Validity of the malnutrition screening tool as an effective predictor of nutritional risk in oncology outpatients receiving chemotherapy

Social and Legal Needs in Patients and Families With Cancer: Interaction With Patient-Level Financial Toxicity

Adverse financial burden and its effect on patients resulting from the costs associated with cancer care, both direct and indirect, is known as financial toxicity. This review explores the interplay between financial toxicity and key social and legal needs in cancer care. Drawing from the WHO's framework and the ASCO's policy statement on social determinants of health, we propose a conceptual model that discusses five key needs-housing insecurity, food insecurity, transportation and access barriers, employment disruptions, and psychosocial needs-which interact with, and are affected by financial toxicity, and adversely influence patients' well-being and adherence to treatment. We review literature addressing the scope of each of these key needs, their effect on patients with cancer, and how each increases the overall burden of cancer treatment. There is an emphasis on both the patient and the caregiver as one unit navigating through cancer treatment together. The aim is to guide interventions at the patient-provider, institutional, and policy levels that alleviate financial toxicity and improve overall care delivery for patients and caregivers by addressing underappreciated social and legal needs.

Deep Learning-Based Body Composition Analysis for Cancer Patients Using Computed Tomographic Imaging

Malnutrition is a commonly observed side effect in cancer patients, with a 30-85% worldwide prevalence in this population. Existing malnutrition screening tools miss ~ 20% of at-risk patients at initial screening and do not capture the abnormal body composition phenotype. Meanwhile, the gold-standard clinical criteria to diagnose malnutrition use changes in body composition as key parameters, particularly body fat and skeletal muscle mass loss. Diagnostic imaging, such as computed tomography (CT), is the gold-standard in analyzing body composition and typically accessible to cancer patients as part of the standard of care. In this study, we developed a deep learning-based body composition analysis approach over a diverse dataset of 200 abdominal/pelvic CT scans from cancer patients. The proposed approach segments adipose tissue and skeletal muscle using Swin UNEt TRansformers (Swin UNETR) at the third lumbar vertebrae (L3) level and automatically localizes L3 before segmentation. The proposed approach involves the first transformer-based deep learning model for body composition analysis and heatmap regression-based vertebra localization in cancer patients. Swin UNETR attained 0.92 Dice score in adipose tissue and 0.87 Dice score in skeletal muscle segmentation, significantly outperforming convolutional benchmarks including the 2D U-Net by 2-12% Dice score (p-values < 0.033). Moreover, Swin UNETR predictions showed high agreement with ground-truth areas of skeletal muscle and adipose tissue by 0.7-0.93 R2, highlighting its potential for accurate body composition analysis. We have presented an accurate body composition analysis based on CT imaging, which can enable the early detection of malnutrition in cancer patients and support timely interventions.

SEOM clinical guidelines for cancer anorexia-cachexia syndrome (2023)

Cancer-related anorexia-cachexia syndrome (CACS) is a debilitating condition afflicting up to 80% of advanced-stage cancer patients. Characterized by progressive weight loss, muscle wasting, and metabolic abnormalities, CACS significantly compromises patients' quality of life and treatment outcomes. This comprehensive review navigates through its intricate physiopathology, elucidating its stages and diagnostic methodologies. CACS manifests in three distinct stages: pre-cachexia, established cachexia, and refractory cachexia. Early detection is pivotal for effective intervention and is facilitated by screening tools, complemented by nutritional assessments and professional evaluations. The diagnostic process unravels the complex interplay of metabolic dysregulation and tumor-induced factors contributing to CACS. Management strategies, tailored to individual patient profiles, encompass a spectrum of nutritional interventions. These include dietary counseling, oral nutritional supplements, and, when necessary, enteral nutrition and a judicious use of parenteral nutrition. Specific recommendations for caloric intake, protein requirements, and essential nutrients address the unique challenges posed by CACS. While pharmacological agents like megestrol acetate may be considered, their use requires careful evaluation of potential risks. At its core, this review underscores the imperative for a holistic and personalized approach to managing CACS, integrating nutritional interventions and pharmacological strategies based on a nuanced understanding of patient's condition.

Exercise capacity prior to major cancer surgery: A cross-sectional observational study of the validity of the 6-minute walk and 30-second sit-to-stand tests

INTRODUCTION

Cardiopulmonary exercise testing (CPET) is the gold standard for measuring exercise capacity, however, it is resource intensive and has limited availability. This study aimed to determine: 1) the association between the 6-min walk test (6MWT) and the 30-s sit-to-stand test (30STS) with CPET peak oxygen uptake (VO2peak) and anaerobic threshold (AT) and 2) 6MWT and 30STS cut points associated with a higher risk of postoperative complications.

METHODS

A cross-sectional study, retrospectively analyzing data collected from a tertiary cancer center over a 23-month period. Measures included CPET VO2peak and AT, 6MWT and 30STS test. Correlations were used to characterize relationships between variables. Receiver operating characteristic curve analyses determined 6MWT and 30STS cut points that aligned with CPET variable cut points.

RESULTS

Note that, 156 participants were included. The 6MWT and 30STS displayed moderate correlations with VO2peak, rho = 0.65, p = 0.01 and rho = 0.52, p < 0.005 respectively. Fair correlations were observed between AT and 6MWT (rho = 0.36, p = 0.01) and 30STS (rho = 0.41, p < 0.005). The optimal cut points to identify VO2peak < 15 mL/kg/min were 493.5 m on the 6MWT and 12.5 stands on the 30STS test and for AT < 11 mL/kg/min were 506.5 m on the 6MWT and 12.5 stands on the 30STS test.

CONCLUSION

Both the 6MWT and 30STS test could be used as alternative tools for measuring exercise capacity preoperatively in the cancer setting where CPET is not available. A range of 6MWT and 30STS cut points, according to sensitivity and specificity levels, may be used to evaluate risk of postoperative outcomes.

Evaluation of nutrition components within prehabilitation programs in gastrointestinal cancers: Is prehab worth the hype?

Nutrition impact symptoms and unintended weight loss are prevalent in patients with gastrointestinal cancers, especially during the perioperative period or while prescribed anticancer treatments. Because patients may experience loss of lean body mass and malnutrition, aggressive nutrition intervention prior to surgery should be considered. Cancer prehabilitation is a process spanning the care continuum from diagnosis to the time of surgery encompassing nutrition support, psychological and physical assessment, and targeted interventions. Thirteen studies published between 2013 and 2023 were included in this review and evaluated prehabilitation programs' impact on postoperative outcomes in patients with gastrointestinal cancers. Literature continues to emerge supporting the integration of nutrition into a prehabilitation program because of its potential to contribute to improved clinical outcomes, quality of life, and cost-effectiveness, but considerable variation exists with respect to the specific recommendations provided by current prehabilitation programs.

