NewsFor country-specific comments click in one of the links below.
Belgium | France | Germany | Italy | Netherlands | Spain | Switzerland | United Kingdom
Families of cancer patients from all over Italy have been contacting Professor Attilio Giacosa, head of gastroenterology and clinical nutrition at the National Cancer Institute, Genoa, after the results of the recent international study of ProSure® were publicized in the media. E-mails continue to come into his office at a rate of 15-20 per day, from the north and south of the country.
'The problem of malnutrition in cancer patients is much greater than has previously been recognized. If cancer patients are in pain or bleeding, we do something about it. But patients lose 25-30 kg in weight and no one does anything because it is seen as 'normal' for cancer,' explains Professor Giacosa.
At the Institute, oncologists and surgeons routinely refer their cachectic patients to Professor Giacosa. But he knows that it is taking time for the message to reach those working in smaller hospitals that something can at last be done for such patients. He plans to develop a consensus agreement on appropriate use of ProSure® through the Italian Society of Enteral and Parenteral Nutrition. This should help local coordinators of the Society to negotiate reimbursement arrangements.
In Genoa, cancer patients must fulfill at least two key criteria to be suitable for ProSure®. They must:
Ideally, Professor Giacosa also likes to measure their C-reactive protein (CRP), as this indicates whether the inflammatory processes known to be involved in cachexia are active.
'If you have a lung or pancreatic cancer patient who has lost 15-20 kg in the last four months you don't really need a CRP test to see that they have cachexia. But it is a useful and informative way of following the progress of patients,' says Professor Giacosa.
Many of the patients he treats with ProSure® are having chemotherapy or radiotherapy, and he wants to do more research to see whether ProSure® can have a preventive role in cachexia if it is started at an earlier stage of the disease.
Cancer cachexia starts developing in the very early stages of cancer and nutritional screening should form a routine part of a cancer patient's therapy, says Dr Maurizio Muscaritoli. 'Patient motivation is also important, as many cancer patients find swallowing difficult and may suffer from anorexia, early satiety and chronic fatigue. Patients need to understand that two servings of ProSure® are needed to achieve the metabolic effects.'
Dr Muscaritoli recommends a number of strategies to help patients take in the recommended amount of ProSure®. 'Choosing a favorite flavor (vanilla, banana or orange) always helps, and patients can also choose to have it hot or cold, with their main meal or to sip it slowly throughout the day."
Dr Muscaritoli has used ProSure® successfully in patients with solid tumours who have lost as much as 35% of their body weight. 'We have found that patients on ProSure® have regained up to 10% of their body weight and increased their muscle mass and grip strength.'
Fifty-two per cent of patients with advanced cancer recruited to a recent Spanish study were malnourished. Eight out of 10 patients need nutritional support, but only 15% had nutritional support. These were the disappointing findings that Professor Carmen Gómez Candela, head of clinical nutrition at Hospital La Paz in Madrid, hopes to change with a new treatment algorithm. It encourages dietitians to assess each patient's nutritional status and prescribe treatment according to their specific needs for dietary counselling, supplements and drugs.
'ProSure® is the first choice for cachexia patients, not only to provide nourishment, but also to induce metabolic changes. Patients know that it is not just a matter of calories and proteins, but that ProSure® has ingredients that have important effects on metabolism,' explains Professor Gómez Candela.
She has used ProSure® in about 100 cachectic patients over the last two years. Most have been treated on an outpatient basis, usually for cancer of the lung, pancreas or oesophagus.
She is fortunate in having established a good collaboration with oncologists in Madrid. A full-time dietitian attends clinics for different types of cancer and assesses those in need of nutritional support.
'It has been a very important change. Before the arrival of ProSure®, we didn't indicate any supplements for cachexia because no one thought that anything worked,' says Professor Gómez Candela.
She has found that patients are well motivated to take ProSure®, once they understand that it is more than just a supplement and more like a drug that they must take regularly:
'They see a difference because they don't continue to lose weight. It also helps their well being and quality of life. Now, we need to find the best time to start treatment – early in cachexia before they have become very thin and it is too late to help.'
Oncologists in Spain have little or no training in the field of nutrition, but this is slowly changing, according to Dr José Antonio Sanchez Calzado, Hospital Universitario Virgen Macarena, Seville. Patients with weight loss due to cachexia are first prescribed megestrol acetate, to counter the anorexia usually associated with cachexia. 'If the weight loss is severe, patients are referred to the nutritional unit where they can be prescribed ProSure®. Occasionally patients from the countryside are reluctant to take a food supplement, as they cannot believe that this can be as good as a home cooked meal. This is why it is important to explain to patients and their families how ProSure® works.'
