Prevalence of malnutrition and current use of nutrition support in patients with cancer

Geriatric nutritional risk index as a prognostic factor in patients with diffuse large B cell lymphoma

The geriatric nutritional risk index (GNRI) is a simple and well-established nutritional assessment tool that is a significant prognostic factor for various cancers. However, the role of the GNRI in predicting clinical outcomes of diffuse large B cell lymphoma (DLBCL) patients has not been investigated. To address this issue, we retrospectively analyzed a total of 476 patients with newly diagnosed de novo DLBCL. We defined the best cutoff value of the GNRI as 96.8 using a receiver operating characteristic curve. Patients with a GNRI < 96.8 had significantly lower overall survival (OS) and progression-free survival (PFS) than those with a GNRI ≥ 96.8 (5-year OS, 61.2 vs. 84.4%, P < 0.001; 5-year PFS, 53.7 vs. 75.8%, P < 0.001). Multivariate analysis showed that performance status, Ann Arbor stage, serum lactate dehydrogenase, and GNRI were independent prognostic factors for OS. Among patients with high-intermediate and high-risk by National Comprehensive Cancer Network-International Prognostic Index (NCCN-IPI), the 5-year OS was significantly lower in patients with a GNRI < 96.8 than in those with a GNRI ≥ 96.8 (high-intermediate risk, 59.5 vs. 75.2%, P = 0.006; high risk, 37.4 vs. 64.9%, P = 0.033). In the present study, we demonstrated that the GNRI was an independent prognostic factor in DLBCL patients. The GNRI could identify a population of poor-risk patients among those with high-intermediate and high-risk by NCCN-IPI.

The determinants of reduced dietary intake in hospitalised colorectal cancer patients

Purpose

Patients with colorectal cancer (CRC) often experience malnutrition and weight loss, largely resulting from reduced dietary intake. The aim of this study was to identify determinants of reduced dietary intake in order to facilitate early recognition of malnutrition and optimise nutritional treatment.

Methods

Data from nutritionDay, an international 1-day survey investigating patient, disease and food profiles, were used. To identify determinants of dietary intake, defined as normal vs. reduced in the last week, univariate and multivariate logistic regressions were performed.

Results

Of 1131 hospitalised CRC patients, 54% reported reduced dietary intake. Patient- and disease-related characteristics significantly associated with reduced dietary intake were female gender (odds ratio (OR) 1.38), cancer stage III (OR 1.52) or IV (OR 1.70) vs. I, performance status 2 (OR 1.56), 3 (OR 2.37) or 4 (OR 4.15) vs. 0, duration since hospital admission of ≥ 4 days (OR 4–7 days, 1.91; 8–21 days, 1.97; > 21 days, 1.92) vs. < 4 days, and unintentional weight loss (OR 2.56). Additionally, higher symptom scores of pain, weakness, depression, tiredness and lack of appetite were associated with reduced intake.

Conclusions

Patient- and disease-related determinants for reduced dietary intake were being female, higher cancer stage, worse performance status, duration since hospital admission ≥ 4 days and unintentional weight loss. Furthermore, multiple symptoms were associated with a reduced dietary intake. Future trials should assess whether early recognition of patients at risk of malnutrition and the combination of treating symptoms and dietary advice result in improved intake and treatment-related outcomes.

Cancer-associated cachexia

Cancer-associated cachexia is a disorder characterized by loss of body weight with specific losses of skeletal muscle and adipose tissue. Cachexia is driven by a variable combination of reduced food intake and metabolic changes, including elevated energy expenditure, excess catabolism and inflammation. Cachexia is highly associated with cancers of the pancreas, oesophagus, stomach, lung, liver and bowel; this group of malignancies is responsible for half of all cancer deaths worldwide. Cachexia involves diverse mediators derived from the cancer cells and cells within the tumour microenvironment, including inflammatory and immune cells. In addition, endocrine, metabolic and central nervous system perturbations combine with these mediators to elicit catabolic changes in skeletal and cardiac muscle and adipose tissue. At the tissue level, mechanisms include activation of inflammation, proteolysis, autophagy and lipolysis. Cachexia associates with a multitude of morbidities encompassing functional, metabolic and immune disorders as well as aggravated toxicity and complications of cancer therapy. Patients experience impaired quality of life, reduced physical, emotional and social well-being and increased use of healthcare resources. To date, no effective medical intervention completely reverses cachexia and there are no approved drug therapies. Adequate nutritional support remains a mainstay of cachexia therapy, whereas drugs that target overactivation of catabolic processes, cell injury and inflammation are currently under investigation.

Occurrence of Malnutrition and Associated Factors in Community-Dwelling Older Adults: Those with a Recent Diagnosis of Cancer Are at Higher Risk

OBJECTIVES

In older adults, nutritional health is essential for good quality of life and living independently at home. Especially in cancer patients, malnutrition is common and known to complicate treatment. This study aims to evaluate the nutritional status and its associated factors in community-dwelling older adults with and without cancer.

DESIGN

This is an observational study.

SETTING

This study focuses on older community-dwelling people.

PARTICIPANTS

This study included older people with and without cancer (≥70 years). Cancer patients included patients with a new diagnosis of breast, lung, prostate, or colorectal cancer.

MEASUREMENTS

Data collection included measures of nutritional status, quality of life, depression, fatigue, distress and functional status. We used multivariate logistic regression analysis to assess the association between personal characteristics and malnutrition.

