Cancer anorexia-cachexia syndrome (CACS) is underrecognized and underreported in patients with advanced lung cancer receiving routine clinical care, according to a retrospective, single-institution study presented at the 2013 Annual Meeting of the Multinational Association of Supportive Care in Cancer. The study found that 62% of patients with stage IV metastatic non–small cell lung cancer
(mNSCLC) met at least 1 of 4 defining criteria for CACS.
The investigators from Duke Clinical Research Institute and Duke Cancer Institute, Durham, North Carolina, said that the underreporting of CACS “demonstrates a substantial opportunity for clinical and patient education as to the presence and impact of the condition, especially as new therapies become available.”
CACS, a multifactorial condition leading to muscle wasting, affects up to 80% of patients with advanced malignancies, said the investigators. The presence of CACS impairs quality of life and compromises response to chemotherapy. Patients with CACS have more frequent and severe toxicity and require more dose reductions and treatment delays than those without the syndrome, thus interfering with the beneficial effect of anticancer therapy.
Reasons for the underrecognition and undertreatment of CACS include lack of a standardized definition, lack of effective treatments, and poor education about CACS and its impact. As new treatment options become available, it is important to look at how CACS is identified and addressed in the current clinical landscape.
To look at the prevalence of CACS in patients with mNSCLC, the Duke investigators gathered data from an electronic patient-reported outcomes (ePRO) database combined with other electronic data systems and paper case notes available at Duke.
CACS was identified according to the following 4 criteria:
- Weight loss ≥5% or weight loss >2% with a body mass index (BMI) <20 kg/m2 within 3 to 6 months of diagnosis.
- CACS-related International Classification of Diseases, Ninth Revision (ICD-9) codes assigned by healthcare providers.
- A score of ≥7 on patient-reported questions related to weight loss or lack of appetite.
- A prescription for drugs that treat CACS (eg, megesterol acetate, dronabinol).
Of 495 patients identified with mNSCLC between May 2007 and April 2012, 307 (62%) met at least 1 of the 4 criteria for CACS. For example, among patients with weight loss data available at 3 and 6 months (n=215), 51% met the criteria. Healthcare providers assigned the ICD-9 code for CACS to 22% of patients. Among patients completing the ePRO survey (n=202) during the course of treatment, 32% met the predefined threshold for severe loss of weight or appetite. Finally, 5% of patients (n=26) received either megesterol acetate or dronabinol.
Of the 109 patients who fulfilled weight loss criteria for CACS, less than 50% were captured by ePRO, ICD-9 code, or medication adherence. The prevalence of CACS was 42% and 17% in patients with weight loss ≥5% at 3 months and 6 months, respectively. Weight loss criteria of ≥2% with a BMI ≤20 kg/m2 were met by 1% of patients at 3 months and 2% at 6 months.
The study’s senior author, Amy Abernethy, MD, commented on the importance of the findings: “In the setting of advanced cancer, anorexia-cachexia syndrome is woefully underrecognized. Over half of the patients with available weight data could have met the criteria for CACS by weight loss criteria alone. In this single setting, over 60% met at least 1 criterion. If we aren’t identifying people burdened by this syndrome, then we cannot initiate approaches to help them. Simple maneuvers like education will help patients and families know what to expect. And, we anticipate that our treatment toolbox will soon be filled with new efficacious medications. We need to learn how to identify the red flags of CACS so that we can be ready to treat people who suffer from the syndrome.”
Benner A, Hirsch B, Abernethy A. Cancer anorexia-cachexia syndrome (CACS) is under-recognized among patients with metastatic non-small cell lung cancer (mNSCLC). Support Care Cancer. 2013;21(suppl 1):S285. Abstract 0808.