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The oncology wall: Could Ali Baba have got to the nutrition treasure without using the correct words?

2012; Elsevier BV; Volume: 32; Issue: 1 Linguagem: Inglês

10.1016/j.clnu.2012.12.003

1532-1983

Alessandro Laviano, Kenneth C.H. Fearon,

Childhood Cancer Survivors' Quality of Life

In 1979, the world famous rock band Pink Floyd released the album The Wall. One of the leading tracks is Comfortably Numb, whose lyrics should inspire us when considering the lack of significant improvement in the prevalence of malnutrition over the last 40 years. In fact, when hearing "I see your lips move, but I cannot hear what you are saying", we should start wondering about our approach to colleagues from other disciplines and specialties who are not familiar with nutrition related issues. Can we ascribe to language barriers our failure to raise interest in the recognition and management of malnutrition?It is acknowledged that producing evidence is the best strategy to raise attention to clinical problems, and it is also undeniable that more high quality randomized trials are needed to develop robust and convincing nutrition guidelines. On the other hand, we should not overlook the importance of recognizing endpoints or outcomes that are key for other disciplines and specialties, and then address these priorities. By paraphrasing Robert McNamara, US Secretary of Defense from 1961 to 1968, the nutrition community should stop making important what is measurable and start measuring what is important!In oncology patients, malnutrition is highly prevalent and negatively affects outcome.1Fearon K.C. The 2011 ESPEN Arvid Wretlind lecture: cancer cachexia: the potential impact of translational research on patient-focused outcomes.Clin Nutr. 2012; 31: 577-582Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Nevertheless, integration of nutrition therapy into routine care of cancer patients is still to be achieved. Understanding the reasons for the discrepancy between what the evidence suggests and current clinical practice is key to enhancing the relevance of nutrition therapy in oncology and in other specialties as well. In this light, the nutrition community should acknowledge that the results of many clinical trials testing the role of nutrition therapy in cancer patients are not useful and not relevant for the average medical oncologist. In fact, many trials, particularly those completed during the last decades of the 20th century, were designed without knowing the pathogenesis of cancer-associated malnutrition and without considering that patients are most likely to respond to nutritional intervention when the cancer is well controlled (i.e., during chemotherapy). Therefore, positive results were not obtained since almost all the then-enrolled patients would today meet the definition of refractory cachexia.2Fearon K. Strasser F. Anker S.D. Bosaeus I. Bruera E. Fainsinger R.L. et al.Definition and classification of cancer cachexia: an international consensus.Lancet Oncol. 2011; 12: 489-495Abstract Full Text Full Text PDF PubMed Scopus (2971) Google Scholar More recent studies have considered the role of inflammation in triggering nutritional deterioration and the role of specific nutrition to ameliorate not only the adverse catabolic effects of the tumour but also those of multimodal cancer therapy. However, the primary endpoints of many studies continue to be nutrition-related outcome measures, including reversal of weight loss or improvement of body composition. Although the nutrition community is well aware that muscle loss robustly predicts the development of chemotherapy-related dose-limiting toxicity,3Prado C.M. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment.Clin Cancer Res. 2009; 15: 2920-2926Crossref PubMed Scopus (726) Google Scholar still body composition changes make little sense for the average oncologist.However, there does seem to be increasing recognition by medical oncologists about the importance of optimal palliative care (i.e., treatments and procedures addressing the host rather than the tumour itself, including nutrition therapy), but they do not feel qualified to deal with specific issues such as nutritional assessment or intervention.4Spiro A. Baldwin C. Patterson A. Thomas J. Andreyev H.J. The views and practice of oncologists towards nutritional support in patients receiving chemotherapy.Br J Cancer. 