# Nutrition support and cachexia management

Source: https://onco.cc/technologies/oncology-nutrition/  
OnCo record `oncology-nutrition` (Technology). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Screening for malnutrition, dietitian-led counselling, supplements and tube or intravenous feeding where indicated, plus treatment of cancer cachexia, the muscle-wasting syndrome that affects up to 80% of advanced patients.

## Summary

Malnutrition affects 20-70% of patients depending on tumour and stage and is an independent predictor of mortality, toxicity and complications. ESPEN (2017, 2021) and ASCO (2020) guidelines recommend routine screening (NRS-2002, PG-SGA), dietitian counselling, oral supplements, enteral feeding for head and neck and oesophageal cancer during chemoradiation, and limited use of parenteral nutrition. Cachexia (weight loss >5% with sarcopenia and inflammation, Fearon 2011 consensus) has its first approved drug in Japan (anamorelin, ghrelin agonist, 2021; EMA refused 2017); ponsegromab (anti-GDF-15) increased weight in a phase 2 trial (NEJM 2024) and is in phase 3. Exercise and protein intake are the non-pharmacologic core; immunonutrition before surgery reduces infections.

## Fields

- Kind: Technology
- Status: established
- Last checked: 2026-09-08
- Tags: gap-fill; supportive
- Principle: Screen at diagnosis and during treatment; intervene in stepwise fashion from counselling to artificial nutrition; treat cachexia as a multimodal problem (nutrition, exercise, anti-inflammatory/appetite drugs) rather than by feeding alone.
- Strengths: Cheap screening and counselling reduce complications; Prehabilitation nutrition improves surgical outcomes; First mechanism-based cachexia drugs (GDF-15) are arriving
- Limitations: Cachexia has no approved drug in the US or EU; Parenteral nutrition rarely helps and carries risk; Dietitian access uneven

## Notes

- Pancreatic cancer is the disease where nutrition support starts with enzymes. Pancreatic Cancer UK's starting doses are at least 50,000 to 75,000 units with a main meal and 25,000 to 50,000 with a snack or milky drink, half with the first mouthfuls and half spread through the meal, swallowed with a cool drink, more for larger or fattier meals, and reviewed regularly; the UK consensus (Phillips 2021) sets the same starting point.
- A population-based study (Roberts 2019) found people with pancreatic cancer prescribed enzyme replacement lived longer than those who were not; NICE NG85 says offer enteric-coated pancreatin in unresectable disease and consider it before and after resection.
- Bowel cancer: Macmillan says to eat at regular times, to try several small meals rather than one or two large ones, to include high-protein foods to help healing, to follow a low-fibre diet for the first few days after surgery and to keep a diary of what you eat and how it affects you. Cancer Research UK says the foods most likely to cause problems are very high fibre fruit and vegetables, onions, brussels sprouts and cabbage, pulses, fizzy drinks, beer and lager, and very rich or fatty foods, and that a food can be tried again after a few weeks.
- Lung cancer: eating is harder when breathing is hard. Macmillan advises sitting up at a table so breathing feels less restricted, smaller meals on a smaller plate, avoiding chewy food, eating slowly with smaller mouthfuls, adding sauces or gravies, sipping fluid often, and using ready meals on difficult days; it says high-protein powders and high-calorie drinks can be prescribed by a GP or dietitian. Cancer Research UK adds that you lose a lot of fluid through your breath, especially breathing through your mouth, and that dehydration makes saliva and phlegm sticky and harder to swallow.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Cachexia
- ESPEN practical guideline 2021: https://doi.org/10.1016/j.clnu.2021.02.005
- Ponsegromab phase 2 (NEJM 2024): https://doi.org/10.1056/NEJMoa2409515
- Pancreatic Cancer UK: diet and pancreatic cancer: https://www.pancreaticcancer.org.uk/information-and-support/managing-symptoms-and-side-effects/diet-and-pancreatic-cancer/
- Pancreatic Cancer UK: how do I take pancreatic enzyme replacement therapy?: https://www.pancreaticcancer.org.uk/information-and-support/managing-symptoms-and-side-effects/diet-and-pancreatic-cancer/pancreatic-enzyme-replacement-therapy-pert/how-do-i-take-pancreatic-enzyme-replacement-therapy-if-i-have-pancreatic-cancer/
- Cancer Research UK: your diet and pancreatic cancer: https://www.cancerresearchuk.org/about-cancer/pancreatic-cancer/living-with/diet
- Phillips et al., consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines (BMJ Open Gastroenterology 2021): https://doi.org/10.1136/bmjgast-2021-000643
- Roberts et al., enzyme replacement improves survival among patients with pancreatic cancer, population-based study (Pancreatology 2019): https://doi.org/10.1016/j.pan.2018.10.010
- Bowel Cancer UK: diet after treatment: https://www.bowelcanceruk.org.uk/about-bowel-cancer/living-with-and-beyond-bowel-cancer/diet-after-treatment/
- Cancer Research UK: eating and bowel cancer: https://www.cancerresearchuk.org/about-cancer/bowel-cancer/living-with/eating
- Macmillan: bowel changes after cancer treatment: https://www.macmillan.org.uk/cancer-information-and-support/bowel-cancer/managing-bowel-changes-after-treatment
- Colostomy UK: diet: https://www.colostomyuk.org/information/diet/
- Macmillan: breathlessness: https://www.macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/breathlessness
- Cancer Research UK: coping with breathlessness when you have lung cancer: https://www.cancerresearchuk.org/about-cancer/lung-cancer/living-with/coping-with-breathlessness
- NICE NG122: lung cancer, palliative interventions and supportive and palliative care: https://www.nice.org.uk/guidance/ng122/chapter/Palliative-interventions-and-supportive-and-palliative-care

