A comparison of the MNA-SF, MUST, and NRS-2002 nutritional tools in predicting treatment incompletion of concurrent chemoradiotherapy in patients with head and neck cancer

Summary of the best evidence for nutritional support programs in nasopharyngeal carcinoma patients undergoing radiotherapy

Objective

To evaluate and summarize the best evidence for nutritional support in patients receiving radiotherapy for nasopharyngeal carcinoma and to offer guidance for clinical practice.

Background

Patients with nasopharyngeal carcinoma undergoing radiotherapy often experience a high prevalence of malnutrition, and there is a lack of compiled guideline recommendations, which complicates the provision of a reference for clinical nursing.

Methods

A systematic literature search revealed the best evidence of nutritional support for nasopharyngeal carcinoma patients undergoing radiotherapy. Included in the review were various types of literature, such as clinical guidelines, expert consensus, systematic evaluations, meta-analyses, evidence summaries, and original studies. The evidence was graded according to the Australian Joanna Briggs Institute Centre for Evidence-Based Health Care Evidence Pre-Grading System (2016 version). Data were gathered from a range of sources, including BMJ Best Practice, the Scottish Intercollegiate Guidelines Network, the Cochrane Library, Embase, PubMed, Web of Science, CINAL, CNKI, the WanFang database, SinoMed, the Yi Maitong Guidelines Network, Dingxiangyuan, the Chinese Nutrition Society, the European Society for Clinical Nutrition and Metabolism website, and the American Society for Parenteral and Enteral Nutrition website. The search spanned from January 2013 to 2023.

Results

A comprehensive review identified a total of 3,207 articles, comprising six guidelines, eight expert consensus articles, four systematic evaluations, five randomized controlled trials, two cohort trials, and two observational studies. From these articles, we synthesized 63 pieces of evidence spanning six domains: nutritional risk screening and assessment, nutrient requirements, nutritional support, management of nutritional symptoms, functional exercise, and nutritional monitoring and follow-up.

Conclusion

A total of lines of evidence supporting nutritional support for nasopharyngeal carcinoma patients receiving radiotherapy were summarized. However, the evidence should be combined with the actual clinical situation, and it should be validated in the future by combining large-sample and multicenter studies to provide a more scientific and beneficial nutritional support program for nasopharyngeal carcinoma patients receiving radiotherapy.

Impact of pretreatment quality of life on tolerance and survival outcome in head and neck cancer patients undergoing definitive CCRT

BACKGROUND

Health-related quality of life (HRQoL) is a predictor of treatment outcomes in cancer patients. This study aimed to evaluate the effect of pretreatment HRQoL on treatment tolerance and survival outcomes in patients with HNC planned for concurrent chemoradiotherapy (CCRT) in Taiwan.

METHODS

This study included 461 patients with HNC planned for definitive CCRT at three medical centers in Taiwan between August 2017 and December 2018. HRQoL was assessed using the QLQ-HN35 one week before the initiation of CCRT. Patients were grouped based on the sum scores of QLQ-HN35 (

RESULTS

The median QLQ-HN35 sum score among 461 patients was 39 (range, 30 to 96), varying with tumor site: 34 for nasopharynx, 44 for oropharynx, 45 for oral cavity, and 38 for hypopharynx. Patients with sum scores ≥ median were associated with higher risk for incomplete CCRT (13.4 % vs 6.5 %, odds ratio [OR] = 2.22, 95 % confidence interval [CI] = 1.17-4.24, p = 0.015), emergency room visits (36.4 % vs 27.0 %, OR = 1.55, 95 % CI = 1.04-2.30, p = 0.030), unexpected hospitalization (33.8 % vs 19.6 %, OR = 2.10, 95 % CI = 1.37-3.21, p = 0.001), ≥ grade 3 hematological toxicities (34.2 % vs 21.3 %, OR = 1.92, 95 % CI = 1.27-2.91, p = 0.002), ≥ grade 3 non-hematological toxicities (78.8 % vs 68.7 %, OR = 1.69, 95 % CI = 1.11-2.58, p = 0.014), and low survival outcomes (hazard radio = 2.76, 95 % CI = 1.67-4.54, p < 0.001). Patients with lower sum scores in nasopharyngeal/oropharyngeal tumors exhibited better OS than those with higher scores, while no significant difference in OS based on HRQoL was observed in oral cavity/hypopharyngeal cancer patients. Higher sum scores remained a negative indicator even after adjusting for other confounding factors.

