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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 498-507

Barriers in Nursing Practice in Cancer Cachexia: A Scoping Review

1 Division of Nursing, Shizuoka Cancer Center, Shizuoka; Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
2 Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
3 Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan

Date of Submission29-Jun-2021
Date of Acceptance08-Jul-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Tateaki Naito
Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apjon.apjon-2152

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This scoping review aims to identify the barriers in practice and clinical trials for oncology nurses in cancer cachexia. We used the framework proposed by Arksey and O'Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Studies written in English and published between 2008 and 2021 were retrieved from five databases: MEDLINE, Cochrane Library, CINAHL, PsycINFO, and EMBASE. A total of 1075 studies were identified, and 34 full-text studies were assessed for eligibility by three researchers. Seventeen studies met the inclusion criteria. This review revealed several barriers to nursing practice and clinical trials in cancer cachexia. First, health-care professionals, including nurses, faced individual barriers (insufficient understanding and skills for diagnosis and management) and environmental barriers (lack of standardized screening tools or treatment options, difficulties in collaboration with other professions, and limited human resources) in practice. Second, studies on nurse-led interventions for cancer cachexia were relatively few and different in objectives, making it challenging to integrate the outcomes. Finally, there were no established educational programs for nurses that explicitly focused on cancer cachexia. This scoping review revealed individual and environmental barriers in nursing practice. In addition, there have relatively few clinical trials involving oncology nurses in cancer cachexia. Continuing education for nurses should cover cancer cachexia to improve the quality of oncology care in the future. It is also necessary to standardize practical assessment tools that are easy to assess daily and lead to interventions and develop nurse-led multidisciplinary care.

Keywords: Cancer cachexia, nurses' role, nursing care, scoping review

How to cite this article:
Sato R, Naito T, Hayashi N. Barriers in Nursing Practice in Cancer Cachexia: A Scoping Review. Asia Pac J Oncol Nurs 2021;8:498-507

How to cite this URL:
Sato R, Naito T, Hayashi N. Barriers in Nursing Practice in Cancer Cachexia: A Scoping Review. Asia Pac J Oncol Nurs [serial online] 2021 [cited 2021 Sep 23];8:498-507. Available from: https://www.apjon.org/text.asp?2021/8/5/498/324784

  Introduction Top

Cancer cachexia occurs in 50%–80% of cancer patients, especially in the advanced stage.[1] Cachexia negatively affects the efficacy and safety of anticancer treatment, physical function, and quality of life, and is related to 20% of cancer deaths.[1],[2],[3] Patients with cancer cachexia often experience psychosocial distress due to reduced oral intake, physical dysfunction, or changes in body image.[4] In addition, patients and their families seek understanding from health-care professionals (HCPs), and expect them to identify, explain, and help manage cachexia-related weight loss.[5]

According to the guidelines for cancer cachexia from the European Society for Medical Oncology, nurses must routinely screen at-risk patients for cancer cachexia as well as nutrition impact symptoms or altered gastrointestinal function in collaboration with other HCPs.[6] An additional international consensus recommends routine assessments for functional and psychosocial effects of cancer cachexia.[2] However, oncology nurses may not sufficiently recognize the importance of following these guidelines or consensus.[7],[8],[9] Furthermore, the nurse's role is often unclearly defined in a multidisciplinary care team,[10],[11],[12] and this is expected to worsen outcomes in cancer cachexia cases.[13],[14],[15],[16] These circumstances may undermine the chances of early detection and intervention for cancer cachexia. Accordingly, the purpose of this review is to identify the barriers in nursing practice and clinical trials and to identify the potential roles of oncology nurses in treating patients with cancer cachexia.

  Methods Top

Search strategies

This review followed the methodological framework developed by Arksey and O'Malley to conduct a scoping review mapping the key concepts underpinning a research area and the main sources and types of evidence available.[17] We have reported our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.[18] A literature search was conducted using MEDLINE, Cochrane Library, CINAHL, PsycINFO, and EMBASE in March 2020. The search keywords included nursing practice (”nursing care,” “oncology nursing,” “nurse 's role,” “nurse,” “nursing”) and cancer cachexia (”cancer cachexia”). The keywords grouped together in parentheses were connected by “OR,” and both the groups of keywords were connected with “AND.” The inclusion criteria were as follows: (1) written in English; (2) focused on nursing practice of cancer cachexia for adult patients with cancer; and (3) published from 2008 to 2021 (cachexia was defined in 2008.)[19] Studies that focused on pediatrics, perioperative nursing, or survivorship were excluded. One researcher reviewed titles and abstracts according to the selection criteria. If the title and abstract met the inclusion criteria, three researchers read the full articles to decide whether they should be included in the review.