2006; 95: 431-434Crossref PubMed Scopus (115) Google Scholar Oncologists feel more confident with outcome measures like response rate, dose-limiting toxicity, disease-free progression and survival. Therefore, it is likely that they are more prone to react to nutrition intervention studies showing a reduction of chemo- or radiotherapy associated toxicity, or any other hard outcome measure. It is acknowledged that palliative/supportive care is target-oriented, addresses host symptoms and should be delivered early during the clinical journey of cancer patients to enhance the efficacy of anti-tumour therapy.5Temel J.S. Greer J.A. Muzikansky A. Gallagher E.R. Admane S. Jackson V.A. et al.Early palliative care for patients for metastatic non-small-cellule lung cancer.N Engl J Med. 2010; 363: 733-742Crossref PubMed Scopus (4858) Google Scholar Nevertheless, the nutrition community should face the reality and until the curriculum of medical oncologists is modified to include more lectures and internships in supportive/palliative care, it has to provide some new resource to provide such nutritional expertise. Moreover, we need to provide an evidence-base that focuses on oncological end-points and thus speaks the language of oncologists not only to reach out to them but more importantly to change their practice. The ongoing financial crisis may help in this effort. Medical oncologists are not so concerned with cost-benefit analysis,6Berry S.R. Bell C.M. Ubel P.A. Evans W.K. Nadler E. Strevel E.L. et al.Continental divide? The attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs.J Clin Oncol. 2010; 28: 4149-4153Crossref PubMed Scopus (59) Google Scholar and this may explain the rising costs of anti-tumour therapy7Mariotto A.B. Yabroff K.R. Shao Y. Feuer E.J. Brown M.L. Projections of the cost of cancer care in the United States: 2010–2020.J Natl Cancer Inst. 2011; 103: 117-128Crossref PubMed Scopus (1831) Google Scholar despite the suboptimal results obtained so far.8Laviano A. Molfino A. Rossi Fanelli F. Cancer-treatment toxicity: can nutrition help?.Nat Rev Clin Oncol. 2012; 9: 605Crossref Scopus (3) Google Scholar Evidence showing that nutrition support is a relatively cheap adjuvant therapy enhancing the efficacy and effectiveness of anti-tumour therapies may contribute to implement nutritional care into daily clinical practice.The issue of language barriers should be taken into careful consideration by the nutrition community, which should work to harmonize definitions and develop solid, reproducible and reliable markers of malnutrition, in order to prevent confusion [i.e., in a geriatric cancer patient how much of muscle loss is sarcopenia (i.e., age-related loss) and how much is myopenia (i.e., disease-related loss?)]. If the nutrition community do not agree on terminology, how can we expect to convince the world outside and convey confidence on nutrition therapy? Indeed, recent consensus statements2Fearon K. Strasser F. Anker S.D. Bosaeus I. Bruera E. Fainsinger R.L. et al.Definition and classification of cancer cachexia: an international consensus.Lancet Oncol. 2011; 12: 489-495Abstract Full Text Full Text PDF PubMed Scopus (2971) Google Scholar, 9Muscaritoli M. Anker S.D. Argilés J. Aversa Z. Bauer J.M. Biolo G. et al.Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics".Clin Nutr. 2010; 29: 154-159Abstract Full Text Full Text PDF PubMed Scopus (1097) Google Scholar and the development of imaging techniques that assess precisely body composition changes and their clinical implications10Prado C.M. Birdsell L.A. Baracos V.E. The emerging role of computerized tomography in assessing cancer cachexia.Curr Opin Support Palliat Care. 2009; 3: 269-275Crossref PubMed Scopus (178) Google Scholar have been welcomed and highly appreciated by the medical community.11Kachaami T. Bajaj J.S. Heuman D.M. Muscle and mortality in cirrhosis.Clin Gastroenterol Hepatol. 