Hi everyone. I think we'll get started. Thanks so much for coming on an early Saturday morning to listen to our talk about sarcopenia. My name is Hannah Oh, recently turned into Hannah Hunter, so apologies for the confusion. I think, I don't know what it says on the slides, Hannah Hunter. I'm a cancer rehab physician at the University of Washington, and luckily I'm joined by some other experts. Kari McMillan leads our medical nutrition team at Fred Hutchinson Cancer Center in Seattle, and Gracia Sirkin is an attending faculty at Memorial Sloan Kettering. So I'm going to start by kind of setting the stage, talking a little bit about the definitions of sarcopenia, sorry it's the screening for sarcopenia, and talk a little bit about screening. I apologize, sometimes I talk so fast that I start inhaling my words, so I will try very hard not to do that. We'll also try to keep an eye on the Q&A, but overall we'll save the majority of questions for the end of our talks. Okay, here we go. Sarcopenia in older adults outside of cancer has been associated with impaired functional status, disability, increased risk of falls, fractures, reduced health-related quality of life, and increased risk of death. It's been studied in the geriatric population as just part of aging. It's been described by Rosenberg in 1989 as a loss of muscle mass that accompanies aging. We know that this is kind of linear after the age of 40, but we've kind of taken a different shift in focus of it when we look at sarcopenia in patients with cancer. Part of this has been a big interest in research in the past few years as we've associated or found that there's an association with sarcopenia with an increased mortality and morbidity in certain cancer types and diagnoses. And part of the challenge in studying sarcopenia is that while we know it's associated with some bad things, we can't come to a consensus on how to define it. So there are many organizations that have interest in this, many letters, and we'll go through some of the definitions or diagnosis criteria that they've all proposed. But since we can't come to a consensus, it's hard to study and quantify something that we can't all agree on in terms of what we should be looking at. Some of the organizations I'll touch on, the top is the European Working Group on Sarcopenia and Older People. That's the EWGSOP. And they put forth a recent criteria, so now we have a number two for it. So initially it was kind of described as a decrease in muscle mass. But now they've proposed that we should also include muscle strength as part of the criteria, because muscle mass and muscle strength is not necessarily linear in terms of their correlation. And now to quantify someone as having severe sarcopenia, we should also include their physical performance. But if you look at all this criteria, somehow we have to evaluate their strength, potentially by hand grip, because we all have a dynamometer in our offices, or do sit to stand. Quantify muscle mass, and this is looking at appendicular skeletal muscle mass, which is sometimes quantified using imaging modalities, and we're all going to quantify that when we look at L3 cut on a CAT scan. And then include a functional performance measure. So this is the European Working Group, and if we look at the bottom, this is the Asian Working Group. And they've put forth some criteria in 2019, also including muscle mass quantification, a test of muscle strength, or physical performance. So while this all kind of sounds similar, the and, ors are very important here, right, to make a diagnosis. And it makes it a little bit tricky if you're doing a study, or even trying to do research in terms of placing patients in a diagnostic criteria group. In the middle, we also have a definition put forth by a consortium, but that just adds to the confusion. I briefly wanted to mention sarcopenic obesity, because of the fact that sarcopenia, and patients with sarcopenic obesity, have a much higher risk of mortality and morbidity in certain circumstances. In patients who are undergoing a gastrectomy, I think they have a six-fold increase in terms of an incidence of post-operative complications, and post-operative infection, even in laparoscopic cases. And again, on definitions, we're a little out of sorts here. Sarcopenia is sometimes used in conversations, and interchanged with, with conditions like frailty and cachexia. But I wanted to mention that these words can't really be used interchangeably. And there's a lot of questions and debate, whether these things are syndromes, and what defines a patient as having sarcopenia, versus a phenotype of frailty, versus being in the category of cachexia. Cachexia is a complex medical condition that is a syndrome associated with an underlying illness. So our patients, particularly with cancer, are at risk for cachexia, which is usually a situation where they have weight loss, muscle loss, with or without loss of fat, in the setting of this pro-catabolic state. And as we know, cancer is very metabolically active, particularly in some cases that are more aggressive. Evans initially put forth a diagnostic criteria in 2008, that described weight loss of at least 5% in 12 months or less, in the presence of an underlying illness, plus three of the following criteria. This was revamped two years later, and published in Lancet Oncology by Fearon, and described as weight loss greater than 5% over the past six months, in the absence of simple starvation, or BMI less than 20, and you can see there's lots of criteria. So we have these potential criteria, and while they're kind of nuanced in their differences, can make it challenging if we want to make an intervention, or look at patient outcomes, because there's almost too much. And why does this happen? We've got multiple factors going on here. We've got an aging population, where you see this boom of geriatric oncology, where they have, where we know that there's this linear sarcopenia going on, associated with age, as well as cancer-related and tumor-related factors, and treatment-related factors. I put this slide in, not so much to look at all the pictures, and potential contributors to systemic inflammation, but wanted to make a note that this is pulled from an article that, in Italy, on sarcopenia and GI cancers, and the conclusion of the authors was that, let me find my quote, that the conclusion of looking at sarcopenia and potential interventions, these oncologists said it should involve, treatment should involve the structured collaboration between oncologists, surgeons, physiatrists, and clinical nutritionists. And I always just love when physiatrists are called out as an intervening group, especially when an article is not written by physiatrists. But sarcopenia is unique in that this is definitely a non-surgical condition that we should be stakeholders in, and kind of take ownership of, because it's a attribute and a clinical state that we can definitely intervene on, as we collaborate with our nutrition colleagues. And again, multifactorial, kind of clinical state that predisposes these patients. For sarcopenia, sometimes referred in the literature as kind of a dual threat, one with the physiologic state of these patients, as well as tumor-related and treatment-related factors. So we'll switch gears a little bit of, like, why is this important, why is this clinically relevant? Again, if we're doing outcomes research or trying to create a prehab program, or create a risk assessment for patients who are at risk for sarcopenia, cachexia, frailty, we have to know what we're looking for and what we should be, what data we should be pulling. Quickly, on the prevalence of sarcopenia, this, I just put in some of these numbers because it does differ on cancer, depending on cancer type. So if we look at colorectal cancer and patients in different age groups, in the study of more than 3,000 adults with colorectal cancer, those who are greater than 70 had a, 58.3% of them were categorized as having sarcopenia, versus those who were younger than 60, it was only 26%. And if we look at other cancers that may not be as aggressive or metabolically active, the HEAL study looked at over 400 patients with breast cancer, and only 16% of them