Phase angle for prognostication of survival in patients with advanced cancer: preliminary findings

Phase Angle but Not Psoas Muscle Predicts Nutritional Risk and Prognosis in Males with Hepatocellular Carcinoma

Despite those with hepatocellular carcinoma (HCC) being at increased risk of malnutrition, there is a notable absence of practical approaches for nutritional assessment in clinical practice. We investigated the usefulness of phase angle (PhA) and Total Psoas Area Index (TPAI) for indicating nutritional risk and HCC prognosis. Weight, height, body mass index (BMI), adductor pollicis muscle thickness (APMT), and handgrip strength (HGS) were assessed. The Nutritional Risk Index (NRI) was calculated. Body composition was assessed using bioimpedance spectroscopy and magnetic resonance imaging. The Child-Turcotte-Pugh (CTP) score and Barcelona-Clinic Liver Cancer (BCLC) classification determined the prognosis. Fifty-one males with HCC were enrolled (CTP C = 11.8%). PhA showed a moderate positive correlation with APMT (r = 0.450; p < 0.001) and HGS (r = 0.418; p = 0.002) and a weak positive correlation with TPAI (r = 0.332; p = 0.021). PhA had a strong positive correlation with NRI (r = 0.614; p < 0.001). Mean PhA values were significantly different according to disease severity (CTP C p = 0.001, and BCLC D p = 0.053). TPAI had no significant correlation with HGS, CTP, or BCLC. PhA was a superior approach for predicting nutritional risk and prognosis in HCC than TPAI. Lower PhA is associated with disease progression, lower muscle mass and function, greater severity of nutritional risk, and increased mortality in HCC.

Palliative prognostic scores for survival prediction of cancer patients: a systematic review and meta-analysis

BACKGROUND

The palliative prognostic score is the most widely validated prognostic tool for cancer survival prediction, with modified versions available. A systematic evaluation of palliative prognostic score tools is lacking. This systematic review and meta-analysis aimed to evaluate the performance and prognostic utility of palliative prognostic score, delirium-palliative prognostic score, and palliative prognostic score without clinician prediction in predicting 30-day survival of cancer patients and to compare their performance.

METHODS

Six databases were searched for peer-reviewed studies and grey literature published from inception to June 2, 2023. English studies must assess palliative prognostic score, delirium-palliative prognostic score, or palliative prognostic score without clinician-predicted survival for 30-day survival in adults aged 18 years and older with any stage or type of cancer. Outcomes were pooled using the random effects model or summarized narratively when meta-analysis was not possible.

RESULTS

A total of 39 studies (n = 10 617 patients) were included. Palliative prognostic score is an accurate prognostic tool (pooled area under the curve [AUC] = 0.82, 95% confidence interval [CI] = 0.79 to 0.84) and outperforms palliative prognostic score without clinician-predicted survival (pooled AUC = 0.74, 95% CI = 0.71 to 0.78), suggesting that the original palliative prognostic score should be preferred. The meta-analysis found palliative prognostic score and delirium-palliative prognostic score performance to be comparable. Most studies reported survival probabilities corresponding to the palliative prognostic score risk groups, and higher risk groups were statistically significantly associated with shorter survival.

CONCLUSIONS

Palliative prognostic score is a validated prognostic tool for cancer patients that can enhance clinicians' confidence and accuracy in predicting survival. Future studies should investigate if accuracy differs depending on clinician characteristics. Reporting of validation studies must be improved, as most studies were at high risk of bias, primarily because calibration was not assessed.

Bioelectrical impedance analysis-derived phase angle (PhA) in lung cancer patients: a systematic review

BACKGROUND

Lung cancer is the second most diagnosed cancer in the world. Up to 84% of diagnosed patients have malnutrition, which can negatively affect quality of life and survival and may worsen with neoadjuvant treatment. Bioelectrical Impedance Analysis-Derived Phase Angle (PhA) in these patients could be a valid tool to assess the nutritional status in order to improve their condition.

METHODS

This review provides an update on PhA assessment in lung cancer patients over the past twenty years. We searched PubMed, Embase, Scopus, Web of Science, and Cochrane, for articles regarding the PhA obtained from Bioelectrical Impedance Analysis in lung cancer patients. The authors independently performed a literature search: sample size, patient population, study type, study dates, survival and interventions were evaluated. The final review included 11 studies from different countries.

RESULTS

Eight studies only considered patients with lung cancer, while three studies considered patients with different kind of cancer, including lung. Correlation data between PhA and age are conflicting. In patients undergoing clinical treatment and patients undergoing surgical treatment lower PhA was observed. A lower PhA is associated with a shorter survival. In three studies emerged a relationship between Karnofski Performance Status and Handgrip Strenght with PhA. From one study, univariate logistic regression analysis showed that higher PhA values represent a protective factor for sarcopenia.

CONCLUSION

Our research underlined interesting, but not conclusive, results on this topic; however more researches are needed to understand the clinical meaning of PhA.

Phase angle - A screening tool for malnutrition, sarcopenia, and complications in gastric cancer

BACKGROUND

Patients with gastric cancer (GC) are more likely to experience malnutrition and muscle wasting. This study aims to investigate the potential of phase angle (PhA) as a screening tool for identifying malnutrition and sarcopenia in GC patients, as well as its association with short-term outcomes after radical gastrectomy.

METHODS

This cross-sectional study enrolled patients diagnosed with GC at The Affiliated People's Hospital of Jiangsu University from October 2021 to September 2022. PhA was measured using bioelectrical impedance analysis. Computed tomography scan images were analyzed for body composition at the level of the third lumbar vertebra. Malnutrition was diagnosed using Global Leadership Initiative on Malnutrition (GLIM) criteria. Sarcopenia diagnosis was based on the Asian Working Group for Sarcopenia (AWGS) 2019 criteria.

RESULTS

A total of 248 patients with GC were analyzed, including 188 patients who underwent radical gastrectomy. Of these, 71.4 % (n = 177) were male and 28.6 % (n = 71) were female and the median overall age was 68 years (IQR: 61-72 years). According to GLIM criteria, 49.2 % (n = 122) of patients were malnourished and 19.8 % (n = 49) had sarcopenia based on AWGS criteria. A one-degree decrease in PhA was significantly associated with GLIM malnutrition (Odds Ratio [OR] = 8.108, 95 % CI:3.181-20.665) and sarcopenia (OR = 2.903, 95 % CI:1.170-7.206). PhA exhibited fair to good diagnostic accuracy in identifying GLIM malnutrition (male: AUC = 0.797; female: AUC = 0.816) and sarcopenia (male: AUC = 0.814; female: AUC = 0.710). Low PhA (OR = 3.632, 95 % CI: 1.686-7.824) and operation time (OR = 2.434, 95 % CI:1.120-5.293) were independently associated with the risk of postoperative complications.

CONCLUSIONS

PhA can serve as a reliable screening tool for identifying patients at risk of malnutrition, sarcopenia, and postoperative complications in GC.

Perception of subjective lived experiences of individuals with anorexia-cachexia in patients with advanced lung cancer

Objective

Cancer cachexia (CC) is a frequent and debilitating syndrome in patients with cancer. It has serious implications for patients, extending beyond physical problems into psychological, and social domains. The objective of our study was to qualitatively understand the experiences related to CC in patients with advanced lung cancer.

Methods

Patients with advanced lung cancer with anorexia (≤ 37 points on Functional Assessment of Anorexia/Cachexia Treatment-ACS) and weight loss were eligible. Patients participated in semi-structured interviews prior to study treatment (n = 19). Qualitative analysis was conducted using interpretative phenomenological approach.

Results

Two super-ordinate themes emerged (anorexia and weight loss). Patients reported experiencing distress related to anorexia, weight loss, lack of social eating, worsening function, body image, and eating habits. The encouragement to eat by the family was often distressing to the patient. The treatment recommendations by their oncologist for anorexia and weight loss was felt inadequate. Patients felt that the treatment for CC should improve appetite and weight gain as well as their mood and be independent.

Conclusions

The findings of the study suggests that anorexia and weight loss results in high levels of distress due to their effects on physical and psychosocial domains. Further studies are needed to better understand the experience of anorexia and weight loss to develop strategies to effectively treat CC.

Trial registration

NCT03637816.

Phase Angle and Postoperative Complications in a Model of Immunonutrition in Patients with Pancreatic Cancer

BACKGROUND

The aim of this study was to determine the influence of our own model of immunonutrition on phase angle and postoperative complications. Our goal was to establish modern prehabilitation procedures for patients operated on for pancreatic cancer.

