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New ESMO guidelines for managing Cancer Cachexia in Adults – Part One

The ESMO Clinical Practice Guidelines for the management of cancer cachexia in adult patients have recently been published, led by many clinicians (including dietitians) from across the world. 

View the full  OPEN ACCESS  ESMO Clinical Practice Guidelines for the Management of Cancer Cachexia in Adult Patients, published in ESMO OPEN Cancer Horizons here

This new publication highlights that cachexia is a complex, multi-faceted condition with both ‘objective’ components (e.g. inadequate food intake, loss of weight loss and muscle mass, inactivity, metabolic derangements inducing catabolism) and ‘subjective’ components (e.g. anorexia and early satiety, taste alterations, chronic nausea, fatigue, loss of concentration).  The authors estimate that around 50% of patients with advanced cancer experience cachexia. 

Despite how common this condition is, identifying and managing cancer cachexia remains a challenge in clinical practice, with this debilitating condition continuing to be under-recognised and under-treated. 

These key guidelines provide a breadth of recommendations to support medical oncologists and other clinicians who care for cancer patients with cachexia on how to screen for cachexia and how best to nutritionally manage this condition, covering interventions from dietary counselling, oral nutritional supplements to enteral tube feeding and parenteral nutrition. Importantly they also consider how the invasiveness of interventions should be tailored depending on the survival of individuals, weighing up benefits versus risks if the end of life is approaching. In contrast, for patients undergoing anticancer treatment, they emphasise the importance of offering all available nutritional therapeutic options, if required.

 

Invasiveness of Interventions Relative to Expected Survival

Recommendations – What and When?

  • Regular nutritional screening and nutritional support, including (if necessary) enteral tube feeding or parenteral nutrition is recommended in all patients receiving anticancer treatment and in those with an expected survival of more than a few months  

  • For those patients with an expected survival of less than a few months, a decrease in the invasiveness of nutritional interventions is recommended, with dietary counselling and oral nutritional supplements (ONS) preferred, if possible

  • For those patients with an expected survival of less than a few weeks, comfort-directed care is  recommended, alleviating thirst, any eating-related distress and other debilitating symptoms 

The guidelines highlight:

  • The importance of screening for nutritional risk regularly, including during anti- cancer treatment and where life expectancy is at least a few months with a validated screening tool. 

  • For those at nutritional risk, they recommend that objective assessment of nutritional and metabolic status (including weight and weight loss, body composition, inflammatory status, nutritional intake, physical activity) is undertaken and repeated regularly (e.g. monthly) as appropriate. In addition, consideration should be regularly given to the presence of nutrition impact symptoms, gastrointestinal dysfunction, chronic pain and psychosocial distress. 

  • For patients about to commence anticancer treatment with a high risk of inducing malnutrition (e.g. combined-modality treatments, high-dose chemotherapy, highly emetogenic agents), they recommend prophylactic nutritional support should be considered. 

 

Parameters of Comprehensive Cachexia Assessment and Recommended Tools

 

Requirements?

When making decisions on the need for nutritional support, they have provided guidance on nutritional requirements. For energy, at least 25-30 kcal/kg body weight daily is recommended, as although resting energy expenditure can be increased in cachexia, total energy expenditure is often normal (25-30 kcal/kg BW/day) as physical activity is often reduced.  They highlight that providing greater energy and protein intakes may also not attenuate weight loss in all patients. In patients with cachexia, regimens with fat contributing half of the non-protein calories are recommended. For protein, due to anabolic resistance in older patients and in chronic diseases, higher than normal amounts of protein (from 1.2 up to 2 g/kg body weight/day) may be required.  

There is a wealth of information in this open access publication so if you are involved in the care of those suffering from cancer cachexia, then take a look at the publication in full here.

See Part 2, for the ESMO recommendations for the use of nutritional support in the management of cancer cachexia.