RESULTS

Data were available for 657 people; 383 people without cancer and 274 with a cancer diagnosis. Overall, malnutrition was detected in 245 (37.5%) people; in cancer patients this was 66.1%. Multivariate analysis showed that having cancer (OR 14.4, 95% CI: 8.01 - 23.3), being male (OR 2.38, 95% CI: 1.49 - 3.70), having depression (OR 13.5, 95% CI: 6.02-30.0), distress (OR 2.60, 95% CI: 1.55 - 4.37) and impaired instrumental activities of daily living (IADL) (OR 2.63, 95% CI: 1.63 - 4.24) were associated with a higher risk of malnutrition.

CONCLUSION

The prevalence of malnutrition in community-dwelling older people is high, particularly in patients with cancer. Benchmarking and routine screening of older patients may be helpful strategies to increase awareness of (risk of) malnutrition among professionals.

Feasibility of systematic handgrip strength testing in digestive cancer patients treated with chemotherapy: The FIGHTDIGO study

BACKGROUND

Handgrip strength (HGS) is a widely studied noninvasive test. Weak strength (dynapenia) seems to be associated with high morbidity and mortality in different populations, notably oncology populations. Despite this, HGS testing is not used in daily practice in oncology. The study was aimed at evaluating the feasibility and acceptability of HGS testing in patients with digestive cancer treated with ambulatory chemotherapy.

METHODS

In this prospective, single-center study, enrolled patients were followed for 6 months. Two consecutive bilateral measures were performed with a Jamar dynamometer during each patient's appointments in the unit for intravenous treatment. A questionnaire was completed by patients and medical team members.

RESULTS

There were 203 consecutive patients, and 201 were recruited. In all, 1704 of 1716 measurements (99.3%) were performed, and 201 patients (99.0%) performed at least 1 measure; 190 (94.5%) performed all expected measures. One hundred sixty-four of 171 participating patients (95.9%) found the test easy to perform, and 167 (97.7%) did not find the test restrictive. All of the 14 medical team members found the test easy to perform, unrestrictive, and undisruptive in their daily practice.

CONCLUSIONS

HGS testing is routinely feasible, inexpensive, and well accepted by patients and medical teams in an ambulatory digestive cancer unit. Cancer 2018;124:1501-6. © 2017 American Cancer Society.

The red distribution width and the platelet distribution width as prognostic predictors in gastric cancer

Background

Increasing attention is focused on the relationship of inflammation biomarkers with malignant tumors. The purpose of the present study was to detect whether the preoperative the red distribution width (RDW) and the platelet distribution width (PDW) can be used to distinguish patients with gastric cancer (GC) or early stage GC from the healthy controls and predict the progression and prognosis of the GC.

Methods

The RDW and PDW values of 227 patients with GC and 164 patients with early GC were retrospectively analyzed comparing with 101 healthy controls. In addition, the clinicopathological features, survival curves and prognosis of the patients with GC were compared between the high and low groups according to the RDW and PDW values.

Results

Significant higher RDW and lower PDW were detected in patients with GC and early GC compared to the healthy controls. A higher RDW was significantly associated with older age, a larger tumor diameter, deeper tumor infiltration, and lymph node metastasis while a lower PDW was significantly associated with male, older age, a larger tumor diameter, deeper tumor infiltration, elevated CEA and CA125. Increased RDW was significantly associated with worse overall survival (OS) and disease-free survival (DFS) for GC (P = 0.042 and P = 0.033, respectively) and early GC (P = 0.037 and P = 0.009, respectively) while decreased PDW indicated a significantly association with poor DFS for early GC (P = 0.006). Univariate and multivariate survival analysis showed that RDW and PDW can act as independent prognostic factors for DFS (P = 0.028 and P = 0.020) in patients with early GC.

Conclusion

The preoperative RDW and PDW were simple and convenient predictive factors for the progression and prognosis of patients with GC.

Malnutrition in Patients With Cancer: Comparison of Perceptions by Patients, Relatives, and Physicians-Results of the NutriCancer2012 Study

BACKGROUND

Malnutrition is a critical predictor of toxicity and outcome in patients with cancer and may be perceived differently by patients, relatives, and physicians.

AIMS

To assess the prevalence of malnutrition in oncology departments and to compare it with the perceptions of nutrition status by patients themselves, their closest relatives, and attending physicians.

MATERIALS AND METHODS

A 1-day multicentric cross-sectional survey on the prevalence of malnutrition was conducted in different oncology departments using patient-, relative-, and physician-specific questionnaires. Malnutrition was defined by a weight loss ≥5% within 1 month or ≥10% within 6 months, a body mass index ≤18.5 kg/m² in patients aged <70 years or ≤21 kg/m² in patients aged ≥70 years, and/or albuminemia <35 g/L. Questionnaires for assessing medical condition, knowledge of nutrition status, and perceptions of the impact of malnutrition on daily life were distributed to consenting patients, attending physicians, and closest relatives.

RESULTS

A total of 2197 patients were included, and 2071 and 976 questionnaires were collected from patients and relatives, respectively. Prevalence of malnutrition was 39%. Physicians overestimated malnutrition (44%), whereas patients and relatives underestimated it (22% and 23%, respectively, P < .001). Conversely, malnutrition-associated symptoms were underestimated by physicians compared with patients and relatives.

CONCLUSION

We found a prevalence of malnutrition of 39%: it was underestimated by patients and relatives and overestimated by physicians.

