Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer

A New weighted scoring system for Subjective Global Assessment

OBJECTIVE

Subjective Global Assessment (SGA) is a widely used and validated method for identifying and classifying malnutrition. Recently, in effort to assess nutritional status more accurately, quantitative systems have been devised in which scores are assigned for items or components of the SGA. In addition to validation of conventional SGA in our patient population, this prospective study investigated the association of a recently devised quantitative SGA (Q-SGA) method and an invented modified Q-SGA (MQ-SGA) scoring system with conventional SGA.

METHODS

A total of 2197 patients was evaluated. Each subject was assessed for malnutrition by SGA, anthropometric measurements, and laboratory testing. The items of SGA were scored by assigning 1 point for each increasing severity level to obtain the Q-SGA score. In the invented MQ-SGA system, the items were entered into the logistic regression model and weighted scores were calculated according to the weighted effect of the SGA items. The efficiencies of Q-SGA and MQ-SGA were compared to predict malnutrition according to SGA.

RESULTS

Eighty-nine percent of patients were classified as well nourished according to conventional SGA, whereas 27 patients (1.2%) were classified as severely malnourished. When patients were grouped according to binary SGA outcome (well nourished versus malnourished), receiver operating characteristics curve areas for the Q-SGA and MQ-SGA scores were 0.897 (95% confidence interval = 0.875-0.919) and 0.952 (95% confidence interval = 0.939-0.964), respectively. The cutoff points for Q-SGA and MQ-SGA were identified as 10 and 18, respectively. Although the sensitivity of these systems in identifying malnutrition were similar (90.0% and 90.9%, respectively), the specificity of MQ-SGA was greater than that of Q-SGA (85.6% versus 67.0%).

CONCLUSIONS

The findings suggest that MQ-SGA outperforms Q-SGA in identifying malnutrition according to SGA. Future nutrition scoring studies need to take into account the weighted effects of items on outcome.

Poor nutritional status prior to peripheral blood stem cell transplantation is associated with increased length of hospital stay

The nutritional status of patients prior to peripheral blood stem cell transplantation (PBSCT) and its impact on length of hospital stay is not well described in the literature. The nutritional status of 66 consecutive patients (46 m:20 f); and the mean age 58.7+/-12.0 years was determined a maximum of 2 weeks pre-transplantation using the scored Patient-Generated-Subjective Global Assessment (PG-SGA). According to the global assessment, 73% patients were well nourished, 23% moderately malnourished and 4% severely malnourished. There was a significant difference in post transplant length of stay (mean difference+/-s.e.m. -7.0+/-2.1 days) between well-nourished and malnourished patients and a trend towards higher mortality in the malnourished group (2 vs 20%). Although 89% of patients described no problems eating, two or more nutrition impact symptoms were reported in 30% of patients. From stepwise multiple regression analysis, nutritional status as determined by PG-SGA score was significantly associated with length of stay, accounting for 12% of the variance. In conclusion, malnutrition prior to PBSCT is associated with increased length of stay. Routine nutrition assessment of patients prior to PBSCT should be undertaken.

Prognostic significance of Subjective Global Assessment (SGA) in advanced colorectal cancer

OBJECTIVE

To evaluate the prognostic significance of Subjective Global Assessment (SGA) in advanced colorectal cancer and create statistically distinct prognostic groups of colorectal cancer patients based on clinical and nutritional variables.

DESIGN

A retrospective clinical epidemiologic study.

SETTING

A private tertiary care American Cancer Center.

SUBJECTS

In total, 234 colorectal cancer patients aged 29-82 y treated at Cancer Treatment Centers of America at Midwestern Regional Medical Center between January 1995 and March 2001.

INTERVENTION

SGA Questionnaire. SGA A-well nourished; SGA B-moderately malnourished; and SGA C-severely malnourished. Malnutrition was defined as either SGA B or SGA C.

RESULTS

The prevalence of malnutrition in this patient population, as determined by SGA, was 52% (113/217). The median survival of patients with SGA A was 12.8 months (95% CI; 9.1-16.5), those with SGA B was 8.8 months (95% CI; 6.7-10.9) and those with SGA C was 6 months (95% CI; 3.9-8.1); the difference being statistically significant at P=0.0013. Regression tree analysis identified prior treatment history, lactate dehydrogenase (LDH) and SGA to be important predictors of survival for our patient cohort. Patients with no prior treatment history (newly diagnosed disease), low LDH scores, and SGA A had the best overall survival of 40.4 months (95% CI; 30.45-50.4), whereas patients with prior treatment history (progressive disease), high LDH scores, and SGA B/C had the worst overall survival of 4.5 months (95% CI; 2.22-6.76).