2012; 10: 100-102Abstract Full Text Full Text PDF PubMed Scopus (19) Google ScholarRecognizing priorities and establishing a common language, by which everyone agrees on what is important and how it is defined, is the first step to address the nutritional needs of patients with acute and chronic diseases. Malnourished patients are everywhere, still we cannot convince the attending physicians that nutrition therapy will benefit them. Maybe we are not using the right words to have ourselves understood. Ali Baba could have shouted "Hocus Pocus!" or "Abracadabra!", but he would not have opened the cave with the nutritional treasure without saying the correct words: "Oncological end-points!".DisclaimerKCHF has never listened to Pink Floyd! In 1979, the world famous rock band Pink Floyd released the album The Wall. One of the leading tracks is Comfortably Numb, whose lyrics should inspire us when considering the lack of significant improvement in the prevalence of malnutrition over the last 40 years. In fact, when hearing "I see your lips move, but I cannot hear what you are saying", we should start wondering about our approach to colleagues from other disciplines and specialties who are not familiar with nutrition related issues. Can we ascribe to language barriers our failure to raise interest in the recognition and management of malnutrition? It is acknowledged that producing evidence is the best strategy to raise attention to clinical problems, and it is also undeniable that more high quality randomized trials are needed to develop robust and convincing nutrition guidelines. On the other hand, we should not overlook the importance of recognizing endpoints or outcomes that are key for other disciplines and specialties, and then address these priorities. By paraphrasing Robert McNamara, US Secretary of Defense from 1961 to 1968, the nutrition community should stop making important what is measurable and start measuring what is important! In oncology patients, malnutrition is highly prevalent and negatively affects outcome.1Fearon K.C. The 2011 ESPEN Arvid Wretlind lecture: cancer cachexia: the potential impact of translational research on patient-focused outcomes.Clin Nutr. 2012; 31: 577-582Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Nevertheless, integration of nutrition therapy into routine care of cancer patients is still to be achieved. Understanding the reasons for the discrepancy between what the evidence suggests and current clinical practice is key to enhancing the relevance of nutrition therapy in oncology and in other specialties as well. In this light, the nutrition community should acknowledge that the results of many clinical trials testing the role of nutrition therapy in cancer patients are not useful and not relevant for the average medical oncologist. In fact, many trials, particularly those completed during the last decades of the 20th century, were designed without knowing the pathogenesis of cancer-associated malnutrition and without considering that patients are most likely to respond to nutritional intervention when the cancer is well controlled (i.e., during chemotherapy). Therefore, positive results were not obtained since almost all the then-enrolled patients would today meet the definition of refractory cachexia.2Fearon K. Strasser F. Anker S.D. Bosaeus I. Bruera E. Fainsinger R.L. et al.Definition and classification of cancer cachexia: an international consensus.Lancet Oncol. 2011; 12: 489-495Abstract Full Text Full Text PDF PubMed Scopus (2971) Google Scholar More recent studies have considered the role of inflammation in triggering nutritional deterioration and the role of specific nutrition to ameliorate not only the adverse catabolic effects of the tumour but also those of multimodal cancer therapy. However, the primary endpoints of many studies continue to be nutrition-related outcome measures, including reversal of weight loss or improvement of body composition. Although the nutrition community is well aware that muscle loss robustly predicts the development of chemotherapy-related dose-limiting toxicity,3Prado C.M. Sarcopenia as a determinant of chemotherapy toxicity and time to tumor progression in metastatic breast cancer patients receiving capecitabine treatment.Clin Cancer Res. 2009; 15: 2920-2926Crossref PubMed Scopus (726) Google Scholar still body composition changes make little sense for the average oncologist. However, there does seem to be increasing recognition by medical oncologists about the importance of optimal palliative care (i.e., treatments and procedures addressing the host rather than the tumour itself, including nutrition therapy), but they do not feel qualified to deal with specific issues such as nutritional assessment or intervention.4Spiro A. Baldwin C. Patterson A. Thomas J. Andreyev H.J. The views and practice of oncologists towards nutritional support in patients receiving chemotherapy.Br J Cancer. 