Guideline sources The following summarized guidelines for the evaluation and management of cancer-associated cachexia are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2021) and the American Society of Clinical Oncology (ASCO 2020). 1 2 Calculator Calculator Eastern Cooperative Oncology G Karnofsky performance status s Guidelines 1. Screening and diagnosis Screening for malnutrition risk: obtain standardized screening (with a validated screening tool) for nutritional risk at regular intervals in all patients undergoing anticancer treatment and in patients with a life expectancy of at least a few (3-6) months. B Show 3 more https://web.pathway.md/diseases/recAYMJF0g3tLMkZX 1/5 6/29/23, 3:24 AM Cancer-associated cachexia Pathway Definition: define cachexia as disease-related malnutrition based on the GLIM definition of malnutrition and the presence of systemic inflammation. B 2. Medical management General principles: As per ESMO 2021 guidelines, offer interventions with the goal of either improving or alleviating the consequences of cachexia in all patients with cachexia. B Show 6 more As per ASCO 2020 guidelines, insufficient evidence to recommend any pharmacologic agent to improve cancer cachexia outcomes. I Corticosteroids: As per ESMO 2021 guidelines, consider offering corticosteroids to increase appetite for a short period of up to 2-3 weeks. Recognize that effects on appetite usually disappear with longer treatment. B As per ASCO 2020 guidelines, consider offering a short-term trial of corticosteroids in patients experiencing loss of appetite and/or body weight. C Progesterone analogs: As per ESMO 2021 guidelines, consider offering progestins (taking the risk of serious side effects, including thromboembolic events, into account) to increase appetite, body weight (but not muscle mass), and quality of life or physical function in patients with cancer-associated cachexia. B As per ASCO 2020 guidelines, consider offering a short-term trial of progesterone analogs in patients experiencing loss of appetite and/or body weight. C Olanzapine: consider offering olanzapine to treat appetite and nausea in patients with advanced cancer. C Other agents: insufficient evidence to recommend the use of metoclopramide, domperidone, I androgens, I NSAIDs, I medical cannabis or its derivatives, or specific combination regimens in patients with cancer-associated cachexia. I End-of-life care: As per ESMO 2021 guidelines, offer comfort-directed care, including alleviating thirst, eating- related distress, and other debilitating symptoms in patients with an expected survival of less than a few weeks. B As per ASCO 2020 guidelines, consider discontinuing previously initiated enteral or parenteral nutrition near the end of life. C 3. Nonpharmacologic interventions https://web.pathway.md/diseases/recAYMJF0g3tLMkZX 2/5 6/29/23, 3:24 AM Cancer-associated cachexia Pathway Nutritional support (general principles): obtain regular nutritional screening and provide nutritional support, including (if necessary) enteral or parenteral nutrition, in all patients receiving anticancer treatment and in patients with an expected survival of more than a few months. B Show 4 more Nutritional support (nutritional requirements): aim to fulfill energy and nutrient requirements through nutritional interventions. B Show 3 more Nutritional support, tube feeding: As per ESMO 2021 guidelines, consider offering enteral tube feeding in patients with dysphagia and preserved small bowel function. B Show 3 more As per ASCO 2020 guidelines, do not offer routine enteral tube feeding to manage cachexia in patients with advanced cancer outside the context of a clinical trial. D Nutritional support, parenteral nutrition: As per ESMO 2021 guidelines, consider offering parenteral nutrition if the oral intake and tube feeding are inadequate or not tolerated. B Show 2 more As per ASCO 2020 guidelines, do not offer routine parenteral nutrition to manage cachexia in patients with advanced cancer outside the context of a clinical trial. Consider offering a short- term trial of parenteral nutrition in very selected patients (such as reversible bowel obstruction, short bowel syndrome, or other issues contributing to malabsorption, but otherwise are reasonably fit). D Dietary supplements: Consider offering oral nutritional supplements as part of dietary counseling to improve energy intake and induce weight gain. C Consider offering n-3 fatty acid oral nutritional supplements enriched in protein to increase body weight, attenuate loss of lean body mass, and improve quality of life in patients receiving chemotherapy, radiotherapy, or chemoradiotherapy. C Exercise: As per ESMO 2021 guidelines: Offer moderate physical exercise guided by professional experts to maintain and improve muscle mass in patients with cancer-associated cachexia. B Offer resistance exercise 2-3 times per week and moderate aerobic (endurance) training in all patients with cachexia. Ensure that the exercise prescription involves a physiotherapist or an adequately trained professional and comprises a structured approach, including mode (aerobic, resistance, flexibility), frequency, intensity, and duration, as well as defined time points for reassessment. B As per ASCO 2020 guidelines, insufficient evidence to recommend other interventions, such as exercise, for the management of cancer cachexia outside the context of a clinical trial. I https://web.pathway.md/diseases/recAYMJF0g3tLMkZX 3/5 6/29/23, 3:24 AM Cancer-associated cachexia Pathway Psychosocial support: assess patients and their families routinely to timely identify any psychosocial distress. B Show 2 more 4. Patient education General counseling: As per ESMO 2021 guidelines: Provide supportive nutritional advice and education about cachexia and psychological and palliative support in all patients experiencing eating-related distress. B Provide dietary counseling as the first choice of nutritional support to improve oral intake and possibly weight gain in cachectic or at-risk patients able to eat. Emphasize protein intake, an increased number of meals per day, treatment of nutrition impact symptoms, and offer nutritional supplements when necessary during dietary counseling. Ensure that adequately trained professionals guide this advice. B As per ASCO 2020 guidelines, consider referring 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. C Clinical findings Symptoms Past medical history Change in smell Malignancy Change in taste Musculoskeletal exam Early satiety Fatigue muscle strength Loss of appetite Hematological findings Nausea Vomiting Anemia Weight loss hematocrit Anthropomorphic exam Malnutrition Lab findings serum CRP serum IL-6 serum albumin https://web.pathway.md/diseases/recAYMJF0g3tLMkZX 4/5 6/29/23, 3:24 AM Cancer-associated cachexia Pathway References 1. J Arends, F Strasser, S Gonella et al. Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines. ESMO Open. 2021 Jun;6 3 100092. Open 2. Eric J Roeland, Kari Bohlke, Vickie E Baracos et al. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol. 2020 Jul 20;38 21 2438 2453. Open 3. Bryony Alderman, David Hui, Sandip Mukhopadhyay et al. Multinational Association of Supportive Care in Cancer MASCC expert opinion/consensus guidance on the use of cannabinoids for gastrointestinal symptoms in patients with cancer. Support Care Cancer. 2022 Dec 16;31 1 39. Open https://web.pathway.md/diseases/recAYMJF0g3tLMkZX 5/5