In Santander, patients with cachexia are also initially started with megestrol acetate, but this is set to change as more is learnt about ProSure®, according to oncologist Dr Maria Eugenia Vega Villegas, H.U. Marques Valdecilla. She finds that the families of patients who have lost large amounts of weight are particularly keen on the idea of a specialized nutritional supplement. 'They are aware that megestrol acetate can cause serious side-effects such as thrombosis and when they understand that ProSure® is not 'just a food' and that it can interact with the real causes of weight loss, they are keen to encourage their family members with cachexia to keep taking it.'
Most patients who take ProSure® tolerate it well and the vanilla flavor is especially well-liked. 'We encourage patients who find swallowing difficult to take small sips throughout the day, added Dr Villegas. So far we have found around one third of the patients who take the supplement have a weight gain of around 1.5 kg and two-thirds have their weight stabilized.'
Dutch dietitians Jose Maessen and Ans Van Stijgeren are seeing a gradual increase in the number of cachectic patients referred for assessment and nutritional support – and they are starting to see the benefits.
Jose Maessen, research dietitian at the University Hospital in Maastricht, explains that, before ProSure®, there was no dietetic intervention because conventional sip feeds were not considered helpful.
'We only saw patients with very bad weight loss, or when they asked for help themselves,' she explains.
Now, however, she has treated 30-50 patients with ProSure®, with some rewarding successes.
'The effects vary from patient to patient, but we had one elderly lady with stomach cancer whose weight increased from 46 to 52 kg. She was able to walk about and take care of herself and she finally died on her 83rd birthday, having lived over nine months longer than expected,' says Jose.
When she decides that a patient could benefit from ProSure®, she gives them a starter kit to take home. After a week, she phones them and checks how they are getting on. As long as they are managing to consume 1½ servings of ProSure® or more per day, she arranges a continuing supply, and completes the paper work for insurance payments.
At The Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Amsterdam, Ans Van Stijgeren gives cancer patients who she thinks might benefit from ProSure® a leaflet about the treatment and sees them or telephones them a few days later to see if they would like to try it. Like Jose, she has seen variable results.
'It's difficult to evaluate because some patients are having other medication or radiotherapy, while some aren't. Some patients feel less tired when they take ProSure® and most are glad that they can do something that may help them,' Ans explains.
She has drawn up a treatment protocol and a feedback form, which goes to the treating physician, so that the whole team can see who has been prescribed ProSure® and why: 'We will be evaluating patients at two, four and eight weeks. It takes time, but we think it is worthwhile to evaluate so we can see who benefits.'
In theory, Dr Guy Jerusalem, Chu Sart Tilman, Service d'oncologie, Liege, would like to prescribe ProSure® for his patients with cachexia, but in practice he is limited by the fact that it is not reimbursable in Belgium. "ProSure® has an effect very early on in the pathophysiology of cachexia so it is logical to prescribe it to patients who are at risk of suffering from severe weight loss. However, as most of my patients cannot afford to pay the cost for two servings per day of ProSure®, I prescribe medroxyprogesterone acetate, which is fully reimbursable. This is not ideal, as any weight gained is due to lipid accumulation and it has no effect on lean body mass. Indeed, corticosteroids have serious side-effects such as thrombo-embolism, muscle wasting and osteoporosis." Dr Jerusalem is hopeful that more data on the benefits of ProSure® for cachexia will soon convince the Belgian authorities to make it fully reimbursable.
Like Dr Jerusalem, Dr Marc Peeters, GI oncologist at Ghent University Hospital, Department of HepatoGastroenterology, also has problems with the fact that ProSure® is not reimbursable in Belgium, but a small study carried out at UZ Gent on the effects of ProSure® has convinced him that patients with GI cancers can benefit from the supplement. "The study looked at the effects of giving either ProSure® or normal dietary advice to two groups of patients with all types of GI cancers. We found that those on ProSure® quickly stabilized their weight and experienced an improvement in their general condition."
Dr Peeters was keen to emphasize the importance of explaining to his patients that ProSure® should be regarded as a medicine. "Some patients find it difficult to begin taking ProSure® and may experience diarrhoea or lack of appetite, but when they understand the benefits, they are usually keen to continue." Like Dr Jerusalem, Dr Peeters is hoping that new data will soon make ProSure® affordable for all his patients.
Newly diagnosed cancer patients who are losing 1-1.5kg or more per month are being offered ProSure® at the GI clinics of the Archet University Hospital in Nice to help them stabilize their weight.
Assistant professor of nutrition, Dr Stéphane Schneider considers it important that cancer patients, who are already showing signs of malnourishment when they are referred for diagnostic investigations, and may have active treatments that make them lose more weight, should have a nutritional supplement that can act on the underlying mechanisms of cachexia.
