Association between early nutritional risk and overall survival in patients with advanced pancreatic cancer: A single-center retrospective study

Prognostic role of nutrition parameters on short- and long-term outcome in patients with primary resectable pancreatic ductal adenocarcinoma

PURPOSE

Nutrition status of patients with pancreatic ductal adenocarcinoma (PDAC) has gained an increasing importance - especially in the preoperative setting. The aim of the present study was to evaluate different preoperative nutritional parameters including body composition parameters regarding their impact on short- and long-term outcome in patients with resectable PDAC.

METHODS

This retrospective single center study included 162 patients, who underwent primary resection of PDAC from January 2003 to December 2018 at the University Hospital of Erlangen. The influence of different preoperative nutrition parameters as well as different CT-based body composition parameters on short- (major morbidity, postoperative pancreatic fistula (POPF) and longer hospital stay) as well as on long-term outcome (overall and disease-free survival) were tested using multiple regression analysis.

RESULTS

Major morbidity and POPF occurred in 30% respectively 18%. Median length of hospital stay was 18 days. Median overall and disease free survival were 20.3 respectively 12.0 months. Multivariate analysis revealed among the different nutritional parameters following independent predictors: PMTH (psoas muscle thickness/height) for major morbidity (HR 2.1, p = 0.038), PMA (psoas muscle area) for a prolonged hospital stay >18 days (HR 7.3, p = 0.010) and NRS (nutritional risk score) for overall survival (HR 1.7, p = 0.043).

CONCLUSION

In our cohort, nutritional parameters played a minor role in predicting short- and long-term outcome in patients with primary resectable PDAC, as there were only significant associations between selected psoas muscle parameters and short-term outcome parameters and the nutritional risk score (NRS) with the overall survival.

Proposal of a nutrition screening algorithm for patients with incurable cancer receiving palliative care: Data from a prospective cohort

OBJECTIVE

To propose and evaluate the clinical utility of a new nutrition screening algorithm, NutriPal, to detect the degree of nutritional risk in patients with incurable cancer receiving palliative care.

METHODS

It is a prospective cohort conducted in an oncology palliative care unit. The NutriPal algorithm was used in a three-step process: (i) administration of the Patient-Generated Subjective Global Assessment short form; (ii) calculation of the Glasgow Prognostic Score; and (iii) application of the algorithm to classify patients into four degrees of nutritional risk. The higher the degrees of NutriPal, the worse the nutritional risk, comparing nutritional measures, laboratory data, and overall survival (OS).

RESULTS

The study included 451 patients that were classified using the NutriPal. They were allocated to the degrees: 1 (31.26%), 2 (27.49%), 3 (21.73%), and 4 (19.71%). Statistically significant differences were found in most of the nutritional and laboratory parameters and in OS with each increment in the NutriPal degrees, and OS was reduced (log-rank <0.001). In addition, NutriPal was able to predict a 120-day mortality: there was a significantly higher risk of death in the patients classified as degrees 4 (hazard ratio [HR], 3.03; 95% confidence interval [95% CI], 2.18-4.19), 3 (HR, 2.01; 95% CI, 1.46-2.78), and 2 (HR, 1.42; 95% CI; 1.04-1.95) than in those classified as degree 1. It also showed good predictive accuracy (concordance statistic, 0.76).

CONCLUSION

The NutriPal is associated to nutritional and laboratory parameters and can predict survival. It could therefore be incorporated into clinical practice for patients with incurable cancer receiving palliative care.

Prognostic potential of nutritional risk screening and assessment tools in predicting survival of patients with pancreatic neoplasms: a systematic review

BACKGROUNDS & AIMS

The nutritional evaluation of pancreatic cancer (PC) patients lacks a gold standard or scientific consensus, we aimed to summarize and systematically evaluate the prognostic value of nutritional screening and assessment tools used for PC patients.

METHODS

Relevant studies were retrieved from major databases (PubMed, Embase, Web of Science, Cochrane Library) and searched from January 2010 to December 2023. We performed meta-analyses with STATA 14.0 when three or more studies used the same tool.

