1. Nalley, Catlin

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There is a high risk of malnutrition, cancer cachexia, and sarcopenia among patients with advanced lung cancer. Given that these conditions are often associated with poor outcomes and reduced quality of life, early identification and intervention is imperative.

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"Cancer-associated malnutrition and muscle wasting are negative prognostic markers in advanced lung cancer and can increase risk of poor outcomes, including reduced treatment tolerance, decreased treatment effectiveness, worsened clinical trial outcomes, decreased survival, poor quality of life, as well as increased health care costs," noted Peter Whooley, DO, a clinical fellow at Fox Chase Cancer Center in Philadelphia.


"Despite increased recent awareness and some improvements in the management of these conditions over the years, cancer cachexia and sarcopenia remain under-recognized and therefore untreated," he told Oncology Times. "As such, there's an urgent need and significant value in efforts to identify these poor prognostic conditions early to intervene aggressively in pursuit of improved outcomes, patient experiences, and cost control."


Malnutrition & Lung Cancer

With reported rates ranging from 34.5 percent to 69 percent, there is a high prevalence of malnutrition among lung cancer patients (Curr Oncol Rep 2020; doi:10.1007/s11912-020-00916-9). It is especially common in patients who have been hospitalized, as well as those with advanced or metastatic disease.


"Unlike simple malnutrition, which should be reversible by ensuring adequate caloric intake, cancer-associated malnutrition and cachexia are far more complex and are associated with changes in the body's metabolism which impair one's response to nutritional repletion," explained Whooley. "Cancer cachexia, a multifactorial syndrome characterized by loss of skeletal muscle mass with or without loss of adiposity, results, in part, from a number of tumor- and host-related factors-likely altered cytokines and systemic inflammation, energy imbalance, or adipose tissue depletion.


"While a large number of patients with advanced lung cancer have malnutrition at cancer diagnosis, adverse effects from chemotherapy and targeted therapy (i.e., nausea, vomiting, diarrhea, taste changes, etc.), immunotherapy (colitis, pancreatitis, etc.), and radiation therapy (mucositis, esophagitis, etc.) further potentiate malnutrition, muscle loss, and diminished functional status," he continued.


Assessment & Management

Treatment of cancer-associated malnutrition and associated muscle wasting remains a challenge; however, progress is being made in the management of these conditions, according to Rishi Jain, MD, MS, DABOM, Assistant Professor at Fox Chase Cancer Center.


There are number of available nutritional screening and assessment modalities. For example, the Malnutrition Screening Tool is an effective predictor of malnutrition risk among oncology outpatients (Support Care Cancer 2006;14(11):1152-6). Another option is the NUTRISCORE screening tool, which emphasizes the nutritional risk of the patient's underlying malignancy and accompanying treatments (Curr Oncol Rep 2020; doi:10.1007/s11912-020-00916-9).


"Regardless of the strategy used, we advocate for the clinical integration of a standardized nutritional screening technique longitudinally throughout the treatment of patients with advanced lung cancer to enhance early identification of-and timely intervention for-patients at risk," wrote Jain and colleagues (Curr Oncol Rep 2020; doi:10.1007/s11912-020-00916-9).


A variety of nutritional interventions can be considered for advanced lung cancer patients, such as dietary counseling and oral nutritional supplements (Curr Oncol Rep 2020; doi:10.1007/s11912-020-00916-9). The right approach will depend on the patient and their individual needs.


Registered dietitians play an integral role in dietary counseling, according to Jain, emphasizing that "ideally, registered dietitians must be fully integrated with the rest of the oncology care team to ensure adequate follow-up as patient needs can fluctuate over time after a diagnosis of lung cancer."


ASCO recently published their first guideline on the management of cancer cachexia (J Clin Oncol 2020; doi:10.1200/JCO.20.00611). The recommendations include offering dietary counseling "with the goals of providing patients and caregivers with advice for the management of cachexia."


The guidelines went on to note, "Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia."


Another intervention to consider is physical activity. "While the role of exercise in cancer-associated malnutrition and cancer cachexia is less clear, given the positive effects of exercise on other important factors such as fatigue or quality of life, patients who are able to be active should be encouraged to do so," Jain suggested.


Ongoing Exploration

Researchers continue to explore ways to improve the identification and management of these conditions. For instance, research is underway that is focused on various investigational agents (e.g., ghrelin receptor agonists or anti-inflammatory agents) to help manage cancer anorexia and cachexia, Jain noted.


"Given the need for multimodal approaches, combination approaches looking at anti-cachexia agents in combination with nutritional support are urgently necessary," he said. "One novel approach includes the utilization of meal delivery programs in conjunction with dietary counseling to ensure that patient access to food is adequate.


"Ongoing studies are also looking at combination approaches with early integration of nutrition and physical activity (aerobic and resistance training) programs for these patients," Jain continued. "We hope that future evidence from these studies will help define the optimal approach to the management of malnutrition and muscle loss in our patients."


Catlin Nalley is a contributing writer.


Immunotherapy & Weight

With the onset of targeted approaches, the treatment of lung cancer has evolved significantly in recent years.


"Immunotherapy has had a marked impact on patients with advanced lung cancer, and while treatment responses vary, far reaching efforts are underway to identify biomarkers or clinical features to better predict treatment response," noted Peter Whooley, DO, a clinical fellow at Fox Chase Cancer Center in Philadelphia.


Interestingly, some studies suggest that overweight or obese patients treated with immunotherapy may have improvements in outcomes, including progression-free survival and overall survival when compared with patients with normal weight, he reported to Oncology Times.


"While further study is indicated, obesity, a risk factor for certain cancers and tumor progression, is known to induce a state of chronic inflammation which may actually lead to an augment immune response to immunotherapeutic agents," Whooley explained. "Additional research is needed to understand the specific mechanisms by which obesity may lead to improved benefit from immunotherapy in lung cancer."