Enhancing oncological care: A guide to setting up a new multidisciplinary cancer cachexia clinic within a tertiary centre

Progress depends as much on our collective differences as it does on our individual IQ scores. ( Scott E. Page1) Cancer cachexia is a complex syndrome affecting an estimated 80% of people with cancer, causing significant morbidity and mortality.2 The presence of cachexia also seriously reduces survival associated with general patient frailty and the ability to withstand the course of chemotherapy and radiotherapy treatments.2-4 Despite the very high prevalence and high impact syndrome, there is overall a low awareness of the symptoms, diagnosis and treatment of cancer cachexia among patients, their carers and healthcare providers. Its insidious onset is commonly overlooked when the focus of oncologists and patients is on treating the cancer itself. Many cancer centres are actively working towards establishing multi-modal clinical models of care, but further innovation is needed for the provision of a world-leading service model.5-9 Existing services, such as centre or home-based pre/rehabilitation and optimization clinics, may capture some patients for diagnosis and treatment; however, there is currently no consistent interdisciplinary approach to screening, assessment and treatment.7, 10 Many separate clinical services are involved, but integrated dedicated cancer cachexia services, whereby patients might be treated in a comprehensive and more coordinated and holistic way, are few.9 Multidisciplinary teams working in specialized clinics are best suited to deliver comprehensive, patient-centred care by disseminating evidence-based information and therapy and serve as a hub for preclinical and clinical research to drive development of innovative treatments while educating and training the next generation of healthcare workers and researchers.5, 7, 8 Establishing a multidisciplinary cancer cachexia clinic is laden with challenges, from resource allocation to regulatory compliance.6 Identifying existing infrastructure resources regarding space, technology and electronic health records and the assessment of needs by understanding the patient population and their specific cancer types is essential and may differ between regions (e.g., the prevalence of sun-related skin and head and neck cancers is higher in Australia).11 To define the cancer cachexia patient population, consideration must be given to the large intersection between cancer cachexia, cancer-related malnutrition, cancer-related sarcopenia and frailty to successfully develop cachexia screening tools. Furthermore, it is important to define and identify patients who are ‘pre-cachectic’ to allow for early intervention. Therefore, to establish such a service, we will need to define the scope of practice (taking into consideration future human and technological resources) and ensure financial sustainability of such as service. Ethical considerations, patient privacy and obtaining institutional review board approvals demand meticulous attention. Multidisciplinary efforts to evaluate the existing expertise enable the planning of a tailored workforce, which has the manpower and skillset to accomplish the set goals while reducing overcapitalization and delaying timeframes. Hiring of new and upskilling of motivated staff, including team-building orientation workshops to establish a flexible and effective team communication across disciplines, will form the foundation for a successful start and effective integration of a cancer cachexia clinic into the hospital’s service infrastructure.6, 7 Bringing together consumers, researchers and clinicians united by an integrated patient-centred clinic has the additional benefit of forming a think tank, including patient perspectives, leveraging on the diverse laboratory, preclinical and clinical resources to advance cancer care innovation. This creates an ideal feedback loop between patients and medical, nursing and allied health (including exercise and nutrition). This enables clinical assessments and interventions to feed into and give rise to new research questions while maintaining continuous quality improvement through audit and evaluation, investigator-initiated studies and, importantly, ready participant cohorts. A combined clinical and research expertise lends itself to a fertile partnership with industry for innovative clinical trials investigating novel therapeutics and investigational products (Figure 1). An important example of one of the main identified barriers is that cancer cachexia cannot be merely attributed to poor nutrition status, lack of exercise or tumour stage.3, 12, 13 The lack of understanding of the manifold crosstalk of pathophysiological processes gives this field a wide scope to do research; however, this also bears the risk of more singular-focused research projects that are too removed from other disciplines and thus have low probability to contribute to or be part of a bigger research strategy or multidisciplinary study. One of the reasons that cancer cachexia diagnosis and treatment has stalled in the past is due to the lack of sophisticated consensus tools to define