Management of Cancer Cachexia: ASCO Guideline
The American Society of Clinical Oncology has released latest evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. The guidelines have been published in the Journal of Clinical Oncology.
Cachexia is a multifactorial syndrome characterized by loss of appetite, weight, and skeletal muscle, leading to fatigue, functional impairment, increased treatment-related toxicity, poor quality of life, and reduced survival. The purpose of this guideline is to provide evidence-based guidance on the optimal approach for the treatment of cachexia in patients with advanced cancer.
Among adult patients with advanced cancer and cachexia, do: (1) nutritional interventions, (2) pharmacologic interventions, and/or (3) other interventions improve clinical outcomes? In this syndrome, there is no single clinical variable widely regarded as the standard primary outcome; therefore, appetite, body weight, lean body mass, physical function, and quality of life were included as appropriate end points.
The target population for observance of guidelines is adult patients with advanced cancer and loss of appetite, body weight, and/or lean body mass.
1. Clinicians may refer patients with advanced cancer and loss of appetite and/or body weight to a registered dietitian for assessment and counseling, with the goals of providing patients and caregivers with practical and safe advice for feeding; education regarding high-protein, high-calorie, nutrient-dense food; and advice against fad diets and other unproven or extreme diets (Type of recommendation: informal consensus; Evidence quality: low; Strength of recommendation: moderate).
2. Outside the context of a clinical trial, clinicians should not routinely offer enteral tube feeding or parenteral nutrition to manage cachexia in patients with advanced cancer. A short-term trial of parenteral nutrition may be offered to a very select group of patients, such as patients who have a reversible bowel obstruction, short bowel syndrome, or other issues contributing to malabsorption, but otherwise are reasonably fit. Discontinuation of previously initiated enteral or parenteral nutrition near the end of life is appropriate (Type of recommendation: informal consensus; Evidence quality: low; Strength of recommendation: moderate).
1. Evidence remains insufficient to strongly endorse any pharmacologic agent to improve cancer cachexia outcomes; clinicians may choose not to offer medications for the treatment of cancer cachexia. There are currently no FDA-approved medications for the indication of cancer cachexia (Type of recommendation: evidence based; Evidence quality: low; Strength of recommendation: moderate).
2.Clinicians may offer a short-term trial of a progesterone analog or a corticosteroid to patients experiencing loss of appetite and/or body weight. The choice of agent and duration of treatment depends on treatment goals and assessment of risk versus benefit (Type of recommendation: evidence based; Evidence quality: intermediate; Strength of recommendation: moderate).
Recommendation 3. Outside the context of a clinical trial, no recommendation can be made for other interventions, such as exercise, for the management of cancer cachexia.
Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. 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. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.
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Journal of Clinical Oncology - published online before print May 20, 2020