Telemedicine-Delivered Nutritional Counseling Versus Standard Care for Cancer Cachexia in Pakistani Cancer Patients: A Pilot Randomized Controlled Trial
Telemedicine-Delivered Nutritional Counseling Versus Standard Care for Cancer Cachexia in Pakistani Cancer Patients: A Pilot Randomized Controlled Trial
What is this study about? Cancer often causes unwanted weight loss and loss of appetite, a condition called "cancer cachexia." This affects patients' strength, quality of life, and ability to tolerate cancer treatment. Proper nutrition is very important to help maintain weight and strength during cancer treatment. Currently, cancer patients receive nutritional counseling during hospital visits, which requires travel time and expense. With telemedicine (video calls on mobile phones), nutritional counseling can be provided from patients' homes.
What is the purpose of this study?
This study compares two ways of providing nutritional counseling to cancer patients who have experienced weight loss:
Telemedicine group: Counseling through video calls (WhatsApp, Zoom, or Microsoft Teams) from home Standard care group: Counseling during in-person hospital visits Both groups receive the same nutritional advice every 2 weeks for 12 weeks. The only difference is how the counseling is delivered (video call vs. in-person).
Who can participate? Adults (18 years or older) with cancer who have lost weight in recent months and have access to a smartphone with internet connection.
What will participants do?
Telemedicine group:
Receive counseling through 20-30 minute video calls every 2 weeks (7 sessions total) Come to hospital only twice: at the beginning and end (Week 0 and Week 12)
Standard care group:
Come to hospital every 2 weeks for 30-45 minute counseling sessions (7 visits total)
Both groups receive:
Personalized dietary advice from registered dietitians Help with eating problems (poor appetite, nausea, taste changes) Pakistani meal plans that fit their preferences Free nutritional counseling throughout the study Reimbursement for travel or mobile data costs
What will be measured? Body weight change over 12 weeks Food and protein intake Arm muscle measurements Nutritional status and quality of life Patient satisfaction with counseling method Costs of each method
Why is this study important? This will be the first study in Pakistan and South Asia to test whether telemedicine nutritional counseling works as well as hospital visits for cancer patients. Results will help make nutritional care more accessible, especially for patients living far from hospitals.
Study Location: King Edward Medical University/Mayo Hospital, Lahore, Pakistan Duration: 12 weeks per participant Total Participants Needed: 80 patients
BACKGROUND AND RATIONALE Cancer cachexia is a metabolic syndrome characterized by progressive involuntary weight loss, skeletal muscle depletion, systemic inflammation, and anorexia, affecting 50-80% of cancer patients and contributing to 30% of cancer-related deaths. International guidelines from ESPEN and ASCO recommend nutritional counselling as a cornerstone of multimodal cachexia management; however, high-quality randomized evidence remains limited, particularly in low-and-middle-income countries.
In Pakistan, 31-97% of cancer patients experience malnutrition, compounded by geographic barriers, critical shortage of trained clinical nutritionists, and catastrophic out-of-pocket healthcare expenditure. No randomized controlled trial has evaluated telemedicine-delivered nutritional counselling for cancer cachexia anywhere in South Asia, representing a critical evidence gap.
STUDY DESIGN Single-centre, parallel-group, pilot randomized controlled trial with 1:1 allocation. Randomization is computer-generated with variable block sizes (4-6), stratified by cancer type (gastrointestinal vs. non-gastrointestinal) using sequentially numbered sealed opaque envelopes. The trial uses a single-blind design: outcomes assessors, laboratory staff, and the statistician are blinded to group allocation; participants and dietitians cannot be blinded due to the nature of the intervention.
INTERVENTION RATIONALE Both arms receive identical nutritional counselling content from the same registered dietitians following standardized ESPEN-based protocols (energy ≥25 kcal/kg/day; protein ≥1.0 g/kg/day), with culturally adapted Pakistani meal plans. Sessions are delivered bi-weekly at equal frequency (7 sessions over 12 weeks) so that delivery modality - not counselling dose - is the sole variable under study. The telemedicine arm uses WhatsApp Video Call as the primary platform (given its widespread use and low-bandwidth requirements in Pakistan), with Zoom or Microsoft Teams as alternatives. Patients participate from home; dietitians conduct sessions from a dedicated workspace at the Department of Medical Oncology, KEMU.
NON-INFERIORITY RATIONALE Given that both groups receive equivalent counselling frequency and content, a non-inferiority design is appropriate. The non-inferiority margin of -1.0 kg for body weight change at 12 weeks was selected based on clinical judgment and published cachexia literature, representing the maximum weight difference that would still be considered clinically acceptable for telemedicine to be adopted as a delivery alternative. Telemedicine will be declared non-inferior if the lower limit of the 95% confidence interval for mean weight difference (telemedicine minus standard care) exceeds -1.0 kg.
SAMPLE SIZE Using G*Power for an independent samples t-test: Cohen's d = 0.75, α = 0.05 (two-sided), power = 85%, yields 29 participants per group. Adjusted for 20% anticipated dropout in cancer cachexia trials, the final sample is 40 per group (80 total), with an expected evaluable sample of 64 participants.