RESULTS

This analysis included 27 articles involving 6,060 PC patients. According to a meta-analysis of these studies, poor nutritional status evaluated using five nutritional screening tools Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status Score (CONUT), Nutrition Risk Screening (NRS2002) and Glasgow Prognostic Score (GPS) was associated with all-cause mortality in PC patients. But Modified Glasgow Prognostic Score (mGPS) did not. Of all tools analyzed, CONUT had the maximum HR for mortality (HR = 1.978, 95%CI 1.345-2.907, P = 0.001).

CONCLUSION

All-cause mortality in PC patients was predicted by poor nutritional status. CONUT may be the best nutritional assessment tool for PC patients. The clinical application value of Short Form Mini Nutritional Assessment (MNA-SF), Generated Subjective Global Assessment (SGA) and Patient-generated Subjective Global Assessment (PG-SGA) in PC patients need to be confirmed. In order to improve patients' nutritional status and promote their recovery, nutritional screening tools can be used.

REGISTRATION

This systematic review was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (number CRD42022376715).

Association between a novel nutrition-inflammation prognostic grading system and overall survival in hospitalized adults with cancer: A retrospective cohort study

BACKGROUND

Malnutrition and increased systemic inflammatory responses are highly prevalent in patients with cancer and they have a negative effect on prognosis. We aimed to develop a nutrition-inflammation prognostic grading system (NIPGS) for patients with cancer, which incorporates the Nutritional Risk Screening 2002 (NRS 2002) and C-reactive protein (CRP) levels.

METHODS

This multicenter retrospective cohort study totally included 6891 patients diagnosed with cancer. A 4 × 4 matrix incorporating the four NRS 2002 categories within each of the four CRP categories was constructed. Groups with approximate hazard ratios (HRs) were clustered into one grade. The NIPGS consists of four grades, with the survival rate gradually decreasing from Grades 1 to 4. The primary outcome was overall survival (OS) and comprehensive survival analyses were performed.

RESULTS

During a median follow-up of 18.70 months, 2818 death cases occurred. Kaplan-Meier curve showed the survival rate decreased from Grades 1 to 4 of NIPGS (P < 0.001). The NIPGS was an independent risk factor associated with OS adjusting for confounders, with HRs increasing from 1.22 (95% confidence interval [CI], 1.09-1.36; P < 0.001) in Grade 2, 1.58 (95% CI, 1.39-1.80; P < 0.001) in Grade 3 to 1.92 (95% CI, 1.73-2.13; P < 0.001) in Grade 4. A high NIPGS grade was also associated with an increased risk of short-term mortality, poor quality of life, and longer hospital stay and expenses. Two internal validation cohorts confirmed the results of our study.

CONCLUSION

The NIPGS could be an effective prognostic tool for patients with cancer.

Effect of preoperative nutritional support in malnourished patients with pancreatobiliary cancer: a quasi-experimental study

BACKGROUND

In malnourished patients, postoperative morbidity, hospitalization period, and medical expenses are reportedly to be high. We evaluated the clinical impact of a preoperative nutritional support program (PNSP) among malnourished cancer patients.

METHODS

For this quasi-experimental study, we enrolled 90 patients who underwent major pancreatobiliary cancer surgery. Malnutrition was defined as at least one of the following: (1) Patient-Generated Subjective Global Assessment (PG-SGA) grade B or C; (2) > 10% weight loss within 6 months; (3) body mass index <18.5 kg/m2; and (4) serum albumin level < 3.0 g/dL. Forty-five malnourished patients allocated to the PNSP group received in-hospital PNSP for a median of 6 (4-35) days. In the PNSP group, the nutrition support team calculated the patients' daily nutritional requirements based on their nutritional status and previous day's intake. The supplementation targets were as follows: total calorie intake, 30-35 kcal/kg/day; protein intake, 1.2-1.5 g/kg/day; and lipid intake, 1-1.5 g/kg/day. Patients who did not meet the diagnostic criteria for malnutrition were allocated to the well-nourished group and underwent surgery without receiving the PNSP (n = 45). We compared the perioperative nutritional indices (as measured using PG-SGA), postoperative outcome, and quality of life (QOL) according to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0.

