Abstract In the field of oncology, it is well recognized that a decrease in mass, density, strength, or function of skeletal muscle is associated to increased treatment toxicities and postoperative complications, as well as poor progression-free survival and overall survival. The ability of amino acids to stimulate protein synthesis in cancer patients is reduced. Considering nutritional intervention, this anabolic resistance could be in a part counteracted by increasing protein or by giving specific amino acids. In particular, Leucine might counteract this anabolic resistance not only by increasing substrate availability, but also by directly modulating the anabolic signal pathway. Few studies showed the possibility of increasing muscle protein synthesis by specific nutriments and/or by increasing amino acids or protein administration. In addition, whereas many studies provide evidence of a benefit of adapted physical activity in advanced cancer patients, it is difficult to specify the most appropriate type of exercise, and the optimum rhythm and intensity. Moreover, the benefits of physical activities and of protein support seem greater when it is started at the precachexia stage rather than at the cachexia stage, and their benefits are limited or nonexistent at the stage of refractory cachexia. Future approaches should integrate the combination of several complementary treatments in order to prevent (or improve) cachexia and/or sarcopenia in cancer patients. muscle, protein anabolism, sarcopenia, cachexia, physical activity Key Message In cancer patients, the loss of muscle mass could be in part counteract by the association of adapted physical activity with the increase in protein intake and the administration of specific amino acids. The benefits seem greater when this association is administrated in the earlier stages of cachexia rather than in refractory cachexia stage. Introduction Nutrition-related disorders represent a serious and often under-recognized consequence of many cancer types. A combination of decreased food intake and metabolic abnormalities can lead to nutrition-related disorders, which in turn are associated with delayed recovery, as well as increased morbidity and mortality. Several recent studies have described this interaction between cancer and such metabolic and nutritional effects [1, 2]. Before the years 2000, nutritionists used to focus on weight loss, and the link between low body mass index (BMI) (or weight loss) on one hand, and outcomes on the other hand. However, focusing on weight is no longer considered the best purpose, since weight changes could be linked to water or to adipose tissue changes. During the past five years, a huge amount of studies about the association between skeletal muscle dysfunction and outcomes have identified skeletal muscle as the Holy Grail. The term of sarcopenia was originally used to define age-related skeletal muscle disorders; however, it is now used to describe skeletal muscle decline in many chronic diseases and in several other conditions such as starvation, denervation, immobilization, physical inactivity, and cancer . For oncologists, studies of the body composition of patients with cancer reveal that it is mainly the loss of skeletal muscle, which predicts risk of postoperative complications, chemotherapy toxicity, and mortality [4, 5], and they use the term of sarcopenia to define muscle mass loss. Impact of skeletal muscle decline on outcomes in cancer patients Cancer patients with low muscle mass have had a decrease in overall survival, an increase in chemotherapy toxicity and an increase in postoperative complications. The leading article by Prado et al. highlighted the interest of studying body composition parameters as prognostic factors . They showed that for obese colorectal and lung cancer patients, those with sarcopenia had an overall survival shortened by 10 months compared with those without sarcopenia. Subsequently, other studies have shown this link between sarcopenia and worse prognosis [5, 6]. The study by Martin et al. is probably the most relevant one; the authors analyzed 1473 lung or gastro-intestinal cancer patients , and showed that high weight loss, low muscle mass, and low muscle density were independent prognostic of survival. Patients who exhibited all three characteristics survived 8.4 months, compared with 28.4 months in patients who had none of these characteristics. In addition to muscle mass, muscle density and muscle strength were also associated to mortality. Muscle function is the third component of muscle assessment and only few studies to date have shown a link