He bases this view on evidence showing that proteolysis-inducing factor (PIF) – one of the substances which induces protein catabolism in cancer cachexia – is expressed in cancer patients who are losing as little as 1-1.5kg per month.
"EPA has both anti-PIF and anti-TNF effects, so I think it is worthwhile to start patients on treatment at an early stage," says Dr Schneider.
The second group that he treats with ProSure® is those with biliary and pancreatic cancers who are referred to the GI department for stenting or other procedures but are not suitable for curative treatment. Some of these patients have already lost large amounts of weight or are likely to do so because of the nature of their cancer and, again, ProSure® can help them maintain weight.
"I can't say that I am seeing effects on survival in patients who I am giving ProSure®. But I'm certainly seeing improvements in the number of patients who keep a stable weight," Dr Schneider explains.
Doctors and nutritionists are also beginning to use ProSure® at nearby cancer centres and, as Dr Schneider points out: "Oncologists tended to see weight loss as a side effect of cancer and mostly relied on cancer treatment to restore the nutritional status, but that is starting to change."
Professor Dr Christian Manegold has called for nutritional therapies to be integrated into protocols used for managing cancer patients. "Despite evidence which suggests that patients with cachexia should be treated early with a specialized nutritional supplement, many oncologists have little or no training or experience in offering any kind of nutritional advice," he said. He added that tumor-induced weight loss is a serious problem, as it often prevents patients from having surgery or further chemotherapy. "New products such as ProSure®, which help to decrease pro-inflammatory cytokines implicated in cachexia, represent a promising step forward."
Seven out of 10 cancer patients who are treated at the clinics of Swiss oncologist, Dr Geoffrey Delmore, are likely to be prescribed ProSure® because they are losing weight.
Dr Delmore, Kantonsspital, Frauenfeld, explains that corticosteroids and progestins have been the mainstay of cachexia treatment for cancer patients in Switzerland, with some doctors also using anabolic steroids. However, he offers a four to six week course of ProSure® to all his cancer patients who are losing weight, including those with pancreatic or other intestinal cancers or lung cancer.
"Patients tolerate the treatment well, especially the vanilla flavoured variety. We tell them it is a medicine, and they understand that it is important that they take it. As a result, we have noticed a stabilisation of weight in the patients who have used ProSure®," explains Dr Delmore.
Some of his colleagues are waiting for more evidence about ProSure® before prescribing it to patients. This is because a recent study, carried out at a local hospital, failed to show any benefits on cachexia from taking EPA capsules. But, as Dr Delmore points out:
"The patients needed to take 10-12 capsules a day, so there may have been compliance problems, especially as the capsules don't taste nice. I also think it is important that an EPA supplement contains calories as well, and this is what ProSure® provides."
Although there is no specific nutritional protocol for treating cancer patients at the Swiss Genolier Clinic, Dr Dominique Schneider, clinical oncologist, gives all patients at risk of cachexia information about ProSure®. "I find that it is important to explain to patients right at the beginning of their therapy that the nutritional support we can offer them is part of their medical treatment," says Dr Schneider. "When they understand that the supplement can help reverse the weight loss which is actually caused by their tumor they are much more likely to persevere with treatment." All patients with cachexia are then referred to a nutritionist based at Dr Schneider's clinic, who can prescribe ProSure® and meet them regularly and encourage them during the whole treatment time.
Edinburgh cancer specialist, Professor Ken Fearon, stressed the importance of getting cancer patients to consume two servings of ProSure® per day – if they are to see the increase in weight, lean muscle mass and quality of life achieved in clinical trials of the treatment.
In the international clinical trial of ProSure®, patients who consumed the full, recommended dose of 1.5-2 servings per day had an EPA intake of approximately 2 grams per day6. They had significant improvements in weight (p=0.001) and lean body mass (p=0.001) at the end of the eight-week study. But those who did not consume the recommended amount did not achieve such improvements.
"We've tried mixing it with drinks or freezing it as ice-lollies, but, in reality, most patients take half a serving, four times a day. It's important that doctors and dietitians give their patients the clear message about taking the full daily amount – just as they would take a medicine," concluded Professor Fearon.
Dr Matthew Barber is happy to explain to his patients with cachexia why they need a specialized nutritional supplement and how and when to take ProSure®. "I always say that they should consider it as part of their treatment and that it is likely to be a lot more effective than the complementary therapies which many of them decide to take."
Find out more about 
here
For expert advice on adult nutrition, please contact Abbott Nutrition Careline at 6277 6366.
Energy Dense, High Protein Nutrition with EPA