METHODS

Patients with pancreatic cancer who qualified for surgical treatment were divided into two groups. Group I (20 patients; 12 with pancreatic head cancer, 8 with pancreatic tail/body cancer) was given immunonutrition (Impact Oral 3× a day, 237 mL, for 5 days before surgery, and after surgery for an average of 3.5 days). Group II (20 patients; 12 with pancreatic head cancer, 8 with pancreatic tail/body cancer) did not receive immunonutrition. Body weight, body mass index and phase angle were assessed on admission to the hospital, after preoperative immunonutrition, on the third and eighth postoperative days. C-reactive protein and Interleukin-1 α were measured on admission to the hospital, after preoperative immunonutrition, on the eighth postoperative day. Postsurgical complications were assessed via Clavien-Dindo classification.

RESULTS

On admission to the hospital, the phase angle was 5.0° (4.70-5.85) in Group I and 5.1° (5.00-6.25) in Group II. After 5 days of using preoperative immunonutrition, it increased statistically significantly (p < 0.02) to 5.35°. In Group I, on the third day after surgery, it decreased statistically significantly (p < 0.001) to 4.65°, and then, increased to 4.85° on the eighth day. In Group II, statistically significant decreases in the phase angle were observed on the third (4.5°; p < 0.002) and eighth (4.55°; p < 0.008) days after surgery. A statistically significant increase in CRP (86.6 mg/dL; p < 0.02) and IL-1α (18.5 pg/mL; p < 0.03) levels was observed on the eighth day after surgery in this group. In Group I, a statistically significant negative correlation (R -0.501106; p < 0.002) of the phase angle after 5 days of preoperative immunonutrition with postoperative complications was observed.

CONCLUSIONS

This study used our own model of immunonutrition in patients undergoing surgery for pancreatic cancer. The applied model of perioperative IN improved the postoperative course of patients operated on due to pancreatic cancer. Fewer complications were observed in patients in the group receiving IN. Also, the PA value increased after the 5-day preoperative IN, and the use of perioperative IN improved the PA value on the eighth postoperative day compared to the group that did not receive IN. On this day, an increase in inflammatory parameters was also observed in the group that did not receive IN. In addition, PA correlated negatively with complications. The PA can be a useful tool to assess the effectiveness of the applied IN, and thus, to predict the occurrence of postoperative complications. Therefore, there is a further need for studies on larger groups of patients.

Is there a difference in the parameters of the bioelectrical impedance obtained from devices from different manufacturers? A cross-sectional study in hospitalized cancer patients

BACKGROUND

Cancer is a disease with high and increasing incidence rates in the world and its course tends to harm the body composition. Monitoring these body changes is very important. Therefore, it is essential to have reliable, accessible, and practical methods for evaluating body compartments. This study aims to evaluate the correlation and agreement of results for the bioelectrical impedance analysis (BIA) obtained from devices from different manufacturers.

METHODS

This is a single-center cross-sectional study including hospitalized patients with cancer. Two devices from different brands used for obtaining the BIA were used; both with a tetrapolar model and a single frequency (50 kHz). The results were evaluated for resistance (R) and reactance (Xc) and used to calculate the phase angle (PhA) and fat-free mass (FFM) indicators. Pearson and Spearman correlation tests and Bland-Altman plots were performed, with results expressed as bias and limits of agreement at 95% confidence intervals (95%CI).

RESULTS

We have included 116 patients, with a mean age of 60.8 ± 14.8, 51.7% were women. We have found very strong correlations between the measurements of R (rho = 0.971) and FFM (r = 0.979), and strong correlations for Xc (rho = 0.784) and PhA (rho = 0.768). However, the measurements did not agree between the methods.

CONCLUSIONS

Commercial brands of devices used for the BIA influence the results generated, a factor that must be considered when choosing the most appropriate method for this analysis.

Phase Angle, Handgrip Strength, and Other Indicators of Nutritional Status in Cancer Patients Undergoing Different Nutritional Strategies: A Systematic Review and Meta-Analysis

Malnutrition in cancer patients is one of the most influential factors in the evolution and mortality of such patients. To reduce the incidence of malnutrition, it is necessary to establish a correct nutritional intervention. For this purpose, precise tools and indicators must be developed to determine the patient’s condition. The main objective of this systematic review and meta-analysis was to analyze the relationship between different nutritional strategies, phase angle (PA), and handgrip strength in patients with cancer, with the secondary objectives being the modification of other indicators of nutritional status, such as weight and body mass index (BMI). A systematic review of randomized clinical trials was carried out in March 2023 in the databases PubMed, Web of Science, Cochrane, and Scopus. As a risk-of-bias tool, RoB 2.0 was utilized. A total of 8 studies with a total of 606 participants were included in the analysis. A significant increase in PA was observed after the different nutritional strategies (SMD: 0.43; 95% CI: 0.10 to 0.77; p = 0.01; I2 = 65.63%), also detecting a significant increase in handgrip strength (SMD: 0.27, 95% CI: 0.08 to 0.47; p = 0.01; I2 = 30.70%). A significant increase in PA and handgrip were observed in cancer patients subjected to different nutritional strategies. These results suggest that these indicators could be used in the nutritional and functional assessment of the patients.

Phase angle and extracellular water-to-total body water ratio estimated by bioelectrical impedance analysis are associated with levels of hemoglobin and hematocrit in patients with diabetes

Background

Anemia is one of the common complications of diabetes and is associated with mortality. Phase angle (PhA), ratio of extracellular water to total body water (ECW/TBW) and skeletal muscle mass index (SMI) estimated by bioelectrical impedance analysis (BIA) have been used as prognostic indicators for various chronic diseases and frailty. We aimed to clarify the clinical significance of PhA, ECW/TBW and SMI for anemia in patients with diabetes.

Materials and methods

The values of PhA, ECW/TBW and SMI were estimated by a portable BIA device and blood samples were collected in 371 Japanese patients with diabetes. The relationships of PhA, ECW/TBW and SMI with hemoglobin (Hgb) and hematocrit (Hct) were statistically evaluated.

Results

In simple linear regression analysis, PhA and SMI were positively correlated with Hgb and Hct levels in total subjects, male subjects and female subjects. In contrast, ECW/TBW was negatively correlated with Hgb and Hct levels regardless of sex. Multivariate regression analysis showed that both PhA and ECW/TBW but not SMI independently contributed to Hgb and Hct levels after adjustment of clinical confounding factors in both males and females.

Conclusions

PhA and ECW/TBW but not SMI were associated with levels of Hgb and Hct in patients with diabetes. Therefore, aberrant values of PhA and ECW/TBW suggest a risk of anemia in diabetic patients.

Association between PhA and Physical Performance Variables in Cancer Patients

Maintaining the physical performance of cancer patients is increasingly considered due to the growing number of cancer patients and the aggressiveness of the treatments. For this reason, bioimpedance is now being used to record patients' body composition by obtaining the phase angle (PhA). Although there is a direct relationship between PhA, age, sex and disease prognosis, it has not been measured as an analysis of physical performance in oncology patients and is a valid tool in the follow-up of cancer patients. For this purpose, 311 patients were evaluated, and both bioelectrical impedance analysis (BIA) and physical performance measurements were performed. The modification of the results concerning PhA was found to be highly relational, as a variation in one of the variables affected the other. It was concluded that each degree increase in PhA modified -22.57 s [-27.58; -17.53] in 400-m walking test (400 mWT); 13.25 kg [10.13; 16.35] in upper-body strength (UBS); 6.3 [4.95; 7.65] in lower-body strength (LBS); 1.55 mL/kg/min [0.98; 2.12] in VO2peak; 6.53 Watts [3.83; 9.20] in ventilatory threshold 1 (VT1); 10.36 Watts [7.02; 13.64] in ventilatory threshold 2 (VT2). It was also noted that age was a factor that affected the relationship between PhA and 400 mWT; the older the age, the higher the relationship. PhA data has been shown to be highly correlated with physical performance. This is of great importance in clinical practice because a cancer patient's physical performance levels can be assessed during treatment.