2006; 95: 431-434Crossref PubMed Scopus (115) Google Scholar Oncologists feel more confident with outcome measures like response rate, dose-limiting toxicity, disease-free progression and survival. Therefore, it is likely that they are more prone to react to nutrition intervention studies showing a reduction of chemo- or radiotherapy associated toxicity, or any other hard outcome measure. It is acknowledged that palliative/supportive care is target-oriented, addresses host symptoms and should be delivered early during the clinical journey of cancer patients to enhance the efficacy of anti-tumour therapy.5Temel J.S. Greer J.A. Muzikansky A. Gallagher E.R. Admane S. Jackson V.A. et al.Early palliative care for patients for metastatic non-small-cellule lung cancer.N Engl J Med. 2010; 363: 733-742Crossref PubMed Scopus (4858) Google Scholar Nevertheless, the nutrition community should face the reality and until the curriculum of medical oncologists is modified to include more lectures and internships in supportive/palliative care, it has to provide some new resource to provide such nutritional expertise. Moreover, we need to provide an evidence-base that focuses on oncological end-points and thus speaks the language of oncologists not only to reach out to them but more importantly to change their practice. The ongoing financial crisis may help in this effort. Medical oncologists are not so concerned with cost-benefit analysis,6Berry S.R. Bell C.M. Ubel P.A. Evans W.K. Nadler E. Strevel E.L. et al.Continental divide? The attitudes of US and Canadian oncologists on the costs, cost-effectiveness, and health policies associated with new cancer drugs.J Clin Oncol. 2010; 28: 4149-4153Crossref PubMed Scopus (59) Google Scholar and this may explain the rising costs of anti-tumour therapy7Mariotto A.B. Yabroff K.R. Shao Y. Feuer E.J. Brown M.L. Projections of the cost of cancer care in the United States: 2010–2020.J Natl Cancer Inst. 2011; 103: 117-128Crossref PubMed Scopus (1831) Google Scholar despite the suboptimal results obtained so far.8Laviano A. Molfino A. Rossi Fanelli F. Cancer-treatment toxicity: can nutrition help?.Nat Rev Clin Oncol. 2012; 9: 605Crossref Scopus (3) Google Scholar Evidence showing that nutrition support is a relatively cheap adjuvant therapy enhancing the efficacy and effectiveness of anti-tumour therapies may contribute to implement nutritional care into daily clinical practice. The issue of language barriers should be taken into careful consideration by the nutrition community, which should work to harmonize definitions and develop solid, reproducible and reliable markers of malnutrition, in order to prevent confusion [i.e., in a geriatric cancer patient how much of muscle loss is sarcopenia (i.e., age-related loss) and how much is myopenia (i.e., disease-related loss?)]. If the nutrition community do not agree on terminology, how can we expect to convince the world outside and convey confidence on nutrition therapy? Indeed, recent consensus statements2Fearon K. Strasser F. Anker S.D. Bosaeus I. Bruera E. Fainsinger R.L. et al.Definition and classification of cancer cachexia: an international consensus.Lancet Oncol. 2011; 12: 489-495Abstract Full Text Full Text PDF PubMed Scopus (2971) Google Scholar, 9Muscaritoli M. Anker S.D. Argilés J. Aversa Z. Bauer J.M. Biolo G. et al.Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics".Clin Nutr. 2010; 29: 154-159Abstract Full Text Full Text PDF PubMed Scopus (1097) Google Scholar and the development of imaging techniques that assess precisely body composition changes and their clinical implications10Prado C.M. Birdsell L.A. Baracos V.E. The emerging role of computerized tomography in assessing cancer cachexia.Curr Opin Support Palliat Care. 2009; 3: 269-275Crossref PubMed Scopus (178) Google Scholar have been welcomed and highly appreciated by the medical community.11Kachaami T. Bajaj J.S. Heuman D.M. Muscle and mortality in cirrhosis.Clin Gastroenterol Hepatol. 2012; 10: 100-102Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Recognizing priorities and establishing a common language, by which everyone agrees on what is important and how it is defined, is the first step to address the nutritional needs of patients with acute and chronic diseases. Malnourished patients are everywhere, still we cannot convince the attending physicians that nutrition therapy will benefit them. Maybe we are not using the right words to have ourselves understood. Ali Baba could have shouted "Hocus Pocus!" or "Abracadabra!", but he would not have opened the cave with the nutritional treasure without saying the correct words: "Oncological end-points!". DisclaimerKCHF has never listened to Pink Floyd! KCHF has never listened to Pink Floyd!