Cancer anorexia–cachexia syndrome is a complex metabolic disorder defined by progressive weight loss and the selective depletion of skeletal muscle, with or without loss of fat tissue. It is far more than simple malnutrition: the syndrome is not fully reversible with conventional nutritional support, and it is closely linked to shortened survival, increased treatment-related toxicity, poor adherence to anticancer therapy, and a marked deterioration in quality of life. For patients with hepatocellular carcinoma, the predominant form of liver cancer and the third leading cause of cancer death worldwide, the problem is especially acute. Approximately one-third of HCC patients already show pre-cachexia at diagnosis, and nearly one in four meets full criteria for cachexia.

The burden is concentrated in the patient population this new trial targets. According to the Barcelona Clinic Liver Cancer staging system, the prevalence of cachexia reaches 23.5 percent among those with stage B disease and 34.7 percent among those with stage C, the advanced stages where curative options have typically been exhausted. Anorexia affects an estimated 50 to 60 percent of HCC patients undergoing transarterial chemoembolization, and roughly 35 percent of those receiving systemic targeted therapy develop cachexia, which has been recognized as an independent adverse prognostic factor for both overall and progression-free survival.

The standard-of-care context is important. For patients with BCLC stage B or C hepatocellular carcinoma, locoregional interventions such as transarterial chemoembolization, in which chemotherapy is delivered directly to the tumor through the hepatic artery followed by embolization of its blood supply, or hepatic arterial infusion chemotherapy, can be combined with systemic agents including tyrosine kinase inhibitors, antiangiogenic drugs, and immune checkpoint inhibitors. These combinations may enhance tumor control and prolong survival. Yet patients who lose weight during treatment generally fare worse, creating an urgent need to protect appetite and body composition while antitumor therapy proceeds.

The drug under investigation is megestrol acetate, a progestational agent widely regarded as a key pharmacological option for cancer-related wasting because of its well-documented effects on appetite stimulation and weight gain. Progestogens are thought to suppress inflammatory cytokines through humoral and neuroregulatory mechanisms, thereby enhancing appetite and promoting weight gain, and animal studies have shown that megestrol acetate stimulates food intake through effects on hypothalamic neuropeptide pathways. Dose–response data from a randomized trial of cancer cachexia patients testing 160, 480, 800, and 1,280 milligrams per day found the greatest improvements in appetite and weight at 800 milligrams daily.

But conventional megestrol acetate has a fundamental pharmaceutical flaw. It is classified as a Biopharmaceutics Classification System class II drug, meaning its dissolution in the gut and subsequent oral bioavailability are strongly influenced by whether the drug is taken with food. Systemic exposure is substantially lower under fasting conditions than fed conditions, producing unpredictable drug levels in patients who, by the nature of their disease, often eat erratically or not at all. The nanocrystalline formulation, delivered as an oral suspension, is designed to reduce this food-dependent variability in absorption. In pharmacokinetic studies, 625 milligrams of nanocrystalline megestrol acetate achieved exposure comparable to 800 milligrams of the conventional formulation under fed conditions, and greater exposure under fasting conditions, although investigators caution these findings do not by themselves establish clinical dose equivalence.

Early clinical signals have been encouraging. A prospective real-world study in China compared nanocrystalline megestrol acetate at 625 milligrams per day with the conventional 800-milligram formulation, both given continuously for 12 weeks, in patients with cancer anorexia–cachexia syndrome. At week 12, the nanocrystalline group achieved a mean weight gain of 4.49 kilograms versus 2.10 kilograms in the conventional group, a mean difference of 2.39 kilograms that was highly statistically significant. Patients on the nanocrystalline drug also showed significantly greater improvements in anorexia, nausea and vomiting, and overall health status. What remains unknown, and what the new trial is designed to determine, is whether these benefits translate into meaningful clinical gains when layered on top of combined systemic and interventional anticancer therapy in HCC patients.