Geriatric Nutritional Risk Index and the Survival of Patients with Hepatocellular Carcinoma: A Meta-Analysis

Malnutrition is a risk factor of adverse clinical outcome in patients with cancer. Recent studies suggest that geriatric nutritional risk index (GNRI) could reflect the nutritional status in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to evaluate the association between GNRI and survival of patients with hepatocellular carcinoma (HCC). Observational studies evaluating the association between pretreatment GNRI and survival of patients with HCC were obtained by search of PubMed, Web of Science, Embase, Wanfang, and CNKI databases. A random-effects model was used to pool the results after incorporating the potential influence of heterogeneity. Seven cohort studies including 2636 patients with HCC contributed to the meta-analysis. Pooled results showed that HCC patients with low pretreatment GNRI were associated with poor overall survival [hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.32 to 2.37, p<0.001; I2=66%) and progression-free survival (HR: 1.62, 95% CI: 1.39 to 1.89, p<0.001; I2=0%) as compared to those with normal GNRI. Sensitivity analyses by excluding one study at a time showed similar results (p all<0.05). Subgroup analyses showed that the association between low pretreatment GNRI and poor survival of patients with HCC was not significantly affected by age of the patients, main treatment, cutoff of GNRI, or the follow-up durations. In conclusion, malnutrition indicated by a low pretreatment GNRI may be a risk factor of poor survival of patients with HCC.

Poor Muscle Status, Dietary Protein Intake, Exercise Levels, Quality of Life and Physical Function in Women with Metastatic Breast Cancer at Chemotherapy Commencement and during Follow-Up

This study aimed to investigate nutritional status, body composition, dietary protein intake, handgrip strength, 6 min or 4 m walk tests, self-reported physical activity, physical function, and quality of life (QoL-EORTC-QLQc30) at commencement of chemotherapy; to detect changes over time (from commencement of chemotherapy, and after 3, 6, 12, 26 and 52 weeks) in women with metastatic breast cancer (MBC); and to investigate the relationship between nutritional variables. 'Sarcopenia' was defined as low muscle mass and strength, 'myosteatosis' as muscle fat-infiltration (CT scan). Continuous variables were analysed using paired t-tests between baseline and follow-ups. Fifteen women (54y, 95% CI [46.3;61.2]) were recruited. At baseline, malnutrition was present in 3 (20%) participants, sarcopenia in 3 (20%) and myosteatosis in 7 (54%). Thirteen (87%) participants had low protein intake; low handgrip strength was observed in 0, and low walk test distance and physical activity in four (27%) participants. Physical function and QoL were low in 10 (67%) and 9 (60%), respectively. QoL between baseline and 52 weeks decreased by 11.7 (95% CI [2.4;20.9], p = 0.025). Other variables did not significantly change over time. In this small study sample, myosteatosis, low dietary protein intake, low exercise levels and impaired quality of life and physical function are common.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

Reprint of: Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults

It is the position of the Academy of Nutrition and Dietetics that, based upon current evidence, the Malnutrition Screening Tool should be used to screen adults for malnutrition (undernutrition) regardless of their age, medical history, or setting. Malnutrition (undernutrition) screening is a simple process intended to quickly recognize individuals who may have a malnutrition diagnosis. While numerous malnutrition screening tools are in use, their levels of validity, agreement, reliability, and generalizability vary. The Academy of Nutrition and Dietetics reviewed the body of evidence supporting malnutrition screening tools and determined a single tool for identifying adults in all settings who may have malnutrition, regardless of their age or medical history. The Nutrition Screening for Adults Workgroup conducted a systematic review of the most robust evidence to promote using the highest-quality malnutrition screening tool available.

Prevalence of malnourishment and predictive factors associated with the nutritional status of gynecologic cancer patients undergoing chemotherapy: a cross-sectional analysis

Objective

To investigate the prevalence and predictive factors of malnourishment in patients with gynecologic cancer during chemotherapy.

Methods

A total of 101 patients treated with chemotherapy between April 2020 and February 2021 were interviewed using the patient-generated subjective global assessment (PG-SGA). Clinical and laboratory data were also collected. The total number of lymphocytes per cubic milliliter (total lymphocyte count, TLC) and serum albumin were calculated to provide an optimal cut-off point using receiver operating characteristic curves. Clinicopathological variables were compared using univariate and multivariate analyses to identify the independent predictive factors for malnourishment.

Results

The prevalence of good, moderate, and severe nourishment was 73.3%, 18.8%, and 7.9%, respectively. The optimal cut-off points for TLC and albumin were 1,450 cells/μL and for albumin was 3.9 g/dL. Univariate analysis indicated that the number of chemotherapy cycles ≤3, albumin level ≤3.95 g/dL, body mass index ≤25 kg/m², TLC <1,450 cells/μL, anemia, and no neutropenia were significantly associated with malnutrition. However, only a serum albumin level ≤3.95 g/dL was independently associated with malnourishment.

Conclusion

Patients with gynecologic cancer treated with chemotherapy were occasionally found to be malnourished, with the independent predictive predictor being a blood albumin level less than or equal to 3.95 g/dL.

Malnutrition risk at solid tumor diagnosis: the malnutrition screening tool in a large US cancer institute

BACKGROUND

In cancer, malnutrition is common and negatively impacts tolerance and outcomes of anti-tumor therapies. The aim of this study was to evaluate the prevalence of malnutrition risk and compare the clinicodemographic features between those with high malnutrition screening tool (MST) scores (i.e., ≥ 2 of 5 = high risk for malnutrition, H-MST) to low scores (L-MST).

METHODS

A cohort of 3585 patients (May 2017 through December 2018), who completed the MST at least once at the time of diagnosis of any stage solid tumor, were analyzed. Logistic regression tested for associations between clinicodemographic factors, symptom scores, and H-MST prevalence.

RESULTS

The median age was 64 years (25-75 IQR, 55-72), with 62% females and 81% White. Most common tumor primary sites were breast (28%), gastrointestinal (GI) (21%), and thoracic (13%). Most had non-metastatic disease (80%). H-MST was found in 28%-most commonly in upper (58%) and lower GI (42%), and thoracic (42%) tumors. L-MST was most common in breast (90%). Multivariable regression confirmed that Black race (OR 1.9, 95% CI 1.5-2.4, p =  < 0.001), cancer primary site (OR 1.6-5.7, p =  < 0.001), stage IV disease (OR 1.8, 95% CI 1.4-2.2, p =  < 0.001), low BMI (OR 4.2, 95% CI 2.5-6.9 p =  < 0.001), and higher symptom scores were all independently associated with H-MST.

CONCLUSIONS

Twenty-eight percent of solid tumor oncology patients at diagnosis were at high risk of malnutrition. Patients with breast cancer rarely had malnutrition risk at diagnosis. Significant variation was found in malnutrition risk by cancer site, stage, race, and presence of depression, distress, fatigue, and trouble eating/swallowing.