## Connected records

- cancers: [Advanced-stage classical Hodgkin lymphoma (stage III to IV)](https://onco.cc/cancers/advanced-stage-classical-hodgkin-lymphoma/), [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [Colorectal cancer](https://onco.cc/cancers/colorectal/), [Diffuse large B-cell lymphoma](https://onco.cc/cancers/dlbcl/), [Early-stage classical Hodgkin lymphoma (stage I to II)](https://onco.cc/cancers/early-stage-classical-hodgkin-lymphoma/), [Follicular lymphoma](https://onco.cc/cancers/follicular-lymphoma/), [Gallbladder cancer](https://onco.cc/cancers/gallbladder/), [Gastric & gastro-oesophageal junction cancer](https://onco.cc/cancers/gastric/), [Head and neck squamous cell carcinoma](https://onco.cc/cancers/head-and-neck/), [Hodgkin lymphoma](https://onco.cc/cancers/hodgkin-lymphoma/), [Lung cancer (all types)](https://onco.cc/cancers/lung-cancer/), [Mantle cell lymphoma](https://onco.cc/cancers/mantle-cell-lymphoma/), [Marginal zone lymphoma](https://onco.cc/cancers/marginal-zone-lymphoma/), [Non-Hodgkin lymphoma (all types)](https://onco.cc/cancers/non-hodgkin-lymphoma/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/), [Oesophageal cancer](https://onco.cc/cancers/esophageal/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/), [Peripheral T-cell lymphomas (including cutaneous T-cell lymphoma)](https://onco.cc/cancers/peripheral-t-cell-lymphoma/), [Prostate cancer](https://onco.cc/cancers/prostate/), [Relapsed and refractory classical Hodgkin lymphoma](https://onco.cc/cancers/relapsed-refractory-hodgkin-lymphoma/), [Small-cell lung cancer](https://onco.cc/cancers/sclc/), [Waldenström macroglobulinaemia](https://onco.cc/cancers/waldenstrom/)
- fronts: [Diet, Exercise & Lifestyle](https://onco.cc/fronts/nutrition-lifestyle/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Bowel function after pelvic radiotherapy](https://onco.cc/technologies/bowel-after-pelvic-radiotherapy/), [Cachexia pharmacotherapy: GDF-15 blockade, anamorelin, olanzapine](https://onco.cc/technologies/cachexia-appetite-pharmacotherapy/), [Cancer rehabilitation: the discipline that puts function back](https://onco.cc/technologies/rejuv-rehab-cancer-rehabilitation/), [CT body composition and sarcopenia measurement](https://onco.cc/technologies/ct-body-composition-sarcopenia/), [Enhanced recovery (ERAS) and perioperative nutrition](https://onco.cc/technologies/eras-perioperative-nutrition/), [Enteral and parenteral nutrition support](https://onco.cc/technologies/enteral-parenteral-nutrition/), [Exercise & lifestyle oncology](https://onco.cc/technologies/exercise-oncology/), [Fish oil (EPA) for cancer weight loss](https://onco.cc/technologies/omega3-epa-cachexia/), [Geriatric assessment](https://onco.cc/technologies/geriatric-assessment/), [Glutamine for mucositis and neuropathy](https://onco.cc/technologies/glutamine-mucositis-neuropathy/), [Immunonutrition before