NCCN Trends™ Highlights: Cancer Anorexia-Cachexia
By Christine MacCracken, MSHEd, BSN, Senior Director, Business Insights, Editor-in-Chief
In 2011, an international consensus statement defined Cancer Anorexia-Cachexia (CACS) as a multi-factorial syndrome characterized by ongoing loss of skeletal muscle mass, with or without loss of fat mass that cannot be fully reversed by conventional nutritional support leading to progressive functional impairment1. While this definition provides additional framework for the diagnosis of cachexia, the underlying causes are not fully understood, and current treatments remain limited to symptom management, which presents challenges to oncology providers as well as the patients with CACS whom they treat.
In 2013, the National Comprehensive Cancer Network® (NCCN®) conducted an NCCN Trends™ survey, which examined knowledge of the international consensus criteria, as well as intervention patterns and perceptions, among oncology care providers.
When asked how familiar they were with the consensus statement, 25% of respondents noted they were “not at all familiar,” with the majority of respondents being “somewhat familiar” (38%) and only 14% being “very familiar” with the criteria:
An international consensus defined cancer anorexia-cachexia as a multifactorial syndrome with weight loss greater than 5% over the past 6 months, or weight loss greater than 2% in individuals already showing depletion according to current body weight and height (body-mass index [BMI] <20 kg/m2) or skeletal muscle mass. Please rate your level of familiarity with this definition:
The data indicate a varying level of familiarity with the latest consensus around diagnosing CACS, which, in conjunction with the patient experience, could be important factors contributing to patient outcomes in cases of advanced cancer. In a study that examined the experience of patients with advanced lung cancer who met the weight-based criteria for CACS (≥5% weight loss in the past 6 months), researchers found not only inferior survival to those without weight loss, but also that therapies to address the condition may be underprescribed.2 Other studies have also examined the correlation of patient reported outcomes to overall survival and while baseline fatigue and overall functioning scores have shown to be important indicators for mortality, this data may also demonstrate value in prognosis and treatment planning for patients with CACS.3
Clinician perception of how Patient Reported Outcomes (PROs) predict quality of life in patients with cancer cachexia-anorexia was also examined in the NCCN Trends™ Survey with the majority of respondents noting “slight” or “moderate” applicability in their current practice:
In a recent prospective non-small cell lung cancer study, Gralla et al correlated Patient Reported Outcomes (PROs) to survival outcomes (J Clin Oncol 2013 suppl; abstr 8087). How applicable are PROs for predicting cancer anorexia-cachexia related quality of life in your practice?
Treatment of this syndrome has proven difficult and furthering this challenge is when interventions are implemented. In some cases, the early use of palliative care in patients with non-small cell lung cancer and CACs has been correlated to longer survival.4
In the 2013 NCCN Trends™ survey, NCCN sought understanding about how early intervention for CACs should be initiated:
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Palliative Care, Version 2.2013 cite an association between cancer-related cachexia and failure of anti-cancer treatment, increased treatment toxicity, delayed treatment initiation, early treatment termination, shorter survival and psychosocial distress. Temel, et al confirms a correlation of early palliative care to longer survival in non-small cell lung cancer patients (N Engl J Med. 2010). In your opinion, how early should an intervention start for cancer anorexia-cachexia?
The majority of respondents indicated that treatment should begin either at the time of diagnosis of advanced cancer with any associated weight loss, or for patients most likely to be at risk for developing CACS. However, a portion of the respondents indicated that they wait for confirmed muscle loss in addition to a loss of 5% or more, indicating potential opportunities for earlier treatment for patients with CACS.
In summary, multiple data sources have demonstrated that cachexia remains a difficult to treat malady, thereby presenting serious challenges for both patients with advanced cancer and clinicians alike. Currently, several compounds and mechanisms of action are being studied with the hope of increasing both the understanding and treatment of CACS.
For a current listing of clinical trials examining cancer anorexia-cachexia, please visit https://clinicaltrials.gov/ct2/results?term=cachexia&Search=Search
For additional recommendations for the treatment of Cancer Anorexia-Cachexia, please visit NCCN.org and register to view NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Palliative Care.
NCCN Trends™ Surveys & Data
NCCN Trends™ is a survey-based analytics tool from NCCN that focuses on how clinicians in the United States and abroad deliver cancer care. NCCN Trends™ Surveys pose questions regarding topics including, but not limited to, patterns of care and awareness and utilization of various treatment modalities, as well as key topics impacting oncology stakeholders, such as how changes in the health care environment impact them and their patients.
Data is gathered through brief electronic surveys to more than 225,000 health care providers who access NCCN.org on a frequent basis and express interest in responding to NCCN Trends™ Surveys. These clinicians consist of practicing physicians in diverse practice settings, including academic/research cancer centers, community hospitals, and private practices. Survey participants also represent pharmacists, nurses, and other oncology stakeholders. In 2013, NCCN conducted 12 NCCN Trends™ Surveys, averaging more than 1,100 clinician respondents per survey.
NCCN Trends™ Surveys and Data are independent of any NCCN Guidelines or other NCCN clinical recommendations.
1Fearon et al. Definition and classification of cancer cachexia: an international consensus 2011; Lancet Onc; 489-95 .
2Nipp et al. Cancer anorexia-cachexia syndrome in advanced lung cancer: An exploratory analysis of patient-reported outcomes data. J Clin Oncol 31, 2013 (suppl; abstr e17521)
3Robinson et al. The prognostic significance of patient-reported outcomes in pancreatic cancer cachexia. J. Support Oncol. 2008 Nov-Dec; 6 (8):348
4Temel et al. Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer. N Eng J Med 2010; 363;8