between muscle function and survival in advanced cancer [7, 8]. The other interesting association is the link between sarcopenia and chemotherapy toxicity. The first study addressing this issue was that of Prado et al. in colorectal cancer patients , showing an impact of 5-fluorouracil dose per kg of lean body mass on the occurrence of dose-limiting toxicities (DLTs). This pivotal work has paved the way for to many other studies [10–12]. For example, among 40 patients with hepatocellular carcinoma treated with sorafenib, sarcopenic patients experienced more frequently DLT than nonsarcopenic patients (82% versus 31%; P = 0.005). The other interesting result is that, on day 28, median sorafenib area under the curve was significantly higher in sarcopenic patients (102.4 mg/l⋅h versus 53.7 mg/l⋅h; P = 0.013) . Another study showed similar results in advanced medullary thyroid carcinoma treated with vandetanib: patients with low skeletal muscle mass have a higher probability of DLT (73% versus 14%) and a higher vandetanib serum concentration (1037 ng/ml versus 745 ng/ml P = 0.04) . These articles raise the hypothesis that the mechanism of this toxicity could be an excessive dose of the chemotherapy, when adjusted to muscle mass. The last suspected relationship is between postoperative morbidity and sarcopenia. We have known for several years that there is a link between weight loss and postoperative complications. Because many studies have shown that sarcopenia alone is not the best predictor of postoperative complications, the concept of “frailty” including muscle function should be added to muscle mass assessment [13, 14]. Muscle anabolism is possible in cancer patients Beyond the demonstration of a link between skeletal muscle dysfunctions (loss of muscle mass; low skeletal muscle density and decrease in muscle function or strength) and outcomes, the main issue lies in the possibility to decrease, or to correct these muscles disorders. The use of computed tomography (CT)-scan image analysis has shown that muscle anabolism is possible, and that an increase in muscle mass can be observed during cancer treatment. Indeed, Tan et al.  surprisingly showed that even in pancreatic cancer patients, one-third had an increase in muscle mass, one-third had a stable muscle mass, and one-third had loss of muscle mass while all except one patient, lost adipose tissue. Prado et al. conducted a study based on CT images analysis for the loss and gain of muscle in a cohort of advanced cancer patients . They showed that 60.2% of patients gained or stabilized muscle mass, and especially those that were far from the date of death. The majority of instances of muscle gain (84.3%) occurred 3 months or more before death . The possible causes of muscle gain have been poorly studied. In the Prado et al. study , the review of medical charts of the top 5% with the quantitatively largest muscle gain showed that for 89% of them, the oncologist reported stable disease. The aforementioned studies are retrospective; however, they suggest that gaining or maintaining muscle mass is possible for cancer patients, and that tumor response is a principal factor of muscle gain. However, few data are available about the other potential factors (and more particularly nutritional factors) that could favor the positive net balance between protein synthesis and protein breakdown. Muscle protein anabolism results from the stimulations of synthesis or the suppression of proteolysis, with a combination maximizing the response. While it has been demonstrated in healthy humans that increasing food and protein intake stimulate protein synthesis, this is not necessarily the case during catabolic situations. The reduced protein synthetic response to food intake has been termed anabolic resistance (AR) and the question concerns the possibility to increase muscle protein synthesis (MPS), and to counteract this AR. Many interconnected and overlapping intracellular pathways regulates MPS . Amino acids (AAs), insulin, and contraction appear to converge and stimulate the mammalian target of rapamycin (mTOR) pathway, which has a pivotal role in controlling protein synthesis. The administration of specific AA could be interesting because in addition to be a substrate, they are one of the potentially modulator of the protein turn over. Many data demonstrate the capacity of Leucine to modulate protein metabolism by increasing substrate availability, increasing the secretion of anabolic hormones such as insulin, and directly modulating anabolic signaling pathways by stimulating protein synthesis and reducing protein breakdown . We