RESULTS

In the PNSP group, the proportion of patients with serum prealbumin <16 mg/dL decreased significantly after PNSP (29.5% vs. 8.9%, p = 0.013). Moreover, patients with PG-SGA grade A had a statistically significant increase (2.2% vs. 50%, p < 0.001). The overall and major complication rates were higher in the PNSP group than in the well-nourished group without significance (51.1%, 33.3%; 42.2%, 26.7%, respectively). However, the overall and major complication rates were similar between the subgroup with PG-SGA improvement after PNSP and the well-nourished group (40.9% vs. 42.2%, p = 0.958; 27.3% vs. 26.7%, p = 0.525, respectively). QOL indicators in the PNSP group were comparable with those in the well-nourished group after PNSP.

CONCLUSION

PNSP may improve perioperative nutritional status and clinical outcomes among malnourished patients with pancreatobiliary cancer.

Nutrition and functional status among Palestinian cancer patients receiving chemotherapy

Objectives

This study aims to determine the prevalence of malnutrition among cancer patients and to assess the nutritional and functional status of cancer patients undergoing chemotherapy at the Oncology unit of Beit Jala Governmental Hospital in Palestine.

Methods

During the data collection period, all patients who received chemotherapy at the hospital's chemotherapy unit were included in this cross-sectional analysis. Anthropometric measurements and biochemical data from the patients' files were used to determine nutritional status. The Nutrition Risk Screening (NRS) 2002 was used to assess the risk of malnutrition. The Functional Assessment of Anorexia/Cachexia Therapy (FAACT) was used to determine functional status. A three-day diet recall was used to determine dietary intake.

Results

A total of 153 patients were included in the final analysis. The results revealed that 23.8% of the patients were at risk of malnutrition. Those who were not at risk of malnutrition had a marginally improved functional position. Furthermore, patients aged ≥65 years, males, smokers or former smokers, and those with four or more comorbidities had a significantly higher prevalence of malnutrition. In the logistic model, age >60 years was the only indicator of malnutrition.

Conclusion

Malnutrition has a considerable prevalence in the study sample. However, the functional status of patients who were not at risk of malnutrition was marginally better than that of those with malnutrition risk.

The impact of nutritional status on pancreatic cancer therapy

INTRODUCTION

Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive disease with poor outcomes. One of the reasons for the dismal prognosis resides in its impressive ability to alter the nutritional status of patients who develop malnutrition, cachexia, anorexia, and sarcopenia in most cases. The ideal way to measure such changes in PDAC patients, in order to readily identify them and avoid complications or discontinuations of treatment is a relatively unexplored area. In addition, most PDAC patients experience pancreatic exocrine insufficiency (PEI) that contributes to the complex puzzle of malnutrition and that can be treated with Pancreatic Enzyme Replacement Therapy (PERT).

AREAS COVERED

We review current knowledge on the impact of nutritional status on both surgical and medical treatments for PDAC, reporting available data on the causes of malnutrition, characteristics, and advantages of different tools to investigate nutritional status and possible strategies to improve patient outcomes.

EXPERT OPINION

All PDAC patients should receive a careful nutritional assessment at diagnosis, and this should be repeated alongside their treatment path. Screening tools and biochemical variables or scores are associated with prognosis, but bioimpedance vector analysis (BIVA) and radiological assessment of body composition seem more accurate in predicting clinical outcomes and postoperative complications.

Pre-treatment Nutritional Risk Assessment by NRS-2002 Predicts Prognosis in Patients With Advanced Biliary Tract Cancer: A Single Center Retrospective Study

We investigated the predictors of survival in patients with advanced BTC according to their baseline nutritional status estimated by the Nutritional Risk Screening (NRS)-2002. From September 2006 to July 2017, we reviewed the data of 601 inpatients with BTC. Data on demographic and clinical parameters was collected from electronic medical records, and overall survival (OS) and progression-free survival were analyzed using the Kaplan-Meier method and the stepwise Cox regression analysis. Patients with an NRS-2002 score of ≤ 2, 3, and ≥ 4 were respectively classified as “no risk,” “moderate risk,” “high risk.” Following initial NRS-2002 score, 333 patients (55%) were classified as “no-risk,” 109 patients (18%) as “moderate-risk,” and 159 patients (27%) as “high-risk.” Survival analysis demonstrated significant differences in the median OS: “no-risk”: 12.6 months (95% confidence interval [CI], 11.5–13.7); “moderate-risk”: 6.1 months (95% CI, 4.3–8.0); and “high-risk”: 3.9 months (95% CI, 3.2–4.6) (p < 0.001). NRS-2002 score was an independent factor for OS (hazard ratio [HR], 1.616 for “moderate-risk”, 95% CI, 1.288–2.027, p < 0.001; HR, 2.121 for “high-risk”, 95% CI, 1.722–2.612, p < 0.001), along with liver metastasis, peritoneal seeding, white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, cholesterol, carcinoembryonic antigen, and carbohydrate antigen 19-9. In conclusion, baseline NRS-2002 is an appropriate method for discriminating those who are already malnourished and who have poor prognosis in advanced BTC patient. Significance of these results merit further validation to be integrated in the routine practice to improve quality of care in BTC patients.

