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PURPOSE OF REVIEW Cancer cachexia is a complex condition that occurs in approximately 50% of cancer patients and in 80% of those with advanced cancer. It is characterized by lean body mass loss, adipose tissue loss, altered metabolism, increased inflammation, and a decrease in quality of life. Cancer cachexia is a frustrating condition to manage and treatment requires an innovative approach. The purpose of this article is to review the current treatments for cancer cachexia and how they could be used in a multimodal approach. RECENT FINDINGS Cancer cachexia has many causes, but is primarily a result of reduced energy-protein intake and altered metabolism augmented by a proinflammatory state. There is not a formal consensus on diagnosing cancer cachexia, but proactive screening and assessments for malnutrition are an effective first step toward identifying high-risk patients. Treatment of cancer cachexia includes optimizing nutrition care, using appropriate pharmacological agents, preserving lean body mass, and the cooperation of the healthcare team. SUMMARY Cancer cachexia is a complex multifactorial condition that can only be successfully managed and treated with a multimodal approach that involves a multidisciplinary team that includes an oncology registered dietitian nutritionist and exercise physiologist that target early detection and management of cancer cachexia.

This pilot study aimed to determine if a biophilic Green Therapy or Virtual Reality environment can decrease an oncology patient’s pain and distress while receiving chemotherapy. A case-crossover pilot study was conducted in a comprehensive cancer infusion center. 33 participants with breast, gynecologic, gastrointestinal, pancreatic and prostate cancers were all included in three rooms in a random order at different cycles: control room, Green Therapy room, and Virtual Reality room to receive chemotherapy, respectively. Participants’ pain, distress, heart rate, blood pressure, and saliva cortisol were measured before and after infusion in each room. No statistical significance differences were shown in the changes of heart rate, systolic, or diastolic blood pressure, saliva cortisol, pain, or distress before and after infusion between the control, Green Therapy, and Virtual Reality rooms. However, more patients reported the experience as “fun” and “enjoyable” when they were in Green Therapy or Virtual reality room as compared to in the control room. Additionally, since participating in the study, 14 patients reported spending at least 30 min or more outside in nature. In this study, we found that patients’ heart rate, blood pressure, and self-reported distress levels were reduced after each biophilic intervention although results are not statistically significant. The study also suggested that biophilic interventions are safe and feasible and may complement the standard of care for oncology patients.

Purpose Only 34% of breast cancer survivors engage in the recommended level of physical activity because of a lack of accountability and motivation. Methodist Hospital Cancer Health Application (MOCHA) is a smartphone tool created specifically for self-reinforcement for patients with cancer through the daily accounting of activity and nutrition and direct interaction with clinical dietitians. We hypothesize that use of MOCHA will improve the accountability of breast cancer survivors and help them reach their personalized goals. Patients and Methods Women with stages I to III breast cancer who were at least 6 months post–active treatment with a body mass index (BMI) greater than 25 kg/m2 were enrolled in a 4-week feasibility trial. The primary objective was to demonstrate adherence during weeks 2 and 3 of the 4-week study period (14 days total). The secondary objective was to determine the usability of MOCHA according to the system usability scale. The exploratory objective was to determine weight loss and dietitian-participant interaction. Results We enrolled 33 breast cancer survivors who had an average BMI of 31.6 kg/m2. Twenty-five survivors completed the study, and the average number of daily uses was approximately 3.5 (range, 0 to 12) times/day; participants lost an average of 2 lbs (+4 lbs to −10.6 lbs). The average score of usability (the second objective) was 77.4, which was greater than the acceptable level. More than 90% of patients found MOCHA easy to navigate, and 84% were motivated to use MOCHA daily. Conclusion This study emphasizes the importance of technology use to improve goal adherence for patients by providing real-time feedback and accountability with the health care team. MOCHA focuses on the engagement of the health care team and is integrated into clinical workflow. Future directions will use MOCHA in a long-term behavior modification study.

