To establish a multidisciplinary Cancer Nutrition Rehabilitation Program (CNRP) for the management of the anorexia-cachexia syndrome (ACS) in an Australian cancer center. 

To determine what benefits and outcomes were achieved by patients following eight weeks of participation in the CNRP. 

Patients were included if they had cancer known to be associated with the systemic inflammatory response and ACS (especially lung cancer, colorectal CA, and upper GI malignancy). Patients were targeted for recruitment if they were referred directly from the oncologist due to clinically apparent ACS, or if via a Malnutrition Screening Tool (MST) given in the waiting room of the clinic. No other formal inclusion/exclusion criteria was included. 

Those that did not meet inclusion criteria were excluded. 

Recruitment

Subjects were recruited from the Sydney Cancer Center, an oncology outpatient clinic of Royal Prince Alfred Hospital. Subjects were recruited one of two ways, either via direct referral from the oncologist if during their physical exam appointment they met the inclusion criteria for ACS, or if they received a positive screening (indicating malnutrition) via a screening tool (the Malnutrition Screening Tool (MST), at least two) which was passed out in the waiting room. 

Design

This was a prospective pre-post evaluation of the cohort.

Blinding used

Not Applicable

Intervention

Those enrolled into the study were initially evaluated by the physician, then the dietitian, and then the physical therapist. An individualized treatment program was created for each patient catering to their needs and included symptom management, supplements if needed, and strength training if needed; with the 'formal' program of treatment lasting eight weeks. 

Statistical Analysis

Descriptive statistics were used to evaluate the data. Odds ratios and 95% confidence intervals for factors predicting attendance at the two-month follow-up were calculated via a free online tool (www.hutchon.net/ConfidOR.htm). No formal categorical data analysis of these factors was performed. 

Timing of Measurements

Measurements were made at baseline and on formal reviews at one, two, three and six months.  

The two-month follow-up visit was the principle end-point of the treatment.  

Dependent Variables

• Demographics and clinical details
• Weight (kg)
• Body composition analysis (BMI, fat percent, fat free mass), using the Tanita Body Composition Analyzer BC-418
• Nutritional assessment using the patient-generated subjective global assessment
• Laboratory parameters of inflammation (CRP, albumin) and calculation of the Glasgow Prognostic Scale (PG-SGA).
• Symptom assessment using Edmonton Symptom Assessment Schedule (ESAS) 
• Performance status using Karnofsky Performance Status (KPS) score
• Six-minute walk test (6MWT)
• Handgrip strength (HGS) using a Jamar hand-held dynamometer
• Strength tests, one repetition maximum (if relevant).

Independent Variables

The individualized treatment plan including symptom/medication management by the physician, oral nutritional supplements or omega 3 fatty acids recommended by the RD, and an individualized activity regimen prescribed by the physical therapist. 

Control Variables

None specifically. No food or activity recalls were kept.  

• Initial N: 58 persons were approached to be included in the study. Of those, 54 enrolled (41 enrolled within the first seven months, 12 enrolled in the final two months) and 39 completed all of the multidisciplinary baseline assessment. 
• Attrition (final N): Of the initial 41 enrollees, 25 returned for the two-month reassessment. 16 dropped out before the eight-week reassessment. 
• Age: Median age at baseline: 62 years old, range 24-85 years old
• Ethnicity: Not specified 
• Other relevant demographics (at baseline):
  • 36 males (68%), 17 females (34%)
  • Cancer Sites: Lung 33%, colorectal 17%, Upper GI 17%, Hepatopancreatobiliary 15%, breast 7%, prostate 4%, other 7% 
  • KPS: Median score 70 with 100% of persons scoring above 50
  • Treatments: Combined chemo/XRT 24%; chemo only 42%, XRT only 13%, no treatment 19%. 
• Anthropometrics (at baseline):

• Location: As listed in recruitment above. 

Key Findings

• The drop out rate increased as time went by with 68% compliant at month one, 58% at month two, and only 12% by month six 
• Those who stayed in the program for two months typically lost less weight, were better nourished, were more fit, and were less likely to have elevated CRP
• Of the 35 participants attending the baseline physical therapy assessment, over 90% of them reported that the CNRP was important to them. 

Odds ratios and 95% confidence intervals for likelihood of returning for eight-week follow-up.  

Due to the high dropout rate, only the results for the 25 patients who returned for the two-month reassessment were reported. Improvement was seen in endurance, strength, symptoms, and inflammatory markers. Significance statistics were not performed in this study. Those that participated appeared to maintain their functional status better and prevent further weight loss and have reduced symptoms. 

Other Findings

• Due to the fact that most persons were recruited once clinical signs of cachexia was obvious, it is possible that participation in the program may show more benefit if patients participated before this decline was clinically evident (via use of a screening tool earlier on in their treatment). 
• The largest factor contributing to attrition from the program was the number of appointments to participate and how they may have conflicted with ongoing treatment appointments.

The CNRP provided a regular and coordinated multidisciplinary approach to the management of anorexia and cachexia syndrome, and was achievable through the development of protocols and procedures. 

Participants in the CNRP for two months shoed improved nutritional status and functional status, endurance, and strength with a decrease in reported symptoms and felt better supported.