[Crossed perceptions about malnutrition in patients and their doctors in oncology]

Malnutrition is common in oncology. However, it is often detected too late and nutritional support is sub-optimal. The patient's opinion, although often sought in therapeutic decisions in oncology, does not appear to be frequently taken into account in dietetic management. In NutriCancer2012 study, we interviewed patients, relatives and doctors about their perceptions of the impact of malnutrition and its quality of care. Of the 2209 patients questioned, majority said they were concerned about nutrition with 75% considering it essential to take appropriate nutritional care but only 19% self-reported link between malnutrition and fatigue. Physicians underestimated impact of malnutrition on patient's "quality of life". Doctors referred to the lack of human resources and knowledge in nutrition, and more than 80% wished the creation of nutrition teams. Sensitization of the general public and patients (and relatives) as soon as the cancer diagnosis could lead to better malnutrition's screening. Better nutrition training for physicians and creation of nutrition team could optimize management and improve efficacy during cancer treatments.

Nutritional counseling with or without systematic use of oral nutritional supplements in head and neck cancer patients undergoing radiotherapy

BACKGROUND

To evaluate the benefit of oral nutritional supplements (ONS) in addition to nutritional counseling in head and neck cancer (HNC) patients undergoing radiotherapy (RT).

METHODS

In a single-center, randomized, pragmatic, parallel-group controlled trial (ClinicalTrials.gov: NCT02055833; February 2014-August 2016), 159 newly diagnosed HNC patients suitable for to RT regardless of previous surgery and induction chemotherapy were randomly assigned to nutritional counseling in combination with ONS (N = 78) or without ONS (N = 81) from the start of RT and continuing for up to 3 months after its end. Primary endpoint was the change in body weight at the end of RT. Secondary endpoints included changes in protein-calorie intake, muscle strength, phase angle and quality of life and anti-cancer treatment tolerance.

RESULTS

In patients with the primary endpoint assessed (modified intention-to-treat population), counseling plus ONS (N = 67) resulted in smaller loss of body weight than nutritional counseling alone (N = 69; mean difference, 1.6 kg [95%CI, 0.5-2.7]; P = 0.006). Imputation of missing outcomes provided consistent findings. In the ONS-supplemented group, higher protein-calorie intake and improvement in quality of life over time were also observed (P < 0.001 for all). The use of ONS reduced the need for changes in scheduled anti-cancer treatments (i.e. for RT and/or systemic treatment dose reduction or complete suspension, HR=0.40 [95%CI, 0.18-0.91], P = 0.029).

CONCLUSION

In HNC patients undergoing RT or RT plus systemic treatment, and receiving nutritional counseling, the use of ONS resulted in better weight maintenance, increased protein-calorie intake, improved quality of life and was associated with better anti-cancer treatment tolerance.

Prevalence of malnutrition in patients at first medical oncology visit: the PreMiO study

BACKGROUND

In cancer patients, malnutrition is associated with treatment toxicity, complications, reduced physical functioning, and decreased survival. The Prevalence of Malnutrition in Oncology (PreMiO) study identified malnutrition or its risk among cancer patients making their first medical oncology visit. Innovatively, oncologists, not nutritionists, evaluated the nutritional status of the patients in this study.

METHODS

PreMiO was a prospective, observational study conducted at 22 medical oncology centers across Italy. For inclusion, adult patients (>18 years) had a solid tumor diagnosis, were treatment-naive, and had a life expectancy >3 months. Malnutrition was identified by the Mini Nutritional Assessment (MNA), appetite status with a visual analog scale (VAS), and appetite loss with a modified version of Anorexia-Cachexia Subscale (AC/S-12) of the Functional Assessment of Anorexia-Cachexia Therapy (FAACT).

FINDINGS

Of patients enrolled (N=1,952), 51% had nutritional impairment; 9% were overtly malnourished, and 43% were at risk for malnutrition. Severity of malnutrition was positively correlated with the stage of cancer. Over 40% of patients were experiencing anorexia, as reported in the VAS and FAACT questionnaire. During the prior six months, 64% of patients lost weight (1-10 kg).

INTERPRETATION

Malnutrition, anorexia, and weight loss are common in cancer patients, even at their first visit to a medical oncology center.

ESPEN expert group recommendations for action against cancer-related malnutrition

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.

"Systemic strategy at the patient's service": a congress report on supportive care in oncology

None.

Dietary Guidelines for Breast Cancer Patients: A Critical Review

Current dietary guidelines for breast cancer patients (BCPs) fail to address adequate dietary intakes of macro- and micronutrients that may improve patients' nutritional status. This review includes information from the PubMed and Biomed Central databases over the last 15 y concerning dietary guidelines for BCPs and the potential impact of a personalized, nutrient-specific diet on patients' nutritional status during and after antineoplastic treatment. Results indicated that BCPs should receive a nutritional assessment immediately after diagnosis. In addition, they should be encouraged to pursue and maintain a healthy body weight [body mass index (BMI; in kg/m²) 20-24.9], preserving their lean mass and avoiding an increase in fat mass. Therefore, after nutritional status diagnosis, a conservative energy restriction of 500-1000 kcal/d could be considered in the dietary intervention when appropriate. Based on the reviewed information, we propose a personalized nutrition intervention for BCPs during and after antineoplastic treatment. Specifications in the nutritional therapy should be based on the patients' nutritional status, dietary habits, schedule, activities, and cultural preferences. BCPs' daily energy intake should be distributed as follows: <30% fat/d (mainly monounsaturated and polyunsaturated fatty acids), ∼55% carbohydrates (primarily whole foods such as oats, brown rice, and fruits), and 1.2-1.5 g protein ⋅ kg^-1 ⋅ d^-1 to avoid sarcopenic obesity. Findings suggest that 5-9 servings/d of fruits (∼150 g/serving) and vegetables (∼75 g/serving) should be encouraged. Garlic and cruciferous vegetables must also be part of the nutrition therapy. Adequate dietary intakes of food-based macro- and micronutrients rich in β-carotene and vitamins A, E, and C can both prevent deterioration in BCPs' nutritional status and improve their overall health and prognosis.

