ESPEN Congress Geneva 2014 LLL LIVE COURSE: NUTRITIONAL SUPPORT IN CANCER. Mechanisms and clinical features of cachexia P.

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1 ESPEN Congress Geneva 2014 LLL LIVE COURSE: NUTRITIONAL SUPPORT IN CANCER Mechanisms and clinical features of cachexia P. Ravasco (PT)

2 Mechanisms and clinical features of nutritional patterns in cancer Paula Ravasco Unit of Nutrition and Metabolism, Institute of Molecular Medicine Laboratory of Nutrition Faculty of Medicine of the University of Lisbon Portugal

3 Van Cutsem E & Arends J. Eur J Oncol Nurs 2005

4 Cancer wasting 8-87% cancer patients may develop undernutrition Head-neck Oesophagus Stomach Pancreas Lung Advanced colon-rectum Ravasco et al 2010; Stratton et al 2003

5 Resolution ResAP(2003)3 on food and nutritional care in hospitals 2003 Nutritional Risk screening assess Nutritional Status individualised Nutrition Care Plan

7 Physicians Systematic screening in cancer is feasible by all professionals,

8 %weight loss time Nutritional assessment in cancer Validated values undernutrition Ottery FD, et al. Nutrition, 1996

9 Symptoms Disease Treatments Nutritional intake Quantity + Diet / nutritional support Ottery FD, et al. Nutrition, 1996

10 Clinical condition Metabolic stress Steroid therapy Fever Physical exam Muscle mass depletion Muscle atrophy Oedema, ascitis Functional capacity Ottery FD, et al. Nutrition, 1996

11 Nutritional status Ottery FD, et al. Nutrition, 1996

12 yet Undernutrition 2000 Undernutrition & overweight Obesity

n=450 Undernourished PG-SGA 29% 160 A - well

20 0 1- well differentiated 2- moderately

13 n=450 Undernourished PG-SGA 29% 160 A - well nourished B - moderately undernourished C - severely undernourished Overweight / obese BMI 25kg/m2 Number of patients % well differentiated 2- moderately differentiated 3- poorly differentiated Ravasco P, et al; The Oncologist 2011

14 Body composition

15 Body composition assessment by CT scans at the L3 15/ D4 level is validated in oncology

16 Survival (median) Obesity + sarcopenia: 55 days (IQ ) days vs Obesity without sarcopenia: 148 days (IQ ) days p=0.003

17 CT SCANS Sarcopenic obesity (15%): independent predictor of survival irrespective of age, sex, and functional status body composition is an important determinant of chemotherapy toxicity

18 Muscle mass and BMI Martin L, et al; JCO 2013

Overweight Reduced survival in pts with 3 prognostic variables: Obesity weight loss >5% Skeletal Muscle Index Muscle Attenuation Independently of BMI

19 Overweight Reduced survival in pts with 3 prognostic variables: Obesity weight loss >5% Skeletal Muscle Index Muscle Attenuation Independently of BMI CT scans: detection of SMI and fat infiltration in muscle fibers (MA) compromising muscle contraction: lower functional capacity Martin L, et al; JCO 2013

20 Bioelectrical Impedance Analisys Body composition Phase Angle Cell membrane integrity Cellularity Cell function Disease activity / cell function treatment toxicity / outcomes

21 BIA + CT scans concurred Sarcopenia in 49% + excess adipocity 60% BIA Phase Angle Sarcopenia (n=35) and treatment toxicity p< low toxicity high toxicity no sarcopenia sarcopenia Toxicity: GI symptoms & involuntary weight loss > 5% n=86 Ravasco P, et al; 36th ESPEN Congress 2014; P84+P94

22 Phase Angle, Stage, Histology 40% > 5th percentile < 5th percentile 9% 0% 57% I/II III/IV unknown 82% 50% 100% well differentiated > 5th percentile moderately differentiated/ undifferentiated unknown < 5th percentile 9% 53% 32% 0% 55% 50% 100% Ravasco P, et al; 36th ESPEN Congress 2014; P84+P94

Phase angle 19% 81% < Percentil 5 > Percentil 5 73% energy intake

009 PA < P5 PA > P5 p Energy (kcal) 1336 ± 462 1972 ± 373 0.

001 Energy (kcal) -426 ± 546-61 ± 357 0.03 Protein (g) -8.

23 Phase angle 19% 81% < Percentil 5 > Percentil 5 73% energy intake 64% protein intake p=0.02 p=0.009 PA < P5 PA > P5 p Energy (kcal) 1336 ± ± Protein (g) 50.5 ± ± 19,8 < Energy (kcal) -426 ± ± Protein (g) -8.7 ± ± Values expressed as mean±sd; Mann Whitney U non-parametric test. Ravasco P, et al; 36th ESPEN Congress 2014; P84+P94

Lipid intake excesso excess mean ± SD 10% cumpre ~ requirements necessidades

Saturated fatty acids 41% Polyunsaturated fatty acids 94% Excessive intake

saturados excess sat FA + + défice de AG polinsaturados deficient PUFAs Sat

24 Lipid intake excesso excess mean ± SD 10% cumpre ~ requirements necessidades deficit défice 39% Phase angle <5th perc 51% 38% ± 4% total energy value Saturated fatty acids 41% Polyunsaturated fatty acids 94% Excessive intake Deficient intake mean ± SD 40% necessidades ~cumpre requirements excesso de AG saturados excess sat FA + + défice de AG polinsaturados deficient PUFAs Sat FAs: 15% ± 2% PUFAs: 5% ± 1% total energy value Ravasco P, et al; 36th ESPEN Congress 2014; P84+P94

25 Phase angle < 5th perc Vitamins C and E intake women % pts intake Men <DRI Δ intake - DRI % <DRI Vitamin C 72% -35.8±15.5 Vitamin E 90% -8.8±2.9 % pts intake <DRI Δ intake - DRI % <DRI 48±21 71% -50.8± ±22 59±19 90% -8.4 ± ±19 Ravasco P, et al; 36th ESPEN Congress 2014; P84+P94

26 Phase angle: indicates cellular health + metabolic performance - tissues electric properties - integrity of cell membrane - balance between intra + extracellular fluid - quantity of body cell mass specific interventions Nutritional Pharmacological Life-style/physical activity modulate cell / metabolic variables PhA determination may have a major role for a more precise + early determination of favorable or unfavorable effect of adjuvant therapies, allowing timely corrections & adaptations. OUTCOMES

27 Roubenoff R. Lancet Oncol, 2008

ESPEN Congress Madrid 2018

ESPEN Congress Madrid 2018 The Role Of Obesity In Cancer Survival And Cancer Recurrence Obesity As A Risk Factor For Cancer P. Ravasco (PT) Obesity as a risk factor for Cancer Paula Ravasco, Nutric, MD,