Multidisciplinary approaches to cancer cachexia
A blog post written by Professor Peter Martin and Dr. Vanessa Vaughan
Cancer cachexia has a high prevalence in palliative care. It can have a huge impact for the patient and their loved ones. Cachexia impact symptoms such as anorexia, early satiety and fatigue are familiar to most palliative care clinicians. Oncology teams increasingly are aware of the more recent literature showing that the degree of muscle wasting has strong associations with treatment related toxicity and the ability to complete “on-time, on-dose” disease modifying treatment regimens. This is probably even more relevant in the age of emerging immunotherapy when cachexia/frailty/sarcopenia limiting performance status may be the primary factor in limiting the ability to continue disease modifying treatment. Sarcopenic obesity has highlighted that weight alone is a crude tool to consider cancer cachexia. Many studies, including our work, have shown that simple nutritional tools such as PGSGA can be useful to both screen and monitor cancer cachexia and has also significant prognostic implications.
There has been extensive advances in the understanding of the pathophysiology and this has led to some pharmacological interventions with more on the horizon but none yet licenced for this indication in Australia. Anamorehlin is one such promising drug.
What has received less attention is how best to screen and care for people with this complex syndrome. In simple terms there is emerging consensus that it is very unlikely a single intervention or drug will act as a “silver bullet” to correct this devastating problem. Most agree that optimal care will be multi-disciplinary and multi-modal. In crude terms this typically involves some type of nutritional assessment and intervention, some form of structured prescribed habitual exercise, scrupulous symptom control, and in the future a specific pharmacological cachexia agent. The goals may both be about quality of life and to enable the person to live longer including the ability to tolerate disease-modifying treatment. In my experience depression and cytokine mediated gastroparesis are the most frequent issues that are not picked up early.
Our recent article specifically looked at the data described from clinical services specific to cancer cachexia.[1] For a syndrome that effects 80% of our patient population, there are remarkably few models to learn from. Many have been part of short-term funding initiatives and even less have been sustained over time.
So, what can we learn from reviewing the literature and these services? It appears that a dedicated team usually is made up of a doctor, nurse, dietician, and physiotherapist/exercise physiologist, though some variation exists. These teams seem to have remarkably similar benefits for the patient and family in terms of quality of life, improved function, and potentially improved survival but more in-depth studies are required.
References
- Vaughan VC, Martin P. Multidisciplinary approaches to cancer cachexia: current service models and future perspectives. Expert Rev Anticancer Ther. 2022 Jul;22(7):737-749. doi: 10.1080/14737140.2022.2088516. Epub 2022 Jun 24. PMID: 35699257.