Sarcopenia in gastric cancer: when the loss costs too much

Sarcopenia is a complex syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Malignancy is a major determinant of sarcopenia, and gastric cancer (GC) is among the most common causes of this phenomenon. As sarcopenia is a well-recognized poor prognostic feature in GC and has been associated with worse tolerance of surgical and medical treatments, members of the multidisciplinary team should be aware of the clinical relevance, pathogenic mechanisms, and potential treatments for this syndrome. The importance of sarcopenia is often underestimated in everyday practice and clinical trials, particularly among elderly or fragile patients. As treatment options are improving in all disease stages, deeper knowledge and greater attention to the metabolic balance in GC patients could further increase the benefit of novel therapeutic strategies and dramatically impact on quality of life. In this review, we describe the role of sarcopenia in different phases of GC progression. Our aim is to provide oncologists and surgeons dealing with GC patients with a useful tool for comprehensive assessment and timely management of this potentially life-threatening condition.

Pretreatment albumin level predicts survival in head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Poor nutritional status in patients with head and neck squamous cell carcinoma (HNSCC) is associated with tumor progression and survival. This study examined the prognostic value of nutritional and hematological markers in patients with HNSCC who received definitive treatments.

STUDY DESIGN

A prospective observational cohort study.

METHODS

This study included 338 consecutive patients who underwent surgery and/or radiotherapy/chemoradiotherapy for treatment-naïve HNSCC. Body weight and nutritional and hematological parameters were regularly measured before and after treatment. Univariate and multivariate analyses using Cox proportional hazards models were performed to identify factors associated with disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Body weight, serum total protein and albumin levels, and hematological variables significantly decreased after treatment. Univariate analyses illustrated that age, tumor site, T and N classifications, overall stage, pretreatment serum albumin (<3.5 g/dL) and hemoglobin (<12 g/dL) levels, and neutrophil-lymphocyte ratio were significantly associated with DFS, CSS, and OS (all P < .05). Multivariate analyses identified age, tumor site, N classification, and pretreatment albumin levels as independent predictors of DFS, CSS, and OS (all P < .05). Patients with low serum albumin levels prior to treatment experienced approximately sixfold increases in the risks of tumor progression and cancer-specific and overall mortality compared to the findings in their counterparts.

CONCLUSIONS

Our results suggest that pretreatment serum albumin levels predict DFS, CSS, and OS in patients who received definitive treatment for HNSCC. These findings might help to predict treatment outcome and guide nutritional intervention in patients with HNSCC.

LEVEL OF EVIDENCE

2b. Laryngoscope, 127:E437-E442, 2017.

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer

Background:

Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention.

Methods:

Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment.

Results:

Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported.

Conclusions:

The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes.

Cachexia Stage, Patient-Generated Subjective Global Assessment, Phase Angle, and Handgrip Strength in Patients with Gastrointestinal Cancer

The aim of this study was to correlate patients with gastrointestinal cancer, classified according to different stages of cancer cachexia (SCC) as proposed by Fearon, with nutritional assessment tools such as PG-SGA, phase angle (PA), and handgrip strength. One hundred one patients with a mean age of 61.8 ± 12.8 yr, with 58.4% being men were included. 32.6% were malnourished according to the body mass index (BMI). A severe or moderate malnutrition had been diagnosed in 63.3% when assessed using the PG-SGA, 60.4% had decreased handgrip strength, and 57.4% had lower grades of PA. Among the patients in the study, 26% did not have cachexia, 11% had precachexia, 56% cachexia, and 8% refractory cachexia. The PG-SGA, PA, and handgrip strength were associated with cachexia (P ≤ 0.001). An increased risk of death was found in patients with cachexia [RR: 9.1; confidence interval (CI) 95%: 0.1-90.2, P = 0.039], refractory cachexia (RR: 69.4, CI 95%: 4.5-1073.8, P = 0.002), and increased serum C-reactive protein (CRP) levels (P < 0.001). In conclusion, most of the patients with digestive system cancer had cachexia or refractory cachexia in the first nutritional assessment. Nutritional risk, as determined by PG-SGA, was correlated with PA and handgrip strength. High CRP levels, cachexia, and refractory cachexia were prognostic factors for cancer patients.

Sociodemographic and economic factors are associated with weight gain between before and after cancer diagnosis: results from the prospective population-based NutriNet-Santé cohort

Purpose

While many cancer patients are affected by weight loss, others tend to gain weight, which may impact prognosis and risk of recurrence and of second cancer. The aim of this prospective study was to investigate weight variation between before and after cancer diagnosis and socio-demographic, economic, lifestyle and clinical factors associated with moderate-to-severe weight gain.