CONCLUSION

In patients with HNC planned for definitive CCRT, pre-treatment HRQoL was significantly associated with treatment-related complications, tolerance, and survival outcomes. Furthermore, our results validated the clinical value of QLQ-HN35 as an indicator for predicting treatment tolerance and outcomes.

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Key Words

• Concurrent chemoradiotherapy
• Head and neck cancer
• Prognosis
• Quality of life

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Affiliation(s)

Chia-Yen Hung Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan; Division of Hema-oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
Mei-Hui Hsu Department of Nursing, Chang Gung University, Taoyuan, Taiwan
Shu-Hui Lee Department of Nursing, Chang Gung University, Taoyuan, Taiwan
Shun-Wen Hsueh Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
Chang-Hsien Lu Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
Kun-Yun Yeh Department of Hematology and Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
Hung-Ming Wang Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan
Joseph Tung-Chieh Chang Department of Radiation Oncology Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
Yu-Shin Hung Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan
Wen-Chi Chou Department of Hematology and Oncology, Chang Gung University, Taoyuan, Taiwan.

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Impact of preoperative frailty on the surgical and survival outcomes in older patients with solid cancer after elective abdominal surgery

BACKGROUND

Frailty is common in older patients with cancer; however, its clinical impact on the survival outcomes has seldom been examined in these patients. This study aimed to investigate the association of frailty with the survival outcomes and surgical complications in older patients with cancer after elective abdominal surgery in Taiwan.

METHODS

We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. They were allocated into the fit, pre-frail, and frail groups according to comprehensive geriatric assessment (CGA) findings.

RESULTS

The fit, pre-frail, and frail groups comprised 62 (18.0%), 181 (52.5%), and 102 (29.5%) patients, respectively. After a median follow-up of 48 (interquartile range, 40-53) months, the mortality rates were 12.9%, 31.5%, and 43.1%, respectively. The adjusted hazard ratio was 1.57 (95% confidence interval [CI], 0.73-3.39; p = 0.25) and 2.87 (95% CI, 1.10-5.35; p = 0.028) when the pre-frail and frail groups were compared with the fit group, respectively. The frail group had a significantly increased risk for a prolonged hospital stay (adjusted odds ratio, 2.22; 95% CI, 1.05-4.69; p = 0.022) compared with the fit group.

CONCLUSION

Pretreatment frailty was significantly associated with worse survival outcomes and more surgical complications, with prolonged hospital stay, in the older patients with cancer after elective abdominal surgery. Preoperative frailty assessment can assist physicians in identifying patients at a high risk for surgical complications and predicting the survival outcomes of older patients with cancer.

Frailty is an independent factor for health-related quality of life in patients with head and neck cancer receiving definitive concurrent chemoradiotherapy

PURPOSE

Health-related quality of life (HRQoL) is associated with treatment-related complications and poor survival in patients with head and neck cancer (HNC). We investigated the effects of frailty on HRQoL in patients with HNC receiving definitive concurrent chemoradiotherapy (CCRT).

METHODS

A total of 461 consecutive patients with locally advanced HNC who received CCRT between 2017 and 2018 at three medical centers in Taiwan were included. Frailty and HRQoL were assessed using the Comprehensive Geriatric Assessment and QLQ-H&N35 before CCRT. The sum score was calculated based on the first 30 questions of QLQ-H&N35. Multivariate analysis was performed to evaluate the impact of frailty on HRQoL.

RESULTS

The overall sum score was 39 (34-49). The sum scores of patients with impairments in 0, 1, 2, 3, and ≥ 4 frailty domains were 34 (32-38), 40 (34-47), 46 (36-55), 48 (41-64), and 56 (50-60), respectively. Patients with impairments in more frailty domains had a higher symptom burden (p for trend < 0.001). Frail patients tended to experience symptoms across all QLQ-H&N35 subscales. Sex, body mass index, tumor type, tumor stage, Eastern Cooperative Oncology Group performance status, and frailty were determinants of HRQoL in the univariate analysis. Frailty was an independent determinant of HRQoL in the multivariate analysis.

CONCLUSION

Routine frailty assessment may serve as a surrogate for the selection of patients with HNC with poor HRQoL before CCRT. Further studies are needed to determine whether appropriate interventions in frail patients would improve their HRQoL during CCRT.

Malnutrition in patients with head and neck cancer undergoing radiotherapy: A cross-sectional study

OBJECTIVE

In this study, we investigated the prevalence of malnutrition and analyzed the related factors among patients with head and neck cancer (HNC) undergoing radiotherapy.

