Nutritional status affects long term survival after lobectomy for lung cancer

Prediction of Poor Outcome Using the Urea to Albumin Ratio in Thoracic Empyema

Purpose

The prognostic performance of urea-to-albumin ratio (UAR) has been assessed in various pulmonary and nonpulmonary conditions, but never in thoracic empyema. Therefore, our aim was to determine whether this marker has the ability to predict outcome in such patients.

Methods

A single-center retrospective study was conducted in a Clinic of Thoracic Surgery at a University Hospital between January 2021 and October 2023. A total of 84 patients who underwent emergency surgery due to thoracic empyema were involved. Serum levels of urea and albumin at admission were used to calculate UAR. We analyzed area under receiver operating characteristics (AUROC) curves of UAR, systemic inflammatory response syndrome (SIRS) and quick-sequential organ failure assessment (qSOFA), and compared their prognostic performance.

Results

The identified in-hospital mortality was 10.7%. The UAR showed the best ability to prognosticate mortality compared to qSOFA (AUROC = 0.828 vs 0.747) and SIRS (AUROC = 0.828 vs 0.676). We established a sensitivity of 87.5% and specificity of 74.2% at optimal cut-off value UAR > 51.1 for prediction of adverse outcome.

Conclusion

In patients with thoracic empyema urea-to-albumin ratio showed significant prognostic performance and a potential for clinical application as a low cost and widely available predictor of death.

Albumin‑bilirubin grade is an independent prognostic factor for small lung cell cancer

Albumin-bilirubin (ALBI) grade was first described in 2015 as an indicator of liver dysfunction in patients with hepatocellular carcinoma. ALBI grade has been reported to have prognostic value in several malignancies including non-small cell lung cancer (NSCLC). The present study aimed to explore the prognostic impact of ALBI grade in patients with small cell lung cancer (SCLC). It retrospectively analyzed 135 patients with SCLC treated at Hebei General Hospital between April 2015 and August 2021. Patients were divided into two groups according to the cutoff point of ALBI grade determined by the receiver operating characteristic (ROC) curve: Group 1 with pre-treatment ALBI grade ≤-2.55 for an improved hepatic reserve and group 2 with ALBI grade >-2.55. Kaplan-Meier and Cox regression analysis were performed to assess the potential prognostic factors associated with progression free survival (PFS) and overall survival (OS). Propensity score matching (PSM) was applied to eliminate the influence of confounding factors. PFS and OS (P<0.001) were significantly improved in group 1 compared with in group 2. Multivariate analysis revealed that sex (P=0.024), surgery (P=0.050), lactate dehydrogenase (LDH; P=0.038), chemotherapy (P=0.038) and ALBI grade (P=0.028) are independent risk factors for PFS and that surgery (P=0.013), LDH (P=0.039), chemotherapy (P=0.009) and ALBI grade (P=0.013) are independent risk factors for OS. After PSM, ALBI grade is an independent prognostic factor of PFS (P=0.039) and OS (P=0.007). It was concluded that ALBI grade was an independent prognostic factor in SCLC.

Blood Biomarkers of Response to Immune Checkpoint Inhibitors in Non-Small Cell Lung Cancer

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment landscape of non-small cell lung cancer (NSCLC), either used in monotherapy or in combination with chemotherapy. While some patients achieve durable responses, some will not get benefit from this treatment. Early identification of non- responder patients could avoid unnecessary treatment, potentially serious immune-related adverse events and reduce treatment costs. PD-L1 expression using immunohistochemistry is the only approved biomarker for the selection of patients that can benefit from immunotherapy. However, application of PD-L1 as a biomarker of treatment efficacy shows many deficiencies probably due to the complexity of the tumor microenvironment and the technical limitations of the samples. Thus, there is an urgent need to find other biomarkers, ideally blood biomarkers to help us to identify different subgroups of patients in a minimal invasive way. In this review, we summarize the emerging blood-based markers that could help to predict the response to ICIs in NSCLC.

The Potential Role of Nutrition in Lung Cancer Establishment and Progression

Lung cancer is a devastating disease with a high incidence and low survival rates, so recent studies have focused on analyzing the risk factors that might prevent this disease from developing or have protective/therapeutic effects. Nutrition is an important key factor in the prevention and treatment of lung cancer. Various factors appear to be involved in the development of the latter, such as cigarette smoking or certain external environmental factors. The increase in oxidative stress is therefore an integral part of the carcinogenesis process. The biological role of bioactive factors derived from adipose tissue, mainly adipokines, is implicated in various cancers, and an increasing body of evidence has shown that certain adipocytokines contribute to the development, progression and prognosis of lung cancer. Not all adipokines stimulate tumor growth; in fact, adiponectin inhibits carcinogenesis by regulating both cell growth and the levels of inflammatory cytokines. Adiponectin expression is deregulated in several cancer types. Many nutritional factors have been shown to increase adiponectin levels and therefore could be used as a new therapeutic strategy for combating lung cancer. In addition, foods with antioxidant and anti-inflammatory properties play a key role in the prevention of many human diseases, including lung cancer. The purpose of this review is to analyze the role of diet in lung cancer in order to recommend dietary habit and lifestyle changes to prevent or treat this pathology.

Twenty-Year Survival of Patients Operated on for Non-Small-Cell Lung Cancer: The Impact of Tumor Stage and Patient-Related Parameters

Surgery is the mainstay treatment of non-small-cell lung cancer (NSCLC), but its impact on very-long-term survival (beyond 15 years) has never been evaluated.

METHODS

All patients operated on for major lung resection (Jun. 2001-Dec. 2002) for NSCL in the Thoracic Surgery Department at Paris-Hôtel-Dieu-University-Hospital were included. Patients' characteristics were prospectively collected. Vital status was obtained by checking INSEE database and verifying if reported as "non-death" by the hospital administrative database and direct phone interviews with patients of families.

