As many as 150,000 people are expected to be diagnosed with cancer in Australia this year. Of these, 1 in 3 will be malnourished or sarcopenic which can have a significant impact on their survival, quality of life, and ability to complete cancer treatment 1,2.
I’m the Chair of the Nutrition Group of the Clinical Oncology Society of Australia (COSA), the peak body representing health professionals who treat people with cancer. This week we have released a position statement on cancer-related malnutrition and sarcopenia published in Nutrition & Dietetics. Along with 17 other health organisations we are asking for improved recognition and treatment of cancer-related malnutrition and sarcopenia for all people with cancer.
What are malnutrition and sarcopenia?
Malnutrition is a condition characterised by loss of weight, loss of muscle mass or a low body mass index (BMI) alongside the presence of reduced food intake or systematic inflammation 3.
Primary sarcopenia is a condition most commonly associated with aging. While there is currently no global consensus on a definition of primary sarcopenia, it generally refers to low muscle mass, low muscle strength with or without low physical performance 4.
Secondary sarcopenia is the condition most people are referring to when they talk about sarcopenia in people with cancer. Secondary sarcopenia refers to disease-related low muscle mass 5.
Understanding the differences in these conditions is key to appropriately identifying and treating them.
Why are they important?
There are many decades of research that demonstrate the severe negative consequences of cancer-related malnutrition. Malnutrition in people with cancer is independently associated with reduced survival, lower likelihood of completing cancer treatment and poorer quality of life 6. More recently, studies have focused on the impact of sarcopenia, or low muscle mass, on people with cancer, demonstrating similar severe negative consequences to those seen with cancer-related malnutrition. Sarcopenia in people with cancer is associated with reduced survival 7, reduced time to cancer progression 8 and twice the risk of dose-limiting treatment toxicities 9.
Both malnutrition and sarcopenia can affect people with any type of cancer diagnosis. Likewise they can affect people of any BMI category, including people who are overweight and obese 10. Our rising obesity rates in Australia mean a higher proportion of people with cancer are presenting as overweight or obese at diagnosis, and throughout treatment and recovery. This means the presence of malnutrition or sarcopenia may not be immediately apparent and creates a risk of missed diagnosis.
Despite these significant implications we see substantial variation in practices relating to malnutrition and sarcopenia among oncology health professionals 11.
How do we recognise malnutrition and sarcopenia?
Most health professionals are aware of the potential for malnutrition, and to a lesser extent sarcopenia, to occur in people with cancer but may not always consider this when a patient is in front of them.
As a first step we are recommending that all people with cancer:
- Should be screened for malnutrition and sarcopenia in all health settings at diagnosis and repeated as the clinical situation changes using a valid screening tool.
- People who are identified as ‘at risk’ of malnutrition should have a comprehensive nutrition assessment using a tool validated in the oncology population.
- People who are identified as ‘at risk’ of sarcopenia should have a comprehensive evaluation of muscle status using a combination of assessments for muscle mass, strength and function.
It’s important that assessments are completed by appropriately trained health professionals. For malnutrition this would involve a dietitian and for sarcopenia this could involve dietitians, exercise physiologists, physiotherapists or medical professionals.
Can malnutrition and sarcopenia be treated?
Yes. Providing medical nutrition therapy that is tailored to a person’s treatment plan, individual needs, symptoms and social situation has been found to improve nutritional status as well as reduce unplanned treatment breaks and hospital admissions.6 Importantly, we know that treating malnutrition and sarcopenia requires a team approach and nutrition is more effective when accompanied by exercise intervention as well as optimal management of physical and psychological symptoms. Exercise training provides the foundation for nutrition intervention to improve, or minimise decline, in muscle mass and function 12. Also important to consider is that these interventions are more effective when initiated early, prior to the onset of severe malnutrition and sarcopenia making timely identification all the more essential.
Furthermore, while not specific to malnutrition in people with cancer, international studies have found the cost benefit to treating chronic disease-related malnutrition to be the equivalent of AUD$800,000 for every 100,000 people in the general population 13.