were diagnosed with sarcopenia, versus lung cancer, or especially advanced stage lung cancer or metastatic cases, it's typically the vast majority can be defined as having sarcopenia. So why is this important? Again, if we look at mortality and morbidity, just wanted to bring up a few examples. Sarcopenia was significantly associated with poor prognosis across these 12 different cancer types, which is pretty all encompassing. And a lot of times it's an independent predictor of mortality. This is the case in a lot of hematologic malignancies, and a recent abstract at ASCO showed that metastatic colorectal cancer patients with sarcopenia at baseline were more likely to experience severe neutropenia during treatment, during full box or full fury. So this is not just about outcomes, but can play a role in clinical decision making from the oncologist standpoint on how to treat and what to look out for in terms of complications. Again, not going to go into every cancer type, but I wanted to share some of the statistics in bladder cancers, this group that I particularly looked at. Again, sarcopenia, it can be an independent predictor of survival in patients with advanced bladder cancer. So these are patients who are not getting a cystectomy, but treated with chemotherapy. It was seen in this study to be associated with shorter overall survival. So patients diagnosed with sarcopenia, their median survival was 11 months versus those without sarcopenia was 31 months. In patients who were surgical candidates, so those getting a cystectomy for bladder cancer, a 10% loss in psoas muscle volume before and after the surgery was an independent predictor for shorter survival. Looking at our rehab patients coming to inpatient rehab, sarcopenia was associated with complications that increased length of stay in those who underwent a bone marrow transplant. Not just looking at functional measures or the functional assessment in these patients, this is a study looking at patients with lung and GI cancers at Mass General, sarcopenia was associated with the worst quality of life and greater depression symptoms. You can look at the blue lines, so these are individuals with sarcopenia who had a significantly increased depression scores. We talk all the time about distress in our patients with cancer. To me, a study like this shows that there's an association or a connection between distress and physical function and mobility. So again, how do we intervene and study how physiatry can be helpful if we don't have a clear definition of sarcopenia? And I think this is something that we can hopefully come together as a group on and agree on, especially as we do research or have interventions at our particular institutions so we can further collaborate. Next, I'll talk briefly on how we can measure or quantify sarcopenia and what we do about it. There's been some recommendations on how to quantify muscle mass on imaging modalities that are already done on our patients with cancer. DEXA was one of the first used and still used, particularly in the geriatric population that doesn't have cancer. But in our patients who are younger and not at risk for osteoporosis, they're not getting a DEXA. So sometimes it's not a study that we're going to order if there's no concern about bone integrity. CTs are great for some patients with like GU cancers or a pelvic tumor because they're already being used for restaging and patients are getting them every three to six months. And we can compare the skeletal muscle index, which is a value that we can look at looking at the L3 cut. And it kind of quantifies the skeletal muscle, psoas, and abdominal musculature and looks at it over time. And you can see in this picture, this patient will probably fit in this category of sarcopenia versus this musculature at looking at the L3 cut looks much more robust. So there is values and cutoffs for the skeletal muscle index, but it's not the easiest value to calculate if we're just looking or scrolling through a CAT scan. Bioimpedance, a lot of times it's quick and easy, sometimes already being used in our patients with lymphedema and breast cancer for surveillance, but it can estimate the fat-free fossil mass using small electrical signals sent through the body. But the accuracy of bioimpedance can be affected by BMI, hydration status, whether a patient just exercised, and overall edema. And other imaging modalities like looking at the temporalis and other musculature. But again, this is not something that we can do quickly during a clinical visit to assess whether a patient's at risk for sarcopenia. So the European Working Group on Sarcopenia in Older People recommends using the SARC-F. It's a five-question questionnaire that's scored between zero and two to screen for sarcopenia. A score greater than four is highly sensitive and specific for sarcopenia. And as you can see, it's a fairly straightforward patient-filled-out survey that's recommended by ESPN and the European Working Group. And one of the last points I'll make is just in survivorship. So say a patient has completed their course of chemotherapy or had curative intent surgery. What happens to their muscle mass and rate of sarcopenia in the next few years or decades? And I think as this group continues to grow in terms of patients who are in the survivorship category, it's something that we have to look at. Because these are the patients that are going into general physiatry outpatient practices with deconditioning, falls, balance impairments, knee pain, back pain. But their treatment trajectory with a course of PT may not look like someone else who did not have that cancer treatment. It's kind of hypothesized that the accelerated sarcopenia that occurs during cancer treatment doesn't level off once that cancer treatment is discontinued. So something to definitely keep in mind and kind of educate our colleagues about that we have to potentially continue an intervention on strength building to kind of combat that accelerated muscle mass decline occurring in these patients. And so what are we doing at our institution? We luckily have a robust, awesome medical nutrition team that often sees patients before physical therapy or before physiatry referrals are placed. We luckily have collaborative PT and nutrition meetings and discussions where we realize the other kind of supportive care team that's getting all the questions about exercise is actually our nutrition colleagues, right? Because as you'll see in the next talks, we need substrate or we need food in order for patients to have substrate to make muscle. So in that collaboration, we realized because of the kind of close bond we have in treating patients that once patients are diagnosed with malnutrition, those are nutrition colleagues place a referral for physical therapy. We've got a doc phrase that says this is because the patient has a diagnosis of malnutrition and doesn't mean that PT is seeing them twice a week for eight weeks, but the auto referral is for one to two sessions for exercise counseling, for strength building, and to kind of combat sarcopenia. So that's our nutrition PT collab. We've been doing that for a few months. And then once PT evaluates the patients, they kind of determine whether these patients should be on a program for a couple of weeks or just have one to two sessions to build a home exercise program. And happy to take a few questions at the end about how that's going. But then I'll pass it on to Kerri. Thanks, Hannah. That was great. And thanks for the nice lead-in to talking about sarcopenia and cancer and how we can collaborate so well between our disciplines. I do not have any disclosures, but I would like to see a show of hands or if you need a sit to stand moment, if you can either raise your hand or stand up if you are actually currently working with a dietician as part of your practice. Awesome. Okay. Well, I'm happy to see that. So what I'd really like to go over today, and like Hannah just said, I'm happy to take questions at the end. I'd love to be able to just spend some time to look at the adverse outcomes that are associated with malnutrition and then actually spend some time describing the guidelines for assessing and diagnosing malnutrition and then