will focus on the role of AA in promoting muscle anabolism with a special interest for Leucine and branched chain AA (BCAA). Role of total and specific amino acids in promoting muscle anabolism In cancer cachexia, muscle protein breakdown (MPB) produces AA needed for the inflammatory protein synthesis . It is more likely that the mechanisms involved in muscle wasting are more complex. Data concerning the relationship between AA administration and muscle protein anabolism are lacking. Scarce results are available from very disparate clinical studies, which concerned a wide variety of situations. Information are obtained both from very sophisticated protein kinetic studies and from clinical trials. Short-term interventions: AAs kinetic studies in cancer patients The studies that used isotopic tracer methodology explored the processes of MPS and MPB that are affected by the administration of AA. These sophisticated studies gave us information about the mechanisms which are involved, but it remains unknown whether repeated AA administration would translate into results similar to those observed after single administration. The translation of acute anabolic effects into gains of muscle mass and function has to be confirmed by long-term intervention trials. It is difficult to draw conclusion from these protein kinetic data, since only six studies, quite heterogeneous in terms of population and protocol, have been published. Three authors have focused on the global protein turn over [19–21], and three have studied muscle protein metabolism by including muscle biopsies in their assessment [22–24]. The interpretation of the results is also made difficult by the fact that the method of AA supplementation (parenteral administration or oral feeding), the amounts of AA, and the administration of specific AA (particularly BCAA), differ from one study to another. In addition, patients at different stages of tumor evolution were included, and there are growing evidences for a link between tumor evolution and a potential AR to AA administration. Tables 1 and 2 summarize the cancer type, the nutritional status, and the mechanisms that are involved when they are recorded [energy intake and systemic inflammatory parameters C-reactive protein (CRP)], the study design, the administration of specific AA, and the effects compared with a group control. Table 1. Characteristics of patients and study design in amino acid kinetic studies: studies assessing the whole-body protein synthesis and the whole body protein balance Author (no. in treated group) Type of cancer Nutritional status Systemic inflammation Energy intake Study design Perfusion versus oral intake AA versus AA + EAA Results Winter (n = 10) Clin Nutr 2012 Non-small-cell lung WL: 7.8%; BMI: 22.0 ± 0.9 CRP: 12.7 Energy intake: 1891 ± 76 Co: AA unknown E: Protein 30 g IV continuously 150 mn Hyperinsulinemic-isoAA: PB ↓ Ca and Co, ↓ PB in Ca > ↓ PB in Co, PS unchanged in Ca and CO, net balance ↓ Ca > ↓ Co Hyperinsulinemic-HyperAA: PB in Ca and Co unchanged PS ↑ in Ca and Co Net balance ↑ in Ca and Co (similar) Engelen (n = 13) Ann Oncol 2015 Non-small-cell lung WL: 8.4%; BMI: 26.5 ± 1 CRP: 9.8 Energy intake: 1944 ± 215 CaCo: AA 70 g (14 g EAA/non EAA) CaE: AA 70 g (14 g EAA 50% Leu) oral 5 mn 250 ml PS and net balance ↑ CaE group > CaCo group (P < 0.001) Van Dijk (n = 8) JCSM 2015 Pancreas WL: 24.3%; BMI: 20.0 CRP: 8.3 Energy intake unknown Co and Cancer: 480 ml (caseine 50 g Leu 5, 25 g) oral 4 h 480 ml Baseline: PB in Ca > PB in Co, PS in Ca > PS in Co Ingestion: PB ↓ Ca and Co PS in Ca equal to baseline, PS ↑ Co, net balance ↑ Ca and Co Author (no. in treated group) Type of cancer Nutritional status Systemic inflammation Energy intake Study design Perfusion versus oral intake AA versus AA + EAA Results Winter (n = 10) Clin Nutr 2012 Non-small-cell lung WL: 7.8%; BMI: 22.0 ± 0.9 CRP: 12.7 Energy intake: 1891 ± 76 Co: AA unknown E: Protein 30 g IV continuously 150 mn Hyperinsulinemic-isoAA: PB ↓ Ca and Co, ↓ PB in Ca > ↓ PB in Co, PS unchanged in Ca and CO, net balance ↓ Ca > ↓ Co Hyperinsulinemic-HyperAA: PB in Ca and Co unchanged PS ↑ in Ca and Co Net balance ↑ in Ca and Co (similar) Engelen (n = 13) Ann Oncol 2015 Non-small-cell lung WL: 8.4%; BMI: 26.5 ± 1 CRP: 9.8 Energy intake: 1944 ± 215 CaCo: AA 70 g (14 g EAA/non EAA) CaE: AA 70 g (14 g EAA 50% Leu) oral 5 mn 250 ml PS and net balance ↑ CaE group > CaCo group (P < 0.001) Van Dijk (n = 8) JCSM 2015 Pancreas WL: 24.3%; BMI: 20.0 CRP: 8.3 Energy intake unknown Co and Cancer: 480 ml (caseine 50 g Leu 5, 25 g) oral 4 h 480 ml Baseline: PB in Ca > PB in Co, PS in Ca > PS in Co