Metagenomics and chemotherapy-induced nausea: A roadmap for future research

Uncontrolled chemotherapy-induced nausea and vomiting can reduce patients' quality of life and may result in premature discontinuation of chemotherapy. Although nausea and vomiting are commonly grouped together, research has shown that antiemetics are clinically effective against chemotherapy-induced vomiting (CIV) but less so against chemotherapy-induced nausea (CIN). Nausea remains a problem for up to 68% of patients who are prescribed guideline-consistent antiemetics. Despite the high prevalence of CIN, relatively little is known regarding its etiology independent of CIV. This review summarizes a metagenomics approach to the study and treatment of CIN with the goal of encouraging future research. Metagenomics focuses on genetic risk factors and encompasses both human (ie, host) and gut microbial genetic variation. Little work to date has focused on metagenomics as a putative biological mechanism of CIN. Metagenomics has the potential to be a powerful tool in advancing scientific understanding of CIN by identifying new biological pathways and intervention targets. The investigation of metagenomics in the context of well-established demographic, clinical, and patient-reported risk factors may help to identify patients at risk and facilitate the prevention and management of CIN.

Translation, validity, and reliability of NUTRISCORE: the nutrition risk assessment screening test for Turkish cancer patients

PURPOSE

The aim was to determine the validity and the reliability of the Turkish version of the screening test named NUTRISCORE in cancer patients.

METHODS

The language validity of the Turkish form of the study scale was provided by the translationback-translation method. NUTRISCORE and nutritional risk screening (NRS)-2002, malnutrition screening tool (MST), and European Diagnostic Criteria (EDC) were administered to 240 volunteers in oncology clinics, and receiver operating characteristic curves (ROC) were calculated for the validity and reliability analysis. Cohen's kappa coefficient was used to determine the fit between the screening tests.

RESULTS

Thirteen experts were consulted for scale content validity, and the content validity index was found to be 0.94. The scale was administered to 67 patients with 4-week intervals for test-retest reliability, and a positive, high-level and statistically significant relationship was found between the two measurements (r = 0.971, P < 0.01). Compared with the reference test NRS-2002, the specificity values of NUTRISCORE, MST, and EDC screening tests were found to be 100%, 83%, and 91%, whereas the sensitivity values of same screening tests were calculated as 85%, 91% and 81%, respectively. According to Cohen's kappa statistics, the kappa agreement between NRS-2002 and NUTRISCORE was 0.88, the kappa agreement between NRS-2002 and MST was 0.34, and it was found to be 0.73 for NRS-2002 and EDC.

CONCLUSION

The nutrition screening test named NUTRISCORE showed adequate validity and reliability in Turkish and can detect malnutrition risk of cancer patients treated in oncology clinics as a screening tool.

Comparation of different malnutrition screening tools according to GLIM criteria in cancer outpatients

BACKGROUND

Many studies have assessed different malnutrition screening tools in oncologic patients. However, very few have been carried out using the new GLIM criteria for malnutrition. The objective of our study is to compare the most recommended screening tools with respect to the new GLIM criteria for malnutrition in cancer patients.

METHODS

Observational, cross-sectional, and single-center study carried out at the Medical Oncology Department at the Lozano Blesa Hospital in Zaragoza. We recruited 165 patients with tumors of the upper-gastrointestinal-tract, colorectal, and head-and-neck region undergoing outpatient treatment. All of them received MST, MUST, Nutriscore, MNA and CONUT screening tools, as well as the GLIM diagnostic criteria, which was used as the gold standard.

RESULTS

MNA-SF showed the best sensitivity (0.99) and lowest specificity while CONUT had the best specificity (0.89) and lowest sensitivity to detect cancer-related malnutrition. We observed high variability in the diagnostic capabilities of Nutriscore when tumor location was considered, reducing sensitivity in patients with colorectal cancer compared to those with tumors of the upper-gastrointestinal-tract or head-and-neck location (0.25, 0.83, and 0.91 respectively). The highest index of agreement between the screening tools was found between MST, MUST and Nutriscore tests. Regarding the GLIM criteria, the highest agreement index was presented by MUST tool (0.66), while CONUT presented the lowest (0.12).

CONCLUSIONS

Selecting the screening tool according to the type of cancer and its location may allow us to optimize its use and increase its performance, exploiting the advantages of each of them in the different populations.

Nutritional predictors of pharyngocutaneous fistula after total laryngectomy: A multivariate analytic study in a single institution

OBJECTIVE

The objective of this study was to evaluate, through multivariate analysis, the configuration of nutritional predictors that impact the development pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

A retrospective cohort study carried out on 203 consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy with neck dissection between June 2015 and June 2020. Patients with risk factors for PCF formation, other than malnutrition, were excluded to eliminate the potential impact of that risk factors on PCF formation and to make the study group homogenous. Five parameters were evaluated including preoperative serum prealbumin, albumin and transferrin levels, Body Mass Index (BMI) and Malnutrition Screening Tool (MST).

RESULTS

Univariate analysis revealed that preoperative prealbumin, albumin and transferrin levels significantly correlated with PCF development. Multivariate logistic regression analysis revealed that preoperative prealbumin level was the best independent nutritional predictor of PCF (P value <0.001, odd ratio 11.951 [95% CI 3.686-38.749]) followed by preoperative albumin (P value 0.006, odd ratio 3.985 [95% CI 1.485- 10.694]).

CONCLUSION

Preoperative prealbumin level is considered the best independent nutritional predictor of PCF. It should be used to evaluate the nutritional status of patients undergoing total laryngectomy and hence their need for nutritional support.

Perioperative nutrition management for gastric cancer

Gastric cancer is one of the most frequently diagnosed and the leading cause of cancer death worldwide. Malnutrition is a substantial problem in patients with gastric cancer, associated with poor treatment tolerance and increased morbidity. It has also been recognized as an independent prognostic factor in individuals with cancer. Early detection of malnutrition and effective perioperative nutrition intervention play an important role in the treatment of gastric cancer. Nutrition screening and assessment are the first steps in nutrition management and provide a basis for further nutrition support. Several tools, including the Nutrition Risk Screening-2002 and Patient-Generated Subjective Global Assessment, have been developed for nutrition screening and assessment. Effective nutrition support can significantly improve nutritional and immune status, reduce the incidence of postoperative complications, and accelerate recovery. The aim of this review was to focus on preoperative nutrition risk screening and assessment, and perioperative nutrition support, which may serve as a framework of perioperative nutrition management for gastric cancer.

Importance of addressing malnutrition in cancer and implementation of a quality improvement project in a gastrointestinal cancer clinic

Malnutrition is exceedingly common in cancer patients, with some of the highest rates seen in gastrointestinal (GI) malignancies. Malnutrition and cachexia in cancer patients is associated with worse quality of life, poor treatment tolerance, and increased morbidity and mortality. The importance of early recognition of malnutrition in cancer patients is key, and numerous screening tools have been validated to aid practitioners in this diagnosis. In this paper, we summarize the importance of identifying and managing malnutrition in GI cancer patients as well as its impact on clinical outcomes. We then focus on presenting our own novel quality improvement project that aims to expand access to dietitian services in a GI cancer clinic at a large safety-net hospital system. Utilizing evidence-based quality improvement methodologies including the Model for Improvement and Plan-Do-Study-Act cycles, we increased the proportion of GI oncology patients seen by a dietitian from 5% to 20% from October 2018 to July 2019. In particular, we outline the challenges faced in the implementation process of a malnutrition screening tool built into the electronic medical record in an outpatient oncology clinic. We focus on the tool's ability to capture a greater number of patients with malnutrition and its clinical impact.