The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature

Compared with the phase angle (PA), the predictive ability of the standardized phase angle (SPA) in assessing nutritional status and clinical outcomes in cancer patients remains uncertain. This review aimed to assess (1) the relationship between SPA and nutritional status and clinical outcomes (including complications and survival) in cancer patients; (2) the predictive ability of SPA alone and in comparison with the predictive ability of PA; and (3) the cut-off value of SPA in cancer patients. Studies that addressed the relationship of SPA use to nutritional status, complications, and survival in cancer patients were searched and identified from six electronic databases (PubMed, Medline, CINAHL, Embase, Web of Science, and the Cochrane Library). The included studies were considered to meet the following criteria: English studies with original data that reflected the effects of SPA on nutritional status and clinical outcomes (including complications and survival) and reported a cut-off value of SPA in cancer patients aged ≥18. Thirteen studies that included a total of 2787 participants were evaluated. Five studies assessed the relationship between SPA and nutritional status, and four of them reported a positive relationship between SPA and nutritional status in cancer patients, even considering SPA as a predictor. Twelve studies assessed the relationship between SPA and clinical outcomes in cancer patients. Two-thirds of the studies that evaluated complications reported the predictive ability of SPA; 30% of survival studies reported a positive relationship, 40% reported SPA as a predictor, and 30% reported no relationship. The standard cut-off value for SPA has not yet been determined. Data from the selected studies suggest that SPA might be a predictor of nutritional status. Further studies are needed to determine the value of SPA in predicting nutritional status and clinical outcomes in cancer patients.

Sex differences in the association of phase angle and lung cancer mortality

Background

Lung cancer is a lethal malignant tumor that is common worldwide and is associated with a high incidence of malnutrition. Phase angle (PA) is a simple, objective, and non-invasive indicator of body composition that has increasingly attracted attention as an indicator of the nutritional status and prognosis of patients with malignant tumors. This study aimed to investigate the association between the PA and overall survival in patients with lung cancer.

Methods

This study prospectively analyzed 804 lung cancer patients in the Investigation on Nutrition Status and its Clinical Outcome of Common Cancers (INSCOC) project from 40 hospitals in China. We used a restricted cubic spline to analyze the sex-specific association between PA and mortality in men and women with lung cancer. Cox regression analysis was used to evaluate the independent association between PA and mortality in men and women. Sensitivity analysis was performed. The Kaplan-Meier method was used to evaluate the survival of patients with high and low PA values.

Results

There was an L-shaped association between PA and survival in both men and women with lung cancer (p = 0.019 and p = 0.121, respectively). Kaplan-Meier survival analysis suggested that patients with a high PA showed a better survival than patients with a low PA (p = 0.007 for men and p < 0.001 for women). Multivariate-adjusted Cox regression analysis showed that PA was an independent risk factor for mortality in men (HR = 0.79, 95% CI = 0.65-0.95, p = 0.015), but not in women (HR = 0.83, 95% CI = 0.67-1.04, p = 0.105).

Conclusion

Phase angle is an independent risk factor for the mortality of male lung cancer patients. However, its role in predicting the mortality of female lung cancer patients seems to be limited.

Diagnostic and prognostic utility of phase angle in patients with cancer

Patients with cancer experience dynamic and longitudinal changes in nutritional status and body composition along the disease trajectory. They often want to know about their outlook with regard to treatment outcomes and overall survival. One of the commonly used measures for body composition is bioelectrical impedance analysis (BIA). BIA is an easy-to-use, quick, inexpensive, noninvasive, and reproducible technique that is often incorporated in daily clinical practice. Phase angle (PA), which is derived from BIA, is an indicator of cell membrane health and integrity. Higher PA values reflect better cell function, higher muscle mass, and lower fat mass. PA is also thought to be a proxy of water distribution (ratio between extracellular water [ECW] and intracellular water [ICW]) and body cell mass. In this narrative review, we discuss studies examining the diagnostic and prognostic value of PA regarding nutritional status, body composition and physical function, complications of cancer treatments, overall survival, symptoms, and quality of life (QOL) in patients with cancer. The literature suggests that PA is moderately to strongly correlated with body composition and physical function but only weakly correlated with nutritional status, complications, survival, symptoms, and QOL. Furthermore, the PA cutoff values vary significantly according to study and patient population with the diversity of bioelectrical impedance technology and electrode composition and placement. Thus, PA has yet to be routinely incorporated into clinical practice for patients with cancer. Future research is needed to determine how to translate scientific understanding of PA to clinical practice.

Phase Angle, a Cornerstone of Outcome in Head and Neck Cancer

In patients with head and neck cancer, malnutrition is common. Most cases are treated by chemo-radiotherapy and surgery, with adverse effects on the aerodigestive area. Clinical and biochemical characteristics, health-related quality of life, survival, and risk of death were studied. The selected subjects were divided into normal- and low-phase-angle (PA) groups and followed up for at least two years. Mean ages were 67.2 and 59.3 years for low and normal PA, respectively. Patients with PA < 4.42° had significant differences in age, anthropometric and biochemical indicators of malnutrition, and inflammatory status compared to patients with PA > 4.42°. Statistical differences were found in the functional and symptom scales, with lower functional scores and higher symptom scores in patients with low PA. Median survival was 19.8 months for those with PA < 4.42° versus 34.4 months for those with PA > 4.42° (p < 0.001).The relative risk of death was related to low PA (2.6; p < 0.001). The percentage of living patients (41.7%) is almost the same as the percentage of deceased subjects (43.1%; p = 0.002), with high death rates in patients with PA < 4.42°. Phase angle was the most crucial predictor of survival and a risk factor for death in the studied cases.

Development and Validation of the PaP Score Nomogram for Terminally Ill Cancer Patients

The validated Palliative Prognostic (PaP) score predicts survival in terminally ill cancer patients, assigning patients to three different risk groups according to a 30-day survival probability: group A, >70%; group B, 30−70%; and group C, <30%. We aimed to develop and validate a PaP nomogram to provide individualized prediction of survival at 15, 30 and 60 days. Three cohorts of consecutive terminally ill cancer patients were used: one (n = 519) for nomogram development and internal validation, and a second (n = 451) and third (n = 549) for external validation. Multivariate analyses included dyspnea, anorexia, Karnofsky performance status, clinical prediction of survival, total white blood count and lymphocyte percentage. The predictive accuracy of the nomogram was determined by Harrell’s concordance index (95% CI), and calibration plots were generated. The nomogram had a concordance index of 0.74 (0.72−0.75) and showed good calibration. The internal validation showed no departures from ideal prediction. The accuracy of the nomogram at 15, 30 and 60 days was 74% (70−77), 89% (85−92) and 72% (68−76) in the external validation cohorts, respectively. The PaP nomogram predicts the individualized estimate of survival and could greatly facilitate clinical care decision-making at the end of life.

Nutritional status of patients with lymphoproliferative neoplasms before and after the first-line treatment

BACKGROUND

Nutritional disorders in cancer patients, including lymphoproliferative neoplasms, occur with varying frequency.

OBJECTIVES

The primary aim of the study was to analyze the changes in the nutritional status of patients with lymphoproliferative neoplasms following first-line chemotherapy.

MATERIALS AND METHODS

46 patients, with a median age of 62 years, participated in a prospective single-center study. Their demographic, biochemical and clinical features were analyzed. The study consisted of several stages that were conducted at two time points. P values < 0.05 were considered statistically significant.

RESULTS

The study included patients with multiple myeloma (48%), non-Hodgkin's lymphoma (28%) or chronic lymphocytic leukemia (24%). After the end of the first-line chemotherapy, a decrease in the concentration of albumin (p = 0.04), transferrin (p = 0.38) and total cholesterol (p = 0.76) were found. Statistically greater unintended weight loss occurred before treatment initiation (p < 0.001). Moreover, a significant decrease in the mean values ​​of the phase angle (p < 0.01) was noted.

CONCLUSIONS

Most patients before the oncological therapy did not show clinical or biochemical symptoms of malnutrition. However, after the treatment was completed, the parameters of the nutritional status showed its deterioration.

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Relationships between Body Composition Parameters and Phase Angle as Related to Lifestyle among Young People

The aim of the study was to indicate which body composition parameters and which lifestyle components affect the phase angle (PA) value in young adults. Two-hundred-and-eighty-one students at Wroclaw Medical University participated in the study. A survey on respondent lifestyles was followed by anthropometric measurements, body composition analysis, and basal metabolic rate (BMR) calculation. The differences in the body composition of men and women corresponded to their sexual anatomy and physiology. Sex-dependent differences in lifestyle were also reported. The study revealed a relationship between PA and height, weight, BMR, BMI (body mass index), FFM (fat-free body mass), bone mass, water mass, muscle mass (r~0.4–0.7), ECW/ICW (extracellular water/intracellular water) and fat mass (r~−(0.4–0.6)) for the entire studied group. The relationship between PA values and lifestyle components concerned consumption of energy drinks, cola, alcohol, water, vegetables and fruits, meat, and also intervals between meals, time for physical exercises, and screen time (r~±0.2). The research shows that the PA value increases with an increase in positive body composition parameters. Following the principles of proper nutrition and physical activity increases PA values in most cases.