RESULTS

345 patients were included. The 15- and 20-year survival rates were 12.2% and 5.7%, respectively. At univariate analysis, predictors of worse survivals were: increasing age at surgery (p = 0.0042), lower BMI (p = 0.009), weight loss (p = 0.0034), higher CRP (p = 0.049), pathological stage (p = 0.00000042), and, among patients with adenocarcinoma, higher grade (p = 0.028). Increasing age (p = 0.004), cumulative smoking (p = 0.045), lower BMI (0.046) and pathological stage (p = 0.0026), were independent predictors of long-term survival at Cox multivariate analysis. In another model, increasing age (p = 0.013), lower BMI (p = 0.02), chronic bronchitis (p = 0.03), lower FEV1% (p = 0.00019), higher GOLD class of COPD (p = 0.0079), and pathological stage (p = 0.000024), were identified as independent risk factors.

CONCLUSIONS

Very-long-term survivals could be achieved after surgery of NSCLC, and factors classically predicting 5- and 10-years survival also determined longer outcomes suggesting that both initial tumor aggressiveness and host's characteristics act beyond the period usually taken into account in oncology.

The advanced lung cancer inflammation index predicts outcomes of patients with non-small cell lung cancer following video-assisted thoracic surgery

OBJECTIVE

The advanced lung cancer inflammation index (ALI) predicts overall survival (OS) in patients with advanced lung cancer. However, few studies have tested ALI's prognostic effect in patients with non-small cell lung cancer (NSCLC) following video-assisted thoracic surgery (VATS), especially patients at stage III. This study investigated the relationship between ALI and outcomes of patients with NSCLC following VATS.

METHODS

We retrospectively examined 339 patients with NSCLC who underwent VATS at Hebei General Hospital, China. Preoperative clinical and laboratory parameters were collected and analyzed. Optimal cutoff values of potential prognostic factors, including ALI, were determined. Kaplan-Meier and Cox regression analyses were used to determine each factor's prognostic value.

RESULTS

The median OS was 31 months. The optimal cutoff value for ALI was 41.20. Patients with high ALI (≥41.20) displayed increased OS (33.87 vs. 30.24 months), higher survival rates, and milder clinical characteristics. Univariate and multivariate analyses showed a significant correlation between ALI and the prognosis of patients with NSCLC, including those at stage IIIA, who underwent VATS.

CONCLUSIONS

Low ALI correlated with poor outcomes in patients with NSCLC following VATS. Preoperative ALI might be a potential prognostic biomarker for patients with NSCLC following VATS, including patients at stage IIIA.

Effect of Lowest Postoperative Pre-albumin on Outcomes after Robotic-Assisted Pulmonary Lobectomy

Objective:

Lower pre-albumin levels have been associated with increased rates of post-surgical complications, prolonged hospital length of stay (LOS), and death. This study aims to investigate the effect of postoperative pre-albumin levels on perioperative and long-term outcomes following robotic-assisted video thoracoscopic (RAVT) pulmonary lobectomy.

Methods:

We retrospectively reviewed 459 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon for known or suspected lung cancer. The lowest pre-albumin values during the postoperative hospital stay were recorded. Twenty-three patients with no pre-albumin levels available were excluded from analysis. Patients were grouped as having normal (≥ 15 mg/dL) versus low (< 15mg/dL) pre-albumin. Outcomes and demographics were compared between groups using Pearson χ², Student’s t, or Kruskal-Wallis tests. Univariate and multivariate generalized linear regression, logistic regression, or Cox proportional hazard ratio models were used to assess the association between outcomes and variables of interest. Kaplan-Meier analyses were performed to estimate and depict survival probabilities for each group.

Results:

Our study population comprised 436 patients. Lowest postoperative pre-albumin below 15 mg/dL was associated with more postoperative complications (44.2% vs 24.9%, p < 0.001), longer chest tube duration (6.9 vs 4.6 days, p = 0.001), and longer LOS (7.0 vs. 4.4 days, p < 0.001). In survival analysis, lowest perioperative pre-albumin levels were found to correlate with decreased 1 year (p = 0.012), 3-year (p = 0.001), and 5-year survival (p = 0.001).

Conclusion:

Lower pre-albumin levels postoperatively are associated with more postoperative complications, longer chest tube duration and LOS, and decreased overall survival following robotic-assisted pulmonary lobectomy.

Advanced Lung Cancer Inflammation Index is a Prognostic Factor of Patients with Small-Cell Lung Cancer Following Surgical Resection

Purpose

Advanced lung cancer inflammation index (ALI) has been shown to predict overall survival (OS) in advanced non small-cell lung cancer (NSCLC), small-cell lung cancer (SCLC) and operable NSCLC. However, there were no studies of the correlation between ALI and operable SCLC. Therefore, this study is aimed to explore the relationship between ALI and the prognosis of operable SCLC.

Patients and Methods

A total of 48 patients with SCLC who underwent surgery at Hebei General Hospital and Zigong First People's Hospital were screened between 2016 and 2020. ALI was calculated as follows: body mass index (BMI, kg/m²)×serum albumin (ALB, g/dL)/neutrophil to lymphocyte ratio (NLR). Receiver operating characteristic (ROC) curve was used to determine the optimal cutoff value of ALI. Patients were divided into two groups according to the cutoff point of ALI: low ALI group with ALI<48.2 and high ALI group with ALI≥48.2. Kaplan-Meier and Cox regression analysis were performed to assess the potential prognostic factors associated with OS.

Results

The optimal cutoff value of ALI was determined as 48.2. The low ALI group displayed more adverse clinical characteristics and poorer survival rates. Multivariate analysis revealed that ALI and Charlson comorbidity index (CCI) were significantly correlated with OS.

Conclusion

Low ALI was correlated with poor prognosis in patients with SCLC who underwent surgery. Preoperative ALI might serve as a potential prognostic marker for patients with operable SCLC.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

The advanced lung cancer inflammation index is an independent prognostic factor after surgical resection in patients with non-small-cell lung cancer

OBJECTIVES

The usefulness of a recently developed advanced lung cancer inflammation index (ALI) has been reported in advanced non-small-cell lung cancer (NSCLC) and small-cell lung cancer. However, no previous studies have examined the prognostic significance of ALI in patients with operable NSCLC. Therefore, the aim of this study was to explore the relationship between ALI and the prognosis of resected NSCLC.

