Does cachexia prevention improve outcome of chronic disease and cancer

One of the greatest achievements in medicine is the potential of new therapies to stabilize chronic illness and cancer. In many cases, the disease cannot be cured completely, but is effectively controlled for many years. These medical advancements have substantially contributed to decrease age-related disability, and to increase active-life expectancy of the population. In addition to specific therapies, patients with cancer and chronic diseases will require integrated health care programs to maintain functional autonomy and quality of life. These adjuvant interventions are mainly based on nutritional support and exercise programs. Nonetheless, malnutrition is commonly seen in patients with cancer or chronic diseases, such as heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), hepatic cirrhosis, rheumatoid arthritis, end-stage kidney disease, human immunodeficiency virus (HIV) infection, diabetes, etc. Long-term activation of the systemic inflammatory reaction combined with poor nutrition and physical inactivity are the key mechanisms leading to cachexia. This clinical syndrome includes severe muscle wasting, fatigue, hypoalbuminemia, impaired immune response, anemia, anorexia and loss of fat. Late-stage cachexia is substantially untreatable, and negatively affects the quality of life of patients as well as interfering with therapy ultimately being a primary cause of morbidity and mortality. At earlier stages, malnutrition can be reversed by appropriate nutritional interventions. Diagnostic criteria for pre-cachexia have recently been defined in order to identify patients at risk of malnutrition [1]. In this issue of Internal and Emergency Medicine, Muscaritoli et al. [2] describe a multi professional and multimodal approach aimed at preventing or delaying cancer-related malnutrition. They suggest that monitoring of nutritional and metabolic abnormalities as well as metabolic care should start at early stages of the disease, and proceed in parallel with the specific oncological therapies. Metabolic intervention should include nutritional counselling, supplement prescription or artificial nutrition (enteral or parenteral) as well as other support interventions such as exercise and physiotherapy. This approach, defined as a ‘‘parallel pathway, was primarily aimed at improving the efficacy of oncological therapies and surgery, and ultimately, at improving patient clinical outcome, and possibly, survival. In fact, it is well established that malnutrition reduces the effectiveness of therapies used for cancer treatment, while chemotherapy and radiotherapy can also negatively influence the nutritional status of patients. Randomized controlled trials (RCTs) indicate that interventions based on enteral or parenteral nutrient supplementations, when prescribed in parallel with chemoradiotherapy or surgery, may improve quality of life and reduce therapy related side-effects and mortality.[3–6]. RCTs also suggest that improving nutritional status is not only beneficial in cancer, but also in patients affected by different chronic diseases. Nutritional support in COPD Commentary to the article ‘‘The parallel pathway: a novel nutritional and metabolic approach to cancer patients’’. by Muscaritoli et al., Intern Emerg Med (Epub ahead of print) July 2.