Ingestion: PB ↓ Ca and Co PS in Ca equal to baseline, PS ↑ Co, net balance ↑ Ca and Co WL, weight loss (% of 6 months prior weight); BMI, body mass index (kg/m2); CRP, C-reactive protein (mg/L); energy intake kcal/day; Ca, cancer patients; Co, control group; E, experimental group; AAs, amino acids; EAA, essential AA; PB, protein breakdown; PS, protein synthesis. Table 2. Characteristics of patients and study design in amino acid kinetic studies: studies assessing muscle protein synthesis and fractional synthetic rate (FSR) Author (no. in treated group) Type of cancer Nutritional status Systemic inflammation Energy intake Study design Perfusion versus oral intake AA versus AA + EAA Results Williams (n = 13) Am J Clin Nutr 2012 Colorectal WL unknown; BMI 27.6 ± 1.1 CRP 8.8 Energy intake unknown IV continuous (bolus 30 mg/kg, continuous 102 mg/kg) Muscle PS ↑ in Co; Muscle PS no change in Ca Muscle PB ↑ in Co and Ca Dillon (n = 6) Clin Nutr 2007 Ovarian WL > 10%; BMI 22.0 ± 3 CRP normal Energy intake unknown Prot 40 g (EAA and non-EAA) oral 540 ml 4 h Compared with basal: Muscle PS ↑, Muscle PB unchanged, net balance ↑ (from negative to zero) Deutz (n = 10) Clin Nutr 2011 Colon lung WL 2, 9% ± 2, 2; BMI 25.1 ± 3.3 CRP 28, 7 Energy intake unknown CaCo: 24 g prot (Leu 2, 0) CaE: 40.1 (leu 7, 5) oral 30 mn CaCo: FSR no change CaE: FSR increase 40% (P = 0.027) Author (no. in treated group) Type of cancer Nutritional status Systemic inflammation Energy intake Study design Perfusion versus oral intake AA versus AA + EAA Results Williams (n = 13) Am J Clin Nutr 2012 Colorectal WL unknown; BMI 27.6 ± 1.1 CRP 8.8 Energy intake unknown IV continuous (bolus 30 mg/kg, continuous 102 mg/kg) Muscle PS ↑ in Co; Muscle PS no change in Ca Muscle PB ↑ in Co and Ca Dillon (n = 6) Clin Nutr 2007 Ovarian WL > 10%; BMI 22.0 ± 3 CRP normal Energy intake unknown Prot 40 g (EAA and non-EAA) oral 540 ml 4 h Compared with basal: Muscle PS ↑, Muscle PB unchanged, net balance ↑ (from negative to zero) Deutz (n = 10) Clin Nutr 2011 Colon lung WL 2, 9% ± 2, 2; BMI 25.1 ± 3.3 CRP 28, 7 Energy intake unknown CaCo: 24 g prot (Leu 2, 0) CaE: 40.1 (leu 7, 5) oral 30 mn CaCo: FSR no change CaE: FSR increase 40% (P = 0.027) WL, weight loss (% of 6 months prior weight); BMI, body mass index kg/m2; CRP, C-reactive protein (mg/l); energy intake kcal/day; Ca, cancer patients; Co, control group; E, experimental group; AA, amino acids; EAA, essential AA; PB, protein breakdown; PS, protein synthesis. Three studies assessed the whole-body protein synthesis and the whole body protein balance [19–21] and showed that cancer patients have the potential for whole body protein anabolism, even under oncologic therapy, and regardless of tumor evolution, by increasing protein administration (containing or not essential AA). These results are consistent with the recommendations of Bozzetti and Bozzetti which are for patient with cancer cachexia, to perfuse solutions with high protein infusion and high proportion of BCAA . However, these studies have assessed the whole body protein turn over and not skeletal muscle protein anabolism, which is the key point of the nutritional support. The increase in whole body protein turn over could be associated to a reprioritization of nitrogen away from peripheral tissue (muscle) toward increased hepatic production of acute phase protein, as it was known and described since 1978 by Lundholm et al. . The “gold standard” for the assessment of MPS is the measurement of the fractional synthetic rate by muscle biopsies. Given the difficulties to design such studies, few data are reported [22–24]. The interesting point in the series by Dillon et al., which was conducted in six ovarian cancer patients, is that these patients were still receiving chemotherapy and that they were not in a terminal stage of their cancer . The nutritional support was based on the infusion of high amounts of AA. Protein synthesis increased significantly from basal to AA support while protein breakdown remained unchanged. The study by Deutz et al.  highlights a few interesting points: (i) the experimental group not only received high amounts of protein as in Dillon et al. study, but also the addition of Leucine and fish oil. (ii) The study was conducted in cancer patients without or with a small amount of weight loss, and with a normal or overweight BMI. We can observe that early in cancer and before the observation of malnutrition, there was a resistance to muscle anabolism, as shown in the group who did not receive AA treatment. (iii) The main result was that after feeding MPS can be increased in these early stages of