Cancer cachexia: A scoping review on non-pharmacological interventions

Objective Cancer cachexia occurs in 30%–80% of patients, increasing morbidity and mortality and impacting the health-related quality of life also for caregivers. Pharmacological interventions have been studied but have shown inconsistent effects on patients' lives in terms of relative outcomes and poor adherence to pharmacological treatment. We provide an overview of the evidence on non-pharmacological interventions for cancer cachexia. Methods We conducted a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping review (PRISMA-ScR). On September 21, 2022, plus an update on January 10, 2024, we searched MEDLINE, Embase, CINAHL, Cochrane, PsycINFO, and Scopus for 2012–2024. We excluded pharmacological interventions defined as “any substance, inorganic or organic, natural or synthetic, that can produce functional modifications, through a chemical, physicochemical or physical action.” Results The search retrieved 9308 articles, of which 17 were eligible. Non-pharmacological interventions included nutritional counseling, complementary therapies (acupuncture), rehabilitation, and psychoeducational/psychosocial support. The data showed small and heterogeneous samples and different disease localization and stages. Thirty-nine percent were multimodal interventions and aimed at patients, not families. The common primary outcomes were body weight and composition, biomarkers, quality of life, psychological suffering, and muscular strength. Only three studies focus on the patient-caregiver dyad. Conclusions Interventions on cancer cachexia should be multimodal and multiprofessional, proposed early, and aimed at quality of life outcomes. The caregiver's involvement is essential. Nurses can play an active role in managing cancer cachexia. More well-designed studies are needed to understand the efficacy and contents of non-pharmacological interventions. Systematic review registration The review protocol has been registered in the OSF registry (DOI: 10.17605/OSF.IO/H4A29).


Introduction
Cancer cachexia occurs in 30%-80% of patients, and its impact on quality of life, treatment-related toxicity, physical function, and mortality is well established. 1The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines 2 define cachexia as disease-related malnutrition, based on the Global Leadership on Malnutrition (GLIM) definition, 3 and the presence of systemic inflammation.Cancer cachexia is a continuum with three stages of clinical relevance: precachexia, cachexia, and refractory cachexia. 4It includes "objective" components (i.e., inadequate food intake, weight loss, inactivity, loss of muscle mass and metabolic derangements, inducing catabolism) and "subjective" components (i.e., anorexia, early satiety, taste alterations, chronic nausea, distress, fatigue and loss of concentration). 2,5ancer cachexia alters appearance, affecting the patient's self-image, self-esteem, and socialization. 6Additionally, it impacts family functioning regarding the role and the meaning of food in the relationship of the patient-caregiver dyad. 67][8] For these aspects, psychosocial interventions such as education, dietary advice, and emotional counseling are proposed, 2,8 which reduce the emotional burden by empowering dyads to cope with the dysfunctions and derangements of cachexia, thus improving their quality of life. 7Tailored information according to the stage of cachexia also empowers the dyad to understand its nature, course, and biological mechanisms and to acknowledge its adverse effects (i.e., weight loss, reduced appetite, early satiety). 2omprehensive treatment requires a personalized and multidisciplinary approach to evaluate the objective signs and relieve the symptoms. 2,9Core component interventions should thus include nutritional support and exercise-based, anti-inflammatory, and educational interventions. 2,9Pharmacological interventions are widely studied, but evidence-based practice has shown that it is difficult for patients to comply with the intake of supplements and non-steroid anti-inflammatory drugs, which are the most abandoned components, especially among patients in palliative care, where a 20% dropout rate has been seen. 10,11Furthermore, this intervention alone cannot respond to the many aspects affected by cachexia.
Although the literature regarding non-pharmacological components is growing, the limited evidence is acknowledged by the international guidelines. 12Studies on psychoeducational approaches to support patients and their families are becoming more common.A scoping review conducted in 2023 explored the extent to which nurse-led education has become part of the multimodal management of cancer cachexia.Nine publications were included in the review.The findings showed that nurses with the knowledge and confidence to provide cancer cachexia education for their patients could potentially play an essential role in the management of cancer cachexia and the mitigation of cachexia-related problems. 13Physical exercise can reduce the effects of cancer cachexia by modulating muscle metabolism, reducing insulin resistance, and decreasing the inflammatory cascade.A scoping review conducted by Canaan Cheung et al., in 2023 included 12 randomized and non-randomized studies, concluding that exercise interventions appear to be safe and acceptable to people with cancer cachexia.They could have a positive effect on body stature (weight and body mass index [BMI]), composition (75%), muscle strength (80%), and less often observed for functional performance (64%) and health-related quality of life (38%). 12n the specific population of patients with an expected survival of less than a few months, comfort-directed care is the recommended approach, including alleviating thirst, eating-related distress, and other debilitating symptoms. 2,10This includes addressing dysfunctions associated with the emotional and social aspects of eating and involving caregivers.
In conclusion, a non-pharmacological approach can contribute to filling the gap caused by low adherence to pharmacological interventions, and it is particularly important in managing both clinical aspects and supporting the emotional distress of the dyad, in particular with patients who have a short life expectancy.Non-pharmacological interventions can also be delivered by trained health professionals such as nurses and physiotherapists, who thus play a crucial role in the multidimensional management of cancer cachexia.
Considering these premises, we decided to provide an overview of the available research evidence on non-pharmacological interventions for cancer cachexia.
Our primary research question was: Which non-pharmacological interventions have been studied for managing cancer cachexia?