Comparison of the GLIM, ESPEN and ICD-10 Criteria to Diagnose Malnutrition and Predict 30-Day Outcomes: An Observational Study in an Oncology Population

The Global Leadership Initiative on Malnutrition (GLIM) criteria are consensus criteria for the diagnosis of malnutrition. This study aimed to investigate and compare the prevalence of malnutrition using the GLIM, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Statistical Classification of Diseases version 10 (ICD-10) criteria; compare the level of agreement between these criteria; and identify the predictive validity of each set of criteria with respect to 30-day outcomes in a large cancer cohort. GLIM, ESPEN and ICD-10 were applied to determine the prevalence of malnutrition in 2794 participants from two cancer malnutrition point prevalence studies. Agreement between the criteria was analysed using the Cohen’s Kappa statistic. Binary logistic regression models were used to determine the ability of each set of criteria to predict 30-day mortality and unplanned admission or readmission. GLIM, ESPEN and ICD-10 criteria identified 23.0%, 5.5% and 12.6% of the cohort as malnourished, respectively. Slight-to-fair agreement was reported between the criteria. All three criteria were predictive of mortality, but only the GLIM and ICD-10 criteria were predictive of unplanned admission or readmission at 30 days. The GLIM criteria identified the highest prevalence of malnutrition and had the greatest predictive ability for mortality and unplanned admission or readmission in an oncology population.

Diagnostic Performance of SGA, PG-SGA and MUST for Malnutrition Assessment in Adult Cancer Patients: A Systematic Literature Review and Hierarchical Bayesian Meta-Analysis

Because cancer-associated malnutrition is a major health complication, timely nutritional screening is of utmost importance. The aim of this study was to conduct a systematic literature review and meta-analysis of three tools in order to identify the method with the best diagnostic performance. PubMed, EMBASE and Cochrane central register of controlled trials were searched for articles published from database inception to January 2021. Studies that assessed the diagnostic accuracy of the SGA, PG-SGA or MUST in adult cancer patients were included. In order to evaluate the quality of each included study, the QUADAS-2 tool was used after which a meta-analysis was conducted using the hierarchical bivariate model. This model accounts for both within and between study variability. 16 studies (18 datasets) were included to evaluate these tools. The overall sensitivity and specificity for SGA was 0.69 and 0.80, 0.95 and 0.81 for PG-SGA, along with 0.83 and 0.83 for MUST respectively. An assessment of the likelihood ratios showed that PG-SGA had the highest LR + and the lowest LR-, it therefore has the best diagnostic performance to confirm malnutrition in adult cancer patients.

Nutrition Care Process Model Approach to Surgical Prehabilitation in Oncology

The nutrition care process is a standardized and systematic method used by nutrition professionals to assess, diagnose, treat, and monitor patients. Using the nutrition care process model, we demonstrate how nutrition prehabilitation can be applied to the pre-surgical oncology patient.

Malnutrition screening tools in gastrointestinal cancer: A systematic review of concurrent validity

OBJECTIVE

Malnutrition is a significant problem in gastrointestinal (GI) cancer, and accurate screening and identification is essential to ensure appropriate nutrition intervention. This study aims to determine current evidence for concurrent validity of malnutrition screening tools in GI cancer.

METHODS

A systematic review was undertaken according to PRISMA guidelines, using four databases. Studies investigating the concurrent validity of malnutrition screening tools against a reference standard of Patient Generated Subjective Global Assessment (PG-SGA) or Subjective Global Assessment (SGA) in adult patients with GI cancer were identified. Screening, quality assessment using the QUADAS-2 checklist, and data extraction were performed by two independent reviewers. Concurrent validity ratings were applied using predefined criteria.

RESULTS

Six studies investigating concurrent validity of the Nutrition Risk Index (NRI), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST) and Nutrition Risk Screening 2002 criteria (NRS-2002) were included. There was variation in concurrent validity ratings ranging from poor-good for all tools, depending on treatment type, stage and population characteristics.

CONCLUSION

Recommendations regarding the use of one tool over another could not be made. However, in the absence of a clear recommendation specific to GI cancer, screening tools that are well validated in general clinical populations should be utilised. The MST can be recommended based on validity data against the PG-SGA and SGA from other oncology populations. If indicated, malnutrition screening should then be followed by thorough nutritional assessment.

Screening Community-Living Older Adults for Protein Energy Malnutrition and Frailty: Update and Next Steps

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI < 20 kg/m² or < 22 if > 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Quality of life, symptoms and dietary habits in oncology outpatients with malnutrition: A cross-sectional study

Cancer-related malnutrition has a high prevalence, reduces survival and increases side effects. The aim of this study was to assess oncology outpatients and risk of malnutrition. Reported symptoms and quality of life (QoL) in patients found to be at risk of malnutrition or malnourished were compared to patients without malnutrition. Using a standardized questionnaire, the European Organization for Research and Treatment of Cancer Questionnaire for Quality of Life and the Mini Nutritional Assessment (MNA), patients in an outpatient cancer clinic undergoing chemotherapy treatment at a German University Hospital were assessed for nutrition, risk of malnutrition and quality of life. Based on the MNA, 39 (45.9%) patients were categorized as malnourished or at risk for malnutrition. Loss of appetite (n = 37.6%, p < 0.001) and altered taste sensation (n = 30,3%, p < 0.001) were the symptoms most frequently associated with reduced food intake. Patients with risk of malnutrition scored lower on the global health status (n = 48.15%, p = 0.001). Side effects of cancer treatments lead to a higher risk of malnutrition and as a consequence lower QoL. These side effects should be addressed more efficiently in cancer care.

Monitoring Rates of Malnutrition Risk in Outpatient Cancer Centers Utilizing the Malnutrition Screening Tool Embedded into the Electronic Health Record

BACKGROUND

The risk of malnutrition in patients with cancer is well documented. However, screening to identify patients at risk in ambulatory cancer centers is not standardized nor uniform. The 2-question Malnutrition Screening Tool (MST) is validated in the ambulatory oncology setting and endorsed by the Academy of Nutrition and Dietetics.

OBJECTIVE

To test the feasibility of operationalizing and standardizing malnutrition risk assessment across 2 large ambulatory cancer centers by embedding the MST into the electronic health record (EHR) with the goal of identifying and quantifying the prevalence of malnutrition risk in outpatient settings.

DESIGN

A Quality Assurance Performance Improvement project was conducted to evaluate malnutrition screening practices by leveraging the EHR. Work standards were developed, implemented, and evaluated to assess the feasibility of utilizing de-identified MST data, entered as discrete variables in an EHR flowsheet, to track monthly MST completion rates and to identify and quantify patients being treated for cancer scoring at risk for impaired nutritional status.

PARTICIPANTS/SETTING

Data from 2 large adult ambulatory community cancer centers in the upper Midwest were collected between April 2017 and December 2018.

RESULTS

Over a 20-month period, the average monthly MST completion rate was 74%. Of those with completed MST screens, the average percentage of patients identified at nutritional risk (MST score ≥2) was 5% in medical oncology and 12% in radiation oncology.