Extracellular water to total body water ratio may mediate the association between phase angle and mortality in patients with cancer cachexia: A single-center, retrospective study

BACKGROUND & AIMS

Recently, prognostic factors for cancer cachexia patients have been reported. We hypothesized that phase angle (PhA), which is measured by bioelectrical impedance analysis (BIA), might be a promising marker for assessing the nutritional status and prognosis of cancer patients. This study aimed to evaluate the predictive utility of PhA, which is mediated by several BIA factors and other anthropometric parameters, such as calf circumference, for the prognosis of cancer cachexia patients.

METHODS

Consecutive patients (114, both outpatients and inpatients) with an unselected stage of cancer cachexia were recruited between July 2018 and December 2019 in Fujita Health University Hospital for this retrospective cohort study. Their mean age was 74.0 years (standard deviation, 8.5); among the total, 70 were men and 44 women. A time-dependent Cox proportional-hazards regression analysis (adjusted for age and sex) was performed to assess the following: 1) the association between potential mediators and mortality; 2) the association between five PhAs and statistically significant mediators from 1); and 3) the association between the five PhAs and mortality. Finally, Kaplan-Meier survival curves were constructed and compared between the two groups based on the patients' median baseline ratio of extracellular water (ECW) to total body water (TBW) using a log-rank test.

RESULTS

The ECW/TBW ratio (hazard ratio [HR] per 1-interquartile range [IQR] increase: 2.87; 95% confidence interval [CI]: 1.46, 5.46; p < 0.001) and skeletal muscle mass index (HR per 1-IQR increase: 0.67; 95% CI: 0.51, 0.89; p = 0.001) were associated with mortality. All five PhAs were associated with the ECW/TBW ratio (p < 0.001). Before adjustment for the ECW/TBW ratio, all five PhAs were associated with mortality (p < 0.001); only the association of the PhAs of the left arm and the trunk retained the statistical significance after adjusting for confounders (p < 0.05). The median survival times in the low (370 days; 95% CI: 168, not calculated) and high ECW/TBW groups (101 days; 95% CI: 61, 219) differed significantly (p < 0.001).

CONCLUSIONS

The association between PhA and mortality in cancer cachexia patients was largely mediated by the ECW/TBW ratio. We believe that adjusting PhA for the ECW/TBW ratio may improve the prognostication of cancer patients with cachexia, ultimately improving their palliative care.

Effect of exercise on phase angle in cancer patients: a systematic review

INTRODUCTION

Body composition is one of the main variables of interest in clinical practice in cancer patients. Specific markers from bioelectrical impedance analysis, such as phase angle (PhA), have been assuming increasing relevance in this population. The aim of the present systematic review was to study and systematise the effect of exercise on PhA in cancer survivors, as compared to control conditions, namely usual care, with no exercise. The effect of exercise on PhA in the population of cancer survivors is not yet established. EVIDENCE ACQUISITIONː This systematic review was conducted on October 13, 2021, through PubMed, Web of Science, Wiley Online Library, Directory of Open Access Journals, Science Direct and JSTOR, following PRISMA guidelines and PICOS model that include: cancer survivors with ≥18 years; intervention of any exercise program for the target group; comparison between intervention group and control group that followed control conditions, namely usual care, with no exercise; outcome related to PhA; and studies of randomized control trials.

EVIDENCE SYNTHESIS

We founded a total of 1244 publications, using selected keywords. Eight studies were included in this systematic review, after inclusion/exclusion criteria considered. Compared with the control conditions, exercise training programs seem associated with a positive effect on PhA, both in solid tumours and haematologic cancer types, but only when using resistance exercise alone. According to the best evidence synthesis criteria, we could not conclude the superiority of any exercise program analysed in the value of the PhA.

CONCLUSIONS

There were several exercise details that may have potential to be beneficial for PhA in cancer patients, including an early start of the exercise intervention (during treatment and immediately after discharge from hospital), the use of resistance exercise or/and aerobic exercise, and mainly a long follow-up period (≥ 4 months) to verify the structural effects of exercise on the PhA. However, there were no effects on the PhA value immediately after the intervention, regardless of the type of protocol and the intervention time.

Effect of Home Enteral Nutrition on Nutritional Status, Body Composition and Quality of Life in Patients With Malnourished Intestinal Failure

Background: The ultimate goal of intestinal failure (IF) management is to maintain optimal nutritional status, improve the quality of life (QoL), and promote intestinal adaptation. Enteral nutrition support is safe and effective in patients with IF and plays a central role in the management of patients with IF. The purpose of this study was to evaluate the effect of home enteral nutrition on nutritional status, body composition (BC), QoL and other clinical outcomes in malnourished patients with intestinal failure. Methods: This prospective observational study included 166 malnourished patients with intestinal failure presented to Jinling Hospital from January 2016 to October 2018. All patients were supported with home enteral nutrition after discharge. We evaluated clinical outcomes, including nutritional status, BC, phase angle (PhA), QoL, mortality, gastrointestinal complications related to enteral feeding, and other clinical outcomes at 1, 3, and 6 months after discharge. Results: Body weight, BC, and other nutritional parameters were maintained or significantly increased during the period of home enteral nutrition after discharge (p < 0.01). Especially, the quality of skeletal muscle mass in body composition was significantly improved (p < 0.01). SF-36 quality of life scores was significantly improved (discharged at 6 months: reported health transition 40.7 ± 12.1 vs. 69.3 ± 16.3, p < 0.01). There were no differences between hospital and out of hospital with respect to tube-related or gastrointestinal complications. Advanced age, disease type, and poor nutritional status were risk factors for poor clinical outcomes. Conclusions: Home enteral nutrition support is effective for malnourished patients with intestinal failure. It improves nutritional status, BC, PhA, and QoL. Clinical Trial Registration: identifier: ChiCTR2000035145.

"The surprise questions" using variable time frames in hospitalized patients with advanced cancer

OBJECTIVE

Several studies supported the usefulness of "the surprise question" in terms of 1-year mortality of patients. "The surprise question" requires a "Yes" or "No" answer to the question "Would I be surprised if this patient died in [specific time frame]." However, the 1-year time frame is often too long for advanced cancer patients seen by palliative care personnel. "The surprise question" with shorter time frames is needed for decision making. We examined the accuracy of "the surprise question" for 7-day, 21-day, and 42-day survival in hospitalized patients admitted to palliative care units (PCUs).

METHOD

This was a prospective multicenter cohort study of 130 adult patients with advanced cancer admitted to 7 hospital-based PCUs in South Korea. The accuracy of "the surprise question" was compared with that of the temporal question for clinician's prediction of survival.

RESULTS

We analyzed 130 inpatients who died in PCUs during the study period. The median survival was 21.0 days. The sensitivity, specificity, and overall accuracy for the 7-day "the surprise question" were 46.7, 88.7, and 83.9%, respectively. The sensitivity, specificity, and overall accuracy for the 7-day temporal question were 6.7, 98.3, and 87.7%, respectively. The c-indices of the 7-day "the surprise question" and 7-day temporal question were 0.662 (95% CI: 0.539-0.785) and 0.521 (95% CI: 0.464-0.579), respectively. The c-indices of the 42-day "the surprise question" and 42-day temporal question were 0.554 (95% CI: 0.509-0.599) and 0.616 (95% CI: 0.569-0.663), respectively.

SIGNIFICANCE OF RESULTS

Surprisingly, "the surprise questions" and temporal questions had similar accuracies. The high specificities for the 7-day "the surprise question" and 7- and 21-day temporal question suggest they may be useful to rule in death if positive.

Effects of sarcopenia and malnutrition on morbidity and mortality in gynecologic cancer surgery: results of a prospective study

BACKGROUND

Malnutrition and sarcopenia often occur simultaneously in cancer patients and are thought to have harmful effects on both surgical and oncological outcomes. Therefore, we want to evaluate the effects of sarcopenia and malnutrition on severe postoperative complications and overall survival in gynecologic cancer patients.