Methods
This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping review (PRISMA-ScR) guidelines. 14Ethical approval was not required.The protocol was published on https://osf.io/registries(OSF Registration DOI: 10.17605/OSF.IO/H4A29) on December 16, 2021.

Search strategy
We conducted an electronic search of the literature on September 21, 2022, and one update on January 10, 2024, in the following databases: MEDLINE (through PubMed), Embase, Cochrane Library, CINAHL, Psy-cINFO, and Scopus.We limited the search to the last 12 years (2012-2024) because the topic has recently been studied more in depth, especially concerning non-pharmacological interventions, and we included only articles in English and articles on humans.The search strategy used was: (Cachexia OR anorexia OR "Cachexia" [Mesh] OR "Anorexia" [Mesh]) AND (cancer OR tumor OR neoplasm OR oncol* OR "Neoplasms" [Mesh]).No additional searching was conducted, but we screened the references of the included articles for any additional relevant articles.

Inclusion criteria
The PICO(S) (Population, Intervention, Comparison, Outcomes, Study design) framework was used to frame the search strategy and to define the inclusion criteria.
Concerning the population, we included original studies with adult human patients (> 18 years) with cancer (regardless of disease location or stage and regardless of ongoing or planned treatment) in which at least 70% of enrolled patients were affected by cancer cachexia.Starting with Fearon's shared definition of cancer cachexia, 4 we tried to take a more comprehensive look at the eligible population.Therefore, we included studies where the description and characteristics of the sample clarified the inclusion of patients with significant weight loss or high risk of malnutrition.The eligible interventions (i.e., "non-pharmacological interventions") were defined starting from the definition of "pharmacological intervention" as "any substance, inorganic or organic, natural or synthetic, that can produce functional modifications, through a chemical, physicochemical or physical action."Based on this definition, we considered "pharmacological intervention" not only medical drugs but also oral nutritional supplements, enriched food, and parenteral and enteral nutrition.Interventions other than those defined as "pharmacological" were defined as "non-pharmacological" and were considered eligible for our review.In the case of randomized controlled trials, we also considered eligible studies where the non-pharmacological component was in the control arm.We also included studies on multimodal interventions, where the pharmacological component was integrated with the non-pharmacological one, but only if the results related to the pharmacological component were residual.
The eligible comparators, when applicable, were pharmacological interventions, placebo, or usual care.
Reported outcomes were related to quality of life, psychological outcomes, muscle strength tests, body composition, and nutritional biomarkers.Since the review aimed to report the non-pharmacological interventions described in the literature rather than assess their efficacy, outcomes were not considered inclusion criteria.Outcomes were described when available in the included studies to provide information on how non-pharmacological interventions were evaluated in the literature.
For the same reason, the study design was not considered as part of the inclusion criteria but was reported to provide information on nonpharmacological intervention assessments published in the literature.

Exclusion criteria
We did not include conference abstracts, case reports, qualitative studies, systematic reviews, expert opinions, descriptive articles, guidelines, or book chapters.Lastly, we excluded ongoing trial and protocol articles.