The Relationship between Nutritional Status and Body Composition with Clinical Parameters, Tumor Stage, CA19-9, CEA Levels in Patients with Pancreatic and Periampullary Tumors

Recent studies have obtained inadequate data on the association between nutritional status, body composition, clinical parameters and tumor stage in patients withpancreatic and periampullary tumors. The purpose of this study was to assess the relationship between nutritional status (NS), body composition (BC) and selected clinical parameters in patients with pancreatic and periampullary cancer, as well as describe the differences between resection and non-resection groups. This is a prospective study of 76 patients with pancreatic and periampullary tumors. We evaluated NS, BMI, body mass loss (BML) and albumin, total protein, CRP, CEA, CA19-9, lipase, amylase, tumor stage, and BC using bioelectrical impedance (BIA). All subjects were divided into resection (n = 59) and non-resection (n = 17) groups. The non-resection group had a worse NS, as well as increased amylase and WBC, compared to the resection. The selected parameters of BC corresponded to BML albumin, TP, NS, age, BMI, Karnofsky, RBC, HCT and HGB. No associations were found between BC with tumor size, CRP, CA19-9, and CEA. We recorded the relationship between metastasis and NRS, as well as tumor size with SGA. The percentage of BML was positively correlated with age and CRP but negatively correlated with RBC, HGB, HCT and anthropometric measurements. We found many statistical correlations with NS and selected parameters, as well as differences between the resection and non-resection group. The detection of early prognostic factors of nutritional impairments would improve the quality of life and reduce the rate of postoperative complications.

Impact of Preoperative Malnutrition on Postoperative Long-Term Outcomes of Patients With Pancreatic Head Cancer

Objective

To evaluate the association between preoperative malnutrition and long-term outcomes in patients with pancreatic head cancer who underwent curative pancreatoduodenectomy (PD).

Methods

From 2004 to 2018, 228 consecutive patients who underwent curative PD for pancreatic ductal adenocarcinoma were included. Preoperative malnutrition was defined by the Global Leadership Initiative in Malnutrition criteria. It is based on both phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and etiologic criteria (reduced intake or assimilation and inflammation).

Results

Seventy-five (32.9%) of 228 patients were classified as suffering from malnutrition. Preoperative malnutrition was associated with an increased risk of estimated blood loss (mL) (816.7 ± 875.2 vs 593.1 ± 489.9, P = 0.015) and longer hospital stay (days) (27.3 ± 15.7 vs 22.9 ± 17.7, P = 0.045). The median follow-up period was 24.5 months. The malnutrition group had poor overall survival compared with "without (WO)-malnutrition" group (P = 0.001) at 1 year (66.3% vs 81.3%), 3 years (18.0% vs 51.8%), and 5 years (12.0% vs 39.3%). The malnutrition group showed poor disease-free survival and cancer-specific survival compared with WO-malnutrition group (P = 0.001) at 1 year (38.9% vs 66.7%) and (69.0% vs 88.7%), 3 years (11.5% vs 45.1%) and (21.1% vs 61.6%), and 5 years (11.5% vs 37.3%) and (14.1% vs 51.2%). In multivariate analysis, the preoperative malnutrition was found to be the predictor of poor prognosis (harzard ratio = 2.29, 95% confidence interval = 1.60-3.29, P = 0.001).

Conclusions

Preoperative malnutrition is associated with poor prognosis in patients who underwent curative PD for pancreatic head cancer.

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.

Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma

BACKGROUND

Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC.

METHODS

Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test.

RESULTS

Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m²(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009).

CONCLUSIONS

Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.