ASCO publishes Rapid Guideline Recommendation Updates that highlight revisions to select guideline recommendations when new data or evidence is practice-changing enough to warrant an update. Based on new data that suggests the drug olanzapine can significantly improve cancer cachexia outcomes and prevent cancer-related or cancer treatment-related weight or appetite loss, ASCO has published such a guideline in the Journal of Clinical Oncology (2023; doi: 10.1200/JCO.23.01280).
Olanzapine is an antipsychotic medication commonly used to treat people with bipolar disorder and schizophrenia. It is also used for decreasing chemotherapy-induced nausea and vomiting. The update is supported by an evidence review. The abstract of the updated guideline notes: "The goal of these articles is to disseminate updated recommendations, in a timely manner, to better inform health practitioners and the public on the best available cancer care options."
In an interview with Oncology Times, Charles L. Loprinzi, MD, Medical Oncologist and Professor of Oncology at Mayo Clinic, explained why the new data and guideline update is significant. He was co-chair of the expert panel and co-author of the Rapid Recommendation Update.
1 Why did the panel decide to update these guidelines now?
"The impetus for the updated guideline was a recent Journal of Clinical Oncology publication regarding the results of a randomized placebo-controlled trial of olanzapine (2023; doi: 10.1200/JCO.22.01997). One of the co-chairs of the ASCO anorexia guidelines suggested that a discussion be had as to whether the ASCO guidelines should be updated based on the new information that became available with this publication. The guideline co-chairs both supported the update of the guidelines and ASCO leadership agreed that this was appropriate.
"The new research relates to a trial, conducted in India, which involved 124 patients with stomach, hepatopancreaticobiliary, or lung cancers, as they initiated chemotherapy for these cancers. The patients in this trial were randomized to receive daily olanzapine versus placebo.
"Weight gain of more than 5 percent occurred in 60 percent of patients in the olanzapine arm versus 9 percent in the placebo arm. Substantially improved appetite was also seen (43% with olanzapine vs. 13% with placebo). In addition, Grade 3 or more chemotherapy toxicity was less common with olanzapine (12%) than with placebo (37%). No substantial olanzapine-associated toxicity was apparent in this trial.
"Of note, the original ASCO guideline did comment on the use of olanzapine for cancer-associated appetite loss and weight loss. The expert panel discussed the potential role for olanzapine because of two published trials which supported that olanzapine was beneficial in patients with advanced cancer who had poor appetite and weight loss. Instead of making a recommendation for olanzapine use in this setting, however, the ASCO guidelines committee decided that more evidence was needed to make a more definitive recommendation supporting the use of olanzapine for treating cancer-associated appetite loss and weight loss. The recently published Journal of Clinical Oncology paper, described above, provided this additional information. This new information led to the guideline recommendation change."
2 What are the key changes included in the guidelines?
"The key change to the guidelines was to state there is now convincing evidence that olanzapine is beneficial in improving appetite and causing weight gain in patients with advanced cancer.
"There is always room for improvement. It would be nice to have a better understanding of the best dose of olanzapine to use to obtain benefit and lessen potential toxicities from this drug. Ongoing research is evaluating other approaches for treating cancer anorexia/cachexia. Information from this work would be valuable to have."
3 What is the takeaway that practicing oncologists and cancer care providers should know about the guideline update?
"Olanzapine is the best effective clinically available agent for treating cancer anorexia or cachexia that we know of to date. It has limited toxicities in the doses that have been studied, and it can also decrease nausea and vomiting troubles in patients with advanced cancer in addition to stimulating their appetite and leading to weight gain. And, it is relatively inexpensive."
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