CONCLUSION

It is feasible to (1) integrate and standardize data collection of the MST into existing EHR flowsheets and (2) identify and quantify patients at risk for malnutrition on a consistent basis.

Malnutrition Prevalence according to the GLIM Criteria in Head and Neck Cancer Patients Undergoing Cancer Treatment

Malnutrition is highly prevalent in people with head and neck cancer (HCN) and is associated with poorer outcomes. However, variation in malnutrition diagnostic criteria has made translation of the most effective interventions into practice challenging. This study aimed to determine the prevalence of malnutrition in a HNC population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and assess inter-rater reliability and predictive validity. A secondary analysis of data available for 188 patients with HNC extracted from two cancer malnutrition point prevalence studies was conducted. A GLIM diagnosis of malnutrition was assigned when one phenotypic and one etiologic criterion were present. Phenotypic criteria were ≥5% unintentional loss of body weight, body mass index (BMI), and subjective evidence of muscle loss. Etiologic criteria were reduced food intake, and presence of metastatic disease as a proxy for inflammation. The prevalence of malnutrition was 22.6% (8.0% moderately malnourished; 13.3% severely malnourished). Inter-rater reliability was classified as excellent for the GLIM criteria overall, as well as for each individual criterion. A GLIM diagnosis of malnutrition was found to be significantly associated with BMI but was not predictive of 30 day hospital readmission. Further large, prospective cohort studies are required in this patient population to further validate the GLIM criteria.

Nutrition and gastroenterological support in end of life care

Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.

Optimization of nutrition support practices early after hematopoietic cell transplantation

Nutrition support is often required during hematopoietic cell transplant (HCT) given the gastrointestinal toxicity that frequently precludes adequate protein-calorie intake. This article reviews the latest evidence for enteral versus parenteral nutrition in the adult and pediatric HCT population and addresses key considerations as well as barriers to implement this in practice. Registered Dietitian Nutritionists are key members of the interdisciplinary team to proactively manage enteral nutrition support to provide timely, adequate protein and calories to help prevent malnutrition, loss of lean body mass, and functional decline as well as provide evidence-based diet recommendations. This article also reviews emerging research supporting the role of luminal nutrients to maintain microbiotal diversity.

Malnutrition Screening and Assessment in the Cancer Care Ambulatory Setting: Mortality Predictability and Validity of the Patient-Generated Subjective Global Assessment Short form (PG-SGA SF) and the GLIM Criteria

Background: A valid malnutrition screening tool (MST) is essential to provide timely nutrition support in ambulatory cancer care settings. The aim of this study is to investigate the validity of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) and the new Global Leadership Initiative on Malnutrition (GLIM) criteria as compared to the reference standard, the Patient-Generated Subjective Global Assessment (PG-SGA). Methods: Cross-sectional observational study including 246 adult ambulatory patients with cancer receiving in-chair intravenous treatment at a cancer care centre in Australia. Anthropometrics, handgrip strength and patient descriptive data were assessed. Nutritional risk was identified using MST and PG-SGA SF, nutritional status using PG-SGA and GLIM. Sensitivity (Se), specificity (Sp), positive and negative predictive values and kappa (k) were analysed. Associations between malnutrition and 1-year mortality were investigated by Cox survival analyses. Results: A PG-SGA SF cut-off score ≥5 had the highest agreement when compared with the PG-SGA (Se: 89%, Sp: 80%, k = 0.49, moderate agreement). Malnutrition risk (PG-SGA SF ≥ 5) was 31% vs. 24% (MST). For malnutrition according to GLIM, the Se was 76% and Sp was 73% (k = 0.32, fair agreement) when compared to PG-SGA. The addition of handgrip strength to PG-SGA SF or GLIM did not improve Se, Sp or agreement. Of 100 patients who provided feedback, 97% of patients found the PG-SGA SF questions easy to understand, and 81% reported that it did not take too long to complete. PG-SGA SF ≥ 5 and severe malnutrition by GLIM were associated with 1-year mortality risk. Conclusions: The PG-SGA SF and GLIM criteria are accurate, sensitive and specific malnutrition screening and assessment tools in the ambulatory cancer care setting. The addition of handgrip strength tests did not improve the recognition of malnutrition or mortality risk.

Malnutrition Screening: An Interprofessional Approach in Outpatient Oncology

BACKGROUND

Malnutrition is highly prevalent in the oncology population and is associated with poor treatment outcomes.

OBJECTIVES

This study aimed to implement a malnutrition screening process using a validated tool in three outpatient cancer centers.

METHODS

Nursing and nutrition department leaders collaborated to establish malnutrition screening. The Malnutrition Screening Tool (MST) was embedded in the electronic health record. Based on the MST, a score of 2 or greater is considered at risk for malnutrition. Nurses were educated on screening all patients completing their first cycle of infusion chemotherapy. Data were collected for six months.

FINDINGS

Interprofessional collaboration established a process to implement malnutrition screening. Twenty-eight percent of patients with cancer were at risk for malnutrition. Fifty-three percent were at risk for malnutrition based on MST scores of 2. Compliance with the MST at first infusion visit was 30%-81% across the three cancer centers.

Nutritional status and its effect on complications in patients with colorectal cancer

BACKGROUND

Nutritional status is an important factor for predicting the risk of developing complications after a surgical procedure. Many nutritional assessments are used in clinical practice, but their role in predicting postoperative outcomes is unknown. Therefore, the aim of this study was to assess the utility of nutritional risk factors at the diagnosis of colorectal cancer (CRC) for predicting early postsurgical complications.

METHODS

This was a prospective observational study including 127 patients with CRC at diagnosis. Their preoperative nutritional status was analyzed by body mass index (BMI), triceps and subscapular skinfolds and two nutritional scales: the Patient-Generated Subjective Global Assessment (PG-SGA) and the Malnutrition Universal Screening Tool (MUST). The outcome variables, including postoperative complications, length of hospital stay and mortality, were analyzed.

RESULTS

Patients identified as malnourished by PG-SGA score had prolonged hospital stays (p = 0.01). The risk of infection was increased in older patients (hazard ratio, HR 1.12; 95% confidence interval, CI 1.04-1.21) but was not associated with nutritional status. Early wound dehiscence was increased in patients with higher BMI (HR 1.15; 95% CI 1.01-1.29), with higher subscapular skinfold thickness and increased age (HR 1.05; 95% CI 1.05-1.10). Postoperative mortality was not significantly associated with nutritional status.

CONCLUSION

Malnourished patients, as identified by the PG-SGA score, stayed longer in hospital than patients who were not malnourished, while increased BMI was recognized as a risk factor for wound dehiscence.

The Role of Malnutrition and Muscle Wasting in Advanced Lung Cancer

PURPOSE OF REVIEW

Malnutrition, cancer cachexia, and sarcopenia often co-occur in patients with advanced cancer and are associated with poorer response to chemotherapy and reduced survival. Here, we evaluate the current literature regarding the role of nutrition and these associated conditions in patients with advanced lung cancer.