malnutrition and counteracts the AR. Finally, Williams et al. study showed different results in colorectal cancer patients : increases in MPS after feeding were evident in healthy control subjects; however, there was no change in fed protein synthesis before surgery when tumor has not yet been removed. After removal of the cancer, MPS had fully recovered in fed-state. Despite the differences in the results of these six studies, general conclusions can be drawn. Early in the tumor evolution with low or normal protein intake, there was a decrease in muscle protein anabolism (two over the three studies with muscle biopsies). This AR was well described in Deutz et al. study , and AR was observed early without or with a very low weight loss (about 2%). Patients had low inflammatory systemic syndrome (CRP levels were normal or near the normal values in five of the six studies), and energy intake was normal in all three studies in which this information was available. This may reflect the fact that patients were at an early stage of their disease, and one could assume that if muscle wasting is reversible, it could be at an early stage of the tumor evolution. With increasing protein intake, whether it contains Leucine or not, five over six studies showed the possibility of increasing the net balance protein. It was observed for the three studies that explored the whole protein turn over, and for two over three that explored the fractional synthetic rate by muscle biopsies. Branched chain amino acids: clinical trials Human interventional studies with specific AA administration are rare and few studies assessing muscle mass or muscle function have been published in cancer patients. BCAAs were the most frequently AA studied. May et al.  studied patients who had weight loss of at least 5%. Patients received a control mixture of non-EAA or an experimental treatment containing β-hydroxyl-β-methylbutyrate, l-arginine, and glutamine. Up to 35% of patients withdrew before the evaluation at 4 weeks. A significant increase in fat-free mass (FFM) in the AA-supplemented group (1.1 kg) was observed, whereas the control patients lost 1.3 kg of FFM (P = 0.02). These results of FFM gain have given hope. Unfortunately, a more recent study with a similar design and much more patients did not find a similar positive effect of essential AA on FFM , and there was no statistically significant difference in the 8-week lean body mass, weight, and quality of life scores. Importantly, in both studies, many patients withdrew before the end of the protocol. The lack of benefit of the nutritional support could be related to the status of progressive disease, and the treated patients could be in the situation of refractory cachexia, where any nutritional support is useless. Regarding the link between specific nutriment and tumor evolution independently from nutritional parameters, a number of small and diverse clinical trials, especially on hepatocellular carcinoma, investigated the benefit of BCAA supplementation on tumor evolution and cancer incidence. Despite the potential beneficial results, the role of specific nutriment supplementation remains to be clarified given the inconsistence of the findings, the heterogeneity of the patients, the small sample size, and the poor study design [28–30]. Other AAs: human cancer studies A recent review summarizes the observations on the role of AA in promoting protein anabolism in human cancer addressing the role of Arginine and Citrulline . Experimental studies have shown that these two AA could be an alternative for muscle protein stimulator to BCAA . Few human studies, most of them conducted for patients undergoing surgery, are available [32, 33]. Therefore, despite the experimental data, there is little evidence to support a beneficial effect of Arginine and Citrulline as a treatment of muscle wasting. The role of physical activity The potential antitumor effect of physical activity (exercise) is still debated, but is supported by several experimental models [34–36]. We will herein focus on the direct effects of exercise on muscle in cancer cachexia models. Physical activity has an anti-inflammatory effect in tumor cachexia models. This effect is intimately linked to increase not only in interleukin 6 (IL-6) synthesis but also in IL-6 receptor, alpha, and in soluble tumor necrosis factor (sTNFr)-1 and 2. These cytokines have an anti-inflammatory effect in muscle, in particular not only by reducing catabolizing effect of TNFα and IL-1 (by direct antagonism and reduction of their synthesis), but also by participating in induction of interleukin 10 (IL-10) production, also