Sarcopenia: looking to muscle mass to better manage pancreatic cancer patients Purpose of review Overall survival of patients with pancreatic cancer is strongly conditioned by tumor biology and the incidence of malnutrition and metabolic disorders. In this landscape, the assessment of body composition is crucial to properly manage the clinical implications of muscle wasting. The pathogenesis of this condition is the result of a complex interplay between cancer and the host. In particular, sarcopenia is induced by an inadequate nutritional intake, hormonal abnormalities, inflammation and imbalance between anabolic and catabolic pathways. Recent findings Recent evidences have highlighted the role of sarcopenia in cancer patients, revealing a prognostic impact on morbidity, mortality and survival. Summary The occurrence of sarcopenia could amplify chemotherapy-induced toxicities, prolong hospitalizations and reduce adherence to anticancer treatment, worsening quality of life and survival. Although considerable efforts have been made to develop treatment strategies, no effective interventions have been identified so far. Nevertheless, if promptly and adequately supported, pancreatic cancer might benefit from adopted dietary intervention to avoid further loss of lean mass. Correspondence to Giuseppe Aprile, MD, Department of Oncology, San Bortolo General Hospital, ULSS8 Berica, East District, Vicenza, Italy. Tel: +39 0444 753259; fax: +39 0444 757341; e-mail: giuseppe.aprile@aulss8.veneto.it Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Living with cancer and multimorbidity: the role of primary care Purpose of review As more people live longer with cancer, the number of patients with cancer and multiple other chronic conditions (multimorbidity) has increased. The presence of multimorbidity impacts on all stages of cancer care, from prevention and early detection through to end of life care, but research into cancer and multimorbidity is in its infancy. This review explores the impact of multimorbidity on adults living with (and beyond) cancer, with particular attention paid to the role of primary care in supporting patients in this situation. Recent findings Patterns of multimorbidity vary depending on cancer type and stage, as well as population characteristics and available data (e.g. number of conditions assessed). Cancer survivors are at increased risk of developing other chronic conditions, due to a combination of shared risk factors (e.g. smoking and obesity), effects of cancer treatments and psychosocial effects. Summary Primary care has a central role to play in supporting multimorbid adults living with cancer, providing holistic care of physical and mental well being, while taking treatment burden and social circumstances into account. New models of person-centred and personalized cancer care include holistic needs assessments, care planning, treatment summaries and cancer care reviews, and depend on improved communication between oncologists and primary care colleagues. Correspondence to David N. Blane, General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK. Tel: +44 0141 330 5765; e-mail: David.blane@glasgow.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interventions for myofascial pain syndrome in cancer pain: recent advances: why, when, where and how Purpose of review Pain is one of the most feared and most common symptoms of cancer, experienced by 38–85% of patients. Pain in terminally ill cancer patients is a multidimensional experience caused by a diverse array of factors – cancer itself, its treatment or other causes. Studies have shown a high incidence of myofascial pain syndrome (MPS) in patients with cancer and the knowledge of myofascial trigger points (MTrPs) is important to address and manage existing pain, and to prevent the recurrence of pain. The present review aims to summarize recent advances in IDDS for patients with cancer. Recent findings Database searches were conducted on MEDLINE, CINAHL, and Google Scholar to locate all studies published from inception until April 2019 using the keywords cancer pain, myofascial pain, TrPs with emphasis of any methodological quality that included interventions for MPS. MPS in advanced cancer patients are more commonly observed along with other cancer pains rather than independently with a prevalence of 11.9–48% in those patients diagnosed with cancer of head and neck and breast cancer. Summary Interventional therapies employing ultrasound guided injection of the MTrPs is gaining popularity in the management of MPS in cancer pain and may be a better alternative than the use of opioid analgesics in the multidisciplinary management. Correspondence to Arun Bhaskar, MBBS, MSc, FRCA, FFPMRCA, FFICM, FIPP, Pain Management Centre, 2nd Floor South, Charing Cross Hospital Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK. Tel: +44 203311 7016; fax: +44 20 3311 7566; e-mail: akbhaskar@btinternet.