A Review of Management of Cancer Cachexia: ASCO Guideline
By Taylor Scialo, Registered Dietitian and Aidan Hadad, Dietetic Intern
In Summer 2020, the American Society of Clinical Oncology (ASCO) released a guideline on the management of cancer cachexia. The guideline was produced after a systematic review of the literature regarding nutritional, pharmacological, and other interventions directed towards cancer cachexia. The purpose of ASCO’s publication was to provide clinicians with evidenced based recommendations on the optimal approach to the treatment of cancer cachexia, which is said to impact 50-80% of patients with advanced cancer1.
The question guiding this paper was “Among adult patients with advanced cancer and loss of appetite, body weight, and/or lean body mass, are outcomes such as weight, lean body mass, physical function or quality of life improved by nutritional interventions, pharmacological interventions, or other interventions (such as exercise)?”
Relating to nutritional interventions, the authors suggest that clinicians refer their patients with advanced cancer, loss of appetite, and/or loss of body weight to a registered dietitian for nutritional assessment, education, and counseling. The guideline also noted the benefit for registered dietitians to advise the patient and family against fad diets and other unproven extreme diets while remaining a source of support for patients and families around feeding. Additionally, it was encouraged that routine use of parenteral and enteral nutrition should not be recommended in patients with advance cancer, referencing the potential harms in relation to low benefit. Noted within the reviewed literature was supporting studies that parenteral nutrition did not significantly improve overall survival. Two registered dietitians were included in the expert review panel, adding strength to these recommendations.
According to this guideline, pharmacological interventions continue to hold insufficient evidence to strongly support any medication to improve cancer cachexia outcomes. Currently, there are no FDA approved medications for the treatment of cancer cachexia, and while many medications have been trialed, most have failed to showcase any significant improvements in weight. Studies did show potential benefit with a short term trial of a progesterone analog or corticosteroid to patients with loss of appetite and body weight, leading to a recommendation that clinicians may offer such trials depending on duration of treatment and treatment goal with consideration for risks versus benefits. Megestrol acetate is noted to improve appetite and body weight. However, the associated weight gain is primarily adipose tissue rather than skeletal muscle2. Unfortunately, no pharmacists held position on the expert review panel, suggesting a limitation of this work.
In regard to other interventions, the guideline notes that outside of clinical trials, no recommendations can be made specifically for exercise as a therapy for cancer cachexia. Although many may think of the benefits of exercise in supporting lean body mass, the authors failed to provide rationale for exploring the research behind the role of exercise in management of cancer cachexia. They did note that while there may be other benefits to physical activity, there is not enough evidence at present to make recommendations for exercise as a therapy for cancer cachexia.
The guideline provided important comment on the complex of symptoms, patient-clinician communication, health disparities, and cost implications relating to cancer cachexia, all of which are related to practice among clinicians working in Veteran Affairs (VA) Medical Centers. It is in the best interest of both patient and clinician to consider a better understanding of not just clinical practice recommendations but also the impact of these concepts that can help clinicians treat the patient as a whole individual. In order to best treat the advanced cancer patient, is it prudent to gain understanding as to the many symptoms of cancer cachexia, the role of caregivers, and the consideration of health disparities that impact the many communities around the country served by VA Medical Centers.
ASCO’s cancer cachexia guideline is applicable to the practice of many clinicians working in cancer care and appears to suggest benefit of a multidisciplinary discussion about the best approach to caring for advanced cancer patients with cancer cachexia. Many VA Medical Centers retain strong access to educational resources for both patients and providers, and with use of ASCO’s guideline, VA providers can better engage multiple team members to care for patients with the condition of cancer cachexia.
Access Management of Cancer Cachexia: ASCO Guideline here: https://ascopubs.org/doi/10.1200/JCO.20.00611
1. von Haehling, S. and Anker, S., 2021. Prevalence, Incidence And Clinical Impact Of Cachexia: Facts And Numbers-Update 2014.
2. Loprinzi CL, Schaid DJ, Dose AM, et al: Body-composition changes in patients who gain weight while receiving megestrol acetate. J Clin Oncol 11:152-154, 1993