Methods

1051 incident cases of first primary cancer were diagnosed in the NutriNet-Santé cohort between 2009 and 2015. Weight was prospectively collected every 6 months since subjects’ inclusion (i.e. an average of 2y before diagnosis). Mean weights before and after cancer diagnosis were compared with paired Student's t-test. Factors associated with moderate-to-severe weight gain (≥5% of initial weight) were investigated by age and sex-adjusted logistic regression.

Results

Weight loss was observed in men (-3.54±4.39kg in those who lost weight, p=0.0002) and in colorectal cancer patients (-3.94±4.40kg, p=0.001). Weight gain was observed in breast and skin cancers (2.83±3.21kg, p=0.04, and 2.96±2.75kg, p=0.04 respectively). Women (OR=1.75[1.06-2.87],p=0.03), younger patients (2.44[1.51-3.70],p<0.0001), those with lower income (OR=1.30[1.01-1.72],p-trend=0.007), lower education (OR=1.32[1.03-2.70],p-trend=0.03), excess weight before diagnosis (OR=1.64[1.12-2.42],p=0.01), lower physical activity (OR=1.28[1.01-1.64],p=0.04) and those who stopped smoking (OR=4.31[1.99-9.35],p=0.005]) were more likely to gain weight. In breast cancer patients, induced menopause was associated with weight gain (OR=4.12[1.76-9.67]), but no association was detected for tumor characteristics or treatments.

Conclusion

This large prospective cohort provided original results on weight variation between before and after cancer diagnosis, highlighting different weight trajectories. Socio-demographic and economic factors appeared to influence the risk of weight gain, illustrating social inequalities in health.

Nutritional status and quality of life of cancer patients needing exclusive chemotherapy: a longitudinal study

BACKGROUND

The aims of this study were to report nutritional status in a large panel of patients with cancer requiring exclusive chemotherapy and to study the influence of nutritional status on their quality of life (QoL).

METHODS

This work was a longitudinal cohort study performed at a French university teaching hospital. Eligible patients were individuals with a cancer needing treatment based on exclusive chemotherapy. Three work-ups were performed: i) before the administration of the first course of chemotherapy: T1, ii) before the administration of the second (for patients with 3 planned courses) or third (patients with 6 planned courses) course: T2, and iii) before the administration of the last planned course: T3. The following data were collected: general health (performance status) and nutritional status (weight, anorexia grading, albuminemia, pre-albuminemia, and C-reactive protein) and QoL.

RESULTS

The nutritional status of patients with cancer was preserved. Functional impairment, the presence of anorexia, the palliative nature of the chemotherapy, and an elevated C-reactive protein dosage were independent predictive factors of a lower QoL among patients assessed at the end of chemotherapy.

CONCLUSIONS

Although larger studies should corroborate these findings, clinicians may include this information in the management of patients with cancer requiring exclusive chemotherapy to identify the most vulnerable patients.

TRIAL REGISTRATION

Current controlled trials NCT01687335 (registration date: October 6, 2011).

Nutritional risk assessment and dietary guidance in postoperative patients with gastric cancer on chemotherapy

AIM

To investigate the nutritional status of postoperative patients with gastric cancer on chemotherapy and to provide timely dietary guidance and nutritional support for these patients.

METHODS

Patients who received curative resection for gastric cancer and were on chemotherapy at Department of Gastrointestinal Surgery of the First Affiliated Hospital of Zhengzhou University from September 2014 to March 2016 were included. The patients were assessed by unified training investigators within 48 h after hospitalization. The questionnaires such as the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and the Chemotherapy Side Effects of Patients with Gastric Cancer Questionnaire were used to assess the nutritional status of patients.

RESULTS

The difference in the nutritional status of patients on different stages of chemotherapy was statistically significant (P < 0.05). With the increase in the number of chemotherapy cycles, the nutritional status of patients became worse. Anorexia was the most common diet-related symptom, and the rates of anorexia in patients on early, medium and late stages of chemotherapy were 34.95%, 56.31%, and 75.73%, respectively. Patients acquired diet knowledge mainly from medical staff. The proportions of patients who acquired diet knowledge from medical staff on early, medium and late stages of chemotherapy were 92.23%, 79.61%, and 75.73%, respectively.

CONCLUSION

With the increase in the number of chemotherapy cycles, the nutritional status of patients becomes worse. Medical staff should provide timely, effective dietary guidance to improve the nutritional status and clinical outcome of patients.

Optimal Nutrition and Hydration Through the Surgical Treatment Trajectory

OBJECTIVES

To review oncology nurses role of informational continuity in regards to nutrition and hydration to ensure continuity of care from one care center to another.

DATA SOURCES

Peer-reviewed literature, PubMed, CINAHL, EMBASE, and web-based resources.

CONCLUSION

Optimal nutrition and hydration during cancer treatment and survivorship requires assessment and preplanning of needs. Oncology nurses play a vital role in preparing patients and caregivers for optimal nutrition during the surgical treatment trajectory.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses should emphasize nutrition planning during the surgical treatment trajectory to enhance survivorship and quality of life of the cancer patient. Educational resources exist for both nursing and cancer patients.

Assessment of Palliative Care in Lung Cancer in Turkey

OBJECTIVE

To investigate the symptoms of lung cancer in Turkey and to evaluate approaches to alleviate these symptoms.

SUBJECTS AND METHODS

This study included 1,245 lung cancer patients from 26 centers in Turkey. Demographic characteristics as well as information regarding the disease and treatments were obtained from medical records and patient interviews. Symptoms were evaluated using the Edmonton Symptom Assessment Scale (ESAS) and were graded on a scale between 0 and 10 points. Data were compared using the χ2, Student t, and Mann-Whitney U tests. Potential predictors of symptoms were analyzed using logistic regression analysis.