RECENT FINDINGS

While rates of malnutrition are high, nutritional intervention studies have generally been limited by small sample sizes. Novel strategies such as home-based meal delivery may have promise. While no therapy is approved for cancer cachexia, ghrelin agonists and other targeted therapies have yielded promising data in clinical trials. Recent data also suggest that obesity may improve immunotherapy responsiveness. Malnutrition and associated muscle wasting are clearly negative prognostic markers in advanced lung cancer. Patients with malnutrition should be urgently referred for dietary counseling and guidelines for nutritional support should be followed. Optimal treatment of these syndromes will likely include nutrition and anti-cachexia interventions used in combination.

Assessing the Concurrent Validity and Interrater Reliability of Patient-Led Screening Using the Malnutrition Screening Tool in the Ambulatory Cancer Care Outpatient Setting

BACKGROUND

The prevalence of malnutrition in cancer patients is reported as high as 65%; however, malnutrition screening is often substandard. The Malnutrition Screening Tool (MST) has been validated for use by health care professionals to detect at-risk patients; however, there is a gap in the literature regarding validation of patient-led MST screening.

OBJECTIVE

The aim of the study was to assess the concurrent validity of patient-led MST against the Subjective Global Assessment (SGA) and the interrater reliability of patient-led MST against dietitian-led MST in patients attending ambulatory cancer care services for chemotherapy or supportive treatments.

DESIGN/PARTICIPANTS

A single-site diagnostic accuracy study of 201 patients between May and June 2017 attending the ambulatory cancer care setting at an Australian metropolitan tertiary hospital in Queensland.

MAIN OUTCOME MEASUREMENTS

The primary outcome measures were concurrent validity and interrater reliability of MST scores as determined by patients (patient-MST), dietitians (dietitian-MST), and SGA as completed by the dietitian.

STATISTICAL ANALYSIS

Concurrent validity of patient-led MST scores against the SGA was determined using specificity, sensitivity, positive predictive values, and negative predictive values. Interrater reliability of patient-MST and dietitian-MST was assessed using κ coefficient.

RESULTS

The ability of the patient-led MST scores (0 to 1 vs 2 to 5) to indicate nutrition status was found to have a sensitivity of 94% (95% CI 81% to 99%), a specificity of 86% (95% CI 79% to 91%), and an area under the receiver operating characteristic curve of 0.93 (95% CI 0.89 to 0.96). The positive predictive value was 59% (95% CI 45% to 71%), and the negative predictive value was 99% (95% CI 95% to 100%). A weighted κ of 0.83 (95% CI 0.82 to 0.87) between patient-MST and dietitian-MST was found.

CONCLUSION

Patient-led MST screening is a reliable and valid measure that can accurately identify ambulatory cancer care patients as at risk or not at risk of malnutrition.

Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey

Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Medical nutrition therapy (MNT) optimizes clinical outcomes, yet registered dietitian nutritionists (RDNs), the healthcare professionals specifically trained in MNT, are not routinely employed in outpatient cancer centers where over 90% of all cancer patients are treated. The objective of this study was to evaluate RDN staffing patterns, nutrition services provided in ambulatory oncology settings, malnutrition screening practices, and referral and reimbursement practices across the nation in outpatient cancer centers. An online questionnaire was developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics and distributed via the ON DPG electronic mailing list. Complete data were summarized for 215 cancer centers. The mean RDN full-time equivalent (FTE) for all centers was 1.7 ± 2.0. After stratifying by type of center, National Cancer Institute-Designated Cancer Centers (NCI CCs) employed a mean of 3.1 ± 3.0 RDN FTEs compared to 1.3 ± 1.4 amongst non-NCI CCs. The RDN-to-patient ratio, based on reported analytic cases, was 1 : 2,308. Per day, RDNs evaluated and counseled an average of 7.4 ± 4.3 oncology patients. Approximately half (53.1%) of the centers screened for malnutrition, and 64.9% of these facilities used a validated malnutrition screening tool. The majority (76.8%) of centers do not bill for nutrition services. This is the first national study to evaluate RDN staffing patterns, provider-to-patient ratios, and reimbursement practices in outpatient cancer centers. These data indicate there is a significant gap in RDN access for oncology patients in need of nutritional care.

Nutritional Aspect of Cancer Care in Medical Oncology Patients

PURPOSE

Awareness of advances in the nutritional aspects of cancer care and translation of this information into clinical practice are important for oncology practitioners to effectively couple oncologic and nutritional approaches throughout the cancer journey. The goal of this consensus statement by a panel of medical oncologists was to provide practical and implementable guidance addressing nutritional aspects of cancer care from the perspective of the medical oncologist.

METHODS

A panel of medical oncologists agreed on a series of statements supported by scientific evidence and expert clinical opinion.

FINDINGS

Participating experts emphasized that both poor nutritional intake and metabolic alterations underlie cancer-related malnutrition. The use of liquid and high energy-dense oral nutritional supplements may enable better patient compliance, whereas higher efficacy is more likely with the use of pharmaconutrient-enriched oral nutritional supplements in terms of improved weight, lean body mass, functional status, and quality of life, as well as better tolerance to antineoplastic treatment. A multimodal approach is currently believed to be the best option to counteract the catabolism leading to cancer-related malnutrition; this treatment is scheduled in parallel with anticancer therapies and includes nutritional interventions, multitarget drug therapies, and exercise and rehabilitation programs. Participating experts emphasized the role of the oncologist as a reference professional figure in the coordination of nutritional care for patients with cancer within the context of complex and different clinical scenarios, particularly for permissive-adjunctive nutritional support.

IMPLICATIONS

This review article provides practical guidance addressing major nutritional aspects of cancer care from the medical oncologist's perspective. Thus, this document is expected to assist oncology practitioners in terms of awareness of advances in the nutritional aspects of cancer care and translation of this information into their clinical practice to effectively couple oncologic and nutritional approaches as part of the continuum of care for patients with cancer.

Helping Patients Eat Better During and Beyond Cancer Treatment: Continued Nutrition Management Throughout Care to Address Diet, Malnutrition, and Obesity in Cancer

Cancer patients and survivors are at risk of poor clinical outcomes due to poor nutritional intake following cancer diagnosis. During cancer treatment, treatment toxicities can affect eating patterns and can lead to malnutrition resulting in loss of lean body mass and excessive weight loss. Following treatment and throughout survivorship, patients are at risk of not meeting national nutrition guidelines for cancer survivors, which can affect recurrence and survival. Obesity, which is highly prevalent in cancer patients and survivors, can affect clinical outcomes during treatment by masking malnutrition and is also a risk factor for cancer recurrence and poorer survival in some cancers. Appropriate and effective nutritional education and guidance by trained clinicians are needed throughout the cancer continuum. This article presents an overview of recommendations and guidelines for nutrition and weight management and provides recent examples of behavioral theory-based targeted lifestyle interventions designed to increase adherence to recommendation by cancer patients and survivors.