METHODS

We included 108 patients with head and neck cancer undergoing radiotherapy from the oncology and thoracic surgery departments of a comprehensive medical center in Qingdao between January 2019 and June 2020. We used the Nutritional Risk Screening-2002 tool (NRS-2002) to evaluate their nutritional status during radiotherapy. We analyzed the basic sociodemographic information and laboratory indicators of the respondents to examine the impact of these factors on nutritional status.

RESULTS

In the 108 patients that we studied, those aged ≥65 years had a significantly higher nutritional risk when compared to patients <65 years of age (P < 0.05). Univariate analysis revealed that a late tumor stage (P = 0.039), the neck being the site of radiotherapy (P = 0.009), the presence of diabetes (P < 0.001), and the presence of anxiety and depression (P = 0.002) were associated with nutritional risks for patients with head and neck cancer undergoing radiotherapy. Multivariate logistic regression analysis identified a late tumor stage, the neck being the radiotherapy site, and combined anxiety and depression as nutritional risk factors in such patients.

CONCLUSION

We found a high incidence of malnutrition in patients undergoing radiotherapy for HNC; this highlights the importance of early identification of patients at risk and evaluation of related risk factors to enhance the efficacy of nutritional interventions.

Effect of prophylactic tube feeding in head and neck cancer patients with high Mallampati score undergoing definitive concurrent chemoradiotherapy

PURPOSE

There is no consensus on the selection of appropriate prophylactic tube feeding in patients with head and neck squamous cell carcinoma (HNSCC) undergoing concurrent chemoradiotherapy (CCRT). This study aimed to evaluate the effect of prophylactic tube feeding in patients with HNSCC who presented with a high Mallampati score and underwent CCRT.

METHODS

We prospectively enrolled 185 consecutive patients with stage II to IVa HNSCC and a pre-treatment Mallampati score of 3 or 4 who received CCRT between August 2017 and December 2018 with follow-up data collected retrospectively. Patients were divided to either with or without prophylactic tube feeding group for comparison of treatment tolerance, toxicities, and quality of life(QOL). Propensity score matching (PSM) was used to achieve balanced covariates across the two groups.

RESULTS

Of the cohort, 52 (28.1%) and 133 (71.9%) patients were allocated to the prophylactic and non-prophylactic tube feeding groups, respectively. Before and after PSM, patients in the tube feeding group had a significantly lower incidence of incomplete radiotherapy, incompletion of chemotherapy, emergency room visits, and grade 3 or higher infection, and improved symptoms of quality of life after CCRT than those in the non-tube feeding group.

CONCLUSION

Prophylactic tube feeding was associated with better treatment tolerance, safety profiles, and quality of life in patients with HNSCC and high Mallampati scores who underwent CCRT. Therefore, Mallampati score might serve as a clinical tool for proactive selection of patients receiving prophylactic tube feeding in HNSCC patients upon receiving CCRT.

Malnutrition universal screening tool predicts postoperative complications following major head and neck cancer surgery

BACKGROUND

Head and neck cancer patients are at risk for malnutrition, which can impact postoperative outcomes. This study evaluates the Malnutrition Universal Screening Tool (MUST) to predict outcomes in major head and neck surgeries.

METHODS

A retrospective chart review included 275 major surgical procedures performed on 242 patients over the age of 18 years between May 2015 and May 2020.

RESULTS

The majority of patients had a MUST score of zero (68.7%). Just under 17% scored 2 or greater indicating malnourishment. Having a MUST score of 2 or higher was associated with occurrence of a postoperative complication (p < 0.001). Patients with alcohol use disorder or depression were 5.2 (CI: 2.0-13.7, p = 0.001) and 2.75 (CI 1.1-7.0; p = 0.033) times more likely to develop a postoperative complication, respectively.

CONCLUSIONS

Malnutrition and comorbidities were associated with complications in our surgical cohort. MUST is a novel tool to identify patients who may benefit from nutritional interventions.

Prevalence of Food Insecurity Among Cancer Survivors in the United States: A Scoping Review

BACKGROUND

Medical financial hardship is an increasingly common consequence of cancer treatment and can lead to food insecurity. However, food security status is not routinely assessed in the health care setting, and the prevalence of food insecurity among cancer survivors is unknown.

OBJECTIVE

This scoping review aimed to identify the prevalence of food insecurity among cancer survivors in the United States before the COVID-19 pandemic.