RESULTS

The most common symptom was tiredness (n = 1,002; 82.1%), followed by dyspnea (n = 845; 69.3%), appetite loss (n = 801; 65.7%), pain (n = 798; 65.4%), drowsiness (n = 742; 60.8%), anxiety (n = 704; 57.7%), depression (n = 623; 51.1%), and nausea (n = 557; 45.5%). Of the 1,245 patients, 590 (48.4%) had difficulty in initiating or maintaining sleep. The symptoms were more severe in stages III and IV. Logistic regression analysis indicated a clear association between demographic characteristics and symptom distress, as well as between symptom distress (except nausea) and well-being. Overall, 804 (65.4%) patients used analgesics, 630 (51.5%) received treatment for dyspnea, 242 (19.8%) used enteral/parenteral nutrition, 132 (10.8%) used appetite stimulants, and 129 (10.6%) used anxiolytics/antidepressants. Of the 799 patients who received analgesics, 173 (21.7%) reported that their symptoms were under control, and also those on other various treatment modalities (dyspnea: 78/627 [12.4%], appetite stimulant: 25/132 [18.9%], and anxiolytics/antidepressants: 25/129 [19.4%]) reported that their symptoms were controlled.

CONCLUSION

In this study, the symptoms progressed and became more severe in the advanced stages of lung cancer, and palliative treatment was insufficient in most of the patients in Turkey.

An Interdisciplinary Nutrition Support Team Improves Clinical and Hospitalized Outcomes of Esophageal Cancer Patients with Concurrent Chemoradiotherapy

Background:

The prevalence of malnutrition is very high in patients with cancer. The purpose of this study was to investigate whether or not a nutrition support team (NST) could benefit esophageal cancer patients undergoing chemoradiotherapy (CRT).

Methods:

Between June 2012 and April 2014, 50 esophageal cancer patients undergoing concurrent CRT were randomly assigned into two groups: The NST group and the control group. The nutritional statuses of 25 patients in the NST group were managed by the NST. The other 25 patients in the control group underwent the supervision of radiotherapy practitioners. At the end of the CRT, nutritional status, the incidence of complications, and completion rate of radiotherapy were evaluated. Besides, the length of hospital stay (LOS) and the in-patient cost were also compared between these two groups.

Results:

At the completion of CRF, the nutritional status in the NST group were much better than those in the control group, as evidenced by prealbumin (ALB), transferrin, and ALB parameters (P = 0.001, 0.000, and 0.000, respectively). The complication incidences, including bone marrow suppression (20% vs. 48%, P = 0.037) and complications related infections (12% vs. 44%, P = 0.012), in the NST group were lower and significantly different from the control group. In addition, only one patient in the NST group did not complete the planned radiotherapy while 6 patients in the control group had interrupted or delayed radiotherapy (96% vs. 76%, P = 0.103). Furthermore, the average LOS was decreased by 4.5 days (P = 0.001) and in-patient cost was reduced to 1.26 ± 0.75 thousand US dollars person-times (P > 0.05) in the NST group.

Conclusions:

A NST could provide positive effects in esophageal cancer patients during concurrent CRT on maintaining their nutrition status and improving the compliance of CRF. Moreover, the NST could be helpful on reducing LOS and in-patient costs.

NUTRISCORE: A new nutritional screening tool for oncological outpatients

OBJECTIVES

The aim of this study was to design a new nutritional screening tool (NUTRISCORE) to detect nutritional risk in outpatients with cancer.

METHODS

A multicenter, cross-sectional study was conducted. We randomly selected outpatients receiving onco-specific, palliative, or symptomatic treatment for malignant neoplasms (including solid tumors and hematologic malignancies). These patients were assessed using the NUTRISCORE tool, the Malnutrition Screening Tool (MST), and the Patient-Generated Subjective Global Assessment (PG-SGA) to detect risk for malnutrition. The new tool included questions regarding the cancer site and active treatment. Sensitivity, specificity, and positive and negative predictive values were calculated for NUTRISCORE and MST using the PG-SGA as a reference method.

RESULTS

We evaluated 394 patients. According to NUTRISCORE, 22.6% were at risk for malnutrition. The MST detected a risk in 28.2%, and the PG-SGA found that 19% were malnourished or at nutritional risk. Using the PG-SGA as a reference method, the MST had a sensitivity of 84% and a specificity of 85.6%, whereas NUTRISCORE exceeded these values, at 97.3% sensitivity and 95.9% specificity. The better performance of NUTRISCORE as compared with MST was confirmed by the receiver operating characteristic curve analysis, with area under the curve values of 0.95 (95% confidence interval, 0.92-0.98) for NUTRISCORE and 0.84 (95% confidence interval, 0.79-0.89) for the MST.

CONCLUSIONS

NUTRISCORE has been found to be a novel, fast, and valid nutritional screening tool for outpatients with cancer. Its simplicity and high level of accuracy in detecting nutritional risk facilitates its applicability.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Hospital malnutrition in Latin America: A systematic review

BACKGROUND

Disease-related malnutrition is a major public health issue in both industrialised and emerging countries. The reported prevalence in hospitalised adults ranges from 20% to 50%. Initial reports from emerging countries suggested a higher prevalence compared with other regions, with limited data on outcomes and costs.