The trial design is a prospective, multicenter, randomized, open-label, parallel-group Phase II study that will enroll 68 adults aged 18 to 75 years with BCLC stage B or C hepatocellular carcinoma who meet protocol-defined criteria for pre-cachexia or cachexia. Participants will be stratified by tumor stage and by the percentage of weight loss during the previous six months, then randomized 1:1 to receive either nanocrystalline megestrol acetate at 625 milligrams per day for 12 weeks alongside antitumor therapy, or antitumor therapy alone. Because no placebo suspension is used, participants and treating investigators will not be blinded, but the imaging and body-composition assessors and the statisticians will remain blinded to treatment allocation. Enrollment is planned from March 2026 to March 2028, followed by 12 months of follow-up after the last participant is enrolled.

The diagnostic thresholds are grounded in international consensus definitions. Pre-cachexia requires anorexia, non-volitional weight loss of up to 5 percent, and systemic inflammation marked by C-reactive protein above 5 milligrams per liter. Cachexia is defined by anorexia or systemic inflammation combined with either non-volitional weight loss exceeding 5 percent within six months, or a body mass index below 18.5 kilograms per square meter with weight loss exceeding 2 percent. The co-primary endpoints at week 12 are the proportion of responders on the Anorexia/Cachexia Subscale-12 questionnaire, defined as a gain of at least 4 points from baseline, and the proportion of body mass index responders, defined as any increase from baseline. Secondary endpoints include objective tumor response by modified RECIST criteria, one-year progression-free survival, changes in the L3 skeletal muscle index measured on CT or MRI, and adverse event rates, with exploratory endpoints tracking inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha, nutritional markers including albumin and hemoglobin, and quality of life via the EORTC QLQ-C30 questionnaire.

The investigators are candid about the study’s limitations. The antitumor regimens are not fully standardized, potentially introducing heterogeneity into efficacy outcomes; the open-label design may bias patient-reported appetite and quality-of-life measures; the sample size limits subgroup analyses; and body mass index can be distorted by ascites and fluid retention in HCC patients, which is why the protocol specifies estimated dry-weight corrections for ascites and edema and pairs BMI with objective muscle measurements at the third lumbar vertebra. The sample size of 68, allowing for 15 percent attrition, was powered at 80 percent with a one-sided alpha of 0.025 to detect appetite response rates of 50 percent versus 15 percent and BMI response rates of 40 percent versus 10 percent. With ethics approval from West China Hospital and registration on ClinicalTrials.gov, the study represents a serious attempt to bring a nanotechnology-enabled formulation to bear on a syndrome that has long resisted treatment, and its results could reshape how clinicians support patients through the most vulnerable phase of advanced liver cancer therapy.

Subject of Research: Nanocrystalline megestrol acetate for cancer cachexia in advanced hepatocellular carcinoma

Article Title: NMA plus antitumor therapy versus antitumor therapy alone in patients with BCLC stage B or C hepatocellular carcinoma and pre-cachexia or cachexia: protocol for a prospective, multicenter, randomized, open-label phase II trial

Article References: Dai, R., Lu, F., Leng, W., He, Q., Guo, W., Hai, T., & Liu, C. (2026). NMA plus antitumor therapy versus antitumor therapy alone in patients with BCLC stage B or C hepatocellular carcinoma and pre-cachexia or cachexia: protocol for a prospective, multicenter, randomized, open-label phase II trial. Frontiers in Gastroenterology, 5, Article 1926294. https://doi.org/10.3389/fgstr.2026.1926294

Image Credits: AI Generated

DOI: 10.3389/fgstr.2026.1926294

Keywords: cancer cachexia, hepatocellular carcinoma, nanocrystalline megestrol acetate, BCLC stage B and C, randomized controlled trial, transarterial chemoembolization, hepatic arterial infusion chemotherapy, anorexia-cachexia syndrome, skeletal muscle index, clinical trial protocol, nutritional intervention, liver cancer