really to hone in on assessing optimal time points in the oncology care continuum for dedicated dietician intervention and assessment. So as Hannah mentioned, sarcopenia is hard to define. There's lots of different proposals out there, but it's very clear that nutrition alone cannot reverse cachexia or sarcopenia, but it is really important to help minimize further loss. So because of this, we know that adequate protein is essential to maintain or gain muscle. So that's where our collaboration really comes in. You can eat protein all day long, but you're not going to gain muscle if you're not getting adequate calories and you're not actually exercising. Likewise, you could be exercising all day long and you're not going to be building muscle adequately if you don't have enough protein and calories for substrate metabolism. So basically, nutrition is that anabolic stimulus and we know that with postprandial increase in circulating amino acids, that's what really triggers the body to enable it to build protein and essentially build muscle. So what we know too is that the quantity and quality of nutrients are essential to increase muscle anabolism and decrease catabolism. So for example, there have been many studies looking at the timing of protein intake. And what we know is that our typical, quote, American eating pattern is a lot of us will wake up and eat cereal in the morning, maybe have a little snack of fruit in the afternoon, and our main protein source comes in the evening. We absorb protein much better and utilize it if it's spread out throughout the day. So that's a key teaching point, excuse me, for patients, is that you don't really wanna just save all your protein intake for your dinner meal. And that can really increase people's overall intake. So why this matters in the oncology patient is patients with cancer often present and they're already malnourished, which means they've already lost muscle. So we know that about 80% of patients receiving multimodal care have unintentional weight loss. And additionally, the side effects of their treatment regimen compound the potential further loss of muscle mass because they have nutrition impact symptoms where they're either not able to eat enough due to anorexia or early satiety, or they may not be able to absorb well in situations like pancreatic cancer if they're not having adequate pancreatic enzymes. So when we look across all the different ways that we could intervene, when we think about the initial and longitudinal impact, we know that muscle loss is rapid in both acute and chronic conditions, in the situation where people are not eating, hypermetabolic due to their disease state or their treatment regimen, and they don't feel well enough to exercise. This is like the perfect recipe to really lose function. We know that, unfortunately, it takes a lot longer to build muscle than lose it. And muscle loss, as Hannah mentioned already, is a defining feature of both cachexia and sarcopenia. When we think about nutrition interventions, my go-to is let's just figure out how to maximize intake with food. People don't always eat and think about what they're eating. They're just hungry, so they eat. When you're not hungry anymore, it's often difficult to even figure out, well, I don't want to eat. I'm not hungry. I shouldn't eat. My body's telling me I'm not hungry. That's one of the cycles we hear a lot from patients. So then we start thinking about oral nutrition supplements, or I even like to think about just homemade smoothies or milkshakes or ways we can really get nutrition into patients, and then we start thinking about nutrition support, such as enteral or parenteral nutrition. As Hannah mentioned, I think another key point is really maximizing our multimodal supportive care interventions. So that collaboration between the RD and the members of the rehab team, including physiatry, making sure we're getting people to the right discipline so they can really maximize their function and understand how to eat. But we must address their changing metabolic needs. So this happens often and frequently. So we've got their disease state, what's happening that might affect their digestion or their metabolism, their comorbidities. As you all know, if you work in oncology, you get patients who often come in with an oncologic diagnosis, but they may have diabetes or they may have hypertension or heart failure already. We have to take all that into account, as well as medications. Think of your patients who are on high-dose steroids for graft-versus-host disease or other complications of treatment. You know, what's coming down the pike with checkpoint inhibitors and steroids and some of those reactions afterwards. And then, of course, surgical outcome is very important, too, what's left in the anatomy and post-surgical healing. So just to summarize, malnutrition is a very common feature in the cancer patient. It's, again, a consequence of both the tumor itself and the anti-cancer treatments. And similar to what Hannah described about how muscle loss affects quality of life, so does malnutrition. It's estimated, sadly, that up to 10 to 20% of cancer patients actually die due to the consequences of malnutrition due to... In addition to just the tumor itself. So again, nutrition is playing a crucial role in multimodal cancer care. So if we look across the spectrum and, you know, if I were to give everyone a magic wand and say, please do this, this is what I would recommend. All oncology patients should be screened throughout their treatment for malnutrition. This allows you to also triage which patient should go see a dietician. If you don't have, a lot of oncology centers are woefully understaffed with registered dieticians. So this can really push to identifying and triaging the ones that are at most risk. So what we know is that dedicated assessment and early intervention has to be individualized to be most effective. If we think about cultural preferences, dietary preferences, food allergies, intolerance, et cetera, it's hard to just come up with a blanket recommendation that everyone's going to be amenable to do. And we know that the later nutrition care is implemented, the more difficult it is to modify a patient's nutrition status. So the key point here is please try to be proactive versus reactive to nutrition status. And again, from a nutrition standpoint, when we think about loss of muscle, it's very similar to what Hannah already mentioned, but what we know is that the loss of skeletal muscle with or without a corresponding loss of fat is the type of cancer-associated malnutrition that has these impacts that are extremely beneficial and also very costly. So risk of physical impairment, post-operative complications, toxicity with chemotherapy that has to lead to dose reductions, and also mortality. So again, here's just a quick slide of... You can see the CT. I mean, it's not a CT, but the idea is there is that just these people lose a lot of function and that can lead to poor quality of life, increased costs, and actually an interruption of their treatment regimen. So other impacts of malnutrition, increased infection, increased inpatient utilization, increased length of stay, increased readmission, and again, treatment interruption. Malnutrition makes a big impact in oncology care, and Hannah mentioned ESPN, the European Society of Metabolism and Nutrition, and they actually really recommend that dieticians are the first line of nutrition therapy just because we're trained in how to lead to lasting behavior change and follow-up with ongoing intervention. The Commission on Cancer also changed our guidelines. If you're in a COC-accredited hospital where if a patient is screened in for malnutrition, they should see a registered dietician, and just for clarity, all dieticians are nutritionists, but not all nutritionists are dieticians. So it does matter. You know, I call myself either one. Sometimes patients hear dietician and they think I'm just gonna come in with a red pen and cross out and say, you're doing this wrong. That is not what a certified specialist in oncology nutrition is going to do, but sometimes people just don't understand our role in oncology care. So similar to what Hannah