METHODS

We assessed nutritional parameters and run a bioelectrical impedance analysis in 226 women. Extracellular mass to body cell mass index, phase angle alpha, muscle mass, and fat mass were evaluated. To determine if patients suffer from sarcopenia, we ran the Timed 'Up and Go' test, performed hand grip strength, and calculated a skeletal muscle index. Postoperative complications were categorized using Clavien-Dindo Classification. Utilizing ROC analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. Kaplan-Meier method and log-rank test were used for overall survival analysis.

RESULTS

Of the 226 female patients, 120 (53%) had a BMI ≥ 25 kg/m2 , 56 (26%) had a phase angle < 4.75°, and 68 (32%) were sarcopenic according to skeletal muscle index < 27%. Within 30 days after surgery, 40 (18%) patients developed severe postoperative complications, and 4% had died. According to multivariable regression analysis, ECOG status > 1 (OR 4.56, 95% CI: 1.46-14.28, P = 0.009), BMI ≥ 25 kg/m2 (OR 8.22, 95% CI: 3.01-22.48, P < 0.001), phase angle < 4.75° (OR 3.95, 95% CI: 1.71-9.10, P = 0.001), and tumour stage ≥ III A (OR 3.65, 95% CI: 1.36-9.76, P = 0.01) were predictors of severe postoperative complications. During 59 months of follow-up, 108 (48%) patients had died. According to multivariable Cox regression ECOG status > 1 (HR 2.51, 95% CI: 1.25-5.03, P = 0.01), hypoalbuminemia (HR 2.15, 95% CI: 1.28-3.59, P = 0.004), phase angle < 4.5° (HR 1.76, 95% CI 1.07-2.90, P = 0.03), tumour stage ≥ III A (HR 2.61, 95% CI: 1.53-4.45, P < 0.001), and severe postoperative complications (HR 2.82, 95% CI: 1.80-4.41, P < 0.001) were predictors of overall mortality.

CONCLUSIONS

We observed that preoperatively assessed ECOG status > 1, BMI > 25 kg, as well as phase angle alpha < 4.75° and FIGO stage ≥ III A are significantly associated with severe postoperative complications within the first month. Whereas ECOG status > 1, hypoalbuminemia, phase angle < 4.5° as well as FIGO stage ≥ III A and severe postoperative complications within 30 days correlate significantly with poor overall survival.

Clinical Significance of TNFRSF1A36T/C Polymorphism in Cachectic Patients with Chronic Heart Failure

Introduction: One of the main factors contributing to the development of nutritional deficits in chronic heart failure (CHF) patients is the systemic inflammatory process. Progressing inflammatory response leads to exacerbation of the disease and could develop into cardiac cachexia (CC), characterized by involuntary weight loss followed by muscle wasting. The aim of this study was to assess the relationship between rs767455 (36 T/C) of the TNFRSF1A and the occurrence of nutritional disorders in CHF patients with cachexia. Materials and Methods: We enrolled 142 CHF individuals who underwent cardiac and nutritional screening in order to assess cardiac performance and nutritional status. The relationship between TNFRSF1A rs767455 genotypes and patients' features was investigated. Results: A greater distribution of the TT genotype among cachectic patients in contrast to non-cachectic individuals was found (TT frequencies of 62.9% and 37.1%, respectively; p = 0.013). We noted a significantly lower albumin concentration (p = 0.039) and higher C-reactive protein (CRP) levels (p = 0.019) in patients with the TT genotype. Regarding cardiac parameters, CHF individuals bearing the TT genotype demonstrated a significant reduction in ejection fraction (EF) (p = 0.033) in contrast to other genotype carriers; moreover, they had a significantly higher concentration of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) in the blood (p = 0.018). We also noted a lower frequency of TT genotype carriers among individuals qualified as grades I or II of the New York Heart Association (NYHA) (p = 0.006). The multivariable analysis selected the TT genotype as an unfavorable factor related to a higher chance of cachexia in CHF patients (Odds ratio (OR) = 2.56; p = 0.036). Conclusions: The rs767455TT genotype of TNFRSF1A can be considered as an unfavorable factor related to a higher risk of cachexia in CHF patients.

Potential bioelectrical impedance analysis (BIA) parameters in prediction muscle strength in women with anorexia nervosa

OBJECTIVES

The role of physical activity in anorexia nervosa (AN) treatment has been investigated. Muscle strength (MS) reflects physical condition and can predict AN patients' response to this novel treatment approach. This study was intended to find bioelectrical impedance analysis (BIA) parameters that predict AN patients' MS.

METHODS

The study included 42 AN patients and 42 healthy ones in the control group. BIA parameters that predict MS were assessed by dividing AN patients into groups by their hand grip strength test score (higher/lower than 22.5 kg).

RESULTS

The highest accuracy for distinguishing AN subjects from the control group was achieved by cell membrane capacitance (AUC = 0.916), impedance at 200 kHz and 5 kHz ratio (AUC = 0.924), phase angle (PA) 5 kHz (AUC = 0.906) and PA 50 kHz (AUC = 0.919). The low MS group had significantly lower values of PA 50 kHz (mean: 4.03 ± 0.80° vs. 4.58 ± 0.65°; p = 0.032) and fat-free mass index (mean: 12.22 ± 1.41 kg/m² vs. 13.14 ± 0.94 kg/m²; p = 0.026). In the univariate model, PA 50 kHz ≥4.037° was associated with the lowest chance of muscle weakness (OR = 0.230; p = 0.005). In the multivariate analysis, PA 50 kHz was the only significant factor of MS (OR = 0.01; p = 0.027).

CONCLUSIONS

PA 50 kHz is the best BIA parameter to predict MS in AN patients. It could be useful for assessment before physical activity treatment application.

Is phase angle a valuable prognostic tool in cancer patients' survival? A systematic review and meta-analysis of available literature

BACKGROUND & AIMS

The phase angle (PA), expressed via bioelectrical impedance, is an indicator of cell membrane health and integrity, hydration, and nutritional status, and may have further application as a prognostic marker in cancer survival. However, the associations between PA and cancer survival are inconsistent and unclear. The present systematic review and meta-analysis investigated the relationship between PA and survival among adult patients diagnosed with cancer.

METHODS

A systematic search of observational studies up to November 2020 was conducted through PubMed, Scopus, and ISI Web of Science. The critical appraisal of the eligible studies was performed using the Newcastle-Ottawa Quality Assessment Scale. Statistical analyses were performed using STATA 11.2 software. A P-value <0.05 was considered statistically significant.

RESULTS

A total of 14 studies covering 2625 participants were included in this study. There was a positive and significant correlation between PA and cancer survival (Fisher's Z: 0.30; 95% CI, 0.21-0.40; P < 0.001; I² = 0.0%). Also, there was a significant prognostic role for PA on patients' survival (HR 0.77; 95% CI, 0.74-0.81; P < 0.001; I² = 0.0%). In other words, patients with low values of PA were 23% less likely to survive than patients with high values of PA.

CONCLUSIONS

Given that predicting survival in advanced cancer patients remains a challenge, the findings of this systematic review and meta-analysis suggest that phase angle may be an important prognostic factor of survival in this population.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Low phase angle is associated with the risk for sarcopenia in unselected patients with cancer: Effects of hydration

OBJECTIVE

Individuals with cancer are affected by a loss of cell membrane integrity due to electrolyte imbalance between the intra- and extracellular fluids. Cell membrane integrity and hydration status can be assessed according to the phase angle (PhA) and the risk for sarcopenia, by using the Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) questionnaire. To our knowledge, this approach has not been validated in patients with cancer. The aims of this study were to verify the prevalence of the risk for sarcopenia, and to analyze the association between PhA and the risk for sarcopenia with and without adjustment for extracellular water content.

METHODS

This was a cross-sectional study conducted with 124 male and female cancer patients (77.4% men). PhA and hydration status were assessed using bioelectrical impedance analysis (BIA), and the risk for sarcopenia (cutoff ≥4) was assessed using the SARC-F questionnaire.

RESULTS

Of the 124 patients, 28 (22.5%) were at risk for sarcopenia (SARC-F ≥4). There was no association between PhA and the risk for sarcopenia in the crude model, nor in the model adjusted for age, sex, smoking, alcohol consumption, and physical activity, nor after adjusting for use of supplements, body mass index, treatment type, performance status, and type and stage of cancer. However, we found an association between lower PhA values and a higher risk for sarcopenia after adjusting for hydration abnormalities (odds ratio, 1.74; 95% confidence interval, 1.03-2.93; P < 0.035).