Validity and Reliability of a Nutrition Screening Tool in Identifying Malnutrition Among Hospitalized Adult Patients

BACKGROUND

Malnutrition among hospitalized patients is closely associated with various medical complications. This study aimed to determine the validity and reliability of a 3-Minute Nutrition Screening (3-MinNS) tool in identifying the risk of malnutrition among hospitalized patients that can be administered by healthcare professionals.

METHODS

A cross-sectional study was conducted between January and December 2012. A total of 350 adult patients in a teaching hospital were screened for risk of malnutrition using 3-MinNS and Subjective Global Assessment (SGA). To assess interrater reliability, each patient was screened for risk of malnutrition using 3-MinNS by 2 different nurses on 2 different occasions within 24 hours after admission. To assess the validity of 3-MinNS, the level of risk of malnutrition identified by the nurses using 3-MinNS was compared with the risk of malnutrition as assessed by a dietitian using SGA within 48 hours after the patients' enrolment into the study. The sensitivity, specificity, and predictive values were calculated in detecting patients at risk of malnutrition. Interrater reliability was determined using κ statistics.

RESULTS

Using SGA, the estimated prevalence of moderate to severe malnutrition was 36.3% (127/350). There was 94% proportional agreement between 2 nurses using 3-MinNS, and interrater reliability was substantial (κ = 0.79, P < .001). The analysis showed that 3-MinNS had moderate sensitivity (61.4%-68.5%) but high specificity (95.1%).

CONCLUSIONS

The 3-MinNS is a reliable and valid screening tool for use by healthcare professionals for identifying newly admitted medical and surgical patients who are at risk of malnutrition.

An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit

Vascular surgery patients are nutritionally vulnerable. Various malnutrition screening and assessment tools are available; however, none has been developed or validated in vascular patients. The present study aimed to: (1) investigate the validity of four commonly administered malnutrition screening tools (Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screen-2002 (NRS-2002) and the Mini-Nutritional Assessment - Short Form (MNA-SF) and an assessment tool (the Patient-Generated Subjective Global Assessment (PG-SGA)) compared against a comprehensive dietitian's assessment and (2) evaluate the ability of the instruments to predict outcomes. Vascular inpatients were screened using the four malnutrition screening tools and assessed using the PG-SGA. Each was assessed by a dietitian incorporating nutritional biochemistry, anthropometry and changes in dietary intake. Diagnostic accuracy, consistency and predictive ability were determined. A total of 322 (69·3 % male) patients participated, with 75 % having at least one parameter indicating nutritional deficits. No instrument achieved the a priori levels for sensitivity (14·9-52·5 %). Neither tool predicted EuroQoL 5-dimension 5-level score. All tools except the MNA-SF were associated with length of stay (LOS); however, the direction varied with increased risk of malnutrition on the MUST and NRS-2002 being associated with shorter LOS (P=0·029 and 0·045) and the reverse with the MST and PG-SGA (P=0·005 and <0·001). The NRS-2002 was associated with increased risk of complications (P=0·039). The MST, NRS-2002 and PG-SGA were predictive of discharge to an institution (P=0·004, 0·005 and 0·003). The tools studied were unable to identify the high prevalence of undernutrition; hence, vascular disease-specific screening and/or assessment tools are warranted.

Nutrition risk and mortality in older oncology patients: An exploratory study

AIM

The primary aim of this analysis was to identify if two standard measures incorporated into the comprehensive geriatric assessment; specifically, malnutrition risk and body mass index (BMI), could predict 12-month mortality in older patients with solid tumours. The secondary aim was to evaluate if malnutrition risk and BMI were associated with chemotherapy outcomes (discontinuation/modification of treatment) in older patients with solid tumours.

METHODS

Older patients (aged ≥70 years) with solid cancers were recruited from the outpatient oncology clinic of a tertiary hospital in Brisbane, Australia. Participants' nutritional parameters, BMI, and malnutrition risk (determined using the Malnutrition Screening Tool (MST)) were recorded at baseline. Mortality data and chemotherapy outcomes were recorded for 12 months.

RESULTS

Seventy-four participants (67% males, median age 77 (±4.4) years) were recruited. Nearly half the cohort was at-risk of malnutrition at baseline (n = 39, 46%). Chemotherapy was prescribed to 39% (n = 29) of the cohort. For patients receiving chemotherapy neither being underweight nor having a low or medium risk of malnutrition was associated with adverse chemotherapy outcomes or 12-month mortality. At a bivariate level, malnutrition risk was significantly associated with 12-month mortality in patients who did not receive chemotherapy (P = 0.018), but not BMI.

CONCLUSIONS

This analysis indicates that malnutrition risk was a potential indicator of 12-month mortality in cases where chemotherapy was considered unfeasible. However, this was not an independent risk factor. Further investigation using a larger sample is required to determine the association between malnutrition risk, quality of life and mortality in patients who are not considered to be fit for chemotherapy.

Patient interpretation of the Patient-Generated Subjective Global Assessment (PG-SGA) Short Form

BACKGROUND

The Patient-Generated Subjective Global Assessment (PG-SGA) is a patient-reported instrument for assessment of nutrition status in patients with cancer. Despite thorough validation of PG-SGA, little has been reported about the way patients perceive, interpret, and respond to PG-SGA. The aim of this study was to investigate how patients interpret the patient-generated part of the PG-SGA, called PG-SGA Short Form.

METHODS

Purposive sampling was used to identify participants that had experienced weight loss and/or reduced dietary intake and/or had a low body mass index. Data were collected from 23 patients by combining observations of patients filling in the PG-SGA Short Form, think-aloud technique and structured interviews, and analyzed qualitatively using systematic text condensation.

RESULTS

Most of the participants managed to complete the PG-SGA Short Form without problems. However, participant-related and questionnaire-related sources of misinterpretation were identified, possibly causing misinterpretations or wrong/missing answers. Participants either read too fast and skipped words, or they struggled to find response options that were suitable for covering their entire situation perfectly. The word "normal" was perceived ambiguous, and the word "only" limited the participants' possibility to accurately describe their food intake. Long recall periods in the questions and two-pieced response options made it difficult for patients to select only one option.

CONCLUSION

The results of this study provide a unique patient perspective of using the PG-SGA Short Form and valuable input for future use and revisions of the form. The identified sources of misunderstanding could be used to develop a standardized instruction manual for patients and health care personnel using the PG-SGA Short Form.

Agreement between the Malnutrition Universal Screening Tool and the Patient-Generated Subjective Global Assessment for Cancer Outpatients Receiving Chemotherapy: A Cross-Sectional Study

Malnutrition is a common occurrence in cancer. Early detection of malnutrition is imperative but often overlooked in busy clinical routine. This study aimed to assess the agreement between malnutrition universal screening tool (MUST) and the patient-generated subjective global assessment (PG-SGA) to detect risk of malnutrition in a medical oncology outpatient setting. A cross-sectional study was conducted with 100 adult patients with cancer receiving chemotherapy. Nutrition screening and assessment were performed using MUST and PG-SGA, respectively. Sensitivity, specificity, predictive values, kappa agreement, and receiver operating characteristics (ROC) curve were used to compare MUST with PG-SGA. Prevalence of malnutrition or risk of malnutrition among subjects was 45% according to the MUST. Body mass index (BMI) against PG-SGA indicated a low capacity to detect malnutrition with 28.9% sensitivity and 96.4% specificity. Unintentional weight loss in the last 3-6 mo against PG-SGA resulted in 55.6% sensitivity and 98.2% specificity. MUST against PG-SGA resulted in 86.7% sensitivity and 94.5% specificity. MUST indicated a perfect agreement with PG-SGA (Kappa = 0.81; P < 0.05) and highest area under the ROC curve (AUC ROC = 0.91). MUST has high level of agreement with PG-SGA to detect chemotherapy outpatients at risk of malnutrition.