STATISTICAL ANALYSIS Primary analysis is intention-to-treat. The primary outcome (body weight change, baseline to Week 12) will be analysed using an independent samples t-test or Mann-Whitney U test as appropriate, with ANCOVA adjusting for baseline weight, cancer type, ECOG performance status, and treatment changes during the study. Missing data will be handled by multiple imputation using chained equations (20 imputations) for <20% missingness, with complete case analysis as a sensitivity check. Per-protocol analysis (participants completing ≥75% of sessions) will be conducted as a secondary analysis. Exploratory subgroup analyses are planned by cancer type, baseline cachexia severity, sex, and urban versus rural residence.
SIGNIFICANCE This is the first RCT of telemedicine nutritional counselling for cancer cachexia in South Asia. The design isolates the effect of delivery modality by equalizing counselling frequency across arms. Results will provide effect size estimates to power a larger multi-centre trial, cost-effectiveness data for health policy decisions, and a scalable evidence-based model for nutritional care delivery in resource-constrained settings.
Inclusion Criteria:
1. Age and Consent Capacity
Age ≥18 years (adults of either biological sex or gender identity)
Able to understand study procedures and provide written informed consent independently or with assistance from legally authorized representative 2. Cancer Diagnosis
Histologically or cytologically confirmed solid tumor malignancy of any type, including but not limited to:
Any cancer stage eligible (Stage I, II, III, or IV) 3. Cancer Cachexia
Documented unintentional weight loss meeting at least one of the following criteria:
Weight loss must be documented by medical records, patient self-report, or measurement at screening visit compared to documented previous weight 4. Active Cancer Treatment
Currently receiving active anti-cancer treatment, OR
Scheduled to begin active anti-cancer treatment within 2 weeks of enrollment
Eligible anti-cancer treatments include:
Patients receiving palliative/supportive care only (without active anti-cancer treatment) are excluded 5. Performance Status
Eastern Cooperative Oncology Group (ECOG) Performance Status 0, 1, or 2:
Access to a smartphone or tablet device with video calling capability (personal device or family member's device that participant can use)
Reliable internet connectivity available via at least one of:
For telemedicine group: willingness and ability to participate in video consultations 7. Language
Able to communicate verbally in Urdu (national language of Pakistan) or English
Able to understand spoken instructions and questions
Literacy not required; illiterate participants eligible with assistance from family/witness for consent and questionnaires 8. Geography
Able to attend in-person assessments at King Edward Medical University/Mayo Hospital, Lahore, Pakistan at baseline (Week 0) and Week 12
For telemedicine group: only 2 hospital visits required (Weeks 0 and 12)
For standard care group: able to attend 7 hospital visits (Weeks 0, 2, 4, 6, 8, 10, 12) 9. Commitment
Willing to participate in the study for the full 12-week duration
Willing to comply with study procedures including dietary assessments, questionnaires, blood tests, and nutritional counseling sessions
Exclusion Criteria:
Inability to Eat Orally
Severe dysphagia (difficulty swallowing) requiring enteral nutrition support via:
Complete bowel obstruction preventing oral intake
Total parenteral nutrition (TPN) as sole nutritional support
Note: Partial oral intake supplemented with enteral nutrition is eligible if patient can consume at least some food by mouth 2. Refractory Cachexia
ECOG Performance Status 3 or 4:
Active cachexia management deemed not clinically appropriate or futile by treating oncologist
Estimated life expectancy <3 months per treating oncologist's assessment
Imminent end-of-life care or transition to hospice care 3. Uncontrolled Comorbid Conditions
Uncontrolled diabetes mellitus defined as:
End-stage renal disease requiring dialysis (hemodialysis or peritoneal dialysis)
o Rationale: Dialysis patients require specialized renal diet with protein, fluid, potassium, and phosphorus restrictions that differ substantially from cancer cachexia nutritional recommendations
Severe heart failure, New York Heart Association (NYHA) Functional Class IV:
Active psychiatric illness that would preclude meaningful participation or informed consent, including:
Cognitive impairment preventing informed consent or ability to participate, including:
Note: Mild cognitive impairment or controlled psychiatric conditions with stable treatment are not exclusionary 5. Concurrent Study Participation
Currently enrolled in another interventional clinical trial testing nutritional interventions, dietary supplements, or appetite stimulants
Rationale: Concurrent nutritional interventions would confound outcome assessment
Note: Participation in observational studies, cancer treatment trials (chemotherapy, radiation), or non-nutritional supportive care trials is permitted 6. Pregnancy or Lactation
Pregnant women (confirmed by urine or serum pregnancy test if reproductive potential)
Breastfeeding/lactating women
Rationale: Pregnancy and lactation have substantially different and increased nutritional requirements that require specialized prenatal/postnatal nutritional counseling beyond the scope of cancer cachexia management in this protocol 7. Severe Food Allergies or Intolerances
Known severe allergy or intolerance to recommended nutritional supplements (oral nutrition supplements, protein powders, vitamins/minerals) for which no suitable alternatives are available in Pakistan
Note: Common food allergies (dairy, eggs, nuts) are not exclusionary as alternative food sources can be recommended 8. Logistical Barriers
Unable to attend baseline assessment visit (Week 0) at King Edward Medical University/Mayo Hospital, Lahore
Unable to attend final assessment visit (Week 12) at the hospital
For telemedicine group: Complete inability to access internet or use smartphone/tablet even with family assistance
No reliable means of contact (no phone number, no address) 9. Other
Enrolled in this study previously (re-enrollment not permitted)
Non-cancer-related causes of weight loss that would confound cachexia assessment:
Any condition that, in the opinion of the principal investigator, would compromise patient safety, study integrity, or ability to complete study procedures