CONCLUSION

We found that 22.5% of patients with cancer presented with a risk for sarcopenia. Additionally, an association between lower PhA values and enhanced risk for sarcopenia highlighted the importance of adequate hydration and evaluation of fluid status via BIA as a new recommendation to prevent sarcopenia.

Dealing with prognostic uncertainty: the role of prognostic models and websites for patients with advanced cancer

PURPOSE OF REVIEW

To provide an updated overview of prognostic models in advanced cancer and highlight the role of prognostic calculators.

RECENT FINDINGS

In the advanced cancer setting, many important healthcare decisions are driven by a patient's prognosis. However, there is much uncertainty in formulating prognosis, particularly in the era of novel cancer therapeutics. Multiple prognostic models have been validated for patients seen by palliative care and have a life expectancy of a few months or less, such as the Palliative Performance Scale, Palliative Prognostic Score, Palliative Prognostic Index, Objective Prognostic Score, and Prognosis in Palliative Care Study Predictor. However, these models are seldom used in clinical practice because of challenges related to limited accuracy when applied individually and difficulties with model selection, computation, and interpretation. Online prognostic calculators emerge as tools to facilitate knowledge translation by overcoming the above challenges. For example, www.predictsurvival.com provides the output for seven prognostic indexes simultaneously based on 11 variables.

SUMMARY

Prognostic models and prognostic websites are currently available to augment prognostication in the advanced cancer setting. Further studies are needed to examine their impact on prognostic accuracy, confidence, and clinical outcomes.

Assessment of the Decision-Making Capacity for Clinical Research Participation in Patients With Advanced Cancer in the Last Weeks of Life

CONTEXT

Few studies have examined how clinicians assess decision-making capacity for research in the last weeks of life.

OBJECTIVES

We examined the decision-making capacity for participation in a research study and its association with clinician impression and delirium among patients with cancer with days to weeks of life expectancy.

METHODS

Patients admitted to our palliative and supportive care unit were approached for a prospective observational study. We assessed for their decision-making capacity based on clinical impression of physician and nurse, Memorial Delirium Assessment Scale (MDAS), and the MacArthur Competency Assessment Tool for Clinical Research (MacCAT-CR).

RESULTS

Among the 206 patients, 131 patients (64%) did not require MacCAT-CR assessment because they were overtly delirious or unresponsive; 37 (18%) patients were alert but did not complete the MacCAT-CR assessment for other reasons, and 38 patients (18%) completed the MacCAT-CR assessment. Among these 38 patients, five (13%) patients were incapable and had normal albeit significantly higher MDAS scores compared with those who were capable (1.8 vs. 4.2; P = 0.002). Compared against MacCAT-CR and MDAS, the overall agreement with capacity assessment with a clinician was 88% (95% CI 82-93) for physicians and 90% (95% CI 82-94) for nurses. The area under the receiver operating characteristics curve was 0.93 (95% CI 0.88-0.96) for physicians and 0.94 (95% CI 0.89-0.97) for nurses, suggesting high discrimination.

CONCLUSION

Most patients in the palliative and supportive care unit lacked decision-making capacity for participation in clinical research. Clinician impression had high accuracy. Few patients with normal MDAS were found to be incapable with MacCAT-CR assessment.

Phase Angle as a Marker of Muscular Strength in Breast Cancer Survivors

BACKGROUND

accurate prognostic tools are relevant for decision-making in cancer care. Objective measures, such as bioelectrical impedance (BI), have the potential to improve prognostic accuracy for these patients. This cross-sectional study aimed to investigate whether phase angle (PhA) derived from the electrical properties of the body tissues is a predictor of muscular strength in breast cancer survivors (BCS).

METHODS

a total of 41 BCS (age 54.6 ± 9.2 years) were evaluated. PhA, obtained at frequency 50 kHz, was assessed with BI spectroscopy, and muscular strength with a handgrip dynamometer. Moderate-to-vigorous physical activity (MVPA) was assessed using the International Physical Activity Questionnaire (IPAQ). Measurements were performed in the morning after an overnight fast.

RESULTS

linear regression analysis showed that PhA accounted for 22% (r² = 0.22) of muscular strength variance. PhA remained a borderline predictor of muscular strength variance independently of age and MVPA.

CONCLUSIONS

the findings of this study suggest that PhA is a significant predictor of maximal forearm isometric strength and a potential indicator of disease-related functionality in BCS.

Cachexia in Cancer Patients: Systematic Literature Review

Introduction Cachexia in cancer patients, especially in advanced stage, is recently known as an emerging problem. Cachexia occurs in about half of all patients with neoplastic disease. The diagnosis of cachexia needs comprehensive evaluation of body weight and body composition for several months. Cachexia will give negative impacts such as increased mortality, chemotoxicity, and decreased quality of life. Here, we review the current evidence describing the definition, stages, mechanisms, diagnosis and treatment of cachexia in cancer patients.

Methods We identified 75 studies and/or review articles evaluating cachexia and weight loss in cancer patients by searching PubMed and EMBASE databases.

Results Cachexia is reported across all stages and types of cancers. The most recent definition of cachexia is reported in a 2011 paper by International Consensus. The mechanism of cachexia in cancer is complex and involved many factors which elaborate together to produce cachexia. The diagnostic evaluation and cut-off measurement of cachexia, especially in cancer varied across studies. The loss of weight that happens during chemotherapy will make a poor prognosis. Cachexia can worsen chemotherapy toxicity. Combination of dietary modification and exercise with supplementation of medication that control appetite and inflammation are important in the management of cachexia in cancer patients.

Conclusion Patients with cancer are the population at risk for developing cachexia before and after chemotherapy. Cachexia diagnosis needs evaluation of body weight and body composition. Nonpharmacological treatments, such as dietary modification and physical exercise, are the best strategy to reduce cachexia in cancer patients.

Impact of phase angle on postoperative prognosis in patients with gastrointestinal and hepatobiliary-pancreatic cancer

OBJECTIVE

Phase angle (PhA), by bioelectrical impedance analysis, has been used in patients with several diseases; however, its prognostic value in patients with gastrointestinal (GI) and hepatobiliary-pancreatic (HBP) cancer is unclear. The aim of the present study was to investigate the effects of PhA on postoperative short- outcomes and long-term survival in these patients.

METHODS

This retrospective study reviewed data from 501 patients with GI and HBP cancers who underwent first resection surgery. The data were divided into the following groups according to the preoperative PhA quartile values by sex: high-PhA group with the highest quartile (Q4), normal-PhA group with middle quartiles (Q3 and Q2), and low-PhA group with the lowest quartile (Q1). Preoperative nutritional statuses, postoperative short-term outcomes during hospitalization, and 5-y survival between three groups were compared. Cox proportional hazard models were used to evaluate the prognostic effect of PhA.

RESULTS

PhA positively correlated with body weight, skeletal muscle mass, and handgrip strength, and negatively correlated with age and levels of C-reactive protein. The low-PhA group showed a higher prevalence of malnutrition (48%) than normal-PhA (25%), and high-PhA groups (9%; P < 0.001). The incidence of postoperative severe complications was 10% for all patients (14% in low-PhA, 12% in normal-PhA, and 4% in high-PhA; P = 0.018). The incidence of prolonged stays in a postoperative high-care or intensive care unit was 8% in all patients (16% in low-PhA, 8% in normal-PhA, and 2% in high-PhA; P < 0.001). The 5-y survival rate was 74% in all patients (68% in low-PhA, 74% in normal-PhA, and 79% in high-PhA; P < 0.001). The multivariate analysis demonstrated that a low-PhA group was an independent risk factor for mortality (hazard ratio, 1.99; 95% confidence interval, 1.05-3.90; P = 0.034).

CONCLUSION

PhA is a useful short-term and long-term postoperative prognostic marker for patients with GI and HBP cancers.

