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Barriers and Practical Suggestions to an Early Detection of Cancer Cachexia

As healthcare professionals, one of our major challenges is how to effectively allocate the time we have for our patients. Logically, we tend to focus on those issues that are central to the disease process. In the care of cancer patients this tends to be the provision of treatments that prolong survival or decrease disease progression.

This leaves us with little time for other issues that maybe extremely important to the quality of life of our patient such as anorexia and cachexia. These two symptoms are increasingly being recognized as important contributors to the heavy symptom burden that cancer patients experience and are linked to poor prognosis, decreased response to therapy and shortened survival.

One potential benefit of increasing the awareness of the medical team of the importance of this condition is that when cachexia is diagnosed in its advanced stages, there is a general consensus that it becomes a ‘refractory’ condition. Also, diagnosing cachexia early in its course allows for more time for the potential treatments to be effective. These two points provide a strong rationale for an early diagnosis.

Establishing the diagnosis of cachexia or assessing the risk of patients for this condition can in most cases be done quickly, particularly if all members of the medical team act in coordination, and can significantly impact our management. Body weight and a body weight history is in most cases already available in the medical record of the patient or can be elicited with simple questions (i.e. how much weight have you lost over the previous 6 months, 1 year, since you were diagnosed with cancer) . A level of activity is usually already being captured through validated questionnaires such as the ECOG and Karnofsky Scales, and a subjective assessment of symptom burden (focusing on anorexia, depression, pain, fatigue, nausea, swallowing, constipation, etc.) can also be done quickly by using a number of different questionnaires such as the Edmonton Symptoms Assessment Scale (ESAS). Another important point is to perform a review of the medications currently being taken by the patient that could be causing the symptoms (i.e. opioids and constipation) and other comorbidities besides cancer that could be contributing to cachexia when not properly managed (i.e. depression, thyroid disease, chronic obstructive pulmonary disease, heart failure, renal failure, liver disease, dysphagia).

After optimization of the medical treatment for cancer and other comorbidities, patients with cachexia or at risk for this condition should be referred to a dietitian and consideration to the prescription of nutritional supplement should be given. After assessing the functional performance status and medical history of the patient, a physical activity plan or referral to a specific physical therapy program may also benefit these patients. Lastly, given that several drugs are in different stages of clinical development for the treatment of cancer cachexia at this point, patients may be interested in participating in a clinical trial until an approved treatment reaches the market. Since all these interventions are more likely to benefit our patients when instituted earlier in the course of the disease, the assessment for cachexia should be done from the time of cancer diagnosis.

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