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Updates in opioid and nonopioid treatment for chronic breathlessness Purpose of review Chronic breathlessness is a troublesome symptom experienced by people with advanced malignant and nonmalignant disease. Disease-directed therapies are often insufficient in the management of chronic breathlessness. Therefore, pharmacological and nonpharmacological breathlessness-specific interventions should be considered for select patients. Recent findings There is some evidence to support the use of low-dose opioids (≤30 mg morphine equivalents per day) for the relief of breathlessness in the short term. However, additional studies are needed to understand the efficacy of opioids for chronic breathlessness in the long term. Nonopioid therapies, including inspiratory muscle training, fan-to-face therapy, L-menthol and inhaled nebulized furosemide show some promise for the relief of breathlessness in advanced disease. There is insufficient evidence to support the use of anxiolytics and benzodiazepines and cannabis for chronic breathlessness. Summary More research is needed to identify therapies for the management of chronic breathlessness. Correspondence to Sara J. Abdallah, PhD, Department of Kinesiology and Physical Education, 475 Pine Avenue West, Montréal, QC, Canada H2W 1S4. Tel: +1 514 398 4184; fax: +1 514 398 4186; e-mail: sara.j.abdallah@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain Purpose of review Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that myofascial trigger points should be considered peripheral pain generators and this critical review will summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points. Recent findings The clinical features of myofascial trigger points and their contribution to the patient pain and disability have been detailed in several recent studies, which support the clinical relevance of the condition. Recent studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed and positive effects on pain and function demonstrated. Summary The myofascial trigger point phenomenon has good face validity validity and is clinically relevant. Clinicians are encouraged to consider the contribution of myofascial trigger points to the patient's pain and disability through a careful medical history and a specific manual examination. Patients with myofascial trigger points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques. Internal and external validity of research within the field must be improved. Correspondence to Prof. Marco Barbero, PT PhD – Head of Laboratory, Head of Laboratory of Rehabilitation Research Laboratory 2rLab, Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Stabile Piazzetta, Via Violino 11, CH-6928 Manno, Switzerland. Tel: +41 (0)58 666 64 35; e-mail: marco.barbero@supsi.ch; website: http://www.supsi.ch/rrlab Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Dietetic assessment and intervention in lung cancer Purpose of review Systemic therapy for lung cancer is increasing in intensity and duration. European nutrition guidelines suggest screening for weight loss and malnutrition, however acknowledges there is a lack of evidence. We discuss current data round this issue and identify opportunities for further research. Recent findings International guidelines now exist to aid the definition of weight loss in cancer, including cachexia, sarcopenia and malnutrition. These allow consistent definition of overlapping, but distinct clinical syndromes. Nutritional status can be assessed in a range of ways including questionnaires, functional assessments, blood markers, physical activity, weight and BMI. Weight loss is commonly associated with a proinflammatory state. Future treatment is likely to be a combination of dietetic support and pharmacological treatment of cachexia. Summary There is a paucity of data on dietetic intervention. It is potentially quick, inexpensive and patient specific, using a holistic approach to aid patients who are malnourished or at risk of malnutrition. Lung cancer-related weight loss is common, further strategies are needed to effectively assess and intervene. Dietetic intervention has the potential to improve patients’ quality of life and outcomes. Correspondence to Dr Iain Phillips, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK. Tel: +0131 537 1000; e-mail: iain.phillips1@nhs.net Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Breathlessness and the brain: the role of expectation Purpose of review Breathlessness debilitates countless people with a wide range of common diseases. For some people, the experience of breathlessness is poorly explained by the findings of medical tests. This disparity complicates diagnostic and treatment options and means that disease-modifying treatments do not always have the expected effect upon symptoms. These observations suggest that brain processing of respiratory perceptions may be somewhat independent of disease processes. This may help to explain the dissonance observed in some patients between physical disease markers and the lived experience of breathlessness. Recent findings A body of breathlessness research using functional neuroimaging has identified a relatively consistent set of brain areas that are associated with breathlessness. These areas include the insula, cingulate and sensory cortices, the amygdala and the periaqueductal gray matter. We interpret these findings in the context of new theories of perception that emphasize the importance of distributed brain networks. Within this framework, these perceptual networks function by checking an internal model (a set of expectations) against peripheral sensory inputs, instead of the brain acting as a passive signal