Study selection process
The results of the study selection process are reported in Fig. 1.Three authors (EB, LB, and FF) independently assessed the titles and abstracts of the articles included in the first search.Then, they discussed all the discrepancies and doubts with a fourth researcher (ST).In all cases, they reached a consensus.The same procedure was carried out for the analysis of the full text.If all three authors (EB, LB, and FF) agreed that the studies met the eligibility criteria, these were included in the results, and any disagreements were discussed and resolved by consensus with a fourth author (ST).

Data extraction
Two reviewers (EB and FF) performed data extraction from included full-text articles using a data extraction form developed by the working group.The data extraction form included the first author's name, year of publication, country, study design, inclusion criteria, exclusion criteria, study population, tumor characteristics (site þ stage), cancer treatments, reference definition of cachexia, description of the intervention, description of comparison (when applicable), follow-up time, adherence, drop-out reasons, and reported outcomes.

Risk of bias assessment
Two authors (LB and ST) independently performed the quality/risk of bias assessment of the included studies.The third expert methodology member of the research group (FV) appraised the data as a supervisor, using different tools according to the different study designs.The Cochrane Risk of Bias tool 2 (RoB2) tool was used to assess the included randomized trials, 15 while the Newcastle-Ottawa Scale 16 was used for non-randomized studies.The results of the risk of bias assessment are reported in detail, separately by study design (i.e., randomized and non-randomized studies), in the Supplementary material (Supplementary File 1 with figures, Supplementary Files 2 and 3 with tables).The risk of bias graph and the risk of bias summary figures were built with Review Manager, using the Web version (https://revman.cochrane.org/info). 17

Synthesis of the results
As the aim of the scoping review was not to evaluate the effectiveness of non-pharmacological interventions, a meta-analysis of the results was not included in the research protocol.We therefore included the possibility of a quantitative and qualitative narrative synthesis of results.We have included an additional table and a figure summarizing the results to speed up the reading and identify the articles of interest.

Results
The search retrieved 9308 records, which were reduced to 5409 records after removing duplicates.After the initial screening by title and abstract, another 5202 articles were excluded.Of the 230 full-text articles retained for further screening, 213 were discarded.Most of the studies were excluded because the sample did not include patients with cancer cachexia, or they were the smallest part.Other articles Fig. 1.Scoping review process.were excluded because of editorials, commentaries, or general treatises on cancer cachexia.Seventeen articles were included in the full review (Fig. 1).These articles correspond to 15 original studies because, in 2015 and 2019, Grundmann and Yoon wrote two articles on the same studies, respectively, on the prospective feasibility pilot study 18,19 and the randomized, single-blind pilot study. 20,21The articles cover five continents: five studies conducted in Europe, [22][23][24][25][26] two in North America, 18,19 four in Asia, [27][28][29][30] one in Africa, 31 one in Australia, 32 and one in two different sites in Australia and Hong Kong. 334]27,[29][30][31]33 Other authors chose pre-post intervention design (n ¼ 2), 18,19 retrospective observational study (n ¼ 2), 32,34 prospective cohort study (n ¼ 1), 25 and prospective pilot study. 26he results showed heterogeneity in populations and interventions, most of which were multimodal.The non-pharmacological components, alone or combined with others, were nutritional counseling, complementary therapies (e.g., acupuncture), exercise, and psychoeducational/psychosocial interventions.The most common primary outcomes were body weight and body composition, biomarkers, quality of life, psychological suffering, and muscular strength (Table 1).
In Fig. 2, we summarized the articles included in the scoping review, highlighting three characteristics: the multimodal structure of intervention, the presence of quality of life among the outcomes, and the population exclusively composed of patients with gastrointestinal cancer.
Table 2 shows a schematic representation of the selected studies based on patient/population, intervention, comparison -where presentand outcomes (PICO) elements for review.We described the narrative synthesis according to PICO.

