Finally set aside time to review @asco #cachexia guidelines and here are my thoughts with top being: In this evidence based guideline -There is insufficient Evidence to recommend d ANY pharmacologic agent—That’s how dare behind we are. A THREAD 1/ https://twitter.com/mdroeland/status/1263210188397400064

First the authors @MDRoeland et al should be applauded for this very difficult assignment of creating guidelines for oncologists when few #cachexia RCTs exist. This was no small task 2/

Although no pharmacologic agents could be recommended, a “short term trial” of progesterone analogs (ie Megace) or corticosteroids could be offered. The issue with these agents is ... 3/

They have only been shown to improve weight (principally fat mass) and appetite and don’t move the needle on important #cachexia outcomes like physical performance, function or muscle mass. Plus... 4/

One has to deal with fallout of side effects. In text authors note that megace was associated w/ increased risk of VTE and death 5/

Interesting there was a significant amount of text dedicated to olanzapine despite its lack of integration in #cachexia -specific clinical trials. Given accessibility and its broad use for chemotherapy-induced nausea, this may be a practical drug to study in future trials /6

Worth noting the panel recommended being for dietary counseling and against parenteral nutrition in those with #cachexia 7/

There remains sufficient evidence for the use of #exercise for cachexia -an intervention we are studying here @WilmotCancer -though many believe a physical activity component to therapy will be important to pair with other interventions 8/

Important: the panel spent considerable time discussing outcomes/endpoints for #cachexia trials. This is a huge sticking point for me... 9/

#cachexia outcomes need to include patient-reported outcomes and need to be standardized. Endpoints are too highly variable making interpretation of the evidence and implementation into clinical practice very challenging 10/

Ultimately, these guidelines, despite sparse data, are a huge win for the cancer #cachexia field. It raises awareness, adds legitimacy to its scholarship, and establishes that we have a lot of work to do to better treat this debilitating syndrome 11/

Finally & unfortunately, clinicians who manage #cachexia still have little guidance in how to improve symptoms-the hope is we have more soon. This leaves #clinicaltrial as a top treatment option. Us researchers owe it to pts 2 design & conduct trials and make more accessible /fin