, body composition changes, functional levels, hospitalizations and survival rates varied significantly across cachexia stages. RESULTS: Two-hundred and ninety-seven advanced cancer patients with primary gastrointestinal and lung tumors were included. Patients were classified into Ca (36%), PCa and RCa (21%, respectively) and NCa (15%). Significant (p < 0.05) differences were observed among cachexia stages for most of the outcome measures (symptoms, body composition, handgrip strength, emergency room visits and length of hospital stays) according to cachexia severity. Survival also differed between cachexia stages (except between PCa and Ca). CONCLUSION: Five clinical criteria can be used to stage cancer cachexia patients and predict important clinical, nutritional and functional outcomes. The lack of statistical difference between PCa and Ca in almost all clinical outcomes examined suggests either that the PCa group includes patients already affected by early cachexia or that more precise criteria are needed to differentiate PCa from Ca patients. More studies are required to validate these findings.

Health professionals' attitudes toward the detection and management of cancer-related anorexia-cachexia syndrome, and a proposal for standardized assessment.

BACKGROUND: The identification and management of patients with cancer anorexia-cachexia syndrome (CACS) can be a challenge despite recent international consensus on the definition of the condition. OBJECTIVES: To describe the current views and practice patterns of community oncologists and oncology nurses in regard to CACS and to propose a standardized, pragmatic assessment of CACS for oncological practice. METHODS AND MATERIALS: Responses from 151 community oncologists and nurses obtained across 5 surveys were analyzed. Questions addressed CACS in general and in patients with non-small-cell lung cancer (NSCLC). Surveys 1-3 were directed at physicians, and surveys 4 and 5 were directed at nurses. Surveys 1, 2, 4, and 5 focused on the recognition and monitoring of CACS, and Survey 3 on symptom management. RESULTS: 67% of medical oncologists in Survey 3 selected weight loss as the most important criterion for diagnosing CACS and cited declining appetite and performance status (PS) as the most bothersome effects for patients and families. Weight maintenance/gain was the primary treatment objective for oncologists. Respondents to surveys 1 and 2 acknowledged the risk for CACS is high (60%) in NSCLC but considered the risk much lower (4%) in patients completing a first course of therapy with good PS. 91% of oncologists in Survey 3 reported that symptoms that had an impact on calorie intake were important/very important, and 73% were willing to consider a symptom assessment instrument that included appetite. Nurses in surveys 4 and 5 reported weight loss and appetite were most commonly used to identify cachexia. They considered responsibility for the initial assessment of cachexia was the oncologist's (32%), followed by the nurse practitioner (28%), and the nurse (16%). CONCLUSION: Most oncologists and nurses recognize the core criteria for the CACS, although there may be under-recognition of the condition's prevalence, particularly earlier in the course of treatment. There is considerable interest in adopting a brief assessment tool for screening, management, and referral of patients who are affected by or at-risk of CACS.

Identifying nutritional, functional, and quality of life correlates with male hypogonadism in advanced cancer patients.

With the availability of a potential treatment to reverse male hypogonadism (MH), the primary aim of this case series study was to determine independent relationships between this condition and the nutritional, functional, and quality of life characteristics of advanced cancer patients (ACP). Free testosterone levels were measured in 100 male patients with advanced lung and gastrointestinal (GI) cancer. Routine blood markers of nutrition and inflammation, self-reporting questionnaires for symptom, nutrition, and functional status along with handgrip dynamometry were assessed for all patients at bedside. Almost half of this cohort underwent further assessments (body composition, lower body strength, in depth quality of life and fatigue questionnaires) at the McGill Nutrition and Performance Laboratory (mnupal.mcgill.ca). Multiple regression analyses were performed to identify independent correlations between free testosterone and the above measures. Seventy-six percent of patients were diagnosed with MH. Using multiple linear regression, low free testosterone (31.2 pmol/L) was independently associated with lower albumin (B = -3.8 g/L; 95% confidence interval CI -6.8:-0.8), muscle strength (-11.7 lbs; -20.4: -3.0) and mass in upper limbs (-0.8 kg; -1.4: -0.1), overall performance status (Eastern Cooperative Oncology Group Performance Scale, ECOG PS 0.6; 0.1:1.1), cancer-related fatigue (Brief Fatigue Inventory, BFI 16.7; 2.0: 31.3), and overall quality of life (MQoL total score -1.42; -2.5: -0.3). Thus MH seems to be highly prevalent in ACP, and it is independently associated with important nutritional, functional, and quality of life characteristics in this patient population.

The abridged patient-generated subjective global assessment is a useful tool for early detection and characterization of cancer cachexia.

Cancer cachexia (CC) is a syndrome characterized by wasting of lean body mass and fat, often driven by decreased food intake, hypermetabolism, and inflammation resulting in decreased lifespan and quality of life. Classification of cancer cachexia has improved, but few clinically relevant diagnostic tools exist for its early identification and characterization. The abridged Patient-Generated Subjective Global Assessment (aPG-SGA) is a modification of the original Patient-Generated Subjective Global Assessment, and consists of a four-part questionnaire that scores patients' weight history, food intake, appetite, and performance status. The purpose of this study was to determine whether the aPG-SGA is associated with both features and clinical sequelae of cancer cachexia. In this prospective cohort study, 207 advanced lung and gastrointestinal cancer patients completed the following tests: aPG-SGA, Edmonton Symptom Assessment System, handgrip strength, a complete blood count, albumin, apolipoprotein A and B, and C-reactive protein. Ninety-four participants with good performance status as assessed by the Eastern Cooperative Oncology Group Performance Status completed additional questionnaires and underwent body composition testing. Of these, 68 patients tested for quadriceps strength and completed a 3-day food recall. Multivariable regression models revealed that higher aPG-SGA scores (≥9 vs 0 to 1) are significantly associated (P<0.05) with the following: unfavorable biological markers of cancer cachexia, such as higher white blood cell counts (10.0 vs 6.7×10(9)/L; lower hemoglobin (115.6 vs 127.7 g/L), elevated C-reactive protein (42.7 vs 18.2 mg/L [406.7 vs 173.3 nmol/L]); decreased anthropometric and physical measures, such as body mass index (22.5 vs 27.1); fat mass (14.4 vs 26.0 kg), handgrip (24.7 vs 34.9 kg) and leg strength; an average 12% greater length of hospital stay; a dose reduction in chemotherapy; and increased mortality. Given its association with the main features of cancer cachexia and its ease of use, the aPG-SGA appears to be a useful tool for detecting and predicting outcomes of cancer cachexia. Additional research is required to determine what impact the aPG-SGA has on quality of care when used in the clinical setting.