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Muscle loss and malnutrition in people with cancer - why prompt screening is essential

By Paula Goodyer

Muscle does more than keep us moving. For people with cancer, good muscle mass - along with good nutrition - is linked to better rates of survival. That’s why screening for both sarcopenia (low muscle mass) and malnutrition should be standard practice once cancer is diagnosed. It’s a message all health services need to hear says the Clinical Oncology Society of Australia (COSA) in its new position paper on cancer-related sarcopenia and malnutrition.  

Of the 150,000 people likely to be diagnosed with cancer in Australia this year, one in three will have malnutrition or sarcopenia - both of which can compromise survival, quality of life and the ability to complete treatment, says Dr Nicole Kiss, Chair of COSA’s Nutrition Group.

"Sarcopenia and malnutrition should be prioritised more than they are at the moment,” she stresses. “If someone is at risk of malnutrition they should be referred to a dietitian but this may not always happen - a 2018 study from Victoria found that a third of people diagnosed with cancer who had malnutrition were not in the care of a dietitian.  

“Even though dietitians are well aware of malnutrition, and screening will occur in most centres where cancer is treated, there’s still room for improvement. Screening may not be done early enough and because most malnutrition screening takes place in hospital it may not be repeated once a patient is being managed by a GP,” she says. “Yet studies in the UK and the Netherlands have found that improving the nutrition of people with cancer saves money and reduces unplanned hospital admissions.”  

But for muscle loss, screening is low on the radar of many health professionals.

Despite growing evidence linking sarcopenia with poorer outcomes in cancer, the recognition of this across health services is patchy, says Nicole Kiss.

“Even when health professionals are aware of the impact of low muscle mass, there may not be the time or resources to do screening. This is why we must get the message out that screening and treatment for sarcopenia should be a standard part of healthcare for people with cancer. “

Why does muscle matter in cancer?

Besides its link to poorer survival in cancer, sarcopenia is associated with twice the risk of toxicity with chemotherapy.  

“Dosing for chemotherapy is based on body surface area but this may not allow for hidden muscle loss and can result in overdosing, if someone has nausea and vomiting to such a degree that they stop treatment it can be life threatening,” Dr Kiss explains. “Lack of muscle may also affect quality of life by exacerbating the debilitating effects of cancer and cancer treatment and making it harder to manage everyday activities or see friends.”

Causes of sarcopenia include ageing, physical inactivity and poor nutrition as well as the effects of cancer or cancer treatment if food intake and physical activity are reduced. Muscle loss with cancer can also be a result of metabolic changes related to some tumours or to systemic inflammation according to COSA.

But a person’s weight isn’t always a reliable guide to their muscle mass, she points out.

“If someone is underweight it’s obvious they may have low muscle mass but it’s less well known that you can be overweight or obese and still have sarcopenia. Both problems are linked to low survival with cancer- it’s a double whammy.”

After screening, what next?

Making screening for sarcopenia and malnutrition part of standard care is just the first step. The next goal is to optimise body composition with the help of a multidisciplinary team that includes an exercise physiologist or physiotherapist and dietitian, along with a psychologist to support behaviour change relating to exercise and nutrition and help with any anxiety or depression that may affect food intake.   

How can dietitians make a difference?

“By incorporating measures of low muscle mass in people with cancer as a routine part of their assessment,” says Dr Kiss.

“Dietitians can also   advocate for change in their workplace and raise awareness of the importance of screening for sarcopenia. Ways of doing this could be including sarcopenia screening tools within existing supportive care screening processes, and looking for opportunities to provide education on the issue to other health professionals in their workplace.”

Dr Nicole Kiss is an Advanced Accredited Practising Dietitian and Co-lead of the Exercise and Nutrition for Cancer research group at Deakin University’s Institute for Physical Activity and Nutrition.

Register for her free upcoming presentation on Cancer-related malnutrition and sarcopenia here