Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello and you are very warmly welcome to this Medal education program. If it's the first time you're joining a Medal program, you're especially welcome. Metal exists To make medical education radically accessible to every colleague everywhere. Always free and always open access. We hope you'll find today's CME session really useful for your practice. My name is Professor Barry Laird. I'm professor of palliative medicine at Oslo University Hospital, Norway. And here are my disclosures. Today I'm gonna talk about recognizing cancer cachexia earlier, standardized screening, assessment and documentation. At the end of this presentation, participants should be able to apply consensus diagnostic criteria and structured screening for cachexia in practice. 2, differentiate cachexia from sarcopenia, malnutrition, and treatment effects. 3, integrate an assessment and documentation into routine patient evaluation in the clinic. We will have some polls in today's session, you will be able to answer them using the chat on the right side of the screen or using the chat icon on mobile. If you place a video on full screen, you will need to exit full screen video to answer the polls. We also have some time for questions and answers at the end, so if you have any questions, please put them into the chat box. So let's start with the recognition gap here. Why is chexia important? Well, it's common, it's consequential, and it's routinely identified far too late. Studies have demonstrated that in patients with advanced cancer, Particularly solid tumors, up to 80% of them are affected by cachexia. And a really conservative estimate is that 20-30% of cancer-related deaths are due to cancer cachexia. Muscle wasting, severe fatigue, lack of oral intake, and overall poor performance status results in the downward trajectory we commonly see near the end of life. Despite it being common and have major consequences for patients. Almost 60% of healthcare professionals report difficulty in identifying cachexia before they really see it with severe weight loss and functional decline. And even more worryingly, less than 20% actually routinely assessed for cachexia. When people do identify it, they often don't use the um appropriate criteria. So it's common and associated with death, but what else does it happen? Well, cachexia results in reduced tolerance of systemic anti-cancer therapy. So that means more dose reductions, more treatment delays, early cessation of treatment, and ultimately cachexia means that cancer therapy doesn't work as effectively as it could do. It also results in a reduced quality of life and psychosocial burden. Eating is one of the main um tenets of everyday life and family life. And when somebody has cancer cachexia, their appetite is usually very low, and that can implement influence a lot of social interactions with family and friends. There's also progressive loss of skeletal muscle. Patients become weaker and this affects their day to day life, such as climbing stairs, um, undergoing personal care, etc. and that's quite difficult to reverse. And as I've said, it results in a proper overall survival. So let's start with a case. Mr. A, 64 year old gentleman, he's on a routine visit before his first cycle of chemotherapy. A newly diagnosed stage 4 pancreatic adenocarcinoma due to start for Fox treatment next week. So essentially it's it's a advanced stage pancreatic carcinoma cancer being treated with um chemotherapy with palliative intent. He's a retired teacher, lives with his wife, and he previously walked 3 miles most mornings, so 5 kilometers most mornings. But over the past 3 months, he's saying he stopped that walking. He's just run out of steam, run out of energy. He's eating about half of his usual portions of food, and after a few mouthfuls, he feels full. He's got no nausea, no vomiting, no dysphagia. His bowels are quite regular. And he's never been seen by a dietician and hasn't had that screening recorded. And here are these vital signs at um today's visit. This is a fairly typical patient. The clinic letter records weight stable, his BMI is normal, and he's well enough for chemotherapy. Review again after cycle 2. So before we delve, we delve in in a bit more detail, I'd like to just um appraise you of the theon um 2011 diagnostic criteria for cachexia. This paper published in The Lancet Oncology in 2011 really was a landmark piece because what it did was it sought to define cachexia and also classify it. And it was defined as a multifactorial syndrome in which skeletal muscle is lost with or without fat loss. We stop there. That's an important distinction. Caucensia is not simply weight loss. It's loss of lean mass or muscle that can be present with or without loss of fat. So it's not just simply weight, it's muscle. The second component aspect is that conventional nutritional support cannot fully reverse. So simply giving people more fuel or more calories does not result And reversing caucasia. And because of this loss of skeletal muscle, because of reduced food intake. Function declines as a result. And the criteria for, for diagnosing caucasia. Is it it's weight loss greater than 5% over the past 6 months, and that's unintentional weight loss. And in this era of people using GLP-1 medications, it's important to establish if it's intentional weight loss or unintentional weight loss. Or people can have a BMI of less than 20 kg per meter squared. Plus they need to give ongoing weight loss over 2%. So when you use a BMI comes into this criteria, you can, it allows us a slightly um lesser magnitude of weight loss or sarcopenia. So a measure reduced um levels of skeletal muscle, um, and there's specific measures you can see if you're doing this. So back to, back to Mr. A, he's got 6.1% unintentional weight loss. So based on the information today, is it, what single finding is sufficient to establish a diagnosis of cancer cachexia? A BMI of 24.3 kg per meter squared, which is within normal range. Unintentional weight loss of 6.1% of body weight over the past three months. An albumin of 31 g per liter and CRP C-reactive protein of 22 mg per liter. An ECOG performance is one. Or a reported appetite, about half his usual intake. So the correct answer is B. It's an unintentional weight loss of 6.1% over three months. Although the criteria states up to six months, over three months is still sufficient. There are aspects, well, BMI of 24 is normal. If your BMI was below 20, that may also that may also count. His albumin is um low and the CRP is slightly high, and this equates with a metabolic change going on, but it's not sufficient criteria based on feed on to diagnose cachexia. Performance status, functional status where we see a decline in physical function as part of cachexia, it's not a diagnostic criteria currently. And again, appetite is certainly a symptom of cachexia, but it's not again a diagnostic criteria. So an important concept regarding cachexia is that it's a trajectory rather than a single event or point in time. In the fear and classification, um, paper, what they did was they defined cachexia into three distinct stages. Pre-cachexia. Cachexia or refractory cachexia. Now we've talked before about the the cachexia stage, greater than 5% weight loss or BMI less than 20 and greater than 2% weight loss. And that's the sort of criteria in the middle of cachexia, but there's also a pre-cachexia stage where there can be minimal or no weight loss. West standard equal to 5%, anorexia and early metabolic change. So in other words these patients may not have the clinical phenotype yet of Caucexa, you may not be able to see it, but it's likely to be coming. Whereas of course the other end of the spectrum which is a refractory cachexia. Where patients have advanced metabolism. Low performance status and a life expectancy of less than 3 months, and these patients that usually refractory to cancer treatment and have reduced performance status. Um, and, and it's important that we try to get people at the right point in the trajectory and we follow discussions on that later on in this, um, present same event. The other thing that's important is how BMI and weight loss are interrelated.