already mentioned, I just wanted to go through... Vicky Barracos and Lisa Martin are out of Canada and they do phenomenal research looking at sarcopenic obesity and impact in cancer care. So I put the full reference here because I thought maybe people would be interested in looking at this study, but basically similar to what Hannah already mentioned, there are very clear outcomes that oncology-related sarcopenic obesity is more favorable for the patient. So you can see in all these diagnoses, the multivariate hazard ratio for death is higher with sarcopenic obesity. Same for surgical complications and also for chemotherapy dose-limiting toxicity. So that's a pretty broad swath of treatment areas that are going to be impacted by sarcopenic obesity. So this is a snip from the 2020 ESPN guidelines regarding the role of clinical nutrition in cancer care. We cover all across the multimodal spectrum, surgery, chemo, radiation, as well as giving appropriate recommendations for survivorship and palliative or hospice care. And then what we're really doing when we see a patient is on the left-hand slide, which is screening and assessment, looking at individual energy and substrate requirements, thinking about what's the appropriate intervention, and then working with our colleagues to really encourage the appropriate exercise regimen and if there are any pharmaconutrients or pharmacologic agents that might impact a nutrition status. And by this, I mean things like immunonutrition as part of an ERAS protocol prior to surgery, or potentially working with our colleagues where perhaps we are recommending an antidepressant or a corresponding stimulus for their appetite. So let's think about redefining malnutrition, which was done in 2012, but I want to spend some time to really go through it. So in the past, the historical definitions of malnutrition were weight loss, low BMI, and serum albumin. I just want to say, and it will come up in a slide again, albumin is not a marker of someone's nutrition status. Please do not use albumin as a defining moment of whether or not patients should go see a dietician. So the ASPEN, the Association of Parenteral and Enteral Nutrition, and the Academy of Nutrition and Dietetics released a joint statement regarding the assessment of malnutrition. It serves as a guide for nutrition assessment that includes a nutrition-focused physical exam, which I'll go into, and really thinking about as our population sadly is becoming more obese or overweight, thinking about up to 70% of our patients now are going to present this way. If we're only using low BMI, that could potentially mask malnutrition. So patients who are living in larger bodies can at the same time meet criteria for malnutrition, and that's a really key point. So to have malnutrition, and I don't have time to go into like the nitty gritty details, you need two of these six criteria. Insufficient energy intake over a defined period of time, whether it's chronic or acute, weight loss, loss of muscle, loss of subcutaneous fat, edema, but hard to quantify when a lot of our patients are on IV fluids, and then hand grip strength is another one, but similar to what Hannah alluded to, we all don't walk around with hand grip dynamometers next to us, but it is a potential way that we could collaborate to think about function. This is how we screen for malnutrition. I can screen you all right now. Have you recently lost weight without trying? Answer your question, and if yes, how much weight have you lost? And have you been eating poorly because of a decreased appetite? That's how long it takes to screen a patient for malnutrition. You can add the score up. If it's two or more, please refer to the dietician. This is evidence-based with high sensitivity and specificity for outpatient oncology care across the multimodal treatments. So malnutrition screening key points are, as I mentioned, overweight and obese patients can be simultaneously malnourished. Malnutrition and oncology also has often an inflammatory component. Albumin is not a marker of malnutrition, and the malnutrition screening tool that I just went over is validated and time efficient. So when should you do malnutrition screening? Recommendations in the literature indicate that it's best if you screen all patients getting medical oncology treatment at diagnosis and the start of each chemotherapy cycle, for radiation patients at diagnosis and weekly while on treatment, and surgery at diagnosis, and if it's present, intervene early. That would be true for all of them, and if they're having multiple surgeries before each surgery. So now I'm gonna switch gear just for a sec and go over the role of RD assessment. I also wanted to just make a quick announcement that this is a SNP. This is a website we run out of Fred Hutch. It's called Cook for Your Life. It's full of patient recipes and advice for different treatment-related side effects. So it's cookforyourlife.org. A registered dietician who is a CSO sits on that, and it's been a wonderful resource for our patients. No cost for anyone to sign up or view it, and there's also a lot of blogs that answer questions for patients like does sugar feed cancer? Should I go keto? So I'm sure you might get those in your practice. The recipes are really good. Oh, thanks. So what we're doing when we're seeing a patient, I'm going over like the big picture here, is we're looking at their intake. What are you eating? How does that compare to normal? Evaluating their nutrition impact symptoms. Are you having diarrhea, nausea, et cetera? And then we're doing a nutrition-focused physical exam. We determine their estimated macronutrient needs and are coming up with an individualized nutrition plan which includes referrals to appropriate disciplines. So like Hannah mentioned, we're doing this. If we define that a patient has malnutrition, we are instantly referring patients to physical therapy who then might be elevated to see a physiatrist. Hannah's our first ever physiatrist at Fred Hutch, and it's been amazing to have her expertise on staff. So on the right hand are all of the areas that we might go into, but as you get into the defined micronutrients like HMB or vitamin D or all these things, their exact relationship to improvement in muscle mass needs more research. I totally concur with Hannah that it's very difficult to point to a study that says, this is exactly what you want to do. But truthfully, I think that because our disciplines are so united in our studies, it's a way that we're not going to ever really be able to study the efficacy of one over the other. We have to be intertwined, and that might be the key in actually having success with patients improving their muscle status. So just wanted to quickly go over two case studies to think about how an RD might interact with a patient. So there's a pancreatic cancer patient who presents with 14% weight loss in two months. These are real examples. There are signs of gas-bloating fullness after eating, but their portions at meals are fairly normal. Then we have an esophageal cancer patient who presents with a 7% weight loss in one month, and their diet's limited to about 50% of their normal intake, just because they're having difficulty swallowing, coughing, et cetera. So hold those people in your mind. I will come back to them in a minute. But when I talk about a nutrition-focused physical exam, this is something that we're implementing into our practice because it's a systematic head-to-toe evaluation of a patient where we're actually touching them and looking for malnutrition via muscle and fat loss, nutrient deficiencies, and also nutrient toxicities. So when we look at this, what we're looking at is actually feeling them for muscle loss. So there's these six areas that we start looking at. We, of course, ask patients if they're comfortable. Obviously, if they've just had surgery, we're not gonna be poking around in a surgical area. But if you think about, if you feel your temporal muscles, and you're all trained in this, so you know, but you can, it's very... It's really obvious when patients have severe malnutrition. You ask them to bite down, you can't feel anything as they do this. When you look at their interosseous