Can Bioelectrical Impedance Analysis and BMI be a Prognostic Tool in Head and Neck Cancer Patients? A Review of the Evidence

Background: Malnutrition can significantly affect disease progression and patient survival. The efficiency of weight loss and bioimpedance analysis (BIA)-derived measures in the evaluation of malnutrition, and disease progression and prognosis in patients with head and neck cancer (HNC) are an important area of research. Method: The PubMed database was thoroughly searched, using relative keywords in order to identify clinical trials that investigated the role of BIA-derived measures and weight loss on the disease progression and prognosis of patients with HNC. Twenty-seven studies met the criteria. More specifically, six studies examined the prognostic role of the tissue electrical properties in HNC patients; five examined the role of the tissue electrical properties on identifying malnutrition; four studies looked at the changes in the tissue electrical properties of HNC patients; and 12 examined the prognostic role of weight loss on survival and/or treatment outcomes. Results: Several studies have investigated the role of nutritional status tools on prognosis in HNC patients. Current studies investigating the potential of BIA-derived raw data have shown that phase angle (PA) and capacitance of the cell membrane may be considered prognostic factors of survival. Weight loss may be a prognostic factor for treatment toxicity and survival, despite some conflicting evidence. Conclusions: Further studies are recommended to clarify the role of BIA-derived measures on patients’ nutritional status and the impact of PA on clinical outcomes as well as the prognostic role of weight loss.

Predictivity of bioimpedance phase angle for incident disability in older adults

BACKGROUND

Bioelectrical impedance analysis (BIA)-derived phase angle is expected to be an efficient prognostic marker of health adverse events with aging as an alternative of muscle mass. We aimed to examine the predictive ability of phase angle for incident disability in community-dwelling elderly and determine the optimal cut-off values.

METHODS

Community-dwelling elderly aged ≥65 years (n = 4452; mean age = 71.8 ± 5.3 years, 48.3% women) without disability at baseline participated in this prospective cohort study. Phase angle and appendicular skeletal muscle mass (ASM) were examined using a multi-frequency BIA at baseline. Other potential confounding factors (demographics, cognitive function, depressive symptoms, medications, and physical performance) were also assessed. Incident disability was monitored on the basis of long-term care insurance certification.

RESULTS

Over a follow-up of 24 months, 4.0% (n = 174) experienced disability, with an overall incidence rate of 20.6 per 1000 person-years. The Cox hazard regression analysis showed that phase angle, as a continuous variable, was independently associated with incident disability after adjusting the covariates [male: hazard ratios (HRs) = 0.61, 95% confidence interval (CI) = 0.37-0.98; female: HR = 0.58, 95% CI = 0.37-0.90], although body mass index adjusted ASM was not. Receiver operating characteristic analysis indicated moderate predictive abilities of phase angle for incident disability [male: area under the receiver operating characteristic curve (AUC) = 0.76, 95% CI = 0.70-0.83; female: AUC = 0.71, 95% CI = 0.65-0.76], while those of body mass index adjusted ASM were low (male: AUC = 0.59, 95% CI = 0.521-0.66; female: AUC = 0.58, 95% CI = 0.52-0.63). Multivariate Cox regression analysis showed that low phase angle categorized by cut-off value (male, ≤4.95°; female, ≤4.35°) was independently related to increased risk of incident disability (HR = 1.95, 95% CI = 1.37-2.78).

CONCLUSIONS

Lower phase angle independently predicts the incident disability separately from known risk factors. BIA-derived phase angle can be used as a valuable and simple prognostic tool to identify the elderly at risk of disability as targets of preventive treatment.

Collapse of Fluid Balance and Association with Survival in Patients with Advanced Cancer Admitted to a Palliative Care Unit: Preliminary Findings

Background: Few studies have investigated water balance as a predictor of survival in cancer patients in the last days of life. Objective: To examine the association between extracellular water (ECW), intracellular water (ICW), ratio of ECW to ICW (ECW/ICW), and survival in nonedematous and edematous patients with advanced cancer admitted to a palliative care unit. Design: A prospective observational study. Setting/Subjects: Patients with advanced cancer admitted to a palliative care unit. Measurements: Upon enrollment, bioelectrical impedance analysis was used to assess ECW, ICW, and body composition. We conducted time-to-event analyses using the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression analyses. Results: A total of 190 of 204 patients who participated in this study had ICW and ECW measures available for analysis. The median survival was 10 days (95% confidence interval [CI] 9-12) days. The median ECW, ICW, and ECW/ICW were 18.9 L, 19.1 L, and 1.0 for 72 nonedematous patients, and 21.9 L, 20.1 L, and 1.1 for 118 edematous patients, respectively. In univariate Cox regression analysis, ICW ≤20 L was associated with a shorter survival in the nonedematous patients (hazard ratio [HR] 1.92, 95% CI 1.10-3.34, p = 0.02) and a longer survival in the edematous patients (HR 0.61, 95% CI 0.41-0.90, p = 0.01). In multivariable analysis, ICW (≤20 L vs. >20 L) remained an independent prognostic factor in edematous patients (HR 0.64, 95% CI 0.43-0.95, p = 0.03). Conclusions: Greater ICW was an independent predictor of poorer survival in cancer patients with edema in the last days of life.

Anthropometrical and Bioelectrical Impedance Analysis Parameters in Anorexia Nervosa Patients' Nutritional Status Assessment

Background and Objectives: Body mass index (BMI) is still the only recommended measurable nutritional status assessment parameter in anorexia nervosa (AN). The aim of this study was to measure other anthropometrical and bioelectrical impedance analysis (BIA) parameters in AN patients and to evaluate their nutritional status assessment value. Materials and Methods: The 46 AN female patients were examined at the beginning of hospitalization and followed-up in three measurements (in 6 ± 2 weeks’ intervals). Anthropometrical assessment was based on BMI, circumferences of arm, calf, thigh, hips, waist, their ratio (waist-to-hip ratio (WHR)), and a skinfold test over biceps and triceps muscle, under the scapula, over the hip, and 2 cm from the umbilicus. The BIA parameters included phase angle (PA), membrane capacitance (Cm), and impedance at 200 kHz, and a 5 kHz ratio (Z_200/5). Results: In the 1st measurement, BMI correlated with all anthropometric and BIA parameters (p < 0.05). For BIA parameters, the correlation included arm circumference and WHR (p < 0.05). In the follow-up, significant changes were observed in BMI and all BIA parameters. The correlation between BMI and all BIA parameters was present in the 2nd and 3rd measurements (p < 0.05). In the 4th measurement, BMI correlated only with Cm (p = 0.0114). Comparison of BIA parameters according to the state of starvation (BMI < 16.0 kg/m²) revealed that all studied BIA parameters were characterized by statistically significant sensitivity and specificity in the detection of this condition (p < 0.05), except PA in the 4th measurement (p = 0.2099). Conclusions: Selected BIA and anthropometrical parameters could be used for AN patients’ assessment. The study confirmed dynamic changes of BIA parameters during the follow-up. They could be useful in the detection of the state of starvation.

Recognizing the Dying Patient, When Less Could be More: A Diagnostic Framework for Shared Decision-Making at the End of Life

Background

Recognizing dying patients is crucial to produce outcomes that are satisfactory to patients, their families, and clinicians.

Aim

Earlier discussion of and shared decision-making around dying to improve these outcomes.

Design

In this study, we interviewed 16 senior clinicians to develop summaries of palliative care in 4 key specialties: Cardiology, Vascular Surgery, Emergency General Surgery, and Intensive Care.

Setting

Oxford University Hospitals.

Results

Based on themes common to our 4 clinical areas, we developed a novel diagnostic framework to support shared palliative decision-making that can be summarized as follows: 1) Is the acute pathology reversible? 2) What is the patient's physiological reserve? 3) What is important to the patient? Will they be fit enough for discharge for a reasonable length of time?

Conclusions

We believe that education using this framework in the medical school and postgraduate curricula would significantly improve recognition of dying patients. This would serve to stimulate earlier conversations, more shared decision-making, and ultimately better outcomes in palliative care and patient experience.

Association Between Plasma Brain Natriuretic Peptide and Overall Survival in Patients With Advanced Cancer: Preliminary Findings

CONTEXT

Atrial and brain natriuretic peptides (ANP and BNP) are established diagnostic and prognostic markers in heart failure, but their utility in patients with advanced cancer is unclear.

OBJECTIVES

Our objective was to examine the association between plasma natriuretic peptides and survival in patients with advanced cancer without clinical evidence of heart failure.

METHODS

This exploratory analysis of a multicenter, randomized clinical trial of cancer patients receiving hospice care assessed the association between elevated plasma ANP, BNP, or Pro-BNP (cutoffs of >77, 100, and 900 pg/mL, respectively) and overall survival. Time-to-event analyses, including multivariate Cox regression, were conducted.