The study population
The results of the review showed small and heterogeneous samples (Table 3).
First, ten out of fifteen authors cited Fearon's cachexia definition, 4 with an increased incidence in the most recent articles.Consequently, the presence of cachexia was challenging to compare.
The authors defined different inclusion criteria related to the stage of the disease, varying from new diagnosis 24,29 to the presence of advanced cancer. 22,31,33,34The criteria to define the presence of cachexia were also quite different.The authors included mainly patients with a weight loss > 5% in the last 6 months, [18][19][20]23,[26][27][28]31 according to Fearon's definition. 4 Other characteristics used to describe the sample included the risk of malnutrition, which was generally high, and the Karnofsky Performance Status (KPS) scores. Despite thecritical weight loss, the patients' BMI generally indicated a healthy weight (18.5-24.9kg/m 2 ).
The population displayed variation in terms of the site of the disease.Eight studies referred to gastrointestinal cancer (esophagus, gastroesophageal junction, gastric or colorectal cancer, biliary) and pancreatic cancer, [18][19][20]24,25,30,31,33 and one to breast cancer. 28 The presenc of active treatments during the interventions was also highly variable between studies. Testudies included the population under active treatment; [18][19][20][21][22]25,26,29,30,34 one included patients waiting to start the first line of chemotherapy; 24 two included patients who had to be out of any treatment plans (chemo-radiotherapy) during the period required for the intervention.18,19 Four authors did not state whether patients were under cancer treatment.23,27,32,33 Two studies included patients no longer receiving potentially curative treatment and patients under best supportive care.22,25 Regarding the variables reported, the only common parameters among the studies were gender, age, and BMI.
Only three studies planned the intervention on the dyad. 22,26,33ll participants were outpatients.
2][33][34] In three studies, the non-pharmacological intervention was the control arm of the randomized controlled trial (RCT). 18,20,25Latenstein aimed to assess dietetic consultation alone for patients with pancreatic cancer and its effect on survival and patient-reported outcome measures (PROMs). 25cupuncture was always studied as a single intervention 18,19,28 or compared with a placebo. 20utritional counseling, or dietetic consultation, was conducted by a trained dietician or nutritionist, who advised increasing the consumption of energy-dense and high-protein foods and the overall dietary intake. 23,24,27,29,30,33,34In Faber's and Sim's studies, dietary counseling was the control arm of a pharmacological randomized controlled trial. 24,29In Bagheri et al., the nutritional counseling focused on prescribing a Mediterranean diet, with specific amounts of kcal/kg and olive oil consumed; the regimen was based on a varied diet and the patient's taste. 30he authors generally did not provide much detail on the frequency and content of visits with the dietician.Only Latenstein and colleagues explained the objectives of the visits with end-of-life patients in detail; the focus of the intervention was on the needs of the patients, aiming to improve comfort and support quality of life. 25sychoeducational/psychosocial interventions aimed to reduce the emotional burden associated with cancer cachexia by empowering patients and families to cope with the dysfunctions and derangements of cachexia, thus improving quality of life. 6Psychoeducational/psychosocial support comprised two distinct types of interventions: (1) meetings on the meaning of food, experiences, and concerns regarding eating-related distress, the impact of weight loss on the patient regarding self-image and self-esteem, and on the dyad 22,26,33 in relation to interactions about mealtime and coping strategies; (2) mindfulness workshops on the theme of taste through the five senses. 23The interventions were conducted by different healthcare professionals, including nurses, 22,26 psychologists, 23 and dieticians. 27,33n Kapoor's study, the same nutritionist who delivered the dietary counseling added advice to increase the low levels of daily physical activity. 27In the studies by Kamel 31 and Parmar, 34 on the other hand, the rehabilitation intervention was more structured and was conducted by an experienced physiotherapist, with exercises to maintain strength, endurance, and flexibility.
The acupuncture intervention in the three studies differed in terms of the frequency of the sessions, varying from eight weekly sessions 18,19 to eight sessions, one every two days. 28The acupuncturists applied needles to points specific to the mechanisms of cachexia.
The duration of the non-pharmacological interventions was variable.The acupuncture intervention ranged from 2.5 weeks 18 to 18 weeks. 28he most extensive intervention was conducted by Kapoor, 27 where dietary counseling was offered twice a month for 6 months.The duration of the interventions does not seem to be correlated to either the type of intervention proposed or the adherence achieved.
Based on the type of intervention, acupuncture achieved the best adherence, with 100% of patients completing the intervention during the pilot study 18,19 and 75% in the RCT. 20,21Exercise alone had 85% adherence, 31 whereas when combined with dietary counseling, the adherence decreased to 57%. 27Psychoeducational intervention alone reached 71% adherence in Hopkinson et al. 22 and 83.3% in Buonaccorso et al., 26 while adherence to dietary counseling varied from 55% to 10% 24,29 to 86.9%. 30When the three types of intervention were combined, adherence was 43%-65%. 23,33In the two retrospective studies, only 42% and 48% of patients, respectively, continued to participate in the intervention after 18 weeks 34 and 12 weeks. 32he main reasons for dropout were death and a decline in clinical condition due to disease progression or re-hospitalization.The third