muscle here, and you can't feel anything when they push together, it's fairly clear that this is a malnourished patient. So we go through these steps, and then we also look at fat loss. And I should mention, this is something we're doing in the outpatient department, as well as with our inpatient colleagues. So with the fat loss, you know, we can feel the fat on the upper arm region, and literally, when you have a patient with very severe malnutrition, it's like you're squeezing together saran wrap. There's really not much there to put your hands on. And you can also tell in the orbital region, it just feels like you're touching something just that's got no cushion at all. So we put these things together, and we can come up with a criteria of severe, mild or moderate fat, and severe, moderate or mild muscle wasting. And so again, if you think back to those two criteria out of six to define malnutrition, you could have someone with weight loss and muscle wasting, and that meets malnutrition diagnosis. The reason this becomes important is because you actually get more reimbursement for your hospital if patients have malnutrition upon diagnosis. So doing this nutrition-focused physical exam aids the diagnosis of malnutrition, which can then lead to greater reimbursement rates for your institution. So sorry that it's eight in the morning and you're getting pictures of someone's intestines, but you're probably used to looking at things like this anyway. But the reason that I bring this up is that what we're also looking at is we can tell people to eat all day long, but if they're having any issues with absorption or utilization, it's not... They need help. They may not be able to absorb all the nutrition. So it's probably hard to read, but the slide D is really like the stage four gut graft versus host disease. We know that that poor little... Those microvilli have atrophied and they are really not going to be able to absorb much until they improve. So we have to really think about how we're managing these patients with appropriate nutrition recommendations. So going back to our case study, the pancreatic cancer patient, the nutrition diagnosis is really impaired nutrient utilization and severe protein calorie malnutrition because this patient was not taking pancreatic enzymes and they didn't understand... Not everyone presents with steatorrhea. Some people just have gas and bloating and floating stools. This patient was really not able to use the nutrition they were putting in and so doing small frequent meals, enzymes with snacks and meals, referral to PT and consistent follow-up really can help ensure that this patient's getting what they need. The esophageal patient has the nutrition diagnosis of inadequate protein calorie intake. Their intake was limited to 50% or less because they couldn't swallow when they were coughing. So they had to change up everything they were doing. And so this patient, as they were proceeding on to trimodal therapy, they actually met criteria to have a PEG placement and then they had referrals also for PT, SLP, home infusion and then follow-up regularly. So I'll close with just one last slide that's where to go from here. We need more research and I think our research will be stronger if we do it together so we can really think about that really nice intersection between yes, you're eating more but are you exercising more? And nutrition-related guidelines are often based mostly on expert consensus and so we just need more research overall before we can start telling people exactly what to do. And I think there's the people, Dr. Google all the time, our patients, and they wanna get all fancy. But I think that just starting at the baseline of are you getting enough calories, are you getting enough protein is a great way to start. And if they are and they're still losing muscle then we can go down and think about more, is it HMB or do we wanna think about X, Y, or Z? But I think just starting at that base level it's like the foundation of a house. Are you getting your macros met? And if yes and you're still having issues then we might wanna elevate our differential diagnoses and what we would do for that patient. And then I guess I'll just close by saying too that we don't know often about the synergistic or additive roles of muscle-building nutrients. So that's just, again, there's a lot of research being done and that could be a whole different talk on how much protein to include and when and the absorption of animal protein versus more vegetarian protein at different stages. There was just a study looking at prevention and survivorship and how in active treatment there's just more of a need for more of the heme-containing protein. Not to say everyone should become a carnivore and eat steak, I don't mean that, but just more of ensuring that if you're able to do fish or poultry or other things there may be advantages in that situation. So I will close there as I just ran out of time anyway and say thank you and I very much look forward to any questions you may have and I will turn it over. All right, good morning, thank you very much for being here and wow, I have a couple of very tough facts to follow. So my name is Grisha, I'm a radiation medicine attending and today we'll be talking about a couple of different things, comparing apples to oranges, how to get people to do stuff and what we know in oncologic population and anabolic steroids. So I have no relevant financial disclosures to make. We will not be talking about off-label use of exercise, sorry, off-label use of medication. Now we're here because we all believe that exercise is medicine. So a couple of objectives for today. So we'll take a big sort of holistic view on what it takes to get a patient to be stronger. What cyptostan performance can tell us. How we compare apples to oranges. How we can have a practical approach to activity recommendation in a cancer patient. And I will try to make a case for cyptostans as the perfect gateway drug to the exercise that is medicine. And then of course, yes, as I promised, we'll talk about anabolic steroids. And I think we will have time to cover one case example at the end. So what does it take to get a patient stronger? Well, as has been pointed out repeatedly, you have to have substrate and energy availability. So you may exercise all you want, but if you don't have calories, if you don't have protein, you know, you're not going to gain much. Then of course, you can't just eat. You also have to exercise. So without an anabolic stimulus in the form of, you know, appropriately delivered muscle stress, the probably won't, you know, things probably won't happen. And then a person's body has to have the synthetic ability. So someone who is in a state of a, you know, chronic ongoing infection, they're acutely or chronically catabolic, they are not able to make protein. They're not going to make protein. And so when you have the perfect intersection of all these three things, then you arrive with, you know, what I call muscle magic. And what muscle magic is, is that if you appropriately feed and stimulate the muscle, it can perform really, really well into, you know, pretty advanced age. And if you thought that Jack LaLanne was impressive, I encourage you all to look up this young lady by the name of Willie Murphy, who recently bulked up to 115 pounds and was able to deadlift 230. So Miss Murphy is a very inspiring example in many ways. She started training when she was 71 years old. She's a natural powerlifter, meaning she's drug-free. Well, she's not purely drug-free because she does take blood pressure medication. And she trains at her local Y three times a week. Now, I'm sure you've all encountered situations where patients tell you, Doc, I have six appointments this week, and you want me to go to the gym? And the answer is, of course not. I don't want you to go to the gym. And so, you know, if you try to, you know, go on Dr. Google and say, well, if I only have time to train one thing, you know, what does Dr. Google tell you? So depending on what your search history is like, your Dr. Google may or may not tell you that you should follow, you know, the blonde bomber's advice. And, you know, if you only train one