METHODS

Five databases (PubMed, Scopus, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Web of Science, and ProQuest Dissertations and Theses) were systematically searched for articles that reported on food security status among US patients receiving active cancer treatment or longer-term cancer survivors and were published between January 2015 and December 2020.

RESULTS

Among the 15 articles meeting the inclusion criteria, overall food insecurity prevalence ranged from 4.0% among women presenting to a gynecologic oncology clinic to 83.6% among patients at Federally Qualified Health Centers. Excluding studies focused specifically on Federally Qualified Health Center patients, prevalence of food insecurity ranged from 4.0% to 26.2%, which overlaps the food insecurity prevalence in the general US population during the same time period (range, 10.5% to 14.9%). Women were more likely than men to report being food insecure, and the prevalence of food insecurity was higher among Hispanic and Black patients compared with non-Hispanic White patients.

CONCLUSIONS

Given significant heterogeneity in study populations and sample sizes, it was not possible to estimate an overall food insecurity prevalence among cancer survivors in the United States. Routine surveillance of food security status and other social determinants of health is needed to better detect and address these issues.

The impact of preoperative nutrition status on abdominal surgery outcomes: A prospective cohort study

BACKGROUND

The European Society for Clinical Nutrition and Metabolism recommends nutrition screening using the Mini Nutritional Assessment Short-Form (MNA-SF) in older adult patients preoperatively. However, the association of nutrition condition with postoperative complications is poorly documented. We aimed to identify preoperative nutrition status using the MNA-SF and to determine whether preoperative nutrition status affects postoperative outcomes.

METHODS

Inpatients aged ≥55 years who underwent elective abdominal surgery under general anesthesia between April 1, 2016, and December 28, 2018, were included. We assessed nutrition status using the MNA-SF before surgery. Multiple logistic regression including the MNA-SF score was applied to determine associated factors with our primary outcome, postoperative complications defined as Clavien-Dindo classification ≥3a. Secondary outcomes including length of hospital stay and unplanned readmission were compared between normal, at risk, and malnourished patients.

RESULTS

The data of 1248 patients with a mean age of 69 years were analyzed. The prevalence of at risk and malnutrition was 33.0% (412 of 1248) and 6.9% (87 of 1248), respectively. Overall, 12.4% (155 of 1248) had major postoperative complications, and the MNA-SF score was a significant predictor (odds ratio: 0.92, 95% CI: 0.86-0.99) after adjusting for confounders. Patients at risk of malnutrition and those with malnutrition had a longer hospital length of postoperative stay than normal patients (P = 0.001); however, there was no statistical significance in unplanned readmission rate between the three groups (P = 0.14).

CONCLUSION

Preoperative nutrition disorder was common, and it affected postoperative adverse outcomes. The MNA-SF score was associated with major postoperative complications.

R-CSS: A clinically applicable score to classify cachexia stages in patients with cancer undergoing intensity-modulated radiation therapy

Objective

Accurate cachexia staging is the key to its management. However, there is currently a lack of tools to distinguish the staging of cachexia in patients with cancer undergoing radiotherapy. The Radiotherapy Cachexia Staging Scale (R-CSS) was developed for the stratification of cachexia in patients undergoing cancer radiotherapy.

Methods

Patients with cancer undergoing radiotherapy were divided into four stages - noncachexia, precachexia, cachexia, and refractory cachexia - by the R-CSS scale, and the clinical outcomes of the four groups were compared.

Results

A total of 270 patients with cancer undergoing radiation therapy were included in the study. All participants were classified into four stages of cachexia: stage 0, I, II, and III. Patients with a higher cachexia stage had a higher prevalence of sarcopenia (P ​= ​0.015). Scores on the 16-item M. D. Anderson Symptom Inventory were higher in patients with higher cachexia stages (P ​< ​0.05), but levels of forgetfulness, numbness, and shortness of breath were not higher in these patients (P ​> ​0.05). Patients with higher cachexia stages exhibited better scores on the QLQ-C30 scale (P ​< ​0.05), except for in the domains of cognitive functioning, diarrhea, and dyspnea (P ​> ​0.05). The incidence of treatment-related events (any grade III or higher grade of [non-]hematologic adverse events, the need for hospitalization, emergency room admission) was higher in patients with higher cachexia stages.

Conclusions

The R-CSS scale is a screening tool that can simultaneously distinguish different stages of cachexia.

A comparison of three preoperative nutritional assessment methods for predicting ovarian cancer patient prognosis: which is better?

