ASCO recently released a new evidence-based guideline regarding the clinical management of cancer cachexia in adults with advanced cancer.1 The guideline is the result of a literature review that included 20 systematic reviews and 13 randomized clinical trials. An expert panel was convened to evaluate this available evidence and formulate recommendations.
Defining cachexia—sometimes referred to as anorexia/cachexia—can be difficult, with the precise definition often evolving, explained Charles L. Loprinzi, MD, of Mayo Clinic, Rochester, Minnesota, and Guideline Co-Chair. The guideline describes cancer cachexia as a “multifactorial syndrome characterized by loss of appetite, weight, and skeletal muscle, leading to fatigue, functional impairment, increased treatment-related toxicity, poor quality of life, and reduced survival.”
Charles L. Loprinzi, MD
Eric J. Roeland, MD
Treating cancer cachexia is a clinical challenge that practicing oncologists face every day, according to Eric J. Roeland, MD, of Massachusetts General Hospital Cancer Center and Guideline Co-Chair. “Outside of treating the underlying cancer, clinicians may be unaware of the existing data regarding evidence-based approaches to treating cancer cachexia,” Dr. Roeland said. “Our goal was to provide ASCO members with the first-ever cancer cachexia guidelines to summarize available data regarding treatment of this distressing syndrome.”
The first recommendations address the use of dietary counseling and nutrition interventions.
“We ended up determining that it is reasonable to have a registered dietitian talk to patients, assess their needs, and help with nutrition suggestions,” Dr. Loprinzi said. “There have been a few studies that randomly assigned patients to see a dietitian vs not see one. Although some studies suggest that seeing a dietitian may slightly increase caloric intake, mildly increase body weight, and/or improve quality of life, the data do not strongly support this and do not support that such helps patients live longer.”
Next, the guideline recommends against the routine use of enteral feeding tubes or parenteral nutrition for most patients with advanced cancer and cachexia.
A short-term trial of parenteral nutrition may be offered to certain patients. For example, it can be offered to those with a reversible alimentary tract obstruction, especially if the prognosis is otherwise reasonably favorable, Dr. Loprinzi said. An example of such a case would be a patient with a low-grade abdominal cancer without other vital organ impairment, whereby parenteral nutrition may serve as a bridge to enteral feeding.
According to the guideline, there is insufficient evidence to strongly endorse any pharmacologic agent to improve cancer cachexia outcomes, noting there are no U.S. Food and Drug Administration–approved medications for this indication.
“Although some of the medications used for cachexia can stimulate appetite or lead to weight gain, they also have side effects,” Dr. Loprinzi said. “Corticosteroids, for example, can cause peptic ulcer disease, increase infection risk, and/or cause muscle weakness.”
Another commonly used medication is megestrol acetate. This medication is also known to stimulate appetite and does not increase the risk of infection. However, it can increase the risk for blood clots, Dr. Loprinzi said.
For those patients experiencing loss of appetite and/or body weight and who want to try an appetite stimulant, the guideline recommends a short-term trial of a corticosteroid or progesterone analog. Currently, no other recommendation can be made for other interventions, such as exercise, for the management of cancer cachexia.
Addressing the Problem
Cachexia/anorexia is a prominent clinical problem, Dr. Loprinzi acknowledged. However, he also said, it can be a bigger problem for patients’ caregivers than for patients themselves. “I often hear, ‘Mom isn’t eating. Dad isn’t eating,’” he said. “Loved ones try hard to encourage patients to eat or almost force-feed them; this can be counterproductive.” Gentle encouragement is ok, Dr. Loprinzi said. If the patient requests food, get it. However, food should not be forced.
“Getting that message out to patients and caregivers tends to help,” Dr. Loprinzi shared. “I have seen many situations where the patient or caregiver is later thankful for having this discussion.”
Drs. Loprinzi and Roeland said they hope these guidelines help educate colleagues and serve as an important resource for patients and caregivers.
“Given its prevalence and impact on quality of life and cancer outcomes, collaborative translational and clinical research focused on cancer cachexia should be a research funding priority,” Dr. Roeland said.
DISCLOSURE: For full disclosures of the panel members, visit asco.pubs.org.
1. Roeland EJ, Bohlke K, Baracos, VE, et al: Management of cancer cachexia: ASCO guideline. J Clin Oncol. May 20, 2020 (early release online).
Originally published in ASCO Daily News. ©American Society of Clinical Oncology. ASCO Daily News, May 21, 2020. All rights reserved.