thing, you train legs. you know, if you only train legs, you do get systemic benefits, you know, both in terms of endocrine changes and of course, you know, functionally observable metrics. And so, all right, so it becomes sort of logical to say, well, you know, what is that one test that we all do in clinical practice that assesses leg power in a very limited physical space? Well, that would be the chair riser sit-to-stand test, okay? Now, if you look at data behind the significance of sit-to-stand testing, you know, you find plenty of good reasons to use it, so it certainly predicts mortality in non-cancerous population fatigue in breast cancer patients. It correlates with PROs on quality of life in stem cell transplant and a step test or another functional performance metric. And more recently it's been tried in lung cancer patients and it correlates strongly with the VO2 peak. So you know, as good of a test as you can get. Now, the one question that I've always had about sit-to-stand testing is that, yes, it's certainly a good test for, you know, tracking one patient longitudinally, but how do you compare performance of different patients? Like, for example, you have a 45-year-old, you know, 6'4", 260-pound guy. How does his sit-to-stand test compare to, let's say, you know, an 81-year-old, you know, 100-pound lady who is maybe about, you know, 95 pounds soaking wet? And so, you know, it turns out somebody already asked this question. And thinking about what happens during a sit-to-stand test is basically this. You're moving a load in a vertical direction. And so if you remember, you know, back to, you know, high school physics, work is defined as force applied over distance. You know, so force in case of a, you know, sit-to-stand test is, of course, a person's body weight, and the distance is how far they rise, right? And so from that we can also derive power, which is work divided by time. And if you look at exercise medicine literature, you know, that studies, you know, elite endurance level athletes like the rowers and the cyclists, they don't really talk much about, you know, times and kilograms, but they do talk about watts. So it seems that fitting that we have this one metric, which is sort of agnostic of what a person looks like, you know, it's all about how much they can put out. And so the question is, well, not everyone has access to an instrumented, you know, bench machine or, you know, cardio pulmonary exercise test or, you know, exercise bicycle with an instrumented crankshaft. And so can you derive work power from a sit-to-stand test? And the answer is, yes, you can. You know, this has been tried already. So the first paper that I could find on the subject... So what you have in this equation, you have the distance, which is the limb length minus the height of the chair times the force, which is their body mass times. And so, in that investigation, the calculated metric was compared to the cross-sectional area of the quads. And it turns out the correlation is very, very strong. And it was also compared to an actual instrumented leg press machine. And again, the correlation between the calculated leg power and the readings on the leg press machine were very, very strongly tied together. And so, you could say, well, it's nice when you take a nice, neatly defined sample of healthy old Japanese adults, but how does it translate to a general population? Well, it turns out it actually translates really well. So, this is a study from Justin Brown's group, published about six years ago, where they took 4,500 of M. Haines III patients, subject studies, subjects, who had 5-second sit-to-stand time documented. They had available limb length and body mass. And they derived this muscle quality index metric. But if you look at what muscle quality index metric is, it is actually power calculation, because you have the distance. And so, okay, how do we... can we use this in oncology practice? Can we not? And so, both of the previous studies that I quoted... And so, my approach has been to basically raise the chair as much as we need to so that patients can in fact do this thing where they get up from a chair without using their arms. And you know, I would just like to share with you all that that particular moment where you ask a patient, they say, but Doc, I can't do this. And then you show them that they in fact can do it, it becomes a neat little buying moment. So I highly encourage it. And so, in my practice, this is what the chair height histograms look like. So on the left side, those are the seat heights from the bone med clinic. And so this big bar here are patients, about 57 patients who are able to use a standard size chair. But you see that there's two-thirds of the patients who can't. And in the bone marrow transplant setting, about half the patients can use. screw up the comparison, so to speak. Well, it turns out it really doesn't have to because this metric of calculating leg power doesn't really care how high the chair is, right? And so, conveniently, this has already been done for us in Netherlands, so this is a very large-scale study of 600 older Dutch people, and it turns out that this artificially derived metric of calculating leg power The left panel over here shows the correlation between sit-to-stand reps and the time up in low speed, and the correlation is just, you know, it's okay. It's about 5.5 Q's exponential equation. However, that great, but if you derive... And so, how does this then... Now, whatever you're asking them to do also should have a very sort of good practical relevance for what they're going to do. So you know, I think patients understand very well that, yeah, if they can get up from a And of course, because we all want to Now, how I use it in my practice. And so, based on this, I have roughly... Now, the middle group are the folks who are able to do between 6 and 10 sit-to-stands. Those are my breakfast, lunch, and dinner group, the BLDs. And so, whatever the number is... So these patients get I And to bring this a little full circle, one of the questions on that SARK F questionnaire is, can you get up from a chair? So we know that it's relevant in terms of screening for sarcopenia using that, but also it's been correlated to risk of fall. So I know for my clinic, if I'm seeing someone for prehab counseling, I'll do a 30-second sit-to-stand, and if they're kind of in that fall risk category, might be more impetus for doing a more structured or supervised prehab exercise program with a physical therapist versus a home exercise program, and also important to telling patients, like, say they're going in for a gastrectomy or colon resection or a cystectomy. Hi, I wanted, it was an absolutely fabulous talk, it was amazing, I wish you could bring this to every oncology center, every cancer rehab location, every nutritionist, every exercise physiologist, fabulous. But I wanted to ask, have you been able to implement this also virtually, if patients couldn't come to your office, for example, or from far, far away? Yes, the last example was all telemedicine. Oh, great. Good morning, thank you for this great talk. I have a question for Ms. McMillan. So many of my patients are taking supplements and also are asking me, and I don't know the answer, what can I do to increase my protein absorption? So could you comment on literature on what is known about boosting absorption of protein, and the other is supplements? Yeah, absolutely, great questions. So I think what I'll start with in terms of the supplements are really, there's very clear guidelines from AICR, it depends on what the supplements are being used for, but if they're thinking of it in terms of cancer prevention or survivorship, there's absolutely no data to support that. In terms of supplements for boosting muscle, if that's what you're thinking, I think it's really important for them to actually go to the, the analogy I gave is build the foundation of the house. You have to assure that patients are actually getting the protein that their body is needing, and because of that, they often just don't know. So I think I would refer them to a registered dietitian just to do an intake assessment, and there are data to just talk about the intake of protein