  Results Top

We identified 1,075 articles from the initial search [Figure 1]. After a title and abstract review, 34 studies were included, and 17 studies that met the inclusion criteria were confirmed after a full-text review.
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for the scoping review process

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Study characteristics

The studies reviewed were conducted in the United Kingdom (n = 5), China (n = 3), Portugal (n = 2), the United States (n = 2), Japan (n = 2), Australia (n = 1), Hong Kong (n = 1), and Jordan (n = 1). Of the 17 studies reviewed, quantitative research using questionnaires was the most common method employed (n = 6), while others included qualitative research using focus group interviews or semi-structured interviews (n = 4), randomized controlled studies (n = 2), quasi-experimental studies (n = 2), pilot studies (n = 2), and single-arm studies (n = 1).

Participants were nurses, doctors, dietitians, other medical staff, patients, and caregivers. The sample sizes ranged from 5 to 497 participants. HCP's average age ranged from 27 to 29 years in two studies, and 6.5 years of experience in one study. The average age of the patients ranged from 52 to 75 years. The most common type of cancer was lung cancer.

Barriers in nursing practice in cancer cachexia

Nine studies were deemed to identify barriers to nurses' implementation of cachexia care in a multidisciplinary setting. Barriers were classified into three subcategories: understanding, assessment, and management of cancer cachexia [Table 1].
Table 1: Barriers in nursing practice in cancer cachexia

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Understanding barriers

Six of the nine studies reported about HCP's knowledge and awareness of cancer cachexia. Many HCPs have realized the importance of nutritional management in patients with cancer.[8],[22],[25],[26] However, few nurses and HCPs understood the etiology and management of cancer cachexia, possibly due to a lack of pre-and post-registration education.[8],[23],[24] Some reports indicated that HCPs did not realize the unfavorable impact of cancer cachexia on patients' activities of daily living or sarcopenic status.[8],[26] In addition, one survey in the US reported that few doctors knew that cancer cachexia was often present even in patients with good performance status who were indicated for active cancer treatment.[25] Cachectic patients and their caregivers reported worrying about appetite loss, change in appearance, and reduced social activity, and also expressed that they received little information concerning cancer cachexia from HCPs.[22],[23]

Assessment barriers

Seven of the nine studies identified issues regarding the assessment of cancer cachexia. In some surveys, nurses routinely assessed vital symptoms of cancer cachexia (e.g. appetite, food intake, nausea, and vomiting) in regular practice[8],[22],[25] and actively screened at-risk patients for malnutrition or cancer cachexia.[25],[26],[27] However, the assessment tools employed were often inconsistent and not standardized.[8],[21],[23],[26] In addition, doctors were more reluctant to use assessment tools than nurses.[8],[25] In general, barriers to screening cancer cachexia include the limited time allotted for HCPs, the complexity of tools, language barriers, and a wide variation in the causes of weight loss.[21],[23],[26] A further complication in assessment was that nurses might not have the authority to refer patients to dietitians in certain settings.[21] Finally, one survey reported that patients or caregivers were more indifferent than HCPs in recognizing malnutrition risk.[27]

Management barriers

Seven of the nine studies reported the management of cancer cachexia. Some reports suggested that nonpalliative care HCPs, including nurses, assigned low priority to cancer cachexia management,[24] and rarely consulted dieticians or other professionals.[20] Other reports[8],[25] showed that nutritional or pharmacological interventions were often prescribed individually, and were seldom combined with other treatment modalities (e.g., exercise therapy). This poor collaboration among HCPs may be due to the lack of standardized treatment recommendations[8],[22],[24] or specific services to manage cachexia,[26] shortage of staff,[24] communication barriers between HCPs,[20],[23] and lack of skills training.[20],[26] Finally, some reports suggested that nurses and dietitians were reluctant to discuss weight loss, especially in nonpalliative care settings, because they feared distressing the patients.[24] This hesitation potentially obstructed early diagnosis of cancer cachexia and advanced care planning for end-of-life care.[23]

Barriers for clinical trials in the nurse-led intervention

There have been four studies on nurse-led interventions for cancer cachexia [Table 2]. One psychosocial, two nutritional, and one physical activity interventions were included for review.[28],[29],[30],[31] The comparability of study outcomes was limited because the study populations (cancer type or stage), objectives, and outcome measures were inconsistent among these studies.
Table 2: Barriers for clinical trials in nurse-led intervention in cancer cachexia