Background: Studies have demonstrated that obesity increases the risk of breast cancer recurrence and death in survivors but only 34% of breast cancer survivors engage in the recommended level of physical activity. This low percentage is related to a lack of accountability and motivation. We hypothesize that using a mobile application (app) incorporating the concept of cognitive-behavioral therapy and dietary and physical activity recommendations will improve breast cancer survivors' accountability and help them reach their personalized health goals; specifically with diet and exercise. Methods: We have created an app, METHODIST HOSPITAL CANCER HEALTH APPLICATION (MOCHA) for the purpose of patient self-reinforcement through the daily accounting of activity and nutrition as well as group feedback and direct interaction with clinical dietician. To test the MOCHA app's feasibility, we enrolled 33 breast cancer survivors with a body mass index (BMI) over 25 who were at least 6 months post active treatment (surgery, chemotherapy, or radiation) for a 4 week feasibility trial. During these 4 weeks, the users used the app to track wellness (mood, sleep or pain), diet (calorie intake) and exercise (walking or steps). Our primary objective was to demonstrate adherence, defined as the number of days recorded on MOCHA during week 2 and 3 of the 4 week study period (14 days). A registered dietitian assigned personalized goals for each user and monitored their usage of the app and followed the progress of their goals. Additionally, the dietitian sent daily push notifications to encourage the user to stay on track. Results: Our results suggests a correlation between utilization of the app and achievement of the goals of weight loss and increased motivation to exercise. The average number of daily uses of the app was approximately 3.76 (0-12) and 50% of enrolled users lost average of 2.14 lbs (0-6lbs) weight during this short 4 week study; preliminary correlation analysis suggest a correlation coefficient of -0.42 between these two variables. This is noteworthy as traditionally we would expect weight increase in this group of users. Our secondary objective was to determine MOCHA's usability using System Usability Scale (SUS) scale. Our average score on the SUS scale is 77%, which is above average. Lastly, users have stated that access to the dietitian in the app improves their food choices and accountability. Conclusion: This study provides essential data that emphasizes the importance of using technology to improve patients' goal adherence by providing real-time feedback and accountability with their healthcare team. Most health mobile apps focus on data acquisition but without the engagement of the health care team, this aspect differentiates MOCHA from the other apps. Our future directions will focus on using our MOCHA app in breast cancer survivors in a long term behavior modification study. Citation Format: Stubbins RE, Cheng TH, Yu X, Puppala M, Chen S, Valdivia Y Alvarado M, Niravath PA, Chang JC, Wong ST, Patel TA. The use of a behavior-modification clinical solution application to improve breast cancer survivors' accountability and health outcomes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-13-03.

The connection between diet and health has been often studied. While certain relationships remain controversial, dietary choices can clearly increase the risk for a number of diseases, including cancer, heart disease, and obesity. Although clearly not completely protective, eating a plant-based diet and eschewing animal sources of protein, especially red meat, have a number of significant health benefits. In addition to improvements in individual health, a broader adoption of a diet rich in fruits and vegetables would potentially have significant positive effects on decreasing the magnitude of climate, decrease pollution, and help prevent loss of biodiversity. In this chapter, we will review the data around diet and the development of cancer as well as look at the adverse ecological consequences of factory farming of animals.

Background: Evidence shows that obesity increases the risk and mortality of many cancers, specifically breast cancer in post-menopausal women. Epidemiological studies demonstrate that males are at an increased risk for developing obesity, diabetes, and cancer compared to females, and after menopause, females mimic the males in their susceptibility to the above diseases. Furthermore, it has been established that obesity increases systemic and adipose tissue inflammation and oxidative stress, which is known to augment cancer progression. However, the role of estrogen in regulating these metabolic processes in adipose tissue is unclear; therefore, our objective is to determine the role of estrogen in adipose tissue morphology, inflammation and oxidative stress. Methods: To determine the role of estrogen in gender differences in the susceptibility to obesity we used C57BL/6J mice (15/group): 1) males 2) nonovariectomized females 3) ovariectomized females and 4) ovariectomized females supplemented with estrogen, which were randomized to the following diets: 30% calorie-restricted, low-fat or high-fat diet. We measured weight gain, percent body fat, abdominal adipose tissue, and adipocyte size. Additionally, we assessed markers of adipose tissue inflammation, DNA damage, and oxidative stress. Results: Male mice were more susceptible to obesity than female mice. Removal of the ovaries eliminated the protection to obesity and estrogen supplementation restored this protection in females. In the low-fat and high-fat diet groups, male and ovariectomized female mice gained more abdominal adipose tissue due to increased adipocyte size compared to nonovariectomized female mice and ovariectomized female mice supplemented with estrogen. In the mice consuming the high fat diet, the enlarged adipocytes observed in the male and ovariectomized female mice were accompanied with crownlike structures surrounding necrotic adipocytes and F480 positive macrophages, suggesting macrophage infiltration. To determine if there were sex differences in oxidative stress, we stained adipose tissue with γH2AX. Results suggest that nonovariectomized female mice and ovariectomized female mice supplemented with estrogen have less oxidative stress compared to males and ovariectomized females. Additionally, our results show that nonovariectomized female and ovariectomized female mice supplemented with estrogen had significantly lower CD68, TNFα and iNOS mRNA expression levels, but higher catalase mRNA expression levels. Conclusion: Male mice are more susceptible to the obesogenic effects of high fat diets compared to nonovariectomized female mice. In ovariectomized females, estrogen supplementation has a protective effect against obesity, adipose tissue inflammation and oxidative stress. Our future studies will determine the mechanisms by which estrogen protects female mice from adipose tissue inflammation and oxidative stress, whether it is a direct or indirect effect. Determining the role of estrogen on the above key metabolic processes related to obesity is necessary to develop effective strategies for cancer prevention specifically in post-menopausal females. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-09-05.