CONCLUSION

The SGA provides useful prognostic information in patients with advanced colorectal cancer.

Assessment of nutritional status in hemodialysis patients using patient-generated subjective global assessment

OBJECTIVE

To evaluate the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in hemodialysis patients.

DESIGN

A cross-sectional observational study assessing the nutritional status of hemodialysis patients.

SETTING

Private tertiary Australian hospital.

SUBJECTS

Sixty patients, ages 63.9 +/- 16.2 years.

INTERVENTION

Scored PG-SGA questionnaire, comparison of PG-SGA score > or =9 with subjective global assessment (SGA), albumin, corrected arm muscle area, and triceps skinfold.

RESULTS

According to SGA, 80% of patients were well nourished and 20% of patients were malnourished. Patients classified as well nourished (SGA-A) attained a significantly lower median PG-SGA score compared with those rated as moderately malnourished or at risk of malnutrition (SGA-B). A PG-SGA score > or =9 had a sensitivity of 83% and a specificity of 92% at predicting SGA classification. There were significant correlations between the PG-SGA score and serum albumin, PG-SGA score, and percentage weight loss over the past 6 months. There was no association between PG-SGA score and body mass index or anthropometric measurements.

CONCLUSION

The scored PG-SGA is an easy-to-use nutrition assessment tool that allows quick identification of malnutrition in hemodialysis patients.

Nutritional screening and assessment tools for use by nurses: literature review

AIM

This paper reports a literature review describing the range of published tools available for use by nurses to screen or assess nutritional status of patients/clients, and to examine whether the validity, reliability, sensitivity, specificity and acceptability of the tool have been investigated. Tools developed specifically for use with older adults are not considered in this review. A screening/assessment tool is described as a tool that uses a questionnaire-type format, contains more than one risk factor for malnutrition and gives an assessment of risk.

BACKGROUND

The incidence of malnutrition in people cared for by nurses is high and screening or assessment tools are often used to identify those with, or at risk of, malnutrition.

METHODS

A comprehensive literature review methodology was employed. A range of electronic databases was searched from 1982 to 2002. Search terms incorporating "nutrition", "screening", assessment, feeding, instrument, tool, validity, reliability, sensitivity and specificity were combined. Manual searches were also conducted.

RESULTS

Seventy-one nutritional screening/assessment tools were identified of which 35 were reviewed. Tools not reviewed included those which incorporated significant use of biochemical measures (8), included complex anthropometric measures (3), were concerned specifically with ingestion (4) or were designated for use with an older population (21). The tools reviewed use a wide variety of risk factors for malnutrition, varying from anthropometric measurements to socio-cultural aspects of eating behaviour. Some identify an action plan based on the score obtained. Many have not been subjected to validity and/or reliability testing and yet appear to be in use in clinical practice. The sensitivity, specificity and acceptability of the tools are often not investigated.

CONCLUSION

There are many published nutritional screening/assessment tools available for use by nurses to screen or assess the nutritional status of patients/clients. Many have not been subject to rigorous testing. Future work should consider a more standardized approach to the use of these tools.

Bioelectrical impedance phase angle as a prognostic indicator in advanced pancreatic cancer

Bioelectrical impedance analysis (BIA) is an easy-to-use, non-invasive and reproducible technique to evaluate changes in body composition and nutritional status. Phase angle, determined by BIA, has been found to be a prognostic indicator in several chronic conditions, such as HIV, liver cirrhosis, chronic obstructive pulmonary disease and lung cancer, and in patients undergoing dialysis. The present study investigated the prognostic role of phase angle in advanced pancreatic cancer. We evaluated a case series of fifty-eight stage IV pancreatic cancer patients treated at Cancer Treatment Centers of America at Midwestern Regional Medical Center (Zion, IL, USA) between January 2000 and July 2003. BIA was conducted on all patients using a bioelectrical impedance analyser that operated at 50 kHz. The phase angle was calculated as capacitance (Xc)/resistance (R) and expressed in degrees. The Kaplan-Meier method was used to calculate survival. Cox proportional hazard models were constructed to evaluate the prognostic effect of phase angle independent of other clinical and nutritional variables. The correlations between phase angle and traditional nutritional measures were evaluated using Pearson and Spearman coefficients. Patients with phase angle <5.0 degrees had a median survival time of 6.3 (95% CI 3.5, 9.2) months (n 29), while those with phase angle >5.0 degrees had a median survival time of 10.2 (95% CI 9.6, 10.8) months (n 29); this difference was statistically significant (P=0.02). The present study demonstrates that phase angle is a strong prognostic indicator in advanced pancreatic cancer. Similar studies in other cancer settings with larger sample sizes are needed to further validate the prognostic significance of the phase angle.