throughout the day, and so I think that that's where I would always start, is thinking about mixed modality protein, making sure they're having a variety in their diet. I think when people get into supplements, it gets tricky because typically in most studies that involve supplements with the oncology patient, there's a few risks. One is that we know over-supplementing does not have the same effect of diet. So I'm going to always recommend just getting a high fiber, broad swath of colors throughout the day so that you can get your phytonutrients, which do synergy with other foods. And then again, I guess the supplement industry is just not regulated well, and so you never know what you're getting, and I've often found that especially with food insecurity, which we should screen for regularly, I didn't have time to go into that, people can be spending so much money on supplements that they're not actually able to get the quality from just real food. So the take-home for patient advising, aside from an RD or other, because this is such a practical question, especially in the elderly cancer population, is small amounts of protein frequently during the day with fiber, without fiber, is that kind of the mix that you go for? Well, again, this is why an individualized assessment is so important because it just depends on the individual and what their oncology diagnosis is. So for example, if I had a pancreatic cancer patient, I would have different recommendations than if they're a post-BMT patient with GVHD or difficulty swallowing. But yes, I mean, if you were gonna think about general, it's one to 1.5... Survivorship group. Yeah, one to 1.5 grams of protein per kilo spread out throughout the day, and make sure you're eating a wide variety of nutrients. Thank you. It all goes back to really boring advice. Wow, this was definitely a good reason to wake up on a Saturday at 8 a.m. I really applaud you for the broad spectrum of information and just a lot of fun. I love how you presented it. I have one or two questions for each of you. So the first one has to do with, in clinical practice, we often see patients that come to us where they're profoundly cachectic, profoundly sarcopenic, et cetera. And the question is, well, when do we entertain the idea of starting them on enteral feeding and things like that? And do you have any guidelines as to what criteria specifically that you use to make that decision? Then for Grisha, a question regarding the sit-to-stand, and in your experience, what are your thoughts about recommending to our oncology colleagues the use of the sit-to-stand as a screening tool that they could use in their clinics and use that as a trigger for rehab and nutrition counseling and so forth? And the last question, I apologize for this, because I have a lot of questions about this. The role of ultrasound in assessing for sarcopenia, there's some literature about that, some star ratios, et cetera, preliminary stuff. But I want to get your thoughts on that as well. Thank you. Maybe we'll go in order that the questions were asked. So I'll start with the enteral nutrition. Great question. So there actually is typically an algorithm that both Aspen and Aspen have in terms of how you start sorting out whether you use enteral nutrition. Think about about 60% of their calorie needs or less times three days in a row is when you start to think about enteral nutrition. But I find that people don't often think about what they eat in terms of their overall calorie needs. So I start with education and the patient to think about things like, you may not have a huge appetite, but here's some calorie-dense foods that will help you meet your goals. Think of avocados, nut butters, things like that, small frequent meals. And really giving them a chance to improve with oral intake first. Most people are not excited about having a tube feeding, which is often the first... And I've found that... But talking through... We always talk through with patients. I like to say, I want to tell you how I'm thinking about it because I want them to know not as a threat, but that we are thinking about an NG2 placement if they're not able to increase their oral intake and really make the connection for them that the reason... And people often don't know this. When they present with weight loss and you ask them, well, how is your physical function? Oh, I can't even get out of bed most days. And then they don't understand that the link is the lack of nutrition and then that just further decline when you don't eat, you don't feel well, you don't have energy, you stay in bed, you lose muscle, it's hard. So I always like to start by education, what nutrients are important, give a plan for how they may be able to do that with food and liquids, because people often don't think about how liquids can be a great source of nutrition as well. And then if... I think the most important area is just follow up, understanding what works. And with those patients, I would definitely follow up in about a week just to see how things are going. And I think it's... Oh, yeah. I have one more. Thank you. This was fascinating. I've got to put in plug for ice cream with peanut butter, great. So the question about using sit to stand as a screener for rehab referral. I generally ask my oncology colleagues that they ask patients two questions. Number one, do you have trouble doing stuff? If the answer is yes, refer to rehab. Or the alternative is, can your patient get up from a chair without using the arms? And the answer is no. Well, then they get referred to rehab. But I'm fortunate in that both of my outpatient practices are embedded within oncology service. So I'm right there. And so it doesn't really take that long. Sorry. I'm just going to comment on the question about the internal nutrition in terms of screening. I think Kerry had a slide on the need for malnutrition screening. Not just at the start of treatment, but also that follow-up, which I think is just so key and instrumental in noticing a decline or change in nutrition status, similar to in the rehab world. Like, we know things happen before the fall, right? The rehab happens after the patient falls or something in the functional status of a patient changes. And that didn't happen over the course of a week or a day. And so it's just so key to have that screening at the start of treatment, but then continually to notice those changes before that diagnosis of malnutrition. And in terms of ultrasound, definitely used in the literature and studies to see change in muscle mass. The study that I think needs to be done is someone looking at ultrasound and comparing that to the L3 cut on CT, to bioimpedance, and then how that is associated to muscle function as well as physical function. And because there's literature using these different modalities and characterizing the skeletal muscle index or muscle bulk, we don't really know, or I don't think we really know how that correlates to strength and then function, which makes it challenging to see if our interventions work because it doesn't, it's not generalizable. Hey, good morning. I had two questions for you guys. The first one was for like bioelectrical impedance and I just wanted to hear how you kind of use it in your own practices because I know it's included within the European and Asian guidelines, but SDOC elected like not to include it in their consensus, but I found it like motivational sometimes for patients when they are looking forward to repeating it. And then the second question was more on like inpatient consults, what are some strategies you use if you're concerned about like low protein intake, but they don't have visitors or anyone to kind of bring things in for them, but they're not really at like supplemental tube feed levels yet and sometimes it's limited in terms of like the insurers and things like that that we can provide. We at our institution have a bioimpedance or a SOZO in our PT clinic and one, and our plastic surgeons also have one. We're primarily using it in a screening study for patients with breast cancer, but because they're, the study is on three years post-op, we have a lot of patients who are coming in who are in the survivorship phase and while it's not