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Esmo Guidelines for Managing Cancer Cachexia in Adults, Part Two

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

The European Society of Medical Oncology (ESMO) have recently published comprehensive clinical practice guidelines for managing adults with cancer cachexia.  In our first article we covered what the guidelines recommend for nutritional screening, how and when to undertake a comprehensive assessment of cachexia and guidance on nutritional requirements. In this second article we take a look at the recommendations ESMO have for the use of nutritional support in the management of cancer cachexia.

Nutritional support can be critical for those with cancer cachexia, with these guidelines providing a steer on how we should focus our nutritional care depending on the individual patient, their clinical condition and their probability of survival. 

In patients with inadequate food intake, nutritional support is recommended with interventions being escalated, as required for those patients with an expected survival of more than several months and in those receiving anticancer therapy

This ‘escalation’ in the ESMO guidelines includes starting if safe, with the oral route as the first option for nutritional support, with dietary intervention and oral nutritional supplements. Enteral tube feeding may be then used if oral intake proves insufficient and/or in cases of dysphagia and if the small bowel function is preserved.  Parenteral nutrition should be considered only if oral intake and tube feeding remain inadequate or are not tolerated/contraindicated.

In situations where a patient’s life expectancy is limited, ESMO recommends only low-risk interventions (e.g. dietary counselling and oral nutritional supplements (ONS)).

ESMO Recommendations for Oral and Enteral Nutritional Support:

Dietary Counselling

  • First choice to improve oral intake and possibly weight gain
  • Focus on protein intake, meal frequency, treatment of nutrition impact symptoms
  • Offering nutritional supplements when necessary
  • Needs an adequately trained professional to give the advice

Oral Nutritional Supplements (ONS)

  • Complement dietary counselling
  • Help improve energy intake and induce weight gain
  • For patients receiving chemotherapy, radiotherapy or chemoradiotherapy, omega-3 containing ONS may be of value to increase weight, attenuate loss of lean body mass and improve quality of life

Tube feeding

  • Recommended for patients with head and neck or upper GI cancers, and particularly those undergoing anticancer therapy, to help weight maintenance if oral intake (including ONS) remains inadequate for more than a few days
  • PEG feeding is recommended for patients requiring >4 weeks of enteral feeding rather than nasogastric tube
  • Alongside tube feeding, identification and management of dysphagia is recommended together with encouragement and education for patients on how to maintain their swallow

In terms of parenteral nutrition (PN), ESMO guidance is to offer home PN only to patients if their quality of life and/or length of survival is expected to be severely compromised by progressive malnutrition. The ESMO guidelines do not support routine use of supplemental PN in hypophagic, malnourished patients receiving chemotherapy.

There is a useful flowchart indicating nutritional intervention options depending on the patient's symptoms:

ESMO Flowchart on Choosing Nutritional Intervention Options

Purple: symptom 
Turquoise: nutritional interventions; white: other aspects of management.
EN, enteral nutrition; GI gastrointestinal; NTF, nasogastric tube feeding; ONS, oral nutritional supplement; PEG, percutaneous endoscopic gastrostomy; PN, parenteral nutrition.


The ESMO guidelines also introduce the importance of multi-modal intervention for the management of those patients with cachexia, combining nutritional support with exercise training and psychological support (see the paper for details).  They also provide guidance on pharmacological interventions.

What about exercise alongside nutritional support?

EMSO state moderate physical exercise is safe and recommended for patients with cancer cachexia to maintain or improve muscle mass but needs to be guided by experts with an exercise prescription. Both resistance exercise (two to three times per week) and moderate aerobic (endurance) training should be offered in a structured approach, devised by a physiotherapist (e.g. mode (aerobic, resistance, flexibility), frequency, intensity, duration of exercise, reassessment window).

What about pharmacological interventions alongside nutritional support?

The ESMO guidelines cover pharmacological interventions and their potential use to ameliorate the consequences of cancer cachexia. Their summary is that:

  • Corticosteroids may increase appetite when used for a short period (up to 2-3 weeks) but any beneficial effect on appetite is usually lost with longer treatment
  • Progestins may be used to increase appetite and weight, but not muscle mass, or functional outcomes in patients with cancer cachexia. There is a risk of serious side-effects to consider.
  • There is insufficient evidence to support the use of medical cannabis or its derivatives to alleviate anorexia or early satiety.
  • Androgens are not recommended as there is no evidence of a beneficial effect on muscle mass.
  • There is moderate evidence to suggest considering using olanzapine to treat anorexia and nausea in those with advanced cancer.
  • There is insufficient evidence to recommend the use of NSAIDs, metoclopramide or domperidone alone to treat cancer cachexia.

Undoubtedly, nutrition plays a critical role in the management of this common, complex and debilitating condition. In addition to dietary approaches, medical nutrition (including oral nutritional supplements, tube feeding) can be vital, if tailored to the patient, their condition and treatment schedule, and considered alongside other management strategies. The full ESMO guidelines provide a wealth of information to guide those health care professionals working in the area of cancer cachexia so take a look at the full publication.

To look at the composition of oral nutritional supplements available, including those containing omega 3 for use in cancer cachexia, look at our product finder.