Risk of bias in the included studies
The review aimed to describe non-pharmacological interventions for cancer cachexia reported in the literature rather than to assess their efficacy.Thus, a risk of bias assessment of the included studies was performed to provide additional information on the current literature about this topic rather than to assess the reliability of estimates coming from the studies.
The overall risk of bias was high for both randomized and nonrandomized studies.We found only one randomized controlled trial with an overall judgment of "low risk" and three with an overall judgment of "some concerns" of risk of bias, while all the other studies were judged to be at "high risk of bias." The main drivers of risk of bias in the included studies were related to missing outcome data and measurement of outcomes among randomized studies and to bias in sample selection and inadequate follow-up rates among non-randomized studies.
The risk of bias graph and risk of bias summary are presented in Supplementary Figs.1-4 by study design (randomized and non-randomized studies).Detailed judgments are reported in Supplementary Table 1 for randomized studies and in Supplementary Table 2 for non-randomized studies.

Discussion
Of the 9308 titles screened, we included 17 articles corresponding to 15 studies.This review aimed to identify which non-pharmacological interventions have been studied for cancer patients with cachexia and refractory cachexia and are most often encountered in palliative care contexts.
We report some specific points that emerged from our data, and we think that focusing on these issues should help healthcare professionals to construct personalized interventions, particularly for advanced cancer patients.

Multimodal component of the interventions and heterogeneity of the population
Only six interventions out of 15 were multimodal (39%), 23,26,[31][32][33][34] even though the literature reported that a personalized treatment and multidisciplinary approach to evaluate the objective signs and relieve the symptoms is required. 2The most common multimodal components were nutritional counseling, exercise, and psychoeducation/psychosocial interventions, suggesting that a comprehensive and multidisciplinary approach could be necessary for this condition. 9,35,36A multimodal approach has strong theoretical backing but can be challenging to implement in clinical practice due to time and resource restraints. 9he studies analyzed included patients with different cachexia stages and cancer sites.Five out of 15 studies involved gastroenteric cancer patients.In 8 out of 15 studies, patients had ongoing active treatment.Although there has been greater adherence to the shared definition of Fearon and colleagues in recent years, 4 these differences in population prevent making solid conclusions. 36he data showed heterogeneity in the duration of the interventions.Moreover, the long follow-up period of some studies raises doubts about the possible feasibility in clinical practice and on patients' adherence to such complex and multidimensional interventions.
Acupuncture has been studied as a single intervention.It seems to reveal a cultural approach, as it has been used primarily in Eastern countries, 18,19 although the selected studies cover five continents (Europe, America, Asia, Africa, and Australia).
In the studies included in our review, the main reasons for dropout were death and a decline in clinical condition due to disease progression or re-hospitalization.As healthcare professionals, our focus should move from end-stage wasting to supporting patients' nutritional and functional state early on, and needs-centered interventions would be desirable. 37ue to the heterogeneity of these elements, we could not proceed with a meta-analysis.However, this also makes it difficult to make a comparison or synthesis of what may be effective intervention elements for the management of cachexia.Further studies that consider these methodological challenges are needed.

Outcomes
A particular reflection should be dedicated to the choice of outcomes.The most common primary outcomes were body weight and body composition, biomarkers, psychological questionnaires, and muscular strength.Nearly half of the studies also included quality of life questionnaires among the outcomes, with an increase seen in more recent studies.This is particularly important in palliative care settings, where the intervention should aim to improve the patient's quality of life, not only his/her weight or laboratory tests. 35,38,39terventions targeting the dyad: a future perspective Our data shows that only three studies were dedicated to the dyad. 22,26,33As the literature suggests, the entire family system will be affected by and respond to the loved one with cancer cachexia. 37,40,41For example, patients who live with their partners report more eating-related distress than those who live alone. 40An extensive survey (76% response rate) of 702 bereaved family members of cancer patients in Japan showed that those who believed they forced the patient to eat to avoid death and those who believed they did not have correct information about cancer cachexia showed a higher risk of bereavement depression. 41