an intervention on looking at that muscle mass number, because our therapists are generating this report for lymphedema screening but also seeing it, they're kind of using it not formally to kind of create a rehab program for the patients, but unfortunately we're not using it for any other patients except for those with... Okay, so this is a really good question that does come up often clinically, and I would look at it really in three different standpoints. One is, is your hospital using the most recent recommendations for oncology patients, meaning the neutropenic diet is not recommended. So people can eat fresh fruits and vegetables, they can, I mean, we wouldn't recommend sushi or undercooked meats, just making sure that that's something that isn't limiting their intake. The other thing is, depending on if you're noticing that a bulk of patients that run into this situation is due to a particular food preference from like a cultural or ethnicity standpoint, that might be something to look into in terms of working with your food service director to get some more culturally appropriate foods on the menu. The other thing I would think about is, do they understand the menu and the ordering system? Because sometimes people don't, and depending on whether it's room service type or order the day ahead, sometimes it's hard to predict what you're going to feel like. So I've found success often if people just have regular meals and snacks ordered for them, especially the snack part. Also just to make sure a diet tech or a dietician visits with the patient. And then the other thing I would recommend if they are really struggling with protein intake is see what kind of modulars you might have on the floor that you could mix into. You can get protein powder that you can mix into soups, you can mix into other things, you can also do fiber modules or other things like that. So that might be like a three-pronged approach is just making sure diet guidelines are up to date and they have plenty of options based on whatever diet order they have. Thinking through just routine ordering of snacks and meals, because people often, you might say to a cancer patient, what do you feel like eating? And they could sit there for six hours and not come up with one idea. So having something that's just small in front of them. And then the second thing is just thinking of additive protein that you can mix into a soup or a smoothie or something that's already available in the hospital. I hope that's helpful. Yeah. Thank you. Can I make a comment? Yeah. All right. So this is, I think, going back a question or two about, actually no, going back one question about ultrasound and CT assessments of skeletal muscle mass and whatnot. So I think we've all seen situations where you have two equally cathartic patients performing at vastly different levels. And so what I often tell my patients is that it doesn't really matter what you have, it's what you can do with what you have and how we can get you to the next step. So certainly a radiographic and other assessments are important, but to me, this other thing that we do on top of foundation, as Kerry already alluded to, is you have to have the basics. You have to have your functional assessment, your rehab plan going forward, and those other things that we do like ultrasound muscle quality or CT muscle mass assessment, they may help us do better science, but they may not necessarily help us do better patient care. Thank you all. I just have one question. I've been trying to incorporate sit-to-stand testing more consistently with my patients and I'm undecided between the five-time sit-to-stand and the 30-second. I find the five-time just a little quicker, so I'm leaning that way, but is there any evidence strongly pointing one way or the other? So how do you score a patient who cannot do any on the five-time sit-to-stand? I actually haven't had that come up yet. So there's one of the studies that are in this section actually quotes something like 60% of patients not being able to do a proper five-time sit-to-stand. I probably could tell and wouldn't even do it in someone like that. Right. So for me, use of sit-to-stand testing, it's not just the metric, it's also exercise entry. This is how I try to get patients to do stuff. So for me, a 30-second sit-to-stand is a better measurement because it also gives me some idea of what their endurance and recovery is like because I check the heart rate before the test, I see how high they peak and if they're able to get back to baseline within one minute after test. So yes, it does add a little bit of time, but it's a time that could be used productively. I feel like you can get a lot of information out of it. So for example, if you have someone who is already tachycardic at baseline and they become even more tachycardic as they complete the test, but then they're able to recover within one minute, that's a person they can probably push slightly higher than someone who is not quite tachycardic at the get-go, but then shoots way over 100 as they do the test and then stays very high in that one minute that you have the conversation with them. So you go through that and all your visits, that sounds like a lot of time. I'm blessed. Okay, thank you. Thank you. Thanks all for a great talk. I'm just going to hold this. So quick question about appetite, stimulants, Drabinol, medical marijuana, and if that's typically used. Dr. Searkin, I was at Sloan and a patient was interested in medical marijuana and we scourged the internet and found one provider at Sloan who had it, but it was tough to get them linked up with them. So I was just wondering, as an institution, do you guys use medical marijuana? Do you guys use Drabinol? Do you find it effective? I know there's a ton of formulations and a lot of stuff that's still being tinkered with, but I just want to hear your perspectives on it. I was going to say, Carrie and I are in Seattle, so it's a little bit of a different environment than New York City in terms of access. Yeah, I would say the access isn't as much of an issue, but what can be challenging for patients and providers alike is it's really frustrating that when you go to a green store or whatever you want to call it, there's no consistent dosing. So I've had patients say that they have a whole brownie and they barely felt anything and then they get the same product and they have a bite and they're on the couch, which doesn't help for their physical activity, sit to stands if they're passed out. We don't use Marinol very frequently. Sometimes we'll give it a try. What I have found to be a bit more effective is ... Okay, I'm totally blanking and excuse me. It's like 5 a.m. my time, so the antidepressant that also has an appetite stimulant. Thank you. Yeah, because I think to Hannah's points and slide earlier, we know that loss of muscle has decreased quality of life, so you can't do as much, which makes you depressed. And then it can lead to poor appetite. So I think it's really true to think about the root and why the rehab psychologist is also so important in a patient's care or social work, just to really get at that. No comments. Thank you. I will say one thing, because I think the comment that Grisha just brought up is really important about how patients measure function, because we have the same issue in nutrition where patients will have two good days of eating and think they're going to gain six pounds on the scale. And so it's important for them to think about what is the appropriate weight or expected rate of weight gain or loss, depending on what you're working on them with, and how fluid can really influence that. And then also, really what it comes down to is, for us, we often think about, is it easier to do things? And that's actually what we say all the time. It will be easier to walk down the hall. It's easier to get up off the toilet. It's easier to get up the set of stairs. And so I tell people often that it's more about your nutrition improving your function than how it should be.

sarcopenia

older adults

cancer

sarcopenic obesity

nutrition

malnutrition

registered dietitians

infection rates

muscle loss

diagnosing malnutrition

nutrient absorption

sit-to-stand testing