RESULTS

Among 97 patients, the mean age was 67.2 years and the overall survival was 16 days (95% CI, 13-23 days). ANP, BNP, and Pro-BNP were elevated in 29 of 36 (81%), nine of 23 (39%), and 32 of 38 (84%) patients, respectively. Elevated ANP, BNP, or Pro-BNP was associated with worse survival (median 14 vs. 21 days; P = 0.02). BNP or Pro-BNP was inversely associated with overall survival (hazard ratio = 2.27; 95% CI, 1.29-3.97) in univariate Cox regression analysis, and remained significant in multivariate Cox regression analysis (hazard ratio = 3.09; 95% CI, 1.40-6.84) after adjusting for treatment group and known prognostic variables such as performance status, albumin, creatinine, delirium, dyspnea, and anorexia. Elevated ANP alone was not significantly associated with survival (P = 0.17).

CONCLUSION

Our preliminary findings suggest that BNP or Pro-BNP may be a novel objective prognostic marker in cancer patients without heart failure. Further research is needed to confirm these findings.

ADIPONECTIN, VITAMIN D AND NUTRITIONAL STATUS IN PATIENTS WITH ADVANCED COLORECTAL CANCER OR DURING FOLLOW-UP

BACKGROUND

Considering the high incidence of colorectal cancer (CRC) related deaths, many studies have investigated variables that can affect survival, with the aim of prolonging survival. The nutritional status can also be predict survival in patients with CRC.

OBJECTIVE

The aim of the present study was to evaluate if BMI, %FAT, PhA, PG-SGA, adiponectin levels, and vitamin D levels are relevant to the characterization and differentiation of patients with advanced CRC and patients with a history of CRC.

METHODS

The study was carried out by patients with advanced colorectal cancer (Group 1) and patients in follow-up after colorectal cancer treatment (Group 2). Nutritional status was assessed using the body mass index, body fat percentage, phase angle from bioelectrical impedance, Patient-Generated Subjective Global Assessment score. Adiponectin concentrations were determined using an enzyme-linked immunosorbent assay, and vitamin D levels were measured using high performance liquid chromatography.

RESULTS

Groups 1 and 2 consisted of 23 and 27 patients, respectively. The body mass index, body fat percentage, phase angle, vitamin D and adiponectin levels were not significantly different between the groups. The mean Patient-Generated Subjective Global Assessment score was significantly higher in group 1 compared with group 2, and was significantly correlated with the long-term mortality risk.

CONCLUSION

Among the nutritional status parameters, only the Patient-Generated Subjective Global Assessment score was significantly different between the groups and was an important predictor of survival in patients with advanced colorectal cancer.

Impact of genetic mutations and nutritional status on the survival of patients with colorectal cancer

Background

The prognosis of colorectal cancer (CRC) patients can be influenced by genetic mutations and nutritional status. The relationship between these variables is unclear. The objective of the study was to verify the variables involved in the nutritional status and genetic mutations, which correlate with survival of CRC patients.

Methods

Patients with surgical intervention for tumor resection were evaluated using body mass index, nutritional screening, patient self-produced global subjective assessment, phase angle, and computed tomography to calculate the areas of visceral adipose tissue (VAT) and subcutaneous adipose tissue, and muscle mass for the determination of sarcopenia. Ten gene mutations involved in CRC carcinogenesis were studied (PIK3CA, KRAS, BRAF, EGFR, NRAS, TP53, APC, PTEN, SMAD4, and FBXW7). DNA was extracted from fresh tumor or paraffin tissues.

Results

Of the 46 patients, 29 (64.4%) were at nutritional risk and 21 (45.7%) were moderately malnourished. However, there was a high percentage of VAT in 24 (61.5%) and sarcopenia in 19 (48.7%) patients. These variables were associated with a higher risk of mortality. Nutritional risk, moderate or severe malnutrition, phase angle < 5°, VAT < 163.8 cm² in men and <  80.1 cm² in women, and sarcopenia were associated with the relative risk of death, with respective hazard ratios/odds ratios and 95% confidence intervals of 8.77 (1.14–67.1), 3.95 (1.11–14.0), 3.79 (1.10–13.1), 3.43 (1.03–11.4), and 3.95 (1.06–14.6). Increased VAT was associated with a lower risk of death, even in patients older than 60 years or those harboring mutated KRAS.

Conclusions

Patients with positive indicators for malnutrition or risk of malnutrition had an increased risk of death. No relationship was identified between the presence of mutations and survival.

Prognostication in advanced cancer: update and directions for future research

The objective of this review is to provide an update on prognostication in patients with advanced cancer and to discuss future directions for research in this field. Accurate prognostication of survival for patients with advanced cancer is vital, as patient life expectancy informs many important personal and clinical decisions. The most common prognostic approach is clinician prediction of survival (CPS) using temporal, surprise, or probabilistic questions. The surprise and probabilistic questions may be more accurate than the temporal approach, partly by limiting the time frame of prediction. Prognostic models such as the Glasgow Prognostic Score (GPS), Palliative Performance Scale (PPS), Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI), or Prognosis in Palliative Care Study (PiPS) predictor model may augment CPS. However, care must be taken to select the appropriate tool since prognostic accuracy varies by patient population, setting, and time frame of prediction. In addition to life expectancy, patients and caregivers often desire that expected treatment outcomes and bodily changes be communicated to them in a sensible manner at an appropriate time. We propose the following 10 major themes for future prognostication research: (1) enhancing prognostic accuracy, (2) improving reliability and reproducibility of prognosis, (3) identifying the appropriate prognostic tool for a given setting, (4) predicting the risks and benefits of cancer therapies, (5) predicting survival for pediatric populations, (6) translating prognostic knowledge into practice, (7) understanding the impact of prognostic uncertainty, (8) communicating prognosis, (9) clarifying outcomes associated with delivery of prognostic information, and (10) standardizing prognostic terminology.

Low Phase Angle Is Correlated With Worse General Condition in Patients with Advanced Cancer

OBJECTIVES

Phase angle (PA) is a poor prognostic factor in patients with advanced cancer. This study aimed to identify possible correlations between PA and symptoms, quality of life, fluid retention, and laboratory data in cancer patients in palliative care settings.

METHODS

Individuals who visited the outpatient clinic or were admitted to the palliative care unit were eligible. Patients with a performance status of 4 and/or those unable to complete questionnaires were excluded. PA was evaluated using a bioanalyzer device. The correlation coefficient between PA and the variables of interest was analyzed.

RESULTS

A total of 102 patients were analyzed. PA was weakly correlated with age (ρ = -0.22), performance status (ρ = -0.30), functional well-being (ρ = 0.20), anorexia/cachexia subscale (ρ = 0.22), and Functional Assessment of Anorexia/Cachexia Therapy trial outcome index (ρ = 0.26). PA was also correlated with fluid retention (ρ = -0.34) and albumin (ρ = 0.32), C-reactive protein (ρ = -0.31), and hemoglobin (ρ = 0.41) levels. Sub-analysis stratified according to sex revealed that males demonstrated the same results; however, female sex demonstrated a correlation between PA and social well-being (ρ = -0.43).

CONCLUSIONS

PA was correlated with physical condition, but not with psychological well-being.

Body composition and phase angle as an indicator of nutritional status in children with juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic, systemic autoimmune connective tissue disease diagnosed in children and adolescents. An important aspect of monitoring of children with JIA is a precise assessment of the nutritional status to identify children and adolescents at risk of malnutrition. The aim of the study was to assess the body composition and phase angle in children diagnosed with JIA in comparison to age and sex matched healthy children since there are scarce reports in paediatric patients.

METHODS

A total of 46 children and adolescents aged 4-18 years, with JIA were included in the cross-sectional study. Controls were selected from the group of healthy children and adolescents. Children with diagnosed JIA and healthy children were strictly matched for age and gender. In both groups BIA with phase angle calculation was performed.

RESULTS

Phase angle score was significantly lower in the study group compared to control group (5.45 ± 0.64 vs. 5.85 ± 0.80, p = 0.010). Also lower percentage of body cell mass (50.63 ± 3.46 vs. 52.70 ± 4.06, p = 0.010) and muscle mass (46.02 ± 6.32 vs. 49.53 ± 6.67, p = 0.005) were revealed. In the analysis of subtypes of JIA we found significant differences between children and adolescents with polyarthritis compared to control group, while no significant differences were found between patients with oligoarthritis and control group.

CONCLUSIONS

The obtained results indicate a higher risk of malnutrition in children and adolescents with JIA compared to healthy peers, predominantly in patients with polyarthritis.