cachexia; the current definition of >5% of body weight loss within 6 months or a weight loss of >2% in patients with a body mass index (BMI) of <20 is too simplified to encapsulate the complexity of the disease.2 Recent emerging artificial intelligence (AI) research is promising to uncover new imaging biomarkers in a faster and innovative way that will shed more light to the underlying processes that promote cancer cachexia. For example, current studies assessing medical imaging-based body composition analysis are focused on how to objectively capture muscle and fat fractions as a more accurate measure of muscle and fat quantity and quality (e.g., sarcopenia, myosteatosis and obesity). These analyses can be performed on already existing routine imaging scans called opportunistic scanning, which thus has no additional burden on the patient, imaging practice workflow or healthcare budget. The additional body composition analysis process could be performed any time after the scan has been acquired and would be performed by the research team or ideally by a fully automated AI tool (Figure 2).14, 15 Initial studies have shown promising predictive value of body composition analysis regarding cardiovascular and oncological risk stratifications.15, 16 Furthermore, the clinic and its patients will offer an opportunity to develop molecular biomarkers (such as circulating biomarkers identified via proteomics or metabolomics) and match these with imaging analyses and clinical functional outputs. Tackling such basic issues and providing better leveraging points to detect and effectively treat (pre-)cachexia could have a big impact on the patients’ cancer journey. This would result in higher patient function, higher number of individualized anticancer treatment options, improved health-related quality of life and better overall survival. Thus, the success of a clinic should be measured against parameters such as the impact of such a clinic in supporting neo-adjuvant care delivery and, in particular, the ability to receive gold-standard care, such as on-time, on-dose chemotherapy, radiotherapy and immunotherapy. The establishment of a federated, privacy-preserving and collaborative learning platform17, 18 for training AI algorithms for body composition analysis across diverse demographics and multiple institutes worldwide represents a ground-breaking step in addressing cancer cachexia. By pooling data from various continents and demography, federated learning enables the development of more accurate and robust algorithms in a privacy-preserved fashion. This approach not only captures the nuances of body composition variations but also ensures the inclusivity of underrepresented populations, leading to more equitable diagnostic and therapeutic solutions. Through collaborative efforts, this federated learning platform has the potential to revolutionize cancer cachexia treatment, ultimately enhancing early detection and personalized interventions for individuals across the globe. A rewarding and cardinal virtue of establishing a multidisciplinary cancer cachexia clinic within a research and academic tertiary healthcare institution is the educational synergy that can be harnessed. Science, allied health and medical students and doctors of all levels will benefit from such a dynamic environment. Learning would be acquired through participation at clinic sessions and at tumour boards, through case discussions and workshops and modified educational curricula. This would cultivate future generations of oncological professionals who will be adept at interdisciplinary collaborations (that includes the consumer voice) and capable of navigating the complexities of cancer cachexia. Catalysing change and the establishment of a multidisciplinary cancer cachexia clinic is not merely an institutional evolution6, 9; it is a transformational endeavour that embraces the opportunity to have a positive impact on patients suffering from cancer cachexia. A patient-centred multidisciplinary clinic would also advance progressive research while educating future generations of healthcare workers. However, this requires careful planning and a judicious balance between clinical care, research endeavours and educational commitments as outlined in this article. The rewards of such a successful clinic are a better understanding and treatment of cancer cachexia. Challenges posed have to be fought with a united front, marked by innovation, empathy and perseverance, which will form the foundation of excellence in care and improved patient outcomes. The authors thank the Bonn Melbourne Research Excellence Fund (grant awardees: Dr Hyun Soo Ko and Prof Shadi Albarqouni) and the Bonn International Fellowship Fund (grant awardee: Prof Ulrike Attenberger to fund A/Prof Louise Cheng) for supporting our international multidisciplinary cancer cachexia research collaboration. No author listed on this manuscript or the institution of the authors have a conflict of interest. There is no relationship, financial or otherwise, with individuals or organizations that could influence the authors’ work inappropriately listed on this manuscript considered for publication.