transducer. Furthermore, other factors beyond the physiology of breathlessness can influence the system. Summary A person's expectations and mood are major contributors to the function of the brain networks that generate perceptions of breathlessness. Breathlessness, therefore, arises from inferences made by the brain's integration of both expectations and sensory inputs. By better understanding individual differences across these contributing perceptual factors, we will be better poised to develop targeted and individualized treatments for breathlessness that could complement disease-modifying therapies. Correspondence to Kyle T.S. Pattinson, BM, DPhil, FRCA, Associate Professor, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK. E-mail: kyle.pattinson@nda.ox.ac.uk This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Standardized measurement of breathlessness during exercise Purpose of review Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion. Recent findings Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time. Summary To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus. Correspondence to Dennis Jensen, Currie Memorial Gymnasium, 475 Pine Avenue West, Montreal, Quebec, H2W 1S4, Canada. Tel: +1 514 398 4184; e-mail: dennis.jensen@mcgill.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Why treatment efficacy on breathlessness in laboratory but not daily life trials? The importance of standardized exertion Purpose of review Treatments for chronic breathlessness, including opioids and oxygen, have shown efficacy in the controlled laboratory setting, whereas effects have been inconsistent or absent in trials in daily life. This review discusses the lack of standardized exertion as a potential cause of false negative findings for breathlessness in daily life. Recent findings The level of breathlessness can be modified by patients by changing their level of physical activity. Effects of opioids and oxygen have been shown at standardized level of exertion (iso-time) but not at the end of symptom-limited (peak) exertion. Trials in daily life reporting no effects on breathlessness did not standardize the exertion or employed insensitive methods, such as the 6-min walk test that should not be used for measuring breathlessness. Novel tests – the 3-min walk and stepping tests have been validated in chronic obstructive pulmonary disease and are responsive for measuring change in breathlessness. Summary Breathlessness should be measured at standardized exertion, otherwise treatment effects may be biased or overlooked. Tests for valid measurement of breathlessness in clinical practice and daily life are available and emerging. Correspondence to Magnus Ekström, MD, PhD, Associate Professor, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Karlskrona SE-371 85, Sweden. Tel: +46(0)455731000; e-mail: pmekstrom@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Recent research on the social network concept and cancer Purpose of review This review covers articles in 2018 and early 2019 that employed the concept of networks and social interactions in research on how patients with cancer cope, receive and respond to medical treatment and allied support. The use of social aspects, and more formally the method of social network analysis for research on cancer is quite new. Although we paid special attention to articles that used formal social network analysis, we noted that those articles cover just over a quarter of the material we reviewed. Most articles that incorporated social aspects of cancer did not intend to formalize them by measuring specific relationships but treated the network concept as a way to characterize social support, social influence, or social responsibilities. Recent findings We identified 74 recent articles that mentioned the network concept for research about cancer, excluding gene interaction networks. Of those 74 articles, 21 measured specific relationships between individuals or organizations and/or attributes of those individuals or organizations connected to participants or to others. Primary foci of the network analysis and nonnetwork analysis studies were breast cancer and social support for patients, and they usually at least considered sex and age of the cancer patients/survivors. Social media received some attention, and there were some studies considering quality of life and mental health. Among network analysis studies, size of network and number of people providing emotional/informational/instrumental support occurred in more than a couple studies but not the majority. There was little similarity among studies – whether using network analysis or not – suggesting that theory building and methodological development are in early stages. Summary Implications of the review include opportunities for more systematic research using the network concept to understand people's experience of cancer as well as research on cancer. Researchers can make considerable contributions at this stage in the field's development, and practitioners can help develop interventions that make fuller use of the insights of social network analysis. Correspondence to Eric C. Jones, UTHSCH, 1851 Wiggins Way, HSN 487, El Paso, TX 79968, USA. Tel: +1 915 747 8503; fax: +1 915 747 8512; e-mail: Eric.C.Jones@uth.tmc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.