METHODS

We performed a systematic literature search for articles on disease-related malnutrition in Latin American countries published between January 1995 and September 2014. Studies reporting data on the prevalence, clinical outcomes, or economic costs of malnutrition in an adult (≥18 years) inpatient population with a sample size of ≥30 subjects were eligible for inclusion. Methodological quality of the studies was assessed by two independent reviewers using published criteria.

RESULTS

We identified 1467 citations; of these, 66 studies including 29 ,474 patients in 12 Latin American countries met the criteria for inclusion. There was considerable variability in methodology and in the reported prevalence of disease-related malnutrition; however, prevalence was consistently in the range of 40%-60% at the time of admission, with several studies reporting an increase in prevalence with increasing duration of hospitalisation. Disease-related malnutrition was associated with an increase in infectious and non-infectious clinical complications, length of hospital stay, and costs.

CONCLUSION

Disease-related malnutrition is a highly prevalent condition that imposes a substantial health and economic burden on the countries of Latin America. Further research is necessary to characterise screening/assessment practices and identify evidence-based solutions to this persistent and costly public health issue.

Factors that affect PERCIST-defined test-retest comparability: an exploration of feasibility in routine clinical practice

PURPOSE

The aim of this study was to evaluate the factors affecting the comparability of F-FDG PET/CT scans using the PERSIST criteria for treatment response evaluation in a clinical PET/CT unit.

PATIENTS AND METHODS

Patients diagnosed with esophageal cancer were assessed for treatment response by comparing 2 F-FDG PET/CT scans, at baseline (PET 1) and 1 month after the end of induction chemoradiation (PET 2). According to the PERCIST recommendations, patients with mean SUV normalized by the lean body mass within reference volume of interest that changed less than 0.3 unit and less than 20% were deemed as comparable. Absolute differences of body weight, blood glucose level, activity of F-FDG, and uptake time between the 2 scans were computed. Binary logistic regression was used to identify the predictive factors, and receiver operating characteristic curves were used for thresholds. P < 0.05 was considered statistically significant.

RESULTS

Sixty-nine subjects were identified. The mean (SD) values at PET 0 and PET 2 were 5.9 (1.04) mmol/L and 6.2 (1.06) mmol/L (P = 0.013), 54.6 (10.0 kg) and 53.3 (10.3 kg) (P = 0.013), 7.7 (1.3 mCi) and 7.6 (1.5 mCi) (P = 0.349), as well as 74.2 (12.4) minutes and 73.0 (12.3) minutes (P = 0.539), for blood glucose level, body weight, injected activity, and uptake time, respectively. Seventeen (24.6%) failed to match the PERCIST-defined comparability criteria. Case-based discrepancies (mean [SD]) were 0.76 (0.62) mmol/L, 3.4 (2.9) kg, 0.8 (0.7) mCi, and 11.7 (9.8) minutes for blood glucose, body weight, injected activity, and uptake time, respectively, of which only uptake time significantly affected comparability (P = 0.046; odds ratio, 1.06; 95% confidence interval, 1.00-1.12), with a limit of 2.2-minute discrepancy identified as the requirement for 100% comparability.

CONCLUSIONS

Uptake time had the strongest effect on PERCIST-defined comparability. Therefore, for response assessment scans, reference to initial scans for determination of optimal uptake time is recommended.

Impact of prognostic nutritional index on long-term outcomes in patients with breast cancer

Background

Prognostic nutritional index has been shown to be a prognostic marker for various solid tumors. However, few studies have investigated the impact of the prognostic nutritional index on survival of patients with breast cancer. The aim of this study was to investigate the impact of the prognostic nutritional index on the long-term outcomes in patients with breast cancer.

Methods

This study reviewed the medical records of 212 patients with breast cancer who underwent mastectomy. The prognostic nutritional index was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm³). Receiver operating characteristic curve analysis was performed to determine the cutoff value of the prognostic nutritional index. The survival curves were calculated by the Kaplan–Meier method. Differences between the curves were analyzed by the log-rank test. Multivariate Cox proportional hazard model was used to evaluate the prognostic significance of prognostic nutritional index in patients with breast cancer.

Results

The mean prognostic nutritional index just before the operation was 51.9, and the median follow-up after surgery was 47.7 months. The optimal cutoff value of the prognostic nutritional index for predicting the overall survival was 52.8 from the receiver operating characteristic curve analysis. The 5-year overall survival rate was 98.3 % in the prognostic nutritional index >52.8 and 92.0 % in the prognostic nutritional index <52.8 (P = 0.013). In the multivariate analysis, a low prognostic nutritional index was an independent predictor for poor overall survival (HR, 5.88; 95 % CI, 1.13–108.01; P = 0.033).

Conclusions

The prognostic nutritional index is a simple and useful marker for predicting the long-term outcomes of breast cancer patients, independent of the tumor stage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0920-7) contains supplementary material, which is available to authorized users.

Subjective taste and smell changes in treatment-naive people with solid tumours

PURPOSE

Taste and smell changes (TSCs) are common in head and neck (H&N) cancer and during and after chemotherapy (CT) and radiotherapy (RT). It is an area that has been under-investigated, particularly in the treatment-naive, but can negatively impact nutritional status. This study examined the prevalence, severity and characteristics of TSCs in people with non-H&N solid tumours, before CT and RT, and their relationship with co-occurring symptoms.