BACKGROUND

The study aimed to compare the predictive values of three widely used nutritional assessment methods, body mass index (BMI), Nutritional Risk Screening 2002 (NRS 2002), and the prognostic nutritional index (PNI), for different clinical prognostic indicators of ovarian cancer patients.

METHODS

Patients diagnosed with ovarian cancer treated in our hospital between January 2017 and March 2019 were retrospectively included. The three nutritional assessment methods were assessed, and multivariable analysis was conducted to explore predictive factors for clinical prognoses. Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUROC) were generated to evaluate the discriminative abilities of the three nutritional assessment tools.

RESULTS

A total of 442 patients were recruited. Multivariable analysis revealed that the PNI value predicted 1-year death and 1-year recurrence and that both the NRS 2002 score and the PNI value predicted 30-day readmission (P < 0.05). For PNI, AUROCs were 0.834 for predicting 1-year death and 0.719 for 1-year recurrence prediction; for NRS, the AUROC was 0.820 2002 for predicting 30-day readmission. The optimal cutoff values that maximized the prognostic prediction ability were PNI values of 47.75 g/L and 50.40 g/L for 1-year death and 1-year recurrence, respectively, and an NRS 2002 score of 3 points for 30-day readmission following discharge.

CONCLUSION

For ovarian cancer patients, the PNI is better at predicting 1-year death and 30-day readmission after discharge, and the NRS 2002 is superior for predicting 1-year recurrence.

The Determination of a Consensus Nutritional Approach for Cancer Patients in Spain Using the Delphi Methodology

Malnutrition has a multifactorial origin and can be caused by cancer. This study determined the consensus of a panel of experts on the nutritional approach for cancer patients in Spain using a multidisciplinary approach. Using the Delphi methodology, a 74-question questionnaire was prepared and sent to 46 experts. The areas of knowledge addressed were the nutritional status of the cancer patient, nutritional screening, nutritional therapy, patient referral, and multidisciplinary care. A total of 91.7% of the experts agreed with the questions posed on nutritional status, 60.0% with those on nutritional screening, 76.7% with those on nutritional therapy, and the entire panel of experts agreed with the questions posed on patient referral and multidisciplinary care. The experts agreed upon a high prevalence of malnutrition among cancer patients in Spain. Unlike medical and radiation oncologists, medical nutrition specialists believe that body composition assessment should not be carried out in all types of cancer patients during nutritional screening and that interventions can be conducted outside the oncology clinic. In general, it is recommended that nursing staff routinely perform nutritional screening before starting cancer treatment. It is necessary to develop a multidisciplinary action protocol that includes nutritional and/or sarcopenia screening.

Current Screening Methods for the Risk or Presence of Malnutrition in Cancer Patients

Malnutrition is highly common among cancer patients and is associated with a poor quality of life, increased treatment toxicities and decreased survival. The screening of malnutrition should be performed in an early stage of cancer disease and should be rapid, not expensive and highly sensitive to identify the risk of developing malnutrition. Importantly, international clinical guidelines suggest to perform screening for malnutrition in all cancer patients and if the risk is present, they recommend to perform a full nutritional assessment. During the screening phase, different nutritional parameters are considered including the loss of appetite, low food intake, body weight loss and burden of the disease. These items are present in several screening tools, such as the Nutrition Risk Screening (NRS)-2002, the Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment (MNA) which represent the most widely used tools to screen for an altered nutritional status in cancer patients. Recently, the Global Leadership Initiative on Malnutrition (GLIM) developed an assessment tool for the diagnosis of malnutrition taking into account the presence of i) involuntary body weight loss, ii) body mass index, iii) low muscle mass, iv) low food intake and disease burden/inflammation; in particular, body weight loss, decreased body mass index (BMI), and low muscle mass are considered as phenotypic criteria, whereas reduced food intake, disease burden and inflammation are defined as etiologic criteria. To perform the diagnosis of malnutrition, GLIM consensus considered the presence of at least one phenotypic and one etiologic criterion. The above-mentioned screening tools were validated in different clinical settings and suggesting the use of one tool vs another is challenging considering, among others, different factors including the type and stage of cancer and the setting (i.e., inpatient or outpatient care). Recent data obtained among large cohorts of cancer patients indicate that personalized nutritional therapy reduced mortality risk and ameliorated quality of life and functionality among cancer patients with high nutritional risk, supporting the urgent need for implementing screening and diagnosis of malnutrition in this context.