Obesity increases the risk of diabetes. The dysregulation of estrogen metabolism has been associated with the susceptibility to obesity and diabetes. Here, we explore the role estrogen plays in sex differences in obesity and glucose metabolism, specifically adipocyte biology. We randomized C57BL/6 J male, non-ovariectomized female, ovariectomized female, and ovariectomized female mice supplemented with 17β estradiol to receive a calorie-restricted, low- or a high-fat diet (15 mice per group). We measured weight gained, calories consumed, percent body fat, abdominal adipose tissue, adipocyte size, lipogenic and adipogenic gene expression, and glucose tolerance. Male mice had a higher susceptibility to obesity than intact female mice. However, removal of the ovaries in female mice eliminated the protection to obesity and estrogen supplementation restored this protection. Male and ovariectomized female mice gained weight predominately in the form of abdominal adipose tissue possibly due to an increase in adipocyte size. Moreover, for mice consuming the high-fat diet, male and ovariectomized female mice had significantly higher levels of leptin mRNA and lower hormone-sensitive lipase mRNA relative to intact female mice and ovariectomized female mice supplemented with estrogen. Additionally, estrogen had a strong inhibitory effect on key adipogenic genes in non-ovariectomized female and ovx-female mice supplemented with estrogen. Finally, we show that male and ovariectomized female mice consuming the high-fat diet had a higher incidence of glucose intolerance. Estrogen protects female mice from obesity and impaired glucose tolerance possibly by modulating the expression of genes regulating adipogenesis, lipogenesis, and lipolysis.

The objective of this review was to analyze the components of vitamin D and their potential usefulness in preventing and treating colorectal cancer. The active form of vitamin D, 1α,25(OH(2) )D(3) , targets the wnt/β-catenin pathway by upregulating key tumor suppressor genes such as E-cadherin, which promotes an epithelial phenotype, but this is only possible when the vitamin D receptor (VDR) is present. Colorectal cell lines have shown that VDR expression levels decrease in the later stages of colon cancer. In colorectal cancers with low VDR expression, treatments to increase VDR expression could target alterations at the genomic and epigenomic levels by modulating transcription factors such as SNAIL1 and by utilizing histone deacetyltransferase inhibitors, respectively. Finally, epidemiological studies suggest that the current US Recommended Dietary Allowance should be increased to 2,000 IU in order to raise serum 25(OH)D(3) levels above 30 ng/mL. This increase in vitamin D status can be obtained most efficiently from sun exposure or vitamin D supplementation. In summary, vitamin D and its metabolites could be utilized in strategies to treat and prevent colon cancer.