METHODS

A prospective, observational study was conducted. Forty consecutive pre-treatment cancer patients, referred to radiation oncology outpatients over 6 weeks, were recruited. Data on TSCs, symptoms and nutritional status were obtained using the 'Taste and Smell Survey' and the 'abridged Patient-Generated Subjective Global Assessment' (abPG-SGA). BMI was measured. SPSS® was used for statistical analysis. Two-sided P values <0.05 were considered statistically significant.

RESULTS

Most patients were newly diagnosed (n = 28; 70 %). Nineteen (48 %) reported TSCs; nine noted a stronger sweet and seven a stronger salt taste. Of these, four reported a stronger and four a weaker smell sensation. Those at nutritional risk reported more TSCs (n = 13/20). TSCs were significantly associated with dry mouth (P < 0.01), early satiety (P < 0.05) and fatigue (P < 0.05).

CONCLUSIONS

TSCs preceded CT or RT in almost half of treatment-naive patients with solid tumours, notably stronger sweet and salt tastes. Half of the study group were at nutritional risk; the majority of these reported TSCs. TSCs were significantly associated with other symptoms. Future research and clinical guidelines, with a common terminology for assessment, diagnosis and management of cancer TSCs, are needed.

Awareness and consideration of malnutrition among oncologists: Insights from an exploratory survey

OBJECTIVES

The attitude toward malnutrition varies considerably among oncologists and many malnourished cancer patients receive inadequate nutritional support. The aim of this brief report was to report the results of the exploratory national survey conducted by the Italian Society of Medical Oncology (AIOM) and the Italian Society of Artificial Nutrition and Metabolism (SINPE) before publication of a consensus document aimed at evaluating current attitudes toward malnutrition and management of nutrition, among Italian medical oncologists.

METHODS

Between January and July 2015, the AIOM and the SINPE conducted a national web-based exploratory survey to investigate the attitude of oncologists toward malnutrition, and the management of nutritional support, before publication of an intersociety consensus document.

RESULTS

Of the 2375 AIOM members, 135 (5.7%) participated in the survey, with a satisfactory distribution across all Italian regions. Nutritional assessment and support were routinely integrated into patient care for 38 (28%) responders. According to 66 (49%) participants, nutritional assessment was carried out only at the patients' request (n = 62), or not at all (n = 4). Availability of clinical nutritionists was reported by 88 (65%) participants. For 131 responders (97%), nutritional status was decisive (n = 63) or often crucial (n = 68) in assessing whether anticancer treatment was practicable or would be tolerated.

CONCLUSIONS

The low response rate may reflect the lack of awareness and consideration of nutritional issues among Italian oncologists. Although malnutrition and nutritional support seemed to be perceived by the responders as relevant factors for the efficacy of oncologic treatments, it seems that nutritional care practices may well be inappropriate. The lack of collaboration between oncologists and clinical nutritionists may be the first obstacle to overcome. Educational intersociety initiatives aimed at improving nutritional support management for cancer patients in Italy appear urgently needed.

Factors associated with (risk of) undernutrition in community-dwelling older adults receiving home care: a cross-sectional study in the Netherlands

Objective

It is generally thought that causes of undernutrition are multifactorial, but there are limited quantitative studies performed. We therefore examined a wide range of potential factors associated with undernutrition in community-dwelling older adults.

Design

Cross-sectional study.

Setting

Community-dwelling older adults (≥65 years) receiving home care in the Netherlands.

Subjects

Data on potential factors associated with (risk of) undernutrition were collected among 300 older adults. Nutritional status was assessed by the SNAQ65+ instrument. Undernutrition was defined as mid-upper arm circumference <25 cm or unintentional weight loss of ≥4 kg in 6 months. Being at risk of undernutrition was defined as having poor appetite and inability to walk up and down stairs of fifteen steps, without resting.

Results

Of all participants, ninety-two (31·7 %) were undernourished and twenty-four (8·0 %) were at risk of undernutrition. Based on multivariate logistic regression analyses, the statistically significant factors associated with (risk of) undernutrition (P<0·05) were: unable to go outside (OR=5·39), intestinal problems (OR=2·88), smoking (OR=2·56), osteoporosis (OR=2·46), eating fewer than three snacks daily (OR=2·61), dependency in activities of daily living (OR=1·21), physical inactivity (OR=2·01), nausea (OR=2·50) and cancer (OR=2·84); a borderline significant factor was depression symptoms (OR=1·83, P=0·053).

Conclusions

The study suggests that (risk of) undernutrition is a multifactorial problem and that associated factors can be found in several domains. These findings may support the development of intervention trials for the prevention and treatment of undernutrition in community-dwelling older adults.

Nutrition support and dietary interventions for patients with lung cancer: current insights

Malnutrition and weight loss are prevalent in patients with lung cancer. The impact of malnutrition on patients with cancer, and specifically in patients with lung cancer, has been demonstrated in a large number of studies. Malnutrition has been shown to negatively affect treatment completion, survival, quality of life, physical function, and health care costs. Emerging evidence is providing some insight into which lung cancer patients are at higher nutritional risk. In lung cancer patients treated with radiotherapy, stage III or more disease, treatment with concurrent chemotherapy and the extent of radiotherapy delivered to the esophagus appear to confer a higher risk of weight loss during and post-treatment. Studies investigating nutrition interventions for lung cancer patients have examined intensive dietary counseling, supplementation with fish oils, and interdisciplinary models of nutrition and exercise interventions and show promise for improved outcomes from these interventions. However, further research utilizing these interventions in large clinical trials is required to definitively establish effective interventions in this patient group.