Implications for nursing practice
In the included studies, the healthcare professionals who conducted the interventions varied widely (nurses, dieticians, physiotherapists, psychologists), sometimes stepping outside their expertise.In Kapoor's study, for example, the same nutritionist who delivered the dietary counseling conducted the physical activity component, adding advice to increase the low levels of daily physical activity. 27The literature, on the other hand, suggests a coordinated intervention by a registered dietician, physiotherapist, palliative care nurse, psychologist, and palliative care specialist. 9,35 nurse should therefore be a member of this multidisciplinary team, which is composed of healthcare professionals with complementary areas of expertise.Though the contribution of some team members is clearly defined (e.g., the physiotherapist supports physical activity/exercise), the nurse's role has not been clearly differentiated. 13In Buonaccorso et al., nurses and physiotherapists attended a brief course together on the psychoeducational needs of patients and their caregivers in the context of cancer cachexia. 26In nursing education on the management of cancer cachexia, as well as for all other professionals, it is fundamental to tailor the training according to the cachexia stage, symptoms, emotional response, and social circumstance. 13

Limitations
This scoping review analyzed data from all over the world, which could give a global vision of the problem.Only peer-reviewed studies were included.Literature via other sources, such as clinical trial registers or pre-print databases, was not searched, so nonpharmacological interventions described in grey literature may have been missed.The high overall risk of bias in the included studies was mainly attributable to outcome measures and missing data due to loss at follow-up.Although the use of self-reported outcomes (e.g., quality of life, patient experience, and so on) is a crucial point for a patientcentered approach, it may introduce bias in assessing the Another reason unrelated to the study (n ¼ 3) The intensity of eating-and weight-related distress was greater in the control group than that in the MAWE group.
From the qualitative analysis: The thematic and content analysis found that MAWE was perceived as helpful by 1) supporting eating well with advanced cancer and 2) supporting self-management.
Faber, 2015 Dietary counseling þ2 doses (2 Â 200 mL sip feed) of active medical food for patients in the 0-5% WL group and at least 2 doses for patients in the !5% WL group.Active medical food is an energy-dense (163 kcal/ 100 mL), nutritionally complete oral supplement (FortiCare) that is high in protein and leucine (9.9 g protein/100 mL and 1.1 g free leucine/100 mL) and is enriched with emulsified fish oil (0.6 g EPA and 0.3 g DHA/100 mL), specific oligosaccharides (1.2 g galactooligosaccharides and 0.2 g fructooligosaccharides/100 mL) and a balanced mix of vitamins, minerals, and trace elements.-Total n-3 PUFAs, EPA, DPA and DHA (P 0.001) in the IG compared with the CG Significant decrease in -body weight in patients in CG ! 5% WL -Serum concentrations of PGE2 in the IG Total n-6 PUFAs, AA and the ratio n-6/n-3 PUFAs (P 0.001) in the IG compared with the CG.Focan, 2015  Standard cachexia management þ mindfulness and diet workshops (4 double workshops every 2 weeks) for a maximum of 10 patients conducted alternatively by psychologists and dieticians.

Not described
In the diet workshops, foods had to be appraised through the five senses.Enrichment techniques and tasting of dishes at the level of the taste, the sense of smell, and the texture (touch) were developed.

Psychologist and dietitian
Standard cachexia management (standard dietetic support and eventual nutritional supplements according to estimated patient needs).FAACT outcomes improved between the first and second visit (FAACT total score P < 0.001, the FACT-G total score P < 0.001, the TOI P < 0.001, anorexia-cachexia symptoms P < 0.001, physical P < 0.001, emotional P ¼ 0.005, and functional wellbeing P ¼ 0.001), and they remained stable after the third visit.

Molassiotis, 2021
The intervention provided three structured sessions (2-3 h) of dietitian direct contact time over a 4-week period, inclusive of telehealth (Australian site only) or telephone follow-ups to monitor, reinforce and adjust goals.The context of the intervention was around nutrition impact symptoms, quality of life and food or eating-related psychosocial concerns in patients and caregivers through nutrition counselling, as well as addressing nutrition-related communication between the dyads, rather than solely achieving sufficient energy/ protein intake, which is a common approach in traditional dietary interventions.
The intervention also included a culturally adapted booklet that was provided to the patients and their caregivers.If patients were admitted to the hospital during the intervention period, the ward dietitian provided dietetic care to the patient while they were an inpatient, and the research dietitian continued with the intervention following discharge.

