This Review on items and domains associated with involuntary weight loss in cancer applied two search strings conceptualised around weight loss (including cachexia, anorexia, and wasting) and cancer. A search was done of the Medline, Cochrane, Embase, PsychINFO, and CINAHL databases for papers that included either a comparison of groups of patients with or without weight loss or patients with various degrees of weight loss. Only papers published between 1976, and 2007, in English or German were
ReviewDefinition and classification of cancer cachexia: an international consensus
Introduction
Cachexia has been recognised for a long time as an adverse effect of cancer. It is associated with reduced physical function,1 reduced tolerance to anticancer therapy,2 and reduced survival.3, 4 Weight loss in patients with cancer is rarely recognised, assessed,5 or managed actively.6, 7 Thus, cachexia represents an important unmet need.
Patients with severe muscle wasting, ongoing catabolism, low performance status, and metastatic disease refractory to therapy are unlikely to have clinically important benefits from multimodal treatment intended to result in gain of lean tissue and function. At this stage, the goal of therapy is palliation of symptoms and reduction in distress for both patient and family.8 Against this spectrum, there would be merit in recognising the onset of cachexia so that interventions to reduce or delay its effect can be implemented.9 However, for this to happen, a definition of the condition and recognition of its diagnostic indicators would be needed.10
Clinical management of cachexia is currently both limited11, 12 and complex.9 Various different procachectic mechanisms can be involved,13, 14, 15 which ideally should be assessed and ranked according to importance and reversibility before a management plan is established.16 However, routine management has not achieved such a level of sophistication.17 Additionally, most randomised trials have investigated single agents in unselected patients presenting with weight loss of any aetiology.18 A more sophisticated characterisation would benefit individual patients and improve the robustness of conclusions drawn from trials.
Although our understanding of cachexia has progressed over the past decade,19 a lack of a definition, diagnostic criteria, and classification has impeded advancement in both clinical trials and clinical practice.20, 21, 22 A generic definition for all types of cachexia in both adults and children has been proposed,23 but the associated diagnostic criteria are not cancer specific and have not been validated.24 Two other definitions of cancer cachexia have also been proposed,4, 25 but both are based on single-centre experience and do not follow any formal consensus process.
The aim of this study was to develop a definition, diagnostic criteria, and classification system specific to cancer cachexia by use of a formal consensus process. The aim was not to agree on a definitive guideline, because precise cutoffs remain to be determined. The added value of the project derives from its cancer-specific focus linked to clinical management, trial design, education, and policy.
Section snippets
Methods
A Delphi process (brainstorming, narrowing down, and quantification) was applied,26 and it is presented in figure 1. Experts in clinical cancer cachexia research (medical and surgical oncologists, palliative medicine specialists, and nutritionists) were identified on the basis of leadership in publication, clinical cancer cachexia research or phase 3 clinical trials, and participation in clinical cancer cachexia peer review panels. Key individuals in assessment and classification of
Definition and diagnosis
Cancer cachexia is defined as a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. The pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. Consensus statements for diagnosis are presented in the panel.
Stage
Cancer cachexia
Conclusion
Cachexia remains a challenging clinical syndrome, the importance of which lies in its prevalence and profound adverse effect on patients' quality and length of life.1, 2, 3 The present consensus definition focuses on the complex interplay between reduced food intake and abnormal metabolism and identifies loss of skeletal muscle as key in patients' functional impairment. Such emphasis supports the concept that skeletal muscle mass can be both a marker for the syndrome and an important
Search strategy and selection criteria
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These authors contributed equally