cancer surgery](https://onco.cc/technologies/immunonutrition-perioperative/), [Measuring muscle and fat on scans the patient already had](https://onco.cc/technologies/rejuv-measure-body-composition/), [Muscle and strength after treatment: sarcopenia, cachexia and what rebuilds](https://onco.cc/technologies/muscle-recovery-after-cancer-treatment/), [Oncology nutrition assessment and medical nutrition therapy](https://onco.cc/technologies/nutrition-screening-mnt/), [Prehabilitation before cancer surgery](https://onco.cc/technologies/prehabilitation/), [Recovery after pelvic exenteration](https://onco.cc/technologies/rejuv-recon-pelvic-exenteration/), [Resistance training and protein for cachexia and sarcopenia](https://onco.cc/technologies/resistance-training-cachexia/), [Swallowing therapy around head and neck radiotherapy](https://onco.cc/technologies/rejuv-rehab-swallowing/), [What a prehabilitation programme actually contains, and how long it needs](https://onco.cc/technologies/rejuv-rehab-prehabilitation-programme/), [What the randomised trials of prehabilitation found, operation by operation](https://onco.cc/technologies/rejuv-rehab-prehabilitation-evidence/)
- key papers: [ESPEN practical guideline: Clinical Nutrition in cancer](https://onco.cc/key-papers/paper-muscaritoli-clin-nutr/)
- journals: [Nutrition and cancer](https://onco.cc/journals/nutrition-and-cancer/)
- terms: [Cancer cachexia](https://onco.cc/terms/cachexia/), [Eating after a Whipple operation: slow stomach emptying, dumping and bowel changes](https://onco.cc/terms/eating-after-whipple/), [Eating after gallbladder removal](https://onco.cc/terms/eating-after-gallbladder-removal/), [Malnutrition screening tools (MUST, NRS-2002, MST, PG-SGA)](https://onco.cc/terms/malnutrition-screening/), [Palliation in pancreatic cancer: biliary and duodenal stents, coeliac plexus block, enzymes and cachexia](https://onco.cc/terms/pancreatic-palliation-obstruction-pain-nutrition/), [Pancreatic enzyme replacement therapy (PERT, pancreatin, Creon) for pancreatic exocrine insufficiency: why and how to take it](https://onco.cc/terms/pancreatic-enzyme-replacement/), [Weight loss, fat digestion and enzymes with gallbladder cancer](https://onco.cc/terms/weight-loss-and-fat-digestion-biliary/)
- drugs: [Pancrelipase (pancreatic enzyme replacement therapy)](https://onco.cc/drugs/pancrelipase/)
- trials: [PREHAB: multimodal prehabilitation before colorectal cancer surgery](https://onco.cc/trials/prehab-trial/)
- ideas: [A dietitian in every gastrointestinal and head and neck tumour board](https://onco.cc/ideas/idea-nl-dietitian-in-every-mdt/)
- roadmaps: [Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment](https://onco.cc/roadmaps/nutrition-lifestyle-roadmap/), [Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards](https://onco.cc/roadmaps/survivorship-roadmap/)

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