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However, these interventions were generally well tolerated,[28],[30],[31] with few dropouts and good compliance. Few adverse events were reported during physical activity intervention.[31] One study reported the effectiveness of psychological intervention in preventing eating- or weight-related distress.[28] Another study reported that nutritional intervention improved serum albumin and prealbumin levels[29] and promoted patient and family engagement in nutrition care.[30] One nurse-based physical activity intervention successfully increased or maintained outdoor and indoor physical activities.[31]

Nursing education programs to break down barriers

Currently, there are no established educational programs for nurses that focus specifically on cancer cachexia. However, there have been four studies on educational programs for nurses on nutrition for cancer patients [Table 3]. Some programs have focused on how to use a specific assessment tool (e.g., MUST).[33],[35] Other programs cover artificial hydration therapy and general nutrition management in cancer patients.[32],[34] Education effectively increased knowledge and confidence[32],[34] but did not improve compliance with nutritional assessment after the intervention.[33],[35] Heterogeneity in types of interventions or outcomes existed, and the participants' age and background varied among studies.
Table 3: Nursing educational programs of cancer patients' nutrition

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  Discussion Top

This review revealed several barriers to nursing practice and clinical trials in cancer cachexia. First, HCPs, including nurses, faced individual barriers (insufficient understanding and skills for diagnosis and management) and environmental barriers (lack of standardized screening tools or treatment options, difficulties in collaboration with other professions, and limited human resources) in practice. Second, there were few studies on nurse-led interventions for cancer cachexia, each with different objectives, making it challenging to integrate the outcomes. Finally, there were no established educational programs for nurses that focused explicitly on cancer cachexia.

Education about cancer cachexia and having care skills before certification is rare. Although both the U.S. and U.K. registered nurse examination guidelines include nutrition knowledge, there is insufficient material concerning the assessment and management of cancer cachexia to adequately prepare nurses for caring for these patients.[36],[37] Therefore, it is unsurprising that there is insufficient understanding and practice of cancer cachexia nursing among nurses.

Meanwhile, some HCPs who have attended the training program in cancer cachexia clinics in continuing education realized the importance of cancer cachexia in their practice. They reported that their experiential learning led to a better understanding and recognition of the importance of recognizing and treating cancer cachexia, and led to a more consistent approach.[38] Despite this, there have been few attempts to provide opportunities for systematic learning about cancer cachexia in any country. Considering that insufficient knowledge and skills may lead to delays in cancer cachexia interventions,[39] it is necessary to provide more educational opportunities for continuing education in the future.

HCPs need to understand the complexity of psychosocial and physical distress associated with cancer cachexia to provide patients and caregivers with the necessary information and effective coping strategies.[40] In addition to typical symptoms associated with cancer cachexia (e.g., “loss of appetite,” “inability to eat,” and “ loss of weight”), patients reported feelings of “hopelessness,” “fretting,” and “ a shortage of information” which exacerbated eating-related distress.[41] Patients and caregivers were reluctant to report weight loss to HCPs, and did not receive information about cancer cachexia from HCPs.[42],[43] On the medical side, there is a lack of awareness of psychosocial and physical distress experienced by patients and caregivers.[24] In addition, the methodology of communication and educational interventions concerning cancer cachexia is not well developed.[40] Therefore, HCPs, including nurses, are responsible for raising awareness of psychosocial and physical distress and communicating about cancer cachexia to alleviate patients' suffering.

Interventions by nurses may also influence changes in the behavior of patients and their caregivers. Hopkinson conducted a scoping review to evaluate nurse-delivered dietary or nutritional advice.[10] They suggested an essential role of nurses in psychoeducational interventions for behavioral changes.[10],[44] Other reports have also suggested a positive effect of incorporating behavioral change techniques in improving or maintaining physical, psychological, and social functioning in cancer patients.[45],[46] In multidisciplinary interventions for cancer cachexia, nurses play an essential role in supporting self-care and instilling motivation in their patients, encouraging them to endure interventions. Buonaccorso et al. recently reported the ongoing study protocol of a psychoeducational intervention lead by nurses combined with exercise intervention for patients with cancer cachexia.[47] In the study, a trained nurse interviewed the patient and the patient's family weekly for a period of 3 weeks. The nurse explained the nature, course, and biological mechanisms of cachexia, and taught patients how to recognize its effects (e.g., weight loss, loss of appetite, and early satiety). In addition, nurses facilitated discussion of the patient and family's perspectives, feelings, and diets, as well as suggestions on how to support each other in managing weight-and eating-related problems. This intervention was combined with at least 24 home exercise sessions conducted by a physical therapist three times a week for 8 weeks. The primary objective was to determine the completion rate of each intervention. Interventions were considered feasible if there was a completion rate of ≥50% for both the components. Such advanced trials may improve nursing care for cancer cachexia.