METHODS

Three hundred and forty-three patients with NSCLC who underwent surgery at our institution between 2008 and 2012 were included. The ALI score was calculated as body mass index × serum albumin/neutrophil to lymphocyte ratio. A Web-based software programme [Cutoff Finder (http://molpath.charite.de/cutoff/)] was used to determine the optimal cut-off value for ALI. The Kaplan-Meier methods and a multivariable Cox proportional hazards model were used to evaluate the potential prognostic factors.

RESULTS

The optimal cut-off value of ALI was defined as 37.66. The low-ALI group (ALI < 37.66) displayed more adverse clinical characteristics. Furthermore, compared with patients in the high-ALI group (ALI > 37.66), those in the low-ALI group had significantly poorer survival rates. On multivariable analysis, gender, histological diagnosis, pN status, serum carcinoembryonic antigen level, serum C-reactive protein level and ALI were associated independently with cancer-specific survival.

CONCLUSIONS

This study is the first to investigate whether ALI is useful for predicting postoperative survival in patients with NSCLC. Preoperative ALI might serve as a potentially clinically valuable marker of the prognosis for patients with operable NSCLC.

Advanced Lung Cancer Inflammation Index Predicts Outcomes of Patients with Pathological Stage IA Lung Adenocarcinoma Following Surgical Resection

Purpose: The correlation of advanced cancer with inflammation and/or nutrition factors is well known. Recently, the advanced lung cancer inflammation index (ALI) was developed as a new prognostic tool for patients with advanced lung cancer. In this study, we examined whether ALI results are correlated with prognosis of patients with early stage lung adenocarcinoma who undergo lung resection.

Methods: From January 2009 to December 2014, 544 patients underwent lung resection due to primary lung cancer at Dokkyo Medical University Hospital, of whom 166 with pathological stage IA lung adenocarcinoma were retrospectively investigated in this study. ALI was calculated as follows: Body Mass Index (BMI; kg/m²) × albumin (g/dL)/neutrophil- to-lymphocyte ratio (NLR).

Results: Multivariate analysis revealed that gender, red cell distribution width (RDW), NLR, and ALI were parameters significantly correlated with overall survival (OS). Patients with an ALI value less than 22.2 had an inferior 5-year OS rate as compared to those with a value of 22.2 or higher (p <0.001) as well as an inferior 5-year recurrence-free survival (RFS) rate (p <0.001).

Conclusion: Low ALI was correlated with poor prognosis in patients with stage IA lung adenocarcinoma. Those with an ALI value less than 22.2 should be carefully followed regardless of cancer stage.

Prevalence of low body mass index among newly diagnosed lung cancer patients in North India and its association with smoking status

There is limited data from South Asia on the prevalence of low body mass index (BMI) among newly diagnosed lung cancer patients at presentation and its association with smoking status. A retrospective analysis of a prospective cohort of newly diagnosed lung cancer patients is presented here. Patients were categorized as normal/overweight (BMI ≥ 18.50 kg/m² ; group I), mild/moderately underweight (BMI = 16.00-18.49 kg/m² ; group II) or severely underweight (BMI < 16.0 kg/m² ; group III). Smoking status was assessed using the smoking index (SI; product of number of bidis/cigarettes smoked per day with number of years smoked). Based on the SI, patients were categorized as never-smokers, light/moderate smokers [SI = 1-300] and heavy smokers [SI ≥ 301]. A low BMI was present in 155 (44.3%) patients. Compared to group I, patients in groups II and III had higher percentages of men and current/ex-smokers. On univariate logistic regression analysis (LRA), SI = 1-300 [odds ratio (OR) = 2.75; 95% confidence intervals (CI) = 1.27-5.97] and SI ≥ 301 [OR = 4.57; 95% CI = 2.20-9.49] were associated with higher odds of the presence of low BMI among non-small cell lung cancer (NSCLC) patients while female sex had lower odds [OR = 0.34; 95% CI = 0.16-0.72]. On multivariate LRA, only SI ≥ 301 [OR = 3.74; 95% CI = 1.59-8.80] had a significant association with occurrence of low BMI. Low BMI is common among newly diagnosed lung cancer patients in North India. Heavy smoking is independently associated with presence of low BMI at presentation among NSCLC patients.

Evaluation of a prognostic scoring system based on the systemic inflammatory and nutritional status of patients with locally advanced non-small-cell lung cancer treated with chemoradiotherapy

Systemic inflammation and poor nutritional status have a negative effect on the outcomes of cancer. Here, we analyzed the effects of the pretreatment inflammatory and nutritional status on clinical outcomes of locally advanced non-small-cell lung cancer (NSCLC) patients treated with chemoradiotherapy. We retrospectively reviewed 89 patients with locally advanced NSCLC treated with chemoradiotherapy between July 2006 and June 2013. Serum C-reactive protein (CRP) was assessed as an inflammatory marker, and serum albumin, body mass index (BMI) and skeletal mass index were assessed as nutritional status markers. The relationships between these markers and overall survival (OS) were assessed. The median OS was 24.6 months [95% confidence interval (CI): 19.4-39.3 months]. During follow-up, 58 patients (65%) had disease recurrence and 52 patients (58%) died. In multivariate Cox hazard analysis, CRP levels and BMI approached but did not achieve a significant association with OS (P = 0.062 and 0.094, respectively). Recursive partitioning analysis identified three prognostic groups based on hazard similarity (CRP-BMI scores): 0 = CRP < 0.3 mg/dl, 1 = CRP ≥ 0.3 mg/dl and BMI ≥ 18.5 kg/m2, and 2 = CRP ≥ 0.3 mg/dl and BMI < 18.5 kg/m2. The CRP-BMI score was significantly associated with OS (P = 0.023). Patients with scores of 0, 1 and 2 had median OS of 39.3, 24.5 and 14.5 months, respectively, and the scores also predicted the probability of receiving salvage treatment after recurrence. The CRP-BMI score is thus a simple and useful prognostic marker of clinical outcome for patients with locally advanced NSCLC treated with chemoradiotherapy.