Acceptability of assessment tools
The assessment tools used were generally acceptable, with a rating !5.18 (on a 0-10 point scale) in both sites.
Outcome assessments Results showed a tendency for improvements in all patient outcome measures in IG compared with CG.These changes reached statistical significance (P < 0.05) for Eating-related distress and FAACT QoL, in the Australian sample, and Eating-related enjoyment, in the Hong Kong sample.Caregiver outcome measures showed a smaller and not statistically significant difference in all variables between IG and CG.Weight was maintained in the IG and decreased slightly in the CG.Clinically significant improvements were observed in the IG in terms of mean energy intake and mean protein intake.

Sim, 2022
The experimental group received regular nutrition counseling and education.Patients in IG were asked to take ONS twice a day (400 mL, 400 kcal).Patients were asked to record the amounts of ONS consumed, and weekly telephone counseling was used to determine and maintain compliance.

Dietitian
Finally, studies before 2012 were not included because we noted an exponential increase in publications on this issue more recently.This could be considered a limitation in a scoping review, even though limiting the search to a specific period is quite common.

Conclusions
This review clarifies which recent studies have been conducted to manage cancer cachexia with non-pharmacological interventions.The results show heterogeneous approaches with good patient adherence, sometimes combined in multimodal interventions.The studies have various methodological limitations, which make the results difficult to compare and apply.However, they are worthy of further research.Welldesigned studies with a clear definition of cancer cachexia involving a homogenous population by type of cancer and active or non-active treatment are needed. 38,39,43o apply the interventions to patients in palliative care, it is essential to pay attention to the choice of outcomes, which should align with the patient's actual needs.Quality of life includes weight or laboratory tests, the management of mealtime, relationships with food and tastes, and support of psychological suffering.Caregiver involvement can be crucial when approaching the subject of food and its related experiences, so interventions involving the dyad will be central. 2,41

Table 1
Characteristics of the included studies based on PICO criteria (patients, intervention, study design, comparison, patients, outcomes).
circumference (MUAC), body fat); nutritional status parameters (dietary intake: Energy, carbohydrate, protein, fat), PG-SGA;In the IG, patients had better control of cachexia symptoms, maintaining or improving the anthropometric, nutritional, and QoL parameters.On the contrary, in the CG, patients worsened with respect to the (continued on next page) E. Bertocchi et al.Asia-Pacific Journal of Oncology Nursing 11 (2024) 100438Table 1 (continued ) (continued on next page) E. Bertocchi et al.Asia-Pacific Journal of Oncology Nursing 11 (2024) 100438 Table 1 (continued ) MAWE, Macmillan Approach to Weight and Eating; VAS, visual analog scale; RCT, randomized controlled trial; WL, weight loss; PS, performance status; QoL, Quality of Life; IG, intervention group; CG, control group; EORTC QLQ-C30, EORTC Quality of Life Questionnaire Core 30; FFMQ, Five Facet Mindfulness Questionnaire; BMI, body mass index; BIA, bioelectrical impedance analysis; PG-SGA, Patient-Generated Subjective Global Assessment; GI, gastrointestinal; FAACT scale, Functional Assessment of Anorexia/Cachexia Therapy scale; EORTC QLQ-C15-PAL, EORTC Quality of Life Questionnaire Core 15 Palliative Care; HADS, Hospital Anxiety and Depression Scale; NA: not available.reason was the withdrawal of consent due to decreased interest or personal reasons.Other reasons included financial problems, transportation arrangements, violation of protocol, or inability to complete within the study timeframe.

Table 2
Summary of the main characteristics of the selected articles.

Table 3
Population of the studies selected.

Table 4
The types of non-pharmacological interventions.

Table 4
(continued ) Nutritional status -PG-SGA scores The paired t test between week 0 and week 8 showed improvements in both groups; only in the IG, the results were statistically significant (P ¼ 0.001).No differences were detected between IG and CG (P ¼ 0.118).Quality of life score -EORTC-QLQ C30 The global health status score was increased only in (continued on next page) E. Bertocchi et al.Asia-Pacific Journal of Oncology Nursing 11 (2024) 100438effectiveness of interventions, especially in unblinded studies.At the same time, a high proportion of loss at follow-up is to be expected in trials of late-stage palliative care interventions and may introduce bias if not managed.Considering these points from the beginning of the study design makes it possible to implement strategies related to the choice of outcomes, assessment time points, and sample size, as suggested by the MORECare statements.