Aims: Obesity is associated with insulin resistance, liver steatosis and low-grade inflammation. The role of oestrogen in sex differences in the above co-morbidities is not fully understood. Our aim was to assess the role oestrogen has in modulating adipocyte size, adipose tissue oxidative stress, inflammation, insulin resistance and liver steatosis. Methods: To determine the role oestrogen has in the above co-morbidities related to obesity, we randomized C57BL/6J mice into four groups (15 mice per group): (i) male, (ii) non-ovariectomized female (novx), (iii) ovariectomized female (ovx) and (iv) ovariectomized female mice supplemented with 17β estradiol (ovx-E). Mice received either a low-fat (LF) or a high-fat (HF) diet for 10 weeks. Outcomes measured were bodyweight, body fat, adipocyte diameter, adipose tissue lipolysis markers, adipose tissue oxidative stress, inflammation, insulin resistance and liver steatosis. Results: Male and ovx-female mice consuming the HF diet had a higher propensity of gaining weight, specifically in the form of body fat. Oestrogen protected female mice from adipocyte hypertrophy and from developing adipose tissue oxidative stress and inflammation. Moreover, novx-female and ovx-female+E mice had higher phosphorylated levels of protein kinase A and hormone sensitive lipase, markers associated with lipolysis. Additionally, male and ovx female mice had a higher propensity of developing liver steatosis and insulin resistance. In contrast, oestrogen protected female mice from developing liver steatosis and from becoming insulin resistant. Conclusion: We show that oestrogen protects female mice from adipocyte hypertrophy and adipose tissue oxidative stress and inflammation. Furthermore, oestrogen prevented female mice from developing liver steatosis and from becoming insulin resistant.

Background The prevalence of obesity has increased dramatically. A direct comparison in the predisposition to obesity between males, premenopausal females, and postmenopausal females with various caloric intakes has not been made. To determine the effects of sex and ovarian hormones on the susceptibility to obesity, we conducted laboratory studies with mice. To eliminate confounders that can alter body weight gain, such as age and food consumption; we used mice with the same age and controlled the amount of calories they consumed. Methods We determined sex-specific susceptibility to obesity between male, non-ovariectomized female, and ovariectomized female mice. To compare susceptibility to gaining body weight between males and females, animals from each sex were exposed to either a 30% calorie-restricted, low-fat (5% fat), or high-fat (35% fat) diet regimen. To establish the role of ovarian hormones in weight gain, the ovaries were surgically removed from additional female mice, and then were exposed to the diets described above. Percent body fat and percent lean mass in the mice were determined by dual energy x-ray absorptiometry (DEXA). Results In all three diet categories, male mice had a greater propensity of gaining body weight than female mice. However, ovariectomy eliminated the protection of female mice to gaining weight; in fact, ovariectomized female mice mimicked male mice in their susceptibility to weight gain. In summary, results show that male mice are more likely to become obese than female mice and that the protection against obesity in female mice is eliminated by ovariectomy. Conclusion Understanding metabolic differences between males and females may allow the discovery of better preventive and treatment strategies for diseases associated with body weight such as cancer and cardiovascular disease.

Background Alcohol consumption is an established risk factor for breast cancer metastasis. Yet, the mechanism by which alcohol promotes breast cancer metastases is unknown. The ability of cancer cells to invade through tissue barriers (such as basement membrane and interstitial stroma) is an essential step towards establishing cancer metastasis. In the present study, we identify and examine the roles of two genes, Nm23 and ITGA5, in alcohol-induced breast cancer cell invasion. Methods Human breast cancer T47D cells were treated with ethanol at various concentrations. Boyden chamber invasion assays were used to measure cellular invasive ability. The mRNA expression level of metastasis suppressor genes including Nm23 was determined by qRT-PCR. ITGA5 was identified using a qRT-PCR array of 84 genes important for cell-cell and cell-extracellular matrix interactions. Nm23 overexpression in addition to Nm23- and ITGA5 knock-down were used to determine the role of the Nm23-ITGA5 pathway on cellular invasive ability of T47D cells. Protein expression levels were verified by Western blot. Results Alcohol increased the invasive ability of human breast cancer T47D cells in a dose-dependent manner through the suppression of the Nm23 metastatic suppressor gene. In turn, Nm23 down-regulation increased expression of fibronectin receptor subunit ITGA5, which subsequently led to increased cellular invasion. Moreover, Nm23 overexpression was effective in suppressing the effects of alcohol on cell invasion. In addition, we show that the effects of alcohol on invasion were also inhibited by knock-down of ITGA5. Conclusions Our results suggest that the Nm23-ITGA5 pathway plays a critical role in alcohol-induced breast cancer cell invasion. Thus, regulation of this pathway may potentially be used to prevent the establishment of alcohol-promoted metastases in human breast cancers.