Low Body Mass Index Is an Independent Predictive Factor after Surgical Resection in Patients with Non-Small Cell Lung Cancer

Background:

The effect of body mass index (BMI) on postoperative survival in non-small cell lung cancer (NSCLC) has been controversial. We retrospectively analysed the effect of preoperative BMI on postoperative outcomes of NSCLC surgery.

Methods:

Consecutive 384 NSCLC patients were enrolled. Patients were subdivided into 3 groups: low BMI group (BMI<18.5 kg/m²), normal BMI group (BMI=18.5-24.0 kg/m²) and high BMI group (BMI>24.0 kg/m²). The prognostic significance of BMI was examined retrospectively.

Results:

The 5-year survival of patients with low, normal and high BMI groups were 46.3%, 74.3% and 84.3%, respectively. The low BMI group had a poorer prognosis than the other groups (p<0.001). The survival of high BMI group had a more favorable trend than that of normal BMI group, but this did not reach statistical significance (p=0.057). On multivariate analysis, significant risk factors for cancer-specific survival were male gender (p=0.0061), non-adenocarcinoma histology (p=0.0003), pN1-2 status (p=0.0007), high serum CEA level (p<0.0001) and low BMI (low vs. others: p <0.0001).

Conclusions:

Preoperative BMI is an independent prognostic factor for NSCLC patients after surgical resection, with low BMI patients having an unfavorable prognosis.

Combination of Advanced Lung Cancer Inflammation Index and C-Reactive Protein Is a Prognostic Factor in Patients With Operable Non-Small Cell Lung Cancer

Background

Previous study of ours showed that advanced lung cancer inflammation index (ALI) and C-reactive protein (CRP) are independent significant prognostic factors in operable non-small cell lung cancer (NSCLC) patients. Since both ALI and CRP are markers of inflammation, the aim of this study was to examine whether the combination of ALI and CRP is a prognostic indicator of resected NSCLC or not.

Methods

Three hundred forty-one NSCLC patients who underwent surgery at our institution between 2008 and 2012 were included. ALI score was calculated as BMI × ALB/NLR with BMI indicating body mass index, ALB indicating serum albumin and NLR indicating neutrophil lymphocyte ratio. The prognostic significance of the combination of ALI and CRP was evaluated.

Results

Compared to patients with high ALI (> 37.67) group, low ALI group had significantly poorer cancer-specific survival. Similarly, patients with high CRP (> 0.15 mg/dL) had poorer survival. Based on the combination of ALI and CRP, patients with high ALI and low CRP were assigned an ALI_CRP score of 0, those with both high or both low were assigned an ALI_CRP score of 1, and those with low ALI and high CRP were assigned an ALI_CRP score of 2. The patients’ cancer-specific survival was significantly related to this ALI_CRP score. On multivariate analysis, gender, histology, pN status, serum carcinoembryonic antigen (CEA) level and the ALI_CRP score were associated independently with cancer-specific survival.

Conclusions

The combination of ALI and CRP is a useful predictor of overall survival and could be a simple prognostic tool to help identify operable NSCLC patients.

Gender differences in the correlation between prognosis and postoperative weight loss in patients with non-small cell lung cancer

OBJECTIVES

The aim of this study was to investigate gender differences in the relationship between preoperative body mass index (BMI), postoperative body weight change and prognosis in patients with non-small cell lung cancer (NSCLC).

METHODS

Two hundred and sixty-three patients with NSCLC were enrolled in this study. Preoperative BMI was categorized based on WHO definition as follows: underweight (BMI <18.5): 21 patients (8.0%), normal (18.5 ≦ BMI <25): 179 patients (68%), overweight and obese (BMI ≧25): 63 patients (24%). Several factors such as age, sex, cancer stage, body weight change and BMI were recorded and correlated to the postoperative overall survival (OS).

RESULTS

For male patients, those in the low-BMI group had the worst prognosis (P < 0.05) whereas female patients with low BMI did not. Male patients with low BMI had statistically significant poorer prognosis compared to corresponding female patients (P < 0.05). Male patients with more than 5% body weight loss within 1 year after operation when compared to preoperative body weight had poorer prognosis than those with less than 5% body weight loss (P < 0.001). Furthermore, these male patients had statistically significant worse prognosis than the corresponding female patients (P < 0.05). In multivariable analysis, gender, more than 5% of body weight loss compared to preoperative body weight, and pathological stage were independent prognostic factors in NSCLC.

CONCLUSIONS

This study illustrates significant gender differences in the relationship between prognosis and BMI or body weight change in patients with postoperative NSCLC.

Low Albumin Levels Are Associated with Mortality Risk in Hospitalized Patients

BACKGROUND

The aim of this study was to investigate the association of albumin levels on admission and change in levels during hospitalization with hospitalization outcomes.

METHODS

Historical prospective data of patients hospitalized between 2011 and 2013 were collected. Levels of albumin were classified as marked hypoalbuminemia (<2.5 mg/dL), mild hypoalbuminemia (2.5-3.5 mg/dL), normal albumin (3.5-4.5 mg/dL), and hyperalbuminemia (>4.5 mg/dL). Main outcomes were length of hospitalization, in-hospital mortality, and long-term mortality.

