Revisiting Cancer Cachexia Staging: Introducing an "At Risk" Category Based on AWGC Components

Cancer cachexia is a multifactorial syndrome characterized by progressive weight loss, muscle wasting, and systemic inflammation. Early identification of individuals at risk for cachexia is essential for timely intervention, yet a universally accepted definition of the "at risk" stage remains lacking. Building on the Asian Working Group for Cachexia (AWGC) framework, we propose that the presence of any one of the five components-low BMI (< 21 kg/m²), weight loss ≥ 2% over 3-6 months, anorexia, low handgrip strength, or elevated CRP levels-may indicate vulnerability to cachexia. We evaluated the prognostic value of this definition in a cohort of 364 patients with palliative cancer. The patients were categorized into three groups: non-cachectic, at risk, and cachectic. Survival analyses demonstrated significant differences across groups (p = 0.005), with the median overall survival not reached in the non-cachectic group, 381 days in the at-risk group, and 157 days in the cachectic group. While low BMI and weight loss were not associated with survival in patients with edema, they became evident in those without edema (HR = 1.54 and 1.58), highlighting the confounding role of fluid retention in anthropometric assessment. Anorexia, low handgrip strength, and elevated CRP levels independently predicted poor prognosis in both full and non-edematous cohorts. These findings support the clinical relevance of an "at risk" category based on AWGC components, especially in patients without edema. This simple and pragmatic definition may facilitate the early identification of patients who could benefit from supportive interventions before cachexia becomes refractory.