Mini nutritional assessment is a better predictor of mortality than subjective global assessment in heart failure out-patients

BACKGROUND & AIMS

There is no consensus on the best method for nutritional screening and assessment in patients with heart failure (HF). This study aimed to determine which nutritional assessment method had the highest prognostic significance for patients with HF treated in outpatient clinics. We also aimed to identify a fast, reliable screening method for detecting malnutrition in these patients.

METHODS

This prospective study included 151 subjects that attended an outpatient HF clinic at a university hospital. All patients completed three nutritional screening tools: the Malnutrition Universal Screening Tool (MUST), the MNA-short form (MNA-SF), and the Malnutrition Screening Tool (MST), and then, two nutritional assessment questionnaires: the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment®(MNA). Patients were followed-up for 2 years. The primary endpoint was all-cause mortality.

RESULTS

Malnutrition or nutritional risk was identified in 15.9% of patients with the SGA and in 25.1% of patients with the MNA. Age, New York Heart Association (NYHA) functional class, and MNA were the only independent all-cause death predictors after adjusting for age, gender, NYHA functional class, body mass index, Barthel index, 25-hydroxyvitamin D concentrations, treatment with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, and treatment with beta-blockers. The SGA could not independently predict all-cause mortality in a multivariate analysis that included the same covariates. The MNA-SF had the best sensitivity, specificity, and kappa coefficient for screening malnutrition, based on the MNA and the SGA as references, compared to the other screening methods.

CONCLUSIONS

In our cohort, malnutrition assessed by MNA, but not by SGA, was an independent predictor of mortality. MNA-SF showed remarkable sensitivity and specificity; thus, it might be a valuable tool for rapidly identifying malnutrition risk in outpatients with HF.

Validated screening tools for the assessment of cachexia, sarcopenia, and malnutrition: a systematic review

Background

There is great overlap between the presentation of cachexia, sarcopenia, and malnutrition. Distinguishing between these conditions would allow for better targeted treatment for patients.

Objectives

The aim was to systematically review validated screening tools for cachexia, sarcopenia, and malnutrition in adults and, if a combined tool is absent, make suggestions for the generation of a novel screening tool.

Design

A systematic search was performed in Ovid Medline, EMBASE, CINAHL, and Web of Science. Two reviewers performed data extraction independently. Each tool was judged for validity against a reference method. Psychometric evaluation was performed as was appraisal of the tools' ability to assess the patient against consensus definitions.

Results

Thirty-eight studies described 22 validated screening tools. The Cachexia score (CASCO) was the only validated screening tool for cachexia and performed well against the consensus definition. Two tools assessed sarcopenia [the Short Portable Sarcopenia Measure (SPSM) and the SARC-F (Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls)] and scored well against the 1998 Baumgartner definition. The SPSM required large amounts of equipment, and the SARC-F had a low sensitivity. Nineteen tools screened for malnutrition. The 3-Minute Nutrition Score performed best, meeting consensus definition criteria (European Society for Clinical Nutrition and Metabolism) and having a sensitivity and specificity of >80%. No tool contained all of the currently accepted components to screen for all 3 conditions. Only 3 tools were validated against cross-sectional imaging, a clinical tool that is gaining wider interest in body-composition analysis.

Conclusions

No single validated screening tool can be implemented for the simultaneous assessment of cachexia, sarcopenia, and malnutrition. The development of a tool that encompasses consensus definition criteria and directs clinicians toward the underlying diagnosis would be optimal to target treatment and improve outcomes. We propose that tool should incorporate a stepwise assessment of nutritional status, oral intake, disease status, age, muscle mass and function, and metabolic derangement.

Risk of malnutrition and emotional distress as factors affecting health-related quality of life in patients with resected cancer

INTRODUCTION

This study analyzes the prevalence of malnutrition, depression, anxiety, and somatization and which factor has the biggest effect on quality of life (QoL) in individuals with resected cancer.

METHODS

A prospective study was conducted among 747 participants. Participants completed the EORTC-QLQ30, MST, and BSI-18 questionnaires.

RESULTS

Prevalence for risk of malnutrition, depression, anxiety, and somatization were 36.4%, 35.5%, 35.2%, and 48.8%, respectively. Hierarchical multiple regression analyses revealed that malnutrition risk, somatization, depression, and anxiety accounted for 50.8% of the variance in functional scale, 45.3% in symptom scale, and 52.2% in global health. Malnutrition, somatization, depression, and anxiety displayed high explanatory power on all health-related QoL (HRQoL) scales.

CONCLUSION

The risk of malnutrition and psychological symptoms is strongly associated with HRQoL in cancer patients; thus, medical oncologists should develop effective interventions that contribute to lowering the risk of malnutrition and psychological distress, thereby improving subjects' HRQoL before initiating adjuvant chemotherapy.

Validation of a frailty index in older cancer patients with solid tumours

Background

Frailty is an indicator of physiological reserve in older people. In non-cancer settings, frailty indices are reliable predictors of adverse health outcomes. The aims of this study were to 1) derive and validate a frailty index (FI) from comprehensive geriatric assessment (CGA) data obtained in the solid tumour chemotherapy setting, and 2) to explore whether the FI-CGA could predict chemotherapy decisions and survival in older cancer patients with solid tumours.

Methods

Prospective cohort study of a consecutive series sample of 175 cancer patients aged 65 and older with solid tumours. A frailty index was calculated using an accumulated deficits model, coding items from the comprehensive geriatric assessment tool administered prior to chemotherapy decision-making. The domains of physical and cognitive functioning, nutrition, mood, basic and instrumental activities of daily living, and comorbidities were incorporated as deficits into the model.

Results

The FI-CGA had a right-skewed distribution, with median (interquartile range) of 0.27 (0.21–0.39). The 99% limit to deficit accumulation was below the theoretical maximum of 1.0, at 0.75. The FI-CGA was significantly related (p < 0.001) to vulnerability as assessed by the Vulnerable Elders Survey-13 and to medical oncologists’ assessments of fitness or vulnerability to treatment. Baseline frailty as determined by the FI-CGA was also associated with treatment decisions (Treatment Terminated, Treatment Completed, No Planned Treatment) (p < 0.001), with the No Planned Treatment group significantly frailer than the other two groups.

Conclusion

The FI-CGA is a potentially useful adjunct to cancer clinical decision-making that could predict chemotherapy outcomes in older patients with solid tumours.