RESULTS

The cohort included 30,732 patients (mean age 67 ± 18 years, 51% male). Most patients had normal albumin levels on admission (n = 20,124, 65%), 29% of patients had hypoalbuminemia, mostly mild (n = 7,334, 24%), and 5% of patients had marked hypoalbuminemia (n = 1436). Hyperalbuminemia on admission was evident in 6% of the patients (n = 1838). Follow-up (median ± standard deviation) was 1675 ± 325 days. Compared with in-hospital mortality with normal albumin on admission (2%), mortality was higher with mild (12%) and marked hypoalbuminemia (34%) and lower with hyperalbuminemia (0.3%). Mortality rate at the end of follow-up was 29% with normal albumin levels, 67% and 83% with mild and marked hypoalbuminemia, respectively. Patients with hyperalbuminemia on admission and before discharge have the best short- and long-term survival. This pattern was similar when analyzed separately in different age groups. In patients with hypoalbuminemia on admission, normalization of albumin levels before discharge was associated with better short- and long-term survival, compared with patients with hypoalbuminemia before discharge.

CONCLUSIONS

Low albumin levels on admission are associated with increased short- and long-term mortality. Normalization of albumin levels before discharge was associated with lower mortality risk, compared with hypoalbuminemia before discharge.

Clinical Value of Nutritional Status in Cancer: What is its Impact and how it Affects Disease Progression and Prognosis?

Malnutrition is a common finding in cancer patients, which can affect disease progression and survival. This review aims to critically summarize the prognostic role of nutritional status, from Body Mass Index (BMI) and weight loss to nutrition screening tools and biochemical indices, in cancer patients. According to the currently available data, Prognostic Nutritional Index (PNI) was a significant prognostic factor of patients' survival, both in univariate and multivariate analyses. Pre-operative albumin was also correlated with worse outcomes, being an independent prognostic factor of survival in several studies. BMI was also well-studied, with contradictory results. Although, lower BMI was found to be an independent prognostic factor of shorter survival in some studies, in others it did not have an impact on survival. In this aspect, this review highlights the significant prognostic role of nutritional status in the disease progression and survival of cancer patients. Further, good-quality prospective studies are needed in order to draw precise conclusions on the prognostic role of specific nutritional assessment tools, and biochemical indices associated with the nutritional status in more cancer types, such as liver, breast and prostate cancer, and hematological malignancies.

Change in potato consumption among Norwegian women 1998-2005-The Norwegian Women and Cancer study (NOWAC)

Studies have shown that potato consumption in Norway have been on the decline in recent years. Increase in income and the association of potato consumption with weight gain and chronic diseases like type 2 diabetes have been identified as some of the factors responsible for the change. The aim of this study was to describe the change in potato consumption within persons and how non-dietary variables influenced that change among participants in the Norwegian Women and Cancer study (NOWAC). A prospective analysis was performed in the NOWAC cohort using linear regression. Data on dietary, lifestyle, socioeconomic and health-related factors were collected by mailed questionnaires. The change in potato consumption among 38,820 women aged 41–70 years was investigated using two measurements taken at intervals of 4–6 years. At baseline, mean intake was 112g per day; this had decreased to 94.5g per day at the second measurement. Results showed that the percentage of women who reported that they ate less than 1 potato a day increased from 24.6% at baseline to 35.5% at the second measurement. Those who reported that they ate more than 3 potatoes a day had decreased from 20.2% of the participants at baseline to 12.1% at the second measurement. Multivariable adjusted results show that geography was an important predictor of potato consumption at second measurement. Living in the north compared to Oslo (the capital) was associated with higher intake of potato at second measurement (B: 0.60, 95% CI: 0.55–0.65). Compared to women living with a partner, living alone was associated with lower potato intake at second measurement (B: -0.13, 95% CI: -0.17 –-0.09) while living with children tended to be associated with higher potato intake at second measurement (B: 0.01, 95% CI: -0.02–0.04). Younger age, more years of education, higher income or BMI was associated with a lower potato intake at second measurement. Smoking was associated with a higher intake of potato at second measurement (B: 0.03, 95% CI: 0.00–0.06 for smokers compared to non-smokers). Having diabetes at baseline was associated with lower intake of potato at second measurement (B: -0.04, 95% CI: -0.14 –-0.06 for non-diabetics compared to diabetics). Potato consumption among women in the NOWAC study showed a decline over the period studied. Change in the consumption was found to be influenced by age, education, income, household structure, region of residence as well as health-related factors like smoking and diabetes. The use of repeated measures is necessary to continue the monitoring and also to understand the stability and direction of the possible change in diet of a population.

Effect of body mass index on survival of patients with stage I non-small cell lung cancer

Background

Body mass index (BMI) has a U-shaped association with lung cancer risk. However, the effect of BMI on prognosis is controversial. This retrospective study aimed to investigate the effect of BMI on the survival of patients with stage I non-small cell lung cancer (NSCLC) after surgical resection.

Methods

In total, 624 consecutive stage I NSCLC patients who underwent radical resection were classified into four groups according to their BMI: underweight (BMI < 18.5 kg/m²), normal weight (BMI = 18.5–22.4 kg/m²), overweight (BMI = 22.5–28.0 kg/m²), and obese (BMI > 28.0 kg/m²). The effect of BMI on progression-free survival (PFS) and overall survival (OS) was estimated using the Kaplan–Meier method and Cox proportional hazards model. Postoperative complications in each group were analyzed using the Chi square test or Fisher’s exact test.

Results

A univariate analysis showed that PFS and OS were longer in the overweight group than in other groups (both P < 0.05). A multivariate analysis showed that OS was longer in the overweight group than in other groups (compared with the other three groups in combination: hazard ratio [HR] = 1.87, 95% confidence interval [CI] 1.30–2.68, P = 0.003; compared with the underweight group: HR = 2.24, 95% CI 1.18–4.25, P = 0.013; compared with the normal weight group: HR = 1.58, 95% CI 1.07–2.33, P = 0.022; compared with the obese group: HR = 2.87, 95% CI 1.48–5.59, P = 0.002), but PFS was similar among the groups (HR = 1.28, 95% CI 0.97–1.68, P = 0.080). A subgroup analysis showed an association between being overweight and prolonged OS in patients at stage T1a (P = 0.024), T1b (P = 0.051), and T2a (P = 0.02), as well as in patients with a non-smoking history (P = 0.001). Overweight patients had lower rates of postoperative complications, such as respiratory failure (compared with the underweight and obese groups: P = 0.014), myocardial infarction (compared with the obese group: P = 0.033), and perioperative death (compared with the other three groups: P = 0.016).