powerful anti-inflammatory in muscle . IL-6 and IL-10 would also contribute to decreased macrophage activation in muscle. Anti-inflammatory cytokines are also involved in the reduction of TNFα-induced insulin resistance, by increasing the expression of GLUT4 via the activation of AMP kinase. They also contribute to the reduction of TNFα-induced lipolysis. The increase in the production of GLUT4 could activate the transcription factor MEF2 and thus stimulate myogenesis and therefore the regeneration and increase of muscle volume. Increased oxidation of lipids by the liver under repeated exercise would contribute to the improvement of insulin resistance . Through PGC-1α4 pathway, exercise, and in particular repeated exercise, inhibits FOXO on one side and NFκB on the other, further contributing to limiting muscle proteolysis related to tumor disease. PGC-1α4 is also one of the actors, in the same way as the production of GH at the hypothalamic level, stimulation of IGF1 production. This activates mTOR and thus inhibits ubiquitin-proteasome-dependent proteolysis via Atrogin1 and MuRF1. Physical activity could also intervene on muscular homeostasis by positively regulating autophagy . Exercise could also have an anti-proteolytic effect during cancer cachexia, by positively regulating enzyme activities involved in elimination of reactive oxygen species in muscle, including SOD and GPx, and by increasing production and glutathione activity. Finally, prolonged physical activity could block the inhibitory effect of myostatin on muscle regeneration, with repeated stimulation of motor plate. The effect of physical activity on appetite in tumor-bearing animals is variable in the literature. The rate of proinflammatory cytokines (TNFα, IL-1) is decreased in hypothalamus of animals subjected to intense and regular exercise but without effect on oral intakes . However, several studies have shown a positive effect of (intense) exercise on the ingesta of cachectic mice [41, 42]. Finally, some authors suggest that repeated physical activity could reduce total energy expenditure by regulating resting energy expenditure via its anti-inflammatory effect. Benefits in the preclinical setting The models of tumor-bearing animals—almost exclusively murine—showing a benefit of exercise on muscle mass or muscle strength are finally few. However, in these studies, physical activity has a positive impact on total weight gain (independent of tumor weight) and on muscle mass [43–46]. In some published models, physical activity (or electrical muscle stimulation) was even able to partially reverse sarcopenia . In other models, it was able to prevent cachexia, and thus improve the survival of mice . Regular exercise during cisplatin chemotherapy seems to limit its adverse effects on the muscle . Repetitive physical exercise in cachectic mice can therefore improve muscle strength [34, 38]. Jee et al. have even shown improvement in behavioral tests (equivalent to a quality of life assessment) in cachectic mice subjected to repeated physical exercise . Benefits in clinical trials On 1 September 2017, using clinicaltrial.gov, we identified three ongoing trials concerning the effect of physical activity or muscular stimulation, associated or not with other therapies (relaxation techniques, omega-3 fatty acids, etc.) on sarcopenia and/or cancer cachexia (NCT03151291, NCT02293239, NCT02330926). Two additional tests have been completed but have not yet been published (NCT01136083, NCT0090492). In a recently published study, a multimodal strategy combining oral nutritional supplements enriched with omega-3, anti-COX2 and physical activity, despite a poor compliance at 6 weeks, found stabilization of weight and muscle mass in experimental group compared with control group . Neither muscle strength nor fatigue score was enhanced by multimodal treatment. In a recent meta-analysis, the effect of physical activity on fatigue in cancer patients was as effective at both metastatic and nonmetastatic stages, and appeared to be equivalent, or even more effective (to the same extent as psychotherapy or relaxation) than medication management . However, the last Cochrane meta-analysis specifically focusing on the effect of physical activity on cancer and cachectic patients concluded that there was insufficient data to determine its safety and efficacy in this context . In sarcopenic cancer patients (head and neck, prostate, lymphoma), or probably sarcopenic but not cachectic, regular physical activity during treatment improves muscle mass and strength, fatigue, and quality of life [51–57]. Several uncontrolled