As a second step we are recommending that:
- All people with cancer-related malnutrition and sarcopenia should have access to the core components of treatment including individualised medical nutrition therapy, targeted exercise prescription and physical and psychological symptom management.
- Treatment for cancer-related malnutrition and sarcopenia should be individualised in collaboration with the multidisciplinary team and tailored to consider multi-morbidities and meet needs at each stage of cancer treatment.
As a third step we are recommending that:
- Health services should ensure a broad range of health professionals across the multidisciplinary team have the skills and confidence to recognise malnutrition and sarcopenia and facilitate timely referrals and treatment.
- Multidisciplinary teams should work towards an individualised and coordinated approach to treating cancer-related malnutrition and sarcopenia.
What is your role as a health professional?
A multidisciplinary approach to cancer-related malnutrition and sarcopenia is essential from diagnosis through to recovery and across all health care settings from acute to primary care. Treatment for these conditions requires the specialist skills of several members of the multidisciplinary team as well as team members skilled in identifying or screening.
The COSA position statement has been developed for health professionals and health services to use to advocate for the resources and services required to support optimal management of cancer-related malnutrition and sarcopenia. The position statement includes tips to help implement the recommendations into practice at your health services as well as links to further supporting resources.
The Position Statement is available on the COSA website here.
- Baracos VE, Arribas L: Sarcopenic obesity: hidden muscle wasting and its impact for survival and complications of cancer therapy. Annals of Oncology 29:ii1-ii9, 2018
- Marshall KM, Loeliger J, Nolte L, et al: Prevalence of malnutrition and impact on clinical outcomes in cancer services: A comparison of two time points. Clinical Nutrition 38:644 – 651, 2019
- Cederholm T, Jensen GL, Correia MITD, et al: GLIM criteria for the diagnosis of malnutrition: A consensus report from the global clinical nutrition community. Clinical Nutrition 38:1-9, 2019
- Cruz-Jentoft AJ, Bahat G, Bauer J, et al: Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing 48:16-31, 2018
- Bauer J, Morley JE, Schols AMWJ, et al: Sarcopenia: A Time for Action. An SCWD Position Paper. Journal of Cachexia, Sarcopenia and Muscle 10:956-61, 2019
- Arends J, Bachmann P, Baracos V, et al: ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition 36:11-48, 2017
- Blauwhoff-Buskermolen S, Versteeg KS, Schueren MAEdvd, et al: Loss of Muscle Mass During Chemotherapy Is Predictive for Poor Survival of Patients With Metastatic Colorectal Cancer. Journal of Clinical Oncology 34:1339-1344, 2016
- Prado CMM, Baracos VE, McCargar LJ, et al: Sarcopenia as a Determinant of Chemotherapy Toxicity and Time to Tumor Progression in Metastatic Breast Cancer Patients Receiving Capecitabine Treatment. Clinical Cancer Research 15:2920-2926, 2009
- Antoun S, Baracos VE, Birdsell L, et al: Low body mass index and sarcopenia associated with dose-limiting toxicity of sorafenib in patients with renal cell carcinoma. Annals of oncology : official journal of the European Society for Medical Oncology 21:1594-1598, 2010
- Prado CMM, Lieffers JR, McCargar LJ, et al: Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. The Lancet Oncology 9:629-635, 2008
- Kiss N, Bauer J, Boltong A, et al: Awareness, perceptions and practices regarding cancer-related malnutrition and sarcopenia: a survey of cancer clinicians. Supportive Care in Cancer, 2020
- Aversa Z, Costelli P, Muscaritoli M: Cancer-induced muscle wasting: latest findings in prevention and treatment. Therapeutic advances in medical oncology 9:369-382, 2017
- Elia M, British Association of Parenteral and Enteral Nutriton (BAPEN), National Institute for Health Research Southhampton Biomedical Research Centre: The cost of malnutriton in England and potential cost savings from nutritional interventions (short version). United Kingdom, 2015