Conclusions

Preoperative BMI is an independent prognostic factor for stage I NSCLC patients after resection, with overweight patients having a favorable prognosis.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

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

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

Is preoperative protein-rich nutrition effective on postoperative outcome in non-small cell lung cancer surgery? A prospective randomized study

Objective

Protein-rich nutrition is necessary for wound healing after surgery. In this study, the benefit of preoperative nutritional support was investigated for non-small cell lung cancer patients who underwent anatomic resection.

Methods

A prospective study was planned with the approval of our institutional review board. Fifty-eight patients who underwent anatomic resection in our department between January 2014 and December 2014 were randomized. Thirty-one patients were applied a preoperative nutrition program with immune modulating formulae (enriched with arginine, omega-3 fatty acids and nucleotides) for ten days. There were 27 patients in the control group who were fed with only normal diet. Patients who were malnourished, diabetic or who had undergone bronchoplastic procedures or neoadjuvant therapy were excluded from the study. Patients’ baseline serum albumin levels, defined as the serum albumin level before any nutrition program, and the serum albumin levels on the postoperative third day were calculated and recorded with the other data.

Results

Anatomic resection was performed by thoracotomy in 20 patients, and 11 patients were operated by videothoracoscopy in the nutrition program group. On the other hand 16 patients were operated by thoracotomy and 11 patients were operated by videothoracoscopy in the control group. In the control group, the patients’ albumin levels decreased to 25.71 % of the baseline on the postoperative third day, but this reduction was only 14.69 % for nutrition program group patients and the difference was statistically significant (p < 0.001). Complications developed in 12 patients (44.4 %) in the control group compared to 6 patients in the nutrition group (p = 0.049). The mean chest tube drainage time was 6 (1–42) days in the control group against 4 (2–15) days for the nutrition program group (p = 0.019).

Conclusions

Our study showed that preoperative nutrition is beneficial in decreasing the complications and chest tube removal time in non-small cell lung cancer patients that were applied anatomic resection with a reduction of 25 % in the postoperative albumin levels of non-malnourished patients who underwent resection.

Systemic inflammation, nutritional status and tumor immune microenvironment determine outcome of resected non-small cell lung cancer

Background

Hypothesizing that nutritional status, systemic inflammation and tumoral immune microenvironment play a role as determinants of lung cancer evolution, the purpose of this study was to assess their respective impact on long-term survival in resected non-small cell lung cancers (NSCLC).

Methods and Findings

Clinical, pathological and laboratory data of 303 patients surgically treated for NSCLC were retrospectively analyzed. C-reactive protein (CRP) and prealbumin levels were recorded, and tumoral infiltration by CD8+ lymphocytes and mature dendritic cells was assessed. We observed that factors related to nutritional status, systemic inflammation and tumoral immune microenvironment were correlated; significant correlations were also found between these factors and other relevant clinical-pathological parameters. With respect to outcome, at univariate analysis we found statistically significant associations between survival and the following variables: Karnofsky index, American Society of Anesthesiologists (ASA) class, CRP levels, prealbumin concentrations, extent of resection, pathologic stage, pT and pN parameters, presence of vascular emboli, and tumoral infiltration by either CD8+ lymphocytes or mature dendritic cells and, among adenocarcinoma type, tumor grade (all p<0.05). In multivariate analysis, prealbumin levels (Relative Risk (RR): 0.34 [0.16–0.73], p = 0.0056), CD8+ cell count in tumor tissue (RR = 0.37 [0.16–0.83], p = 0.0162), and disease stage (RR 1.73 [1.03–2.89]; 2.99[1.07–8.37], p = 0.0374- stage I vs II vs III-IV) were independent prognostic markers. When taken together, parameters related to systemic inflammation, nutrition and tumoral immune microenvironment allowed robust prognostic discrimination; indeed patients with undetectable CRP, high (>285 mg/L) prealbumin levels and high (>96/mm2) CD8+ cell count had a 5-year survival rate of 80% [60.9–91.1] as compared to 18% [7.9–35.6] in patients with an opposite pattern of values. When stages I-II were considered alone, the prognostic significance of these factors was even more pronounced.

Conclusions

Our data show that nutrition, systemic inflammation and tumoral immune contexture are prognostic determinants that, taken together, may predict outcome.

Characteristics of taste and smell alterations reported by patients after starting treatment for lung cancer

PURPOSE

Taste and smell alterations (TSAs) in patients with lung cancer are poorly understood. This study investigates characteristics of TSAs when most severe, reported by patients after starting treatment for lung cancer.

METHODS

Data was collected regarding TSAs, symptoms, food intake and nutritional status through structured interviews using the Taste and Smell Survey, the Patient-Generated Subjective Global Assessment and 3-day food diaries. This data derives from a longitudinal project and the interview with each patient when TSAs were most severe was purposefully selected for analysis.

RESULTS

Sixty-one of the 89 patients reported TSAs, and the TSAs group were on average younger and more frequently smokers. Thirty-one patients reported symptoms impacting negatively on food intake, with 87 % in the TSAs group and 13 % in the no-TSAs group. Most commonly reported were loss of appetite, nausea and early satiety. Gender differences were seen with more women reporting stronger sensation(s) and more men reporting weaker sensation(s) and other changes. TSAs were described as affecting enjoyment of food and eating. A trend was seen where energy intakes declined with increasing TSAs. Energy intakes in the total study population were below recommended.

CONCLUSION

TSAs varied in characteristics and interacted with other symptoms. Gender differences may highlight a need to investigate approaches for identification and management of TSAs in men and women. Patients reported TSAs impacting on food enjoyment, and the hypothesis that patients with higher TSS scores have lower nutritional intakes should be followed up with a larger study in the lung cancer population.