Bioelectrical impedance phase angle in clinical practice: implications for prognosis in advanced colorectal cancer

BACKGROUND

Phase angle, determined by bioelectrical impedance analysis (BIA), detects changes in tissue electrical properties and has been found to be a prognostic indicator in several chronic conditions-such as HIV, liver cirrhosis, chronic obstructive pulmonary disease, and lung cancer-and in patients receiving dialysis.

OBJECTIVE

This study was conducted to investigate the prognostic role of phase angle in advanced colorectal cancer.

DESIGN

We evaluated a case series of 52 patients with histologically confirmed stage IV colorectal cancer. BIA was conducted on all patients and phase angle was calculated. The Kaplan-Meier method was used to calculate survival. Cox proportional hazard models were constructed to evaluate the prognostic effect of phase angle independent of other clinical and nutritional variables.

RESULTS

Patients with a phase angle < or =5.57 had a median survival of 8.6 mo (95% CI: 4.8, 12.4; n=26), whereas those with a phase angle >5.57 had a median survival of 40.4 mo (95% CI: 21.9, 58.8; n=26; P=0.0001).

CONCLUSION

Phase angle is a prognostic indicator in patients with advanced colorectal cancer. Similar studies of other cancer types with larger sample sizes are needed to further validate the prognostic significance of phase angle in cancer treatment settings.

Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area

Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51M : 9F; mean age 61.9±14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.

Baseline Nutritional Assessment in Advanced Cancer Patients Receiving Palliative Chemotherapy

Depletion of nutritional reserves and significant weight loss can lead to an increased risk of morbidity, reduced chemotherapy response, and shorter survival in patients with cancer. Weight loss and malnutrition are recognized to result from multifactorial processes, which if assessed and managed appropriately may lead to improved treatment outcome. Numerous methodologies are used for the assessment of nutritional status. However, it remains unclear which of these tools is the most appropriate in the setting of cancer chemotherapy. The aim of this study was to investigate the use of various fundamental assessment tools that could be applied to the routine clinical evaluation of nutritional status in patients with advanced solid malignancies before treatment with palliative chemotherapy. We investigated the interrelationships between biochemical indices, anthropometric measures, and a nutritional screening tool, the Mini-Nutritional Assessment, in 73 patients. Many of these measures were highly interrelated, but the baseline history of weight loss in these patients was strongly correlated to the Mini-Nutritional Assessment (MNA) score (P < 0.0005). In turn, baseline weight loss and the MNA score were strongly correlated to serum C-reactive protein (a marker of acute-phase response). In some patients, malnutrition was linked to disease- or treatment-related upper digestive tract morbidity. Testing for the serum concentration of C-reactive protein at baseline may identify a subset of patients for whom a decline in nutritional status is linked to the presence of an active inflammatory response, a recognized precursor of cachexia

The scored Patient-generated Subjective Global Assessment (PG-SGA) and its association with quality of life in ambulatory patients receiving radiotherapy

OBJECTIVE

To evaluate the scored Patient-generated Subjective Global Assessment (PG-SGA) tool as an outcome measure in clinical nutrition practice and determine its association with quality of life (QoL).

DESIGN

A prospective 4 week study assessing the nutritional status and QoL of ambulatory patients receiving radiation therapy to the head, neck, rectal or abdominal area.

SETTING

Australian radiation oncology facilities.

SUBJECTS

Sixty cancer patients aged 24-85 y.

INTERVENTION

Scored PG-SGA questionnaire, subjective global assessment (SGA), QoL (EORTC QLQ-C30 version 3).

RESULTS

According to SGA, 65.0% (39) of subjects were well-nourished, 28.3% (17) moderately or suspected of being malnourished and 6.7% (4) severely malnourished. PG-SGA score and global QoL were correlated (r=-0.66, P<0.001) at baseline. There was a decrease in nutritional status according to PG-SGA score (P<0.001) and SGA (P<0.001); and a decrease in global QoL (P<0.001) after 4 weeks of radiotherapy. There was a linear trend for change in PG-SGA score (P<0.001) and change in global QoL (P=0.003) between those patients who improved (5%) maintained (56.7%) or deteriorated (33.3%) in nutritional status according to SGA. There was a correlation between change in PG-SGA score and change in QoL after 4 weeks of radiotherapy (r=-0.55, P<0.001). Regression analysis determined that 26% of the variation of change in QoL was explained by change in PG-SGA (P=0.001).

CONCLUSION

The scored PG-SGA is a nutrition assessment tool that identifies malnutrition in ambulatory oncology patients receiving radiotherapy and can be used to predict the magnitude of change in QoL.