Cachexia has been recognised for a long time as an adverse effect of cancer. It is associated with reduced physical function, reduced tolerance to anticancer therapy, and reduced survival. Weight loss in patients with cancer is rarely recognised, assessed, or managed actively. Thus, cachexia represents an important unmet need.

Cancer-related malnutrition is a multimodal process because many factors collude to impair food intake, increase energy and protein needs, decrease anabolic stimuli such as physical activity, and alter metabolism in different organs or tissues. The multimodal drivers of malnutrition form a rationale for use of multiple therapeutic strategies to prevent, delay, or treat malnutrition in people with cancer

Cancer causes morbidity and mortality by effects on sites which are involved by tumor, and by remote or systemic effects of the cancer. Weight loss anda decrease in activity are recognized systemic effects of cancer. A decrease in activity or decreased performance status has long been recognized as an important prognostic factor which affects response to chemotherapy and duration of survival . Weight loss has received less quantitative study but in a few studies has been noted to influence the response to chemotherapy or the duration of survival .

Clinical trials have demonstrated that increasing dietary intake is not usually effective for treating cancer-induced weight loss..1,2 Since cancer-induced weight loss is the result of inadequate energy intake, increased REE, and the complex interaction of many metabolic mediators, treatment can succeed only when underlying metabolic changes are addressed.3 The inclusion of metabolically-active substrate eicosapentaenoic acid (EPA) in the diet is now recognized to be helpful in interfering with mechanisms underlying metabolic perturbations of cachexia.⁴

ESPEN's evidence-based nutrition guidelines for adult patients with cancer raise awareness by drawing attention to the high prevalence of malnutrition and its adverse impacts on response to treatment, prognosis, and survival. The Academy of Nutrition and Dietetics (AND) has also developed guidelines on nutritional management for patients with cancer in acute care and ambulatory settings [48]. Such updates help clinicians keep pace with advances in the science behind cancer and nutrition, and advise them how to translate information into practice. Of similar importance are wellargued calls for action to effectively couple oncologic and nutritional approaches throughout the patients' journey [49]. As we will discuss in this paper, many strategies are available to update nutritional care in patients with cancer. For example, most patients with cancer experience some degree of metabolic stress, which can now be quantified by measures of inflammatory biomarkers. Also, today's patients with cancer may be either underweight or overweight, but both groups are at high risk for cachexia and sarcopenia and its adverse effects. Sensitive new methods facilitate early and accurate measures of body cell and muscle mass. Medical nutrition care strategies have been updated, including recommendations for energy and protein requirements and the use of immune modulators and specialized nutrients to lessen adverse inflammatory and catabolic effects.

In patients with cancer, systemic inflammation inhibits nutrient utilization and promotes catabolism, thus leading to muscle breakdown. Calorie and protein fortification of regular foods, even with standard ONS, does not reduce systemic inflammation. Updated nutritional strategies now suggest considering nutrition with anti-catabolic and inflammation-suppressing ingredients.¹

Intention to treat group comparisons indicated that at the mean dose taken, enrichment with n-3 fatty acids did not provide a therapeutic advantage and that both supplements were equally effective in arresting weight loss. Post hoc dose-response analysis suggests that if taken in sufficient quantity, only the n-3 fatty acid enriched energy and protein dense supplement results in net gain of weight, lean tissue, and improved quality of life. Further trials are required to examine the potential role of n-3 enriched supplements in the treatment of cancer cachexia

EPA supplemented early EN is associated with preservation of lean body mass post esophagectomy compared with a standard EN. These properties may merit longer-term study to address its impact on recovery of function and quality of life in models of complex surgery or multimodal cancer treatment regimens.

Patients with NSCLC receiving ONS-EPA significantly improves energy and protein intake, body composition. and decreased fatigue, loss of appetite and neuropathy.

Administration of an EPA-enriched oral nutrition supplement seems effective in improving the nutritional status and quality of life of lung cancer patients undergoing chemotherapy

N-3 Polyunsaturated FAs may beneficially affect quality of life, performance status and physical activity in patients with NSCLC undergoing multimodality treatment