[Managing nutritional support in thoracic oncology]

INTRODUCTION

Cancer treatments are based on specific anticancer chemotherapy. However, there is increasing interest in general aspects of care, which are increasingly evidence based.

STATE OF THE ART

The importance of muscle mass is becoming increasingly evident. Its role is not only limited to the maintenance of physical performance and quality of life. In oncology, recent studies have shown a close link between sarcopenia (low muscle mass) and mortality as well as between sarcopenia and chemotherapy toxicity. To treat malnutrition and the lack of energy intake, nutritional support is considered, whether through the prescription of oral nutritional supplements, enteral nutrition or even parenteral nutrition. Scientific arguments are often absent and few studies have been carried out in patients with lung cancer.

PERSPECTIVES

There are many experimental arguments and a few clinical trials that support using omega 3 fatty acids to modulate inflammatory reaction and to reduce its consequences on muscular proteolysis. The benefit of regular physical activity has already been proven in chronic respiratory disease and its use in association with nutritional support must be recommended in oncologic care.

CONCLUSION

Given the increasing recognition of the role of muscle mass in cancer, the purpose of any nutritional support must be focused on increasing muscle anabolism and decreasing proteolysis.

Low perioperative serum prealbumin predicts early recurrence after curative pulmonary resection for non-small-cell lung cancer

BACKGROUND

Early recurrence after surgery for non-small-cell lung cancer (NSCLC) is often observed in spite of pathologically proven early-stage disease. The aim of this study was to identify biomarkers that might be useful in predicting postoperative early recurrence of lung cancer. In this study we evaluated the perioperative nutritional status of the patients by measuring the serum level of prealbumin and analyzed the correlation between this factor and early recurrence.

METHODS

Forty-four patients with NSCLC were enrolled in the study. Serum level of prealbumin was measured 5 days before and 7 days after surgery, respectively.

RESULTS

For the patients who developed early recurrence, the perioperative serum prealbumin level was statistically significantly lower than those of the patients who did not develop recurrence (p<0.05). Furthermore, the patients with low prealbumin level showed statistically significantly poorer outcomes compared with the patients with higher prealbumin level (p<0.001). On the other hand, there was no correlation between the pathological stage and the serum prealbumin level. Multivariate analysis revealed that low perioperative serum prealbumin level could be an independent prognostic factor of poor outcome (hazard ratio, 10.1; 95% confidence interval, 2.8-35.5; p=0.0003).

CONCLUSIONS

Low serum prealbumin level in the perioperative period is associated with a poorer prognosis in NSCLC patients and could serve as a marker for identifying patients at high risk, even at an early clinical stage.

Completion pneumonectomy in patients with cancer: postoperative survival and mortality factors

OBJECTIVE

To describe postoperative complications and long-term outcomes of completion pneumonectomy and highlight prognostic factors.

METHOD

We retrospectively reviewed the records of 46 patients (38 men, 8 women) who underwent completion pneumonectomy for lung cancer between 1995 and 2009 in one of two thoracic surgery departments. Most were current or former smokers (n = 41; 89%) and did not undergo chemotherapy (n = 38; 83%) or radiotherapy (83%) before surgery.

RESULTS

Complications after surgery were respiratory failure (n = 11; 24.4%), bronchopleural fistula (n = 6; 13%, with no side preference), and empyema (n = 6; 13%). Blood transfusion was necessary for 43% of the cases (n = 20). The day 90 death rate was 15.2% (n = 7). Postoperative staging showed mostly limited disease. Ten patients (21.7%) underwent operation for a second primary cancer, 25 for local recurrence (54.3%), five for microscopically incomplete resection, and six for other reasons. Median overall survival after completion surgery was 30 months (median follow-up: 46.5 months). Among the 15 living patients (33%), 11 are free of disease (24%). In a Cox regression model, factors negatively influencing overall survival were: age older than 65 years (odds ratio [OR] = 2.47; p = 0.012), current smoker status (OR = 2.285; p = 0.033), postoperative pulmonary (OR = 5.144; p = 0.004), cardiac (OR = 3.404; p = 0.033), or parietal wound complications (OR = 5.439; p = 0.016).

CONCLUSION

Despite its increased postoperative complications and mortality compared with standard pneumonectomy, completion pneumonectomy offers encouraging long-term results. Five main factors seem predictive of shorter overall survival.

The impact of decreasing cutoff values for maximal oxygen consumption (VO(2)max) in the decision-making process for candidates to lung cancer surgery

BACKGROUND

Maximal oxygen consumption (VO(2)max) is considered a decisive test for risk prediction in patients with borderline cardiopulmonary reserve. Guidelines have adopted decreasing VO(2)max cut-off values to define operability within acceptable mortality and morbidity limits. We wanted to investigate how the adoption of decreasing VO(2)max cut-off-values assessment contributed to better select lung surgery candidates.

METHODS

One hundred and nineteen consecutive surgical candidates have been prospectively analyzed as a sample population. Preoperative work-up included spirometry and transfer factor (DLco); irrespective of the spirometric values, these patients were subjected to VO(2)max assessment. Surgical eligibility was decided by the same surgeon throughout the series. In the postoperative period, overall mortality and the occurrence of any, major or minor complications was recorded and graded according to the Common Terminology Criteria for Adverse Events v.4.3.

RESULTS

Three arbitrary cut-offs were introduced at 15, 14 and 12 mL(.)kg(-1) (.)min(-1). Notably, 15 and 12 mL(.)kg(-1) (.)min(-1) correlated with percentage VO(2)max values of 50% and 35% of predicted (P<0.0001 and 0.0079), respectively. Accordingly, the patients were subdivided into groups in which the prevalence of postoperative morbidity was recorded. The groups were homogeneous as to age, BMI, preoperative absolute and percentage FEV1 and DLco. In the Cox proportionate-hazards multivariate analysis, VO(2)max less than 35% (P=0.0017) and CTCAE >2 (P=0.0457) emerged as significant predictors of survival after surgery. Conversely on logistic regression analysis, age over 70 years (P=0.03) and pneumonectomy (P=0.001), but not VO(2)max cut-off values, were significant predictors of major (CTCAE >2) morbidity.