prospective studies have shown positive effects of physical activity in patients with advanced cancer of function or muscle strength [58–60], functional status or nutritional status and fatigue or quality of life [60, 61]. A randomized controlled trial in patients identified as cachectic showed a stabilization of muscle function (hand grip test and 6-minute walk test) in patients undergoing a physical activity, endurance and aerobic program, of 8 weeks with 2 sessions per week . However, 35.5% of randomized patients “physical activity” group (22.6% in control group) did not follow the initially planned program. Indeed, the follow-up (or adherence) of physical activity programs in patients with locally advanced or metastatic cancer is debated. A compliance rate between 50 and 65% was found in other studies [48, 59, 61, 63]. In a survey of advanced cancer patients, 100% felt they were physically able to follow an adapted physical activity (APA) program, but only two-thirds had undertaken to do so . In the study by Chasen et al., the only independent predictor of good adherence to an APA program in patients with advanced cancer was low CRP, suggesting the lack of interest in APA in patients with severe or refractory cachexia . APA associated with other therapies may be more effective in cachectic or precachectic patients. In the study by Pyszora et al., a physiotherapy program including physical exercise (compared with standard care) twice daily for 12 days in 60 patients with an average Karnofsky performance status (KPS) of 47% significantly improved the fatigue score (Brief Fatigue Inventory) and several symptoms, including anorexia, included in the Edmonton Symptom Assessment Scale . Several studies combining physical activity with dietary advice (with or without nutritional supplements) have improved nutritional status, appetite or ingesta [63, 66, 67], or quality of life . Conclusions In cancer patients, we can express that a decrease in mass, density, strength, or function of skeletal muscle is linked to a decrease in survival, and associated with poor outcome. Muscle wasting is associated to chemotherapy toxicities, progression free survival, overall survival, and postoperative complications. The question of the possibility in increasing muscle mass or minimizing skeletal muscle disorders is still open. In physiologic conditions, skeletal muscle is characterized by a protein breakdown in the fasting state and MPS in the postprandial state. The net balance at the end of the day is a stable muscle mass. In cancer patients, the ability of AA to stimulate protein synthesis is reduced. Considering nutritional intervention, this AR could be in a part counteracted by increasing protein, AA quantity and administration of specific AA specialty Leucine. Leucine, by increasing substrate availability and by directly modulating the anabolic signal pathway, might counteract this AR. Few well designed and sophisticated kinetic studies, showed the possibility of increasing MPS by specific nutriments and/or by increasing amino acids or protein administration. However, the translation of acute anabolic effects into gains of muscle mass and function have to be confirmed. Further research is needed in order to validate the hypothesis of Deutz and Wolf that there are no upper limits to the anabolic response to protein or amino acid intake . As far as exercise is concerned, while many studies provide evidence of a benefit of APA in advanced cancer patients, it is difficult to specify the most appropriate type of exercise and the optimum rhythm and intensity. It is likely that the benefits of physical activity are greater when it is started at the precachexia stage rather than at the cachexia stage, and its benefit is limited or nonexistent (in addition to not be feasible) at the stage of refractory cachexia. Finally, future approaches should integrate the combination of several complementary treatments in order to prevent or improve cachexia and/or sarcopenia. Acknowledgement The authors wish to thank Dr Olivier Mir for his support to this work. Funding This supplement was made possible by funding support from Helsinn. Helsinn did not have any influence on the content and all items are subject to independent peer-review. Disclosure SA has acted as board member for Chugai; BR has received honoraria from Fresenius Kabi France as member of the NUTRICANCER2012 advisory board. References 1 Blum D, Stene GB, Solheim TS et al. 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Annals of Oncology – Oxford University Press
Published: Feb 1, 2018
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