Although the psychosocial impact of cancer cachexia is clear,[4],[48] there are no standard tools to identify it in clinical practice. Several evaluation methods have been used to estimate the effects of cancer cachexia on physical functioning, including the Karnofsky score, activity meters, and specific activity checklists.[2] However, for psychosocial effects, a method for the routine assessment by asking questions about eating-and weight-related distress has been recommended.[2] Additional tools to evaluate the psychosocial impact of cancer cachexia, such as the Functional Assessment of Anorexia/Cachexia Treatment[49] and the European Organization for Research and Treatment of Cancer QLQ Module for Cancer Cachexia (QLQ-CAX24),[50] have been developed. However, such tools are primarily used for research purposes at present. An assessment tool that can be used clinically and in research could create new opportunities for nurses to study cancer cachexia and help them consider how to develop multidisciplinary interventions to meet the needs of cancer cachexia patients.[51],[52] To address the unmet needs of patients and caregivers, HCPs, including nurses, are responsible for recognizing cancer cachexia early, communicating well with patients and caregivers, and promoting clinical trials to standardize screening and assessment tools.


First, since the articles included in this review were English only, and most countries were limited to developed countries, we could not apply our results to other medical situations or language areas. It is expected that the recognition of HCPs, patients, and caregivers toward cancer cachexia will differ depending on the nationality, environment, and culture, and more detailed studies are needed. Second, we must also consider the context and culture of the country and institution regarding differences in health-care systems, roles of HCPs, and the nature of the health-care team. Finally, there are limitations in generalizing the results of this review as the current practices and barriers of cancer cachexia nursing because it includes studies that focus not only on cancer cachexia but also on the general nutritional management of cancer patients.

Nursing implications

HCPs should routinely assess cancer patients' physical and nutritional changes based on established guidelines and consensus.[2],[6] It is also essential for HCPs to be aware of the signs, symptoms, and effects of cancer cachexia as early as possible in the treatment courses.[2],[6],[53] However, awareness of cancer cachexia among HCPs, including nurses, is currently limited. More continuing education opportunities should be provided for HCPs to learn about cancer cachexia. The routine use of assessment tools for cachexia can help HCPs recognize early signs and symptoms and provide early, tailored interventions for cancer cachexia in cooperation with multidisciplinary teams. Nurses who are in close contact with patients can make a difference in the worsening trajectory of cachectic patients if they recognize the patient's condition and integrate multidisciplinary care early.

Finally, psychoeducational interventions by nurses are essential. Simply asking a patient about eating-related distress may help them cope with the situation in palliative care settings.[54] HCPs should provide patients and their caregivers with information appropriate to the stage of cachexia so that they can recognize the nature, course, and adverse effects of cancer cachexia, thereby increasing caregiver and patient awareness of the clinical condition and the need for early multidisciplinary intervention.[4],[6] The clinical framework for quality care in cancer cachexia presents assessments and management for each stage of cancer cachexia and may help oncology nurses to determine what knowledge and skills are needed to provide cancer cachexia care in practice.[55] Further research is required on this topic.

  Conclusions Top

This scoping review revealed individual and environmental barriers to nursing practice; however, there have been relatively few clinical trials for oncology nurses in cancer cachexia. In the future, it is necessary to introduce the content on cancer cachexia into continuing education programs for nurses and to standardize tools that are easy to assess in daily practice and lead to interventions. There is also a need to develop nurse-led interventions for multidisciplinary interventions. Further studies are needed to establish a practical guide for the nursing management of cancer cachexia.


We thank Ms. Sakiko Aso and Ms. Nozomi Shuntoh for their instruction on designing this study.

Financial support and sponsorship

This work was supported by the Japan Agency for Medical Research and Development (AMED, Grant No. 21ck0106673 h0001) and Japan Society for the Promotion of Science (Grant No. JP21K18292).

Conflicts of interest

The corresponding author, Prof. Tateaki Naito, is the associate editor of the journal.

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