CONCLUSIONS

Since VO(2)max is increasingly used to contribute to risk prediction for the individual patient, surgeons need to be advised that the concept of a definitive, generalized cut-off value for VO(2)max is probably a contradiction in terms. Patient-specific VO(2)max values are more likely to contribute to risk assessment since they may reflect the primarily affected component among the determinants of maximal oxygen consumption. Whether patient-specific VO(2)max should be routinely used by surgeons to define operability for borderline patients needs further evaluation.

Nutritional status of patients undergoing chemoradiotherapy for lung cancer

Impaired nutrition is an important predictor of perioperative complications in lung cancer patients, and preoperative chemoradiotherapy increases the risk of such complications. The goal of this study was to assess the effect of an immune-enhancing diet on nutritional status in patients undergoing lung resection after chemoradiotherapy. We compared the preoperative nutritional status in 15 patients with lung cancer undergoing lung resection without chemoradiotherapy and 15 who had chemoradiotherapy. Body mass index and lymphocyte counts were lower in patients who had chemoradiotherapy. Although there was no difference in the rate of postoperative morbidity between groups, the chemoradiotherapy patients were more likely to have severe complications postoperatively. After chemoradiotherapy in 12 patients, 6 received oral Impact for 5 days, and 6 had a conventional diet before surgery. Oral intake of Impact for 5 days before surgery modified the decrease in transferrin and lymphocytes after the operation. Preoperative immunonutrition may improve the perioperative nutritional status after induction chemoradiotherapy in patients undergoing lung cancer surgery, and reduce the severity of postoperative complications. These potential benefits need to be confirmed in a randomized controlled trial.

Nutritional status, acute phase response and depression in metastatic lung cancer patients: correlations and association prognosis

BACKGROUND AND AIM

Cancer cachexia is a metabolic syndrome related with poor outcome. Cytokines play a key role in the pathophysiology of that syndrome. The aim of this study was to investigate the potential correlations between nutritional status, systemic inflammation, and psychological distress in cancer patients. The prognostic significance of the recorded parameters was also assessed.

PATIENTS AND METHODS

Patients with metastatic lung cancer were eligible. Mini Nutritional Assessment (MNA) was used for the evaluation of nutritional status, Glasgow Prognostic Score (GPS) for the estimation of systemic inflammation, and Hospital Anxiety and Depression Scale (HADS) for psychological assessment.

RESULTS

Totally, 122 patients were enrolled (71.3% with NSCLC and 28.7% with SCLC). The following correlations were observed: MNA and GPS (r = 0.289, p = 0.001), MNA and HADS (depression scale) (r = 0.275, p = 0.002), GPS and HADS (depression scale) (r = 0.256, p = 0.004), and GPS and HADS (anxiety scale) (r =0.194, p =0.033). In univariate analysis, GPS (p = 0.002) and MNA (p = 0.010) emerged as significant predictors of survival. In multivariate analysis, both MNA (p = 0.032) and GPS (p = 0.020) retained their importance.

CONCLUSIONS

This study highlights the associations between nutritional status, systemic inflammation, and psychological distress, supporting their common underlying pathophysiological mechanisms and further suggesting the necessity of a holistic anti-cachectic approach.

Nutrition aspects of lung cancer

Lung cancer is the most common type of cancer, excluding nonmelanoma skin cancer, and is the leading cause of cancer death in the United States. Notable carcinogens involved in the development of lung cancer include smoking, secondhand smoke, and radon. Lung cancer is divided into 2 major types: non-small-cell lung cancer, the most prevalent, and small-cell lung cancer. Treatment includes surgery, chemotherapy, radiation, or a combination of the same. Medical nutrition therapy is often required for nutrition-related side effects of cancer treatment, which include but are not limited to anorexia, nausea and vomiting, and esophagitis. The best protection against lung cancer is avoidance of airborne carcinogens and increased consumption of fruits and vegetables. Studies have shown that smokers taking large amounts of beta-carotene and vitamin A supplements had increased lung cancer incidence and mortality. However, ingestion of beta-carotene from foods, along with a diet rich in fruits and vegetables, has a protective role against lung disease. The use of complementary and alternative medicine by lung cancer patients is prevalent; therefore, clinicians should investigate whether complementary and alternative therapies are used by patients and advise them on the use of these therapies to avoid any potential side effects and interactions with conventional therapies. The article concludes with a case study of a patient with non-small-cell lung cancer and illustrates the use of medical nutrition therapy in relation to cancer treatment side effects.

Serum albumin levels as an independent predictor of 4-year mortality in a community-dwelling 80-year-old population

BACKGROUND AND AIMS

Although serum albumin levels are associated with mortality in non-institutionalized elderly people under 80 years old, as well as in the institutionalized very elderly, little is known about the relationship in community-dwelling very elderly people. We, therefore, examined the association in a Japanese population of 80-year-old community residents.

METHODS

Serum albumin levels were measured in 672 (267 men, 405 women) out of 1282 80-year-old individuals. Over the following 4 years, the dates and causes of death were recorded from resident registration cards and official death certificates.

RESULTS

Of the above individuals, 107 subjects died (58 men, 49 women: 27 due to cancer, 27 cardiovascular disease, and 22 pneumonia). Survival rates were compared among 4 groups (highest >or=45 g/L, higher than 43-44 g/L, lower than 41-42 g/L, lowest <or=40 g/L). After adjustment for confounding factors, total death or cardiovascular death in the lowest albumin group was 3.1 times and 10.7 times more incident than in the highest albumin group, but there were no differences among groups as regards deaths due to cancer or pneumonia.

CONCLUSION

Serum albumin levels are an independent predictor of mortality due to all-cause or cardiovascular disease, but not of mortality due to cancer or pneumonia in very elderly Japanese community residents.