Call to Improve Coding of Cancer-Associated Cachexia

Abstract

Cachexia is a systemic wasting syndrome prevalent in patients with cancer that significantly affects quality of life, health care costs, and therapeutic outcomes. Despite its clinical importance, cachexia is rarely formally diagnosed. This deficiency presents a challenge for effective patient management and care, health care resource allocation, and the advancement of therapeutic approaches. Here, we highlight impedances to the diagnosis and coding of cachexia, including the absence of standardized therapy, a lack of incentives for accurate coding, and overlapping clinical features with other conditions. We differentiate cachexia from related conditions like unintentional weight loss, sarcopenia, frailty, and protein-calorie malnutrition, outlining their distinct clinical features and inter-relations. We propose an approach to enhance diagnostic accuracy and coding for cachexia. This effort will enable better prevalence data, translation of mechanism-based therapy development, patient identification and stratification, and ultimately advanced diagnostics and US Food and Drug Administration-approved treatments for cachexia.

Fig. 1. Cachexia Screening and Evaluation Opportunities

To improve the identification and care of patients with cancer cachexia, we propose screening and evaluation at multiple timepoints over the course of diagnosis and treatment. Obtaining historical weight information is useful at diagnosis to understand the extent of weight loss, which commonly occurs before patients present with cancer. If no prior objective body weight measures are available in the medical record, then patients can be queried on their recall of body weight 6 and 12 months ago. When prior body weights are not available, other indicators may reveal a cachexia diagnosis. For example, a low body mass index (<20 kg/m²), a negative weight loss trajectory (>1 kg/month loss), obvious physical wasting, or a positive malnutrition screening test should prompt a focused evaluation for cachexia. The Global Leadership Initiative on Malnutrition (GLIM) criteria can effectively identify patients with malnutrition. Baseline assessments of body composition (fat and muscle mass), physical function, and food intake can be efficiently performed by office staff at diagnosis and then interval restaging appointments (yellow dots). We recommend direct observation of subcutaneous fat amount and muscle bulk for assessment of body composition, a 30 second sit-to-stand test for physical function (normative values found in refs^, and www.cdc.gov/steadi), and the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) Anorexia Cachexia Scale to assess symptoms of low food intake. If cachexia is not identified, then every subsequent touch point (green dots) is an opportunity to screen for cachexia. Patients should be weighed and queried about subjective weight loss and weakness at each visit. These screening sessions can be performed by any member of the medical team and at opportunistic moments, such as during treatment infusions or while patients are waiting for interval imaging studies. A “concern for cachexia” note can be placed in the medical chart for subsequent evaluation. If cachexia is confirmed, it should be diagnosed and coded (e.g., R64). Key interventions involve treating nutrition-impact symptoms (may offer olanzapine), recommending a daily caloric intake of 30–35 kcal/kg with 20–40% of calories from protein (1.0–1.5 g/kg/day), and referring patients to a registered dietitian nutritionist (RDN) for personalized medical nutrition therapy. If the patient responds positively to nutritional support, the diagnosis can be updated to protein-calorie malnutrition (e.g., E44 series).